NHS Salford Clinical Commissioning Group Governing Body Meeting Wednesday, 23rd May 2018 14:00 – 17:00Hrs Salford and Worsley Rooms, St. James’s House
AGENDA
Part I
14:00 Public Meeting Welcome and Introductions - open agenda for members of the public to raise items previously shared with the Clinical Commissioning Group
14:10 Start of NHS Salford Clinical Commissioning Group Governing Body Meeting
Item Time Description Lead 1 14:10 Patient Story Chair a) Apologies for absence Chair
2 14:15 b) Declaration of Interest in items on this Chair Meeting’s Agenda
Minutes of the meeting and matters arising a) 21st March 2018 Meeting Minutes Chair b) 21st March 2018 Action Log Chair 3 14:20 th c) 25 April 2018 Meeting Minutes Chair d) Matters arising Chair
Leadership Reports a) Chair (Verbal) Chair 4 14:25 b) Chief Accountable Officer (Paper) Chief Accountable Officer
For Assurance/Decision Strategy a) Quality and Safety Strategy (Paper) Medical Director 5 14:40 b) Integrated Commissioning (Paper) Chief Accountable Officer
Performance
14:55 a) Quality of Commissioned Services (Paper) Medical Director
15:10 b) Governing Body Assurance Framework Chief Accountable Officer 6 Report (Planning, Performance and Risk) (Paper)
15:25 c) Financial Performance (Paper) Chief Finance Officer
15:40 d) Information Governance Tool Kit (Paper) Chief Finance Officer
15:55 e) Annual Report (Paper) Chief Accountable Officer
Process 7 16:10 a) Constitution Changes (Paper) Chief Accountable Officer
For Information Minutes/Reports of Partnership Boards/Sub Committees 16:25 a) Commissioning Committee Report (Paper) Chair of the Commissioning Committee
16:30 b) Primary Care Commissioning Committee Chair of the PCCC (PCCC) Part 1 (Paper) 8 16:35 c) Executive Team Report (Paper) Chief Accountable Officer
16:40 d) Association of Greater Manchester CCG’s Chair Governing Group (AGG) Report (Paper)
16:45 e) Audit Committee Report (Paper) Chair of the Audit Committee
Reflection a) Key Decisions Chair 9 16:50 b) Key Messages Chair c) Benefits to the Population of Salford Chair
10 17:00 Meeting to close
Date and Time of Next Meeting: 14:00-17:00Hs on 18th July 2018 Venue: Salford & Worsley Rooms, St James’s House, Pendleton Way, M6 5FW
MINUTES OF NHS SALFORD CLINICAL COMMISSIONING GROUP GOVERNING BODY MEETING Held on 21 March 2018, Salford Room, St James’s House
Governing Body reports and previous minutes can be found by following the link: http://www.salfordccg.nhs.uk/GoverningBodyMeetings.asp
Part I Present: Dr Tom Tasker (TT) Chair Dr Nick Browne (NB) Neighbourhood Lead Mr Steve Dixon (SD) Chief Finance Officer Mr David Flinn (DF) Neighbourhood Lead Mr Anthony Hassall (AH) Chief Accountable Officer Mr David Herne (DH) Director of Public Health Mrs Kate Jones (KJ) Neighbourhood Lead Dr David McKelvey (DM) Neighbourhood Lead Mr Paul Newman (PN) Lay Member – Innovation Matters Dr Jeremy Tankel (JT) Medical Director Dr Ben Williams (BW) Neighbourhood Lead Mr Brian Wroe (BWR) Lay Member – Patient and Public Participation Mrs Alison Kelly (AK) Governing Body Nurse Dr Chris Babbs (CB) Governing Body Secondary Care Mr Harry Golby (HG) Assistant Director of Commissioning
In attendance: Mrs Hannah Dobrowolska (HD) Director of Corporate Services Mrs Francine Thorpe (FT) Director of Quality and Innovation Ms Jade Booth (JB) Assistant to Chief Accountable Officer Miss Dawn Taylor (DT) Personal Assistant (minute taker)
Apologies: Mr Edward Vitalis (EV) Lay Member - Audit, Remuneration and Conflicts of Interest Dr Tom Regan (TR) Clinical Director for Transformation Consultant Mrs Karen Proctor (KP) Director of Commissioning Cllr. Gina Reynolds (GR) Lead Member for Adult Services, Health and Wellbeing
1. Questions raised by members of the public and CCG Video 1.1 During the public part of the meeting the issue of the intermediate care unit at the hospital was raised and an enquiry made as to what the current situation was. It was pointed out that a public meeting was held in December but no information following that meeting had been sent out and no minutes were available.
1.2 TT responded by confirming that the CCG has written twice since the public meeting to the individual raising the question. Judd Skelton from the CCG has provided an update and this will be forwarded to the individual. The issue was discussed at this week’s Integrated Care Advisory Board at which all relevant stakeholders were in attendance. Two sets of plans are being considered, one for the unit to be sited on NHS Salford Clinical Commissioning Group Governing Body Meeting 21 March 2018 the Stott Lane car park and one for it to be sited on the main hospital campus. An initial assessment from the hospital will be received back by the end of April, and then it will go to the Council for progression The Council has committed to update the Claremont and Weaste Community Committee as things progress.
1.3 SD commented that he was at the public meeting and local residents raised issues which Salford Royal Foundation Trust (SRFT) has put forward resolutions for. Confirmation on the progress made with these resolutions needs obtaining. SD confirmed that 60 intermediate care beds had continued to be available through this winter elsewhere at Barton Brook and The Limes and that the new unit would consolidate the 60 beds onto one site, rather than creating additional capacity. When a decision on the site has been made the plan would need to go through the Council’s planning process.
1.4 TT informed members that the meeting was being recorded and enquired if they were in agreement with this. Members confirmed their acceptance of this. SD confirmed that the recording was only for the purpose of producing the minutes and would be deleted. ACTION - JB to send an update to the individual member of the public ACTION - JS and colleagues to ensure future communications are handled appropriately
1.5 Patient Story 1.6 Members watched a video presentation on carbon literacy. As an organisation Salford CCG has pledged to become an accredited carbon literate organisation and approximately 20 of the senior management team have undergone carbon literacy training.
2. Apologies for Absence and Declarations of Interest 2.1 Apologies were received from Cllr Gina Reynolds, Mrs Karen Proctor, Mr Edward Vitalis and Dr Tom Regan.
2.2 There were no declarations of interest received.
3. Minutes of the last meeting and matters arising 3.1 Minutes from 31 January 2018 3.1.1 The minutes were approved as a true and accurate reflection of the meeting.
3.2 Action Log from 31 January 2018 and Matters Arising 3.2.1 It was noted there were no outstanding actions.
3.3 Matters Arising 3.3.1 There were no matters arising.
4 Leadership Reports 4.1 Chair’s Report 4.1.1 TT reported that on a GM level there were changes to the governance structure with the Health and Social Care Partnership. The Greater Manchester Strategic Partnership Board is now the Health and Care Board.
4.1.2 The Greater Manchester Joint Commissioning Board now has a much closer remit and meets on a monthly basis. NHS Salford Clinical Commissioning Group Governing Body Meeting 21 March 2018
4.1.3 TT stated that he chairs the Greater Manchester Mental Health Programme Delivery Board, which approves business cases for Pan GM projects. Investment funds have now been approved and plans can be progressed.
4.1.4 TT sated he was also involved with a new programme board at GM level concerning housing and health. An introductory workshop with partners was held last week.
4.1.5 TT noted that Bev Humphrey, Chief Executive of Greater Manchester Mental Health Foundation Trust (GMMHFT), will be retiring in March. On behalf of the Governing Body TT acknowledged the contribution she had made.
4.1.6 TT confirmed that Salford CCG was continuing work with Council colleagues regarding the commissioning review and its implementation, and members would be kept advised of progress.
4.1.7 TT informed members he attended a recent Citizen Patient Panel Event which included presentations on the mental health strategy, Salford Together’s urgent care work and Child and Adolescent Mental Health Services (CAMHS) care model, and policy and safety were given.
4.1.8 TT had also attended a PIPS event (Practice Improving Processes in Salford), which is a Salford CCG funded scheme commissioned from Haelo. There was a lot of learning to be taken from this event and it was important to share this across the neighbourhoods.
4.1.9 It was confirmed that practice visits were underway and it was hoped all 45 practices will be visited by the end of the year.
4.1.10 TT stated that BWR has been appointed Deputy Chair and Senior Lay Member from April. TT expressed his thanks to Edward Vitalis for his support and contribution.
4.1.11 The Governing Body noted the verbal update provided in the Chair’s Report.
4.2 Chief Accountable Officer Report 4.2.1 AH reported that work with partners was being undertaken to resolve the winter pressure issues.
4.2.2 Stranded patients are an issue at present. These are patients who are ready to move out of an acute hospital setting into a setting requiring a lower level of intervention or their own home. Work with SRFT is being progressed on this.
4.2.3 As Salford has a high level of falls, fall prevention is a priority for the CCG. A programme has been developed and delivered to address this and the data suggests benefits are being seen.
4.2.4 AH indicated that the Practice Nurse Awards have been held and 2 practices in Salford have won accolades.
4.2.5 Progress was being made around delivering the 7 day cancer waiting times.
4.2.6 In relation to the continuity of service agreement, whereby NHS organisations acknowledge length of service that has been delivered in the local government sector, it was felt this should be supported.
NHS Salford Clinical Commissioning Group Governing Body Meeting 21 March 2018 4.2.7 The NHS staff survey results were positive for Salford CCG. Only 58 CCGs participate nationally. Some areas of development are noted in the appendix.
4.2.8 BWR raised the issue of severe mental illness and enquired if the target figure was accurate and whether it was challenging enough. He supported the mandatory training for conflicts of interest and the continuity of service agreement. He noted the Practice Nurse Awards update and indicated the CCG Excellence Awards were coming up.
4.2.9 TT confirmed that the target figure was an error and it should be 81% of patients with severe mental health issues have received physical health checks. The Salford Standard target is 75% not 60%. Delivery has improved this year. This is one of the indicators where Salford Primary Care Together (SPCT) were leading neighbourhoods to improve performance.
4.2.10 NB enquired why dermatology had been excluded from the 7 day cancer referral target and what the impact on pensions would be as a result of the continuity of service agreement. In response AH stated he assumed dermatology was excluded owing to the level of demand, but would check on this, and that continuity of service will have no impact on pensions.
4.2.11 In relation to the staff survey PN felt it should be compulsory for CCGs to take part in order to give a truer picture.
4.2.12 TT informed members that the continuity of service agreement had also gone through the Greater Manchester Association of Clinical Commissioning Groups.
4.2.13 The Governing Body noted the report and gave approval to adopt proposals to recognise continuity of service between a range of public sector health and social care organisations in Greater Manchester from 1 April 2018. ACTION - AH to check why dermatology was excluded from the 7 day cancer referral target
5 Salford Mental Health Commissioning Strategy 5.1 Tony Marlow (TM), Claire Mayo (CM), and Judd Skelton (JS) from the Integrated Commissioning Team between the CCG and Salford City Council joined the meeting.
5.2 TT explained the paper was in two parts. The first part gave an update on the 5 year forward view and the mental health needs assessment work. The intention was to implement an all age group integrated mental health strategy. It was agreed this item would come back to the Governing Body for approval in September.
5.3 JS indicated that one of the highlights was the waiting time around IAPT and there was a workshop planned for May to increase the access rate. JS pointed out the early intervention psychosis target was a challenge owing to capacity. There had also been an increase in people going out of the area which needs addressing. The employment pathway was an area where work was progressing in partnership with CVS.
5.4 TT stated the second section of the report detailed areas the strategy needed to cover. Highlights were physical health and mental health, homelessness and housing, discharge planning and recovery, isolation and social interaction, supporting parents and families, criminal justice, developing integrated ways of working, dementia support, co-design with voluntary organisations, and accessing services. NHS Salford Clinical Commissioning Group Governing Body Meeting 21 March 2018
5.5 JS confirmed that key objectives were being identified.
5.6 BWR stated that performance in relation to accessing psychological therapy presented challenges which included waiting time. It was appreciated that work was underway to resolve waiting times. Homelessness and housing were also problems which required concentrating on. The emphasis on engagement should continue as well as education to address the ongoing stigma, of not just service users and carers but the public as well. However, engagement and education raised cultural barriers which would need to be overcome.
5.7 NB supported the non-medical approach, such as housing and employment, but felt preventative aspects required progressing, especially in schools.
5.8 JT queried what the IAPT access target figure of 25% meant and how it was planned to reduce the large number of older people who are isolated and at higher risk of mental health issues. In response TM confirmed that the target was 15.8% of the population with mental health issues and CM indicated discussions in relation to investment in addressing isolation were being held.
5.9 KJ noted the suicide prevention strategy was coming to an end and enquired if another strategy was in place. In response JS stated that work was ongoing with GMMHFT and other partners. A training session on suicide prevention with barbers, hairdressers and tattooists had been arranged for Monday.
5.10 KJ enquired what the timeline for reducing out of area placements was. JS stated the target was zero out of area placements by 2020.
5.11 AH pointed out that up to 2030 demographic changes will present challenges, as will the current demand on urgent care. Social media was also likely to create different demands too.
5.12 DM felt the issue of poor communication between discharge, the home based treatment team and the mental health team, required addressing. In response TT agreed that appropriate strategies to allow a seamless patient journey were important
5.13 PN enquired whether challenges resulting from isolation in young people were being felt and whether they were increasing. CM stated that different approaches towards engagement were being utilised to overcome this risk.
5.14 The Governing Body noted the contents of the report and provided comments.
6 Performance 6.1 Quality Performance 6.1.1 Quality and Safety Overview JT presented the report highlighting the following areas: the update on safeguarding which included an overview of primary care assurance as well as information on how the CCG is progressing with the requirements in relation to learning disability mortality reviews. The report also outlined progress made in relation to the 2017/18 quality work plan.
6.1.2 AK commented that the summary of the work programme seemed very positive and enquired whether any areas were not progressing as well as anticipated. JT responded one area was nursing homes. NHS Salford Clinical Commissioning Group Governing Body Meeting 21 March 2018
FT replied that whilst progress had been made in all areas further work was required to continue to support improvement in the care home sector, she also identified that patient experience was an area where further work was required and it will be helpful to make more links with CCG colleagues who are working with services users to ensure that we capture their stories. The Safer Salford programme was hugely ambitious and some areas had progressed well for example medicines safety, however other areas had less of an impact for example the safety culture surveys. FT did highlight that through this programme she felt that the conversations about safety and improvement had helped to create a consistent system wide safety culture. A SWOT analysis has been undertaken to identify the weaknesses and threats in the current work programme and this has been considered in the development of the refreshed strategy.
6.1.3 BW raised the issue of quality assurance for primary care asking whether the information considered could indicate that practices might receive an inadequate rating by the Care Quality Commission (CQC) as one of the Swinton practices CQC report had recently been published and was rated as Inadequate. FT commented that having read the CQC inspection report for the practice concerned the issues that had been highlighted related to internal governance processes and therefore would not have been identified through the dashboard. TT pointed out that the CQC was the regulator for GP practices and that this was not part of the role of the CCG. FT commented that the dashboard might be of assistance to practices in helping them to identify areas for improvement and that some of the bigger providers do carry out mock CQC inspections.
6.1.4 AH suggested that information contained within the dashboard could be triangulated with other intelligence to prompt deeper dives which may help to predict practice ratings. He suggested that the Primary Care Quality Group should be asked to review this and work with practices to highlight areas where they needed to make improvement. JT commented that whilst practices could be told about concerns, it is then up to the practice to take appropriate action.
6.1.5 In respect of safer care homes CB referred to the ‘pimp my zimmer’ initiative and the interaction between schools and care homes as he had read about this elsewhere in the country. He enquired how wide spread this work was in Salford. FT indicated that the initiative to involve schools had been part of the Salford programme led by Haelo. ACTION - JT to Request the Primary Care Quality Group to look at ways of predicting low practice CQC ratings.
6.1.6 The Governing Body noted the contents of the report.
6.2 Quality of Commissioned Services 6.2.1 JT presented the report highlighting the following key issues: Concerns about the rapid access chest pain clinic at SRFT and subsequent discussions was an example of responding to soft intelligence regarding waiting lists increasing. This has resulted in the production of an action plan and evidence of improvement can be seen. There had been a district nursing presentation on a scheduling tool which had been introduced to improve efficiency and had also contributed to improvements in quality and safety. It is hoped that this software would be rolled out to other community services
6.2.2 He highlighted that the issue of cancelled operations remains a problem for SRFT and assurance had been sought in relation to plans for improvement as well as how NHS Salford Clinical Commissioning Group Governing Body Meeting 21 March 2018 patient experience was being managed The problem was often related to high bed occupancy and urgent care demand; however, having patients in the hospital provides sufficient tension in the system to ensure operations are carried out and productivity maintained.
6.2.3 In relation to the recent CQC inspection for Greater Manchester Mental Health Trust (Prestwich Hospital site) an overall rating of Good with a ‘requires improvement’ rating for safety had been given.
6.2.4 The outcome of Pennine Acute Hospital Trust (PAHT) CQC re-inspection was included which found some evidence of improvement. The overall rating had changed from Inadequate to Requires Improvement.
6.2.5 It was reported that 2 nursing homes currently were not taking patients, one temporarily and one permanently.
6.2.6 In relation to cancelled operations resulting from technical difficulties AK enquired what these were. In response JT stated that rusting of surgical instruments had caused cancelled operations. It was confirmed that whilst these instruments were sterile they were not used and no safety issues resulted. If an operation was cancelled it should be rescheduled within 28 days, but this had been breached on occasions.
6.2.7 AK questioned whether the closure of the nursing homes would have an impact on capacity across the system. FT confirmed it should not have any impact, but the situation would be closely monitored.
6.2.8 BWR noted that the number of overdue serious incidents had reduced and this was positive. In relation to CQC ratings for care homes he enquired whether overall performance in Salford was improving or deteriorating and whether this gave any reason for concern. FT commented that a report published by Independent Age about care homes performance in respect of CQC inspection ratings in March 2017 indicated that Salford was the second worst area in the country for the percentage of homes rated as inadequate or requires improvement. The same report has just been published for 2018 and Salford remains in the worst 20 performing local authorities in the country, it is the local authority area that has seen the biggest improvement. She highlighted that the picture therefore was an improving one although there is clearly much more work to do with this sector.
6.2.9 DM commented that the use of soft intelligence data to highlight concerns was positive. He thought that the ‘golden patient’ information highlighted in the PAHT CQC report was interesting and queried whether discharging people from hospital earlier in the day would lower readmission rates asking whether any of this work was being undertaken at SRFT. FT replied that one of the workstreams in relation to urgent care improvement related to patient flow and included early consultant ward rounds and discharging before noon which was being tracked through the Urgent and Emergency Care Delivery Board.
6.2.10 CB commented that an early in the day discharge could be achieved by having everything in place the night before rather than on the day of discharge. In relation to PAHT improvement he felt this coincided with the secondment of SRFT management team and queried whether this would affect SRFT performance as well as the timescale for the secondment and next steps. AH stated that the formation of the Northern Care Alliance between SRFT and PAHT was permanent. He outlined that the Executive team at SRFT had indicated that there would be benefits from this NHS Salford Clinical Commissioning Group Governing Body Meeting 21 March 2018 alliance and he would bring a paper to the next meeting indicating the benefits and next steps.
6.2.11 PN asked that benefits to Salford patients needed to be apparent as well as organisational benefits.
6.2.12 SD indicated that Salford residents use maternity and A&E services on the North Manchester site and that the inspection ratings for both of these services have moved from ‘requires improvement’ to ‘good’, so the impact in Salford should be positive. ACTION - AH to produce report on the benefits and next steps in relation to the Northern Care Alliance for the population of Salford.
6.2.13 The Governing Body noted the contents of the report and received assurance that relevant information is being sought and processes established to scrutinise the quality and safety of commissioned services.
6.3 Governance Assurance Framework Report 6.3.1 AH indicated the report gave a children’s and adolescent mental health update which showed improvements in waiting times and pointed out that work was continuing with GMMHFT.
6.3.2 In relation of hospital performance, the 18 week standard access to planned care was continuing to be delivered despite pressures. However, the 4 hour urgent care standard was proving challenging.
6.3.3 The Urgent Care Board is looking at improving delivery of the 4 hour standard. Salford is ranked middling for performance in this and is seeing an increase in patients from outside the area.
6.3.4 There were significant challenges around ambulance response times and the North West Ambulance Service (NWAS) are the worst performer in the country. The lead commissioner for the service is Blackpool CCG and concerns have been raised with NWAS through Blackpool CCG.
6.3.5 All the extended access hubs across Salford have now gone live and this pilot will continue to be monitored and reviewed.
6.3.6 NB pointed out that some antibiotics were showing an increase in prescription levels whilst others were decreasing, and felt there was a need to look at septicaemia in relation to primary care. He also queried how winter pressures were impacting on elective care and what measures were being taken to avoid elective care being impacted. It was noted that delayed transfers of care had improved, but the percentage of over 65 year olds at home after 91 days of discharge has gone down and wondered whether they were linked.
6.3.7 AH stated the triangulation links could be looked at with SRFT. It would also be interesting to obtain examples of issues around the 18 week standard processes. In respect of the 62 day target, a significant piece of work had been done looking at breaches, which has been shared with SRFT and an action plan produced. MRI waiting times were under pressure, plans are in place to address this and the situation would be monitored monthly.
6.3.8 HG stated that SRFT were reviewing their access policy.
NHS Salford Clinical Commissioning Group Governing Body Meeting 21 March 2018 6.3.9 FT reported that the Scheduled Care Board discussion triangulates with Quality and Outcomes discussion and data has been requested on clinical oversights to cover the softer side of quality.
6.3.10 AH indicated that delays in patient care moving from SRFT to the Christie can result in breaches of the cancer 62 day standard. The CCG has challenged SRFT on this.
6.3.11 BWR raised the issue of increased prescribing of pain killers, and specifically whether pharmaceutical companies were inappropriately influencing the prescribing. He also enquired what the reasoning behind the decline of women smoking at the time of delivery in quarter 3 was. In addition he queried why the target for children waiting 18 weeks or less for a wheelchair was 77% and not 100%. In relation to the percentage of practices achieving at least 56% of prescriptions via EPS it was proposed stronger enforcement should be carried out with those practices regularly breaching this KPI.
6.3.12 TT responded by stating no new antibiotics were being promoted and the Medicines Optimisation Team are working on this with practices.
6.3.13 HG stated there was a GM programme trying to introduce a new model in relation to smoking at the time delivery. In relation to wheelchairs for children, there were issues with children’s equipment services which have been raised with the provider and resolutions are being sought.
6.3.14 SD stated that all practices have now signed up to and should be using the electronic prescription service. There were 8 practices not achieving target but this was not all down to the practice. There were some issues with Community Pharmacists and this will go the Primary Care Commissioning Committee for further consideration.
6.3.15 BWR raised his concerns in relation to NWAS performance and noted that he was pleased that this has been raised with the appropriate parties.
6.3.16 The Governing Body noted the latest performance position; accepted the recovery plans set out for the measures currently underperforming; noted the updated risk position and confirmed that the current level of risk is acceptable in line with risk treatment plans; noted the update in relation Salford Locality Assurance.; noted the update in relation to GM Performance and Delivery and noted the work ongoing to review this report and supporting appendices as part of the annual business planning process.
6.4 Financial Performance 6.4.1 SD stated that whilst the report was being presented at the end of month 11 (February 2018), the contract activity and spend related to month 10 (January 2018). There was a forecast hospital overspend of £4.3m which is an increase spend of around £1m compared with the forecast presented at the last Governing Body. In addition, the CCG’s total forecast spend has increased due to a high cost mental health package of care in Avon and Wiltshire. The CCG was made aware of this individual in March 2017 when the provider invoiced the CCG although, at that time, the CCG was not the responsible commissioner nor had been involved in the placement of this individual. Salford CCG escalated this issue to NHS England to establish who was the responsible commissioner, which concluded that Salford CCG was responsible from August 2017 onwards. Salford CCG is working looking at commissioning a different, more local care package for this individual.
NHS Salford Clinical Commissioning Group Governing Body Meeting 21 March 2018 6.4.2 Salford CCG is still on track to achieving the statutory financial duties. The year-end position shows minimal financial risk for the rest of the year as the financial value for the remainder of 2017/18 has been agreed with Salford Royal NHS Foundation Trust.
6.4.3 DF raised the issue of price increases and other commitments and queried what these were and whether they would continue. SD indicated SRFT is paid by activity and activity is based on a national tariff. Each unplanned admission attracted a different price which was driven by the complexity of the patient. Checks are carried out that activity is being appropriately coded and all hospitals are audited on their coding. In respect of committed developments, there was very little left and information was analysed through the Service and Finance Group. SD agreed to provide further detail on request and asked Governing Body to comment on the level of information contained within the finance report and whether more or less detail was required from members in future meetings. BWR confirmed he was happy with the level of detail provided.
6.4.4 BWR enquired how long the care package would be required for. SD stated the patient had been in long term care for at least 2 years and was uncertain of the length of time the care package would be necessary. Placing patients out of the area can raise particular difficulty for the CCG in relation in both monitoring the quality of care wrapped around the individual and monitoring the quality of the provider. 6.4.5 The Governing Body noted the contents of the report and the risks.
6.5 Operational Business Planning 6.5.1 AH acknowledged the work which has been undertaken and continues to be undertaken, and noted the final plan for sign off would be brought to the Governing Body in April.
6.5.2 The Governing Body noted the contents of the report and approved the Plan on a Page.
7 Minutes / Reports of Partnership Boards/Sub Committees 7.1 Commissioning Committee Report 7.1.2 The Governing Body noted the content of the report
7.2 Primary Care Commissioning Committee Meeting (PCCC) 7.3.1 The Governing Body noted the contents of the Part 1 meeting minutes from the PCCC held on 30 January 2018.
7.3 Executive Team Report 7.4.1 The Governing Body noted the contents of the report.
7.4 Audit Committee Report 7.4.1. The Governing Body noted the contents of the report.
7.5 Association of Greater Manchester CCG Summaries 7.5.1 The Governing Body noted the contents of the report
7.6 Salford Children and Young People’s Trust 7.6.1. The Governing Body noted the contents of the report
8 Reflection NHS Salford Clinical Commissioning Group Governing Body Meeting 21 March 2018 8.1 TT reflected on the key decisions reached during the meeting and thanked everyone for their papers.
9 The Meeting closed at 16:45Hrs.
NHS Salford Clinical Commissioning Group Governing Body Meeting 21 March 2018 Governing Body Meeting 21 March 2018 Part 1: Action Log
Ref. Subject Action Responsible Status
Questions raised by The 2 previous responses originally sent to the JB to send an update to the member of th th 1.4 members of Jade Booth member of the public dated 5 and 20 February have the public st the public and been re sent again on 1 May. CCG video
Questions The Intermediate Care Unit is ongoing and it’s been raised by JS was to ensure that all future noted to ensure all communications are handled 1.4 members of communications were appropriately Judd Skelton accordingly. the public and handled
CCG video
Although referral numbers into dermatology for suspected cancer too high a volume to successfully implement the 7 day target in the first tranche – SRFT are planning to include dermatology in a later phase of the roll out. Chief AH to check why dermatology was Accountable 4.2.13 excluded from the 7 day cancer referral Anthony Hassall Officer’s Proportionally very few actually convert to a cancer target Report diagnosis and 100% of dermatology cancers are treated within the 62 day target to treat cancer. This shows that reducing the 14 day referral target from referral to first outpatient appointment to 7 days would have no impact on treating patients’ within the current national treatment target.
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This is on the agenda for the next meeting. Informal discussion amongst staff is that it is when there is evidence of mounting management problems and clinical leadership. This tended to be in the form of soft intelligence. Changes in the team, people retiring leaving a vacuum, deadlines for submissions not being met even after reminders. There will, however, always be surprises. The quality assurance dashboard highlights any practice that are underperforming on key quality measures. This intelligence is then
triangulated at the Primary Care Reference Group, any Quality and JT to request the Primary Care Quality key issues escalated to PCQG and, where 6.1.5 Safety Group to look at ways of predicting low Jeremy Tankel appropriate, quality assurance visits scheduled. Overview practice CQC ratings Members of the team have a close relationship with
the CQC and regularly discuss concerns. A piece of work to identify key ‘must do’ areas for practices to follow in preparation for CQC inspections is being undertaken. SPCT have also planned to implement mock inspections as part of its quality improvement but they have confirmed this work stream is on hold due to capacity. This is something they wish to do in the future. In time the group hopes to work alongside them on this to ensure we get assurance from the mock inspections.
AH to produce a report on the benefits Quality of Slides have been received from David Dalton and will and next steps in relation to the Northern 6.2.12 Commissioned Anthony Hassall be circulated to GB members Care Alliance for the population of Services Salford
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MINUTES OF NHS SALFORD CLINICAL COMMISSIONING GROUP EXTRODINARY GOVERNING BODY MEETING Held on 25th April 2018, Salford Room, St James’s House
Governing Body reports and previous minutes can be found by following the link: http://www.salfordccg.nhs.uk/GoverningBodyMeetings.asp
Part I Present: Dr Tom Tasker (TT) Chair Dr Nick Browne (NB) Neighbourhood Lead Mr Steve Dixon (SD) Chief Finance Officer Mr David Flinn (DF) Neighbourhood Lead Mr Anthony Hassall (AH) Chief Accountable Officer Dr David McKelvey (DM) Neighbourhood Lead Mr Paul Newman (PN) Lay Member – Innovation Matters Dr Jeremy Tankel (JT) Medical Director Dr Ben Williams (BW) Neighbourhood Lead Mr Brian Wroe (BWR) Lay Member – Patient and Public Participation Mrs Alison Kelly (AK) Governing Body Nurse Dr Chris Babbs (CB) Governing Body Secondary Care Mr Harry Golby (HG) Acting Director of Commissioning Mr Edward Vitalis (EV) Lay Member - Audit, Remuneration and Conflicts of Interest
In Attendance: Mrs Hannah Dobrowolska (HD) Director of Corporate Services Miss Jade Booth (JB) Assistant to Chief Accountable Officer
Apologies: Mrs Kate Jones (KJ) Neighbourhood Lead Dr Tom Regan (TR) Clinical Director for Transformation Consultant Mrs Karen Proctor (KP) Director of Commissioning Cllr. Gina Reynolds (GR) Lead Member for Adult Services, Health and Wellbeing
1. Apologies for absence 1.1 Apologies were noted
1.2 No declaration of interests were raised.
2. Leadership Reports a) Approval of the CCG Financial Plan and Operating Plan 2018/19
2.1 SD introduced the item by explaining that Governing Body has seen both parts of the paper in draft form in various previous meetings. The report shows planned delivery of a balanced financial plan for 2018/19 and for the next 3 years. The CCG has met
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all the financial business rules set by NHS England at a national level. In addition, the CCG has increased investment in mental health and primary care to meet the national Five Year Forward View ambition. In addition, the CCG recognises that it is not performing well against the cancer standards and therefore significant additional investment has been set aside in the financial plan for cancer services. The financial consequences of all new investments have been factored into the plan and these are shown in the final section of the paper.
2.2 TT welcomed the well written paper and asked for questions. EV asked if there were any operational constraints on delivering the plan including the risks and challenges in delivering required savings.
2.3 SD responded that in developing the Business Plan consideration had been given to aligning investment to deliver the outcomes required. This has included a process to ensure we have sufficient staff in place to deliver this and a prioritisation process. SD reiterated the plans have been taken to various strategy groups to ensure the plan is ambitious yet deliverable.
2.4 SD explained that the financial position will be managed over 3 years instead of yearly, offering flexibility but although there is a balanced plan for 2018/19 the savings required in 2019/20 do increase, hence the need to adopt a rigorous and structured approach to identify opportunities for, and to deliver, efficiency savings. SD reminded members that 1% savings were identified and delivered in the opening 2018/19 plan.
Note: Nick Browne joined the meeting at 13:25
2.5 SD explained the CCG’s approach to develop practical plans to address the future efficiency challenge. This includes launching a Best Value Programme to identify efficiency opportunities now for 2019/20 onwards. The CCG has funded a post to initially look at data and opportunities to deliver a joint efficiency programme with the council.
2.6 JT referred to appendix 1 and section 5 with his concerns about the financial position looking difficult for the years 2021/22 and 2022/23. SD acknowledged challenges in the 2021/22 position but reiterated that in order to be in a balanced financial position in 2021/22 we have got to start planning now. He repeated that the work we are doing on “Best Value” will allow us to identify opportunities that can impact the 2021/22 position. SD responded to JT challenge on his confidence levels for the “books to balance”, explaining the further in the future you go, the harder it is to predict yet. There are a number of assumptions built into future years’ financial plans, not least assumptions on funding growth for the NHS. The actual funding settlement will not be known until much later in the year and likely to be announced in the 2019/20 planning guidance.
2.7 AH provided a supplementary point that we only know what we know now. The point of the Best Value Programme is to help us to mitigate against the risks that are unknown, but to assure we put quality at the centre; ensuring we have money spent
Page 2 of 3
where it is needed. The challenge going forward is how we are progressing this and how this is delivered over the next 24/36 months.
2.8 The Governing Body approved the financial plan for 2018/19 to 2022/23, enabling the submission of the CCG’s Business Plan 2018/19 plan to NHS England by the deadline of 30 April 2018.
2.9 SD informed that part B of the paper has tried to ensure the actions within the operating plan will make the desired levels of population health improvements needed. The plan highlights where we require improvements, for example on cancer and mental health.
2.10 AH noted the plan as a very strong piece of work and the next steps are to translate this across the objectives of the Executives and then through to their team members to ensure everyone in the CCG is clear the part they are to play in delivery of the plan.
2.11 EV asked how the Lay Members can be better informed over their aligned areas. AH explained at each Governing Body the performance reports are presented which detail progress. However there is reason here to give this some thought separately regarding lead member roles. AK confirmed from a lead point of view clarity would be useful.
Note: EV left the room at 14:40
2.12 NB asked if there is an opportunity for bespoke outcomes and measures as some of these do not always seem to work for local populations. AH confirmed a lot of the matrix of performance is laid down by Greater Manchester or NHS England. The plan has tried to triangulate the metrics into the operational plan but acknowledged this is imperfect and will consider NB thoughts further.
2.13 The Governing Body noted the content of the update including business planning assurances provided and approved the CCG business plan for 2018/19
2.2.1 AOB
2.2.2 TT informed the committee of BW resignation as lead for Swinton; thanking him for his hard work and input.
3. Close at 14:45 HRs
Page 3 of 3
NHS SALFORD CLINICALCOMMISSIONING GROUP GOVERNING BODY MEETING AGENDA ITEM NO 4(b)
Item for: Decision/Assurance/Information
23 May 2018
REPORT OF: Chief Accountable Officer
DATE OF PAPER: 5 May 2018
SUBJECT: Report of the Chief Accountable Officer
IN CASE OF QUERY Gina Magson PLEASE CONTACT: Senior Corporate Services Officer 0161 212 4593
Please tick which strategic priorities the paper relates to: STRATEGIC PRIORITIES:
Quality
Community Based Care
Integrated Care
In Hospital Care
Long Term Conditions and Mental Health
Effective Organisation
PURPOSE OF PAPER:
This paper contains summaries of local and national policies, strategies and relevant news to ensure that the NHS Salford Clinical Commissioning Group (CCG) Governing Body remains up to date on the latest developments relevant to the organisation and are asked to note the content.
Page 1 of 14
Further explanatory information required
HOW WILL THIS BENEFIT THE This paper contains summaries of local and HEALTH AND WELL BEING OF national policies, strategies and relevant news SALFORD RESIDENTS OR THE to ensure that the NHS Salford Clinical CLINICAL COMMISSIONING GROUP? Commissioning Group (CCG) Governing Body remains up to date on the latest developments relevant to the organisation to benefit the health and wellbeing of Salford residents.
WHAT RISKS MAY ARISE AS A N one identified. RESULT OF THIS PAPER? HOW CAN THEY BE MITIGATED?
WHAT EQUALITY-RELATED RISKS None identified. MAY ARISE AS A RESULT OF THIS PAPER? HOW WILL THESE BE MITIGATED?
DOES THIS PAPER HELP ADDRESS None identified. ANY EXISTING HIGH OR EXTREME RISKS FACING THE ORGANISATION? IF SO WHAT ARE THEY AND HOW DOES THIS PAPER REDUCE THEM?
PLEASE DESCRIBE ANY POSSIBLE None identified. CONFLICTS OF INTEREST ASSOCIATED WITH THIS PAPER.
PLEASE IDENTIFYANY CURRENT None identified. SERVICES OR ROLES THAT MAY BE AFFECTED BY ISSUES WITHIN THIS PAPER:
Document Development
Not Comments and Date Process Yes No Outcome Applicable (i.e. presentation, verbal, actual report) Public Engagement √ (Please detail the method i.e. survey, event, Clinical Enga gement √ (Please detail the methods i.e. survey, event, Has ‘due rega rd ’been given to Equality √ Analysis (EA) of any adverse impacts? (Please detail outcomes, including risks and how these will be managed. Legal Advi ce Sought √ Presented to the Commissioning Committee √
Presented to the Health and Wellbeing Board √ Presented to the Integrated Commissioning √ Joint Committee
Presented to any other groups or committees, √ This paper was shared Amendments will be including Partnership Groups electronically with the Chief made in light of any (Please specify in comments) Accountable Officer and Director comments received. of Corporate Services on 10 May 2018
Note: Please ensure that it is clear in the comments and date column how and when particular stake holders were involved in this work and ensure there is clarityintheoutcomecolumnshowingwhatthekeymessageordecisionwasfromthatgroupandwhetheramendmentswererequestedaboutaparticularpartofthework.
Report of the Chief Accountable Officer
1 Executive Summary
This paper contains summaries of local and national policies, strategies and relevant news to ensure that the Governing Body remains up to date on the latest developments relevant to the organisation.
2. National Update
2.1 MAST LIFT AND Carillion Group The collapse of Carillion Group earlier this year has had a much more tangible impact on the business and it has therefore been necessary to look at other arrangements to find alternative Facilities management for all former Lift buildings including those in Mast Lift.
The vast majority of the Carillion Group went into compulsory liquidation in January 2018, this included Carillion Integrated Services (CIS) who deliver FM services to our LIFT buildings. It became a matter of priority that all services were “normalised” in a very short period of time to ensure that the services provided continued in a seamless manner.
The LIFT team looked at a number of options and after a short time have commenced negotiations with a company called FES Group. Whilst FES is not as well-known as Carillion it already services several LIFT buildings in the North of England and Scotland and to date has demonstrated a commitment to take on CIS LIFT contracts in our area. These negotiations are still on-going and not yet finalised but both sides are confident of a successful conclusion.
2.2 NHS e-Referral Service - Helping patients manage their referral online NHS Digital will be sending information packs out this month to general practices that offer patients information about how to book their hospital appointments online. The packs are designed to encourage patients to use the NHS e-Referral Service Manage Your Referral website to book their own appointments online on a convenient date and time, at their preferred hospital or clinic. Patients can also check, change and cancel appointments online without help from their practice. Each pack contains leaflets and posters for practice staff and patients. The national telephone appointment line will still be available for patients who prefer it.
2.3 National Audit of Intermediate Care 2018 The National Audit of Intermediate Care (NAIC) provides the only comprehensive data on intermediate care services which are key to maintaining older people’s independence and avoiding unnecessary hospital admissions for this vulnerable cohort. In 2018, NHS England is funding the NAIC, so that all commissioners and providers of intermediate care services can take part free of charge. The purpose of the audit is to improve intermediate care services for older people by providing benchmarked information on service models, spend, activity, workforce and, importantly, outcomes.
NHS Salford CCG and Salford Royal NHS Foundation Trust RFT have signed up for this years’ Intermediate Care National Audit. The data collection opened last Tuesday (8 May) and is open until the 27 July. I have led the process from commissioning for all the previous Intermediate Care National Audits and I have always collaborated with SRFT through the data collection
stage of the audit. Michelle Bridson and Dr Tim Pattison are SRFT leads for this work. We have used previous Audit outputs to support the commissioning review of Intermediate Care and are using last years Audit to improve performance monitoring arrangements through 2018/19 and also to support the transformation programme of services.
2.4 Online GP consultations: Surveys now open NHS England is seeking views from GPs, practice teams and members of the public on what people think about the idea of online consultations so we can improve the service and increase the availability and use. Online consultations are a way for patients to contact their GP practice without having to wait on the phone or take time out to come into the practice. There are two short online surveys which CCGs are asked to share with practices, partners and on their own websites.
NHS Salford CCG’s member practices are promoting the online service to patients and have increased uptake significantly. The CCG are about to launch a new online platform for all practices that will enable them to send reminders and receive cancellations by text. The solution will also enable app users to book appointments online. We are working with Salford Royal NHS Foundation Trust who have just launched DrDoctor (which offers similar 2 way messaging services for outpatient clinics) to have a unified message to Salford residents that the NHS is open for online business.”
2.5 NHS70: spotlight on primary care As part of the NHS70 celebrations, NHS England is showcasing how primary care has changed, the exciting things happening now and a look to the future across general practice, dentistry, eye care services and community pharmacy.
2.6 Changes in legislation enable advanced paramedics to prescribe A change in legislation means advanced paramedics are now able to prescribe, bringing huge benefits to patients and the NHS. This means there will be better use of paramedics’ skills, allowing them to provide care closer to home. It will also improve patient experience while easing demand on other busy urgent and emergency care services, as well as reducing NHS costs. Once these paramedics have received a period of additional training they will be able to prescribe medicines for their patients. This is likely to happen in practice early next year.
Salford practices currently have two advanced practitioners who are paramedics and have been unable to prescribe as part of this role. This change in legislation will allow them to train to be prescribers and add this skill to their service delivery, making medication supply more streamlined for Salford patients.
The medicines optimisation team is currently in conversation with the North West universities providing non-medical prescribing training (and have confirmed Salford university have been accredited by the Health and Care Professions Council) to ensure systems are in place to utilise this change in legislation and develop this work force locally. They will also ensure the paramedic workforce in primary care is added to the CCG governance processes for non- medical prescribers.
2.7 Improving services for victims and survivors of sexual assault and abuse NHS England has published Strategic direction for sexual assault and abuse services, which sets out what is needed to improve services and consequently patient experience for those who have experienced sexual assault and abuse. Co-designed with a range of partner organisations,
as well as the victims and survivors of sexual assault and abuse, the strategic direction takes into account a lifelong pathway of care for survivors. It also outlines how services need to evolve and work together to ensure that as much as possible can be done to safeguard individuals and support them at times of crisis and at the point of disclosure.
NHS Salford CCG has various responsibilities that relate to those who have experienced sexual assault and abuse. These include its safeguarding duties and its role as commissioner of support and other related services (e.g. mental health, abortion and emergency services.) The document makes recommendations for CCGs including strengthening prevention work, introducing quality standards for services and ensuring specifications support joint working. Service leads within the CCG will work together to develop a local action plan.
2.8 NHS England Conflict of Interest – Update on Mandatory Training Module To further support CCGs to manage conflicts of interest, NHS England has launched new online training. The training package has been developed in collaboration with NHS Clinical Commissioners and aims to raise awareness of the risks of conflicts of interest and how to identify and manage them. Module one of the training is mandatory for some CCG staff and will need to be completed by 31 May 2018. We will be working with CCG leaders and staff over the coming weeks to ensure we meet the requirements of training relevant leaders and staff by the deadline.
3. Greater Manchester Update
3.1 Greater Manchester Shared Service update There have been a number of organisational changes in the Greater Manchester Shared Service (GMSS) in-line with wider changes across Greater Manchester. GMSS’s organisation objectives remain unchanged, however some leadership changes have taken place and progress and plans have been made in relation to theme 2, transforming community based care and support, and theme 4, standardising clinical support and back office services. Appendix 1a and 1b provides additional information around the objectives and structure overview.
4. Salford CCG Update
4.1 Commissioning Review At the part 2 meeting in March, the Governing Body agreed in principle to greater integrated commissioning with Salford City Council from April 2019 noting the significant benefits to Salford residents of more integrated working between the City Council and the CCG. The preferred option to achieve this is the development of a single integrated health and social care fund for children’s, public health, adults and primary care spend between the City Council and CCG. Plans are now being developed to give effect to this decision from 1 April 2019 and progress will be reported to Governing Body.
4.2 Voluntary, Community and Social Enterprise (VCSE) sector’s strategy and investment plan A strategy for the voluntary, community and social enterprise sector in Salford 2018 – 2023 The purpose of this Strategy is to describe the position and role of Voluntary, Community and Social Enterprise (VCSE) sector in Salford in terms of how the sector supports and benefits local people, delivers services and influences city-wide policy and strategy. To ensure it is grounded within the sector it has been built around the 6 Pillars of Salford’s VCSE manifesto as outlined below:
• Include • Involve • Collaborate • Value • Invest • End (poverty)
The aim of this Strategy is to achieve the following in Salford:
• A clear position and role for the VCSE sector in strategic partnerships • Recognition and agreement about how the sector supports and benefits local people, delivers services and influences policy and strategy • Shared understanding between the VCSE sector, Salford City Council and NHS Salford CCG of the relationship that the VCSE sector has with its key stakeholders • Resources that are appropriate, accessible, and sustainable • A consistent approach to strategic and operational thinking • Consistency of practice and high standards in the conduct of the relationships between the VCSE sector and key public sector partners • A VCSE sector which works in partnership with the City Council and NHS Salford CCG for the benefit of the people of Salford.
4.3 2017/18 Operational Plans and Investment Agreements – Post contract sign-off The CCG was tasked to submit a draft of the operational plan for the City, alongside our current investment agreement ambitions. We have received confirmation from Greater Manchester Health and Social Care Partnership (GMHSCP) that all localities in Greater Manchester have been asked to provide a brief summary of the current level of assurance, with the need to provide further supporting information where appropriate.
GMHSCP were “generally satisfied with the alignment between Salford’s operating plan and investment agreement, based on the underlying activity assumptions for 2018/19”. The CCG has continued to work with GMHSCP’s Planning Team to ensure that work was completed by the end of April. NHS Improvement colleagues have also shared some outputs which attempt to triangulate provider and CCG activity plans covering each locality in Greater Manchester.
I can confirm that a final draft version of the operational activity plans was submitted before the end of April. GMHSCP’s Planning Team colleagues will contact the CCG in due course with regards to the mechanism for facilitating this. Once further information is available I will provide an update my report to the Governing Body.
4.4 Excellence Awards The last 12 months have once again been ‘outstanding’ for the NHS in Salford as we achieved the top rating from NHS England for the second year running. Salford remains the only CCG in Greater Manchester to be rated ‘outstanding’ by NHS England – making Salford one of only two places in the country with a CCG and acute provider trust to earn the highest accolades.
This is an enormous achievement, cementing Salford’s reputation as being one of the leading healthcare economies in the UK and is the result of the commitment and hard work by our GPs, practice and CCG staff to improve the standards of care for the people of Salford.
The Excellence Awards were an opportunity for us to reflect and celebrate the achievements of our Members and CCG staff. The categories and winners were:
Working Together Winner – CCG Finance Team
Improving Quality Winner – Sue Harris, Lead Nurse Quality Assurance and Improvement, and Kate Cooper, Senior Contract Manager
Putting Patients at the Heart Winner – Barbara Slater, Practice Manager at Langworthy Medical Practice
Living our Values Winner – Tony Marlow, Mental Health Integrated Commissioning Manager
Above and Beyond Winners – Denise Wright, Personal Assistant, and Sarah Rust, Practice Nurse at St Andrews Medical Centre
4.5 Ingleside Birth and Community Centre I attended the launch of Ingleside Birth and Community Centre on the 19 April. It was a momentous occasion for us, the City of Salford and our Maternity Pioneer.
The launch was a great success due to our speakers, our local primary school and our community groups who were all involved in the event.
All partners worked hard together to achieve what will be a fantastic facility for our communities. The hard work will now continue to further develop Ingleside into the community hub for early months services and to finalise the model of service delivery to achieve the innovative plans we have for the centre.
We have no doubt you will be watching the developments closely and we will keep you updated throughout the next stages.
4.6 Meetings/Visits Over the past few weeks, Tom and I have met with a number of practices as part of our annual programme of visits. The visits are a key part of the CCG’s engagement process with its member practices. It is an opportunity for practices to raise key issues they are faced with and also to share good news stories. The remaining visits are booked in over the next few months and I will continue to update you via this report.
Since the Governing Body meeting held in March, I have been involved in a number of engagements and liaison meetings, including being asked to take part in the ‘buddy programme’ for NHS Clinical Commissioners for other CCGs across the country. Other key meetings and events that I have also attended include:
• Lord Peter Smith, to discuss carbon literacy and the plans for Salford and also to encourage others across Greater Manchester. • Andrew Dillon, Chief Executive of The National Institute for Health and Care Excellence (NICE) • Salford has been shortlisted as a finalist in the 2018 MJ Awards for ‘Local Authority of the Year’. I attended a ‘presentation pitch’ in London with members of Salford City Council as part of the nomination. The award ceremony will be held in June 2018 in
London. • I was invited to speak at an event in Leeds about Salford Urgent and Emergency Care Delivery Board • Positive meeting with NHS England around Quarter 4 assurance • Met with Barbara Keeley, MP to update her on plans and programmes that Salford is involved in.
5 Recommendations
5.1 The Governing Body is asked to: • Note the information contained in this report.
Appendix 1a - GMSS Corporate Objectives The GMSS Senior Management Team agreed that the organisations 2017/18 Corporate Objectives are still relevant for 2018/19 because the purpose and goals of the organisation remain largely unchanged. These objectives have been expanded to recognise that the organisation is entering a period of transformation and transition.
The 2018/19 Corporate Objectives are: *Text shown in green is where the objectives have been expanded for 2018/19
1.Develop and maintain effective business relationships across Greater Manchester to ensure GM shared services are fit for purpose now and in the future. 2.Engage with Greater Manchester to influence and support a future shared services transition into a combined organisation, in line with the GM Corporate Functions Review / GM Commissioning Hub. 3. Ensure our services offer best value for money. 4. Continually improve and enhance our services. 5. Become an “Employer of Choice” by embedding a culture of health and wellbeing, continuous development and empowered staff. 6. Support our greatest asset – our staff - through the transition.
Collaboration
The GMSS Vision and Values remain unchanged
Vision Everyone Reliable and To be a quality, trusted and valued partner supporting our Counts Professional clients in the delivery of efficient and effective health and social care across Greater Manchester. Values
Values
All staff are expected to demonstrate the organisations Innovative Integrity values in all that they do. The organisations values are detailed in the diagram to the right. 2 Appendix 1b - GMSS organisational overview
NHS MD Oldham New shared GMH SCP CCG service Organisation
Chief IM&T Andrea Finance Andrew Anderson Transformation White Officer Director
CORPORATE TRANSITION AND IM&T COMMISSIONING SERVICES FINANCE AND CLINICAL SUPPORT
4 February 2018
NHS SALFORD CLINICAL COMMISSIONING GROUP GOVERNING BODY MEETING AGENDA ITEM No 5 (a)
Item for: Decision/Assurance/Information
23 May 2018
REPORT OF: Clinical Lead for Quality & Safety
DATE OF PAPER: 14th May 2018
SUBJECT: 2018/20 Quality and Safety Strategy
IN CASE OF QUERY Francine Thorpe PLEASE CONTACT: Director of Quality & Innovation 0161 212 4906
STRATEGIC PRIORITIES: Please tick which strategic priorities the paper relates to:
Quality √
Community Based Care
Integrated Care
In Hospital Care
Long Term Conditions and Mental Health
Effective Organisation
PURPOSE OF PAPER: The purpose of this paper is to present an integrated Quality and Safety Strategy for Governing Body to approve. In developing the strategy we have engaged a range of stakeholders and considered national and local documents relating to quality and safety. Members of Governing Body are asked to: • Consider whether the ambitions, objectives and work programmes outlined are consistent with our approach to quality assurance and improvement. • Approve the 2018/2020 Quality and Safety Strategy
Further explanatory information required
HOW WILL THIS BENEFIT THE By consistently raising the quality of care HEALTH AND WELL BEING OF residents of Salford receive from services SALFORD RESIDENTS OR THE commissioned on their behalf. CLINICAL COMMISSIONING GROUP?
WHAT RISKS MAY ARISE AS A None RESULT OF THIS PAPER? HOW CAN THEY BE MITIGATED?
WHAT EQUALITY-RELATED RISKS None identified MAY ARISE AS A RESULT OF THIS PAPER? HOW WILL THESE BE MITIGATED?
DOES THIS PAPER HELP ADDRESS No ANY EXISTING HIGH OR EXTREME RISKS FACING THE ORGANISATION? IF SO WHAT ARE THEY AND HOW DOES THIS PAPER REDUCE THEM?
PLEASE DESCRIBE ANY POSSIBLE The strategy references quality assurance and CONFLICTS OF INTEREST improvement of primary medical services. GP’s ASSOCIATED WITH THIS PAPER. and Neighbourhood Leads on Governing Body are providers of primary medical services in Salford therefore may be conflicted
PLEASE IDENTIFY ANY CURRENT Quality by its very nature is everyone’s SERVICES OR ROLES THAT MAY BE business therefore it will impact across all areas AFFECTED BY ISSUES WITHIN THIS of care planning and delivery PAPER:
Footnote:
Members of NHS Salford Clinical Commissioning Group Governing Body will read all papers thoroughly. Once papers are distributed no amendments are possible.
Document Development
Not Comments and Date Process Yes No Outcome Applicable (i.e. presentation, verbal, actual report) Public Engagement Presentation / workshop with Feedback incorporated (Please detail the method ie. survey, event, √ Citizen Focus Group 22/02/18 into final document. consultation) Presentation / workshop at Improvement themes Citizens’ Panel event 13/03/18 reinforced Clinical Engagement √ Developed in conjunction with Feedback incorporated (Please detail the method ie survey, event, consultation) Medical Director and GP Quality into final document. Lead. Draft versions presented to GP Clinical Leads 15/11/17 Has ‘due regard’ been given to Equality √ Equality Impact Assessment Analysis (EA) of any adverse impacts? Screening Form submitted and (Please detail outcomes, including risks and how confirmation that full assessment these will be managed) is not required Legal Advice Sought √ √ CCG Quality Commissioning Confirmed support for the Presented to the Commissioning Committee Committee 24/01/18 improvement themes identified Presented to the Health and Wellbeing Board √ Presented to ICJC √ Approved Presented to any other groups or committees, √ Executive Team Minor amendments made including Partnership Groups (Please specify in comments)
Note: Please ensure that it is clear in the comments and date column how and when particular stakeholders were involved in this work and ensure there is clarity in the outcome column showing what the key message or decision was from that group and whether amendments were requested about a particular part of the work.
2018/20 Integrated Quality and Safety Strategy
1 Executive Summary
The attached Quality and Safety Strategy outlines an integrated approach both quality assurance and quality improvement for health and care services that are commissioned by NHS Salford CCG and Salford City Council. This paper outlines the process for development of the strategy; seeking out and incorporating the views of relevant stakeholders. NHS Salford CCG Governing Body is asked to: 1. Consider whether the ambitions, objectives and work programmes outlined are consistent with our approach to quality assurance and improvement 2. Approve the 2018/20 Quality and Safety Strategy
2 Introduction and Background
2.1 Over the past four years NHS Salford Clinical Commissioning Group has had a sustained focus on the quality and safety of services that are commissioned on behalf of the citizens of Salford. The CCG’s Quality and Safety Strategy was initially approved in April 2014 and outlined a consistent approach to quality assurance and quality improvement. In 2016 along with partners in the City Council and the Integrated Care Organisation (ICO) we embarked on the Safer Salford programme which introduced a collaborative approach to measurement and monitoring of safety within health and care services adopting the principles of the Vincent Framework1; as well as targeting areas for safety improvement.
2.2 Since the establishment of the ICO in July 2016 the CCG and City Council have been developing our approach to quality assurance of the services that we commission through the pooled budget. The attached strategy has been developed as part of this work and outlines how we intend to continue to drive quality improvements where necessary; ensuring that we focus on concerns that are identified.
2.3 Developing an integrated approach to quality assurance and improvement across health and social care is outlined as good practice in the Greater Manchester Health and Social Care Quality Improvement Framework and the national strategy document Adult Social Care – Quality Matters.2 The integration of health and adult social care is strongly promoted as a model that reinforces high quality care. The priorities outlined resonate well with our local approach to improvement as part of the Safer Salford programme and elements of the documents link directly to our local processes around quality assurance, measurement and improvement.
3 Process for Development
3.1 The Director of Quality and Innovation and the Assistant Director Integrated Commissioning have worked collaboratively to develop the strategy. This work has included: • SWOT analysis of the current approach to quality and safety
1 The Measurement and Monitoring of Safety; Vincent et al, Health Foundation 2013 2 Adult Social Care Quality Matters; Department of Health & Social Care and Care Quality Commission. July 2017
• Review of relevant national and Greater Manchester documents • Review of the learning from the Safer Salford partnership work • Review of good practice from other areas • Building on the collaborative improvement work undertaken with care homes • Direct discussions with a range of stakeholders
4 Stakeholder Engagement
4.1 The Director of Quality and Innovation was identified as lead author for the document. Early drafts and revisions were developed in conjunction with the Assistant Director – Integrated Commissioning.
4.2 Clinical oversight has been provided by the CCG Medical Director and GP Lead for Quality and Safety who have both helped to shape the strategy. Discussions were held with GP Governing Body representatives to seek out a broader range of views. Handover from hospital back to primary care and issues with medications are two key themes that are consistently raised by member practices in relation to quality and safety. Therefore we expect that that a continued focus on improvement in these areas will be supported by GP colleagues.
4.3 Discussions have been held with CCG and SCC colleagues as part of the business planning process for 2018/19. Early drafts of the document have been reviewed and commented upon by the CCG and SCC leadership teams. Discussions have also been held with the Lead Member for Adult Services, Health and Wellbeing who confirmed her support for the improvement areas identified.
4.4 A citizen’s focus group was held in February where the draft strategy was discussed with a small number of volunteers from the Citizen and Patient Panel. A presentation and workshop session was subsequently held at the Citizen’s Panel event in March with over 100 attendees. At these events members of the public were asked whether they thought that we were focusing on the right areas to try and make improvements in quality and safety and to consider whether there were any specific areas where there were concerns that had not been included.
4.5 Discussions with members of the public confirmed that quality in care homes remained a concern for them and they welcomed the focus on this area. There was support expressed on all round table discussions in relation to improving handover between services and sectors; various examples were highlighted of how the quality of care is compromised when handover and communication is poor. Medicines safety was also recognised as a key issue for most attendees who could relate specific examples of poor quality care in relation to medicines. These themes resonate with feedback that we have gained from other sources for example complaints and incident reporting.
4.6 Other areas that were highlighted by members of the public include access to GP appointments which is being addressed through ongoing work as part of the Salford Standard and access to mental health services which is being picked up through the mental health commissioning strategy.
4.7 Draft versions of the strategy were also shared with the Governing Body Nurse and Secondary Care Clinician on the Governing Body for their feedback.
4.8 The improvement programmes that have been developed to build on the Safer Salford work were discussed with senior leaders from partner organisations as part of the evaluation. Colleagues from SRFT including those leading the ICO, Salford Primary Care Together and Greater Manchester West Mental Health Trust are committed to their continued involved in this work.
4.9 The strategy was presented at the Integrated Commissioning Joint Committee (ICJC) on 9th May and was approved. There was considerable discussion in relation to care homes and the importance of continuing to work on improvement initiatives in this sector.
5 Summary
5.1 A clear commitment to quality and safety is articulated within the locality plan and partners across the system have been engaged in the Safer Salford programme over the past two years. This strategy builds on this work and provides a framework for the CCG and the City Council to continue to drive forwards improvements in quality and safety. A systematic and consistent approach to quality assurance as outlined will enable appropriate oversight and scrutiny of the quality of care provided. This will then inform future improvement projects.
5.2 All stakeholders consulted in the development of this strategy confirm their support for the visions and objectives outlined as well as targeting improvement programmes around: • Quality in care homes • Handover and communication • Medicines safety
6 Recommendations
6.1 Members of NHS Salford Clinical Commissioning Group Governing Body are asked to: • Consider whether the ambitions, objectives and work programmes outlined are consistent with our approach to quality and safety • Approve the 2018/20 Quality and Safety Strategy
Jeremy Tankel Medical Director and Clinical Lead Quality & Safety
Salford Clinical Commissioning Group
Quality and Safety Strategy
2018 – 2020
NHS Salford Clinical Commissioning Group and Salford City Council (Health and Care)
1
Contents
Page
Section 1 Context 2
Section 2 Definition and scope 5
Section 3 Our vision 7
Section 4 Bringing clarity to quality 10
Section 5 Measuring and publishing quality 10
Section 6 Recognisng and rewarding quality 11
Section 7 Maintaining and safeguarding quality 12
Section 8 Building capability 12
Section 9 Staying ahead 13
Section 10 Implementation 13
Section 11 Expected outcomes 15
Section 12 Monitoring and evaluation 16
Section 13 Appendix 1 17
2 12
Section 1 Context
1.1 Introduction
Over the past four years NHS Salford Clinical Commissioning Group (CCG) has had a sustained focus on quality and safety. Their Quality and Safety Strategy was launched in April 2014 and has been refined and developed to take account of local and national changes that impact the health and care economy.
The development of integrated commissioning arrangements for adult services in conjunction with Salford City Council has resulted in an integrated approach to quality assurance and improvement for the services that are in the scope of the pooled budget. As a result of the Greater Manchester Health and Social Care Partnership (GMHSCP) commissioning review, NHS Salford CCG and Salford City Council are working in partnership to further develop our integrated approach to commissioning health and care services for children as well as all age population health services. This will shape our approach to quality and safety as we refine our integrated commissioning plans.
Integrated commissioning arrangements between the CCG and City Council have been in place for mental health and adult social care services for a number years. The approach to quality assurance and improvement that was articulated in the CCG’s 2014/17 strategy has been applied to mental health services which includes regular oversight of quality and performance data, review of patient experience, quality visits, use of commissioning levers to incentivise improvement and involvement of mental health partners in the Safer Salford programme.
The approach to quality assurance and improvement in adult social care has been less well developed with limited information available on the quality of service provision. However, since the inception of the Integrated Care Organisation (ICO) work has been ongoing to develop a suite of quality metrics for adult social care that are now being used for quality assurance. During 2017/18 an integrated approach to the quality of care homes across Salford has been developed using the Care Quality Commission (CQC) ratings as indicators of quality. A strategic oversight group has been established as well as a Quality Improvement Network involving a range of professionals across the health and care system to work with care homes to support improvement. Nine care homes in Salford have been involved in the Safer Salford programme. This collaborative work provides a solid foundation for building a truly integrated approach to quality, ensuring that we commission the best possible services for the people of Salford.
Quality remains an overarching principle of our locality plan and is clearly articulated as a fundamental component of our transformation programmes. Our approach to the measurement and monitoring of safety in conjunction with our partners has resulted in the Safer Salford programme which has underpinned the development of integrated services for adults across the city. We intend to build on this approach in ensuring that we retain a sustained focus on safety improvement as an integral part of this strategy.
1.2 Strategic Developments
The impact of a number of strategic changes that have occurred over the past four years have been considered in the development of the 2018/20 strategy:
Integrated commissioning The move to integrated commissioning arrangements between the CCG and the City Council has meant that this strategy forms part of our joint plans around quality and safety. In the first instance it
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will be used to underpin the joint commissioning arrangements that we already have for adult health and care services. We will work together during 2018/19 to identify an integrated approach to the quality and safety of children’s services and those commissioned by Public Health.
Primary Care The shift of commissioning responsibility from NHS England to the CCG in 2016/17 changed the emphasis of our approach to quality assurance of GP practices. We have now adopted the same approach to quality assurance of GP practices that we had for other providers. This is evident through the governance structures that we have created through the Primary Care Quality Group which reports to our Primary Care Commissioning Committee. While we now have better oversight of quality indicators in GP practices we intend to develop more robust process for earlier identification of concerns and mechanisms to secure improvement.
Greater Manchester Health and Social Care Partnership (GMHSCP) The GMHSCP Quality Improvement Framework was approved in September 2017 and reinforces an integrated approach to quality improvement across health and social care. Key components of the framework include:
Development of a common framework for understanding quality and safety Consistent use of quality improvement methodology to drive change System-wide approach to quality improvement across organisations Creating a system of shared leadership and responsibility Creating “communities of practice” to lead change Measurement and monitoring of quality and safety indicators Refining financial incentives to improve quality Use of research and innovation to improve quality
These components have been considered and incorporated into the development of the intentions outlined within this strategy.
Quality in Adult Social Care A national quality strategy for adult social care1 was published in August 2017, developed and endorsed by representatives from organisations including service users, carers, commissioners, providers and regulators. The document sets out clear principles and priorities that all stakeholders can use to drive quality improvement in adult social care.
This strategy is helpful in clearly articulating the role of commissioners in relation to quality:
Commissioners should recognise their role in commissioning for quality and be able to easily understand national guidelines, policy and priorities and how they can make best use of those tools to maintain and improve the quality of care they commission.
Commissioners should ensure:
People and communities are at the heart of what they do Commissioning is outcomes-based and focusses on outcomes that matter most to people They work with people and communities as equal partners and decision makers They commission high quality care through services that are safe, effective, caring, responsive and well-led
1 Adult Social Care - Quality Matters: July 2017, www.gov.uk/government/publications. 4 23
They are trained and sufficiently knowledgeable to work with providers and partners as equals to promote quality. They commission for quality and procure in a way that is effective, efficient and economic A coherent system of assurance, measurement and regulation and they are able to align their own quality assurance mechanisms with the wider system That assessors advise people how to access information about quality and what to expect They do not fund new services or placements that have been identified as inadequate or failing to meet people’s needs. Where such services are already funded they are reviewed and no further placements made The importance of commissioning for social value is recognised and embedded into commissioning Services are commissioned for quality and improvement and the cost of quality is recognised.
This document acknowledges the role of strategic commissioning in terms of commissioning services that meet the needs of a population, as well as commissioning packages of care for individuals. The CCG and the City Council currently undertake both of these functions therefore it is helpful to see both elements considered and included. It is our intention to review how well these principles are embedded in our current plans during this year.
This document also reinforces a ‘single shared view of quality’ across health and social care and the principles that are outlined align with the National Quality Board’s strategy.
National Quality Board (NQB) During 2016 a National Quality Board was established to provide co-ordinated leadership for quality and included representatives from:
Care Quality Commission (CQC) NHS England NHS Improvement Public Health England National Institute for Health and Care Excellence (NICE) Health Education England
The NQB aligns well with developments across Greater Manchester in promoting an integrated approach to quality across health and social care, involving a wide range of partner organisations. In December 2016 the NQB published a Shared commitment to quality.2 This document outlines the importance of supporting health and care systems to be focused on shared learning and improvement at all levels. The single shared view of quality promoted within this document has been incorporated into the GMHSCP Quality Improvement Framework and Quality in Adult Social Care; therefore we have used this as a basis for the development of this strategy.
The commitment and principles outlined within all three documents resonate well with the approach that we have taken to quality and safety over the past four years. We have reflected on the success and learning from the implementation of the CCG’s existing strategy and have incorporated this into our future plans. The reflection undertaken is included as a SWOT analysis in Appendix 1.
2 Shared commitment to quality: National Quality Board, December 2016; NHS England Gateway Ref: 05691 5 42
Section 2 Definition and scope
2.1 A Single Shared View of Quality
The model outlined by the NQB provides the foundation for our local strategy:
High Quality Person Centred Care - means that the person using health and care services is at the centre in the way that care is planned and delivered. Care is based around their individual needs, preferences and priorities. We intend to ensure that providers can effectively demonstrate person-centred care planning through our routine quality assurance monitoring.
This is especially important when individuals have complex needs and require long term health and social care. Where we are responsible for commissioning individual packages of care we will ensure that these are commissioned as close to home as possible, are regularly reviewed and that the quality of provision is maintained.
The use of personal health budgets for individuals in receipt of health and social care is one way of promoting personalisation. We will explore how opportunities to access these budgets can be maximised for individuals where appropriate.
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2.2 Seven Steps to Improving Quality
The steps outlined below in conjunction with our SWOT analysis (appendix 1) have been used as the basis for articulating our strategy and clarifying our priorities for the next two years:
Setting clear direction and priorities
Bringing clarity to quality
Measuring and publishing quality
Recognising and rewarding quality
Maintaining and safeguarding quality
Building capability
Staying ahead
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Section 3 Our vision
3.1 In terms of articulating our vision around quality and safety, we have amended our current ambition to reflect the integrated system.
In terms of our vision around quality and safety we aim to be: The safest health and social care system in the country
We recognise that it has proved almost impossible to demonstrate being “the safest” as benchmarking data is very limited in many parts of our system. However we intend to continue to actively promote a shared culture of safety improvement and develop programmes that measure progress to demonstrate a system that is becoming safer.
3.2 Our objectives
We have built upon the objectives that were outlined within the CCG’s 2014/17 strategy and amended them to incorporate an integrated approach to health and social care; as well as articulating the link between quality and outcomes.
1. Engage with all sections of our population to encourage their involvement in improving the quality of care provided. Actively seeking feedback on their experiences of health and social care, using this information to improve services. 2. Work with all our providers to ensure that they deliver safe, effective, accessible, person centred services; minimising variation and secure continuous improvement. 3. Commission services that are outcomes focused, based on the best available evidence; to address the health and social care needs of the Salford population 4. Foster a system-wide culture that promotes safety and safety improvement
3.3 Safety improvement
In developing our approach to safety improvement through the Safer Salford programme we have maintained a focus on handover and communication. People who use services as well as staff working within the Salford system have confirmed that they identify handover as an area where things often go wrong. The biggest single factor identified in analysing incidents where harm occurs, relates to poor communication and this is often a key feature in complaints about poor quality care. In developing a system that integrates health and social care provision we should continue to strive to improve handover and communication.
Our priorities for safety improvement will remain as:
1. Improving handover 2. Improving communication 3. Improving medicines safety
Specific improvement programmes are already being implemented in these areas and we will continue to focus on them. The principles of good communication, safe handover and medication
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safety will underpin our commissioning plans and we expect to see that they are considered in service reviews, pathway development and embedded in our transformation programmes.
Our quality assurance visits will pay particular attention to seeking out the views of service users and staff as to how these principles are embedded locally.
In addition to these overarching priorities we are keen to establish system wide improvement plans to address nationally recognised safety issues. The early identification and appropriate management of sepsis has been highlighted as a safety concern nationally for some time. We intend to focus on this area as part of the Safer Salford programme 2018/20.
3.4 Improving medicines safety
Medicines are the most widely used intervention in health. Research evidence shows that medication errors and adverse drug reactions are common at all stages of the medicines use process.They are associated with a high cost in terms of patient outcomes as well as financial consequences due to additional treatment or litigation. This too is an area where members of the public and staff across all sectors readily provide examples of harm due the prescription, dispensing or administration of medicines. Recognising this, we have identified the use of medicines within the health and social care economy as a key area for improvement.
The CCG Medicines Optimisation team will each year develop and deliver a medicines optimisation quality and safety programme which will be approved by the CCG Quality commissioning committee.During 2018-2020 this will focus on:
Improving medication safety within an integrated system aligning systems, processes and learning Responding to the World Health Organisation’s ( WHO) Third Global Patient Safety Challenge; Medication Without Harm Implementing the recommendations in the Department of Health and Social Care document reducing medication-related harm Improving medication safety in primary care Improve medicines management in Salford care homes Continue the work that has been started with Salford Royal Foundation Trust on medicines related admissions
There will also be ongoing reactive work to deliver assurance against Central Alerting System (CAS) alerts that require action by primary care or secondary care providers.
3.5 Safeguarding Children and Adults at Risk
Safeguarding children and adults at risk is a priority for the CCG and the City Council; both organisations have statutory safeguarding responsibilities and are a key component of the quality agenda. Both organisations are committed to the work of Salford Safeguarding Boards. We will continue to work collaboratively with other partners in the city to support the implementation of the strategic priorities of both our organisations and the safeguarding boards.
The strategy reflects our commitment to the continuous improvement of safeguarding across the health and social care economy. Working with partner agencies we will ensure that a collaborative approach is adopted which influences safeguarding culture and practice to improve outcomes for children and adults at risk.
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Priorities
The safeguarding teams will develop and deliver an annual safeguarding and quality programme. During 2018-2020 this will focus on:
Defining and developing integrated safeguarding assurance processes in line with the annual contractual audit standards. Continuing to discharge statutory organisational safeguarding responsibilities Continuing to discharge statutory safeguarding responsibilities on behalf of the Safeguarding Boards. Aligning our work programmes with the priorities of the safeguarding boards which include: . Tackling domestic abuse . Early help . Neglect . Complex safeguarding . Making Safeguarding Personal Continuing to develop and strengthen statutory arrangements for Looked after Children in Salford Ensure compliance with the Prevent Duty Support compliance with the Mental Capacity Act across the Salford health and care economy. Establish effective safeguarding arrangements with GMHSCP and fulfil key priority and statutory requirements.
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Section 4 Bringing clarity to quality
4.1 Salford performs relatively well against the NHS constitutional standards and where performance falls below what is expected we work with providers to try and secure improvement. Nationally agreed standards in relation to community and adult social care services are limited and the quality of service provision is less clear.
The key lines of enquiry within the CQC inspections do however provide a baseline overview of the quality care. The CQC rating for our main acute and community provider is ‘outstanding;’ our local Mental Health provider is rated as ‘good’, the ratings for Salford GP practices are mainly ‘good’ whereas over a third of care homes are rated as ‘requires improvement’ or ‘inadequate’.
4.2 Where there are limitations in terms of nationally mandated standards we have developed a locally agreed process for example the Salford Standard for GP practices which articulates our expectations in terms of the quality of care across a range of indicators. We intend to evaluate these standards in 2018/19 using this information to refine and develop the standards for 2019/20
4.3 We have also worked closely with colleagues within the Integrated Care Organisation to develop local quality measures for adult social care which are currently being piloted. This set of metrics is unique and means that in Salford we will have a much better understanding of quality in this sector, with a transparent and evidence based approach to the current delivery and future commissioning of adult social care services.
4.4 While there are national guidelines and standards relating to medicines; through our medicines safety work we have identified that the standards are not uniformly applied across the health and care system. It is our intention to develop a city-wide medicines strategy that seeks to address this variation.
Section 5 Measuring and publishing quality
5.1 We have developed a robust quality assurance framework that has been used successfully with our main healthcare providers. This has been adapted over the past 12 months to facilitate a systematic approach to quality assurance of GP practices. The principles that underpin the framework are equally applicable to adult social care providers as well as providers from other sectors. We intend to continue to use this four stage approach to apply rigour and consistency in our quality assurance processes.
5.2 Regular quality and performance reports are received at the CCG’s Governing Body meetings that highlight a range of information on the quality of services. Where concerns are identified, information is included on actions being taken to secure improvement. Quality and performance reports to Primary Care Commissioning Committee and the Integrated Care Joint Commissioning Committee are less well developed which reflects the maturity of the measurement and assurance processes that are in place. We intend to refine and develop these reporting processes over the next 12 months to ensure transparency in the publication of quality related information.
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5.3 As part of the Safer Salford programme we have promoted the principles outlined in the Measurement and Monitoring of Safety Framework3. This encourages the use of predictive data and analysis to identify the potential for harm, enabling mitigating actions to be put in place. We have developed the Safer Salford dashboard to measure safety improvement in relation to falls and medicines. We intend to build on this work over the next two years so that measures of safety improvement are routinely used as part of our integrated systems across Salford.
Section 6 Recognising and rewarding quality
6.1 A key element of our improvement work over the past three years has been focused on shared learning and the dissemination of good practice. This has largely been in relation to specific topic areas and among staff that are involved in improvement programmes. We will maintain an emphasis on shared learning and promoting best practice across the health and social care system in Salford and with partners in Greater Manchester.
6.2 Over the past three years we have used local incentives for example the Commissioning for Quality Innovation (CQUIN) payments to drive improvement. The CQUIN schemes have been targeted specifically to address quality issues that have been identified through our quality assurance processes. During the next two years we intend to refine and further develop our incentive payments across health and social care pathways, enabling care to be delivered in the most appropriate setting.
6.3 The Salford Standard for GP practices is an excellent example of how we can use commissioning incentives to drive quality improvement. We will explore the opportunity to develop a Salford Standard for care homes that utilises the same principles as a means of securing quality improvement in this sector.
3 The Measurement and Monitoring of Safety, April 2013, Charles Vincent et al. The Health Foundation. 12 112
Section 7 Maintaining and safeguarding quality
7.1 A key component of this principle outlines the need for professionals and sectors to work together to protect people using services from harm. This reinforces the collaborative approach to safety and safety improvement that we have adopted locally through our Safer Salford programme. We have incorporated the learning from the evaluation of this programme into our safety improvement plans for the next two years. The areas that we intend to develop further are:
Continue to progress the Safer Handover programme to improve the transfer of care between GPs and hospital consultants. Build on the Safer Care Homes programme to support targeted improvement work within the care homes sector; linking this to the areas of improvement highlighted within CQC reports. Introduce an improvement programme to focus on Safer Handover between hospital and care homes Refine and develop the Safer Leadership programme to expose a wider range of system leaders to the principles of the Vincent Framework.
7.2 The need to ensure that feedback from service users is considered and used to improve services is highlighted within this principle. Over the past two years the CCG and City Council have developed an integrated approach to citizen engagement which has enabled the views of Salford citizens to be incorporated into our plans. We intend to continue to build on this work moving forwards.
Ensuring that our providers seek out the views of people using services and have plans in place to act on feedback to make improvements is a key element of the CCG’s patient experience strategy. We will continue to review service user feedback mechanisms and work in partnership with our providers and Healthwatch to progress this area of work. Patient stories have become a regular feature of our governance meetings and will continue to be utilised to reinforce the importance of hearing about services through the words of people that have used them.
Section 8 Building capability
8.1 Salford’s locality plan outlines a shared commitment to quality and clearly articulates our ambition to secure safe, high quality health and social care services. We recognise the need to ensure that our integrated system can demonstrate safety improvement in terms of handover, communication and medicines.
8.2 Executive leaders across the system have demonstrated their support to this aim through their involvement in the Safer Salford programme. We have begun to build and embed a consistent culture around safety in Salford and supported a cohort of system leaders through a development programme to foster a shared understanding of quality and safety. We will build on this firm foundation over the next two years extending the numbers of staff that are involved in quality and safety improvement programmes.
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Section 9 Staying ahead
9.1 The use of research and innovation to support improvements in the quality of care is clearly evidenced. Innovation and research is a component of Salford’s locality plan and we are already implementing a research and innovation strategy.
9.2 NHS Salford CCG’s innovation fund has been used to support quality improvement in a wide range of services. Good links between the CCG and Salford City Council are already in place to facilitate an integrated approach to innovation and research; we intend to develop these further to support the implementation of the locality plan.
9.3 Our approach in using innovation to test improvements in quality and safety to date has been rather ad-hoc as ideas have been generated. We intend to adopt a more targeted approach to using innovation to support quality improvement over the next two years and better align the two strategies. We also intend to align our approach to innovation to support improvement in population health; targeting improvement programmes to address the health inequalities that we know exist across the city.
9.4 Salford’s integrated approach to quality and safety makes us uniquely placed to be generating ideas for areas of research. We intend to make better use of our relationships with Health Innovation Manchester and academic institutions to assist us in generating evidence to support the commissioning of quality services.
Section 10 Implementation
10.1 Much of the work around quality assurance is now embedded within our governance processes and is seen as “business as usual”. We will continue to review and refine these processes to ensure that we retain oversight of the quality and safety of the services that we commission. This includes ensuring that services user feedback is incorporated into our analysis and routinely considered in any commissioning decisions.
10.2 The following high level intentions in relation to quality improvement have been identified as our key priorities for the next two years. Detailed plans and agreed actions that underpin them for 2018/19 have been developed as part of our business planning process. This process will be repeated for 2019/20 to ensure that progress continues to be made in all areas.
1. Develop a standardised approach to medicines across Salford 2. Improve handover between GPs and hospital consultants 3. Improve handover between hospital and care homes 4. Improve the quality of care delivered to residents in Salford care homes 5. Develop financial incentives to drive up quality and deliver agreed outcomes 6. Minimise the variation in care delivered by GP practices across Salford 7. Continue to support the development of a consistent safety culture 8. Develop an integrated approach to quality assurance and improvement for children’s services and public health
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9. Develop an annual safeguarding and quality programme that reflects the priorities identified by Salford’s Safeguarding Boards. 10. Use research and innovation to support improvements in quality
10.3 Oversight of the plans will be monitored along with other objectives and work programmes and regularly reported through our internal governance structures.
10.4 Finance
The CCG has set aside £350k recurrent funding to implement the quality improvement elements of this strategy. This funding is in addition to other funding streams that already exist in the system, such as the innovation fund, Salford Standard for primary care and CQUIN payments to NHS provider organisations.
This £350k will be targeted at the 2018/19 priority areas, namely:
Safer Salford initiatives including £250k non recurrent in 2018/19. This funding Care Homes Excellence will be used in year one to support and evaluate Safer handover projects the Safer Salford programme* Leadership Targeted quality improvement work in nursing £50k to recruit a nursing post to provide ongoing homes to work alongside existing dedicated support pharmacist Training and development of relevant staff £50k
*Safer Salford improvement programme – priorities will be agreed on an annual basis
In addition to the above, the CCG has set aside funding to develop an outcomes and incentive payment approach for provider organisations. Some of this funding will be used to target a different approach to engage with Care Homes and reward them for improvements against specific quality improvement measures in 2018/19
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Section 11 Expected outcomes
11.1 Each of the intentions outlined above is underpinned by action plans and measurable benefits have been incorporated. In terms of the outcomes that we expect to see as a result of the implementation of this strategy, they include:
Reduction in gram negative blood stream infections Reduction in inappropriate antibiotic prescribing Reliable implementation of the toolkit Stopping Over-medication of people with Learning Difficulties Reduction in harm related to omissions or delays when care is handed over from hospital to GP or vice versa Fewer incidents reported in relation to omissions or delays in care for service users when care is handed over from one sector to another Improved service user experience when their care is transferred from hospital to GP or vice versa Fewer readmissions from care homes to hospital Fewer incidents reported by care homes in relation to problems experienced when care of their residents is resumed following a stay in hospital Improvement in quality measures for Salford care homes including CQC ratings and other locally defined measures Improvements in reported experience from service users and their families in relation to the quality of care in Salford care homes Salford Standards for GP practices being achieved across neighbourhoods Contracts with providers are based on the achievement of agreed outcomes and standards that are routinely measured Quality and Safety strategy is included as part of further integration between NHS Salford CCG and Salford City Council Safety is routinely discussed and considered as part of governance processes within providers and by commissioners Evidence that research studies and innovation are being used to drive improvements in quality and safety Evidence that health and care services in Salford are becoming safer Measurable improvements in measures related to the recognition and management of sepsis Good or outstanding CQC ratings for the majority of health and social care providers in Salford
11.2 Work is already underway to develop these anticipated outcomes into a dashboard so that improvement can be tracked. For some measures baseline data is limited and relies on incidents or issues being reported. Where specific improvement programmes are being implemented measures will be identified at the outset.
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Section 12 Monitoring and evaluation
12.1 Quality is everybody’s business and this strategy outlines a wide ranging programme that underpins the work of teams across both organisations. Actions and measurable outcomes have been included into the business planning process for 2018/19 and will be incorporated into the 2019/20 planning process.
12.2 Progress will be monitored regularly through the year as part of our established governance structures. Regular reports on various aspects relating to quality, safety and patient experience will be received at Quality Commissioning Committee and the Integrated Commissioning Joint Committee (ICJC).
12.3 Annual reports in relation to the following areas will include information that outlines achievements in the implementation of this strategy:
Safeguarding Children Looked After Children Safeguarding Adults Medicines Optimisation Research and Innovation Continuing Health Care (CHC)
12.4 In addition to the information included in these reports, a summary of the quality improvement activity that includes the benefits realised will be collated at the end of each year.
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Section 13 Appendix 1
SWOT Analysis of the effectiveness and impact of the CCG’s Quality & Safety Strategy 2014-17
Strengths Weaknesses
Sustained focus on quality & safety Limited focus on quality assurance of GPs Robust governance arrangements implemented Limited oversight and influence over Care Homes Dedicated team to support sector Systematic Quality Assurance framework developed Current CQC ratings of Care Homes sector in Salford Evidence of quality improvements Limited availability of benchmarking data for some Built QI capability in some GP practices and within services the CCG Paucity of data to monitor social care providers Commitment to the Safer Salford programme across system Limited partnership with Oaklands as a significant local provider Salford Standard developed CQC rating of Oaklands Used contractual levers (CQUIN’s) to drive improvement Safer Salford programme based on evidence from hospital sector – some elements may not easily Built relationships between GPs and consultants transfer to other sectors Safeguarding – meeting all standards within Lack of robust baseline measures across all sectors Assurance & Accountability framework with clear aims for sustainability and improvement Systems & tools to support GP practices (Datix, Safer Salford programme does not extend to all Dashboard) providers Listened to patient voice (patient stories) Limited use of soft intelligence Effective partnership with SRFT to enable scrutiny Inconsistent approach to quality assurance of health Collaborative safeguarding arrangements with and social care providers partners
Opportunities Threats
Appointment of new QA post for primary care Fragility of Care Home and domiciliary care sector ICJC arrangements create greater opportunity for a Rising and sustained demand for health care collaborative approach across a broader range of services threatens the ability of clinicians to free up providers capacity to focus on improvement Pooled budget gives greater flexibility to drive Excessive demand threatens the quality and safety15 improvements of provision Links made with national safety experts through Approach to quality improvement with GPs over the Safer Salford programme could enable innovative past 3 years may have contributed to further approaches to safety work variation Use of innovation monies to test safety improvement Inability to influence improvements in quality and Further development of GP ↔ consultant safety in some services/sectors relationships through Clinical Standards Board and Early warning of concerns may not be identified Safer Handover work which could then lead to quality and safety of care Research & Innovation Strategy to support evidence being compromised base Some providers may not be capable of securing Maximise links with AHSN to support innovation necessary improvement Develop better links with the Patient Safety Translational Research Centre which is based in Salford
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NHS SALFORD CLINICAL COMMISSIONING GROUP GOVERNING BODY MEETING AGENDA ITEM No 5 (b)
Item for: Decision/Assurance/Information
23 May 2018 Anthony Hassall REPORT OF: Chief Accountable Officer
DATE OF PAPER: 10 May 2018
Integrated Commissioning with Salford City SUBJECT: Council
Hannah Dobrowolska IN CASE OF QUERY Director of Corporate Services PLEASE CONTACT: [email protected] 0161 212 4830
Please tick which strategic priorities the paper relates to: STRATEGIC PRIORITIES:
Quality
Community Based Care
Integrated Care
In Hospital Care
Long Term Conditions and Mental Health
Effective Organisation
PURPOSE OF PAPER:
This paper outlines agreement in principle given by NHS Salford CCG (Part 2 Governing Body on 21 March 2018) and Salford City Council (Cabinet on 27 March 2018) to increase integrated commissioning for health and social care, covering adult, children, public health and primary care services. It details the benefits and risks associated with such change, and outlines the options considered including high level financial and governance implications. The majority of this paper is a shared paper between the CCG and Salford City Council.
The purpose of this paper is to: - Bring into the public domain the Governing Body (part 2) decision made in March 2018 to support the recommendations outlined which agree in principle to greater integrated commissioning with Salford City Council from April 2019, subject to specific implementation detail being agreed through 2018/19.
Further explanatory information required
HOW WILL THIS BENEFIT THE This is outlined in this paper, including through HEALTH AND WELL BEING OF appended case studies which are written in SALFORD RESIDENTS OR THE more publically accessible format. CLINICAL COMMISSIONING GROUP?
WHAT RISKS MAY ARISE AS A Risks and mitigating actions are identified in RESULT OF THIS PAPER? HOW CAN this paper. THEY BE MITIGATED?
WHAT EQUALITY-RELATED RISKS These will be reviewed prior to any decisions MAY ARISE AS A RESULT OF THIS being made. PAPER? HOW WILL THESE BE MITIGATED?
DOES THIS PAPER HELP ADDRESS No not any specific current risks, however if ANY EXISTING HIGH RISKS FACING these significant changes take place, the CCG THE ORGANISATION? IF SO WHAT and Salford City Council will be in an improved ARE THEY AND HOW DOES THIS position to address a range of risks. PAPER REDUCE THEM?
PLEASE DESCRIBE ANY POSSIBLE As a result of greater integrated commissioning, CONFLICTS OF INTEREST the role of Governing Body members, Executive ASSOCIATED WITH THIS PAPER. Team members and wider CCG staff are expected to change. The detail of this is not yet known.
PLEASE IDENTIFY ANY CURRENT As a result of greater integrated commissioning, SERVICES OR ROLES THAT MAY BE the role of Governing Body members, Executive AFFECTED BY ISSUES WITHIN THIS Team members and wider CCG staff are PAPER: expected to change. The detail of this is not yet known however staff will be engaged in any changes.
Footnote:
Members of NHS Salford Clinical Commissioning Group Governing Body will read all papers thoroughly. Once papers are distributed no amendments are possible.
Document Development
Not Comments and Date Process Yes No Outcome Applicable (i.e. presentation, verbal, actual report) Public Engagement This will be undertaken as further detail is drawn up, (Please detail the method ie survey, event, consultation) with this topic being covered at the Patient Panel Event in the summer of 2018. Clinical Engagement The CCG Chair and Medical Director (both GPs) are (Please detail the method ie survey, event, consultation) involved in the Reference Group guiding this work. Has ‘due regard’ been given to Equality This will be undertaken as proposals are drawn up. Analysis (EA) of any adverse impacts? (Please detail outcomes, including risks and how these will be managed) Initial legal advice has been sought and discussions Legal Advice Sought commenced, as outlined in the paper. Further advice will be obtained as proposals are drawn up. Presented to the Commissioning Committee Presented to the Health and Wellbeing Board Presented to the Integrated Commissioning Joint Committee Presented to any other groups or committees, The Executive Team have commented on this paper including Partnership Groups and an informal briefing was provided to the Governing (Please specify in comments) Body in February 2018.
Note: Please ensure that it is clear in the comments and date column how and when particular stakeholders were involved in this work and ensure there is clarity in the outcome column showing what the key message or decision was from that group and whether amendments were requested about a particular part of the work.
Integrated Commissioning with Salford City Council
1 Executive Summary
This paper outlines agreement in principle given by NHS Salford CCG (Part 2 Governing Body on 21 March 2018) and Salford City Council (Cabinet on 27 March 2018) to increase integrated commissioning for health and social care, covering adult, children, public health and primary care services. It details the benefits and risks associated with such change, and outlines the options considered including high level financial and governance implications. The majority of this paper is a shared paper between the CCG and Salford City Council.
The purpose of this paper is to: - Bring into the public domain the Governing Body (part 2) decision made in March 2018 to support the recommendations outlined which agree in principle to greater integrated commissioning with Salford City Council from April 2019, subject to specific implementation detail being agreed through 2018/19.
2. Details to note
2.1 Decision paper
2.1.1 Attached as attachment 1 is a shared decision paper regarding this matter between Salford City Council and NHS Salford CCG. This paper was presented to the CCG’s Governing Body on 21 March 2018 (part 2, in private) and Salford City Council’s Cabinet on 27 March 2018 (public meeting with papers issued publicly on 20 March 2018). This is a significant decision and as such Salford City Council Cabinet will recommend agreement to the recommendations to a full Salford Council meeting in due course.
2.1.2 The recommendations agreed by the CCG’s Governing Body in March were adapted in this cover paper to be relevant to the CCG. Governing Body members were also asked to consider the information in this cover paper, which was not included in the shared paper. This information focuses on the risks associated with this decision and how we plan to manage these risks as we develop the detail associated with the proposals through 2018/19. This information was particularly requested by Governing Body members in discussion at January’s Governing Body part 2 meeting and February’s informal Governing Body meeting.
2.2 Risks
2.2.1 There remain a number of risks that need to be considered in greater detail before a final decision is made in relation to greater integrated commissioning of health and social care in Salford. In March a decision in principle was made. On the basis of information currently known, we do not currently believe any of these areas of risk are sufficient to prevent us entering into greater integrated commissioning arrangements, as mitigating actions can be taken to manage the level of risk involved. In summary these fall into the following five areas.
2.2.2 Ability to fulfil statutory responsibilities
The CCG, as well as Salford City Council, has a range of duties, functions and requirements that it must fulfil. For the CCG our statutory or legal obligations are largely outlined in our Constitution, in addition we have requirements set by NHS England. The ultimate responsibility for these sits with the CCG’s Accountable Officer, though our Constitution, through our scheme of delegation, outlines where specific responsibility for various duties or other matters sits e.g. with which committee or individual role. Similarly Salford City Council has statutory duties and responsibilities, in particular held by lead members, the Director of People’s Services (who holds the role of both Director of Children’s Services (DCS) and Director of Adult Social Services (DASS)) and the Director of Public Health. Similarly their local arrangements are outlined in their Constitution.
To manage the risk that either organisation will not continue to fulfil their statutory or other duties and responsibilities, we have already engaged legal advice to the CCG, and Salford City Council have their own legal advice. We have also established a Governance Working Group, with membership from the CCG and Salford City Council. This group will ensure that governance arrangements are developed based on clear legal advice, though also on the practical level, to be as streamlined and simple as is possible. We recognise that we are going further than many other areas in integrated commissioning, with a desire to include responsibilities that can be combined into a formal pooled budget, but also wider matters where this is not legally possible, hence our use of the term “Integrated Funds”.
Our legal advice to date indicates that what we are trying to achieve, i.e. maximum shared decision making across the totality of the health and social care commissioning responsibilities, is possible. Together we are exploring a range of options to achieve this from a governance perspective, that will be both legal and pragmatic. We hope to have a draft Governance Framework available for comment early in the summer, with formal approval in late summer by the CCG’s Governing Body and Salford City Council’s Cabinet. Our aim is to establish shadow arrangements in the autumn to test our approach prior to these arrangements becoming formal on 1 April 2019.
2.2.3 Deficit position of budgets
The shared paper as part of this item, provides a clear outline of the predicted financial positions of both the CCG and Salford City Council in 2021/22. Based on a range of assumptions, the position is provided in a “do nothing” scenario as well as in two scenarios of integrated commissioning, which relate to the options which have been considered in most detail. In all scenarios there is a need to make £15.6m savings on a recurrent basis by 2021/22 across health and social care commissioning. This is a significant challenge.
Currently the responsibility for these savings lies largely with Salford City Council, except in relation to the existing adults pooled arrangements, where the risk share arrangements mean that the risk is shared between the CCG and Council based on the proportion of our contributions to the pool. Currently this is 70.9% to the CCG and 29.1% to the council.
There are a range of measures that will be considered to manage the risk of this deficit, which is based on the difference between our predicted funding and spending
positions across health and social care commissioning. In particular this will be through the development of our formal risk share agreement. The current risk share agreement for the existing adult pool provides a strong base for this, however this is in the context of the CCG having funds outside the pool which can be used to fund overspends within the pool. The future proposals for greater integrated commissioning include all CCG commissioning spend. At present, within these options, the CCG has kept some elements of its total allocation outside of the integrated funds, namely the contingency reserves. Similarly the council has not included any of its reserves within the integrated fund options. Thought will also need to be given as to how the position is managed in which expected savings are not achieved, creating additional pressures on the integrated funds. This will be detailed in the risk share agreement developed. We expect this to be developed in the summer of 2018 and agreed in the autumn by the CCG’s Governing Body and Salford City Council’s Cabinet.
The other area of work that will take place throughout 2018/19 will be to develop clear plans for the shared use of the integrated commissioning funds, based on Salford’s Locality Plan ambitions. These plans will detail the actions needed to reduce the predicted spend by 2021/22 of £15.6m to achieve a balanced financial plan prior to the integrated commissioning arrangements commencing in April 2019. Realistically, we will outline plans to deliver a balanced financial plan for 2019/20 within these timescales and an approach to collectively identify areas where we can make efficiencies in future years to ensure a balanced financial position by 2021/22. This service and financial plan will be formally approved by the CCG’s Governing Body and Salford City Council’s Cabinet in early 2019. This is similar in approach to our preparations for the current adults pooled budget and previous older people’s pooled budget.
We recognise that greater integrated commissioning moves significant financial risk from Salford City Council to Salford CCG, this is detailed in the shared paper. In summary in the “do nothing” option the CCG has a £2.8m financial risk, in “option 5: 3 integrated funds” this increases to £7.3m and in “option 6: single integrated fund” increases further to £11.1m. It should be noted that this is the worst case risk – i.e. the financial risk if the interventions or schemes we identify to make financial efficiencies are unsuccessful, then the integrated fund will overspend. This overspend is shared back to the CCG and Council. Outlined above are the ways we will manage this risk, however this risk cannot be removed entirely. Importantly, we believe that the benefits to the people of Salford outweigh this financial risk to the CCG as an organisation. It will be better for the people of Salford and the health and care system to make the necessary savings from a bigger integrated fund, than from the smaller Salford City Council spend or integrated funds. Whilst in the different scenarios the value of the financial risk increases for the CCG, the size (percentage) of the saving required across the relevant fund decreases, from the largest percentage savings required in the “do nothing” scenario being 16.7% for public health and 10.6% for children’s, the largest percentage saving required in “option 5: 3 integrated funds” scenario being 8.4% for children’s and under “option 6: single integrated fund” this sits at 2.6% across the full fund. It is clearly more realistic to make a smaller percentage saving, which will be less likely to have such significant impacts on front line services. The bottom line is the same under all options there is a £15.6m financial challenge across health, social care and public health.
Importantly we must finally recognise that if cost saving decisions are made by Salford City Council alone, as is currently the case for services not in the adults
pooled budget, they will inevitably impact upon services commissioned by the CCG and likely create additional demand on NHS services. So savings made in isolation by one organisation are less likely to be true savings across the system. Without integrated commissioning the CCG will have limited influence over such saving plans.
For all the reasons outlined above, although the same financial savings will need to be made with or without integrated commissioning, we expect integrated commissioning decisions to have less impact on front line services.
2.2.4 Management of new areas of risk
In addition to the risk outlined above in relation to the existing deficit position of the integrated funds, it might be that there are new areas of financial risk. For example additional spending requirements, perhaps relating to new technologies, increased unanticipated demand for existing services or a national, Greater Manchester or local requirement to deliver a new service or service standard. Similarly there could be reductions in our expected income, due to national policy or local events.
The approach to managing these risks will be similar to the actions outlined in 2.2.3. Namely through having a financial risk share in place and making shared decisions regarding cost savings. The strong relationships that are already in place between Salford City Council and Salford CCG will be further developed to help manage such challenges. These relationships will ensure we jointly own any financial risks arising and find joint solutions to minimise the impact on front line services and the people of Salford.
In addition to financial risks, other risks may arise. A clear risk management strategy and approach, including clear processes and procedures will be agreed. This will ensure all risks are actively managed in the best possible way to minimise the impact on front line services and the people of Salford.
2.2.5 Bringing together of cultures
The NHS and local government cultures have a number of significant differences, these stem from a range of factors including history and Politics, they are influenced by both the national and local context. In order for greater integrated commissioning to be as effective as possible, it is important that at both the leadership and staff level consideration is given to these cultural differences and building relationships to overcome any potential associated difficulties which could pose a risk to effective joint decision making.
To minimise this risk, discussion has already commenced between the organisational development (OD) leads within the CCG and Salford City Council. A programme for leaders and staff will be developed to help understand any cultural differences and associated behaviours, with the aim of, over time, building a new shared culture that takes the best from each individual organisation. There is learning in this area at a leadership level from the OD undertaken when the Integrated Adult Health and Social Care Commissioning Joint Committee (ICJC) was established, and at a staff level from the OD undertaken as part of the establishment of the Integrated Care Organisation. Both of these programmes were commissioned from external providers, however the skills base and experience within the internal teams is now greater, providing us with a range of options in this area.
Leaders from both organisations have discussed the matter of culture and its importance and are committed to providing support to actively addressing any matters that could give rise to friction to positive working relationships.
2.2.6 Distraction from delivery of the CCG’s operational plan during implementation of changes
In a significant change programme, such as the move to integrated commissioning between the CCG and Salford City Council, there will inevitably be some level of uncertainty for staff and work to undertake to implement the change. There is a risk that this will distract staff from a focus on delivering organisational objectives during this period. This risk cannot be entirely avoided, and indeed, given that we believe that this change will put us in a better combined position to deliver against the Locality Plan ambitions, this work is part of delivering our objectives, rather than additional to it.
Nonetheless we will seek to minimise this risk in a number of ways to ensure we continue to deliver wider objectives which benefit local services and people. Firstly the requirements associated with implementing these changes are being incorporated into the CCG operational plan and individual staff objectives for 2018/19. This will ensure that this work is prioritised alongside a range of other programmes, and any concerns relating to capacity will be highlighted. Secondly we have already begun to develop a communication and organisational development (OD) plan to support these changes. This will ensure that staff are fully informed about all aspects of the move towards greater integrated commissioning and engaged in these changes, as outlined in 2.2.5. Thirdly we have dedicated specific staff capacity to support this programme in relation to programme management at administrative, tactical and strategic level within the CCG.
3. Recommendations
3.1 Governing Body is asked to note in this public part of the Governing Body meeting May 2018, the approval of the recommendations below which was given in the part 2 (private part of the) Governing Body meeting, in March 2018:
• noted the significant benefits to Salford residents of more integrated working between the City Council and Salford CCG;
• agreed in-principal that the preferred option of NHS Salford CCG to achieve this is by closer working between the two bodies including the development of a single integrated health and social care fund for children’s, public health, adults and primary care spend between the City Council and CCG;
• noted the risks to Salford CCG of moving to a single integrated health and social care fund;
• agreed that detailed financial, legal, governance and decision making arrangements, and other technical support plans, should be developed to give effect to this decision from 1 April 2019;
• agreed that a final decision will be subject to agreed review points, milestones, and regular evaluation of progress against these;
• asked for regular progress reports to Governing Body.
3.2 Governing Body is asked to note the short verbal update which will be provided in the meeting regarding progress in this work since the March meeting.
Anthony Hassall Chief Accountable Officer
Attachment 1
Part 1 – ITEM NO.
REPORT OF
THE DEPUTY CITY MAYOR LEAD MEMBER FOR CHILDREN’S AND YOUNG PEOPLE’S SERVICES LEAD MEMBER FOR ADULT SERVICES, HEALTH AND WELLBEING
TO
CABINET
27 MARCH 2018
TITLE: COMMISSIONING REVIEW – INTEGRATED WORKING WITH THE CCG
RECOMMENDATION
City Mayor, with Cabinet, is asked to:
• note the significant benefits to Salford residents of more integrated working between the City Council and Salford Clinical Commissioning Group;
• agree in principle that the preferred option of the Council to achieve this is by closer working between the two bodies including the development of a single integrated health and social care fund for children’s, public health, adults and primary care spend between the City Council and CCG;
• agree that detailed financial, legal, governance and decision making arrangements, and other technical support plans, should be developed to give effect to this decision from 1 April 2019,
• agree that a final decision will be subject to agreed review points, milestones, and regular evaluation of progress against these;
• recommend this approach to the next meeting of Council for their decision as it outside the current Budget and Policy Framework; and
• require regular progress reports to Cabinet and to the Overview and Scrutiny Committee.
Attachment 1
EXECTIVE SUMMARY
In May 2017, the City Council and CCG agreed to develop options for closer working, which would include the potential for shared commissioning decisions and arrangements including the integration of commissioning budgets for the totality of health and social care in Salford. In addition to existing joint commissioning of much of adult health and social care, the two organisations agreed to explore whether and how this could include those services supported through the Council’s public health and children’s services budgets and the CCG’s children’s, primary care and residual adults services budgets.
We are not though looking to create an Integrated Care Organisation for Children’s or for Public Health, and nothing in this report impacts on the existing remit of the current ICO.
The work to explore potential options has been led for the Council by the Deputy City Mayor, and the Lead Member for Children’s and Young People’s Services and the Lead Member for Adult Services, Health and Wellbeing. CCG leadership has been provided by the Chair (Dr Tom Tasker) and by the Medical Director (Dr Jeremy Tankel). A joint Reference Group has provided democratic and clinical leadership and oversight for the options as they have developed.
This report outlines the benefits to be gained from more integrated working; the financial situation facing both organisations; and the options we have considered. It recommends a single integrated fund for children’s, public health, adults and primary care budgets as the preferred option.
BACKGROUND DOCUMENTS:
Salford Locality Plan, ‘Start Well, Live Well, Age Well: Our Salford’ GM Commissioning Review
1. BACKGROUND
1.1. The Salford Locality Plan, ‘Start Well, Live Well, Age Well: Our Salford’, sets a clear vision and strategy for the health and social care system in Salford. The vision laid out in the Locality Plan is “People across Salford will experience health on a parallel with the current ‘best’ in Greater Manchester (GM), and the gaps between communities will be narrower than they have ever been before”. The Locality Plan also sets out a series of service transformations which will change the way care is delivered and the relationship between statutory organisations, and between statutory organisations and the public. The Plan sets out how the City Council, commissioners and providers in the NHS, the wider public sector, and the voluntary, community and social enterprise sector will build on what is already in place so that services work better and cost less.
1.2. Our ambition is that people in the city will be able to ‘start well, live well and age well’. By this we mean: Attachment 1
Start well: I will grow up and achieve my potential in life, eduction and employment
I have parents / guardians who look after me
I am a healthy and active child
Live Well: I take care of my own health and wellbeing and can manage the challenges life may throw at me
I am happy in life and feel supported by my family, friends and local community
My lifestyle helps stop any long term condition or disability getting worse and affecting my life
Age Well: If I need it, I will be able to access high quality care and support
I know that when I die, this will happen in the best possible circumstances
I am an older person who is looking after my health and delaying the need for care
1.3. Set against these ambitions, public services, and particularly the health and social care system – nationally and here in Salford – faces an unprecedented financial pressure, as well as challenges with regard to quality and performance of services and persistently poor population health outcomes. More people are calling Salford ‘home’ and more of our residents are living longer and often with more complicated health conditions. This means people need more help and support to stay well. In Salford, we will be spending £613m by 2021/22 on the areas included in the proposed integrated fund, which will exceed budget provision and create additional pressures. The Locality Plan sets out how to meet these challenges and is a plan that is shared by the local authority, health and wider partners, commissioners and providers. The Locality Plan includes a clear statement of intent to explore closer working, to standardize clinical and back office functions through integrated commissioning.
1.4. At the same time, and as part of the aspirations within the Greater Manchester strategic health and social care plan ‘Taking Charge’, there is a stated intention to integrate commissioning approaches at both GM and locality level.
“Each locality will start to align the CCG and local authority commissioning functions from April 2016 to develop a single commissioning plan, pool budgets, integrate governance, decision- making and commissioning skills. Across GM we have committed to Attachment 1
pool £2.7 billion. This will ensure outcomes that health and wider public services aim to achieve, are aligned.”
1.5. In early 2017, the GM Health and Social Care Partnership completed a review of commissioning arrangements across GM, and recommendations were agreed in July 2017. The review made recommendations in three areas: place, scale and support services. In relation to place, the review made four specific recommendations:
• Local authorities and CCGs to come together to form a single, small and strong Single Commissioning Function (SCF) with a breadth of responsibilities.
• The SCF to support the locality hospital group – in our case SRFT – to strengthen neighbourhood leadership systems, to include both political and clinical leadership, personalization of care, asset based community development, and resident and community engagement.
• Local authorities and CCGs to deliver a significant pooled budget across health, social care and wider public services, enabled by a risk sharing agreement.
• Local authorities and CCGs to adopt an investment led approach to commissioning and decommissioning, and support the move away from hospital and residential care services to investment in prevention and early intervention.
1.6 The GM review suggests that Salford continues to be one of, if not, the most advanced in terms of its joint commissioning arrangements for adult health and social care. It is though also clear that other districts are now rapidly catching up.
1.7 This report focuses on work to develop a Salford response to the third of the points at paragraph 1.5 – options to explore development of a significant pooled budget between the council and Salford CCG.
2. CURRENT WORK
2.1. Salford City Council (SCC) and Salford CCG (SCCG) have a long and successful history of integrated commissioning for health and social care.
• Pooled budgets have been in place since 2001 for areas such as learning difficulties, community equipment, and in 2009 intermediate care. We also have integrated commissioning arrangements in place, although without a pooled budget, for services such as mental health.
• An integrated commissioning team was established in 2010, comprising joint commissioning roles across health and social care, to ensure high quality, efficiency and effective services for residents. This team covers areas such as mental health, learning difficulties, carers, advocacy, Attachment 1
social care, etc and works closely with organisation specific teams. These arrangements play an important role in enabling good practice to be implemented for the benefit of all our residents.
• In 2014 the Older People’s Pooled budget was established – with a value of £112m. This was followed in 2016 by significantly increased pooling in the Adults Pool to a value of £240m, extending the scope of the pool to include all adults. The Adults Pool now covers a range of services and service providers, not all of which are provided by the ICO. The Integrated Adult Health and Social Care Commissioning Joint Committee (ICJC) was formed to govern this pooled commissioning budget, ensuring that decisions were taken jointly by the Council and CCG.
• The 0-25 programme has already begun to explore the opportunities for developing shared commissioning, with three test cases now in development. The Emotional Health and Wellbeing work has focused on a more integrated approach to Child and Adolescent Mental Health Services; the Children with Disabilities work is focused on improved resource allocation processes and streamlining assessment panels, leading to better outcomes for families and children; and, the work on speech, language and communication is looking to develop an emphasis on mainstream provision by moving resource into the community through schools and education settings.
2.2. Throughout 2016, SCC and SCCG discussed the potential to further explore integration of Public Health and Children’s Services. In the summer of 2017, the City Mayor and the CCG agreed to explore further opportunities to increase integrated commissioning arrangements to cover those services supported through the Council’s children’s services and public health budgets, and the CCG’s children’s, primary care and residual adults services budgets, and to include the potential for integrating budgets.
2.3. This work is being led by the Deputy City Mayor, the Lead Member for Children’s and Young People’s Services, and the Lead Member for Adults Services, Health and Wellbeing. Clinical leadership is being provided for the CCG by the Chair (Dr Tom Tasker) and by the Medical Director (Dr Jeremy Tankel). A joint Reference Group has been established to provide shared leadership across the two organisations.
2.4. An initial engagement meeting was held with the Trade Unions on Thursday 8 February. Trade Union colleagues welcomed this early engagement. Union representatives indicated they were not opposed to exploring options for closer working with the CCG, and would welcome ongoing engagement as the options were developed in greater detail. We have undertaken to continue to engage with the Unions, and to agree with them a framework for that engagement.
3. VISION AND BENEFITS
Attachment 1
3.1. Currently, our commissioning system sits across the City Council and the CCG – whilst we have strong partnership working, there is still duplication of effort and resources, limiting our flexibility and potential to make the most of the scare resources we have for the benefit of people living in the city. If we are to achieve the ambitions set out in the Locality Plan it is important that we find a way to strengthen our systems so that we prevent the loss or erosion of vital services that our city needs.
3.2. Bringing our planning, decision making and budget decisions closer together will directly affect the experience of our residents – ensuring they are able to see the right people, in the right place, with the right skills and experience. Current joint working between the council and the CCG has already demonstrated the value of working in this way. On the flip side, we still have examples where our two systems are failing to deliver the patient experience and outcomes that we have committed to delivering.
3.3. Most importantly, through more integrated decision making we will be able to ensure the coordinated and proactive care essential to achieve the population health outcomes we have agreed and to meeting the needs of our growing and ageing population. Integrated care is most easily achieved when planning, decision making and investment decisions are also unified. For example, integrated planning and decision making has driven a single approach to the design and delivery of improved mental health provision across the city. Community psychiatric nursing, inpatient provision, supported accommodation, intermediate support, and 24/7 home based treatment is more effective as a result. This means more people are being supported at home, and carers are now contacted within 72 hours of inpatient or home based treatment. Margaret’s experience illustrates the improved care and personal outcomes that result (case study 1 – Appendix 1).
3.4. Similarly, until recently there were five different commissions and contracts for five different types of advocacy across health and social care – Independent Mental Capacity Advocacy, Independent Mental Health Advocacy, Care Act Advocacy, NHS Complaints Advocacy and non-statutory advocacy. These have been brought together into one, delivered through a single joint budget, meaning patients now keep the same advocate as they progress through treatment, meaning consistency of relationships and better experience and outcomes for patients.
3.5. Integrated planning, decision making and budgeting will also protect ever scarcer resources – ensuring we can protect front line services for the benefits of residents. Our joint approach to investment in adult social care, through a pooled budget and single integrated commissioning team, has already protected social care services in the city every year. Without the pooled arrangements crucial services would have been lost. The risk of increasing demand for these services is now shared by the City Council and CCG, with the CCG accepting 70% of the risk for the continued funding of critical services. These are services that would otherwise have been lost to the city. For example, since 2008, we have developed a joint approach to supporting carers, which has brought council and CCG investment together Attachment 1
and this now means we have greater investment in Carers Personalised Budgets than seen anywhere else in GM.
3.6. In contrast, whilst the City Council and CCG have begun to work together on the commissioning of services for children there is more to be done to ensure the services experienced by children and their parents are seamless. We are looking at ways to strengthen the voice of the parent in decisions for children with special educational needs. There remain multiple panels for education, care and health. In recent years a lack of integrated working meant changes to the ways special educational needs assessments were dealt with resulted in unanticipated pressures on paediatric health services and long waiting times for some children to get their plans. The City Council and CCG have agreed to trial a new approach in West locality, using a single panel with the voice of parents at the centre. Joint working across agencies mean this pilot has been planned together and its impact on the whole system, as well as the outcomes for children, can be understood. The experience of Charlie, Lewis and Elsa help to illustrate the improvements that are needed (case study 2 – Appendix 1).
3.7. Whilst pooled budgets and joint investment decisions are a necessary condition to support better services – it is not in itself sufficient. If Salford is to play a clear strategic role in shaping health and care services in the future, then being able to respond to the scale and pace of change, having clarity in our relationships with providers, and exerting influence at Greater Manchester level, will all be strengthened if we are to act with a single voice. For example, we have recently led on the commissioning of joint substance misuse service across Salford, Bolton and Trafford, taking the best elements of Salfords established lead provider model and applying common standards across a number of areas. Salford is consistently the best performer across GM for both opiates and non-opiates treatment. Our successful treatment completion rate is double the national rate.
3.8. Nearly all patient journeys involve a mixture of elements from voluntary, social, primary, community, secondary and specialist care. The quality, safety and outcomes of the patient experience have never been more dependent on systems working well together. The experience of James and his parents illustrates this well (case study 3 – Appendix 1).
3.9. Further integration will enhance the opportunity for both democratic and clinical involvement in a wider range of decisions. Elected members bring a strong democratic voice, local passion and perspective. GPs’ time is focused on meeting the needs of local people. Both have strong local insight and understanding. Bringing the two perspectives together, alongside wider clinical and professional expertise across the system will provide the opportunity to ensure all resource and service decisions benefit from the combined perspective.
3.10. For example, all of the decisions about general practice services in Salford are currently made in the Primary Care Commissioning Committee – decisions are currently made without elected member input. With significant population growth anticipated over the next 20 years, elected member Attachment 1
knowledge of planning, housing, local communities and education would be critically beneficial in helping to shape primary care decision making. Genuine neighbourhood planning, investment and commissioning of services to reflect local need across the council, CCG and Salford Primary Care Together could be developed. This contrasts with current practice, where primary care services are reactive to developments across the city. Residents will receive a better service.
3.11. Bringing democratic and clinical decision making closer together, will also simplify decision making, reduce bureaucracy and directly benefit residents. For example, separate plans for Young Person’s Emotional Health and Well Being, and Child and Adolescent Mental Health Transformation, have been brought together into a single plan, jointly owned by the City Council and CCG. However without formal integrated governance arrangements any variation to the plan must still go through the twin tracks of City Council and CCG governance. In practice this means the plan needs to be presented to seven meetings and committees before it is agreed – some of this bureaucracy could be reduced through new arrangements.
3.12. The CCG as a commissioner of primary care have focused on quality and safety. If we were to ask the public what mattered to them they would talk about access and patient experience (both measures of quality), and engagement. The CCG has a strong track record in engagement, however given the direct links to local communities in wards across the city, elected members could positively influence primary care decision-making so that it even better reflects the needs of the population both organisations serve.
4. FINANCIAL BASELINE
4.1. So as to understand the financial opportunities and risks from a more expansive integrated commissioning fund, a high level strategic financial plan for 2018/19 to 2020/21 has been developed. This is based on a ‘do nothing’ scenario – beginning with what we know now about each organisations’ budget decisions, service demand growth assumptions, and funding reductions or growth. No assumptions have been made about future budget decisions. Those decisions remain subject to ratification by respective sovereign bodies. A consistent format has been applied to children’s, public health and CCG budgets so as to enable a like for like comparison.
4.2. This ‘do nothing’ strategic financial plan is based on a number of assumptions on both funding available and expenditure plans. These include: the level of baseline funding and spend for 2017/18; levels of inflation; volume growth in both demand and activity; contributions to organisational funding reductions; specific grants; Better Care Fund; council tax levels and any funding growth. This plan also assumes that planned reductions in 2018/19 will be delivered in full, but makes no assumptions about additional savings in 2018/19. Based on this approach the forecasts for Children’s, Public Health, the Adults Pooled Budget, Primary Care and other CCG spend, are each attached as Appendix 2 (A-D).
Attachment 1
4.3. This scenario has been developed to enable a full and shared understanding of the level of financial risk currently being carried by both organisations, and by the system jointly. In this context financial risk is the difference between predicted funding and predicted expenditure, based on the assumptions we have outlined.
4.4. What this high level strategic baseline assessment shows clearly is that if we do nothing then decisions would be needed on how to save £15.6m recurrently across the health and social care system in order to deliver a balanced financial plan by 2021/22. If we continue to operate under existing governance and decision making arrangements this £15.6m pressure would fall approximately £12.8m to the Council, and £2.8m to the CCG. This does not include additional savings required in other parts of the City Council as a result of budget reductions.
4.5 Whilst there will inevitably be some adjustment in the exact financial numbers due to the assumptions made, these numbers should be seen as broadly representative of the scale of the financial challenge facing both the Council and CCG. The table below summarises where these pressures would fall, and the percentage of savings required from the existing budget of those services.
Options 1 and 2: No Change/Minimal Change to Integrated Funds or Governance
FUNDING PROJECTED SPEND SHORTFALL Savings 2021/22 2021/22 2021/22 required as CCG Council Total CCG Council Total CCG Council Total CCG Council Total % of Budget £000s £000s £000s £000s £000s £000s £000s £000s £000s % Split % Split % Split Children's 0 78,235 78,235 0 86,505 86,505 0 -8,270 -8,270 0.0% 100.0% 100.0% -10.6% Public Health 0 20,121 20,121 0 23,471 23,471 0 -3,351 -3,351 0.0% 100.0% 100.0% -16.7% Adults Pool 180,057 73,771 253,828 167,072 90,745 257,818 -2,830 -1,160 -3,990 70.9% 29.1% 100.0% -1.6% CCG 245,226 0 245,226 245,226 0 245,226 0 0 0 100.0% 0.0% 100.0% 0.0% Total 425,283 172,126 597,410 412,299 200,721 613,020 -2,830 -12,780 -15,610
Financial risk sits with each statutory organisation with the exception of adults pooled budget (where overspends split on basis of proportion of funding)
4.6 The creation of an integrated or pooled budget between the council and CCG will not negate the need for difficult financial decisions. A minimum of £15.6m savings will still need to be realised simply to manage the pressures within the budgets outlined. However, under a ‘do nothing’ option each organisation will be required to make these savings individually, with the resulting threat to services. Under this ‘do nothing’ option, 100% of the pressures in Children’s and Public Health would fall to the City Council, representing 10.6% and 16.7% of the Children’s and Public Health budgets respectively. In this scenario it would be likely that savings are made in one part of the system (such as City Council’s spend) that cause at least some Attachment 1
additional demand and costs to another part of the system (potentially the CCG’s spend). As such, these may not realise savings to the public sector as a whole, instead shunting costs, and would likely create a poorer experience for the public.
5. OPTIONS CONSIDERED
5.1. In considering how to achieve the benefits outlined and to respond to the financial challenges facing both organisations, six options were initially considered. These options ranged from ‘do nothing’ to maximum pooling and integration of budgets, planning, and decision making across public health, adult services, children’s services and primary care. Following consideration of all options, officers have been asked to develop a detailed proposal of two of these.
5.2. The six options initially considered were :
• Option 1 - No change: existing joint and pooled arrangements would be maintained, with some closer working on commissioning support services and between commissioners. There would though be no further pooling of budgets or integration of planning and decision making.
• Option 2 - Aligned decision making, but no formal pooling or integration of budgets.
• Option 3 - Integrated budgets for each of adults, children and primary care with some elements of pooled budgets for each. Public Health would be absorbed into the age specific pooled budget as appropriate. This would mean integrated decision making for adults, children, and primary care, covering some elements of each area in three limited integrated funds¸ with public health absorbed into the age specific funds.
• Option 4 - A single integrated fund for all adult, children, public health and primary care budgets, with aligned decision making but no additional formal pooling of budgets. This would mean integrated decision making for all adult, children, public health and primary care through four integrated funds.
• Option 5 - A single integrated fund as above, with pooled budgets for each of adults, children and primary care, with public health absorbed into the age specific pool as appropriate. This would mean integrated decision making for all adult, children and primary care through three integrated funds with public health absorbed into the age specific funds.
• Option 6 – a single integrated fund for all adult, children, public health and primary care budgets, with all funds managed within a single integrated budget. This would mean integrated decision making across Attachment 1
all adult, children, publlic health and primary care budgets in a single integrated fund.
5.3. Each option was considered broadly against a number of criteria –
• benefits to local people; • legal opportunities and risks; • finance opportunities and risks; • governance and decision making; • commissioning options; and • opportunities to work differently through support services.
5.4. At this stage all options were identified as feasible. However, both lead members and GP members of the Reference Group agreed that the greater the level of shared decision making and integration of commissioning the greater the flexibility and therefore benefits for the people of Salford by using our resources to combined effect. In governance terms, we have considered the risks to fulfilling statutory duties, both as organisations and for specific roles, and are confident that arrangements could be found to protect these duties within each of the options.
5.5. As a result, and following initial discussion, elected members and GPs asked officers to more fully explore three options – options 2, 5 and 6. Lead members further discussed the benefits to the Council of option 2 (aligned decision making) and agreed this did not merit further detailed appraisal. It offered no financial benefit to the Council, each organisation would continue to operate in isolation and offered no immediate benefit in terms of increased democratic accountability, as decisions would remain as they are now.
5.6. We have therefore given further consideration to the practical benefits and operation of option 5 (three integrated funds) and option 6 (a single integrated fund).
Possible decision making framework
5.7. The detailed governance and decision making frameworks that would support either option continue to be developed – and will be subject to detailed due diligence consideration before any final decision over the next 12 months. Once a preferred option is agreed by both SCC and SCCG, detailed governance agreements will be drafted, that take account of both joint decision making arrangements and the residual decision making by the council and CCG as sovereign organisations.
5.8. Initial thinking on the decision making arrangements under the two final options is illustrated below. We would stress that these are initial illustrations only – detailed arrangements are still to be drafted and will be subject to a diligence process.
• Under option 5 (three integrated funds) joint decisions would be taken in three joint committees; accountable to SCC Cabinet and to the CCG Attachment 1
Governing Body. Whilst decision making would be relatively simple, it would be constrained to the specific areas of focus, limiting the ability to fully integrate care and service pathways, particularly at the points of transition between adults and children, and between primary care and other services.
• Under Option 6 (one integrated fund) an overarching group would make decisions across the full remit of health and social care, with the ability – subject to agreed limits – to move funding between service areas and functions. Decisions about this agreed limit would be returned to each of SCC and SCCG for decision making. Under this option, specific sub- groups would most likely be created to oversee each of children’s, adults and primary care. This option would provide the maximum flexibility to use resources in areas of greatest need.
Attachment 1
5.9. In developing the possible decision making arrangements to support both these options members have agreed a number of high level principles which will frame the governance and decision making regardless of the option or structures eventually agreed.
• Whilst still in the early stages, the statutory and / or reserved matters for both the Council and CCG that are not able to be included in an integrated fund or in joint decision making will be clearly identified, and will be specified as part of the final decision making arrangements.
• Where decisions are taken jointly, elected members and GPs will hold an equal number of votes on all decision making groups. Elected members and GPs will hold a majority of the vote in any decision making forum.
• Any decision making sub-groups will involve both elected member and GP decision makers.
• Joint decisions will be taken solely by the City Council and CCG.
• The Council’s existing rules on transparency, including the public notification of planned key decisions, and the advanced circulation of papers, will also apply to joint decisions.
• Subject to agreed criteria and financial limits, decisions on virement between funds (e.g. Adults to Children) will require the agreement by both sovereign organisations separately.
5.10. These principles will apply regardless of the preferred option agreed by SCC Cabinet and the CCG Governing Body. More detailed governance and decision making arrangements will be drawn up for agreement by both organisations on the basis of the preferred option. A legal due diligence check will also be undertaken before final arrangements are brought forward for agreement.
6. FINANCIAL OPPORTUNITIES AND RISKS
6.1. So as to understand the financial benefits and risks of the two options lead members and GPs have asked to be more fully developed, the strategic financial baseline outlined in section 4 has been re-presented in line with the governance and decision making arrangements outlined for both options.
6.2. It is important to note that under both options the financial challenge across health and social care will remain the same – i.e. the two organisations will still need to make savings of £15.6m by 2020/21 to achieve a balanced budget. Difficult decisions will continue to be needed. However, there are important differences under the two preferred options:
• the level of financial risk on each organisation if savings are not realised;
• responsibility for decision making; and Attachment 1
• the level of challenge each service area will face and as a result the ability to deliver the necessary savings.
6.3. A number of assumptions have been made to underpin the financial modelling for each of the two considered options. Specifically:
• Children’s: or CCG budgets, those areas that are entirely Children’s or are easily extracted from contracts (e.g. community paediatrics) are included. Also included are: paediatric outpatient activity from hospital contracts; CAMHS outpatients; and maternity services. For SCC budgets, Public Health funding for 0-25 health visiting; school nursing; and family nurse partnership service has also been included within the scope of a potential children’s pool.
• Some public health budgets currently contribute to wider public services. They have been excluded from the scope of this exercise.
• Running and staff costs – for both commissioning teams and corporate functions in both organisations - have been excluded from this modelling exercise.
• CCG contingency reserves and council reserves have been excluded from this exercise.
• The modelling assumes that agreed savings plans for 2018/19 are achieved and delivered in full. If savings are not delivered then the level of financial risk will increase from £15.6m to £19m by 2020/21.
• Modelling does not include the risk of overspend against existing plans in 2018/19.
• The model assumes a level of growth in both hospital and children’s services. If we do nothing, then spend will continue to increase. The reverse is also true, if we manage to contain demand and activity growth, then we should be able to contain expenditure.
• Some estimates have been made for future funding reductions – however decisions regarding the totality of organisational contributions to the integrated funds would continue to be for sovereign organisations and so could change, particularly should the context within which we are operating change.
• It is assumed that the principles of the current adult pooled budget risk share arrangements would continue i.e. risk would be managed by the pool in year, or if carried over across years would fall to both organisations according to budget contribution. The existing adults’ pool risk agreement is 70% CCG and 30% SCC. For a potential children’s pool it would be 70% SCC and 30% CCG. The details of the future risk Attachment 1
share arrangements would be agreed by SCC and SCCG during 2018/19 to take into account the wider integrated funds approach.
6.4. In line with the assumptions set out in sections 6.2 and 6.3 the level of financial risk for both option 5 (three integrated funds) and option 6 (a single integrated fund) is shown below. The total level of required saving remains the same under both – the level of risk that falls to each service area (adults, children, primary care) and each organisation (SCC and SCCG) does though vary significantly. Specifically:
• Under option 5: the financial risk would fall differently across each of the integrated funds. 72.5% of the risk on children’s spend will fall to the City Council (this is currently the area of greatest pressure). The saving required over 5 years, would represent 8.4% of the combined children’s budgets.
76.9% of the risk on the adult’s pool would fall to the CCG – and savings would represent 1.6% of the combined adults budgets.
100% of the risk on primary care would fall to the CCG, there are currently no predicted savings required in this area.
• Under option 6: 71.2% of the risk across all funds would fall to the CCG. Savings would represent 2.6% of the overall integrated funds. Option 6 clearly provides the maximum flexibility for the system as a whole to realise the necessary savings.
Option 5: 3 Separate integrated Funds and Governance
FUNDING PROJECTED SPEND SHORTFALL Savings 2021/22 2021/22 2021/22 required as CCG Council Total CCG Council Total CCG Council Total CCG Council Total % of Budget £000s £000s £000s £000s £000s £000s £000s £000s £000s % Split % Split % Split Children's Integrated Fund 31,231 82,275 113,506 123,011 -2,615 -6,890 -9,505 27.5% 72.5% 100.0% -8.4% Adults Integrated Fund 299,216 89,851 389,067 395,173 -4,695 -1,410 -6,105 76.9% 23.1% 100.0% -1.6% Primary Care Integrated Fund 94,846 0 94,846 94,846 0 0 0 100.0% 0.0% 100.0% 0.0% Total 425,294 172,126 597,420 613,030 -7,311 -8,300 -15,610
If operate 3 integrated funds/pooled budgets, then apply financial risk share to each pooled budget separately (based on funding contribution)
Option 6: A Single Integrated Fund
FUNDING PROJECTED SPEND SHORTFALL Savings 2021/22 2021/22 2021/22 required as CCG Council Total CCG Council Total CCG Council Total CCG Council Total % of Budget £000s £000s £000s £000s £000s £000s £000s £000s £000s % Split % Split % Split Total: Single Integrated Fund 425,294 172,127 597,420 613,031 -11,113 -4,498 -15,610 71.2% 28.8% 100.0% -2.6%
If operate a single integrated fund, then financial risk is split based on proportion of funding contribution made by each organisation
7. SUPPORT AND ENABLING FUNCTIONS
7.1. Whilst the work so far has focused on developing closer working with the CCG on Children’s Services, Public Health, primary care and both residual and pooled budget areas of adult services we have also started to explore the potential to further develop the sharing of support and enabling functions across the two organisations. Greater integration will allow us to explore how our support and enabling services can come together – ensuring the Attachment 1
optimum use of available resources, and the effective and transparent delivery of integrated fund related and organisational business. This also includes exploring options for joint accommodation and estates.
7.2. A joint integrated commissioning team for adults has been in place since 2010. This team covers areas such as mental health, learning difficulties, carers, advocacy, social care, etc and works closely with organisation specific teams. Both organisations have already tested the sharing of a lead role for performance and planning on an interim basis, facilitating a cost saving, and leading to skills transfers, and improvements in joint planning and the understanding of system performance. Continuing this approach will enhance democratic accountability for health and social care in the city and clinical contribution to wider determinants of health. We will ultimately create a single outcomes framework that will assure the public they are receiving the best possible services and outcomes from the NHS and local government. Importantly, greater joint working of staff and staff teams will ensure best possible use of commissioning and support services across both organisations, may provide an opportunity to reduce costs and maximise resources to the front line.
7.3. Options will be developed and discussed with relevant lead members and CCG leads before progressing and being presented to SCC Cabinet and CCG decision makers. Work is still at an early stage, but it is envisaged that proposals will be brought forward for consideration by Lead Member and CCG decision makers in summer 2017.
8. NEXT STEPS
8.1. Given the financial information set out, option 6 – a single integrated fund between the Council and CCG - is recommended as the preferred option to deliver the strongest benefits to residents.
8.2. A final decision on adopting this option will be subject to the high level governance and decision making framework set out in this report.
8.3. It is recommended this option is agreed in principle, with a view to full implementation in April 2019. A phased approach to detailed decision making through 2018/19 and regular progress reports to SCC Cabinet and SCCG Governing Body, which will include phased implementation and any emerging risks. This will allow due diligence to be undertaken on proposed legal, governance, financial and risk arrangements to be undertaken before decisions are finalised.
FINANCIAL IMPLICATIONS Supplied by: Joanne Hardman, Chief Finance Officer, 0161 793 3156
The report sets out the assumptions which support the baseline ‘do nothing’ scenario. This includes continuing pressures upon children’s services and a requirement for both Public Health and Children’s Services to contribute to council wide savings Attachment 1 targets in future years. These are the main drivers in the forecasted shortfall in funding for future service delivery.
The level of risk associated with each scenario is set out within the report. Based upon current forecasts of expenditure and funding, the Council is carrying more risk under the ‘do nothing’ scenario. Option 6, based on current expenditure and funding forecasts, provides the greatest opportunity to mitigate the Council’s risk. Further development of option 6 should include consideration of issues such as:-
• Budget setting for the integrated funds • Flexibility to vary contributions into the fund to meet future savings requirements • Budget monitoring arrangements • Any restrictions on virement of funds across service areas • Analysis of any restrictions on spending decisions across the fund • VAT implications
PROCUREMENT IMPLICATIONS Supplied by: N/A
HR IMPLICATIONS Supplied by: Sam Betts, Assistant Director, HR & OD, 0161 607 8602
There are no direct workforce implications at this point. However, through the Joint Secretaries, the trade unions have requested early and ongoing engagement in advance of any formal decisions being made which is being facilitated. Closer working and integration across the two organisations, and in particular the work to develop our approach to sharing support and enabling functions will be underpinned by an organisational and workforce development plan including communications, employee engagement and future skills development.
LEGAL IMPLICATIONS Supplied by: Jacqui Dennis, Interim City Solicitor for Manchester & Head Shared Legal Service, 0161 234 3053 and Miranda Carruthers- Watt , City Solicitor, Salford
The Council currently has arrangements in place pursuant s75 of the National Health Service Act 2006 allowing pooling arrangements for adults and public health commissioning. There are a number of functions which must be discharged by statutory officers in both the Council and the CCG. In addition there are a number of complexities regarding effective decision making which need to be considered. The shared Legal Service will provide advice and assistance to achieve a positive outcome that mitigates risks from the Council’s perspective. Legal support will be available to workstreams to ensure that full consideration is given to any additional or expansion of current arrangements to ensure that the statutory role of the DCS is protected and that the Council would ensure it continues to meet its statutory duties. Proposals will be developed jointly which provide clear mechanisms into the Attachment 1
Council’s Scrutiny functions as well as respecting the areas where statutory responsibility lies with the CCG. There are limited examples of this work in other authorities and it will be necessary to work alongside national bodies and GM to ensure that any legislative anomalies are recognised.
A detailed assessment will be completed to ensure that any potential constitutional changes are identified and clear processes for decision making which fully reflect the need for democratic engagement.
The Shared Legal Service will liaise with the City Solicitor in order to identify the relevant legal resources that will be required to support the project.
OTHER DIRECTORATES CONSULTED: People; Public Health; Service Reform
CONTACT OFFICER:
Charlotte Ramsden Strategic Director People TEL NO: 0161 778 0130 David Herne Director of Public Health TEL NO: 0161 793 3518 Jacquie Russell Assistant Director Strategy TEL NO: 0161 793 3577
Wards to which this relates: All
Attachment 1
Appendix 1 – Case Studies
Case Study 1 – mental health
‘Margaret’ is a 44 year old mother of two with a severe and enduring mental illness and is under the Care Programme Approach (CPA). Previously referred to Community Engagement Recovery Team (CERT) in May 2016 - due to the high volume of referrals at that time Margaret would have been placed onto a long waiting list, so did not access support from the team from this initial referral. Following the merger of the CERT service into the Commuity Mental Health Teams (CMHTs), Margaret was re- referred to CERT and contact was made with the client within the agreed 7 day response period (as outlined in the revised service specification) and a goal plan was completed during the first aspirational meeting.
Margaret had been attempting to access employment since April 2016 when she had been allocated a Community Psychiatric Nurse (CPN). Margaret would apply for jobs on a daily basis, yet did not secure any of the roles. CERT Workers have the knowledge and links to mainstream community organisations and the dedicated time to spend with a client to facilitate interventions.
CERT was able to introduce Margaret to an employment company based within Salford. The CERT worker initially attended meetings with Margaret but as time progressed she felt confident to go on her own. Given support in writing job applications, interview skills and self-confidence. Margaret has since gained a full time employment post at McDonalds, and has recently spoken to management to enquire about joining their intensive management training programme, which will enable her to manage one of their UK restaurants.
Margaret has also commenced some voluntary work to widen her experience and ‘give something back’. She has also completed an application for completing her PhD in Psychology focusing on Mental Health (she completed a degree in psychology in 2015).
Margaret now has the means and motivation to complete decoration work on her home to allow her to sell her property. The property had been up for sale for over a year and recently an offer has been made. Margaret has also now commenced driving lessons, which she would have struggled to do on benefits.
Margaret’s self-esteem has improved significantly. The CERT engagement worker has supported her to build confidence, self-esteem, motivation and resilience. Margaret has demonstrated how being supported to improve outcomes in one key area of her life has resulted in improvements in a whole range of areas which will improve the quality of life, health and wellbeing of her and her children.
Attachment 1
Case Study 2 - Emotional Health
Charlie is 16. She and Lewis have a little girl called Elsa, Elsa was born prematurely.
Charlie (the mum) is a Looked After Child and receives support from the Next Steps service. Charlie also receives support from the CAMHS service due to a history of self harm, and anxiety and depression.
In order to support Charlie effectively, a number of services need to wrap around and give the family support, this includes the Midwifery service (commissioned by the CCG), the Family Nurse Partnership (commissioned by Public Health), the 0-19 health service (commissioned by Public Health), the parenting support team (delivered by Children’s Services), the peri-natal mental health team (commissioned by the CCG), adult mental health services in liaison with the CAMHS service (partly commissioned by SCC and partly by the CCG) and the Next Steps service (provided by SCC).
Currently services take a lead professional role for families, in this instance the Family Nurse Partnership would act as the lead professional and would coordinate support for the family, reducing duplication, enabling support and facilitating conversations. However, there are current barriers to information sharing, knowledge of partners working with a family and co- location of staff. An integrated commissioning approach and specification could allow services to be defined and strategic commissioning oversight could allow the services to flex to meet need more effectively, it could allow commissioners to work in a person centred and innovative way.
The commissioner could ensure resources were made available at the right time for Charlie, Lewis and Elsa, dealing with preventative issues as well as responding to needs as they arise.
Attachment 1
Case study 3 – Quality, safety and patient experience
‘James’ is 6 and has behavioural difficulties. Earlier this year, his parents asked the GP to refer James for an assessment about his emotional health and wellbeing. James’ school had advised the GP to make a referral via the NHS because they were concerned about waiting times for educational psychology.
In James’ case, the GP made an initial referral to Community Paediatrics (who’d previously seen these sorts of cases as an initial assessment) who advised the referral be sent to CAMHS.
After informing James’ parents (and sorting out resulting paperwork) a referral was made – only for the referral to be rejected as it didn’t meet the threshold for CAMHS.
CAMHS advised the GP to make a referral to The Bridge, which was duly completed.
Salford has a very strong Educational Psychology service, with a strong buy-back system from schools. The EP service is a traded model to schools but schools can make direct referrals if required
It took three referrals before James’ case was accepted. This delay impacted on James and his parents, on the GP, and in wasted time and resource. It points to a need to explore opportunities to further expand the work to connect educational psychology to schools not currently purchasing the excellent emotionally friendly schools package, developed by the team, and to joint work with the CCG on emotional and mental health.
Attachment 1 Appendix 2 – financial tables (See Excel attachment)
Appendix 2a - Adults Baseline Yearly Summary 2017/18 2018/19 2019/20 2020/21 2021/22 CCG Council Total CCG Council Total CCG Council Total CCG Council Total CCG Council Total Notes £000s £000s £000s £000s £000s £000s £000s £000s £000s £000s £000s £000s £000s £000s £000s Baseline Funding £167,567 £65,576 £233,143 £167,537 £58,004 £225,541 £167,537 £54,199 £221,736 £167,537 £52,335 £219,872 £167,537 £52,335 £219,872 Other income (Specific Grants, Client Income, Other LAs) - £500 £500 - £500 £500 - £500 £500 - £500 £500 - £500 £500 Commissioner Funding Added for Growth £451 - £451 £451 - £451 £451 - £451 £451 - £451 £451 - £451 Inflation Funding £823 £510 £1,333 £2,492 £1,036 £3,528 £4,235 £1,573 £5,808 £6,005 £1,957 £7,962 £6,005 £1,957 £7,962 Additional Funding (Council Tax Precept, CCG Growth) £5,616 £3,924 £9,540 £6,717 £6,548 £13,265 £7,717 £6,548 £14,265 £8,717 £8,618 £17,335 £8,717 £8,618 £17,335 Additional BCF allocation - £7,219 £7,219 - £14,791 £14,791 - £19,125 £19,125 - £21,125 £21,125 - £21,125 £21,125 Less: New Home Bonus Grant - (£1,535) (£1,535) - (£3,760) (£3,760) - (£3,335) (£3,335) - (£3,716) (£3,716) - (£3,716) (£3,716) Funding Reductions - (£1,762) (£1,762) - (£3,524) (£3,524) - (£5,286) (£5,286) - (£7,048) (£7,048) - (£7,048) (£7,048) RECURRENT FUNDING £174,457 £74,432 £248,889 £177,196 £73,595 £250,790 £179,939 £73,324 £253,262 £182,709 £73,771 £256,480 £182,709 £73,771 £256,480 % Increase/(Decrease) in Recurrent Funding 70.1% 29.9% 1.6% -1.1% 0.8% 1.5% -0.4% 1.0% 1.5% 0.6% 1.3% 0.0% 0.0% 0.0% Return of Prior Year Over Spend (£303) (£303) (£271) (£678) (£949) £44 £44 (£1,315) (£1,315) (£2,652) (£2,652) Return of Prior Year Under Spend - - - - - NON RECURRENT FUNDING (£303) - (£303) (£271) (£678) (£949) £44 - £44 (£1,315) - (£1,315) (£2,652) - (£2,652)
TOTAL FUNDING £174,154 £74,432 £248,585 £176,924 £72,917 £249,841 £179,983 £73,324 £253,306 £181,395 £73,771 £255,165 £180,057 £73,771 £253,828 % Split of Contributions into the Pool 70.1% 29.9% 70.8% 29.2% 71.1% 28.9% 71.1% 28.9% 70.9% 29.1% - - - Adult Social Care - ICO £7,345 £79,913 £87,259 £7,343 £79,910 £87,253 £7,343 £79,910 £87,253 £7,343 £79,910 £87,253 £7,343 £79,910 £87,253 Mental Health Services - GMW £29,743 - £29,743 £29,688 - £29,688 £29,688 - £29,688 £29,688 - £29,688 £29,688 - £29,688 SRFT Acute £75,500 - £75,500 £76,004 - £76,004 £76,004 - £76,004 £76,004 - £76,004 £76,004 - £76,004 SRFT Community £29,787 £84 £29,871 £29,627 £84 £29,712 £29,627 £84 £29,712 £29,627 £84 £29,712 £29,627 £84 £29,712 Falls Service also in PH Spend Adult Social Care - Non-ICO £2,100 £1,376 £3,476 £2,102 £1,380 £3,482 £2,102 £1,380 £3,482 £2,102 £1,380 £3,482 £2,102 £1,380 £3,482 Adult Social Care - Capital - £2,407 £2,407 - £2,407 £2,407 - £2,407 £2,407 - £2,407 £2,407 - £2,407 £2,407 Continuing Health Care & Funded Nursing Care £7,044 - £7,044 £7,044 - £7,044 £7,044 - £7,044 £7,044 - £7,044 £7,044 - £7,044 MH Services - Private & Voluntary Sector £6,006 - £6,006 £6,006 - £6,006 £6,006 - £6,006 £6,006 - £6,006 £6,006 - £6,006 Community Assets/ Voluntary Sector £2,028 - £2,028 £1,871 - £1,871 £1,871 - £1,871 £1,871 - £1,871 £1,871 - £1,871 Committed Developments £2,694 £3,372 £6,066 £350 £4,329 £4,679 £350 £6,158 £6,508 £350 £6,445 £6,795 £350 £6,445 £6,795 Show living wage separately- service growth? Inflation costs - - - £1,331 £128 £1,459 £3,074 £380 £3,454 £4,845 £519 £5,364 £4,845 £519 £5,364 Additional costs built in for hopital growth £2m- if contain this, then Service growth/volume growth - - - £191 - £191 £1,191 - £1,191 £2,191 - £2,191 £2,191 - £2,191 achieve balanced plan BCF spend/schemes ------Planned service reductions/CIP identified ------TOTAL - Adult's £162,248 £87,153 £249,401 £161,559 £88,238 £249,797 £164,302 £90,319 £254,621 £167,072 £90,745 £257,818 £167,072 £90,745 £257,818
TOTAL EXPENDITURE £162,248 £87,153 £249,401 £161,559 £88,238 £249,797 £164,302 £90,319 £254,621 £167,072 £90,745 £257,818 £167,072 £90,745 £257,818
3 year plan for Adults pooled budget was balanced at 2019/20 but DIFFERENCE £11,906 (£12,721) (£815) £15,366 (£15,322) £44 £15,681 (£16,996) (£1,315) £14,322 (£16,975) (£2,652) £12,985 (£16,975) (£3,990) this assumed £1m surplus in 2017/18. Actual 2017/18 position is 0.3m overspend (ie £1.3m worse) Appendix 2b - Children Baseline Yearly Summary 2017/18 2018/19 2019/20 2020/21 2021/22 CCG Council Total CCG Council Total CCG Council Total CCG Council Total CCG Council Total Notes £000s £000s £000s £000s £000s £000s £000s £000s £000s £000s £000s £000s £000s £000s £000s Baseline Funding - £44,139 £44,139 - £46,508 £46,508 - £46,508 £46,508 - £46,508 £46,508 - £46,508 £46,508 Other income (specific grants, c - £32,621 £32,621 - £30,252 £30,252 - £30,252 £30,252 - £30,252 £30,252 - £30,252 £30,252 Commissioner Funding Added f ------Inflation Funding - - - - £749 £749 - £1,497 £1,497 - £1,871 £1,871 - £2,246 £2,246 Assumption pay increase is funded from council reserves- need confirmation from CH/JH Additional Funding (council tax - - - - £3,307 £3,307 - £2,570 £2,570 - £2,570 £2,570 - £2,570 £2,570 £4.5m additional funding going into Children's, comprising £2.6m from Council and £2m Additional BCF allocation - - - - £1,193 £1,193 - £1,930 £1,930 - £1,930 £1,930 - £1,930 £1,930 from Better Care Fund Less: New Home Bonus Grant ------Council expects to reduce Children's services funding by £2.6m over 3 years to repay the £2.6m investment made by the council in 2018/19. In addition this model assumes Funding Reductions ------(£1,757) (£1,757) - (£3,513) (£3,513) - (£5,270) (£5,270) Children's services to contribute to the overall council's savings target by £0.9m per annum for 3 years. Total funding reduction = £5.2m RECURRENT FUNDING - £76,759 £76,759 - £82,008 £82,008 - £81,000 £81,000 - £79,618 £79,618 - £78,235 £78,235 % Increase/(Decrease) in Recur 0.0% 100.0% #DIV/0! 6.8% 6.8% #DIV/0! -1.2% -1.2% #DIV/0! -1.7% -1.7% #DIV/0! -1.7% -1.7% Return of Prior Year Over Spend - - - - - Return of Prior Year Under Spend - - - - - NON RECURRENT FUNDING ------
TOTAL FUNDING - £76,759 £76,759 - £82,008 £82,008 - £81,000 £81,000 - £79,618 £79,618 - £78,235 £78,235 % Split of Contributions into the 0.0% 100.0% 0.0% 100.0% 0.0% 100.0% 0.0% 100.0% 0.0% 100.0%
Leadership & Safeguarding - £1,786 £1,786 - £1,806 £1,806 - £1,806 £1,806 - £1,806 £1,806 - £1,806 £1,806 Leadership Team removed Specialist Services - £39,376 £39,376 - £39,582 £39,582 - £39,582 £39,582 - £39,582 £39,582 - £39,582 £39,582 SEN, Access & Inclusion - £10,538 £10,538 - £10,713 £10,713 - £10,713 £10,713 - £10,713 £10,713 - £10,713 £10,713 PFI/ICT Managed Service removed Education & Helping Families - £13,099 £13,099 - £13,542 £13,542 - £13,542 £13,542 - £13,542 £13,542 - £13,542 £13,542 Capital Asset Charges removed Specific Grants - £17,254 £17,254 - £17,254 £17,254 - £17,254 £17,254 - £17,254 £17,254 - £17,254 £17,254 Inflation costs - - - - £749 £749 - £1,497 £1,497 - £1,871 £1,871 - £2,246 £2,246 Assumption 2% Pay increase for 18/19 and 19/20 and 1% future years Service growth/volume growth ------£1,000 £1,000 - £2,000 £2,000 - £3,000 £3,000 What is historic year on year growth? £1m sufficient or too high? BCF spend/schemes ------Planned service reductions/CIP - - - - (£1,637) (£1,637) - (£1,637) (£1,637) - (£1,637) (£1,637) - (£1,637) (£1,637) £1.6m identified for 2018/19 ------TOTAL - Children's - £82,053 £82,053 - £82,008 £82,008 - £83,756 £83,756 - £85,131 £85,131 - £86,505 £86,505
TOTAL EXPENDITURE - £82,053 £82,053 - £82,008 £82,008 - £83,756 £83,756 - £85,131 £85,131 - £86,505 £86,505
DIFFERENCE - (£5,294) (£5,294) - £0 £0 - (£2,756) (£2,756) - (£5,513) (£5,513) - (£8,270) (£8,270) This is the unidentified savings required (assuming service/volume growth continues) Appendix 2c - Public Health Baseline Yearly Summary 2017/18 2018/19 2019/20 2020/21 2021/22 CCG Council Total CCG Council Total CCG Council Total CCG Council Total CCG Council Total Notes £000s £000s £000s £000s £000s £000s £000s £000s £000s £000s £000s £000s £000s £000s £000s Baseline Funding - £18,622 £18,622 - £18,622 £18,622 - £18,622 £18,622 - £18,622 £18,622 - £18,622 £18,622 Other income (specific grants, client income, othe - £5,859 £5,859 - £5,859 £5,859 - £5,859 £5,859 - £5,859 £5,859 - £5,859 £5,859 £765k relates to GM SHIP contract Commissioner Funding Added for Growth ------Inflation Funding ------Nil additional funding for inflation or pay award- all costs need to be from PH Grant Additional Funding (council tax precept, CCG grow ------Additional BCF allocation ------Less: New Home Bonus Grant ------PH grant to reduce by 2.6% in 2018/19 and 2019/20 (£0.5m recurrently in both of these years). Funding reductions - (£361) (£361) - (£1,121) (£1,121) - (£2,561) (£2,561) - (£3,461) (£3,461) - (£4,361) (£4,361) Also assumes further funding reductions to contribute to overall council target- assumed £0.9m for 3 years. RECURRENT FUNDING - £24,120 £24,120 - £23,360 £23,360 - £21,921 £21,921 - £21,021 £21,021 - £20,121 £20,121 % Increase/(Decrease) in Recurrent Funding 0.0% 100.0% #DIV/0! -3.2% -3.2% #DIV/0! -6.2% -6.2% #DIV/0! -4.1% -4.1% #DIV/0! -4.3% -4.3% Return of Prior Year Over Spend - - - - - Return of Prior Year Under Spend - - - - - NON RECURRENT FUNDING ------
TOTAL FUNDING - £24,120 £24,120 - £23,360 £23,360 - £21,921 £21,921 - £21,021 £21,021 - £20,121 £20,121 % Split of Contributions into the Pool 0.0% 100.0% 0.0% 100.0% 0.0% 100.0% 0.0% 100.0% 0.0% 100.0%
PH Core Costs ------PH Drugs and Alcohol - Substance Misuse - Salford - £3,474 £3,474 - £3,474 £3,474 - £3,474 £3,474 - £3,474 £3,474 - £3,474 £3,474 GM Contract led by Salford. £3,474k SCC Costs PH Drugs and Alcohol - Substance Misuse - Other - £5,094 £5,094 - £5,094 £5,094 - £5,094 £5,094 - £5,094 £5,094 - £5,094 £5,094 GM element of contract off-set by income above PH Drugs and Alcohol - Other Contracts - £258 £258 - £258 £258 - £258 £258 - £258 £258 - £258 £258 4 Other Salford contracts PH Sexual Health - £1,851 £1,851 - £1,851 £1,851 - £1,851 £1,851 - £1,851 £1,851 - £1,851 £1,851 PH GM SHIP - Salford - £138 £138 - £138 £138 - £138 £138 - £138 £138 - £138 £138 GM Contract held led by Salford. £138k SCC share of costs PH GM SHIP - Other GM - £765 £765 - £765 £765 - £765 £765 - £765 £765 - £765 £765 GM element of contract off-set by income above PH Sexual Health Cross Charging (GM) - £396 £396 - £396 £396 - £396 £396 - £396 £396 - £396 £396 PH Sexual Health Cross Charging (OOA) - £129 £129 - £129 £129 - £129 £129 - £129 £129 - £129 £129 PH LES Sexual Health - £65 £65 - £65 £65 - £65 £65 - £65 £65 - £65 £65 PH Tobacco - £440 £440 - £440 £440 - £440 £440 - £440 £440 - £440 £440 PH LES Tobacco - £168 £168 - £168 £168 - £168 £168 - £168 £168 - £168 £168 PH Reducing Obesity - £350 £350 - £350 £350 - £350 £350 - £350 £350 - £350 £350 PH Wellbeing Services - £1,370 £1,370 - £1,370 £1,370 - £1,370 £1,370 - £1,370 £1,370 - £1,370 £1,370 PH Child Health - £25 £25 - £25 £25 - £25 £25 - £25 £25 - £25 £25 PH Falls - £84 £84 - £84 £84 - £84 £84 - £84 £84 - £84 £84 Already part of Adults spend within community contract - Double Count in costs PH Long Term Conditions - £250 £250 - £250 £250 - £250 £250 - £250 £250 - £250 £250 PH Regional Contracts - £35 £35 - £35 £35 - £35 £35 - £35 £35 - £35 £35 PH Other Contracts - £77 £77 - £77 £77 - £77 £77 - £77 £77 - £77 £77 PH 0-19 Services - £5,270 £5,270 - £5,270 £5,270 - £5,270 £5,270 - £5,270 £5,270 - £5,270 £5,270 PH LES Health Checks - £210 £210 - £210 £210 - £210 £210 - £210 £210 - £210 £210 PH Investment Fund - £3,669 £3,669 - £3,669 £3,669 - £3,669 £3,669 - £3,669 £3,669 - £3,669 £3,669 PH DAAT ------Inflation costs ------Only volume related service is c£1.85m of sexual health contract. Assume 2% volume risk year on Service Growth/Volume Growth - - - - £37 £37 - £74 £74 - £111 £111 - £148 £148 year BCF Spend/Schemes ------Assumed no additional investment in new services Planned service reductions/CIP identified - - - - (£206) (£206) - (£206) (£206) - (£206) (£206) - (£206) (£206) Savings identified for 2017/18 reductions (part year 18/19)- plans in place to reduce contracts ------TOTAL - Public Health - £24,120 £24,120 - £23,951 £23,951 - £23,988 £23,988 - £24,025 £24,025 - £24,062 £24,062
TOTAL EXPENDITURE - £24,120 £24,120 - £23,951 £23,951 - £23,988 £23,988 - £24,025 £24,025 - £24,062 £24,062
Additional savings required £3.9m: 2018/19 and 2019/20 grant reductions (£1.1m), DIFFERENCE - (£0) (£0) - (£591) (£591) - (£2,068) (£2,068) - (£3,005) (£3,005) - (£3,942) (£3,942) growth/volume risk (£0.1m), contiution to council funding reductions £2.7m Appendix 2d - CCG Baseline Yearly Summary 2017/18 2018/19 2019/20 2020/21 2021/22 CCG Council Total CCG Council Total CCG Council Total CCG Council Total CCG Council Total Notes £000s £000s £000s £000s £000s £000s £000s £000s £000s £000s £000s £000s £000s £000s £000s Baseline Funding £262,046 - £262,046 £256,511 - £256,511 £260,163 - £260,163 £260,163 - £260,163 £260,163 - £260,163 Confirmed allocation only till 2018/19. 2019/20 onwards based on assumptions Other income (specific grants, client income, other LAs) ------Commissioner Funding Added for Growth ------Inflation Funding ------Additional Funding (council tax precept, CCG growth) - - - £6,315 - £6,315 £13,121 - £13,121 £13,121 - £13,121 £13,121 - £13,121 Additional BCF allocation ------Less: New Home Bonus Grant ------Funding reductions ------RECURRENT FUNDING £262,046 - £262,046 £262,826 - £262,826 £273,284 - £273,284 £273,284 - £273,284 £273,284 - £273,284 % Increase/(Decrease) in Recurrent Funding 100.0% 0.0% 0.3% 0.0% 0.3% 4.0% 0.0% 4.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% Return of Prior Year Over Spend - - - - - Return of Prior Year Under Spend - - - - - NON RECURRENT FUNDING ------
TOTAL FUNDING £262,046 - £262,046 £262,826 - £262,826 £273,284 - £273,284 £273,284 - £273,284 £273,284 - £273,284 % Split of Contributions into the Pool 100.0% 0.0% 100.0% 0.0% 100.0% 0.0% 100.0% 0.0% 100.0% 0.0%
Ambulance £8,824 - £8,824 £8,833 - £8,833 £8,878 - £8,878 £8,878 - £8,878 £8,878 - £8,878 NHS 111 £720 - £720 £721 - £721 £725 - £725 £725 - £725 £725 - £725 Hospital Contracts £117,380 - £117,380 £117,173 - £117,173 £117,181 - £117,181 £117,181 - £117,181 £117,181 - £117,181 Community Services £9,986 - £9,986 £9,934 - £9,934 £9,934 - £9,934 £9,934 - £9,934 £9,934 - £9,934 Mental Health £3,984 - £3,984 £3,853 - £3,853 £3,853 - £3,853 £3,853 - £3,853 £3,853 - £3,853 Placements/Non Contracted Activity £4,236 - £4,236 £4,065 - £4,065 £4,081 - £4,081 £4,081 - £4,081 £4,081 - £4,081 Other Contracts £5,334 - £5,334 £4,170 - £4,170 £4,171 - £4,171 £4,171 - £4,171 £4,171 - £4,171 Includes Transformation funding in 17/18. Primary Care - Salford Standard £7,793 - £7,793 £8,687 - £8,687 £8,687 - £8,687 £8,687 - £8,687 £8,687 - £8,687 Primary Care - GP Prescribing £42,715 - £42,715 £41,273 - £41,273 £40,432 - £40,432 £40,432 - £40,432 £40,432 - £40,432 Primary Care - GP contracts £40,868 - £40,868 £39,587 - £39,587 £39,438 - £39,438 £39,438 - £39,438 £39,438 - £39,438 Contingency/Business Rules £4,088 - £4,088 £4,172 - £4,172 £4,301 - £4,301 £4,301 - £4,301 £4,301 - £4,301 £2m contingency + £2m risk reserve Committed Development £6,333 - £6,333 £6,045 - £6,045 £6,045 - £6,045 £6,045 - £6,045 £6,045 - £6,045 Investments (decisions made in 2017/18) Inflation costs - - - £2,400 - £2,400 £5,282 - £5,282 £5,282 - £5,282 £5,282 - £5,282 Service growth/volume growth - - - £2,262 - £2,262 £4,579 - £4,579 £4,579 - £4,579 £4,579 - £4,579 BCF spend/new schemes/investment ------£6,035 - £6,035 £6,035 - £6,035 £6,035 - £6,035 CCG's investment plan £6m- future investments Planned service reductions/CIP identified ------Nil savings required ------TOTAL - CCG Potential Pooling £252,262 - £252,262 £253,175 - £253,175 £263,621 - £263,621 £263,621 - £263,621 £263,621 - £263,621 Corporate Costs £4,225 - £4,225 £4,103 - £4,103 £4,103 - £4,103 £4,103 - £4,103 £4,103 - £4,103 Running Costs £5,560 - £5,560 £5,548 - £5,548 £5,560 - £5,560 £5,560 - £5,560 £5,560 - £5,560 ------TOTAL - CCG £262,046 - £262,046 £262,826 - £262,826 £273,284 - £273,284 £273,284 - £273,284 £273,284 - £273,284
TOTAL EXPENDITURE £262,046 - £262,046 £262,826 - £262,826 £273,284 - £273,284 £273,284 - £273,284 £273,284 - £273,284
DIFFERENCE ------
NHS SALFORD CLINICAL COMMISSIONING GROUP GOVERNING BODY MEETING AGENDA ITEM NO 6 (a)
Item for: Decision/Assurance/Information
23 May 2018
REPORT OF: Clinical Lead for Quality & Safety
DATE OF PAPER: 15 May 2018
SUBJECT: Quality of Commissioned Services
IN CASE OF QUERY Francine Thorpe PLEASE CONTACT: Director of Quality & Innovation 0161 212 4906
Please tick which strategic priorities the paper relates to: STRATEGIC PRIORITIES:
Quality √
Community Based Care
Integrated Care
In Hospital Care
Long Term Conditions and Mental Health
Effective Organisation
PURPOSE OF PAPER: This paper provides information and analysis on key aspects of the quality and safety of services commissioned by NHS Salford Clinical Commissioning Group (CCG). The following three areas:
• Patient safety • Patient experience • Clinical effectiveness
Remain the main focus of data scrutinised in the preparation of this report.
Further explanatory information required
HOW WILL THIS BENEFIT THE By consistently raising the quality of care HEALTH AND WELL BEING OF residents of Salford receive from services SALFORD RESIDENTS OR THE commissioned on their behalf. CLINICAL COMMISSIONING GROUP?
WHAT RISKS MAY ARISE AS A None RESULT OF THIS PAPER? HOW CAN THEY BE MITIGATED?
WHAT EQUALITY-RELATED RISKS None MAY ARISE AS A RESULT OF THIS PAPER? HOW WILL THESE BE MITIGATED?
DOES THIS PAPER HELP ADDRESS No ANY EXISTING HIGH OR EXTREME RISKS FACING THE ORGANISATION? IF SO WHAT ARE THEY AND HOW DOES THIS PAPER REDUCE THEM?
PLEASE DESCRIBE ANY POSSIBLE None CONFLICTS OF INTEREST ASSOCIATED WITH THIS PAPER.
PLEASE IDENTIFY ANY CURRENT Quality by its very nature is everyone’s SERVICES OR ROLES THAT MAY BE business therefore it will impact across all areas AFFECTED BY ISSUES WITHIN THIS of care planning and delivery PAPER:
Footnote:
Members of NHS Salford Clinical Commissioning Group Governing Body will read all papers thoroughly. Once papers are distributed no amendments are possible.
Document Development
Not Comments and Date Process Yes No Outcome Applicable (i.e. presentation, verbal, actual report) Public Engagement N (Please detail the method ie. survey, event, consultation) Clinical Engagement Clinical Lead for Quality and Informed content for (Please detail the method ie survey, event, consultation) Y Safety inclusion Has ‘due regard’ been given to Equality Analysis (EA) of any adverse impacts? (Please detail outcomes, including risks and how these will be managed) Legal Advice Sought N Y Reports discussed at Quality & Informed content for Presented to the Commissioning Committee Safety Commissioning Committee inclusion Group in April 2018
Presented to the Health and Wellbeing Board N Presented to the Integrated Commissioning N Board Presented to any other groups or committees, Y Executive Team Minor amendments made including Partnership Groups (Please specify in comments)
Note: Please ensure that it is clear in the comments and date column how and when particular stakeholders were involved in this work and ensure there is clarity in the outcome column showing what the key message or decision was from that group and whether amendments were requested about a particular part of the work.
Quality of Commissioned Services
1 Executive Summary
This paper provides an overview on a number of issues that are used to measure the quality and safety of patient care within the services commissioned by NHS Salford CCG. Issues that have been discussed at the regular quality meetings with providers are outlined to highlight the level of challenge and scrutiny that occurs through these discussions. An update on Serious Incidents reported at Salford Royal NHS Foundation Trust (SRFT) and Greater Manchester Mental Health NHS Foundation Trust is included along with information on how any themes or trends are being identified and associated actions taken. Key issues discussed with other local providers are also outlined along with information on how any concerns are being addressed.
2 Introduction and Background
2.1 This paper provides some detail in the analysis of quality information about Salford Royal Foundation Trust (SRFT) as our main provider of acute and community services and Greater Manchester Mental Health Foundation Trust as our main provider of mental health services. Information is included about issues that have been discussed with these providers at the regular quality meetings along with quality and safety information gained from other sources.
2.2 An update is provided on progress made in reviewing investigations of Serious Incidents (SI’s), including any themes identified.
2.3 Information is also included in relation to other local providers from a range of sources including direct discussions, Care Quality Commission inspection reports and from the Greater Manchester Health and Social Care Quality Board.
3 Salford Royal NHS Foundation Trust (SRFT ) Update
3.1 Key issues that have been discussed at the recent Quality and Outcomes meetings with SRFT are outlined below
3.1.1 Patient Responsiveness Report
An update was provided at the April Quality and Outcomes meeting in relation to the Trust’s complaints activity during March 2018. This information had been requested as a result of deteriorating performance in respect of the timescales for responding to complaints. The expectation is that 90% of complaints will be responded to within the timeframe agreed with the complainant at the outset
In February 2018 the Trust achieved 75% of responses within this time frame but this had deteriorated to 57% in March 2018.
The reduction in performance was attributed to increased pressures in clinical services leading to delays. The following actions have been put in place to support teams to be more responsive:
• Additional administrative support to relieve some of the pressure on clinical staff
• Additional training for staff involved in investigations to ensure that all aspects of the complaint are addressed at the outset. • Monthly performance reports are being scrutinised at the Trust’s Executive Patient Experience Committee to monitor an internal improvement trajectory that has been agreed. • Information provided at the May meeting indicates an upward trend to 61% • Regular updates have been scheduled for future meetings to monitor progress
The report included the outcomes of six complaints that were upheld and highlighted the actions that had been taken as a result. Commissioners reviewed a summary of the lessons learned and found all were appropriate and no concerns were raised.
3.1.2 CQC Inspection
The Trusts Director of Nursing provided a verbal update on the recent CQC inspection that had been undertaken at SRFT at the May meeting. The process outlined within the new inspection framework indicates that organisations rated as Outstanding will receive an inspection of core services every 5 years, SRFT was last inspected in 2015.
Feedback given was that the review was extremely thorough involving 3 inspection teams as well as including a process that is being trialled where a separate team review the investigation and learning from Never Events. The following areas were inspected:
• Urgent care services including A&E • Surgery and Neurosurgery • General medicine • Out patients • Critical care • Community Dental Services
One of the inspection teams focused specifically on how people with mental health issues were managed in A&E and acute wards.
Verbal feedback received from the inspectors indicated how impressed they were with all the staff that they spoke to in terms of their commitment and approach to the care of their patients. No concerns requiring immediate action have been raised by the inspection team and a follow up “well-led” assessment of the executive team is yet to be held.
The report will be shared with the Trust for factual accuracy and published in due course; the Trust’s Director of Nursing will keep commissioners updated in terms of timescales so a review can be scheduled.
3.2 Serious Incidents (SI’s)
The number of serious incidents reported in 2017/18 is outlined in table 1 below:
Table 1 Number of SI’s reported 71 Number of Never Events (included in the overall total above) 7
Number Closed 39 Number Awaiting Action (reviewed and further assurance 7 requested) Number ongoing (not yet due or not yet reviewed) 16 Number Overdue RCA’s 9
The issue of overdue incidents was discussed at the Quality and Outcomes meeting in May and the Director of Quality and Innovation has written formally to the Trusts Director of Nursing outlining an expectation that they will be received prior to the next SI Closure Panel.
The categories of incidents reported are outlined in table 2
Table 2 TOTAL 71 Never Events 7 Slips/Trips/Falls 22 Pressure ulcer 12 Surgical/invasive procedure incident 2 Sub-optimal care of the deteriorating patient 7 Diagnostic incident including delay 5 Medical equipment/ devices/disposables incident 3 Abuse/alleged abuse of child patient by third party 2 Apparent/actual/suspected self-inflicted harm 2 HCAI/Infection control incident 2 Abuse/alleged abuse of adult patient by staff 1 Incident affecting patient's body after death 1 Unexpected / potentially avoidable injury causing serious harm 1 Maternity/Obstetric incident 1 Medication incident 1 Operation/treatment given without valid consent 1 Treatment delay 1
3.2.1 Falls and pressure ulcers remain the highest reported incidents within the Trust; regular overview of the actions being taken to reduce these incidents is maintained by CCG representation at the Trusts Falls and Pressure Ulcer Steering Group. Recent initiatives that have been promoted by this group include: • The creation of a monitoring dashboard to improve visibility of the overall rate of falls and pressure ulcers which can be drilled down to department and ward level.
• This tool will be used at departmental and directorate governance meetings • Implementation of a Falls Prevention Bulletin which will be issued monthly.
The CCG Quality Team is reviewing rates of falls and pressure ulcers at other similar organisations in order to undertake some comparative work. This will be included in the next Learning from Incidents report that will be presented to Quality Commissioning Committee.
3.2.2 Six of the Never Events reported during 2017/18 relate to wrong level spinal surgery; a presentation was received at the May meeting from one of the spinal surgeons and the senior manager for neurosciences. This focused on the work that the Trust has been doing to analyse and review the incidents, investigations and any associated learning points. Key points to note include: • Analysis of each of the incidents reported during this year did not identify any significant themes • Each investigation included a review of whether the correct level policy was followed and it was in every case
The correct level spinal policy was reviewed by the Royal College of Surgeons when they conducted an external review in 2016 and deemed to be good practice which they have shared elsewhere. The Trust confirmed that all recommendations arising from that external review had been implemented.
Additional actions that have been introduced to minimise the error rate include: • The introduction of a gold spinal marker to improve x-ray identification • A regular workshop for clinicians and relevant staff to review any incidents and share best practice.
The Trust has undertaken some comparisons against other spinal units and international published data which indicates that their error rate is below the reported average.
4 Greater Manchester Mental Health Foundation Trust
4.1 Out of Area Placements
A presentation was received at the April Quality and Outcomes meeting in respect of Out of Area Placements for Salford residents. An in depth analysis has been undertaken, key points to note include: • Increased demand for adult acute and intensive care beds in the last 12 months • Increased activity in RAID team but conversion rate to inpatient activity remains static • Fidelity to the community care pathways that were agreed in terms of timely access and length of stay in home based treatment with no increase in admissions or readmissions • Significant increase in service users staying longer than 50 days
Actions being taken to address the issues highlighted include: • Trust wide adult patient flow meeting has been established with an associated work programme • Links with the Greater Manchester Out of Area Placement group • Work in partnership with commissioners on care pathways
4.2 Serious Incidents (SI’s)
4.2.1 Table 3 below shows the numbers reported by GMMH Salford services during the 2017/18 and the status of the incidents.
Table 3 Number of SI’s reported 41 Number of Never Events (included in the overall total above) 0
Number Closed 22 Number Awaiting Action (reviewed and further assurance 10 requested) Number ongoing (not yet due or not yet reviewed) 9 Number Overdue RCA’s 0
Table 4 below highlights the incident categories as reported.
Table 4 TOTAL 41 Never Events 0 Apparent/actual/suspected self-inflicted harm 23 Slips/Trips/Falls 5 Disruptive/ aggressive/ violent behaviour 4 Pressure Ulcer 3 Pending review 2 Abuse/alleged abuse of adult patient by staff 1 Commissioning incident 1 Failure to obtain appropriate bed for child who needed it 1 Medication incident 1
The highest reported incident category relates to self-inflicted harm for individuals that are in receipt of mental health services, this is in line with other mental health providers.
The organisation is involved in a number of improvement initiatives directed at the prevention of suicide and self-harm. This issue was discussed in some detail at the Quality Commissioning Committee in April where it was agreed that further work would be undertaken to gain an understanding of any reduction in incidents of this nature as a result of the improvement work.
5 Care Homes Care Quality Commission (CQC) Ratings
5.1 The most recent ratings for Care Homes in Salford is outlined in appendix 1:
5.2 Changes since the last Governing Body report are: • A reduction in the number of homes rated as good from 25 to 24 • An increase in the number of homes rated as Inadequate from 4 to 5
5.3 Three inspection reports were published in April the outcomes are as follows: • The Willows Nursing Home has been rated as Requires Improvement when previously rated as Good • Beech House Residential Care Home has been rated as Inadequate from a previous rating of Requires Improvement • Laburnum Court Nursing Home retained a rating of Requires Improvement
5.4 Feedback from colleagues at the CQC through our Quality Improvement Network has indicated that they are prioritising inspections within homes where they have identified concerns. Representatives from the Quality Improvement Network were already involved in working with the homes outlined above. Action plans have been drafted and will be shared with the CQC and partners according to agreed timescales.
5.5 The launch of our Care Homes Excellence programme took place on 3rd May facilitated by Haelo; representatives from 19 care homes attended the event. This included managers from care homes rated as Inadequate and Requires Improvement by the CQC as well as those rated as Good. A range of improvement areas were identified and will be taken forwards over the next 12 months
5.6 A summary report from Healthwatch in relation to the Enter and View visits conducted in Salford’s car homes has now been received. This is scheduled for discussion at the next Care Homes Strategy meeting and will be used to inform the development of our improvement programme.
6 Summary
6.1 A range of issues in relation to the quality of care provided have been highlighted within this paper. .
6.2 Where concerns have been identified the CCG continues to utilise the quality assurance framework to monitor improvements. This includes seeking assurance from direct observations of care as well as evidence relating to actions taken.
6.3 Themes and trends that are emerging through the triangulation of data are being highlighted to providers so that challenge and scrutiny is evident within our quality and safety discussions. It is expected that this will lead to improvements in the quality and safety of services provided to our population.
7 Recommendations
7.1 NHS Salford Clinical Commissioning Group Governing Body is asked to: • Note the contents of this report • Receive assurance that relevant information is being sought to scrutinise the quality and safety of our commissioned services.
Jeremy Tankel Clinical Lead Quality & Safety
Appendix 1 Salford Care Homes CQC Ratings
** results used in Independent Age reports released in April 17 and March 18
NHS SALFORD CLINICAL COMMISSIONING GROUP GOVERNING BODY MEETING AGENDA ITEM No 6 (b)
Item for: Decision/Assurance/Information
23 May 2018
REPORT OF: Chief Accountable Officer
DATE OF PAPER: 10 May 2018
Governing Body Assurance Framework Report SUBJECT: (Planning, Performance and Risk Update)
IN CASE OF QUERY Emma Reid, PLEASE CONTACT: Senior Planning and Performance Manager
STRATEGIC PRIORITIES: Please tick which strategic priorities the paper relates to:
Quality
Population Health and Prevention
Integrated Community Based Care and Long Term Conditions
Transforming Hospital Care
Mental Health
Enabling Transformation
PURPOSE OF PAPER:
The purpose of this paper is to provide the Governing Body with assurance and scrutiny of Salford CCG’s latest position in relation to;
• Strategic Performance Indicators, • Strategic risks – All, • Greater Manchester (GM) Health and Social Care Partnership (HSCP) assurance of the Salford health and social care system – update.
The report also provides the Governing Body with:
• Latest key provider oversight (from the NHS Improvement oversight framework), where changes have occurred since last reported. • Summary GM Health and Social Care performance and key issues.
Further explanatory information required
This report provides a high level summary of Salford HOW WILL THIS BENEFIT THE CCG’s latest position in relation to current performance; HEALTH AND WELL BEING OF the Operational Plan; and strategic risks. Further detail SALFORD RESIDENTS OR THE has been provided in relevant appendices (referenced CLINICAL COMMISSIONING GROUP? in this report) for areas of high risk and underperformance.
WHAT RISKS MAY ARISE AS A RESULT OF THIS PAPER? HOW CAN None. THEY BE MITIGATED?
WHAT EQUALITY-RELATED RISKS MAY ARISE AS A RESULT OF THIS None. PAPER? HOW WILL THESE BE MITIGATED?
DOES THIS PAPER HELP ADDRESS Areas of high risk and underperformance have been ANY EXISTING HIGH RISKS FACING summarised within this report. Detailed performance THE ORGANISATION? IF SO WHAT recovery plans and risk treatment plans are included in ARE THEY AND HOW DOES THIS appendices as appropriate. PAPER REDUCE THEM?
PLEASE DESCRIBE ANY POSSIBLE CONFLICTS OF INTEREST None. ASSOCIATED WITH THIS PAPER.
PLEASE IDENTIFY ANY CURRENT SERVICES OR ROLES THAT MAY BE Any issues are described within the paper. AFFECTED BY ISSUES WITHIN THIS PAPER:
Footnote:
Members of NHS Salford Clinical Commissioning Group Governing Body will read all papers thoroughly. Once papers are distributed no amendments are possible.
Document Development
Not Comments and Date Process Yes No Outcome Applicable (i.e. presentation, verbal, actual report) Public Engagement (Please detail the method ie survey, event, consultation) Clinical Engagement (Please detail the method ie survey, event, consultation) Has ‘due regard’ been given to Equality Analysis (EA) of any adverse impacts? (Please detail outcomes, including risks and how these will be managed) Commissioning Committee This report forms part of the HWBB assurance Presented to the Health and Wellbeing Board scrutiny of Locality Plan delivery along with reports from the Locality Programme Board. Presented to the Integrated Adult Health and Social Care Commissioning Joint Committee Presented to any other groups or committees, Reviewed by the CCG Executive Team. including Partnership Groups (Please specify in comments)
Note: Please ensure that it is clear in the comments and date column how and when particular stakeholders were involved in this work and ensure there is clarity in the outcome column showing what the key message or decision was from that group and whether amendments were requested about a particular part of the work.
Governing Body Assurance Framework Report (Planning, Performance and Risk Update)
1 Executive Summary
The purpose of this paper is to provide the Governing Body with assurance and scrutiny of Salford CCG’s latest position in relation to;
• Strategic Performance Indicators, • Strategic risks – All, • Greater Manchester (GM) Health and Social Care Partnership (HSCP) assurance of the Salford health and social care system – update.
The report also provides the Governing Body with:
• Latest key provider oversight (from the NHS Improvement oversight framework), where changes have occurred since last reported. • Summary GM Health and Social Care performance and key issues.
The NHS Salford Clinical Commissioning Governing Body is asked to:
• Consider the CCG’s latest performance position and accept the recovery plans set out for the indicators currently underperforming; • Note the updated risk position and confirm that the current level of risk is acceptable in line with risk treatment plans; • Note the update in relation Salford Locality Assurance. • Note the update in relation to GM Performance and Delivery.
2 Performance update and current issues
2.1 The CCG’s Delivery Dashboard (Appendix 1) is based on the latest available published data. In addition to the CCG’s delivery dashboard indicators, the appendix also includes the latest position for the Greater Manchester Investment Agreement (GMIA). Oversight for these measures sits with the Integrated Care Advisory Board (ICAB) but it is also routinely reported to the Integrated Commissioning Joint Committee (ICJC). A full exceptions report is provided to that group as part of performance reporting arrangements and so performance recovery plans are not duplicated in this report. The GMIA data contained in Appendix 1 is provided for information only. Detailed recovery plans for areas of underperformance within the CCG’s Delivery Dashboard can be found within Appendix 2.
2.2 CAMHS Waiting Times Governing Body has previously expressed concern regarding waiting time for children and young people who are referred to Child & Adolescent Mental Health Services (CAMHS). A recovery plan has been agreed with the main provider, Manchester NHS Foundation Trust and is being monitored closely. 2017/18 quarter 3 data showed an improvement in waiting times to first and second contact. Quarter 4 data has been recently received. It shows that improvement has been sustained. Average waits from referral to first contact was 10.2 weeks (target 11 weeks)
and average wait from referral to second contact was 16.2 weeks (target 17 weeks). There has been a significant reduction in the number of patients breaching the respective waiting time targets. Commissioners are meeting with the provider on 15 May to discuss the quarter 4 submission in more detail and understand whether further reductions in waiting times can be achieved.
2.3 Quarterly monitoring of services is currently in place and from April 2018, the provider has been requested to provide monthly waiting time data so this can be tracked more frequently. The monthly data will be aligned to new requirements to report the % of children and young people seen within 11weeks and 18 weeks respectfully (rather than average wait). The Community Eating Disorder Service continues to achieve national waiting time standards.
2.4 Flu Data A data quality issue has been identified in respect of some previously reported flu vaccination figures which form part of the Integrated Care System dashboard. The rate of vaccinations has been over-reported on local indicators GMMIA 11 and GMMIA 12, which relate to the “over 65s” and “at risk” cohorts respectively. This is because some vaccinations by “other” providers (i.e. not GP practices) have been double-counted. Other national measures of flu vaccination rates are unaffected. A briefing report is being prepared and trajectories for these indicators will be refreshed.
3 Operational Plan Update
3.1 In 2017/18 the CCG undertook an extensive planning exercise to ensure that all national ‘must do’s’ and local priorities could be effectively delivered as part of a 2 year operational planning process (2017-19).
3.2 The planning process included detailed self-assessments and stock takes through the CCG clinical leads, committees and joint committee against the NHS national planning guidance, the NHS Improvement and Assessment Framework (IAF), national clinical priorities, and comparator insights including JSNAs and NHS Right Care insights.
3.3 Although the National Planning guidance published in 2017/18 covered a two year period (2017-19) further planning guidance was published in January 2018.
3.4 The new guidance included updated requirements for operational (activity) planning, reporting and monitoring however it did not outline any additional commissioning requirements. The 2018 planning guidance has been used to finalise business and operational planning for 2018-19.
3.5 Planning for outcomes
The Salford Locality Plan (2016-21) contains the shared health and wellbeing outcomes for the city developed with residents and partners to ensure everyone living in the city; start wells, live wells and age wells. These are underpinned by the CCG’s strategic aims; to reduce health inequality, prevent ill health, and improve the quality of health care.
3.6 In developing the CCG business plan and workstream plans for 2018-19 there has been detailed consideration of how the proposed transformation work links to these outcomes and supporting metrics as well as known performance challenges and risks to ensure the CCG is playing a lead role in improving wider health and wellbeing and ensuring high quality care.
3.7 Governing Body members will recall, this year business planning was split across a series of workstreams building on the joint planning arrangements in place across Salford with integrated commissioning planning for; children and young people, population health and adult health and social care. These have included clinical and lay and involvement as appropriate; and where joint plans overlap into Council accountabilities and delegation, lead member briefings are also a key part of the process.
3.8 The Salford Health and Social Care Commissioning ‘plan on a page’ for 2018/19 was approved by Governing Body in March and the Operational Plan 2018/19 was approved at the extraordinary Governing Body meeting in April.
3.9 The Operational Plan 2018-19 is being monitored through the CCG’s Performance system, Pentana and as part of the staff appraisals process.
3.10 Progress against the strategic programmes is reported to Governing Body on a 6 monthly basis in May and November. The year-end programme updates for 2017/18 are included at Appendix 3 for information.
4 Strategic Risk Update
4.1 In line with the CCG’s current Risk Management Strategy the full Strategic Risk Register (SRR) is reported to Governing Body twice per year in May and November; see Appendix 4.
4.2 Governing Body is asked to note that the SRR and programme risk registers are currently undergoing a full review including refining the descriptions for the risks included and new risk assessments where required. This review is part of an ongoing piece of work to ensure that the risk management process remains robust and effective. A risk identification workshop has been scheduled for Informal Governing Body in August 2018; further details regarding this session will be shared nearer the time.
4.3 Salford CCG’s latest strategic risk profile is summarised below. A full strategic risk register is included at Appendix 4. There are currently 18 Strategic Risks, 2 of which are scored as High (Red).
4.4 Since the last Planning, Performance and Risk report, there has been 1 new risk added as follows:
Distraction from delivery of organisational objectives during organisational changes associated with integrated commissioning
4.5 Salford CCG’s Programme risk profile is summarised overleaf. The full programme risk registers are available on request.
5 GM Health and Social Care Partnership (GM HSCP) assurance of Salford’s health and social care system
5.1 The GM Health & Social Care Partnership did not convene a 2017/18 Quarter 3 Locality Assurance Meeting with Salford as they agreed to meet with localities by exception to address specific areas of concern.
5.2 The next Locality Assurance Meeting for Salford is for Quarter 4 and was held on Tuesday 15th May 2018, 14:30am-16:30pm. Extensive preparation was conducted in advance of the meeting including responses to a series of Key Lines of Enquiry (KLOEs).
5.3 Key discussion points from the Q4 assurance meeting are summarised below; further details regarding the outcome of this meeting will be provided in a future report.
System Performance • Urgent Emergency Care - 4 Hr 95% Standard & Directory of Services • Diagnostics • Cancer o 2 Wk Wait – Breast o 31 Day Subsequent Surgery • IAPT • EIP
CCG IAF Q3 Dashboard
Quality • HCAI o E. Coli o C. Diff • Prevent • CHC • CQC • 7 Day Services • Ingleside Birthing Centre
Primary Care • 7 Day GP Access • Direct Booking into GP Practices • Core Contractual Requirements • Primary Care Streaming • Workforce Strategies
Population Health • Smoking • CvD considered preventable • Physical Inactivity
Carers Charter
Transformation and Strategy • LCO Peer Review Learning / Development • Medicines • Workforce
Finance • 2017/18 Delivery Position • Alignment • 2018/19 Locality Plan Delivery
6 Single Oversight Framework for NHS Providers
6.1 NHS Improvement’s (NHSI) Single Oversight Framework (SOF) was made effective from 1 October 2016 and replaced the Monitor 'Risk Assessment Framework' and the NHS Trust Development Authority 'Accountability Framework'.
6.2 The SOF sets out how NHSI oversees NHS trusts and NHS foundation trusts, using one consistent approach. It helps to determine the type and level of support that organisations need to meet the requirements.
6.3 The objective is to help providers to attain and maintain Care Quality Commission ratings of ‘Good’ or ‘Outstanding’, meet NHS constitution standards and manage their resources effectively, working alongside their local partners.
6.4 The framework helps to identify NHS providers' support needs across five themes; Quality of care, Finance and use of resources, Operational performance, Strategic change and; Leadership and improvement capability.
6.5 Each trust is segmented into one of the following four categories according to the level of support they need. Where improvements in performance are required, a package of support is developed with the provider to help them achieve this.
Segment Description
1 Providers with maximum autonomy: no potential support needs identified. Lowest level of oversight; segmentation decisions taken quarterly in the absence of any significant deterioration in performance.
2 Providers offered targeted support: there are concerns in relation to one or more of the themes. We've identified targeted support that the provider can access to address these concerns, but which they are not obliged to take up. For some providers in segment 2, more evidence may need to be gathered to identify appropriate support.
3 Providers receiving mandated support for significant concerns: there is actual or suspected breach of licence, and a Regional Support Group has agreed to seek formal undertakings from the provider or the Provider Regulation Committee has agreed to impose regulatory requirements.
4 Providers in special measures: there is actual or suspected breach of licence with very serious and/or complex issues. The Provider Regulation Committee has agreed it meets the criteria to go into special measures.
6.6 Salford CCG monitors the latest published NHS Improvement (NHSI) segmentation results for Greater Manchester provider trusts and reports any changes to Governing Body.
6.7 Since the last report in March, there has been one change as outlined below.
Organisation Name Sector Previous New Direction Segment Segment Manchester University NHS Foundation Acute 2 1 Improved Trust
7 GM Performance & Delivery Board Feedback
7.1 As part of the GM HSCP governance structure, the GM Performance and Delivery Board meets on a monthly basis to review delivery across health and social care, including but not limited to NHS constitutional standards and performance against the CCG Improvement and Assessment Framework (IAF) metrics. The emphasis of the meetings is to evaluate performance and delivery at a GM level, as well as highlighting localities where particular delivery challenges are apparent, and to agree further actions.
7.2 The latest IAF (Salford summary) for April 2018 is included at Appendix 5 for information. Areas of underperformance were discussed at the GM Assurance Meeting for quarter 4; see section 5 of this report.
7.3 The latest performance and delivery board feedback letter for March 2018 is included at Appendix 6 for information.
8 Recommendations
8.1 The NHS Salford Clinical Commissioning Governing Body is asked to:
• Consider the CCG’s latest performance position and accept the recovery plans set out for the measures currently underperforming; • Note the updated risk position and confirm that the current level of risk is acceptable in line with risk treatment plans; • Note the update in relation Salford Locality Assurance. • Note the update in relation to GM Performance and Delivery.
Anthony Hassall Chief Accountable Officer
APPENDICES:
Appendix 1a – Delivery Dashboard 2017-18 Appendix 1b – ICS Dashboard Appendix 2 – Performance Recovery Plans Appendix 3 – Year-end strategic programme updates 2017/18 Appendix 4 - Strategic Risk Register – All Risks Appendix 5 – CCG Improvement and Assessment Framework (Salford summary) April 2018 Appendix 6 – GM Performance and Delivery Board Feedback (March 2018)
Appendix 1a – CCG Delivery Dashboard
1. Quality of Care
Apr May Jun Q1 Jul Aug Sep Q2 Oct Nov Dec Q3 Jan Feb Mar Q4 2017/18 2016/17 Code Short Name 2017 2017 2017 2017/18 2017 2017 2017 2017/18 2017 2017 2017 2017/18 2018 2018 2018 2017/18 Value Value Value Value Value Value Value Value Value Value Value Value Value Value Value Value Value Target Value Target E.A.S.04 HCAI Measure MRSA (CCG) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 3 0 E.A.S.04 HCAI Measure MRSA (SRFT) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2 0 E.A.S.05 HCAI Measure CDIFF (CCG) 5 6 12 11 2 10 4 7 9 6 5 6 83 62 59 62 E.A.S.05 HCAI Measure CDIFF (SRFT) 0 3 3 3 1 2 1 1 6 1 3 2 26 21 21 21 Mixed Sex Accommodation Breaches E.B.S.01 4 0 1 2 1 3 2 0 0 1 1 3 18 0 19 0 (CCG) Mixed Sex Accommodation Breaches E.B.S.01 0 0 0 0 0 0 0 0 0 0 0 1 1 0 2 0 (SRFT) Number of patients not treated within 28 E.B.S.02 days of last minute elective cancellation 15 1 1 17 0 53 0 (SRFT) E.B.S.04 RTT: Incomplete Pathways (>52 weeks) 0 0 1 1 4 2 1 1 3 3 3 19 0 13 0 % of Care Homes rated as Requiring INSP.01 43.6% 34.9% 36.6% 36.8% 36.8% 30% Improvement or Inadequate Number of GP practices rated as Requiring INSP.02 4 2 1 1 1 3 4 Improvement Number of GP practices rated as INSP.03 1 0 0 1 1 0 Inadequate QP.01a Antibiotics prescribed in primary care 1.214 1.212 1.21 1.206 1.204 1.202 1.202 1.197 1.19 1.195 1.193 1.193 1.161 1.219 1.233 Number of Escherichia coli (E. coli) QP.06a 18 16 15 17 19 15 21 15 21 17 21 10 205 154 187 bacteraemia (CCG) Reduction in the Trimethoprim : QP.06b i) 0.848 0.84 0.827 0.821 0.806 0.786 0.758 0.73 0.709 0.689 0.68 0.68 0.798 Nitrofurantoin prescribing ratio. Number of Trimethoprim items prescribed QP.06b ii) 5000 4983 4980 4980 5016 4941 4861 4744 4662 4579 4585 4585 4910 to patients aged 70 years or greater.
2. Population Health and Prevention
Apr May Jun Q1 Jul Aug Sep Q2 Oct Nov Dec Q3 Jan Feb Mar Q4 2017/18 2016/17 Code Short Name 2017 2017 2017 2017/18 2017 2017 2017 2017/18 2017 2017 2017 2017/18 2018 2018 2018 2017/18 Value Value Value Value Value Value Value Value Value Value Value Value Value Value Value Value Value Target Value Target Women's Smoking Status at Time of SATOD.01 12.9% 11.4% 13.5% 11.6% 12.3% 13% 12.7% 13% Delivery
1 Appendix 1a – CCG Delivery Dashboard
3. Integrated Community Based Care and Long Term Conditions
Apr May Jun Q1 Jul Aug Sep Q2 Oct Nov Dec Q3 Jan Feb Mar Q4 2017/18 2016/17 Code Short Name 2017 2017 2017 2017/18 2017 2017 2017 2017/18 2017 2017 2017 2017/18 2018 2018 2018 2017/18 Value Value Value Value Value Value Value Value Value Value Value Value Value Value Value Value Value Target Value Target Delayed Transfers of Care - Bed Days DTOC.01 3.3% 4.6% 4.2% 3.4% 4.4% 3.7% 2.9% 2.5% 2.6% 3.5% 3.5% 6.1% 3.5% (SRFT) Proportion of older people 65 and over still E.A.S.03 at home 91 days after discharge into 75.4% 69.9% 71.3% 71.3% 79.6% 79.6% 78% rehabilitation Delayed transfers of care, per 100,000 E.J.01 953 892.1 682 682 1027.9 1047.2 692.9 population (aged 18+) Long term support needs of older people E.J.02 (aged 65 and over) met by admissions to 216.1 421.2 626.2 626.2 967.2 973 896.6 residential and nursing care homes Number of personal health budgets that E.N.1 have been in place, at any point during the 303.18 quarter, per 100,000 CCG population. Percentage of children waiting 18 weeks or E.O.1 60.5% 92% 85.7% 91.7% 80.3% 92% less for a wheelchair % of practices (out of a possible 44) that are registered for online access and PO.07 45.5% 45.5% 45.5% 45.5% 15.9% 20.5% 27.3% 27.3% 100% 27.3% 100% achieving the national 20% target for appointments booked/cancelled online Patients Online - Appointments made or PO.08 3241 3579 3633 3657 2513 2886 3830 3830 3624 3624 2535 cancelled using online capability NHS CHC eligibility decision is made by 28 QP.CHC.a 44.8% 92% 96% 96% 80% days from the receipt of the Checklist NHS CHC assessments take place in an QP.CHC.b 31.6% 10% 9% 9% 15% acute hospital setting
4. Transforming and standardising acute and specialist hospital care (Including Hospital Group - acute collaboration)
Apr May Jun Q1 Jul Aug Sep Q2 Oct Nov Dec Q3 Jan Feb Mar Q4 2017/18 2016/17 Code Short Name 2017 2017 2017 2017/18 2017 2017 2017 2017/18 2017 2017 2017 2017/18 2018 2018 2018 2017/18 Value Value Value Value Value Value Value Value Value Value Value Value Value Value Value Value Value Target Value Target NWAS Ambulance Response Programme | ARP.01 Category 1 - Life threatening (mean 10:07 09:50 09:29 09:44 11:17 09:51 08:55 09:53 07:00 response time [07:00]) NWAS Ambulance Response Programme | ARP.02 Category 1 - Life threatening (90th 15:59 16:21 15:36 16:14 18:37 16:44 15:15 16:23 15:00 percentile in 15mins)
2 Appendix 1a – CCG Delivery Dashboard
Apr May Jun Q1 Jul Aug Sep Q2 Oct Nov Dec Q3 Jan Feb Mar Q4 2017/18 2016/17 Code Short Name 2017 2017 2017 2017/18 2017 2017 2017 2017/18 2017 2017 2017 2017/18 2018 2018 2018 2017/18 Value Value Value Value Value Value Value Value Value Value Value Value Value Value Value Value Value Target Value Target NWAS Ambulance Response Programme | ARP.03 Category 2 - Emergency (mean response 24:20 25:04 25:55 30:34 44:49 39:59 31:58 31:48 18:00 time [18:00s]) NWAS Ambulance Response Programme | 00:55:5 00:56:1 00:57:4 01:10:1 01:43:5 01:31:3 01:09:4 01:12:1 00:40:0 ARP.04 Category 2 - Emergency (90th percentile in 4 1 1 8 8 3 8 1 0 40mins) NWAS Ambulance Response Programme | 01:37:2 01:58:2 02:01:5 02:02:0 02:54:4 03:14:1 02:54:5 02:23:2 02:00:0 ARP.05 Category 3 – Urgent (90th percentile in 7 1 8 2 7 6 2 3 0 120mins) NWAS Ambulance Response Programme | 02:34:2 02:40:2 02:28:4 02:36:0 03:33:3 03:16:3 03:01:0 02:52:5 03:00:0 ARP.06 Category 4 – Less Urgent (90th percentile 1 8 7 0 5 1 3 7 0 in 180mins) E.B.03 RTT: Incomplete pathways (<18 weeks) 93.5% 93.5% 93.5% 92.8% 92.8% 92.5% 92.7% 93% 92.4% 92.6% 92.6% 93.1% 92% 93.6% 92% E.B.04 Diagnostic Test Waiting Times 1.2% 1% 2.2% 2.2% 4.2% 3.6% 2.5% 2.6% 4.6% 3.5% 1.4% 2.6% 1% 1.2% 1% A&E Waiting Time - Seen within 4 hours E.B.05 89.3% 84.5% 85.3% 91% 91.3% 89.3% 88.1% 89.1% 81.6% 82.6% 78.3% 82.3% 86.1% 95% 86.4% 95% (CCG) A&E Waiting Time - Seen within 4 hours E.B.05 89.9% 82.1% 83.7% 88.4% 93% 89.5% 87.3% 90.2% 81.7% 82.3% 75.6% 82% 85.5% 95% 86% 95% (SRFT) Cancer Patients - 2 Week Waits (Urgent E.B.06 91.9% 96.8% 95.4% 94.9% 96.3% 95.9% 95.4% 95.9% 96.2% 96.5% 96.7% 96.5% 97% 97.9% 96.7% 97.2% 96.1% 93% 95.1% 93% GP Referral) Cancer Patients – 2 week wait for breast E.B.07 symptoms (where cancer was not initially 91% 94.3% 89.4% 91.5% 89.1% 85.4% 86% 86.9% 75% 94.6% 95.5% 88.6% 89.4% 92.4% 89.7% 90.4% 89.3% 93% 93.7% 93% suspected) E.B.08 Cancer Waits - 31 Days (All Cancers) 96.2% 100% 100% 98.9% 98% 97.2% 99% 98.1% 98.9% 100% 99% 99% 98.8% 100% 98.1% 99.3% 98.8% 96% 98.2% 96% E.B.09 Cancer Waits - 31 Days (Surgery) 90.5% 95% 94.4% 94.9% 100% 96.3% 100% 98.8% 95.5% 95.7% 100% 97.1% 100% 92.9% 100% 98.5% 97.5% 94% 98% 94% E.B.10 Cancer Waits - 31 Days (Drugs) 95.5% 100% 100% 98.3% 100% 91.7% 100% 98.2% 100% 100% 100% 100% 100% 100% 100% 100% 99.1% 98% 100% 98% E.B.11 Cancer Waits - 31 Days (Radiotherapy) 100% 100% 100% 100% 100% 100% 96.3% 99% 100% 96.3% 100% 99% 100% 100% 100% 100% 99.4% 94% 99.7% 94% Cancer Waits - 62 Days (Urgent GP E.B.12 73.3% 88.5% 81% 83.7% 84.4% 78.4% 87% 84% 77.1% 80% 82.1% 79.7% 80.4% 87.5% 83.7% 84.2% 82.9% 85% 82.9% 85% Referral) Cancer Waits - 62 Days (Screening E.B.13 33.3% 80% 88.9% 77.3% 100% 100% 80% 95% 0% 100% 100% 92.9% 100% 100% 75% 91.7% 88.2% 90% 95.2% 90% Service) Cancer Waits - 62 Days (Decision to E.B.14 82.6% 75% 83.3% 80.9% 88.9% 88.9% 93.3% 90.4% 78.6% 78.9% 83.3% 81.4% 77.8% 100% 87.5% 90.2% 85.6% 85% 83.5% 85% Upgrade) E.B.S.05 Trolley Waits in A&E (>12 Hours) (SRFT) 0 0 0 0 0 0 0 0 1 0 0 0 1 0 7 0 Urgent Operations Cancelled for a Second E.B.S.06 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Time (SRFT)
3 Appendix 1a – CCG Delivery Dashboard
5. Mental Health
Apr May Jun Q1 Jul Aug Sep Q2 Oct Nov Dec Q3 Jan Feb Mar Q4 2017/18 2016/17 Code Short Name 2017 2017 2017 2017/18 2017 2017 2017 2017/18 2017 2017 2017 2017/18 2018 2018 2018 2017/18 Value Value Value Value Value Value Value Value Value Value Value Value Value Value Value Value Value Target Value Target E.A.03 IAPT Roll-Out (CCG) - PUBLISHED 1.6% 2.2% 1.9% 1.9% 2.2% 1.9% 2.2% 2.1% 1.5% 2% 19.5% 14% 24% 15% E.A.S.01 Dementia (aged 65 and over) 88% 87% 87.9% 89.1% 88.5% 89% 88.1% 89.2% 88.7% 87.2% 86.5% 85.2% 85.2% 88% 87.9% 87.5% E.A.S.02 IAPT Recovery Rate (CCG) - PUBLISHED 50% 47.3% 48.2% 41.1% 44.3% 46.9% 44.4% 41.4% 45.5% 42.9% 45.2% 50% 42.6% 50% E.B.S.03 Care Programme Approach (CCG) 98.6% 98% 98.1% 98.1% 95% 98.4% 95% IAPT Waiting Times - 6 Week Wait Ended E.H.1_A1 85.1% 84.8% 83.6% 80.3% 83.3% 81.5% 72.9% 71.1% 73.3% 70.2% 78.6% 75% 80.5% 75% Referrals (CCG) - PUBLISHED IAPT Waiting Times - 18 Week Wait Ended E.H.2_A2 100% 98.7% 100% 100% 100% 98.2% 95.7% 92.1% 93.3% 92.5% 97% 95% 97% 95% Referrals (CCG) - PUBLISHED People experiencing a first EIP treated E.H.04 70% 54.5% 100% 66.7% 87.5% 91.7% 100% 100% 100% 83.3% 83.3% 82.7% 85.1% 50% within two weeks of referral E.H.09 Improve access rate to CYPMH 12.4% 21.7% 29.2% 29.2% 30% Waiting times for Routine Referrals to E.H.10 Children and Young People Eating 72% 100% 90.9% 82.6% Disorder Services Waiting times for Urgent Referrals to No E.H.11 Children and Young People Eating 100% 100% 100% Activity Disorder Services
4 Integrated Commissioning System (ICS)| Reports
Key ‐ applies to GMIA.01, 02, 04, 05, 06, 16 Select Report Advisory Board Select starting month Apr‐17 Meets the target Between 2.5‐5% above the target Select starting quarter Q1 17/18 2017/18 0‐2.5% above the target 5% above the target
Greater Manchester Investment Agreement (GMIA) 12‐month 12‐month 2017‐18 2017‐18 2015‐16 Q1 Q2 Q3 Q4 Code Measure (Aim) 2016‐17 Apr‐17 May‐17 Jun‐17 Jul‐17 Aug‐17 Sep‐17 Oct‐17 Nov‐17 Dec‐17 Jan‐18 Feb‐18 Mar‐18 rolling data rolling data Latest Data Period Target Target Baseline 17/18 17/18 17/18 17/18 (Ambition) (Do nothing) (Do nothing) (Ambition)
GMIA.01 Non‐elective admissions (reduction) 36,678 35,800 2694 3091 3068 3083 2967 3037 3293 3132 2916 3143 2704 3167 36,295 36,295 36,295 Mar‐18 37,829 34,678
GMIA.02 A&E attendances (reduction) 106,325 107,204 8796 9300 8965 9073 8508 8883 9854 9466 9243 9054 8160 9311 108,613 108,613 108,613 Mar‐18 109,615 99,025
GMIA.03 Care home admissions (reduction) 989.7 967.1 216.1 199.5 210.6 241.2 241.2 Q4 17/18 846
GMIA.04 Elective planned admissions (reduction) 32,196 33,041 2465 2711 2749 2592 2597 2617 2631 2873 2341 2689 2627 2711 31,603 31,603 Mar‐18 32098
GMIA.05 First outpatient appointments (reduction) 57,053 59,499 4302 5286 5231 4983 5370 5365 5975 5914 4517 5612 5314 5781 63,650 63,650 Mar‐18 57117
GMIA.06 Outpatient follow‐up appointments (reduction) 148,204 143,859 10393 12225 12235 11600 11565 11952 12647 13322 10343 13482 11332 12511 143,607 143,607 Mar‐18 147709
Health‐related quality of life for people with long term conditions GMIA.07 69.9% 68.5% 68.5% 2016/17 71.3% (increase) Health‐related quality of life for carers with long term conditions GMIA.08 78.2% 78.1% 78.1% 2016/17 78.9% (increase) Proportion of people that feel supported to manage their own GMIA.09 65.7% 65.0% 65.0% 2016/17 65.8% condition (increase)
GMIA.10 Satisfaction with care & support provided (increase) 64.2% 62.8% 62.8% 2016/17 65.3%
Seasonal Flu Vaccine Uptake | 65 and overs (includes GP, GMIA.11 73.8% 73.5% 0.0% 0.0% 0.0% 0.0% 0.0% 0% 64.6% 71.7% 72.9% 74.8% 0.0% 0.0% 74.8% 2017/18 80.1% Pharmacy and outside healthcare organisations) (increase) Seasonal Flu Vaccine Uptake | Under 65s at risk (includes GP, GMIA.12 42.8% 47.4% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 31.8% 39.7% 43.5% 45.8% 0.0% 0.0% 45.8% 2017/18 47.5% Pharmacy and outside healthcare organisations) (increase)
GMIA.13 Proportion of people that die at usual place of residence (increase) 43.1% 40.4% 41.2% 40.8% 41.6% 0.0% 41.6% Q3 17/18 44.8%
GMIA.14 % of expected Dementia prevalence (aged 65 and over) (increase) 89.2% 87.9% 88.0% 87.0% 87.9% 89.2% 88.5% 89.0% 88.1% 89.2% 88.7% 87.2% 86.5% 85.2% 85.2% Mar‐18 88.0%
Patients diagnosed with dementia whose care plan has been GMIA.15 reviewed in a face‐to‐face review in the preceding 12 months 79.0% 79.9% 79.9% 2016/17 80.4% (increase)
GMIA.16 Reduce the growth for primary care prescribing by 1% £39,322,000 £40,713,311 £3,028,204 £3,400,497 £3,522,298 £3,449,680 £3,346,986 £3,380,175 £3,549,291 £3,473,177 £3,266,672 £3,354,368 £2,959,634 £0 £40,308,619 £40,308,619 Mar‐18 £41,527,577
Drugs monitored in‐line with the shared protocol monitoring GMIA.17 100.0% 100.0% 100% 100% 100% 100% 100% Q4 17/18 100% guidance for each drug at GP Practices (increase) Total number of care home placements for Salford residents over GMIA.18 825 831 796 794 779 764 764 Q4 17/18 808 65* Median length of stay in nursing / residential care homes for GMIA.19 15.8 13.5 17.1 15.2 17.0 17.0 17.0 Q4 17/18 13.5 residents 65+ (months) % of homes with CQC rating of inadequate or requires GMIA.20 67.0% 52.0% 41.0% 36.7% 36.7% 34.2% 34.2% Q4 17/18 30% improvement Appendix 2 – Performance Recovery Plans
NWAS Ambulance Response Programme | Category 1 - Life threatening (mean response time ARP.01 [07:00]) Ambulance Response Programme (ARP) Category 1 is for 999 calls about people with life-threatening injuries and illnesses. These will be responded to in an average time of seven minutes.
Desired Performance against Target: Aim to Minimise Latest Data: February 2018 result Latest update provided: 01-Mar-2018
Note: The below recovery plan applies to all ARP indicators (ARP.01 – 06) and so is not duplicated on the following pages. Data is provided for information.
Following the largest clinical ambulance trials in the world, NHS England implemented new ambulance standards across the country. On 7th August 2017 the North West Ambulance Service (NWAS) fundamentally changed the incident classification and response measures it uses. This means that any reports which were based on Reds/Greens or measuring 8/19 minute response times are no longer available or relevant.
NWAS is now using the Ambulance Response Programme (ARP) to categorise their 999 calls and performance targets have changed accordingly.
The CCG received the data for the period August 2017-December 2017 on 16th February 2018. The data shows that NWAS are not currently meeting performance targets. The CCG has approached NHS Blackpool CCG, as the lead commissioner for the service for clarity on performance improvement plans.
Actions being taken: The contract with the North West Ambulance Service (NWAS) is managed on behalf of Greater Manchester by Blackpool CCG. The Blackpool CCG Team are working with NHS Improvement (NHSI), NHS England (NHSE) , the Strategic Partnership Board (SPB) and NWAS on a Performance Improvement Plan to deliver immediate actions and plans for the next 3-6 months to ensure sustainable improvement to meet the national Ambulance Response Programme (ARP) targets.
As part of the Improvement Plan, there is a specific section relating to assurance on patient safety and a section focusing on system wide pressures including handover and turnaround.
The development of the plan is being overseen jointly by NHSI and NHE at an NHS North of England level and the Chief Officer SPB leads. Progress against the draft plan is being monitored at weekly meetings between NHSE/ NHSI and the lead commissioning team with NWAS. Progress is shared with SPB and will remain the focus of future SPB
1 Appendix 2 – Performance Recovery Plans meetings until such time as performance improves to meet the ARP standards. Greater Manchester version of the NWAS Improvement Plan has been developed with the intention that progress against this version will be overseen by representatives from Greater Manchester localities.
Current Status: Expected Outcome: Lead Manager: Tori Quinn Executive Lead: Karen Proctor
NWAS Ambulance Response Programme | Category 1 - Life threatening (90th percentile in ARP.02 15mins) Ambulance Response Programme (ARP) Category 1 is for 999 calls about people with life-threatening injuries and illnesses. (e.g. 9 out of 10 people have a response time within the target)
NWAS Ambulance Response Programme | Category 2 - Emergency (mean response time ARP.03 [18:00s]) Ambulance Response Programme (ARP) Category 2 is for 999 emergency calls. These will be responded to in an average time of 18 minutes.
2 Appendix 2 – Performance Recovery Plans
ARP.04 NWAS Ambulance Response Programme | Category 2 - Emergency (90th percentile in 40mins) Ambulance Response Programme (ARP) Category 2 is for 999 emergency calls. (e.g. 9 out of 10 people have a response time within the target)
ARP.05 NWAS Ambulance Response Programme | Category 3 – Urgent (90th percentile in 120mins) Ambulance Response Programme (ARP) Category 3 is for 999 Urgent calls. (e.g. 9 out of 10 people have a response time within the target)
3 Appendix 2 – Performance Recovery Plans
ARP.06 NWAS Ambulance Response Programme | Category 4 – Less Urgent (90th percentile in 180mins) Ambulance Response Programme (ARP) Category 4 is for 999 Less Urgent calls. (e.g. 9 out of 10 people have a response time within the target)
E.A.S.01 Dementia (aged 65 and over) Estimated diagnosis rate for people with Dementia (aged 65 and over)
Desired Performance against Target: Aim to Maximise Latest Data: March 2018 result Latest update provided: 02-May-2018 Trend analysis indicates that the GP pathway is working as expected and referrals from primary care to the Memory Clinic (MATS) remain at a good level. However recent underperformance in MATS has resulted in a reduction of the
4 Appendix 2 – Performance Recovery Plans total number of people aged 65+ with a diagnosis of dementia from 2,016 in November 2017 to 1,911 in February 2018, with increasing waiting time to diagnosis. The performance matter has been escalated to the contract meeting that is held with GMMH and a recovery plan will be requested. In addition commissioners will be attending the MATS team meeting to discuss performance and work through solutions to make improvements.
Actions being taken: The Data Quality Team has identified the following practices to target improvement efforts as their dementia registers show the largest potential for improvement: The Poplars / The Sides / Sorrell Group / The Lakes.
The Data Quality Team is in the process of conducting practice visits to further investigate this issue which is suspected to be related to data integrity/quality. However, this cannot be confirmed until the practice visits are concluded.
In addition to this investigation, the CCG’s Lead Manager for Dementia has approached Greater Manchester Mental Health (GMMH) Memory Assessment and Treatment Service (MATS) and asked them to contact the practices through their GP Liaison service in case there are any issues around confirmation of dementia diagnosis between MATS and the practices.
Current Status: Expected Outcome: Timescale for Recovery: Further investigation ongoing. Lead Manager: Paul Walsh Executive Lead: Judd Skelton
E.A.S.02 IAPT Recovery Rate (CCG) - PUBLISHED Measures the proportion of people who complete treatment who are moving to recovery.
Desired Performance against Target: Aim to Maximise Latest Data: January 2018 result Latest update provided: 02-May-2018 We have just received our full year local data for IAPT for 2017/18. This shows that the annualised recovery rate did fail target, but only by 1% (49% for the full year). If the data issue is remedied (as discussed below), recovery rate should be achievable going forward for Salford. The full year local data also shows that, in spite of the step 3 staffing issues (outlined below), annualised performance in relation to 6wk and 18wk waits was 76.6% and 96% respectively
5 Appendix 2 – Performance Recovery Plans so meeting target for the year. However, this does not change the fact that performance has been on the decline over the last 6 months – hence the plan as outlined below. The principal reasons for the challenges in achieving the targets are as follows;
1. The service is under-resourced at step 3, which has seen more people flowing in at that level than was anticipated when the SPA model was implemented 2 years ago. The impact of the under-resourcing is that a big backlog developed, and this started to negatively impact on waiting times. To some extent this will also impact on recovery rate in that if patients have waited excessively to enter therapy the recovery challenge is much greater. 2. We have a long-standing data flaw issue around how NHS digital interprets data for any people who step out of our Step 2 service (Six Degrees), and into our Step 3 service (GMMH NHS Trust). They need to be treated as progressing along one IAPT pathway, but they aren’t. NHS Digital treats them as ended episode in step 2 service, and starting afresh in step 3 service. This artificially inflates access rate and deflates recovery rate. Commissioners believe that, without this data flaw, our published recovery rates would be consistently above 50%.
Actions being taken: Our local plan to resolve the above is as follows: • The recovery rate/data flaw issue was explored with the IAPT Support Team at a Salford workshop session in late November 2017. Following this the CCG commissioner for IAPT made contact (again) with NHS Digital, who have assured us that they are actively working on a solution. • A business case is awaiting CCG decision – this is focused upon expanding capacity at step 3 to meet existing demand, close the immediate gap and staff the service to a suitable level to meet 2018/19 access rate target of 19%, whilst also seeing people quickly enough (most people within 6 weeks). Commissioners are confident that, once new staff are in post this will gradually correct the waiting time deficits, whilst maintaining a healthy access rate. In addition to the action above, this aspect will also have a positive impact on recovery rates, and will also see additional specialist practitioners recruited to focus on perinatal mental health within IAPT. Full performance impact not likely to be visible until 2018/19 late Q3/early Q4
We are progressing with our planning around integrated approaches for LTCs. The national clinical lead for LTC IAPT has delivered a workshop in Salford which brought bring together service staff from the fields of IAPT, Diabetes, Audiology, COPD, Cardiology and Health Psychology. We will explore how we can integrate our local pathways and improve access for these important groups.
Current Status: Expected Outcome: Timescale for Recovery: See notes above. Lead Manager: Tony Marlow Executive Lead: Judd Skelton
6 Appendix 2 – Performance Recovery Plans
E.A.S.03 Proportion of older people 65 and over still at home 91 days after discharge into rehabilitation Proportion of older people (65 and over) who were still at home 91 days after discharge from hospital into reablement / rehabilitation services
Desired Performance against Target: Aim to Maximise Latest Data: Latest result for 2017/18 as of Q3 2017/18 Latest update provided: 18-Jan-2018 The provider has reported challenges in complexity and acuity of patients as a contributory factor to not achieving the target. The provider has also reported a number of staffing challenges over the first two quarters of 2017/18, including access to homecare reablement capacity via Intermediate Care.
Actions being taken: The transformation project for Intermediate Care and the retender of ASC homecare services over the next few months will address these challenges.
There are a number of initiatives in place and developing to support people to remain in their own homes. For example the Crisis Team is due to launch in the Spring and the new Home Care Service is currently being procured.
Current Status: Expected Outcome: Timescale for Recovery: 2018/19 Lead Manager: Paul Walsh Executive Lead: Judd Skelton
7 Appendix 2 – Performance Recovery Plans
E.A.S.05 HCAI Measure CDIFF (CCG) Healthcare acquired infection (HCAI) measure (clostridium difficile infections)
Desired Performance against Target: Aim to Minimise Latest Data: Cumulative result for 2017/18 as of March 2018 Latest update provided: 16-Mar-2017 SRFT are now at trajectory for CDI cases. RCA's are undertaken on all cases and are reviewed with the CCG at the CDI Review Panel, where any lapses in care and associated actions are identified. CDI's are discussed at the joint Acute / Community CDI Action Review Group which is held quarterly
Actions being taken: All cases are discussed at the Salford Royal NHS Foundation Trust (SRFT) CDIFF Action Review Group and with the Infection Control Link Nurses from wards / departments. The Root Cause Analysis (RCA) for all community cases are discussed by the Community Infection Prevention Control Team (CIPCT) with the patients’ GP to enable lessons learnt to be shared. The joint HCAI meeting led by the CCG is a forum for discussion relating to HCAI and sharing learning across the health economy. MRI cases - monitoring and reports picked up by Manchester CCG’s infection prevention control team.
Current Status: Expected Outcome: Lead Manager: Sue Harris Executive Lead: Francine Thorpe
8 Appendix 2 – Performance Recovery Plans
E.A.S.05 HCAI Measure CDIFF (SRFT) Healthcare acquired infection (HCAI) measure (clostridium difficile infections)
Desired Performance against Target: Aim to Minimise Latest Data: Cumulative result for 2017/18 as of March 2018 Latest update provided: 16-Mar-2017 SRFT are now at trajectory for CDI cases. RCA's are undertaken on all cases and are reviewed with the CCG at the CDI Review Panel, where any lapses in care and associated actions are identified. CDI's are discussed at the joint Acute / Community CDI Action Review Group which is held quarterly
Actions being taken: Salford Royal Foundation Trust (SRFT) Infection Prevention and Control (IPC) Team continues to undertake Root Cause Analysis (RCA) on all cases. Collaborative working with Salford City Council (SCC) Health Prevention Team continues to ensure all information is captured for the RCA.
Themes and trends form cases are discussed at the health economy CDI (clostridium difficile infections) Review Group. All CDI cases are discussed at the CCG led CDI Review panel where determination is made using evidence provided in the RCA as to whether cases are avoidable / unavoidable and any preventative actions that can be taken.
Current Status: Expected Outcome: Lead Manager: Sue Harris Executive Lead: Francine Thorpe
9 Appendix 2 – Performance Recovery Plans
E.B.04 Diagnostic Test Waiting Times Percentage of patients waiting six weeks or more for a diagnostic test.
Desired Performance against Target: Aim to Minimise Latest Data: February 2018 result Latest update provided: 15-May-2018 The national target is that fewer than 1% of patients should wait 6 weeks or more for a diagnostic test.
Performance improved in February and March to 1.4%. There were 79 Salford patients who breached the target in March, 53 of these were waiting for MRI scans at Salford Royal.
Salford Royal state an increase in demand for MRI scans has led to a high number of breaches. The CCG requested the Trust submit an improvement plan and this has now been received. This plan does not state when performance will be back to the waiting time standard, the CCG has requested clarity on this.
Actions being taken: CCG staff have raised the MRI capacity issues and recovery plans for discussion at the scheduled care board. Improvement plans are being progressed and the Trust is still unable to state when the position will be recovered. The Trust has sourced additional temporary MRI capacity from InHealth, The Manchester Institute of Health and Performance and Spire. The SRFT Board of Directors is to make a decision on a long term solution to the capacity issues within MRI. Monthly updates will continue to come to the board until performance has improved. Current Status: Expected Outcome: Timescale for Recovery: 2018/19 Lead Manager: Tori Quinn Executive Lead: Karen Proctor
10 Appendix 2 – Performance Recovery Plans
E.B.05 A&E Waiting Time - Seen within 4 hours (CCG) Percentage of A&E attendances where the patient spent 4 hours or less in A&E from arrival to transfer, admission or discharge. CCG figure based on weighting.
Desired Performance against Target: Aim to Maximise Latest Data: March 2018 result Latest update provided: 12-Apr-2018 Performance in March was 82.3%, an improvement on February, but significantly below the 95% standard.
Approximately 70% of the Salford CCG population’s A&E attendances are at SRFT so performance against the standard for the Salford CCG population is largely driven by performance at SRFT. This % has fallen in 2017/18 as attendances at SRFT have stayed constant, but attendances at other A&Es continue to rise. See the update on performance against the A&E standard at Salford Royal Foundation Trust (SRFT) for more information.
Actions being taken: The CCG is a member of the Greater Manchester Urgent and Emergency Care Network (GMUECN) which is developing overarching delivery plans for the implementation of the Urgent and Emergency Care Review. Under oversight of the network a Greater Manchester Urgent and Emergency Care Taskforce led by a team of four senior leaders from secondary & primary care, a Council and a CCG is being established which will be responsible for comprehensively understanding the urgent and emergency care challenges for Greater Manchester and for delivery of the following;
• Assurance – when something is supposed to be happening as outlined in the GM UECN Plan • Implementation – when something good isn’t happening everywhere • Facilitating solutions & action – identifying innovative solutions to common problems
The Urgent and Emergency Care Delivery Board (UECDB) is working collaboratively to improve the current position. The Trust has completed data analysis which showed that Delays to Transfers of Care and an increase in Length of Stay was stopping flow through the hospital and causing delays within the Emergency Department.
The number of Delayed Transfers of care has now decreased. The Trust continues to work closely with Trafford to improve discharge and examine ways of working differently together; the Trusts are currently discussing Trusted Assessor procedures which should speed up the process of discharging medically fit patients. In addition to this the Trust is implementing the 3 new Greater Manchester Discharge Policies – Trusted Assessor, Patient Choice and Discharge to Assess.
Salford Royal is working on an Urgent Care Improvement Programme focussing on three key improvement areas;
11 Appendix 2 – Performance Recovery Plans
Emergency Village Flow, System Dynamics and Stranded Patients. This work began in June and a Senior Service Improvement Manager from the CCG will be working at the Trust 2 days per week to oversee the work and provide assurance to the CCG, UECDB and the Greater Manchester team. Current Status: Expected Outcome: Timescale for Recovery: June 2018 Lead Manager: Tori Quinn Executive Lead: Karen Proctor
E.B.05 A&E Waiting Time - Seen within 4 hours (SRFT) Percentage of A&E attendances where the patient spent 4 hours or less in A&E from arrival to transfer, admission or discharge. (Data for SRFT Only)
Desired Performance against Target: Aim to Maximise Latest Data: March 2018 result Latest update provided: 12-Apr-2018 Performance against the 4 hour 95% standard for A&E at SRFT improved in March. Performance was 82% against February performance of 75.6%. The majority of the 4 hour breaches in A&E at SRFT continue to relate to waits for bed capacity for those patients who require admission.
Actions being taken: The CCG chairs the Urgent and Emergency Care Delivery Board (UECDB) and this board is working collaboratively to improve performance against the 4 hour 95% standard for A&E. The Trust has completed data analysis which showed that Delays to Transfers of Care and a marked increase in Length of Stay was stopping flow through the hospital and causing delays within the Emergency Department.
The number of Delayed Transfers of care has now decreased. The Trust continues to work closely with Trafford to improve discharge and examine ways of working differently together; the Trusts are currently discussing Trusted Assessor procedures which should speed up the process of discharging medically fit patients. In addition to this the Trust is implementing the 3 new Greater Manchester Discharge Policies – Trusted Assessor, Patient Choice and Discharge to Assess.
Salford Royal is working on an Urgent Care Improvement Programme focussing on three key improvement areas; Emergency Village Flow, System Dynamics and Stranded Patients. This work began in June and a Senior Service Improvement Manager from the CCG is working at the Trust 2 days per week to oversee the work and provide
12 Appendix 2 – Performance Recovery Plans assurance to the CCG, UECDB and the Greater Manchester team.
Current Status: Expected Outcome: Timescale for Recovery: June 2018 Lead Manager: Tori Quinn Executive Lead: Karen Proctor
E.B.07 Cancer Patients – 2 week wait for breast symptoms (where cancer was not initially suspected) Percentage of patients, referred urgently with breast symptoms (where cancer was not initially suspected) by a GP, who waited less than two weeks for first outpatient appointment.
Desired Performance against Target: Aim to Maximise Latest Data: March 2018 result Latest update provided: 10-May-2018 The 2WW (breast symptoms – cancer not suspected) issues have been caused by consultant staffing issues (sickness and waiting for new consultants to start) at Bolton FT. The service has been fully established since January.
Actions being taken: Close monitoring continues and the Trust have a recovery plan in place however performance has been below the national standard in each of the last 3 months.
Current Status: Expected Outcome: Timescale for Recovery: 2018/19 Lead Manager: Annette Donegani Executive Lead: Karen Proctor
13 Appendix 2 – Performance Recovery Plans
E.B.12 Cancer Waits - 62 Days (Urgent GP Referral) Percentage of patients who waited a maximum two months (62 Days) from urgent GP referral to first definitive treatment for cancer.
Desired Performance against Target: Aim to Maximise Latest Data: March 2018 result Latest update provided: 15-May-2018 2017-18 performance is at 82.9% which, as forecast is below the national target of 85%. There were performance improvements in Q4 compared to Q3 which was due to performance at 87.5% in February 2018, however March 2018 performance was below target at 83.7%.
As previously reported analysis shows that complex diagnostics and in-patient/out-patient capacity are the main reasons for the majority of our 62-day breaches during the year.
Actions being taken: On-going work with SRFT during 2017/18 is continuing into 2018/19 to establish the following improvements to pathways and systems which will impact on the ability to meet the national 62-day cancer treatment standard: • 7 day target for first outpatient appointment for suspected cancer referral • 28 day faster diagnostic standard for yes/no cancer diagnosis • improvements to tumour specific treatment pathways • on-going GP cancer training
Current Status: Lead Manager: Annette Donegani
Expected Outcome: Executive Lead: Karen Proctor Timescale for Recovery:
14 Appendix 2 – Performance Recovery Plans
E.B.13 Cancer Waits - 62 Days (Screening Service) Percentage of patients who waited a maximum two months (62 Days) from referral from an NHS Screening Service to first definitive treatment for all cancers.
Desired Performance against Target: Aim to Maximise Latest Data: March 2018 result Latest update provided: 03-May-2018 The small cohort size for this measure has a significant impact on swings in performance. For example, Q1 performance was 77.3% (5 of the 8 breaches were experienced in Q1) and although improvements can be seen during Q2, Q3 and Q4 with these quarters meeting the 90% target the main contributing factor was Q1. In total there were 68 referrals for the year of which 60 were seen within target.
All 8 breaches in 2017/18 were for Lower GI - Bowel Screening with the first seen provider being Bolton FT and either The Christie or SRFT being the 1st treatment Trust. Reasons for breaching include 2 administrative delays, 3 late referrals to treating Trust, 2 treatment delays due to medical reasons and 1 delay due to elective capacity issues. Actions being taken: A review of breaches has taken place led by the Lead Manager and clinical lead for Cancer. The lead manager continues to attend SRFT’s monthly Cancer Governance Board where individual cancer wait time breaches (for 31 and 62 days) are scrutinised; every breach is discussed by tumour type and patient cancer timelines are analysed thoroughly. Patient timelines detail exactly what happened, where the gaps / delays occurred and why. This enables the board to determine if the breaches are considered avoidable (lessons are identified for future improvements) or unavoidable (due to patient choice, patient being too ill to proceed etc.)
The Cancer Governance Board provides a regular forum for the CCG to work with the provider to identify performance issues and agree, monitor and evaluate improvement actions on an ongoing basis.
Current Status: Expected Outcome: Timescale for Recovery: 2018/19 Lead Manager: Annette Donegani Executive Lead: Karen Proctor
15 Appendix 2 – Performance Recovery Plans
E.B.S.01 Mixed Sex Accommodation Breaches (CCG) Number of mixed sex accommodation breaches
Desired Performance against Target: Aim to Minimise Latest Data: Cumulative result for 2017/18 as of March 2018 Latest update provided: 03-May-2018 There were 3 MSA breaches in March for Salford CCG. These took place at Salford Royal Foundation Trust (RM3) and two at Pennine Acute Hospital NHS Trust (RW6). Actions being taken: There were three breaches of the MSA target in January which occurred at Bolton Foundation Trust (FT), Pennine Acute Foundation Trust and Warrington & Halton Hospitals Foundation Trust.
Salford CCG liaises regularly with colleague CCG’s in order to gain assurance around this measure.
Bolton FT had 18 MSA breaches in January, one of which was a Salford CCG patient; the breaches are due to step down procedures in the Intensive Care Unit (ICU). This is an ongoing problem for Bolton FT and is related to estates and bed flow issues.
The senior team at Greater Manchester Health and social care partnership have recently visited Bolton FT to review the issue and agree that it is extremely challenging find a resolution. All breaches are discussed at the Bolton CCG Quality and Performance meeting and a Root Cause Analysis (RCA) is completed by the trust for every performance breach.
The Salford patient who breached at Pennine was on the coronary care ward and this was down to bed pressures; the patient was due to be stepped down but a bed was not available. The patient was moved after 12 hours and 30 minutes. Pennine acute continues to monitor all of their breaches which have all been related to step down from the ICU and coronary care in this financial year.
Warrington CCG has not yet reviewed their January breach report and therefore do not have sufficient assurance from the trust. They have advised Salford CCG that they too have issues with step down and can presume the breaches relate to this. Salford CCG has requested a copy of the root cause analysis and will monitor the situation. Current Status: Expected Outcome: Failed for year (zero tolerance) Timescale for Recovery: Not applicable. Lead Manager: Rachel Farn
16 Appendix 2 – Performance Recovery Plans
Executive Lead: Francine Thorpe
E.B.S.02 Number of patients not treated within 28 days of last minute elective cancellation (SRFT) Number of patients not treated within 28 days of last minute elective cancellation
Desired Performance against Target: Aim to Minimise Latest Data: Cumulative result for 2017/18 as of Q3 2017/18 Latest update provided: 11-Jan-2018 There have been a total of 17 patients affected. The key issue resulting in cancellation is the availability of beds with their having been a significant number of medical outliers; also theatres overrunning and starting late due to cases taking longer than expected have impacted on cancellations. Patient factors have also influenced this indicator with their inability to attend when offered an operation date / time within the 28 day period.
Actions being taken: There is a comprehensive action plan in place with ‘stretch’ target to reduce cancelled operations in 2017/18 to 2.27% and the establishment of a surgical short stay unit which includes 10 ring fenced beds. This is monitored at the provider quality meeting.
Current Status: Expected Outcome: Failed for year (zero tolerance) Timescale for Recovery: Not Applicable. Lead Manager: Rachel Farn Executive Lead: Francine Thorpe
17 Appendix 2 – Performance Recovery Plans
E.B.S.04 RTT: Incomplete Pathways (>52 weeks) The number of incomplete patients yet to start a consultant-led treatment, who are waiting more than 52 weeks since referral.
Desired Performance against Target: Aim to Minimise Latest Data: Cumulative result for 2017/18 as of February 2018 Latest update provided: 15-May-2018 Since the last report in March, there have been a further 9 breaches relating to SCCG patients. This occurred over the months of December, January and February at a rate of 3 breaches per month.
5 of these breaches occurred at Manchester Foundation Trust (MFT). As previously reported there is a comprehensive recovery plan in place and this is being monitored by Manchester commissioners.
2 of the breaches occurred at Bolton and relate to step down from critical care (breaches occur because of the layout of the department). Members of Greater Manchester health and social care partnership have carried out a walk- around with Bolton commissioners and plans are in place to correct the issues relating to layout however there are currently no timescales for work to be undertaken.
The final 2 breaches took place at Oaklands and relate to Trauma and Orthopaedics patients; both of these are due to errors in process and administration. The first was a patient whose pathway was closed in error and the second relates to a patient whose previous pathway was left open in error as it was agreed that treatment was not appropriate at that time; sometime later a new referral was made and an appointment booked, this should have been started as a new pathway but due to the previous error of leaving the old pathway open it was flagged as a 52 week breach.
All breaches have been reported via the quality and performance meeting and it has been confirmed that no patient harm has occurred. Oakland’s have also implemented a system to double check for errors in pathway management. Actions being taken: MFT (formerly UHSM) has been working on RTT improvement for over two years, following identification of poor systems and processes back in March 2015. Firstly, validating lists, enhancing systems and processes, developing educational packages, re-writing data scripts and understanding available capacity against known demand. For some time now, performance improvement has been the focus, with a trajectory of improvement in place to return to delivering constitutional standards in March, 2018. As part of this work, it became apparent that there were capacity constraints to manage a particular procedure within the specialty of Plastic Surgery in line with RTT standards.
Following a number of performance/clinical and commissioning meetings, we collectively recognised that the limiting factor in developing a robust business case for expansion was that tariff did not cover costs. The contracts teams at
18 Appendix 2 – Performance Recovery Plans the Trust and MHCC have overcome this obstacle and agreed on a local tariff that is fit for purpose and will now allow the Trust to progress with short and longer terms solutions to delivering a sustainable service. The Trust is working on a comprehensive review of demand in addition to an improvement plan to eliminate over 52 week waiters.
MHCC has reinstated fortnightly meetings with the Trust to track these long waiters. Oakland’s have also implemented a system to double check for errors in pathway management.
All breaches have been reported via the quality and performance meeting and it has been confirmed that no patient harm has occurred.
Current Status: Expected Outcome: Failed for year (zero tolerance) Timescale for Recovery: 2018/19 Lead Manager: Rachel Farn; Sue Harris Executive Lead: Francine Thorpe
E.B.S.05 Trolley Waits in A&E (>12 Hours) (SRFT) Number of patients spending more than 12 hours from decision to admit to admission. (SRFT data)
Desired Performance against Target: Aim to Minimise Latest Data: Cumulative result for 2017/18 as of March 2018 Latest update provided: 15-Mar-2017 There were 7 reported 12 hour trolley breaches reported by Salford Royal in December.
Actions being taken: SRFT had a number of trolley breaches in December, the first reported in a long time. The CCG has been advised by SRFT that the actual number of breaches is 7, originally they reported 6 – this has also been confirmed by the Business Intelligence Team who pulls the data from the NHS statistical website.
In December there were 10 patients recognised as potential breaches. Following review SRFT established that 6 of these had breached as per the 12 hour trolley breach guidance, it was later discovered that a further patient also met this criteria which is why 7 were recorded.
19 Appendix 2 – Performance Recovery Plans
All breaches are subject to full review under Root Cause Analysis (RCA) and the CCG is expecting to receive these in the coming weeks. Actions from any lessons learned will be monitored by the SCCG SI Panel.
Current Status: Expected Outcome: Failed for year (zero tolerance) This is s a zero tolerance measure and so performance will not be recovered in Timescale for Recovery: 2017/18. Lead Manager: Rachel Farn Executive Lead: Francine Thorpe
E.H.1_A1 IAPT Waiting Times - 6 Week Wait Ended Referrals (CCG) - PUBLISHED The proportion of people that wait 6 weeks or less from referral to entering a course of IAPT treatment against the number of people who finish a course of treatment in the reporting period.
Desired Performance against Target: Aim to Maximise Latest Data: January 2018 result Latest update provided: 02-May-2018 Step 3 performance is the principal issue for overall pathway waiting times being below target. We need to increase staffing at step 3 and a business case is in train regarding this. The business case for increased investment at step 3, to finance more therapist capacity, was discussed at Service & Finance group on May 1st 2018. It now has the support of Service & Finance group but needs to go to commissioning committee for final decision.
Actions being taken: Not applicable, see above.
Current Status: Expected Outcome: Timescale for Recovery: Not applicable, see latest position. Lead Manager: Tony Marlow Executive Lead: Judd Skelton
20 Appendix 2 – Performance Recovery Plans
E.H.2_A2 IAPT Waiting Times - 18 Week Wait Ended Referrals (CCG) - PUBLISHED The proportion of people that wait 18 weeks or less from referral to entering a course of IAPT treatment against the number of people who finish a course of treatment in the reporting period.
Desired Performance against Target: Aim to Maximise Latest Data: January 2018 result Latest update provided: 02-May-2018 The business case for increased investment at step 3, to finance more therapist capacity, was discussed at Service & Finance group on May 1st 2018. It has the support of Service & Finance Group but now needs to go to commissioning committee for decision.
Actions being taken: The recovery plan in relation to this involves CCG needing to approve additional investment in step 3 service resources. The failed performance in regard to waiting times is directly due to commissioned capacity at step 3 being insufficient to manage referral demands. A business case went to the CCG Service & Finance Group on May 1st 2018 and this will now go to commissioning committee for a final decision regarding the funding.
Current Status: Expected Outcome: Timescale for Recovery: Quarter 2 2018/19 Lead Manager: Tony Marlow Executive Lead: Judd Skelton
21 Appendix 2 – Performance Recovery Plans
E.O.1 Percentage of children waiting 18 weeks or less for a wheelchair Percentage of children where equipment was delivered in 18 weeks or less of being referred to the wheelchair service
Desired Performance against Target: Aim to Maximise Latest Data: Latest result for 2017/18 as of Q4 2017/18 Latest update provided: 01-Mar-2018 The CCG narrowly failed to achieve the waiting time standard for children’s wheelchairs. The standard was that 92% or more children should receive a wheelchair within 18 weeks of being referred to the service by the end of Quarter 4 2017/18. The CCG achieved 91.7% in Quarter 4. Actions being taken: Currently the wheelchair assessment service is provided by occupational therapy, the assessment determines whether a wheelchair is provided. Certain wheelchairs are part of the local equipment loan store provision, some are more specialist in nature. A recent review of wheelchair provision has to date focused on adults and did not include children and young people. The CCG has now initiated a workstream relating to the provision of equipment for children, which includes the loan store and wheelchair waiting times. CCG commissioner leads are meeting with operational managers and a recovery plan is to be agreed and monitored. Further work in relation to children’s equipment is underway at a Greater Manchester level via the GM Children and Maternity Group which the CCG participates in. Current Status: Expected Outcome: Timescale for Recovery: 2018/19 Lead Manager: Stephen Woods Executive Lead: Karen Proctor
22 Appendix 2 – Performance Recovery Plans
INSP.01 % of Care Homes rated as Requiring Improvement or Inadequate "Number of Care Homes with Beds Requiring Improvement or Inadequate" as a percentage of the “Total Number of Care Homes inspected”.
Desired Performance against Target: Aim to Minimise Latest Data: Latest result for 2017/18 as of Q4 2017/18 Latest update provided: 10-M1y-2018 Through 2017/18 Salford has been undertaking a QI project which has shown significant improvements in our CQC care home ratings for Inadequate and Requires Improvement at year end. Our improvement has gone from 62% Jan 17, 36% Sept 17 although November dipped slightly (38%) due to 2 further inspections being carried out resulting in one home being rated 'requires improvement' and one home being rated as 'inadequate', our year end position was 34 %. We set a target of 30% which means we have missed our target by two homes being Requires Improvement rather than Good. Salford now ranks 6th in GM.
Over the course of 17/18 we saw a rapid improvement in our position up to October 2017 (36%) and since October our performance has levelled off. In 17/18 we saw 2 care homes move from Good to Requires Improvement and 4 care homes beds that have moved from Requires Improvement to Good.
Over 2018/19 the CCG with partners will be developing a Care Home Excellence programme. This programme was launched in April 2018 and will be a service improvement programme designed with homes. Partners will continue to work directly with care home and with the CQC to ensure homes that are inspected through 2018/19 will be supported to Good.
Actions being taken: The Council/CCG/SRFT/GMMH have established new governance and service improvement oversight of the care homes market in the last 12 month.
A Care Homes Strategy Group alongside a Quality Improvement Network (QIN) has oversight of the market. The QIN is a group that brings together local intelligence, including from the CQC and shares information about current and emerging operational matters for all care homes and takes action directly with care homes.
In May 2018 Salford launched the Care Home Excellence programme based on the best practice model that has been developed through GM H&SC. This programme will support homes to make further improvements in their practice and quality. The CCG has commissioned the service improvement organisation Haleo to support this work programme.
23 Appendix 2 – Performance Recovery Plans
A refresh of care homes improvement approach will be prioritised for 2018/19.
Current Status: Expected Outcome: Timescale for Recovery: 2018/19 Lead Manager: Paul Walsh Executive Lead: Judd Skelton
INSP.03 Number of GP practices rated as Inadequate Number of GP practices rated as Inadequate (CQC Inspections)
Desired Performance against Target: Aim to Minimise Latest Data: Latest result for 2017/18 as of Q4 2017/18 Latest update provided: 11-Apr-2018 The Lakes currently rated as inadequate.
Actions being taken: The practice is working towards an action plan, set by NHSE and have met with NHSE and the CCG to update on progress.
The practice is progressing well and is receiving support from the Royal College of General Practitioners.
Current Status: Expected Outcome: Failed for year (zero tolerance) Timescale for Recovery: 2018/19 Lead Manager: Lisa Best Executive Lead: Francine Thorpe
24 Appendix 2 – Performance Recovery Plans
% of practices (out of a possible 44) that are registered for online access and achieving the PO.07 national 20% target for appointments booked/cancelled online “% of practices (out of a possible 44) that are registered for online access and achieving the national 20% target for appointments booked/cancelled online *National standard is all practices meeting 10% target which increased to 20% from August 2017
Desired Performance against Target: Aim to Maximise Latest Data: Latest result for 2017/18 as of February 2018 Latest update provided: 15-Feb-2018 The action plans submitted have been reviewed and practices have been asked to update them at an event hosted by the LMC where good practice was shared. The national data is flawed (acknowledged by NHS Digital) and the CCG is taking the best of the last 3 published/available figures to estimate the current position.
Salford now predicts that not all practices will meet the 20% aspirational target in March 2018. It is estimated 15 practices will meet this target. There are a further 15 who are currently at 10-14% who will certainly make progress and may meet 20%, but this cannot be certain.
Three practices have changed their clinical system this year which effectively sets them back as they have to reregister patients on the new system. We have assessed their status as the level they were at prior to system change, assuming that they will recover, although not necessary by the end of March 2018.
The final 15 practices are split between under 5% and 5-9%. 3 have large Jewish orthodox communities and national benchmarks show the current highest score for these is 7% registration so far. We have recommended practices network with their benchmarks to share experience. All practices are being supported to improve their position. The CCG is exploring additional technical solutions to ensure the patients can access their appointments more easily.
The care homes practice is exceptional and although proxy access by the home is being explored, uptake is minimal at present as might be expected.
Actions being taken: • Education sessions generally. • Targeted practice based discussions. • Case studies of successful practices in Salford to be shared. • Raise at neighbourhood forums. • Work with Salford City Council GoONline team to promote the availability of use.
25 Appendix 2 – Performance Recovery Plans
• Link to patient engagement team on other methods to promote use by patients. Current Status: Expected Outcome: There will be active promotion of these facilities throughout the financial year, Timescale for Recovery: planning all practices to meet by March 2018 Lead Manager: Caroline Rand Executive Lead: Steve Dixon
QP.01a Antibiotics prescribed in primary care Improving antibiotic prescribing in primary care Part a) Reduction in the number of antibiotics prescribed in primary care
Desired Performance against Target: Aim to Minimise Latest Data: Latest result for 2017/18 as of February 2018 Latest update provided: 10-Apr-2018 Seasonal increase being seen.
Actions being taken: Reviews of long term antibiotic use by the Medicines Optimisation team will help in the reduction of total number of prescriptions but as the majority of these prescriptions are acute, the opportunities to influence by the team are limited. Those practices with high levels of antibacterial prescribing will receive targeted message from the GP clinical lead. Current Status: Expected Outcome: Timescale for Recovery: Achieving target remains a challenge for the year. Lead Manager: Claire Vaughan Executive Lead: Francine Thorpe
26 Appendix 2 – Performance Recovery Plans
QP.06a Number of Escherichia coli (E. coli) bacteraemia (CCG) The QP measure states a 10% reduction (or greater) in all E coli BSI reported at CCG level based on 2016 performance data.
Desired Performance against Target: Aim to Minimise Latest Data: Cumulative result for 2017/18 as of March 2018 Latest update provided: 08-Mar-2018 Monthly review of all cases continues.
Actions being taken: An oversight group has been convened involving the Lead Nurse Quality Assurance & Improvement and Head of Medicines Optimisation from the CCG, SRFT senior infection control staff and Health Protection colleagues from Salford city council. This group has developed an improvement plan that describes how the health economy will achieve a 50% reduction in healthcare associated GNBSIs by March 2021, with a focus on a 10% or greater reduction of E.coli in 2017/18 and has submitted it to GMHSCP, as requested. Francine Thorpe has been identified as the executive level lead.
Current Status: Expected Outcome: As there has previously been no focus on these infections it will be challenging Timescale for Recovery: to deliver the 10% reduction as we do not have any baseline data or have yet identified areas for improvement. Lead Manager: Claire Vaughan Executive Lead: Francine Thorpe
27 Strategic Programme Updates – Year End 2017/18
1. Quality of Care What we said we’d do What we’ve done
• Work with providers to secure improvements in the quality, The CCG has been working on implementing a Quality and Safety strategy, available safety and safeguarding of commissioned services via www.salfordccg.nhs.uk/publications, with agreed action plans refreshed on an • Ensure that patients experience of using services is captured annual basis. and used to drive improvements • Developing a culture where the potential for harm is actively Scrutiny of the quality of care is written into provider contracts and provider quality considered, processes are embedded for early identification of assurance includes a number of processes to collate and triangulate information risks and mitigation strategies implemented to minimise any gathered from regular inspections and quality walk rounds from within the system and adverse impact on people using services by external bodies such as; CQC, NHS England and Monitor. Salford is one of three • Develop a culture of evidence based commissioning and areas that took part in a new national CQC pilot, 'Quality of Care in a Place'. This is decision making that utilises research evidence, innovation really about increasing that level of openness even further by building a picture of and knowledge translation. what the whole quality of care is like for people living in a particular area – including how well services are co-ordinated and working together.
Safer Salford, the two-year programme which began in April 2016, builds on the learning from the successful Making Safety Visible programme by focusing on reducing avoidable harm in health and care, emphasising communication handover between services and professionals and medication safety.
During 2017/18, Safer Salford achieved the following:
More than 30 leaders from partner organisations in Salford have been involved in a development programme to understand the principles of the Measurement and Monitoring of Safety framework and this has resulted in a range of safety improvements in different care settings across Salford
Nine care homes completed the Safer Care Homes collaborative and were able to make small changes in reducing falls for individual residents. Knowledge exchange visits have been implemented as part of this work to share learning
Two Safer Handover events for GPs and hospitals consultants have been facilitated and a series of improvements are being implemented as a result.
The programme is being evaluated and developed further for 2018/19 with a continued focus on care homes and handover. More information is available Strategic Programme Updates – Year End 2017/18
via www.safersalford.org
What else did we achieve in 2017/18?
Implemented the Year 1 actions within our patient experience strategy, available via www.salfordccg.nhs.uk/publications, and agreed Year 2 actions making sure patient feedback and experience becomes an integral part of the commissioning processes and is used to influence and improve commissioned services
Extended the use of our quality assurance framework so that the fundamental elements are incorporated into the processes to monitor the quality and safety of primary care services. The information gathered is used when planning and undertaking quality assurance visits to commissioned services, which now includes GP practices
Working with Salford City Council, amended our Governance processes around quality to include oversight of information relating to adult social care services. An integrated quality and safety strategy is in development which will be implemented from April 2018.
Implemented a consistent and collaborative approach to supporting care homes in improvements, identified following CQC inspection ratings
Our Medicines Optimisation Annual Report 2017 was presented to the CCG’s Governing Body in January 2018 and available via www.salfordccg.nhs.uk/governingbody-minutes
What we’re going to do next
• Develop and begin delivery of a new Quality and Safety Strategy (2018-20). • Refine the Quality Assurance Process for the Integrated Care Organisation (ICO). • Develop an integrated approach to quality assurance for Children’s and Public Health Services. • Deliver year 3 priorities form the Research and Innovation Strategy. • Implement a process to secure quality improvement in General Practice. • Implement a clinical assessment process for Children’s Continuing Healthcare. • Develop a system wide approach to shared learning around safety. • Establish an improvement collaborative to achieve smoother handover between Strategic Programme Updates – Year End 2017/18
hospital and care homes. • Develop new Salford Carer’s Strategy. • Improve handover between hospital and GP practices. • Co-produce the care homes excellence programme in partnership with the ICO to ensure that investment is resulting in improved quality in care homes and an improved service user experience.
2. Population Health and Prevention What we said we’d do What we’ve done
• To use behavioural approaches towards the achievement of • £3.4m Population Health Transformation Fund bid approved (5/12/17). population scale prevention and self-care. • Population Health delivery oversight being established to refine and finalise • To support the social movement for change by developing an plans and oversee the delivery of the population health plan ensuring integrated, place-based approach to achieving improvement to alignment to existing governance. people’s wellbeing in the City. • Ingleside Birth Centre in Salford on track to open in the spring providing • To raise aspirations and put in place support which will enable greater choice for women due to give birth from March onwards. young people to achieve their potential in life, as well as • GM Working Well – the new Work and Health programme went live on Jan reduce demand for services in the medium to long term. 29th 2018 and will support over 2,000 residents in Salford over the next five • To put in place public health programmes which will promote, years. support and enable healthy lifestyles at all ages, in order to • Implementation of a new outcomes framework for Healthy Living Centres. improve health outcomes and reduce demand for primary and acute care. • To put in place programmes, activities and services which will What we’re going to do next promote, support and enable good mental wellbeing at all ages, in order to improve health outcomes and reduce demand • Deliver enhanced voluntary sector capacity and develop/implement a Neighbourhood for clinical care. approach to Social Prescribing. • To increase the effectiveness of screening and early detection • Implement plans relating to cancer screening, early detection and prevention. programmes so that disease can be detected early, more • Improve access to Diabetes structured education and Diabetes prevention effectively and treated with the minimum need for expensive programmes. and aggressive treatments. • Review and redesign stop smoking services across Salford. • To work with partners to reduce the harmful impact of the • Complete service review of Tier 3 weight management service. social, environmental and economic conditions in which people • Implement Physical Activity Framework (PAF) actions for 2018-19. live on their health and wellbeing. • Enhance partnership working to agree and deliver a health and housing approach to tackle the impact of poor housing on health.
Strategic Programme Updates – Year End 2017/18
3. Integrated Community Based Care and Long Term Conditions What we said we’d do What we’ve done
• Implement the integrated care system (ICS) to enable the Integrated Care achievement of the Integrated Care Programme improvement • Completion of Salford’s Big Health and Care Conversation, continuing the targets by 2020. public engagement with Integrated Care developments. • Through the integrated care organisation, redesign person • A preferred option agreed for the development of bedded intermediate care centred services through integrated pathways, workforce nursing capacity in Salford. alignment and supply chain arrangements. • Agreement of new Home Care specification aligned with the integrated care • Develop and agree a vision, objectives and deliverables to neighbourhood vision. Procurement process commenced. extend the benefits of integrated care to children, young • Commencement of Primary Care Streaming in A&E in October 17. people and families. • A review of Multidisciplinary Groups (MDGs) has been completed and • Receive a comprehensive evaluation (National Institute of recommendations agreed to further develop integrated working. Health Research) on the effectiveness of the integrated care • Neighbourhood and city wide transformation projects approved and launched programme by 2017. in year include: • Design and implement the Integrated Care System new model • Enhanced Carer Transformation Project of care within a neighbourhood footprint by 2017. • Salford Urgent Care Team • Improve access to primary care services, including improved • Enhanced Care in Neighbourhoods opening at weekends and the evening and supporting the • Falls Pathway Redesign & Implementation delivery of 7 day access to health and social care. • Advice & Guidance • Facilitate opportunities for practices to work in a federated way • Established children’s integrated care pathfinder services covering Early Help, with each other or with other services, where this is expected Special Education Needs & Disability and Speech, Language & to improve patient experience or be efficient in terms of cost or Communication. workforce; Primary Care • Develop a working relationship with primary care provider • Salford Wide Extended Access Pilot service (GP extended access) mobilised organisations in order to identify opportunities to contract for in each of the 5 Neighbourhoods in Salford in 2017/18. primary care based services at scale, rather than at individual • Neighbourhood Integrated Practice Pharmacists Service (NIPPS) is providing practice level. input to all 45 Salford GP practices and is evaluating positively. • Invest in the workforce to increase capacity and capability and • Workflow Optimisation: Clinical Correspondence / Care Navigation proposal by building a primary care development and education approved which will provide training of reception and clerical staff, to enable programme; them to play a greater role in the navigation of patients and the handling of • Incentivise practices to more pro-actively identify and manage clinical paperwork to release GP time. individuals with, or at risk of, illness and improve the quality of • A temporary primary medical services contract to service the Ordsall South provision in primary care. population has been commissioned. • Work with all providers of physical health, mental health and • Locally Commissioned Service reviews completed: social care services, to develop and invest in out of hospital • On Demand Availability of Palliative Care Drugs Service Strategic Programme Updates – Year End 2017/18
services, delivered where appropriate at a neighbourhood • Homeless Service level. • Agreed revisions to the Salford Standard contract for 18/19, to better • Invest in high quality community premises and improved incentivised practices to improve the quality of primary care provision technology to enable primary care to be the hub of out of • A core primary care contract has been transferred to the local GP federation hospital care. which provides a foundation for commissioning primary care at scale • Move towards more of a primary care focus for the • Acute Home Visiting Scheme mobilised in the Ordsall & Claremont management of patients with LTCs as a first step towards our Neighbourhood in March 2018. ambition for community based care with greater integration across community areas and a shift towards more proactive Service Developments care with patients better enabled to self-manage care needs. • On the back of successfully evaluated innovation projects the following schemes have been supported to continue: • Go2Physio; a self-referral to Physiotherapy scheme. • Health promotion and screening in the Musculoskeletal Assessment Service • Impaired Glucose Regulation (IGR) Exercise Service addressing physical activity and weight issues for those at risk of developing diabetes. • Self-management in Inflammatory Bowel Disease; patient access to web-based support to enable self-management and reduce outpatient attendances. • Engagement in the National Diabetes Prevention Programme Digital Evaluation Pilot; a new digital programme incorporating web-based and telephone support for patients at risk of developing diabetes. • A system-wide action plan to increase referrals to the Pulmonary Rehabilitation service and improve the number of people completing the programme has been developed and implemented. • Changes to the GP x-ray service were agreed to improve ‘drop-in’ access and reduce waiting times; this has been successfully evaluated in year. • A Community Consultant Led Eye Service Specification has been developed and a procurement process commenced to select a suitable provider. Strategic Programme Updates – Year End 2017/18
What we’re going to do next
Integrated Care • Review delivery of the Adult Service and Financial Plan 17/18 – 20/21 and produce a plan for the Adults Integrated Fund (19/20) working with all partners. • Work with partners to collaboratively redesign neighbourhood health and social care delivery models, considering emerging evaluation findings from transformation projects. • Redesign the proactive care model to ensure the benefits delivered from MDGs are maintained, with both improved efficiency and alignment to other neighbourhood developments, such as Enhanced Care. • Set out Salford’s strategic approach in establishing new models of Extra Care service to meet our strategic objectives around reducing reliance on care home provision and improving quality and outcomes. • Oversight and assurance of the new Home Care model in meeting the needs of service users and providing ethical terms of employment. Primary Care • Evaluate the impact of the Primary Care Transformation schemes which support the ‘sustainable primary care’ priority of integrated care including Extended Access, GP Streaming, acute home visiting, neighbourhood working and care navigation. • Monitor the outcomes of the Ordsall South temporary primary medical services contract. • Undertake a fundamental and comprehensive review of the Salford Standard with revised standards rolled out for the 2019/20 contract. Service Developments • Undertake identified reviews of community services and locally commissioned services. • Scope options for the expansion of Personal Health Budgets, make recommendations on a model to broaden the current offer and establish test cases. • Develop, implement and monitor an outcomes based contracting model for community service bundles. • Complete the procurement process, award the contract for and mobilise the Community Eye Service. • Further develop integrated care for children and young people
Strategic Programme Updates – Year End 2017/18
4. Transforming Hospital Care What we said we’d do What we’ve done
Development of a Standard Operating Model • Progressed implementation of the model of care for Healthier Together across the North West Sector • Governance model for Trusts which form part of Group • Carried out service reviews to ensure local services meet the quality standards for • Improved and more effective decision making neuro-rehabilitation, breast surgery, paediatrics, dermatology, neurology and • Delivery of Outcomes Based Healthcare – based on the elective orthopaedics Porter model of value based healthcare • Taken lead commissioner responsibility for bariatric surgery on behalf of Greater • Delivery of the digital health enterprise – delivering Manchester, shared information regarding specialist medical weight management efficiency and a reduction in spend through digital services and agreed common standards. transformation • Continued to achieve national Referral to Treatment Times standards • Deliver a model which is replicable at a local, regional and • Diagnostic waiting times standards have been achieved for the majority of national level patients, however capacity issues for specific diagnostics (e.g. endoscopies and MRI scans) meant the overall standard has not been consistently achieved Emergency Department (ED): throughout the year, recovery plans have been agreed • Achieved some, but not all cancer waiting times, agreed recovery plans in those • Reduce time to patient assessment and increase the areas where performance does not meet national standards percentage of patients seen by a senior decision maker • Agreed an Urgent Care Improvement Programme to improve performance as • Increase the percentage of A & E attendances waiting less urgent care standards (i.e. A&E, ambulance) have proved very challenging, both than 4 hours locally and nationally • Acute Medicine: • Commissioned Ingleside Birth and Care Centre as a free standing midwifery unit in • Reduce length of stay and patients admitted from acute to Salford and established Bolton, Salford & Wigan as a national maternity pioneer other wards site • Improve mortality rates
General Surgery:
• Improve mortality rates and emergency general surgery patients seen by a consultant 24/7 • Reduce length of stay, re-admission and achieve consistent and timely access to theatre, critical care and diagnostic services
Paediatrics: Strategic Programme Updates – Year End 2017/18
• Reduce admissions whose needs could be met in the What we’re going to do next community or at home • Support Greater Manchester CCG’s to ensure effective specialist (i.e. Tier 3 and • Improve mortality rates and emergency admissions seen by a 4) weight management pathways are in place. consultant paediatrician within the first 24 hours of admission • Support and engage with GM in relation to the GM Cancer Plan. • Increase patient satisfaction and hospital staff satisfaction • Provide advice and support on behalf of GM CCG Directors, to GM Theme 3 projects for Neuro-rehabilitation and Breast services. • Assess urgent care services and develop and implement mid-term and long-term action plans for priority areas. • Implement the Maternity Pioneer Programme – widening choice and personalisation. • Establish Ingleside as a safe and comfortable environment for women to have a positive experience of child birth. • Support a review of breast services across the NW sector. • Review paediatric services in response to GM and Bolton, Salford and Wigan Partnership (BS&WP) case for change and standards. • Support the development and commissioning of a local Advice and Guidance system. • Develop a GM Dermatology model framework, assessment criteria for key conditions and review of GM wide advice and guidance. • Ensure the Healthier Together model for General Surgery is delivered in line with GM timescales. • Ensure the Healthier Together model for Acute Emergency Medicine is delivered in line with GM timescales.
Strategic Programme Updates – Year End 2017/18
5. Mental Health and Learning Disabilities What we said we’d do What we’ve done • Progressing plans for MH investment to meet Five Year Forward View compliance • Early intervention – meeting needs early and preventing the and support VCSE capacity escalation of mental health problems (including transition • GM investment for the Salford MH Liaison service secured and allocated and planning from children’s services) recruitment underway • Addressing the stigma and discrimination that surrounds • Exceeding Early Intervention in Psychosis targets mental health • Excellent IAPT access rates. • Rapid and convenient access at all times (and in all services, • MH Needs Assessment completed, informed by GM priorities and local and relevant settings) understanding of need • Fair access, based on people’s needs, not who they are, or • Salford Suicide Prevention strategy is now fully approved and launched and where they live in Salford actions underway with specific awareness raising and communication • Recovery – with service users returning to full health, moving workstreams through services, and being discharged where clinically • GM work relating to suicide bereavement will be led by Salford CCG. appropriate • Application for national suicide prevention accreditation process is underway. • Recognition of the links between physical health and mental • GM MH workstreams regarding Out of Area Placements and Early Intervention in health, and the government pledge to achieve parity of esteem Psychosis underway and informing local Salford approaches and investment • Support to remain in your own home and to live independently • Approved investment with a VCSE sector organisation for improved employment for as long as possible support for adults with mental ill health • The lowest possible number of people placed out of area • IAPT Business Case being developed with GMMH to address current capacity (outside of Salford) issues and ensure 5YFV compliance regarding access targets and also peri-natal • The best possible outcomes for service users, their carers, and mental health their families (including fewer symptoms of ill-health, the ability • Work undertaken to better understand high cost care packages in LD to lead as normal a life as possible, and maintain contacts with • LD Supported Tenancy specification revised family, friends and local communities) • The lowest possible number of complaints and untoward incidents • Excellent value for money Strategic Programme Updates – Year End 2017/18
What we’re going to do next • Develop business case to address high demand in Early Intervention in Psychosis. • Develop and launch new all age Mental Health Commissioning Strategy. • Implement Salford Suicide Prevention Strategy and action plan. • Support the development of the GM Suicide Prevention Strategy and lead the commissioning of the GM Suicide Bereavement service. • Develop and improve the employment pathway for people with serious mental health problems. • Improve IAPT capacity and pathway to meet the increased access rate, waiting times and ensure that IAPT provision has a perinatal frame of mind to meet perinatal mental health duties. • Ensure Salford’s MH Liaison service meets 24-7 compliance and access targets. • Develop a grants programme for the VCSE sector to enable a broader response in meeting mental health need and supporting improved mental wellbeing. • Improve pathways between IAPT services and key physical health services. • Develop diagnostic and post diagnostic services for ASD and ADHD in line with national policy and standards. • Deliver the national policy and strategy around Transforming Care for people with a learning disability and/or autism. • Review supported employment pathways for adults with learning disabilities. • Explore new models of mental health care; identify opportunities for development and transformation in Salford. • Implement priorities of CAMHS Transformation plan and Emotional Health & Well Being test case for children and young people.
Strategic Programme Updates – Year End 2017/18
6. Enabling Transformation What we said we’d do What we’ve done
• Streamlining, joining up and sharing responsibility and budgets • Gained agreement in principle to create a single health and social care integrated for commissioning of services. fund across the CCG and Salford City Council, allowing us to work more closely • Streamlining, joining up and sharing responsibility and budgets together to achieve the ambitions outlined in our Locality Plan. for ‘back office’ commissioning support. • Achieved extremely positive feedback through the results of the 2017 Staff Survey • Maximise the opportunities to achieve efficiency through the in relation to staff satisfaction and engagement, and the 2018 360 Stakeholder use of digital technology. Survey, in relation to engagement with our members and partners. • Rationalise the use of public sector estate to achieve • Completed review of the Conflicts of Interest policy and arrangements in light of efficiencies and effectiveness in delivery across all sectors and new guidance. allow provision of a range of accessible settings. • Commenced development programme for the CCG Governing Body continuing • Enable a suitably skilled workforce and working conditions in (second of four sessions complete). order to achieve transformation and new ways of working. • Shortlisted for HSJ CCG of the year award. • Work collaboratively with VCSE and other local providers to • Undertook deep-dive midyear review of the CCG’s financial position which maximise reach, outcomes and impact beyond statutory identified non recurrent funding available for investment in 2017/18. provision. • Continued implementing our Engagement and Communication Strategy available • Build from Salford’s successful innovation and research via www.salfordccg.nhs.uk/publications, along with our Engagement Annual programme to test and embed new ways of working to support Report. The CCG won a number of awards in this area in 2017/18. our transformation aims. • Created a new Equality Impact Assessment framework for use when • Radically change engagement practice from consultation to commissioning new services, reviewing/redesigning existing services or involvement of the public in an equal conversation introducing new processes. • Refreshed the diversity and inclusion contractual obligations for providers. • Refreshed the CCG’s 5 year financial plan, presented to the CCG’s Governing Body in May 2018 and available via www.salfordccg.nhs.uk/governing-body- minutes • Led the delivery of the Salford Locality Plan and Salford’s contribution to Greater Manchester’s ‘Taking Charge’ plan. • Sustained Salford CCG’s ‘Outstanding’ status improving performance, quality, safety, staff, stakeholder and patient insights. • Integrated planning for health and social care across the CCG, Council and ICO. • Made NHS public wifi available in all GP practices. • Completed our roll out of electronic prescribing in general practices. • Promoted the use of online access to records via our general practices so that all patients can book appointments or order repeat prescriptions online. • Agreed detailed implementation plan for 2017/18 for the Strategic Estates Group • Business case for new Little Hulton community hub completed and approved by Strategic Programme Updates – Year End 2017/18
CCG, procurement route approved • Continued to maximise usage of gateway buildings by converting void space to clinical rooms • Transferred antenatal and maternity services off the Salford Royal, including antenatal services now delivered at Walkden Gateway and establishment of Freestanding Midwife Unit (FMU) at Ingleside. • Site condition survey (six facet surveys) completed on all premises delivering primary medical services • Detailed work commenced for the Lower Broughton development
What we’re going to do next
• Establish a Strategic Commissioning Function (SCF) and integrated commissioning decision making for health and social care between the CCG and Salford City Council. • Scope the requirements for integrated enabling functions across the CCG and Salford City Council. • Establish a Best Value Workstream considering efficiencies and savings required across health and social care commissioning. • Ensure the CCG continues to meet its wide range of statutory duties, maintaining and improving its robust governance and performance management systems. • Support the development of incentive payments across health and social care pathways enabling care to be delivered in the most appropriate setting. • Provide contract and finance support to GM and GM Health and Social Care Partnership to deliver the objectives of the GM Devolution Programme. • Lead the process to develop new payment and contract models for Salford. • Deliver Locality IM&T plan. • Roll out a single solution across all GP systems to engage patients with online services. • Deliver communications and engagement work plans for the CCG, Locality Plan and other partnerships. • Further improve staff and member engagement, building on high Staff and Stakeholder Survey results. • Deliver the Diversity and Inclusion work plan including embedding the Equality Analysis (EA) process and the role of Personal, Fair, Diverse staff champions. • Deliver the Social Value work plan with a focus on Carbon Literacy and taking action to support those living in poverty, including through promoting the Real Living Wage. Strategic Programme Updates – Year End 2017/18
• Review Locality Plan delivery arrangements including programme management. • Work with Salford City Council to review risk management strategies and arrangements. • Develop integrated city wide planning, performance and programme management arrangements. • Establish joint business intelligence and informatics function to inform future planning. • Refresh Salford estates strategy and agree detailed implementation plan for 2018/19 • Construction of Little Hulton community hub to commence in autumn 2018 • Complete relocation of Manchester Foundation Trust antenatal from SRFT to Lance Burn Health Centre • Complete business case for new build in Lower Broughton • Options appraisal for primary care accommodation in Walkden
Strategic Risk Register - All Risks
Generated on: 10 May 2018
New Risks
SRR.02 Distraction from delivery of organisational objectives during organisational changes associated with integrated commissioning If leaders and staff focus too heavily on the organisational changes associated with integrated commissioning, this programme could distract staff from delivery of their commissioning related objectives and mean that these are not delivered, meaning that the ambitions set out in our Locality Plan are not likely to be achieved. Risk Profile Current Risk DoT Target Risk Treatment Plan and Latest Update (Notes) Additional programme resource to support integrated commissioning I 4 Score I 4 Score Continue with clear programme arrangements for delivery and staff communication and (pay and non pay) during 2018/19 from the CCG and Salford City engagement. Council. Objective setting for staff has focused on their main commissioning role. Where staff are required to undertake work Existing relating to this programme, this is included in their own objectives to Controls ensure sufficient capacity/prioritisation of work. Staff are being L 2 8 L 1 4 engaged in the changes with clear communication and OD plans in place which should help minimise any staff anxiety associated with change.
Staff survey results remain high. Feedback from Staff Forum does Risk Owner Hannah Dobrowolska New risk added as part of annual risk review process. Assurances not indicate a significant risk in this area. Risk Sponsor Anthony Hassall Governance Group Governing Body Gaps None identified. Last Reviewed: 10-May-2018
Existing Risks
SRR.09 Failure to achieve national performance targets against constitutional standards If pressures in the health and social care system are not effectively monitored and managed then we may fail to achieve national performance targets. This may result in patient harm, poor patient experience, negative media attention (reputational damage), reduced patient confidence and could cause further pressures in the wider health system. Risk Profile Current Risk DoT Target Risk Treatment Plan and Latest Update (Notes) I 4 Score I 4 Score Risk will continue to be mitigated through continuous performance management practices within Monthly breach reports. Systems Resilience Group, Contract CCG and with providers/partners. Existing Management Group, Quality and Outcomes Group in place. Controls Performance is also managed locally by providers. Regular L 4 16 L 2 8 discussion at CCG Executive Team meetings, with formal reporting to Governing Body including performance recovery plans.
Organisational Performance Report including performance recovery Risk Owner Hannah Dobrowolska Risk revised as part of annual risk review process. Assurances plans and Risk reports presented to every Governing Body meeting. Risk Sponsor Anthony Hassall Governance Group Governing Body Gaps None identified. Last Reviewed: 10-May-2018
1 Strategic Risk Register - All Risks
Generated on: 10 May 2018 SRR.15 Cyber Security threat The risk that computer systems are accessed illegally resulting in failure to protect data and systems essential to delivery of care with the potential to disrupt services including disruption to commissioning functions. Risk Profile Current Risk DoT Target Risk Treatment Plan and Latest Update (Notes) GMSS have a number of controls to manage the risk of cyber I 4 Score I 4 Score The risk is constantly monitored and managed. attacks. These are documented in their IG toolkit submission. The GMSS IT managers have a dedicated sub group to IT security where Existing threats and actions are monitored. Controls The CCG has a Business Continuity Policy and detailed Business L 4 16 L 3 12 Continuity Plan (BCP). Contracts require providers to have business continuity plans. The Health Economy Resilience Group (HERG) allows the local system to maximise resilience arrangements. CCG monitors the GMSS performance. CCG sends out regular Risk Owner Steve Dixon No change from last assessment- high impact and likelihood. Continue to work with GM Shared cyber security awareness messages to staff and practices. Service on additional controls to detect and prevent. Reported to CCG's IMT group and working Assurances The BCP is reviewed every year as part of the GM Emergency across GM with other CCGs/GMSS. Preparedness, Resilience and Response (EPRR) Assurance Risk Sponsor Anthony Hassall process, which also covers our main providers.
The CCG does not quality assure the business continuity plans of Governance Group Governing Body Gaps providers. Last Reviewed: 10-May-2018
SRR.01 Capacity and capability of workforce is insufficient Capacity and capability of workforce is insufficient Risk Profile Current Risk DoT Target Risk Treatment Plan and Latest Update (Notes) A number of primary care workforce development schemes in place I 4 Score I 4 Score Continue with existing controls. with CCG funding. Effective CCG staff structure in place with clear mechanisms to support staff performance and development. Existing Workforce matters discussed with providers as appropriate and part Controls of the Healthier Together implementation work and North West L 3 12 L 2 8 sector single service plans. Salford workforce plan in place across partners linked to GMHSCP. CCG HR data and capacity/capability reviewed regularly by the Risk Owner Francine Thorpe No change. Executive Team with high level information presented to Governing Body. Primary Care workforce data and developments reported to Commissioning Committee (for advice) and Primary Care Assurances Commissioning Committee (for decision). Risk Sponsor Anthony Hassall Provider workforce matters escalated as necessary from contract and planning meetings. Salford Workforce Group in place and reviews actions and requirements across a range of partners. Governance Group Governing Body Gaps Particular risks exist currently for the Primary Care workforce. Last Reviewed: 10-May-2018
2 Strategic Risk Register - All Risks
Generated on: 10 May 2018 SRR.06 Changes in patient behaviour fail to materialise resulting in ongoing health inequalities and ever increasing demand for services Changes in patient behaviour fail to materialise resulting in ongoing health inequalities and ever increasing demand for services Risk Profile Current Risk DoT Target Risk Treatment Plan and Latest Update (Notes) Locality Plan in place with significant focus on prevention and I 4 Score I 4 Score Continue with existing controls. associated Communications, Engagement and Social Marketing Plan agreed across partners. This is being implemented with support of partners across Salford. Significant work programme associated Existing with self care, particularly linked to long term conditions. Significant Controls work programme associated with mental health. Regular campaigns L 3 12 L 2 8 associated with appropriate use of services. Good availability and use of health inequalities data to guide commissioning decisions. CCG Communications and Engagement Strategy in place and work ongoing. Salford and GM level public health led work ongoing. Update reports provided to EEMG which reports exceptions for Risk Owner Hannah Dobrowolska No change. action or information for assurance to Executive Team. Update Assurances reports provided to Health and Wellbeing Board for Locality Plan Risk Sponsor Anthony Hassall related activities. Governance Group Governing Body Gaps None. Last Reviewed: 10-May-2018
SRR.14 Quality assurance for services where Salford CCG is not the lead commissioner If Salford CCG is unable to gain sufficient assurance for the quality of services where we are not the lead commissioner, then here is a risk that patients may not receive consistent, high quality care across Salford. Risk Profile Current Risk DoT Target Risk Treatment Plan and Latest Update (Notes) CCG has regular dialogue with quality teams within lead I 4 Score I 4 Score Influence through the GM Quality Board, CCG has an opportunity to work more in partnership with Existing commissioning organisations, greater Manchester quality board commissioners on a sector wide basis in relation to quality assurance. CCGs are increasingly Controls meets bi-monthly and is a forum to raise significant concerns. L 3 12 L 2 8 collaborating across GM to manage provider performance.
CCG receives reports from lead commissioners as required and Risk Owner Francine Thorpe Annual Risk assessment completed; changes made: Reworded risk title and description. Updated Assurances target risk score. Existing controls, gaps, assurances and treatment plan do not require changes. feeds in to appropriate governance routes. Risk Sponsor Jeremy Tankel
No single quality assurance process has been agreed and Governance Group Governing Body Gaps communicated across all commissioners. Last Reviewed: 10-May-2018
SRR.18 Stability of GM Shared Service Future stability of GM Shared Service Risk Profile Current Risk DoT Target Risk Treatment Plan and Latest Update (Notes) Communication with Greater Manchester Shared Service (GMSS) as I 4 Score I 4 Score Continue to work with GMSS to ensure high quality service received by CCG required to escalate service delivery difficulties to CCG and agree Existing recovery action where necessary, largely via CFOs. Service Controls specifications in place. One to ones with GMSS service leads and L 3 12 L 2 8 CCG leads as required. GMSS Governance Arrangements in place through Chief Finance Officers and Salford CCG leadership for some
3 Strategic Risk Register - All Risks
Generated on: 10 May 2018
services, with formal reporting to the CCG's Executive Team. Where services do not perform, alternative provision implemented, e.g. OD and equality services moved in house from April 2018, in house resource for primary care IM&T added to GMSS resource. GM wide work on theme 4 relating to back office functions ongoing with regular updates to the CCG which are shared with the Executive Team and reported to Governing Body as appropriate. Relevant reports received by the Executive Team. Internal Audit Risk Owner Hannah Dobrowolska Risk reviewed as part of annual review process. Assurances review of arrangements for management of this contract completed in 2013/14 providing significant assurance. Risk Sponsor Anthony Hassall Service issues being experienced in some services. Discussions to Governance Group Governing Body improve service performance are ongoing. Action being taken within GMSS to reduce agency usage. Publication of GM Commissioning Gaps Review recommendations and a number of CCGs (including Salford) giving notice on GMSS contracts on will result in uncertainty for staff Last Reviewed: 10-May-2018 and potential staffing risks impacting on customers (including Salford).
SRR.19 Resilience of specific hospital services Workforce, funding and other issues mean some specific hospital services are not resilient. The risk is that a change, for example loss of a key clinician, creates a gap in service for Salford patients which the provider is not able to manage in the short term. This is an overarching risk, specific recent local examples have been paediatric ophthalmology and breast surgery. Risk Profile Current Risk DoT Target Risk Treatment Plan and Latest Update (Notes) Transformation Theme 3 of the Greater Manchester “Taking Charge” I 4 Score I 4 Score Treat – continue to lead and support work at Greater Manchester, North West Sector and locally to plan aims to reconfigure acute services as does the North West progress acute service reconfiguration Sector Partnership, which is limited to the Bolton, Salford and Wigan localities. Both programmes have prioritised clinical specialties Existing where concerns regarding the resilience of services have been Controls identified. CCG clinicians and managerial staff are actively involved L 3 12 L 2 8 in these programmes. The CCG has established workstreams in areas outside the scope of these programmes (e.g. paediatric ophthalmology, neurology, etc.) Karen Proctor; Tori Quinn; Risk revised as part of annual risk review process. Risk descriptions updated as well as existing Commissioning Committee and CCG Executive Team receive Risk Owner Assurances regular updates from the Theme 3 and North West Sector Stephen Woods controls, gaps, assurances and treatment plan. Partnership, as well as other local workstreams. Risk Sponsor Anthony Hassall
Timescales may not match up i.e. gaps in service may appear before Governance Group Commissioning Committee Gaps significant service reconfiguration is implemented. Last Reviewed: 10-May-2018
SRR.21 Care Homes Quality There is a risk that provision of care will not meet the level of quality expected by the commissioner and we may fail to achieve the 20% target for care homes rated as inadequate or requires improvement under the CQC inspection criteria by 2021. There is also a risk around market sustainability which is directly linked to the management and oversight of care homes quality Risk Profile Current Risk DoT Target Risk Treatment Plan and Latest Update (Notes) Performance monitoring of CQC ratings on a monthly basis. A I 3 Score I Score The Quality group has a detail action plan of the care home who are either inadequate or requires Existing Quality group (Quality Improvement Network) is in place that has improvement and is working with home and the CQC on those action plans. Controls oversight of performance and improvement L 4 12 L
4 Strategic Risk Register - All Risks
Generated on: 10 May 2018
The Quality group is working with both the Care Homes and the Risk Owner Judd Skelton; Paul Walsh The year end position of 34% mean the target of 30% has not been achieved. Assurances regulator CQC to assess and action the identified improvements plans. Risk Sponsor Anthony Hassall As GM assessment undertaken as part of the Care Home Excellence Governance Group Governing Body programme has identified gaps in Salford's contract Gaps monitoring/improvements resource. This has been mitigated through Last Reviewed: 16-Apr-2018 the use of the Improved Better Care Funding.
SRR.16 Timely delivery of revised Salford Standard for 2019/20 and beyond There is a risk that we will be unable to review, update and implement a revised Salford Standard by 31/03/2019 due to timescales involved and capacity required. This is likely to damage our reputation with GP member practices, reduce confidence in the CCG, reduce value for money, continue variation in the quality of patient care across Salford. Risk Profile Current Risk DoT Target Risk Treatment Plan and Latest Update (Notes) I 3 Score I 3 Score Salford Standard Design Group established. Additional capacity contracted into the CCG to manage this Overarching aims and objectives for Salford Standard 2019/20 and beyond have been approved Existing programme. Project Initiation Document agreed with associated via CCG Executive Team and Commissioning Committee. Logic model in development building on Controls project plan agreed. Salford Standard Design Group established and L 3 9 L 2 6 these aims and objectives.. meeting fortnightly to progress work programme. Approach to evaluating existing Salford Standard agreed. Communications and engagement plan in development.
Salford Standard Design Group reports monthly to CCG Executive Risk Owner Harry Golby; Natalie McInerney Risk revised as part of annual risk review process. Assurances Team. Risk Sponsor Anthony Hassall Governance Group Governing Body Gaps None. Last Reviewed: 10-May-2018
SRR.20 Transforming Care targets and pressures, LD budget pressures The Transforming Care Programme is focussed on getting people with an LD and/or Autism out of hospital placements, and back to communities. Targets are set for GM as a whole and Salford, which are to be achieved by 2019. The patients remaining in hospital are complex and would often be unsafe to place directly into community provision. There are also people in crisis in community placements, who we need to avoid being admitted to hospital. As a result, there has been an increase in high cost packages of care in CCG funded hospital placements and residential placements, as well as some costly packages of community based care that will need to be commissioned from specialist providers. The team looks to place in the least restrictive setting possible, and in order to make these placements safe, a high staffing ratio is often required. This work is overseen by the Commissioner and Complex Needs lead via the Transforming Care CTR processes, as well as an Out of Borough meeting, and a process to agree and authorise placements. Risk Profile Current Risk DoT Target Risk Treatment Plan and Latest Update (Notes) 1. Transforming Care – Care & Treatment Reviews (CTRs) carried I 3 Score I 3 Score Commission a number of new projects to accommodate complex adults being discharged from Existing out by commissioner. hospital placements. This will me managed and monitored by SRFT with oversight from SCCG. Controls 2. Out of Borough meeting and Risk Register maintained. L 3 9 L 2 6 3. Process developed for approving placements Risk Owner Judd Skelton; Kerry Thornley Risk and impact remains the same. One patient is presenting significant risk at present, NHSE and Assurances None. senior leadership have been engaged in trying to resolve this - financial impact of any resolution is Risk Sponsor Anthony Hassall likely to be high. Query if any funding is available from NHSE to follow patients once Governance Group Governing Body Gaps secure beds are closed. Last Reviewed: 10-May-2018
5 Strategic Risk Register - All Risks
Generated on: 10 May 2018 SRR.08 Implementation of the new Greater Manchester Health and Social Care arrangements may not deliver expected benefits for Salford GM Devolution emerging potential changes in governance as a consequence of the devolution work across Greater Manchester for Health and Social Care may result in decisions being made for the benefit of Greater Manchester as a whole which could have a detrimental impact for elements of Salford’s population. Risk Profile Current Risk DoT Target Risk Treatment Plan and Latest Update (Notes) Governance Arrangements approved and in place form 1 April 2016. I 4 Score I 4 Score Continued engagement in Greater Manchester's Health and Social Care work. Development of the Greater Manchester Plan and Commissioning Strategy in place. The Locality Plan Implementation Plan. Existing Governing Body, staff and members have been briefed on this Controls matter. There is support for the underpinning principle of subsidiarity L 2 8 L 1 4 (meaning that Salford is ultimately in control of our own allocation). Strong Salford Locality Plan in place. Regular updates through Association of GM CCGs, Salford Health Risk Owner Karen Proctor Risk assessment completed; changes made: re-scored using 4x4 matrix Assurances and Wellbeing Board, Salford CCG Governing Body and Executive Team. Risk Sponsor Anthony Hassall
Implementation Plan for all the GM Plan and the Salford Locality Governance Group Governing Body Gaps Plan. Last Reviewed: 10-May-2018
SRR.10 Failure to commission high quality, stable provision of Primary Care services for the population of Salford If there is a disruption in the delivery of primary care services (GP, Dentists, Community Pharmacists, Optometrists), patients may not be able to access appropriate clinical care which may lead to patient harm and impact on wider service delivery across the system. Risk Profile Current Risk DoT Target Risk Treatment Plan and Latest Update (Notes) NHS Salford CCG has established a Primary Care Commissioning I 4 Score I 4 Score Existing Committee (PCCC) that focuses on delivery of primary medical Controls services. L 2 8 L 1 4 Collaborative working through GM Health and Social Care Risk Owner Harry Golby; Eejay Whitehead Risk reviewed - no changes made / updates required partnership for assurances around wider primary care. Assurances Primary Care Operational Group and Primary Care Quality Group Risk Sponsor Anthony Hassall currently monitor and manage primary medical practice delivery. We currently have limited collaborative working arrangements for Governance Group Governing Body primary medical care. This has been identified as a Programme Risk Gaps and is being managed as such. Limited coordination of wider primary Last Reviewed: 10-May-2018 care services which are managed across multiple organisations.
SRR.13 Delivery of high quality, resilient and sustainable services for the population of Salford If providers are unable to deliver high quality, resilient and sustainable services then the population of Salford will not receive the level of service that meets our expectations as a commissioner. Risk Profile Current Risk DoT Target Risk Treatment Plan and Latest Update (Notes) I 4 Score I 4 Score This is a low risk that can be tolerated by the CCG therefore there is no target risk score or Existing Robust quality assurance processes with our main providers. treatment plan. CCG will continue to improve existing controls - including better capture of soft Controls Ongoing workstreams with partners around quality improvement. L 2 8 L 2 8 intelligence. The CCG has an agreed improvement programme in place across all care homes in Salford. Assurances We have external assurance from the CQC that our main provider is Risk Owner Francine Thorpe Annual Risk assessment completed; changes made: updated assurances, gaps, existing controls
6 Strategic Risk Register - All Risks
Generated on: 10 May 2018
rated Outstanding. Our mental health provider is rated as good by and treatment plan. Also added target score (tolerate risk so score is same as current RAG). the CQC. Risk Sponsor Jeremy Tankel The majority of our GP practices are rated as good by the CQC. An improvement plan is in place for those that aren't.
Two thirds of our care homes are currently rated as requires Governance Group Governing Body Gaps improvement or inadequate by the CQC. Last Reviewed: 10-May-2018
SRR.05 Failure to deliver SRFT organisational, Salford Together and Locality Plan objectives as a result of Northern Care Alliance group arrangements If the Salford Royal NHS Foundation Trust (SRFT) leadership team are focused on the implementation of the Northern Care Alliance group arrangements, they might be distracted and less focused on delivering fully against the SRFT organisational, Salford Together and Locality Plan objectives. Risk Profile Current Risk DoT Target Risk Treatment Plan and Latest Update (Notes) This matter is a standing item in the Governing Body’s meetings I 3 Score I Score Continue with existing controls. Existing (part 2) and the CCG is kept appraised of the position through Controls regular communication with SRFT. L 2 6 L Execs from SRFT and CCG met in October 2017 to review current Risk Owner Anthony Hassall Risk assessment completed; no changes to risk assessment. Anthony Hassall met with David arrangements and priorities. The Salford Local Care Organisation Dalton to discuss this risk in January 2018. has a full management team in place and has an agreed objective Assurances framework to deliver from the Northern Care Alliance Group. Execs will meet with SLCO every 3 months to review progress and priorities Risk Sponsor Tom Tasker in order to mitigate against any risk of Group diluting management and leadership focus Governance Group Governing Body Gaps None identified. Last Reviewed: 10-May-2018
SRR.04 NHS Funding If economic stagnation continues or funding to the NHS is reduced, then the CCG may need to commission services with less money so it may be necessary to reprioritise and potentially decommission services. Risk Profile Current Risk DoT Target Risk Treatment Plan and Latest Update (Notes) The CCG has been notified of the financial allocation for 2018/19. A I 2 Score I 2 Score Risk at Target Level and below 'Acceptable Risk' level. Maintain watching brief upon funding 5 year finance plan has been presented to the Governing Body for developments and review accordingly. 2018/19 onwards. However, financial allocations for 2019 and beyond are indicative and the CCG has made assumptions on the Existing level of growth funding in future years and therefore still a degree of Controls uncertainty if these indicative allocations change or assumptions on L 2 4 L 2 4 growth are incorrect. However, the five year financial modelling for Salford CCG assumes a balanced financial position with a low savings target requirement. Annual refresh of the 5 year plan presented to Governing Body and financial risks updated.
Informs commissioners of the likelihood of funding issues and allows Risk Owner Steve Dixon Risk revised as part of annual review process. No change from last update. Delivered statutory Assurances them to plan services and service redesign programs accordingly. financial duties in 2017/18. Regular updates to Governing Body and Commissioning Committee on Risk Sponsor Anthony Hassall financial forecasts. CCG has been notified of its allocation for 2018/19 and Governing Body has NHSE has only issued indicative allocations for 2019 onwards which Governance Group Governing Body approved the five year financial plan in April 2018- this shows CCG likely to achieve financial Gaps are subject to change. Planning guidance, including CCG balance in next 3 years although allocations for 2019/20 onwards will not be formally notified until allocations, will be issued in October 2018. CCG funding formula Last Reviewed: 10-May-2018 October 2018.
7 Strategic Risk Register - All Risks
Generated on: 10 May 2018
could change.
SRR.07 Commissioning decisions are influenced by conflicts of interest and do not represent the best solutions for the people of Salford Commissioning decisions are influenced by conflicts of interest and do not represent the best solutions for the people of Salford Risk Profile Current Risk DoT Target Risk Treatment Plan and Latest Update (Notes) Updated Conflicts of Interest Policy approved in September 2017 in I 2 Score I 2 Score Implementation of full and up to date CCG Conflict of Interest Registers ongoing. Staff training in line with new national guidance. Implementation commenced. line with NHS England requirements to be completed by all relevant staff by the end of May 2018. Training delivered to Governing Body members. Clear minuting of Implementation of management actions following Internal Audit review to be complete by July Existing decisions where any real or perceived conflict of interest issues 2018. Controls occur. Staff excluded from decision and discussion as appropriate. L 2 4 L 1 2 New NHS England on line mandatory training rolled out to relevant staff. Conflicts of Interest Registers for Governing Body members, relevant Risk Owner Hannah Dobrowolska Risk reviewed as part of annual review process. staff and CCG members in place. Internal Audit review of Conflicts of Increased likelihood from very unlikely to unlikely due to recent Internal Audit review of Interest in March 2017 gave partial assurance. 18 of the 27 areas arrangements which provided a number of recommendations which require action reviewed were rated as fully compliance, the remaining areas were Assurances partially compliant. Implementation of the agreed management actions has commenced in line with the audit recommendations. Risk Sponsor Anthony Hassall Conflict of Interest monitoring returns made to GM in line with requirements. Where concerns are raised, these are investigated and any required action taken. Full implementation of up to date the Conflict of Interest Registers for Governance Group Governing Body Gaps staff, members and committee members. Adequate minuting of how conflicts of interest are managed within decision making groups. Last Reviewed: 10-May-2018
8 CCG Summary Dashboard
NHS Salford CCG 2016/17 Year End Rating: Outstanding
Better Health Period CCG Peers England Trend Better Care Period CCG Peers England Trend 2013/14 to R 102a % 10‐11 classified overweight /o2015/16 37.5% 10/11 167/207 R 121a High quality care ‐ acute 17‐18 Q3 64 3/11 30/207 103a Diabetes patients who achieved2016‐17 41.3% 6/11 68/207 R 121b High quality care ‐ primary care 17‐18 Q3 67 5/11 66/207 103b Attendance of structured educa2016‐17* 3.4% 7/11 139/207 R 121c High quality care ‐ adult social c 17‐18 Q3 59 7/11 159/207 R 104a Injuries from falls in people 65y17‐18 Q2 2,961 10/11 203/207 R 122a Cancers diagnosed at early stag 2016 52.2% 3/11 110/207 R 105b Personal health budgets 17‐18 Q3 186.31 2/11 7/207 R 122b Cancer 62 days of referral to tre17‐18 Q3 79.7% 10/11 158/207 R 106a Inequality Chronic ‐ ACS & UCSC17‐18 Q2 2,745 8/11 171/207 122c One‐year survival from all cance2015 70.6% 7/11 160/207 R 107a AMR: appropriate prescribing 2017 12 1.190 8/11 185/207 122d Cancer patient experience 2016 8.9 5/11 24/207 R 107b AMR: Broad spectrum prescribi 2017 12 10.2% 11/11 158/207 R 123a IAPT recovery rate 2017 12 43.6% 10/11 186/207 R 108a Quality of life of carers 2017 0.70 1/11 19/207 R 123b IAPT Access 2017 12 5.7% 3/11 8/207 Sustainability Period CCG Peers England Trend R 123c EIP 2 week referral 2018 02 82.6% 5/11 70/207 R 141b In‐year financial performance 17‐18 Q3 Green #N/A #N/A 123d MH ‐ CYP mental health (not available) R 144a Utilisation of the NHS e‐referral 2018 01 106.4% 2/11 3/207 R 123f MH ‐ OAP 17‐18 Q3 340 Leadership Period CCG Peers England Trend 123e MH ‐ Crisis care and liaison (not available) R 162a Probity and corporate governan17‐18 Q3 Fully Compliant #N/A #N/A R 124a LD ‐ reliance on specialist IP car 17‐18 Q3 51 1/11 77/207 163a Staff engagement index 2016 3.80 2/11 86/207 124b LD ‐ annual health check 2016‐17 48.9% 4/11 101/207 163b Progress against WRES 2016 0.15 10/11 144/207 124c Completeness of the GP learnin 2016‐17 0.45% 10/11 117/207 164a Working relationship effectiven 16‐17 70.04 6/11 85/207 R 125d Maternal smoking at delivery 17‐18 Q3 13.5% 1/11 138/207 166a CCG compliance with standards of public and patient participation (not available) 125a Neonatal mortality and stillbirth2015 7.3 7/11 193/207 R 165a Quality of CCG leadership 17‐18 Q3 Green Star #N/A #N/A R 125b Experience of maternity service 2017 84.0 2/11 76/207 Key R 125c Choices in maternity services 2017 60.0 3/11 121/207 Worst quartile in England R 126a Dementia diagnosis rate 2018 02 86.5% 2/11 5/207 Best quartile in England 126b Dementia post diagnostic suppo2016‐17 79.9% 2/11 72/207 Interquartile range R 127b Emergency admissions for UCS 17‐18 Q2 3,518 10/11 202/207 R 127c A&E admission, transfer, discha2018 03 82.1% 6/11 101/207 Note: There are no data for NHS Manchester CCG (14L) for the following indictors: 121a, 121b, 121c, 122d, 125b, 125c, R 127e Delayed transfers of care per 102018 02 8.6 6/11 83/207 163a, 163b and 164a R 127f Hospital bed use following eme 17‐18 Q2 587.2 10/11 188/207 * Patients diagnosed in 2015; # Patients diagnosed in 2014 105c % of deaths with 3+ emergency admissions in last three months of life (not available) 128b Patient experience of GP service2017 84.2% 6/11 123/207 R 128c Primary care access 2018 01 75.0% 6/11 96/207 R 128d Primary care workforce 2017 09 0.94 7/11 133/207 R 129a 18 week RTT 2018 02 92.6% 2/11 31/207 130a 7 DS ‐ achievement of standards (not available) R 131a % NHS CHC assesments taking p17‐18 Q3 8.8% 7/11 71/207 132a Sepsis awareness (not available)
Note: peer and England rankings are unavailable for indicator 123f because it is not currently produced as a rate
Greater Manchester Health & Social Care Partnership 4th Floor 3 Piccadilly Place London Road Manchester M1 3BN
Telephone No: 0161 625 7791 Email address: [email protected] Ref: JR/JB
27th March 2018
Letter sent via email GM CCG AOs and Chief Officers GM LA CEOs and DASS GM Provider Chief Executives and Directors of Operations
Dear Colleagues
Performance and Delivery Board Feedback – March 2018
As part of the GMHSC governance structure, the Performance and Delivery Board meets on a monthly basis to review delivery across health and social care, including but not limited to NHS constitutional standards and performance against the CCG Improvement and Assurance Framework metrics. From the February meeting, following the governance review, we are also including the transformation portfolio in discussions at Performance and Delivery Board. The emphasis of the meetings is to evaluate performance and delivery at a GM level, as well as highlighting localities where particular delivery challenges are apparent, and to agree further actions.
To try to avoid multiple communications throughout the month it was agreed to provide a summary of key issues discussed at the Board as outlined below, which you may wish to discuss within your own organisations and your own collective governance meetings. For more detailed information or to see specific papers from the Board please contact Janet Butterworth ([email protected]).
TRANSFORMATION
The Board discussed the risks identified for the transformation programmes, including localities delivering what they set out to deliver and releasing the intended benefits. Work is underway to establish overarching metrics to provide assurance for the transformation programme and this will include the standardisation of data capture for ambulatory care.
As part of the current planning work it is essential to address the alignment of operational plans with investment agreements, taking account of the latest planning guidance and requirements of the GM programmes over the next 3 years.
Work is underway to agree what needs to happen in 2018/19 and prioritise for 2019/20. I would urge colleagues to escalate issues early given the significant amount of work to be done and to make best use of the national tools, particularly the aggregation tool.
Once this initial piece of work is complete we will be able to provide more detail relating to the locality deep dives to be presented and discussed at the Board.
NURSING REPORT
The quarterly Nursing Report acknowledged the Pennine Acute CQC rating had improved from inadequate to good. There have been five SEND inspections now in GM with concerns from the Oldham inspection and an action plan was submitted to Ofsted in March. Quality of care homes is a priority and the report acknowledged work across GM to make improvements. Of note is that Alvanley Practice received the award for Practice Nursing Team of the Year in the Practising Nursing Awards.
Now that all CQC inspections are complete it seems an appropriate time to collate a list of providers requiring improvement or judged to be inadequate, so that it is clear where our attention should be focused. Updating this list on a quarterly basis would enable the use of the information to focus at the quarterly locality assurance meetings. To do this we will look at information currently being prepared for the Quality Board as well as information on the CQC website.
PUBLIC HEALTH
The first cut of the Public Health Dashboard was presented to the Board. Work will continue to develop the dashboard and will be utilised within the quarterly locality assurance meetings and 5YFV evaluations. The software enables comparison between GM and its CIPFA neighbours as well as comparison between GM localities, trends and future predictions to 2021. Metrics will be created at GM level to enable performance monitoring of chosen indicators. The Board discussed the frequency of data collection and the use of proxy measures and composite indicators. As this work develops we will discuss further at the Board.
URGENT CARE & DELAYED TRANSFERS OF CARE
At the time of the meeting the most up to date data for 4 hour performance shows 82% for Feb and 76% to date for March. (This position has improved to see degree in the period since.) GM has seen a gradual increase over the last 6 weeks in bed occupancy and stranded patients in some trusts are up to 60% plus. Work is underway to complete an improvement plan to meet the requirements of the GM Assurance Agreement with NHSE and this will be completed by the end of March. The requirement is to demonstrate how GM will deliver a 90% standard.
DTOC is performing well compared to nationally and tacking slightly below the North of England position. It is important that we do not normalise our DTOC performance and continue to focus on what is happening outside hospital. Bury CCG have agreed to share their Discharge to Access Model and this will be circulated as soon as it is available.
AMBULANCE RESPONSE TIMES
An amended recovery plan is currently being prepared by NWAS. Locality engagement is essential as we start to support NWAS to improve performance. We are working closely with the NW NWAS commissioners.
ELECTIVE PERFORMANCE INCLUDING CANCELLED OPERATIONS
The 92% RTT standard is tracking downwards at 90.8% for January. This position was expected following winter and localities are urged to monitor elective performance carefully as we look towards recovering the GM position in the spring.
In GM we are continuing to monitor recovery and impact of winter on the elective position. Your support in engaging with requests for information is crucial and we have taken on board feedback and think now we have a weekly information request that is manageable for localities to respond to and hope therefore to be able to develop an accurate picture. Early feedback from this work is showing only a small number of cancellations on the day and before the day across GM but a downward trend in waiting list size.
Fifty-two week waiters are not a significant concern for us in GM but I would like to urge localities to identify and investigate all patients waiting more than 52 weeks and ensure their pathways are unblocked. Work is currently underway in Manchester to address the issues for patients waiting over 52 weeks for breast reconstructive surgery which represent the majority of patients waiting more than 52 weeks in GM.
The GM Elective Hub was launched on 21st March. Work programmes are now underway at pace and outputs will be made available on the GM website and flagged for your attention in this monthly letter. Thanks to those who have supported the scoping and design of this important demand management programme.
DIAGNOSTIC WAITING TIMES
Diagnostic waiting times are continuing to deteriorate at 2.3% reported in January. We have undertaken some detailed analysis to really understand the areas of concern and have identified colonoscopy in Bolton and MRI in Salford as key areas for focus. We will make contact with those localities to understand more about the issues and offer support for recovery.
CANCER
As predicted cancer performance in January has dipped, with the 62 day RTT standard reported at 81.6% in January (86.4% in December) against the standard of 85%. Suzie Penney’s report has been circulated following this meeting and we are supporting the Cancer Board in the recovery and sustainability of the cancer standards. Localities are urged to monitor adherence to the recommendations of the report.
MENTAL HEALTH
The April Performance and Delivery Board will receive reports dedicated to mental health. Sectors are encouraged to send appropriate representatives to the meeting.
EARLY INTERVENTION IN PSYCHOSIS (EIP)
Performance against this standard continues to be a concern although GM remains above the 50% standard although in the lowest quartile nationally. It seems sensible now given the clear increase in demand for EIP to work on understanding predictions of performance over the coming months and your input into this work will be essential for us to really understand our worsening position and how we can recover.
IAPT RECOVERY
IAPT recovery is a worsening position for GM. There will be a further discussion at next month’s Board, with particular focus on the population groups who are more likely not to show recovery.
IAF
The Board discussed those IAF indicators where GM is in the bottom quartile and these were included in this month’s Performance report. The only indicator amongst these, which is not currently picked up in our GM working groups is concerned with primary care workforce. It was agreed there was a need to review the future model for primary care employment and understand more about what the GP federations are doing with regard to investment as well as accelerate workforce planning across GM.
The next meeting of the Performance and Delivery Board will be 11 April 2018, 1 – 3.30 pm. In addition to standing items, this meeting will focus on mental health.
Yours sincerely
Jon Rouse Chief Officer Greater Manchester Health and Social Care Partnership
NHS SALFORD CLINICAL COMMISSIONING GROUP GOVERNING BODY AGENDA ITEM No 6 (c)
Item for: Decision/Assurance/Information
23 May 2018
REPORT OF: Chief Finance Officer
DATE OF PAPER: 14 May 2018
SUBJECT: Annual Accounts Review 2017-18
IN CASE OF QUERY Elaine Vermeulen, Deputy Chief Finance PLEASE CONTACT: Officer 0161 212 4874
Please tick which strategic priorities the paper relates to: STRATEGIC PRIORITIES:
Quality
Community Based Care
Integrated Care
In Hospital Care
Long Term Conditions and Mental Health
Effective Organisation
PURPOSE OF THIS PAPER:
This report is to present the 2017-18 Annual Accounts to the Governing Body.
RECOMMENDATION OF THIS PAPER:
The NHS Salford Clinical Commissioning Group Governing Body is asked to approve the 2017-18 Annual Accounts, for signature by the Chief Accountable Officer and submission to NHS England.
(Please see further explanatory requirements overleaf)
Further explanatory information required
HOW WILL THIS BENEFIT THE None. HEALTH AND WELL BEING OF SALFORD RESIDENTS OR THE CLINICAL COMMISSIONING GROUP?
WHAT RISKS MAY ARISE AS A None. RESULT OF THIS PAPER? HOW CAN THEY BE MITIGATED?
WHAT EQUALITY-RELATED RISKS None. MAY ARISE AS A RESULT OF THIS PAPER? HOW WILL THESE BE MITIGATED?
DOES THIS PAPER HELP ADDRESS None. ANY EXISTING HIGH OR EXTREME RISKS FACING THE ORGANISATION? IF SO WHAT ARE THEY AND HOW DOES THIS PAPER REDUCE THEM?
PLEASE DESCRIBE ANY POSSIBLE None. CONFLICTS OF INTEREST ASSOCIATED WITH THIS PAPER.
PLEASE IDENTIFY ANY CURRENT None. SERVICES OR ROLES THAT MAY BE AFFECTED BY ISSUES WITHIN THIS PAPER:
Footnote:
Members of NHS Salford Clinical Commissioning Group Governing Body will read all papers thoroughly. Once papers are distributed no amendments are possible.
Document Development
Not Comments and Date Process Yes No Outcome Applicable (i.e. presentation, verbal, actual report) Public Engagement X (Please detail the method ie survey, event, consultation) Clinical Engagement X (Please detail the method ie survey, event, consultation) Has ‘due regard’ been given to Equality X Analysis (EA) of any adverse impacts? (Please detail outcomes, including risks and how these will be managed) Legal Advice Sought X Presented to the Commissioning Committee X Presented to the Health and Wellbeing Board X Presented to the Integrated Joint X Commissioning Board X The accounts were presented in Audit committee members draft form to the Audit Committee will provide a verbal update Presented to any other groups or committees, on 26 April, and again as audited at Governing Body, as the Audit Committee will meet to including Partnership Groups final accounts on 23 May. consider recommending (Please specify in comments) approval of the accounts immediately preceding Governing Body.
Note: Please ensure that it is clear in the comments and date column how and when particular stakeholders were involved in this work and ensure there is clarity in the outcome column showing what the key message or decision was from that group and whether amendments were requested about a particular part of the work.
Annual Accounts Review 2017-18
1 Executive Summary
This paper provides an update on the financial position of NHS Salford Clinical Commissioning Group (CCG) at the end of March 2018, and presents the 2017-18 Annual Accounts to the Governing Body, attached as Appendix 1. The CCG has met all its statutory targets, as detailed in section 3 below. The draft accounts were reviewed in detail by the Audit Committee at its meetings on 26 April and 23 May 2018 and have been examined by external audit. They are recommended for approval by the Governing Body, and will be submitted to NHS England by 29 May 2018.
Additional information is presented in Appendix 2 to assist members in their review of the accounts.
2 Introduction and Background
2.1 This report is to present the 2017-18 Annual Accounts to the Governing Body for approval, in accordance with the CCG’s constitution. These are attached at Appendix 1.
2.2 The draft accounts were examined in detail by the Audit Committee on 26 April and members raised questions regarding the accounts for clarification by management. The accounts have now been subject to external audit, who will provide their formal opinion on the accounts at the Audit Committee meeting of 23 May 2018. The approved audited accounts will be submitted in line with the NHS England deadline of 29 May 2018.
3 Statutory Targets
3.1 The CCG operated on a sound financial basis throughout the year and has achieved all of its statutory targets as detailed in note 19 of the annual accounts. The CCG has four performance management targets against which it is measured:
• Revenue resource use does not exceed the amount specified in Directions; • Revenue administration resource use does not exceed the amount specified in Directions; • Capital resource use does not exceed the amount specified in Directions; • Better Payments Practice Policy.
3.2 Revenue resource use - The CCG has a legal duty to maintain spending within its resource limit. There are two separate limits against which the CCG is measured: revenue and cash. In 2017-18 the CCG met both requirements and reported:
• A £2.3m under spend (surplus) against it’s in year resource limit of £440m. Although the planned target surplus was breakeven, the CCG was advised that the 0.5% non recurrent reserve of £1.9m could not be spent and had to be released to increase the target surplus. In addition, in line with national reporting requirements, the CCG’s category M prescribing savings of £0.4m had to remain unspent, so these two items contributed to the CCG’s surplus
of £2.3m. The CCG also has an historical cumulative surplus of £13.1m, which together with the 2017-18 surplus of £2.3m will be carried forward to future years for drawdown over a period of time.
• The cash book balance at the end of the year was £331k which was within the monthly limit approved by NHS England.
3.3 Revenue administration resource use - Salford CCG has been allocated a running costs allowance of £5,560k. In 2017-18, the CCG’s running cost expenditure was £5,513k and so has remained within the allowable expenditure limit.
3.4 Capital resource use - The CCG received no capital allocation in 2017-18 and has incurred no capital expenditure.
3.5 Better Payment Practice Code - In line with other public sector bodies, NHS organisations are required to pay invoices within 30 days or within the agreed payment terms, whichever is the sooner. This is known as the Better Payment Practice Code. CCGs are required to ensure that at least 95% of invoices are dealt with in line with this code. The CCG paid 99.34% of non NHS invoices and 99.6% of NHS invoices by volume within target and 99.09% of non NHS and 100% of NHS invoices by value within target.
4 Financial Position 2017-18
4.1 The finance report presented to Governing Body in March, based on month 11 results, indicated that the CCG expected to achieve the planned breakeven position, but as outlined in section 3.2 above a surplus of £2.3m has been achieved.
4.2 The main movements between the previous report to Governing Body based on the forecast position at month 11 and the final outturn position at month 12 relate to:
- Acute contract over spend of £4.4m (month 11 £3.6m) has increased mainly due to further over performance on non elective care and non contract activity
- Committed developments have increased by £2.4m, of which £1.9m relates to the release of the uncommitted 0.5% reserve - The underspend on prescribing is £1m (month 11 £0.3m) and whilst £0.4m of
this relates to the Category M savings, there has been an underlying improvement of a further £0.3m as the cost of No Cheaper Stock Obtainable drugs continues to decrease month on month. - The overspend on the pooled budget is £1.8m (month 11 £2.2m) and this has been improved mainly due to additional adult social care client receipts of £0.3m and reduced continuing healthcare expenditure of £0.2m.
5 Statutory Accounts
5.1 The Healthcare Financial Management Association has produced a guidance document for governing body members to make the task of reading and understanding a CCG’s annual report and accounts easier. It sets out a number of pertinent questions members may wish to ask to enable them to challenge the finance team and auditors where necessary. The majority of the questions regarding the annual accounts are set out in Appendix 2, along with management’s responses.
5.2 The accounting policies have been derived from the model policies included in the annual reporting guidance, modified for local application.
6 Recommendation
6.1 The NHS Salford Clinical Commissioning Group Governing Body is asked to note the achievement of the statutory financial targets and approve the accounts for the year ended 31 March 2018.
Steve Dixon Chief Finance Officer
Appendix 3 – HFMA guide to reviewing annual accounts
Question Rationale Management Response OVERALL PERFORMANCE Has the organisation met its statutory duties? If NHS bodies are ‘creatures of statute’ with a number of All statutory duties have been achieved. the organisation has not met one or more of the duties set down in law that must be achieved. You targets, was this expected and do you know why should know what these are but if not, find out. this is the case? Has the organisation met the better practice Failure to meet this administrative duty indicates that Yes payment code target i.e. to pay at least 95% of there could be underlying cash flow issues. Performance invoices within the agreed terms? against this target should tie up to the movement in balances on payables. Are the accounting policies consistent with what Example accounting policies provided by NHS There have been no amendments to the accounting policies you know the organisation does in practice? Improvement and NHS England must be tailored to since 2016-17. reflect local circumstances. Do the accounts include disclosures relating to: Do these disclosures reflect your understanding? Have The calculation of running costs has been undertaken in • judgements made when applying key these issues been raised by auditors? Are there issues accordance with NHS England national guidance and accounting policies that auditors have raised which are not reflected in the definitions. However the application of the rules for each • areas where there is uncertainty about the accounts? organisation involves an application of professional estimates used judgement to particular circumstances The assessment of the pooled budget as a joint arrangement, resulting in accounting for the clinical commissioning group's share of transactions on a net basis. Owing to the time lag in obtaining actual prescribing information, accruals are made based on estimated costs. Do the accounts include a disclosure on going NHS bodies prepare their accounts on a going concern Management has assessed the CCG as being a going concern? basis. However, disclosures are required on concern. managements’ assessment of going concern and any uncertainties relating to that status. This disclosure should reflect any concerns about the financial position or cash flows of the NHS body. Can you see the impact of any savings schemes This is to check whether known changes have been The CCG has achieved £4.8m in QIPP in 2017-18, mainly during the year? These schemes may include a reflected. Successful savings schemes should be through changes in the maternity pathway, savings in reduction in headcount, income generation or reflected in the accounts – for example, reductions in prescribing and renegotiation of block contracts. changes to procurement? How are savings headcount should result in reduced staff costs. managed? Appendix 3 – HFMA guide to reviewing annual accounts Question Rationale Management Response Are the financial assumptions consistent with the If in-year forecasting and reporting is accurate, there Year end accounts are in accordance with the CCG’s organisation’s annual plan and previous financial should not be any surprises at the year end: the year- forecasts during the year. Although target was breakeven, information provided? end accounts should reconcile to the in-year financial the CCG expected at the outset to have to release the 0.5% reports. If there are any inconsistencies, can they be uncommitted reserve to the bottom line, and this was explained? further augmented by the category M savings. Have there been any significant issues raised with If there is any potential missing information or doubts The Head of Internal Audit opinion gives significant the governing body/ board during the year - for over assumptions, have these been explained? assurance on internal controls. Any variances between example, significant weaknesses in systems, or planned and actual activity have been highlighted during variances between planned and actual activity, the year and incorporated into forecasts as soon as they are that could cast doubts on the assumptions made? apparent. Do the disclosures in relation to the external The auditor’s work under the Code of Audit Practice (the Grant Thornton only undertake the statutory external audit auditor reflect your understanding of the terms of audit of the financial statements and value for money work and provide no other services to the CCG. The auditor their engagement? work) should be disclosed as audit remuneration. Work has not set any limit to their liability. on the quality report/ accounts should be shown as ‘other services: audit-related assurance services’. Any other work which does not relate to the audit should be disclosed as non-audit fees. Each NHS body should have a policy on the amount of non-audit work an auditor can undertake – are the fees disclosed in accordance with this policy? The auditor may set a limit on their liability. This should be disclosed in the notes to the accounts. Does the amount reflect the amount that has been agreed in the letter of engagement? Have the annual governance statement and head A key part of the year-end process, the accountable/ No of internal audit opinion recorded any internal accounting officer must review the system of internal control issues? control and whether or not the organisation has faced any significant control issues – for example, serious incidents. Do these disclosures reflect your understanding? Have any issues raised the previous year been resolved? Are milestones in place for outstanding issues?
Appendix 3 – HFMA guide to reviewing annual accounts Question Rationale Management Response ACCOUNTS PREPARATION Does the financial outturn in the accounts tie up All financial reports should be based on the financial Yes to the management accounts? ledger with very few adjustments. If the amounts reported in the management accounts differ from the amounts reported by the financial reporting team there could be unexpected surprises at the year end. Do you understand and agree with any There are always areas of judgment/ estimation when The increase in provisions for dilapidations expenditure was judgements/ estimates that have a material preparing the accounts. For example, in considering the based on a “per sq m” estimate provided by NHS Property impact on the financial statements? level of provisions that should be established; the basis Services. The judgement not to write down the investment of valuation of non-current financial assets; write-off of in North West eHealth was based on review of their receivables/ stock. These should be consistent with your management accounts post their year end. understanding of the organisation and its wider policies/ strategies. Do the financial statements as a whole (and as Some disclosures in the financial statements are In management’s opinion, yes. part of the annual report and accounts) focus on required by either the Department of Health or the important issues and highlight the key accounting standards. However, there is an initiative financial issues for the NHS body? within financial reporting to ‘cut the clutter’ which means taking out immaterial disclosures, zero rows and columns to help the reader of the accounts identify what is important. Taking a step back, think about whether the accounts, as a whole, reflect your understanding of the financial position of your organisation. STATEMENT OF COMPREHENSIVE NET EXPENDITURE How have the figures changed compared to last For changes that you were expecting, do the figures look No material changes in receivables and payables. year and the year before that? Are any changes right? If no changes were anticipated, you would expected/ unexpected? generally expect figures to increase with inflation. If there are movements that are much larger than this, you should find out why. Any unexpected changes need to be identified and explained. Do the figures seem reasonable and complete, Is any information missing? If it is, do you know the including those entries that are zero? reason? Is the surplus/ deficit consistent with the If in-year forecasting is accurate, there should not be The only additional surplus is the uncommitted reserve and forecasts made during the year? any surprises at the year end. If there is a significant category M savings, now released to the bottom line in change, can it be explained? accordance with national instructions. Appendix 3 – HFMA guide to reviewing annual accounts Question Rationale Management Response Has there been a prior period adjustment? Is this due to a change in accounting policy that should No be reflected in the opening note to the accounts, or another reason? Do you know what expenditure has been included Expenditure is expected to fall into the specified No material, only £5k. in the ‘other’ category? categories in most cases. If it is included in ‘other’, do you know what this is and understand why it does not fit with any of the specified categories? What has caused changes in pay expenditure? How much of the change relates to pay awards? What Main change is due to the transfer of staff to Salford has been the impact of the agency cap? Which areas of Primary Care Together, reducing the payroll cost in 2017-18 staff expenditure are still increasing? and increasing the contract value under healthcare purchases. Does any movement in staff costs correspond to If there are significantly more people in post compared Yes the change in staff numbers? to this time last year, has a new service come on stream? Otherwise, is the organisation paying significantly more (or less) for no extra staff? Do any material amounts of employee benefits Any unexpectedly high levels may highlight the need for Not applicable and early retirements due to ill health correspond further review. with your expectations? Does the organisation have any staff who are Most NHS staff will be part of the NHS pension scheme No directly employed members of staff are members of a members of a local government pension scheme? which is reflected as a cost in the notes to the SOCI/ local government pension scheme. If so, have the details been disclosed? Also, has SOCNE. The cost reflects the contribution made by the the organisation disclosed the financial liability (or NHS body as an employer and can therefore be forecast financial asset, if the scheme is in surplus) of any accurately. Accounting for local authority pension local government pension scheme? You should be schemes is very different and, in part, the amounts able to see this within ‘other financial liabilities’ included in the accounts are dependent on actuarial (or possibly ‘other financial assets’) on the valuations. As the valuation can change and is only statement of financial position. made at the end of the financial year, there can be an impact on the financial position of the NHS body which is difficult to forecast. Are you satisfied that you understand the impact that staff belonging to this scheme could have on the financial position of the organisation? Appendix 3 – HFMA guide to reviewing annual accounts Question Rationale Management Response To the best of your knowledge, does the Do the figures reflect your knowledge of directors in This disclosure is in the annual report. disclosure in relation to directors’ remuneration position during the year and any changes? Do the appear complete? amounts disclosed reflect your understanding of the amounts paid to each individual? Does the organisation pay any staff ‘off-payroll’? Where it is determined that the off-payroll rules apply The CCG has never paid any senior management or If so, how has this changed during the year? (and the individual would be classified as an employee if Governing Body staff off payroll and an audit from HMRC they were not being paid via an intermediary), the confirmed this in 2017-18. organisation is responsible for deducting and paying employment taxes and national insurance (NI) contributions relating to the engagement. Do the expenditure figures appear reasonable and A wider understanding of what expenditure is expected can officers explain the reasons for any significant can flag potential areas of omission or where further changes from the previous year? For example, do review is needed. you know what services you now buy from another organisation that you did not buy last year? Is there a meaningful change in the depreciation Has the organisation changed the useful economic lives Not applicable as there are no fixed assets. figure in the statements? of its assets (this should be reflected in the accounting policies noted above). If so, this will reduce expenditure in-year without affecting the amount of cash held. This means that overall financial performance has been ‘propped up’ by an accounting adjustment that isn’t matched by cash If there has been an impairment (loss in asset Assets lose value due to changes in the economic Not applicable as there are no fixed assets. value), do you know why? Does the property, climate and damage/ obsolescence. Is any change plant and equipment note to the accounts reflect reasonable based on your knowledge of the the situation accurately and clearly? organisation and the prevailing economic climate? Does the organisation have (or is it party to) a It is important to identify how this part of the business Yes, the CCG has a 20% share in North West eHealth and subsidiary, associate, joint venture or special or contract is performing and whether or not core accounts for this investment as an associate as it has purpose vehicle? This includes pooled budget activities are keeping it afloat. Are gain/ loss share significant influence over its performance. The CCG hosts arrangements for CCGs arrangements in place? What are they and is there a the adult health and social care pooled budget. ‘parent guarantee’ (i.e. where the parent organisation guarantees to meet any liabilities)? Does it have an impact on the organisation’s core business? Appendix 3 – HFMA guide to reviewing annual accounts Question Rationale Management Response Can officers explain the reasons for any significant Have any material leases been signed during the year or No substantive changes in leased premises costs during changes in leasing costs and/ or commitments? have any come to an end? 2017-18 A wider understanding of what lease changes are expected can flag potential areas of omission or area for further review. Has the organisation incurred any expense under If so, do you know why? It is important to understand No, the CCG continues to achieve excellent compliance with the Late Payment of Commercial Debts (Interest) the reasons – for example, it may indicate a cash flow the Better Payment Practice Code. Act 1988? difficulty or possibly a temporary shortage of staff processing invoices? STATEMENT OF CHANGES IN TAXPAYER’S EQUITY Do the lines that should net to zero do so when Do you understand the reason for any transfer? Looking No transfers in 2017-18 added together? Lines which net to zero are at the lines may identify any omissions or amendments transfers between reserves. elsewhere in the accounts that have not tracked through. Has there been a prior period adjustment? Is this due to a change in accounting policy that should No be reflected in the opening note to the accounts, or another reason? Are there any significant changes to the Have these been explained and does the reason fit with No revaluation reserve? (See also the questions on what you know? Are revaluations based on appropriate non-current assets under the statement of assumptions? Have those assumptions been discussed financial position.) and reviewed by the audit committee? Is the amount of Parliamentary funding the For CCGs, funding from NHS England is shown in this £437,958k amount that you expected? Does it tie up with the statement. note on the financial performance of the CCG? STATEMENT OF FINANCIAL POSITION Have any items changed significantly since last Do any changes fit with your knowledge of the Movements in trade and other payables/receivables not year? organisation’s activities? Use the note references to find significant. Pennine Acute underperformance £0.7m out more detail about any items that look unusual. included in 16/17 receivables. Does the movement in the valuation of property, Assets lose value due to changes in the economic Not applicable plant and equipment agree to the revaluations climate and damage/ obsolescence. Is any change and impairments of these assets and are they reasonable based on your knowledge of the what you expect? organisation and the prevailing economic climate? Assets can increase in value due to changes in the property market or changes in the building trade - for example, the price of building materials. Appendix 3 – HFMA guide to reviewing annual accounts Question Rationale Management Response Do non-current asset additions and disposals tie A wider understanding of asset movements expected The £14k movement in the value of the North West eHealth in with your knowledge of the organisation’s can flag potential areas of omission or further investment is the correction of the acquisition accounted capital programme? investigation. The level of additions and disposals should for in 2016-17 accounts but formally transacted in 2017-18 tie in with your understanding of the capital programme with NWeH and other shareholders. and estates management plans. Has there been a professional valuation of the There is no requirement to have an annual valuation but Not applicable estate this year? the asset values must be materially correct. Do you understand your organisation’s policy on valuation? Do movements in property, plant and equipment Can any movement in property, plant and equipment be Not applicable agree with your understanding of the capital explained by asset disposals or acquisitions? programme? Has there been a loss on the disposal or sale of an Any disposals should be part of the wider capital Not applicable asset? Was this expected? programme. It is worth asking why there was a loss on disposal. A wider understanding of expected asset movements can flag potential areas of omission or error. Are receivables growing? Does the organisation What are the underlying reasons? Is there a prompt There is an effective debt recovery process and this is have more money tied up in debtors? Is there an payment policy? The longer debts take to be paid, the regularly reported to governing body effective debt recovery process? greater the pressure on the organisation’s cash flow. Are there any particularly large receivables this When reviewing receivables, it is important to consider No, small overall reduction in receivables. year, or significant changes from the prior year? the ‘collectability’ of balances. If receivables increase, Can officers explain the reasons for these? what is the effect on aged debtors and debtor days? Any unexpected or unexplained large movements may highlight an area for further review. How has the agreement of balances process Are there any underlying issues of which NEDs/ lay There are no items in dispute with other organisations progressed during the year and at year end? members should be aware? For example, have NHS disputes been particularly difficult to resolve? Are these disputes with neighbouring organisations? Can officers explain the level of bad debts that Bad debt provision is a judgement – are the No write off has been required or actioned. have been provided for and written off? Has it assumptions used in calculating this in line with been reflected in the losses and special payments expectations? schedule? Does the provision for impairment of receivables Provisions are based on judgement – are the None look reasonable? assumptions used in calculating this in line with expectations? Appendix 3 – HFMA guide to reviewing annual accounts Question Rationale Management Response Have prepayments only been made to Public sector bodies generally should not make Yes organisations that have sound financial standing payments in advance of receiving goods or services. and where the organisation gains value from the Such payments should only be made to achieve value prepayment? for money. The risk that the goods/ services may not be delivered should be recognised and a mitigation strategy put in place. The organisation’s cash flow should also be protected. If the stock/ inventories figure is different to last Any unexpected or unexplained large movements may Not applicable year, why is this? highlight an area for further review. For example, stock taking processes may need to be looked at to ensure they remain fit for purpose. Do stock movements reflect the procurement policies of the NHS body? Is the level of write-off of stock a concern? Have trade payables (creditors) grown? How If this is increasing, the organisation may be Trade creditors have reduced overall. much money does the trust owe its suppliers? experiencing cash flow problems and delaying payment to creditors to manage its cash position. If payables are increasing, has there been a corresponding fall in performance against the prompt payment requirements? Are there any particularly large trade or other An increase in payables may indicate cash flow No significant changes overall payables this year, or significant changes from the problems. Does the movement in payables correlate prior year? Can officers explain the reasons for with performance against the prompt payment metric? these? Any unexpected or unexplained large movements may highlight an area for further review. Can officers explain significant receipts in advance Public sector bodies generally should not make None and deferred income? payments in advance of receiving goods or services. Given that NHS bodies generally trade within the NHS, they would not generally expect to have significant receipts in advance. Have the services/ goods that have already been paid for been taken into account in forecasts? What is the reason for the deferral? If there is a judgement required, has it been discussed and agreed with both the third party involved and both sets of auditors? Receipts in advance and deferred income require agreement with the third party involved. Failure Appendix 3 – HFMA guide to reviewing annual accounts Question Rationale Management Response to gain appropriate agreement can result in in material income and expenditure mismatches. This may result in audit adjustments at the year end. If the cash balance has changed, do you know This needs to be looked at alongside receivables and Although the CCG’s cash balance has increased over the why? payables to get the full picture: low cash balances, previous year, it is within the permissible level set out in growing receivables and payables means cash flow national guidance. difficulties. If cash balances are falling, does this correspond with a falling surplus or increasing deficit? If not, ask how the financial performance in the SOCI ties up to the movement in cash balances? If provisions have changed, why is this? Provisions should be reasonable to cover the Provisions have increased to take account of stranded organisation against future liabilities5. If there are GMSS contract costs, dilapidations at St James House as increases in provisions what is the reason for this? nearing the lease expiry date, and for overseas visitors. Equally, if provisions have fallen, is this because they have been discharged and payment made or is it due to a change in estimates? If the estimation basis has changed, are you happy with the reasons for this change? If there are large borrowings, do you know what Does the organisation have any loans that it is in the Not applicable they are? process of repaying? Has it made the repayments it should have done during the year? Do the figures seem reasonable and complete, Where entries for current and prior years are zero, or including those entries that are zero? where a line is missing, check whether this is because of rounding or because it reflects a lack of activity. STATEMENT OF CASH FLOWS Do the changes in cash and cash equivalents Liquidity problems are highlighted by cash inflows in the Net inflow as the CCG’s cash balance has increased from result in a net cash outflow or a net cash inflow? year that are less than cash outflows. £60k to £331k, but this is not material. Do you understand the reasons for any large A large capital programme may result in a net outflow of None movements? cash. Equally, loans may result in an increase. However, any unexpected or unexplained large movements may highlight areas for further review. Does the organisation’s reported cash flow If in-year forecasting is accurate, there should not be Cash flow is not reported during the year, other than to position at the year-end correspond with that any surprises at the year end. If there is a significant note that the CCG remains within its allowable cash reported during the year? change, can it be explained? balance. Appendix 3 – HFMA guide to reviewing annual accounts Question Rationale Management Response Has the organisation bought any assets during the Capital purchases should all be reflected in the capital No year? Can you see them in the payments for programme. The overall effect of capital purchases may property, plant and equipment? not affect cash balances if the purchase is funded by a loan. Do the purchases have the expected effect on cash? Has the organisation bought or invested in any This may result in cash outflows and have an impact on No, the investment in NWeH was accounted for the first subsidiaries or other organisations during the the organisation as a whole. time in 2016-17 year? Has the organisation made any loan repayments If payments are due and have been delayed, is this Not applicable during the year? Are you aware of the reasons because there is insufficient cash flow to meet why the organisation has a loan and what its commitments? repayment profile is? Have the organisation’s cash balances increased Is there a long term plan as to how to use these Yes, but not material or of significance. overall during the year? balances? Is this expected? Or is it because payments have been delayed? The cash balances should be in line with reported plans.
NHS SALFORD CLINICAL COMMISSIONING GROUP GOVERNING BODY MEETING AGENDA ITEM No 6 (d)
Item for: Decision/Assurance/ Information
23 May 2018
REPORT OF: Steve Dixon, Chief Finance Officer and Deputy Chief Accountable Officer
DATE OF PAPER: 12 April 2018
SUBJECT: Information Governance Annual Report and Toolkit Final Assessment 2017/18
Ruth Quinn, Senior Information Governance & IN CASE OF QUERY Audit Officer, Greater Manchester Shared PLEASE CONTACT: Services 0161 212 6166
ACTION REQUIRED: Discussion/Decision/Information/Assurance (Please highlight in bold and underline)
Please tick which strategic aims the paper relates to: STRATEGIC AIMS:
Prevent ill health
Reduce health inequalities
Improve healthcare quality: - safety - experience - effectiveness
Improve health and wellbeing outcomes
PURPOSE OF PAPER: The CCG’s Governing Body is responsible for ensuring effective arrangements are in place within the CCG for Information Governance (IG). The Governing Body needs to be assured that adequate policies and procedures are in place throughout the organisation and that staff adhere to these standards.
Salford CCG’s Information Governance (IG) Support is delivered by the GM Shared Services (GMSS). Throughout 2017/2018 a significant amount of work has been undertaken by the GMSS support team and staff within the CCG to improve on the strong IG processes already in the organisation.
This report provides Governing Body with an overview of the work undertaken in 2017/18 to establish systems and processes around Information Governance and to give assurance of the controls in relation to Information Governance.
(Please see further explanatory requirements overleaf)
Further explanatory information required
HOW WILL THIS BENEFIT THE Assurance that the organisation is delivering its HEALTH AND WELL BEING OF statutory requirements in relation to information SALFORD RESIDENTS OR THE management. CLINICAL COMMISSIONING GROUP?
WHAT MAY ARISE AS A RESULT OF N/A THIS PAPER? HOW CAN THEY BE MITIGATED?
WHAT EQUALITY-RELATED RISKS None MAY ARISE AS A RESULT OF THIS PAPER? HOW WILL THESE BE MITIGATED?
DOES THIS PAPER HELP ADDRESS Mitigates risk of non-compliance with the Data ANY EXISTING HIGH OR EXTREME Protection Act and provides assurance to the RISKS FACING THE ORGANISATION? Board that there are robust Information IF SO WHAT ARE THEY AND HOW Governance processes in place. DOES THIS PAPER REDUCE THEM?
PLEASE DESCRIBE ANY POSSIBLE None CONFLICTS OF INTEREST ASSOCIATED WITH THIS PAPER.
PLEASE IDENTIFY ANY CURRENT None SERVICES OR ROLES THAT MAY BE AFFECTED BY ISSUES WITHIN THIS PAPER:
Footnote:
Members of NHS Salford Clinical Commissioning Group Governing Body will read all papers thoroughly. Once papers are distributed no amendments are possible.
Document Development
Not Comments and Date Process Yes No Outcome Applicable (i.e. presentation, verbal, actual report) Public Engagement X (Please detail the method ie survey, event, consultation) Clinical Engagement X (Please detail the method ie survey, event, consultation) Has ‘due regard’ been given to Equality Analysis (EA) of any adverse impacts?
(Please detail outcomes, including risks and how X X these will be managed) Legal Advice Sought X Presented to the Programme Management X Group Presented to the Health and Wellbeing Board X Presented to the Integrated Commissioning X Board Presented to any other groups or committees, IM&T Programme Group The paper was supported. including Partnership Groups SIRO/CCG IG Lead (Please specify in comments)
Note: Please ensure that it is clear in the comments and date column how and when particular stakeholders were involved in this work and ensure there is clarity in the outcome column showing what the key message or decision was from that group and whether amendments were requested about a particular part of the work.
Information Governance Annual Report and Toolkit Final Assessment 2017/18
1 Executive Summary
The CCG’s Governing Body is responsible for ensuring effective arrangements are in place within the CCG for Information Governance (IG). The Governing Body needs to be assured that adequate policies and procedures are in place throughout the organisation and that staff adhere to these standards.
Salford CCG’s Information Governance (IG) support is delivered by the GM Shared Services (GMSS). Throughout 2017/2018 a significant amount of work has been undertaken by the GMSS support team and staff within the CCG to improve on the strong IG processes already in the organisation and build on the evidence collated for 2016/2017.
Key areas to report to the Governing Body:
IG Toolkit – All CCGs are mandated to submit a self-assessment against all 28 requirements of the Information Governance Toolkit. The national requirement is to achieve Level 2 compliance in all 28 standards. Salford CCG met this requirement by achieving at least Level 2 in all of the standards and submitted a Level 3 against 18 of these standards. This is an improvement on last year submission when 13 Level 3’s were achieved.
Training – There is a requirement for NHS organisations to be at a 95% compliance level for mandatory Information Governance training throughout the year. Salford CCG achieved 97% compliance as at the end of March 2018.
Incidents and Risks – The organisation has reported 2 serious information risk incidents (SIRIs) to the Information Commissioner Organisation (ICO). The ICO took no further action on reviewing the information on the incidents, the lessons learned and the changes Salford CCG made in processes as a result of the incidents.
Internal Audit – A selection of ten standards from the Information Governance Toolkit were audited by Mersey Internal Audit Agency (MIAA). MIAA agreed with the CCG’s self- assessment scores on all of the standards selected for audit and issued a ‘significant assurance’ audit report.
Informal Audits – A rolling programme of auditing and spot checks have taken place within the CCG. These audits have provided assurance on security of data, staff awareness and staff understanding of Information Governance policies and procedures.
This report provides Governing Body with an overview of the work undertaken in 2017/18 to establish systems and processes around Information Governance and to give assurance of the controls in relation to Information Governance.
2 Introduction and Background
2.1 The NHS Chief Executive has made it clear that the ultimate responsibility for Information Governance (IG) rests with the Governing Body of the organisation. Governing bodies should be assured that adequate policies and procedures are in place to address the key actions required to support effective Information Governance and that the organisation is compliant with the Information Governance Toolkit annual submission.
2.2 Staff training and awareness of their responsibilities toward confidentiality and security and adequate capacity and capability to deliver the IG agenda are key requirements to achieving the mandated IG standards.
2.3 During 2017/18 Salford CCG’s IG support has been delivered by the GM Shared Services (GMSS). This support includes:
• Resource to support and manage evidence gathering for IG Toolkit returns
• Provide suite of generic IG documents - IG policies, procedures, guidance for staff, information sharing templates
• Advice and guidance to support projects and general day to day queries
• Monitoring of IG training, briefing sessions and publications to staff
• Guidance in the management, and reporting of information incidents, through to resolution
2.4 The CCG’s Senior Information Risk Owner (SIRO) is the Chief Finance Officer (CFO). The SIRO has executive responsibility for information risk and information assets. The SIRO is supported by the Head of Business Intelligence and IT who manages the IG service. The IG agenda and work programme within the CCG is reported and monitored through the Information Management & Technology Programme Group, which meets monthly, and reports to the CCG Executive Team.
2.5 This report provides Salford CCG’s Governing Body with an overview of the work undertaken in 2017/18 to establish systems and processes around IG and to give assurance of the controls in place.
3 Information Governance Toolkit
3.1 The Information Governance Toolkit is the mechanism through which NHS and related organisations demonstrate their compliance with a number of IG requirements. For 2017/18, CCGs were required to self-assess against 28 requirements. Each requirement is scored on a level from 0 to 3 depending on how well the organisation meets the criteria:
• Level 0: Either not applicable or no action identified to meet the required standard
• Level 1: Work has been planned, documented and approved
• Level 2: Approved plans being implemented and result of this work are being reported on
• Level 3: Current plans are being assessed, updated if identified and reapproved
3.2 Submission of the Information Governance Toolkit (IGTK) assessment is annually on the 31st March. The IGTK assessments are scored as either ‘Satisfactory’ or ‘Non- Satisfactory’. A satisfactory status is where all 28 requirements have attained a Level 2 or above. This is converted to a composite score requirement of 66%.
3.3 Salford CCG met this requirement by achieving Level 2 in all of the standards and exceeded the minimum requirement in eighteen of the standards achieving Level 3 in those areas. The composite score for Salford CCG is 90%. This is an improvement on last year’s submission (85%).
3.4 To give further assurance of the self-assessment, in February 2018 the IG Toolkit was audited by the CCG’s internal auditors, Mersey Internal Audit Agency (MIAA). MIAA audited a random sample of ten requirements and agreed with the CCG’s self- assessment scores. MIAA concluded ‘significant assurance’ to this audit.
4 Information Governance Activity and Good Practice – 2017/18
4.1 Salford CCG has undertaken a significant amount of work around IG in 2017/18. The main areas of activity and good practice are noted as follows:
4.2 IG Culture - Good practice is demonstrated through the embedding of IG culture throughout the organisation by establishment of the IM&T Programme Group, which is accountable to the Executive Team. This shows the commitment to IG standards by senior management within the CCG and provides a forum for IG topics to be properly raised and attended to.
4.3 IG policies & procedures: have been quickly adopted by the CCG ensuring that staff have a robust IG framework within which to operate.
4.4 Routine Monitoring: Good practice is demonstrated through the establishment and regular monitoring of the IG programme via the monthly Information Management & Technology Programme Group. This provides a forum for IG topics to be properly raised and attended to. This group reports to the CCG Executive Team via the Senior Information Risk Officer. The Senior Information Risk Officer for Salford CCG is the Chief Finance Officer (CFO).
4.5 Privacy Impact Assessments (PIAs): The CCG has embedded the use of PIAs within the Innovation Process. PIA’s are required when a new system is being procured or it develops new ways of working where there is the potential for personal confidential data to be used. They are crucial to ensure privacy and confidentiality concerns are risk assessed prior to implementation of a project or system. The assessment has been developed and shared with services within the CCG.
4.6 Training: IG training has been rolled out within the CCG at various levels. All staff had to complete the mandatory IG training modules. In addition specific groups of staff have undertaken additional modules:
• IG mandatory training is a requirement for NHS organisations to have 95% compliance level for all staff in mandatory IG training throughout the year. The CCG achieved 97% compliance in March 2018.
• The Senior Information Risk Officer (SIRO) and Caldicott Guardian attended specialist training regarding their roles.
4.7 Confidentiality Audit (Walk around audit): The IG team conducted two walk round audits within the CCG over the 12 month period. The result from the audit was positive. Staff are aware of how to report an incident, the importance of locking screens and keeping documents filed away, for example. Further communications have been forwarded to staff as there were some areas where there was a lack of knowledge.
4.8 Data Flow Maps: The CCG has reviewed personal confidential data flows within the organisation, allowing a systematic and comprehensive mapping of information and data flows. A report of the review was provided to the Senior Information Risk Officer which highlighted no high risk areas.
4. 9 Information Assets: Information Asset Registers (IAR) contain details about assets which are forms of information that have value to the organisation. This provides a comprehensive log and allows risks to the information to be easily understood and managed. Work has been completed throughout the year to review the existing Information Asset Register.
4.10 Paperlight: The organisation is moving towards a paperlight organisation. Documents have been removed from desks and the Governing Body has moved towards receiving meeting papers on electronic devices. Work is taking place within the Continuing Health Care (CHC) team to move to an electronic collection and storage of their data. A paperlight organisation will assist in the prevention of data breaches from loss of paperwork.
5 Information Governance Incidents and Risks
5.1 Incidents of data loss continue to occur across the NHS and in some cases these can be significant and in breach of national guidance. All NHS organisations are required to report a Level 2 IG related Serious Incident Requiring Investigation (IG SIRI) on the Information Governance Toolkit incident reporting tool.
5.2 The Information Commissioners Office (ICO), Department of Health and NHS England (where appropriate) will be notified via the tool of the reported IG SIRI. All information recorded under a ‘Closed’ IG SIRI on the IG Toolkit Incident Reporting Tool will be published quarterly by NHS Digital.
5.3 The CCG has an IG Incident Reporting Procedure in place and this has been reviewed. This procedure is to be used for staff for the recording, reporting and reviewing of information governance and information security incidents.
5.4 Salford CCG has had two IG SIRIs during 2017/18. These were reported to the IM&T Programme Group and to the Information Commissioners Office (ICO). After reviewing the information on the incidents, the lessons learned and the changes Salford CCG made in processes as a result of the incidents, the ICO closed the incidents with no further actions required.
6 2017/18 Information Governance Work Plan
6.1 The IG team has a work plan in place to maintain evidence standards for the IG Toolkit. The main work streams include:
• Actions as a result of changes to the Data Protection Act to the new General Data Protection Regulation (GDPR). An action plan has been produced, which was approved by the CCG’s Executive Team and this will be reviewed by the IM&T Programme Group moving forward.
• IG Policies and Procedures - The IG team will be reviewing to incorporate GDPR elements.
• IG Training – Training and awareness continue to ensure that all staff remain aware of their own responsibilities with regard to information governance.
• Data Flow Mapping – continuation of capture of all flows of personal confidential data and business confidential data in and out of the organisation.
• Information Asset Register (IAR) renewal – this will be reviewed by Information Asset Owners for accuracy.
6.2 The full work plan for IG over the 2017/18 year will be formally established once the requirements for the new version of the IG Toolkit are known.
7 Recommendations
7.1 The NHS Salford Clinical Commissioning Group Governing Body is asked to receive and note this report.
Steve Dixon Chief Finance Officer and Deputy Chief Accountable Officer
NHS SALFORD CLINICAL COMMISSIONING GROUP GOVERNING BODY MEETING AGENDA ITEM NO 6 (e)
Item for: Decision/Assurance/ Information
23 May 2018
REPORT OF: Head of Governance and Policy
DATE OF PAPER: 15 May 2018
SUBJECT: Annual Report 2017/18
IN CASE OF QUERY Jenny Noble PLEASE CONTACT: 0161 212 4950
Please tick which strategic priorities the paper relates to: STRATEGIC PRIORITIES:
Quality
Community Based Care
Integrated Care
In Hospital Care
Long Term Conditions and Mental Health
Effective Organisation
PURPOSE OF PAPER:
To consider the Annual Report 2017/18 for approval.
(Please see further explanatory requirements overleaf)
Further explanatory information required
HOW WILL THIS BENEFIT THE N/A HEALTH AND WELL BEING OF SALFORD RESIDENTS OR THE CLINICAL COMMISSIONING GROUP?
WHAT RISKS MAY ARISE AS A N/A RESULT OF THIS PAPER? HOW CAN THEY BE MITIGATED?
WHAT EQUALITY-RELATED RISKS N/A MAY ARISE AS A RESULT OF THIS PAPER? HOW WILL THESE BE MITIGATED?
DOES THIS PAPER HELP ADDRESS N/A ANY EXISTING HIGH OR EXTREME RISKS FACING THE ORGANISATION? IF SO WHAT ARE THEY AND HOW DOES THIS PAPER REDUCE THEM?
PLEASE DESCRIBE ANY POSSIBLE N/A CONFLICTS OF INTEREST ASSOCIATED WITH THIS PAPER.
PLEASE IDENTIFY ANY CURRENT N/A SERVICES OR ROLES THAT MAY BE AFFECTED BY ISSUES WITHIN THIS PAPER:
Footnote:
Members of NHS Salford Clinical Commissioning Group Governing Body will read all papers thoroughly. Once papers are distributed no amendments are possible.
Document Development
Not Comments and Date Process Yes No Outcome Applicable (i.e. presentation, verbal, actual report) Public Engagement (Please detail the method ie survey, event, consultation) Clinical Engagement (Please detail the method ie survey, event, consultation) Has ‘due regard’ been given to Equality Analysis (EA) of any adverse impacts? (Please detail outcomes, including risks and how these will be managed) Legal Advice Sought Presented to the Commissioning Committee Presented to the Health and Wellbeing Board Presented to the Integrated Commissioning Board First draft was presented to the Audit Comments have been Presented to any other groups or committees, Committee on 26 April 2018 and incorporated into latest Executive Management Team on 18 including Partnership Groups version May 2018. Final draft will be (Please specify in comments) presented to the Audit Committee on 23 May 2018.
Note: Please ensure that it is clear in the comments and date column how and when particular stakeholders were involved in this work and ensure there is clarity in the outcome column showing what the key message or decision was from that group and whether amendments were requested about a particular part of the work.
Annual Report 2017/18
1 Executive Summary
To provide the Annual Report 2017/18 for approval. The first draft has been submitted to NHS England and final version is due 29 May 2018. It has also been considered by the Audit Committee and Executive Team. Comments have been incorporated into the latest version as well as informal feedback received from internal and external audit.
2 Introduction and Background
2.1 NHS Salford is required to submit a first draft of the Annual Report 2017/18 to NHS England followed by a final draft on 25 May 2018. This year’s guidance has been simplified and is in line with the previous year.
The structure is: • Performance Report o Performance Overview o Performance analysis • Accountability Report o Corporate Governance Report including the Governance Statement o Remuneration and Staff Report o Parliamentary Accountability and Audit Report
3 Recommendations
3.1 The NHS Salford Clinical Commissioning Group Governing Body is asked to approve of the 2017/18 Annual Report to the membership.
Jenny Noble Head of Governance and Policy
23 May 2018 Agenda Item No 6 (g)
NHS SALFORD CLINICAL COMMISSIONING GROUP GOVERNING BODY MEETING AGENDA ITEM NO 6 (g)
Item for Information
23 May 2018
REPORT OF: Head of Governance and Policy
DATE OF PAPER: 15 May 2018
SUBJECT: Annual Report 2017/18
IN CASE OF QUERY Jenny Noble PLEASE CONTACT: 0161 212 4950
Please tick which strategic priorities the paper relates to: STRATEGIC PRIORITIES:
Quality
Community Based Care
Integrated Care
In Hospital Care
Long Term Conditions and Mental Health
Effective Organisation
PURPOSE OF PAPER:
To consider the Annual Report 2017/18 for approval.
(Please see further explanatory requirements overleaf)
Page 1 of 4
23 May 2018 Agenda Item No 6 (g)
Further explanatory information required
HOW WILL THIS BENEFIT THE N/A HEALTH AND WELL BEING OF SALFORD RESIDENTS OR THE CLINICAL COMMISSIONING GROUP?
WHAT RISKS MAY ARISE AS A N/A RESULT OF THIS PAPER? HOW CAN THEY BE MITIGATED?
WHAT EQUALITY-RELATED RISKS N/A MAY ARISE AS A RESULT OF THIS PAPER? HOW WILL THESE BE MITIGATED?
DOES THIS PAPER HELP ADDRESS N/A ANY EXISTING HIGH OR EXTREME RISKS FACING THE ORGANISATION? IF SO WHAT ARE THEY AND HOW DOES THIS PAPER REDUCE THEM?
PLEASE DESCRIBE ANY POSSIBLE N/A CONFLICTS OF INTEREST ASSOCIATED WITH THIS PAPER.
PLEASE IDENTIFY ANY CURRENT N/A SERVICES OR ROLES THAT MAY BE AFFECTED BY ISSUES WITHIN THIS PAPER:
Footnote:
Members of NHS Salford Clinical Commissioning Group Governing Body will read all papers thoroughly. Once papers are distributed no amendments are possible.
Page 2 of 4
23 May 2018 Agenda Item No 6 (g)
Document Development
Not Comments and Date Process Yes No Outcome Applicable (i.e. presentation, verbal, actual report) Public Engagement (Please detail the method ie survey, event, consultation) Clinical Engagement (Please detail the method ie survey, event, consultation) Has ‘due regard’ been given to Equality Analysis (EA) of any adverse impacts? (Please detail outcomes, including risks and how these will be managed) Legal Advice Sought Presented to the Commissioning Committee Presented to the Health and Wellbeing Board Presented to the Integrated Commissioning Board First draft was presented to the Audit Comments have been Presented to any other groups or committees, Committee on 26 April 2018 and incorporated into latest including Partnership Groups Executive Management Team on 18 version May 2018. Final draft will be (Please specify in comments) presented to the Audit Committee on 23 May 2018.
Note: Please ensure that it is clear in the comments and date column how and when particular stakeholders were involved in this work and ensure there is clarity in the outcome column showing what the key message or decision was from that group and whether amendments were requested about a particular part of the work.
Page 3 of 4
23 May 2018 Agenda Item No 6 (g)
Annual Report 2017/18
1 Executive Summary
To provide the Annual Report 2017/18 for approval. The first draft has been submitted to NHS England and final version is due 29 May 2018. It has also been considered by the Audit Committee and Executive Team comments have been incorporated into the latest version as well as informal feedback received from internal and external audit.
2 Introduction and Background
2.1 NHS Salford is required to submit a first draft of the Annual Report 2017/18 to NHS England followed by a final draft on 25 May 2018. This year’s guidance has been simplified and is in line with the previous year.
The structure is: Performance Report o Performance Overview o Performance analysis Accountability Report o Corporate Governance Report including the Governance Statement o Remuneration and Staff Report o Parliamentary Accountability and Audit Report
3 Recommendations
3.1 The NHS Salford Clinical Commissioning Group Governing Body is asked to recommend approval of the 2017/18 Annual Report to the membership.
Jenny Noble Head of Governance and Policy
Page 4 of 4
Annual Report and Accounts 2017/18
1 Our approach to this report
This report is produced in response to the NHS England requirements, as published in the Department of Health Group Accounting Manual 2017/18. It aims to describe how we carry out our role as NHS Salford Clinical Commissioning Group (CCG). It summarises our responsibilities and tells the story of our achievements, our performance and the challenges we’ve faced during 01 April 2017 and 31 March 2018. It also cross-references other sections of the Annual Report for further details where relevant. It is split into three core sections:
The Performance Report, including an overview, performance analysis and performance measures
The Accountability Report, including the members report, corporate governance report, annual governance statement, remuneration and staff report
Annual Accounts
Contents
Our approach to this report ...... 2 PERFORMANCE REPORT ...... 4 Performance Overview ...... 5 Performance Analysis ...... 18 ACCOUNTABILITY REPORT ...... 29 Corporate Governance Report ...... 30 Remuneration Report ...... 49 Staff Report ...... 54 Parliamentary Accountability and Audit Report ...... 57
2 Foreword
NHS Salford Clinical Commissioning Group (CCG) is the organisation that decides how to spend the NHS budget on the majority of health services for 270,000 people registered with a GP in Salford. This includes the care and treatment you receive in hospital, maternity services, community and mental health services. We also have delegated responsibility for commissioning general practice services.
Established under the Health and Social Care Act 2012 as a statutory body, every GP from the city’s 45 practices is a Member of Salford CCG. As a CCG, we work hard to understand what is happening in Salford’s communities in order to commission the right services for the public.
To do this, the vast majority of decisions about how we use the public’s money is made by those clinicians who are closest to the people they look after – GPs and their practice staff. We work in partnership with health and social care partners (e.g. local hospitals, local authorities, the community and voluntary sector) and our Governing Body is made up of eight representatives of general practice from across Salford along with a chief accountable officer, chief finance officer, registered nurse, secondary care specialist and three lay members.
Salford is a growing city. Billions of pounds are being invested creating thousands of new jobs and homes. Yet Salford is a city of contrasts. Although there are diverse levels of affluence within the city, Salford is ranked as one of the most deprived local authority areas in England with life expectancy lower than the England average. Even within the city itself, people living in poorer areas live up to 14 years less than those in our richer neighbourhoods.
We’re also an ageing city. As more people call Salford ‘home’, more of us are living longer and often with complicated health conditions. This means more people need more help and support to stay well.
Our vision is for Salford CCG to commission (buy) high quality services to enable our population to live longer, healthier lives, which aligns with the vision of the Salford Locality Plan:
“Salford people will start, live and age well. People in Salford will get the best start in life, will go on to have a fulfilling and productive adulthood, will be able to manage their health well into their older age and die in a dignified manner in a setting of their choosing. People across Salford will experience health on a parallel with the current ‘best’ in Greater Manchester, and the gaps between communities will be narrower than they have ever been before.”
Our Annual Report tells the story of what Salford CCG did towards achieving this during 2017/18 and details all the information we are required to provide to the public. I hope you enjoy reading it and, if you have any comments or queries on the information within it, please do let us know using the contact details at the end of the report.
Dr Tom Tasker Chair
3
PERFORMANCE REPORT
Anthony Hassall, Chief Accountable Officer 23 May 2018
4 Performance Overview
An overview from our Chief Accountable Officer
The last 12 months have been one of the most challenging periods for the NHS, both in Salford and nationally. “Winter pressures” is a term often dominating the media headlines, but winter pressures do not exist – the pressure on the health and social care system is all year round and we have seen unprecedented demand during 2017/18 across primary, community, social and hospital care.
Despite these challenges, the CCG, our member GP practices and our partners both in Salford and across Greater Manchester have been working hard to respond to this to help the sickest people in our community stay out of hospital wherever possible and continue to deliver high quality, safe, patient-centred care.
We are incredibly ambitious in Salford. Salford’s vision for joined up health and social care is outlined in the Salford Locality Plan and there have been a number of significant and exciting milestones during 2017/18 to turn this plan into a reality for the people of Salford.
For the second year running, Salford CCG was rated outstanding against NHS England’s CCG Assurance Framework for 2016/17. This makes Salford one of only six CCGs in the north of England to receive the highest national rating for performance, and one of 21 CCGs nationally.
Greater Manchester Health and Social Care Partnership (GMHSCP) also gave the CCG the highest rating, Green Star, for quality of leadership for 2016/17. We were shortlisted for HSJ Awards CCG of the Year 2017, recognising the CCGs in which clinicians are truly leading; organisations that are starting to build truly integrated care across their geographic patches; and commissioners with an unwavering focus on patients.
However, the most important rating from 2017/18 was being named one of the best CCGs for the way in which the people of Salford are given a voice over how health care is provided across the city. The assessment – conducted by the NHS National Public Participation team – rated Salford CCG as ‘outstanding’ scoring us 14 out of a possible 15 for our public engagement work. This demonstrates the effort and commitment of our staff – and those at Salford City Council, with whom we jointly carry out much engagement activity – to make sure that we build, foster and develop positive relationships with the people of Salford. By speaking to Salford residents about what they want from their local health services, we can better understand their needs and make the right improvements.
These ratings are, of course, very positive news for Salford but we are never complacent. The key challenge now for us all will be for us to continue to make real differences for the great people of Salford who we serve and whose health and wellbeing continues to be a challenge. This annual report gives a flavour of the work we are progressing, but it can only touch the surface of the work we continue to deliver in partnership across Salford.
Salford has a long and strong history of partnership working which has been built on sound foundations of joint working between the various public, private and community sector organisations in the city.
5 Throughout 2017/18 our GPs continued to work with local councillors, as well as other clinicians and key management leaders across the system, making decisions together about how to spend our significant funding for adult health and social care together. We also worked together on wider issues such as tackling poverty and responding to our city’s changing population. We are determined to grasp opportunities to work together more to improve wellbeing and health and care services for our entire population in the future.
Once again we invested significantly in Salford’s voluntary, community and social enterprise (VCSE) sector with £1 million to identify projects encouraging people to live healthier lifestyles and improve access to services. The VCSE sector makes a significant contribution to addressing local health and wellbeing needs, supporting individuals, families and communities. The main aim of our Third Sector Fund is to enable Salford Community and Voluntary Service (CVS) to use their position in the city to reach voluntary organisations, community groups and social enterprises across Salford. The fund provides access to investment opportunities, to support localised activity and help address some of the key health priorities in Salford supporting delivery of the Locality Plan.
To coincide with World Mental Health Day 2017, we launched a new suicide prevention strategy and action plan as a member of the Salford Suicide Prevention Partnership. We join a number of public sector organisations, including NHS, Salford City Council, Greater Manchester Police, HM Prison Forest Bank, Greater Manchester Fire and Rescue, local voluntary, community and social enterprises and Healthwatch Salford, working towards Salford being a city with no deaths by suicide. The strategy includes plans to help those affected by suicide by providing information, services, resources and training, which you can read more about here, www.salfordccg.nhs.uk/preventsuicide.
We have also further strengthened our partnership with neighbours in Salford and Wigan, with the progression of the Bolton, Salford and Wigan Partnership. Working together will mean that we can join up our resources and workforce to provide hospital care more safely and efficiently. Our hospitals are doing well but we know we can do even better together.
Our work as a maternity pioneer in partnership with Bolton and Wigan reached a milestone as Salford became home to the only freestanding midwifery-led unit in Greater Manchester for women who want to give birth in a home-from-home environment. With the addition of the new Ingleside Birth and Community Centre, women in Salford can choose from a full range of maternity services, along with a home birth or a hospital birth.
CCG leaders and staff continue to play an active role in leading on a range of Greater Manchester-wide transformational workstreams. For example, standardising acute care, breast services, bariatric surgery, neuro-rehabilitation, incentivising reform (new contracting and payment models), mental health, dementia, dermatology and hyper acute/community stroke. This Greater Manchester level work is fundamental and complementary to delivery of our Locality Plan within Salford. The CCG was successful in gaining a place on the prestigious NHS Employers 2017/18 Annual Diversity and Inclusion Partners Programme. After 12 months we gained national accreditation with ‘Partner Status’, granted due to delivery of our robust action plan to develop and improve our overall equality performance.
6 Finally, Salford CCG received Living Wage accreditation. Accreditation as a living wage employer strengthens our position as a responsible employer and employer of choice, whereby we are able to recruit and retain the best talent. With the CCG's accreditation, over 50% of members of the Salford Health and Wellbeing Board are Living Wage employers. Being a real living wage employer recognises the value we place on our dedicated employees and the hard work that they do in making sure the people of Salford have access to the very best health care services.
While we continue to face difficult challenges as our health services come under increased pressure, we are excited about the many opportunities and developments ahead of us during 2018/19 and are extremely proud of what we have achieved so far towards our vision of the people of Salford living longer, healthier lives.
Anthony Hassall, Chief Accountable Officer
7 Our vision and aims
Our vision is to commission (buy) high quality services to enable our population to live longer, healthier lives. To achieve this, we have four aims to provide the best possible care for our patients.
These are: 1. Prevent ill health 3. Improve healthcare quality 2. Reduce health inequalities 4. Improve health and wellbeing outcomes
To achieve these four aims, Salford CCG had five strategic programmes in 2017/18: Quality of care Population health and prevention Integrated community based care and long term conditions Transforming and standardising acute and specialist hospital care Mental Health
This is supported by an additional internal work programme of Enabling Transformation.
Underpinning these is a set of values embedded through the way we work and carry out business: collaboration; innovation; and working with integrity.
Our priorities for 2017/18
Ensure strong alignment and engagement with all our stakeholders – both locally and at Greater Manchester level - and in particular our members, local partners and population.
Deliver on our 2017/18 objectives and deliverables of the Salford CCG operational plan and associated outcomes, including all national requirement within the NHS Mandate and planning guidance – in particular, ensuring strong primary care in the further development of community based and integrated care.
Drive the further development of integrated commissioning with Salford City Council and, as appropriate, a North West sector approach to delivery of acute services where single service configuration meet the needs of the population and particularly in the context of planning for Healthier Together implementation.
Contribute in a leading way to the work of the Greater Manchester Health and Social Care Partnership (GMHSCP), ensuring all key stakeholders are involved and consulted on service transformation.
Key risks
Our Governance Statement discloses strategic, commercial, operational and financial risks which may significantly affect the implementation of Salford CCG’s strategies and objectives. Our policy for managing principal risks is available via www.salfordccg.nhs.uk/policies-and- procedures.
8 Performance summary
Quality
What are we aiming to achieve for Salford over the next three years?
Our goal is to be the UK’s safest health and social care system by 2022 where the voice of our patient and their experiences of our services is captured and drives improvements. We are developing a culture where the potential for harm is actively considered, risks to quality are identified early and we have strategies to minimise any impact on someone using services.
What did Salford CCG achieve during 2017/18?
The CCG has been working on implementing a Quality and Safety strategy, available via www.salfordccg.nhs.uk/publications, with agreed action plans refreshed on an annual basis.
Scrutiny of the quality of care is written into provider contracts and provider quality assurance includes a number of processes to collate and triangulate information gathered from regular inspections and quality walk rounds, from within the system and by external bodies such as; CQC, NHS England and Monitor. Salford is one of three areas that took part in a new national CQC pilot, 'Quality of Care in a Place'. This is about increasing that level of openness by building a picture of what the whole quality of care is like for people living in a particular area – including how well services are co-ordinated and working together.
Safer Salford, the two-year programme which began in April 2016, builds on the learning from the successful Making Safety Visible programme. It focuses on reducing avoidable harm in health and care, emphasising communication handover between services and professionals and medication safety.
During 2017/18, Safer Salford achieved the following:
More than 30 leaders from partner organisations in Salford have been involved in a development programme to understand the principles of the Measurement and Monitoring of Safety Framework and this has resulted in a range of safety improvements in different care settings across Salford Nine care homes completed the Safer Care Homes Collaborative and were able to make small changes in reducing falls for individual residents. Knowledge exchange visits have been implemented as part of this work to share learning Two Safer Handover events for GPs and hospitals consultants have been facilitated and a series of improvements are being implemented as a result
The programme is being evaluated and developed further for 2018/19 with a continued focus on care homes and handover. More information is available via www.safersalford.org
9 What else did we achieve in 2017/18?
Implemented the Year 1 actions within our patient experience strategy, available via www.salfordccg.nhs.uk/publications, and agreed Year 2 actions making sure patient feedback and experience becomes an integral part of the commissioning processes and is used to influence and improve commissioned services Extended the use of our quality assurance framework so that the fundamental elements are incorporated into the processes to monitor the quality and safety of primary care services. The information gathered is used when planning and undertaking quality assurance visits to commissioned services, which now includes GP practices Working with Salford City Council, amended our Governance processes around quality to include oversight of information relating to adult social care services. An integrated quality and safety strategy is in development which will be implemented from April 2018 Implemented a consistent and collaborative approach to supporting care homes in improvements, identified following CQC inspection ratings Produced a Medicines Optimisation Annual Report 2017 which was presented to the CCG’s Governing Body in January 2018, available via www.salfordccg.nhs.uk/governing-body-minutes
Salford CCG’s Innovation Fund
Our Innovation Fund was created to test and evaluate products and services aiming to improve the experience and outcomes of patients in Salford. Each year we identify key gaps/areas by creating designated calls and use diverse and independent innovation panels to shortlist and award innovative bids. In 2017/18, we invested £2m into innovation bringing our total investment to more than £7m over the last five years. With more than 430 submitted bids, our Innovation Fund has led to 10 new commissioned services since 2013.
Some examples of projects we agreed to fund in 2017/18 include:
GP Desensitisation Resource Box – conversations with people with learning disabilities at engagement events like Big Health Day suggested fears around medical equipment and not knowing what to expect at GP appointments was leading to Salford’s low uptake of routine health tests. The box contains a selection of commonly used medical equipment so people with learning disabilities can learn about, touch and explore medical equipment reducing anxiety/fear Minor Illness Workshops – aimed at parents, carers and children to build parents’ knowledge and confidence to manage children’s minor illness at home without going to the GP or A&E unnecessarily Kafoodle Kare – a digital project to help care homes provide meals that are as nutritious as they can be based on complex needs. With 30-42% of patients admitted to care homes at risk of malnutrition, this trial will help care homes determine accurate nutritional information of meals so that residents can be as healthy as they can be via the food that they eat. This in turn will decrease malnutrition, reduce the need for supplements and ultimately improve the quality of life of elderly residents
Our Innovation and Research Strategy is available via www.salfordccg.nhs.uk/innovation- research
10
Population Health and Prevention
What are we aiming to achieve for Salford over the next five years?
We want to improve the overall health outcomes of the population of Salford by preventing ill health and encouraging more people to look after themselves (i.e. self-care).
Work to encourage Salford people into changing their behaviour to prevent ill health and self- care more will play a significant part in reducing the demand and dependency on health and care services. In 2017/18, Salford was awarded £3.4 million from the Greater Manchester Health and Social Care Partnership to improve population health in line with Salford’s Locality Plan. This is in addition to the £18 million received in 2016 from the Greater Manchester Transformation Fund. Areas for investment include training for frontline staff to identify mental health needs and early help for families with a focus on speech, language and communication, and providing support to the most vulnerable young people in the city.
What did Salford CCG achieve during 2017/18?
Salford’s Health and Wellbeing Board, of which the CCG is a member, has overarching responsibility for the successful implementation of Salford’s Locality Plan and, in 2016, created communications groups to work in partnership and lead on public awareness health improvement campaigns around the pillars of Start Well, Live Well and Age Well.
Examples of the campaigns carried out during 2017/18 include: Start Well – worked with the 1st Boothstown Brownies to tackle tooth decay by creating a new ‘Sugar Smart’ badge, which the Brownies earn by completing an activity book Live Well – worked with the Manchester and Salford Ramblers to arrange a Workforce Walking Challenge for employees from across the NHS, Salford City Council, Salford fire service and the voluntary sector, based on feedback from the public that we should “practice what we preach” Age Well – launched a falls prevention campaign promoting six simple exercises and advice on home hazards to tackle Salford having one of the highest rates of falls causing injuries requiring hospital admission amongst older people in Greater Manchester. More information on this campaign is available via www.salfordccg.nhs.uk/preventing-falls
Third Sector Fund
The Third Sector Fund is a voluntary, community and social enterprise (VCSE) grants programme developed in partnership, delivered by Salford CVS and funded by Salford CCG with the support of Salford City Council.
Established in 2014, the fund has awarded grants to over 174 voluntary organisations, community groups, social enterprises and schools to enable them, with a small investment, to address some of the key health priorities based on the Salford locality plan’s Start Well, Live Well and Age Well.
In 2017/18, we announced a further £3m to be invested into the Third Sector Fund over the next three years. More information on the Third Sector Fund is available via www.salfordccg.nhs.uk/third -sector-fund 11
Integrated Community Based Care and Long Term Conditions
What are we aiming to achieve for Salford over the next five years?
Salford Together is a partnership between Salford CCG, Salford City Council, Salford Royal NHS Foundation Trust, Salford Primary Care Together (SPCT) and Greater Manchester Mental Health NHS Foundation Trust.
The partnership is working to transform the commissioning and delivery of the health and social care system in Salford by integrating health and social care, bringing the commissioning budgets and services of GPs, nursing, social care, mental health, community based services and voluntary organisations into a more joined up system that focuses on a person’s individual needs and provides them with the support to manage their own care.
We are working towards person-centred services through integrated pathways and an integrated workforce. Following the integration of adult services, we are now developing an agreed vision, objectives and deliverables to integrate care for children, young people and families. Key to an integrated care system is a neighbourhood population health model, something which our GP practices in Salford have been building the foundations towards for several years. This means we have a good basis to build on our neighbourhood capacity, develop the capability of our primary care workforce and deliver more specialist services in the community.
During 2017/18, Salford Together achieved the following:
Co-located the Integrated Care Organisation and SPCT leadership teams to drive implementation of integrated care transformation Completed the Big Health and Social Care Conversation, a widespread public engagement exercise. More information available www.salfordtogether.com/survey-big- health-and-care-conversation Agreed four priority areas: 1. Developing neighbourhood teams 2. Providing more services that can help at home or in the community 3. Improving access to GP and community services 4. Improving care pathways Approved and launched transformation projects, including the Enhanced Care Team, and Salford Urgent Care Team Redesigned the falls pathway to increase the number of referrals to the Salford Falls Service and prevent falls in later life, which can result in serious injury and hospital admission Launched a Streaming Service within Salford Royal’s Emergency Department to redirect patients coming to A&E with a primary care need to a more appropriate service
For more information on Salford Together, visit www.salfordtogether.com
12 What did Salford CCG achieve during 2017/18?
As we continue to commission in line with Salford’s Primary Care Strategy, approved by our Governing Body in January 2016 and available via www.salfordccg.nhs.uk/publications, investment continues to scale up community-based services including GPs, community pharmacists, and community services so we can increase the care provided outside hospital.
Continued to commission in line with the service and financial plan for the pooled budget for adult health and social care services through the Integrated Health and Care Commissioning Joint Committee (ICJC). The ICJC brings GPs and councillors together to make decisions with regards to health and social care matters for adults Rolled out Salford Wide Extended Access Pilot giving all residents registered with a Salford GP access to primary care evening/weekend appointments Commissioned SPCT to design a new approach to general practice to serve the increasing population in Ordsall South Launched an Acute Home Visiting service in Ordsall and Claremont and Walkden and Little Hulton to improve home visits and increase capacity within GP practices With Salford City Council and wider partners, we continued to implement the Child and Adolescent Mental Health (CAMHS Transformation Plan with key achievements including the launch of a community eating disorder service and the Single Point of Contact in CAMHS; and establishing an i-Thrive network. More information is available in the refreshed plan via www.salfordccg.nhs.uk/camhs Implemented the Better Births recommendations as part of the National Maternity Pioneer Programme in partnership with Bolton and Wigan, including developing the Ingleside Birth and Community Centre in Salford and trialling personal maternity care budgets in Wigan and Bolton Progressed our Primary Care Workforce Strategy, including upskilling the administrative workforce to be trained to review clinical correspondence estimated to save up to 40 minutes per day per GP. Available via www.salfordccg.nhs.uk/publications Commissioned the Practices Improving Processes in Salford (PIPS) programme providing eight practices with the training and tools to help them reduce waste and inefficiencies, reduce cost and improve productivity, such as increasing numbers of patients booking appointments or requesting repeat prescriptions online Commissioned CLAHRC (Collaborations for Leadership in Applied Health Research and Care) to undertake a two-year evaluation on the impact of new roles within primary care Following successful evaluation of innovation projects, funded the following schemes: o Go2Physio, a self-referral physiotherapy scheme o Impaired Glucose Regulation (IGR) Exercise Service, tackling physical activity and weight issues for those at risk of diabetes o Self-management in Inflammatory Bowel Disease, patient-access web-based support to help them manage the condition themselves Changed the GP x-ray service to improve ‘drop in’ access and reduce waiting times Continued to develop a CCG approach to Personalised Health Budgets, which will be finalised in 2018/19 Approved plans for a new £4.6million health centre in Little Hulton
13 Transforming and Standardising Acute and Specialist Hospital Care
What are we aiming to achieve for Salford over the next five years?
The main provider of acute health services in Salford, Salford Royal NHS Foundation Trust (SRFT), is an ‘outstanding’ organisation (CQC 2015/16) working with us towards Salford being the safest and most productive health and social care system in England.
As the Bolton, Salford and Wigan Partnership, Salford Royal, Bolton and Wrightington, Wigan and Leigh NHS Foundation Trusts are working together to create ‘single shared services’ for our combined populations for complex surgery and urgent care. Building on this, the partnership` – which includes the three CCGs - are exploring ways of joining up more surgical, medical and clinical support services – subject to public engagement.
What did Salford CCG achieve in 2017/18?
Continued work on implementing the Healthier Together recommendations for general surgery and urgent, emergency and acute medicine through our partnership working with Bolton and Wigan Began work to ensure local services are meeting the quality standards for dermatology, paediatrics, breast services, elective orthopaedics and benign urology From April 2017, we became the responsible commissioner for bariatric surgery, a service which is performing well. Greater Manchester specialist medical weight management services have been reviewed, common standards agreed and implemented Continued to achieve national Referral to Treatment Times standards Achieved diagnostic waiting times standards for the majority of patients, however capacity issues for specific diagnostics (e.g. endoscopies and MRI scans) mean the overall standard has not been consistently achieved throughout the year and recovery plans have been agreed Agreed an Urgent Care Improvement Programme to improve performance as urgent care standards (i.e. A&E, ambulance) have proved very challenging, both locally and nationally Supported improvements such as GP streaming which has been operational in Salford Royal’s A&E since October 2017. The aim is to replicate the primary care setting as a ‘front-of-house’ service, stream patients from A&E back into primary care, as well as educate and navigate where their care needs can be met in the community and primary care
14 Mental Health
What are we aiming to achieve for Salford over the next five years?
Every year, one in four adults experience at least one diagnosable mental health problem. In Salford, this number is higher than other parts of the UK with around 24,500 people experiencing low levels of personal happiness and 20,700 people experiencing common mental health conditions.
Our integrated approach to mental health commissioning invests around £40million each year on mental health service provision. This mainly focuses on adult provision, in addition to the issues concerning the mental health of young people who are making the transition to adulthood and adult services. Sitting alongside this, the Children and Young People Emotional Health and Wellbeing Partnership oversees the work of the 0-25 programme, including Children and Adults Mental Health Services (CAMHS).
Despite ongoing financial constraints, mental health services are a key priority in Salford. A planned increase of around £1million each year for the next three years will ensure that we continue to meet national access and quality outcomes targets. We are also investing in specific areas, including children and young people’s mental health, perinatal mental health and supporting early intervention teams and improving access to psychological therapies. We are committed to protecting effective services and developing new services with an increased focus on building resilience for communities and individuals, together with prevention and early intervention, to meet the rising demand within the resources available.
What did Salford CCG achieve in 2017/18?
Reviewed delivery of the redesigned Community Engagement Recovery Team (CERT), which helps enhance and maintain service users’ role in society, including supporting them in employment Our local Early Intervention in Psychosis service is achieving the national target of people experiencing first episode psychosis starting a NICE-recommended package of care within two weeks of referral (100% in December 2017 against a 50% target). However, the service is facing pressures to capacity. With Greater Manchester Mental Health NHS Foundation Trust (GMMH), we carried out a deep dive to understand why there was pressure and what could be done to address it and will be taking this work forward in 2018/19 Continued to monitor Improved Access to Psychological Therapies and work towards increasing the number of people accessing psychological therapies for anxiety/depression to achieve access target of 25% by 2021. This includes focusing on people who have co-existing long-term physical health conditions Launched the Salford Suicide Prevention Strategy, available via www.salfordccg.nhs.uk/salford-suicide-prevention-strategy Invested in a Mental Health Police Interface Team, where a mental health practitioner is co-located with Greater Manchester Police to manage the high volume of calls Continued to work with GMMH to develop a specialist perinatal community service Approved plans to develop a two-year pilot with the VCSE sector to improve support for people with secondary care mental health problems to keep them in employment
15 Enabling Transformation
What are we aiming to achieve for Salford over the next five years?
In 2016, the Greater Manchester Health and Social Care Partnership agreed to conduct an independent review of the commissioning arrangements in Greater Manchester, to explore if organisations are taking advantage of the benefits of working together, both locally and across Greater Manchester. The recommendations were:
Local Authorities and CCGs must come together to form a Single Commissioning Function (SCF) delivering a significant pooled budget across health, social care and wider public services Commissioning decisions should be predominately taken at locality level but, for some services and functions, we should establish GM commissioning arrangements. For other services, GM should offer SCFs strategic support or develop common sets of standards.
During 2017/18, we agreed with Salford City Council (SCC) to build on the strong integration and partnership working arrangements already in place between the two organisations and, in principle, to create a new SCF for health and social care making it easier for councillors and local GPs to make decisions about health and social care in our city together.
The CCG has used shared posts in areas including commissioning, planning and performance and engagement to support an increasing move towards integrated commissioning and budgets across the CCG and Salford Council. Planning has been integrated for children and young people’s services, both commissioned and those provided in house by SCC. Similarly, planning across all areas of adult health and social care including public health has been integrated providing a strong a stable foundation for the development of more integrated governance which has been emerging following an independently commissioning review undertaken by Deloitte across Greater Manchester. What else did we achieve in 2017/18?
Kept our ‘outstanding’ status improving performance, quality, safety, staff, stakeholder and patient insights Continued implementing our Engagement and Communication Strategy available via www.salfordccg.nhs.uk/publications, along with our Engagement Annual Report. Created a new Equality Impact Assessment framework for use when commissioning new services, reviewing/redesigning existing services or introducing new processes Achieved extremely positive feedback through the 2017 360 Stakeholder Survey, available via www.salfordccg.nhs.uk/publications, and 2017 Staff Satisfaction Survey Carried out a deep-dive midyear review of the CCG’s financial position, which identified non-recurrent funding available for investment in 2017/18 Refreshed the CCG’s 5 year financial plan, presented to the CCG’s Governing Body in May 2018 and available via www.salfordccg.nhs.uk/governing-body-minutes Made NHS public wifi available in all GP practices Completed our roll out of electronic prescribing in general practices Promoted the use of online access to records via our general practices so that all patients can book appointments or order repeat prescriptions online
16
Greater Manchester Health and Social Care Partnership – the devolution difference
In April 2016, Greater Manchester signed a devolution deal. Together we took control of our £6bn health and care budget and received £450m to transform services. Devolution gives us the freedom and flexibility to do things that benefit everyone in Greater Manchester. We are making our own decisions and it is starting to pay off, some changes are already making a difference.
Strong partnerships built through devolution help us redesign and streamline services quickly so they work more effectively. For example, in 2017 the formation of the Northern Care Alliance NHS Group brought together five hospitals, 2,000 beds, specialist and acute services, a range of associated community services and over 17,000 staff across Salford Royal NHS Foundation Trust and The Pennine Acute Hospitals NHS Trust Giving children a better start – we’re spending an extra £1.5m on oral health to improve children’s teeth and getting more children ‘school ready’ We’re helping 115,000 smokers quit over the next three years We’re fighting cancer with a mobile screening programme and community ‘cancer champions’ We’re spending £74m on child and adolescent mental health and training teachers on mental health We’re spending a further £50m on adult mental health services Our services are rapidly improving, for example our stroke centres are top-rated and we estimate that 200 lives have been saved because of the specialist care people have received We’re creating more services closer to people’s homes and making it easier to see medical professionals at convenient times through extended opening hours We’re spotting and treating dementia quicker – seven more people a day are diagnosed with dementia and getting the help and support they need
More information is available via www.gmhsc.org.uk
17 Performance Analysis
Performance measures
The CCG’s approach to performance monitoring, reporting and improvement incorporates a balanced view across patient access, quality, service performance, patient and staff insights, financial performance and risk elements. Performance dashboards have been developed to quantify both the outputs and outcomes of the CCG’s annual plan and priorities which are aligned with the wider health and social care strategy in Salford - The Locality Plan. The performance reporting also aligns with all national planning requirements as well as those developed regionally in the devolved health and social care integrated care system of Greater Manchester. A full copy of the CCG annual plan and the key performance measures for 2018-19 can be found on the CCG website: http://www.salfordccg.nhs.uk/publications
The integrated reporting of performance includes progress against plans, performance, risks and their mitigation supported by a clear risk strategy and escalation process to ensure performance issues are clearly identified and owned at a level appropriate for their mitigation. At a strategic level these are overseen by the CCG Governing Body and delegated committees including those which the CCG operates in partnership with Salford Council through pooled budget arrangements. Beneath the strategic level there are contracts and finance, quality and outcome and a variety of strategy specific performance and delivery oversight groups in place. As with the strategic boards these mirror the governance arrangements and include a triangulation of performance, progress against plans and risks with clear ownership and accountability.
Monthly quality and outcome and performance and contract meetings with key providers ensure robust scrutiny of performance gaps and the development of effective recovery plans to address these. The CCG Executive Team and Governing Body reviews progress against the entirety of the Operational Plan on a bi-monthly basis and publishes these reports through the Salford CCG website. The Integrated Adult Health and Care Commissioning Joint Committee also meets bi-monthly to review the progress being made towards an integrated care system, with updates on decisions included within the published CCG Governing Body papers, www.salfordccg.nhs.uk/governing-body-minutes
Performance Analysis
Detailed performance analysis for all key performance measures where the CCG is not on track is contained within the bi-monthly Governing Body organisational performance report. This year the CCG has sustained ‘Outstanding’ status (for 2016/17) and continued to work with primary care to improve the quality of services. The CCG has also led a city wide initiative to improve the quality of care homes across Salford which has begun to see some improvements with the majority of the focus coming in 2018-19 through the Care Homes Excellence programme.
Where performance is not on track, accountable commissioning leads and clinical leads work with the relevant providers to develop and agree recovery plans and a timetable – these are also included within the Governing Body reports. These recovery plans include any additional resources with any financial commitments approved through the appropriate commissioning governance groups.
18 Over 2017-18 performance highlights include:
Sustained delivery of diagnosis rates for dementia in primary care amongst the highest in the UK with Salford taking the lead role in GM for the Dementia United programme Reduced the number of people falling aged over 65 through a system wide review of falls services and early interventions with wider partners Halved the % of delayed transfers of care year on year through integrated working with partners in social care, integrated care organisation and council Extended access to all Salford residents for GP led care – 7 days a week through neighbourhoods with the Salford Wide Extended Access Programme (SWEAP). Implemented GP streaming in the Emergency department and developed the arrangements for urgent treatment, rapid response and enhanced community care for delivery in 2018 Sustained the delivery of national referral to treatment time performance (<18 weeks) in every month despite significant winter pressures Achieved urgent cancer 2 week wait times Continued to deliver high levels of access to psychological therapies following the development of a shared point of access service model across Salford with improved recovery rates year on year Significantly ahead of the national targets for Early Intervention in Psychosis for people experiencing a first episode treated within two weeks (~85%, national target = 50%)
Areas where performance remains challenging include:
Ambulance response times. The lead commissioner for the North West Ambulance Service is Blackpool CCG. Ambulance response times are an issue across the Greater Manchester and the region and impacted by the ability of hospitals to admit patients and peaks in demand both seasonal and fluctuations each week. CAMHS treatment times due to provider capacity and high demand. A full recovery plan is being progressed. Cancer 62 day waits for first definitive treatment is slightly below target (82.5%, target =85%). These are often due to complex patients where cancer treatment is delayed due to other health factors and / or complex diagnostics. All cancer breaches are reviewed with providers through the cancer / scheduled care board. A and E 4 hour performance is comparable with last year at 85%. The key issue is length of stay and the CCG has been working together with the main provider to deliver a joint urgent and emergency care improvement plan.
Full recovery plans and the complete CCG performance dashboard covering each of the strategic programmes can be found here: www.salfordccg.nhs.uk/governing-body-minutes The CCG is also subject to external assurance by NHS England. Salford CCG’s 2017/18 year- end assessment will be available on www.nhs.uk/servicesearch/performance/search from July 2018. This assessment includes a full review of the quality of the CCG’s leadership as well as the national improvement and assessment framework and local transformation improvement areas developed with the Greater Manchester Health and Social Care Partnership.
19 Report of the Chief Finance Officer
Summary Financial Performance 2017-18
The CCG has four statutory financial duties against which it is measured:
1. Revenue resource use does not exceed the amount specified in Directions 2. Revenue administration resource use does not exceed the amount specified in Directions 3. Capital resource use does not exceed the amount specified in Directions 4. Better Payments Practice Policy
In 2017-18, Salford CCG achieved all of its statutory financial duties and this reflects the strong financial management within the organisation. The financial statements of the CCG are detailed on pages XXX to XXX. The performance against each of the statutory targets is summarised as follows:
Revenue resource use: The CCG has a legal duty to maintain spending within its resource limit i.e. cannot overspend against its total budget. There are two separate limits against which the CCG is measured: revenue and cash. In 2017-18 the CCG met both requirements.
The CCG reported an in year under spend (surplus) of £2.3m against its revenue budget (resource limit) of £440m. The CCG planned to achieve a breakeven position and therefore exceeded the planned surplus by £2.3m.
As set out in the NHS Planning Guidance for 2017-18, CCGs were required to hold a 0.5% reserve uncommitted from the start of the year. NHS England requested CCGs did not spend this reserve and release this to the bottom line, to show this as an underspend, in order to offset the financial overspends elsewhere in the NHS. This accounted for £1.9m of Salford CCG’s underspend in 2017-18. In addition, NHS England determined that savings from Category M drugs price reductions could not be spent in 2017-18 and accordingly this increased Salford CCG’s surplus by a further £0.4m, to £2.3m in total.
This additional surplus will be carried forward for drawdown in future years. Salford CCG has a historical cumulative surplus from previous years totalling £13.1m, so the amount carried forward to future years is now £15.4m.
The cash book balance at the end of the year was £0.3m which was within the £0.5m limit approved by NHS England.
Revenue administration resource use: Salford CCG has been allocated a running costs allowance of £5.56m. In 2017-18, the CCG’s running cost expenditure was £5.51m and so has remained within its running cost target
Capital resource use: The CCG received no capital allocation in 2017-18 and has incurred no capital expenditure
Better Payment Practice Code: In line with other public sector bodies, NHS organisations are required to pay invoices within 30 days or within the agreed payment terms, whichever is the sooner. This is known as the Better Payment Practice Code 20 CCGs are required to ensure that at least 95% of invoices are dealt with in line with this code. In 2017-18 the CCG exceeded this target:
o NHS invoices: 100% by invoice value and 99.6% by invoice number o Non NHS invoices: 99.1% by value and 99.3% by number o Overall: 99.8% by value and 99.4% by number
How did Salford CCG spend its allocation of £440m in 2017-18?
During 2017-18 the CCG achieved a surplus of £2.3m and spent £438m in delivering its objectives across a variety of services, as identified in figure one below:
Salford CCG - Allocation of Total Expenditure 2017-18 - £438m
Other £17m Running Costs £5m
Continuing Care £7m
Primary Care £50m
Acute £212m Prescribing £42m
Community Health £38m
Mental Health £44m
By far the biggest area of spend relates to Acute services which equates to £212m, which is 48% of the total CCG spend. Acute services relate to hospital services (accident and emergency attendances, inpatient admissions, diagnostics and outpatients) as well as ambulance services. Whilst the majority of acute care is commissioned from Salford Royal NHS Foundation Trust (SRFT), other NHS and non NHS providers are also used. The services we buy from these providers are shown in figure two below:
21 Salford CCG - Purchase of Acute Services 2017-18 - £212m
Others £14m NW Ambulance £9m
Oaklands £9m
Pennine Acute NHST £7m
Bolton FT £15m
Salford Royal FT £123m
Manchester FT £35m
Looking forward into 2018-19
In January 2016, Salford CCG was notified of its financial allocations for the next 5 years (2016- 17 to 2020-21). CCGs’ allocations are based on a national funding formula, which includes weightings for the age profile of populations and the deprivation of localities, for example.
The November 2017 Budget allocated a further £1.6bn to the NHS and this means that Salford CCG will receive an additional recurrent uplift of 0.8% or £3.2m for 2018-19, over and above the previously announced uplift of £9.4m.
The CCG has been permitted to carry forward the cumulative surplus that was delivered in 2017-18 and previous years (£15.4m). There are rules set at a national level that determine the amount that can be used in any given year and the timescales that this funding can be drawn down. Salford CCG intends to use this surplus over the next 5 years to invest in service transformation. An amount of £2.6m will be used in 2018-19.
Salford CCG plans to make use of recurrent growth funding and the non-recurrent surplus over the next 5 years to achieve better outcomes for the population of Salford. Some of the investments planned for 2018-19 are as follows:
22
An additional £350k has been set aside recurrently to implement the CCG’s Quality Strategy. This funding will be used primarily in 2018-19 to continue the work on the Safer Salford initiatives (£250k) and £100k specifically for additional support to the Care Homes
An additional £200k is set aside for Children and Young people’s mental health to implement the children’s elements of the Five Year Forward View for Mental Health, and a further £200k for maternal mental health pre and post birth. An investment of £1m recurrently in health and wellbeing services commissioned from the voluntary sector
The CCG continues to invest £2m recurrently in the Innovation Fund, and this is planned to increase by £500k from 2019-20.
Non recurrent funds have been set aside to increase the availability of lung health checks to improve early detection of cancer (£900k) and the refurbishment of Lance Burn Health Centre (£720k) so that antenatal services can relocate to the community from the Salford Royal site.
It is evident that Salford CCG will have funds available to invest over the next five years. The challenge for Salford CCG is to target this funding to make significant inroads into addressing those areas where there are poor health outcomes in Salford.
During 2018-19 the CCG will be exploring with Salford City Council as to how it can make effective joint decisions on health and social care budgets, to the advantage of the Salford population and ensure effective service delivery.
Steve Dixon Chief Finance Officer
23 Sustainable development
On 10 November 2017, the Social Value Alliance in Salford launched the 10% Better Campaign.
As part of this campaign we implemented the following principles:
Optimising the social, environmental and economic well-being of Salford and its people in everything that we do Thinking long-term – turning investment into long-lasting outcomes Working together across sectors to provide social value outcomes Having values including inclusion, openness, honesty, social responsibility and caring for others Having a clear and current understanding of how social value can make Salford a better place to live Working together to measure, evaluate and understand social value, as well as reporting publicly to the people of Salford about the social value that we create
The CCG also committed to improving the following in Salford:
MORE volunteering MORE young people who are in employment, education and training MORE Salford people saying that they have good wellbeing LESS waste – fuel, rubbish, energy, water, etc MORE recycling MORE green travel e.g. buses, trams, trains, bikes, lift shares, electric vehicles, walking MORE use of parks and green spaces MORE companies paying the Living Wage Foundation Living Wage MORE local people from vulnerable groups accessing new jobs, apprenticeships, training and work experience placements LESS fuel poverty MORE purchasing from Salford based companies
NHS Salford CCG pledged to continue to:
Continue to work with the Salford Poverty Truth Commission to explore ways to reduce poverty and create local prosperity Play a leading role in encouraging the Salford health and social care system to implement the Living Wage Continuing to use social value in commissioning and contract evaluation to invest in health and wellbeing locally Explore the opportunities to develop high quality apprenticeships with partners Continue to improve staff health and wellbeing including through the second ‘One You’ health improvement programme Continue to explore further options to reduce the environmental impact of travel to meetings our meetings and continue to pursue paperless working
24 Other achievements in relation to social value over 2017/18 include:
Maintained an active membership in the Locality Workforce Group Joined the Carbon Literacy Consortium, tested the training, rolled it out to senior leaders and applied for bronze Carbon Literacy accreditation – the first NHS organisation nationally to do so Managed the Third Sector Fund (innovation investment) through year two of a three year investment programme and continued to contribute to addressing the health priorities for Salford. Voluntary organisations, community groups, social enterprises and schools have continued to benefit from the Third Sector Fund. The programme is continuously developing to respond to local need and also provides a mechanism to lever additional funds into Salford and the VCSE sector Completed the Salford Poverty Truth Commission, www.salfordpovertytruth.org.uk, with Joseph Rowntree Foundation supported by CCG innovation funding and with CCG Chair representation as a public life commissioner Delivered a One You Fest with staff to help improve physical and emotional wellbeing of the workforce Included Social Value aims and monitoring within the service specification template and tender evaluation process Continued to default black and white and duplex printing, together with all committees remaining paperless Continued to sort the CCG’s rubbish off site, so as much as possible is recycled
25 Patient and public involvement
Salford CCG is committed to putting the voice of patients and the public at the heart of its commissioning. This was recognised in November 2017 when the NHS National Public Participation Team rated us as outstanding against the new Patient and Community Engagement Indicator, scoring 14 out of a possible 15 and describing Salford CCG as an “example of excellence”.
We have continued to address the shift in the health and care landscape towards prevention and people living longer and healthier lives by strengthening our co-production style of engagement. Conversations with communities take an asset based approach, enabling us to develop solutions together and ask not just what we can do for citizens, but what citizens can do for themselves.
The integration of the health and social care engagement teams has been fundamental to co- production. It has enabled the CCG to have a wider reach into communities of interest and vulnerable groups bringing the existing forums together to create a ‘wheel of engagement’ (available via www.salfordccg.nhs.uk/publications) with a continuous cycle of discussion on key topics. This includes a Citizen Panel of over 2,500 citizens (1% of the population) and forums for mental health, learning difficulties, black and ethnic minorities, physical and sensory impairments, older people, people with dementia and young people.
During 2017/18 we have engaged with an estimated 6,000 citizens on a range of topics including suicide prevention; integrated care; maternity and community services; and safeguarding. Each year the CCG publishes an engagement report which outlines all our engagement work and the difference the feedback from patient and the public has made. This is available via www.salfordccg.nhs.uk/publications.
Examples include:
Throughout the summer we attended a number of community events - such as Eccles Festival, Peel Park Pink Picnic and Broughton Community Day - speaking to 225 people about where and with whom suicide prevention information/training should be carried out. This information is integrated into the Salford Suicide Prevention Strategy, www.salfordccg.nhs.uk/salford-suicide-prevention-strategy Through our Innovation Fund project, Open Doors, we spoke with 300 individuals, statutory and non-statutory organisations on how to reduce barriers to engaging with and accessing health services within the black, Asian and minority ethnic (BAME) communities Our BAME ambassadors, i.e. representatives from BAME groups across Salford who meet monthly to learn about the latest developments in health and social care and to cascade it back to their respective communities and the groups they represent Recruited 45 volunteers to become Greater Manchester Cancer Champions, against a target of 14 Our award-winning mental health drama workshop, A Spiralling Minds, once again toured all high schools in Salford, along with pupil referral units and secure units, reaching more than 2,500 young people We achieved a 52% response rate to our breast service satisfaction survey gaining feedback on people’s experiences of the Nightingale Unit
26 The Salford Dementia Champions are people living with mild to moderate dementia and their carers, who work with the CCG and Salford City Council to improve dementia services. They were presented with the Ceremonial Mayor's Citizen Award to recognise their outstanding contribution to turning Salford into a dementia-friendly city
We continue to seek new ways to improve our established methods to involve the local community in our work. Our bi-monthly Governing Body meetings are held in public and we maintain our long standing “public comments and questions” section at the beginning of all public Governing Body meetings, often receiving a range of queries from the public either in relation to general matters, or items on the meeting’s agenda. The formal part of our Governing Body always begins with a patient story, either shared directly by the people concerned, by way of a video or read by a member of staff.
It was the result of a workshop with members of our Citizen Panel that we took on the suggestion to combine our summer Citizen Panel event with our 2017 AGM and Governing Body meeting. To make our Annual Report 2016/17 more accessible, we presented a film to tell the story of the previous 12 months and live-streamed both the Citizen Panel and AGM, reaching a total 4,300 Facebook users. Our Annual Report film was split into several smaller films to share on social media and was watched a total 6,500 times.
At the locality level, our Start Well, Live Well, Age Well Plan (Locality Plan) is now firmly embedded across all key partners and continues to be delivered jointly with the City Council, Healthwatch, providers and the voluntary sector. Our Citizen Advisory Panel support us to communicate and engage with the community to achieve the aims of the plan. This year’s themes for engagement and discussion have been developed by the citizen members and include self-responsibility, people powered health and supporting others.
As a member of the Bolton, Salford and Wigan Partnership (BSWP), we are working with Healthwatch to make sure our transformation work is shaped and delivered with the patient voice at the very centre. We have established the Equalities and Experience Reference Group (EERG), which is a group of patients, service users and public representatives set up to help the BSWP improve patient experience and make sure that services are high quality, safe and accessible. The EERG meets every two months, with each meeting focusing on a subject linked to equalities and experience.
Reducing inequality
It is a core requirement of Salford CCG to demonstrate how we embed equality, diversity and human rights across all work streams. This involves identifying, reporting and setting objectives on health inequality outcomes against each of the nine protected characteristic groups in our planning and decision making processes.
We achieve this by ensuring we engage with local community groups to identify key barriers to accessing services and on proposed key changes in healthcare to identify any potential adverse impacts for them. Through this consultation, we place the patient voice at the heart of this process which helps us to shape fair, accessible services that take account of individual needs and help reduce inequalities.
27 Our fifth Diversity and Inclusion Annual Report provides information on how we met our legal and mandated duties with regards to diversity and inclusion over the time period 01 September 2016 – 31 August 2017 and is available via www.salfordccg.nhs.uk/diversity-inclusion. It shows our commitment to promoting equality and reducing health inequalities and sets out the way we fulfil our responsibilities arising from the Equality Act 2010. The report sets out what we have done in key areas as well as the challenges we know we need to address to achieve our equality objectives:
1) Improve health and narrow the gaps in access, experience and outcomes 2) Improve collection and use of data/evidence for all protected groups 3) Communicate and engage with all protected groups 4) Develop equality and diversity competent and well supported staff 5) Develop leadership, corporate commitment and governance arrangements for equality and diversity
We are pleased with the progress in our equality assurance with health care providers and contract management, governance arrangements for reviewing equalities and, in particular, getting closer and engaging with our local communities.
The report also gives an overview of our current understanding of Salford’s diverse population and health challenges. It recognises our legal responsibilities in demonstrating ‘due regard’ to the Public Sector Equality Duty and what we are doing to achieve it, as well as progress against our Equality Objectives and commissioning for inclusion.
We are increasingly assured that the organisations providing the services we commission can effectively collect and analyse data to improve service provision and achieve better health outcomes for vulnerable groups in Salford.
The report highlights examples of work we have undertaken to take account of the needs of our vulnerable communities, looks at our plans to improve the way we commission services and identifies future areas for development. It shows our approach to inclusion, with examples of work we have undertaken to take account of the needs of our vulnerable communities.
In 2017, we were successful in gaining a place on the prestigious NHS Employers 2017/18 Annual Diversity and Inclusion Partners Programme. After 12 months we gained national accreditation with ‘Partner Status’, granted due to delivery of our robust action plan to develop and improve our overall equality performance.
28
ACCOUNTABILITY REPORT
Anthony Hassall, Chief Accountable Officer 23 May 2018
29 Corporate Governance Report
Members’ Report
NHS Salford CCG’s Constitution is available on our website: www.salfordccg.nhs.uk/salford- ccg-constitution. The Constitution was made between the Members of NHS Salford CCG and has been effective since 1 April 2013, when the organisation was established. All GPs in Salford have confirmed agreement to, and signed the NHS Salford CCG Constitution.
Member profiles
Section 3.1 of NHS Salford CCG’s Constitution provides full details of the Membership of the organisation. The Constitution has periodically been updated to reflect a number of national and local changes. The appropriate process has been followed to make these changes culminating in NHS England approval.
Member practices
Information regarding the eligibility for Membership and arrangements for leaving the CCG is provided in Section 3 of the CCG’s Constitution. In addition, Section 8.4 provides detail regarding the methods the CCG uses to engage with its Member Practices.
Composition of Governing Body
Governing Body Members Dr Tom Tasker, Chair Anthony Hassall, Chief Accountable Officer Steve Dixon, Chief Finance Officer Dr Jeremy Tankel, Medical Director Dr Tom Regan, Clinical Director for Transformation Dr Ben Williams, Neighbourhood Lead for Swinton Dr David McKelvey, Neighbourhood Lead for Ordsall and Claremont Dr Nick Browne, Neighbourhood Lead for Little Hulton and Walkden David Flynn, Neighbourhood Lead for Broughton Kate Jones, Neighbourhood Lead for Eccles, Irlam and Cadishead Dr Chris Babbs, Governing Body Secondary Care Clinician Edward Vitalis (Deputy Chair), Lay Member of Finance and Governance Brian Wroe, Lay Member for Engagement Paul Newman, Lay Member for Commercial
Ex Officio Governing Body Members (non voting) Cllr Gina Reynolds, Salford City Council Executive Lead Member – Health and Wellbeing Charlotte Ramsden, Salford City Council Strategic Director, People David Herne, Salford City Council Director of Public Health
Executive Team Governing Body Attendees Karen Proctor, Director of Commissioning Francine Thorpe, Director of Quality and Safety Hannah Dobrowolska, Director of Corporate Services
30 Committee(s), including Audit Committee
Audit Committee
Edward Vitalis, Lay Member for Finance and Governance (Chair) Dr Jeremy Tankel, Medical Director Alison Kelly, Governing Body Nurse
Details of the membership of the Remuneration Committee are included in the Remuneration Report. Details of membership – including attendance - of all other Governing Body Prime Committees are included in the body of the Governance Statement below or at Appendix A.
Register of Interests
NHS Salford CCG has a Conflicts of Interest policy which is in line with statutory guidance on managing conflicts of interest for CCGs. The register of interests is available at: www.salfordccg.nhs.uk/publications
There have been two personal data related incidents during 2017/18 formally reported to the information commissioner’s office. These were closed by the Information Commissioner’s Office with no further actions required.
Statement of Disclosure to Auditors
Each individual who is a member of the CCG at the time the Members’ Report is approved confirms:
so far as the member is aware, there is no relevant audit information of which the CCG’s auditor is unaware that would be relevant for the purposes of their audit report the member has taken all the steps that they ought to have taken in order to make him or herself aware of any relevant audit information and to establish that the CCG’s auditor is aware of it.
Modern Slavery Act
Salford CCG fully supports the Government’s objectives to eradicate modern slavery and human trafficking but does not met the requirements for producing an annual Slavery and Human Trafficking Statement as set out in the Modern Slavery Act 2015.
The CCG was actively involved in developing Multi Agency Modern Day Slavery policies and procedures (now shared across Greater Manchester). Modern Day Slavery is included within relevant CCG Policies or appropriate links included to the multi- agency polices/procedures. This includes the GP Safeguarding Policy.
The CCG has supported the delivery of Multi Agency Complex Safeguarding Training across Salford on behalf of the Safeguarding Adult and Safeguarding Children’s Boards, this has been inclusive of Multi Agency Modern Day Slavery training.
Assurance from providers is sought via the CCG Safeguarding Team using the Greater Manchester Safeguarding standards as part of contractual arrangements.
31 Statement of Accountable Officer's Responsibilities
The National Health Service Act 2006 (as amended) states that each Clinical Commissioning Group shall have an Accountable Officer and that Officer shall be appointed by the NHS Commissioning Board (NHS England). NHS England has appointed Mr Anthony Hassall to be the Accountable Officer of Salford CCG.
The responsibilities of an Accountable Officer are set out under the National Health Service Act 2006 (as amended), Managing Public Money and in the Clinical Commissioning Group Accountable Officer Appointment Letter. They include responsibilities for:
The propriety and regularity of the public finances for which the Accountable Officer is answerable For keeping proper accounting records (which disclose with reasonable accuracy at any time the financial position of the Clinical Commissioning Group and enable them to ensure that the accounts comply with the requirements of the Accounts Direction) For safeguarding the Clinical Commissioning Group's assets (and hence for taking reasonable steps for the prevention and detection of fraud and other irregularities) The relevant responsibilities of accounting officers under Managing Public Money Ensuring the CCG exercises its functions effectively, efficiently and economically (in accordance with Section 14Q of the National Health Service Act 2006 (as amended)) and with a view to securing continuous improvement in the quality of services (in accordance with Section14R of the National Health Service Act 2006 (as amended)) Ensuring that the CCG complies with its financial duties under Sections 223H to 223J of the National Health Service Act 2006 (as amended)
Under the National Health Service Act 2006 (as amended), NHS England has directed each Clinical Commissioning Group to prepare for each financial year financial statements in the form and on the basis set out in the Accounts Direction. The financial statements are prepared on an accruals basis and must give a true and fair view of the state of affairs of the Clinical Commissioning Group and of its net expenditure, changes in taxpayers' equity and cash flows for the financial year.
In preparing the financial statements, the Accountable Officer is required to comply with the requirements of the Group Accounting Manual issued by the Department of Health and in particular to:
Observe the Accounts Direction issued by NHS England, including the relevant accounting and disclosure requirements, and apply suitable accounting policies on a consistent basis Make judgements and estimates on a reasonable basis State whether applicable accounting standards as set out in the Group Accounting Manual issued by the Department of Health have been followed, and disclose and explain any material departures in the financial statements; and Prepare the financial statements on a going concern basis.
32 To the best of my knowledge and belief, I have properly discharged the responsibilities set out under the National Health Service Act 2006 (as amended), Managing Public Money and in my Clinical Commissioning Group Accountable Officer Appointment Letter.
I also confirm that:
As far as I am aware, there is no relevant audit information of which the CCG's auditors are unaware, and that as Accountable Officer, I have taken all the steps that I ought to have taken to make myself aware of any relevant audit information and to establish that the CCG's auditors are aware of that information That the annual report and accounts as a whole is fair, balanced and understandable and that I take personal responsibility for the annual report and accounts and the judgments required for determining that it is fair, balanced and understandable
Anthony Hassall Chief Accountable Officer 23 May 2018
33 Governance Statement
Introduction and context
NHS Salford Clinical Commissioning Group (CCG) is a corporate body established by NHS England on 1 April 2013 under the National Health Service Act 2006 (as amended).
The clinical commissioning group’s statutory functions are set out under the National Health Service Act 2006 (as amended). The CCG’s general function is arranging the provision of services for persons for the purposes of the health service in England. The CCG is, in particular, required to arrange for the provision of certain health services to such extent as it considers necessary to meet the reasonable requirements of its local population.
As at 1 April 2017, the clinical commissioning group is not subject to any directions from NHS England issued under Section 14Z21 of the National Health Service Act 2006.
Scope of responsibility
As Accountable Officer, I have responsibility for maintaining a sound system of internal control that supports the achievement of the clinical commissioning group’s policies, aims and objectives, whilst safeguarding the public funds and assets for which I am personally responsible, in accordance with the responsibilities assigned to me in Managing Public Money. I also acknowledge my responsibilities as set out under the National Health Service Act 2006 (as amended) and in my Clinical Commissioning Group Accountable Officer Appointment Letter.
I am responsible for ensuring that the clinical commissioning group is administered prudently and economically and that resources are applied efficiently and effectively, safeguarding financial propriety and regularity. I also have responsibility for reviewing the effectiveness of the system of internal control within the clinical commissioning group as set out in this governance statement.
Governance arrangements and effectiveness
The main function of the governing body is to ensure that the group has made appropriate arrangements for ensuring that it exercises its functions effectively, efficiently and economically and complies with such generally accepted principles of good governance as are relevant to it.
The Governing Body
NHS Salford CCG’s Governing Body has approved the vision, values and overall strategic direction of the organisation and authorises any matters that amend the CCG’s Constitution, including Terms of Reference for the Governing Body, its committees, the Membership of those committees, the overarching scheme of reservation and delegation and the standing orders and prime financial policies.
NHS Salford CCG’s Constitution permits that the Governing Body must not comprise less than 6 Members and that the Chair will be a GP. In addition, five representatives of Member Practices (covering the various neighbourhoods) coupled with two other GPs or primary care health professionals, one registered nurse (with a lead role on assurance for safeguarding and quality) and one secondary care specialist doctor (with a lead role on assurance associated
34 with clinical matters including clinical systems and research and development) make up its clinical Membership.
Furthermore, three lay Members (one of whom will be the Deputy Chair) respectively lead on audit, remuneration and conflict of interest matters; patient and public participation matters; and commercial issues. Finally, the Accountable Officer and the Chief Finance Officer complete the composition of the Governing Body.
To add value to its work, NHS Salford CCG routinely extends an invitation to Salford City Council’s Director of Public Health, its Strategic Director, People and its Lead Member for Adult Services, Health and Wellbeing.
Members of the CCG’s Executive Team are also present at Governing Body meetings as non- voting members.
Committees of the Governing Body
To support the successful delivery of its functions and activities, NHS Salford CCG has several Prime Committees (outlined below), each accountable to the Governing Body. Improvements and amendments to the organisation’s Constitution were made in 2017/18 to reflect the developing roles of these committees.
All Governing Body Members have undertaken an appraisal during 2017/18, and routine, informal Governing Body developmental sessions serve to facilitate the transfer of knowledge and aid aspects of each Member’s personal development. The main body of the Annual Report provides comprehensive highlights of the work led by NHS Salford CCG’s committees and sub- committees.
Audit Committee
The Audit Committee provides the Governing Body with an independent and objective view of the CCG’s financial systems, financial information and compliance with laws, regulations and directions governing the group in so far as they relate to finance. In addition, NHS Salford CCG’s Governing Body has conferred/delegated the following functions, connected with the Governing Body’s main function to its Audit Committee:
To review the implementation and ongoing quality of integrated governance, risk management and internal control, across the whole of NHS Salford CCG’s activities (both clinical and non-clinical); and Act as the arbiter for any issues which may arise from conflicts of interest in relation of the awarding of contracts, in particular to primary care providers and/or primary care independent contractors.
The Committee directed that a number of reviews be undertaken, prioritised on a combination of risk rating and organisational impact. Assurance was obtained on the areas included in the Head of Internal Audit Opinion below.
35 Remuneration Committee
The Remuneration Committee makes decisions on determinations about the remuneration, fees and other allowances for employees and for people who provide services to the organisation and on determinations about allowances under any pension scheme that the CCG may establish as an alternative to the NHS pension scheme.
Commissioning Committee
The Commissioning Committee oversees commissioning activities including service developments, Quality, Innovation, Prevention and Productivity (QIPP) plans, investments/disinvestments, quality assurance and contract management.
Primary Care Commissioning Committee
The Primary Care Commissioning Committee oversees commissioning activities associated with the commissioning of Primary Care. These commissioning activities include GMS, PMS and APMS contracts, newly designed enhanced services; design of local incentive schemes; decision making on whether to establish new GP practices in an area; approving practice mergers; and making decisions on ‘discretionary’ payment.
Executive Team
The Executive Team is responsible for compliance with statutory and regulatory duties, operational delivery of all CCG functions and performance management of the objectives of the organisation. It is also specifically responsible for the functions of health, safety and risk, information management and technology (IM&T) including information governance, equality and diversity and health economy resilience.
Integrated Adult Health and Care Commissioning Joint Committee (joint commissioning arrangement with Salford City Council)
The Integrated Adult Health and Care Commissioning Joint Committee oversees commissioning activities associated with the Adult Health and Care Pool, including commissioning the Integrated Care Organisation and other providers. These commissioning activities include service strategy, service design and market management. The Integrated Adult Health and Care Commissioning Joint Committee also manages system performance and agrees the Commissioning Plan for the Integrated Care System.
Appendix A provides summary detail of attendance at meetings throughout 2017/18. Terms of Reference for each Prime Committee are available within the NHS Salford CCG’s Constitution on our website www.salfordccg.nhs.uk/publications
36 Joint Arrangements
NHS Salford CCG is one of 10 member CCGs of the Greater Manchester Association of CCGs, a collaborative body which acts as a single commissioning voice within Greater Manchester and a vehicle for joint working. NHS Salford CCG’s Clinical Chair and Chief Officer represent the CCG’s interests at the Association Governing Group (AGG), the Association’s most senior decision-making body. The CCG also has representatives on the AGG’s sub- committees, including Heads of Commissioning and Chief Finance Officers. Through the Greater Manchester Association of CCGs, Member CCGs are able to share best practice, access peer support and work collaboratively on a wider footprint to achieve the best possible health outcomes for their patients.
NHS Salford CCG has also entered into joint arrangements with Salford City Council and other Salford based organisations as follows:
Salford Safeguarding Adults Board; Salford Safeguarding Children’s Board; Salford Health and Wellbeing Board; Integrated Care Advisory Board; and the Greater Manchester Health and Social Care Partnership.
Terms of Reference for each committee highlighted above coupled with detailed attendance records are available upon request.
UK Corporate Governance Code
NHS Bodies are not required to comply with the UK Code of Corporate Governance. However, compliance is considered to be good practice. This Governance Statement is intended to demonstrate NHS Salford CCG’s compliance with the principles set out in the code.
For the financial year ended 31 March 2018, and up to the date of signing this statement, the CCG has complied with the provisions set out in the Code, and equally applied the principles laid out therein.
Discharge of Statutory Functions
In light of recommendations of the 1983 Harris Review, the clinical commissioning group has reviewed all of the statutory duties and powers conferred on it by the National Health Service Act 2006 (as amended) and other associated legislative and regulations. As a result, I can confirm that the clinical commissioning group is clear about the legislative requirements associated with each of the statutory functions for which it is responsible, including any restrictions on delegation of those functions.
Responsibility for each duty and power has been clearly allocated to a lead Director. Directorates have confirmed that their structures provide the necessary capability and capacity to undertake all of the clinical commissioning group’s statutory duties.
37 Risk management arrangements and effectiveness
NHS Salford CCG’s Risk Management Strategy underpins a Risk Management Framework as part of its wider governance arrangements. The Framework illustrates how our strategic programmes, key work programmes and activities are aligned and explains the method by which risks are assessed, scored, monitored and reported.
Our strategic programmes and key deliverables (objectives) are the primary focus for risk identification and horizon scanning. Strategic risks are recorded in our strategic risk register which is held in the integrated performance and risk system, Pentana (formerly known as Covalent). Operational risks are captured in specific programme/project risk registers across the organisation.
All risks across the organisation are aligned to objectives and so the CCG does not operate a process of escalation/de-escalation. If a risk is no longer considered to be relevant to a strategic objective, it can be moved to an operational risk register provided that the risk would have an impact on the achievement of objectives at that level i.e. for a programme/project. In turn, a programme/project risk could be moved to the strategic risk register provided that the assessment could demonstrate a risk to the achievement of one or more of our strategic objectives. This process is closely managed by the Senior Planning and Performance Manager, the CCG’s risk practitioner.
Details on the CCG’s Risk appetite, risk assessment process, risk ownership and accountability and training and reporting arrangements can be found in the CCG’s latest Risk Management Strategy.
NHS Salford CCG reported one programme risk in relation to Information Governance in 2017/18 as follows:
A breach of Information Governance or data security processes may result in the release of Patient Confidential Data, Patient Identifiable Data, confidential corporate data or other highly sensitive information.
The risk was identified in 2015/16 and was carried over in to 2016/17 and subsequently in to 2017/18. The risk has strong existing controls and assurances with no gaps identified in the controls. The CCG is comfortable with the level of risk which has been rated as low (green) and therefore tolerates the risk.
The CCG did not identify any risks to compliance with the CCG’s licence in 2017/18.
NHS Salford CCG reported one strategic risk to its internal controls in 2017/18 as follows:
Commissioning decisions are influenced by conflicts of interest and do not represent the best solutions for the people of Salford.
Existing controls are in place and assurances have been provided. Gaps in assurances were identified in 2015/16 and further controls were applied as part of the risk treatment plan. This risk was carried forward in to 2016/17 and again in to 2017/18 but remains low (green).
In 2017/18, NHS Salford CCG reported one strategic risk in relation to organisational performance as follows:
38 If pressures in the health and social care system are not effectively monitored and managed then we may fail to achieve national performance targets. This may result in patient harm, negative media attention (reputational damage), reduced patient confidence and could cause further pressures in the wider health system.
The risk was originally identified in 2015/16 and has been carried forward since then due to ongoing pressures in the system. Existing controls and assurances are in place. There are currently no gaps in assurances but this risk remains high (red).
In addition to the risk above, the Governing Body receives an integrated planning, performance and risk report (Governing Body Assurance Framework (BAF) Report) at every meeting which details the latest performance breaches including plans for recovery.
All risks are subject to a bi-monthly review. This process is automated with system alerts being generated as risks reach their next scheduled risk assessment date. The process is overseen by the Senior Planning and Performance Manager, the CCG’s risk practitioner.
Other sources of assurance
Internal Control Framework
A system of internal control is the set of processes and procedures in place in the clinical commissioning group to ensure it delivers its policies, aims and objectives. It is designed to identify and prioritise the risks, to evaluate the likelihood of those risks being realised and the impact should they be realised, and to manage them efficiently, effectively and economically.
The system of internal control allows risk to be managed to a reasonable level rather than eliminating all risk; it can therefore only provide reasonable and not absolute assurance of effectiveness.
The committee and reporting structures of NHS Salford CCG provide the basis of the framework and process that maintains, monitors and reviews the effectiveness of the system of internal control and risk management. The governance structure and sub committees comprise of a mix of senior managers, clinical professionals, independent contractors and internal audit representation to provide an effective balance between the Membership, executive and audit functions and furthermore to ensure that decision making is effectively triangulated.
The Governing Body’s role is to provide active leadership of the CCG within a framework of prudent and effective controls that enable risk to be managed. Consequently, the Governing Body’s Risk Assurance Framework itself provides the Governing Body with high level assurance of the progress of achievement of the CCG's aims, objectives and priorities within a robust risk based framework. In addition, the Governing Body also receives regular reports offering internal assurances on financial, organisational and quality performance.
39
For the 2017/18 financial year, Mersey Internal Audit (MIAA) have assessed the organisation’s Assurance Framework as being structured to meet the NHS requirements, visibly used by the Governing Body and a clear reflection of the risks discussed by the Governing Body.
The Audit Committee specifically advises the Governing Body on the effectiveness of the system of internal control by the review of the internal audit report, external audit report and the Risk Assurance Framework. Any significant control issues are routinely reported to the Governing Body by the Audit Committee.
Annual audit of conflicts of interest management
The revised statutory guidance on managing conflicts of interest for CCGs (published June 2016) requires CCGs to undertake an annual internal audit of conflicts of interest management. To support CCGs to undertake this task, NHS England has published a template audit framework.
On behalf of the CCG, MIAA has carried out our annual internal audit of conflicts of interest. Following the review, internal audit has assigned compliance levels to each area as follows:
Scope Area Compliance Level RAG rating
Governance Arrangements Partially Compliant
Declarations of interests and gifts Partially Compliant and hospitality
Register of interests, gifts and Partially Compliant hospitality and procurement decisions
Decision making processes and Partially Compliant contract monitoring
Reporting concerns and Partially Compliant identifying and managing breaches / non-compliance
In the majority of cases (18 out of the 27 requirements set by NHS England for the 2017/18 year), the CCG is compliant with legal requirements and statutory guidance in relation to the management of conflicts of interest and gifts and hospitality and has a clear plan of action to address the areas identified for improvement in this audit.
40 Data Quality
Data provided to the Membership and the Governing Body to inform decision making has a high degree of provenance. It is obtained from trusted sources: NHS data sets; National Institute for Health and Care Excellence (NICE); the Joint Strategic Needs Assessment (JSNA); etc., and from trusted advisers: Greater Manchester Shared Services (GMSS); the National Health Service Litigation Authority (NHSLA); the National Health Service Business Services Authority (NHSBSA); etc.
The Audit Committee and internal audit team play pivotal roles in assuring and challenging, where relevant, the data and assumptions made from that data in reports destined for the Governing Body and other decision making committees or sub groups of the Governing Body.
Information Governance
The NHS Information Governance Framework sets the processes and procedures by which the NHS handles information about patients and employees, in particular personal identifiable information. The NHS Information Governance Framework is supported by an Information Governance Toolkit and the annual submission process provides assurances to the clinical commissioning group, other organisations and to individuals, that personal information is dealt with legally, securely, efficiently and effectively. The CCG has submitted a satisfactory level of compliance with the Information Governance Toolkit. The full detail of our compliance with the assessment was presented to the Governing Body held in May 2018, and is available on our website.
We place high importance on ensuring there are robust information governance systems and processes in place to help protect patient and corporate information. We have established an information governance management framework and have developed information governance processes and procedures in line with the information governance toolkit. We have ensured all staff undertake annual information governance training and have implemented a staff information governance handbook to ensure staff are aware of their information governance roles and responsibilities.
There are processes in place for incident reporting and investigation of serious incidents. We have developed formation risk assessment and management procedures and a programme will be established to fully embed an information risk culture throughout the organisation against identified risks.
Business Critical Models
No significant internal control issues have been identified in this respect as the CCG uses only those quality assurance models prescribed by NHS England.
The CCG has received third party assurance from Greater Manchester Shared Services (GMSS), who provide a number of support services to NHS Salford CCG. GMSS have had a number of internal audits for which they have received significant assurance. These include key financial systems, people services and emergency preparedness, resilience and response. This confirms that significant assurance can be made in respect of governance, risk management and internal control arrangements operated by GMSS.
41 Control Issues
No significant control issues currently facing the CCG were identified via the Month 9 Governance Statement return.
Review of economy, efficiency and effectiveness of the use of resources
The Governing Body and its committees and sub committees receive proposals that are based upon evidence based commissioning intentions. A wide variety of data sources are used to inform the development of our commissioning intentions, but chief amongst these is the Joint Strategic Needs Assessment. Summary business cases are also provided for each commissioning intention that comprises an assessment of the cost benefit analysis of the proposal, equality assessment and an appropriate risk assessment.
The Audit Committee provides the assurance overview for the effective use of resources, and the internal audit team have an annual work programme that complements that role and focuses upon all work areas covered by the CCG.
While CCGs have a responsibility to promote comprehensive healthcare within the resources available, this does not mean an obligation to provide every treatment. As a commissioning organisation, NHS Salford CCG strives to take into account the resources available to it and the competing demands on those resources.
The Greater Manchester Shared Service (GMSS) Effective Use of Resources (EUR) team works closely with NHS Salford CCG to facilitate and support making those judgments at an individual patient level known as Individual Funding Requests (IFRs). GMSS’s EUR team combines regional best practice and benchmarking with local knowledge gained from a strong client relationship and deep knowledge and expertise. A regional overview improves consistency across boundaries, leading to an improved patient experience.
Salford CCG was rated 'outstanding' in 2015/16 and 2016/17 by NHS England and commended in areas such as strong and robust leadership, involving and engaging patients and the public and getting best value for money. It is the only CCG in Greater Manchester rated 'outstanding' including Outstanding / Green Star for the Quality of its leadership. The CCG Quarter 4 assurance meeting for 2017/18 will take place on 15th May 2018, the results of which will be published once available.
The CCG has submitted a Quality of Leadership assessment although no feedback has been received to date. It is anticipated that the indicator will be also be discussed at the Quarter 4 assurance meeting referred to above.
Delegation of functions
GMSS undertake a number of functions on behalf of the CCG including finance. There are no other significant delegated functions that are not already covered elsewhere in the governance statement.
42 Counter fraud arrangements
The CCG has made the following arrangements regarding its managing of counter fraud: An Accredited Counter Fraud Specialist is contracted from TIAA (Counter Fraud Services) to undertake counter fraud work proportionate to identified risks. The CCG’s Audit Committee receives a report against each of the Standards for Commissioners at least annually. There is commitment to provide executive support and direction for a proportionate proactive work plan should this report identify any risks to the organisation. A member of the Executive Team is proactively and demonstrably responsible for tackling fraud, bribery, and corruption.
Head of Internal Audit Opinion
Following completion of the planned audit work for the financial year for the clinical commissioning group, the Head of Internal Audit issued an independent and objective opinion on the adequacy and effectiveness of the clinical commissioning group’s system of risk management, governance and internal control. The Head of Internal Audit concluded that, for the period 1 April 2017 – 31 March 2018:
Substantial Assurance can be given that that there is a good system of internal control designed to meet the organisation’s objectives, and that controls are generally being applied consistently.
During the year, internal audit issued the following audit reports:
Area of Audit Level of Assurance Given Patient Access: Out of Hours and 7 Day Significant Key Finance Systems Significant Use of Research in Commissioning Significant Cyber Security – Organisational Controls Significant Information Governance Toolkit Significant Estates and Property Services Limited
Appendix B provides the full Director of Audit Option and Annual Report 2017/18
Review of the effectiveness of governance, risk management and internal control
My review of the effectiveness of the system of internal control is informed by the work of the internal auditors, executive managers and clinical leads within the clinical commissioning group who have responsibility for the development and maintenance of the internal control framework. I have drawn on performance information available to me. My review is also informed by comments made by the external auditors in their annual audit letter and other reports.
Our assurance framework provides me with evidence that the effectiveness of controls that manage risks to the clinical commissioning group achieving its principles objectives have been reviewed.
43 I have been advised on the implications of the result of this review by:
The Governing Body The Audit Committee Internal audit Other explicit review/assurance mechanisms
The role and conclusions of each were that the committee and reporting structures of NHS Salford CCG provide the framework and processes that maintain, monitor and review the effectiveness of the system of internal control and risk management. The governance structure and subcommittees comprise of a mix of senior managers, clinical professionals, independent contractors and internal audit representation.
The Governing Body’s role is to provide active leadership of the CCG within a framework of prudent and effective controls that enable risk to be managed. High risks are reported to each meeting of the Governing Body where gaps in controls and assurances are identified and remedial actions agreed. The Governing Body also receives regular reports giving internal assurances on financial, organisational and quality performance.
The Audit Committee is pivotal in advising the Governing Body on the effectiveness of the system of internal control by the review of the internal audit report, external audit report and the Risk Assurance Framework. Any significant control issues are reported to the Governing Body by the Audit Committee.
Conclusion
No significant issues have occurred during 2017/18 which would have a significant impact upon the organisation. My review confirms that NHS Salford CCG has a generally sound system of internal control that supports the achievement of its policies, aims and objectives.
Anthony Hassall Chief Accountable Officer 23 May 2018
44 Appendix A Attendance at Governing Body Meetings and Prime Committees in 2017/18
Members
lthand Social
Governing Body CommitteeAudit Primary Care Commissioning Committee Remuneration Committee Commissioning Committee Executive Management Team Integrated Adult Hea Care Commissioning Committee Joint Governing Body Members
Dr Tom Tasker, Chair 6/6 - - 3/3 9/14 26/38 -
Anthony Hassall, Chief Accountable Officer 5/6 - 5/7 - 3/14 29/38 3/6
Steve Dixon, Chief Finance Officer & Deputy Chief Accountable Officer 6/6 4/4 6/7 - 10/14 34/38 5/6
Dr Chris Babbs, Governing Body Secondary Care 5/6 - - 2/3 1/14 - -
Dr Nick Browne, Neighbourhood Lead 6/6 - - - 11/14 - 6/6
David Flynn, Neighbourhood Lead 6/6 - - - 10/14 - 5/6
Kate Jones, Neighbourhood Lead 6/6 - - - 11/14 - 3/6
Alison Kelly, Governing Body Nurse 4/6 0/4 - 2/3 1/14 - -
Dr David McKelvey, Neighbourhood Lead 6/6 - - - 12/14 - 5/6
45 Paul Newman, Lay Member – Innovation Matters 6/6 - 6/7 3/3 - - -
Dr Tom Regan, Clinical Director of Transformation 5/6 - - - 10/14 - 4/6
Dr Jeremy Tankel, Medical Director 6/6 4/4 3/7 - 11/14 - 3/6
Edward Vitalis, Lay Member, Audit, Remuneration & Conflicts of Interest 5/6 4/4 2/3 - - -
Dr Ben Williams, Neighbourhood Lead 5/6 - - - 13/14 - 5/6
Brian Wroe, Lay Member – Patient and Public Participation 5/6 - 5/7 2/3 - - -
Executive Team
Hannah Dobrowolska, Director of Corporate Services 6/6 - - 3/3 - 28/38 -
Karen Proctor, Director of Commissioning 3/6 - 4/7 - 8/14 22/38 4/6
Francine Thorpe, Director of Quality and Innovation 6/6 - 5/7 - 11/14 31/38 5/6
Jennifer McGovern (Left the CCG in Sept 2017) - - - - - 6/11 -
Judd Skelton (replaced Jennifer McGovern) - - - - - 14/33 4/6
46
NB
The attendance information is only included for voting members and key supporting leads of each committee, and only formal meetings are included in the information provided. Many absences from the above meetings are a result of prioritisation of other meetings relevant to the CCG and, where appropriate, deputies provide cover.
- Indicates not applicable
47
REMUNERATION AND STAFF REPORT
Anthony Hassall, Chief Accountable Officer 23 May 2018
48
Remuneration Report
Remuneration Committee
For the period from 1 April 2017 to 31 March 2018, details of the membership of the Remuneration Committee were as follows: Edward Vitalis - Chair – Governance Dr Chris Babbs - Secondary Care Consultant Paul Newman - Lay Member – Commercial Brian Wroe - Lay Member – Engagement Alison Kelly - Governing Body Nurse
The Remuneration Committee follows national guidance issued by the Department of Health to determine the remuneration and terms and conditions of senior managers using the national Very Senior Managers pay framework (VSM). The Remuneration Committee is also responsible for the remuneration of the clinical members. Summary detail of attendance at meetings throughout 2017/18 is provided as an appendix to the Governance Statement.
The performance of VSMs is assessed through the CCG’s Personal Development Review system in line with NHS policy. Remuneration is not performance related. Termination of contracts, and any relevant payments, are calculated on an individual basis, taking into account circumstances of termination, notice periods, length of service and salary. All calculations are in line with statutory and NHS terms and conditions.
Policy on the remuneration of senior managers
The policy on the remuneration of directors for the current and future years is in line with the CCG’s Approved Standing Orders. There are no senior managers earning in excess of £142,500.
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Senior manager remuneration (including salary and pension entitlements)
Senior managers for the purposes of the remuneration report are the members of the Governing Body plus the executive directors of the CCG.
2017/18 (a) (b) (c) (d) (e) (f) Salary Expense Performance pay and Long term All pension-related TOTAL (bands of £5,000) payments bonuses performance pay benefits (a to e) Name and Title (taxable) (bands of £5,000) and bonuses (bands of £2,500) (bands of £5,000) to nearest £100 (bands of £5,000)
£000 £ £000 £000 £000 £000 Tom Tasker Chair 95-100 25-27.5 120-125 Anthony Hassall Chief 130-135 112.5-115 245-250 Accountable Officer Steve Dixon Chief 110-115 42.5-45 155-160 Finance Officer Karen Proctor Director 85-90 27.5-30 115-120 of Commissioning Francine Thorpe 90-95 12.5-15 100-105 Director of Quality & Innovation Hannah Dobrowolska 60-65 62.5-65 125-130 Director of Corporate Services Harry Golby Acting 5-10 5-10 Director of Commissioning Tom Regan Clinical 55-60 55-60 Lead for Transformation Jeremy Tankel Medical 65-70 65-70 Director Nick Browne 25-30 5-7.5 35-40 Neighbourhood Lead David McKelvey 25-30 267.5-270 295-300 Neighbourhood Lead Ben Williams 25-30 140-142.5 170-175 Neighbourhood Lead Kate Jones 25-30 25-30 Neighbourhood Lead David Flinn 30-35 30-35 Neighbourhood Lead
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2017/18 (a) (b) (c) (d) (e) (f) Salary Expense Performance pay and Long term All pension-related TOTAL (bands of £5,000) payments bonuses performance pay benefits (a to e) Name and Title (taxable) (bands of £5,000) and bonuses (bands of £2,500) (bands of £5,000) to nearest £100 (bands of £5,000)
£000 £ £000 £000 £000 £000 Alison Kelly Governing 5-10 5-10 Body Nurse Chris Babbs Governing 10-15 10-15 Body Secondary Care Clinician Brian Wroe Lay 5-10 5-10 Member Edward Vitalis Lay 10-15 10-15 Member Paul Newman Lay 5-10 5-10 Member
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Pension benefits as at 31 March 2018
Name and Title (a) (b) (c) (d) (e) (f) (g) (h) Real increase Real increase in Total accrued Lump sum at Cash Equivalent Real Increase in Cash Equivalent Employers in pension at pension lump sum pension at pension age Transfer Value at Cash Equivalent Transfer Value at Contribution to pension age at pension age pension age at 31 related to accrued 1 April 2017 Transfer Value 31 March 2018 partnership pension (bands of (bands of £2,500) March 2018 pension at 31 £2,500) March 2018 (bands of £5,000) (bands of £5,000)
£000 £000 £000 £000 £000 £000 £000 £000 Anthony Hassall 5-7.5 10-12.5 30-35 80-85 380 105 485 Chief Accountable Officer Steve Dixon Chief 2.5-5 0-2.5 30-35 80-85 459 63 522 Finance Officer Karen Proctor 0-2.5 0-2.5 25-30 65-70 407 49 456 Director of Commissioning Francine Thorpe 0-2.5 2.5-5 40-45 120-125 860 66 927 Director of Quality & Innovation Hannah 2.5-5 5-7.5 20-25 55-60 278 51 329 Dobrowolska Director of Corporate Services Harry Golby 0-2.5 2.5-5 15-20 45-50 273 25 298 Acting Director of Commissioning Tom Tasker 0-2.5 0-2.5 20-25 55-60 315 66 381 Chair Tom Regan Clinical Director of Transformation Nicholas Browne 0-2.5 0-2.5 10-15 35-40 204 11 215 Neighbourhood Lead David McKelvey 10-12.5 35-37.5 20-25 60-65 185 269 454 Neighbourhood Lead Ben Williams 5-7.5 17.5-20 5-10 20-25 26 103 129 Neighbourhood Lead
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Cash equivalent transfer values
A cash equivalent transfer value (CETV) is the actuarially assessed capital value of the pension scheme benefits accrued by a member at a particular point in time. The benefits valued are the member’s accrued benefits and any contingent spouse’s (or other allowable beneficiary’s) pension payable from the scheme.
A CETV is a payment made by a pension scheme or arrangement to secure pension benefits in another pension scheme or arrangement when the member leaves a scheme and chooses to transfer the benefits accrued in their former scheme. The pension figures shown relate to the benefits that the individual has accrued as a consequence of their total membership of the pension scheme, not just their service in a senior capacity to which disclosure applies.
The CETV figures and the other pension details include the value of any pension benefits in another scheme or arrangement which the individual has transferred to the NHS pension scheme. They also include any additional pension benefit accrued to the member as a result of their purchasing additional years of pension service in the scheme at their own cost. CETVs are calculated within the guidelines and framework prescribed by the Institute and Faculty of Actuaries.
Real increase in CETV
This reflects the increase in CETV effectively funded by the employer. It takes account of the increase in accrued pension due to inflation, contributions paid by the employee (including the value of any benefits transferred from another scheme or arrangement) and uses common market valuation factors for the start and end of the period.
Compensation on early retirement of for loss of office
None
Payments to past members
None
Pay multiples
Reporting bodies are required to disclose the relationship between the remuneration of the highest paid director in their organisation and the median remuneration of the organisation's workforce. The annualised full-time equivalent remuneration of the highest paid member of the Salford Clinical Commissioning Group in the financial year 2017-18 was £155k-160k (2016-17 £155k-£160k) This is 3.6 times (2016-17, 3.8x) the median remuneration of the workforce, which was £42k (2016-17 £41k). In 2017-18, no employees (2016-17, nil) received remuneration in excess of the highest paid member of the governing body. Remuneration for 2017-18 ranged from £15k to £160k (2016-17, £15k - £158k). Total remuneration includes salary, non-consolidated performance related pay and benefits in kind. It does not include severance payments, employer pension contributions and the cash equivalent transfer value of pensions.
53
Staff Report
Number of senior managers
Executive Team As at 31 March 2018:
Payscale Description No. Chief Operating Officer * 1 Chief Finance Officer * 1 Very Senior Manager 2 Chair * 1 Agenda for Change 1 Council payscale (joint appointment) 1 Total 7 * Data is provided here only, although these individuals are also part of the CCG’s Governing Body.
Governing Body As at 31 March 2018:
Payscale Description No. Governing Body Lay Member 3 Governing Body Clinical or 8 Neighbourhood Leads Total 11 In addition, one Governing Body Member paid through a secondment agreement with their employing NHS Trust.
Staff numbers and costs
Employee Number of Costs Status Employees Permanent 124 £4,944,849
Fixed Term 18 £449,899 Temporary Total 142 £5,394,748
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Staff composition
At the end of the 2017/18 financial year, Salford CCG staff comprised:
Employee Group* Male Female Total Executive Team ** 3 3 6 Governing Body 9 2 11 Senior Managers*** 10 31 41 Other Clinical Leads 11 6 17 All other employees 16 56 72 Total 49 98 147 * Statistics drawn from NHS Electronic Staff Records (ESR) 2018, as such it includes information of staff members employed directly by the CCG only and not those on secondment to the CCG or in joint roles where the employer is not the CCG ** 3 members of the Executive Team are also Governing Body Members (Chair, Chief Accountable Officer and Chief Finance Officer), their data is only included in the Executive Team to avoid double counting *** Staff at bands 8a – 8d, when not included in Executive Team above
Note: All Governing Body, other Clinical Leads and all but one female member of the Executive Team are paid at locally agreed pay rates, sometimes referred to as Very Senior Manager (VSM) pay grade.
Sickness absence data
Salford CCG’s average sickness absence rate over the year 2017/18 was 2.9% per cent (2.9% for 2016/17) compared with an average score of 3.03 per cent for all North West CCG’s for the period Jan 2017 – Dec 2017 , as issued by the Health and Social Care Information Centre.
Staff policies
Staff policies are available on the intranet and on request.
Expenditure on consultancy
The CCG has incurred £38k in consultancy expenditure for 2017/18 (£197k in 2016/17). This was for Organisational Development support to review and further improve partnership relationships and approaches as part of the integration agenda across health and social care.
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Off-payroll engagements
Table 1: Off-payroll engagements longer than 6 months
For all off-payroll engagements as at 31 March 2018, for more than £220 per day and that last longer than six months: Number Number of existing engagements as of 31 March 2018 2
for less than one year at the time of reporting 1 for between one and two years at the time of reporting for between 2 and 3 years at the time of reporting for between 3 and 4 years at the time of reporting 1 for 4 or more years at the time of reporting
The CCG confirms that all existing off-payroll engagements have at some point been subject to a risk based assessment as to whether assurance is required that the individual is paying the right amount of tax and, where necessary, that assurance has been sought.
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Table 2: New off-payroll engagements
For all new off-payroll engagements between 01 April 2017 and 31 March 2018, for more than £220 per day and that last longer than six months:
Number Number of new engagements, or those that reached six months in 0 duration, between 1 April 2017 and 31 March 2018 Number of new engagements which include contractual clauses giving Salford CCG the right to request assurance in relation to income tax and National Insurance obligations Number for whom assurance has been requested Of which: assurance has been received assurance has not been received engagements terminated as a result of assurance not being
received.
Table 3: Off-payroll engagements / senior official engagements
For any off-payroll engagements of Board members and / or senior officials with significant financial responsibility, between 01 April 2017 and 31 March 2018.
Number of off-payroll engagements of board members, and/or senior officers with significant financial responsibility, during 0 the financial year Total no. of individuals on payroll and off-payroll that have been deemed “board members, and/or, senior officials with significant financial responsibility”, during the financial year. 0 This figure should include both on payroll and off-payroll engagements.
Exit packages, including special (non-contractual) payments There have been three exit packages paid during 2017/18, totalling £17k (2016/17 Nil). Parliamentary Accountability and Audit Report NHS Salford CCG is not required to produce a Parliamentary Accountability and Audit Report. Disclosures on remote contingent liabilities, losses and special payments, gifts, and fees and charges are included as notes in the Financial Statements of this report at [insert cross-reference(s) as required]. An audit certificate and report is also included in this Annual Report in Appendix B.
Anthony Hassall Chief Accountable Officer 23 May 2018
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58
Director of Audit Opinion and Annual Report 2017/18
NHS Salford Clinical Commissioning Group
Director of Audit Opinion and NHS Salford Annual Report 2017/18 Clinical Commissioning Group
Contents
1. Introduction 2. Director of Internal Audit Opinion – Executive Summary 3. Director of Internal Audit Opinion – Detailed Commentary 4. MIAA Quality of Service Indicators
P a g e | 1 Director of Audit Opinion and NHS Salford Annual Report 2017/18 Clinical Commissioning Group
1. Introduction
1.1 Purpose of this Report The purpose of this Director of Internal Audit Opinion is to contribute to the assurances available to the Accountable Officer and the Governing Body which underpin the Governing Body’s own assessment of the effectiveness of the organisation’s system of internal control. This Opinion will assist the Governing Body in the completion of its Annual Governance Statement (AGS), along with considerations of organisational performance, regulatory compliance, the wider operating environment and health and social care transformation. Section 3 of this report provides additional information to support your AGS.
This opinion is provided in the context that the Clinical Commissioning Group like other organisations across the NHS is facing a number of challenging issues and wider organisational factors.
1.2 Roles and Responsibilities The whole Governing Body is collectively accountable for maintaining a sound system of internal control and is responsible for putting in place arrangements for gaining assurance about the effectiveness of that overall system.
The Annual Governance Statement (AGS) is an annual statement by the Accountable Officer, on behalf of the Governing Body, setting out:
how the individual responsibilities of the Accountable Officer are discharged with regard to maintaining a sound system of internal control that supports the achievements of policies, aims and objectives;
the purpose of the system of internal control as evidenced by a description of the risk management and review processes, including the Assurance Framework process; and
the conduct and results of the review of the effectiveness of the system of internal control, including any disclosures of significant control failures together with assurances that actions are or will be taken where appropriate to address issues arising.
P a g e | 2 Director of Audit Opinion and NHS Salford Annual Report 2017/18 Clinical Commissioning Group
The organisation’s Assurance Framework should bring together all of the evidence required to support the AGS requirements.
In accordance with Public Sector Internal Audit Standards, the Director of Internal Audit (HoIA) is required to provide an annual opinion, based upon and limited to the work performed, on the overall adequacy and effectiveness of the organisation’s risk management, control and governance processes (i.e. the organisation’s system of internal control). This is achieved through a risk-based plan of work, agreed with management and approved by the Audit Committee, which can provide assurance, subject to the inherent limitations described below. The outcomes and delivery of the internal audit plan are provided in Section 3.
The opinion does not imply that Internal Audit has reviewed all risks and assurances relating to the organisation. The opinion is substantially derived from the conduct of risk-based plans generated from a robust and organisation-led Assurance Framework. As such, it is one component that the Governing Body takes into account in making its AGS.
P a g e | 3 Director of Audit Opinion and NHS Salford Annual Report 2017/18 Clinical Commissioning Group
2. Director of Internal Audit Opinion – Executive Summary My opinion is set out as follows:
Basis for the opinion;
Overall opinion; and
Commentary 2.1 Basis for the Opinion
1. An assessment of the design and operation of the underpinning Assurance Framework and supporting processes.
2. An assessment of the range of individual assurances arising from our risk-based internal audit assignments that have been reported throughout the period. This assessment has taken account of the relative materiality of systems reviewed and management’s progress in respective of addressing control weaknesses identified.
3. An assessment of the organisation’s response to Internal Audit recommendations, and the extent to which they have been implemented.
My opinion is one source of assurance that the organisation has in providing its AGS other third party assurances should also be considered. In addition the organisation should take account of other independent assurances that are considered relevant.
2.2 Overall Opinion My overall opinion for the period 1 April 2017 to 31 March 2018 is:
High Assurance, can be given that there is a strong system of internal control which has been effectively designed to meet the organisation’s objectives, and that controls are consistently applied in all areas reviewed.
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Substantial Assurance, can be given that that there is a good system of internal control designed to meet the organisation’s objectives, and that controls are generally being applied consistently. Moderate Assurance, can be given that there is an adequate system of internal control, however, in some areas weaknesses in design and/or inconsistent application of controls puts the achievement of some of the organisation’s objectives at risk. Limited Assurance, can be given that there is a compromised system of internal control as weaknesses in the design and/or inconsistent application of controls impacts on the overall system of internal control and puts the achievement of the organisation’s objectives at risk. No Assurance, can be given that there is an inadequate system of internal control as weaknesses in control, and/or consistent non-compliance with controls could/has resulted in failure to achieve the organisation’s objectives.
2.3 Commentary The overall opinion is underpinned by the work conducted through the risk based internal audit plan, including Key Financial Systems, Patient Access: Out of Hours and 7 Day Working, Information Governance Toolkit, and Cyber Security - Organisational Controls.
This opinion is provided in the context that the Clinical Commissioning Group like other organisations across the NHS is facing a number of challenging issues and wider organisational factors.
Financial Position The CCG’s financial plan has been rated as Green by NHS England. Key financial targets are on track to be achieved as at the March 2018 report to Governing Body. CCG Annual Assessment The CCG has been rated as outstanding by NHS England in its annual assessment of performance against key performance indicators. Senior Management Senior management within the CCG has remained stable during 2017/18. Changes
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Provider Performance The CCG has continued to regularly report providers’ performance against a range of national and local targets. The CCG’s primary provider, Salford Royal NHS Foundation Trust has been consistently achieving good performance against these targets as has been recognised by the CQC assessment which awarded an ‘Outstanding’ rating. It is noted that the Trust has struggled to maintain required performance levels for, the four hour A&E target and 62 day waiting times referral to treatment (RTT) target. It is acknowledged that these targets are a challenge across the sector and at a regional level this is an area under review. Primary Care is also regularly reported. The Clinical Commissioning Group needs to continue to work with providers to ensure performance improvements are achieved. Greater Manchester The health and social care landscape in England is changing, with huge funding pressures across all public Health & Social Care services. The CCGs Locality Plan is underpinned by ‘Taking charge of our Health and Social Care in Greater Partnership Manchester, The Manchester Agreement’.
The CCG together with Salford Royal NHS Foundation Trust, Salford Council and other health and social care provider organisations have worked jointly to develop Salford Locality Plan with the aim of delivering real improvements in health and wellbeing for Salford people and make services more sustainable for the future, in terms of money and patient care. Moreover, these arrangements are part of a broader strategy for Greater Manchester that is aimed at achieving improved health outcomes for the region.
In providing this opinion I can confirm continued compliance with the definition of internal audit (as set out in your Internal Audit Charter), code of ethics and professional standards. I also confirm organisational independence of the audit activity and that this has been free from interference in respect of scoping, delivery and reporting. Tim Crowley Director of Audit, MIAA March 2018
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3. Director of Internal Audit Opinion – Detailed Commentary
Performance against Plan
The Internal Audit Plan has been delivered in accordance with the schedule agreed with the Audit Committee at the start of the financial year. This position has been reported within the progress reports across the financial year, with the final report concluding completion of the Internal Audit Plan, with the exception of Commissioning and Pooled Budgets; Property Services and Estates Strategy; and Third Party Assurances which are in progress. The reviews will be reported to the Audit Committee upon completion.
Assurance Framework
The organisation’s Assurance Framework is structured to meet the NHS requirements, is visibly used by the Governing Body and clearly reflects the risks discussed by the Governing Body.
Conflicts of Interest
As required by NHS England’s Managing Conflicts of Interest: Revised Statutory Guidance for CCGs an audit of conflicts of interest was completed following the prescribed framework issued by NHS England. Overall, the CCG were fully complaint in 18 of the 27 key elements within each of the five scoped areas.
The following compliance levels were assigned to each scope area:
Scope Area Compliance Level RAG rating
1. Governance Arrangements Partially Compliant
2. Declarations of interests and gifts & Partially Compliant hospitality
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3. Register of interests, gifts and Partially Compliant hospitality and procurement decisions
4. Decision making processes and Partially Compliant contract monitoring
5. Reporting concerns and identifying Partially Compliant and managing breaches / non compliance
Risk Based Reviews
The audit assignment element of the Opinion is limited to the scope and objective of each of the individual reviews. Detailed information on the limitations to the reviews has been provided within the individual audit reports and through the Audit Committee Progress reports throughout the year. The table below provides a summary of the reviews and overall objectives contributing to this element of the Opinion.
Title Overall Objective Recommendations C H M L
HIGH ASSURANCE: Our work found some low impact control weaknesses which, if addressed would improve overall control. However, these weaknesses do not affect key controls and are unlikely to impair the achievement of the objectives of the system. Therefore we can conclude that the key controls have been adequately designed and are operating effectively to deliver the objectives of the system, function or process. None of the reviews received High Assurance. SIGNIFICANT ASSURANCE: There are some weaknesses in the design and/or operation of controls which could impair the achievement of the objectives of the system, function or process. However, either their impact would be minimal or they would be unlikely to occur.
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Title Overall Objective Recommendations C H M L
Patient Access: Out To assess the arrangements around the development, monitoring and oversight of delivery 0 0 2 0 of Hours and 7 Day of the pilot scheme that ensures patient access is being improved through addressing the Working variability in core hours provision and extending provision towards out of hours, 7 day service; and confirm the CCG has promoted an increasing awareness of out of hours GP services to the population of Salford. Key Finance To provide assurance with respect to the design and operation of the key controls within 0 0 2 1 Systems the finance systems covering General Ledger, Non-Pay Expenditure and Budgetary Control. Use of Research in To evaluate the CCG’s systems and controls for use of research funds in commissioning, 0 0 1 1 Commissioning determining whether these promote the best practice in driving forward outcomes Cyber Security - To provide assurance on the controls established by management to prevent, or minimise 0 0 2 1 Organisational the impact of, cyber related attacks and identify opportunities for improvement, where Controls appropriate. Information To assess the organisation’s structures for delivering IG, the validity of scores recorded 0 0 0 0 Governance Toolkit within the IG Toolkit and any resultant risk exposures. LIMITED ASSURANCE: There are weaknesses in the design and / or operation of controls which could have a significant impact on the achievement of the key system, function or process objectives but should not have a significant impact on the achievement of organisational objectives. Both of these reports are at draft stage. The reports have been agreed in principle and are awaiting management responses on the recommendations raised. Estates and To assess the effectiveness of the arrangements the CCG has in place with NHS Property 0 2 1 0 Property Services Services Limited, the CHP (Community Health Partnership), and other landlords for the provision and maintenance of healthcare premises and offices for now and into the future including accounting for relevant recharges. NO ASSURANCE: There are weaknesses in the design and/or operation of controls which [in aggregate] have a significant impact on the achievement of key system, function or process objectives and may put at risk the achievement of organisational objectives.
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Title Overall Objective Recommendations C H M L
None of the reviews received No Assurance.
ADVISORY SUPPORT AND GUIDANCE: Areas where MIAA have supported the organisation in strengthening arrangements in respect of governance, risk management and internal control. QIPP: MIAA has been involved in a review of QIPP/ICIP programmes for 2018/19, applying constructive challenge to determine the risk adjusted QIPP position i.e. practical achievability, value and delivery profile/milestones. This is currently at draft stage. CONTRIBUTION TO GOVERNANCE, RISK MANAGEMENT AND INTERNAL CONTROL ENHANCEMENTS: Additional areas where MIAA has provided added value contributions. MIAA Briefing Notes: To provide a range of briefing notes and benchmarking reports on topical issues to support organisations in keeping up to date on key issues and challenge questions. Briefing notes issued in 2017/18 included Learning from Deaths, Vanguards and Chargeable Patients (Overseas Visitors). MIAA Benchmarking Insights: To provide a range of benchmarking reports on topical issues to provide organisations with an opportunity to consider best practice and compare themselves with others. Benchmarking reports in 2017/18 included ‘What keeps CCG Governing Bodies Awake at Night’, Managing Conflicts of Interest and Fraud Investigations. MIAA Events: Our events and conference programmes attract leading speakers from the NHS, government, policy and voluntary sector, giving delegates access to the latest policy thinking, best practice and innovation across the UK, whilst also providing an ideal networking opportunity. Events in 2017/18 included Thinking Differently about Patient Safety and Shaping Health & Social Care. Detailed insight into the overall Governance and Assurance processes gained from liaison throughout the year with the Deputy Chief Finance Officer, regular review of Governing Body papers and ongoing advice to develop the Assurance Framework. Ongoing discussion with lead officers, managers and lay members throughout the year. Specific audit review of third party assurances to the Clinical Commissioning Group (e.g. GMSS). Effective utilisation of internal audit including in year communication and changes to the audit plan in respect of conflicts of interest.
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Follow up
An important aspect of the internal audit process is the follow up to ensure that opportunities for enhancement are delivered. During the course of the year we have undertaken follow up reviews and can conclude that the organisation has made good progress with regards to the implementation of recommendations. We will continue to track and follow up outstanding actions. Other key areas for consideration in the completion of your Annual Governance Statement
In addition to the Director of Audit Opinion, we have identified a number of other strategic challenges that should be considered by the Governing Body when drafting the AGS. Whilst the scope of the Internal Audit Plan would have considered elements of these, it is important that the Clinical Commissioning Group reflects more widely on how these should be factored into the AGS. Areas for consideration include:
Outcomes from external governance reviews, and assessment and feedback from the NHS England Improvement and Assessment Framework processes in year.
Organisation performance, including unprecedented challenges in achieving financial duties, ongoing financial viability, delivery of QIPP, service pressures and key relationships with and performance of Providers.
Continued establishment and delivery of cross-organisation arrangements for pooled budget developments.
Wider partnership working across the local health economy, including the management and monitoring of the Salford Locality Plan, integrated commissioning developments, Greater Manchester devolution and transformation programmes and also to consider any key risks from partner organisations as integration continues to progress.
Relationship and management of 3rd party providers upon which the Clinical Commissioning Group places reliance, and the provision of assurances from these (including Greater Manchester Shared Services).
Communication and engagement with the membership, key stakeholders and other partners.
Information governance arrangements, risks and any associated incidents relating to Patient Identifiable Data.
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4. MIAA Quality Service Indicators
MIAA Service Delivery It is important that client organisations ensure an effective Internal Audit Service, and whilst input and process measures offer some assurance, the focus should be on outcomes and impact from the service. The figure below confirms the measures that we believe demonstrate an effective service to you.
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MIAA regularly report on input and process KPIs as part of our Audit Committee Progress reports, and the impact and effectiveness measures can be assessed through the HOIA Opinion.
Client feedback is a key part of assessing effectiveness and ensuring continuous improvement. We seek and receive this in a number of ways across our client base, including regular contact and relationships with you, formal questionnaires after each assignment, periodic client surveys and regular post event feedback. A snapshot of this feedback is provided below.
MIAA Compliance with Internal Audit Standards MIAA comply fully with professional best practice, internal audit standards and legal requirements. This includes guidelines issued by the Auditing Practice Governing Body, professional bodies, NHS Improvement’s Audit Code and the Institute of Internal Auditors. The Public Sector Internal Audit Standards (wef. 2013) and our operational Internal Audit Manual are central to our continued external quality accreditation (BS EN ISO 9001:2000).
The outcome of MIAA’s External Quality Assessment (EQA), undertaken by CIPFA, which evaluated the organisation’s compliance with Public Sector Internal Audit Standards, confirmed that MIAA conforms to the standards. An EQA is required every 5 years and is of huge significance, as it provides assurance both internally and externally of MIAA’s compliance with these Standards across all of the functions that are provided as part of the internal audit plan and via advisory services.
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MIAA Quality Assurance MIAA continue to ensure that quality remains central to our core objective of providing our clients with the best service. To achieve this we have in place a number of internal and external quality processes. These include:
Investors in People BS EN ISO 9001/2000 underpinned by comprehensive internal quality assurance processes Professional Body Accreditations (including ACCA Gold and CIPFA Platinum Accreditations) Continued adoption of the EFQM Business Excellence Model
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NHS SALFORD CLINICAL COMMISSIONING GROUP GOVERNING BODY MEETING AGENDA ITEM NO 7 (a)
Item for: Decision/Assurance/Information
23 May 2018
REPORT OF: Chief Accountable Officer
DATE OF PAPER: 15 May 2018
SUBJECT: Refresh of CCG Constitution
Jenny Noble, Head of Governance and Policy IN CASE OF QUERY Tel 0161 212 4950 PLEASE CONTACT: Please tick which strategic priorities the paper relates to: STRATEGIC PRIORITIES:
Quality
Community Based Care
Integrated Care
In Hospital Care
Long Term Conditions and Mental Health Effective Organisation
PURPOSE OF PAPER:
To provide an update on the proposed changes to the CCG’s Constitution agreed by Governing Body in January 2018, including further changes agreed by the Chief Accountable Officer, Chair and Medical Director prior to submission to NHS England.
To propose changes to the CCG’s Scheme of Reservation and Delegation (SoRD) to ensure that current and planned business plan objectives can be delivered within a governance framework that is fit for purpose.
There are no proposed changes outlined in this report that relate to the establishment of a single Strategic Commissioning Function (SCF). Any constitutional changes arising from the establishment of an SCF will be considered in a future revision of the Constitution, as necessary.
Further explanatory information required
HOW WILL THIS BENEFIT THE The CCG’s Constitution is the foundation upon HEALTH AND WELL BEING OF which clear, open and transparent decision SALFORD RESIDENTS OR THE making is discharged for the benefit of Salford CLINICAL COMMISSIONING GROUP? residents.
WHAT RISKS MAY ARISE AS A N/A RESULT OF THIS PAPER? HOW CAN THEY BE MITIGATED?
WHAT EQUALITY-RELATED RISKS N/A MAY ARISE AS A RESULT OF THIS PAPER? HOW WILL THESE BE MITIGATED?
DOES THIS PAPER HELP ADDRESS N/A ANY EXISTING HIGH OR EXTREME RISKS FACING THE ORGANISATION? IF SO WHAT ARE THEY AND HOW DOES THIS PAPER REDUCE THEM?
PLEASE DESCRIBE ANY POSSIBLE Recommendations contained in this report refer CONFLICTS OF INTEREST to proposed changes to the CCG’s Scheme of ASSOCIATED WITH THIS PAPER. Reservation and Delegation (SoRD). Members of the Governing Body will be impacted by these changes.
PLEASE IDENTIFY ANY CURRENT All areas of CCG business are affected by SERVICES OR ROLES THAT MAY BE changes to the CCG’s Constitution. AFFECTED BY ISSUES WITHIN THIS PAPER:
Footnote:
Members of NHS Salford Clinical Commissioning Group Governing Body will read all papers thoroughly. Once papers are distributed no amendments are possible.
Document Development
Not Comments and Date Process Yes No Outcome Applicable (i.e. presentation, verbal, actual report) Public Engagement (Please detail the method ie survey, event, consultation) Clinical Engagement (Please detail the method ie survey, event, consultation) Has ‘due regard’ been given to Equality Analysis (EA) of any adverse impacts? (Please detail outcomes, including risks and how these will be managed) Legal Advice Sought Presented to the Commissioning Committee Presented to the Health and Wellbeing Board Presented to the Integrated Commissioning Board Presented to any other groups or committees, Amendment to the CCG’s Scheme of Recommended for Reservation and Delegation (SoRD) including Partnership Groups approval by the CCG was presented to the Audit Governing Body (Please specify in comments) Committee on 22 February 2018.
Note: Please ensure that it is clear in the comments and date column how and when particular stakeholders were involved in this work and ensure there is clarity in the outcome column showing what the key message or decision was from that group and whether amendments were requested about a particular part of the work
Refresh of CCG Constitution
1. Background and Introduction
1.1 The Constitution provides the legal and governance framework within which the CCG is authorised to operate.
1.2 At the meeting on 31st January 2018, the Governing Body approved the proposed changes to the CCG’s Constitution and delegated authority to the Chief Accountable Officer, Chair and Medical Director to approve the detail of minor further changes requested within the meeting.
1.3 The changes since the Governing Body meeting are:
In main body of Constitution:
To the membership section, reworded borough wide services, namely to now read “Salford Care Homes Practice (managed by SRFT)” rather than the other way round. And removed reference to SSP Health in borough wide service, we can review again should this provider end up holding any additional contracts.
Amended throughout any reference of chairman to chair.
Added “help resolve” before this bullet in the explanation of the Deputy Chair/Senior Lay member’s role to give clarity: • help resolve Governing Body (including Chair) performance issues;
Amended from CCG to Governing Body in following bullet: • lead a meeting of the Lay Members at least annually without the Chair to evaluate the Chair’s performance, as part of the process agreed with members of the Governing Body for appraising the Chair;
In the Member Engagement section, made the following amendment: 8.4.1 NHS Salford CCG recognises that its strength comes from being a membership organisation. As such active engagement of all its member practices is vital. This would ordinarily be through a General Practitioner from member practices.
In Standing Orders section
Selection process for Deputy Chair/Senior Lay Member changes:
2.2.3 The Deputy Chair/Senior Lay Member, as listed in paragraph 7.5 of the group’s constitution, is subject to the following appointment process:
a) Nominations – any eligible member of the Governing Body may nominate themselves
b) Eligibility – the Deputy Chair/Senior Lay Member shall be an existing lay member of the Governing Body
c) Appointment process – All applicants are required to submit an expression of interest, following which there will be an interview with the panel comprising the Chair, an Audit Committee Member and a person who is independent and external to the CCG. Vote of the Governing Body Members
Amended minor typo at 2.2.8 which is about the appointment of Lay Members: a) Appointment process – when the role becomes vacant a job description and person specification will be advertised widely followed by short-listing and interview (other testing may be applied as agreed by the Chair and Chief Accountable Officer). The interview panel shall include at least the Chair of the Governing Body, a Neighbourhood Clinical Lead/Neighbourhood Lead, one of the Governing Body Lay members and a nominee of the NHS England with the appropriate expertise.
1.4 Following final approval by the Chief Accountable Officer, Chair and Medical Director the application was submitted to NHS England on 23 February 2018 and approved on 9 May 2018.
1.5 In addition two minor changes as required by NHS England have been made as follows: paragraph 7.5.4 has been changed to reflect that the role of senior lay member can only be filled by the lay members on the Governing Body and amendments to the membership of the CCG, namely removing the duplication of the Care Homes Practice in our Broughton neighbourhood (rather than only within the borough wide services section) and the removal of Salford Health Matters.
1.6 NHS Salford CCG’s Constitution is available on our website: www.salfordccg.nhs.uk/salford-ccg-constitution
2. Summary of Proposed Changes to the SoRD
2.1 The Scheme of Reservation and Delegation (SoRD) is an integral part of the Constitution, and as such, forms part of the legal and governance framework within which the CCG is authorised to operate.
2.2 The proposed changes to the SoRD outlined in more detail with tracked changes in the attached tables A and B have been recommended for approval by the Audit Committee and subject to the approval of the CCG membership, as recommended to the CCG membership by the CCG’s Governing Body, will be sent to NHSE.
2.3 The proposed changes to the SoRD seek to clarify and update:
• which decisions ought properly to be reserved to the membership or to the Governing Body – usually high level strategic or key policy decisions that will impact upon all, or a substantial part of the CCG’s members and/or services; and, • which decisions can be properly delegated to sub-committees of the Governing Body or to a named or group of named officials – usually the Chief Accountable Officer and/or the Chief Financial Officer
3. Recommendations
3.1 The NHS Salford CCG Governing Body is recommended to:
(i) Note the update provided; (ii) Recommend, to the CCG membership, the proposed changes to the CCG’s Scheme of Reservation and Delegation outlined in this report; (iii) Subject to the Governing Body’s agreement to above, the Neighbourhood Leads on the CCG’s Governing Body, acting as the CCG’s membership, are asked to approve the proposed changes outlined in this report; (iv) Subject to agreement to the two recommendations above, note that an application for these CCG Constitution changes to be made will be sent to NHS England for approval; (v) Give delegated authority to the Chief Accountable Officer to agree any minor changes required by NHS England, and note that any such changes will be reported to the Governing Body at the next meeting.
TABLE A
Matter Delegated To Matter Responsible for Reserved to Ref Reserved to Recommending Operational the Governing Individual Reserved or Delegated Matter the a course of Responsibility No Governing Body or Member or Membership action Body Committee Officer 1. REGULATION AND CONTROL
1.1 Determine the arrangements by which the members of the group Chief Membership approve those decisions that are reserved for the membership N/A N/A Chair N/A Accountable
where they have not been delegated Officer
1.2 Consideration and approval of applications to the NHS on matters Governing Chief Execs concerning changes to the group’s constitution, including Membership N/A Body N/A Accountable Governing Body proposed changes to the appendices to its constitution N/A Officer 1.3 Exercise or delegation of those functions of the clinical commissioning group which have not been retained as reserved Chief Chief by the group or delegated to the governing body or to a N/A N/A N/A Accountable N/A Accountable committee or sub-committee of the group or to one of its members Officer Officer or employees 1.4 Approval of the group’s overarching scheme of reservation and delegation, which sets out those decisions that are in statute the responsibility of the group and that are reserved to the membership and those delegated to the Governing Audit Chief • Membership N/A Body N/A Committee Accountable group’s governing body N/A Governing Body Officer • committees, sub-committees, or advisory panels of the group or • its members or employees 1.5 Prepare the scheme of reservation and delegation, which sets out those decisions that are in statue the responsibility of the governing body are reserved to the governing body and Chief Finance Officer Chief those delegated to the Governing Execs N/A N/A Chief Accountable • Body N/A governing body’s committees and sub-committees, Accountable Officer • members of the governing body, Officer • an individual who is member of the group but not the governing body or a specified person
1.6 Promulgate the governance arrangements of the group to Chief Chief
members, employees of the group and to people working on N/A N/A N/A Accountable Accountable N/A behalf of the group Officer Officer TABLE A
Matter Delegated To Matter Responsible for Reserved to Ref Reserved to Recommending Operational the Governing Individual Reserved or Delegated Matter the a course of Responsibility No Governing Body or Member or Membership action Body Committee Officer 1.7 Final authority on interpretation of the group’s constitution and Accountable supporting appendices (i.e. standing orders, prime financial N/A N/A N/A Chair N/A Officer policies and scheme of reservation and delegation) 1.8 Disclosure of non-compliance with the group’s constitution Accountable (incorporating its standing orders, prime financial policies and N/A N/A N/A All Staff N/A Officer scheme of reservation and delegation) Chief Chief Finance 1.9 Suspension of standing orders Chief Finance N/A Governing Accountable Officer N/A Officer Membership Body Officer N/A N/A N/A Director of 1.10 Review of suspension of standing orders Deputy Chief Audit Corporate N/A N/A N/A Finance Officer Committee Services N/A N/A Audit Chief Finance 1.11 Approval of the group’s operational scheme of delegation that Governing Committee Officer Chief Finance underpins the group’s ‘overarching scheme of reservation and N/A Body N/A Governing Audit Officer delegation’ as set out in the constitution (Table B) N/A Body Committee 1.12 Approve the group’s prime financial policies – Appendix D of the Governing Chief Finance Chief Finance N/A N/A N/A Constitution Body Officer Officer Chief 1.13 Approve detailed financial procedures Deputy Chief Accountable Chief Finance Officer N/A N/A N/A Officer Finance Officer Chief Finance Executive Officer Officer Director of 1.14 Approve arrangements for managing exceptional funding requests Commissioning Governing Medical Director Commissioning Committee N/A Body N/A Commissioning Chief Governing N/A Committee Accountable Body Officer 1.15 Set out who can execute a document by signature / use of the Governing N/A Chief Chief Chief seal N/A Body Governing Accountable Accountable Accountable N/A Body Officer Officer Officer TABLE A
Matter Delegated To Matter Responsible for Reserved to Ref Reserved to Recommending Operational the Governing Individual Reserved or Delegated Matter the a course of Responsibility No Governing Body or Member or Membership action Body Committee Officer N/A
2 PRACTICE MEMBER REPRESENTATIVES AND MEMBERS OF THE GOVERNING BODY 2.1 Approve the arrangements for Chair Chair, Chief Chief • identifying practice members to represent practices in matters Governing Membership Accountable Accountable concerning the work of the group N/A Body N/A Officer and Officer • N/A appointing clinical leaders to represent the group’s Chief Finance Chair membership on the group’s governing body Officer 2.2 Approve the appointment of governing body members, the Chief process for recruiting and removing non-elected members to the Accountable governing body (subject to any regulatory requirements) and Chief Officer Chief Accountable Chair, Chief Accountable succession planning Membership N/A N/A Officer Accountable Officer N/A Officer and Chair Chief Finance Officer 2.3 Approve arrangements for recruiting the group’s chief accountable Chair officer Chair, Chief Accountable Chair Membership N/A N/A Officer and Chair N/A Chief Finance Officer
3 STRATEGY AND PLANNING 3.1 Approve the vision, values and overall strategic direction of the Relevant Prime Committees group Governing N/A Chief Neighbourhood N/A Body Governing N/A Accountable groups and N/A Body Officer commissioning strategy groups Chief Chief 3.2 Approve the group’s operating structure Governing Execs N/A N/A Accountable Accountable Body N/A Officer Officer TABLE A
Matter Delegated To Matter Responsible for Reserved to Ref Reserved to Recommending Operational the Governing Individual Reserved or Delegated Matter the a course of Responsibility No Governing Body or Member or Membership action Body Committee Officer 3.3 Approve the group’s commissioning plan Relevant Prime Committees Commissioning Chief Governing N/A Committee Accountable N/A Body Governing N/A (taking into Officer N/A Body account the Chair views of the commissioning strategy groups) 3.4 Approve the group’s arrangements for engaging the public and Director of key stakeholders in the group’s planning and commissioning Governing N/A Execs Commissioning arrangements N/A Body Governing N/A Commissioning Chief N/A Body Committee Accountable Officer 3.5 Approve the group’s corporate budgets that meet the financial Governing Execs Chief Finance Chief Finance N/A N/A duties of the group Body N/A Officer Officer 3.6 Approve variations to the approved budget where variation would have a significant impact on the overall approved levels of income Governing Chief Finance Chief Finance N/A N/A N/A and expenditure or the group’s ability to achieve its agreed Body Officer Officer strategic aims 4 ANNUAL REPORTS AND ACCOUNTS 4.1 Approval of the group’s annual report and annual accounts Accountable Governing Audit Officer & Chief N/A N/A N/A Body Committee Finance Officer Respectively 4.2 Approval of the arrangements for discharging the group’s Chief Finance Officer statutory financial duties Governing Chief Finance N/A N/A N/A Chief Body Officer Accountable Officer 5 HUMAN RESOURCES & ORGANISATIONAL DEVELOPMENT
5.1 Approve the terms and conditions, remuneration and travelling or Remuneration N/A Chair, Membership N/A N/A other allowances for governing body members, including pensions Committee Chair, Chief Accountable TABLE A
Matter Delegated To Matter Responsible for Reserved to Ref Reserved to Recommending Operational the Governing Individual Reserved or Delegated Matter the a course of Responsibility No Governing Body or Member or Membership action Body Committee Officer and gratuities N/A Accountable Officer and Officer and Chief Financial Chief Finance Officer [subject Officer (subject to independent to independent advice if advice if required] required) Chief Accountable Officer (excluding own post – for own post the Chair) 5.2 Approve terms and conditions of employment for non-AFC Chair, employees of the group including, pensions, remuneration, fees Accountable and travelling or other allowances payable to employees and to Officer and other persons providing services to the group Chief Financial Remuneration N/A Officer [subject Governing N/A Committee N/A Remuneration to independent Body N/A Committee advice if required] Chief Accountable Officer Director of 5.3 Approve any other terms and conditions of services for the Director of Corporate group’s AFC employees Governing Execs Corporate Services N/A Body Governing N/A Services Chief N/A Body Remuneration Accountable Committee Officer 5.4 Approve disciplinary arrangements for employees, including the Director of accountable officer (where he/she is an employee or member of Director of Corporate Governing Execs Corporate Services the clinical commissioning group) and for other persons working N/A N/A on behalf of the group Body N/A Services Chief Executive Team Accountable Officer
5.5 Approve disciplinary arrangements where the group has joint N/A Governing Execs N/A Director of Director of TABLE A
Matter Delegated To Matter Responsible for Reserved to Ref Reserved to Recommending Operational the Governing Individual Reserved or Delegated Matter the a course of Responsibility No Governing Body or Member or Membership action Body Committee Officer appointments with another group and the individuals are Body N/A Corporate Corporate employees of that group. Services Services Remuneration Chief Committee Accountable Officer Director of 5.6 Approval of the arrangements for discharging the group’s Director of Corporate statutory duties as an employer Corporate Governing Execs Services N/A N/A Services Body N/A Chief Remuneration Accountable Committee Officer 5.7 Approve human resources policies for employees and for other Director of Director of Corporate persons working on behalf of the group Governing Execs Corporate Services N/A Body N/A N/A Services Chief N/A Executive Team Accountable Officer 5.8 Approve the group’s succession planning for elected members Chair and other governing body nominations and members Chair, Chief Chair Chair Accountable Chief Membership N/A N/A N/A Officer and Accountable Chief Finance Officer Officer 5.12 Approve the group’s organisational development plans Director of Corporate Governing N/A Execs Services N/A Body Governing N/A Remuneration Chief N/A Body Committee Accountable Officer 6 QUALITY AND SAFETY 6.1 Approve arrangements, including supporting policies, to minimise Relevant Prime Medical clinical risk, maximise patient safety and to secure continuous Governing N/A Committee Director / improvement in quality and patient outcomes N/A Body Governing N/A Clinical Director of N/A Body Commissioning Quality and and Quality Innovation TABLE A
Matter Delegated To Matter Responsible for Reserved to Ref Reserved to Recommending Operational the Governing Individual Reserved or Delegated Matter the a course of Responsibility No Governing Body or Member or Membership action Body Committee Officer Outcomes Chair Group Director of 6.2 Approve the group’s arrangements for handling complaints Director of Corporate Corporate Governing Execs Services Services N/A Body Governing N/A Clinical Chief N/A Body Commissioning Accountable and Quality Officer Outcomes Clinical 6.3 Approve the group’s arrangements for safeguarding children and Governing Execs Commissioning vulnerable adults N/A Body Governing N/A Chair and Quality N/A Body Outcomes 6.4 Approve the group’s arrangements for engaging patients and their Director of Director of Relevant Prime Commissioning Commissioning carers in decisions concerning their healthcare Governing Committee Clinical / Assistant Dir N/A Body N/A Governing Commissioning Integrated N/A Body and Quality Commissioning Outcomes Chair 6.5 Approve arrangements for supporting the NHS in discharging its Director of Quality & responsibilities in relation to securing continuous improvement in Primary Care Director of Innovation the quality of general medical services Governing Commissioning Quality and N/A N/A Clinical Body Committee Innovation Commissioning N/A Chair and Quality Outcomes 7 OPERATIONAL AND RISK MANAGEMENT 7.1 Prepare and recommend an operational scheme of delegation Chief Finance Execs Officer Chief Finance that sets out who has responsibility for operational decisions N/A N/A N/A within the group N/A Audit Officer Committee Audit Chief Finance 7.2 Approve the group’s counter fraud and security management Governing Chief Finance N/A Committee N/A Officer arrangements Body Officer N/A Audit TABLE A
Matter Delegated To Matter Responsible for Reserved to Ref Reserved to Recommending Operational the Governing Individual Reserved or Delegated Matter the a course of Responsibility No Governing Body or Member or Membership action Body Committee Officer Committee
Chief 7.3 Approval of the group’s risk management arrangements Governing Chief Finance N/A N/A N/A Accountable Body Officer Officer 7.4 Approve arrangements for risk sharing and or risk pooling with Chief other organisations (for example arrangements for pooled funds Governing Chief Finance N/A N/A N/A Accountable Body Officer with other clinical commissioning groups or pooled budget Officer arrangements under section 75 of the NHS Act 2006) 7.5 Approve a comprehensive system of internal control, including Chief Governing Chief Finance budgetary control, that underpin the effective, efficient and N/A N/A N/A Accountable Body Officer economic operation of the group Officer Chief 7.6 Approve the thresholds above which quotations or formal tenders Governing Chief Finance N/A N/A N/A Accountable must be obtained Body Officer Officer Chief 7.7 Approve the arrangements for seeking professional advice Governing Execs Chief Finance N/A N/A Accountable regarding the supply of goods and services Body N/A Officer Officer 7.8 Approve proposals for action on litigation against or on behalf of Governing Execs Chief Chief the clinical commissioning group N/A Body Governing N/A Accountable Accountable N/A Body Officer Officer Chief Chief 7.9 Approve the group’s arrangements for business continuity and Governing Execs N/A N/A Accountable Accountable emergency planning Body N/A Officer Officer Governing N/A Chief Finance 7.10 Approve the group’s banking arrangements Chief Finance Chief Finance N/A Body Governing Officer Officer Officer N/A Body N/A 8 INFORMATION GOVERNANCE
IM&T Board (IG) 8.1 Approve the arrangements for ensuring appropriate and Governing Execs Senior Chief safekeeping and confidentiality of records and for the storage, N/A Body Governing N/A Information Accountable management and transfer of information and data N/A Body Risk Owner Officer TABLE A
Matter Delegated To Matter Responsible for Reserved to Ref Reserved to Recommending Operational the Governing Individual Reserved or Delegated Matter the a course of Responsibility No Governing Body or Member or Membership action Body Committee Officer IM&T Board (IG) 8.2 Approve information sharing protocols with other organisations Governing Execs Senior Chief N/A Body Governing N/A Information Accountable N/A Body Risk Owner Officer 9 PARTNERSHIP, JOINT OR COLLABORATIVE WORKING (see also paragraph 7.3 above and paragraph 11.3 below of this Scheme of Reservation and Delegation) 9.1 Approve the arrangements governing joint or collaborative Relevant Prime arrangements between the group and another statutory body(ies), Committee Chief Chief where those arrangements incorporate decision making Governing N/A N/A N/A Accountable Accountable responsibilities Body Officer/Commis Officer sioning Committee 9.2 Approve the delegated decision making responsibilities of Relevant Prime individual members or employees of the group who represent the Committee Chief Chief group in joint or collaborative arrangements with another statutory Governing N/A N/A N/A Accountable Accountable body(ies) Body Officer/Commis Officer sioning Committee
9.3 Receive the minutes of meetings of, or reports from, joint or Chief Governing collaborative arrangements between the group and another N/A N/A N/A N/A Accountable Body statutory body(ies) Officer 9.4 Approve decisions delegated to joint committees established Relevant Prime under section 75 of the 2006 Act Committee Chief Chief Governing N/A N/A N/A Accountable Accountable Body Officer/Commis Officer sioning Committee 9.5 Authorise an individual to act on behalf of the group in discharging the group’s duty in respect of statutory and local joint working Governing N/A Chief Chief N/A Body Governing N/A Accountable Accountable arrangements, within the financial limits determined under N/A Body Officer Officer sections 10 and 12 of this scheme of reservation and delegation. TABLE A
Matter Delegated To Matter Responsible for Reserved to Ref Reserved to Recommending Operational the Governing Individual Reserved or Delegated Matter the a course of Responsibility No Governing Body or Member or Membership action Body Committee Officer For example: • Safeguarding (children’s and adult) • Health and Wellbeing Board 10 TENDERING
Governing N/A Chief 10.1 Approve the group’s tendering arrangements for any Chief Finance N/A Body Governing N/A Accountable commissioning or corporate support in excess of £1,000,000 Officer N/A Body Officer Relevant Prime 10.2 Approve the group’s tendering arrangements for any Governing N/A Committee Chief Finance commissioning support below a value of £1,000,000. N/A Body Governing N/A Commissioning Officer N/A Body Committee Governing Execs Chief Finance 10.3 Approve the group’s tendering arrangements for any corporate Chief Finance N/A Body Governing N/A Officer support below a value of £1,000,000. Officer N/A Body Executive Team 11 COMMISSIONING AND CONTRACTING FOR CLINICAL SERVICES 11.1 Approve the arrangements for discharging the group’s statutory Relevant Prime duties associated with its commissioning functions Governing N/A Committee Chief N/A Body Governing N/A Chief Accountable N/A Body Accountable Officer Officer Relevant Prime 11.2 Approve arrangements (including where appropriate, an Governing N/A Chief Committee individual’s authority to act) for co-ordinating the commissioning of N/A Body Governing N/A Accountable Commissioning services with other clinical commissioning groups N/A Body Officer Committee 11.3 Approve arrangements (including where appropriate, an Relevant Prime individual’s authority to act) for co-ordinating the commissioning of Governing N/A Committee Chief services with the local authority(s) N/A Body Governing N/A Commissioning Accountable N/A Body Committee Officer
N/A Chief Finance 11.4 Approval of contracts for clinical services (Refer to Table C Chief Finance N/A N/A Governing N/A Officer Financial Delegated Limits for Approval and Authorisation) Officer Body Chief TABLE A
Matter Delegated To Matter Responsible for Reserved to Ref Reserved to Recommending Operational the Governing Individual Reserved or Delegated Matter the a course of Responsibility No Governing Body or Member or Membership action Body Committee Officer Accountable Officer 12 COMMISSIONING AND CONTRACTING FOR NON-CLINICAL SERVICES 12.1 Approve arrangements for co-ordinating the commissioning of Director of Director of Corporate Corporate non-clinical services with other groups Execs Services Services N/A N/A Governing N/A Chief Chief Body Accountable Accountable Officer Officer 12.2 Approve arrangements for co-ordinating the commissioning of Director of Director of Corporate Corporate non-clinical services with local authority(ies) Execs Services Services N/A N/A Governing N/A Chief Chief Body Accountable Accountable Officer Officer 12.3 Approval of contracts for non-clinical services (Refer to Table C Director of Director of Corporate Corporate Financial Delegated Limits for Approval and Authorisation) Execs Services Services N/A N/A Governing N/A Chief Chief Body Accountable Accountable Officer Officer 13 COMMUNICATIONS 13.1 Approve arrangements for handling Freedom of Information Director of Corporate requests Governing Execs Chief Services N/A Body Governing N/A Accountable Chief N/A Body Officer Accountable Officer
TABLE B
DELEGATED MATTER DELEGATED TO OPERATIONAL RESPONSIBILITY 1. Audit Arrangements a) Advise the Governing Body on Internal Audit Committee Chief Finance Officer and External Audit Services
b) Monitor and review the effectiveness Audit Committee Chief Finance Officer of the internal audit function
c) Review, appraise and report in accordance NHS internal audit standards Audit Committee Head of Internal Audit and/or public sector internal audit standards
d) Provide an independent and objective Audit Committee Internal Audit / External Audit view on internal control and probity
e) Ensure cost-effective audit service Audit Committee Chief Finance Officer
f) Implement recommendations Accountable Officer Relevant Officers
2. Bank Accounts/Cash (Excluding Charitable Fund (Funds Held on Trust) Accounts) a) Operation:
Managing banking arrangements and Finance Manager, Greater operation of bank accounts (Governing Chief Finance Officer Manchester Shared Service Body approves arrangements)
Opening bank accounts. Chief Finance Officer Chief Finance Officer
Authorisation of transfers between NHS Finance Manager, Greater Salford Clinical Commissioning Group Chief Finance Officer Manchester Shared Service bank accounts.
Approve and apply arrangements for the Finance Manager, Greater Chief Finance Officer electronic transfer of funds. Manchester Shared Service
Authorisation of: - OPG schedules Finance Manager, Greater - BACS schedules Chief Finance Officer Manchester Shared Service - Automated cheque schedules - Manual cheques
Refer to Table C Financial b) Petty Cash Chief Finance Officer Delegated Limits for approval and authorisation TABLE B
DELEGATED MATTER DELEGATED TO OPERATIONAL RESPONSIBILITY 3. Capital Investment – subject to Clinical Commissioning Group Delegated Limits a) Programme:
Ensure that there is adequate appraisal and approval process for determining capital expenditure priorities and the Accountable Officer Chief Finance Officer effect that each has on business plans / Service development Strategy
Preparation of Capital Investment Accountable Officer Chief Finance Officer Programme
Preparation of a business case Accountable Officer Members of Executive Team
Financial monitoring and reporting on all capital scheme expenditure including Chief Finance Officer Deputy Chief Finance Officer variations to contract
Refer to Table C Financial Authorisation of capital requisitions Accountable Officer Delegated Limits for approval and authorisation
Assessing the requirements for the operation of the construction industry Chief Finance Officer Chief Finance Officer taxation deduction scheme
Responsible for the management of capital schemes and for ensuring that Accountable Officer Chief Finance Officer they are delivered on time and within cost
Ensure that capital investment is not undertaken without availability of Accountable Officer Chief Finance Officer resources to finance all revenue consequences
Issue procedures to support: - capital investment Accountable Officer Chief Finance Officer - Staged payments
Issue procedures governing financial management, including variation to Chief Finance Officer Chief Finance Officer contract, of capital investment projects and valuation for accounting purposes
Issuing the capital scheme project manager with specific authority to commit Accountable Officer Chief Finance Officer capital, proceed / accept tenders in accordance with the standing orders and TABLE B
DELEGATED MATTER DELEGATED TO OPERATIONAL RESPONSIBILITY standing financial instructions
b) Private Finance: Demonstrate that the use of private finance represents best value for money and transfers risk to the private sector. Accountable Officer Chief Finance Officer Proposal to use Private Finance Initiative must be specifically agreed by the Governing Body
c) Leases (property and equipment) • Granting and termination of leases with Annual rent < £50k Accountable Officer Chief Finance Officer • Granting and termination of leases of Governing Body > £50k should be reported to the Governing Body
4. Clinical Audit Medical Director Director of Quality & Innovation 5. Commercial Sponsorship Approval and registration in line with Greater Manchester Agreement to proposal Accountable Officer Standards of Business Conduct and relevant policy (to be developed) 6. Commissioning and Service Agreements a) Commissioning of Acute and Community Services from both NHS and non NHS providers, having regard for Chief Finance Officer/ Accountable Officer quality, cost effectiveness, and Clinical Chair/Accountable Officer Commissioning Group strategic commissioning plans
b) Commissioning of Mental Health, Learning Disability and Continuing / Intermediate care services from both Chief Finance Officer/ NHS and non NHS providers, having Accountable Officer Chair/Accountable Officer regard for quality, cost effectiveness, and Clinical Commissioning Group strategic commissioning plans
c) Commissioning of Primary Care services from both NHS and non NHS providers, having regard for quality, cost Chief Finance Officer/ Accountable Officer effectiveness, and NHS Salford Clinical Chair/Accountable Officer Commissioning Group strategic commissioning plans
All Directors / Head of d) Negotiation of all other contracts Accountable Officer Contracting
Refer to Table C Financial e) Signing of Contracts Accountable Officer Delegated Limits for approval TABLE B
DELEGATED MATTER DELEGATED TO OPERATIONAL RESPONSIBILITY and authorisation f) Quantifying and monitoring of Non Contracted Activity Chief Finance Officer Deputy Chief Finance Officer
g) Costing Service Level Agreement Contract and Non Commercial Contracts Chief Finance Officer Head of Contracting
h) Ad-hoc costing relating to changes in activity, developments, business cases Chief Finance Officer Deputy Chief Finance Officer and bids for funding
i) Sound system of financial monitoring to ensure effective accounting of expenditure under the Service Level Chief Finance Officer Deputy Chief Finance Officer Agreement. Including suitable audit trail but maintaining patient confidentiality
7. Complaints (Patients & Relatives) a) Overall responsibility for ensuring that all complaints are dealt with effectively Accountable Officer Director of Corporate Services
b) Responsibility for ensuring complaints are investigated thoroughly Accountable Officer Director of Corporate Services
c) Medico - Legal Complaints Coordination of their management Accountable Officer Director of Corporate Services
8. Confidential Information
Review of the NHS Salford Clinical Commissioning Group's compliance with Accountable Officer Senior Information Risk Owner the Caldicott report on protecting patients’ confidentiality in the NHS
Freedom of Information Act compliance Senior Information Risk Director of Corporate Services code Owner
9. Data Protection Act
Review of Clinical Commissioning Group compliance Accountable Officer Senior Information Risk Owner
Undertake duties and responsibilities of Senior Information Risk Senior Information Risk Owner Senior Information Risk Officer Owner
10. Declaration of Interest
Director of Corporate Services Maintaining a register of interests Accountable Officer Chief Finance Officer
Declaring relevant and material interest Governing Body All staff TABLE B
DELEGATED MATTER DELEGATED TO OPERATIONAL RESPONSIBILITY
11. Disposal and Condemnations • Items obsolete, redundant, Deputy Chief Finance Officer in irreparable or cannot be repaired accordance with agreed policy. cost effectively Chief Finance Officer Refer to Table C Financial • Develop arrangements for the sale of Delegated Limits for approval assets and authorisation
12. Environmental Regulations
Review of compliance with environmental regulations, for example those relating to Accountable Officer Chief Finance Officer clean air and waste disposal
13. Financial Planning / Budgetary Responsibility a) Setting:
Submit budgets to the Governing Body Chief Finance Officer Deputy Chief Finance Officer
Submit to Governing Body financial Chief Finance Officer Deputy Chief Finance Officer estimates and forecasts
Compile and submit to the Governing Body a business plan which takes into account financial targets and forecast limits of available resources.
The Business Plan will contain: • a statement of the significant Accountable Officer Chief Finance Officer assumptions on which the plan is based • details of major changes in workload, delivery of services or resources required to achieve the plan
b) Monitoring:
Devise and maintain systems of Chief Finance Officer Deputy Chief Finance Officer budgetary control.
Monitor performance against budget. Chief Finance Officer Deputy Chief Finance Officer
Delegate budgets to budget holders Accountable Officer Chief Finance Officer
Ensuring adequate training is delivered to budget holders to facilitate their Chief Finance Officer Deputy Chief Finance Officer management of the allocated budget
Accountable Officer Chief Finance Officer TABLE B
DELEGATED MATTER DELEGATED TO OPERATIONAL RESPONSIBILITY Submit in accordance with the NHS North requirements for financial monitoring returns
Identify and implement cost Accountable Officer Chief Finance Officer improvements
c) Preparation of:
Head of Financial Services, Annual Accounts Chief Finance Officer GMSS
Annual Report Accountable Officer Members of Executive Team
d) Budget Responsibilities Ensure that: • no overspend or reduction of income that cannot be met from virement is incurred without prior consent of the governing body • approved budget is not used for any other than specified purpose subject Chief Finance Officer All budget Holders to rules of virement • no permanent employees are appointed without the approval of the Chief Officer (Accountable Officer) other than those provided for within available resources and manpower establishment
e) Authorisation of Virement: It is not possible for any officer to vire from non-recurring headings to recurring Refer to Table C Financial budgets or from capital to revenue / Accountable Officer Delegated Limits for approval revenue to capital. Virement between and authorisation different budget holders requires the agreement of both parties
14. Financial Procedures and Systems a) Maintenance and Update on Clinical Commissioning Group Financial Chief Finance Officer Deputy Chief Finance Officer Procedures.
b) Responsibilities: • Implement CCG financial policies and co-ordinate corrective action • Ensure that adequate records are Chief Finance Officer Deputy Chief Finance Officer maintained to explain CCG transactions and financial position • Providing financial advice to members of the Governing Body and TABLE B
DELEGATED MATTER DELEGATED TO OPERATIONAL RESPONSIBILITY staff • Ensure that appropriate statutory records are maintained • Designing and maintaining compliance with all financial systems
15. Fire precautions Ensure that the Fire Precautions and prevention policies and procedures are adequate and that fire safety and integrity Accountable Officer Director of Corporate Services of the estate is intact
16. Fixed Assets a) Maintenance of asset register including asset identification and Accountable Officer Chief Finance Officer monitoring
b) Ensuring arrangements for financial control and financial audit of building and engineering contracts and property Chief Finance Officer Deputy Chief Finance Officer transactions comply with CONCODE and ESTATECODE
c) Calculate and pay capital charges in accordance with the requirements of the Chief Finance Officer Deputy Chief Finance Officer Department of Health
d) Responsibility for security of NHS Salford Clinical Commissioning Group’s assets including notifying discrepancies to the Chief Finance Officer and reporting Accountable Officer All staff losses in accordance with NHS Salford Clinical Commissioning Group’s procedures
17. Fraud (See also 26, 33) a) Monitor and ensure compliance with Chief Finance Officer Local Counter Fraud Specialist. Secretary of State Directions on fraud Audit Committee Chief Finance Officer and corruption
b) Appointment of the Local Counter Chief Finance Officer Local Counter Fraud Specialist. Fraud Specialist Audit Committee Chief Finance Officer
c) Notify NHS Protect and External Audit Chief Finance Officer Local Counter Fraud Specialist. of all suspected Frauds.
18. Funds Held on Trust (Charitable and Non Charitable Funds) Salford Clinical Commissioning Group does not plan to hold any funds on trust. The Constitution makes provision for the introduction of a Charitable Funds Committee if this situation changes. Chief Finance Officer Deputy Chief Finance Officer TABLE B
DELEGATED MATTER DELEGATED TO OPERATIONAL RESPONSIBILITY a) Management: Funds held on trust are managed appropriately.
b) Maintenance of authorised signatory Chief Finance Officer Deputy Chief Finance Officer list of nominated fund holders.
Refer to Table C Financial c) Expenditure Limits Chief Finance Officer Delegated Limits for approval and authorisation d) Developing systems for receiving Chief Finance Officer Deputy Chief Finance Officer donations
e) Dealing with legacies Chief Finance Officer Deputy Chief Finance Officer
f) Fundraising Appeals Chief Finance Officer Deputy Chief Finance Officer
g) Preparation and monitoring of budget Chief Finance Officer Deputy Chief Finance Officer
h) Reporting progress and performance Chief Finance Officer Deputy Chief Finance Officer against budget. i) Operation of Bank Accounts:
Managing banking arrangements and Head of Financial Services Chief Finance Officer operation of bank accounts GMSS
Head of Financial Services Opening bank accounts Chief Finance Officer GMSS j) Investments:
Nominating deposit taker Chief Finance Officer Chief Finance Officer
Head of Financial Services Placing transactions Chief Finance Officer GMSS
k) Regulation of funds with Charities Head of Financial Services Chief Finance Officer Commission GMSS
19. Health and Safety Review of all statutory compliance with legislation and Health and Safety requirements including control of Accountable Officer Director of Corporate Services Substances Hazardous to Health Regulations 20. Hospitality/Gifts Accountable Officer Director of Corporate Services TABLE B
DELEGATED MATTER DELEGATED TO OPERATIONAL RESPONSIBILITY a) Keeping of hospitality register
All staff declaration required in b) Applies to both individual and NHS Salford Clinical collective hospitality receipt items. See Accountable Officer Commissioning Group table C for limits Hospitality Register
21. Infectious Diseases and Notifiable Director of Quality and Accountable Officer Outbreaks Innovation 22. Information Management and Technology Finance and Information Systems • Developing systems in accordance with the Clinical Commissioning Group IM&T Strategy • Implementing new systems ensure they are developed in a controlled manner and thoroughly tested • Seeking third party assurances Head of Business Intelligence regarding financial systems operated Chief Finance Officer and IT and Deputy Chief externally Finance Officer • Ensure that contracts for computer services for financial applications define responsibility re security, privacy, accuracy, completeness and timeliness of data during processing and storage
Information Governance:
Ensure that risks to the Clinical Information Governance Lead Commissioning Group from use of IT are Chief Finance Officer for Salford, Greater Manchester identified and considered and that Shared Service disaster recovery plans are in place
Information Governance Lead Undertake duties and responsibilities of Chief Finance Officer for Salford, Greater Manchester Senior Information Risk Officer Shared Service
Ensure compliance with Information Information Governance Lead Governance requirements and annual Chief Finance Officer for Salford, Greater Manchester completion of Information Governance Shared Service toolkit
23. Legal Proceedings a) Engagement of Clinical Director of Corporate Services Commissioning Group Solicitors / Legal Accountable Officer Chief Finance Officer Advisors
b) Approve and sign all documents which Director of Corporate Services will be necessary in legal proceedings, Accountable Officer Chief Finance Officer i.e. executed as a deed
c) Sign on behalf of the Clinical Accountable Officer Director of Corporate Services TABLE B
DELEGATED MATTER DELEGATED TO OPERATIONAL RESPONSIBILITY Commissioning Group any agreement or Chief Finance Officer document not requested to be executed as a deed
24. Losses, Write-off & Compensation a) Prepare procedures for recording and accounting for losses and special payments including preparation of a Chief Finance Officer Deputy Chief Finance Officer Fraud Response Plan and informing NHS Protect of frauds
Losses • Losses of cash due to theft, fraud, overpayment & others. • Fruitless payments (including abandoned Capital Schemes). Refer to Table C Financial • Bad debts and claims abandoned. Delegated Limits for approval • Damage to buildings, fittings, and authorisation furniture and equipment and loss of equipment and property in stores and in use due to culpable causes (e.g. fraud, theft, arson).
Special Payments Compensation payments by Court Order Ex-gratia Payments: • To patients/staff for loss of personal effects Refer to Table C Financial • For clinical negligence after legal Chief Finance Officer Delegated Limits for approval advice and authorisation • For personal injury after legal advice • Other clinical negligence and personal injury • Other ex-gratia payments
b) Reviewing appropriate requirement for Chief Finance Officer Chief Finance Officer insurance claims
c) A register of all of the payments should be maintained by the Finance Head of Financial Services, Chief Finance Officer Department and made available for GMSS inspection
d) A report of all of the above payments should be presented to the Audit Chief Finance Officer Deputy Chief Finance Officer Committee
25. Controlled Drugs
Discharge to duties of the Accountable Officer Head of Medicines Optimisation Chief/Accountable Officer for Controlled TABLE B
DELEGATED MATTER DELEGATED TO OPERATIONAL RESPONSIBILITY Drugs
26. Safeguarding - Adults a) Discharge the duties of the Lead Accountable Officer Director of Quality & Innovation Director of Safeguarding Adults.
b) Ensure compliance with statutory Designated Nurse for requirements and policies and Accountable Officer Safeguarding Adults procedures for Safeguarding Adults.
27. Safeguarding - Children a) Discharge the duties of the Lead Accountable Officer Director of Quality & Innovation Director of Safeguarding Children
b) Review and develop the Strategy for Designated Nurse for Accountable Officer Safeguarding Children Safeguarding Children
c) Review and develop the policies and Designated Nurse for Accountable Officer procedures to Safeguarding Children Safeguarding Children
d) Ensure compliance with statutory Designated Nurse for requirements and policies and Accountable Officer Safeguarding Children procedures for Safeguarding Children
28. Non Pay Expenditure a) Maintenance of a list of managers authorised to place requisitions/orders Accountable Officer Chief Finance Officer and accept goods in accordance with Table C
b) Obtain the best value for money when Accountable Officer Chief Finance Officer requisitioning goods / services
c) Non-Pay Expenditure for which no specific budget has been set up and which is not subject to funding under Accountable Officer Chief Finance Officer delegated powers of virement. Subject to the limits specified above in (a)
d) Develop systems for the payment of Head of Financial Services, Chief Finance Officer accounts GMSS
Head of Financial
Services Management e) Prompt payment of accounts Chief Finance Officer Accounts, Greater Manchester
Shared Service Chief Finance Officer Refer to Table C Financial TABLE B
DELEGATED MATTER DELEGATED TO OPERATIONAL RESPONSIBILITY f) Financial Limits for ordering / Delegated Limits for approval requisitioning goods and services and authorisation
g) Approve prepayment arrangements Chief Finance Officer Deputy Chief Finance Officer
29. Personnel & Pay a) Nomination of officers to enter into contracts of employment regarding staff, Accountable Officer Chief Finance Officer agency staff or consultancy service contracts
b) Develop Human resource policies and strategies for approval by the governing Accountable Officer Director of Corporate Services body including training, industrial relations
c) Authority to fill funded post on the Accountable Officer Chief Finance Officer establishment with permanent staff
d) The granting of additional increments Accountable Officer Chief Finance Officer to staff within budget
e) All requests for re-grading shall be dealt with in accordance with Clinical Accountable Officer Chief Finance Officer Commissioning Group Procedure f) Establishments
Additional staff to the agreed establishment with specifically allocated Chief Finance Officer Deputy Chief Finance Officer finance
Additional staff to the agreed establishment without specifically Accountable Officer Chief Finance Officer allocated finance
Self financing changes to an Chief Finance Officer Deputy Chief Finance Officer establishment
g) Pay
Presentation of proposals to the NHS Salford Clinical Commissioning Group Accountable Officer /Chief Accountable Officer Governing Body for the setting of Finance Officer remuneration and conditions of service for those staff not covered by the TABLE B
DELEGATED MATTER DELEGATED TO OPERATIONAL RESPONSIBILITY Remuneration Committee.
Authority to complete standing data Accountable Officer / Chief forms effecting pay, new starters, Accountable Officer Finance Officer variations and leavers
Authority to complete and authorise Accountable Officer / Chief Chief Finance Officer positive reporting forms (SAR’s) Finance Officer
Accountable Officer / Chief Authority to authorise overtime Chief Finance Officer Finance Officer
Members of Executive Authority to authorise travel and Chief Finance Officer Team/Accountable Officer / subsistence expenses Chief Finance Officer
h) Leave
Annual leave. Accountable Officer Refer to Annual Leave Policy
Special Leave Accountable Officer Refer to Annual Leave Policy
Sick leave Accountable Officer Refer to Annual Leave Policy
Refer to Maternity, Adoption &
maternity Support (Paternity Maternity Leave Accountable Officer Leave) Policy & Procedure
Study Leave Accountable Officer Refer to Training Policy i) Removal Expenses, Excess Rent and House Purchases Chief Finance Officer Chief Finance Officer All staff above Band 5 (agreed at interview) Maximum £8,000
Authorisation of payment of removal Chief Finance Officer expenses incurred by officers taking up Refer to Table C Financial Chief Finance Officer new appointments (providing Delegated Limits for approval consideration was promised at interview) and authorisation
Refer to Grievance Policy and j) Grievance Procedure Accountable Officer Procedure
k) Authorised - Car Users Chief Finance Officer Chief Finance Officer • Leased car Chief Finance Officer Chief Finance Officer • Regular user allowance
Chief Finance Officer Budget holders TABLE B
DELEGATED MATTER DELEGATED TO OPERATIONAL RESPONSIBILITY l) Mobile Phone Users / Mobile Devices
m) Renewal of Fixed Term Contract Accountable Officer Chief Finance Officer
n) Staff Retirement Policy Authorisation of return to work in part Accountable Officer Chief Finance Officer time capacity under the flexible retirement scheme
o) Redundancy Accountable Officer Chief Finance Officer
p) Ill Health Retirement Decision to pursue retirement on the Accountable Officer Chief Finance Officer grounds of ill-health following advice from the Occupational Health Department
To be applied in accordance q) Disciplinary Procedure (excluding Accountable Officer with the CCG Disciplinary Executive Directors) Procedure
r) Ensure that all employees are issued with a Contract of employment in a form approved by the Governing Body and Accountable Officer Director of Corporate Services which complies with employment legislation s) Engagement of staff not on the establishment Refer to Table C Financial Management Consultants Chief Finance Officer Delegated Limits for approval and authorisation
Booking of agency staff • nursing Chief Finance Officer Members of the Executive Team • other
30. Quotation, Tendering & Contract Procedures a) Services
Best value for money is demonstrated for all services provided under contract or in- Accountable Officer Chief Finance Officer house
Nominate officers to oversee and manage the contract on behalf of the Accountable Officer Chief Finance Officer Clinical Commissioning Group b) Competitive Tenders TABLE B
DELEGATED MATTER DELEGATED TO OPERATIONAL RESPONSIBILITY
Refer to Table C Financial Authorisation Limits Accountable Officer Delegated Limits for approval
and authorisation
Maintain a register to show each set of Accountable Officer Chief Finance Officer competitive tender invitations despatched
Receipt and custody of tenders prior to Accountable Officer Chief Finance Officer opening
Two officers from the approved Opening Tenders Accountable Officer list as authorised by the Governing Body
Decide if late tenders should be Accountable Officer Chief Finance Officer considered
Ensure that appropriate checks are carried out as to the technical and Accountable Officer Chief Finance Officer financial capability of the firms invited to tender or quote
Refer to Table C Financial c) Quotations Accountable Officer Delegated Limits for approval and authorisation Refer to Table C Financial d) Waiving the requirement to request Accountable Officer Delegated Limits for approval and authorisation
Refer to Table C Financial Tenders - subject to SOs (reporting to the Accountable Officer Delegated Limits for approval Governing Body) and authorisation
Chief Officer /Chief Finance Quotes - subject to SOs Chief Finance Officer Officer
31. Healthcare Contracts a) Payments to Healthcare Providers where supported by a Governing Body Refer to Table C Financial Approved Service Agreement or part of Governing Body Delegated Limits for approval an approved expenditure programmes as and authorisation per the Annual Financial Plan
32. Records a) Review NHS Salford Clinical Commissioning Group’s compliance with Accountable Officer Director of Corporate Services the Records Management Code of Practice
Head of Financial Services b) Ensuring the form and adequacy of the Chief Finance Officer GMSS financial records of all departments TABLE B
DELEGATED MATTER DELEGATED TO OPERATIONAL RESPONSIBILITY
33. Reporting of Incidents to the Police a) Where a criminal offence is suspected • criminal offence of a violent nature Accountable Officer Director of Corporate Services • arson or theft • other
Chief Internal Auditor / Local b) Where a fraud is involved Chief Finance Officer Counter Fraud Specialist
c) Deciding at what stage to involve the police in cases of misappropriation and Accountable Officer Director of Corporate Services other irregularities not involving fraud or corruption
34. Risk Management
Ensuring the Clinical Commissioning Group has a Risk Management Strategy Accountable Officer Director of Corporate Services and a programme of risk management
Developing systems for the management Accountable Officer Director of Corporate Services of risk
Developing incident and accident Accountable Officer Director of Corporate Services reporting systems
Compliance with the reporting of Accountable Officer All staff incidents and accidents
35. Seal a) The keeping of a register of seal and safekeeping of the seal Accountable Officer Director of Corporate Services
b) Attestation of seal in accordance with Chair /Accountable Officer / Chief Finance Officer Standing Orders chief Finance Officer
c) Property transactions and any other Chair/Accountable Officer / Chief Finance Officer legal requirement for the use of the seal Chief Finance Officer
36. Security Management a) Monitor and ensure compliance with Directions issued by the Secretary of Chief Finance Officer/ Local State for Health on NHS security Accountable Officer Security Management management including appointment of Specialist the Local Security Management Specialist
37. Setting of Fees and Charges (Income) Chief Finance Officer Deputy Chief Finance Officer TABLE B
DELEGATED MATTER DELEGATED TO OPERATIONAL RESPONSIBILITY a) Non patient care income
b) Informing the Chief Finance Officer of monies due to the Clinical Chief Finance Officer All Staff Commissioning Group
Head of Financial Services, c) Recovery of debt Chief Finance Officer GMSS d) Security of cash and other negotiable Chief Finance Officer Deputy Chief Finance Officer instruments
38. Stores and Receipt of Goods a) Responsibility for systems of control Members of the Executive over stores and receipt of goods, issues Chief Finance Officer Team and returns
b) Stocktaking arrangements Chief Finance Officer Deputy Chief Finance Officer
NHS SALFORD CLINICAL COMMISSIONING GROUP GOVERNING BODY MEETING AGENDA ITEM No 8 (a)
Item for: Decision/Assurance/Information
23 May 2018
REPORT OF: Chair of the Commissioning Committee
DATE OF PAPER: 16 May 2018
SUBJECT: Commissioning Committee Report
IN CASE OF QUERY Harry Golby PLEASE CONTACT: Acting Director of Commissioning 0161 212 5654
Please tick which strategic priorities the paper relates to: STRATEGIC PRIORITIES: Quality Community Based Care Integrated Care In Hospital Care Long Term Conditions and Mental Health
Effective Organisation
PURPOSE OF PAPER: This is a report from the Salford Clinical Commissioning Group’s Commissioning Committee, which is a formal Committee reporting to the CCG’s Governing Body. The report aims to provide assurance relating to commissioning programmes, outlining key decisions made by the Committee and seeks, as appropriate, ratification of commissioning decisions.
The Governing Body is asked to note the content of the report, including decisions made by the Commissioning Committee in March and April 2018.
Further explanatory information required
HOW WILL THIS BENEFIT THE The Commissioning Committee oversees the HEALTH AND WELL BEING OF organisation’s commissioning activities aimed SALFORD RESIDENTS OR THE at delivering the organisation’s strategic CLINICAL COMMISSIONING GROUP? priorities.
WHAT RISKS MAY ARISE AS A N/A RESULT OF THIS PAPER? HOW CAN THEY BE MITIGATED?
WHAT EQUALITY-RELATED RISKS N/A MAY ARISE AS A RESULT OF THIS PAPER? HOW WILL THESE BE MITIGATED?
DOES THIS PAPER HELP ADDRESS N/A ANY EXISTING HIGH OR EXTREME RISKS FACING THE ORGANISATION? IF SO WHAT ARE THEY AND HOW DOES THIS PAPER REDUCE THEM?
PLEASE DESCRIBE ANY POSSIBLE Conflicts of interest are inherent for the CONFLICTS OF INTEREST Commissioning Committee as clinical members ASSOCIATED WITH THIS PAPER. are also providers of services. Items with particular material conflicts of interest are highlighted in the report.
PLEASE IDENTIFY ANY CURRENT N/A SERVICES OR ROLES THAT MAY BE AFFECTED BY ISSUES WITHIN THIS PAPER:
Footnote:
Members of NHS Salford Clinical Commissioning Group Governing Body will read all papers thoroughly. Once papers are distributed no amendments are possible.
Document Development Not Comments and Date Process Yes No Outcome Applicable (i.e. presentation, verbal, actual report) Public Engagement Commissioning programmes include public (Please detail the method i.e. survey, event, engagement as appropriate consultation) Clinical Engagement Clinical chair of the Commissioning Committee (Please detail the methods i.e. survey, event, presents the report. The Committee includes all consultation) Governing Body clinicians. Has ‘due regard ’been given to Equality Commissioning programmes undertake EAs as Analysis (EA) of any adverse impacts? appropriate (Please detail outcomes, including risks and how these will be managed. managed)
Legal Advice Sought Presented to the Commissioning Committee Presented to the Health and Wellbeing Board Presented to the Integrated Commissioning Joint Committee Presented to any other groups or committees, including Partnership Groups (Please specify in comments)
Note: Please ensure that it is clear in the comments and date column how and when particular stakeholders were involved in this work and ensure there is clarity in the outcome column showing what the key message or decision was from that group and whether amendments were requested about a particular part of the work.
Commissioning Committee Report
1 Executive Summary
This report summarises the Commissioning Committee’s business during March, April and May 2018, comprising four meetings. The report includes the following business:
Strategic planning and commissioning: • Received updates and held a workshop relating to urgent and emergency care across the city. • Received reports relating to the CCG’s Operational Plan*, Integrated Community Based Care*, Research Strategy*, Primary Care Workforce Strategy*, Children’s & Young People Services, Ingleside Birth & Community Centre, Third Sector Investment, Salford Standard* and Innovation Fund* • Agreed the CCG’s response to consultations on prescribing of over the counter medicines* and knee arthroscopies • Authorised the outcome of the procurement of for a community ophthalmology service
Finance: • Considered a report provided by the CCG’s Service and Finance Group.
Quality and Safety: • Received reports regarding Serious Incidents, Safeguarding*, Medicines Optimisation & Safety* and Maternity Services • Received a report from Healthwatch Salford that summarised common messages and emerging themes identified from members of the public • Agreed the CCG’s assurance statement regarding Salford Royal Hospital NHS Foundation Trust 2017/18 quality accounts
* As a GP-led organisation, conflicts of interest are not entirely avoidable. To help manage such conflicts openly, items marked with an asterisk indicate where there have been commissioning decisions or significant discussions that represent a conflict of interest between the commissioning and provider roles of clinical members of the Commissioning Committee. The Commissioning Committee manages all conflicts of interests in line with the CCG’s Conflict of Interest Policy.
2 Introduction and Background
2.1 The Commissioning Committee is a formal reporting Committee of the Clinical Commissioning Group (CCG) Governing Body, to which it is accountable.
2.2 This report summarises the Committee’s business during March, April and May 2018, which involved four meetings. The purpose of the report is to provide assurance relating to the CCG’s commissioning programmes, outlining key decisions made and seeking, if appropriate, ratification of commissioning decisions.
2.3 This report covers the Committee’s business under the following headings: • Strategic planning and commissioning decisions; • Quality and Safety; and • Finance.
3 Strategic Planning and Commissioning Decisions
3.1 Monthly update reports were presented to the Commissioning Committee regarding the work of the urgent and emergency care services across the City. The Commissioning Committee were informed of the ever changing position in urgent and emergency care services due to pressures being experienced across the local, regional and national systems.
A group has been established to undertake local review of the urgent care system. The May meeting of the Commissioning Committee was devoted to a workshop to agree principles that should inform this review. The workshop considered what urgent care should look like from a patient perspective, on the hospital site and off the hospital site. The output has been fed into the group undertaking the review.
3.2 The Commissioning Committee received and discussed a report from the CCG’s Integrated Community Base Care Commissioning Group. The report provided updates on a range of areas including Self-referral to MSK-Physio, Neighbourhood Integrated Practice Pharmacists, District Nursing, a review of Multi-Disciplinary Group Working and the Salford Standard. These are each areas which have a significant impact on GP Practices and the committee’s conflict of interest were considered.
3.3 The Commissioning Committee agreed the CCG’s response to a national consultation on conditions for which over the counter items should not be routinely prescribed in primary care. A draft response had been prepared based on extensive engagement with patients and partners locally. Some local concerns had been raised regarding the implications of the national approach. The Committee agreed these concerns should be reflected in the CCG’s formal response to the national committee.
3.4 The Commissioning Committee received an update regarding the Ingleside Birth and Community Centre and the associated model which enables midwives from different provider organisations to enable women to give birth in the unit. The committee agreed a range of actions that the CCG could take to maximise utilisation of the centre in the future.
3.5 The Commissioning Committee received a regular update regarding the CCG Effective Use of Resources Policy and the work of the Greater Manchester Medicines Management Group. Greater Manchester recommendations regarding Caesarean Section; Wide Bore, Open and Upright MRI Scanning; Correction of Dermatochalasis; Freestyle Libre Flash Glucose Monitoring System were supported. The Greater Manchester team were consulting on the development of a new Knee Arthroscopy Policy and the Committee agreed the CCG’s response to this consultation, recognising this policy had the potential to change the offer of care to hundreds of Salford patients per year.
3.6 The Commissioning Committee received an update on the CCG’s operational plan for 2018/19. The Committee approved the draft workstream plan which related directly to its areas of responsibility and noted the full plan would be presented to the CCG’s Governing Body.
3.7 The Commissioning Committee received a quarterly update from the Children & Young Peoples’ Commissioning Group. The report summarised the work of the CCG in relation to children’s services, much of which is done in partnership with the City Council. This included updates around children with Special Education Needs & Disabilities and Emotional Health & Well Being. The committee noted the links to what can be achieved in partnership with schools, which is a work programme that is not currently visible to the committee. The update provided information on two areas where long waits had been escalated as local issues – Child & Adolescent Mental Health Services (CAMHS) and Paediatric Ophthalmology Services. The committee noted a recovery plan for CAMHS waiting times had been agreed and the latest information available had indicated waits had reduced. The number of children waiting to see a Paediatric Ophthalmologist had also reduced since the committee had supported a recommendation to commission Manchester Foundation Trust to provide this service.
3.8 The outcome of the procurement for a Community Ophthalmology Service was presented to the committee. Four bids had been received and the Commissioning Committee authorise the award of the contract to the recommended bidder (at the time of writing the bidder could not be named as the process allows for appeals to be lodged by unsuccessful bidders).
3.9 The CCG is undertaking a review of the Salford Standard, a significant investment in General Practice services, in order to develop proposals for 2019/20 and beyond. In view of the conflicts of interests for GPs associated with this work the CCG’s Executive Team have a significant role in this workstream. A revised set of aims and objectives for the Salford Standard had been developed and the Executive Team had agreed these should be shared with the Commissioning Committee for comment, to ensure there was appropriate consideration of clinical issues. The discussion highlighted issues the working group would need to consider and proposed some minor amendments to proposed aims and objectives.
3.10 The Commissioning Committee received an update on the North West Sector’s work programme. This is a partnership between the NHS organisations in Salford, Bolton and Wigan working together to develop resilient service models for some hospital services. The update covered breast services, elective orthopaedics, paediatric general surgery, benign urology and general surgery – progress in different areas and links to “Theme 3” of the Greater Manchester “Taking Charge” plan were noted.
3.11 The Commissioning Committee received an update on the CCG’s £1m investment in third sector services through Salford’s Council for Voluntary Services. 2018/19 would be year 2 of a three year programme. The report described the proposed breakdown into different schemes based on learning from year 1 and to better support Salford’s Locality Plan. The committee supported the proposals.
3.12 The Commissioning Committee received a quarterly update relating to the CCCG’s Research Strategy, Primary Care Workforce Strategy and Innovation Fund. The report provided details of a range of initiatives including the successful recruitment of 3 Quality Improvement and Academic GP posts, the impact of a range of innovation schemes, training to support workflow optimisation in GP practices and a summary of the evaluation the CCG has commissioned from CLAHRC (Collaborations for Leadership in Applied Health Research and Care) relating to the impact of new roles in primary care.
4 Finance
4.1 The Commissioning Committee received an update from the Service & Finance Group. The committee noted the update which included the latest performance monitoring data against NHS constitutional standards (e.g. A&E waits, cancer waits, referral to treatment waits) – which are reported in more detail in the Performance Report to Governing Body.
4.2 There were no investment decisions for the Commissioning Committee to make in the period covered. The updated noted the service & Finance Group had decided to extend time limited investment in a scheme for some specialist physiotherapists to provide NHS Health Checks and blood tests to identify diabetic patients, and another scheme to support people with serious mental illness to start or stay in work.
5 Quality and Safety
5.1 The Commissioning Committee considered a report on learning from incidents which detailed the numbers, as well as themes in relation to serious incidents. The report detailed serious incidents which have occurred in commissioned services delivered by Salford Royal Hospital NHS Foundation Trust, Greater Manchester Mental Health NHS Foundation Trust and Oaklands Hospital. The paper outlined the status of incidents in each of these commissioned services which provided assurance to the Commissioning Committee that reviews of incidents are actively used to drive improvement in services commissioned by the CCG. The Commissioning Committee discussed and received additional assurance relating to the management of falls, pressure ulcers and using early warning to identify deteriorating patients in SRFT. The committee considered the number of serious incidents reported by Oaklands and requested a benchmarking exercise was undertaken to compare Oaklands with other similar organisations.
5.2 The Commissioning Committee received a report identifying the themes of serious incidents reported by Greater Manchester Mental Health NHS Foundation Trust in 2016/17 that related to Salford’s services. The committee noted links to the local suicide strategy and requested an update on the action plan supporting the suicide strategy.
5.3 The Commissioning Committee supported the CCG’s proposed Medicines Optimisation and Safety Programme for 2018/19. The programme forms a key part of the CCG’s Quality & Safety Strategy and as such has workstreams that extend beyond primary care into care homes, hospital pharmacy and the Integrated Care Organisation. The committee agreed the strategy was appropriately comprehensive and ambitious, it suggested priorities could relate to use of statins, stopping over- medication of people with learning disabilities and medicines safety in care homes.
5.4 A report was received which allowed the Commissioning Committee to review the work of the CCG’s Safeguarding Team in respect of the priority safeguarding children and adult at risk issues, including developments in these areas of work. The report included details of the results of the 2017/18 safeguarding assurance process, safeguarding training, serious case reviews, learning disability mortality reviews and looked after children (health) reviews.
5.5 Healthwatch Salford presented a report prepared for the 2018 Greater Manchester Healthwatch Quality Summit. The paper identified common messages and emerging themes identified by Healthwatch organisations across Greater Manchester. Broad themes related to access to GP practices, access to dialysis (not an issue noted by Salford Healthwatch), accessing interpreters, A&E performance and voluntary sector grant funding. Commissioning committee welcomed the work of Healthwatch to collect the views of members of the public. It discussed how GP access and A&E performance may be linked. The committee advised if Healthwatch was able to access patients in A&E departments it would be helpful to understand whether those patients had been unable to access their GP prior to attending A&E.
5.6 Commissioning Committee was informed of work across Greater Manchester and Eastern Cheshire aiming to provide high quality, safe, sustainable and appropriate maternity services. The committee was supportive of the broad aims of the work but expressed concern that there was currently limited data to provide assurance regarding the quality and safety of these services. Plans to address this issue were discussed and the committee agreed the CCG should establish a group to address this locally.
5.7 All providers are required to publish annual quality accounts in relation to quality, safety and patient experience. Commissioners are required to review the draft Quality Accounts prior to their publication and include an assurance statement within the document. Commissioning Committee considered Salford Royal Foundation NHS Trust’s draft Quality Accounts for 2017/18 and provided feedback to support the CCG’s assurance statement.
5.8 Commissioning Committee received feedback from the Greater Manchester Quality Board. The report provided details of how other CCG’s assure themselves of the quality and safety of services which some patients from Salford access (e.g. hospitals in Bolton and Manchester, ambulance service).
6 Recommendations
6.1 The Governing Body is asked to note the content of the report, including decisions made by the Commissioning Committee in March, April and May 2018.
Dr Jeremy Tankel Chair of the Commissioning Committee Salford Clinical Commissioning Group
Minutes of NHS Salford Clinical Commissioning Group Primary Care Commissioning Committee (PCCC) 27 March 2018, 10:30-12:00Hrs in the Salford Room St James’s House, Salford
Part I Present: Mr Brian Wroe (BW) Lay Member for Engagement, Salford CCG (Chair) Mr Paul Newman (PN) Lay Member for Commercial, Salford CCG Mr Steve Dixon (SD) Chief Finance Officer, Salford CCG Mr Anthony Hassall (AH) Chief Accountable Officer, Salford CCG Mrs Sara Roscoe (SR) Head of Primary Care Transformation - Greater Manchester Health and Social Care Partnership (GMHSCP) NHS England Dr Jeremy Tankel (JT) Medical Director, Salford CCG Dr Jennifer Walton (JW) GP/Salford & Trafford LMC Representative
In Attendance: Mrs Francine Thorpe (FT) Director of Quality and Innovation, Salford CCG Mr Harry Golby (HG) Assistant Director of Commissioning, Salford CCG Mrs Anna Ganotis (AG) Head of Service Improvement, Salford CCG Mrs Sam Glynn-Atkins (SGA) Service Improvement Manager, Salford CCG Mrs Hilary Rothwell (HR) Senior Service Improvement Manager, Salford CCG Mrs Victoria Quinn (VQ) Senior Service Improvement Manager, Salford CCG Ms Eejay Whitehead (EW) Senior Service Improvement Manager, Salford CCG Mrs Natalie McInerney (NMc) Service Improvement Manager, Salford CCG Mrs Emma Reid (ER) Senior Planning and Performance Manager, Salford CCG Miss Jade Booth Assistant to Chief Accountable Officer, Salford CCG Mrs Lesley Lowe Personal Assistant, Salford CCG
Apologies: Mrs Karen Proctor Director of Commissioning, Salford CCG Eve Donelon Chief Executive – Salford and Trafford ‘Local Medical Committee’ (LMC) Mrs Delana Lawson Chief Officer Healthwatch Salford Mrs Gunjit Bandesha Consultant in Public Health, Salford City Council
1. Apologies 1.1 BW welcomed everyone present and introductions were made. The above apologies were noted. There were no questions raised by members of the public either at the meeting or in advance.
2. Declarations of Interest 2.1 There were no declarations of interest.
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3. Minutes of the last Meeting of 30th January 2018 3.1 The minutes of the meeting were approved as a correct record.
4. Action Log and Matters Arising from 30th January 2018 4.1 Action Log 4.1.1 The committee went through the action log - SR confirmed the 2018 price uplift and that the contract has been announced and sent to DT for circulation to the committee - Log 48 is now closed. 4.1.2 SR confirmed the new PMS agreement will be incorporated into the review - Log 49 is now closed. 4.1.3 HG shared the extended access communications plan with DL – Log 50 is now closed. 4.1.4 FT informed in relation to action 51 this has been appended to the Primary Care Quality Group dashboard papers – Log 51 is now closed.
4.2 Matters Arising from the meeting held on 30th January 2018 4.2.1 There were no matters arising.
4.3 Primary Care Commissioning Risk Register 4.3.1 AG provided the latest six monthly update. There have been no new risks since the last report, however there have been two increased risks: Primary Care resilience has changed from green to amber, reflecting the ongoing organisational issues in a GP practice. Primary Care Workforce Strategy and the impact of temporary staff shortages also has increased in risk.
4.3.2 AG announced Primary Care Commissioning Committee risks will be reported in September 2018 with any new risks or amendments.
4.3.3 HG announced that we will need to change the Salford Standard risk 2018/19 to 2019/20.
5. Community Based Care 5.1 Primary Care Investment Agreement (6 month update) 5.1.1 AG reported that since the discussion in September the submission for Primary Care transformation funding has been approved by Greater Manchester Health & Social Care Partnership (GMH&SCP). AG explained that we are currently awaiting confirmation from the GM Team on performance metrics.
Action: AG to prove a further update will be provided in six months’ time.
5.1.2 FT highlighted that the section on care navigation and medical assistance links to the Primary Care workforce strategy which shows our strategies are well aligned. The use of innovation resources is also helping to achieve digital advances.
5.1.3 SD highlighted the good news that the Salford population have achieved 100% access to primary care, 7 days per week. Bank holidays are not included in the Salford Specification; however they are in the work plan for 2018/19. SD said that a meeting took place with Salford Primary Care Together, and there was a possibility to introduce bank holiday cover in August 2018. Page 2 of 5
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5.2 Interpretation Services Review 5.2.1 AG reported Interpretation Services have been discussed at a number of finance committees which identified a need to review the service. It was highlighted the commissioning arrangements in place were historic. The review has enabled the CCG to make some improvements such as checking invoices to help reduce overspend. SD welcomed the review and good work around due diligence but highlighted it was a process review and highlighted the need for a service model review as contracts are out of date. SD asked that this be a priority to ensure the contracts are fit for purpose going forward.
5.2.2 JW suggested an on-line model moving forward. FT noted a gap in terms of quality of the service provided and asked that Healthwatch have sight of this review and provide feedback. JT queried the role of primary care to encourage service users to attend English lessons as an alternative option. FT suggested it would be useful to speak to Irfan in the Communications and Engagement Team, who has interpretation experience along with DL.
5.2.3 Action: FT to send the Interpretation Services review report to DL to comment and think about this at other locations around GM to assist us through learning from good practice.
5.2.4 SD concluded the review satisfies the committee on finances and that financial savings have been achieved but highlighted the need for contractual relationship with providers. SD felt that there was a need for an action plan, assurance and a broader multidisciplinary review to look at the service model, led by the service improvement team.
5.2.5 Action: HG to bring suggestions, and terms of reference to the next meeting to outline what this piece of work would look like.
5.2.6 The Committee discussed the process when interpretation services are required and queried how it is monitored and how we know if the interpretation is correct. PN suggested looking at GM and learning from best practice. SD explained the accreditation process and that there is a list of providers to use who have already been accredited and approved. GPs can then choose the provider they wish to use from the list. JW identified cultural issues where some women may not want a male interpreter. AG added as part of a further review there will be a communication to practices around interpretation services as well as there being more interpretation information in the Salford Standard this year along with a list of approved providers.
5.3 Business Planning Update 5.3.1 ER presented the Salford CCG business plan update asking the committee to approve the draft plan on a page, which has been approved at Governing Body. ER reported this year has taken a lighter approach on how to structure the planning process across nine work streams, with both virtual and face to face sessions, which was agreed at Execs plus. ER has gone through the planning process supported by GMH&SCP to ensure plans align with GM. ER reported the Primary Care plan has been shared with the Primary Care Group and has been amended and re-issued. It was agreed the draft workstream plan would come to this group before it went to Page 3 of 5
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Governing Body. The comprehensive plan aligns with what the CCG is trying to achieve with the overall strategy. BW asked the group to note the plan on a page and recognise the plan for Primary Care and approve the draft work stream plan.
5.3.2 SD advised Interpretation Services needs to be a priority on the work plan for 2018/19 and responsibility identified, to look at resources and be realistic what can be achieved. FT advised to ensure the Primary Care Workforce Strategy is included.
5.3.3 The group approved the draft work stream plan for 18/19 and noted the plan on a page.
6. Performance 6.1 Financial Performance 6.2 SD outlined the financial position on Primary Care underspend. The reported Quality Outcomes Framework (QOF) overspend was in relation to how the budget was set and not as a result of QOF points. SD informed the group that 10 out of 21 GM practices highlighted as achieving less than 85% of QOF in a recent GM report are from Salford. SD referred to point 2.4 of the report forecast of which the delay in recruitment in clinical fellows resulted in £100,000 under spend. The overspend on interpretation service costs is due to increased volumes. Invoices have been checked to ensure that what is being paid is correct. BW commented that the report was neat and comprehensive and clearly explained the QOF overspend.
6.3 JW asked whether there was any correlation with practices who have not achieved 85%. HG reported Salford has historically been poor around QOF which should have been taken into account in the development of the Salford Standard.
6.4 The Committee noted the report.
Note: AH joined the meeting at this point.
7. Minutes / Reports of Partnership Boards / Sub Committees 7.1 Primary Care Operational Group Report 7.1.1 HG provided an update on the Primary Care Operational Group report and asked the Committee to note reference of the transfer of contracts to Salford Primary Care Together (SPCT), on track to commence on 1st April 2018.
7.1.2 HG reported the reviewed terms of reference are included in the paper and that there had been no significant changes highlighted. HG said that proposed KPIs to assess the Ordsall pilot are also included in the report. HG commented he is happy to receive comments outside of this meeting and asked that any comments/feedback should be directed to EW.
7.1.3 AH expressed his disappointment that the Ordsall development hadn’t moved quicker and that deadlines need to be met. SD responded that there was a contract meeting due to take place with SPCT, where it will be flagged and the importance highlighted. BW reiterated we should reflect and support Anthony’s comments to ensure work goes ahead promptly. Page 4 of 5
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7.2 Primary Care Quality Group Report (Includes Primary Care Quality Dashboard appendices) 7.2.1 FT asked the committee to note a CQC inspection has been carried out on the Lakes Medical Practice, and it has been rated as “Inadequate”. The Practice has developed an action plan and has received support from the CCG and Local Medical Committee (LMC). Implementation of the action plan will be monitored and progress reported to the Primary Care Quality Group chaired by Dr Tankel.
7.2.2 Action: Jeremy Tankel to ensure that implementation of the action plan is reported to Primary Care Quality Group
7.2.3 FT informed the group of the positive news that Irlam Practice have gone from an inadequate to a good rating, highlighting cross reference work with PCQG and PCCC. FT referred to a request last meeting to include highlight information from the Quality Assurance Dashboard and this is appended.
7.2.4 BW complimented the group on good, concise reports, capturing all relevant information and the good work carried out to bring practices up to speed. BW also advised the Committee to continue to share good practice.
7.2.5 HG raised a comment regarding information shared within the public domain. FT and AH confirmed that this information is appropriate to share, however it was discussed that we had not been explicit with practices that we were doing this and FT suggested we advise the practices the dashboard information (such as Salford Standard and Safeguarding information) is now public. AH expressed surprise at some of the lower rankings and queried quality. AH and FT both raised a query in relation to the coding and attribution of rankings and it was agreed that a key would be added in future reports.
7.2.6 The group discussed the threshold for what good practice looks like and the minimum standard expected. PN agreed we need to announce the rankings and express what we are doing about it. He also asked if GP ratings are published elsewhere and highlighted risks if the information is acted on by the public. There could be an influx of patients wanting to register with top ranked practices. BW said we recognise people will draw conclusions on the rankings top and bottom. BW agreed there should be openness and publication but the need to bear in mind some of the risks.
7.2.7 Action: FT to ask the Primary Care Quality Group (PCQG) to review the comments and take into consideration as the use of the dashboard is developed
9 Any Other Business 9.1 BW closed the meeting, nothing further to discuss.
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NHS SALFORD CLINICAL COMMISSIONING GROUP GOVERNING BODY MEETING AGENDA ITEM No 8 (c)
Item for: Decision/Assurance/Information
23 May 2018
REPORT OF: Chief Accountable Officer
23 May 2018 DATE OF PAPER:
SUBJECT: Executive Team Report
IN CASE OF QUERY Hannah Dobrowolska PLEASE CONTACT: Director of Corporate Services 0161 212 4830
Please tick which strategic priorities the paper relates to: STRATEGIC PRIORITIES:
Quality
Community Based Care
Integrated Care
In Hospital Care
Long Term Conditions and Mental Health x Effective Organisation
PURPOSE OF PAPER:
This is a report from the Salford Clinical Commissioning Group Executive Team Meeting, which is a formal committee reporting to the Governing Body. The report’s purpose is to provide assurance relating to the functions undertaken by the Executive Team in line with the CCG’s Constitution and the Executive Team Meeting’s Terms of Reference.
The report outlines key decisions made at the Executive Team Meetings and seeks, as appropriate, ratification of decisions.
The NHS Salford Clinical Commissioning Group Governing Body is asked to: - note the content of the report, outlining the business undertaken through the Executive Team meetings in March and April 2018. - note that for this period there are no decisions made by the Executive Team that require ratification by the Governing Body
Further explanatory information required
HOW WILL THIS BENEFIT THE The Executive Team Meeting conducts the day HEALTH AND WELL BEING OF to day operational business of the CCG, which SALFORD RESIDENTS OR THE allows the CCG to deliver against its Strategic CLINICAL COMMISSIONING GROUP? Plan.
WHAT RISKS MAY ARISE AS A As part of any Executive Team decision, risks RESULT OF THIS PAPER? HOW CAN are considered. THEY BE MITIGATED?
WHAT EQUALITY-RELATED RISKS As part of any Executive Team decision, MAY ARISE AS A RESULT OF THIS diversity and inclusion is considered, and any PAPER? HOW WILL THESE BE associated risks. MITIGATED?
DOES THIS PAPER HELP ADDRESS As part of any Executive Team decision, impact ANY EXISTING HIGH OR EXTREME on existing high or extreme risks are RISKS FACING THE ORGANISATION? considered. IF SO WHAT ARE THEY AND HOW DOES THIS PAPER REDUCE THEM?
PLEASE DESCRIBE ANY POSSIBLE Conflicts of interest are present for the GP CONFLICTS OF INTEREST members attending the Executive Team ASSOCIATED WITH THIS PAPER. Meetings. These are inherent as clinical members are also providers of services. Any Conflicts of Interest are managed by the team in line with the CCG’s policy.
PLEASE IDENTIFY ANY CURRENT As part of any Executive Team decision, impact SERVICES OR ROLES THAT MAY BE current services or roles are considered. AFFECTED BY ISSUES WITHIN THIS PAPER:
Footnote:
Members of NHS Salford Clinical Commissioning Group Governing Body will read all papers thoroughly. Once papers are distributed no amendments are possible.
Document Development
Not Process Yes No Comments and Date Outcome Applicable (i.e. presentation, verbal, actual report) Public Engagement Business conducted by the (Please detail the method ie survey, event, consultation) Executive Team involves engagement as appropriate Clinical Engagement The Chair routinely attends the (Please detail the method ie survey, event, consultation) Executive Team meeting, deputised by the Medical Director. Has ‘due regard’ been given to Equality Business conducted by the Analysis (EA) of any adverse impacts? Executive Team involves EIAs as (Please detail outcomes, including risks and how appropriate these will be managed) Legal Advice Sought Presented to the Commissioning Committee Presented to the Health and Wellbeing Board Presented to the Integrated Commissioning Joint Committee Presented to any other groups or committees, This paper was shared with the including Partnership Groups CAO for comment. (Please specify in comments)
Note: Please ensure that it is clear in the comments and date column how and when particular stakeholders were involved in this work and ensure there is clarity in the outcome column showing what the key message or decision was from that group and whether amendments were requested about a particular part of the work.
Executive Team Report
1 Executive Summary
This report summarises the Executive Team meeting’s business.
The Governing Body is asked to:
- note the content of this report, outlining the business undertaken through the Executive Team meetings in March and April 2018 - note that for this period there are no decisions made by the Executive Team that require ratification by the Governing Body
2 Introduction and Background
2.1 The Executive Team Meeting is a subcommittee of the Clinical Commissioning Group (CCG) Governing Body, to which it is accountable.
2.2 This report summarises the business conducted at the Executive Team Meetings in line with the CCG’s Constitution and the Executive Team Meeting’s Terms of Reference.
2.3 The responsibilities of the Executive Team are:
2.3.1 To oversee the day to day running of the organisation and therefore be responsible for a range of operational matters, including but not limited to: • Human Resources, • Communications • Engagement • Organisational development • Financial management and those already mentioned • Health, Safety and Risk • IM&T including Information Governance • Organisational Performance • Continuing Healthcare (operational matters) • Integrated Commissioning (operational matters) • Safeguarding (operational matters) • External commissioning support • Strategic and operational estates planning • Emergency planning, resilience and response
2.3.2 To receive reports from the: • Health Economy Resilience Group • IM&T Programme Board • Salford Strategic Estates Group
2.3.3 To promote innovation in commissioned services and internal working practices.
2.3.4 To lead the development of governance frameworks with the CCG’s principal partners to support the delivery of joint commissioning priorities.
2.3.5 To prioritise the business of the CCG to meet its annual objectives, providing the programme management framework and final decision making forum to enable realisation of the operational plan.
2.3.6 To provide assurances to the NHS Salford CCG in respect of their statutory requirements associated with day to day management of the organisation and its operations, including the development and management of corporate governance arrangements.
2.3.7 Where required, due to Conflict of Interest concerns, take decisions delegated to the Executive Team by other committees or groups of the CCG where the committee or group that would ordinarily take the decision cannot appropriately manage the Conflict of Interest concerns within its own membership.
3 Executive Team Meeting summaries
3.1 5 March 2018
The Executive Team held a special meeting due to upcoming Wednesday slots being used for other purposes in early March. The Executive Team commented on the Integrated Commissioning paper ahead of Governing Body consideration later in March. Feedback was provided on a draft Integrated Commissioning peer to peer assessment process proposed across Greater Manchester. An Emergency Planning, Preparedness and Response (EPRR) update was noted and it was agreed to move from the current bleep system to mobile phones for the CCG’s on call arrangements.
3.2 7 March 2018
This was a Salford City Council Corporate Management Team to CCG Executive Team meeting.
The group discussed the plans and decision making process in relation to greater Integrated Commissioning for health and social care between Salford City Council and the CCG. In particular our ambition in this work, as well as practical matters such as Organisational Development and Communications.
3.3 14 March 2018
Carbon Literacy training was provided to the Executive Team, the Executive Plus group and other key individuals from across the CCG.
3.4 21 March 2018
The Executive Team noted a monthly finance report regarding CCG running costs, a planning update and an update on the maternity services changes. Delays in the relocation of specialist antenatal clinics will be escalated with the provider.
Charlotte Ramsden, the Director of People from Salford City Council, attended the Executive Team meeting to outline the financial pressures within children’s services, the background to this and action being taken to manage these pressures.
The Executive Team shared feedback on Governing Body members as part of an ongoing 360 feedback process to support upcoming appraisals.
The Executive Team noted a verbal update on the Greater Manchester Health and Social Care Partnership including work associated with integrated commissioning.
3.5 28 March 2018
The Executive Team noted a health and safety update and approved a revised Health and Safety Policy. A report from the Engagement and Inclusion Management Group (EIMG) was noted together with a communications update. The Executive Team reviewed proposals regarding improvements to the running of Governing Body and assurance that all the CCG’s statutory duties are being discharged effectively. It was asked that further work is done with regard to a Governing Body forward plan and report template.
Comments were provided on an updated Project Initiation Document in relation to the review of the Salford Standard. Going forward, monthly updates regarding the Salford Standard review will be shared with the Executive Team, given the importance of this work to the CCG and its members.
The Executive Team noted a verbal update on the Greater Manchester Health and Social Care Partnership including work associated with integrated commissioning.
3.6 4 April 2018
The Executive Team noted the IM&T Programme Board draft minutes for part 1, which covers Information Governance, and an Organisational Development (OD) and Social Value update, including Carbon Literacy accreditation and mandatory training compliance. The Executive Team agreed the list of staff who need to undertake mandatory conflict of interest training by the end of May 2018. The Executive Team received a fortnightly planning update, providing information and assurance including a draft CCG Business Plan 2018-19. This information will be used in Personal Development Reviews (PDR)/appraisal conversations. A proposal for a Salford Best Value Programme was approved.
The Executive Team noted a verbal update on the Greater Manchester Health and Social Care Partnership including work associated with integrated commissioning.
3.7 11 April 2018
There was no Executive Team Meeting due to conflicting commitments.
3.8 18 April 2018
The Executive Team noted a fortnightly planning update and reviewed the draft CCG Business Plan prior to it going to Governing Body for approval, together with the Financial Plan. An update on a practice contractual and quality matter was provided and next steps agreed to ensure sufficient information is available for the Primary Care Commissioning Committee (PCCC) to make a timely decision. An HR update was noted. The Draft Annual Report and Annual Governance Statement was reviewed and comments made prior to submission to NHS England later in the week.
The Executive Team noted a verbal update on the Greater Manchester Health and Social Care Partnership, noting the Association of Greater Manchester CCGs Committees summaries. An update on integrated commissioning was noted.
3.9 25 April 2018
This was an Executive Team Plus meeting, including those staff who report closely to Executive Team members, largely those at 8b or above within the CCG. The group received a general update as well as an update on Integrated Commissioning. A briefing regarding outcome based contracting and commissioning was shared. The third of three “Key Skills for Managers” training slots was provided.
The Executive Team only continued their meeting where they commented upon the draft Voluntary, Community and Social Enterprise (VCSE) sector strategy and investment plan.
3.10 27 April 2018
The Executive Team held an away day where they considered the following areas: • Progress to date and implementation plans with regard to integrated commissioning with Salford City Council, which has been agreed in principle to commence in April 2019. • A strategic risks review. • CCG team and individual objectives. • Team capacity and associated prioritisation of work, considering action needed in areas within the CCG experiencing particular pressures and possible future saving requirements.
4 Recommendations
4.1 The NHS Salford Clinical Commissioning Group Governing Body is asked to:
- Note the content of this report, covering Executive Team Meetings in March and April 2018 - note that for this period there are no decisions made by the Executive Team that require ratification by the Governing Body
Anthony Hassall Chief Accountable Officer Salford Clinical Commissioning Group
FINAL AGG Minutes 06 February 2018 v
GM ASSOCIATION OF CCGs: Association Governing Group (AGG) 06 February 2018 13:30 – 16:30 AJ Bell Stadium, 1 Stadium Way, Barton-upon-Irwell, Salford, M307EY
Attendance: Trish Anderson (TA) NHS Wigan Borough CCG Wirin Bhatiani (WB) NHS Bolton CCG Philip Burns (PB) NHS Manchester Health & Care Commissioning Alan Dow (AD) NHS Tameside & Glossop CCG Noreen Dowd (JD) NHS Oldham CCG Chris Duffy (CD) NHS Heywood, Middleton & Rochdale CCG Ranjit Gill (RG) NHS Stockport CCG Anthony Hassall (AH) NHS Salford CG Su Long (SL) NHS Bolton CCG Margaret O’Dwyer (MOD) NHS Bury CCG (DoC Chair) Stuart North (SN) NHS Bury CCG Kiran Patel (Chair) (KP) NHS Bury CCG Tom Tasker (TT) NHS Salford CCG Cameron Ward (CW) NHS Trafford CCG
Apologies: Tim Dalton (TD) NHS Wigan Borough CCG Steve Dixon (SD) NHS Salford CCG (CFO Chair) Mark Jarvis (MJ) NHS Trafford CCG Gaynor Mullins (GMu) NHS Stockport CCG Steven Pleasant (SP) NHS Tameside & Glossop CCG Ian Williamson (IWi) NHS Manchester Health & Care Commissioning Simon Wootton (SW) NHS Heywood, Middleton & Rochdale CCG
In Attendance: Rob Bellingham (RB) GM Association of CCGs Andrea Dayson (ADa) GM Association of CCGs Sarah Price (SP) H&SCP Team Yvonne Rogers (YR) H&SCP Team Mike Eecklaers (ME) H&SCP Team/GMACCGs David Boulger (DB) H&SCP Team Jennet Peters (JP) GMCA
1.WELCOME & APOLOGIES FOR ABSENCE
The Chair welcomed members to the meeting, apologies were noted
2. DECLARATION OF INTEREST
None.
3. MINUTES OF THE LAST MEETING OF 09.01.18
The minutes of the last meeting were accepted as an accurate record.
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ACTIONS:- Item 4 – Association MD and Chair report Theme 3 update: - RB presented a Theme 3 programme progress report and highlighted the need for an agreed narrative around which the whole system can mobilise. At a recent CO meeting AH, SL, and IW were mandated by the CO’s to start a conversation with nominees from the Provider Federation Board (PFB), Mike Deegan and David Dalton to progress an agreed approach Work ongoing to develop Theme 3 at a GM level to ensure this interfaces very clearly into Theme 2, i.e. how we connect the hospital narrative to the out of hospital narrative There is also work going on to look at data modelling which again needs a coordinated discussion with the PFB. Communications and Engagement: Jackie Robinson has been assigned to start this conversation with GMACCGs and the PFB - RB has a further meeting with Jackie Robinson to discuss the progress of this. All agreed that no further presentation to come to AGG until the narratives have been approved across GMACCGs and the PFB. Next week there is a Theme 3 board, only one attendee from a CCG will be attending, important to engage with this process. Need for clarity on closing the financial gap in locality plans; they included assumption of contributions which would close the gap. Some providers are looking for a radical Theme 3 programme, verging on Heathier Together 2 which may be too radical for some parties to support. SN expressed an interest in being more involved in the discussions around Theme 3 and Theme 2. There is merit in how these changes at locality are transacted. We need to ensure that the vision is delivered from an integrated commissioning perspective as opposed to a pure health perspective.
All other actions were noted as completed.
ACTION: CO’s to further discuss the Theme 3 narrative – RB
4. ASSOCIATION REPORT
Chair & MD Report: - KP will be standing down from the Chair of the Association and Bury CCG to take on the role of Medical Director of the Bury GP Federation. In light of this and the ongoing leadership changes across a number of CCGs a draft paper will be tabled in March to discuss the future direction for the Association. KP is happy to have a hand-over period around March to support his successor. There was a helpful discussion about the GM Commissioning Hub (GMCH) at the JCB following this an initial draft operating model has been drafted which to date is not in a state to share with members but will support the GMCH ongoing discussions The operating model is being developed so as to address the concerns around governance, scope and accountability. We need to consider how we prevent any mission creep and use the best of the
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existing resources already in the system. Need to also describe how the GMCH is going to be held to account for delivery of functions. CO’s on Friday suggested a to complete a ‘stock take’ to see where the GMCH is now and how has it got there that is to detail where decisions were made etc. At the Jan JCB it was agreed that the Feb JCB will not have an agenda but will be a developmental session. There was a question about a lack of clarity from the last JCB meeting about where the GMCH ends and locality takes over. We could take a service such as LGBT and use as an example to how the GMCH would support to provide further clarity of processes. All of the GMCCG’s must be brought into this process currently the Local authorities have had a more limited representation at the JCB but this will improve over time and as the agenda matures. RB provided an update on the Medicine Strategy; given the issues the AGG highlighted in that the strategy was not costed there is now a working group to develop this further. KP presented Burys prescribing work at the SPB around best practice this should be highlighted in the Medicine Strategy as best practice. KP stated the importance of engaging with the public on the development of the Medicine Strategy, and must be prepared to mitigate negative impacts on vulnerable members of the community. There is a national consultation around this issue the CCG’s could lead the way and offer to take the lead. PB confirmed that the team developing the strategy are representing AGG views as GM but noted that we need to have a local view as well. We don’t not want to duplicate and triplicate processes as this can hit patients directly. 18/19 Planning Guidance has landed: RB had a summary in hard copy covering finance, emergency care, next steps priorities and processes. SL, IW, AH, and RB have been nominated to attend a quickly arranged leadership meeting led by Jon Rouse. This is going to be a complicated process we need the CFO’s to engage with this process and advice. There are ongoing discussions with Paul Baumann which appears to be open to GM doing things slightly differently to accommodate devolution working. A letter will be coming out from Jon Rouse which will cover a lot of the content in the e-mail sent by Jon Rouse which RB forwarded. Part of the content states that GM has ten locality plans and cannot be driven by the planning process. Responding back as GM is something we would not have had the opportunity to do under the previous system. There was a paper that went to the SPBE which was summarised and agreed and a paper will be produced on next steps post-2021. This discussion at the SPBE on the triangulation of the planning process, two things were discussed: 1. Retrospective analysis of investment agreement 2. Prospecting position: How are you incorporating any recurrent impact of your investment agreement into your 5-year plan - the investment agreement review should not be a separate process.
ACTION: Substantive discussion/session on the GMACCGs future direction at the next AGG – RB
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To complete a stocktake of all decision relating to the agreements to establish and develop the Commissioning Hub – RB SL/IW/AH and RB to attend meeting chaired by Jon Rouse on the response to the 18/19 planning guidance – need CFO input – RB Monthly Board Summary distributed to members for information.
5. H&SCP
Much of the updates are to be provided in item 7
6. TRANSFORMATION FUND UPDATE
Deferred
ACTION: SW on the forward plan – AD
7. WORKFORCE STRATEGY
Yvonne Rogers provided AGG with a workforce strategy update included the work on the continuous service protocol: - This first part of the paper looks at how these changes are implemented and why the changes are needed: The Workforce Strategy covers four key priorities: - Filling difficult gaps, - Grow Our Own, - Talent, Development, and Leadership, and - Employer Offer and Brands. There are 11 strategic action areas which details the aims to be covered by 2021. The Strategic Workforce Board has been in place for some time and the Workforce Collaborative has gained momentum. The paper details what we have achieved to date. We have also established the Theme 2 Workforce Reference group which will start to build the Workforce Plans around Theme 1. This includes population health, adult social care, primary care, and LCO development. Bringing this together because of the interdependency with Theme 3 to understand the differences and commonalities between the two. Another key piece of work is the understanding of what localities want to achieve, and priorities going into 2018-19 and 2020-21. 2nd element of paper details Continuity of Service Protocol: initially there was some resistance to adopt the principals due to financial concerns relating to transfer of large numbers of staff. This concern has been addressed. Localities will be offered the chance to voluntarily adopt the protocol. It was suggested to create some FAQ’s to clarify certain issues. There was broad support for the proposal with a proposed start date of 1st April.
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The last part of the paper details the leadership agenda which is underpinned by key principles being a common public service leadership programme We need to use previous leading GM approaches with the primary driver being people and place. Member of staff recruited to lead on workforce comms who will send out regular updates across the system. Last section is on workforce race equality we need to engage with the LCOs on this area. About to employ a Primary Care Workforce Lead. As a priority area we need to ensure the retention and development of clinical leadership we also need to engage with localities on this issue.
ACTION: Members noted the updates and approved the principle of the continuous service protocol Regular communications will be provided to inform the system of workforce developments – YR
8. POPULATION HEALTH
Quarterly update on the PH programme (SP, Mike Eecklaers) Significant moves re Public Health transformation since July 2017. First steps to creating a unified Population health system in 2016- by focusing on those resources held at GM level- PHE, NHSE and DPH network resources. 2016 onwards- GMHSCP- bringing to life commitments in Taking Charge and devolution agreement – H&SC response and Public Health clearly seen as system wide issue – with system wide response through agreement of single GM plan. There are up to 20 programmes which will have the biggest impact on the GM population. January’s Population Health Board included a focus on several project areas under development, including Health Checks, HIV and Lung Health Check Programme. The Board also endorsed a recommendation by the Population Health Investment Sub Group to approve the Health and Employment Investable proposition Had some very good news about Sport England: GM was chosen as one of the twelve sites to deliver initiatives around sport & exercise. 2018 Tobacco campaigns are planned /underway including ‘Don’t be the one’ as well as the Salford ‘Swap to Stop’ project, working with social housing providers in the city to offer e-cigarettes kit to social housing tenants to try and engage 1000 smokers in Salford to take up an offer of a reduced price e-cigarette kit. Make Smoking History Day on Monday; consolidate the strategy with the public and others about how we intend to take a multi-faceted approach to tackle this problem. Focused care workers have been in post for 9 months and are now embedded into pilot practices and we hope to see this making a further impact. The Food and Nutrition ‘traffic lights’ focusing on malnutrition for the over-65’s. Need to step-up the pace of change which is difficult as there is so much to be done. Huge ambition the reality is there is a large amount of work programmes. These will not be launched all at the same time but hope to roll out most in 2018-19. The Population Health Plan has 23 programmes we will look at making sure these programmes will deliver what they say they will.
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Nutrition is one of the biggest issues and we need to look at that across all of GM and involve councils. For example child nutrition and how we make sure food is available to children during school holidays. Preventative actions such as diet and exercise initiatives for the over-65s. A question was asked if we are doing enough comms around these issues? There was interest in the art therapy initiatives Sugar Smart badge for Brownies will be rolled out quickly these stories should have wider news coverage to raise awareness. Health Innovation Manchester have some very good initiatives: need to connect these together. Everyone is at a different stage of development with no one single model which will be relevant as these initiatives roll out and we need to be mindful of this. Noted members unsure of the time frame and what does ‘good’ looks like. Need a discipline around de-commissioning.
Sexual Health & Reproductive Health Strategy (David Boulger) Brought in a formative paper for maximum engagement noting the final product will look very different once scrutinised. Why are we doing this? 25,000 new cases of Sexually Transmitted Diseases (STDs) across GM in 2016 equates to 843 per 100,000. This must be re-balanced to be at worst commensurate with the national picture or at best better than the national picture. Concerned noted if the strategy goes far enough and understanding why is GM an outlier as we must be up-front about the failings. 2013 Health and Social Care Act, the funding comes from various bodies which present big challenges. It is an open access system, with a lot of confidentiality around it. Moved from a 10 service system to one system across GM as such we must make sure we have a good specification. New system where everybody pays for their residence to take away the perverse incentive to overcharge and thus over-treat. Took a lot of money out of the system in the past with new secondary care services in place. The only element of the system that has been struggling is primary care; now looking at what is offered at a GP and pharmacy level to see what the basic offer in a neighbourhood should be and what the specialist offer should look like. Reduction of HIV must be seen in a wider context of STD reduction. A number of people with HIV come from the BME population as such it is important to work with this group to reduce STI’s. Confident that the digital offer can help with patients reluctant to come through the door. Taken a number of areas with very poor performance such as late terminations. A central booking system has brought down waiting times. Looking at doing more with late-acting contraceptives to ensure that the right prescriptions are given. Sexual health to be multi-faceted model across localities; need to set standards across GM but this cannot be a once-size fits-all approach. Within the HIV eradication programme we are looking at the largest cohort at risk of getting HIV and looking behaviour change initiatives. It becomes difficult to set a locality standard compared to a GM standard. There is an understanding of the variances across localities; we need to make sure
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spend is in the right place and used in the right way. The Direction of travel was supportedBy DoCs; R Demaine agreed to be the GM DOC lead. Following observations made by DoCs: Clarification of how patients, the public and service users have been involved in developing the Strategy Objectives need to be made “SMART” A focus on primary care was noted, however further work to be undertaken to confirm ability to implement With HIV eradication resulting resources freed up requires further narrative Information on what could be decommissioned would be helpful (HIV Services are in the purview of specialised commissioning)
Draft GM Drug and Alcohol Strategy (David Boulger and Jennet Peters) This is also a formative strategy currently being engaged across the system. Why are we bothering? There are 65,000 dependant drinkers across GM. Hundreds of thousands thought to be drinking to harmful or hazardous levels. 33,306 children estimated to be living with a dependent drinker. 23,709 children who live with a problem drinker with a co-morbid mental health need. 1,195 who live with a foetal alcohol spectrum disorder. GM is a significant outlier in the country in terms of alcohol-specific mortality, admissions and drug-related death. 60% admission rates and 55% mortality rates which is above the national picture. GM is the worst conurbation in terms of alcohol related harm and the worst nationally. We need to reflect on whether the strategy works sufficiently to reflect the new delivery landscapes. Keep the focus on non-dependent drinking and over-the-counter drug addictions. The strategy may need to be stronger around primary care, particularly the role of pharmacy in primary care. Need for scale and experimentation in order to prove new models of care relating to drugs and alcohol. The Big Alcohol Conversation: A wide ranging dialogue across the GM population that acts in itself as an intervention, to discover why GM has such a problem compared to other parts of the country. Community alternatives to treatment: 82% of dependent drinkers do not engage with treatment programmes as they don’t perceive treatment as being right for them. A credible response look like for people with varying needs across localities need to be developed. Third focus is eradicating cases of foetal alcohol spectrum disorder (FASD). Estimate 30-40 children are diagnosed from an estimated 1,195, the scale of the challenge is huge. We estimate that 24% of all looked-after children have FASD with known the long- term problems in adoption and fostering placements for these children. Alcohol price would make a massive difference Manchester could potentially lead the way as this is a public health emergency issue. Note the impact of extra licencing laws around alcohol financially on a city like Manchester. Making a connection with the Maternity Board around FASD is important. One of the challenges is the need to be more closely linked with mental health services.
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The minimum price now has broad support in the AGG. A strategic commissioning function role should help develop a focus. Direction of travel was supported with the following observations for the next iteration: Clarification of how patients, public and users have been involved in the development of the Strategy. The objectives need to be made “SMART”. High level costings need to be included expected to come from TFOG needs to be more explicit including what can be decommissioned.
ACTION: The updates were noted and the direction of travel was supported The strategies will return to AGG when developed and costed
9. ELECTIVE HUB PROGRAMME
Janet Butterworth provided an update on the Elective Hub programme: - The Elective hub has come out of a national piece elective programme to encourage all STP areas to engage with elective work. Negotiation with NHSE confirmed we can look at funding in a way that meets the needs of our localities in GM. The paper submitted will go to a primary care advisory group, the Provider Board next week, and SPBE at the end of Feb. The principles are around improving elective work across GM noting that we do not want to work on any one area for a long time. We have overarching data quality worksheet. Completed a piece of scoping work around what elective services localities wanted. There were strong asks around data quality and the need to create standards across the board. Proposing three Task and Finish groups: - 1. Building on the work Jen Riley has done in Bolton; development of guidelines from local learning and analysis to support patients on elective and cancer pathways to go straight to scope following referral onto a gastro pathway. Exploration of the value of FIT testing as a GM option to manage gastro demand and improve patient experience. 2. Work led by Ranjit Gill in Stockport: The increase in provision of dermatoscopes in Stockport supported by training, enabling more detailed examination of skin lesions. Development of a more robust imaging sharing mechanism which integrates into electronic booking processes, working alongside MDSAS and Emis. Web with support from the GM Digital Team and continued engagement from Salford Royal Hospital, providers of tertiary dermatology services. Consider methodologies for reducing consultant to consultant referrals in the dermatology specialty. The Elective Hub have secured additional funding from NHSE to support this work programme 3. Starting with the Oldham MSK model which has been established for a number of years: Understand the key standards and key areas of impact for the service. Engage with a number of services to understand the differences and impact on referrals, clinical management and patient experience. Support testing
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across services. Develop a toolkit of key standards to support commissioning and contract management. Consider the benefit of training in the areas of triage models and shared decision making. Data quality initiatives are being developed In relation elective care, triage, PTL management which can be variable from trust to trust. If these systems are not managed properly, patients can get lost in the system. We want to work with our providers in an open and transparent way using our new visualisation tool around tableaux. Asking providers to share their PTL’s and flow those into an open and transparent system to see how they are performing in terms of capacity across the system. Competencies in managing elective care: The British Lung Foundation have agreed to do some action learning steps to learn about what matters to people who do use elective services. Looking at a launch event on 21st March. We have to be clear about our approach to EUR. MOD advised that in terms of Planned Care Lead their remit has become huge and difficult to manage. Jen Riley the Planned Care Leads Chair has linked in with JB on how they support the elective programme that have a defined number of priorities and how GM supports that. Needs to be much more system approach with one set of priorities that feed into Elective Hub Programme. Noted the inclusion of Right Care which has been scoped within the programme. Noted that the Dermatology and other programmes that there is a collaborative commissioning arrangement that needs to be captured.
ACTION: AGG noted the update and need to align Planned Care Leads – MOD Collaborative commissioning work needs to be captured with the elective work – JB Elective Hub Launch Event 21st March venue to be confirmed.
10. PERFORMANCE & DELIVERY BOARD/SPBE
SPBE: Paperwork has gone out. Performance & Delivery Board: One next week.
ACTION: RB to feed each CCG position statement back into the CHC.
BUSINESS ITEMS
11. CFO UPDATE
SD has sent apologies – notes have been circulated in the monthly summary
12. DoC Update
Update provided by MOD as DoC Chair: -
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DoCs agreed to fund the ODN team (on a 50:50 split with providers) for a further period of 12 months. CO’s having been reviewing their CCG progression in meeting the neuro and stroke rehabilitation specification. DoCs agreed to continue funding to support the cancer commissioning infrastructure for a fixed term period of 2 years supported by the CFOs also. This agreement was made in context of a team that is already in situ and we need to look at future funding to support the commissioning hub going forward. Living with & Beyond Cancer – draft strategy currently being socialised. Targets identified as unrealistic and needs further review. Concerns noted around the investment required to deliver the cancer plan: there has not been that much separately identified in locality resources for the cancer plan. Dermatology Groups: The work is looking at workarounds as there are not enough Dermatologists in the system. On concerns around the investment required to deliver the cancer plan: We have had our locality session in Bury there are 6 more localities to go. There has not been that much separately identified in locality resources for the cancer plan. DoCs received proposal from Richard Preece for the potential of having a GM approach to CHC. DoCs reviewing proposal and providing comments by CCG supported further by RB. Cautionary note on the CHC; HMR has the lowest spend in the North of England we have to be careful that this isn’t compromised further. National TCH pilot led by Care England and adopted by H&SCP to define the model and identify minimum standards which would be required for care homes to be recognised as a TCH. The programme aims to significantly improve the quality of care being provided at care homes across GM which will include a review of workforce Market management in the independent sector needs to be about cost, payment, and the market.
ACTION: Agreed the Neuro rehab ODN team finding (on a 50:50 split with providers) for a further period of 12 months. Agreed funding to support the cancer commissioning infrastructure for a fixed term period of 2 years
13. AOB
As a CCG we have financial challenges, one of the things on the ‘unthinkable list’ is denying the choice and repatriate private services. If we don’t do this work together then we could be setting different moral standards across GM. A lot of activity with the independent sector tends to be the same consultants. The rise in orthopaedics is a real challenge. We need to understand NHS position on this and learn from the Blackpool experience where Monitor put an enforcement order in to make sure Blackpool offered choice and compensation was awarded. We have to make sure the regulators will support our direction. LCO’s are a perfect opportunity if we have capitated budgets devolved to SCO’s, they become subcontractors for care and they decide what and where they pay for
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services. If there is a clinical or outcome rationale for using NHS over private we should retain NHS. Some areas are currently trying to minimise the independent sector spend through discussions with them and other trusts on how we can achieve that aim. We extended an invitation to Health Innovation Manchester to come and speak today but they could not attend but will come next time.
ACTION: Health Innovation Manchester to be booked in for the next AGG 6th March.
FUTURE AGENDA ITEMS HInM Digital Report Theme 3 engagement and data modelling Quality Update GM Health Checks
ITEMS FOR INFORMATION ONLY AGG Final Minutes Association Monthly Board Summary GM H&SCP Chief Officer Report EUR Policy Development Programme
NEXT MEETING DATE: 06/03/2018 TIME: 13:30 -16:30 Venue: AJ Bell Stadium, 1 Stadium Way, Barton-upon-Irwell, Salford, M307EY
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NHS SALFORD CLINICAL COMMISSIONING GROUP GOVERNING BODY MEETING AGENDA ITEM NO 8 (e)
Item for: Decision/Assurance/Information
23 May 2018
REPORT OF: Chair of CCG Audit Committee
DATE OF PAPER: 10 May 2018
SUBJECT: CCG Audit Committee Update
IN CASE OF QUERY Ms Elaine Vermeulen, Deputy Chief Finance PLEASE CONTACT: Officer 0161 212 4874
Please tick which strategic priorities the paper relates to: STRATEGIC PRIORITIES:
Quality
Community Based Care
Integrated Care
In Hospital Care
Long Term Conditions and Mental Health
Effective Organisation
PURPOSE OF THIS PAPER:
This paper updates the NHS Salford Clinical Commissioning Group Governing Body Board on decisions and risks identified at the last Audit Committee meeting held on 26 April 2018.
RECOMMENDATION OF THIS PAPER:
The NHS Salford Clinical Commissioning Group Governing Body is asked to note the contents of this report and the assurances provided.
(Please see further explanatory requirements overleaf)
Further explanatory information required
HOW WILL THIS BENEFIT THE Provides assurance that controls are effective. HEALTH AND WELL BEING OF SALFORD RESIDENTS OR THE CLINICAL COMMISSIONING GROUP?
WHAT RISKS MAY ARISE AS A None. RESULT OF THIS PAPER? HOW CAN THEY BE MITIGATED?
WHAT EQUALITY-RELATED RISKS None. MAY ARISE AS A RESULT OF THIS PAPER? HOW WILL THESE BE MITIGATED?
DOES THIS PAPER HELP ADDRESS Summarises the work of the Audit Committee ANY EXISTING HIGH OR EXTREME around controls assurance. RISKS FACING THE ORGANISATION? IF SO WHAT ARE THEY AND HOW DOES THIS PAPER REDUCE THEM?
PLEASE DESCRIBE ANY POSSIBLE None. CONFLICTS OF INTEREST ASSOCIATED WITH THIS PAPER.
PLEASE IDENTIFY ANY CURRENT None. SERVICES OR ROLES THAT MAY BE AFFECTED BY ISSUES WITHIN THIS PAPER:
Footnote:
Members of NHS Salford Clinical Commissioning Group Governing Body will read all papers thoroughly. Once papers are distributed no amendments are possible.
Document Development
Not Comments and Date Process Yes No Outcome Applicable (i.e. presentation, verbal, actual report) Public Engagement X (Please detail the method ie survey, event, consultation) Clinical Engagement X (Please detail the method ie survey, event, consultation) Has ‘due regard’ been given to Equality X Analysis (EA) of any adverse impacts? (Please detail outcomes, including risks and how these will be managed) Legal Advice Sought X Presented to the Commissioning Committee. X Presented to the Health and Wellbeing Board X Presented to the Integrated Commissioning X Board Presented to any other groups or committees, This report is a summary of the Minutes of the previous including Partnership Groups meeting of the CCG Audit meeting were approved by (Please specify in comments) Committee. the CCG Audit Committee.
Note: Please ensure that it is clear in the comments and date column how and when particular stakeholders were involved in this work and ensure there is clarity in the outcome column showing what the key message or decision was from that group and whether amendments were requested about a particular part of the work.
Audit Committee Update
1 Executive Summary
This report details the main issues arising from the CCG Audit Committee Meeting held on 26 April 2018.
The Governing Body is asked to note the contents of this report and the assurances provided.
2 Audit Committee Minutes
2.1 The minutes of the previous meeting were approved subject to one amendment.
3 Matters Arising
3.1 The log of outstanding matters arising was reviewed and it was agreed that all outstanding actions could be closed.
4 Reports Presented to the CCG Audit Committee
4.1 Annual Items 4.1.1 Review Draft Annual Report The Director of Corporate Services presented the draft Annual Report and requested any comments. She explained the timeframe for producing the final report and that this will be presented to the Governing Body meeting in May. It was agreed that External Audit and the Members of the Audit Committee will provide comments by the end of week commencing 30 April 2018.
4.1.2 Presentation of Draft Annual Accounts The Deputy Chief Finance Officer presented the draft Annual Accounts. She explained that the CCG had met all of its statutory financial duties for 2017/18. It was noted that the CCG had planned to breakeven in 2017/18, but has generated a surplus of £2.2 million due to releasing the un-committed reserve of £1.8 million and the Category M prescribing savings of £0.4 million which the CCG was required to retain. The External Auditors (Grant Thornton) will now review the accounts in detail and will provide comments by the middle of May.
4.2 Internal Audit 4.2.1 Internal Audit Progress Report The Audit Manager, Mersey Internal Audit Agency (MIAA) presented the Progress Report and highlighted that three reports had been finalised since the last Audit Committee meeting. These were in relation to Management of Conflicts of Interest, the Use of Research in Commissioning and Information Governance. The group noted the contents of the report.
4.2.2 Review the Head of Internal Audit Opinion Report The Audit Manager, MIAA explained that this is an annual report which supports the Annual Governance Statement. He explained that MIAA had given the CCG Substantial Assurance on the Systems of Internal Control. The group accepted the report.
4.2.3 MIAA Insight The Audit Manager, MIAA explained that this provides details of events which are free for members of the Audit Committee to attend. He drew the Committee’s attention to one event taking place on 11 May 2018 entitled “Where Next for Commissioning”. The group noted the contents of the paper.
4.2.4 Capita PCSE ISAE 3402 Type II Interim Report The Deputy Chief Finance Officer presented the paper. Concern was expressed that Capita had reported a pre-tax loss of £515 million and that they had asked shareholders to raise money. It was agreed that this should be added to the CCG’s Risk Register as there is a potential for this to impact on the CCG and assurance is needed from NHS England regarding any plans to review service delivery and ongoing relationships with Capita, as the CCG’s contractual relationship with Capita is through NHS England.
4.3 External Audit 4.3.1 External Audit Progress Report The Director of Audit, Grant Thornton presented the report. He explained that the report provides details of where External Audit are in their annual cycle of work. The group noted the report.
4.3.2 Approval of the Annual External Audit Fee It was noted that the CCG had already agreed last year to a three year contract with Grant Thornton and therefore no fee letter was required this year.
4.4 Counter Fraud 4.4.1 Draft Counter Fraud Workplan The Local Counter Fraud Specialist, TIAA presented the paper and explained that the document combines the Risk Assessment and Strategic Workplan. He explained that the document provides a number of known fraud risks and these are provided in a table which is split into three categories – Nationally identified risks, TIAA’s portfolio of fraud clients across the country and Salford CCG specific risks.
It was noted that the CCG are in a strong position for a number of the risks and the scoring of these risks has contributed to the plan included in Annex B of the document. He highlighted that TIAA have chosen Continuing Health Care and Personal Health Budgets as an area to concentrate on in 2018/19.
The group agreed the workplan for 2018/19.
4.4.2 The Local Counter Fraud Annual Report The Local Counter Fraud Specialist, TIAA explained that this document will come to a future Audit Committee meeting. He explained that the self-review tool had
been submitted by the deadline of 31 March 2018 and the organisation was scored as green. It was noted that all work for 2017/18 had been completed.
4.5 Other Regular Items 4.5.1 Approval of Amendments to the Scheme of Reservation and Delegation It was noted that no amendments had been made to the Scheme of Reservation and Delegation since the last meeting of the Audit Committee.
4.5.2 Presentation of Gifts and Hospitality/Register of Interests The Director of Corporate Services presented the documents for information and explained that there is some data cleansing work needed on the register of interests, which will be done over the next few months. The group noted this.
5 Recommendations
5.1 The NHS Salford Clinical Commissioning Group Governing Body is asked to note the contents of this report and the assurances provided.
Mr Edward Vitalis Chair of the Audit Committee