Governing Body Meeting in Public Thursday 25 July 2019

Governing Body Meeting in Public

Thursday 25th July 2019 [Intentionally left blank] Governing Body Public Meeting Thursday 25th July 2019, 9:00am-11:00am Focolare Centre (Meeting Room 1) – Welwyn Garden City

AGENDA

Item Time Subject Report Action

1. 09:00 WELCOME AND APOLOGIES FOR ABSENCE Chair - Verbal

2. DECLARATIONS OF INTERESTS . To receive any new declarations of interest or Chair - Verbal declarations relating to matters on the Agenda. . To reconfirm current declarations on the Register of Interests are accurate and up-to- date.

3. 09:05 MINUTES OF THE LAST MEETING HELD ON RD 23 MAY 2019 AND MATTERS ARISING Chair Approve Enclosed

4. ACTION TRACKER To discuss the progress against the Chair Discuss Enclosed Action Tracker.

GOVERNANCE, FINANCE AND PERFORMANCE 5. 09:10 CHIEF EXECUTIVE’S REPORT Chief Executive Discuss Enclosed

6. 09:20 GOVERNANCE REPORT Chief Finance Approve Enclosed Officer

7. 09:30 7A - NHS INTERIM PEOPLE PLAN: BRIEFING FOR BOARD MEMBERS Director of Note Enclosed Workforce 7B - HEALTH AND SOCIAL CARE WORKFORCE STRATEGY, MAY 2019 Note Enclosed

8. 09:40 FINANCE REPORT MONTH 2 2019-20 Chief Finance Information Enclosed Officer

9. 09:50 PRESCRIBING REPORT Director of Discuss Enclosed Nursing and Quality

Page 1 of 3 Item Time Subject Report Action

10. 10:00 INTEGRATED PERFORMANCE AND QUALITY REPORT Director of Note Enclosed Nursing and Quality

11. 10:10 DELEGATED PRIMARY MEDICAL CARE COMMISSIONING: QUARTER 1 2019/2020 Director for Note Enclosed REVIEW Primary Care Development

12. 10:20 QUALITY COMMITTEE ANNUAL REPORT Lay Member, Note Enclosed Governance and Audit

13. ANNUAL COMPLAINTS REPORT 2018/19 Director of Note Enclosed Nursing and Quality

14. SAFEGUARDING CHILDREN, LOOKED AFTER CHILDREN AND CARE LEAVERS ANNUAL Director of Note Enclosed REPORT Nursing and Quality

15. 10:35 CONSOLIDATED FUNDING FRAMEWORK 2018- 19: OUTCOMES AND LEARNING Chief Finance Discuss Enclosed Officer

16. 10:45 PRIMARY CARE COMMISSIONING COMMITTEE MINUTES Lay Member, Note Enclosed To note the Minutes of the meeting held on Co- electronically . 2nd May 2019 Commissioning 17. LOCALITY COMMITTEE MINUTES To note the Minutes of the locality meetings held on: Locality Lead Note Enclosed . Lower Lea Valley – 27th March 2019, 3rd April GPs electronically 2019 . North Hertfordshire –21st March 2019, 15th May 2019 . Stevenage – 2nd April 2019, 14th May 2019 . Stort Valley and Villages – 25th April 2019, 23rd May 2019 . Upper Lea Valley – 16th January 2019 . Welwyn and Hatfield – 28th March 2019

Page 2 of 3 Item Time Subject Report Action

18. JOINT COMMISSIONING AND PARTNERSHIP PROGRAMME COMMITTEE MINUTES Director of Note Enclosed To note the Minutes of the meeting held on: Nursing and electronically Quality . 27th March 2019 19. 10:50 QUESTIONS FROM MEMBERS OF THE PUBLIC To receive any questions from members of the - - - public.

20. 10:55 ANY OTHER URGENT BUSINESS To consider any other matters which, in the opinion All Discuss Verbal of the Chair, should be considered as a matter of urgency.

21. 11:00 DATE OF NEXT MEETING - - - 24th October 2019 18:00 – 20:00 - Public Session

Focolare Centre, Meeting Room 1

Resolution to exclude members of the press and public The Governing Body of the Clinical Commissioning Group resolves that representatives of the press, and other members of the public, be excluded from the remainder of this meeting having regard to the confidential nature of the business to be transacted, publicity of which would be prejudicial to the public interest, in accordance with the Public Bodies (Admissions to Meetings) Act 1960.

Page 3 of 3 Agenda Item No: 2

Date of Meeting: 25th July 2019

Governing Body Meeting in Public

Paper Title: Registers of Interest

Decision or Approval Discussion Information

Report author: Maryla Hart, Governing Body Administrator

Report signed off by: Sarah Feal, Company Secretary

Executive Summary: The purpose of this paper is to receive any new declarations of interest or declarations relating to matters on the Agenda.

Members to reconfirm their current declarations on the Declarations of Interests Register are accurate and up-to-date (see Governance Report – Appendix 3).

In addition, members are asked to confirm that all offers of Gifts and Hospitality received in the last 28 days have been registered with the Governance and Corporate Affairs Team.

Recommendations . To review the Register of Interests of the Governing Body or to the members: relevant committee membership, and highlight any potential conflicts, which the Chair needs to manage: http://www.enhertsccg.nhs.uk/declarations-interest

. To declare those interests at the start of the meeting. . To complete a declaration form available from the Company Secretary. This will be recorded in the Minutes of the meeting.

Conflicts of Interest . There are none identified. involved:

Page | 1 Conflict of Interest Definitions

The following table describes the sub-classifications of interests:

Type Description Financial Interests This is where an individual may get direct financial benefits from the consequences of a commissioning decision. Non-Financial This is where an individual may obtain a non-financial professional Professional benefit from the consequences of a commissioning decision, such Interests as increasing their professional reputation or status or promoting their professional career. Non-Financial This is where an individual may benefit personally in ways which are Personal Interests not directly linked to their professional career and do not give rise to a direct financial benefit. Indirect Interests This is where an individual has a close association with an individual who has a financial interest, a non-financial professional interest or a non-financial personal interest in a commissioning decision.

Page | 2 17/07/2019 Declarations of Interest Register 2019-20

First NameLast Name Current position(s) held in Declared Interest Type of interest: Is the Nature of Interest Date of Interest: Action taken to mitigate risk the CCG (Name of the organisation and interest i.e. Governing Body nature of business) direct or member; Committee indirect? member; Member practice; CCG employee or other Financial Non- Non- Indirect From: To: Date received Date no change financial financial interest form received professio personal nal

Mark Andrews GP Governing Body Hertfordshire Community NHS y Indirect Wife is employee of HCT (Hertfordshire 01/04/2017 Ongoing Declare interests as required 02/05/2018 14/02/2019 Member, Representing Trust Community NHS Trust) as a Perinatal Upper Lea Valley Locality / Mental Health Lead. Chair of Upper Lea Valley Commissioning Board / Clinical Cancer and End of Life Lead

Mark Andrews GP Governing Body The Limes Surgery y Direct Salaried General Practitioner at the Limes 01/04/2018 31/03/2019 Declare interests as required 02/05/2018 14/02/2019 Member, Representing Surgery. I no longer represent the Limes at Upper Lea Valley Locality / Locality Meetings. I am chair of Upper Lea Chair of Upper Lea Valley Valley Commissioning Board. Commissioning Board / Clinical Cancer and End of Life Lead

Tara Belcher GP Governing Body The Portmill Surgery y Direct GP Partner providing commissioned 01/04/2007 Ongoing Declaration 17/01/2018 Member representing North 114 Queen Street, Hitchin, Herts services Mitigation embedded in GGC 18/03/2019 Herts Locality SG4 9TH processes for all GP GB members.

Tara Belcher GP Governing Body 12 Point Care Ltd (company y Direct The Portmill Surgery has a share in the 25/09/2014 Ongoing Will declare before relevant 17/01/2018 Member representing North number 09214266) local Federation, 12 Point Care Ltd which discussions. 18/03/2019 Herts Locality Kingston Smith LLP may provide bid for services Orbital House, 20 Eastern Road, commissioned by the CCG Romford, Essex RM1 3PJ

Tara Belcher GP Governing Body Health Education England y Direct GP Trainer (Health Education England) 03/10/2012 Ongoing Declaration 17/01/2018 Member representing North (Eastern Deanery) 18/03/2019 Herts Locality

Tara Belcher GP Governing Body Portmill Surgery y Direct The Portmill Surgery holds the contract for 01/04/2017 Ongoing Declaration 08/03/2019 Member representing North the Special Allocation Scheme for ENHerts Herts Locality and Herts Valleys CCGs.

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Tara Belcher GP Governing Body Mills and Reeve LLP (company y Indirect Spouse Christopher Belcher is a Partner at 01/10/2009 Ongoing Declaration 17/01/2018 Member representing North number OC326165) Mills & Reeve LLP who have a contract Abstain from any discussion / 18/03/2019 Herts Locality 4th Floor, Monument Place, 24 with ENHerts CCG and may bid for other votes in which Mills and Reeve Monument Street, London EC3R legal work from this and other CCGs and have a financial interest 8AJ Hospital Trusts.

Denise Boardman Director for Primary Care Occupational Therapist y Direct As a registered Occupational Therapist and Sep-17 Ongoing Any requests received are 16/04/2018 09/01/2019 Development Royal College of Occupational former member of the Royal College of discussed in 1:1 meetings with Therapy Occupational Therapy Professional my line manager prior acceptance. Practice Board, I receive “ad hoc” requests to deliver presentations to specialist sections of the Royal College of Occupational Therapy.

Dianne Desmulie Lay Member - Co- Pieve Solutions Ltd Company No, y Direct & Director of my own company: Pieve Nov-14 Ongoing Provide new declaration of 21/02/2018 05/02/2019 Commissioning 5600186. Registered Indirect Solutions Ltd. I have worked through this interest in event of either myself address: Orchard House, Park company as a freelance Management or my husband entering into a Lane, REIGATE, Surrey, RH2 8JX. Consultant. consultancy contract with a Nature of business: I have My husband, Robert Pinkham, is a supplier to the CCG worked through this company as freelance management consultant and also a freelance Management a director of this company Consultant.

Dianne Desmulie Lay Member - Co- Hoddesdon Carers' Support Hub y Direct I am the Volunteer Hub Lead for the Feb-16 Ongoing Declare non financial personal 21/02/2018 05/02/2019 Commissioning Hoddesdon Carers' Support Hub. This is interest at any meeting where part of Carers in Hertfordshire, a charity contract or performance of CinH which contracts with Herts County Council (Carers in Hertfordshire) is to be and the CCG and NHS locally. This discussed particular project is funded by the Big Lottery.

Dianne Desmulie Lay Member - Co- Hanscombe House Patient y Direct I am a practice patient and a Member of Nov-14 Ongoing Declare non financial personal 21/02/2018 05/02/2019 Commissioning Participation Core Group Hanscombe House Patient Participation interest where funding or Core Group. I am acting secretary for the performance of Hanscombe group. House practice is to be discussed

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Sarah Dixon GP Governing Body Member South Street Surgery y Direct GP Partner, South Street Surgery. Apr-18 Ongoing Declare conflict at meetings when 20/11/2018 29/01/2019 representing Stort Valley necessary and Villages

Sarah Dixon GP Governing Body Member Stort Valley and Villages (SVV) y Direct GP Workforce and Education Lead for Stort Apr-18 Ongoing Declare conflict at meetings when 20/11/2018 29/01/2019 representing Stort Valley Locality Valley and Villages (SVV) necessary and Villages

Sarah Dixon GP Governing Body Member STORT VALLEY HEALTHCARE y Direct South Street Surgery Practice is a member Apr-18 Ongoing Declare conflict at meetings when 20/11/2018 29/01/2019 representing Stort Valley LIMITED of Locality Federation. necessary and Villages Registered office address - C/O GP Partner Dr Kwasi Appiah is a Parsonage Surgery Hertfordshire Federation Director & Essex Community Hospital, Cavell Drive, Bishops Stortford, Hertfordshire, United Kingdom, CM23 5JH Company number 09489615 (Locality Federation)

Sarah Dixon GP Governing Body Member West Essex Vocational Training y Direct GP Trainer West Essex Vocational Training Apr-18 Ongoing Declare conflict at meetings when 20/11/2018 29/01/2019 representing Stort Valley Scheme Scheme and Princess Alexandra Hospital necessary and Villages and Foundation Programme Princess Alexandra Hospital Foundation Programme

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Sarah Dixon GP Governing Body Member NHS England – Midlands and East y Direct GP Appraiser Apr-18 Ongoing Declare conflict at meetings when 20/11/2018 29/01/2019 representing Stort Valley necessary and Villages

Sharn Elton Director of Operations Nil 20/12/2017 09/01/2019

Linda Farrant Lay Member, Governance Audit Committee of Care Quality y Direct Independent Member of Audit Committee Jul-15 Ongoing As appropriate to situation 09/03/2018 12/01/2019 and Audit Commission (CQC) of Care Quality Commission (CQC)

Linda Farrant Lay Member, Governance South Street Surgery, Bishop y Direct Patient of South Street Surgery 2001 30/04/2019 As appropriate to situation 09/03/2018 12/01/2019 and Audit Stortford

Beverley Flowers Chief Executive / Herts at Home Ltd. Company y Direct Non remunerated Non-Executive Director 01/02/2019 Ongoing Declare at meetings where 22/01/2019 Accountable Officer number 11360947. Registered role with Herts at Home Ltd a company relevant. office address County Hall, Pegs established and fully owned by Lane, Hertford, United Kingdom, Hertfordshire County Council to provide SG13 8DE. . care and support within the County.

Beverley Flowers Chief Executive / Hertfordshire Criminal Justice y Direct Member of the Hertfordshire Criminal 31/01/2017 Ongoing None 22/01/2019 Accountable Officer Board Justice Board representing the NHS

Sachin Gupta GP Governing Body Member Garden City Practice, 11 y Direct Partner -Garden City Practice, 11 Guessens 01/08/2010 Ongoing Declare interests at meetings 29/01/2019 Representing WelHat Guessens Road, Welwyn Garden Road, Welwyn Garden City, AL8 6QW. GP where necessary Locality. Locality Co-Chair City, AL8 6QW. Partner since 01/08/2010. at WelHat Locality Meetings.

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Sachin Gupta GP Governing Body Member Ephedra Healthcare Ltd, Suite 3, y Direct Garden City Practice is a shareholder in 01/08/2010 Ongoing Declare interests at meetings 29/01/2019 Representing WelHat Middlesex House, Rutherfield Welwyn Hatfield GP Federation - Ephedra where necessary Locality. Locality Co-Chair Close, Stevenage, SG1 2EF. Healthcare Ltd at WelHat Locality Meetings. Company No: 06560722 (Welwyn Hatfield GP Federation)

Sachin Gupta GP Governing Body Member SG Healthcare Limited. y Direct and Director and shareholder in company used 03/12/2012 Ongoing Declare interests at meetings 29/01/2019 Representing WelHat Registration No: 08316300 Indirect for locum GP sessions, Urgent Care where necessary Locality. Locality Co-Chair Address: Bracey's Accountants, sessions and GP appraisal work. at WelHat Locality Meetings. Wilbury Way, Hitchin, SG4 0TW. Wife is a shareholder.

Sachin Gupta GP Governing Body Member Blossom Group Holdings Limited, y Direct Director and shareholder in group holdings 01/03/2017 Ongoing Nil as not involved in any 29/01/2019 Representing WelHat Company no 10645623 company for care homes. ENHCCG service provision Locality. Locality Co-Chair 1, The Cam, Wilbury Way, Hitchin, at WelHat Locality Meetings. SG4 0TW

Sachin Gupta GP Governing Body Member Pearl Blossom Ltd, Co. No. y Direct Director: Pearl Blossom Limited. 05/05/2016 Ongoing Nil as not involved in any 29/01/2019 Representing WelHat 10163796. Incorporated ENHCCG service provision Locality. Locality Co-Chair 05/05/2016. Address: Bracey's at WelHat Locality Meetings. Accountants, Wilbury Way, Hitchin, SG4 0TW. Provider of a residential nursing care home in Lincolnshire

Sachin Gupta GP Governing Body Member Amber Blossom Ltd, Co No y Direct Director: Amber Blossom Ltd. 01/05/2017 Ongoing No conflict perceived as trading 29/01/2019 Representing WelHat 10673689 Incorporated 16/03/2017. outside of Hertfordshire. Locality. Locality Co-Chair Address: Bracey's Accountants, at WelHat Locality Meetings. Wilbury Way, Hitchin, SG4 0TW. Provider of a residential care home in Lincolnshire.

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Sachin Gupta GP Governing Body Member Jade Blossom Ltd, Co. No. y Direct Director: Jade Blossom Limited. 08/01/2018 Ongoing Nil as not involved in any 29/01/2019 Representing WelHat 11137242. Incorporated 08/01/18. ENHCCG service provision Locality. Locality Co-Chair Address: Bracey's Accountants, at WelHat Locality Meetings. Wilbury Way, Hitchin, SG4 0TW. Operates care homes in Lincolnshire.

Sachin Gupta GP Governing Body Member Ruby Blossom Limited, company y Direct Director – no trading business at present 01/09/2018 Ongoing Nil as not involved in any 29/01/2019 Representing WelHat no 11589368 ENHCCG service provision Locality. Locality Co-Chair 1, The Cam, Wilbury Way, Hitchin, at WelHat Locality Meetings. SG4 0TW

Sachin Gupta GP Governing Body Member Diamond Blossom Limited, y Direct Director – no trading business at present 01/09/2018 Ongoing Nil as not involved in any 29/01/2019 Representing WelHat company no 11589396 ENHCCG service provision Locality. Locality Co-Chair 1, The Cam, Wilbury Way, Hitchin, at WelHat Locality Meetings. SG4 0TW

Sachin Gupta GP Governing Body Member Lotus Services and Management y Direct Director – Admin services activities 01/01/2019 Ongoing Nil as not involved in any 29/01/2019 Representing WelHat Limited, company no 11776771 ENHCCG service provision Locality. Locality Co-Chair 18-20 High Street, Stevenage, SG1 at WelHat Locality Meetings. 3EG

Sachin Gupta GP Governing Body Member NHS England y Direct I am a Disciplinary Specific Practitioner 10/07/1905 Ongoing No conflict perceived 29/01/2019 Representing WelHat (DSP) for NHSE – PAG (Performance Locality. Locality Co-Chair Advisory Group) meetings and PLDP at WelHat Locality Meetings. (Performers List Decision Making) Panel. I have not attended any meetings in role in the last 12 months

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Russell Hall GP Board Member / Locality GP Practice, Chells Way, y Direct GP Partner, Chells Way Surgery. GP May-00 Ongoing Declare at meetings 01/02/2018 14/01/2019 Co-Chair Stevenage Stevenage, SG2 0NH Partner and Provider - GMS Services.

Russell Hall GP Board Member / Locality Stevenage Health Ltd (Stevenage y Direct Chells Practice is a member of Stevenage Jul-15 Ongoing Declare at meetings 01/02/2018 14/01/2019 Co-Chair Stevenage Federation) Federation, a private company.

Rachel Joyce Medical Director Spire Harpenden Hospital and y y Direct/ Married to Ear, Nose and Throat Surgeon 2000 Ongoing Will declare any 07/05/2019 Pinehill Ramsay Hospital In Indirect who works at these hospitals. Income from potential interest at Hitchin, One Hatfield Hospital Private Practice is shared. the start of any (Private Hospitals) Locally. relevant meeting, to allow the Chair to manage the conflict. Will not be on any procurement panels for this specialty.

Rachel Joyce Medical Director Herts and West Essex y Direct Clinical and Professional Director of the Apr-19 Mar-20 Will declare any potential interest 07/05/2019 Sustainability and Tranformation Herts and West Essex STP with any relevant agenda items Partnership (STP)

Pragasen Moodley Chair, East and North Herts Stanmore Medical Group y Direct Principal GP Partner, 01/09/2018 Ongoing I declare this at meetings where 01/10/2018 10/01/2019 CCG 5 Stanmore Road, Stevenage, SG1 Stanmore Medical Group relevant according to the 3QA [Canterbury Way Surgery & St Nicholas statutory guidelines. Health Centre have both fully merged with the Stanmore Medical Group] Both provider and commissioner

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Pragasen Moodley Chair, East and North Herts AVM Medical. Suite 3 Middlesex y Direct Director: AVM Medical 01/09/2018 Ongoing I declare this at meetings where 01/10/2018 10/01/2019 CCG House, Rutherford Close, relevant. Stevenage, Hertfordshire, United Kingdom, SG1 2EF. Company number 10507387 I use this company to carry out private medicals and nursing home ward rounds

Pragasen Moodley Chair, East and North Herts Stevenage Health Limited, Dr. Raj y Direct My Practice is part of the Federation. 01/09/2018 Ongoing I declare this at meetings where 01/10/2018 10/01/2019 CCG Kaja, The Health Centre, Stanmore Stevenage Health Limited. I am not directly relevant. Road, Stevenage, Hertfordshire, involved. England, SG1 3QA. Company number 08877494

Pragasen Moodley Chair, East and North Herts Dr Anindita Saha, known as Dr y I am in a relationship with Dr Saha, who is 01/09/2018 Ongoing Written declaration made. 01/10/2018 10/01/2019 CCG Rini Saha a GP in Stevenage and a GP Governing Body Member for Stevenage as of 01/10/2018.

Dermot O'Riordan Secondary Care West Suffolk NHS Foundation y Direct Consultant Surgeon & Chief Clinical Sep-01 Ongoing Declare in line with conflict of 21/03/2019 Representative on the Trust Information Officer, West Suffolk NHS FT interest policy. Governing Body

Dermot O'Riordan Secondary Care East Suffolk and NE Essex NHS y Indirect My wife is a consultant in East Suffolk and 2017 Ongoing Declare in line with conflict of 21/03/2019 Representative on the Foundation Trust NE Essex NHS Foundation Trust interest policy. Governing Body

Dermot O'Riordan Secondary Care Kheiron Medical y y Indirect My wife does sessional advisory work for 2018 Ongoing Declare in line with conflict of 21/03/2019 Representative on the Kheiron Medical. Nature of business: interest policy. Governing Body involved in use artificial intelligence in interpreting mammograms

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Alan Pond Chief Finance Officer GP Partner in Herts Valleys CCG y y Indirect Partner (Corina Ciobanu) 01/08/2010 Ongoing If ENHCCG ever seeks to procure 11/12/2017 09/01/2019 (Haverfield Surgery, Kings services from GPs and/or GP Langley) and Chair of Dacorum Surgeries outside the CCG, I will Locality keep confidential any information I receive that could be of benefit to Haverfield Surgery and/or Corina Ciobanu. Should Haverfield Surgery and/or Corina Ciobanu submit a proposal to undertake any work for ENHCCG I will declare this interest and will not take part in any discussions and/or decisions on any appointment.

Alan Pond Chief Finance Officer Director of Assemble Community y Direct These companies form the LIFT (Local Jul-08 Ongoing My role on the Board of the LIFT 11/12/2017 09/01/2019 Partnership Ltd (Company Improvement Finance Trust) for South East Company Group is to represent Number 06471276) and associated Midlands which was created to develop the interests of the local public companies community premises for the NHS. The sector, provide insight, but also to Assemble Fundco 2 Ltd (Company shares in the companies are held by oversee the financial and Number 08309498) Guildhouse Ltd and Community Health governance arrangements of the Assemble Holdco 2 Ltd (Company Partnership, the latter being a company companies. Number 08309495) wholly owned by the Department of Health. The Group of Companies was Wolverton Holdings (Company The directorship is unpaid, nominated by created to provide benefits to the Number 08307564) Community Health Partnerships and NHS locally and a conflict is Wolverton Fundco 1 Ltd represents the interests of the CCGs in the highly unlikely to occur. Should (Company Number 08306830 LIFT area, including East and North any conflict of interest arise, I Assemble Fundco 1 Ltd (Company Hertfordshire CCG. would excuse myself from both Number 06471659) parties for the relevant matter and Assemble Holdco 1 Ltd (Company should an Ongoing conflict arise Number 06471233) would resign my director position All of 128 Buckingham Palace with the Group of Companies Road, London, SW1W 9SA.

Sheilagh Reavey Director of Nursing & Daughter y Indirect Daughter undertaking bank admin work 01/10/2019 Ongoing Not a decision making post and 07/02/2019 Quality within Prior Approval/IFR Team line management, time sheets HR issues etc through AD not Director. Independent CCG Director oversaw recruitment.

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Anindita "Rini" Saha GP Governing Body King George Surgery y Direct GP Partner, Kind George Surgery since 01/10/2018 Ongoing Declare all interests at meetings 16/01/2019 Member, Stevenage Locality 2007/08 where relevant and follow Both commissioner and provider statutory guidelines.

Anindita "Rini" Saha GP Governing Body Stevenage Health Limited, y Direct King George Surgery is a member of 01/10/2018 Ongoing Declare all interests at meetings 16/01/2019 Member, Stevenage Locality Registered office address Stevenage Health Limited – which is the where relevant and follow The Health Centre, Stanmore Stevenage Locality Federation. I am not a statutory guidelines. Road, Stevenage, Hertfordshire, director. I am not a direct shareholder England, SG1 3QA Company number 08877494

Anindita "Rini" Saha GP Governing Body Dr Prag Moodley, Chair of East y Indirect I am in a relationship with Dr Prag 01/10/2018 Ongoing Written declaration made. 16/01/2019 Member, Stevenage Locality and North Herts CCG Moodley, the Chair of East and North Herts CCG.

Ashish Shah Vice-Chair of ENHCCG. Wrafton House Surgery y Direct Principal GP and GP Trainer 01/11/2014 Ongoing Any conflict arising out of 01/05/2019 GP Governing Body Member 9-11 Wellfield Road Wrafton House Surgery. Both provider and discussions regarding same at representing WelHat Hatfield commissioner. meetings will be raised at the Locality. Locality Chair – AL1 OBS meeting. WelHat Locality.

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Ashish Shah Vice-Chair of ENHCCG. Abhirush Limited. y Direct Director (Joined) of Abhirush Limited. I 01/11/2014 Ongoing Any conflict arising out of 01/05/2019 GP Governing Body Member Company registered address work through the Limited Company as an discussions regarding same at representing WelHat 5 Chedburgh Out of Hours GP at Herts Urgent Care. meetings will be raised at the Locality. Locality Chair – Welwyn Garden City meeting. WelHat Locality. AL7 2PU. Company No: 07998120 Nature of Business: I work through the Limited Company as an Out of Hours GP at Herts Urgent Care.

Ashish Shah Vice-Chair of ENHCCG. Ephedra Healthcare Ltd, Suite 3, y Direct Principal GP at Wrafton House Surgery. 01/11/2014 Ongoing Any conflict arising out of 01/05/2019 GP Governing Body Member Middlesex House, Rutherford Practice is a Shareholder of Ephedra discussions regarding same at representing WelHat Close, Stevenage, Herts, SG1 2EF. Healthcare Limited, which is a local meetings will be raised at the Locality. Locality Chair – Company no: 06560722 federation for WelHat Locality. meeting. WelHat Locality. Ephedra Healthcare Ltd.

Ashish Shah Vice-Chair of ENHCCG. Locality Lead for Workforce y Direct I Work as a Locality Lead for Workforce 01/01/2016 Ongoing Any conflict arising out of 01/05/2019 GP Governing Body Member Planning and Educational Planning and Educational Network for discussions regarding same at representing WelHat Network for Welwyn and Hatfield Welwyn and Hatfield Locality meetings will be raised at the Locality. Locality Chair – Locality meeting. WelHat Locality.

Ashish Shah Vice-Chair of ENHCCG. Spouse y Indirect Spouse works a GP in Hertford and 01/05/2019 Ongoing Any conflict arising out of 01/05/2019 GP Governing Body Member Corporate GP lead for ULV on ENHCCG discussions regarding same at representing WelHat Governing Body. meetings will be raised at the Locality. Locality Chair – meeting. WelHat Locality.

Rupal Shah GP Governing Body Member Hanscombe House Surgery, 52A y Direct Salaried GP. Both provider and 01/05/2019 Ongoing Any conflict arising out of 02/05/2019 Representing ULV Locality. St Andrews Street, Hertford, SG14 commissioner. discussions regarding same at Locality Co-Chair: ULV 1JA the meeting will be raised at the Locality meeting.

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Rupal Shah GP Governing Body Member Abhirush Limited. y Direct Director (Joined) of Abhirush Limited. 01/05/2019 Ongoing Any conflict arising out of 02/05/2019 Representing ULV Locality. Company registered address discussions regarding same at Locality Co-Chair ULV 5 Chedburgh the meeting will be raised at the Locality Welwyn Garden City meeting. AL7 2PU. Company No: 07998120 Nature of Business: I work as a locum GP via the limited company.

Rupal Shah GP Governing Body Member GENERATING HEALTHCARE y Direct Salaried GP at Hanscombe House Surgery. 01/05/2019 Ongoing Any conflict arising out of 02/05/2019 Representing ULV Locality. LIMITED – Upper Lea Valley Practice is a Shareholder of Generating discussions regarding same at Locality Co-Chair ULV Company number 08830754 Healthcare , which is a local federation for the meeting will be raised at the Locality Registered office address ULV Locality. meeting. 2 Tower House, Tower Centre, Hoddesdon, Hertfordshire, England, EN11 8UR.

Rupal Shah GP Governing Body Member Upper Lea Valley Locality Provider y Direct I work as a GP Representative for Hertford 01/05/2019 Ongoing Any conflict arising out of 02/05/2019 Representing ULV Locality. Board on the Provider Board at ULV Locality discussions regarding same at Locality Co-Chair ULV the meeting will be raised at the Locality meeting.

Rupal Shah GP Governing Body Member Spouse y Indirect Spouse works as a GP in Hatfield and 01/05/2019 Ongoing Any conflict arising out of 02/05/2019 Representing ULV Locality. Deputy Chair and Corporate GP Lead on discussions regarding same at Locality Co-Chair ULV ENHCCG Governing Body. the meeting will be raised at the Locality meeting.

Nabeil Shukur GP Governing Body South Street Surgery y Direct GP Partner, South Street Surgery 2001 Ongoing I need to declare when any 24/02/2018 21/02/2019 Member,Stort Valley and 83 South Street Nature of conflict: Primary Care Provider discussion about the benefit to Villages Locality Bishops Stortford practices and CCG investment in Herts Bishops Stortford primary care CM23 3AP

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Nabeil Shukur GP Governing Body NHA Medical Ltd y Direct & Director and 20% shareholder. NHA Medical 2012 Ongoing I need declare when any 24/02/2018 21/02/2019 Member,Stort Valley and 4 Beech Drive Indirect Ltd discussion is related to the above Villages Locality Sawbridgeworth two specialities and if for any CM21 0AA Provides Musculoskeletal Services and reason there is a discussion Co No: 08386895. Dermatology services. I am MSK provider. about NHA medical Provides Musculoskeletal My wife a is a dermatology provider. Services (MSK) and Dermatology services.

Nabeil Shukur GP Governing Body NHA Medical Ltd y Indirect Wife and son are both directors and 2012 Ongoing I will declare if there is any thing 24/02/2018 21/02/2019 Member,Stort Valley and 4 Beech Drive shareholders. related to NHA medical or the Villages Locality Sawbridgeworth above two specialities mentioned CM21 0AA Co No: 08386895. Provides Musculoskeletal Services and Dermatology services.

Nabeil Shukur GP Governing Body GP with Special Interest in y Direct GP with Special Interest in orthopaedics. 2006 Ongoing Need to be declare if there is any 24/02/2018 21/02/2019 Member,Stort Valley and orthopaedics. service redesign or procurement Villages Locality for MSK service

Nabeil Shukur GP Governing Body Clinical Referral Service. y Indirect GPSI (GP with Special Interest) contracted 2013 Ongoing As above with contracts related to 24/02/2018 21/02/2019 Member,Stort Valley and Provided by Stellar Health Care by the Stellar Health Care MSK Villages Locality Ltd, I am not employed by Stellar 4 Spencer Close, Epping, Essex, Health Care CM16 6TN.

Nabeil Shukur GP Governing Body STORT VALLEY HEALTHCARE y Indirect My practice is part of federation: 2014 Ongoing I will need to declare if there is 24/02/2018 21/02/2019 Member,Stort Valley and LIMITED STORT VALLEY HEALTHCARE LIMITED discussion bout awarding Villages Locality Orbital House, 20 Eastern Road, contract to Stort Valley Health or Romford, Essex, RM1 3PJ any discussion about making Company number 09114753 changes which makes them favourable

Page 13 of 13 Agenda Item No: 3

Date of Meeting: 25th July 2019

Governing Body Meeting in Public

Paper Title: Draft – Governing Body Minutes

Decision or Approval Discussion Information

Report author: Tracey Middleton, Governing Body Clerk

Report signed off by: Leon Adeleye, Corporate Governance Manager

Executive Summary: To approve the draft Minutes of the meeting held on 23rd May 2019.

Recommendations . To approve the Minutes. to the members:

Conflicts of Interest . There are none identified. involved:

Conflict of Interest Definitions

The following table describes the sub-classifications of interests:

Type Description Financial Interests This is where an individual may get direct financial benefits from the consequences of a commissioning decision. Non-Financial This is where an individual may obtain a non-financial professional benefit Professional Interests from the consequences of a commissioning decision, such as increasing their professional reputation or status or promoting their professional career. Non-Financial This is where an individual may benefit personally in ways which are not Personal Interests directly linked to their professional career and do not give rise to a direct financial benefit. Indirect Interests This is where an individual has a close association with an individual who has a financial interest, a non-financial professional interest or a non- financial personal interest in a commissioning decision.

Page | 1 Governing Body Meeting in Public Thursday 23rd May 2019 Focolare Centre, WGC, Meeting Room 2

MINUTES Present: Tara Belcher [TB] GP Lead, North Herts. Denise Boardman [DB] Director for Primary Care Development Dianne Desmulie [DD] Lay Member, Co-Commissioning Sarah Dixon [SD] GP Lead, Stort Valley and Villages Sharn Elton [SE] Director of Operations Linda Farrant [LF] Lay Member, Governance and Audit Beverley Flowers [BF] Chief Executive (Accountable Officer) Sachin Gupta [SG] GP Lead, Welwyn and Hatfield Russell Hall [RH] GP Lead, Stevenage Alison Jackson [AJ] GP Lead, Lower Lea Valley Prag Moodley [PM] Chair Dermot O’Riordan [DO] Secondary Care Specialist Alan Pond [AP] Chief Finance Officer Sheilagh Reavey [SR] Director of Nursing and Quality Rini Saha [RS] GP Lead, Stevenage Ashish Shah [AS] Deputy Chair, GP Lead, Welwyn and Hatfield Rupal Shah [RSh] GP Lead, Upper Lea Valley Nabeil Shukur [NS] GP Lead, Stort Valley and Villages Vacant Director of Commissioning Vacant GP Lead, North Herts. Vacant GP Lead, Stevenage Vacant Lay Member, Patient and Public Engagement

In Attendance: Peter Chapman [PC] Patient Representative Nakiya Jafferji [NJ] Corporate Governance Manager Tracey Middleton [TM] Governing Body Clerk

Page 1 of 12 Gerry Moir [GM] Interim Associate Director Localities Kerry Murphy [KM] Pfizer Ltd, Account Manager Jo O’Connor [JO] Acting Associate Director Performance Michael Taylor [MT] Patient Representative - Healthwatch

Item Subject Action by

1. WELCOME AND APOLOGIES FOR ABSENCE The meeting opened at:09.00

The Chair welcomed all to the meeting especially RS.

Apologies were received from:

• Mark Andrews, GP Lead, Upper Lea Valley • Rachel Joyce, Medical Director • Simon Chatfield, North Herts Locality Link • Sarah Feal, Company Secretary • Hein Scheffer, Director of Workforce

The Chair declared that the meeting was quorate.

2. DECLARATIONS OF INTERESTS

The Chair invited the members to reconfirm their current declarations on the Register of Interests and advise of any new declarations.

All members confirmed their declarations were accurate and up- to-date.

The Chair invited members to declare any declarations relating to matters on the Agenda.

1. Item 8 - Locality Committee Annual Report 2018-19. There is a potential indirect financial interest to governing body members and practice partners who chair or sit on locality committees as these committees can influence commissioning decisions.

The Chair agreed that colleagues could remain in the meeting but

Page 2 of 12 Item Subject Action by not be involved in decision making where there is an actual conflict.

3. MINUTES OF PREVIOUS MEETING AND MATTERS ARISING

The minutes of the meeting held on 28.03.19 were approved as an accurate record.

4. ACTION TRACKER

The contents of the Action Tracker were discussed.

The following actions were agreed to be closed:

• Action 39. Governance Report • Action 40. Individual Funding Request (IFR) and Prior Approval Policy • Action 38. Any Other Business (AOB). Update: the Sustainability and Transformation Partnership (STP) and 3 CCG boards will receive a comprehensive paper in June.

The following updates were provided:

• Action 41 - East and North Herts CCG 2017/18 Workforce Equality Data Report. Update: The Equality and Diversity Lead will support the Equality Delivery System (EDS2) Group to enable them to deliver an action plan. This action plan will come to a Governing Body meeting in November.

ACTION: The Action Tracker to be updated to reflect the MH updates.

5. INTEGRATED PERFORMANCE AND QUALITY (IPQR) REPORT

The Report which was circulated in advance of the meeting was introduced by the Acting Associate Director Performance.

1. The Governing Body noted the update on the performance and quality of local NHS Trusts in relation to key national performance standards. It included quality and performance

Page 3 of 12 Item Subject Action by information at CCG level and also at provider level (East and North Herts NHS Trust (ENHT), Princess Alexandra Hospital NHS Trust (PAH), Hertfordshire Community NHS Trust (HCT), East of England Ambulance Service NHS Trust (EEAST), Herts Partnership Foundation NHS Trust (HPFT) and Herts Urgent Care (HUC). 2. The performance and quality metrics included within the report are published information predominantly for the March position. All metrics have been included with commentary for exceptions where performance standards have not been met. 3. Governing Body: IPQR Report - Performance to March 19; includes complete year performance for 2018/19 and comparison to 2017/18. CCG Performance headlines of the constitutional metrics: 4. Referral to Treatment (RTT) performance continued to improve in March, ending the year just short of the 92% standard at 90.87% (17/18 at 89.46% but would not include ENHT as off reporting). 5. Accident & Emergency (A&E) performance remains challenged and although March saw a slight improvement, performance continues below 80%, predominantly driven by poor performance at PAH (come on to discuss under Provider updates). Ended the year at 82.59% against the 95% standard (similar to 17/18 at 81.88%). 6. For 18/19, CCG achieved 6 cancer standards including 2 week waits for all cancer and breast, 31 day first, subsequent drug and subsequent radiotherapy and 62 day upgrade. 62 day performance saw a decline in March (73.55%), driven by the performance at ENHT and ended the year at just under 75% (a decline on performance on 17/18 - 80.25%). 7. Although Delayed Transfers of Care (DTOC) position was slightly higher in March, ENHT achieved considerably better than the 3.5% standard at 1.69% for the year, also achieving the 2.5% stretch target. 8. 2018/19 Contract Performance Notices (CPNs) for A&E, Cancer and Infection Prevention Control IPC have been closed with Remedial Action Plans (RAPs) embedded in the new 19/20 contract. A new CPN for discharge summaries has been issued for the 19/20 contract. 9. Discharge summaries – no harm has been identified in completed audits and progress continues to be monitored carefully; the latest report showed 65.4% sent within 24 hours. Trajectory being agreed with the Trust for 100% to be sent in 7 days by August and 90% in 48hours and 80%

Page 4 of 12 Item Subject Action by within 24 hours by September. 10. RTT Trust achieved the best position since the return to reporting in March, just below standard at 90.37%. Diagnostics also improved falling just short of 99% standard by less than 1%. 11. A&E performance improved slightly in March on February, however, remained in low 80s (81%) and finished 18/19 at just below 86% - this is compared to 83% for 17/18. 12. Cancer performance has improved across the year and in March met 5 standards; 62 day saw a dip, however at 73.40%, falling short of the recovery trajectory - April performance is back on track to achieve trajectory. For 18/19 only 3 standards were met (2 week all cancer, 31 day sub drug and radiotherapy). 62 day finished 18/19 at 73.13% post Inter Trust Transfer Policy (ITTP) a decline on 17/18 performance. 13. PAH - Continuation of low DTOC rate in March with significant improvement over the year; achieved just over 2% for the year. 14. PAH also continued to meet the 92% RTT standard and 6 week diagnostic standard in March and for the year. 15. Cancer 62 day performance returned to meet standard in March at 85.22% however fell short of the standard for 18/19 at 82.40% (a decline on performance in 17/18 - 88.44%). 16. A&E performance continues as PAH’s main challenge; although performance improved slightly in March (72.2%) performance for the year finished at just under 75% (compared to 70.90% in 17/18); weekly calls are being held with NHSE to review actions and performance for turnaround. 17. HPFT – Improving Access to Psychological Therapies (IAPT) access and recovery performance met standard in March and for 2018/19. 18. Early Intervention Psychosis (EIP) constitutional standard, continued to meet in March and for the year (standard to increase to 56% from 2019 and 60% by end of 20/21 but in a very positive position). 19. Dementia diagnosis improved in March to meet target for the month however fell just short for the year at 66.01% - a number of practice visits have contributed to improvement in performance over the year. 20. DTOC improved in March at 5.29% meeting the local target of 5.4%. Finished the year just outside target at 5.76%. 21. IAPT 6 week wait remains a challenge with performance declining in Quarter f with increases in referrals. HPFT

Page 5 of 12 Item Subject Action by have submitted a recovery trajectory to recover performance in Quarter 1 19/20. 22. Child and Adolescent Mental Health Services (CAMHS) 28 day routine wait time performance also remains a challenge and declined in Quarter 4 with increases in demand (recruitment in the East also an issue, however a permanent consultant started in March). 23. HCT - DTOCs further improved in March at 5.80% and ended the year at 12.8% - an improvement on 17/18 (13.49%). Work continues with system partners to improve patient flow and discharge. 24. EEAST - Handover performance continues below standard, however initial stages of ambulance handover action plan has been implemented focusing on role of Hospital Ambulance Liaison Officer (HALO) and fit2sit campaign. 25. 999 call response times – C1 currently meeting Ambulance Response Programme 7 minute (mean) response time at CCG level however EEAST fell just short of the Independent Service Review standard for Quarter 4 (7:37 minutes). EEAST region wide action plan in place to improve organisational delivery which is currently on track and Red Amber Green (RAG) rated Amber. 26. HUC - Home Visits and Base Face to Face consultations remain challenged within required timescales although some improvements have been seen in February and March; a series of deep dive meetings have been set up with HUC commencing end of May to agree actions to address performance. 27. Direct bookings into Integrated Urgent Care (IUC) or extended access have not met standard in Quarter 4 due to a change in reporting to include in hours contracts (where direct booking is not available – denominator increases); this is a national reporting error which will be corrected in June. 28. The overall target and expectations regarding discharge summaries at ENHT were clarified. The Trust has assured the CCG that systems are in place to capture all summaries. 29. The CAMHS performance was challenged and a deep dive is being undertaken by the Governance and Audit Committee. 30. The Governing Body congratulated HPFT which was rated as outstanding in their recent inspection. 31. ACTION: CCG performance levels to be reported separately. JO 32. The reporting of handover metrics was outlined

Page 6 of 12 Item Subject Action by 33. The Governing Body noted that the format and quality of the report has been helpful and useful. Assurance was given that the new national reporting framework will be considered to reflect the context and regulatory requirements. It was agreed that reporting without losing the effectiveness of local decision making which is making improvements e.g. care homes will be reflected in the reporting system. 34. Concern was raised with the increase in A&E attendance and admissions and it was noted that this is being addressed. JO left the meeting at 09.35 The Governing Body noted the report.

6. ANNUAL REPORT AND ACCOUNTS 2018/19

The Chief Finance Officer presented the Report, which was circulated in advance of the meeting. A summary of changes to the report was tabled at the meeting.

1. The Chair noted that the Governing Body members had read the Annual Report and Accounts 2018/19 and members confirmed that:

• So far as the member is aware, there is no relevant audit information of which the clinical commissioning group’s auditor is unaware that would be relevant for 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 clinical commissioning group’s auditor is aware of it.

2. The summary of changes was outlined and it was noted that the Governance and Audit Committee reviewed the draft report and recommended it for approval. 3. In summary the financial position has met the statutory duties and 2018/19 has been a successful year. 4. The Finance Team, Governance and Audit Committee and Communications Team were thanked for their contribution in achieving this positive outcome. 5. The Auditor has referred to prescribing over expenditure and over accrual on the Consolidated Funding Framework (CFF) in management reporting. Confirmation was given

Page 7 of 12 Item Subject Action by that no changes are required in the accounts.

The Governing Body approved the Annual Report and Accounts 2018/19.

7A. DELEGATED COMMISSIONING: FIRST YEAR REVIEW

The Report which was circulated in advance of the meeting was introduced by the Director for Primary Care Development.

1. The paper provided an overview of the work undertaken by the Primary Care Commissioning Committee during 2018/2019 since the CCG became delegated. An evaluation of what the committee set out to do at its inception, examples of what it has achieved, work in progress and future plans that will be aligned to both national and local priorities was undertaken. 2. Following a successful submission to NHS England (NHSE), the CCG commenced delegated commissioning duties for Primary Medical Services on 1st April 2018. This is with the aim of developing more integrated out-of-hospital services and to improve the quality of primary care. 3. To undertake these duties since April 2018 the following have been established: • CCG Primary Care Commissioning Committee (PCCC) • CCG Primary Medical Care Contracting Panel • CCG Primary Care Transformation & Resilience Panel • CCG Primary Care Improvement Grant Panel • New Primary Care Development Directorate • CCG Directorate recruitments across quality, finance, contracts and governance 4. The work of the PCCC is informed by the priorities of the CCG and the Localities in response to the needs of the population and the delegated duties as per its Terms of Reference. This is then translated into a work plan informing an annual business cycle. The PCCC high level work plan is available on request. 5. The Committee agreed that it was important that there were a number of initiatives that could be delivered in the short term and the focus would be on the schemes that would have the greatest clinical impact and which delivers transformational change.

Page 8 of 12 Item Subject Action by 6. A separate PCCC paper was presented at the March meeting giving an overview of the recently launched NHS Long Term Plan and the NHSE and British Medical Association document “Investment and Evolution”; five year framework for GP contract reform. 7. On balance the committee has achieved much during 2018/19 and its first internal audit has found the Governing Body can take substantial assurance that the controls in place are operating effectively. 8. However, there have also been lessons learned, expenditure was not maximised against the available CCG discretionary funds e.g. Transformation & Resilience fund and the CCG needs to be more explicit with member practices regarding what they can bid for by strengthening the application pack. 9. Work is also underway sense checking the current PCCC work plan to ensure it is fit for purpose and will meet any new requirements going forward in 2019-2020 and beyond. This will also include strengthening the engagement and communications of what the committee is doing. This to ensure all its stakeholders especially its constituent member practices continue to inform and be sighted on all the work underway. 10. The multi directorate team was acknowledged in overcoming the challenges and rolling out Extended Access. The focus on raising quality for patients has been effective as demonstrated in inspection outcomes. IT support is an area of focus for the coming year. 11. Feedback from the members are being sought. 12. How the CCG assures itself about Primary Care was debated. The PCCC minutes support the reporting of this area and it was agreed that some indicators are reported to the Governing Body. 13. It was also noted that there continues to be only two lay members on the committee and the wider CCG Governing Body. The Chief Exec agreed to update the Governing Body as soon as possible on the proposal to increase lay membership.

The Governing Body noted the report. 7B. PRIMARY CARE NETWORKS (PCNS)

The Report which was circulated in advance of the meeting was introduced by the Assistant Director for Primary Care Development.

Page 9 of 12 Item Subject Action by 1. The Primary Care Networks (PCNs) are groups of GP practices working more closely together, with other primary and community care staff and health and care organisations, providing integrated services to their local populations. 2. The NHS Long Term Plan, PCNs become an essential building block of every Integrated Care System, and general practice takes the leading role in every Primary Care Network. 3. In accordance with national requirements, as of 15 May 2019, the CCG had received 12 PCN applications from groups of GP practices, which collectively covered 100% of the CCG population. 4. The PCN Task & Finish Group will continue to oversee, support and guide the establishment of PCNs in each locality up until 1 July 2019. 5. This has been a successful exercise and welcomed examples of collaboration provided. 6. The Local Medical Committee (LMC) has been commissioned to support the PCNs.

The Governing Body noted the report.

8. LOCALITY COMMITTEE ANNUAL REPORT

The Interim Associate Director Localities introduced the Report, which was circulated in advance of the meeting. 1. The paper described the progress in locality commissioning and development over the last 12 months. Developments were detailed at CCG level and for each locality. 2. Analytical information is being sought for the next report. 3. A&E attendance and benchmarking were discussed and it was agreed that the streaming and dispersion of patients would inform the planned community work. 4. It was agreed that the evaluation of the CFF approach to compare and contrast outcomes is an area to develop.

The Governing Body noted the progress made to date. The Governing Body supported the recommendations in the report.

Page 10 of 12 Item Subject Action by 9. GOVERNANCE AND AUDIT COMMITTEE ANNUAL REPORT 2018/19

The Report which was circulated in advance of the meeting was introduced by the Lay Member, Governance and Audit.

1. The report summarised the work of the Governance and Audit Committee for 2018/19 and provided assurance of the processes and systems in place. 2. Substantial assurance was provided regarding governance of PCCC, conflicts of interest and prescribing. 3. Thanks were extended to the committee members. The self-assessment on effectiveness was positive despite the vacancy of the third lay member. 4. Assurance was provided that the General Data Protection Regulation (GDPR) progress is satisfactory.

The Governing Body approved the report.

10. GOVERNANCE AND AUDIT COMMITTEE MINUTES

The minutes of the meeting dated 13.03.19 were introduced to the Governing Body.

The Governing Body noted the minutes.

11. HBL ICT STAEHOLDER BOARD MINUTES

The minutes of the meeting dated 21.01.19 were introduced to the Governing Body.

The Governing Body noted the minutes.

12. PRIMARY CARE COMMISSIONING COMMITTEE MINUTES

The minutes of the meetings dated 10.01.19 and 19.03.19 were Introduced to the Governing Body.

The Governing Body noted the minutes.

13. LOCALITY COMMITTEE MINUTES

The minutes of the following meetings were introduced:

Page 11 of 12 Item Subject Action by

1. Lower Lea Valley – 30.01.19 and 06.02.19 2. Stevenage – 05.03.19 3. Stort Valley and Villages – 24.01.19 4. Welwyn and Hatfield – 17.01.19

The Governing Body noted the minutes.

14. JOINT COMMISSIONING AND PARTNERSHIP PROGAMME COMMITTEE MINUTES

The minutes of the meeting dated 12.12.18 were introduced to the Governing Body.

The Governing Body noted the minutes.

15. QUESTION FROM MEMBERS OF THE PUBLIC

1. No questions were raised by the 3 members of the public in attendance.

16. ANY OTHER BUSINESS

1. A Patient Representative joined the quality assurance team which visited the Lister Hospital. The Patient Representative advised that they are remarkably thorough and the findings are extremely well communicated. It was noted that the Quality Committee reviews progress against the recommendations which are addressed during the follow up visits to monitor sustainability of improvements. 2. Congratulations were extended to the Chief Executive Officer who has been appointed as the Joint STP Lead Officer.

17. DATE OF NEXT MEETING:

Thursday 26th July 2019 Focolare Centre, WGC, Meeting Room 1 11:00 – 12:00 The meeting closed at:10.15

Page 12 of 12 Agenda Item No: 4

Date of Meeting: 25th July 2019

Governing Body Meeting in Public

Paper Title: Action Tracker

Decision or Approval Discussion Information

Report author: Maryla Hart, Governing Body Administrator Tracey Middleton, Governing Body Clerk Report signed off by: Nakiya Jafferji, Corporate Governance Manager

Executive Summary: The purpose of this paper is to discuss the Action Tracker.

Recommendations . To discuss the Action Tracker. to the members:

Conflicts of Interest . There are none identified. involved:

Conflict of Interest Definitions

The following table describes the sub-classifications of interests:

Type Description Financial Interests This is where an individual may get direct financial benefits from the consequences of a commissioning decision. Non-Financial This is where an individual may obtain a non-financial professional benefit Professional Interests from the consequences of a commissioning decision, such as increasing their professional reputation or status or promoting their professional career. Non-Financial This is where an individual may benefit personally in ways which are not Personal Interests directly linked to their professional career and do not give rise to a direct financial benefit. Indirect Interests This is where an individual has a close association with an individual who has a financial interest, a non-financial professional interest or a non- financial personal interest in a commissioning decision.

Page | 1 Governing Body in Public Action Tracker

No. Meeting Date Item No. and Title Action Responsible Past deadlines Deadline Current Position Status Manager (Since Revised)

41 28/03/2019 10. East and North Herts CCG A proactive Action Plan regarding workforce equality and Director of Workforce 28/11/2019 05/04/2019: The Equality and Diversity Lead will support the EDS2 Open 2017/18 Workforce Equality diversity was recommended and it was agreed that it will be Group to enable them to deliver an action plan. This action plan will Data Report provided in the future. come to a Governing Body meeting in November. 12/07/2019: EDS2 working group is being formed, led by Steve Madden. Discussions on work areas to assess under EDS2 have been undertaken and a short list drawn up. Still on target to meet 28/11/2019 deadline.

42 23/05/2019 5.IPQR EEAST. CCG performance levels to be reported separately Director of Operations 25/07/2019 08/07/2019: The action has been completed and will be reflected in Close on the July version of the IPQR. 2019-07-25

Page 1 of 1 Agenda Item No: 5

Date of Meeting: 25th July 2019

Governing Body Meeting in Public

Paper Title: Chief Executive’s Report

Decision or Approval Discussion Information

Report author: Sarah Feal, Company Secretary

Report signed off by: Beverley Flowers, Chief Executive

Executive Summary: The purpose of this paper is to provide information on activities being undertaken by the Clinical Commissioning Group.

Recommendations To discuss the report. to the members:

Conflicts of Interest There are none identified. involved:

Conflict of Interest Definitions

The following table describes the sub-classifications of interests:

Page 1 of 6 1. Executive Summary

The purpose of this paper is to provide information on activities being undertaken by the Clinical Commissioning Group (CCG).

2. 2018/19 CCG Annual Assessment

The CCG annual assessment for 2018/19 provides each CCG with a headline assessment against the indicators in the CCG Improvement and Assessment Framework. The headline assessments have been confirmed by NHS England’s Statutory Committee.

The table below shows the number of CCGs receiving each rating in 2018/19 compared to 2017/18.

2018/19 2017/18 Outstanding 24 20 Good 102 100 Requires 58 69 Improvement Inadequate 11 18 TOTAL 195 207

Our CCG is one of only nine across the country to have been rated ‘Outstanding’ for three years in a row. The Governing Body is extremely proud of this achievement and we know that it has only been possible thanks to the hard work, dedication and professionalism of all of the staff. I think that it is also testament to the excellent relationships we’ve built up across the system and the long-term work we’re doing, which is now delivering better outcomes for patients.

NHS England praised the CCG for its robust financial leadership and risk management, highlighting that quality, performance and financial risks were well understood, and underpinned by clear governance arrangements.

The results of other CCGs can be found on the NHS England website here: https://www.england.nhs.uk/wp-content/uploads/2019/07/ccg-annual-assessment-report- 2018-19.pdf

3. Public engagement – proposal to close the Welwyn Garden City Urgent Care Centre overnight

The CCG is currently engaged in a comprehensive 12 week public engagement process on proposals to close the Urgent Care Centre (UCC) in Welwyn Garden City between 10pm and 8am.

Page 2 of 6 Running from 14 June – 4 September, senior CCG representatives, supported by representatives from East and North Hertfordshire NHS Trust, are engaging with patients, the public, stakeholders and NHS staff across east and north Hertfordshire to seek their views on our proposal. Our engagement approach is based on national best practice and our previous experience of gathering local views about proposed NHS service changes.

A number of local political representatives, including the MP for Welwyn Hatfield, representatives from Welwyn Hatfield Borough Council and Hatfield Town Council and the Labour Party’s Prospective Parliamentary Candidate for Welwyn Hatfield have taken up our offer of private meetings to discuss our proposals. Throughout the process we aim to be:

Clinically-led We are giving the public opportunities to talk directly to local clinicians: GPs; hospital doctors; nurses and senior leaders from both the CCG and East and North Hertfordshire NHS Trust at our drop-ins and public meetings. Their direct experiences are helping to answer people’s questions and clearly explain the rationale behind the proposal.

Visible and approachable Our drop-ins and meetings are being held in a range of community locations, during the day, in the evening and at weekends. We are holding sessions in prominent places, including supermarkets and libraries, to proactively seek the views of those who might not usually attend an NHS event. We are using our online and social media platforms, and those of our partners, to ensure the engagement information, questionnaire and event dates reach a broad audience. All our events can be found on our engagement site: https://qeiiucc.enhertsccg.nhs.uk

Inclusive and easily accessible We have produced our information in ‘easy read’ format and will directly meet with groups who we feel might have particular needs in accessing urgent care services; for example those with caring responsibilities, older people and new parents. Our volunteers in Patient Participation Groups are supporting our efforts to share information widely within communities.

Open and transparent We are listening carefully to all views and have appointed an experienced independent research company to analyse all responses we receive. As we progress though the 12 weeks, we are updating the engagement microsite with answers to questions people are asking us.

Informative and educational We are using the opportunities of face-to-face discussions with the public, stakeholders and staff to explain about the range of NHS services available to people when they need urgent medical help, for example NHS 111, GP practices which now open in the evening and at weekends and the support available from pharmacies. Feedback gathered during these events show that people are coming away from events feeling that they have a better knowledge of the services available to them across the east and north Hertfordshire area.

Page 3 of 6 Questionnaire responses and letters are being collated and analysed by an independent market research company, Opinion Research Services. Opinion Research Services will produce a report which will be presented to an extraordinary meeting of the Governing Body of East and North Hertfordshire CCG on Thursday 24 October, at which all feedback and evidence gathered during the engagement process will be considered before a decision is made on the proposal.

4. Patient and public participation in commissioning health and care

CCGs have a statutory duty to involve the public in commissioning. In addition to meeting statutory responsibilities, effective patient and public participation helps CCGs to commission services that meet the needs of local communities and tackle health inequalities.

Following the national assessment and moderation process, the CCG has been rated as ‘Green’ in the CCG Improvement and Assessment Framework (IAF) Patient and Community Engagement Indicator 2018/19.

If you live in East and North Hertfordshire and would like to help shape your local health services, please visit www.enhertsccg.nhs.uk/get-involved

5. Lay Member, Patient and Public Involvement

The CCG is pleased to confirm that Alison Gardner has agreed to take up position from August 2019. Alison is already the Lay Member for Herts Valleys CCG and will continue as such, alongside working with us. The appointment follows discussions between the CEOs and Chairs of both CCGs and we all see it as an opportunity to share best practice and learning in Patient and Public Involvement and Engagement across the organisations. This initiative will also support our transformation as part of the STP and our general direction of travel in terms of working more closely and collaboratively as CCGs.

6. The Healthcare Transformation Awards

The CCG has also received an award for Innovation in the Care of Long Term Conditions.

Innovation can take place at many different levels: at individual level through person empowerment and self-care; at the level of the consultation through a partnership approach to care planning; at the team level through multi-disciplinary approaches; at the health systems level through integrated care; at the level of communication through information technology and social media; and of course through research and development of technologies including new drugs.

The CCG submitted an entry to this category in relation to the programme of work that has been underway since 2015 aimed at improving palliative and end of life care. Through partnership working, reviewing evidence and introducing a new approach to normalising palliative care across our health system; dramatic improvements have been achieved in the care of people reaching the end of their life in east and north Hertfordshire.

Page 4 of 6 7. Transforming Care Partnership

Earlier this year the CCG took part in an NHS England benchmarking exercise against the requirement for the transforming care recommendations for children. The aim of the review was to gain assurance that as a ‘Transforming Care Partnership’ we have good foundations in place for developing community processes and support for children and young people within Transforming Care. Overall we were rated as ‘Green / Amber’.

Areas such as there being a continued strategic, multi-agency commitment to children and young people within transforming care and the proactive focus on reducing admissions and strengthening the community response were highlighted as notable process. The feedback from the review recommended the Hertfordshire system focusses on:

. Information to be included to sign-post families of young people with learning disabilities, autism or both experiencing challenging or risky behaviours to support Care Education and Treatment Reviews (CETR’s) . Continued focus on the early identification of children and young people with risk factors to support a multi-disciplinary response prior to crisis . The review and updating of the risk of admission register criteria and CETR processes to ensure timely reviews for those at risk of admission . Continued completion and review of root cause analyses with relevant partners to identify any learning and actions for improvement

This work is being progressed through the Transforming Care Board and supported by the CCG.

8. Personal Health Budget Target

The Personalised Care Programme for 2018/19 focused on delivering more personalised approach to health and care so that people have greater choice and control over their care planning. Along with improving supported self-management, social prescribing and enabling choice and control, the programme also focused on developing and delivering a greater number of Personal Health Budgets through effective personalised care and support planning. We had ambitious targets set to deliver the agenda and following fantastic local engagement, the target of 1,280 Personal Health Budgets was exceeded, delivering over 1,400 for the year. The CCG performed exceptionally well, exceeding the local CCG target by 44%.

In line with the NHS Long Term Plan, we will seek to continue the programme into 2019/20, aligning the ambitions of the Personalised Care Model to local priorities, delivering the comprehensive model for personalised care, comprising six, evidence-based standard components, intended to improve health and wellbeing outcomes and quality of care, whilst also enhancing value for money. Implementation will continue to be guided by delivery partnerships with local government, the voluntary and community sector and people with lived experience, recognising the power of individuals as the best integrators of their own care.

Page 5 of 6 9. Issues

Not Applicable.

10. Options

Not Applicable.

11. Resources implications

There are none identified.

12. Risks/Mitigation Measures

Not Applicable.

13. Recommendations

The Governing Body is asked to note the report.

14. Next Steps

Not Applicable.

Page 6 of 6 Agenda Item No: 6

Date of Meeting: 25th July 2019

Governing Body Meeting in Public

Paper Title: Governance Report

Decision or Approval Discussion Information

Report author: . Sarah Feal, Company Secretary . Nakiya Jafferji, Corporate Governance Manager . Leon Adeleye, Corporate Governance Manager Report signed off by: . Alan Pond, Chief Finance Officer . Linda Farrant, Lay Member Governance and Audit (section 2.3) . Dianne Desmulie, Lay Member Co-Commissioning (section 2.4)

Executive Summary: This paper seeks the approval of the Governing Body to a number of matters, as required by the CCG’s Constitution, that have been agreed at Governing Body Workshops, including matters approved that require reporting to the Governing Body Meeting in Public for ratification.

This paper provides information on corporate governance activities being undertaken by the Clinical Commissioning Group (CCG).

Recommendations The Governing Body is asked to: to the members: . note and ratify the decisions made at the Governing Body Workshops, . note the report from the Governance and Audit Committee, . note the report from the Primary Care Commissioning Committee. . the Governing Body is asked to consider any specific areas of the business where further assurance of health and safety management systems is thought to be required.

Page 1 of 10 Conflicts of Interest There are none identified. involved:

Conflict of Interest Definitions

The following table describes the sub-classifications of interests:

Page 2 of 10 1. Executive Summary This paper seeks the approval of the Governing Body to a number of matters, as required by the CCG’s Constitution, that have been agreed at Governing Body Workshops, including matters approved that require reporting to the Governing Body Meeting in Public for ratification.

2. Background

2.1 Introduction This paper provides information on corporate governance activities being undertaken by the Clinical Commissioning Group (CCG).

2.2 Governing Body Workshops Summarised below are key discussions and actions agreed from the Governing Body Workshops:

2.2.1 25 April 2019 . Approved the Hertfordshire Partnership University NHS Foundation Trust Mental Health and Learning Disability Services Contract . Approved the outline Communications Plan for My Care Record Information Sharing Agreement

2.2.2 9 May 2019 . Approved the HBL ICT Stakeholder Board Terms of Reference . Approved the recommendations from the Hertfordshire Medicines Management Committee regarding mandatory NICE Technology Appraisal treatments, and for treatments not included in the NICE work programme. . Approved new Faecal Immunochemical Test documentation.

2.2.3 11 July 2019 . Approved the recommendations from the Hertfordshire Medicines Management Committee regarding mandatory NICE Technology Appraisal treatments, and for treatments not included in the NICE work programme. . Approved the recommendations for allocation of winter resilience funding for 2019/20. . Approved the Fitness for Surgery Policy and its implementation plan. . Approved the Beds and Herts Priorities Forum guidance for the following: - Dysthyroid Eye Disease - Ankylosing Spondylitis Therapy - Tonsillectomy for Tonsilloliths - Varicose Veins

The Governing Body is asked to note and ratify the decisions made at the Governing Body Workshops.

Page 3 of 10 2.3 Governance and Audit Committee Meeting The minutes of the Governance and Audit Committee of 13 March 2019, as approved at the 17 May 2019 meeting are being submitted, as required by the Committee’s Terms of Reference. Items of business considered by the Committee at its May meeting included the following:

. Registers of Interest . Draft Annual Report and Accounts 2018/19 . Quality Assurance Report . Internal Audit Progress Report and Annual Report (including Head of Internal Audit Opinion 2018/19) . Local Counter Fraud Services – Annual Report (including Fraud Risk Assessment) . External Audit ISA260 Report . Internal Audit Recommendations (progress reviewed on tracker) . Information Governance Annual Review (including Six Monthly Report and the Freedom Of Information Annual Report) . Policies and Procedures update – Raising Concerns (Whistleblowing) Policy and Operating Procedure; Health and Safety Policy . Health and Safety Annual Report . Governance and Audit Committee Annual Report . Annual cycle of business 2019/20

The Governing Body is asked to note the report from the Governance and Audit Committee.

2.4 Primary Care Commissioning Committee Meeting The minutes of the Primary Care Commissioning Committee meetings of 10 January 2019, 21 March 2019 and 2 May 2019, as approved by the 21 March 2019, 2 May 2019 and 4 July 2019 meetings respectively are being submitted, as required by the Committee’s Terms of Reference.

Items of business considered by the Committee at its March meeting include the following:

Public meeting

. Finance update . General Practice Forward View updates including Welwyn/Hatfield evaluation of Extended Access and Quarter 3 (2018/19) update on Primary Care Workforce and Education Network . Transformation and Resilience Fund update . Update on the Primary Care Commissioning Work Plan 2018/19 . Report on the Impact of the NHS Long Term Plan and NHS England British Medical Association Document ‘Investment and Evolution’; Five Year Framework for GP Contract Reform . An annual review of the Committee Terms of Reference . Primary Care Quality Report . Contracts update . Patient Participation Group update . Report on the Improvement Grant Programme 2019/20

Page 4 of 10 . Update on Primary Care Delivery in Care Homes: the care home LES and model development

Private meeting

. Update on the Internal Audit on Delegated Commissioning . Update on Hertford and Letchworth Collaborative Working Support . Primary Care Networks update . Ware Primary Care Centre (Dolphin House) update . Estates and Technology Transformation Fund update . Update on Primary Care Resourcing within the CCG

Items of business considered by the Committee at its May meeting include the following:

Public meeting

. Update on the Primary Care Commissioning Work Plan 2019/20 . Finance update . NHSE General Practice Forward View update . General Practice Forward View updates including GP Practice E-consultation programme and Primary Care Networks . Sustainability and Transformation Plans Vision and Framework update . Primary Care Quality Report . Contracts update

Private meeting

. Primary Care Quality, Contracts and Premises update . Primary Care Delegated Commissioning 2019/20 Financial Plan . Review of Alternative Provider Medical Services (APMS) contracts . First year review of Delegated Commissioning . NHS England Occurrence Report on Controlled Drugs concerns

Items of business considered by the Committee at its July meeting include the following:

Public meeting

. Progress update on the roll-out of the Primary Care Mental Health Service . Update on the Primary Care Commissioning Work Plan 2019/20 . Finance update . General Practice Forward View updates including Extended Access and Primary Care Networks . Primary Care Development Risk Register . Primary Care Quality Report . Contracts update . Hertfordshire and West Essex (HWE) Sustainability and Transformation Plans (STP) Draft Primary Care Strategic Framework and Vision . Flu update

Page 5 of 10 Private meeting

. Primary Care Quality, Contracts and Premises update . Primary Care Commissioning Committee Effectiveness Survey 2018/19 . Consolidated Funding Framework 2018/19 Financial Balance Outcome

The Committee also undertook a mandatory training session in July on Primary Care General Practice Contracts.

The Governing Body is asked to note the report and minutes from the Primary Care Commissioning Committee

2.5 Health and Safety Annual Report Appendix 1 provides a summary of the progressive activity within East and North Hertfordshire Clinical Commissioning Group (the CCG) with regards to health and safety procedures, including recent training and updating of policies for the period 01 April 2018 to 31 March 2019.

2.6 Annual Cycle of Business 2019-20 Public and Private The Annual Cycle of Business is available from this link: http://www.enhertsccg.nhs.uk/governing-body-meetings-in-public

3. Issues Not Applicable.

4. Options Not Applicable.

5. Resources implications There are none identified.

6. Risks/Mitigation Measures Not Applicable.

7. Recommendations The Governing Body is asked to:

. note and ratify the decisions made at the Governing Body Workshops, . note the report from the Governance and Audit Committee, . note the report from the Primary Care Commissioning Committee,

8. Next Steps Not Applicable.

Page 6 of 10 Appendix 1 – Health and Safety Annual Report

1.0 Introduction

This paper provides a summary of the progressive activity within East and North Hertfordshire Clinical Commissioning Group (the CCG) with regards to health and safety procedures, including recent training and updating of policies for the period 01 April 2018 to 31 March 2019.

The CCG is required to comply and manage health and safety in the workplace as detailed in UK and European legislation and NHS regulations.

2.0 Health and Safety Activity 2018/19

The previous contract for the provision of Health and safety support with SERCO ASP Risk Services ceased on 31 March 2018 at their request, and a Service Level Agreement subsequently agreed with Hertfordshire County Council to provide advice and support on health and safety to the CCG.

2.1 Health and Safety Policy

The Health and Safety Policy, including the Health and Safety General Risk Assessments, has been reviewed with minor changes for approval by the Governance and Audit Committee.

2.1.1 Health and Safety Advice:

Health & Safety advice has been provided by the Competent Person during the year during site visits, by telephone and e-mail, on a variety of health and safety topics including provision of defibrillators, fire evacuation and the use of evacuation chair.

2.1.2 Incident Reporting:

There have been no reportable incidents under Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013 (RIDDOR).

2.2 Health and Safety Training for Staff:

The corporate induction training package for staff includes the key health and safety requirements:

. Health and Safety, including Display Screen Equipment and Fire Safety, . Risk Management, . Incident Reporting and Investigation,

Page 7 of 10 Fire Warden and Evacuation chair training sessions have been provided for staff during 2018/19 in addition to a Health and Safety briefing for the Governing Body.

2.3 Fire Safety

A Fire Risk Assessment of the CCG demise area at Charter House was reviewed and updated during October 2017 and February 2018 by the Competent Person.

The Fire Evacuation Procedure for Charter House was reviewed at the Fire Warden meeting on 12 April 2019 and approved by the Executive Team on 08 May 2019.

The main update was that there are currently 15 trained Fire Wardens including the newly trained Fire Wardens on 31 January 2019. These Fire Wardens are assigned across each floor excluding the ground floor in Charter House. This is based on the agreement that Fire Wardens assigned to the third floor will be responsible for the evacuation checks on the ground floor in the unlikely event of a fire.

Refresher training sessions are being planned for those with certificates that will soon expire and volunteering staff. The Fire Evacuation Procedure has been updated according and continues to be tested periodically through planned fire evacuation drills.

2.3.1 Fire Wardens:

The following fire warden meetings have taken place with the tenants of Charter House: . 17 April 2018 . 2 August 2018 . 11 December 2018 . 12 April 2019

3.0 National picture / emergent risks

3.1 HSE involvement and fee for intervention (FFI) The hourly rate which organisations found to be in material breach of health and safety laws must pay to the Health and Safety Executive (HSE) for its time has increased from £129 to £154 per hour, with effect from 6th April 2019.

The fee for intervention (FFI) cost recovery scheme was introduced back in 2012 and was designed to shift some costs of regulating workplace health and safety from the taxpayer to those responsible for breaches.

Under the scheme, those found to be in 'material breach' of health and safety laws are liable for payment of HSE's related costs, including those incurred as a result of inspection, investigation and taking enforcement action.

Page 8 of 10 3.2 HSE annual enforcement statistics

The HSE have released their annual H&S statistics for 2017/18. Whilst there’s been a fall in the overall number of cases prosecuted the change in the Sentencing Guidelines has resulted in larger fines being implemented against individuals and organisations.

The average fine handed to organisations found guilty of safety offences has risen since the new sentencing guidelines were introduced, according to figures published by the Sentencing Council. In particular, there has been a considerable increase in fines for larger organisations. See figure 1 below.

Figure 1

Source: http://www.hse.gov.uk/statistics/enforcement.htm

3.3 Relevant HSE priority areas for public services for 19/20 are as follows:

. Reducing ill health levels from work related stress (The adoption of stress management standards approach to tackle work related stress); . Re-energising controls for managing Musculoskeletal Disorders in healthcare . Direction and guidance on violence and aggression in the workplace . Improving awareness of existing standards

Page 9 of 10 4.0 Next Steps – Forward Plan 2019/20

The following activity is proposed for the year ahead:

. Fire Warden Meetings . Fire Warden Refresher Training . Undertake Health and Safety site inspections to ensure compliance, including Fire Risk Assessments for the CCG areas. . Advice and contribution from the Competent Person for the review of Health and Safety Policies/Procedures in accordance with legislation requirements (Ongoing)

In addition ongoing and reactive work will be undertaken as follows:

. Accident/incident investigation where warranted. . Monitoring national trends, forthcoming changes in legislation and HSE cases where they may be relevant. . Assistance with DSE risk assessments and workstation set ups. . Assistance with general risk assessments as well as those for pregnancy stress and return to work. . Provision of general advice to Managers and staff.

5.0 Recommendations

As part of the health and safety planning process the Governing Body is asked to consider any specific areas of the business where further assurance of health and safety management systems is thought to be required.

Page 10 of 10 Agenda Item No: 7A

Date of Meeting: 25th July 2019

Governing Body Meeting in Public

Paper Title: NHS Interim People Plan: Briefing for Board Members

Decision or Approval Discussion Information

Report author: NHS Employers NHS England and NHS Improvement Health Education England Report signed off by: Hein Scheffer, Director of Workforce

Executive Summary: The Interim People Plan for the NHS has been developed over the last few months and sets an agenda to tackle the range of workforce challenges in the NHS with a particular focus on the actions for this year.

The plan sets out a vision for our people and the urgent actions we all need to take this year, both to make immediate improvements but also to build a plan for our people that is fully integrated with those for financial and operational delivery.

The Key Themes of the plan are:

• Making the NHS the best place to work

• Improving NHS leadership culture

• Addressing workforce shortages

• Delivering 21st century care

• Developing a new operating model for workforce. Recommendations . To note to the members:

Page | 1 Conflicts of Interest None perceived involved:

Conflict of Interest Definitions

The following table describes the sub-classifications of interests:

Type Description Financial Interests This is where an individual may get direct financial benefits from the consequences of a commissioning decision. Non-Financial This is where an individual may obtain a non-financial professional benefit Professional Interests from the consequences of a commissioning decision, such as increasing their professional reputation or status or promoting their professional career. Non-Financial This is where an individual may benefit personally in ways which are not Personal Interests directly linked to their professional career and do not give rise to a direct financial benefit. Indirect Interests This is where an individual has a close association with an individual who has a financial interest, a non-financial professional interest or a non- financial personal interest in a commissioning decision.

Page | 2 NHS Interim People Plan

Briefing for board members Introduction

The Interim People Plan for the NHS has been developed over the last few months and sets an agenda to tackle the range of workforce challenges in the NHS with a particular focus on the actions for this year.

Baroness Harding has described the interim plan as follows:

“This interim People Plan doesn’t answer all the questions we know need answering, nor does it set out a detailed 5 -10 year roadmap.

“It does, however, set out our vision for our people and the urgent actions we all need to take this year, both to make immediate improvements but also to build a plan for our people that is fully integrated with those for financial and operational delivery.” Background

. Workforce supply is acknowledged as the biggest challenge facing the NHS but the plan is clear that the quality of staff experience must be improved or those extra people will not stay, or come at all. . The NHS Interim People Plan has been developed with involvement from NHS Employers and a wide range of other stakeholders to set out an initial approach to tackling the range of workforce challenges. . The substantive People Plan will be published following the Spending Review. Key financial commitments will be decided as part of the Spending Review. . NHS organisations will be expected to undertake initial actions and further action following the publication of the final People Plan. Key themes

. Making the NHS the best place to work

. Improving NHS leadership culture

. Addressing workforce shortages

. Delivering 21st century care

. Developing a new operating model for workforce. Making the NHS the best place to work

. The plan acknowledges that people working in the NHS report ‘growing pressure, frustration…, and rising levels of bullying and harassment’.

. BME staff report the poorest workplace experiences.

. Sickness absence runs 2 percentage points higher than the rest of the economy.

. 1 in 11 staff leave the NHS permanently each year. Making the NHS the best place to work

. NHS organisations will be asked to develop their approach to making their organisation the best place to work.

. They will also be asked to contribute ideas to the development of a new offer for staff setting out the support they can expect from the NHS as a modern employer.

. There will be a summer of conversation led by the new chief people officer to develop this offer to staff. Making the NHS the best place to work

This offer would cover:

. creating a healthy inclusive and compassionate culture (including ensuring equality and diversity, tackling bullying and reducing violence) . enabling great development and fulfilling careers (including CPD and ensuring recognition of qualifications between employers) . ensuring everyone feels they have a voice, control and influence (including freedom to speak up, health and wellbeing and flexible working).

A balanced scorecard will be developed to assess organisations in these areas via the NHS Oversight Framework and the CQC Inspection Framework (Well Led Assessment). Pensions

. As part of the theme of making NHS the best place to work, there is an acknowledgement of the impact of the current pension taxation policy on staff retention, particularly in relation to senior clinicians.

. Accordingly, the government is bringing forward a consultation on a proposal for new pension flexibility for senior clinicians.

. The proposal would give senior clinicians the option to halve the rate at which their NHS pension grows, in exchange for halving their contributions to the scheme.

. This consultation is expected to take place over the summer, and it may lead to changes from April 2020. Improving leadership and culture

The plan says NHS leaders should have: . 'a compassionate inclusive culture' including senior leaders, clinical and non-clinical roles and the 'vital middle manager layer.’ . It should have a greater focus on collaborative talent management and a range of measures for greater board assurance. NHS England/Improvement will work to develop an agreed set of competencies for senior leadership roles and will engage widely on options for assuring leadership (which will enable a response to the Kerr and Kark reviews). They will agree a new compact setting out the ‘gives and gets’ to shape the development of senior leaders. Leadership priority areas

. System leadership . Quality improvement . Talent management . Inclusion and diversity.

These leadership challenges apply just as much to the national NHS arms- length bodies, which have an equally important role to play in fostering a new leadership culture. Addressing workforce shortages

The plan includes measures to improve workforce supply and retention across the NHS clinical workforce. There will be a focus on nursing in terms of immediate actions which include:

. NHS England/Improvement expanding its retention support programme with a focus on the most challenged areas

. increasing clinical placements by 25% to 5,000 by September 2019

. developing a new return to practice scheme in conjunction with Mumsnet

. better coordination of international recruitment with a national procurement framework for lead agencies. Addressing workforce shortages

The final People Plan, which is scheduled for release later this year, will cover:

. entry routes into the profession building on the nurse apprenticeship and nurse associate routes

. the development of a 'blended learning nursing degree' programme working with higher education providers

. greater focus on primary and community nursing.

Subject to resources being allocated within the spending review, the aim would be to achieve a phased restoration of previous CPD funding levels over five years. Delivering 21st century care

In order to deliver the vision of care set out in the NHS Long Term Plan, the report calls for a reshaping of the NHS workforce. It specifically calls for:

. a transformed workforce with a more varied and richer skill mix, new types of roles and different ways of working

. the scaling up of new roles via multi-professional credentialing and more effective use of the apprenticeship levy.

There will be further detailed planning work across all major NHS workforce care groups and discussion with the service over future needs before the final plan. Delivering 21st century care

On nursing, the plan calls for further expansion of the nursing associate role to reach 7,500 nursing associates by the end of 2019.

On medical workforce, it pledges an expansion of doctors in primary care by 5,000, further roll out of medical credentialing and support for shortage areas and for the development of more generalist roles.

There will also be action to expand AHP, scientific and other roles as well further develop multi-professional team working starting in primary care networks.

A new programme entitled Releasing Time to Care, which has a focus on using technology to support better deployment of staff time and increase productivity, will be launched. A new operating model for workforce

The interim plan accepts that the workforce planning model in the NHS needs to change.

It argues that functions should be undertaken at the best level to meet the needs of the services. It commits to devolution of responsibility to the Integrated Care Systems (ICSs) as over time they will 'take on greater responsibility for people planning and transformation activities, in line with their developing maturity.'

A newly developed ICS workforce ‘maturity framework’ will be used to assess the readiness of ICS to take on responsibilities including workforce planning. Developing the final People Plan

This interim plan will be followed by work over the summer with a range of stakeholders to help develop a fully-costed final plan.

The aim is to publish a full, five-year plan later this year, following the Spending Review and the development of five-year STP/ICS plans.

The final plan will include:

. measures to embed culture change and develop leadership capability

. more detail on changes to professional education and on investment in CPD

. more detail on additional staff needed. Developing the final People Plan

. The final plan will be developed via National People Board (to be chaired by the CPO, Prerana Issar) and an advisory board (to be chaired by Baroness Harding).

. The way of working will reflect that established in the last phase with working groups chaired by senior leaders including chief executives drawn from the service (Navina Evans, Rob Webster, Julian Hartley).

. The plan will seek investment from the CSR, but is clear that there must be a focus on the things that are in the control of the NHS. Letter from Ruth May, Lisa Bayliss-Pratt, Mark Radford

Directors of Nursing (providers) Directors of Nursing (CCG, ICSs)

3 June 2019

Dear Colleague

Interim NHS People Plan

We are writing to let you know about the interim NHS People Plan that we have jointly published today and to ask for your support with the challenges we face with the nursing workforce. Our sincere thanks to all of you who have been actively involved in its production.

In developing the plan, we have made a thorough and detailed assessment of the issues, drivers and potential actions that we need to take. Within the wider plan we have set out our vision for how people working in the NHS will be supported to deliver the NHS Long Term Plan.

It is evident from this assessment and engagement that to deliver the NHS Long Term Plan we will need more nurses working in health and social care, and more people working across different professions and roles, in all care settings. But more of the same will not be enough. We need to examine not just the number of staff, but how they work and with whom. Our patients, service users and staff tell us they need us to work differently if we are to create the NHS we all want to see. The way we work needs to be more collaborative, more agile and flexible, more multidisciplinary. We have listened to you, and many in the system, and we need to face the current workforce shortages honestly and urgently.

We need to make the NHS the best place to work so we can attract and retain the very best people. Focusing on our people, their working environment, career development and ways of working is critical to the success of the NHS. Nationally we know we need to make people management, recruitment, retention and people development a higher priority, and we ask that you do the same.

This interim NHS People Plan doesn’t answer all the questions that we know need answering; nor does it set out a detailed 5-10 year roadmap. It, however, sets out our vision for our people and the urgent actions we all need to take this year, to make immediate improvements but also to build the full plan for our people that is integrated with those for financial and operational delivery.

It also focuses on the actions we need to take now as a system, working collaboratively to deal with the nursing workforce crisis. There are those urgent and immediate actions that will quickly make a difference in 2019/20 – such as expanding the roll-out of retention programmes and the number of clinical placements for nursing students for September 2019. Others are about laying longer term foundations for culture change throughout the NHS, such as the work the

NHS Improvement NHS England Health Education England NHS Chief People Officer Prerana Issar is leading to agree a core offer for all staff and a leadership compact for current and aspiring leaders.

First, we need to address retention of our nurses and midwives. Improving retention of our staff is vital. The NHS Improvement programme has already made a difference in improving retention and will be rolled out to all providers and to other sectors including general practice, high secure units and urgent and emergency care areas.

The next phase of the NHS People Plan will outline more strategic long-term actions that will enable us to get to a sustainable position. We know that in some areas, such as mental health and learning disability nursing, there are strategic workforce risks in relation to delivering the NHS Long Term Plan. We also know that continuous professional development (CPD) requirements are critical. Therefore, we will be working over the summer to build a more detailed implementation plan including how we will expand our offer of CPD and support for mental health and learning disability nurses and mature students.

As part of developing 5-year plans, local systems will be asked to build detailed people plans over the summer, integrated into and fully consistent with local system financial and operational 5-year plans. You will shortly be briefed on the process for developing those overall 5-year plans and we ask you to start thinking about how to build your people plan within that. We expect to publish our final NHS People Plan once the local system plans have been built and the outcome of the government’s comprehensive spending review is known for future years.

Secondly, we need to address the supply of registered nurses (RN). This will be actioned in a number of ways:

• A recent survey from The Council of Deans of Health highlights that universities could take more students if placement capacity were increased. Through providers we have developed a system-wide funding programme to do this for September this year. We recognise that we are already into the education cycle and clearing, and boosting the January intake will be a priority. • We will also undertake a more comprehensive review of current clinical placement activity, identify outliers and provide support to remove barriers to expansion for future intakes. This will include options for expanding the provision of placements in primary and social care and explore how innovative approaches and best practice can support expansion. • We will only increase numbers of student nurses if we reduce the attrition from the courses, and Health Education England (HEE) will be rolling out the REPAIR improvements to all regions with a commitment to reduce this. • The nursing associate role is a key part of the workforce and commitment to expand this in 2019 by 7,500 is underway in your areas. Many nursing associates wish to move on to RN careers and HEE will lead the work to ensure this option is available. • International recruitment will be a key part of our short and medium term approach. HEE will lead a national programme of recruitment, linked with regional offices to ensure that this is done at scale and appropriately with international partners. • The perception of nursing can be improved. The Nursing Now England programme is designed to focus on challenging stereotypes and raising the profile of the profession as a whole. This will be co-ordinated and linked to the Ambassadors Programme schools and the education cycle to encourage applications to nursing and midwifery courses.

NHS Improvement NHS England Health Education England In developing and producing this interim NHS People Plan, we have aimed to role model the leadership behaviours we know work best in healthcare: collaboration, inclusivity and compassion. All three of us are keenly aware that our own national organisations need to consistently role model these behaviours if we are to support you effectively and we know there is work for all of us to do to deliver this commitment. We are all committed to leading this change and to playing our part in making the NHS an aspirational place and we hope that you will join us on this journey.

We ask you to read the plan, share it with your staff, discuss it with your board or governing body and work with us to make the NHS the best place to work.

Best wishes,

Ruth May

Chief Nursing Officer

NHS England and NHS Improvement

Lisa Bayliss Pratt

Chief Nurse

Health Education England

Mark Radford

Deputy Chief Nursing Officer

NHS England and NHS Improvement

NHS Improvement NHS England Health Education England Agenda Item No: 7B

Date of Meeting: 25th July 2019

Governing Body Meeting in Public

Paper Title: Health and Social Care Workforce Strategy, May 2019

Decision or Approval Discussion Information

Report author: Hertfordshire and West Essex STP Essex County Council Hertfordshire County Council Report signed off by: Hein Scheffer, Director of Workforce

Executive Summary: Our health and care system has set out an ambitious strategy for a healthier future of high quality, person centred and proactive care; which is better joined up, improves outcomes, and increases value.

This strategy sets out the STP’s approach to ensuring we have a workforce that delivers care at the right time; in the right way; in the right place; by the right person, with the right skills and values.

It will act as a guideline for the STP and the organisations within it to support and develop our workforce.

For further introduction and overview please see pages 2-3 of the Strategy. Recommendations . To note to the members:

Page | 1 Conflicts of Interest None perceived involved:

Conflict of Interest Definitions

The following table describes the sub-classifications of interests:

Type Description Financial Interests This is where an individual may get direct financial benefits from the consequences of a commissioning decision. Non-Financial This is where an individual may obtain a non-financial professional benefit Professional Interests from the consequences of a commissioning decision, such as increasing their professional reputation or status or promoting their professional career. Non-Financial This is where an individual may benefit personally in ways which are not Personal Interests directly linked to their professional career and do not give rise to a direct financial benefit. Indirect Interests This is where an individual has a close association with an individual who has a financial interest, a non-financial professional interest or a non- financial personal interest in a commissioning decision.

Page | 2 Hertfordshire and West Essex Sustainability and Transformation Partnership

Health and Social Care Workforce Strategy May 2019

‘One workforce across Hertfordshire and West Essex; delivering high quality, seamless, and person centred care’

Right Right Right Right Right Right Right Care Time Way Place Person Skills Values Our health and care system has set out an ambitious strategy for a healthier future of high quality, person centred and proactive care; which is better joined up, improves outcomes, and increases value. We will also harness new technologies that offer an opportunity to deliver health and care on a more efficient and tailored basis than ever before. We can only deliver this by working together, as a single system, at greater scale and in a more integrated way. If we are to achieve this aspiration then our workforce - the single most important factor in the quality of care and the way in which it is delivered - will be at the heart of this change and integral to realising our Integrated Health Introduction and Care Strategy. Against this backdrop, this Workforce Strategy sets out our approach to ensuring we have a health and social care workforce that delivers care at the right time; in the right way; in the right place; by the right person, with the right skills and values. It will act as a guiding framework for the STP and the organisations within it to support and develop Our health and care system has the health and social care workforce. set out an ambitious strategy for a healthier future of high quality, The strategy has been developed through discussion with a range of stakeholders across Hertfordshire and west person centred and proactive Essex (HWE), facilitated through discussions with partners at the Local Workforce Action Board and associated care; which is better joined up, Workstream Leads meetings. In addition, content has been developed with input from a range of workforce groups improves outcomes, and across Hertfordshire and west Essex and individual discussions, and also takes into consideration other national and increases value. local drivers.

This strategy sets out the STP’s The strategy describes: approach to ensuring we have a workforce that delivers care at A vision for the the right time; in the right way; in The workforce needs workforce with a set of the right place; by the right identified from An evaluation of the associated core person, with the right skills and implementing the A clear strategy to implications of principles, and how values. Health and Care deliver our vision implementing the we will know when we Strategy and other strategy have achieved our It will act as a guideline for the drivers of change vision STP and the organisations within it to support and develop our workforce. Strategy Overview

In line with the Long term plan, our Against this backdrop, we will need to Our vision is therefore to create: Our strategy to deliver this vision is built on 5 Integrated Health and Care Strategy set ensure that our health and care key themes: out an ambitious blueprint for a healthier workforce: “One health and care workforce across future of high quality, proactive care; Hertfordshire and West Essex; delivering • Attraction, recruitment, and retention which is better joined up, improves  Has the necessary capacity to meet high quality, seamless, and person outcomes, and increases value. changing demand across the system centred care” • Education and Training

At its heart is a population health  Has the required skills, capabilities, and We will know we achieved this when: • Innovation and Technology management approach; delivering roles to deliver our future model of care integrated, person centred care  Works in new ways across professional The right care is delivered at the right • Leadership and System Wide designed around our population, and organisational boundaries; and time; in the right way; in the right place; Organisational Development standardising treatment, and by the right person, transforming the key pillars of our system  Is empowered to deliver change by our who has the right skills and values. • Enabling a ‘One Workforce’ approach to ensure their sustainability and culture and leadership resilience.

Making our workforce strategy a reality will require investment, brave leadership, and an approach which puts the best interests of residents and patients above those of individual member organisations. Above all, we must commit to working in partnership in all that we do.

3 • Our workforce strategy covers the broad range of Health and professionals that contribute towards the health and wellbeing of our population. Social Care • This includes staff working in health and social Workforce care, and also recognises the close links we must make with voluntary, community and private sector organisations - whose capacity and capabilities will need to be harnessed to best Our workforce strategy covers the broad range of professionals that meet the needs of our population. contribute towards the health and wellbeing of our population, • We recognise the vital contribution that including: volunteers, carers and families make as part of our workforce. • Healthcare • We will also need to work closely with other • Social Care partners, in particular schools, universities, and • Voluntary sector other academic institutions to secure and upskill our workforce. • Private sector • Our workforce strategy therefore sits alongside, Carers and families also play a and is aligned to, a number of local workforce vital role in our workforce. strategies including local authority social care Schools, universities, and other workforce strategies and those of individual NHS academic institutions are key organisations. partners in securing our workforce. Our Current Workforce 7% of social care workforce are directly employed by our local authorities 14% staff turnover rate across the STP, rising to 30% 38% of staff within social care, where surveyed in 2018 are not sure if there is recruitment and retention is a system leadership group in place particularly challenged.

14% of staff leaving social care go to the NHS 12% average vacancy rates 57,000 staff average across the STP, and a reliance provide or Around 25% of our on bank and agency staff to fill gaps commission health and social care to our workforce are over 50. population This number is higher still within primary care settings

Over 50% of our healthcare staff work in hospitals. In 2017/18, c. 85% of workforce growth was in the acute sector. Adult nurse recruitment was down There was a reduction in community staff 27% in 2018. Learning disabilities nurse recruitment was down 63% 70% of our workforce will still work 5 in the system in 10 years time The health and care system within Herts and west Essex does not operate in isolation, with a range of connections within and outside of the system at a national, regional, and local level. This strategy must therefore be cognisant of these connections and their impact, whether they be national policy, social and cultural trends, or other drivers so that it is effective and deliverable. Key examples are outlined as follows: Context

Our system is made up of a partnership of health and social care providers and commissioners which each have their own pressures and There are a number of Local places and opportunities. The strategies of these organisations, and their implications factors at a national, neighbourhoods for the future workforce, have been considered to ensure that this strategy is aligned with local needs. system and local level which will not only influence our behaviours Our Integrated Health and Social Care strategy is a key driver in what but also shape our our future workforce requirements will be. Our current workforce position, System future ambition (as set out in the Health and Care Strategy), changing workforce requirements demographics, and medium term financial plan all influence this workforce strategy

A number of national reviews, strategies and policy documents will have National an impact on the way that health and care are delivered in Hertfordshire and west Essex in future. These include the recently published NHS Long Term Plan, Topol review, and upcoming Health Education England workforce strategy. Additionally, national political decisions which aren’t directly within the health and care landscape are likely to have an impact on future workforce requirements. The Key Drivers for Change

National Hertfordshire & West Essex System Local

• The NHS Long Term Plan (LTP) - continued focus on • Our current workforce has high vacancy rates, is • West Hertfordshire - Future model of care based on Primary, Community and Mental Health care and a shift ageing, and we are facing difficulty in recruiting proactive measures to prevent ill health, joined up away from silo working towards more integrated services new staff, especially in social care. Workforce care, the centralisation of specialist care, and a delivered closer to people’s homes. Investment in the growth is higher in hospitals than in other settings. locality based community model. Reconfiguration development of Primary Care Networks. However, 70% of our current workforce will still be of acute services is planned, for example the • The Topol Review - genomics, digital medicine and with us in 10 years time. development of ‘hot’ and ‘cold’ sites and capital artificial intelligence to improve care. The workforce will investment to improve facilities and infrastructure. need to develop the skills, attitudes and behaviours • Ambition to develop integrated, person-centred care, designed to meet the needs of our required to become digitally competent and confident. • East and North Hertfordshire – Improved prevention population, delivered in local neighbourhoods Leadership will be vital in planning and delivering these and Primary Care services, an enhanced changes. wherever possible. community model and improved acute services. • Nationally, many staffing groups have significant gaps • Population health management approach. Investment in the hospital buildings to make it more where demand is outstripping supply – high vacancy suitable for the delivery of modern healthcare. rates in nursing, midwifery and medical professions in • Effective and efficient health and care delivered in particular. Furthermore, the impact of Brexit is still the right place, by the right person, at the right time. • West Essex – Primary and community service unknown. Shift care from reactive to proactive when possible, integration through the development of • A 2019 funding settlement will also be reached with and standardise our approach to treatments. neighbourhood model and Primary Care Networks; Social Care, although the publication date of the Social • Transform the key pillars of our health and care supporting the system to manage demand away Care Green Paper is still to be confirmed. A funding system, to ensure they are sustainable and resilient. from hospitals. Improving the quality of acute settlement will also be reached with Health Education services and developing new hospital facilities. England (HEE). • Put in place the staff, culture and systems we need • HEE is due to release a national workforce strategy to to support transformation. • Development of Primary Care Networks serving compliment the LTP populations of 30-50k.

Our workforce needs to evolve in response to this changing landscape in order to provide high quality health and care services for our population.

7 What happens if we don’t change?

• Our wage costs make up c.70% of the costs of delivering care to our population

• Health and social care employees are the most influential factor in the quality of care and the way it is delivered in our area

• If we continue to deliver services in the same way, we know that activity will increase by 29% over the next 10 years across all parts of the system

• Without a different approach, our workforce would also need to increase in line with this increased activity– estimated as some 22% within the NHS alone, and a 3% increase a year in social care

• Increasing staff numbers at this rate would also contribute towards a funding gap of some £1bn across health and social care by 28/29

Given our current vacancy rates and difficulties in recruiting staff, this position is neither viable, sustainable, or affordable.

All figures taken from the HWE medium term financial plan and the Hertfordshire social care workforce strategy 8 Impact on workforce numbers

We recognise the need to do further modelling work in order to determine the required size and shape of our future workforce, if we a)do nothing; and b) implement the changes proposed in the Health and Care Strategy and this workforce strategy.

This will include taking account of factors such as:

Changes in Current staffing Recruitment and Vacancy rates demographics and numbers retention rates demand

New ways of working, New models of care innovation, and New roles Increased productivity technology

9 • Our healthcare workforce will need to remain • Our workforce will need to be person centred around the same overall size as is budgeted rather than organisationally focussed for now, yet mitigate against rising demand for • Staff will be able to work anywhere, in any- services. The social care workforce will way across the system to deliver integrated increase in line with changing demographics. Our care and improved outcomes for our • Workforce capacity will shift towards planned population and preventative care, with a relative • Multidisciplinary working across traditional increase in workforce numbers across primary, Workforce organisational and professional boundaries in community and mental health services neighbourhoods and primary care networks • There will be more growth in generalist roles will be common place Needs relative to those with highly specialist skills • Digital technology will enable us to • There will be a reduced reliance on improve and streamline routine temporary staff, in particular external processes, enabling staff to prioritise Against this backdrop, we will need agencies, to fill gaps in capacity supporting people’s health and to ensure that our health and care wellbeing workforce:

 Has the necessary capacity, in the right places, to meet changing demand across the system; • There will be collective leadership • A more flexible skills base working at all levels of the system, which is across a wider range of health and inclusive and compassionate  Works in new ways across care support needs • More diversity in our leadership that professional and organisational reflects the diversity of our workforce • Better understand each others’ roles boundaries; and our residents and the value we add • Our leaders will put the needs of the • Make best use of specialist skills  Has the required skills, population first; before that of • We will need new roles such as care planning capabilities, and roles to deliver their individual organisations and care navigation our future model of care ; and • A collaborative and trusting culture that enables staff to work in different ways • Increased use of alternatives to GPs in primary care as part of Primary Care Networks • Empower staff to put change in to action and  Is empowered to deliver change do the right thing by people • Improved digital competence and confidence by our culture and leadership. • Our leaders will champion the adoption and • Ability to use new tools and better interpret spread of new technology data • Talent will be shared across the system One workforce across Hertfordshire and West Essex; delivering high quality, seamless, and person centred care Our vision Right Right Right Right Right Right Right and Care Time Way Place Person Skills Values principles

PRINCIPLES Our vision is to create one health and care workforce across Hertfordshire and west Essex; Value staff as integral to Adopt a consistent and delivering high quality, seamless, delivering care now and collaborative approach to and person centred care in the future managing the workforce

We will know we have achieved this when the right care is delivered at the right time; in the Become employers of Promote the health and right way; in the right place; by choice – retaining our wellbeing of our workforce the right person; with the right current staff and and empower staff to deliver skills and values. attracting new talent change where needed This will involve working closely with our partners in the voluntary, community, and private sectors; as well as universities and other Embrace innovation, Recognise the contribution academic institutions. technology, new roles, of and develop close links and new ways of with the voluntary, private, working and education sectors Our Capacity Capability Ways of working Culture and leadership workforce Attraction, Education and Innovation and Leadership and recruitment, and training technology organisational strategy on a retention development Training and Create a HWE page HWE Talent developing our New ways of Leadership Academy own supply of working Academy staff Our strategy is built on five key themes: Shared system Affordable New curriculums Digitally enabled Wide housing for our and pathways working organisational • Attraction, recruitment, and staff development retention

• Education and training Enabling a one workforce approach • Innovation and technology

Workforce • Leadership and organisation Single Integrated passports to development HWE temporary Shared Support Close Links with enable staff to staffing agency / Employment Services Voluntary Sector work across bank Approach • Enabling a one workforce organisations approach

Multi-professional working Attraction, recruitment, and Hertfordshire and West Essex Affordable Housing and Transport Talent Academy – supporting - influence the creation of retention the system to attract, recruit, affordable housing and and retain staff. improved transport infrastructure for our workforce to help us In order to ensure our workforce attract and retain staff. has the necessary capacity to meet changing demand across the system, we will focus on System-wide apprenticeship Targeted attraction and attracting, engaging, recruiting, scheme and pooled levy - retention strategies - best and retaining staff – by making focusing on core workforce practice learning and HWE a place to fulfil people’s requirements across the system. adoption so that we do all we career ambitions. can to make staff want to join and stay within the system. We will target groups including Focus on young, students, young people, apprentices and Influence private and current workforce, our former students, our current workforce, employees (or our alumni). and our former employees. independent sectors– recognise our roles as market Core areas of work will include the makers and our ability to development of our own talent influence the private sector academy, a system-wide through commissioning. apprenticeship scheme, and advocating for affordable housing for our staff. Education Improved education and and System wide funding for training - new curriculums, Continuing Professional training portfolios and Training Development – using local pathways to develop the right funding to maintain skills and skills and capabilities for our centralised funding to workforce. Improving education and training transform and develop new will be vital to develop a flexible skills. workforce that can support people with a wide range of Developing our staff to work Harmonised approaches to health and care needs. differently – supporting, training training – standardising and developing our existing capability and delivering Greater influence over the supply workforce to work in new ways greater consistency of practice of our future workforce will allow or perform new roles within the across the system. us to grow staff within HWE through our own training system. programmes, and enable us to develop new curriculums and Career development routes – training pathways which support looking after our workforce and new roles and job descriptions. supporting them to develop their careers within the HWE system, across health and social care. Innovation and New ways of working – Multi- Supporting staff to implement professional working across new technology – so that we Technology organisational and professional can harness the potential of boundaries to deliver areas such as genomics, digital integrated care. medicine, and artificial Innovation and technology will intelligence. mean our workforce can work flexibly and productively across Enable staff to make better use Development of new roles and the system, delivering of data – so that we can adopt job descriptions – for example collaborative, integrated health an evidence based approach community navigators to and social care. and embrace the principles of deliver our new models of care. population health management.

Digital and technology enabled working – increasing An agile workforce – enabled productivity and driving by technology to work additional capacity from our anywhere within the system. current establishment by adopting technology. Leadership Leadership Academy – to Shared executive develop greater system responsibilities and roles across and OD leadership capacity and our health and care system– capability at all levels within the promoting a ‘one workforce’ system. approach and delivering efficiencies. Developing collective leadership at all levels of the system, which puts the needs of the population before that of their individual Develop system leadership Sharing talent – Putting the organisations and empowers staff networks – bringing leaders needs of our residents, patients to deliver change, is a core part across professional groups and and service users above those of our strategy. organisations together to of individual organisations and This will be achieved through the promote ‘one workforce’ sharing talent where it is development of a system wide approach. needed most. leadership academy and a system wide approach to organisational development. A system wide approach to Proactive succession planning organisational development – – to increase and sustain to embed the right culture and leadership capacity. behaviours. Enabling ‘one A single bank operating across Adopting a more integrated all acute trusts - enabling approach to employment - e.g. workforce’ temporary staff to work flexibly harmonised job descriptions and across the system and reduce contracts, allowing capacity to the reliance on agency staff. be deployed more flexibly.

We will ensure that our workforce is person centred rather than organisationally focused. Shared support services - Single Workforce passports - enabling This will mean that staff can work support services across the staff to work across anywhere, in any way, across the system, with centralised organisational boundaries system to deliver integrated care functions and localised making it possible for staff to work and improved outcomes for our delivery. where they are needed most by population. patients and service users.

Alignment and co-location of Closer links with the voluntary staff – facilitating staff to come and private sectors – supporting together to support integrated the system to harness the / multidisciplinary working in capacity of local volunteers and local communities and our wider partners. neighbourhoods. What makes our strategy stand out?

Attraction, recruitment, and  The development of a HWE Talent Academy retention  Influencing the development of affordable housing

 Greater ownership of nursing, midwifery, and medical Education and training education within HWE

 Digitally competent and confident staff Innovation and technology  Embedding technology and a culture of quality improvement

 A HWE leadership academy, developing collective Leadership and organisational leadership at all levels of the system development  System wide OD

Enabling a one workforce  A single temporary staffing agency / bank approach  A single and consistent approach to employment

18 The A commitment to ‘one workforce’ Investment implications of our Realising our vision for ‘one workforce’ will Delivering our strategy will require mean putting the needs of our population investment in talent; technology; strategy above individual organisations and organisational development; and thinking of our own staff as part of the education. Making our workforce HWE workforce. strategy a reality will require investment, brave leadership, and a different mindset where Bold Leadership Consistent Partnership Working we put the needs of our residents, patients and service users above our We will need to make bold decisions as The partnership working required to deliver own organisations. leaders – for example will we commit to our strategy cannot be a pick and mix Above all, we must working together to deliver affordable approach – we must adopt a consistent commit to working in housing for health and care staff or new approach to working in partnership across partnership in all that we education courses within HWE? all that we do. do. Future Workforce Planning

The diagram below provides an early indication of where workforce planning roles and responsibilities could sit within the future system architecture:

• System-wide workforce strategy as a guiding framework • System wide organisational development • Investment and funding • Single and consistent employment approach • Development of leadership and talent academies ICS • Establishing a single staff bank and shared support services (1.5m) • Greater ownership of education and training and partnerships with universities

• Developing new roles and ways of working aligned to local models of care ICA • Detailed workforce planning to establish local capacity requirements • Influence over private and independent sectors through commissioning • Development of affordable housing and transport with local partners (500k) • Enabling staff to work across organisational boundaries

• Implementation of new roles and ways of working Primary Care Network (30-50k) • Alignment and co-location of staff • Multi professional working • Closer links with voluntary sector

20 Managing and assuring the delivery of our strategy

In order to assure the delivery of our strategy, we have put in place a robust governance structure based around key sub-workstreams. Each sub- workstream is headed by a leader within the system with an appropriate programme and project governance in place. These sub-workstreams will report into the Hertfordshire and West Essex Local Workforce Action Board (LWAB) and subsequently into the STP CEO Steering Group. This will ensure both local and system focus on our work in line with this strategy.

STP Project STP CEO Steering Management Group Office (PMO) CEO Support Network Professional Networks

Local Workforce Action Board (LWAB) (stakeholder partnership – quarterly) Staff / Partnership Forums Health STP Workforce Workstream STP Comms & Education (strategic oversight of delivery groups – Engagement Group England monthly) (HEE)

HR SERVICES REVIEW WORKFORCE PLANNING ATTRACTION, STP WORKFORCE WORKFORCE REDESIGN LEADERSHIP AND OD TEMPORARY STAFFING SRO: Hein Scheffer AND SUPPLY RECRUITMENT AND TRANSFORMATION AND DEVELOPMENT SRO: Paul Da Gama SRO: Paul Da Gama (Dir. Workforce Hertfordshire MODELLING RETENTION PRIORITIES FROM THE SRO: Tracey Carter (Dir. HR WHHT) (Dir. HR WHHT) & West Essex CCGs) SRO: Paul Da Gama SRO: Ogechi Emeadi STP WORKSTREAM (Chief Nurse WHHT) (Dir. HR WHHT) (HR Director PAH)

• Mental Health • STP wide approach to • New role design • Workforce profiling • Attraction strategy system leadership • Consolidation of HR • Cancer • Development of the • Demand and supply • Youth engagement • Existing role training services • Primary Care temporary staffing modelling development • Student offer • Leadership academy bank / agency across • Shared services across • Urgent and • Future STP • Benchmarking • Collaborative development the system core HR functions Emergency Care commissioning of workforce recruitment • STP talent mapping required workforce • Frailty and supply

21 Next Steps

April – June 2019 May – June 2019 June 2019 onwards

01 Programme 02 Workforce 03 Implementation Planning Modelling

• Workstream leads to check if current • Baseline of current workforce • Adopt a robust portfolio management workstream plans will deliver strategy projections under a ‘do nothing’ approach to manage implementation scenario and realise benefits • Incorporate any newly identified areas into existing plans • Quantify the impact of STP clinical • Evaluation of future investment costs workstreams on future workforce e.g. Talent Academy, Leadership • Scope and develop plans for newly requirements Academy etc identified initiatives • Quantify impact of workforce • Business case development as applicable • Agree what will be delivered in the strategy initiatives on recruitment, next 1, 3, and 5 years retention, etc. • Regular reporting against delivery plan milestones and benefits • Model future workforce requirements • Regular programme reviews to ensure • Gap analysis between future work continues to be aligned with requirements and do nothing objectives and outcomes projections

Ongoing Programme Management

22 Contacts and further information

For further information on the Hertfordshire and West Essex Health and Social Care Workforce Strategy please contact:

• Paul Roche STP Workforce Director [email protected]

• Mark Edwards STP Workforce Programme Manager [email protected] www.healthierfuture.org.uk

Published May 2019 Agenda Item No: 8

Date of Meeting: 25th July 2019

Governing Body Meeting in Public

Paper Title: Finance Report Month 2 2019-20

Decision or Approval Discussion Information

Report author: Amber Willson, Senior Finance Manager Sunday Adeniyi, Deputy Chief Finance Officer Report signed off Alan Pond, Chief Finance Officer by:

Executive Summary: This paper provides details of the finance position at the end of May 2019, Month 2.

The control total agreed with NHS England for this financial year is an underspend of £18.851m. The expected in-year financial position is to breakeven.

The financial position as at the end of May 2019 is an underspend of £3.323m representing an in year underspend of £181k and surplus brought forward of £3.142m.

Recommendations To note the month 2 position. to the members: Conflicts of Interest There are no conflicts of interest involved:

Conflict of Interest Definitions The following table describes the sub-classifications of interests: Type Description Financial Interests This is where an individual may get direct financial benefits from the consequences of a commissioning decision. Non-Financial This is where an individual may obtain a non-financial professional benefit Professional Interests from the consequences of a commissioning decision, such as increasing their professional reputation or status or promoting their professional career. Non-Financial This is where an individual may benefit personally in ways which are not Personal Interests directly linked to their professional career and do not give rise to a direct financial benefit. Indirect Interests This is where an individual has a close association with an individual who has a financial interest, a non-financial professional interest or a non- financial personal interest in a commissioning decision.

1 Finance Report 2019-20 CCG Governing Body Meeting in Public 25th July 2019

APPENDICES Appendix 1 – Acute Commissioning

TERMS/ACRONYMS USED IN THE REPORT

Initials In full B&CF Barnet and Chase Farm Hospital Trust BEH Barnet, Enfield and Haringey BPPC Better payments practice code BSA Business Services Authority CCG Clinical Commissioning Group CHC Continuing healthcare CUFT Cambridge University Foundation Trust DOL Deprivation of liberty ED Emergency department FNC Funded nursing care FYE Full year effect HCT Hertfordshire Community Trust HPFT Hertfordshire Partnership Foundation Trust IR Identification Rule MCD Maximum cash drawdown MH Mental health MVCC Mount Vernon Cancer Centre NHSE NHS England PAH Princess Alexandra Hospital POD Point of Delivery RTT Referral to treatment SLAM Service Level Agreement Monitoring T&O Trauma and Orthopaedics UCC Urgent care centre UCLH University College London Hospitals YTD Year to date

2 1. EXECUTIVE SUMMARY

The control total agreed with NHS England for this financial year is an underspend of £18.851m.

The financial position as at the end of May 2019 is an underspend of £3.323m representing an in year underspend of £181k and surplus brought forward of £3.142m. To support this YTD position £432k of the contingency reserve has been used and it is expected that £1.585m of the contingency reserve will be required to deliver the year end Control total.

The CCG has QIPP programmes totalling £13.00m for 2019-20. Year to date, the CCG has delivered £1,653k against a plan of £1,977k representing under delivery of c£324k. The forecast for the year is QIPP delivery of £11.6m resulting in an under delivery of £1.4m, equating to delivery of 89.23% of the plan.

The CCG also delivered against the BPPC performance target. The target is to pay at least 95% of invoices within 30 days. Actual performance YTD is 99.06% for NHS and 98.64% for Non NHS.

2. KEY PERFORMANCE INDICATORS

The table below shows CCG performance against key performance indicators.

KEY PERFORMANCE INDICATORS - MONTH 2

Year to Date Full Year No Indicator Name Plan Actual Variance YTD Plan Actual Variance Forecast Narrative £'000 £'000 £'000 Rating £'000 £'000 £'000 Rating Opening recurrent allocation is £866,185k and added to this 1 Resource Limit vs Spend 146,608 146,608 0 890,250 890,250 0 is the surplus brought forward of £18,851k. In year non recurrent allocation of £5,214k has been received to date.

The CCG agreed control total is an in-year breakeven + 2 Over/Under vs Control total (3,142) (3,323) (181) (18,851) (18,851) 0 cumulative surplus brought forward of £18,851k. The CCG is reporting delivery of the control total agreed with NHSE.

The CCG running cost budget is on track and is forecast to 3 Running Cost/Admin 2,119 2,020 (99) 12,712 12,378 (334) underspend against corporate running cost allocation

The CCG programmes are forecasting to deliver 89.23% 4 QIPP Performance (1,977) (1,653) 324 (13,000) (11,600) 1,400 against plan.

£432k contingency reserve has been used to date, and it is 5 Contingency Reserve Utilised 432 - (432) 3,946 2,361 (1,585) expected that £1,585k will be required to deliver the required year end position

BPPC-Number -NHS (%) 95.0% 99.06% 95.0% 95.0% BPPC-Number -Non-NHS (%) 95.0% 98.64% 95.0% 95.0% 6 BPPC-Value - NHS (%) 95.0% 100.00% 95.0% 95.0% BPPC-Value - Non-NHS (%) 95.0% 99.41% 95.0% 95.0%

3 3. CCG ALLOCATION & BUDGETS

The CCG notified allocation as at May 2019 is £890,250k as shown in the table below. The CCG received in-year allocations totalling £5.214m which is detailed in the table below:

Delegated CCG Month Month Total Month £'000 £'000 £'000

Allocation brought forward 791,449 74,736 866,185

Brought Forward Surplus/(Deficit) 18,851

Transforming Care retrospective adult only 19-20 payment 1,260 1,260 Excess Treatment Costs (36) (36) DWP Employment Advisors in IAPT 498 498 Improving Access Allocations 19/20 3,398 3,398 MOCH 2019 Q1 and Q2 - £94,326 94 94 0

Total notified allocation 796,663 74,736 890,250

4. CCG EXPENDITURE OVERVIEW

The financial position as at the end of May 2019 is surplus of £181k which is in addition to the required underspend. A summary of the CCG financial position is shown below.

POSITION AS AT MAY 2019

Annual Forecast Annual YTD budget YTD Actual YTD Variance Description budget Outturn Variance (£) (£) (£) (£'000) (£'000) (£'000)

Allocation 146,608 146,608 0 890,250 890,250 0

Budget Heading Acute Commissioning 75,931 77,326 1,395 458,540 463,400 4,860 Non Acute Commissioning 35,509 34,956 (553) 213,054 211,644 (1,410) GP Prescribed Drugs 13,067 12,883 (184) 80,513 79,172 (1,341) Other Primary Care 4,404 4,096 (308) 26,763 26,239 (524) Running Costs 2,066 2,020 (46) 12,378 12,378 0 Resilience Funding 154 154 0 1,469 1,469 0 Transformation reserve 0 0 0 0 0 0 Contingency reserve 432 0 (432) 3,946 2,361 (1,585) Total CCG in year position 131,564 131,435 (129) 796,663 796,663 0

Primary Care Devolved Budgets 11,903 11,850 (52) 74,736 74,736 0

Total expenditure 143,467 143,286 (181) 871,399 871,399 0

Underspend brought forward 3,142 (3,142) 18,851 (18,851)

TOTAL (UNDER)/OVER SPEND (3,323) (18,851)

4 4.1 Locality Financial Performance

Locality allocations and budgets are currently being finalised and will be issued shortly.

4.2. Programme Budget – Acute Commissioning

4.2.1 Financial Performance

Acute Commissioning reported an overspend of c£1.4m as at the end of May which is mainly due to East & North Herts Trust (c£1.8m over) as detailed in the table below.

ACUTE COMMISSIONING POSITION AS AT MAY 2019

YTD Annual Forecast Annual YTD budget YTD Actual Description Variance Budget Outturn Variance (£'000) (£'000) (£'000) (£'000) (£'000) (£'000)

East and North Herts Trust 39,598 41,428 1,830 240,538 244,521 3,983 Princess Alexandra Hospital 10,892 11,195 303 65,354 65,354 0 Royal Free FT 4,783 4,877 94 28,700 29,264 564 Cambridge University Hospitals 3,133 3,057 (76) 18,795 18,795 0 Independent Sector 4,178 4,048 (130) 25,068 24,893 (175) Other Acute 13,348 12,721 (627) 80,085 80,573 488 Reserves /QIPP 0 0 0 0 0 0

Total 75,931 77,326 1,395 458,540 463,400 4,860

The acute QIPP savings for 2019-20 is £12.256m, which has been incorporated within individual provider plans. Therefore the figures shown in the table above are net of QIPP.

The table below shows breakdown of acute spend by point of delivery. Total acute budgets have overspent by 1.8% mainly within Non-Elective (c£1.4m, 6.6%), and Outpatients (c£0.67m, 4.5%).

M2 PLAN M2 ACTUAL VAR % VAR Acute Commissioning Expenditure £,000 £,000 £,000

A&E and MIU 5,381 5,569 188 3.5%

Outpatient First 5,149 5,214 64 1.2% Outpatient Follow-Up 5,252 5,121 (130) -2.5% Outpatient procedures 2,732 3,080 348 12.7% Diagnostics 1,956 2,347 391 20.0% Total Outpatient 15,089 15,762 673 4.5%

Day Case 7,925 7,980 56 0.7% Elective 6,647 6,345 (302) -4.5% Total Elective 14,572 14,325 (247) -1.7%

Non-Elective (excluding Maternity) 21,266 22,667 1,402 6.6%

Maternity (Births) 3,060 3,015 (45) -1.5% Maternity (Ante Natal Pathways) 2,033 1,916 (117) -5.7% Maternity (Post Natal Pathways) 319 293 (26) -8.3% Total Maternity 5,412 5,224 (188) -3.5%

Critical Care 2,215 2,509 294 13.3% Excluded Drugs 2,299 1,964 (336) -14.6% Excluded Devices 355 381 26 7.3% CQUIN 898 746 (152) -16.9% Other (including contract adjustments) 8,443 8,179 (265) -3.1%

Total 75,931 77,326 1,395 1.8%

5 Non Elective activity for the main Trusts is shown in the table below:

M2 PLAN M2 ACTUAL VAR Non Elective Expenditure by Provider % VAR £,000 £,000 £,000

East & North Herts Trust 13,379 14,455 1,076 8.0% Princess Alexandra 4,410 4,692 283 6.4% Royal Free 1,272 1,345 74 5.8% North Middlesex 619 705 86 13.8% Other providers 1,586 1,470 (116) -7.3%

Total 21,266 22,667 1,402 6.6%

East and North Herts Trust

The reported overperformance of c£1.8m at month 2 has been adjusted to exclude challenges of c£1.4m. A significant proportion of these relate to non-elective activity. (8% above plan for activity and 13% above plan for costs.) Concerned with this trend, we have identified the following areas to be investigated.

• Increased demand for non-elective services by the 0-4 and over 70 age groups • Increased demand for non-elective services for Respiratory and UTI conditions • Increase in GP heralded attendances

Other factors include the phasing of QIPP schemes and a population increase due to the commissioning of new housing developments in Buntingford and Hitchin.

If the current trend continues into M3, it is proposed that a joint investigation is commenced in order to establish reasons and agree suitable interventions which will mitigate the future effect of this growth. Alternatively, an Activity Query Notice could be raised by either CCG or Trust which would formalise the investigation.

Princess Alexandra Hospital (PAH)

The Month 2 SLAM Report received from PAH indicates a year to date overspend of £303k against the CCG’s straight line plan, which includes £1.4m of QIPP savings not yet in the contract.

The activity and finance plan in the SLAM file has been loaded at HRG level, but the national tariff/local tariff split been applied inconsistently and will need amending.

In addition, a large proportion of Month 2 spells is un-coded. As noted previously, the impact of full coding has had little effect on the overall cost, although activity shifts between PODs can be significant. Some un-coded NEL spells convert to NEL Short Stay/Same Day which are less expensive, while some Outpatient attendances convert to Outpatient Procedures which are more expensive.

Year to date there is overspend in comparison to the agreed plan, particularly in the following areas:

• A&E is approximately £60k over contract plan. However, activity is marginally under plan, indicating a shift to more complex higher-cost attendances. • Adult Critical Care activity is over plan by £57k, due to very high activity in April. May activity has returned to below planned levels. 6 • Non-Elective expenditure in total is 4% (c.£232k) over the agreed plan (subject to review of assessment space pricing), although activity is only 1% over plan.

Current analysis of the Non-Elective activity is subject to change, according to the outcomes of the planned Bailey & Moore audit. The audit will provide a view on best practice for coding activity in assessment spaces, which is currently coded as spells.

Royal Free NHS FT (RF)

The month 2 position is an overspend of £94k. The main areas of overspend are Elective (£145k over) and Non Elective (£73k over). These overspends are offset by underspends in Day cases, Outpatients and Excluded Drugs.

4.2.2 CCG Activity Performance

The following charts show total CCG activity trend by point of delivery for May 2019.

Total Elective Activity April May June July Aug Sep Oct Nov Dec Jan Feb Mar Total YTD 2017-18 4,961 5,697 5,705 5,521 6,271 6,410 6,372 6,609 5,404 6,528 5,764 6,326 71,568 10,658 2018-19 6,317 6,883 6,718 6,796 6,380 6,352 7,073 6,895 5,893 7,081 6,384 6,914 79,686 13,200 2019-20 6,793 6,865 13,658 13,658 2019-20 Plan 6,808 7,148 6,808 7,828 7,148 7,148 7,828 7,148 6,127 7,488 6,808 7,487 85,774 13,956 Variance (%) -0.2% -4.0% -2.1% Total Elective Activity 9,000 8,000 7,000 s

n 6,000 o i s

s 2017-18 i 5,000 m

d 2018-19 A

4,000 f o

2019-20 o 3,000 N 2019-20 Plan 2,000 1,000 0 April May June July Aug Sep Oct Nov Dec Jan Feb Mar

Elective activity is 2.1% below plan as at May 2019 but 3.4% higher than for the same period in 2018-19.

A&E Activity April May June July Aug Sep Oct Nov Dec Jan Feb Mar Total YTD 2017-18 17,201 18,364 18,251 18,240 16,979 17,313 17,844 17,174 16,807 16,922 15,586 17,755 208,436 35,565 2018-19 17,016 18,618 18,283 18,966 17,540 17,466 18,606 17,659 17,370 17,916 16,906 18,837 215,183 35,634 2019-20 16,371 17,408 33,779 33,779 2019-20 Plan 17,719 18,309 17,719 18,309 18,309 17,719 18,309 17,719 18,309 18,309 17,127 18,307 216,164 36,028 Variance (%) -7.6% -4.9% -6.2% A&E Activity 20,000 18,000 16,000

s 14,000 e c n a 12,000 2017-18 d n e

t 10,000

t 2018-19 A

f 8,000

o 2019-20

N 6,000 2019-20 Plan 4,000 2,000 0 April May June July Aug Sep Oct Nov Dec Jan Feb Mar

A&E activity is below plan for both April and May, cumulatively 6.2% under.

7 Non-Elective Activity April May June July Aug Sep Oct Nov Dec Jan Feb Mar Total YTD 2017-18 4,226 4,546 4,527 4,396 4,483 4,245 4,258 4,471 4,432 4,534 4,227 4,616 52,961 8,772 2018-19 4,375 4,754 4,654 4,583 4,697 4,605 5,122 5,027 4,952 5,220 4,484 5,034 57,507 9,129 2019-20 4,638 5,378 10,016 10,016 2019-20 Plan 4,842 5,004 4,842 5,004 5,004 4,842 5,004 4,842 5,004 5,004 4,680 5,003 59,075 9,846 Variance (%) -4.2% 7.5% 1.7% Non-Elective Activity 6,000

5,000 s e

c 4,000 n a 2017-18 d n e

t 3,000 2018-19 t A

o 2019-20

o 2,000 N 2019-20 Plan

1,000

0 April May June July Aug Sep Oct Nov Dec Jan Feb Mar

Non Elective admissions were 4.2% below plan for April but 7.5% above plan for May and 1.7% above plan cumulatively to date.

Total Outpatient April May June July Aug Sep Oct Nov Dec Jan Feb Mar Total YTD 2017-18 38,526 44,839 46,052 43,779 43,145 40,057 44,795 48,904 37,098 45,803 41,107 43,572 517,677 83,365 2018-19 41,867 46,328 43,891 44,976 49,055 48,604 55,494 53,425 42,510 56,086 49,552 52,226 584,014 88,195 2019-20 52,539 55,006 107,545 107,545 2019-20 Plan 51,225 53,786 51,225 58,908 53,786 53,786 58,908 53,786 46,102 56,348 51,225 56,346 645,431 105,011 Variance (%) 2.6% 2.3% 2.4%

Total Outpatient 70,000

60,000

50,000 2017-18 40,000 2018-19 30,000 2019-20 20,000 2019-20 Plan 10,000

0 April May June July Aug Sep Oct Nov Dec Jan Feb Mar

Total YTD Outpatients are 2.4% above plan and 21.9% higher than for the same period in 2018-19.

4.3 Programme Budget – Non Acute Commissioning

The Non Acute position as at the end of May is an underspend of £553k which is detailed in the table below:

8 COMMISSIONING NON ACUTE POSITION AS AT MAY 2019

YTD Annual Forecast Annual YTD budget YTD Actual Description Variance budget Outturn Variance (£'000) (£'000) (£'000) (£'000) (£'000) (£'000)

Mental Health (incl. LD, Dementia, NCA) 13,305 13,299 (6) 79,829 79,829 0 IAPT 1,173 1,173 0 7,038 7,038 0 Hertfordshire Community Trust (HCT) 7,479 7,479 0 44,874 44,874 0 Community Services (excl HCT Contract) 980 749 (231) 5,879 4,989 (890) Continuing Healthcare & FNC 8,212 8,169 (43) 49,271 49,761 490 Intermediate Care 409 378 (31) 2,452 2,452 0 Better Care Fund 2,359 2,359 0 14,153 14,153 0 Hospices 542 542 (0) 3,251 3,251 0 Palliative Care 45 41 (4) 271 271 0 Wheelchair Services 246 246 0 1,477 1,477 0 NHS Property Services Ltd 14 10 (4) 84 84 0 Prior year balance 0 (239) (239) 0 (1,011) (1,011) Other Non Acute 176 179 4 1,053 1,053 0 NHS 111 350 350 0 2,102 2,102 0 Other Transformation Programmes 220 220 (0) 1,320 1,320 0 TOTAL 35,509 34,956 (553) 213,054 211,644 (1,410)

The main areas of underspend to date are Community Services £231k and Prior year £239k. Continuing Healthcare is underspent by £43k; however, there is a potential risk to the CCG as the position may change due to the high cost of packages.

4.4 Programme Budget – Primary Care Commissioning

The Primary Care position as at the end of May is an underspend of £492k which is detailed in the table below:

COMMISSIONING PRIMARY CARE POSITION AS AT MAY 2019 Annual YTD YTD YTD Annual Forecast Budget Description budget Actual Variance budget Outturn Variance (£'000) (£'000) (£'000) (£'000) (£'000) (£'000)

GP Prescribed Drugs 13,067 12,883 (184) 80,513 79,172 (1,341) Central Drugs 409 380 (29) 2,523 2,523 0 Oxygen 102 94 (7) 627 627 0 Scriptswitch 28 25 (2) 165 165 0 Medicine Management Team 233 194 (39) 1,396 1,396 0 Local Enhanced Services 337 290 (46) 2,020 1,772 (247) Commissioning Framework 982 982 0 5,894 5,894 0 £1 per patient 58 58 0 602 602 0 PCN 165 165 0 989 989 0 Primary Care IT 299 299 (0) 1,796 1,796 0 Out of Hours 941 941 0 5,645 5,645 0 Acute in hours visiting service 285 285 0 1,708 1,708 0 GP Forward View 566 382 (184) 3,398 3,122 (276)

TOTAL 17,472 16,980 (492) 107,276 105,411 (1,865)

To date we have received 1 month of Prescribing costs, the Business Services Authority (BSA) run approximately two months behind the actual period incurred. Prescribing is reporting a year to date underspend of £184k, and a forecast underspend of c£1.3m.

9 4.5 Primary Care Devolved budget

The Primary Care Devolved position as at the end of May is an underspend of £52k which is detailed in the table below:

PRIMARY CARE DEVOLVED COMMISSIONING POSITION AS AT MAY 2019 Annual Annual Forecast YTD budget YTD Actual YTD Variance Budget Description budget Outturn (£'000) (£'000) (£'000) Variance (£'000) (£'000) (£'000)

GMS Contracts 7,685 7,703 18 46,256 46,256 0 APMS Contracts 487 477 (10) 2,928 2,928 0 Enhanced Services 326 351 25 1,886 1,886 0 Primary Care - Other 178 201 23 1,070 1,070 0 Prescribing/Dispensing 167 139 (27) 1,516 1,516 0 QOF 1,244 1,244 0 7,463 7,463 0 Premises 1,263 1,216 (47) 7,368 7,368 0 Primary Care Networks 165 165 (0) 1,960 1,960 0 Headroom Allocated 388 355 (33) 2,114 2,114 0

Sub Total Allocated Budget 11,903 11,850 (52) 72,561 72,561 0

Uncommitted Headroom/Reserve 1,790 Contingency 385 Total 74,736

In addition to this there is both the uncommitted headroom (£1,790k) and contingency (£385k).

4.6 Corporate Running Costs

The CCG running cost allocation for 2019-20 is £12,712k however an annual budget of £12,378k has been set.

As at the end of May, the running cost budget is reporting an underspend of £46k against budget set as shown in the table below.

CORPORATE POSITION AS AT MAY 2019 Annual YTD YTD YTD Annual Forecast Budget Description budget Actual Variance budget Outturn Variance (£'000) (£'000) (£'000) (£'000) (£'000) (£'000)

Directors Office 262 228 (34) 1,569 1,569 0 Primary Care Directorate 69 70 1 413 413 0 Finance Directorate 949 988 39 5,694 5,694 0 Commissioning Directorate 149 127 (21) 875 875 0 Operations Directorate 216 214 (2) 1,296 1,296 0 Nursing Directorate 237 227 (9) 1,422 1,422 0 Medical Directorate 185 168 (17) 1,109 1,109 0 Other 0 (2) (2) 0 0 0

Total 2,066 2,020 (46) 12,378 12,378 0

10 5. Quality, Innovation, Productivity and Performance (QIPP)

The CCG planned financial savings for 2019-20 is £13.0m and is reporting a delivery of £11.6m (89.2%). The year to date status regarding delivery is £324k under plan.

The table below shows the overall summary and status of QIPP programmes to date and the projected forecast for the financial year.

East & North Hertfordshire CCG QIPP Programme 2019/20 YTD QIPP Annual Forecast Forecast YTD Actual YTD Programme Category QIPP Scheme Description Savings Planned Outturn Outturn QIPP Achieved Variance Target Savings Savings Variance £ £ £ £ £ £ A&E A&E Avoidance schemes £88,563 £37,023 -£51,539 £441,619 £423,339 -£18,280 Non Elective Demand Management / Pathways £707,321 £383,317 -£324,004 £4,876,527 £4,618,021 -£258,506 Ambulance (EEAST) Ambulance Savings £328,186 £329,556 £1,370 £2,073,890 £1,064,947 -£1,008,943 Outpatient first attendances Demand Management / Pathways £45,295 £95,423 £50,128 £1,092,471 £1,060,681 -£31,790 Outpatient follow ups Demand Management / Pathways £45,072 £20,221 -£24,851 £428,331 £335,353 -£92,978 Elective Demand Management / Pathways £233,326 £245,848 £12,522 £1,239,617 £1,250,421 £10,804 Prescribing Prescribing savings £490,141 £501,561 £11,420 £2,597,761 £2,597,481 -£280 CCG Running costs e.g. staffing £56,247 £57,558 £1,311 £249,785 £249,758 -£27 Total £1,994,151 £1,670,508 -£323,644 £13,000,000 £11,600,000 -£1,400,000

6. KEY FINANCIAL RISKS/MITIGATION MEASURES

The CCG financial plan identified potential risks of £2.2m which are currently mitigated by the contingency held. The risks can be broken down as follows:

• Acute services £1.2m relating to potential under delivery in QIPP and the increase in demand. • Continuing Care £500k - Risk of further increase in expenditure is estimated at £500k due to growth (in number and complexities) higher than currently forecast. • Prescribing £500k

11 7. BALANCE SHEET

7.1 Cash

The table below shows the total amount of cash utilised compared with the amount that would be expected if the annual amount, referred to as maximum cash drawdown (MCD) was spent equally throughout the year. The MCD is calculated as the CCG’s allocation adjusted for non-cash items (depreciation), non-recurrent reserve, the planned underspend, and the opening cash bank balance.

Cumulative year to Date £ 000's

Cash Drawn from NHSE 130,000 CHC retrospective payment 0 Drugs recharges 12,436 Home oxygen recharges 93 Total cash drawings 142,529 Cash book position (3,873) Total cash utilised 138,656

Maximum cash drawdown (MCD) 864,469 Cash Phasing Equal 1/12ths 144,078 Disproportionate Usage (5,422) ( ) indicates less cash drawn than expected

This table shows the CCG has utilised £5,422k less than 2/12th of the plan.

7.2 Balance sheet as at 30th May 2019

The following table shows the movement in the balance sheet between the end of March 2019 and end of May 2019.

Closing Closing balance 31 YTD current March movement balance 2019 £'000 £'000 £'000 Non-current Assets Property, Plant & Equipment 4,260 4,003 (257)

Current Assets Debtors 3,498 2,234 (1,264) Pre-payments 4,067 5,336 1,269 Cash & Cash Equivalents 430 3,873 3,443

Total Assets 12,255 15,445 3,190

Current Liabilities Trade & Other Payables: (57,560) (61,504) (3,944) Provisions (118) (122) (4) Total Current Liabilities (57,678) (61,625) (3,947)

Total Assets Employed (45,423) (46,180) (757)

Financed by Taxpayers’ Equity General Fund 45,423 46,180 757 of which: Cash drawings & top-slice (142,529) Expenditure 143,286

Total Taxpayers’ Equity 45,423 46,180 757

N.B: Debtors figures shown on the balance sheet included VAT adjustments which accounts for the difference in debtors figure shown in section 7.3

12 7.3 Debtors

The table below shows an analysis of the debtors (CCG sales invoices) outstanding, by length of time since the raising of invoices. The CCG has £1,894k of debtors.

£0 Current 0 Overdue 1-30 days 1,476 Overdue 31-60 days 292 Overdue 61-90 days 45 Overdue 91-120 days 72 Overdue 121-180 days 0 Overdue 181-360 days 9 Overdue 361+ days 0 Total Due Amount 1,894 AR overdue 91+ amount 81 91+ days % of total 4.28%

8. RECOMMENDATIONS

To note the report and associated risks.

9. NEXT STEPS

To finalise the Locality budgets to ensure we can provide detailed finance performance reports.

Alan Pond Chief Finance Officer July 2019

13 Appendix 1

ACUTE COMMISSIONING POSITION AS AT MAY 2019

Annual YTD Annual Forecast YTD budget YTD Actual Budget Variance budget Outturn (£'000) (£'000) Variance (£'000) (£'000) (£'000) £'000 Contracts Local Trusts EAST AND NORTH HERTFORDSHIRE TRUST 39,598 41,428 1,830 240,538 244,521 3,983 PRINCESS ALEXANDRA HOSP NHST 10,892 11,195 303 65,354 65,354 0 ROYAL FREE NHS FT 4,783 4,877 94 28,700 29,264 564 INDEPENDENT SECTOR 4,178 4,048 (130) 25,068 24,893 (175) CAMBRIDGE UNIVERSITY HOSP NHS FT 3,133 3,057 (76) 18,795 18,795 0 WEST HERTFORDSHIRE HOSP NHST 645 573 (72) 3,870 3,798 (72) Other Trusts NORTH MIDDLESEX HOSP NHST 1,583 1,577 (6) 9,498 9,464 (34) UNIVERSITY COLLEGE LONDON NHSFT 1,471 1,444 (27) 8,825 8,825 0 MOORFIELDS EYE HOSPITAL NHS FT 807 767 (40) 4,839 4,839 0 BARTS HEALTH NHS TRUST 506 514 8 3,035 3,035 0 ROYAL NAT ORTHOPAEDIC HOSPITAL NHST 457 394 (63) 2,740 2,677 (63) LUTON/DUNSTABLE HOSPITAL NHS FT 424 446 22 2,544 2,544 0 GUYS ST THOMAS NHSFT 327 250 (77) 1,960 1,960 0 IMPERIAL COLLEGE NFT 270 198 (72) 1,621 1,621 0 MID ESX HOSP SVC NHST 248 201 (47) 1,487 1,487 0 ROYAL PAPWORTH HOSP NHSFT 207 206 (1) 1,241 1,241 0 ROYAL BROMPTON NHSFT 185 149 (37) 1,112 1,112 0 BHR UNIV HOSP NHST 151 66 (85) 907 775 (132) LONDON NORTH WEST NHS TRUST 138 119 (19) 827 827 0 GOSH NHS FOUNDATION TRUST 127 96 (31) 760 760 0 BASILDON THURR UNIV HOSP NHSFT 94 107 13 566 566 0 WHITTINGTON HEALTH NHS TRUST 75 55 (20) 448 428 (20) BEDFORD HOSPITAL NHST 73 127 55 436 548 112 CHELSEA & WESTMINSTER HOSP NHS FT 59 35 (24) 354 330 (24) KINGS COLL HOSP NHSFT 57 99 42 342 383 41 HOMERTON NHSFT 54 71 18 321 321 0

EAST OF ENGLAND AMBULANCE 3,593 3,750 157 21,560 22,560 1,000 PATIENT TRANSPORT 616 531 (85) 3,697 3,454 (243) Other Acute NON CONTRACT ACTIVITY (NCA) 915 695 (220) 5,490 5,490 0 IVF 98 85 (13) 589 512 (77) PLANNED CARE 29 30 1 173 173 0 URGENT CARE 141 136 (5) 843 843 0

RESERVES/QIPP 0 0 0 0 0 0 PRIOR YEAR BALANCE 0 0 0 0 0 0

TOTAL 75,931 77,326 1,395 458,540 463,400 4,860

14 Agenda Item No: 9 Date of Meeting: 25th July 2019

Governing Body Meeting in Public

Paper Title: Prescribing Report

Decision or Approval Discussion Information

Report author: Sue Russell – Lead Pharmacist, Pauline Walton- AD of Pharmacy & Medicines Optimisation. East & North Hertfordshire CCG Report signed off Sheilagh Reavey (Director of Nursing & Quality). Dr Ash Shah by: (Lead GP for Medicines Optimisation) Executive Summary At the end of March 2019 the CCG had a under-spend against its prescribing allocation, of £5,545,390 (-6.70%) against a budget of £82.8M (incl. QIPP savings). This is higher than the forecast reported in March (-5.68%). The domiciliary oxygen budget ended 2018/19 marginally underspent.

Spend for April 2019 was £41K higher than April 2018. This is against a background of increased Drug Tariff prices from April mitigated by work of the In-Practice Pharmacist team, and practices reducing prescribing of low-value medicines and items that can be purchased ‘over-the counter’.

For 2018-19 to date £13.8M worth of National Tariff-excluded high cost drug (HCD) charges have been scrutinised by PMOT staff resulting in challenges of £3.9M being made to providers.

There were varying levels of achievement across the practices in respect of prescribing metrics for 2018/19. Although the CCG met the NHSE higher target threshold for reducing prescribing of antibacterial drugs, the lower one was missed. Several practices individually did achieve it. Work continues in PMOT on this agenda of national importance. The QIPP target for reducing the costs associated with prescribing of low value medicines was met. Overall levels of achievement for the CCG Consolidated Funding Framework for the year resulted in four practices achieving all targets and the remainder getting between zero and the maximum.

The prescribing decisions of HMMC from the April 2019 meeting were ratified by the Governing Body workshop on May 9th. • Three NICE appraisals were included and 8 other CCG guidelines or prescribing decisions. • 11 NICE TAs that are the commissioning responsibility of NHSE were noted. There was a very positive outcome for PMOT from the internal auditors who focussed on HMMC processes.

PMOT’s governance pharmacist has contributed to the development of local NHSE processes to deliver actions in response to the 1 independent panel report into the events that took place at Gosport Memorial Hospital in the 1980’s and 90’s.

Efforts continue to develop integrated pharmaceutical working across the STP, including with colleagues in community pharmacy. Progress has also been made on medicines areas of mutual concern to both the health and social care sectors, both in and out of formal care settings.

Recommendations The Governing Body is asked to note the financial position as at to the members: March 31st 2019 and the work undertaken by practices & the PMOT to continue to develop and provide quality services to our population, within available resources. Conflicts of Interest • Dr Shah is a partner in Wrafton House Surgery, Welwyn & involved: Hatfield Locality whose data is included in the Locality totals • All GP Board members who have prescribed in the period of the report will have contributed to the data included. • GP Board representatives’ practices are members of Locality federations which are private companies which may provide CCG commissioned services • No other conflicts identified – this report is for information not decisions.

Conflict of Interest Definitions The following table describes the sub-classifications of interests:

Terms / Acronyms Potentially Used in this Report Not Otherwise Defined Initials In full CFF Consolidated Funding Framework Category M Category M is used to set the NHS reimbursement prices of over 500 medicines. It is the principal price adjustment mechanism to ensure delivery of the retained margin guaranteed as part of the community pharmacy contractual framework.

CQC Care Quality Commission

2 DHSC Department of Health & Social Care.

ENHT East & North Herts Hospital Trust ePACT2 data Electronic Prescribing Analysis and Cost Tool (data from National Health Services Business Services Authority – NHS BSA). HCC Hertfordshire County Council HMMC Hertfordshire Medicines Management Committee HPFT Hertfordshire Partnership Foundation Trust HVCCG Herts Valleys CCG KPI Key Performance Indicator LPC (Hertfordshire) Local Pharmaceutical Committee MHRA Medicines and Healthcare products Regulatory Agency MOU Memorandum of Understanding NHSE NHS England OTC Over the Counter medicine PAH Princess Alexandra Hospital Trust PCMMG Primary Care Medicines Management Group PCN Primary Care Network PMOT Pharmacy & Medicines Optimisation Team of CCG PSNC Pharmaceutical Services Negotiating Committee QIPP Quality, Innovation, Productivity and Prevention initiatives QP Quality Premium (NHSE scheme for CCGs) STP Sustainability and Transformation Partnership UTI Urinary Tract Infection

1. Executive Summary

See cover sheet.

2. Background

This report informs the Governing Body of the financial position of ENHCCG cost centres and practices against their respective budgets at March 31st 2019 and the progress against the local medicines optimisation agenda to date of meeting. The report and appendices present an overall summary of all the key performance indicators and QIPP projects related to prescribing for the year to date including GP prescribing costs, ScriptSwitch® activity, and prescribing KPIs.

- Appendix 1a, 1b – Locality-level Finance Report, Oxygen report and ScriptSwitch report at March 31st 2019 - Appendix 1c – Practice prescribing metric performance 2018/19 at March 31st 2019 (Each element is available to practice level to support local monitoring, and this data is shared with each Locality and practice prescribing lead by their Pharmaceutical Adviser regularly throughout the year). - Appendix 1d – Care Home team activity summary 18/19 as at end of March 2019 - Appendix 1e: Graph showing the camparison of numbers and percentages of items not dispensed over the same five month period within two consequetive years

3. Issues • The CCG spend on prescribing to March 31st 2019 was £77,225,147 which represents a year-end underspend of over £5.5M on the budget allocated. This is reflected in a smaller budget overall for 2019/20. • The CCG continues to achieve its antimicrobial prescribing NHSE QP target in relation to trimethoprim prescribing in the over-70s and the higher threshold for reducing overall antibacterial use – but not the lower.

3 • There has been de-prescribing of medicines not recommended for routine prescribing in primary care by NHSE, meaning that the CCG made a cost saving over the previous year on the category spend but not all of this can be attributed to the impact of the CFF. • Decreasing prescribing for medicines that can be purchased over the counter without a prescription remains a challenge, although costs have come down over the last year. • Both the Care Home Pharmacy and also In-Practice Pharmacist work streams continue to deliver significant savings to the CCG as well as benefits to patients by improving prescribing safety and efficiency and helping to minimise waste and errors. • The pan-Herts HMMC process for managed entry of drugs to the local health economy continues to deliver on its work plan across the year supported by implementation guidance from PCMMG. The work of HMMC was scrutinised by internal auditors in 2018/19 with a very positive outcome • PMOT input into the NHSE STP ‘’Integrating Pharmacy Medicines Optimisation (IPMO)’’ continues to deliver results, and is also supporting other CCG teams as they support the introduction of Primary Care Networks.

4. Options Not applicable – paper is for information

5. Resource Implications Not applicable – paper is for information

6. Risks & Mitigating Actions

6.1 Primary Care Prescribing Expenditure Please refer to Appendix 1a - 31st March 2019 for a fuller breakdown.

Table 1: Summary of Prescribing Financial Position at March 31st 2019

Prescribing Spend to year-end (net of Out-Turn against Estimated annual Budget 2018- 19 adjustments for items re- budget at year-end growth in spend vs charged to other 2017/18 commissioners)

£82,770,536 £77,225,147 £5,545,390 (-6.7%) -3.56%

Table 2: Gross Breakdown of changes in spend by BNF Category of Medicine

4 BNF Chapter N.B. The totals shown here have not been Total Total adjusted down for drugs re-charged to Prescription Total Cost Prescription Total Cost Actual growth % growth % growth other commissioners Items 2017-18 2017-18 Items 2018-19 2018-19 cost items cost Gastro-Intestinal System 992,566 £4,582,742 999,058 £4,450,049 -£132,693 0.65% -2.90% Cardiovascular System 3,812,062 £11,438,663 3,806,106 £11,864,775 £426,112 -0.16% 3.73% Respiratory System 748,767 £9,702,220 745,815 £8,810,518 -£891,702 -0.39% -9.19% Central Nervous System 1,849,102 £14,322,943 1,868,382 £12,191,075 -£2,131,868 1.04% -14.88% Infections 418,792 £1,968,149 391,588 £1,769,166 -£198,982 -6.50% -10.11% Endocrine System 1,201,011 £12,458,549 1,225,972 £12,643,241 £184,692 2.08% 1.48% Obstetrics,Gynae+Urinary Tract Disorders 330,054 £3,065,809 336,631 £2,884,524 -£181,284 1.99% -5.91% Malignant Disease & Immunosuppression 56,767 £1,870,140 57,039 £1,774,957 -£95,183 0.48% -5.09% Nutrition And Blood 599,948 £6,250,718 599,944 £5,736,686 -£514,032 0.00% -8.22% Musculoskeletal & Joint Diseases 331,334 £1,563,639 318,168 £1,740,663 £177,024 -3.97% 11.32% Eye 200,629 £1,521,830 191,895 £1,693,964 £172,134 -4.35% 11.31% Ear, Nose And Oropharynx 112,945 £608,087 106,750 £597,254 -£10,832 -5.48% -1.78% Skin 331,846 £2,455,509 299,311 £2,303,540 -£151,969 -9.80% -6.19% Immunological Products & Vaccines 133,156 £1,094,441 136,664 £1,284,389 £189,948 2.63% 17.36% Anaesthesia 16,729 £168,359 17,389 £158,851 -£9,508 3.95% -5.65% Preparations used in Diagnosis 1 £16 0 £0 -£16 -100.00% -100.00% Other Drugs And Preparations 12,298 £424,505 11,911 £337,079 -£87,426 -3.15% -20.59% Dressings 94,783 £2,061,639 90,849 £2,212,101 £150,461 -4.15% 7.30% Appliances 239,295 £3,237,037 247,669 £3,390,512 £153,475 3.50% 4.74% Incontinence Appliances 21,873 £604,967 22,982 £642,809 £37,843 5.07% 6.26% Stoma Appliances 50,222 £2,825,294 54,051 £2,991,845 £166,551 7.62% 5.89% Total 11,554,180 £82,225,256 11,528,174 £79,477,999 -£2,747,256 -0.23% -3.34%

As in previous reports, the greatest increases in spend for individual drugs are for NOACs and other cardiovascular drugs. The increase for apixaban alone was over £800K but this was offset by savings in other areas e.g. rosuvastatin which lost its patent in-year.

There has been no update since the previous report regarding negotiations around the national community pharmacy contract. Category M prices rose from April 1st, as expected. There may be revised arrangements from October but nothing is known as yet. The CCG is still having to absorb cost pressures from medicines that are currently on a ’price concession’. This was over £75K in April 2019 (latest data). The budget for primary care prescribing in 2019/20 is £80,513,163 of which £301,200 is retained by the Finance team for defined purposes. There is no forecast out-turn available based on April 2019 data alone, but PMOT has noted that the month’s net spend was up by £41K compared to April 2018.

The PMOT In-practice pharmacists (IPP) have systematically completed a number of initiatives with General Practice which have delivered in-year savings for the financial year (2018-2019) as per the table below. The current work in progress includes:

1. Vitamin D review – a clinical piece of work to review the prescribing of vitamin D with the aim to stop prescribing (where appropriate) and advise patients to buy OTC. 2. Methylphenidate switch – patients prescribed generic methylphenidate or Concerta XL® brand to switch to Delmosart XL® brand at a possible saving of £80,000. IPPs are responsible for finding and reviewing patients to provide advice to prescribers on a switch. Prescribers are to perform the switches via a face to face or telephone approach method (due to the legal classification of the drug and indication for use). 3. Cilest® switch – patients prescribed Cilest® to switch to Cilique® brand following the planned discontinuation of the contraceptive in July 2019. In addition the switch is estimated to save £14,000.00 by the use of a more cost effective brand. 4. Patent expiries – switch of brand to generic prescribing for the following drugs: ezetimbe, vardenafil, Ivabradine, atomoxetine and solifenacin in anticipation of patent expiries and the emergence of significantly reduced-price generics. 5 The figures do not include cost avoidance from ad-hoc pieces of work. In-Practice Pharmacist intervention work has produced adhoc savings of £5297. Other projects planned for 2019/20 include switch savings for more brand to generic switches (including Travatan® to travoprost approx. £18,000), buprenorphine patch brand switch (approx. £127,000) and review of “ghost” generic drugs (a niche number of patient prescribed drugs prescribed as generic but supplied and charged as brand, saving approx. £200,000). All work continues to be supported by a governance structure, including input and approval from the PCMMG and is protocol-driven.

Table 3: IPP Savings by Locality

Estimated savings to Estimated savings year end 2018/19 from 2019/20 to date Locality work done in-year Lower Lea Valley £48,396 £8,757 North Herts £76,820 £5,012 Stevenage £50,986 £1,558 Stort Valley and Villages £42,328 £675 Upper Lea Valley £43,249 £6,655 Welwyn & Hatfield £72,741 £7,197 Total £334,519 £29,884

For 2019-20 the QIPP savings target for medicines optimisation in primary care is £1.6M. As well as IPP savings, there are targets for the reduction of costs for OTC items, drugs deemed by NHSE to be ‘low clinical value’, expiries of patent protection and the work of the care home pharmacists

6.2 Domiciliary Oxygen The amount spent on domiciliary oxygen supplies at March 2019 was £592,332 which gives an underspend on the year’s budget of £44,668. The budget for 2019/20 is £627K.

6.3 ScriptSwitch® electronic messages at the point of prescribing The annualised savings (i.e. net savings after costs, made in year grossed up) for a 12-month period at March 2019 are estimated at £221K from the use of this decision-making software. All mainstream practices now have this functionality. As well as calculated cost-savings, benefits in improved prescribing practice come from the information messages in the system.

6.4 KPIs/ CFF metrics for general practice in 2018/19 Please refer to Appendix 1b. • The CCG itself achieved the higher QP target for reduction in overall antibacterial prescribing by March 2019 but just missed the lower one, despite 35 of the practices achieving it at an individual level and thus achieving that CFF target. • The CCG achieved the overall QP target for reduction in prescribing of trimethoprim in the 70yrs and over age group. Forty five practices achieved this CFF element. • 37 practices achieved the CFF metric for prescribing of selected broad spectrum antibiotics (co-amoxiclav, cephalosporins and quinolones) to not exceed 10% of all antibacterial items prescribed. • For the metric related to stopping the prescribing of certain drugs deemed ‘not recommended for primary care prescribing’ (low value medicines): - 50 practices had stopped all prescribing of co-proxamol by Quarter 4 - 27 had stopped prescribing omega-3 fish oils except for rare exceptional cases - 12 had stopped all prescribing of rubefacients, glucosamine, homeopathic & herbal preparations and lutein/antioxidants.

Overall, 4 practices had maximum achievement on the four CFF metrics, and one had zero. Although cost savings are not the objective of the antibacterial QP elements, the CGG spent 6 £169K less in 2018/19 vs 2017/18. For the element related to selected low value medicines, costs were down by £110K with a total saving on the category of £262K.

For the indicators for the 19/20, April data has shown continued progress on antibacterial prescribing reduction. The CGG spend on items available OTC had reduced by £195K in the twelve months to April compared with same period 2017/18. April 2019 spend was also down by £10K.

6.5 Community Pharmacy The STP- wide project launched in November within community pharmacies, to minimise medicines waste by asking patients to ‘’Look in the Bag’’ whilst still in the dispensing pharmacy continues. In ENHCCG there is an estimated annual £7m lost on medicines waste. Data shows that the number of items prescribed but not dispensed had increased over a 5 month period by over 1600, as unwanted items were returned. This has helped to decrease medicines waste across the system. See appendix 1e for details.

The Electronic Medicines Optimisation Pathway (EMOP). The electronic transfer of medicines information following patients’ discharge to an agreed Community Pharmacy continues its roll out within PAH. ENHT started in October 2018 and are now referring 100 patients per month, with a target of 275 per month by December 2019.

6.6 Governance surrounding medicines use 6.61 Improving Prescribing of Antibacterials (‘Antimicrobials Stewardship’) including self-care • 7.3% reduction in total antibiotic prescribing per denominator (antibacterial STAR-PUs) in the 12 months to April 2019. • As of April 2019, the total antibiotic prescribing (1.031 items per STAR-PU) remains below the first NHSE Quality Premium target (1.161 items per STAR-PU) but above secondary Quality Premium target (0.965 items per STAR-PU). • Prescribing of trimethoprim has fallen below the NHSE reduction target. This required a CCG 30% reduction in prescribing (from baseline June 15 to May 16). • The CCG ratio of broad-spectrum antibiotics to all antibacterial prescribing remains below national 10% ceiling for CCGs. • PMOT have supported the CCG infection control lead in assessing provider appeals against sanctions for excess numbers of C.difficile cases throughout 2018/19. • A quality Improvement (QI) project targeted the 20 highest antibiotic prescribing practices across the CCG. This initiative resulted in a 12% reduction in antibiotic prescribing over 12 months over the targeted practices and was commended as part of the annual Public Health England Antibiotic Guardian Awards. • GP practice clinical pharmacists have enhanced the drive for appropriate antimicrobial prescribing across the STP. This year we analysed prescribing rates in practices with pharmacists and found they were more than 4% lower than those practices without. This finding may form the basis of a bid to a Health Education England AMR Innovation Fund. The fund aim is to encourage and support initiatives that will contribute to workforce development in this area, through education and training, particularly around behaviour change with evidence of outcomes. • The new pathway for the prevention and management of suspected Urinary Tract Infections (UTIs) in Care Homes has continued to be rolled out across the CCG. The work was showcased as an oral presentation at the Health plus Care Conference 2018 • The planned STP-wide review of the local Antimicrobial Guidelines was completed on time to be noted by HMMC at its July meeting.

6.62 Medication Safety The government has published its response to the report of the Gosport Independent Panel into what happened at Gosport War Memorial Hospital. The DHSC response sets out a number of measures that have been put in place since the events described in the report, which refers to the 7 period between the late 1980s and 2001. It was published on 21 November 2018. The recommendations include stronger measures to ensure the safety of controlled drugs (CDs), and an independent, clinically led inspectorate. The response document also describes future changes following the panel’s report, including measures to protect whistle-blowers and the introduction of medical examiners. Local actions (NHS England Central Midlands): 1. The national occurrence reporting framework now has additional questions for Trusts 2. A training event was held for all CD Accountable Officers in November 2018 3. National benchmarking will start to include reviewing summaries of occurrence reports and care home data 4. National quality assurance of Local Intelligence Networks is being reviewed by CQC 5. A pain summit was held in one STP a few weeks ago, supporting the safe use of high dose opioids and learning will be shared 6. A national opioid audit facilitated by NHSE is planned for all ENH CCG GP practices in September 2019 7. Regular NHSE CD Occurrence Reports are presented to the Primary Care Commissioning Committee

Medication safety is one of the new Quality Improvement indicators in the GP contract’s Quality & Outcomes Framework from April 2019. There are a number of audits available on clinical systems that can assist practices with undertaking this work and most localities have at least provisionally agreed to retain their Prescribing Leads forums as the mechanism for the required peer reviews. In addition, in September practices will be invited to participate in an NHSE audit reviewing the use of opioid medication at high doses.

7.63 PMOT Internal Audit A review of Prescribing was undertaken as part of the annual internal audit plan for 2018/19, with a specific focus on the effectiveness of the HMMC and associated governance structures. We are pleased to report that the audit concluded that the governance processes in place with respect to the HMMC were found to be well-designed and effective. In particular, the terms of reference and remit of the committee had been clearly and deliberately aligned to NICE guidance regarding local formulary decision making groups. There was adequate evidence that it was fulfilling its remit, and there was an effective process for providing assurance to the Governing Body regarding the work of the HMMC. The auditors were able to confirm that there was substantial assurance around the areas reviewed within the audit scope. There were no resulting actions for PMOT from the audit findings.

6.7 High Cost Drugs Use in Secondary Care For 2018-19 to date £13.8M worth of National Tariff-excluded high cost drug (HCD) charges have been scrutinised by PMOT staff resulting in challenges of £3.9M being made to providers. These challenges raised include targeting poor data quality, lack of funding applications submitted for patients, or lack of information to enable the CCG to properly manage available resources. Additionally a further £91k of credit has now been agreed against some of the 2017-18 HCD challenges which remained unresolved when last year’s accounts closed.

6.8 Engagement with Acute & Provider Trusts PMOT has been working with HPFT / HCC and Acute Trusts to implement the requirements of STOMP (Stopping Over-Medication of People with a Learning Disability) & STAMP (Supporting Treatment and Appropriate Medication in Paediatrics). Work is ongoing across the STP to agree reporting templates to identify patients who should be reviewed. https://www.england.nhs.uk/wp- content/uploads/2019/02/STOMP-STAMP-a5-leaflet.pdf Senior pharmacists in PMOT meet regularly with secondary care colleagues from our main providers to provide local primary care commissioning input. The system-wide ongoing work to agree principles for ‘’shared care’’ – where clinicians in primary and secondary care work with patients to ensure that specialised medicines can be prescribed and monitored safely is almost 8 finalised. HMMC has the feedback from the shared care stakeholder day and the task and finish group co-ordinated to progress template documents and processes.

6.81 Hertfordshire Medicines Management Committee (HMMC) Previous reports have summarised the former outputs from HMMC. Report / recommendations from the April 2019 meeting were ratified at the Governing Body Workshop on 9th May 2019. A summary of the main recommendations is below:

HMMC recommendations for the following mandatory NICE Technology Appraisal (TA) treatments which are the commissioning responsibility of the CCG were ratified and any associated costs noted/approved: • Abatacept not recommended for treating psoriatic arthritis after DMARDs in line with TA568 terminated appraisal • Ertugliflozin recommended for restricted use as monotherapy or dual therapy option for treating type 2 diabetes in line with TA572 • Dupilumab for atopic dermatitis (TA534) – revised eligibility criteria recommended for use

HMMC recommendations for the following treatments not included in the NICE work programme which are the commissioning responsibility of the CCG were ratified and any associated costs / savings were noted / approved: • FreeStyle Libre® for diabetes monitoring – recommended for restricted use in NHS England patient cohorts in new patients. To fund existing patients initiated in line with previous HMMC patient cohorts • Wound Care Products Formulary (Community) Update – recommended for use • Beclometasone / formoterol / glycopyrronium (Trimbow®) and Fluticasone / umeclidinium / vilanterol (Trelegy®) inhalers for COPD - recommended for restricted use • Alimemazine for chronic urticaria, paediatric procedures, hay fever - not recommended for prescribing in primary and secondary care for adults; recommended for restricted use for children only as an option as a sedative prior to diagnostic scans (secondary care prescribing only) • SGLT2-inhibitors comparison document update – recommended for use • Rheumatoid arthritis biologics treatment pathways for adults update – recommended for use • West Herts Formulary – traffic light status update Chapters 3,6, 9 and minor adjustments to traffic light definitions – approved • Guideline Updates - HMMC and the Governing Body noted: o Management of Chronic Asthma for Adults - minor amendments to the local guidance agreed with local specialists o Nebido® prescribing support document – developed to support the ‘amber initiation’ status

NICE TAs that are the commissioning responsibility of NHS England HMMC and the Governing Body noted 11 NICE TAs for medicines and indications that are the commissioning responsibility of NHS England.

Recommendation documents/guidelines and relevant funding application pro-formas for providers are uploaded to the CCG website (funding application pro-formas also available on Blueteq system): http://www.enhertsccg.nhs.uk/local-decisions .

6.82 Primary Care Medicines Management Group (PCMMG) PCMMG met five times in 2018-19 year, and to date, twice in 19/20 to provide direction on the practical implementation of the decisions of HMMC and to discuss and advise on medicines optimisation strategic QIPP priorities for 2019-20 and beyond. Main topics since the last report related to: • Noting and commenting on a guidance document for the care sector and practices on the use of ‘Homely Remedies’ (medications a patient living in their own home would ordinarily have easy access to e.g. paracetamol or a laxative).

9 • Contributing to the draft local guidance on appropriate use of monitored dosage systems • The role of PMOT in supporting Localities as practices move to implement the requirements to constitute Primary Care Networks, and the option to employ clinical pharmacists to diversify the skill mix in primary care

6.9 Care Home Pharmacists Team 2018-19 (see also Appendix 1d).The team are continuing to work in care homes identified as having quality concerns identified by the CCG Quality team , HCC or CQC in addition to GP requests. The team are also contributing to the national Medicines Optimisation in Care Homes audit on waste and how this can be minimised. Across the STP aligned system and process reviews are being developed with associated good practice guidance to support care homes. To date in 19/20, team work has saved £66K across drugs, appliances, nutritional product review and waste management. Twenty six hospital admissions have possibly been prevented.

The HCC medicines policy for medicines in social care settings (e.g. care agencies) has been agreed. One of the outcomes of this has been that care agencies are required to ensure all staff are trained to administer medication from original packs (as dispensed by the pharmacist) reducing the need for medication compliance aids. Work on the place of compliance aids is ongoing with the LPC, HVCCG and GP representatives. Guidance is being developed to support pharmacist when reviewing the need for support with medicine administration in line with the Equality Act 2010. This will also reduce reliance upon compliance aids.

6.10 PMOT & the Wider Health Economy The NHSE STP ‘’Integrating Pharmacy Medicines Optimisation (IPMO)’’ one year project is working well with the STP’s Integrated Clinical Oversight Group (ICOG). The project is focussing on building consistent systems to reduce unnecessary poly-pharmacy within the frailty pathways including medicines that may cause falls. A system-wide lead frailty pharmacist post will be advertised shortly. A workforce sub-group is developing integrated working opportunities between ENHT and community pharmacists. There are also plans for shared placement of pre-registration pharmacists. The mapping of the STP pharmacy workforce is to be updated to include vacancies. The University of Hertfordshire is also supporting the group.

The advent of PCNs and the opportunities for obtaining a clinical pharmacist has led to the STP medicines optimisation group developing a succinct explanatory presentation for each of the STP’s delivery boards. Three offers for the employment of pharmacists within PCNs have been developed by different providers and these have been shared with clinical directors with the offer of support from the PMOT team.

7. Recommendations The Governing Body is asked to note the financial position as at March 31st 2019 and the work undertaken by practices and the PMOT to June 2019 to provide quality services to our population, within available resources.

8. Next Steps As part of the re-organisation of the agendas for Governing Body meetings in public the next prescribing report will be presented for information and discussion at the March 2020 meeting. This will reflect the financial position at the end of December 2019 and data down to PCN level will be included.

10 Appendix 1a – CCG Prescribing Finance Board Report – July 2019 meeting - Primary Care prescribing data at March 31st 2019

11 Appendix 1b - CCG Prescribing Finance Board Report - Oxygen & ScriptSwitch Savings to March 2019

£ Variance Oxygen Oxygen Spend Locality Budget Y-T-D of spend to Budget 2018-19 Year to Date budget ytd LOWER LEA VALLEY £87,891 £87,891 £76,213 -£11,678 NORTH HERTS £129,891 £129,891 £131,302 £1,411 STEVENAGE £87,808 £87,808 £86,469 -£1,339 STORT VALLEY & VILLAGES £86,333 £86,333 £69,734 -£16,599 UPPER LEA VALLEY £105,244 £105,244 £100,678 -£4,566 WELWYN HATFIELD £133,890 £133,890 £123,052 -£10,838 Other/Unidentified £5,943 £5,943 £4,884 -£1,059 ENHCCG Total £637,000 £637,000 £592,332 -£44,668 In 2017-18 the average monthly spend was £50,902. For 2018-19 it has reduced to £49,361

Scriptswitch Actualised Savings (Rolling 12 months staged)*

Actualised Actualised Total Net Actualised Savings Savings Savings Total Actualised LOCALITY NAME (total actualised savings minus Acute Repeat Savings SS annual costs @) April 2018) Prescriptions Prescriptions LOWER LEA VALLEY £10,068 £37,639 £47,706 £24,084 NORTH HERTS £21,410 £75,415 £96,825 £56,613 STEVENAGE £14,195 £55,447 £69,643 £39,629 STORT VALLEY & VILLAGES £10,777 £42,790 £53,567 £34,429 UPPER LEA VALLEY £17,200 £53,366 £70,566 £32,660 WELWYN HATFIELD £16,854 £54,674 £71,527 £33,563 ENHCCG £90,504 £319,331 £409,835 £220,978 * Against total actual cost charged to budget ** ScriptSwitch net saving to date includes repeat savings for previous rolling 12 months and the cost of ScriptSwitch to date. the following practices did not have ScriptSwitch installed in 2018/19: Haileybury College, Orchard Surgery, Sawbridgeworth Medical Services 12 Appendix 1c - East & North Hertfordshire CCG Prescribing KPIs 2018/19 - to March 2018 (Antibiotics KPIs are Rolling 12 Month) Prev Mon lookup >> 7

The table below shows Locality performance against achievement thresholds that were set based on performance at the end of 2013/14 for the NHSE antibacterials target, 2015/16 performance for trimethoprim prescribing in the over 70s and an aspirational expectation for the other indicators as set by NHS Improvement or agreed with PCMMG at the start of the financial year . Numbers in green font mean the threshold was achieved, red equals not achieved. Improvement is also stated and is shown by green-filled cells with red indicating a deterioration.

CFF2 Trimethoprim: CFF4 - de- 30% reduction in CFF3 - Broad prescribing of Improved items prescribed to Improved spectrum antibiotics Improved NHSE-listed items Improved CFF1 - All Antibiotic on patients >= 70 y on items as a on not recommended on Prescribing (Target = Previous (individual to each Previous proportion of all Previous for routine Previous 0.965) Report? practice) distance Report? antibacterial Report? prescribing in Report? from achievement prescribing primary care threshold (target 0)

LOWER LEA VALLEY 0.960 Y -346 Y 9.02% N 114 Y

NORTH HERTS 0.885 Y -897 Y 9.20% Y 105 Y

STEVENAGE 0.923 Y -542 Y 7.43% N 142 N

STORT VALLEY & VILLAGES 0.955 Y -162 Y 10.16% Y 72 N

UPPER LEA VALLEY 0.972 Y -598 Y 10.13% Y 179 Y

WELWYN HATFIELD 0.904 Y -353 Y 7.76% Y 126 N

ENHCCG 1.002 Y -3018 Y 9.16% Y 741 Y

Key 1.16 0.00933 0.70 0.55 0.328 Threshold not achieved >0.965 > Ach Threshold >10% >1 Threshold to Achieve Indicator <=0.965 ≤ Ach Threshold <=10% <1 Highest achievement in CCG this month* 0.540 -272 4.43% 0 Number of Practices Achieving CFF Metric 35 45 37 10

Indicator Type Indicator Basis Description of Indicator

This indicator is the subject of a Quality Premium target for the CCG. It is the ratio of number of antibiotic items prescribed CFF 1 - Patient Safety - Improved Antibiotic Prescribing in Primary Care – Quality NHSE / PCMMG per antibacterial STAR-PU (list size weighting specific to the therapeutic area). This year there are 2 levels of achievement for Total Prescribing the CCG, the CFF focuses on the more stringent level of achievement

This indicator is the subject of a Quality Premium target for the CCG. Urinary tract infection is a key risk factor for sepsis.This indicator works to decrease the appropriate use of trimethoprim for the empirical management of UTI in older patients in primary care, which is reported to have a significantly higher rate of non-susceptibility in ‘at risk’ groups. NHSE reports that CFF 2 Trimethoprim: 30% reduction in items prescribed to patients >= 70 y Quality NHSE / PCMMG the age group with the highest rates of E. coli bacteraemia in England have been observed amongst the elderly (75 years and over). Public Health England data for E coli blood stream infections stated that 50% cases related to the urogenital tract, and in these 72% occurred in patients >65years

This indicator focuses on improving appropriate antibiotic prescribing in primary care, in particular broad spectrum antibiotics. Reducing the inappropriate use of antibiotics will delay the development of antimicrobial resistance that leads to patient harm CFF 3 - Broad spectrum antibiotics items as a proportion of all antibacterial Quality NHSE / PCMMG from infections that are harder and more costly to treat. Reducing inappropriate antibiotic use will also protect patients from prescribing healthcare acquired infections such as Clostridium difficile infections. Broad spectrum antibiotics, such as co-amoxiclav, cephalosporins and quinolones, should only be prescribed in line with prescribing guidelines and local microbiology advice.

This element relates to the recently published guidance from NHSE on what CCGs should consider in respect of the de- prescribing of drugs deemed to have low clinical value. There are 18 in total on the list but some will require additional services in order to de-prescribe and provide suitable alternatives in some cases. There are 7 where no routine exceptions to CFF 4 - de-prescribing of NHSE-listed items not recommended for routine Financial/Qu NHSE / PCMMG prescribing have been identified by NHSE and PCMMG agreed these should be the focus of de-prescribing initially. Drugs prescribing in primary care ality included are co-proxamol, lutein and antioxidants, glucosamine, rubefacients, omega-3 and fish oils, herbal therapy, homeopathic therapy.

*excluding Haileybury College 13 Appendix 1d – Care Home team activity summary 18/19 as at end of March 2019

14 Appendix 1e: Graph showing the camparison of numbers and percentages of items not dispensed over the same five month period within two consequetive years

15 Agenda Item No: 10

Date of Meeting: 25th July 2019

Governing Body Meeting in Public

Paper Title: Integrated Performance and Quality Report

Decision or Approval Discussion Information

Report author: Jo O’Connor – Acting Associate Director Performance Rosie Connolly – Quality Manager Report signed off by: Jo Burlingham – Associate Director of Operations and Resilience Sheilagh Reavey – Director of Nursing and Quality

Executive Summary: This Integrated Performance and Quality report provides an update on the performance and quality of local NHS Trusts in relation to key national performance standards. It includes quality and performance information at CCG level and also at provider level (ENHT, PAH, HCT, EEAST, HPFT and HUC).

The performance and quality metrics included within the report are published information predominantly for the May position. All metrics have been included with commentary for exceptions where performance standards have not been met.

Recommendations . To note to the members:

Page | 1 Conflicts of Interest None to declare. involved:

Conflict of Interest Definitions

The following table describes the sub-classifications of interests:

Type Description Financial Interests This is where an individual may get direct financial benefits from the consequences of a commissioning decision. Non-Financial This is where an individual may obtain a non-financial professional benefit Professional Interests from the consequences of a commissioning decision, such as increasing their professional reputation or status or promoting their professional career. Non-Financial This is where an individual may benefit personally in ways which are not Personal Interests directly linked to their professional career and do not give rise to a direct financial benefit. Indirect Interests This is where an individual has a close association with an individual who has a financial interest, a non-financial professional interest or a non- financial personal interest in a commissioning decision.

Page | 2 1. Executive summary (half page maximum)

This Integrated Performance and Quality report provides an update on the performance and quality of local NHS Trusts in relation to key national performance standards. It includes quality and performance information at CCG level and also at provider level (ENHT, PAH, HCT, EEAST, HPFT and HUC).

2. Background

N/A

3. Issues

N/A

4. Options

N/A

5. Resources implications

N/A

6. Risks/Mitigation Measures

N/A

7. Recommendations

. To note

8. Next Steps (including when the decision will be reviewed)

N/A

Page | 3 REPORT MONTH: May 2019 ENHCCG INTERGRATED PERFORMANCE AND QUALITY REPORT

Contents Report Authors Introduction

This Integrated Performance and Quality report provides an update on

Jo O'Connor Acting Assistant Director of the performance and quality of local NHS Trusts in relation to key ENHCCG ...... Page 2 Performance national performance standards. It includes quality and performance

ENHT ...... Page 3 information at CCG level and also at provider level. In this report the Rosie Connolly Quality Manager published metrics being reported are for May 2019 unless stated

otherwise. PAH ...... Page 4

HPFT & HCT ...... Page 5 Director Sign off Data Sources

EEAST & HUC ...... Page 6 Jo Burlingham Associate Director of Operations . Cancer: NHS Digital and Resilience . RTT, A&E, Diagnostics, DToC: NHSE Statisitcs Comparative Performance ...... Page 7 . Ambulance, DToC, Stroke, HPFT, HUC: Individual Trust Reports Sheilagh Reavey Director of Nursing and Quality . C.Diff, MRSA: Hertfordshire and West Essex HCAI Monthly Report System Overview ...... Page 8

Performance Headlines

. The CCG has been rated as outstanding in their annual assessment for the third year running; . A&E performance remains challenged continuing below 80% at CCG level, predominantly driven by performance at PAH; . RTT 18 week performance declined in the first two months of 19/20 to 86.19% in May, in line with a decrease in performance at ENHT; . The CCG achieved 5 of the 9 cancer standards in May including 2 week wait all cancer and 2 week wait breast. 62 day first performance saw a decline in May after an improvement in April, with both PAH and ENHT missing the 85% standard; . Dementia Diagnosis has returned to meet the 66.70% standard in June; . CAMHS 28 day performance remains challenged with performance declining further from the end of 18/19 to 22.14% in May against the 95% standard.

Quality Headlines

. The CQC will be undertaking an inspection at ENHT over the coming weeks; . The CPN for discharge summaries remains in place at ENHT. The roll-out of the revised discharge summary process has been completed, the latest data available for June indicates that 69.5% of discharge summaries were sent out within 24 hours; . NHSI undertook a further IPC visit to ENHT in June 2019; overall the visit was positive and NHSI were assured that there have been sustained improvements meaning that the overall IPC status for the Trust remains at ‘green’; . PAH have had their CQC inspection and are awaiting the outcome.

P.1 ENHCCG May 2019

Standard/ Area Metric Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar YTD Trend Threshold A&E 1 % Seen within 4 hours 95% 76.49% 78.39% 77.44% C1 (Median) 07:00 07:53 07:12 07:32 Ambulance C2 (Median) 18:00 31:26 30:03 30:44 Response C3 (90th Percentile) 02:00:00 4:40:00 4:18:05 4:29:03 Times 2 C4 (90th Percentile) 03:00:00 3:18:15 4:18:13 3:48:14 2ww All Cancer 93% 94.77% 95.31% 95.04% 2ww Breast Symptoms 93% 87.77% 93.72% 90.74% 31 day First 96% 97.57% 94.19% 95.88% 31 day Sub Surgery 94% 97.37% 86.21% 91.79% Cancer 31 day Sub Drug 98% 98.44% 96.67% 97.55% 31 day Sub Radiotherapy 94% 98.55% 98.67% 98.61% 62 day First 85% 83.46% 70.34% 76.90% 62 day Screening 90% 85.00% 100% 92.50% 62 day Upgrade 85% 77.50% 91.30% 84.40% Incomplete Pathways 92% 88.95% 86.19% 86.19% RTT 3 52 weeks 0 4 5 5 Diagnostics 6 week wait 99% 98.06% 98.67% 98.67% C. Diff 112 (Annual) 8 8 HCAI MRSA 0 3 3

1 Seen within 4 hours 2 Ambulance Response Times 3 Incomplete Pathways 100% 00:33:20 100% 90% 00:26:40 95% 00:20:00 80% 00:13:20 90% 70% 00:06:40 85% 00:00:00

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Commentary Further detail is provided on the Provider pages A&E May's performance against the requirement for 95% of patients attending A&E to be treated, admitted or transferred within 4 hours of arrival, saw an improvement on the April position which had deteriorated. Performance continues below 80% at CCG level, predominantly driven by poor performance at PAH. CCG ambulance response times remain outside national ARP standards, however improved in April and May for C1. RTT CCG performance deteriorated in the first two months of 19/20 to 86.19% in May against the RTT standard for 92% of patients to have been waiting less than 18 weeks for treatment; this is driven by declining performance at ENHT with PAH continuing to achieve standard. Cancer The CCG achieved 5 of the 9 cancer standards in May including 2 week wait all cancer, 2 week wait breast and 31 day subsequent radiotherapy standards. Performance against the 62 day first standard declined in May however against an improvement in April, with both PAH and ENHT failing the standard. 62 day screening and upgrade standards were met. P.2 East and North Herts NHS Trust May 2019 Standard/ Area Metric Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar YTD Trend Threshold A&E 1 % Seen within 4 hours 95% 80.54% 81.64% 84.55% 81.09% Handover To A&E <15 mins 100% 40.00% 40.00% 40.00% DToC 2 DToC Rate % 3.50% 1.40% 1.45% 1.43% 2ww All Cancer 93% 95.94% 95.59% 95.77% 2ww Breast Symptoms 93% 88.68% 92.68% 90.68% 31 day First 96% 93.52% 94.93% 94.23% 31 day Sub Surgery 94% 96.77% 80.00% 88.39% 31 day Sub Drug 98% 98.19% 97.81% 98.00% Cancer 31 day Sub Radiotherapy 94% 96.90% 98.27% 97.58% 62 day First 85% 79.57% 72.17% 75.87% 3 62 day post ITTP 85% 82.30% 76.00% 79.15% 62 day Screening 90% 80.95% 100% 90.48% 62 day Upgrade 85% 48.00% 80.00% 64.00% Incomplete Pathways 92% 87.91% 83.71% #N/A #N/A #N/A 83.71% RTT 52 weeks 0 4 5 #N/A #N/A #N/A 9 Diagnostics 6 week wait 99% 98.41% 98.98% #N/A #N/A #N/A 98.98% C. Diff 11 (Annual) 1 1 HCAI MRSA 0 1 1

1 Seen within 4 hours 2 DToC Rate 3 ENHT Cancer 62 Days Target 4% 100% 100% 90% 3% 90% 80% 80% 2% 70% 60% 1% 70% Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar % Seen within 4 hours Target % DToC Rate % Target % Target % ENHT post ITTP ENH post ITTP Trajectory Target % Commentary Discharge Summaries: CPN remains in place to closely monitor the Trust’s progress in relation to the timeliness of discharge summaries being sent to primary care. An improvement trajectory has been agreed with the Trust who are required to send 80% of discharge summaries within 24 hours and 90% of discharge summaries within 24 hours by the end of September 2019, and all discharge summaries to be sent to primary care within 7 days by the end of August 2019. The trajectory for October 2019 to March 2020 is currently being negotiated. The roll-out of the revised discharge summary process has been completed and the Trust continues to review processes to make further improvements. The latest report for week ending 28th June reported that a total of 86.9% of discharge summaries had been sent out for April with 61.0% sent within 24 hours, 81.1% of discharge summaries had been sent out for May with 61.2% sent within 24 hours, and June to date had a total of 80.3% of discharge summaries sent with 69.5% sent within 24 hours. IPC: NHSI undertook a further IPC visit to ENHT in June 2019; overall the visit was positive and NHSI were assured that there have been sustained improvements meaning that the overall IPC status for the Trust remains at ‘green’. As a result of the progress made, NHSI will not be undertaking further visits however it was agreed that the CCG would continue to undertake regular IPC walkabouts in addition to the routine Quality Assurance Visits. May data indicates that IPC performance remains positive for hand hygiene, however antibiotic review within 72 hours has decreased slightly to 88%, which is just below the 90% target. Whilst there has been some improvement compared to April’s data, performance relating to cleanliness of commodes and equipment, and the proportion of G4S audits accompanied by a nurse, remains below the required standards. RTT: Performance declined in the first two months of 19/20 to 83.71% in May. The number of 52 week breaches has increased, reporting 5 in May; a validation review has identified a co-hort of patients with incorrect clock stops who have subsequently had their pathways re-opened and been added to the waiting list. An on-going validation, training and monitoring process is in place and patients identified are being reviewed by a weekly harm review panel. Work continues to reduce the 18 week backlog with targeted analysis by specialty and associated action plans. Diagnostic performance continued to improve falling just short of the 99% standard by 0.2% in May; action plans are in place for outlying areas. A&E: After a decline in A&E performance from the end of 18/19, improvements have been made each month with June reporting 84.55%. Three work streams continue to work to improve flow, assessment and discharges. The ED/front door improvement plan has been reviewed to ensure it will meet the mandated UEC deliverables for 19/20, with a focus on reducing waits to triage and time to be seen by senior clinical decision makers, as well as improving pathways for ambulance handovers and Mental Health. The key priority ahead of Winter 19 is to deliver Same Day Emergency Care and enhanced acute frailty pathways. Although below standard, handover performance has improved from the end of 18/19 to 40% in April and May. Cancer: Cancer performance declined in May with the Trust meeting 3 of the Cancer standards including 2 week wait all cancer. 62 day first performance dipped from an improved position in April, with post ITTP performance declining to 76% and not meeting the revised recovery trajectory of 77.2% for May. RALP capacity, CNS support and complex pa thways have been identified as issues for Urology, Gynae and Lower GI specialties. An audit has been requested of these tumour sites. 62 day screening performance improved to achieve 100% for May. ECIST support continues with the second phase of work reviewing MDT processes and further demand and capacity planning. The Cancer Support Unit is also supporting the Trust with Root Cause Analysis work.

P.3 Princess Alexandra Hospital NHS Trust May 2019

Standard/ Area Metric Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar YTD Trend Threshold A&E 1 % Seen within 4 hours 95% 69.63% 73.96% 78.17% 71.79% Handover To A&E <15 mins 100% 27.00% 38.00% 32.50% DToC 2 DToC Rate % 3.50% 3.16% 0.99% 2.08% 2ww All Cancer 93% 95.00% 93.25% 94.12% 2ww Breast Symptoms 93% 91.04% 92.61% 91.83% 31 day First 96% 100% 97.80% 98.90% 31 day Sub Surgery 94% 100% 75.00% 87.50% Cancer 31 day Sub Drug 98% 100% 92.86% 96.43% 31 day Sub Radiotherapy 94% 62 day First 85% 80.43% 76.74% 78.59% 62 day Screening 90% 75.00% 93.33% 84.17% 62 day Upgrade 85% 95.35% 96.15% 95.75% Incomplete Pathways 92% 92.33% 92.31% 92.31% RTT 3 52 weeks 0 0 0 0 Diagnostics 6 week wait 99% 99.55% 99.19% 99.19% C. Diff 10 (Annual) 2 2 HCAI MRSA 0 0 #N/A 0

1 Seen within 4 hours 2 DToC Rate 3 Incomplete Pathways 4% 100% 95% 98% 3% 85% 96% 2% 94% 75% 1% 92%

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Mar May % Seen within 4 hours Target % DToC Rate % Target % Incomplete Pathways % Target % Commentary A&E A&E continues as the most challenged area of performance for PAH; after a decline in April from the end of 18/19, performance has improved each month to 78.17% in June. Weekly calls continue to be held with NHSI to review remedial actions and performance. Work is underway on potential options to redesign the integrated front door pathway(s), including the requirement to implement an urgent treatment centre by December 2019. Ambulance Although below standard, there has been a significant improvement in handover performance in May to 38%, which is attributabl e to the recruitment of a substantive Hospital Ambulance Handover Liaison Officer (HALO). Cancer Cancer performance declined in May with the Trust meeting 4 of the standards including 2 week wait all cancer and 31 day firs t. 62 day first performance has declined in the first two months of 19/20 falling below standard to 76.74% in May; an action plan to support recovery is in place which is expected to achieve in July. 2 week wait breast performance has also declined with an increase in referrals, particularly from out of area; recovery is expected in June. RTT PAH continued to meet the RTT and Diagnostic standards in April and May with the number of 52 week waiters also continuing at 0. DToC Although meeting the standard, DToC was at an increased rate in April however returned back to below 1% in May. Mortality The May release of SHMI data (covering the rolling year to December 2018) showed a slight improvement in mortality performanc e following 11 successive increases, however remains rates categorised as ‘higher than expected’. P.4 Herts Partnership Foundation Trust May 2019

Standard/ Area Metric Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar YTD Trend Threshold 18 week RTT 95% 98.65% 99.42% 99.42% IAPT Recovery 40% 54.44% 56.31% 55.38% 6 Week Wait 75% 22.33% 25.83% 25.83% National Dementia Diagnosis 66.7% 66.60% 66.60% 66.70% Standard 66.60% DToC DToC Rate % 1 3.5% 5.52% 7.41% 6.46% Access EIP 14 day wait 56% 100% 77.78% 88.89% 28 day routine waiting CAMHS time 95% 28.99% 21.54% 25.26% Commentary 1 DToC Rate IAPT IAPT 6 week wait performance has deteriorated with an increase in demand; a significant expansion in capacity has been agreed to mitigate. The 18 week wait and recovery standards are being met. 8% Dementia Dementia diagnosis continued to fall just short of standard in April and May by 5 people, however achieved in June at 66.7% W aiting times 6% for the EMDASS service are improving which will continue to have a positive impact on diagnosis performance. DToC DToC rates remain below standard and increased to 7.41% in May. The main delays are from adult inpatient services. A detailed ac tion 4% plan has been agreed to improve this position and the DToC rate is expected to reduce accordingly in June. 2% CAMHS 28 CAMHS 28 day performance remains very challenged with performance declining further from the end of 18/19 to 22.14% in May ag ainst 0% day the 95% standard. Additional weekend clinics are being run to help clear the backlog which have been well attended, with low DNA rates.

Teams are keeping in touch with those waiting to be seen to mitigate any risk of harm. A system wide demand and capacity rev iew is being

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Mar commissioned to identify the broader demand issues that underlie this decline in performance. May DToC Rate % Target % Herts Community NHS Trust Standard/ Area Metric Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar YTD Trend Threshold Stroke 42 37.0 36.9 37.0 ALoS Non-Stroke 21 21.6 21.2 21.4 Health 5.70% 4.50% 5.10% Social Care 0.20% 0.10% 0.15% DToC Both 0.00% 0.30% 0.15% 2 Total 3.5% 5.90% 4.80% 5.35% Commentary 2 DToC Rate ALoS The ALoS for non-stroke patients remains slightly over threshold at 21.2 in May against a standard of 21, but is an improvement on 8% April. 6% DToC A continued improvement has been seen in HCT's DToC rate which reduced to 4.8% in May against the 3.5% standard. This is the 4% lowest rate delivered in over a year and performance continues to be monitored. 2%

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Nov Mar DToCMay Rate % Target % P.5 East of England Ambulance Service NHS Trust May 2019

Standard/ Area Metric Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar YTD Trend Threshold Handover to ENHT <15 mins % 100% 60.00% 57.00% 58.50% clear PAH <15 mins % 100% 48.00% 44.00% 46.00% ENHT > 30 mins (No. breaches) 480 368 424 PAH > 30 mins (No. breaches) 370 216 293 Arrival to ENHT > 60+ mins (No. breaches) 2 5 4 handover PAH > 60+ mins (No. breaches) 4 3 4 ENHT Average Handover Time (mins) 26 23 25 PAH Average Handover Time (mins) 24 22 23 Commentary Arrival to Handover > 30 Mins 1 550 The CCG is meeting bi-weekly with ENHT and EEAST to improve handover times to meet the required mandated standards for 2019. An 450 agreed action plan is in place with phased implementation. Actions implemented to date include: 350 250 . Introduction of fit2sit criteria and policy; 150 . Review of escalation protocols and management oversight; Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar ENHT > 30 mins (No. breaches) . Trial relocation of clinical handover station and admin function.

ENHT Trajectory Consistent improvement in performance has been seen over recent weeks, which has also continued throughout June. PAH > 30 mins (No. breaches) Herts Urgent Care Standard/ Area Metric Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar YTD Trend Threshold Average time to call answer (ss) 60 sec 43 45 44 Calls abandoned after 30 secs ≤5% 2.90% 4.00% 3.45% Direct booking into IUC or Extended ≥95% 82.20% 81.64% Access 81.92% National Direct Booking into UTC ≥50% Data not yet live Standards Revalidation of Cat. 3 & 4 ambulance ≥95% dispositions 98.05% 97.97% 98.01% Revalidation of ED dispositions ≥95% 98.05% 97.94% 97.99%

Triaged calls to receive clinical input ≥50% 71.18% 78.42% 74.80% Urgent visits within 2 hrs ≥95% 82.44% 91.79% 87.12% Home Visits Routine visits within 6 hrs ≥95% 87.78% 86.45% 87.12% Base face to Urgent consultations within 2 hrs ≥95% 89.47% 91.37% 90.42% face Routine consultations within 6 hrs ≥95% 95.67% 97.06% 96.37% % Routine visits <6 hrs ≥95% 99.18% 98.56% 98.87% AiHVS 2 Clinician Staffing Percentage ≥95% 99.40% 99.23% 99.32% Total Activity 2768 2959 5727 111 Online Ambulance Disposition 453 522 975 Of which CAS validated (Cat 3&4) 152 181 333 ED Disposition 113 139 252 Emergency Department 281 323 604 Total number of ITK call backs 458 548 1006 Commentary AiHVS 2 100% 99% . Direct booking into IUC: NHSE has confirmed direct booking will not include GP in-hour appointments which will improve 98% performance against this indicator going forward. There is also clarification being sought if the indicator includes Extended Hours 97% and/or Extended Access. 96% . Home Visiting and Face to Face consultations: A deep dive is being undertaken to understand the challenges in delivering the se 95% 94% standards. HUC have submitted an improvement plan to address demand and capacity, clinical and non clinical productivity, shi ft fill Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar and rota review, skill mix, recruitment, IT and technology initiatives and location of bases. An improvement trajectory has been % Routine visits <6 hrs agreed. Clinician Staffing Percentage Target % P.6 Comparative Performance May 2019 31 days 31 days 31 days 31 days 2 week 62 days 62 days 62 days Context Cancer 2 week breast First subsequent subsequent subsequent 62 days upgrade all cancers standard screening Post ITTP treatment surgery drug radio The following tables detail performance against the same period last year Standard 93% 93% 96% 94% 98% 94% 85% 90% 85% 85% (2018/19) with arrows indicating the change. Comparative performance is ENHCCG 95.31% 93.72% 94.19% 86.21% 96.67% 98.67% 70.34% 100% 91.30% also shown at CCG and provider level as ENHCCG performance is impacted 2018/19 92.14% 92.54% 96.14% 94.59% 100.00% 95.06% 77.04% 80.95% 90.48% predominantly by performance at ENHT and also PAH. Performance h h i i i h i h h ENHT 95.59% 92.68% 94.93% 80.00% 97.81% 98.27% 72.17% 100% 80.00% 76.00% 2018/19 92.09% 91.82% 92.41% 95.83% 99.34% 90.65% 70.63% 75.00% No Data 72.70% Performance h h h i i h h h i h PAH 93.25% 92.61% 97.80% 75.00% 92.86% No data 76.74% 93.33% 96.15% 2018/19 95.91% 95.45% 100% 100% 100% No data 76.92% No data 83.33% Performance i i i i i g i i h To Note

NHS Social Care DToC DTOC Rate % RTT Patients waiting Incomplete % 52wk Breaches . ENHT were unable report RTT and diagnostic data from August 17 to September18. Resubmission of (days) (days) Standard 3.50% Standard 92% 0 their data started from October 18. ENHT 237 0 1.45% ENHCCG 51568 86.19% 5 2018/19 176 0 1.92% 2018/19 18161 90.61% 12 Performance + = h Performance + i h PAH 85 15 0.99% ENHT 44863 83.71% 5 % & number seen within 4 hours 2018/19 103 15 2.65% 2018/19 No data No data No data A&E Total A&E attendances Performance — = h Performance i i h 95% Pts <4 hours HCT 538 136 4.80% PAH 16857 92.31% 0 ENHT 14306 4286 81.64% 11680 2018/19 (Herts) 586 135 12.10% 2018/19 16569 90.00% 18 2018/19 14037 3984 90.00% 12587 Performance — + h Performance + h h Performance + + i — HPFT 783 7 7.41% HCT 2229 90.58% 0 PAH 9152 3182 73.96% 6769 2018/19 (Herts) 458 40 5.29% 2018/19 2171 93.37% 0 2018/19 8829 2657 75.77% 6690 Performance + — i Performance + i g Performance + + i +

<4 hrs to stroke 90% on stroke Thromb < 3 C3 (90th C4 (90th Diagnostics > 6 weeks Stroke EEAST C1 (medium) C2 (medium) unit unit hours percentile) percentile) Standard 99% 99% Standard 90% 80% 12% Standard 00:07:00 00:18:00 02:00:00 03:00:00 ENHT 98.98% PAH 99.19% ENHT 59.30% 94.00% 14.30% ENHCCG 00:07:12 00:30:03 04:18:05 04:18:13 2018/19 No data 2018/19 99.48% 2018/19 77.60% 86.60% 7.20% 2018/19 00:08:36 00:28:44 02:41:46 03:02:16 Performance i Performance i Performance i h h Performance h i i i

Arrival to Arrival to ENHT AVG PAH AVG IAPT 18 week IAPT 6 week Dementia Handover to Handover to Mental Health IAPT Recovery EIP 14 days wait CAMHS 28 day EEAST handover <15 handover <15 Handover Time Handover Time RTT wait Diagnosis clear <15 Lister clear <15 PAH Lister PAH (mins) (mins) Standard 95.00% 50.00% 75.00% 66.70% 50% 95.00% Standard 100% 100% 100% 100% HPFT 99.42% 56.31% 25.83% 66.60% 77.78% 21.54% EEAST 40.00% 38.00% 57.00% 44.00% 23 22 2018/19 99.85% 52.17% 55.46% 63.90% 100.00% 58.06% 2018/19 52.00% 27.00% 63.00% 50.00% 19 23 Performance i h i h i i Performance i h i i i h

Key (compared with 2018/19) Commentary Cancer Cancer performance remains more challenged at ENHT than at PAH, impacting the overall CCG performance. The CCG's 62 day first performance is at a lower position in May 19 than it was in May 18, however h Improvement in performance performance at ENHT has improved over the same period. 2 week wait all cancer and 2 week wait breast performance met standar d in May 19 at CCG level with improved performances against the same period last year, however both ENHT and PAH fell just short of the standard. 31 day performance did not achieve standard in any area except subsequent radiotherapy, with declined performances compared to last year. i Deterioration in performance RTT ENHT were off reporting between August 17 and October 18, however performance has declined in May 19; their performance together with HCT Trust wide performance is impacting on the CCG position which was also at a declined position in May and lower than the same period in 18/19. The ENH split for HCT shows that the standard is being met for the CCG, however the trust wide position is currently reflecte d in g No change in performance national reporting. PAH continue to meet the standard for May 19 which is an improvement on May 18. Diagnostics PAH also continue to meet the standard for 99% of patients to have a diagnostic within 6 weeks. ENHT have missed the standar d by less than 1% in May; the Trust were off reporting in May 18. Urgent Care A&E performance has declined at both Trusts in May 19 when compared to the same period last year. The total number of A&E attendances and total number of emergency admissions has increased, however + Increase in numbers some activity may be due to changes in pathways, counting and coding. Although below the standard, Ambulance handover times have improved at PAH in May 19 compared to the previous year, however ENHT performance has deteriorated. Stroke The <4 hours direct to stroke unit target remains a challenge, with performance at a declined level compared to last year. ENHT continue to meet the standard for 90% of time on a stroke unit and have also met - Decrease in numbers the 3 hour thrombolysis standard, with both of these indicators showing an improvement in performance compared to May 18. Mental HPFT continue to meet the IAPT 18 week and recovery standards with improved performances when compared to the same period last year, however IAPT 6 week wait p erformance has deteriorated significantly. = No change in numbers Health CAMHS 28 day performance and the DToC rate has also declined compared to May 18. Although just missing standard in May 19, th e dementia diagnosis rate has improved compared to last year and has met standard for June. EIP 14 days wait continues to achieve standard however with lower performance levels compared to May 18. DTOC With the exception of HPFT, DToC performance improved across all providers in May 19 compared to the previous year, with performance significantly above the performance standard.

P.7 East and North Herts System Overview May 2019 System Status Integrated dashboard - Daily organisation status

Context System Overview System Overview The monthly system overview is generated from daily submissions to the • → System on OPEL 2 throughout May SRG Integrated Dashboard; an operational dashboard of key performance • → Staffing levels across all organisations predominantly on OPEL 1 or 2 indicators across the system, linked to the Surge and Escalation Plan, to Urgent Care Access aide early identification of system pressures and allow for the proactive • → 111 average call answering predominantly on OPEL 1 management of patient flow. • ↑ Increase in percentage of calls abandoned after 60 seconds, however within target for reporting period and at OPEL 1 • ↑ Re-validation of Ambulance and ED calls at increased levels to previous month • → Continued average Ambulance Handover time of 1 minute at 10am, OPEL 1 • ↓ Increase in average number of daily ED attendances but decrease in numbers of breaches to previous month Notes • ↑ Improvement in 4 hour performance across the reporting period and to previous month, continuing at OPEL 3 • → Continuation of an average of 4 DTAs per day, OPEL 2 Data Range: Daily data from 29/04/19 to 02/06/19 (or 31/05/19 for • → 'Average time to be seen by 1st clinician' at 1 hour and 17 minutes OPEL 1, however inconsistent reporting (not submitted working days). Weekly data from wk beg 07/01/19 to wk beg for April) • ↑ Increase in average weekly number of emergency admissions for period 28/04/19 - Feb , Mar, Apr, May and June. In Hospital Flow • ↑ Increase to an average of 2 assessment spaces available per day in both AMU and SAU, continuing at OPEL 3 Key Dates: New metrics in line with revised Surge and Escalation Plan • ↓ Decrease in bed occupancy, continuing at OPEL 3 (V23) implemented April 2019. Weekend reporting from Apr. • → Similar average number of super stranded patients >14 days, continuing at OPEL 1 19/04/19, 22/04/19 and 27/05/19 are bank holidays. • ↑ Increase in average number of beds available per day, continuing at OPEL 2 • → Similar lower levels of planned daily discharges, continuing at OPEL 3, however inconsistencies in data reporting Data Source: Weekday system status as per Surge Plan organisational • → Similar number of MDT Fit patients on daily TCon, continuing at OPEL 2 matrix. Weekend and bank holiday system status as per Trust status. • ↓ Decrease in number of IDT DTOCs, continuing at OPEL 1 • → Resource to ACS on OPEL 2 (limited capacity in 48 hours) • ↑ Increase in number of patients waiting in the acute trust for a MH Assessment Act, moving to OPEL 2 • ↑ Significant increase in average number of HPFT patients with a DTA made and waiting to be admitted, moving to OPEL 3 Key (compared with previous month) Out of Hospital Capacity • ↑ Increase in bed occupancy for HCT to previous month, however remained at OPEL 1 h Negative increase in performance • ↓ Decrease in number of HCT DTOCs, continuing at OPEL 1 • ↓ Decreased levels of patients waiting over 72 hour target, moving to OPEL 2 i Negative decrease in performance • → HCT ICT priority levels remain predominantly on OPEL 2 (priority level 1/2) • ↓ Significant decrease in numbers on HCT waiting list at an average of 5, moving to OPEL 1 g Performance similar to previous month • ↓ HCT planned discharges at declined position, predominantly on OPEL 3 but with increased instances of OPEL 4 • ↑ Increase in HPFT bed occupancy to 100%, moving to OPEL 4 h Positive increase in performance • ↑ HPFT DTOCs at increased levels moving to OPEL 4 • ↓ Decrease for period in weekly uncovered packages of care required in terms of hours and service users i Postive decrease in performance

P.8 Agenda Item No: 11

Date of Meeting: 25th July 2019

Governing Body Meeting in Public

Delegated Primary Medical Care Commissioning: Quarter 1 Paper Title: 2019/2020 Review.

Decision or Approval Discussion Information

Report author: Denise Boardman: Director for Primary Care Development.

Report signed off by: Beverley Flowers: CCG Accountable Officer.

Executive Summary: The purpose of the paper is to provide an overview to the CCG’s Governing Body on the work of the Primary Care Commissioning Committee in 2019/2020 Quarter one (Q1).

Following a successful submission to NHSE, the CCG commenced delegated commissioning duties for primary medical services on 1st April 2018. This is with the aim of developing more integrated out-of- hospital services and to improve the quality of primary care.

During 2019/2020 Q1 headlines from the different CCG directorates supporting delegated commissioning include:

• Establishment of 12 Primary Care Networks across the CCGs’ geographical patch meeting NHSE requirements.

• The Nursing & Quality Team working alongside the Contracts team have undertaken practice visits & launched a GP Resource pack

• The Primary Care Workforce & Education Team has successfully led the STP International GP Recruitment scheme. 13 vacancies, 12 applicants interviewed, 9 offered posts with 4 in east & north Herts CCG area.

• Phase 2 of the eConsultation, the procurement (mini competition from the NHSE framework) has now been successfully completed. Thirteen practices have put themselves forward to be ‘champion’ sites and work with the project team to evaluate the selected product for 6 months.

• 5 premises schemes including those under the Estates, Transformation & Technology Fund, are progressing well.

• PCCC governance has undertaken and reported on the first

1 | P a g e PCCC Effectiveness survey.

Recommendations For the Governing body to note the progress of the Primary Care to the members: Commissioning Committee in 2019/20 quarter one.

Conflicts of Interest No conflicts in the preparation of this paper. involved: CCG Governing Body GPs are local practising GPs and therefore may be affected by some of the potential future functions and associated decision making of the Primary Care Commissioning Committee (PCCC). However the terms of reference for PCCCs are nationally prescribed as part of the delegation arrangements and this paper is presented to the Governing Body for information only.

2 | P a g e 1. Executive summary The purpose of the paper is to provide an overview to the CCG’s Governing Body on the work in quarter one of the CCGs’ Primary Care Commissioning Committee.

Following a successful submission to NHSE, the CCG commenced delegated commissioning duties for primary medical services on 1st April 2018. This is with the aim of developing more integrated out-of-hospital services and to improve the quality of primary care.

This paper highlights for Q1- 2019/2020 both work underway and achievements made across the different work streams as we develop more integrated out-of-hospital services and improve the quality of primary care.

2. Background The CCG became a delegated CCG on 1st April 2018 and in accordance with section 13Z (6) of the NHS Act, NHS England retains liability in relation to the exercise of the Delegated Functions by CCGs. This means the CCG has a duty to demonstrate to NHSE it is discharging NHS England’s statutory primary medical care functions effectively.

The following sections provide an overview of the work underway that supports the CCG in meeting its requirement to assure NHSE it is discharging NHS England’s statutory primary medical care functions effectively.

2.1 Governance Arrangements The work of the CCG Primary Care Commissioning Committee (PCCC) is informed by the priorities of the CCG and the Localities/Primary Care Networks (PCNs) in response to the needs of the population and the delegated duties as per its Terms of Reference. This is then translated into a work plan informing an annual business cycle.

As advised previously in earlier Governing Body updates to undertake these duties since April 2018 the following have been established:

• CCG Primary Care Commissioning Committee • CCG Primary Medical Care Contracting Panel • CCG Primary Care Transformation & Resilience Panel • CCG Primary Care Improvement Grant Panel • New Primary Care Development Directorate • CCG Directorate recruitments across quality, finance, contracts and governance.

Additionally the first PCCC Effectiveness Survey was recently undertaken as part of an annual activity. This is to gain and evaluate feedback from the members of the Primary Care Commissioning Committee regarding their thoughts relating to six key topics of the PCCC:

1. Committee Focus 2. Committee Team Working 3. Committee Effectiveness 4. Committee Engagement 5. Committee Leadership 6. Enhancing the PCCC.

Highlights from the report include the many positives regarding how the committee members work together in an integrated way, the preparatory work of the primary care medical contracts

3 | P a g e panel supporting the work of the committee and the overall skills and expertise of panel member’s.

The major themes for attention include agenda management in terms of planning and prioritising items to allow sufficient time for topic discussion and clarity of purpose regarding decisions. Another key area for focussed work is maximising internal and external communication channels regarding the work of the committee with particular reference to stakeholders including CCG Localities/PCNs and patient groups (including PPG) and listening to the views of practices and patients.

2.2: Finance and investments The finance position at the end of May 2019, Month 2 is a revised allocation for devolved commissioning is £74.736m. As at Month 2, Primary Care Devolved Commissioning budget reported an underspend of £97k against allocated budget. The available uncommitted headroom as at Month 2 is £1,920K and contingency of £385k.

Primary care devolved commissioning allocation & budgets The table below shows a summary of 2019-20 CCG devolved commissioning allocation and planned spend as approved by the Primary Care Committee Board.

Summary of 2019/20 Allocation vs Planned Spend:

2019-20 Committee Budget Allocated for schemes started in 2018-19 A number of schemes were approved by the Primary Care Committee in 2018-19 which are planned to continue in 2019-20. These now total £1.910m as shown in the list below. In addition, the CCG has £1.920m uncommitted/reserve.

4 | P a g e Primary care devolved commissioning expenditure overview Primary Care Devolved commissioning reported a year to date underspend of £97k. The uncommitted headroom /reserve is £1.920m and the CCG has a contingency of £385k. The table below is the summary of the financial position as at May 2019:

A paper is being prepared for the September PCCC with options and recommendations for expenditure against the uncommitted budget.

2.3: PCCC Work Programmes The full high level PCCC work plan is available on request and is also available on the CCG’s website published as part of the public Primary Care Commissioning Committee pack. The most recent PCCC meeting was held on the 4th July.

The following gives the reader more detailed information from a selection of the current work streams and achievements in Q1.

2.3.1 Joint Contracts and Quality visits The Primary Care Quality Framework (May 2018) describes the CCGs proposed approach to monitoring and assuring quality and improvement in all Primary Care commissioned medical services for which ENHCCG has responsibility. The CCG plans to visit all 56 practices on a proactive basis once every 2 years by the CCG primary care quality lead, contract lead, and the locality manager.

In Q1 2019/20 the joint contract/quality visits commenced. The Q1 practices received an invite letter and an information sheet detailing the process. Overall the visits have been well received. The CCG will aim to see on average 7 practices per quarter. A 6 monthly update will be presented to PCCC, including a summary of themes and areas of good practice. The visits for Q2 2019/20 are currently being arranged and will include independent clinical support where required. Practices will also be asked to invite a member of their Patient Participation Group (PPG) to attend.

ENHCCG CQC inspection preparation ‘mock’ visits The purpose of the CCG CQC inspection preparation visits is to help practices prepare for future CQC inspections. The CQC has advised the CCG on the process and appropriate template to follow so that a CQC inspection is replicated as closely as possible. The CQC are supportive of the approach.

5 | P a g e In Q1 2019/20 the CCG completed 2 ‘mock’ CQC inspections. The visits have been positive with practices being able to demonstrate that overall there were systems and processes in place across many of the CQC domain areas. Representation from the CCG has included a clinician, a quality lead and a specialist (for example, safeguarding nurse specialist and a lead pharmacist). Practices receive feedback directly on the day of the inspection and a summary report with recommendations and actions are sent to the practice within 10 working days for the practice to continue to work on. This support offer will continue to be promoted going forward.

General Practice Patient Survey (GPPS) A number of practices were contacted in January 2019 and asked to share their actions/learning from the GPPS 2018 results. A summary report was presented in the May 2019 PCCC meeting. The key areas of improvements identified by practices are described in the table below:

Identified Actions/Improvements - Themes

Phone System changes • New telephone systems. • Regular review of the phone system/calls. • Call queuing messages to inform patients. • Key Performance Indicators (KPIs) of the phone system (review response time, performance issues). Appointment system changes • Consistently reviewing appointment system. • Increasing pre-bookable appointments. • Audit/data collection - demand audits. • Review of the emergency appointment system. • Promote extended access. • Use of text message services. • Walk-in service offered. Recruitment/Staffing • Employing more staff (GPs, Nurses, and Administrative staff). • Employment of other workforce e.g. in-house Pharmacist, Gynaecology and Mental Health nurse. • More staff dedicated to answering phones and reception area. • Increase visibility of staff (reception area). • Reduce use of locums, more permanent staff. Training • Upskilling staff – for example investing in training for Practice Nurses (minor illness course, prescribing course), administrative staff trained on reading/coding medical letters. Involve PPG • Discuss results of GPPS survey. • Develop in-practice surveys. • Implementing local health campaigns/ raising awareness e.g. cancer campaign. Capture and review feedback • Monitor NHS choices. • Practice specific surveys. • Review complaints received (monitor if there has been decrease following any changes) • Online questionnaires –for example, for those with Long Term Conditions to reduce need for face-to-face appointments.

6 | P a g e Flexible service • Flexible appointments e.g. for those unable to call or for those with complex conditions or alert of notes to offer same day appointment for newly diagnosed cancer patients. • Signposting- to other services such as extended access clinics and social prescribing clinics.

Specific improvement initiatives • For example, for patients with Long Term Conditions including Mental Health and Learning Disabilities. • Trialling reception changes- more staff to answer calls at peak time, reviewing and utilising space at the practice.

Resource guide During Q1 2019/20, a resource guide for practices capturing information, templates and examples (including those shared by practices) was developed with the support of the CCG Public Engagement Manager. It was also reviewed by the LMC. The resource guide will be circulated to practices via the GP bulletin and on the Primary Care website in early July. The GPPS 2019 results are due to be published on 11 July 2019.

Joint ENHCCG / CQC Conference In Q1 2019/20 the CCG started planning a joint ENHCCG and CCG conference. The aim of the conference is to provide an opportunity for practices to meet the CQC and discuss key CQC topics (including registration and the new annual regulatory reviews). The General Practice Patient Survey (to be published July 2019) will also be discussed. An initial date has been planned for 15th November 2019. Further details will be shared going forward.

2.3.2 East & North Herts Primary Care Education & Workforce Network (PCWEN) The work of the PCWEN is underpinned by the NHS Long Term Plan (LTP) published on 7th January 2019 and “Investment and evolution” the five-year framework for GP contract reform. This is to implement The NHS Long Term Plan and seeks to address workload issues resulting from workforce shortfall by introducing a new additional roles reimbursement scheme” for Primary Care Networks (PCNs)

A recent presentation by the GP Clinical Lead Dr Robin Christie at the March 2019 PCCC, gave an overview of the data collation. This illustrated to the PCCC how the PCWEN workforce initiatives underway are informed by the data collection, the future direction of travel including the ongoing collaboration with the STP CCG partners and going forward how this data can help the evolving PCNs.

During 2018/19 the data told us: • GP Workforce: Increase in vacancies and an increase in expected retirements • Increase for General Practice Nurses (GPNs) in post, decrease in vacancies • Large increase in clinical pharmacists • Increase in all training (except Apprenticeships)

Therefore the priority work-streams for 2019/20 include: • Recruitment and attraction initiatives • GP Retainer schemes – GP Career Plus • GP Fellowship schemes • GP International Recruitment • National Plan for Practice Nurses

7 | P a g e • GPN Ten point plan • Practice Manager Training.

Also new from Health Education England are Primary and Community Care “Training Hubs” which are networks of education and service providers based in the Community to realise the potential of all the initiatives underway. Their function is to develop and expand capacity of high quality learning placements at undergraduate and postgraduate level; including provision for training and development for multi-professional educators. To aid better understanding of local workforce planning needs and how these might be realised across the Sustainability and Transformation Partnership, Integrated Care System and Primary Care Network level across health and social care.

We held two residential International GP Recruitment weekends in East Hertfordshire where 12 GPs were invited to meet 12 Practices form across the STP where they would visit practices and be interviewed by representatives from the Practice; and those who attended the event had a total of 13 vacancies. The events were successful with 9 GPs being offered positions and all 9 offers were accepted. The practices that will have an international GP start with them are:

• Cuffley & Goffs Oak Medical Practice • Stockwell Lodge Medical Centre • Church Street Surgery • South Street Surgery A further round is being planned for Quarter 2.

GP Fellowship scheme – second round of interviews took place 22nd June. Practices participating in the GP Fellowship Programme:

Practice Specialist area of Interest South Street Practice, Bishop Stortford Population Health Management Stanmore Medical Group, Stevenage Frailty Birchwood Surgery, Letchworth, Hitchin Frailty Birchwood Surgery Public Health

Health Education England awarded 8 places for Advanced Clinical Practitioners course, 4 in ENHCCG. These places have been given to General Practice Nurses, Clinical Pharmacists and Emergency Care Practitioners. The Primary Care Education & Workforce team also successfully bid for a Hertfordshire & west Essex Workforce Development Investment of £108k. These funds will be used to increase the CPD offering to our Multi-professional workforce to include: Health Care Assistants, General Practice Nurses, Clinical Pharmacists and Emergency Care Practitioners. The CCG’s Workforce and Education Lead Nurse, Lucy Eldon, has been awarded regional champion for East of England region in the NHS Parliamentary Awards and was shortlisted to attend the awards ceremony in Parliament on 10th July.

The Practice Manager’s Development Programme completed in March 2019 and initial response has been positive with further collation of more formal feedback to understand their development needs to devise a plan for future Practice Manager training.

2.3.3 CCG Primary Medical Care Contracting Panel One of the key work-streams in quarter 1, 2019-20 was the preparation for the establishment of the Primary Care Networks from 1st July 2019. ENHCCG developed a PCN Registration Panel

8 | P a g e which met on 21st May 2019, having received delegated authority from the PCCC, to preside over network registration approval. The panel reviewed all the individual submissions to ensure that all paperwork was received and contained all the requested information. The Panel approved the applications for the 12 PCNs and each PCN was formally notified along with the next steps prior to go live on 1st July 2019.

Going forward, the Contracts paper presented to the PCCC will include an update on Primary Care Networks along with the position on list closures, mergers, APMS contracts and other contractual items for practices in East and North Hertfordshire.

The Panel has recently been granted delegated authority for decision making for practice mergers and any amendments to Primary Care Networks (PCNs). At the present time any amendments to PCNs, such as change of practices within a PCN or, amendments to the national job description of the Social Prescriber are required to go to PCCC for consideration. The joint contract and quality visits have been established and are now embedded as business as usual. The practices have engaged well with this process and there has been positive feedback.

The CCG Contracts Team has been working closely with the Programme Management Office to support the development of the 2019-20 CFF monitoring processes as well as the FAQ weekly document. The team has also sent out the required documentation for the 2019-20 Locally Enhanced Services for sign up by practices.

The Extended Access contracts will be monitored by the Contracts Team going forward and will be supported by the ongoing work streams being undertaken by the Primary Care Development team.

2.3.4 Primary Care Development Good progress has been made on the Care Homes project with care delivery models in each locality having been identified for support and evaluation. A key project milestone was an analysis of the Salford single care home practice model and this has been completed including a project team field trip. The project remains on track to deliver recommendations on a preferred model(s) for the provision of care to residents in care homes from 1 April 2020.

The PCCC has supported a further Transformation & Resilience fund of £250K in 2019-20 to enable practices and groups of practices to obtain support to implement new ways of working and service improvement initiatives as part of bolstering their future sustainability and improving quality of care for patients. The Transformation & Resilience fund wasn’t fully utilised in 2018-19 and the Primary Care Development Directorate (PCD Directorate) is committed to helping ensure that 2019-20 sees a greater level of investment in primary care from this fund, the information on the fund that has been provided to practices on application eligibility criteria has now been revised and recirculated. The timeliness of some aspects of the process e.g. informing applicants of the panel’s decision had proved challenging initially, however clear target turnaround times are now in place to cover the entire process start to finish and a robust tracking and monitoring process has been implemented with a designated staff member now having responsibility for ensuring these times are met. Target times were met for the last wave of applications.

The Primary Care Development Directorate completed the evaluation of Extended Access Primary Care services with a report presented to PCCC early July 2019. The report showed a generally positive picture with increasing shift fill and appointment utilisation. The CCG has secured direct booking from Integrated Urgent Care /111 into Extended Access in four of the six of Extended Access services and is actively working with the remaining two service providers to achieve this. A further key outstanding development is implementation of ICE functionality to

9 | P a g e enable blood tests and diagnostic imaging requests to be ordered electronically in Extended Access, the unavailability of this functionality is currently putting unnecessary pressure on the wider ‘in-hours’ primary care system with patients in some cases having to return to their home practice for a referral for the test that they require. As such this is a priority task and has already been escalated to the relevant CEOs.

Additional primary care information governance support has been commissioned from the CCG’s shared IT service provider, HBLICT and this will complement the existing Data Protection Officer function for practices that is already commissioned and attracting positive feedback.

Phase 2 of the eConsultation, the procurement (mini competition from the NHSE framework) has now been successfully completed and the CCG is presently in the process of signing a contract with the successful bidder. Thirteen practices have put themselves forward to be ‘champion’ sites and work with the project team to evaluate the selected product for 6 months (phase 3 of the project); implementation in these practices should be complete by the end of July. This represents a good start and efforts are continuing to engage all of the remaining practices, the CCG is required to achieve a minimum of 75% population coverage by March 2020 per NHSE Operational Planning Guidance 2019-20.

2.3.5 Primary Care ICT HBLICT colleagues have continued at pace with the rollout of Windows 10 across the primary care estate, and have now upgraded 84% of the 1794 devices. The rollout of Windows 10 has enabled the implementation of security standards defined by the National Cyber Security Centre, for example port control which restricts the use of devices with the potential to flow data in and out of practices.

Concurrently we rolled out Advanced Threat Protection (ATP) to the entire estate and were one of the first CCGs in England to achieve 100% coverage. ATP is a range of security solutions that defend against sophisticated malware or hacking based attacks, strengthening our cyber resilience in Primary Care and building on our strong commitment to security and the provision of reliable and robust infrastructure.

The proactive rolling hardware replacement programme in Primary Care, which is dependent on NHSE capital funding has been mothballed in Q1 due to delay in NHSE approving the capital bids submitted in January 2019. A decision on the bids is expected in July 2019 but ENHCCG has agreed to fund, at risk, hardware orders to enable us to carry out essential replacements.

To support and enhance the work of the team a GP IT Facilitator post has been recruited to within the HBL ICT Informatics team. The aim of this role is to deliver support and guidance to GP practices in east and north Hertfordshire around data quality and coding standards within their clinical system, as well as assisting practices in the extraction, collation and reporting of what will be higher quality data to the CCG and national bodies. The post holder will also gather information and conduct Clinical System health-checks in order to help practices move towards best practice working and support them through the development of Primary Care Networks.

The application training team delivered 103 training work packages, providing practices with a wide range of support and training and are currently looking at redesigning the application training function. This is with a view to moving away from one to one onsite delivery to offering more scheduled classroom based courses, WebEx sessions and online bite-size and refresher training.

The implementation and utilisation team have continued to support and promote the use of national systems such as the Electronic Prescription Service (EPS) and Patient OnLine

10 | P a g e services. The NHS app has been rolled out to all practices, which enables patients to register for online services without intervention from, or increasing workload for, practices. Work with care homes is supporting the ordering of medication on behalf of their residents via online services which is reducing administration overheads for practices.

There is also joint working with the Local Pharmacy Committee (LPC) fostering good partnership working; focusing on Electronic Repeat Prescriptions (eRD), working with the Meds Management team to increase take up of the system with numbers increasing steadily.

With regard to e-Referrals, after the successful paper switch off at East and North Herts Trust, HBLICT continue to support the CCG and practices around issues referring into secondary care. We have established direct communication routes with Trusts which has drastically reduced the time taken to investigate and resolve issues with electronic referrals. We have also supported the CCG with the advice and guidance element of the CQUIN and have worked with the contracts team to develop and embed the e-Referral process in new and existing pathways.

The Business Change team have continued to provide support of Extended Access (EA) Services across the CCG and have worked with Knebworth Surgery supporting their move from the North Herts EA service to become part of the Stevenage service. The team have supported the soft merger of Castlegate Surgery with Church Street and provided support for Garden City Surgery’s clinical system migration to TPP SystmOne.

As part of the national move towards a paperless NHS, provider organisations would like to enable documentation for discharge and transfer of care messages to be sent to GP Practices electronically where possible, rather than by post. Currently many organisations are still sending paper documents to practices via post. This represents a huge waste of resources for practices to consume and process paper documentation, in comparison to receiving electronically directly into the clinical system. Locally East and North Herts Trust have begun to implement electronic messaging with some SystmOne practices and we have received a request from Spire Healthcare and others to begin using electronic messaging. Other health economies that practices may interact with are already doing so e.g. UCLH and Moorfields. All SystmOne practices have been advised how to enable this function.

2.3.6: Premises Prioritisation to support planned new growth and transformation continues at a pace Local Authorities have confirmed housing trajectories and patient growth, Net Internal Area (NIA) gap analysis arising therefrom and Pipeline Projects have been submitted to the STP.

During Q1 2019/20 the following progress and achievements have been made:

Guessens Road Practice, Welwyn Garden City completed its Estate Technology Transformation Fund (ETTF) project and located its main and two branch surgeries into the former Parkway Clinic. The project completed at the end of May 2019 and the opening took place on 4 June; it was very special that the new surgery premises were opened by the two oldest patients of the practice. This was recognition of years of work by the practice, the commissioners and NHS Property Services that delivered the project under exceptionality terms for 100% funding despite the expected Premises Cost Directions yet to be released.

Central Surgery, Sawbridgeworth, is also another project under ETTF that is progressing well. Phase One which is the new extension completed and was occupied by the practice in mid-June 2019 enabling the practice to vacate its existing premises to enable Phase Two, the refurbishment of the existing premises to begin. The final phase is completing the link between the new and the old. Completion of the whole project is forecasted for October 2019.

11 | P a g e Two other ETTF projects, Puckeridge Surgery and Dolphin House projects achieved approval on their Full Business cases and are progressing the projects to the next stage. Knebworth Surgery finally started on site in May 2019 after years of significant challenges and the construction project is progressing well; completion is expected November 2019.

3. Options N/A

4. Resources implications Workforce resource requirements for delegated commissioning were scoped and agreed during 2017-18 as part of the due diligence and preparations for delegated commissioning in 2018-19. These posts have now been recruited to and in addition the CCG has funded some additional posts such as the ICT staff and support to the Care Home project.

5. Risks/Mitigation Measures There were two risks originally included on the corporate risk register: OP5: Risk Description: If the CCG fails to establish an adequate and appropriate commissioning plan that is informed by member practices. Risk Event: Then we may not be able to commission effective services that enhance the wellbeing of our residents within the available resources. Impact: Resulting in poor patient outcomes.

PC1: Cause: If member practices hand back their contracts due to financial, and/or workforce or quality issues. Risk Event: Then the CCG may not be able to commission the capacity and quality of primary care services. Impact: Resulting in the local population having reduced access to primary care services. However both of these have now been de-escalated and there are currently no risks on the corporate risk register.

The Primary Care Development Directorate has recently reviewed its arrangements for risk identification and monitoring. The directorate risk register will now be routinely reviewed at team meetings and in this way risk systematically tracked. Currently the register is a standalone excel document, however this will transfer to the new DATIX system shortly.

Project risks are currently recorded on individual project risk registers and managed as part of project management processes, however going forwards the plan is to consolidate and input all of these risks into the DATIX system for greater visibility and scrutiny.

6. Recommendations For the Governing body to note the progress of the Primary Care Commissioning Committee work programmes for Q1- 2019/20.

7. Next Steps Ongoing work as per PCCC work plan and annual business cycle; including the monitoring against plans and trajectories, updates on schemes and initiatives e.g. online consultations, care home project within the CCG and across the Sustainability and Transformation Partnership.

12 | P a g e Agenda Item No: 12

Date of Meeting: 25th July 2019

Governing Body Meeting in Public

Paper Title: Quality Committee Annual Report 2018/19

Decision or Approval Discussion Information

Report author: Rosie Connolly, Quality Manager

Report signed off by: Linda Farrant, Chair of Quality Committee / Lay Member, Governance and Audit

Executive Summary: This report provides an overview of the Quality Committee’s work during 2018/19 including a summary of discussions held, key actions taken, policies approved and prioritisation frameworks reviewed by the Quality Committee. The report also includes a summary of key areas of focus for 2019/20.

Recommendations To note to the members:

Conflicts of Interest None involved:

Conflict of Interest Definitions

The following table describes the sub-classifications of interests:

Type Description Financial Interests This is where an individual may get direct financial benefits from the consequences of a commissioning decision. Non-Financial This is where an individual may obtain a non-financial professional benefit Professional Interests from the consequences of a commissioning decision, such as increasing their professional reputation or status or promoting their professional career. Non-Financial This is where an individual may benefit personally in ways which are not Personal Interests directly linked to their professional career and do not give rise to a direct financial benefit. Indirect Interests This is where an individual has a close association with an individual who has a financial interest, a non-financial professional interest or a non- financial personal interest in a commissioning decision.

Page 1 of 8 1. Executive summary This report provides an overview of the Quality Committee’s work during 2018/19 including a summary of discussions held, key actions taken, policies approved and prioritisation frameworks reviewed by the Quality Committee. The report also includes a summary of key areas of focus for 2019/20.

2. Quality Committee Annual Report 2018/19 2.1 Terms/ Acronyms Used in the Report

CCG Clinical Commissioning Group HUC Herts Urgent Care CQC Care Quality Commission KPI Key Performance Indicator ENHCCG East and North Hertfordshire LD Learning Disabilities Clinical Commissioning Group ENHT East and North Hertfordshire LeDeR Learning Disabilities Mortality NSH Trust Review GP General Practitioner PAH Princess Alexandra Hospital NHS Trust HPFT Hertfordshire Partnership STP Sustainability and Foundation Trust Transformation Partnership

2.2 Introduction The Quality Committee is established in accordance with section 6 of NHS East and North Hertfordshire Clinical Commissioning Group’s (ENHCCG) Constitution, as a Committee of the Governing Body.

The role of the Committee is to bring together information from a variety of sources to review the quality of care commissioned by ENHCCG; this includes all aspects of quality, patient experience and patient safety. The Committee looks to identify any early signs of quality failure, and implements or recommends appropriate actions.

The Committee ensures robust quality reporting to the Governing Body to enable ENHCCG to maintain quality as a fundamental priority, escalating issues to the Governing Body as required.

2.3 Purpose The purpose of the report is to provide an overview of the work of the Quality Committee during 2018/19.

The report includes a summary of discussions held and key actions taken by the Quality Committee during 2018/19. The report also includes a summary of key areas of focus for 2019/20.

2.4 Meetings held during 2018/19 Quarterly meetings were held on the following dates during 2018/19; - Thursday 14th June 2018 - Thursday 13th September 2018

Page 2 of 8 - Thursday 13th December 2018 - Thursday 7th March 2019 Additionally an extraordinary meeting took place on Thursday 31st January 2019. All meetings were quorate.

2.5 Summary of key areas reviewed during 2018/19 To support the Committees review of key areas of quality, patient experience and patient safety the following documents have been standing agenda items on the Quality Committee agenda; - Quality Report; this covers all aspects of quality relating to our main providers, key issues and actions taken - Hotline Report; reviewing activity, key issues and actions taken. - Complaints Report; focussing on complaints and concerns received by the CCG - Feedback on quality from the Patient Network - Herts and West Essex STP Infection Prevention and Control Minutes

The Committee has also reviewed and sought assurance from annual reports including Infection Prevention and Control, Safeguarding Adults, Safeguarding Children and Looked After Children, and Complaints, and been involved in the review of provider Quality Accounts and drafting of the commissioner statements.

Throughout the year, topics for focused discussions and future agenda items are agreed, both through the business cycle and as ad-hoc agenda items; these could be due to emerging quality issues or as a result of new guidance and publications.

Given the quality challenges and size of the contract, discussions have inevitably concentrated on the issues at East and North Hertfordshire NHS Trust (ENHT). The Committee has wide ranging and robust conversations about how, as a CCG, we should continue to challenge, support and tackle these issues with the Trust using all means at our disposal including but not limited to, Board to Board conversations, escalation to regulators, and face to face discussions. The Committee, supported by the Nursing and Quality Team, looks for formal, informal, tactical and pragmatic solutions to encourage and influence improved quality at the Trust. This approach has provided an effective forum for debate and agreed action.

A summary of other key topics discussed has been included below;

Herts Urgent Care (HUC) Whistleblowing Investigation: A whistleblowing letter raising a number of concerns had been sent to ENHCCG, a neighbouring CCG, NHS England and the Care Quality Commission (CQC). ENHCCG worked with HUC to investigate the concerns raised, and the Quality Committee were presented with an overview of the concerns raised and investigation findings. Concerns related to staff wellbeing, the HUC management team, NHS Pathways Model and Information Governance. The Committee were assured by the information presented, and follow up arrangements via Quality Assurance Visits and Quality Review Meetings.

Page 3 of 8 Learning Disabilities Mortality Review (LeDeR): The Committee was presented with an overview of the LeDeR national programme and how this was being implemented locally, as well as a summary of achievements to date and recommendations. Actions agreed by the Quality Committee included the LD team attending Target events to raise awareness, the LeDeR lead working more closely with the CCG’s End of Life steering group, and a review of the LD pathways for dementia and epilepsy to ensure they were aligned to the CCG’s current pathways. The Committee requested that the presentation was also made to the Governing Body to raise awareness; this has now taken place.

Mortality at Princess Alexandra Hospital (PAH): Following an ongoing decline in mortality rates at PAH the Medical Director of PAH presented a report detailing the current position, and key work streams in place to improve mortality rates. The Committee found the detail provided encouraging, and were assured that a detailed improvement plan was in place. PAH’s Medical Director advised the Committee of some of the current challenges and a number of actions were agreed as a result. These included CCG GP leads supporting GP engagement, supporting work with a nursing home regarding End of Life care, and CCG and Trust Caldicott Guardians agreeing a way forward regarding the sharing of patient records.

Hertfordshire Partnership Foundation Trust (HPFT) Suicide Review: The Committee was presented with an overview of the numbers of suicides and unexpected deaths of people known to HPFT as well as a deep dive into unexpected deaths and incidents of serious self- harm over a six month period. Whilst assurance was provided that monitoring was in place, and that there had been improvements in clinical engagement, the Committee was disappointed that the recommendations were very similar to those presented several years earlier, with limited progress. A further deep dive discussion has therefore been added to the 2019 Quality Committee business cycle.

2.6 Policies/ Strategies Reviewed The following policies and strategies were reviewed by the Quality Committee during 2018/19;

Date of meeting Policy/ Strategy Approval Status 14.6.18 Prioritisation Framework Policy Approved 13.9.18 Safeguarding/ Looked After Children Approved and Care Leaver Strategy and Work Plan 13.9.18 Serious Incident Policy Deferred- the Policy will be reviewed following publication of the new national framework (originally due December 2018, now delayed to April 2019) 13.12.18 Safeguarding Children and Looked After Approved Children Policy 13.12.18 Covert Administration of Medication Approved Guidelines for Care Homes Policy 7.3.19 Managing Safeguarding Allegations Approved Against Staff Policy and Procedure 7.3.19 Safeguarding Adults Policy and Approved Procedure

Page 4 of 8 7.3.19 Adult Safeguarding Training Strategy Approved 7.3.19 Review of Arrangements following a Approved Child Death

2.7 Prioritisation Frameworks Reviewed The Committee is responsible for reviewing Prioritisation Frameworks that exceed the threshold for review by the Director of Nursing and Quality and Medical Director. The following Prioritisation Framework documents have been reviewed by the Committee during 2018/19;

Date of meeting Policy/ Strategy Approval Status 14.6.18 Community Frailty Not approved; the Committee requested a number of amendments/ additions including; - Early Intervention Vehicle timelines and impact of change of base - Key KPIs - Further details regarding workforce - Details of monitoring and escalation to ensure rapid action can take place if required Due to timescales involved it was agreed a revised document would be added to the July Governing Body Workshop for further review and approval. 13.12.18 HPFT Contract (2019) Approved 31.1.19 QEII Urgent Not approved; the Committee requested assurance Treatment Centre regarding the proposed model; - How gaps are to be covered in the medical staffing rota (GP’s or middle grade doctors) - Details of plans in place to ensure that appropriately trained staff are available for the management of babies and children - Ensuring that there is a requirement for ENHT to inform the CCG of staffing gaps. - That System 1 is being used effectively and that information on attendances goes directly into patient records. Additionally the following amendments were requested to the Prioritisation Framework; - Risk scores to be reviewed and amended. - CQC outcomes to be made consistent in the paper. - Costs to be removed from the paper - Strengthen the anticipated health gains to more explicitly support the outcomes. Due to timescales involved it was agreed a revised document would be added to the February Governing Body meeting for further review and approval.

Page 5 of 8 2.8 Committee Effectiveness The United Kingdom Corporate Governance Code (September 2014) requires Boards to “monitor the company’s risk management and internal control systems and, at least annually, carry out a review of their effectiveness”. The Quality Committee manages this Code’s provision by reviewing its effectiveness on an annual basis.

Discussions are based on committee focus, team working, effectiveness, engagement and leadership. The annual review took place in March 2019; members of the Committee agreed that the Committee is effective, with members noting where the Committee has had an impact on quality issues. Members also considered that the Committee was chaired particularly well.

Through this discussion it was agreed that a quarterly report on primary care quality will be provided to the Committee in 2019 for information and monitored by exception, and that a primary care focus will be added to the 2019 business cycle. Additionally it was suggested that an annual report on the work of the Quality Committee should be produced and shared with the Governing Body, hence this report being provided.

2.9 Business Cycle 2019 The current version of the 2019 Quality Committee business cycle can be found in Appendix 1.

3. Issues Not applicable

4. Options Not applicable

5. Resources implications There are none identified.

6. Risks/Mitigation Measures Not applicable

7. Recommendations The Governing Body is asked to note the report.

8. Next Steps Not Applicable.

Page 6 of 8 Appendix 1: 2019 Quality Committee Business Cycle

7th March 2019 13th June 2019 5th September 2019 5th December 2019 09.00-13.00 09.00-13.00 09.00-13.00 09.00-13.00 Charter 1.2 Charter 1.2 Charter 1.2 Charter TBC • Quarterly Quality Report • Quarterly Quality Report • Quarterly Quality Report • Quarterly Quality report • GP Hotline Quarterly Report • GP Hotline Quarterly Report • GP Hotline Quarterly Report • Complaints Bi-annual Report • Feedback on quality from • Feedback on quality from • Feedback on quality from • GP Hotline Quarterly Report Patient Network Patient Network Patient Network • Feedback on quality from • Quality Accounts • Primary Care Quality Report Patient Network • Primary Care Quality Report • Primary Care Quality Report Focus areas/ Updates Focus areas/ Updates Focus areas/ Updates Focus areas/ Updates • HUC Innovation pilots • Child and Adolescent Mental • Primary Care deep dive • HPFT Suicide review • Getting it right first time (GIRFT) Health Services (CAMHS) deep • Getting it right first time (GIRFT) • Public Health Suicide review (inc update dive (to be included in Quality update benchmarking data) Report) • Adult Safeguarding Training • Maternity Transformation and Strategy • Paper for Mental Capacity Act ENHT maternity performance Amendment Bill

Annual Reports Annual Reports Annual Reports Annual Reports • Complaints Annual Report • Safeguarding Adults Annual • Safeguarding Children Annual Report Report • Infection Prevention and Control annual report • Quality Committee Annual Report Policies to be approved Policies to be approved: Policies to be approved: Policies to be approved • Safeguarding Adults policy • Chaperone policy • SI policy (dependent on publication of national framework)

Page 1 of 8 7th March 2019 13th June 2019 5th September 2019 5th December 2019 09.00-13.00 09.00-13.00 09.00-13.00 09.00-13.00 Charter 1.2 Charter 1.2 Charter 1.2 Charter TBC Prioritisation Frameworks Prioritisation Frameworks Prioritisation Frameworks Prioritisation Frameworks

Assurance Framework / Corporate Assurance Framework / Corporate Assurance Framework / Corporate Assurance Framework / Corporate Risk Register Risk Register Risk Register Risk Register

Committee Self-Assessment and Review Business Cycle review of Terms of Reference Herts and West Essex STP Infection Herts and West Essex STP Infection Herts and West Essex STP Infection Herts and West Essex STP Infection Prevention and Control Minutes Prevention and Control Minutes Prevention and Control Minutes Prevention and Control Minutes

Page 2 of 8 Agenda Item No: 13

Date of Meeting: 25th July 2019

Governing Body Meeting in Public

Paper Title: Annual Complaints Report 2018/19

Decision or Approval Discussion Information

Report author: Ella Inzani, Patient Safety and Experience Manager

Report signed off by: Sheilagh Reavey, Director of Nursing and Quality

Executive Summary: To inform the Governing Body of complaints received and investigated by ENHCCG in 2018/19, including numbers, themes and learning Recommendations No note to the members:

Conflicts of Interest None involved:

Conflict of Interest Definitions

The following table describes the sub-classifications of interests:

Type Description Direct (or personal) A direct financial interest is one where there is or appears to be financial interest opportunity for personal financial gain or financial gain to close family members, close friends and associates, and business partners (dependent on the circumstances and the nature of such relationships). Indirect (or non- An indirect financial interest involves payment or other benefit to a personal) financial department or organisation in which the individual is employed or interest otherwise engaged but which is not received personally. Non-financial interests A non-financial interest is one where there is or appears to be an opportunity for non-financial gain (e.g. status), or where an individual’s decision making is or could be compromised for example due to a conflict of loyalty.

Page | 1 1. Executive summary The report details the numbers, themes and learning of complaints investigated by ENHCCG in 2018/19.

2. Background Annual report.

3. Issues Not applicable

4. Options Not applicable

5. Resources implications Not applicable

6. Risks/Mitigation Measures All issues being managed through appropriate processes.

7. Recommendations The Governing Body is asked to consider the report and advise where more information or further action is required.

8. Next Steps Not applicable

Page | 2

ANNUAL COMPLAINTS REPORT: 2018-19

1. ACRONYMNS BMI Body Mass Index IVF In vitro fertilisation CCG Clinical Commissioning Group KPI Key Performance Indicator CEO Chief Executive Officer LA Local Authority CHC Continuing Healthcare MP Member of Parliament EEAST East of England Ambulance Service NHS National Health Service Trust ENHT East and North Hertfordshire NHS NHSE NHS England Trust ENHCCG East and North Hertfordshire NICE National Institute of Clinical Clinical Commissioning Group Excellence FSL Freestyle Libre PAH Princess Alexandra Hospitals Trust GFF Gluten-free foods PALS Patient Advice and Liaison Service GP General Practitioner PTS Patient Transport Service HCT Hertfordshire Community Trust PHSO Parliamentary and Health Service Ombudsman HPFT Hertfordshire Partnership Q1… Quarters 1, 2, etc. Foundation Trust HUC Herts Urgent Care QE2 Queen Elizabeth II Hospital HVCCG Herts Valleys Clinical Commissioning Group IFR Individual Funding Request

2. INTRODUCTION East and North Hertfordshire Clinical Commissioning Group (ENHCCG) is committed to providing our patients, families and members of the public with the opportunity to raise concerns and share their experience relating to any service we provide and/or commission. The CCG recognises this as a fundamental mechanism through which we can understand the level of care being provided to our patients and the feedback is a key opportunity for ourselves and other organisations to learn.

The purpose of this report is to;  Provide information regarding the numbers and themes of complaints investigated by ENHCCG during 2018/19. (Section 3.1 -3.3)  Show examples in which data from complaints and lessons learned from complaints investigations have been used to improve the quality of patient care (Section 3.4)  Provide assurance that ENHCCG follows its complaints policy and best practice when investigating and responding to formal complaints. (Section 3.6)  To report achievement against the CCG’s action plan to improve complaints handling in 2018/19 and set out actions for continuation in 2019/20 (Section 3.7)

Complaints about CCG responsibilities include issues in relation to commissioning decisions about services, service providers, individual patient funding and National Health Service (NHS) funded Continuing Healthcare (CHC) process and decisions. ENHCCG provider organisations are responsible for managing their own services and complaints however ENHCCG will provide support and advice where required as well as managing complex and multi-organisational complaints.

All formal complaints received are fully investigated in accordance with ENHCCG’s Complaints Policy (2017). Complaints and their responses are reviewed and scrutinised by ENHCCG’s Chief Executive Officer (CEO). Bi-annual reports regarding ENHCCG complaints and handling, as well as provider complaints are discussed at the CCG’s Quality Committee, a sub-committee of the Governing Body. The Committee has delegated responsibility for reviewing complaints by ENHCCG’s Governing Body.

3. ENHCCG Complaints 3.1 Complaints and Patient Advice and Liaison Service (PALS) Figures : 2018/19 The following table details the number of Complaints and PALS received by ENHCCG in 2018/19;

ENHCCG Complaints: 2018/19 30

Number 10

0 Augus April May June July Sept Oct Nov Dec Jan Feb March t Number of Complaints Received 28 19 22 22 27 26 22 20 16 18 20 16 Number of Complaints Investigated 18 7 11 8 15 6 8 7 10 11 6 9 Number of PALS Enquiries 14 12 8 10 11 21 15 16 10 11 15 12

**Number of Complaints Investigated includes MP Enquiries**

During 2018/19 ENHCCG received 256 complaints relating to ENHCCG patients. Out of those 256 complaints, 116 were investigated by ENHCCG; including 50 Member of Parliament (MP) Enquiries. The remaining 140 complaints related to ENHCCG provider organisations or other CCGs and therefore the complaints were directed to the appropriate provider or CCG complaints team to take forward. During the same time period 155 PALS enquiries were received.

The number of complaints received and investigated in 2018/19 (116) has increased slightly by 3% compared to 113 investigated in 2017/18. This is the 5th consecutive year showing an increase. The numbers have fluctuated during the year with the highest number of complaints received in Q2, and then a decrease during Q3 and Q4. Common themes of investigated complaints during the reporting year were similar to the previous year, largely relating to Continuing Healthcare; the CCG’s policy relating to the prescribing of the Free Style Libre system; and Individual Funding Requests. Please refer to section 3.2 for further information regarding themes and trends. 2

There was a small decrease in the number of PALS enquiries received during 2018/19 compared to the previous year (173). As a CCG, we do receive a lower number of PALS enquiries compared to provider organisations.

3.2 Themes/Trends Please find below a graph detailing the main specialities and subjects for ENHCCG Complaints investigated in 2018/19.

Complaints by Subject (Primary) and Speciality (Primary)

Complaints in 2018/19 by Speciality (Primary) and Subject (Primary)

Access to premises 25 Clinical Treatment

20 Commissioning Decision Communication/information to patients 15 Confidentiality

10 Discharge & transfer arrangements Documentation 5 Funding

0 Medicines Other/Not Elsewhere Classified

Patient Care

Service Provision

Staff attitude/behaviour

Waiting lists, community services

The majority of investigated complaints during 2018/19 have related to the CCG policy regarding prescribing of the Freestyle Libre (FSL) system; Individual Funding Requests (IFR); and Continuing Healthcare (CHC). There was also a lobby from local MPs around local funding support for the charity, Headway.

During 2018/19 there was a repeated theme of a number of complaints relating to communication, delays and processes within the CHC Team.

Those complaints relating to IFR were largely around the CCG’s updated policy on in vitro fertilisation (IVF) due to the change in criteria and reduction in number of cycles funded for eligible patients.

FSL continues to be a common theme in complaints. There is no current NICE guidance on the use of FSL, but NHS England have recently published guidance on the funding of the system. ENHCCG are urgently reviewing current local guidance and prescribing policies, and aim to have this work completed by the end of Q1 2019/20.

3.3 Complaint Outcomes Please find below a graph detailing the outcomes of ENHCCG investigated complaints in 2018/19.

Outcome of ENHCCG Investigated Complaints Closed in 2018/19

1% 2% 7%

4% Enquiry Only Information only No response from complainant Not upheld

27% Partially upheld 57% Passed to another trust Resolved as PALS Upheld

1% 1%

57% of complaints closed within 2018/19 were closed as Enquiry Only. This relates to communication, primarily from MPs, where the CCG has been asked to provide further information about a specific area. In such cases a formal complaint investigation is not undertaken and therefore it is not possible to provide an outcome. However the communication is recorded and triangulated along with other patient experience data to provide essential data to the CCG.

11% of complaints closed within 2018/19 were either upheld or partially upheld.

3.4 Learning The majority of complaints relate to CCG policies that are in place; whilst there has been no specific learning from these, the CCG continues to take patient feedback into account when making commissioning decisions.

CHC have introduced monthly complaints discussions at their team meetings and the review of one complaint relating to an elderly patient moved into a Nursing Home from a hospice, led the team to develop a patient journey presentation. The wider learning from this complaint is detailed below:

• Continuing Healthcare (CHC) Team to ensure that there is clinical review of the patient if they have not been placed within 4 days of referral. • CHC to remind providers that the CHC team are the first point of contact rather than the family, when reviewing ongoing placements. • Review with Hospice the issues identified within the complaint. There will be specific reference to; – Recognition of deterioration in patients – Reviewing patients on discharge – Discharging the patient with ‘Just in Case’ medication. 4

• Discussion with ENHCCG Medicines Optimisation Team regarding the standardising of ‘Just in Case’ medication. • Support to be offered to Nursing Home in relation to training in the recognition of the dying patient, including the East of England ABC Education programme in End of Life. • Nursing Home to review and amend their End of Life policy to reflect learning from this complaint. • Patient story to be developed based on the complaint, in order that learning can be shared. • Assistant Director of CHC to join the ENHCCG End of Life steering group to share the concerns that have been identified and develop a plan to support improvement in nursing homes. • Three month pilot of Frailty Nurse supporting care homes managing frail, complex patients; ensuring that care plans reflect patient’s needs and anticipate changes. Supporting nurses and carers in delivering end of life care

3.5 Parliamentary and Health Service Ombudsman (PHSO) During the 2018/19 reporting year, the PHSO requested 2 case files from ENHCCG, the details for which are as follows:

 2534 relating to Prescribing of Armour Thyroid (liothyronine). PHSO reviewed the complaint and CCG information, and closed the case without investigation.  2553 relating to a CHC Retrospective Review. The complaint was reviewed by the CCG and reimbursement provided for the period in question. The PHSO closed this case without investigation.

Additionally during 2018/19, the PHSO investigated and reported on 2 cases where they had requested the files during the 2017/18 reporting year. The details are:

 1898 relating to a CHC Retrospective Review. PHSO investigated the complaint and the outcome was that the complaint was not upheld.  1623 relating to care provided in a care home. PHSO investigated the complaint and the outcome was that the complaint was not upheld.

3.6 ENHCCG Complaints Handling ENHCCG’s complaints handling Key Performance Indicator (KPI) for 2018/19 is as follows;

METRIC THRESHOLD Q1 Q2 Q3 Q4 2018/19 All complainants to be 100% 97% 83% 100% 100% 95% acknowledged within 3 working days Complaints to be responded to 90% 86% 93% 88% 96% 91% within the agreed timeframe. The KPI for acknowledgement within 3 working days has been met in Q3 and Q4 2018/19. As detailed in the Q2 complaints report, 6 complaints breached the timescale in Q2 due to delays in the complaints being passed to the Nursing and Quality team. Processes have been put in place to reduce the likelihood of this occurring again. We have met the KPI overall for responding within the agreed timeframe this reporting year, an improvement of 3% on 2017/18, however, we would like to ensure this standard is consistently met throughout the year and this will form part of our priorities for the coming year.

3.7 Areas for Improvement In the 2017/18 Annual Complaints Report, ENHCCG committed to undertaking a series of actions to ensure continual improvement of complaints handling within the organisation. Progress against the actions has been detailed in the following table. 2018/19 Priorities ACTION PURPOSE OUTCOME Audit: An internal complaints audit, To internally review the quality of complaints’ This work is ongoing – the Patient Experience and Safety with agreed tool, to be undertaken logging, processing and responses. Manager is undertaking regular audits of the logging and in Q2 2018/19. processing of complaints on the DATIX system. The quality of responses is also being reviewed on a case by case basis and one of the Nursing and Quality Team’s priorities next year is to work with Directorates to develop the quality of ‘first’ drafts coming to the team which in turn will improve the response rates under the KPI. Re-opened cases: To put in place To measure complainant satisfaction and quality of A process is now in place to monitor re-opened cases and this monitoring of re-opened cases. initial responses. will be reported in future reports. There were 24 cases re- opened in 2018/19; 7 of these related to complaints originally logged in the previous year (2017/18). Themes are largely CCG prescribing policies relating to FSL and GFF, and CHC reviews. The CCG has a robust process in place for reviewing complaint responses prior to CEO sign off and the Nursing and Quality Team has set a high standard for final responses. The majority of the re-opened cases relate to CCG policies that complainants are unhappy with, and not the quality of responses or the complaint process. Learning/Actions: Review of To ensure that learning and actions from Learning and actions identified in 2018/19 largely relate to learning and actions and how these complaints are implemented at a CCG level. CHC related complaints, regarding policies/processes and staff are implemented and embedded attitude. Similar to last year, complaints identifying significant within the CCG. delays in CHC were reviewed against processes and gaps identified. Some issues with communication, timings and staff attitude, were also addressed with teams and individuals reflecting on practice and identifying where improvements could be made. This will be an ongoing priority in 2019/20.

The CCG complaints policy will be reviewed during 2019/20 in line with any relevant national guidance updates and as indicated below, as part of an alignment of policies across Hertfordshire CCGs.

2019/20 Priorities ACTION HOW WILL IT BE ACHIEVED? TIMEFRAME Alignment of processes across Hertfordshire:  Review ENHCCG and HVCCG Complaints Handling Policies in Review March 2020 Work with Herts Valley CCG to review and align tandem to ensure that policies are aligned where possible. current processes for complaints and PALS  Ensure related processes (timescales, escalation, sign off) queries to ensure consistency across the County. are similar in both CCGs to ensure consistency. Quality of Responses within the CCG: Work with  Reviewing expectations of Complaints Handling Team to Review December 2019 teams internally to ensure consistent high-quality ensure consistent message is conveyed. first drafts and sign-off within Directorates.  Internal training/updates with teams to share expectations and responsibilities in terms of response drafts.  Review sign-off process for initial drafts. Learning/Actions: Implement a new process to  Develop a system to record, monitor and follow-up actions Review September 2019 track and monitor learning and actions and learning from complaints. implemented as a result of complaints to the CCG.  Work with Directorates to ensure that actions are implemented, embedded and reported to the Nursing and Quality Team.

4. Provider Complaints Each provider organisation has their own patient experience function, which includes the processing of informal queries (PALS) and formal complaints. The majority of concerns are received directly by the provider, and a summary of the numbers, themes and trends has been provided below.

Where the CCG receives concerns relating to a provider organisation, the Patient Experience and Safety Facilitator makes contact with the complainant, or enquirer, and seeks consent to forward the concern to the relevant organisation, or provides contact details for the organisation concerned. In most cases this is accepted by the enquirer as the provider organisation has the medical records, staff members etc. available in order to investigate the concerns. The CCG does request a copy of the complaint responses provided in order to seek assurance that the concerns have been adequately addressed.

Where complaints relate to multiple provider organisations, or are particularly complex, the CCG leads these investigations and works with the providers to ensure a joint response is provided to the complainant. These cases are included in the ENHCCG complaint figures detailed in section 3 of the report.

For each of our main provider organisations, ENHCCG receives a regular summary of complaints received in order to be sighted on the issues being raised, and to identify themes and trends. Complaints and patient experience are also key items discussed during Contract Quality Review Meetings.

4.1 East and North Hertfordshire NHS Trust (ENHT)

Total ENHT PALS & Complaints

1400 1200

1000 800 600 Number 400 200 0 Q1 (18/19) Q2 (18/19) Q3 (18/19) Q4 (18/19) Complaints 274 283 256 213 PALS 1031 1168 991 1085

During 2018/19 ENHT received 1026 complaints; this is a 6% decrease from the 1096 complaints received during 2017/18. During 2018/19 there has been a continued trend in complaints relating to the quality of care received. Other continuing themes include communication and attitude of staff, waiting times, and delays with treatment.

4.2 Princess Alexandra Hospitals Trust (PAH)

Total PAH Complaints and PALS 800

600 400

Number 200 0 Q1 Q2 Q3 Q4 (18/19) (18/19) (18/19) (18/19) Complaints 65 46 59 38 PALS 550 568 631 648

During 2018/19 PAH received 208 complaints; this represents an 11% decrease compared with 233 complaints received during the previous year. The main themes for complaints remain the same as the previous year; medical care expectations, communications, and nursing.

4.3 Hertfordshire Community Trust (HCT)

Total HCT Complaints and PALS 350 300

250

200

150 Number 100 50 0 Q1 (18/19) Q2 (18/19) Q3 (18/19) Q4 (18/19) Complaints 35 41 36 48 PALS 160 248 288 183

During 2018/19 HCT received 160 complaints, this is a slight increase compared with 157 complaints received in 2017/18. The top three types of concerns reported were standards of care, staff attitude and behaviour, and appointment dates.

4.4 Hertfordshire Partnership Foundation Trust (HPFT)

Total HPFT Complaints and PALS 2018/19

300

250

200 150

100 Number 50 0 Q1 (18/19) Q2 (18/19) Q3 (18/19) Q4 (18/19) Complaints 72 67 64 81 PALS 240 212 198 219

During 2018/19 HPFT received 284 complaints, this is a 38% increase compared to the previous year when 206 complaints were received. The two main themes remained aspects of clinical practice, and systems and procedures.

4.5 EEAST

Total EEAST Complaints 25

20 15

10 Number 5 0 Q1 Q2 Q3 Q4 2018/19 2018/19 2018/19 2018/19 Complaints 10 17 11 22

There have been 60 complaints raised in 2018/19 for the ENHCCG area; this represents an 11% decrease from the 72 complaints received in 2017/18. Themes for complaints continue to be delays in ambulance arrival, attitude of staff and clinical treatment and assessment.

4.6 Herts Urgent Care (HUC)

Total HUC Complaints 2018/19 80

Number 20

0 Q1 (18/19) Q2 (18/19) Q3 (18/19) Q4 (18/19) Complaints 63 56 59 44

During 2018/19 HUC received 222 complaints; this is a 27% decrease compared with 305 complaints received the previous year. The majority of complaints continue to relate to the out of hours GP service, particularly delays and GP attitude. A number also relate to the 111 service, mainly regarding call handler or health adviser attitude.

5. Conclusion ENHCCG is committed to learn and continually improve our services as a result of complaints received. During 2019/20 the CCG will be working to ensure the actions identified for improvement are embedded and that our provider organisations continue to improve their own complaint processes.

Agenda Item No: 14

Date of Meeting: 25th July 2019

Governing Body Meeting in Public

Safeguarding Children, Looked After Children and Care Paper Title: Leavers Annual Report.

Decision or Approval Discussion Information

Report author: Siobhan Appleton, Deputy Designated Safeguarding Children’s Nurse Report signed off by: Sheilagh Reavey, Director of Nursing and Quality

Executive Summary: This Annual Report provides an overview of the work undertaken by the CCG Safeguarding Children and Looked After Children (LAC) Team during the financial year 2018/19. Key achievements in relation to Safeguarding Children and LAC for the reporting period are detailed, providing assurance to the CCG’s governing body that statutory responsibilities to safeguard the welfare of children in East and North Hertfordshire have been discharged.

The local safeguarding landscape is described including information pertaining to children with a Child Protection Plan, Looked After Children and Children in Need. Current focus for safeguarding children in Hertfordshire is discussed including emerging themes which will drive the Safeguarding Team performance during 2019/20.

Governance arrangements, partnership working and monitoring of commissioned services are detailed. A comprehensive analysis of previous, present and future arrangements relating to Primary Care support and training is included.

Recommendations To note to the members:

Page 1 of 3 Conflicts of Interest None noted. involved:

Conflict of Interest Definitions

The following table describes the sub-classifications of interests:

Type Description Financial Interests This is where an individual may get direct financial benefits from the consequences of a commissioning decision. Non-Financial This is where an individual may obtain a non-financial professional benefit Professional Interests from the consequences of a commissioning decision, such as increasing their professional reputation or status or promoting their professional career. Non-Financial This is where an individual may benefit personally in ways which are not Personal Interests directly linked to their professional career and do not give rise to a direct financial benefit. Indirect Interests This is where an individual has a close association with an individual who has a financial interest, a non-financial professional interest or a non- financial personal interest in a commissioning decision.

Page 2 of 3 1. Executive summary

As documented above.

2. Background

Safeguarding Children, Looked After Children and Care Leavers Annual Report for 2018/19.

3. Issues

None noted.

4. Options

N/A.

5. Resources implications

No resource implications at this time.

6. Risks/Mitigation Measures

Where Safeguarding risk is identified across any safeguarding function, mitigation measures are documented.

7. Recommendations

None at this time.

8. Next Steps

Priorities for 2019/20 documented within body of report.

Page 3 of 3 This image cannot currently be displayed.

Safeguarding Children, Looked After Children and Care Leavers

Annual Report

May 2019 Contents

...... 0 1. Introduction ...... 3 2. Purpose ...... 3 3. Safeguarding Children Key Achievements 2018/19 ...... 3 4. The Local Context ...... 5 4.1 What is it like growing up in East and North Hertfordshire? ...... 5 4.2 The Safeguarding Landscape in Hertfordshire ...... 7 4.2.1 Number of Children with a Child Protection Plan ...... 7 4.2.2 Category of Abuse for those children with Protection Plan ...... 8 4.2.4 Children in Need ...... 8 4.2.5 Looked After Children ...... 9 5. NHS Governance Arrangements for Safeguarding at E&N CCG ...... 9 6. Partnership Working ...... 10 6.1 Accountability and Assurance ...... 10 6.2 NHS England Area Team ...... 10 6.3 Hertfordshire Safeguarding Children Partnership (HSCP) ...... 10 6.3.1 New Arrangements as of February 2019 ...... 10 6.3.2 New Arrangements for the Child Death Review Process in Hertfordshire ...... 11 6.4 Safeguarding Children in Primary Care ...... 12 6.4.1 Support for Primary Care ...... 12 6.4.2 Training for Primary Care Staff ...... 13 7. Safeguarding Monitoring of Commissioned Services ...... 13 7.1 Contract Monitoring ...... 13 7.2 Section 11 Annual Visit to Provider Services ...... 14 7.3 Quality Assurance Visits ...... 14 7.4 Monitoring of Non-NHS Provider Services ...... 15 8. Safeguarding Children Priorities for 2019/2020 ...... 15 9. Looked After Children and Care Leavers ...... 16 9.1 What is a Looked After Child? ...... 16 9.2 Local Landscape ...... 16 9.2.1 Unaccompanied Asylum Seeking Children...... 17 9.2.2 Care Leavers ...... 17

1 9.2.3 Health Assessments for Looked After Children in Hertfordshire ...... 18 10. Looked After Children Key Achievements 2018/19 ...... 18 11. Looked After Children priorities for 2019/2020 ...... 18 12. Conclusion ...... 19 13. Appendices ...... 20 14. References ...... 26

2 1. Introduction

This report provides an overview of the work undertaken by the Designated Safeguarding Children and Looked After Children Team for East and North Hertfordshire Clinical Commissioning Group (CCG) during the financial year, 2018/19.

Within the body of the report the term children is defined as any child or young person up to the age of 18 years. Looked after Children are those children in the care of the Local Authority, resident with foster carers, in residential homes or with family members. Care Leavers are those children who have been looked after by the Local Authority and are now being supported to live independently, with an age range of 17 to 25 years.

2. Purpose

The purpose of the report is to provide assurance to the East and North Herts Clinical Commissioning Group’s (ENHCCCG’s) governing body that statutory responsibilities to safeguard the welfare of children living in local communities have been discharged. The requirements upon health are encompassed within a legislative framework for safeguarding children (Children Act, 1989; 2004), supported by supplementary guidance (HM Government, 2018).

The report will detail key achievements and areas of activity during 2018/19 as well as planned areas for priority Safeguarding, Looked After Children and Primary Care function in the coming year. In addition, governance arrangements, partnership working and monitoring of commissioned services are detailed.

3. Safeguarding Children Key Achievements 2018/19

This reporting period of 2018/19 has seen the growth and development of the Safeguarding/Looked After Children Team following a long period of historical instability. The increase in safeguarding work across 2018/19 has continued to escalate with the establishment of new safeguarding arrangements, in line with legislative change, as well as expansion into contemporary areas reflecting safeguarding themes and issues affecting Hertfordshire today.

Key achievements for 2018/19 included the following:

• Full participation in planning and progression of new arrangements for the Hertfordshire Safeguarding Children Partnership (HSCP). Further information is contained within the report (Section 6.3.1). • Hertfordshire wide scope and review of service provision for children who have been subjected to Sexual Abuse resulting in a transfer of commissioning responsibility to NHS England Specialised Commissioning, generating a change in care provider to permit alignment with surrounding counties within and outside the East of England. East and North Herts Trust (ENHT) continued to assess and support those children referred for other

3 categories of abuse/neglect. Service provision will be monitored from a quality assurance perspective in the upcoming reporting period. • Safeguarding Supervision and Management Oversight Strategy ratified in October 2018. Further work is taking place to support implementation across the school network. Contribution to the health component and related items detailed within ‘Hertfordshire Violent Crime Strategy’ document (led by Police and District Council). The Strategy has been disseminated to all agencies and a Task and Finish group is underway to determine service requirement needed to fulfil actions and recommendations. • There was extensive revision of the contract and Dashboard metrics for relevant provider services, where appropriate, to afford certain core inclusions such as statistical information relating to Violent Crime and contextual safeguarding issues escalating within Hertfordshire. • Continued and enhanced improvements to correspondence between Maternity Services and Primary Care following an audit, recommended following findings from a Serious Case Review, of information sharing processes. Service changes included updating template letters and information sharing forms aimed to facilitate the sharing of vulnerabilities and potential safeguarding risks during the antenatal period. • Successful bid of £15,000 won to implement a pioneering ‘Real Care Dolls’ research project, in collaboration with Maternity Services (West Herts) and Children’s Services (see Appendix I for further information). • Continued support to services following Serious Incidents/Serious Case Review (SCR). Within the reporting period, three Serious Case Reviews have been concluded. Two of these have been published, with the third unpublished due to ongoing criminal proceedings. A further two have been declared and are currently in progress (see Section 6.3.1 for further information regarding new SCR arrangements). • Conclusion of a number of requested Serious Case Review actions and, where advised, consequent development of multi-agency policies, to ensure safe and effective safeguarding practice (e.g. development of enhanced information sharing practices across maternity and Primary Care; Safeguarding Supervision and Management Oversight Strategy). • Development of a concise self-assessment template for smaller provider services commissioned by ENHCCG. Key standards, in line with Section 11 of the Children Act (2004), were outlined and explained in basic terms to act as a benchmark for high quality safeguarding and quality assurance practices. The aim of the document was twofold; to help smaller organisations recognise what systems need to be in place to protect children and to assist the CCG Nursing and Quality Team to monitor quality assurance practices, clearly delineated within the document. • Development of ‘Safeguarding Children – Guidelines for Policy Formulation’ – this document was created to assist smaller providers, commissioned by ENHCCG, in producing a creditable Safeguarding Policy to include distinct primary principles and procedures required to protect children from harm. Full guidance and associated templates are included, based on current best practice informed by legislation. • Commencement and continuation of a number of multi-agency work streams that will ultimately lead to the development of safe, robust and high quality safeguarding related practice across all partner agencies in Hertfordshire. Work streams include Honour Based Abuse, Neglect, Domestic Homicide Review, Private Fostering, Revision of Children’s Services

4 referral forms, development of enhanced information sharing between provider services and revision of Hertfordshire Safeguarding Children Partnership (HSCP) policies. • Comprehensive revision and updating of the HSCP Pre-Birth Protocol, to reflect changes in Information Sharing and service development (incorporating service change for Substance Misuse and Domestic Abuse). • Successful advancement of CCG priorities outlined in the Hertfordshire Safeguarding Children Partnership (HSCP) Business Plan (e.g. development of numerous training programmes, revision of auditing processes related to key concerns and expert and advice and support as necessitated). • Completion of Section 11 visits to provider services as well as attendance, with the Nursing and Quality Team to Quality Assurance Visits as requested. • Formulation and completion of a selection of audits of provider services, informed by recommendations/actions identified following Section 11 visits. • Participation in the Local Authority ‘Scrutiny’ of the effectiveness of the HSCP and provider service offer in relation to Violent Crime, with a particular emphasis on Knife Crime. • Establishment of a dedicated Safeguarding Children page within the CCG’s website, providing a centralised electronic platform to collate information in relation to training, legislative change, information and resources. • Following consultation with Child Protection Conference colleagues, an improved report template has been created to underpin GP’s contribution to Initial Child Protection Conference where attendance is not possible. • Formulation of a Primary Care Dashboard to provide the Clinical Commissioning Group (CCG) with a single tool to capture key indicators and selected key areas of performance relating to safeguarding children arrangements within General Practice to support them in achieving and maintaining these required standards. It is envisaged that the information captured will identify areas of good practice and highlight areas where further support or guidance may be required and provide valuable benchmarking and evidence for Care Quality Commission (CQC) inspections. • Formulation of revised Level 2 Safeguarding Children training for those CCG employees whose job description necessitates enhanced training. • Consistent mandatory safeguarding children training figures of 90 -95% and above across ENHCCG (92% as of April 2019). • Safeguarding Children training compliance, in relation to Primary Care (Safeguarding Practice Leads), is currently 100%.

4. The Local Context

4.1 What is it like growing up in East and North Hertfordshire?

The health and wellbeing of children in Hertfordshire is generally better than the England average (PHE 2018). However, Hertfordshire remains a county of contrasts – between rich and poor, rural and urban, tradition and innovation. Some of its strengths can also be a source of weakness, with the predominant affluence exacerbating problems of those living in poverty.

5 The level of child poverty, although significantly better than the England average, continues to demonstrate a higher percentage than the regional areas. Deprivation remains a key concern within Hertfordshire, with just under 25,000 children living in poverty (PHE, 2018). This is of particular significance for those residing in the most underprivileged lower-layer super output areas in Stevenage, Waltham Cross, Broxbourne and Letchworth, where challenges in relation to low incomes, long term unemployment, disability, crime and housing issues are evident. This is reflected in safeguarding themes current within the county, exhibited across the Contextual Safeguarding landscape.

Family homelessness is on the increase, with figures significantly higher than the regional average, and, due to further increases during 2017/18, now higher than the England average. In real terms, this equates to approximately 1000 families per year. Areas of particular concern include Broxbourne and Welwyn/Hatfield (PHE 2018; HCF 2017).

The number of reported Domestic Abuse incidents and drug related crime remain above the national average, predominantly in Stevenage, Broxbourne and Waltham Cross (HCF 2017). The most significant change to the Hertfordshire landscape, reflecting the national picture, is the continuing rise in knife crime, demonstrated by a 44% increase over the last 3 years, representing the highest level for 7 years. Domestic Abuse related knife crimes currently account for 20% of all Hertfordshire knife crime, with alcohol and drug related knife crime accounting for 15% and 5% respectively. High harm incidences have seen an increase of 60% and street robberies have increased by 116% across the county, particularly in the Cheshunt and Waltham Cross areas (Hertfordshire Police 2019).

Nationally, the rate of young people being admitted to hospital as a result of self-harm is increasing, and this is also the case in Hertfordshire. Although current rates are below the England average, they are higher than the regional average and 38% higher than the recorded England best. Nationally, levels of self-harm are higher among young women than young men and this is reflected within the county (PHE 2018).

6 4.2 The Safeguarding Landscape in Hertfordshire

4.2.1 Number of Children with a Child Protection Plan

Number of children subject to a Child Protection Plan 700 601 590 576 600 533 540 543 497 497 479 466 500 448 443 430 r

e 400 b m u

N 300

200

100

0 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Month

Number of children subject to CPP

Following an all-time low of numbers of children with a Child Protection Plan in November 2018, numbers have risen steadily month on month, with a documented total of 557 in March 2019. This is reportedly due to a rise in referrals from a number of agencies as well as an increase in escalation of those cases previously held as Children in Need. Themes and Trends and associated findings, related to the number increase, will be analysed through the HSCP Performance and Audit sub-group and reported to the HSCP Executive Partnership.

The majority of children with a Protection Plan are aged five to nine years (consistently around 35%). Under one year (including unborn babies) represent approximately 25% of the numbers; ages one to four and ten to fifteen demonstrate a steady figure of approximately 20%. Sixteen plus aged children may be under represented within the social care system, with a total of less than 1% currently with a Protection Plan.

Despite the rise in numbers of children with a Child Protection Plan, the county total remains significantly lower than the national average (18.6 per 10,000 as opposed to 45.3 and Statistical Neighbours 44.2). Hertfordshire is ranked 4th nationally, remaining in the top quartile. Anecdotal evidence would suggest that the reduction in numbers is, in part, due to the Family Safeguarding initiative, based on a motivational change model of care delivery, developed by Hertfordshire County Council in partnership with other local agencies including the ENHCCG as well as the successful Early Help Offer for those families demonstrating initial caring difficulties for their children.

7 70% of children with a Protection Plan are of white ethnicity, which reflects previous months’ figures and is a consistent finding when compared to preceding years.

4.2.2 Category of Abuse for those children with Protection Plan

Category of Abuse (by Percentage) (of Total Number of 557) as of March 2019

6% 4% Emotional Abuse 46%

Neglect 44% Physical Abuse

Sexual Abuse

Category representation in Hertfordshire has changed considerably in recent months, attributable to revised guidelines (specifically for Principal Officers) relating to classification of abuse indicators. For example, Domestic Abuse, is now, in the majority of cases, categorised under Emotional Abuse. In addition, historical information is closely scrutinised to enable capture of initial professional and/or familial concerns to inform abuse set, rather than tending towards overarching neglect issues arising from the assessment process.

4.2.4 Children in Need

The number of children in Hertfordshire with a Child in Need Plan (on average 1130 children April 2017 to December 2018) has continued to decrease in 2019 (1084, 1068 and 1054 in January, February and March 2019 respectively) and is significantly less than the national average. The reason for this is not wholly understood although it may reflect the growth of Children’s Services’ Early Help Service offer (Families First) and a transfer of those cases on threshold edge to the Family Safeguarding Service for higher level support, under the umbrella of a Child Protection Plan.

8 No. of Children with CIN Plan 1250 1195 1169 1177 1200 1166 1166 1156 1139 1150 1139 1123 1129 1150 1112 1113 1122 1112 1099 1103 1097 1088 1093 1100 1078 r

e 1050 b m

u 1000 N 950 900 850 800

Month

To ensure children remain safe, monitoring of Child in Need practice, from a multi-agency perspective, to ensure appropriate management oversight of cases, and adherence to protocol, will be the subject of an audit managed under the guise of the HSCP Performance and Audit Sub-Group, chaired by the CCG Designated Office.

4.2.5 Looked After Children

Number of Looked After Children in Hertfordshire April May June July Aug Sep Oct Nov Dec Jan Feb Mar 2018 2018 2018 2018 2018 2018 2018 2018 2018 2019 2019 2019 907 916 929 942 944 946 943 940 948 935 939 936

The number of Looked After Children in Hertfordshire saw a significant reduction during 2016/17 and remained consistently low throughout the reporting period of 2017/18. This financial year (2018/19) has seen a slight increase (approximately 5%) although numbers remain lower than the national average. Further information relating to Looked After Children may be seen in Section 9.

5. NHS Governance Arrangements for Safeguarding at E&N CCG

The CCG recognises its essential duty to determine that all statutory obligations as defined in the Accountability and Assurance Framework (NHSE 2015) and Working Together to Safeguard Children (2018) are in place across the health economy. This includes ensuring that all NHS commissioned services have Named Professionals for Safeguarding Children and Looked After Children in place with dedicated time to fulfil their roles and responsibilities as outlined in the Intercollegiate Document (RCN, 2019). Additionally, the CCG secures designated professional knowledge to enable

9 safeguarding direction and expertise advice across all parts of the commissioning cycle, from procurement to quality assurance.

The Director of Nursing and Quality is the CCG’s executive lead for safeguarding children and is responsible for ensuring that safeguarding is embedded within the entire health economy, monitored through the quality committee, Governing Body and the Hertfordshire Safeguarding Children Partnership (HSCP) (see Section 6.3.1 for further information).

6. Partnership Working

6.1 Accountability and Assurance

Regular attendance and involvement in strategic Safeguarding forums, meetings and committees provides assurance and clarifies accountability within the CCG. The Safeguarding Children Strategy (2018) identifies key safeguarding priorities . Designated professionals represent the CCG at the HSCP, Executive, Domestic Abuse Executive, Children Looked After commissioning meetings, the Corporate Parenting Board and the NHS England Safeguarding Forum.

6.2 NHS England Area Team

NHS England is the policy lead for safeguarding and has safeguarding responsibilities for directly commissioned services. The close working relationship between the CCG and NHS England has ensured that safeguarding remains a priority in Primary Care during the transitional period from co- commissioning to delegated responsibility, with consequent amendment to the CCG’s constitution. Support has been enhanced through the secondment and employment of four Named GPs and a Primary Care Safeguarding Nurse Specialist who ensure that safeguarding arrangements are maintained.

6.3 Hertfordshire Safeguarding Children Partnership (HSCP)

East and North Herts CCG is a committed partner to the HSCP, demonstrated by regular attendance and involvement of the Director of Nursing and Designated Professionals in board meetings, executive meetings, all HSCP sub-groups and development forums. The main NHS health providers have Director level representation on the HSCP board, with service leads/named professionals attending HSCP sub-groups. Through attendance at all HSCP events and sub-groups, oversight of provider contribution to safeguarding children is assured and partnership working is achieved to constantly improve the outcomes for children in East and North Hertfordshire.

6.3.1 New Arrangements as of February 2019

Following the government’s review of the roles and functions of Local Safeguarding Children Boards in 2016 and related recommendations, Hertfordshire was successful in securing funding to become an early adopter of the new arrangements, which went live on 1st February 2019. The HSCB will now be termed the Hertfordshire Safeguarding Children Partnership (HSCP), with ‘Health’ acting as an equal partner alongside the Local Authority and Police, with CCG representation at Executive Level. Key focus areas included development of an Independent Scrutiny process to enable development of

10 continuous improvement in the commissioning and delivery of protective services to children; continued work with education partner agencies to ensure they have strategic and operational input and development of a cohesive partnership to successfully address local practice challenges such as gangs, knife crime and county lines in Hertfordshire.

Transition to the new arrangements has been a substantial piece of work, involving revision of current sub-groups with applicable Terms of Reference, members and Chairs and development of new ‘Learning Hubs’, for progression of topical safeguarding training and discussion, utilising a feedback loop system between front line practitioners and the Strategic Partnership. The CCG will continue to attend newly revised HSCP sub-groups, with chairing responsibilities for 2 of the groups. Provider services will be represented from Executive Level to sub-groups.

The Serious Case Review (SCR) process has also undergone varying changes, in line with recommendations outlined in the Children and Social Work Act (2017). The SCR Panel is now termed the Child Safeguarding Practice Review Panel (CSPRP) and includes a move to a rapid response framework, requiring partners to provide information relating to the child in question within 5-10 days. Notification of each case, to the National Panel, is made by the Local Authority, within 15 working days of the event. All agency actions from the CSPRP will be now be monitored through the Practice, Policy and Procedure HSCP sub-group.

The Designated office has a central role in fulfilling the actions outlined in the current HSCP Business Plan. Safeguarding priorities for 2019/20 will include a focus on Neglect, Domestic Abuse, Contextual Safeguarding (Child Exploitation – Criminal and Sexual; Gangs, County Lines and Knife Crime), self- harming behaviour and suicide as well as understanding the impact of Hertfordshire’s changing demographics and culture. Work will progress via the HSCP’s five sub-groups, with an expectation that this financial year will see a number of deep dive and themed audits, driven by identified Hertfordshire Safeguarding themes.

6.3.2 New Arrangements for the Child Death Review Process in Hertfordshire

Although the Child Death Overview Panel (CDOP) function does not form part of the new HSCP arrangements, administrative support for the process remains under the guise of the HSCP and is therefore closely linked to all HSCP operation. The full Child Death Review process is overseen by the CCG Designated Office to ensure health provider processes in Hertfordshire, when responding to, investigating and reviewing the death of any child, from any cause, are in accordance with the newly published Child Death Review Statutory and Operational Guidance (2018) and Working Together to Safeguarding Children (2018) document. Current health practice and policy across the county has been examined and key features set out for adoption by all agencies (from the time of a child’s death to the completion of the review by the Child Death Overview Panel). An Action Tracker is in place to determine progress of practice implementation where gaps across the health economy exist.

With regards to the CDOP, a backlog of cases (for review) exists, which is being managed through extra meetings, additional administrative support and transfer to a contemporary electronic system (e-CDOP). It is expected that the backlog will be resolved by September 2019, in line with statutory regulation.

11 6.4 Safeguarding Children in Primary Care

Following a period of consultation, the Primary Care safeguarding team, consisting of 4 Named General Practitioners (GPs) and a Safeguarding Nurse Specialist, were transferred, in line with TUPE regulations, from NHS England to ENHCCG employment on 1st March 2019. The team work collaboratively to ensure that Safeguarding Children practices are robust and effective across all aspects of Primary Care.

6.4.1 Support for Primary Care

Primary Care support provided during the reporting period includes expert advice, training, specialised supervision as well as support with policy development and preparation for regulatory inspections. The Designated Doctor provides Peer Review support for the Named GPs on a quarterly basis, affording an opportunity to share knowledge, information and learning from cases as well as review of local and national guidance with a view to local application. Support for GP practice Safeguarding Children Leads remains a priority, equipping them with the skills and confidence to undertake their role. This is achieved through Practice visits, underpinned by the Safeguarding Children Audit Tool (RCGP, 2014); information updates, training opportunities and policy and procedure guidance. Further training appropriate for the Leads has been scheduled during the next reporting period, supported by the Designated Safeguarding Children team.

In addition, the team will endeavour to attend scheduled CCG Quality Assurance visits to ensure effective safeguarding children arrangements are in place and that any areas for improvement are identified promptly and specialist support is provided where required. The team’s involvement in these activities will additionally facilitate the identification of areas of good practice that may be shared with Primary Care colleagues across Hertfordshire.

Audit activity throughout the reporting year has identified areas of good practice along with areas for improvement within Primary Care. Learning and associated actions arising from an audit to examine the quality of information provided by Primary Care staff within safeguarding referral forms to the Hertfordshire Multi Agency Safeguarding Children Hub (MASH), with a focus on timely, pertinent, robust information sharing, adherence to due processes, identification of potential risks to the child and a ‘Think Family’ approach have contributed to the creation of a multi-agency electronic referral form, launched in May 2019. This will enhance information sharing processes between partner agencies within Hertfordshire and ‘revolutionise how professionals make contacts about children’ (Herts Children’s Services, 2019).

Following recommendations from a Hertfordshire Serious Case Review and subsequent audit, the Primary Care Team have continued to work closely with Maternity Services to improve information sharing processes with Primary Care. Enhanced templates and processes have underpinned early identification of women with known or potential vulnerabilities, in particular those who self-refer for Antenatal care, where failure to disclose safeguarding concerns may have previously introduced potential risks to the unborn baby. Further work is continuing to ensure the most effective, safe solutions to transferring sensitive information are implemented.

12 Planned audits within Primary Care for the year ahead include the review of Multi-Disciplinary Team Meeting arrangements to ensure that local and national Serious Case Review recommendations for good practice are observed and the required guidance and support to imbed these practices is provided.

6.4.2 Training for Primary Care Staff

A number of approaches have been considered to capture mandatory Safeguarding Children Training compliance figures within Primary Care. As of Q2 (2019/20), compliance figures will be incorporated within Primary Care Workforce Data quarterly returns to the CCG. This data will enable the CCG Designated Safeguarding Children team to identify Practices where focused specialised support and training may be required, thus ensuring that all GP Practices are compliant with national recommended training competencies outlined within The Intercollegiate Document (RCN, 2019).

Due to outstanding evaluation and subsequent high demand extensive face to face training sessions, including bespoke conferences to meet specific need and higher level training to supplement mandatory training, continue for Primary Care staff. The training provides GPs with crucial information to support their work, facilitating prompt identification, decision making and appropriate response to safeguarding concern.

Recent specialised safeguarding training was arranged in association with Hertfordshire Community Trust, providing Level 4 safeguarding children training relating to Fabricated Induced Illness (FII). A leading Child Psychiatrist from Great Ormond Street Hospital provided an expert overview of this challenging, rare form of child abuse in addition to the presentation of a local multi-agency FII pathway to support professionals in their work with children and families. It is planned that a Hertfordshire Multi-agency FII Pathway will be created, with the CCG Primary Care Safeguarding Team taking a leading role, in the year ahead.

7. Safeguarding Monitoring of Commissioned Services

The CCG is required to provide assurance that safeguarding children processes within all commissioned services meets national and local safeguarding standards. This is achieved using a variety of methods, as demonstrated below.

7.1 Contract Monitoring

The safeguarding elements of the provider contracts have been reviewed in this reporting period. Providers’ Safeguarding/Looked After Children (LAC) Dashboards, reflecting reporting requirements and any associated changes, are scrutinised on a quarterly basis as part of the quality schedule.

Dashboard metrics are formulated by the Designated Office, with certain core inclusions such as staff safeguarding training compliance and other metrics tailored to the particular provider service. Customised Dashboards may have specific metrics to monitor, for instance, safeguarding supervision of staff, safeguarding referrals made to children’s services and additional reporting information in

13 line with multi-agency response to management of current local safeguarding concern such as violent crime/knife crime.

7.2 Section 11 Annual Visit to Provider Services

Assurance that health provider safeguarding processes are in place and robustly monitored is gained through annual Section 11 visits, as outlined in the Working Together (2018) document. Compliance with key standards, as defined in the CCG Section 11 Audit Template, is assessed, with expectation of submission of appropriate evidence to verify and validate findings.

During the reporting period, Section 11 visits have been carried out with all main provider services ENHT, West Herts Hospital Trust (WHHT), Hertfordshire Community NHS Trust (HCT), Hertfordshire Urgent Care (HUC) and Hertfordshire Partnership Foundation Trust (HPfT). Support to colleagues within Public Health, to ensure a high quality Section 11 audit process for public health commissioned services including Sexual Health and the Change, Grow, Live Service have been provided.

Action plans, to reflect recommendations made during the visit to enhance safeguarding practice, are provided to the CCG with additional assurance for those areas where an increased need for oversight is necessary. The Designated office will monitor action plans to ensure full implementation, within a given timeframe. Further evaluation of recommended actions is assessed through Dip Sample Audit.

There have been no significant Safeguarding practice concerns identified at Section 11 visits during the reporting period. Concerns, in relation to Training and Supervision compliance with specific Providers have been determined through quarterly Dashboard reporting and monitored on a monthly basis where necessary to ensure appropriate resolution. Staff training compliance issues, within one particular Provider, is no longer of concern but will continue to be monitored closely. Safeguarding Supervision compliance within one provider service remains under scrutiny.

The Designated Office is represented at all Provider safeguarding committee meetings on a quarterly basis to provide support and challenge as required.

7.3 Quality Assurance Visits

The Designated Office has attended, alongside Nursing and Quality colleagues, a number of Quality Assurance Visits during the reporting period. This approach is of particular benefit within Primary Care to further enhance established support processes across Safeguarding Children and Adults. It affords collaborative leadership for safeguarding whilst ensuring proportionality and balance, with a Quality focus. In addition, it provides a mechanism, across all services, to ensure that learning from Serious Incidents, Serious Case Reviews and Domestic Homicide Reviews has been embedded in practice.

14 7.4 Monitoring of Non-NHS Provider Services

The Designated Office continues to provide advice to the Public Health Commissioning Team in relation to safeguarding practice and assurance for many services including Integrated Sexual Health, Smoking Cessation, Alcohol and Substance misuse and Supported Housing services. It is important that this relationship with Public Health continues to ensure safeguarding children remains an integral part of service provided.

8. Safeguarding Children Priorities for 2019/2020

The CCG Safeguarding Team priorities for 2019/20 reflect those of the Hertfordshire Safeguarding Children Partnership (as outlined in Section 6.3.1). Neglect clearly needs to remain as a priority for both the CCG and the HSCP. Although there has been progress to address identification, less is presently understood about prevention and very early intervention. The present Neglect Strategy for Hertfordshire is due for reconsideration, alongside an exploration of existing operational approaches, both successful and unsuccessful, to recognition and response of associated concerns.

Further Key Safeguarding Children Priorities for 2019/20 are listed below. Additional information relating to a selection of topical items including priority rationale, current concern position, with supporting evidence, may be seen in Appendix I.

• Domestic Abuse – this is a focus due to the overall increase in Domestic Abuse notifications in the reporting period (DAISU 2019), with the highest number of clustered incidents occurring in the Stevenage and Broxbourne area. • Child Exploitation (CE) – This encompasses Criminal and Sexual Exploitation and is a focus for the HSCP Strategic Safeguarding Adolescent sub-group. Extensive work is currently underway to enable identification systems for those children at risk. • County Lines, Gangs and Knife Crime. This has become a particular concern and multi-agency focus for Hertfordshire due to the rapid increase in county lines offending, associated gang affiliation and knife/gun crime. • Review of the ‘Front Door’ arrangements in Hertfordshire for referrals into Children Social care via the Customer Services Centre. This will include a review of the effectiveness and partnership arrangements across social care, exploring the child’s journey and pathways selected from initial referral through to assessment within the Multi-agency Safeguarding Hub, Targeted Youth Services, Joint Child Protection Investigation Team and Early Help Services. • Self-Harm and Suicide in Children - due to the increase in self-harm and suicide in children across the county and difficulties associated with recognition, management and reporting. • Safeguarding Supervision and Management Oversight Policy/Strategy implementation across the school network and realisation of recommended guidance through funding for Multi- agency Safeguarding Supervision training as well as operational support and advice regarding implementation.

15 • Progression of enhancement of the Emergency Care Data Set (ECDS) in ENHT to enable collection of statistical information relating to violent crime and contextual safeguarding issues escalating within Hertfordshire. • Development of the ‘Real Care Dolls’ research project, in collaboration with Maternity Services (West Herts) and Children’s Services. • Formulation of a Multi-agency Care Pathway for Fabricated Induced Illness. • Primary Care team attendance at relevant HSCP and Adult Board key meetings to ensure GP participation in development of local policies and procedures.

9. Looked After Children and Care Leavers

9.1 What is a Looked After Child?

In UK law, a Looked After Child (LAC) is a child who is accommodated by the Local Authority for more than 24 hours. Legally, this could be when they are subject to planned or emergency Care Orders, in a secure children’s home or youth offender institution, unaccompanied asylum seeking children or Looked After with their parents’ agreement. A child will stop being ‘Looked After’ when they are adopted, return home or reach the age of 18 years. Following publication of the Social Work Act in 2017, the Local Authority now has a responsibility to support those children leaving care until the age of 25.

9.2 Local Landscape

East and North Hertfordshire CCG is a responsible commissioner of health services for Looked After Children, regardless of whether the placement is in or out of the county. Providers East and North Hertfordshire NHS Trust (ENHT) and Hertfordshire Community Trust (HCT) undertake Initial Health Assessments (IHA) and Review Health Assessments (RHA) for Looked after Children.

• Family Safeguarding amongst other initiatives has led to a reduction in the numbers of children requiring entry to care. Numbers of Hertfordshire children in care is now at 936, a decrease of 84 since 2016. • Care Leavers (CL) are enabled through recent legislation to apply for additional support should it be required from the Local Authority. The age was extended from 21 to 25 years for CL and further information is available through the Local Offer website. • Unaccompanied Asylum Seeking Children numbers have increased from 59 in 2016 to 92 in 2019 which increases requirement for mental health and unmet physical health needs. • A National and Local agenda has driven the Child and Adolescent Mental Health Service (CAMHS) transformation to improve access to mental health services from Early Help to Tier 4. This includes Targeted services for LAC.

The number of Looked After Children in Hertfordshire has continued to decrease significantly since June 2016, opposing the national trend. Children placed out of county represent 32.5% of the total Looked After Children population, lower than the national average of 38% (HCC 2018b; DfE 2016).

16 9.2.1 Unaccompanied Asylum Seeking Children

Unaccompanied Asylum Seeking Children (UASC) health assessments are undertaken in line with statutory guidance. Their needs differ dependent on life experience prior to arrival in the UK. Psychological support is provided for those who are known to have suffered psychological trauma. Many have unmet physical health issues, gaps in immunisations, cultural knowledge deficit around sexual health and poor sleep hygiene due to life events, compounded by travelling long distances. Referrals are made to relevant services to meet their health needs and ‘sleep packs’ are now provided to every UASC. The LAC Health team within HCT, with social workers and police, have held a sexual health workshop to introduce UASC to UK cultural norms aiming to address deficits in knowledge around consent and sexual health. This was well evaluated by the young people.

9.2.2 Care Leavers

The majority of Care Leavers in Hertfordshire appear to no longer require support from Hertfordshire County Council. Those who are vulnerable often have mental health needs. In order to promote seamless care Hertfordshire’s Health and Social Care Services, including Commissioners of Services, work together to ensure that care leavers over the age of 18 years who are admitted to an Adult Mental Health Service Provision are discharged to community based services in a supportive and planned way, with an aim to expedite their recovery. A Joint Framework between Hertfordshire’s Services for Young People and Hertfordshire Partnership NHS Trust Adult Mental Health Services is in place to support the admission and discharge of young adults. This promotes timely sharing of information, risk assessment and a discharge pathway to meet the needs of the young adult.

Over the last year to eighteen months Hertfordshire Services have experienced unexpected deaths of Care Leavers. A pathway for conducting a multi-agency review when a Hertfordshire Care Leaver dies unexpectedly has been implemented and formalises previous practice. The pathway sits within the framework of the Safeguarding Children Partnership, regardless of whether the Care Leaver is aged under or over 18 years, and outlines how the process should be co-ordinated and learning disseminated.

Annual training is delivered to GPs across the County with the opportunity to cover topics related to LAC & CL. Each year a speaker presents on topic matter such as exploitation, modern day slavery, trafficking and mental health to continually promote the needs of Care Leavers.

A Personal Health Information Pack (PHIP) is provided to all young people (YP) on leaving care; this important document contains information about their health history. All young people are encouraged to have a copy of their PHIP, although some do not wish to receive the information. A copy of the PHIP is also provided to the GP where it is integrated into the young person’s records and is accessible thereafter at any time.

17 9.2.3 Health Assessments for Looked After Children in Hertfordshire

An Initial Health Assessment (IHA) is completed, within 28 days of a child coming into care, by a medical professional (GP or Consultant Paediatrician). Review Health Assessments are completed by Registered Nurses on a 6 monthly basis for those children aged 0 to 5 years and annually for children aged 5 years and above. The CCG has a comprehensive process in place to monitor the healthcare and quality of health assessments including audit, review of health plans, quarterly dashboard KPI’s and the presence of a Designated Nurse at operational meetings.

Compliance with the completion of ‘In County’ Health assessments meets the contractual target of 85% for IHAs and 90% for RHAs. Out of County Health assessments are not compliant with the set timescale of 6 months and 12 months. The LAC Health team monitor compliance through the use of a tracker and escalate assessments not completed to the Designated Nurse, Safeguarding Children. Further escalation by the CCG Director of Nursing to Regional level is used as required.

Further information in relation to Multi-agency oversight and integrated practice initiatives may be seen in Appendix II.

10. Looked After Children Key Achievements 2018/19

• Timeliness for completion of health assessments has continued to improve. A tracker is in place to monitor out of county assessments. • Joint training was undertaken to address needs of UASC. • Sleep packs were provided to all UASC. • A Health Needs Analysis of Hertfordshire Looked After Children has been commissioned. Initial results are available and a full report is awaited. • Audit completed of Special Education Needs and Disabilities cohort. • Evidence uploaded to NHSE Safeguarding Assurance Tool for LAC. • Designated Paediatricians contribute regularly to the Complex Case Panel. • Pathway designed and implemented to support review of Care Leaver death. • Joint framework in place to support admission and discharge of CL with mental health needs.

11. Looked After Children priorities for 2019/2020

• Following completion of the Health Needs Analysis, Designated Professionals will review the Looked After Children and Care Leavers dashboard to ensure it fully reflects the identification of health needs specific to Looked After Children and Care Leavers in Hertfordshire. • To finalise an updated Health of Looked After Children and Care Leavers Strategy following completion of the Health Needs Analysis. • To work in partnership with Hertfordshire Children’s Services to evidence the Care Leaver Health Offer following recommendations from the Children and Social Work Act (2017). • Audit to review the use of health passports. To include those placed in and out of county.

18 • Designated Professionals to continue to work with colleagues to address unwarranted variation through the Regional and National Looked After Children forums. • To develop a Health of Looked After Children and Care Leavers Multi-Agency Conference in Hertfordshire. • In partnership with Hertfordshire Children’s Services to complete a joint review of the multi- agency risk assessment panel and disseminate findings across the professional network.

12. Conclusion

This report has provided an overview of the work undertaken by the Safeguarding Children and Looked After Children Designated Team for East and North Hertfordshire Clinical Commissioning Group (CCG) during the financial year, 2018/19.

There continues to be significant transformation within safeguarding practices across the NHS and partner agencies, steered by legislative change and a collective aim to ensure that all safeguarding processes are effective. Further enhancement is expected during 2019/20, building on existing systems to support sustained improvement and service compliance in relation to safeguarding standards internally and externally. Future priority fulfilment will permit opportunities to develop stronger partnerships, with the aim of achieving positive outcomes for those who need safeguarding, and enhance the practice and work satisfaction of safeguarding colleagues.

19 13. Appendices

Appendix I – Safeguarding Children Priorities for 2019/20

Domestic Abuse

Domestic abuse remains high on the CCG’s agenda in line with Hertfordshire’s Domestic Abuse Strategy (2016-2019), which is overseen by the HSCP Practice, Policy and Procedure sub group. Evidence has indicated that Domestic Abuse is under reported in Hertfordshire with additional vulnerabilities increasing barriers for certain groups including, Black and Minority Ethnicity, those with a disability or those in same sex relationships (HCC 2015).

Due to a change in operational process in 2018, all Domestic Abuse incidents and associated notifications classed as Medium or High Risk (utilising a Hertfordshire formulated criteria) are assessed within the Multi-agency Safeguarding Hub (MASH), affording joint decision making within a Children’s Services, Police and Probation sphere of practice. Initial concern, highlighted by health service provider and CCG, regarding lack of notification to partner agencies for those notifications classified as Standard Risk, was discussed at length and risk assessed fully with the ultimate decision that a triage process within the Domestic Abuse Command allows swifter identification of risks to children that can be highlighted at source. Due to the change in process, there has been a reduction in numbers referred into the MASH of cases where threshold for safeguarding is not met. The Designated Office has been working closely with the DAISU to ensure that all cases where children are present are highlighted and referred. A process is in place for distribution of Medium and High Risk notifications, where children are present at the time of the incident, to schools and health visiting/school nursing service for assessment and appropriate follow up.

Numbers of notifications received per month fluctuate between 800 – 1000, with varying levels of risk and injury sustained. Alcohol is regularly seen as an aggravating factor (MASH report, 2019). Stevenage and South East Herts demonstrate the highest number of Domestic Abuse Incidents where children are present, which is of high importance to the CCG. Since the annual cost to health care is estimated at £28.5 million, full participation of all key provider services and stakeholders is necessary to ensure effective services, robust pathways and successful outcomes for victims of Domestic Abuse in East and North Hertfordshire.

A Domestic Homicide Review (DHR) sub-group is attended by a representative from the Designated Office to ensure that a consistent approach is in place for the operational management of a DHR, where children are involved, thus offering assurance that lessons learned support the commissioning of service improvement across Hertfordshire.

Child Exploitation

Sexual Exploitation

Child Sexual Exploitation (CSE) continues to be a priority area in Hertfordshire and a key multi- agency action plan, overseen by the HSCP, is in place and reviewed at the Strategic Safeguarding Adolescent sub group (SSAG). All healthcare providers in Hertfordshire have screening tools in place

20 and referral numbers for acute and community trusts are reported to the Designated Office on a quarterly basis.

Recent intelligence has demonstrated an increasing risk for exploitation by criminals involved in Class A drug supply and/or County Lines. Those young people at risk are frequently Looked After Children and young people who go missing from home, with many falling into both categories. CSE and criminal involvement appear to be move evident in Watford and Stevenage, although Stevenage represents a more acute and constant picture, highlighted, to some extent by the current focus on drug supply, gangs and county lines.

Police investigations have proven very challenging due to difficulties engaging the young people involved, many of whom have had previous involvement with Children’s Services. Due to the very evident “pockets” of CSE risk within the county, the CCG will continue to support recognition/response training and education in identified areas.

Information regarding young people at risk is shared at a multi-agency panel meeting, attended by the Designated Office. This enables both an operational and strategic approach to provider service care planning. Service offer to families, where sexual abuse has taken place or is suspected, is mainly within the Child and Adolescent Mental Health Service (HPfT) and includes Mentalisation Based Therapy, Dyadic Development Psychotherapy and Art Therapy. However, there is more to do to improve support to ensure a better coordinated approach for those who have suffered sexual abuse or are exhibiting sexually harmful behaviour.

Criminal Exploitation and County Lines

Within Hertfordshire, County Lines is seen as an established network between urban hubs and county locations into which drugs (primarily heroin, crack and cocaine) are supplied. Drug deals are completed utilising a branded mobile phone, which is established in the marketplace and promoted throughout the customer base. A relay system (another phone) is used to pass orders onto dealers in the rural marketplace. Those within the network exploit young or vulnerable persons to achieve storage and/or supply of drugs and to secure the use of dwellings (commonly referred to as cuckooing). The individuals exploited regularly travel between the urban hub and the county market to replenish stock and deliver cash. County lines networks/groups impose high levels of violence, including the prevalent use of knives to intimidate and control members of the group and associated victims (NCA 2017). County lines activity and associated violent crime is a real and present concern for Hertfordshire, linked to wider issues around safeguarding, sexual exploitation, domestic abuse, modern slavery and missing persons. Hertfordshire is now an export hub with numerous county lines, although the true scale of the activity is difficult to determine. Hertfordshire Constabulary’s Operation Mantis and dedicated gangs and county lines team aim to disrupt activity and support victims. There are currently in excess of 120 young people known to Hertfordshire Police who have links to county lines. Of those that reside in Hertfordshire, most originate from Stevenage, Welwyn Hatfield and Watford (County Community Safety Unit, 2018). Although the exploitation of children continues to be reported, the true scale of abuse remains an intelligence gap.

As discussed in the body of the report, knife crime in Hertfordshire has seen a 44% increase in the last three years. The number of hospital admissions for under 18s for knife injuries has increased in

21 2018-19, especially in East and North Herts. Statistical information and narrative is reported to the CCG on a quarterly basis. The Designated Office focus will ensure multi-sector collaboration to develop reliable data (knife reporting statistics) as well as supporting the development of a gang activity and gang-related serious youth violence Strategy through work within the Safeguarding Adolescent HSCB sub-group. A whole system approach is required incorporating prevention, early identification, intervention and enforcement. The CCG has had full involvement with the recent development of a needs analysis and will continue to support multi-agency partners during 2019/20 in the planned development of a related Protocol.

Mental Health, Wellbeing, Self-Harm and Suicide in Children

Nationally, the rate of young people being admitted to hospital as a result of self-harm is increasing, and this is also the case in Hertfordshire (PHE, 2018). Although the direct causation for self-harming behaviour is not fully understood, indications would suggest a number of contributing factors such as low self-esteem, bullying and substance misuse.

The rate for child inpatient admissions for mental health conditions at 79 per 100 000 is similar to the England average. The rate for admission due to self-harm is much lower than the England average (254 per 100 000 vs 406 per 100 000). Although the county generally performs better than the England average, there are some specific markers, in relation to emotional health and wellbeing to consider where the county demonstrates the converse. This includes percentage of Primary school children with social, emotional and mental health need.

In a recent Hertfordshire Public Health survey (2018) for parents, to determine areas of required support, 94% of parents reported a need for advice and guidance relating to mental health of their children, with the highest percentage for children aged 11 to 14 years.

Considerable work is currently being undertaken in Hertfordshire relating to the Mental Health and Wellbeing of children and young people, with a preventative and universal approach, aiming to target those at risk of developing poor mental health; providing early support mild symptoms and enhanced support for those awaiting or receiving input from the Child and Adolescent Mental Health Service (CAMHS). All work aligns with priorities of the CAMHS Transformation Plan for Hertfordshire. Key areas for development in 2019/20 include increasing mental health wellbeing work across Primary schools; increased advice and guidance for parents and improvement of communication between agencies, particularly CAMHS, Primary Care and Schools.

In addition, a Suicide Prevention Strategy (HCC 2017) underpins a Suicide Prevention Plan based on six priority action areas identified nationally.

The implementation of the Emergency Care Data Set (ECDS) in late 2018 should help provide an improved level of detail regarding admission of children and young people to Accident and Emergency departments with issues relating to mental health and wellbeing. The ECDS contains 108 data items including chief complaint, diagnosis, injury information and safeguarding concerns which are expected to afford better consistency in self-harm reporting. The Designated Office is supporting the introduction of the ECDS across the health economy to ensure accurate reporting figures are captured within the Quality Dashboards.

22 Real Care Babies

The Designated Office has secured funding from NHS England to progress a contemporary research project relating to ‘Real Care Babies’. The University of Hertfordshire have agreed to lead the development, in collaboration with a Maternity Unit within an Acute Trust (most probably WHHT).

Real Care Babies are dolls that act as an advanced simulator of a new-born baby with associated demands with wireless programming and reporting capabilities on 24/7 care offered by expectant parents. Actions such as rocking, feeding, head support, and gentle/rough handling are recorded utilising a sophisticated software package. Research indicates that the longer a baby remains within a stressful family environment the worse the developmental outcomes can be. Nevertheless, parents must be afforded opportunity to demonstrate change to enable adoption of a sustainable caring environment with an aim to fulfilling a permanent parental role. It is proposed that the Real Care Babies could provide additional information to Children’s Services and partner agencies, when completing a full pre-birth assessment of potential parenting capacity of expectant parents. The Real Care Babies would not be considered as a standalone assessment tool but as an additional parenting data resource.

Although there is multi-agency agreement in principle for commencement of this work, research project implementation planning is in its infancy and there is much to determine from a legal and ethical perspective prior to initiation.

23 Appendix II – Multi-agency Oversight of LAC and Care Leavers and Integrated Working Practices.

A number of meetings and forums provide assurance of the CCGs and Local Authority strategic responsibility for LAC and CL. Quality oversight is achieved through ‘Health of Looked After Children Leadership’ meeting, a forum for commissioning and provider partner agencies to share information in order to improve existing services and meet the identified needs of this vulnerable group of children. Dashboards encompassing information in relation to Looked After Children clearance rates, health review and CAMHS compliance are scrutinised and evaluated ensuring gaps in service provision are identified.

The Designated Team attend and contribute to the:

• Corporate Parenting Board • Children in Care Council (CHICC) • CLA & SGC Commissioning meeting • Life Long Links Steering Group

The Deputy Designated Nurse promotes the integration of Health through her work with young people to develop the ‘Be Healthy’ report. Contribution is also made by Health to the procurement of services and ensures health standards are included within the specifications as required. Support is offered to CHICC through promotion of health information and stalls at CHICC events, particularly around mental health and wellbeing services.

Audits are undertaken to measure the quality of IHA’s and RHA’s and SEND (Special Education Needs and Disability) action plans on a regular basis The Designated Doctor reviews every IHA and provides feedback to practitioners as necessary. In addition, the LAC Health Team (HCT) audits quality of RHA’s. The quality of health assessments and timely response to actions has improved significantly, as evidenced through a recent SEND audit.

The emotional health and well-being of children entering care is assessed through a Strengths and Difficulty Questionnaire (SDQ) completed by the child, foster carer and teacher. This provides enhanced information to assist professionals form a view about the emotional wellbeing of individual looked after children. Co-operation between health and social work teams has led to the sharing of SDQ scores with relevant LAC health professionals prior to completion of health assessments.

Data is collected to provide an overview of the health needs of LAC including numbers who access the smoking cessation service, chlamydia screening, those who are pregnant and those who have children. The numbers of LAC accessing the ‘STEP 2’ and PALMS (Positive behaviour, Autism, Learning Disability and Mental Health Service) service is monitored to enable commissioning decisions. PALMS work across the county providing a specialist multi-disciplinary approach to children and young people aged 0-19 who have a global learning disability and/or Autistic Spectrum Disorder and their families. PALMS clinicians comprise a ‘virtual team’ delivering a consistent service in a variety of community settings. STEP 2, provided by HCT, is an Early Intervention Child and Adolescent Mental Health Service for children and young people in Hertfordshire aged 0-19. Public Health collect health and social information on children through a schools survey, however this does not identify LAC within the cohort surveyed.

24 Integrated Working Practices

The transition to adult services, mental health difficulties and criminal/sexual exploitation all present a risk to Children and Young People (CYP). As CYP are best served when agencies work together to meet their needs, health organisations and Children’s Services have implemented a collaborative approach of multiagency panels to address this need. The Complex Case Panel, Transition to Adulthood Panel and Multi-Agency Panel meetings are attended by Paediatricians, CAMHs professionals, Social Workers, Police and the LAC Team Health professionals. All professionals work together to identify services that enable assessment of behavioural, emotional, mental health and complex needs. Risk management plans are regularly reviewed to enable provision of the right service at the right time for LAC and CL. Professionals

The Complex Case Panel is a multiagency forum to address complex needs of children and young people who are known to a number of agencies, where agencies have worked together and require additional expertise to achieve the right response for the young person. Clinicians and practitioners from different disciplines provide advice, guidance and medical/psychological expertise to strengthen risk management planning. The panel collaborate to simplify and improve services to children and young people and their families with complex social, educational and health needs where a multi-agency approach is used to progress plans where previously barriers existed. Clear criteria for referral and escalation processes are in place should it be required.

The Transition to Adulthood Panel (TAP) receives referrals for young people with additional needs who are due to transition from children’s services to adult services. Transitioning to adult services is in itself a significant culture change, from a position of decisions made with the young person (YP) to the YP taking responsibility for their care. A recent review demonstrates that the TAP has been effective in supporting children and young people in their transition to Adult services.

SEARCH consists of a multi-agency panel, who review CYP at risk of exploitation due to missing episodes, inability of carer(s) to protect them or involvement with gangs. Cases are presented and discussed with a multiagency risk management plan agreed, and recorded with date for the next review. The sharing of information enables key practitioners to respond, maintain safety and engage the young person in a meaningful way to protect them against the risk of harm or exploitation.

25 14. References

Channel Duty Guidance: Protecting vulnerable people from being drawn into terrorism Statutory guidance for Channel panel members and partners of local panels. (2015). H M Government.

Counter-Terrorism and Security Act. (2015). Norwich: The Stationery Office.

Domestic Abuse Investigation and Safeguarding Unit (DAISU) (2018). Domestic Abuse Conference.

Department for Education (2016). Children Looked After in England. Year ending 31 March 2016. Available at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/556331/SFR41_20 16_Text.pdf

Domestic Abuse Executive Board (2015) Domestic Abuse Joint Strategic Needs Analysis for Hertfordshire.

Hertfordshire Community Foundation (2017) Hertfordshire Community Needs Analysis. HCF.

Hertfordshire County Council (2017) Hertfordshire Suicide Prevention Strategy. HCC.

Hertfordshire Police (2019) Youth Gang Activity and Knife Crime and Problem Solving Conference. A Multi-Agency Vision.

HM Government (2019) Child Death Review. Statutory and Operational Guidelines (England). London: Cabinet Office.

HM Government (2018) Working together to safeguard children: a guide to interagency working to safeguard and promote the welfare of children, London: The Stationery Office.

HM Government (2017) Children and Social Work Act. London: The Stationery Office.

HM Government (2015) Serious Crime Act. London: The Stationery Office.

National Crime Agency (2017) County Lines Violence, Exploitation & Drug Supply.

NHS England (2015) Safeguarding Vulnerable People in the NHS – Accountability and Assurance Framework.

Public Health England (2018) Child Health Profiles. PHE.

Royal College of Nursing (2019) Safeguarding Children and Young People: roles and competencies for health care staff. Intercollegiate Document.

Safeguarding Children and Young People: The RCGP/NSPCC Safeguarding Children Toolkit for General Practice (2014). London: NSPCC.6

26 Agenda Item No: 15

Date of Meeting: 25th July 2019

Governing Body Meeting in Public

Paper Title: CFF 2018-19: Outcomes and Learning

Decision or Approval Discussion Information

Report author: Cathy Harris, Senior Contracts Manager Ozlem Cholak, Head of Primary Care and Community Contracts Report signed off by: Alan Pond, Chief Finance Officer

Executive Summary: • This report summarises the impact of the 2018-19 CFF • The context to CFF is summarised, as well as the financial impact of the scheme to date • The degree to which each area of the CFF was met across localities is summarised • The impact of each of the schemes is outlined • Lessons learnt are outlined, as well as proposed changes for 2019-20

Recommendations . To discuss and note the outcome of the 2018-19 CFF. to the members:

Conflicts of Interest GP Governing Body Members who are GP Partners will have a involved: financial interest, as the CFF is a source of income for their Practices.

Page | 1 Conflict of Interest Definitions

The following table describes the sub-classifications of interests:

Type Description Financial Interests This is where an individual may get direct financial benefits from the consequences of a commissioning decision. Non-Financial This is where an individual may obtain a non-financial professional benefit Professional Interests from the consequences of a commissioning decision, such as increasing their professional reputation or status or promoting their professional career. Non-Financial This is where an individual may benefit personally in ways which are not Personal Interests directly linked to their professional career and do not give rise to a direct financial benefit. Indirect Interests This is where an individual has a close association with an individual who has a financial interest, a non-financial professional interest or a non- financial personal interest in a commissioning decision.

Page | 2 1. Executive summary This report summarises the impact of the 2018-19 CFF for discussion and noting by the Governing Body members. A background context of the scheme is provided, as well as a financial impact of the scheme to date. It is noted that two elements are still due to be evaluated in Q3 2019-20, and have not been included. These are the Diabetes scheme and the Cancer Screening Uptake.

The report summarises the degree to which each area of the CFF was met across localities, as well as the impact of the schemes. Finally, some lessons learnt are outlined, as well as proposed changes for 2019-20.

2. Background

The Consolidated Funding Framework (CFF) is an investment into primary care and general practice. The CFF of 2018-2019 was the second year of a two year CFF scheme aimed at supporting primary care to focus proactively on patients who frequently use services, and who have a Long Term Condition and are complex and with multiple needs. The use of effective clinically led care plans was seen as a core building block of a proactive joined up approach to supporting these patients in the community. In addition, primary care focus on other core clinical areas such as diabetes and cancer were a key part of the CFF, supporting practices to increase the number of patients with diabetes who receive all 8 care processes, and to improve the early detection and screening for cancer. Ultimately, the large majority of the CFF’s stated aims and outcomes are about improving patient care, based on best practice and evidence.

For 2018-19, the CFF was simplified and split into 5 key sections, across clinical and non- clinical elements:

Non-clinical – (£2.50)

• Financial Balance (£1.50) • Engagement (£1)

Clinical Services – (£7.60) • Frailty and Care Management (£4.75) • Cancer (£1.75) • Planned Care (£1.10)

The CFF is a voluntary Locally Enhanced Service (LES) scheme. 2 Practices (Haileybury College and Sawbridgeworth) did not sign up for the CFF schemes in 2018-19.

Page | 3 3. Results

Overall, the CCG made available £4,635,802 for the below reviewed CFF schemes. As noted above, this does not include the Diabetes and Cancer elements that are to be assessed in Q3 2019-20. Of the available funds, the 6 localities were successful in achieving £4,019,236, i.e.: 87% of the available funding. The achievement per locality is demonstrated below:

£5,000,000 £4,500,000 £4,000,000 £3,500,000 £3,000,000 £2,500,000 £2,000,000 Overall CFF £1,500,000 Max earnings £1,000,000 £500,000 Overall CFF Actual earnt £0

The above is subject to appeal from Practices, as they review their final assessment of achievement. Spend per locality against each scheme is outlined below, as well as a summary of the aims and impact of each CFF scheme for 2018-19.

3.1 Financial Balance

Financial balance was assessed by locality, with overall locality spending to be no greater than the agreed budget for 2018-19, measured at the end of the year (31st March 2019). Achievement of financial balance 2018-19 is outlined below:

Locality Financial Balance Achieved? North Herts Yes Lower Lea Valley No Stevenage Yes Welwyn & Hatfield Yes Upper Lea Valley Yes Stort Valley & Villages Yes

Page | 4 £1,000,000 £900,000 £800,000 £700,000 £600,000 £500,000 £400,000 Financial balance - £1.50 £300,000 Max earnings £200,000 £100,000 Financial Balance - £1.50 Actual earnt £0

3.2 Engagement

The overall aim of the engagement scheme was to achieve fully engaged practices in delivering agreed service priorities for 2018-19. This was to be demonstrated through actions such as integrated locality working, for example: attending STP and CCG events; improving PPG engagement, and improving primary care workforce data to help with recruitment and retention. Achievement against these elements is demonstrated below.

£250,000.00

£200,000.00

£150,000.00

£100,000.00 Attendance at specified CCG events / meetings Max earnings £50,000.00 Attendance at specified CCG events/meetings £0.00 Actual earnt

Page | 5 £35,000

£30,000

£25,000

£20,000

£15,000 Q1 & 4 PPG reports - 5p £10,000 Max earnings £5,000 Q1 & 4 PPG reports - 5p Actual earnt £0

£35,000

£30,000

£25,000

£20,000

£15,000 5 x workforce returns 5p £10,000 Max earning £5,000 5 x workforce returns 5p Actual earnt £0

3.3 Frailty and Care Management

3.3.1 Care Planning

Following the work undertaken in 2017-18, Practices were asked to identify all patients believed to be at risk of admission if they do not have a managed care plan. Patients identified as ‘at risk’ were to have a care plan implemented as part of this. The aim of this

Page | 6 element was to reduce avoidable A&E admissions. Applicable funding was capped at practice list size at £3.25 per patient.

£2,500,000.00

£2,000,000.00

£1,500,000.00 £3.25 per patient (Total capped per practice) – Paid at £150 for £1,000,000.00 a new care plan and £50 care plan review Max earnings £500,000.00 £3.25 per patient (Total capped per practice) – Paid at £150 for £- a new care plan and £50 care plan review Actual earnt

Impact: Whilst targets were set as to the number of care plans to be implemented, there was no real progress as to the finalisation of a standardised content. Whilst the CCG intended to audit all Practices, in reality, this was not deemed feasible. As such, whilst a large number of care plans were put in place, there is no assurance as to the quality of the plans. There is also not the ability to ascertain with any certainty that a care plan has reduced A&E admissions, as a full patient’s journey has not been reviewed.

For 2019-20, the CCG has considered these shortcomings, and addressed them in the following ways:

- Provided detail for the required contents of a care plan - Provided support through templates and supply of the appropriate read-codes

3.3.2 End of Life (EoL – including GSF and PDA’s)

GSF – Gold Standards Framework

This element of the 2018-19 CFF required those who signed up to CFF to identify a Practice or neighbourhood GSF/MDT Co-ordinator, and host regular GSF/MDT Meetings for complex patients.

Page | 7 £160,000 £140,000 £120,000 £100,000 £80,000

£60,000 GSF 25p £40,000 max earnings £20,000 GSF 25p actual earnt £0

Impact: The CCG has seen an improvement in the % of patients who are coded as ‘on the GSF register.’ These patients are more likely to have been coded as EoL by the Practice and the CFF has encouraged them to identify which stage. This means, in an emergency, someone not directly involved in the patients care will be able to see on the summary care record that the patient is potentially in the last few days of life and make a decision to keep the patient in their preferred place rather than admitting to hospital. The data collected as part of the CFF for 2018-19 has allowed the CCG to set targets for Practices for 2019-20 to ensure that patients who are EoL receive as a minimum the core elements that will support them to have a good death.

Post Death Audits (PDAs)

This element of the CFF is a continuation from the previous years, and has helped the CCG to identify variation in practice across the CCG. The results of the PDAs are used to improve patient care and identify good areas of practice that can be shared. It also supports the CCG to identify where the EoL programme of work has had an impact.

• 4460 deaths occurred in 2017-18 and the Practices submitted 3412 PDA’s (76.5%) • 4042 deaths occurred in 2018-19 and the Practices submitted 3929 PDA’s (97.2%)

Page | 8 £70,000

£60,000

£50,000

£40,000

£30,000 PDAs completed 10p £20,000 Max earnings £10,000 PDAs completed 10p Actual earnt £0

Impact: All Practices achieved the PDA scheme, and data collected enables the CCG to identify any gaps in the system. For example, in requesting Practices to report on patients achieving their preferred place of death, the CCG can utilise this information to identify where there have been difficulties in achieving this. Improving patient care for those who are EoL ensures that some of the most vulnerable people are able to achieve a good death, regardless of where they are living or who provides care.

Practices have also been asked to provide their end of life registers. This has led to the identification of miscoding of patients by other providers. The CCG has been able to rectify this with the other providers, resulting in better coding, which will benefit the patient.

3.3.3 Catheter

Practices were requested to compile and maintain a catheter register, and use this to ensure that there is active management of each patient with a passport, and appropriate follow up and escalation plans in place through their care plan.

Page | 9 £140,000 £120,000 £100,000 £80,000 £60,000 £40,000 Catheter register 20p £20,000 Max earnings £0 Catheter register 20p Actual earnt

Impact: Practices achieved 100% compliance against this element of the CFF. It is believed that this process has thereby allowed General Practitioners to effectively manage a number of patients with catheters, thereby mitigating the risk of complications due to non-elective admissions for UTIs. Upon review for 2019-20, it has been agreed that the CCG will support the delivery of this element, by proactively identifying patients discharged with a catheter.

3.3.4 Mental Health

Practices were incentivised to ensure that care plans are in place and shared for all patients diagnosed with dementia, and that the plans are reviewed annually. Practices were also asked to deliver physical health checks for serious mental health (SMI) patients, and care plans.

Impact: The CCG expectation for this scheme was that Practices complete 50% of the CFF physical health checks for their eligible patients on the SMI register. In Q4, data received from Practices indicated that 17% of people on the SMI registers had received the full health check. This was a similar level of achievement to that of Herts Valley CCG Practices, who were not incentivised in 2018-19 to deliver this scheme. It is therefore noted that incentivising this scheme has not improved delivery. This scheme has been removed for 2019-20, and the Integrated Health and Care Commissioning Team are developing plans to meet the 60% target set by NHSE by Q4 2019-20.

3.4 Cancer

Lessons learnt in 2017-18 enabled changes to be made to the cancer CFF scheme. The associated income from this scheme was also increased in 2018-19, in recognition of the additional work required of Practices. However, it is still recognised that some of the metrics were considered vague, thereby making assessment of compliance difficult.

Page | 10 Practices were asked to undertake three elements, one of which will be assessed in Q3 2019-20:

- Promoting Early Presentation - Cancer Case Analysis - Improve Screening Uptake (Q3 Assessment)

Achievement against the Promoting Early Presentation and Cancer Case Analysis is outlined below:

£450,000 £400,000 £350,000 £300,000 £250,000 £200,000 £150,000 Cancer 70p Max earnings £100,000 £50,000 Cancer 70p Actual earnt £0

It is acknowledged that the audit required was cumbersome for many Practices, and it was unclear if the Practices felt any practical benefit from the collation of the information. For 2019-20, the CCG have used GP feedback to reduce the reporting burden, both in terms of what is audited, as well as automating the process through Ardens reports.

Impact: The results in terms of more people being screened are collected nationally and run 12 months behind the delivery at practice level so measuring impact will be in 2019-20. As regards the elements already assessed, it is felt that the CFF contributed to better outcomes for patients, but it is felt that with some work, the schemes will deliver more comprehensively in 2019-20.

3.5 Planned Care

3.5.1 Compliance with Pathways

The aim of this element was to ensure that all Practices comply with the requirements of pathways, including using the appropriate referral criteria, referral forms and appropriate tests before referral. This element also required that patients be offered options to allow

Page | 11 them to meet their goals with self-care and self-management, thereby improving patient outcomes.

£250,000

£200,000

£150,000 Knowledge of compliance with £100,000 Pathways (CCG Website or Ardens) 35p Max earnings £50,000 Knowledge of compliance with Pathways (CCG Website or £0 Ardens) 35p Actual earnt

Impact: Coding and pathways are two of the biggest elements that can impact upon patient care. As noted above, in regards to Diabetes, the CFF has helped to improve this. As illustrated above, all localities are compliant with this element of the CFF, thereby directly impacting upon the quality of care offered to the patients of East and North Hertfordshire.

3.5.2 Compliance with Prior Approval

The aim of the 2018-19 IFR/PA scheme was to monitor compliance of General Practice in seeking appropriate approval before onward referral. Whilst the CCG is able to monitor compliance, this has not been fully accurate. Issues in 2018-19 have included communications to GPs for the hip and knee pathway; confusion over MSK referrals, and patients who are already under acute care, so therefore the hospital application will not match the GP application. Given the issues outlined above, ENHCCG has adopted a lower percentage compliance of 50% for payment of the 18-19 CFF.

Page | 12 £250,000

£200,000

£150,000

£100,000 IFR 35p Max earnings £50,000 IFR 35p Actual earnt £0

Impact: monitoring of this scheme has informed the CCG of areas of non-compliance, and the PA/IFR team have focused efforts on particular localities/Practices as required, to support their understanding of the IFR/PA process. Lessons learnt from the 2018-19 scheme have informed the development of the 2019-20 scheme, such as amending the system this year to account for surgeon-to-surgeon referrals and making the system more robust so that the policy is applied equally.

3.5.3 Medicines Optimisation

4 key areas of prescribing were identified to reflect national and local policies and guidelines. Practices were asked to achieve the targets of reduction in these 4 key areas. 2 elements of the scheme were broadly achieved by the CCG, whilst 2 were not.

Page | 13 £300,000

£250,000

£200,000

£150,000

£100,000 Meds Optomisation Max earnt (40p) £50,000 Meds Optomisation Actual earnt (40p) £0

Impact: For the element related to selected Low Value Medicines (LVM), costs were down by £110K on those drugs covered by the CFF with a total saving on the LVM category of £262K.

- 50 practices had stopped all prescribing of co-proxamol by Quarter 4 (the biggest saving, very few practices actually used it so good practice was rewarded) - 27 had stopped prescribing omega-3 fish oils except for rare exceptional cases - 12 had stopped all prescribing of rubefacients, glucosamine, homeopathic & herbal preparations and lutein/antioxidants. - 8 practices achieved all three sections of this metric, two got zero.

This element required practices to have stopped all their prescribing by the end of Q3 so that Q4 would be zero. This type of criteria will be re-evaluated for future metrics because it is possible that a practice might issue a script late in the year that was not dispensed at the pharmacy and submitted for payment until January. The data would not pick this up. Overall, 4 practices had maximum achievement on the four CFF metrics, and one had zero.

4. Lessons Learnt and Actions for 2019-20

4.1 Clarity of Schemes

It is noted that a number of the schemes were vaguely worded, thereby leaving some ambiguity as to compliance/achievement by Practices. For 2019-20 the CFF schemes are more prescriptive in relation to the criteria required to necessitate achievement/compliance.

Equally, some of the 2018-19 schemes have identified ways in which to further improve and develop the care offered in Primary Care. Some of the ‘unintended’ outcomes of the CFF have also been reviewed and built upon for 2019-20. To avoid any ambiguity around the 2019-20 schemes, regular FAQ’s have been produced and issued to the Practices.

Page | 14 4.2 Changes in Administration (2018-2020)

The CFF moved from the CCG Localities team during 2018-19. The administration/monitoring of the 2018-19 schemes became the remit of the CCG Contracts team. The development of the 2019-20 schemes became the remit of the Programme Office, with support from the Contracts & Information team, who will undertake the ongoing monitoring of the schemes throughout 2019-20. Whilst the CFF scheme in its entirety had moved, some elements remained with other teams for review and assessment at year-end achievement.

The Contracts team have established a dedicated email address to support Practices communication with the team in 2019-20, and to receive submissions. Having undertaken the monitoring of the 2018-19 CFF scheme mid-year, the Contracts team will continually review the capacity required for the ongoing support and analysis of the 2019-20 schemes.

5. Recommendations

It is recommended that:

- The achievements of the 2018-19 CFF are discussed and noted - The changes to the administration of the 2019-20 CFF are noted - The planning process for any subsequent CFF begins earlier in the year - There is careful consideration of the capacity for monitoring and analysis for both compliance and impact of the CFF

Page | 15 Agenda Item No: 16

Date of Meeting: 25th July 2019

Governing Body Meeting in Public

Paper Title: Primary Care Commissioning Committee Minutes

Decision or Approval Discussion Information

Report author:

Report signed off by: Primary Care Commissioning Committee

Executive Summary: Approved minutes of the Primary Care Commissioning Committee attached for the Governing Body to note

Recommendations To note the minutes of the Primary Care Commissioning to the members: Committee:

• 2nd May 2019

Conflicts of Interest n/a involved:

Conflict of Interest Definitions

The following table describes the sub-classifications of interests:

Type Description Financial Interests This is where an individual may get direct financial benefits from the consequences of a commissioning decision. Non-Financial This is where an individual may obtain a non-financial professional benefit Professional Interests from the consequences of a commissioning decision, such as increasing their professional reputation or status or promoting their professional career. Non-Financial This is where an individual may benefit personally in ways which are not Personal Interests directly linked to their professional career and do not give rise to a direct financial benefit. Indirect Interests This is where an individual has a close association with an individual who has a financial interest, a non-financial professional interest or a non- financial personal interest in a commissioning decision.

Page | 1 Primary Care Commissioning Committee in Public Thursday 2nd May 2019: 09:00am – 11:00am Meeting Room 2, Focolare Centre, Welwyn Garden City

MINUTES Present: Tara Belcher [TB] GP Lead, North Herts Denise Boardman [DB] Director for Primary Care Development Fahim Chowdhury [FC] Independent GP Dianne Desmulie [DD] Lay Member for Co-Commissioning, Chair Beverley Flowers [BF] Chief Executive Alan Pond [AP] Chief Finance Officer Sheilagh Reavey [SR] Director of Nursing and Quality Ashish Shah [SH] GP Lead, Welwyn Hatfield Nabeil Shukur [NS] GP Lead, Stort Valley and Villages

In Attendance:

Ozlem Cholak [OC] Head of Primary Care and Community Contracts Holly Fairhurst [HF] Assistant Director of Contracts Sarah Feal [SF] Company Secretary Sue Fogden [SFo] Assistant Director – Premises Veronica Fraser [VF] Patient Representative James Gleed [JG] Associate Director of Commissioning Primary Care Karolyn Hallam [KH] Quality Lead – Primary Care Cathy Harris [CH] Senior Contracts Manager – Primary Care Nakiya Jafferji [NJ] Corporate Governance Manager John Light [JL] Project Manager, Seneca Advisory Limited Tracey Middleton [TM] Governing Body Clerk Michael Taylor [MT] Healthwatch, Hertfordshire Andrew Tarry [AT] Head of Primary Care Development Nicky Williams [NW] Bedfordshire and Hertfordshire Local Medical Committee Kelly Young [KY] Primary Care Quality Manager

Page 1 of 11 Item Subject Action by

1. WELCOME AND APOLOGIES FOR ABSENCE The meeting opened at:09.03 The Chair welcomed all to the meeting.

Apologies were received from:

• Linda Farrant [LF] Lay Member, Governance and Audit • Cath Slater [CS] Associate Director – Nursing and Quality • Peter Graves [PG] Bedfordshire and Hertfordshire Local Medical Committee

The Chair declared that the meeting is quorate

2. DECLARATIONS OF INTERESTS

The Chair invited the members to reconfirm their current declarations on the Register of Interests and advise of any new declarations.

All members confirmed their declarations were accurate and up- to-date.

The Chair invited members to declare any declarations relating to matters on the Agenda.

1. Item 6.2 - NHSE GPFV - CCG PCCC GPs are local practising GPs and therefore will have the opportunity to benefit from the GPFV funding available. 2. Item 7.1 7.1 - GP Practice eConsultation programme - HBLICT and all members of the procurement panel - the procurement is being run by HBLICT and all members of the procurement panel have signed Confidentiality and Conflict of Interest declarations 3. Item 7.2 - Primary Care Networks (PCN) – PCC GPs - CCG PCCC GPs are local practising GPs and therefore could be personally affected by the creation of new Primary care networks. The development of new networks requires the support of general practice as it demands new ways of working. The PCCC GPs will need to play a pivotal role in shaping new structures that will receive the necessary wider support from the CCG membership 4. 8 - Primary Care Quality Report - GP Committee

Page 2 of 11 Item Subject Action by representatives’ practices are members of Locality federations which are private companies which may provide CCG commissioned services

The Chair agreed that colleagues could remain in the meeting but not be involved in decision making where there is an actual conflict.

3. MINUTES OF PREVIOUS MEETING AND MATTERS ARISING

The Minutes of the meeting held on 21.03.19 were approved as an accurate record subject to the following amendments:

• Item 8.2 paragraph 4 – amended to an action point • Item 13.2 – ‘burden’ to be replaced with ‘workload’

ACTION: The final minutes of the meeting held on 21.03.19 to NJ be updated to reflect amendments.

4. ACTION TRACKER

The contents of the Action Tracker which was circulated in advance of the meeting were reviewed

The following actions were agreed to be closed:

• Action 37 • Action 38 • Action 40 • Action 42 • Action 43 • Action 44 • Action 45

The following updates were provided:

ACTION: Action 39 - An update on provision of cervical JG screening to be provided at the next meeting.

• Action 41 - 6.2 - GP Extended Access Service - Programme Update Primary Care Development are liaising with HUC to further understand impact on out of hours

Page 3 of 11 Item Subject Action by provision

ACTION: The Action Tracker to be updated to reflect the NJ updates.

5. HIGH LEVEL WORK PLAN 2019/20 : UPDATE

The Plan which was circulated in advance of the meeting was introduced by the Associate Director for Primary Care Development.

1. An overview of the issues, items archived and resource implications as detailed in the report was provided. 2. Progress against item 14 was acknowledged and a request for continuing work relating to performance not to be archived. JG ACTION: Item 14 to remain live

3. Item 18 – communication options were referred to and further activity is required including feedback information from this committee to Patient Participation Groups in lay terms. JG ACTION: Item 18 to remain live

The Committee noted the update.

6.1 FINANCE REPORT

The report which was circulated in advance of the meeting was presented by the Chief Finance Officer.

1. It was noted that the adjusted allocation as at Month 12 is £70.898m. 2. As at Month 12, Primary Care Devolved Commissioning budget reported an underspend of £237k against allocated budget. 3. Available uncommitted headroom as at Month 12 remains at £569K and contingency of £358k. 4. An update was provided on the various primary care allocations received to date. 5. Additional winter schemes will be run over the Easter periods.

Page 4 of 11 Item Subject Action by 6. After much discussion, assurance was provided that the £1m underspend will be appropriately allocated and early identification of spend is being encouraged and will be maintained.

The Committee noted the report.

PRIMARY CARE DELEGATED COMMISSIONING 2019-20 FINANCIAL PLAN

The report which was circulated in advance of the meeting was presented by the Chief Finance Officer (CFO).

1. The Committee noted that NHS England has published primary care allocation and planning assumptions for 2019-20. The Governing Body has approved the financial plan which is affordable and within the allocation notified to it. 2. The Committee considered the proposed budgets for Delegated Commissioning. The budget has modelled all the changes as published in the planning guidance. It has also allocated funding to local schemes as approved by the PCC board. 3. A detailed explanation was provided of the changes to clinical negligence arrangements in 2019/20 and the financial implications. 4. The APMS budget line is showing a reduction compared to the 2018/19 spend largely because transitional payments drop out and list sizes have reduced. 5. Enhanced services commissioned by CCGs across the new region are being compared to identify where there is inconsistency in paid service provision and/or prices paid. 6. Future new enhanced services will be considered in light of this work on regional comparison to ensure equity of funding across the CCG. Suggested services to be commissioned so far are ear syringing, treatment room and spirometry.

ACTION: List to be provided to the LMC regarding additional DB GP services that might be commissioned during 2019/20

7. A concern regarding extended access and extended hours and associated funding was debated and the future service specification is awaited.

Page 5 of 11 Item Subject Action by 8. The funding of £1.50 per patient to PCNs was to support their development and management. Practices would also receive Network Participation funding of £1.76 per patient. The new staff roles to be reimbursed under the PCN DES would support delivery of the 7 new service specifications. The introduction of PCNs and the corresponding financial arrangements represented a significant change to organisation structure and financial flows. The CFO recommended that during 2019/20 the CCG should review primary care funding e.g. the Consolidated Funding Framework to identify changes that might need to be made for engagement, financial balance and the clinical elements to ensure any overlap with PCN funding was considered to avoid excess payment for services.

ACTION: Review of potential funding flow changes to be undertaken and reported to PCCC for consideration AP

9. The Committee discussed the assumptions and risks.

The Committee approved the delegated commissioning budget for 2019-20, noted the identified risks and asked for a focused report on expenditure to be scheduled for September meeting so decisions could be made on releasing some of the headroom.

ACTION: A focused report on expenditure to be scheduled for AP September meeting

ACTION: Finance and Primary Care Development to scope AP/DB options paper regarding the uncommitted headroom for the Committee to discuss at September meeting

ACTION: PCN training development was debated and it was DB acknowledged and the national training programme is awaited. This will also inform any local offers including the potential for an STP wide offer

The Committee approved the delegated commissioning budget for 2019-20 and noted the identified risks

6.2 NHSE GPFV

The report which was circulated in advance of the meeting was introduced by the Director for Primary Care Development

Page 6 of 11 Item Subject Action by

1. The Committee noted the successful pilot by NHSE in 2018/19 with mid and South Essex STP/CCGs (in which a new methodology was adopted) has shown that taking an alternative approach to NHSE GPFV funding has the opportunity to deliver increased benefit across a local area. This approach enabled the STP and CCGs to decide collectively, how best to deploy the GPFV funding for four specific GPFV programmes. NHSE are now using this approach and rolling this out to all STPs/ICSs from 2019/20. 2. The paper outlined the approach detailing the funding and the respective programmes. It also outlined the decision the STP Primary Care Oversight Group chaired by the CCG’s Accountable Officer, made at their meeting on 17.04.19 on how best to meet this requirement during 2019/2020. 3. Confirmation was given that there is GP representation

The Committee ratified the approach the STP Primary Care Oversight Group is taking forward to meet NHSE requirements. The Committee supported the STP Primary Care Oversight Group in this endeavour. The Committee agreed to receive an update report over the coming months on the progress made regarding the proposed methodology to support expenditure from Quarter 3 & 4 of 2019/2020.

7.1 GP FORWARD VIEW GP PRACTICE eCONSULTATION PROGRAMME The report which was circulated in advance of the meeting was presented by the Project Manager from Seneca Advisory Limited

1. The Committee noted in the executive summary that following the release of national funding to explore and pilot the functionality of eConsultation tools, ENHCCG appointed Seneca Advisory Limited and HBLICT to perform a discovery and engagement programme across ENHCCG to recruit champion practices. NHS England established a framework of “approved digital eConsultation products” to ease the burden of procurement for CCGs. This is called the dynamic purchasing system, which allows an eConsultation product to be selected via a mini competition rather than a full procurement.

Page 7 of 11 Item Subject Action by 2. Following a structured engagement programme, 13 practices have self-selected to be a ‘champion practice’ or pilot site, with at least one practice participating from each locality. They collectively represent over 180,000 registered patients. Seneca Advisory performed a digital assessment with each of these champion practices to assess their needs. 3. A procurement panel has been formed and terms of reference agreed, the Associate Director Commissioning Primary Care is the SRO. There is representation on the panel from champion practices (GPs or Practice managers), patients and teams including Primary Care Development, Quality, Finance, Information Governance and Technical (IT). Appropriate governance with reference to conflicts of interest and confidentiality has been observed. The procurement documentation has been finalised and is due to be approved by the procurement panel and subject to this the procurement via mini- competition will be launched. 4. The selected product will be deployed within each Champion practice during June and July 2019. This will be fully supported by Seneca Advisory and HBLICT. 5. The eConsultation product will be evaluated monthly at each practice (by clinical staff, administration staff and patients). At the end of 3 months and six months an interim report will be produced and then a final report produced and presented to the CCG. The final phase of the project will be full rollout across the CCG with the benefit of learning from the pilot. 6. The Committee agreed that the GPs who are championing this programme are able to publicly endorse the initiative. Managing demand is challenging for the GPs which it is hoped that this programme will address. 7. Confirmation was given that the GMS contract refers to all practices delivering this by April 2020. 8. Confirmation was given that testing the hub model will be scoped during this pilot which will support the PCN approach.

The Committee noted the report JL left the meeting at 10.21 7.2 PRIMARY CARE NETWORKS

The report which was circulated in advance of the meeting was

Page 8 of 11 Item Subject Action by introduced by the Associate Director Commissioning Primary Care

1. The Committee noted that the details of the new Primary Care Network Direct Enhanced Service (DES) were published at the end of March 2019. 2. The national timetable remains unchanged requiring practices to sign and submit their completed Network Contract DES registration form to the CCG by 15 May 2019 (the CCG is still requesting that practices work to 8 May). 3. The PCN task & finish group met for the second time on 29 March 2019 and as requested by the Governing Body, the invitation for this meeting went to all Governing Body GPs. The group will continue to oversee, support and guide the planning work in each locality up until 1 July 2019. 4. A CCG PCN Registration Panel is being established, which will have delegated authority from the Primary Care Commissioning Committee (PCCC) to preside over network registration approval. Terms of reference have been drafted and meeting dates are currently being arranged. The dispute resolution procedure is being finalised, with the intention being to establish a process across the Hertfordshire and West Essex STP CCGs. This will bring consistency and independence to the proceedings (both draft documents can be found at Appendix 1 of the paper). 5. The latest position in each of the six localities summary: North Herts Exploring possibility of having 1 PCN otherwise will be 2 networks. Upper Lea Valley 3 PCNs confirmed, however configuration has not been finalised with regards to Buntingford and Puckeridge Medical Practice. Stort Valley and Villages 1 PCN confirmed. Stevenage 2 PCNs confirmed: Stevenage North and Stevenage South. Knebworth and Marymead Currently in North Herts Locality will be joining the Stevenage South PCN and the locality commissioning boundaries will be redrawn to move this practice into Stevenage Locality. Lower Lea Valley 1 PCN confirmed, however this will operate across multiple neighbourhoods consistent with existing working practices Welhat 3 PCNs confirmed. 6. Assurance was provided and the geography in particular

Page 9 of 11 Item Subject Action by relating to Ashwell was discussed

The Committee noted the report

ACTION: Circulate the updated Terms of Reference for the JG Primary Care Network Registration Panel

The Committee supported the proposed next steps and receive a further update on progress in due course

8. STP VISION AND FRAMEWORK UPDATE

A verbal update was provided by the Director For Primary Care Development.

ACTION: Update to be circulated to Governing Body GPs and DB localities

The Committee noted the update.

9. PRIMARY CARE QUALITY REPORT

The report which was circulated in advance of the meeting was introduced by the Primary Care Quality Manager

1. The Committee reviewed the latest information available for a number of quality indicators relating to GP Practices in ENHCCG, it highlighted the themes identified through the Care Quality Commission (CQC) visits that have already taken place at ENHCCG practices and outlined some of the actions taken to support practices to address these. 2. The Committee acknowledged the achievements of the work undertaken by the Primary Care Quality Manager.

ACTION: GP survey resource guide to be shared KY The Committee noted the current CQC updates. The Committee supported the course of action proposed for supporting the CQC rated ‘Inadequate’ and ‘Requires Improvement’ practices.

10. OVERVEW OF PRIMARY MEDICAL CARE CONTRACTS

Page 10 of 11 Item Subject Action by The report which was circulated in advance of the meeting was presented by the Senior Contracts Manager.

1. The Committee considered the list closures, mergers, APMS contracts and other contractual items for practices in East and North Hertfordshire.

The Committee noted the report.

11. ANNUAL CYCLE OF BUSINESS

The draft which was circulated in advance of the meeting was presented by the Chair.

1. The Committee discussed the content in particular the scheduling of Consolidated Funding Framework (CFF) progress and future proposals.

ACTION: It was agreed to move Extended Access from the NJ September to the July meeting and the Annual Cycle of Business to be updated accordingly.

The Committee approved the report.

12. QUESTIONS FROM THE MEMBERS OF THE PUBLIC

None

13. ANY OTHER BUSINESS

None

14. DATE OF NEXT MEETING:

Thursday 4th July 2019 9:00am-11:00am Focolare Centre, Welwyn Garden City (Meeting Room 2) The meeting closed at:10.39

Page 11 of 11 Agenda Item No: 17

Date of Meeting: 25th July 2019

Governing Body Meeting in Public

Paper Title: Locality Commissioning Committee Minutes

Decision or Approval Discussion Information

Report author:

Report signed off by: Locality Commissioning Committee Meetings

Executive Summary: Approved minutes of the Locality Commissioning Committee Meetings attached for the Governing Body to note Recommendations To note the approved minutes of the Locality Commissioning to the members: Committee Meetings:

• Lower Lea Valley – 27th March 2019, 3rd April 2019 • North Hertfordshire –21st March 2019, 15th May 2019 • Stevenage – 2nd April 2019, 14th May 2019 • Stort Valley and Villages – 25th April 2019, 23rd May 2019 • Upper Lea Valley – 16th January 2019 • Welwyn and Hatfield – 28th March 2019

Conflicts of Interest None identified. involved: Conflict of Interest Definitions The following table describes the sub-classifications of interests:

Type Description Financial Interests This is where an individual may get direct financial benefits from the consequences of a commissioning decision. Non-Financial This is where an individual may obtain a non-financial professional benefit Professional Interests from the consequences of a commissioning decision, such as increasing their professional reputation or status or promoting their professional career. Non-Financial This is where an individual may benefit personally in ways which are not Personal Interests directly linked to their professional career and do not give rise to a direct financial benefit. Indirect Interests This is where an individual has a close association with an individual who has a financial interest, a non-financial professional interest or a non- financial personal interest in a commissioning decision.

Page | 1

Lower Lea Valley, Locality Commissioning Committee Wednesday 27th March 2019 2.30pm – 3.30pm The Maples MINUTES

Present:

Denise Boardman – DB Director for Primary Care Development - ENHCCG Dr Alison Jackson – AJ GP, The Maples (Chair) Dr M Hossain – MH GP, Stanhope Surgery Dr Bill Neville - BN GP, Abbey Road Surgery Emma Ross – ER Nurse, The Maples Dr Aneela Sattar - AS GP, High Street Dr Rashid GP, Warden Lodge Dr Navina Sullivan - NS GP, Stockwell Lodge Medical Centre Dr Pauline Taylor - PT GP, Cuffley & Goffs Oak

In Attendance: Claire Arno – CA PM, The Maples Teresa Bird - TB PM, Cuffley & Goffs Oak Ann Freeman - AF The Maples PPG Adnan Choudhury - AC PM, Abbey Road Surgery Caroline Gillett - CG PM, Stockwell Lodge Faisal Ijaz – FI PM, Cromwell & Wormley Medical Centre Richard Moore - RM Acting CEO, Lea Valley Health Federation (LVH) Michelle Morrissey-Chisholm Locality Team Admin - ENHCCG Helen Moth – HM PM, Warden Lodge Gabriel Olumide - GO PM, High Street Surgery Helen Rouse - HR PPG, Stockwell Lodge Julie Sampson – JS Senior Pharmaceutical Advisor - ENHCCG Trisha Featley – TF LVH Engagement Officer Melissa Hudson HCT Project Officer Paul Brown Transformation Manager Serena NG HCT GMTS NHS Trainee Kirsty Watts Matron Cheshunt MIU Tracy Behr HCT Locality Manager Sean Dale-Malloy HPFT Lead Jackie Hollywell ACS Shita Shah Assistant PM, Abbey Road Dr Janice Vernazza GP, Cuffley & Goffs Oak Fiona Mcmillan-Shields HPFT Tony Wood PM, Stanhope Surgery

Page 1 of 4

Item Subject Action by

1. WELCOME AND APOLOGIES FOR ABSENCE The Chair welcomed all to the meeting and introduced Cathy Wybrow from the National Association of Primary Care (NAPC).

Apologies were received from the following:

 Deena Keefe

The Chair declared that the meeting is quorate.

1. DECLARATIONS OF INTERESTS The Chair invited the members to reconfirm their current declarations on the Register of Interests and advise of any new declarations.

All members confirmed their declarations were accurate and up-to-date.

The Chair invited members to declare any declarations relating to matters on the Agenda.

All members confirmed they have no declarations in relation to matters on the Agenda.

2. PRIMARY CARE NETWORKS (PCNs)

 A presentation was provided by DB, introducing PCNs and the expectation on localities. The rationale was discussed, and DB assured the group that as a locality LLV are already ahead of the changes as there are already two Primary Care Home areas within the locality.  The response to NHSE was discussed and the group were advised that the aim of PCNs is to provide extra investment to primary care and reduce the pressure practices are currently under by encouraging collaborative working. Whilst primary care needs extra investment, DB highlighted that this is not about merging unless the practices wish to further down the line.  The discussion turned to size and scale, with the group being advised that the PCN needs to feel local and not too big in order to not lose focus. The NHSE advice of a hard floor and a soft ceiling was discussed, highlighting that PCNs should not go below a population size of 30k, but there is much more flexibility above 50k as long as collaborative working can be shown. Geographical links between practices are much more important.  The group were informed that the DES specification is due to be released shortly and will require all practices to sign up. There

Page 2 of 4

Item Subject Action by

will be 3 areas included in the DES, as well as a network agreement and MOU. The network will need to decide their own governance.  A Clinical Director will need to be appointed for each PCN as an accountable leader, although this individual does not need to be a GP, and will be funded for 2 days a week. It was confirmed that this role will be crucial to the structure of PCNs, and more guidance is expected regarding this.  The distribution of funding was discussed, with the possibility of this flowing through either a lead practice or a federation, dependant on further guidance being provided.  The process for submissions and PCN registrations was discussed, with a subcommittee of the PCCC due to be worked up to look at registrations received and any dispute resolutions. It was confirmed that any practice that did not join a network will have their patient list assigned to one.  The group discussed the benefits of the locality continuing as one or two PCNs, and a formal vote was taken. Decision: LLV locality will proceed as one PCN.  The expected funding was further discussed, alongside the years for recruitment suggested by NHSE. Discussion turned to the current Clinical Pharmacist role held in the Locality by Chris, and possible alternative ways of funding this. It was agreed that the role was beneficial to the locality and funding should be found to ensure the post continued. Decision: Discussion to be had with HCT regarding the Clinical Pharmacist’s role and funding to ensure the post continues to be looked into.  AJ advised that Expressions of Interest for the Clinical Director role will be discussed during the next LCC due to be held on the 03.04.19. Formal applications of PCN formations are due to be made to the CCG on the 08.05.19. Further support required from NAPC to be decided.

3. ANY OTHER BUSINESS

 No update provided.

DATE OF NEXT MEETING: LCC 3rd April 19 Weds 1pm to 2pm Stockwell Lodge ICDB 22nd May 19 Weds 1pm to 3pm The Maples LCC 5TH June 19 Weds 1pm to 3pm Stockwell Lodge TARGET Event 19th June 19 Weds 12.30 to 6.30pm DeVere Theobalds Estate

Page 3 of 4 No. Meeting Date Item No. and Title Action Responsible Manager Deadline Current Position Status

To be presented at CCG Dementia Steering group on 4.Feedback from Dementia Evaluation to be done on Dementia Pilot, RM 22nd Jan 19, Liaising with Karen Malone at CCG. 17 03/10/2018 Provider Board to circulate results when available. RM 28/11/2018 06.02.19 - Still awaiting data from RM ONGOING 06.02.19 - it was advised that the CCG are due to give Transgender Prescribing – suggested adding this training guidance on whether or not practices can prescribe and 19 19/12/2018 3. Prescribing Update to a future TARGET event. DK 30/01/2019 to ensure practices feel secure. ONGOING

4. Feedback from the 23 19/12/2018 Provider Board DK to get HILS to present at target event DK 30/01/2019 ONGOING 06.02.19 - AJ described the new process for Dementia 4. Feedback from the referrals to Chase Farm, which should help reduce 24 19/12/2018 Provider Board AJ to circulate the Dementia referral template. AJ 30/01/2019 waiting times. ONGOING

Claire Arno to send all practices contact email details for 25 19/12/2018 5. LTC Feedback Dr Winacour. CA 30/01/2019 COMPLETED CLOSED

DK to liaise with Sam Williamson regarding the effect of COMPLETED - Sam Williamson confirmed read codes will 26 19/12/2018 5. LTC Feedback current coding and SNOMED issue. DK 30/01/2019 be transferred CLOSED

4. Feedback from the DK to share Denise Boardman’s slides regarding PCNs 30 06.02.19 Provider Board previously presented at Welhat Target with the locality DK 27/03/2019 Ongoing

4. Feedback from the DK to look into report that care home in Enfield is not 31 06.02.19 Provider Board covered by HUC. DK 27/03/2019 Ongoing

4. Feedback from the All to give examples of issues with ICT to AJ and 32 06.02.19 Provider Board Contracts Hotline. AJ to escalate. All/AJ 27/03/2019 Ongoing DK to share information and the format used in Respiratory Education Sessions at other locality 33 06.02.19 5. LTC Feedback meetings. DK 27/03/2019 Ongoing

34 06.02.19 5. LTC Feedback DK to share CCG message regarding spirometry training. DK 27/03/2019 Ongoing 6. PATIENT DK to flag financial and printing issues being PARTICIPANTION experienced by the PPG to the CCG to see whether 35 06.02.19 GROUP FEEDBACK support is available. DK 27/03/2019 Ongoing

8. END OF LIFE Mandy Whiteman contact details to be shared for any 36 06.02.19 DASHBOARD further queries. DK 27/03/2019 Ongoing

DK to confirm with Adnan Choudhury that Abbey Road 10. ANY OTHER admin staff will be able to do their own in-house 37 06.02.19 BUSINESS training and may not need to attend the TARGET event. DK 27/03/2019 Ongoing Page 4 of 4 11. DEMAND AUDIT RM to shared Demand Audit Results presentation with 38 06.02.19 RESULTS all. RM 27/03/2019 Completed CLOSED

Lower Lea Valley, Locality Commissioning Committee Wednesday 3rd April 2019 1pm – 2.30pm Stockwell Lodge Medical Centre, EN7 6HL

MINUTES

Present:

Denise Boardman - DB Director for Primary Care Development - ENHCCG Dr Alison Jackson - AJ GP, The Maples Dr Nikunj Malde - NM GP, Cromwell & Wormley Medical Centre Emma Ross – ER Nurse, The Maples Dr Aneela Sattar - AS GP, High Street Nicole Stanley – NSt Nurse, Warden Lodge Dr Navina Sullivan - NS GP, Stockwell Lodge Medical Centre Dr Pauline Taylor - PT GP, Cuffley & Goffs Oak Dr Mo Hossain GP, Stanhope Surgery Dr Catherine Orji GP, Warden Lodge Dr Rahman GP, Abbey Road Surgery

In Attendance: Claire Arno – CA PM, The Maples Teresa Bird - TB PM, Cuffley & Goffs Oak Caroline Gillett - CG PM, Stockwell Lodge Richard Moore - RM Acting CEO, Lea Valley Health Federation (LVH) Michelle Morrissey-Chisholm - MMC Locality Team Admin - ENHCCG Helen Moth – HM PM, Warden Lodge Helen Musson - HMu Herts LPC Gabriel Olumide - GO PM, High Street Surgery Helen Rouse - HR PPG, Stockwell Lodge Julie Sampson – JS Senior Pharmaceutical Advisor - ENHCCG Trisha Featley – TF LVH Engagement Officer Tony Wood - TW PM, Stanhope Surgery Gemma Cranfield - GC MSK

Page 1 of 8

Item Subject Action by

1. WELCOME AND APOLOGIES FOR ABSENCE The Chair welcomed all to the meeting. Apologies were received from the following:

 Deena Keefe  Verinder Bhoombla  Ann Freeman

The Chair declared that the meeting is quorate.

1. DECLARATIONS OF INTERESTS The Chair invited the members to reconfirm their current declarations on the Register of Interests and advise of any new declarations.

All members confirmed their declarations were accurate and up-to-date.

The Chair invited members to declare any declarations relating to matters on the Agenda.

All members confirmed they have no declarations in relation to matters on the Agenda.

2. MINUTES OF PREVIOUS MEETING AND MATTERS ARISING

The Minutes of the meeting held on 30th Jan and 6th Feb and 27th March 2019 were virtually approved as an accurate record.

2. ACTION TRACKER The contents of the Action Tracker were discussed.

The following updates were provided:

 Action 17 - Dementia evaluation – RM confirmed that a report is currently being written and will be circulated when available, at which point the action can be closed.  Action 19 - Transgender prescribing – AJ advised that guidance has been circulated which should provide clarity.  Action 23 – HILs – action is still ongoing.  Action 24 – Dementia referrals and CT scan requests – AJ confirmed that the CT Scans information to put on request forms will be circulated.  Discussion took place regarding this and AJ requested that on

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Item Subject Action by

referral GPs should order a CT scan and ensure that they put in the following details: History suggests dementia. Please comment on vascular loading and any hippocampal/ misial temporal lobe atrophy.  Action 32 – ICT – AJ confirmed that the action will remain ongoing as a reminder to practices to monitor any issues regarding the ICT hub, referrals and any patients not being appropriately managed.

3. MSK (Gemma Cranfield)

 The new referral structure was circulated to the group, and GC updated that there have been some minor changes, including the length of time for referral.  The current service being provided through Extended Access was discussed and it was confirmed that patients requiring simple treatment can be booked in immediately. Patients with co- morbidities or who are seeing another physio are not suitable for the Extended Access service.  It was confirmed that no other localities within the CCG have taken the service up yet, although it does seem to be working and is currently at 100% utilisation. AJ commented that she would like to look at building on the model to stop it from being as ad-hoc for patients and RM confirmed that he will be looking into this. The service is currently not receiving referrals from the MIU.

4. Prescribing Update – Julie Sampson

 The Prescribing update was shared with the group prior to the meeting.

5. OTC POLICY AND PRESCRIBING – HAY FEVER

 AJ explained that she would like information provided on each practice’s website signposting patients to where they can get help and advice for hay fever.  JS explained that a number of practices had reduced their number of hay fever prescriptions and a discussion took place regarding how this had been achieved. JS advised that information regarding the work Cuffley and Goffs Oak had completed around this had been circulated as best practice.  HMu encouraged the group to inform community pharmacy of this as well to aid with providing information to patients and screen as necessary.  TF advised that she is able to request information to be added to

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Item Subject Action by

all LLV practice’s website via Silicon FootFall and will liaise with CA regarding which information should be added.  It was agreed that there are certain groups of patients/indications that are not suitable for OTC hay fever medicine, examples of these may be under 12s, pregnant women/breastfeeding and those suffering from long term respiratory conditions. These should be reviewed by a HCP prior to decision to stop prescribing.

6. FEEDBACK FROM MEETINGS

Provider Board  AJ provided an update, informing the group that the Integrated Smoking Cessation Service is available to refer patients to, aiming mainly at the cohort of patient who are really difficult to find or very addicted.  The Shape Up service is also available in the area, with a course th starting locally on the 14 April 2019.  Diabetes was also discussed, with the NDPP criteria being confirmed as patients with HbA1c between 42-47. EMPOWER is also now available for newly diagnosed diabetics.

 It was confirmed that the Broxbourne Healthy Hub is still being

developed.

 A discussion took place regarding frailty and falls, which is also a part of the upcoming CFF. It was agreed that the locality will need to develop a plan regarding how best to deliver on this. It was suggested that this could be included in the next TARGET event.  ICT was also discussed, and AJ reminded practices to highlight any issues. Non-elective admissions for the locality are also being looked into to see whether they have increased since the change within the service. If a change is evident then information can be provided to the Governing Body for review to see whether resources could be re-allocated to the locality.

Governing Body

 No update was provided.

7. LTC FEEDBACK

 The LTC Key Messages table was discussed and the following points were highlighted:  EMPOWER is the new provider for type 2 diabetes education.  Regarding bowel cancer screening test kits there is now a number for patients to call to request a kit. It was suggested that

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Item Subject Action by

this information could be added to practice’s websites as there is a section for this online. Discussion moved on to FIT Testing and when this is due to start. CA advised that some useful guidance is being circulated regarding this, and AJ suggested that information should be added to the website when available. Action: DB to find out from the CCG when FIT Testing is due to start. DB Action: CA to circulate FIT Testing guidance. CA  A Task and Finish group for Spirometry Respiratory training has been set up in order to look at the requirements and whether funding could be made available. AJ suggested that this could possibly fit in with PCN working.  Regarding End of Life, DNACPR guidance has been written in relation to the Mental Capacity Act and will be circulated when available.  Dementia diagnosis rates have seen a decrease recently, practices are asked to look at coding to identify whether this is the reason. • RM updated on AF, advised that a programme is being worked on with the aim on going live in May 2019. JS asked for clarification on how the locality will ensure that the locality pathway was aligned to and consistent with the ENHCCG AF pathway currently being developed.  The ECG pathway is also being worked on.

8. PATIENT PARTICIPATION GROUP (Helen Rouse)

 Ann Freeman sent apologies. HR provided an update, advising that the Carers Café is still doing very well, with a special thanks being given to Tesco for providing free biscuits for each session.  A meeting has also taken place between the PPGs from High Street and Cromwell to try and establish better collaborative working and communication, with the aim of being more proactive between practices.  A representative from Park Run has been invited to attend the next PPG meeting on 14th May to discuss the sessions and to look at trying to establish a more local park run in the area.

9. FINANCE AND LIP

 Locality Information and Finance Packs have been circulated.  Verinder Bhoombla sent apologies; a narrative from Verinder was requested for each meeting if cannot attend in person.  The locality felt that there had been a lack of finance representation at previous meetings and requested a presence at upcoming meetings.

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Item Subject Action by

10. COMMUNITY PHARMACY UPDATE (Helen Musson)

 HMu provided an update, advising that the LMC are developing a shortage form, which should provide practices with more information when sent back and should therefore be more useful.  Blood pressure checks were reported to still be ongoing.  HMu advised that community pharmacy would be interested in being a part of the PCN work which is happening in the locality. AJ agreed and provided a brief update on the progess with PCNs so far, advising that community pharmacy will need to fit into the structure. Discussion took place regarding Clinical Pharmacists and the need to develop a pharmacist network to ensure effective working.  RM commented that it would be useful to develop a link between the British Heart Foundation Hypertension project and AF. RM and HMu to discuss.

11. ANY OTHER BUSINESS

 PCNs – AJ advised that funding is available to get PCNs up and running, and is available as backfill for meetings. This money is currently being held by the federation and can be invoiced for. Next steps involve developing priorities, governance processes st and identifying a Clinical Director prior to the 1 July 2019. Discussion turned to the process of identifying a Clinical Director and AJ expressed an interest in becoming the Clinical Director for the PCN, advising that she would like to step down as CCG

GP Lead to focus on the role if appointed.

Decision: AJ to become Clinical Director for the PCN with no objections.

Discussion then moved on to the subsequent vacancy for two GP

Leads for the locality. Navina Sullivan and Mo Hossain both expressed an interest in the role and AJ advised that the letter regarding the roles should be circulated shortly. Conversation returned to PCN development and AJ suggested that two meetings are set up, before and after the next TARGET event scheduled for the 19th June 2019, dates to be circulated once agreed.  Home Visits Audits – AJ advised that there are plans to look at joining up HUC and HCT to create a new visiting service single point of access in order to use the service more effectively. An audit will need to take place to work out the required capacity for the service; two practice’s data is still required. The criteria for each practice was confirmed as being 1 per 6,000 patients currently.  Research Cluster Contract – RM advised that the federation are exploring the possibility of setting up a contract with a company which coordinates research across the region. Information to be taken back to each practice for a decision, deadline for return is

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Item Subject Action by

18th April 2019. Discussion moved on to Discover Me, a project circulated by RM previously, for which the deadline for decision is due Friday 5th April, practices to let RM know.  Federation AGM – RM advised that the AGM is due to take place on the 16th May from 12.30pm.  PCN Event – Feedback was provided from the recent event, highlighting that the emergence of federations is very important for the PCN work. RM confirmed that the federation is happy to coordinate the PCN funding.  Federation Visits – practices queried whether RM and the federation could be more visible in practices. RM agreed to attend practice meetings and provide updates.  Stockwell Lodge – NS informed the group that they have achieved the Purple Star award, Maples confirmed that they are also pursuing the award.  MIU Update – RM confirmed that the new MIU contract is up and running and achieving targets. He expressed thanks to practices for their help regarding prescribing issues experienced and advised that the issues should be resolved shortly. The service referral criteria was confirmed as being the same as previously, with the service being available 8am to 8pm, 7 days a week, with the quiet period being from 6pm onwards on weekdays. The service is also able to prescribe.

DATE OF NEXT MEETING:

ICDB 22nd May 19 Weds 1pm to 3pm The Maples LCC 5TH June 19 Weds 1pm to 3pm Stockwell Lodge TARGET Event 19th June 19 Weds 12.30 to 6.30pm DeVere Theobalds Estate

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No. Meeting Date Item No. and Title Action Responsible Manager Deadline Current Position Status

To be presented to the CCG in March, then share with 4.Feedback from Dementia Evaluation to be done on Dementia Pilot, RM the locality. 17 03/10/2018 Provider Board to circulate results when available. RM 28/11/2018 03.04.19 - report to be circulated shortly ONGOING 06.02.19 - it was advised that the CCG are due to give guidance on whether or not practices can prescribe and to ensure practices feel secure. 03.04.19 - AJ advised that guidance has been circulated Transgender Prescribing – suggested adding this training which should provide clarity - CCG clarification email 19 19/12/2018 3. Prescribing Update to a future TARGET event. DK 30/01/2019 sent on 02.04.19 ONGOING

4. Feedback from the All to give examples of issues with ICT to AJ and 32 06.02.19 Provider Board Contracts Hotline. AJ to escalate. All/AJ 27/03/2019 ONGOING

DB to find out from the CCG when FIT Testing is due to 39 03.04.19 7. LTC Feedback start. DB 22/05/2019 ONGOING

40 03.04.19 7. LTC Feedback CA to circulate FIT Testing guidance. CA 22/05/2019 ONGOING

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North Herts Locality Meeting Weds 21.3.2018 from 12.30 – 2.30 Letchworth Centre for Healthy Living

MINUTES Present: Dr Simon Chatfield (SC) Locality Lead (Chair) Dr Tara Belcher (TB) GP Dr Matt Jarvis (MJ) GP Mark Pilling (MP) Practice Manager Dr Richard Stanley (RS) GP Michael Sissens (MS) Practice Manager Dr Rob Graham (RG) GP Zoe Smith (ZS) Practice Manager Dr Keith Greenish (KG) GP Denise Robson (DR) Practice Manager Dr Adrian Wood (AW) GP Anne Hegarty (AH) Practice Manager Dr Rob Newby (RNe) GP Ken Spooner (KS) Practice Manager Dr Mel Lacy (ML) GP Gill Wilcox (GW) Practice Manager Dr Jeremy Cox (JC) GP David Roberts (DR) Practice Manager Melanie Felgate (MF) Practice Manager Dr Victoria Fraser (VF) GP Hayley Marshall (HM) Practice Manager Dr Adrian Richardson (AR) GP Sandie Ince (SI) Practice Manager Dr Rajpreet Millan (RM) GP Amy Elliott (AE) Practice Manager Jennifer Piggott (JP) Patient Rep Alan Pond (AP) Finance Director Saskia Vercaeren (SV) Prescribing Advisor Sue Russell (SR) Prescribing Lead Victoria Robinson (VR) Locality Manager Phil O’Meara (POM) Finance Team Leader

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Item Subject Action by

1. WELCOME AND APOLOGIES FOR ABSENCE

The Chair welcomed all to the meeting. Apologies were received from:

 Victoria Robinson  Dr Denise Robson  Anne Hegarty  Dr David Roberts  Phil O’Meara  Saskia Vercaeren  Sue Russell

The Chair declared that the meeting is quorate.

2. DECLARATIONS OF INTERESTS

The Chair invited the members to reconfirm their current declarations on the Register of Interests and advise of any new declarations or any declarations relating to matters on the Agenda..

All members confirmed their declarations were accurate and up-to-date and they have no declarations in relation to matters on the Agenda.

3. MINUTES OF PREVIOUS MEETING AND MATTERS ARISING

The Minutes of the meeting held on 21st February 2018 were approved as an accurate record.

SC informed the Locality the reason behind the late arrival of the minutes and apologised for the admin. A discussion followed around the communication between the Practice and the CCG. AP stated to the Locality that the papers need to be sent out within a week of the meeting.

ACTION: AP to discuss with HB the timeline of the preparation of the AP minutes.

Significant issues had been raised at the end of the last meeting but were not incorporated into the last set of minutes this would be raised with VR. RN will provide these corrections to SC to be incorporated into the minutes.

SC said it was clear we could not process the content of the minutes usefully in this meeting and asked the Locality to share any concerns they may have outside of the meeting.

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4. ACTION TRACKER The contents of the Action Tracker were discussed. Completed actions were closed.

5. Provider Board Update (SC)

 The DRAFT TOR is a work in progress to be used across Localities

 ICDB attendees includes representatives from HCT, Care Homes Association, Mental Health teams and representatives from the PPG. No representation from secondary care providers which seems to be a continuing wider problem.

 Provider Board is still evolving and still not complete and different in each Locality. Not at a stage where all of the processes are being shared with the Locality. The Locality is being asked for their views and what they want.

 North Herts HCT currently has 5 staff; the 2 WTE leaving have been replaced. There are gaps which are related to staff leaving. The posts are all filled but there is turnover. HCT are 92% across the whole provision including admin and nurses

(64.7 of 70 funded WTEs). Aiming to recruit over 105%.

 Equalisation funding will be spread out due to North Herts having a

higher population but due to understaffing within HCT. We should not notice a change to the level of service. Expectation of 69 full time equivalents in the next.financial year. The Frailty index data was calculated on the national demographics of the local population in North Herts. There is recognition there is a North Herts burden of frailty and currently that suggests in the funding we have 22% of that burden in the Locality, recognised in the funding formula. 2 new care home nurses being employed to assist us - not exactly sure how that's going to work yet

 Knebworth and Marymead – Moving from the current share pot of North Herts would get more funding. Calculations were done using the population as a whole and the substance of that; the Knebworth practice is actually served by the Stevenage Locality. If their service is going to be provided out of Stevenage team, that 2.5% would need to be put into Stevenage.

 North Herts Home First Team was first set up to have dialogue being Home First in Stevenage that went on in HCT Home First teams. It is not suitable to get them to come from Hitchin to go to Stevenage. The Locality needs to accept what they are given and will feed this

back and let HCT provide the service.

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 1st July is new community frailty service launch date.

 HCT also want to deal with an issue being spread out across the localities and would prefer one centralised hub. Some Localities are in support of this, but others not. Conversations are being held about what the Locality want and will have a say in how they could deliver the service.

 Invite HCT and Liz Kendrick to a Locality meeting VR

 Re-visit purple forms and their use in the Locality

 Warfarin administration; is this is a district nurse function to make sure the patient takes the medicine. SC to investigate SC

 A single point of access for new referrals to HCT will be implemented st as from 1 July. More than one IPA/HCT form can be used and they accept either.

 Practices should be set up to constantly read urgent request emails

 The Early Intervention Vehicle is the home first replacement hosted by NHS England. There are 2 vehicles that operate out of West Herts Hitchin, triggered by 999 calls. There will be 4 across the CCG.

 Feedback being considered around HUC, AIHVS, out-of-hours

service and Rapid Response, and the delivery of the service and the

changes to make them more flexible and more patient-centred.

 Community Frailty on the agenda for the next Target Day. SC will speak to VR. SC

 Suggestion to hold Provider Board on a different day to the Locality Meeting. SC to speak to the TB prior to 1st July. SC/TB

6. CFF

VR will be providing an update on the CFF metrics.

MS asked about e-referrals and whether these are in the metrics for this year and the issue around the fact that the data is only being measured if the patient attends. This was in the metric for last year.

SC said there is something in the GMS contract for next year.

ACTION: VR to provide CFF Metrics Update VR

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7. Any other business

Dementia – Membership feedback around SC dementia tasks email? ALL

Physiotherapy - Higher numbers than anticipated going through the MSK triage service creating long delays. If practices want someone to go to a physiotherapist please email [email protected] this has been the process since 1.12.2017, if you do that 70% of your patients will be seen within 8 weeks and 90% percent within 12 weeks. New clarification communications are being sent from the CCG. Complex patients will need to see a specialist which will go to the MSK triage service through e-referrals

service. Both physio and phlebotomy are possibly going to be pulled from

central contract and could be provided by federation.

Phlebotomy – long delays on this service; SC is going to approach HB as this is still an issue. Concerns also raised re the Contracts Hotline. Still no improvement the trust around the issues with Lorenzo.

Extended access – last update received from Dee Boardman still in discussions with the Federation. Request update from DB. SC

Clinical pharmacists – Can currently only be employed by somebody who holds a GMS contract; if we can find a GMS contact holding employer within the locality or outside the locality who is prepared to take these people on then the funding exists. The next closing date is the 13th April; also the deadline for the next round of submissions.

Ambulatory Care – Have practices experienced any problems with ambulatory care for DVT and cellulitis.

Patients are being told by GP’s to go straight to A&E. SC: query whether they can produce an up to date list of what you should SC send where and how.

It was suggested that writing a letter with DVT and Ambulatory Care clearly headed will work.

GDPR – CCG will offer GDPR to Practices by the employment of a Data Protection Officer which will be independent of senior management.

ACTION: SC Phlebotomy - SC is going to approach HB as this is still an issue.

8-8 working - The new extended hours -no appetite for locality to take it on the previous extended hours scheme will remain at least until 1.4.2019

Diabetes - It appears that in 10 of 12 local practices -our diabetics have had no diabetic eye screening at all. Is it a coding issue?

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Frequency of locality meetings - CCG board want 2 large meetings a year with representative from every practice in whole CCG -56 practices. we all felt they were a complete waste of time and said to reconsider.

Has the CCG board agreed ambulances downgrading response times for patients actually in GP premises - they have not and will look into it.

There is a shortage of community palliative care nurse -leading to poor service for patients (and more work for practices)

In-house cancer review meetings - who at CCG is looking at our feedback -as mostly we're highlighting 2ry care issues and that needs to be actioned

DATE OF NEXT MEETING:

16th May 2018 Letchworth Centre for Healthy Living 12.30-2.30

ACTION TRACKER Person Date Progress responsible AP to discuss with HB – Timeline for minutes to be AP 25th April 18 In Progress distributed

Invite Liz Kendrick to the next Locality Meeting VR 25th April 18 In Progress

Community Frailty on the next TARGET agenda VR 25th April 18 Frailty Nurses on agenda. Speakers arranged

Suggestion of ICDB on different day of the week SC/TB 25th April 18 In Progress

Feedback to SC around dementia tasks email All 25th April 18 In Progress

VR to provide an update on the CFF Metrics VR 25th April 18 In Progress

SC to chase Extended Access update from Denise SC 25th April 18 In Progress Boardman

SC to query A&E list of guidance for sending patients SC 25th April 18 In Progress where and how

SC to feedback ongoing issues around Phlebotomy to SC 25th April 18 In Progress HB

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North Herts Locality Locality Committee Commissioning Meeting Wednesday 15th May 2019 Letchworth Centre for Healthy Living Letchworth

MINUTES Present: Name Job Title Dr Tara Belcher GP Portmill Surgery

Dr Matthew Calcasola GP Portmill Surgery

Dr Simon Chatfield Locality Lead (Chair)

Dr Alka Chandrayan GP Bancroft Medical Centre Dr Victoria Fraser GP Regal Chambers

Dr Agnieszka GP Sollershott Rzadzinska-Prosser Dr Rob Graham GP Birchwood Surgery

Dr Matt Jarvis GP Ashwell Surgery Dr Mel Lacy GP Nevells Road Surgery Dr Nick Nosina GP Whitwell Surgery

Alan Pond Finance Director E&N Herts CCG

Dr Richard Stanley GP The Baldock Surgery

Dr Adrian Wood GP Garden City Surgery

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In Attendance: Name Job Title Melanie Felgate Practice Manager Portmill Surgery

Helen Hemmingfield Team Administrator ENHCCG

Jackie Mead Practice Manager Sollershott

Anthony Deitsch Locality Manager E&N Herts CCG

Hayley Marshall Practice Manager Regal Chambers

Phil O’Meara Senior Finance Manager ENHCCG

Mark Pilling Practice Manager Ashwell Surgery

David Roberts Practice Manager Bancroft Medical Centre

Michael Sissens Practice Manager The Baldock Surgery

Claire Brown Practice Manager Whitwell Surgery

David Monn Practice Manager Nevells Road Surgery

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Item Subject Action by

1. WELCOME AND APOLOGIES FOR ABSENCE

The Chair welcomed all to the meeting. Apologies were received from:

 Sue Russell  Gerry Moir

TB asked TD to find out about EPaCCS (Electronic Systems to help improve patient care).

Dr Purandhar Nosina and Dr Adrian Wood declared they are now Clinical Directors of PCNs, HH to speak to the Governance Team.

TD reminded the locality that all paperwork has been uploaded onto the GP website this was sent out in an email with a web link. However the locality also asked for an email to be sent out with attachments.

The Chair declared that the meeting is quorate.

2. DECLARATIONS OF INTERESTS

The Chair invited the members to reconfirm their current declarations on the Register of Interests and to advise of any new declarations.

All members confirmed their declarations were accurate and up-to-date.

The Chair invited members to declare any conflicts of interest in relation to matters on the Agenda.

All members, and those in attendance, confirmed they had no conflicts of interests in relation to matters on the Agenda.

3. MINUTES OF PREVIOUS MEETING AND MATTERS ARISING

The Minutes of the meeting held on 6th March 2019 were virtually approved as an accurate record.

Any other business was discussed at the end of the meeting about shared urgent eye clinic at Lister Hospital, ICE, gastroenterology and PSA monitoring.

SC was asked to raise a concern about there being no nurse representation at locality meetings, SC promised to share this with the locality.

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Item Subject Action by 3. UPDATED LIP  Month 10 update of the locality information pack was displayed, a SD financial figure error was raised and AP confirmed this.  This information pack has been reformatted.  Month 12 financial data was also shared this is a much more complex spreadsheet.  Whilst month 10 shows overspend, month 12 position has changed and North Herts has achieved financial balance with a small underspend.  Acute services and prescribing showed a good result all round.  The locality needs to reduce the curve of increasing spending around Frailty and how we use the Frailty Teams to prevent unplanned admissions.  PCNs will require new data and new groupings.  In the commentary part of the locality pack if anyone has any feedback about whether they find this section useful or not. Please inform TD and he will feed back to Penny Cresswell Clinical Fellow from the CCG.  Discussions were held around emergency admissions for the locality; TB said it would be helpful to have this data broken down into disease areas to show where the higher outliers are. The focus of this will change from month to month.  Discussions held around whether the data could show planned referrals by speciality, this would also be useful.  TD has been out to help out with training for the locality with Mede Analytics.  SC suggested that PCNs should be asking for network level of information around delivering data in new groupings.

4. PCNs (Primary Care Networks)

 TB circulated thoughts about networks and the proposed meeting structure of the PCNs. This discussion is about what the locality does from July 1st 2019.  Discussions around whether to merge the locality commissioning meeting and Integrated Care Delivery Board (ICDB), it was suggested to invite 12 Point Care to these meetings.  TD reported that the Transformation Managers at a recent ENH Operational Delivery Group (ODG) meeting were concerned about having time to attend more meetings if they do split the provider board meetings.  In the interim it was suggested to have separate meetings for PCNs and not to make the decision now.  The next North Herts Locality Commissioning Meeting is scheduled on Wednesday 10th July and the structure was discussed.  Discussions were also held around management of Clinical Pharmacists and whether they needed a support admin person.  Richard Moore the Business Manager in Lower Lea Valley is happy to share his Job Description and business plan.

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Item Subject Action by  SC asked if the individual networks could come back to provide the way going forward at the next Locality Committee Commissioning Meeting (LCC).  David Brewer Head of Engagement at the Lister Hospital is proposing in coming to the next North Herts ICDB meeting and is very keen to get involved, he attends the Stevenage meetings also.  A question was raised does the locality need a joint meeting with LMC Law, Andrew Tarry Head of Primary Care Development from ENHCCG is looking into this. Please email Andrew Tarry with any queries on this work stream.

5. CLINICAL PHARMACISTS  TB sent out a financial working document about Clinical Pharmacists, with Knebworth and Marymead leaving the locality the amount has been reduced to £35,000.  Discussions were held about costings in year one, two and three with NHS England subsidiary and how many sessions per year each practice would have to contribute.  Across the locality there will be one pharmacist for each PCN in the first year this is not pro-rata. This is also broken down into how many sessions each practice could have across the locality.

 Discussions were also held around treatment room LES and

services outside of the GMS core services.

 SC asked the locality for a decision about the pharmacists and sharing of services. A decision will be made at the next locality meeting.  Salaries and ongoing costs were requested from 12 PointCare.

ACTION: 12 PointCare to provide salary and ongoing costs for Clinical Pharmacists.

6. DISCRETIONARY FUNDS  Discretion around £104,000 from £1 patient money.  55p per patient money from last to this year for collaborative working not spent has been rolled over.  Earnest Gardiner Treatment Centre is already set up.  Discussions around admin support post for clinical pharmacists.  Option to remove ear micro suction and training and workforce development off the budget.  PCNs will have admin support from £1.50 patient money  TB to rewrite the spreadsheet and send out.

7. REVIEW ICDB – CFF 55P

A discussion took place and there were no defined outcomes.

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Item Subject Action by

8. NURSE REPRESENTATION AT LOCALITY MEETINGS SC reported at the recent TARGET meeting at the breakout session there was a strong sense from our Nurses that they feel a little left out and are not being involved in discussions, particularly about workforce plans in the practice. Maybe nurses do not feel they have a voice to be heard and possibly a Nurse Tutor could look into this.

SC said he would report this back to the locality and the action was to discuss whether we should have a nurse representation in these meetings.

SC suggested putting this on the agenda at the next meeting in June if there is no consensus of opinions then the locality can take a vote on this.

TB suggestion was that nurses are invited to attend the delivery board meetings where there is funding for this in the management budget. As this is where we they are deciding on services and would have a view on where practice nurses can work together. Or perhaps the locality needs a paramedic to attend.

Or instead of having two GPs attending could we have one GP and one Nurse or Practice Manager attending as opposed to having 2 GPs and how could we fund this.

The locality agreed with the above proposal.

ACTION: TB asked TD to look into whether the locality can use the management fund.

9. AOB Urgent eye clinic issues at Lister – capacity issues At the Lister Eye clinic over the past several month’s capacity issues to see patients has been happening. Patients are being turned away irrelevant to the complaint and being told to come back the following day. TD is going to raise this concern with Sharn Elton Director of Operations at the ENHCCG.

In the interim please raise any cases to the contract hotline on [email protected]

Shared care agreements and DMARD monitoring by Gastroenterology Department Lister for IBD patients

There have been an increasing number of inflammatory bowel disease patients being prescribed with DMARDs with the assumption they are being monitored by Primary Care.

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Item Subject Action by Until a member of the practice has signed the shared care agreement no shared care agreement exists, all prescribing leads have been reminded of this recently.

If you sign one you are signing on behalf of the whole practice. This is a practice decision. Addenbrooks Hospital have a separate issue. The CCG have no control over them because they are distant with a small amount of patients.

A shared care officer is being recruited into the pharmacy team to which all shared care agreements will be sent out to the practices. Any individual cases must be reported to the contract hotline.

VF raised a concern about PSA monitoring, a conference call has been arranged with Kishen Morarji a clinical fellow from the CCG and Dr Mark Andrews, if anyone has anything they need to raise please let VK know.

Another issue was raised about Moorfields Hospital who have requested that patients with retinol melanoma be monitored with annual liver ultrasounds.

An issue was also raised around ICE which could be a cached problem and this should be escalated to the Trust.

Printing problems at Portmill Surgery.

DATE OF NEXT MEETING LCC 10th July 2019 12.30 – 2.30 Letchworth Centre for Healthy Living

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Stevenage ICDB and Locality Commissioning Committee Tuesday 2nd April 2019 1.30pm – 2.30pm Cromwell Hotel, High Street, Stevenage SG1 3AZ

MINUTES Present: Name Job Title Dr Keith Aubin [KA] GP, Stanmore Medical Group Dr Sola Osindero [SO] GP, Chells Way Surgery DR S Kota [SK] GP, Bedwell Medical Centre Dr Richard Paramour [RP] GP, King George Surgery Sheilagh Reavey [SR] Director of Nursing & Quality ENHCCG Dr Rini Saha [RS] GP, King George Surgery, (CCG GP Lead) Karen Smith [KS] Nurse, Manor House Dr M Duggan [MD] GP, Manor House Dr Russell Hall [RH] GP, Chells Way Surgery (CCG Corporate GP Lead) (Chair) Dr Kathryn McManus [KMc] GP, Knebworth and Marymead Dr K Kaminski [KK] GP, Stanmore Medical Group Dr P Raveendran [PR] GP, Bedwell Medical Centre

LCC In Attendance: Sunday Adeniyi [SA] ENHCCG Finance Lead Mark Banks [MB] Federation Manager/ ICDB Chair Mary Bishop [MPB] PM, Stanmore Medical Group Elaine Cook [EC] PM, Bedwell Medical Centre Sandra Copping [SC] PM, Manor House Maxine Davis [MD] Senior Pharmaceutical Advisor ENHCCG Amy Elliott [AE] PM, King George Surgery Susan Lincoln [SL] PM, Stanmore Medical Group Fiona Lucas [FL] PM, Symonds Green Michelle Morrissey-Chisholm [MMC] Locality Team Admin, ENHCCG Michelle Myers [MM] PM, Chells Way Ken Spooner [KSp] PM, Knebworth and Marymead Anthony Deitsch [AD] Locality Manager, ENHCCG Chirag Shah ENHCCG Gill Benveniste [GB] ENHCCG

ICDB In Attendance: David Brewer ENHT – Lister Spencer Langham Respiratory Nurse Specialist Matt Partridge Stevenage Borough Council Julie Phipps HPFT Yasha Rai HCT Community Locality Manager

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Item Subject Action by

1. WELCOME AND APOLOGIES FOR ABSENCE

The Chair welcomed all to the meeting. Knebworth and Marymead surgery were officially welcomed to the locality and Ken Spooner, Practice Manager and Dr MacManus were introduced.

Apologies were received from:

 Dr Cormack  Manjit Phugura  Deena Keefe

The Chair declared that the meeting is quorate.

2. DECLARATIONS OF INTERESTS

The Chair invited the members to reconfirm their current declarations on the Register of Interests and advise of any new declarations.

All members confirmed their declarations were accurate and up-to-date.

The Chair invited members to declare any declarations relating to matters on the Agenda.

All members confirmed they have no declarations in relation to matters on the Agenda.

3. INTEGRATED CARE DELIVERY BOARD (ICDB)

 See separate notes

Action: Discussion took place regarding the Canterbury Way Mental Health service and confusion regarding the pathway. Practices were All asked to feedback any comments or issues to localities mailbox. Further clarity will be sought regarding what the service provides and will be fed back to the group.

5. MINUTES OF PREVIOUS MEETING

 The Minutes of the meeting held on 5th March 2019 were approved virtually as an accurate record.

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Item Subject Action by

6. ACTION TRACKER AND MATTERS ARISING

The Action Tracker from the meeting held on 5th March 2019 was approved virtually as an accurate record.

MATTERS ARISING

PCNs Update – RS updated, advising that the locality are ahead in terms of development. There has been no formal submission deadline provided by the CCG as of yet, and localities have been advised that all proposals will need to be signed off together in order to ensure all practices are included in a network. Funding was discussed and the group were advised that funding for backfill to attend PCN meetings is currently being held by the federation, except for Knebworth, whose funding is being held by Portmill Surgery. Practices can now invoice for this funding.

7. CARE HOME MODEL DEVELOPMENT AND LES (Gill Benveniste)

 A presentation was provided, outlining the delivery of the care home LES and explaining that it has previously proven tricky for practices. GB advised that she is currently looking for feedback and comments from practices regarding the LES to aid with its development as it has changed significantly since it was first introduced in 2014.  Figure were provided regarding the number of care home beds in each locality and it was confirmed that these will need updating following the changes within the locality and the additional of

Knebworth and Marymead.  GB queried whether any comments or learnings from the Care Home Ward Rounds project run by the locality could be shared and advised that feedback from the North Herts Frailty Nurses project would be circulated as soon as available.

8. HOME VISITS AUDIT

 RH asked practices to read through the letter which had been circulated, informing the group that there are plans to look at joining up HUC and HCT to create a new visiting service single point of access. Practices were asked to complete an audit to help with progress.

9. EXTENSION OF WINTER RESILIENCE FUNDING TO COVER EASTER

 RH advised that funding has been extended until the end of April

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Item Subject Action by 2019. KSp queried the process for Knebworth and Marymead and were asked to link with TD.

10. CARE HOME WARD ROUNDS 19/20 - £1PP FUNDS (Sue Lincoln)

 SL updated that these were due to finish at the end of March 2019 before being extended until the end of April 2019. There was a discussion regarding PCNs and how this would affect the Care Home Ward Rounds proceeding and it was suggested that the Ward Round should continue until the 1st July 2019 as a locality, after which point each PCN will need to decide how to proceed. Decision: All agreed that Care Home Ward Rounds will continue as previously agreed for the locality until the 1st July 2019, at which point further discussion will be needed within each PCN regarding how to proceed. Funding was approved by the locality from the £1pp funds.

11. UPDATES

FINANCE & LOCALITY INFORMATION PACK (Sunday Adeniyi)

 SA gave a finance update on the current locality position, advising that the locality’s overspend had increased from £466k last month to £1m in line with an increase in activity.  All details discussed were referenced from the Month 10 finance report narrative, below is some of the high level detail:  Locality Acute spend remains above budget and this is mainly due to Non-Elective admissions and Elective admissions  Non Elective activity have increased by 7.9% compared to last year and compared to plan the spend has increased by 17% suggesting an increase in average cost due to casemix changes.  Main area contributing to overspend within non-elective are Pneumonia, UTI and septicaemia. The meeting noted there is an issue in the way activity is being coded within the main acute trust as sometimes the information on the discharge summary does not tally with the coding.  Elective Admissions for the locality have increased by 9.5% compared to the same period last year. This is more than the growth of 5.4% across the whole CCG.  Main area contributing to overspend within elective are Osteoarthritis (mainly hip replacements).  Cataracts is also another area with increased activity within elective along with gastrointestinal disorders and breast cancer  SA encouraged the group to look into possible projects to reduce non-elective admission activity.  SA advised that as it stands the locality will not gain financial balance, however encouraged the group not to give up yet due to

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Item Subject Action by the application of the contingency which is due to be shared across the localities.

MENTAL HEALTH (Keith Aubin)

 KA provided an update following the previous meeting held a few weeks ago, advising that dementia and CAMHS were the main topics discussed.  KA advised that new NICE guidance states that dementia can be diagnosed by a GPwSI, however CCG guidance regarding this and further changes to the pathway has not been circulated yet, and practices were encouraged to wait for this before making any changes.  In regards to CAMHS, data regarding the number of referrals received last year was provided, outlining an average of 750 referrals per month. The service is aware that they are currently under-performing, but advised that they are very under-staffed compared to national guidance, with some teams having 40% vacancies. Currently only 46% of referrals are seen within the target, with an upward trend in referrals being identified.  It was reported that CAHMS will accept referral for 17 year olds sent to adult services. KA advised that a list of alternative resources has been provided and SR reported that the providers have been asked develop ways of stopping children from getting to the point of crisis, with the focus being mainly on prevention.  KA also reminded practice to ensure LD health checks are completed and claims are sent in.

12. VIRTUAL REPORTS

 Prescribing and LTC reports were shared with locality before the meeting.  KS queried the use and prescription of warfarin following an issue experienced recently with a particular patient. RH advised that the practice should have a conversation with the Trust regarding this before prescribing.

13. PATIENT PARTICIPATION GROUP UPDATE (Ken Moore)

 No update provided. KM sent apologies.

14. EXTENDED ACCESS UPDATE (Mark Banks)

 MB updated, advising that service utilisation during March was 84%, with Manor House and Stanmore using the most

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Item Subject Action by appointments. MB encouraged practices to ensure weekday appointments are filled and reported that on the day appointments are mainly utilised, with HUC booking 100% of their available allocation. It was confirmed that Knebworth and Marymead is due to join the service from the 1st July subject to CCG approval.  There was a discussion regarding how ANP usage can be increased and MB advised that these appointments are mostly used, although the majority of appointments are scheduled on-the- day. Practices were encouraged to get receptionists to signpost patients to ANPs where possible.  It was confirmed that ANP appointments are available to book 7 days in advance, or 48 hours advance for GPs, with some availability on day.

FLU UPDATE (Mark Banks)

 MB confirmed that practices are due funding for letters sent to patients. MB due to circulate information shortly in order to enable practices to invoice. Each invoice to include evidence that letters have been sent.

15. UPDATED FROM GOVERNING BODY (Russell Hall)

 RH updated, informing the group that the 3 CCGs combined meetings are becoming more frequent.  Regarding the Home Visit Audits, a meeting with HUC and HCT has taken place to discuss possible changes and the possibility of developing a unified visiting service. AiHVS is currently being under-utilised.  Progress in regards to Transgender was also discussed, with guidance being finalised and due to be circulated shortly. The expectation on GPs was discussed, as well as how providers will need to provide evidence proving they are certified.

16. ANY OTHER URGENT BUSINESS

 No update was provided.

DATE OF NEXT MEETING

ICDB/LCC 14th May 2019 12:30 to 14:30 Cromwell Hotel, High Street, Stevenage TARGET 16th May 2019 12.00 to 18.30 Stevenage Football Club, The Lamex Stadium ICDB/LCC 11th June 2019 12:30 to 14:30 Cromwell Hotel, High Street, Stevenage TARGET 2nd July 2019 12.00 to 18.30 Stevenage Football Club, The Lamex Stadium

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83 12.02.19 AOB DK and EC to liaise regarding possible Spirometry speaker at TARGET. EC/DK Ongoing MP to produce a template and share with locality to capture MSK data. 84 05.03.19 MATTER ARISING Agree dates of when data capture will take place. MP Ongoing SL to send an email to all practices to establish whether they want to 85 05.03.19 AOB continue ward rounds in 19/20 and use £1/patient funds. SL Ongoing

Practices to feedback any comments or issues with the Mental Health service to the localities mailbox. Further clarity will be sought 86 02.04.19 ICDB regarding what the service provides and will be fed back to the group. All Ongoing

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Stevenage Locality Committee Commissioning Meeting Tuesday 14th May 2019 1.30pm to 2.30pm Cromwell Hotel,High Street, Stevenage, SG1 3AZ.

MINUTES Present: NAME Job Title Dr Keith Aubin (KA) GP, Stanmore Medical Group Dr Laura Epstein (LE) GP, Shephall Dr Russell Hall (RH) GP, Chells Way Surgery (CCG Corporate GP Lead) Dr Eleanor Jones (EJ) GP, Chells Way Surgery Dr Konrad Kaminski (KK) GP, Stanmore Medical Group Dr R Mahalingam (RM) GP, King George Surgery Dr Prag Moodley (PM) GP, Stanmore Medical Group (CCG Chair) Dr Rob Newby (RN) GP, Knebworth and Marymead Dr Richard Paramour (RP) GP, King George Surgery Dr Swarnalatha Kota (SK) GP Bedwell Medical Centre Sheilagh Reavey (SR) Director of Nursing & Qualilty ENHCCG Dr Rini Saha (RS) GP, King George Surgery (Chair) Dr S Coxall (SC) Chells Way In Attendance: NAME Job Title Sunday Adeniyi (SA) ENHCCG Finance Lead Mark Banks (MB) Federation Manager/ ICDB Chair Jane Baumeister (JB) Clinical Services Manager, GHHC Mary Bishop (MPB) PM, Stanmore Medical Group Elaine Cook (EC) PM, Bedwell Medical Centre Sandra Copping (SC) PM, Manor House Maxine Davis (MD) Senior Pharmaceutical Advisor ENHCCG Amy Elliott (AE) PM, King George Laura Epstein (LE) GP, Shephall Katie Farrell (KF) HCNS Jessica Hansell (JH) GP Trainee, Stanmore Medical Group Helen Hemmingfield (HH) Team Administrator CCG Deena Keefe (DK) Locality Manager CCG Fiona Lucas (FL) PM, Symonds Green Anna Makepeace (AM) HCC/CCG Gerry Moir (GM) Interim Director Localities, ENHCCG Michelle Myers (MM) Chells Way Surgery Allison Seymour (AS) Asst PM, Bedwell Medical Centre ICDB ATTENDANCE David Brewer (DB) Head of Engagement ENHT – Lister Jacqui Carrett (JC) Service Manager – ICRS Matt Charles (MC) Age UK Herts/ Hospital & Community Navigation service Julie Phipps (JP) HPFT Wendy Allam (WA) HPFT Sabina Tai (ST) HCT

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Item Subject Action by

1. WELCOME AND APOLOGIES FOR ABSENCE

The Chair welcomed all to the meeting. Apologies were received from:  Ken Spooner  Manjit Phugura  Dr Masood  Ken Moore The Chair declared that the meeting is quorate.

2. DECLARATIONS OF INTERESTS

The Chair invited the members to reconfirm their current declarations on the Register of Interests and advise of any new declarations.

All members confirmed their declarations were accurate and up-to-date.

The Chair invited members to declare any declarations relating to matters on the Agenda.

All members confirmed they have no declarations in relation to matters on the Agenda.

3. MINUTES OF PREVIOUS MEETING AND MATTERS ARISING RS

The Minutes of the meeting held on 2nd April were virtually approved as an accurate record.

4. ACTION TRACKER (RS) Item 83 – Spirometry the locality needs to understand further what funding is needed for training, there is a business case ongoing. Spencer Langham th will be available on TARGET day 16 May 2019 for any questions. Item 84 – ongoing MP is going to circulate a template for audit data on MSK. th Item 85 – Locality agreed to fund care ward rounds until 30 June, then PCNs can decide what they will do after that. 86 – Mental Health Service issues still ongoing and awaiting for mental health team feedback. Service will be moving St Nicolas and MB will inform the practices of the details.

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Item Subject Action by 5. Locality Funding streams

£1pp - £110,777 includes Knebworth and Marymead 2019/20  Money from £1 per patient for 18/19 was used on Care ward rounds, e-learning training Skills for Health and face to face training for Chells and phlebotomy clinics.  Training - As previously agreed the £1 per patient for 19/20 will be used for Skills for Health and to reimburse Stanmore Medical Group who have paid for years two and three in full. Agreed; to reimburse Stanmore Medical Group for years two and three in full including any admin costs incurred. Pay Chells for face to face training for the same amount as the year before.

 Phlebotomy - Discussions were held regarding the clinics at

Shephall Health Centre. SMG confirmed clinics will cease on 30th June. After this date query was raised whether the PCNs can take this on as part of the new service or remain with SMG? MPB confirmed they were happy to continue to do this.  RS/RH suggested the funds for the care ward rounds and the phlebotomy should be reserved up to 31st March 2020 in order that the locality can continue offering these services, all agreed that that was a good idea.  Locality queried the Phlebotomy procurement SR informed the locality that the procurement was not successful. No successful bids were received; therefore the CCG will have to revisit the business case and look at new models to bring the service into these areas.  RS and RH suggested that the locality should approach the CCG and see if there is a budget to cover the Phlebotomy clinics in the meantime rather than use locality £1 per patient funds.

 The locality need to look at how many care ward rounds they have

per week, Knebworth and Marymead currently have 3 Care Homes

and were used to a Frailty Nurse in North Herts however now need to join the Stevenage care ward round scheme and DK confirmed that the budget reflected the addition of Knebworth and Marymead.

ACTION: SR/DK to investigate with CCG for a budget to cover the SR/DK Phlebotomy clinics. ACTION: SL and DK to review the funding and possibilities of care SL/DK ward round cover for Knebworth and Marymead.

£1.50 GPFV Training Budget claims

ACTION: MB reminded practices that they need to send in their £1.50 MB GPFV Training Budget Claim invoices together with the evidence requested in order that he can get reimbursement from the CCG.

CFF 55p 2018/19 project claims ACTION: MB/DK will send details of how to claim for the works that they have carried out with regards to the locality projects.

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Item Subject Action by

8. FINANCE AND LOCALITY INFORMATION PACK

SA gave a finance update on the current locality position, following serious overspending in the locality, now in month 12 the Stevenage locality are underspent which means they have met financial balance for CFF 18/19 payment.

There has been a significant overspend on elective and non-electives, which will need some focus going forwards.

For CFF 18/19 there was an underspend on antibiotic prescribing in all the localities which was a benefit to the locality and in comparison from month 11 to month 12. The CCG was able to allocate contingency money back to Stevenage locality and the other localities.

PCN (Primary Care Network) financial plans have already been set and an amount has been set aside. An additional £1.50 is going to support the management structure of the PCNs. A breakdown per PCN will follow soon.

There were two localities who did not meet financial balance, they have asked that the CCG look carefully at how their allocation of fair shares was drawn up; these allocations will be submitted to the Governing Body for approval, SA will update the locality on the decision.

9. LTC UPDATE DNAR problems

Virtual report was sent to the locality.

Problems were reported that the DNAR forms being completed at the hospital and not being shared with the GPs, homes and ambulance services and also not accepting some printed DNAR forms – if any problems please feedback to contract hotline.

ACTION: Completed DNAR forms from Hospital not being shared with DK GPs, Homes and ambulance services, Flag this with DB ICBD member Head of Engagement at Lister Hospital and contracts hotline.

10. VIRTUAL REPORTS PRESCRIBING UPDATE MD will share as it is just being prepared for the month 12 data on prescribing with practices next week.

MENTAL HEALTH – no update.

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Item Subject Action by

11. PATIENT PARTICIPATION GROUP – no update.

12.. EXTENDED ACCESS UPDATE – MB update

For the month of April 2019, 716 appointments were offered, 644 of those were booked, giving an 80% uptake, and include a total of 56 DNA across the month. We provided 180.5 hours which gave us a 99% usage of provision of the service. High users for April were Manor House, Stanmore Medical Group and Chells, everyone else was a lot lower. MB wanted some feedback from practices about the service.

Knebworth and Marymead are joining the Extended Access service from 1st July 2019. This will be an increase in hours to 50 hours per week from 1st July 19 for the locality.

13. UPDATE FROM MEETINGS:- THE GOVERNING BODY PCNs (Primary Care Networks) will be discussed at TARGET day on 16th May 2019.

Fit testing is coming live on 1st June, all practices are being sent a package with a clinical decision making kit to follow. Hopefully this will be incorporated within ICE, it is estimated it will take 7 days to get the result then maybe a 2ww referral to follow on from the results. This is STP wide service going across the three CCGs at the same time.

Freestyle Libre prescribing issue, a decision has been made that after 6 months of consultant prescribing will come out to primary care with an agreed process. Secondary care has to initiate and carry out 3 reviews within the 6 months, before being passed to Primary Care. There is a funding cap for it funded by NHS England which will be reviewed each year as numbers will start growing. There will be a cohort of patients that are already being seen in Primary Care. CCG has decided not to stop those patients who are getting this in primary care and there will be guidance sent out by MD soon.

14 ANY OTHER URGENT BUSINESS

Transgender update letter sent by NHSE with clarification which was shared with locality a couple of months ago. NHS providers should be prescribing and update themselves with prescribing issues medication.

RS spoke to the locality about a General Practice Development Programme NHSE offer (deadline 17th May) a few practices were interested to sign up as a locality. This is GP quick start for your practice funded by NHS

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Item Subject Action by England. This is an on-site, hands-on, short term support package for practices.

ACTION: DK to send an email reminder to practices if all can confirm to DK if their practice wants to take part in the General Practice Development Programme.

Flu claims funding given by the CCG, MB is still waiting for a number of practices to submit evidence that the letters have been sent out. MB cannot reimburse practices without the evidence. Evidence and invoices need to be submitted by the 31st May to MB otherwise funding will have to go back to the CCG.

DATE OF NEXT MEETING

TARGET 2nd July 19 12.00 to 18.30 Stevenage Football Club, The Lamex Stadium ICDB/LCC 9th July 19 12.30 to 14.30 Cromwell Hotel, High Street, Stevenage ICDB/LCC 10th Sept 19 12.30 to 14.30 Cromwell Hotel, High Street, Stevenage

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No. Meeting Date Item No. and Title Action Responsible Manager Current Position Status SCHOOL NURSING – LINKED TO CARE DK to invite School Nursing to return and update annually at LCC meeting 74 11.12.18 NAVIGATION or target DK Ongoing CCG lead on the speakers for the TARGET Events, so will 83 12.02.19 AOB DK and EC to liaise regarding possible Spirometry speaker at TARGET. EC/DK liaise with them. Ongoing MP to produce a template and share with locality to capture MSK data. 84 05.03.19 MATTER ARISING Agree dates of when data capture will take place. MP Ongoing SL to send an email to all practices to establish whether they want to 85 05.03.19 AOB continue ward rounds in 19/20 and use £1/patient funds. SL Ongoing Practices to feedback any comments or issues with the Mental Health service to the localities mailbox. Further clarity will be sought regarding 86 02.04.19 ICDB what the service provides and will be fed back to the group. All Ongoing Locality Funding SR/DK to investigate with CCG for a budget to cover the Phlebotomy clinics. 87 14.05.19 Streams SR/DK Ongoing Locality Funding SL and DK to review the funding and possibilities of care ward round cover 88 14.05.19 Streams for Knebworth and Marymead SL and DK Ongoing MB reminded practices that they need to send in their £1.50 GPFV Training Locality Funding Budget Claim invoices together with the evidence requested in order that 89 14.05.19 Streams he can get reimbursement from the CCG. MB Ongoing Completed DNAR forms from Hospital not being shared with GPs, Homes and ambulance services, Flag this with DB ICBD member Head of 90 14.05.19 LTC Update Engagement at Lister Hospital and contracts hotline. DK 06.06.19 - DK emailed DB and GP Contract Helpline. Ongoing DK to send an email reminder to practices if all can confirm to DK if their practice wants to take part in the General Practice Development 91 14.05.19 AOB Programme from NHSE offer. DK 14.05.19- DK sent an email to all practices - completed Ongoing

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Stort Valley and Villages Locality Committee Commissioning Meeting Rhodes Arts Complex, Bishops Stortford Thursday 25th April 2019 MINUTES Present:

Name Job Title

Dr Kwasi Appiah GP, Representative South Street Surgery Dr Sarah Dixon GP Locality Lead, GB Board Member Sharn Elton CCG Executive Director SVV Dr Deborah Kearns GP Representative, Central Surgery Dr Nathalie Oates GP, Representative Much Hadham Health Centre Dr Nabeil Shukur Chair, SVV Locality, GB Board Member Dr Sian Stanley GP Representative Church Street Partnerships Dr Jagjit Takhar GP Representative, Parsonage Surgery

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In Attendance: Name Job Title

Sandie Ince South Street, Manager, Dr S Das GP Central Surgery Christopher Deane-Bowers Patient Representative Michelle Ford Parsonage Surgery, Practice Manager Helen Hemmingfield Meeting Secretariat CCG Deena Keefe Locality Manager, CCG David Ladenheim Prescribing Advisor, CCG Dr A Rahman GP Central Surgery Dr K Remedios GP Central Surgery Liz Scott Central Surgery, Practice Manager, Michelle Shanahan Locality Lead Nurse Liz West Transformation Manager, Stort Valley & Villages Andrew Wilkinson Much Hadham Health Centre, Practice Manager, Amber Wilson Finance Manager, CCG (Apologies)

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Item Subject Action by

1. WELCOME AND APOLOGIES FOR ABSENCE

The Chair welcomed all to the meeting. Apologies were received from:

 Amber Wilson  Pam Jardine

Meeting started without Sharn Elton and Nabeil Shukur.

The Chair declared that the meeting is quorate.

2. DECLARATIONS OF INTERESTS

The Chair invited the members to reconfirm their current declarations on the Register of Interests and advise of any new declarations.

All members confirmed their declarations were accurate and up-to-date.

The Chair invited members to declare any conflicts of interest in relation to matters on the Agenda.

All members, and those in attendance, confirmed they had no conflicts of interests in relation to matters on the Agenda.

3. MINUTES OF PREVIOUS MEETING AND MATTERS ARISING SD

The Minutes of the meeting held on Thursday 24th January were approved as an accurate record.

4. ACTION TRACKER The action tracker was not included with the circulation of papers this was SD due to an administrative error.

However the following action was agreed to be closed and the following updates were provided by MS.

Action: MS to find out suitable criteria for nurses training courses  For nurse training Nurses need to be in post for at least one year and there is funding available for a 3 years nurse Practitioner course.  Heidi Santoz, Tissue Viability Nurse for the CCG is collating

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Item Subject Action by information at the moment, tissue viability study days and compression training dates will be released in September 2019.  No funding is available for Doppler training.  A query was raised about referring tissue viability patients through HCT and what pathways are being used.  Practices queried whether looking after patients for wound management was a core or enhanced service.  One of the practices highlighted that they had a member of staff who is training as a phlebotomist, however they are struggling to get the sign off as no one can mentor and assess. One of the other practices suggested that they would be happy to mentor and sign off staff member.

ACTION: The Action Tracker has been updated

5. INTEGRATED COMMISSIONING Dl Medicines Waste SD/LW DL deferred this item to the next meeting.

Sharn Elton and Nabeil Shukur arrived at the meeting at 13.25.

Palpitations Pathway/24hr ECG SD circulated an email to the locality about Palpitations Pathways and Atrial Fibrillation.

 For ENHT patients there will be a virtual clinic with 24 hour ecg service.SD is going to attend a meeting at PAH who are developing a similar pathway with West Essex.  Pilot being tested in a couple of neighbourhoods for next 3 months.  LW has provided some costings for the Federation if the locality decides to go ahead but may want to wait the outcome of PAH pilot.

Atrial Fibrillation  Conversations have been held with LLV Federation who are working with Pfizer and AHSN (Science network).  They are using AliveCor devices in practices which give you a one lead ecg reading in over a minute, each reading can be emailed through to the practices through NHS mail.

 Surgeries will need a tablet or phone to use these devices.

 Some funding is available from ASHN if we wanted to apply for a

project related to AF detection.

 Could target high risk patients that see the podiatrist.  Could use pharmacists in extended access to provide an anticoagulation service.  SD asked for thoughts from the locality.  Consider targeting patients already on anticoagulation medication.  Amwell Surgery is using these devices at their Flu clinic.

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Item Subject Action by  Query raised whether an HCA could use this device.  Discussions were held around the possibility of it being a Locally Enhanced Service (LES) and whether a business case could be put forward.

ACTION: To look at whether there is funding for tablets and devices. SD

ACTION: Anti coagulation services business case needs to be SD refreshed to see if this is viable.

JT raised a concern about some Practices ECG machines being affected by newly upgraded computers with Windows 10.

ACTION: Please email localties1 mailbox or HH to give examples of software not working due to upgrade of Windows, so that this can be escalated to the CCG IT Team.

6. PRACTICE MANAGERS FEEDBACK LS/AW  LS reported that discussions were being held around CFF as this was still unclear  Practices have asked for further MedeAnalytics training as they have not used this for a while.  Practices have received a notification about outbreaks of Measles however it has been reported that some schools were not notified, an update has been sent to AW as some communications have been sent to some local schools. Practices are contacting patients who have not been immunised.  AW reported to the locality that Westland Green traveller’s community .  For CQC, vaccinations for front line staff and GPs need to be recorded.  All staff should have the option to have the vaccine or an immunity blood test which would cost £29 per person – this could be offered at PAH.  Practices can do vaccinations themselves and a question was asked whether this could this be done in extended access.  It was noted in the latest Finance Report that the locality was under spent by £1.5 million and AW would like further breakdown on this?  DK asked if the locality could use some of the underspend for these services and a viable business case should be presented for these.

ACTION: Practices have asked for further MedeAnalytics training. ACTION: AW to liaise with Amber Wilson for a breakdown of the finance

7. UPDATE FROM THE GOVERNING BODY NS/SD

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Item Subject Action by  SD reported feedback on the locality and financial packs.  The packs have been updated to include more clinical information.  SD asked if the locality could provide feedback on how they found the new format; each Practice does have someone allocated to look at this.  Next month will be around cardiovascular and stroke related issues and each month will be shaped to the feedback.  The next Respiratory meeting is on 7th May 2019 and will be held at the Southstreet practice.  If you would like to go please let LW know names, there will also be a consultant attending.  On 16th May a consultant will be going over respiratory cases, if your practice would like to be involved please let SD know, so time can be allocated for each practice to discuss their cases.  FIT testing kits not being sent out until June 2019.  Ongoing issues with DNAR and CPR decision forms not being accepted by the ambulance service and Care Homes are only accepting a wet signature these concerns must continue to be reported to the Contract Hotline.  The STP end of life group need to look into and come up with one process as we are failing to meet patient’s wishes.  Concerns were also raised about e-referrals, patients are being informed there are no appointments available, these problems must be reported to the Contract Hotline.

8. UPDATE FROM PCG CD-B

We have met only once on 21 February 2019, Chaired by Dr Sarah Dixon. Joy Hale is now the link at the CCG and she will come to the next locality meeting.

1) Scott Downham, clinical pharmacist at Church Street Surgery talked through the over the counter medicines policy in the area. SD spoke to the group regarding over the counter (OTC) medicines and the changes in prescribing. Practices are limiting the routine prescription of medicines, products and food supplements for short- term conditions and minor illnesses, except in exceptional circumstances. In future, people will need to buy these themselves from pharmacies or shops.

SD explained the outcome of the Let’s Talk consultation held in 2017/18 which covered these changes The aim for the locality is to reduce the use of prescribed medicines that could be OTC by 20% A list of the things that can be brought over the counter: poster should be up in your practices already.

ME/LH to update GP slides on what medicines are no longer being prescribed, except in exceptional circumstances. In future, people will need to buy these themselves from pharmacies or shops.

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Item Subject Action by

SD explained the outcome of the Let’s Talk consultation held in 2017/18. The aim for the locality is to reduce the use of prescribed medicines that could be OTC by 20% A list of the things that can be brought over the counter; this poster should be up in your practices already. Mark Edwards and Lauren Hague to update GP slides on what medicines are no longer being prescribed.

LH to include Breathe Easy Group signposting in STP Respiratory video.

2) Sarah Dixon updated members on the premises strategy. There is a big increase to the local population coming. And the practices are now working on a longer term strategy to work out how to meet the health needs of the growing population.

Practices are working together and looking at list sizes, the square footage of premises and seeing if anything can be altered to help. Practices have enlisted the help of someone from a commercial and NHS property background to help guide them.

3) ME updated the group on the Cancel Out Cancer. It has now been launched online. We are now looking for people to deliver the sessions out in the community and grow the initiative gradually. North Herts College students are developing a web and app version.

Members to contact ME/LH if you would like to get a group together and we can arrange a session.

4) Central Surgery: JY/MT to share with ME. An Admin Box has been placed in reception so patients no longer to have to queue up to hand in discharge letter. Receptionists are now trained in care navigation, and there is to be an iPad in reception so patients can come in and order prescriptions online and staff will help with a workshop on 2nd March to help people get online, and a ‘How to log on’ guide has been produced. There is a new Dementia Club.

Hadham: Health Connector’s Event has been held in the village but unfortunately was poorly attended. They have been focussing on healthy eating, and have been trying to get a park-run route in the village but now going to tie in to the Bishop’s Stortford’s run. There are Dementia Friendly Screenings at Hertford Cinema, which are free for the carer.

6) CCG IAF Assessments: ME informed the group of recent assessments by NHS England of the CCG. The CCG had scored a ‘good’ in diabetes and mental health, and a ‘requires improvement’ in dementia and learning disability. Members can view the full results on the My NHS website.

7) Community Trust: Hertfordshire Community Trust will no longer provide Adult Care Services for Herts Valleys. ME/LE will keep the group updated on any developments.

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Item Subject Action by

8) CFF survey –Survey to get the general feeling about practices from patients - likes and dislikes across all different services and then how we can support the surgery. Goes to direct to practice and will send it out via text message.

9) Update on Long Term Conditions Workshop; either see Attender myself CDB, or alternatively the full presentation and details of the meeting can be found on the website.

10) ME mentioned about Summer Conference to be held: Saturday 6 July that would cover Social Prescribing and Self-care.

CD-B also raised a concern about one London hospital going electronic, previously patient letters would go the GP Practice and the Practice would forward the letter onto the patient, the contracts team need to check this issue. A lot of trusts do outsource the typing of the patient letters.

Dates of meetings in 2019: Thursday 16 May, 26 September, Thursday 21 November.

9. ANY OTHER BUSINESS ALL

SS reported at a GP leads meeting last month, GPs met across the county to discuss ongoing issues with CAMHS tier 1 and tier 2 services.

Following on from this meeting SS has been invited to attend a small working party to link in with more local services.

More support is needed from GPs and if anyone is interested in joining this working party please let SS know.

It was suggested to set up clinics similar to social prescribing in order to help guide people through the pathways. One GP Practice used extended access to create an adolescent clinic in the evenings.

School nurse team to meet with PPG and GPs, it was highlighted that private schools do not have access to the school nurse team as they have their own counsellors.

HPFT are piloting health workers but unfortunately not in Stort Valley and Villages area.

10. DATE OF NEXT MEETING:

Thursday 23rd May, 2019

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Item Subject Action by Rhodes Arts Complex, Bishops Stortford From 2.00 - 3.30

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Stort Valley and Villages Locality Committee Commissioning Meeting Rhodes Arts Complex, Bishops Stortford Thursday 23rd May 2019 MINUTES Present:

Name Job Title Dr Kwasi Appiah GP, Representative South Street Surgery Dr Sarah Dixon GP Locality Lead, GB Board Member Sharn Elton CCG Executive Director SVV Dr Nathalie Oates GP, Representative Much Hadham Health Centre Dr Nabeil Shukur Co-Chair, SVV Locality, GB Corporate Board Member Dr Sian Stanley GP Representative Church Street Partnerships Dr Jagjit Takhar GP Representative, Parsonage Surgery

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In Attendance: Name Job Title Jacqui Carrett Service Manager ICRS Dr S Das GP Central Surgery Michelle Ford Parsonage Surgery, Practice Manager Helen Hemmingfield Meeting Secretariat CCG Pam Jardine Locality Manager, CCG David Ladenheim Prescribing Advisor, CCG Gerry Moir Associate Director Localities Liz Scott Central Surgery, Practice Manager, Michelle Shanahan Locality Lead Nurse Karen Thomson South Street, Manager, Liz West Transformation Manager, Stort Valley & Villages Andrew Wilkinson Much Hadham Health Centre, Practice Manager, Sarah Wilms ICRS (HCT) Paramedic

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Item Subject Action by

1. WELCOME AND APOLOGIES FOR ABSENCE

The Chair welcomed all to the meeting. Apologies were received from:

 Deborah Kearns  Amber Wilson  Christopher Dean Bowers

The Chair declared that the meeting is quorate.

2. DECLARATIONS OF INTERESTS

The Chair invited the members to reconfirm their current declarations on the Register of Interests and to advise of any new declarations.

All members confirmed their declarations were accurate and up-to-date.

The Chair invited members to declare any conflicts of interest in relation to matters on the Agenda.

All members, and those in attendance, confirmed they had no conflicts of interests in relation to matters on the Agenda.

3. MINUTES OF PREVIOUS MEETING AND MATTERS ARISING SD

The Minutes of the meeting held on Thursday 25th April 2019 were approved subject to a minor amendment in Sec 6, Page 5 Practice Manager’s Feedback. Correction should read: The Westland Green Travelling Community has moved in. (AW did not report that there was an outbreak of measles).

General Discussion  There was a general discussion about Leg Ulcer training and ways in which this can be funded. Other localities use their £1.50 and £1 patient money.  SE suggested in the short term conversations should be held with HCT to find out what it would cost to put on training sessions with respect to leg ulcer dressings.  SE also suggested that the locality should get an understanding of current funding arrangements are for leg ulcer service across the CCG and what the locality could expect HCT to provide.  Atrial Fibrillation device to be discussed later as this could be a project to progress.  Computers to be upgraded to Windows 10 by December 2019.

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Item Subject Action by Parsonage raised an issue. Practices need to understand whether there are issues across in other practices.  The localities have requested MedeAnalytics training – GM to look into this. Action: SE suggested in the short term conversations should be held with HCT to find out what it would cost to put on training sessions with respect to leg ulcer dressings.

4. ACTION TRACKER - SD

 Item 15 - Extended Access is being well utilised. Extended Hours - there could be an option for this to be nurse led and not necessary to have a GP. The Federation need to know the st hours the practices will be delivering from 1 July 2019. Information to be sent to LW.  Query on Silicon footfall regarding its functions and whether practices would like this website.  It was noted the locality need to decide on their choice of platform by

the 31st May. Update will be given at the next meeting.

 Item 19 – Recommissioning of Mental Health. Agreed to close.

 Item 20 – Practice Managers Feedback. Agreed to close. Draft

pathways on tissue viability coming out. Need to carry out gap analysis to look at training shortfall. SD Action: Locality to look into this function and determine whether they need Silicon Footfall

5. INTEGRATED COMMISSIONING – SD

£1 Per Patient Proposal Project – GP into the Integrated Community Team (continued for another 12 months) Proposal was circulated by email – the locality need to formally agree proposal for a further 12-month contract for the GP (employed via South Street Surgery).

Action: SD to discuss claim for Medical Defence with Dr Jordan and inform PJ of any adjustment to finance requirement in proposal.

Decision: Approved. To adjust MDU claim.

Medicines Waste – DL DL attended to discuss the issues around medicines waste and the different aspects to waste.

ACTION: DL to investigate and report back any progress to the locality.

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Item Subject Action by

Priorities for 2019/20 for agreement - SD  GP into ICT £1 Per Patient Proposal Project.  Premises project, Mark Cammies to meet again on 5th June.  Salary for Transformation Manager – around the role and where this sits going forward.  AliveCor – costs are being sourced to supply devices to practices for use in LTC clinics, this could be funded from £1.50 patient money – LW is looking into sourcing the best deal. Stroke is the second highest disease in the locality and this would be worth looking into.  Pneumonia is still the highest. SD enquired whether the locality would like to consider pathways that Herts and West Essex are using.  Diabetes Empower Clinics – clinics should be up and running.  PJ to email Oliver Brooks to enquire about venues

ACTION: PJ to email Oliver Brooks to enquire about venues for clinics and frequency of clinics.

Locality End of Year Financial Position - NS  NS as reported that the locality has achieved financial balance.  A letter explaining the funding reward will be circulated to the locality.  There were then general discussions on the use of funds.  Discussion held around the phlebotomist in the community service.

Locality Visit Data – SD SD asked the locality to collect data for AIHVS referrals for the month of November 2018. Data required to determine how useful AIHVS is.

Locality Packs - SD The locality asked for a drill down on data for Type 1 and 2 illnesses into A&E to provide a more detailed analysis. LW reported that she meets with Sam Williamson on monthly basis to discuss but more narrative is required.

6. PRACTICE MANAGERS FEEDBACK No update given.

INTEGRATED CARE DELIVERY BOARD 7. UPDATE FROM THE GOVERNING BODY NS/SD  FIT test – roll out beginning of June.  Request FIT Test on ICE, PAH into normal courier service  Grid circulated shows which patients are suitable or not suitable.  Dr Landy presented about FIT testing at PMs meeting on 22/5/19.  Freestyle Libre – new guidance coming out. Any queries to be sent

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Item Subject Action by to David Ladenheim 8. UPDATE FROM PCG CD-B Information from PCG Rep circulated with meeting papers.

LEADS UPDATE Mental Health newsletter was circulated with meeting papers.

9. ANY OTHER BUSINESS ALL

None

10. DATE OF NEXT MEETING:

Thursday 4th July, 2019 Rhodes Arts Complex, Bishops Stortford From 2.00 - 3.30

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Upper Lea Valley Locality Commissioning Meeting Wednesday 16th January, 2019 Ware Priory, Ware

MINUTES

Present: Name Job Title Dr Mark Andrews (MA) Locality Chair Dr Alice Baldock (AB) GP, Rep Hailey View Dr Rachel Joyce (RJ) Executive Director, CCG Dr M Khan (MK) GP Locum, Rep The Limes Dr Jay Kuruvatti (JK) GP, Rep Wallace House Dr Megan Phillimore-Brown GP, Rep Buntingford Medical Centre (MP-B) Dr Rupal Shah (RP) GP, Rep Hanscombe House Dr Phil Lancaster (PL) GP, Rep Castlegate Dr Jo Roberts (JR) GP, Rep Amwell Street Dr Jacqui Sheridan (JS) GP, Rep Park Lane Lucy Eldon (LE) Dept Rep Church Street & ULV Lead Nurse

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In Attendance: Name Job Title Ade Aina-Princess (AA-P) Prescribing Advisor, CCG Barry Canterford (BC) Chair ULV PCG Teresa Davidson (TD) Practice Manager, Buntingford & Puckeridge David Eyre (DE) Manager, GHC Federation Helen Hemmingfield (HH) Administrator, CCG Pam Jardine (PJ) Locality Manager, CCG David Ladenheim (DL) Prescribing Advisor, CCG Anna Makepeace (AM) Transformation Manager, ULV Gerry Moir (GM) Interim AD Localities, CCG Val McCann (VMC) Practice Manager, Hailey View Jill O’Brien (JOB) Practice Manager, Dolphin House Alison Saward (AS) Finance Manager, CCG Julie Tripp (JP) Practice Manager, Amwell Street Oliver Brooks (OB) Spirit Healthcare Mandy Whiteman (MW) HCT Brenda Harrap (BH) GP

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Item Subject Action by

1. WELCOME AND APOLOGIES FOR ABSENCE

The Chair welcomed all to the meeting.

Apologies were received from:  Dr N Williams  Dr M Davies  Dr D Shah  Dr Natasha Larmie  Melanie Hunt  Rachael Hunt

The Chair declared that the meeting was quorate.

2. DECLARATIONS OF INTERESTS

The Chair invited the members to reconfirm their current declarations on the Register of Interests and to state any new declarations.

All members confirmed their declarations were accurate and up-to-date.

MA reminded the locality that declarations have to be renewed on an annual basis and that all returns should be returned to Maryla Hart, in the Governance Team at the CCG.

All other members confirmed their declarations were accurate and up-to- date.

The Chair invited members to state any declarations of interest relating to matters on the Agenda.

All members confirmed they have no declarations in relation to matters on the Agenda.

3. MINUTES OF PREVIOUS MEETING AND MATTERS ARISING

The Minutes of the meeting held on Wednesday 14th November were approved as an accurate record

4. MATTERS ARISING:

 Practice Visits are to be scheduled from April 2019 onwards  Practices asked once again about the extended hours LES. CCG confirmed that they were still waiting to hear of this from NHSE

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Item Subject Action by  Questions were raised on issues around shared care arrangements of Dementia drugs and transferred care  GP Online E-consultations – a number of practices have come forward as champions. Practices were reminded that if there are any other interests, they should contact Nigel Gausden directly on [email protected]  There was a discussion around the closure of the Ware contraception clinic this has since closed on the 21st January 2019  MA asked if DE could look into extended access providing a contraceptive service

5. ACTION TRACKER The contents of the Action Tracker were discussed.

The following updates were provided:  Data is being used by the PCCC (Primary Care Commissioning Committee) after the CCG became delegated – this is in development and can be closed  Item 4 – Matters Arising: payments from HPFT no response from Simon Pattison, update still needed as still unresolved. To be left leave on the action log  Item 11 AOB – Locality Pack – still being developed and improved

ACTION: The Action Tracker to be updated to reflect the updates.

6. INTEGRATED COMMISSIONING Diabetes Training Project Presentation was given by Oliver Brooks from Spirit Healthcare this is a structured diabetes education programme which is taking over from the st current provider from 1 February 2019. PJ asked for the list of sites when they are available.

ACTION: Presentation to be sent to Practice Managers in the Locality. HH

Clinical Representatives for Hubs – MA MA MA spoke to the Locality about the request for clinical representatives for the hubs. There is a temporary maternity vacancy in Hertford and also a vacancy in Ware. Dr N Williams has come forward as being interested in the lead role in Ware and the Locality were happy to accept this.

PJ Dr Rupal Shah has come forward for the Hertford area. No other names

have been submitted.

There is also a vacancy for a lead in the Community Care Frailty Team.

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Item Subject Action by

A concern was raised by JR about hubs possibly being relocated to different areas, to potentially realign them within the boundaries of the district councils. Nothing formal has been announced.

Action: PJ to liaise with Dr Shah separately and arrange for her to be invited to ICBD meetings. PJ to contact separately.

Locality Financial Position as at Month 7 - AS Overall Position: AS  At Month 7, 3 CCG localities are overspent (ULV, LLV & Stevenage), 2 are underspent (SVV & Welhat), 1 is broadly on plan (NH)  ULV is the most overspent locality with a YTD variance of £2.5m (3%), of which £2.9m relates to Acute activity, offset by underspends in GP Prescribing (£0.2m) and Intermediate Care (£0.1m)  Acute over-performance is across most PODS, particularly Non Elective (£1.3m), Elective (£1.0m), Outpatient First (£0.4m), A&E (£0.4m) and Maternity (£0.3m)  The Non Elective overspend of £1.3m is offset to an extent by credits for Avoidable Readmissions and Marginal Rate Emergency Threshold (admissions over 2008-09 baseline)

Actions/investigations suggested by ULV to explain position:  Check basis of budget (what year) – are localities at full capitation for 2018-19?  Check population growth since then, compared to other localities  Check population growth split by age (3 x Nursing Homes recently opened in ULV, with another due to open soon – this may have increased A&E and NEL admissions)  Look at OP and Elective – which Specialties and which Providers  Check births across localities by Provider – Welhat is low, ULV is high  Check cancer prevalence across localities – some practices in ULV have risen significantly since last year

7. PRIMARY CARE Federation update on extended access and progress on various DE projects managed by GHC – DE  Extended access due to move to Hanscombe House in the first week of February. The GP websites were changed and the hours will be exactly the same as they were in Ware  Social Prescribing - still no development  Results on ICE still not working – this is a web based system that delivers results electronically within one hour of authorisation, improving patient safety and NHS efficiency  Booking system working well and screening clinics are well

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Item Subject Action by attended with appointments being taken up  Looking at Health Checks to be carried out by HCAs  The Federation reported that they are offering family planning clinics in extended access  On 1st April Ware Road Surgery will be moving into Castlegate Surgery this is in progress  Records for Castlegate and Ware Road Surgery are being digitalised  PPG are aware of this and is on the website  Orchard Surgery had a CQC visit last year this was rated as inadequate and now under special measures. A re-inspection visit will happen within 6 months.  Ware Road also had a CQC visit and was rated as requires improvement. They will have another visit within 12 months of publication of the report.  The Federation are working jointly to submit tenders for Phlebotomy. DE will keep the locality informed.  AGM end of February/early March, invites will be sent out within a couple of weeks.  DE informed the locality that Jill O’Brien had resigned from the Federation

8. INTEGRATED CARE DELIVERY BOARD MW End of Life Dashboard – Mandy Whiteman, Locality Clinical Lead Demonstration/presentation given by Mandy Whiteman on end of life dashboard.

Concerns were discussed around record sharing and questions were raised around Read codes on Ardens and whether they were the same as HCT’s.

Dr J Kuruvatti raised a concern about a referral to CAMHS. He was asked to forward this question to the Contracts Hotline. AM Update on projects from ICDB – Anna Makepeace  MST (Multi Service Team) project running last few months and working well – the MST project is about getting people in place at one time, to make a plan for that patient  Technical issues finally fixed  JS is meeting with Charlotte Project Lead supported by Amy Morris, the Project officer this is a pilot – feedback well received, need data behind it to see if this is making an impact  Regular statistics coming in monthly – Amy Morris is collecting these and will be reviewed continually  Referrals to be made from System1  A newsletter has been introduced and went to Practices a couple of months ago and will be sent bi-monthly if anyone has any ideas

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Item Subject Action by for the newsletter please let Amy Morris know  Project running with care home. Lucy Eldon is supporting the locality, this will be rolled out in the Summer of 2019  Matthew Turmaine will be Anna Makepeace’s replacement and will be starting end of February 2019, his contact details will be circulated

9. PCG UPDATE – Barry Canterford BC  Hoddeson patients have a growing concern about speculation that there could be merger with Lower Lea Valley  This is a big concern and the members of the patient group would like to know what they are trying to achieve  BC is going to attend a meeting on the 5th February and hopes to get a further update  Beating Cancer Together Project have produced a pack, to give instruction or teaching on how to go about informing their own patient groups about cancer issues such as, what are the causes, how to spot cancer, early diagnosis, prevention measures, key signs and symptoms and screening that is available

10. UPDATE FROM THE GOVERNING BODY No update given from the Governing Body.

11. ANY OTHER URGENT BUSINESS Long Term Conditions Forum MD sent his apologies and MA provided the locality with an update from Long Term Conditions Group.

These are some of the headlines around the CFF:- There will be much more coded information, less written and more read codes; no change in financial balance element; changes in engagement and rules around this element; a question around whether the prescribing meeting will be included in this.

Collaborative working money will be rolled over if underspent and no change to workforce information.

Record sharing, incentives to share records more particularly around end of life need, if the enhanced summary care records are shared there is a bigger range of information that can be collected. This will help new working in the out of hour’s service in HUC.

There will be a change in the core part of the care plan, respiratory work; discharge summaries; repeated and unplanned admissions.

There will be little change in Diabetes and no changes in funding referrals.

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Item Subject Action by

Paper going to the CCG Governing Body on the 24th January 2019. The final sign off will be before 1st April 2019.

A practice raised a concern about the pressure to prescribe ADHD medication. Following on from this, David Ladenheim CCG Prescribing Manager arranged for the CCG to circulate the existing protocol to the locality on ADHD shared care together with other HMMC recommendations.

12. DATE OF NEXT MEETING:

Tuesday 23rd April 2019 Ware Priory, Ware 1-3pm

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WelHat Locality Commissioning Meeting Thursday 28th March, 2019 Fielder Centre, Hatfield, AL10 9TP MINUTES Present:

Name Job Title

Dr Sachin Gupta (SG) GP Garden City Practice Dr Sarah Hoole (SH) GP Potterells Medical Centre Dr Ann Kelley (AK) GP Wrafton House Dr Richard Lavelle (RL) GP Lister House Surgery Dr S Maheswaran (SM) GP Bridge Cottage Dr Rahul Shah (RS) GP Garden City Practice Dr Ashish Shah (AS) GP Wrafton House Dr Vivian Tangang (VT) GP Burvill House

In Attendance: Name Job Title

Sunday Adeniyi (SA) Deputy CFO ENHCCG James Brookman (JB) PM Peartree Lane Surgery Lillian Cross (LC) Practice Manager Potterells Medical Centre Debbie Crossley (DC) Practice Manager Bridge Cottage Anthony Deitsch (AD) Locality Manager ENHCCG Sarah Ellingworth (SE) Practice Manager Garden City Practice Kieran Haywood (KH) Finance, ENHCCG Helen Hemmingfield (HH) PA/Team Administrator ENHCCG Anne Knight (AK) Practice Manager Hall Grove Surgery Corrine Nightingale (CN) Practice Manager Spring House Alan Pond (AP) Chief Finance Office, ENHCCG John Phipps (JP) Practice Manager Burvill House Peter Wilson (PW) PCG Chair PCG

Item Subject Action by

1. WELCOME AND APOLOGIES FOR ABSENCE

The Chair welcomed all to the meeting. Apologies were received from:

 Dr T Gillham  Alison Baldwin from ENHCCG  Dr A Parry  Sylvia Lane

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The Chair declared that the meeting is quorate.

2. DECLARATIONS OF INTERESTS

The Chair invited the members to reconfirm their current declarations on the Register of Interests and advise of any new declarations.

All members confirmed their declarations were accurate and up-to-date.

All other members confirmed their declarations were accurate and up-to- date.

The Chair invited members to declare any declarations relating to matters on the Agenda.

All members confirmed they have no declarations in relation to matters on the Agenda.

3. MINUTES OF PREVIOUS MEETING AND MATTERS ARISING

The Minutes of the meeting held on 17th January 2019 were virtually approved as an accurate record.

ACTION TRACKER The contents of the Action Tracker were discussed. All items on the action were closed.

3. PRIMARY CARE AS/SG LEADS UPDATE

 AS provided the locality with a CCG update looking at the quality and performance from providers  Cancer 62 day Target performance has gone down slightly as compared to the past few months and is at 73.5%  Demand and capacity is being worked on in the modelling to improve performance  In January A&E has been 85.2% new ways are being looked at for patient flows and medicine discharges  On medicine discharge summaries an independent review took place in February this year the formal report is still pending but feedback will be shared once this is received by SG

 Following a LTC meeting which SG attended CAMHS are

proposing a new model for mental health in children, with the focus on early intervention and single point of access to catch children at

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stage 2 SG to send out more information  The STP have agreed 3 new Frailty pathways, these will be circulated shortly and are included in the new CFF for 2019/20 they also include the Rockwood and Loneliness assessment  SG to circulate these Frailty pathways  Discussions have been held to look at how the 3 CCGs can work collaboratively and whether there can be one single Executive team, SG will share the presentation  QE11 urgent treatment centre consultations are going on to change the opening hours, draft guidance is being worked on, once this has gone to consultation it will be communicated to the public  Some streamline guidance is being developed by the GMC about Transgender and non-binary individuals, the guidance is quite clear that GPs should be following up these patients in primary care for treatment  AS informed the locality the new HPFT Mental health update plan been circulated  SG confirmed that feedback from the diabetes improvement plan will be circulated shortly

PPG UPDATE – Peter Wilson  News announcement about a new approach in mental health, special teams are being appointed and money has been allocated in Hertfordshire and several other areas to pilot this approach, currently only available in St Albans and Borehamwood  Discussions in patient groups about communicating with patients, some practices are not allowing patients to communicate with the PPG using practice software as concerns over GDPR  Other practices are communicating well with their patients on email and Facebook  PW asked for explicit guidance around this and the CCG have been asked to generate something  The Patient Engagement Communications Team at the CCG have developed a workshop model for creating patient awareness of early symptoms of cancer named Lets Cancel Out Cancer similar to the initiative that was undertaken for Dementia friendly cafes  Someone will come to the group to give training and go through the workshop with them

4. FINANCE UPDATE SA  Sunday Adeniyi gave a finance update on the current locality position, advising that WelHat have Year to date underspend of £168k  All details discussed were referenced from the Month 10 finance report narrative, below is some of the high level detail  Locality Acute spend remains above budget and this is mainly due to Non-Elective admissions and Elective admissions  Non Elective activity have increased by 3% compared to last year

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and compared to plan the spend has increased by 12% suggesting an increase in average cost due to casemix changes.  Main area contributing to overspend within non-elective are Pneumonia and UTI’s. The meeting noted there is an issue in the way activity is being coded within the main acute trust as sometimes the information on the discharge summary does not tally with the coding.  Elective Admissions for the locality have increased by 9.8% compared to the same period last year. This is more than the growth of 5.4% across the whole CCG.  Main area contributing to overspend within elective are Osteoarthritis (mainly hip replacements).  Cataracts is also another area with increased activity within elective along with gastrointestinal disorders and breast cancer  Coding issues were discussed especially around chest infections and pneumonia and whether there should be an audit  Discussions were also held around discharge letters and whether coding was being used incorrectly  SA informed the meeting that the final locality report will be issued which will include releasing some of the centrally held budgets now distributed to localities on fair share. This will have the effect of increasing the level of underspend for the locality hence recognising the contribution to CCG meeting its financial balance.

ACTION: SA to circulate the final locality finance paper for 2018-19 financial year.

5. CARE HOME PROJECT UPDATE – AG AG

 Much discussion has centred around the role of ECP and whether this was felt to be the best fit for the locality to provide support into care homes  The plan was that interviews would have taken place by now however both candidates who applied have withdrawn  Could the locality look at recruiting a Matron or Minor Illness role in place of an ECP  The role would be a prescribing role and more aligned to LTC management, caseload management and problem solving  Care Homes have drawn up short lists on specialist areas falling out of the ward rounds this is affecting quality of care and Anil has met with some of the Practice Managers  These posts need to be networked across the localities as they are not stand alone, two Task and Finish meetings have been set up with one planned in April

ACTION: The locality agreed to take this forward from recruiting an ECP to a Prescribing Matron.

6. LOCALITY CFF CANCER UPDATE – SG SG

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 SG informed the locality he had received Q2 and Q3 data submissions from the practices  SG asked if everyone was happy with the data and did they have any questions – no response was received  SG confirmed that the locality were happy to receive updates at the locality commissioning meetings, however it was suggested that the Cancer leads could meet up separately if wanted  CFF 18/19 and 19/20 concerns were raised by VT in particular breast screening, 3 yearly cycle for breast screening, mammograms, cancer indicators not being achievable and concerns around money already been paid to practices  SG has discussed this with Rachel Joyce and Trudi Southam at the CCG who look after Cancer and they have responded to the concerns and SG shared this with the locality  If practices do not reach their Targets there is an appeals process  SE also raised an issue around possible coding issues in cancer indicators and a concern that in the 1st quarter last year this had dropped by 12%  SG will take back all of the above concerns to the CCG Cancer Steering Group

7. PROPOSAL FOR COLLABORATIVE WORKING FUNDS/GPFV FUNDS SG/SE 19/20 – SG & SE

 A discussion was held around Care Home projects and Pharmacists for the locality  A decision was made by the locality to cancel the Pharmacist Pharmacy Hub Project and replace with the physio project as the PCNs will be able to recruit the pharmacists  By using First Point SE talked about the proposal for the introductions of physiotherapists working in the Welwyn Hatfield practices  Patients can refer into the physiotherapist without a GP appointment this enables the patient to see the right person with specialist advice given straight away  Training will also be given to reception staff to ensure the best service is given this is at no additional cost  The aim is to provide 1-2 sessions per week per practice  Total costs for 1 year of service £129,000  TD confirmed figures of £60,000 (for the cancellation of the Pharmacy Hub Project) + £23,270.84 giving a total of £83,270.84  SG confirmed this is what the locality has as current spend at the moment and moved onto agenda item number 6

ACTION: To cancel the Pharmacist Pharmacy Hub Project

8. CARE HOME LES – Gill Benevieste

 GB gave a presentation about the Care Home LES  GB informed the locality about EASE (Educate Advise Support

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Empower) pilot project scheme which is being tested by the Isabel Hospice, GB can provide the locality with this information  If anyone is interested in this MDT project - please contact either Gill Beneviste or Anil Garcia  Funding from the £1 patient money is being looked into

9. ANY OTHER URGENT BUSNESS Winter Pressures (SE)  SE sent a note out to advise that funds were available for Easter pressures  Funding has been allocated for the 2 weeks each side of Easter  SG confirmed we have funding through the CCG from winter pressures, £1 patient money and additional money from the Mondays and Fridays and Care Home rounds this is around 60 sessions  AP has agreed for these in-hour sessions in primary care appointments to be used in April giving additional capacity to practices  These could also be extended into May  Some practices might not have used the Care home and CCG sessions and these can be distributed equally between the practices  All practices were happy with this Physiotherapists as part of GPFV (SE)  This was discussed earlier in the meeting  DES for minor treatment (SE)  This project is at the early stages and has been taken to other Federations this has been done in Herts Valleys CCG and they have shared the LES  Other CCGs have funded ear syringing and suture removing as this is outside of the GMS contract and not funded  If the practices are already carrying out these services then please let the CCG know  A discussion followed around hospitals and what is covered in their contracts and a question was asked are they funded for suture removals etc.  AP asked for the proposal to the finalised and be sent to the CCG MJOG Contract (SE)  MJog is being used as part of GPFV money it provides advanced text, voice and email service, it enables users to automatically send and receive a regular stream of communication  SE asked if the clinical training budget could be used for £1 a patient this was confirmed  PW asked for more information to learn more on what is happening on the provision of services for children with mental health problems

10. DATE OF NEXT MEETING:

Page 6 of 8

6th June 2019, 12.30 – 2.30 p.m. Fielder Centre, Hatfield Business Park Hatfield Avenue, AL10 9TP

The Provider board meeting is going to be a lunchtime meeting going forward but it needs another GP to nominate on behalf of the locality time will be paid for the GP and Practice Manager.

Page 7 of 8

No. Meeting Item No. and Title Action Responsible Deadline Status Date Manager SA to circulate the final locality finance paper for 45 28/03/2019 4. Finance Update 2018/19 financial year. Sunday Adeniyi 06/06/2019 In Progress 5. Care Home 46 28/03/2019 Project Update Locality to recruit ECP and Prescribing Matron Anil Garcia 05/04/2019 In Progress 7. PROPOSAL FOR COLLABORATIVE WORKING FUNDS/GPFV 47 28/03/2019 FUNDS 19/20 Cancel the Pharmacy Hub Project Anthony Deitsch 29/03/2019 Closed 7. PROPOSAL FOR COLLABORATIVE WORKING FUNDS/GPFV 48 28/03/2019 FUNDS 19/20 Add First Point Physio Project to GPFV budget Anthony Deitsch 29/03/2019 Closed Send information around the provision of services for children with mental health problems 49 28/03/2019 9. AOB to Peter Wilson ?? 06/06/2019 In Progress

Page 8 of 8 Agenda Item No: 18

Date of Meeting: 25th July 2019

Governing Body Meeting in Public

Joint Commissioning and Partnership Programme Committee Paper Title: Minutes

Decision or Approval Discussion Information

Report author:

Report signed off by: Joint Commissioning and Partnership Programme Committee

Executive Summary: Approved minutes of the Joint Commissioning and Partnership Programme Committee attached for the Governing Body to note

Recommendations To note the minutes of the Joint Commissioning and Partnership to the members: Programme Committee:

. 27th March 2019

Conflicts of Interest n/a involved:

Conflict of Interest Definitions

The following table describes the sub-classifications of interests:

Type Description Financial Interests This is where an individual may get direct financial benefits from the consequences of a commissioning decision. Non-Financial This is where an individual may obtain a non-financial professional benefit Professional Interests from the consequences of a commissioning decision, such as increasing their professional reputation or status or promoting their professional career. Non-Financial This is where an individual may benefit personally in ways which are not Personal Interests directly linked to their professional career and do not give rise to a direct financial benefit. Indirect Interests This is where an individual has a close association with an individual who has a financial interest, a non-financial professional interest or a non- financial personal interest in a commissioning decision.

Page | 1 Joint Commissioning and Partnership Programme Committee (JCPPC)

27th March 2019, 12:30PM - 15:00PM, MR1.2 Charter House, Welwyn Garden City, AL8 6JL

MINUTES

Present:

Sheilagh Reavey (SR) (CHAIR) Director of Nursing at ENHCCG Sharn Elton (SE) (CO-CHAIR) Director of Operations

Ruth Harrington (RH) Head of Integrated Community Commissioning (or deputy) , HCC

Tom Hennessey (TH) AD Health Integration, HCC / ENHCCG Marion Ingram (MI) Operations Director, Specialist Services for Children, HCC

Simon Pattison (SP) Head of Integrated Health & Care Commissioning Team (IHCCT), HCC, ENHCCG, and HVCCG.

In Attendance:

Anna Hall (AH) Senior Commissioning Manager (MH) IHCCT, HCC

Linda Mercy (LM) on behalf Public Health, HCC of Jim McManus

Adam Solomon (AS) Commissioning Manager, MH, IHCCT, HCC

Tracey Brennan (TB) Commissioning Manager LD, IHCCT, HCC

Jan Gates (JG) Senior Commissioning Manager - LD, IHCCT, HCC

James Salmon (JS) Commissioning Manager, IHCCT, HCC

Page 1 of 16 Item Subject Action by

1. WELCOME AND APOLOGIES FOR ABSENCE

1. The Chair welcomed all to the meeting and colleagues introduced themselves.

2. Apologies were received from:

Jim McManus (JM) Director of Public Health, HCC

Sally Orr (SO) Head of Family Services Commissioning, Children's Services, HCC

Further apologies: Hansa Nariapara Commissioning Officer - HCC (HN)

3. The Chair declared that the meeting is quorate.

2. DECLARATIONS OF INTERESTS

The Chair invited the members to reconfirm their current declarations on the Register of Interests, and advise of any new declarations.

1. All members confirmed their declarations were accurate and up- to-date.

The Chair invited members to declare any declarations relating to matters on the Agenda.

2. All members confirmed they have no declarations in relation to matters on the Agenda.

3. MINUTES OF PREVIOUS MEETING AND MATTERS ARISING

The Minutes of the meeting held on 12.12.19, were approved as an accurate record.

Page 2 of 16 Item Subject Action by The Matters Arising were considered

LD Health checks potentially going to the CFF( Consolidated Funding Framework) -

1. A different way forward has been agreed, and that LD Health checks for East and North Herts, should now be collected via Mede, and for TB to be linking in with Sam Williamson.

4. ACTION TRACKER

The action tracker was circulated in advance of the meeting.

The contents of the Action Tracker were discussed.

The following updates were provided:

1. Action 6 – KB to speak with CS re: Looked After Children (LAC) reviews. Can these be aligned with Learning Disability (LD) Health Checks?

SR – suggested waiting until the next Looked After Children (LAC) quarterly meeting has taken place, as this issue was raised there, in order to feedback regarding the progression of this action. - LAC will review both, the Looked after children reviews, and the LD Health Checks, to see if there are commonalities, and to see if the two can be combined. - An update or feedback can be expected, after the next LAC quarterly meeting scheduled for 12th May 2019.

2. Action 39 – PM to raise the issue of CT (Computerised tomography) Scan at GP leads meeting for discussion.

SP – The CT (Computerised tomography) scan issue has not yet been resolved. There is a Mental and Physical health group (which includes GPs and HPFT - Hertfordshire Partnership NHS Foundation Trust), that is dealing with CT scans. - The issue also involves trying to identify how much capacity there is, in the contracts. - CCG (Clinical commissioning groups) input is not required at this stage.

Page 3 of 16 Item Subject Action by - ACTION - Further update to be provided at the next SP meeting

3. Action 53 – Improving Access to Psychological Therapies (IAPT) Pre-Procurement Market Engagement (PPME) Options – The JCPPC felt that the best option would be to negotiate with HPFT, regarding what the realistic costs would be, for them to grow IAPT capacity. SP to take forward.

SP – This is regarding the option to expand IAPT, as the target was set for 22% in regards to year 2019/20, and 25% for year 2020/21. - It was agreed that this would be done through HPFT, and this is now covered within the HPFT contract. - This can be covered when discussing the HPFT contract

4. Action 58 – KT to provide community navigation service update

ACTION - KT – The item has been deferred, and an update KT will be provided at the next JCPPC meeting (25th June 2019).

5. Action 62 - Workshop to be planned for the end of Feb 2019.

SR – In relation to the discussion that took place at the last JCPPC meeting on the 12th December 2018, about how the JCPPC was functioning, a number of proposals for improvement were taken on board as an outcome of this discussion. - One of the suggestions included planning a workshop, in order to further develop the matters discussed. - One of the main issues discussed, was the Better Care Fund (BCF), and a review of the BCF was mentioned in the NHS Long Term Plan that was published in January 2019, however the review of the Better Care Fund is yet to be published.

SR – Spoke to Iain McBeath and agreed that there is more value in planning the workshop, once the review of the BCF has been published, and once funding has been agreed in order to have an informed discussion.

6. Action 64 - SR and SP to review the wording of the TOR (Terms

Page 4 of 16 Item Subject Action by of Reference), and consider changes to be made in addition to input from members.

SR - The TOR was discussed at the last meeting when the effectiveness of the Committee was also reviewed; changes have been made to the TOR to reflect this, and circulated to members for any further comments. - The updated TOR will be going to Governing Body (GB) tomorrow (28th March 2019). - SR requested members to confirm as to whether the TOR is now suitable for its purpose. All members at the meeting agreed that the current TOR is fit for purpose.

SR – The TOR will continue to be reviewed on an annual basis following sign off by GB.

7. Action 65 - Individual Placement Support (IPS) - outcome of Expression of Interest bid.

SP – IPS is the bid that was submitted to NHS England (NHSE) for funding, to expand Mental Health (MH) employment support. Currently, no formal response has been received, regarding whether this has been successful or unsuccessful.

8. Action 66 - Hospital and Community Navigation Service Update (data and IBCF funding) - update at next meeting.

- Item has been covered within; Action 58

The Action Tracker has been updated to reflect the updates provided.

The Committee noted the Action Tracker.

5.1 Operational Performance

5.1.1 IHCCT Exception report

1. The report which was circulated in advance of the meeting provided an update on current issues relevant to the IHCCT portfolio.

Page 5 of 16 Item Subject Action by SP provided the following highlights:

HPFT Performance:

2. The Adult 28 days and CAMHS 28 days wait - still remains a challenge. Adult 28 days wait, will be discussed within the HPFT contract negotiations. A way forward has been agreed with HPFT in the form of a remedial recovery action plan to be submitted from HPFT to IHCCT by 15th April 2019 so will have this for circulation to the next JCPPC meeting as an update. In relation to improvement trajectories, these are for HPFT to provide by the 15th April 2019, alongside the recovery action plan.

ACTION - SR requested for the improvement trajectories and AH/ the recovery action plan to be added on to the agenda at the IHCCT next JCPPC meeting, and reported on a monthly basis.

3. In terms of outcomes of CAMHS Did Not Attend (DNA) audit, this is due in June 2019, and will go to the Quality Review Meeting.

IAPT Any Qualified Provider (AQP)

4. SP – Currently below target in terms of the AQP performance. 5. Currently above target in terms of HPFT performance. 6. Recovery has been good; however waiting times still remain a challenge for IAPT, which is partly due to capacity issues in relation to AQP Providers, and more people being referred into HPFT than was originally commissioned. 7. Alongside a proposal to invest additional funding into AQP providers per session, a new AQP framework commissioning process will commence this year to increase capacity.

8. SP – HPFT have reduced their over performance 9. Growing overall IAPT capacity via HPFT

10. SE – Report highlights plans for delivering 19%, and 25% over the next few years, so would be helpful to see a trajectory.

11. ACTION – trajectory to be provided in next IHCCT exception AS report

Dementia

12. SP – Number of dementia diagnosis’ required to meet target,

Page 6 of 16 Item Subject Action by decreased from 12 below target, to 40 below target, so there is work to do with practices in order to improve coding. TB 13. AS – A recovery action plan has been put in place in regards to East and North Herts Dementia coding.

14. SE – It is important to ensure that locality managers are linked in to letters addressed to practices, advising them of their position, and then focusing on practices that are below target.

15. SP – This can be a new item for the next contract meeting next week.

16. SE – It should be considered as to whether all appointments are necessary, in order to look at ways that capacity can be expanded. Perhaps test this for at least one month.

17. Review and audit of the One Stop Shop pathway will be conducted in Q4

EMDASS

18. SR – A list of actions have been provided however, it is unclear as to how significant the impact will be. 19. AS – This issue is that once moving over to the one stop model, HPFT are not able to provide the data, and so reporting took longer than expected. We have requested a detailed trajectory; however one of the issues is the fact that CT scanning still has not been resolved, and there are also time issues in regards to HPFT. 20. SP – We are taking this to contract meeting

ACTION – SP/AS to raise issue regarding CT scanning at the next SP/AS Contract meeting

Learning Disabilities Health Check Performance

21. TB – The Quarter 4 figures for the LD annual health checks will be available after the 11th April 2019, which is the NHSE deadline for all GP claims to be submitted.

22. GPs have been responsive to Newsletters circulated to practices regarding submitting claims by the 11th April 2019 deadline.

Page 7 of 16 Item Subject Action by 23. The assessment carried out by NHSE of the LD Annual Health Check figures (2017/18), indicated that there was a discrepancy between actual completed figures and the number claimed within the timescales set by NHS Digital. This has led to the CCG performance figure being significantly lower than what was actually achieved.

ACTION - TB to check discrepancies regarding QOF register TB numbers, and NHS reporting

Learning From Death Reviews LeDeR

24. TB - The figures have been broken down according to the number of deaths from East and North. 25. TB – Integrated Health Oversight Group (IHOG) is moving forward on a number of issues, from the joint action plan with LeDeR (IHOG and LeDeR joint action plan)

26. TB – Improving Health Outcomes Group (IHOG) moving forward on a number of areas. Both LeDeR and the IHOG group have an outcome based joint action plan. 27. A number of specific pieces of targeted work is happening, which will have elements of measurement to understand progress: • Impact of specialist physiotherapy and postural support • Advanced care planning with people with complex needs • Flu immunisation vs hospital admissions • Uptake of training

STOMP - STAMP

28. TB – This is in relation to overmedication of people with LD and/or autism. 29. The Task and finish group has been reviewed and widened: 30. Representation will be provided from the Autism Board 31. Sally Orr in Children’s Services and health commissioners will be representing children.

32. TB – The Learning Disability strategy was signed off at the last ENHCCG Governing Body (13th March 2019.).

Transforming Care

33. JG – There are four disputes around responsible commissioning

Page 8 of 16 Item Subject Action by currently. Maintaining balance of patient needs is proving to be challenging. 34. Conversation needed with each CCG equivalent of Director of Nursing to resolve. 35. There are increasing pressures in Hertfordshire areas in terms of placements for individuals, so currently developing community services to place people into. JG and Eleanor Atrill are currently working on negotiation and escalation regarding this. 36. There are some challenges with the Mental capacity act, as there have been activity and counter activity reports about the legalities of people deemed to have capacity excepting community packages where they are restricted; due to jurisdiction practices. 37. There is a cohort of people who have had CETRs/CTRs 38. In terms of funding pressures, this will be more apparent with more people not known to services, coming into the team through A&E and S136 suites.

39. MI - There are also Safeguarding issues for staff and service users to consider, who are put into supported arrangements where there are staffing issues/concerns regarding quality of care provided.

40. Need to consider how to share risk with providers on packages for people placed. Currently the provider holds all the risks.

SPA

41. AH – The overall numbers have increased in terms of capacity, including CAMHS referrals. 42. SP – This partly reflects more people using SPA as a singular access point to CAMHS (40-50% higher than in 2014).

First Response Crisis Service

43. AH – This is a new Service with the Crisis Assessment treatment team (CATT) workers working within SPA.

NHSI E-Referral System (E-RS) pilot

44. AS – This is currently in the early stages, and a meeting with NHS Digital and single point of access HPFT has taken place. 45. Trials will take place across North West Hertfordshire – with 33 surgeries. 46. The long term plan is to have this migrated to East and North.

Page 9 of 16 Item Subject Action by 47. Suggestion that there is an opportunity for learning from Acute Trust, as there are a number of companies supporting them implementing their ERS systems. These companies might be able to assist with ERS establishment within primary care for MH referrals.

ACTION – AS to investigate contacting AS CAMHS 28 day access

48. SP – The major issue is the 28 day wait performance for January which dropped to 28.36% across Herts and 39.29% in East and North. 49. The view from HPFT is that demand has increased, and there are also staffing issues which affect this. 50. This also feeds into the contract negations, as HPFT state that they would not be able to meet the target without a whole system re-design. 51. It has been agreed that there will be a whole system demand and capacity piece of work within the next 6 months, and HPFT are expected to hit the target by 2020. 52. SE – How realistic would it be to deliver against the trajectory? 53. SP – This would be a remedial action plan through the contract process, and what has been built into the contract process. An action plan is to be provided by end Q1 and updated against this is to be reported monthly. 54. SR – It would be useful to see the detailed recovery trajectory to understand aspirations.

ACTION - SP – To update at the next meeting regarding the CAMHS SP 28 day wait recovery trajectory.

PALMS

55. MI –Highlighted the issue of having carers delivered against the PALMS model of intervention and outreach workers to provide the same. This was the main reason why Children’s social care provided funding into PALMS contract. When Wilbury was closed, this was about having this support in the home so that children did not need an overnight respite. 56. Marion requested this in incorporated into review (social care elements)

Mental Health (MH) Discharge Home to Assess (DH2A) pilot

Page 10 of 16 Item Subject Action by

57. AH – This pilot is planned to start by April, next financial year – 2019/20, running for 6 months, and then possibly looking at wider supported living procurement or other options that come out of the evaluation. 58. Suggested at ENHCCG SRG meeting (March 2019) that ECIST colleagues are contacted to seek NHSE support for pilot/evaluating model which has not been done before.

59. ACTION: AH to flag with JS and feedback AH

5.2 Strategy/policy issue (commissioning intentions)

5.2.1 Operating Plan – MH/LD Funding Commitments/Requirements

1. SP – The key areas highlighted include – meeting the MH investment standard in 18/19 and insuring that this is delivered by having extra CCG funding put into HPFT Another area includes the agreements made within the HPFT contract, in which the aim is to have this signed by Friday – subject to Cambridge and Peterborough agreeing their contribution. The Perinatal MH team - the team was established with NHSE funding, which is coming to an end, and will be picked up by the CCGs There is also the issue of Crisis and expanding Crisis provision within HPFT in line with the 5 year forward view requirement. In terms of IAPT, a 2 year trajectory has been agreed Mediation – Cambridge and Peterborough have requested to reduce their contribution to the HPFT contract by 1.2 million which went to NHSE for a decision. Pooled budgets have been agreed and set up

2. MI – Suggested other key areas to invest in, which includes Self harm (linked to suicide), and recommended investing in self-harm toolkits or educational support, rather than suicide - spot the signs funding.

ACTION - SR – Discussions regarding targeted funding for CYP, in SR relation to self-harm; to be raised at the CAMHS Board. 5.2.2 Voluntary Sector Contracts Report

1. AS – A number of contracts have been transferred over to IHCCT

Page 11 of 16 Item Subject Action by from the Community and well-being commissioning team. Fundamentally contracts are working within the contract requirements, and there are a few changes that may be made in future, so on this basis, an extension has been recommended on these contracts, in order to allow commissioners to go out to procurement. 2. SE – Need clarity on how these contracts differ in terms of the services, so work to be done around looking at queries of duplication, and overlap. Also what are the benefits? 3. AS – The services will be further reviewed, and non-IAPT compliant services will be short term. 4. SP – The plan will be to have strategic conversations with the providers including Herts Mind, in order to look at what they can do within the current cash envelope. 5. SE – suggested shorter timescales, as 21 months is too long, so 12 months would be adequate and also carrying out market development sessions to signal intent regarding what IHCCT are planning to do. 6. TH – The impact and the value being provided needs to be demonstrated, and 12 months would be adequate to prompt the pace for providers to respond. 7. RH – recommended considering how to request the providers to work together and implementing a pilot for one year, then to go out to tender, the following year. 8. RH – offered to provide support as RH has links or connections with Mind organisations

AS/RH ACTION: AS to link in with RH

5.2.3 Lower Lea Valley (LLV) GPwSI pilot evaluation

1. JS – This was discussed at East and North OPD. The paper captures an evaluation of the pilot project that has been running in Lower Lea Valley since April 2018, where GPs are diagnosing cases of suspected dementia in a community clinic as an alternative to sending individuals through EMDASS. 2. In terms of outcomes – the levels of satisfaction of the patients that reviewed the process were consistently high. 3. Good communication with patients around meetings, and appointments, which has led to lower DNA rates in GPwSI clinic than seen in EMDASS. 4. There is still work to do in looking at how much support HPFT EMDASS services provide into the clinic, so work around triaging cases etc. Recommendations that came from OPD, included: 5. To continue with the pilot and look at engaging with Primary Care

Page 12 of 16 Item Subject Action by to discuss how a similar model or variant model that suits another locality can be adapted and implemented, so seeing if this would be transferable.

ACTION - SE – Need to see more figures/ data from the services, which may come from the triaging. JS to provide. JS

5.2.4 HPFT Contract

1. AH – The challenges currently involve Cambridge and Peterborough(C&P) CCG contribution. This was advised late in the process, and the recommendation from mediation, was for reduction to be made over 3 years, down from £1.6k to £400k. 2. Currently waiting on confirmation of an interpretation of this from C&P, including data around figures.

3. What has been completed, in terms of the contract includes: • The Quality schedule • Section 75 • Service specifications and • CQUIN (nationally mandated) has been agreed

6. Integrated Care Programme Team

6.1 Better Care Fund Quarterly Report (including funding commitments)

Performance

1. TH – In terms of non-active admissions, this has increased within Q3. 2. An increase in Sickness and flu at the beginning of winter, which contributed to the increase in admissions. During this period, there has also been change in how East and North Herts Trusts have been coding admissions. 3. In regards to - Long term support needs for older adults, met by admissions to residential nursing – there has been an increase, so expecting this position to improve by Q4. 4. Currently reviewing a short-stay bed strategy for East and North Herts with HCC, and this is attempting to review capacity.

Page 13 of 16 Item Subject Action by 5. Will be looking to bring paper to the next JCPPC meeting. 6. On target in regards to hospital readmissions, which may be due to the community navigator service or integrated care frailty service launched in December 18 7. There has been a downward trend for DToCs over the last 12 months from a social care perspective. The data does not specifically highlight the position of Eats and North Herts. 8. Challenges still remain around packages of care – particularly for social care which has been a consistent issue. 9. Overall East and North Herts have a more positive performance in terms of BCF matrix.

10. SR – It would be useful to see how each of the sub schemes are performing in order to understand whether the problem with meeting targets is an issue stemming from the schemes collectively, or an issue with an individual scheme. 11. SE – highlighted that there are inconsistencies in both reports, in terms of the figures.

ACTION - TH to ensure future reports address performance of each sub scheme and to present paper at the next meeting TH (25th June 2019) regarding - review of short -stay bed strategy, looking at capacity.

7.1 Community Commissioning for Adult Disability Services

Community Spend Update

1. RH – This is informational, and regarding the general spend for adults under 65 in the community (Day services) 2. This is work that runs alongside the supported living transformation 3. It is also a summary of a number of engagement events, and discussions with users of current services - including future possible users of community spend, in order to insure the shaping of a market; to meet the needs of the future. 4. There is an ongoing contract management of over 70 providers (voluntary sector, and small community organisations) – looking at quality assurance, financial stability etc. 5. In house provision is more than 50%, and costs are being reviewed 6. There are a number of projects planned to run within the next year – focussing on: Cash savings, preventable spend, market shaping and legal requirements.

Page 14 of 16 Item Subject Action by

Agreed Projects/ work streams: 7. Community spend tender 19/20 to get consistent pricing, more enablement, training and work focused services. 8. Modernisation of in-house Day Service 9. Focus on Direct Payments. Tariffs & contract negotiation with existing Providers

ACTION - SR – The East & North Herts Delivery Board and the Primary Care Networks will have a key role in this, so this should be presented to the Delivery Board. RH

8 Papers/Updates for Information 8.1 None this month

9 ANY OTHER URGENT BUSINESS

None this month

10 SUMMARY OF ACTIONS AGREED AND BUSINESS CYCLE ITEMS FOR NEXT MEETING

1. SR – highlighted the issue mentioned in the review of the JCPPC regarding the agenda currently being mostly adult focused, which needs to be taken into account when looking at the business cycle.

2. ACTION - AH – Requested Joint Children Services assessment tool, to be brought to the next meeting (25th AH June 2019)

3. ACTION - SR – agreed for the SEND update item to be a AH standing item for JCPPC meetings.

11 DATE OF NEXT MEETING –

Page 15 of 16 Item Subject Action by 25th June 2019, 13:30 – 16:00, MR1.2 Charter House, Welwyn Garden City, AL8 6JL

Please send any apologies to IHCCT Admin Support [email protected]

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