A Meeting of the NHS Barnsley Clinical Commissioning Group

A meeting of the NHS Barnsley Clinical Commissioning Group Governing Body will be held on Thursday 14 March 2019 at 9.30 am in the Boardrooms, Hillder House, 49/51 Gawber Road, Barnsley S75 2PY. AGENDA (Public)

Item Session GB Enclosure Time Requested Lead to 1 Apologies Note 9.30 am

2 Quoracy Note

3 Patient Story Note 9.35 am 10 mins 4 Declarations of Interest relevant to the Assurance GB/Pu 19/03/04 9.45 am agenda Nick Balac 5 mins

5 Patient and Public Involvement Activity Assurance GB/Pu 19/03/05 9.50 am Report Chris Millington 10 mins

6 Minutes of the meeting held on 10 January Approval GB/Pu 19/03/06 10.00 am 2019. Nick Balac 5 mins

7 Matters Arising Report Note GB/Pu 19/03/07 10.05 am Nick Balac 5 mins

Strategy

8 Chief Officers Report Approval GB/Pu 19/03/08 10.10 am Lesley Smith 10 mins

9 Primary Care Networks Information / Verbal 10.20 am Presentation Jeremy Budd 10 mins

10 Clinical Pharmacists Programme - Phase 2 Information GB/Pu 19/03/10 10.30 am Jeremy Budd 10 mins

11 Children’s Commissioning Report Assurance & GB/Pu 19/03/11 10.40 am Information Patrick Otway 10 mins

12 Transforming Care Update Assurance & GB/Pu 19/03/12 10.50 am Information Patrick Otway 10 mins

Page 1 of 3

13 South Yorkshire and Bassetlaw Approval GB/Pu 19/03/13 11.00 am Commissioning for Outcomes Policy Jeremy Budd 10 mins Adebowale Incorporating Evidence Based Intervention Adekunle Guidance

Quality and Governance

14 PDA Approval GB/Pu 19/03/14 11.10 am Jackie Holdich 10 mins Sudhagar Krishnasamy

15 Medicines Ordering – Safety and Waste Decision and GB/Pu 19/03/15 11.20 am Update Assurance Chris Lawson 10 mins

16 Clinical Forum Review 2018/19 Information GB/Pu 19/03/16 11.30 am Nick Balac 5 mins Jamie Wike 17 Quality Highlights Report Assurance GB/Pu 19/03/17 11.35 am Martine Tune 10 mins 18 Risk & Governance Exception Report Assurance GB/Pu 19/03/18 11.45 am Richard Walker 10 mins

Finance and Performance

19 Integrated Performance Report Assurance and GB/Pu 19/03/19 11.55 am Information Roxanna Naylor 5 mins Jamie Wike

20 QIPP Programme Reporting Assurance and GB/Pu 19/03/20 12.00 noon Information Jamie Wike 5 mins

Committee Reports and Minutes

21 21.1 Minutes of the Finance and Assurance GB/Pu 12.05 pm Performance Committee Meeting 19/03/21.1 10 mins held on: Nick Balac  3 January 2019  7 February 2019

21.2 Minutes of the Audit Committee Held Assurance GB/Pu on 24 January 2019 19/03/21.2 Nigel Bell 21.3 Minutes of the Quality and Patient Assurance GB/Pu safety Committee held on 13 19/03/21.3 Sudhagar December 2018 Krishnasamy

21.4 Minutes of the Membership Council Assurance GB/Pu held on 22 January 2019 19/03/21.4 Nick Balac

21.5 Assurance Report of the Primary Assurance GB/Pu Care Commissioning 29 November 19/03/21.5 2018 & 31 January 2019 Chris Millington

Page 2 of 3

21.6 Minutes of the Equality and Assurance GB/Pu Engagement Committee held on 15 19/03/21.6 November 2018 Chris Millington

22 Questions from the Public on Barnsley Note Nick Balac 12.15 pm Clinical Commissioning Group business 10 mins

23 Reflection on how well the meeting’s Assurance Nick Balac 12.25 pm business has been conducted: 5 mins  Conduct of meetings  Any areas for additional assurance  Any training needs identified

General

24 Date and time of the next meeting: 12.30 pm Thursday 9 May 2019 at St John and St Close Mary Magdalene Church Parish Hall, Lockwood Road, Goldthorpe, S63 9JY

Signed

Dr Nick Balac – Chairman

Exclusion of the Public:

The CCG Governing Body should consider the following resolution: “That representatives of the press and other members of the public be excluded from the remainder of this meeting due to the confidential nature of the business to be transacted - publicity on which would be prejudicial to the public interest” Section 1 (2) Public Bodies (Admission to meetings) Act 1960

Page 3 of 3

GB/Pu 19/03/04

GOVERNING BODY

14 March 2019

Declarations of Interests, Gifts, Hospitality and Sponsorship Report

PART 1A – SUMMARY REPORT

1. THIS PAPER IS FOR

Decision Approval Assurance x Information

2. REPORT OF

Name Designation Executive Lead Richard Walker Head of Governance & Assurance Author Paige Dawson Governance, Risk & Assurance Facilitator

3. EXECUTIVE SUMMARY

Conflicts of interest are defined as a set of circumstances by which a reasonable person would consider that an individual’s ability to apply judgement or act, in the context of delivering, commissioning, or assuring taxpayer funded health and care services is, or could be, impaired or influenced by another interest they hold.

The table below details what interests must be declared: Type Description

Financial interests Where individuals may directly benefit financially from the consequences of a commissioning decision e.g., being a partner in a practice that is commissioned to provide primary care services;

Non-financial professional Where individuals may benefit professionally from the interests consequences of a commissioning decision e.g., having an unpaid advisory role in a provider organisation that has been commissioned to provide services by the CCG;

Non-financial personal Where individuals may benefit personally (but not professionally interests or financially) from a commissioning decision e.g., if they suffer from a particular condition that requires individually funded treatment;

Indirect interests Where there is a close association with an individual who has a financial interest, non-financial professional interest or a non- financial personal interest in a commissioning decision e.g., spouse, close relative (parent, grandparent, child, etc.) close friend or business partner.

1 GB/Pu 19/03/04 Appendix 1 to this report details all Governing Body Members’ current declared interests to update and to enable the Chair and Members to foresee any potential conflicts of interests relevant to the agenda. In some circumstances it could be reasonably considered that a conflict exists even when there is no actual conflict.

Additions / Removals The Managing Conflicts of Interest Guidance states that expired interests can be removed after 6 months. The Corporate Affairs Team will ask members for their approval to remove declarations from the register. All previous registers are retained in the CCG Register of Interest archive.

There has been an update in relation to the Lay Member for Patient and Public Engagement & Primary Care Commissioning.

There have been no other additions or removals to the Governing Body Declarations of Interest since the last meeting held on 10 January 2019.

Members should also declare if they have received any Gifts, Hospitality or Sponsorship.

4. THE GOVERNING BODY IS ASKED TO:

 Note the contents of this report and declare if Members have any declarations of interest relevant to the agenda or have received any Gifts, Hospitality or Sponsorship.

5. APPENDICES

 Appendix 1 – Governing Body Members Declaration of Interest Report

Agenda time allocation for report: 5 minutes

2 GB/Pu 19/03/04 PART 1B – SUPPORTING INFORMATION

1. Links to the Governing Body Assurance Framework Risk ref(s) This report provides assurance against the following risks on n/a the Governing Body Assurance Framework:

2. Links to CCG’s Corporate Objectives Y/N To have the highest quality of governance and processes to Y support its business To commission high quality health care that meets the needs of individuals and groups Wherever it makes safe clinical sense to bring care closer to home To support a safe and sustainable local hospital, supporting them to transform the way they provide services so that they are as efficient and effective as possible for the people of Barnsley To develop services through real partnerships with mutual accountability and strong governance that improve health and health care and effectively use the Barnsley £. 3. Governance Arrangements Checklist 3.1 Financial Implications Has a financial evaluation form been completed, signed off NA by the Finance Lead / CFO, and appended to this report?

3.2 Consultation and Engagement Has Comms & Engagement Checklist been completed? NA

3.3 Equality and Diversity Has an Equality Impact Assessment been completed and NA appended to this report?

3.4 Information Governance Have potential IG issues been identified in discussion with NA the IG Lead and included in the report? Has a Privacy Impact Assessment been completed where NA appropriate (see IG Lead for details)

3.5 Environmental Sustainability Are any significant (positive or negative) impacts on the NA environment discussed in the report?

3.6 Human Resources Are any significant HR implications identified through NA discussion with the HR Business Partner discussed in the report?

GB/Pu 19/03/04.1

NHS Barnsley Clinical Commissioning Group Register of Interests This register of interests includes all interests declared by members and employees of Barnsley Clinical Commissioning Group. In accordance with the Clinical Commissioning Group’s Constitution the Clinical Commissioning Group’s Accountable Officer will be informed of any conflict of interest that needs to be included in the register within not more than 28 days of any relevant event (e.g. appointment, change of circumstances) and the register will be updated as a minimum on an annual basis.

Name Current position (s) Declared Interest held in the CCG

Adebowale GP Governing Body  GP Partner at Wombwell Chapelfields Medical Centre Adekunle Member

 The practice is a member of Barnsley Healthcare Federation which may provide services for Barnsley CCG

 Clinical sessions with Local Care Direct Wakefield

 Clinical sessions at IHeart

 Member of the British Medical Association

 Member Medical Protection Society

GB/Pu 19/03/04.1

Name Current position (s) Declared Interest held in the CCG

Nick Balac Chairman  Partner at St Georges Medical Practice (PMS)

 Practice holds AQP Barnsley Clinical Commissioning Group Vasectomy contract

 Member of the Royal College of General Practitioners

 Member of the British Medical Association

 Member of the Medical Protection Society

 The practice is a member of Barnsley Healthcare Federation which may provide services for Barnsley CCG

 Two Partners at St Georges Medical Practice (PMS) are Partners on the Practice Contract at Kingswell Surgery (PMS).

Nigel Bell Lay Member -  Ad hoc provision of Business Advice through Gordons LLP Governance

Mehrban Medical Director  GP Partner at The Rose Tree Practice trading as the White Rose Medical Practice, Cudworth, Barnsley Ghani (on secondment)  GP Appraiser for NHS England

GB/Pu 19/03/04.1

Name Current position (s) Declared Interest held in the CCG

 Directorship at SAAG Ltd, 15 Newham Road, Rotherham

 The practice is a member of Barnsley Healthcare Federation which may provide services for Barnsley CCG

Madhavi GP Governing Body  GP partner at The Grove Medical Practice Guntamukkala Member (on secondment)  Husband is a partner at The Grove Medical Practice and Lakeside Surgery

 Member of the Royal College of General Practitioners

 Member of the British Medical Association

 The practice is a member of Barnsley Healthcare Federation which may provide services for Barnsley CCG

John Harban GP Governing Body  GP Partner at Lundwood Medical Centre and The Kakoty Practice, Barnsley Member

 AQP contracts with the Barnsley Clinical Commissioning Group to supply Vasectomy, Carpal Tunnels and Nerve Conduction Studies services

GB/Pu 19/03/04.1

Name Current position (s) Declared Interest held in the CCG

 Owner/Director Lundwood Surgical Services

 Wife is Owner/Director of Lundwood Surgical Services

 Member of the Royal College of General Practitioners

 Member of the faculty of sports and exercise medicine (Edinburgh)

 The practice is a member of Barnsley Healthcare Federation which may provide services for Barnsley CCG

 Chair of the Remuneration Committee at Barnsley Healthcare Federation

M Hussain GP Governing Body  GP Partner in Hollygreen Practice Kadarsha Member

 Director of FGGP which hold the PMS contract for Dodworth Medical Practice

 The practice is a member of Barnsley Healthcare Federation which may provide services to Barnsley CCG

 Member of the British Medical Association

GB/Pu 19/03/04.1

Name Current position (s) Declared Interest held in the CCG

 Director of YAAOZ Ltd, with wife

Sudhagar Associate Medical  GP Partner at Royston Group Practice, Barnsley Krishnasamy Director

 Member of the Royal College of General Practitioners

 GP Appraiser for NHS England

 Member of Barnsley LMC

 Member of the Medical Defence Union

 Director of SKSJ Medicals Ltd

 Wife is also a Director

 The practice is a member of Barnsley Healthcare Federation which may provide services for Barnsley CCG

 Undertakes sessions for IHeart Barnsley

GB/Pu 19/03/04.1

Name Current position (s) Declared Interest held in the CCG

Jamie Governing Body  GP Partner at Dove Valley Practice MacInnes Member

 Shareholder in GSK

 3A Honorary Senior Lecturer

 Wife is a T/L Fellow Oncoplastic / breast trainee but applying for a Consulting Post

Chris Lay Member  Partner Governor Barnsley Hospital NHS Foundation Trust (ceased July 2018) Millington  Partner Governor Barnsley Hospital NHS Foundation Trust (since 6 February 2019)

Roxanna Chief Finance Officer  Partner works at NHS Leeds Clinical Commissioning Group. Naylor

Mike Simms Secondary Care  Provider of Corporate and Private healthcare and delivering some NHS Contracts. Clinician

Mark Smith GP Governing Body  Senior Partner at Victoria Medical Centre also undertaking training and minor surgery roles. Member

 Director of Janark Medical Ltd

Lesley Smith Governing Body  Husband is Director/Owner of Ben Johnson Ltd a York based business offering office interiors solutions, Member furniture, equipment and supplies for private and public sector clients potentially including the NHS.

GB/Pu 19/03/04.1

Name Current position (s) Declared Interest held in the CCG

 Member of the Regional Leadership Council (RLC), Yorkshire and Humber Leadership Academy, Health Education England

 Chair, South Yorkshire Cancer Alliance

 Deputy Lead SYB, Integrated Care System

 Chief Executive Lead for Strategy, Planning and Transformation SYB, Integrated Care System

Martine Tune Chief Nurse (Acting)  Works on an ad-hoc basis for the Care Quality Commission as a Specialist Advisor.

 Husband is an employee of Rotherham NHSFT at the middle manager level.

Sarah Tyler Lay Member for  Volunteer Governor / Board Member, Northern College Accountable Care

 Voluntary trustee / Board Member for Steps (community care provider for early years / nursery)

 Interim Health Improvement Specialist for Wakefield Council (ceased July 2018)

 Quality For Health Manager, Voluntary Action Calderdale (VAC) in partnership with the Calderdale Clinical Commissioning Group

7 GB/Pu 19/03/05

Governing Body

14 March 2019

Patient and Public Involvement Activity Report

1. THIS PAPER IS FOR

Decision Approval Assurance x Information

2. REPORT OF

Name Designation Executive Lead Lesley Smith Chief Officer Presenting Chris Millington Lay Member for patient and public engagement

3. EXECUTIVE SUMMARY

We have asked local stakeholders to review our Patient and Public Involvement Strategy. The existing strategy was developed in collaboration with the Patient Council members and other stakeholder back in 2016.

Having shared the strategy for review in 2018, some minor amendments have been made following the feedback received. This includes acknowledging the emergence of the South Yorkshire and Bassetlaw Integrated Care System and the strengthened collaborative approach of involvement by partners in Barnsley. The Patient Council were keen to keep the guiding principles as they are and felt they were still current. The strategy was approved at the CCG Engagement and Equality Committee in February 2019.

We are progressing work with partners in the Dearne area to develop a community engagement champion model where local residents will be the ones who lead the conversations to shape the wider health and wellbeing plans for that area.

4. THE GOVERNING BODY IS ASKED TO:

 Note the updated CCG Patient and Public Involvement Strategy 19/21.  Note the content of the report.

Agenda time allocation for report: 10 minutes

1 GB/Pu 19/03/05 PART 1B – SUPPORTING INFORMATION

1. Links to the Governing Body Assurance Framework Risk ref(s) This report provides assurance against the following risks on 1.2 the Governing Body Assurance Framework: 2. Links to CCG’s Corporate Objectives Y/N To have the highest quality of governance and processes to Y support its business To commission high quality health care that meets the needs of Y individuals and groups Wherever it makes safe clinical sense to bring care closer to Y home To support a safe and sustainable local hospital, supporting Y them to transform the way they provide services so that they are as efficient and effective as possible for the people of Barnsley To develop services through real partnerships with mutual Y accountability and strong governance that improve health and health care and effectively use the Barnsley £. 3. Governance Arrangements Checklist 3.1 Financial Implications Has a financial evaluation form been completed, signed off by N the Finance Lead / CFO, and appended to this report? Are any financial implications detailed in the report? NA

3.2 Consultation and Engagement Has Comms & Engagement Checklist been This paper is for completed? assurance and there are no engagement requirements. Is actual or proposed engagement activity set out in Yes. the report?

3.3 Equality and Diversity Has an Equality Impact Assessment been completed and appended NA to this report?

3.4 Information Governance Have potential IG issues been identified in discussion with the IG NA Lead and included in the report? Has a Privacy Impact Assessment been completed where NA appropriate (see IG Lead for details)

3.5 Environmental Sustainability Are any significant (positive or negative) impacts on the environment NA discussed in the report?

3.6 Human Resources Are any significant HR implications identified through discussion with NA the HR Business Partner discussed in the report?

2 GB/Pu 19/03/05 PART 2 – DETAILED REPORT

1 INTRODUCTION

This report gives an overview of our recent and future patient and public involvement activity in Barnsley CCG.

1.1 CCG patient and Public Involvement Strategy 2019 – 2021

We have been inviting comments on the refresh of the CCG’s patient and public involvement strategy.

The strategy, which was developed in collaboration with the Barnsley patient Council and shared with wider stakeholders, patients and public for their views, has now been refreshed. It was approved by the CCG engagement and equality in February 2019 (Appendix 1).

The following guiding principles were originally developed in 2016 in collaboration with members of the Barnsley Patient Council. This was in additional to input from colleagues working within the field of engagement from some of our local partner organisations, who reflected the feedback they had received from local patients and the public.

These principles have been revisited and reaffirmed during a workshop session held with Patient Council members as part of the refresh.

 We understand that it is easier to hear some voices than others and we are keen to engage with a more diverse group of patients and public, particularly those who have traditionally been less engaged. We will work with our partners across health and social care alongside patient groups, and local voluntary, faith and community groups to achieve this.

 “More integration/co-operation across services/borders” - We do not want to duplicate the work of other organisations and we are committed to working in partnership to increase our reach and maximise our collective resources and networks wherever it is possible and appropriate to do so.

 “Don’t expect people to always come to you” - We want to build ongoing relationships with local people and organisations and be more systematic in how we involve patients in decision making across whole of the commissioning cycle in a timely fashion.

 We understand that there are many voices and views in Barnsley. In making commissioning decisions, we must ensure that we maintain a balance between the range of views expressed alongside clinical effectiveness and financial implications. We will always aim to be open and transparent about our decision making and justify how we reach decisions that reflect this.

 “I’m a part-time patient but a full time person” - We will work towards creating an environment in which people are empowered to be equal partners in managing their own health and wellbeing and understand how to access the services and tools that they need to enable them to do so.

3 GB/Pu 19/03/05  Importance of carer/family views in addition to patients and service users - We will ensure that feedback from patients and carers helps to improve the quality and safety of local services. We will listen to patient and carer stories and experiences and ‘walk’ the patient journey in order to gain a full picture of the quality of local services to provide us with a starting point in terms of any service development.

 “Don’t use jargon – be clear about what you are asking and why” - We will be clear about when we are ‘communicating’ information and when we are ‘engaging’ and ‘consulting’ and the differences between these.

 We will strive to effectively manage expectations by being open and up front about what each engagement and/or consultation process can achieve and will feedback the results publicly to all who took part. If for any reason we cannot meet the requirements asked of us, we will explain why.

 “Learn from the good” - We will utilise and share best practice in terms of what works well in relation to engagement activities/ methods.

2 INVOLVEMENT ACTIVITY

How public and patient involvement is influencing the decisions we make.

Activity Outcomes/findings Volunteer community Volunteers would be asked to commit typically champions - Dearne around two hours per week. The main part of this role will be to seek the views of local The Dearne residents in relation to the set priorities. The two neighbourhood team, priorities for the task group over the next six (which we are a part of), is months will be young people and emotional well- recruiting community being. champions to work alongside us in developing The community champions will be based in local health and social care services, attend local groups/ events and other services in the Dearne areas which have the biggest footfall in the area. area. This will all be overseen and coordinated by the neighborhood task group and area team. Community champions will be right at the heart of The community champions will also receive influencing changes to the support and training in relation to this role and way services are offered. attend the neighbourhood task group in order to provide updates.

As they collect ideas and insights from local residents, we will report these back through our regular updates on integrating care in Barnsley.

Evaluation of changes to We have been working with our local GP the way people order practices over the past year to put in place a their repeat change to how some people order their repeat prescriptions. prescriptions.

4 GB/Pu 19/03/05 This is being rolled out across Barnsley and we are now asking patients in the practices which have made the changes, what they think of the changes.

NHS Long Term Plan and Over the coming weeks and months we’ll be Barnsley CCG plan for talking patients, the public, to staff and other 19/20 stakeholders about the NHS Long Term Plan means for Barnsley.

This will help shape our commissioning plans for 2019/20 and beyond. This will include conversations on integrating care across Barnsley.

This will include the work that has been taking place in collaboration with partners and residents in the Dearne and looking at how that model might work across the rest of the borough.

Healthwatch England and Age UK have been appointed nationally to carry out some of these conversations locally and collect people’s views.

5 Appendix 1

NHS Barnsley Clinical Commissioning Group

Patient and Public Involvement Strategy

2019 – 2021

NHS Barnsley Clinical Commissioning Group (CCG) Patient and Public Engagement (PPE) Strategy 2019 – 2020

1 Appendix 1

Final version approved by the CCG Equality and Engagement Committee on 14 February 2019

Contents Page

1. Introduction to our refreshed strategy 3

2. Why is patient and public engagement important to us? 3-4

3. National context, legal framework and drivers for engagement 4-5

4. Guiding principles 6-7

5. The changing structures in health and care locally 9

6. The Engagement Cycle 10-11

7. How you can help us and give your views on NHS health services in 12-14 Barnsley

8. How will we review how we are getting on? 15

9. Associated Strategies 15-16

10. What do you think of our strategy? 16

Appendix 1 - Engagement Expenses Reimbursement, Payments for 17-18 patients and members of the Public

2 Appendix 1

1. Introduction to our refreshed strategy

This is a refreshed version of our Patient and Public Involvement Strategy which incorporates recent and emerging changes to structures, at both a Barnsley and South Yorkshire and Bassetlaw level in relation to the partnership work taking place to integrate heath and care across both Barnsley (place) and South Yorkshire and Bassetlaw (system).

This strategy outlines how we are committed to engaging, involving and consulting with a wide range of audiences, using the most appropriate tools and techniques. It also reaffirms publicly our commitment as an organisation to patient and public engagement and how we aim to deliver on this.

Much of this strategy is based on the previous version that was developed in 2016 alongside our patient council members, staff and local partners. Within this refreshed version, we set out our main aims for effective patient and public engagement, reiterate our guiding principles for this, and describe why this work is so important.

We know that the NHS faces some real challenges, but as a Clinical Commissioning Group (CCG) we are committed to working with our local health and care partners towards collective solutions across the borough.

2. Why is patient and public engagement important to us?

Introduction

‘The Government aims for there to be “no decision about me, without me” for patients and their own care. The same goes for the design of health and social care services at both a local and a national level’. 1

In order to effectively plan and buy the right services on behalf of our local community, we need to find out the views and experiences of members of the public, patients, and their carers, including those people who are less likely to speak up for themselves.

As the people who use and pay for the local NHS, it is really important for us to hear comments, experiences, ideas and suggestions from local people from across Barnsley about the ways in which we can develop and improve services to benefit our local communities.

1 https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/138262/B3.-Factsheet- Greater-voice-for-patients-300512.pdf

3 Appendix 1

CCGs who engage with their local community and build the feedback and views they gain from this into their commissioning decisions will be better placed to offer services that respond to the needs of local people and are accountable.

Patient and public engagement is the active participation of patients (also often referred to as service users), carers, community groups and the general public in how our health and well-being services are planned, delivered and evaluated. This can range from an individual conversation to working with a particular population group. It is broader and deeper than traditional consultation and the giving of information. Effective patient and public engagement leads to improvements in health services, and is part of everyone’s role in the NHS; ‘every interaction counts!’

We will be able to better meet people’s needs if we listen to what people tell us, instead of relying on existing knowledge and assumptions. We can develop improved, more responsive services if we involve and truly listen to not only those who are already using services, but also those who are not.

As an organisation we are committed to ensuring that meaningful engagement with patients, carers and the public is at the heart our decision making process. Through effective commissioning we want to deliver high quality and safe services that meet the needs of Barnsley people.

We want to develop an organisation where everyone recognises and promotes the value of involving patients and the public, and their role in commissioning and improving services.

Both the previous strategy which ran from 2016 - 2018 and this refreshed version have been developed in partnership with members of the Barnsley Patient Council and with input from our staff and local partners working within health and social care organisations across Barnsley.

3. National context, legal framework and drivers for engagement

Involving people in health and care guidance

Patient and public participation in commissioning health and care: statutory guidance for CCGs and NHS England and Involving people in their own health and care: statutory guidance for CCGs and NHS England sets out the context, benefits and principles of involving people in health and care, the relevant legal duties and key actions for CCGs and NHS England.

The two sets of guidance supersede the original ‘Transforming Participation in Health and Care’ guidance, which was published in 2013.

In brief our engagement responsibilities as a Clinical Commissioning Group (CCG) are as follows:

4 Appendix 1

 Ensuring that patients, carers and the public have opportunities to be involved in the commissioning of health services;

 Ensuring that consultation and engagement around service changes and developments is carried out to an appropriate level to meet legal requirements;

 Supporting the collection, collation and dissemination of patient experience data and ensuring that it feeds into patients’ engagement;

 Promoting patient choice;

 Promoting each patient’s involvement in decision about their own care;

 Building and protecting the relationship of the local NHS;

 Building effective relationships with staff, public, patients, carers, partners and the media;

 Providing different ways in which patients, carers, the public and partners can share their views;

 Ensuring the provision of information for patients is appropriate and timely; and that local information will aid the implementation of these roles and responsibilities, with particular attention being paid to the equality agenda and the information highlighted in the Barnsley Joint Strategic Needs Assessment

Service reconfiguration and consultation

Any public body wishing to make major changes to services (service reconfiguration) has a statutory duty to involve those who will potentially be impacted by the change. As defined within the latest statutory guidance; this could be by being consulted, or provided with information etc. This refers to Section 14Z2 of the NHS Act 2012.

In recent years, there has been an increasing focus on this duty. The most recent statutory guidance for CCGs offers additional clarity, strengthening the focus on and need for public and patient engagement that is both appropriate and proportional to any service change.

Our aim is that any service change is informed by patient views and experience, with conversations taking place from the start between all stakeholders identified.

5 Appendix 1

4. Guiding principles

“It’s not about how much it costs to engage people; it’s about how much it costs if you don’t engage people: How much does it cost if the CCG commissions things wrongly? If it doesn’t benefit patients/service users it costs financially but also in terms of patients not getting the right service!”

Barnsley Patient Council Member

The following guiding principles or aims and objectives were originally developed in 2016 in conjunction with members of the Barnsley Patient Council, CCG staff and with input from colleagues working within the field of engagement from some of our local partner organisations.

These principles have been revisited and reaffirmed during a workshop session held with Patient Council members as part of the refresh at the end of 2018.

 “I’m a part time patient but a full time person” - We will work towards creating an environment in which people are empowered to be equal partners in managing their own health and wellbeing and understand how to access the services and tools that they need to enable them to do so.

 Importance of carer/family views in addition to patients and service users - We will ensure that feedback from patients and carers helps to improve the quality and safety of local services. We will listen to patient and carer stories and

6 Appendix 1

experiences and ‘walk’ the patient journey in order to gain a full picture of the quality of local services to provide us with a starting point in terms of any service development.

 We will strive to effectively manage expectations by being open and upfront about what each engagement and/or consultation process can achieve and will feedback the results publicly to all who took part. If for any reason we cannot meet the requirements asked of us, we will explain why.

 “Learn from the good” - We will utilise and share best practice in terms of what works well in relation to engagement activities/ methods.

To help to achieve our aims, we will continue to develop and utilise the following groups/mechanisms;

 CCG Equality and Engagement Committee - this is our internal assurance committee which meets bi-monthly as a sub-committee of our Governing Body. This committee is chaired by our CCG Lay Member for Patient and Public Engagement and takes part in discussions regarding the work of the CCG, oversees our communications, engagement and equality activities and forward plans, and seeks to provide assurance to our Governing Body that we meet our statutory duties in terms of engagement and equality.

The Equality and Engagement Committee oversees our internal processes of undertaking both Equality Impact Assessments and Patient and Public Participation Assessment Forms to help shape our equality and engagement work in relation to each piece of work undertaken by the CCG.

 We encourage people who want to work with us in the development of new and existing services to join our public membership database – OPEN (Our Public Engagement Network). The title reflects the culture that we strive for: to be OPEN about our ambitions and challenges, as well as being OPEN to ideas, and OPEN to unlimited membership. We contact people on this database whenever there’s an opportunity for them to get involved and will also provide them with periodic members’ newsletters. Involvement opportunities can range from being part of a discussion group, completing a questionnaire, joining a service user group or telling us what they think about local services. For more information regarding this please visit the ‘get involved’ section on our website at www.barnsleyccg.nhs.uk

 Local GP Practice Patient Reference Groups (PRGs) – PRGs are groups of patients interested in health and healthcare issues, who want to get involved with and support the running of their local GP Practice.

7 Appendix 1

Most PRGs also include members of practice staff, and meet at regular intervals to decide ways and means of making a positive contribution to the services and facilities offered by the practice to its patients. The activities of PRGs vary because they develop to meet the local needs within their area.

 Barnsley Patient Council – The Patient Council is made up of Barnsley residents who are also members of OPEN and/or their local GP Patient Reference Group. They meet every month (with the exceptions of August and December) on a Wednesday evening between 6pm and 7:30pm.

The purpose of the Patient Council is to ensure that the people, communities and populations served by the CCG have a voice which is heard and wherever possible, responded to, in the development and delivery of services. The members work with the CCG to improve health care services and to ensure high quality and sustainable health care by putting the people of Barnsley first. They also helped to co-develop the guiding principles for this strategy.

Members of the Patient Council provide feedback to their local PRGs and vice versa in relation to their respective activities.

 Healthwatch Barnsley - Healthwatch is the independent health and care champion created to gather and represent the views of the public in relation to health and social care.

Healthwatch plays a role at both a national (via Healthwatch England) and local level and aims to ensure that the views of the public and people who use health and social care services are taken into account by both the Providers and Commissioners of local services. Further information regarding your local Healthwatch can be found by visiting their website at the following address; www.healthwatchbarnsley.co.uk

 South Yorkshire and Bassetlaw Engagement Leads Network – the aim of this group, which meets on a quarterly basis, is to bring together colleagues working within the field of patient, service user, public and carer engagement across predominantly CCGs working within our region in order to discuss and share ideas/ areas of best practice, potential areas for joint working and provide peer support.

 Barnsley Engagement Networks - To support the wider partnership arrangements and strengthen the engagement and equality work delivered by the CCG, Barnsley Council and the wider voluntary and community sector, the CCG provides a financial contribution to the local authority.

8 Appendix 1

5. The changing structures in health and care locally

A key focus both across Barnsley and across our wider region of South Yorkshire and Bassetlaw is about integrating health and care services.

The Barnsley Plan - Health and Care Working Together across Barnsley

The Barnsley Plan has been developed through partnership across the public sector and voluntary community sector organisations.

It draws on inputs through the engagement and design of our health and care services as well the priorities set out in key documents including the Barnsley Health and Wellbeing Strategy, the Five Year Forward View, GP Forward View, Mental Health Forward View, Facing the Future and National Cancer Strategy.

The development of the plan has been overseen and driven via the Barnsley Senior Strategic Development Group and is one part of the delivery model for the Health and Wellbeing Strategy for Barnsley

South Yorkshire and Bassetlaw Integrated Care System (ICS)

In order to avoid duplication, reduce inequalities and increase efficiency across South Yorkshire and Bassetlaw, NHS Barnsley CCG works within an Integrated Care System (ICS) responsible for looking after the health and care of the 1.5 million people living in Barnsley, Bassetlaw, Doncaster, Rotherham and Sheffield.

The ICS is made up of 23 organisations from the NHS, local authorities and key voluntary sector and independent partners in the region, to ensure health and care services are the best they can possibly be. Working together in this way means that we will be able to better join up GPs and hospitals, physical and mental healthcare, social care and the NHS and give our patients the seamless care they have told us they want.

The ICS has separate structures for communication and engagement, with which Barnsley staff work closely and in partnership for campaigns and events. There is also a Citizens Panel that considers and advises on specific issues and work streams, and includes representatives from all the areas, including Barnsley.

Further details regarding the South Yorkshire and Bassetlaw Integrated Care System can be found at www.healthandcaretogethersyb.co.uk

9 Appendix 1

6. The Engagement Cycle

The Engagement Cycle was developed by InHealth Associates on behalf of the Department of Health and shows how involvement can and should be a continuous process in planning and commissioning services. It shows how involvement activity and shared decision making help us to commission services that work for our local communities and that provide value for money.

We want to show clearly how we plan to engage with patients and the public in a more systematic way; showing where and how people and groups can contribute and how their views will be used by the CCG to improve services and make commissioning decisions.

To try to demonstrate this, we have used the engagement cycle tool and tailored this for Barnsley

7. How you can help us and give your views on NHS health services in Barnsley?

GIVE YOUR COMMENTS

 Share your experiences of health services in Barnsley

How you do this will depend on the service:

 Your GP practice: through your Patient Reference Group (PRG) or via the receptionist or practice manager. You can also answer the ‘friends and family’ short questionnaire that is often either found in the waiting area or sent via text message.

 Barnsley Hospital: through the hospital’s Patient Advice and Complaints Team. Contact details for Barnsley Hospital can be found here: http://www.barnsleyhospital.nhs.uk/feedback/

 Hospital in-patient services: by answering the ‘Friends and Family’ question after you have stayed in Barnsley Hospital. Patients will be asked whether they would recommend hospital services to their friends and family if they needed similar care or treatment. We will be monitoring our local hospital on the answers that patients give to this question.

 Mental Health and Community Health Services such as district nursing and physiotherapy: via South West Yorkshire Partnership NHS Foundation Trust (SWYPFT) (SWYPFT provides the majority of these services for Barnsley residents). Contact details for their customer services team can be found on their website: http://www.southwestyorkshire.nhs.uk/service-users-and-carers/help- and-advice/customer-services/

 You can also send the CCG your comments through our website: http://www.barnsleyccg.nhs.uk/about-us/feedback-and-enquiries.htm

 Tell Healthwatch Barnsley about your experience of the quality of local services

Healthwatch Barnsley is independent from the health and social care services you use. Their job is to ensure that local people’s views are heard in order to improve the experience and outcomes for people who use local services. They will also help to monitor the quality of services.

We meet regularly with Healthwatch Barnsley to hear the local people’s views that they have collected.

How? For further information please visit the Healthwatch Barnsley website at www.healthwatchbarnsley.co.uk or call 01226 320106

 Ask us to visit your group

We will visit different community groups throughout the year to hear what their members think. We are particularly keen to hear from people who have traditionally not been engaged in local health services.

How? Invite us to visit your group by contacting the Communications and Engagement Team at [email protected] / 01226 433773.

 Join OPEN (Our Public Engagement Network)

You can join OPEN to receive regular news updates from the CCG. We will also use our website and news updates to advertise any consultations/ engagement opportunities that we are running or to ask for people’s feedback on specific issues e.g. through surveys.

How? Email us at [email protected] to be added to our mailing list.

GIVE SOME OF YOUR TIME

 Join your GP practice’s patient reference group (PRG)

A PRG is a group of patients who are interested in health and healthcare issues, and who want to get involved with and support the running of their local GP practice.

Most groups also include members of practice staff, and meet at regular intervals to discuss how to make a positive contribution to the services and facilities offered by the practice to its patients. It is a requirement for all GP practices to have some form of patient group which meets either in person or is linked into the practice virtually. We will be working with local practices to help and support them to develop their groups going forwards to help them reach their full potential.

Some PRG members also link into the CCG Patient Council. The Patient Council is made up of representatives from PRGs and from OPEN. The group meets for ten months of the year and helps us to develop our plans. The Patient Council also shares with us information about the quality of local services using information from their PPG.

How? Ask at your GP practice reception for further information about your practice patient group and how you can get involved.

 Come along to our bi-monthly Governing Body meetings held in public and our themed engagement events

Our Governing Body now meets bi-monthly and the agenda and papers can be accessed via the about us section on our website. Members of the public are encouraged to attend. If you would like more information regarding the Governing Body meetings please call us on 01226 433791. 13

We always start our meetings with a patient story, something which reflects the experiences of the people who are using health and care services, from their point of view. We use these stories to bring the patient voice into the discussions and decisions we make as a CCG. You can see films of the patient stories from previous Governing Body meetings by visiting the Governing Body section of our website at www.barnsleyccg.nhs.uk

We have a Patient and Public Involvement update as part of the agenda at each meeting to provide an overview of the activity that is both planned and has already taken place. We also have a section for members of the public to ask questions later on in the meeting as part of the agenda.

The venue of the meetings changes on a regular basis, so we can visit different areas of the borough and more people can attend the meetings.

We also hold engagement events throughout the year where local people can come along and tell us what they think about local services. These are often themed around a particular issue and are promoted via our website and social media channels along with via our networks and wider partners.

How? Meetings and events will be advertised on our website at www.barnsleyccg.nhs.uk and through our news updates and through our local partners.

 Be involved in the development of health services

When we are thinking about the services that we have commissioned and how they are working, we want to involve local people with experience of those services and people who are ‘expert patients’ (expert patients are people with a long-term condition like diabetes who are generally members of a peer support group).

This may be through involvement in working group meetings, via recruitment panels when interviewing new members of staff or through involvement on procurement panels when we are looking at finding providers for local services.

How? If you live in Barnsley and would like to be involved in helping to shape the services that we plan and buy and how they are run and monitored, please join OPEN to indicate your interest.

8. How will we review how we are getting on?

The CCG has established an Equality and Engagement subcommittee of the Governing Body which will meet quarterly and review how we are getting on with delivering our patient and public involvement strategy. We will also get feedback throughout the year from the Patient Council, OPEN network, GP Patient Groups Healthwatch Barnsley, patient and public surveys, our local partners and via our website and social media channels.

One of our key aims is to work with our partner organisations working across health and social care in Barnsley to develop a common way in which to measure the success of our engagement activities to help us to review how we are getting on.

In 2018, all CCGs were assessed using NHS England’s 10 principles of participation; Barnsley was assessed as ‘Good’ overall and we will strive to improve upon this going forwards. We will continue to use these guiding principles to underpin all our work.

9. Associated Strategies

 Equality, Diversity and Human Rights Policy

Equality is a legal principle to eliminate discrimination and promote equality of opportunity to people and groups. The Equality Act 2010 defines this protection based on protected characteristics. These are: race, sex, gender identity, age, sexual orientation, religion or belief, marriage and civil partnership and pregnancy and maternity.

We define diversity as the valuing of our individual differences and talents, and creating a culture where everyone can participate, thrive and contribute. Equality and diversity form the basis of our values and how we operate as an organisation.

Equality is relevant to everyone, not just certain groups of people. Everybody is protected under the Equality Act 2010 from discrimination or harassment, if this treatment is because of what is often referred to as a protected characteristic e.g. their gender, race, sexual orientation, religion, age, disability etc.

As part of the Public Sector Equality Duty, we are committed to embedding equality and diversity values into our policies, procedures, employment practice and the commissioning processes that secure health and social care for the people of Barnsley. Our Equality, Diversity and Human Rights Policy sets out our overarching aims to help us to achieve this.

 Barnsley Health and Wellbeing Strategy

As a member of Barnsley’s Health and Wellbeing Board, we are committed to working together with our local partners working across health and social care and the voluntary and community sector to improve the health and wellbeing of the people of Barnsley.

The associated Health and Wellbeing Strategy sets out how key health partners within the borough will work together to produce better health and wellbeing for the people of Barnsley.

One of its key objectives is to ensure the engagement of individuals and communities in helping inform and shape local health and social care policies and in holding services to account.

Further information can be found regarding the Health and Wellbeing Board via the Barnsley Metropolitan Borough Council website at www.barnsley.gov.uk or by clicking here

 Barnsley’s All – Age Mental Health and Wellbeing Strategy 2014- 2019

Mental health is everyone’s business - individuals, families, employers, educators and communities all need to play their part to improve the mental health and wellbeing of the people in Barnsley and to keep people well, by improving the outcomes for people with mental health problems.

This strategy describes the work that is needed over the next five years to ensure that the residents of Barnsley have improved mental health and where necessary receive the right support at the right time and in the right place to support them through to sustained recovery

Further information can be found via the Barnsley CCG website at www.barnsleyccg.bhs.uk or by clicking here

10. What do you think of our strategy?

This strategy has been developed following input from our Patient Council members, CCG staff, and colleagues from our local partner organisations and now we’d really like to hear what you think.

 After reading the strategy, do you understand how to get involved, including giving your feedback? Do you think we have missed anything from this strategy?

 Do you think our Barnsley engagement cycle diagram shows how we will continuously involve people in all we do?

Please send any comments and feedback to us via the following ways:

Via email: [email protected]

Write to: Communications and Engagement Team, NHS Barnsley CCG, FREEPOST RTCH-GAZH-TZJH, Hillder House, 49-51 Gawber Road, Barnsley, South Yorkshire, S75 2PY

Call us: 01226 433773

This information can be made available in alternative formats, such as easy read or large print, and may be available in alternative languages, upon request.

Please contact 01226 433773 or email [email protected]

Please note that this guidance is subject to review during 2019 in line with CCGs across South Yorkshire and Bassetlaw to develop and agree consistent guidance for use across our region.

APPENDIX 1

Engagement Expenses Reimbursement Payments for Patients and members of the Public

Although volunteering is unpaid, it should not cost a volunteer anything either. All patients, carers and the public asked to participate and be involved in the business of the CCG are entitled to claim out-of-pocket expenses. This would include reimbursement of costs such as:

 Mileage (45p per mile recommended by Volunteering England)  Public transport costs (including bus, rail and underground fares)  Associated parking costs (excluding parking/speeding fines)

The person claiming would be asked to complete and sign a short form and would be reimbursed in cash from a float.

Additional expenses incurred to enable a person to contribute could, with prior arrangement by the lead manager, include:

 Taxi fares (for a person unable to use other forms of transport and, where possible, booked via the CCG account)  Carer’s costs (in the case where a ‘sitting service’ is required, the full cost of the service will be reimbursed. In the circumstance where a paid personal assistant is required, the hours whilst at the meeting, together with the travel time from the patients house and back, will be reimbursed)  Subsistence costs (for people engaged with an activity for more than four hours. Maximum cost of reimbursement is £7.50)  Translation costs (including languages other than English, Braille, signer costs etc.)

If the cost of stationary and printer ink is prohibitive to a persons’ involvement, the offer will be made by the CCG to supply relevant information pre-printed rather than via online methods. The cost of telephone calls will be reimbursed when demonstrated via a bill.

When to claim? All expenses must be claimed within a three month period of the activity undertaken, unless in exceptional circumstances. In order for a person to claim their out of pocket expenses, a person will be asked to complete and sign a short form attach any receipts and have the form counter-signed by the relevant service lead who has arranged the engagement activity. The payment will then be made in line with the CCG financial procedures. 18

Expenses Claim Form

Name

Address

Phone number/ Email Address

What are you claiming for? e.g. travel to and from CCG engagement meeting on 14/11/18, care of a dependent (please give contact details of the carer)

How much are you owed? (45p per mile by car, bus fare etc.)

Is a receipt attached?

Signed

Date

For office use Date received Financial code

Date paid Payment Authorised

19 GBPu 19/03/06

Minutes of the meeting of the Barnsley Clinical Commissioning Group Governing Body (PUBLIC SESSION) held on Thursday 10 January 2019 at 9.30 am in the Boardroom, Hillder House, 49/51 Gawber Road, Barnsley, S75 2PY

MEMBERS PRESENT Dr Nick Balac Chairman Dr Adebowale Adekunle Member Nigel Bell Lay Member for Governance Dr John Harban Member Dr M Hussain Kadarsha Member Dr Sudhagar Krishnasamy Member & Associate Medical Director (from minute ref GB 19/01/11) Dr Jamie MacInnes Member Chris Millington Lay Member for Patient and Public Engagement & Primary Care Commissioning Roxanna Naylor Chief Finance Officer Mike Simms Secondary Care Clinician Lesley Smith Chief Officer Dr Mark Smith Member Martine Tune Chief Nurse (Acting) Sarah Tyler Lay Member for Accountable Care

IN ATTENDANCE Jeremy Budd Director of Commissioning Jackie Holdich Head of Delivery Integrated Primary / Out of Hospital Care Siobhan Lendzionowski Lead Commissioning and Transformation Manager (For minute reference GB 19/01/14 only) Kay Morgan Governance & Assurance Manager Patrick Otway Head of Commissioning (Mental Health, Children’s and Maternity) (For minute references GB 19/01/12 & GB 19/01/13 only) Kirsty Waknell Head of Communications and Engagement Richard Walker Head of Governance and Assurance Jamie Wike Director of Strategic Planning and Performance

APOLOGIES No Apologies

MEMBERS OF THE PUBLIC

Peter Deakin Member of the Public Nora Everitt Member of the Public Louisa Fletcher Member of the Public Alan Higgins Member of the Public Margaret Sheard Member of the Public

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GBPu 19/03/06 The Chairman wished everyone a Happy New Year and welcomed members of the public to the January 2019 meeting of the Governing Body.

Agenda Item Action Deadline

GB QUORACY 19/01/01 The meeting was declared quorate.

GB PATIENT STORY 19/01/02 The Governing Body received a patient story reflecting the experiences of a patient on the the two week cancer pathway. The patient was swiftly referred by the GP and received excellent care but contemplated that patients could have a better chance of being cured if they knew more about the signs/symptoms of cancer and consulted their GPs earlier.

The following comments were received in relation to the Patient Story:

 The two week cancer pathway enabled patients to be seen by cancer specialists in a very responsive time period.  The patient story illustrated the pivotal role of Primary Care in the early diagnosis of cancer. Practice receptionists were often the ‘first port of call for patients’ assisting patients to access the most appropriate services.  Talking therapies; the ‘My Best Life’ service, counselling services and speaking with other patients provided opportunities for patients to talk and gain other perspectives about their condition.  Healthcare professionals had an essential role in educating and encouraging patients to take up national cancer preventative screening programmes and also recognising the need to support carers who can put the health of the people they are caring for before themselves. It was highlighted that the way patients are invited to participate in cancer screening tests could affect take up rates.  It was noted that the Barnsley ‘Be Cancer Safe’ service provided by the Voluntary Sector aims to promote awareness about the signs and symptoms of cancer and the benefits of attending screening.

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GBPu 19/03/06 Agenda Item Action Deadline

A Member of the Public commended the work of the Limes Day Therapy Unit at the Barnsley Hospice which provided talking therapy services and in particular sessions for cancer patients.

The Chairman concluded the discussion, commenting that in this instance the human element i.e. the relationship between the patient and Practice receptionist as the first port of call had rapidly steered the patient on the right pathway to treatment.

The Governing Body noted the Patient Story.

GB DECLARATIONS OF INTEREST, SPONSORSHIP, 19/01/03 HOSPITALITY AND GIFTS RELEVANT TO THE AGENDA

The Governing Body considered the Declaration of Interests, Gifts, Hospitality and Sponsorship Report. No further declarations were received.

It was noted that GP Members will have an interest in agenda item 12 ‘PDA – Practice Delivery Agreement‘. The Chairman advised that this item was not for decision but discussion only, namely around the content of the PDA and determined therefore that GP members could therefore remain in the meeting and participate in the discussion.

The Head of Governance & Assurance advised that in order to facilitate the management of conflicts of interests, approval of the financial schedule and ongoing contractual management of the PDA would be undertaken by the Primary Care Commissioning Committee.

GB PATIENT AND PUBLIC INVOLVEMENT ACTIVITY 19/01/04 REPORT

The Head of Communications and Engagement introduced the Patient and Public Involvement (PPI) Activity Report to the Governing Body.

Arising from discussion, it was highlighted that the South Yorkshire and Bassetlaw Travel and Transport Advisory Panel should consider the Sheffield City Region Mayoral Combined Authority’s Transport Vision, travel boundaries

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and implications for Barnsley people.

The Chairman commented that the move to provide care closer to home and use of technology in healthcare may reduce the number of people travelling to hospitals.

Health Care Services for people who are blind or who have a visual impairment

The Head of Communications and Engagement reported that the Local Authority is undertaking further work on the findings of the review by Healthwatch Barnsley’s into the health and care services available for people who are blind or who have a visual impairment.

The Governing Body noted the report.

GB MINUTES OF THE PREVIOUS MEETINGS HELD ON 19/01/05 8 NOVEMBER 2018

The minutes of the previous meeting held on 8 November 2018 were verified as a correct record of the proceedings.

Minute reference GB/Pu 18/11/19 Questions from the Public Social Prescribing

The Lay Member for Accountable Care thanked the member of the member of public for informing the Governing Body about the extended social prescribing scheme in Oldham and reported that some good practice and learning had been identified from the Oldham scheme.

Minute reference GB/PU 18/11/09 Cancer Update

It was noted that a regional cancer website with local information was being developed. Dr John Harban proposed the re-instatement of the CCG Cancer Website.

GB MATTERS ARISING REPORT 19/01/06 The Governing Body considered the Matters Arising Report.

Minute reference GB 18/11/04 Patient and Public Activity Report

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GBPu 19/03/06 Agenda Item Action Deadline

A member of the public reported that Barnsley Save Our NHS were not aware of the CCG’s plans re consultation on Commissioning Intentions. The Head of Communications and Engagement advised that Barnsley Save Our NHS had been emailed about Commissioning Intentions but would further pick up this issue outside of the meeting. KW

Minute reference GB 18/11/07 Chief Officers Report – Bowel Cancer Prevention and Screening.

This action was deemed complete.

Minute reference GB 18/11/13 Commissioning of Children’s Services Monitoring Report

It was noted that the Commissioning of Children’s Services Monitoring Report to the March meeting of the Governing Body will include the ‘value for money’ aspects of the Therapy services and a proposed model of support for PO Practices around referrals.

STRATEGY

GB CHIEF OFFICER’S REPORT 19/01/07 The Chief Officer provided the Governing Body with a summary of key points for clinical commissioners about the recently-published NHS Long Term Plan. Discussion took place and the following main points were noted:

Chapter 1: Using new service models (‘A new Services for the 21st Century) - the network contract approach.

Dr John Harban expressed concern that one CCG covering an ICS footprint with a regional budget then sub areas for example Barnsley may start to lose control over locally provided services. It was clarified that there would have to be a local focus for local decision making with local leads working in close partnership with the Local Authority. The resource budget and allocation for each borough was based on Practice registered patient population and this equates to the Barnsley £ to provide services for the benefit of Barnsley people.

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GBPu 19/03/06 Agenda Item Action Deadline

Chapter 2: Preventing ill-health and reducing inequalities (‘More action on prevention and health inequalities’)

The chapter featured new funding streams. It was noted that this resource had not yet been received by the CCG as the CCG has not yet been notified of its allocations.

Chapter 7: Implementation (‘Next Steps’)

The Governing Body noted the potential legislative changes to accelerate integration.

The Chief Officer advised that Barnsley’s Commissioning Intentions were in alignment with the aims of NHS Long Term Plan.

The Governing Body was informed of a national move to enable newly qualified doctors and nurses to extend training straight into GP Practice or Practice Nurse training. It was noted that the CCG continued to support newly qualified GPs in Barnsley to develop their skills and competencies with the hope that these GPs will remain in Barnsley.

The Governing Body noted the summary report of the NHS Long Term Plan.

GB BARNSLEY INTEGRATED CARE UPDATE 19/01/08 The Director of Commissioning provided an update on the development of Integrated Care in Barnsley. The Governing Body considered the priorities determined from the Dearne Neighbourhood work stream stakeholder event held on 30 November 2018 as follows:

 Support for Parents and parental education – The Secondary Care Clinician reported that 26 different groups and 16 agencies provided support services for parents but some people were still unaware of these services. There is a challenge to co-ordinate and align all existing services.  Working with schools and pre-schools on ways to improve emotional wellbeing and resilience for children and young people. It was queried if this

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GBPu 19/03/06 Agenda Item Action Deadline

priority area will identify the hungry, cold, children living in poor housing conditions?  Community Engagement  Development of multidisciplinary team working that is flexible to meet the pattern of local need. – Dr John Harban suggested that Rightcare Barnsley could act as a central coordination point, co-ordinating and directing patients to the appropriate services.

The Chairman concluded the discussion, commenting that the outcome from the Dearne workshop provided a clear understanding of required priorities as seen by the frontline workforce and the general public. This was a significant shift from a purely medical model.

All six localities had scoped the services provided to patients in their areas and been surprised over the totality of services available for patients. The learning form the Dearne will be taken across the developing localities.

The Governing Body noted the report.

GB URGENT AND EMERGENCY CARE UPDATE 19/01/09 The Director of Strategic Planning and Performance introduced the Urgent and Emergency Care Update. The update provided the Governing Body with an overview position including; progress against the 2017-2019 Deliverables of the Next Steps on the NHS Five Year Forward View and the South Yorkshire and Bassetlaw Shadow ICS Programme Highlight Report for the Urgent and Emergency Care Network.

The Chief Officer highlighted that the decision taken by the Governing Body to support winter resilience was reaping rewards; Barnsley was performing well in terms of urgent and emergency care with performance of the system as at 31 December 2018 being 96.11%.

The Governing Body:

 Noted the current position and progress in delivering the Urgent Care Key Deliverables of the Next Steps on the NHS Forward View.

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 Ratified the urgent decision taken in relation to the procurement of a new integrated Urgent Care Services to begin in April 2019.

GB PRIMARY CARE UPDATE 19/01/10 The Head of Delivery (Integrated Primary and Out of Hospital Care) presented the Primary Care Update on the implementation for the GP Forward View (GPFV) and an overview of three priority areas for Primary Care:

1. Sustainability and Co-ordinated Recruitment 2. Home Visiting Service 3. Developing Integrated Care Networks

The Governing Body considered sustainability of and recruitment to Primary Care, and the following main points were noted:

 The APEX capacity / workforce tool was operational in one practice with five other practices interested in joining the pilot. Dr John Harban queried the cost to Practices for the tool once the pilot had ceased?

 The range of development and training opportunities available for Practice Managers with fifteen Practice Managers having attended the Practice Managers Leadership Development Programme.

 Barnsley CCG was positively exploring all options to attract, recruit, support and retain GPs and other healthcare professionals to work in Barnsley.

The Chairman advised that a multi skilled workforce approach to deliver Primary Care Services in Barnsley was required. Locums demanded high remuneration, the CCG could not indefinitely subsidise this additional and escalating cost for Practices. The Governing Body noted the contents of the report

Agreed Action:

To discuss the skills, competencies and roles of JHa/MT/ nursing staff required / available within the Practice JHo Team.

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GBPu 19/03/06 Agenda Item Action Deadline

GB PDA 19/01/11 The Head of Delivery (Integrated Primary and Out of Hospital Care) introduced the draft 2019/20 Practice Delivery Agreement (PDA) to the Governing Body for discussion re the scheme content. It was noted that the budgets and financial schedules of the PDA will be agreed by the Primary Care Commissioning Committee to manage any potential conflicts of interest. The Committee has no voting GP Members.

The Head of Delivery (Integrated Primary and Out of Hospital Care) explained that the six core schemes of the PDA are based on priorities and the challenges facing the health of the population and developed with appropriate input from clinicians, the Public Health Department, the Practices Managers Group, and Local Medical Committee.

The Governing Body considered the draft PDA.

The Lay Member for Governance requested assurance that baselines had been accurately calculated and Practice data is available to measure improvement. It was confirmed that quantitative data was available but qualitative data was more difficult to collect. The Lay Member further highlighted the need for strict criteria to determine accurate end of year PDA payments to Practices.

Dr John Harban queried the figures provided in the Health Inequalities Target Scheme relating to CVD.

The Chief Officer commented that at the outset of the PDA, the CCG had provided investment into Practices for staff and infrastructure to enable Practices to deliver new models of care, rather than a points for £ approach. Therefore the CCG should consider a move to population outcomes arrangements for 2020/21.

Dr Sudhagar Krishnasamy, Member & Associate Medical Director joined the meeting.

The Chief Finance Officer asked whether the PDA targets could be more aspirational rather than ‘maintenance’ targets and there should be a more dominant focus on development of the Integrated Care Networks included

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within the agreement.

The Chair responded to note that the maintenance targets were clinically appropriate and further work was required in relation to development of Integrated Care networks.

The Governing Body agreed that the PDA should be SK/JHo further developed taking into account exacting criteria on which to determine payment to Practices and more focussed on Integrated Care Networks.

Siobhan Lendzionowski, Lead Commissioning and Transformation Manager joined the meeting.

GB MATERNITY UPDATE 19/01/12 The Head of Commissioning (Mental Health, Children’s, Maternity and Specialised Commissioning) introduced the Local Maternity Service Update to the Governing Body. The Governing Body also viewed two short films produced by Barnsley Hospital NHS Foundation Trust:

 Your Pregnancy Choices  Stop Smoking and Safe Sleep

The Chairman advised that an amalgamation of all existing pre-conception advice and support services would be beneficial to provide patients with a point of contact.

The Lay Member for Accountable Care commented that less than 1% of all births were home births. Cultural changes will be required for pregnant women deemed not in the high risk category to consider a home birth option.

It was noted that the figures in the report relating to percentage of women smoking at booking and time of delivery appeared to be transposed. In response to questions raised the Head of Commissioning (Mental Health, Children’s, Maternity and Specialised Commissioning) clarified that parenting skills was included in the detailed Local Maternity Plan and linked to the work being undertaken in the Dearne.

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The Governing Body noted the report and Local LMS (Local Maternity Services) Plan. Agreed actions.

 To include more detailed information relating to PO smoking in pregnancy in the next Maternity Update Report to the Governing Body.

 To provide the Lay Member for Accountable Care KM with the links to the Maternity information films.

GB MENTAL HEALTH 5 YEAR FORWARD VIEW BUSINESS 19/01/13 CASE The Head of Commissioning (Mental Health, Children’s, Maternity and Specialised Commissioning) presented the Mental health Investment Update to the Governing Body, highlighting the financial pre-commitment necessary to continue the successes already achieved and the recommended priority areas for additional investment in 2019/20 and beyond.

It was proposed that the NHSE evidence suggesting that an IAPT-LTC service can significantly reduce acute healthcare costs associated with long term conditions be considered by the Clinical Forum.

It was noted that the Five Year Forward View Mental Health transformation monies are not yet confirmed until planning guidance is received and notified allocations are received. Although papers reflect a fair shares allocations based on information received in 2016/17 the NHS financial position has changed during this time and planning guidance may set out alternative planning assumptions.

In terms of value for money the CCG would not wish to invest in more of the same services if not achieving good outcomes for the People of Barnsley. Investment needs to focus on delivery of the Five Year Forward View requirements and deliver value for money.

The Chairman commented that the Business cases appeared light on clinical input and it is important for community clinicians to be involved in the service model proposed and provided by partners.

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The Governing Body noted the report and approved the priority areas for investment. Agreed Action To submit NHSE evidence to the Clinical Forum re how PO an IAPT-LTC service can reduce acute healthcare costs associated with long term conditions.

GB CANCER DEVELOPMENT PROPOSAL 19/01/14 Dr Kadarsha (Clinical Lead for Cancer) introduced the Improving Cancer Early Diagnosis / Screening delivery Proposal to the Governing Body. The report outlined a number of opportunities to improve the uptake of screening and earlier cancer diagnosis Namely:

 Barnsley Healthcare Federation Proposal – Primary Care Improvement and Liaison Nurse  Barnsley Healthcare Federation Proposal – Extended Service  Cancer Safe Proposal

The Governing Body considered the current rates and performance variation regarding two week wait referrals for suspected cancer and referrals resulting in cancer diagnosis. It was noted that Barnsley compared well to the national averages, however the variation in range across Practices was highlighted. It was suggested that practice comparison data would be helpful in order to support Practices with low patient uptake of cancer screening.

The Governing Body Considered the proposals.

MRI capacity - It was clarified that costs for additional MRI capacity will be picked up via tariff arrangements.

Capacity in LIFT Buildings – the Governing Body was informed that the Chief Executive of Barnsley Hospital NHS Foundation Trust is to undertake a tour of the available facilities within LIFT buildings with a view to providing more services within the community. Effective use of the available estate is integral to the operation of Integrated Care Networks

Promotion of Cancer Screening – The Lay Member for Accountable Care stressed the importance of promoting

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and providing accessible cancer screening services.

Be Cancer Safe - It was noted that funding for the ‘Be Cancer Safe’ Service had been accounted in section 75 arrangements with the Local Authority. However, should the Cancer Alliance provide funding for the project the monies will be reinvested in other priority areas?

The Chief Executive advised that the schemes may need further work particularly with regard to prevention. The indicative figures in the proposals could be used to inform section 75 arrangements.

The Governing Body

 Agreed that the Be Cancer Safe option is funded (from within the section 75 prevention) from April 2019 by the CCG (if the Cancer Alliance is unable to do this)  Approved the action that the CCG continues to develop further the options outlined within the paper  Agreed that when the business case is developed further on the options outlined in the paper these are presented to Governing Body for funding decision and approval.

GB EU EXIT OPERATIONAL READINESS 19/01/15 The Director of Strategic Planning and Performance presented a report, bringing to the attention of the Governing Body the recently published EU Exit Operational Readiness Guidance highlighting the specific actions for Commissioners. It was noted that the guidance had been written on the basis of a ‘no deal’ exit and had been distributed to all providers of NHS Services including Primary Care organisations.

It was reported that Business Continuity Planning for an EU Exit was in progress including workforce and a focus on Primary Care. The Chairman advised that The Barnsley Healthcare Federation would provide support for Primary Care should a Business Continuity situation arise.

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The Governing Body noted the Report and that the CCG’s designated EU Exit Director is the Director of Strategic Planning and Performance.

QUALITY AND GOVERNANCE

GB QUALITY HIGHLIGHTS REPORT 19/01/16 The Chief Nurse (Acting) introduced the Quality Highlights Report. The Governing Body noted the two new policies supporting safe practice in Barnsley namely:

 Safeguarding People Policy  General Practice Staff Guidance on Children and Young People Who Are Not Brought to Healthcare Appointments.

The Governing Body noted the Quality Highlights Report.

GB RISK AND GOVERNANCE EXCEPTION REPORT 19/01/17 The Head of Governance and Assurance presented the Risk and Governance Exception Report. The Governing Body noted that the residual risk score for risk reference CCG 18/03 relating to the Barnsley Health Care Federation CQC Inspection Report is likely to reduce following a recent positive re-inspection and pending consideration at the meeting of the Quality and Patient Safety Committee.

The Governing Body  Reviewed the summary of the GBAF for 2018/19, and determined that the risks are appropriately described and scored, and there is sufficient assurance that they are being effectively managed as 10 January 2019  Did not identify any additional positive assurances relevant to the risks on the GBAF  Reviewed the extract of the Corporate Risk Register and confirmed all risks are appropriately scored and described, and did not identify any potential new risks  Approved the reduction in the overall rating for risk 13/3 from 20 (red) to 12 (amber)

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 Approved the proposed amendments to the Terms of Reference of the Equality & Engagement Committee and the Remuneration Committee  Noted the outcome of the review of the Emergency Planning, Resilience and Response (EPRR) Policy and Business Continuity Policy  Approved QPSC’s decision to co-opt Dr Ibrar Ali as an expert clinical adviser.

GB MANAGEMENT OF SERIOUS INCIDENTS POLICY 19/01/18 The Chief Nurse (Acting) introduced the Management of Serious Incidents Policy to the Governing Body.

The Governing Body approved the Policy subject to a MT change in the target Audience for the Policy to include Providers of NHS funded Services.

FINANCE AND PERFORMANCE

GB INTEGRATED PERFORMANCE REPORT 19/01/19 Finance

The Chief Finance Officer presented the key messages from the Financial Report. As at 30 November 2018 The CCG is forecasting to achieve all financial duties and planning guidance requirements with an in-year balanced budget position. The forecast position at month 8 shows headroom of £832k which will be utilised to manage further in year pressures.

Members’ attention was drawn to the Quarter 3 Financial Control, Planning and Governance Self - assessment and the one ‘red’ rated domain around leadership in the Capability and Capacity domain. The Chief Officer advised that the rationale for the scoring should be challenged with the NHSE and the CCGs self-assessment score for this domain being rated as ‘green’. This was in light of appropriate leadership arrangements being in place within the CCG, including acting up arrangements, and having regard to the NHSE required 20% reduction in management costs.

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To report in Governing Body public session that the CCG had a rating of ‘red’ for leadership was not a true reflection of the CCG’s capability and capacity. It was noted that the self-assessment did not form part of the NHSE year-end review of the CCG.

Approved

The Governing Body approved a self-assessment rating of ‘Green’ for the Quarter 3 Financial Control, Planning and Governance Self - assessment Capability and Capacity domain.

Agreed Action

To confirm with NHSE that the CCGs Quarter 3 RN Financial Control, Planning and Governance Self - assessment Capability and Capacity domain rating will be changed from a ‘red’ to a ‘green’ and followed up with a written response on the basis of the Governing Body decision.

Performance

The Director of Strategic Planning and Performance introduced key performance indicators by exception to the Governing Body. Overall performance continues to be generally strong for Barnsley patients with key standards in relation to A&E, referral to treatment, diagnostics and mental health all being achieved in the performance period. A&E performance in December was at 98%.

The Governing Body noted the challenges within the cancer pathway.

The Governing Body noted the contents of the report including:

 The 2018/19 performance to date  Projected delivery of all financial duties, predicated on the assumptions outlined in this paper  The current forecast position on the CCG’s efficiency programme  The Quarter 2 submission of the Financial Control ,

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Planning and Governance self-assessment.

GB QIPP DELIVERY REPORT 19/01/20 The Director of Planning and Performance introduced the Quality, Innovation, Productivity and Prevention (QIPP) Programme Report to the Governing Body. The report provided assurance that the QIPP Programme was on track to deliver the required efficiency savings with some schemes over achieving. The Director of Planning and Performance advised that the Demand Management Scheme was in line to be rated green in the next report to the Governing Body.

The Chief Officer highlighted that continuing health care cost and programme was a challenge to the CCG. It was therefore appropriate for the Governing Body to receive performance data relating to Continuing Healthcare.

The Governing Body:

 Noted the content of the dashboard and the current position against the £11.5m target.

Agreed action:

To include Performance data for Continuing Healthcare JW in the Integrated Performance Reports to the Governing Body.

COMMITTEE REPORTS AND MINUTES

GB COMMITTEE REPORTS AND MINUTES 19/01/21 The Governing Body received and noted the following Committee minutes & assurance reports:

 GB Assurance Work Plan Agenda Timetable

Agreed Actions To delete the Hospice Grant from the Governing KM Body Work Plan. To provide the Governing Body with a report on JW

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performance against the Hospice KPI’s

 Finance and Performance Committee Meeting held on 1 November 2018 and 6 December 2018

 Quality and Patient Safety Committee held on 11 October 2018

 Assurance Report Equality, Inclusion & Engagement Committee 15 November 2019

The Lay Member for Patient and Public Engagement & Primary Care Commissioning commended the Healthwatch Report, ‘Service Provision for Blind and Partially Sighted People in Barnsley’ to members of the Governing Body

 Minutes of the Membership Council held on 20 November 2018

 Minutes of the Health and Wellbeing Board on 4 December 2018

In response to a question raised regarding development of the Health and Wellbeing Board it was clarified that there is a series of ongoing development reviews / workshops. The next session would be facilitated by Dr Nick Balac and Councillor Andrews.

It was noted that the Barnsley Wellbeing Service Business Case was being further discussed with partners prior to consideration by the Health and Wellbeing Board.

Agreed action: To share with Governing Body members a copy of the full response to a question raised by a local councillor to Health and Wellbeing Board on the CQC inspection at Barnsley Healthcare Federation. (Noting that this is now out of date as the providers CQC rating is good).

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 Minutes of the South Yorkshire and Bassetlaw Sustainability and Transformation Partnership Collaborative Partnership Board held on 19 October 2018.

GB QUESTIONS FROM THE PUBLIC ON BARNSLEY 19/01/22 CLINICAL COMMISSIONING GROUP BUSINESS

The Chairman requested questions from members of the public. The following comments, questions and responses were noted:

A member of the public on behalf of a Barnsley Save Our NHS Representative asked a series of three questions.

1. Question - Long Term Plan. Will there be one CCG per Integrated Care System STP area and will the public be involved in these plans?

Response – One CCG per ICS STP area may not be universally applied due to geography. CCGs are statutory organisations and it would be in the best interests of patients to involve the public in any plans re CCGs.

2. Question - Primary Care Plans. Will there be public involvement in the Barnsley Primary Care 5 Year Forward View Plans.

Response - The Public will be involved for any service changes in Primary Care.

All Practices provide opportunities for patients to engage with them via Practice Patient Reference Groups (PRG). Various other forums are used to involve the public in for example; proof of concept, use of technology and feedback on Primary Care. Innovations.

The Associate Medical Director advised that there had been an irregular heart beat (AliveCor) pilot in certain Practices within the South Locality, should the pilot be successful this will be rolled out to other Practices. The member of the Public commented that the pilot could be widened with public involvement and engagement. If

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there is nothing more than individual practice involvement and nothing is advertised how the public would know to get involved?

3. Questions - eConsultations How will eConsultations be provided and queried costs of the service to the public i.e. not all members of the public had access to computers.

Response – The move towards eConsultations is nationally dictated, and represents one response to a growing public appetite for more varied means for accessing health care. The public had a choice over the options to contact a doctor. eConsultations would not be suitable for all members of the public – patients would have a choice and could continue to access face to face consultations if they preferred. There was also a cost for a patients travelling to attending surgery.

Question – Transparency in the Development of Integrated Care Arrangements, Statutory Duty Around Public Involvement and Delivery of the Barnsley Plan for Health and Care

A member of the public raised a series of questions and also in writing regarding public information/ involvement in the development of integrated care arrangements, delivery of the Barnsley Plan for health and care and the CCGs statutory responsibilities around public engagement. A written response was requested in respect of the questions raised.

Response - It was highlighted that an update about Integrated Care in Barnsley was a standing agenda item at every meeting of the Governing Body in public session. As JB requested a written response will be provided to the member of the public.

Comment - eConsultations

A member of the public referred to the Babylon Health and on line Doctor Consultation Service and with regard to the GP shortage put forward a view that if approved by the NHSE there may be benefits in streaming some patients to this kind of service.

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The Governing Body noted that patients have to register with Babylon for eConsultations and there may be issues regarding the sharing of patient records. The concept was a good idea, but maybe best progressed as an NHSE national service.

Question – Maternity Services

A member of the Public queried:

 Whether expectations are being raised in pregnant women around home births. There is a high number of pregnant women who are deemed as ‘high risk’ and therefore home births will not be an option for them?  In future will there be a possibility for Consultant led maternity services to be based at a distance from Barnsley and if so is there a plan for Barnsley patients?

Response - It was hoped that options for home births will covered in information provided to pregnant woman and through the conversations with the maternity team.

The HSR options around the provision of Maternity Services including consultant led units and midwifery led units are not know at present but may be available by the end of 2019.

GB REFLECTION ON HOW WELL THE MEETING’S 19/01/23 BUSINESS HAS BEEN CONDUCTED

The Governing Body agreed that the business of the meeting had been conducted appropriately and agreed to proceed to the private part of the agenda.

GB DATE AND TIME OF THE NEXT MEETING 19/01/24 Thursday 14 March 2019, 9.30 am in the Boardroom, Hillder House, 49/51 Gawber Road, Barnsley S75 2PY.

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GOVERNING BODY (Public session)

14 March 2019

MATTERS ARISING REPORT 1. The table below provides an update on actions arising from the previous meeting of the Governing Body (public session) held on 10 January 2019. Table 1

Minute ref Issue Action Outcome/Action

GBPu MATTERS ARISING REPORT - 19/01/06 Patient and Public Activity Report – Commissioning Intentions

The Head of Communications and KW COMPLETE Engagement advised that Barnsley Save Our NHS had been emailed about Commissioning Intentions but would further pick up this issue outside of the meeting.

GBPu MATTERS ARISING REPORT - 19/01/06 Commissioning of Children’s Services Monitoring Report

To include ‘value for money’ PO COMPLETE aspects of the Therapy services and a proposed model of support for Practices around referrals in the Commissioning of Children’s Services Monitoring Report to the March meeting of the Governing Body.

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GBPu PRIMARY CARE UPDATE 19/01/10 To discuss the skills, JHa/MT/JHo The skills, competencies competencies and roles of nursing and future roles will be staff within the Practice Team. discussed as part of the wider Barnsley Integrated workforce development steering group. GBPu PDA 19/01/11 To develop the PDA taking into JHo COMPLETE – account exacting criteria on which to determine payment to Practices The PDA focus and and more focussed on Integrated therefore the delivery has Care Networks. now a greater emphasis on how this will be enabled through working in collaboration through the development of the ICN’s. The element for utilising specific resource for the development of ICN’s will form part of a separate development budget rather than enhancing the PDA.

GBPu MATERNITY UPDATE 19/01/12  To include more detailed PO COMPLETE information relating to smoking in pregnancy in the next Maternity Update Report to the Governing Body.

 To provide the Lay Member for KM COMPLETE Accountable Care with the links to the Maternity information films.

GBPu MENTAL HEALTH 5 YEAR 19/01/13 FORWARD VIEW BUSINESS CASE

To submit NHSE evidence to the PO ONGOING – Clinical Forum re how an IAPT- LTC service can reduce acute The IAPT Business Case healthcare costs associated with does provide some of the long term conditions. evidence.

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GBPu MANAGEMENT OF SERIOUS 19/01/18 INCIDENTS POLICY

The Governing Body approved the MT COMPLETE Policy subject to a change in the target Audience for the Policy to include Providers of NHS funded Services.

GBPu INTEGRATED PERFORMANCE 19/01/19 REPORT - FINANCE - FINANCIAL CONTROL, PLANNING AND GOVERNANCE SELF - ASSESSMENT CAPABILITY AND CAPACITY DOMAIN.

To confirm with NHSE that the RN COMPLETE – Submitted CCGs Quarter 3 Financial Control, return with a ‘GREEN’ Planning and Governance Self - rating. assessment Capability and Capacity domain rating will be changed from a ‘red’ to a ‘green’ and followed up with a written response on the basis of the Governing Body decision.

GBPu QIPP DELIVERY REPORT 19/01/20 To include Performance data for JW COMPLETE Continuing Healthcare in the Integrated Performance Reports to the Governing Body.

GBPu COMMITTEE REPORTS AND 19/01/21 MINUTES - GB ASSURANCE WORK PLAN AGENDA TIMETABLE

 To delete the Hospice Grant from KM COMPLETE the Governing Body Work Plan.

 To provide the Governing Body JW COMPLETE - Quarterly with a report on performance Information is received and against the Hospice KPI’s shared with the Clinical Lead – Q3 information has been circulated to GB members for information.

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GBPu COMMITTEE REPORTS AND 19/01/21 MINUTES - MINUTES OF THE HEALTH AND WELLBEING BOARD

To share with Governing Body LS COMPLETE members a copy of the full response to a question raised by a local councillor to Health and Wellbeing Board on the CQC inspection at Barnsley Healthcare Federation. (Noting that this is now out of date as the providers CQC rating is good).

GBPu QUESTIONS FROM THE 19/01/22 PUBLIC ON BARNSLEY CLINICAL COMMISSIONING GROUP BUSINESS

Transparency in the JB COMPLETE Development of Integrated Care Arrangements, Statutory Duty Around Public Involvement and Delivery of the Barnsley Plan for Health and Care - To provide a written response to the member of the public.

2. ITEMS FROM PREVIOUS MEETINGS CARRIED FORWARD TO FUTURE MEETINGS

Table 2 provides an update/status indicator on actions arising from earlier Governing Body meetings held in public. Table 2

Minute Issue Action Outcome/Actions Ref GBPu COMMITTEE REPORTS AND 18/09/18 MINUTES - FPC 18/151 – Sexual Health

To ascertain the funding envelope RN BMBC have confirmed for the Sexual Health Procurement funding envelope not yet determined for the procurement

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GBPu CHIEF OFFICER’S REPORT 18/11/07 The Chief Officer and Secondary LS/MS meeting held to clarify the Care Clinician to discuss Bowel issues. Cancer Prevention and Screening nationally and at Integrated Care System level outside of the meeting.

GBPu CANCER UPDATE 18/11/09 To provide data re cancer HK/SL Information will be shared screening uptake and share with with localities by 16 January Localities. 2019

GBPu COMMISSIONING OF 18/11/13 CHILDREN’S SERVICES MONITORING REPORT

To provide the Governing Body PO ONGOING - A meeting has with a report regarding the ‘value been planned with SWYPFT for money’ aspects of the Therapy on 31 January 2019 to services and a proposed model of discuss the demand / Support for Practices around capacity modelling. referrals.

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GOVERNING BODY

14 March 2019

REPORT OF THE CHIEF OFFICER

1. THIS PAPER IS FOR

Decision Approval X Assurance Information

2. REPORT OF

Name Designation Executive Lead Lesley Smith Chief Officer Author Lisa Kell Director of Commissioning, SYB ICS

3. EXECUTIVE SUMMARY

This report provides the Governing Body with the Developing System Commissioning Arrangements in 2019/20.

This paper sets out the approach for expanding commissioning arrangements in South Yorkshire and Bassetlaw to provide a strategic commissioning focus for 2019/20 with priorities managed through the Joint Committee of CCGs (JCCCGs) strengthened with delegated decision making authority where agreed by the five CCGs to secure single commissioning decisions.

The Long Term Plan (LTP) sets out a clear direction that commissioning arrangements will change over the next few years and NHS England and NHS Improvement are to publish an engagement document setting out specific proposals to primary legislation at the end of February. lCS’s will need to have in place streamlined commissioning arrangements to enable a single set of commissioning decisions at system level and CCGs will become more strategic organisations supporting health and care partners to jointly focus on population health, service redesign and long term plan implementation.

The SYB CCGs have traditionally worked together to develop and deliver commissioning and contracting responsibilities on behalf of each other as efficiently as possible, from a best use of resources, standardisation, quality and cost perspective and to avoid duplication. These collaborative arrangements are wide ranging and largely cover undertaking a lead role on behalf of the five for a commissioning function or activity, leading a service transformation programme or a lead commissioner for an NHS contract.

Additional priorities for system commissioning have been considered where there is an opportunity in SYB to:  Standardise to reduce unwarranted variation, improve equity of service, access, quality, outcomes, pathways and specifications , metrics

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 Improve financial efficiency and best utilisation of resources  Improve population health and outcomes

A set of SYB proposed priorities has been developed and a JC CCG work plan is underway for 2019/20, informed by discussions with Governing Body, Accountable Officers and the Joint Committee of CCGs. The priorities are recognised by SYB commissioners as a good step towards developing system commissioning signalled in the NHS Long Term Plan. Work is progressing in relation to proposing which priorities could be delegated to the JCCCGs from CCGs for single decision making. The revised final work programme and proposals for delegated authority to the JC CCG will be presented to Governing Bodies in Quarter 1 2019/20.

4. THE GOVERNING BODY IS ASKED TO:

 Consider the content of the paper and support the approach to expand on and implement system commissioning in SYB during 2019/20 in line with the NHS Long Term Plan requirements  Agree the draft 2019/20 JCCCG priorities and support the JCCCG to develop the work programme and propose which priorities should be given delegated authority from CCGs to the JCCCGs for 2019/20  Support the next steps and timeline

5. APPENDICES

Appendix 1 – Briefing for SYB CCG Governing Bodies in Public Appendix 2 - Existing system commissioning arrangements - Services and functions done on behalf of each other - across the 5 CCGs

Agenda time allocation for report: 10 mins

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PART 1B – SUPPORTING INFORMATION

1. Links to the Governing Body Assurance Framework Risk ref(s) This report provides assurance against the following risks on the 5.1 Governing Body Assurance Framework: 2. Links to CCG’s Corporate Objectives Y/N To have the highest quality of governance and processes to √ support its business To commission high quality health care that meets the needs of √ individuals and groups Wherever it makes safe clinical sense to bring care closer to √ home To support a safe and sustainable local hospital, supporting √ them to transform the way they provide services so that they are as efficient and effective as possible for the people of Barnsley To develop services through real partnerships with mutual √ accountability and strong governance that improve health and health care and effectively use the Barnsley £. 3. Governance Arrangements Checklist 3.1 Financial Implications Has a financial evaluation form been completed, signed off NA by the Finance Lead / CFO, and appended to this report? Are any financial implications detailed in the report? NA

3.2 Consultation and Engagement Has Comms & Engagement Checklist been completed? NA Is actual or proposed engagement activity set out in the NA report?

3.3 Equality and Diversity Has an Equality Impact Assessment been completed and NA appended to this report?

3.5 Environmental Sustainability Are any significant (positive or negative) impacts on the NA environment discussed in the report?

3.6 Human Resources Are any significant HR implications identified through NA discussion with the HR Business Partner discussed in the report?

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Appendix 1 – Briefing for SYB CCG Governing Bodies in Public Developing System Commissioning Arrangements in 2019/20 March 2019

1. Purpose

1.1. This paper sets out the approach for expanding commissioning arrangements in South Yorkshire and Bassetlaw to provide a strategic commissioning focus for 2019/20 with priorities managed through the Joint Committee of CCGs (JC CCGs) strengthened with delegated decision making authority where agreed by the five CCGs to secure single commissioning decisions.

2. Background

2.1 The SYB CCGs have traditionally worked together to develop and deliver commissioning and contracting responsibilities on behalf of each other as efficiently as possible, from a best use of resources, standardisation, quality and cost perspective and to avoid duplication. These collaborative arrangements are wide ranging and largely cover undertaking a lead role on behalf of the five for a commissioning function or activity, leading a service transformation programme or a lead commissioner for an NHS contract. The list of collaborative commissioning arrangements already in place in SYB is shown in appendix 1.

2.2 In 2016 the SYB Sustainability and Transformation Plan (STP) set out the intention to review commissioning to support the development of places and working together strategically as a system. In summer 2017/18 the JC CCGs agreed to explore how SYB could develop new arrangements for commissioning/ contracting with specific aims: o At SYB – commission, plan and deliver some activities ‘once’ across SYB system where it is more efficient and effective to do so to reduce unwarranted variation improving equity of access, quality and standardisation of service to achieve improved population health outcomes for patients. o At Place - commission, plan and deliver services locally, with a focus on integrated health and care with partners to improve population health at a place e.g. through new models of integrated care, and a consistency in approach to support providers to deliver services more equitably for the local population.

2.3 The five CCG Governing Bodies agreed to explore and scope out opportunities of system commissioning and the required delegated decision making arrangements through the JC CCGs to enable this. A series of Governing Body workshops were held during 2018 to develop the approach for system commissioning and the future role of the JC CCG.

3. Implementing System Commissioning in SYB

3.1 The opportunity of moving to system commissioning across SYB is hindered by the Health and Social Care Act, 2012 where CCGs are statutorily responsible for commissioning the majority of NHS health care. Delegating responsibility from CCGs for non-statutory commissioning functions to ‘do once’ is legally permissible through the Joint Committees of CCGs.

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3.2 Where it is not possible to shift priorities fully to system commissioning, the commissioning cycle (fig. 1) can be split across place and system to enable consistency and standardisation of elements of commissioning e.g. clinical pathways, policies, service specifications and contractual arrangements to deliver improved population outcomes, reduce inequalities and efficiency of resources. This process is already in place for SYB Integrated Care System (ICS) transformation priorities, delivered through the ICS work streams and commissioning oversight and delegated decision making through the JC CCG.

Fig 1 NHS Commissioning Cycle

Current strategic commissioning in SYB mainly covers the planning element of the commissioning cycle

4. National Context - NHS Long Term Plan Requirements for Commissioning

4.1 The Long Term Plan (LTP) sets out a clear direction that commissioning arrangements will change over the next few years. lCS’s will need to have in place streamlined commissioning arrangements to enable a single set of commissioning decisions at system level and CCGs will become more strategic organisations supporting health and care partners to jointly focus on population health, service redesign and long term plan implementation. NHS England and NHS Improvement are to publish an engagement document setting out specific proposals to primary legislation at the end of February 2019.

4.2 A new integrated NHSE/I operating model will be fully introduced in 2019/20 reducing NHS administration costs. This is also a requirement of CCG’s with a 20% reduction in running costs required by 2020/21. CCGs will have the flexibility to determine locally how these efficiencies can be delivered and plans are required by March 2020.

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4.3 Across the north region the emerging approach to assuring that the reduction in running costs is secured will be through assurance that CCGs are building the future system by paying equal and proportionate attention to developing new models of commissioning as part of the emerging NHS architecture including:  place based integration of commissioning  place based integration of commissioning and provision through integrated delivery models  supporting the development of primary care networks /neighbourhoods  supporting the development of the commissioning system at an ICS level

5. Local Context – Place Commissioning 5.1 The vast majority of commissioning activities in SYB are done at place to meet local population health needs. A significant amount of progress has been made in each place over the last few years to integrate care and develop place commissioning established through Integrated Care Partnerships (ICPs). These arrangements are underpinned by strong relationships with local authority, providers, wider public services and voluntary sector partners to develop a shared vision to improve the health and care of the local population. Each has a place plan with a collaboration agreement or memorandum of understanding to formalise the partnership working, expectations, governance, roles, and responsibilities.

5.2 Each ICP has introduced integrated care models and approaches within a defined neighbourhood encompassing a cluster of GP practices called Primary Care Networks (PCNs). PCNs largely cover populations of around 50,000 and are a key requirement of the LTP to strengthen and enable primary and community care to work together with other health and care professionals to provide multi-disciplinary integrated care. Additionally, ICPs have implemented new commissioning infrastructures including joint posts with integrated portfolios across health and care, commissioning teams / hubs and funding for specific priorities secured from partners to drive forward service transformation. Some have introduced more formal joint health and care commissioning functions through a Section 75 agreement (pooled budget arrangements) with Local Authorities to support delivery of ICP priorities and are building further on this in 2019/20.

6. Guiding Principles for SYB System Commissioning

6.1 A guiding principle for any changes to commissioning and/or joint decision making must be that it demonstrates added value to patients for place and ICS including improvement in outcomes and population health, standardisation of care, financial efficiency, better use of resources including scarce workforce and avoids unnecessary duplication. Unintended significant risks for a CCG, place or ICS should be avoided.

6.2 Robust ICS governance arrangements and business processes are crucial to enable system commissioning for business case development including the following steps: project scope, a clinical evidence base and clinical leadership and involvement, commissioner and provider involvement, patient and public engagement, robust financial modelling and investment requirements, implementation planning and joint decision making arrangements through the JC CCGs to ensure ongoing commissioner support throughout the process to reduce the potential of dispute or any unintended consequences for CCGs that could have been otherwise avoided. Senior commissioning expertise and capacity will also be required to support the running of the JC CCGs.

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6.3 It is important that system commissioning priorities are clinically developed to ensure an agreed SYB consensus to pathways, policies and protocols. Assurance will be required that the case for change is underpinned by a robust clinical evidence base and best practice with local clinicians in each place having the opportunity to engage, influence and develop. To enable this a standard approach to clinical engagement will be agreed by the JC CCG for Governing Bodies with clear processes to be followed.

7. Governance Arrangements and Delegating Authority to Joint Committee of CCGs

7.1 The JCCCGs plays an important role in commissioning in relation to joint working and streamlining decision making. Delegated authority to the JCCCG was agreed in 2017 by the five CCG Governing Bodies for the Stroke HASU Service and Children’s Surgery and Anaesthesia transformation programmes which have been largely completed.

7.2 Expanding system commissioning arrangements in SYB is linked into the wider ICS governance review currently underway which will when completed reflect the joint working between ICS commissioners and providers consistent with the LTP direction of travel for system integration.

7.1 North Derbyshire CCG and Wakefield CCG will be engaged in the work where agreed ICS system commissioning priorities impact on North Derbyshire and Wakefield patients. The agreed work plan will determine their ongoing involvement in the JC CCG for 2019/20.

7.2 New support infrastructure and governance arrangements will be put into place to support the JC CCGs:  JC CCGs Sub group with Accountable Officer and Director level membership will be responsible for managing the work programme; assuring clinical engagement and leadership and setting the JC CCGs agenda for both public and private meetings. The JC CCGs Sub group will liaise with the ICS Transformation Programmes and the place based commissioners and providers on the JC CCG in taking forward the priorities.

JCCCGs CCGs/ GBs

JCCCG Subgroup

ICS Transformation JCCCG Programmes Clinical Reference Group

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7.3 Due consideration will be given by commissioners regarding public communications and engagement requirements where decisions are to be delegated to JC CCG.

8 SYB System Commissioning Priorities and JC CCGs Work Plan

8.1 Priorities for system commissioning have been considered where there is an opportunity in SYB to:  Standardise to reduce unwarranted variation, improve equity of service, access, quality, outcomes, pathways and specifications , metrics  Improve financial efficiency and best utilisation of resources  Improve population health and outcomes

8.2 The SYB system commissioning approach will need to respond to the Hospital Services Programme (HSP) and providers joint working plans as they emerge, for example how the commissioners and the JC CCGs supports and enables hosted networks and other transformation and reconfiguration priorities being taken forward by the HSP.

8.3 The proposed 2019/20 list of SYB System Commissioning priorities is shown below and has been developed from the Governing Body workshops held in 2018 and ongoing discussion with SYB commissioners. The priorities are recognised by commissioners as a good initial step towards implementing system commissioning signalled in the LTP. The priorities will be further developed by the JC CCGs into a work programme and proposing which priorities could be delegated to the JC CCGs for single decision making. The final work programme and proposals for delegated authority will require Governing Body approval in quarter 1 2019/20.

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2019/20 SYB Proposed System Commissioning Priorities Services / contracting  999/111 SYB lead commissioner with options for additional delegated

authority for decision making through AOs  Outpatient follow up and Outpatient first appointments*  Tariff and payment reform* (also linked to OPs and Quality incentives contracting and the work on payment reform Efficiency Board )  Developing Quality outcomes Incentives based contracting*  Perinatal Mental Health*  Developing outcomes incentive based contracts*  Community diagnostics and digital technology, telecare/ telehealth – supporting Neighbourhoods / PCHs*

 Joint working with Spec Com to align service pathways specialised/non- specialised

Medicines optimisation in primary care standard SYB policies*  Over the counter prescribing  Gluten free  Avastin

SYB Commissioning Policies and commonality of quality standards and outcomes: Commissioning for outcomes – new priorities and a review of the existing SYB

policy*  IVF inclusion and exclusion criteria and number of IVF cycles  Developing Prevention and Population Health approaches and interventions embedding principles into commissioning and decision making to reduce unwarranted variation*  QUIT in hospital scheme*

Service Transformation  HSP implementation working jointly with providers  Stroke HASU Sheffield CCG Lead commissioner  Cancer – service pathways and patient testing *  Perinatal MH standardised pathways and lead contracting arrangements*

*Also priorities of the LTP

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9 Next Steps and timeline

9.1 The next steps to conclude this work are:

March  Developing System Commissioning Arrangements 2019/20 taken through (Public) Governing Bodies April  JCCCG to propose delegation for identified priorities in work plan for Governing Body approval May  Governing Body consideration and approval of final work plan with delegated authority to JCCCG June  Revised JCCCG Manual Agreement and Terms of Reference approved by Governing Bodies  Terms of Reference approved for JCCCG Sub Committee and Clinical Reference Group

Recommendations

Members of the Governing Body are asked to:

 Consider the content of the paper and support the approach to expand on and implement system commissioning in SYB during 2019/20 in line with the Long Term Plan requirements

 Agree the draft 2019/20 JCCCG priorities and support the JCCCG to develop the work programme and propose which priorities should be given delegated authority from CCGs to the JCCCGs for 2019/20

 Support the next steps and timeline

Paper prepared by

Lisa Kell,

Director of Commissioning,

SYB Integrated Care System

On behalf of SYB Accountable Officers

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Appendix 2 – Existing system commissioning arrangements - Services and functions done on behalf of each other - across the 5 CCGs

CCG NHSE – direct commissioning Barnsley Bassetlaw Doncaster Rotherham Sheffield  GPFV transformation team  BHNFT & SWYPFT lead  Chair CFO CCG SYB  DBH Lead commissioner  Sheffield City Region Joint  Lead commissioner for  Primary care Commissioner meeting. • CHC appeals lead for Assets Board HASU services commissioning – pharmacy  Patient Discharge Service  National Diabetes Rotherham, Wakefield, representative  Host for IFR team (SY&B) and optometry contract lead for Prevention Programme Doncaster & Barnsley  RFT Contract Coordinator  Host for Procurement team  Dental services Doncaster/Rotherham lead for Rotherham , • PUPoC lead for all SY&B  Yorkshire & Humber for Sheffield, Rotherham, commissioning (Urgent,  Armed Forces network lead for Doncaster & Bassetlaw plus Wakefield, Maternity Network Barnsley & Bassetlaw

Acute and Community) S Yorkshire  Lead for implementation Huddersfield & Calderdale  Yorkshire & Humber  Transactional HR Service  National screening  Yorkshire and Humber of APEX workforce tool • Renal Transport service and Neonatal Network (All 5 CCGs) and HR programmes Perinatal Mental Health across SYB. contract lead for SYB  Medicines Management Advisory Service (All CCGs  National immunisation commissioner Lead (for S  Lead for e-consultation • Cancer Alliance Business Manager Lead except Doncaster) programmes (including Yorkshire procurements for Intelligence  Health & Safety (All 5  Sub Regional Lead 999/111 public health Support)  Regional Adult ASD Assessment Sheffield, Bassetlaw, • Provision of performance CCGs) South Yorkshire  Commissioning healthcare and Diagnostic service lead (for Barnsley and Doncaster. intelligence for live CHC  Fire Safety (All 5 CCGs)  Contract Coordinator for in the secure and detained South Yorkshire)  Lead for implementation cases  Business Continuity (All 5 STH, SCH, SHSC, estate (prison, YOI, secure of GP wifi across SYB. • CHC Workforce and CCGs) Independent Sector children’s homes and IRC  Chair of D2 Digital IT Education lead  Emergency Planning (All 5 providers and custody) workstream on behalf of • Primary Care Workforce CCGs) SYB. tool procurement lead  GP IT (Rotherham & • Y&H ASC/PD TCP Doncaster) Collaborative procurent lead  Financial Services (Rotherham & Barnsley)  NCAs (Rotherham,

Barnsley & Bassetlaw) Existing system Lead Commissioning responsibility Commissioning Lead system Existing  Commissioning sexual assault referral services  Commissioning liaison & diversion services and

street triage

 Integrated Assurance and  Deputy ICS lead  ICS lead Elective &  ICS TCP LD Lead  ICS Estates Lead  ICS Primary Care, Operational Planning  Finance Host for ICS Diagnostics  ICS Clinical Cancer Lead  ICS Digital Lead (clinical population health and  ICS Cancer Lead  ICS lead Medicines  ICS Joint Mental Health and and managerial) prevention Lead Optimisation Learning Disability Lead  ICS Children’s &  ICS Co-Lead UEC  ICS Lead - Integrated Maternity Lead  Finance functional Host Assurance &  SY&B Local Maternity for ICS Improvement Delivery System SRO

for the ICS

ICS lead areas of of areas ICSlead responsibility

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Governing Body

14 March 2019

Clinical Pharmacists Programme - Phase 2

PART 1A – SUMMARY REPORT

1. THIS PAPER IS FOR

Decision Approval Assurance Information X

2. REPORT OF

Name Designation Executive Lead Jackie Holdich Head of Delivery (Integrated Primary and Out of Hospital Care) Author Chris Lawson Head of Medicines Optimisation Author Janine Lee Project Manager

3. EXECUTIVE SUMMARY

This paper describes the expansion of the clinical pharmacist workforce programme, building on the very successful phase one programme. This will be through recruiting a second phase of clinical pharmacists releasing the first phase to be supported in clinical skills training and prescribing, developing to Advanced Care Practitioners (ACPs).

Introduction

Over the last three years there has been a national drive for the recruitment and training of Clinical Pharmacists (CP’s), the NHS England Clinical Pharmacist Programme as of September 2018 have recruited and trained 810 WTE clinical pharmacists. The general practice CP role is one that is attractive to pharmacy professionals due to CP’s being able to have positive impact on patients, providing clinical assessment and treatments, and being able to utilise their expert knowledge of medicines for long-term conditions. Due to the national drive of the CP role there is now a highly trained CP workforce available for recruitment. Barnsley CCG has a good reputation as an employer but in particular the Barnsley Clinical Pharmacist model is an attractive one for Pharmacist professionals due to the support and development opportunities it offers. Recent Barnsley CCG CP recruitment has seen a high quantity of high quality applicants and most applicants were already independent prescribers.

The extended role of Clinical Pharmacists will provide a more targeted support offer to individual practices to help reduce unwarranted variation and be an additional asset to the developing multidisciplinary team in general practice to alleviate the general practice workforce vacancies.

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To support workforce development there has been some real success to date in Barnsley by extending the Primary Care Team to include clinical pharmacist support. These roles have delivered additional capacity and capability to the workforce; increasing access, reduce waiting times and have enabled more proactive earlier intervention for wider numbers of patients, particularly improving the quality of medicines related interventions .and outcomes. The successful local recruitment of 15 clinical pharmacists has delivered the below:

 Managed and prescribing for patients with long-term conditions  Carrying out medication reviews  Carrying out face-to-face or telephone follow up with patients  Prescription and medicines management  Supporting the GPs and other practice staff to deliver on QIPP agenda, QOF and locally commissioned enhanced services  Answering medicine information enquiries from GPs, other healthcare professionals and patients  Working with GPs and practices nurses to agree, and then manage, practice formularies to improve the choice and cost effectiveness of medicines  Supporting patient and practice staff education  The re-authorisation of repeat medication  The review of test results and follow up’s

Two fifths of clinical pharmacist time is currently spent undertaking medicines management QIPP activities, which on an invest to save basis, funds the whole of the clinical pharmacist programme costs. The remaining three fifths of their time is spent undertaking clinical pharmacist activities described below. Fifteen WTE clinical pharmacists are currently employed which releases 9 WTE * of clinical pharmacist activity to support the primary care workforce in other ways

Delivery Model The Phase 1 clinical pharmacists are established within practices and have become an integral part of the practices clinical team, the CCG would nurture and build on this workforce providing clinical skills and prescribing training in a structured and formal way with externally accredited and recognised qualifications. The additional provided clinical pharmacist Phase 2 resource (additional to the practices existing clinical pharmacist allocation) would “free up” current Phase 1 pharmacists from their medicines optimisation activities to directly take on GP and ANP clinical related activity. Additional ANP training provided to a proportion of the pharmacists would expand delivery of clinical patient facing activity. . Introduction of Band 5 technicians would after initial training support release Band 6 technicians within the MMT to undertake a proportion of the Phase 1 and Phase 2 pharmacist medicines work and releasing further capacity.

Practices were historically allocated Phase 1 clinical pharmacist resource on a weighted population basis. It’s proposed that the same methodology will be included for allocation of the additional Phase 2 resource. However there are plans to analyse data that identifies significant variation, the resource may also be allocated using quality dashboard information to target the support at either practice or ICN level.

Development of the Primary Care Pharmacy workforce – Delivering the Integrated Care Network (ICN) model

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Primary Care Lead Pharmacists BCCG commissioning model is moving towards a more place based approach where pathways and incentives are aligned to locality working.

The lead pharmacists will lead and champion integration between all pharmacy services across each neighbourhood. They will, by analysis of prescribing variation and trends, influence the direction of the integrated care network focus and work.

A key role for the lead pharmacists in each ICN would be to develop relationships with the integrated care network including primary, secondary and social care to support the formation of integrated teams. The clinical pharmacist role is one that is already bridging the gap between general practice and community pharmacy.

To further increase the specialisms within the clinical pharmacist workforce the band 8b Primary Care Lead pharmacist would be required to commit to a 2/3 year PGDIP/MSC in Advanced Clinical Practice.

Once qualified the Advanced Care Practitioners (ACP/APs) will be able to carry out all the activities that Physicians Associates(PA’s) but without the dependencies that’s the PA role currently has, ACP/APs are able to prescribe and require little supervision, they can even become autonomous practitioners within practice, so are a much more time effective resource. As a relatively new role in the UK, physician associates are still seeking statutory regulation; ACP/APs are registered with a regulatory body and have one of the most relevant degrees.

The qualification would typically provide the pharmacist with learning in the following areas;

PG Certificate - Year 1 Core modules: • Postgraduate Induction and your Professional Development • Clinical Examination Skills for Health Care Professionals • Clinical Investigations and Diagnostics for Health Care Professionals PG Diploma - Year 2

Core modules: • Understanding Research Critical Appraisal in Health Care • Introduction to Management in Health Care Organisations

Choice of one optional core module: • Health Care Ethics • Critical Care: Advanced Emergency Practice • Critical Care: Critical Care Transfer • Critical Care: Pre-Hospital Special Incident Management • Community-Based Care

The CCG will fully fund the training programme; a time commitment is required for mentorship and supervision from GPs within the 8b pharmacist practice to support the individuals.

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Once qualified as Advanced Practitioners (AP’s) the pharmacists will be able to undertake a wide variety of advanced practice roles within primary care. The AP role could increase access to urgent on- the-day appointments these skills could be utilised on a locality needs basis and support the delivery of the ICN’s high- level outcome of high quality co-ordinated care.

The AP could also provide clinical mentorship to support the development of the 8a Clinical Pharmacist where there is an AP role identified within the practice and the clinical pharmacist has personal development aspiration to work towards a more advanced role further increase the variety of outward facing roles the clinical pharmacist can undertake.

Once qualified the Advanced Care Practitioners (ACP/APs) will be able to carry out all the activities that Physicians Associates (PA’s) provide but without the dependencies that’s the PA role currently have, i.e. not being able to prescribe medicines. ACP/APs are able to prescribe and require little supervision, they can even become autonomous practitioners within practice, and so is a much more time effective resource. As a relatively new role in the UK, physician associates are still seeking statutory regulation; ACP/APs are registered with a regulatory body and have one of the most relevant degrees.

Primary Care Technicians

Following feedback from CCG clinical pharmacists and a review of clinical pharmacist activity data it has been identified that pharmacy technicians can also play in role in carrying out practice activities. It is estimated that approximately 60% of medicines reconciliation and medicines queries could be carried out by an experienced Band 6 pharmacy technician - therefore releasing pharmacists to focus on patient facing activities.

At the present time it is recognised that there is a limited pool of experienced primary care technicians to achieve the required level of recruitment to ‘free up’ clinical pharmacist resource across the patch. This recruitment would develop this valuable resource.

Due to the possibilities the CCG would like to work on the development of Primary Care technicians and recruit 2 x band 5 pharmacy technicians.

The CCG’s medicines management team will develop a full induction programme to support the workforce development opportunity. A programme of rotation across the Medicines Management teams/work streams will be facilitated and the technicians will be required to commit themselves to undertaking the 100hr CPPE learning programme ‘General practice - the fundamentals of working with GPs’. The programme will provide the Primary Care Technicians with an introduction to local general practice, medicines optimisation, medication review, prescribing and repeat prescribing, prescribing data, clinical information technology systems, audits, evidence-based use of medicines, working with the multidisciplinary team and person-centred professionalism. The programme is currently is free of charge to pharmacy professionals who are registered with the CPPE.

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The additional recruitment will contain the following roles:

Description 1 x 8 b Lead Pharmacist 1 x Uplift Band 6 to 7 6 x 8 a Clinical Pharmacist Post 6 x Independent Prescribers Qualification* 3 x Advanced Practitioner PGdip/MSC** 2 x Band 5 Primary Care Technicians Indemnity costs technicians/CP's

Total 576,983.00

The funding for this additional recruitment was approved by the Primary Care Commissioning Committee on 31 January 2019.

Recruitment Timeline

Programme Leadership

1 x 8b lead pharmacist post to support the clinical leadership of the programme, and an uplift of the existing band 6 operational manager to a band 7 due to the programme growth in size and operability. The medicine management team currently have a 0.5 wte lead pharmacist vacancy which will be used to further compliment the Clinical Pharmacist programme leadership.

The 8b lead pharmacists posts will be put out to recruitment as 3 x 0.5 WTE posts – the post will be split into 0.5 x 8a clinical pharmacist and 0.5 x 8b lead pharmacist post – this will ensure that the pharmacists are maintaining their Continued Professional Development, prescribing competencies and are working within a clinical environment.

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Outcomes

The recruitment of additional clinical pharmacists will provide the resource required to support delivery against the Barnsley ICN high level outcomes and design principles of;  A population health management * approach to develop strategies to improve the health and wellbeing of the population and reduce health inequalities  Maximise the agreed outcomes within the resources available to deliver best possible value for the Barnsley pound  Focus on self-care to promote independence and reduce pressures on the health and care system  Improve health inequalities by ensuring improvement is faster for those with the greatest need  Prevention and the wider determinates of peoples health and wellbeing are prioritised  Improve population health and wellbeing.

* Population Health Management – Artificial Intelligence (AI) Resource

Objectives set within the NHSE mandate 18/19 (reference 1) detail a plan to lead a step change in the NHS in preventing ill health and supporting people to live healthier lives. The escalating demands of ill health driven by our lifestyles also threaten the long-term sustainability of the NHS. Embedding prevention is therefore crucial to improving and lengthening lives, reducing health inequalities, and to reducing avoidable demand for NHS services.

There is an opportunity to increase and develop use if current Eclipse Live (AI) resource to provide targeted care to patients. The software is currently being used by all practices identifying patients at high medicines related risk through its RADAR platform. It has the additional capability, through a number of additional therapeutic platforms which are available at no additional cost, to stratify and identify patients at the highest clinical risk within practices. A proportion of the additional Phase 2 workforce could be used to deliver targeted healthcare to patients identified to be at highest clinical risk across selected patient pathways which would to deliver and could also measure real life improved outcomes for patients. The choice of pathway(s) would be informed by health intelligence data and prioritised by locality plans.

Financial “Invest to Save” Delivery

It is the intention that from April 2021 onwards the investment in the additional clinical pharmacist‘s would be able to demonstrate delivery of recurrent £QIPP equivalent or greater than staffing costs. The £ QIPP would be separately calculated and reported each year and would be delivered in the following ways:-

 Activity undertaken by clinical pharmacists within practice (non-directed QIPP time) has in the last two years reported additional £QIPP delivery. Only a proportion of this activity is currently recorded (when the savings are deemed significant for an individual patient). A minimum of £250K approx. would be delivered by the introduction of the additional staffing.

 Approximately 5 % of hospital admissions were associated with adverse drug reactions. Higher rates were found in elderly patients who are likely to be receiving multiple medications for long-term illnesses. The impact of clinical pharmacist activity on non-elective admissions is currently not calculated, which in some practices currently includes undertaking targeted Eclipse Live RADAR* alerts. Delivering high

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quality radar reviews has in other CCG localities have been shown to deliver up to a 4% reduction in admissions. It is proposed to increase the number and quality of reviews undertaken using the PINCER** approach and also for the impact of the reviews on non-elective activity to be measured.

 Clinical pharmacists will be directing and undertaking more focused practice population health management through prescribing data analysis It is proposed that this work is recorded and the impact and outcomes measured and verified. The appropriate selection of high risk patients for intervention would enable a significant £QIPP impact to be achieved.

*Eclipse Live RADAR alerts The Eclipse Radar alerts identify patients who are at risk of medicines related harm by and provide a window of opportunity for intervention to reduce this risk. Eclipse Live software runs algorithms against the latest ‘UKMI Drug Monitoring in Adults in Primary Care’ suggestions and the National Institute for Health and Care Excellence current best practice. By combining this national best practice with highly specific alert criteria, the alerts identify patients who have genuine reversible risk. The result is that the Eclipse live RADAR empowers Barnsley GP Practices to optimise patient safety for many of our most vulnerable patients and to significantly reduce Secondary Care admissions

**PINCER (pharmacist-led information technology intervention for medication errors)

PINCER is an audit tool involving a search of the GP Practice computer system and identifies patients who are being prescribed medicines that are commonly and consistently associated with medication errors ; nonselective non-steroidal anti- inflammatory drugs (NSAIDs) and β blockers, and the monitoring of angiotensin- converting-enzyme (ACE) inhibitor or loop diuretics, methotrexate, lithium, warfarin, and amiodarone. The PINCER approach applied Root Cause Analysis ( RCA ) techniques to more effectively reduce the chance of an identified medicines risk recurring and is more effective than simple feedback.

The results of the first trial (reference 2) , published in the Lancet in February 2012,10 showed that the PINCER intervention is an effective method for reducing a range of clinically important and commonly made medication errors in primary care. For this reason, there is much interest in rolling out the approach taken in the PINCER Trial to general practices in the UK. Not only might this approach help prevent unnecessary harm to patients, but it may also reduce the costs associated with dealing with prescribing errors, a proportion of which require hospital admission.

Targeted £QIPP medicines management activity would be a final but robust alternative to £ QIPP delivery .Opportunities arise each year for targeted work which is limited by medicines management staffing capacity. This option would involve up to 2WTE of clinical pharmacists additionally diverting their time (from clinical pharmacist activity) to the delivery of centrally directed £QIPP work.

The CCG Medicines Management team analyse prescribing intelligence and data to identify potential opportunities on an ongoing basis. For example in the 2019/20 year work is progressing identifying and intervening in patients with Anticholinergic Burden (ACB), Acute Kidney Injury (AKI) and high dose opioid use to reduce risk, as well as the most efficient approach to undertaking polypharmacy reviews.

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References

1. The Government’s mandate to NHS England for 2018-19 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attach ment_data/file/691998/nhse-mandate-2018-19.pdf 2. A pharmacist-led information technology intervention for medication errors (PINCER): a multicentre, cluster randomised, controlled trial and cost-effectiveness analysis https://www.thelancet.com/action/showPdf?pii=S01406736%2811%2961817-5

4. THE COMMITEE IS ASKED TO:

Note the information detailed within the Phase 2 Clinical Pharmacist Programme.

5. APPENDICES No appendices

Agenda time allocation for report: 10 minutes

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PART 1B – SUPPORTING INFORMATION

1. Links to the Governing Body Assurance Framework Risk ref(s) This report provides assurance against the following risks on NA the Governing Body Assurance Framework: 2. Links to CCG’s Corporate Objectives Y/N To have the highest quality of governance and processes to Y support its business To commission high quality health care that meets the needs Y of individuals and groups Wherever it makes safe clinical sense to bring care closer to Y home To support a safe and sustainable local hospital, supporting N them to transform the way they provide services so that they are as efficient and effective as possible for the people of Barnsley To develop services through real partnerships with mutual Y accountability and strong governance that improve health and health care and effectively use the Barnsley £. 3. Governance Arrangements Checklist 3.1 Financial Implications Has a financial evaluation form been completed, signed off N by the Finance Lead / CFO, and appended to this report? Are any financial implications detailed in the report? Y

3.2 Consultation and Engagement Has Comms & Engagement Checklist been completed? NA Is actual or proposed engagement activity set out in the N report?

3.3 Equality and Diversity Has an Equality Impact Assessment been completed and N appended to this report?

3.5 Environmental Sustainability Are any significant (positive or negative) impacts on the Positive environment discussed in the report?

3.6 Human Resources Are any significant HR implications identified through N discussion with the HR Business Partner discussed in the report?

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GOVERNING BODY

14 March 2019

COMMISSIONING OF CHILDREN’S HEALTH SERVICES UPDATE

1. THIS PAPER IS FOR

Decision Approval Assurance x Information x

2. REPORT OF

Name Designation Executive Lead Lesley Smith Chief Officer Author Patrick Otway Head of Commissioning (Mental Health, Children’s, Maternity and Specialised Services)

3. EXECUTIVE SUMMARY

This report aims to update the Governing Body on the work that has been undertaken since the November 2018 update in relation to the commissioning of Children’s Health Services in Barnsley.

Key issues in relation to the commissioning of Children’s Health Services in Barnsley are highlighted and are focused upon the continued implementation of the refreshed Future in Mind Barnsley Local Transformation Plan re Emotional Well Being; CAMHS performance – particularly in relation to access and waiting times; children’s therapy services; the SEND programme and challenges within the children’s ASC and ADHD pathways.

4. THE GOVERNING BODY IS ASKED TO:

 Note the progress made and the risks highlighted

5. APPENDICES

 Appendix 1 – LTP – 2018/19 Q2 Assurance Feedback Letter  Appendix 2 – MindSpace report  Appendix 3 – Link to Chilypep Monitoring Report  Appendix 4 – CAMHS – KPI Performance Report

Agenda time allocation for report: 10 mins

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SUPPORTING INFORMATION

1. Links to the Governing Body Assurance Framework Risk ref(s) This report provides assurance against the following risks on 4.1 the Governing Body Assurance Framework: 2. Links to CCG’s Corporate Objectives Y/N To have the highest quality of governance and processes to Y support its business To commission high quality health care that meets the needs Y of individuals and groups Wherever it makes safe clinical sense to bring care closer to Y home To support a safe and sustainable local hospital, supporting them to transform the way they provide services so that they are as efficient and effective as possible for the people of Barnsley To develop services through real partnerships with mutual Y accountability and strong governance that improve health and health care and effectively use the Barnsley £. 3. Governance Arrangements Checklist 3.1 Financial Implications Has a financial evaluation form been completed, signed off N by the Finance Lead / CFO, and appended to this report? Are any financial implications detailed in the report? NA

3.2 Consultation and Engagement Has Comms & Engagement Checklist been completed? N Is actual or proposed engagement activity set out in the NA report?

3.3 Equality and Diversity Has an Equality Impact Assessment been completed and NA appended to this report?

3.5 Environmental Sustainability Are any significant (positive or negative) impacts on the NA environment discussed in the report?

3.6 Human Resources Are any significant HR implications identified through NA discussion with the HR Business Partner discussed in the report?

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1. INTRODUCTION

Subsequent to the arrangements described in previous papers to the Governing Body the following updates are provided:

 LTP (Local Transformation Plan)  CAMHS performance - focusing on waiting times  Children’s therapy services  SEND Inspection  ASC / ADHD pathways  NHS Long Term Plan

2. ISSUES

2.1 Local Transformation Plan

The overarching focus of the LTP is to ensure we provide the most appropriate intervention at the earliest possible time to prevent escalation and the need for more specialist mental health support. The core services developed as part of Future in Mind to deliver this ambition include MindSpace, CAMHS SPA (Single Point of Access), CAMHS support to the Youth Offending Team, Young peoples engagement facilitated by Chilypep (includes mental health training and the Young Commissioners plus the Peer Mentors at Barnsley College) and the implementation of the THRIVE model in a number of our Primary Schools.

An aspiration of Barnsley’s refreshed Local Transformation Plan is for all 77 of Barnsley’s Primary schools to implement the THRIVE model (currently 50% of our Primary schools are engaged in the programme) and for us to develop a second mental health therapeutic support team to focus on providing support to our Primary School children, Post 16 students and the more vulnerable children within the borough, such as those young people who are educated at home. We also need to consider how we can better support the emotional health and wellbeing of those pupils attending the boroughs only SEMH (Social Emotional Mental Health) Special School.

The reports at Appendix 2 and 3 highlight the fantastic work being undertaken by MindSpace and Chilypep to better support all of Barnsley’s children and young people’s emotional health and wellbeing.

Although significant progress has been made within the borough, as indicated within NHS England’s feedback (Appendix 4), a number of challenges remain, including the need to develop a robust workforce strategy to enable continued delivery of the Future in Mind recommendations and more recently, that of the NHS Long Term Plan, and the need to focus on young peoples experience when transitioning from children’s healthcare services to adult healthcare services in order to make it a more positive experience for all concerned.

2.2 NHS Specialist CAMHS

The referral information into Barnsley’s NHS Specialist CAMHS service during the most recent 12 month period is detailed on pages 4 and 5 of Appendix 4 to this report.

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In the first 9 months of 2018/19 there has already been 1,358 referrals into the Barnsley NHS Specialist CAMHS service, showing continued high demand. Although local services have been developed to support children and young peoples’ lower levels of emotional health and wellbeing (e.g. MindSpace, implementation of THRIVE), it is anticipated that over time, these support services will reduce demand on Specialist CAMHS, although this is not their primary objective.

The average waiting time of the four CAMHS pathways combined remains steady at 247 days with the longest waits generally experienced by those young people on the complex behaviour pathway. There are a number of workstreams progressing that will potentially reduce the waiting times experienced on all of the CAMHS pathways but which are initially focused on the ADHD pathway (which is a significant element of the complex behaviour pathway.)

These workstreams include enhancing the parenting support to those children who may potentially need to be on the ADHD pathway; developing one neurodevelopmental pathway for ASC/ADHD assessment and diagnosis, with an early help assessment being a pre-requisite to accessing the pathway; waiting list initiatives working towards improving outcomes; targeted work on medication issues arising within the ADHD pathway, including increasing access to shared care protocols. Additional investment will be required to deliver a number of these initiatives and the funding requirements are outlined in the ‘Transformational Funding Investment’ report for the Governing Body (Private Agenda).

2.3 Children’s Therapy Services

As reported previously, the Children’s Physiotherapy and Occupational Therapy services provide intervention for:

 Children aged 0 – 16 years in mainstream school (0 – 19 years in specialist education provision)  Children who have been identified as having physical, sensory, perceptual or learning difficulties that affect their function / independence

In November 2018 a paper was presented to Governing Body outlining the key challenges within therapy services of increased waiting times to access the service due to a consistently increasing demand for the service since 2013 and lack of current capacity within an already lean service.

In 2016 the CQC undertook a review of therapy services and although the service was evaluated as good with outstanding for caring the CQC recommended that the service needed to work towards reducing the referral to treatment times as waiting times were in breach of the national recommended 18 weeks. The current waiting times remain in breach of the 18 week RTT.

Governing Body acknowledged the issues facing children’s therapy services but wanted to be clearer as to how the levels of investment required had been calculated. The investment outlined in the Business Case was in excess of £600k. Consequently, a meeting was held in January 2019 between colleagues from SWYPFT and the CCG’s Clinical lead for children plus representatives

4 GBPu 19/03/11

from the CCG’s commissioning and contracting teams. SWYPFT colleagues worked through the demand and capacity tool utilised for their business case clarifying a number of assumptions that they had included within the model.

The funding requirements are outlined in the ‘Transformational Funding Investment’ report for the Governing Body (Private Agenda).

2.4 SEND Inspection

New duties on local areas regarding provision for children and young people with special educational needs and / or disabilities are contained in the Children and Families Act 2014 and amplified in regulations and in the ‘Special educational needs and disability code of practice: 0 – 25 years. The Code of Practice is statutory guidance published by the Department for Education (DfE) and the Department of Health (DoH). The duties came into force in 2014.

The Minister of State for Children and Families has tasked Ofsted and the Care Quality Commission (CQC) with inspecting local areas on their effectiveness in fulfilling the new duties – that is, their effectiveness in identifying and meeting the needs of children and young people who have special educational needs and/or disabilities.

Ofsted and CQC are required to carry out their work in ways that encourage the services they inspect and regulate to improve, be user-focused and be efficient and effective in their use of resources. The inspections provide an independent external evaluation of how well a local area carries out its statutory duties in relation to children and young people with special educational needs and /or disabilities in order to support their development.

The inspection will review how local areas support these children and young people to achieve the best possible educational and other outcomes, such as being able to live independently, secure meaningful employment and be well prepared for their adult lives. Therefore, although the inspections are designed to hold local areas to account, they also intend to assist local areas in improving and developing their processes and support systems in order that local areas become more effective and deliver better outcomes for children and young people.

The inspection leads to a published report that:

 Provides children and young people, parents, elected council members, local providers and those who lead and manage the delivery of services at local level with an assessment of how well the local area is meeting the needs of children and young people with special educational needs and / or disabilities, and how well service providers work together to deliver positive outcomes  Provides information for the Secretary for State for Education about how well the local area is performing its role in line with its statutory responsibilities and the Code of Practice  Promotes improvement in the local area, its education, health and social care provision  Where relevant, requires the local area to consider the actions that it

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should take in light of the report and prepare a written statement that sets out those actions and the timetable for them.

It is important to note that these inspections will evaluate how effectively the ‘local area’ meets its responsibilities, and not just the local authority. The local area includes the local authority, clinical commissioning groups (CCG’s), public health, NHS England for specialist services, early year’s settings, schools and further education providers.

All local areas are to be inspected over a 5 year period, with the first inspection commencing in May 2016. Barnsley is still to be inspected. In preparation for the inspection, which could happen any time, the Local Authority and partners have completed a self-evaluation which is continually updated and have established an ‘evidence bank’ of all relevant documents / reports / Board papers etc. A SEND Programme Board is established and more recently a SEND Inspection Preparedness Board which focuses entirely on ensuring the local area is as prepared as possible for whenever the Inspection takes place. The CCG is represented on both Boards by the CCG SEND lead (Head of Commissioning – Mental Health, Children’s, Maternity and Specialised) supported by the CCG’s lead nurse for children with complex health needs and the CCG’s nominated officer for the SEND Inspection, Carol Williams.

It is suggested that the Barnsley SEND self-evaluation assessment be shared with Governing Body members when it has been fully updated, following the next SEND Programme Board due to be held in March 2019.

2.5 ASC / ADHD Pathways

As previously reported Governing Body members will be aware of current challenges faced with both the ASC and ADHD pathways. The issues around the ADHD pathway have already been outlined in 2.2 of this report. The key challenge on the ASC pathway is the increasing waiting times from referral to completion of assessment – on the 5 – 11 pathway the current wait, on average, is 9 months but on the over 11 pathway the current wait is 2 years and still growing.

In 2015 there was a significant backlog of young people on the ASC pathway. The CCG provided non-recurrent funding at that time to eradicate the backlog and the ASC pathways were redesigned with the Paediatricians at BHNFT being responsible for the 5 – 11 pathway and SWYPFT taking responsibility for the over 11 pathway.

The commissioned capacity from SWYPFT on the over 11 pathway is one session (a half day) per week. The consultant leading on this pathway was very experienced and it was evident spent much more of her time than the one session per week leading the ASDAT panel and associated administrative functions. Unfortunately the consultant resigned from her post and left in August 2018. A replacement came into post in February 2019, therefore no ASDAT panels have taken place since August resulting in over 132 children on the waiting list with approximately 10 referrals per month to this pathway. The newly appointed SWYPFT consultant only provides the commissioned capacity and therefore sees one child per week.

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This situation is unacceptable to all and the Paediatricians have suggested that they become responsible for the over 11 pathway whilst maintaining access to the SWYPFT consultant psychologist for advice and support. All partners agree that this solution could eliminate the backlog and improve access and waiting time standards on all ASC pathways. However, this will need additional funding and a business case is considered within the ‘Transformational Funding Investment’ report for the Governing Body (Private Agenda).

2.6 NHS Long Term Plan

The recently published NHS Long Term plan states that ‘the health of children and young people is determined by far more than healthcare. Household income, education, housing, stable and loving family life and a healthy environment all significantly influence young people’s health and life chances. By itself, better healthcare can never fully compensate for the health impact of wider social and economic influences. Nevertheless, the NHS plays a crucial role in improving the health of children and young people: from pregnancy, birth and the early weeks of life; through supporting essential physical and cognitive development before starting school; to help in navigating the demanding transition to adulthood. Working closely with local government and other public services, the NHS can also play an important role in tackling obesity and improving mental health.’

Under the Long Term Plan the NHS is making a commitment that funding for children and young peoples mental health services will grow faster than both overall NHS funding and total mental health spending. Key areas for this investment include:

 Continued expansion of access to community-based mental health services  Further investment on eating disorder services  Expanding timely, age-appropriate crisis-services  Embed mental health support for children and young people in schools and colleges  Extension of current service models to create a comprehensive offer for 0 – 25 year olds that reaches across mental health services for children, young people and adults (such as the Thrive model)

In relation to children with cancer, from 2019 all children with cancer will be offered whole genome sequencing to enable more comprehensive and precise diagnosis, and access to more personalised treatments.

From September 2019; all boys aged 12 and 3 will be offered vaccination against HPV – related diseases, such as oral, throat and anal cancer.

Over the next five years NHS England will increase its contribution to the Children’s hospice grant programme by match-funding CCG’s who commit to increase their investment in local children’s palliative and end of life care services.

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3. RISKS TO THE CLINICAL COMMISSIONING GROUP

Risk to realising benefits, or reducing risk, in relation to waiting times to access treatment from CAMHS leading to poorer outcomes for the children and young people.

Risks in relation to not providing appropriate and timely care for children and young people with or expected to have ASC /ADHD and /or LD

Increased complaints and poorer outcomes for children in relation to extended waiting times to access children’s therapy services

Inability to deliver the recommendations of the NHS Long Term Plan if appropriate investment is not possible

4. CONCLUSION

The CCG continues to pursue improved outcomes for vulnerable children and young people and is ensuring that all associated supporting work is progressed to deliver sustainable services to achieve this.

8 Appendix 1

PRIVATE & CONFIDENTIAL (Yorkshire and the Humber) Mr Patrick Otway Oak House Head of Commissioning (Mental Health, Children’s Moorhead Way and Specialised Services) Rotherham S66 1YY By Email Only [email protected] [email protected] Cc: [email protected], [email protected]

15 January 2019

Dear Patrick

Children and Young People’s Local Transformation Plan Refresh - October 2018

Thank you for the submission of your October 2018 refreshed Local Transformation Plan (LTP) for Children and Young People. An extensive panel comprising representation from Health and Justice, Specialised Commissioning, Public Health England, Transforming Care and the Yorkshire and the Humber Clinical Network (including the Local Authority Advisor and Clinical Leads) reviewed your refreshed plan in December 2018. Your plan was also reviewed by a representative from Stairways and feedback has been included within this letter.

At this stage of the five year plan we have reviewed refreshed LTPs against the delivery of the recommendations outlined within Future in Mind (FiM) under each of the five themes. An overall confidence rating of delivery of the FiM recommendations to date was agreed by the panel for each of the themes and these are set out below. We acknowledge that LTPs are five year plans and that work will still be in progress and ongoing for the remainder of the plan.

Overall Comments

Your plan was highly regarded by the panel for being comprehensive, ambitious and innovative. Your areas of focus were strategically framed within the context of the wider system (i.e. South Yorkshire and Bassetlaw Integrated Care System) with your commitment to partnership working and stakeholder engagement clearly evident. It would have been helpful, and would have strengthened your plan further, if clarity was provided on the ambition, aims and objectives of each of your priority areas.

Your progress was clearly outlined, with the impact and outcomes of your work clearly demonstrated through data, feedback, newspaper articles and case studies. Your plan was transparent, identifying challenges and areas requiring further work throughout, with a whole system approach to the mitigation of risk. The panel acknowledged that your highest priorities were reducing access and waiting times into specialist CAMHS. It was helpful to read of your pro-active approach to addressing gaps in services, e.g. alternatives to medication reviews for ADHD and your commitment to continuous improvement and learning, e.g. request for IST support and your peer review with Doncaster.

1 The panel were able to identify lots of positive work undertaken since the last LTP refresh, with your ‘Wellbeing Wednesday’ sessions, ‘Youth Mental Health First Aid Kit ‘Belonging Resilience and Vocabulary’ (BRV) projects all highly regarded. Your future ambitions were clearly set out along with the rationale. It would be helpful to outline your initial plans for sustainability and thinking beyond Future in Mind (i.e. post 2020/2021).

Whilst your supporting appendices were informative this did make the size of the document overwhelming, which had an impact upon the accessibility of the document. It may be worth including hyperlinks to the appendices in future iterations.

1. Promoting Resilience, Prevention and Early Intervention

Your plan demonstrated a clear emphasis on early help, prevention and resilience and showcased your extensive whole schools approach, including Peer Mentoring provision in colleges. Your ambition to roll out Mindspace and THRIVE principles was acknowledged, along with your commitment to progress your green paper bid regardless of the outcome. The panel were also pleased to read of your plans to expand your digital and self-care offer through the extension of Mindspace, provision of digital counselling and app development.

Your Joint Strategic Needs Assessment undertaken in 2018 was highly commended by the panel for highlighting wider determinants of health such as poverty and housing and demonstrated clear links to the development of your priorities.

The panel found your chapter on ‘Service Transformation’ extremely informative, with universal services of particular interest. It was positive to note the breadth of early years support available including family centres, wellbeing practitioners and parenting programmes. It would be helpful to receive further detail on how these have impacted upon outcomes for families, including their experiences of services. Your use of the validated screening tool, alongside other measures was also acknowledged.

Your comprehensive update on perinatal mental health was well regarded by the panel, particularly the work to develop a Community Specialist Mental Health service and the appointment of a Specialist Mental Health Midwife. It was interesting to note the links between the Specialist Mental Health Midwife and the IAPT service, with approximately 300 women referred per year. It was also encouraging to see the identification of gaps for perinatal mental health and your plans to address these. Your plan would benefit from further reference to the work programme of the South Yorkshire and Bassetlaw Local Maternity System on perinatal mental health to ensure integrated pathways are developed.

The panel were therefore fully confident of your delivery of the Future in Mind recommendations for this theme.

2. Improving Access to Effective Support

It was encouraging to read that your eating disorder pathway was accepting self-referrals and had been revised to include GP and paediatric protocols across the four CCGs within the collaborative. The panel were pleased to note that SYEDA had been commissioned to pilot a student in school eating disorder service within four schools in Barnsley and would welcome further updates on the impact and outcomes of this work following the evaluation in March 2019. Your Body, Image and Feelings group (BIF) was also highly regarded.

The panel acknowledged that waiting times remained a particular challenge, particular for children and young people entering the complex behaviour pathway including LD, ADHD and ASD. It was pleasing to read that you have plans in place to try and address these waits, for example revisions to pathways, consideration of a single neurodevelopmental pathway and system wide developments of a sustainable approach to the assessment, care and treatment of CYP with ADHD.

It would have been helpful for you to provide further detail of your plans, estimated timescales and any barriers/challenges to ensuring all of the positive work and activity taking place is accurately reflected through the Mental Health Services Dataset (MHSDS) to demonstrate your delivery against the CYP access standard (32% for 2018/19). The panel acknowledged that you hoped this would be considered and addressed as part of the proposed IST review.

Your plans to improve your crisis support offer were welcomed, particularly given your high emergency admission and self-harm rates, through the development of an all age psychiatric liaison service and pre-crisis support within the community. We look forward to seeing the impact and outcomes of these developments.

Finally, your intentions to further develop transition pathways were positively received, particularly your plans to improve young people’s experiences of transitioning from Year 6 to Year 7. Reference to the Transition CQUIN would have further strengthened your plan. It would also be helpful to understand your plans for a truly integrated single point of access and tierless service offer.

The panel were therefore partially confident of your delivery of the Future in Mind recommendations for this theme, but recognised the plans you have in place to improve crisis support, waiting times and access to services.

3. Care for the Most Vulnerable

The panel were pleased to read of your positive interventions for vulnerable children, for example your jointly commissioned sexual abuse and rape crisis service (BSARCS) and Multisystemic Therapy (MST) for Youth Offending Services. Your revisions to the Children in Care CAMHS service pathway were noted, along with your work to progress the support provided to Care Leavers, including the Local Authorities awareness raising of mental health practitioners to the specific vulnerabilities of Care Leavers. It was also positive to read that your Youth Offending CAMHS staff were trained to deliver evidenced based interventions.

The panel were therefore fully confident of your delivery of the Future in Mind recommendations for this area.

4. Accountability and Transparency

Your plan evidenced clear and effective system wide engagement with strong lines of accountability, reporting and governance. Extensive participation and co-production with children and young people was demonstrated throughout, with the examples provided e.g. Suicide Prevention and CAMHS SPA poster being highly regarded by the panel. It was pleasing to see that work had been progressed in response to feedback received from children, young people and their families. You may wish to consider including children and young people’s artwork on the front cover of your plan and developing an introductory section with children and young people, as this has proven effective elsewhere and would further enhance your plan.

The panel were therefore fully confident of your delivery of the Future in Mind recommendations for this theme.

5. Developing the Workforce

The panel welcomed your plans to develop a robust, system wide workforce strategy in 2019 as this will provide further assurance of your ability to deliver on the recommendations outlined within Future in Mind. You may also wish to consider the development of a coordinated training and development offer. It was also positive to note your plans to upskill your workforce through training and your exploration of alternative ways to undertake medication reviews for CYP with ADHD.

At this stage of the Local Transformation Plan the panel were able to be partially confident of your delivery of the Future in Mind recommendations in this area but acknowledged your ongoing commitment and priorities to further develop this theme.

Please get in touch if you have any queries and thank you for all your continuing work with Children and Young People’s Mental Health.

Yours sincerely

Dr David Black Medical Director (joint) NHS England Yorkshire and Humber and Deputy National Clinical Director Specialised Commissioning

Appendix 2

MindSpace report January 2019

Referrals from schools

From the 29TH October 2018 to 18th January 2019, we have received 70 referrals directly from the schools.

Schools Number of referrals Male Female Barnsley Academy 5 2 3 Darton Academy 10 5 5 Dearne ALC 2 1 1 Holy Trinity 8 4 4 Horizon College 4 0 4 Kirk Balk 6 3 3 Netherwood 8 3 5 Outwood Carlton 6 3 3 Outwood Shafton 18 10 8 Penistone Grammar 3 1 2

There has been a rise in referrals from Outwood Shafton, this has been a result of the pupil who took her life. The school have heightened anxieties and struggled to rationalise hence 18 referrals. There has been a number of meetings to support the school and closer working with school staff prior to referring young people.

Referrals from the weekly Single Point of Access.

Since 29th October 18 we have taken 21 referrals from CAMHS SPA.

11 male & 10 female. 11 for Anxiety, 7 for low mood, 2 for depression & 1 for anger.

MindSpace have taken 6 referrals to SPA, CAMHS agreed to offer them an initial assessment.

Up to date numbers for young people and parents accessing the MindSpace service.

May 2018 to December 2018 Number of children and young people accessing the 1:1 service 162 Male 65 Female 97 Number of referrals (from parents) who access counselling or 16 services from the Family Practitioner or both Number of parents accessing the Parent Service 73 Male 4 Female 69 Number of consultations with parent counsellor and Family 35 Practitioner and family Number of children and young people pending 8

Number of consultations with young people not requiring 44 MindSpace intervention but require either signposting to other services or we provide the young people with self-help strategies Male 11 Female 33

Number of young people accessing group sessions 338 Male 140 Female 198

The parent group is close to starting, we are following the Charlie Waller Memorial Trust delivery model, we are utilising the MindSpace CAMHS practitioner and Lisa who has been through the MindSpace parent service will co-facilitate the group. We have sourced premises at one of our primary academies rent free. The parent counsellor, family practitioner and Lisa the parent went to an information session at Prestwich hospital January 18th to gather ideas for the parent group. A name for the group will be decided at the first session co-produced by the parents attending. The group is for parents who have children with mental health difficulties and parents who may have their own mental health difficulty, we will deliver training to parents to support their son/daughter, delivered by the CAMHS practitioner, we will liaise with CAMHS to direct parents to our group. This is thrilling for everyone involved. A representative from Charlie Waller will visit Barnsley offering support to set up the group.

Appendix 4

CAMHS Key Performance Indicators Barnsley

December - 2018

Produced by Performance & Information Barnsley - CAMHS Key Performance Indicators Page 1 of 12 Contents

Indicator Page Supporting Information 3 Referrals Received 4 Emergency Referrals 6 Assessment (Choice) 7 Treatment (Partnership) 9 Other Information: 11 Discharges Caseload Average Length of Episode Average Contact per Referral Households with Multiple Referrals Out of Area Referrals Received

Produced by Performance & Information Barnsley - CAMHS Key Performance Indicators Page 2 of 12 Supporting Information

For the following KPI topics, activity and performance are reported based on the CCG of the client:

• Referrals

• Contacts

• Waits

• Did not attend (DNA)

• Caseload

• For example - Total referrals received KPI: contains any Barnsley CCG client no matter which SWYPFT CAMHS service they have accessed.

• The CCG of a client is determined by the GP practice the client is registered with.

• Since the upgrade to the RiO clinical system in November 2015, there has been intermittent problems accessing the system that have hampered real time data capture and created problems with extracting data for reporting purposes across the organisation, particularly during January. Data for November 2015 to March 2016 should be used with caution.

• Please note that if a cell is blank there is no activity for that month.

Produced by Performance & Information Barnsley - CAMHS Key Performance Indicators Page 3 of 12 Referrals Received

Total Referrals Received Referrals Received by Source

Dec- Jan- Feb- Mar- Apr- May- Jun- Jul- Aug- Sep- Oct- Nov- Dec- Dec- Jan- Feb- Mar- Apr- May- Jun- Jul- Aug- Sep- Oct- Nov- Dec- 17 18 18 18 18 18 18 18 18 18 18 18 18 17 18 18 18 18 18 18 18 18 18 18 18 18 Self Referral 3 8 7 3 4 4 4 2 6 10 5 4 1 Barnsley CAMHS 114 140 138 140 114 183 168 166 82 122 168 160 168 GP 42 56 63 44 31 61 64 60 32 59 68 59 62 Other SWYPFT CAMHS 5 3 10 2 4 3 5 2 1 1 5 1 5 Community based Paediatrics 13 5 6 8 10 12 14 8 4 1 5 10 8 Total 119 143 148 142 118 186 173 168 83 123 173 161 173 Hospital based Paediatrics 7 11 5 7 22 19 26 14 7 13 29 26 16 School Nurse 2 2 1 3 3 4 4 2 1 4 3 3 Education Service 17 14 19 20 10 23 9 24 14 18 12 26 Social Services 4 7 4 7 3 5 1 6 1 2 6 5 NHS Hospital Staff - Other 8 19 20 24 15 26 20 17 5 11 10 22 18 Other 23 21 23 26 20 32 31 35 27 13 28 20 39 Total 119 143 148 142 118 186 173 168 83 123 173 161 173

Referrals not requiring Assessment and or Intervention Referrals not requiring Assessment and or intervention by Source

Dec- Jan- Feb- Mar- Apr- May- Jun- Jul- Aug- Sep- Oct- Nov- Dec- Dec- Jan- Feb- Mar- Apr- May- Jun- Jul- Aug- Sep- Oct- Nov- Dec- 17 18 18 18 18 18 18 18 18 18 18 18 18 17 18 18 18 18 18 18 18 18 18 18 18 18 Barnsley CAMHS 49 37 59 65 48 67 60 74 46 51 62 50 68 Self Referral 1 2 1 3 1 3 2 Total 49 37 59 65 48 67 60 74 46 51 62 50 68 GP 27 19 37 31 23 26 30 44 26 34 40 30 39 Community based Paediatrics 2 2 5 5 9 7 6 3 1 6 5 Hospital based Paediatrics 3 3 2 5 7 5 1 4 4 3 1 School Nurse 1 1 3 2 4 1 1 1 3 1 2 Education Service 5 4 12 10 7 10 7 9 1 5 5 7 6 Social Services 3 3 1 1 1 2 1 NHS Hospital Staff - Other 2 4 1 3 2 2 1 2 1 Other 9 5 3 10 5 9 5 7 13 3 5 2 14 Total 49 37 59 65 48 67 60 74 46 51 62 50 68

Produced by Performance & Information Barnsley - CAMHS Key Performance Indicators Page 4 of 12 Referrals Received Cont. Signposted Referrals Signposted Referrals by Source

Dec- Jan- Feb- Mar- Apr- May- Jun- Jul- Aug- Sep- Oct- Nov- Dec- Dec- Jan- Feb- Mar- Apr- May- Jun- Jul- Aug- Sep- Oct- Nov- Dec- 17 18 18 18 18 18 18 18 18 18 18 18 18 17 18 18 18 18 18 18 18 18 18 18 18 18 Barnsley CAMHS 44 28 50 55 43 57 56 69 39 49 56 48 66 Self Referral 1 2 1 2 2 Total 44 28 50 55 43 57 56 69 39 49 56 48 66 GP 25 18 35 31 23 25 30 41 24 34 37 29 38 Community based Paediatrics 2 2 3 5 8 7 6 3 1 6 5 Hospital based Paediatrics 2 2 1 3 6 5 1 4 2 2 1 School Nurse 1 1 3 2 4 1 1 3 1 2 Education Service 5 2 9 7 7 9 6 8 4 5 7 6 Social Services 2 1 1 1 1 2 1 NHS Hospital Staff - Other 2 2 1 1 1 1 Other 7 3 2 8 4 7 4 7 9 3 5 2 13 Total 44 28 50 55 43 57 56 69 39 49 56 48 66

Description: Referrals not requiring assessment and or intervention

Referrals received includes all referral sources, urgencies and those referrals received that are assessed as not requiring a service from CAMHS . Referrals not requiring assessment and or intervention’ includes all referrals marked in the electronic patient record as "inappropriate","inappropriate advice/liaison given" or "inappropriate (signposted)" upon discharge. This could be done as soon as the referral comes in to the service or may happen after the initial or choice appointment. It does not include any clients where they have been signposted to another organisation/agency after treatment with the service. Signposted referrals are a subset of the total ‘Referrals not requiring assessment and or intervention’ .

Comments:

Produced by Performance & Information Barnsley - CAMHS Key Performance Indicators Page 5 of 12 Emergency Referrals

Emergency Referrals Received

Dec- Jan- Feb- Mar- Apr- May- Jun- Jul- Aug- Sep- Oct- Nov- Dec- 17 18 18 18 18 18 18 18 18 18 18 18 18 Barnsley CAMHS 8 28 19 26 35 38 36 27 11 21 34 40 26 Other SWYPFT CAMHS 1 4 1 1 2 1 Total 9 28 23 26 36 39 38 27 11 21 35 40 26

Description:

Emergency Referrals Received counts any referral with an urgency of "Emergency". Response within 4 hours is a direct (face to face) or indirect contact following receipt of the referral. Where ‘Other SWYPFT CAMHS’ is stated the data relates to clients previously with an address, and/or GP, from other CAMHS within the SWYPFT geographical footprint . Comments:

Produced by Performance & Information Barnsley - CAMHS Key Performance Indicators Page 6 of 12 Assessment (Choice)

Total Choice Contacts Average Wait to Choice Contacts (days)

Dec- Jan- Feb- Mar- Apr- May- Jun- Jul- Aug- Sep- Oct- Nov- Dec- Dec Jan Feb Mar Apr May Jun Jul- Aug Sep Oct Nov Dec 17 18 18 18 18 18 18 18 18 18 18 18 18 -17 -18 -18 -18 -18 -18 -18 18 -18 -18 -18 -18 -18 Barnsley CAMHS 39 52 40 42 42 44 46 38 30 26 28 35 25 Barnsley CAMHS 10 9 18 15 7 8 12 10 10 11 22 34 21 Total 39 52 40 42 42 44 46 38 30 26 28 35 25 Overall Average 10 9 18 15 7 8 12 10 10 11 22 34 21 (Days)

Total Referrals Waiting for Choice Contacts

Dec- Jan- Feb- Mar- Apr- May- Jun- Jul- Aug- Sep- Oct- Nov- Dec- 17 18 18 18 18 18 18 18 18 18 18 18 18 Barnsley CAMHS 45 41 45 39 31 34 28 25 15 23 39 35 57 Total 45 41 45 39 31 34 28 25 15 23 39 35 57

Produced by Performance & Information Barnsley - CAMHS Key Performance Indicators Page 7 of 12 Assessment (Choice) Cont.

Choice DNA Choice DNA Rate

Dec- Jan- Feb- Mar- Apr- May- Jun- Jul- Aug- Sep- Oct- Nov- Dec- Dec- Feb- Mar- Apr- May- Jun- Jul- Aug- Sep- Oct- Nov- Dec- 17 18 18 18 18 18 18 18 18 18 18 18 18 17 18 18 18 18 18 18 18 18 18 18 18 Barnsley CAMHS 3 1 3 3 3 7 3 3 2 1 3 4 3 Barnsley CAMHS 7% 7% 7% 7% 14% 6% 7% 6% 4% 10% 10% 11% Total 3 1 3 3 3 7 3 3 2 1 3 4 3 Overall Percentage 7% 7% 7% 7% 14% 6% 7% 6% 4% 10% 10% 11%

Description:

Total choice contacts are only those cases that are new referrals to generic CAMHS for those clients opting into the service. This does not include referrals where the necessary information is available at the point of triage in the Single Point of Access (SPA) to enable them to be placed directly to a specialist pathway without a face to face initial ‘generic’ assessment or internal referrals . These specialist pathways include for example : Children in Care (CiC) , Eating Disorder , Medication review and prescribing. Total referrals waiting for choice contacts as above only includes clients waiting for generic CAMHS and does not include those clients placed directly to specialist pathways.

Comments:

Next Available appointment as at 08-01-19: New St – 14-01-19 Grimethorpe – 15-01-19 Total clients waiting for choice as at 08-01-19: 35 (29 booked and 6 waiting for opt-in contact of these 1 were given 2nd opt-in)

Produced by Performance & Information Barnsley - CAMHS Key Performance Indicators Page 8 of 12 Treatment (Partnership) Contacts

Total Partnership Contacts Total Waiting for Treatment

Dec- Jan- Feb- Mar- Apr- May- Jun- Jul- Aug- Sep- Oct- Nov- Dec- Dec- Jan- Feb- Mar- Apr- May- Jun- Jul- Aug- Sep- Oct- Nov- Dec- 17 18 18 18 18 18 18 18 18 18 18 18 18 17 18 18 18 18 18 18 18 18 18 18 18 18 Barnsley CAMHS 428 604 513 558 461 592 602 521 371 457 577 656 494 Barnsley CAMHS 457 473 479 480 489 464 434 443 456 441 456 472 491 Total 428 604 513 558 461 592 602 521 371 457 577 656 494 Total 457 473 479 480 489 464 434 443 456 441 456 472 491

Barnsley CAMHS: Partnership Current Waits Average Length of Wait to Partnership

Dec- Jan- Feb- Mar- Apr- May- Jun- Jul- Aug- Sep- Oct- Nov- Dec- Apr17 - Apr17 - Apr17 - Apr17 - Apr18 - Apr18 - Apr18 - Apr18 - Apr18 - Apr18 - Apr18 - Apr18 - Apr18 - Dec17 Jan18 Feb18 Mar18 Apr18 May18 Jun18 Jul18 Aug18 Sep18 Oct18 Nov18 Dec18 17 18 18 18 18 18 18 18 18 18 18 18 18 Barnsley CAMHS 251 250 248 249 332 361 302 290 280 269 260 254 255 0 - 3 Months 105 92 88 82 94 74 66 97 102 83 78 102 110 Other SWYPFT CAMHS 1 1 1 2 51 35 35 27 27 22 16 16 11 3 - 6 Months 80 96 106 111 90 106 99 94 68 66 81 71 70 Overall Avg Days 244 243 239 240 324 352 298 285 276 264 253 248 247 6 - 9 Months 78 82 73 66 77 93 98 74 91 85 80 54 57 9 - 12 Months 74 66 70 68 77 62 53 67 79 91 72 83 77 > 12 Months 120 137 142 153 151 128 118 111 116 116 145 162 177 Total 457 473 479 480 489 463 434 443 456 441 456 472 491

Produced by Performance & Information Barnsley - CAMHS Key Performance Indicators Page 9 of 12 Treatment (Partnership) Contacts Cont.

Partnership DNA Partnership DNA %

Dec- Jan- Feb- Mar- Apr- May- Jun- Jul- Aug- Sep- Oct- Nov- Dec- Dec- Jan- Feb- Mar- Apr- May- Jun- Jul- Aug- Sep- Oct- Nov- Dec- 17 18 18 18 18 18 18 18 18 18 18 18 18 17 18 18 18 18 18 18 18 18 18 18 18 18 Barnsley Barnsley 18% 13% 17% 14% 10% 11% 15% 16% 17% 11% 12% 12% 11% CAMHS 108 107 115 105 56 80 122 113 88 66 88 105 74 CAMHS Overall Total 108 107 115 105 56 80 122 113 88 66 88 105 74 18% 13% 17% 14% 10% 11% 15% 16% 17% 11% 12% 12% 11% Percentage Description:

MDT process are implemented across the service and the MDT allocate from the waiting lists. The Service has an automated report for un-outcomed appointments not recorded in the patient record system and the data manager continues to issue this to staff on a monthly basis to sustain timely recording of contact data

Comments:

Produced by Performance & Information Barnsley - CAMHS Key Performance Indicators Page 10 of 12 Other Information

Total Discharges Caseload

Dec- Jan- Feb- Mar- Apr- May- Jun- Jul- Aug- Sep- Oct- Nov- Dec- Dec- Jan- Feb- Mar- Apr- May- Jun- Jul- Aug- Sep- Oct- Nov- Dec- 17 18 18 18 18 18 18 18 18 18 18 18 18 17 18 18 18 18 18 18 18 18 18 18 18 18 Barnsley CAMHS 89 108 119 173 129 166 144 179 151 119 146 119 146 Barnsley CAMHS 1328 1358 1381 1355 1364 1403 1416 1413 1368 1366 1363 1387 1381 Other SWYPFT CAMHS 8 1 4 3 6 4 7 3 2 3 1 6 Other SWYPFT CAMHS 5 7 12 12 9 8 5 5 5 6 8 7 7 Total 97 109 123 176 135 170 151 182 153 119 149 120 152 Total 1333 1365 1393 1367 1373 1411 1421 1418 1373 1372 1371 1394 1388

Average Length of Episode (days) Average Contact per Referral

Dec- Jan- Feb- Mar- Apr- May- Jun- Jul- Aug- Sep- Oct- Nov- Dec- Dec- Jan- Feb- Mar- Apr- May- Jun- Jul- Aug- Sep- Oct- Nov- Dec- 17 18 18 18 18 18 18 18 18 18 18 18 18 17 18 18 18 18 18 18 18 18 18 18 18 18 Barnsley CAMHS 436 431 344 413 424 531 398 426 424 415 469 489 365 Barnsley CAMHS 10 11 11 12 15 12 12 11 9 9 12 10 17 Other SWYPFT CAMHS 10 47 5 32 54 25 70 125 542 108 65 Other SWYPFT CAMHS 2 5 2 5 2 2 13 4 23 Overall Average (Days) 374 425 322 402 396 514 374 423 424 415 472 482 343 Overall Avg Contact 10 11 11 12 14 12 12 10 9 9 12 10 17

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Discharge Reasons

Dec- Jan- Feb- Mar- Apr- May- Jun- Aug- Sep- Oct- Nov- Dec- Jul-18 17 18 18 18 18 18 18 18 18 18 18 18 Failed to attend (repeated DNA, Cancel/CNA) 1 10 3 13 8 15 8 11 6 11 5 7 10 Failed To Attend At All 1 7 2 4 1 1 3 4 4 3 6 Inappropriate Referral 4 3 4 4 3 6 2 1 3 1 3 1 1 Inappropriate Referral (Advice/Liaison Given) 2 6 5 6 2 4 2 4 4 1 3 1 1 Inappropriate Referral (Signposted) 44 28 50 55 43 57 56 69 39 49 56 48 66 Moved Out Of Area 2 5 2 5 3 2 6 6 2 5 3 Other 16 17 17 39 32 33 40 39 54 17 34 40 42 Patient Discharged Him/Herself Or Was Discharged By A Relative Or Advocate 2 3 7 2 2 3 3 3 2 1 2 Patient Discharged On Clinical Advice Or With Clinical Consent 21 28 24 48 26 36 32 35 22 35 37 10 18 Signposted to a Locala service 1 2 1 6 4 2 Signposted to External Organisation/Agency 2 2 5 1 3 5 1 3 3 2 1 Transferred to adult mental health service 4 1 2 3 7 4 2 5 5 1 4 3 2 Transferred to other health care provider - not medium/high secure unit 1 1 1 1 1 Total 97 109 123 176 135 170 151 182 153 119 149 120 152

Description:

Average length of episode is from initial contact to discharge based on discharges in the month. Average number of contacts per referral is from referral to discharge and excludes inappropriate referrals., emergency referrals and those with zero or one contact.

Comments:

Produced by Performance & Information Barnsley - CAMHS Key Performance Indicators Page 12 of 12 GBPu 19/03/12

GOVERNING BODY

14th March 2019

Transforming Care Update

PART 1A – SUMMARY REPORT

1. THIS PAPER IS FOR

Decision Approval Assurance Information x

2. REPORT OF

Name Designation Executive / Clinical Lead Lesley Smith Chief Officer Author Patrick Otway Head of Commissioning (Mental Health, Children’s, Maternity and Specialised Commissioning)

3. SUMMARY OF PREVIOUS GOVERNANCE

The matters raised in this paper have been subject to prior consideration in the following forums:

Group / Committee Date Outcome Governing Body 10/1/19 Noted

4. EXECUTIVE SUMMARY

Governing Body members were provided with a comprehensive update and overview of NHS England’s Transforming Care Programme, which formally ends on 31 March 2019, although the aims and objectives of the programme will continue beyond this date. There remains the possibility of a successor programme but no further details have been provided.

Rather than re-provide the detailed information that was contained within the November Governing Body report this paper.

5. THE GOVERNING BODY IS ASKED TO:

 Note the current trajectory position

Agenda time allocation for report: 10 minutes

1 GBPu 19/03/12

PART 1B – SUPPORTING INFORMATION

1. Links to the Governing Body Assurance Framework Risk ref(s) This report provides assurance against the following risks on 4.1 the Governing Body Assurance Framework: 2. Links to CCG’s Priority Areas Y/N 1 - Urgent & Emergency Care 2 - Primary Care 3 - Cancer 4 - Mental Health Y 5 - Integrated Care System (ICS) 6 - Efficiency Plan 7 - Transforming Care for People with Learning Disabilities and / or Autistic Spectrum Conditions 8 - Maternity Y 9 - Compliance with Statutory and Regulatory Requirements 3. Governance Arrangements Checklist 3.1 Financial Implications Has a financial evaluation form been completed, signed off NA by the Finance Lead / CFO, and appended to this report? Are any financial implications detailed in the report?

3.2 Consultation and Engagement Has Comms & Engagement Checklist been completed? NA Is actual or proposed engagement activity set out in the report?

3.3 Equality and Diversity Has an Equality Impact Assessment been completed and NA appended to this report?

3.5 Environmental Sustainability Are any significant (positive or negative) impacts on the NA environment discussed in the report?

3.6 Human Resources Are any significant HR implications identified through NA discussion with the HR Business Partner discussed in the report?

2 GBPu 19/03/12

PART 2 – DETAILED REPORT

1. INTRODUCTION/ BACKGROUND INFORMATION

As stated in the November 2018 Governing Body report the focus of the Barnsley Transforming Care plan is on those in hospital and those at risk of admission and this aligns with other priorities and cross-cutting programmes of work.

There are nine principles underlying the Transforming Care Programme:

1. I have a good and meaningful everyday life 2. My care and support is person centred, planned, proactive and coordinated 3. I have choice and control over how my health and care needs are met 4. My family and paid support and care staff get the help they need to support me to live in the community 5. I have a choice about where I live and who I live with 6. I get good care and support from mainstream health services 7. I can access specialist health and social care support in the community 8. If I need it I get support to stay out of trouble 9. If I am admitted to a hospital setting for assessment and treatment I get good care and I don’t stay there longer than I need to

As the support required by this extremely diverse group of people is highly individualised, providing appropriate support presents numerous challenges and it therefore takes time for any movement to occur. As there has been little movement in the past 2 months this paper aims to provide an updated position on the refreshed trajectories for Barnsley. 2. DISCUSSION/ISSUES

As previously reported our Transforming Care Partnership has recently been identified by NHSE as one struggling in terms of progress to discharge patients. This has had the effect of putting our trajectory into Amber/ Red.

The refreshed trajectories for Barnsley for 2019/20 are outlined below.

NHS Barnsley LD Figures Q1 Q2 Q3 Q4 CCG numbers 11 9 7 5

Spec Comm 7 7 6 5 numbers

Although the Q4 trajectory of 5 falls short of the original anticipated target of 3 for Barnsley, the TCP footprint overall is expected to achieve its original targets.

A new complex case manager post is due to be appointed to in March 2019 and this full time post will focus solely on the Transforming Care Programme aims and principles and undertake all CTR’s (Care and Treatment Reviews) and CETR’s (Care ,Education and Treatment review)

3 GBPu 19/03/12

3. IMPLICATIONS

3.1 Financial implications

The current cost to the CCG of patients in in-patient care is £1.3 million per year.

4. RISKS TO THE CLINICAL COMMISSIONING GROUP

The risks to the CCG remain as previously reported but are primarily:

a) Risk of failure to meet the NHSE required trajectories for discharge which may result in people being placed inappropriately in high cost in- patient accommodation and negative publicity for the CCG in terms of outcomes for this vulnerable group.

b) A possibility of a financial impact for the CCG, resulting from the need to develop bespoke housing solutions in the community for a small number of patients from secure services with particularly complex and challenging needs. These will be identified on a case-by-case basis.

c) The TCP has not yet been able to identify suitable ‘Safe Place’ / crisis accommodation to support people in a crisis and avoid the requirement for a hospital admission. This is largely due to CQC registration requirements.

5. APPENDICES TO THE REPORT

None.

6. CONCLUSION

The aims, objectives and principles of the Transforming Care Programme will continue beyond the programmes formal end date and work will be progressed to ensure that appropriate placements are made, as close to Barnsley as possible, for all those people with a Learning Disability for whom it is appropriate and where it will provide an improved quality of life for that individual.

4 GBPu 19/03/13

GOVERNING BODY

14 March 2019

Updating the South Yorkshire and Bassetlaw Commissioning for Outcomes Policy to incorporate the Evidence Based Intervention Guidance.

PART 1A – SUMMARY REPORT

1. THIS PAPER IS FOR

Decision Approval X Assurance Information

2. REPORT OF

Name Designation Executive Lead Jeremy Budd Director of Commissioning Clinical Lead Dr Adebowale Adekunle Clinical Lead Author David Lautman Lead Commissioning and Transformation Manager

3. SUMMARY OF PREVIOUS GOVERNANCE

The matters raised in this paper have been subject to prior consideration in the following forums:

Group / Committee Date Outcome Clinical Forum 06/09/2018 Provided feedback on the national Evidence Based Interventions (EBI) consultation.

07/02/2019 Noted outcome of consultation and comments provided on revised clinical criteria. Management Team 19/09/2018 Noted national EBI consultation and provided additional feedback.

12/12/2018 Noted statutory guidance and approved approach to incorporate EBI into CFO policy. Directors of 11/01/2019 Considered local variances and agreed Commissioning single paper to be presented at CCG Governing Bodies.

GBPu 19/03/13 4. EXECUTIVE SUMMARY

As part of the Elective and Diagnostic Integrated Care Systems (ICS) work stream commissioners from South Yorkshire and Bassetlaw (SYB) CCGs have considered the Evidence Based Intervention (EBI) guidance (clinically ineffective interventions and co-produced an updated SYB Commissioning for Outcomes (CFO) policy.

Governing Body is presented with an updated South Yorkshire and Bassetlaw Commissioning for Outcomes Policy which incorporates the national Evidence Based Intervention guidance) for approval.

5. THE GOVERNING BODY IS ASKED TO:

 Approve and adopt the revised South Yorkshire and Bassetlaw Commissioning for Outcomes Policy.  Approve the proposed implementation of the Policy from April 2019 6. APPENDICES / LINKS TO FURTHER INFORMATION  Appendix 1 – Comparison of Variances between Evidence Based Intervention Guidance and Commissioning for Outcomes Policy (V19) & Summary of Changes to Local Evidence Based Interventions.  Appendix 2 – South Yorkshire and Bassetlaw Commissioning for Outcomes Policy (V20). Hard copy available on request.  NHS England Evidence Based Interventions Webpage: https://www.england.nhs.uk/evidence-based-interventions/

Agenda time allocation for report: 10 minutes

GBPu 19/03/13 PART 1B – SUPPORTING INFORMATION

1. Links to the Governing Body Assurance Framework Risk ref(s) This report provides assurance against the following risks on 9.1 the Governing Body Assurance Framework: 2. Links to CCG’s Priority Areas Y/N 1 - Urgent & Emergency Care N 2 - Primary Care N 3 - Cancer N 4 - Mental Health N 5 - Integrated Care System (ICS) Y 6 - Efficiency Plan N 7 - Transforming Care for People with Learning Disabilities and / N or Autistic Spectrum Conditions 8 - Maternity N 9 - Compliance with Statutory and Regulatory Requirements Y 3. Governance Arrangements Checklist 3.1 Financial Implications Has a financial evaluation form been completed, signed off NA by the Finance Lead / CFO, and appended to this report? Are any financial implications detailed in the report? NA

3.2 Consultation and Engagement Has Comms & Engagement Checklist been completed? NA Is actual or proposed engagement activity set out in the NA report?

3.3 Equality and Diversity Has an Equality Impact Assessment been completed and Y1 appended to this report?

3.5 Environmental Sustainability Are any significant (positive or negative) impacts on the NA environment discussed in the report?

3.6 Human Resources Are any significant HR implications identified through NA discussion with the HR Business Partner discussed in the report?

1 A national Equalities and Health Inequalities Analysis has been completed (see section 7 of detailed report). A local EIA will be delegated to the Equality and Engagement Committee for completion. GBPu 19/03/13 PART 2 DETAILED REPORT

Updating the South Yorkshire and Bassetlaw Commissioning for Outcomes Policy to incorporate the Evidence Based Intervention Guidance.

March 2019

1. Purpose 1.1. The purpose of this paper is to present CCG Governing Bodies with an updated South Yorkshire and Bassetlaw Commissioning for Outcomes (CFO) Policy to incorporate the national Evidence Based Intervention (EBI) guidance (clinically ineffective interventions). 1.2. Whilst CCG Governing Bodies have previously agreed a process for decision making whereby policy minor amendments and updates to the CFO policy e.g. to reflect new NICE guidance can be delegated to commissioners. On this occasion the whole policy is presented for approval and adoption because incorporating evidence based interventions represents a significant rewrite. 1.3. This paper also provides assurance that the SY&B approach reflects national guidance. 1.4. In addition to incorporating the EBI guidance, SY&B commissioners in conjunction with the Lead Medical Adviser & the Head of IFR have reviewed, and where appropriate refreshed, the aspects of the policy not covered by the EBI guidance. This includes a review of local evidence based interventions and the specialist plastics policies.

2. Introduction 2.1. As research is carried out and medicine advances, treatments can be found to be inappropriate in certain circumstances therefore it is important to ensure only appropriate treatments are offered. Sometimes, a safer, less invasive alternative becomes available. Surgical interventions can be painful and can result in unintended complications or harm. Therefore, they should only be offered to patients who really need it. 2.2. To ensure an equitable approach across the country, in November 2018 NHS England and partners (NHS Clinical Commissioners, the Academy of Medical Royal Colleges, NHS Improvement and NICE) issued statutory guidance to CCGs via the Evidence Based Interventions (EBI) guidance for CCGs. 2.3. The aim of the Evidence Based Interventions programme is to prevent avoidable harm to patients, avoid unnecessary operations and to free up clinical time by only offering interventions on the NHS that are evidence-based and appropriate. 2.4. The guidance looks at how to best reduce the number of unnecessary interventions provided by the NHS and focuses commissioning guidance and clinical criteria for when seventeen interventions should be commissioned and offered. Four that should not be routinely offered to patients unless there are exceptional circumstances and thirteen interventions that should only be offered to patients when certain clinical criteria are met. 2.5. The interventions are summarised in Table 1 below. GBPu 19/03/13

Table 1 – National Evidence Based Interventions

Category 1 Interventions which should not be routinely commissioned or performed A Snoring surgery in absence of OSA B D&C for heavy menstrual bleeding C Knee arthroscopy for osteoarthritis D Injections for non-specific lower back pain Category 2 - Interventions which should only be routinely commissioned or performance when specific criteria are met E Breast reduction, asymmetry and gynaecomastia F Removal of Benign Skin Lesions G Grommets for glue ear in children H Tonsillectomy for recurrent tonsillitis I Haemorrhoid surgery J Hysterectomy for heavy menstrual bleeding K Chalazia removal L Arthroscopic Decompression of the shoulder for sub-acromial pain M Carpal tunnel release N Dupuytren's surgery O Ganglion surgery P Trigger finger release Q Varicose vein surgery

2.6. The guidance will come into effect from 1 April 2019 via changes to reimbursement in the National Tariff Payment, and will apply to all patients added to the waiting list from 17 January 2019.

3. South Yorkshire & Bassetlaw Approach 3.1. Many local health systems have already developed and implemented policies that address the above issues, engaging and consulting local clinicians, providers and their populations. 3.2. In South Yorkshire and Bassetlaw criteria for commissioning certain interventions (procedures of limited clinical value, prior approval and clinical thresholds) have been in place for several years from CCG formation. 3.3. More recently the South Yorkshire and Bassetlaw Commissioning for Outcomes Policy (CFO) has brought together commissioning policies from across the region into a single standardised policy. SY&B Commissioners and the Individual Funding Request (IFR) team have therefore completed a comparison of the variances between the SYB Commissioning for Outcomes (CFO) policy and the national EBI policy which is summarised in Appendix 1. 3.4. This review highlighted that there were only minor variances between local and national guidelines. GBPu 19/03/13 3.5. The approach that commissioners have taken is to update the existing CFO policy to incorporate the national guidance. Commissioning for Outcomes is a broader policy which includes additional local evidenced based procedures, specialist plastics policy, fertility policies and procedures not routinely commissioned. Where necessary local documentation has been updated to reflect national wording and evidence base. 3.6. For some conditions, applying an evidenced based approach; commissioners believe there is justification to vary from the national policy. These conditions are:  Breast reduction / asymmetry & gynaecomastia (male breast reduction)  Tonsillectomy  Arthroscopic Decompression of the shoulder  Varicose Veins Surgery

3.7. The majority of variances proposed are included to ensure that the policy can be implemented in primary and secondary care and so are about processes rather than clinical policy. 3.8. The exception is Varicose Veins where the current policy requires patients to have a BMI of 30 or less. Whilst this is not a feature of the national guidance, NICE clinical guidance 168 notes that a raised BMI is identified as a factor associated with increased risk of progression of varicose veins and notes that the surgical outcome with increased BMI is worse (there is a higher risk of reoccurrence). 3.9. The following justification and rationale has been arrived at for deviation from national guidance in the areas outlined in section 3.4 and to maintain additional policies (listed in Table 2):  The national guidance states that the EBI programme does not seek to reverse local decisions which have been legitimately reached. The SYB CFO policy has been arrived at via legitimate local decision making.  The development of these commissioning policies has been consistent with national guidance.  To remove the policies would conflict with the CCGs’ statutory responsibilities to commission a range of services from providers that will best meet the needs of their patients and population overall.  To remove the policies could result in an increase in referrals or activity that would be contrary to the objectives of the EBI programme. 4. Local Evidenced Based Procedures 4.1. In addition to incorporating the EBI guidance, South Yorkshire and Bassetlaw (SY&B) commissioners have reviewed, and where appropriate refreshed, the aspects of the policy not covered by the EBI guidance. This includes local evidence based interventions and fully incorporating the specialists plastics policies into the CFO policy. 4.2. The following additional procedures have been added to the specialist plastics policy:  Correction of male pattern baldness (not routinely commissioned)  Vaginoplasty and hymen reconstruction (not routinely commissioned)  Surgical Repair of torn or split earlobes (not routinely commissioned).

GBPu 19/03/13 Table 2 – Local Evidence Based Interventions

Procedures that are subject to a local evidence based intervention but not included in the national proposals 1. Osteoarthritis (Hip Replacement) 2. Osteoarthritis (Knee Replacement) 3. Management of Gall Bladder Disease 4. Surgical Repair of Hernias 5. Cataract Surgery 6. Male Circumcision 7. Benign Perianal Skin Lesions 8. Ingrown Toe Nail 9. Bunions 10. Blepharoplasty 11. Grommets for Adults Procedures not routinely commissioned 12. Acupuncture 13. Vasectomy under General Anaesthetic 14. Procedures in the Specialist Plastics Policy 15. Procedures in the Fertility Policy

4.3. The following procedures have been removed from the specialists plastics policy as they are covered by checklists in the Commissioning for Outcomes Policy:  Benign Skin Lesions  Blepharoplasty

4.4. Furthermore, work has been undertaken to update and rewrite sections of the policy and checklists and remove variances e.g. where there were differences in criteria or referral procedures. These are also summarised in Appendix 1.

5. Anticipated Benefits & Risks 5.1. The Evidence-Based Interventions programme as a whole, is guided by the following five goals:  Reduce avoidable harm to patients. With surgical interventions, there is always a risk of complications. Weighing the risks and benefits of appropriate treatments should be co-produced with patients.  Save precious professional time, when the NHS is severely short of staff, professionals should offer appropriate and effective treatment to patients.  Help clinicians maintain their professional practice and keep up to date with the changing evidence base and best practice.  Create headroom for innovation. If we want to accelerate the adoption of new, proven innovations, we need to reduce the number of inappropriate interventions. This allows innovation in healthcare, prescribing and technology to improve patients’ ability to self-care and live with long term conditions. GBPu 19/03/13  Maximise value and avoid waste. Inappropriate care is poor value for the taxpayer. Resources should be focused on effective and appropriate NHS services

5.2. The aims of the local CFO policy in line with national guidance are to:  improve the quality of care provided for all patients by following evidence based policies / providing & commissioning evidence based care.  offer more equitable access for patients by reducing variation between individual GPs (i.e. not just SY&B CCGs)  review and bring together similar commissioning policies from across the region with the aim of reducing variance between individual CCG policies by producing a standardised policy.  reduce the number of policies providers are expected to follow.

5.3. The following risks may apply to implementing this programme of work based on prior experience of mobilising the policy:  There is a risk that if Primary Care clinicians are not suitably engaged in the programme then this could result in low confidence of adherence to the policy.  There is also a risk of a lack of compliance and adherence of the clinical thresholds by both Primary and Secondary Care.  There is a risk that if insufficient engagement takes place then the programme is unable to progress within stated timescales. There is also a subsequent risk to the CCG’s reputation.

6. Impact of Implementing the Policy 6.1. In addition to setting out clinical guidance the Evidence Based Intervention (EBI) guidance also sets out local activity goals. From 1 April 2019 the national activity goals expected that:  No Category 1 interventions will be performed unless accompanied by an IFR and therefore the numbers of activity for Category 1 interventions will reduce to near zero.  Category 2 interventions should be reduced to the 25th percentile of the age-sex standardised rate of CCGs.

6.2. As noted in section 3 of this paper, CCGs in South Yorkshire have had commissioning criteria for interventions in place for several years. Each area will have therefore made progress against national activity targets since adopting the Commissioning for Outcomes Policy in 2018/19 and as a result of previous policies.

7. Patient and Public Involvement 7.1. A national public consultation exercise on EBI took place between 4 July and 28 September 2018. NHS England and partners received 707 online responses and 97 individual submissions. They also spoke to 397 individuals by hosting or attending events across the country. The response to the public consultation is published here: https://www.england.nhs.uk/publication/evidence-based- interventions-response-to-the-public-consultation-and-next-steps/ 7.2. As part of the development and implementation of the original SYB CFO policy, individual CCGs have engaged local clinicians, providers and their populations. GBPu 19/03/13 Local engagement on the SYB CFO policy continues to be place led taking a proportionate and incremental approach building on previous work.

8. Equalities and Health Inequalities Analysis 8.1. NHS England have published an Equalities and Health Inequalities Analysis on their website: https://www.england.nhs.uk/publication/evidence-based- interventions-policy-equality-and-health-inequalities-full-analysis-form/ 8.2. The analysis did not note any significant concerns in equality groups or health inclusion groups. Noting that the work aims to reduce health in equalities in access and outcomes for all patients groups by ensuring offer of appropriate treatment. Furthermore none of the interventions are subject to a blanket ban; if a clinician feels that a patient’s circumstances are exceptional and may benefit from any of these treatments then they can be referred to the IFR Panel. 8.3. For age the analysis highlights that a number of the interventions have a similar age profile to elective interventions overall. Where the age-profile differs (tonsillectomies, hysterectomy due to menstrual bleeding and knee arthroscopy) this is consistent with the age groups at which the underlying problem is most prevalent. 8.4. For ethnicity, the analysis looked at the profiles of patients referred in 2017/18 noting that the prevalence for these interventions are similar to all elective care. In the whole there is no substantial difference between the proportion of these interventions that are accessed by ethnic groups compared to the white British group when you take account of the different ethnic groups in different age groups. 8.5. The analysis did note that some conditions (chalazia removal and dupuytrens) were more common in different ethnic groups. However the guidance advance equality by prompting consideration of what is the most appropriate treatment between the doctor and their patient, meaning patients will always receive the most appropriate treatment. 8.6. To address any impacts the guidance has been reviewed to ensure it is NICE, and/or NICE-accredited and specialist society guidance and that the interventions will be available to people who meet the criteria and in exceptional circumstances through an individual funding request where appropriate. 9. Recommendation 9.1. CCG Governing Bodies are asked to approve and adopt the revised South Yorkshire and Bassetlaw Commissioning for Outcomes Policy. 9.2. Approve the proposed implementation of the Policy from April 2019.

Paper prepared by: David Lautman, Lead Commissioning and Transformation Manager, Barnsley CCG

On behalf of: The SY&B Commissioning for Outcomes Working Group & Anthony Fitzgerald, Director of Strategy and Delivery, Doncaster CCG, Elective and Diagnostic Work stream Commissioning Lead. 21 February 2019 GBPu 19/03/13 Appendix 1

National Evidence Based Interventions: Category 1 Interventions – Not Routinely Commissioned

Procedure currently Recommend EBI Procedure features within adopting EBI Proposed Prior Approval method Additional Comments Ref SYB CFO policy? policy? Intervention for snoring (not A No Yes IFR OSA) Yes - Not routinely Dilatation and curettage for commissioned B Yes IFR heavy menstrual bleeding (part of hysterectomy threshold) Knee arthroscopy with C No Yes IFR osteroarthritis Sheffield CCG previously excluded Injection for non-specific Yes - Not from MSK interventions. This has D low back pain without routinely Yes IFR now been amended so all CCGs sciatica commissioned follow the same policy

National Evidence Based Interventions: Category 2 Interventions – Only commissioned where criteria met

Procedure Proposed Continue use of an Recommend currently features Prior EBI Ref Procedure adopting EBI SYB CFO Rationale for Variation Additional Comments within SYB CFO Approval policy? checklist? policy? method SY&B Commissioners have elected to follow the existing local Specialist Plastics Policy for these interventions (referral via IFR).

Breast Reduction

Referrals for breast reduction under the

national criteria would require the clinician to The IFR panel will continue to provider accurately assess the weight of breast tissue to clinical oversight for these procedures. Yes – (Plastics IFR Application be removed [500gms or 4 cup sizes]. Additional Breast reduction / Policy) E No IFR (Clinical Letter & All CCGs will now follow the same asymmetry Not routinely clinical input is required hence the Questionnaire) criteria for assessment as variations in commissioned recommendation to use IFR. terms relating to BMIs and use of scans The local policy requires a minimum G cup (Doncaster CCG have been removed). which has been professionally measured to

ensure equity. For cases that are borderline medical photographs are requested.

Asymmetrical Breasts For asymmetrical breasts the Evidence Based GBPu 19/03/13

Procedure Proposed Continue use of an Recommend currently features Prior EBI Ref Procedure adopting EBI SYB CFO Rationale for Variation Additional Comments within SYB CFO Approval policy? checklist? policy? method Interventions guidance states a difference of 150-200g is required whereas the local policy stipulates a difference of two cup sizes with a professional measurement.

The national Evidence Based Interventions guidance states that surgery to correct gynaecomastia will only be commissioned for men with a history of prostate cancer. IFR Application

Gynaecomastia No IFR (Clinical Letter & SY&B Commissioners have elected to follow Questionnaire) the existing local Specialist Plastics policy for gynaecomastia which provides more comprehensive guidance on where this corrective intervention may be funded. For Benign Skin Lesions SY&B commissioners have elected to maintain the existing referral checklist (which is in line with the EBI policy) as the national criteria are very broad and unmanageable via checklist in long-form.

Removal of benign skin Yes - Existing CFO F Yes Checklist To ensure the referral process is manageable lesions Checklist checklist the checklist groups the criteria where a lesion might be removed.

Any patients that do not meet the threshold criteria can be referred to the IFR panel who will assess patients against the EBI guidance. The EBI policy only applies to glue ear (otitis media with effusion). Barnsley CCG previously required IFR The CCG will routinely fund additional approval. This has been amended so Yes - Checklist updated G Grommets in Children Yes Checklist conditions provided a checklist is completed to all CCGs follow the same referral Checklist to reflect EBI evidence a patient meets the criteria. process.

A separate policy is included for adults (part of CFO but not EBI) SY&B Commissioners noted that referrals for The National Evidence Based Interventions policy only applies to tonsillectomy for recurrent tonsillitis require No - IFR recurrent tonsillitis. Yes - application via additional clinical input to assess against H Tonsillectomy No IFR Checklist checklist and national criteria (number of occurrences of sore Additional local guidance is provided in clinical letter throats) hence the recommendation to use IFR. the CFO policy for conditions broader than recurrent tonsillitis e.g:  Recurrent Quinsy GBPu 19/03/13

Procedure Proposed Continue use of an Recommend currently features Prior EBI Ref Procedure adopting EBI SYB CFO Rationale for Variation Additional Comments within SYB CFO Approval policy? checklist? policy? method  Severe halitosis secondary to tonsillar crypt debris  Failure to thrive secondary to difficulty swallowing caused by enlarged tonsils  Obstructive sleep apnoea  Biopsy/removal of lesion on tonsil The requirement for IFR approval will apply to all tonsillectomy referrals Yes - Checklist updated I Haemorrhoidectomy Yes Checklist Checklist to reflect EBI Removed previous references to hysteroscopy which is NICE approved Hysterectomy for Yes - Checklist updated and Dilatation and Curettage for heavy J Heavy Menstrual Yes Checklist Checklist to reflect EBI menstrual bleeding which is covered by Bleeding (Category 1 – Ref B).

Yes - Checklist updated K Chalazia removal Yes Checklist Checklist to reflect EBI Commissioners have elected to follow the existing local policy for Arthroscopic shoulder decompression for sub-acromial shoulder pain. Existing CFO Arthroscopic Yes - checklist updated to Although the national policy mentions that non- L Decompression of the No Checklist Checklist reflect EBI operative management is effective, the existing Sheffield CCG previously excluded shoulder language. SYB policy is clearer on the clinical criteria for from MSK interventions. This has now conservative treatments. been amended so all CCGs follow the same policy. Checklist amended to reflect EBI policy Yes - Checklist updated M Carpal Tunnel Yes Checklist Checklist to reflect EBI Yes- Checklist updated N Dupuytren’s Disease Yes Checklist Checklist to reflect EBI Yes - Checklist updated O Ganglion Yes Checklist Checklist to reflect EBI Yes - Checklist updated P Trigger Finger Yes Checklist Checklist to reflect EBI In addition the SYB Policy requires patient to have a BMI of 30 or less Barnsley CCG previously required IFR NICE clinical guidance 168 notes that a raised Yes - approval. This has been amended so Q Varicose Veins Surgery No Checklist Mix of CFO and EBI BMI is identified as a factor associated with Checklist all CCGs follow the same referral increased risk of progression of varicose veins process. and notes that the surgical outcome with increased BMI is worse (there is a higher risk of reoccurrence). GBPu 19/03/13

Local Evidence Based Interventions There are 11 procedures were a local evidence based clinical threshold applies (procedures not included in the national guidance):

Procedure Comment / Revision / Update Osteoarthritis (Hip Replacement) Checklist and policy revised to clarify options for Patients with a BMI of > 35. These patients should be referred for weight management interventions for a minimum of 6 months. If the patient fails to lose weight to a BMI less than 35 then may consider referral through the IFR process. (Get Fit First applies for Barnsley patients). Sheffield CCG previously excluded from MSK interventions. This has now been amended so all CCGs follow the same policy Osteoarthritis (Knee Replacement) Checklist and policy revised to clarify options for Patients with a BMI of > 35 as above. Sheffield CCG previously excluded from MSK interventions. This has now been amended so all CCGs follow the same policy. Management of Gall Bladder Disease Policy statement in relation to one episode of mild abdominal pain clarified. Barnsley and Rotherham CCG patients will only be referred after one episode of mild abdominal pain. The threshold in respect of mild (one episode of mild abdominal pain) does not apply to Doncaster, Bassetlaw and Sheffield CCG. Surgical Repair of Hernias No changes made. Cataract Surgery Conversion chart between Snellen / Logmar added. Male Circumcision No changes made. Benign Perianal Skin Lesions No changes made. Ingrown Toe Nail No changes made. Bunions Wording related to conservative measures revised. Ordering of criteria on checklist changes to fit with ordering of patient work up. Sheffield CCG previously excluded from MSK interventions. This has now been amended so all CCGs follow the same policy Blepharoplasty No changes made. Grommets for Adults All CCGs will now use checklist to make referrals. Previously this was an IFR for Barnsley.

There are also additional procedures covered by the specialist plastics policy and fertility policy and procedures not routinely commissioned:  Acupuncture (no changes)  Vasectomy under General Anaesthetic (no changes)

Specialist Plastics Policy Procedure Summary of change Abdominoplasty Clarification that procedure may be considered if there is recurrent severe infection or ulceration beneath the skin fold despite conservative treatment or problems associated with poorly fitting stoma bags. Breast Augmentation Further examples where procedure will not be commissioned for cosmetic reasons. Clarification that revision surgery will only be commissioned for implant rupture. Correction of male pattern baldness New procedure added to policy. Facelift Clarification that this includes dermal fillers. Labiaplasty Extension to cover vaginoplasty and hymen reconstruction (not routinely commissioned) Liposuction Clarification that this procedure will not be commissioned simply to correct the distribution of fat. Surgical Repair of torn or split earlobes New procedure added to policy

GBPu 19/03/14

GOVERNING BODY

14 March 2019

2019/20 Practice Delivery Agreement Development

PART 1 SUMMARY REPORT

1. THIS PAPER IS FOR

Decision Approval  Assurance Information

2. REPORT OF

Name Designation

Lead Dr Sudhagar Krishnasamy GP Governing Body Lead

Authors Lynne Richards Primary Care Transformation Manager

3. EXECUTIVE SUMMARY

The purpose of this report is to present the final draft of the Practice Delivery Agreement for 2019/20 for Governing Body Members approval.

Introduction

Since 2014/15 Barnsley CCG has developed and implemented a local contract between itself and its 33 Member GP Practices called the Barnsley Practice Delivery Agreement (PDA). This is commissioned via an NHS Standard Contract. The aim of the 2019/20 Barnsley Practice Delivery Agreement (PDA) has been reviewed and refreshed to align to the NHS Long Term Plan and the changing landscape of the NHS as well as delivering on the integration agenda.

Whilst a number of schemes within this 19/20 PDA are set at individual GP practice level, GP practices will be encouraged to form into Integrated Care Networks to work towards a placed based care approach as referenced within the NHS Long Term Plan. Integrated Care Networks will build on the core of current primary care GBPu 19/03/14

services and enable greater provision of proactive, personalised, coordinated and more integrated health and social care.

The concept of the Practice Delivery Agreement (PDA), whilst supporting practices to invest in the infrastructure to deliver a comprehensive range of services to their practice population, also supports the CCG to deliver its general duties as outlined within the Health and Social Care Act Part 1 Section 26.

Principles and Methodology

The principle of the PDA is that practices sign up to deliver all schemes written into the contract. Schemes have been developed based on current national and local priority work programmes and are focussed on the health needs of the Barnsley population.

Draft schemes have been developed with input from the Practice Managers Group and the Local Medical Committee. This has provided the opportunity for Practice engagement during the early stages of development of the 2019/20 Practice Delivery Agreement to ensure that proposed schemes are achievable and supported in Primary Care. It has also provided the opportunity for Primary Care to propose their own scheme ideas for inclusion within the PDA based on population health need and current priorities identified from working on the front line of primary care.

GBPu 19/03/14

The above diagram illustrates the input that has gone into the developing the PDA schemes and also demonstrates the governance structure for the development and approval.

GP Practices are provided with a set of Key Performance Indicators (KPIs) for each scheme and individuals finance schedules are sent to practices. The CCG will develop reporting templates which will allow practices to demonstrate that KPI’s have been achieved over 4 submission periods. This process will also be facilitated, wherever possible, by EMBED Health Consortium through the production of standard codes, templates and searches.

Progress

The CCG has developed the draft 2019/20 Practice Delivery Agreement schemes based on priorities and the challenges facing the health of the population and the health service in general.

The 2019/20 PDA has 7 core schemes:

1. Integrated Care Networks 2. Medicines Optimisation Scheme 3. Get Fit First 4. Referral Support Toolkit 5. Health Inequalities Target Scheme (HITS) including: • CVD • Diabetes • COPD • Cancer 6. GP Forward View & Integrated Care Network Development • Social Prescribing - My Best Life • Dementia & Carer Support • Workforce • Phlebotomy

7. Medicines Management • Shared Care Drugs

The full schemes are appended to this report at Appendix 1.

Approval

Members have received the draft schemes at the Governing Body public meeting in January and also at the January 2019 Membership Council meeting. Feedback and comments from both meetings have been incorporated into the final specifications which are put forward for approval.*

*Please note that due to recent changes in QOF the CVD scheme specification has been amended as to not duplicate schemes. The changes are highlighted with track changes for members information.

The budgets and financial schedules of the PDA have been drafted and will be discussed and agreed at the Primary Care Commissioning Committee to manage GBPu 19/03/14

any conflicts of interests.

4. THE GOVERNING BODY IS ASKED TO:

 Review and comment on the 2019/20 Draft Practice Delivery Agreement Schemes.

5. APPENDICES  Appendix 1 – Barnsley Practice Delivery Agreement (PDA) April 2019 to March 2020  Appendix 2 – Draft Integrated Care Network spec  Appendix 3 - 2019/20 Draft Primary Care Practice Level Medicines Optimisation Scheme  Appendix 4 – Get Fit First In Barnsley 2019/20  Appendix 5 – Barnsley Referral Support Toolkit 2019/20  Appendix 6 - Cardiovascular disease 2019/20  Appendix 7 - Diabetes 2019/20  Appendix 8 - COPD 2019/20  Appendix 9 - Cancer 2019/20  Appendix 10 – My Best Life 2019/20  Appendix 11 - Dementia Specification 2019/20  Appendix 12 – Apex / Access & Workforce 2019/20 Specification  Appendix 13 – Phlebotomy Specification  Appendix 14 – Shared Care Drugs

Agenda time allocation for report: 10 minutes

GBPu 19/03/14

1. Links to the Governing Body Assurance Framework Risk ref(s) This report provides assurance against the following risks on the 2.1 Governing Body Assurance Framework: 2. Links to CCG’s Corporate Objectives Y/N To have the highest quality of governance and processes to Y support its business To commission high quality health care that meets the needs of Y individuals and groups Wherever it makes safe clinical sense to bring care closer to Y home To support a safe and sustainable local hospital, supporting N them to transform the way they provide services so that they are as efficient and effective as possible for the people of Barnsley To develop services through real partnerships with mutual Y accountability and strong governance that improve health and health care and effectively use the Barnsley £. 3. Governance Arrangements Checklist 3.1 Financial Implications Has a financial evaluation form been completed, signed off NA by the Finance Lead / CFO, and appended to this report? Are any financial implications detailed in the report? NA

3.2 Consultation and Engagement Has Comms & Engagement Checklist been completed? NA Is actual or proposed engagement activity set out in the NA report?

3.3 Equality and Diversity Has an Equality Impact Assessment been completed and NA appended to this report?

3.5 Environmental Sustainability Are any significant (positive or negative) impacts on the NA environment discussed in the report?

3.6 Human Resources Are any significant HR implications identified through NA discussion with the HR Business Partner discussed in the report?

Appendix 1

BARNSLEY PRACTICE DELIVERY AGREEMENT (PDA) April 2019 to March 2020

The Barnsley Practice Delivery Agreement has been developed in order to:-

1. Support the development of a local Integrated Care Network

2. Invest in the Primary Care infrastructure to deliver high quality equitable services for the registered population of Barnsley as close to home as possible

3. Support Primary care sustainability through a longer-term investment profile

4. Deliver a population health management approach to address the demographic health challenges on an Integrated Care Network footprint

5. Build a mutually accountable relationship that is centered on improving health outcomes in Barnsley

NHS STANDARD CONTRACT 2017/18 and 2018/19 PARTICULARS (Shorter Form) (Updated January 2018) 2018-19 PDA

Contents

Section 1 Page No.

The Barnsley PDA introduction 23 - 26

Section 2 28

The Barnsley PDA Schemes

Scheme 1 Integrated Care Networks

Scheme 2 Medicines Optimisation 30

Scheme 3 Get Fit First 32

Scheme 4 Referral Toolkit 48

Scheme 5 Health Inequalities Target Scheme (HITS): 5.1 CVD 61 5.2 Diabetes 74 5.3 COPD 87 5.4 Cancer 5.5 Phlebotomy

Scheme 6 General Practice Forward View: 6.1 Social Prescribing 93 6.2 Dementia & Carer Support 96 6.3 Workforce 98

Scheme 7 Medicines Management Scheme 105

NHS STANDARD CONTRACT 2017/18 and 2018/19 PARTICULARS (Shorter Form) (Updated January 2018) 2018-19 PDA

The Barnsley Practice Delivery Agreement

1.1 INTRODUCTION

Barnsley CCG has an agenda to improve the health and wellbeing of the people of Barnsley. It shares this ambition with partners from across health and care as well as voluntary and community based organisations. The aim of the 2019/20 Barnsley Practice Delivery Agreement (PDA) has been reviewed and refreshed to align to the NHS Long Term Plan and the changing landscape of the NHS as well as delivering on the integration agenda.

The focus of the Practice Delivery Agreement has always been to invest in the infrastructure to deliver and enhanced quality of care which reduces health inequalities of patients living in Barnsley. The aim of the 2019/20 PDA is to further develop this work to embed and support the development of Integrated Care Networks as the strategic direction of travel for fully integrated community-based healthcare in Barnsley. As part of this contract GP practices will receive a consistent income level to increase staffing capacity and be resilient to meet to changing landscape of the NHS. Whilst a number of schemes within this 19/20 PDA are set at individual GP practice level, GP practices will be encouraged to form into Integrated Care Networks to work towards a placed based care approach as referenced within the NHS Long Term Plan. Integrated Care Networks will build on the core of current primary care services and enable greater provision of proactive, personalised, coordinated and more integrated health and social care. 1.2 2019/20 PDA SCHEMES The 2019/20 Practice Delivery Agreement is broken down into 7 core schemes: 1. Integrated Care Networks

2. Medicines Optimisation Scheme

3. Get Fit First

4. Referral Toolkit

5. Health Inequalities Target Scheme (HITS)

6. General Practice Forward View

7. Medicines Management

For 2019/20 Barnsley CCG is investing a further £4.2 million into Primary Care. This is broken down as follows; (£?) Integrated Care Networks, (£?) Medicines Management, (£?) Get Fit First, (£?) Referral Toolkit, plus (£?)for the Health Inequalities Target Scheme and (£) for General Practice Forward View. (£?) will cover existing medicine management schemes, Eclipse live, 3

NHS STANDARD CONTRACT 2017/18 and 2018/19 PARTICULARS (Shorter Form) (Updated January 2018) 2018-19 PDA

specialist drug service/shared care, Anticoagulation initiation and maintenance. The total investment enables the CCG to set a guaranteed and consistent income level giving practices the investment to increase staffing capacity and resilience and deliver quality improvement. The aim being to meet rising demand and deliver improved access and better outcomes for patients. The intention is for the Barnsley Practice Delivery Agreement to pay for itself with the Medicines Optimisation and HITS Schemes delivering a return on investment in year. The long term beneﬁts to population health will be through implementation and adherence to the approved Get Fit First policy and an improved quality and consistency of referrals by adherence to NICE advice and best practice guidance The Health Inequalities Target Scheme reflects the aims of the Barnsley’s Health and Wellbeing Strategy and practices are encouraged to start to work with partners on an MDT approach to deliver placed based care.

The CCG recognises the need for a more integrated model going forward to ensure that primary care delivers a sustainable and resilient service. We recognise that in responding to new ways of working we need to develop the skills and competencies in collaboration with our partners and our patients. As our Integrated Care Networks develop during 2019/20 we must also ensure that both clinical and non-clinical staff continue to feel valued and fully recognised for the invaluable contribution they make to achieving healthier communities.

1.2 PURPOSE

The concept of the Practice Delivery Agreement (PDA) is that whilst supporting practices to invest in the infrastructure to deliver a comprehensive range of services to their practice population it will also support the CCG to deliver its general duties as outlined within the Health and Social Care Act Part 1 Section 26.

The CCG’s regulatory duties specifically related to the PDA include; promoting the delivery of the NHS Constitution, the improvement of the quality of services including primary medical services, reducing health inequalities, (that could be associated with practice variation and differential uptake of locally commissioned services) and patient involvement that will be achieved through Patient Reference Group (PRG) developments.

1.3 CONTEXT

The concept of a Practice Delivery Agreement between the CCG and each of its Member practices had arisen from workshops held by the CCG primary care work stream with practices during 2014/15 and was approved by the Governing Body at its September 2014 meeting. Full implementation commenced in April 2015.

NHS STANDARD CONTRACT 2017/18 and 2018/19 PARTICULARS (Shorter Form) (Updated January 2018) 2018-19 PDA

The 2019/20 PDA continues the investment into Primary Care over a four year period to a total of £21m.

Barnsley CCG has an agenda to improve the health and wellbeing of the people of Barnsley. It shares this ambition with partners from across health and care as well as voluntary and community based organisations. We recognise that fundamental to achieving this ambition is to have strong and resilient primary care services. This requires a more integrated system to support a workforce that is multi-skilled and able to adapt to the changes in the way that health and care services are provided as our services transform into new models of care. We recognise that in responding to new ways of working we need to develop these skills and competencies in collaboration with our partners and our patients. In 2019/20 NHS Barnsley CCG remain committed to working together to make significant steps forward in transforming health and care services in Barnsley and particularly making progress against the commitments set out in the NHS Long Term Plan and to support the development of Integrated Care Networks in Barnsley.

Our vision is a future in which the current model of primary care is allowed to deliver its full potential and adapt to meet the challenges of the future. It is for an integrated wider primary and community care offer, which is comprehensive and serving the full range of need found in the community, while doing more to reduce inequalities faced by Barnsley people and ensure parity of esteem for mental health care and support. It goes beyond medicine, reaching into communities and supporting people to live well for longer before they need to access healthcare.

To deliver our vision we will work with all partners across the Integrated Care System (ICS) footprint as well as with our local health and social care partners. The challenges we face are significant, financially but also to deliver the scale of change required to enable us to continue to deliver the best services possible for our local residents and to deliver the improved outcomes that we have signed up to delivering along with our Health and Wellbeing partners in Barnsley. We will use population health management data to support a placed based approach for delivering integrated working.

In Barnsley, one of the ways that we aim to deliver this required change is through the development of new care models and ways of delivering services to patients. We have an ambitious strategy to integrate the delivery of health and care for the people of Barnsley through the development of an integrated care model and ultimately an integrated care organisation. This ambition is reflected across the Integrated Care System (ICS) footprint and is supported locally by our commissioning partners in Barnsley Metropolitan Borough Council and our provider partners in Barnsley Hospital NHS Foundation Trust (BHNFT) and South West Yorkshire Partnership NHS Foundation Trust (SWYPFT) and by the Barnsley Healthcare Federation (BHF).

NHS STANDARD CONTRACT 2017/18 and 2018/19 PARTICULARS (Shorter Form) (Updated January 2018) 2018-19 PDA

The first step on our journey towards a truly Integrated Care Organisation which moves the boundaries between commissioning and provision, will be to have an integrated provider model up and running from 2018/19, covering a range of services, where work on the new model of integrated care is already most advanced.

Our GP Forward View (GPFV) Plan also sets out the ambition for new models of primary care which will increase capacity and time for care across Primary Care and contribute to the wider vision of reshaping primary and community care as set out in the ICS and support our developments of ICO models and our ambition to develop a truly integrated care organisation. This vision will be further embedded as the CCG starts to deliver the ambitions within the NHS Long Term Plan and the New GP contract.

1.4 KEY PRINCIPLES

There are a number of key principles that the CCG and practices are expected to follow that are underpinned by the PDA.

 Sharing best practice – through working together and based on experience  Working together – working collaboratively with the CCG to shape the further development of the PDA outcome measures and key performance indicators.  High level trust – engage with practices to help develop light touch governance (balanced with Accountability – High Level Trust Agreement).  Mutual assurance and respect – to meet both individual and collective key objectives.

1.5 DEVELOPING THE PRACTICE DELIVERY AGREEMENT

There are a number of schemes within the PDA that have been prioritised based on the challenges facing the health of the population and the health service in general. The Health Inequalities Target Scheme covers four priority areas, CVD, COPD, Diabetes and cancer. CVD has been agreed as a priority area for the Integrated Care Organisation as a whole system. For 2019/20 we have also introduced cancer as a priority area for inclusion within the PDA, this follows an agreement between member practices, partners and on looking at patient outcomes to identify if work can be undertaken in Primary Care to improve cancer care.

The Practice Delivery Agreement has been developed with input and engagement for Primary Care to ensure that schemes are meaningful and achievable.

1.6 PRACTICE DELIVERY AGREEMENT 2019/20

NHS STANDARD CONTRACT 2017/18 and 2018/19 PARTICULARS (Shorter Form) (Updated January 2018) 2018-19 PDA

This Practice Delivery Agreement sets out the assurances between the CCG and individual practice to form a longer term investment profile.

In signing up to the PDA practices are giving a commitment to working towards fully implementing all seven schemes within the PDA.

1.7 REPORTING PERIODS

Reporting Periods for schemes 1 to 7 are as follows (unless stated otherwise in the individual specifications):

Submission 1: Submission 2: Submission 3: Submission 4:

Reporting Templates will be distributed to all Practice Manager 4 weeks prior to each reporting deadline.

Scheme 7 (Shared Care) is based on activity based and practices will submit returns of numbers of patients on each shared care drug.

Section 2

The Practice Delivery Agreement – SCHEMES

Section 1

The Barnsley PDA introduction

Section 2

The Barnsley PDA Schemes

Scheme 1 Integrated Care Networks

Scheme 2 Medicines Optimisation

Scheme 3 Get Fit First

Scheme 4 Referral Toolkit

Scheme 5 Health Inequalities Target Scheme (HITS): 5.1 CVD 5.2 Diabetes

NHS STANDARD CONTRACT 2017/18 and 2018/19 PARTICULARS (Shorter Form) (Updated January 2018) 2018-19 PDA

5.3 COPD 5.4 Cancer 5.5 Phlebotomy

Scheme 6 General Practice Forward View: 6.1 Social Prescribing 6.2 Dementia & Carer Support 6.3 Workforce

Scheme 7 Medicines Management Scheme

APPENDIX 2 - INTEGRATED CARE NETWORKS 2019/20

National Local Priority Priority TITLE Integrated Care Network Development x x (what is the contractual requirement) RATIONALE FOR In common with many areas in the country, INCLUSION Barnsley Primary Care has a number of (Intended challenges around workforce, finances, Outcomes) sustainability of services, quality and access. For these reasons there has been a national drive to support GP practices to work together in Local Care Networks to look at how care can be delivered differently in an integrated approach. This approach is further underpinned by the publication of the NHS Long Term Plan and the Network Contract Direct Enhanced Service (DES) coming into place during 2019. Importantly the new DES contract is designed to “turbo charge” the formation of Primary Care Networks (PCNs) by July 2019.

For the last two years GP practices in Barnsley have been coming together at locality meetings, these have brought GP practices together to enable conversations to start around how practices could work together for the benefit of patients and the practices. Now that practices have a forum and regular time out to work together we want to support practices to build on this to engage with other service providers to create a system which arranges services around the individual and provides people with the support they need to stay or get well – whether physical, emotional or social. The next step beyond locality meetings is for practices to sign up to the national DES and to support the development of a Supra network. A Supra Network will continue building on the local successful model of working as one across primary care in Barnsley. This model will not only bring together primary care services but will be underpinned by neighbourhood working which will incorporate a range of health, care and wellbeing services. By being more joined-up services can be more responsive, ensuring people have the help and support they need to keep themselves as healthy and well as APPENDIX 2 - INTEGRATED CARE NETWORKS 2019/20

possible.

HOW TO… The role and ask of GP practice in the Supra (Step by step, Network development is described below: how would a practice 1) Elected GP and Practice Manager to implement this) attend the bi-monthly Network Meetings. 2) Oversee the alignment of community services, teams and resource to the 6 or 3 locality teams 3) Develop and sign Locality agreements or Memorandum of Understanding (MOU) with partners to agree principles and ways of working. 4) Utilise available information such as population health management data to agree priorities and projects

MEASUREMENT 1) At least 1 GP from each practice is (How would you required to attend the network meetings. robustly 2) GP to attend 5/6 ICN meetings through- measure, ensure out the year outcomes) 3) Invite the Practice Manager and members of the wider practice team 4) Oversee the alignment of community services, teams and resource to the 6 or 3 locality teams 5) Complete and submit the Network MOU 6) Localities to submit to the Network a plan which supports integrated working and reduces health inequalities 7) Review information and take action between meetings as defined within the working agreement.

FREQUENCY 2019/2020 ICN Meeting dates are as follows: AND DEADLINES FOR REPORTING 10 April 2019

19 June 2019

04 September 2019

16 October 2019

11 December 2019

February 2020 (date TBC).

Attendance registers will be taken at each APPENDIX 2 - INTEGRATED CARE NETWORKS 2019/20

meeting as the method of measurement.

READ CODES None required. -eMBED

TEMPLATES AND LINKS

CCG LEAD Louise Dodson OFFICER Primary Care Transformation Manager CONTACT 01226 433631 DETAILS [email protected]

[TypeAppendix text] 3

PRIMARY CARE PRACTICE LEVEL MEDICINES OPTIMISATION SCHEME 2019-2020

Background

The purpose of this scheme is to encourage high quality cost-effective use of medicines across the patient pathway.

Principles  A Medicines Optimisation does not simply reward low cost prescribing, but should include criteria relating to the quality of prescribing.

 To maximise financial opportunities (best use of the Barnsley £) and ensure financial stability within the Clinical Commissioning Group (CCG), its vital that the CCG and its constituent practices maintain oversight and control of prescribing costs. Any reduction of prescribing costs at the expense of compromising patient health is not acceptable.

 An incentive scheme should encourage practices to consider both cost and also quality, and hence the cost-effectiveness of their prescribing, and reward practices appropriately.

 There is recognition that where practices are already achieving the targets specified in the scheme practices should be rewarded in the same way as those practices meeting the targets for the first time, however that all practices should work to meet a minimum target and therefore will be required to undertake some work against each of the schemes criteria.

Details of the Scheme

 Completing ALL of the work within the scheme would reward practices £5.00 per weighted patient on the 1 January 2019. The investment for this scheme is equal to the investment for demand management.

 A target deadline has been set for each area. Payments to practices will be 100% awarded to practices who meet ALL of the target and completion deadlines. A reporting template will be provided to practices with dates for return (attached Appendix A).

 Any practice failing to meet any of the scheme criteria targets will forfeit their right to any payment under the scheme. It’s expected that practices will actively undertake work to achieve against all work areas.

 Practices who have missed a deadline for not completing work due to exceptional

Page 1 of 18

circumstances may submit an appeal for consideration by CCG’s Quality and Cost Effective Prescribing Group (QCEPG)

 Calculated rewards will be endorsed by the QCEPG in March 2020 and payments will be made to practices on or before the 30th April 2020:-

o The QCEPG will review 2019/2020 EPACT and Eclipse Live prescribing data against the same Medicines Optimisation Scheme criteria to validate /verify changes. They may request that searches are run again by practices to validate reporting.

o Where there has found to be an error in practice reporting or reversal of any scheme implemented changes then the CCG retains the right to request proportional reimbursement for practice payments which have been made under this scheme.

o Where there has been a significant reduction in the quality of prescribing e.g. excessive waste identified as occurring which has been reported to the practice. Then the CCG retains the right to request proportional reimbursement for practice payments which have been made under this scheme.

o Any offer of practice support made, particularly if not taken up, would be taken into consideration by the QCEPG when making a decision to forfeit, suspend or reduce a practice payment.

 Any practice list size changes greater than +/- 1% 1 January 2020 compared with 1 January 2019 will be taken into consideration when calculating end of year outturn.

 To ensure financial stability of the CCG, there will be a maximum total payment under the Medicines Optimisation Scheme of £1,461,810

Finance Issues

 National guidelines govern the types of expenditure that are permitted using these payments. Payments should be used for the benefit of the patients of the practice, having regard to the need to ensure value for money

 It should be noted that these payments cannot be used for the purchase of health care (hospital or community services), or for drugs.

Support

 Practices will be provided with a summary of their prescribing position against the criteria within this scheme and their practice target for each of the criteria.

 The CCG Medicines Management Team is happy to support practices to review prescribing in the areas within the scheme and this should be discussed and agreed with the medicines management team member(s) supporting your practice. The overall responsibility for completion of work within the scheme and reporting lies entirely with the practice.

Page 2 of 18

Scheme Criteria

Indicator Measure 1. QIPP Changes a. The reviews will be carried out in line with the 2019/20 CCG QIPP resource pack:

 Metrogel® to Acea® or Anabact® gel (depending on the indication)  Prednisolone soluble to standard tablets  Olanzapine orodispersible to standard tablets if suitable or sugar free orodispersible if an orodispersible preparation is required  Lancets to cost effective formulary choice of brand (brand TBC)  Pen needles to cost effective formulary choice of brand (brand TBC)  Sodium hyaluronate 0.2% preservative free eye drops to Evolve® HA 0.2% preservative free eye drops

To be completed by 21st June 2019

b. Patients are to be reviewed and changed using ScriptSwitch when the prescription is re-authorised. Any remaining patients are to be reviewed in line with the CCG QIPP resource pack between the 17th August and the 20th September 2019.

 Metformin MR tablets to Yaltormin® SR tablets

To be completed by 20th September 2019.

c. The practice will complete the following reviews in line with the CCG protocols and APC guidance:

 Isosorbide Mononitrate MR tablets to twice daily standard release or formulary choice of cost effective MR brand if standard release tablets are unsuitable  Oral diltiazem review of preparation, dosage and frequency

To be completed by 28th February 2020.

100% of appropriate patients to be offered a change in therapy.

Please note that this is not an exhaustive list and any additional areas agreed by the QCEPG/APC before

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December 2019 may also be incorporated. 2.Self Care/ Items Local/National Guidance: Self Care which should no The practice will review patients prescribed the longer be routinely medicines included within local and/or national prescribed in guidance and make changes in line with the primary care recommendations in the guidance. (including additional NHS England Guidance: Items which should no local/national longer be routinely prescribed in primary care guidance issued in The practice will review patients prescribed the 2019) eighteen medications included and make changes in line with the recommendations in the guidance.

In January 2019 a consultation was launched for an additional nine medications to be considered. The practice will agree to review any additional patients included in any future guidance published following on from this consultation.

https://www.engage.england.nhs.uk/consultation/items- routinely-prescribed-update/user_uploads/low-priority- prescribing-consultation-guidance.pdf

A CCG supporting resource pack will be made available.100% of appropriate patients to be offered a change in therapy.

To be completed by deadlines set by the Medicines Management Team. 3. Appliance & The practice will engage with the Specialist Nurse(s) to Wound Care complete a review between April 2019 and February Reviews 2020 of all patients prescribed appliances & wound care products to ensure that prescribing is appropriate and in line with formulary choices. A report summarising the review and changes made will be submitted to the CCG by the Specialist Nurse(s).

To be completed by 28th February 2020 Please Note: This area’s inclusion is dependent on appointment of a specialist nurse(s). 4. Endocrinology: Blood Glucose Monitoring Blood Glucose & a. The practice will continue to review choice and Ketone Monitoring frequency of use and continue to offer a formulary choice of blood glucose test strips to appropriate diabetic patients in line with local guidance. b. A meeting will take place between the practice nurse(s) and the MMT members supporting the practice to discuss the review and an action plan will be agreed setting out how the practice will

Page 4 of 18

achieve this element of the scheme. The action plan will be submitted before the 21st June 2019. c. The MMT will monitor progress with the reviews and complete the audit detailed below with a random sample of eligible patients who have had their annual review between March 2019 and September 2019. A follow up meeting to discuss this will be held with the nurses by the 30th September 2019. d. An audit will be completed for a random sample of 20* diabetes patients who have been prescribed a formulary glucose test strip and 20* diabetes patients who have been prescribed a non-formulary glucose test strip since 1st March 2019 and who have had an annual review between March 2019 and November 2019 (patients included in the audit in part c can comprise up to 75% of the sample). Practices will need to demonstrate that the usage & choice of test strips/meter is in line with local guidance for at least 75% of patients. e. The audit will be completed by the MMT in advance of the submission date to enable the findings to be discussed with the practice.

*For practices that have less than 20 eligible patients, all patients on the search should be included in the audit.

To be completed by 17th January 2020.

Ketone Monitoring a. The practice will continue to offer the first line formulary choice of ketone test strips “Glucomen Areo®” to appropriate diabetic patients. b. A meeting will take place between the practice nurse(s) and the MMT members supporting the practice to discuss the review and an action plan will be agreed setting out how the practice will achieve this element of the scheme. The action plan will be submitted before the 21st June 2019. c. The MMT will monitor progress with the reviews and complete the audit detailed below with a random sample of eligible patients who have had their annual review between March 2019 and September 2019. A follow up meeting to discuss this will be held with the nurses by the 30th September 2019. d. An audit will be completed for a random sample of 20* diabetes patients who have been prescribed a ketone test strip which is not first line formulary

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choice since 1st March 2019 and who have had an annual review between March 2019 and November 2019 (patients included in the audit in part c can comprise up to 75% of the sample).Practices will need to demonstrate that patients have been considered for a change to the first line formulary choice Glucomen Areo® for at least 75% of patients. e. The audit will be completed by the MMT in advance of the submission date to enable the findings to be discussed with the practice.

*For practices that have less than 20 eligible patients, all patients on the search should be included in the audit.

To be completed by 17th January 2020. 5. Cardiology: Heart Warfarin Monitoring Failure & Practices who are monitoring Warfarin under the Anticoagulation Barnsley CCG commissioned anticoagulation services Reviews will use INR STAR software to record details of patient anticoagulation management and will sign up to use of the INR STAR Analytics * platform.

Note * INR STAR refresher training (inc. INR STAR analytics platform training) will be made available for practice staff in 2019. The INR STAR Analytics platform licence is funded by the CCG and available at no additional cost to the practice.

To be completed by 28th February 2020.

Practices will review patients prescribed warfarin to ascertain if they are suitable for self-monitoring of their INRs and offer to appropriate patients.

To be completed by 28th February 2020.

Direct Oral Anticoagulants (DOACs) Practices will review a cohort of patients prescribed a DOAC to ensure: a. Patients have been prescribed appropriately in line with local anticoagulation guidance b. Patients are compliant with their medication

To be completed by 28th February 2020.

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6. Nutrition: Oral Oral Nutritional Supplements in Adults Nutritional The practice will continue to engage with the Medicines Supplements in Management Dietitian to ensure prescribing is in line Adults & Paediatric with local APC guidance. Nutrition Enteral nutrition in Paediatrics The practice will continue to engage with the Medicines Management Dietitian to ensure prescribing is in line with local APC guidance.

7. Polypharmacy The practice has completed a review of a cohort of Reviews patients identified using Eclipse Live to be:  80 years of age or more AND  Have fifteen or more medications on repeat prescription

The practice will submit a report summarising the review (CCG report template available).

To be completed by 15th November 2019. 8. Oral Triptan The practice has undertaken a review of all patients Prescribing prescribed oral triptans in line with the CCG protocol.

 Suitable patients to be stopped or changed in line with the protocol by 20th September 2019  Patients who are highlighted as requiring a clinical review to be reviewed by 28th February 2020

The practice will submit a report summarising the review (CCG report template available).

9. High Dose The practice has undertaken pain management Opioids: Pain reviews on a cohort of patients who are prescribed Management 120mg/day of morphine or equivalent. Reviews To be completed by 28th February 2020. 10. Gastrointestinal: Use of Proton Pump inhibitors (PPIs) Use of Proton Pump The practice has reviewed 20% of all patients Inhibitors (PPIs) & prescribed a PPI and stepped down or stopped where Gaviscon Advance appropriate. a. The practice will be required to review a minimum of 10% of the patient list (or 20 patients whichever is smaller) each month and submit on the monthly CCG report template.

To be completed by 28th February 2020.

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Gaviscon Advance The practice has reviewed all patients prescribed Gaviscon Advance and changed to an alternative formulary choice where clinically appropriate and where an NHS prescription is appropriate in line with local and national guidance (see section 2).

The practice will submit a report summarising the review (CCG report template available).

To be completed by 13th December 2019. 11.Shared care The practice has completed selected audits as audits requested by the Area Prescribing Committee and/or CCG Medicines Management Team:

 90% of prescribing is in line with local guidance  Agreed and implemented an action plan

(N.B. This is separate to the annual audit within the specialist drugs scheme)

To be completed by 13th December 2019. 12. ScriptSwitch a. The practice has ScriptSwitch in place and activated for ALL prescribers (including locums) for 100% of the time for the period 1st April 2019 to 28th February 2020. AND b. i. Have discussed a quarterly ScriptSwitch report in every practice meeting between April 2019 and February 2020 which will be summarised within the practice action plan following each meeting.

ii. The practice does not reject any of the prompts for areas included within this scheme without exceptional reason and prescribers will use the feedback prompt to advise of the reason.

iii. Practices will review the quarterly ScriptSwitch report and review at least 5 different QIPP areas where there have been missed savings Patients will be reviewed and offered a change where appropriate to the QIPP brand/ product in line with the formulary guidance. The reviews will be completed by the following month’s deadline following the practice meeting.

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AND c. The acceptance rate OR the percentage of the potential cost benefit achieved in the period April 2019 to February 2020 is equal to or greater than the CCG average for the 18/19 year OR, if below the 18/19 averages, an increase of 20% in the acceptance rate OR the potential cost benefit is achieved compared to the individual practice data for 18/19

If there are technical difficulties due to ScriptSwitch suppliers and not the practice then this will be taken into account. Practice level ScriptSwitch activity will be monitored and points will not be awarded to practices who are deemed to be deliberately changing their prescribing behaviour in order to achieve part c. 13. Antibiotic The practice has: Prescribing and Antimicrobial  Reduced the number of trimethoprim items Stewardship prescribed to patients aged 70 years and over in line with the 2019-20 Quality Premium targets (January to December 2019 compared with January to December 2018). AND  Reduced the percentage of cephalosporin, quinolone and co-amoxiclav prescribing from all antibiotics prescribed by 10% (January to December 2019 compared with January to December 2018) OR to below 8%. AND  Reduced antibiotic prescribing (Items/STARPU) by 5% (January to December 2019 compared with January to December 2018) OR items/STAR PU (January to December 2019) is equal to or less than the target set by the CCG AND  Run an antibiotic patient awareness campaign for at least a one month period to coincide with the European Antibiotic Awareness Day in November (18th). The practice will submit a photograph and/or a summary of the activities undertaken during the campaign.

AND  The practice has completed selected audits identified by the Medicines Management Team which form part of the CCG medicines management antibiotic audit pack and: o 80% of prescribing is in line with local guidance

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o Agreed and implemented an action plan which will include any further actions required where practices have not achieved the 80% target

The practice will submit a report summarising the review and the action plan which has been agreed and implemented (CCG report template available).

To be completed by 28th February 2020. 14. Practice At least three meetings* held and attended by 50% of Meetings relevant practice clinical staff (including at least one nurse representative) and allocated CCG Medicines Management staff for a time dictated by the agenda, in the year ending 28th February 2020 AND have a practice medicines management action plan in place which will be updated and submitted by the following deadlines:

1st Meeting: 17th May 2019 2nd Meeting: 18th October 2019 3rd Meeting: 28th February 2020

An action plan template is available to use. It is recommended that the agenda is circulated one week prior to the meeting.

*Where meetings have not taken place due to CCG staff being unavailable for any reason then this will be taken into account. 15. Respiratory: ICS High dose ICS in Asthma use in asthma, Use a. The practice will continue to offer step down of of SABA and inhaled corticosteroids in patients with asthma who Over ordering of have good control. preventer Inhalers b. Any practice that showed as part of the MOS 18/19 work that step down is not being routinely discussed at annual reviews are to hold an in- house nurse education session.by the 21st June 2019 c. A meeting will take place between the practice nurse(s) and the MMT members supporting the practice to discuss the review and an action plan will be agreed setting out how the practice will achieve this element of the scheme. The action plan will be submitted before the 21st June 2019. d. The MMT will monitor progress with the reviews and complete the audit detailed below with a random sample of eligible patients who have had their annual review between March 2019 and September 2019.. A follow up meeting to discuss

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this will be held with the nurses by the 30th September 2019. e. An audit will be completed for a random sample of 20* asthma patients who are prescribed a high dose ICS (i.e. 800 micrograms beclomethasone per day or equivalent), and who have had an annual review between March 2019 and November 2019 (patients included in the audit in part d can comprise up to 75% of the sample). Practices will need to demonstrate that step down has been considered and discussed for at least 75% of patients with good control. f. The audit will be completed by the MMT in advance of the submission date to enable the findings to be discussed with the practice.

*For practices who have less than 20 asthma patients who are prescribed a high dose ICS, and who have had an annual review between March 2019 and November 2019, all patients should be included in the audit.

To be completed by 17th January 2020.

Use of SABA in Asthma & COPD patients a. The practice will continue to review the use of salbutamol and terbutaline in all asthma & COPD patients during their annual reviews. b. A meeting will take place between the practice nurse(s) and the MMT members supporting the practice to discuss the review and an action plan will be agreed setting out how the practice will achieve this element of the scheme. The action plan will be submitted before the 21st June 2019. c. The MMT will monitor progress with the reviews and complete the audit detailed below with a random sample of eligible patients who have had their annual review between March 2019 and September 2019. A follow up meeting to discuss this will be held with the nurses by the 30th September 2019. d. An audit will be completed for a random sample of 20* patients who are have ordered more than 12 salbutamol or terbutaline inhalers in the period 1st April 2018 – 31st March 2019 and who have had an annual review between March 2019 and November 2019 (patients included in the audit in part c can comprise up to 75% of the sample). Practices will need to demonstrate that SABA usage has been reviewed, discussed and changes made to

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therapy where clinically indicated and that the most cost effective option ‘Salbutamol 100mcg/puff CFC free MDI’ has been considered where appropriate in at least 75% of patients. e. The audit will be completed by the MMT in advance of the submission date to enable the findings to be discussed with the practice.

To be completed by 17th January 2020.

Over ordering of preventer inhalers The practice have completed a audit of patients prescribed inhalers which have been identified in the CCG protocol as having the potential to be over ordered.

Patients who are identified as over ordering will be contacted to check if over-using or stock piling a. If stock piling, patient education will be given and changes made to the repeat prescription where appropriate b. If over-using, patients will be required to attend a review with the practice

To be completed by 13th December 2019. 16. Respiratory: Home Oxygen Reviews Supporting The practice will engage with the CCG to help facilitate secondary care with the review of selected patients prescribed home oxygen and nebule oxygen between April 2019 and February 2020. reviews Nebule Reviews The practice will engage with the CCG to help facilitate the review of selected patients prescribed nebules between April 2019 and February 2020.

To be completed by 28th February 2020.

17. Generic versus The practice has completed a review of potential brand prescribing; generic savings data provided by the CCG for their Potential Generic practice over a recent 6 month period. Savings 100% of appropriate patients are to be offered a change to a generic product

AND Any practice with potential annual generic savings greater than a target set by the CCG has demonstrated a 40% reduction in the percentage of potential generic savings or weighted potential generic savings [£/PU] (based on quarter 3 2019-20 data)

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The practice will submit a report summarising the review (CCG report template available).

To be completed by 15th November 2019. 18. Unlicensed a. The practices has provided details of patient’s Specials Review prescribed generic Midazolam Liquid unlicensed including special to the SWYFT Epilepsy Nursing Team who Midazolam liquid will review patients and change to a licensed product or refer patients to the appropriate service where appropriate.

To be completed by 17th May 2019

b. The practice has completed a review of Unlicensed Specials data provided by the CCG for their practice over a recent 6 month period.

100% of appropriate patients are to be offered a change to a licensed product

The practice will submit a report summarising the review (CCG report template available).

To be completed by 18th October 2019. 19. Dose The practice has completed a dose optimisation Optimisation review of patients prescribed medication identified in Review the CCG protocol.

The practice will submit a report summarising the review and the changes made (CCG report template available).

To be completed by 16th August 2019.

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20. Acute Kidney a. The practice will complete medication reviews on a Injury (AKI) cohort of patients who are at high risk of acute kidney injury (AKI) to provide them with a ‘sick day rule’ to help reduce their risk of illness and hospital admission. b. Practices will continue to utilise the sick day rule cards and provide to and discuss with at risk patients during clinical reviews c. A search will be run on the practice system to identify the number of patients who have been provided with written information and education about acute kidney injury between 1st April 2019 to 31st January 2020. The practice will submit a report summarising the review (CCG report template available).

To be completed by 28th February 2020.

21. Eclipse Live: a. The practice will be signed up to Eclipse Live RADAR Reviews & software; will run RADAR reports a minimum of once a High Cost Drug week, and review patients in line with the Eclipse Live Report specification.

To be completed every week/month up to 28th February 2020.

b. The practice has completed a review of High Cost drug data available via the Eclipse Solutions website for their practice over a recent 6 month period. 100% of patients are to be reviewed to ensure prescribing is appropriate and in line with local guidance.

To be completed by 20th September 2019.

22. Medicines The practice will continue to engage with the Medicines Ordering Safety & Ordering Safety & Waste (MOSW) project. Waste Project Practices will be required to:

 Attend a practice planning meeting facilitated by the MOSW project team.  Agree a cut-off date for no-longer accepting request from 3rd party companies  Agree dates for staff training to support improvements to the practice repeat prescribing systems  Attend a community pharmacy planning meeting  Provide a work station for the project team that has access to the practice system and a telephone line  Agree a process to manage patients requiring

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support following the cut-off date  Agee for patients to be contacted by the MOSW team to be provided with training and education on the ordering of their prescriptions  Ensure all patients signed up to electronic repeat dispensing have a 6 monthly review to ensure the process is working efficiently for them

23. Optional area: Practices are given the opportunity to identify a new Practice selected medicines-related work area not previously completed work area in Barnsley by the CCG Medicines Management Team and submit a proposal for the work to be completed by practice staff between 1st April 2019 – 28th February 2020.

The work area will be considered by the CCG Medicines Management Team and if approved AND completed by the practice staff only, the practice will be entitled to 50% of the savings accrued from the completion of the work.

To be completed by 28th February 2020. 24. Additional There may arise in year opportunities which will deliver Prioritised QIPP greater savings to the healthcare economy than work Areas within the plan. Should this arise practices will be provided with explicit plan of work.

The practice will review all patients as requested for appropriateness and switch to cost-effective alternatives where indicated in line with local APC guidance.

The practice will submit a report summarising the review and the changes made (CCG report template available).

Individual target timeframe and reporting arrangements will be set.

Page 15 of 18 Appendix A: Work allocation and deadlines Medicines Optimisation Scheme 2019/20 Deadline date for completion of work area 17th May 21st June 19th July 16th Aug 20th Sept 18th Oct 15th Nov 13th Dec 17th Jan 28th Feb [Type text] 19 19 19 19 19 19 19 19 20 20 NHS England Guidance: Items which should no longer be STILL TO BE DECIDED routinely prescribed in primary care Self Care STILL TO PPI review - 20% of all patients prescribed PPI to be reviewed BE and step down/stop where appropriate (10% of review list (or * * * * * * * * * * a minimum of 20 patients if greater) to be reviewed each month) ScriptSwitch - check activated for all prescribers including locums * * * * * * * * * * Eclipse Live - run reports weekly * * * * * * * * * * Eclipse Live - review alerts * * * * * * * * * * Practice prescribing meetings held with 50% of relevant practice clinical staff & action plan in place * * * ScriptSwitch - discussed report at prescribing meeting * * * Unlicensed specials review - provide details of Midazolam liquid patients to epilepsy nurses for review * Scriptswitch - reviewed 5 different missed savings per report & reviewed & changed where appropriate * * * Metrogel to Acea or Anabact gel (depending on the indication) * Prednisolone soluble to standard tablets * Olanzapine orodispersible to standard tablets * Lancet Switches * Pen Needle Switches * Sodium hyaluronate 0.2% PF eye drops to Evolve HA 0.2% PF eye drops * Step down asthma training session - if required * Ketone Monitoring audit * * * Blood Glucose Monitoring audit * * * Asthma ICS audit * * * SABA audit * * *

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Dose optimisation review * Metformin MR tablets to Yaltormin SR tablets (switches not to be completed by MMT until after 16th August) * Triptan Review * * Eclipse - High cost drug review * Unlicensed specials review * Potential Generic Savings Review * Polypharmacy review * Antibiotic awareness campaign * Gaviscon advance review * Inhalers: REVIEW PATIENTS OVER ORDERING * Shared care audit review * Isosorbide Mononitrate MR tablets to standard release or formulary choice of cost effective brand if standard release * unsuitable Oral diltiazem review of preparation, dosage and frequency * Antibiotics audit * Antibiotics action plan * Oxygen Reviews - information gathering when requested * Nebule Reviews - information gathering when requested * Risk of AKI review * Pain management reviews in patients identified as prescribed high dose opioids over 120mg/day * Appliance & Wound Care Reviews * Warfarin Monitoring * DOAC Review * ONS in adults Practices to continue to engage with dietitian Enteral nutrition in paediatrics Practices to continue to engage with dietitian Antibiotics - Targets to be set in line with quality targets No feedback required - to be measured using data from January to December 2019 compared to January to December 2018 ScriptSwitch - practice to meet target for acceptance rate for No feedback required - to be measured using data from April 2018 to February 2019 acute scripts OR potential cost benefit OR the practice have achieved a percentage increase equal to or greater than the target set by the CCG MOSW Project - practices to engage Additional priority areas agreed by the QCEPG or APC within As instructed the agreed time scales

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Key * Deadline

Medicines Management Technician/Pharmacist Clinical Pharmacist Practice with Medicines Management Team support (Technician, Pharmacist, Clinical Pharmacist) where required All Medicines Management Team/Practice staff

Specialist Nurse Dietitian

CP admin with technician/pharmacist support and oversight in line with agreed SOPs

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Appendix 4 - Get Fit First in Barnsley – PDA Proposal (v3.0)

The proposal is to continue the 2018/19 Get Fit First scheme into 2019/20. The following refinements are made:  Additional emphasis on completing the ‘Follow Up Template’ in clinical systems / coding of a referral to a surgical specialty to capture the outcome of the health improvement period and the specialty where patients completing the health improvement are referred to.  Additional searches added to practice monitoring requirements to return data in relation to the above bullet via an additional end of year submission.

National Local Priority Priority Get Fit First In Patients who are severely Both the NHS The Active Barnsley overweight and/or who smoke will Ten Year Plan People Survey be asked to spend a period of (2019) and The (2012/14) time getting fit before being NHS Five Year estimates that 7 referred for surgery and will be Forward View out of 10 adults signposted to support to help (2014) makes (71.6%) in them to do so. the case for Barnsley are action on overweight or The Get Fit First in Barnsley prevention, and obese, which is policy applies to the following describes the significantly surgical specialties: impact from the higher than the rise in obesity. proportion for • General Surgery The Forward England • Cardiothoracic View states the (64.6%). • ENT NHS will back hard-hitting In Barnsley, this • Gynaecology national action equates to • Neurosurgery on obesity, 36.5% of adults • Plastic Surgery smoking, being • Trauma & Orthopaedics alcohol and overweight and (including MSK) other major 35.1% of adults • Urology. health risks. being obese.

If the patient has a BMI of 30 or Tackling For England, above AND/OR is an active obesity is also 40.6% of adults smoker, they should be offered one of the are overweight the opportunity to attend a course priority areas and 24.0% are of weight management AND/OR for Public obese. smoking cessation services Health before the referral is made unless England. Their In Barnsley, exclusions apply. If exclusions do strategy From smoking rates, apply, it is good practice to still Evidence into whilst offer lifestyle advice. Action: decreasing Opportunities remain high. In Practices are asked to: to Protect and 2016, 21.2% of  Follow the Get Fit First Policy Improve the adults in in Barnsley Nation’s Health Barnsley

 Carry out review of BMI and (2014) noted smoke, which is smoking status prior to any that if we could significantly referral to a surgical speciality reduce obesity higher than the in secondary care (non-urgent) back to 1993 England levels, five average of  Ensure all eligible patients are million cases of 16.9%. informed of the policy and disease could discuss the benefits of weight be avoided. loss and/or smoking cessation and the support services Tobacco available with the patient. smoking Distribute patient leaflets as remains the appropriate. single greatest cause of  All patients who engage are preventable supported in their health illness and improvement / referral premature (including referral to external death in support sources). For those England. It is patients who decline offer also the largest support in line with the single cause of commissioning policies. inequalities in health and  Evidence in referrals to accounts for secondary care/MSK that about half of patients meet the criteria in the the difference Get Fit First Policy in life expectancy  Use the Get Fit First data entry between the templates (initial appointment lowest and and follow up appointment) to highest income record data in the clinical groups. systems and submit a monthly monitoring report to the CCG.

 In the monthly report flag occasions where there is a discharge notice when only a Form A Part 1 (referral for opinion) has been submitted.

 Complete follow-up extra consultation AND follow-up assessment template each time a patient concludes the health improvement period (led by a health professional).

 Use the speciality codes detailed in the Read Code section on the patient’s record

to capture the surgical specialty where patients completing the health improvement have been referred to and submit an end of year report to the CCG.

RATIONALE The introduction of active CCGs in Barnsley CCG’s FOR interventions to encourage and England have Commissioning INCLUSION support patients to improve their been provided plan focuses on (Intended general health and offer patients with a number effective Outcomes) who have a BMI ≥ 30, or who smoke, a referral to weight of expectations demand management or smoking in the NHS management cessation services for a period of Five Year for elective time to enable heath Forward View. activity in improvement before being secondary care. considered for referral for routine Amongst these surgery could positively priorities are To ensure local encourage and embed lifestyle actions on resources are changes. smoking and used efficiently There are also evidenced benefits obesity, which and the to weight loss and smoking the CCG treatment that is cessation on outcomes after recognise as provided is surgery. playing an based on the The high level objectives for this important role best clinical intervention are to: in individual’s evidence; health and Barnsley CCG  Improve the prevalence rates wellbeing. developed the for obesity, hypertension, pre- Get Fit First in diabetes and diabetes for The point of Barnsley patients Barnsley policy referral for non- which was  Overall improve the health and urgent elective implemented in wellbeing of our population surgery January 2018. provides an  Reduce the post-operative opportunity for complications and improve health patient safety improvement.  Ensure negative impacts on health in the short term be mitigated by the net long-term health gains

 Defer demand for elective surgery

HOW TO… The practice should: (Step by step, how would a  Ensure the Get Fit First data

practice entry template is available in implement this) clinical systems

 Complete the data entry template to accurately reflect the patient pathway from initial appointment to completion of the health improvement period prior to elective surgery (initial assessment and follow up assessment)

 Complete follow-up extra consultation AND follow-up assessment template each time a patient concludes the health improvement period (led by a health professional).

 Use the specialty codes detailed in the Read Code section on the patient’s record to capture the surgical specialty where patients completing the health improvement have been referred to.

 Complete the monthly monitoring report and the end of year submission.

 In the monthly report flag occasions where there is a discharge notice when only a Form A Part 1 (referral for opinion) has been submitted.

 In the end of year submission provide a breakdown of the specialty where patients completing the health improvement are referred to and their outcomes.

The CCG will provide:

 A Get Fit First Data Entry Form in SystmOne and EmisWeb that will provide drop down menus to automatically code

the initial appointment and follow up appointments to enable monthly reporting.  A template to support monthly and end of year reporting.  A patient leaflet and guidance on following the policy on the BEST Website

MEASUREMENT To be extracted via the data entry template: (How would you robustly measure, Part 1. BMI / Smoking status at ensure outcomes) initial referral

1.1 Non-smokers and also have a

BMI below 29.9

1.2 Smokers at initial assessment 1.3 Non-smokers at initial assessment 1.4a BMI below 29.9 1.4b BMI between 30.0 and 34.9 1.4c BMI over 35.0

Part 2. Referrals 2.1 Patient accepted referrals to: 2.1a Smoking cessation 2.1b Weight management 2.1c Both smoking cessation and weight management

2.2 Patient declined referrals to: 2.2a Smoking cessation 2.2b Weight management 2.2c Both smoking cessation and weight management

2.3 Patients given advice, therapy or intervention (without an accepted referral) to: 2.3a Smoking cessation 2.3b Weight management 2.3c Both smoking cessation and weight management

2.4 Patients where no advice was given for: 2.4a Smoking cessation 2.4b Weight management 2.4c Both smoking cessation and weight management

Part 3. Outcomes post-health improvement period 3.1 Patients meeting weight loss targets 3.2 Patients smoking cessation quits achieved

The following section is to be extracted via use of the follow up template AND speciality Read Codes on patients record. 3.3 – 3.10 Patients meeting weight loss target AND referred to specialty 3.11 – 3.18 Patients with a smoking cessation quit achieve AND referred to speciality

Part 4 – Surgery outside of Policy In the monthly report flag occasions when a discharge notice has been received when only a Form A Part 1 (referral for opinion) has been submitted with the referral.

KPIs KPIs are based on practice adherence to the policy. Practices will not be held accountable via the PDA if patients do not engage/comply with the health improvement period.

Practices should ensure that patients are clear that GFF does not constitute a denial of referral and invite patients to return for their referral after 6 months if they do not engage or earlier if they meet their health improvement targets or condition worsens.

Practices should complete the searches to extract the data outlined in the measurement section and submit the monthly monitoring report in the timescales requested by the CCG to evidence following the

following processes (100% completion of data).

 Carry out review of BMI and smoking status prior to any referral to a surgical speciality in secondary care (non-urgent)

 Ensure all eligible patients are informed of the policy and discuss the benefits of weight loss and/or smoking cessation and the support services available with the patient.

 All patients who engage are supported in their health improvement / referral (including referral to external support sources)

 Evidence in referrals to secondary care that patients meet the criteria in the Get Fit First Policy FREQUENCY Monthly Monitoring (ex 3.3- AND 3.18) DEADLINES Submission of monthly monitoring FOR reporting template (using clinical REPORTING system searches) via email to [email protected] between the 1st and 7th calendar day of each month. A timetable will be provided End of Year Monitoring (inc. 3.3-3.18) Submission of an additional end of year report (by the final PDA deadline) using clinical system search to identify the surgical specialty where patients completing the health improvement have been referred to.

READ CODES -  Referral Needed EMBED  Referral to weight management  Referral to smoking cessation  Referral declined

Data Entry Template Codes:

Get Fit First Read Codes v2.doc

Surgical Speciality Codes:

Microsoft Word Document TEMPLATES Note there are 4 templates to support this scheme.

1. Referral Template to evidence that referrals meet the criteria in the Get Fit First Policy – available in clinical systems.

Note separate templates for GFF and combined templates for clinical thresholds exist.

2. Get Fit First Data Entry template (initial assessment and follow up assessment) available in clinical systems

3. Reporting Template 1 to provide monthly monitoring submission (Excel document)

4. Reporting Template 2 to provide end of year submission (Excel document)

CCG LEAD David Lautman OFFICER 01226 773739 CONTACT [email protected] DETAILS

Appendix 5 - Barnsley Referral Support Toolkit 2019/20 v3.0

Context: This builds on the 2018/19 Referral Toolkit which provides practices with evidence based pathways and policies, tools and monitoring information to reduce the number of inappropriate referrals to outpatient appointments.

Practices are expected to continue to follow the evidence based best practice pathways and maintain or reduce the number of first outpatient appointments in specialities associated with the referral management.

The South Yorkshire and Bassetlaw Commissioning for Outcomes Policy has been updated for 2019/20 to reflect national guidance published under the ‘evidence based interventions’ banner. Additional pathways are provided for snoring surgery and shoulder Arthroscopy. Existing clinical criteria and checklist have also been updated to reflect the latest guidance. There are also changes to referral routes; grommets and varicose veins no longer require IFR approval but will need a completed checklist. All requests for tonsillectomy should be made using the Individual Funding Request process.

This year the scheme is split into 4 elements; together the elements comprise the Barnsley Referral Support Toolkit which aims to support efficiencies in referrals whilst delivering quality care to patients. Each element will receive separate reward.

The 4 elements are: 1. Advice and Guidance 2. Clinical Peer Review 3. Referral Processes – Training Event for practice staff involved in referrals / procedures 4. Adherence to Commissioning Policies

Scheme Indicator (Contract National Rationale for Inclusion Measurement Frequency Requirement) / Local (Intended Outcomes) and Deadlines Priority 1 Advice and All requests for advice and National Ensure patients are seen Evidence use of The CCG will Guidance guidance (including letters) should Priority and treated in the right the BHNFT A&G use activity (A&G) be transmitted electronically via the place, at the right time as Service across a data from locally selected system quickly as possible range of BHNFT to (NHS E-Referral system) and coded using the ‘Choose and Book specialties. assess Advice and Guidance Request’ Reduce demand on practice Practices must Read Code: elective care where usage.  EMIS - 98E appropriate. have demonstrated  SystmOne - XaYv5 use of A&G (In 2019/20 a Helps referrers to make function across a tariff will be Practices should ensure that cases better and more range of specialties aligned to A&G are worked up appropriately and in informed decision on the (i.e. more than one for secondary line with referral pathways prior to most appropriate course speciality). care providers. requesting advice / guidance. SLAM data will of actions for their Practices can use be broken Sending requests for advice and patients; including those the "Choose and guidance electronically has the under shared care, with down by GP book advice and practice). following benefits; chronic or long term guidance request” . improve the response time conditions or previously Read Codes to (within 48 hours) under the care of a code in clinical . provides an audit trail. secondary care clinician. systems. This will, in combination with Practices should respond to Supports integration a clinical system requests for additional guidance / between primary and search (RefTool1), clarity within 14 working days. secondary care Failure to do so will result in the allow practices to case being closed on NHS E-

Scheme Indicator (Contract National Rationale for Inclusion Measurement Frequency Requirement) / Local (Intended Outcomes) and Deadlines Priority Referral. track progress. Alternatively Practices are encouraged to practices will be discuss comparative patient able to see outcomes as part of peer review. requests and worklists via the eRS

2 Clinical Undertake regular monthly review National To ensure practices 1. Provide 1. Submission Peer of referrals (minimum frequency of Priority understand their referral completed Peer of Peer Review 10 per year). data and approaches Review Template Review Plan for Template  Review referral data and meet To improve the quality undertaking Plan by PDA regularly to discuss as a of referrals monthly peer Submission practice, undertaking peer review as appropriate. Referral Reduce inappropriate review. deadline 1 data maybe practice own data referrals AND EITHER AND EITHER or CCG provided data.

 Code referrals that have been 2. Provide subject to peer review using the 2. Submission evidence on Peer following codes: of 10 x Peer o For SystmOne: Referral Review Summary Review review (Y0af3) Template that Summary o For EMIS: Checking monthly peer Templates by referral procedure review have been final PDA (EMISNQCH72) undertaken (dates, submission  All practices should undertake participants and

Scheme Indicator (Contract National Rationale for Inclusion Measurement Frequency Requirement) / Local (Intended Outcomes) and Deadlines Priority a prospective review of summary of deadline. referrals from locums, registrars learning / feedback and F2s before they leave from each session) OR practices.

 Practices are expected to have OR an agreed plan for frequent peer review. The format of this 3. Complete Peer 3. Submission will not be prescribed by the Review End of of Peer CCG unless covered under the Year Search Review End targeted support agreement. Report (RefTool.2) of Year to evidence that Search referrals have been Report reviewed regularly (RefTool.2) by between 1 April the final PDA 2019 and 31 March submission 2020. This will be deadline based on the date Embed will of review (not date provide of clinical instructions on consultation). The how to break focus will be on down the regular of review report by date. and not number of cases reviewed.

Scheme Indicator (Contract National Rationale for Inclusion Measurement Frequency Requirement) / Local (Intended Outcomes) and Deadlines Priority 3 Referral The CCG will run a training event Local To improve the content Each practice Event to be Processes in BEST time for non-clinical staff Priority of referrals ensuring that should send at held in Q1 – Training involved in referrals / procedures to adequate evidence is least one member 2019/20 Event ensure processes and provided to providers. of staff to the CCG responsibilities are clear. This will led training event Follow up take into account any policy Support Compliance to ensure event in Q3 changes or updates. and understanding of processes and for practices agreed referral responsibilities not complying processes. around medical with agreed correspondence referral are clear. processes.

100% attendance at training event.

4 Adherence 5.1 Practices should adhere to Local To improve the quality Number of First CCG will to Evidence the South Yorkshire and Priority of referrals Outpatient provide Bassetlaw Commissioning for

Scheme Indicator (Contract National Rationale for Inclusion Measurement Frequency Requirement) / Local (Intended Outcomes) and Deadlines Priority Based Outcomes Policy Reduce inappropriate Appointments monthly Commissio referrals reporting ning The policy has been updated for Practices will be packs to 2019/20 to reflect national Policies Support compliance set an individual practices from guidance published under the target for outpatient June 2019 ‘evidence based interventions’ To enable familiarisation activity in 2019/20 banner. Additional pathways are e.g. Month 1 with updated pathways. at 2018/19 year provided for snoring surgery and April 2019 Shoulder Arthroscopy. Existing The use of best practice end. data will be clinical criteria and checklist have pathways and This target will be available mid- been updated to reflect the latest checklists, advice and June 2019. guidance. The new policy will apply set on actual guidance and the MSK from 1 April 2019. practice outpatient triage will support the Guidance on first attendance interpreting Practices should ensure they use reduction in first activity between 1 packs will also the appropriate referral method: outpatient appointments. April 2018 – 31 be provided.  Utilising updated checklists March 2019 (the where appropriate. Maintain and continue 2018/19 baseline).  Completing IFR these reductions. questionnaires / checklists. Outpatient activity  Writing clinical letters in will only include the cases of exceptionality for specialities procedures not routinely commissioned associated with the referral A clinician may also request IFR management* and funding for any of the procedures the referral source should their patient not meet the will be ‘referred by

Scheme Indicator (Contract National Rationale for Inclusion Measurement Frequency Requirement) / Local (Intended Outcomes) and Deadlines Priority commissioning criteria, providing GP’. that they can provide evidence of clinical exceptionality. The 2018/19 baseline will take Note: For Prior Approval requests into account practices should respond to service changes requests for additional information such as the within 30 days. introduction of A list of procedures is provided MSK triage and under the commissioning section Get Fit First which of the BEST website. will have reduced outpatient activity 5.2 All referrals to Orthopaedics, in 2019/20 in Rheumatology and all referrals addition to practice in respect of Musculoskeletal (MSK) conditions will be referred efforts. to the SWYPFT Barnsley MSK For 2019/20 Triage Service in accordance with NICE guidance. Where individual practices patients require onward referral should maintain or to secondary care patients will reduce the number be offered choice by the MSK of first outpatient Triage appointments

compared to Note: Referrals to MSK do not count towards OPFA attendances. 2018/19.

Any practice who 5.3. Direct patients to the Minor

Scheme Indicator (Contract National Rationale for Inclusion Measurement Frequency Requirement) / Local (Intended Outcomes) and Deadlines Priority Eyes Conditions Service. has not met the outpatient target in 5.4 Follow best practice 2018/19 will be set pathways published on the an adjusted target. BEST website. Please note: new procedures may be added or These practices clinical guidance may change will be set an during the year. individual target for outpatient activity 5.4 Practices should ensure all in 2019/20 at referrals covered by the 2018/19 year end. commissioning policies are:  Made via the NHS E-Referral Where applicable: System (eRS). Practices are  Where a clinical thresholds expected to applies (see list of procedures) ensure the engage with referral is accompanied by targeted support. the appropriate combined Failure to do so will referral form in all result in non- circumstances. payment.

Practices who are persistently not following agreed referral processes as outlined at the

Scheme Indicator (Contract National Rationale for Inclusion Measurement Frequency Requirement) / Local (Intended Outcomes) and Deadlines Priority referral process training event will not be eligible for payment.

Practice Support Offer In addition to the above tools, the CCG will offer support via a virtual team to help practices to achieve targets. In the first instance this will be targeted at practices who are not meeting targets. As part of the PDA agreement all practices are expected to accept an offer of support within a reasonable timescale.

List of Specialties Associated with Referral Management 1. Cardiology 2. Colorectal Surgery 3. ENT 4. Gastroenterology 5. General Medicine 6. General Surgery 7. Gynaecology 8. Hepatobiliary & Pancreatic Surgery 9. Paediatric ENT 10. Paediatric Trauma And Orthopaedics 11. Plastic Surgery 12. Trauma & Orthopaedics 13. Upper Gastrointestinal Surgery 14. Vascular Surgery

HOW TO… To support practices the CCG will; (Step by step, how would a  Publish best practice pathways on the BEST website and update clinical threshold practice implement this) checklists in line with national guidance.  Provide an overview of commissioning policies / list of pathways practices are expected to follow.  Provide guidance on how to interpret the Outpatient activity data  Provide access to advice and guidance from specialists via e-referral system. Publish supporting advice and guidance information e.g. common queries, pathways, minimum information requirements on BEST website.  Provide a training event for non-clinians on referral processes.  Provide a practice support offer. CCG Lead Officer: David Lautman [email protected] 01226 433739

Appendix 6 - CVD Specification

INDICATORS Summary: CVD01 CVD01 High risk of cardiovascular disease (CVD) annual review - 12 points All patients at high risk of CVD should be invited for an annual review to discuss their risk factors and intervention/support offered to enable them to lower their risk, including referral to health trainer or other appropriate CVD02 services to support with healthy lifestyle choices. - 6 points CVD03 CVD02 High risk of cardiovascular disease (>20%) on statin - 6 points (CVD01-03 weighted CVD 03 High risk of cardiovascular disease (10-19.9%) on statin by practice prevalence of All patients with a CVD risk >10% should be offered a statin to lower their people with high risk of CVD) cholesterol

CVD04 CVD04 Heart failure/LVSD register validation - 6 points The practice will validate their heart failure (HF) / left ventricular systolic dysfunction (LVSD) register using the GRASP-HF audit tool (available (CVD 05/06 weighted by from PRIMIS). This will ensure accurate registers for QOF. practice prevalence of people with hypertension) CVD05 Lipid modification in people with CVD CVD05 All patients with existing cardiovascular disease should have their - 12 points individual risk discussed and prescribed a high intensity statin. (weighted by The practice should screen for patients who may have familial practice prevalence of people with CVD) hypercholesterolaemia

CVD06 CVD06 Screening for Familial hypercholesterolaemia (FH) - 10 points All patients identified as at risk of FH are assessed using the Simon Broome criteria and STH referral guidance and referred to Lipid clinic / FH (weighted by practice prevalence clinic as appropriate (Excluding any patients reviewed in 2018-19) of people at risk of FH identified) CVD07 CVD07 Offer of referral to cardiac rehabilitation - 8 points All patients with chronic stable angina or heart failure (NYHA Class 2-3), who have not completed cardiac rehab in the last 2 years should be (weighted by practice prevalence offered referral to cardiac rehabilitation group or home programme of people with stable angina or heart failure) CVD08 12 Lead ECG Monitoring in primary care CVD08 Practices will be offered a block payment for undertaking 12 lead ECG - 10 points monitoring in primary care, for example for: (weighted by  Irregular pulse rhythm practice 12lead ECG activity)  New hypertension diagnosis CVD09: Ambulatory Blood Pressure Monitoring (ABPM) in primary Page 1 of 16

Appendix 6 - CVD Specification

CVD09 care - 10 points Practices will be offered a block payment for undertaking ABPM in (weighted by primary care for people with an elevated clinic blood pressure reading to practice ABPM confirm diagnosis (excluding those with existing hypertension dx) activity)

CVD10: Ambulatory/home blood pressure monitoring (A/HBPM) CVD10 audit - 10 points Practices will follow NICE guidance (CG127) by offering ABPM or HBPM (weighted by to people with an elevated clinic BP >140/90 and this will be used to practice ABPM confirm diagnosis (dx) of hypertension. activity) TOTAL: 90 Points DEFINITION High risk of CVD The ‘High risk of CVD’ register is made up of people with a QRISK2 Score of :  >20%. OR  10-19.9% AND on a statin Patients with a record of CVD high risk review or CVD high risk review declined will be counted from 1st April 2019 to 31st March 2020. Patients with QRISK2 Score of 10-19.9% (after 1st Dec 2014*) who are not on a statin should be offered a statin if not contraindicated *Only QRISK 10-19.99% recorded after 1st Dec 2014 following introduction of new NICE guidance in July 2014

Hypertension Diagnosis:  Ambulatory BP – average day-time readings of >135/85  Home blood pressure readings (exclude first day of readings) – average of remaining readings over 4-7days of >135/85 See BEST website for further guidance : Hypertension diagnosis and treatment Guidelines Barnsley Anti-hypertensive Medication Flow Chart http://best.barnsleyccg.nhs.uk/clinical-support/local-pathways-and- guidelines/hypertension-barnsley-guidelines/16133

Lipid Modification Local guidance on statin prescribing can be found at: http://best.barnsleyccg.nhs.uk/clinical-support/medicines/prescribing- guidelines/Lipid%20Management%20Algorithm.pdf Familial Hypercholesterolaemia

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Appendix 6 - CVD Specification

See BEST website for: Simon Broome1 diagnostic criteria for Familial Hypercholesterolemia http://best.barnsleyccg.nhs.uk/clinical-support/diagnostic- tools/Cadiovascular/Familial%20hypercholesterolaemia%20Simon%20Br oome%20criteria.pdf STH Referral Pathway for familial hypercholesterolaemia / lipid clinic (NB satellite clinic held at Barnsley hospital) http://best.barnsleyccg.nhs.uk/clinical-support/local-pathways-and- guidelines/Sheffield%20Pathways/Sheffield%20referral%20pathway%20f or%20adult%20patients%20with%20query%20Familial%20Hypercholeste rolaemia%20FH%20December%2017.pdf

Cardiac rehabilitation Details of current venues and referral forms can be found on the BEST website: http://best.barnsleyccg.nhs.uk/clinical-support/services/cardiac- pulmonary-rehab-service/16947

New York Heart Association Classification Class Symptoms l No limitation: ordinary physical exercise does not cause undue fatigue, dyspnoea or palpitations. ll Slight limitation of physical activity: comfortable at rest but ordinary activity results in fatigue, palpitations or dyspnoea. lll Marked limitation of physical activity: comfortable at rest but less than ordinary activity results in symptoms. lV Unable to carry out any physical activity without discomfort: symptoms of heart failure are present even at rest with increased discomfort with any physical activity.

RATIONALE The new long term plan for the NHS includes a new national focus on FOR cardiovascular disease, including stroke. Both have been recognised as INCLUSION clinical priorities, and a major ambition to prevent 150,000 strokes, heart (Intended attacks and dementia cases over the next 10 years. Improving the Outcomes) detection and treatment of the high-risk conditions of AF, hypertension (high BP) and high cholesterol has the potential to unlock considerable health gains. It also enables early identification of other risk factors for CVD, such as smoking and obesity Annual review of people at high risk of CVD offers the opportunity to support / signpost people to other lifestyle interventions that can significantly reduce their risk, e.g. smoking cessation, increasing physical

1 Austin MA, Hutter CM, Zimmern RL, Humphries SE. Genetic causes of monogenic heterozygous familial hypercholesterolemia: a HuGE prevalence review. American journal of epidemiology. 2004;160:407-420.

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Appendix 6 - CVD Specification

activity, weight reduction. Cardiovascular disease has been identified as a priority for the CCG: • CVD <75 mortality 20% higher than national average • CHD 14% worse than best 5 peer CCGs • Mortality from acute MI 43% worse than average of best 5 comparator CCGs • Non-elective admission spend 44 % higher than lowest spending 5 peer CCGs Controlling modifiable risk factors is a crucial part of a wider cardiovascular disease programme to address these issues:

a) Hypertension – new indicators now included in revised Quality and Outcomes Framework indicators for CHD, stroke/TIA and hypertension for 2019-20, so this indicator has been removed from the PDA

b) Heart Failure register validation Changes to Quality and Outcomes Framework (QOF) since 2012/13 coding meant a drop in the size of left ventricular dysfunction (LVD) registers (used for Heart Failure (HF) 003 and 004 performance indicators) as codes for Left Ventricular Failure (LVF) and Left Ventricular Diastolic Dysfunction (LVDD) were no longer included in the rule sets. Only codes specifically stating ‘left ventricular systolic dysfunction’ (LVSD) place patients on the LVSD register and they must also have a heart failure (HF) diagnosis to ensure they are on the overall HF register. So HF001 and HF002 include patients with Heart Failure, which includes those with LVSD, whereas each patient needs to have a Heart Failure code and an LVSD code (if appropriate) to be included in the denominator of HF003 and HF004 GRASP-HF (run via CHART and available from PRIMIS) highlights potential patients who are yet to be coded with a HF or an LVSD diagnosis and also identifies patients with LVSD codes but no HF diagnosis code (and vice versa), and therefore not included in the overall HF register. This is important to the clinician on two levels: 1. A patient who is not coded and identified cannot be appropriately managed, since the clinical system will not automatically prompt the clinical team to ensure optimal medication. 2. If QOF populations are not appropriately identified, less payment is received. So lack of appropriate dual coding can decrease your prevalence factor significantly.

c) Lipid Management

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Appendix 6 - CVD Specification

Familial Hypercholesterolaemia (FH) or genetic inherited high cholesterol is a congenital condition present from birth. As such knowledge and recoding of relevant family clinical history is key. The siblings or children of someone with FH have a one in two (50%) chance of having the condition. The UK prevalence of FH is currently unknown, but is estimated to be 1:250. Around 80-90% of FH cases remain undiagnosed. If left untreated, about 50% men and 30% women with FH will develop coronary heart disease by the time they are 55. Early identification and effective treatment can help to ensure people with FH have a normal life expectancy2.

d) Cardiac rehabilitation Cardiac rehabilitation reduces both cardiovascular mortality and episode of acute hospitalisation, whilst also improving functional capacity and perceived quality of life. Cardiac rehabilitation supports an early return to work and the development of self-management skills and can be delivered effectively in a variety of formats, including traditional supervised centres as well as domestic settings3. Several NICE guidelines recommend referral to a CR programme: • CG172 Myocardial infarction: cardiac rehabilitation and prevention of further cardiovascular disease November 2013: recommendation 1.1.1, • CG94 Unstable angina and NSTEMI: early management Updated November 2013: recommendation 1.5.10 • NG106 Chronic heart failure in adults: diagnosis and management 12 September 2018: recommendation 1.9.1 Despite strong evidence bases for cardiac rehabilitation, the National Audit of Cardiac Rehabilitation 2018 report noted national uptake rates of: 33% in patients who had an MI 57% in patients who had had an MI and PCI 49% in patients who had had a PCI 71% in patients who had had CABG 50% Overall uptake in these groups HOW TO… Practices should review their baseline position and individual targets (where indicated) with regards to each CVD clinical area. Baseline positions are taken from:  CVD02/03: High risk of CVD registers and statin prescribing taken from data submitted at April 2017 as part of 2016-17 PDA – individual practice targets have been extended from those set in

2 Heart UK (November 2016) FH Available: https://heartuk.org.uk/fh-familial-hypercholesterolemia

3 BACPR 2017 Standards and Core Components for Cardiovascular disease Prevention and Rehabilitation

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Appendix 6 - CVD Specification

2018-19  CVD04: Heart Failure/LVSD register validation – baseline register sizes taken from QOF data 2017-18.  CVD05: Patients with cardiovascular disease who have had a cholesterol test in the last 15m AND it is <5 taken from baseline QOF data from 2016-17 - targets have been extended from those set in 2018-19  CVD07: patients with angina and heart failure taken from QOF data from 2017-18 And are shown in: Table 1: People at high risk of CVD (>20%) on a statin Table 2: People at high risk of CVD (10-19.9%) on a statin Table 3: People on Heart Failure / LVSD register Table 4-5: Lipid management in people with CVD Table 6: Offer of cardiac rehabilitation to people with angina/heart failure (NYHA class 2-3) Prevalence factors for each practice in each clinical area will be calculated using end of year 2019-20 submissions A quality improvement approach should be used to document any actions/changes within the practice that have been implemented to improve clinical outcomes for people with or at risk of CVD. Support for this approach can be obtained from the Academic Health Science Network (AHSN). http://www.ahsnnetwork.com/ It should also be noted that all practice pharmacists have undergone clinical training in CVD management for hypertension, and heart failure in February – March 2018.

High risk of Cardiovascular disease (CVD) As in previous years, clinical system searches will be provided to identify the target population:  People at high risk (>20%) or  Moderate risk (10-19.9%) AND on a statin All should be offered an annual review to discuss their risk factors and intervention/support offered to enable them to lower their risk, including support with healthy lifestyle choices and offered statin treatment. Ensure it is recorded if a patient declines or fails to attend following three invites. Also ensure that patients already identified as high risk of CVD are recorded as having a high risk of CVD annual review NOT an NHS Health Check in subsequent years. Patients with a risk score of >20% or those on a statin (excluding any with CVD diagnosis) are excluded from the NHS health check and you will not get a payment for this. See High risk of CVD annual review or NHS health Check Decision Flowchart:

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Appendix 6 - CVD Specification

http://best.barnsleyccg.nhs.uk/commissioning/CVD%20risk%20assessme nt%20decision%20flowchart.pdf In addition, all patients with a risk score of 10-19.9%* who are not on a statin should be offered a statin as per NICE guidance. Practices should record any patients who are contraindicated/intolerant of statins or who have, declined statins – these will be included in the percentage achievement target for those at 10-19.9% risk. *Only QRISK 10-19.99% recorded after 1st Dec 2014 following introduction of new NICE guidance in July 2014 Heart Failure / LVSD register validation Practices should run the GRASP-HF casefinder audit tool (Available from PRIMISHub). Please contact Sarah Pollard, Health Improvement Nurse, NHS Barnsley CCG (see ‘CCG Support’ below) for support running and/or using the audit tool. Using the HF-Casefinder workbook review those with:  HF only recorded – to determine if they have LVSD, LVDD, HFPEF (heart failure with preserved ejection fraction) o Read code using one of the following as appropriate: - Left ventricular systolic dysfunction (XaIIq/G5yy9) - Left ventricular diastolic dysfunction () - Echocardiogram shows LVSD (XaJ98/585f) - Echocardiogram shows LVDD (XaJ99/585g) - Heart failure with normal ejection fraction (XaWyi /G583)  Diagnosis of LVSD or LVDD but no additional code for HF: o Heart Failure (G58% - suffix – ensure included in QOF cluster of Read codes) o Heart failure with normal ejection fraction (XaWyi /G583) N.B. if no symptoms of HF, and LVSD finding is incidental, use Read code XaJ9G/662f: New York Heart Association Functional Classification (NYHA) Class I - No limitation of physical activity, i.e. asymptomatic. Reviewing these two groups as a minimum will validate your existing QOF HF/LVSD registers and maximise QOF points/payment. Practices undertake casefinding to identify any patients ‘missing’ from the HF/LVSD register, if prevalence of HF is below 1%: Using the HF-Casefinder workbook review those with:  Those with neither HF or LVSD diagnosis, but who have indicative items recorded that suggest HF: o H/O heart failure or suspected HF o Prescribed metolazone, ivabradine or aldosterone antagonist o HF monitoring codes o BNP >100

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Appendix 6 - CVD Specification

o Diagnosed with cardiomyopathy / cardiomegaly o Abnormal echocardiogram o Shortness of breath and oedema – optional Confirming diagnosis: a. Look for ECHO report/ Consultant letter/ NTproBNP /BNP results.  BNP>400pg/ml or NT-proBNP>2000pg/ml -refer for specialist assessment and ECHO within 2 weeks; ; (NB: high levels can be caused by LVH, ischaemia, tachycardia, right ventricular overload, hypoxaemia[including PE],GFR<60ml/minute, sepsis, COPD, diabetes, age>70yrs and liver cirrhosis)  BNP 100-400pg/ml or NT-proBNP 400-2000pg/ml – refer for specialist assessment and ECHO within 6 weeks  BNP<100pg/ml or NT-proBNP<400pg/ml – normal levels NICE recommends that HF should not be diagnosed by clinical symptoms / BNP alone, but should be confirmed by ECHO and specialist assessment - NICE guideline 108 August 2010 b. If unable to identify how the diagnosis has been made, recommend for GP to confirm diagnosis e.g. perform NTproBNP; contact consultant cardiologist, etc. C. Identify patients who may have had a ‘1 off’ diagnosis of HF i.e. alcohol induced / infection. Suggest adding Read code for ‘first episode of HF’ in preference to HF resolved which removes permanently for HF register. d. The ‘type’ of HF i.e. LVSD or HFPEF/LVDD (left ventricular diastolic dysfunction or heart failure with a preserved ejection fraction/ left ventricular diastolic dysfunction). If type of heart failure is not clear on ECHO report, review consultant letters, or request clarification from cardiologist. As care pathways for LVSD and HFPEF/LVDD differ, it is important to confirm whether ventricular function is compromised.

Lipid Modification Clinical system searches will be provided to enable practices to identify patients that have existing CVD (coronary artery, cerebrovascular, peripheral arterial disease) who:  have not had cholesterol tested in L15m  are not currently on a statin and NOT contraindicated  latest cholesterol results indicate total cholesterol >5 Patients fitting the above criteria should be reviewed to establish if further investigation or follow-up is required to ensure all patients are offered appropriate treatment and drug titration to reach treatment target. Practices may also want to consider other strategies:  Patient decision aids for communicating risk and deciding

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Appendix 6 - CVD Specification

treatment options  videos and leaflets increasing awareness or consider group education  participation in local and national campaigns

Familial hypercholesterolaemia (FH) Practices should use the clinical system searches to identify people as per NICE clinical guidelines4:  younger than 30 years, with a total cholesterol concentration greater than 7.5 mmol/l OR  30 years or older, with a total cholesterol concentration greater than 9.0 mmol/l And ensure all those that have not yet been screened are screened using Simon Broome criteria and referred to specialist FH clinic if apprprpiate. Please note: baseline triglycerides should be <2.5 mmol/l to be eligible for referral to FH clinic. If >2.5 mmol/l consider referral to Lipid Clinic, especially if total cholesterol >9 mmol/l. These individuals should be assessed against the Simon Broome criteria to make a provisional clinical diagnosis of FH in primary care settings. When considering referral, please refer to the Sheffield Teaching Hospitals referral pathway for adult patients with query Familial Hypercholesterolaemia (FH). Those meeting the criteria should be referred to the Sheffield/Rotherham FH service for diagnostic testing and potential cascade testing in family members.

Cardiac rehabilitation Practices should use clinical system searches provided to identify all patients with chronic stable angina or heart failure, and offer referral to cardiac rehabilitation group or home programme (if they have not completed cardiac rehab in the last 2 years). The benefits of cardiac rehabilitataion should be discussed with the patients and recorded in their medical notes as referred, declined or unsuitable.

12 lead ECG Monitoring in primary care Practices should use the clinical system searches provided to identify the number of ECGs undertaken within the practice by primary care clinicians. ECGs undertaken in secondary care or imported from other sources will be excluded. At the end of the year a practice’s payment will be adjusted according to

4 NICE Familial hypercholesterolaemia: identification and management. Clinical guideline [CG71] Published date: August 2008 Last updated: November 2017. https://www.nice.org.uk/guidance/cg71/chapter/Recommendations#case-finding-and-diagnosis

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Appendix 6 - CVD Specification

the amount of activity undertaken as a proportion of total activity across all practices.

Ambulatory Blood Pressure Monitoring in primary care Practices should use the clinical system searches provided to identify the number of ABPM procedures undertaken within the practice by primary care clinicians. ABPM procedures undertaken in secondary care or imported from other sources will be excluded. At the end of the year a practice’s payment will be adjusted according to the amount of activity undertaken as a ratio of total activity across all practices.

ABPM/HBPM audit Practices will review patients that:  have a dx of hypertension without an average day-time ABPM/HBPM >135/85 and document reasons (e.g. dx in secondary care, ABPM/HBPM declined or not tolerated)  Have an ABPM/HBPM reading >135/85 with no subsequent dx of hypertension MEASUREMENT Individual practice KPIs are set out in the data tables below, according to original baseline data used in PDA 2018-19. New indicators for cardiac rehabilitation and heart failure/LVSD registers has been taken from QOF 2017-18. Please see Table 7 for details on monitoring indicator progress and calculating achievement CVD01: Annual review of people at high risk of CVD - Measure: percentage of people at high risk receiving a high risk of CVD annual review (excluding declined from denominator) Target: 55% for 4 points, 65% for 8 points, 75% for 12 points

CVD 02: High risk on statin (>20%) Measure: Percentage of patients >20% risk on statin (including exceptions, i.e. percentage receiving the intervention) Relative practice target: to move towards or exceed 60% (See table 1)

CVD 03: High risk on Statin (10-19.99%) Measure: Percentage of patients 10-19.9% risk on statin (excluding declined/C/I or intolerant, i.e. percentage receiving the intervention) Relative practice target: to move towards or exceed 75% (See table 2)

CVD 04: Heart Failure / Left ventricular systolic dysfunction register validation/case-finding

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Appendix 6 - CVD Specification

Measure: Self-certification that register has been validated for HF/LVSD dx using GRASP-HF tool Target:  Increase in prevalence of LVSD.  In practices with overall HF prevalence of <1% at baseline, increase in overall HF and LVSD prevalence (See table 3)

CVD05: Lipid Management Measure: percentage of people with existing CVD whose cholesterol has been checked in the last 15 months and is controlled to <5mmol/L5 Relative practice target: to move towards or exceed:  90% of people with CVD have had a cholesterol test in last 15 months (See table 4)  85% with a cholesterol of <5 (See table 5)

CVD06: Assessing for Familial hypercholesterolaemia Measure:  Number patients identified as high risk of FH  % of patients identified as at risk of FH  Number of patients screened using Simon Broome criteria EVER  % of patients at high risk of FH screened using Simon Broome criteria  Number of patients referred to lipid /FH clinic  % of patients referred to lipid clinic / FH clinic percentage of those identified as high risk who have been assessed using the Simon Broome criteria / STH referral guidance Target: 75% of those at risk of FH are screened (including those screened in 2017-18) Numbers referred to lipid clinic should also be submitted

CVD07: Offer of referral to cardiac rehabilitation Measure: Percentage of people with stable angina or heart failure (NYHA class 2-3) who have been offered cardiac rehab programme Percentage of patients referred to, unsuitable or declined cardiac rehabilitation Target: 65% offered cardiac rehabilitation (see table 6 for indicative

5 Recommendations taken from NICE Clinical Guideline 181: Lipid Management, 2014,

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Appendix 6 - CVD Specification

referral targets)

CVD08: 12 Lead ECGs undertaken in primary care. Measure: number of 12 lead ECG undertaken by a primary care clinician in the practice as a proportion of all ECGs undertaken in Barnsley (population>17y) No target

CVD09: Ambulatory blood pressure monitoring procedures undertaken in primary care Measure: number of ABPM procedures undertaken by a primary care clinician in the practice as a proportion of all ABPM procedures undertaken in Barnsley (population>17y and excluding those with existing diagnosis of hypertension) No target

Data for all the above indicators to be submitted on reporting template every 4 months:  August 2019 (data to end July)  December 2019 (data to end November)  April 2020 (data to end March 2019) Data from clinical system searches (to be provided), for all the above indicators except CVD04. For CVD04 practices will be required to run GRASP-HF audit tool and upload to CHART online

CVD10: Ambulatory/home blood pressure monitoring procedures – audit Measure:  Number of people with hypertension dx in L12  Number of people with hypertension dx in L12 with ABPM or HBPM within 3/12 prior to diagnosis  Number of people with average day time blood pressure readings or average home blood pressure readings >135/85 with no subsequent dx of hypertension  Reasons for dx without ABPM/HBPM to be submitted  Reasons for elevated ABP/HBP readings with no subsequent dx of hypertension

Target: A/HBPM data to be submitted on reporting template from clinical system searches (to be provided) plus audit details re: exceptions and actions and outcomes for improvement at:

Page 12 of 16

Appendix 6 - CVD Specification

 End Quarter 2 (October 2019)  End of year (April 2020)

Practices should note the number of patients where any significant issues/exceptions affecting performance are identified, for example, elderly population and/or care home residents or house bound. Other factors, in particular those beyond the control of primary care teams.

FREQUENCY See MEASUREMENT above /DEADLINES READ CODES High risk of CVD SystmOne EMIS Web/ Term SNOMED (CTV3) Vision (V2) CVD high risk review XaQ9Z 66f2 1060761000000119 CVD high risk review XaQ9Y 8IAK 1060701000000118 declined Statin contraindicated XaG2V 8I27 459877017 Statin not tolerated XaJYw 8I76 2474720017 Patient on maximal tolerated XaJ5i 8BL1 2159169011 lipid lowering therapy Administrative codes CVD high risk monitoring XaPlb 9Ox2 1705561000006111 invitation first letter CVD high risk monitoring XaPIc 9Ox3 1705571000006116 invitation second letter CVD high risk monitoring XaPld 9Ox4 1705581000006118 invitation third letter CVD high risk monitoring XaNOh 9Ox0 1628811000006115 telephone invitation

Hypertension Established Read codes within QOF business rules for blood pressure recording SystmOne EMIS Web/ Term SNOMED (CTV3) Vision (V2) Patient on maximal tolerated XaJ5h 8BL0 2159168015 antihypertensive therapy

Lipid Modification Read codes to support numeric values for nonHDL/LDL cholesterol levels (via lab links) and prescribing codes linked via medication prescriptions on clinical system.

Page 13 of 16

Appendix 6 - CVD Specification

See statin exception codes in above table under High risk of CVD

Familial Hypercholesterolaemia Read codes to support recording of diagnosis, and assessment. SystmOne EMIS Web/ Term SNOMED (CTV3) Vision (V2) Assess using Si Broome diagn criteria familial XaR6H 3878 1739071000006119 hypercholest Familial Hypercholesterolaemia- X40X2 Heterozygous C3200 1773186016 Familial Hypercholesterolaemia- X40X1 Homozygous Possible Familial XaX3u 1W1 1659061000000112 Hypercholesterolaemia Referral to Lipid Clinic 8HT1. 248058012 Family history of MI in 1st XaQvy degree relative <60 years Family history of MI in 2nd XaQvx degree relative <50 years

FH: Myocardial infarction 12C5 397701010

FH: total chol >7.5 mmol/L XaQwa 1st or 2nd degree relative FH: total chol >6.7 in child XaQwb or sibling <16 yrs FH: High cholesterol / XaBZH 1262 397 Raised blood lipids Tendinous Xanthoma* X50Fo N228 1233200015 Xantholasma* F4E51 499732017

*Tendon xanthoma only occur in people with FH, xanthelasma may happen for other reasons.

Cardiac Rehabilitation SystmOne EMIS Web/ Term SNOMED (CTV3) Vision (V2) Referral to cardiac rehab XaXgu 8Hkk programme Referral to cardiac rehab XaXgr 8IE3 programme declined

Page 14 of 16

Appendix 6 - CVD Specification

Not suitable for cardiac Xactw 9NSV rehab programme Cardiac rehabilitation XaYWa 8F97 programme completed

ECG and ABPM / HBPM SystmOne EMIS Web/ Term SNOMED (CTV3) Vision (V2) 12 Lead ECG XE1PZ 321B Standard ECG 3212 Average day interval XaF4L 246Y systolic blood pressure Average day interval XaF4a 246X diastolic blood pressure Ambulatory blood pressure 315B Ambulatory blood pressure XaZv8 8IEb recording declined Average home systolic XaKFx 246d blood pressure reading Average home diastolic XaKFw 246c blood pressure reading Blood pressure recorded XaJVi 662j by patient at home Self-measured blood XaoQP 246g pressure reading Home blood pressure XagQr monitoring declined

TEMPLATES Support and guidance will be available from: and LINKS  Health Improvement Nurse for Vascular Disease, BCCG [see contact details below)  Clinical System Support Officer, EmBed  Practice Clinical Pharmacists, BCCG Local templates are available for:  CVD High risk reviews  Hypertension*  CHD*  Diabetes*  Heart Failure*  CKD *Also QOF templates available in clinical systems

Page 15 of 16

Appendix 6 - CVD Specification

CCG LEAD TBC OFFICER CCG Sarah Pollard, Health Improvement Nurse – Vascular Disease SUPPORT Tel: 01226 433741 Email: [email protected]

Page 16 of 16

Appendix 7 - DIABETES SPECIFICATION 2019/20

Nationa Local l Priority Priority TITLE Summary: Yes as The (what is the DIAB01 Type 2 – Three Treatment Targets Require targets d for were in contractual All patients with a diagnosis of Type 2 diabetes to be requirement) national PDA invited for an annual review to complete 3 treatment Diabete 2018- targets. The target will be 30% and each practice will s Audit 19. have either to maintain current performance or move from their current position at least one third towards meeting the target. Each practice will be given an individual target. Those above the target will be allowed a 10% leeway unless below the average target of 30%. DIAB02 –Type Two Structured Education - all patients with Type 2 diagnosis within 6 months of being diagnosed to be referred for structured education programme via Diabetic Integrated Service SPA. DIAB03 High risk of diabetes – glycaemic assessment in L12M All patients identified at high risk of diabetes to be invited to have a glycaemic assessment. The target will be 75% and each practice will have to maintain current performance (if meeting target) or move from their current position at least one third towards meeting the target. Each practice will be given an individual target. Those above the target will be allowed a 10% leeway unless they go below the target of 75%. DIAB04 Invitation to self-refer/direct referral to NDPP for eligible patients All patients with a history of pre-diabetes/non-diabetic hyperglycaemia (elevated blood glucose reading) should be invited for an annual review to have their glucose level checked and to discuss their risk factors and offered intervention/support to enable them to lower their risk, including support with healthy lifestyle choices and invitation to self-refer or direct referral to National diabetes prevention programme (NDPP) if meet criteria. RATIONALE The PDA included diabetes targets last year. Practices’ FOR targets were based on the national diabetes audit INCLUSION results and the contract was to increase targets by one third to achieve patients with Type 2 diabetes towards (Intended Outcomes) a target of 50% for 3 treatment targets respectively. For 2019-2020 this target has been set from assessing Appendix 7 - DIABETES SPECIFICATION 2019/20

practices 2018-19 position and setting targets based on this achievement. Practices at target should aim to improve from baseline and will be allowed a 10% leeway unless they go below the targets set. Barnsley currently performs relatively well, for people with type 2 diabetes, in terms of achieving all eight care processes however, in terms of achieving all three treatment targets Barnsley is the has a variation in performance across practices. This indicator specifically looks at achievement of target values for HbA1c, blood pressure and cholesterol. Improvement in achieving the 3 treatment targets also supports the delivery of the cardiovascular disease prevention programme – Stage 1 – CHD and risk factors. Type two diabetes patients can greatly improve their health outcomes by taking part in a structured education programme. There is strong clinical evidence shows that tight blood glucose control is associated with a reduction in diabetes complications and patients attending a structured education programme. It has therefore been recommended by NICE since 2005, as there is good evidence that diabetes education courses improve key outcomes, reduce the onset of serious complications and are cost effective or even cost saving. The NICE guidelines - Type 2 diabetes in adults: management [NG28] (2017) recommends that that SE is delivered by trained educators who have an understanding of educational theory appropriate to the age and needs of the person, and who are trained and competent to deliver the principles and content of the programme. It also needs to be quality assured, and reviewed by trained, competent, independent assessors who measure it against criteria that ensure consistency. Barnsley Integrated Diabetes Service EXPERT courses are compliant with the NICE guidelines. HOW TO… Regards to the clinical areas. Baseline positions are (Step by step, taken from: how would a DIAB01: Type 2 – Three Treatment Targets taken practice from local assessment of practices achievement of implement this) 2018-19 targets. A quality improvement approach should be used to document any actions/changes within the practice that have been implemented to improve clinical outcomes for people with or at risk of diabetes. A system search will be provided to enable Appendix 7 - DIABETES SPECIFICATION 2019/20

ongoing monitoring of achievement towards the 3 treatment targets as per NDA criteria. The search will identify patients who are target population as having risk factors :  Gestational diabetes  prediabetes or non-diabetes hyperglycaemia  Insulin resistance  Impaired glucose tolerance  Coded at risk of diabetes  HbA1c Value between >=42 and <=47  Fasting blood sugars <=5.5 and >=6.9 Practices should consider their current performance, review individual and data at patient and practice level. Consider the causes of variation achieving the 3 treatment targets and possible alternative solutions to improve. Practices may also want to consider other strategies:  Patient decision aids for communicating risk and deciding treatment options  videos and leaflets increasing awareness  specialist support, including structured group education DIAB02 –proportion of new type two diabetes patients eligible for Structured Education that diagnosed in 2018-19. Use local search to identify new patients who have been diagnosed and numbers referred for SE and those who have declined. Practices should refer patients to the Diabetes Integrated service structured education programme EXPERT via the SPA. Practices may want to consider: Patient decision aids for communicating risk; videos and leaflets about the benefits of group structured education programmes. Patient information on SE courses can be accessed via the BEST website. Practices should explain to patients and their carers that structured education is an integral part of diabetes care. DIAB03: High risk of diabetes – glycaemic assessment in L12M taken from local assessment of practices achievement of 2018-19 targets via system search Practices should invite all patients with a history of pre-diabetes/non-diabetic hyperglycaemia for an Appendix 7 - DIABETES SPECIFICATION 2019/20

annual review to have their glucose level checked and to discuss their risk factors and offered intervention/support to enable them to lower their risk, including support with healthy lifestyle choices and invitation to self-refer or direct referral to National diabetes prevention programme (NDPP). DIAB04: Invitation to self-refer/direct referral to NDPP for eligible patients taken from NDPP provider data on referrals at November 2018 and via system search Practices to use the local system search to identify patient level data and to monitor progress:  Identifying people at risk of diabetes, pre- diabetes and those eligible for invite/referral to the National Diabetes Prevention Programme  Monitoring recording of invites, referrals and numbers declined MEASUREMEN DIAB01: Type 2 – Three Treatment Targets T (How would Practices will be given individual targets. Refer to you robustly tables on page 5 for baseline data and expected measure, targets (will be added in final document.) The target ensure will be 30% and each practice will have either maintain outcomes) this target or move from their current position at least one third towards meeting the target. This indicator will measured by using a system search. DIAB02 –proportion of new type two diabetes patients eligible for Structured Education that diagnosed in 2018-19. This will be measured via search and data from local provider – Barnsley Integrated Diabetes Service. DIAB03 High risk of diabetes – glycaemic assessment in L12M See tables on page 6 for baseline data and target. (Will be added in final document.)The target will be 75% and each practice will have either maintain this target or move from their current position at least one third towards meeting the target. Each practice will be given an individual target Practices should note the number of patients where any significant issues/exceptions affecting performance are included, for example, elderly population and/or care home residents or house bound. Other factors, in particular those beyond the control of primary care teams. DIAB01/02/3 Appendix 7 - DIABETES SPECIFICATION 2019/20

Achievement of the indicators will be taken from local search data. DIAB04: Invitation to self-refer/direct referral to NDPP for eligible patients will be taken from NDPP provider data and via system search. Practices would be expected to increase referrals from 50% eligible target 2018-19 PDA to 55% for 2019-20. . FREQUENCY The provisional timetable for collection and reporting AND is:- DEADLINES Extract August 2019 - publish November 2019 FOR REPORTING Extract November 2019 - publish January 2020 Extract February 2020 - publish April 2020

READ CODES All required Read codes are in National Diabetes Audit and QOF data -eMBED set/business rules and within locally developed template. The following Read codes are suggested to record diagnosis and referral to NDPP:

EMIS SystmO Web/ Action Term ne SNOMED Vision (CTV3) (V2) Invited to self-refer, NHS DPP 258752100000 i.e. provided info (PROXY XaeCf 679m 0117 and letter* CODE) Referral to 102532100000 Direct referral XaeDH 679m4 NHS DPP) 0109 Referral to Referral/invite 102530100000 NHS DPP XaeDG 679m3 declined 0100 declined NDPP started NHS DPP 102527100000 XaeD0 679m2 (date) started 0103 NDPP completed NHS DPP 102525100000 XaeCz 679m1 (date) completed 0107 NDPP not NHS DPP not 102521100000 XaeCw 679m0 completed completed 0108 2990619013 Non-diabetic XaaeP C317 Hyperglycaem Diagnosis ia 222100100000 XaZq8 C11y5 Pre-diabetes 0112

TEMPLATES AND LINKS Appendix 7 - DIABETES SPECIFICATION 2019/20

CCG LEAD Siobhan Lendzionowski, Lead Commissioning and OFFICER Transformation Manager CONTACT [email protected] DETAILS

Appendix 8 - COPD SPECIFICATION 2019/20

INDICATOR 1 COPD National Local (Contractual Priority Priority Requirement) COPD1 - Pulmonary Rehabilitation: All diagnosed COPD patients who attend their Yes Yes COPD annual review at their GP Practice should be considered for their appropriateness to attend Implementation Pulmonary Rehabilitation. Upon the primary care of an integrated representative checking to ensure that the respiratory patient meets the Pulmonary Rehabilitation model for Service’s inclusion criteria (see below), a Barnsley is in discussion should be held with the patient to line with outline the benefits of accessing the service and national policy to make them aware of the various venues including: across Barnsley that this service is now offered. Primary care will be able to utilise both the short NHS Five Year film clip and service brochure to actively Forward View encourage patients to agree to being directly and the GP referred to the Pulmonary Rehabilitation Service. Forward View;

Pulmonary Rehab Inclusion Criteria: Getting serious - Diagnosis of COPD or chronic lung about condition. prevention, - Clinical assessment must have been undertaken including spirometry and Empowering oxygen saturation levels at rest. patients, - Offer to all appropriate patients including those who have a recent hospitalisation Bringing Care for an exacerbation, those that consider Closer to themselves functionally disabled by Home, COPD (usually MRC grade 3 and above). - Optimised respiratory medication / New Models of therapy. Care; delivering - Motivated to attend and complete the transformational programme. change across an integrated Pulmonary Rehab Exclusion Criteria: pathway. - Unstable angina or recent myocardial infarction (3 months). - Severe aortic stenosis. - Hypertension >200mmHg Systolic / 100mmHg Diastolic. - Other co-morbidity disease with prognosis < 6 months. - Impaired cognitive function. - Physical disability preventing safe exercise performance (i.e. unsuitable for 1

people unable to walk). - Awaiting results of further investigations (i.e. cardiac).

RATIONALE Improving the respiratory health in Barnsley will; FOR INCLUSION - Decrease incidence, prevalence morbidity (Intended and mortality from acute and chronic Outcomes) respiratory diseases - Decrease the numbers of people who require consultant outpatient review, A&E or hospital admission and to decrease length of hospital stay - Reduce inequalities in respiratory health care - Enhance the quality of life for people living with chronic respiratory diseases, enabling them to lead as full and active life as possible - Enable people with respiratory diseases to receive an early and accurate diagnosis, to receive the information and support they need to share fully in decision making and manage their respiratory disease

HOW TO… COPD1: All COPD patients that meet the Pulmonary Rehabilitation referral criteria should be informed of the benefits of accessing pulmonary rehabilitation and that they have actively encouraged participation by showing the short film and issuing the patient with an accompanying brochure. Individual discussions regarding pulmonary rehabilitation should be recorded, alongside a breakdown of the numbers of patients directly referred into the service and the numbers of those patients that refused to be referred. The referral form to Pulmonary Rehabilitation Service is available via clinical systems and the following link; http://best.barnsleyccg.nhs.uk/clinical- support/local-pathways-and-guidelines/copd- local-guidelines/37492

Individual referral targets to the Pulmonary rehabilitation Service based on COPD population size (QOF).

MEASUREMENT COPD1: External audit by the Pulmonary Rehabilitation Service (provider SWYPFT) of the number of referrals by practice.

FREQUENCY COPD1: external referral data will be monitored AND quarterly by Provider (SWYPFT) and shared DEADLINES with practices (via the Quality Dashboard).

READ CODES Please refer to Table 1 for a full list of COPD related READ codes.

TEMPLATES COPD local guidelines:

- Updated service guide for local COPD services for practitioners - Patient information leaflet on COPD services - Template self-management plan - Patient information leaflet on rescue medications - Prescribers guide to rescue medications

http://best.barnsleyccg.nhs.uk/clinical- support/local-pathways-and-guidelines/copd- local-guidelines/37492

2) GOLD 2017 Global Strategy for the Diagnosis, Management and Prevention of COPD http://goldcopd.org/gold-2017-global-strategy- diagnosis-management-prevention-copd/

3) COPD - Algorithm for inhaled therapies: http://best.barnsleyccg.nhs.uk/clinical- support/local-pathways-and-guidelines/copd- algorithm-for-inhaled-therapies-/10791

CCG LEAD Lynsey Bowker OFFICER

Appendix 9 - CANCER SPECIFICATION 2019/20

Section Cancer:

Introducti This document describes practices indicators for cancer. They focus on on prevention of cancer, improving early diagnosis and the ongoing care and support for people who have cancer or are living beyond having it. There are six indicators for practices to deliver.

A. Early Diagnosis The aim of this cancer indicator is to increase overall cervical, bowel and breast screening uptake for eligible populations in Barnsley; and to reduce the number of people diagnosed with cancer as a result of an emergency admission or late stage diagnosis. It is also to reduce health inequalities.

A1. Practice Screening Rates For Barnsley although the screening rates are above the national average this hides the large variation of uptake between different GP practices. The table below shows this variation:

Screening Barnsley National Barnsley Average Average variation Breast 77.8% 72.1% 69.7% - 84.0% screening Bowel 60.8% 59.6% 47.1% - 70.2% screening 1. Cervical 76.2% 71.7% 62.0% - 81.9% Scheme screening Elements The CCG will support practices with obtaining the indicator by:  Rolling out of the FIT screening  NHS England Screening Programme support at practice level  Linking them in with the Be Cancer Safe programme

CA01 -Practices to follow up screening DNAs for those patients currently not participating in the screening programme(s) by GP sending 1 supporting letter or reminder (e.g. text) to individual patients to encourage uptake, in addition to letters from the screening service. To use at every opportunity a behaviour change intervention to encourage those not attending screening appointments to attend. Practices to also raise awareness and promote the benefits of screening to patients on their practice list.

CA01 Indicator will be measured by an audit template that will be provided by the CCG. That practices are to complete by August 2019.

A2. Symptomatic Referrals Barnsley needs to improve the recognition and early referral of symptomatic cancers and improve early detection and survival rates for Barnsley people so that we reduce emergency admissions. Appendix 9 - CANCER SPECIFICATION 2019/20

The CCG will support practices to do this by :  Working with the Trust and practices to introduce Straight to Test opportunities for: o Lung o Prostate/urology o Colorectal

 Introduction of revised 2 week referral forms  Introduction of Lower GI pathway including FIT symptomatic and FCP testing in Primary Care

CA02 - Practices to adopt the lung, prostate/urology; colorectal and Lower GI rapid integrated pathways including use of FIT and FCP as published on the BEST website

B. End of Life Care /Palliative Care 50% of people are dying in hospital rather than their preferred place of death, and too many patients are being admitted through A&E in the last three months of their lives. The national average is 20%. The aim of the indicator is to ensure all patients have advanced care planning in place and get the best support they need.

CA03 Practices to work on ensuring patients on palliative care list are consulted about their preferred place of death. To be evidenced within the EPaCCS template along with palliative care plan details. Practices to ensure patients are consenting to their records being shared, and allow summary care records to be shared across the MIG

This will allow the Electronic Palliative Care Coordination System (EPaCCS) to transfer patient data between healthcare providers through the Summary Care Record / MIG, thus improving patient choice and appropriate advanced care planning

The CCG will support practices by:  Providing a template  Providing Training on EPaCCS  Via the Macmillan ANP working with care homes to improve palliative care

 Encouraging the Palliative Care Consultant to provide outreach to

areas with low hospice attendance

C. Living With and Beyond Cancer (LWABC)

CA04 – Practices to make sure patients newly diagnosed with cancer and on the cancer register to have a completed holistic cancer care review within 6-9 months of diagnosis. This to be in the first instance via a face to face appointment (unless patient prefers a telephone call.) Practices to use the cancer care template that is on the clinical system and to use Macmillan information within it to ensure patient gets a holistic review. Practices to use information within treatment Appendix 9 - CANCER SPECIFICATION 2019/20

summaries provided by BHNFT with the aim to ensure the patient receives a holistic review. For housebound this to be completed during a home visit. D. Patient Experience and Service Improvement

Patient experience surveys have identified that 64% of patients thought that GPs and nurses at their general practice did everything they could to support them. The areas that they said they wanted improving were around being provided with information.

The CCG wants to ensure that patients have the information that they need to navigate ever shorter diagnosis and treatment pathways, particularly with Straight to Test options, and that they understand the potential implications.

This will provide improved patient experience in primary care for patients with suspected cancer.

The CCG will support this by:  Providing site specific and generic patient information leaflets that will support patient expectation and understanding  Create revised referral documentation that will support GPs with pre- diagnosis information requirements

CA05 – Practices to put forward a Lead GP who will work with the Macmillan GP to consider the practice needs with regards to support and input.

CA06 – Practices to undertake the national cancer diagnosis audit. Completion to be evidenced via notification to the CCG . To have undertaken 50% of audit completed by Q3 October 2019. And 100% by end of Q4 April 2020 to meet indicator.

The National Cancer Diagnosis Audit (NCDA) is referred in Achieving World Class Cancer Outcomes‘: a strategy for England 2015-2020’ which highlighted the critical role of national clinical audit in driving improvement. The opportunity for clinical improvement is the main driving factor behind the audit. It looks specifically at clinical practice in order to understand: 1.interval length from patient presentation to diagnosis 2.use of investigations prior to referral 3.what the referral pathways for patients with cancer are and how they compare with those recorded by the cancer registry

The Cancer Research UK facilitator will be available to offer advice and support in the collection and submission of the data. To join and register : www.cruk.org/ncda 2. In Barnsley cancer is the most common cause of mortality accounting for RATIONA 31% of all deaths. This is slightly above the national average of 29%. LE FOR Collectively cancers account for 17.9% of the gap between the Barnsley and INCLUSIO England average for male life expectancy and 29.1% of the gap in female N life expectancy. The four most common cancers in Barnsley are lung, Appendix 9 - CANCER SPECIFICATION 2019/20

(Intended prostate, breast and colorectal, accounting for 50% of all cancer deaths in Outcome Barnsley, compared to 46% across England. s) The Five Year Forward View (2014) set an ambition to improve outcomes across the whole cancer pathway, including better prevention, swifter diagnosis and better treatment, care and aftercare. In response, NHS England established the Independent Cancer Taskforce which published its report -Achieving World-Class Cancer Outcomes A Strategy for England 2015-2020. The vision for Barnsley CCG is in line with the national strategy – to prevent people from having to experience cancer in the first place but, where cancer is suspected, there should be early diagnosis to ensure the best outcomes for treatment are available and enable people to live for as long and as well as is possible. Primary Care has a vital role in delivering this ambition.

High mortality and the National Cancer Strategy has ensured that Cancer is a strategic priority for Barnsley CCG. With key stakeholders, Barnsley CCG has developed a local programme plan to implement the key priorities outlined in the national cancer strategy to reduce smoking, increase screening uptake, early diagnosis and improve patient cancer pathway experience including survivorship and end of life care. Key to implementation of the plan is the involvement of General Practice which is a key point of contact for someone with cancer and is involved in important milestones during their treatment.

Screening rates for Barnsley is varied across communities and tumour site programmes. Research shows that ‘GP endorsement of screening programmes achieves better participation than a centralised invitation letter’ (Zajac et al, 2010); this has been carried out for multiple Screening programmes including Breast and Bowel Screening. Targeting patients who do not attend by GP’s will increase the screening rates.

The CCG is implementing the lower GI pathway, as colorectal cancer is the fourth most common cancer registered in England and a major cause of mortality and morbidity. It is the second biggest cancer killer but if diagnosed early enough there’s more than a 90% chance of successful treatment. Last year in the UK over 240,000 patients with lower abdominal symptoms were seen by a specialist following an urgent General Practice referral for suspected cancer. The majority of these will be referred for a colonoscopy, however only about 4% of them will have cancer.

It is becoming increasingly important to utilise tests that have lower associated risks and can rule out cancer. The use of Faecal Immunochemical Testing (FIT) in symptomatic patients is being advocated by the national cancer taskforce programme as one of the transformation programmes to enable early diagnosis and support delivery of the 62 day cancer standard (GP referral to treatment).

In addition NICE guidance has also been recently issued on FIT. This makes recommendations to include the adoption of FIT in primary care to guide Appendix 9 - CANCER SPECIFICATION 2019/20

referral for suspected colorectal cancer in people without rectal bleeding that have unexplained symptoms but do not meet the criteria for a suspected cancer pathway referral outlined in their guidelines on suspected cancer.

The CCG is implementing EPaCCS in order that patients on the palliative care register are better able to communicate their choice of where to die, and that all professionals can access this information in one place. In Barnsley a number of people die in hospital rather than at home, which was their choice. The implementation of EPaCCS will help to bring the number of people who are attending A&E in the last three months of life down to the national average. Primary care can support this by working on improving the identification and management of patients palliative care needs. Areas managing a properly maintained register of palliative care need and use of EPaCCS have evidenced that 80%+ will die in their preferred place of death rather than hospital.

The National Living With and Beyond Cancer strategy asks health care to support a number of activities. Primary care is central to the delivery of this strategy. The strategy asks primary care to: 1. To implement risk stratified follow up pathways for breast, colorectal and prostate cancers. This will reduce unnecessary follow up, targeting support and allow people to live their lives as normally as possible. 2. To implement all 4 core components of The Recovery Package:  Holistic Needs Assessment and individualised Care Planning (undertaken at key pathway points) and adopting an eHNA electronic needs assessment approach and remote access capability.  Treatment Summaries – improving communication with primary care and providing more robust guidance related to on-going primary care management and late effects.  Health and Well-being programmes – developing varied opportunities for people affected by cancer from all tumour groups which promote better awareness and understanding of cancer; as well as facilitating the transition from the acute phase of treatment towards supported self-management. This will include access to local lifestyle services and physical activity opportunities under the new Physical Activity Partnership. Work will be linked to place based Area Councils to ensure consistency in approach and equity of local access.  Cancer Care reviews – to support educate and train primary care in the delivery of high quality, integrated, meaningful reviews.

The CCG will support practices by:

 Undertaking eHNA in secondary care as part of treatment plans  Provide GPs with detailed treatment summaries  Identify appropriate follow up regimes and risk stratification of patient needs  Provide a Macmillan approved Cancer Care Review template in clinical systems Appendix 9 - CANCER SPECIFICATION 2019/20

 Providing support from a Macmillan GP

The National Cancer Diagnosis Audit (NCDA) looks at primary and secondary care data relating to patients diagnosed with cancer.

The audit looks specifically at clinical practice in order to understand: 1. interval length from patient presentation to diagnosis 2. use of investigations prior to referral 3. what the referral pathways for patients with cancer are and how they compare with those recorded by the cancer registry. The aim of the audit is to improve early diagnosis at practice level and support practices to audit their current position. The audit will provide practices with a baseline audit that will identify areas that can be improved within the practice. 3. HOW CA01 Practices to identify patients who have been called for screening but TO… are DNAs. Then to send 1 supporting letter or reminder (e.g. text) to (Step by individual patients to encourage uptake, in addition to letters from the step, how screening service. They also need to show via the audit template how they would a have a process in place that they use behaviour change interventions when practice they have contact with a person who has DNA to raise awareness and are implemen promoting the benefits of screening to patients on their practice list. This t this) could be via offering a patient a leaflet about screening; during appointments staff use a ‘brief intervention’ approach about benefits of screening; working with the NHS England local screening lead on raising awareness of screening in the practices neighbourhood etc. The Be Cancer Safe project has produced a Care Navigation Template that can be used to promote the update of screening with patients.

CA02 – Practices to follow the pathways as advertised on the BEST website. For the FIT to ensure the kit is stored at the practice; the sample tracked via ICE and a monitoring system in place for tracking compliance. A number of updated 2 week wait referral forms are being introduced to support the new straight to test pathways and are to be used by practices. Further details and information for patients is at this link: CA Integrated Lower GI Pathway

CA03- Practices to ensure patients on palliative care list are consulted about their preferred place of death. This to be evidenced within the EPaCCS template along with palliative care plan details. Practices to complete the Palliative Care and EPaCCS template for anyone classed as palliative care and recording via using EPaCCS READ code.

CA04 - Practices to ensure patients on cancer register who are newly diagnosed have a completed a cancer care review within 6-9 months of diagnosis. And to be annually if clinical need or requested by patient. All practices to use the cancer care review template and treatment summaries as the basis. To be recorded via using READ code. To do this practice will need access to the treatment summary and e-HNA information from secondary care. Then to complete the CCR template on practices clinical systems with the patient at a face to face appointment (unless patient Appendix 9 - CANCER SPECIFICATION 2019/20

requests a telephone call) or in their homes if housebound. This appointment can be with a practice nurse or GP but to focus on a holistic assessment of the patient’s needs. To discuss:  General Health  Lifestyle discussion and advice.  Problems with treatment  Specific symptom review  Signposting to local services

https://www.macmillan.org.uk/_images/carrying-out-an-effective-ccr_tcm9- 297613.pdf Macmillan Cancer Care Review

For details of EMIS Macmillan cancer care template: https://www.youtube.com/watch?v=drjFy_JTZUo

CA05 - Practices to nominate a Lead GP who can engage with the Macmillan GP to determine practice needs with regards to support and input. This person to work individually with the GP on cancer PDA areas, attend education events and work with them on embedding clinical and service improvements areas, to ensure people living with and beyond cancer needs are met. To include implementing the recovery package. CA06 - The National Cancer Diagnosis Audit (NCDA) looks at primary and secondary care data relating to patients diagnosed with cancer. Instructions will be distributed by Barnsley CRUK Facilitator in April 2019 and via the BEST website.

Practices will submit information gathered on their patients to the Public Health England’s National Cancer Registration and Analysis Service (NCRAS) database. Information will be collected from the period of a patient first presenting with symptoms to their diagnosis, including: consultations, key dates, investigations, symptoms and referrals. Information will also be collected on patient characteristics such as reasons why patients might find it difficult to communicate with a GP, attend the GP surgery and other health conditions.

Information will be combined at Public Health England’s National Cancer Registration and Analysis Service (NCRAS) and analysed centrally. This information is then reported back to Practices.

4. A. Early Diagnosis MEASUR CA01 Practices to provide quarterly evidence of number of DNA’s and how EMENT have attempted to encourage take up e.g. letters/texts sent. Indicator will be (How measured by an audit template that will be provided by the CCG. First would template to be completed by August 2019. Appendix 9 - CANCER SPECIFICATION 2019/20 you A2 Symptomatic Referrals robustly CA02 CCG will monitor the number of FIT and FCP tests the practice has measure, used and evidence of using new national timed pathways. Practices uptake ensure will be monitored remotely by the CCG. outcomes ) CA03 CCG will monitor data from Practice recorded Palliative Care Register data via READ code and EPaCCS uptake data set against:  National Expectations  Known practice deaths and expected EPaCCS uptake

CA04 Practices are to provide audit of Cancer Care Review quality based on:  Face to Face  Patient expectations  Timeliness  Link to eHNA

The indicator will be measured by an audit template that will be provided by the CCG. First template to be completed by August 2019.

CA05 Practices to engage with the Macmillan GP and to be attending educational events held by the post holder. Feedback will be sought from the person about the practices engagement and via attendance at educational events.

CA06 Practices to complete annual national cancer diagnosis audit and include practice patients in the audit. A monitoring template that is produced by CCG to be completed by practice twice a year that provide details of number of audits completed versus total number to be undertaken. Full audit to be completed by end of Q4. 5. As above FREQUE NCY AND DEADLIN ES FOR REPORTI NG 6. READ Read codes need to be identified before the contract is distributed to CODES practices. -eMBED

7. These will be produced before the contract is distributed. TEMPLAT ES AND LINKS

8. CCG Siobhan Lendzionowski, Lead Commissioning and Transformation Manager. LEAD Appendix 9 - CANCER SPECIFICATION 2019/20

OFFICER Tel: 01226 433 775 CONTAC E-mail: [email protected] T DETAILS

Appendix 10 - MY BEST LIFE 2019/20

National Local Priority Priority INDICATOR 1 Social Prescribing Service: Maintain links and (Contractual referrals into the My Best Life Service and continue Requirement) to have an in house My Best Life Champion

RATIONALE FOR These KPIs continue to build on the PDA INCLUSION requirements for 2018/19 and embed links between (Intended Primary Care and Social Prescribing. Outcomes) The outcomes of the scheme are as follows:

 Increase capacity in primary care  Reduce attendances at A&E  Enabling consistency of care at scale

HOW TO… These indicators continue to strengthen and embed the service into primary care, as well as supporting a stronger focus on cohort 2, which focuses on frequent attenders in A&E.

MBL 1

My Best Life Champion to maintain links with the MBL Advisor by:

- Inviting them to Practice meetings, demonstrating the advisor is part of the practice team. - 121 discussions with advisor as appropriate

My Best Champion to attend at least 3 out 4 quarterly champion network meetings.

Practice to submit number of referrals made to MBL from 01 April 2019 to 31 March 2020.

Based on 2018/19 practices will be given individual targets for referrals into the MBL service over 2019/20.

MBL 2

Each referral to My Best Life to include last 3 months GP appointment/contact data, which is requested on the My Best Life Referral form – all referrals not including this data will be returned.

Action information requests for patient data 3 months following the My Best Life referral and support.

MBL 3 Utilising D1 information to identify frequent attenders and refer to Social Prescribing if appropriate.

MBL 4

Advise Barnsley CCG of any changes in personnel for the My Best life Champion.

MEASUREMENT 1. No of referrals to My Best life 2. Attendance at MBL Champion Network Meetings and/or training 3. FREQUENCY 1. Monthly via the social prescribing service AND DEADLINES 2. End of reporting to identify if targets had been met READ CODES Referral to social prescribing Social prescribing offered Social prescribing declined Frequent attender of accident and emergency dept Seen in A&E

TEMPLATES

CCG LEAD Louise Dodson OFFICER Primary Care Transformation Manager 01226 433760 [email protected]

Appendix 11 - DEMENTIA 2019/20

National Local Priority Priority INDICATOR 1 Improve Dementia Diagnosis Rate and support the x x (Contractual borough in being a Dementia Friendly Town. Requirement)

RATIONALE FOR Increasing Dementia diagnosis and improving INCLUSION access to support for patients with Dementia and (Intended their carers has not only been a priority for Barnsley Outcomes) CCG but is a priority for Barnsley Town as a whole. Barnsley Town is working to become Dementia Friendly and GP practices play a crucial role within this ambition.

HOW TO… To support the towns aspirations GP practices are asked as part of the PDA to:

1. Maintain a register of People with Dementia and reconcile with the Memory Team on a quarterly basis

2. Maintain a register of carers who care for someone with dementia

3. Have an in house trained Dementia Champion who can undertake the Barnsley CCG Dementia Champion Job Profile and inform the CCG of any changes in personnel

4. Participate in the virtual Dementia Champion network

5. Ensure that the practice is a Member of the Barnsley Dementia Action Alliance

6. Disseminate local support services across registers

7. Liaise with the Memory Team Advisors

8. Evidence that any building changes take into account the dementia environment checklist

9. Promotion of the Herbert Protocol

10. Ensure that the CCG is informed if the

Practice Dementia Champion changes.

MEASUREMENT 1. Quarterly Reconciliation of Dementia Registers.

2. Participate in the virtual Dementia Champion network

3. Membership of the Barnsley Dementia Action Alliance

FREQUENCY As above. AND DEADLINES

READ CODES None.

TEMPLATES Dementia Champion Job Role

CCG LEAD Louise Dodson OFFICER Primary Care Transformation Manager 01226 433760 [email protected]

Appendix 12 - APEX/ ACCESS & WORKFORCE 2019/20 SPECIFICATION

National Local Priority Priority ACCESS This combined specification aims to cover roll out X INDICATOR 1 of the Apex Tool, the quarterly return of practice (Contractual workforce data and also improved access in Requirement) relation to the Home Visiting Service.

RATIONALE Barnsley CCG requests that each practice FOR continues to submit their workforce information on INCLUSION a quarterly basis. During 2019/20 it is expected (Intended that practices submit workforce data via the Apex Outcomes) Tool.

Practices should engage with Apex Team to have the tool deployed out to the practice. Apex will support the practice is loading the workforce information onto the tool to create a baseline.

Practices should review the baseline information quarterly and should consider the following:

 new staff members and leavers  new vacancies and vacancies that have now been filled closed  any periods of absence during the quarter  any new skills or qualifications gained

The CCG will co-ordinate support to Practices if there are any issues with regards to the Apex deployment. Apex will also support practices through the development of the Supra Network during 2019/20.

Workforce remains high on the local and national agenda. Skills and recruitment shortages means that Primary Care are delivering services with less than the recommended number of workforce types per 1,000 patients. This issue is consistent in Barnsley where GP and Nurse numbers are lower than the national average. With mounting pressures and the national drive to bring care out of hospital the CCG are committed to supporting our GP practises to access any national workforce funding and schemes where possible. To achieve this the CCG needs to be aware of

our local workforce profile, down to practice level, so that this can be monitored and practices targeted when relevant workforce schemes may be beneficial. The CCG also requires this data to pre-populate the workforce section of the Quality Dashboard.

The 2019 Home Visiting Service aims to provide additional capacity in Primary Care by procuring a separate service to support practices by undertaking home and care home visits. The CCG expects all practices to provide additional capacity and improved access in Practice for every home visit that is referred onto the Home Visiting service. The CCG will seek to use Apex to monitor practices offering improved access to general practice.

HOW TO… 1. Contact the Apex team to have the tool installed and deployed in practice (contact [email protected] ) 2. Upload the practice appointment and workforce data to ensure that the tool is fully functional in practice 3. Utilise the Apex Tool to submit workforce data, this data can then be extracted and shared with the CCG via Apex.

FREQUENCY 1. Each practice to have Apex installed by 31 AND May 2019. DEADLINES 2. Workforce Extraction dates will be confirmed to practices as and when (there will be no more than 4 workforce extractions per year).

READ CODES None

TEMPLATES None

CCG LEAD Lynne Richards OFFICER Primary Care Transformation Manager 01226 433631 [email protected]

Appendix 13 - PHLEBOTOMY SPECIFICATION 2019/20

National Local Priority Priority TITLE Blood Tests Requested by Secondary Care x (what is the Providers contractual requirement) RATIONALE FOR Barnsley Clinical Commissioning Group is INCLUSION committed to the delivery of high quality, safe (Intended and effective care. The CCG’s Primary and Out Outcomes) of Hospital Care Strategy cements the vision that wherever possible care should be delivered out in the community and closer to the patients home. BCCG has developed this specification to support the additional workload coming to Primary Care as a result of blood tests being requested by Secondary care in advance of outpatient appointments.

The aims of this service specification is to:  Provide care closer to home for patients  Enhance patient experience  Avoid unnecessary hospital appointments  Reduce expenditure in secondary care

A community based phlebotomy service is highly valued by patients and a vital part of the overall health economy. Patients attending their own local GP practice for Phlebotomy appointments delivers care closer to home and is also cheaper for patients to attend and a more cost effective service than attending secondary care. The CCG recognizes that phlebotomy falls into the category of non-core unfunded services and therefore is aiming to make this service more equitable for Primary Care to deliver this additional work.

Appendix 13 - PHLEBOTOMY SPECIFICATION 2019/20

HOW TO… To distinguish the extent of phlebotomy (Step by step, requests coming into Primary Care from how would a secondary care the CCG must first establish practice a baseline. (It is ultimately anticipated that implement this) the CCG would aim to fund practices per blood tests carried out in the practice at the request of secondary care).

On receiving a request for Primary Care to undertake a blood test it must consider if the test is needed i.e have routine bloods already been completed previously as part of a review.

If the practice deem that a new blood test is required in advance of the outpatient appointment the practice should undertake this request and use the READ code: XaK2I or 9N7D.

The information will be collected quarterly and this will support the CCG in identifying a baseline of requests coming to Primary Care. Best practice states that routine phlebotomy should be offered within 5 working days. The practice should, in addition, be willing to provide early appointments for those patients needing a fasting blood test. The practice will ensure the prompt and safe dispatch of samples for analysis.

Exceptions: This specification does not cover blood tests carried out as part of the routine care of patient in primary care, or where covered in the specifications of other primary care services commissioned by BCCG (e.g. Warfarin Monitoring, Near Patient Testing).

MEASUREMENT Practice will use the READ code when (How would you undertaking bloods at the request of or to support robustly measure, a secondary care appointment. ensure outcomes)

FREQUENCY The practices will run a clinical system search AND DEADLINES quarterly and return the number of bloods tests FOR REPORTING undertake with the above READ code to the CCG.

Appendix 13 - PHLEBOTOMY SPECIFICATION 2019/20

READ CODES XaK2I or 9N7D - Phlebotomy generated from -eMBED secondary care

TEMPLATES AND LINKS

CCG LEAD Louise Dodson OFFICER CONTACT Primary Care Transformation Manager DETAILS 01226 433760 [email protected]

Appendix 14

AMBER (SPECIALIST) DRUG MANAGEMENT SERVICE

1. Population Needs

1.1 National/local context and evidence base It has been accepted for many years that some drug treatments for certain indications should be initiated by specialists, but may be suitable for transfer to ongoing prescription by General Practitioners (GPs) at an appropriate point. These are known in Barnsley as Amber drugs. The status of any drug in the Barnsley NHS health community is determined by the Barnsley Area Prescribing Committee (APC) using published criteria http://www.barnsleyformulary.nhs.uk http://barnsleybest.nhs.sitekit.net/news/area-prescribing-committee.htm Ongoing prescription of Amber drugs by GPs is more convenient for patients and makes better use of specialist care services. However, it is imperative for patient safety that these drugs are prescribed only by GPs who understand and accept the shared responsibilities and are confident and competent to accept the clinical responsibility for that drug in that indication. The Department of Health has confirmed that clinical responsibility for the patient’s response to treatment lies with the person who signs the prescription. This service establishes the standards of care expected from service providers (usually GP practices) commissioned by Barnsley CCG to undertake the management of specified Amber drugs and the associated management of treatment (“The Service”) and the payment arrangements for the Service. Some, but not all, Amber drug treatments require regular monitoring. A number of Shared Care Guidelines (SCGs) have been developed by doctors and pharmacists from both primary and secondary care and are endorsed by the Barnsley APC. These guidelines, which form the basis of the ‘shared care agreement’, set out the monitoring requirements for most of these drug treatments. All Amber drugs (those with guidance and those with a shared care guideline) have now been incorporated into the Amber Drugs Service. This is in recognition that although not all drugs require additional monitoring, the prescriber has agreed to take over the responsibility for prescribing a more specialised drug.

2. Outcomes

Appendix 14

2.1 NHS Outcomes Framework Domains & Indicators

Domain 1 Preventing people from dying prematurely

Domain 2 Enhancing quality of life for people with long- term conditions

Domain 3 Helping people to recover from episodes of ill-health or following injury

Domain 4 Ensuring people have a positive experience of care

Domain 5 Treating and caring for people in safe environment and protecting them from avoidable harm

2.2 Local defined outcomes This service establishes the standards of care expected from service providers (usually GP practices) commissioned by NHS Barnsley CCG to undertake the management of Amber drugs and the associated management of treatment (“the Service”) and the payment arrangement for the service. Activities identified are in line with the NHS Barnsley CCG Medicines Optimisation Plan and the National Medicines Management and Procurement Quality, Innovation, Productivity and Prevention strategy.

3. Scope

3.1 Aims and objectives of service The Service will operate in accordance with the Principles of Shared Care included in Appendix A. This document can also be found at the following link: http://barnsleybest.nhs.sitekit.net/clinical-support/medicines/shared- care-guidelines/Principles-of-Shared-Care.pdf 3.2 Service description/care pathway The Service relates to the prescription of drugs that require monitoring (for example Amber drugs) by service providers including the associated monitoring of treatment. It includes all clinical indications for Amber drugs in the list published by Barnsley APC and updated from time to

Appendix 14

time and available online at :- http://barnsleybest.nhs.sitekit.net/clinical-support/medicines/shared- care-guidelines/ This section establishes the minimum requirement for service providers commissioned by Barnsley CCG for providing this Service.

3.2.1 Accreditation, competency and training Service providers who have previously provided services similar to this Service and who satisfy at appraisal and revalidation that they have such continuing medical experience, training and competence as is necessary to enable them to provide this Service shall be deemed professionally qualified to do so. It is the responsibility of the service provider to make all reasonable efforts to acquire sufficient competence to provide the Service safely and adequately in respect to the Amber drugs they agree to prescribe. The specialist department seeking the shared care arrangement will assist by offering any specific training which may be requested by the service provider, such as specialist injection techniques, etc. 3.2.2 Referrals to the Service Amber – Shared Care guideline Prescribing and monitoring responsibility relating to any individual patient will be transferred to the service provider only, once the service provider has agreed regarding that named patient. The specialist department seeking the shared care arrangement will continue to prescribe and monitor treatment until transfer of responsibilities has been agreed. The service provider must inform the specialist department within 14 days of the receipt of a written or email request to enter into a shared care agreement if it is unwilling or unable to provide the Service for that patient. The only exception to the above paragraph is for conditions where a collaborative shared care guideline is in place (Drugs to treat epilepsy and Parkinson’s disease). GPs sign up to collaborative shared care prospectively prior to individual patients being transferred. Amber – With Guidance Prescribing and monitoring responsibility relating to any individual patient will be transferred to the service provider once the service provider has initiated the drug according to the relevant Amber-G guidance document.

Appendix 14

3.2.3 Record keeping Service providers must have a written practice protocol in place detailing the process for dealing with requests for Amber drugs. A template protocol is available from the Medicines Management Team. A record must be made when a patient is started on an Amber drug. This should form part of a computerised database that allows for patient recall. Details must include: a) Name b) Date of birth c) Address d) Contact telephone number e) Past medical history f) Medication history g) Previous blood results h) Information relating to significant events, eg. Hospital admissions, death of which the practice has been notified, route of return and reason i) Recall information regarding future blood tests A record must be kept of all the patient’s blood results and the results of other relevant investigations or measurements, on a system that allows previous results to be accessed easily and trends observed. Records must be kept of all dose adjustments. For certain specified medicines (such as methotrexate), the specialist initiating treatment should provide the patient with a monitoring booklet approved by Barnsley APC to be kept by the patient that allows for blood results (and where applicable urinalysis results) to be recorded. If for any reason a patient has not received a booklet from the specialist department, this should be supplied by the service provider. Booklets can be obtained from the Medicines Management Team at NHS Barnsley CCG. The service provider will enter blood results (and where applicable urinalysis results) in the booklet. 3.2.4 Information for the patient The service provider will be responsible for providing oral and/or written advice as appropriate regarding: a) The Service being provided and what the patient can expect from the Service. b) The drugs and potential side effects from these drugs. If Barnsley

Appendix 14

APC has approved a patient information leaflet (PIL) the service provider must provide the patient with a copy of this PIL if the patient has not previously been provided with it by the specialist department. 3.2.5 Monitoring requirements Monitoring of Amber drugs must be conducted under a shared care agreement between the service provider and the specialist department seeking the shared care arrangement. Monitoring should be conducted at appropriate intervals as set out in the relevant SCG approved by Barnsley APC. If no SCA has been developed the monitoring schedule must be proposed for the individual patient by the specialist department and agreed by the service provider. There may be cases where an amber drug has been prescribed, but was first initiated prior to the introduction of a shared care guideline (i.e. historical prescribing). In this case the service provider should ensure monitoring is up to date according to requirements in the shared care guideline or those given by the specialist. It is the responsibility of the service provider and the specialist department to ensure there is mutual clarity of understanding regarding respective responsibilities relating to the care of the individual patient. This may be by reference to the relevant SCG or by letter or email. 3.2.6 Monitoring arrangements Blood taking 1. The patient must be given appropriate appointments to have blood taken, or other monitoring to be conducted as appropriate. These appointment times and locations must be reasonably accessible by patients. 2. Where monitoring is being conducted by the specialist department this must be clearly stated and recorded. A copy of the hospital letter confirming this must be kept with the patient notes. Any variation to monitoring arrangement (frequency or location) must be agreed between the patient, the service provider and the specialist department and recorded. 3. The service must have adequate patient recall facilities. 4. Patient must be identified and followed up if they do not attend to have blood taken, or other monitoring conducted. This should consist of the patient being telephoned and written to and there should be written communication with the patients consultant. It must be ensured that prescriptions cannot be issued to patients if monitoring is not being carried out.

Appendix 14

5. If patients fail to keep an appointment for monitoring then there must be communication between the GP and the patient’s consultant to determine whether monitoring is being done by the hospital. The service provider must ensure that prescriptions cannot be issued to patients if monitoring is not being conducted (regardless of whether responsibility for monitoring being conducted is by the service provider or the specialist department). 3.2.7 Analysis Where SCGs so specify, the service provider would interpret the blood results or results of other monitoring and be responsible for making recommendations about further actions (i.e. repeat bloods and dose changes) based on these results. If no SCG was in place when the patient first commenced treatment (i.e. Historical prescribing - patient initiated treatment prior to the shared care guideline being developed), then arrangements for interpretation and advice on dose changes must be made between the service provider with advice from the specialist department where appropriate. 3.2.8 Communication The service provider will be responsible for communicating the results of blood tests or other monitoring and any further action required to the patient. In the case of the service provider not being the patient’s GP practice, the service provider will be responsible for communicating blood/other monitoring results and further action required with the patient’s GP practice. When the result is abnormal, communication with the patient (and the GP practice where appropriate) must occur within 1 working day of the result being received.

3.3 Population covered

3.4 Any acceptance and exclusion criteria and thresholds Monitoring related to co-prescribed drugs (not being amber drugs), other health conditions and the patient’s general health is not included in the Service. For the avoidance of doubt, it should be noted that a service provider who enters into shared care arrangements for the Amber drugs under this Service is not thereby obliged to enter into shared care arrangement for other drugs.

3.5 Interdependence with other services/providers

Appendix 14

3.6 Monitoring and Evaluation

Service providers will be required to agree to an NHS Service Level Agreement period at the start of the period for “the Service”. The Service will run through to the end of March. During the period covered by this agreement there will be a meeting between the service provider and NHS Barnsley CCG to ensure the specification for this Locally Commissioned Service is being met.

Activity and audit data will be provided to NHS Barnsley CCG when requested to enable the CCG to monitor, evaluate and review performance with regard to the agreed service specification.

The service provider will provide the following information annually, by 31st December:

a. Practice protocol for dealing with requests for Amber drugs

b. Number of patients where shared care has been declined by the service provider (READ code 8BM6 or XaKAl), the relevant drug and the reason(s) for this being declined

c. Number of patients in whom shared care has had to cease and care revert to the specialist (READ code 8BM7 or XaKAm), the relevant drug and the reason(s) for this reversion

d. Numbers of patients who are receiving shared care drugs and the relevant drugs (READ code 8BM5 or XaK6z)

e. An audit of 20% of patients (selected at random, with a minimum of 20 patients) to confirm that the shared care agreements are being followed. The audit should be representative across all drugs and disease states.

This audit should include:

i. An audit of referrals to the service provider from specialist departments to ensure that they meet the requirements of 3.2.2 above

ii. An audit of the patient held monitoring books (where these are used) to ensure correct entry of blood results iii. Audit of the communication pathways to ensure GPs and patients are being notified of results appropriately

iv. Audit of the blood tests to ensure they are done at the specified

Appendix 14

interval and time specific reviews for signs and symptoms are being carried out.

v. A minimum standard of 90% of patients on specified shared care drugs should be being monitored in accordance with the appropriate guidelines. This is to be monitored across disease groups and drug groups. This data will be cross referenced by NHS Barnsley Primary Care Medicine Management Team. Failure to achieve this minimum standard will result in the development of an action plan to rectify any issues. (This may require additional ongoing audits to be undertaken to demonstrate improvement). If the action plan is not fulfilled within the timescales set, then funding for the service may be withdrawn/notice may be given to decommission the service

3.7 Financial Details Practices will submit quarterly returns of numbers of patients on each amber drug and will be paid, by the end of the following month, the rates included in Appendix 2 per patient as a quarterly fee. All practices will be expected to use Eclipse live software to make these quarterly returns. Pre-populated returns may be prepared by the CCG and endorsed by the practice. Practices will be required to submit an annual audit in line with the requirements of this specification by 31st December each year to the CCG Medicines Management Team Failure to submit the required audit by 31st December will result in the suspension of any further payments until the audit has been received, and may result in the recovery of some or all monies already paid to the service provider in good faith for delivery of the service to the specified quality. Practices will be subject to a post payment verification process undertaken by the CCG contracting and medicines management teams. Practices paid for undertaking the management of patients on any of the drugs within this scheme would not be eligible, within the same time period, for payment under any other local CCG service eg. DMARDS service.

Appendix 1

Appendix 14

Principles of Shared Care

1. Introduction

Application of the following principles will facilitate effective shared care. However, it should be noted that GPs are not obliged to enter into shared care arrangements for a particular patient simply because the relevant drug has an amber classification. The Department of Health has confirmed that clinical responsibility for the patient’s response to treatment lies with the person who signs the prescription.

2. Principles of Shared Care

2.1. Best interest of the Patient The best interests of the patient should be at the centre of any shared care agreement. Arrangements should never be detrimental to or inconvenient for the patient. 2.2. Individual, patient by patient arrangements Shared care prescribing guidelines should be accompanied by individual patient information, outlining all relevant aspects of that patient’s care. 2.3. Reasonably predictable clinical situation Transfer of clinical responsibility to primary care should be considered only where a patient’s clinical condition is stable or predictable 2.4. Willing & informed consent of all parties, including patients and carers All parties to the agreement must have sufficient, accurate, timely information in an understandable form. Consent must be given voluntarily. Specialists and general practitioners are encouraged to communicate with each other directly where questions arise around shared care for a particular patient. If issues remain, after these discussions, the department of the Chief / Senior Pharmacist at the CCG or Hospital Trust should be contacted for advice. 2.5. Clear definition of responsibility The areas of care for which each partner in the arrangement has responsibility should be clearly defined and should be patient specific 2.6. Communication network & emergency support Appropriate contact details should be provided to enable GPs to contact specialists readily, including (where appropriate) out-of-hours arrangements 2.7. Clinical information This should include a brief overview of the disease and more detailed information on the treatment(s) being transferred including (as a minimum):  Where the treatment is not licensed for any indication in the UK, or is licensed for other indications but not this indication, a note to this effect with an indication of the strength of evidence to support its use for this indication

Appendix 14

 Dose, route of administration and duration of treatment  Common adverse effects (incidence where known, identification, importance and management)  Monitoring requirements and responsibilities  Clinically important drug interactions and their management  Contacts for more detailed information

2.8. Training It is the responsibility of the service provider to make all reasonable efforts to acquire sufficient competence to provide the Service safely and adequately. The specialist department seeking the shared care arrangement will assist by offering any specific training which may be requested by the service provider, such as specialist injection techniques, etc 2.9. Review Shared Care Agreements (SCAs) have a review date and will be reviewed by the Barnsley APC prior to that date or more frequently if clinically required. 3. Involving the Patient

The consultant should obtain the consent of the patient (and his/her carers if appropriate) only after the GP has agreed in principle to sharing care. Patients should never be used as a conduit for informing the GP that prescribing is to be transferred, nor should they be placed in a position where they are unable to obtain the medicines they need because of lack of communication between primary and secondary/ tertiary care. 4. Agreement of shared care between specialist and GP

Prescribing and monitoring responsibility relating to any individual patient will be transferred to the GP only once the GP has agreed regarding that named patient. The specialist department seeking the shared care arrangement will continue to prescribe and monitor treatment until transfer of responsibilities has been agreed. The GP must inform the specialist department within 14 days of receiving the written or e-mail request if they are unwilling or unable to provide the Service for that patient, with reasons.

GB Pu 19/03/15

GOVERNING BODY

14th March 2019

Medicines Ordering – Safety and Waste

Progress Report

PART 1A – SUMMARY REPORT

1. THIS PAPER IS FOR

Decision √ Approval Assurance √ Information

2. REPORT OF

Name Designation Executive Dr John Harban GP and Governing Body Lead(s) Member Author Christine Lawson Head of Medicines Optimisation

3. EXECUTIVE SUMMARY

This is a report detailing the progress the Barnsley Medicines Ordering – Safety & Waste (MOSW) Programme.

The programme is successfully reducing medicines waste associated with third party ordering (TPO). The programme has progressed through over two thirds of Barnsley practices and is currently online to deliver £1.926K QIPP savings (£126K 17/18 and £1.8million 2018/19) by the 31st March 2019. This report also makes recommendations on work required to consolidate implemented changes in light of emerging risks and further work which potentially could be undertaken to support patients to order only the medicines which they need.

Background in June 2017 the Barnsley CCG Governing Body endorsed this work programme with the aim of improve prescribing safety and reducing prescription waste. This programme offered funded support to Barnsley GP practices , via employment of a small team of trained MSOW staff , to direct , enable and if necessary, undertake changes required to GP practice prescription ordering processes in order to:-  Enable and empower patients (or their carers) to be directly involved in the ordering of their repeat medications from GP practices, thereby reducing and if possible, eliminating Third Party Ordering (TPO) of prescriptions.

1 GB Pu 19/03/15

 Put in place systems and processes to support patients who are unable to manage their own prescription ordering.  Offer support to those GP practices in greatest need, via a phased approach.

It was also hoped that larger numbers of Barnsley patients, through receipt of campaign information, would be encouraged and empowered to take responsibility for ordering only the medicines which they need. A potential opportunity of extending the work around patient education in ordering of medicines is recommended within this paper.

It was identified that this work also provided an ideal opportunity to review Barnsley locality prescribing systems in respect of safety and waste issues and risks. Two emerging risks have been identified which are that of consolidating work undertaken and also reviewing electronic repeat dispensing and third party ordering applications which are being increasingly marketed to patients.

4. THE GOVERNING BODY / COMMITTEE IS ASKED TO:

The Governing Body is asked to :-

 Note the report, particularly the assurance provided regarding the progress of Medicines Ordering Safety and Waste ( MOSW) programme work being undertaken across Barnsley GP practices.

 Advise whether a business case should be prepared to facilitate a decision on an “invest to save” permanent option prior to the end of this planned programme work (October 2019), in the context of the emerging risks but also opportunities for expansion of the programme.

5. APPENDICES

 Appendix 1 – MOSW Stakeholder Steering Group Focus Paper

Agenda time allocation for report: 10 minutes

2 GB Pu 19/03/15

PART 1B – SUPPORTING INFORMATION

1. Links to the Governing Body Assurance Framework Risk ref(s) This report provides assurance against the following risks on 2.1, 6.1 the Governing Body Assurance Framework: 2. Links to CCG’s Corporate Objectives Y/N To have the highest quality of governance and processes to Y support its business To commission high quality health care that meets the needs Y of individuals and groups Wherever it makes safe clinical sense to bring care closer to N home To support a safe and sustainable local hospital, supporting N them to transform the way they provide services so that they are as efficient and effective as possible for the people of Barnsley To develop services through real partnerships with mutual Y accountability and strong governance that improve health and health care and effectively use the Barnsley £. 3. Governance Arrangements Checklist 3.1 Financial Implications Has a financial evaluation form been completed, signed off N by the Finance Lead / CFO, and appended to this report? Are any financial implications detailed in the report? Y

3.2 Consultation and Engagement Has Comms & Engagement Checklist been completed? Y Is actual or proposed engagement activity set out in the Y report?

3.3 Equality and Diversity Has an Equality Impact Assessment been completed and Y appended to this report?

3.5 Environmental Sustainability Are any significant (positive or negative) impacts on the N but is environment discussed in the report? Positive

3.6 Human Resources Are any significant HR implications identified through NA discussion with the HR Business Partner discussed in the report?

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1. DISCUSSION/ISSUES

Summary of Programme Work After a period undertaking initial staff recruitment and intensive training, the eighteen month programme of work began within the first practice in December 2017.

A multidisciplinary Stakeholder Group was established in July 2017 this group oversaw the programme of work required to deliver implementation of the project. There have been ten meetings represented by key stakeholders who are involved in, or who can support, the work. The Group is chaired by the Head of Medicines Optimisation; MSOW Project Team members, GP, Clinical Pharmacist, Practice Manager, Receptionist, LPC representatives, LMC representatives, social care, Neighbourhood Nursing Service, CCG Communications team representative.

The financial management of the project was undertaken internally, via the CCG Medicines Management Team (MMT) through the CCG Quality & Cost Effective Prescribing Group. Progress and outcomes were reported through the CCG‘s QIPP Delivery Group and through this to the Finance and Performance Committee. More detail is included within the financial section of this report, but savings are verified as just over £1 million at the end of December 2018.

MSOW Staffing  MOSW team staff were intensively trained and are now highly experienced in:-  Communication, predominantly with GP practice staff, Community Pharmacy staff and speaking to members of the public.  GP Practice systems, particularly EMIS Web, System 1 and Vision software  Registering patients for online ordering process, using different practice software systems, to the level of training practice staff.  Identifying from patient characteristics who may require additional support  Knowledge of prescription ordering processes in GP practices and use of ordering tools e.g. Evergreen application and Patient Partner system.  Knowledge of Community Pharmacy dispensing processes and systems

MSOW Practice Work Programme(s) Meetings with Providers are held, and a planning template is completed. This planning template has been developed to capture all information necessary to implement the necessary work from both the GP Practice and the Pharmacy perspective. From it an individualised implementation plan for each practice is developed :-  Describing rationale and benefits of the work  Practice systems and preferences – ability to support  Identifying how many and which patients would require contacting and agreeing how this will be done.  Plan describing how work will be undertaken  Offering training to practice staff

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 Simplification of practice processes to encourage online prescription ordering

Once the plan is completed then a “go live “date is agreed; this date is from which all patients, except those who meet criteria and require support , would order their own medicines. By this date all patients who currently have their medicines ordered by a third party would have been contacted by letter and also an additional contact attempted other than letter. Any patients who appear potentially to require support would have two or perhaps three additional attempts made to contact them prior to the practice “go live” date.

Current Position

Phase 1 COMPLETED 13 Practices - completed August 2018 Initially to be rolled out over 10 practices where audits had identified issues relating to safety, this phase expanded to incorporate an additional three practices at practice request. The thirteen practices, including six large practices covering 37% of the Barnsley population.

Phase 2 ONGOING 11 Practices – on target for completion mid- March 2019 Has been rolled out geographically, as recommended by of MOSW Stakeholder Group, but areas amended responsively where intelligence identified particular issues relating to safety and waste. Nine practices have so far completed in this phase:-

 Three practices completed in October 18  Two large practices (with a combined list size of approx. 15k ) completed at the end of November 18  Two practices completed mid-January 2019  Two large practices completed mid-February 2019  Two practices are working towards and agreed completion date of mid- March 2019

Phase 3 STARTED 10 Practices – currently behind target for completion by October 2019.

 Planning meetings have been scheduled for two practices  One practice has been postponed long term until practice issues are resolved.

Programme Activity Data

The MSOW team have compiled an activity summary with feedback and issues experienced. This shows the practice to practice variation which has required versatility and adaptability in the work being undertaken. Highlights from this report are :-

 That most GP staff were engaged with the project – one practice even had a dedicated practice administration staff being an “online champion”.  Practices which did not have dedicated practice phone lines to support patients with their prescription ordering ( only accepting paper requests ,

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online ordering or where available Patient Partner telephone ordering ) had greater issues and an increased proportion of patients who were left with requiring support via Community Pharmacies using Ordering (CPO) criteria.  There were technical difficulties with solutions such as the “Patient Partner “telephone ordering system in some practices had ongoing technical difficulties, which the team did support with. In some practices was not enabled due to issues experienced.  Greater communication issues appeared to be experienced across GP practice branch surgery sites.  Community pharmacy engagement and support (patients requiring support there were some pharmacies who initially refused to support with an all or nothing attitude. Following negotiation by the MOSW team we were able to get pharmacies on board.  Practice staff awareness of the key messages of programme aims e.g. safety and improved systems - all relaying the same messages to patients - not just about saving money.  Staffing resource within the MMT - once practice implementation starts its cannot be delayed due to financial implications i.e. patient resources leaflets and promotion of cut off dates  Patients challenging the changes have generally been those who wanted the ordering for convenience and had access to online ordering but didn’t want to take on the responsibility. Community Pharmacy Ordering (CPO) Criteria developed via the Stakeholder Group. These criteria supported the team’s ability to challenge and persuade patients to take on the responsibility when they didn’t meet the criteria set – this provided clarity to the team as to the characteristics of patients who may require support, confident of criteria and the list has not required updating throughout and has proved to be a useful tool.

The programme activity data shows that :-

 over one fifth (54,100) of the Barnsley population have received a letter and leaflet advising them about the programme and proposed changes to their practice prescription ordering processes with an offer of support from the MOSW team and their GP practice.  The MOSW team attempted to additionally make telephone make contact with one sixth of these (9,023) patients and were successful in contacting over half (4,661).  After the work was completed an additional 1,802 patients had been registered and enabled to use online ordering, which is approximately a 3.3% increase in patients using the online ordering services.

Feedback from Patient, GP Practice and Community Pharmacy Surveys

One of the key risks associated with implementation of this work was not meeting the needs of patients who require support in ordering of their medicines. This has remained a key focus of the MOSW team throughout implementation.

There have been no CCG complaints or significant incidents reported.

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Three surveys have been undertaken by the CCG Communications team . A low level of response was obtained for all three surveys which is being interpreted as positive in respect that if there had been significant issues then an increased volume of response would be more likely to have been received.

Patients: The majority (69%) of patient responses (34/49) were received from patients of two practices which were known to have experienced particular issues. Despite this the majority (69%) reported that they had received a letter about changes to the ordering of their repeat prescription and majority (82% ) found the information clear and thought it was useful.(67%) . A high proportion (67%) were happy with the level of support and information offered. Just under half (49%) thought the dedicated MOSW emails and telephone line was useful. Over half (59%) thought the patient leaflet was useful and that the poster material in GP practices was useful (61%). One third thought that there were areas for improvement and offered comments, however some of the responses indicated misinterpretation of the focus of the survey e.g. referring to improvement in GP appointment times or availability of particular medicines. Responses relating to the programme were mixed with a proportion of patients supportive of changes but more patients requesting to move back to old system as they were finding ordering through their GP practice problematic.

It is proposed to offer feedback to each of the respondents where possible to support them in solving particular issues. Also, to plan another simpler and more balanced survey targeting a random selection of patents from each practice by letter.

GP Practice: Three GP practices responded to the survey. All of these (100%) were satisfied with the level of communication received prior to the project starting. All (100%) were happy with the level of support and resources available; MOSW project team 100%; project email and telephone line 100%; patient resources 100%. All (100%) were extremely or very satisfied with the overall experience.

One practice did think one minor thing could be improved upon, which was regarding that completion of a registration form should have been clarified with Practice Manager and continued ; it was noted that NHS digital advise this is not required and not required by other practices but should have been communicated more clearly to the practice staff. There were many positive comments:-

We were consulted before and all the way through the process; there were two meetings which were very helpful and informative; We had a lot of communication from the team in the form of telephone calls and meetings, they gave us lots of information to get us prepared; It ensured that workload on current staff was significantly reduced; All very good.

It is proposed to follow up for further responses.

Community Pharmacy: three of greater than thirty five Community Pharmacies who were known to have been involved in Phase 1 and 2 of

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the work responded to the survey. All of these (100%) were satisfied with the level of communication received prior to the project starting. The majority (80%) were happy with the level of support and resources available; MOSW project team 100%; project email and telephone line 60%; patient resources 80%. All (100%) were to some degree satisfied with the overall experience; 60% extremely or very satisfied. There were two positive comments received in relation to receiving sufficient information available at the right time

One community pharmacy reported that they had some patients at a practice but had not been contacted, however information had been sent to all Barnsley community pharmacies who dispensed any practice prescriptions one month prior to practice “go live “date.

It is proposed to follow up for further response.

Potential Risks & Barriers

GP Practice Engagement: GP practice engagement in the first two phases of the programme have been high. There was an anticipated increase in GP activity (particularly responding to patients queries and concerns) short-term as a result of the recommended changes. This has not materialised. Some practices have verbally reported reduced workload to the MOSW team; however this has not been reported within the practice survey.

Community Pharmacy Engagement: It was anticipated that some community pharmacies and also representative of national and local bodies may not be supportive of the changes. There were some initial concerns regarding impact on patients; however Pharmacies have reported improved communication with GP practices and reduced workload after the work was completed, however this was not reported in the Community Pharmacy survey. The LPC Chair and Secretary were members of the Stakeholder Steering Group and had considerable input into the process.

Patient Concerns and Confusion: The primary concern of the team was that of compromising patients who require support ordering their medicines. This has not emerged as a risk due to the focus of the work undertaken in contacting all patients and offering support. Although patients are often acutely aware of the issues of waste medicines, it was expected that there would be a proportion of patients who did not fully understand the changes being recommended. Also, that there may be unwarranted concerns that pharmacies may not be able to deliver medicines. Support was provided by the MSOW team supported by experienced Pharmacists and Pharmacy technicians working within practices which has successfully mitigated these concerns.

Emerging Risks

Staff Recruitment and Retention: Difficulties in initial staff recruitment delayed start of project by two months. Ongoing retention issues has delayed progress by approximately a further two months due to training of new staff. Impact of the staffing shortfall has been mitigated as much as possible by mobilising Clinical Pharmacist administration support staff working additional hours and

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undertaking less QIPP work and this in the long term is not sustainable. Staff members require a high level of training before working in the practice and this requires significant commitment from Medicines Management Team (MMT) staffing. The team have a low turnover of staff and it’s recognised that the introduction of permanent posts would potentially put an end to these issues.

CCG Management Team have supported temporary extension( s) of contracts to enable recruitment and have recently supported extensions of remaining staff contracts until October 2019 to support staff retention. The CCG MT recently endorsed using funding from an MMT CCG permanent staff post in order to retain the MOSW Band 4 post on a recurrent basis.

Consolidation of Work: Reviews in practices after work has been completed has identified that a risk is emerging in maintaining the impact of the work. In a short period of time changes in practice and/or community pharmacy staffing as well as systems and process changes have been found to have “undone “a proportion of the work. It is not possible to quantify the exact proportion. Examples of this are:-

 One practice had a significant number of new administration staff which were unaware of MOSW processes which had been put in place.

 A post box was reported as being introduced within a local store to collect patient prescriptions and it was found that the box was being collected by a local Community Pharmacy

 Requests are being received from Community Pharmacies whom have secured the patients order via a local phone application. It is not clear whether the Pharmacy is selecting items to be ordered on behalf of the patient or if they are being ordered by the patient. This is not acceptable to the GP practice and there has been a significant increase in the number of these applications appearing since local MOSW work has started, particularly by online Pharmacies.

There is a need to consolidate the work of the MSOW programme to maintain and improve savings; there has been an identified loss to patency of the systems and processes left in place which increases with time which it is not at this point able to quantify. A dedicated MSOW team could undertake this work but additionally they could :-

 Ensure that tackling medicines waste remains high on the CCG work plan and agenda  Ensure that medicines waste reduction initiatives are continually developed and implemented  Reduce unnecessary or inappropriate prescribing  Ensure the continual review of working processes; identifying opportunities for further waste reduction  Increase the support for stakeholders on waste reduction initiatives  Provide all stakeholders with a nominated point of contact regarding medicines waste issues  Increase the promotion and utilisation of non-pharmacological alternatives for improving patient health and wellbeing

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 Raise awareness of the most cost-effective working processes and prescribing

Electronic Repeat Dispensing (eRD) : Is being publicised by NHS Digital to GP practices as a vehicle to increase Electronic Prescribing volume; it is part of the NHSBSA strategy to maximise Electronic Prescribing in order to increase efficiency and reduce NHSBSA workload. ERD is not necessary to increase the volume of electronic prescriptions.

eRD allows the prescriber to authorise and issue an electronic batch of repeatable prescriptions for up to 12 months with just one digital signature. These prescriptions are stored on the NHS Spine and are downloaded at the request of the patient's nominated community pharmacy.

The NHS Digital and NHSBSA campaign cites the extra benefits of eRD over paper repeat dispensing and repeat prescribing, highlighting that 80% of prescribing is repeat and therefore advocates use of ERD , however the majority of these prescriptions require frequent small changes and ERD is only suitable for a small proportion of patients who have a stable medication regime. Additionally, due to over ordering it is difficult if not impossible to identify which patients are stable from practice prescribing information until several months after the MOSW programme has been completed.

A process of monitoring the quality of eRD has been introduced as a workstream though the MOSW Stakeholder Group and initial reviews from the first two practices have found that the majority of patients have not been asked if they require all their medications prior to order. If eRD is widely implemented without the necessary quality controls being put in place, there are significant risks that patients may once again be disempowered and excluded from their repeat prescription ordering.

Emerging Opportunities

MSOW “Invest to Save” Work ; Savings of approximately £27K were delivered in the 2017/18 year when the MSOW team routinely contacted 266 patients as part of GP practice prescription audit and monitoring work. Prescription items which were reported by the patient as not routinely required ordering were (with the patient and practice authorisation) suspended until the date stock was used up, or where items were no longer required items were requested to be removed from ordering. Each patient contact took on average 10 minutes. It was noted undertaking a modest proportion of this work (approximately one person undertaking contacts for ten weeks a year) could deliver savings equivalent of approximately £75K to recurrently fund and retain a small MSOW team made up of 2.8 WTE staff; Band 4 (0.8) and Band 3 (2).

Patient Ordering Pilot: Many of the patients contacted through the MOSW programme identified that there was no systematic ordering process behind their prescription requests. Patients views on the prescribing of medicines, convenience, their beliefs and misconceptions were potential drivers to what appeared to be inappropriate ordering. Examples of the responses and misconceptions which have been encountered by the team are :-

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 Patients who receive free prescriptions admitted giving their excess medicines to family members or friends, with some stating that family members now rely on them to supply these medicines to treat their own ongoing ailments.  Patients saying that they over order and stockpile their medicines out of fear of running out.  ‘I worry that my doctor will stop the medicine if I don't order it’  Just over 15% of the patients spoken to still believed that pharmacies can reuse medication returned to the pharmacy  ‘I order everything because I don’t understand the system and it’s just easier’  GP’s get paid for every item they prescribe  Patients not understanding their own impact on waste - the bigger picture  NHS budget can absorb the waste – News reports billions in the pot  Tablets must be cheap? They are free to most people (only cancer and HIV drugs are high cost)

Educating patients has the potential to deliver savings as its estimated that 20% of medicines waste is generated from patient over ordering which would equate to >£1.2 million per year over the Barnsley locality. Only a proportion of this waste could be reduced through patient education work, however its hoped that half the waste could be reduced by half this amount, equivalent to £600K per annum recurrent.

There is a possible extended programme of “Patient Ordering” work which could be rolled out systematically through the practices after completion of the Phase 3 of the MOSW work. In October 2018 the CCG Management Team endorsed the MMT using a small amount of their team funding to develop resources, (including a video) and targeted educational sessions and this pilot is currently ongoing. The detail of a patient education campaign has also been discussed with the CCG Communications team.

Definitions

Third Party Ordering: Third party ordering is where a third party, who is not the patient or their nominated carer ( not a paid care worker) , order repeat prescriptions on the patient’s behalf. This is usually a high street pharmacy, appliance contractor or internet pharmacy which order repeat prescriptions on behalf of a patient and this is an additional non-funded service that they offer patients. Whilst such services may provide convenience for patients, it has been evidence that third party ordering disempowers patients, removing from them the responsibility but also the control of ordering the medicines they require each month. Third party ordering does not include prescription requests from other healthcare professionals such as district nurses.

Waste medicine: Medicine that is prescribed and dispensed but not taken correctly to achieve the intended therapeutic outcome. It includes medicines not taken at all, but also those which patients take infrequently or not as intended, whether intentionally or unintentionally.

Electronic Prescribing Systems (EPS) Systems by which prescriptions are issued electronically from the GP practice to the NHS spine, without the need

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for a paper prescription to be issued. These can be downloaded at the request of the patients nominated pharmacy or by using an electronic script token. 2. IMPLICATIONS

2.1 Financial implications

The original 2017 business case set out efficiency estimated at £2.411m over 18 months before investment of the team of £259k.

Recruitment and retention issues outlined in an earlier section of this report delayed the programme by several months and brought financial reporting over three years instead of the initial planned two. Targets have also been amended in light of revisions to Quality, Improvement, Productivity and Performance (QiPP) delivery plans.

Current targets and reported delivery over three years are shown in Table 1 below.

The verification process is complex due to the high volume and varied amount of Medicines Optimisation QIPP currently work being undertaken across all practices and across different workstreams. MSOW outcome is verified using an agreed financial process, the detail of which is scrutinised by the Quality and Cost Effective Prescribing Group (QCEPG). Electronic Prescribing Analysis and Cost ( EPACT) information is used for this process, which is reported approximately 6 weeks after month end and requires a further 2 weeks ( two months in total ) to verify through QCEPG.

The programme has progressed through over two thirds of Barnsley practices and is currently online to deliver £1.926K QIPP savings ( £126K 17/18 and £1.8million 2018/19) by the 31st March 2019.

Table 1 – MOSW £QIPP Financial Highlight Report information

Plan Outcome Plan Outcome Plan 2017/18 2017/18 2018/19 2018/19 2019/20 £137K Verified £1.8 million 1st February £406K £126K at reported June 18 £1.49 QCEPG million year to date position. 1st April to 31st October 2018 verified £875K at Dec 18 QCEPG

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2.2 Consultation & Engagement ‘Involving people in their own health and care: Statutory guidance for clinical commissioning groups and NHS England’ highlights that CCGs have a key role to play in ensuring that providers make individuals’ personal involvement in their health and care a reality. This work programme supports CCGs to fulfil their legal duties to involve people in their health and care.

Putting people and their carers in control of their own repeat ordering of medications, will help ensure people experience better quality care and improved health and wellbeing, and the system makes more efficient use of resources.

Section 14U of the National Health Service Act 2006 (amended by the Health and Social Care Act 2012) states that CCGs must promote involvement of each individual, their carer in decisions relating to, in this case, their care or treatment. This proposal supports that and builds on ad hoc feedback from the public and elected members expressing concern re medicines wastage.

Engagement activities have been phased and focus on talking with patients, carers and representatives at a GP practice and individual level. At a practice level, this is to provide information on the proposals and understand how best to implement any changes.

MSOW staff have been working with GP practice staff , clinicians , community pharmacies and patient groups via its Steering Group and are constantly refining working processes

All patients and carers who are identified as using a third party to order on their behalf, have been contacted ahead of any changes to discuss the options and offer any support they may need.

2.3 Equality & Diversity An Equality and Diversity impact assessment was completed and submitted to the Governing Body with the June 2017 Options paper. This is held by the CCG Corporate Affairs team and additionally by the Head of Medicines Optimisation.

2.4 Information Governance A Privacy impact assessment was completed and submitted to the Governing Body with the June 2017 Options paper. This is held by the CCG Corporate Affairs team and additionally by the Head of Medicines Optimisation. 2.5 Environmental Sustainability Implementation would reduce inappropriate waste of prescription medicines and therefore would have a positive environmental impact. 2.6 Human Resources There are no associated significant Human Resource issues.

2.7 Other Implications

3. RISKS TO THE CLINICAL COMMISSIONING GROUP

There is a financial risk associated with recruitment and retention issues and delivery against 2019/20 £QIPP targets which is highlighted within the financial

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section of this report.

There are also a number of emerging risks which have been identified but are not possible at this point to quantify.

4. APPENDICES TO THE REPORT

 Appendix 1 – MOSW Stakeholder Steering Group Focus Paper

5. CONCLUSION

Wasted medicines is a national problem (and not just a Barnsley problem) which drains valuable resources that would be better spent on improving patient care and implementing new NHS services. The implications of medicines waste are significant but particularly tare safety focussed; patients cannot gain therapeutic benefit from medicines they do not take, and not taking them places a huge burden on health services across both primary and secondary care. Ordering medicines which are not taken leads to inaccurate medical records which hinder health care professional’s ability to determine if medicines are taken (when assessing a patient). This is also associated with stockpiling safety issues such as the risk of misuse and out of date medicines being consumed. Issues identified by the MOSW Steering Group have been summarised in a Steering Group focus paper (Appendix 1).

Significant work has been undertaken in over two thirds of Barnsley practices over the last eighteen months by a small but focussed MSOW team; however the problem is sizeable and challenging. Phase 1 and Phase 2 of the work programme have successfully been completed in line with Project Plans. Phase 3 of the work programme is now fin danger of falling behind target associated with ongoing fixed term staff recruitment and retention issues.

Several additional workstreams have been found to be substantially contributing to medicines waste, which are additional to the original scope of the programme; patient ordering, care home ordering, electronic repeat prescription ordering, pharmacy applications and the continued monitoring and patients who require additional support. It has been also identified that completed work require additional and ongoing consolidation to maintain the across the Phase 1 and Phase 2 practices.

The Governing Body is asked to :-

 Note the report, particularly the assurance provided regarding the progress of Medicines Ordering Safety and Waste (MOSW) programme work being undertaken across Barnsley GP practices.

14 Putting patient back in control of their medicine needs will Appendix 1 help to identify any issues relating to compliance. Non‑adherence may limit the benefits of medicines, resulting in lack of improvement, or deterioration, in health. When a Medication is requested and a prescription issued it will be documented on  Stockpiling medicines could a patient’s medical record as if the patient is increase the risk of an accidental overdose by another member of taking and needs the medication. the family, a child or a pet.  Over-ordering and stockpiling Summary Care Records and Medical increases the risk of medicines Compliance Inoperable Gateway (MIG) may be expiring before they are used inaccurate when reviewed at the hospital for which means people can end up inpatient. This could cause the clinicians to taking medicine which is no longer Inaccurate be working off in accurate care records. If a effective Medical  Advising how patients can safely clinician/work enters details onto the Stockpiling Records use up stockpiled medication system without using a smartcard, the summary care record is not updated immediately. Safety Issues

Medicines wastage associated with third- party ordering is estimated as £2 million Running out per annum in Barnsley. Prescription item Waste of Patients with a number of repeat items will growth in 16/17 was 3.4% despite the often run out at different times. When this medication happens, they will either request the item they implementation of a significant volume of have run out of when needed, or order Barnsley wide Medicines QIPP work, everything regardless of whether it is all undertaken in line with the Five Year needed. This can result in; Communication Forward View; this reduced medicines risk  More frequent requests. through undertaking medication review  Increased practice workload. and in undertaking this work a proportion  Inconvenient for patient. of unnecessary prescribing was stopped  Over ordering / stockpiling.  Waste of NHS resources.  Increased risk to patient

 flexibility - Consideration to those patients who cannot fit into systems  Patients may have their own ways of requesting medications such as asking for BP tablets rather than the medicine name.  Involving local community pharmacy in the patient engagement and plans  Each practice may have different ordering systems – ensuring pharmacies have the information to advise patients.  Improving communitcation between pharmacies and clincians GBPu 19/03/16

GOVERNING BODY

14 March 2019

CLINICAL FORUM REVIEW AND ASSURANCE REPORT

PART 1A – SUMMARY REPORT

1. THIS PAPER IS FOR

Decision Approval Assurance X Information X

2. REPORT OF

Name Designation Clinical Lead Dr N Balac Chair Author Jamie Wike Director of Strategic Planning and Performance

3. SUMMARY OF PREVIOUS GOVERNANCE

The matters raised in this paper have been subject to prior consideration in the following forums:

Group / Committee Date Outcome Clinical Forum 3/1/2019 Recommended presentation of review paper to Governing Body

4. EXECUTIVE SUMMARY

At the request of the Chair, a review of the Clinical Forum activity and impact was undertaken and presented to the forum in January 2019.

The purpose of the review was to evaluate the role that the Clinical Forum has had through provision of clinical input to programmes and projects being undertaken by the CCG since its inception in April 2017.

The Review and Assurance Report presented to the Clinical Forum in January is attached at Appendix A for review by the Governing Body.

In summary the review found that the clinical forum was most effective when there was a clear ‘ask’ of the forum and where papers have been presented with this clarity for guidance and direction on a service development that will affect

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the delivery of healthcare or the outcomes for patients, the forum have been able to positively affect the final specification/service model or outcome.

In considering this review, the clinical forum also noted the importance of having the relevant amount and detail of information available to support them to make informed judgements and also the importance of having clinical input throughout the life of individual projects to ensure ongoing input.

A recent review of lessons learned through the Quality, Innovation, Productivity and Prevention (QIPP) programme also identified the importance of clinical input and the confidence which this provided to non-clinical employees responsible for delivering service improvement and transformation projects.

5. THE GOVERNING BODY IS ASKED TO:

 Note – the content of the review and assurance report presented at Appendix A  Consider the findings of the review and provide feedback on any potential developments which would strengthen the role of clinical forum in supporting the CCG and Governing Body by ensuring appropriate clinical input to key pieces of work.

6. APPENDICES / LINKS TO FURTHER INFORMATION  Appendix A – Review and Assurance Report – January 2019

Agenda time allocation for report: 10 minutes.

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PART 1B – SUPPORTING INFORMATION

1. Links to the Governing Body Assurance Framework Risk ref(s) This report provides assurance against the following risks on 6.1 the Governing Body Assurance Framework: 2. Links to CCG’s Priority Areas Y/N 1 - Urgent & Emergency Care Y 2 - Primary Care Y 3 - Cancer Y 4 - Mental Health Y 5 - Integrated Care System (ICS) Y 6 - Efficiency Plan Y 7 - Transforming Care for People with Learning Disabilities and / or Autistic Spectrum Conditions 8 - Maternity 9 - Compliance with Statutory and Regulatory Requirements Y 3. Governance Arrangements Checklist 3.1 Financial Implications Has a financial evaluation form been completed, signed off NA by the Finance Lead / CFO, and appended to this report? Are any financial implications detailed in the report? N/A

3.2 Consultation and Engagement Has Comms & Engagement Checklist been completed? NA Is actual or proposed engagement activity set out in the NA report?

3.3 Equality and Diversity Has an Equality Impact Assessment been completed and NA appended to this report?

3.5 Environmental Sustainability Are any significant (positive or negative) impacts on the NA environment discussed in the report?

3.6 Human Resources Are any significant HR implications identified through NA discussion with the HR Business Partner discussed in the report?

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Appendix A

CLINICAL FORUM 3 January 2019

REVIEW AND ASSURANCE REPORT

1. INTRODUCTION

1.1 As set out in its Terms of Reference which have been approved by the Governing Body the purpose of the Clinical Forum is to inform the development of commissioning proposals, strategies and plans ahead of formal presentation to the Governing Body or other appropriate groups.

The Clinical Forum provides an opportunity to discuss possible courses of action to achieve improved, cost-effective, clinical pathways. It provides a clinical and service perspective to potential QIPP and other CCG work streams and a pragmatic view on implementation feasibility.

The Clinical Forum works in parallel to the QIPP Delivery Group to provide a steer for the development of proposals from outline business case (OBC) to full business case (FBC) with regard to preferred clinical models and methods of implementation. It also identifies and explores interdependencies between clinical services and thereby reduces the risk of unintended consequences arising from commissioning decisions.

1.2 The purpose of this report is to review the activity of the clinical forum since its inception in April 2017, evaluate the role it has had through provision of clinical input to programmes and projects being undertaken by the CCG and provide assurance that the Committee has discharged its functions set out in its Terms of Reference. The Report has been requested by the Chair

2. CONDUCT OF THE COMMITTEE’S BUSINESS

2.1 The Clinical Forum membership comprises the GP members of the Governing Body and the Governing Body Secondary Care Consultant.

Attendance of the Clinical Forum during 2017/18 is set out in the table below:

2.2 Name Role % of meetings attended Dr Nick Balac The Chair of the Governing Body 15 out of 17 (Chair)

Dr Mehrban Ghani Medical Director 10 out of 13

Dr Sudhagar Elected Governing Body Member 15 out of 17 Krishnasamy

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Dr A. Adekunle Elected Governing Body Member 14 out of 17

Dr Mark Smith Elected Governing Body Member 12 out of 17

Dr Hussain Elected Governing Body Member 14 out of 17 Kadarsha

Mike Simms Elected Governing Body Member 16 out of 17 (Consultant)

Dr John Harban Elected Governing Body Member 16 out of 17

Dr Madhavi Elected Governing Body Member 12 out of 13 Guntamukkala

Dr James Holloway Elected Governing Body Member 9 out of 11

2.3 In total the Clinical Forum have met 17 times from the first meeting in April 2017 to December 2018.

3. REVIEW OF COMMITTEE’S EFFECTIVENESS

3.1 The Clinical Forum has the skills and competencies necessary to discharge its functions and is supported where appropriate by the attendance of officers to provide input specific proposals, business cases, pathways and service developments.

3.3 A review of all of the activity of the Clinical Forum has been undertaken by the Director of Strategic Planning and Performance to evaluate and assess the role and impact that the Forum has had in shaping service developments and pathway improvements. The table attached at appendix 1 provides the detail of the evaluation including all items that have been considered as part of the Clinical Forum agendas up to the meeting on 4 October 2018.

4. CONCLUSION

4.1 Having reviewed the activity and impact of the clinical forum, it appears that the forum does provide an opportunity for clinical input to key areas of work in a ‘safe’ setting outside of formal Governing Body decision making processes.

4.2 The impact upon the topic area being discussed is variable depending upon the purpose of the engagement and the clarity of the ask of the forum. Where papers are presented for information (health profiles, DPH annual report etc) the forum have tended to note the content and provide suggestions on wider engagement with the CCG membership or future use of the information. However, where the papers have been presented with a clear ask from the forum for guidance and direction on a service development that will affect the delivery of healthcare or the outcomes for patients, the forum have been able to positively affect the final specification/service model or outcome.

5 GBPu 19/03/16

4. THE FORUM IS ASKED TO:

 Note the contents of this paper and review the evaluation included at Appendix 1.  Provide feedback on the evaluation and agree any changes to be made prior to presentation to Governing Body  Consider the future role of the Clinical Forum and provide views on any potential changes to the role and remit of the forum to ensure it continues to provide an effective mechanism for clinical engagement and involvement in key pieces of work.

6 Appendix 1 Evaluation of Clinical Forum Activity

Clinical Forum Topic Dates discussed Input of the Clinical Forum Current Position

Health Optimisation/Get Fit First 6 April 2017 Clinical Forum reviewed the initial proposal and Get Fit First is in place and the policy is being supported exploring the area of work. Forum applied by GP Practices requested that clinical engagement and public Weight Management and Exercise engagement be included in the work and that programme have been commissioned to support for patients to access other services e.g. support patients impacted by the GFF policy. weight management should also be included.

7 September 2017 Clinical input provided to inform BMI thresholds and the decision not to apply the policy retrospectively to patients already listed for surgery. Proposed amendments suggested re smoking cessations.

3 August 2018 Clarification to ensure consistent interpretation of clinical threshold and GFF policies – BMI 30

Medicines Waste 4 May 2017 Clinical forum views sought on proposed Scheme was approved by GB in June 2017. medicines waste initiative – forum requested that Support is being provided to practices to evidence be sought from other areas to provide implement required changes by the assurance of neutral impact on Primary Care Medicines Ordering and Waste Team work load. Share with Membership Council, BEST Some delays have occurred due to staffing and Practice Managers issues however Management Team agreed Phased approach should be taken and support to extend the project to ensure roll out to all should be provided to practices practices. Additional areas of work identified from the learning during the project are currently being explored.

Appendix 1

Clinical Forum Topic Dates discussed Input of the Clinical Forum Current Position

Medicines Optimisation – Self 4 May 2017 Agreed not to proceed until the national review The national and local consultation on the Care/Over the counter medicines and consultation was concluded. reduction in prescribing over the counter medicines has now finished. Revised national guidance for CCGs was issued reflecting the need for prescribers to have to make the final medical decision, particularly with respect to vulnerable patients. The CCG Governing Body approved the adoption of the national guidance and is now working on an implementation plan which gives both onward signposting guidance to prescribers and clear thresholds for when self-care is not appropriate. This will be for each of the conditions. It is proposed that these changes will go live from April 2019. National Guidance shared with GPs.

Musculoskeletal (MSK) 4 May 2017 Input to the development of proposed Unable to deliver proposed model within model/specification resource envelope through managed change. GB agreed to go to procurement in June 2017. Procurement complete and new service in place from April 2018.

Appendix 1

Clinical Forum Topic Dates discussed Input of the Clinical Forum Current Position

Pain Management 1 June 2017 Initial consideration of scope for a full review of It was agreed at QDG in December 2017 that Pain Management following the earlier cessation due to the expiry of the current provider of acupuncture for lower back pain and local contract at the end of the next financial year injections. Proposed that the review include pain and capacity within the CCG that the management treatments for all providers development of a new specification should excluding those in the MSK pathway and align to this time period. prescribing. 2 November 2017 The forum agreed that their preferred model In June 2018 an update was provided to would be a locally based chronic pain service with QDG noting that the CaT team was looking at short waiting times and a focus on psychological the possibility of providing locality based and supportive interventions as well as short term services to prevent unnecessary referrals into clinical interventions where appropriate. It was secondary care. Training for GP’s has been noted that this would need to be a new model and provided (17th October and 14th November there would need to be processes for managing 2018) to enable increased numbers of joint referrals, consideration of appropriate thresholds injections to be undertaken in Primary Care for procedures and a process for reassessing Nice guidance has now been produced which patients currently within the system. reduces the number of pain management interventions available and therefore the CAT team are developing options for future pain management services post the current contract.

Clinical Thresholds Phase 2 /SYB 1 June 2017 The Clinical Forum provided a view on whether Membership Council was presented with Commissioning for Outcomes NHS Barnsley CCG should develop a second proposals in July 2018. phase of clinical thresholds (wave 2) and to CfO policies agreed across SYB with some advise and comment on the clinical value and local variation to thresholds and sense check the evidence presented for further implementation approach. procedures identified for inclusion in Wave 2 Policies included in contracts from 2018/19 Clinical Thresholds. and included in referral guidelines and demand management section of the 2018/19 3 May 2018 Further consideration of specific procedures PDA (Cataracts, Dupytrens, and Hysterectomy) and provided input to inform finalisation of thresholds.

Appendix 1

Clinical Forum Topic Dates discussed Input of the Clinical Forum Current Position

Cardio Vascular Disease 6 July 2017 Considered the 2017 CVD needs assessment CVD is currently one of the 3 priority and agreed that CVD should be promoted as a programme for health and care in Barnsley priority in Barnsley. along with frailty and neighbourhoods

5 October 2017 Reviewed the high level CVD Plan and supported the 15 recommendations for areas of work to be taken forward by partners

Care Homes 6 July 2017 Clinical Forum considered and input to the Care Allocation process agreed for care homes Homes work on a number of occasions. This has and in place. 2 November 2017 included focus on the process and criteria for allocating new care home patients to a GP Clinical Forum requested an update in 7 December 2017 practice through an alignment and community November 2018 on the wider Care Home matron model and the universal support to be work. This will be presented in January 2019 provided to care homes and their universal consistent offer to patients.

Cataracts Surgery – NICE draft 7 September 2017 Clinical Forum members were asked to support It was agreed to await the outcome of the guidance compliance with NICE guidelines for cataracts legal challenge before amending the local treatment. clinical thresholds.

7 December 2017 Due to a legal challenge by Moorfield Hospital Guidance for cataracts is now included within against implementation of thresholds by CCG’s in the Optometry First Scheme London the Clinical Forum were asked to provide guidance on implementation of the NICE guidance and inclusion in thresholds.

Appendix 1

Clinical Forum Topic Dates discussed Input of the Clinical Forum Current Position

Opticians First/Optometry First 7 September 2017 Clinical forum considered the potential for Optometry First scheme has been procured extending the PEARS scheme to include during 2018/19 and is now in place. 1 March 2018 additional conditions and supported development (paper circulated of a specification which would see a reduction in for comment due the numbers of people requiring hospital to meeting being treatment. cancelled) Input was provided to the final spec by way of comment on the draft prior to consideration and approval by Governing Body

Non Elective Activity 7 December 2017 Non Elective admission activity data has been Work is ongoing and will be presented to presented to the Clinical Forum to identify areas clinical forum initially in January 2019 for 1 February 2018 where there appears to be high levels of activity. UTI’s and abdominal pain and paediatric This lead to further analysis to consider activity by admission *focussed on short length of stay). NEL – Impact of case mix 6 September 2018 primary diagnosis and specialty to provide further granularity. An update on the current service to provide first dose IV antibiotics was presented to A number of specific areas for follow up were clinical forum in February 2018 and a review identified. These were: of the current pathway for IVI’s in the  UTI’s and abdominal pain community will be undertaken in Q4 2018 with a view to increasing take up of the  Paediatric viral infection and UTI current offer and identifying options for expanding the service to cover conditions  Cellulitis of other parts of the Limb and other than just cellulitis. Ulcer of lower limb - Link to new pathway for 1st dose IVI’s in the Community

Transgender Prescribing Protocol 7 December 2017 Initial consideration of the protocol and suggested The protocol has been further considered that expressions of interest be sought from within the CCG and the Medicines Barnsley practices to identify those who could Management Team are taking forward potentially support this group of patients via the implementation following a discussion at Membership Council. Membership Council

Appendix 1

Clinical Forum Topic Dates discussed Input of the Clinical Forum Current Position

Intravenous Antibiotics 1 February 2018 Members supported roll out of the initial pilot with A review of the current pathway for IVI’s in the caveat that additional areas be considered for the community will be undertaken in Q4 2018 inclusion with the aim of improving patient with a view to increasing take up of the experience e.g. other infection (wound infections, current offer and identifying options for leg ulcers) and supported early discharge. expanding the service to cover conditions other than just cellulitis.

Barnsley Health Profiles 1 February 2018 Clinical Forum reviewed the profile with the aim of The profiles were shared at BEST/Locality focusing on areas across Barnsley that could be planning meeting on 14th February as part of commissioned differently. the locality development work.  Members discussed the need to inspire children and change attitudes to health lifestyle.

 Target the areas of high health need  Public health interface and intervention  Members highlighted the need to adopt a multi-agency approach (Public Health, Education etc.)  Members raised concerns regarding alcohol unit pricing, 24 hour licensing, the impact of gambling and the need for the law and advertising to change.

Faecal Immunochemical Testing 3 May 2018 Reviewed proposal for FIT testing in Primary Care Updates have been provided to GB as part of (Fit) in Primary Care being rolled out across SYB. regular cancer updates. Presented by: Agreed requirement to share at Membership FIT testing is due to be implemented early in Louise Merryman, GP Clinical Lead, Council and BEST. FIT pathway and Faecal 2019 as part of the lower GI pathway Cancer Alliance - GP, North Calprotectin reviewed. Derbyshire Sophia Manik, Programme Lead, Lower GI Pathway – SY&B

Appendix 1

Clinical Forum Topic Dates discussed Input of the Clinical Forum Current Position

Paediatric Referrals 3 May 2018 The Clinical Forum was presented with the The new pathways have been presented to outcome of a review of confirmed UTI in Membership Council, agreed by the paediatric patients in A&E department. Governing Body and submitted to Clinical Quality Board to ensure the process and The review recommendation was for a change to decision was documented and implemented the pathways to ensure ED consultants review by BHNFT MSU results, contact parents and send a letter for children with confirmed UTI. For children over 6m age with complicated / recurrent UTI, ED consultant to arrange a renal USS and e-Referral to paediatrics for follow up as per NICE guidelines. This system already exist in SCH (Sheffield Children’s Hospital)

Forum supported the changes based on the alignment to best practice guidance and seamless follow up.

Frailty Template 3 May 2018 Input provided to a new frailty template to support Template has now been agreed and is frailty reviews in General Practice. Clinical Forum included in clinical systems to support members felt the template needed to be simplified identification and review of frail patients and provided feedback to support this.

Cryopreservation Policy 7 June 2018 Members agreed that a policy was required and needed to be delivered at scale consistently and therefore welcomed the national guidance.

Appendix 1

Clinical Forum Topic Dates discussed Input of the Clinical Forum Current Position

Improving Parenting Support 3 August 2018 Members reflected on the on the summary paper Proposals are being developed for presented by M. Simms. implementation in partnership with BMBC as Discussions were held regarding the potential part of a new Section 75 agreement on benefits and challenges of promoting literacy and prevention and improved parenting support education attainment and the possibility of the antenatal period being a window of opportunity for the Midwifery services to signpost Mothers to services that will improve their own literacy skills and to target literacy for children earlier in life. Members agreed that BCCG would support the initiative and therefore recommended escalating the item to the Governing Body (private) for further consideration. The wider issue of supporting parenting was discussed.

Community Shop 3 August 2018 Update provided and noted

NHSE Consultation on Evidence 6 September 2018 Members have provided input to the consultation The implementation approach is being Based Intervention response and on the implementation approach to considered across SYB to ensure the new national guidelines including consistency as far as possible. consideration of how these link to the current policies and thresholds National contracts will include restrictions for the 17 interventions from April 2019

Discharge of patients on 6 September 2018 A proposal from SWYPFT regarding shared care Proposals including new shared care fees for antipsychotics from SWYPFT for patients on antipsychotics was discussed and GP’s have been considered and agreed by Shared Care further clarity sought before presenting a further Management Team and shared with paper to Management Team. Membership Council in November 2018. Membership Council advised further scoping from practices re: feasibility and capacity

Appendix 1

Clinical Forum Topic Dates discussed Input of the Clinical Forum Current Position

Home Visiting 6 September 2018 Input to specification for Primary Care Home Home Visiting Specification has been visiting service including inclusion and exclusion considered by Primary Care Commissioning 4 October 2018 criteria. Committee and agreed subject to inclusion of Consideration of feedback and queries from visits for Care Home patients. Procurement membership council and clarification of a number plans are in place to have the new service in of areas of the specification. place and mobilised by 1 May 2019

Director of Public Health Annual 4 October 2018 Presented for information and comment Feedback provided Report Healthcare Public Health Advice 4 October 2018 Input to the emerging work being taken forward Feedback provided that a community by the Hospital Consultant in Public Health on approach should be developed with co- prevention and upstream interventions, and ordination of services at a locality level. Population Health Management (Dr Andy Snell) Noted importance of including MH pathways as part of the prevention agenda.

Dermatology 4 October 2018 Input to proposals for improving dermatology Pilot being developed for community based services in the context of increasing numbers for outreach service. To focus on high referring 2 week wait referrals. Forum provided direction, practices and to include an evaluation of cost referencing previous work in this area to ensure effectiveness. learning is taken into account. To be presented to BEST meeting

GBPu 19/03/17

GOVERNING BODY

14 March 2019

QUALITY HIGHLIGHTS REPORT

PART 1A – SUMMARY REPORT

1. THIS PAPER IS FOR

Decision Approval Assurance X Information

2. REPORT OF

Name Designation Executive Lead M Tune Chief Nurse (Acting) Author H Fitzgerald Quality Manager

3. EXECUTIVE SUMMARY

Provide the March 2019 Governing Body with the agreed highlights of the February 2019 Quality & Patient Safety Committee.

The information provided is in addition to the monthly performance report and ongoing risk management via the Assurance Framework and Risk Register.

Five quality issues are highlighted and rated:  Performance of Thames Ambulance Service Ltd - Red  Outstanding concerns around D1s - Amber  Positive CQC inspection reports for Barnsley Healthcare Federation and Hollygreen Practice - Green  Management of Patient Experience Feedback Policy - Green  Annual Patient Experience Report - Green

4. THE GOVERNING BODY / COMMITTEE IS ASKED TO:

 Note the Quality Highlights identified

5. APPENDICES  Appendix A – Quality Highlight Report

Agenda time allocation for report: 10 minutes

GBPu 19/03/17

PART 1B – SUPPORTING INFORMATION

1. Links to the Governing Body Assurance Framework Risk ref(s) This report provides assurance against the following risks on 6.1 & 9.1 the Governing Body Assurance Framework: 2. Links to CCG’s Corporate Objectives Y/N To have the highest quality of governance and processes to Y support its business To commission high quality health care that meets the needs Y of individuals and groups Wherever it makes safe clinical sense to bring care closer to Y home To support a safe and sustainable local hospital, supporting Y them to transform the way they provide services so that they are as efficient and effective as possible for the people of Barnsley To develop services through real partnerships with mutual Y accountability and strong governance that improve health and health care and effectively use the Barnsley £. 3. Governance Arrangements Checklist 3.1 Financial Implications Has a financial evaluation form been completed, signed off NA by the Finance Lead / CFO, and appended to this report? Are any financial implications detailed in the report? NA

3.2 Consultation and Engagement Has Comms & Engagement Checklist been completed? NA Is actual or proposed engagement activity set out in the NA report?

3.3 Equality and Diversity Has an Equality Impact Assessment been completed and NA appended to this report?

3.5 Environmental Sustainability Are any significant (positive or negative) impacts on the NA environment discussed in the report?

3.6 Human Resources Are any significant HR implications identified through NA discussion with the HR Business Partner discussed in the report?

GBPu 19/03/17

Appendix A –February 2019 QPSC Quality Highlight Report

Issue Consideration Action Thames Ambulance The Chief Nurse (Acting) alerted Barnsley CCG is involved in Service Ltd contract Q&PSC to concerns regarding enhanced monitoring the performance of Thames arrangements for TASL and is Ambulance Service Ltd (TASL) providing support with the which provides on day discharge completion of their remedial patient transport services for action plan. Barnsley, Rotherham and Doncaster acute hospitals. (Barnsley CCG is the lead commissioner).

D1s Q&PSC reviewed the risk on its Q&PSC agreed that additional risk register relating to D1s. assurance was required from Concerns persist about the lack BHNFT, and will ask for a clear of information to assure the and concise report on the Committee that the risk is being outcome of the audit of D1s. effectively mitigated.

CQC Inspections Q&PSC received confirmation Q&PSC agreed that advice that BHF and Hollygreen Practice from Comms should be sought have recently received very around publicising the positive positive CQC inspection reports. inspection reports outside of Q&PSC acknowledged the the CCG. significant progress made by BHF in a short timescale to improve on their previous CQC inspection rating.

Management of The Management of Patient Q&PSC approved the policy to Patient Experience Experience Feedback Policy has go forward to Governing Body Feedback Policy been extensively updated. with a recommendation to Q&PSC scrutinised the policy to adopt the policy. Following confirm/challenge its fitness for adoption, communication of the purpose prior to it being ratified plan will include relevant by the Governing Body in May members of the CCG. 2019.

Annual Patient Q&PSC reviewed the Annual Q&PSC approved the report. Experience Report Patient Experience Report The Annual Patient Experience 2017/18, which outlines how the Report for 2018/19 will be CCG handled the complaints it presented to Q&PSC in June received in this period compared 2019. with statutory requirements.

Green = positive assurance Amber = concern being monitored, for information Red = articulated risk or escalation

GB/Pu 19/03/18

GOVERNING BODY

14 March 2019

RISK AND GOVERNANCE EXCEPTION REPORT

PART 1A – SUMMARY REPORT

1. THIS PAPER IS FOR

Decision Approval  Assurance  Information

2. REPORT OF

Name Designation Executive Lead Richard Walker Head of Governance & Assurance Author Paige Dawson Governance, Risk & Assurance Facilitator

3. EXECUTIVE SUMMARY

Introduction This report presents to the Governing Body a number of matters, specifically:  Full Governing Body Assurance Framework  Full Corporate Risk Register  Internal Audit (360 Assurance) Governing Body Survey Outcomes  Information Governance & Cyber Security Update  Domestic Abuse Support Policy  Yorkshire Ambulance Service YAS (Patient Transport Service).

Governing Body Assurance Framework The Governing Body Assurance Framework (GBAF) facilitates the Governing Body in assuring the delivery of the CCG’s annual strategic objectives. In line with the new Corporate Calendar the Governing Body will now receive the full Assurance Framework (GBAF) at every other meeting with a summary being brought to intervening meetings. In line with these reporting timescales a full GBAF is therefore presented to the March 2019 meeting of the Governing Body (Appendix 1). There are currently no risks on the GBAF 2018/19 rated as ‘red’ extreme risk.

Corporate Risk Register The Corporate Risk Register is a mechanism to effectively manage the current risks to the organisation. Governing Body receives the full Risk Register twice a year (September and March) with exception reports brought to intervening meetings. This report therefore provides the Governing Body with a full report of the Corporate Risk Register (Appendix 2).

1 GB/Pu 19/03/18 Red (extreme) risks: There are currently 6 extreme risks on the CCG’s Risk Register which have been escalated to the Assurance Framework as gaps in assurance against risks on the Assurance Framework. The risks are:  Ref CCG 18/04 (rated score 16, ‘extreme’) - If the health and care system in Barnsley is not able to commission and deliver out of hospital urgent care services which have sufficient capacity and are effective in supporting patients in the community to avoid the need for hospital attendance or non-elective admission there is a risk that non- elective activity will exceed planned levels potentially leading to (a) failure to achieve NHS Constitution targets (with associated reputational damage, and (b) contractual over performance resulting in financial pressure for the CCG.  Ref CCG 18/03 (rated score 15, ‘extreme’) - If there is not an adequate and rapid response from Barnsley Healthcare Federation to the areas identified by CQC in their recent inspections there is a risk that the BHF does not meet contractual and service requirements potentially leading to poor quality or unsafe services for the people of Barnsley; reputational /brand damage; strategic implications for the CCG; risks to continuity of service; and a risk of patients and practices not accessing services provided by BHF.  Ref CCG 18/02 (rated score 16, ‘extreme’) - If the CCG and BMBC do not develop a collaborative commissioning approach underpinned by shared values there is a risk that BMBC commissioned services will not meet the requirements and aspirations of the CCG for the people of Barnsley leading to increased health inequalities and poorer health outcomes.  Ref CCG 14/10 (rated 16, ‘extreme’) - If the Barnsley area is not able to attract & retain a suitable & sufficient Primary Care clinical workforce there is a risk that: (a) Some practices may not be viable, (b) Take up of PDA or other initiatives could be inconsistent, (c) The people of Barnsley will receive poorer quality healthcare services, (d) Patients services could be further away from their home.  Ref CCG 14/15 rated 15, ‘extreme’) - There are two main risks: 1. Scant or absent information relating to why medication changes have been made. Poor communication of medication changes , even if changes are appropriately made for therapeutic/safety reasons, creates a patient safety risk when post discharge medicines reconciliation is being undertaken by the GP practice. The risk being that the GP practice may either accept inappropriate changes when all the patients’ risk factors have not been accounted for by the hospital clinicians or an error has been made or not accept clinically important changes as not confident about the reasons for the change. 2. Clinically significant safety alerts, such as contraindicated combinations of medication, are being frequently triggered by primary care prescribing systems during post discharge medicines reconciliation when adding medicines to the Patients Primary Care Record. This indicates that either the hospital is not reconciling medicines using the GP Practice Summary Care Record or that the reconciliation is not sufficiently robust.  Ref CCG 15/07 rated 15, ‘extreme’) - If improvement in Yorkshire Ambulance Service (YAS) performance against the ARP response time targets is not secured and sustained, there is a risk that the quality and safety of care for some patients could be adversely affected.

2 GB/Pu 19/03/18 Additions / Removals

As its meeting on 21 February 2019 the Quality and Patient Safety Committee agreed the addition of a new risk relating to Dodworth Medical Centre as follows ‘If there is not an adequate and rapid response from Dodworth Medical Centre to the areas identified by CQC in their recent inspections there is a risk that the Practice does not meet contractual and service requirements’. The Committee agreed a rating of 10 ‘amber’ (high risk) for this risk.

The Quality and Patient Safety Committee also recommend the removal of risk reference CCG 18/03 relating to Barnsley Healthcare Federation rated as 15 ‘red’ (extreme risk). The Quality and Patient Safety Committee determined that the rationale for removal of this risk from the Risk Register was the recent CQC re inspection of the Federation and an overall rating of ‘good’ across all domains being received.

Governing Body is asked to approve these changes.

Internal Audit (360 Assurance) Governing Body Survey Outcomes At its meeting in January 2019 the Audit Committee received and considered the Head of Internal Audit (HOIA) Work Programme: Stage 2 Memo. The memo, which is attached at Appendix 3, comments on the findings from 360 Assurance’s recent Governing Body survey on governance, risk management and culture; and on the extent to which the organisation is utilising the Governing Body Assurance Framework as a strategic management tool. Audit Committee requested that the memo be provided to Governing Body for information and comment.

The memo contains a number of positive messages with regard to the GBAF. It notes that the GBAF has continued to be presented throughout the year to the Governing Body and its Committees in line with the Integrated Risk Management Framework. The GBAF is aligned with the Strategic Objectives mapped against national and local priority areas. A review of the GBAF reported to Governing Body in November 2018 demonstrates that updates have been made during the year including identification of additional sources of assurance and key controls to mitigate threats.

These positive messages are supported by the findings from our Governing Body survey. The survey contained 21 questions over 7 areas. Participants were asked to rate each of the statements from a range of 1 (strongly disagree) to 5 (strongly agree). 11 responses (85% response rate) were received. Overall, the survey results provided a positive picture for the CCG with respondents scoring an average of 4 or 5 for each question. Barnsley CCG’s results were compared against the circa 120 responses across 360 Assurance’s CCG client base and in every instance our scores were more positive than the average. There were however a small number of responses which indicated that some members were unsure or strongly disagreed with the CCG may wish to consider further, relating to whether:  All Members are clear about the success measures that indicate whether or not the CCG’s strategic objectives are being met (Q2)  The GBAF exclusively focuses on strategic objectives and associated risks (Q5)  The GBAF adequately covers all areas of strategic risk (Q6).

3 GB/Pu 19/03/18 Information Governance & Cyber Security Update A replacement for the NHS IG Toolkit is now in use. The new Data Security & Protection (DSP) Toolkit, which is a self-assessment by the CCG of our arrangements for complying with good practice in terms of GDPR and cyber security, is less prescriptive and shifts the emphasis onto IT / Cyber Security.

The work necessary to complete the Toolkit, which is being led by the eMBED IG Lead, is progressing well and is on schedule to allow submission in advance of the 31 March 2019 deadline. Areas of work still in progress include:  Information Asset Reviews  A ‘permissions audit’ of network user accounts  Ensuring 95% or more of CCG staff are compliant in their DSA training.

360 Assurance are currently undertaking an annual review of a sample of our evidence for the Toolkit. So far no areas of concern have been identified. Once the report is received any necessary actions will be expedited promptly in advance of the Toolkit deadline.

It is proposed that consistent with prior years the following procedure will be followed to sign off and submit the Toolkit:  Any recommendations from the 360 Assurance review will be addressed  The eMBED IG Lead complete the compilation and uploading of all necessary evidence into the Toolkit  The Head of Governance & Assurance will review the evidence and sign off the assertions  The Head of Governance & Assurance will seek approval from the IG Group to submit the Toolkit in advance of the 31 March 2019 deadline.

Domestic Abuse Support Policy At its meeting in February 2019 the Equality & Engagement Committee approved a new Domestic Abuse Support Policy (Appendix 4). The development of this policy was led by the CCG’s HR Manager and prior to Committee approval the Policy had been through a wide ranging consultation exercise covering CCG staff, staff side, the E&D Lead and the local counter fraud service. The intention of the Policy is to:  Ensure all employees recognise that domestic abuse is a serious issue within society  Provide effective, confidential and sympathetic support to employees and recognises they may not wish to divulge this fact, even in strict confidence, to any other employee of the organisation  Ensure employees are aware of the various external organisations which can offer support and guidance.

As this is a new Policy the Governing Body is now asked to give final approval. Once approved the Policy will be publicised to all staff through a variety of routes and a toolkit for managers and staff, and other resources, will be published on the intranet.

4 GB/Pu 19/03/18 Yorkshire Ambulance Service YAS (Patient Transport Service) Sheffield CCG (Lead Commissioner) and YAS have been in discussions regarding pressures on the PTS contract relating to on-day discharges and increases in weekend activity above levels included within the procurement.

An urgent meeting was held on 29 January 2019 with all parties (including Barnsley CCG). The CCG Chief Officer and Chair gave the Chief Finance Officer delegated responsibility to reach agreement with YAS on behalf of Barnsley CCG with a funding risk expected to be between £86.5k and £173k. The outcome of this meeting was that Barnsley would make an additional contribution of £108,700 to support the cost pressures within YAS to 31 August 2019. It was also agreed that the CCG would need to work with BHNFT to ensure patient discharge processes were effective, with bookings for discharges being made wherever possible in advance to allow YAS to plan effectively and reduce the need for additional crews. The CCG also needs to consider the implications and issues of the TASL service that may be impacting on YAS.

It was agreed that a full review would be undertaken with the outcome being used to inform recurrent funding arrangements for YAS from 1 September 2019. Further updates will be provided to the Governing Body once this work is concluded in May 2019.

4. THE GOVERNING BODY IS ASKED TO:

 Review the full GBAF for 2018/19, and consider whether the risks are appropriately described and scored, and whether there is sufficient assurance that they are being effectively managed as 10 January 2019  Identify any additional positive assurances relevant to the risks on the GBAF  Review the Corporate Risk Register to confirm all risks are appropriately scored and described, and identify any potential new risks  Approve the removal of risk 18/03 from the Risk register recommended by the Quality & Patient Safety Committee  Note and comment on the Internal Audit (360 Assurance) Governing Body Survey Outcomes  Note the current progress with and arrangements for signing off and submitting the Data Security & Protection Toolkit  Approve the Domestic Abuse Policy  Ratify the urgent decision to make an additional contribution £108,700 to support the cost pressures within YAS to 31 August 2019 and note the proposed way forward.

5. APPENDICES

 Appendix 1 – Full GBAF 2018/19  Appendix 2 – Full Corporate Risk Register  Appendix 3 - Head of Internal Audit (HOIA) Work Programme: Stage 2 Memo  Appendix 4 – Domestic Abuse Support Policy

5 GB/Pu 19/03/18 Agenda time allocation for report: 10 minutes

6 GB/Pu 19/03/18

1. Links to the Governing Body Assurance Framework Risk ref(s) This report provides assurance against the following risks on All the Governing Body Assurance Framework: 2. Links to CCG’s Corporate Objectives Y/N To have the highest quality of governance and processes to Y support its business To commission high quality health care that meets the needs Y of individuals and groups Wherever it makes safe clinical sense to bring care closer to Y home To support a safe and sustainable local hospital, supporting Y them to transform the way they provide services so that they are as efficient and effective as possible for the people of Barnsley To develop services through real partnerships with mutual Y accountability and strong governance that improve health and health care and effectively use the Barnsley £. 3. Governance Arrangements Checklist 3.1 Financial Implications Has a financial evaluation form been completed, signed off NA by the Finance Lead / CFO, and appended to this report? Are any financial implications detailed in the report? NA

3.2 Consultation and Engagement Has Comms & Engagement Checklist been completed? NA Is actual or proposed engagement activity set out in the NA report?

3.3 Equality and Diversity Has an Equality Impact Assessment been completed and NA appended to this report?

3.5 Environmental Sustainability Are any significant (positive or negative) impacts on the NA environment discussed in the report?

3.6 Human Resources Are any significant HR implications identified through NA discussion with the HR Business Partner discussed in the report?

7 Appendix 1 NHS Barnsley CCG Governing Body Assurance Framework 2018-19

PRIORITY AREA 1: URGENT & EMERGENCY CARE Delivery supports these CCG objectives: PRINCIPAL THREATS TO DELIVERY • Enhance front door clinical streaming Highest quality governance If partners locally and across the ACS do not engage constructively together, • Improved patient flow High quality health care  to develop a model for urgent care at a South Yorkshire and Bassetlaw and • Free up hospital beds - Reduce non-elective activity and length of stay Care closer to home  Barnsley level, in line with best practice and national guidance there is a risk • More GP appointments evenings & weekends that urgent care services are unable to meet the growing demand, constitution Safe & sustainable local services  • Increased clinical assessment of calls to NHS 111 & CAS standards for urgent care are not achieved and the quality of patient care is • Delivery of 4 hour A&E standard (90% by Sept 2018, 95% March 2019) Strong partnerships, effective use of £  negatively impacted • Delivery of ambulance targets / conveyance Links to SYB STP MOU 8.4. Urgent and Emergency Care

Committee Providing Assurance FPC Executive Lead JW Clinical Lead SK Risk rating Likelihood Consequence Total 15 Date reviewed Feb-19 Initial 3 5 15 Rationale: Likelihood currently judged to be 'possible' given 10 Current 3 4 12 current pressures and challenges across the urgent care system and the developing nature of plans to deliver outcomes Appetite 3 4 12 5 of the national urgent care review. Consequence is judged as Approach Tolerate 0 major due to the potential impact on patient care. A M J J A S O N D J F M Key controls to mitigate threat: Sources of assurance Rec'd? Operational planning templates 2017-2019 were submitted to NHSE in December 2016 along Refreshed Plan submitted to NHSE in line with required deadlines and the CCG have worked Jun-18 with a planning narrative setting out plans to deliver agreed activity reductions, standards and with NHSE on the final assurance of plans following initial feedback received in March 2018. targets. Refreshed plans were submitted in April 2018 in line with NHS England planning Confirmation has been received following the CCG Annual Improvement and Assessment requirements and agreed contract activity levels. Meeting that plans have been assured and approved by NHSE. Planning has commenced for 2019/20 with draft operational plans submitted to NHSE setting Final Operational Plans will be submitted in April for assurance through the SYB ICS, NHSE and out plans to deliver agreed activity levels in line with provider contracts. NHSI Barnsley UEC Delivery Board meets monthly, with representation from the CCG, to ensure CCG Associate Medical Director and Director of Strategic Planning and Performance represent Ongoing oversight of performance and planning for urgent care locally and ensure delivery of urgent the CCG as members of the local delivery board. care standards including local system wide planning for winter and other seasonal pressures. UEC Delivery Board plans in place UEC Delivery Board winter plan submitted to NHSE October 2018 and assured November 2018. Winter schemes are being monitored through the UEC Delivery Board. UEC Delivery Board Performance Dashboard is in place enabling all key performance and activity information from across partners to be reviewed by the Board.

Urgent and Emergency Care Steering Board is in place as the UEC Programme Board of the CCG Delivery of Integrated Care collection template reported by SYB Urgent and Emergency Ongoing South Yorkshire and Bassetlaw Integrated Care System. Care Network to NHS England to demonstrate progress of the Network. Representation in place for the A&E Delivery Board partners on the Steering Group and Oversight by the SYB Steering Board and locally through the UEC Delivery Board. Commissioner Reference Group. SY&B gap analysis undertaken against national integrated urgent care specification and plans being developed to deliver against key implementation milestones. Procurement of new Integrated Urgent Care service concluded December 2018 to commence April 2019, replacing the current NHS111 service. An Integrated extended hours and out of hours primary care services (IHEART 365) is in Contract and contract management arrangements are in place for BHF services. The contract is Ongoing place with contracts for both elements of service delivered by Barnsley Healthcare being finalised to incorporate the Out of Hours specification requirements and national Federation. standards. Monitoring arrangements are in place and being refined on an ongoing basis to ensure that the CCG have a clear understanding of delivery and performance against all national standards and requirements and local specifications for all services including extended hours and out of hours. A monthly IHEART Performance Report is received by the CCG - This has been revised to reflect the changes to the service following commencement of delivery of the OOH service from July 2017. GP Streaming Services are in place in line with national guidelines and best practice. Oversight of Performance by the UEC Delivery Board. Contract in place between BHNFT and Ongoing BHF.

BHF commenced provision of streaming on 4th September 2017, initially in A&E with a GP providing streaming. Building works were complete by end November 2017 enable the new extended streaming model, adjacent to A&E to commence on 4th December 2017.

Performance reports to Governing Body on the delivery of constitution standards and CCG Monthly reporting through the Integrated Performance Report to Finance and Performance Ongoing Improvement and Assessment Framework. Committee and Governing Body

Gaps in assurance Positive assurances received

Gaps in control Actions being taken to address gaps in control / assurance (risk ref 13/3) Failure to deliver 4 hour A&E waits target. Target not achieved in 2017/18. Actions are in place to deliver improved performance going forward, overseen by the A&E Delivery Board. IHEART Barnsley service, offering out of hours GP appointments on evenings and Saturdays, now well established. Strengthened GP Streaming adjacent to ED in place and working well. Winter plan including non-recurrent funding is also in place to strengthen resilience and maintain the good performance seen to date in 2018/19.

RR 15/07: If improvement in Yorkshire Ambulance Service (YAS) performance against the ARP response times Regular consideration of YAS incident reporting by QPSC and GB to understand the frequency targets is not secured and sustained, there is a risk that the quality and safety of care for some patients could be and severity of incidents associated with ambulance response. adversely affected.

RR 18/04: If the health and care system in Barnsley is not able to commission and deliver out of hospital urgent Activity levels are monitored on an ongoing basis through contract/performance management care services which have sufficient capacity and are effective in supporting patients in the community to avoid the arrangements. need for hospital attendance or non-elective admission there is a risk that non- elective activity will exceed NEL activity has been reviewed and work commenced to identify opportunities to support more planned levels potentially leading to (a) failure to achieve NHS Constitution targets (with associated reputational patients at home to avoid the need for emergency hospital admission. damage, and (b) contractual over performance resulting in financial pressure for the CCG NHS Barnsley CCG Governing Body Assurance Framework 2018-19

PRIORITY AREA 2: PRIMARY CARE Delivery supports these CCG objectives: PRINCIPAL THREATS TO DELIVERY Delivery of 'GP Forward View' and 'Forward View - Next Steps for Primary Highest quality governance There is a risk to the delivery of Primary Care priorities if the following threat(s) are Care' to: High quality health care  not successfully managed and mitigated by the CCG: a) deliver investment into Primary Care Care closer to home  • Engagement with primary care workforce b) improve Infrastructure Safe & sustainable local services  • Workforce and capacity shortage, recruitment and retention c) ensure recruitment/retention/development of workforce • Under development of opportunities of primary care at scale, including new Strong partnerships, effective use of £  d) Address workload issues using 10 high impact actions models of care e) Improve access particularly during the working week, more bookable • Not having quality monitoring arrangements embedded in practice Links to SYB STP MOU appointments at evening and weekends. • Inadequate investment in primary care 8.3. General Practice and primary care f) Every practice implements at least 2 of the high impact 'time to care' • Independent contractor status of General Practice. actions g) Deliver delegated Primary Care functions Committee Providing Assurance PCCC Executive Lead JH Clinical Lead NB Risk rating Likelihood Consequence Total 201 Date reviewed Feb-19 Initial 3 4 12 Rationale: Likelihood has been scored at 3 (possible) but will be 0.510 Current 3 4 12 kept under review. Consequence has been scored at 4 (major) Appetite 3 4 12 00 because there is a risk of significant variations in quality of and A M J J A S A O N D J F M access to care for patients if the priorities are not delivered. Approach TOLERATE

Key controls to mitigate threat: Sources of assurance Rec'd? 1. Incentivise practices to complete HEE Workforce Analysis tool All practices have now completed the HEE tool to allow the CCG to create a workforce Ongoing baseline. The workforce data was been presented to September 17 BEST meeting supported by Mark Purvis from HEE. This continues to be incentivised through the 2018/19 PDA.

2. Additional investment above core contracts through PDA delivers £4.2 to Barnsley Ongoing monitoring of PDA (contractual / QIPP aspects via FPC, outcomes via PCCC). Ongoing practices to improve sustainability and attract workforce to the Barnsley area

3. Optimum use of BEST sessions BEST programme and Programme co-ordination Ongoing

4. Development of locality working 6 localities established. A GP Clinical Lead and PM lead allocated to each locality. A series of Ongoing locality meetings held August, October and December 2017. Large locality event on 14 February 2018 to develop locality based plans and identify areas for development. Further locality event in Dec 2018 to further develop locality working and plans for 2019-2020.

5. BHF - Existence of strong federation supports Primary Care at Scale BHF contract monitoring, oversight by PCCC Ongoing

6. Practices increasingly engaging with voluntary and social care providers (e.g. My Best Monitored through PDA Contract monitoring of the My Best Life Service Ongoing Life) 7. Programme Management Approach of GPFV & Forward View Next steps Reported to GB in November 2017. GPFV assurance returns submitted bi-monthly to NHSE. Ongoing Further update to PCCC in June 2018 to report on GPFV progress from 2017/18. GPFV update submitted to PCCC in June 2018 as planned..

8. Care Navigation roll out - First Port of Call Plus BHF contract monitoring, oversight by PCCC, also included in GPFV assurance returns Ongoing

9. Engagement and consultation with Primary Care (Membership Council, Practice Managers NHS England 360 Stakeholder Survey results reported to Governing Body. 16/17 results Ongoing etc) reported to Membership Council Spring 2017. SY Workforce Group in place; STP has a workforce chapter developed in collaboration with BCCG is represented on the group. Ongoing CCG's, HEE, providers and Universities. Gaps in assurance Positive assurances received None identified Report on implementation of the GP Forward View being presented at PCCC June 2018. Await any further recommendations. Report accepted at PCCC with recognition of work undertaken and progress.

Gaps in control Actions being taken to address gaps in control / assurance RR 14/10:If the Barnsley area is not able to attract & retain a suitable & sufficient Primary Care clinical BCCG has a baseline of the Primary Care workforce following the 30 June 2017 submission for workforce there is a risk that: baseline data via the HEE Tool. Data presented at BEST event in September. The CCG and BHF (a) Some practices may not be viable, will then work with member practices to address any gaps/ variance and to develop a workforce (b) Take up of PDA or other initiatives could be inconsistent plan going forward. Actively exploring option of international recruitment with 16 practices (c) The people of Barnsley will receive poorer quality healthcare services expressing an interest. BHF looking to host a number of these GPs if the initiative goes forward. (d) Patients services could be further away from their home. Practices encouraged to look at skill mix with innovative recruitment.

RR 18/03: If there is not an adequate and rapid response from Barnsley Healthcare Federation to the areas Barnsley Healthcare Federation have appointed a new Clinical Director/ Chair and have had a identified by CQC in their recent inspections there is a risk that the BHF does not meet contractual and service Senior Management restructure. A detailed action plan to address all areas of concern highlighted requirements potentially leading to: within the CQC report has been produced and is being monitored through both PC contracting and (a) poor quality or unsafe services for the people of Barnsley; Quality Surveillance at the CCG. Regular updates and evidence on progress is being provided by (b) reputational /brand damage; the Chief Executive which is offering assurance on progress. (c) Strategic implications for the CCG in terms of delivery of the out of hospital strategy and primary care at Resilience funding through NHSE has been sourced and provided and the Federation GP scale. practices are signed up to the releasing time for care programme. (d) Continuity of service CQC re-inspection of BHF and iHeart services has been performed (Nov18) and awaiting the (e) Risk of patients and practices not accessing services provided by BHF outcome report. NHS Barnsley CCG Governing Body Assurance Framework 2018-19

PRIORITY AREA 3: CANCER Delivery supports these CCG objectives: PRINCIPAL THREATS TO DELIVERY • Reduced Inequalities especially those diagnosed at emergency admission Highest quality governance  1. Risk to delivery of the 62 day wait NHS Constitution standard if clear • Better cancer survival to be diagnosed at stage 1 or 2 pathways from cancer diagnosis to treatment are not developed and shared by • Implement rapid assessment and diagnosis pathways for lung, prostate & High quality health care  partner 2. Risk to colorectal cancers delivery of early diagnosis if: • Roll out of FIT in bowel screening Care closer to home  (a) the CCG does not effectively promote to the people of Barnsley the • Access to the most modern cancer treatment national screening programme Safe & sustainable local services  • Improve Patient Experience along pathways and LWBAC (b) Practices do not consistently apply NICE guidance for cancer diagnosis • Deliver Survivorship Program (LWABC) including recovery package and referral. Strong partnerships, effective use of £  • Stratified follow up pathways breast, prostate and urology rolled out 3. Risk that, if the CCG does not have a clear local strategy for delivering • Commissioning for Value adopted if appropriate Links to SYB STP MOU cancer priorities and performance, the CCG will not secure full access to • Implement new cancer waiting times system & begin data collection cancer transformation funding which would impact negatively on securing • Achieve 8 waiting time standards including the 62 day referral-to-treatment 8.6. Cancer improvements to services for people Living With and Beyond Cancer cancer standard. The ‘10 high impact actions’ implemented in Trust. Cancer (LWABC) and improving 62 day target and 8 WT standards . transformation funding will be linked to delivery of the 62 day cancer standard. 4. Risk that the incidence of cancer is not reduced, and of poorer outcomes post treatment, if steps to promote healthy lifestyles for Barnsley people are not successful.

Committee providing assurance FPC Executive Lead JB Clinical Lead Dr H Kadarsha Risk rating Likelihood Consequence Total Date reviewed Feb-19 Initial 3 4 12 20 RATIONALE: Likelihood has been scored at 3 (possible) but Current 3 4 12 10 will be kept under review. Consequence has been scored at 4 (major) because there is a risk of significant variations in Appetite 3 4 12 0 quality of and access to care for patients if the priorities are not Approach A M J J A S O N D J F M Tolerate delivered. A number of areas may not deliver due to workforce capacity and funding affected if performance is not met.

Key controls to mitigate threat: Sources of assurance Rec'd? Overall arrangements Development of delivery programme and bids to deliver prevention, early diagnosis, and Reporting arrangements for delivery of cancer priorities - Barnsley Cancer Steering Group Ongoing . Full LWABC. CCG will continue to secure cancer transformation funding for prevention, early Chaired by Clinical Lead and responsible for providing assurance to SSDG. Assurance update to implementation of diagnosis, and LWABC Bid funding agreed. Project Manager now in place for LWABC and the Governing Body submitted to November meeting was approved. CCG cancer action plan LWABC plan by April 2020 action plan developed. updated and triangulated with Alliance plan. Assurance ongoing via CCG Finance & Performance group and through Cancer Alliance Board monthly reporting arrangements. Vague symptoms project starting in february and agreed bid conditions with provider. Assurance for Vague Symptoms Cancer Transformation Funding bid submitted and approved. Stakeholder Apr-19 Social movement project implementation overseen by CCG at place level and also via discussions clarified direction of delivery. Access to be through radiology £70k funding has attandance at Cancer Alliance Assurance group. Improving early diagnosis and screening been received to support this work. proposal being submitted to Governing body in January that outlines a number of options that will contribute to improving delivery of programme. Reporting arrangements for delivery of cancer priorities - Barnsley Cancer Steering Group Chaired by Clinical Lead and responsible for providing assurance to SSDG. Assurance update to Governing Body submitted to November meeting was approved. CCG cancer action plan updated and triangulated with Alliance plan. Assurance ongoing via CCG Finance & Performance group and through Cancer Alliance Board monthly reporting arrangements. Vague symptoms project starting in february and agreed bid conditions with provider. Assurance for Social movement project implementation overseen by CCG at place level and also via attandance at Cancer Alliance Assurance group. Improving early diagnosis and screening proposal being submitted to Governing body in January that outlines a number of options that will contribute to improving delivery of programme. Social Movement commissioned that will focus on improving screening uptake in those areas Apr-19 with low uptake currently. 1 Year Contract. Be Cancer SAFE brand launched at January Best Event. Launch completed. Project ongoing and targeting specific communities and localities where screening is low or late stage diagnosis is high. Targeting specific groups during Q3 period . Being limited by ability of screening programme, and particularly the bowel screening programme, to meet demand. Exceeded expected target for numbers of cancer champions recruited .

1. 62 Day wait target Recovery plans (if necessary) in place with local providers BCCG was compliant against the headline 62 day target for Q4 86.3 (85% target) validated Ongoing. performance. Year end 2017/18 was compliant. Q1 2018/19 performance was not compliant as Aiming performance was 84.3%. It is expected that Q2 will not be compliant as there has been a high compliance by number of Urology breaches due to problems in both diagnostics in Barnsley and treatment in Q4 Sheffield that has impacted on performance through the quarter. Actions are in place to alleviate at both ends of the pathway and across the Alliance. This includes implementing new timed pathways and straight to Test pathways by April 2019 for prostate, Lower GI and colorectal. The GP referral form is being improved to reduce inapproriate referrals; the introduction of the new lower GI pathway in January will support the recovery as the introduction of the new FIT test will reduce demand on colonoscopy and endoscopy by reducing inappropriate referalls and release capacity that can be allocated to the 2WW pathway.

Sign off and mobilise inter Trust transfer policy Acute Trust and CCG agreed the Inter Provider Transfer Policy. Policy included in contract. Ongoing - April 2019 Routine monitoring of performance against 62 day wait NHS Constitution target. Review of CCG meets regularly with Trust to monitor performance and attends Trust bi-monthly Ongoing Gastro and Head and Neck pathways ongoing in the Alliance to improve 62 day performance. performance and improvement group to gain assurance that recovery plans on track. CCG Locally reviewed Lung Pathway launched. Urology Pathway now being reviewed locally. Bid attends Cancer Alliance Operational Group that monitors performance and improvement. was successful to the Alliance against the Prostate pathway for increased MRI capacity to allow pre biopsy MRI scans, significantly improving the service. 6 Month funding approved. Trust attends Monthly Alliance intelligence /operational group to support PTL movement and unblock shared pathways blockages. 2. Early diagnosis Comms / Public Health Strategy to reach affected communities Evidence of effective engagement (reduced screening inequalities, reduced late / A&E diagnosis, Ongoing Primary Care Audit of late / A&E diagnosed cancers). Barnsley Local Action Plan ongoing. Social Movement implemented to raise awarenessof early cancer symptoms and the importance of early diagnosis. CCG communication team targeting communties via Be Cancer Safe campaigns. FIT Bowel Screening to be rolled out. Business case to develop a Primary Care Symptomatic Roll out of FIT Bowel Screening being delivered by the Screening Program to increase take up of Apr-19 FIT test accepted by the Alliance. screening. Timeline for roll out of symptomatic FIT is by March 2019. Clinical Forum has reviewed and accepted pathway. Primary care engagement will take place during October- January 2019. Pathology model been approved by CCG SM August 2018. Business case for lower GI pathway submitted to governing body in September. Communication and mobilisation plan in place. Routine monitoring of performance in respect of early cancer diagnosis Via Integrated Performance Report to FPC and by exception to GB, and via NHSE IAF clinical Ongoing priorities published on MyNHS. Barnsley screening meeting arranged for October to ensure targeting areas of low screening and late presentation at ED. A number of indicators being prepared to be included in 2019-20 PDA to ensure early diagnosis improved.

3. LWABC Drive LWABC in Barnsley to deliver Survivorship program. Funding agreed. Project Manager Delivery of LWABC Delivery Plan monitored by CAT team and reported via FPC. The Apr-20 in Place. First tasks are to build patient engagement, map support services and create job programme reports 6 weekly to cancer steering group on progress. A number of indicators being descriptions for additional roles. Being supported through new Cancer Alliance network group. prepared to be included in 2019-20 PDA to ensure LWABC and shared care improved in Primary Risk stratified pathways being implemented in partnership with Trust and Primary care. New care. Macmillan GP appointed to support primary care with cancer care reviews and transistions stratified pathways will be reviewed by clinical forum and engagement with Primary care via between secondary and primary care . membership council and locality structure to ensure smooth delivery.

Gaps in assurance Positive assurances received Cancer services are have detailed and copious volumes of data from a variety of areas including Dr Foster, PHE Breaches are being reviewed across the Alliance. 62 day target in October for BHNFT was and NHSE, as well as local BI and Provider data in Open Exeter. Whilst we do not believe that additional 93.5% against (85% target) hospital have a recovery plan is in place and task and finish information will be required to identify compliance additional information will be brought to bear as appropriate groups to ensure delivery of straight to test and new timed pathways. CCG working with and necessary to interrogate specific areas. hospital to address performance and Cancer Alliance. Q2 BHNFT position 87.2%. Remains a risk that Q3 target not met due to Urology capacity issues at STH and breaches via other pathways. CCG October 62 day target was 86.7% .

Gaps in control Actions being taken to address gaps in control / assurance

NHS Barnsley CCG Governing Body Assurance Framework 2018-19

PRIORITY AREA 4: MENTAL HEALTH Delivery supports these CCG objectives: PRINCIPAL THREATS TO DELIVERY • Increase the number of children and young people receiving evidence-based Highest quality governance If the CCG and its partners are unable to manage and mitigate the potential treatment to improve their emotional health and wellbeing barriers to improving mental health services - lack of workforce capacity, limited • By Q4 2018/19 to improve access to psychological therapies (IAPT) to 19% of High quality health care  financial resources, and legacy 'backlogs' - there is a risk that the CCG's ambitions the local prevalent population and to 25% by 2021. for these services will not be achieved and that delivery of the five year forward Care closer to home  • Improve the IAPT moving to recovery rate to an ambitious targets of 60% view for Mental Health will not be achieved. acknowledging the national target is 50% Safe & sustainable local services  • Improve pre and post mental health crisis care support • Crisis care: extend the Liaison Mental Health service in A&E to include children Strong partnerships, effective use of £  and young people • Reduce the numbers of suicides in Barnsley to the national average as a Links to SYB STP MOU minimum • Continue to Improve perinatal mental health 8.5. Mental Health • Develop a South Yorkshire and Bassetlaw sustainable regional ASD /ADHD diagnosis and treatment service for adults • Meet the Mental Health Investment Standard (MHIS) • Improve access to healthcare and deliver annual physical health checks for the population

Committee providing assurance FPC & QPSC Executive Lead PO Clinical Lead Dr M Smith Risk rating Likelihood Consequence Total Date reviewed Feb-19 20 Initial 4 3 12 Rationale: Likelihood set as 4 (likely) because delivering the Current 4 3 12 10 recommendations of the five year forward view of mental health is Appetite 4 3 12 0 dependent upon additional financial resources and a fully trained, accessible workforce. IAPT services have been successfully Approach Tolerate A M J J A S O N D J F M tendered and the new service will commence from 1 August 2018 which will deliver a more ambitious programme. In order to increase access to Mental Health services, the capacity of the mental health services needs to be increased, primarily by increasing the workforce. There are limited, accredited training courses available locally which limits the ability of the service to grow. The South Yorkshire and Bassetlaw ICS MH/LD Board have estsablished a workforce strategy group for South Yorkshire collaborating closely with Health Education England Consequence set as 3 (moderate) because the mitigated actions outlined will enable mental health services to provide, good quality outcomes and be in a state of readiness to effectively utilise the additional resources as and when they become available. NB Rising clinical need is escalated and responded to.

Key controls to mitigate threat: Sources of assurance Rec'd? Recurrent investment to implement the local transformation plan (improving children and young Quarterly Assurance reports / feedback to NHS England, October 2018 Overview & Scrutiny Ongoing peoples emotional wellbeing). Committee; monitored by C&YPT(Children and Young Peoples Trust) ECG (see note 2). ECG minutes to F&P Committee. Perinatal Mental Health - continue to implement the specialist perinatal health team and to fund the ICS Reporting Framework. Action notes to JCU for info. Quarterly updates to Governing Body Ongoing specialist mental health midwife post at BHNFT. Service provider developing robust workforce plans in conjunction with Health Education England MHFYFV Dashboard, monitored via Adult Joint Commissioning Group (see note 1) Ongoing National Workforce Strategy. Increase the commissioning of ASD / ADHD services to 50% of the local evidence based ICS Reporting Framework. Successful Paper to May Governing Body re increased resource awaiting Ongoing prevalence. To develop a south Yorkshire and Bassetlaw regional ASD / ADHD diagnostic and service mobilisation treatment service. Progress monitoring by AJC Group Continue to promote the local social prescribing service Monitored via Adult Joint Commissioning Group (see note 1) Ongoing IAPT: SWYPFT IAPT action plan (re: IST review) continues to be implemented and milestones Oversight by F&PC, reporting into Governing Body. Aug-18 achieved. Successful IAPT re tender with a new ambitious service specification for a new service to be in place on 1st August 2018. Barnsley will bid for monies for 24 hour liaison compliance in Wave 2 funding round (during 2018) as Monitored via Adult Joint Commissioning Group (see note 1) Ongoing advised by NHS England, Crisis Care Concordat Group keeps multiagency focus.

Note (1) - Adult Joint Commissioning group minutes go to F&PC for information. It reports into the Health & Wellbeing Board which is attended by the CCG CO and Chair and minutes go to GB. Note (2) - the Childrens & Young People's Trust ECG minutes go to F&PC for information. It reports via TEG to H&WB which is attended by the CCG Chair and CO and minutes go to GB. Specific issues may be raised with GB via quarterly Children's Services updates.

Gaps in assurance Positive assurances received Local Transformation Plan refreshed annual (October) and quality assurance reports to NHSE.

Gaps in control Actions being taken to address gaps in control / assurance

NHS Barnsley CCG Governing Body Assurance Framework 2018-19

PRIORITY AREA 5: INTEGRATED CARE SYSTEM (ICS) Delivery supports these CCG objectives: PRINCIPAL THREATS TO DELIVERY

System Level: There is a shared view that in order to transform services to the Highest quality governance  The effectiveness of the ICS will be undermined if any of the member parties is degree required to achieve excellent and sustainable services in the future, we High quality health care  unable to sign up to the system MOU, the direction of travel, and the need a single shared vision and plan in each Place and across South Care closer to home  mechanisms for collective decision making. Yorkshire and Bassetlaw. Partners from across health and social care in each Safe & sustainable local services  Place have come together to develop a single shared vision and plan as part of an Integrated Care System.

CCG contributions to system wide working & enabling work streams: Strong partnerships, effective use of £  Leadership and programme support

Links to SYB STP MOU

8.7 Workforce; 8.8 Digital & IT; 8.9. Development of Integrated Care in Place & System; 8.10. Commissioning reform; 8.11. Sustainable Hospital Services Review

Committee Providing Assurance ICS CPB Executive Lead LS Clinical Lead NB JCC of CCGs Likelihood Consequence Risk rating Total 10201 Date reviewed Feb-19 Initial 3 3 9 Rationale: Likelihood has been scored at 3 (possible) because 0.5105 Current 3 3 9 individual organisation will be required to deliver on their Appetite 3 4 12 00 statutory duties and may prioritise these over partnership commitments. Consequence has been scored at 3 (moderate) Approach A M J J A S A O N D J F M Tolerate because whilst we would not be able to harness the full benefits of integrated health and care the commissioning and provision of health and care services for Barnsley people would continue.

Key controls to mitigate threat: Sources of assurance Rec'd? Collaborative Partnership Board (CPB) provides strategic direction and oversight of the ICS, Minutes of both CPB and JCCC of CCGs are taken through the Governing Body Ongoing while the Joint Commissioning Committee of CCGs facilitates collective commissioning decisions over defined areas. ICS Memorandum of Understanding signed by all parties in place outlining sign up to direction ICS MOU signed off by Governing Body and all Parties to the ACS for 17/18. MOU for 2018/19 Oct-18 of travel in system and in place, recognising journey to local Integrated care partnerships between NHSE/I and ICS agreed and signed off by 1 October 2018. ICS go Live October 2018.Integration agreements between place and system developed(from October 2018 ).

Clear governance arrangements in place to enable to ICS to make both collective Minutes of both CPB and JCCC of CCGs are taken through the Governing Body. Governing Dec-18 commissioning and provider decisions through the Joint Committee of Clinical Commissioning Body receives and signs up to ICS governance arrangements for Level 3 ICS from April 19 Groups (JCCC) and Providers Committee in Common (CiC) The ICS has a clear management structure with sufficient capacity and resources to take Agreement of 2018/19 ICS nationally allocated transformation funding and partner contributions Jul-18 forward its transformation programmes on behalf of the system. and sign off of 2018/19 ICS budget. Revised ICS Executive Management Team in place.

Delegation of decision making for 2018/19 ICS programmes of work delegated to JCCC Governing Body attendance at JCCC workshops running between June and Sept 18 which will Sep-18 lead to the development of a revised MOU, workplan and terms of reference for JCCC.

Collective approach to decision making in relation to the Hospital Services Review in place Hospital Services Review received both by ICS Collaborative Partnership Board and by Barnsley Jun-18 within the Barnsley partnership and across the ICS. CCG Governing Body. Governing Body agrees to the publication of the Straxtegic Outline Case October 2018.

Gaps in assurance Positive assurances received

Gaps in control Actions being taken to address gaps in control / assurance NHS Barnsley CCG Governing Body Assurance Framework 2018-19

PRIORITY AREA 5.2: INTEGRATED CARE AT PLACE LEVEL Delivery supports these CCG objectives: PRINCIPAL THREATS TO DELIVERY

• Development of Integrated care arrangements in Barnsley bringing Barnsley Highest quality governance  • Local public and political support because of a misunderstanding of the service providers and commissioners together to plan and deliver care. High quality health care  ambition of integrated health and care, partly because of the term Care closer to home  “accountable care”, which has previously been used in the NHS, is associated with an American model of privatised health and care Safe & sustainable local services  • Planned consultation on the NHS contract for integrated care resulting in Strong partnerships, effective use of £  technical barriers • The new integrated support and assurance process (ISAP) impacts on the process for securing integrated services and the overall scope of ambition. Links to SYB STP MOU • Maturity of the local provider partnership, financial and operating pressures in 8.7 Workforce; 8.8 Digital & IT; the system affect their ability to implement transformational change 8.9. Development of Accountable Care in Place & System; 8.10. Commissioning reform; • There is also a specific risk in relation to the GP Federation following on from 8.11. Sustainable Hospital Services Review the recent CQC inspection, which may impact on their capacity to invest time and resource in development of integrated service solutions

Committee Providing Assurance TBC Executive Lead JB Clinical Lead NB Risk rating Likelihood Consequence Total 10201 Date reviewed Feb-19 Initial 3 3 9 Rationale: 0.5105 Current 3 3 9 • Likelihood of national media interest Appetite 3 4 12 00 • Likely challenge to the procurement from incumbent provider, A M J J A S A O N D J F M pro-NHS groups Approach Tolerate • Unforeseen challenges could reasonably be expected to pressurise the budget • Potential for challenge or criticism from NHS national body e.g. NHS Improvement because of potential impact on provider sustainability

Key controls to mitigate threat: Sources of assurance Rec'd? Oversight of process by CCG Governing Body Routine reporting of progress into every meeting of the Governing Body Ongoing Engagement with Membership Council to share and obtain support for the strategic direction Membership Council agreed to strategic direction at the meeting held on 3 July 2018 completed

Appropriate supporting governance arrangements being developed including use of a specially Governing Body approved Governance arrangements at GB held in June 2018. GB approved Ongoing constituted Committee to make key decisions to manage conflicts of interest establishment of Integrated Care Procurement Committee to oversee procurement process and governance. Independent legal advisors appointed Record of legal advice received and feedback from ISAP Early Engagement Panel Ongoing Formal market and public engagement Detailed plans in place with appropriate legal advice. Information gathering and financial due diligence Cost information from current providers and financial modelling. Staff engagement Briefings, Q&A and feedback. Ongoing

Engagement with national bodies Integrated Support and Assurance Process and engagement with New Business Models team

Experience gained through alliance contracting Oversight by Alliance Management Board Gaps in assurance Positive assurances received

Gaps in control Actions being taken to address gaps in control / assurance 18/02; If the CCG and BMBC do not develop a collaborative commissioning approach underpinned by shared • Escalation of CCG concerns to BMBC senior management values there is a risk that BMBC commissioned services will not meet the requirements and aspirations of the • Escalation via SSDG and health & wellbeing board CCG for the people of Barnsley leading to increased health inequalities and poorer health outcomes.

SCORE: A M J J A S O N D J F M Likelihood 3 3 3 3 3 3 3 3 3 3 3 Consequence 3 3 3 3 3 3 3 3 3 3 3 Risk rating 9 9 9 9 9 9 9 9 9 9 9 Tolerance 12 12 12 12 12 12 12 12 12 12 12 NHS Barnsley CCG Governing Body Assurance Framework 2018-19

PRIORITY AREA 6: EFFICIENCY PLANS Delivery supports these CCG objectives: PRINCIPAL THREATS TO DELIVERY • Free up hospital beds Highest quality governance  If the CCG does not develop a robust QIPP plan supported by effective • Best value across all CCG expenditure High quality health care  delivery & monitoring arrangements, there is a risk that the required QIPP • Reduce avoidable demand Care closer to home  savings will not be achieved, resulting in a failure to achieve statutory financial • Reduce unwarranted variation in clinical quality and efficiency duties and non compliance with NHSE business rules. Safe & sustainable local services  • Cut the costs of corporate services and administration • Financial accountability and discipline for all trusts and CCGs Strong partnerships, effective use of £ 

Links to SYB STP MOU 8.2. Managing demand and demand management 8.1. Efficiency programmes

Committee Providing Assurance FPC Executive Lead RN Clinical Lead Various Likelihood Consequence Risk rating Total 20 Date reviewed Feb-19 Initial 3 4 12 Rationale: Likelihood currently judged to be 'possible' but will 10 Current 3 4 12 be kept under review. Consequence judged to be 'major' in Appetite 3 4 12 0 light of potential impact on statutory duties, performance A M J J A S O N D J F M ratings, and organisational reputation. Approach Tolerate

Key controls to mitigate threat: Sources of assurance Rec'd? PMO continues to be in place to maintain operational oversight of QIPP Projects NHS England commissioned a Deloitte review of CCGs QIPP programme to assess governance, Apr-18 planning, modelling and ability to deliver. The CCG achieved a 'Green' rating across all areas of governing. 6 of the 10 schemes assessed were rated overall as 'Green' with only minor recommendations on the remaining 4 with an 'Amber' rating.

F&PC scrutinised proposed monitoring on an ongoing basis & made recommendations to GB Ongoing

Structured project management arrangements in place to support delivery Progress reports to QIPP Delivery Group Ongoing QIPP Delivery Group continues to be in place to maintain oversight of the QIPP programme

Clinical Forum provides clinical oversight of projects Monthly reports to Finance & Performance Committee and Governing Body Ongoing Continued development and review of the CCG's Demand Management Programme (high Continual improvements and assessment of modelling of activity related schemes Ongoing value scheme)

Ongoing engagement with primary care and secondary care to support delivery of activity related Ongoing schemes

Continued development and review of the CCG's Medicines Optimisation QIPP 2018/19 to Clinical Pharmacists and Medicines management team continue to engage with Primary care Ongoing deliver prescribing efficiencies (high value scheme) and a validation of all efficiencies reported as delivered is undertaken within the Medicines Management team. Forecasts across most planned schemes are now forecast to deliver against planned levels with Ongoing Prescribing and Demand management being above plan. Schemes are currently forecast to deliver above planned with no significnat risk to non delivery Ongoing as at Month 8.

Gaps in assurance Positive assurances received The Deloitte review of the CCGs QIPP programme assesses governance, planning, modelling and ability to deliver. The CCG achieved a 'Green' rating across all areas of governing. 6 of the 10 schemes assessed were rated overall as 'Green' with only minor recommendations on the remaining 4 with an 'Amber' rating. The CCG continues to assume delivery of all financial duties and targets with a review of budget being undertaken to mitigate the shortfall in delivery of planned schemes.The CCG continues to achieve delivery of the programmes with no significant risks to non delivery and planned schemes continue to deliver against plan or above planned levels.

Gaps in control Actions being taken to address gaps in control / assurance NHS Barnsley CCG Governing Body Assurance Framework 2018-19

PRIORITY AREA 7: TRANSFORMING CARE FOR PEOPLE WITH Delivery supports these CCG objectives: PRINCIPAL THREATS TO DELIVERY LEARNING DISABILITIES AND / OR AUTISTIC SPECTRUM CONDITIONS Transform the treatment, care and support available to people of all ages with a Highest quality governance If the CCG and its partners are unable to provide focussed case management and learning disability, autism or both so that they can lead longer, happier, healthier High quality health care  wrap around services there is a risk that: lives in homes not hospitals by: Care closer to home  • People with a learning disability or autistic spectrum conditions will enter • Reducing inappropriate hospitalisation hospital inappropriately Safe & sustainable local services  • Improve access to healthcare and deliver annual physical health checks (eg • There will be difficultly discharging current patients cervical screening) Strong partnerships, effective use of £  • Potential prohibitively high cost of meeting needs • Invest in community teams Links to SYB STP MOU • Inability of current provider market to meet needs • Ensure all children with learning disabilities, autism or both receive Community • Difficulty in ensuring that the quality of care is high. Care, Education and Treatment Review (CETR) if appropriate • Ensure all adults with learning disabilities, autism or both receive Community Care and Treatment Review (CTR) as appropriate

Committee providing assurance FPC & QPSC Executive Lead PO / AR Dr M Smith Risk rating Likelihood Consequence Total Date reviewed Feb-19 20 Initial 4 3 12 Rationale: likelihood assessed as 4 'likely' because the local Current 4 3 12 10 market is not sufficiently developed to enable all aspects of the Appetite 4 3 12 0 transforming care plan to be delivered. Consequence judged to be moderate (3) because in terms of direct impact higher levels of Approach Tolerate A M J J A S O N D J F M care are viewed as 'safer' but longer term promoting independence and quality of life is compromised, hence this focus by NHSE. Key controls to mitigate threat: Rec'd? Role has been agreed for CETR Transforming Care Clinical Lead within BCCG - funding agreed 10 JCU reports to Finance & Performance Committee with any Quality issues escalated to Quality & May-18 May 2018 Governing Body Committee Patient Safety Committee. Joint Commissioner Unit Lead Practitioner in role. Ongoing Strong partnership arrangements with Calderdale, Wakefield and Kirklees (Transforming Care Ongoing Partners CKWB) which will continue despite realignment of reporting footprint (Barnsley now to be reported with South Yorkshire & Bassetlaw)

Development of LD Strategic Health & Social Care Improvement Group to maintain oversight of key Ongoing legislation inc LEDER learning and transforming care

Gaps in assurance Positive assurances received

Gaps in control Actions being taken to address gaps in control / assurance

SCORE: A M J J A S O N D J F M Likelihood 4 4 4 4 4 4 4 4 4 4 4 Consequence 3 3 3 3 3 3 3 3 3 3 3 Risk rating 12 12 12 12 12 12 12 12 12 12 12 Tolerance 12 12 12 12 12 12 12 12 12 12 12 NHS Barnsley CCG Governing Body Assurance Framework 2018-19

PRIORITY AREA 8: MATERNITY Delivery supports these CCG objectives: PRINCIPAL THREATS TO DELIVERY Continue to implement the Saving Babies' Lives care bundle to further reduce still Highest quality governance 1/ Dependent upon implementing the outcomes of the Hospital Services Review birth, neonatal deaths, maternal deaths and brain injuries. High quality health care  2/ Lack of investment in additional staff resources to enable 'continuity of carer' Implement the SYB LMS (Local maternity service) and: Care closer to home  3/ Dependent on ICS maternity services therefore failure of the ICS providers to - Deliver the continuity of carer integrate working practices fully to implement the LMS Safe & sustainable local services  - Improve maternity safety, choice and personalisation - Liaise closely with the local 4/ Lack of staff rotation between hospital and community based services may MVP (Maternity Voice Partnership) to ensure local women are able to influence and Strong partnerships, effective use of £  reduce the likihood of fully delivering continuity of carer shape the delivery of future services Links to SYB STP MOU 8.5.

Committees providing assurance FPC & QPSC Executive Lead PO Clinical Lead Dr M Smith Risk rating Likelihood Consequence Total Date reviewed Feb-19 20 Initial 4 3 12 Rationale: Likely primarily due to the staffing issue inherent in Current 4 3 12 10 delivering continuity of carer and there are no additional funding Appetite 3 4 12 0 streams available. Consequence is moderate because this is primarily a local issue Approach Tolerate A M J J A S O N D J F M which will potentially result in the late delivery of the key objective within the better birth recommendations of delivering the 'continuity of carer.' Key controls to mitigate threat: Sources of assurance Rec'd? Revisit the BHNFT position re Better Births in Summer 2018 at the Clinical Quality Board (DQB) NHSE LMS assurance process Ongoing meeting CQB for each provider reports to Q&PSC Yorkshire and Humber maternity dashboard (enables benchmark) Ongoing Governing Body oversight Reporting into QPSC, minutes to Governing Body with specific issues escalated by the Quality Ongoing Highlights Report

Gaps in assurance Positive assurances received In 2017/18 BHNFT benchmarked well positive update to June Governing Body Gaps in control Actions being taken to address gaps in control / assurance

SCORE: A M J J A S O N D J F M Likelihood 4 4 4 4 4 4 4 4 4 4 4 Consequence 3 3 3 3 3 3 3 3 3 3 3 Risk rating 12 12 12 12 12 12 12 12 12 12 12 Tolerance 12 12 12 12 12 12 12 12 12 12 12 12 NHS Barnsley CCG Governing Body Assurance Framework 2018-19

PRIORITY AREA 9: COMPLIANCE WITH STATUTORY AND Delivery supports these CCG objectives: PRINCIPAL THREATS TO DELIVERY REGULATORY REQUIREMENTS • Delivery of all the CCG's statutory responsibilities Highest quality governance  If the CCG fails to deliver its statutory duties, due to weaknesses in its • Deliver statutory financial duties & VFM High quality health care  corporate governance and control arrangements, it will result in legal, financial, • Improve quality of primary & secondary services (inc reductions in HCAI, and / or reputational risks to the CCG and its employees. ensuring providers implement learning from deaths, and reductions in Care closer to home  medication errors); Safe & sustainable local services  • Involve patients and public; Strong partnerships, effective use of £  • Promote Innovation; • Promote education, research, and training; Links to SYB STP MOU • Meet requirements of the Equality Act; • Comply with mandatory guidance for managing conflicts of interest Section 7 'Governance, Accountability, & Assurance' • Adhere to good governance standards.

Committee Providing Assurance Various Executive Lead RW Lay / Clinical Leads MG,MT,NBa, NBe, CM Likelihood Consequence Risk rating Total 201 Date reviewed Feb-19 Initial 2 5 10 Rationale: Likelihood is 'unlikely' as arrangements now well 100.5 Current 2 5 10 established. Consequence is catastrophic due to very Appetite 3 4 12 00 significant quality, financial & reputational impact of failure. A M J J A S A O N D J F M Approach Tolerate Key controls to mitigate threat: Sources of assurance Rec'd? Overall: Constitution, Corporate Manual, Prime Financial Policies, and suite of corporate Audit Committee provides oversight, supported by internal & external audit reports & opinions, Ongoing policies LCFS work etc Governing Body & Committee Structure underpinned by clear terms of ref and work plans GB members sit on Committees. All Committee minutes taken to GB and significant issues Ongoing are escalated. Committees produce annual assurance reports for the GB. Management Structure - responsibilities clearly allocated to teams and individuals Management action monitored by regular senior management team meetings. SMT decisions Ongoing with a financial consequence reported through F&PC. Finance: Budgetary control, contract monitoring & QIPP monitoring arrangements. Scheme of Financial Plan signed off by GB each year. Monthly finance report to FPC and GB; internal & Ongoing Delegation requires SMT approval for spending commitments <£100k and GB approval over external audit reviews and opinions; GB formally adopt annual report & accounts. this level.. Performance monitoring arrangements Integrated Performance Reports to FPC provides assurance across all NHS Constitution Ongoing pledges. Summary reports to GB. Quality: comprehensive and well established arrangements in place to monitor, assure and Reporting of all relevant information to the Quality & Patient Safety Committee, with assurance Ongoing improve the quality of all commissioned services including Clinical Quality Boards, Quality to Governing Body through Quality Highlights reports and sharing of minutes. Assurance visits, benchmarking, Primary care Quality Improvement Tool, outcomes from CQC inspections in both primary and secondary care, review of serious incidents and never events, complaints & compliments, review of FFT, nurse leads for safeguarding adults & children who represent the CCG on the local safeguarding boards. Patient & Public Involvement: strategy in place, well established Patient Council and OPEN Oversight by Equality & Engagement Committee. Assurance to Governing Body via minutes Ongoing network, close working with healthwatch, co-ordination of activity with partners, appropriate and monthly PPI Summary reports. In 2017/18 Internal Audit Reviews and NHSE assurance engagement & involvement re service changes, membership of consultation institute, active process also provided assurance re robustness of our arrangements. patient reference groups locally. Equality: Equality Strategy; Equality Action Plan; E&D Lead; E&D training provided to all staff; Progress monitored by Equality, Diversity & Inclusitivity Group and reported quarterly to Ongoing EQIA policy in place and EQIAs attached to GB papers where appropriate; Staff survey results Equality & Engagement Committee. Assurance to GB via E&E Committee Minutes and annual considered & acted upon; HR policies approved & embedded. assurance report.

Conflicts of Interest: standards of business conduct policy in place & compliant with statutory Oversight by Audit Committee. Regular reports to GB. Declarations at every Committee and Ongoing guidance; registers of interests maintained & published; declared conflicts managed in GB meeting. Annual IA review of arrangements. NHSE Quarterly self certification process. meetings and / or during procurements; online training provided to key staff; oversight by Audit Committee; Conflicts of Interest Guardian in place; PCCC has delegated authority where GB cannot make decisions.

Information Governance: strategy & policies in place, SIRO / Caldicott Guardian identified, IG Toolkit compliance (Level 2) achieved every year. Assurance in 2018/19 will be via Ongoing training provided for all staff, information asset register in place, committee report & business completion of the DSA Toolkit with reporting via IG Group==>QPSC==>GB. case template prompts consideration of IG issues. GDPR action plan in place. Risk Management: Risk management framework (GBAF and RR) provides assurance that GBAF and Risk register updated monthly and considered at all Committees and meetings of Ongoing risks have been identified and are being managed the GB Health & Safety and Business Continuity Group established to oversee compliance with Annual Report & update reports taken to Audit Committee. Ongoing statutory Fire & Health & Safety requirements MAST: Statutory & Mandatory training programme in place for all staff, inc GB members, as L&D team provides dashboard which is considered by management team on a regular basis. Ongoing well as IPR reviews, development sessions for Governing Body inc conflicts of interest, risk management & assurance etc Gaps in assurance Positive assurances received NHSE approval received for latest batch of Constitution updates, Oct-18 IA review of GDPR Compliance (Dec 18) gave 'significant assurance' opinion and review of Workforce Planning likewise gave 'significant assurance' opinion.

Gaps in control Actions being taken to address gaps in control / assurance RR 14/15 Discharge medication risks related to poor or incomplete D1 discharge letters Audit of discharge letters currently underway. Outcomes will be considered by Quality & Patient Safety Committee.

SCORE: A M J J A S O N D J F M Likelihood 2 2 2 2 2 2 2 2 2 2 2 Consequence 5 5 5 5 5 5 5 5 5 5 5 Risk rating 10 10 10 10 10 10 10 10 10 10 10 Tolerance 12 12 12 12 12 12 12 12 12 12 12 Risk Register Escalation to GB Assurance Framework

Appendix 2 RISK REGISTER – February 2019 Likelihood Consequence Scoring Description Current Review Domains Risk No’s 1. Adverse publicity/ reputation Almost Certain 5 Catastrophic 5 Red Extreme Risk (15-25) 7 Monthly 2. Business Objectives/ Projects Likely 4 Major 4 Amber High Risk (8- 12) 15 3 mthly 3. Finance including claims Possible 3 Moderate 3 Yellow Moderate Risk (4 -6) 4 6 mthly 4. Human Resources/ Organisational Development/ Staffing/ Unlikely 2 Minor 2 Green Low Risk (1-3) 3 Yearly Competence Rare 1 Negligible 1 5. Impact on the safety of patients, staff or public Total = Likelihood x Consequence (phys/psych) 6. Quality/ Complaints/ Audit The initial risk rating is what the risk would score if no mitigation was in place. The residual/current risk score 7. Service/Business Interruption/ Environmental Impact is the likelihood/consequence (impact) of the risk sits when mitigation plans are in place 8. Statutory Duties/ Inspections

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Consequence Consequence CCG 1,2, If the health and care 5 4 20 Regular review of activity data Director of Contract and 4 4 16 02/19 February 2019 03/19 18/04 3, system in Barnsley is as part of contract and Strategic Performance Non Elective 5,6, not able to performance management and Planning & Monitoring activity has 8 commission and monitoring arrangements. Performance increased above deliver out of hospital plan and case mix urgent care services Other data reviewed and (Finance & continues to be which have sufficient analysed to identify new Performance higher the plan capacity and are opportunities to reduce non Committee) which is resulting effective in supporting elective activity e.g. NHS in increased costs patients in the Rightcare Packs, Dr Foster as reflected in the community to avoid data etc. IPR Finance the need for hospital Report. Delivery attendance or non- A&E Delivery Board is of constitutional elective admission established (Barnsley Urgent targets however there is a risk that and Emergency Care Delivery remains good and non- elective activity Board) with responsibility for contractual over will exceed planned delivering improvements to performance is levels potentially urgent care services and being managed in leading to (a) failure to achieving related targets. 2018/19. This are achieve NHS of work will be a Constitution targets CCG funding identified to priority for the 1

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Consequence Consequence (with associated support winter planning and CCG during reputational damage, resilience with a specific 2019/20. and (b) contractual focus on avoiding A&E over performance attendance and reducing December 2018 resulting in financial emergency admissions. Position remains pressure for the CCG. Process has commenced to similar to October identify schemes/proposals however for investment. admissions have started to CCG commissioned Out of increase above Hospital Services in place plan. Winter e.g. Intermediate Care & schemes Rightcare Barnsley, including Neighbourhood Nursing, additional GP BREATHE, IHEART streaming, intermediate care, IHEART and home visiting are in place to help to manage demand over winter. (Subject to discussion at F&P on 03.01.19) October 2018 Non-elective activity up to month 5 remains in line with the CCG operational plan however case mix is resulting in 2

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Consequence Consequence increased costs as reflected in the IPR finance report. A&E attendances remain around 10% above plan.

CCG 1, If there is not an 3 5 15 BHF has an action plan in CQC 3 5 15 02/19 February 2019 03/19 18/03 2, adequate and rapid place as required by the CQC SK (Clinical inspection Recommend 5, response from and CCG to achieve Lead) removal by 6, 8 Barnsley Healthcare compliance no later than 6 Q&PSC on 21 Federation to the months from date of JH (Exec February 2019 in areas identified by publication of reports Lead) light of ‘good’ CQC in their recent ratings across all inspections there is a Progress against the action domains from risk that the BHF does plan is to be reported to (Quality & CQC re not meet contractual CCG/BHF contract Patient inspection. and service monitoring meeting Safety requirements Committee) December 2018 potentially leading to: CCG has provided a package Report arising of support to BHF to assist in from the CQC poor quality or unsafe the development of the action inspection services for the people plan expected soon – of Barnsley; risk to be Support includes senior reviewed in light reputational /brand management input from the of its findings damage; CCG Medical Director and (which are CCG Head of Delivery (out of expected to be Strategic implications Hours and Primary Care). positive) for the CCG in terms of delivery of the out Support to BHF by BCCG of hospital strategy Communications Team 3

Initial Risk Residual

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Consequence Consequence and primary care at The CCG continues to make November 2018 scale. financial investment in BHF had a CQC primary care at scale. revisit recently Continuity of service and got positive QPSC and PCCC are both outcomes (the Risk of patients and fully sighted on the issues official CQC practices not and the action plan. Regular report not yet accessing services update reports will be published). provided by BHF provided

Primary Care Quality Improvement Group are to complete a full Quality Review Profile for BHF and will also provide the mechanism to ensure a coordinated approach to the support for BHF and also monitoring of the CQC action plan and will update QPSC/PCC as appropriate.

CQC will re inspect within 6 months of publication of report

Ongoing monitoring of delivery of the iHeart 365 service through routine contract management arrangements

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Consequence Consequence 18/02 1,2, If the CCG and 4 4 16 Escalation of CCG concerns LS Added to the 4 4 16 02/19 February 2019 03/19 5,6 BMBC do not to BMBC senior management Corporate BMBC and the develop a (SSDG Risk register CCG have agreed collaborative Escalation via SSDG and in context of to develop a commissioning health & wellbeing board long standing proposal for a approach and JCB and take that underpinned by To be raised and discussed at frequently through their shared values there H&W Board development articulated respective is a risk that BMBC Session (August 2018) concerns with governance commissioned respect to a mechanisms for services will not basket of consideration. meet the BMBC requirements and commissione December 2018 aspirations of the d services Explore potential CCG for the people notably: of a Joint of Barnsley leading Commissioning to increased health 0-19 Board with inequalities and Health BMBC. poorer health Checks outcomes. Weight August 2018 management Formal escalation & smoking of concerns by cessation Chief Officer to Chief Executive BMBC

CCG 1,3, If the system, via the 4 5 20 A&E Delivery Board is Director of Risk 3 4 12 01/19 January 2019 04/19 13/3 5,6, Urgent and established (Barnsley Urgent Strategic Assessment Updates agreed 8 Emergency Care and Emergency Care Delivery Planning & by Governing Delivery Board fails to Board) with responsibility for Performance Body held on 10 deliver and sustain delivering improvements to January 2019 improvements in urgent care services and (Finance & urgent care services achieving related targets. Performance January 2019 5

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Consequence Consequence which in turn improve Committee) To reflect recent BHNFT’s performance Analysis of A&E activity data is good performance against the target that being undertaken to F&PC agreed In 95% of A&E patients understand the drivers behind January 2019 to are treated or attendances and changes in reduce the discharged within 4 patterns and trends likelihood score hours there is a risk from 5 to 3 that the Trust will not UEC Delivery Board (subject to meet the level of representatives participating in Governing Body performance required the NHSE/I Action on A&E approval). The to achieve its Provider programme – Developing and Committee will Sustainability Funding implementing plans to improve continue to (PSF) and also that in hospital patient flow. monitor the CCG will fail to performance on a deliver the NHS Daily Reporting and SitRep monthly basis. constitution standard calls including local health and not achieve the and care partners December 2018 Urgent Care element Performance of the Quality Winter & Bank Holiday against the A&E Premium. Planning arrangements standard remains strong and CCG funding identified to continues to be support winter planning and above 95% for Q3 resilience. Process has (Subject to commenced to identify discussion at schemes/proposals for F&P on 03.01.19) investment.

IHEART Barnsley established and operational offering out of hours GP appointments on evenings and Saturdays

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Consequence Consequence Strengthened GP Streaming adjacent to ED in place. BHF commenced provision of service in September 2017 in ED but with a GP providing the service and from December 2017 in new separate primary care area adjacent to ED.

IHEART 365 service established, bringing together extended access and OOH GP services.

CCG 2, If the Barnsley area 3 3 9 NHS England’s Primary Care Senior Governing 4 4 16 02/19 February 2019 – 03/19 14/10 5, 6 is not able to attract Strategy includes a section Primary Care Body No changes to & retain a suitable on workforce planning Commissioni report & sufficient Primary ng Manager. Care clinical The CCG’s Primary Care December 2018 workforce there is a Development Programme (Primary No updates to risk that: has a workforce workstream Care report (a) Some practices and Primary Care workforce Commissioni may not be Strategy is in development. ng November 2018 viable, Committee) No changes to (b) Take up of PDA Links have been developed report or other with the Medical School to October 2018 initiatives could enhance attractiveness of There are no be inconsistent Barnsley to students changes to report (c) The people of Barnsley will The CCG continues to invest September 2018 receive poorer in primary care capacity. Practices quality The PDA enables practices to continue to report 7

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Consequence Consequence healthcare invest in the sustainability of their workforce services their workforce. The figures and these (d) Patients successful PMCF (now known are presented and services could as GP Access Fund) has monitored through be further away enabled additional capacity to each practices from their be made available outside quality home. normal hours via the iHeart dashboard. In Barnsley Hubs. BHF is also 2018/19 15 lots of actively developing physicians resilience funding associates roles. have been approved for The CCG has funded 15 Barnsley Clinical Pharmacists to provide practices which support to all Practices in will support Barnsley. recruitment and future resilience. The CCG has also funded 14 Apprentices to provide additional capacity in Primary Care.

The PDA requires Practices to submit a workforce baseline assessment to the CCG on a quarterly basis. This will be monitored via the Primary Care Quality Improvement Tool to identify any capacity issues or pressure points.

GP Forward View includes a section on workforce, with additional funding being made 8

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Consequence Consequence available to support Primary Care sustainability.

14/15 1, There are two main 4 4 16 Ongoing discharge Head of Risk 3 5 15 02/19 February 2019 03/19 5, 6 risks: medication risks escalated to Medicines Assessment & Provisional D1 1. BCCG Chief Officer and Optimisation audit of audit results Scant or absent Chief Executive of BHNFT discharge discussed at Jan information relating resulted in 2 quality risk letters 19 meeting which to why medication meetings (August and showed some changes have been November 2016) (Quality & improvement on made. Poor Patient previous audits. communication of Area Prescribing Committee Safety These results medication changes , (APC) monitor concerns and Committee) were presented at even if changes are will report 2017 audit to the a D1 summit on appropriately made Quality & Patient Safety 31st Jan 19. for therapeutic/safety Committee BHNFT have reasons, creates a advised APC that patient safety risk A working Group (with reps full audit results when post discharge from Practice managers have been medicines Group & BHNFT) looking at collated and reconciliation is D1 Discharge Summary finalising the final being undertaken by Letters. audit report. the GP practice. The risk being that the December 2018 GP practice may Provisional either accept BHNFT D1 audit inappropriate results available changes when all the for 14th Jan 19 patients’ risk factors meeting . Draft have not been 2017/18 primary accounted for by the care D1 re-audit hospital clinicians or report showed an error has been improvement over 9

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Consequence Consequence made or not accept 2014 and 2016 clinically important audits. Agreed to changes as not combine BHNFT confident about the and primary care reasons for the audit results into change. one 2019 report.

2. D1 summit has Clinically significant been planned for safety alerts, such as 31st Jan 2019. contraindicated combinations of September 2018 medication, are MD audit across being frequently secondary and triggered by primary primary care care prescribing using same systems during post criteria was not discharge medicines possible due to reconciliation when information adding medicines to access. Format of the Patients Primary D1 medicines Care Record. This information indicates that either section was the hospital is not changed by Trust reconciling in August 2018. medicines using the Primary Care GP Practice audit data Summary Care collection was Record or that the undertaken reconciliation is not between Nov 17 sufficiently robust. and Dec 17 and a report is being compiled for Nov 10

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Consequence Consequence 18 APC. A joint meeting (11th Sept) chaired by Trust Medical Director took place where the Trust has agreed to plan and undertake internal audit of quality of D1 medicines information during Autumn 18. Meeting scheduled for 23rd Oct to finalise the Trust audit criteria and plan.

CCG 1,5, If improvement in 4 5 20 July 2016 Chief Nurse Risk 3 5 15 02/19 February 2019 03/19 15/07 6 Yorkshire Ambulance Regular consideration of YAS (Acting) Assessment Continue to work Service (YAS) incident reporting by QPSC with other CCG’s performance against and GB to understand the (Quality & (Sheffield lead the ARP response frequency and severity of Patient commissioner) to time targets is not incidents associated with Safety improve flow of secured and ambulance response. Committee) quality monitoring sustained, there is a data and ensure risk that the quality quality indicator and safety of care for data measured some patients could accurately and be adversely affected. consistently. Concerns remain in relation to 11

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Consequence Consequence ambulance response with appropriate resources in a time frame that is appropriate to the patient’s needs.

December 2018 Escalated to Assurance Framework as a gap in control. - Monitoring and reporting YAS SI’s separately - YAS 111/999/IUEC on agenda in Clinical Governance and Quality Steering Group and Contract Management Meeting

September 2018 The CCG continues to monitor the level of serious incidents reported 12

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Consequence Consequence by YAS in their quarterly South Yorkshire & Bassetlaw YAS 111 / 999 / IUEC Clinical Governance & Quality Steering Group & Contract Management Meeting.

CCG If the response from 3 4 12 At the Trust Board meeting Head of CQC reviews 2 4 8 02/19 February 2019 05/19 18/05 SWYPFT to the areas held on 31 July 2018 the Commissioni The SWYPFT assessed as ‘requiring specific actions outlined in ng (MH, Action Plan improvement’ in the response to the recent CQC Childrens & following CQC recent CQC report is visit were: Specialised assessment in inadequate there 1) Submission of Action Services) July 2018 has would then be a risk Plan against been received that the Trust would regulatory breaches (Quality & and reviewed. not meet the required to CQC – 30th July Patient The action plan standards of care, 2) Develop an Safety continues to be potentially leading to overarching action Committee) implemented and poor quality or unsafe plan (Quality the progress is services being Improvement and reviewed by the delivered to the Assurance Team/ Head of people of Barnsley Business Delivery Commissioning Units / Support (Mental Health, services) as an Children's, internal working Maternity and document to include Specialised). all CQC actions (regulatory breaches, 13

Initial Risk Residual

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of the risk Risk

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Consequence Consequence must do’s and should November 2018 do’s) SWYPFT Action 3) Instigate formal Plan still to be monitoring of Action shared with CCG Plan although actions are already being The SWYPFT Action Plan is implemented. to be shared with the CCG Action Plan has and will be taken to QPSC for been requested. review. October 2018 Of the 70 domains assessed Included in by CQC over 85% were register assessed as ‘Good’ or ‘Outstanding’. One domain was assessed as ‘Inadequate’ which led to an overall rating of ‘Requires Improvement’

The CCG will consider undertaking quality assurance visits to areas of concern highlighted within the CQC report should this be required once the Action plan has been reviewed and progress monitored.

CCG 1,2, There is a risk that if 3 4 12 A Programme Management Chief Risk 3 4 12 02/19 February 2019 05/19 13/31 3, 8 the CCG does not Office is established with Finance Assessment The CCG is on develop a robust QIPP monthly reports on progress Officer track to deliver plan supported by against targets through against planned 14

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Consequence Consequence effective delivery and revised organisational Governing schemes for monitoring governance arrangements: Body 2018/19. Further arrangements, the QIPP Delivery Group reporting development of CCG will not achieve to Finance and Performance (Finance & 2019/20 and its statutory financial Committee and onward to the Performance 2020/21 schemes duties and NHS Governing Body. Committee) is required to England business ensure recurrent rules. Monthly Reports on the CCG’s QIPP is identified financial position and forecast and delivered. outturn to Finance and Performance Committee and December 2018 Governing Body as part of The CCG Integrated Performance continues to Report (IPR) deliver QIPP and current forecasts Robust financial management suggest over is in place for each area of delivery against budget with monthly budget planned schemes. meetings to identify variances from budget and mitigating October 2018 actions. The CCG continues to Development of further QIPP deliver against the programmes and savings QIPP plan with schemes to be overseen by full achievement Programme Management expected either Office. through planned schemes or in Budget Holders receive year identified training and support from the mitigations. finance team to allow variations from plan and mitigating actions to be 15

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Consequence Consequence identified on a timely basis.

Prime Financial Procedures and Standing Orders are in place

Internal Audit Reports on general financial procedures and Budgetary Control Procedures (including review of shared service functions)

Annual Governance Statement

Local Counter Fraud Specialist Progress Reports to Audit Committee

Annual Report & Accounts subject to statutory external audit by KPMG, reported via Annual Governance (ISA260) Report, and Annual Audit Letter.

Monthly monitoring reporting to NHS England

Internal Audit (360 Assurance) to follow up recommendation from 2016/17 QIPP review.

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Consequence Consequence CCG If BHNFT are 3 4 12 The CCG’s strategic Chief Risk 3 4 12 02/19 February 2019 05/19 15/13 unable to achieve objectives aim to support a Finance assessment The CCG their control total, as safe and sustainable local Officer continues to work agreed with NHS hospital. with the Trust to Improvement, there (Finance & ensure delivery of is a risk that the In addition to the core Performance the control total. financial contract for 2017/18, the Committee) sustainability of the CCG is providing a further December 2018 Trust may have a £450k non-recurrent funding The CCG detrimental impact for 2017/19 to assist the continue to work on the future of local Trust in achievement of its with the Trust to services for the control total. understand the people of Barnsley. expected outturn Revised contract governance position and arrangements (in operation impact on from Oct 2015) will facilitate Provider regular engagement of sustainability Board/Governing Body funding. Risks colleagues with an update continue to be being provided by the Trust managed on the financial position between partners with the CCG The Sustainability meetings providing financial held with the Trust have been resilience support reestablished to ensure to to contribute to ensure that sustainable delivery of the services are delivered for the Trusts control people of Barnsley. total.

October 2018 The Trust has indicated to the CCG that there is 17

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Consequence Consequence a risk of control totals not being achieved. The CCG is currently working with the trust to assess the level of risk and support in the identification of mitigating actions

15/12 1, If BHNFT does not 4 3 12 The CCG and the provider Director of Risk 3 3 9 02/19 February 2019 05/19 2, improve its are working as part of a Strategic assessment BHNFT continue 5, performance in South Yorkshire Cancer Planning & to deliver cancer 6 respect of people Alliance and continuing to Performance standards on a waiting longer than improve and develop services consistent basis 62 days to be treated to ensure delivery of cancer including delivery following an urgent standards (Finance & of the 62 day cancer referral, there Performance standard. is a risk to the BHNFT have undertaken a Committee) reputation of the CCG self-assessment against the 8 December 2018 and the quality of key priorities identified by the The 62 day care provided to the Cancer Waiting Times Task standard was people of Barnsley in Force and are implementing achieved in respect of this improvements to ensure October however service. compliance with all of the referrals are priorities. Progress is being increasing and reviewed by the System therefore Resilience Group. challenges remain. BHNFT performance remains strong.

Initial Risk Residual

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Consequence Consequence CCG 1,2, Lack of completed 3 3 9 Policy on the Managing Head of Risk 3 3 9 03/19 March 2019 06/19 13/41 4,8 Declarations in respect Conflicts of Interest and the Governance Assessment No change to of the Policy on the Acceptance of & Assurance Identified by assessed risk Managing Conflicts of Sponsorship, Gifts and Audit level. Internal Interest Hospitality Committee Audit provided and the Acceptance of (Audit 30.05.13 significant Sponsorship, Gifts and Reminders to Membership Committee) assurance in their Hospitality Council to submit declarations annual review 9Jan 19) Annual Annual Internal Audit review refresh of all staff of Conflicts of Interest declarations provided significant currently assurance (Jan 2019) underway.

September 2018 Decs of Interest continue to be updated as received. All key staff completed Conflicts of Interest training as per NHSE requirements.

June 2018 Annual update of the Register of Interests is complete and updated registers are uploaded to the website 19

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Consequence Consequence CCG 1, CCG as Level 2 4 3 12 Contribute to Barnsley Health Director of Risk 3 3 9 12/18 December 2018 03/19 13/19 5, 8 Responder and Social Care Emergency Strategic Assessment LHRP Assurance planning group and work Planning & completed in Barnsley CCG does programme, including testing Performance October 2018. not meet legislation of plans and training and standards in (Finance & September 2018 relation to protecting Continue to Local Health Performance Self-Assessment Barnsley people from Resilience Partnership (LHRP) Committee) undertaken in harm related to major either directly or through Lead August against incidents and other CCG rep. EPRR Core emergencies. Standards and considered at Nominated CCG “Accountable Governing Body Emergency Officer” in September. The compliance Ensure contracts with provider statement has organisations contain relevant been submitted emergency preparedness and confirming response elements including substantial Business Continuity compliance.

Emergency Preparedness Memorandum of Understanding with Public Health

Public Health (including CCG) Incident Response Plan, Outbreak Plans etc.

Reports to Governing Body on emergency resilience issues, including Business Continuity 20

Initial Risk Residual

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of the risk Risk

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Consequence Consequence Management

NHS England Area Team monitoring report re Emergency Planning

Winter Planning Arrangements

CCG 1,2 If the CCG fails 4 4 16 CCG Engagement and Head of Risk 3 4 12 01/19 January 2019 04/19 13/13 effectively to engage Equality Committee reporting Communicati Assessment No further b with patients and the into Governing Body in place ons & updates at this public in the Engagement time. Self- commissioning or co- Refreshed Patient and Public assessment commissioning of Engagement Strategy (Governing against NHSE IAF services there is a risk Body) criteria currently that: PPE Operational Delivery underway. Group (Equality and (a) services may Engagement October 2018 not meet the Barnsley Patient Council and Committee) No updates to needs and OPEN report wishes of the July 2018 people of Good relationships with Local No changes to Barnsley, and Healthwatch report (b) the CCG does not achieve its The Comms & Engagement March 2018 statutory duty team proactively develops No changes to to involve and maintains links with report. patients and partner organisations to the public. facilitate effective February 2018 engagement in co- NHS England has commissioning activities both assessed the locally and regionally CCG as Good against the new 21

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Consequence Consequence Barnsley Engagement Hub patient and community Effective Service Change engagement Guidance and Toolkit / indicator Patient and Public participation in commissioning health and care - Statutory Guidance

Organisational member of The Consultation Institute (tCI)

CCG links with the Voluntary Sector

PRGs are a requirement of the GP core contract / Practice Delivery Agreement

CCG If the CCG does not 3 4 12 The CCG has access to Senior Risk 2 4 8 02/19 February 2019 – 05/19 15/03 effectively discharge existing primary care Primary Care Assessment Recruited staff its delegated commissioning resource Commissioni now in post will responsibility for within the Area Team under ng Manager support the CCG contract performance the RASCI agreement. to meet its management there is delegated a risk that the CCG’s The CCG will seek to (Primary responsibilities. reputation and integrate Area team Care relationship with its resources to ensure that the Commissioni November 2018 membership could be role is carried out consistently ng Successful damaged. with the CCG’s culture & Committee) recruitment to the approach. CCG’s Primary care team to 22

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Consequence Consequence The CCG is also undertaking support the a review of management delegated capacity which will responsibilities incorporate proposed delegated responsibilities. September 2018 The CCG The CCG has an open continues to channel of communication effectively with the Membership Council managing its regarding commissioning and delegated contracting arrangements (eg responsibility. equalisation). Strong links have been made with the NHSE Area Team and the contracting team to ensure that this function is effective.

August 2018 No updates to report

June 2018 No updates to report

responsibility for contract performance effectively. This is supported by 23

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Consequence Consequence the CCG’s Primary Care Team and the NHS England Area Team

CCG 1, If a culture supportive 3 4 12 CCG has an Equality Lay Member Risk 3 4 12 01/19 January 2019 04/19 14/16 4, 8 of equality and Objectives Action Plan, now for Patient & Assessment EDS2 self- diversity is not developed & monitored by Public assessment embedded across the Equality Working Group, Engagement completed, no CCG there is a risk chaired by Chief Nurse and significant that the CCG will fail reporting to the Equality & weaknesses in to discharge its Engagement Committee (Equality and CCG arrange- statutory duties as an Engagement ments identified. employer and will not Expert support & advice PRN Committee) Training session adequately consider held for GB Jan- issues of equality Full suite of HR policies in 19 to embed good within the services place supported by robust practice. we commission. EIA. October 2018 Robust EIA required to No updates to support all policies and report proposals – new EQIA Toolkit being developed & rolled out July 2018 (Nov 18). Effectiveness to be Additional Expert monitored via ED&I Group / support now in E&EC. place with the appointment of E&D training is a mandatory Colin Brotherston- requirement for all staff (92% Barnett compliant).

Values & behaviors included 24

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Consequence Consequence within corporate performance review documentation.

Values & behaviours embedded through use of values based recruitment techniques and ‘radiators’ group.

Regular staff surveys with resulting action plans.

CCG 1,2, Failure to receive 2 4 8 Monthly integrated Director of Risk 2 4 8 12/18 December 2018 03/19 13/15 3,6, assurance on performance report provides Strategic Assessment IPR continues to 8 performance targets information on all constitution, Planning & be reported on a CCG IAF and other KPI’s. Performance monthly basis to provide IPR is submitted and assurance against reviewed at Finance and (Finance & national and local Performance Committee and Performance KPI’s Governing Body. Committee) September 2018 Contract Monitoring meetings (Governing Performance between commissioner and Body) reporting ongoing Providers as described

Quality & Patient Safety June 2018 Committee review quality and IPR has been safety indicators reviewed and updated to reflect Clinical quality performance national indicators reports and standards as set out in the 25

Initial Risk Residual

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Likelihood Likelihood

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assessment

Consequence Consequence Contract Compliance visits 2018/19 planning Independent Contractors requirements and in line with the agreement at F&P in June on the back of the review of Outcome Indicators.

CCG 1, 8 Failing to meet the 3 4 12 Fire Brigade inspections Head of Risk 2 4 8 03/19 March 2019 06/19 13/16 requirements of the (Held by H & S department) Governance Assessment Fire safety Regulatory Reform & Assurance arrangements (fire safety) Order to HSE inspections continue to be effectively, manage Reviewed (Finance & monitored via the our fire safety Performance H&S&BC Group. arrangements Fire and Health and Safety Committee) No significant Training within CCG risks have been Mandatory training reports identified through risk assessments Local shared Fire & H&S and all actions are service provides oversight in hand. Fire drills health and safety and fire completed twice a advice through corporate year revealed no services team major issues. Training Landlord (NHSPS) provides compliance levels routine maintenance of remain high and emergency lights, fire efforts are extinguishers etc underway to raise compliance prior Annual Organisational Risk to year end. Assessments with action 26

Initial Risk Residual

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Lead Owner Source of Ref Risk Description Mitigation/Treatment

of the risk Risk

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assessment

Consequence Consequence plans overseen by H&S December 2018 Group The biannual fire drill took place in Oversight of Fire Safety October and saw Arrangements by H&S Group a reduction in the reporting to Audit Committee time taken to 2 minutes 6 seconds.

CCG 1, 6 Conflicts of interest re 3 4 12 CCG has a conflict of interest Head of Risk 2 4 8 03/19 March 2019 06/19 13/20 commissioning, policy and declarations of Governance Assessment No substantive decommissioning and interest are included on every & Assurance change. Home procurement agenda. Visiting & AQP processes. (Finance & procurements In anticipation of Audit Committee has a Performance have been National scrutiny of standing item regarding Committee) delegated to commissioning declarations of interest and PCCC to facilitate decisions made by provides scrutiny of its management of Clinical application. conflicts. Commissioning Group we need to ensure we Governing Body development December 2018 have: sessions have taken place and The risk has been training provided to Governing reviewed, the  Robust processes Body Members and CCG staff position remains in place for the on the management of as previously review of services conflicts of interest. reported and no which are reason to change auditable resulting Register of Procurement risk description or in the Decisions maintained and score at this commissioning or published on website detailing stage. decommissioning how any conflicts have been 27

Initial Risk Residual

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of the risk Risk

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assessment

Consequence Consequence of services; managed September 2018  Clear and The CCG consistent Procurement Policy approved continues to documentation of Sep 2016 includes detailed enhance its declarations of section on managing C of I in arrangements. A interest procurement. new Committee has been Procurement Checklist used established to for large procurements with manage conflicts potential conflicts. with respect to a possible ICO Primary Care Commissioning procurement. Committee established to Other which procurement decisions procurements can be delegated where continue to be conflicts of interest preclude delegated to Governing Body from taking PCCC where them. This responsibility has appropriate under been incorporated into the delegated PCCC ToR (Nov 2017). arrangements.

Governing Body has approved a decision making process for determining when procurement decisions will be delegated to PCCC (Nov 2017).

17/02 1 2 If the CCG does not 3 4 12 eMBED manages and Head of Internal Audit 3 3 9 02/19 February 2019 05/19 3 6 put in place maintains CCG IT systems Governance Review Still awaiting 7 8 appropriate and robust and servers and ensures & Assurance confirmation from arrangements to appropriate safeguards are in NHSD re GB mitigate cyber attack place. Assurance report development there is a risk that the received. session. DSP 28

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Consequence Consequence CCGs business IT Group Toolkit completion systems could be CCG staff aware of need for QPSC now well comprised leading to vigilance re suspicious emails underway and reputation damage etc – regular reminders via internal audit business interruption weekly comms and direct currently in and potential financial email. progress. loss Updates of data SIRO identified as flows and risk organizational lead cyber assessments for security key assets underway, and IT Group receiving routine staff currently not reports on Cyber Security compliant with DSA Training 360 Assurance delivered have been briefing on cyber security to reminded to Governing Body in July 2017 complete asap. and to staff in Sept 2017. November 2018 Training on cyber security to NHSD to provide be provided to all staff via a cyber workshop online mandatory data security for the GB early in module. 2019. eMBED and the CCG IG From April 2019 the IG Toolkit Lead developing is replaced by the DSP Toolkit detailed action which gives greater emphasis plan to ensure to data security. compliance with DSP Toolkit requirements.

Initial Risk Residual

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Consequence Consequence 17/05 If the planned 4 3 12 IAPT procurement Director of Performance 4 3 12 02/19 February 2019 05/19 added improvements to the undertaken during 2018 for a Strategic Monitoring Improvements in Octob IAPT Service do not revised model and Planning & performance are er 17 result in delivery of the specification which aims to Performance being sustained nationally mandated deliver improved outcomes F&P with all waiting performance targets and performance. times all KPI’s there is a risk that the currently being CCG reputation will be IAPT Intensive Support Team achieved damaged. Review completed and final report received in December December 2018 2017. Performance against MH Action/improvement Plan standards is being developed by SWYPFT to delivered in line address all recommendations with the revised in the IST report. specification.

Performance monitored and August 2018 reported via the IPR. Procurement complete and new service model commenced. Performance against key standards improved as a result of implementing the improvement action plan and this is expected to be sustained through delivery 30

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Consequence Consequence of the new service specification. 17/06 If the planned changes 4 3 12 IAPT Intensive Support Team Head of Performance 4 3 12 02/19 February 2019 05/19 added to the IAPT Service do Review completed - final Commissioni monitoring IAPT service Octob not result in more report now received. ng (MH, continues to er 17 patients being treated children, achieve the in accordance with Action/improvement Plan Specialised) national waiting time targets developed by SWYPFT to recommended there is a risk that the address all recommendations targets for access efficacy of the in the IST report. and moving to treatment they receive QPSC recovery. The will be diminished CCG issued contract PO IAPT service is performance notice to now part of the SWYPT requiring Alliance contract development of a final action and will therefore plan on receipt of the IST be subject to the report. The delivery of the alliance improvement plan will be governance and monitored via contract assurance monitoring arrangements. processes in addition to the Assurance provided to GB processes already Nov 17 that achievement of in place. agreed improvement trajectory would lead to key November 2018 targets being met by the end The new IAPT of 2017/18. Performance will service has been be monitored and reported operational since via the IPR. September 2018 and all national and local IAPT targets are being achieved. The 31

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Consequence Consequence local 60% moving to recovery target remains aspirational whilst the Quality Premium target is for an achievement of 53% by the end of March 2019.

August 2018 IAPT service specification revised and service successfully tendered – contract awarded to SWYPFT and new, more ambitious service to be delivered from August 2018.

Interim pathway has met its agreed targets and is no longer in operation. IAPT service will be monitored on a 32

Initial Risk Residual

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of the risk Risk

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Likelihood Likelihood

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assessment

Consequence Consequence monthly basis. Any performance issues will be flagged early and reported via the IPR.

IAPT Service has been meeting the national waiting and access targets consistently throughout 2018.

CCG 1, If there is not an 2 5 10 New contract holders with JH (Exec CQC 2 5 10 02/19 February 2019 05/19 19/01 2, adequate and rapid ‘good’ CQC ratings in their Lead) inspection Q&PSC approved (Added 5, response from current Practices have been the risk and risk Feb 6, Dodworth Medical varied onto the contract. SK (Clinical score on 21 19) 8 Centre to the areas Lead) February 2019. identified by CQC in There is an action plan in their recent place as required by the CQC (Quality & February 2019 inspections there is a and CCG to achieve Patient Q&PSC to risk that the Practice compliance no later than 6 Safety consider approval does not meet months from date of Committee) of this new risk. contractual and publication of reports service requirements December 2018 potentially leading to: Progress against the action Risk drafted for plan is to be monitored by the inclusion on the Practice remaining in CCG’s Primary care team. corporate risk ‘special measures’; register subject to QPSC and PCCC are both consideration and Poor quality or fully sighted on the issues approval at 33

Initial Risk Residual

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of the risk Risk

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Likelihood Likelihood

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assessment

Consequence Consequence unsafe services for and the action plan. Regular QPSC. the people of Barnsley; update reports will be provided Reputational /brand damage. CQC will re inspect within 6 months of publication of report

CCG If the CCG is unable to 3 5 15 CCG considered its strategic Head of Risk 2 3 6 02/19 February 2019: 08/19 15/04 secure sufficient capacity & capability as part Delivery Assessment The 2 new staff operational & strategic of the successful application (Integrated members are now capacity to fulfil the process. Primary and in post to support delegated functions Out of the CCG in this may impact on the The CCG has access to Hospital managing its ability of the CCG to existing primary care Care) delegated deliver its existing commissioning resource responsibilities. delegated statutory within the Area Team under (Primary duties, for instance in the RASCI agreement. In Care September 2018 relation to quality, addition the CCG is recruiting Commissioni The Primary Care financial resources a Head of Quality for ng Team have and public Commissioning Primary Committee) appointed to 2 participation. Medical Services. news posts which will support the The CCG is undertaking a CCG in managing review of management its delegated capacity including delegated responsibilities for responsibilities. Primary Care. The posts will lead on contract management and transformation.

Initial Risk Residual

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Lead Owner Source of Ref Risk Description Mitigation/Treatment

of the risk Risk

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assessment

Consequence Consequence March 2018 Primary Care team in place and working effectively

January 2018 Primary Care team in place and working effectively

June 2017 The CCG has a Primary Care Team to support management of delegated commissioning; this includes individuals with the responsibility for Primary Care Contracting and Quality. May 2017 The CCG has a Primary Care Team to support management of delegated commissioning; this includes 35

Initial Risk Residual

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Consequence Consequence individuals with the responsibility for Primary Care Contracting and Quality. CCG 1, If the CCG does not 3 3 9 Standards of Business Head of Risk 2 3 6 03/19 March 2019 09/19 15/05 3, 8 comply in a fully Conduct Policy and Governance Assessment No change. IA transparent way with Procurement Policy updated. & Assurance review Jan 19 the statutory Conflicts provided of Interest guidance Registers of Interests (Primary significant issued in June 2016 extended to incorporate Care assurance there is a risk of relevant GP practice staff. Commissioni opinion. Annual reputational damage to ng refresh of the CCG and of legal Declarations of interest tabled Committee) declarations challenge to the at start of every meeting to currently procurement decisions enable updating. underway. taken. Minutes clearly record how September 2018 any declared conflicts have Issues raised by been managed. Internal Audit have been PCCC has Lay Chair and Lay addressed. No & Exec majority, and GP further update at members are non-voting. this stage.

Register of Procurement March 2018 decisions established to Annual internal record how any conflicts have audit review of been managed. conflicts of interest provided Guidance provided to minute significant takers on recording decisions assurance and re managing conflicts of raised just 3 low 36

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of the risk Risk

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Likelihood Likelihood

Datefor re

assessment

Consequence Consequence interest. risk actions which are currently being addressed.

January 2018 Unchanged since the last update

December 2017 CCG continues to comply. So FBC Policy has been updated again to reflect minor changes to the statutory guidance. Arrangements for managing conflicts in procurement clarified and strengthened through GB agreeing a ‘decision tree’ in November 2017. PCCC ToR now specify that the Committee will be the decision making body where GB cannot 37

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assessment

Consequence Consequence take decisions due to conflicts.

June 2017 Third lay member now in post and attending meetings of PCCC.

March 2017 Third Lay now recruited and will commence on 1.4.17. Internal Audit has found CCG fully or partially compliant across all areas.

CCG 1, NHS Barnsley does 1 5 5 Annual DSP Toolkit and Head of Risk 1 5 5 02/19 February 2019 08/19 13/30 5, 8 not operate within the associated improvement Governance Assessment eMBED IG Lead legal information programme & Assurance currently finalizing processing framework the evidence for NHS Barnsley IG Framework the 2018/19 DSp Clinical Risk regularly reviewed and Governing Toolkit updated Body submission. Internal Audit of a Full suite of IG Policies (Quality and sample of approved, regularly updated, Patient evidence currently and available to staff via Safety underway. It is website Committee) expected that the 38

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of the risk Risk

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Likelihood Likelihood

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assessment

Consequence Consequence Toolkit will be IG Incident reporting process completed and approved by Internal Audit annual reviews SIRO / IG group of DSP Toolkit evidence in advance of the deadline of Mandatory CCG wide training 31.3.19 on Data Security & Protection

SIRO & Caldicott Guardian in post

Data Protection Officer (DPO) in place under contract from eMBED

IG expertise commissioned from commissioning support provider (eMBED)

Information Asset register in place and regularly updated

Privacy Impact Assessments form part of the CCG standard project management approach

GDPR action plan in place to ensure compliance CCG If GP Practices opt to 2 4 8 Impact could be mitigated by Head of 1 4 4 02/19 February 2019: 08/19 16/02 cease provision under local provision e.g. BHF Delivery The 2 new staff their Primary Medical (Integrated members are now 39

Initial Risk Residual

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of the risk Risk

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Likelihood Likelihood

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assessment

Consequence Consequence Services Contract APMS Contracts allow Primary and in post to support there is a risk that the increased diversity of Out of the CCG in CCG could not source provision. Hospital managing its appropriate provision Care) delegated of services in all responsibilities. localities in Barnsley. (Primary September 2018 Care Barnsley CCG Commissioni approved the ng emergency Committee) provider framework in May 2018 which would support the CCG in appointing a provider should any practice opt to stop provision under the PMS contract.

March 2018 – position remains as below

January 2018 The risk remains in place. CCG would follow NHSE Policy and Guidance Manual to secure emergency 40

Initial Risk Residual

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Likelihood Likelihood

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Consequence Consequence provision

CCG There is a risk that if 2 3 6 The CCG has a well- Head of Risk 1 3 3 02/19 February 2019 02/20 15/06 the CCG does not established and effective Communicati Assessment No changes to effectively engage PPE function, as well as ons & report with the public, robust governance supporting Engagement member practices the function. March 2018 and other (Primary No changes to stakeholders on The existing primary care Care report matters relating to commissioning resource and Commissioni the delegated expertise within the Area ng February 2018 commissioning of Team can be accessed by Committee) NHS England has primary care the CCG. assessed the (including redesign of CCG as Good service delivery), the The CCG considered its against the new CCG’s reputation strategic capacity & capability patient and with its key as part of the successful community stakeholders could application process. engagement therefore be affected. indicator The CCG is a member of the Consultation Institute and as such uses learning, best practice and advice service to support any consultation activity.

CCG 1, If the CCG does not 2 3 6 Completion of Self Review Chief Risk 1 3 3 07/18 July 2018 07/19 13/38 3, 8 have sufficient Toolkit (SRT) in relation to Finance Assessment No update processes and 2015/16 Commissioner Officer controls in place to Standards – along with March 2018 prevent fraud there is production of an action plan for (Audit SRT submission a risk of loss of development/rectification. Committee) in March 2018 resources and damage scored the CCG 41

Initial Risk Residual

Score Risk Score

Lead Owner Source of Ref Risk Description Mitigation/Treatment

of the risk Risk

Score Score

Update

Domain

DateRisk

Progress/

Assessed

Likelihood Likelihood

Datefor re

assessment

Consequence Consequence to the CCG’s Annual Budgets and review of as ‘green’ overall, reputation. these on a periodic basis maintaining the score from March Budgetary control system 2016. Regular Financial Reporting April 2017 Cash flow Projections SRT submission in March 2017 Fraud Policy in place scored the CCG as ‘green’ overall, Fraud Awareness an improvement from ‘amber’ Fraud locally agreed work plan overall in 2016.

Prime Financial Procedures, Standing Orders and Scheme of Delegation

Audit Reports to Governance Risk and Audit Group and Audit Committee

Local Counter Fraud Specialist Progress Reports to Audit Committee

Internal Audit Reports on Treasury Management Financial Controls

Counter Fraud Officer in place

External Audit Reports 42

Initial Risk Residual

Score Risk Score

Lead Owner Source of Ref Risk Description Mitigation/Treatment

of the risk Risk

Score Score

Update

Domain

DateRisk

Progress/

Assessed

Likelihood Likelihood

Datefor re

assessment

Consequence Consequence Annual Local Counter Fraud Reports

17/04 5,6 The CCG is taking 2 3 6 Recruited and trained team Medical Risk 1 3 3 02/19 February 2019 02/20 (added forward an ambitious supporting changes in Director Assessment The CCG has August programme over 18 practices in addition to completed 14 2017) months to improve support from Pharmacy staff (Quality & months of work the quality and cost- working within practices Patient against this effectiveness of Safety programme. The primary care Engagement with all parties Committee) work undertaken prescribing by limiting through a stakeholder group focused on third-party ordering of and communications plan supporting repeat prescriptions which will identify patients patients designed and improving quality who may require additional to mitigate against of how medicines are support these potential ordered. risks and there have been no There is a risk that in issues reported. A this process progress report vulnerable patients will be received may not receive their by the Governing necessary medicines Body at the March through changes in 2019 meeting. their repeat medicine supply system and March 2018 some patients may Ongoing not understand changes. September 2017 On 14 September 2017 the Governing Body approved new risk 17/04 for inclusion 43

Initial Risk Residual

Score Risk Score

Lead Owner Source of Ref Risk Description Mitigation/Treatment

of the risk Risk

Score Score

Update

Domain

DateRisk

Progress/

Assessed

Likelihood Likelihood

Datefor re

assessment

Consequence Consequence on the Risk Register.

NEW RISK FEBRUARY 2019

CCG 1, If there is not an 2 5 10 New contract holders with JH (Exec CQC 2 5 10 12/18 Feb 2019 03/19 19/01 2, adequate and rapid ‘good’ CQC ratings in their Lead) inspection Q&PSC approved 5, response from current Practices have been the risk and risk 6, Dodworth Medical varied onto the contract. SK (Clinical score on 21 8 Centre to the areas Lead) February 2019. identified by CQC in There is an action plan in their recent place as required by the CQC (Quality & Feb 2019 inspections there is a and CCG to achieve Patient Q&PSC to risk that the Practice compliance no later than 6 Safety consider approval does not meet months from date of Committee) of this new risk. contractual and publication of reports service requirements December 2018 potentially leading to: Progress against the action Risk drafted for plan is to be monitored by the inclusion on the Practice remaining in CCG’s Primary care team. corporate risk ‘special measures’; register subject to QPSC and PCCC are both consideration and Poor quality or fully sighted on the issues approval at unsafe services for and the action plan. Regular QPSC. the people of Barnsley; update reports will be provided Reputational /brand damage. CQC will re inspect within 6 months of publication of report

NHS Barnsley Clinical Commissioning Group Head of Internal Audit (HOIA) Work Programme: Stage 2 Memo Published January 2019 (report reference 1819/BCCG/09M)

Introduction and Background The Public Sector Internal Audit Standards (PSIAS) state that the annual internal audit opinion must conclude on the overall adequacy and effectiveness of the organisation’s framework of governance, risk management and control. As highlighted in our Stage 1 memo1, the year- end Head of Internal Audit Opinion statement is Assurance Follow-up of Framework based upon the findings of our annual work agreed and strategic programme which focuses on the three areas actions risk outlined in the opposite diagram. management This report, covering stage 2 of our work programme, is aimed at providing a level of Internal Audit plan ongoing assurance on the effectiveness of the outturn organisation’s Governing Body Assurance Framework and strategic risk management. It seeks to highlight any issues, in advance, which may adversely impact our year-end opinion. It should be noted that this is a summary of the output from our stage 2 review. It is not intended to be a full Head of Internal Audit Opinion assessment. Further work undertaken in stage 3, your reported follow-up rate to Audit and Integrated Governance Committee and the opinions from individual audit reviews (in particular those which are core) continue to be considered as part of our year-end Head of Internal Audit Opinion.

Audit Objectives and Scope To undertake a comprehensive annual work programme to test the effectiveness of strategic risk management, leadership and committee governance arrangements, supporting the use of the Assurance Framework. Stage 2 of our work programme comments on:  The findings from our Governing Body survey on governance, risk management and culture;  The extent to which the organisation is utilising the Governing Body Assurance Framework as a strategic management tool (e.g. ‘live’ document). This includes ensuring that processes outlined (at Stage 1) regarding the review, update and monitoring of the Governing Body Assurance Framework are functioning effectively;  Progress against actions agreed as part of our 2017/18 year-end Head of Internal Audit Opinion and our 2018/19 Stage 1 Memo; and  Outturn of individual audit assignments and follow-up implementation rate (year-to- date).

1 Published July 2018 (report reference 1819/BCCG/02M)

Limitations of scope: The scope of our work is limited to the areas identified above. It is not designed to give assurance on the entirety of the organisation’s risk management system or full organisational governance framework. We are not assessing the appropriateness of the organisation’s own scoring or response to risks in accordance with the organisation’s risk appetite.

Audit Opinion We will provide our Head of Internal Audit Opinion, incorporating our assessment of the design and operation of the Assurance Framework, towards the year-end in accordance with the reporting requirements to support your Annual Governance Statement.

Stage 2 Summary Conclusion Governing Body Assurance Framework The CCG has refreshed its Integrated Risk Management Framework in August 2018. This has included an update to the GBAF reporting timescales to Governing Body in line with a review of frequency of meetings. As a result it was agreed that the Governing Body would receive a summary of the GBAF, and details of risks rated as extreme, at every meeting and that the full assurance framework would be received at least 3 times a year.

The GBAF has continued to be presented throughout the year to the Governing Body, Audit Committee, Finance and Performance Committee and Quality and Patient Safety Committee in accordance with the revised Framework. The GBAF is a “rolling” document and an updated version was presented to the Governing Body in November.

The GBAF is aligned with the Strategic Objectives against which priority areas are identified. A review of the GBAF reported to Governing Body in November 2018 demonstrates that updates have been made during the year including identification of additional sources of assurance and key controls to mitigate threats.

The GBAF is underpinned by a Risk Register. The Risk Register contains current risks to the CCG and risks in the GBAF for which there are gaps in control or assurance. Risks on the Risk Register are allocated to a responsible Committee and the relevant extract has been reported to each Committee during the year. Minutes reflect any actions arising from the view and that updates have been ‘noted’.

We reviewed the minutes of Governing Body discussions during the year to confirm that key issues are being reflected in the CCG’s risk management framework. These were:  Integrated Care Partnership (Priority Area 5 and 5.2);  CAMHS (Mental Health Services) (Priority Area 4); and  Hospital Services Review (Priority Area 5 and 5.2).

Our view is supported by the findings from our Governing Body survey. Our summary survey results are provided in Appendix A. Overall, the survey results provide a positive picture for the CCG with respondents scoring an average of 4 or 5 for each question. There were a small number of responses which indicated that members were unsure or strongly disagreed with the CCG may wish to consider further.

Individual Audit Assignments At the time of writing this memo, we have issued six individual audit assignments to the CCG, all of which have been provided with significant assurance.

Follow Up As at January 2019 the current level of recommendations implemented based on their initial agreed timescales is 47% (88% overall). This falls within the 'significant' opinion level for this segment.

We have confirmed the all actions agreed as part of our 2017/18 year-end Head of Internal Audit Opinion and our Stage 1 review have been satisfactorily addressed by the CCG. We have not raised any further recommendations as a result of our Stage 2 review.

Kay Meats, Client Manager Tel: 01709 428704 Email: [email protected]

Reports prepared by 360 Assurance and addressed to NHS Barnsley CCG directors or officers are prepared for the sole use of NHS Barnsley CCG, and no responsibility is taken by 360 Assurance or the auditors to any director or officer in their individual capacity. No responsibility to any third party is accepted as the report has not been prepared for, and is not intended for, any other purpose and a person who is not a party to the agreement for the provision of Internal Audit between NHS Barnsley CCG and 360 Assurance dated 1st April 2018 shall not have any rights under the Contracts (Rights of Third Parties) Act 1999. The appointment of 360 Assurance does not replace or limit NHS Barnsley CCG’s own responsibility for putting in place proper arrangements to ensure that its operations are conducted in accordance with the law, guidance, good governance and any applicable standards, and that public money is safeguarded and properly accounted for, and used economically, efficiently and effectively. The matters reported are only those which have come to our attention during the course of our work and that we believe need to be brought to the attention of NHS Barnsley CCG. They are not a comprehensive record of all matters arising and 360 Assurance is not responsible for reporting all risks or all internal control weaknesses to NHS Barnsley CCG. This report has been prepared solely for your use in accordance with the terms of the aforementioned agreement (including the limitations of liability set out therein) and must not be quoted in whole or in part without the prior written consent of 360 Assurance.

Summary Survey Results Our survey contained 21 questions over 7 areas. Participants were asked to rate each of the statements from a range of 1 (strongly disagree) to 5 (strongly agree). We received 11 responses (85% response rate). We shared the responses with the Head of Governance and Assurance on 27 December 2018. Overall, the survey results provided a positive picture for the CCG with respondents scoring an average of 4 or 5 for each question. There were a small number of responses which indicated that members were unsure or strongly disagreed with the CCG may wish to consider further. We compared the responses for the CCG against the circa 120 responses we had received across our CCG client base. The results are shown below: Key

Question/Commentary Survey Results 1. I clearly understand my organisation’s strategic objectives and was appropriately engaged in their development.

Average score: 5

1 2 3 4 5 2. I am clear about the success measures that indicate whether or not my organisation’s strategic objectives are being met.

Average score: 4

One respondent strongly disagreed.

1 2 3 4 5 3. I understand the purpose of my organisation’s Assurance Framework and how it is developed.

Average score: 5

1 2 3 4 5

Question/Commentary Survey Results 4. The format of my organisation’s Assurance framework is clear and understandable.

Average score: 5

1 2 3 4 5 5. My organisation’s Assurance Framework exclusively focuses on strategic objectives and associated risks.

Average score: 4

One respondent strongly disagreed.

1 2 3 4 5 6. The Assurance Framework adequately covers all areas of strategic risk faced by my organisation.

Average score: 5

One respondent strongly disagreed.

1 2 3 4 5 7. There is meaningful review and challenge of the Assurance Framework at Governing Body level (and/or nominated delegated Joint Committees).

Average score: 5

1 2 3 4 5

Question/Commentary Survey Results 8. The Assurance Framework is supported by summary reports / covering papers to facilitate Governing Body members’ awareness and understanding of how strategic risks are being managed.

Average score: 5

1 2 3 4 5 9. Where committees have delegated responsibility, I receive assurance at Governing Body that they have reviewed and challenged the Assurance Framework.

Average score: 5

One respondent was unsure. 1 2 3 4 5 10. The assurances referenced in the Assurance Framework are reliable, and of good quality, and give me confidence that risks are being effectively managed.

Average score: 5

1 2 3 4 5 11. There is an appropriate balance between assurances that are obtained from internal sources (i.e. prepared by management within the organisation - the 1st and 2nd lines of defence) and those that are commissioned from, or provided by, external sources (3rd line of defence).

Average score: 4

1 2 3 4 5 One respondent was unsure.

Question/Commentary Survey Results 12. There are sufficient and robust actions in place to address gaps in control and/or assurance within my organisation’s Assurance Framework.

Average score: 4

1 2 3 4 5 13. I receive sufficient and timely updates on the implementation of actions and, where actions are not achieved, there appropriate challenge.

Average score: 4

One respondent was unsure.

1 2 3 4 5 14. I receive sufficient information to be assured that risk is being well managed within my organisation.

Average score: 5

1 2 3 4 5 15. I understand the difference between my organisation’s risk register(s) and the Assurance Framework and how these link together.

Average score: 5

1 2 3 4 5

Question/Commentary Survey Results 16. My organisation’s risk appetite has been agreed by the Governing Body.

Average score: 5

1 2 3 4 5 17. The target risk scores in my organisation’s Assurance Framework reflects our agreed risk appetite.

Average score: 5

1 2 3 4 5 18. The Governing Body discuss the reasons why target risk scores are not achieved and take action as appropriate.

Average score: 5

1 2 3 4 5 19. I receive sufficient information to be assured on the effectiveness of the organisation’s system of internal control. (i.e. to support the Accountable Officer’s declaration within the Annual Governance Statement).

Average score: 5

1 2 3 4 5

Question/Commentary Survey Results 20. As a Governing Body, we are collectively able to assess whether or not gaps in control identified in the Assurance Framework cast doubt on the effectiveness of the overall system of internal control.

Average score: 5

1 2 3 4 5 21. There is a culture at Governing Body level that allows open debate and challenge about the strategic risk issues the organisation faces.

Average score: 5

1 2 3 4 5

DOMESTIC ABUSE SUPPORT POLICY

Version 1 Date ratified Policy Number Name of originator/author Head of HR Name of Sponsor Chief Nurse Name of responsible committee Equality and Engagement Committee Date issued April 2019 Review date April 2022 Target audience All staff working within or on behalf of NHS Barnsley CCG

To ensure you have the most current version of this policy please access via the NHS Barnsley CCG Intranet Site by following the link below:

Final Version XXXX 1

Appendix 4 POLICY AUDIT TOOL

Please give status of Policy: New

1. Details of Policy 1.1 Policy Number HR035/08/2021 1.2 Title of Policy: Domestic Abuse Policy 1.3 Sponsor Chief Nurse 1.4 Author: Head of HR 1.5 Lead Committee Equality and Engagement Committee 1.5 Reason for policy: Legislative and best employment practice 1.6 Who does the policy affect? All employees 1.7 Are the National Guidelines/Codes No of Practices etc issued? Has an Equality Impact Assessment Yes been carried out? 2. Information Collation 2.1 Where was Policy information See 1.6 obtained from? 3. Policy Management 3.1 Is there a requirement for a new or n/a revised management structure for the implementation of the Policy? 3.2 If YES attach a copy to this form. 3.3 If NO explain why. Current management structure satisfactory 4. Consultation Process 4.1 Was there external/internal Yes consultation? 4.2 List groups/persons involved Staff Chair/Trade Unions Designated Professional - Safeguarding Staff Engagement Forum 4.3 Have external/internal comments Yes been included? 4.4 If external/internal comments have n/a not been included, state why. 5. Implementation 5.1 How and to whom will the policy be All employees via the intranet distributed? 5.2 If there are implementation Ongoing via mandatory training requirements such as training please detail. 5.3 What is the cost of implementation No funding required and how will this be funded 6. Monitoring 6.2 How will this be monitored Workforce Reports 6.3 Frequency of Monitoring Quarterly

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Appendix 4

CONTENTS

Page

Section A – Policy

1. Policy Statement, Aims & Objectives 4

2. Legislation & Guidance 4

3. Scope 4

4. Accountabilities & Responsibilities 4

5. Dissemination, Training & Review 5

Section B – Procedure

1. Domestic Abuse Definition 7

2. Basic Principles 8

3. Support for employees experiencing Domestic Abuse 8

4. Confidentiality 9

5. Manager’s Responsibilities 9

APPENDIX 1 Good Practice Guidelines 11

APPENDIX 2 Helplines and Contact Information 12

APPENDIX 3 External Agencies Providing Advice/Support

APPENDIX 4 Equality Impact Assessment 13

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Appendix 4 SECTION A – POLICY

1. Policy Statement, Aims and Objectives

1.1 NHS Barnsley Clinical Commissioning Group (CCG) values the views and experiences of all employees and seeks such information through regular communication and staff surveys. In addition, the organisation encourages employees who are, or have been the victim or the perpetrator of domestic abuse to seek support and information.

1.2 There is an increasing demand for flexibility in the workplace and a requirement for high level skills therefore the retention and motivation of employees is important.

1.3 The development of this policy:

 Ensures all employees recognise that domestic abuse is a serious issue within society  Provides effective, confidential and sympathetic support to employees and recognises they may not wish to divulge this fact, even in strict confidence, to any other employee of the organisation  Ensures employees are aware of the various external organisations which can offer support and guidance.

2. Legislation and Guidance

2.1 The following legislation and guidance has been taken into consideration in the development of this procedural document.

 Domestic Violence, Crime and Victims (Amendment) Act 2012  Government strategy to tackle Violence Against Women and Girls (VAWG)  Home Office ‘Domestic Violence & Abuse’ (https://www.gov.uk/domestic- violence-and-abuse )  Domestic abuse: a toolkit for employers

3. Scope

3.1 This policy applies to those members of staff that are directly employed by NHS Barnsley CCG and for whom the CCG has legal responsibility. Seconded staff are covered by the policy of their employing organisation. For those staff covered by a letter of authority / honorary contract or work experience, this policy is also applicable whilst undertaking duties on behalf of the CCG or working on CCG premises and forms part of their arrangements with the CCG. As part of good employment practice, agency workers are also required to abide by CCG policies and procedures, as appropriate, to ensure their health, safety and welfare whilst undertaking work for the CCG.

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Appendix 4 4. Accountabilities and Responsibilities

4.1 Overall accountability for ensuring that there are systems and processes to effectively ensure compliance with this Policy lies with the Chief Officer. Responsibility is delegated to the following:

 Maintaining an overview of the corporate ratification and governance process associated Chief Officer with the policy.  Ensuring that the policy is applied fairly, consistently and in a non-discriminatory manner.

 Leading the development, implementation and review of the policy. Head of HR  Providing advice and guidance to managers and employees in relation to this policy.  Ensuring the policy and procedure is reviewed and updated as required

 With HR Lead, senior leader with responsibility for the workplace policy on domestic Head of Quality abuse. and Safeguarding

 Ensuring they understand and adhere to their obligations in relation to the policy. Appointing  Ensuring the policy is applied fairly and Officers/ Line consistently to all employees. Managers  Ensuring employees are aware of this Policy including referring new employees to the policy as part of their induction process.

 Ensuring they understand their responsibilities in All Employees relation to this Policy

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Appendix 4

 Ensuring they are familiar with the Policy and procedure. Staff Side  Advising and representing employees who are members of a recognised Trade Union

5. Dissemination, Training and Review

5.1 Dissemination

The effective implementation of this procedural document will support openness and transparency. NHS Barnsley Clinical Commissioning Group will:

 Ensure all employees and stakeholders have access to a copy of this procedural document via the organisation’s website.  Ensure employees are notified by email of new or updated procedural documents.  Ensure that relevant training programmes raise and sustain awareness of health and wellbeing.

5.2 Training

All line managers and employees will be offered relevant training commensurate with their duties and responsibilities. Employees requiring support should speak to their line manager in the first instance. Support may also be obtained through Human Resources.

All employees are required to undertake Safeguarding training appropriate to their role, to help enable them to recognise domestic abuse.

5.3 Review

5.3.1 As part of its development, this procedural document and its impact on staff, patients and the public has been reviewed in line with the CCG’s Equality Duties. The purpose of the assessment is to identify and if possible remove any disproportionate adverse impact on employees, patients and the public on the grounds of the protected characteristics under the Equality Act.

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Appendix 4 5.3.2 The procedural document will be reviewed every three years, and in accordance with the following on an as and when required basis:  Legislatives changes  Good practice guidelines  Case Law  Significant incidents reported  New vulnerabilities identified  Changes to organisational infrastructure  Changes in practice

5.3.3 Procedural document management will be performance monitored to ensure that procedural documents are in-date and relevant to the core business of the organisation.

SECTION B – PROCEDURE

1. Domestic Abuse Definition

1.1 Domestic abuse can be described as a range of behaviours which are used against someone in order to gain power, control and compliance. It can be extremely complicated with victims experiencing many tactics of abuse at any one time. Some forms of abuse can be subtle, others are more extreme and visible to people around them. This can make domestic abuse hard to identify and hard for the victim to understand.

NHS Barnsley CCG and its partners use the national definition of domestic abuse, which is:

“any incident or pattern of incidents of controlling, coercive or threatening behaviour, violence or abuse between those aged 16 or over who are, or have been, intimate partner or family members regardless of gender or sexuality. This can encompass but is not limited to psychological, physical, sexual, financial and emotional abuse”. (Home Office, 2013)

Controlling behaviour is: a range of acts designed to make a person subordinate and/or dependent by isolating them from sources of support, exploiting their resources and capacities for personal gain, depriving them of the means needed for independence, resistance and escape and regulating their everyday behaviour.

Coercive behaviour is: an act or a pattern of acts of assault, threats, Final Version XXXX Page 7 of 18

Appendix 4 humiliation and intimidation or other violence that is used to harm, punish, or frighten their victim. This definition, which is not a legal definition, includes so called 'honour’ based violence, female genital mutilation (FGM) and forced marriage, and is clear that victims are not confined to one gender or ethnic group.

1.2 Domestic abuse is any abuse which takes place in an intimate or family relationship. It can happen to anyone although most frequently it overwhelmingly concerns men's abuse of power over their female partner or ex-partners, and the children of those women. However, it is important to recognise that men can be abused and women can be abusers and that abuse can and does happen in same gender relationships. Services in Barnsley are available to both male and female victims. The abuse may be physical, sexual, emotional/ psychological, financial or, more likely, a combination of these. Domestic Abuse describes all forms of violent and controlling behaviour, and is inclusive of the experiences of children and young people living in fear of such behaviour. As such, this policy should also be followed when managing situations involving Child Sexual Exploitation and other forms of historical sexual abuse or trauma such as Female Genital Mutilation. This is not an exhaustive list.

As we recognise that both men and women can be victims of domestic abuse, for simplicity throughout these guidelines we have referred to the victim as a person.

1.3 A list of forms of abuse and potential indicators are listed in Appendix 1.

2. Basic Principles

2.1. Abuse is unacceptable and should not be condoned in any circumstance.

2.2 Employees need to consider their own personal safety and must not expose themselves to unnecessary risk. Employees should, where possible keep line managers informed.

2.3 Advice should always be offered where possible and by an appropriate person (e.g. line manager, Human Resources Team, Safeguarding professionals), information given and signposted to specialist services.

Employees who are victims of domestic abuse should be given time and space to make choices and be supported, whatever decision they make.

2.4 Do not blame the victim for the abuse.

2.5 Always believe a victim who discloses abuse.

2.6 Treat employees with respect and dignity.

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Appendix 4

2.7 Victims living with domestic abuse will not necessarily want to end their relationship, or may decide to return to an abusive partner. They should be offered a choice of options, time to talk these through and non-judgemental support in making their own choices.

2.8 Harassment or intimidation by a CCG employee whether of a partner or ex- partner who is employed by the CCG or not, will be considered misconduct and may lead to disciplinary action being taken.

Conduct outside of work (whether or not it leads to a criminal conviction) may also lead to disciplinary action being taken because of the impact it may have on the employee’s suitability to undertake their role and/or because it undermines public confidence in the CCG. Advice must be sought from Human Resources, Chief Nurse and Safeguarding Team.

Any allegations of this nature would be fully investigated and action taken as appropriate in accordance with the Disciplinary Policy and if necessary reported to the relevant agencies through the Local Safeguarding Team.

2.9 All staff should be aware of the Good Practice guidelines that are available in Appendix 2.

3. Support for employees experiencing or affected by Domestic Abuse

3.1 Any employee who is experiencing, or is affected by, domestic abuse is encouraged to seek support and speak to their Director, line manager, HR Team, Trade Union representative, the Employee Assistance Programme or the Occupational Health Service, who will help to identify the appropriate specialist support.

Staff to whom disclosure has been made may also be in need of support and guidance and are encouraged to access the sources of support listed above.

3.2 The matter will be dealt with on a strictly confidential basis and only those who need to be aware from an advice or support perspective will be made aware of the situation.

3.3 Any employee who feels that domestic abuse is having an impact on their self-esteem can arrange to attend one to one counselling sessions.

3.4 Employees who are experiencing domestic abuse often require to take time off work in order to visit solicitors, banks, schools, support agencies etc and this can be accommodated through the organisation’s Special Leave Policy; such arrangements should be made, in confidence, through the employee’s line manager. Alternatively, this can be progressed through the HR Team,

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Appendix 4 Trade Union representative or the Occupational Health service, who may then discuss the matter with the line manager.

3.5 Further details of external agencies who can provide advice and/or support to victims of domestic abuse are listed in Appendix 3.

3.6 Notwithstanding any action taken under 2.8 above, the CCG would also seek to provide support to any employee who discloses that they are the perpetrator of domestic abuse. Managers should signpost the employee to a Perpetrator Programme which can be accessed via self-referral to South Yorkshire Community Rehabilitation Company. Tel: 01142 567 270; website: inspiretochange.co.uk or email: [email protected]

4. Confidentiality

4.1 The CCG will treat any breach of confidentiality committed by an employee under the provisions of the appropriate employee conduct procedure, in which case the range of penalties open to the organisation will include dismissal.

4.2 The need for confidentiality generally includes ensuring that an employee’s address, telephone number and work location is not identified.

4.3 To protect the confidentiality of employees, the CCG will ensure that any disclosures which are required under its data protection registration, or its responsibilities under the Freedom of Information Act, do not have the potential to compromise employees who may be experiencing domestic abuse. The CCG will also ensure that, in cases where an employee is known to suffer from domestic abuse, only those other employees who “need to know” about the employee’s situation are informed.

4.4 If a line manager feels there is a child/adult safeguarding concern, managers should speak to the safeguarding team within the CCG.

4.5 Extreme care should be taken to protect employees affected by abuse and no information should be disclosed which may breach their safety e.g. where staff are contacted by a third party trying to use the whereabouts of children to trace a mother. This would apply even if the enquirer were a professional, partner or family member who worked in a local agency.

4.6 It needs to be made clear to employees that there are limits to the extent of confidentiality and that in cases where children or adults who are at risk are living in a violent household, information may be passed to other agencies in line with child protection procedures and similarly for adults in line with adult safeguarding procedures.

5. Manager Responsibilities

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Appendix 4

5.1 All chief officers, senior/line managers and supervisors must be aware that domestic abuse can influence the health and self-confidence of people who may be reticent to confide in others, or seek help. They should, therefore, be alerted to the signs of possible domestic abuse e.g. distracted and/or lacking in self-confidence, which may be reflected in work performance, while being aware that domestic abuse may not always be the reason behind such conditions. Any sign of physical injury, particularly if these are repeated, should also be noted. 5.2 Where an abusive situation is disclosed the manager should consult the Safeguarding Team who will assess whether or not a referral should be made to a Multi-Agency Risk Assessment Conference (MARAC) and the employee informed of this. 5.3 All managers should recognise the importance of employee welfare and appreciate that, by supporting an employee who may be affected by domestic abuse; they will potentially contribute to an improvement in service delivery and a reinforcement of good management/employee relations.

5.4 All managers should ensure that employees are aware of the issues surrounding domestic abuse by bringing this policy to their attention and the services that can offer help to them.

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Appendix 4 APPENDIX 1 FORMS OF ABUSE AND POTENTIAL INDICATORS

PHYSICAL THREATS  Punching  To kill her/him  Shoving  To kill or hurt her/his children  Hitting  To abuse children  Drowning  To withhold care if ill or disabled  Biting  To find her/him if she/he leaves  Beating  To have her/him locked up – she/he is  Pushing mad/unfit  Choking  Blame her/him for breaking up family  Stabbing  Turn children against her/him  Rape  Abuse her/him in front of children  Burning  Smash or burn everything  Scalding  Mutilate  Denying sleep

EMOTIONAL SEXUAL  Jealousy  Rape  Telling her/him she/he’s worthless  Buggery  Boasting about abuse to friends  Forcing sex when ill or tired  Forcing to do things at exact times, in exact ways  Forcing sex with others  Undermining  Forcing to mimic pornography  Telling her/him she/he’s a bad mother/father  Using objects during sex  Telling her/him she/he couldn’t manage on her/his  Forcing sex with friends own  Forced prostitution  Repeated criticism  Forcing to be photographed

ISOLATION FINANCIAL/ECONOMIC  No visitors, friends, family  Making her/him beg for money  Locking in house/room  Threatening to kick her/him out of house  Not allowed to work/attend college/evening class  Withholding information re welfare benefits  Accompanying him/her to and from work by isolating her/him  Not allowed out on own  Running up debts in her/his name  When out not allowing to talk to anyone, walking  Withholding money for basic necessities him/her to the toilet  Monitoring/controlling the use of phonecalls  Using tracking technology to monitor whereabouts

POTENTIAL INDICATORS  suspicious injury or attempts to disguise an injury through clothing and make-up; Final Version XXXX Page 12 of 18

Appendix 4  partner / family member always present and answering for the person;  depression; alcohol and drug abuse;  self-harm;  anxiety and self-neglect;  regular non-attendance for appointments;  restrictions on access to money;  restrictions in relation to work, education and social life;  children having issues such as behavioural difficulties, being withdrawn or sleep problems.

APPENDIX 2

GOOD PRACTICE GUIDELINES FOR MANAGERS OR COLLEAGUES Final Version XXXX Page 13 of 18

Appendix 4

 Do give priority to ensuring the employee’s immediate safety  Do ensure that the employee understands the confidentiality policy  Do be sensitive and believe what the employee is telling you  Do find out what the employee wants and see if you can help to achieve it  Do help to explore ways of maximising the employee’s safety.  Do give up to date information on what other agencies have to offer  Do place the responsibility for the abuse with the perpetrator. The violence is not the employee’s fault  Do take personal responsibility for ensuring that appropriate information and support is offered  Do use non-threatening, open questions  Do always allow time for the person to talk  DO NOT ignore your intuition if you suspect an employee is being abused  DO NOT ask her/him what she/he did to provoke the violence  DO NOT just focus on what she/he alone can do in the situation  DO NOT assume the perpetrator’s age or sex  DO NOT share your own experiences  DO NOT act as a go-between, between victim and perpetrator

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Appendix 4 APPENDIX 3 – External Agencies Providing Advice and/or Support

National Domestic Abuse Helpline: 0800 2000 247 National LGBT+ Domestic Abuse Helpline: 0800 999 5428Mankind Confidential Helpline for male victims of domestic abuse and domestic violence. Tel: 01823 334 244 Domestic abuse services in Barnsley are provided by IDAS. Their website gives more information: https://www.idas.org.uk/our-services/domestic-abuse/ IDAS provide support to anyone who is a victim or survivor of domestic abuse regardless of their gender.

Advice and support specifically for LGBT+ people can be found at: http://www.galop.org.uk/domesticabuse/ and at https://lgbt.foundation/how-we-can- help-you/domestic-abuse Mankind Initiative is a registered charity and a member of the Helplines Partnership. Their website is a source of information and support for men who are victims and survivors of domestic abuse as well as for their families and loved ones. https://www.mankind.org.uk/help-for-victims/ In an emergency dial 999. Domestic abuse is taken very seriously by the police. For advice on what to do if you have concerns about a child follow the CCG Safeguarding Vulnerable Clients Policy or contact the Designated Nurse Safeguarding Children for advice and support. Appendix 4 Domestic abuse: a toolkit for employers https://www.bitc.org.uk/sites/default/files/bitc_phe_domestic_abuse_toolkit.pdf

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Appendix 4 NHS Barnsley CCG Equality Impact Assessment 2016

Title of policy or service Domestic Abuse Policy

Name and role of Officers completing Head of HR the assessment Date assessment started / completed January 2019 Updated

1. Outline

Give a brief summary of your policy or NHS Barnsley Clinical Commissioning Group (CCG) values the views and service experiences of all employees and seeks such information through regular  Aims communication and staff surveys. In addition, the organisation encourages  Objectives employees who are, or have been the victim or the perpetrator of domestic  Links to other policies, including partners, abuse to seek support and information. national or regional  Ensures all employees recognises that domestic abuse is a serious issue within society  Provides an effective, confidential and sympathetic support to employees and recognises that they may not wish to divulge this fact, even in strict confidence, to any other employee of the organisation  Ensures employees are aware of the various external organisations which can offer support and guidance.

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Appendix 4 2. Gathering of Information This is the core of the analysis; what information do you have that indicates the policy or service might impact on protected groups, with consideration of the General Equality Duty. What What difference will this make? What key impact have you identified? action do Positive Neutral Negative you need Impact impact impact to take to address these issues? Human rights  Age  Carers  Disability 

Sex  Race  Religion or belief  Sexual orientation  Gender reassignment  Pregnancy and  maternity Marriage and civil  partnership (only eliminating discrimination) Other relevant group

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Appendix 4 Please provide details on the actions you need to take below.

3. Action plan

Issues identified Actions required How will you measure Timescale Officer impact/progress responsible

4. Monitoring, Review and Publication

When will the proposal be reviewed and by whom? Lead Officer Review Head of HR April 2022 Date:

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GB/Pu 19/03/19

GOVERNING BODY

14 MARCH 2019

INTEGRATED PERFORMANCE REPORT

PART 1A – SUMMARY REPORT

1. THIS PAPER IS FOR

Decision Approval Assurance X Information X

2. REPORT OF

Name Designation Executive Lead Roxanna Naylor / Jamie Chief Finance Officer / Wike Director of Strategic Planning and Performance Author Roxanna Naylor/ Jamie Chief Finance Officer/ Wike Director of Strategic Planning and Performance

3. SUMMARY OF PREVIOUS GOVERNANCE

The matters raised in this paper have been subject to prior consideration in the following forums:

Group / Committee Date Outcome Finance and Performance 7/3/19 Noted current position and Committee agreed reporting to Governing Body

4. EXECUTIVE SUMMARY

4.1 The Finance and Performance reports aim to provide an overview of the performance of NHS Barnsley Clinical Commissioning Group (BCCG) up to the end of January 2019.

4.2 The reports provide details of the latest performance against key performance indicators and an overview of the financial performance of the CCG up to 31 January 2019 or the latest available position.

1 4.3 The Finance and Performance Committee have received a more detailed report containing all indicators monitored by the CCG and detailed financial analysis to enable them to maintain oversight of performance and finance and provide assurance to Governing Body.

4.4 The performance report attached at Appendix 1 provides a high level dashboard and an exception report which covers the NHS Constitution standards, quality indicators, key performance indicators linked to local priorities and financial performance.

4.5 Performance continues to be generally strong for Barnsley patients with key standards in relation to A&E, referral to treatment, diagnostics, mental health and CHC all being achieved for the latest performance period.

This continues positive performance particularly in relation to A&E, RTT and diagnostics is set in the context of increasing demand over recent months with activity levels above plan for December.

Achievement of key cancer waiting times standards continues to be challenging with the following not achieving the required standards in December:

 The number of people waiting longer than 31 days from diagnosis to first definitive treatment  The number of people waiting longer than 62 days from referral to first definitive treatment (Cancer)  The number of people waiting longer than 62 days from referral to first definitive treatment (Cancer)

4.6 The detailed finance report, attached at Appendix 2, provides an assessment of the current financial performance of the CCG up to 31 January 2019, together with forecasts for the year end. The report contains the headline messages along with monthly financial monitoring.

4.7 As at 31 January the CCG is forecasting to achieve all financial duties and planning guidance requirements, with an in-year balanced budget. Reflected within this position is a £1m increase to the CCGs surplus as agreed at November private Governing Body and with NHS England. The forecast position as at Month 10 shows ‘headroom’ of £100k which will be utilised to manage further in-year pressures. Further information on the CCG’s financial performance targets is set out in section 2 of Appendix 2.

The CCG’s efficiency programme position as at 31 January is that planned schemes are expected to deliver £11.7m against the £11.5m target. Governing Body are asked to note that whilst there is not an immediate need to identify further in year mitigations this may be required should the forecast position of the CCG deteriorate. The Governing Body will be kept informed of the financial position through this report which is a standing agenda item.

5. THE GOVERNING BODY / COMMITTEE IS ASKED TO:

Note the contents of the report including:  2018/19 performance to date  projected delivery of all financial duties, predicated on the assumptions

2 outlined in this paper  the current forecast position on the CCG’s efficiency programme

6. APPENDICES / LINKS TO FURTHER INFORMATION Performance Section  Appendix 1 – Barnsley CCG Monthly Performance Report to January 2019

Finance Section  Appendix 2 – Finance Report 2018/19 – Month 10

Agenda time allocation for report: 5 minutes.

3 PART 1B – SUPPORTING INFORMATION

1. Links to the Governing Body Assurance Framework Risk ref(s) This report provides assurance against the following risks on 1.1, 1.3, 1.4, the Governing Body Assurance Framework: 3.1 and 4.1 2. Links to CCG’s Priority Areas Y/N 1 - Urgent & Emergency Care Y 2 - Primary Care Y 3 - Cancer Y 4 - Mental Health Y 5 - Integrated Care System (ICS) Y 6 - Efficiency Plan Y 7 - Transforming Care for People with Learning Disabilities Y and / or Autistic Spectrum Conditions 8 - Maternity Y 9 - Compliance with Statutory and Regulatory Requirements Y 3. Governance Arrangements Checklist 3.1 Financial Implications Has a financial evaluation form been completed, signed off NA by the Finance Lead / CFO, and appended to this report? Are any financial implications detailed in the report? Section 4

3.2 Consultation and Engagement Has Comms & Engagement Checklist been completed? NA Is actual or proposed engagement activity set out in the NA report?

3.3 Equality and Diversity Has an Equality Impact Assessment been completed and NA appended to this report?

3.5 Environmental Sustainability Are any significant (positive or negative) impacts on the NA environment discussed in the report?

3.6 Human Resources Are any significant HR implications identified through NA discussion with the HR Business Partner discussed in the report?

4 NHS Barnsley Clinical Commissioning Group Performance Report for Governing Body

CCGs are accountable to their local populations and to NHS England for planning and delivering comprehensive and high quality care that meets the needs of their local community.

We have created the tools that you need to ensure that your activities and operations are compliant with the targets set within the CCG Assurance Framework. Governing Body Exception Report Dashboard

Exception Report 2018/19 Key Performance Indicators by Exception Indicator Target Actual Period Actual YTD Period Performance

9 of 44 patients waited longer than 62 days for treatment in December following urgent referral. Of these 3 were Gynae, 2 Lower GI 2 Upper GI, 1 Lung and 1 head and neck.

Barnsley Hospital continue to achieve this target. Cancer - % Patients seen within 62 days of referral 85.00% 79.55% 83.55% from GP 4 of the breaches involved Inter Provider Transfers between Barnsley Hospital and Sheffield Teaching Hospital. Of the other 5, 1 involved and IPT between Rotherham and STH, 1 between Doncaster and STH and 3 at Barnsley. In Barnsley the Cancer Group are continuing to work on local pathways to ensure waiting time standards are achieved including developing straight to test pathways where appropriate. Barnsley Hospital achieved the 85% target.

During December 5 of 107 patients waited longer than 31 days for treatment following diagnosis. 4 of the breaches were at STH (2 Urology 1 Lung and 1 head and neck) and 1 was at Barnsley (Urology).

Barnsley Hospital continue to achieve this target. Cancer - % Patients seen within 31 days from referral 96.00% 95.33% 95.62% to treatment 4 of the breaches were due to elective capacity at Sheffield Teaching Hospital. The 1 breach at Barnsley Hospital was due to medical reasons. The number of breaches is low however the CCG continue to work with Sheffield CCG as the lead commissioner for STH to support imporvement.

During December 2 of 6 patients waited longer than 62 days for for treatment following a referral from a screening service. 1 breach was at Barnsley Hospital and the other a shared breach resulting from a IPT between Barnsley and Sheffield.

Cancer - % Patients seen from referral within 62 days Barnsley Hospital are achieving this target for the year to date but did not achieve in December. 90.00% 66.67% 88.41% (Screening Service: Breast, Bowel & Cervical) Performance against this standard is impacted by the very low numbers which result in a small number of breaches having a big impact upon the % performance. The vast majority of patients are seen within 62 days and therfore no additional commissioner action is proposed however performance will continue to be monitored and discussed with providers. Governing Body Exception Report Dashboard

Governing Body Report 2018/19 Performance Outcomes Target Actual Period Actual YTD Period Trend Improved Access to Psychological Services-IAPT: People entering treatment against level of need 1.59% 1.58% 1.52% Jan-19 Improved Access to Psychological Services-IAPT: People who complete treatment, moving to recovery 50.0% 56.2% - Jan-19 Estimated diagnosis rate for people with dementia 68.1% 70.8% 69.1% Jan-19 CHC eligibility within 28 days 80.0% 42.6% - Q3 18/19 Number of CHC Referrals - 29 254 Jan-19 Number of CHC Referrals Completed Within 28 Days - 24 123 Jan-19 % of CHC Referrals Completed Within 28 Days 80.0% 82.8% 48.4% Jan-19 Percentage of NHS Continuing Healthcare assessments taking place in an acute hospital setting 15.0% 0.0% - Q2 18/19 Number of DSTs Completed in Acute Hospital Setting - 0 1 Jan-19 % DSTs Completed in Acute Hospital Setting 15.0% 0.0% - Jan-19 % Patient experience of primary care - GP Services - 81.0% - Aug-18 % Patient experience of primary care - GP Out of Hours services - 67.7% - Aug-18 % 4 hour A&E waiting times - seen within 4 hours - CCG (Monthly) 89.0% 90.5% 93.5% Jan-19 % 4 hour A&E waiting times - seen within 4 hours (Type 1 BHNFT) (Monthly) 89.0% 91.1% 94.0% Jan-19 % Patients on incomplete non-emergency pathways waiting no more than 18 weeks (Commissioner) 92.0% 94.2% 93.7% Dec-18 Number of 52 week Referral to Treatment Pathways Incomplete (Commissioner) 0 0 4 Dec-18 % Patients waiting for diagnostic test waiting > than 6 wks from referral (Commissioner) 1.00% 0.73% 0.60% Dec-18 Cancer - % Patients seen within 2wks referred urgently by a GP 93.0% 96.0% 95.4% Dec-18 Cancer - % Patients referred with breast symptoms seen within 2 wks of referral 93.0% 93.7% 92.7% Dec-18 Cancer - % Patients seen within 31 days from referral to treatment 96.0% 95.3% 95.6% Dec-18 Cancer - % Patients seen within 31 days for subsequent treatment (Surgery) 94.0% 100.0% 95.8% Dec-18 Cancer - % Patients seen within 31 days for subsequent treatment (Drugs) 98.0% 100.0% 100.0% Dec-18 Cancer - % Patients seen within 31 days for subsequent treatment (Radiotherapy) 94.0% 100.0% 96.7% Dec-18 Cancer - % Patients seen within 62 days of referral from GP 85.0% 79.5% 83.5% Dec-18 Cancer - % Patients seen from referral within 62 days (Screening Service: Breast, Bowel & Cervical) 90.0% 66.7% 88.4% Dec-18 Cancer - % Patients being seen within 62 days (ref. Consultant) 85.0% 100.0% 83.0% Dec-18 Category1 - YAS Mean Response Time 07:00 06:59 07:26 Jan-19 Category2 - YAS Mean Response Time 18:00 19:49 20:45 Jan-19 Proportion of people on Care Programme Approach (CPA) who were followed upwithin 7 days of discharge 100.0% 95.1% 96.0% Q3 18/19 Urgent operations cancelled for a second time 0 0 0 Dec-18 Ambulance handover delays of over 30 mins 0 232 1109 Jan-19 Ambulance handover delays of over 1 hour 0 18 63 Jan-19 Satisfaction with accessing primary care 71.0% 62.0% - Aug-18 % Patient experience of primary care - GP Services - 81.0% - Aug-18 Trolley waits in A&E -zero waits from decision to admit to admissions over 12 hours - BHNFT (Month) 0 0 0 Jan-19 Proportion of people waiting 18 weeks or less from referral to first IAPT treatment appointment 95.0% 100.0% - Jan-19 Proportion of people waiting 6 weeks or less from referral to first IAPT treatment appointment 75.0% 97.2% - Jan-19 Cancelled operations rebooked within 28 days 0 0 0 Dec-18

Quality Outcomes Target Actual Period Actual YTD Period Trend Patient experience of hospital care 77.3 75.8 - YTD 2015/16 Incidence of healthcare associated infection (HCAI) - MRSA (Commissioner) 0 0 3 Dec-18 Incidence of healthcare associated infection (HCAI) - MRSA (Provider) - BHFT 0 0 2 Dec-18 Incidence of healthcare associated infection (HCAI) - C.Diff (Commissioner) YTD Target - 45 3 27 Dec-18 Incidence of healthcare associated infection (HCAI) - C.Diff (Provider) - BHFT YTD Target - 9 2 12 Dec-18 Number of mixed sex accomodation breaches (Commissioner) 0 0 3 Dec-18 Appendix 2

Putting Barnsley People First

NHS Barnsley Clinical Commissioning Group Finance Report 2018/19 Month 10

1 Headline Messages and contents Headline Messages Contents 1 Headline Messages and  As at 31 January, the CCG forecasts to achieve all financial duties and planning guidance requirements, with an in-year Content balanced budget. Reflected within this position is an increase to the CCGs surplus of £1m. This position is predicated on the continued delivery of the CCG’s £11.5m efficiency programme and in year forecast position which continues to be forecast 2 Financial Performance Targets above planned levels. Further information on the CCG’s financial performance targets is provided in section 2. 3 Monthly Finance Monitoring  Acute contract activity data has been received for Month 9. The forecast position shows an overtrade position of £2.0m; with Statement – Executive the main forecast overtrade of £5.5m being with Barnsley Hospital NHS Foundation Trust (BHNFT). The BHNFT position has Summary increased by £240k from the position last month. Non-elective admissions continue to be above plan with activity 6.30% above YTD plan and expenditure 10.58% above YTD plan. The forecast overspend on non-elective admissions are estimated to 3.1 Detailed Summary be approx. £6m against plan for BHNFT with total non-elective forecast expenditure being £61.5m (42.2% of the BHNFT Resource Allocation – contract). The Trust maintain that the improvement in coding in addition to that which has already taken place and is reflected Detailed Summary in the expenditure increase above, will have a further financial impact on the forecast before the year end. This forecast also includes £1m of support to ensure that the Trust can achieve its control total and further assumed pressure in non-elective activity of £600k. Activity across most associate contracts is below planned levels across all points of delivery, with Mid Yorkshire and Sheffield Teaching & Leeds Teaching being above planned levels. The acute contract risk budget has been released to support the pressure across contracts.

 Primary Care prescribing data has been received to Month 8 from NHS Business Services Authority (BSA). The current forecast including income, and underutilised 2017/18 accruals is a £2.2m underspend. The forecast includes pressures relating to Category M Drug of £280K, no cheaper obtainable stock of £932k and increasing Prescribing pressures during the winter period of £250k. These will continue to be closely monitored with the Head of Medicines Optimisation and Head of Finance/Chief Finance Officer to ensure an accurate forecast position is reported.

 The CCG’s Efficiency Programme Management Office (PMO) will continue to monitor and review delivery of the CCG’s £11.5m efficiency programme. The forecast position on planned schemes, as reported by project managers shows a £244k over achievement against the £11.5m target. It is not anticipated further QIPP will be required, however that this position may need to be reviewed if the forecast position significantly deteriorates during the remaining part of the year.

 Risks and Mitigations were considered by the Finance and Performance Committee . The current projections in the ‘Most Likely’ scenario indicate a potential net mitigation of £1,029k, this together with a forecast overspend of £927k provides ‘headroom’ of £100k. Work will continue to assess risk and further potential mitigations and this will be reported on an ongoing basis to the Finance and Performance Committee.

 Cash management information was also considered by the Finance and Performance Committee to ensure appropriate oversight of the cash position within the CCG. Cash remains above the 1.25% set by NHSE due to outstanding invoices from BMBC and BHNFT, however this will be managed to within the 1.25% for Month 12.

2 Financial Performance Targets

1) Financial Duties

2018/19 NHS Act 2018/19 Actual 2018/19 Actual Duty Section Target £'000 Performance Achievement £'000 223H (1) Expenditure not to exceed income 423,031 422,031 YES 223I (2) Capital resource use does not exceed the amount specified in Directions 0 0 YES 223I (3) Revenue resource use does not exceed the amount specified in Directions 422,851 421,851 YES 223J(1) Capital resource use on specified matter(s) does not exceed the amount specified in Directions 0 0 YES 223J(2) Revenue resource use on specified matter(s) does not exceed the amount specified in Directions 0 0 YES 223J(3) Revenue administration resource use does not exceed the amount specified in Directions 5,598 4,450 YES 2) Financial targets/NHS England Business Rules requirements

2018/19 Actual 2018/19 Actual 2018/19 Performance Achievement Target/Business Rule Requirement Target £'000 Delivery of in year balanced position 0 0 YES 0.5% Contingency to manage in-year pressures 2,106 2,106 YES

Comments The CCG is currently forecasting to achieve all financial duties/targets and NHS England (NHSE) Business Rules, this is however predicated on the delivery of the CCG’s efficiency programme and in year forecast position. Financial Performance targets represent an in year financial balanced budget, with the CCG planning to utilise £1,148k of administration resource to cover additional spending on commissioned services for the population of Barnsley.

It is important to note that whilst the in year position reflects a balanced budget the CCG has a historic surplus held by NHSE. NHSE has approved a drawdown from this resource in 2018/19 of £600k and the CCG has further increased its surplus by £1m as agreed at November Governing Body. The historic surplus balance in 2018/19 now totals £14,532k. The CCG will have access to £2m of this surplus in 2019/20 as agreed with NHS England; however access to resource above this is unlikely to be accessed without NHSE approval and consideration to the national financial position across the NHS.

3 Monthly Finance Monitoring Statement – Executive Summary

ANNUAL YTD OUTTURN ANNUAL TOTAL BUDGET YTD YTD VARIANCE FORECAST VARIANCE BUDGET ANNUAL PROGRAMME AND RUNNING COST AREAS NON BUDGET ACTUAL OVER / OUTTURN OVER / RECURRENT BUDGET RECURRENT £'000 £'000 (UNDER) £'000 (UNDER) £000 £000 £000 £ £ PROGRAMME EXPENDITURE Acute 208,513 (443) 208,070 173,066 174,327 1,261 210,076 2,006 Mental Health 32,743 202 32,946 27,637 27,111 (526) 33,046 101 Community Health 46,180 729 46,909 39,174 38,683 (492) 46,381 (529) Primary Medical Services (Co-Commissioning) 36,193 296 36,489 30,101 29,546 (554) 35,658 (831) Primary Care Other 57,672 1,554 59,226 49,693 46,395 (3,297) 56,406 (2,820) Continuing Health Care 19,326 290 19,616 16,338 16,632 294 20,540 924 Other Programme Costs 8,073 1,113 9,186 7,914 11,097 3,183 12,183 2,997 TOTAL COMMISSIONING SERVICES (INCLUDING PRIMARY CARE RESERVES) 408,701 3,741 412,442 343,923 343,791 (131) 414,291 1,849 Corporate Costs 2,523 0 2,523 2,102 1,717 (386) 2,119 (404) Depreciation / Property Charges 1,059 0 1,059 883 555 (328) 689 (370) TOTAL CORPORATE COSTS 3,582 0 3,582 2,985 2,272 (713) 2,808 (774) TOTAL PROGRAMME COSTS (INCLUDING PRIMARY CARE RESERVES) 412,283 3,741 416,024 346,908 346,063 (845) 417,099 1,075 RUNNING COSTS Pay 3,332 (9) 3,324 2,769 2,043 (727) 2,554 (769) Non Pay 2,314 91 2,404 2,003 1,441 (562) 2,106 (298) Income (130) 0 (130) (108) (93) 15 (210) (80) TOTAL RUNNING COSTS 5,516 82 5,598 4,665 3,390 (1,274) 4,450 (1,148) CCG Reserves 2,156 (927) 1,229 0 0 0 1,229 0 NHS England Planning Guidance Reserves 0 0 0 0 0 0 0 0 In year surplus 0 (1,000) (1,000) (833) 0 833 0 1,000 In Year (Over)/underspend 0 0 0 0 1,285 1,285 (927) (927) TOTAL RESERVES/CONTINGENCY (EXCL. PRIMARY CARE RESERVES) 2,156 (1,927) 229 (833) 1,285 2,119 302 73 TOTAL EXPENDITURE 419,955 1,896 421,851 350,739 350,739 0 421,851 (0) Programme 414,761 2,492 417,253 346,908 346,908 0 417,253 0 Running Costs 5,481 117 5,598 4,665 4,665 0 5,598 0 RESOURCE ALLOCATIONS 420,242 2,609 422,851 351,572 351,572 0 422,851 0

SURPLUS/(DEFICIT) 287 713 1,000 833 833 (0) 1,000 0

Comments  Acute contract activity data has been received for Month 9. The forecast position shows an overtrade position of £2.0m; with the main forecast overtrade of £5.5m being with Barnsley Hospital NHS Foundation Trust (BHNFT). The BHNFT position has increased by £240k from the position last month. Non-elective admissions continue to be above plan with activity 6.30% above YTD plan and expenditure 10.58% above YTD plan. The forecast overspend on non-elective admissions are estimated to be approx. £6m against plan for BHNFT with total non-elective forecast expenditure being £61.5m (42.2% of the BHNFT contract). The Trust maintain that the improvement in coding in addition to that which has already taken place and is reflected in the expenditure increase above, will have a further financial impact on the forecast before the year end. This forecast also includes £1m of support to ensure that the Trust can achieve its control total and further assumed pressure in non-elective activity of £600k. Activity across most associate contracts is below planned levels across all points of delivery, with Mid Yorkshire and Sheffield Teaching & Leeds Teaching being above planned levels. The acute contract risk budget has been released to support the pressure across contracts.

 Community Services are forecasting an underspend position due to the release of £400k non recurrent budget which is not expected to be utilised and CQUIN achievement from 2017/18.

 Prescribing forecasts are projecting a forecast underspend is a £2.2m underspend. The forecast includes pressures relating to Category M Drug of £280K, no cheaper obtainable stock of £932k and increasing Prescribing pressures during the winter period of £250k. These will continue to be closely monitored.

 Primary Care Services (Co-Commissioning) – This underspend relates in the main to underutilisation of 2017/18 accruals and national resource to support GP contract uplifts which were funded from within CCG baseline budgets.

 Continuing Care forecasts continue to be reviewed due to the volatile nature of these budgets. A full review of all care packages has been undertaken and the impact of this review is included within the forecast position. This will continue to be reviewed on an ongoing basis.

 Other programme costs are forecasting an overspend due to the contribution to BMBC for the Prevention section 75 agreement and contribution to resilience as agreed with Governing Body.

 Running Costs are forecasting a significant underspend due to a number of vacancies currently being held and other non-recurrent savings. A full review of running costs will be undertaken to ensure that the reduction in running cost allocations for 2020/21 is achieved and provides sustainability for the commissioning of services.

3.1 Resource Allocation – Detailed Summary

NON NON RECURRENT TOTAL RECURRENT TOTAL RESOURCE ALLOCATIONS - PROGRAMME, RESERVES & SURPLUS RECURRENT RESOURCE ALLOCATIONS - RUNNING COSTS RECURRENT £000 £000 £000 £000 £000 £000 Description Month £ £ £ Description Month £ £ £ Anticipated Allocation 1819 M1 378,863 378,863 2018/19 Allocation M1 5,481 5,481 Surplus drawdown M1 600 600 NR - HSCN - Running costs M1 35 35 NR - Paramedic Rebranding M1 64 64 Market Rents - admin M1 47 47 NR - HSCN M1 47 47 Pay award uplift - AfC M5 35 35 Anticipated Allocation 1819 - Primary Care Co-Commissioning M1 35,917 35,917 AFC pay award uplift Rec to NON - REC Admin M10 (35) 35 Primary Care Co-Commissioning tfr to prgramme - GPFV M3 (220) (220) Primary Care Co-Commissioning - suspending Dr budgets M3 (28) (28) Primary Care Co-Commissioning tfr to prgramme - GPFV M3 220 220 SCH Amber services M3 70 70 Diabetes Transformation Fund: TT DTCN06 M3 32 32 Diabetes Transformation Fund: SE DTCN06 M3 40 40 2018-19 CYP IAPT Trainee staff salary support funding M3 12 12 SCH Amber services - Adj to M3 transfer to correct value M4 (1) (1) AfC pay award - Programme Costs M5 43 43 Dental element of interpreting service M5 (60) (60) NDPP to Q2 Non Rec M6 25 25 Diabetes Transformation Fund: TT DTCN06 M6 40 40 Diabetes Transformation Fund: SE DTCN06 M6 32 32 Calderdale, Wakefield, Kirklees and Barnsley Transforming Care Partnership M7 270 270 NDPP Q3 1819 M7 12 12 CYP IAPT Trainee salary support M7 12 12 Excess treatment costs - As agreed at Management Team/Governing Body M7 (7) (7) Suicide prevention monies M8 78 78 Change exempt overseas visitors CEOV M8 (361) (361) Windows 10 Upgrades M9 26 26 GP Uplift on contracts (1%) M9 296 296 Development of Primary Care networks M9 284 284 Quality Premium Tranche 1 Measures 2 - 6 M9 578 578 Cancer 62 Day Performance Improvement Funding (Barnsley Hospitals) M9 10 10 Diabetes Transformation Fund: DTCN06 SE M9 40 40 Diabetes Transformation Fund: DTCN06 TT M9 32 32 Advanced practice manager course - part funding for ICS M9 2 2 LD Transforming Care additional support funding per C Swithenbank M9 17 17 Mental Health Winter Pressures M9 42 42 Green paper waiting times M10 61 61 ICS population health management M10 40 40 Maternity Transformation funding M10 96 96 NDPP Transformation funding M10 13 13 Transforming Cancer Allocation M10 13 13 AFC pay award uplift Rec to NON - REC programme M10 (43) 43 0 LD Complex Case M10 3 3

TOTAL RESOURCE ALLOCATION 414,761 2,492 417,253 TOTAL RESOURCE ALLOCATION 5,481 117 5,598

SUMMARY £'000 £'000 £'000 Programme 414,761 2,492 417,253 Running Costs 5,481 117 5,598 TOTAL RESOURCE ALLOCATION 420,242 2,609 422,851

Comments Allocations in Month 10 relating to the following:  Green paper Mental Health waiting time initiatives - £61k  ICS Population Health Management - £40k  Maternity Transformation Funding - £96K  National Diabetes Prevention Programme - £13K  Cancer Transformation - £13K  Agenda for Change pay award funding – change from non-recurrent to recurrent £43k Programme/£35k  Transforming Care – Complex 3.5Case funding Better - £3k Payment Practice Code – Detailed Summary GB Pu 19/03/20

GOVERNING BODY

14 MARCH 2019

Quality, Innovation, Productivity and Prevention (QIPP) Programme Reporting

1. THIS PAPER IS FOR

Decision Approval Assurance X Information X

2. REPORT OF

Name Designation Executive Lead Jamie Wike Director of Strategic Planning and Performance Author Jamie Wike Director of Strategic Planning and Performance

3. SUMMARY OF PREVIOUS GOVERNANCE

The matters raised in this paper have been subject to prior consideration in the following forums:

Group / Committee Date Outcome Finance and Performance 7/3/18 Noted the current position Committee

4. EXECUTIVE SUMMARY

4.1 The QIPP programme reporting dashboards aim to provide the Governing Body with an overview of progress and performance against the schemes within the CCG QIPP/Efficiency Programme. The progress of each scheme has been reviewed by the QIPP Delivery Group and the dashboards have been reviewed by the Finance and Performance Committee and are therefore presented for assurance and information.

4.2 The Governing Body usually receive 2 dashboard designed to provide a high level overview of current delivery of the QIPP programme following review by the Finance and Performance Committee to provide assurance on the overall programme delivery. All of the projects currently still in the delivery phase are currently on track and therefore this month the Governing Body are only presented with the dashboard which provides a summary of the performance against key performance indicators for those schemes which have been

1 GB Pu 19/03/20

implemented and are expected to deliver benefits and efficiencies during the year.

Details of the current assessment of the financial position against the CCG efficiency programme are included within the Integrated Performance Report. The position as at 31 January 2019 is that schemes are expected to deliver £11.7m against the £11.5m target.

The Governing Body are asked to note that whilst there is not an immediate need to identify further in year mitigations this may be required should the forecast position of the CCG deteriorate.

5. THE GOVERNING BODY IS ASKED TO:

 Note the content of the dashboard and identify any specific actions that the Governing Body agree in relation to the QIPP/Efficiency Programme.  Note the current position against the £11.5m target.

6. APPENDICES / LINKS TO FURTHER INFORMATION  Appendix 1 QIPP Reporting and Escalation Dashboards

Agenda time allocation for report: 5 minutes.

2 GB Pu 19/03/20

PART 1B – SUPPORTING INFORMATION

1. Links to the Governing Body Assurance Framework Risk ref(s) This report provides assurance against the following risks on 6 the Governing Body Assurance Framework: 2. Links to CCG’s Priority Areas Y/N 1 - Urgent & Emergency Care Y 2 - Primary Care Y 3 - Cancer Y 4 - Mental Health Y 5 - Integrated Care System (ICS) N 6 - Efficiency Plan Y 7 - Transforming Care for People with Learning Disabilities N and / or Autistic Spectrum Conditions 8 - Maternity N 9 - Compliance with Statutory and Regulatory Requirements Y 3. Governance Arrangements Checklist 3.1 Financial Implications Has a financial evaluation form been completed, signed off NA by the Finance Lead / CFO, and appended to this report? Are any financial implications detailed in the report? NA Whilst no financial evaluation form has been completed and there are no direct financial implication relating to this report, the report and proposed dashboard will provide an overview of financial performance against the CCG efficiency plans. The Integrated Performance Report provides further details relating to current reported financial performance against the CCG Efficiency Plan. 3.2 Consultation and Engagement Has Comms & Engagement Checklist been completed? NA Is actual or proposed engagement activity set out in the NA report?

3.3 Equality and Diversity Has an Equality Impact Assessment been completed and NA appended to this report?

3.5 Environmental Sustainability Are any significant (positive or negative) impacts on the NA environment discussed in the report?

3.6 Human Resources Are any significant HR implications identified through NA discussion with the HR Business Partner discussed in the report?

3 2018/19 QIPP Schemes Appendix 1

Total Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 Total YTD DEMAND MANAGEMENT 2018/19

Demand Management Baseline 8,034 9,488 9,299 8,814 8,631 8,631 9,422 9,332 7,564 8,195 7,398 7,545 79,215 102,353 2018/19 8,004 8,412 7,826 8,237 7,850 7,691 9,048 8,366 7,115 72,549 72,549 Get Fit First Actual Reduction/Increase -30 -1,076 -1,473 -577 -781 -940 -374 -966 -449 -6,666 Variance to Baseline -0.4% -11.3% -15.8% -6.5% -9.0% -10.89% -3.97% -10.35% -5.94% -8% Actual Cost Reduction/Increase -£197,304 -£194,826 -£305,707 -£200,740 -£99,645 -£74,203 -£106,685 -£5,873 £247,658 -£937,325

Demand Management Baseline 846 934 1,067 911 1,003 913 986 1,002 751 779 897 768 8,413 10,857 2018/19 874 973 917 900 810 755 902 925 672 7,728 7,728 Clinical Thresholds - Procedures Actual Reduction/Increase 28 39 -150 -11 -193 -158 -84 -77 -79 -685 Variance to Baseline 3% 4% -14% -1% -19% -17% -9% -8% -11% -8% Actual Cost Reduction/Increase -£11,049 £6,468 -£332,703 -£70,815 -£358,756 -£436,407 -£259,406 -£353,897 -£261,938 -£2,078,503

Demand Management Baseline 312 312 312 312 312 312 312 312 312 312 312 312 2,810 3,747 2018/19 275 245 264 249 258 42 80 51 43 1,507 Expected Reduction 0 0 0 0 0 0 -309 -297 -210 -302 -292 -258 -1,668 Acupuncture Actual Reduction/Increase -37 -67 -48 -63 -54 -270 -232 -261 -269 -1,303 Variance to Baseline -12% -22% -15% -20% -17% -87% -74% -84% -86% -46% Actual Reduction/Increase -£2,293 -£4,381 -£3,233 -£4,313 -£3,623 -£14,894 -£12,771 -£14,234 -14,883 -£74,625

Demand Management - Get Fit First

No of referrals from GP to smoking cessation programme 26 15 19 12 23 24 17 37 20 193

Demand Management - Get Fit First

No of referrals from GP to weight loss programme 55 65 43 39 17 51 24 18 16 328 Total Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 Total YTD BREATHE - RESPIRATORY 2018/19

BREATHE - Respiratory Target 76 77 69 60 46 54 78 76 112 137 93 99 648 977 2018/19 105 101 86 69 84 70 90 91 140 836 Non Elective Admissions for COPD Actual Reduction/Increase 29 24 17 9 38 16 12 15 28 188 Variance to Target 38% 31% 25% 15% 83% 30% 15% 20% 25% 29% Actual Cost Reduction/Increase £54,139 £58,222 £51,945 £2,109 £55,682 £9,602 £22,580 £28,581 £44,973 £327,835

BREATHE - Respiratory Target 162 142 197 195 215 171 212 207 131 237 185 179 1,632 2,233 Number of adult respiratory NEW 2018/19 185 190 226 191 139 200 191 155 175 1,652 secondary care outpatient appointments Actual Reduction/Increase 23 48 29 -4 -76 29 -21 -52 44 20 at BHNFT Variance to Baseline 14% 34% 15% -2% -35% 17% -10% -25% 34% 1% Actual Cost Reduction/Increase £4,851 £9,903 £5,366 -£1,443 -£17,264 £5,981 -£4,913 -£11,569 £9,044 -£43

BREATHE - Respiratory Target 210 236 259 257 423 324 399 362 210 464 389 302 2,680 3,835 Number of adult respiratory FUP 2018/19 235 295 367 298 239 261 301 260 197 2,453 secondary care outpatient appointments Actual Reduction/Increase 25 59 108 41 -184 -63 -98 -102 -13 -227 at BHNFT Variance to Baseline 12% 25% 42% 16% -43% -19% -25% -28% -6% -8% Actual Cost Reduction/Increase £2,187 £5,412 £10,167 £3,665 -£17,872 -£6,288 -£9,823 -£10,170 -£1,575 -£24,296 Total DIABETES Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 Total YTD 2018/19

Diabetes - Decrease over two years the number of hospital admissions in people aged over 18 years at Barnsley Hospital with a diagnosis of Diabetes or Specifically Related Conditions by 10% each year Target 4 8 8 5 5 8 12 14 5 11 8 10 68 96 2018/19 11 6 6 1 9 5 5 7 10 60 Ketoacidosis Actual Reduction/Increase 7 -2 -2 -4 5 -3 -7 -7 5 -8 Variance to Target 206% -26% -26% -78% 100% -38% -57% -48% 85% -11% Actual Cost Reduction/Increase £8,268 -£6,506 -£8,375 -£6,533 -£10,614 -£9,005 -£14,026 -£11,050 £5,977 -£51,863

Diabetes - Decrease over two years the number of hospital admissions in people aged over 18 years at Barnsley Hospital with a diagnosis of Diabetes or Specifically Related Conditions by 10% each year Target 0 2 1 0 2 0 0 0 1 0 0 1 5 6 2018/19 0 0 0 0 0 1 0 1 0 2 Hypoglycaemia Actual Reduction/Increase 0 -2 -1 0 -2 1 0 1 -1 -3 Variance to Target 0% -100% -100% 0% -100% 100% 0% 100% -100% -63% Actual Cost Reduction/Increase £0 -£1,917 -£2,437 £0 -£3,396 £467 £0 £1,700 -£2,437 -£8,020

Diabetes - Decrease over two years the number of hospital admissions in people aged over 18 years at Barnsley Hospital with a diagnosis of Diabetes or Specifically Related Conditions by 10% each year Target 0 1 0 0 2 2 0 0 0 0 0 0 5 5 2018/19 1 2 0 0 2 0 0 0 0 5 Hyperglycaemia Actual Reduction/Increase 1 1 0 0 0 -2 0 0 0 0 Variance to Target 100% 100% 0% 0% 0% -100% 0% 0% 0% 0% Actual Cost Reduction/Increase £3,167 £1,780 £0 £0 -£1,442 -£2,219 £0 £0 £0 £1,286

Diabetes - Decrease over two years the number of hospital admissions in people aged over 18 years at Barnsley Hospital with a diagnosis of Diabetes or Specifically Related Conditions by 10% each year Target 4 11 9 5 8 10 12 14 6 11 8 11 78 108 2018/19 12 8 6 1 11 6 5 8 10 67 Combined Actual Reduction/Increase 8 -3 -3 -4 3 -4 -7 -6 4 -11 Variance to Target 233% -27% -33% -78% 33% -41% -57% -41% 59% -14% Actual Cost Reduction/Increase £11,435 -£6,643 -£10,812 -£6,533 -£15,451 -£10,758 -£14,026 -£9,350 £3,540 -£58,597

Diabetes - Transfer current outpatient activity into Primary Care / Community settings Target 98 86 104 86 126 102 81 105 81 79 99 98 869 1,145 2018/19 113 104 104 80 74 68 73 77 77 770 Reduction in Outpatient Activity 10% Actual Reduction/Increase 15 19 1 -6 -52 -34 -8 -28 -4 -99 each year - Firsts Variance to Target 15% 22% 0% -7% -41% -33% -10% -27% -5% -11% Actual Cost Reduction/Increase £1,999 £2,845 -£935 -£1,388 -£11,282 -£4,733 £1,748 -£1,988 £1,036 -£12,698

Diabetes - Transfer current outpatient activity into Primary Care / Community settings Target 404 448 542 409 482 371 438 427 398 392 323 365 3,919 4,999 2018/19 414 389 463 363 325 269 478 318 301 3,320 Reduction in Outpatient Activity 10% Actual Reduction/Increase 10 -59 -79 -46 -157 -102 40 -109 -97 -599 each year - Follow Ups Variance to Target 2% -13% -15% -11% -33% -27% 9% -25% -24% -15% Actual Cost Reduction/Increase -£4,738 -£11,305 -£14,204 -£6,905 -£18,829 -£4,393 £5,489 -£3,982 -£4,880 -£63,746 Total PEARS Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 Total YTD 2018/19

Contract Change Baseline 161 161 161 161 161 161 0 0 0 0 0 0 966 966 2018/19 2 1 0 0 1 0 N/A N/A N/A N/A N/A N/A 4 Expected Reduction -97 -97 -97 -97 -97 -97 0 0 0 0 0 0 -580 PEARS (c/fwd from 2017/18) Actual Reduction/Increase -159 -160 -161 -161 -160 -161 N/A N/A N/A N/A N/A N/A -962 Variance to Baseline -99% -99% -100% -100% -99% -100% 0% 0% 0% 0% 0% 0% -100% Variance to Baseline -£7,950 -£8,000 -£8,050 -£8,050 -£8,000 -£8,050 N/A N/A N/A N/A N/A N/A -£48,100

GBPu 19/03/21.1

Minutes of the Meeting of the NHS Barnsley Clinical Commissioning Group FINANCE & PERFORMANCE COMMITTEE held on Thursday 3 January 2019 at 10.30am in the Boardroom, Hillder House, 49 – 51 Gawber Road, Barnsley S75 2PY.

PRESENT:

Dr Nick Balac (Chair) - Chair Dr John Harban - Elected Member Governing Body - Contracting Lesley Smith - Chief Officer Roxanna Naylor - Chief Finance Officer Dr Adebowale Adekunle - Elected Member Governing Body Jamie Wike - Director of Strategic Planning & Performance Nigel Bell - Lay Member Governance Dr Andrew Mills - Membership Council Member Dr Jamie MacInnes - Elected Governing Body Member

IN ATTENDANCE:

Leanne Whitehead - Executive Personal Assistant Adrian Bailey - Head of Finance: Statutory Accounts and Financial Reporting (attending as agreed in PDR)

APOLOGIES:

Patrick Otway - Head of Commissioning (MH, Children, Specialised)

The Chair and Committee welcomed Dr MacInnes to his first meeting of the Finance and Performance Committee.

Agenda Action & Item Deadline FPC19/01 QUORACY

The meeting was declared quorate.

FPC19/02 DECLARATIONS OF INTEREST, SPONSORSHIP, HOSPITALITY AND GIFTS RELEVENT TO THE AGENDA

The Committee noted the declarations of interest report. There were no declarations of interest raised relevant to the agenda.

FPC19/03 MINUTES OF THE PREVIOUS MEETING HELD ON 6 DECEMBER 2018 – Approved with a few minor amendments from LW - the Chair. actioned

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FPC19/04 MATTERS ARISING REPORT

FPC18/210 – Minutes of the Children’s Executive Commissioning Group

It was noted that the CAMHS Contracting Meeting notes were expected for the next agenda.

The Chair reported he had spoken with the Head of Commissioning in relation to the CAMHS report to Governing Body in January and noted that a further report would also come to the March Governing Body.

Agreed Actions:  CAMHS Contracting Meeting Notes to next meeting. PO

The Committee received and noted the report and updates.

FPC19/05 UPDATE ON RECENT PUBLISHED AND EXPECTED GUIDANCE

The Chief Finance Officer presented the report to the Committee which provided information on letters received from NHS England regarding planning and administration cost reduction. It was noted that part one of the planning guidance was received since the report was completed and this had been shared with members, part two was expected during the early part of January. It was reported that the NHS England expectation is that any 2019/20 running costs savings should fund any restructuring costs.

The Chief Finance Officer reported that the first cut of activity was due for submission on the 14 January 2019 and she was meeting with the Trusts Finance Director the following week to discuss. It was noted that the financial plan couldn’t be completed as allocations had not been received but planning work had commenced. A plan had been started to look at running costs and to explore working with LA and other CCGs as the NHS Long Term Plan was expected to reinforce the requirement for further integration across place and at a system level.

Chief Finance Officer reported that further primary care funding had been received from NHS England in Month 9. This was for investment to deliver Primary Care Networks (further £1 per head) and also to provide the contract uplift growth of 1% which had been paid to practices from the 1 April 2018. Agreed Actions:  Invite Director of Strategic Planning & Performance to meeting with Trust.  Head of Commissioning to look at first draft of plan re RN Mental Health and work with the Chief Finance Officer on any changes.

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GBPu 19/03/21.1

 Further update on primary care funding. RN/PO  GP Laptops for mobile working – Management Team RN requested an update on how this funding had been utilised and timelines for when equipment would be deployed. Update at next meeting. LS/RN

The Committee were asked to:  Note the contents of the report  Note the updates on planning and the requirements for the submission on 14 January 2019.  Note the requirement to reduce administration costs by 20% and suggested opportunities to explore provided by NHS England.

FPC19/05 UPDATE ON CONTRACTING CYCLE

The Chief Finance Officer presented the Update on Contracting Cycle to the Committee. The Committee were asked to note since the report was circulated a request for revenue contributions and considerations of the tariff proposals for the HASU were to be discussed at the next Joint Commissioning Committee as Mid Yorkshire Hospitals had made further requests for consideration.

An update was given on the Thames Ambulance Service, reporting that there have been issues with the service. Discussions remain ongoing and the contract requirements and process continue to be enforced with legal advice potentially being required.

The Committee were asked to note the contents of the report including:  the update on the Alliance Contract  the contract monitoring update  the update on the NHS 111 IUC procurement  the update on the HASU reconfiguration  planning for 2019/20 contracts

FPC19/06 APPROVAL AND OR UPDATE ON PROCUREMENTS

The Chief Officer presented the paper to the Committee noting that the Barnsley Primary Care Home Visiting Services was out to procurement and due to close on the 21 January 2019 the service commencement date was the 1 May 2019.

The Committee received and noted the report.

FPC19/07 INTEGRATED PERFORMANCE REPORT

Finance

The Chief Finance Officer presented the finance section of the report to the Committee highlighting that the CCG are forecasting

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to achieve all financial duties. It was reported that plans needed to be worked up and put in place to utilise available resource. Discussion was had around the HASU capital and revenue resource request from Mid Yorkshire Hospitals and it was agreed that a discussion should take place to at Governing Body. The Chief Finance Office provided an update on the coding audit and noted that it was anticipated that the audit results would be expected in February and this would be reported back to the Committee on the findings.

The Quarter 3 Financial Control, Planning and Governance Self- Assessment had been approved for submission by the Chief Officer and Audit Committee Chair and was presented to the committee for information and oversight. This would also be provided to the Governing Body before submission on 11 January 2019.

Performance

The Director of Strategic Planning and Performance reported that performance continues to be generally strong for Barnsley patients with key standards in relation to A&E, referral to treatment, diagnostics and mental health all being achieved for the latest performance period. It was reported that there were however two cancer standards which were not achieved in October, these were:

 The number of people waiting longer than 31 days for treatment following diagnosis.  The number of people waiting longer than 31 days for subsequent treatment, where that treatment was surgery.

Discussion was had around A&E performance and the overall good performance of the system approach as a whole which is working well together with winter support.

Agreed Actions:  Recommendation for Governing Body on HASU and Mid RN/LS Yorks capital resource.  Report back at next meeting results from coding audit. RN  Look at the 2 week wait urology referrals data. JW

The Committee received and noted the reporting including:  2018/19 performance to date  projected delivery of all financial duties, predicated on the assumptions outlined in this paper  the current forecast position on the CCG’s efficiency programme  the Quarter 2 submission of the Financial Control, Planning and Governance self-assessment.

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FPC19/08 QIPP PROGRAMME REPORTING

The Director of Strategic Planning and Performance presented an update on the QIPP Programme to the Committee with the appended dashboards showing the progress and performance of schemes and as of the 30 November schemes are expected to deliver £11.6 of the £11.5 target.

Members discussed the delivery and how it was having the desired effect following get fit first and clinical thresholds and focus was needed for next year’s QIPP. It was noted a session was planned for the QIPP Delivery Group for the 7 January to look at QIPP and potential opportunities for next year before feeding into clinical forum.

The Committee received and noted the report including:

 Note the content of the dashboard and identify any specific actions that the committee agree in relation to the QIPP/Efficiency Programme.  Note the current position against the £11.5m target.  Agree the content of the dashboard and any risks for escalation for presentation to Governing Body.

FPC19/09 ASSURANCE FRAMEWORK

The Director of Strategic Planning and Performance presented the Assurance Framework to the Committee. There were 6 amber risks 3 of which are shared with the Quality and Patient Safety Committee.

The Committee were asked to:  Review the risks on the 2018/19 Assurance Framework for which the Finance and Performance Committee is responsible  Note and approve the risks assigned to the Committee  Review and update where appropriate the risk assessment scores for all Finance and Performance Risks  Identify any new risks that present a gap in control or assurance for inclusion on the Assurance Framework  Agree actions to reduce impact of high risks  Identify any sources of positive assurance to be recorded on the Assurance Framework to reassure the Governing Body that the risk is being appropriately managed.

FPC19/10 RISK REGISTER

The Director of Strategic Planning and Performance presented the Risk Register to the Committee. There were 2 red risks on the

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register. The Committee discussed Risk 13/3 A&E 4 hour target and how performance was positive and perhaps looking to decrease the score on this looking at the system approach. Following some apprehension from the Chair the Committee agreed to score the risk a 3/4 making this an amber rating and agreed to monitor this on a monthly basis through the performance report.

Agreed Actions:  A&E isn’t highlighted as a specific area of focus in Assurance Framework and they should link together. JW  Decrease scoring of risk 13/3 and report to Governing Body. JW

The Committee were asked to:

 Review the Finance and Performance Committee Risk Register extract for completeness and accuracy  Note and approve the risks assigned to the Committee  Review the risk assessment scores for all Finance and Performance risks  Identify any other new risks for inclusion on the Risk Register  Agree actions to reduce impact of extreme and high risks  Identify any positive assurances relevant to these risks for inclusion on the Assurance Framework

FPC19/11 MINUTES OF THE BHNFT CONTRACT EXECUTIVE BOARD – 15 November 2018 – Noted and noted that 19/20 Contract conversations will start shortly.

FPC19/12 MINUTES OF THE SWYPFT CONTRACT EXECUTIVE BOARD – 21 November 2018 – Cancelled

FPC19/13 MINUTES OF THE CHILDRENS EXECUTIVE COMMISSIONING GROUP – 15 November 2018 – Noted, Chief Finance Officer reported meetings are operational and a review of joint meetings with BMBC and section 75 probably needs to be done in the future, particularly in light of the expectations of planning guidance.

FPC19/14 MINUTES OF THE ADULTS JOINT COMMISSIONING GROUP – 17 July 2018 and 6 November 2018 – Noted.

FPC19/15 MANAGEMENT TEAM DECISIONS WITH FINANCIAL IMPLICATIONS

The Director of Strategic Planning and Performance presented the report the Committee. The Finance & Performance Committee were asked to note that the following decisions to commit expenditure were taken by Management Team during December

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2018:  Agreed £8k + expenses contribution towards the cost of KPMG facilitated provider workshops  Agreed up to £100,000 funding for 4.5 WTE staff on a temporary basis in the CHC team to support the clearance of backlogs.

Members raised concerns over the cost associated with facilitating the recent workshops which were duly noted and agreed this would not be done in the future and was a one off. It was suggested perhaps the Committee could limit the use of consultants in line with guidance and raise this awareness and feedback from the Committee with budget holders. It was noted that a report with further detail re CHC staffing would be presented at Governing Body in January.

The Committee received and noted the report.

FPC19/16 ANY OTHER BUSINESS

No items were raised under this heading.

FPC19/16 AREAS OF ESCALATION TO GOVERNING BODY

 Risk Register score change for A&E 4 hour performance  HASU and Mid Yorks  Finance Update

FPC19/18 REFLECTION ON HOW THE MEETINGS BUSINESS WAS CONDUCTED Members felt the meeting went well and all relevant business was covered.

FPC19/19 DATE AND TIME OF NEXT MEETING

Thursday 7 February 2019 at 10.30 am in the Boardroom at Hillder House, 49 – 51 Gawber Road, Barnsley, S75 2PY.

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FPC 19/03/21.1a

Minutes of the Meeting of the NHS Barnsley Clinical Commissioning Group FINANCE & PERFORMANCE COMMITTEE held on Thursday 7 February 2019 at 10.30am in the Boardroom, Hillder House, 49 – 51 Gawber Road, Barnsley S75 2PY.

PRESENT:

Dr Nick Balac (Chair) - Chair Dr John Harban - Elected Member Governing Body - Contracting Roxanna Naylor - Chief Finance Officer Jamie Wike - Director of Strategic Planning & Performance Nigel Bell - Lay Member Governance Dr Andrew Mills - Membership Council Member Dr Jamie MacInnes - Elected Governing Body Member

IN ATTENDANCE:

Leanne Whitehead - Executive Personal Assistant

APOLOGIES: Dr Adebowale Adekunle - Elected Member Governing Body Patrick Otway - Head of Commissioning (MH, Children, Specialised) Lesley Smith - Chief Officer

Agenda Action & Item Deadline FPC19/20 QUORACY

The meeting was declared quorate.

FPC19/21 DECLARATIONS OF INTEREST, SPONSORSHIP, HOSPITALITY AND GIFTS RELEVENT TO THE AGENDA

The Committee noted the declarations of interest report. There were no declarations of interest raised relevant to the agenda.

FPC19/22 MINUTES OF THE PREVIOUS MEETING HELD ON 3 JANUARY 2019 – Approved with minor changes.

FPC19/23 MATTERS ARISING REPORT

FPC19/05 Update on Recent and Expected Guidance

The Chief Finance Officer reported that the Head of Commissioning was revisiting the report that was previously discussed at Governing Body in relation to mental health investments and the level of resource expected and had been

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asked to include all investments for further discussion with members. It was agreed a process was needed for any future investments committed as there was currently 2019/20 investment planned to achieve standards but some were missing from the original report and further requests for mental health funding were still being received. The Lay Member Governance suggested that perhaps Governing Body need a summarised overview of what’s been agreed and what has been requested and whether resource is being used efficiently and value for money. This would come back to Governing Body for further discussion.

FPC18/174 IPR (Breathe)

Dr J Harban reported that the RAP was ready for sign off. The Chief Finance Officer reported that she had raised concerns with the Lead Commissioning and Transformation Manager as activity seemed to be rising. Dr J Harban had requested the team look at 0 length of stays, only December figures had been seen so activity may improve in month 10 data.

FPC19/07 IPR (Urology)

The Director of Strategic Planning and Performance reported that changes in relation to urology referrals went out to practice at the end of 2018. Data for quarter 1 was awaited to see if it was showing any impact/changes in relation to urology 2 week referrals.

Agreed actions:  Report urology referrals data findings once received to Committee. JW

FPC19/24 INTEGRATED PERFORMANCE REPORT

Finance

The Chief Finance Officer presented the finance section of the report to Committee highlighting that the CCG were forecasting to achieve all financial duties and planning guidance requirements with an in-year balanced budget. It was reported there were some risks in the system looking at month 10 data from the Trust and the finance team were working on this. It was noted that the coding report was awaited from the recent audit taken place, but indication was that the Trust could be losing income on coding, the final report would come to the Committee for discussion. It was reported that there could be a number of CHC back dated claim cases, so could be some risks around this and managing year end could be tight. QIPP remains on track and working on month 10 data now. The Chief Finance Officer drew the Committee’s attention to section 6 of the report which was a new spreadsheet showing the CCG’s cash management, drawdown and ledger balance. The Committee reviewed this and were comfortable.

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Agreed Actions:  Bring final report on coding audit to Committee for discussion once available. RN  Trust not using MIG, issues to pick up via IT prospective on this. RN

Performance

The Director of Strategic Planning and Performance updated members on the performance section of the report with the following areas highlighted with exception:

 The number of people accessing IAPT services  The number of people waiting longer than 2 weeks following urgent referral with breast symptoms (not initially suspected to be cancer)  The number of people waiting longer than 62 days from referral to first definitive treatment (Cancer)  The number of CHC referrals completed within 28 days

It was reported that CHC referrals completed within 28 days were now included in the performance report and would continue to be included in future reports. It was noted that year to date performance for A&E was looking to achieve its 95% target.

Agreed Actions:  Dermatology back log, White Rose sub contract with Trust, Committee requested some company information/update on this service. RN The Committee noted the report including:  2018/19 performance to date  projected delivery of all financial duties, predicated on the assumptions outlined in this paper  the current forecast position on the CCG’s efficiency programme

FPC19/25 QIPP PROGRAMME REPORTING

The Director of Strategic Planning and Performance presented an update on the QIPP Programme to the Committee. It was reported that all plans were reporting green on the dashboard and were all on track. The activity was shared and it was noted that the challenge was for a strong programme for next financial years to deliver the QIPP target. It was agreed to look at non electives.

The Committee received and noted the report.

FPC19/26 FINANCIAL PLAN – HIGHLIGHT PRESENTATION

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The Chief Finance Officer gave a presentation to members on the financial plan including planning guidance, allocations and what was included in the draft of plan which required submission of the first draft on Monday 11 February. The Chief Finance Officer took members through the slides and discussion was had.

The Committee agreed the proposed plan and QIPP planning for 2019/20.

Agreed Actions:  Review non elective admissions and potential opportunities for 2019/20 QIPP plans. ALL

FPC19/27 MANAGEMENT TEAM DECISIONS WITH FINANCIAL IMPLICATIONS

The Director of Strategic Planning and Performance presented the report the Committee. It was reported that no decisions to commit expenditure were taken by Management Team during January 2019.

The Committee received and noted the report.

FPC19/28 ANY OTHER BUSINESS

No items were raised under this heading.

FPC19/29 AREAS OF ESCALATION TO GOVERNING BODY

Financial Plan to be discussed at March Governing Body. RN

FPC19/30 REFLECTION ON HOW THE MEETINGS BUSINESS WAS CONDUCTED The Committee felt the meeting went well.

FPC19/31 DATE AND TIME OF NEXT MEETING

Thursday 4 April 2019 at 10.30 am in the Boardroom at Hillder House, 49 – 51 Gawber Road, Barnsley, S75 2PY.

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Minutes of the Meeting of the Barnsley Clinical Commissioning Group AUDIT COMMITTEE held on Thursday 24 January 2019 at 09.30 am in Meeting Room 1, Hillder House, 49/51 Gawber Road, Barnsley S75 2PY

PRESENT:

Nigel Bell Audit Committee Chair – Lay Member for Governance Dr Adebowale Adekunle Elected Member Governing Body Chris Millington Lay Member for Patient and Public Engagement and Primary Care Commissioning

IN ATTENDANCE:

Adrian Bailey Head of Finance Claire Croft Counter Fraud Leanne Hawkes Deputy Director 360 Assurance Kay Meats Client Manager, 360 Assurance Kay Morgan Governance and Assurance Manager Roxanna Naylor Chief Finance Officer Richard Walker Head of Assurance Clare Partridge Partner - KPMG

APOLOGIES

None

The Committee Chair opened the meeting and welcomed Leanne Hawkes, Deputy Director 360 Assurance and Clare Partridge, Partner – KPMG.

Agenda Note Action Deadline Item

AC QUORACY - The meeting was declared quorate 19/01/01

AC DECLARATIONS OF INTEREST, SPONSORSHIP, 19/01/02 GIFTS AND HOSPITALITY

The Committee noted the Declaration of Interests Report. No new declarations of interest were received.

AC MINUTES OF THE PREVIOUS MEETING HELD ON 19/01/03 11 OCTOBER 2018

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The Minutes of the meeting held on 11 October 2018 were verified as a correct record of the proceedings.

The Chief Finance Officer referred to minute reference AC 18/10/06 regarding the Internal Audit review of the CHC Broadcare System and confirmed that all recommendations and improvements to the system will be implemented by 31 March 2019 with a re-audit of the Broadcare System scheduled for Q1 2019/20.

AC MATTERS ARISING 19/01/04 The Audit Committee agreed that the following actions are complete:

 Minute reference AC 18/10/06 Internal Audit Progress report.  Minute reference AC 18/07/06 Local Counter Fraud Specialist Progress Report.

STANDING AGENDA ITEMS

AC ASSURANCE ON COMPLIANCE WITH STANDING 19/01/05 ORDERS AND PRIME FINANCIAL POLICIES

The Audit Committee were provided with assurance in respect of compliance with the CCG’s Standing Orders and Prime Financial Policies. Members’ attention was drawn to a decision not to apply competitive tendering relating to the extension of the SLA for SWYPT Transport Services.

In response to questions raised the Head of Governance advised that the SLA had been inherited from the PCT. Part of the service paid for by the CCG is intertwined with services in other local NHS partner organisations and would be difficult to disentangle in a meaningful way. The SLA was substantively the same as in previous years and logical to roll forward.

It was noted that a report about the future of CCG procurements, existing contracts and options will be considered by the Governing Body in March 2019.

The Audit Committee noted the report and the decision not to apply competitive tendering in respect of the extension to the SLA for SWYPT Transport Services.

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THIRD PARTY ASSURANCE

AC LOCAL COUNTER FRAUD PROGRESS REPORT 19/01/06 The Local Counter Fraud Specialist presented the Counter Fraud, Bribery and Corruption Report to the Audit Committee. The Committee noted that performance was on track to deliver the 2018/19 work plan and nothing of concern had arisen from the Staff Fraud Survey. Work is in progress looking at Declaration of Interests specifically to identify individuals who may not have declared all interests to the CCG.

With regard to an overpayment identified by an NHSCFA investigation the Local Counter Fraud Specialist reported that monies are starting to be recovered. The value for Barnsley was £8K. The learning from the investigation had been discussed with the Head of Medicines Optimisation in Barnsley and actions are in place. The Chief Finance Officer commented that she was not aware to controls put in place by the Head of Medicines Optimisation and a further discussion was required with the Local Counter Fraud Specialist to ensure appropriate checks were being carried out.

In response to questions raised the Committee noted that the Local Counter Fraud Specialist:

 Reviewed new and existing CCG policies / procedures with regard to measures for reducing fraud, bribery and corruption.  All ad-hoc requests for advice from the Local Counter Fraud Specialist were subsequently discussed with the Director of Finance.

The Audit Committee noted the Counter Fraud, Bribery and Corruption Report.

Agreed Actions:

 To send the detail of the Local Counter Fraud CC contract performance to Audit Committee Members.  To determine that the actions and controls put in RN CC place within the CCG following an NHSCFA CL investigation regarding medicines overpayment are appropriate.

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AC INTERNAL AUDIT PROGRESS REPORT 19/01/07 The Client Manager, 360 Assurance introduced the key messages from the Internal Audit Progress Report. The Committee noted the current contract performance and work completed. The Client Manager, 360 Assurance informed that Committee that the 12 contingency days will be offset against clinical coding work.

The Committee consider the Internal Audit Progress Report and the following main points noted:

 Terms of Reference for the Primary Care Commissioning Committee - To be aligned to actual responsible reporting / assurance lines.  Conflict of Interest Reviews - The differences between the Conflict of Interest Reviews undertaken by Internal Audit and Counter Fraud Service were explained. The internal audit review had a focus on the CCGs adherence to due processes as outlined in NHSE guidance. Whilst the Counter Fraud work looked at individuals who may not have declared all relevant interests to the CCG.  Review of Key Financial Systems which included Treasury & Cash Management - The Chief Finance Officer referred to the review which included treasury and cash management and in particular the statement that there is no routine reporting of cash management to a CCG Committee. The Committee were advised that the Finance and Performance Committee will in the future receive reports at each meeting, monitoring and maintaining an overview of the CCG’s financial position. The Chief Finance Officer commented that there were currently no penalties imposed re performance against the NHSE guideline for closing monthly cash positions to be within 1.25%. This only has implications at year end, when trying to achieve a low cash balance and there are justifiable reasons why the CCG has held cash above the 1.25% throughout the year and this has to date been reviewed by the Head of Finance and the Chief Finance Officer. However noting the recommendation of this audit this will be reported to the Finance and Performance Committee..  Recommendations Tracker - The Committee was pleased to note the reduced number of outstanding recommendations. The Chief Finance Officer advised

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that where responses are not provided on a timely basis these are followed up with individual responsible lead officers.  Follow up status of previous recommendations – CHC

It was noted that the recommendation relating to timescales for reviews had been closed. A lack of resource had been identified within the CHC Team and the Governing Body had subsequently approved further staff resources which are hoped to be in place by March 2019. A further review of Continuing Healthcare will be undertaken in Q1 2019/20.

Head of Internal Audit (HOIA) Work Programme: Stage 2 Memo

The Deputy Director 360 Assurance reported that the responses from the Governing Body Survey on Governance, Risk Management and Culture were positive overall with just a couple of exceptions. It was noted that:

 The results of the survey will be further considered by the Governing Body on 14 March 2019.  The draft HOIA will be submitted to the next meeting of the Audit Committee in March 2019 and the final HOIA in April 2019.

The Audit Committee noted the Internal Audit Progress Report

Agreed actions  To circulate 360 Assurance Client Briefing to KM Governing Body Members.

AC UPDATE FROM EXTERNAL AUDITORS AND 2018/19 19/01/08 AUDIT PLAN

The Audit Committee noted the update from the External Internal Auditors KPMG, Audit Plan 2018/19 including previously agreed audit fee.

ITEMS FOR APPROVAL

AC GOVERNANCE YEAR END PROCESS 2018/19 19/01/09 The Head of Finance Statutory Accounts and Financial

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reporting provided the Audit Committee with the year-end timetable, accounting policies and assurance requirements for the 2018/19 accounts. The Committee Chair queried the availability of a national assurance report on ESR. In terms of payroll, it was noted that as the CCGs payroll was provided by Victoria Pay Services Sheffield Teaching Hospital the CCG would not seek to place reliance on the ESR report. Victoria Pay Services is audited by 360 Assurance.

360 Assurance and KPMG confirmed that the timetable for year-end submissions appeared consistent with the previous year and changes were not expected.

The Audit Committee :

 Approved the accounting policies for the 2018/19 Annual Accounts (Appendix 1)  Approved the draft 2018/19 Governance Year End Timetable (Appendix 2)  Noted that the accounts will be prepared on a Going concern principle  Noted the audit assurance requirements for Primary Care Co-Commissioning  Approved the principle of using the audit assurance requirements for the Shared Financial Services with RCCG in line with agreed processes for 2017/18.

AC DRAFT AUDIT COMMITTEE ANNUAL ASSURANCE 19/01/10 REPORT 2018/19 The Head of Governance and Assurance presented the Draft Audit Committee Annual Assurance Report. It was suggested that the Report include:

 the outcome of the Committees review of the new Audit Committee handbook.  Expansion of section 2.4 to include specific issues / concerns escalated by the Audit Committee to the Governing Body.

The Committee noted the draft Annual Assurance Report and agreed the following actions:

 To undertake a review and assessment against the RW/KM 21.03.19 Audit Committee Handbook checklist and reflect outcome in the Annual Assurance Report.

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 Section 2.4 to expand to include specific issues / RW/KM 21.03.19 concerns escalated by the Audit Committee to the Governing Body.  At paragraph 2.2 Delete reference to Acting Chief RW/KM 21.03.19 Finance Officer and replace with Chief Finance Officer

AC CCG CODE OF GOVERNANCE COMPLIANCE 19/01/11 The Head of Governance and Assurance provided the Audit Committee with assurance that the principles in the UK Code of Governance had been adhered to by the CCG. The Committee were informed that there is no requirement for the CCG to comply with the UK Code of Governance however self-assessment against the Code supported the CCGs 2018/19 Governance Statement.

The Committee noted the CCGs self-assessment against the UK Code of Governance.

Agreed action To reword section 12 in respect lay members and RW 21.03.19 Committee Chair roles.

AC SFIs SOD & PRIME FINANCIAL POLICIES 19/01/12 The Chief Finance Officer advised the Committee that a review of the SFIs, SOD and Prime Financial Policies will be undertaken in light of latest guidance and NHS Long Term Plan. The review will be submitted to the next meeting of the Audit Committee on 21 March 2019. RN 21.03.19

AC HEALTH, SAFETY, FIRE AND BUSINESS CONTINUITY 19/01/13 UPDATE The Committee considered the Health, Safety and Business Continuity Update. It was noted that a fire drill had highlighted problems opening an external fire door on the first floor and turning off the alarm. The door was subsequently checked and deemed to be satisfactory. It was proposed to provide training to fire wardens in respect of opening and closing the fire door.

The Committee noted the Health, Safety and Business Continuity Update.

AC AUDIT COMMITTEE WORKPLAN AND AGENDA 19/01/14 TIMETABLE

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The Head of Governance and Assurance introduced the Audit Committee Work Plan and Agenda Timetable. The Committee considered reducing the number of meetings per year, suggesting a merger of the September and November meetings into one meeting towards the end of October 2019.

The Audit Committee approved the work plan agenda timetable subject to a possible reduction in the number of meetings held per year.

Agreed action To scope a reduction in the number of Audit RW/KM 21.03.19 Committee meetings held by merging the September and November meetings into one meeting.

GOVERNANCE

AC ASSURANCE FRAMEWORK AND RISK REGISTER 19/01/15 The Head of Governance and Assurance presented the GBAF and Risk Register Exception Report to the Audit Committee. Members attention was drawn to risk reference CCG 18/03 regarding the Barnsley Healthcare Federations CQC inspection rating. It was noted that the risk will be reassessed by the Quality and Patient Safety Committee in the light of a recent CQC re-inspection and improved overall rating.

The Audit Committee noted the exception report.

AC REGISTERS - UPDATE 19/01/16 The Audit Committee considered the Register of Gifts, Hospitality and Sponsorship and Register of Procurement Decisions. The four outstanding declarations of interest relating to CCG new starters were highlighted. The Head of Governance and Assurance advised the Committee that new members of staff had 28 working days to submit their declarations of interest.

The Audit Committee noted the three procurements in progress relating to AQP Carpal Tunnel, vasectomy and Home Visiting.

The Audit Committee noted the Registers Update.

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Agreed Action: To determine whether the outstanding declarations RW 21.03.19 from new CCG staff had been received.

ITEMS FOR DISCUSSION

AC AUDIT COMMITTEE TRAINING REQUIREMENTS 19/01/17 Dr Adekunle confirmed that he was reading information for new Audit Committee members.

The Committee Chair referred to the information about the new Audit Committee Handbook in the KPMG Audit Sector Report. It was agreed to hold an Audit Committee RW/KM 21.03.19 Development Session to consider the handbook and any required actions following the Audit Committee on 21 March 2019.

AC ESCALATION OF ITEMS TO GOVERNING BODY 19/01/18 The following item was agreed for escalation to the Governing Body:  Audit Plan KPMG  Outcome of Governing Body Survey on Governance`  Approved Governance Year End Processes and Timetable. Draft Annual Report underway  UK Code of Governance Compliance  Audit Committee Development Session to consider the new Audit Committee Handbook requirements and checklist.

ITEMS FOR INFORMATION

AC BUDGET TIMETABLE PROCEDURE 19/01/19 The Head of Finance; Statutory Accounts and Financial Reporting introduced the Budget Timetable Procedure to the Audit Committee. The Committee noted the changes proposed to the Budget Timetable Procedure to increase capacity and resilience whilst maintaining management hierarchy and financial control.

The Audit Committee noted the Budget Timetable Procedure for information.

AC REFLECTION ON HOW WELL THE MEETINGS 19/01/20 BUSINESS HAS BEEN CONDUCTED

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It was noted that meeting had been conducted at a good pace and all items well covered.

AC DATE AND TIME OF NEXT MEETING 19/01/21 The next meeting of the Audit Committee will be held on Thursday 21 March 2019 at 9.30 am, in Meeting Room 1, Hillder House, 49/51 Gawber Road, Barnsley, S75 2PY.

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Minutes of the NHS Barnsley Clinical Commissioning Group QUALITY & PATIENT SAFETY COMMITTEE Thursday 13 December 2018, 13:00pm-15:00pm Meeting Room 1, Hillder House

PRESENT:

Dr Sudhagar Krishnasamy - Associate Medical Director (Chair) Martine Tune - Chief Nurse (Acting) Chris Millington - Lay Governing Body Member for Public and Patient Engagement Mike Simms - Governing Body Secondary Care Doctor Chris Lawson - Head of Medicines Optimisation Dr Mark Smith - SWYPFT Contracting Lead from the Governing Body Dr Shahriar Sepehri -Dr Membership Shahriar Sepehri Council Representative

IN ATTENDANCE:

Richard Walker - Head of Governance and Assurance Angela Fawcett - Designated Nurse – Safeguarding Children Lynne Richards - Primary Care Transformation Manager Paige Dawson - Quality Administrator (minutes) Hilary Fitzgerald - Quality Facilitator

Agenda Note Action Deadline Item

Q&PSC APOLOGIES & QUORACY 13/12/01 The meeting was declared quorate. There were no apologies.

Q&PSC DECLARATIONS OF INTEREST RELEVANT TO 13/10/02 THE AGENDA No declarations of interest relevant to the agenda were declared.

Q&PSC MINUTES OF THE PREVIOUS MEETING - 13/12/03 11/10/2018

The minutes from the meeting on 11 October 2018 were approved as an accurate record.

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Q&PSC MATTERS ARISING REPORT 13/12/04 30/08/08 - SWYPFT CQC Findings Presentation – It was also agreed that the Chief Nurse (Acting) and the SWYPFT Contracting Lead from the Governing Body will liaise with Patrick Otway, Head of Commissioning (Mental Health, Children’s, Maternity and Specialised Services, BCCG), to gain more assurance in relation to SWYPFT’s mental health services.

13/12/18 – The Committee members had not yet had chance to liaise regarding this matter. It was agreed to defer this action to the next meeting. Post meeting note: The Chief Nurse (Acting) has raised this issue with Patrick Otway (Head of Commissioning (Mental Health, Children's, Maternity and Specialised, BCCG) on 10 December 2018 and he agreed to provide a briefing paper that can be shared with Committee members which will identify all the current work streams, including actions in place to mitigate risks, gaps in provision, and the next steps to address these. This briefing paper will be circulated with the minutes.

11/10/07 - The Primary Care Transformation Manager

and the Head of Governance and Assurance to meet to agree wording for a new risk to be added to the risk register in relation to Dodworth Medical Practice (Apollo Court). 13/12/18 – This item was discussed at agenda item 11/10/06.

11/10/15 – Clinical Quality Board (CQB) meetings - It was agreed for the Q&PSC Chair to liaise with Nick Balac, BCCG Chair, to discuss attendance of GP membership at the Clinical Quality Boards. 13/12/18 – It was confirmed that the frequency of CQB meetings going forward will be quarterly subject to approval from the Governing Body. It was agreed SK Jan 19 that the Chair will take this forward with the BCCG Chair.

11/10/18 - The Chief Nurse (Acting) agreed to check whether district nurses should provide flu vaccinations to house bound patients as part of the Neighbourhood Nursing Service contract and to report back to the Associate Medical Director outside of the Committee. 13/12/18 – The Committee agreed for this to be removed from the Matters Arising as the action is now complete.

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QUALITY AND GOVERNANCE

The Governing Body Secondary Care Doctor arrived at the meeting at 13.15pm.

Q&PSC RISK REGISTER & ASSURANCE FRAMEWORK 13/12/05 (STANDING ITEM) The Head of Governance and Assurance presented for assurance the relevant extract from the Assurance Framework and Risk Register. It was confirmed that there were no new risks to be added to the Risk Register and the Assurance Framework, and no requests to remove any of the risks.

The key item for the Committee to note was in

relation to the risk in relation to the Barnsley Healthcare Federation (Ref 18/03). Following the positive feedback from the recent CQC inspection it is likely that the risk will be removed from the register, but no action will be taken until after the final report from the CQC is released in January 2019.

Q&PSC MONTHLY QUALITY METRICS REPORT – 13/12/06 (STANDING ITEM) The Chief Nurse (Acting) presented the Quality Metrics report which focused on patient safety. Members were informed that there were no concerns in relation to the CCG’s routine quality monitoring that required further scrutiny. The main items to note were as follows:

 In relation to Infection, Prevention and Control, Barnsley Hospital NHS Foundation Trust is close to its target for the number of C-diff cases. The Chief Nurse (Acting) highlighted that there are good systems in place at the Trust and they investigate all infections. There is a lot of scrutiny of practice both in hospital and in the community.

 The Healthcare Safety Investigation Branch

(HSIB) has produced a report on the work they are doing on incorrect ocular lens incidents as these were the most commonly reported Never Event in England between April 2016 and March 2017. QPSC was reminded that Barnsley Hospital NHS Foundation Trust reported two such incidents in 2017/18.

 In relation to diagnostic incidents, work is ongoing to analyse such incidents reported by Barnsley

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Hospital NHS Foundation Trust to establish whether there are any trends or themes in the data. When the work is complete, the results will be reported to QPSC.

The Committee was assured in relation to this section of the report.

The Primary Care Transformation Manager then presented the Primary Care section of the Quality Metrics report. It was highlighted that:

 Barnsley Healthcare Federation received positive feedback from their recent CQC inspection. The provider has now been removed from special measures. The final report will be published in the public domain in January 2019.

 Apollo Court was visited by the CQC in October 2018 and rated inadequate. It was agreed at a meeting of the Primary Care Commissioning Committee on 29 November 2018 that new providers would vary onto the contract. These providers have an action plan in place to address the concerns raised by the CQC and to provide a high quality service to patients. The CCG’s Primary Care team will be providing close support to the new providers. The Committee agreed that a contractual risk should be drafted and added to the Primary Care Commissioning Committee (PCCC) risk register to ensure this practice is monitored.

 Following a CQC visit to Caxton House Surgery on 10 October 2018 the practice has received a letter of intent to remove their registration as a provider. The provider has appealed against this decision. It was highlighted that this will be a lengthy process and the Committee will be kept updated on the matter. The Chief Nurse (Acting) raised a query regarding the provider being a member of one of Barnsley CCG’s Committees. It was agreed for this query to be raised at the PCCC. Agreed actions:  A risk in relation to Apollo Court to be drafted and added to the Primary Care Commissioning Committee (PCCC) risk register to ensure the LR/RW Dec 18 Practice is monitored.

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 In relation to Caxton House Surgery, the SK Jan 19 provider’s membership of a CCG Committee to be raised at PCCC.

Q&PSC DEEP DIVE ON SWYPFT SERIOUS INCIDENTS 13/12/07 The Quality Facilitator presented the report for assurance. The Committee were reminded that at its meeting on 30 August 2018, the Quality and Patient Safety Committee agreed that a deep dive would be undertaken to on SWYPFT’s serious incidents to establish if there were any underlying issues.

The Committee was advised that there is a downward trend in serious incidents reported by the Barnsley BDU of SWYPFT, and there has been a significant reduction in the first half of 2018/19. This is in line with a downward trend for serious incidents for the whole of the Trust. The Quality Facilitator informed QPSC that it is difficult to confirm at this stage what the reason was for decline in the number. Benchmarking against another similar Trust using readily available data did not identify any concerns about under reporting of serious incidents

The Chief Nurse (Acting) informed the Committee that there was no reason at this stage to be concerned about the level of serious incident reporting.

Agreed actions:  The Committee agreed for the CCG to maintain a watching brief on serious incident reporting HF April 19 levels and report back to the Quality and Patient Safety Committee at the end of the 2018/19 financial year when the full year effect is available from the NRLS, and the total number of serious incidents for the Barnsley BDU is confirmed.

Q&PSC EQUALITY IMPACT ASSESSMENT AND QUALITY 13/12/08 IMPACT ASSESSMENT FOR INTEGRATED LOWER GI PATHWAY The Chief Nurse (Acting) presented the assessment and asked QPSC members whether the judgment and scoring that had been applied within the Equality Impact and Quality Impact assessments were accurate in relation to patient safety.

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The Governing Body Secondary Care Doctor highlighted there was a delay in the implementation of the pathway due to a number of factors.

The Committee was satisfied with the judgements applied within the Equality and Quality Impact Assessment.

Q&PSC QUALITY SURVEILLANCE PROGRAMME - 13/12/09 CANCER SERVICES SELF-ASSESSMENT The Chief Nurse (Acting) presented the CCG’s annual self-assessment of cancer services for information. The assessment which is completed with input from Barnsley Hospital NHS Foundation Trust examines cancer pathways to ensure that they are operating well. The Chief Nurse (Acting) informed the Committee that the CCG have had no feedback from NHSE about the information that the CCG has submitted.

Q&PSC INFORMATION GOVERNANCE UPDATE 13/12/10 The Head of Governance and Assurance presented a comprehensive update on the key national and local developments in information governance since the last update. The main highlights to note were as follows:

 In relation to National developments, the General Data Protection Regulations (GDPR) came into force in from May 2018.

 A replacement for the NHS IG Toolkit has now been published. The new Data Security and Protection (DSP) Toolkit has a greater emphasis on data security and keeping data safe.

 The introduction of the National Data Opt-Out, which enables people to go to one place e.g. their GP and record that they do not with their information being used for wider NHS management and research purposes. This will then be recorded on the SPINE.

 The CCG has taken a range of actions to meet its obligations under DPA2018/GDPR such as establishing a system for Data Protection Impact Assessments; amending all existing contracts to ensure they have data protection clauses which

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are compliant with the GDPR.

 Internal Audit has completed a two phase review of the CCG’s preparations and progress in meeting their obligations under GDPR. Phase 1 of the audit was completed in April 2018 and was allocated a significant assurance rating. Phase 2 is of the audit is underway and is expected to issue a final report in the coming weeks.

The Designated Nurse, Safeguarding Children arrived to the meeting at 14.00pm.

Q&PSC SAFEGUARDING PEOPLE POLICY 13/12/11 QPSC received the Safeguarding People Policy which has been updated to reflect changes in terminology following the introduction of the Care Act for adults. QPSC approved the policy to go forward to Governing Body with a recommendation to adopt the policy. Post Meeting Note – confirmation was received that this Policy does not need to be presented to the Governing Body for approval.

Q&PSC GENERAL PRACTICE STAFF GUIDANCE ON 13/12/12 CHILDREN AND YOUNG PEOPLE WHO ARE NOT BROUGHT TO HEALTHCARE APPOINTMENTS QPSC received guidance developed to help ensure that appropriate measures are taken when children or young people are not brought to health appointments with consideration to their welfare. QPSC approved the guidance and agreed that it should be promoted in Primary Care.

The Chair raised an event he had recently experienced in relation to a child missing their vaccines. The Designated Nurse, Safeguarding Children agreed to check process for suspension immunisation, and feed back to the Committee.

Agreed actions:

It was agreed for the guidance to be uploaded to the BEST website, and to check process for AF Dec 18 suspension of immunisation, and feed back to the Committee. Post Meeting Note: It has been confirmed that in order to initiate a suspension/refusal, this should be discussed with the

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family, who should be asked to sign the appropriate

form and return via e mail to [email protected] .

 To be added to the Practice Managers meeting LR Dec 18 agenda and to have a section in the next Primary Care news.

 The Chief Nurse (Acting) agreed to send some MT Jan 19 information to the Communications team to promote children having their vaccinations.

Q&PSC ACCESS TO FERTILITY POLICY 13/12/13 The Chief Nurse (Acting) informed the Committee that since the Policy was ratified at BCCG Governing Body, a number of CCGs across South Yorkshire and Humber have submitted further queries which they wish to raise before they formally adopt the Policy. Subsequently, the BCCG Senior Management Team agreed to adopt the current Policy as a Barnsley Policy and it will be updated later, if needed, following the outcome of the discussions of the latest queries at the Expert Fertility Panel in January 2019.

COMMITTEE REPORTS AND MINUTES GENERAL

The Head of Medicines Optimisation arrived at the meeting at 14.35pm.

Q&PSC MINUTES OF THE 12 SEPTEMBER 2018 AND 10 13/12/14 OCTOBER AREA PRESCRIBING COMMITTEE (APC) QPSC received the minutes for information.

Also, the Head of Medicines Optimisation informed the Committee that at their meeting in September 2018 the APC had endorsed the use of gum based thickeners in preference to cellulose based thickeners as the former are safer and more palatable. This will affect a significant number of patients. The SWYPFT Contracting Lead from the Governing Body raised that supply of gum based thickeners has been an issue, and so prescribers have had to prescribe cellulose thickeners.

The Head of Medicines Optimisation drew attention to the issue of increasing levels of out of stock medicines both locally and nationally and the potential

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Agenda Note Action Deadline Item

impact upon the CCG’s prescribing budget. This issue has been raised at the QIPP Delivery Group. QPSC noted the efforts by the Medicines Management Team to mitigate the effects of any shortages.

Also, the Head of Medicines Optimisation raised that the last two APC meetings had not been quorate due to lack of Primary Care representation. To help address this issue, an additional representative has been sourced and a schedule of attendance will be used to formally record attendance.

Q&PSC MINUTES OF THE 5 SEPTEMBER 2018 AND 4 13/12/15 OCTOBER 2018 PRIMARY CARE QUALITY & COST EFFECTIVE PRESCRIBING GROUP MEETING For information.

Q&PSC CLINICAL QUALITY BOARDS: 13/12/16  Adopted SWYPFT minutes – 26 Sept 2018  Adopted BHNFT CQB – 02 Aug 2018 For information.

Q&PSC MINUTES OF 18 OCTOBER 2018 HEALTH 13/12/17 PROTECTION BOARD MEETING For information.

GENERAL

Q&PSC ANY OTHER BUSINESS 13/12/18 The Head of Governance and Assurance raised that a previous member of QPSC was no longer a Membership Council representative and therefore queried whether he could continue to attend QPSC. The Committee agreed that he could attend as a co- opted member until another Membership Council representative is appointed.

Q&PSC AREAS FOR ESCALATION TO THE GOVERNING 13/12/19 BODY AND ITEMS TO BE COVERED IN HIGHLIGHT REPORT There were no items to escalate to the Governing Body.

It was agreed the highlight report to Governing Body HF Dec 18 should include:  Supplies of Medicines – Red

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Agenda Note Action Deadline Item

 Safeguarding People Policy – Green  Was not brought to healthcare guidance – Green

Q&PSC REFLECTION ON HOW WELL THE MEETING’S 13/12/20 BUSINESS HAS BEEN CONDUCTED:  CONDUCT OF MEETING  ANY AREAS FOR ADDITIONAL ASSURANCE  ANY TRAINING NEEDS IDENTIFIED There were no items to raise.

Q&PSC DATE AND TIME OF NEXT MEETING 13/12/21 Thursday 21 February 2019 at 1pm in the Boardroom, Hillder House, 49-51 Gawber Road, Barnsley, S75 2PY

Adopted Q&PSC Minutes 2018.12.13 Page 10 of 10

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Minutes of the meeting of the Membership Council held on Tuesday 22 January 2019 at 7.00 pm at Hillder House, 49/51, Gawber Road, Barnsley, S75 2PY

PRESENT

Dr Nick Balac Chair & Practice Representative (St Georges Medical Practice) Dr A Adekunle Practice Representative (Wombwell Chapelfield Medical Centre (from minute reference MC 19/01/05) Dr Ali Practice Representative (Woodland Drive Medical Centre) Dr Mehrban Ghani Practice Representative: The Rose Tree PMS Practice BHF Brierley Medical Centre BHF Goldthorpe Surgery BHF Apollo Court BHF Highgate Surgery BHF Lundwood Practice Dr Z Ibrahimi Practice Representative (Hoyland First PMS Practice) Dr G Kay Practice Representative (Huddersfield Road) Dr Sudhagar Krishnasamy Practice Representative (Royston Group Surgery) Dr Jamie MacInnes Practice Representative (Dove Valley Practice) Dr Andy Mills Practice Representative (Ashville Medical Centre) Dr Sepehri Practice Representative (Hillbrow Surgery Mapplewell) Dr Heather Smith Practice Representative (Dr Mellor and Partners PMS Practice) Dr Stuart Vas Practice Representative (Penistone Group Practice) Dr Angela Walker Practice Representative (Hoyland Medical Practice)

IN ATTENDANCE

Mike Austin Primary Care Support Jackie Holdich Head of Delivery (Integrated Primary and Out of Hospital Care) Chris Millington Lay Member for Patient and Public Engagement & Primary Care Commissioning Kay Morgan Governance & Assurance Manager Lesley Smith Chief Officer Richard Walker Head of Governance and Assurance

APOLOGIES

Dr Eddy Czepulkowski Practice Representative (High Street Royston) Dr John Harban Practice Representative (Lundwood Medical Centre and The Kakoty Practice) Dr M Hussain Kadarsha Practice Representative (Apollo Court) Dr J Maters Grimethorpe Surgery Mike Simms Governing Body Secondary Care Clinician

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The Chair welcomed Practice Representatives to the Membership Council meeting and wished everyone a Happy New Year.

Agenda Note Action Deadline Item MC QUORACY 19/01/01 The meeting was declared quorate.

MC DECLARATION OF INTERESTS INCLUDING 19/01/02 SPONSORSHIP & HOSPITALITY

The Membership Council noted the Declarations of Interests Report. No new declarations were received.

The Head of Governance and Assurance highlighted that all Practice Representatives would have an interest in agenda item 6 – ‘The 2019/20 PDA’. In order to manage these interests’ decisions in respect of financial schedules and payments would be undertaken by the Primary Care Commissioning Committee. It was noted that the GP Members of the Primary Care Commissioning Committee did not have voting rights. This evening’s paper was for discussion and clinical engagement re the content of the scheme.

MC MINUTES OF THE MEETING HELD ON 20 NOVEMBER 19/01/03 2018

The minutes of the Membership Council meeting held on 20 November 2018 were verified as a correct record of the proceedings.

MC MATTERS ARISING 19/01/04 The Membership Council considered the Matters Arising Report:

 MC 18/11/06 Shared Care (Specialist) Drug Management Service

Agreed action: - To remind the Head of Medicines KM 19/02/19 Optimisation to write to Practices about the review of the Primary Care Shared Care (Specialist Drugs) Service.

 MC 18/11/10 IT UPDATE – HSCN ENGINEERS,

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Agenda Note Action Deadline Item COORDINATION OF INSTALLATION WORK WITH PRACTICES

Agreed action: - Mike Austin, Primary care Support MA 19/02/19 agreed to further this action and liaise with Dr John Harban

 MC 17/03/06 PDA AND HITS – Clinical Thresholds & MPs. - The Chairman reported that this action was now complete

MC 2019/20 PDA 19/01/05 The Membership Council noted that due to current changing landscapes within the NHS, it was anticipated that more developed proposals for integrated care networks would be finalised within the next few weeks.

The Chairman advised that Integrated Care Networks (ICNs) represented the future model for delivering services to meet the needs of the local population. The CCG will provide more support to localities in their development of integrated care networks and systems of care.

Dr Vas asked about potential budget allocations for the integrated care networks. It was noted that the CCG is exploring arrangements and virtual budgets for the integrated care networks. Core support from the CCG will be provided to ICNs to ensure required actions are progressed between meetings. The Chairman commented that ICNs will work closely with Health, social care and voluntary sector partners to jointly manage and provide services to address the health needs of their local populations.

Dr Sudhagar Krishnasamy provided the Membership Council with a brief overview of the PDA and presented the 2019/20 PDA Core Schemes to the Membership Council as follows:

1. Integrated Care Networks (formerly Locality working) – New scheme in line with the NHS Long Term Plan

2. Primary Care Practice Level Medicines Optimisation

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Agenda Note Action Deadline Item Scheme

 Indicator 7 - Polypharmacy Reviews is a new area within the scheme.

 Indicator 10 - Gastrointestinal Use of Proton Pump Inhibitors (PPIs) and Gaviscon Advance.

It was noted that some medicines are provided at reduced cost to hospitals but normal charges applied when prescribed by Primary Care. Drs Ghani and Krishnasamy commented that the adoption of one Barnsley formulary and drug budget would enable more effective control over the entirety of the medicines budget including risk share and motivation to effect improvements in spend.

3. Get Fit First

The New requirements of the scheme were highlighted to Members

 READ Codes embed – Agreed action: - To request David Lautman (Lead Commissioning and Transformation Manager) to check accuracy of READ Codes and / or removal of the codes.

4. Barnsley Referral Support Toolkit

 Indicator 5.3 Direct Patients to the Minor Eye Conditions Service - It was clarified that there is one or more optician in each geographical area providing the Minor Eye Conditions Service.

5. Health Inequalities Target Scheme (HITS)

 Cardiovascular Disease - It was noted that some new indicators for this scheme had been proposed by the Local Medical Committee

 Cardiovascular Disease Indicators CDV 02 & 03 – It was commented that this indicator may be difficult for practices to achieve when there are changes to NICE Guidance. It was noted that the initial backlog of patients with a CVD risk of 10% since April 2015

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Agenda Note Action Deadline Item should now be cleared.

 Cardiovascular Disease Indicator CVD08 – 12 Lead ECG Monitoring in Primary Care. Agreed action: Mike Austin Primary Care Support MA agreed to ascertain ECG / Practice software compatibilities and availability of READ Codes for all indicators and report back to Dr Sudhagar Krishnasamy.

 Diabetes – Members were informed that the Diabetes scheme had been reduced from the previous year’s scheme. The Chief Officer reported that Barnsley had been rated as ‘outstanding’ for Diabetes in the national CPA assessments.

 CANCER – A new area for 2019/20. The Chairman advised that objective measures were required to monitor and demonstrate performance of the indicators. .

6. GP Forward View & Integrated Care Network Development.

 My Best Life. Indicator MBL 1 It was highlighted that the indicator may be difficult to achieve. Agreed action - To change the wording of the indicator to read: ‘My Best Life Champion to maintain links with the SK MBL advisor by Inviting them to attend Practice meetings and ICNs as appropriate demonstrating the advisor is part of the Team.

 APEX /Access & Workforce Agreed action: To consider how to demonstrate SK capacity released back into Practice from utilisation of the Home Visiting Service.

 Phlebotomy – A new area for 2019/20

7. Shared Care (Specialist) Drug Management Service

It was noted that there was an absence of shared care arrangements where patients had private

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Agenda Note Action Deadline Item consultations. Prescribing and monitoring arrangements were still undertaken by primary care without payment. A shared care mechanism was needed not to disadvantage patients and GPs.

Agreed action – To request the Head of Medicines CL Optimisation to check the 2019/20 Annual Medicines Monitoring Requirement & Rates In particular relating to workloads for Triptorelin in comparison with Testosterone.

Wynford Morgan, Practice Manager at Penistone Group Practice and Chair of Practices Managers Group had queried the timescales for PDA payments to Practices. The Membership Council recognised that cash flow could be a problem for most Practices.

The Membership Council noted the PDA schemes

Agreed Action:

To contact Wynford Morgan with regard to PDA SK payment schedules and produce an equitable proposal regarding staging of PDA payments to Practices.

To share the final PDA with the Local Medical SK Committee.

MC ANY OTHER BUSINESS 19/01/06 06.1 BHF CQC

Dr Ghani formally thanked colleagues for their support in the recent CQC inspections of the Barnsley Health Care Federation (BHF). The BHF received an initial rating of inadequate and was placed in special measures. A CQC re- inspection of the federation across 5 domains determined an overall rating of good. It was a phenomenal achievement for the BHF previously in special measures to achieve a CQC rating of good and not many providers do this.

The CQC inspectors deemed the ‘sepsis’ work undertaken by the Federation as outstanding.

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Agenda Note Action Deadline Item

The BHF were offering to support other practices with CQC inspections if required.

06.2 CCG 360 Stakeholder Survey 2018/19

The Membership Council was informed about the CCG 360 Stakeholder Survey commissioned by NHS England and undertaken by Ipsos Mori. It was noted that NHSE had informed practices directly about the survey. The CCG was hoping to achieve a high response rate and member Practices were urged to complete the survey. The survey was open until 22 February 2019 and was shorter and more focussed than in previous years.

It was highlighted that Information gained from the survey feeds into the NHSE’s annual assessment of the CCG.

MC MEMBERSHIP COUNCIL BRIEFING 19/01/07 It was agreed that the following items would be included in the Membership Council Briefing:

 PDA – In particular highlighting changes from the 2018/19 PDA to the 2019/20.  BHF - Offer of support to Practices with CQC Inspection visits  360 Stakeholder Survey  A summary of the Long Term Plan  IT Projects – informing Practices of current IT JHo/JF projects and expected timescales for engineers to undertake work in Practices.

MC REFLECTION OF HOW WELL THE MEETING’S 19/01/08 BUSINESS HAD BEEN CONDUCTED

The business of the meeting had been well conducted.

MC DATE AND TIME OF NEXT MEETING 19/01/09 The next meeting of the Membership Council will be held on:

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Agenda Note Action Deadline Item  Tuesday 19 March 2019 at 7.00 pm in the Boardroom Hillder House, 49/51 Gawber Road, Barnsley S75 2PY.

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GOVERNING BODY PUBLIC

14 March 2018

PRIMARY CARE COMMISSIONING COMMITTEE HIGHLIGHTS REPORT

PART 1A – SUMMARY REPORT

1. THIS PAPER IS FOR

Decision Approval Assurance X Information

2. REPORT OF

Name Designation Lay member C Millington Lay Member Lead Author L Richards Primary Care Transformation Manager

3. EXECUTIVE SUMMARY

This report provides the March Governing Body with the agreed highlights of the public Primary Care Commissioning Committee held on 29 November 2018 and 31st January 2019.

It was agreed at the meeting on the 29th November that the following two issues would be highlighted:  GP WiFi – Roll out  i-HEART Triage changes

It was agreed at the meeting on the 31st January that the following two issues would be highlighted:  Integrated Care Networks development  Compliance against GP core contracts (e-declaration).

4. THE GOVERNING BODY / COMMITTEE IS ASKED TO:

 Note the Highlights identified

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PART 1B – SUPPORTING INFORMATION

1. Links to the Governing Body Assurance Framework Risk ref(s) This report provides assurance against the following risks on 2.1 the Governing Body Assurance Framework: 2. Links to CCG’s Corporate Objectives Y/N To have the highest quality of governance and processes to Y support its business To commission high quality health care that meets the needs Y of individuals and groups Wherever it makes safe clinical sense to bring care closer to Y home To support a safe and sustainable local hospital, supporting Y them to transform the way they provide services so that they are as efficient and effective as possible for the people of Barnsley To develop services through real partnerships with mutual Y accountability and strong governance that improve health and health care and effectively use the Barnsley £. 3. Governance Arrangements Checklist 3.1 Financial Implications Has a financial evaluation form been completed, signed off NA by the Finance Lead / CFO, and appended to this report? Are any financial implications detailed in the report? NA

3.2 Consultation and Engagement Has Comms & Engagement Checklist been completed? NA Is actual or proposed engagement activity set out in the NA report?

3.3 Equality and Diversity Has an Equality Impact Assessment been completed and NA appended to this report?

3.5 Environmental Sustainability Are any significant (positive or negative) impacts on the NA environment discussed in the report?

3.6 Human Resources Are any significant HR implications identified through NA discussion with the HR Business Partner discussed in the report?

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29 November 2018 Primary Care Commissioning Committee Highlight Report

Issue Consideration Action

GP WIFI GP WIFI The Committee suggested Members were informed that escalating the concerns to the NHS Digital had been working NHS Board of Commissioners, to ensure that everyone has however as the January 2019 access to free WIFI in NHS timescale had not yet lapsed it sites across England, as set was agreed to review this if the out in the NHS England January deadline was missed. General Practice Forward View.

Concerns were raised over the timescales for roll out and the possibility of timescales being met. i-HEART Barnsley In September 2018 Barnsley The Committee agreed that Contract Changes Healthcare Federation revised utilisation and patient feedback the triage process for i-HEART would continue to be monitored Barnsley’s extended hour’s via the monthly contracting service. meetings. The decision to change the triage element of the service was made following a clinical audit and CQC’s findings from their inspection in February 2018.

The new process is as follows:

 4.00pm – 6.00pm Monday to Friday and 8.00am – 9.30am during weekends and on Bank Holidays. This is now be staffed by admin personnel who are only booking patients into the i- HEART clinics, just like it happens at most GP surgeries, and will NOT be providing a clinical triage service over the phone.  The i-HEART evening clinic times have changed during week days to 6.30pm -10.30pm

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Issue Consideration Action

however will remain the same time over a weekend and bank holiday where we will be offering clinics between 10.00am - 1.00pm at the same clinic locations.

31 January 2019 Primary Care Commissioning Committee Highlight Report

Issue Consideration Action

Integrated Care The development of the The CCG to continue to work with Networks Barnsley Integrated Care Primary Care at the February development Networks is being measured 2019 Locality meetings to discuss against the NHS England the future formation and Maturity Matrix. developments of ICN’s.

The Maturity Matrix gives an Action: Integrated Care example of the journey for the Networks Update to remain a development of Primary Care standing item on the Public Networks (PCN) from the Primary Care Commissioning foundations for transformation Committee agenda until further and through three further notice. steps:-

Step 1: Practices identify PCN partners and develop shared plan for realisation.

Step 2: PCNs have defined future business model and have early components in place.

Step 3: PCN business model fully operational (as reflected in the NHS Long Term Plan)

Compliance The Committee were advised The Committee to have against GP core that all GP Practices had oversight of any areas on non- contracts (e- submitted their annual e- compliance, this will be declaration) Declaration for assurance of reported in due course. compliance with their core contract.

The Primary Care team are undertaking a process to identify areas of non-

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Issue Consideration Action

compliance which would be discussed with the practice.

Any areas of concern would be escalated and reported to the Committee in due course.

Green = positive assurance Amber = concern being monitored, for information Red = articulated risk or escalation

GBPu 19/03/21.6

Minutes of the Meeting of the EQUALITY AND ENGAGEMENT COMMITTEE held on Thursday 15 November 2018 at 1pm in the Meeting Room 1, Hillder House, Gawber Road, Barnsley, S75 2PY.

PRESENT:

Chris Millington (Chair) Lay Member for Patient & Public Engagement Kirsty Waknell Head of Communications & Engagement Lynne Richards Primary Care Transformation Manger (Deputy for Senior Primary Care Commissioning Manager Martine Tune Chief Nurse (Acting) Richard Walker Head of Governance & Assurance

IN ATTENDANCE:

Emma Bradshaw Engagement Manager Louise Exley Project Coordinator Lorna Lewis Healthwatch Adult Engagement Officer Carol Williams Project Coordinator/Committee Secretary

APOLOGIES Colin Brotherston-Barnett Equality, Diversity & Inclusion Lead Dr Adebowale Adekunle Elected Governing Body Member Dr Indra Saxena Membership Council Representative Julie Frampton Senior Primary Care Commissioning Manager Susan Womack Healthwatch Manager

Agenda Item Note Action Deadline

EEC APOLOGIES 18/11/01 Apologies were received as above. The Primary Care Transformation Manager attended as deputy for Primary Care and the Adult Engagement Officer from Healthwatch attended on behalf of Healthwatch.

EEC QUORACY 18/11/02 The Chair of the Committee declared that the meeting was quorate.

EEC DECLARATIONS OF INTEREST RELEVANT TO THE 18/11/03 AGENDA

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Agenda Item Note Action Deadline

The Committee considered the above report. No additional declarations of interest were received. EEC SERVICE PROVISION FOR BLIND & PARTIALLY SIGHTED 18/11/04 PEOPLE IN BARNSLEY The Adult Engagement Manager for Healthwatch presented the above report to the committee for information which highlights the issues for some of the blind and partially sighted people living in Barnsley:

 Overall services for blind and partially sighted people in Barnsley are limited, underfunded and stretched beyond their capacity  People in Barnsley are accessing IT training and social groups by going to the Sheffield Royal Society for the Blind or Sight and Sound in Rotherham.  Concerns were raised for those people who are isolated from the community as a result of lack of local provision because of waiting lists for assessments and this was impacting on people’s mental health.

Sheffield Royal Society for the Blind have started working with partners in Barnsley to identify a ground floor level access building to deliver their services in Barnsley. Work is still ongoing in relation to this. Key areas of the National Vision Strategy for 2013- 18 outcomes were not met by BMBC. A consultation event planned for 2018 did not go ahead. Challenges remain for capacity as more people become aware of what is available. SWYPFT deliver The Sensory Impairment service which is jointly commissioned by Barnsley CCG and BMBC. The team of 3 had been understaffed with only 1 person in post for the past 8 months impacting on service delivery, resulting in a backlog.

Recommendations from the Healthwatch report were shared with BMBC and responses were received though these largely did not address issues being raised.

Committee members heard some of the individual stories and committed to taking action by influencing how services are commissioned. The CCG priorities for Equality, Diversity & Inclusion are currently being reviewed and this will include the Accessible Information Standard for the CCG and providers of services we commission.

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Agenda Item Note Action Deadline

Agreed Actions:  The Chief Nurse (Acting) to discuss this report in 1 to 1's with BHNFT & SWYPFT Chief Nurses and the Executive Director for People at BMBC and to MT 14.02.19 feedback to this committee  The Head of Communications & Engagement to speak to the Chief Nurse (Acting) and also Joint Commissioning colleagues in relation to the KW 14.02.19 content of this report

EEC MINUTES OF THE PREVIOUS MEETING HELD ON 18/11/05 16 AUGUST 2018 The minutes of the meeting were verified as a correct record of the proceedings.

EEC MATTERS ARISING REPORT 18/11/06 The Committee noted the matters arising report and actions noted as complete. The following updates were given:

EEC 18/05/08 Development of poster for deaf service users The Equality, Diversity & Inclusion Lead to develop a poster promoting text service for complaints and general information. In Progress – Final amendments with Comms, once KW 14.02.19 completed the Head of Communications & Engagement to share the poster with the CCG complaints team.

EEC 18/08/09 National LGBT Survey / Action Plan The Equality, Diversity & inclusion Lead to review the survey and action plan and ensure the Equality Impact Assessment (EIA) Toolkit is updated with any relevant information and that awareness of LGBT issues would be emphasised in the EIA training sessions. In Progress EIA Toolkit training session planned for CBB 14.02.19 January 2019 with plans to roll-out to CCG staff during the year. The training will also cover the Public Participation Form 14Z2.

The potential risk of CCG staff signing off EIA’s was discussed as this is not their field of expertise. Assurances were given that the Equality, Diversity & Inclusion Lead would audit EIA’s to ensure these were being completed in accordance with the guidelines outlined in the EIA Toolkit. The Equality, Diversity & Inclusion Lead to continue to sign of EIA’s until training rolled out.

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Agenda Item Note Action Deadline

The Elected Governing Body Member to promote DrA 14.02.19 services within their GP practice to ensure LGBT patients are aware of services relevant to them. In Progress – the Elected Governing Body Member had sent apologies for this meeting therefore this item was carried forward to the February 2019 meeting.

EEC 18/08/13 HR Policies MT 14.02.19 The Chief Nurse (Acting) to review the Professional Registration policy and feedback directly to the Head of Governance & Assurance. In Progress - The Chief Nurse (Acting) apologised for not being able to review this policy due to their work load and gave assurances that the review will be completed as quickly as possible. The current policy remains in place until this is completed.

PATIENT AND PUBLIC ENGAGEMENT

EEC MINUTES OF THE PATIENT COUNCIL MEETING 18/11/07 HELD ON 25 JULY , 26 SEPTEMBER & 31 OCTOBER 2018 The Committee received minutes of the Patient Council meetings held on 27 June 2018 and 25 July 2018. Verbal reports were given from 26 September 2018 and 31 October 2018 meetings.

27 June 2018 – Improving Home Visiting The session considered how to make home visits more efficient, avoid late admissions to hospital and offer treatment to people at home. Current issues, patient concerns, new ways of working and the results of a recent survey of GP practices were discussed. A local GP outlined how utilising a paramedic to save on GP time was allowing them to be more proactive within the surgery and able to see more patients

25 July 2018 - Be Cancer Safe Funded by the Cancer Alliance, the aim of Be Cancer Safe is to increase the number of people attending screening, reduce the number of people diagnosed with late cancer in A&E and promoting early diagnosis. Some of the work undertaken was with voluntary sector organisations, local groups, shops, cafes pubs and working men’s clubs and activity on social media. This work was initially in the Deane Valley, Stairfoot and St Helen’s wards seeking out seldom heard groups and people with disabilities / physical limitations. The next phase of engagement which will ensure messages are

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Agenda Item Note Action Deadline

accessible to people who do not have English as their first language. The focus on GP practices, schools & colleges, business organisations, men and follow up on groups visited in the earlier months.

26 September 2018 – Reviewed contribution Patient Council had made during 2018 Members previewed the film shown at the CCG AGM showing where the CCG had focussed its resources throughout the year on joining up care to make health services seamless for people in Barnsley. It looked back at some of the main achievements over the past 12 months, along with an overview of CCG’s accounts for 2017/18.

31 October – Revisit Patient & Public Engagement Strategy (verbal update as minutes were not available at the time of the EEC) The session focussed on reviewing the current PPE strategy, which had been implemented two years ago, to ensure this was still fit for purpose. Members agreed the eight guiding principles were still appropriate and needed to remain broad enough to move with the times and cover any system changes. Suggestion made to promote the purpose of the CCG in GP waiting rooms to help patients understand the organisations role. In addition the CCG could reach further out to the public depending upon the piece of work/timescales. Suggestion made that PPGs could use local media to reach a wider audience to promote messages to patients and also stated that there is a need for education to maximise awareness and empower patients to feel confident to talk and ask questions about their own health.

The feedback would be used to refresh the strategy.

The Committee thanked the Chair for the updates.

EEC PATIENT AND PUBLIC INVOLVEMENT ACTIVITY 18/11/08 REPORT

The Head of Communications & Engagement presented the Patient and Public Involvement Activity report and stated that due to timing of meetings this had already been seen by members of the Governing Body at the November meeting. The following was highlighted from the report:

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Agenda Item Note Action Deadline

Recruitment: Macmillan GP with focus on cancer The CCG has recently recruited someone with experience of local cancer services to be part of the recruitment process for a Macmillan GP who will be working with practices across the borough.

NHS long term plan and Barnsley CCG plans for 2019/20 - In December the CCG would be talking to staff, patients, the public and other stakeholders to help us determine what the NHS Long Term plan means for Barnsley, how services can be adapted to improve and how this will help shape our commissioning plans for 2019/20 and the following five years.

Big Conversation with Barnsley Deaf community 13 people from Barnsley Deaf community joined a workshop in October, run by SWYPFT, to continue the regular conversations on what is working well and what could be improved for Deaf people who use health and care services. Feedback showed good results with texting services though there are still some challenges accessing interpreter services and also the way complex conditions are explained. The Equality, Diversity & Inclusion Lead has been asked to review the report and bring back findings to Barnsley Deaf Community, having first shared these with this committee’s members.

The Committee thanked the Head of Communications & Engagement for their report.

EEC EQUALITY & ENGAGEMENT COMMITTEE SELF 18/11/09 ASSESSMENT REPORT The Head of Communications and Engagement gave a verbal update on the self-assessment survey that committee members had completed; of the 11 people sent the survey, 10 responded. The last survey had been completed two years ago and last year the committee had undertaken a Patient and Public Involvement audit. The following was highlighted:

 100% of people responding knew that the committee terms of reference are reviewed on an annual basis and were adopted by the Governing Body  2 or 3 people were unsure that the committee reviews its performance so we need to ensure we consistently do this - the self-assessment survey being part of the evidence that the committee does review its performance and at each meeting

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Agenda Item Note Action Deadline

the chair asks how members felt the meeting had been conducted and if there are any training needs.  2 or 3 people were unsure about the mechanism of how we keep aware of best practice issues/guidance. Comms to consider how this could be achieved. Highlighted that the completion of the EDS2 document to fulfil our Public Sector Equality Duties is a good example of members deliberating best practice.  Some members did not think our objectives had been achieved this year. Comms to circulate to remind members of these  The committee is assured that we meet statutory duties for patient and public involvement and equality, diversity and inclusion.  All other responses were either strongly agreed or agreed with and overall was a positive self- assessment

Feedback will be given via direct channels i.e. the PPE Ops Group, the ED&I Working Group and the minutes of this meeting being sent to Governing Body. It is possible that that the survey could be replicated for other committees where appropriate.

The Head of Communications and Engagement thanked members for their contribution and stated that this had been a useful thing to undertake.

Agreed Actions:  The Head of Communications and KW 14.02.19 Engagement to follow up on comments, ideas and suggestions and circulate these to members and offer support to members where ‘unsure’ responses were given

The Chair thanked the Head of Communications and Engagement for sharing this information.

EQUALITY

EEC EQUALITY, DIVERSITY & INCLUSION WORKING GROUP 18/11/10 ACTION LOG

The Chief Nurse (Acting) presented the Equality, Diversity & Inclusion Working Group Action Log from the meeting held on 28 September 2018, progress re the following items was highlighted:

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Agenda Item Note Action Deadline

Accessible Information Standard (AIS) The Equality, Diversity & Inclusion Lead is still working with primary care colleagues at Park Grove in relation to planning and ED&I training session.

The Chief Nurse (Acting) confirmed that she had met with the Head of Delivery (Integrated Primary/Out of Hospital Care and the Chief Executive of Barnsley Healthcare Federation to discuss how AIS evidence of good practice could be collected from within primary care. Seven practices were due to be inspected by the CQC and AIS would be one of the indicators looked at. The CQC reports could be used to determine if they give the CCG assurance. The Chief Nurse (Acting) to follow this up and update at the next working group.

The key point for this committee in terms of where we bring assurance over our equality duties and demonstrate compliance is the EDS2 process which is a comprehensive self-assessment. The completed EDS2 will be published on the CCG website by the end of January 2019. From this an action plan will be produced and this will feedback into the Equality & Engagement Committee.

The Committee thanked the Chief Nurse (Acting) for the update from the Equality & Diversity Working Group.

EEC EQUALITY IMPACT ASSESSMENTS (EIA’s) 18/11/11 The Committee received the Equality Impact Assessments Report and were asked to note the contents which shows completed EIA's that have been signed off since the committee last met. Members agreed it would be useful to know of EIA's in progress or due to be reviewed to provide an overview of progression throughout the year and provide assurance to this committee. It was agreed that links with the PMO function and Primary Care Workstream committee need to be strengthened to ensure that all EIA's from across the CCG are being captured. The Governing Body would have assurance that EIA's were being completed by receiving the minutes of this committee and more details provided on request. Members agreed to include Privacy Impact Assessments (PIA's) and Quality Impact Assessments (QIA’s) in this report.

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Members agreed that the Equality, Diversity & Inclusion Lead would be responsible for this agenda item going forward as they were more sighted on this work.

Agreed Actions: The Engagement Manager, the Equality, Diversity & Inclusion Lead, the Head of Governance & EB, 14.02.19 Assurance to meet to coordinate EIA, PIA and QIA CBB & quarterly reporting process to this committee. RW

The Committee thanked the Chief Nurse (Acting) for the update on Equality Impact Assessments.

QUALITY GOVERNANCE

EEC CCG RISK REGISTER AND ASSURANCE 18/11/12 FRAMEWORK The Committee received the Risk Register and Assurance Framework on behalf of the Head of Governance & Assurance.

Governing Body Assurance Framework (GBAF) There are no risks on the Assurance Framework where the Equality and Engagement Committee provides assurance.

Risk Register There are currently 2 risks rated amber on the Corporate Risk Register for which the Equality and Engagement Committee are responsible for managing :

 Risk Reference 13/13b (rated 12, amber high) – Potential failure of the CCG to engage with patients and the public in the commissioning of services.

 Risk Reference CCG 14/16 (rated 12, amber high) – If a culture supportive of equality and diversity is not embedded across the CCG there is a risk that the CCG will fail to discharge its statutory duties as an employer and will not adequately consider issues of equality within the services we commission. It was proposed that the review of the EIA & 14Z2 process be added as further assurance for this risk.

There were no changes proposed for this risk.

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Agreed Action:  The Head of Governance and Assurance to RW 14.02.19 add details of the EIA and 14Z2 work to risk 14/16

The Chair thanked the Head of Governance & Assurance for the updates provided on the Risk Register and Assurance Framework report. EEC HR POLICIES 18/11/13 Standing Agenda item. No policies to review.

GENERAL

EEC REVIEW OF EQUALITY, DIVERSITY & INCLUSION 18/11/14 WORKING GROUP AND EQUALITY & ENGAGEMENT COMMITTEE TERMS OF REFERENCE The Head of Governance & Assurance presented the terms of reference for the Equality, Diversity & Inclusion Working Group and the Equality & Engagement Committee.

The Equality & Diversity Working Group had agreed to change the group name to Equality, Diversity & Inclusion Working Group and reviewed the terms of reference. Changes were reflected in the Equality and Engagement Committee terms of reference and both were presented to this committee for approval.

Committee members agreed to the changes. It was highlighted that the Patient and Public Engagement Operational Group did not have terms of reference and these would be developed.

Agreed Actions:  The Head of Governance & Assurance to make RW 14.02.19 relevant changes to theToR for submission to the December Governing Body  The Head of Communications & Engagement KW 14.02.19 to develop ToR for the Patient and Public Engagement Operational Group to bring back to this committee  The committee secretary to accept changes to CW 14.02.19 the ED&I ToR

EEC REVIEW OF THE COMMITTEE WORKPLAN 18/11/15 The bi-annual review of the committee work plan was undertaken to ensure this was reflecting the work that

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the committee does. Minor scheduling changes agreed.

Agreed Actions:  The Committee Secretary to make minor CW 14.02.19 changes to the committee work plan and submit this to the Governing Body. EEC ANY OTHER BUSINESS 18/11/16 No items were raised.

EEC ITEMS FOR INCLUSION WITHIN THE GOVERNING 18/11/17 BODY ASSURANCE REPORT Minor changes made to the EEC terms of reference will be included in the assurance report to the Governing Body by the Head of Governance and Assurance.

The report from Healthwatch could provide a patient story to a future Governing Body meeting.

Agreed Actions:  The Head of Governance & Assurance to RW 14.02.19 ensure the minor changes to the committee ToR were included in the assurance report to the Governing Body

EEC REFLECTION ON HOW WELL THE MEETING’S 18/11/18 BUSINESS HAD BEEN CONDUCTED The Chair thanked members for their input, good quality and content of papers and a good meeting.

EEC DATE AND TIME OF THE NEXT MEETING 18/11/19 The next meeting of the Equality and Engagement Committee will be held on 14 February 2019 at 1pm in Meeting Room 1, Hillder House.

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