East Leicestershire and Rutland Clinical Meeting Commissioning Group – Governing Date Tuesday 9 April 2019 Title Body meeting Meeting 57 Time 9:30am – 12:10pm no.
Dr Ursula Montgomery Venue / Council Chamber, County Hall, Chair (Chair) Location Glenfield, Leicester, LE3 8TB.
AGENDA ITEM ACTION PRESENTER PAPER TIMING Welcome and Introductions Dr Ursula B/19/19 9:30am Montgomery Apologies for Absences: To Dr Ursula B/19/20 verbal 9:30am receive Montgomery To Dr Ursula B/19/21 Notification of Any Other Business verbal 9:30am receive Montgomery To B/19/22 Declarations of Interest on Agenda Topics All verbal 9:35am receive Minutes of the meeting held on 12 To Dr Ursula B/19/23 A 9:40am February 2019 approve Montgomery
Matters Arising: Update on actions from To Dr Ursula B/19/24 B 9:45am the meeting held on 12 February 2019 receive Montgomery
To receive questions from the Public in To Dr Ursula B/19/25 verbal 9:50am relation to items on the agenda only receive Montgomery REPORTS To Dr Ursula B/19/26 Chair’s Report 10:00am receive Montgomery C To B/19/27 Accountable Officer’s Corporate Report Karen English 10:05am receive D ITEMS FOR DECISION, ACTION AND ESCALATION Summary report from the Financial To B/19/28 Alan Smith E 10:15am Turnaround Committee (March 2019) receive To B/19/29 Finance Report: Month 11 update Donna Enoux F 10:20am receive To B/19/30 LLR System Operational Plan 2019/20 Simon Pizzey G 10:35am approve Summary report from the Audit Committee To Warwick B/19/31 H 10:50am (March 2019) and draft terms of reference approve Kendrick To B/19/32 Board Assurance Framework 2018/19 Karen English I 11:00am approve
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AGENDA ITEM ACTION PRESENTER PAPER TIMING Register of Interests and Register of Gifts To B/19/33 Karen English J 11:10am and Hospitality approve To K B/19/34 Quality Strategy Tracy Burton 11:15am approve Summary report from the Provider To Warwick B/19/35 Performance Assurance Group meeting L 11:25am receive Kendrick (February 2019) Summary report from the Integrated To Warwick B/19/36 Governance Committee meeting (5 March M 11:35am receive Kendrick 2019)
To B/19/37 Corporate Performance Assurance Report Paul Gibara N 11:45am receive Locality Chairs’ Report: . Oadby and Wigston . Syston, Long Clawson and Melton To Locality B/19/38 . Rutland O 12:00pm receive Chairs . Harborough . North Blaby . South Blaby and Lutterworth ITEMS FOR INFORMATION Summary Report from the Commissioning To B/19/39 Dr Andy Ker P 12:15pm Collaborative Board (March 2019) receive
System Leaders’ Team meeting To B/19/40 Karen English Q 12:20pm November 2018 and February 2019 receive DATE OF NEXT MEETING The next meeting of the East Leicestershire and Rutland CCG
Governing Body will take place on Dr Ursula B/19/41 12:25pm Tuesday 11 June 2019, Council Montgomery
Chamber, County Hall, Glenfield, Leicester, LE3 8TB.
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A Blank Page Paper A East Leicestershire and Rutland CCG Governing Body Meeting 9 April 2019 EAST LEICESTERSHIRE AND RUTLAND CLINICAL COMMISSIONING GROUP
Minutes of the Governing Body Meeting held on Tuesday 12 February 2019 at 9.30am In the Council Chambers, County Hall, Leicester LE3 8TB
Present: Dr Ursula Montgomery Chair Mrs Karen English Managing Director Dr Andy Ker Clinical Vice Chair Mr Tim Sacks Chief Operating Officer Ms Donna Enoux Chief Finance Officer Mr Paul Gibara Chief Commissioning and Performance Officer Mrs Tracy Burton Interim Chief Nurse and Quality Officer Mr Warwick Kendrick Independent Lay Member Mr Alan Smith Independent Lay Member Mr Clive Wood Deputy Chair and Independent Lay Member Dr Tabitha Randell Secondary Care Clinician Dr Vivek Varakantam GP Locality Lead, Oadby and Wigston Dr Nick Glover GP Locality Lead, South Blaby and Lutterworth Dr Anuj Chahal GP Locality Lead, Harborough Dr Simon Vincent GP Locality Lead, North Blaby Dr Hilary Fox GP Locality Lead, Rutland Dr Tim Daniel Public Health Consultant
In Attendance: Mrs Daljit K. Bains Head of Corporate Governance and Legal Affairs Mrs Emma Casteleijn Head of Communications and Public Affairs Dr Janet Underwood Healthwatch Rutland Chair Ms Olufunmilola Adewumi (Lola) GP Trainee, Public Health (observing) Mrs Claire Middlebrook Corporate Affairs Support Officer (minutes)
Members of the public: Five members of the public were seated in the public gallery.
ITEM DISCUSSION LEAD RESPONSIBLE B/19/1 Welcome and Introductions
Dr Ursula Montgomery welcomed members of the Governing Body and members of the public to the Governing Body meeting. Dr Montgomery congratulated Dr Hilary Fox on her appointment as ELR Locality Lead for Rutland, and Dr Janet Underwood on her recent appointment as Chair for Healthwatch Rutland.
B/19/2 Apologies for Absences
Apologies for absence were received from: • Dr Girish Purohit , GP Locality Lead, Syston, Long Clawson and Melton.
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Paper A East Leicestershire and Rutland CCG Governing Body Meeting 9 April 2019 ITEM DISCUSSION LEAD RESPONSIBLE B/19/3 Notification of Any Other Business
Dr Montgomery informed that she had received no additional items of business.
B/19/4 Declarations of Interest on Agenda Topics
All GP members declared an interest in items relating to primary care where a potential conflict may arise and also where there are any items concerning the Leicester, Leicestershire and Rutland Provider Arm where GP members’ are minor shareholders. The conflict was noted and will be managed during the discussions as required, it was also noted that the Register of Interests is published on the CCG website detailing declarations made by Governing Body members.
Mrs Karen English noted her conflict with Paper E - Update on next steps to greater collaboration between the CCGs in Leicester, Leicestershire and Rutland. As the report was for receiving only, Mrs English would remain in the room for the update.
It was RESOLVED to:
• RECEIVE the declarations of interest and NOTE the actions being taken.
B/19/5 Minutes of the meeting held on 11 December 2018
The following amendments were noted for the minutes of the Governing Body meeting held on 11 December 2018:
• Page 6, B/18/220; Ms Donna Enoux noted that the figures in the second bullet point should be the same as within the last paragraph and she would need to confirm the correct figure outside of the meeting.
• Page 12 North Blaby update; Dr Simon Vincent noted that in the final bullet point the words ‘choose and book’ should be replaced with ‘advice and guidance’.
It was RESOLVED to:
• APPROVE the minutes of the meeting held on Tuesday 11 December 2018 subject to the amendments made.
B/19/6 Matters Arising: Update on actions from the meeting held on 13 December 2018 (Paper B)
The action log (Paper B) was received and the following updates
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Paper A East Leicestershire and Rutland CCG Governing Body Meeting 9 April 2019 ITEM DISCUSSION LEAD RESPONSIBLE noted:
• B/18/205 Locality Chairs report, rota for attendance of senior officers at meeting – Mrs Karen English confirmed that a draft programme for Directors attendance is in place; however, this needs checking against topics being discussed to ensure that the Director is the most appropriate. Action closed.
• B/18/216 Blood Pressure Monitoring – Dr Andy Ker confirmed that the Locality is trying to find a local solution to the problem. Dr Montgomery agreed to allocate the action to the Locality. Action Closed.
• B/18/227 Locality Chairs report, PRISM and MSK triage for EMIS practices - Mr Paul Gibara confirmed that he has spoken to the Alliance, who confirmed that EMIS practices can access MSK triage via EMISweb. Any practices who are experiencing problems should contact Ms Helen Mather. Action closed.
It was RESOLVED to:
• RECEIVE and NOTE the update on the actions.
B/19/7 To receive questions from the Public in relation to items on the agenda only
Dr Montgomery invited questions from the members of the public relating to items on the agenda. There were no questions raised on agenda items.
It was RESOLVED to:
• NOTE that no questions were raised on agenda items from the public.
B/19/8 Chair’s Report (Paper C)
Dr Montgomery noted that it had been another busy month and highlighted the following from her Chair’s report:
The CCG Constitution has recently been approved by NHS England, following changes made to the internal governance structure and the establishment of the Commissioning Collaborative Board (CCB) as a joint Committee of the three Leicester, Leicestershire and Rutland (LLR) CCGs.
The Chair attended the Rutland County Council meeting to provide an overview of the Better Care Together acute reconfiguration.
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Paper A East Leicestershire and Rutland CCG Governing Body Meeting 9 April 2019 ITEM DISCUSSION LEAD RESPONSIBLE
ELR CCG staff held a development day in December 2018, which enabled staff to look back at the past 12 months and plan for the challenges expected in the next 12 months.
The Chair recently attended the Joint Executive Steering Group to progress the discussion on the move to a single accountable officer.
Dr Montgomery also attended the CCB and is currently the Chair of this meeting.
It was RESOLVED to:
• RECEIVE the report and NOTE the update.
B/19/9 Accountable Officer’s Corporate Report (Paper D)
Mrs Karen English highlighted the report noting the following two items:
• CCG delegation of commissioning function for a new model of management of Excess Treatment Costs (ETC) - Commissioning guidance has now been received and this is moving forward to the next stage in the model.
• Commissioning capability programme - Mrs English reported that along with the Chief Finance Officer and Chair, she is part of the commissioning capability programme. ELR is in the last phase of this 12 week programme; which NHS England is encouraging CCGs to take forward. The programme looks at developing the leadership capability of senior commissioning teams across five learning streams; including governance and aims to give commissioners a single voice.
Dr Montgomery noted the recommendations, including approving the delegation of the ETCs to Nottingham City CCG as the lead for the region.
It was RESOLVED to:
• RECEIVE the report
• APPROVE to delegate the commissioning function for ETCs to Nottingham City CCG, the lead CCG for ETC commissioning for East Midlands LCRN region in line with the scheme of delegation as provided by NHS England.
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Paper A East Leicestershire and Rutland CCG Governing Body Meeting 9 April 2019 ITEM DISCUSSION LEAD RESPONSIBLE B/18/10 Update on next steps to greater collaboration between the CCGs in Leicester, Leicestershire and Rutland (Paper E)
Dr Montgomery confirmed that the paper provides an update on the current situation regarding the recruitment of a single accountable officer, since the previous update in December 2018.
The main points to note are the timelines for the recruitment and processes involved and the development of an organisational development programme.
The Commissioning capabilities programme is leading on the governance structures involved with this process.
It was RESOLVED to:
• RECEIVE the report and NOTE the update
B/19/11 Summary report from the Financial Turnaround Committee (January 2019) (Paper F)
Mr Smith presented the paper and took the report as read and no questions or queries were raised.
It was RESOLVED to:
• RECEIVE the Summary report from the Financial Turnaround Committee (January 2019)
B/19/12 Finance Report: Month 9 update (Paper G)
Ms Enoux presented Paper F and took the paper as read; highlighting the following items;
At month nine, the CCG is reporting a break even position, with a year to date adverse variance of £2.5m, which is a slight improvement since month eight.
Encouraged by NHS England the LLR CCGs are being encouraged to ensure that the system is working better.
There is still a shortfall with the Quality Innovation Productivity and Prevention (QIPP) programme and therefore the CCG cannot currently report a break even position.
The cash flow target has been met for month 9 and the Better Payment Practice Code is in excess of 99% compliance. The Commissioning Support Unit (CSU) have met all 9 formal KPIs.
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Paper A East Leicestershire and Rutland CCG Governing Body Meeting 9 April 2019 ITEM DISCUSSION LEAD RESPONSIBLE The draft plan for 2019/20 was submitted to NHS England on 25 January 2019 and will be re-submitted at noon today. The CCG is required to submit a break even plan and therefore will only be allowed to spend the allocation. This will mean a £20.3m QIPP requirement; which is equal to 4.5% of the allocation.
Mr Kendrick asked if Ms Enoux could provide an analysis of appendix D, for the accruals, outside of the meeting. Ms Enoux confirmed that this will be completed.
It was RESOLVED to:
• RECEIVE for information the contents of the report and the appendices attached.
B/19/13 Summary report from the Provider Performance Assurance Group meeting (January 2019) (Paper H)
Mr Kendrick took the report as read and highlighted the following:
The Provider Performance Assurance Group (PPAG) Committee were not assured that the action plan from East Midlands Ambulance Service (EMAS), to improve performance, will deliver and therefore will continue to follow this up in discussions with NHS England and NHS Improvement.
The staffing levels at Thames Ambulance Service Limited (TASL), University Hospitals of Leicester NHS Trust (UHL) and Leicestershire Partnership Trust (LPT) were highlighted and noted as a concern.
Dr Glover queried paragraph 16 in the report and asked why TASL have been allowed to keep the additional money from NHS England, when they are carrying out less activity. Mr Kendrick confirmed that NHS England did not want TASL to fail, due to financial difficulties and therefore agreed that they could keep the additional money to support them over the winter period. The performance of TASL will continue to be closely monitored.
Mr Gibara noted that procurement lessons have been learnt with the TASL contract and TASL are gradually improving their performance.
Dr Montgomery noted that in the report, the escalation process is mentioned on a few occasions and queried when ELR CCG will know when a decision has been made, particularly in relation to UHL and LPT. Mr Kendrick confirmed that PPAG can only request information and as Leicester City CCG (LC CCG) lead on the contracts they have been asked to report back to PPAG with a recommendation; which is likely to be further discussions with NHS England / NHS Improvement or a Board to Board meeting. A further update will be provided in
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Paper A East Leicestershire and Rutland CCG Governing Body Meeting 9 April 2019 ITEM DISCUSSION LEAD RESPONSIBLE April.
Mrs Tracy Burton reported that the same quality issues are reported regionally at the Clinical Quality Review Group (CQRG).
It was RESOLVED to:
• RECEIVE the Summary report from the Provider Performance Assurance Group meeting (January 2019).
B/19/14 Corporate Performance Assurance Report (Paper I)
Mr Gibara highlighted that this report has been previously been to Provider Performance Assurance Group (PPAG) and Integrated Governance Committee meetings and therefore assurance had already been provided. The main items to note from the report were highlighted as follows;
There has been significant discussion regarding performance at PPAG and CQRG meetings.
The cancer performance for UHL remains under trajectory and although improving did not hit the target for December. The cancer alliance has a 90 day plan with UHL to try and improve performance.
The Referral to Treatment (RTT) trajectory was not designed to hit the 92% and the number of patients waiting is only 0.2% below target, according to soft intelligence.
The Improving Access to Psychological Therapies (IAPT) currently has a more stable performance level.
There may be an overall £600k benefit to the CCG, if the planning and financial modelling is correct, through a quality premium.
Mr Alan Smith queried the cancer figures on page 4 of the report and asked if there was a known reason why West Leicestershire CCG (WL CCG) has a better performance than ELR. Mr Gibara responded that there is no particular reason for these results and UHL see patients on a needs basis.
Dr Montgomery asked where the LLR Carers Programme reports into; Mr Gibara was unable to answer the query and will confirm and provide feedback outside the meeting.
It was RESOLVED to:
• RECEIVE the Corporate Performance Assurance Report.
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Paper A East Leicestershire and Rutland CCG Governing Body Meeting 9 April 2019 ITEM DISCUSSION LEAD RESPONSIBLE B/19/15 Summary report from the Integrated Governance Committee meeting (January 2019) (Paper J)
Dr Randell took the paper as read and noted the following from the report:
A report from the medicines quality related sub groups was received and actions from the Leicestershire Medicines Strategy Group were ratified. A discussion took place on the possible EU Exit and the national and regional planning advice, including not stock piling drugs etc. Following a query, Mrs Daljit confirmed that the EU Exit has been added to the Board Assurance Framework for 2018/19 as a corporate risk.
It was RESOLVED to:
• RECEIVE the report.
B/19/16 Locality Chairs’ Report: (Paper K)
Melton Rutland and Harborough Dr Fox highlighted the following for the Rutland Locality;
• Updates were received on the four transformation projects • A discussion took place on MSK Referral Support Service in relation to Out of County hospitals, as anecdotally patients appear not to be being offered choice
Dr Ker noted a recent MSK referral to Peterborough; which he tried to make through the triage service, to be told that a separate referral was required. Dr Fox agreed to liaise with Dr Ker regarding this incident in order to ascertain the reason behind the additional request.
Dr Anuj Chahal provided the following feedback from the Harborough locality:
• Ms Enoux was thanked for her attendance at the recent meeting and helped to support the conversation on Primary Care Networks (PCN). • Updates were received from the sub-localities; the main updates related to the Diabetes service for Rutland, the Harborough Physio service and the Emergency Care Practitioner service in Syston, Long Clawson and Melton.
North Blaby Dr Simon Vincent highlighted the following for the North Blaby locality:
• The success of Multi-Disciplinary Team (MDT) meetings was
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Paper A East Leicestershire and Rutland CCG Governing Body Meeting 9 April 2019 ITEM DISCUSSION LEAD RESPONSIBLE highlighted; these are taking place at The Limes and include the local Social Worker and District Nurse. • The exercise referral service provided by Blaby District Council is being rolled out to other practices within the locality as part of the transformational planning. • The Advanced Nurse Practitioner (ANP) for frailty is working across practices in the locality. • The Mental Health Practitioner is working well, across four practices in the locality. • The Referral Support Service (RSS) was discussed and the proposal to start phase one of the service; although questions were raised by members over why this was being provided by the Alliance.
South Blaby and Lutterworth Dr Glover highlighted the following from the South Blaby and Lutterworth Locality;
• The four elements of transformation are working well; including the investment in ANPs and GP TeamNet. • Practices are positive regarding Primary Care Networks and the direction of working. • The Integrated Leadership Team meeting was chaired by Nikki Rainbow (Services Manager for older adults) and improvement areas for Mental Health were identified. A presentation was received on suicide prevention and the group looked at risk assessment and risk management in this area. The presentation was well received and members were asked to cascade the message to colleagues. • A presentation was received on the Pathology Project; although members were unsure why this was presented by Deloittes and not a clinical colleague. • Mrs Tracy Ward, Head of Patient Safety for ELR CCG was in attendance at the meeting and thanked for her work on reporting of patient safety concerns. Mrs Ward provided updates on two serious incidents and the group agreed to test relevant systems in relation to the Pathology project.
Oadby and Wigston Dr Varakantam highlighted the following for Oadby and Wigston;
• Joint working was highlighted and the in particular the two whole time equivalent Physios, as part of the First Contact Physio service who are being utilised effectively. • The recent Protected Learning Time (PLT) focussed on Active Signposting, which is to be implemented at practice level. Practices in the Oadby and Wigston locality are keen to have
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Paper A East Leicestershire and Rutland CCG Governing Body Meeting 9 April 2019 ITEM DISCUSSION LEAD RESPONSIBLE more locality based PLTs as this is more inclusive. • The Oadby and Wigston summit is due to take place on 28 February and feedback will be given at the next locality meeting
Dr Tim Daniel thanked the CCG for their support with the summit, which aims to try and address the health inequalities identified in the locality. Since the initial report was produced further information has been made available which shows that the situation has worsened and therefore the summit is very timely.
It was RESOLVED to:
• RECEIVE the Locality Chairs’ Report.
B/19/17 Summary Report from the Audit Committee (January 2019) (Paper L)
Mr Kendrick took the paper as read and highlighted that the Committee agreed that a separate risk should be added to the Board Assurance Framework 2018/19 on EU Exit, in order to ensure that the risks and controls have been identified. ELR is working with LC and WL CCGs to ensure a smooth transition.
It was RESOLVED to:
• RECEIVE the Summary Report from the Audit Committee (January 2019)
B/19/18 Date of next meeting
The next meeting of the Governing Body of the East Leicestershire and Rutland CCG Governing Body will be take place on Tuesday 9 April 2019, Council Chamber, County Hall, Glenfield, Leicester, LE3 8TB.
The meeting concluded at 10.10am.
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B Blank Page Paper B ELR CCG Governing Body Meeting 9 April 2019
NHS EAST LEICESTERSHIRE AND RUTLAND CLINICAL COMMISSIONING GROUP Key ACTION NOTES Completed On-going Outstanding Minute Meeting Item Responsible Action Required To be Progress as at Status No. Officer completed April 2019 by No actions AMBER
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C Blank Page Paper C East Leicestershire and Rutland CCG Governing Body meeting 9 April 2019 EAST LEICESTERSHIRE AND RUTLAND CLINICAL COMMISSIONING GROUP GOVERNING BODY MEETING 9 April 2019
Chair’s Report
Introduction
1. The purpose of this report is to provide an overview and update of some of the key constitutional and strategic updates that affect the Governing Body; and provide an overview of meetings that I have attended.
Secondary Care Clinician
2. Dr Tabitha Randell, the CCG Secondary Care Clinician, left the CCG on 31 March 2019 following over 6 years of working with the CCG as a Governing Body member. Dr Randell wished to increase the focus on her clinical role. On behalf of the Governing Body I would like to thank Dr Randell for her contributions to the CCG as a Governing Body member; as a member of the various internal committees; and for her dedication and commitment to the children and young people work stream across Leicester, Leicestershire and Rutland.
3. We wish her all the very best as she continues in her clinical role.
Meetings attended
4. Over the last few weeks, I have attended a number of meetings:
i. I have continued to attend the regular meetings established to review and explore further the collaborative working arrangements across the three CCGs.
ii. On 14 February 2019 I attended the Quarterly Assurance Meeting with NHS England along with colleagues from ELR CCG, West Leicestershire CCG and Leicester City CCG. NHS England continues to review each CCG’s performance against the national requirements, and also as a collective group of CCGs operating within the Leicester, Leicestershire and Rutland health system.
iii. I attended the Commissioning Collaborative Board meeting in February 2019 and the System Leaders’ Team meetings.
iv. On 25 February 2019 I attended the Women Leaders’ Engagement Event, facilitated by the East Midlands Leadership Academy, along with Karen English and Donna Enoux. The event focused on the positive contribution of women in leadership roles ensuring inclusion and engagement.
1 Dr Ursula Montgomery Chair Paper C East Leicestershire and Rutland CCG Governing Body meeting 9 April 2019 v. NHS England held an event on 27 February 2019 entitled “Supporting the development of primary care networks”, which I attended along with other colleagues.
vi. I was in attendance to support the special health summit on 28 February 2019 held in Wigston to discuss the health inequalities in the area. This was an extremely positive event bringing together partners from across health and local authority, including local councillors, to identify ways in which we could work together to reduce the health inequalities in the local area.
vii. On 7 March 2019 I attended the engagement event with Rutland Communities to support better engagement.
viii. I attended and supported the CCG’s Practice Engagement Event on 14 March 2019 which focused on the development of primary care networks and 2019/20 primary care commissioning intentions. The event was well attended by our member practices.
ix. On 26 March 2019 we held the interviews for the new post of Chief Executive across the three CCGs. I am pleased to say that we have been successful in identifying a preferred candidate. This individual is external to our system. However, this selection remains subject to various local and national approval processes and, as such, I am unable to provide more detail at this stage. The Governing Body members will be kept appraised of progress.
Recommendations
The East Leicestershire and Rutland CCG Governing Body is requested to:
RECEIVE the contents of the report.
2 Dr Ursula Montgomery Chair D Blank Page Paper D East Leicestershire and Rutland CCG Governing Body meeting 9 April 2019 EAST LEICESTERSHIRE AND RUTLAND CLINICAL COMMISSIONING GROUP GOVERNING BODY MEETING 9 April 2019
Accountable Officer’s Corporate Report Introduction
1. This report sets out to the Governing Body some of the key updates and activities the Executive Management Team (EMT) and I have been involved in since the last meeting of the Governing Body in February 2019.
2. There are a number of reports on the main Governing Body meeting agenda covering the areas which the EMT have been heavily involved with, in addition EMT have been planning for next year’s commissioning intentions.
Urgent Care Services from April 2019
3. I am pleased to confirm that from 1 April 2019 patients in East Leicestershire and Rutland will benefit from changes to evening and weekend urgent care services. The changes come after engagement with patients and stakeholders across East Leicestershire and Rutland. 4. The changes include the introduction of a new urgent care centre in the Blaby District and extended opening hours and access options for urgent care services in Lutterworth. In Melton, Rutland and Harborough, opening hours at urgent care services are changing to remove the overlap in opening times with GP practices. The changes take effect from 1 April 2019. 5. Urgent care services, which offer appointments with a GP or Nurse, can be accessed by patients if they need urgent medical attention for conditions which are not life-threatening. 6. Local people have told us that having services close to home is important to them, ensuring the services are simpler so its clearer where they need to go when they have an urgent care need. We have listed and have changed the opening hours of some of our urgent care centres so that they are open when local GP practices close, making it simpler for people to know which service to go to when. 7. We have also opended a new urgent care centre in Enderby, bringing care closer to home for people in the Blaby District. Services in Lutterworth are being extended so they will be open for longer and people can also walk-in for treatment. 8. We believe the changes will help to improve access to urgent care services for all of our patients, but should also ease the pressure on our accident and emergency departments. 9. The changes were approved and announced by the CCG in September 2018 following conversations with the public and a survey last summer. Further conversations took place with the public in November 2018, where local people’s views used to help determine the site of the new service in Blaby District.
Karen English 1 Accountable Officer Paper D East Leicestershire and Rutland CCG Governing Body meeting 9 April 2019 10. The new services across East Leicestershire and Rutland will be provided by DHU Health Care and the East Leicestershire and Rutland GP Federation following a procurement process. 11. The new opening hours are listed in the table below:
Commissioning Capability Programme
12. The CCG senior leaders continue to participate in the Commissioning Capability Programme provided by NHS England to support leaders develop the skills they need to tackle today’s and tomorrow’s challenges across the health system.
13. Governing Body members were invited to join the workshop session on building a sustainable strategy in early April 2019.
Better Care Together (BCT) Partnership Update
14. Appended to this report at Appendix 1 is the BCT Partnership Update providing an overview of the work undertaken across the partnership.
15. Appendix 2 is a proposal put forward by the BCT Programme for establishment of a partnership group. The Governing Body is asked to consider the proposal and the draft terms of refrence and provide feedback.
PUBLICATIONS
16. Publications and updates published by NHS England via its fortnightly newsletter Bulletin for CCGs can be found at the following http://www.england.nhs.uk/publications/bulletins/bulletin-for-ccgs/. The Executive Management Team undertakes a regular review of the content of the Bulletin and ensure actions are taken accordingly. Assurances and updates are reported through to the Governing Body as evident on the agenda and through updates in the Accountable Officer’s report.
Recommendation The East Leicestershire and Rutland CCG Governing Body is requested to: • RECEIVE the report. • CONSIDER the proposal to establish a partnership group as at Appendix 2.
Karen English 2 Accountable Officer
Appendix 1
Better Care Together Partnership Update A business update for partner boards, governing bodies and members
March 2019
Welcome to the first of a regular business update from the System Leadership Team (SLT) of Better Care Together. The purpose of this update is to inform governing bodies, boards and members on the key business and strategic programmes of work being discussed and taken forward SLT.
Responding to the NHS Long Term Plan
In January NHS England published the NHS Long Term Plan. This has been developed nationally – in partnership with frontline health and care staff, patients and their families – in response to the Government’s commitment to provide an extra £20.5 billion annual funding for the NHS in England by 2023/24.
The Long Term Plan sets out a strategy to make sure the NHS is fit for the future, providing high-quality care and better health outcomes through every stage of life. It also describes the actions that will be needed at local, regional and national levels to make this ambitious vision a reality.
To respond to the NHS Long Term Plan, Better Care Together partners will produce a refreshed version of our own local plan in the coming months.
This will build on the work we have already done together as a partnership and focus on the priority areas we have already identified for transforming our health and care services.
Indeed, it’s encouraging to see that a lot of the detail in the NHS Long Term Plan is very much aligned with our own priorities for Leicester, Leicestershire and Rutland – including our focus on creating integrated local health and care services closer to people’s homes, giving people more control of their own health and care, our efforts to improve prevention of ill-health and tackle health inequalities, and working to prevent unnecessary hospital admissions and speed up discharges home.
Between now and late 2019 we will be working with our BCT partners and wider stakeholders, including the public, to produce our refreshed five-year plan. Governing bodies, boards and members will also of course be involved in those discussions, and we will also keep you informed through future editions of this update and via our website. In the meantime you can read more about the NHS Long Term Plan at www.longtermplan.nhs.uk.
SLT reviews BCT governance
SLT is currently undertaking a review of its governance arrangements. This work is being undertaken in order to future proof the local health system, while also supporting its response to delivering the requirements of the NHS Long Term Plan.
It is anticipated that the outcomes of the review will strengthen overall governance of the programme and support delivery of the system’s strategic priorities through robust management and oversight.
As part of the review SLT is to propose updated Terms of Reference, which will be shared within health and care organisations for discussion and agreement as appropriate.
Under the proposals SLT will continue to be constituted as a formal joint committee of the three CCGs – allowing the commissioners to make collective decisions. Other partners continue to make decisions in line with any authority delegated to its individual representatives.
It is also recommended that Derbyshire Health United be invited to join the group as members, reflecting the The role of SLT organisation’s position as a key provider of services in LLR. The System Leadership Team is Meanwhile, a new BCT Partnership Group is proposed to be the senior management group established in line with guidance contained within the Long which oversees all aspects of the Term Plan. development and delivery of the BCT plan for the Leicester, The group, led through the appointment of an independent Leicestershire and Rutland (LLR). chair, would bring together non-executive, lay and political representation to scrutinise and challenge the operation of It brings together clinical and SLT as well as the delivery of the wider programme. It will executive leadership of health and also take a key role in ensuring adequate and effective local authority partners to serve patient and public engagement. three core purposes: In doing so it would provide an oversight function for Set the direction and oversee statutory partners in particular, ensuring they receive delivery of the BCT programme common and shared assurance in relation to BCT. for LLR, including the development of an Integrated Draft Terms of Reference for the Partnership Group have Care System (ICS) and five- been developed and circulated to partner organisations for year BCT plan; discussion and feedback. Support collective problem Finally, to support the development of the refreshed five-year solving and decision-making for plan it is proposed that the BCT Interdependencies Group be system-wide issues; and re-established and tasked with its delivery, reporting into the System Leadership Team. Provide oversight and monitoring of performance To support the proposed refreshed governance against planned outcomes, arrangements a comprehensive governance handbook is agreeing actions to address any also being developed. This user-led document will include variances from the plan – e.g., Terms of Reference for the Partnership Group and SLT as system finance position – with well as all sub-groups, a comprehensive guide to the appropriate reference to the overarching governance hierarchy and assurance flows, and governance arrangements of an agreed set of system-wide leadership behaviours and each organisation. standards of business conduct.
System Leadership Team work programme
The SLT has agreed that the future schedule of its meetings would be a mix of more formal business- focused meetings interspersed with workshop-type development sessions. It is anticipated that these development sessions would happen quarterly.
Agendas for SLT meetings will have an emphasis on more system-level conversation and a focus on understanding and unblocking issues that prevent system priorities from being delivered.
This will include a rolling programme of work stream deep dives, with an indicative schedule set out below.
Prevention and Inequalities April 2019 Mental Health April 2019 Learning Disabilities April 2019 Planned Care June 2019 Cancer June 2019 Integrated Community Services July 2019 Primary Care July 2019 Urgent Care August 2019 Workforce October 2019 IM&T October 2019 Note updates will include: What the key priorities are and how they link to the Long Term Plan; What has been achieved; Priorities for the next 12 months; and risks and issues
Outside of the above deep dive schedule any other work stream issues will be escalated to SLT by exception for consideration and recommendations for resolution as appropriate.
In addition to the above there are a number of known business items that will need to be dealt with throughout the year, and these are set out below.
Systems Finance and Activity Monthly Estates Update Quarterly STP Risk Register Quarterly Outcomes Framework Quarterly Communications and Engagement Update Quarterly Response to Long Term Plan (Draft) August 2019 Memorandum of Understanding (Draft) August 2019 Response to Long Term Plan (Final) October 2019 Memorandum of Understanding (Final) October 2019
Working towards becoming an Integrated Care System
One of the key requirements of the NHS Long Term Plan is for all STP footprints to have evolved into an Integrated Care System by April 2021.
Integrated Care Systems – or ICSs – are a way of working, collaboratively, between a range of health and social care organisations, to help proactively manage and improve people’s health. What it is not is a creation of a new organisation.
Instead, they bring together local organisations to redesign care and improve population health, creating shared leadership and common action. The Long Term Plan describes them as “…a pragmatic and practical way of delivering the ‘triple integration’ of primary care and specialist care, physical and mental health services, and health with social care.”
An ICS will have a key role in working with local authorities at ‘place’ level and, through ICSs, commissioners will make shared decisions with providers on how to use resources, design services and improve population health.
Every ICS will need streamlined commissioning arrangements to enable a single set of commissioning decisions at system level. This will typically involve a single strategic commissioner for each ICS area.
As a result Clinical Commissioning Groups (CCGs) will become leaner, more strategic organisations that support providers to partner with local government and other community organisations on population health, service redesign and Long Term Plan implementation.
Locally, the CCGs have already agreed to appoint one Chief Executive Officer and senior management team across the three organisations. The second phase of the work will be to consider whether a merger of the three Clinical Commissioning Groups should happen. This work will take place during 2019.
In the meantime, SLT came together during January for a facilitated development session to discuss the local journey towards creating an ICS and set out a roadmap for delivery.
The outcome was agreement in principle that it intends to develop a delivery plan by September 2019 and be ready to work in shadow form as an Integrated Care System from April 2020.
The Good Governance Institute Maturity Matrix has been used to assess where we currently are as a system and what actions we need to take next. This has identified the following key areas of focus for the year ahead:
Purpose and clarity of remit - rearticulate vision, purpose and principles System Infrastructure, leadership, financial framework Governance and decision making, including establishing transparent oversight arrangements and putting in place a Memorandum of Understanding Internal and external stakeholder engagement, including joint approaches to communications and engagement activities with staff and stakeholders Priorities and outcomes, including tangible programmes of joint work.
Boards and governing bodies will be fully involved in discussions about delivery of the above priority areas over the course of the coming months.
Leicester’s Hospitals’ investment and reconfiguration plans
Final approval and funding for the £31m interim Intensive Care Unit (ICU) consolidation and associated services scheme has now been received. This scheme transfers Level 3 intensive care beds from the Leicester General Hospital to Glenfield Hospital. It also moves dependent specialist surgical services to Glenfield, and consolidates general surgery at the Royal Infirmary site.
The key building components and dates when the construction completes within this scheme are:
Expansion of Glenfield ICU – Dec 2019 New wards at Glenfield for HPB and renal transplant – Feb 2020 New Interventional Radiology Department at Glenfield – March 2020 Refurbished wards at the Royal for emergency general surgery and colorectal surgery (wards 15,16 and 21) – October 2019.
Part of this scheme will include moving some day case surgery from the Royal Infirmary and Glenfield to the General.
In addition to this scheme, UHL is also relocating the children’s element of the East Midlands Congenital Heart Centre (EMCHC) from Glenfield to the Royal Infirmary. This £14m scheme will see a number of moves within the Kensington Building, supported by the development of a new build Cardiac theatre and catheter lab.
Enabling works include the move of Gynaecology outpatients into the Jarvis building and the gynaecology assessment unit and early pregnancy assessment unit into ward 8 in the Balmoral building. The EMCHC service is scheduled to move in June 2020 as the first phase of the new standalone children’s hospital project.
All of these investments will provide great new facilities. At the same time as progressing these schemes, we have been pursuing a larger bid as part of the national capital process. This bid is designed to provide enough funding for us to complete our reconfiguration over a number of years.
National NHS colleagues have been very clear that our bid has made good progress and that they wish it to continue to do so, so that it is in the best position it can be to get further funding when new money becomes available. This is likely to be later this year or early in 2020. The UHL Trust Board has also recently reviewed the position and confirmed that the plan remains the best one available to ensure that patients and staff have access to high quality, sustainable facilities and clinical services.
Our plan remains that, once capital funding is secured in principle, we will move to full consultation on our acute reconfiguration plans.
Reconfiguration plans shared with patients and the public
Although we are not in a position to formally consult on our plans until capital support is obtained in principle the partnership has been engaging extensively over the course of recent months. Nine public engagement events were held in the city and two counties in the lead up to Christmas, while this year plans have been shared through more than 30 outreach meetings with seldom heard and hard to reach communities.
A video and information booklet demonstrating the case for change and our outline plans has been produced and will shortly be shared publicly. These can be accessed by visiting the BCT website: www.bettercareleicester.nhs.uk.
A new approach to communications and involvement
A refreshed approach to engagement, involvement and communication for the BCT programme has recently been discussed and supported by SLT.
The approach sets out when and how the partnership will communicate with and involve patients and the public, staff and other stakeholders in the work of Better Care Together.
Agreement has been given to driving the involvement of patients and stakeholders through and by work streams and work stream senior responsible officers in partnership with communications and engagement leads.
At its heart is a culture and mind set where engagement is seen as ‘an always event’ when services are redesigned or modified. To support this work stream leads will be provided with a better understanding of the legal and statutory duties of engagement – as well as the many practical and real benefits of involving patients in the process through the sharing of experience and expertise.
In addition a commitment has been given to the use of the BCT brand consistently across all work streams and BCT partners to increase awareness of the overall programme and the many positive improvements it is already making.
This emphasis in approach will be discussed with work streams through the BCT Interdependencies Group, as well as through communications and engagement leads. A copy of the document setting out the approach to communications and engagement can be accessed here.
Proposed new structure for Patient and Public Involvement
A comprehensive review of the existing Patient and Public Involvement Group (PPIG), which provides support and advice for engagement activities across the BCT programme, has been undertaken in partnership with group members.
The review concluded that there is a broad level of support within the group to refresh arrangements and create a new two-step approach - with complementary parts concentrating on assurance and networking.
A new Patient and Public Involvement Assurance Group (PPIAG), consisting of 10 to 12 people with significant experience of patient engagement, will be established. This group will replace the existing PPIG and will work within an agreed assurance framework to review, comment on and recommend actions in respect of patient involvement and engagement across BCT projects.
It will also liaise with work streams to ensure that insights and business intelligence gained through involvement and engagement influences decision making. PPIAG will be represented on, and report findings to, the new BCT Partnership Group once established. It is envisaged that the Partnership Group will agree a programme of review with input from the Senior Leadership Team, work stream SROs, PPIAG and the Communications and Engagement Group.
Creating a Citizens’ Panel
In order to further support a consistent approach to engagement, and to connect with local networks, we have secured £40k from NHS England to develop a Citizens’ Panel.
The Panel, which will be largely online, will provide BCT with an additional systematic approach to gathering insights and feedback on a range of health and care issues from a representative sample of our circa 1.1 million population.
We wish to co-create the panel with support from BCT partners, the newly created PPIAG and our upper and second tier local authorities and parish councils. Community Services Redesign work continues
Work has continued at pace on the Community Services Redesign (CSR) in recent months. The project, initiated by the CCGs in April 2018 to address identified issues within existing community services provision, aims to ensure services are configured appropriately to deliver the best possible care for patients in community settings.
The scope of the redesign work includes the following services provided by Leicestershire Partnership NHS Trust:
District nursing services – which provide home-based patients with ongoing nursing care for long- term conditions or end-of-life care, with treatments such as wound care and continence care Integrated Community Support service – a ‘virtual ward’ providing healthcare services in a patient’s own home Community hospital beds (including stroke beds) Community physiotherapy services (not including MSK physiotherapy) and community stroke rehabilitation service Primary care co-ordinators – who work in hospitals to support staff to help get patients home as quickly as possible once they are ready to leave hospital Single Point of Access.
Due to the complexity of the work, achieving significant change is being seen as a two to three year transformation programme which follows a systematic process. The emerging proposed new model is based around the following main services:
Neighbourhood community nursing – teams would manage the majority of care of complex patients in the community (for example those who are frail, have multiple conditions or other complex/costly health and care needs), working closely with social care and primary care networks (groups of GP practices with 30,000– 50,000 patients). Neighbourhood teams would provide both planned and same day urgent care, providing improved continuity of care.
Home First services – these are integrated health and social care crisis response rehabilitation and reablement services, which would deliver intensive short-term care for up to six weeks. Home First services will be accessed via Locality Decision Units, with health and social care services working on the basis of trusted assessment and delivering co-ordinated packages of care.
Community bed based care - delivered either in community hospitals for patients requiring medical rehabilitation needing significant 24/7 nursing care and on-site therapies, and in reablement beds for patients with lower medical needs requiring reablement and a degree of 24/7 support.
Initial changes to the staffing in current ICS teams will be made, redesigning them into neighbourhood nursing teams and Home First services. A second phase of work will then be undertaken to engage on and generate options for longer term changes to community health services which would deliver a greater shift towards supporting more people to be cared for at home (where that is appropriate for their needs). This work will include setting out options for the range of services delivered from community hospital sites, and the future community bed model. Whilst CCG governing bodies have agreed the model in principle specific options will require further discussion and approval.
Meanwhile, the CSR team has undertaken extensive engagement with patients, carers, staff, as well as the public, local authority elected members and executive teams on the work done to date. This has played back the results of the engagement work so far, describing the vision for integrated community health and care services and seeking support for the direction of travel. Feedback from these discussions will be used to inform and shape next steps.
Frailty work programme comes to a close
The Frailty programme, commissioned by SLT in May 2018, has come to the end of its initial phase.
The original aims of the programme were to design and implement 16 high-impact drivers which the system agreed could influence the delivery of an integrated system of care for our functionally frail cohort of patients in LLR.
By their nature, most of these 16 drivers were not straightforward to design or deliver. This is because all 16 projects spanned multiple organisations, multiple IMT systems and, most importantly, multiple differing organisational cultures.
However, although originally daunting, in reality it was this complexity that led to success of the work stream – giving a group of motivated and likeminded staff the mandate to ‘fix’ an issue in a patient- focussed and collegiate manner.
This has led to a range of solutions to long-standing issues faced by our patients and staff across LLR.
Ten of the original sixteen drivers have been fully delivered, with a further four partially completed.
The final two actions were deferred as they fell into the scope of the Community Services Redesign programme – principally to ensure alignment with the emerging model. As a result, no further work was completed in relation to this through the frailty programme. Other outstanding actions have been agreed with the relevant STP work stream.
Within the LLR frailty programme there were a number of actions specifically for UHL. Whilst these have been delivered embedding the processes will take time and further engagement within the Trust.
As a result the Trust, supported by SLT, has agreed that the UHL element of the frailty programme remains active. This will enable Leicester’s hospitals to embed frailty scoring across the wider Trust, as well as ensuring that the outputs of related work streams - such as the CSR - are fully aligned with long-term requirements.
Appendix 2 Leicester, Leicestershire and Rutland Better Care Together Programme
Proposal to Establish a Partnership Group
Background
1. Over the past few months the System Leadership Team (SLT) has been reviewing various aspects of its business in order to further strengthen its arrangements as we develop into an Integrated Care System (ICS).
2. As part of this review a number of organisations and individuals together with an assessment of our maturity as an ICS system have highlighted the need to establish a group that will support the good governance of the partnership and provide non- executive, lay and oversight and challenge to the operation of the Sustainability and Transformation Partnership and to the System Leadership Team.
3. The recently published NHS Long Term Plan requires each ICS to establish arrangements for involving non-executive members of Boards and governing bodies and to appoint a non-executive Chair.
4. Therefore this paper sets out the proposals agreed by SLT to the establishment of a Leicester, Leicestershire and Rutland Sustainability and Transformation Partnership Group and the appointment of an Independent Chair of the group.
Partnership Board
5. The Terms of Reference for the proposed Partnership Group are attached as Appendix 1. Membership will be drawn from non-executive, elected or lay members from the following organisations:
• Leicester City Council Health and Wellbeing Board Chair • Leicestershire County Council Health and Wellbeing Board Chair • Rutland County Council Health and Wellbeing Board Chair • University Hospitals of Leicester NHS Trust • Leicestershire Partnership NHS Trust • DHU Health Care • NHS East Leicestershire and Rutland Clinical Commissioning Group • NHS Leicester City Clinical Commissioning Group • NHS West Leicestershire Clinical Commissioning Group • Representation from Healthwatch • Clinical Directors of Primary Care Networks • Chair of the PPG • Representative from the voluntary sector
6. It is proposed the Partnership Group would meet at least four times a year and be a meeting held in public.
Independent Chair
7. A proposed Job Description for the Independent Chair of the LLR STP Partnership Group is attached as Appendix 2. The main role of the position is to provide clear leadership to the delivery of the Sustainability and Transformation Partnership, and through executive officers, to hold the respective organisations to account in their commitment to do so.
8. The remuneration in relation to the post will be in line with similar NHS non-executive roles.
Recommendations
Organisations are asked to consider and provide feedback on the Partnership Group Terms of Reference and the Role Description for the Independent Chair. Appendix 1
LLR STP Partnership Group Terms of Reference
Purpose 1. To support the good governance of the Sustainability and Transformation Partnership (STP) and the provide non-executive, lay and oversight and challenge to the operation of the STP and to the Senior Leadership Team (SLT). 2. To ensure early engagement and involvement of senior health, care and political leaders in the development of Leicester, Leicestershire and Rutland (LLR) plans. 3. To provide advice and challenge on specific development proposals in advance of formal consultation. 4. Provide an oversight function such that statutory organisations receive common and shared assurance on the development of the LLR STP. 5. To ensure that non-executive directors and elected members have input into discussions that affect the strategic direction of the STP. 6. To build collective understanding of important strategic issues so as to take such knowledge and insight back into statutory organisations at the highest level. 7. To ensure and hold to account the STP on the implementation of the agreed principles, values and behaviours.
Membership Chair – an independent chair will be appointed on a yearly basis. The role of the independent chair will be to: • To Chair the Partnership Group. • Has a personal objective to oversee the implementation of the agreed principles, values and behaviours. • To reflect back to the individual organisational chairs any concerns about failure to live the agreed principles, values and behaviours. • To meet with chair of organisations on a regular basis. • To produce a report every six months as to the extent to which the system are living the principles, values and behaviours.
Members – the membership will be drawn from organisations within the area of the STP footprint, ensuring involvement from a range of organisations and groups operating within the communities served by the STP. Membership will be made up as a minimum from non- executive, elected or lay members from the following organisations:- • Leicester City Council Health and Wellbeing Board Chair • Leicestershire County Council Health and Wellbeing Board Chair • Rutland County Council Health and Wellbeing Board Chair •
• University Hospitals of Leicester NHS Trust • Leicestershire Partnership NHS Trust • DHU Health Care • NHS East Leicestershire Clinical Commissioning Group • NHS West Leicestershire Clinical Commissioning Group • NHS Leicester City Clinical Commissioning Group • Representatives from Healthwatch • Clinical Directors of Primary Care Networks • Chair of the PPG • Representative form the voluntary sector
In addition the STP will be represented by the STP lead and the chair of the SLT. Initial membership will be reviewed by the chair and the STP lead every six months.
Responsibilities 1. To provide advice to the senior leadership team on the overall strategic direction. 2. To consider specific proposals or work from the SLT and provide advice and feedback. 3. To ensure the operation and effectiveness of the STPs governance arrangements. 4. To request from the SLT additional work or briefings as required, to fulfil their purpose. 5. To receive updates and progress reports on the delivery of the plans.
Frequency of meetings 1. The Group will meet at least 4 times per year to conduct its business. 2. The meeting will be held in public, to ensure openness and transparency.
Required attendance It is expected that members will prioritise these meetings and make themselves available. Exceptionally, where this is not possible a deputy may attend if of sufficient seniority to perform their role in accordance with the purpose set out in the terms of reference.
Quorum The meeting will be quorate with half the number of the expected attendance.
Reporting procedures 1. It will be the responsibility of the individual group members to make such reports to their host organisations. In doing so, Group members must have the appropriate regard to the confidential nature of the group discussions or information shared. 2. Minutes of the group and recommendations will be sent to the SLT.
Declaration of Interests Where matters to be considered by the group give rise to an actual or perceived conflict of interest, members should declare such a potential conflict to the Chair. As circumstances require, the Chair may determine that such group member(s) should not take part in a discussion on that item.
Review date After 6 months, then annually from the inception of the group.
LLR STP – ToR – March 2019 – DRAFT 2
Version control Date Version Status Author Notes 16/11/18 Initial Draft Peter Miller For consideration, Senior Leadership Team, 22/11/18 21/1/19 V2 Draft Peter Miller For consideration at Chief officers group 13/2/19 V3 Draft Peter Miller For consideration at SLT February 2019 26/3/19 V4 Draft Sarah Prema Changes for consideration by member organisatons
LLR STP – ToR – March 2019 – DRAFT 3
Appendix 2
Role Description – Independent Chair of the LLR STP
Partnership Group
Independent Chair – Role
The Chair’s main role is to provide clear leadership to the delivery of the STP, and through executive officers, to hold the respective partner organisations to account in their commitment to do so. A strong personal commitment to the NHS and wider public service is essential, as are the highest standards of integrity and probity. An ability to communicate with a wide range of organisations and individuals is vital.
Key responsibilities
• Ensure a drive and focus on the delivery of the STP plans across LLR. • Lead and Chair the Sustainability and Transformation Partnership (STP) Group working closely with the STP CEO Lead and core STP team. • Ensure that the STP Partnership Group is effective in all aspects of its role; and that the agendas are appropriately focused on key responsibilities. • Develop a constructive, frank and open relationship with members of the STP Board providing support, challenge and advice. • Facilitate and nurture the development of constructive relationships between the members of the STP Group. • Promote a culture of openness and transparency, including wider engagement as appropriate. • To oversee the implementation of the agreed principles, values and behaviors. • To reflect back to the individual organisational chairs any concerns about failure to live the agreed principles, values and behaviors. • To meet with chair of partners organisations on a regular basis. • Ensure the Group continues to monitor and further develop strategies for STP delivery and implements this in line with the agreed plan, which maintains a clear focus on outcomes and benefits for the public and the stakeholder organisations.
Public and Stakeholders
• Ensure the patient voice and stakeholder engagement is clearly embedded in all components of development and delivery of the plan. • Work with NHSE and other stakeholders within the evolving NHS governance frameworks as the STP progresses its ambition to move to an Integrated Care System. • Promote and explain the STP remit, actions and achievements to key stakeholders and the wider public, acting as the Programme’s ambassador or ensuring that this task is appropriately delegated. • Engage with the STP Chair Clinical Leadership Group and its clinical representatives. • Ensure that there is good communication with neighbouring health and social care economies. • Ensure the Group works effectively, with good collaboration between its members. • Encourage and support the development of cross system working to ensure the strategic
1 Appendix 2
objectives of the STP are achieved on behalf of the stakeholders.
Governance
• Set the tone and style of the STP Group discussions, which support open and constructive debate. • Ensure that STP Group receives high quality, accurate, concise, objective, timely and clear information and explanation that is appropriate for their respective duties and relevant to the decisions they have to make. • Ensure good information flows in and between the Group and other stakeholders as appropriate. • Ensure that all members are able to make an effective contribution. • To ensure the STP Group acts according to the highest ethical standards of public service and that any conflicts are appropriately resolved. • To ensure that the STP Group and associated programme board membership have the range of skills, experience and knowledge in order to discharge their responsibilities effectively. • Provide assurance that the STP Group operates in synchrony with its stakeholder member organisations and that any conflicts of interest are appropriately managed. • Ensure that the Group addresses and incorporates best practice with regard to relevant legislation and guidance, including equality and diversity in its functioning.
2 E Blank Page Paper E East Leicestershire and Rutland CCG Governing Body Meeting 9 April 2019
EAST LEICESTERSHIRE AND RUTLAND CLINICAL COMMISSIONING GROUP GOVERNING BODY MEETING
Front Sheet REPORT TITLE: Summary report from the Financial Turnaround Committee (26 February and 26 March 2019)
MEETING DATE: 9 April 2019
REPORT BY: Claire Middlebrook, Corporate Affairs Support Officer
SPONSOR: Mr Alan Smith, Chair of the Financial Turnaround Committee
PRESENTER: Mr Alan Smith, Chair of the Financial Turnaround Committee
PURPOSE OF THE REPORT: This report provides a summary of the key areas of discussion and outcomes from the Financial Turnaround Committee meeting held on 26 February and 25 March 2019; and items for escalation and consideration by the Governing Body ensuring that the Governing Body is alerted to emerging risks or issues.
RECOMMENDATIONS: The East Leicestershire and Rutland CCG Governing Body is requested to:
• RECEIVE the report.
REPORT SUPPORTS THE FOLLOWING STRATEGIC AIM(S) 2018 – 2019: Transform services and enhance quality of Improve integration of local services between life for people with long-term conditions health and social care; and between acute and primary/community care. Improve the quality of care – clinical Listening to our patients and public – acting effectiveness, safety and patient on what patients and the public tell us. experience Reduce inequalities in access to Living within our means using public money healthcare effectively Implementing key enablers to support the strategic aims (e.g. constitutional and governance arrangements, communications and patient engagement).
EQUALITY ANALYSIS An Equality Analysis and due regard to the positive general duties of the Equality Act 2010 has not been undertaken in respect of this report.
Page 1 of 3 Paper E East Leicestershire and Rutland CCG Governing Body Meeting 9 April 2019
EAST LEICESTERSHIRE AND RUTLAND CLINICAL COMMISSIONING GROUP GOVERNING BODY MEETING
9 April 2019
Summary Report from the Financial Turnaround Committee (FTC)
Introduction
1. This report provides a high-level summary of the key items discussed at the Financial Turnaround Committee meetings held on 26 February 2019 and 26 March 2019.
February 2019
2. Finance report Month 9 – the month 10 forecast is to deliver a break even position. The year to date variance has improved slightly for month 10 and currently there is a £1.5m adverse year to date variance.
3. The main area of concern relates to the increase in activity at University Hospitals of Leicester NHS Trust (UHL) in quarter 4; this is being appropriately challenged with UHL and a letter written to query the increase in activity, when UHL have previously stated that they do not have the capacity to increase activity levels.
4. 2018/19 QIPP Update - the Committee received a copy of the system wide Leicester, Leicestershire, and Rutland (LLR) Quality Innovation Productivity and Prevention (QIPP) report which was presented at the Commissioning Collaborative Board (CCB) meeting. It was reported that the LLR Clinical Commissioning Groups (CCGs) are forecasting an under delivery of the QIPP plan for 2018/19 of £0.625m, a favourable movement of £0.305m since last month.
5. Prescribing Finance Report, Month 8 – It was reported that for month 8, the Prescribing QIPP has slightly under delivered in-month; £215k against the plan of £188k. At month 8, the prescribing budget is overspent by £950k. The continued cost pressure of No Cheaper Stock Obtainable (NCSO) and Direct Oral Anticoagulants (DOACs) continues to have a direct impact on the prescribing budget.
March 2019
6. Finance report Month 11 - the month 11 forecast is to deliver a break even position. The year to date variance has improved slightly for month 11 and currently there is a £1m adverse year to date variance. The majority of risks previously flagged have been closed off and a series of mitigating actions between the CCGs transacted in month 11 with more to be transacted in month 12.
7. Although there have been some movements in QIPP, this does not materially affect the CCG’s forecast financial position. The month 12 position is due to be closed shortly
Page 2 of 3 Paper E East Leicestershire and Rutland CCG Governing Body Meeting 9 April 2019 and apart from the ongoing risk with additional University Hospitals of Leicester (UHL) activity; all other material items have been closed.
8. 2018/19 QIPP update – LLR CCGs are forecasting a under delivery of QIPP for 2018/19 of £0.866m, an adverse movement of £0.241m since last month. It was noted that there is an increased financial assurance and clarity on individual schemes. The biggest movements in the month include Pathway 3 where there is now a better understanding of the activity / calculation and Learning Disability pooled budgets due to acceleration in the impact of package reviews. There has been adverse movements in high cost drugs and the increase in UHL activity has also had a detrimental impact on a number of Acute activity based QIPPs.
9. Prescribing Finance Report, Month 9 – it was reported that for month 9, the Prescribing QIPP has delivered in-month £338,499 against the plan of £245,082, which is 138% delivery against plan. The main risks to the prescribing QIPP are Over the Counter medications; Low Clinical Value; and Frailty. The Prescribing budget is overspent at month 9 by £1.43m which is attributed to the continued cost pressures of No Cheaper Stock Obtainable; Category M and Direct Oral Anticoagulants.
10. Draft Financial Plan 2019/20 – the draft LLR wide financial plan was discussed and members commented on the content, and requested further information ahead of the discussion at the Governing Body.
Recommendation:
11. The East Leicestershire and Rutland CCG Governing Body is requested to:
• RECEIVE the report.
Page 3 of 3
Blank Page Paper F East Leicestershire and Rutland Governing Body 9th April 2019
EAST LEICESTERSHIRE AND RUTLAND CLINICAL COMMISSIONING GROUP GOVERNING BODY MEETING
Front Sheet
REPORT TITLE: Finance Report – February 2019 (month 11)
MEETING DATE: 9 April 2019
REPORT BY: Colin Groom, Deputy Chief Finance Officer
SPONSORED BY: Donna Enoux, Chief Finance Officer
PRESENTER: Donna Enoux, Chief Finance Officer
EXECUTIVE SUMMARY: This report confirms the reported financial position for 2018/19 for East Leicestershire and Rutland Clinical Commissioning Group (ELR CCG) at month 11. The first page of this report contains an Executive Summary.
RECOMMENDATIONS: The ELR CCG Governing Body is requested to: Receive for information the contents of the report and the appendices attached Note the year to date overspend and forecast breakeven position reported at month 11. Note the submission of the detailed planning template for 2019/20 confirming approximately 4.8% QIPP savings requirement. Note the summary financial plan submission at Appendix G.
REPORT SUPPORTS THE FOLLOWING STRATEGIC AIM(S) 2017 – 2018: Transform services and enhance quality of Improve integration of local services between life for people with long-term conditions health and social care; and between acute and primary/community care. Improve the quality of care – clinical Listening to our patients and public – acting effectiveness, safety and patient on what patients and the public tell us. experience Reduce inequalities in access to Living within our means using public money healthcare effectively Implementing key enablers to support the strategic aims (e.g. constitutional and governance arrangements, communications and patient engagement).
EQUALITY ANALYSIS An Equality Analysis and due regard to the positive general duties of the Equality Act 2010 has not been undertaken in the development of this report as it is judged that it is not proportionate on the basis that the financial reporting underpins the commissioning strategy and priorities of the CCG. The commissioning strategy and priorities have and continue to be equality impact assessed as the strategy is reviewed and refreshed and this includes the financial plans. This completes the due regard required.
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Paper F East Leicestershire and Rutland Governing Body 9th April 2019 EAST LEICESTERSHIRE AND RUTLAND CLINICAL COMMISSIONING GROUP GOVERNING BODY MEETING 9 April 2019
Finance Report
Executive Summary
2018/19 Financial Position
1. This report confirms the year to date and forecast position as at February 2019 (Month 11) based on ten months of activity information and nine months of prescribing data.
2. Due to timing, verified QIPP reporting for month 10 has been used in compiling the month 11 financial position with updates made by exception for any further known items. The forecast QIPP delivery for the year remains unchanged from month 10 at £19.156m, a likely shortfall of £0.491m against the £19.647m plan. Other mitigations are therefore in place to cover this shortfall.
3. As previously reported, due to identified cost pressures the 0.5% contingency was released in full into month 4.
4. Despite this release of contingency and identified mitigations, cost pressures and QIPP slippage have continued to be encountered but as a result of a level of QIPP acceleration and a number of other mitigations, the year to date position reported at month 11 has improved by £0.463m over month 10 and stands at an adverse variance of £1.051m.
5. The month 11 forecast is to deliver a breakeven position and the CCG has a range of mitigations in place to cover the identified risks in conjunction with neighbouring CCGs and NHSE, to ensure it can deliver the in year control total.
Other Financial Metrics
6. Cash flow – Cash target met for the month.
7. Better Payment Practice Code – continued strong performance in month. All cumulative metrics in excess of 99% compliance
8. CSU Performance – CSU report for month 11 confirms all formal KPIs achieved.
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Paper F East Leicestershire and Rutland Governing Body 9th April 2019 EAST LEICESTERSHIRE AND RUTLAND CLINICAL COMMISSIONING GROUP GOVERNING BODY MEETING 12 March 2019
Detailed Finance Report
Introduction
1. This report provides details of the financial position for East Leicestershire and Rutland Clinical Commissioning Group (ELR CCG) at month 11 of 2018/19, the pressures contained within that position and the risks to the delivery of the CCG’s financial targets for the year.
2018/19 Allocations
1. The overall revenue allocation for ELR CCG at month 11 stands at £435.517m, an increase of £2.758m since month 10 including funding to support transition and specific pressures.
2. The CCG has no identified core capital funding for 2018/19.
3. The allocation is detailed in Appendix A. Included in the allocation is the carry forward from 2017/18 of the CCG cumulative surplus of £2.45m. This cumulative surplus will be excluded from the total allocation when calculating the 18/19 financial performance against the in-year allocation of £433.067m.
Financial Performance
4. The budget statement in Appendix B details the ledger position for 2018/19 as at month 11. Due to timing, verified QIPP reporting for month 10 has been used in compiling the month 11 financial position with updates made by exception for any further known items. The current forecast QIPP delivery for the year remains unchanged at £19.156m, a likely shortfall of £0.491m against the £19.647m plan. Other mitigations are therefore in place to cover this shortfall.
5. As previously reported, the 0.5% contingency reserve of £1.91m had been released in month 4 to support the overall financial position. Despite this, as a result of further cost pressures and QIPP slippage, the year to date position shown on Appendix B is a £1.051m adverse variance against plan. The main components of the movement from month 10 are shown below;
Key YTD Variance Components Movement from Month 10-11 Ar e a Detail £000
Month 10 Year to date variance 1,514
Acute Expenditure Net performance, QIPP and transitional support funding (169) Non acute expenditure Includes slippage on specific transformation programmes and (1,168) transitional support funding GP Prescribing Ongoing NCSO pressures and net QIPP delivery/ Growth 467 GP Co-Commissioning Ongoing baseline cost pressures 176 Other Primary Care Other minor variances including QIPP shortfall 232 Other Other minor variances (1)
Month 11 Year to date variance 1,051
3
Paper F East Leicestershire and Rutland Governing Body 9th April 2019
6. Following the progression of material system wide mitigations with neighbouring CCGs the CCG is forecasting the achievement of it’s in year breakeven target and will continue to tightly manage the financial position to ensure no further risks jeopardise this delivery.
7. As a result of the phasing of a number of expenditure areas, the profile of QIPP delivery and other mitigations, a number of the expenditure lines on Appendix B vary significantly between the year to date and forecast variance positions. Comments have been added to Appendix B to describe some of the more material elements of these movements.
8. Acute budgets total £219.075m, an increase of £2.695m over month 10 following the receipt of additional transitional funding and the transfer of funding from reserves to accommodate the realignment of Specialised Services transfers. The Acute budgets include reserves to cover anticipated growth not attached to individual contracts and to support the delivery of Referral to Treatment (RTT) waiting time targets.
9. In aggregate, assuming the delivery of identified stretch QIPP and a range of further mitigations, acute budgets are forecast to underspend by £2.806m. Risks within this position include the potential that the existing forecasts do not contain sufficient elective activity to match the planned growth.
10. The UHL contract value is £143.998m. Based on 10 months’ activity data the forecast continues to show material overspends on Outpatient procedures but the forecast overspend on Non elective activity has materially increased and Elective inpatients have switched from a slight underspend to a significant overspend in month 11. The CCG continues to monitor this position very closely to ensure the existing forecasts in this area are sufficient.
11. Out of County NHS contracts total £30.369m and in aggregate are forecast to overspend by £1.278m, a worsening of £0.213m from the position reported at month 10, mainly driven by activity increases in the Kettering and Nottingham contracts..
12. Independent sector provider contracts total £10.162m and are currently forecast to overspend by £0.351m, largely unchanged from month 10.
13. Non acute budgets total £107.972m including £56.155m for Leicestershire Partnership Trust (LPT). As a result of variability in a range of cost and volume activity lines and slippage in QIPP, this contract is forecast to overspend by £1.042m.
14. Continuing Healthcare (CHC) and similar individually commissioned packages of care budgets have been realigned to include the Learning Disability Pooled Budget with West Leicestershire CCG and Leicestershire County Council and as a result now total £31.298m. These areas have seen strong QIPP delivery throughout the year but as a result of a level of growth, particularly in Section 117 and Alternative Hospital Placement packages of care, and pressures from the settlement of 17-18 disputes the forecast for these budgets is a likely overspend of £0.592m.
15. Primary Care budgets for the year total £95.620m.
16. Prescribing elements total £46.208m and are forecasting an aggregate overspend of £2.320m by year end. This overspend continues to include the ongoing cost pressure of
4
Paper F East Leicestershire and Rutland Governing Body 9th April 2019 approximately £1.924m relating to nationally driven product pricing issues and is despite significant success in the delivery of QIPP savings by GP Practices and the CCG team. The forecast position is stabilising as it is now based on 9 months’ data but the potential for further growth in prescription volumes and pricing issues linked to risks in the supply chain by the end of March remains a risk.
17. The CCG has a co-commissioning allocation for the year of £42.518m. £40.732m is shown directly on Appendix B and a further £1.786m relating to the Oadby walk in centre is included within the Primary Care Services total of £8.681m.
18. The month 11 forecast is for the Co-Commissioning budget to overspend by £1.297m. The Primary Care Services budget line is also forecast to overspend by £0.859m, largely due to the non delivery of QIPP.
19. Miscellaneous (Inc. reserves) represents a range of budgets totalling £3.537m supporting the Commissioning function and £1.823m of identified reserves.
20. These identified reserves include a contingency reserve of £1.906m (equal to 0.5% of the programme allocation). This reserve was released in full in the month 4 position to support identified cost pressures and represents the majority of the £1.961m forecast underspend on this line.
Running Costs
21. Running cost budgets for the year total £6.863m. The budgets were set deliberately lower than the total allocation of £6.975m in order to support patient facing services. The current forecast is to be £0.068m overspent by year end, which still remains within the Running Cost allocation.
Capital
22. The CCG had not been allocated any capital in its base plan for 2018-19. The CCG is managing schemes to support GPIT investments on behalf of NHSE but the resultant assets are held on the NHSE asset register and are not counted as CCG capital expenditure.
Better Payment Practice Code (BPPC)
26. The BPPC performance for the CCG as at month 11 is shown in Appendix C and confirms continued strong performance across all metrics taking the cumulative performance to the following levels;
• NHS creditors (number) – 99.39% • NHS creditors (value) – 99.80% • Non NHS creditors (number) – 99.74% • Non NHS creditors (value) – 99.38%
CSU Performance
27. The ‘Month End Summary CFO Report’ for month 11 confirms all formal KPIs have been achieved. 4 tasks internal to the CSU were not completed on time but these items had no impact on the CCG’s reporting processes and are considered more of a guide within the 5
Paper F East Leicestershire and Rutland Governing Body 9th April 2019 CSU monthly processes. The finance team have met with counterparts in the CSU to review the current service provision and ensure robust plans are in place to provide support for the upcoming annual accounts process.
28. All payroll payovers were made by the deadlines and all control accounts were reconciled and the full reconciliation pack distributed. The manual payments code is rated amber as it contains a balance from month 10 that will not be resolved until April. All other codes are rated green.
29. The CCG closing cash book balance for month 11 was £0.050m and the closing bank balance was £0.261m. Since its authorisation, the CCG has monitored itself against the initial NHSE requirement to hold no more than 1.25% of their monthly draw down at month end. The implied target for February was £0.4m and therefore the CCG has comfortably met the target.
Balance Sheet and Cash Flow Statement
30. Appendix D contains the balance sheet at 31 March 2018 and the most recent three months of the current year. Trade receivables have reduced in the month following the collection of a number of CCG corporate recharge debts. Accrued income has dropped significantly in the month and this includes the reduced income assumption in respect of Specialised Commissioning service transfers for 2018-19 and the accrual of a credit note to part cancel the equivalent 2017-18 invoice following the NHSE led mediation process.
31. In aggregate current liabilities have also remained broadly unchanged however individual lines have varied in month as a result of providers catching up with invoice processing as we head towards the financial year end.
32. Appendix E outlines the Cash Flow Statement for ELR CCG for Month 11. Accounting for recent increases in the overall CCG allocation, the CCG is now approximately £1.334m behind a 1/12ths profile. This will unwind in Month 12 as approximately £0.5m of contract arrears will be paid to LPT in respect of recently issued contract variations and £0.4m paid to UHL towards net over performance on the contract.
33. The CCG is in the process of finalising its cash reconciliations for the year end as at 31 March 2019 but the preliminary reconciliation confirms the CCG has achieved its cash target for the year which is a significant achievement considering the pressures that have been experienced throughout the year.
NHSE Reporting
34. The most recent CCG metric return submission covered month 11 finance and month 10 Activity. The return focuses on activity reporting and overall financial profile. The majority of activity points of delivery are within the 2% tolerance level. Other (non GP) referrals, Non-elective admissions over 1 day and A&E attendances are currently over plan. Appendix F contains the summary activity reporting included in the metric return.
2019/20 Financial Plan
35. LLR CCGs continue to work in collaboration to produce financial plans for 2019/20 in accordance with the national timetable produced by NHS England. As part of this timetable, the CCGs submitted a high level planning return on 8 February 2019 and a first 6
Paper F East Leicestershire and Rutland Governing Body 9th April 2019 iteration of the detailed financial plan on 12 February 2019. A final version of the plan was approved by Governing Bodies prior to submission to NHSE on 4 April 2019. Appendix G contains a high level summary of the plan and will form the basis of the base budgets for 2019/20.
Risks and mitigations
36. There are several risks that have the potential to adversely affect the CCG’s financial position for 2018/19 as outlined below:
• Further growth in CHC, S117, prescribing and NCSO. • Non achievement of QIPP schemes • Potential pressures from 17/18 • In year Acute activity beyond current forecasts • In year cost pressures relating to Running Costs • Potential EMAS and NEPTS contractual pressures
37. The CCG continues to progress a range of mitigations to offset any cost pressures that may materialise.
Summary
38. At month 11 the in-year financial position of ELR CCG is reporting a year to date overspend of £1.051m and a year-end forecast position of breakeven.
Recommendations:
The ELR CCG Governing Body is requested to: Receive for information the contents of the report and the appendices attached Note the year to date overspend and forecast breakeven position reported at month 11. Note the submission of the detailed planning template for 2019/20 confirming approximately 4.8% QIPP savings requirement. Note the summary financial plan submission at Appendix G.
7
ELR CCG Allocation 2018/19 Appendix A
Movement M1 M2 M3 M4 M5 M6 M7 M8 M9 M10 M11 from M1 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 Recurrent allocation (programme) Recurrent baseline 373,525 373,525 373,525 373,525 373,525 373,525 373,525 373,525 373,525 373,525 373,525 0 Primary Care Co-Commissioning 42,170 42,170 42,170 42,170 42,170 42,170 42,170 42,170 42,170 42,170 42,170 0 Market Rent 509 509 509 509 509 509 509 509 509 509 509 0 Adult influenza and pnuemococcal vaccine funding (538) (538) (538) (538) (538) (538) (538) 0 Total recurrent allocation (programme) 416,204 416,204 416,204 416,204 416,204 415,666 415,666 415,666 415,666 415,666 415,666 (538)
Non recurrent allocation (programme) 2017/18 Brought Forward Surplus/Deficit 0 2,450 2,450 2,450 2,450 2,450 2,450 2,450 2,450 2,450 2,450 2,450 18/19 Paramedic Allocations 115 115 115 115 115 115 115 115 115 115 115 0 HSCN 103 103 103 103 103 103 103 103 103 103 103 0 GP WIFI Maintenance 2018/19 26 26 26 26 26 26 26 26 26 26 LPFT Agreement + Transformation Support + Risk Share 1,830 1,830 1,830 1,830 1,830 1,830 1,830 1,830 1,830 1,830 2018-19 CYP IAPT Trainee staff salary support funding 25 25 25 25 25 25 25 25 25 25 GPFV-Improving Access to General Practice 829 829 829 829 829 829 829 829 829 829 Share of 18/19 Ambulance Funding 89 89 89 89 89 89 89 89 89 Transformation - M04 IAT Adjustment for IR Changes (1) (1) (1) (1) (1) (1) (1) (1) (1) LD Transformation Funding to TCP (full amount 18/19) 238 238 238 238 238 238 238 238 238 LD programme funding for Community Service Investments 250 250 250 250 250 250 250 250 250 Sterile Products and suspended doctors 03W (77) (77) (77) (77) (77) (77) (77) (77) Financial Resilience Support to the LLR QIPP programme 100 100 100 100 100 100 100 100 Kings Way Practice Resilience ELR 117 117 117 117 117 117 117 117 AfC Pay award uplift - Programme 7 7 7 7 7 7 7 7 LD TC - bed closures,complex cases,community services,mobilising care 30 30 30 30 30 30 30 30 Flu transfer; transition 125 125 125 125 125 125 125 2018 GP OOH Services Funding Allocation 14 14 14 14 14 14 14 GP WIFI MAINTENANCE YEAR 2 26 26 26 26 26 26 26 IGPR Project Band 8b 40 40 40 40 40 40 40 Excess Treament Programme (9) (9) (9) (9) (9) (9) 2018-19 CYP IAPT Trainee staff salary support funding 25 25 25 25 25 25 Prosthetics & Environmental Services (128) (128) (128) (128) (128) QIPP support from NHS E. Committed resource 94 94 94 94 94 QIPP support 456 456 456 456 456 Charge Exempt Overseas Visitor (CEOV) Adjustment - [email protected] (229) (229) (229) (229) (229) IPC sites support MOU Q1, 2 & 3 1819 69 69 69 69 69 TC Workforce Plan Funding from Region - ref Clare.Nagle 8 8 8 8 8 ELR Share of National Diabetes Prevention Prog Allocation recd M08 10 10 10 10 LLR Transformation Funding 1,775 1,775 1,775 1,775 LD transforming care additional funding agreed 11 Dec 60 60 60 60 Mental Health Winter Pressures 70 70 70 70 OSV Adjustment 309 309 309 LLR re-allocation of transformation monies 1,225 1,225 1,225 BME Dementia Project 20 20 20 IPC sites support MOU Q4 plus expenses 1819 27 27 27 Risk Share Agreement 2018/19 2,700 2,700 Share of NHS E funding re TASL 58 58 Total non recurrent allocation (programme) 218 2,668 5,378 5,954 6,131 6,336 6,352 6,622 8,537 10,118 12,876 12,658 Total allocations (programme) 416,422 418,872 421,582 422,158 422,335 422,002 422,018 422,288 424,203 425,784 428,542 12,120
Recurrent allocation (running costs) Recurrent baseline 6,911 6,911 6,911 6,911 6,911 6,911 6,911 6,911 6,911 6,911 6,911 0
Non recurrent allocation (running costs) HSCN - running Costs 3 3 3 3 3 3 3 3 3 3 3 0 AfC Pay award uplift 61 61 61 61 61 61 61 61
Total allocations (running costs) 6,914 6,914 6,914 6,914 6,975 6,975 6,975 6,975 6,975 6,975 6,975 61
TOTAL ALLOCATIONS 423,336 425,786 428,496 429,072 429,310 428,977 428,993 429,263 431,178 432,759 435,517 12,181
Capital Funding Approved by NHSE 0 0 0 0 0 0 0 0 0 0 0 0
Allocations formally received 0 0 0 0 0 0 0 0 0 0 0 0 Allocations anticipated East Leicestershire & Rutland CCG Summary - 2018/19 Month 11 Appendix B
Year to Date Forecast Outturn Month 12 Variance Straight Line Difference Variance using (between Budget Expenditure Variance Budget Expenditure Variance Comments month 11 YTD straight line and (£000) (£000) (£000) (£000) (£000) (£000) (£000) forecast) (£000)
Total allocation Excluding Brought 397,613 397,613 0 433,067 433,067 0 Forward Surplus
Profile of acute QIPP, traditionally lower elective Acute Commissioning 201,125 199,108 (2,016) 219,075 216,268 (2,806) (2,200) (607) activity in quarter 4 and transitional support received in month 11.
Profile of Continuing Healthcare and Community Non-acute Commissioning 98,967 99,941 974 107,972 108,245 273 1,062 (789) services QIPP, the recognition of a number of short term cost pressures earlier in the year and transitional support received in month 11.
Profile of over the counter prescribing QIPP and Practice Prescribing 42,262 44,567 46,208 48,528 2,514 (194) traditionally lower prescribing in Q4 following 2,304 2,320 peaks over winter.
GP Commissioning 37,337 38,519 1,181 40,732 42,028 1,297 1,289 8
Commencement of Acute Access development in Primary Care Services 8,136 8,780 645 8,681 9,540 859 703 156 quarter 3.
Miscellaneous (inc reserves) 3,478 1,490 (1,988) 3,537 1,576 (1,961) (2,169) 207 Contingency reserve utilised in full by month 4.
Total Programme Expenditure 391,305 392,405 1,100 426,204 426,185 (19) 1,200 (1,219)
Total Running Costs 6,308 6,260 (49) 6,863 6,882 19 (53) 72 Impact of vacancies earlier in the year.
Total Expenditure 397,613 398,664 1,051 433,067 433,067 0 1,147 (1,147)
In year position Programme control total (85) (134) (49) (112) (93) 19 Running Costs control total 85 134 49 112 93 (19) Total control total 0 0 0 0 0 0
Cumulative Surplus Programme control total 2,160 1,061 (1,100) 2,338 2,357 19 Running Costs control total 85 134 49 112 93 (19) Total control total 2,246 1,195 (1,051) 2,450 2,450 0 Appendix C East Leicestershire & Rutland CCG
Better Payment Practice Code February 2019
NHS Creditors Non NHS Creditors A B C D E F A B C D E F % Value of % Value of No of Bills No of Bills % of Bills Value of Bills Value of Bills No of Bills No of Bills % of Bills Value of Bills Value of Bills Bills Paid Bills Paid Paid Within Paid Within Paid Within Paid Within Paid Within Paid Within Paid Within Paid Within Paid Within Paid Within Within Within Period Target Target Period Target Period Target Target Period Target Target Target No. No. % £'000 £'000 % No. No. % £'000 £'000 % April 339 338 99.71 21,917 21,916 100.00 508 506 99.61 2,500 2,498 99.90 May 200 199 99.50 21,388 21,387 100.00 725 724 99.86 3,933 3,930 99.93 June 316 316 100.00 20,051 20,051 100.00 574 573 99.83 3,234 3,233 99.96 July 265 264 99.62 22,758 22,733 99.89 556 554 99.64 3,037 3,034 99.88 Aug 302 300 99.34 22,368 22,367 100.00 754 753 99.87 3,707 3,599 97.09 September 278 274 98.56 22,112 22,111 99.99 481 480 99.79 3,128 3,128 100.00 October 210 209 99.52 21,594 21,588 99.97 732 732 100.00 3,046 3,046 100.00 November 357 354 99.16 23,045 22,999 99.80 586 583 99.49 3,025 2,920 96.55 December 246 242 98.37 21,394 21,011 98.21 607 607 100.00 4,067 4,067 100.00 January 304 303 99.67 21,779 21,762 99.92 507 504 99.41 3,216 3,210 99.83 February 279 278 99.64 21,414 21,414 100.00 818 814 99.51 4,200 4,197 99.94 March
Totals 3,096 3,077 99.39 239,820 239,339 99.80 6,848 6,830 99.74 37,092 36,861 99.38 Appendix D
Balance as at Balance as at Balance as at Balance as at 31st March 31st December 31st January 28th February Statement of Financial Position 2018 2018 2019 2019 £'000s £'000s £'000s £'000s Non Current Assets: Premises, Plant, Fixtures & Fittings 1,393 1,166 1,144 1,123 IM&T 68 49 47 45 Other 0 0 0 0 Long-term Receivables 0 0 0 0 TOTAL Non Current Assets 1,461 1,215 1,191 1,167 Sub Analysis 28 February 2019 Current Assets: Inventories 0 0 0 0 Trade Receivables 1,001 1,626 2,695 2,236 Trade Receivables Volume Value (£'000) Bad & Doubtful Depts Prov (23) (23) (23) (23)
UHL Maternity Prepayment 1,590 1,590 1,590 1,590 Not yet due 32 130 Includes £100k outstanding with NHS England for GPIT and GL Hearn rates rebates. Includes £265k outstanding with West CCG for mainly Hosted team recharges and £136k outstanding with City CCG for Urgent care centre recharges. Also includes £148k outstanding with Leicestershire County Council for Pathway 3 recharges and £59k Prepayments – In Month 467 862 770 491 1-30 days 60 728 outstanding with NHS England for GPIT. Accrued Income 3,968 2,678 1,380 290 31-60 days 7 94 Includes £47k for Quarter 3 for Alliance Capital charges with UHL. VAT and CHC Risk Pool 55 45 218 212 61-90 days 0 0 Cash and Cash Equivalents 239 88 34 51 91+ days 48 1,284 Includes £47k outstanding with Central Nottinghamshire Clinical Services, company is in administration.£125k outstanding with UHL re LTC and Alliance assets. £30k outstanding Other Receivables 0 0 0 0 147 2,236 with UHL re GP recruitment. £897k Specialised Commissioning IR allocation changes. TOTAL Current Assets 7,297 6,866 6,664 4,847 £102k outstanding with City CCG re patient charged to the LD Pool.
TOTAL ASSETS 8,758 8,081 7,855 6,014 Value (£'000) Trade Payables (1,709) (1,793) (1,273) (3,504) Trade Payables Volume Prescribing Accruals (6,786) (6,966) (6,999) (7,030) Not yet due 79 3,387
This balance has been paid in March 19. Other Accruals (9,060) (12,330) (12,602) (9,879) 1-30 days 28 145
£7k of the balance has been paid in March 19. Payroll Creditors (183) (493) (478) (474) 31-60 days 21 18
Includes debit balance of (£70k) mainly with a CHC provider that has been taken in March 19, also includes another debit balance with North Bristol NHS Trust for (£26k). Provisions (109) (38) (38) (84) 61-90 days 15 -83 Borrowings 0 0 0 0 91+ days 24 36 £27k of the balance has been paid in March 19. Total Current Liabilities (17,847) (21,620) (21,390) (20,971) 167 3,504
TOTAL LIABILITIES (17,847) (21,620) (21,390) (20,971)
ASSETS LESS LIABILITIES (Total Assets Employed) (9,089) (13,539) (13,535) (14,957)
TAXPAYERS EQUITY General Fund (Opening Balance, Fixed) (9,112) (9,089) (9,089) (9,089) Income & Expenditure (year to date) (419,589) (326,249) (361,679) (398,664) Parliamentary Funding (year to date) 419,609 321,799 357,233 392,797 Co Commissioning (year to date) 0 0 0 0 Revaluation Reserve 3 0 0 0 Other Reserves 0 0 0 0 Total (9,089) (13,539) (13,535) (14,957) Appendix E East Leics and Rutland Cashflow Reporting 03W Month 11 2018/19
Year to date 2018/19 April May June July August September October November December January February £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000
Receipts
Balance b/fwd 232 243 222 254 265 229 320 1,167 150 100 152 98 NCB-Drawdown 354,368 32,900 31,568 32,200 32,600 34,000 31,800 31,430 31,300 32,700 31,870 32,000 Other (including VAT) 7,469 564 300 614 316 299 964 679 1,225 367 475 1,666
Total Receipts 362,069 33,707 32,090 33,068 33,181 34,528 33,084 33,276 32,675 33,167 32,497 33,764
Payments Creditors NHS 242,351 22,212 21,251 20,166 23,213 22,523 23,044 21,719 23,153 21,525 22,009 21,537 Creditors BACS/CHAPS 68,754 7,484 6,047 6,901 5,193 7,640 4,409 7,316 4,604 6,615 5,913 6,632 Salary BACS/CHAPS 2,797 241 243 234 245 262 253 255 264 270 267 263 Pensions (Including GP pensions) 3,949 425 393 409 352 265 429 253 422 289 363 350 Tax & NI 1,318 113 116 115 106 115 129 120 120 126 130 128 Standing Orders /Direct Debits 0 0 0 0 0 0 0 0 0 0 0 0 PCS Payments 42,650 3,010 3,787 4,977 3,843 3,404 3,652 3,464 4,011 4,190 3,718 4,594 Total - Expenditure 361,819 33,485 31,837 32,803 32,952 34,208 31,917 33,126 32,575 33,015 32,399 33,503
Balance c/fwd 222 254 265 229 320 1,167 150 100 152 98 261
April May June July August September October November December January February £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 Cumulative Cash Drawn 32,900 64,468 96,668 129,268 163,268 195,068 226,498 257,798 290,498 322,368 354,368 Assumed Drawdown in equal 1/12ths 32,337 64,673 97,010 129,346 161,683 194,020 226,356 258,693 291,029 323,366 355,702 Cumulative Variance to equal 1/12ths profile 563 (205) (342) (78) 1,585 1,049 142 (895) (531) (998) (1,334) Appendix F ACTIVITY DATA COLLECTION: PLANNED CARE POINTS OF DELIVERY
Notes 1. Please input in Yellow Cells Only. All other cells are locked. 2. The Month Cell automatically populates to equal Month data reported. This will amend the calculation of the YTD performance to set it to the reported period only.
Calculated Metrics (National Data) Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Annual Referrals to Elective Conversion 16-17 41.4% 42.9% 42.2% 44.2% 43.1% 42.2% 42.8% 42.5% 46.6% 45.3% 42.2% 41.0% 43.0% Referrals to Elective Conversion 17-18 42.7% 40.8% 40.2% 40.3% 41.9% 43.3% 43.0% 44.6% 46.6% 43.9% 43.8% 43.1% 42.8% Referrals to Elective Conversion 18-19 41.1% 41.7% 40.8% 40.4% 42.1% 42.6% 41.2% 42.3% 43.3% 41.7%
Month 10 From Dashboard (1 month in arrears)
Elective Daycases (EM10a)
Explanation of Variance Required No If YTD variance is >2.0% adverse to Plan Rectification Plan Required No If YTD variance is >3.0% adverse to Plan 1 2 3 4 5 6 7 8 9 10 11 12 THIS YEAR Metric Source Currency Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 Totals YTD @ M10 Change on % Change Prior Year 18/19 Plan From Unify Submission Atts 3,186 3,444 3,491 3,224 3,415 3,408 3,436 3,678 3,133 3,393 3,227 3,534 40,569 33,808 944 2.8% Actual/Forecast CCG Input Atts 3,184 3,507 3,331 3,280 3,379 3,293 3,536 3,543 2,988 3,662 33,703 33,703 (2,105) -6.2% Variance to Plan Calculated Atts 2 (63) 160 (56) 36 115 (100) 135 145 (269) 3,227 3,534 6,866 105 % In-Month Variance Calculated % 0.1% -1.8% 4.6% -1.7% 1.1% 3.4% -2.9% 3.7% 4.6% -7.9% 100.0% 100.0% 16.9% 0.3%
18/19 Actual National Data Atts 3,239 3,564 3,396 3,347 3,451 3,381 3,645 3,631 3,066 0 0 0 30,720 30,720 (2,144) -7.0% Variance to Plan Calculated Atts (53) (120) 95 (123) (36) 27 (209) 47 67 3,393 3,227 3,534 9,849 3,088 Variance to Plan Calculated % -1.7% -3.5% 2.7% -3.8% -1.1% 0.8% -6.1% 1.3% 2.1% 100.0% 100.0% 100.0% 24.3% 9.1% Difference between National & CCG Data Calculated (55) (57) (65) (67) (72) (88) (109) (88) (78) 3,662 0 0 2,983
Other Local Proxy Measures for Performance Other CCG (please Specify) CCG - Other CCG (please Specify) CCG -
LAST YEAR Metric Source Currency Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Totals YTD Total Change on % Change Prior Year 17/18 Plan From Unify Submission Atts 17/18 Actual (CCG) From CCG Rtns Atts 3,166 3,690 3,763 3,518 3,672 3,468 3,718 3,955 3,175 3,683 3,436 3,589 42,833 Variance to Plan Calculated Atts % Variance Calculated %
17/18 Actual National Data Atts 2,963 3,367 3,265 3,071 3,321 3,251 3,438 3,649 2,973 3,566 3,250 3,332 39,446 32,864 827 2.1% 16/17 Actual National Data Atts 3,093 3,177 3,369 3,054 3,170 3,222 3,100 3,432 3,077 3,369 3,045 3,511 38,619 32,063 1,364 3.7% 15/16 Actual National Data Atts 3,072 2,818 3,141 3,164 2,788 3,221 3,237 3,246 3,164 3,077 3,073 3,254 37,255
Explanation of adverse variance to Plan
Actions to bring activity back into line with Plan
Elective Ordinary Admissions (EM10b)
Explanation of Variance Required Yes If YTD variance is >2.0% adverse to Plan Rectification Plan Required Yes If YTD variance is >3.0% adverse to Plan 1 2 3 4 5 6 7 8 9 10 11 12 THIS YEAR Metric Source Currency Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 Totals YTD @ M10 Change on % Change Prior Year 18/19 Plan From Unify Submission Atts 525 532 558 524 508 536 564 577 475 563 529 582 6,473 5,362 449 8.4% Actual/Forecast CCG Input Atts 420 514 519 515 523 492 552 500 451 508 4,994 4,994 (488) -9.8% Variance to Plan Calculated Atts 105 18 39 9 (15) 44 12 77 24 55 529 582 1,479 368 % In-Month Variance Calculated % 20.0% 3.4% 7.0% 1.7% -3.0% 8.2% 2.1% 13.3% 5.1% 9.8% 100.0% 100.0% 22.8% 6.9%
18/19 Actual National Data Atts 419 516 518 516 523 490 558 503 452 0 0 0 4,495 4,495 (418) -9.3% Variance to Plan Calculated Atts 106 16 40 8 (15) 46 6 74 23 563 529 582 1,978 867 Variance to Plan Calculated % 20.2% 3.0% 7.2% 1.5% -3.0% 8.6% 1.1% 12.8% 4.8% 100.0% 100.0% 100.0% 30.6% 16.2% Difference between National & CCG Data Calculated 1 (2) 1 (1) 0 2 (6) (3) (1) 508 0 0 499
Other Local Proxy Measures for Performance Other CCG (please Specify) CCG - Other CCG (please Specify) CCG -
LAST YEAR Metric Source Currency Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Totals YTD Total Change on % Change Prior Year 17/18 Plan From Unify Submission Atts 17/18 Actual (CCG) From CCG Rtns Atts 524 613 557 544 540 582 610 619 537 356 416 429 6,327 Variance to Plan Calculated Atts % Variance Calculated %
17/18 Actual National Data Atts 465 531 541 479 462 523 569 549 454 340 360 454 5,727 4,913 (851) -12.9% 16/17 Actual National Data Atts 581 543 582 577 554 549 563 602 492 531 474 530 6,578 5,574 (121) -1.8% 15/16 Actual National Data Atts 514 544 555 592 592 544 587 561 502 591 567 550 6,699
Explanation of adverse variance to Plan Activity is 6.9% favourable to (i.e. below) plan. Underperformance is associated with the ongoing effects of the winter pressures at UHL and elective pause in April 2018, and intermittent under-performance in subsequent months. Underperformance is predominantly within ENT and Urology at UHL, however this has been mitigated by over-performance in Orthopaedics at the local IS providers (predominantly Nuffield). This will be kept under continuous review via the contractual and triangulation meetings to understand the impact for RTT performance and inter-provider transfers to local IS providers.
Actions to bring activity back into line with Plan The under performance is under continuous review via the Contracts Team, including triangulation with waiting list information to assess the extent to which the coding, pathway and capacity factors are impacting on underlying demand and activity. The CCGs have established a monthly activity triangulation meeting with local providers (UHL and Alliance) to monitor and proactively manage activity, waiting lists, performance, and transfers to independent sector providers. The CCGs, in conjunction with UHL and the Alliance providers, have reviewed activity plan phasing and aligned this to the LLR winter plan. UHL have now confirmed that due to the success of the winter plan, their capacity for electives in Q4 is higher than originally expected, therefore we anticipate a switch away from IS transfers, as this activity will be provided by UHL in-house (focusing primarily on Orthopaedics and General Surgery). It has been established via this process that UHL are on plan to achieve the waiting list stabilisation standard for 2018/19, notwithstanding the under-performance against IP plan at M10 YTD.
Outpatients - First (EM8)
Explanation of Variance Required No If YTD variance is >2.0% adverse to Plan Rectification Plan Required No If YTD variance is >3.0% adverse to Plan 1 2 3 4 5 6 7 8 9 10 11 12 THIS YEAR Metric Source Currency Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 Totals YTD @ M10 Change on % Change Prior Year 18/19 Plan From Unify Submission Atts 7,507 8,469 8,572 7,775 8,397 8,404 8,498 9,075 7,085 8,056 7,993 8,636 98,467 81,838 4,641 5.7% Actual/Forecast CCG Input Atts 7,530 8,460 8,305 8,103 7,907 7,786 8,907 8,531 6,892 8,411 80,832 80,832 2,480 3.1% Variance to Plan Calculated Atts (23) 9 267 (328) 490 618 (409) 544 193 (355) 7,993 8,636 17,635 1,006 % In-Month Variance Calculated % -0.3% 0.1% 3.1% -4.2% 5.8% 7.4% -4.8% 6.0% 2.7% -4.4% 100.0% 100.0% 17.9% 1.2%
18/19 Actual National Data Atts 7,499 8,388 8,283 8,084 7,905 7,770 8,889 8,548 6,892 0 0 0 72,258 72,258 (4,939) -6.8% Variance to Plan Calculated Atts 8 81 289 (309) 492 634 (391) 527 193 8,056 7,993 8,636 26,209 9,580 Variance to Plan Calculated % 0.1% 1.0% 3.4% -4.0% 5.9% 7.5% -4.6% 5.8% 2.7% 100.0% 100.0% 100.0% 26.6% 11.7% Difference between National & CCG Data Calculated 31 72 22 19 2 16 18 (17) 0 8,411 0 0 8,574
Other Local Proxy Measures for Performance Other CCG (please Specify) CCG - Other CCG (please Specify) CCG -
LAST YEAR Metric Source Currency Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Totals YTD Total Change on % Change Prior Year 17/18 Plan From Unify Submission Atts 7,148 7,264 7,988 7,351 7,381 7,949 7,724 8,126 7,085 7,394 7,416 8,056 90,882 17/18 Actual (CCG) From CCG Rtns Atts 7,530 8,179 8,056 7,248 7,973 7,914 8,206 8,533 6,566 8,147 7,249 7,660 93,261 Variance to Plan Calculated Atts (382) (915) (68) 103 (592) 35 (482) (407) 519 (753) 167 396 (2,379) % Variance Calculated % -5.3% -12.6% -0.9% 1.4% -8.0% 0.4% -6.2% -5.0% 7.3% -10.2% 2.3% 4.9% -2.6%
17/18 Actual National Data Atts 6,708 8,275 8,086 7,267 7,922 7,856 8,084 8,512 6,514 7,973 7,043 7,479 91,719 77,197 235 0.3% 16/17 Actual National Data Atts 7,390 7,536 7,796 7,151 7,611 7,701 7,679 8,488 6,668 7,814 7,235 8,415 91,484 75,834 6,458 7.6% 15/16 Actual National Data Atts 6,531 6,395 7,450 7,064 6,695 7,615 7,334 7,361 7,101 6,805 7,322 7,353 85,026
Explanation of adverse variance to Plan
Actions to bring activity back into line with Plan Outpatients - Follow-up (EM9)
Explanation of Variance Required No If YTD variance is >2.0% adverse to Plan Rectification Plan Required No If YTD variance is >3.0% adverse to Plan 1 2 3 4 5 6 7 8 9 10 11 12 THIS YEAR Metric Source Currency Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 Totals YTD @ M10 Change on % Change Prior Year 18/19 Plan From Unify Submission Atts 13,612 14,870 15,415 13,682 14,722 15,155 14,876 16,212 12,892 15,102 14,551 15,195 176,284 146,538 1,198 0.8% Actual/Forecast CCG Input Atts 14,403 15,286 14,531 14,246 14,269 14,099 15,882 15,486 12,212 15,389 145,803 145,803 (4,156) -2.9% Variance to Plan Calculated Atts (791) (416) 884 (564) 453 1,056 (1,006) 726 680 (287) 14,551 15,195 30,481 735 % In-Month Variance Calculated % -5.8% -2.8% 5.7% -4.1% 3.1% 7.0% -6.8% 4.5% 5.3% -1.9% 100.0% 100.0% 17.3% 0.5%
18/19 Actual National Data Atts 14,213 15,012 14,461 14,239 14,222 14,056 15,813 15,635 12,347 0 0 0 129,998 129,998 (15,342) -11.8% Variance to Plan Calculated Atts (601) (142) 954 (557) 500 1,099 (937) 577 545 15,102 14,551 15,195 46,286 16,540 Variance to Plan Calculated % -4.4% -1.0% 6.2% -4.1% 3.4% 7.3% -6.3% 3.6% 4.2% 100.0% 100.0% 100.0% 26.3% 11.3% Difference between National & CCG Data Calculated 190 274 70 7 47 43 69 (149) (135) 15,389 0 0 15,805
Other Local Proxy Measures for Performance Other CCG (please Specify) CCG - Other CCG (please Specify) CCG -
LAST YEAR Metric Source Currency Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Totals YTD Total Change on % Change Prior Year 17/18 Plan From Unify Submission Atts 13,245 12,909 14,450 13,023 13,000 14,294 13,587 14,657 12,523 14,026 13,516 14,173 163,403 17/18 Actual (CCG) From CCG Rtns Atts 14,403 15,086 15,349 13,847 14,877 14,925 15,797 16,616 12,697 16,362 14,539 15,211 179,709 Variance to Plan Calculated Atts (1,158) (2,177) (899) (824) (1,877) (631) (2,210) (1,959) (174) (2,336) (1,023) (1,038) (16,306) % Variance Calculated % -8.7% -16.9% -6.2% -6.3% -14.4% -4.4% -16.3% -13.4% -1.4% -16.7% -7.6% -7.3% -10.0%
17/18 Actual National Data Atts 12,604 15,446 15,335 13,786 14,514 14,544 15,006 16,386 12,262 15,457 13,549 14,334 173,223 145,340 5,663 3.4% 16/17 Actual National Data Atts 13,944 13,629 14,358 12,605 13,723 14,543 13,492 15,336 12,515 14,784 13,661 14,970 167,560 138,929 6,452 4.0% 15/16 Actual National Data Atts 12,553 12,061 14,247 13,454 12,338 14,101 13,752 14,108 12,774 13,913 14,003 13,804 161,108
Explanation of adverse variance to Plan
Actions to bring activity back into line with Plan
GP Referrals (EM7a)
Explanation of Variance Required No If YTD variance is >2.0% adverse to Plan Rectification Plan Required No If YTD variance is >3.0% adverse to Plan
1 2 3 4 5 6 7 8 9 10 11 12 THIS YEAR Metric Source Currency Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 Totals YTD @ M10 Change on % Change Prior Year 18/19 Plan From Unify Submission Atts 5,783 6,222 6,429 5,847 6,063 5,947 6,109 6,417 4,969 5,630 5,660 6,330 71,406 59,416 1,799 3.0% Actual/Forecast CCG Input Atts 5,566 5,975 5,904 6,185 5,937 5,563 6,304 6,121 5,033 6,183 58,771 58,771 796 1.4% Variance to Plan Calculated Atts 217 247 525 (338) 126 384 (195) 296 (64) (553) 5,660 6,330 12,635 645 % In-Month Variance Calculated % 3.8% 4.0% 8.2% -5.8% 2.1% 6.5% -3.2% 4.6% -1.3% -9.8% 100.0% 100.0% 17.7% 1.1%
18/19 Actual National Data Atts 5,566 5,975 5,939 6,185 5,937 5,563 6,304 6,121 5,083 0 0 0 52,673 52,673 (4,944) -9.4% Variance to Plan Calculated Atts 217 247 490 (338) 126 384 (195) 296 (114) 5,630 5,660 6,330 18,733 6,743 Variance to Plan Calculated % 3.8% 4.0% 7.6% -5.8% 2.1% 6.5% -3.2% 4.6% -2.3% 100.0% 100.0% 100.0% 26.2% 11.3% Difference between National & CCG Data Calculated 0 0 (35) 0 0 0 0 0 (50) 6,183 0 0 6,098
Other Local Proxy Measures for Performance Other CCG (please Specify) CCG - Other CCG (please Specify) CCG -
LAST YEAR Metric Source Currency Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Totals YTD Total Change on % Change Prior Year 17/18 Plan From Unify Submission Atts 5,711 5,953 5,762 5,394 5,479 5,563 5,573 5,877 5,360 5,726 5,755 5,983 68,136 17/18 Actual (CCG) From CCG Rtns Atts 5,566 6,301 6,231 5,849 6,019 5,574 6,137 6,088 4,620 5,590 5,261 5,593 68,829 Variance to Plan Calculated Atts 145 (348) (469) (455) (540) (11) (564) (211) 740 136 494 390 (693) % Variance Calculated % 2.5% -5.8% -8.1% -8.4% -9.9% -0.2% -10.1% -3.6% 13.8% 2.4% 8.6% 6.5% -1.0%
17/18 Actual National Data Atts 5,209 6,301 6,231 5,849 6,019 5,574 6,137 6,088 4,619 5,590 5,261 5,593 68,471 57,617 (966) -1.4% 16/17 Actual National Data Atts 5,959 5,714 6,186 5,442 5,688 5,910 5,659 6,303 4,975 5,563 5,454 6,584 69,437 57,399 5,143 8.0% 15/16 Actual National Data Atts 5,176 5,061 5,578 5,545 4,985 5,442 5,444 5,435 5,202 5,309 5,478 5,639 64,294
Explanation of adverse variance to Plan
Actions to bring activity back into line with Plan
Other Referrals (EM7b)
Explanation of Variance Required Yes If YTD variance is >2.0% adverse to Plan Rectification Plan Required Yes If YTD variance is >3.0% adverse to Plan
1 2 3 4 5 6 7 8 9 10 11 12 THIS YEAR Metric Source Currency Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 Totals YTD @ M10 Change on % Change Prior Year 18/19 Plan From Unify Submission Atts 2,970 3,212 3,312 2,963 3,085 3,186 3,139 3,360 2,796 2,986 2,986 3,156 37,151 31,009 30 0.1% Actual/Forecast CCG Input Atts 3,333 3,802 3,624 3,387 3,495 3,518 3,893 3,662 3,046 3,939 35,699 35,699 4,216 11.8% Variance to Plan Calculated Atts (363) (590) (312) (424) (410) (332) (754) (302) (250) (953) 2,986 3,156 1,452 (4,690) % In-Month Variance Calculated % -12.2% -18.4% -9.4% -14.3% -13.3% -10.4% -24.0% -9.0% -8.9% -31.9% 100.0% 100.0% 3.9% -15.1%
18/19 Actual National Data Atts 3,333 3,802 3,645 3,387 3,495 3,518 3,893 3,662 3,046 0 0 0 31,781 31,781 802 2.5% Variance to Plan Calculated Atts (363) (590) (333) (424) (410) (332) (754) (302) (250) 2,986 2,986 3,156 5,370 (772) Variance to Plan Calculated % -12.2% -18.4% -10.1% -14.3% -13.3% -10.4% -24.0% -9.0% -8.9% 100.0% 100.0% 100.0% 14.5% -2.5% Difference between National & CCG Data Calculated 0 0 (21) 0 0 0 0 0 0 3,939 0 0 3,918
Other Local Proxy Measures for Performance Other CCG (please Specify) CCG - Other CCG (please Specify) CCG -
LAST YEAR Metric Source Currency Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Totals YTD Total Change on % Change Prior Year 17/18 Plan From Unify Submission Atts 2,825 3,022 2,988 2,759 2,744 2,825 2,852 3,020 2,779 2,963 2,967 2,915 34,659 17/18 Actual (CCG) From CCG Rtns Atts 3,333 3,260 3,242 2,958 3,012 3,150 3,172 3,315 2,730 3,311 2,987 3,191 37,661 Variance to Plan Calculated Atts (508) (238) (254) (199) (268) (325) (320) (295) 49 (348) (20) (276) (3,002) % Variance Calculated % -18.0% -7.9% -8.5% -7.2% -9.8% -11.5% -11.2% -9.8% 1.8% -11.7% -0.7% -9.5% -8.7%
17/18 Actual National Data Atts 2,827 3,260 3,242 2,958 3,012 3,151 3,172 3,315 2,731 3,311 2,987 3,191 37,157 30,979 1,384 3.9% 16/17 Actual National Data Atts 2,921 2,957 3,169 2,777 2,957 3,016 2,903 3,189 2,682 3,050 2,888 3,264 35,773 29,621 1,807 5.3% 15/16 Actual National Data Atts 2,722 2,651 3,080 2,989 2,531 2,893 2,923 2,984 2,732 2,730 2,891 2,840 33,966
Explanation of adverse variance to Plan Activity is 15.1% adverse to (i.e. above) plan, which is broadly consistent with the trend over recent months. Circa 35% of the adverse variance to plan can be accounted for by the ELR plan baseline (set at 2017/18 month 8) which was significantly below the actual outturn for 2017/18, effectively under-stating the plan for 2018/19. Once adjusted for, this brings the underlying year on year growth to circa 11%, which is consistent with the growth observed for LC and WL CCGs. As reported previously, with two main identified areas driving this change are: firstly, additional attendances to "hot clinic" (admissions avoidance) OPA activity at UHL (most of which is diverted from A&E and therefore recorded as Other Referral source); and secondly ophthalmology, where national retinal screening activity has begun to be incorrectly assigned to CCGs, and there is also an element of coding change which has moved some ophthalmology activity away from GP referral and into Other referral. Actions to bring activity back into line with Plan A clinical review of hot clinics and ambulatory / assessment services at UHL (via the LLR A&E Delivery Board) was undertaken in December, and the Contracts Team have also initiated an activity query notice with UHL to further understand the increase in hot clinic attendances following the co-location of the ambulatory assessment units alongside ED in June 2018. These pieces of work have identified pathway transformation actions which will impact on the Other referrals in 2019/20. With regards to the ophthalmology coding changes, UHL have confirmed that these changes have arisen due to paper switch off processes, and this will be taken into account in setting the plans for 2019/20. ACTIVITY DATA COLLECTION: URGENT CARE POINTS OF DELIVERY
Notes 1. Please input in Yellow Cells Only. All other cells are locked. 2. The Month Cell automatically populates to equal Month data reported. This will amend the calculation of the YTD performance to set it to the reported period only.
Calculated Metrics (National Data) Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Annual A&E Conversion Rate: 16-17 28.4% 27.5% 27.8% 25.0% 25.8% 27.0% 27.2% 27.4% 26.9% 29.4% 29.8% 28.3% 27.5% A&E Conversion Rate: 17-18 25.0% 27.1% 27.8% 27.1% 28.9% 28.9% 28.9% 28.8% 27.8% 31.6% 29.8% 29.2% 28.4% A&E Conversion Rate: 18-19 26.5% 27.0% 26.1% 26.3% 27.1% 24.6% 28.3% 29.0% 26.2% 26.8%
Month 10 From Dashboard (1 month in arrears)
Non Elective - 0 LoS (EM11a)
Explanation of Variance Required Yes If YTD variance is >2.0% adverse to Plan Rectification Plan Required No If YTD variance is >3.0% adverse to Plan 1 2 3 4 5 6 7 8 9 10 11 12 THIS YEAR Metric Source Currency Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 Totals YTD @ M10 Change on % Change Prior Year 18/19 Plan From Unify Submission Atts 782 887 836 801 808 819 819 776 773 745 759 809 9,614 8,046 122 1.5% Actual/Forecast CCG Input Atts 769 873 846 754 779 675 812 805 747 799 7,859 7,859 (1,053) -13.4% Variance to Plan Calculated Atts 13 14 (10) 47 29 144 7 (29) 26 (54) 759 809 1,755 187 % In-Month Variance Calculated % 1.7% 1.6% -1.2% 5.9% 3.6% 17.6% 0.9% -3.7% 3.4% -7.2% 100.0% 100.0% 18.3% 2.3%
18/19 Actual National Data Atts 770 875 849 757 781 675 811 809 749 0 0 0 7,076 7,076 (848) -12.0% Variance to Plan Calculated Atts 12 12 (13) 44 27 144 8 (33) 24 745 759 809 2,538 970 Variance to Plan Calculated % 1.5% 1.4% -1.6% 5.5% 3.3% 17.6% 1.0% -4.3% 3.1% 100.0% 100.0% 100.0% 26.4% 12.1% Difference between National & CCG Data Calculated (1) (2) (3) (3) (2) 0 1 (4) (2) 799 0 0 783
Other Local Proxy Measures for Performance Other CCG (please Specify) CCG - Other CCG (please Specify) CCG -
LAST YEAR Metric Source Currency Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Totals YTD Total Change on % Change Prior Year 17/18 Plan From Unify Submission Atts 17/18 Actual (CCG) From CCG Rtns Atts 875 890 879 868 828 939 957 921 811 944 885 902 10,699 Variance to Plan Calculated Atts % Variance Calculated %
17/18 Actual National Data Atts 707 804 775 740 757 792 801 825 807 916 727 830 9,481 7,924 1,739 22.5% 16/17 Actual National Data Atts 626 728 673 624 628 638 663 626 638 608 606 684 7,742 6,452 290 3.9% 15/16 Actual National Data Atts 565 565 619 591 621 626 652 610 673 610 652 668 7,452
Explanation of adverse variance to Plan Activity is 2.3% favourable to (i.e. below) plan. We have associated this with the increased use of admission avoidance (hot clinics), which are coded as OP activity and therefore do not feature in this POD. In addition, there has been a change in the pathway for paediatric emergencies, which commenced on 16/7/18. The new pathway has increased the number of children attending Type 1 ED at UHL, however there has been an associated decrease in the number of short stay admissions (as more children are seen and treated within ED, rather than being admitted directly to the Children's Assessment Unit).
Actions to bring activity back into line with Plan
Non Elective - +1 LoS (EM11b)
Explanation of Variance Required No If YTD variance is >2.0% adverse to Plan Rectification Plan Required No If YTD variance is >3.0% adverse to Plan 1 2 3 4 5 6 7 8 9 10 11 12 THIS YEAR Metric Source Currency Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 Totals YTD @ M10 Change on % Change Prior Year 18/19 Plan From Unify Submission Atts 1,891 1,983 1,903 1,911 1,908 1,952 1,954 1,996 2,066 2,074 1,875 2,098 23,611 19,638 97 0.5% Actual/Forecast CCG Input Atts 1,929 2,009 1,942 2,005 2,004 1,835 2,017 2,097 1,958 2,084 19,880 19,880 (2,183) -11.0% Variance to Plan Calculated Atts (38) (26) (39) (94) (96) 117 (63) (101) 108 (10) 1,875 2,098 3,731 (242) % In-Month Variance Calculated % -2.0% -1.3% -2.0% -4.9% -5.0% 6.0% -3.2% -5.1% 5.2% -0.5% 100.0% 100.0% 15.8% -1.2%
18/19 Actual National Data Atts 1,908 1,998 1,912 1,974 1,992 1,827 2,012 2,079 1,964 0 0 0 17,666 17,666 (1,875) -10.6% Variance to Plan Calculated Atts (17) (15) (9) (63) (84) 125 (58) (83) 102 2,074 1,875 2,098 5,945 1,972 Variance to Plan Calculated % -0.9% -0.8% -0.5% -3.3% -4.4% 6.4% -3.0% -4.2% 4.9% 100.0% 100.0% 100.0% 25.2% 10.0% Difference between National & CCG Data Calculated 21 11 30 31 12 8 5 18 (6) 2,084 0 0 2,214
Other Local Proxy Measures for Performance Other CCG (please Specify) CCG - Other CCG (please Specify) CCG -
LAST YEAR Metric Source Currency Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Totals YTD Total Change on % Change Prior Year 17/18 Plan From Unify Submission Atts 17/18 Actual (CCG) From CCG Rtns Atts 2,019 2,110 2,175 2,124 2,209 2,236 2,214 2,243 2,333 2,400 2,123 2,472 26,658 Variance to Plan Calculated Atts % Variance Calculated %
17/18 Actual National Data Atts 1,840 1,927 1,868 1,891 1,975 1,967 1,967 1,980 2,003 2,123 1,856 2,145 23,542 19,541 867 3.8% 16/17 Actual National Data Atts 1,862 1,942 1,843 1,844 1,741 1,824 1,872 1,885 1,981 2,035 1,812 2,034 22,675 18,829 366 1.6% 15/16 Actual National Data Atts 1,918 1,765 1,833 1,871 1,847 1,744 1,911 1,855 1,981 1,886 1,742 1,956 22,309
Explanation of adverse variance to Plan
Actions to bring activity back into line with Plan
Accident & Emergency (EM12)
Explanation of Variance Required No If YTD variance is >2.0% adverse to Plan Rectification Plan Required No If YTD variance is >3.0% adverse to Plan 1 2 3 4 5 6 7 8 9 10 11 12 THIS YEAR Metric Source Currency Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 Totals YTD @ M10 Change on % Change Prior Year 18/19 Plan From Unify Submission Atts 10,146 10,508 9,839 10,393 9,860 9,897 10,040 9,999 10,542 10,496 9,354 10,353 121,427 101,720 4,193 4.1% Actual/Forecast CCG Input Atts 10,072 10,628 10,523 10,367 10,200 10,161 9,957 9,870 10,288 10,249 102,315 102,315 5,250 5.1% Variance to Plan Calculated Atts 74 (120) (684) 26 (340) (264) 83 129 254 247 9,354 10,353 19,112 (595) % In-Month Variance Calculated % 0.7% -1.1% -7.0% 0.3% -3.4% -2.7% 0.8% 1.3% 2.4% 2.4% 100.0% 100.0% 15.7% -0.6%
18/19 Actual National Data Atts 10,119 10,649 10,561 10,395 10,247 10,176 9,976 9,961 10,352 0 0 0 92,436 92,436 (5,091) -5.5% Variance to Plan Calculated Atts 27 (141) (722) (2) (387) (279) 64 38 190 10,496 9,354 10,353 28,991 9,284 Variance to Plan Calculated % 0.3% -1.3% -7.3% 0.0% -3.9% -2.8% 0.6% 0.4% 1.8% 100.0% 100.0% 100.0% 23.9% 9.1% Difference between National & CCG Data Calculated (47) (21) (38) (28) (47) (15) (19) (91) (64) 10,249 0 0 9,879
Other Local Proxy Measures for Performance A&E Sitreps NHS England Atts 0 Other CCG (please Specify) CCG 0
LAST YEAR Metric Source Currency Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Totals YTD Total Change on % Change Prior Year 17/18 Plan From Unify Submission Atts 8,437 9,508 8,856 9,231 9,029 8,861 9,016 8,835 9,069 8,836 7,871 8,727 106,276 17/18 Actual (CCG) From CCG Rtns Atts 10,209 10,047 9,468 9,718 9,405 9,251 9,559 9,689 10,086 9,633 8,682 10,140 115,887 Variance to Plan Calculated Atts (1,772) (539) (612) (487) (376) (390) (543) (854) (1,017) (797) (811) (1,413) (9,611) % Variance Calculated % -21.0% -5.7% -6.9% -5.3% -4.2% -4.4% -6.0% -9.7% -11.2% -9.0% -10.3% -16.2% -9.0%
17/18 Actual National Data Atts 10,194 10,093 9,505 9,722 9,445 9,534 9,582 9,724 10,109 9,619 8,676 10,195 116,398 97,527 5,736 5.2% 16/17 Actual National Data Atts 8,768 9,716 9,066 9,876 9,184 9,124 9,337 9,160 9,721 8,998 8,120 9,592 110,662 92,950 35 0.0% 15/16 Actual National Data Atts 9,356 9,948 9,317 9,269 9,550 9,170 9,244 8,961 8,910 9,005 8,468 9,429 110,627
Explanation of adverse variance to Plan
Actions to bring activity back into line with Plan Appendix G 2018/19 Forecast Total 2019/20 Plan Outturn East Leicestershire and Rutland CCG £'000 £'000
Income: Programme Baseline 373,495 394,589 Running Costs 6,911 6,913 NR Allocation 10,904 - Total Income excluding PCCC 391,310 401,502 Primary Care Co Commissioning 42,170 43,405 NR Co-Commissioning Allocation (413) - Total Income PCCC 41,757 43,405
Total Income 433,067 444,907
Expenditure: Acute - NCAs 3,990 4,105 Acute QIPP (518) (4,522) Acute - Other - 160 Prior Year 1,394 - Alliance - PCL (Non-Contract) 179 253 Alliance - PCL 831 3,772 Alliance - UHL (Contract) 7,082 7,012 Acute - Out of County 31,953 34,063 Acute - Independent Sector 10,514 11,037 EMAS 8,770 9,445 UHL Contract 145,695 153,409 UHL Non-Contract (74) (79) Total Acute 209,815 218,655 LPT Contract - CHS 31,410 31,734 LPT Contract - LD 3,001 3,092 LPT Contract - MH 22,243 22,461 LPT Non-Contract - CHS - 6 LPT Non-Contract - MH - 1,093 S117 3,202 3,368 AHP 1,859 1,806 LD Pool 38 40 MH Other 746 654 CHS Other 605 638 IAPT 2,046 2,273 Urgent Care 930 2,175 Other MH SLAs 305 433 Other CHS SLAs 21 22 MH NCAs 264 278 CHS NCAs 376 395 Non-Acute QIPP MH - (367) Non-Acute QIPP CHS (250) 403 Community Equipment 1,256 1,282 Total Mental Health & Community 68,052 71,784 CHC Main 24,519 24,468 Childrens CHC 784 701 Funded Nursing Care 1,411 1,562 CHC Admin 981 853 Total CHC 27,695 27,585 Primary Care Co-Commissioning 43,054 43,405 Primary Care 4,138 634 GP IT 904 1,070 Out of Hours 3,960 4,169 Prescribing 51,071 51,207 Total Primary Care 103,126 100,484 Running Costs 6,882 6,443 Programme Infrastructure 626 681 NHS 111 947 1,086 Patient Transport 1,546 2,180 Better Care Fund - Local Authority Led Services 11,484 11,607 Voluntary Sector 945 813 Partnerships 476 629 Other Programme (Non-Acute) 605 764 Step Down Beds 898 898 Total Other Programme 17,527 18,658 Commissioning Reserve (30) (710) Contingency Reserve - 2,008 Total Reserves (30) 1,298 Total Expenditure 433,067 444,907 G Blank Page Paper G East Leicestershire and Rutland CCG Governing Body Meeting 9 April 2019
EAST LEICESTERSHIRE AND RUTLAND CLINICAL COMMISSIONING GROUP GOVERNING BODY MEETING
Front Sheet REPORT TITLE: Leicester, Leicestershire and Rutland System Operational Plan 2019/20
MEETING DATE: 9 April 2019
REPORT BY: Sarah Prema, Director Strategy and Implementation, LC CCG Simon Pizzey, Head of Planned Commissioning and Strategy, ELR CCG
SPONSOR: Karen English, Managing Director
PRESENTER: Simon Pizzey, Head of Planned Commissioning and Strategy, ELR CCG
PURPOSE OF THE REPORT: As part of the planning process for 2019/20 each Sustainability and Transformation Partnership has been asked to develop a System Operational Plan. This plan needs to set out: • System Priorities and deliverables • Care Redesign – including development of an Integrated Care System • Activity Assumptions • Capacity Planning • Workforce • System Financial Position and Risk Management • Efficiencies
The first draft of the plan was submitted on 19th February 2019 in line with national requirements and feedback was subsequently received from NHS England. An updated version is due to be submitted on 11th April 2019 and this version is attached as Appendix A for consideration by the Governing Body. In addition to the plan a detailed financial and activity aggregation tool will be resubmitted which is designed to demonstrate how all individual organisational plans align to the system plan.
The plan sets out the system plans, within its resources, for 2019/20 and the steps we will take over the next year to develop our Integrated Care System as set out in the NHS Long Term Plan. In addition the plan sets out the financial position across the system and the steps we will be taking to ensure the system can deliver the system wide control total in 2019/20.
RECOMMENDATIONS: The East Leicestershire and Rutland CCG Governing Body is requested to: • APPROVE the Leicester, Leicestershire and Rutland System Operational Plan 2019/20.
Page 1 of 2 Paper G East Leicestershire and Rutland CCG Governing Body Meeting 9 April 2019
REPORT SUPPORTS THE FOLLOWING STRATEGIC AIM(S) 2018 – 2019: Transform services and enhance quality of Improve integration of local services between life for people with long-term conditions health and social care; and between acute and primary/community care. Improve the quality of care – clinical Listening to our patients and public – acting effectiveness, safety and patient on what patients and the public tell us. experience Reduce inequalities in access to Living within our means using public money healthcare effectively Implementing key enablers to support the strategic aims (e.g. constitutional and governance arrangements, communications and patient engagement).
EQUALITY ANALYSIS An Equality Analysis and due regard to the positive general duties of the Equality Act 2010 has not been undertaken in respect of this report, however each individual proposal within the Plan has had an equality impact risk assessment carried out.
Page 2 of 2 Leicester, Leicestershire and Rutland
Integrated Care System
Draft 10 2019/20 Operational Plan
April 2019
Contents
1. Executive Summary
2. Introduction to Leicester, Leicestershire and Rutland
3. Care Redesign
4. Our Priorities and Key Deliverables
5. Activity Assumptions, Capacity & Winter Planning
6. System Financial Position, Risk Management, Current System Efficiencies & Future System Arrangements
7. Enablers
SECTION 1
EXECUTIVE SUMMARY
Section 1: Executive Summary
The vision of the Leicester, Leicestershire and Rutland (LLR) Better Care Together In LLR we have agreed a new model of care (Section (BCT) programme – the local Sustainability and Transformation Partnership (STP) - is ‘To develop an outstanding, integrated health and care system that delivers 3) that is focused on a stronger system of primary excellent outcomes for the people of Leicester, Leicestershire and Rutland”. and community care connected with specialist care. This is based on an established culture of GP In August 2017 the BCT partnership published its Next Steps to Better Care in practices working together in localities moving Leicester, Leicestershire and Rutland document which set out the progress we had made on our plans and the next steps in developing an effective integrated health towards Primary Care Networks. system in LLR. With the publication of the NHS Long Term Plan in January 2019 our BCT partnership is reviewing its plans to ensure they will be able to respond to the requirements of the Long Term Plan and we will publish a new five year plan in the Our plans are based on the following priorities: Autumn of 2019. Keep people well and out of hospital In the meantime this Integrated Care System Operational Plan sets out an overview of More care closer to home what the system will deliver for its population with its share of NHS resources for Care in a crisis 2019/20 and the progress the system expects to make over the year towards its long- term transformation objectives. It also sets out how we intend to develop our High quality specialist care Sustainability and Transformation Partnership into an Integrated Care System (ICS) across Leicester, Leicestershire and Rutland.
The STP is a collaboration of system partners brought together to create a place based care system in which we rise to the challenges and deliver a transformation that improves and integrates care and makes us operationally and financially sustainable over the long term. We first formed our Better Care Together Partnership in 2014 and the plans set out here are built from that early work.
Health and social care structures and the geography offer ideal opportunities for delivering outstanding integrated care. Across LLR we have two main providers one for acute care and one for community, mental health and learning disability services. In addition we have three local authorities providing children and adult social care services. Together we provide care for over a million people and have a NHS workforce of over 22,000 and a social care workforce of 32,000. There is considerable variation in the health of people and life expectancy across LLR. An example of this is more people in Leicester City live in deprivation and experience early mortality than in Leicestershire and Rutland.
SECTION 2
INTRODUCTION TO LEICESTER, LEICESTERSHIRE AND RUTLAND
Section 2: Introduction – Our Partners
Our Better Care Together Partners are: 3 Trusts Leicester City CCG (LCCCG) responsible for commissioning health services in Leicester City to a population of 415,213 with 58 GP practices.
East Leicestershire and Rutland CCG (ELRCCG) responsible for 3 Councils commissioning health services in East Leicestershire and Rutland to a population of 321,188 with 30 GP practices.
West Leicestershire CCG (WLCCG) responsible for commissioning health services in West Leicestershire to a population of 397,441 with 48 GP 1,133,842 people practices. GP Practices
University Hospitals of Leicester (UHL) responsible for delivering the majority of acute services for Leicester, Leicestershire and Rutland patients. 3 CCGs
Leicestershire Partnership Trust (LPT) responsible for delivering all-age community services and mental health care and learning disability services in Leicester, Leicestershire and Rutland. Rutland County Council an upper tier authority responsible East Midlands Ambulance Service NHS Trust (EMAS) who provide for commissioning and providing social and population and emergency transport. public health services to residents of Rutland.
Leicestershire County Council an upper tier authority responsible for Derbyshire Health United (DUH) provide a range of urgent commissioning and providing social and population and public health care and general practice services across the system and are services to residents of Leicestershire. due to become partners in the Better Care Together Programme from March 2019. Leicester City Council an upper tier authority responsible for commissioning and providing social and population and public health services to residents of Leicester City.
Section 2: Our vision, goals and principles
The aim of the BCT partnership is to improve the provision of health Our goals care in Leicester, Leicestershire and Rutland by bringing together NHS Keep more people well and out of hospital through better organisations and other partners, including local authorities and the public health and prevention of illness, early detection and voluntary and community sector closer together to deliver a better management of disease, support for patients at home and services and to do so more efficiently. The following diagrams explain in their community. our vision, principles and goals for a sustainable, affordable system Care in a crisis from NHS 111 to 999, urgent care to the that is fit for purpose. The vision, goals and principles has been emergency department, including an urgent and emergency developed by the clinical leadership group and have been agreed by all response for people experiencing mental health episodes. partners. Our vision More care closer to home from the management of long term conditions to planned procedures and follow-ups.
High quality specialist care to support patients in their homes, community facilities and hospitals to get the best possible outcomes. Our principles: how we work Section 2: The key system challenges we face
In Leicester, Leicestershire and Rutland, and throughout England, the NHS faces unprecedented demands for health and care services. This is making it harder to deliver high quality services and control costs. Our plans for LLR have been developed by clinicians to meet this rising demand and provide safe, high quality care in a sustainable way. A summary of the challenges we face is detailed below.
Increased demand – a growing and ageing population means the NHS must treat more patients and a greater number with complex conditions. By 2023 the population of LLR is estimated to increase by 5.2% to 1,124,300 people. The number of people aged 75 and older is set to increase by increase by 25.7% to 104,100 people.
How we provide care – the NHS was developed when medical interventions were less effective. People tended to die younger. Now people generally live longer but more patients have multiple long-term illnesses. Care is not a one-off event, but an ongoing process, involving a multitude of health and care agencies. We also have opportunities to use digital technology to improve care and outcomes.
Inefficient buildings – some NHS facilities are old and have high running costs, while some services are split across multiple sites, undermining care quality, leading to duplication and increased cost.
Staff recruitment and retention – shortages of doctors, nurses, midwives and paramedics undermines the quality of care and increases the cost of services as NHS organisations pay for expensive agency staff. Providers are also competing with each other to attract the same workforce.
Advances in medical treatment - the availability of more sophisticated treatment allows us to do more than ever before for patients, but this is often at a higher cost.
Increasing financial pressure - demand is increasing quicker than available resources. As result our local health and social are services are under increasing financial pressure. Section 2: The health issues we face
Leicester
The 2017 population estimate for Leicester is 353,540, of which 50% are female and 50% male. Leicester’s population is relatively young compared with England; a third of all city households include dependent children, 20% of Leicester’s population (71,400) are aged 20-29 years old (13% in England) and 12% of the population (41,500) are aged over 65 (18% in England). The large proportion of younger people in Leicester reflects the student population attending Leicester’s two universities and inward migration to the city.
In 2011, over a quarter (32,447) of city households included a person with a long-term health problem or disability that limits the person's day- to-day activities, and has lasted, or is expected to last, at least 12 months. This includes problems that are related to old age.
A quarter of Leicester households in which at least one person has a long-term health problem or disability (7,909), also include dependent children. As expected, the incidence of disability in the City is highest in areas where the population is older (such as Thurncourt), and lower where the population is younger (for example, City Centre). According to Leicester’s 2018 Health and Wellbeing Survey, almost three in ten residents (28%) have a long-standing illness or disability. Of these, two thirds (66%) say this limits their day to day activities in some way.
Leicester has a high level of deprivation compared to the country as a whole and is ranked 21st out of 326 local authority areas in England, on the 2015 national Index of Deprivation (where 1 is worst). Leicester has 18 lower super output areas that are in the 5% most deprived in the country. 44% of Leicester’s population live in the most deprived 20% of areas in England and a further 32% live in the 20-40% most deprived areas. Only 1% of the Leicester population live in the 20% least deprived areas.
Life expectancy in Leicester is significantly lower than the England average and although it has continued to improve over the past decade, it has shown a slower improvement than England overall. In the period 2006-08 to 2015-17, life expectancy in Leicester increased by 1.3 years; for men this is an increase from 75.7 to 77, and for women from 80.2 to 81.9. However, in England life expectancy increased by 1.8 years for men to 79.6 and 1.3 years for women to 83.1. Overall, the gap between Leicester and England has been widening, reaching a peak in 2008-10, however this has shown a small improvement in subsequent years.
The main causes of death in Leicester are heart disease and stroke, cancers and respiratory diseases. Together these account for nearly two thirds of all deaths. Cancer is the main cause of premature deaths (in the under 75s), accounting for over a third of early deaths, followed by heart disease and respiratory diseases. The proportion of deaths from heart disease and stroke in Leicester are slightly higher than nationally in all ages and in under 75 year-olds, whilst the proportion of deaths from cancers is slightly lower in Leicester. However, Leicester residents are on the whole dying at a younger age and have a lower life expectancy than average.
Smoking is the greatest single cause of preventable death. The average number of smoking related deaths in Leicester City is 412 (2014-2016). Smoking prevalence rates are higher in more deprived areas and areas to the west of the city. Smoking prevalence is significantly higher amongst those of white ethnicity and significantly lower in under 19s, over 65s and Asian ethnic groups.
Section 2: the health issues we face
Leicestershire At the end of 2017 the population of Leicestershire was 690,212, with the county having a higher than national average level of older adults (those falling in the 45-74 years old age bands). The population of Leicestershire is projected to increase by 15.8% to 787,500 by 2041 (an increase of 107,100). Leicestershire will see higher levels (than both the East Midlands as well as National average) of growth during this time period. It is anticipated that the greatest level of growth (to 2041) will be within the 65+ age group.
In 2015 an exercise was undertaken to identify the level of deprivation within the county and the outcomes of this process demonstrated that in overall terms Leicestershire is not a deprived county (being ranked in the upper-tier of deprivation). However, within the county there are pockets of deprivation with 12,500 people being identified as living in the most deprived national deciles. Across the key JSNA parameters the Leicestershire health economy ranks equally or better than the national average. The following are areas where Leicestershire performs below the national average and which require focus from both local authority and the NHS:
Cardiovascular diseases - Leicestershire performs below the national average for the number of new hypertension that have received a cardiovascular risk assessment. Diabetes -Leicestershire GP practices on fewer occasions (both type 1 & 2) record the smoking status of diabetic patients. Fewer Type 1 and 2 diabetic patients (in comparison to the national average) within Leicestershire receive all recommended 8 care processes. Diabetic patients in Leicestershire are less likely (than the national average) to record a blood glucose level of 48mmol/mol. Finally, diabetic patients in Leicestershire are less likely to have their BMI recorded (than the national average). Early Years - Children (0-1 & 1-4 years old) in Leicestershire attend A&E on more occasions than the national average.
Rutland The population of Rutland in 2016 was 38,606, an increase of 1.5% since 2015. Rutland has an older population with almost a quarter, 23.9%, of the population aged over 65 compared to 17.9% nationally. The population of Rutland is projected to grow by 7.9% by 2039 which is below the expected national increase of 14.6%. The number of people aged 85 and over in Rutland is predicated to grow by 142.9% which is high than the predicated national rate of 127.1%. The military population accounts for 5.8% of the population. 23.8 % of the population live in a rural town and fringe; 28.1% in urban city and town; and 48.1% in rural village and dispersed. 65.5% of the population live in neighbourhoods in the three least deprived deciles nationally. The county is ranked 148th our of 152 upper tier authorities in England where 1st is the most deprived. Compared to the national average the rate of premature mortality is significantly lower and both life expectancy and healthy life expectancy is significantly better than the national average.
The plans that are set out in this System Operational Plan are designed to impact on the key system challenges and the health issues within Leicester, Leicestershire and Rutland.
SECTION 3
CARE REDESIGN
Section 3: Overview of the Leicester, Leicestershire and Rutland Clinical Care Model
Our evolving model of care will create a far more clinically effective Our care model will deliver a shift in emphasis from reactive to cost efficient system. It will be built around individuals, supporting proactive care where those with long term conditions will discuss their them to be active and as independent as they can be. Wherever it is future needs with clinicians and contribute to the development of clinically appropriate we will aim to treat people at or close to home. their care plan. We will always ask “how best can we keep this person at home?” or “Why is this patient not at home?” Focusing on a philosophy of “Home First” we will deliver care as close to home as possible. We recognise that some people will require on- The model will strengthen primary care and the provision of GP going care. For this group, continuity of service is important where all services through the development of Primary Care Networks (PCNs). who deliver their care have access to shared information. The GP surgery with its registered patients will remain the central pillar of local care. Recruitment to new roles within the PCNs, As the complexity of a patient’s needs increases, we will work with the supported by integration of care for people with long-term and individual and their family to develop an integrated care plan to keep complex conditions through multi-disciplinary teams and practices them independent in their own home as long as possible. working more closely together within PCNs, will increase the capacity available. Where either a planned or unplanned hospital admission is necessary both the admission and the discharge will be co- ordinated to We anticipate that multi-disciplinary teams including staff from social minimise the amount of time spent in hospital. care and the voluntary sector, working on a place-based model of care through Primary Care Networks will reduce the number of emergency admissions.
Population health management will be used to help us target care for those most likely to benefit. It is a process which takes a defined population, analyses its needs in detail and, as a result, creates tailored health and social care services.
Working with our local authorities and the voluntary sector prevention of ill health and maximisation of wellbeing is integral to our model.
Those with minor illnesses or long term conditions will have the confidence to manage their own health or have their needs met in primary care by a pharmacist or a general practice.
Section 3: Our clinical care model focuses on population health management
The NHS Long Term Plan focuses on the use of population health All practices across LLR now have access to risk stratified data which approaches to support improvement in outcomes for patients and will enable them to target support. financial sustainability in the NHS. We are also using data at a strategic commissioning level to In LLR, Leicester City CCG, has been using a population health understand the numbers of patients in each risk category, the cost of management approach over the last three years to support those that providing care attributable of to the risk categories and what services are high risk of admission to hospital, those with complex needs and are required to respond to need. This is informing how we use Better those that are frail. Risk stratified data is available to each practice to Care Funds, develop Primary Care Networks and the current review of enable them to target and proactively manage patients. This is community health services. It will be an integral part of how the CCGs supported by investment into social and community services through will move into a more strategic commissioning role in the new NHS the Better Care Fund and an enhanced service within General Practice. architecture.
By using a population health management approach we are able to target support and interventions to the right patients. We are now expanding this approach across all LLR CCGs.
Section 3: Integrated Care System
Our Integrated Care System (ICS) journey began in 2014 with the development of our Better Care Together (BCT) programme which has built a strong collaborative partnership across the health and social care sector within LLR. In November 2016 the BCT partnership published its draft proposals for the development of local health and social care services. In it we described how we will work together on the triple aims of the NHS Five Year Forward View. These include improving the health outcomes of people, providing better quality care and ensuring financial sustainability.
The basis for our redesigned system is described below and we are developing our models at each level, the main components of which are the infrastructure to enable the Integrated Care System to function effectively by bringing partners together to agree how we will operate as an ICS. At a place level considerable work is being done to redesign our community based physical and mental health services working with our councils to ensure that where services need to be provided at a place level these are effective and complement the rest of the system offer. At neighborhood level we have already developed locality teams which are providing integrated care to complex patients but we know we could do better, and through our work to develop Primary Care Network we will redefine our neighborhood offer based on a population health management approach. Level Population Size Purpose
• Deliver high quality primary care. 30,000 Neighborhood • Proactive care via integrated locality teams for defined populations and to 50,000 (Health Needs Neighborhood and cohorts.
Localities) • Asset based community development to support health, wellbeing and
prevention.
• Based on upper tier authority boundaries. Place • Delivery of specialised based integrated community services, including Leicester City 37,000 to 610,00 social care. Leicestershire County • Delivery of reablement, rehabilitation and recovery services. Rutland • Prevention services at scale.
• System strategy, planning and implementation. • Work across the system on specialist areas such as cancer, mental health and Systems urgent care. 1,000,000+ (Leicester, Leicestershire and Rutland) • Make best use of all our combined assets including staff and buildings. • Manage performance and system finances. • Establish a system framework for prevention. Section 3: Developing our Integrated Care System
The System Leadership Team (SLT) have been working to build relationships and resilience across the whole local system in order to develop fully integrated approaches to health and well-being. It intends to develop a plan for delivery across the different organisations by September 2019 and be ready to work in shadow form as an Integrated Care System by April 2020. We have used the Good Governance Institute Maturity Matrix to assess where we are and what actions we need to take. This has identified the following key activities for 2019; (1) Purpose & Clarity of Remit (Element 1) - Rearticulate vision, purpose and principles; (2) System Infrastructure, leadership, financial framework (Element 8); (3) Governance and decision making (Element 9) including establishing transparent oversight arrangements and a Memorandum of Understanding; (4) Internal & External stakeholder Engagement (Elements 5 & 6) including joint approaches to communications and engagement activities with staff and stakeholders ; and (5) Priorities and outcomes (Element 10) including tangible programmes of joint work . A programme for this work is detailed below. In addition the CCGs are undertaking a Commissioning Capability Programme to support the future commissioning arrangements.
Quarter 1 Quarter 2 Quarter 3 Quarter 4
• Review and agree • Identify key risks • Develop system vision, purpose areas and how leadership skills • Review progress and values these will be • Establish on maturity • Develop managed outcomes • Prepare for behaviour • Review progress • Agree financial shadow year expectations on maturity frameworks • OD programme • Oversight matrix • Review progress structure agreed • Establish shared on maturity • Agree priority governance and matrix areas of work accountability • OD programme • Co-creation • Agree a workshop Memorandum of • Review and agree Understanding Terms of • Engage on five Reference for SLT year plan • Develop OD and • OD programme engagement strategies Section 3: Our emerging community model
In 2018/19 the CCGs have undertaken a review of community Improved discharge processes: from UHL and close working with services to develop a future model. The reasons for this change are: community locality decisions units will enable clinician to clinician conversations that support patients to be discharged faster and There is not enough capacity in community nursing and hospital admissions avoided. therapies to respond to patients’ needs in the way needed to deliver a preventative and reabling model that also supports Community support to primary care networks: will include a genuine continuity of care for the frail population and those with multi-disciplinary team inclusive of GPs, practice nursing, community multiple long term conditions. Local bed audits have shown 30% nursing and therapy, social care, care co-ordinators, mental health of patients in bed based care are in the wrong place to best support, housing and voluntary sector support. These teams will meet their needs. manage the majority of care for people with frailty, long term Services are not designed to support integrated care, or to work conditions, and complex needs (including end of life), who can be closely with GP practices as part of neighbourhood teams or managed in a community setting. Over a number of years it is deliver a population health management approach. anticipated that these local neighbourhood teams will move towards There is insufficient medical support to achieve the potential for managing resources locally. We will develop a new model of care co- patients to be cared for well at home, preventing admission and ordination to support patients and the professionals working in these ensuring high quality care after discharge from hospital. teams to proactively deliver care in the right setting at the right time. The current model is not well aligned to a future integrated care system approach. Home First services: will be ‘place’ based aligned to local authority areas. These will be ‘integrated health and social care crisis response (including virtual ward) and reablement services, which would deliver In 2019/20 CCGs, together with system partners, will start to intensive, short term care for up to 6 weeks. These services will be implement the new LLR model of care for core community based accessed when a patient is at risk of hospital admission or requires services. The future model of care has been designed with strong multi-disciplinary intensive support to enable them to be discharged clinical leadership and reflects significant engagement with from hospital before stepping down to neighbourhood team support. stakeholders, patients, carers and staff. The model has been By routing all referrals for Home First services and community beds developed based on evidence on best practice models of integrated through the same clinically manned decisions unit people will be community care both nationally and locally. treated in the most appropriate setting. With health and social care services working on the basis of trusted assessment and delivering co- The new model is based on a number of key building blocks: ordinated packages of care. Medical responsibility will remain with the GP, but additional investment will be made in primary care to strengthen the medical offer to the Home First service. Community bed based care: delivered either in community hospitals for patients requiring medical rehabilitation or needing significant 24/7 nursing care and on-site therapies, and in ‘Pathway 3’ reablement beds for patients with lower medical needs requiring reablement and a degree of 24/7 support. We will review the medical model of support to community hospitals.
Section 3: Our emerging community model
Section 3: Our emerging primary care networks
Primary Care Networks will involve groups of practices and other local health and social care providers working in partnership, as one team, to provide proactive, personalised, coordinated and more integrated primary and community services to improve health outcomes of their population. Practices will work together with other local health and social care providers around natural geographical communities of between 30,000 and 50,000 registered patients. They will deliver expanded neighbourhood teams comprising of a range of staff including GPs, primary care staff, pharmacists, district nursing, community geriatricians, Allied Health Professionals joined by social care and the voluntary sector. This will be supported by a network contract. In LLR considerable work has been done over the last three years to develop our neighbourhood offer and all CCGs have well established footprints on which discussions will take place with practices and providers with a view to confirming the geography of each Primary Care Networks by 31st May 2019.
The existing footprints are based around community nursing and social care localities and over the last twelve months more multi disciplinary work has been undertaken by these teams to support patients with complex needs. The development of Primary Care Networks will be overseen by the Better Care Together Primary Care Board.
SECTION 4
OUR KEY PRIORITIES AND KEY DELIVERABLES
Section 4: Our priorities and key deliverables
To deliver the plans set out in this Operational Plan the following The following sets out our system priorities for 2019/20, these are governance arrangements are in place. drawn from our Better Care Together work-streams and form the key deliverables within individual organisations ‘ Operational Plans. At a system level: The overall delivery of the plans are overseen by a Senior Leadership Team made up of Chief Executives from providers; CCG Managing Directors; very senior representation from local authorities; and a clinical lead from each of the NHS organisations. Integrated Care System Development led by the System Leadership Team Each member of SLT has a sponsor role to a number of key schemes set out in this Operational Plan. They are responsible for the overall delivery of their schemes supported by a Senior Responsible Officer Enablers Transformation Programmes and Implementation Leads. Planned Care Cancer Finance and Contracting At a scheme level: There is an Executive Senior Responsible Officer Urgent Care for each scheme to ensure delivery. For clinical programmes there is IM&T Digital a lead clinician and where appropriate there are clinical leads from Integrated Community Services Workforce commissioners and providers. An Implementation Manager is in Primary Care Communications and Engagement place to oversee the day to day implementation of the programme. Mental Health A group or board oversees the development and implementation of Estates Learning Disabilities each programme.
Children and Adolescent Mental Health Programmes are supported by enabling work-streams. Children’s, maternity & neonates Prevention and health inequalities The following pages set out our key priorities for 2019/20 in these programmes. Our plans for developing our Integrated Care System Medicine Optimisation and Integrated Community Services are detailed in section 3.
Section 4: NHS Constitutional Standard Performance & Assurance Process
As a system our current performance concerns include A&E, RTT, 62 day & 31day (surgery) cancer waits and increasing IAPT access rates. Performance trajectories have been reviewed with key providers to agree realistic trajectories, alongside improvement, plus a process of transformation with key deliverables.
The Provider Performance and Assurance Group (an LLR group made up of Executives; clinical leads and lay member) oversees provider performance including relevant NHS Constitutional Targets. Structures are also in place to manage performance through system owned Boards including the A&E Delivery Board, Planned Care Board, Cancer Pathway Performance Board and the Mental Health STP work-stream.
This provides a clear and robust governance process for managing all key performance areas , including a targeted system owned work-plan for A&E held by the ‘A&E Delivery Board’, the high level work-plan outlined in the next section with a more in-depth action plan placed in the LLR Operational Plan 2019-20.
As a system the 92% Referral to Treatment (RTT) standard remains below expectation in 2019/20. The plan to address this under performance is an element in all our Operational Plans. Our focus on Planned Care is outlined in the section below, with performance and governance held jointly across the system at the Planned Care Board. Additionally, there will be an ongoing focus to ensure delivery of the second RTT operational standard – to ensure that we do not have any more patients on incomplete pathways at March 2020 than we did at March 2018.
The Cancer Waits standard for 62day and 31day surgery will also be a considerable challenge to the system, the work-plan is outlined in the next section with the more in-depth plan forming part of the LLR Operational Plan 2019-20 with governance held at the ‘Cancer pathway performance Board’ .
The system is also focusing on more patients to be accessing IAPT services. With jointly agreed trajectories to achieve compliance with the national standard. Detail is outlined in the following section, with grip maintained through the system owned Mental Health STP work- stream.
Structures are in place to manage performance also through our commissioning and contracting teams. Our plans take account of the 2019/20 Planning Guidance requirements and the Operational Plans detail specific actions being taken.
In order to hold the system to account on NHS Performance targets individual CCGs monitor progress through the Integrated Governance Committees and Quality & Performance meetings and escalate to CCG Boards as necessary.
Section 4: Key priorities – Planned Care
Overview The LLR Planned Care Programme supports patients to have access to safe, high quality and effective care, delivered locally. Planned care can be defined as routine services with planned appointments or interventions in hospitals, community settings and GP practices. We want our planned care services to deliver high quality, personalised care, which enables patients to see the right person, in the right place, at the right time; working with local services to make sure that patients only go to hospital if they need to be there and that we have safe, high quality care available in community settings to improve patient outcomes. The Programme focuses on ensuring appropriate demand in an acute setting and maximising the opportunities in the Alliance, it also considers improvements in patient flow and treatment once on an acute elective pathway.
Why is it an important As a system we will transform planned care services via specific schemes for LLR residents. Our aim is to improve patient care and priority? health outcomes. By changing the way we use community and GP facilities we can bring more care closer to home. This will free-up space at University Hospitals of Leicester for patients needing emergency and specialist services including treatment for cancer, neurology and complex maternity services. As well as bringing more services into the community, we are improving the way different parts of the local NHS work together. This will give patients more control over their care, and make sure that they are always seen by the right person, in the right place at the right time. We are also working on new ways to help patients take control of their health, helping them make better, more informed decisions about their health and care.
Key deliverables in • Creation and Delivery of a Referral Support Service. 2019/20 • Increased capacity in a Community setting particularly for Dermatology, Ophthalmology, General Surgery, ENT and MSK. • Appropriate usage of pathology and diagnostic services. • Increased GP Advice and Guidance offered by Providers.
• Reductions in outpatient follow up rates, moving to alternatives such as non-face to face appointments. • Implementation of 2 way text reminders to improve both clinic utilisation and theatre utilisation. • Continued admitted efficiencies increasing number elective surgery rate. Includes improvements in scheduling, reduction in cancellations from hospital, patient and due to clinical reasons via improved operative assessment.
For specific detail on how these deliverables will be achieved please see Pages 18- 32 of the Leicester, Leicestershire and Rutland (LLR) Operational Plan 2019-20
Outcomes and benefits • Improve care by delivering it closer to home. • Improved utilization of available capacity. • Increased efficient use of available resources. • Potential to re-patriate out of county activity.
Section 4: Key priorities – Cancer
Overview Cancer is a priority across Leicester, Leicestershire and Rutland (LLR). The NHS Long Term Plan makes clear commitments to diagnose cancer earlier and push the prevention agenda. These are local priorities as LLR recognises the need to further improve our services and care for patients. Cancer outcomes vary across the three CCGs with one-year survival rates ranging from 67.3% - 73.3% across the patch but with a national requirement to achieve 75% by 2020. Preventing cancer, diagnosing cancer, screening for cancer and offering high quality treatment in addition to caring for 50,200 people who are survivors of cancer by 2030 must be our priority.
Why is it an important Diagnosing cancer early not only saves lives but limits treatment costs. When lung cancer is detected at Stage 1 the five year priority? survival rate is more than three in ten with treatment costs of £8,000. However if detected at Stage 4 the five year survival is less than one in ten with treatment costs of £13,100. One of the best ways to diagnose cancers early is through the three national screening programmes. Rates are differential across Leicester, Leicestershire and Rutland – for example for people aged 60-69 screened for bowel cancer in the last 30 months in 2016/17 uptake rates varied from 46% - 65% against a national average of 59% and a 2020 target of 75%.
Key deliverables in • Prevention: Develop and continue to run programmes to prevent and detect early stage cancers and reduce known risk factors 2019/20 such as smoking and obesity. Smoking is the biggest preventable cause of all cancers. • Improve the early detection of cancers: To ensure good progress towards the 2010/21 ambition for 62% of patients to be diagnosed at stage 1 or 2 we will do this through a programme of prevention and early detection in primary care, raising the
profile of symptoms, improving pathways and access to diagnostics. • Diagnostics: The system will ensure full implementation of the nationally agreed rapid assessment and diagnostic pathways for lung, prostate and colorectal cancers, ensuring that patients get timely access to the latest diagnosis and treatment. • Providing a dedicated multi-site facility for Clinical Radiology, Diagnostic Radiography and Sonography. • Implementation of FIT testing in primary care; Optimal Lung Cancer Pathway; and the RAPID Prostate Pathway. • Recovery packages and Risk Stratified Follow Up, primarily focused on Lower GI, Breast, Prostate and Lung pathways over the next 2 years.
For specific detail on how these deliverables will be achieved please see Pages 72- 76 of the Leicester, Leicestershire and Rutland (LLR) Operational Plan 2019-20
Outcomes and benefits Improved prevention of cancer. Earlier detection and treatment of cancer. Improved experience of patients on the cancer pathway. Section 4: Key priorities – Urgent Care
Overview Our vision is to create a health and care system that provides responsive, accessible person-centred services as close to home as possible. We aim to implement a model that will wrap care around the individual, promoting self-care and independence, enhancing recovery and reablement, through integrated health and social care services, exploiting innovation and promoting care in the right setting at the right time. By doing this we anticipate we can better manage patients with long term and complex conditions and also manage the increasing demand on the Emergency Department and ambulance services. To do this, we have taken forward a significant redesign of community urgent care services in LLR, to deliver services accessible 24 hours per day, seven days a week in community and hospital settings. This includes improving ‘Front of House’ Frailty Service plus access to the home based support offer with our partners at the point of discharge from hospital. Why is it an important We remain committed to resolving the areas that cause under performance within our own gift and working across the system to priority? support a reduction in attendances and admissions alongside returning patients to their home more quickly. Our plans will also maintain that no patient arriving by ambulance should wait more than 15 minutes from arrival to handover. Our model is based on making improvements in 4 major areas based on previous diagnostic work identifying areas of failure that have interlinked but
distinct challenges. • Decreasing non-admitted breaches in the daytime (8am – 9pm). • Improving overnight performance (Non-admitted breaches & admitted breaches that are primarily attributed to process). • Decreasing admitted breaches that represent potential short term improvement. • Decreasing admitted breaches , not included elsewhere, that relate to delays associated with flow (excludes clinically appropriate breaches). Key deliverables in • Investment in the Frailty Front Door Multidisciplinary team to enable improved processing of patients and avoid admission of the 2019/20 most vulnerable patients. • Continuation of acute medical staff input at the front door to increase adoption of Same Day Emergency Care (SDEC) pathways. • Improved organisation and management of the discharge team to enable more consistent staffing levels and approaches, aimed
at reducing stranded and super stranded patients. • Investment in flow coordinators – non clinical roles to enable patient flow allowing clinicians to focus on clinical intervention. • Procure an LLR Clinical Navigation Hub to deliver increased and improved clinical assessment across the NHS111 system. • Improve integrated urgent care services through working with EMAS on dispositions; care homes; telemedicine; improved mental health support, skill mix and capacity in services. For specific detail on how these deliverables will be achieved please see Pages 33- 39 of the LLR Operational Plan 2019-20 Outcomes and benefits • To improve access to out of hospital services in order to reduce demand on acute services, the Emergency Department and ambulances (Inflow). • To improve hospital operational processes in order to improve the delivery of national targets, and to reduce patient delays including long stay patients (Flow). Improve Continuing Health Care discharges in Community Hospitals. • To improve patient and carer experience of discharge by improving discharge processes across the system and reducing delayed transfers of care (Discharge). Section 4: Key priorities – Primary Care
Overview The LLR vision for primary care as set out in the STP plan. This is much more about how general practice will need to evolve and adapt over the next few years to manage the demand and the changing nature of primary care and an ageing population. This has been detailed in the LLR GP 5 year forward view plan which can be viewed here https://eastleicestershireandrutlandccg.nhs.uk/wp- content/uploads/2018/02/3.-GPFYFVFinal.pdf . This strategy will be updated for 2019/20 onwards with a clear direction for how Primary Care Networks will design, commission and deliver as part of the Integrated Care System. The Primary Care Board within LLR will drive forward this work to ensure resilient and effective General Practice at the centre of the local health care system.
Why is it an important Primary Care is the key to ensuring our clinical model of care can be delivered. Primary Care is crucial due to its ability to access and priority? support patients providing a differential service according to need. Not every patient requires contact with a doctor or an appointment on the same day. A cohort of patients, especially those with multiple co-morbidities who are at risk of admission for their complex condition require a more pro-active offer that could involve a multi-disciplinary team including social care, community nursing and specialist care. Integrated care combines a range of disciplines across health, social services and voluntary organisations to create person-centred care.
Key deliverables in • Configure and implement Primary Care Networks. 2019/20 • Continue the implementation of the GP Forward View ‘High Impact Changes’. • Consolidate Extended Access across the system. • Continue investment into Primary Care.
• Support Practices through the Sustainability and Resilience Fund. • Support practices to develop learning and ‘good practice’ across the system. • Continue to improve recruitment, training and retention of staff in primary care.
For specific detail on how these deliverables will be achieved please see Pages 70- 72 of the Leicester, Leicestershire and Rutland (LLR) Operational Plan 2019-20
Outcomes and benefits • Encourage Universal Services across General Practice. • Establish a resilient and stable Primary Care. • Improve access to Primary Care plus bespoke care planning. • More care provided closer to home through the development of integrated primary care networks.
Section 4: Key priorities – Adult Mental Health
Overview In LLR the Mental Health Transformation Board provides strategic and operational oversight of our health economies mental health programme (including transformation).
Mental health proposals within our Better Care Together programme support the left shift of activity away from inpatient acute
settings and enhancing community and primary care services. Our All Age Mental Health Transformation Programme will continue to design and implement new pathways, including the use of digital resources, to focus primary and community mental health services on detection, planned care and recovery. These anticipatory care models will proactively intervene where an individual’s mental health deteriorates with the aim of minimising impact on the individual and reducing the likelihood of an inpatient stay.
Why is it an important The LLR Mental Health system benchmarks nationally as an outlier for adult acute Mental Health length of stay, bed utilisation, crisis, priority? and community caseloads (including patient contacts). This position results in poor patient flow across our main provider inpatient services and potential out of area placements as well as Delayed Transfers of Care (DTOC’s).
In line with NHS England requirements, LLR is required to invest (based on our Clinical Commissioning Group allocation growth) additional resources into mental health. During 2018/19 we have worked with system partners to identify priorities for this additional investment (in 2019/20) and identified the required associated outcomes. Key deliverables in • Reduction in Acute lengths of Stay. 2019/20 • Liaison Psychiatry (Core 24). • Deliver Early Intervention in Psychosis target. • Increase access to IAPT.
• Crisis team enhancements. • Admission Avoidance: in 2019/20 the focus will be on the creation of alternatives to acute admission. • Reduce suicide and increase resilience and promote recovery and independence through working in partnership with public health. • Meet an increased proportion of mental health recovery and rehabilitation needs locally. • Implement an enhanced Individual Placement Support service. • Deliver physical health checks and interventions to people with severe mental illness. • Review Mental Health Workforce. • Develop a Mental Health Digital Strategy to maximise opportunities.
For specific detail on how these deliverables will be achieved please see Pages 58- 62 of the LLR Operational Plan 2019-20
Outcomes and benefits • Improved Mental Health access across the system to ensure parity of esteem and better outcomes for patients. • Reduction in acute lengths of stay leading to improved recovery and care in the community. • Ensuring the physically as well as mental health needs are being met for our populations.
Section 4: Key priorities – Learning Disabilities
Overview During 2019/20 we will continue to ensure the delivery of responsible, high quality, appropriate learning disability services and support in the community that maximises independence, offers choice, are person-centred, good value, and meets the needs and aspirations of individuals and their family carers.
In line with national guidance on Transforming Care, our all age approach focuses on transforming the care for people with learning disabilities and/or autism, including implementing enhanced community provision including forensic support, with a corresponding reduction in inpatient capacity, and undertaking our care and treatment reviews.
Why is it an important 2019/20 will also see the publication on an LLR strategic vision for people with a learning disability and/or autism. This will support priority? the local transition of the Transforming Care Partnership programme into “business as usual”, and ensure that individuals with a learning disability and/or autism are supported to live as independently as possible and achieve a fulfilling life.
Key deliverables in • Continue to provide proactive, preventive care via Personal Health Budgets and review of short breaks. 2019/20 • Reduce inappropriate hospitalisation. • Continue to provide specialist multi-disciplinary support. • Improve health and wellbeing through prevention.
• Improve access to health care checks through our Primary Care Providers. • Development of a new LLR complex care and rehabilitation pathway. • Support for Children and Young People: throughout 2019/20 we will work with partners to provide appropriate support with early intervention to prevent crisis, and admissions and improve pathways for transition. • Care, Education and Treatment Review (CETR): in 2019/20 we will continue to build upon our approach with CETRs to reduce inappropriate hospitalisation.
For specific detail on how these deliverables will be achieved please see Pages 63- 64 of the Leicester, Leicestershire and Rutland (LLR) Operational Plan 2019-20
Outcomes and benefits • Improved patient health and experience of healthcare services.
Section 4: Key priorities – Children and Adolescent Mental Health
Overview Our ambition is that children & young people will have access to the right help at the right time through all stages of their emotional and mental health development. For this to happen, we have developed a whole system approach to delivering a range of emotional, mental health and wellbeing services that meet all levels of need.
We have engaged with children & young people and their families and all stakeholders including education, social care, health, police, housing and justice. We have developed a shared work plan with key priorities and joint commissioning. We have improved the interfaces between our agencies to reduce fragmentation in commissioning and service delivery so that organisational boundaries are not barriers to care.
Why is it an important Children and young people need to have access to the right health through all stages of their emotional and mental health priority? development. In LLR:
• 1 in 10 children and young people will have a mental health disorder.
• 1 in 20 children and young people will have a conduct disorder. • Approximately 3,000 children and young people will experience emotional disorder.
Key deliverables in • Work together across agencies to transform our children and young people’s emotional, mental health and wellbeing services to 2019/20 create a system wide pathway of care. • To work across the system to improve access to the right service to meet their needs and reduce waiting times. • To focus on improving the quality and accuracy of the reporting and data provided to the system, through improved service
specifications with key performance and quality indicators. • Increasing Skills and capacity of the workforce - to increase the number of C&YP accessing evidence based interventions. • Commence development of a new CAHMS unit.
For specific detail on how these deliverables will be achieved please see Pages 77- 78 of the Leicester, Leicestershire and Rutland (LLR) Operational Plan 2019-20
Outcomes and benefits • Improved Mental Health access across the system. • Reduction in acute lengths of stay leading to improved recovery and care in the community. • Improved service for eating disorders.
Section 4: Key priorities – Maternity, childrens and neonates
Overview The system’s focus is on improving outcomes in maternity, children’s emotional health and wellbeing, young people and family services. This involves a range of organisations working together efficiently to improve productivity across universal, targeted and specialist services to improve outcomes for children and young people. The system has developed and continues to develop a New Children Hospital Model. The new model will consider choice and appropriate service delivery for children and young people aged 0 - to 18 and 365 days.
Why is it an important Leicester has a young population and the city is seeing major increases in the number of children and young people living here. The priority? city is home to 130,726 children and young people aged up to 24 years, an increase of 12.5% since 2015, which is more than double the increase seen in England as a whole. This growth includes a big increase in the number of young children aged 0-4 years which rose by nearly 25% from 20,726 in 2005 to 25,884 in 2015.
Life expectancy in Leicester is below the England average, with significant differences in how long people live according to where they live: many of the patterns for this are laid down in childhood. Children’s health and well-being is therefore not only important as a goal in itself but is a key priority to improving the overall health of the entire area.
Key deliverables in • Deliver the New Children Hospital Model. 2019/20 • Continue to deliver the Children’s Single Front Door Model. • Review joint commissioning arrangements for Children with SEND across LLR. • Develop an enhanced and targeted continuity of carer model to help improve outcomes for the most vulnerable mothers and
babies; a universal offer to all women who smoke during their pregnancy; support work to achieve a 50% reduction in stillbirth, maternal mortality, neonatal mortality and serious brain injury by 2025. • Support local trusts with a maternity and neonatal service to be part of the National Maternal and Neonatal Health Safety Collaborative, supported by Local Learning Systems. • Roll out the Saving Babies Lives Care Bundle during 2019. To support the progress towards Maternity digital care records. • Continue to work with midwives, mothers and their families to implement continuity of carer. • To ensure maternity services deliver an accredited, evidence-based infant feeding programme. • Our plans to improve emotional health and wellbeing are described in the Child and Adolescent Mental Health sections.
For specific detail on how these deliverables will be achieved please see Pages 79- 81 of the Leicester, Leicestershire and Rutland (LLR) Operational Plan 2019-20
Outcomes and • Simplified and improved access to care. Benefits • Prevention strategies to reduce harm for both mother and child. • Improved outcomes for infant and children’s healthcare. Section 4: Key priorities – Prevention
Overview The public sector has a crucial leadership role around prevention through its role as a major local employer and the priority it gives to prevention as part of core business. We want to accelerate this work locally by making sure that all staff are equipped to provide basic advice about healthy lifestyles and that patients who need extra support to make changes to improve their health and well- being can be referred onto lifestyle services that may help to reduce or slow down deterioration of existing conditions, or prevent other problems from developing. Our current plans focus on many of the key tenants of prevention, however in 2019/20 we will be reviewing and re-focusing our work, jointly with the local authorities to consider the key areas outlined in the Long Term Plan including:
• Smoking • Obesity • Alcohol • Air Pollution • Antimicrobial resistance Why is it an important The system recognises the key determinants of variations in health demography. As shown in Section 2 there is clear variation in priority? access to health and outcomes, including life expectancy across LLR. The system recognises to target the variation in health outcomes there needs to be clear focus on targeted prevention and self-care provision and services.
Key deliverables in • Develop an inpatient smoking cessation provision. 2019/20 • Specific Pathway changes on: Cardiovascular Disease, Alcohol, Diabetes. • Make Every Contact Count. • Lifestyle services.
• Self-care: develop new approaches to supporting self-care, including implementing a Healthy Living Pharmacy scheme across LLR. • Workplace health: prioritise workplace health across public sector providers.
For specific detail on how these deliverables will be achieved please see Pages 82- 84 of the Leicester, Leicestershire and Rutland (LLR) Operational Plan 2019-20
Outcomes and benefits Reduction in variation of Life Expectancy across LLR. Improvement in health outcomes.
Section 4: Key priorities – Medicines Optimisation
Overview Medicines Optimisation is an STP work-stream supported by existing Medicines Optimisation activities in each individual organisation The collaborative work will be led by the LLR Medicine’s Optimisation Programme Board. Over the last three years the NHS organisations in LLR have implemented a range of evidence-based prescribing measures. This has included medicine switches, reducing wastage and implementing local and national guidance. We recognise that there is still further work that can be done to improve medicine optimisation by working collaboratively across all NHS organisations both within the STP and beyond. To meet the needs of our population we are developing and implementing a LLR Pharmacy Workforce Strategy across the STP including a Pharmacy framework.
Why is it an important Nationally 6.5% of emergency admissions and re-admissions are caused by avoidable adverse reactions to medicines; there is over priority? £150m a year of avoidable medicines wastage and only 16% of patients take their medicines as prescribed.
Key deliverables in Sharing and standardisation (where possible) standards and policies across LLR. 2019/20 Rationalise and streamline supply of medicines across the primary/secondary care interface. Standardised Audit tool across LLR based on shared audit standards. Develop a system wide medication safety strategy.
Reduce waste in primary and secondary care in relation to repeat prescription processes. Develop effective medication reviews particularly aimed at decreasing admission, readmission and waste. Improve the timely discharge of patients by piloting new ways of working and improve the appropriateness of prescriptions. Continue the biosimilar switch programme enabled in 2018/19. Interface with Care Homes across LLR. Develop STP wide formularies, including electronic system of pre-approval of high cost drugs. For specific detail on how these deliverables will be achieved please see Pages 53- 55 of the LLR Operational Plan 2019-20
Outcomes and benefits • Strong quality and safety assurance with the respect to the use of medicines.
• A competent workforce to deliver Medicines Optimisation maximising benefits of a shared workforce and provision.
• The financial investment in medicines will represent value for money and deliver the best outcomes for patients. • Patients will be empowered to be equal partners in all decisions about their medicines. • Reduction in avoidable adverse reactions to medicines. • Improve the timely discharge of patients.
Section 4: Key priorities – Specialised Commissioning
Overview Specialised services support people with a range of rare and complex conditions. They often involve treatments provided to patients with rare cancers, genetic disorders or complex medical or surgical conditions. They deliver cutting-edge care and are a catalyst for innovation, supporting pioneering clinical practice in the NHS. The specialised services commissioned by NHS England have been grouped into six National Programmes of Care (NPoC). Each has an
NPoC Board which coordinates and prioritises work across the services in that programme of care. The six National Programmes of Care are: Internal medicine – digestion, renal, hepatobiliary and circulatory system. Cancer Mental health Trauma – traumatic injury, orthopedics, head and neck and rehabilitation. Women and children – women and children, congenital and inherited diseases. Blood and infection – infection, immunity and haematology.
Key deliverables in The Specialised Commissioning Strategic Priorities nationally are in development. The Midlands and East priorities have been 2019/20 developed with staff and stakeholders across the Midlands and East. These priorities form the basis of the operational plan and are underpinned by the national operational plan for specialised commissioning.
The Deliverables and Enablers that underpin the Strategic Priorities have been developed to support our teams to deliver the national and regional priorities.
Section 4: Key priorities – Specialised Commissioning
Key deliverables in General and Acute Services: 2019/20 Cancer:
• Working with the EMCA, implement the radiotherapy service specification and ODN. • Work together on the urology pathway for robotic assisted surgery for radical prostatectomies. • Implement the Children and Young People Cancer Service Specification and network arrangements. • Undertake a quality review of complex gynaecological cancer services and ensure quality standards are met. • Develop options for the head and neck cancer services across the East Midlands.
Women and Children:
• Review the provision of paediatric critical care and surgery; including addressing gaps in paediatric critical care transport services and setting up of a PIC and Surgery ODN. • Working with the LMS to implement recommendations of the National Maternity Review: Better Births to ensure mothers and babies have the best care; including ensuring capacity in neonatal services through reducing full term admissions; development of a neonatal outreach service (funding dependant); and improvements in system wide flows.
Trauma:
• Assess if there is a clinical need to change adult critical care pathways. • Embed the complex spinal surgery protocols and ODN, ensuring pathways are defined and there is a consistent quality of care across the East Midlands.
Internal Medicine/Blood and Infection:
• To set up asthma networks so that specialised asthma services are supporting non-specialised provider to ensure appropriate care. • Implement a lead haemoglobinopathy centre across the East Midlands and work towards ensuring sustainability of the services.
Section 4: Key priorities – Specialised Commissioning
Key deliverables in Mental Health Services: 2019/20 Child and Adolescent Mental Health (CAMHs):
• Ongoing regional assessment for CAMHs services being undertaken by public health consultant to determine future need across the East Midlands as part of national Mental Health Service Review. • Expansion within East Midlands of CAMHs, PICU and Eating Disorder services.
Transforming Care:
• The Programme continues to work alongside CCG and LA commissioners to develop pathways from hospital to community. • Bed reduction plan work continues with our providers across the East Midlands to align service provision with identified need. • Providing support to local Transforming Care Boards.
Adult Mental Health:
• Continue to work towards a New Care Model with all providers in the East Midlands for adult secure services. Planned shadow process from April 2019/20 with go live April 2020/21. • Adult Secure Mental Health Service Review to review national capacity and the procurement of secure mental health services.
Future Planning and Services Development
There will be a Strategic Planning Board established by Specialised Commissioning in line with the guidance in early 2019/20 which will include all STPs and Trusts across the East Midlands. This will be used to share priority areas and with a view to aligning pathways and work streams. The local specialised commissioners are members of the STP Cancer Board.
The Programme Board for the head and neck cancer project is led by Specialised Commissioning and includes representatives across all of the STPs from the East Midlands. https://www.england.nhs.uk/wp-content/uploads/2018/12/ANNEXE1.pdf
SECTION 5
ACTIVITY ASSUMPTIONS, CAPACITY & WINTER PLANNING
Section 5: Activity assumptions and capacity (Acute only)
Activity
Commissioners have developed a demand plan for 2019/20 recognising that the lead provider is unlikely to have sufficient capacity to meet demand. To mitigate this position the system has produced joint initiatives and an establish pathway review programme. As a system we have then reviewed all provider capacity and overlaid this onto the demand plan. The main challenge in order to deliver care to the assumed demand will be to ensure QIPP delivery and to manage how the released capacity is used in a managed way.
An activity triangulation meeting has been in place for the last year to ensure that provider and commissioners can identify and respond quickly to activity variances. It is intended that this group will continue and will report into the director level contract performance meeting. Included within the Activity Planning Assumptions (APA) is an agreed way of working together to manage to (or below) the indicative activity plan in a controlled way. All parties will have incentives aligned.
Capacity
Overall system demand and capacity has been modelled taking into account historic trends and seasonality to inform the plan. Numbers of days per month have also been factored in, as has the impact of the leap year. The system worked together early in 2018/19 to prepare a winter plan which has proved to be effective this winter. The same approach will be taken in preparation for the 2019/20 winter.
The system is well sighted on the demand requirements and available system capacity within the lead provider and Independent Sector (IS) and Out of County (OOC) providers. IS and OOC providers have supported the system to deliver the demand requirements in recent years.
The activity triangulation meeting will provide oversight on progress in terms of meeting the required demand and managing available capacity.
Section 5: Winter Planning Provider Plans
The System Priorities for Winter Planning have been outlined in the Urgent Care section and are managed via the A&E Delivery Board. All key providers are members of that Board including Local Authority, Primary Care, Acute, Community and Ambulance Trusts. Each provider has taken a System approach to Winter and Capacity Planning please see brief descriptions below:
Leicestershire Partnership NHS Trust Winter planning is conducted collaboratively with partner organisations via the A&E Delivery Board and is supported by the LPT Protocol for the use of 4x4 vehicles which ensures our community staff can reach out to all patients in periods of disruptive weather.
The LPT Winter Contingency Plan is assured and tested through stakeholder table top exercises, and developmental activity with the Local Resilience Forum (LRF). This plan is reviewed during the winter period to ensure accuracy and validity of triggers and responses and is aligned to operational pressures escalation levels (OPEL) guidance. Services have local business continuity plans which are mobilised in the event of disruption to service delivery. The Trust actively conducts a Flu Fighting campaign in line with the NHSI national campaign to provide extra resilience for all frontline staff.
University Hospitals of Leicester NHS Trust
The Trust leads a programme of work across the LLR STP area to design an enhanced system of care for frail and multi-morbid patients across the local health and care system, this will continue into 2019/20. The objective of this ‘Frailty task force’ will be to ensure that this cohort of patients have access to evidence-based integrated care both pre-, during and post-hospital episodes. Our plans are based on the Kings Fund ‘High Impact Interventions’ this programme will enable capacity throughout the system but particularly in Winter.
Secondly the Trust is attempting to protect some of the elective capacity by increasing overall bed capacity as part of winter resilience plans. We have assumed that we will open the same number of escalation beds as we did as part of the 2018/19 winter plan. This means we plan to open 28 escalation beds at the Glenfield and 2 x 28 bedded wards at the LRI during periods of sustained changes in demand; this will enable us to protect emergency and elective flow. We will use the final 19/20 plans to model the beds required for in 19/20 based on a range of different bed occupancy assumptions.
SECTION 6
SYSTEM FINANCIAL POSITION, RISK MANAGEMENT, CURRENT SYSTEM EFFICIENCIES & FUTURE SYSTEM ARRANGEMENTS
Financial position
. • In 2018/19 all organisations (excluding UHL) are on plan to achieve their control totals. • Control totals set for CCGs in 2019/20 are proving challenging due to 2018/19 exit underlying positions. • Realistic control totals have been set for providers which take account of 2018/19 performance. • All organisations are aiming to achieve control totals set for 2019/20 but CCGs currently have unidentified QIPP and therefore potential unmitigated net risks of £11.2m
Receipt of Net Unmitigated Risk to Gross Control Centralised Organisation Control Total achievement of control Total Funding (PSF, FRF total & MRET)
£m £m £m £m UHL -48.7 38.1 -10.7 LPT 0 2.1 2.1 LCCCG 0 0 0 ELRCCG 0 0 0 5.98 WLCCG 0 0 0 5.26 LLR STP Total -48.7 40.2 -8.5 11.24 Section 6: Current System Efficiencies
Our financial modelling for 2019/20 requires an unprecedented level of system-wide efficiencies to be delivered across LLR to support financial and capacity stability across the system. Many of the system-wide schemes are intended to involve service transformation such as new models of care, service configuration and re-designed pathways. The CCGs and providers have produced a number of schemes and plans to improve efficiency and value for money focusing on Integrated Care, planned care and joint working on areas such as Medicines Management.
The schemes have been developed in partnership across LLR as part of the Better Care Together Programme and system planning process and have undergone a ‘confirm and challenge’ process to ensure they are clinically safe and financially robust to move the system towards its goals and have been developed in conjunction with the local clinicians. They have considered available benchmarking data such as Rightcare, Model Hospital and GIRFT . • 2019/20 progress against savings targets is set out below. • Savings plans are classified between Red, Amber and Green or unidentified based on expected financial delivery at this point in time. • Against the total level of savings planned of £96m, there is currently a risk of non delivery of £27.5m across the system
RISK (100% TOTAL SAVING Organisation RED AMBER GREEN UNIDENTIFIED Unidentifed, 50% PLANNED Red, 25% Amber)
£000 £000 £000 £000 £000 £000
UHL 13,850 9,732 3,062 26,644 6,525 LPT 1,433 1,210 904 3,547 1,262 CITY CCG 2,809 4,109 10,112 0 17,030 2,432 EAST CCG 2,909 7,527 10,000 5,980 26,416 9,316 WEST CCG 3,060 4,773 9,259 5,264 22,356 7,987
LLR ICS TOTAL 8,778 31,692 40,313 15,210 95,993 27,522 Section 6: Current System Efficiencies Specific to Providers
Specific efficiency savings for 2019/20 for University Specific efficiency savings for 2019/20 for Leicestershire Hospitals of Leicester Partnership Trust
The trust has a comprehensive three year Efficiency Strategy The planned CIP target for 2019/20 is currently based on with the aim of achieving upper quartile productivity 2.7% target efficiency. However progress in identifying this (compared to peers) across all areas for the Trust. This level of efficiency has proved very difficult in the context of strategy is based around a wide range of sources including the rising operational pressures and with large scale following: transformation. NHSI Model Hospital. Recommendations for the Carter Programme. Therefore the trust is drafting a long term productivity, The Getting it Right First Time (GIRFT) Programme. efficiency and sustainability plan which will define the work NHSI Theatre Efficiency Programme (using Four Eyes the Trust needs to do to ensure long term transformational consultancy). change. As this strategy has not yet delivered the framework for long term plans, the Trust may need to deliver the The Trust’s 5 year strategy. minimum level of CIP requirement in 2019/20. Decision on the final level of CIP will be taken in March 2019.
Quality Impact Assessments and Governance The commissioners and providers have produced a clear governance and processes to ensure that all defined efficiencies across the system are in line with National Quality Board Guidance. Details are contained within each individual organisations Operational Plan and outlined in their Quality Strategies. The CCGs have engaged in a Joint Clinical and Quality review process for Business Cases and QiPP Initiatives prior to approval. Regular system quality reviews are held with providers through established Clinical Quality Review Group. The Executive Lead for the STP is the Interim Accountable Officer of West Leicestershire CCG. Section 6: Future System Arrangements & Plans for closing the gap
In relation to the delivery of the LLR System Control Total, the previous slide shows that as a system there is: . • A total of up to £27.5m of risk across all organisations in delivering cost savings and hence control totals. • Net risk of circa £11.2m within CCG plans.
In order to mitigate this risk and deliver the system control total the following describes our high level governance to close the gap, working as a system.
The actions in the plan and approach are based on the LLR system working together on a cost out approach. There are actions that commissioners and providers could take, such as coding and counting actions and provider fines, but at this stage the system has agreed that the solution to financial sustainability is to focus on costs out rather than adversarial approaches that just move the financial problem between organisations. The system will need to agree how it ensures no single system partner is unfairly disadvantaged by taking this approach.
Key Steps
• Commence delivery of current financial plans and efficiencies identified • Identify further efficiencies and use of contingency to close the gap April to June 2019 • Establish system wide Sustainability Group to ensure system delivery of current plans and identification and implementation of actions required to close the gap
Section 6: Proposed Governance Arrangements for System Sustainability Group & support groups i.e. ‘Existing Scheme Group’ & ‘New Scheme Group’
Section 6: Proposed purpose and responsibilities of the System Sustainability Group
Purpose: To work together to ensure that Leicester, Leicestershire and Rutland health system can deliver the system control total set by NHSE and NHSI
Responsibilities Function 1 - Implementing existing Schemes Function 2 - Developing New Schemes Function 3 - System monitoring Function 4 – Escalation
The Group will be jointly owned and supported with:
• A dedicated executive lead (released from current responsibilities) identified to support the delivery of the system wide control totals and efficiency plans. • A virtual system wide Programme Management Office will be established utilising current commissioner and provider resources. • System wide reporting process and templates will be put in place to ensure a consistent approach across all programmes and projects. • Each programme or project will have a Senior Responsible Officer and Implementation Officer and be supported by the relevant finance, contracting, BI and planning expertise. • Purpose being to maximise delivery of existing QIPP & CIP programmes focussed on a “cost out” approach.
Section 6: Risk Management
The key risks to the system achieving the financial targets are:
Underlying financial positions of organisations in comparison to control targets set.
Managing demand growth.
Making sufficient savings/efficiencies in order to deliver control totals.
Financial delivery conflicts with other key priorities.
Delivering in year whilst also ensuring actions are aligned to the Longer Term Strategy.
Commissioners entering a year of organisational change as they move towards a single management team and explore potential merger.
Significant changes to financial architecture and Primary Care Commissioning.
Achievement of Mental Health investment standard and other metrics.
Successful implementation of the QiPP Programme
SECTION 7
ENABLERS
Section 7: Enablers – IM&T and Digital
Our ambition is to use an integrated patient record to improve patient care and safety and deliver significant savings to the LLR SOverview health and care system in terms of money and time. However, there are a number of challenges to overcome in order to achieve this aim. Within the local health care system organisations have their own IT systems, which in many cases are unable to share
and make use of each other’s information. This is a significant barrier to creating a transferable care record. It would be far safer and more efficient if clinical systems in use by different health and social care organisations were integrated or just the same.
There is currently no national solution to achieve this. Locally we recognise that using existing systems and national initiatives that become available is better than ad hoc or separate systems. The NHS Long Term Plan (January 2019) compliments this locally derived ambitions.
In addition, there is a challenge in supporting staff to take up new IT solutions. Previous technological improvements have not been adopted by all of the workforce and full benefit has not been realised. Similarly, communication and engagement is needed with patients to make them aware of the health and social care benefits that are becoming available with better use of technology.
Why is it an important Improve communication within Health and Care, e.g. communication between hospitals and GP practices can be refined to priority? highlight actions points to improve the quality of care. By removing the use of paper and moving the majority onto secure electronic communications and deliver paper free at point of care, with a key focus to make the use of fax obsolete as a method of communication.
Not only will this integration and improvement be safer and more efficient in terms of time and money spent by the NHS, it will also make a huge difference to the patient experience, since people will not have to constantly repeat the same information whenever they are transferred from one part of the system to the other. In addition, the LLR vision includes empowering patients to use technology, like apps, to support self-care but with the
promise of direct access to services should the patient require it, as opposed to booked follow up appointments and clinics. Use of real-time and historic data will help predictive modelling and improvements in clinical service delivery at the point of care. While population health analysis will support the planning and purchase of health services for local people. Section 7: Enablers – IM&T
Key deliverables in The LLR IM&T continues to work towards extending TPP SystmOne as the main system supporting pathways in the 2019/20 community and Trusts so that all providers have access to records. Support the University Hospitals of Leicester in its progress to paperless system management. Continue to support PRISM as a pathway navigation tool, ensure there is robust governance of SystmOne and EMIS templates, and that there is electronic transmission of that information along the pathway. Develop through a partnership approach a resource of shared expertise within LLR to blend a mixture of procurement, integration, business change and product development to deliver a set of Digital Self Care products (Apps) supporting patients and clinicians, initial target areas being scoped are Falls, Prevention and Out-Patient Follow Up reduction. Support the implementation of an LLR business intelligence strategy, including data sources, storage and analytic tools and develop a collaborative approach to the utilisation of this shared resource. Support the implementation of a Research and Development Primary Care data extraction and analysis service to combine with secondary and social care data. Commencement of work to move LPT to a single electronic patient record. Responding to the NHS Long Term Plan in relation to digital offer including assistive technology in the home, new tools for professionals and consumer to use to interact with the NHS and each other and developing business intelligence capabilities.
For specific detail on how these deliverables will be achieved please see Page 87- 89 of the Leicester, Leicestershire and Rutland (LLR) Operational Plan 2019-20
Outcomes and Improved patient experience by increased access to the whole patient record. benefits Improved patient experience through reduced repetition of their health care needs. Improved patient experience via reduced unnecessary travel. Section 7: Enablers - Workforce
There is approximately 20,000 whole time equivalent healthcare staff We have acknowledged that we cannot continue to grow the currently working across the three main NHS provider organisations in workforce in line with population increases and the greater use of LLR. As with Adult Social care, many of the challenges faced by NHS digital technologies will support this. providers of healthcare reflect the national situation. Private providers contracted to deliver services in LLR are also feeling the effect of With the recent publication of the NHS Long Term Plan, service workforce challenges. There are recruitment issues and high vacancies commissioners and providers will be reviewing models of care to across a number of staff ground which are reflective of the national ensure that we make every attempt to future proof healthcare for picture. future populations.
LLR as part of its whole system approach is developing a System-wide
Workforce Strategy. The approach has considered all provider workforce issues and also considered national guidance as outlined in Digital Technology & AI (National and LLR) The Facing the Facts, Shaping the Future (2017) workforce consultation document which highlighted six workforce priority areas aligned to the Next Steps Five Year Forward View priority areas with Primary Maternity the inclusion of Maternity and a spotlight on Learning Disability. Care
Individual provider workforce initiatives including the GP Workforce Plan can be reviewed in the individual organisations Operational Plan. Mental Cancer Health Care
There are a number of key work-streams across LLR that bring together key improvements in patient care plus improving workforce pressures. For instance, a Community Services Redesign programme Workforce has been launched which will significantly change how we deliver care Urgent & Learning Priority with a focus on Home First and community care rather than acute Emergency Disability care areas for & Autism based care. This will require a redesign of the workforce to support the LLR changing models of care as they emerge. There is also a Pre
Consultation Business Case submission which proposes the majority of acute services to be based on two sites which will improve delivery of care and improvements in working conditions for staff. We acknowledge the need to embrace the advancements in digital technologies, AI and genomics. Digitalisation has the ability to take pressure off the workforce in all aspects of care delivery from booking UHL Site Reconfiguration & Community Services Redesign (LLR Specific) appointments on-line to telemedicine.
Section 7: Enablers - Workforce
University Hospitals of Leicester and Leicestershire Partnership General Practice Trust The local picture mirrors the national evidence of significantly lower UHL is one of the country’s largest acute teaching Trusts and growth in GPs compared to hospital consultants in the last decade. provides health and care services across three sites for the This creates a shortage of GPs compounded by substantial difficulties population of LLR, specialised clinical services for the population of with recruitment, both of qualified GPs and GP trainees, with local the East Midlands and some highly complex services nationally. training places unfilled. There are fewer GPs working full-time in There is a compelling clinical case for movement of the majority of patient- facing General Practice, some working full-time but taking on services onto a two site model allowing greater separation of other responsibilities, including roles in Clinical Commissioning Groups emergency and elective pathways in order to improve flow and (CCGs), management tasks in their own practice or in a wider reduce the number of cancellations. The three site models impacts federation. There is also a growing demand for GPs to take on significantly on the workforce, stretching resources and increasing substantive posts or provide sessional work within community urgent pressure on staff. care provision and out of hours.
Leicestershire Partnership Trust is undertaking the biggest transformation in response to the mental health drivers and the All Age Transformation programme, the Transforming Care Partnership’s Learning Disability and Autism strategic workforce plan and the Community Services redesign programme.
Section 7: Enablers - Workforce
East Midlands Ambulance Service The workforce is moving from complete sessional and agency working EMAS provides emergency and urgent services for 4.8 million people to substantive posts, although vacancy rates in the clinical workforce across six counties of the East Midlands. remain high (62%). There is a significant reliance on sessional working and agency workers with a strategy to reduce agency spend and convert agency workers to substantive posts. There are no substantive EMAS Key Workforce Facts: posts; all posts are sessional or agency. GPs that work in the service Challenge to meet NHSE workforce trajectory are working within general practice which will be putting additional Recruiting newly qualified paramedics from Australia pressure on the general practice workforce which is already Recruitment from EU states less successful due to amount of up- understaffed. Since its establishment in July 2018, DHU has recruited skilling required 157 new members of staff. The Home Visiting service is predominantly Band 6 paramedic posts are being developed to deliver See & Treat, a nursing workforce and tends to be 50:50 agency and substantive. the Frailty pathway and mentorship and this is being done through both external and internal CPD education programmes Reviewing our aspiration to have 50:50 split of registered and non- Contracted Non-NHS Provider Key Workforce: registered staff with a paramedic on every crew – 150 in total • High reliance on sessional and agency workers Supply of NQ paramedics not meeting demand (De Montfort University starting Paramedicine BSc (Hons) commencing • Problems with recruitment to substantive posts September 2019 to attract local trainees) Competition for paramedics to work in other parts of the • Reliance on general practice and ANPs (already stretched healthcare system such as general practice and urgent care centres workforce and under-supply) further impacts on EMAS workforce • DHU has particular issues with attracting high calibre ANPs and is EMAS currently filling paramedic vacancies with Technician roles looking to develop its own pathway to recruit and train staff and are considering employment of ANPs • High vacancy rates at DHU Sickness levels at 5.22% against target of 5.2% • Need to reduce agency spend Exploring retention strategies guaranteed rest day are now in place • Concerns regarding the number of hours that sessional clinicians and agency workers are working elsewhere Heavily reliant on private ambulances due to workforce challenges this will continue through Quarter 1 and 2 of 2019/19 • DHU able to flex staff across the geography and between services
Contracted Non-NHS Health and Care Providers The workforce consists of health advisors, advanced nurse practitioners with GP cover, despatchers, receptionists, admin support officers. Section 7: Enablers - Workforce
10 LLR System Mitigations 10 Specific Provider Mitigations
1. A Nursing Associate Programme has been developed in partnership with 1. Use of Recruitment & Retention Premium. the local education provider to support a career pathway from HCA to Registered nurse.
2. Return to practice programmes for nurses, doctors and therapists who 2. Systematic processes for the creation and development of New Roles. want to return to work.
3. Increase in Apprenticeship opportunities including clinical apprentices 3. Identifying and supporting staff who are effected by EU Exit. and making best use of the levy across LLR.
4. Career progression opportunities such as the Nurse Associate role. 4. International Recruitment Programmes.
5. Introduction of more flexible working for staff, particularly medical 5. Shared posts from Acute into Community. trainees.
6. Development of new and extended roles such as advanced practitioners 6. Reviewing ‘hotspots’ in regards retention and improving exit interviews. and Physician Associates.
7. Better sickness reporting procedures plus support for staff with 7. Rotational Trust Grade Programmes. common ailments e.g. back problems , anxiety, stress and depression.
8. Development of a talent pipeline . 8. Certificate of Eligibility for Specialist Registration (CESR) Programme for Doctors.
9. Design and development of a LLR wide Pharmacy Workforce. 9. Increased internal Medicine training numbers.
10. National strategy to recruit more trainee doctors. 10. Implementation of Health & Well-being Annual Plans .
Section 7: Enablers - Workforce
Supporting Transformation of the LLR Workforce: Given the workforce challenges and context locally and nationally, this section outlines how we will organise ourselves locally to deliver the required changes described in more detail in the LLR Workforce Plan. All LLR workforce plans will be developed using The Six Steps Methodology to Integrated Workforce Planning template to provide consistency. Workforce planning and development across LLR is governed through a structure that is responsible for setting the strategic direction of the LLR workforce.
Governance Arrangements: Health Education England (Midlands & East) is supporting the workforce elements of the Sustainability and Transformation Partnership (STP) through the Local Workforce Action Board (LWAB). Established in 2016, the LWAB will ensure that decisions about the NHS and social care workforce take place in the right place at the right time with the right people to deliver high quality outcomes for our people. LWAB has two areas of responsibility: Supporting STPs across a broad range workforce and HR activity. Local delivery of the HEE Mandate from the Department of Health and other key workforce priorities in line with national policies. Section 7: Enablers – Communications and engagement
Engagement has been integral to the Better Care Together Programme (BCT) – the Sustainability and Transformation Partnership for Leicester, Leicestershire and Rutland since it was established. A wide variety of stakeholders have been involved ranging from statutory bodies, elected officials, local authorities, the voluntary and community sector, right through to patient and public groups.
In 2018/19 intensive communication discussing the acute and maternity reconfiguration, the community services redesign and other CCG level projects took place. BCT partners collectively undertook this engagement.
In addition, individually BCT partners have engaged and involved patients, carers, staff and other stakeholder in the various aspects of BCT work stream activities. This work has included engagement on the Carers Strategy, the Dementia Strategy, All Age Transformation for Mental Health and Learning Disabilities. We have also undertaken a formal consultation on Planned Care Policies across LLR.
The insights and business intelligence yielded from this engagement work has been fed into each work stream in order to impact the design of services, and where required the pre-consultation businesses cases to determine the shape of future services.
Engagement in 2019/20
In 2019/20 year there are a number of schemes within Better Care Together that require engagement and involvement with patients, service users, carers and staff to understand their experiences of the care they receive and what matters most to them. In addition, a number of schemes previously engaged on are now at a stage where formal consultation is required.
Topics for engagement and involvement which will be led by either clinical commissioning groups or providers partners are potentially:
Changes and improvements within primary care. Community services review. Various planned care services including dermatology and ophthalmology. All age mental health transformation. Learning Disability. Improving Access to Psychological Therapies (IAPT). Various schemes within the Integration agenda including Long Term Conditions.
Section 7: Enablers – Communications and engagement
Each area will be reviewed and the appropriate level of engagement and consultation acted upon.
In addition, we continue to work through the processes of approval on the reconfiguration of acute and maternity services provided at University Hospitals of Leicester NHS Trust. We also wait to hear whether our bid for capital funds has been successful. The scheme is working through the processes of NHS England, NHS Improvement, the Department of Health and Treasury. While this process is being followed it is essential that ongoing engagement on these programmes of work continues in order to keep people informed and involved.
The Hinckley Community Services Review will be formally consulted on during 2019/20. The timing of the consultation will be dependent on the approvals process of NHS England.
At a local level we are also responsible for communicating this year the vision and direction of travel of the national Long Term Plan and articulating what the plan means for LLR and how it aligns with our local plans. This work will take place concurrently with the ongoing engagement and consultation of BCT programmes. It will inform the local refresh of our BCT plan, to be produced later in the year.
In order to complement the engagement work undertaken by BCT partners collectively and through work streams we will launch in 2019/20 a BCT Citizens’ Panel. The Panel will provide the Partnership with an additional systematic approach to gathering insight and feedback on a range of health and care issues from a representative sample of our circa 1.1 million population. It will also assist in aligning the Patient and Public Involvement Group with the views of citizens that demographically and attitudinally are representative of the citizens of LLR.
We will work with partners to recruit by the end of the financial year 1,100 people to a virtually panel ensuring that representation is statistically and demographically aligned with our entire population as well as in tune with their attitudes.
Section 7: Enablers – Clinical leadership
An LLR wide clinical leadership group has been established since 2014. This has multi-professional representation from primary care, secondary care, local authorities, universities and patient groups.
A programme of work has been developed including quarterly ‘MATH’ (Making Things Happen) events which are system wide and focused on implementation, development of and participation in several leadership development programmes , through the OD leads in the system and attendance at national STP leads events .
Over 100 clinicians are involved in the BCT programme through nine clinical workstreams. Current plans include:
Developing the Clinical Leadership Group to meet the needs of the Integrated Care System via a development workshop working with the national STP team. Provisional plans to introduce four principal clinical leadership roles in the BCT (GP, consultant, therapist, nursing). Rationalisation of GP clinical leadership roles including a LLR GP reference group.
All the CCGs are involved in a NHS Commissioning Capability Programme (CPP). Section 7: Enablers – Estates
The NHS estate across Leicester, Leicestershire and Rutland totals 464,034m² over 252 sites (mixture of owned and leased) with an annual running costs of circa £146m. Conditions across the sites varies from modern purpose built facilities to converted residential properties. Our acute estate is suboptimal in clinical, performance and financial terms. In order to improve the estate across LLR, tackle the challenges of the current configuration and condition and respond to the future healthcare requirements we have set out a vision and ambition for our estate.
Vision Ambitions
Services should be delivered from an estate which meets clinical need; is Developing the estate, subject to significant public investment, so there are accessible; offers value for money; is of acceptable quality; and meets appropriate facilities in which to deliver 21st century healthcare as efficiently safety and legislative compliance, supporting integrated teams working as possible. Ourout key of prioritiescommunity in hubs 2019/20:. Continuing to develop our proposals for the reconfiguration of the Wherever possible, buildings will be designed to be flexible to adapt to Sustainability and Transformation Partnership’s acute hospitals including a changing needs over time. move of services to predominately 2 Acute Trust sites from 3. Complete the reconfiguration of ITU and associated specialities from Leicester General Hospital by Quarter 4 2019/20. Use of physical assets will be maximised. Ensuring better utilisation across the estate to facilitate improved care in TheComplete estate is of the mixed CAMHS tenure and should Eating be Disorder adapt to changesnew unit in by service Quarter need 4. 2019/20.the community including Community Hospitals. TheGain use approvalof technology for the will Pre be Consultation maximised to Business support Caseefficient for theand Hinckleyagile andReviewing Bosworth the facilitiesCommunity we will Health need Services in the community changes as and more con caresult moveson workingthese duringpractices 2019/20. and Followingreduce thisdependence submit final on Business fixed Caseoffice for approval.out of those acute hospitals closer to people’s homes. accommodation. Improving Primary Care facilities enabling GPs to provide a wider range of BuildingContinue utilisation the work rates to should gain approvalbe a minimum to our of 85Pre%-.Consultation Businessservices for the. reconfiguration of acute hospital services . PublicDevelop sector a assets primary will carebe promoted estate strategy. to maximise utilisation. Providing improved inpatient and outpatient services including diagnostics. PropertyContinue will to be support invested practices in to provide who have modern, received fit- forfunding-purpose, to improve 21st their premises. centuryWork facilities with our reducing partner onbacklog our One maintenance Public Estate and programme. running costs .
Our key priorities for 2019/20:
Complete the construction of new ITU and associated services by Quarter 1 2020/21. Complete the CAMHS and Eating Disorder new unit by Quarter 4 2019/20. Gain approval for the Hinckley and Bosworth community services Pre Consultation Business Case and consult on the proposed changes. Gain approval for the Pre Consultation Business care for the reconfiguration of acute hospital services. Develop primary care estate strategy. Continue to support practices who have received funding to improve their premises. Work with our partners on the One Public Estate Programme. Appendices
The Leicester, Leicestershire and Rutland Draft 2019/20 Integrated Care System Operational Plan consolidates the transformation and operational plans from across the system. The System Operational Plan should be read in the context of the LLR Operational Plan, University of Leicester NHS Trust and Leicestershire Partnership NHS Trust Operational Plans
H Blank Page Paper H ELR CCG Governing Body meeting 9 April 2019 NHS EAST LEICESTERSHIRE AND RUTLAND CCG GOVERNING BODY MEETING
Front Sheet Title of the report: Summary Report from the Audit Committee (20 March 2019) Report to: Governing Body meeting
Date of the meeting: 9 April 2019
Report by: Daljit K. Bains, Head of Corporate Governance and Legal Affairs Presented by: Warwick Kendrick, Chair of the Audit Committee
PURPOSE OF THE REPORT: This report provides a summary of the key areas of discussion and outcomes from the Audit Committee meeting held in March 2019, including the review of the Committee terms of reference and the Board Assurance Framework 2018/19.
This report provides assurance to the Governing Body in respect of the effectiveness of risk management systems and processes across the CCG; and also items for escalation for consideration by the Governing Body ensuring that the Governing Body is alerted to emerging risks or issues.
RECOMMENDATIONS: The East Leicestershire and Rutland CCG Governing Body is requested to:
• RECEIVE the summary report.
• APPROVE the terms of reference as at Appendix 1.
REPORT SUPPORTS THE FOLLOWING STRATEGIC AIM(S) 2019 – 2020: Transform services and enhance quality of Improve integration of local services life for people with long-term conditions between health and social care; and between acute and primary/community care. Improve the quality of care – clinical Listening to our patients and public – effectiveness, safety and patient experience acting on what patients and the public tell us. Reduce inequalities in access to healthcare Living within our means using public money effectively Implementing key enablers to support the strategic aims (e.g. constitutional and governance arrangements, communications and patient engagement).
EQUALITY ANALYSIS An Equality Analysis and due regard to the positive general duties of the Equality Act 2010 has not been undertaken in respect of this report. The Audit Committee, through its review of effectiveness in risk management systems and processes, also seeks assurances in respect of compliance with statutory requirements, including compliance with the Equality Act. The equality 1
Paper H ELR CCG Governing Body meeting 9 April 2019 analysis can be found within each document, for example, within the policy documents referred to within the Board Assurance Framework.
RISK ANALYSIS AND LINK TO BOARD ASSURANCE FRAMEWORK: The Audit Committee has the remit to seek assurance in respect of the implementation and maintenance of an effective risk management system and process underpinning all strategic aims through seeking assurance in respect of the regular review of the corporate risks captured within the Board Assurance Framework.
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Paper H ELR CCG Governing Body meeting 9 April 2019 NHS EAST LEICESTERSHIRE AND RUTLAND CCG GOVERNING BODY MEETING 9 April 2019
Summary report from the Audit Committee
Summary and outcome of meeting
1. The CCG Audit Committee met on 20 March 2019 and the minutes from the January 2019 meeting were approved and are available should members of the Governing Body wish to review them.
Keys areas of discussion from March 2019 meeting:
2. Terms of reference for the Committee – the Committee carried out the regular annual review of its terms of reference and minor amendments were proposed noting the departure of the CCG Secondary Care Clinician. The Governing Body is asked to note that should the position of the Secondary Care Clinician be filled, the Committee would request a further review of the terms of reference to include this post within its membership in the future. The draft terms of reference are as at Appendix 1 with proposed amendments highlighted. The Governing Body is asked to approve the terms of reference.
3. The Committee also noted that work is in progress across the 3 LLR CCGs to ascertain if there is an opportunity to work collaboratively across the three Audit Committees. This would mean meeting in common for aspects of the Audit Committee’s programme that would overlap and lend itself to meeting together with the other two CCGs’ Audit Committees. It was noted that in line with legislative requirements the Audit Committee, as a statutory committee, cannot be formed as a joint committee; each CCG must establish its own Audit Committee.
4. Counter Fraud, Bribery and Corruption Progress Report – activity and work against the agreed plan was noted as progressing well.
5. Internal Audit Progress Report and Audit Plan for 2019/20: the Internal Auditors provided an overview of the progress made to complete various audit reviews noting that progress across a few audits had been slower than anticipated, however were now being progressed to complete in time for year- end processes. The Internal Audit Plan for 2019/20 was approved focusing on risk areas that are mandated to be reviewed, with the addition of an audit review on QIPP. The Committee noted that the Plan aligned with Leicester City CCG and West Leicestershire CCG.
6. External Audit Plan – year ending 31 March 2019 – the External Auditors informed that the audit reviews are progressing well.
7. Follow-up of audit recommendations (management’s report): the report was received and read in conjunction with the Internal Auditors’ update. The Committee members noted that implementation of recommendations following an internal audit review continues to progress well.
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Paper H ELR CCG Governing Body meeting 9 April 2019
8. Update on the review of the Board Assurance Framework and Risk Registers – the regular review of the Board Assurance Framework was undertaken, noting that the Executive Management Team recommended amendments to the content and risk scoring. The Governing Body will be receiving this as a separate item on the agenda for approval at the April 2019 meeting, below is a summary of the amendments noted and supported by the Committee:
i) BAF 2(a): QUALITY – NON-ACUTE - The quality of care provided by non- acute providers does not match commissioner’s expectation with respect to quality and safety - the residual risk score has increased from 12 (impact 4 x likelihood 3) to 16 (impact 4 x likelihood 4) due to a gap in controls regarding waiting times for Children and Adolescent Mental Health Services (CAMHS); and the publication of a Care Quality Commission (CQC) report following an inspection review in October – November 2018. This provided an overall rating of “Requires Improvement” for the Leicestershire Partnership NHS Trust (LPT). Audit Committee members agreed with the change in the risk score and asked that the change in risk score be drawn to the Governing Body’s attention.
ii) BAF 5(a): QIPP - CCG QIPP programme, comprising CCG, Better Care Fund (BCF) and Better Care Together (BCT) / Sustainability Transformation Partnership (STP) initiatives fail to deliver against the CCG QIPP Plan resulting in failure to deliver in-year efficiencies and transform delivery for sustainable efficiency - The residual risk score decreased from 16 (impact 4 x likelihood 4) to 9 (impact 3 x likelihood 3) due to robust plans in place to mitigate this risk from an ELR CCG perspective.
iii) BAF 10: Finance - Non achievement of 2018-19 year end control total surplus which is dependent on achievement of c£19.645m (4.6%) QIPP schemes - This residual risk score has been reduced from 20 (impact 5 x likelihood 4) to 15 (impact 5 x 3 likelihood) due to new controls being in place.
iv) BAF 8: URGENT CARE - Increased pressure on the Emergency Department which could result in sub-optimal care due to ability to access urgent care services – The residual risk score for this risk was reduced in November 2018 from 12 to 9. The Executive Management Team at the request of the Audit Committee re-considered this and have reinstated the residual risk score which is now 12.
9. Primary Care Commissioning Committee (PCCC) register of interests and how the conflicts were managed (as at December 2018) – the register of declarations and interests for the Primary Care Commissioning Committee is a report to be received and reviewed by the Audit Committee, providing assurance that conflicts of interest are being raised and managed within this forum.
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Paper H ELR CCG Governing Body meeting 9 April 2019 i) Waiver of Standing Orders: the Committee received the updated report on waivers of standing orders and noted the contents. ii) Losses and Special Payments: the Committee received the updated report.
Recommendation:
The East Leicestershire and Rutland CCG Governing Body is requested to:
• RECEIVE the summary report.
• APPROVE the terms of reference as at Appendix 1.
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Paper H ELR CCG Governing Body meeting 9 April 2019 APPENDIX 1 NHS EAST LEICESTERSHIRE AND RUTLAND CCG
Audit Committee
Terms of Reference (version 2, draft 3, March 2019)
1. Introduction
The Audit Committee (the Committee) is established in accordance with the East Leicestershire and Rutland Clinical Commissioning Group’s Constitution. These terms of reference set out the membership, remit and responsibilities, and reporting arrangements of the Committee and shall effect as if incorporated into the Constitution.
2. Membership and voting
The Committee shall be appointed by the Clinical Commissioning Group (CCG) as set out in the Clinical Commissioning Group’s Constitution. The membership shall be appointed from amongst the Independent Lay Members (ILM) of the CCG and the secondary care clinician; and shall consist of 2 3 members. A quorum shall be 2 members. The Chair of the Committee will be the lay member with responsibility for audit and conflicts of interest; with the second lay member as the vice chair of the Committee. The Chair of the CCG shall not be a member of the Committee.
A member from one of the local Health and Wellbeing Boards will be invited to attend as a co-opted member as considered appropriate by the Chair of the Committee to support the Committee in its review and scrutiny in relation to primary care commissioning. The member of the local Health and Wellbeing Board shall be considered as a full member of the Committee for the part of the meeting s/he is attending.
A decision put to a vote at a meeting shall be determined by a majority of the votes of members present. In the case of an equal vote, the Chair of the Committee shall have a second and casting vote.
3. Attendance
The Chief Finance Officer, the Chief Nurse and Quality Officer, the Head of Corporate Governance and Legal Affairs, the Head of Internal Audit or their deputy, the Counter Fraud Specialist and representatives from External Audit shall normally attend meetings. At least once a year the Committee should meet privately with the External and Internal Auditors without any executive / CCG Officers present.
The Accountable Officer and other officers and GP Governing Body Members should be invited to attend, but particularly when the Committee is discussing areas of risk or operation that are the responsibility of that officer.
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Paper H ELR CCG Governing Body meeting 9 April 2019 The Accountable Officer should be invited to attend and should discuss at least annually with the Audit Committee the process for assurance that supports the Annual Governance Statement. He or she should also attend when the Committee considers the draft internal audit plan and the annual accounts.
The Head of Corporate Governance and Legal Affairs shall provide appropriate support to the Committee Chair and committee members and be responsible for the provision of secretarial support to the Committee to take minutes of the meeting.
Regardless of attendance, external audit, internal audit, counter fraud, and security management providers will have full and unrestricted rights of access to the Audit Committee.
4. Frequency of Meetings
Meetings shall be held not less than five times a year. The External Auditor, Head of Internal Audit, or Counter Fraud Specialist may request a meeting if they consider that one is necessary.
5. Authority
a) The Committee is authorised by the CCG Governing Body to investigate any activity within its terms of reference. It is authorised to seek any information it requires from any employee and all employees are directed to cooperate with any request made by the Committee.
b) The Committee is authorised by the CCG Governing Body to obtain external legal or other independent professional advice and to secure the attendance of advisers with relevant experience and expertise if it considers this necessary.
c) The Committee has delegated responsibility from the CCG Governing Body for approval of the annual financial statements; annual report and the annual governance statement.
6. Duties
The duties of the Committee can be categorised as follows:
a) Governance, Internal Control and Risk Management
The Committee shall review the establishment and maintenance of an effective system of integrated governance, internal control and risk management across the CCG for both clinical and non-clinical activities, including partnerships, that support the achievement of the organisation’s objectives.
The Committee will review the adequacy and effectiveness of:
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Paper H ELR CCG Governing Body meeting 9 April 2019 • all risk and control related disclosure statements (in particular the Annual Governance Statement), together with any accompanying Head of Internal Audit statement, external audit opinion or other appropriate independent assurances, prior to endorsement by the CCG Governing Body;
• conflicts of interest policy and processes. The Committee will review and scrutinise the effectiveness of the policy and processes ensuring due process was followed across all decision-making committees and sub-groups, in particular relating to primary care commissioning;
• the structures, assurance processes and responsibilities for identifying and managing key risks facing the organisation, indicating the degree of achievement of corporate objectives, as laid down in the CCG’s Annual Governance Statement and the Board Assurance Framework;
• the policies for ensuring that there is compliance with relevant regulatory, legal and code of conduct requirements and related reporting and self-certification;
• the operational effectiveness of policies and procedures;
• all work related to fraud, bribery and corruption, to ensure compliance with NHS Counter Fraud Authority’s ‘Standards for Commissioners: Fraud, Bribery & Corruption’.
In carrying out this work the Committee will primarily utilise the work of Internal Audit, External Audit, the Counter Fraud Specialist, NHS Counter Fraud Authority and other assurance functions, but will not be limited to these sources. It will also seek reports and assurances from directors and managers as appropriate, concentrating on the overarching systems of integrated governance, risk management and internal control, together with indicators of their effectiveness.
This will be evidenced through the Committee’s use of an effective Board Assurance Framework to guide its work and that of the audit and assurance functions that report to it. b) Internal Audit
The Committee shall ensure that there is an effective internal audit function appointed by management that meets mandatory Internal Audit Public Standards NHS Internal Audit Standards and provides appropriate independent assurance to the Audit Committee, Accountable Officer and Governing Body. This will be achieved by:
• consideration of the provision of the internal audit service, the cost of the audit and any questions of resignation and dismissal;
• review and approval of the internal audit strategy, operational plan and more detailed programme of work, ensuring that this is consistent with
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Paper H ELR CCG Governing Body meeting 9 April 2019 the audit needs of the organisation as identified in the Board Assurance Framework and through other mechanisms;
• considering the major findings of internal audit work (and management’s response), and ensuring coordination between the internal and external auditors to optimise audit resources
• ensuring that Internal Audit is adequately resourced and has appropriate standing within the organisation;
• an annual review of the effectiveness of internal audit.
c) External Audit
The Committee shall review the work and findings of the External Auditors and consider the implications and management’s responses to their work. This will be achieved by:
• consideration of the appointment of the External Auditor as far as the rules governing the appointment permit;
• consideration of the performance of the External Auditor,
• discussion and agreement with the External Auditors, before the audit commences, of the nature and scope of the audit as set out in the Annual plan, and ensuring coordination, as appropriate, with other External Auditors in the local health economy;
• a policy or guidance in place in relation to the External Auditor undertaking non-audit work;
• discussion with the External Auditors of their local evaluation of audit risks and assessment of the CCG and associated impact on the audit fee;
• review of all External Audit reports, including the report to those charged with governance, agreement of the annual audit letter before submission to the Governing Body and any work undertaken outside the annual audit plan, together with the appropriateness of the management responses.
The Committee shall review the interface between the internal and external auditors ensuring synergy in audit reviews avoiding duplication. d) Financial Reporting
The Committee shall monitor the integrity of the financial statements of the CCG and any formal announcements relating to the CCG’s financial performance.
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Paper H ELR CCG Governing Body meeting 9 April 2019 The Committee should ensure that the systems for financial reporting to the Governing Body, including those of budgetary control, are subject to review as to completeness and accuracy of the information provided to the Governing Body.
The Committee shall review and approve the CCG’s Annual Report and approve the Financial Statements, focusing particularly on:
• the wording in the Annual Governance Statement and other disclosures relevant to the Terms of Reference of the Committee; • changes in, and compliance with, accounting policies and practices; • major judgemental areas; and significant adjustments resulting from the audit; • Unadjusted mis-statements in the financial statements; • Letter of representation. e) Other Assurance Functions
The Audit Committee shall review the findings of other significant assurance functions, both internal and external to the organisation, and consider the implications to the governance of the organisation.
These will include, but will not be limited to, any reviews by Department of Health Arm’s Length Bodies or Regulators/Inspectors (e.g. Care Quality Commission, NHS Resolution etc.), professional bodies with responsibility for the performance of staff or functions (e.g. Royal Colleges, accreditation bodies, etc.)
In addition, the Committee will review the work of other committees within the organisation, whose work can provide relevant assurance to the Audit Committee’s own scope of work. This will include committees and groups that have a remit for clinical governance, risk management and commissioning.
In reviewing the work of these committees, and issues in relation to clinical governance and clinical risk management, the Audit Committee will wish to satisfy itself on the assurance that can be gained from the clinical audit function. f) Counter Fraud, Bribery and Corruption
The Committee shall satisfy itself that the organisation has adequate arrangements in place for countering fraud, bribery and corruption and shall review the outcomes of counter fraud, bribery and corruption work. The Committee shall seek assurance regarding the organisation’s compliance with NHS Counter Fraud Authority’s ‘Standards for Commissioners: Fraud, Bribery & Corruption’, by means including: reports from the Counter Fraud Specialist, the CCG’s annual Self-Assessment Review Toolkit (SRT) submissions to NHS Counter Fraud Authority, and from NHS Counter Fraud Authority inspection reports.
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Paper H ELR CCG Governing Body meeting 9 April 2019
g) Management
The Committee shall request and review reports and positive assurances from directors and managers on the overall arrangements for governance, risk management and internal control.
They may also request specific reports from individual functions within the organisation (e.g. clinical audit) as they may be appropriate to the overall arrangements.
7. Reporting
The minutes of Audit Committee meetings shall be formally recorded by the Head of Corporate Governance and Legal Affairs and submitted to the Governing Body. The Chair of the Committee shall draw to the attention of the Governing Body any issues that require disclosure to the full Governing Body, or require executive action.
The Committee will report to the Governing Body annually on its work in support of the Annual Governance Statement, specifically commenting on the fitness for purpose of the Board Assurance Framework, the completeness and embeddedness of risk management in the organisation, the integration of governance arrangements.
8. Other Matters
The Committee shall be supported administratively by the Head of Corporate Governance and Legal Affairs whose duties in this respect will include:
• agreement of agenda with Chairman and attendees and collation of papers;
• being responsible for the provision of secretarial support to take the minutes and keeping a record of matters arising and issues to be carried forward;
• advising the Committee on pertinent issues / areas;
• enabling the development and training of Committee members.
Approved: xxxx by the Governing Body
Review due: March 2020
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I Blank Page Paper I ELR CCG Governing Body meeting 9 April 2019 NHS EAST LEICESTERSHIRE AND RUTLAND CCG GOVERNING BODY MEETING Front Sheet
Title of the report: Board Assurance Framework 2018/19
Report to: Governing Body meeting
Date of the meeting: 9 April 2019
Report by: Daljit K. Bains, Head of Corporate Governance and Legal Affairs Sponsoring Director: Karen English, Managing Director
Presented by: Karen English, Managing Director
PURPOSE OF THE REPORT: The purpose of the report is to provide the Audit Committee with assurance in respect of the systems and processes in place across the organisation to identify, evaluate, manage and monitor strategic risks through the Board Assurance Framework.
RECOMMENDATIONS: The East Leicestershire and Rutland CCG Governing Body is requested to:
APPROVE the Board Assurance Framework as at Appendix 1 for 2018/19 year-end and as the starting point for 2019/20.
REPORT SUPPORTS THE FOLLOWING STRATEGIC AIM(S) 2018 – 2019: Transform services and enhance quality of Improve integration of local services life for people with long-term conditions between health and social care; and between acute and primary/community care. Improve the quality of care – clinical Listening to our patients and public – effectiveness, safety and patient acting on what patients and the public tell experience us. Reduce inequalities in access to Living within our means using public healthcare money effectively Implementing key enablers to support the strategic aims (e.g. constitutional and governance arrangements, communications and patient engagement).
EQUALITY ANALYSIS An Equality Analysis and due regard to the positive general duties of the Equality Act 2010 has not been undertaken in respect of this report.
RISK ANALYSIS AND LINK TO BOARD ASSURANCE FRAMEWORK: The Board Assurance Framework provides an overview of all strategic risks identified in relation to delivering the CCG’s strategic aims and statutory duties.
1 Paper I ELR CCG Governing Body meeting 9 April 2019 NHS EAST LEICESTERSHIRE AND RUTLAND CCG GOVERNING BODY MEETING 9 April 2019
Board Assurance Framework 2018 - 19
Introduction
1. This report provides the Governing Body with an update on the corporate risks contained within the East Leicestershire and Rutland CCG’s Board Assurance Framework (i.e. corporate risk register). The report aims to demonstrate that the Board Assurance Framework is a ‘live’ document underpinned by a process of regular review and effective management of principal risks in order to support the achievement of the strategic aims of the CCG. The Board Assurance Framework (BAF) has been regularly reviewed by the Executive Management Team and also the Audit Committee.
2. The Board Assurance Framework provides a structure for the evidence that supports the Annual Governance Statement that the Accountable Officer is required to sign as part of the statutory accounts and annual report. This places an emphasis on the need for the Governing Body to be able to demonstrate that it has been properly informed about the totality of the risks, both clinical and non- clinical.
Board Assurance Framework (BAF)
3. During 2018 – 2019 the Board Assurance Framework has been reviewed and updated on a regular basis. This included reviewing the risk profile of the CCG, and level of risks to escalate following feedback from the Audit Committee, Governing Body members and the Executive Management Team. The Executive Management Team is responsible for ensuring corporate risks facing the CCG are current; have been captured and evaluated appropriately; and actions undertaken in a timely manner.
4. The Executive Management Team and members of the Governing Body in the main identified the risks considering the political, economical, social, technological environment (PEST analysis) in which the CCG operates. In the regular review of the Board Assurance Framework, risks identified from “bottom-up” are also considered, for example, review of directorate level risk registers, cluster of incidents, cluster of complaints, through performance management arrangements.
5. The identification, evaluation and review of the risks within the Board Assurance Framework have been in line with the CCG Risk Management Strategy and Policy. At its regular review of the BAF, EMT is asked to consider if the actions for the risks are still the correct actions and / or whether the risk appetite score remains the correct level of risk appetite for the CCG. The EMT agreed with the risk appetite scores and reviewed the residual risk scores.
6. The content of the Board Assurance Framework will continually be reviewed to ensure the changing risk profile of the CCG is captured, including the changing financial challenges, potential risks across the system for the organisation in line
2 Paper I ELR CCG Governing Body meeting 9 April 2019 with the Operational Plan; and the Sustainability and Transformational Partnership Plan.
7. Appendix 1 is the updated Board Assurance Framework for 2018/19 (Version 2, draft 13 – as at 21 March 2019). EMT reviewed and considered the BAF and the directorate level risk registers at their meeting on 18 March 2019, and subsequently it was reviewed by the Audit Committee on 20 March 2019 ahead of the Governing Body meeting.
8. The Audit Committee noted and supported the following changes to the risk scores within the BAF in March 2019:
a) BAF 2(a): QUALITY – NON-ACUTE - The quality of care provided by non- acute providers does not match commissioner’s expectation with respect to quality and safety. The residual risk score has increased from 12 (impact 4 x likelihood 3) to 16 (impact 4 x likelihood 4) due to a gap in controls regarding waiting times for Children and Adolescent Mental Health Services (CAMHS); and the publication of a Care Quality Commission (CQC) report following an inspection review in October – November 2018, which provided an overall rating of “Requires Improvement” for the Leicestershire Partnership NHS Trust (LPT). A Quality Risk Review meeting is to be held with NHS England and NHS Improvement in April 2019; and an Oversight Group to be established to monitor improvement and progress against the CQC actions identified.
b) BAF 5(a): QIPP - CCG QIPP programme, comprising CCG, Better Care Fund (BCF) and Better Care Together (BCT) / Sustainability Transformation Partnership (STP) initiatives fail to deliver against the CCG QIPP Plan resulting in failure to deliver in-year efficiencies and transform delivery for sustainable efficiency. The residual risk score has decreased from 16 (impact 4 x likelihood 4) to 9 (impact 3 x likelihood 3) due to robust plans in place to mitigate this risk from an ELR CCG perspective.
c) BAF 10: Finance - Non achievement of 2018-19 year end control total surplus which is dependent on achievement of c£19.645m (4.6%) QIPP schemes This residual risk score has been reduced from 20 (impact 5 x likelihood 4) to 15 (impact 5 x 3 likelihood). The rationale for the reduction in the residual risk score is due to having secured and transacted the vast majority of mitigations that will enable the CCG to achieve the control total position for this year including the confirmed receipt of anticipated transitional support funding in months 11 and 12. . d) BAF 8: URGENT CARE - Increased pressure on the Emergency Department which could result in sub-optimal care due to ability to access urgent care services – the residual risk score for this risk was reduced in November 2018 from 12 to 9. In January 2019, the Audit Committee asked the EMT again to re-consider and re-instate the original residual risk score as the rationale presented for the reduction related to a recent procurement exercise which had not mobilised at the time of the review. Hence, the controls were not in place and therefore until the controls are in place the residual risk score is to
3 Paper I ELR CCG Governing Body meeting 9 April 2019 remain at 12. EMT agreed with the Audit Committee’s comments and the residual risk score of 12 has been reinstated, which is supported by the Audit Committee. This will be reviewed when the risk is next due for review at the end of April 2019.
9. The Governing Body is asked to note that work is in progress to review and align the format of the BAF and the content of the Risk Management Strategies and Policies across the three CCGs in Leicester, Leicestershire and Rutland to support the collaborative work underway. For now, the BAF format and content will remain as is currently; and the version, as approved by the Governing Body in April 2019, will provide the starting point for the ELR CCG BAF 2019 – 20.
Recommendations The East Leicestershire and Rutland CCG Governing Body is requested to:
APPROVE the Board Assurance Framework as at Appendix 1 for 2018/19 year-end and as the starting point for 2019/20.
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Appendix 1 NHS East Leicestershire and Rutland CCG Board Assurance Framework 2018 – 2019
(Version 2, draft 13 – as at 21 March 2019)
To be read in conjunction with the Risk Management Strategy and Policy
Version Control Version and Date Version number and description of changes / review Version 1, draft 13 . Report to the Audit Committee with updates following the Governing Body meeting noting that the year end BAF is starting point of 2018/19 BAF. Version 2, draft 1 . Circulated for EMT members to review and update. Version 2, draft 2 . Amendments made and version to be presented to the Audit Committee in May 2018. Version 2, draft 3 . Circulated for EMT members and Heads of Department to review and update. Version 2, draft 4 . Amendments made and version to be presented to the Audit Committee on 1 August 2018 and EMT on 2 August 2018 for review and consideration. Version 2, draft 5 . As at 14 September 2018, circulated for EMT members and Heads of Department to review and update. Version 2, draft 6 . Version presented to EMT on 24 September 2018 to review. Version 2, draft 7 . Further updated version to be presented to the Audit Committee in October 2018 (Audit Committee meeting was cancelled so presented in November 2018). Version 2, draft 8 . Amendments made by EMT incorporated into report for the Governing Body meeting in December 2018. Version 2, draft 9 . Amendments made by EMT incorporated into this version for discussion at EMT on 7 January 2019. Version 2, draft 10 . Updated following discussion at EMT on 7 January 2019. For discussion at Audit Committee on 16 January 2019. Version 2, draft 11 . Version circulated to EMT members to update ahead of EMT and Audit Committee meetings in March 2019. Version 2, draft 12 . Updated following receipt of comments from Chief Officers in early March 2019. Presented to the Audit Committee in March 2019. Version 2, draft 13 . BAF Risk 8 Urgent Care – residual risk score reinstated as 12 following Audit Committee meeting. Presented to Governing Body.
CONTENTS
Page
Strategic Aims 2018 – 2019 3
Definitions and risk matrix 4
Summary of the Board Assurance Framework 6
Detailed version of the Board Assurance Framework 8
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Strategic Aims 2018 – 2019
1. Transform services and enhance quality of life for people with long-term conditions 2. Improve the quality of care – clinical effectiveness, safety and patient experience 3. Reduce inequalities in access to healthcare 4. Improve integration of local services between health and social care; and between acute and primary/community care. 5. Listening to our patients and public – acting on what patients and the public tell us. 6. Living within our means using public money effectively
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Definitions (as within the Risk Management Strategy and Policy, March 2018)
Areas Definitions Risk Description Articulate the risk: . what could happen? . how could it happen? . What would the effect be? Risk Category . Clinical – e.g. clinical care issues, medicines management. . Organisational – e.g. corporate governance, human resources, health and safety, reputation, competition. . Financial – e.g. poor financial control, ineffective insurance arrangements, fraud. . Information – e.g. theft / loss of personal information, damage to computer systems. Risk Appetite / This is the level of exposure to the risk the organisation is willing to accept. The risk appetite provides a baseline to Tolerance Level monitor each risk against i.e. the net risk / residual risk will be reviewed against the risk appetite to monitor the effectiveness of controls and whether actions are being addressed to ensure that the risk remains below the tolerance level. Use 5 x 5 risk matrix: . the impact = describes the impact or outcome component of risk i.e. the outcome or the potential outcome of an event. There may be more than one impact / consequence of a single event.
. the likelihood = describes the probability or frequency of a consequence occurring i.e. how probable it is that the risk (the event or outcome) will occur. Gross / Inherent This is the risk evaluation before controls are applied. The higher the score the more attention the risk will require and Risk more likely the Board would seek assurance as to how it was being managed whether directly or via sub-committee.
Use 5 x 5 risk matrix. Key controls “Internal control” is the response which is initiated within the organisation to manage a risk and may involve one or more of the following treatment options to manage the risk: terminate / avoid risk, treat / reduce risk, transfer risk, or tolerate / accept the risk. Net / residual risk This is the risk evaluation once the controls have been applied to reduce / manage the risk identified. This evaluation of a risk compared with the tolerance level is useful as a guide for prioritising risks and determines the appropriate level of managerial supervision and action.
Use 5 x 5 risk matrix. Source of Need to identify sources of assurance which inform the organisation that the controls are effective. assurance Gaps in controls Controls: Where are the gaps in our control / systems? Where are we failing to make them effective? and / or assurance Assurance: Where is the CCG failing to gain evidence that the controls / systems are effective?
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5 x 5 Risk Assessment Matrix (Risk Management Strategy and Policy)
5 LIKELIHOOD IMPACT 5 10 15 20 25 4 1 RARE 1 MINOR 4 8 12 16 20
2 UNLIKELY 2 MODERATE / LOW 3 3 6 9 12 15
IMPACT 2 3 MODERATE / 3 SERIOUS 2 4 6 8 10 POSSIBLE 1 4 LIKELY 4 MAJOR 1 2 3 4 5 5 ALMOST CERTAIN 5 FATAL / 1 2 3 4 5 CATASTROPHIC LIKELIHOOD
This will result in risks being rated in one of the following four categories:
Risk score Category 1 - 3 Low risk (green) 4 - 6 Moderate risk (yellow) 8 - 12 High risk (amber) 15 - 25 Extreme risk (red)
Key: KE = Karen English, Managing Director TS = Tim Sacks, Chief Operating Officer TB = Tracy Burton, Acting Chief Nurse and Quality Officer DE = Donna Enoux, Chief Finance Officer PG = Paul Gibara, Chief Commissioning and Performance Officer
Summary of the Board Assurance Framework content (as at 21March 2019) (Summary to be completed by the Corporate Affairs Team)
Initial / Risk Appetite Current / Current / Comments (e.g. new risk Exec Inherent / tolerance residual residual risk escalated, de-escalate, close Risk Ref and Description: Lead risk score score risk score score trend etc) impact x likelihood = risk score since last month BAF 1: QUALITY – ACUTE: The quality of care provided by acute providers does not TB 16 6 16 match commissioner’s expectation with respect to quality and safety. BAF 2(a): Gaps identified in waiting QUALITY – NON-ACUTE: The quality of care provided by non-acute times for CAMHS; CQC providers does not match commissioner’s expectation with respect to quality TB 16 6 16 report published against and safety. Inspection in Q3 2018/19 (‘Requires Improvement).’ BAF 2(b): QUALITY – NON-ACUTE: The quality of care and service delivery provided TB by emergency patient transport services does not match commissioner’s 16 6 12 expectation with respect to quality and safety BAF 2(c): QUALITY – NON ACUTE: The quality of care and service delivery provided by non-emergency patient transport services does not match commissioner’s TB 20 6 20 expectation with respect to quality and safety - mobilisation of TASL not providing service in line with expectations. BAF 3: QUALITY – PRIMARY CARE: The quality of care provided by primary care TB providers does not match commissioner’s expectation with respect to quality 16 6 9 and safety. BAF 5(a): QIPP – CCG QIPP programme, comprising CCG, Better Care Fund (BCF) mitigation plans in place to and Better Care Together (BCT) / Sustainability Transformation Partnership PG 16 4 9 (STP) initiatives fail to deliver against the CCG QIPP Plan resulting in failure reduce risk. to deliver in-year efficiencies and transform delivery for sustainable efficiency. BAF 5(b): QIPP – Robust systems and processes are not in place to support the CCG PG 16 4 9 QIPP Programme comprising of CCG, (BCF) and BCT / STP initiatives BAF 6(a): OUT OF HOSPITAL – PRIMARY CARE: Risk in relation to Out of Hospital Services – Primary Care: Primary Care Commissioning – ability to perform TS 15 6 9 delegated duties whilst maintaining member relations and Clinical
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Initial / Risk Appetite Current / Current / Comments (e.g. new risk Exec Inherent / tolerance residual residual risk escalated, de-escalate, close Risk Ref and Description: Lead risk score score risk score score trend etc) impact x likelihood = risk score since last month Engagement. BAF 6(b): OUT OF HOSPITAL – PRIMARY CARE: Risk in relation to Out of Hospital
Services – Primary Care: Primary Care transformation – the workforce and TS 15 6 12 capability of general practice and CCG to develop transformation. BAF 6(c): OUT OF HOSPITAL – PRIMARY CARE: Risk in relation to Out of Hospital Services – Primary Care: Finance – budget inherited from NHS England TS 20 6 9 covers current costs / service and therefore new development and transformation will require additional funding (e.g. premises). BAF 7: OUT OF HOSPITAL – COMMUNITY SERVICES: Failure to agree service model for future Out of Hospital Services further to consultation and TS 20 4 16 engagement BAF 8: Residual risk score URGENT CARE: Increased pressure on the Emergency Department which TS 16 6 12 reinstated as at 20 March could result in sub-optimal care due to ability to access urgent care services. 2019. BAF 9: ORGANISATIONAL CAPACITY: Organisation is at risk of not being able to KE 16 6 12 meet its statutory functions due to capacity within teams. BAF 10: Reduction in the residual risk FINANCE: Non achievement of 2018/19 year end control total surplus which score due to having secured and is dependent on achievement of c£19.645m (4.6%) QIPP schemes transacted the vast majority of mitigations that will enable the DE 20 6 15 CCG to achieve the control total position for this year including the confirmed receipt of anticipated transitional support funding in months 11 and 12. BAF 11: EPRR: Lack of systematic and continuous processes in place for Emergency TS 20 6 9 Preparedness, Resilience and Response (EPRR) BAF 12: PG Risk archived as forms part of contract management of new provider. On COMMISSIONING SUPPORT: Commissioning Support Provider fails to directorate risk register (December 2017). deliver contracted standards, KPIs and outcomes. BAF 13: PG Risk archived now that new provider in place (September 2017). CONTINUING HEALTH CARE (CHC): Lack of engagement from current Provider during procurement of CHC. 7
Initial / Risk Appetite Current / Current / Comments (e.g. new risk Exec Inherent / tolerance residual residual risk escalated, de-escalate, close Risk Ref and Description: Lead risk score score risk score score trend etc) impact x likelihood = risk score since last month BAF 14: EU EXIT: inability to implement the Department of Health and Social KE Care’s EU Exit Operational Readiness Guidance (published 21 20 9 20 December 2018)
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BAF 1: QUALITY – ACUTE: The quality of care provided by acute providers does not match commissioner’s expectation with respect to quality and safety.
Section A Section B Section C A1. Corporate Objective / A3. Risk to be treated, Risk rating (impact x likelihood = risk score (see Strategic Aim the risk is confirm frequency of pages 3 and 4 above) aligned to: review by lead? Strategic Aim 2 Monthly Quarterly B1. Executive Lead (risk Tracy Burton C1. Initial / inherent risk 4 x 4 = 16 R ☐ ☒ owner): score: A2. Date Risk identified: A4. Risk Category: B2. Officer Lead (action Amanda Bland C2. Risk appetite / 3 x 2 = 6 Y owner): tolerance score: 2016/17 initially Clinical ☒ B3. Date last reviewed: January 2019 (next C3. Current / residual review April 2019) risk score: 4 x 4 = 16 R Organisational ☐ Finance ☐ B4. Committee / group with Integrated C4. Date current / residual January 2019 oversight for risk? Governance risk score assessed: Information ☐ Committee
Section D: Key Controls Section E: current risk score trend What key controls / systems does the CCG have in place to manage the risk? • Clinical quality schedules and contracting performance monitoring arrangements in (Corporate Affairs Team to update graph showing trend current risk score place. against risk appetite score) • Integrated Governance Committee oversight. 20 • Collaborative Commissioning Board (Joint Committee) in place and Provider Performance Assurance Group (PPAG) (meetings in common) for contracting and 15 performance monitoring of collaborative contracts which includes details of UHL and all out of county acute contracts and Independent Sector contracts. 10 Risk Appetite • Contract lead organisation oversight and contracting arrangements, including clinical lead oversight. 5 Current / • Membership of and ability to escalate to Quality Surveillance Group (QSG). Residual Risk • Triangulation of data to inform unannounced quality visits in place. This includes 0 incidents, serious incidents and feedback from GPs via GP concerns / transferring care reporting. Jul-18 Apr-18 Oct-18 Jun-18 Jan-19 Mar-19 Feb-19 Nov-18 Dec-18 Aug-18 Sep-18 • RTT/Cancer Board oversee improvement plans. Breach / harm reporting in place for May-18 Cancer 100+ day waits. Brief rationale for any change in current risk score:
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Section F: Internal and / or External Assurances Where can we gain evidence that our controls / systems on which we are placing our reliance are effective? Internal External • Summary report from Integrated Governance Committee to Governing Body. ☒ ☐ • PPAG deep dives into specific provider performance risk areas and PPAG assurance report to Governing Body ☒ ☐ • Quality Surveillance Group (NHS England) minutes and public reporting to Governing Body. ☐ ☒
Section G:
G1: Gaps in Controls and / or Assurance G2: Detail the actions to be taken G3: Action G4: Will the action reduce Where are the gaps in our control / systems? Where are (including brief note on updates / progress where appropriate to be impact of risk score or we failing to make them effective? and confirm when action completed) completed likelihood or both? What actions are required to bridge the gaps in controls and / Where is the CCG failing to gain evidence that the by (date) Impact Likelihood Both controls / systems are effective? or assurance? Despite controls in place risks remain with regard to • Despite ongoing actions in place performance remains of Ongoing achievement NHS Constitutional targets for: concern and therefore no change on impact or likelihood. • RTT ☐ ☐ ☒ • Cancer • A&E
CQC Improvement notice issued to UHL following inspection • Ambulance handover delays improved Ongoing visit in December 2015. Highlighted quality concerns • New Emergency Department floor has improved patient regarding: experience in terms of environment. • Ambulance handovers • ☐ ☐ ☒ • overcrowding in ED Management of sepsis pathway is improving monitored via • management of sepsis CQRG. • CQC inspection in February 2018 – requires improvement.
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BAF 2(a): QUALITY – NON-ACUTE: The quality of care provided by non-acute providers does not match commissioner’s expectation with respect to quality and safety.
Section A Section B Section C A1. Corporate Objective / A3. Risk to be treated, Risk rating (impact x likelihood = risk score (see Strategic Aim the risk is confirm frequency of pages 3 and 4 above) aligned to: review by lead? Strategic Aim 2 Monthly Quarterly B1. Executive Lead (risk Tracy Burton C1. Initial / inherent risk 4 x 4 = 16 R ☒ ☐ owner): score: A2. Date Risk identified: A4. Risk Category: B2. Officer Lead (action Amanda Bland C2. Risk appetite / 3 x 2 = 6 Y owner): tolerance score: ☒ B3. Date last reviewed: 2016/17 Clinical March 2019 C3. Current / residual 3 12 risk score: 4 x = R Organisational ☐ 4 16 Finance ☐ B4. Committee / group with Integrated C4. Date current / residual March 2019 oversight for risk? Governance risk score assessed: Information ☐ Committee
Section D: Key Controls Section E: current risk score trend What key controls / systems does the CCG have in place to manage the risk? • Clinical quality schedules and contracting performance monitoring arrangements in (Corporate Affairs Team to update graph showing trend current risk score place. against risk appetite score) • Collaborative Commissioning Board (Joint Committee) in place and Provider 20 Performance Assurance Group (PPAG) (meetings in common) for contracting and performance monitoring of collaborative contracts with ELR clinical oversight. 15 • Integrated Governance Committee oversight. • Triangulation of data to inform unannounced quality visits in place. 10 Risk Appetite • Membership of and ability to escalate to Quality Surveillance Group (QSG). • Additional finances to be invested to support improvement in response times in EMAS. 5 Current / Residual Risk 0
Jul-18 Apr-18 Oct-18 Jun-18 Jan-19 Mar-19 Feb-19 Nov-18 Dec-18 Aug-18 Sep-18 May-18
Brief rationale for any change in current risk score:
11
Section F: Internal and / or External Assurances Where can we gain evidence that our controls / systems on which we are placing our reliance are effective? Internal External • Summary report from Integrated Governance Committee to be presented to the Governing Body. ☒ ☐ • PPAG deep dives into specific provider performance risk areas and PPAG assurance report to Governing Body. ☒ ☐ • QSG minutes and public reporting to Governing Body. ☐ ☒
Section G:
G1: Gaps in Controls and / or Assurance G2: Detail the actions to be taken G3: Action G4: Will the action Where are the gaps in our control / systems? (including brief note on updates / progress where appropriate to be reduce impact of risk Where are we failing to make them effective? and confirm when action completed) completed score or likelihood or What actions are required to bridge the gaps in controls and / Where is the CCG failing to gain evidence that the by (date) both? or assurance? controls / systems are effective? Impact Likelihood Both Despite key controls in place, concern remains with respect to • Continued oversight via CQRG: ongoing service provided by Leicestershire Partnership Trust: o Specific oversight of staffing across physical and - the quality of care provided by community services to mental health services ELR CCG residents, due to gaps in staffing and clinical Triangulation of data to review hot spots and seek leadership within community nursing teams o - staffing levels in place within inpatient adult mental assurance with regard to LPT Board oversight of risk. health services - staffing levels in place within adult community mental • Length of stay on AMH slowly reducing. ☐ ☐ ☒ health services - Number of patients placed in out of county MH beds. • AMH DTOC and CHS DTOC under review to improve - Service provision for children and young people with pace. mental health illness.
• Enhanced surveillance agreed by LNR Quality Surveillance Group
• Staffing issues in CAMHS community service. • Focused recovery action plan in place to improve CAMHS ongoing • Waiting times for CAMHS community service access including review of all long - Wait time for Initial Assessment waits. - Wait time for further assessment / treatment ☐ ☐ ☒ • CAMHS Quality, Performance and Service Improvement Meeting.
• CQC report published against Inspection carried out • Enhanced surveillance status as agreed by LNR Quality ongoing Q3 2018/19 (October/ November 2018); Overall Surveillance Group to continue ☐ ☐ ☒ rating for Trust – ‘Requires Improvement.’
12
• Quality Risk review meeting by NHSE/ NHSI to be held • Domains assessed: April 2019 - Safe; requires improvement - Effective; requires improvement • Oversight group to be established to monitor and oversee - Caring; Good improvement and progress against actions required by - Responsive; Requires improvement CQC and improvement plan. - Well-led; Inadequate
• 5 services inspected; - Acute wards for adults of working age and psychiatric intensive care units; Inadequate () - Community based mental health services for older people; Good () - Specialist Community mental health services for children and young people; Requires improvement (=) - Long stay/ rehabilitation mental health wards for working age adults; Inadequate () - Wards for people with a learning disability or autism; Requires improvement (=)
13
BAF 2(b): QUALITY – NON-ACUTE: The quality of care and service delivery provided by emergency patient transport services does not match commissioner’s expectation with respect to quality and safety.
Section A Section B Section C A1. Corporate Objective / A3. Risk to be treated, Risk rating (impact x likelihood = risk score (see Strategic Aim the risk is confirm frequency of pages 3 and 4 above) aligned to: review by lead? Strategic Aim 2 Monthly Quarterly B1. Executive Lead (risk Tracy Burton C1. Initial / inherent risk 4 x 4 = 16 R ☒ ☐ owner): score: A2. Date Risk identified: A4. Risk Category: B2. Officer Lead (action Amanda Bland C2. Risk appetite / 3 x 2 = 6 Y owner): tolerance score: Escalated from WL CCG Clinical ☒ B3. Date last reviewed: March 2019 C3. Current / residual September 2016 (risk risk score: 5 x 4 = 20 R Organisational ☐ description amended December 2017) Finance ☐ B4. Committee / group with Integrated C4. Date current / residual March 2019 oversight for risk? Governance risk score assessed: Information ☐ Committee
Section D: Key Controls Section E: current risk score trend What key controls / systems does the CCG have in place to manage the risk? • Routine reporting of serious incidents / incidents review and sign off at regional level by (Corporate Affairs Team to update graph showing trend current risk score EMAS and Hardwick CCG and LLR level. against risk appetite score) • Range of actions in AEDB High Impact Action plan aimed at reducing handover delays, 25 ECIP support, charting protocol in escalation protocols. • Escalation to QSG to understand wider impact. 20
15 Risk Appetite 10
5 Current / Residual Risk 0 Jul-18 Apr-18 Oct-18 Jun-18 Jan-19 Mar-19 Feb-19 Nov-18 Dec-18 Aug-18 Sep-18 May-18
14
Brief rationale for any change in current risk score:
Section F: Internal and / or External Assurances Where can we gain evidence that our controls / systems on which we are placing our reliance are effective? Internal External • PPAG deep dives into specific provider performance risk areas and PPAG assurance report to Governing Body. ☒ ☐ • The CQC Inspection - CQC acknowledge that the Trust has made significant improvements as required by the July 2016 ☐ ☒ warning notice, however there continue to be concern around response times. • AEDB meeting (fortnightly). ☐ ☒ • Quarterly QAG meetings and monthly EMAS CCM meetings. ☐ ☒
Section G:
G1: Gaps in Controls and / or Assurance G2: Detail the actions to be taken G3: Action G4: Will the action Where are the gaps in our control / systems? Where are (including brief note on updates / progress where appropriate to be reduce impact of risk we failing to make them effective? and confirm when action completed) completed score or likelihood or What actions are required to bridge the gaps in controls and / Where is the CCG failing to gain evidence that the by (date) both? or assurance? controls / systems are effective? Impact Likelihood Both • Quality Improvement Plan at both Regional and • Monitor delivery of the improvement plan – noting the ongoing County levels through the agreed meeting structure revised national targets impact on ability to review local and assurance groups. delivery. • Review ECIP recommendations, consider rapid handover protocol. ☐ ☐ ☒ • Continue to implement HIA Plan. • Monitor delivery of Quality Improvement Plan at both Regional and County levels through the agreed meeting structure and assurance groups. • Performance against national standards has Actions as above. ongoing deteriorated. Additional monies have been agreed to help improve response times against the Ambulance Response Programme ☐ ☐ ☒ standards. Monitoring of ARP standards continues via PPAG and Integrated Governance Committee and then reported to the Governing Body.
15
BAF 2c: QUALITY – NON ACUTE : The quality of care and service delivery provided by non- emergency patient transport services does not match commissioner’s expectation with respect to quality and safety - mobilisation of TASL not providing service in line with expectations.
Section A Section B Section C A1. Corporate Objective / A3. Risk to be treated, Risk rating (impact x likelihood = risk score (see Strategic Aim the risk is confirm frequency of pages 3 and 4 above) aligned to: review by lead? Strategic Aim 2 Monthly Quarterly B1. Executive Lead (risk Tracy Burton C1. Initial / inherent risk 5 x 4 = 20 R ☒ ☐ owner): score: A2. Date Risk identified: A4. Risk Category: B2. Officer Lead (action Amanda Bland C2. Risk appetite / 3 x 2 = 6 Y owner): tolerance score: Escalated from WL CCG Clinical ☒ B3. Date last reviewed: March 2019 C3. Current / residual December 2017 risk score: 5 x 4 = 20 R Organisational ☐
Financial aspect escalated Finance ☒ B4. Committee / group with Integrated C4. Date current / residual March 2019 in July 2018. oversight for risk? Governance risk score assessed: Information ☐ Committee
Section D: Key Controls Section E: current risk score trend What key controls / systems does the CCG have in place to manage the risk? • Regular risk meetings in place with NHS England via lead CCG (WL CCG). Review (Corporate Affairs Team to update graph showing trend current risk score underway to determine if provider is appropriately funded against demand. against risk appetite score) • Regular review meetings in place with the provider. 25 • TASL CEO attended Commissioning Collaborative Board meeting in May 2018 to respond to commissioner concerns regarding performance. 20 15 Risk Appetite 10 5 Current / Residual Risk 0 Jul-18 Jan-19 Jun-18 Oct-18 Apr-18 Sep-18 Feb-19 Dec-18 Aug-18 Nov-18 Mar-19 May-18
16
Brief rationale for any change in current risk score:
Section F: Internal and / or External Assurances Where can we gain evidence that our controls / systems on which we are placing our reliance are effective? Internal External • PPAG deep dives into specific provider performance risk areas and PPAG assurance oversight and reports to Governing Body ☒ ☐ • Routine single item update to Governing Body ☒ ☐ • ☐ ☐
Section G:
G1: Gaps in Controls and / or Assurance G2: Detail the actions to be taken G3: Action G4: Will the action Where are the gaps in our control / systems? Where are (including brief note on updates / progress where appropriate to be reduce impact of risk we failing to make them effective? and confirm when action completed) completed score or likelihood or What actions are required to bridge the gaps in controls and / Where is the CCG failing to gain evidence that the by (date) both? or assurance? controls / systems are effective? Impact Likelihood Both • Financial Stability of provider. • Regular risk review meetings taking place with NHS England. • Review of funding against demand taking place to ongoing ☐ ☐ ☒ determine if appropriately funded for the service. • Contingency plans drawn up by the lead CCG i.e. WL CCG.
17
BAF 3: QUALITY – PRIMARY CARE: The quality of care provided by primary care providers does not match commissioner’s expectation with respect to quality and safety.
Section A Section B Section C A1. Corporate Objective / A3. Risk to be treated, Risk rating (impact x likelihood = risk score (see Strategic Aim the risk is confirm frequency of pages 3 and 4 above) aligned to: review by lead? Strategic Aim 2 Monthly Quarterly B1. Executive Lead (risk Tracy Burton C1. Initial / inherent risk 4 x 4 = 16 R ☒ ☐ owner): score: A2. Date Risk identified: A4. Risk Category: B2. Officer Lead (action Amanda Bland C2. Risk appetite / 3 x 2 = 6 Y owner): tolerance score: Clinical ☒ B3. Date last reviewed: March 2019 C3. Current / residual risk score: 3 x 3 = 9 A Organisational ☐ Finance ☐ B4. Committee / group with Integrated C4. Date current / residual March 2019 oversight for risk? Governance risk score assessed: Information ☐ Committee / PCCC
Section D: Key Controls Section E: current risk score trend What key controls / systems does the CCG have in place to manage the risk? • Oversight of Primary Medical Care commissioning undertaken through the Primary (Corporate Affairs Team to update graph showing trend current risk score Care Commissioning Committee (PCCC) and quality through Integrated Governance against risk appetite score) Committee. 10 • Primary Care quality dashboard place. • Risk sharing arrangements in place with NHS England. 8 • General Practice support framework in place. 6 • GP QIPP schemes in place and delivery reviewed regularly. Risk Appetite • Reporting to QSG of high risk practices. 4 2 Current / Residual Risk 0
Jul-18 Apr-18 Oct-18 Jun-18 Jan-19 Mar-19 Feb-19 Nov-18 Dec-18 Aug-18 Sep-18 May-18
Brief rationale for any change in current risk score:
18
Section F: Internal and / or External Assurances Where can we gain evidence that our controls / systems on which we are placing our reliance are effective? Internal External • Summary reports from the Primary Care Commissioning Committee to the Governing Body. ☒ ☐
• Quarterly self-certification completed and returned to NHS England relating to delegated functions in particular primary care ☐ ☒ commissioning and risks / issues and conflicts of interest. Quarterly self-certification for delegated primary care functions no longer required as covered within CCG assurance review process. • Locality meetings and reporting to the Governing Body. ☒ ☐
• CQC Practice Inspection outcomes, work ongoing with CQC ☐ ☒
• Internal Audit review in 2018/19 on primary care delegated functions. ☐ ☒
Section G:
G1: Gaps in Controls and / or Assurance G2: Detail the actions to be taken G3: Action G4: Will the action reduce Where are the gaps in our control / systems? Where are (including brief note on updates / progress where appropriate to be impact of risk score or we failing to make them effective? and confirm when action completed) completed likelihood or both? What actions are required to bridge the gaps in controls and / Where is the CCG failing to gain evidence that the by (date) Impact Likelihood Both controls / systems are effective? or assurance? • Collaborative work underway across LLR to ensure • Consistent approach to quality reviews across LLR to be End March consistency of approach of escalation to NHS E. developed linked to 5 Year Forward View. 2019 ☐ ☐ ☒
• Internal Audit Review on primary care delegated • Audit to be undertaken in line with audit plan by end End March ☐ ☐ ☒ functions as required to undertake by NHS England. March 2019. 2019
19
BAF 5(a): QIPP – CCG QIPP programme, comprising CCG, Better Care Fund (BCF) and Better Care Together (BCT) / Sustainability Transformation Partnership (STP) initiatives fail to deliver against the CCG QIPP Plan resulting in failure to deliver in-year efficiencies and transform delivery for sustainable efficiency.
Section A Section B Section C A1. Corporate Objective / A3. Risk to be treated, Risk rating (impact x likelihood = risk score (see Strategic Aim the risk is confirm frequency of pages 3 and 4 above) aligned to: review by lead? Strategic Aim 6 Monthly Quarterly B1. Executive Lead (risk Paul Gibara C1. Initial / inherent risk 4 x 4 = 16 R ☒ ☐ owner): score: A2. Date Risk identified: A4. Risk Category: B2. Officer Lead (action Spencer Gay, WL C2. Risk appetite / 2 x 2 = 4 Y owner): CCG tolerance score: ☐ B3. Date last reviewed: 2018/19 Clinical March 2019 C3. Current / residual 4 4 16 risk score: x = A Organisational ☐ 3 3 9 Finance ☒ B4. Committee / group Financial Turnaround C4. Date current / residual March 2019 with oversight for Committee risk score assessed: Information ☐ risk?
Section D: Key Controls Section E: current risk score trend What key controls / systems does the CCG have in place to manage the risk? • Programme Dashboard - demonstrating delivery against finance and activity plan delivery against (Corporate Affairs Team to update graph showing trend current risk score individual scheme plan. against risk appetite score) 20 • Review of QIPP schemes via ELR CCG QPDM QIPP Delivery Group meetings and via the established Financial Turnaround Committee. 15 • Mitigation plans are in place • QIPP Plan forecasting under delivery of £400k at Month 10. 10 Risk Appetite • Schemes are reviewed by the SRO, PMOs and Finance Team. • Confirm and Challenge occurs through agreed Committees (i.e. QAG and FTC). 5 Current / • New consolidated system wide QIPP process put in place. Residual Risk • Standardised reports across LLR – presented to CCB by LLR QIPP Lead, WL CCG 0 CFO. Jul-18 Apr-18 Oct-18 Jun-18 Jan-19 Mar-19 Feb-19 Nov-18 Dec-18 Aug-18 Sep-18 May-18
• Brief rationale for any change in current risk score:
20
Section F: Internal and / or External Assurances Where can we gain evidence that our controls / systems on which we are placing our reliance are effective? Internal External • Assurance report on QIPP presented to the Governing Body captured within the monthly finance report. ☒ ☐ • Minutes of the QAG, CCB, JMT and EMT. ☒ ☐ • QIPP presented at FTC, QAG and CCB; Financial delivery presented at Governing Body as part of the finance report. ☒ ☐ ☐ ☐
Section G:
G1: Gaps in Controls and / or Assurance G2: Detail the actions to be taken G3: Action G4: Will the action reduce Where are the gaps in our control / systems? Where are (including brief note on updates / progress where appropriate to be impact of risk score or we failing to make them effective? and confirm when action completed) completed likelihood or both? What actions are required to bridge the gaps in controls and / Where is the CCG failing to gain evidence that the by (date) Impact Likelihood Both controls / systems are effective? or assurance? Robust plans required for some QIPP schemes to • To review in detail the plans in place to support the End March ensure delivery e.g. planned care. delivery of the planned care QIPP to determine robustness 2019 of plans – initial review of planned care QIPP schemes ☐ ☐ ☒ complete, QPDMG / LLR QAG continue to review other QIPP schemes. ☐ ☐ ☐
21
BAF 5(b) : QIPP – Robust systems and processes are not in place to support the CCG QIPP Programme comprising of CCG, (BCF) and BCT / STP initiatives.
Section A Section B Section C A1. Corporate Objective / A3. Risk to be treated, Risk rating (impact x likelihood = risk score (see Strategic Aim the risk is confirm frequency of pages 3 and 4 above) aligned to: review by lead? Strategic Aim 6 Monthly Quarterly B1. Executive Lead (risk Paul Gibara C1. Initial / inherent risk 4 x 4 = 16 R ☒ ☐ owner): score: A2. Date Risk identified: A4. Risk Category: B2. Officer Lead (action Spencer Gay, WL CCG C2. Risk appetite / 2 x 2 = 4 Y owner): tolerance score: 2017/18 Clinical ☐ B3. Date last reviewed: January 2019 C3. Current / residual risk score: 3 x 3 = 9 A Organisational ☒ Finance ☐ B4. Committee / group Financial Turnaround C4. Date current / residual January 2019 with oversight for Committee risk score assessed: Information ☐ risk?
Section D: Key Controls Section E: current risk score trend What key controls / systems does the CCG have in place to manage the risk? • Detailed approved QIPP Plan. Leads for schemes identified. Weekly report to EMT. (Corporate Affairs Team to update graph showing trend current risk score • Scope work and QIPP development at Financial Turnaround Committee and weekly against risk appetite score) QPDM meetings. 10 • PMO arrangements in place i.e.: - Programme dashboard developed – reporting monthly to Financial Turnaround 8 Committee 6 - Finance and activity dashboard developed for monitoring delivery by scheme Risk Appetite reporting to Financial Turnaround Committee 4 - Revised programme documentation in draft to be signed off for development of new 2 Current / schemes. Residual Risk 0
Jul-18 Apr-18 Oct-18 Jun-18 Jan-19 Mar-19 Feb-19 Nov-18 Dec-18 Aug-18 Sep-18 May-18
• Brief rationale for any change in current risk score:
22
•
Section F: Internal and / or External Assurances Where can we gain evidence that our controls / systems on which we are placing our reliance are effective? Internal External • Programme dashboard reports presented to Financial Turnaround Committee. ☒ ☐
☐ ☒ ☐ ☐ ☐ ☐
Section G:
G1: Gaps in Controls and / or Assurance G2: Detail the actions to be taken G3: Action G4: Will the action reduce Where are the gaps in our control / systems? Where are (including brief note on updates / progress where appropriate to be impact of risk score or we failing to make them effective? and confirm when action completed) completed likelihood or both? What actions are required to bridge the gaps in controls and / Where is the CCG failing to gain evidence that the by (date) Impact Likelihood Both controls / systems are effective? or assurance? See dashboard reports and action plans as reported to Actions and progress within QIPP reports. ongoing ☐ ☐ ☒ QIPP meetings. ☐ ☐ ☒
23
BAF 6(a): OUT OF HOSPITAL – PRIMARY CARE: Risk in relation to Out of Hospital Services – Primary Care: Primary Care Commissioning – ability to perform delegated duties whilst maintaining member relations and Clinical Engagement.
Section A Section B Section C A1. Corporate Objective / A3. Risk to be treated, Risk rating (impact x likelihood = risk score (see Strategic Aim the risk is confirm frequency of pages 3 and 4 above) aligned to: review by lead? Strategic Aim 4 Monthly Quarterly B1. Executive Lead (risk Tim Sacks C1. Initial / inherent risk 5 x 3 = 15 R ☐ ☒ owner): score: A2. Date Risk identified: A4. Risk Category: B2. Officer Lead (action Jamie Barrett C2. Risk appetite / 3 x 2 = 6 Y owner): tolerance score: 2016/17 Clinical ☐ B3. Date last reviewed: January 2019 C3. Current / residual (next review April) risk score: 3 x 3 = 9 A Organisational ☒ Finance ☐ B4. Committee / group with Integrated C4. Date current / residual January 2019 oversight for risk? Governance risk score assessed: Information ☐ Committee / PCCC
Section D: Key Controls Section E: current risk score trend What key controls / systems does the CCG have in place to manage the risk? • Primary Care Commissioning Committee in place with delegated authority from NHS England. (Corporate Affairs Team to update graph showing trend current risk score • Conflicts of Interest Policy updated and approved. against risk appetite score) • Team of 4 NHS England staff seconded to CCG to perform duties. • Membership engagement plan in place which includes: Protected Learning Time; Locality 14 meetings; Federation meetings; annual quality visits. 12 • Through attendance at the Practice Managers Forum and with Practice Managers sitting on the 10 Primary Care Delivery Group actions and decisions are discussed openly and transparently 8 Risk Appetite 6
4 2 Current / Residual Risk 0 Jul-18 Apr-18 Oct-18 Jun-18 Jan-19 Mar-19 Feb-19 Nov-18 Dec-18 Aug-18 Sep-18 May-18
• Brief rationale for any change in current risk score:
24
• Positive actions taken to engage with membership including the Practice Managers.
Section F: Internal and / or External Assurances Where can we gain evidence that our controls / systems on which we are placing our reliance are effective? Internal External • Reporting to NHS England via the CCG assurance review process. ☐ ☒
• Internal Audit Review on conflicts of interest to be carried out in 2018/19. Audit Committee has a scrutiny role in relation to primary care ☐ ☒ commissioning decision making. • Feedback in relation to membership engagement via the 360 Stakeholder Survey completed on an annual basis. ☐ ☒
• Feedback from Locality meetings on pressures and issues in General Practice. Fed through to the Governing Body. ☒ ☐ • STP plan for primary care Five Year Forward View is being delivered to support future of General Practice in LLR.
Section G:
G1: Gaps in Controls and / or Assurance G2: Detail the actions to be taken G3: Action G4: Will the action reduce Where are the gaps in our control / systems? Where are (including brief note on updates / progress where appropriate to be impact of risk score or we failing to make them effective? and confirm when action completed) completed likelihood or both? What actions are required to bridge the gaps in controls and / Where is the CCG failing to gain evidence that the by (date) Impact Likelihood Both controls / systems are effective? or assurance? • Involve and engage all CCG Governing Body GPs in Monthly clinical lead meetings and engagement via relevant Ongoing ☐ ☐ ☒ process to ensure collaboration. committees • Financial pressures with the CCG and increased QIPP Fortnightly QIPP delivery meetings to identify, consider and Ongoing demands from primary care and increased work load on mitigate risks ☐ ☐ ☒ primary care has the risk of creating relationship issues with member practices. • Risks for Practices on workforce and finances could lead Development of local implementation plan for the GP5YFV March 2019 to issues with service sustainability. workforce plan ☐ ☐ ☒
• Engagement with Primary Care as CCG reviews Engagement to take place with localities and through the on quarterly discretionary funding on an ongoing basis. Practice Managers’ Forum. basis ☒ ☐ ☐
25
BAF 6(b): OUT OF HOSPITAL – PRIMARY CARE: Risk in relation to Out of Hospital Services – Primary Care: Primary Care transformation – the workforce and capability of general practice and CCG to develop transformation.
Section A Section B Section C A1. Corporate Objective / A3. Risk to be treated, Risk rating (impact x likelihood = risk score (see Strategic Aim the risk is confirm frequency of pages 3 and 4 above) aligned to: review by lead? Strategic Aim Monthly Quarterly B1. Executive Lead (risk Tim Sacks C1. Initial / inherent risk 5 x 3 = 15 R ☒ ☐ owner): score: A2. Date Risk identified: A4. Risk Category: B2. Officer Lead (action Paula Vaughan C2. Risk appetite / 3 x 2 = 6 Y owner): tolerance score: 2016/17 Clinical ☐ B3. Date last reviewed: January 2019 C3. Current / residual (next review April) risk score: 4 x 3 = 12 A Organisational ☒ Finance ☐ B4. Committee / group with PCCC / Integrated C4. Date current / residual January 2019 oversight for risk? Governance risk score assessed: Information ☐ Committee
Section D: Key Controls Section E: current risk score trend What key controls / systems does the CCG have in place to manage the risk? • LLR wider primary care workforce planning group (CCGs, Health Education East (Corporate Affairs Team to update graph showing trend current risk score Midlands, Local Deanery) in place for GPs and Practice Nurses. against risk appetite score) • Federation formed with 100% member sign off to support general practice. 14 • Primary Care Commissioning Committee and the Primary Care Quality Delivery Group 12 in place to support and develop ideas and transformation plans to support this agenda. 10 • STP Workforce plan development and management via the GP Workforce Group. 8 Risk Appetite • Formation and implementation of transformation plan for localities – facilitated by 6 transformation funding. 4 • Linking of workforce plans to locality transformation and acute access plans. 2 Current / Residual • Redesign of GP Safety Improvement Plan (SIP) and other additional funding sources 0 Risk into General Practice to support new models of working and additional staff to give capacity Jul-18 Apr-18 Oct-18 Jun-18 Jan-19 Mar-19 Feb-19 Nov-18 Dec-18 Aug-18 Sep-18
May-18
Brief rationale for any change in current risk score:
26
Section F: Internal and / or External Assurances Where can we gain evidence that our controls / systems on which we are placing our reliance are effective? Internal External Full GP work force survey undertaken in October 2017 by HEEM and ELR to understand pressures and gaps. Model of Sustainable General ☒ ☐ Practice and the workforce implications fundamental to the STP plan. This puts forward potential new staffing models and methods of supporting a resilient future general practice GP SIP and Primary Care investment targeted at the necessary areas to support resilience and patient outcomes. ☒ ☐ ☐ ☐ ☐ ☐
Section G:
G1: Gaps in Controls and / or Assurance G2: Detail the actions to be taken G3: Action G4: Will the action reduce Where are the gaps in our control / systems? Where are (including brief note on updates / progress where appropriate to be impact of risk score or we failing to make them effective? and confirm when action completed) completed likelihood or both? What actions are required to bridge the gaps in controls and / Where is the CCG failing to gain evidence that the by (date) Impact Likelihood Both controls / systems are effective? or assurance? • Encouraging future workforce by making primary care Development of local implementation plan for the GP5YFV March 2019 ☐ ☐ ☒ more attractive. workforce plan • CCG to support through the Federation and investment Development of local implementation plan for the GP5YFV March 2019 plan new ways of working to improve breadth and quality workforce plan ☐ ☐ ☒ of GP careers. • STP GP Board set-up with full LLR engagement. Groups GP5YFV Programme Board up and running - all GP leads Ongoing ☐ ☐ ☒ to develop workforce, IM&T and care models in place. attend quarterly
27
BAF 6(c): OUT OF HOSPITAL – PRIMARY CARE: Risk in relation to Out of Hospital Services – Primary Care: Finance – budget inherited from NHS England covers current costs / service and therefore new development and transformation will require additional funding (e.g. premises).
Section A Section B Section C A1. Corporate Objective / A3. Risk to be treated, Risk rating (impact x likelihood = risk score (see Strategic Aim the risk is confirm frequency of pages 3 and 4 above) aligned to: review by lead? Strategic Aim 4 Monthly Quarterly B1. Executive Lead (risk Tim Sacks C1. Initial / inherent risk 4 x 5 = 20 R ☐ ☒ owner): score: A2. Date Risk identified: A4. Risk Category: B2. Officer Lead (action Jamie Barrett C2. Risk appetite / 3 x 2 = 6 Y owner): tolerance score: 2016/17 Clinical ☐ B3. Date last reviewed: January 2019 C3. Current / residual (next review April) risk score: 3 x 3 = 9 A Organisational ☒ Finance ☐ B4. Committee / group with Financial C4. Date current / residual January 2019 oversight for risk? Turnaround risk score assessed: Information ☐ Committee / PCCC
Section D: Key Controls Section E: current risk score trend What key controls / systems does the CCG have in place to manage the risk? • GP5YFV as the direction of travel and high level operational plan. (Corporate Affairs Team to update graph showing trend current risk score • GP Programme Board, providing general oversight and accountability for the delivery of the against risk appetite score) GP5YFV. • ELR GPSIP – focusing on delivering local service improvement within primary care. 10 • Acute Access – focusing investment into supporting core primary care to improve 8 access for patients and practice sustainability. 6 • PMS/FDR reinvestment to support practice sustainability and fair funding. Risk Appetite • Premises review to support prioritisation of development of the right primary care sites. 4 • GPSIP plan 2018/19 developed and implemented to focus on practice sustainability. Current / Residual • Full finance review in October 2018 to plan and agree budgets and risks for 2019/20 2 Risk onwards. 0 Jul-18 Apr-18 Oct-18 Jun-18 Jan-19 Mar-19 Feb-19 Nov-18 Dec-18 Aug-18 Sep-18 May-18
• Brief rationale for any change in current risk score:
28
•
Section F: Internal and / or External Assurances Where can we gain evidence that our controls / systems on which we are placing our reliance are effective? Internal External • NHS England sign-off of the 5yr investment plan / strategy. ☐ ☒
• Primary Care Commissioning Committee to receive update and report on full premises review. ☒ ☐
• Implementation of the transformation funding to develop stronger localities. ☒ ☐
• Primary care performance dashboard and benchmarking data sets by locality to drive transformation and improvement. ☒ ☐ • Three year budgetary planning to support financial management ☒ ☐
Section G:
G1: Gaps in Controls and / or Assurance G2: Detail the actions to be taken G3: Action G4: Will the action reduce Where are the gaps in our control / systems? Where are (including brief note on updates / progress where appropriate to be impact of risk score or we failing to make them effective? and confirm when action completed) completed likelihood or both? What actions are required to bridge the gaps in controls and / Where is the CCG failing to gain evidence that the by (date) Impact Likelihood Both controls / systems are effective? or assurance? • GPSIP plan to support the implementation of Acute Access March 2019 Risk of demand and increasing over capacity and need ☐ ☐ ☒ for associated funds to support. • GPSIP 2019/20 plans must align to locality improvement Development of a new form of GPSIP for 2019/20. March 2019 ☐ ☐ ☒ KPIs owned by the locality leadership team.
29
BAF 7: OUT OF HOSPITAL – COMMUNITY SERVICES: Failure to agree service model for future Out of Hospital Services further to consultation and engagement
Section A Section B Section C A1. Corporate Objective / A3. Risk to be treated, Risk rating (impact x likelihood = risk score (see Strategic Aim the risk is confirm frequency of pages 3 and 4 above) aligned to: review by lead? Monthly Quarterly B1. Executive Lead (risk Tim Sacks C1. Initial / inherent risk Strategic Aim 5 5 x 4 = 20 R ☐ ☒ owner): score: A2. Date Risk identified: A4. Risk Category: B2. Officer Lead (action Paula Vaughan C2. Risk appetite / 2 x 2 = 4 Y owner): tolerance score: 2018/19 Clinical ☐ B3. Date last reviewed: January 2019 C3. Current / residual (next review April) risk score: 4 x 4 = 16 R Organisational ☒ Finance ☐ B4. Committee / group with OHCB / Integrated C4. Date current / residual January 2019 oversight for risk? Governance risk score assessed: Information ☐ Committee
Section D: Key Controls Section E: current risk score trend What key controls / systems does the CCG have in place to manage the risk? • Strategy set by and actions managed by the Out of Hospital Care Board. (Corporate Affairs Team to update graph showing trend current risk score • Formation of 6 x Integrated Locality Leadership Teams to take accountability of against risk appetite score) integration on a local level and development of 6 locality plans to give clear baselining 25 of services and clear plans on which areas to develop for local populations. • Redesign of locality structure to support placed based care design and delivery. 20 • Federation in place to act as broker in development of the 6 locality teams. 15 • BCT/ STP Delivery board. Risk Appetite 10 • Development of Out of Hospital Care Strategy linked to locality development. • Community services review aimed at supporting the system to align staff to keep 5 Current / Residual patients out of hospital. 0 Risk • Detailed estate analysis commissioned for Lutterworth and Oakham to support options for services which will inform public engagement. Jul-18 Apr-18 Oct-18 Jun-18 Jan-19 Mar-19 Feb-19 Nov-18 Dec-18 Aug-18 Sep-18 May-18 • Brief rationale for any change in current risk score:
30
Section F: Internal and / or External Assurances Where can we gain evidence that our controls / systems on which we are placing our reliance are effective? Internal External • Out of Hospital Steering Group reporting to Sustainability and Transformation Plan Integrated Care Board. ☒ ☐
• New Integrated delivery programme set out through the STP governance structure coordinating LLR wide approach in model and contract. ☐ ☒ CCG OOH group leading on design and implementation • Deputy COO leading on programme, leading and managing Out of Hospital Care Board work programme including integration with LLR ☒ ☐ workstreams. • Rrealignment of CCG teams to drive the locality commissioning agenda ☒ ☐ • Estates review commissioning that is assured through Information Governance Committee ☒ ☐
Section G:
G1: Gaps in Controls and / or Assurance G2: Detail the actions to be taken G3: Action G4: Will the action reduce Where are the gaps in our control / systems? Where are (including brief note on updates / progress where appropriate to be impact of risk score or we failing to make them effective? and confirm when action completed) completed likelihood or both? What actions are required to bridge the gaps in controls and / Where is the CCG failing to gain evidence that the by (date) Impact Likelihood Both controls / systems are effective? or assurance? • Home First clinical business case in development stage. Locality community care plans to be developed x 6 December 2018 ☐ ☐ ☒ COMPLETE • Locality level work plans for 2018/19. To be agreed at the Out of Hospital Care Board in August August 2018 ☐ ☒ ☐ 2018. COMPLETE • Locality lead work plan delivery by December 2018 Work underway. December to form plan and structure for 2019/20 onwards. Although this action is complete, need to review in line with 2018 ☐ ☒ ☐ NHS Longer Term Plan in relation to Primary Care Networks – COMPLETE reviewing at present in terms of further actions required.
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BAF 8: URGENT CARE: Increased pressure on the Emergency Department which could result in sub- optimal care due to ability to access urgent care services.
Section A Section B Section C A1. Corporate Objective / A3. Risk to be treated, Risk rating (impact x likelihood = risk score (see Strategic Aim the risk is confirm frequency of pages 3 and 4 above) aligned to: review by lead? Monthly Quarterly B1. Executive Lead (risk Tim Sacks C1. Initial / inherent risk Strategic Aim 2 4 x 4 = 16 R ☒ ☐ owner): score: A2. Date Risk identified: A4. Risk Category: B2. Officer Lead (action Paula Vaughan C2. Risk appetite / 2 x 3 = 6 Y owner): tolerance score: ☒ B3. Date last reviewed: 2016/17 Clinical March 2019 C3. Current / residual 3 9 risk score: x 3 = A Organisational ☐ 4 12 Finance ☐ B4. Committee / group with OHCB / Integrated C4. Date current / residual March 2019 oversight for risk? Governance risk score assessed: Information ☐ Committee
Section D: Key Controls Section E: current risk score trend What key controls / systems does the CCG have in place to manage the risk? • Opening of 7 days working urgent services across 4 sites in ELR. (Corporate Affairs Team to update graph showing trend current risk score • Supporting general practice to deliver same day care via development of Acute Access. against risk appetite score) • Re-commissioning elements of integrated LLR UC system to improve access and right 14 care first time, including single front door and LLR UC visiting service. 12 • Introduction of fully functioning Clinical Navigation Hub to improve access to right 10 service first time for patients. Risk Appetite • A&E Delivery Board in place review performance. 8 • Development of an integrated extended primary care service to improve access, 6 integration and equality of access across the CCG – due October 2018 / April 2019. 4 • New extended Primary Care service commissioned from April 2019 with increased 2 Current / hours and an additional site in Blaby to improve patient access. 0 Residual Risk Jul-18 Apr-18 Oct-18 Jun-18 Jan-19 Mar-19 Feb-19 Nov-18 Dec-18 Aug-18 Sep-18 May-18 • Brief rationale for any change in current risk score:
32
•
Section F: Internal and / or External Assurances Where can we gain evidence that our controls / systems on which we are placing our reliance are effective? Internal External • ELR urgent care contract meetings. ☒ ☐ • A&E Delivery Board, ORG / SRG and sub-groups focusing on system flow. ☐ ☒ • ELR fortnightly Urgent Care Delivery Group. ☐ ☐ • Re-procurement of service form April 2019 ☒ ☐
Section G: G4: G1: Gaps in Controls and / or Assurance G2: Detail the actions to be taken G3: Action G4: Will the action reduce Where are the gaps in our control / systems? Where are (including brief note on updates / progress where appropriate to be impact of risk score or we failing to make them effective? and confirm when action completed) completed likelihood or both? What actions are required to bridge the gaps in controls and / Where is the CCG failing to gain evidence that the by (date) Impact Likelihood Both controls / systems are effective? or assurance? • Increased attendance and under utilisation of ELR Urgent • Remodelling of service alongside Acute Access to better fit Oct 2018 ☐ ☐ ☒ Care service. with patient needs and improve usage COMPLETE • Model of acute access and extended primary care • CCG Urgent Care Delivery Group to be held to account for Oct 2018
still unclear. model development by CCG OHCB. COMPLETE • Practice at various stages of engagement with • Locality based discussion, individual practice being Oct 2018 ☐ ☐ ☒ theory and delivery of acute access. supported and visited by the CCG. COMPLETE • Assurance that acute access and extended primary • Regular updates with the system via the Urgent Care Oct 2018 care model will fit with and integrated effectively Delivery Group. COMPLETE ☐ ☐ ☒ with the rest of the LR urgent care system.
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BAF 9: ORGANISATIONAL CAPACITY: Organisation is at risk of not being able to meet its statutory functions due to capacity within teams.
Section A Section B Section C A1. Corporate Objective / A3. Risk to be treated, Risk rating (impact x likelihood = risk score (see Strategic Aim the risk is confirm frequency of pages 3 and 4 above) aligned to: review by lead? Monthly Quarterly B1. Executive Lead (risk Karen English C1. Initial / inherent risk Strategic Aims 1 - 6 4 x 4 = 16 R ☒ ☐ owner): score: A2. Date Risk identified: A4. Risk Category: B2. Officer Lead (action Chief Officers C2. Risk appetite / 3 x 2 = 6 Y owner): tolerance score: 2016/17 Clinical ☐ B3. Date last reviewed: March 2019 C3. Current / residual risk score: 4 x 3 = 12 A Organisational ☒ Finance ☐ B4. Committee / group with Executive C4. Date current / residual March 2019 oversight for risk? Management Team risk score assessed: Information ☐
Section D: Key Controls Section E: current risk score trend What key controls / systems does the CCG have in place to manage the risk? • Recruitment to vacant funded posts under way. (Corporate Affairs Team to update graph showing trend current risk score • Formal vacancy control system and process in place. against risk appetite score) • Additional financial resource of approximately £1.4m to be received from NHS England 14 to support transformation and QIPP across LLR. 12 • In December 2018 the Governing Body approved the proposal to appoint a single 10 accountable officer across LLR CCGs. Process underway and progress to be reported 8 to the Governing Body at agreed intervals. Risk Appetite • Risk reviewed in March 2019 and no changes at present. 6 4 Current / Residual 2 Risk 0 Jul-18 Apr-18 Oct-18 Jun-18 Jan-19 Mar-19 Feb-19 Nov-18 Dec-18 Aug-18 Sep-18 May-18
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Brief rationale for any change in current risk score:
Section F: Internal and / or External Assurances Where can we gain evidence that our controls / systems on which we are placing our reliance are effective? Internal External • Chief Officer oversight and scrutiny ☒ ☐ • Governing Body has oversight of the appointment process to appoint single accountable officer. ☒ ☐ ☐ ☐
Section G:
G1: Gaps in Controls and / or Assurance G2: Detail the actions to be taken G3: Action G4: Will the action reduce Where are the gaps in our control / systems? Where are (including brief note on updates / progress where appropriate to be impact of risk score or we failing to make them effective? and confirm when action completed) completed likelihood or both? What actions are required to bridge the gaps in controls and / Where is the CCG failing to gain evidence that the by (date) Impact Likelihood Both controls / systems are effective? or assurance? • Running costs are being contained within the • Ensure there is a defined process to agree how LLR ongoing allocation. Whilst there is a vacancy control in place system plans are taken forward if ELR CCG is a lead for it does allow for us to review the structure to ensure specific work programme. ☒ ☐ ☐ we are fit to respond to the requirements of the CCG and the wider LLR issues. • Need to consider roles and responsibilities. - Review of ongoing ☐ ☐ ☒ capacity and roles underway across LLR CCGs. • Consider impact of financial position which adds further ongoing pressure to the challenge of recruitment and vacancy ☐ ☐ ☒ control processes (see above additional financial resource to be received from NHS England).
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BAF 10: FINANCE: Non achievement of 2018/19 year end control total surplus which is dependent on achievement of c£19.645m (4.6%) QIPP schemes
Section A Section B Section C A1. Corporate Objective / A3. Risk to be treated, Risk rating (impact x likelihood = risk score (see Strategic Aim the risk is confirm frequency of pages 3 and 4 above) aligned to: review by lead? Monthly Quarterly B1. Executive Lead (risk Donna Enoux C1. Initial / inherent risk Strategic Aim 6 5 x 4 = 20 R ☒ ☐ owner): score: A2. Date Risk identified: A4. Risk Category: B2. Officer Lead (action Colin Groom C2. Risk appetite / 2 x 3 = 6 Y owner): tolerance score: 2018/19 Clinical ☐ B3. Date last reviewed: March 2019 C3. Current / residual risk score: 5 x 3 = 15 R Organisational ☐ Finance ☒ B4. Committee / group with Financial Turnaround C4. Date current / residual March 2019 oversight for risk? Committee / risk score assessed: Information ☐ Governing Body
Section D: Key Controls Section E: current risk score trend What key controls / systems does the CCG have in place to manage the risk? • Monthly review of financial position by finance team, formal confirm and challenge with (Corporate Affairs Team to update graph showing trend current risk score CFO (and MD in the second half of the year) and monthly budget holder meeting to against risk appetite score) review and approve financial position. • Enhanced LLR QIPP monitoring processes in place led by nominated CFO to ensure 30 consistency and process efficiency. QIPP process continues to hold QIPP leads to account, monitor schemes and report on delivery and recovery trajectories if necessary. 25 • Close working with NHS E turnaround team to identify additional cost saving 20 opportunities. Dedicated senior turnaround support appointed by the CCG to ensure 15 Risk Appetite delivery of key turnaround milestones, including but not limited to supporting QIPP delivery. 10 Current / Residual • Challenge by finance team to hosted finance teams producing the provider financial 5 positions. Increased LLR wide collaboration to ensure consistency and share workload Risk and drive efficiency within the finance function. Creation of virtual teams within finance 0 to share expertise and knowledge in line with the temporary CFO portfolio changes.
• Monthly reports from ML CSU providing assurance on outsourced Financial Accounting Jul-18 Apr-18 Oct-18 Jun-18 Jan-19 Mar-19 Feb-19 Nov-18 Dec-18 Aug-18 Sep-18 May-18 function. • CFO / Deputy CFO log of all existing risk (and flexibilities) quantified where possible. Brief rationale for any change in current risk score: Specific session held during 2017/18 closedown period to run through detailed risks The rationale for the reduction in the residual risk score is due to with Audit and Financial Turnaround Committee Chairs. Process being repeated 36
throughout 2018/19 along with other recommendations of external review into finance having secured and transacted the vast majority of mitigations that will processes. enable the CCG to achieve the control total position for this year • LLR wide collaboration via finance virtual team (matrix working) introduced for 2018/19 including the confirmed receipt of anticipated transitional support to ensure consistency and sufficient resource to review financial challenges effectively. funding in months 11 and 12. Key risks being targeted to close down include finalisation of 2017/18 accrual estimates and impact of acute activity delivery across NHS and independent sector contracts being contained within identified reserves. • Controls and processes remain unchanged from previous assessment.
Section F: Internal and / or External Assurances Where can we gain evidence that our controls / systems on which we are placing our reliance are effective? Internal External • Challenge of financial position at the Financial Turnaround Committee and challenge of position at monthly Governing Body ☒ ☐ meetings. • Regular ELR and LLR QIPP meetings to monitor relevant QIPP schemes and identify further schemes. ☒ ☐ • Challenge at quarterly Checkpoint and monthly operational meetings with NHS England. ☐ ☒ • Internal Audit Review on Key financial systems awarded an opinion of significant assurance for 2017/18. 2018/19 review ☐ ☒ being planned. • External audit of value for money. External Service Auditor Reports on financial service provision of the CSU, Capita, SBS ☐ ☒ and other national systems/service providers. • Dedicated resource in place across LLR to support the identification and implementation of QIPP programme. ☒ ☐ • Dedicated senior resource in place to support wider Financial Turnaround ☒ • Participation by Deputy CFO at monthly NHSE monthly assurance meetings ☒ ☐
Section G:
G1: Gaps in Controls and / or Assurance G2: Detail the actions to be taken G3: Action G4: Will the action reduce Where are the gaps in our control / systems? Where are (including brief note on updates / progress where appropriate to be impact of risk score or we failing to make them effective? and confirm when action completed) completed likelihood or both? What actions are required to bridge the gaps in controls and / Where is the CCG failing to gain evidence that the by (date) Impact Likelihood Both controls / systems are effective? or assurance? • Delays in obtaining assurance for certain QIPP • Increased focus of LLR QIPP group confirm and challenge. 30/11/2018 programmes • Processes and focus of confirm and challenge has ACTION improved to a stage where the PMO assurance process is COMPLETE ☐ ☐ ☒ considered robust. This has resulted in a number of schemes being confirmed as slipped or non-deliverable. • Significant proportion of QIPP programme currently • Confirm and challenge of QIPP through Q1 to confirm 30/06/2018 ☐ ☐ ☒ 37
rated Amber or Red deliverability of major schemes. • Significant slippage and non delivery identified during Q1 process. A range of further extensions and new schemes ongoing have been identified at very outline stage and will be progressed to confirm the level of in year deliverability for month 4 reporting at which point, if a material gap remains, the CCG will need to consider its ability to deliver its agreed control total. • Month 5 updates confirm further QIPP slippage/non delivery and additional cost pressures. Mitigating stretch 31/03/2018 QIPP and other cost control measures have been identified but these will be reviewed in detail for month 6 and in preparation for NHSE Assurance meeting at which point confirmation of ability or otherwise to achieve control ☐ ☐ ☒ total will be required. • Month 8 process has confirmed further slippage in a range of schemes such that the programme is unlikely to deliver the full targeted £19.6m and alternative non-QIPP mitigations are being progressed to supplement any shortfall.
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BAF 11: EPRR: Lack of systematic and continuous processes in place for Emergency Preparedness, Resilience and Response (EPRR)
Section A Section B Section C A1. Corporate Objective / A3. Risk to be treated, Risk rating (impact x likelihood = risk score (see Strategic Aim the risk is confirm frequency of pages 3 and 4 above) aligned to: review by lead? Monthly Quarterly B1. Executive Lead (risk Tim Sacks C1. Initial / inherent risk Strategic Aims all 6 5 x 4 = 20 R ☐ ☒ owner): score: A2. Date Risk identified: A4. Risk Category: B2. Officer Lead (action Daljit K. Bains C2. Risk appetite / 3 x 2 = 6 Y owner): tolerance score: Clinical ☒ B3. Date last reviewed: December 2018 C3. Current / residual (next review April) risk score: 3 x 3 = 9 A Organisational ☒ Finance ☐ B4. Committee / group with Executive C4. Date current / residual December 2018 oversight for risk? Management Team risk score assessed: Information ☐
Section D: Key Controls Section E: current risk score trend What key controls / systems does the CCG have in place to manage the risk? • CCG Business Continuity Policy and Plan in place, and LLR Incident Response (Corporate Affairs Team to update graph showing trend current risk score Plan in place. against risk appetite score) • Compliance against the EPRR core standards. 10 • Participation in Local Health Resilience Partnership at executive and working 8 group level. 6 • Contributing through LHRP to risk management through LHR Forum. Risk Appetite • Testing of business continuity plans and emergency planning coordinated via 4 WL CCG hosted function. 2 Current / • Annual self-assessment return completed and submitted to NHS England in 0 Residual Risk October 2018. Outcome of assessment received from NHS England, actions being completed. Jul-18 Apr-18 Oct-18 Jun-18 Jan-19 Mar-19 Feb-19 Nov-18 Dec-18 Aug-18 Sep-18
May-18
• Brief rationale for any change in current risk score:
•
39
Section F: Internal and / or External Assurances Where can we gain evidence that our controls / systems on which we are placing our reliance are effective? Internal External • External verification of level of compliance provided by NHS England on annual basis (expected in September /October ☐ ☒ 2018). • 6 monthly / annual report on EPRR core standards to the Governing Body (last reports in September and October 2018). ☒ ☐ • NHS England quarterly Checkpoint meeting to review CCG performance. NHS E review of CCG core standards. ☐ ☒ • LHRP work plan and meetings with NHS England. ☐ ☒ • Directorate on-call training. ☒ ☐ • ☐ ☐
Section G:
G1: Gaps in Controls and / or Assurance G2: Detail the actions to be taken G3: Action G4: Will the action reduce Where are the gaps in our control / systems? Where are (including brief note on updates / progress where appropriate to be impact of risk score or we failing to make them effective? and confirm when action completed) completed likelihood or both? What actions are required to bridge the gaps in controls and / Where is the CCG failing to gain evidence that the by (date) Impact Likelihood Both controls / systems are effective? or assurance? • Table-top exercise to be arranged to test the ELR Exercise to be arranged (Tim Sacks). March / April ☐ ☐ ☒ CCG updated Business Continuity Policy and Plan. 2019
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BAF 14: “EU EXIT”: inability to implement the Department of Health and Social Care’s EU Exit Operational Readiness Guidance (published 21 December 2018)
Section A Section B Section C A1. Corporate Objective / A3. Risk to be treated, Risk rating (impact x likelihood = risk score (see Strategic Aim the risk is confirm frequency of pages 3 and 4 above) aligned to: review by lead? Monthly Quarterly B1. Executive Lead (risk Karen English C1. Initial / inherent risk Strategic Aims all 6 5 x 4 = 20 R ☒ ☐ owner): score: A2. Date Risk identified: A4. Risk Category: B2. Officer Lead (action Mike Ryan (WL C2. Risk appetite / 3 x 3 = 9 A owner): CCG) tolerance score: December 2018 Clinical ☒ B3. Date last reviewed: March 2019 C3. Current / residual risk score: 5 x 4 = 20 R Organisational ☒ Finance ☒ B4. Committee / group with Executive C4. Date current / residual March 2019 oversight for risk? Management Team risk score assessed: Information ☐
Section D: Key Controls Section E: current risk score trend What key controls / systems does the CCG have in place to manage the risk? • NHS England have advised that Local Resilience Forums are already setting dates for (Corporate Affairs Team to update graph showing trend current risk score EU Exit Tactical Coordinating Groups (TCG) and Strategic Coordinating Groups (SCG). against risk appetite score) • NHS England has formally delegated to CCGs the responsibility to be the strategic 25 NHS representation at SCGs, representing the interests of the local health system. • The Interim Director of Urgent Care and Emergency Planning (WL CCG) is the LLR 20 lead for the SCG and for emergency planning. 15 Risk Appetite 10 5 Current / 0 Residual Risk Jul-18 Apr-18 Oct-18 Jun-18 Jan-19 Mar-19 Feb-19 Nov-18 Dec-18 Aug-18 Sep-18 May-18
• Brief rationale for any change in current risk score:
•
41
Section F: Internal and / or External Assurances Where can we gain evidence that our controls / systems on which we are placing our reliance are effective? Internal External • ☐ ☐ • ☐ ☐ • ☐ ☐ • ☐ ☐ • ☐ ☐ • ☐ ☐
Section G:
G1: Gaps in Controls and / or Assurance G2: Detail the actions to be taken G3: Action G4: Will the action reduce Where are the gaps in our control / systems? Where are (including brief note on updates / progress where appropriate to be impact of risk score or we failing to make them effective? and confirm when action completed) completed likelihood or both? What actions are required to bridge the gaps in controls and / Where is the CCG failing to gain evidence that the by (date) Impact Likelihood Both controls / systems are effective? or assurance? • Further details of the risk being evaluated by the Risk under review. April 2019 Interim Director of Urgent Care and Emergency ☐ ☐ ☒ Planning. • ☐ ☐ ☐ • ☐ ☐ ☐
Collaborative Risks - current high risks for information
See Corporate Performance Report and also Provider Performance Assurance Report for details.
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J Blank Page Paper J East Leicestershire and Rutland CCG Governing Body meeting 9 April 2019 EAST LEICESTERSHIRE AND RUTLAND CLINICAL COMMISSIONING GROUP GOVERNING BODY MEETING
Front Sheet
REPORT TITLE: Register of Interests 2018/19 and Register of Gifts and Hospitality 2018/ 2019 MEETING DATE: 9 April 2019
REPORT BY: Daljit K. Bains, Head of Corporate Governance and Legal Affairs
SPONSORED BY: Karen English, Managing Director
PRESENTER: Karen English, Managing Director
PURPOSE OF THE REPORT: 1. All Governing Body members and senior employees of the East Leicestershire and Rutland CCG have a legal obligation to act in the best interests of the Clinical Commissioning Group (CCG) and have a duty to conduct NHS business with probity. The Code of Accountability for NHS Boards; Standards for members of Boards and CCG Governing Bodies; and the CCG’s Conflicts of Interest, Gifts and Hospitality and Sponsorship Policy 2017 (which is in line with NHS England’s guidance) set out the requirement that chairs and all Governing Body members should declare any conflict of interest that arises in the course of conducting NHS business.
2. Governing Body members, committee members and CCG staff are expected to demonstrate high standards of corporate and personal conduct including impartiality, integrity and objectivity in the execution of their roles and responsibilities. This also means adherence to the standards of probity outlined in the ‘Seven Principles of Public Life’ (i.e. the Nolan Principles).
3. All members and senior employees of the CCG are therefore expected to declare any personal or business interest which may influence, or may be perceived to influence, their judgement in line with the updated CCG Conflicts of Interest, Gifts and Hospitality and Sponsorship Policy (as approved in December 2017 by the Audit Committee). This includes, as a minimum: financial interests, non-financial professional interests; non-financial personal interests; and indirect interests which includes such interests of close family members.
4. As detailed within the CCG Constitution, the Accountable Officer is responsible for an annual review of the declarations of interest register. The updated register is as at Appendix 1 and will be published on the CCG website. The register of interests relates to declarations during 1 April 2018 – 31 March 2019 and continues to be updated on a regular basis, and in line with the Policy. Governing Body members are asked to review the content to ensure the conflicts are an accurate reflection.
5. The register containing staff declarations of interest and conflicts is held within the Corporate Office. In addition, there is also a more detailed register covering
1 Paper J East Leicestershire and Rutland CCG Governing Body meeting 9 April 2019 declarations raised at the Primary Care Commissioning Committee meetings, which also documents how the risk of potential and actual conflicts within this Committee have been managed, which is then reviewed by the Audit Committee.
6. Furthermore, all Governing Body members, senior employees and staff are also required to declare any gifts or hospitality received or offered in connection with their role in the CCG. A register is maintained by the Head of Corporate Governance and Legal Affairs and updated on a regular basis. The current register is as at Appendix 2.
7. This report provides assurance to the Governing Body that systems and processes are in place to demonstrate compliance with the CCG’s governance arrangements as outlined within its Constitution.
RECOMMENDATIONS: The East Leicestershire and Rutland CCG Governing Body is requested to:
RECEIVE and APPROVE the report and the register of interests as at Appendix 1 and the register of gifts and hospitality at Appendix 2 ahead of publishing these versions as at 31 March 2019.
2
Appendix 1 EAST LEICESTERSHIRE AND RUTLAND CLINICAL COMMISSIONING GROUP
Declarations of Interest - 2018 - 2019 (v4, 31 March 2019) N.B. including dates "to", "from" or both as per guidance relating to the interest where new or circumstances have changed through the year. Name Job Title Financial Interests Non-financial professional Non-financial personal interest Indirect Interests Actions to be taken to mitigate the risks interests (see Conflicts of Interest Policy for details)
Mrs Karen Managing Member of Chartered Institute of Husband is the owner of Graham English If consultancy firm required Karen would not English Director N/A Public Finance and Accountancy. N/A Consultancy Ltd. be part of the procurement process. Dr Richard Palin CCG Chairman GP Partner at Bushloe End Surgery, Wigston. Member Royal College of General Friend is the Managing Director for Insypher In relation to financial interests, to ensure Practitioners and British Medical Ltd (data analytics) and Managing Director individual does not participate in the decision- (until 19 October GP at HMP Leicester (until May 2018). Association Member. of Your Products Ltd (medical food making process in committee meetings (e.g supplements). to absent themselves from meetings at the 2018) Leicestershire Partnership Trust Clinical Director for Prisons. relevant point on the agenda); during Governance role as part of contract held by my practice Brother-in-law is the chairman of the procurement processes individuals to seek Bushloe Surgery (until May 2018). Doctors' and Dentists' Remuneration advice if and up to which part of the process Committee. individuals can be involved in, or not involved Board member and Medical Director of Spirit Clinical Services with at all etc. N/A Ltd. Employed role providing governance support and advice to clinical services company on limited part-time basis.
Practice is a member of the East Leicestershire and Rutland GP Federation.
Practice is a minor shareholder in Leicester, Leicestershire and Rutland Provider Company Ltd. (LLR Provider Company Ltd). Dr Ursula CCG Chair GP Partner at Central Surgery and South Wigston Health Husband is an employee of Phillips In relation to financial interests, to ensure Montgomery Centre. Healthcare. individual does not participate in the decision- making process in committee meetings (e.g Practice is a member of the East Leicestershire and Rutland to absent themselves from meetings at the (from 22 October GP Federation. relevant point on the agenda); during 2018) procurement processes individuals to seek Minor Shareholder in the Leicester, Leicestershire and Rutland advice if and up to which part of the process Provider Company Ltd. (LLR Provider Company Ltd). individuals can be involved in, or not involved with at all etc. Dr David Andrew GP Governing GP Partner in Oakham Medical Practice and Market Overton Member of the British Medical Wife is a partner at Oakham Medical In relation to financial interests, to ensure James Ker Body Member, and Somerby Surgery. Association and Royal College of Practice and Market Overton and Somerby individual does not participate in the decision- Clinical Vice Chair General Practitioners. Surgery. (25 March 2019 confirmed wife making process in committee meetings (e.g Practice is a provider of minor injury services. now retired). to absent themselves from meetings at the relevant point on the agenda); during Practice is a member of the East Leicestershire and Rutland procurement processes individuals to seek GP Federation. Partner at the Practice is a Board member on advice if and up to which part of the process the ELR Federation Board. individuals can be involved in, or not involved N/A with at all etc. Minor Shareholder in the Leicester, Leicestershire and Rutland Provider Company Ltd. (LLR Provider Company Ltd).
Oakham Medical Practice and Market Overton and Somerby Surgery are minority shareholders in The Leicester, Leicestershire and Rutland Provider Company Ltd. (LLR Provider Company Ltd). Dr Nicholas GP Governing GP Partner at Northfield Medical Centre, Blaby. Member of the Royal College of In relation to financial interests, to ensure Glover Body Member, General Practitioners and British individual does not participate in the decision- South Blaby and GP Trainer, East Midlands Deanery. Medical Association. making process in committee meetings (e.g Lutterworth Locality to absent themselves from meetings at the Lead Member of the Leicester, Leicestershire and Rutland Local relevant point on the agenda); during Medical Committee. procurement processes individuals to seek N/A N/A advice if and up to which part of the process Practice is a member of the East Leicestershire and Rutland individuals can be involved in, or not involved GP Federation. with at all etc.
The Northfield Medical Centre is a minor shareholder in Leicester, Leicestershire and Rutland Provider Company Ltd. (LLR Provider Company Ltd). Name Job Title Financial Interests Non-financial professional Non-financial personal interest Indirect Interests Actions to be taken to mitigate the interests risks Dr Graham GP Governing GP Partner at Wycliffe Medical Practice. In relation to financial interests, to ensure Johnson Body Member, individual does not participate in the decision- Blaby and Member of the Leicester, Leicestershire and Rutland Local making process in committee meetings (e.g Lutterworth Locality Medical Committee. to absent themselves from meetings at the (until 31 October Lead relevant point on the agenda); during 2018) Practice is a member of the East Leicestershire and Rutland N/A N/A N/A procurement processes individuals to seek (until 31 October GP Federation. advice if and up to which part of the process 2018) individuals can be involved in, or not involved Wycliffe Medical Practice is a minor shareholder in Leicester, with at all etc. Leicestershire and Rutland Provider Company Ltd. (LLR Provider Company Ltd). Dr Simon Vincent GP Governing GP Partner at The Limes Medical Centre, Narborough. In Fellow of the Royal College of In relation to financial interests, to ensure Body Member, addition to usual GP services the Practice holds the contract General Practitioners and individual does not participate in the decision- (from 1 November North Blaby for the Medical Services to Stewart House, Mill Lodge and the Member of the British Medical making process in committee meetings (e.g Locality Lead Violent Patient Service. Association to absent themselves from meetings at the 2018) relevant point on the agenda); during As a GP Partner at The Limes Medical Centre in receipt of procurement processes individuals to seek rental income from the on site pharmacy, Peak Pharmacy. advice if and up to which part of the process N/A N/A individuals can be involved in, or not involved Practice is a member of the East Leicestershire and Rutland with at all etc. GP Federation.
The Limes Medical Centre is a shareholder in the Leicester, Leicestershire and Rutland Provider Company Ltd (LLR Provider Company Ltd). Dr Girish Purohit GP Governing Director Holiday Club 4 Kids Services Ltd and Nurseries 'R' Us In relation to financial interests, to ensure Body Member, Ltd - child care and nursery manned by wife. individual does not participate in the decision- Syston, Long making process in committee meetings (e.g Clawson and Dr Purohit and his wife are Directors of Purohit Property Ltd to absent themselves from meetings at the Melton Locality (from 1st May 2018). relevant point on the agenda); during Lead procurement processes individuals to seek GP Partner at The Jubilee Medical Practice, Syston Health advice if and up to which part of the process Centre, Syston, Leicestershire. individuals can be involved in, or not involved with at all etc. The Practice is also the Jubilee Medical Practice Academy and Training Hub. N/A N/A N/A
Practice is a member of the East Leicestershire and Rutland GP Federation.
The Jubliee Medical Practice is a shareholder in The Leicester, Leicestershire and Rutland Provider Company Ltd (LLR Provider Company Ltd).
Dementia Lead for East Midlands Clinical Mental Health Network (from 23 May 2018). Name Job Title Financial Interests Non-financial professional Non-financial personal interest Indirect Interests Actions to be taken to mitigate the interests risks Dr Vivek GP Governing GP Partner at The Croft Medical Centre, Oadby, Leicester. FY2 Trainer in general practice Wife is shareholder in Bushby Lodge In relation to financial interests, to ensure Varakantam Body Member, (Health Education East Midlands) Medical (medical services company). individual does not participate in the decision- Oadby and Director Bushby Lodge Medical Personal Health Services (Out making process in committee meetings (e.g Wigston of Hours) Member of the Royal College of Wife commenced post in Interserve in care to absent themselves from meetings at the General Practitioners and British at home (therefore conflicted with e.g. CHC) - relevant point on the agenda); during Resigned Director - LLR Provider Company. Medical Association member. March 2015. procurement processes individuals to seek advice if and up to which part of the process The Practice is also the Jubilee Medical Practice Academy Academic Champion / Research individuals can be involved in, or not involved and Training Hub. Fellow for University of Leicester. with at all etc.
Undertakes examination of medical students at the University N/A of Leicester.
The Croft Medical Centre is a shareholder in the Leicester, Leicestershire and Rutland Provider Company Ltd (LLR Provider Company Ltd).
Practice is a member of the East Leicestershire and Rutland GP Federation. Partner at the Practice, Dr Shiraz Makda, is a Board member on the ELR Federation Board. Dr Tim Daniel Consultant in Consultant in Public Health Medicine – Leicestershire County Member of Royal College of Wife appointed as Non-Executive Director at In relation to financial interests, to ensure Public Health Council (from 01.04.2013); East Midlands Public Health General Practitioners and British Derby Hospitals Foundation Trust (October individual does not participate in the decision- Medicine Foundation Programme Director for LNR; Salaried GP Medical Association. Fellow of 2014). making process in committee meetings (e.g Kegworth and Gotham Medical Practice; Sessional GP for Faculty of Public Health to absent themselves from meetings at the Nottingham Emergency Medical Services and Rushcliffe CCG N/A Wife is Professor of Healthcare Research at relevant point on the agenda); during Extended Access Primary Care Scheme. University of Nottingham . procurement processes individuals to seek advice if and up to which part of the process individuals can be involved in, or not involved with at all etc. Public Health Public Health Consultant - Leicestershire County Council Husband is a Consultant Anaesthetist at In relation to financial interests, to ensure Consultant (from 13 August 2018) University Hospitals of Leicester NHS Trust. individual does not participate in the decision- making process in committee meetings (e.g to absent themselves from meetings at the Dr Katherine Fellow of Faculty of Public Health, Member of British Medical N/A relevant point on the agenda); during Packham Association procurement processes individuals to seek advice if and up to which part of the process individuals can be involved in, or not involved with at all etc. Dr Tabitha Louise Consultant Consultant Paediatric Endocrinologist, Nottingham University Member of British Society of Husband is employed by Leicestershire In relation to financial interests, to ensure Randell Paediatric Hospitals NHS Trust. Paediatric Endocrinology and Partnership Trust as Paediatric Advanced individual does not participate in the decision- Endocrinologist Diabetes. Nurse Practitioner. making process in committee meetings (e.g (Board member: Clinical Teaching Fellow, Warwick Medical School. Received Member of British Medical to absent themselves from meetings at the (until 31 March secondary care lecture fees from NovoNordisk, Lilly and Abbott Diabetes Care. Association. N/A relevant point on the agenda); during 2019) clinician) Received consultancy fees from Abbott Diabetes Care. Fellow of the Royal College of procurement processes individuals to seek Paediatrics and Child Health. advice if and up to which part of the process Member of advisory board of individuals can be involved in, or not involved diabetes.co.uk with at all etc. Dr Anuj Chahal GP Governing GP Partner at the Two Shires Medical Practice, Kibworth, Member of the British Medical In relation to financial interests, to ensure Body Member, Leicestershire. Association and Royal College of individual does not participate in the decision- (from 1 December Harborough General Practitioners. making process in committee meetings (e.g Locality Lead Resigned Director - LLR Provider Company. to absent themselves from meetings at the 2017) Resigned Director - ELR GP Federation relevant point on the agenda); during procurement processes individuals to seek N/A N/A The Two Shires Medical Practice is a sharehodler in the advice if and up to which part of the process Leicester, Leicestershire and Rutland Provider Company Ltd individuals can be involved in, or not involved (LLR PRovider Company Ltd). with at all etc. Practice is a member of the East Leicestershire and Rutland GP Federation. GP Trainer, East Midlands Deanery. Name Job Title Financial Interests Non-financial professional Non-financial personal interest Indirect Interests Actions to be taken to mitigate the interests risks Dr Hilary Fox GP Governing Salaried GP at Oakham Medical Practice, Oakham, Rutland, In relation to financial interests, to ensure (from 3 January Body Member, Leicestershire. Fellow Royal College of General individual does not participate in the decision- 2019) Rutland Locality Practitioners and British Medical making process in committee meetings (e.g Lead Practice is a member of the East Leicestershire and Rutland Association member. to absent themselves from meetings at the GP Federation. relevant point on the agenda); during N/A N/A procurement processes individuals to seek The Oakham Medical Practice is a shareholder in the advice if and up to which part of the process Leicester, Leicestershire and Rutland Provider Company Ltd individuals can be involved in, or not involved (LLR Provider Company Ltd). with at all etc.
Mr Warwick Independent Lay Member of Chartered Institute of Kendrick Member N/A Management Accountants N/A N/A N/A (CIMA).
Mr Clive Wood Deputy Chair / Vice President Section UK, Son is employee of Total Community Care In relation to financial interests, to ensure Independent Lay International Police Association Ltd which provides specialist care services individual does not participate in the decision- Member (until end May 2018). for individuals with spinal cord injury and making process in committee meetings (e.g other neurological conditions. to absent themselves from meetings at the N/A President Section UK, N/A relevant point on the agenda); during International Police Association procurement processes individuals to seek (from 9 June 2018). advice if and up to which part of the process individuals can be involved in, or not involved with at all etc. Mr Alan Frederick Independent Lay Member of the Chartered Institute Smith Member of Public Finance and N/A Accountancy. N/A N/A N/A
Mr Tim Sacks Chief Operating Wife was a partner at Oakham Medical Officer N/A N/A N/A Practice (from 1st July 2013 - end February N/A 2015). Tracy Burton Interim Chief Nurse Registered with the Nursing Husband is a lay member with South West (from 1 April 2018) and Quality Officer N/A Midwifery Council. N/A Lincolnshire CCG . N/A
Ms Donna Enoux Chief Finance Member of the Chartered Institute Registered as a patient at The Jubilee Note that interest is not a direct financial Officer of Management Accountants. Medical Practice, Syston Health Centre, interest, and as a member of the CCG Syston, Leicestershire, which is the Practice Executive Team and a member of the CCG of one of the Governing Body members. Governing Body it may not be possible for the individual not to participate in the decision- N/A N/A making process in committee meetings relating to this Practice. However, if a direct potential or actual conflict of interest arises then appropriate action to be taken in line with the Policy. Mr Paul Gibara Chief Commissioning (from 24 July N/A N/A N/A N/A N/A 2017) and Performance Officer
Appendix 2 EAST LEICESTERSHIRE & RUTLAND CLINICAL COMMISSIONING GROUP
Register of Gifts & Hospitality 2018-19 (v4, 31 March 2019) Ref Name of receipient and job Date of offer / receipt of Description of gift / hospitality Estimated Value Supplier / Offeror Name and Details of Previous Offers Details of the officer Declined or Reason for declining or Other Comments title gift / hospitality £ Nature of Business or Acceptance by this reviewing and approving accepted and date accepting Offeror/ Supplier the declaration made and date
1 Shazia Patel - Senior 21/06/18 Payment for lunch at PLT £378 Gee Gahir - Thornton and No previous offers made. Tim Sacks, Chief Accepted 31/05/18 Accepted in line with current Pharmacist educational event on 21/06/18 Ross Pharamceutical Co. Operating Officer policy. 2 Shazia Patel - Senior 21/06/18 Payment for lunch at PLT £378 Harprett Pangli - Fontus No previous offers made. Tim Sacks, Chief Accepted 31/05/19 Accepted in line with current Pharmacist educational event on 21/06/18 Health Pahrmaceutical Co. Operating Officer policy. 3 Vishal Mashru - Head of 10/10/18 Payment for lunch at PLT £228 Neon Diagnostics No previous offers made. Tim Sacks, Chief Accepted Accepted in line with current Prescribing educational event for Pharmacists Operating Officer policy. on 10/10/18. 4 Vishal Mashru - Head of 18/10/18 Payment for lunch at PLT £175 Internis Pharma No previous offers made. Tim Sacks, Chief Accepted Accepted in line with current Prescribing educational event for Pharmacists Operating Officer policy. on 18/10/18. 5 Jamie Barrett - Head of 14/11/18 Green and Blacks Organic £6 Kibworth Health Centre No previous offers made by Paula Vaughan, Deputy Accepted 14/11/18 Accepted in line with current Primary Care Chocolate Selection the Practice. Chief Operating Officer policy. 6 Tim Sacks - Chief Operating 14/11/18 Green and Blacks Organic £6 Kibworth Health Centre No previous offers made by Paula Vaughan, Deputy Accepted 14/11/18 Accepted in line with current Offcier Chocolate Selection the Practice. Chief Operating Officer policy. 7 Seema Gaj - Primary Care 14/11/18 Green and Blacks Organic £6 Kibworth Health Centre No previous offers made by Paula Vaughan, Deputy Accepted 14/11/18 Accepted in line with current Contract Management, NHS Chocolate Selection the Practice. Chief Operating Officer policy. England 8 Khatija Hajat - Primary Care 14/11/18 Green and Blacks Organic £6 Kibworth Health Centre No previous offers made by Paula Vaughan, Deputy Accepted 14/11/18 Accepted in line with current Contracts Manager Chocolate Selection the Practice. Chief Operating Officer policy. 9 Pragati Baddhan - Senior 14/11/18 Green and Blacks Organic £6 Kibworth Health Centre No previous offers made by Paula Vaughan, Deputy Accepted 14/11/18 Accepted in line with current Communications and Chocolate Selection the Practice. Chief Operating Officer policy. Engagement Manager 10 Nicola Smith - Lead Nurse 20/12/2018 Box of Hotel chocolates £18 Langdale Care Home Previously a chocolate box Tracy Burton, Interim Chief Accepted 20/12/18 Tried to decline without Chocolates shared Quality and Contracts was accepted. Nurse offending the provider. with team. 11 Karen Wood - Clinical Quality 07/01/2019 Box of Hotel chocolates £18 Langdale Care Home Previously a chocolate box Tracy Burton, Interim Chief Accepted 7/1/2019 Tried to decline without Chocolates shared Lead was accepted. Nurse offending the provider. with team. 12 Sarah Warmington - 24/1/19 - 25/1/19 Health Service Journal (HSJ) £98 bed and HSJ - fully sponsored event N/A Karen English, Managng Accepted 24/1/2019 The two day event was Associate Director of Mental Health Summit breakfast Director inclusive of bed and Commissioning Mental Health breakfast provisions, and and Learning Disability this was accepted given the distance to travel to the event from home. 13 Vishal Mashru - Head of 14/03/2019 Payment for lunch at PLT £404 Fontus Health Fontus Health sponsored Tim Sacks, Chief Accepted 14/3/2019 Accepted in line with current Prescribing educational event for Pharmacists an event in June 2018 Operating Officer policy. on 10/10/18.
14 Vishal Mashru - Head of 14/03/2019 Payment for PLT educational £404 Daiichi UK N/A Tim Sacks, Chief Accepted 14/3/2019 Accepted in line with current Prescribing event for Pharmacists on Operating Officer policy. 10/1/2019. K Blank Page Paper K ELR CCG Governing Body Meeting 9 April 2019
EAST LEICESTERSHIRE AND RUTLAND CLINICAL COMMISSIONING GROUP GOVERNING BODY MEETING
Front Sheet
REPORT TITLE: Quality Strategy 2019-2021
MEETING DATE: 9 April 2019
REPORT BY: Amy Linnett, Quality Lead
SPONSORED BY: Tracy Burton, Chief Nurse and Quality Officer
PRESENTER: Tracy Burton, Chief Nurse and Quality Officer
EXECUTIVE SUMMARY: The ELRCCG Quality Strategy has been written to reflect the 2019-2021 priorities in accordance with the NHS England Improvement and Assessment Framework indicator 57: Compliance with statutory guidance on patient and public participation in commissioning health and care
RECOMMENDATIONS: The East Leicestershire and Rutland CCG Governing Body is requested to: • APPROVE ELRCCG Quality Strategy 2019-2021
REPORT SUPPORTS THE FOLLOWING STRATEGIC AIM(S) 2017 – 2018: Transform services and enhance quality of Improve integration of local services life for people with long-term conditions between health and social care; and between acute and primary/community care. Improve the quality of care – clinical X Listening to our patients and public – X effectiveness, safety and patient experience acting on what patients and the public tell us. Reduce inequalities in access to healthcare X Living within our means using public money effectively Implementing key enablers to support the strategic aims (e.g. constitutional and governance arrangements, communications and patient engagement). X
EQUALITY ANALYSIS An equality analysis and due regard to the positive general duties of the Equality Act 2010 has been undertaken in the development of this report and its influence on the recommendation(s) is evidenced in Appendix 1
RISK ANALYSIS AND LINK TO BOARD ASSURANCE FRAMEWORK: The content of the report identifies BAF action(s) to be taken / are being taken
1
Paper K ELR CCG Governing Body Meeting 9 April 2019 to mitigate the following corporate BAF risk(s) as identified in the Board Assurance Framework:
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Paper K ELR CCG Governing Body Meeting 9 April 2019
EAST LEICESTERSHIRE AND RUTLAND CLINICAL COMMISSIONING GROUP GOVERNING BODY MEETING
ELRCCG Quality Strategy 2019-2021 9 April 2019
BACKGROUND
1. The ELRCCG Quality Strategy 2019-2021 has been created to support the commissioning intentions, explain the quality commitments and provide a framework of quality assurance within ELRCCG.
2. The Strategy has been written based on the following national quality drivers: o Leading Change, Adding Value, o National Quality Board; Shared commitment to Quality o Care Quality Commission standards
3. We believe the areas which matter most to people who use services are: o Safety: people are protected from avoidable harm and abuse. When mistakes occur lessons will be learned. o Effectiveness: people’s care and treatment achieves good outcomes, promotes a good quality of life, and is based on the best available evidence. o Positive experience: - Caring: Staffs involve and treat you with compassion, dignity and respect. - Responsive and person-centred: services respond to people’s needs and choices and enable them to be equal partners in their care.
4. We know that to provide high-quality care, we need high performing providers. We are committed, as Commissioners to working together with providers in partnership with, and for the local people and communities. We seek to commission services from providers that: o Are well-led: they are open and collaborate internally and externally and are committed to learning and improvement. o Use resources sustainably: they use their resources responsibly and efficiently, providing fair access to all, according to need, and promote an open and fair culture. o Are equitable for all: they ensure inequalities in health outcomes are a focus for quality improvement, making sure care quality does not vary due to characteristics
5. The Strategy references the recently published NHS Long Term Plan, and the development of the Leicestershire and Rutland’s (LLR) Integrated Care
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Paper K ELR CCG Governing Body Meeting 9 April 2019
System (ICS) as an enabler to turn the plan into local actions to improve services and health and wellbeing of the communities we serve.
6. The Strategy is applicable to all ELRCCG commissioned health care services, and includes those services commissioned by ELRCCG on behalf of LLR. There are a number of ELRCCG policies that support this strategy such as Serious Incident Policy, Safeguarding Policy and the Equalities and Inclusion Strategy.
7. The ELRCCG strategic quality commitments reflect those of the National Quality Board and include:
8. The strategy includes the commissioning cycle, role of the Integrated Governance Committee and the quality assurance, improvement and early intervention processes including the route for escalation of risk.
9. There is a supportive Quality Improvement Framework structuring routes of assurance to and from the Governing Body and a Risk Escalation Framework detailing routes for raising concerns and the appropriate forum to do so.
10. The Quality Strategy is required for inclusion on the CCG’s Improvement and Assessment Framework; Indicator 57 – compliance with statutory guidance on patient and public participation in commissioning health and care, which is due for submission to NHS England on 8th March 2019.
11. The Quality Strategy has been to ELRCCG Integrated Governance Committee for comment; those received are reflected within this final version, namely the inclusion of a Risk Escalation Framework.
Recommendation: The East Leicestershire and Rutland CCG Integrated Governance Committee is requested to: • APPROVE the ELRCCG Quality Strategy 2019-2021
4
QUALITY STRATEGY
2019-2021
Reference number: ELR CORPORATE 051 Title: Quality Strategy 2019-2021 Version number: Version 1 draft 1 (February 2019) Policy Approved by: Date of Approval: Date Issued:
Review Date: February 2021
Document Author: Amy Linnett, Quality Lead, ELRCCG
Director: Tracy Burton, Chief Nurse, ELRCCG
Version Control
Version Approval / Amendments made Date number (Month Year) Version 1, draft 1 New Strategy Written Feb 2019
DOCUMENT STATUS: This is a controlled document. Whilst this document may be printed, the electronic version posted on the intranet is the controlled copy. Any printed copies of the document are not controlled.
RELATED DOCUMENTS: This document will reference additional policies and procedures which will provide additional information
Quality Strategy 2019-2020 v1.0 Published April 2019
Foreword
Healthcare services across England are facing the combined challenges of rising demand, escalating costs, advancing science changing expectations and tough economic circumstances. Meeting these challenges whilst maintaining and improving quality will not be easy, but is essential for the sustainability of our NHS.
The development of our Leicester, Leicestershire and Rutland (LLR) Integrated Care System (ICS), is specifically focused on the health and wellbeing, care and quality, finance and efficiency care gaps. This, along with the development of new models of care challenges our way of assuring and continually improving the quality of services that our patients experience.
The quality of the care that our patients receive defines the success of NHS East Leicestershire and Rutland CCG.
This quality strategy maintains the East Leicestershire and Rutland Clinical Commissioning group’s (ELR CCG) ability to assure the quality of the services that we commission and are provided to our patients, through a focus on clinical effectiveness, safety and the patient experience. We will develop the culture and skills to ensure that continual quality improvement is central to all of our commissioning and the services of our providers.
Tracy Burton Dr Ursula Montgomery Chief Nurse Clinical Chair East Leicestershire and Rutland East Leicestershire and Rutland Clinical Commissioning Group Clinical Commissioning Group
Quality Strategy 2019-2020 v1.0 Published April 2019
Contents
Equality Impact Statement 5
Our Vision for Quality 5
What Quality means to us 5
Leicester, Leicestershire and Rutland Integrated Care System 6
East Leicestershire and Rutland CCG 6
Quality Commitments 7
Quality at the Heart of Commissioning 8
Integrated Governance Committee 8
Quality Improvement 9
Quality Assurance and Early Intervention 10
Escalation of Risk 10
Monitoring and Review 10
References 11
Appendix 1- Quality Assurance Framework 12
Appendix 2 - Escalating Concerns Process 12
Quality Strategy 2019-2020 v1.0 Published April 2019 4
Equality Impact Statement
1. The organisation is committed to promoting equality in all its responsibilities – as commissioner of services, as a provider of services, as a partner in the local economy and as an employer. This policy will contribute to ensuring that all users and potential users of services and employees are treated fairly and respectfully with regard to the protected characteristics of age, disability, gender, reassignment, marriage or civil partnership, pregnancy and maternity, race, religion, sex and sexual orientation. A copy of the full Equality Impact Assessment is available on request.
Our Vision for Quality
2. This strategy outlines how East Leicestershire and Rutland CCG (ELRCCG) will continue to ensure that quality is at the heart of everything we do. It is built around the priorities identified by ELRCCG for commissioning high quality healthcare services for its residents.
3. The people of ELR deserve to enjoy the best possible health and wellbeing, and receive quality health care when they need it. We believe in everyone getting the right care, in the right place, at the right time. The NHS Five Year Forward View (2015) confirmed a national commitment to high-quality, person-centered care for all and described the changes that are needed to deliver a sustainable health and care system.
What Quality means to us
4. The national policy drivers for quality are underpinned by six fundamental values: care, compassion, competence, communication, courage and commitment (6Cs) – these six areas of action will help to support the CCG to commission excellent care and promote enduring values and behaviours.
5. The NHS England strategy; Leading Change Adding Value, has developed further upon the 6Cs and is based upon 10 commitments.
6. The National Quality Board’s Shared Commitment to Quality is also reflected within this strategy.
7. We believe the areas which matter most to people who use services are: • Safety: people are protected from avoidable harm and abuse. When mistakes occur lessons will be learned. • Effectiveness: people’s care and treatment achieves good outcomes, promotes a good quality of life, and is based on the best available evidence. • Positive experience: - Caring: staff involve and treat you with compassion, dignity and respect. - Responsive and person-centred: services respond to people’s needs and choices and enable them to be equal partners in their care.
Quality Strategy 2019-2020 v1.0 Published April 2019 5
8. We know that to provide high-quality care, we need high performing providers. We are committed, as Commissioners to working together with providers in partnership with, and for the local people and communities.
9. We seek to commission services from providers that:
• Are well-led: they are open and collaborate internally and externally and are committed to learning and improvement. • Use resources sustainably: they use their resources responsibly and efficiently, providing fair access to all, according to need, and promote an open and fair culture. • Are equitable for all: they ensure inequalities in health outcomes are a focus for quality improvement, making sure care quality does not vary due to characteristics such as gender, race, disability, age, sexual orientation, religion, belief, gender reassignment, pregnancy and maternity or marital or civil partnership status
Leicester, Leicestershire and Rutland’s (LLR) Integrated Care System (ICS)
10. In 2019 NHS England published the Long Term Plan which further supports qualitative improvements. The Long Term Plan identifies that as medicine advances, health needs change and society develops, the NHS has to continually move forward so that in 10 years’ time there is a service fit for the future.
11. As Leicester, Leicestershire and Rutland’s (LLR) Integrated Care System (ICS) develops, East Leicestershire and Rutland CCG will work together with neighbouring CCGs, local councils and other partners to develop and implement a strategy to turn the NHS Long Term Plan into local actions to improve services and the health and wellbeing of the communities we serve.
East Leicestershire and Rutland CCG
12. This quality strategy will cover all ELRCCG commissioned health care services. This will include those services commissioned by ELRCCG on behalf of Leicester City and West Leicestershire CCG to provide services across LLR. ELRCCG leads on work to improve the safety of care across the LLR system via the Patient Safety Team and has established the Transferring Care Safely programme which collates specific incidents, identifies themes and holds providers to account to ensure change and then ensures learning is shared across LLR via Patient Safety Reports. ELRCCG has a team who monitor the quality of health care within the Nursing homes providing care commissioned by the LLR CCGs and has driven forward the Enhanced Health in Care Homes agenda across LLR.
13. We will review progress made in respect of improving the quality of all services and reducing avoidable harm and keeping people safe. We will explore how we have made a positive difference to the patient experience. We will actively foster and promote a learning culture across the health economy.
14. This Quality Strategy, processes and procedures are based on not only delivering national standards but where possible innovating to exceed them. There are a number of CCG policies that support this strategy such as Serious Incident Policy, Safeguarding Policy and the Equalities and Inclusion Strategy.
15. We are fully committed to the Public Sector Equality Duty as set out in the Equality Act
Quality Strategy 2019-2020 v1.0 Published April 2019 6
(2010). This ensures that the services we commission are equitable and comply with the principles of ‘Due regard’.
16. During the next 2 years ELRCCG’s priority and focus will be on the following domains:
• During 2019/20 we will develop further improvement targets for clinical outcomes, patient safety and patient experience, ensuring that all providers including our general practices are fully aware of the quality
standard requirements. We will support the development of the ICS 2019/20 ensuring that quality is central to innovative models of patient care.
• During 2020/21 we will raise the quality agenda further within all our providers. ELRCCG has a responsibility for general practice and care homes as well as our larger NHS providers and hosted services and will proactively support improvements by working with all providers. ELRCCG 2020/21 will actively support the sharing of best practice acroos providers , with key partners and the public.
Quality Commitments
17. ELRCCG strategic quality committees reflect those of the National Quality Board:
Quality Strategy 2019-2020 v1.0 Published April 2019 7
Quality at the Heart of Commissioning
18. Whilst the primary focus of quality is the services patients use, we aim to become a high quality commissioning organisation in order to commission high quality services and support our members effectively. Quality is central to our whole commissioning cycle and impacts our commissioning and contracting decisions for prospective services. (See Figure 1 below).
Assessing Health Needs
Identifying Monitor and Gaps in Manage Service Performance Patient feedback Provision Evidence based best practice Clinical outcomes Quality Assurance
Deciding Priorities and Procurement service redesign
19. We will use Quality Impact Assessments to support our commissioning decisions, supported by confirm and challenge.
Integrated Governance Committee
20. We will use a Quality Assurance Framework to identify, monitor and challenge quality in the organisations we commission services from (see Appendix 1). Good quality information is a pre-requisite to understanding current services, for gaining improvement and planning future services. It supports our role to commission the right services and best possible care for our resident population. Assurance about the quality of local providers is monitored by analysis of quality indicators within the quality schedules within all contracts, directly by Clinical/ Contract Quality Review Groups for our larger providers, which report to the Governing Body through the Integrated Governance Committee (a sub-committee of the Governing Body) or by quality assurance reports for other providers.
21. The remit of the Integrated Governance Committee, along with other priorities is to: • Seek assurance that patient, public, partner and stakeholder engagement is integral to commissioning decisions. • Ensure that quality, patient safety, patient experience, and due regard to the public sector equality duty is integral to commissioning functions by identifying themes and trends which influence commissioning decisions.
Quality Strategy 2019-2020 v1.0 Published April 2019 8
• Seek assurance from the appropriate groups (e.g. Provider Performance Assurance Group (collaborative meeting) and the Primary Care Commissioning Committee (CCG committee)) in relation to the quality and performance aspects of provider care provision (including primary medical care) to ensure appropriate monitoring of and identification of risks within commissioned services. • Receive assurance on actions in respect of quarterly reports which impact on quality and patient safety (such as complaints, serious incidents, Health Care Associated Infections (HCAIs), safeguarding and prescribing and medicines management reports); workforce reports. • Approve CCG specific clinical policies on behalf of the Governing Body; and make recommendations to the Governing Body in respect of region wide or national clinical policies • To have oversight of and receive assurance regarding Research and Innovation.
22. The IGC ensures the Governing Body is sighted on how commissioned services and CCG member practices are delivering safe and effective services via a number of early warning systems. These ensure the CCG is aware of quality and safety concerns within the organisations we commission services from. Significant risks are presented to the Governing Body through the directorate risk register and highlight reports from the Integrated Governance Committee.
23. The workforce that leads the Quality agenda brings together professionals and clinicians with specific expertise. They hold clear roles and responsibilities across the CCG and are linked to each of our provider contracts, GP Practices and Care Homes. Collectively, this workforce enables East Leicestershire and Rutland CCG to scrutinise and challenge providers as well as identify and provide leadership for improvements.
Quality Improvement
24. ELRCCG is committed to improving the quality of the services we commission including the promotion of shared learning and best practice to allow innovation and reduced variation to prevail. We will adopt the National Quality Board seven steps, as below, to enable us to maintain and improve the quality of care that people within ELR experience.
Quality Strategy 2019-2020 v1.0 Published April 2019 9
Quality Assurance and Early Intervention
25. We have a system of quality assurance and early warning processes in place which provides information about the safety, effectiveness and patient experience of services we commission. We use data to assess, measure and improve quality enabling a proactive approach in identifying early warning signs and the action required where standards fall short. It also helps to inform our commissioning decisions at all stages of the commissioning cycle ensuring that quality is at the heart of everything we do.
Escalation of Risk
26. Where early intervention is recognised via either of these forums, the relevant quality improvement processes will be enacted and monitored, prior to escalation of the risk.
27. Escalation of risk is overseen by variety of routes dependent on the severity and impact. These routes have been established to systematically bring together the different parts of the system ensuring:
• A collaborative view of risks to quality through sharing intelligence; • An early warning mechanism of risk to identify quality concerns; • Opportunities to coordinate actions and drive improvement are maximised
See Appendix 2.
Conclusion
28. The quality of the care that our patients receive defines the success of East Leicestershire and Rutland CCG. We recognise that this is best achieved by working in collaboration with our partners to deliver the quality across the LLR Integrated Care System. This partnership working enables synergy, a continuing quality improvement journey and effective and safe health care for our population, whilst enhancing the patient experience.
Monitoring and review
29. This policy will be reviewed on expiry, and in accordance with the following on an as and when required basis:
• legislative changes; • good practice guidance; • case law; • significant incidents reported; • new vulnerabilities; and • changes to organisational infrastructure.
Quality Strategy 2019-2020 v1.0 Published April 2019 10
References
Care Quality Commission; what to expect from a good care service (2019) https://www.cqc.org.uk/help-advice/what-expect-good-care-services/what-expect-good-care- service
NHS England; Leading Change, Adding Value (2019) https://www.england.nhs.uk/leadingchange/about/
National Quality Board; Shared commitment to quality (2016) https://www.england.nhs.uk/wp-content/uploads/2016/12/nqb-shared-commitment-frmwrk.pdf
Quality Strategy 2019-2020 v1.0 Published April 2019 11
Appendix 1
Quality Strategy 2019-2020 v1.0 Published April 2019 12
Appendix 2 Escalating Concerns Process
Stage 1: Triangulation of information from Provider data, Healthwatch, Infection Prevention Escalation of Risk and Control, Safeguarding, Patient Safety, Local Authority, NHS England
Operational CQRG pre-meet Risk Share Meeting pre-meet
Operational CQRG (monthly) Risk Share Meeting (monthly)
Quality Report to
PCCC (GP Quality) PPAG (Provider Assurance CHQAG (Care contracts) Governing Body Homes) (Monthly)
Stage 2: External Escalation
Extraordinary Actions agreed, such as: Quality Committee • Quality Visit (Senior Oversight • Quality Surveillance Meeting - As Group required
Stage 3: Next Steps Risk Review in line with National Guidance (As required)
L Blank Page Paper L East Leicestershire and Rutland CCG Governing Body meeting 9 April 2019
EAST LEICESTERSHIRE AND RUTLAND CLINICAL COMMISSIONING GROUP GOVERNING BODY MEETING
Front Sheet
REPORT TITLE: Assurance Report from the Provider Performance Assurance Group (PPAG) – February 2019
MEETING DATE: 9 April 2019
REPORT BY: Jayshree Raval Commissioning Collaborative Support Officer ELR CCG
SPONSORED BY: Karen English, Managing Director
PRESENTER: Warwick Kendrick, Independent Lay Member and Chair of PPAG
PURPOSE OF THE REPORT: This report is from the Provider Performance Assurance Group (PPAG); a meeting held in common of the 3 Leicester, Leicestershire and Rutland CCGs. This report provides the Governing Body with assurance about the arrangements in place to collaboratively monitor the contract arrangements and performance of our key providers.
RECOMMENDATIONS: The East Leicestershire and Rutland CCG Governing Body is requested to:
• RECEIVE the assurance report from PPAG.
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Paper L East Leicestershire and Rutland CCG Governing Body meeting 9 April 2019
EAST LEICESTERHSIRE AND RUTLAND CLINICAL COMMISSIONING GROUP
GOVERNING BODY MEETING 9 April 2019
Assurance Report from the Provider Performance Assurance Group (PPAG) – February 2019 Introduction
1. The purpose of this report is for Provider Performance Assurance Group (PPAG) to provide the Governing Body with a summary of the assurance received from the Contract Leads in relation to performance across the collaborative contracts, and the respective providers’ performance.
2. In addition, the report provides a summary of the items for escalation from PPAG during February 2019 for consideration by the Governing Body, and to ensure that the Governing Body is alerted to emerging risks or issues.
3. PPAG is a meeting held in common consisting of members from across each of the 3 Leicester, Leicestershire and Rutland CCGs. PPAG’s role is to:
• Receive assurance and hold to account the Contract Leads; • Advise, make suggestions and recommend actions on provider performance as appropriate; and • Provide onward assurance to the respective Governing Bodies.
Provider review and areas of concern
4. At the meeting in February 2019, PPAG received a report from each of the Contract Leads from across the 3 CCGs with the main focus on the University Hospitals of Leicester (UHL’s) contractual performance.
5. This report provides an overview and update on key areas of discussion and highlights issues for escalation from PPAG to the Governing Body.
Deep –Dive report from Leicester City CCG:
University Hospitals of Leicester (UHL)
6. It was reported that there are a number of longstanding performance issues at UHL affecting the expected standards for access and quality of care. The purpose of the deep-dive was to review the position and outline further contractual actions required to improve the provider’s performance. It was highlighted that in December 2018, UHL achieved 82.2% cancer 62day target against the 85% national standard. This has been an improvement to previous months performance. Monthly review of the remedial action plan (RAP) takes place via the Cancer Working Group and Cancer Pathway Programme Board.
7. The presentation highlighted the actions undertaken in developing to support cancer performance improvement. It was reported that writing of the Cancer Strategy for LLR is underway. In addition there is a joint system wide 90 day plan in respect of strengthening the governance and improvement of the cancer performance. Furthermore a joint 2ww joint Cancer audit is to be undertaken to understand the educational/support requirements. In addition the contract teams are looking to see if the actions from the 90 Page 2 of 5
Paper L East Leicestershire and Rutland CCG Governing Body meeting 9 April 2019
day plan could be incorporated into the 2019/20 contract the Service Development Improvement Plan (SDIP) to enable tightening up of the contractual requirements regarding cancer performance improvements.
8. Waiting List Stabilisation: PPAG noted that the a revised trajectory has been agreed by the Trust, CCGs and NHS Improvement to meet the refreshed 2018/19 planning guidance to ensure that the Trust waiting list is not larger at the end of 2018/19 than it was at the end of 2017/18. One element of the plan was for the Trust to transfer patients to the independent sector to support additional activity.
9. Cancelled Operations: It was reported that UHL have agreed to two local STP Commissioning for Quality and Innovation (CQUIN) schemes in theatres for 2018/19 and the achievements are reported through the Clinical Quality Review Group (CQRG). PPAG were made aware that the action plan for recovery has been reviewed and this indicates that the provider will be able to achieve the CQUIN schemes. It was however highlighted that a formal Contract Performance Notice would be issued if improvement to the trajectory is not met.. PPAG were assured that clinical priority is always at the forefront of any decision made by UHL.
10. A&E 4 hours: It was noted that performance continues to be below the required standard of 95%. The main root causes for this is the increased acuity of patients, internal process issues at UHL and increased attendances. Discharges are lower than normal which is impacting on the flow. PPAG were informed that the A&E Delivery Board (AEDB) have an oversight on the actions within the emergency recovery plan. Furthermore it was noted that the CCGs are conducting live audits of GP referrals to ED to prevent avoidable attendances.
11. Ambulance handover delays: It was reported that performance improvements observed earlier in the year have not been sustained. The system continues to be under significant pressure with handover delays with a high number of conveyances. One of the actions’ the CCGs are taking is arranging Multi-agency admission avoidance days (MAAD events) to identify short, medium and long term actions to improve ambulance handover delays, and increasing options for non-conveyance to secondary care.
12. PPAG noted there is a renewed focus on contractually agreed RAPs, with improved contractual oversight via CQRG. There is an on-going focus on actions to recover performance through CQRG and dialogue with UHL. There is improved CQRG escalation route into Contract Performance meeting and approval process in the event of slippage on actions being delivered.
13. PPAG members stated that they do not feel assured with UHL’s overall performance. It was reported that due to concerns within certain areas there is a wider impact noticed on other areas and inevitably impacting patient care. Furthermore PPAG were unsure of how the 90 day system plan would assist in sustaining improvement. PPAG members reiterated from the last meeting that they are in support of a Board to Board meeting being held between UHL and the CCGs to focus on performance concerns and to agree a collective way-forward. PPAG were informed that discussions are underway between the Managing Directors of Leicester City CCG and UHL to agree a mutually convenient date to hold the meeting. It was noted that PPAG members will be kept informed of the progress.
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Paper L East Leicestershire and Rutland CCG Governing Body meeting 9 April 2019
Exception Report from West Leicestershire CCG: (Non- Acute Contracts)
East Midlands Ambulance Service (EMAS)
14. It was reported that there was a 1.6% reduction in the volume of calls received by EMAS in January 2019 in comparison to December 2018. However, despite the reduction in calls there was a 0.6% increase in See and Treat(S&T) and 0.3% increase in See, Treat and Conveyance (ST&C). It does indicate that although activity is increasing, EMAS are managing their capacity more effectively and aligning to the nature of demand.
15. Ambulance Response Performance (ARP): It was reported that performance for Leicester, Leicestershire and Rutland (LLR) improved in four out of six standards, but declined for category 2 90th centile. It was highlighted that the initial analysis of the January 2019 performance shows that EMAS are on track to achieve two of the six performance trajectories for Q4 for Category 1 and Category 4.
16. Handovers: It was reported that there was a 1.7% decrease in handovers from December 2018 but a 3% increase from January 2018. It was noted that despite the fall in handovers at UHL, only 38% of the handovers were completed within the national standards of 15minutes across the three sites. It was highlighted that Leicester Royal Infirmary (LRI) had the highest number of handovers in the region in January 2019 for the fifth consecutive months.
17. Furthermore it was noted that handover delays are a system issue, which is impacting on LLR performance as a result facing national scrutiny. PPAG were informed that CCGs have recently arranged Multi-agency admission avoidance days (MAAD events) to resolve these root cause problems across multiple parts of the system. It was highlighted that the action plan following these MAAD events have provided clear data along with patient stories to enable collaborative working within the system to improve the patient journey, experience and care.
Exception report from East Leicestershire and Rutland CCG:
Leicestershire Partnership NHS Trust (LPT)
18. It was reported that staffing remains a concern over all services with vacancies across all services. Concerns were specifically noted in Leicester City East Community Nursing Staffing. Furthermore gaps were identified in medical staffing across some of the services, primarily in the CAMHS service.
19. Furthermore PPAG was informed that the latest Care Quality Commission (CQC) report had been published which indicated overall rating as “requires improvement”.
Child & Adolescent Mental Health Service (CAMHS).
20. It was reported that concerns remain on increasing waiting times for access to the service and requires risk management of waiting children. The recent CQC report was presented at the Clinical Quality Review Group (CQRG) and discussions are underway to amend Page 4 of 5
Paper L East Leicestershire and Rutland CCG Governing Body meeting 9 April 2019
the current contractual quality schedule to incorporate reports to highlight that the care plans and risk assessments are completed and are of the required quality. Furthermore there is additional scrutiny scheduled through a separate CAMHS Quality and Performance meeting with LPT.
21. In terms of Data Quality, PPAG were assured that improvement was noted which supports in triangulating information across some of the service areas.
Personalised Commissioning including Continuing Health Care (CHC)
22. CHC Quality Premium (QP): It was reported that for the month of January 2019, West Leicestershire CCG did not achieve the 28 day standard however work is underway and should be able to achieve the 80% target.
23. Joint Funded Reviews: It was highlighted that following the review of these cohort received from CHS who were still in receipt of health funding; panels have commenced with both City and County Local Authorities (LAs) to agree the appropriate funding split.
24. The panels are planned to continue through February 2019 and March 2019 until an agreement has been reached on all cases. The issue for delays was noted due to the length of time taken to discuss each case and parties coming to an agreement in regards to who should be responsible for the future funding stream. It was reported that some reviews had identified gaps in services due to the County LA not necessarily aligning to the same framework implemented by City LA. These differences in interpretation of the regulations is impacting and thus taking longer to review each case. This has resulted in an increasing number of cases being set for an urgent re-review.
25. It was reported that Midlands and Lancashire (MLCSU) had identified a backlog of overdue reviews which required further analysis to understand how overdue they were, priority of cases and a timeframe for completion. During that time MLCSU had indicated requirement of additional funding to commence the backlog review. PPAG noted that funding had been approved and the reviews are underway.
RECOMMENDATIONS
East Leicestershire and Rutland CCG Governing Body is requested to:
• RECEIVE the assurance report from the Provider Performance Assurance Group.
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M Blank Page Paper M East Leicestershire and Rutland CCG Governing Body Meeting 9 April 2019
NHS EAST LEICESTERSHIRE AND RUTLAND CCG GOVERNING BODY MEETING
Front Sheet
Integrated Governance Committee summary report Title of the report: (5 March 2019) Report to: Governing Body meeting Date of the meeting: 9 April 2019 Daljit K. Bains, Head of Corporate Governance and Report by: Legal Affairs
Natasha Parekh, Corporate Affairs Support Officer Presented by: Mr Warwick Kendrick, Independent Lay Member
PURPOSE OF THE REPORT: This report provides a summary of the key areas of discussion and outcomes from the Integrated Governance Committee meeting held on 5 March 2019; and items for escalation and consideration by the Governing Body ensuring that the Governing Body is alerted to emerging risks or issues.
RECOMMENDATIONS: The East Leicestershire and Rutland CCG Governing Body is requested to:
• RECEIVE the report.
REPORT SUPPORTS THE FOLLOWING STRATEGIC AIM(S) 2018 – 2019: Transform services and enhance quality Improve integration of local services of life for people with long-term between health and social care; and conditions between acute and primary/community care. Improve the quality of care – clinical Listening to our patients and public – effectiveness, safety and patient acting on what patients and the public experience tell us. Reduce inequalities in access to Living within our means using public healthcare money effectively Implementing key enablers to support the strategic aims (e.g. constitutional and governance arrangements, communications and patient engagement).
EQUALITY ANALYSIS An Equality Analysis and due regard to the positive general duties of the Equality Act 2010 has not been undertaken in respect of this report.
RISK ANALYSIS AND LINK TO BOARD ASSURANCE FRAMEWORK: The Integrated Governance Committee has the remit to have oversight and seek assurance in respect of the mitigation actions in relation to all risks on the Board Assurance Framework where appropriate.
Page 1 of 3 Paper M East Leicestershire and Rutland CCG Governing Body Meeting 9 April 2019 EAST LEICESTERSHIRE AND RUTLAND CLINICAL COMMISSIONING GROUP
GOVERNING BODY MEETING 9 April 2019
Integrated Governance Committee: Summary Report (March 2019)
Introduction
1. The ELR CCG Integrated Governance Committee held its meeting on 5 March 2019; the following provides a summary of the key areas of discussion during the meeting. The approved minutes from the February 2019 meeting are available upon request.
2. Summary of ELR CCG Financial Position month 10 – the Committee received the summary report on the financial position for 2018/19 at month ten. It was noted the CCG is currently facing a shortfall of £0.5m against the total plan of £19.647m.
3. CCG Corporate Performance Report 2018/19 – the Committee raised ongoing concerns in relation to the performance of providers deteriorating across a number of the national standards and requirements. It was noted that the CCG may achieve the quality premium for this financial year due to a recent investment planned in quarter four.
4. Leicestershire Better Care Fund Plan 2019/20 – an update was received from the Director of Health and Care Integration (Leicestershire County Council) on the work being undertaken to prepare the Leicestershire Better Care Fund (BCF) plan for 2019/20. The Committee welcomed the update and provided some recommendations for the team to consider, prior to being presented to the Governing Body for approval.
5. Quarter 3 Workforce Metrics Report – the Committee received the quarter 3 update report, noting that the CCG is currently ranked in the thirteenth lowest place in direct comparison with peer CCGs for sickness absence rates. It was noted the CCG is ranked as the second highest for mandatory training compliance at 92.76% against an average for peer groups being 81.29% which was positive.
6. Freedom to Speak up Policy – the Committee received the refreshed policy. The policy was approved.
7. Draft Quality Strategy 2019/2021 – the Committee received and commented on the draft Quality Strategy 2019/2021, prior to being presented to the Governing Body for approval.
8. Summary report from the Medicines Quality related sub-groups – the committee received an update on actions taken by the various sub-groups.
9. Patient Group Directions (PGD) – the Committee approved the PGD relating to Flucloxacillin.
Page 2 of 3 Paper M East Leicestershire and Rutland CCG Governing Body Meeting 9 April 2019
10. Information Governance Report – the Committee received an overview of the work undertaken during 2018/19 to ensure compliance with the Data Security and Protection Toolkit (DSPT) requirements for the CCG in preparation for the year end submission by 31 March 2019. On behalf of the Governing Body, the Committee agreed to and approved the submission of the DSPT self-assessment at the end of March 2019, noting that actions across a few standards were due to be completed ahead of the submission.
11. Infection Prevention and Control Report Quarter 3 2018/19 – the Committee welcomed the quarter 3 2018/19 Infection Prevention Control (IPC) report, noting that the number of Healthcare Associated Infections (HCAI) cases across LLR during quarter 3 remain stable and fall just under regional and national rates. The Committee approved for the following policies to be archived: Environmental Guidance for minor surgery in primary care; and Infection Prevention and Control Policy for primary care.
12. Patient Safety Report Quarter 3 2018/19 – the quarter 3 2018/19 Patient Safety report was presented to the Committee. It was noted the patient safety and quality team remain concerned with UHL failing to learn from never events and are working with NHS Improvement colleagues to support UHL.
13. Integrated Patient Experience and Engagement report Quarter 3 – the report provided an overview of the patient experience and engagement undertaken during quarter 3.
14. CCG Combined Safeguarding Report and Safeguarding Performance Report Quarter 3 2018/19 – the Committee had previously asked for further detail in relation to the risks identified on the safeguarding risk register, the detail was presented to the Committee within this report. The three risks related to the following areas: domestic abuse - information sharing with GP Practices; Designated Nurse capacity for safeguarding and Looked After Children (LAC); and Child Protection information sharing.
15. Care Quality Commission (CQC): Review of services for Children Looked After and Safeguarding in Leicestershire – the Committee received an update following the recent CQC inspection which was conducted under section 48 of the Health and Children’s Social Care Act 2008, which permits CQC to review the provision of healthcare and the exercise of functions of NHS England and CCGs. It was reported that the safeguarding team were generally pleased with the outcome of the report and that an action plan is being compiled.
16. Research and Development 6 Monthly Report – the Committee received the 6 monthly Research and Development update for information.
RECOMMENDATIONS
17. The East Leicestershire and Rutland CCG Governing Body is requested to:
• RECEIVE the report.
Page 3 of 3 N Blank Page Paper N ELR CCG Governing Body meeting 9 April 2019 EAST LEICESTERSHIRE AND RUTLAND CLINICAL COMMISSIONING GROUP GOVERNING BODY MEETING
Front Sheet
REPORT TITLE: Performance Report 2018/19
MEETING DATE: 9th April 2019
REPORT BY: Alison Buteux, Performance Manager, (MLCSU)
SPONSORED BY: Karen English, Managing Director, (ELR CCG)
PRESENTER: Paul Gibara, Chief Commissioning and Performance Officer, (ELR CCG)
EXECUTIVE SUMMARY: The report sets out performance against the Key Performance Indicators that CCG’s are held to account for. These are detailed in the Improvement & Assessment Framework (IAF) and are part of the NHS Mandate.
Summary:-
• Cancer Waiting Times - 2 out of 8 cancer metrics achieved target for January 19, these are 31 day surgery and 31 day drug treatment, the remaining cancer targets have not achieved target. Whilst 2 metrics achieved for January, 3 metrics continuing to achieve the YTD position, these are 31 day cancer standard, drug treatment and radiotherapy.
• 2 week waits for December was 31.43% for January this improved to 66.67% but still low compared to previous months in 2018/19.
• One year survival for all cancers and cancer patient experience are above baseline, therefore are green. For cancers diagnosed at an early stage the data for 2016 within the IAF shows a decline in the position from 2015. However after a review of the Public Health England data for 2017/18 it shows there is an improvement for the CCG.
• RTT performance remains under national target and the total number of patients waiting remain over target.
• 52 week waiters for January 2019 is zero for the first time in 2018/19.
• Personal Health Budgets (PHB) for Q3 2018/19 achieved target, improvements have been made through this year and the quality of data for this quarter has been assured.
• BCF reported for December 2018 Leicestershire and Rutland. For Leicestershire all 4 metrics have been achieved, Rutland achieved 1 metric out of 4.
Paper N ELR CCG Governing Body meeting 9 April 2019
RECOMMENDATIONS: The East Leicestershire and Rutland CCG Governing Body is requested to: receive the contents of the report.
REPORT SUPPORTS THE FOLLOWING STRATEGIC AIM(S) 2018 – 2019: Transform services and enhance quality Improve integration of local services of life for people with long-term between health and social care; and conditions between acute and primary/community care. Improve the quality of care – clinical Listening to our patients and public – effectiveness, safety and patient acting on what patients and the public experience tell us. Reduce inequalities in access to Living within our means using public healthcare money effectively Implementing key enablers to support the strategic aims (e.g. constitutional and governance arrangements, communications and patient engagement).
EQUALITY ANALYSIS An Equality Analysis and due regard to the positive general duties of the Equality Act 2010 has not been undertaken in the development of this report as it is judged that it is not proportionate on the basis that the Performance Assurance reporting underpins the commissioning strategy and priorities of the CCG. This completes the due regard required.
RISK ANALYSIS AND LINK TO BOARD ASSURANCE FRAMEWORK: The content of the report identifies BAF 1: ACUTE – The quality of care provided action(s) to be taken / are being by acute providers does not match commissioner’s taken to mitigate the following expectation with respect to quality and safety. corporate risk(s) as identified in the BAF 2: QUALITY – The quality of care provided Board Assurance Framework: by non-acute providers does not match commissioner’s expectation with respect to quality and safety. BAF 8: URGENT CARE – Increased pressure on the Emergency Department which could results in sub-optimal care due to ability to access urgent care services.
EAST LEICESTERSHIRE AND RUTLAND CLINICAL COMMISSIONING GROUP GOVERNING BODY Performance Report APRIL 2019
INTRODUCTION
1. The performance report is the vehicle to ensure that appropriate governance and assurance process is in place for CCGs. In November 18 NHS England refreshed the Improvement and Assessment Framework (IAF) for CCGs for 2018/19.
2. The Better Health and Better Care dashboards within the appendix of this report mirror the format of the new 2018/19 IAF. Previously reported key performance indicators, that are not contained within the IAF, are also reported in other dashboards in the appendix to ensure full performance reporting.
The report contains performance on;
• Improvement & Assessment Framework (Better Health & Better Care) – Appendix A • Constitution & Other Key Performance Indicators (Constitution) – Appendix B • CCG Quality Premium 2018/19 (QP1819) – Appendix C • ELR ONLY - LLR Long Waiters Cancer report (Cancer Long Waiters) – Appendix D • Better Care Fund – Appendix E
3. The report sets out performance against the Key Performance Indicators that CCG’s are held to account for. These are detailed in the Improvement & Assessment Framework and are part of the NHS Mandate.
SUMMARY
• Cancer Waiting Times - 2 out of 8 cancer metrics achieved target for January 19, these are 31 day surgery and 31 day drug treatment, the remaining cancer targets have not achieved target. Whilst 2 metrics achieved for January, 3 metrics continuing to achieve the YTD position, these are 31 day cancer standard, 31 day drug treatment and 31 day radiotherapy.
• 2 week waits for December was 31.43% for January this improved to 66.67% but still low compared to previous months in 2018/19.
• One year survival for all cancers and cancer patient experience are above baseline, therefore are green. For cancers diagnosed at an early stage the data for 2016 within the IAF shows a decline in the position from 2015. However after a review of the Public Health England data for 2017/18 it shows there is an improvement for the CCG.
• RTT performance remains under national target and the total number of patients waiting remain over target.
• 52 week waiters for January 2019 is zero for the first time in 2018/19.
• Personal Health Budgets (PHB) for Q3 2018/19 achieved target, improvements have been made through this year and the quality of data for this quarter has been assured.
1
• BCF reported for December 2018 Leicestershire and Rutland. For Leicestershire all 4 metrics have been achieved, Rutland achieved 1 metric out of 4. More information is provided in Appendix E.
CCG IMPROVEMENT AND ASSESSMENT FRAMEWORK
Better Health Dashboard
4. This section looks at how the CCG is contributing towards improving the health and wellbeing of its population. Further details are shown in Appendix A. Narrative relates to ‘At risk’ indicators within the Better Health dashboards are:
Indicator Target LC ELR WL Action in Place % 10-11 classified Less than 16/17 17/18 due out in August 2019. overweight / obese previous 36.5% 28.7% 31.4% BetterHealthDashb annual out- oard turn Diabetes patients Higher than 17/18 There is considerable work going on across LLR to who achieved all 3 previous improve the variation in practices achieving the 3TT but NICE targets annual out- 39% 39% 38% this work wont yet be seen in the 17/18 data. An BetterHealthDashb turn improvement should be seen in NDA data for 1819. oard Source; Integrated Teams Feb 19 Attendance of Higher than 2016 cohort (17/18) The Structured education result does not reflect the data structured previous received from the local provider. Local Provider data education course annual out- 1.8% 2.6% 2.2% shows a higher attendance than national data. with 1 yr of turn There is a problem with practices coding the patients diabetes diagnosis correctly and LLR have used transformation funding to BetterHealthDashb employ IMT facilitators to correct this problem but the oard 17/18 extraction may have taken place at the very start of this work.
Source; Integrated Teams Feb 19 Emergency hospital Less than Q3 17/18 There is a key representation from Public Health (PH). admissions for previous A pilot programme is taking place in Leicestershire and injuries due to falls annual out- 1569 1572 1632 Rutland regarding triage and assessment to improve the in persons aged turn care and patient pathway. 65+ per 100,000 population A postural stability programme has been commissioned BetterHealthDashb for Leicestershire through PH. This is essentially a oard strength and balance prevention programme to support patients.
East Midlands Academic Health Services network (EMAHSN) is piloting a falls prevention programme and currently engaging with CCG practices.
Through the Falls Steering Group, we are working with East Midlands Ambulance Service on an Electronic Falls Risk Assessment Tool (eFRAT) as well as Leicestershire Fire Service who have trained educators who can visit the most vulnerable people to reduce fire risks and accordingly can identify other risks such as falls, dementia and refer on.
Personal Health Less than Q3 18/19 Budgets per or equal to 100,000 population plan 53.96 60.11 49.95 BetterHealthDashb oard Target Target Target 49.63 54.65 49.69
2
Indicator Target LC ELR WL Action in Place Inequality in Less than Q1 18/19 unplanned previous 2479 1886 1783 hospitalisation for annual out- chronic ambulatory turn care sensitive & urgent care sensitive conditions BetterHealthDashb oard Anti-microbial 2018-19 12 month rolling to Dec 18 This relates to the number of antibiotics prescribed in resistance: CCG primary care per Item based on Specific Therapeutic Appropriate IAF Target group Age-Sex related Prescribing Unit (STAR-PU). prescribing of Value 0.917 0.967 0.989 antibiotics in to be 0.965 December’s data has been added to the performance primary care or below report, please could you update the narrative and send BetterHealthDashb back to me by Tuesday 19th March. The existing oard narrative is below. Anti-microbial 2018-19 resistance: CCG IAF 8.2% 10.4% 9.5% The December data for antimicrobial resistance Appropriate Target indicators for ELR show month on month improvement prescribing of broad Value to be for Appropriate Prescribing of Antibiotics in primary care spectrum antibiotics 10% or vs target (0.967 items / STAR PU vs 0.965 items / STAR in primary care below PU). ELR CCG has 22 practices achieving the target of BetterHealthDashb 0.965, whilst the other 8 practices have improved since oard September. The indicator for Appropriate prescribing of broad spectrum antibiotics in primary care has remained at 10.4% consistently since July 2018. ELR CCG has 50% of practices achieving this target.
All practices as part of the GP Service Improvement Plan (SIP) and ongoing antimicrobial prescribing are expected to complete audits on prescribing related to both indicators and submit these to the MQT. Practices are also expected to embed the learning and raise awareness with peers and highlight any variation in prescribing.
Source:- ELR CCG Prescribing Team March 2019 The proportion of GP Patient 2018 GP Survey This metric will help understand the amount of support carers with a long Questionna IAF IAF IAF given to carers who have one or more long term term condition who ire re- 61% 54% 60% conditions. feel supported to developed manage their for 2018. A range of carer support services are commissioned condition across Leicester, Leicestershire and Rutland (LLR) including support groups, advocacy, support to complete a carer’s assessment form, and information and advice for carers including information on local services, and services specifically for young carers. Through an assessment process carers may also receive a personal budget, and councils can provide respite to give carers a break from caring (including breaks for parent carers). LLR have drawn together national guidance, local data, the key themes from the engagement activity undertaken, and considered the local carers offer to determine key areas of development and improvement during the lifetime of this strategy. The LLR carers programme is being delivered via the carers delivery group which has developed.
Source: - LLR Carers Strategy 2018-2021
3
Better Care Dashboard
5. This principally focuses on care redesign, performance of constitutional standards, and outcomes, including key clinical areas. Narrative relates to ‘At risk’ indicators within the Better Care dashboards are:
Indicator Target LC ELR WL Action in Place Overall scores Q1 2018/19 Overall scores indicative of the quality of care in a CCG indicative of the Higher area as determined by CQC inspection ratings based on quality of care in a than five key questions are: Is it safe? Is it effective? Is it CCG area as previous caring? Is it responsive? Is it well-led? determined by CQC out-turn Hospital, Primary Medical Services, Adult Social Care inspection BettercareDashboa rd Cancers diagnosed Higher 2017 There has been a programme of interventions throughout at early stage than 49.1% 52% 51% 2018 to improve the cancer early diagnosis for patients BettercareDashboa previous including; rd out-turn - Colorectal Cancer Pathway Redesign - lung Cancer Pathway Redesign - Prostate Cancer Pathway Redesign Further details reported to Leics County Council HOSC in March 19. Cancer 62 days of >85% January 19 referral to treatment UHL 69.6% 79.7% 72.9% Narrative forms part of the cancer waits delivery and long BettercareDashboa revised in waiters report. ConstitutionNarrative rd Aug 18 that target to be met in Dec 18 One-year survival Higher 2015 diagnosis 2016 diagnosis results due March 19 for all cancer than 67.3% 73.3% 71.6% BettercareDashboa previous rd out-turn Cancer patient Higher 2017 Public events will be held across the City and County experience than during October and November 2018 and focus will be on BettercareDashboa previous 8.4 8.8 8.8 informing people in Leicester, Leicestershire and Rutland rd out-turn of all the ongoing and future plans to support people affected by cancer. Commissioning of a comprehensive Recovery Package for patients and follow-up pathways are taking place. This work stream will be a partnership between LLR CCGs, UHL, cancer network, Macmillan and patient representatives.
Source: Strategy and Implementation Team, LC. November 2018 IAPT Recovery November 18 A number of actions have been identified which are BettercareDashboa >50% positively affecting the delivery of the service for the rd 54% 53% 45% County service. A further escalation call with NHSE is due to take place Local Local Local in February 2019. data at data at data at Jan 19 Jan 19 Jan 19 IAPT LTC provision is being implemented within Cancer, 56% 52% 52% COPD and Diabetes. In addition, a pilot is taking place in 2 health centres in Leicester City - patients on GP LTC IAPT Access >15% 13% 16% 17% registers will be contacted informing them of the service BettercareDashboa rising to and the benefits that it can offer. rd 19% by Local Local Local Q4 18/19 Jan 19 Jan 19 Jan 19 Work has begun on the procurement of the LLR IAPT – – – services. 18.6% 19.7% 17.8% Source: PPAG February 2019 4
Indicator Target LC ELR WL Action in Place Early Intervention >50% January 19 Psychosis (EIP) 2 71% 68% 86% week referral
BettercareDashboa rd
Delivery of the Q2 18/19 The MHIS is the requirement for CCGs to increase mental health investment in mental health services [excluding Learning investment Disabilities and Dementia] in line with their overall standard (MHIS) increase in programme allocation each year. They are BettercareDashboa assessed on a quarterly basis using the forecast outturn rd financial position for the CCG and then again at the end of the financial year. LD - reliance on LLR Q3 18/19 The expected discharges have been delayed due to the specialist IP care target following reasons; BetterCareDashboa <43.8 58.8 rd1 • Building works required to accommodation (38 pts) (51 LLR patients) • Recruitment and training of staff • Delay in CQC registration • Increase in Patient anxieties so length of transition was increased
As at end of Feb 19 there were 49 LLR patients.
Source: Learning Disability Team March 19
Proportion of 17/18 2018/19 has been a transition year for the CCG. people with a Higher learning disability than 60.8% 50.1% 49.4% The CCG has concentrated on rolling out a full training on the GP register previous programme within year to educate and reintroduce the receiving an annual out-turn importance of LD HCs across the practices. health check BetterCareDashboa The CCG is working with the practices in Q4 to help rd1 improve the uptake of health checks. The CCG is confident that the work undertaken in year will support LD HCs provision in the future.
Source: Learning Disability Team March 19
Proportion of the 17/18 17/18 QoF. Baseline based on 16/17 QoF. population (all Higher 0.57 0.38 0.41 ages) that are than included on a GP previous Learning Disability out-turn register BetterCareDashboa rd1
SATOD Less than Q3 18/19 BetterCareDashboa previous 10.2% 5.3% 10.6% rd1 annual out-turn Neonatal Mortality Less than 2016 No update to data from previous reports. Next report due BetterCareDashboa previous 6.8 5.1 3.9 in June 19. rd1 out-turn Small numbers within the metric can shift levels.
Dementia diagnosis January 19 rate >66.7% BetterCareDashboa 88.2% 67.0% 71.1% rd1
5
Indicator Target LC ELR WL Action in Place Dementia care Higher 17/18 Across LLR we are looking to have the Joint LLR Living planning and post- than Well with Dementia Strategy 2019 – 2022 launched in diagnostic support previous 78.3% 73.2% 72.8% January. (Patients diagnosed out-turn with dementia Underneath this will be a CCG level action plan which whose care plan will have number of ‘asks’ for general practice re has been reviewed dementia best practice, diagnosis and care planning in a face-to-face being in them. review in the preceding 12 Source: Primary Care Team, WL. November 18 months) BetterCareDashboa rd1 Rate of unplanned Less than Q1 18/19 hospital admissions previous 2995 2072 2173 for urgent care out-turn sensitive conditions, per 100,000 registered patients BetterCareDashboa rd1 A&E & UCCs Primary challenges to 4hr standard delivery are largely admission, transfer, >90% by February 19 affiliated with the volume of attendances into ED, discharge within 4 Sept 18 82.2% increases in walk-in and ambulance conveyances. There hours and >95% remain variances between admission/discharge profiles BetterCareDashboa by March Emergency Departments Monday to Sunday impacting flow and disabling quick rd2 19 only – 76.1% recovery at points of surge and heightened pressure Urgent Care Centres only – (particularly low discharge at weekends but busiest UHL 98.6% inflow on Mondays). trajectory shows no Non-admitted breaches remain higher than expected and plan to a priority area of focus and improvement, however non- achieve elective admissions at UHL has reduced comparatively. 95% in High attendances on Mondays remain. 18/19 (revised Front door performance continues to vary. There has June 18) been an improvement in filling the number of rota gaps and UHL and DHU continue to work closely to monitor any gaps.
UHL have continued to experience challenges in respect of ambulance handover performance. However, in January further measures have helped speed flow into and through the Emergency Department and have accordingly revised escalation protocols. February performance has been much improved.
System-wide collaboration has improved during peak periods of activity and UHL had to declare its highest state of escalation – Level 4 – on three occasions only during January 2019, a significant improvement on the same period last year.
Source; LAT Feb 19 & UHL Board March 19
Delayed transfers Less than December 18 of care per 100,000 previous The numbers relate to the average delays per day within population years out- 17 40 40 the month. BetterCareDashboa turn (Leics) (Leics) rd2 3 (Rut) 6
Indicator Target LC ELR WL Action in Place Hospital bed use Less than Q1 18/19 following previous emergency out-turn 507 539 575 admission BetterCareDashboa rd2
Percentage of Less than 2017 The 2017 End of Life Care business case set out to Deaths with 3 or previous 7.1% 7.2% 7.0% define the LLR approach to the key issues with regards more emergency out-turn to the delivery of End of Life Care identified from the LLR admissions in last 3 wide Health Needs assessment undertaken in 2016, months of life mapped with national and local ambitions for the delivery BetterCareDashboa of quality End of Life Care to patients. rd2
Through the business case the CCGs agreed to commission an LLR Integrated Community based End of Life Care service, so patients with End of Life Care needs would have access to rapid response community based care. It was agreed that this would be through re- designing existing services, commissioning service gaps and investing in the new service. CCGs are in the mobilisation year of this service which will include a co- ordination hub offer to patients and a single point of access. It is anticipated that the full roll out of this service will be in the Spring of 2019.
In addition to the re-design of services CCGs are working across LLR to improve Advance Care planning and rolling out the ReSPECT agenda.
Source; EoL /LLTIC Project Lead, WLCCG Nov 18 Patient experience Higher 2018 GP patient survey summaries provided to each Primary of GP services than Care team across LLR and publicly available BetterCareDashboa previous 74% 84% 85% rd2 out-turn https://www.gp-patient.co.uk/surveysandreports
Primary care August 18 access - GP 100% by provision of pre- April 19 100% 100% 100% bookable appointments during extended hours on weekdays and weekends BetterCareDashboa rd2 Primary care Higher May 18 No update to data from previous reports. Next report due workforce than 0.83 1.2 1 March 19. BetterCareDashboa previous rd2 out-turn Count of the total Q2 18/19 investment in primary care transformation made by CCGs compared with the £3 head commitment made in the General Practice Forward ViewBetterCareDas hboard2 7
Indicator Target LC ELR WL Action in Place 18 week RTT >92% and January 19 UHL are transferring patients to the independent sector BetterCareDashboa waiters in at the point of referral and capacity alerts have gone live rd3 March 19 86% 86% 86.5% on the e-Referral Service for gynaecology, urology, less than dermatology and liver/GI to divert patients at the point of in March referral to providers with capacity in those specialities. 18. 24,441 21,510 24,575 waiters waiters waiters The theatre productivity programme should increase UHL - – – productivity ensuring capacity is fully utilised and reduce trajectory 24,120 20,661 23,384 cancellations. Work is on-going with IS providers to shows no in in In streamline the transfer process through use of plan to March March March information sharing agreements and standard operating achieve 18 18 18 procedures. 92% in 18/19 The longest waits for patients remain those awaiting an (revised admitted procedure. Whilst theatre capacity is available Aug 18) prior to the winter period, services have priorities admitted clinical activity over outpatients, which has resulted is a reduction in the patients waits in this area.
Source: PPAG Feb 19 & UHL Board March 19
% of patients January 19 waiting 6 weeks or <1% more for a 1.08% 1.1% 0.75% diagnostic test BetterCareDashboa rd3 % NHS CHC December 18 assessments taking <15% place in acute 0% 7.14% 6.90% hospital setting BetterCareDashboa rd3
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Constitutional & Other Key Performance Indicators
6. This identifies other KPIs not associated with the CCG IAF above, but that are still notable. Further information is contained within Appendix B. Narrative relates to ‘At risk’ indicators:
Indicator Target LC ELR WL Action in Place % of patients seen January 19 2 Week Wait within 2 weeks for >93% 88.2% 88.4% 89.5% Due to the backlog clearance during November and an urgent GP December 2018, there was a significant impact on referral UHL’s performance against this standard. UHL cleared Constitution the 2ww breast backlog which is being reflected in the % of patients seen 64.6% 66.7% 67.0% performance position for both November and December. within 2 weeks for >93% Patients are now being booked within 14 days. To an urgent referral ensure the improved backlog position, UHL has for breast established a Working Group to look at transformational symptoms change. Trust visits to Peer Group Trusts (Barts and Constitution Nottingham) being planned to support transformational % of patients >96% 93.4% 92.5% 94.4% change. receiving definitive UHL to treatment within 1 meet Capacity constraints continue to impact on the service. month of a cancer target Year to date growth is 4.3% higher than same period diagnosis from June last year. Additional clinics at the weekend to provide Constitution 18 extra sessions are currently in place. Breast Awareness % of patients >94% 96.0% 94.0% 87.2% campaign in October has impacted on referrals. receiving The expectation is that the 2ww standard predicted to subsequent UHL to will recover in January 2019. treatment for meet cancer within 31 target 31 Day Surgery days (Surgery) from Sept Majority of the breaches are in Urology. Tertiary referrals Constitution 18 remain a concern specifically for Urology (robotic % of patients 100% 100% 100% surgery) and late tertiary referrals to Lung. HDU/ITU receiving >98% constraints is a contributing factor for the current subsequent performance treatment for cancer within 31 62 Day Wait days (Drug Focus on reducing the backlog and maximising capacity Treatment) continues. Constitution % of patients 93.9% 93.5% 93.4% Urology continues to have the biggest backlog at UHL. receiving >94% Late tertiary referrals continue to have a significant subsequent impact in this tumour site. UHL working with Nottingham treatment for and NHS England to explore a combined approach to cancer within 31 service provision allied to Consultant vacancies in days (Radiotherapy Radiology and Oncology. Treatment) Constitution Preparations for the shadow reporting of the new 28 Day % of patients >85% 69.6% 79.3% 72.8% Faster Diagnostic Standard from 1st April 2109 are receiving 1st Target to progressing. System wide deep dive into the findings of definitive treatment be met the Patient Experience Survey to develop action plans to for cancer within 2 Dec 18 support areas of improvement. months (62 days) Constitution Reviewing alternative skill mix to free up critical roles % of patients >90% 85.7% 66.7% 78.9% (Radiology, Oncology). Weekend lists in place for receiving treatment UHL to treatment and diagnostics. for cancer within 62 meet days from an NHS target Source; LAT Feb 19 Cancer Screening from Aug Service 18 Constitution
9
Indicator Target LC ELR WL Action in Place % of patients 76.0% 66.7% 76.5% receiving first N/A definitive treatment for cancer within 62 days of a consultant decision to upgrade their priority status Constitution Proportion of 2018/19 Q3 To improve performance against the CPA seven day patients on (CPA) >95% standard, the Adult Mental Health and Learning discharged from 81% 86% 81% Disabilities directorate (AMH.LD) have redesigned the inpatient care who monitoring process for CPA seven day with an aim to are followed up undertake the CPA seven day follow-ups within 48 within 7 days hours. Daily individualised proactive reports and Constitution2 reminders will be provided to wards to undertake reviews; and missed reviews will be escalated to the service manager.
Weekly performance reports will be reviewed by the business team with escalations made to the business manager for relevant action. The new processes will be incorporated into the existing standard operating process (SOP) in March 2019. Source; LPT Board Report Feb 19 IAPT Waiting Times >75% November 18 - 6 Week Waiters 92% 75% 81% Constitution2 IAPT Waiting Times >95% 98% 99% 98% - 18 Week Waiters Constitution2 The number of Q3 18/19 Due to small numbers within the service, large completed CYP 95% by fluctuations in performance are seen. Eating Disorders 2020 71% 62% 76% Commissioners are working with ED lead to develop the urgent referrals 10/14 8/13 16/21 current pathway, offering alternative services for the within 4 weeks patients patients patients disordered eating / food avoidance to reduce the number Constitution2 of children and young people referred into the ED The number of service that do not meet the criteria. completed CYP 95% by N/A 67% 0% Eating D urgent 2020 No 2/3 0/2 This work will be aligned to the development of the referrals within 1 patients patients patients triage and navigation service between March - May week 2019. Constitution2 Source: PPAG February 2019 Mixed sex January 19 accommodation Zero breaches - All 3 3 4 Providers Constitution2 Referral to January 19 Treatment RTT - Zero LC – 1 @ London NW University Hospitals (ENT) No of Incomplete 1 0 1 Pathways Waiting WL – 1 @ Oxford (Gynae) >52 weeks Constitution3 NHS e-Referral 80% by October 18 ERS continues to be promoted through discussion at Service (e-RS) Sept 17 80% 80% 79% locality meetings and through the monthly practice Utilisation and 100% newsletters. ELR CCG continues to work with UHL to Coverage by Sept implement the paper switch off project which will Constitution3 18 strengthen and promote ERS usage. Paper switch off went live June 2018. Source: LAT March 2019
10
Indicator Target LC ELR WL Action in Place Number of MRSA YTD February 19 Surveillance around Healthcare Associated Infections incidences Zero 3 2 1 (HCAIs) across LLR continue within individual Constitution3 organisations. The outcomes trends and any analysis are then discussed in the LLR IPC multiagency delivery group. Quarter 3 was discussed in December and no further response was required across LLR. Our number of HCAI’s are relatively stable across Q3 and remain under local and national average. Jan and Feb so far paint a positive picture and show a small reduction in our CDI cases across LLR in comparison to this point last year.
Source; Infection Prevention & Control Team March 2019
Number of Below C.Difficile CCG 60 64 85 incidences standard Constitution3 Ambulance Waits January 19 Cat 1 LLR: 6:04 9:19 8:31 Ambulance Waiting Time performance in January for Constitution4 7 in Q4 LLR improved for four out of the six standards. It is National Mean in noted that the performance for LLR was better than the 7mins regional average for Cat 1 (both standards) but was LLR: 9:42 16:06 14:44 worse that the regional average for the other four National 90th in 15mins in standards. 15mins Q4 Cat 2 Ongoing work continues with the aim to maintain Constitution4 LLR: 31:53 39:06 35:48 continual improvement in Ambulance Handovers. National Mean in 22.59 in 18mins Q4 Reduced conveyance, by providing frailty training to EMAS staff, and having GPs in EMAS fast response National 90th in LLR: vehicles; 40mins 48.21 in 1hr 11 1hr 19 1:14 Q4 Real time escalation by duty team to Director on call of Cat 3 LLR: 4:37 4:25 4:14 all patients that have waited longer than 60 minutes in Constitution4 3hr 22 in an ambulance; National 90th in Q4 2hrs Dedicated person in Ambulance Assessment managing Cat 4 LLR: 2:23 2:07 3:26 time of arrival to handover. Constitution4 3hr 31 in National 90th in Q4 Escalation protocol in place when ambulance 3hrs assessment bay hits 8 patients via the flow manager. Ambulance 0% January 19 Handovers & Crew waiting Patients arriving by ambulance are assessed to see if Clear over Ambulance Handovers they are fit to sit and if this is the case, they are handed Constitution3 30mins 14.8% waiting 30-60mins over to the walk in assessment zone to free up cubicle space in ambulance assessment. This ensures 12.3% waiting +60mins ambulance assessment is freed up for improved handover.
Crew Clear Source: - PPAG February 2019 7.3% waiting 30-60mins
0.4% waiting +60mins
11
Indicator Target LC ELR WL Action in Place Cancelled Ops - % YTD January 19 Improved oversight of cancelled operations performance of patients re- and related actions via the Activity Triangulation Meeting admitted within 28 100% 82.2% and the UHL Technical meeting days (UHL) Constitution3 Action plan for recovery to be reviewed and updated by UHL with any further actions and improvements from the FourEyes work and other initiatives underway and presented at the next Technical Meeting.
Source: - PPAG February 2019 Children’s 92% Q2 18/19 wheelchair waits 100% by 92% Constitution3 Q4
QUALITY PREMIUM 18/19
7. The following table outlines the current expected position for the Quality Premium 18/19. This is dependent on finalised published national data agreeing to local data where this has been used. Further detail can be found in Appendix C QPDetail.
Emergency Quality section Total expected Demands section ELR £0k £0 £0 LC £0k £0 £0 WL £0k £0 £0
RECOMMENDATIONS:
The Committee is requested to:
• NOTE the contents of the report • IDENTIFY any areas for in depth reviews at future IGC Sub-group meetings.
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13
APPENDIX A BETTER HEALTH
Indicator Description / Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 YTD Latest Latest Target Position Baseline Standard Outturn/ Standard 16/17 Obesity Percentage of children aged 10 - 11 classified as 29.2% Below Childhood 1 2015/16 CCG 28.7% overweight or obese CCG Baseline (29.7% Leicestershire CC / Rutland 24.5% UA / 33.8% England)
Diabetes patients that have achieved all of the 2015/16 NICE-recommended treatment targets 41.9% Above 42.6% 2 2015/16 3 Targets - Adults HBA1C - Cholesterol & Blood (CCG) Baseline 2016/17 Pressure - Children HBA1C (39% National) 2.4%
Diabetes 2014 People with diabetes diagnosed less than a year (CCG) Above 3 2013 3.4% who attend a structured education course 1.9% Baseline (England) (CCG)
Injuries from falls in people aged 65 and over Q4 Reduction on Q1 2017/18 Q2 2017/18 Q3 2017/18 4 2016/17 Falls (per 100,000 population) 1442 baseline 1507 1529 1572
Trajectory Q1 Q2 Q3 Q4 Personal Health Budgets (PHB) 2018/19 36.43 45.54 54.65 63.75 No of PHB per 100,000 population Q1 - 25.1 (Number of PHB's in place per 100,000 CCG Q2 - 22.6 5 2017/18 Increase to 50 - population (based on the population the CCG is Q3 - 25.1 100k by 2020 29.75 63.75 60.11
and choiceand responsible for) CCGs are aiming for between 100- Q4 - 44.0
Personalisation 200 per 100,000 by 2021. (England)
Inequality in unplanned hospitalisation for chronic ambulatory care sensitive and urgent care sensitive 2016/17 Gradient Reduction in Q1 Q2 Q3 6 conditions (linked to deprivation) (Low score is Q4 of 1650 Gradient 1644 1631 1395 Health good. Baseline indicates average inequality levels
Inequalities compared to other CCG)
2018-19 CCG Anti-microbial resistance: Appropriate prescribing of IAF Target 7 antibiotics in primary care Mar-18 1.001 Value 0.998 0.993 0.988 0.984 0.980 0.975 0.974 0.973 0.967 (Star PU) to be 0.965 or below 2018-19 CCG Anti-microbial resistance: Appropriate prescribing of Target Value to 8 broad spectrum antibiotics in primary care Mar-18 10.5% 10.5% 10.5% 10.5% 10.4% 10.4% 10.4% 10.4% 10.4% 10.4% be 10% or
Anti-microbial Resistance (Antibiotic-Co-Amoxiclav) below
Quality of life for carers Above 2018 54% 9 (Proportion of carers with a long term condition N/A N/A
Carers Position 2018 who feel supported to manage their condition) BetterHealthNarrative
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APPENDIX A BETTER CARE
Indicator Description Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 YTD Target Position Standard Outturn/ Standard/ Latest Baseline Baseline Latest
Overall scores indicative of the quality of care in a CCG area as determined by CQC inspection ratings based on five key questions are: Is it safe? Is it effective? Is it caring? Is it responsive? Is it well-led?
10 Hospital 54 => 54 54
2017/18 11 Primary Medical Services 66 => 66 Q4 67 Provision of High Quality Care
12 Adult Social Care 62 => 62 62
Above 2015 50.3% Position 2016 Cancers diagnosed at early stage - % of cancers 13 2015 52.1% diagnosed at stage 1 & 2 Above 2016 2017/18 2017/18 Q4 Q1 Q2 52% 55% 53% Local 85.5% 86.6% 87.6% 88.6% 89.5% 90.2% 90.9% 91.5% 89.7% 88.3% 90.5% 92.0% Cancer 62 Day Waits - % of patients receiving first Trajectory 82.6% 14 definitive treatment for cancer within 62 days of an 2016/17 Q4 urgent GP referral for suspected cancer National
Cancer 76.-% 83.-% 83.1% 8-.4% 68.9% 69.4% 81.9% 80.0% 85% 86.4% 79.4% 78.7%
2015 Above 15 One-year survival for all cancer 2014 72.5% (Followed up December 2016) Baseline 73.3% 2017 8.6 Above 16 Cancer patient experience 2016 8.8 (CCG) Published September 2018 CCG Baseline Patient`s average rating of care scored from very poor to very good
50% 52% 17 IAPT Recovery Rate (CCG) 2017/18 64.00% 50% 61.50% 58.00% 51.00% 52.00% 52.00% 43.00% 45.00% 53.00% Local Data Local Data
IAPT Access >15% rising to 11.74% 19.74% 18 Proportion of people that enter treatment against 2017/18 13.50% 19% by Q4 19.57% 15.66% 14.23% 19.14% 15.87% 12.61% 15.44% 16.00% the level of need in the general population (CCG) 18/19 Local Data Local Data Completed within 30 50% of people experiencing first episode of psychosis 2 Weeks No Activity 19 to access treatment within two weeks of referral Total 50% 50.00% 66.70% 83.33% 66.67% 66.67% 66.67% 33.33% 100.00% 68.00% 37 Published (CCG) Patients 2016/17 81.08%
Improve access Rate to Children and Young People Mental Health (CYPMH) Increase in the % of CYP (aged 0-18) receiving 20 New Indicator community services as a proportion of the CYP population with a diagnosable mental health disorder
Out of area placements for acute mental health Reduction on inpatient care (no of bed days for inappropriate baseline 21 New Indicator
Mental Health OAPS in mental health services for adults in non- Eliminate by specialist acute inpatient care (eliminate by 20/21) 20/21
Mental health crisis team provision (proportion of crisis resolution and home treatment (CHRT) services 22 New Indicator able to meet selected core functions (by 20-21 all To be assessed via Health Education England commissioned survey (not yet in publication - Annual Data) areas to deliver best practice 24/7 CRHT)
Proportion of people on GP severe mental illness 23 New Indicator register receiving physical health checks NHS England SMI Physical Health Checks data collection. Collection to start autumn 2018 - NEW FOR 2018/19
Cardio metabolic assessment in mental health 24 New Indicator environments Inpatient - annual CQUIN audit carried out by the Royal College of Psychiatrists - NEW FOR 2018/19
Delivery of the mental health investment standard 25 New Indicator (MHIS) Compliant Compliant
Quality of mental health data submitted to NHS 26 New Indicator NHS Digital quarterly DQMI publication MHSDS SCORE (%) - NEW FOR 2018/19 Digital (DQMI) BetterCareNarrative
15
APPENDIX A
Indicator Description Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 YTD Target Position Standard Outturn/ Standard/ Latest Baseline
Target 48.42 Trajectory <46.11 <43.80 <41.50 <38.04 (42 2018/19 (40 LLR patients) (38 LLR patients) (36 LLR patients) (33 LLR patients) Reliance on specialist inpatient care for people with patients) Q4 27 a learning disability and/or autism 2016/17 (per 1m pop) ALL LLR 51.87 54.18 51.87 58.79 (45 LLR patients (ELR) 47 LLR Patients 45 LLR Patients 51 LLR Patients for LLR) (9 ELR) (10 ELR) (11 ELR) Learning Disability Proportion of people with a learning disability on the Above 28 2016/17 58% National Data is Published Annually GP register receiving an annual health check baseline
Completeness of the GP Learning Disability Register Above 29 Proportion of the population (all ages) that are 2016/17 0.36% National Data is Published Annually included on a GP Learning Disability register baseline
Below Q1 Q2 Q3 30 Maternal Smoking at Delivery 2017/18 8.1% Baseline 6.0% 7.9% 5.3%
2016 Neonatal mortality and still births per 1,000 4.65 Below 31 2015 5.1 population ONS Data Baseline (Data Source - MBRRACE-UK - Perinatal Mortality Surveillance Report) 2017 79.2 Higher Than Maternity 32 Women's experience of maternity services (England) 2015 Change in definition from 2015 Survey (CCG) Baseline 79.6 2017 67.3 Higher Than 33 Choices in maternity services 2015 Change in definition from 2015 Survey (CCG) Baseline 62.8
Standard/ Indicator Description Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19
Latest Latest Target Position Baseline Standard Outturn/
Estimated diagnosis rates for people with dementia 66.7% 67.8% 67.6% 67.6% 67.7% 67.4% 67.7% 67.7% 67.1% 67.5% 67.0% 67.2%
People Diagnosed with Dementia (Age 65+) 2017/18 34 68.2% Recorded 3099 3104 3110 3123 3115 3141 3141 3118 3148 3121 3148 Numerator March Dementia People estimated Prevalence (Age 65+) Denominator Estimated 4574 4590 4603 4614 4622 4638 4637 4645 4665 4657 4683
Dementia care planning and post-diagnostic support 2017/18 (The percentage of patients diagnosed with dementia 74.3% Above 16/17 35 2016/17 73.2% whose care plan has been reviewed in a face-to-face (CCG) baseline review in the preceding 12 months) (IAF Nov 18)
BetterCareNarrative
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APPENDIX A
Standard/ Indicator Description Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 YTD Target Position Standard Outturn/ Latest Baseline Local A&E Waiting Time - % of patients admitted, trajectory 75.7% 87.2% 81.9% 84.4% 88.3% 90.0% 90.2% 88.6% 88.1% 85.7% 85.0% 90.2% transferred or discharged from A&E within 4 hours Mar-17 36 2016/17 (28/9/18) including 83.90% Standard All UHL+UCCs 82.1% 90.8% 86.5% 82.3% 82.3% 84.2% 83.4% 78.7% 80.1% 78.3% 82.2% 83.7% 95%
UHL - A&E Type 1 & 2 76.1% 88.2% 82.1% 76.3% 76.3% 79.5% 78.2% 72.4% 73.7% 70.7% 76.1%
UCC Attendances (VoCare and DHU) 97.0% 97.5% 97.2% 97.6% 97.9% 96.8% 97.6% 96.6% 96.9% 98.8% 98.6%
A&E Waiting Time - % of patients admitted, transferred or discharged from A&E within 4 hours - 77.32% 88.03% 82.88% 78.04% 78.32% 80.8% 80.35% 74.72% 74.86% 71.22% 75.82% ELR CCG Urgent Emergency and Care
DTOC attributable to the NHS per 100,000 population Average Reduction on Average number of delayed bed days per day per day in 50 33 26 30 32 38 34 43 35 40 42 (Leicestershire LA Level) 2017/18 baseline 37 DTOC attributable to the NHS per 100,000 population Average Reduction on Average number of delayed bed days per day per day in 2 2 4 1 1 1 3 2 2 3 2 (Rutland level) 2017/18 baseline
Population use of hospital beds following emergency Reduction on 38 2017/18 519 539 admission days baseline
Indicator Description Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 YTD Target Position Standard Outturn/ Standard/ Latest Baseline
End Of Life Percentage of Deaths with 3 or more emergency Reduction on 7.2% 39 2016 6.1 admissions in last 3 months of life baseline 2017
Indicator Description Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 YTD Target Position Standard Outturn/ Standard/ Latest Baseline
Equal to or 84% 40 Overall Patient Experience of G.P Services 2017 83.5% above 83.5% 2018 Extended Access 87.5% (28 out of 31 Primary Care Access - % of registered population practices) - partial Planning offered full extended access provision Round 41 (General Practice provision of pre-bookable 90.3% (3 out of 31 100% 100% 100% 100% 100% 100% 100% 100% 100% appointments during extended hours on weekdays 2018/19 practices) - no and weekends) 100% Primary Care provision March 2018
Primary Care Workforce Sept 2017 March Above 42 Number of GPs and Practice Nurses (full-time 1.22 1.22 2017 baseline equivalent) per 1,000 weighted patients by CCG Full Time Equivalent Number of GPs, Practice Nurses and Direct patient care staff per 1,000 weighted patients at 31 March 2017
Count of the total investment in primary care transformation made by CCGs compared with the £3 43 New Indicator head commitment made in the General Practice 18/19 18/19 Forward BetterCareNarrative
17
APPENDIX A
Indicator Description Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 YTD Target Position Standard Outturn/ Standard/ Latest Baseline
Total Waiters Waiters Waiters Waiters Waiters Waiters Waiters Waiters Waiters Waiters Waiters RTT - Incompletes - Patients waiting 18 weeks or less March 44 20,661 92% 21,117 21,401 22,089 22,450 21,669 21,600 21,703 21,636 21,462 21,510 from referral to hospital treatment (ELR CCG) 2018 18 wk 85.8% 86.9% 87.3% 87.1% 86.7% 86.5% 87.0% 86.8% 85.9% 86.0% 85.4% Elective Access Elective
Diagnostic Test Waiting Time >6 weeks (CCG) 45 2017/18 0.80% 1.00% NEW to IAF FOR 18/19 4.96% 2.64% 2.96% 2.70% 2.14% 1.55% 1.00% 0.76% 0.83% 1.01% 1.98%
29 16 18 20 21 10 9 13 18 22 26 17 No Publication date Compliance with the four priority clinical standards 2, 5, 6, 8 for delivery of 7 day services Achievement of clinical standards in the delivery of 7 Standard 2 - Time to Consultant Review - Percentage of patients reviewed by an appropriate consultant within 14 hours of admission 46 day services Standard 5 - Access to Diagnostics - Proportion of consultants who said that diagnostic tests were always or usually available when needed for critical and urgent patients
7 Services Day Standard 6 - Access to Consultant-directed Interventions - Proportion of the nine possible consultant- directed interventions provided by the trust 7 days a week on-site or by formal arrangement Standard 8 - On-going Review - Proportion of patients in the trust who need it, receive a daily or twice daily review by a consultant
Percentage of NHS Continuing Healthcare full assessments taking place in an acute hospital setting Less Than 47 20.93% 0.00% 15% 19.35% 4.55% 9.68% 6.45% 0.00% 7.14% Care (CCGs to ensure that less than 15% of all full NHS 15% CHC assessments take place in an acute hospital) NHS Continuing
Evidence that Sepsis awareness raising amongst Annual Self-Assessment 48 healthcare professions has been prioritised by the New Indicator CCGs are expected to provide evidence that they have prioritised the issue of sepsis awareness Safety Patient CCG No Publication Date
In-year financial performance - An assessment of CCG 2017/18 49 financial plans by NHS England local teams Q4
80% utilisation Utilisation of the NHS e-referral service to enable 50 Mar-18 75% target By Sept 76% 76% 76% 76% 80% 78% 80% Sustainability choice at first routine elective referral 17 and 100% by Sept 18
Rated as 2017/18 51 Probity and corporate governance compliant or Q1 Q2 Q3 Q4 not
Staff engagement index 1 to 5 scale (5 52 2017 3.78 Engagement index on a 1 to 5 scale (5 good) good)
Higher scores indicate Progress against the Workforce Race Equality higher 53 Standard - score (higher scores indicate higher 2017 0.16 differences, 0 indicates equality) differences, 0 indicates equality
Score Leadership Effectiveness of working relationships in the local between 0- 54 system (NHS England – annual CCG stakeholder 360 2017/18 60.9 100 survey) 100 is the best possible score
Compliance with statutory guidance on patient and Overall Score 55 public participation in commissioning health and 2017 care out of 15 Quality of CCG leadership The indicator is based on three key lines of enquiry, Rated as concerning: 2016 56 compliant or Q1 Q2 Q3 Robust culture and leadership sustainability Q4 Quality not Governance, including financial governance BetterCareNarrative
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APPENDIX B Cancer Waiting Times
% Patients seen within two weeks for an urgent GP referral for Latest Date: 31/01/2019 RAG G G R R R G G R R R R suspected cancer (MONTHLY) The percentage of patients first seen by a specialist within two weeks East Leicestershire P = Published Status P P P P P P P P P P - when urgently referred by their GP or dentist with suspected cancer and Rutland CCG U = Unpublished Actual 94.08% 94.63% 92.44% 92.78% 91.91% 94.42% 94.48% 89.04% 83.73% 88.36% 91.63%
Target 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00%
% of patients seen within 2 weeks for an urgent referral for breast Latest Date: 31/01/2019 RAG R R R R R R R R R R R symptoms (MONTHLY) Two week wait standard for patients referred with 'breast symptoms' not East Leicestershire P = Published Status P P P P P P P P P P - currently covered by two week waits for suspected breast cancer and Rutland CCG U = Unpublished Actual 90.00% 91.43% 83.33% 92.31% 85.19% 90.38% 74.58% 71.43% 31.43% 66.67% 73.89%
Target 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% % of patients receiving definitive treatment within 1 month of a cancer Latest Date: 31/01/2019 RAG R G G R G G G G G R G diagnosis (MONTHLY) The percentage of patients receiving their first definitive treatment within East Leicestershire P = Published Status P P P P P P P P P P - one month (31 days) of a decision to treat (as a proxy for diagnosis) for and Rutland CCG U = Unpublished Actual 94.93% 97.78% 97.30% 94.19% 98.76% 96.15% 96.43% 96.72% 99.33% 92.50% 96.41% cancer Target 96.00% 96.00% 96.00% 96.00% 96.00% 96.00% 96.00% 96.00% 96.00% 96.00% 96.00% 96.00% 96.00% % of patients receiving subsequent treatment for cancer within 31 days Latest Date: 31/01/2019 RAG R G R G G R R R G G R (Surgery) (MONTHLY) 31-Day Standard for Subsequent Cancer Treatments where the treatment East Leicestershire P = Published Status P P P P P P P P P P - function is (Surgery) and Rutland CCG U = Unpublished Actual 83.33% 97.37% 87.50% 97.30% 97.14% 82.61% 92.50% 89.19% 97.56% 94.00% 92.21% Target 94.00% 94.00% 94.00% 94.00% 94.00% 94.00% 94.00% 94.00% 94.00% 94.00% 94.00% 94.00% 94.00% % of patients receiving subsequent treatment for cancer within 31 days Latest Date: 31/01/2019 RAG G G R R G G G G G G G (Drug Treatments) (MONTHLY) 31-Day Standard for Subsequent Cancer Treatments (Drug Treatments) East Leicestershire P = Published Status P P P P P P P P P P - and Rutland CCG U = Unpublished Actual 100.00% 100.00% 97.30% 97.50% 98.00% 100.00% 100.00% 100.00% 100.00% 100.00% 99.30% Target 98.00% 98.00% 98.00% 98.00% 98.00% 98.00% 98.00% 98.00% 98.00% 98.00% 98.00% 98.00% 98.00% % of patients receiving subsequent treatment for cancer within 31 days Latest Date: 31/01/2019 RAG G G G G G R G G G R G (Radiotherapy Treatments) (MONTHLY) 31-Day Standard for Subsequent Cancer Treatments where the treatment East Leicestershire P = Published Status P P P P P P P P P P - function is (Radiotherapy) and Rutland CCG U = Unpublished Actual 96.43% 100.00% 100.00% 100.00% 100.00% 93.88% 100.00% 98.31% 98.15% 93.55% 97.96%
Target 94.00% 94.00% 94.00% 94.00% 94.00% 94.00% 94.00% 94.00% 94.00% 94.00% 94.00% 94.00% 94.00% % of patients receiving 1st definitive treatment for cancer within 2 Latest Date: 31/01/2019 RAG R R R R R R R R G R R months (62 days) (MONTHLY) The % of patients receiving their first definitive treatment for cancer within East Leicestershire P = Published Status P P P P P P P P P P - two months (62 days) of GP or dentist urgent referral for suspected cancer and Rutland CCG U = Unpublished Actual 75.00% 82.83% 83.13% 80.39% 68.89% 69.16% 81.90% 80.00% 86.36% 79.35% 78.71%
Target 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00%
% of patients receiving treatment for cancer within 62 days from an NHS Latest Date: 31/01/2019 RAG R G R G R G R R R R R Cancer Screening Service (MONTHLY) Percentage of patients receiving first definitive treatment following referral East Leicestershire P = Published Status P P P P P P P P P P - from an NHS Cancer Screening Service within 62 days. and Rutland CCG U = Unpublished Actual 83.33% 100.00% 86.67% 100.00% 71.43% 100.00% 75.00% 80.00% 83.33% 66.67% 85.33% Target 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% % of patients receiving treatment for cancer within 62 days upgrade Latest Date: 31/01/2019 RAG their priority (MONTHLY) % of patients treated for cancer who were not originally referred via an East Leicestershire P = Published Status P P P P P P P P P P - urgent GP/GDP referral for suspected cancer, but have been seen by a and Rutland CCG U = Unpublished Actual 75.00% 80.00% 87.50% 90.00% 100.00% 96.43% 77.78% 89.29% 85.71% 66.67% 85.34% clinician who suspects cancer, who has upgraded their priority. Target ConstitutionNarrative
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APPENDIX B
Indicator Description Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 YTD Latest Latest Target Position Baseline Standard Outturn/ Standard/ Cancer Numbers of over 104 day breaches, treated in month 17/18 44 Reduction 2 4 6 5 4 13 6 2 6 3 (ELR patients All Providers)
Indicator Description Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 YTD Latest Latest Target Position Baseline Standard Outturn/ Standard/
75% of people with relevant conditions to access 82.00% 82.00% 2017/18 52% 75% 50.50% 43.00% 36.00% 55.00% 63.00% 67.00% 78.00% talking therapies in 6 weeks Local Data Local Data
95% of people with relevant conditions to access 98.50% 99.00% 2017/18 96% 95% 93.80% 95.00% 92.00% 97.00% 96.00% 97.00% 99.00% talking therapies in 18 weeks Local Data Local Data
Mental Health - Care Programme Approach (CPA) - % of patients under adult mental illness on CPA who were Mental Health 2017/18 98.2% 95% 67% 91% 85.71% 81% followed up within 7 days of discharge from psychiatric in-patient care
% of routine CYP Eating Disorder Referrals waiting 2017/18 92% 95% by 2020 50% 82% 62% 64% within 4 weeks (complete)
% of urgent CYP Eating Disorder Referrals waiting 0% Q4 16/17 0% (1 pt) 95% by 2020 100% 67% 60% within 1 week (complete) (1 Patient)
Indicator Description Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 YTD Latest Latest Target Position Baseline Standard Outturn/ Standard/
Trolley Waits in A&E - Number of patients who have 40 waited over 12 hours in A&E from decision to admit to 2017/18 Zero Tollerance 0 0 0 0 0 0 0 0 0 0 0 0 Total UHL admission (UHL only)
Patients between 30 6321 mins 1 sec- 1 hour 476 126 198 477 440 280 511 549 653 859 4569 Ambulance Handover time - Number of handover 2017/18 Total (all time delays of > 30 mins and <60 mins (UHL) 62714 bands) 5140 5457 5210 5245 5123 5247 5799 5839 5930 5812 54802
10.1% Zero Tollerance 9.3% 2.3% 3.8% 9% 9% 5% 9% 9% 11% 15% #DIV/0! #DIV/0! 8.3%
Urgent Emergency and Care Patients 2498 over 1 hour 1 sec 195 6 41 213 159 77 95 191 387 717 2081
Ambulance Handover time - Number of handover Total (all time 2017/18 62714 5140 5457 5210 5245 5123 5247 5799 5839 5930 5812 54802 delays of > 1 hour (UHL) bands)
4.0% Zero Tollerance 3.8% 0.1% 0.8% 4% 3.1% 1.5% 1.6% 3.3% 6.5% 12.3% #DIV/0! #DIV/0! 3.8%
ConstitutionNarrative
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APPENDIX B
Standard/ Indicator Description Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 YTD
Latest Latest Target Position Baseline Standard Outturn/
EMAS <7mins 00:08:38 00:08:06 00:07:15 00:07:41 00:07:34 00:07:26 00:07:37 00:07:51 00:07:43 00:07:40 Local LLR: LLR Average 7m31s - Q2 00:08:22 00:07:49 00:07:07 00:07:52 00:07:41 00:07:22 00:07:42 00:07:30 00:07:39 00:07:39 7m13s - Q3 Category 1 – Calls from people with life-threatening ELR 7mins - Q4 00:10:20 00:09:50 00:09:05 00:10:03 00:09:58 00:09:16 00:10:01 00:09:36 00:09:48 00:09:19 illnesses or injuries (eg; cardiac arrest or serious allergic reaction) EMAS 00:15:42 00:14:36 00:12:58 00:13:53 00:13:48 00:13:20 00:13:31 00:13:37 01:13:47 00:13:30
LLR 90th centile <15mins 00:15:09 00:13:59 00:12:41 00:14:06 00:14:03 00:13:15 00:13:21 00:13:21 01:13:34 00:13:17
ELR 00:18:42 00:18:22 00:17:01 00:18:03 00:16:56 00:16:34 00:17:38 00:17:55 00:17:46 00:16:05
EMAS <18mins 00:31:57 00:30:45 00:31:10 00:33:17 00:31:29 00:32:42 00:29:46 00:31:01 00:31:19 00:30:52 Local LLR: LLR Average 25m40s - Q2 00:34:01 00:32:33 00:35:02 00:38:59 00:35:01 00:35:36 00:32:12 00:33:28 00:35:53 00:35:14 25m02 - Q3 ELR 22m59s - Q4 Category 2 – Emergency calls (eg; burns, epilepsy or 00:37:21 00:34:49 00:38:09 00:41:55 00:37:57 00:38:13 00:34:23 00:36:47 00:38:51 00:39:06 stroke) EMAS <40mins 01:08:06 01:04:35 00:55:36 01:10:26 01:06:53 01:08:48 01:01:52 01:04:42 01:06:32 01:05:40 Local: LLR 90th centile 51m52s - Q2 01:12:43 01:07:57 01:12:48 01:24:17 01:14:16 01:12:51 01:05:24 01:08:16 01:14:16 01:14:50 50m46s - Q3 ELR 48m21s - Q4 01:16:44 01:11:29 01:15:51 01:29:09 01:19:36 01:17:12 01:08:50 01:13:04 01:16:00 01:18:42
Urgent Emergency and Care EMAS 02:41:18 02:53:55 02:51:48 03:13:58 03:02:22 03:11:45 02:45:50 02:55:19 03:39:17 03:29:50 <2hrs Local LLR: Category 3 – Urgent calls (eg; late labour, non-severe LLR 90th centile 3hrs 26m - Q2 03:20:19 03:46:43 03:33:37 04:12:56 03:39:31 04:10:54 03:16:26 03:32:46 04:40:17 04:24:42 burns or diabetes – may be seen in own home) 3hrs 25m - Q3 3hrs 22m - Q4 ELR 03:23:28 03:17:37 03:16:56 04:00:48 03:20:19 04:07:07 03:07:57 03:28:27 04:32:42 04:25:05
EMAS 02:01:15 02:42:50 02:09:08 02:29:24 02:47:18 02:27:50 02:16:13 02:45:58 02:50:27 02:21:50 <3hrs Category 4 – Less urgent calls (eg; diarrhoea & vomiting Local LLR: or urinary infections – may be referred to GP or called LLR 90th centile 3hrs 36m - Q2 01:01:14 02:40:45 03:11:03 02:18:40 02:43:34 02:17:02 02:35:26 03:16:41 02:38:37 02:34:03 back) 3hrs 34m - Q3 3hrs 31m - Q4 ELR 01:03:53 02:17:07 03:26:39 02:41:37 02:28:34 03:39:29 01:58:23 03:04:51 02:16:48 02:06:20
Zero Crew Clear delays of > 30 and <60 minutes (LRI) 4.3% 5.5% 7.6% 8.2% 8.0% 8.0% 7.9% 7.7% 6.5% 7.0% 7.4% Tollerance 2017/18 Zero Crew Clear delays of > 1 hour (LRI) 0.4% 0.5% 0.2% 0.4% 0.4% 0.3% 0.4% 0.5% 0.3% 0.4% 0.4% Tollerance ConstitutionNarrative
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APPENDIX B
Standard/ Indicator Description Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 YTD
Latest Latest Target Position Baseline Standard Outturn/
Zero 52 Week Waiters Mar-18 3 1 4 4 3 2 1 1 1 1 0 18 Tollerance 100%
Elective Access Elective Cancelled Operations - % of patients re-admitted 79.1% 78.2% 79.9% 82.6% 78.3% 77.7% 78.5% 86.3% 86.4% 88.7% 81.9% 2017/18 National within 28 days (UHL) 338 24 pts 28 pts 24 pts 35 pts 22 pts 17 pts 19 pts 18 pts 11 pts 198 pts Target 24 28 24 35 22 17 19 18 11 198
Indicator Description Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 YTD Latest Latest Target Position Baseline Standard Outturn/ Standard/
Zero Mixed Sex Accommodation 2017/18 13 2 0 3 2 1 1 0 1 0 3 13 Tollerance Zero Healthcare acquired infection (HCAI) measure (MRSA) 2017/18 2 0 0 1 0 0 0 0 1 0 0 0 Tollerance Trajectory 6 12 18 25 31 38 44 51 57 64 70 77 Healthcare acquired infection (HCAI) measure 2018/19 2017/18 76 (Clostridium diffficile infection) YTD 6 12 18 26 36 44 48 55 58 63 64
Mar-18 4.4% <4% 4.1% 5.3% 1.7% 11.9% 6.7% 2.0% 1.2% 2.7% 2.5% 2.0% 4.0% NHS111 - Abandoned Calls after 30 seconds Mar-18 75% >95% 81.3% 77.4% 89.6% 63.4% 72.0% 90.6% 94.3% 86.9% 90.6% 90.7% 83.7% Additional Indicators requiring focus NHS111 -Calls answered within 60 secsonds 92.6% 93.3% 93.9% 100.0% Q4 92% Children waiting more than 18 weeks for a wheelchair 2017/18 87.5% 100% by Q4 97.20% 91.7%
ConstitutionNarrative
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APPENDIX C Quality Premium 2018/19
It should be noted that 2018/19 reporting is at an early stage with very limited data available. Therefore, reported Expected Quality Premium should not be taken as a meaningful predication until we are closer to having 2018/19 out-turn positions.
Quality Premium - Quality Elements
The indicators remain largely unchanged from 2017/18 and are still subject to reduction if Constitution Gateway indicators are below target. There are now 2 such constitution indicators;
• RTT incomplete waiting list which was over target higher in January 2019, therefore not achieving. • Cancer 62 day waits which were not meeting national target as at January YTD 2019.
Current projected income in this section is therefore £0 at this stage.
Emergency Demand Management Indicators
This new section is not subject to the Constitution Indicators Gateway. Therefore, any payments achieved will be made even if the 2 constitution indicators are below target.
Indicators - A1 Type 1 A&E and A2 Emergency Admissions with Length of Stay (LOS) = 0. Both indicators need to be on target to achieve the payment of £599,653. Based on January 19 (YTD) data A2 is on target but A1 is not.
Indicator B - Actual number of non-elective admissions with LOS of 1 day or more is not on target no change from last month’s position. This is worth £599,653. January YTD is not on target.
Current projected income in this section is therefore £0 at this stage.
EMERGENCY DEMAND MANAGEMENT INDICATORS A1 - Actual number of Type 1 A&E Plan 2018/19 Jan 19 attendances to be no greater than the <= 65,370 Jan 19 YTD YTD N planned number of Type 1 A&E 2018/19 Annual Plan 55,004 58,104 attendances. 50% £599,653 £0 A2 - Actual number of non-elective Plan 2018/19 Jan 19 admissions with LOS =0 to be no greater <= 9,614 Jan 19 YTD YTD Y than the planned number of non-elective 2018/19 Annual Plan 8,046 7,874 admissions with LOS =0 (EM11a) B - Actual number of non-elective admissions with LOS of 1 day or more to Plan 2018/19 Jan 19 <= 23,611 be no greater than the planned number of Jan 19 YTD YTD 50% £599,653 N £0 2018/19 Annual Plan non-elective admissions with LOS of 1 day 19,638 19,746 or more (EM11b) EXPECTED QUALITY PREMIUM ACHIEVED FROM THIS SECTION. (NHS CONSTITUTION GATEWAY RULE DOES NOT APPLY TO ED MANAGEMENT) CURRENT POSITION £0 MAXIMUM QUALITY PREMIUM AVAILABLE FROM THIS SECTION (75.5% of total QP) £1,199,306
CCG Population > 317697 Price per head > £5 Potential Quality Premium > £1,588,485
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APPENDIX C QUALITY PREMIUM 2018/19 QUALITY INDICATORS 18/19 Current Position Quality % Value for Measure Measure 2017/18 Standard Baseline (Monthly/ Premium of QP CCG Achieving Quarterly/Annually) Funding Cancers Diagnosed at early stage 1. Demonstrate a 4% point improvement in the proportion of cancers (specific cancer sites, morphologies and behaviour*) that are diagnosed at stages 1 and 2 in the 2013 - 48.9% 2017 data due June 19 2018 calendar year compared to the 2017 calendar year. 2014 - 52.2% Cancers Diagnosed at early stage Target of xx in 2018 17% £66,160 N £0 Or 2015 - 52.1% (due Jan 20) 2. Achieve greater than 60% of all cancers (specific cancer 2016 - 50.3% sites, morphologies and behaviour*) that are diagnosed at stages 1 and 2 in the 2018 calendar year Overall experience of making a GP appointment Either: 1. Achieve a level of 85% of respondents who said they had Overall experience of making a GP a good experience of making an appointment, or; 2017 2018 data to be 17% £66,160 N £0 appointment 2. Achieve a 3 percentage point increase from July 2018 84% published 2019 publication on the percentage of respondents who said they had a good experience of making an appointment NHS Continuing Healthcare A two part indicator: (a) worth 50% - CCGs to ensure that in more than 80% of 90.48% cases with a positive NHS CHC Checklist, the NHS CHC >80% 8.5% £33,080 Y £33,080 Jan 2019 NHS Continuing Healthcare eligibility decision is made by the CCG within 28 days from receipt of the Checklist (b) worth 50% - CCGs to ensure that less than 15% of all full 9.52% <15% 8.5% £33,080 Y £33,080 NHS CHC assessments take place in an acute hospital Jan 2018 Mental Health Awaiting national baseline from NHS England - Recognising the issues early on with data quality (to be expected with any data collection in its infancy), Option Chosen by CCG & NHSE: Out of A 33% reduction in the number of inappropriate adult NHS England is reviewing how best to assure local 17% £66,160 N £0 Area Placements (OAPs) OAPs for non-specialist adult acute care performance on reducing OAPs over 2017/18 for those CCGs which selected the OAPs Quality Premium, to ensure it is awarded appropriately. Anti-biotic Prescribing A three part indicator: Reduction in the number of gram negative blood stream E coli BSI 12 mth rolling data infections across the health economy Jan-Dec 2016 Baseline December 2018 5.1% £19,848 N £0 (ai) A 10% reduction (or greater) in all E Coli BSI reported at 189 199 CCG level based on 2016 performance data (aii) Collection and reporting of a core primary care data set for E coli cases (100% of all E coli BSI cases in Q2 (10% National Data 2.6% £9,924 N £0 weighting) and 50% of all E coli BSI cases in Q3 (5% No Publication Date weighting) in 2018/19) Reduction of inappropriate antibiotic prescribing for UTI 2018-19 Reducing Gram Negative Bloodstream in primary care 12 mths rolling data to QP Target Value Infections (GNBSIs) and inappropriate (bi) A 30% reduction (or greater) in the number of November 2018 3.4% £13,232 Y £13,232 30% reduction antibiotic prescribing in at risk groups Trimethoprim items prescribed to patients aged 70 years 5,777 (or greater) or greater on baseline data (June15-May16) Sustained reduction in in-appropriate prescribing in primary care 2018-19 CCG 12 mths rolling data to (ci) Items per Specific Therapeutic group Age-Sex Related Target Value November 2018 1.7% £6,616 Y £6,616 Prescribing Unit (STAR-PU) must be equal to or below to be 1.161 or below 0.973 England 2013/14 mean performance value of 1.161 items per STAR-PU (cii) Additional reduction in Items per Specific Therapeutic 2018-19 CCG 12 mths rolling data to group Age-Sex Related Prescribing Unit (STAR-PU) equal to Target Value November 2018 4.3% £16,540 N £0 or below 0.965 items per STAR-PU. to be 0.965 or below 0.973 Local Priority Baselines: 2014/15 = 73.72% (equates to 1830 out of 17/18 2482) 73.16% 2015/16 = 74.04% (2272 out of 3059) Patients diagnosed with dementia whose Increase in % of patients diagnosed with dementia whose (equates to 2119 out of care plan has been reviewed in a face-to- care plan has been reviewed in a face-to-face review in the 2862) 15% £58,377 N £0 18/19 face review in the preceding 12 months preceding 12 months 2016/17 = 74.27% National data to be (equates to 2272 out of published 3059) November 2018 Targets: 2018/19 = 74.87% Quality Premium Achieved from indicators above £86,009 Constitution Rights & Pledges Referral to Treatment Times The number Target of patients on an incomplete pathways Jan 19 <= 20,661 (Total waiters March 18) Jan 19 50% £43,004 N £0 (Total) not to be higher in March 2019 21,510 19,938 than in March 2018 Maximum 62 day (2 month) wait from Jan YTD urgent GP referral to first definitive National Standard 85% 50% £43,004 N £0 85.4% treatment for cancer Quality Premium Adjustments taken from for NHS Constitution Measures £0 MAXIMUM QUALITY PREMIUM AVAILABLE FROM THIS SECTION (24.5% of total QP of £1.59m) £389,179 24
APPENDIX C Emergency Demand Management Activity and Plans January 2019
The tables below shows the emergency demands activity against the YTD plan. In order to achieve target all the indicators should not be no greater than the planned activity.
A1 – Type 1 A&E Attendances
Type 1 A&E Attends. Period Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar TOTAL FY16/17 Actual 4,238 4,624 4,396 4,594 4,491 4,466 4,464 4,407 4,336 4,086 3,763 4,550 52,415 FY17/18 Actual 4,618 5,650 5,398 5,467 5,361 5,456 5,503 5,759 5,663 5,353 4,786 5,469 64,483
18/19 Actual 5,487 11,285 17,065 22,791 24,293 34,458 40,247 46,178 52,076 58,104 18/19 Plan to Da 5,368 11,043 16,439 21,944 27,344 32,585 38,110 43,892 49,592 55,004 59,823 65,370 18/19 Plan 5,368 5,675 5,396 5,505 5,400 5,241 5,525 5,782 5,700 5,412 4,819 5,547 65,370
A2 – Zero Length of Stays
Zero LoS Spells Period Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar TOTAL FY16/17 Actual 626 727 673 624 628 638 663 626 638 608 606 675 7,732 FY17/18 Actual 704 805 776 739 756 790 797 827 808 913 726 831 9,472
18/19 Actual 765 1,637 2,491 3,243 4,015 4,705 5,519 6,331 7,076 7,874 18/19 Plan to Da 782 1,669 2,505 3,306 4,114 4,933 5,752 6,528 7,301 8,046 8,805 9,614 18/19 Plan 782 887 836 801 808 819 819 776 773 745 759 809 9,614
This is split into 2 parts, weighting 50%, Both A1 and A2 need to achieve plan to achieve payment.
B – 1 Day+ Length of Stays
1 day + LoS Spells Period Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar TOTAL FY16/17 Actual 1,862 1,942 1,843 1,844 1,741 1,824 1,872 1,885 1,981 2,035 1,811 2,035 22,675 FY17/18 Actual 1,839 1,933 1,875 1,888 1,987 1,979 1,971 1,972 1,996 2,121 1,864 2,129 23,554
18/19 Actual 1,908 3,833 5,807 7,795 9,767 11,283 13,627 15,685 17,666 19,746 18/19 Plan to Da 1,891 3,874 5,777 7,688 9,596 11,548 13,502 15,498 17,564 19,638 21,513 23,611 18/19 Plan 1,891 1,983 1,903 1,911 1,908 1,952 1,954 1,996 2,066 2,074 1,875 2,098 23,611
Payment of this indicator can be achieved when the total number of type 1 A&E attendances for 2018/19 is no greater than their total planned number of type 1 A&E attendances in 2018/19.
25
APPENDIX D
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APPENDIX D
27
APPENDIX D
28
APPENDIX D
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APPENDIX D
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APPENDIX D
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APPENDIX E Better Care Fund Metrics
Leicestershire County Council as at December 2018 RAG- Latest Data Metric Target rated Trend Aim / Polarity DOT Commentary Data RAG data The RAD-rated data shows the January forecast for 2018/19, based aETRL/ 1: termanent admissions of Dood performance is on /tLLs. The ./C target for 18/19 is a maximum of 890 admissions. older people (aged 65 and over) to 624.1 37.17 600.2 G represented by a fall The current full year forecast is 856 admissions (or 600.2 per residential and nursing care homes, per in the figures 100,000 population). terformance is RAD-rated green and is 100,000 population, per year statistically similar to the target. aETRL/ 2: troportion of older people Cor hospital discharges between Aug and Oct '18, 89.3% of people (65 and over) who were still at home Dood performance is discharged from hospital into reablement / rehabilitation services 91 days after discharge from hospital 87.0% n/a 8E.3% G represented by a rise were still at home after 91 days. This is above the 18/19 target of into reablement / rehabilitation in the figures 87%. terformance is RAD-rated green and is statistically similar to services the target.
Ln December there were 1,245 days delayed, a rate of 229.02 per 100,000 population against a target of 244.38. This is RAD-rated as Dood performance is aETRL/ 3: Delayed transfers of care green and is statistically significantly better than the target. Cor the 244.38 n/a 22E.02 G represented by a fall from hospital per 100,000 population different attributable organisations (NHS, social care, and jointly in the figures attributable), 80.4% of these delays were attributable to the NHS, 6.3% attributable to Social /are and 13.3% Jointly attributable.
Cor the period Apr-18 to Dec-18 there have been 50,560 non- elective admissions, against a target of 52,647 – a variance of - 2,087. This is RAD-rated as green. Curthermore, the forecast for the end of the 2018/19 financial year is that there could be 68,482 admissions, against a target of 70,569. This would be RAD-rated as green.
aETRL/ 4: Total non-elective Dood performance is Cor the month of December there has been 5,571 non elective admissions into hospital (general and 866.D6 82D.1E 807.04 G represented by a fall admissions, against a target of 5,982 - a variance of -411. The acute), per 100,000 population, per in the figures monthly rate is 807.04 against a monthly target of 866.56 and this is month RAD-rated green.
The RAD methodology is green if non-elective admissions/rate is less than or equal to the monthly target, amber if non-elective admissions/rate is between the monthly target and monthly minimum, and red if non-elective admissions/rate is greater than the monthly minimum.
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APPENDIX E Rutland County Council as at 2018-19 Q3
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O Blank Page Paper O ELR CCG Governing Body Meeting 9th April 2019
EAST LEICESTERSHIRE AND RUTLAND CLINICAL COMMISSIONING GROUP GOVERNING BODY MEETING
Front Sheet
REPORT TITLE: ELR CCG GP Locality Meeting Themes February and March 2019
MEETING DATE: Tuesday 9th April 2019
REPORT BY: Becky Hunt, Operations Support Officer
SPONSORED BY: Jamie Barrett, Head of Primary Care
PRESENTER: Dr G Purohit, GP Locality Lead SLAM Dr Vivek Varakantam, GP Locality Lead Oadby and Wigston Dr Simon Vincent, GP Locality Lead North Blaby Dr Nick Glover, GP Locality Lead South Blaby and Lutterworth Dr Anuj Chahal, GP Locality Lead Harborough Dr Hilary Fox, GP Locality Lead Rutland
EXECUTIVE SUMMARY: The purpose of this report is to provide an overview of the monthly GP Locality meetings held across Blaby and Lutterworth, Oadby and Wigston and Melton, Rutland and Harborough. These meetings are key to the CCG development and allow member practices an opportunity to debate current general practice and highlight themes they wish to inform the Board. The report has been divided into common themes across all localities and the specific locality discussions.
RECOMMENDATIONS: The East Leicestershire and Rutland CCG Governing Body is requested to: RECEIVE the report.
REPORT SUPPORTS THE FOLLOWING STRATEGIC AIM(S) 2016 – 2017: Transform services and enhance quality of Y Improve integration of local services Y life for people with long-term conditions between health and social care; and between acute and primary/community care. Improve the quality of care – clinical Y Listening to our patients and public – Y effectiveness, safety and patient experience acting on what patients and the public tell us. Reduce inequalities in access to healthcare Y Living within our means using public Y money effectively Implementing key enablers to support the strategic aims (e.g. constitutional and governance Y arrangements, communications and patient engagement).
EQUALITY ANALYSIS An Equality Analysis and due regard to the positive general duties of the Equality Act
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Paper O ELR CCG Governing Body Meeting 9th April 2019
2010 has not been undertaken in the development of this report as it is judged that it is not proportionate on the basis that on the basis that this purely an information summary of discussions which has occurred.
This completes the due regard required.
RISK ANALYSIS AND LINK TO BOARD ASSURANCE FRAMEWORK: The content of the report identifies BAF 6 action(s) to be taken / are being taken to mitigate the following corporate BAF 10 risk(s) as identified in the Board Assurance Framework:
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Paper O ELR CCG Governing Body Meeting 9th April 2019
EAST LEICESTERSHIRE AND RUTLAND CLINICAL COMMISSIONING GROUP GOVERNING BODY MEETING
GP Locality Meetings – February and March 2019
9th April 2019
1. INTRODUCTION
The 30 GP practices across the CCG are split into 6 geographical localities, 1. Oadby and Wigston (OW) 2. Rutland (RUT) 3. Harborough (HARB) 4. Syston, Long Clawson and Melton (SLAM) 5. North Blaby (NB) 6. South Blaby and Lutterworth (SBL)
The purpose of the locality structure is to provide a forum for member practices to feed into the CCG, feedback to their practices, discuss key issues and concerns and work together in localities. In addition the locality structure provides:
• Meetings held monthly either in these localities or as a wider locality • Promotion of two-way discussion on all business and a mechanism for GPs to be updated on CCG matters to inform commissioning and planning processes. • Opportunity to share learning from adverse events - safeguarding issues etc. • Opportunities for clinical discussion and education • Monitoring of performance and quality through the sharing of benchmarked data and information. • Reflecting the emerging PCN structure.
2. LOCALITY MEETING CONTENT
Each practice across the CCG is represented at one of the six locality meetings. A total of 12 locality meetings took place in February and March (6 each month). The themes for the February and March 2019 meetings were the following:
Clinical Topics in February – • Community Services Redesign • Primary Care Networks • INR Electronic Reporting • Low Carb Diets • Sharing learning on gynaecology and dermatology. • Dementia, Falls Risk Assessment
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Clinical Topics in March • FeNO Testing Proposal • Exercise Referral Scheme • Multi-Organisational Updates from LPT, District Nursing, etc. • First Contact Physiotherapy • MSK Triage • 24 hour BP monitoring • Dementia • Dermatology
Other Agenda Items (February & March) • Locality/ Joint Working (All localities) • LILT updates (varies across localities) • Transformation Plan Updates (varies across localities) • Governing Body Update (varies across localities) • Primary Care Networks Update (all localities) • Commissioning Intentions 19-20 (all localities).
3. OVERALL LOCALITY THEMES
The sections below represent the key themes from the Localities for the months of February and March 2019. These themes are covered across all localities and the narrative below is an overall commentary capturing the discussions.
Primary Care Networks - In February all of the Locality Meetings openly discussed Primary Care Networks (PCNs) and received a summary of the GP Contract. In NB, SBL, SLAM, HARB and RUT discussions were lengthy; however in OW the locality meeting was shorter due to the Health Summit so the more lengthy discussion will take place at the March meeting. In all localities it was acknowledged that there was an opportunity to either form into a PCN based on existing locality groupings or to form other groupings within the criteria set (Practices forming a PCN need to share a boundary and have a combined population size between 30,000 and 50,000). The outcome of these discussions varied between localities with some happy to form a PCN with their existing group and others wishing to discuss and investigate other options which take into account their size, geography and LILT partners. Further specific details can be found under each locality section below.
Community Services Redesign - Several of the localities discussed the Community Services Redesign proposals in order to provide clinical feedback and perspective to the Better Care Together Team. Tamsin Hooton had provided four questions for localities to consider. The main focus of discussions for GPs was the Medical Model for Home First which will require GPs to provide an enhanced level of care to a specific cohort of patients. Further specific details can be found under each locality section below.
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Paper O ELR CCG Governing Body Meeting 9th April 2019
Common Themes March 2019
• Primary Care Networks – All agreed that the ACD role should be open to all clinicians in practices including nurses and pharmacists.
• Commissioning Intentions 19-20 – all localities received an update on plans for the Primary Care Commissioning Intentions for 19/20.
• Federation Proposal – PCN support – Proposal for the Federation to support PCNs in 19/20.
INDIVIDUAL LOCALITY THEMES FEBRUARY AND MARCH 2019 COMBINED
These are specific locality themes over and above those featured in common themes.
4. OADBY AND WIGSTON – Chair Dr Vivek Varakantam
4.1 Health Summit - The Locality Health Summit took place involving a variety of stakeholders including GP practices, Local authority, public health, district nursing and PPG representatives. The event was well attended and was the first crucial step in exploring the health inequalities within the borough and understanding and addressing the potential issues. There were a lot of good round table discussions which have been captured and will be collated for further review. This was extremely successful with lots of positive comments from participants reflecting on the event.
5. RUTLAND HEALTHCARE LOCALITY – Chair Dr Rysz Bietzk and Dr Hilary fox
5.1 Patient choice - Acute visiting service and MSK triage - Practices requested assurance that access to the DHU home visiting service was equitable at the periphery of the ELR area. Rutland practices are low users of the service, but find that patients are frequently redirected back to the practices. For EMIS practices referral is still a long phone call which can take 30 minutes, and it was requested that secure email referrals be accepted by DHU. A review of the quality and equality of access across localities was requested. Practices also reported that the MSK triage hub was directing referrals back to the practice for direct referral to Peterborough when this was the patient’s choice.
5.2 Staying Stable, Being Able- The programme was presented. This is a digital assessment of patients’ gait and balance, to give an objective measure of eligibility for the falls prevention program including FAME, and the effectiveness of the programs. Demonstration of improvement can help to provide confidence for patients.
5.3 Rutland Hub - The members were pleased to hear that the model was commended by NHS England as being the first successful implemented model
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nationally. NHS England has asked to look at the model with a plan to use and replicate elsewhere nationally.
6. HARBOROUGH LOCALITY – chair Dr Anuj Chahal
6.1 First Contact Physiotherapy Service – This has been appraised well by a survey of patients in February. Of 140 responses 99.3% were positive (the remaining 0.7% didn’t answer the question). Practices were keen to continue the service to bridge between the end of the pilot on 2 May to the 2020/21 FY when FCP services will be required from PCNs. However, there is concern about funding arrangements for such a bridge arrangement and if there is no support from GB practices may decide to remove their support, from the FCP service.
6.2 Primary Care Networks – The Harborough and Bosworth Partnership remain uncommitted to any potential Harborough PCN mainly due to their Partners not having discussed it in sufficient detail as yet. All practices agreed to have a definitive position available by Wednesday 10 April to allow further work and development of the PCN.
6.3 Future of the Federation – This was discussed with James Watkins present. The Federation is considering how best to support the fledgling PCNs and supporting all potential ELR PCNs would give economies of scale. The Locality agreed in principle that Federation support for PCN development would be welcomed but that the financial implications need to be re-worked.
7. SLAM LOCALITY – Chair Dr Girish Purohit
7.1 Clinical Variation – Hypertension, Dementia and Local Dermatology Service (Latham House) - Member practices studied the Locality Intelligence Pack (LIP) in line with the PHE ambitions for CVD and shared their approaches to increasing hypertension prevalence including the use of HCAs, nurses and pharmacists to support the GP in confirming diagnosis. As a starting point, all practices agreed to use existing searches to identify patients with hypertension - not coded, diabetics with hypertension - not coded and patients on hypertensives - not coded with a view to improving clinical variation (prevalence and treatment) within the locality. Discussion on ways of improving dementia prevalence highlighted a number of suggestions for capturing patients including the involvement of ECPs in the distribution of the memory questionnaires at home visits. In addition, Dr Hirani outlined the criteria and availability of his Dermatology service on ERS. Being provided at a reduced tariff, the practices in SLAM agreed to refer to the service from 1st April as clinically appropriate.
7.2 Community Services Redesign - Detailed discussion took place around the proposals for Community Services redesign. The group commented on the questions posed to them with the following observations: • They want to see more therapies included in the specification • More clarity on anticipated numbers of patients per PCN/practice basis
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• Speedier communication channels with community nursing needed together with closer working to ensure a responsive service • They agreed that the medical model for Home First should be delivered through registered practices or PCNs. Bearing in mind the geography of SLAM, perhaps practice level would be more responsive. Practices want to know the potential caseload and funding. • Care coordination is not consistent across SLAM with only one practice happy with the service.
7.3 Primary Care Networks - A discussion around potential options for the SLAM practices to form into Primary care Networks took place. It was acknowledged that Latham House could register alone as a PCN, however the practice did recognise the position of the other practices and did not discount the option of SLAM becoming a PCN with its current constituent practices. There was a view that in retaining SLAM in its current form, there might be scope to create a two sub regions to acknowledge the distinct geographical locations of Syston, Latham house and Long Clawson. The location of Long Clawson together with its two Lincolnshire practices added another dimension to the discussions for the PCN.
7.4 ECP Service – This pilot has been received well by two of the three practices using it and they would like to see it continue pending the commissioning intentions of the CCG for 19/2/
7.5 Federation Proposal – Members agreed to support the proposal in principle pending a breakdown of costs.
8. NORTH BLABY Locality– Chair Dr Simon Vincent
8.1 Locality Integrated Leadership Team (LILT) – The members discussed the success of the multi organisational MDT’s taking place, timely patient safeguarding information and the ability for community nurses to be able to task the GP Link Workers via SystmOne. An update on the Exercise Referral Clinic being piloted in The Limes also highlighted success with clinics being well utilised. Enderby Medical Centre has now commenced with the clinics and other practices were asked to express their interest. Practices were asked if they had room for community mental health clinics to take place and to express their interest if this was the case.
8.2 Transformation Planning – The Frailty Service Model was discussed and due to there being no clear funding stream this would need to go on hold. James Watkins presented a proposal to the group of support the Federation could give PCNs in the coming year.
8.3 NHS 5 year Framework – Dr Vincent presented the key principles and changes that would be in place this year. The members discussed the implications for the locality and agreed that they would remain together to form a PCN.
8.4 Locality Intelligence Pack – Variations in the QoF clinical indicators were discussed by the practices and sharing of best practice.
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Paper O ELR CCG Governing Body Meeting 9th April 2019
8.5 FeNO testing – Dr Sudip Ghosh presented to the practices on a service which would work well with PCN collaborative working and also reduce secondary care usage and reduce prescribing spend.
9. SOUTH BLABY AND LUTTERWORTH PARTNERSHIP HUB – Chair Dr Nick Glover
9.1 Transformation Projects – Members updated on progress of the individual work streams. Concerns were raised over losing the benefit of current Access work into 2019/20 with the uncertainty of funding. The implications of this would be a loss of progress on the impact of the changes made in working and the losing valuable staff.
9.2 Locality Integrated Leadership Team (LILT) – Updates from the team included: • The team continues with positive optimising of working as an integrated care system and jointly discussed the various issues around the community services review and PCN’s. • Details of 6 Falls programmes to take place across Blaby this year and who to refer • Exercise referral programmes available • New GP Link Worker appointed for Lutterworth practices. • Community nursing primary care co-ordinators are leaving UHL to work back in the community again.
9.3 Social Prescriber Role – The new PCN contract will fund a social prescriber for each PCN. The practices discussed this role and the need for it to compliment other services and roles and not duplicate. Practice Managers saw the role educating staff on signposting in addition actively working with patients to guide them through existing services. The practices will be looking at job descriptions from other areas of the country in preparation for a full discussion at the next meeting.
Recommendation:
The East Leicestershire and Rutland CCG Governing Body are requested to:
RECEIVE the report
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P Blank Page Paper P East Leicestershire and Rutland CCG Governing Body meeting 9 April 2019 EAST LEICESTERSHIRE AND RUTLAND CLINICAL COMMISSIONING GROUP GOVERNING BODY MEETING
Front Sheet
REPORT TITLE: Summary Report from the Public Commissioning Collaborative Board (CCB) – March 2019
MEETING DATE: 9 April 2019
REPORT BY: Amardip Lealh Corporate Governance Manager, ELR CCG SPONSORED BY: Karen English, Managing Director
PRESENTER: Dr Andy Ker, Clinical Vice Chair
PURPOSE OF THE REPORT: This report is from the Commissioning Collaborative Board (CCB); which is a joint committee of NHS East Leicestershire and Rutland CCG, NHS West Leicestershire CCG and NHS Leicester City CCG. The CCB supports joint decision making and undertakes collective strategic decisions on those areas where authority has been delegated by the respective CCG Governing Bodies.
RECOMMENDATIONS: The East Leicestershire and Rutland CCG Governing Body is requested to:
RECEIVE the report from Commissioning Collaborative Board in March 2019;
NOTE the approval of the ‘LLR Guidelines for the treatment of minor ailments and self-limiting conditions.’
Page 1 of 4 Paper P East Leicestershire and Rutland CCG Governing Body meeting 9 April 2019 EAST LEICESTERSHIRE AND RUTLAND CLINICAL COMMISSIONING GROUP GOVERNING BODY MEETING
9 April 2019
Highlight Report from the Public Commissioning Collaborative Board (CCB) – March 2019
Introduction
1. The purpose of this report is to provide the Governing Body with an update on decisions made; issues identified and risks escalated from the Commissioning Collaborative Board (CCB) meeting.
2. The CCB is a joint committee of NHS East Leicestershire and Rutland CCG, NHS West Leicestershire CCG and NHS Leicester City CCG. CCB’s role is to:
Support CCGs to create a financial sustainable health system in Leicester, Leicestershire and Rutland (LLR);
Ensure clinically led co-design of service models for health services within LLR are safe, effective and efficient;
Provide a forum where commissioners can agree and align priorities and identify opportunities for further collaboration and consistency;
Provide onward assurance to the respective Governing Bodies.
3. The key areas of discussion and outcomes from the CCB meeting on 28 March 2019 meeting are summarised below.
Progress Update on QIPP Schemes
4. The CCB received its regular monthly update from the LLR Programme Management Office (PMO) on the QIPP report and noted the following:
LLR CCGs are forecasting an under delivery of £0.866m on the QIPP plan for 2018-19, which is an adverse movement of £0.241m from the previous month;
Leicester City CCG are reporting an over delivery of £1.012m against plan; and both East Leicestershire and Rutland CCG and West Leicestershire CCG are reporting an under delivery of £0.413m and £1.465m respectively against plan;
Senior Responsible Officers (SROs) are forecasting QIPP delivery of £57.3m for 2018-19, of which £56m is deemed achievable;
Further work is currently ongoing to ensure lessons learnt as part of the current financial year are incorporated into the QIPP plan for 2019-20; and an update will be presented to the CCB in April 2019.
Page 2 of 4 Paper P East Leicestershire and Rutland CCG Governing Body meeting 9 April 2019 Clinicians agreed it was a timely opportunity to ensure their views were taken into consideration as part of the review to ensure consistency across the LLR CCGs, in conjunction with best practice / areas for improvement; and to enhance collaborative working arrangements
LLR Guidance on self-care for Minor Ailments and Self-limiting Conditions
5. Following the national public consultation on ‘Conditions for which Over the Counter (OTC) items should not routinely be prescribed in primary care,’ and the publication of NHS England’s National Guidance for CCGs in March 2018, a series of engagement exercises were undertaken to obtain views from patients, GPs including Prescribing Lead GPs, the Local Pharmaceutical Committee, senior colleagues across LLR CCGs, University Hospitals of Leicester (UHL) NHS Trust and Derbyshire Health United (DHU).
6. As a result of the above, the CCB were presented with the ‘LLR Guidelines for the treatment of minor ailments and self-limiting conditions’ for approval, which aims to develop a system wide approach in all care settings for this treatment and were supported by the Leicestershire Medicines Strategy Group (LMSG) in February 2019. Clinicians noted the guidelines could be overridden by GPs in appropriate circumstances as all clinicians are bound by the national formulary.
7. Following a brief discussion in relation to the proposed dissemination methods, implementation (and monitoring) of the guidance; as well as linking to existing services such as Urgent Care, further concerns were raised in relation to the cost of OTC medication that can vary from the supplier and their location, which may hinder the implementation of the guidelines. It was noted the cost of the OTC medication did not fall within the remit of the CCB and it was agreed for the Prescribing Leads to feedback the issues raised at a regional level.
8. The CCB approved the ‘LLR Guidelines for the treatment of minor ailments and self-limiting conditions,’ which will be hosted on the LMSG website and promoted / disseminated to clinicians and thereafter.
Update on Contract Negotiations for 2019-20
9. The CCB received an update in relation to the following contracts:
UHL LC CCG confirmed that following a mediation process in order to review and test the proposed split of the revised contract into tariff based activity and non-elective based activity, a final version of the proposed contract with UHL for 2019-20 was agreed on 27 March 2019, which is to be signed shortly.
LPT ELR CCG confirmed that LPT have fully engaged with the CCG in terms of negotiating a different approach to its contract for 2019-20, which is positive. However, work continues with colleagues across LLR CCGs to bridge the additional £800k cost pressure identified by LPT and the £2m QIPP shortfall for CCGs (e.g. Mental Health, Learning Disabilities, and Community Services Redesign).
Page 3 of 4 Paper P East Leicestershire and Rutland CCG Governing Body meeting 9 April 2019 It was noted that NHS England have requested any contractual issues to be reported by midday on 29 March 2019 as the deadline for contracts to be finalised is 1 April 2019.
RECOMMENDATIONS
10. The East Leicestershire and Rutland CCG Governing Body is requested to:
RECEIVE the Commissioning Collaborative Board report from the meeting held in March 2019;
NOTE the approval of the ‘LLR Guidelines for the treatment of minor ailments and self-limiting conditions.’
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System Leadership Team Meeting 23 Chair: Peter Miller Date: Thursday 22nd November 2018 Time: 9.35 – 12:00 Venue: 8th Floor Conference Room, St Johns House, East Street, Leicester, LE1 6NB Present: Peter Miller (PM) LLR STP Chair, Chief Executive, Leicestershire Partnership Trust
Mark Andrews (MA) Deputy Director for People, Rutland County Council
Sue Elcock (SE) Medical Director, Leicestershire Partnership Trust
Karen English (KE) Managing Director, East Leicestershire and Rutland CCG
Azhar Farooqi (AFa) Clinical Chair, Leicester City CCG
Mayur Lakhani (ML) Chair, West Leicestershire CCG, GP, Sileby and Chair Clinical Leadership Group Roz Lindridge (RL) Locality Director Central Midlands, NHS England
Sue Lock (SL) Interim LLR STP Lead, Managing Director, Leicester City CCG
Ursula Montgomery Chair, East Leicestershire and Rutland CCG and GP (UM)
Sarah Prema (SP) Director of Strategy and Implementation, Leicester City CCG
Evan Rees (ER) Chair, BCT PPI Group
Paul Traynor (PT) Director of Finance, University Hospitals of Leicester NHS Trust
Caroline Trevithick (CT) Interim Managing Director, West Leicestershire CCG
Jon Wilson (JW) Director of Adults and Communities, Leicestershire County Council
Apologies: John Adler (JA) Chief Executive, University Hospitals of Leicester NHS Trust
Steven Forbes (SF) Strategic Director for Adult Social Care, Leicester City Council
Andrew Furlong (AF) Medical Director, University Hospitals of Leicester NHS Trust
John Sinnott (JS) Chief Executive, Leicestershire County Council
In Attendance: Shelly Heap Board Support, BCT(Minutes)
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SLT 22/11/01 Welcome and introductions Dr Ursula Montgomery, Chair East Leicestershire and Rutland CCG was welcomed to the group.
The chair will rotate every three months between PM, KE, JA and CT
SLT 22/11/02 Apologies for Absence and Quorum Apologies were received from Steven Forbes, Andrew Furlong, John Adler (Paul Traynor representing), and John Sinnott (Jon Wilson representing)
SLT 22/11/03 Declarations of interest on Agenda Topics ER declared his role as trustee for Voluntary Action Leicestershire for item 8, paper D. There were no further declarations to note.
SLT 22/11/04 Minutes of meeting held on 16th August 2018 and 18th October 2018 The minutes of the meetings on 16/08/18 and 18/10/18 were approved as a true and accurate record.
SLT 22/11/05 Action notes of the meeting held on 16th August 2018 Both actions are on the meeting agenda for today.
SLT 22/11/06 Key updates STP Events SL provided feedback from two recent events. The first event was about the NHS long term plan at which Matt Hancock talked about three broad areas of focus as follows: Workforce - there was acknowledgment about the challenge to find the right people with the right skills and qualifications to implement new working models. Prevention – previous investment has been for the treatment of illness rather than prevention, however, funding will be channelled into better health going forward. Technology – the NHS has been slow to adopt and use technology consequently missing out on efficiencies.
Simon Stevens outlined the five year funding deal, emphasising that the first two years will continue to be tough with little financial flexibility due to the number of pre-commitments against the funding. It was clear that we will need to work differently with a focus on the priority issues in the short to medium term to achieve financial balance. There are five tests/key issues which are outlined in the long term plan: 1. Return to financial balance across providers and commissioners 2. Productivity growth to be improved by at least 1.1% per annum 3. Delivering reduced growth in demand through integration 4. Operational and quality performance 5. To make better use of capital investments
There were four areas highlighted where the findings on health outcomes are not as good as they should be. These are Cancer, CVD, Respiratory and Perinatal Mortality. Mental Health was also cited as an important issue. Time will need to be set aside for the system to start to organise transformation activities as well as to look at block contracting to start with effect from 2020. It was advised to start work as soon as possible as activity trends are already known; the guidance will be available shortly. It was acknowledged that 2019/2020 will be a very difficult time although work has already started on planning.
There was feedback regarding Integrated Care Systems (ICS). There will not be any legislative changes or a blueprint for an ICS, although there will be some flexibility in size. Examples were
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discussed from other ICSs nationally, whilst some are working on the whole scope Lancashire and South Cumbria are developing an ICS with a focus on older people including the provision of enhanced services in established care homes.
The second event was the STP clinical leads meeting at the end of October 2018 . They stressed that fragmentation of systems is a key driver for inefficiency and extra cost. There was acknowledgment that there is a growing number of STPs who have an integrated vision but that delivery is fragmented. There was emphasis on organisational development and the need for talent management to identify people within our partnership organisations who have potential for development. The use of consistent Quality Improvement methodologies was also cited as important along with the building of informal relationships between GPs and consultants, clinicians and the public as well as between health and the local authorities as these were identified as key criteria for an effective ICS.
CT added that both events had a focus on the wider determinants of health at a local level, highlighting the importance of a neighbourhood approach and understanding of local health needs in addition to how to link this with prevention. There was also a discussion about clinical engagement work and how a step change is needed to engage the LLR whole clinical population to bring them along on the journey towards an ICS. The recent Making Things Happen (MaTH) event was very good but more can be done in relation to this.
UM told the partners that the newly formed Integrated Community Service Board has been looking at aspects of the LLR population health, prevention, care coordination as well as bringing together teams who work across boundaries. There are 13 Locality Teams already set up from which data could be analysed centrally to inform decisions about the direction of travel.
There was a group discussion about community and place with an opportunity to do something to bring everyone together to best serve the LLR community. The use of LA boundaries to define place could be used. PM noted that this needs to be defined in order to create strong partnerships to best develop services.
PM highlighted the great work that is currently being undertaken by Cheryl Davenport to develop a Business Intelligence system for LLR.
Engagement Events There have been 7 events held so far with varying numbers and a wide variety of different people attending. Pressure groups have been at most events therefore; there has been a focus on ICU and whether our duty to consult with the public has been discharged. The Oakham event had much more focus on local services. There are two further events next week at Hinckley and the City (De Montfort University). The outputs will be captured and there will continue to be an ongoing dialogue with the public. Early feedback is that the public feel they haven’t had enough opportunity to give their views, additionally that they haven’t been listened to, therefore this is a good opportunity to learn from experience to improve in future.
The importance of developing a range of engagement activities rather than just public events was recognised. John Adler will be leading on Communications and Engagement and will be picking this up with Richard Morris and Sue Venables. SL expressed thanks and well done to all of those involved in the events.
SL highlighted that these events did not contain any update on mental health and that this was a gap to address at future events by having someone available to speak to the public and answer any questions.
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SLT 22/11/07 System Leadership Team Terms of Reference Refresh SL updated the partners that it has been more complex than first thought to draft the SLT Terms of Reference as SLT was initially set up as a subcommittee of the CCGs, therefore the corporate governance side is more complicated. Consequently, further time is needed to continue to have one to one conversations with partners to understand the process to ensure the right level of SL input. It was agreed to have an outline of the key principles and guidance for discussion at the December SLT meeting. The full proposal should be ready for the January SLT meeting.
SLT 22/11/08 Development of an Oversight Group Terms of Reference Pete Miller outlined the proposal in Paper D for the development of the terms of reference for the proposed new oversight group that was agreed by partners recently. The paper outlines the purpose and responsibilities of the group.
Partners were invited to give their feedback and comments on the draft document as follows: There was support for an oversight group to bring good governance to hold SLT to account on principles and behaviours as well as to provide guidance and support The term ‘oversight’ should be changed as the group will not have any statutory power. Both SLT and the oversight TOR cannot be done in isolation as SLT with inform the later. The oversight TOR should clearly define the function of the group (including Liaison and Engagement) as well as outline responsibilities, power, limitations in addition to how the group links to CCG governing bodies. The difference between the oversight group and SLT should also be specified. Membership should include Health and Wellbeing chairs, lay members, patients and the voluntary sector although it was acknowledged that it will be challenging to identify a single voluntary sector representative. There was support for an internal chair initially but this would be kept under review If the oversight group is open to the public consideration is required on how confidential issues will be discussed.
It was agreed that SL and PM will work jointly on both Terms of Reference. In addition a pack of governance papers will be developed to include a memo of understanding, the values, purpose and behaviours etc. Corporate Governance will also be involved. SL/PM Lincolnshire has a similar group which is called the Lincolnshire Co-ordinating Board and the System Executive sits underneath.
RL will share the newly published guidance which will be very helpful.
SLT 22/11/09 Progress towards an ICS PM highlighted the progression of LLR towards becoming an ICS along with the criteria that will make the process successful as outlined in the table in Paper E. There is a NHS England Aspirant ICS Programme with entry criteria which will support systems to make the transition.
The criteria are good indicators of success and include the following: Effective leadership and strong relationships, Track record of delivery Strong financial management Focussed on care redesign Defined population
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The partners agreed to start development work in the new year with a view to move to the early stages of an ICS next spring 2019. The partners discussed the proposal and the following points were made: Start a self-assessment against the outlined criteria SP Organise a ICS Development Session in January 2019 PM Begin to make small incremental changes towards becoming an ICS Look at ways to improve relationships Do this work in parallel with the STP plan refresh, adding next steps towards an ICS plans and time both to be completed at the same time
SP highlighted that a lot of work was already started at the last SLT time out session and she will begin to gather more evidence for each of the categories for use at the January Development Session. It was acknowledged that a more effective PPI will be very important component and noted that there is currently a PPI review underway.
RL supported the self-assessment as a very useful approach and suggested learning from others would be helpful. For example Wakefield, Cheshire and Suffolk will provide the national view and RL will put us directly in contact with them. RL advised that the National System Transformation Group is there to support ICS development and they will be happy to come and speak to partners or help facilitate the planned Development Session.
SLT 22/11/10 LLR Digital Roadmap Ian Wakeford, IM&T Senior Responsible Officer attended the meeting to give an update on the LLR Digital Roadmap, Paper F attached.
PM recently took on leadership of the IM& T workstream and a refresh of the digital roadmap was done to establish the direction of travel. IM&T have worked closely with the workstreams to understand their needs and this has informed the strategy. It was highlighted that the strategy is a technical business document and therefore it isn’t public facing, however, there will be an IM&T annual report which will be public facing and which will include the IM&T achievements. The Roadmap is now ready for SLT approval.
The context and the strategic drivers were explained: Local • BCT model of care supported by digital technology and transformational change • Supporting service redesign and what patients want • What patients, service users and staff have told us National • NIB Framework – paper free at point of care 2020, Transfers of Care • GP five year forward view, health and care integration • Secretary of State vision for health and care
The vision and principles of the Strategy are aligned to the NHS plan and include: • Digital for all • Digital transformation • Having a single patient record is critical
Transformational change is a golden thread running through the big 4 strategic objectives: 1. Improving record sharing and access rights to view summary care records, having fewer systems to avoid silo working 2. Supporting pathways e.g. all of the necessary information in the pathway is available to
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support safe transfers of care and shared care. 3. Digital Self Care – the use of apps for the public and clinicians and remote sensing to measure and monitor health (e.g. falls or blood sugar levels) 4. LLR wide Business Intelligence strategy to support public health, research and service redesign work is almost complete.
Leadership and Governance: • Clinically led leadership and oversight • IM&T strategy developed in partnership with major stakeholders who are involved in the IM&T Delivery Board • Strong links with Information Governance • AO links with SLT as route of escalation • Annual planning cycle and priority refresh • Strong links with the Public and Patient Involvement Group to capture valuable contributions
Funding and sources of investment – the various sources of funding have been non recurrent capital. Bids are coordinated for this money and these have been successful to date, however a national revenue funding model is needed to enable efficiency gains through moving to capital based services. The current three year plans will cost circa £27m. £16m funding is available which leaves a gap of £11m. There is a prioritisation framework in place and therefore some of the non-critical schemes with a medium level of benefit may have to wait or be reprioritised should further funding become available.
The partners asked questions and provided feedback as follows:
PT asked about the £11 m funding shortfall and if it would be likely that the non-critical schemes can be carried out given the 3 year plan is nearing the end of the term. IW explained that it is unknown whether there will be further non recurrent capital available that we can bid for and if so this would change the figures. Additionally some of the schemes may not go ahead and some schemes may be funded directly by the relevant organisation should capital funding become available.
PT asked whether there was change management resource available for Transformation Scheme implementation. IW answered yes; however, IM&T challenge bidders to ensure that schemes are Transformational and that they themselves have the necessary resources for implementation. If IM&T aren’t assured that this is the case they can refuse a scheme.
UM asked about the UHL outpatient transformation and the linking of systems as it seems that this is not included in the roadmap. IW and PM explained the background and the decisions that have already been made in relation to this at IM&T board. The UHL IM&T strategy is to maximise the use of nerve centre and pull information from the System One record for viewing instead of using System One directly. From the end user perspective it is better to use just one system.
MA thanked IM&T for the excellent approach that has been taken and the work that has been carried out to provide real tangible success. This has been linked to improvements for patients and the change has been clear to see. MA suggested this approach be used across all of the programmes.
JW told the partners that the LLR BI application had just been approved and everyone was very pleased with the great news.
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JW asked about the national digital work that has taken place in regard to data anonymization to protect personally identifiable information, the joining of national and local data and the need for a local BI warehouse. IW said that conversations with NHS digital have clarified the process for data anonymization. National data can be joined with local data so long as the same tool and process is used, however, that would always need to be a local BI warehouse as there are some data sets that would need to be held locally.
ML asked if the digital self-care objective is transformational and ambitious enough as others are beginning to use new technology such as an apps library, on-line access to results/blood tests, on-line booking of hospital appointments, remote consulting etc. IW responded that the current 3 year strategy ambitions were limited by the current kit, technology and funding. However, most of the current contracts will be coming to an end in 2020/21 and therefore the Strategic Vision for 2012 will certainly incorporate the next generation of technology to support the NHS national strategy and Matt Hancock’s cyber vision and the use of artificial Intelligence and new technology.
The strategy was approved and it was agreed to give some thought to outpatient inclusion. The investment position and implications of the strategy were noted.
SLT 22/11/11 BCT Outcomes Framework & Key Risks Jon Adamson, STP Performance Analyst attended the meeting to present the up to date Outcomes Framework in Paper G. SP provided an overview of previous work on the framework which was approved at SLT in May 2017 where it was agreed to regularly report back to SLT.
The framework has just been updated with the most current data. 22 of the measures have been RAG rated, there are six red, one amber, 15 green. Further detail against each measure is detailed in the report.
JA has been reviewing the indicators along with the introduction of a new NHS dashboard for health and social care interface. Five recommendations to improve and strengthen the framework have been made as follows: 1. Future updates of the Framework should report enablers of success separately to outcome measures. 2. It is recommended that seven outcome measures are removed or replaced (8, 23, 25, 29, 31, 32, 35) and part of one (13a) is removed. 3. Outcome measures should continue to be RAG-rated at the STP area level but, wherever possible, data should also be reported at a lower geography, either Local Authority area, Clinical Commissioning Group area or Locality area. 4. Review where additional measures relating to Local Authority activity could be included to strengthen the BCT Outcomes Framework. 5. There is a need to strengthen the link between existing workstream activity and reporting (including QIPP) and the BCT Outcomes Framework.
The partners were asked for input and comments as follows: The secondary care workforce measure is showing as green and this isn’t correct so it will need to be looked into. No measures should be removed but there should be further discussion with workstream leads to ensure KPIs are identified or alternatives are found. National Assurance statements will move to reporting at the system level in future. Some
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CCG improvement indicators might be useful to include such as Mental Health. There was an offer from RL for NHS E to help to triangulate the information. Cancer measures at the local level would be helpful to understand in more detail. There is an analyst at East Midlands Cancer Alliance who can help with this. JA was asked to make contact. It was agreed that it would be useful to know who leads on each measure and that there is a plan in place to address any issues. This information will be added to the framework.
The recommendations were agreed as follows: 1. Agreed 2. KPIs to be agreed for all measures with relevant workstream leads or replaced with an alternative. Measure 31 to be replaced with one regarding rationalisation from the Estates Strategy 3. Agreed 4. Additional LA measures will be agreed through the ICB Board 5. Agreed
It was acknowledged that a structure is needed for how the framework will be used for performance management at SLT as well as for dealing with escalations.
Actions: Discussion with workstream leads to ensure KPIs are found for the seven outcome measures identified or that alternatives are found To make contact with the analyst at East Midlands Cancer Alliance to look at local level cancer measures. Leads and plans for monitoring each measure to be included in the outcome framework SP/JA Process to be developed for performance management of the outcomes framework at SLT and for dealing with escalations.
SLT 22/11/12 Frailty Update Paul Traynor highlighted some blockages which need to be flagged or progressed as outlined in Paper H. The programme is largely on track to timescales There are some delayed actions; however these are in hand with the Frailty Taskforce. LLR non-weight bearing pathway – it is recommended that the A&E Delivery Board formally take on delivery of this. LLR therapy pathway – still to be identified Care homes has been taken by Rutland County Council – it was highlighted that this must move at pace and there will be an update on this item at the next SLT meeting. Community Services Redesign is high risk as this is operationally a key issue.
It was noted that there are potential resolutions for most of the issues.
SLT 22/11/13 Notification of Any Other Business There was no other business raised.
Date, time and venue of next meeting 9am-12pm Thursday, 20th December 2018, 8th Floor Conference Room, St John’s House
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System Leadership Team Meeting No. 24 Chair: Peter Miller Date: Thursday 21 February 2019 Time: 9.00 – 12:00 Venue: 8th Floor Conference Room, St Johns House, East Street, Leicester, LE1 6NB Present: Peter Miller (PM) LLR STP Chair, Chief Executive, Leicestershire Partnership Trust
Karen English (KE) Managing Director, East Leicestershire and Rutland CCG
Azhar Farooqi (AFa) Clinical Chair, Leicester City CCG
Mayur Lakhani (ML) Chair, West Leicestershire CCG, GP, Sileby and Chair Clinical Leadership Group Roz Lindridge (RL) Locality Director Central Midlands, NHS England
Sue Lock (SL) Interim LLR STP Lead, Managing Director, Leicester City CCG
Ursula Montgomery Chair, East Leicestershire and Rutland CCG and GP (UM) Evan Rees (ER) Chair, BCT PPI Group
Caroline Trevithick (CT) Interim Managing Director, West Leicestershire CCG
John Adler (JA) Chief Executive, University Hospitals of Leicester NHS Trust
Steven Forbes (SF) Strategic Director for Adult Social Care, Leicester City Council
Andrew Furlong (AF) Medical Director, University Hospitals of Leicester NHS Trust
John Sinnott (JS) Chief Executive, Leicestershire County Council
In Attendance: Sarah Prema (SP) Director of Strategy and Implementation, Leicester City CCG
Richard Morris (RM) Director of Operations and Corporate Affairs, Leicester City CCG
Tim Sacks (TS) Chief Operating Officer, Director of (items 19/12 and 19/13 only)
Ruth Lake (RLa) Director, Adult Social Care and Safeguarding, Social Care and Education, Leicester City Council (items 19/12 and 19/13 only)
Tamsin Hooton (TH) Director of Service Improvement/CSR (items 19/12 and 19/13 only)
Cheryl Davenport (CD) Director of Health and Care Integration and SRO Business Intelligence Strategy (for item 19/20) Jon Adamson (JAd) Jon Adamson, STP Performance Analyst, MLCSU (for item 19/20)
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Clare Mair Board Support Officer, Leicester City CCG (Minutes)
Apologies: Sue Elcock (SE) Medical Director, Leicestershire Partnership Trust
Mark Andrews (MA) Deputy Director for People, Rutland County Council
Ben Holdaway (BH) Director of Operations, EMAS
Jon Wilson (JW) Director of Adults and Communities, Leicestershire County Council
Paul Traynor (PT) Director of Finance, University Hospitals of Leicester NHS Trust
SLT 21/01/02 Welcome and introductions Peter Miller, Chief Executive, Leicestershire Partnership Trust welcomed everyone to the meeting. Introductions were made.
SLT 21/01/03 Apologies for Absence and Quorum Apologies were received from Mark Andrews, Ben Holdaway, Sue Elcock, Jon Wilson and Paul Traynor.
SLT 21/01/04 Declarations of interest on Agenda Topics No declarations of interest were noted.
SLT 21/01/05 Minutes of meeting held on 22 November 2018 (Paper A) The minutes of the meetings on 22 November 2018 were approved as a true and accurate record.
SLT 21/01/06 Action notes of the meeting held on 22 November 2018 (Paper B) The action log was reviewed and it was noted all actions were green.
SLT 21/01/07 LLR SLT Terms of Reference (Paper C) Sue Lock presented the revised terms of reference which had been amended to reflect the feedback from discussions at the last SLT meeting and email input outside of the meeting. SL noted the changes and reference had now been made in the ToR to the STP Partnership Group and SLT having sign off prior to any issues being taken to external clinical senates and before commencement of external or system-wide consultation. DHU had been included in future membership and subject to approval today would be invited going forward. A governance pack would be developed and the terms of reference would form part of that.
CT asked whether there was merit in future proofing the terms of reference in readiness for primary care representation. SL responded that any reference at this point would need to be vague. Early guidance had stated PCN clinical leads would be on the partnership groups, assuming there was consensus about what was meant by partnership groups. The terms of reference would be reviewed once PCN arrangements were known.
JS referred to paragraph 35 on the accountability of the SLT to the HWBs and he felt it would be more technically accurate to use the word ‘reporting’ to rather than being accountable to. SL undertook to amend that.
MP noted the SLT chair role in paragraph 17 may be subject to change as the ICS took on
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different chair arrangements. SL was satisfied the terms of reference reflected the current arrangement and undertook to make the review period for the terms of reference more prominent.
JS asked why it had been decided that chairs of provider trusts would not be members of SLT but commissioning chairs would. JA responded that provider chairs did not have an executive role and he felt the UHL Chair would not feel it appropriate to a member of SLT. ML understood why some local authority chairs may challenge that decision but commissioning chairs were a hybrid role of executive leadership and clinical leadership.
JA noted the current shared leadership model and once a single AO/CEO was appointed there would need to be a further collective review about STP leadership and the associated chairing of this group. The last SLT meeting, at which Paul Traynor had been present, had discussed the STP role in relation to the single AO role. RM had discussed with NHSE the need to have clear water between the AO role and STP role, held by the same person, but if there was to be a change in ICS governance the two would need to be extricated.
It was RESOLVED - To accept the revised terms of reference, subject to some minor amendments requested above.
SLT 21/01/08 Partnership Terms of Reference (Paper D) Peter Miller presented the LLR STP Partnership Group terms of reference, who as a group would provide an oversight function in order that statutory organisations receive common and shared assurance on the development of the LLR STP. It was noted the reference to confidential items was to be removed. An independent chair would be appointed on a yearly basis. The role of the independent chair and some high-level bullet points on the role had been added to the terms of reference. A job description and person specification would be developed. The chair role would include holding the system to account and behaviours.
JS asked how selecting one representative from the voluntary sector would be achieved given the many voluntary organisations and that they did not represent each other. JS also noted the difference between infrastructure providers and direct providers. ER suggested approaching the voluntary sector for a view on how someone could be mandated as a representative on behalf of the sector.
JA noted each LA would have a representative and then the HWBs were mentioned separately, however he thought the LA representatives would be the HWB chairs. JS said he too read the Terms of Reference as the LA having both an officer and elected member, however SF interpreted had it as one representative. It was agreed the positions would be taken up by the HWB chairs.
RL asked if Healthwatch would have a place on the partnership group. JA explained Healthwatch wanted to keep a distance from the structure and therefore had not been included. SL agreed nothing had changed in terms of Healthwatch’s intention to keep a distance and undertake a scrutiny role. JA felt it would be courteous however to ask Healthwatch and he would take the opportunity to do that when meeting with them later today.
JS asked whether lessons learned from the BCT partnership group had been considered in drawing up these terms of reference as he felt the remits were similar. PM agreed wider group engagement had failed but the opportunity presented in how the group would be used to make the difference going forward.
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PM would speak with the universities (DeMontfort, Leicester and Loughborough) to see whether this was the right forum for them.
It was RESOLVED - To agree to the terms of reference, subject to the changes agreed today - To devise the chair JD and PS. - To invite applications for the partnership group chair role.
SLT 21/01/09 LLR Estates Forum Update (Paper E) Karen English provided an update on the estates strategy. The LLR estates strategy had been submitted and NHSE/I indicated it was satisfactory and had asked for a number of actions to be followed through. There were specific actions for people who manage and own the estate such as being rigorous about potential disposals and maximising opportunity. LPT undertook a comprehensive disposal exercise 3-5 years ago and that was outside of this monitoring timeline. UHL also has a very comprehensive strategy. KE noted the percentage of estates underutilisation was quite high and not particularly limited to one place or one provider. The next step was to pull together a comprehensive primary care strategy and some additional money had been identified to start a 6 facet survey on the primary care estate. That would inform the amount of available estate for left shift work and the PCN footprints. KE would ensure the strategy was regularly refreshed as the system moved forward and that any associated costs were current.
ER commented that the question of estates disposal had been raised at a number of engagement events and asked that the issues being faced and intentions were articulated. PM said that would be subject to consultation when clear plans were available.
A further update would be received by SLT in July 2019.
It was RESOLVED - To receive the update report from the LLR Joint Estates Forum (23 January 2019) and to note the actions agreed.
SLT 21/01/10 Developing our Long Term Plan (Paper F) Sarah Prema explained she had undertaken this work in response to a request for every ICS area to refresh their 5 year plan. The plan included development of this system’s ICS model and a move to block arrangements with system controls. The governance for ICS would need to be refreshed and the programmes reviewed against the plans for the next 5 years. There would be a requirement to engage on the changes to the refreshed plan and make some adjustments before final submission in August. As this was quite a challenging date, SP had included an early timetable and asked for views, particularly around the engagement work.
ER was of the view that the timescales for engagement were too late by which time a lot of the plan would have been finalised and people would get a sense of that. PM agreed ideas could be engaged on earlier and the work streams would therefore be required to do that. The engagement could then be evidenced in the plan in terms of ‘you told us and we did this’. KE felt it would be useful to make reference in the CSR to that linking into the long term plan and that would help people understand that this work was ‘business as usual’.
MP noted the focus on prevention and digital but saw little reference to exercise and lifestyle. Digital, AI and innovation would be key drivers for medicine and the local plan did not yet reflect the ambition in the national plan. MP appreciated the IM&T group work around local systems and sharing records but felt a further digital stream was needed. PM gave assurance that this had been considered and a digital sub group would be established to respond to the long term plan
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requirements. SL commented that work streams needed to understand the greater potential they could have with the right IM&T systems and support.
JS commented the long term plan felt like a plan written by the NHS for the NHS and healthcare and whilst the local authority would want to participate in the ICS discussions, it was difficult to see how the LA could sign off a formal plan in Autumn. UM referenced the areas of work in the plan which were non-medical and supported vulnerable and hard to reach groups and that would be an area of integrated work with the local authorities. That link would be made clearer.
SP undertook to establish the inter-dependencies group.
It was RESOLVED - To receive the plan and proposed timescales, noting the engagement work would be brought forward to inform the plan.
SLT 21/01/11 Draft 2019/20 System Operational Plan (Paper G) Sarah Prema explained as part of the 2019/20 planning process, NHS organisations had been asked to produce individual organisation plans and also a system plan. The first draft of the system plan had been submitted on 19 February and SP apologised for the late distribution of the draft plan due to the tight timescales. The next iteration was due to be submitted on 4 April which would allow sufficient time for NHSE to feedback and make changes where needed. An alignment tool for finances and activity had been submitted in the previous week and NHSE would also provide comment on that. The financial position and efficiency would shift as contracts and budgets were finalised. Priorities for 2019/20 had been taken from individual operational plans and linked back to BCT plans to ensure they were congruent as a system.
JA remarked this was an impressive document given the short timeframe. JA added a note of caution regarding section 6 (system finance) as it alluded to an outcome of fixed income and expenditure and it might not be as straight forward as that. SP would update that section when a decision had been reached between providers and commissioners on the contracting terms.
JS referred to the key priority areas in section 4 and did not concur with the positive views on CAMHS service quality and responsiveness. However as this had been reflected as a key priority, any sub-optimum areas of service delivery would be addressed.
SP undertook to provide a final draft to the March SLT and if that was not achievable she would seek final agreement outside by the meeting for the 4 April submission. SP requested comments on the draft plan from anytime now.
It was RESOLVED - To receive the draft operational system plan and note the need for further refinements to be made and agreed to prior to final submission on 4 April 2019.
SLT 21/01/12 Primary Care Networks - Next steps for LLR (Paper H) Tim Sacks gave an overview on PCNs, the actions to be undertaken in the short term and the impact on the system.
• PCNs will comprise around 30k to 50k patients. • PCNs will have a clinical accountable director (CAD) for which guidance is awaited on the role description. • Contracts outside of core GP work will go through a PCN rather than practices and services delivered at PCN level.
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• By 15th May PCNs must be mapped out and all practices signed up to a PCN contract. Pictorial maps will show where each PCN sits in LLR and each PCN will need their own bank account. • In year 1 funding will be available to support practices to sign up and for some additional non- GP staff, such as social prescribing link workers, clinical pharmacists, physicians associates, first contact physios and first contact community responders. PCNs will only receive money to support posts when they have been filled and this is not a 100% contribution. There will be workforce challenges. • There will be an ‘impact fund’ and PCNs can gain up to £5 per patient in 5 years for avoiding ED and making prescribing savings and that will be used to fund staff – not a cash benefit. • EOL and care homes have a need for investment of time and resource and there needs to be a clear strategic direction for all of those in the PCNs. • More information will come down over the next few weeks and a number of local and national events are taking place.
JS asked whether primary care welcomed this change. TS commented it felt like people were quite excited and this was probably the biggest fundamental change since GP services became part of the NHS. AF felt this was necessary for the system because primary care needed strengthening, more resources and could enact change at scale. MP welcomed the shift in resource and power.
TS advised a session for primary care was taking place in the afternoon to understand the governance. It was likely LLR would have 25 PCNs. The national contract would be very prescriptive and the challenge would be to manage that locally to deliver a shared direction of travel. It was recognised that PCNs would be bottom up organisations and needed support to grow and develop but at the same time ensure equity of provision by PCNs matched to patient need. A national programme would be on offer to develop leadership skills for PCNs whilst recognising the need for a local programme to bolster that. The CAD would have a place at the ICS.
JA asked if PCNs would replace federations. AF responded that federations were the blueprint for PCNs and in the city the federations could provide umbrella support for back office functions. Federations would remain but have a different role.
It was RESOLVED - To note PCNs in the context of the LLR ICS development and the national drive for PCNs to be the Neighbourhood/HNN structures.
SLT 21/01/13 Integrated Community Services Programme Stocktake And Community Services Redesign Update (Paper I) Tamsin Hooton updated on the work of the CSR work stream. The ICB was established with a broad remit of out-of-hospital services and the stocktake captured the work undertaken on care homes, long term conditions, end of life etc. The work was being delivered on the basis of place based structures. TS would lead the primary care board which would absorb a lot of this work. TS and TH would align and work together. A range of community services would be wrapped around the PCNs. The CSR, once implemented, would be an enabler of that.
The CSR set out a high level model and would review three main blocks of care; community nursing teams configured on PCN level, home first for crisis response and reablement and rehabilitation. The review would identify the level of need for pathway 3 beds for reablement commissioned from care homes and the number of community beds required. The transformation programme would take 2-3 yeas to deliver, enabling neighbourhood nursing teams to respond to
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same day need, access to therapy reablement and step up/down of support after acute discharge.
The work reports into the Integrated Community Board and commissioning decisions are taken at CCB. There is an implementation group below the Integrated Community Board. Place based governance is recognised and any proposed changes affecting social care teams would be routed through the LAs.
AF had a slight concern that implementation was planned for October and he asked if testing could be done before the winter period to safeguard in case of unintended consequences. TH assured testing was already happening, particularly with home first in the County and it was hoped the locality decision unit would have been established prior to that. TH said the city already had a well-integrated model for care within the first 72 hours of step up/down. A formal management of change process would be required for affected LPT staff.
AF asked how nursing team alignment to PCN footprints would be achieved. TH responded that some locality team configurations were already coterminous with PCNs. Other PCNs would share across to give resilience to same day responses. Further work would be done on identifying a base for the nursing teams and if the provider needed to change their work base. SP noted that district nurses were already aligned to practices but the management of that was at a much higher level. TH commented there might be higher level managers covering 3 to 4 PCNs. PM noted it would be challenging to achieve genuinely integrated locality services across health and social care but if it could be delivered, it would be of great benefit.
MP noted PCNs would be a key driver and whilst there was reference to PCNs employing therapists and pharmacists there was little steer on how they would link with community care. MP commented that functional integration had not worked in the past and the new models of procurement going forward would need to be more defined and include shared employment and shared access to records.
SL asked that further consideration be given to the decision making route as the city did not have integration executives.
UM asked how this work would feed into the estates strategy. TH said the CSR would consider estates requirements for primary care, community hospitals and community nursing team bases. Co-location was very important to delivering the community services redesign along with identifying and delivering on IM&T requirements.
It was RESOLVED - To note the update on the work of the Integrated Community programme and Community Services Redesign - To note that the remit of the ICB is under review in the light of the NHS Long Term Plan and the workstream arrangements for developing Primary Care Networks - To approve the proposed future responsibilities of the Integrated Community Board and the Primary Care Board as described in sections 12 and 13 - To note progress on the Community Services Redesign work and next steps - To approve the governance arrangements of the Community Services Redesign described in this paper
SLT 21/01/14 BCT Communications and Engagement (Paper J) John Adler and Richard Morris presented a summary of the activities undertaken in 2018/19 to engage with communities in LLR. JA thanked Sue Venables and Richard Morris for their work on communications and engagement and Evan Rees for his engagement support.
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RM gave the key headlines; BCT communications and engagement over the past 12 months had been better but there was more to be done. As well as a summary of activities undertaken there was also a forward look to the focus on work for 2019/20 of which some areas would require significant engagement and formal engagement requirements such as CSR. It was planned to increase the volume of communications to ensure BCT and SLT messages were resonating more widely with the public. Patients, public and stakeholders were not always recognising the communication work if it was not badged as BCT, including elected members. It was therefore clear that different approaches to engagement and consultation were needed across the CCGs and other NHS partners in LLR. RM, Evan and Sue Venables intended to update the current PPI structures and would form a PPI assurance group, with a mandate from the SLT, to ensure consultation and engagement was appropriate and met legislation. A citizens’ panel would be formed to build on existing arrangements.
CT felt it would be good to see some visibility around the engagement plans. JS asked what was envisaged in the short term about communicating with the public and elected members. RM recognised the stakeholder bulletins had been sporadic towards the end of the year and going forward there would be a commitment to getting these out on a monthly basis, coinciding with this meeting, to report on what was happening across the system. The communications functions of each organisation were being relied on to disseminate this information down and RM was not clear whether elected members were not recalling seeing the bulletins or whether they had not been received. RM was asking for assurance on how these were being cascaded down.
RM advised nine public engagement events had taken place for CSR or BCT and attendance had been good. JA felt it would be worthwhile mapping who the key stakeholders are and stating how those different constituencies would be kept up to date because some information would be different and some would be common.
UM welcomed the citizens’ panel, especially the remit to reach into schools and colleges.
Appendix A listed the identified engagement and consultation for LLR in 2019/20. RM said there was potential to simplify and bring elements of engagement and consultation together and bring the long term plan into that narrative where possible. ER commented that the structure of the PPI group was irrelevant and the key point was holding the work streams to account and ensuring opportunities for co-design were built in early on. ER said the question should not be did you involve, but when did you involve. JA asked whether a template was needed to ask those questions of the work streams. RM responded that SROs were being offered training and development to ensure they understood the engagement requirements and legalities of consultation. RM said SROs were both held to account to deliver transformation programmes with a financial saving and to also meet the statutory requirements of engagement and consultation and taking those views into account for service redesign. RM said the CEOs needed to recognise those opposing requirements and to reiterate the message about early consultation.
It was RESOLVED
- To agree the direction of travel in creating an integrated and consistent approach to communications, engagement and where necessary consultation. - To agree to the work programme
SLT 21/01/15 Integrated working – Feedback from LLR STP Development Session & Maturity Matrix (Paper K) Peter Miller fed back on the outputs from the SLT development sessions in September 2018 and
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January 2019 at which work had taken place to populate the maturity matrix and identify required actions to progress to an ICS. PM had also produced a document setting out the purpose, principles, behaviours and values for BCT that would form part of the governance pack. The independent chair role would hold the system to account. AF welcomed the useful summary.
KE advised the CCGs had been asked to undertake a Commissioning Capability Programme for a period of 12 weeks and would then come back to the system and report on what the CCG’s had learnt and whether the maturity would shift to the right.
SL was of the view that the workshops had been really useful and thanked PM for the work to identify next steps. SL felt it would be useful to go through what was every day work, what was best done through collective ownership and use a workshop style, where needed, to work through some of these elements.
JA noted the system had marked itself quite low on the maturity matrix because it did not have some of the building blocks in place, however he believed it would not be too difficult to address that and there was a danger of under-playing the current situation and the resultant impact on the image of the system. JA encouraged the view of maturity to be moved to the right sooner rather than later, provided that could be substantiated. JS was in agreement with JA’s view but questioned how that would be achieved and whether that came back to the issue of programme support. PM and SP would continue to lead on this piece of work.
SP advised early discussions would be needed on the ICS development to frame and develop the new five year plan for the Autumn. SF reminded members that there were local elections in May 2019.
PM undertook to circulate a revised proposal. Tim Whitworth and Bernie Brooks from the Leadership Centre were waiting to put dates into their diaries. It was agreed SLT would continue to use the support of the Leadership Centre.
It was RESOLVED - To receive the summary of outputs from the LLR STP development session in January 2019 and the ICS maturity matrix.
SLT 21/01/16 Outline OD and leadership support 2019 (Paper L) Peter Miller advised resources for developing OD were available, subject to a successful bid. PM proposed every third SLT could be used for a collective OD session rather than a business meeting and the leadership centre would provide support. The next OD session could bring a broader set of leaders and elected members together to develop that shared purpose. JA supported the mixed economy approach but felt the content needed some more work and there was repetition of work already done. JA felt there was the opportunity to make more progress and sign off some of the maturity matrix. JS felt a larger session in May would be too soon to organise the materials and get invites out and suggested a further SLT session prior to that.
It was RESOLVED - To receive an outline timetable for SLT OD sessions in 2019/20, to be supported by the Leadership Centre.
SLT 21/01/17 SLT Programme Arrangements (Paper M) Sarah Prema advised a desk top review had taken place on the back of conversations at the January SLT development session regarding local priorities and in response to the publication of the Long Term Plan. SP advised the work stream arrangements and LT plan mapped across
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well. SP had not marked the area of health inequalities as green because that was not yet implicit in the prevention work stream or other work streams, which all had a duty to reduce health inequalities. SP felt personally the current work streams were still valid in light of the LT plan but there was merit in discussion around these and some adjustments would be needed. ICS was being developed as a leadership group and the CCP work was being undertaken as part of the CCG reorganisation. The proposed changes made by Tasmin and Tim to their work streams (CSR and PC) needed to be reflected. SP proposed to ask the Health Prevention Board to help develop the work on health inequalities. As the ICS developed, more conversations would be needed about contracting methodology.
SP proposed to keep the work streams fairly unchanged and request that SROs revise their Terms of Reference and bring those back to SLT. In response to the proposal; • AF commented the GB GPs could become more involved in the work streams because PCNs would be clinically led. • Estates work steam to be added as an enabling work stream. • JA fed back that the frailty the task force had made good progress recently and SLT would receive a report in March. The remaining actions were mainstream and needed to go into the relevant work streams. Therefore JA proposed winding up the frailty task force. • JA questioned the logic of end of life being part of the community services work stream. It was agreed to have a time limited end of life task force, to be chaired by Mayur Lakhani and an executive lead to be identified.
SP would re-establish the interdependencies group to ensure there was integration between the work streams.
It was RESOLVED - To approve the programme arrangements set out in paragraph 5 and the changes outlined in paragraph 3.
SLT21/01/18 Learning Disabilities and/or Autism (Transforming Care) Workstream Proposal Steven Forbes, Leicester City Council reported work had been underway during the past 18 months on the transforming care programme and to move the local system out of recovery. The system remained away from trajectory and it would be a challenge to achieve by Q4 the required reduction in inpatient beds for both adults and children. The step down from specialised commissioning was particularly challenging. The LA identified that focussing on only the programme elements would not be sufficient to keep those in crisis in the community, therefore a new governance and accountability structure had been developed at LLR level. The system would not achieve drafting a single LD strategy because the County and City had taken two different routes on that but would retain an overarching direction of travel. A resource commitment to posts after 2019/20 was needed. It was not clear whether Ministry of Justice initiated placements would be counted in the system numbers.
RL suggested further conversations take place with specialised commissioning.
SP asked SLT members to note specialised commissioning would be setting up a local board and representation would be requested in due course.
It was RESOLVED
- To agree the need to expand the remit and focus of the Learning Disabilities and Autism Workstream, from Transforming Care to the proposed 5 – 6 priority areas. - To approve development of an LLR Learning Disability and Autism Strategy across health
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and social care system, and to receive a draft proposal in March 2019. - To commit resource to develop the Strategy and Workstreams, for delivery from April 2019 - To confirm named leads for the 5 – 6 priority areas. - To consider longer term commitment of resources for delivery of the Workstream.
SLT21/01/19 Update from STP Leads meeting Sue Lock reported on key messages from the recent leadership forum;
• NHSE/I restructuring was discussed. Senior management level appointments had been made with Dale Bywater appointed as the Regional Director for Midlands and East. • PHSE will become a member of the regional executive board. • A health and social care green paper will be considered on 6 March. • Consideration would be given to PCNs and governance and clinical director representation on the ICS partnership board. • Cancer Alliance footprints are not currently in keeping with STP or ICS footprint and may be made smaller. • Regarding ICS it was noted the maturity matrix was being updated (4 levels and 5 themes) and it was not clear when that would be released. • Approval processes for ICS would be done in waves and would be conducted at regional level. There had been mention that organisations would have up to two years to become an ICS and concern was raised that ICS status was based on attainment rather than impending timescales. • The importance of digital and IM&T to underpin the priorities of both clinical and medical work was discussed. Shared records were a first step in this process.
SLT21/01/20 LLR Dashboard and Tools for ICS and BCT (Paper O) Cheryl Davenport and Jon Adamson provided a briefing paper on strategic direction and progress across three of the four IMT and BI priority areas (Analytics, tools and workforce, Population profiling and risk stratification, Data Integration and Warehousing).
SLT was sighted on how each dashboard was being developed, including over the next year a fully formed jigsaw of business intelligence. Nationally and locally a number of dashboards were available, but there were three main ones; • STP care and outcomes tool - produced by NHS England on a quarterly basis and reports on five main themes. • Integrated Operational Report (IOR) - produced by NHS England on a monthly basis. The national performance and health development dashboard was being rolled out for wave 1 ICS. • BCT Outcomes Framework – developed by MLCSU pulls together a range of different metrics and an STP dashboard, using the Aristotle data tool. This has a high degree of functionality for finance and contracting and the addition of frailty and mental health had been discussed and ultimately the BCT outcomes framework could be hosted on that. These local developments have the benefit of reporting on local priorities in a more timely way than the national data can deliver.
The BI strategy is considering how LA data sets and metrics can be included. ACG data will be developed for locality teams and include public health and social care data where possible. A local data integration and warehousing tool will be required to enable and allow data to be in one place for health and social care; provider, commissioner and social care. It is intended to implement this in 2019. The IMT Board held in February recommended this approach to the Partnership. The warehousing was possible due to getting a data sharing agreement from NHS Digital.
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No one tool will be able to perform all of the purposes and there will be a requirement to have a combination of tools going forward.
UM was encouraged by the progress with national tools and noted the new GP contract talked about having to get data from a national dashboard. MP asked for reassurance that Aristotle was the right tool as GPs were not using it. The BCT Outcomes Framework would continue to be used, through excel or Aristotle, recognising the work undertaken to identify local priorities. There would be an opportunity to review this as other dashboards were further developed. The ACG tool cannot be linked to the integrated warehousing tool because guidance prevents that.
The cost of £103k to deliver integrated data across the partnership was noted and JMT would consider that request.
It was RESOLVED - To note the stage of development of the national and local system tools that will form the foundation of Business Intelligence for health and social care across LLR as outlined in this report and provide any feedback or further direction needed. - To support the roll-out of the MLCSU-developed STP Dashboard in Aristotle for LLR. - To support the development of the Outline Business Case for the integrated data warehousing solution, as a key enabler to Better Care Together and the journey to becoming an ICS - To note that the SLT will receive this Outline Business Case for consideration and approval (via the IM&T Board) in Spring 2019.
SLT21/01/21 IM&T Update The IM&T Update report was received for information.
SLT 21/01/22 Notification of Any Other Business There was no other business raised.
Date, time and venue of next meeting 9am-12pm Thursday 21 March 2019, 8th Floor Conference Room, St John’s House
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