Herts Valleys Clinical Commissioning Group

Session in Public

Thursday, 18 January 2018 at 2.00pm at Niland Conference Centre, Rosary Priory, 93 Elstree Road, Bushey Heath, Watford, Herts. WD23 4EE

Note concerning HVCCG management of conflicts of interest.

A conflict of interest occurs where an individual’s ability to exercise judgement, or act in a role is, could be, or is seen to be impaired or otherwise influenced by his or her involvement in another role or relationship. In some circumstances, it could be reasonably considered that a conflict exists even when there is no actual conflict. In these cases it is important to still manage these perceived conflicts in order to maintain public trust.

Members and attendees of the Board are reminded of their responsibilities.

To ensure transparency and openness, individuals should notify the Chair of any potential conflicts of interest in relation to agenda items, even if the interest is already formally recorded.

Herts Valleys Clinical Commissioning Group Agenda

Board Meeting Held in Public Thursday, 18 January 2018 at 1.00pm (session in public at 2.00pm) at Niland Conference Centre, Rosary Priory, 93 Elstree Road, Bushey Heath,Watford, Herts. WD23 4EE Meeting in private 1.00 pm to 2.00 pm Led by In accordance with section 1 (2) Public Bodies (Admissions to Meetings Act 1960), The Board resolves that: Representatives of the press, and other members of the public, be excluded from this meeting having regard to the confidential nature of the business to be transacted, publicity on which would be prejudicial to the public interest

Note to representatives of the press and members of the public Members of the public are reminded that CCG Board meetings are meetings held in public, not public meetings. However, the Board provides members of the public at the start of each meeting the opportunity to ask questions that relate to the agenda items. The Chair will not normally allow more than one question per person due to time constraints. The time given over to questions will need to be limited in order for the board to cover their agenda fully within the given time

Members of the public are urged, if possible, to give notice of their questions at least 48 hours before the beginning of the meeting in order that a full answer can be provided; if notice is not given, an answer will be provided whenever possible but the relevant information may not be available at the meeting. If such information is not available, the CCG will provide a written answer to the question as soon as is practicable after the meeting.

The Secretary can be contacted by email ([email protected]), by telephone (01442 284074), or by post to: Board Secretary, Herts Valleys Clinical Commissioning Group, Hemel One, Boundary Way, Hemel Hempstead, HP2 7YU.

Audio Visual Recording The CCG does not permit audio or video recording of the board meeting unless expressly agreed by the Chair in advance of the meeting and with prior agreement of all members of the public present at the meeting. Anyone found using such a device without prior agreement will be asked to cease recording and may be asked to leave the meeting.

Herts Valleys Clinical Commissioning Group Agenda

Administrative items Led by 1. Chair’s introduction Verbal – for information Nicolas Small 2.00 pm 2. Interests to declare Verbal – for information Nicolas Small 2.05 pm Link to registers of interest: http://hertsvalleysccg.nhs.uk/about-us/managing-conflicts-of-interest 3. Minutes of previous meeting Attachments - for approval Nicolas Small 2.10 pm 9 November 2017 4. Matters arising and action log Attachment - for approval Nicolas Small 2.15 pm 5. Chief Executive’s report Attachment – for discussion Kathryn Magson 2.25 pm Strategic discussion 6. Board Assurance Framework Attachment – for discussion Rod While 2.40 pm 7. STP progress report Attachment – for information Kathryn Magson 2.55 pm 8. Rapid Assessment Interface and Discharge Attachment – for approval David Evans 3.05 pm (RAID) Simon Pattison Break 3.20 – 3.30 pm 9. Committee chairs reports Attachment - for discussion Committee chairs 3.30 pm 10. Integrated Quality, Finance and Attachment – for discussion Stuart Bloom 3.40 pm Performance report Diane Curbishley 10a. Quality and performance 10b. Finance Caroline Hall 11. Appointment of the patient representative Attachment – for approval Alison Gardner 4.00 pm to the board 12. Communications and engagement Update Attachment – for information Juliet Rodgers 4.10 pm 13. ENH CCG / HVCCG Joint Committee draft Attachment – for approval Nicolas Small 4.20 pm minutes 12 October 2017 14. West Herts Hospitals Trust CQC Report Attachment - for discussion Katie Fisher 4.30 pm 15. Urgent care services in Hemel Hempstead Attachment – for approval David Evans 5.00 pm – consultation proposal Richard Pile Corina Ciobanu

16. Committee meetings minutes 5.25 pm 16.1 Primary care commissioning committee Attachment – for Information Thelma Stober 26 October 2017

16.2 Commissioning executive committee Attachment –for information David Buckle 21 September / 19 October 2017 / 16 November 2017

16.3 Quality committee Attachment –for information Stuart Bloom 2 November 2017 / 14 December 2017

16.4 Integrated quality and finance & Attachment –for information Paul Smith performance committee 2 November 2017 / 14 December 2017

16.5 Finance & performance committee Attachment –for information Paul Smith

Herts Valleys Clinical Commissioning Group Agenda

2 November 2017 / 16 November 2017 / 14 December 2017

17. Risks identified during the meeting For Agreement Chair 18. Date and time of next meeting Verbal Chair 5.30 pm Venue The Stanborough Centre 1pm for private session, 2pm for public session 8 March 2018

DRAFT

Item 03

Meeting : NHS Herts Valleys CCG Board Meeting in Public

Date : 9 November 2017

Time : 14.10 – 17.40

Venue : Watermill Hotel and Conference Centre, London Road, Bourne End, Hemel Hempstead, Herts, HP1 2RJ

Members present: Nicolas Small (NS) Chairman (Hertsmere GP) Stuart Bloom (SB) Board Lay Member Paul Smith (PS) Board Lay Member Thelma Stober (TS) Board Lay Member Alison Gardner (AG) Board Lay Member Mike Edwards (ME) Board GP Member (Hertsmere) Corina Ciobanu (CC) Board GP Member (Dacorum) Trevor Fernandes (TF) Board GP Member (Dacorum) Richard Pile (RP) Board GP Member (St Albans and Harpenden) Mike Walton (MW) Board GP Member (St Albans and Harpenden) Rami Eliad (RE) Board GP Member (Watford and Three Rivers) Caroline Hall (CH) Chief Finance Officer Kathryn Magson (KM) Chief Executive Officer Clair Moring (CM) Board GP Member (Watford and Three Rivers) Clare Saunders (CSa) Deputy Director Nursing and Quality Thida Win (TW) Secondary Care Clinician In attendance: John Wood (JW) Chief Executive and Director of the Environment, Herts County Council David Evans (DE) Director of Commissioning Brian Gunson (BG) Healthwatch Representative Hein Scheffer (HS) Director of Workforce David Buckle (DB) Medical Director Juliet Rodgers (JR) Associate Director, Communications and Engagement Caroline Sutherland (CSu) Patient Representative Avni Shah (AS) – to B/115/17 Programme Director – Planned and Primary Care Ian Armitage (IA) B/117/17 to B/118/17 Programme Director – Urgent Care Rod While (RW) Head of Corporate Governance

B/107/17 Welcome and apologies 107.1 The Chair welcomed the board and members of the public. Apologies for absence were received from Daniel Carlton-Conway, Raja Ganguly, Jim McManus, Iain MacBeath, Kevin Barratt and Diane Curbishley (Clare Saunders attending).

B/108/17 Declarations of interest 108.1  All board members declare their conflicts of interest which are published on the HVCCG website and also specifically declare interests in any agenda item to the board secretary in advance of each board meeting. GP members of the board have confirmed their usual conflicts, specifically in relation to CCG financial budgets and primary care services. Other interests declared were as follows: o JW declared an interest in the items: “CEO Report”, “Board Assurance Framework”, “committee chairs reports” “integrated quality and finance report” and “outcomes of joint committee with East and North Herts CCG and amended policies”. o It was agreed that all GPs were somewhat conflicted for the “outcomes of joint committee with East and North Herts CCG and amended policies” item as decisions made on policies could impact their practices. It was agreed that this would not prevent GPs from making a decision on the policies.  A detailed breakdown of conflicts of interest is attached as appendix 1. 108.2 The board noted the declarations of interest

B/109/17 Minutes of previous meeting 109.1 PS noted that 93.5, 8th bullet should read 4% of turnover or £20m. 109.1 The board approved the minutes of the meeting held on 14 September 2017, subject to the above amendment.

B/110/17 Action Log 110.1  B/93.7/17: Preparation for GDPR is still open.  The due dates for 99.4 and 100.4 have not yet been reached.  The three completed items: 91.4, 93.6 and 104.1 can be closed. 110.2 The board noted the updates

B/111/17 Chief Executive Officer’s Report 111.1 KM introduced the report with the following points:  In terms of financial assurance, the CCG has been de-escalated by NHSE.  A thematic CAMHs review has been held across Herts, the visit went well.  Since the last board meeting, the January 2017 decision on Nascot Lawn has been set aside on advice that the legal advice received at the time of the decision was inaccurate. The CCG is currently in the process of concluding the engagement work with families and a new funding decision will be made on 16 November at the finance and performance committee. We have extended the additional engagement time period for families and outcomes of this is being finalised.  Private Ambulance Services were issued a winding up order by HMRC in October and we needed to establish a new provider within 24 hours. The new service provided by East of England Ambulance Service (EEAST) is not completely in place as yet but is performing reasonably well considering the circumstances. Work is continuing on a more permanent multi-year contract with the EEAST.  The demand management programmes are progressing well with each locality developing plans to address the quality of referrals.  The CCG board has agreed to re-commission community services via a competitive dialogue process. We intend to award a contract to start in April 2019. 111.2 The following points were made in discussion:  RE stated that regarding CAMHs we have been particularly effective in securing national funding for tier 2 services and perinatal mental health.  It was clarified that the CCG will be seeking financial redress for the original incorrect legal advice regarding Nascot Lawn.  It was clarified that HCC has confirmed that it has a statutory responsibility to commission respite care and board members expressed disappointment that a funding 2

proposal from HCC had not been received.  ME stated that he was very disappointed regarding comments made by councillors in the press regarding Nascot Lawn, implying that the CCG should be funding respite care.  KM stated that we plan to make a statement to the media following the decision on 16 November, whatever the decision outcome.  NS stated that the process around Nascot Lawn had been very humbling and moving. We have heard from parents and families in great detail and this is a very difficult decision that the CCG is considering.  TF stated that our members welcome the activities of the GP Forward View and winter resilience. 111.3 The board noted Chief Executive Officer’s Report

B/112/17 Patient Story 112.1 HS introduced the item with the following points:  Over the past 18 months, we have established a working relationship with the Watford Workshop.  We have a volunteer policy which provides for staff to work in our community for 5 days per year.  The Watford Workshop is a sheltered employment organisation to whom we have supplied CCG volunteers.  The organisation provides people with learning disabilities with life skills and employment placements.  In HR we have now employed an individual from the workshop – WP.  HS welcomed MB who had experienced the workshop and was here to relate her story to the board. 112.2 MB gave her story as follows:  At the age of 7 she fell off her pushbike and suffered a life changing accident which caused a massive brain haemorrhage.  Her parents were told by doctors that she would not survive.  After leaving school she went to college and then tried for two years to get a job, without success.  She volunteered at a number of organisations but could not get a permanent job. Most days she would get up and have nothing to do.  Eventually the job centre asked her to go to Watford Workshop to do some admin work.  She was given a friendly welcome and not treated any differently because of her disability.  After a few months she got a job as a fund raising coordinator and is still working in this position.  She has seen a number of people from the workshop move on to mainstream employment.  After a large fund raising event she was approached by the manager of a local business who offered her a one day a week job. She now also does admin work at a construction company.  These companies are very inclusive and do not treat her any differently. 112.3 The following points were made in discussion:  MW asked whether there were any ways in which doctors and nurses had helped her. MB stated that she had been told she would never work but that the physiotherapists had pushed her. She was in the hospital for three months so she owes her life to the NHS.  NS asked how an employer could make it easier for people with learning disabilities to work. MB said that this was about being open and giving people the opportunity.  SB stated that his experience was that organisations needed to train their staff in how to

work with people with learning disabilities. It was noted that the CCG had done this in the case of WP. 112.4 The board thanked MB for her eloquent and inspiring story.

B/113/17 Board Assurance Framework 113.1 RW introduced the BAF with the following points:  He reminded board members that we had moved the BAF to the beginning of the board agenda to enable all other papers to be put into context. The full BAF sits behind the summaries that are included in the paper.  Following the last board meeting we have now added an end of year forecast to every risk on the BAF.  There are number of proposed changes in risk score: o 1.2 Practice engagement from 16 to 12 o 2.2b NEPT reduced from 20 to 16 now that contingencies have been put in place o 4.2a QIPP scheme identification 20 to 12 o 4.2b Delivery of QIPP 20 to 16 113.2 The following points were made in discussion:  TF stated that there some tough negotiations with West Herts Hospitals Trust (WHHT) and drew attention to 3.2 “…insufficient support from local bodies…” and the possible need to increase the risk score for this.  KM stated that she was also concerned about 3.2 as we have no definitive timelines for the WHHT SOC and no current commitment from the regulators.  It was noted that the forecast for 3.3 should be red rather than amber.  KM stated that she had received comments from public health regarding risk S03/03 on the corporate risk register. There are two risks as part of this. One is that the public health consultant was going on maternity leave, it was noted that this had now been addressed with the recruitment of a locum. The other aspect is attendance of meetings and we have received assurance that the Director of Public Health or his deputy will be attending board and primary care commissioning committee meetings. The risk score should be adjusted to reflect this.  MW referred to BAF 1.2 – practice and stakeholder engagement – and asked what evidence there was that this had improved. DB stated that there was a plan in place to improve engagement around DXS, the number of GP forums has increased and it was felt that the October meeting was very successful. KM stated that 12 was still a high score and there was still a great deal of work to be done on this.  PS felt that the BAF constrained the board as it covered a calendar year and risks were more long term than that. The board should now be looking at strategic objectives for 2018/19 to make sure we have continuity. KM stated that we should begin to look at strategic objectives in January in order to develop risks for 2018/19. 113.3 The board noted the BAF and CRR assurance summaries and review and approved the adjusted risk scores and the addition of a forecast for end of Q4. 113.4 ACTION: DE to review BAF 3.2 with a view to increasing the current risk score. 113.5 ACTION: DE to review CRR risk S03/03 – public health support.

B/114/17 STP progress report 114.1 KM introduced the report with the following points:  The challenge for the CCG over the next few months is to integrate our areas of transformation with that of the wider STP. This has been the case for the frailty workstream which is completely integrated across the STP.  The challenge for the STP presently is to define what the added value is.  CEO led meetings take place every two weeks and increasingly workstreams are presenting this group on progress.  As an STP we are a system in deficit and this is an area of major focus. 4

 114.2 The following points were made in discussion:  In response to a question from RE, KM clarified that three winter plans had been developed across the STP and these have been aligned and submitted to NHS England.  SB asked whether provider and commissioner financial forecasts were significantly different. KM stated that this was significant for HVCCG as we believed there were a number of acute areas that had not been commissioned. A number of trusts are struggling with elective capacity.  PS stated that he was struggling to see the progress against closing the system financial gap of £550m by 2020/21. KM stated that we will not close the gap this year and we need to understand as a system how activity will change as a result of the transformation programmes.  TF stated that there are a number of risks associated with the STP strategy and one is the difference in culture between primary and secondary care clinicians. Another risk is the achievability of workforce plans.  NS stated that pace of delivery across the STP needs to be stepped up.  CS stated that there was a disconnect in the public’s understanding of Your Care Your Future and the STP.  SB observed that the challenges for the CCG are very different now compared with two years ago when the STP was first put in place.  We have a responsibility to drive forward the STP agenda in order to ensure that we transform services to meet the needs of local patients. 114.3 The board noted the TP progress report

B/115/17 Award of MSK contract 115.1 DE introduced the paper with the following points:  A contract award was made for integrated community MSK, pain, rheumatology and postural stability in October to Connect Physical Health Centres Limited. This is a 3 year contract with an option to extend for two years.  We now need to ensure that the service is effectively mobilised to begin delivery from January. 115.2 The following points were made in discussion:  TF asked whether we were confident about the financial health of the organisation. DE stated that this had been thoroughly addressed.  CC asked whether there had been any engagement between the acute trust and the new provider. AS stated that discussions were taking place with WHHT and the Royal Free.  PS stated that for all contracts we need to ensure that providers are compliant with the General Data Protection Regulations (GDPR). AS stated that this will be incorporated into the mobilisation plans and we require an annual return that assures us that the provider is compliant.  NS asked to what extend Connect was going to utilise the existing workforce in their services. AS stated that at present all of the workforce that was within the AQP providers will not TUPE but staff from HCT would. AS clarified that physiotherapists from AQP providers were not required to deliver the service.  KM proposed that the full mobilisation plan should be submitted to commissioning executive committee and the GP forum. 115.3 The board noted the award of MSK contract 115.4 ACTION: DE to take MSK mobilisation plan to commissioning executive committee and GP forum.

B/116/17 Committee Chairs Reports 116.1  Regarding the quality committee SB stated that the committee was still concerned about WHHT and their complaints procedures and poor response rates. 5

 TF stated that WHHT mortality rates were good and all cancer targets were now being achieved.  It was noted that HUC were to deliver “spotting the sick child” training and the committee had requested further information on this.  KM noted that we have invited HUC to attend the next meeting and present on a number of issues. 116.2  Regarding PPI committee AG stated that “Let’s Talk” had been a subject of assurance at the meetings and the committee was assured that the process had been effective. 116.3 PS stated that he thought the management team were doing a good job in supporting the chairs reports and this was a good process. 116.4 The board noted the chairs reports

B/117/17 Quality and performance report 117.1 KM introduced the paper with the following points:  Feedback on the revised format of the report has been positive.  The national direction of travel is focused on A&E, cancer 62 days and financial balance.  Delayed Transfers of Care (DTOCs) – we have submitted a trajectory to be at 3.5% by the end of November. We are still slightly above this and progress is being made. HCT have made progress in length of stay.  We remain slightly below target on referral to treatment (RTT targets).  There is a dedicated report on urgent care as one of the papers as all boards have been asked to review this.

117.2 The following points were made in discussion:  TF noted that the dementia diagnosis performance against target had improved very much over the past few months. MW however was concerned that care and support needed to be in place now that more people were being diagnosed. DE stated that there is a growing need and that there was a plan in place with the voluntary and community sector to address this.  ME felt it was important to remember that whilst RTT was not a major focus at present, we need to remember that there are patients behind these figures and we should not lose focus on it.  TF stated that in relation to patient experience for cancer patients that there was a plan in place at WHHT to improve this.  AG raised a concern about the performance on the stakeholder survey 164a “the effectiveness of working relationships in the local system” and wished to know what actions were being taken to address this. NS stated that the performance was a reflection of where we were when the survey was done. AG felt that this remains an ongoing issue as the evidence was that when we make a difficult decision, the relationships do not appear to be a strong as we had thought. KM stated that this is on the BAF for that reason.  IA stated that we are undergoing some shared training with the System Resilience Group and how we overcome the fallout of difficult decisions. 117.3 IA introduced the urgent care report with the following points:  We are seeing improvements in DTOCs.  We have developed a discharge to assess approach.  Targets for ambulance handover times are not yet being achieved but are improving.  NHS 111 calling handling service is above target.  GP in ED service is being revised in December to generate more activity through to the primary care clinician, rather than A&E.  An urgent care strategy is being developed and the main focus of this is the development of an urgent treatment centre.

 The winter plan has been assured by NHS England but SRG is doing further work on this. 117.4 The following points were made in discussion:  RP stated that we would like to implement point of care testing in ED as currently if the GP in ED wants diagnostic tests; the patient has to go and wait in majors.  NS raised a concern about on-going IT issues at WHHT which did not seem to be improving.  TF agreed that IT was critical to patient flow and bed management.  KM stated that the trust had accepted that they needed to implement a new bed management system, but there is no delivery date at present. We therefore need to consider what actions we can take in the near future to support system resilience.  KM has authorised the purchase of more step down bed resource to support winter and to put some pressure on patient flow from HCT.  TF stated that there was an issue with the DVT service in Hemel Hempstead as a number of patients were diverted to Watford as GPs weren’t always clear on whether the service was running at any particular time.  NS stated that we have not, despite all of the hard work, seen evidence of anything that would transform urgent care performance. CM felt that point of care testing would achieve this.  ME stated that we need be assured that enough is being done to prevent patients entering the system inappropriately. JR stated that we are supporting the national “stay well this winter” campaign. There is some evidence that negative messages encouraging people not to behave in a certain way actually causes them to do just that. The focus therefore is on using 111 or pharmacy; however the 111 campaign is not a national campaign.  NS noted in conclusion that there are systemic issues such as IT, manpower issues and also national issues. A further discussion is required at commissioning executive to explore further potential solutions.

117.5 The board noted the performance report, including the significant challenges in urgent care this winter 117.6 ACTION: IA to bring further discussion on urgent care solutions to commissioning executive.

B/118/17 Finance Report 118.1 CH introduced the paper with the following points:  The report went to F&P committee last week.  The YTD position is a deficit of £2.6m but we believe we can pull this back to our control total by the end of the year.  We are reporting a slight over performance on QIPP but there are still risks such as contractual variations with the trust. 118.2 The following points were made in discussion:  KM stated that we have begun to negotiate with the trust on what the year-end position might look like, though those discussions have not been fruitful so far.  TF asked about over performance at Luton and Dunstable Hospital (L&D) and KM stated that discussions with the trust had been productive. We are also seeing a flow of activity towards the L&D from Dacorum and St Albans due to patient choice and the L&D are covering some activity at weekends to cope with the increased demand.  NS asked whether there are any particular trends that are of concern. CH stated that CHC was a significant concern, even though our understanding is better than it has been before. 118.3 The board noted the financial report

B/119/17 Community Education Provider Network (CEPN) achievements 119.1 HS introduced the paper with the following points: 7

 HS introduced Joyce Sweeney who has led the programme over the past two years and thanked her for all the hard work.  The initial focus of the programme has been on GP and practice nurse development programmes and we now have 6 GP fellows who have completed the programme and 10 practice nurses.  A number of train the trainer sessions have been facilitated.  A training needs analysis was carried out for local practices.  The care homes “red bag” initiative was implemented in 2017 for patients transferring from a care home to hospital. 79 care homes are now using the red bag for resident admissions to hospital.  Three apprentices have been placed in general practices and care homes. 119.2 The board noted the report

B/120/17 General Data Protection Regulations (GDPR) action plan 120.1 CH introduced the paper with the following points:  A similar paper went to audit committee as the committee wanted assurance around our plans for implementation of GDPR.  GDPR comes into force on 25 May 2018 and replaces the data protection act.  The principles remain the same but the there is a bigger focus on evidence based compliance and more extensive rights for data subjects and bigger penalties for non- compliance.  An action plan is attached and this shows how we intend to implement GDPR, though much of the detail is not yet available. 120.2 The following points were made in discussion:  HS asked how GDPR affects shared services provision as a great deal of information is shared across 4 CCGs. CH stated that there will need to be a number of privacy impact assessments and analysis of data flows.  TF stated we need to consider our role in supporting local practices in the implementation of GDPR.  TS stated that awareness in the organisation needs to be not just a one off but needs to be embedded into all our work. She also had concerns about implementation in general practice due to the type of data kept.  PS stated that it was the intention that audit committee would continue to monitor the implementation of the CCG plans.  MW asked whether the CCG could work alongside the LMC to offer support to practices. KM stated that our resources were limited but we will discuss with LMC.

120.2 The board noted the GDPR action plan 120.4 ACTION: KM/CH/DB to discuss with LMC how we can work together to support practices

B/121/17 STP Memorandum of Understanding 121.1 KM introduced the paper with the following points:  All STP constituent boards are being asked to approve the MOU but we haven’t seen feedback from others yet.  There are some issues. One is the management of confidential information between commissioners and providers. Another is how decisions are made given that STP is not a statutory organisation. 121.2 The following points were made in discussion:  PS had a number of points which he would share with KM by email. He wished to be assured that we had received advice that the MOU was in line with our statutory responsibilities. KM stated that we had not received legal advice but the MOU was couched in terms of “doing the right thing”. JW suggested that HCC were reasonably

content with the document as a description of how organisations within the STP will work together.  NS stated that whilst we wanted to make decisions quickly, we did not have scope to do that within this agreement.  SB stated that the document is acceptable based on the principle of “less is more” 121.3 The board did not feel it was in a position to sign off the MOU at the present time and members were invited to submit written feedback to KM. 121.4 ACTION: All to email KM with comments regarding the MOU B/122/17 Outcomes of Joint Committee with East and North Herts CCG and amended policies 122.1 DB introduced the paper with the following points:  The policies are the final step in a long process involving feedback from a large number of stakeholders and are the same as or consistent with the policies of ENHCCG.  The policies do not give the solution to every practical issue and remaining questions will be addressed during the mobilisation phase.  We still need to resolve the provision of CO monitors 122.2 The following points were made in discussion:  RE stated that communication of the policies to practices and other stakeholders critical.  JR stated that there is a need to communicate clearly what the policies mean for people and what we expect of everyone.  RP felt that the requirements of practices needs to be more assertive with words such as “require” rather than “support”.  KM stated that there were different messages which needed to be targeted to GPs and to patients. 122.3 The board approved the revised policies subject to amendments as discussed

B/123/17 Communications and engagement update 123.1 JR introduced the paper with the following points:  We were very open about the let’s talk decisions and spoke to local media straight after the joint committee meeting. We proactively released a statement the following day.  There was a great deal of national coverage and also international coverage but we did not accept invitations to appear on national TV and radio because our focus is on local people.  Our local messages regarding the urgent treatment centre were not very effective despite our very best efforts. 123.2 The board thanked the communications and engagement team for all their work on “let’s talk” and the board noted the update report.

B/124/17 Committee meetings minutes 124.1 The board noted the committee meetings minutes

B/125/17 Additional risks identified 125.1  Risks associated with the STP as discussed during the meeting.  GDPR

B/126/17 Next meeting 126.1 The next board meeting will take place on 18 January 2018 at 1pm

Appendix 1 Declarations of interest and apologies – Board 9 November 2017 Agenda Item Aim Interests Declared by How managed General Local GPs may be conflicted at times due to the fact that they are providers of services. Part 2 - Public 1. Chair’s introduction Info Not Applicable 2. Interests to declare Info Not Applicable 3. Minutes of previous meeting Approve Not Applicable 4. Matters arising and action log Approve Not Applicable 5. Chief Executive’s report Discuss John Wood Discussion only 6. Patient story Discuss None 7. Board Assurance Framework Discuss John Wood Discussion only 8. STP progress report Info None 9. Award of MSK contract Info None 10. Committee chairs reports Info John Wood Info only 11. Integrated Quality, Finance and Info John Wood Info only Performance report 12. CEPN achievements 2016-17 Info None 13. General Data Protection Regulation Info None (GDPR) action plan 14. STP Memorandum of Understanding Approve None 15. Outcomes of Joint Committee with East Approve John Wood JW is not a voting and North Herts CCG and amended Mike Edwards member. policies Mike Walton GPs have a partial conflict due to impact on their practice / patients but will be involved in decision. 16. Communications and engagement Update Info None 17. Committee meetings minutes Info Not Applicable Nil returns Not Applicable Stuart Bloom Alison Gardner Hein Scheffer David Evans Thida Win Thelma Stober Kathryn Magson Caroline Sutherland No Returns Juliet Rodgers David Buckle Caroline Hall Raja Ganguly Apologies for meeting received Daniel Carlton-Conway Diane Curbishley (Clare Saunders attending) Iain MacBeath (John Wood attending) Jim McManus Kevin Barratt

Item 04

Herts Valleys CCG Board Action Log Action Log Date of Meeting Subject Action Responsible Due Date Comments Date of Status Officer Meeting to be Reviewed B/93.7/17 14.09.17 Chairs' reports Preparations for GDPR to be discussed with HCC colleagues C Hall 08.11.17 08.11.17 Completed EPRR Ensure that there is lay member scrutiny of the next EPRR assessment Not yet due 08.11.17 Open B/99.4/17 14.09.17 C Hall Aug-18 Audit Committee Annual AC annual report to come to the board in support of the annual report and Not yet due 08.11.17 Open B/100.4/17 14.09.17 C Hall May-18 Report accounts for 2017/18 DE to review BAF 3.2 with a view to increasing the current risk score. The current risk score has been increased to 16 to reflect legal and other challenges 18-01-2018 Completed Board Assurance B/113.4/17 09.11.17 D Evans 18-Jan-18 received by the CCG in relation to some recent decisions. Framework

Board Assurance DE to review CRR risk S03/03 – public health support This risk has been updated and de-escalated from the corporate risk register. 18-01-2018 Completed B/113.5/17 09.11.17 D Evans 18-Jan-18 Framework DE to take MSK mobilisation plan to commissioning executive committee and On the agenda for Commissioning Executive for the 21 December 2017 and Providers 18-01-2018 Completed B/115.4/17 09.11.17 Award of MSK contract D Evans 18-Jan-18 GP forum. and Clinical lead aware to present at the January GP Forum. IA to bring further discussion on urgent care solutions to commissioning 18-01-2018 Completed B/117.6/17 09.11.17 Urgent care performance D Evans 18-Jan-18 executive KM/CH/DB to discuss with LMC how we can work together to support practices 18-01-2018 Completed B/120.4/17 09.11.17 GDPR D Buckle 18-Jan-18 All to email KM with comments regarding the MOU All Board Follow up with STP PMO pending 18-01-2018 Completed B/121.4/17 09.11.17 STP MOU 18-Jan-18 Members

NHS Herts Valleys Clinical Commissioning Group Board Meeting Date of Meeting: 18 January 2018

Title Chief Executive Officer’s Report Agenda item 5 Purpose* (tick) Decision ☐ Approval ☐ Discussion ☒ Assurance ☐ Information only ☐

Author and job title Responsible director and job title Director signature Contributions from the Executive Team and Kathryn Magson Kathryn Magson Kathryn Magson Chief Executive Officer Chief Executive Officer

Short summary of paper This paper provides an update for the Board on recent CCG developments

Recommendation(s) The Board is being asked to: Note, discuss and provide any feedback on contents of the report. Engagement with n/a patients/public/staff and other stakeholders Links to Strategic Objectives (tick all that apply) Objective 1: We will continually improve engagement with patients, carers, the public and member practices ☒ so that they contribute to and influence our work and activities. Objective 2: We will commission safe, high quality services that meet the needs of the population, reducing ☒ health inequalities and supporting local people to stay well and avoid ill health. Objective 3: We will work with health and social care partners to transform the delivery of care through the ☒ implementation of Your Care, Your Future, the strategic review in west Hertfordshire. Objective 4: We will ensure that there is a financially sustainable and affordable healthcare system in West ☒ Hertfordshire. Board Assurance Framework Refer to assurance levels table below and latest BAF report here: N:\Nursing & Quality\8 Risk Management System\2. Board Assurance Framework\BAF 201718\Current versions for front sheet reference N.B. The executive summary for this paper explicitly points to the evidence to support the assurance level indicated above. For example: Very high – what is the evidence to support the current strong position & how will it be sustained? High – what is being done to strengthen controls and mitigate the likelihood of this risk materialising? Medium - what is being done to address gaps in assurance and how successful is this action proving? Low - what are the urgent actions planned to address the lack of assurance? Ref. Risk Risk description Current risk Target risk Assurance Owner score and score Level movement since last month ALL BAF RISKS APPLY New strategic risks identified by this report

Other significant risks related to this report (from the CRR)

Resource Not applicable CFO Signature implications n/a

Potential conflicts Not applicable of interest Equality and Not applicable quality impact analyses (indicate the key points the analysis has identified relevant to decision required) Equality delivery Better Health Outcomes ☒ system (identify Improved Patient Access and Experience ☒ which goal your A Representative and Supported Workforce ☒ proposal / paper supports) Inclusive Leadership ☒ Report history Not applicable Which Groups or Committees have seen this report and when? Where does the report go next? Appendices Not applicable

**Assurance levels – use this guide to identify the level of assurance indicated in the risk table above. Level Details Very high Taking account of the issues identified in this report, the Board can take reasonable assurance that the controls upon which the organisation relies to manage this risk are suitably designed, consistently applied and effective. High Taking account of the issues identified in this report, the Board can take reasonable assurance that the controls upon which the organisation relies to manage this risk are suitably designed, consistently applied and effective. However, we have identified issues that, if not addressed, increase the likelihood of the risk materialising. Medium Taking account of the issues identified in this report, whilst the Board can take some assurance that the controls upon which the organisation relies to manage this risk are suitably designed, consistently applied and effective, action needs to be taken to ensure this risk is managed. Low Taking account of the issues identified, the Board cannot take assurance that the controls upon which the organisation relies to manage this risk are suitably designed, consistently applied or effective. Action needs to be taken to ensure this risk is managed.

1. Leadership

1.1 NHS England assurance Our last quarterly assurance meeting was on Friday 13 October 2017. The session went well with good feedback following. Key assurances were provided to NHS England according to their set agenda in the following areas:  Urgent and emergency care – progress against the 2017-18 National delivery plan and in particular A & E performance at WHHT. Assurance was provided regarding the continued reduction in DTOCs and the remaining issues to address.  Finance, activity and QIPP. It was noted that recent actions and progress has meant that the CCG is no longer under regional escalation and NHSE congratulated the CCG on the considerable work that has been completed to get to this point.  Cancer performance – recognition of the continued strong performance, and an ongoing focus around timed pathway delivery.

It has been agreed that future quarterly review sessions will be held with CCGs collectively across the STP footprint and the next meeting will take place on Friday 26 January 2018.

1.2 Appointment of Deputy CEO

Following a testing interview process the CCG has just appointed Diane Curbishley as Deputy Chief Executive for Herts Valleys CCG. Diane will continue with her leadership of the nursing and directorate, with the deputy role adding to her responsibilities which will include, for example, having a broader leadership role and greater visibility across the CCG. Diane will play a key role the development of the STP as well as provide support in the CCG’s engagement with external stakeholders, including the public – supporting the wider CCG objectives.

2. Operational Areas

2.1 Nascot Lawn update

The finance and performance committee met on 16 November 2017 and unanimously concluded that Herts Valleys CCG cannot continue to fully fund the respite service for children and young people at Nascot Lawn.

The CCG has now given Hertfordshire Community Trust six months’ notice, in accordance with our contract with the Trust. The CCG’s funding for Nascot Lawn will come to an end on 17 May 2018.

The committee discussed all the options at length and all feedback received including emails from families was made available to the committee. The meeting was observed by three stakeholders and Healthwatch presented a statement to the committee.

Officers’ preference as discussed at the committee meeting was to use health-related spending to fund Nascot Lawn to the maximum value of £100,000 per full year until March 2019, as part of a joint-funding model with Hertfordshire County Council (as reflected in either option 3 or 4). Officers went on to confirm that HCC approach will be to fund the three existing HCC-funded respite centres only. In view of this, the option of joint funding of Nascot Lawn was unavailable and the committee therefore agreed the withdrawal of CCG funding (option1).

The committee went on to support officers in that if the county council decide to reconsider their position and provide an option for four respite units or indicate a willingness to fund respite services at Nascot Lawn as part of a three centre approach then the CCG will be happy to contribute to the funding of this service up to the maximum noted above as in options 3 and 4 until March 2019.

Subsequently, the county council as statutory provider is now taking the lead (with the CCG supporting) in working with families to determine future provision. We have agreed to support respite provision in the county to the value of £100k regarding Continuing HealthCare cases for any county provision. The same request has been made to E& N Herts CCG and we understand that both CCGs will support this request.

Focus continues on ensuring that the families at Nascot Lawn have a new respite provision offering with weekly and fortnightly operational meetings with the CCG and HCC. When new placements have been agreed the CCG will ensure that the appropriate training in line with the required care plans are completed. Several courses have already been offered/delivered to respite centre staff from the three county council units, and we are encouraging HCC to ensure that the centre staff attend.

2.2 Non-emergency patient transport update

Contract with EEAST

The Consortium; consisting of Luton CCG, Bedfordshire CCG and East & North Herts CCG led by Herts Valleys CCG formally signed the contract with East of England Ambulance Service Trust (EEAST) on 22 December 2017. The contract term is for two plus one years with an option to renew further if required.

These contract negotiations have been taking place over the last two months; detailing and affirming a new service specification that outlines service delivery and out of hours provision and a contract that enables a quality incentive premium to be paid on key performance indicators; strict timely pickups and delivery of patients.

Whilst the contract negotiations were taking place a recovery position has been provided by EEAST and a number of local providers sourced individually by each CCG. This will need to continue as a mobilisation plan is implemented and EEAST builds capacity. EEAST will now put staff under consultation regarding TUPE and recruit as required. Herts Valleys CCG has set up further local transport for the short term whilst this work is completed.

DTOCS

Currently the HVCCG DTOC target has been exceeded and is at 2% against a target of 3.5%. The recent improvement to below target, recognising that we have been running at just over 5% now for a few months, is in the main due to bedded and non-bedded capacity commissioned in an more productive integrated way going into the peak period - some of which will now be funded through the recently announced additional winter monies and iBCF funding in place with HCC. The system resilience team have been particularly proactive and diligent in managing patient flow on a daily basis and all parties should be

congratulated on the work that has taken place to reach this point. There remain concerns regarding social care capacity in some parts of the county, alongside self-funders which continue to block rehab health beds.

More broadly the CCG has received assurance from NHSE that our BCF joint plan with HCC and E & N Herts CCG is fully assured. DTOCS are a key metric in the delivery of our plan.

2.3 GP Forward View (GPFV)

Background

‘GP shortages and the increasing demands on them mean that they no longer have the time to use their expertise on patient issues that can safely and competently be managed by others. This investment to improve primary care delivery will support training for receptionists and clerical staff to play a greater role in navigation of patients and handling clinical paper work to free up GP time’.

Primary Care Training Funding to support training for Active Signposting and Document Management funding is now being released to the value of £277k as mandated by NHSE. The Practice Managers forum were tasked to decide following a mini-procurement process on their preferred trainers. a) Active Signposting Training - progress

Active Signposting Level One training will have been delivered across the localities by the end of March; so far with 143 practice staff attending 4 training sessions from all 68 practices. There has also been support for PMs and deputies, ‘Leading your team for Signposting’, which includes an overview of the receptionist programme, management & leadership skills in assessing competency and how to give and receive feedback, a process for due diligence, the role of the GP champion and the practice protocol for implementing signposting in a practice.

Bronze Level Two training available from April onwards; for those who have been assessed as competent and work do at least four sessions a week, the opportunity of further training that includes partnering with social prescribing. b) Practice manager development

Three masterclasses for PMs & deputies will commence in the spring by RCGP Learning and includes the following topics; Manager, Leader or both; Quality Improvement in Practice; Assessing, Managing and Minimising Risk. c) Work Flow Optimisation - document management

Following a rigorous evaluation process HVCCGs PM forum selected two providers, AT Medics and HERE. Communication & engagement workshops start mid-January, an initial 17 practices are in the first cohort, we are currently seeking practices for the second cohort to commence in February.

GPFV (GP Forward View) Workforce Plan

The Hertfordshire and South Midlands STP has developed its draft workforce plan this has been approved by each CCG in principle and submitted to NHS England, Central Midlands. The plan has been approved in principle by Central Midlands Assurance Outcome panel and recommended that the Herts and West Essex

STP Workforce Plan is assured with conditions. These conditions are linked to the following elements of the plan where further clarity or detail is required:

 Achievement of GP numbers through recruitment and retention strategy / initiatives  Financial affordability of implementation and delivery of the plan  Working to deliver the plan on an STP footprint

The STP will be submitting an application for the recruitment of overseas doctors to NHS England on 24 January 2017. This is the national timeline for applications from interested CCGs. There are 9 GP practices in Herts Valleys that have expressed an interest in the overseas doctor programme. The expectation of this programme is that following recruitment the practices, employ the GP with the aim of them becoming future partners to the GMS contract.

2.4 Demand Management update

All four localities have submitted plans which have been approved which include a peripatetic team of peers to work with practices highlighted through our ‘heatmap’ analysis as having good practice to share or variance to others that requires further investigation and support. All include a peer review element; this has rolled out in the past month but continues to develop.

Each locality is forming Transformation Teams to support provision of sustainable increases in care delivery in non acute settings. The teams are clinically led have strong links with member practices and will explore opportunities for cross practice review and support. All the plans have been endorsed by the Locality executive Boards, the CCG Commissioning Executive and discussed at locality meetings thus ensuring an appropriate level of communication and GP involvement in implementation.

Each plan has specific Key Performance Indicators (KPIs) to address areas where demand deflection to a different care setting or managing potential referrals in primary care will result in reduced activity in the acute sector and improved quality for patient experience. The CCG continues to support this with dedicated senior input and monitors progress through the recognised locality governance and specific Chief Executive led monthly meetings.

Each plan, with some local variation of approach, asks all practices to consider how variance to a weighted population benchmark of referral by pathway can be reviewed and thus all practices have considered and are constructing an approach to peer review; two examples are the introduction of partner review prior to referrals by locums and salaried GPs being confirmed, peer discussions through the transformation teams already showing change at practice level and a clear plan for further visits and some practices directing al referrals, if the pathway is available to community services unless active review and approval by the GP for an acute admission can be demonstrated.

2.5 Winter Resilience

Carers

The HVCCG carers’ strategy (2015-18) is under review for relaunch in April 2018. The Local Incentive Scheme (LIS) has shown continued improvement year on year with carers registered with primary care standing at 9,626 (up 12% on the previous year) as at March 2017. Last year 63 practices achieved the bronze element of the LIS, 48 silver, 40 gold and 31 all three. Carers in Herts report an increase in referrals to them between 2012-13 and 2016-17 of nearly 300% (from 144 to 571). NHSE are using this work as a case study.

Social Prescribing

NHSE has identified HVCCG as one of five leading CCGs and Tim Anfilogoff and Paul O’Hare are helping in the design of a ‘flat pack guide’ to setting up social prescribing (SP) schemes. Paul is now the manager of the new expanded Herts SP scheme, building on the community navigator scheme, creating an integrated service with some 40 staff across Herts all linked through HertsHelp as the single point of access. Paul is working closely with Sarah Hill to ensure full links between HertsHelp and the developing active signposting agenda.

2.6 Adult Community Services

Re-procurement of adult community services

We will be engaging with staff, patients and local people so that they can influence the way we recommission adult community health services in west Hertfordshire. This is a major project that will see rapid progress towards achieving the service transformation outlined in our Your Care, Your Future plans. This engagement will build on high level feedback from Your Care, Your Future but further engagement will be needed to get specific feedback relating to the services are ‘in scope’ to support the development of the new service specification. Patient representatives will be involved in the procurement process so that we have a patient perspective in all discussions. There will also be wider conversations through our PPG network and at our next PPI development session. And we will target communication with users and support groups. A market engagement event planned for January will also initiate discussions with and feedback from potential providers.

Urgent care and West Herts Medical Centre contract

There has been engagement with patient groups, PPI committee members and other patient representatives as part of work to develop the west Hertfordshire urgent care strategy. Patients’ feedback is being used to inform the approach to extending access to urgent treatment as part of the strategy. Communications are in line with Your Care, Your Future messages about redesigning services to ensure that people receive the right level of care for their needs in the right place and in a timely manner.

An urgent treatment centre (UTC) at Hemel Hospital opened on 1 December. Initial communications has focused on explaining what the UTC offers as part of wider plans to encourage take up of urgent care services in order to alleviate pressure on A&E. The UTC has opened on the interim hours that were introduced for the urgent care centre in December 2016. A consultation about opening hours starts at the end of January. At the same time we will consult on procurement options for West Herts Medical Centre as the contract is due for renewal. Options for both services will be explored in the context of the draft urgent care strategy and other national developments such as extended GP access and encouraging greater use of NHS111.

2.7 Adult community services

Community Ear Nose and Throat (ENT)

Following decision by the Commissioning Executive, in 2016, it was agreed to go out to an Open Market Procurement for an Enhanced Community ENT Service for patients with non-emergency ENT conditions across all four localities. This specialist community model will be provided and community based, enabling quicker access to specialist assessment of patients in the community including diagnostics and treatments, and choice of an elective care provider if required. It will focus on clearly defined clinical pathways, GP

support and education. The service will be provided by appropriately trained clinicians including ENT consultants, GPs with specialist interest trained in ENT. The service will be delivered for patients over the age of 5 years.

The procurement process will launch on 5 February 2018 with the new service commencing in November 2018.

Community Ophthalmology

Following the decision by the Commissioning Executive in 2016 it was agreed to go out to an Open Market Procurement for a Community Ophthalmology Service. The new service is a community based model where GPs and local optometrists will refer into a single point of triage where the service would identify the appropriate clinician to treat the patient or send onward referral to secondary care if appropriate. The service would be provided by appropriately trained clinicians including, optometrists, GPs with specialist interest and consultants. The service provision will include out-patient appointments as well as minor surgical procedures and managing patients with glaucoma with shared care with the secondary care provider.

The procurement process will launch on 5 February 2018 with the new service commencing in November 2018.

Community MSK (musculoskeletal), Pain, Physiotherapy, Postural Stability and Rheumatology Service

Following the update at the last Board meeting, Connect Physical Health start taking new referrals for the new enhanced community MSK service from 15 January 2018. The service will be provided across all four localities. Connect are working closely with the CCG on the new pathways as well as working through a smooth transition from the existing providers of all patients currently receiving the physiotherapy in the community.

Other procurements

Two other procurements are underway. The first is following the CCG Board decision on the Let’s Talk consultation, the CCG has launched the procurement for a three year community vasectomy service and the second is the to procure a community nutrition and dietetics service which will bring care closer to home for patients having access to dietetics and will include the delivery of the tier 3 obesity pathway.

2.8 General Data Protection Regulation (GDPR) update

The CCG is working towards ensuring we are GDPR compliant by the May 2018 deadline. We have an action plan in place to highlight the key tasks and have named leads who need to take these actions forward. We have nominated a Data Protection Officer. We are currently making sure that the Board and the Senior Leadership Team are clear on their responsibilities under GDPR. This awareness will then be passed to all staff so that we can give assurances that the CCG meets the relevant level on the Information Governance Toolkit. We are amending all relevant policies to encompass GDPR and are establishing processes that ensure Data Protection Impact Assessments are an integral part of all projects we undertake.

2.9 Estates

We are working as an STP to understand how we best use the premises available to us to deliver the services we commission. This will help us move towards establishing locations where integrated services can be delivered and support the Your Care, Your Future agenda of moving services closer to home.

2.10 Herts Urgent Care (HUC) Deep Dive

HUC quality and performance

HUC were invited to attend the HVCCG Quality Committee in December 2017 in line with the deep dive workplan the CCG committees have in place.

David Archer, Chief Executive of HUC attended the Committee and presented an update on key issues.

The following was noted:

 Integrated Urgent Care performance against key performance indicators (KPIs) is intensively scrutinised. Some of the KPIs are national and others have been created locally by the CCG.  Three contact centres have been networked to achieve these and this has led to an improvement in the times for call answering  Hertfordshire call handling is some of the best in the country, with calls answered after an average of 14.2 seconds (three rings) on weekdays – better than the target average of 60 seconds. The target average is also being achieved at the weekends, including during recent snowy weather.  National targets for KPIs relating to the percentage of calls handled by a clinician were previously increased from 30% to 50% by 31 December 2017 and will be further increased to 60% by 31 March 2018. HUC is already achieving 66%.  A large number of the clinical assessment service (CAS) targets were locally drafted to try and introduce benchmarks. As is suggested by the KPI achievement figures, 10 these targets need to be reviewed to establish whether they are achievable.  There has been 94% rota fill at HQ since the start of the IUC. The focus has been on developing a multi-disciplinary team, including doctors, pharmacists, palliative care nurses and dental nurses.  Out of hours (OOH) performance has improved with 87.7% of urgent visits undertaken within two hours, against a target of 95% (performance was 78% in August).  Analysis suggests that 5,600 green ambulance calls and 3,000 visits to the emergency department (ED) have been diverted since the service started. All of these instances required clinical intervention which has resulted in an increase in home visiting and out of hours appointments.  It was noted that adjustments to the delivery model may be necessary to achieve best value for money. For example more visiting capacity may be better value for money than the Potters Bar site.

In addition to the deep dive at Quality Committee, a multi disciplinary meeting has been held to consider how performance and quality issues can be better managed across this contracts within the CCG. The following actions are in place:

 Monthly contract meetings.  Monthly quality meetings monthly.  Multi disciplinary pre meets in place and to be enhanced to ensure performance and Business intelligence team and quality representatives regularly involved.  A review of HVCCG input into HUC monitoring meetings to be undertaken, recognising that this contract is led by E & N Herts CCG

3. HR and organisational development and learning update

3.1 Annual staff survey - 2017 The 2017 staff survey closed on 30 November 2017 with the final response rate being 80%, (135 staff out of a possible 169); a slight increase on last year. Below provides a breakdown of responses in terms of directorates:

Locality 1 Eligible Responden Response Sample ts Rate Delivery, Systems Resilience and Contracting & 19 13 68.4% Resilience Development 15 14 93.3% Executive, AO and Communications & Engagement 18 13 72.2% Finance & Corporate 28 21 75.0% Medical 30 21 70.0% Nursing Quality 40 37 92.5% Workforce 19 16 84.2%

The majority of the results of the staff survey have been made available to the CCG and the headlines will be shared with the Senior Leadership Team on 10 January 2018 and the Staff Involvement Group on 31 January. Reports and action plans will be devised and shared in due course. Full release of the results is still under embargo until March 2018.

3.2 HR and ODL Forward Plans

Work is currently underway in developing the HR and ODL Forward Plans for 2018. The plan will guide the work of the HR and ODL team over the next year to ensure that the CCG is supported in achieving its strategic objectives through the workforce.

3.3 Accelerated Director Development Scheme The CCG has signed up to the Accelerated Director Development Scheme (ADDS). The scheme is a CEO led approach to identify and develop NHS leaders. It provides an individualised approach to leadership development providing secondment and acting up opportunities and is supported by the CEO/HRD Talent Forum. Four applications have been submitted by Herts Valleys CCG and will undergo a robust automatic selection process with the cohort launch taking place on 6 March 2018.

3.4 Policy Forum The Policy Forum met on 7 December 2017 to review five policies: Maternity/Maternity Support (Parental)/Adoption Policy, Grievance Policy, Probation and Induction Policy, Raising Concerns (Whistleblowing) Policy and Attendance Management Policy. No significant changes were made to these policies apart from the Attendance Management Policy whereby the group were asked to consider amending the ‘trigger’ point currently being used (a trigger point is the time in which a formal process is triggered). A recommendation was made and the group agreed with the recommendation. It was also suggested that the process within the policy be reviewed as it was recognised that this not very clear.

The Staff Involvement Group (SIG) were updated on the policies and it was agreed that SIG and all staff (via the weekly news roundup) would be advised on which policies were to be reviewed at each forthcoming Policy Forum and given the opportunity to feedback or comment on prior to them going to the Policy Forum.

3.5 Talent Management and Succession plans The Talent Management and Succession planning process and analysis has been conducted based on the information provided in the appraisal returns. The annual appraisal cycle for the CCG was from April – August 2017. As at 31 August 2017, the Learning and Development team received a total of 136 returns equating to a rate of 80.47%.

The appraisal documents submitted enabled the identification of a talent score for individuals (where given). Additionally, staff records enabled the identification of age, gender and pay band to facilitate succession planning for business critical posts or posts which could become vacant due to upcoming retirement. These posts are defined as those positions that have a critical impact on the delivery of business strategy and an absence of which can have a significant impact if there are no contingency plans in place to mitigate risks. These posts are considered as those that are a statutory requirement for the CCG and those that tend to take longer to recruit due to the specialist skills set required.

3.6 Review of the current Talent Map Tool The CCG are currently in the process of reviewing the current Talent Map Tool to ensure that it is ‘fit for purpose’. The CCG will embark to promote more coaching conversations to ensure that staff are empowered to be actively involved in the process of identifying talent, developing talent and promoting talent.

3.8 East of England Ambulance Service (EEAST) PTS Contract The CCG shared services team have worked continuously in providing its support to EEAST in the transition of the non-emergency transport services for staff whom were contracted by the previous provider. This work will continue as the TUPE process is now underway.

Terms/acronyms used in report

HVCCG Herts Valleys Clinical Commissioning Group HCC Hertfordshire County Council EEAST East of England Ambulance Service Trust DTOC Delayed Transfer of Care GPFV GP Forward View NHSE NHS England PM Practice Manager RCGP Royal College of General Practitioners STP Sustainability Transformation Plan KPIs Key Performance Indicators LIS Local Incentive Scheme SP Social Prescribing PPI Patient and public involvement UTC Urgent treatment centre A&E Accident & Emergency MSK Musculoskeletal GPsSI GP with special interest GDPR General data protection regulation HUC Herts Urgent Care CAS clinical assessment service IUC Integrated urgent care OOH Out of hours ED ? discharge HR Human Resources ODL Organisational Development and Learning ADDS Accelerated Director Development Scheme CEO Chief Executive Officer HRD Human resources and development SIG Staff Involvement Group

NHS Herts Valleys Clinical Commissioning Group Board Meeting 18 January 2017

Title BAF Strategic Risk Report Agenda item 6 Purpose* (tick) Decision ☐ Approval ☐ Discussion ☒ Assurance ☐ Information only ☐

Author and job title Responsible director and job title Director signature Katy Patrick Rod While Rod While Governance and Risk Manager Head of Corporate Governance Short summary of paper The paper presents in summary the Board Assurance Framework (BAF) for 2017/18 Q3 at 31 December 2017 and tracks change since Q1. It also presents a summary of changes to the Corporate Risk Register. Recommendation(s) The Board is being asked to:  review and approve the BAF 2017/18, Q3 at 31 December proposal including, adjusted risk scores and forecast for end of Q4;  note the assurance summaries in appendices 1 and 2. Engagement with State briefly and engagement activities and relevant outcomes of that engagement patients/public/staff and other stakeholders Links to Strategic Objectives (tick all that apply) Objective 1: We will continually improve engagement with patients, carers, the public and member practices ☒ so that they contribute to and influence our work and activities. Objective 2: We will commission safe, high quality services that meet the needs of the population, reducing ☒ health inequalities and supporting local people to stay well and avoid ill health. Objective 3: We will work with health and social care partners to transform the delivery of care through the ☒ implementation of Your Care, Your Future, the strategic review in west Hertfordshire. Objective 4: We will ensure that there is a financially sustainable and affordable healthcare system in West ☒ Hertfordshire. Board Assurance Framework Refer to assurance levels table below and latest BAF report here: N:\Nursing & Quality\8 Risk Management System\2. Board Assurance Framework\BAF 201718\BAF Current version for front sheet reference All of the risks on the Board Assurance Framework (BAF) and Corporate Risk Register (CRR) are relevant to this report. Resource None CFO Signature implications

Potential conflicts Conflicts of interest are published on the CCG registers and any specific interests relating to of interest agenda items are notified to the Chair in advance of the meeting. Equality and N/A quality impact analysis (indicate the key points the analysis has identified relevant to decision required) Equality delivery Better Health Outcomes ☐

1 system (identify Improved Patient Access and Experience ☐ which goal your A Representative and Supported Workforce ☐ proposal / paper Inclusive Leadership ☐ supports) Report history All risks are reviewed monthly with risk owners and reported quarterly to key committees and Which Groups or the Board. Committees have seen this report and when? Where does the report go next? Appendices Appendix 1 BAF Summary presentation Appendix 2 CRR Summary presentation

1. Introduction

1.1 The Board Assurance Framework (BAF), as part of the fundamental core of HVCCG’s internal control systems, identifies all risks which potentially threaten achievement of the CCG’s four strategic objectives.

1.2 The nature and relative sizes of these threats are set out in Section 2.1 below. This chart notes proposed changes to current risk scores since the Q3 October report approved by Board on 9 November 2017 as follows:

 BAF risk 2.1, “Risk that we do not deliver on all NHS Constitutional pledges, key national targets and priorities.” It is proposed that the current risk score is reduced to 12 to reflect the recent significant improvements with delayed transfers of care.  BAF risk 2.2b, “Risk that the non-emergency patient transport service does not meet patient safety and quality needs”. It is proposed that the current score for this risk is reduced to 12 now that the formal recovery contract has been negotiated.  BAF 3.2, “Risk that there will be insufficient support from local bodies and key stakeholders to transform the delivery of care in west Hertfordshire.” It is proposed that the current score for this risk is increased to 16 to reflect the legal and other challenges that the CCG is receiving in relation to some recent decisions.

1.3 This paper provides the Board with a summary of the updated BAF proposal for 2017/18 and the Quarter 3, 31 December 2017, position following meetings with individual risk owners and taking account of comments made at Committee meetings and groups. Movements in BAF current risk scores since Q1 2017/18 are tracked in Section 2.2 below.

1.4 The BAF Summary at Appendix 1 collates the current assurance summaries for all BAF risks. This report includes graphs showing movement in inherent, current and target risk scores over time as well as a forecast score for end of Q4 2017/18.

1.5 Whilst this framework identifies the significant potential risks which may threaten achievement of HVCCG’s strategic objectives, any related risks requiring specific mitigating actions are cross- referenced and documented fully within the CCG’s Corporate Risk Register (CRR). A summary of the

CRR at Q3, 31 December 2017 is included at Appendix 2. This summary recommends the following changes:

- An reduction in the current risk score for SO2/31, “Risk that we do not reduce delayed transfers of care (DTOCs) to the target of 2.5%”, since the target has been exceeded currently at 2.0% and is above the expected trajectory at both WHHT and HCT.

- The addition of a new risk, SO2/38, “Risk that the CCG will have a high rate of morbidity and mortality from E coli blood stream infection (BSI), and will not meet the Quality Premium target of a 10% reduction in E coli BSIs by 31st March 18.” A total of 237 cases have been reported in the Herts Valleys population against a limit of 195 for this point in year.

- De-escalation from the corporate risk register of risk SO3/03, “Risk of failure to ensure that Public Health is sufficiently embedded within the CCG programmes and localities”, since the interim public health consultant is in post and has been very engaged with commissioning plans and the Director of Public Health is invited to attend Board and Committee meetings.

- Closure of risk SO3/09, “Risk that there will be increased pressure on health services due to a reduced level of provision for social care services”, since this risk is now being monitored by the Strategic Partnership Board as part of SO3/05, “Risk that we fail to successfully transform health and social care through use of the Better Care Fund.”

2. Strategic risks 2017/18, Q3 at 31 December 2017. 2.1 Relative positions of threats to strategic objectives.

2.2 Summary of change over time (Q1 2017/18 to Q3 2017/18).

 Changes proposed at end of Q3 as discussed above (1.2) are also reflected in this table.

 Individual graphs embedded in the BAF summary document (Appendix 1) show movement since Quarter 1 2017/18 of inherent (unmitigated) and current (mitigated) risk scores in relation to their target risk scores. The target score is the level of risk to the achievement of that strategic objective that the Executive Team considers to be tolerable and justifiable and timescales for achievement vary.

Risk Deteriorating ↓ Risk Improving ↑ No Movement → STRATEGIC OBJECTIVE 1: Effective Engagement. We will continually improve engagements with member practices, patients, the public, carers and our staff to contribute to and influence the work of HVCCG Q1 17/18 Q2 17/18 Q3 Oct 17/18 Q3 Dec 17/18 Risk Risk Ref Current Risk Current Risk Current Risk Current Risk Owner Score Score Score Score 1.1 JR Risk score unchanged. “Risk that we do not engage effectively with a range of our 12 16 16 16→ patients, population and stakeholders” 1.2 DB/JR Risk score unchanged “Risk that member practices and other partners do not see the 12 16 12 12 → potential positive impact of their engagement with HVCCG” 1.3 JR Risk score unchanged “Risk that we have an unengaged staff body.” 4 4 4 4→

STRATEGIC OBJECTIVE 2: High Quality. We will commission safe, high quality services that meet the needs of the population, reducing health inequalities and supporting local people to avoid ill health and stay well. Q1 17/18 Q2 17/18 Q3 Oct 17/18 Q3 Dec 17/18 Risk Ref Risk Current Risk Current Risk Current Current Owner Score Score Risk Score Risk Score 2.1 CWo Risk score reduced “Risk that we do not deliver on all NHS Constitutional pledges, 16 16 16 12↑ key national targets and priorities” 2.2a DC Risk score unchanged “Risk that we are unable to ensure high quality, safe and 12 12 12 12→ sustainable services for the population and patients of west Herts ” 2.2 CWo Risk score reduced b “Risk that the non-emergency patient transport service does 12 20 16 12↑ not meet patient safety and quality needs.” 2.3 DE Risk score unchanged “Risk that our plans do not promote sufficient focus on 12 12 12 12→ health promotion and reduction of health inequalities” 2.4 CH Risk score unchanged “Risk of lack of adequate system 16 16 16 16→ capability in the management

and security of information, data and technology” 2.5 DB Risk score unchanged “Risk that we are unable to ensure high quality, safe and sustainable services for the 16 12 12 12→ population and patients of west Hertfordshire in the delegated commissioning of primary medical services.” STRATEGIC OBJECTIVE 3: Transforming Delivery. Work with health and social care partners to transform the delivery of care through the implementation of “Your Care, Your Future”, the strategic review in west Hertfordshire. Q1 17/18 Q2 17/18 Q3 Oct 17/18 Q3 Dec 17/18 Risk Ref Risk Current Risk Current Risk Current Current Owner Score Score Risk Score Risk Score 3.1 DE Risk score unchanged “Risk that the joint submission to obtain additional capital resource to successfully 16 16 16 16→ transform the delivery of care in west Hertfordshire is unsuccessful.” 3.2 DE Risk score increased “Risk that there will be insufficient support from local 12 12 12 16 ↓ bodies and key stakeholders to transform the delivery of care in west Hertfordshire.” 3.3 DE Risk score unchanged “Risk that workforce issues will prevent us from transforming 16 16 16 16 → the delivery of care across the local health and social care system.”

STRATEGIC OBJECTIVE 4: Affordable & Sustainable Care. We will ensure that there is a financially sustainable and affordable healthcare system in West Hertfordshire Q1 17/18 Q2 17/18 Q3 Oct 17/18 Q3 Dec 17/18 Risk Ref Risk Current Risk Current Risk Current Current Owner Score Score Risk Score Risk Score 4.1 CH Risk score unchanged “Risk that we do not deliver a financially sustainable health 16 20 20 20→ and social care system.

4.2a DE/DC Risk score reduced ” Risk that we do not identify the right QIPP schemes or decisions to commission/ 20 20 12 12→ recommission/decommission, of sufficient value.” 4.2b DE/DC Risk score reduced ”Risk that we do not make sufficient progress on the QIPP 20 20 16 16→ schemes identified.” 4.3 CH Risk score unchanged “Failure to achieve financial 20 20 20 20→ balance in 2017/18”

3. Recommendations

3.1 The Board is asked to:  review and approve the BAF 2017/18, Q3 at 31 December proposal including adjusted risk scores;  note the assurance summaries in appendices 1 and 2.

4. Appendices

1. BAF assurance summary 2. CRR assurance summary

Board Assurance Framework Summary

STRATEGIC OBJECTIVE 1: Effective Engagement. We will continually improve engagement with member practices, patients, the public, carers and our staff to contribute to and influence the work of Herts Valleys CCG. BAF RISK 1.1 Risk that we do not engage effectively with a range of our patients, population and stakeholders. CAUSES: (A) Lack of commitment, (B) Unclear approach and absence of strategy, (C) Availability of funding, (D) Limited workforce capacity and 25 capability. RISK OWNER & LEAD: Associate Director of Communications & Engagement ASSURANCE SUMMARY Q3 2017/18 (18 December): The risk score continues at its slightly elevated level since June 2017 due to some of the 20 sensitive decisions that the CCG has been faced with. We are making use of the new contacts we developed through our "Let's Talk" Inherent programme. In the coming months there will be intensive engagement on our urgent care and adult community services. 15 Current

10 Target

5 Forecast Inherent risk score Current risk score Forecast for end of Q4 Target risk score 0 20 16 → 16 8 Q1 17/18 Q2 17/18 Q2 17/18 Q3 17/18 Q3 17/18 (no change) Jun Aug Oct Dec

BAF RISK 1.2 Risk that member practices and other partners do not see the potential positive impact of their engagement with HVCCG CAUSES: (A) Failure to communicate effectively (B) Pressures in general practice (C) Unclear approach and absence of strategy 25 RISK OWNER: Medical Director RISK LEAD: Associate Director of Communications & Engagement ASSURANCE SUMMARY Q3 2017/18 (31 December): Practices have a full understanding of the CCG financial decision and how their delegated budget is being utilised and the financial reserves that 20 the CCG is required to make. Engagement is being supported in practices on a regular and on-going basis by the directorate including the PMOT Inherent team to reflect matrix working across the department. Winter plans, demand management and enhanced commissioning framework all now in 15 place. Have started board development discussions on the ambitions for general practice and primary care. This will be a programme of work Current over forthcoming months that will support development of our primary care contracting commissioning intentions for 2018/19. 10 Target

5 Inherent risk score Current risk score Forecast for end of Q4 Target risk score Forecast

20 12→ 8 8 0 (no change) Q1 17/18 Q2 17/18 Q2 17/18 Q3 17/18 Q3 17/18 Jun Aug Oct Dec

BAF RISK 1.3 Risk that we have an unengaged staff body. 18 CAUSES: (A) Failure to implement internal communications strategy (B) Failure to adhere to specific timetables for circulation RISK OWNER & LEAD: Associate Director of Communications & Engagement 16 14 ASSURANCE SUMMARY Q3 2017/18 (18 December): The staff involvement group (SIG) continues to play an important role in the CCG. It Inherent 12 reviews in detail all suggestions made and agrees responses. The group has agreed to do some work to embed values and behaviours. For the wider staff group, monthly face-to-face staff briefings with the CEO continue, with written follow-up produced and disseminated. The staff 10 Current weekly round-up and CEO’s blog are other ways that staff are able to hear about news and key issues. We have recently completed a round of 8 director breakfast meetings which are being reported on. 6 Target

4 Forecast 2 Inherent risk score Current risk score Forecast for end of Q4 Target risk score 0 Q1 17/18 Q2 17/18 Q2 17/18 Q3 17/18 Q3 17/18 Jun Aug Oct Dec

16 4→ 4 4 (no change) STRATEGIC OBJECTIVE 2: High Quality We will commission safe, high quality services that meet the needs of the population, reducing health inequalities and supporting local people to avoid ill health and stay well BAF RISK 2.1 Risk that we do not deliver on all NHS Constitutional pledges, key national targets and priorities CAUSES: (A) Availability of funding, (B) Limited workforce capacity and capability, (C) Competing priorities in the west Herts health and social care 25 economy (D) Increased attendance at A&E (E) Delays in progressing through ED (F) Demography RISK OWNERS: Director of Contracting and Performance RISK LEADS: Head of System Resilience/Senior Contracts Manager ASSURANCE SUMMARY Q3 2017/18 (31 December): The system partners have worked together to establish an integrated winter plan with 20 the aim to improve urgent care and patient flow. Individual work streams are in place to tackle high impact areas and delayed transfers of care Inherent in order to achieve revised targets. Key individual performance risks, including A&E 4 hour target, DTOCs, RTT and priority ambulance targets 15 are being tracked in detail by the corporate risk register. Current Trust staffing issues and capacity remain a major challenge to ED flow. Streaming is constrained due to surge pressure. Outpatients and electives have been cancelled and consultants are utilising their time either in additional ward rounds or in ED assessments. Trust surge policy 10 Target to protect the assessment capacity, electronic bed management system to be in place by the end of January. Recruitment of additional senior ops managers. Trust has been working on SAFER week in January. 5 The 3.5% target has been exceeded currently; at 2.0% and is above the expected trajectory at both WHHT and HCT. This has been due to the Forecast improved patient flow through capacity gained in application of winter monies applied through bed and package purchases. Ongoing escalation to system partners via the A&E Delivery Board continues, with significant resource directed to generating additional capacity and 0 improving discharge processes. Q1 17/18 Q2 17/18 Q2 17/18 Q3 17/18 Q3 17/18 The approach by HVCCG is now much more co-ordinated, with weekly MDT meetings between system resilience, quality and commissioning Jun Aug Oct Dec teams who have been using the winter assurance money to purchase additional capacity to assist flow through the health and social care system. Inherent risk score Current risk score Forecast for end of Q4 Target risk score

20 12↑ 12 8 (improving) BAF RISK 2.2a Risk that we are unable to ensure high quality, safe and sustainable services for the population and patients of west 18 Hertfordshire. CAUSES: (A) Poor systems for monitoring and escalating provider quality issues, (B) Responsiveness of HVCCG, (C) Ambiguity over quality assurances required from partners, (D) Poor quality of assurances from providers commissioned directly and indirectly, (E) Availability of 16 funding, (F) Limited workforce capacity and capability 14 RISK OWNER: Director of Nursing & Quality RISK LEAD: Deputy Director of Nursing & Quality Inherent 12 ASSURANCE SUMMARY Q3 2017/18 (19 December): Monthly oversight group meetings and quality assurance visits continue. There are however, positive assurances that the Trust is maintaining 10 Current safe services with positive outcomes. Mortality rates are lower than the national average and improvement has been made in targets around 8 cancer and diagnostics. Following the CQC re-inspection of WHHT in April, a full inspection took place on 29 August 2017. Deep dive areas were 6 Target identified, where previous concerns had been highlighted by the CQC for scrutiny at oversight meetings and for quality assurance visits. The report is still awaited – now expected January 2018. Nursing & Quality team is also working to support mitigation of any quality risks in 4 Forecast relation to other provider contracts. 2

0 Q1 17/18 Q2 17/18 Q2 17/18 Q3 17/18 Q3 17/18 Jun Aug Oct Dec Inherent risk score Current risk score Forecast for end of Q4 Target risk score 16 12→ 8 8 (no change)

BAF Risk 2.2b Risk that the non-emergency patient transport service does not meet patient safety and quality needs. 25 CAUSES: (A) Shortage of vehicles and drivers in transition period; (B) Lack of communication between partners and providers

20 Inherent

15 ASSURANCE SUMMARY Q3 (31 December): Contingency arrangements were put in place with East of England Ambulance Service Trust Current (EEAST) while a recovery contract was negotiated. During the contingency arrangements EEAST was supported by additional approved local providers to deliver a safe and reliable patient transport delivery service. A formal recovery contract has been negotiated on behalf of the 10 consortia and was signed on 22nd December 2017. Target

5 Forecast

Inherent risk score Current risk score Forecast for end of Q4 Target risk score 0 20 12↑ 8 8 Q1 17/18 Q2 17/18 Q2 17/18 Q3 17/18 Q3 17/18 Jun Aug Oct Dec (risk improving) BAF RISK 2.3 Risk that our plans do not promote sufficient focus on health promotion and reduction of health inequalities. 18 CAUSES: (A) Lack of focus on prevention, early intervention and diagnosis when implementing strategic plans (B) Limited workforce capacity and 16 capability for implementation. RISK OWNER: Director of Commissioning RISK LEAD: Programme Director, Planned & Primary Care 14 Inherent ASSURANCE SUMMARY Q3 2017/18 (31 December): 12 Locality hubs and urgent treatment centres are being developed. Hemel UTC went live 1st December and other localities are to follow. These 10 Current will support access and improve quality of services. Demand management in localities and revisions to processes for Individual Funding 8 Requests (IFRs) and Equality and Quality Impact Assessments (EQIAs) focus attention on protected characteristics and health inequalities. Outline business case for Harpenden and St Albans to the Board in November 2017. CFO working on estates considerations. 6 Target 4 Forecast 2 Inherent risk score Current risk score Forecast for end of Q4 Target risk score 0 16 12→ 8 8 Q1 17/18 Q2 17/18 Q2 17/18 Q3 17/18 Q3 17/18 (no change) Jun Aug Oct Dec

BAF RISK 2.4 Risk of lack of adequate system capability in the management and security of information, data and technology CAUSES: (A) Historic under-investment in IT, (B) Lack of vision of using IT to support clinical services (C) Lack of joined up approach for providers. RISK OWNER: Chief Finance Officer RISK LEAD: Head of IM&T ASSURANCE SUMMARY Q3 2017/18 (18 December): All partnership Boards including HVCCG have signed off the Local Digital Roadmap (LDR) and it has been published on the Hertfordshire and west Essex STP website. All providers are meeting regularly to co-ordinate plans for implementation of the LDR. It is not possible to judge whether the forecast for end of Q4 2017/18 will be an improvement on the current risk position as providers have just re-submitted their digital maturity work to NHSE and the results have not yet been received by the CCG. For the moment the forecast is therefore 16, with potential for improvement if the re-submissions include new evidence. The target risk score of 8 has an expected achievement date of March 2019. The programme is on track with in-year milestones and plans are being progressed around the shared care record with an STP pilot using the “medical information gateway” that commenced in Q1 2017/18, roll out began Q2 and a proposal is being prepared for Commissioning Exec in Q3 for GP records to be accessed in ED. Planning process underway for roll out in Q1 2018/19. The most recent digital maturity matrix assessment suggests that Hertfordshire and west Essex are below average on 48 of the 70 return categories. However, community and mental health trusts already have a full electronic patient record and both Hertfordshire acute trusts have on-going IM&T programmes that move them towards paperless working by 2020.

Inherent risk score Current risk score Forecast for end of Q4 Target risk score 25 20 16→ 16 8 (no change) 20 Inherent

15 Current

10 Target

5 Forecast

0 Q1 17/18 Q2 17/18 Q2 17/18 Q3 17/18 Q3 17/18 Jun Aug Oct Dec

BAF RISK 2.5: Risk that we are unable to ensure high quality, safe and sustainable services for the population and patients of west Hertfordshire in the delegated commissioning of primary medical services. 18 CAUSES: (A) Range of outstanding contractual, performance and procurement issues to be addressed in the transition plan of primary medical services commissioned by NHSE passed to HVCCG. (B) Shortages of clinical and non-clinical staff to provide the appropriate services in general 16 practice and primary care. (C) General practice as a provider is struggling with a number of individual practices facing specific difficulties and 14 challenges. (D) Patient numbers and demand continue to increase and yet general practice will struggle to respond to our strategic plan of moving Inherent 12 patients from secondary to primary care. RISK OWNER: Medical Director/Director of Primary Care Development RISK LEAD: Assistant Director Localities & Primary Care Development 10 Current ASSURANCE SUMMARY Q3 2017/18 (31 December): 8 Workforce staffing has been recruited to with an additional Band 8a and Band 7, both previously NHSE employees, now substantive HVCCG 6 Target employees. NHSE are now offering the CCG a Band 8a seconded position, employed and paid for by NHSE, and will combine with a Band 7 assigned to the CCG. 4 Forecast The nursing and quality team is supporting primary care commissioning team with quality monitoring and serious incident monitoring 2 processes. The Board can be assured that the primary care commissioning team now have clarity on the nature of the issues and the plans to resolve 0 them are regularly presented to the Primary Care Commissioning Committee. Q1 17/18 Q2 17/18 Q2 17/18 Q3 17/18 Q3 17/18 Jun Aug Oct Dec The CCG is aware that approximately 6 practices are struggling to provide basic GMS services due to a range of issues including financial, contractual and staffing. A Primary Care Resilience Panel is being established by HVCCG in January 2018 to review applications for discretionary financial and contractual support, including external facilitation of support for five practices, two of which are contractually vulnerable. Inherent risk score Current risk score Forecast for end of Q4 Target risk score

16 12→ 8 8 (no change) STRATEGIC OBJECTIVE 3: Transforming Delivery. We will work with health and social care partners to transform the delivery of care through the implementation of “Your Care, Your Future”, the Strategic Review in west Hertfordshire. BAF RISK 3.1 Risk that the joint submission to obtain additional capital resource to successfully transform the delivery of care in west Hertfordshire is unsuccessful. CAUSES: (A) Failure to make a compelling case for transformation, (B) Failure to communicate effectively with national bodies, key stakeholders and patients, (C) Limited workforce capacity and capability, (D) Requirement for an Estates Strategy RISK OWNER & LEAD: Director of Commissioning ASSURANCE SUMMARY Q3 2017/18 (31 December): Initial feedback on the STP plan did not include any decision about capital funding. NHSE has, however, indicated that the capital pot available for investment over the next five years is limited and could potentially not meet the demands identified in the STP. HVCCG remodelled Your Care, Your Future figures in line with the current financial position. The reviewed plans were then aligned with the plans for STP capital expenditure. Proposals for the Strategic Outline Case for acute reconfiguration were discussed 4

and approved by at a HVCCG Board meeting in public on 29 June 2017. The proposal is now with the regulator, NHS Improvement (NHSI), for 25 consideration and a decision is expected in Q3 of 2017/18. The controls identified to manage this risk include financial transparency across the health and care system. The current risk score reflects the challenges involved in securing NHSE capital funding made available for the STP. The risk position is forecast to improve by March 2018, but the decision is out of HVCCG’s hands and will depend on the outcome of the NHS 20 Improvement process. Inherent 15 Inherent risk score Current risk score Forecast for end of Q4 Target risk score Current

20 16→ (no change) 12 8 10 Target

5 Forecast

0 Q1 17/18 Q2 17/18 Q2 17/18 Q3 17/18 Q3 17/18 Jun Aug Oct Dec

BAF RISK 3.2 Risk that there will be insufficient support from local bodies and key stakeholders to transform the delivery of care in west 25 Hertfordshire CAUSES: (A) Failure to make a compelling case for transformation, (B) Failure to communicate effectively with national bodies, key stakeholders and patients, (C) Limited workforce capacity and capability, (D) Requirement for an Estates Strategy 20 RISK OWNER & LEAD: Director of Commissioning Inherent 15 ASSURANCE SUMMARY Q3 2017/18 (31 December): Widespread consultation during 2016/17 established significant public and political Current support for acute reconfiguration plans locally. Following their decision to support the Strategic Outline Case proposals, the Board 10 acknowledges that there are still individuals and groups who do not support the plans and continues to engage with them. Target An extensive programme of stakeholder engagement around future commissioning plans has been completed in partnership with East & North Herts CCG. Decisions were taken by the Joint Committee in October 2017, taking under advisement the public feedback, and have been 5 published. The current risk score has been increased to reflect the legal and other challenges that the CCG is receiving in relation to some Forecast recent decisions. Inherent risk score Current risk score Forecast for end of Q4 Target risk score 0 Q1 17/18 Q2 17/18 Q2 17/18 Q3 17/18 Q3 17/18 20 16↓ 12 8 Jun Aug Oct Dec (risk deteriorating) BAF RISK 3.3 Risk that workforce issues prevent us from transforming the delivery of care across the local health and social care system. 25 CAUSES: (A) Unclear approach and absence of strategy, (B) Limited workforce capacity and capability, (C) Workforce culture not congruent with required changes, (D) Poor communication with health and social care partners RISK OWNER: Director of Commissioning RISK LEAD: Director of Workforce 20 ASSURANCE SUMMARY Q3 2017/18 (31 December): Planned and Primary Care team are setting out requirements for workforce plan within Inherent submissions for new pathways and re-procurements of existing services. Commissioning team are working with partners to identify workforce 15 capacity and capability requirements involved in multiple procurements and flag key risks to the Executive and Board. Current HVCCG Director of Workforce has expressed concerns about the lack of partner engagement (including other CCGs), HR collaboration and 10 resource available to support the workstream and take forward STP plans. Although steps are being taken by the CCG to encourage necessary Target workforce action for new pathways, the broader actions necessary across the STP have some distance to go. For this reason the forecast risk 5 Forecast 5

0 Q1 17/18 Q2 17/18 Q2 17/18 Q3 17/18 Q3 17/18 Jun Aug Oct Dec

score for March 2018 is 16.

Inherent risk score Current risk score Forecast for end of Q4 Target risk score

20 16→ 16 8 (no change) STRATEGIC OBJECTIVE 4: Affordable & Sustainable Care We will ensure that there is a financially sustainable and affordable healthcare system in West Hertfordshire. BAF RISK 4.1 Risk that we do not deliver a financially sustainable health and social care system. CAUSES: (A) Reliant upon the engagement of partners in a common financial strategy for both STP (5 years) and Your Care Your Future (10 years), 30 (B) Additional financial uncertainty related to the requirement that utilisation of 1% of CCG non-recurrent spend remains fully uncommitted to create a system risk reserve with spending subject to HM Treasury approval. 25 RISK OWNER: Chief Finance Officer RISK LEAD: Director of Commissioning ASSURANCE SUMMARY Q3 2017/18 (18 December): The controls identified to manage this risk include financial transparency across the Inherent 20 health and care system. HVCCG has remodelled Your Care, Your Future to reflect the difficult financial situation, with the review proposals fed into the Strategic Outline Case for acute reconfiguration approved by the Board on 29 June and recommended to the regulators, NHS Current 15 Improvement (NHSI). A decision by the regulators on the SOC is expected by end of Q3 2017/18. A financial turnaround plan has been developed, including a medium-term financial strategy approved by NHSE. The CCG improvement plan 10 Target addresses the broader issues identified by the recent Deloitte capacity & capability and governance reviews. The current risk score reflects the challenges involved over the next few months, but the CCG is currently forecasting breakeven for the year, with financial risk offset by mitigations. The risk score forecast is therefore that the target will be reached by 31 March 2018. 5 Forecast Inherent risk score Current risk score Forecast for end of Q4 Target risk score 0 25 20→ 10 10 Q1 17/18 Q2 17/18 Q2 17/18 Q3 17/18 Q3 17/18 (no change) Jun Aug Oct Dec

BAF RISK 4.2a Risk that we do not identify the right QIPP schemes or decisions to commission/recommission/decommision, of sufficient value. 30 CAUSES: (A) Failure to identify schemes early enough; (B) Failure to identify alternative schemes for lost savings; (C) Not adopted Right Care methodology. 25 RISK OWNERS: Director Programmes & Commissioning/Director of Nursing & Quality RISK LEAD: Interim Director of Development ASSURANCE SUMMARY Q3 2017/18 (31 December): All schemes for the 2017/18 plan were identified by September 2017. Schemes for Inherent 20 2018/19 are already being drafted with most now identified. Current 15

10 Target

5 Forecast Inherent risk score Current risk score Forecast for end of Q4 Target risk score 0 25 12→ 8 8 Q1 17/18 Q2 17/18 Q2 17/18 Q3 17/18 Q3 17/18 (no change) Jun Aug Oct Dec

BAF RISK 4.2b Risk that we do not make sufficient progress on the QIPP schemes identified. 25 CAUSES: (A) Lack of ownership of individual schemes; (B) Lack of consistent programme management approach; (C) We do not derive the benefits available from engagement with the programme boards RISK OWNERS: Director Programmes & Commissioning/Director of Nursing & Quality RISK LEAD: Interim Director of Development 20 Inherent ASSURANCE SUMMARY Q3 2017/18 (31 December): All schemes have now been reviewed bottom-up and are now being further scrutinised to refine. Some schemes are over-performing, the most material being contract validation with WHHT. Some transformation schemes are back- 15 Current ended to the end of year meaning there are risks in the forecast. It is relatively early in the year so the current risk score remains high but has improved. During and M6 and since the M6 forecast submission to NHSE, the PMO team continued a ‘deep dive’ exercise to improve the 10 accuracy of the forecast for the CCG’s QIPP year-end position. The conclusions were that a realistic achievement is £33m, being £5.5m below Target plan. The target score has therefore been raised to 12 from 8. There are offsetting mitigations above plan. For these reasons the forecast is 5 Forecast 6

0 Q1 17/18 Q2 17/18 Q2 17/18 Q3 17/18 Q3 17/18 Jun Aug Oct Dec

that progress on QIPP schemes by end of March 2018 will result in achievement of the new target risk score of 12.

Inherent risk score Current risk score Forecast for end of Q4 Target risk score 20 16→ 12 12 (no change) BAF RISK 4.3 Risk that we do not achieve financial balance in 2017/18 CAUSES: (A) Acute activity levels and/or (B) Financial values of activity above those detailed in the 2017/18 financial plan. 25 RISK OWNER: Chief Finance Officer RISK LEAD: Director of Contracting and Performance

ASSURANCE SUMMARY Q3 2017/18 (18 December): At the end of month 7 of 2017/18 HVCCG is reporting a year-to-date (YTD) deficit of 20 £1.8m (£2.6m at month 6) and continues to forecast break-even overall. The deficit is largely due to acute activity running at a higher level Inherent than planned, and pressures in continuing healthcare from new as well as backdated claims. The month-on-month improvement in the year- 15 to-date deficit is due to acute expenditure overall being lower than plan. QIPP delivery has fallen below 100% but the CCG has mitigations to Current cover it and the CCG’s net risk remains zero. The financial risks identified are being offset by mitigations in year. These are a combination of 10 non-recurrent benefits from prior year accruals no longer required and budgetary underspends in other programme areas. The current risk Target score remains high due to the effort required to deliver the financial plan, however the forecast risk score at year end is equal to the target. Some certainty has been gained as a result of mediation between ourselves and West Herts Hospital Trust (WHHT). 5 Forecast Inherent risk score Current risk score Forecast for end of Q4 Target risk score 0 20 20→ 10 10 Q1 17/18 Q2 17/18 Q2 17/18 Q3 17/18 Q3 17/18 (no change) Jun Aug Oct Dec

Corporate Risk Register Summary

CORPORATE RISK REGISTER SUMMARY REPORT Q3 2017/18 under amendment Q3 - 9 January 2018 STRATEGIC OBJECTIVE 1: Effective Engagement. Inherent Current Target We will continually improve engagement with member practices, patients, the public, carers and our staff to contribute to and influence the work of Herts Valleys CCG. Risk Risk Risk

SO1/24 Risk that public and stakeholders are not informed effectively. 20 12 8 ASSURANCE SUMMARY Q3 (31 December): There continues to be significant media interest and coverage of some recent issues. STRATEGIC OBJECTIVE 2: High Quality Inherent Current Target We will commission safe, high quality services that meet the needs of the population, reducing health inequalities and supporting local people to avoid ill health and stay well. Risk Risk Risk SO2/01 Risk of a lack of proportionate and effective controls on the use, sharing and publication of information. ASSURANCE SUMMARY Q3 (4 December): An audit of the shared drives is to be carried out in January 2018 to ensure that all PID has been removed from the shared drives, BI and Finance will be the first areas to be audited so that assurance can then be given to SIRO and communicated to the Board. These confirmations will be used as evidence on a destruction certificate that can be sent to NHS Digital to demonstrate compliance. The CCG should no longer receive any patient identifiable data, other than for direct care (e.g. CHC, pharmacy or safeguarding purposes). All other data now goes through the DSCRO, is 16 12 8 turned into pseudonymised data and then flows to NELCSU as our nominated data processor. The CCG has to provide NHS Digital with assurance that all PID will be removed from the Accredited Safe Haven (ASH) and from any other files it might be in (other than files for direct care). The CFO and Head of IM&T have sent out regular updates to the team confirm that all of this work has been completed. Preparations for compliance with the General Data Protection Regulations (GDPR) from 25 May 2018 are underway. Action plan was approved by SLT at their meeting on 2 October. Training was delivered to the CCG board on 26 October with a further training session for CCG staff on 10 November. Training will be delivered to SLT on 11 December. Local update sessions will be provided for CCG early next year. GDPR has been added to staff induction. SO2/15b Risk that CHC performance is inadequate. ASSURANCE SUMMARY Q3 (31 December): Improvement plan remains on track with many actions now part of business as usual activity, updates to improvement plan reported through quality committee quarterly. Audit outcomes taken to Finance & Performance Committee in October and the committee stated that they were assured. CHC dashboard presented with exception report to quality committee monthly. 16 12 8 QA issues have been escalated to the IT provider by Director. Once QA issues are resolved the current risk score is likely to decrease as this is currently preventing the team from reporting activity, i.e. reviews, accurately and requires manual checking. At that time this risk will be recommended for de-escalation from the Corporate Risk Register. Joint operational forum in place with social care and bi monthly strategic meetings – there continues to be poor capacity in social care to complete joint assessments resulting in delays to assessment process and not meeting the 28 day checklist to assessment target a number of patients. Monthly meetings are in place to address these issues. SO2/26 Risk to the CCG of not implementing the objectives of Building the Right Support via the Transforming Care Programme ASSURANCE SUMMARY Q3 (31 December): Transforming care partnership continues and is reported monthly to NHSE - all elements on track to deliver. Projects are at risk due to uncertainty of future funding. Funding bids submitted to NHSE for 2017/18 & 2018/19 were not successful however, the application to carry forward of Fast Track funding to Investment Committee was agreed and work will be able to continue in 2017/18 only. Funding application to Investment Committee for people transferring from NHSE 20 16 6 Specialist Commissioning was not agreed; subsequently funding applications are being made on a case by case basis by IHCCT with Herts Valley CCG. Review of budgets to identify alternative sources of funding to make up short fall e.g. a) Bid for Shared Lives Plus funding being progressed. NHSE decision due 09/17; b) Projects to become business as usual with use of PHBs to fund services; c) Continued applications to NHSE for accelerated discharge payments where appropriate. Exploring budget alignment: letter to NHSE highlighting financial risks to TCP from Funding Transfer Agreement budget alignment protocols. SO2/30 Risk that patients are not assessed with a management plan and exited/admitted or discharged out of the Emergency Department (ED) within 4hrs. ASSURANCE SUMMARY Q3 (10 January): Trust staffing issues and capacity remain a major challenge to ED flow. Streaming is constrained due to surge pressure. Outpatients and 16 16 8 electives have been cancelled and consultants are utilising their time either in additional ward rounds or in ED assessments. Trust surge policy to protect the assessment capacity, electronic bed management system to be in place by the end of January. Recruitment of additional senior ops managers. Trust has been working on SAFER week in January. SO2/31 Risk that we do not reduce delayed transfers of care (DTOCs) to the target of 2.5%. ASSURANCE SUMMARY Q3 (10 January 2018): The 3.5% target has been exceeded currently; at 2.0% and is above the expected trajectory at both WHHT and HCT. This has been due to the improved patient flow through capacity gained in application of winter monies applied through bed and package purchases. Ongoing escalation to system partners via the A&E 16 12 8 Delivery Board continues, with significant resource directed to generating additional capacity and improving discharge processes. The approach by HVCCG is now much more co-ordinated, with weekly MDT meetings between system resilience, quality and commissioning teams who have been using the winter assurance money to purchase additional capacity to assist flow through the health and social care system.

SO2/32 Risk that we do not deliver on the constitutional pledge to refer to treatment within 18 weeks at WHHT. ASSURANCE SUMMARY Q3 (21 December): Due to December surge pressures at A&E at WHHT the trust has had to cancel procedures, which have been overseen by the Quality team 16 12 8 for patient safety issues. The RTT position at WHHT has deteriorated due mainly to pressures with A&E and elective cancellations, plus there are still remain some theatre issues. NHSI have agreed a new trajectory for Sustainability and Transformation Fund (STF) purposes. SO2/33 Risk that we do not deliver on priority ambulance key performance indicators. ASSURANCE SUMMARY Q3 (21 December): Ambulance response programme has been launched from 18 October where targets have been changed allowing for more transportable 16 16 8 resource to be deployed. EEAST overall performance will therefore improve but the challenge will remain in arrival to handover times at hospital. Ambulance arrivals slightly lower than 6 week average for the week ending 10.12.17 SO2/35 Risk that the standard of delivery of adult community services will deteriorate. ASSURANCE SUMMARY Q3 (21 December): HVCCG has conveyed its intention to re-procure adult community services, working to tight deadlines. 20 16 8 The provider has been encouraged to demonstrate innovation and change in their method of delivery in order to be a recognised contender for the service. The provider is being held to account under more robust contractual outcomes. SO2/36 Risk that the decision to cease funding respite services for families at Nascot Lawn will impact the relationship that the CCG has with its stakeholders. ASSURANCE SUMMARY Q3 (6 December): Herts Valleys CCG has decided to set aside its decision from January 2017 regarding the funding of respite services at Nascot Lawn and will make a new decision on this matter. When the CCG took the decision to cease funding respite services at Nascot Lawn in January 2017 our decision was informed by legal advice that indicated the CCG had no power to fund these services. We have recently established that this legal advice was unfortunately inaccurate. We have been clear throughout our recent discussions with families and carers of children attending Nascot Lawn, and with Hertfordshire County Council, that the CCG has a discretionary ability, but not a legal duty, to fund respite services. We have also been clear that the CCG has a statutory responsibility to work within its allocated budget and we therefore must to prioritise spending on health services that we have a duty to commission. In recognition of the inaccurate legal advice in the original decision-making process the CCG will now make a new decision. Prior to making this new decision, the CCG has held further engagement meetings with families. Representatives of Hertfordshire County Council Children’s Services have also attended these meetings. These meetings have been an opportunity for parents and carers to provide the CCG with their views before the new decision is taken. In addition, we have invited all parents and carers 20 15 6 to send the CCG any written comments about the future funding of respite services at Nascot Lawn. An engagement document has also been sent to families and stakeholders. In making its new decision the CCG will build on the engagement that we have had with families and other stakeholders since June. The points raised through this engagement process together with any matters arising from our previous discussions with families and other relevant stakeholders will feed into our new decision about funding Nascot Lawn. We will also give due regard to all of the information that has been generated as a result of the recent legal proceedings, the joint needs assessments that have recently been carried out and confirmation from Hertfordshire County Council that it has a statutory duty to provide a range of short breaks including daytime and overnight care for families. A new Equality, Health Inequality and Quality Assessment will also be carried out before the new decision is taken. The new decision will be taken in line with the CCG’s agreed corporate governance process. We have confirmed our extension of funding until the end of January 2018, as agreed by all parties following the Full Council meeting of the 19 July 2017, and will ensure that a new decision on funding beyond that point is made and communicated to all parties well in advance of that funding coming to an end. SO2/37 There is a risk that the health and care system in West Hertfordshire will not be adequately prepared for influenza outbreaks in care homes ASSURANCE SUMMARY Q3 (31 October): Interim arrangements are available for outbreaks that develop prior to the CCGs contractual solution being operational. CHIT nurse are being redirected to support swabbing and GPs are being paid to prescribe antiviral prophylaxis. 20 16 12 Influenza season declared by CMO on 19.12.17 so antivirals now available on FP10. Herts One will not be able to operationalise the swabbing and prophylaxis service until 22nd January 2018. Interim arrangements for swabbing via HCT and prescription of prophyaxis via HUC are now in place until that time. A teleconference taking place re transfers from acute care during respiratory outbreaks taking place on 21.12.17 between, NHSE, PHE, CCG, HCC. The purpose is to agree criteria for transfers to care homes during an outbreak. SO2/38 * New risk added Risk that the CCG will have a high rate of morbidity and mortality from E coli blood stream infection (BSI), and will not meet the Quality Premium target of a 10% reduction in E coli BSIs by 31st March 18. August 2017 data highlights that a total of 145 cases have been reported in the Herts Valleys population against a limit of 123 for this point in year. 15 15 9 ASSURANCE SUMMARY Q3 (December 2017): Progress reviewed against 2017/18 HCAI & AMR work plan at September HIPC meeting. Due for next review at December HIPC meeting. A total of 237 cases had been reported by the end of November against a ceiling of 195 for this point in the year. STRATEGIC OBJECTIVE 3: Transforming Delivery. Inherent Current Target We will work with health and social care partners to transform the delivery of care through the implementation of Your Care, Your Future, the Strategic Review in west Risk Risk Risk Hertfordshire. SO3/02 Risk that localities will not be aligned with CCG strategic objectives. ASSURANCE SUMMARY Q3 (31 December): Re-structuring of core locality structures will have a short-term adverse effect on some localities, but in the longer term will reduce 20 12 6 duplication.

SO3/03 Risk of failure to ensure that Public Health is sufficiently embedded within the CCG programmes and localities. * Recommended for de-escalation ASSURANCE SUMMARY Q3 (31 December): Public Health has been very engaged with commissioning plans and consultation. Interim Public Health Consultant is in post. Director of 12 3 3 Public Health is invited to attend Board and Committee meetings. SO3/05 Risk that we fail to successfully transform health and social care through use of the Better Care Fund. ASSURANCE SUMMARY Q3 (31 December): BCF Plan 2017/18 was submitted on 11 September 2017 and sign off ratified by the board on 14 September 2017. HVCCG engagement and 16 12 8 involvement in plan includes sessions at a number of CCG committees, led by AD Integration. Governance improvements, including the establishment of the HCC - HVCCG Strategic Partnership Board and a rewrite of the underpinning section 75 are underway. SO3/08 Risk that lack of available workforce in primary care prevents delivery of services identified as key to transformational change. ASSURANCE SUMMARY Q3 (31 December): STP has submitted GP Forward View draft workforce plan supported by NHSE Central Midlands with caveats on budget, recruitment at 16 16 12 scale. Plan has been progressed to the next stage of the process for review by NHSE regional team with outcomes to be known by early January 2018. SO3/09 Risk that there will be increased pressure on health services due to a reduced level of provision for social care services. * Recommended for closure and for the situation to continue to be monitored as part of SO3/05 20 16 8 ASSURANCE SUMMARY Q3 (31 December): Chief Executives from HVCCG and HCC working on joint solutions that can be agreed between the partners including joint consideration of how to use the improved Better Care Fund monies. STRATEGIC OBJECTIVE 4. Affordable & Sustainable Care. Inherent Current Target We will ensure that there is a financially sustainable and affordable healthcare system in West Hertfordshire. Risk Risk Risk SO4/22 Risk that there are higher levels of hospital activity than planned/anticipated. ASSURANCE SUMMARY Q3 (31 December): Acute contracts are being robustly managed. Formal challenges have increased and are currently delivering above target. Providers 20 16 8 continue to be held to account and meetings are being held to agree system-wide transformation and QIPP solutions. Lower levels of activity reported in M7 are partly due to lower elective activity following temporary theatre closures at WHHT. SO4/23 Risk that additional expenditure will occur which is not budgeted for. ASSURANCE SUMMARY Q3 (31 December): At the end of month 7 of 2017/18 HVCCG is reporting a year-to-date (YTD) deficit of £1.8m (£2.6m at month 6) and continues to forecast break-even overall. The deficit is largely due to acute activity running at a higher level than planned, and pressures in continuing healthcare from new as well as backdated claims. The month-on-month improvement in the year-to-date deficit is due to acute expenditure overall being lower than plan. QIPP delivery has fallen below 100% but the CCG has mitigations to 20 20 10 cover it and the CCG’s net risk remains zero. The financial risks identified are being offset by mitigations in year. These are a combination of non-recurrent benefits from prior year accruals no longer required and budgetary underspends in other programme areas. The current risk score remains high due to the effort required to deliver the financial plan, however the forecast risk score at year end is equal to the target. Some certainty has been gained as a result of mediation between ourselves and West Herts Hospital Trust (WHHT). SO5: RISKS THAT RELATE TO ALL STRATEGIC OBJECTIVES Inherent Current Target Risk Risk Risk SO5/01 Risk that the landlord for Hemel One will impose a restriction on parking spaces that accommodates only 30% of the current occupancy. ASSURANCE SUMMARY Q3 (4 December): Met with landlords agent to renegotiate the lease from 2018, this will include additional parking. DBC also submitting detailed proposal for 16 12 8 space at the forum which ill then need to be fully costed. Further search being carried out for commercial properties. Paper to go to Board in March with concrete, costed options. SO5/02 Risk that HVCCG is not protected from cyber attacks ASSURANCE SUMMARY Q3 (31 December): Internal audit of HBLICT shared ICT services cyber security arrangements reported reasonable assurance overall, based on HBL’s use of the ’10 steps to cyber security framework’ published by the information security arm of GCHQ. Further work recommended to strengthen controls has been completed. HVCCG has 20 8 4 improved oversight of shared service, receiving a number of self-assessment and audit assurances. Awareness is regularly raised among HVCCG staff about cyber threats, with specific threats also being notified. All staff have been reminded that failure to follow policy and procedures in relation to cyber security may be subject to disciplinary action. SO5/03 Risk that conflicts of interest will not be managed effectively. ASSURANCE SUMMARY Q3 (31 December): There is a good level of awareness in the organisation about the need to declare conflicts of interest. The staff register has recently been updated and re-published. Board members have been asked to review their declarations and amend as necessary. A new register for board members will be published in January 2018.. New staff are made aware of the policy and procedure as part of their induction. Declarations received from members were cross-checked in October with locality registers of practice members and practices will be asked to review and confirm or update their 20 16 4 declarations by the end of January 2018. This request will also specifically ask those with shares or directorships of primary care provider organisations to declare those interests. The CCG now have fully delegated primary care commissioning arrangements, which represents an additional challenge in effectively managing the perception of conflicts of interest when decisions are made which affect the business of individual practices. The NHSE training module will be released within the next 4 weeks and the CCG will ensure that staff, board members, committee members and practices undergo training by the end of March 2018.

NHS Herts Valleys Clinical Commissioning Group Board Meeting Date of Meeting: 18 January 2018

Title STP update report Agenda item 7 Purpose* (tick) Decision ☐ Approval ☐ Discussion ☐ Assurance ☐ Information only ☒

Author and job title Responsible director and job title Director signature Peter Cutler, Programme Director Peter Cutler, Programme Director Peter Cutler, Helen Edmondson, Associate Programme Programme Director Director Andrew Geldard, STP Finance Lead Alison Gilbert, Transformation Lead Charles Allan, Transformation Lead Nuala Milbourn, Communications lead Short summary of paper The paper is intended:  To provide an update on programmes  To provide an update on STP risks Recommendation(s) The Board is being asked to: Note the report Engagement with Not applicable patients/public/staff and other stakeholders Links to Strategic Objectives (tick all that apply) Objective 1: We will continually improve engagement with patients, carers, the public and member practices ☐ so that they contribute to and influence our work and activities. Objective 2: We will commission safe, high quality services that meet the needs of the population, reducing ☐ health inequalities and supporting local people to stay well and avoid ill health. Objective 3: We will work with health and social care partners to transform the delivery of care through the ☒ implementation of Your Care, Your Future, the strategic review in west Hertfordshire. Objective 4: We will ensure that there is a financially sustainable and affordable healthcare system in West ☒ Hertfordshire. Board Assurance Framework Refer to assurance levels table below and latest BAF report here: N:\Nursing & Quality\8 Risk Management System\2. Board Assurance Framework\BAF 201718\BAF Current version for front sheet reference N.B. The executive summary for this paper explicitly points to the evidence to support the assurance level indicated above. For example: Very high – what is the evidence to support the current strong position & how will it be sustained? High – what is being done to strengthen controls and mitigate the likelihood of this risk materialising? Medium - what is being done to address gaps in assurance and how successful is this action proving? Low - what are the urgent actions planned to address the lack of assurance? Ref. Risk Risk description Current risk Target risk Assurance Owner score and score Level movement since last month 4.1 CH Risk that we do not deliver a financially sustainable 20→ 10 Medium health and social care system. New risks identified by this report

Other significant risks related to this report

Resource Not applicable CFO Signature implications

Potential conflicts None of interest Equality and quality impact analysis Equality delivery Better Health Outcomes ☐ system (identify Improved Patient Access and Experience ☐ which goal your A Representative and Supported Workforce ☐ proposal / paper supports) Inclusive Leadership ☐ Report history STP CEOs Board Which Groups or Committees have seen this report and when? Where does the report go next? Appendices

Hertfordshire and West Essex STP

CEOs Board

December 2017

Title Programme Directors Report

Purpose To provide an update on the NHSE stocktake and Chairs Oversight Board.

To provide an update on Clinical Leads objectives.

To provide a finance update of the position at month 7. To provide an update on activity information for the STP.

To provide an update on the refreshed PMO work plan.

To provide an update on the progress of STP workstreams.

To update on work underway to develop an Accountable Care System ACS

To provide an update on communications and engagement activities.

Report authors Peter Cutler, Programme Director Helen Edmondson, Associate Programme Director Andrew Geldard, STP Finance Lead Alison Gilbert, Transformation Lead Charles Allan, Transformation Lead Nuala Milbourn, Communications lead

Short summary of the paper The Programme Director has met with the Clinical Leads to draft objectives.

The STP team had a positive NHSE Stocktake meeting and attendance Chairs Oversight Board.

There has been a further deterioration of the provider side financial position but they are forecasting their end of year position will improve. Commissioners continue to report achieving their

agreed end of year position.

The STP is generally seeing an activity underperformance against Planned Care and A& E plans.

Recommendations To note progress to date.

Programme Director’s Report

December 2017

1. Introduction

This report provides an update on:

 STP Performance Dashboard  STP Clinical Leadership  Stock take meeting  STP Chairs Oversight Board  STP Financial position  Activity trends  Update on PMO work plan  Work stream activities  Communications and Engagement activities

2. Appendices

Appendix 1 Activity trends

3. STP Performance Dashboard

3.1 All the data in the table is the same as the last Programme Directors report apart from DTOCs. For DTOCs the figures for October are distorted by there being no data for ENHT reported. Individually WHHT improved from 5.9% to 5.6%. PAHT remained the same at 3.9%.

Latest STP Category Performance Metric Date of Data Benchmark Performance Hospital Mid-November A&E waiting time performance 77.70% 95% Performance 2017 Referral to Treatment waiting September (except 90.20% 92% time performance ENHT) Providers in special measures 2 October 2017 0 Healthcare associated infections 0.7 2017/18 0 - MRSA Healthcare associated infections 13.7 2017/18 15 - c. difficile Patient Focussed Extended access 17.30% March 2017 75% Change Patient satisfaction with opening 75% Annual survey 70% times Improving Access to Psychological Therapies 53.50% August 2017 50% recovery rate Early Intervention in Psychosis 77.40% September 2017 60% 2-week waits % of cancers diagnosed at stage 56% August 2017 Tbc 1 or 2 62-day waits 78.70% September 2017 85% Cancer patient experience score 8.5 Annual survey Tbc 90 Transformation Emergency admissions rate 88 Tbc Emergency bed days rate 450 Delayed Transfers of Care rate 5.90% October 2017 3.5% System-wide leadership Established Annual survey CCG/Trust performance vs. -0.70% 2017/18 financial control total

4. STP Clinical Leadership

4.1 The three clinical leaders have met with the STP Programme Director to scope and draft their objectives. The Clinical Leads have a significant responsibility in terms of enhancing professional engagement and getting professional ‘buy in’ to the required STP clinical transformation and the objectives provide a framework for this.

5. Chairs Oversight Board

5.1 The STP Leader (Tom Cahill) and Programme Director (Peter Cutler) presented to the STP Chairs Oversight Group on 16th November 2017. The meeting updated the Chairs on key developments in the STP, including progress with transformation workstreams; the proposed mandate and outline

plan for progressing an accountable care system; feedback from the NHSE stocktake meeting and the recruitment of a full-time leader for the STP.

5.2 The Chairs were supportive of the developments to date and made some detailed comments on the work plan to progress the Accountable Care System.

6. Stocktake

6.1 On 13th November 2017 Tom Cahill, Deborah Fielding, Peter Fairley and Peter Cutler attended the STP Stocktake with Paul Watson and Elliot Howard- Jones. The meeting was positive with Paul Watson complimenting the STP on the progress it has made and in particular the clear governance and support arrangements in place.

6.2 The meeting focused on the need for the STP to clearly identify where it can add value over and above the assurance and programmes in place and to answer the question “What will be different because of the STP?”

6.3 A draft timetable and list of tasks required to progress to an Accountable Care System was also discussed. The work programme was considered to be appropriate and the approach was considered “far sighted” in terms of early design of an ACS.

6.4 It was agreed that Paul Watson would meet with the STP leadership as a whole, and it is expected that this will take place by the end of January 2018.

7. Month 7 Financial Position

7.1 Overall Position

7.1.1 The Month 7 (September) financial results from STP organisations are now available.

7.1.2. The key theme within the overall position is the further deterioration of the provider side position with the in-year deficit now standing at £65.461m up from £58.337m reported at month 6. Against plan this represents a significant shift out of the year-to-date variance of £7.540m to £28.275m indicating that actions expected to stabilise the overall provider financial position are not having the desired effect.

7.1.3 However, on the whole provider organisations continue to forecast that their position at year-end will improve and that their control totals will be met. There are two exceptions to this in HCT which continues to display a technical issue relating to a loss on disposal of a property and WHHT which has now agreed with NHSI that their reported position will move out from £15.04m to £35.00m.

7.1.4 Within Commissioning Organisations, HVCCG continue to report an in-year pressure although at Month 7 this has improved. The CCG continues to anticipate that this pressure will be resolved during the second half of the year as they forecast achieving their control total at year-end.

7.1.6 For west Essex, the CCG continues to report an ‘on-target’ position both within year and at month end whilst the position for ENHCCG remains constant.

7.2 Performance Against CIP/QIPP Targets

7.2.1 In relation to CCG QIPP delivery, CCGs continue to forecast that the vast majority of QIPP aspirations will be delivered with total now forecast as £70.112m against a target of £73.313. However, the year-to-date delivery of QIPP savings would appear to be lagging behind the required run-rate by £7.101m increasing the overall requirement in the second half of the year.

7.2.2 For providers, the collective position is indicating that they are some £2.914m behind target CIP delivery at Month 7 which indicates acceleration in delivery compared with Month 6. All providers, with the exception of WHHT remain confident of achieving their annual CIP targets.

7.3 Year-End Forecasts: Best and Worst Case Scenarios

7.3.1 Given the variability in the CCG/Acute Provider ‘inter-trade positions and the importance of these to organisational year-end forecasts STP CEOs asked for best case and worst case scenarios to be produced.

7.3.2 The current best case is to approximate the current control totals, whereas on a worst case the STP could face up to a £80m variance to control.

7.3.3 STP FDs have agreed to repeat this exercise during December with the aim of creating a ‘likely case’ scenario.

8. STP Activity Performance

8.1 The PMO has constructed an initial view of the STP’s activity plan for 2017/18. This has been achieved by bringing together the activity plans of the three CCGs as per their on-going returns to NHSE. The returns contain details of actual activity levels for 2015/16 and 2016/17. The returns also show the performance against the in-year plan.

8.2 Whilst Appendix 1 gives details of the month by month activity over the 4-year period, table 8 below gives a summary of the overall trends for the 6 key metrics collected by NHSE. In essence, the STP’s collective plans show a growth in expectation regarding Outpatients attendances and Referrals. However nationally reported actual 16/17 and 15/16 activity levels have been

changed. 17/18 Plan levels compared to 16/17 actual now shows a reduction for Elective and A & E activity and a smaller level of growth for Non-elective activity. The same information reported at Month 5 has been included for reference.

Table 8: STP Activity – Historic, Plan and Current

As at Month 6 2015/16 2016/17 Actual to 2017/18 Plan to 2017/18 Act to 2017/18 Act to Actual 15/16 Actual 16/17 Actual 16/17 ytd M6 plan ytd M6 Planned Care Revised

Elective Admissions 174,664 4% -2% -1% -1% Outpatient Attendances 1,390,174 5% 2% -2% -4% GP Referrals 348,067 1% 3% -3% -6% All Referrals 533,997 2% 4% -2% -5%

Urgent Care Non-Elective Admissions 136,253 -2% 1% 5% 0% A&E Attendances 490,604 4% -1% -3% -3%

- Reduction in activity

15/16 Actual 16/17 Actual Plan 17/18 17/18 Actual Plan 17/18 From Unify From Unify Data Source: National Data National Data Submission CCG Input Submission 15/16 Actual 16/17 Actual 16/17 Actual 17/18 Actual National Data National Data National Data CCG Input

As at Month 5 2015/16 2016/17 Actual to 2017/18 Plan to 2017/18 Act to 2017/18 Act to Actual 15/16 Actual 16/17 Actual 16/17 ytd M5 plan ytd M5 Planned Care Revised

Elective Admissions 165,788 4% 4% 4% -2% Outpatient Attendances 1,390,174 5% 2% 0% -3% GP Referrals 348,164 1% 3% -3% -6% All Referrals 534,155 2% 4% -2% -5%

Urgent Care Non-Elective Admissions 133,945 -2% 2% 7% 0% A&E Attendances 489,121 4% 0% -3% -3%

- Reduction in activity

8.3 In relation to activity performance in 2017/18 year-to-date, the STP is generally seeing an underperformance against Planned Care and A & E plans. The performance against plan comparing month 6 vs month 5 year to date for Elective activity appears to show a very slight change.

8.4 At month 6, 2017/18 activity compared to 2016/17 actual shows, in elective and urgent care a larger gap between the years in comparison to month 5.

9. Updated PMO Work plan

9.1 The PMO team continue to make progress in delivering the PMO work plan. Particular highlights are:

 Finalisation of the STP winter plan  STP wide communications for winter  Attendance at HVCCG Governing Body to improve clinical engagement  Appointment process for STP Leader  Externally facilitated, system wide ACS event  Re-energising of back office task and finish group

10. Workstream Update

10.1 Below is an update on the work streams on progress since the last Programme Directors report.

10.1.1 Frailty

The work stream is aiming for an STP system wide launch and implementation of the single hard copy plan of care from 1st March 2018. On 23rd January 2018 there will be an STP developmental workshop to refine the plan of care and to enhance and build on the existing workshop output. The aim is to ensure that the ownership, contribution and wider engagement with the workforce enables the best practice design of the care plan in preparation for the launch.

Final professional and operational sign off of the new plan will be followed by an agreement to operationally test in three localities across the STP footprint.

It is recognised that the operational mobilisation planning will be key to success of the STP large scale roll-out and this may be phased to target the relevant groups of the frail population using the newly designed frailty care pathways.

The outcomes expected include:  Improvement in person –centred and coordinated care  A consistent and collective focus on an improvement in proactive and planned care

 A sustainable reduction in the urgent care demand on primary care community services, hospitals and social care services  Increased join up of health and care teams and services  An efficient approach to care planning which is consistent and reduces duplication  An emphasis on improved measurement of outcomes for patients

The urgent care, primary care and frailty workstreams have now formalised a stronger working connection with recognition of the need to utilise the place based care locality delivery infrastructure where appropriate.

The frailty / falls pathways (frailty means falls) pathways have been redesigned based on good practice, local testing and development with staff in STP engagement workshops. They have been agreed in principle and the existing work and support services linked to the frail have been recognised and work is underway to step up a more co-ordinated approach.

The frailty evaluation framework tool is being explored and it has been agreed to review the use of the urgent care ‘channel shift’ modelling framework which will need to include a focus on the impact on the workforce and future skill requirements / place of care.

The frailty work stream clinical leads will be presenting the following to the STP CEO steering group in December 2017:

- My health management plan - Best practice frailty/falls pathways - Frailty STP peer review methodology

STP frailty multi-professional peer review will take place January to March 2018 and will inform the baseline for the proposed service changes. Site visits to exemplar good practice services in the country are being explored.

10.1.2 Urgent and Emergency Care

Pauline Phillip has contacted all CEOs of trusts with a further Winter Briefing. The letter sets out expectations around the operational management of winter, specifically the Winter Operating Model, Local Winter Teams and Local escalation plans.

STP Winter Plans have been updated following the Pauline Phillip letter. Final discussions have taken place with EEAST and the STP Escalation process established, to be led by EEAST Traffic Management.

Each LDB continues to implement its recovery plans with the aim of achieving the 95% target by 31st March 2018.

The UEC Dashboard proposal has been approved by the E&N Herts CCG LDB. It has been presented to the Herts Valleys CCG LDB and is due to be discussed at the next West Essex CCG LDB meeting.

Work is continuing to explore the functionality of the NHSE Vanguard Channel Shift model and whether this can be used with the Frailty work stream.

10.1.3 Clinical Support Services

Pathology: STP PMO had an informal meeting with David Wells, Head of Pathology Services Consolidation for NHSI, to better understand NHSI’s expectations regarding the proposed pathology networks. His overall feedback is that NHSI are not going to be too prescriptive around how the networks are structured and aligned and they have already made adjustments to these based on some of the feedback they have received following their letter in Sept 2017. NHSI however feel strongly that all hospitals should work within larger networks as it is through these larger (virtual or actual) organisations that the savings and efficiencies can be realised. He emphasised the importance of Trusts engaging around the proposed networks.

Implementation managers have been recruited and will be leading on developing the network. The roles will take the lead and NHSI would like the STP to be linked and kept aware of any developments.

The PMO are making the linkages between pathology and other work streams for example cancer and the established cancer networks.

Radiology: The NHSI Pathology link has agreed to the STP PMO into the NHSI lead for Radiology as a network has also been suggested for Radiology. When the PMO has further information this will be taken to the Clinical Support Services Work stream.

Medicines Optimisation Approval secured for roll out of PharmOutcomes (IT-enabled Clinical Handover)) in ENHT and PAH for roll out in January 2018. STP PMO continues to support WHHT ensure roll out before the end of the financial year. GP Clinical Lead to be identified to raise awareness amongst GPs about how PharmOutcomes will support their patients. The main risk is delayed organisational IT approval as the scheduling process could slow the roll out of the project.

The Open the Bag campaign will follow on from the Over the Counter consultation and implementation plan for roll out over Easter 2018. The campaign will focus on public education and engagement with community pharmacy for implementation.

The preliminary phase one Stoma products business case was approved by Chief Pharmacists on the 15 November 2017 and will now progress through the STP governance process. There is clear recognition that a future phase 2 transformation case is required.

At a recent National Pharmaceutical Integration event held in London on 16th November 2017, Herts and west Essex STP medicines optimisation work was recognised as an exemplar of good practice. It was agreed that it would be shared nationally to progress the transformation work within STP's and through the wider medicines optimisation work led by the National Pharmaceutical Officer.

The Royal Pharmaceutical Society recently produced a letter and support newsletter to encourage STPs to involve pharmacists to ensure that the opportunities for shared learning and transformation are fully utilised. Their recommendations are congruent with the work already being undertaken within the STP.

10.1.4 Planned Care

Stakeholder event on evidence based pathways was held on 24th November. It was well attended and brought together clinicians from across the STP. There was representation from all acute trusts and CCGs plus community services and GPs. Allied Health Professionals and specialist nurses were also in attendance. There were productive discussions and challenge around the priority identified clinical pathways: palpitations, breathlessness and gastroenterology.

It has been agreed to adopt the 100 days approach to pathway review for these pathways in an amended form and make a formal application to NHSE to the next wave of the programme subject to support from the executive body. The three pathway groups are now working up their project plans and the 100 days exercise will start in early January.

The fragile service work has paused at the moment due to clarity being sought around the interventional radiology programme. A clinical lead from EN Herts is also needed and as yet this has not been identified. This requires a period of intense focus to restart this work stream and reprioritise.

Implementation of Shared Decision making will be addressed in two ways. Firstly, it will be woven through the clinical pathway review work for individual pathways. There is also a significant cultural change piece of work necessary to train and embed the principles into practice and this will be delivered across the STP. This links to the frailty and prevention work streams and the STP wide training will be addressing all three requirements. Good progress is being made with NHSE support.

10.1.5 Cancer

ENHT has made 12% improvement on 62 Day Cancer Wait Targets with trajectory of achieving 85% in January. If this improvement is sustained and the trajectory met then it will mean that the STP can apply for the transformation money to be released by the Cancer Alliance. In anticipation of this the work stream is developing the mobilisation plans.

The STP Cancer Locality Group has pulled together Plans on a Page across 9 workstreams. A prioritisation exercise is being carried out in the next Locality Group

meeting on 14/12/18 to confirm Cancer Delivery Plan for 2017-2019. The key areas identified are:

o Sharing best practice for improvement of timed cancer pathways across the STP to maintain 62 Day wait target o Task and Finish Groups for implementation of FiT in Primary and Prostate Pathway Redesign – focus to produce Business Case in preparation for release of Cancer Alliance Transformation funds o Task and Finish Groups for Living with and Beyond Cancer to scope gaps and produce Business Cases for Recovery Package and Risk Stratified Pathways Cancer Alliance Transformation Funding o Task and Finish Group for STP wide National Cancer Patient Experience Survey (NCPES) Action Plan. Patient voice will be at the heart of this action plan with funding being applied to from Macmillan to hold patient engagement events o Working with STP Comms Lead to consider comms plan for Prevention workstream focusing on health living and early diagnosis campaigns.

A national Radiotherapy Consultation is underway where Mount Vernon Cancer Centre has been identified as being within the London Network. Deadline for the consultation is 18th December 2017. The Cancer Locality Group is producing the STP wide response to the consultation.

10.1.6 Mental Health and Learning Disabilities

In the last month the Mental Health and Learning Disability workstream has responded to the national request to develop an STP wide Out of Area Placements plan and this was submitted on 29th November 2017. We have also received a request from NHS England and HEE to develop a mental health workforce plan for the STP and will be developing this with the Workforce STP group before the deadline of the end of March 2018.

On 23rd November 2017 a meeting was held with Learning Disability leads across the STP to consider how best to ensure that the STP delivers improved health outcomes for people with learning disabilities. A number of actions were identified and will be fed into STP workstreams.

Agreement has also been received to go ahead with three pilots for Primary Care Plus models of mental health support which will start early in the New Year, the pilots are in Stevenage, Hertford and Watford.

10.1.7 Prevention

The STP Medicines Optimisation work stream have agreed a Community Pharmacy Proposal led by Herts and west Essex Local Pharmaceutical Committees (LPC). It was presented to the prevention workstream and the proposal was supported with recognition that Community Pharmacies are key services to promote and develop the prevention agenda over and above existing work. There will be a connection

initiated with the pharmacy lead to help clarify what can be done ‘now’ to support prevention.

The STP Prevention workstream will support a bid for British Heart Foundation (BHF) money to enable an improvement in early identification of cases of raised BP. Deadline for the submission is March 2018. All three CCGs are aware and the submission is being developed.

It was agreed that a focus on the variation in the identification and management of CVD in primary care would be a work stream priority alongside the primary care work stream. The workstream will review for impact some of the approaches currently being taken in the CCGs, and then make recommendations.

Self-management work stream will be re-launching the programme of work in December 2017 to support a wider provider engagement and approach to delivery. The work stream has identified important links with the Frailty Workstream with regard to the Care Plan development, particularly around self-care/management etc. This work will be joined-up where appropriate.

The community navigators are now in post and the social prescribing model is being adapted and applied according to local needs in the community.

Colleagues from Public Health England (PHE) gave a presentation outlining the tools and resources that are available to support the STP. Their social marketing lead will contact the STP comms group lead to discuss how they can work with us to support campaigns such as ‘One-You’.

10.1.8 Estates, Facilities and Capital

This workstream is focusing on the completion of a five-year strategic plan for the effective deployment of STP estates resources to support the new models of care emerging from the clinical transformation workstreams. An initial draft of the plan has been completed and is now being refined with detailed data. The revised plan will be presented and discussed with the STP CEO board in early February 2018.

Key features of the plan include:

- A detailed review of estate condition and investment requirements; - Mapping of underutilised resources; - A disposals plan which will reduce running costs and release assets for re- investment; - Proposals for reducing estates running costs and improving facilities management.

The investment proposals balance the need to improve and refurbish large facilities within acute hospitals with the delivery of community and primary care facilities that enable improved clinical pathways and care closer to home.

10.1.9 Procurement

Following the submission of the outline business case, CEO approval for the investment in the PPIB tool was given and the product and consultancy commissioned. Work has begun to collect the procurement and finance data from the three Acute Trusts to populate the Procurement Dashboard. This will then enable the opportunity assessment work to be commenced. This has highlighted some issues around the disparate IT systems involved in data collections.

A Joint Procurement Working Group has been formed of Procurement representatives across the STP and is tasked to work up a plan detailing how the organisations will initially work more collaboratively together and ultimately move towards the vision of a single shared procurement function across the STP. The group has already begun some collaborative initiatives.

10.1.10 Primary Care

ENHCCG GPFV team, (as HVCCG & WECCG are already providing this) has met with HCC Social Prescribing leads to align the upcoming GPFV active signposting training with the STP Social Prescribing offer. It is anticipated the training provider (West Wakefield) will commence training with ENHCCG localities January 2018.

Herts and west Essex STP Workforce Plan was submitted to NHSE CM on 31st October 2017. Feedback from NHSE was predominantly positive and requested additional information e.g. Approach to workforce planning with LMC, GP loss rates and workforce implications of new models of care, more detail on Mental Health professional recruitments and their training needs, plans to maximise sharing of back office functions within general practice and 10 High Impact Actions underway (GPFV). It was re-submitted on 15th November 2017.

The Central Midlands assurance panel met on the 17th November 2017 to review workforce plans prior to submission to the NHSE regional team. The panel recommended that the Herts and West Essex STP Workforce Plan is assured with conditions. These conditions are linked to the following elements of the plan where further clarity or detail is required:

The CCGs are reflecting on this and taking the plan through their governance routes.

GP Online Consultation System Fund was launched by NHSE on 30th October 2017 as part of the General Practice Forward View, a £45 million fund has been created to contribute towards the costs for practices to purchase online consultation systems, improving access and making best use of clinicians’ time. Digital Technology is a key enabler to the delivery of integrated care for patients. Information shared with

STP and CCG ICT Teams. Monies to support this from NHSE have been given to CCGs. NHSE also included an application template for submission by 8 December 2017.

Given the short timescale for response, an STP Technology meeting is being convened with NHSE to discuss this requirement and all the options available.

The General Practice Forward View (GPFV) included a commitment to deliver a major international recruitment drive to attract up to 500 appropriately trained and qualified GPs from overseas by 2020. A programme to deliver this commitment commenced in the autumn of 2016 focusing on a number of high priority areas of the country in advance of the planned expansion of the programme to other areas from April 2017.

On 22 August 2017, NHS England announced a major expansion of the International GP Recruitment (IGPR) Programme. The expanded programme will now accelerate the original plans, and aim to recruit 2000 GPs from overseas by 2020. The recruitment scheme is fully funded by NHS England, on a rolling phased approach. Funding is available to support the process of recruitment including sourcing and selecting applicants, training, relocation and accommodation costs.

A GP International Recruitment Office has been established to organise and run the scaled up international recruitment programme. The role of this office is to coordinate the recruitment, provide support for and relocation of recruited doctors, working closely with regional and local colleagues and partner organisations.

Building on the success of the initial pilot run in Essex in 2016/17, West Essex CCG were originally scheduled to join the six other Essex CCGs in submitting an Essex wide bid by 30th November 2017, but on the 22nd November, new NHSE guidance stated CCGs should only be bidding to participate in this on an STP wide footprint. Therefore west Essex CCG will now join the Hertfordshire bid and to allow this and sufficient time for engagement with GPs, the bid for International Recruitment being developed will be submitted in January 2018 as highlighted above.

10.1.11 Placed Based Care

The place based care mapping exercise has been completed for the following parts of the place based care transformation work:

- Place based care work stream - East and North Herts place based care delivery board and localities - West Essex neighbourhoods steering group and neighbourhoods - Herts Valleys place based care delivery board and localities will be undertaken in January 2018

The aim was to map the level of understanding and ownership of the 6 place based care priorities and the progress to date with implementation. It would also identify what is working well in addition to blockages.

Priorities: 1. Shared leadership offer 2. Common populations 3. Organisational development 4. Workforce skills 5. Shared delegated resources 6. System levers e.g. information sharing, enabling policies.

A paper will be presented to the place based care work stream on 6th December 2017 providing recommendations. These will enable sustainable implementation within localities and neighbourhoods based on local progress to date and comparison to National good practice against the 6 place based care priorities.

10.1.12 Technology

The group are collectively exploring opportunities for a Shared Care Record across Hertfordshire and West Essex. This work is focussed on:

 Developing a Full Business Case comprising detailed specification  Building on work already conducted in West Essex on “My Care Record” and expanding that across the wider STP  Delivering interim solutions through a “quick wins” programme including MIG deployment and digitised Admission, Discharge and Withdrawal (ADW) notifications

This group have explored a small number of pilot proposals relating to shared intelligence (based on integrated data analysis). In addition, they have shared native data sets to share understanding.

The group hosted some specification workshops to explore and define the future needs of integrated intelligence tools. The results of these are being collated.

There is a new workstream of Assistive Technology for the programme. The work stream needs to crystallise with Terms of Reference and establish a clear remit. Currently, the work stream is embarking on the following activity:

 Provide a centralised view of cross-system AT activity  Support learning / best practise  Provide clinical/practise leadership and insight  Provide an oversight of activity to prevent duplication

10.1.12 Women and Children’s

NHS England has provided positive feedback on the Herts & west Essex Local Maternity System Transformation plan that was submitted to NHS England on 31st October 2017. A further iteration will be submitted NHSE based on their feedback.

The work stream received useful feedback from at the STP Director and Clinical Engagement event held on 31st October 2017 at The Colonnades. Two key areas for development emerged, first, the need to engage clinicians across the STP area in discussions about variations in outcomes and performance from children’s’ services. It was felt by clinical colleagues that this would drive up quality and improve outcomes. The second was the engagement of providers in service re-design and the workstream leads agreed to ensure that they had the most appropriate clinicians and management support present at future meetings.

10.1.13 Carers

The guiding principle of the STP approach to supporting carers builds on a legacy of multi-agency working over many years. It is not an ‘extra’ process but a pulling together of existing reviews of strategies to ensure maximum integration and the best possible use of resources to support carers. Learning from (for example) the Dacorum carers’ pilot to be shared across the footprint.

The draft ‘Carers Strand’ of the STP identifies four key priorities to underpin the work of all agencies across the footprint. These are:

- Identification – ensuring mechanisms for early identification are in place - Promoting carer wellbeing - using contact with carers to help them stay well - Carer friendly support – making sure services either provide high quality support to carers themselves and/or ensure, wherever possible, that support to the people they care for doesn’t make carers’ lives any more complicated. All agencies to know how to refer carers on to support - Promoting carers ability to work (both to stay in or return to work)

Hertfordshire is looking to adopt a draft five-step carers’ pathway to help agencies identify their respective contributions for strategic action planning and delivering the priorities and to publicise a carers’ charter/ ‘minimum offer’ setting out what carers can expect.

These are: - Identification (clarifying each agency’s role – from libraries to hospitals, housing officers to pharmacies, safe and well visitors to faith groups - in carer identification and onward referral) - Welcoming carers (ensuring carers feel valued and respected) - Supporting carers – providing carer-friendly information and advice, and practical carer support or support to the person in a way which best supports the carer and/or has no negative impact on the carer, as appropriate to each agency - Involving carers – ensuring carers are listened to in relation to their caring role (as appropriate in relation to the views of the person they care for) and have opportunities to influence services

- Helping carers through change (making sure that carers are supported through complex changes eg bereavement, moving in and out of caring, transitions between services etc)

11. ACS

11.1 A development session was held for CEO’s and Chairs on 21st November 2017 covering Accountable Care Systems (ACS) and Accountable Care Organisations (ACO). The session was facilitated by Mike Farrar, from Carnell/ Farrar, who is a former senior NHS Chief Executive and was involved in developing Accountable Care in England.

11.2 Accountable Care is being introduced into the NHS because of a background of rising demand, reducing resources, and failing standards. Additionally GP earnings have reduced by 15% over the last five years and local authority care is increasingly difficult to access. Overall the health and care system has become fragmented and Accountable Care is attempting to rectify this, by bringing budgets together, aligning incentives for clinicians and getting providers to work together. The aim is to add value in the range of 30 – 40p per pound spent and improve outcomes. This will be delivered by removing transaction costs, encouraging longer term investment, reducing variation and inequality through population based commissioning and place based care. Examples from around the world have shown up to 20% efficiency improvements through service integration, and alignment of incentives that promote best value across a system. The NHS universal coverage platform provides a good platform for achieving the gains of Accountable Care.

11.3 Discussion centred around a way forward for Herts & west Essex and there was agreement that four key issues needed to be developed:

 Geography  Finance  Timeframe  Transformation Process

11.4 There was also agreement that the PMO would draft an options paper for ACS/ACO, detailing timeline, criteria for decision making and a mandate for progress/ governance. This paper will be discussed at the CEO/Chairs meeting on 9th January 2018. The paper will also include a narrative about why change is taking place, why accountable care and why it matters to Herts and west Essex. Finally it will make proposals about what could be developed and trialled locally from April 2018 onwards.

12. Communications and Engagement

12.1 Communications representatives from our STP were invited to lead workshop sessions at a national STP transformation and engagement event in London on 29th November 2017. Entitled ‘Mainstreaming vanguards work: getting over the ‘not invented here’ mind-set,’ the sessions gave our STP the opportunity to showcase some of the best-practice Care Homes Vanguard projects which are now being adopted across our STP area.

12.2 Following a successful bid to NHS England for funding to support communications and engagement in our STP area, approximately £200,000 has been granted to pay for staff and campaigns until March 2019…The STP comms and engagement lead will now work with colleagues to ensure that this money is used effectively to further the aims and objectives of the Partnership.

Appendix 1

17,000 Elective Admissions 16,500 • Actual activity at M6 YTD is 1% below 16/17 levels with WE CCG 7% below 16/17 levels 16,000

15,500 • 1718 activity at M6YTD is 1% below 17/18 plan with WE 15,000 CCG 4% and ENH CCG 2% below plan 14,500 14,000 13,500 13,000 12,500 12,000 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

17/18 Act Nat 17/18 Act CCG 17/18 Plan CCG 16/17 Act Nat 15/16 Act Nat

137,000 Outpatient Attendances • Activity at M6YTD is 2% below 16/17 levels with EN CCG at 132,000 6% below while WE CCG 2% above 16/17 level (CCG input 127,000 data vs National 16/17) 122,000 Actual activity at M6 YTD is 4% below plan with ENH 8% and 117,000 • WE CCG 3% below plan. 112,000

107,000

102,000

97,000

92,000 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

17/18 Act Nat 17/18 Act CCG 17/18 Plan CCG 16/17 Act Nat 15/16 Act Nat

34,000 GP referrals • Actual activity 17/18 (CCG Input) YTD M6 is 3% below 16/17 32,000 actual YTD M6 (National data) and 6% below 17/18 YTD M5 plan 30,000

28,000

26,000

24,000

22,000 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

17/18 Act Nat 17/18 Act CCG 17/18 Plan CCG 16/17 Act Nat 15/16 Act Nat

53,000 All Referrals • Actual activity 17/18 YTD M6 (CCG input) is 2% below 16/17 51,000 Actual YTD M6 (National data) and 5% below 17/18 YTD M6 49,000 plan (unify submission)

47,000

45,000

43,000

41,000

39,000

37,000 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

17/18 Act Nat 17/18 Act CCG 17/18 Plan CCG 16/17 Act Nat 15/16 Act Nat

Appendix 1

47,000 A&E Attendances 46,000 • Actual activity in M6 YTD(CCG input) is 3% below plan (unify submission) and 16/17 YTD (National data) 45,000 44,000 43,000 42,000 41,000 40,000 39,000 38,000 37,000 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

17/18 Act Nat 17/18 Act CCG 17/18 Plan CCG 16/17 Act Nat 15/16 Act Nat

12,500 Non Elective Admissions • Actual activity 17/18 YTD M6 is 5% above 16/17levels 12,000 with ENH CCG at 3% and WE CCG at 19%

11,500

11,000

10,500

10,000

9,500

9,000 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

17/18 Act Nat 17/18 Act CCG 17/18 Plan CCG 16/17 Act Nat 15/16 Act Nat

NHS Herts Valleys Clinical Commissioning Group Governing Body Public Meeting Date of Meeting: 18 January 2018

Title Evaluation of the Rapid Assessment, Interface and Discharge (RAID) Service Agenda item 8 Purpose* (tick) Decision ☐ Approval ☒ Discussion ☐ Assurance ☐ Information only ☐

Author and job title Responsible director and job title Director signature Covering paper - Anna Hall, Senior David Evans, Director of Commissioning Commissioning Manager, Integrated Health and Care Commissioning Team (IHCCT)

RAID Evaluation Report - Lucy Macro, Business Manager, Hertfordshire Partnership University NHS Foundation Trust (HPFT) Short summary of paper This paper was requested by the Investment Committee at the start of 2017 as an outcome of the paper presented to Investment Committee on the Rapid Assessment, Interface and Discharge (RAID) at that time. The paper summarises the information available on the effectiveness of the RAID service.

Recommendation(s) The Board is being asked to: - To note the national NHS strategic direction of travel for the expansion of Mental Health Psychiatric Liaison services using the RAID model. - To discuss the evaluation report and commissioners comments and agree RAID is providing a valuable, high quality service to service users and impacts on the acute trusts and wider healthcare system. - To agree to ongoing funding of the existing Watford RAID services (£994,000 currently funded on a non-recurrent basis in HVCCG budget) and to funding of the extended CORE 24 service (£351,666) once NHS England pump priming funding is exhausted. Engagement with None directly on this paper. Viewpoint (mental health service user led organisation) patients/public/staff and and Carers in Herts are represented on the Herts Valleys Mental Health and other stakeholders Learning Disability Programme Board and contribute to discussions about RAID and other mental health priorities through that forum. Both organisations support the continuation of RAID. Links to Strategic Objectives (tick all that apply) Objective 1: We will continually improve engagement with patients, carers, the public and member practices ☐ so that they contribute to and influence our work and activities. Objective 2: We will commission safe, high quality services that meet the needs of the population, reducing ☒ health inequalities and supporting local people to stay well and avoid ill health. Objective 3: We will work with health and social care partners to transform the delivery of care through the ☒ implementation of Your Care, Your Future, the strategic review in west Hertfordshire. Objective 4: We will ensure that there is a financially sustainable and affordable healthcare system in West ☒ Hertfordshire. Board Assurance Framework Refer to assurance levels table below and latest BAF report here: N:\Nursing & Quality\8 Risk Management System\2. Board Assurance Framework\BAF 201718\Current versions for front sheet reference N.B. The executive summary for this paper explicitly points to the evidence to support the assurance level

1 indicated above. For example: Very high – what is the evidence to support the current strong position & how will it be sustained? High – what is being done to strengthen controls and mitigate the likelihood of this risk materialising? Medium - what is being done to address gaps in assurance and how successful is this action proving? Low - what are the urgent actions planned to address the lack of assurance? Ref. Risk Risk description Current risk Target risk Assurance Owner score and score Level movement since last month Risk that we do not deliver on all NHS constitutional 2.1 CWo pledges, key national targets and priorities. 16→ 8 Medium 2.2a DC Risk that we are unable to ensure high quality, safe and sustainable services for the population and 8 Medium patients of west Hertfordshire. 12→ 4.2a CWh Risk that we do not identify the right QIPP schemes or decisions to commission/re- 8 Medium commission/decommission, of sufficient value. 12↑ New strategic risks identified by this report

Other significant risks related to this report (from the CRR) SO1/ JR Risk that public and stakeholders are not informed Medium 12 8 24 effectively. SO2/ CWo Risk that patients are not assessed with a Medium 30 management plan and exited/admitted or 16 8 discharged out of the Emergency Department (ED) within 4hrs. SO2/ CWo Risk that we do not reduce delayed transfers of care Medium 12 8 31 (DTOCs) to the target of 2.5%. SO4/ CWo Risk that there are higher levels of hospital activity Medium 16 8 22 than planned/anticipated. SO4/ CH Risk that additional expenditure will occur which is Medium 20 10 23 not budgeted for. Resource The cost of the RAID service is included within the HPFT contract CFO Signature implications on a recurrent basis. However a significant proportion of the cost (£994,000) is currently funded on a non-recurrent basis within the CCG budget. To continue with the RAID service this funding will need to be identified in the 2018/19 CCG budget.

Funding to continue to deliver the extended CORE 24 service at Watford General Hospital from once NHS England pump priming funding is exhausted will also need to be identified.

RAID is currently funded from MRET and the recommendation is that this, plus any expansion, is also funded from there. CCG will request LDB to approve the funding to continue RAID, which is being presented on15th January. Board will be update on this position. If not agreed at LDB the CCG will need to consider this funding request for Mental Health in line with all other funding requests for 18/19

Potential conflicts HPFT colleagues authored the RAID evaluation report. HPFT are also commissioned providers of interest of the RAID service. This would present an actual (i.e. relevant and material) conflict of

interest in that HPFT will directly benefit from the financial resource, should HVCCG identify and approve the funding for i) continuation of the RAID service and ii) the continued funding of the extended CORE 24 service following NHSE pump priming funding ends.

Equality and The evaluation of RAID includes details on outcomes for users and carers. People with mental quality impact ill health (including dementia) on average have poorer outcomes from stays in acute hospitals analyses and a higher than average length of stay. The RAID service is in place to reduce these (indicate the key disparities and so has a positive impact on equalities from this perspective. points the analysis has identified The Quality Impact Assessment (QIA - Appendix B) shows RAID has a positive quality impact on relevant to all monitor areas should HVCCG Governing Body agree with the recommendations above. It decision required) should be noted, if a decision is made by HVCCG Governing Body to cease RAID funding there would be negative impact on all the areas outlined in the QIA and another QIA will need to be completed to ensure the risk of decommissioning this service is understood.

Equality delivery Better Health Outcomes ☒ system (identify Improved Patient Access and Experience ☒ which goal your A Representative and Supported Workforce ☐ proposal / paper supports) Inclusive Leadership ☐ Report history State which groups or committees have previously reviewed this report or a version of this report. State the date and Which Groups or any relevant recommendations from that committee. Also state what the next steps are for report – does it go to another committee for example? Committees have seen this report None and when? Where does the report go next? Appendices Appendix 1: RAID Evaluation completed by HPFT Appendix 2: RAID Evaluation Recommendations Quality Impact Assessment (QIA)

1) Introduction

The RAID Service is an enhanced mental health liaison service model, which has shown to deliver significant improvements in quality, system-wide cost savings and improvements in overall urgent care delivery. The Hertfordshire Partnership University NHS Foundation Trust (HPFT) RAID services have been operational since May 2013.

The RAID service forms a recurrent part of the contract that the CCG has with HPFT. This contract is managed through the countywide mental health pooled budget by the Integrated Health and Care Commissioning Team (IHCCT). Currently, within Herts Valley CCG, a significant proportion (£994,000) of the overall cost of RAID is funded from a non-recurrent source. A paper was presented to Finance and Performance Committee in January 2017 to request the continuation of funding for RAID into 2017/18. This was agreed on the condition that an evaluation of the effectiveness of RAID was completed during 2017/18.

2) Background to RAID

The NHS Five Year Forward View outlined that the “proper funding and integration of mental health crisis services including liaison psychiatry” was a priority for the NHS. The Five Year Forward View for Mental Health reinforced this ambition by clearly stating that “by 2020/21 no acute hospital should be without all-age mental health liaison services in emergency departments and inpatient wards, and at least 50% of acute hospitals should be meeting the “Core24” service standard as a minimum”. Core24 standards include the requirement that some elements of the RAID team are working 24 hours a day 7 days a week within the acute hospital to provide better support for patients. The national evidence is that people with mental health needs are three times more likely to present at the Emergency Department (ED) and five times more likely to be admitted than the general population, with peak hours of presentation being between 11pm and 7am.

Mental health liaison services support key objectives in the acute provider Emergency Department (ED) Improvement plan such as streaming at the front door, patient flow and improved discharge processes. They are also clearly part of NHS England’s (NHSE) phased transformation programme to improve the “7 Day NHS for mental health”. As such NHS England made available funding to support the enhancement of mental health liaison services so that people presenting to emergency departments in acute hospitals have 24/7 rapid access to high quality, compassionate care. The two Hertfordshire CCGs in partnership with HPFT were successful in bidding for one year of NHS England transformation funding to extend the current RAID service to meet the Core24 service specification by the end of the financial year 2017/18. Core24 will be fully implemented by mid-November 2017 at Lister Hospital and the end of November 2017 at Watford Hospital.

3) Evaluation of the RAID Service

The paper attached is an evaluation of the RAID service (pre Core24 service specification delivery). The purpose of the evaluation was threefold:

1. To recognise the need for continual evaluation to inform service developments and reflect on best practice. 2. To meet the specific request of Investment Committee for an evaluation of RAID at Watford Hospital in January 2017. 3. To provide a baseline from which Core24 can be evaluated.

A first version of this evaluation was presented at Herts Valleys A&E Local Delivery Board on 21 November 2017. Local Delivery Board partners were strongly in support of the continuation of the RAID service but requested further detail on non-elective admission avoidance and the associated cost savings. Further work on this area has taken place and data collected by RAID has been included in the body of the report (section 6 Results, 6.1.1 Activity data, pages 8 – 9). Whilst this data does not evidence admission avoidance, it does show that for those seen by RAID in ED the majority are discharged home / out of the hospital.

The evaluation is set out under the following headings and the main findings as laid out in the report are summarised in the table below:

Heading Findings 1. Improved quality of care for  RAID consistently performs well against current access times. patients with mental health Demand on Watford RAID is 36% higher than at Lister in needs in acute hospitals: spite of the longer operating hours. o timely access  RAID has worked in partnership with West Herts Hospital o better patient experience Trust to develop a multi-disciplinary / agency pathway for o improved health outcomes inpatients, in particular the old age wards.  Service user and Carer feedback through Have Your Say feedback, Friends and Family test and from compliments consistently evidence a high level of satisfaction in their experience with RAID.  Feedback from acute staff demonstrates RAID input contributes to the quality of care provided. One acute consultant noted that without RAID “The acute trust would not have been able to assess and manage risk in this patient or deploy appropriate Mental Health Act legislation in timely manner”.  Data from across both RAID teams shows approximately 65% of patients had a clinician rated improved outcome (where it was recorded) as a result of a RAID intervention. 2 Improved efficiency and  Lister and Watford RAID teams deliver rapid response times; patient flow in hospitals in the last year consistently performing well against the 1 hour ED response time (>98%) and the 24 hour ward referral response times (>97%). It is reasonable to conclude that the rapid response element of RAID (compared with pre-RAID) will have a positive impact on length of stay.  Evidence that RAID interventions have improved service users’ engagement in physical health treatment. Results from the case reviews showed that in 94% of the cases RAID intervention facilitated the patients’ engagement with physical health treatment.  RAID provides a range of inputs including mental health risk assessment, mental health diagnosis, liaison with other mental health services and advice to nursing/medical staff all of which will have a positive impact on service users and staff to improve recovery and early discharge through multidisciplinary working.  Report demonstrates that RAID is able to reduce length of stay, through; rapid response, support engagement in physical health and provide a range of interventions with improved outcomes. However, currently unable to analyse

data in a number of areas: o Re-attendances and admissions from ED, but improved coding in 2017/18 (through Acute CQUIN) will aid evaluation of RAID Core24 in future. o Identification from the data the extent of reduction in length of stay. However, the scenarios presented (noting caveats) provide an insight into the possible financial effect across a range of scenarios that are consistent with other findings. 3 System learning: Improved  Feedback from acute staff following training from RAID is knowledge & confidence of very positive with 95% of those at Watford hospital reporting ED & acute staff to identify that their learning objectives were met. and respond to MH needs  At every RAID intervention, members of acute staff receive informal training through the support, advice and guidance given by the RAID team. RAID attendance at MDTs and ward rounds helps to improve the knowledge and confidence of acute staff to identify and respond to MH needs. 4 Trust & confidence in RAID  100% of the acute / ED consultants who completed the case team reviews reported that if RAID had not been available this would have affected the quality of care for this individual.

4) Commissioners comments

The evaluation report presents positive findings which supports continuation of the RAID service and its valuable interface with the acute ED system and wards. Whilst it is difficult to be certain about the overall financial impact of the RAID service from local data, despite the further work completed since Local Delivery Board in 21 November, the scenarios presented (noting caveats) provide an insight into the possible financial effect across a range of scenarios that are consistent with national evaluation of the RAID Model and findings. Acute hospital mental health coding improvements form part of the CQUIN scheme for 2017-19 and this will aid evaluation of RAID Core24 in future.

The original economic evaluation of RAID in Birmingham (Birmingham City Hospital and North West London collaboration), undertaken by the London School of Economics (LSE), has demonstrated that it can achieve the following outcomes, over and above traditional liaison services:

- Reduce admissions, leading to a reduction in daily bed requirement of 44 beds per day, saving the NHS £3.55 million per annum through decommissioning acute beds (in a hospital of 600 beds);

- Reduce discharges to institutional care for elderly people by 50%, saving local authorities £3 million per annum in contributions to residential care;

- Produce a consequent cost-to-return ratio of £1 to £4. Further research since the initial LSE evaluation of RAID in Birmingham has suggested that for “various reasons this is probably on the optimistic side and a more realistic assessment might take, as an upper limit, an initial return of £3 for every £1 invested, in line with the findings of the RAID roll-out study, falling over time to £2.50” (Centre for Mental Health, 2016)

- In terms of hospital efficiency, waiting times for mental health patients in the ED have been reduced by 70%, which is reflected in an overall improvement in ED waiting times.

The report captures the overall impact (other than financial) of having a distinct RAID service located within Emergency Departments. These include the impact on ED flow through early intervention and potential admission avoidance, on improving the ability of acute staff on the wards and ED to influence patient flow, due to RAID training and the formal and informal support given to acute hospital staff to help them identify and better manage patients with a mental health diagnosis. All of these elements, including service user and carer experience should form part of the discussion on whether or not to fund RAID in the future.

Alongside the BAF a number of risks are implicit within the report. The most significant are:

- Impact on patient safety, outcomes and quality if RAID services ceased - Impact on the CCG’s assurance framework rating if key mental health targets are not met - Overall CCG commitment to deliver the Five Year Forward View, in terms of the A&E 4 hour wait, Delayed Transfers of Care and mental health parity of esteem.

Commissioners support the ongoing funding of the existing Watford RAID service and the identification of funding to continue the extended CORE 24 service once NHSE funding has ended.

5) Recommendations

Governing Body is asked to:

 Note the national NHS strategic direction of travel for the expansion of Mental Health Psychiatric Liaison services using the RAID model.  Discuss the evaluation report and agree RAID is providing a valuable, high quality service to service users and impacts on the acute trusts and wider healthcare system.  Agree to ongoing funding of the existing Watford RAID services and to funding of the extended CORE 24 service once NHS England pump priming funding is exhausted.

Item 8

Appendix 1: RAID evaluation completed by HPFT Appendix 1

Contents Page Number

1.0 Glossary. 2 2.0 RAID Service Summary. 3 2.1 Cost of RAID 3 3.0 Background. 4 4.0 Purpose of Evaluation. 4 5.0 Methodology. 5 6.0 Results: 7 6.1 RAID data: 7 6.1.1 Activity Data. 7 6.1.2 Response Rates. 9 6.1.3 Clinical Rated Outcome Measure (CROM). 10 6.1.4 Acute Training. 12 6.1.5 Patient Experience. 12 6.1.6 System Colleague Feedback. 14 6.2 Case Reviews. 15 6.3 Acute data. 18 6.4 National evidence. 21 6.5 PLAN: 21 6.5.1 Lister Acute Colleague Feedback. 21 6.5.2 Watford Acute Colleague Feedback. 22 7.0 Conclusion: 23 7.1. Improved quality of care for patients with MH needs in acute hospitals: 24 7.1.1 Timely Access. 24 7.1.2 Better Patient Experience. 24 7.1.3 Improved Health Outcomes. 25 7.2 Improved efficiency and patient flow in hospitals. 25 7.3 System learning. 29 7.4 Trust & Confidence. 29 8.0 Recommendations 30

Appendices: Appendix 1: RAID Case Review Questions. 31 Appendix 2: Service User / Carer feedback. 32

1.0. Glossary

Initials In full CCG Clinical Commissioning Group CGI-I Clinical Global Impression Scale CQUIN Commissioning for Quality and Innovation CROM Clinician Rated Outcome Measure ED Emergency Department (A&E) ENHCCG East and North Herts Clinical Commissioning Group ENHT East and North Herts NHS Trust EPR Electronic Patient Record FA Frequent Attenders HCA Health Care Assistant HPFT Hertfordshire Partnership University NHS Foundation Trust HRG Healthcare Resource Groups HVCCG Herts Valleys Clinical Commissioning Group HYS Having Your Say IDT Integrated Discharge Team LD Learning Disabilities LoS Length of Stay LSE London School of Economics MH Mental Health MUS Medically Unexplained Symptoms NCEPOD National Confidential Enquiry into Patient Outcome and Death NICE National Institute for Health and Care Excellence PREM Patient Reported Experience Measure PROM Patient Reported Outcome Measure PLAN Psychiatric Liaison Accreditation Network (PLAN) RCPsych Royal College of Psychiatrists RAID Rapid Assessment, Interface and Discharge Spectrum / CGL Main local drug and alcohol service provider - Care Grow Live parent company, Spectrum Hertfordshire name WHHT West Herts Hospitals Trust

2.0 RAID Service Summary

The Rapid Assessment, Interface and Discharge (RAID) Service is an enhanced mental health liaison service model which has been evaluated nationally1 and shown to deliver significant improvements in quality, system-wide cost savings and improvements in overall urgent care delivery. The HPFT RAID services have been operational since May 2013. Each RAID service is led by two Consultant Psychiatrists and comprises a multidisciplinary team of mental health professionals.

The RAID service operates out of Watford General Hospital (West Herts Hospitals Trust, WHHT) and Lister Hospital (East and North Herts NHS Trust; ENHT) Emergency department (ED) and inpatient wards. Whilst the service offer is the same at each site, commissioned hours of operation vary:

 Watford Hospital: 08:30 – 00:00 (midnight), seven days a week.  Lister Hospital: 08:30 – 21:00, seven days a week.

RAID is commissioned to work with anyone from age 16+ and is a single point of access/referral to mental health services for anyone within in the acute setting. The service is currently commissioned to provide a response within 1 hour to ED emergency referrals and a response within 24 hours to inpatient ward referrals, within operating hours. The team also works to build capacity within the acute setting through workforce development.

Additional specialist projects:

In addition to the service offer described above, the RAID teams have tailored their service to the needs of each hospital and as such also offer the following:

1) Frequent Attenders (FA) / Medically Unexplained Symptoms (MUS) 2) Delirium pathway (Watford) / Dementia Care – inc. best poster award. RAID has been part of developing an initiative with West Herts Hospital Trust and Hertfordshire County Council Adult Care Services in developing a multi-disciplinary/agency pathway for patients suffering from a persistent delirium. Previously patients were either stranded in hospital, due to poor resolution of their delirium, or were at risk of going into long term care. Subsequently the pathway has been successful in discharging patients to home and effectively treating the patient and in the majority of cases, avoiding long term residential care. 3) Co-working with Spectrum (provider of Drug and Alcohol Services)- The RAID teams have provided desk space in the RAID offices to allow for co-location of Spectrum staff. Spectrum liaison staff also have access to PARIS, the mental health electronic patient record (EPR). Both sites now have joint clinics run by RAID and Spectrum staff for patients who would benefit from a joint review. 4) 1:1 working with Lister’s enhanced nursing care team. These are Health Care Assistants (HCAs) working as a peripatetic team supporting patients throughout the hospital, through 1:1 support, who have dementia and other mental health challenges. The Lister RAID Team

1 https://www.centreformentalhealth.org.uk/liaison-psychiatry-nhs

has provided training to the HCAs which has included mental health awareness as well as training in carrying out mental health observation.

2.1 Cost of RAID

The annual cost of the RAID service is broken down as follows:

Table 2.1: RAID funding

Annual RAID funding Lister RAID Watford RAID Funding for current (non-Core 24) RAID Service £1,227,372 £1,403,454 Additional funding to reach Core24 £421,243 £351,666 Total funding for RAID Core24 £1,648,615 £1,755,120

Note: Watford RAID costs are higher primarily due to direct pay costs which for Watford include High Cost Area (HCA) payments.

The two Hertfordshire CCGs in partnership with HPFT were successful in bidding for one year of NHSE transformation funding to deliver Core24 service specification by end of financial year 2017/18. Core24 will be fully implemented by mid-November 2017 at Lister Hospital and the end of November at Watford Hospital.

3.0 Background

NHS Five Year Forward View2 outlined “proper funding and integration of mental health crisis services including liaison psychiatry” as a priority for the NHS. The Five Year Forward View for Mental Health reinforced this ambition by clearly stating that “by 2020/21 no acute hospital should be without all-age mental health liaison services in emergency departments and inpatient wards, and at least 50% of acute hospitals should be meeting the “core24” service standard as a minimum”3. People with mental health needs are three times more likely to present at the ED and five times more likely to be admitted than the general population, with peak hours of presentation being 11pm and 7am.

Mental Health is one of the 9 “must do” priority areas outlined in the NHS Operating Plan and Contracting Guidance 2017-19. There is an action for CCGs to “ensure delivery of the mental health access and quality standards including 24/7 access to community crisis resolution teams and home treatment teams and mental health liaison services in acute hospitals.”4

Mental health liaison services, alongside supporting key objectives in the ED Improvement plan (streaming at the front door, patient flow and improved discharge processes), are clearly part of NHS

2 https://www.england.nhs.uk/wp-content/uploads/2014/10/5yfv-web.pdf (page 23) 3 https://www.england.nhs.uk/wp-content/uploads/2016/02/Mental-Health-Taskforce-FYFV-final.pdf (page 12) 4 https://www.england.nhs.uk/planning-guidance (page 9)

England’s phased transformation programme to improve the “7 Day NHS for mental health”. As such NHSE has made available funding to support the enhancement of mental health liaison services so that people presenting to emergency departments in acute hospitals have 24/7 rapid access to high quality, compassionate care. The two Hertfordshire CCGs in partnership with HPFT were successful in bidding for one year of NHSE transformation funding to deliver Core24 service specification by end of financial year 2017/18. Core24 will be fully implemented by mid-November 2017 at Lister Hospital and the end of November at Watford Hospital.

4.0 Purpose of Evaluation

The purpose of the evaluation of RAID is three fold:

1) It is important to recognise the need for continual evaluation to inform service developments and reflect on best practice. 2) HVCCG specifically, have requested an evaluation of RAID at Watford hospital as part of the 2017 investment committee process. 3) This evaluation will provide a baseline from which Core24 can be evaluated.

5.0 Methodology

The evaluation analysed data from 5 areas:

1) Routinely collected RAID data was used to report activity, response rates, outcome measures, acute staff training, patient experience and system colleague feedback; this has been evaluated for 2016/17 and Q1 17/18 where possible. 2) Case reviews considering the impact of RAID and what would have happened if RAID did not exist (see appendix 1 for the full questionnaire). These were undertaken jointly by a consultant psychiatrist from RAID and an acute hospital consultant from the ED or ward for patients attending ED or on a ward during Q1 17/18. 3) Acute data relating to patients with a recorded MH diagnosis was used to identify length of stay, readmissions and ED attendances for Q1 17/18 4) National evidence from a range of papers etc. that have already evaluated the benefits of RAID and identified associated savings to the healthcare system. 5) Feedback from acute colleagues as part of the Psychiatric Liaison Accreditation Network (PLAN) 2015 review for both RAID teams.

In addition, anecdotal evidence has been provided by some acute & wider system colleagues to also evidence the outcomes. Where possible Lister and Watford data is reported separately and split by age range 16-64 and 65+.

This data will evidence the following outcomes for RAID which will be used as the hypotheses for the evaluation (adapted from the RAID Core24 Logic Model).

Table 5.1: RAID outcomes

Outcome Measure / indicator Source Responsibility Improved quality of care for Response times to ED and RAID data HPFT patients with mental health ward referrals needs in acute hospitals: Patient experience HYS HPFT  timely access Clinician Rated Outcome RAID data HPFT  better patient Measure – Clinical Global experience Impression Improvement  improved health Scale (CRI-I) outcomes If RAID were not available Case reviews HPFT & Acute would this have impacted (HPFT Lead) the quality of care for individuals referred to RAID Improved efficiency and Reduced ward LoS and Case reviews & Acute WHHT & ENHT patient flow in hospitals non-elective bed days data used Readmission Case reviews & Acute data Delay prevention Case reviews HPFT & Acute (HPFT Lead) Reduce avoidable ED re- Case reviews & Acute WHHT & ENHT attendance rates data RAID facilitation in Case reviews HPFT & Acute patients engagement with (HPFT Lead) physical health treatment System learning: Improved MH diagnosis recording in Case reviews & Acute HPFT & Acute knowledge & confidence of Acute data data (HPFT Lead) ED & acute staff to identify Number of acute staff Training registers HPFT and respond to MH needs receiving formal MH training Number of acute staff that Training evaluation HPFT reported their learning questionnaire objectives were met Trust & confidence in RAID Acute & wider system Additional comments HPFT team Feedback from Case Reviews & Staff accounts

In addition to the data above, RAID activity data will build a picture of the context in which RAID operate and the type of referrals coming through to the services.

6.0 Results

6.1 RAID Data

6.1.1 Activity data

The number of referrals broken down by hospital and department it shown in table 6.1a below. Liaison numbers fluctuate day to day and the RAID team is staffed to cover the breadth of service and respond to peeks. Watford data for Q1 and Q2 16/17 was higher than expected and during this time HPFT had to over resource the RAID team to cope with the demand on the service. The number of referrals since Q3 16/17 represents a more routine picture of activity for the funded team.

Table 6.1a: Number of referrals

2016/17 2017/18 Average across 15 No of referrals Q1 Q2 Q3 Q4 Q1 months

Total No of ED referrals 249 254 234 244 274 251 Lister Total No of ward referrals 220 208 226 213 231 220

Total No of ED referrals 301 307 236 253 261 272

Watford Total No of ward referrals 369 382 314 360 327 350

Graph 6.1b: Time of referral (Q1 17/18 data)

Time of referral 160 140 120 100

80 Lister 60 Watford 40 20 0 07:00 - 09:00 - 11:00 - 13:00 - 15:00 - 17:00 - 19:00 - 21:00 - 23:00 - 08:59 10:59 12:59 14:59 16:59 18:59 20:59 22:59 00:59

Within current operational hours the peak time for referrals is between 9-11am at Lister and 11am – 1pm at Watford. The Lister peaks in particular is explained as coinciding with the end of hospital handover times where referral activity will pick up again after a quiet period during the handover. In addition, the RAID teams do not currently operate overnight and therefore it is expected that there will be a higher level of referrals first thing accounting for night activity. It is expected that some of this activity will smooth out when RAID starts to operate 24/7.

Table 6.1c: Age range split by ED/Ward (Q1 17/18 data)

Source of referral 16-64 65+ ED 66% 28% Lister Ward 34% 72% Total 70% 30% ED 63% 10% Watford Ward 37% 90% Total 64% 36%

At both Lister and Watford hospitals the data above shows that approximately 2/3rds of referrals relate to adults (16-64), with the remainder relating to older adults (65+). However, in practice the demand on the service is the same across adult and older adults. This is because the majority of adults are seen in the ED where most require only one RAID contact, whereas the majority of older adults are seen on the wards and a vast majority of these require follow-up contacts.

Table 6.1d: Service user currently open to HPFT service (Q1 17/18)? Open to HPFT? No Yes Lister 351 (70%) 154 (30%) Watford 477 (79%) 130 (21%) Grand Total 828 284

In Q1 17/18, 74% of service users seen were not already open to HPFT (note this does not mean they are not known to HPFT, but that they are currently not receiving HPFT services). Where appropriate, a key function of RAID is to facilitate access onto an appropriate care pathway within secondary care MH services which should result in better MH outcomes in the long–term (Centre for Mental Health (2013) Economic evaluation of a liaison psychiatry service).

The following tables (6.1x and 6.1y) show the destination (where known) of the person seen by RAID in A&E following the RAID assessment/intervention. This data does not evidence admission avoidance, however it does show that for those seen by RAID in A&E the majority are discharged home / out of the hospital. Where the destination is “blank” or “remains in hospital”, this is the situation following the RAID assessment/intervention which is part of a chain of services. Ultimately the final destination is a medical call and RAID cannot admit to a general hospital.

Table 6.1x: Lister RAID discharge destination (for those seen in A&E)

Lister RAID Home 79.09% MH Unit Herts 7.98% Other 5.74% Other Hospital 2.14% Homeless Hostel 1.65% (blank) 1.26% MH Unit Out Area 1.17% Residential Home 0.39% Nursing Care 0.39% Res Home 0.19%

Table 6.1y: Watford RAID discharge destination (for those seen in A&E)

Watford RAID Home 64.72% (blank) 15.30% MH Unit 10.61% Other 4.59% Remains in Watford General Hospital 4.40% Residential Home 0.38%

6.1.2 Response rates

The service is currently commissioned to provide a 1 hour response to ED referrals and 24 hour response to ward referrals within operating hours. The Core24 transformation funding will enable the team to amend these definitions slightly to meet those required for Core24 – 1 hour response to ED and inpatient ward emergency referrals and 24 hour response to urgent/non-emergency referrals from inpatient wards 24/7. It is expected that RAID will be able to achieve these within 2 months of the service going 24/7. In addition RAID and the Acute Trusts will have to start collecting and reporting Time from arrival in ED to time seen by an MH professional, and, Time from arrival in ED to discharge. These measures will support the delivery of the 4 hour ED target for Acute Trusts.

Performance against the current RAID response measures (during current operating hours) is as follows:

Table 6.1e: Response rates

2016/17 2017/18 Success Measure / KPIs Q1 Q2 Q3 Q4 Q1 % of ED referrals seen

within 1 hour 100.0% 98.8% 99.15% 99.59% 99.64%

Lister % of Ward referrals seen within 24 hours 100.0% 100.0% 100.0% 100.0% 100%

% of ED referrals seen within 1 hour 91.4% 98.7% 98.7% 98.8% 98.5% % of Ward referrals seen Watford within 24 hours 97.8% 100.0% 97.5% 99.2% 99.1%

6.1.3 Clinician Rated Outcome Measure (CROM):

HPFT routinely collect the Royal College of Psychiatrists FROM-LP data5 for Clinician Rated Outcome Measures (CROM). This data has been collected as a pilot across both RAID teams and the Core24 transformation funding will enable this to continue. In line with RCPsych recommendations and NICE guidelines, the Clinical Global Impression Improvement Scale (CGI-I) is used by RAID as the CROM and is shown below for 2016/17 and Q1 17/18 for each RAID team.

[Note: Patient Reported Outcome Measures (PROM) will be implemented as part of the Core24 transformation funding in line with the RCPsych FROM-LP data.]

Graph 6.1f: 2016/17 Lister CROM:

CGI-I 2016/17 Lister RAID 500

400

300

200

100 176 308 261 392 13 6 1 0 Very Much Much Minimally No Change - 4 Minimally Much Worse - Very Much Improved - 1 Improved - 2 Improved - 3 Worse - 5 6 Worse - 7

5 http://www.rcpsych.ac.uk/pdf/FRLP02.pdf

Graph: 6.1g 2016/17 Watford CROM:

CGI-I 2016/17 Watford RAID 800

600

400

200 135 395 749 708 12 5 3 0 Very Much Much Minimally No Change - 4 Minimally Much Worse - Very Much Improved - 1 Improved - 2 Improved - 3 Worse - 5 6 Worse - 7

Graph 6.1h Q1 2017/18 Lister CROM

CGI-I Q1 2017/18 Lister RAID 200 150 100 50 70 95 149 164 8 1 0 Very Much Much Minimally No Change - 4 Minimally Much Worse - Improved - 1 Improved - 2 Improved - 3 Worse - 5 6

Graph 6.1i Q1 2017/18 Watford CROM CGI-I Q1 2017/18 Watford RAID 200

150

100

50 28 116 183 186 4 3 0 Very Much Much Minimally No Change - Minimally Much Very Much Improved - Improved - Improved - 4 Worse - 5 Worse - 6 Worse - 7 1 2 3

6.1.4 Acute training

During the period July 2016 - July 2017, 708 members of staff at Watford hospital received formal mental health training. Of the staff that completed a feedback form (n.479), 99.6% reported that the training met their learning objective. At Lister hospital, during the same period, 555 staff received formal mental health training, of those completing a feedback form (n.351), 95% reported that the training met their learning objective.

Feedback about the training is largely positive and reported that the training was relevant, helpful, informative, useful, engaging and interesting. The main area of negative feedback was that the training was too short and needed to be longer to cover the breadth of the topic.

6.1.5 Patient Experience

RAID currently use the HPFT Having Your Say (HYS) questionnaire. This questionnaire asks service users and carers a number of questions about their experience.

[Note: as part of the move to Core24, RAID will implement a new service user experience questionnaire in line with the NICE service user experience guidelines. Thus, RAID will start reporting a Patient Reported Experience Measure (PREM).]

The Friends and Family test score (how likely are you to recommend our service to friends and family if they needed similar treatment?) between July 2016 – July 2017 was 100% for Lister RAID (n.33) and 94% for Watford RAID (n.160).

Questions in the HYS relating to the quality of care are identified below.

Graph 6.1j: Lister RAID (July 16 – July 17)

Question 4: Did staff explain the service and how they were going to help you?

Available Score Answers Did not answer 1 Yes 31 (93.94%) Partly 0 No 0 Don't Know 1 (3.03%) Total 33

Question 12: Do the services you receive help you to feel more hopeful about the future?

Available Score Answers Did not answer 2 Yes 29 (87.88%) No 0 Don't Know 2 (6.06%) Total 33

Graph 6.1k: Watford RAID (July 16 – July 17)

Question 4: Did staff explain the service and how they were going to help you?

Available Score Answers Did not answer 1 Yes 150 (92.59%) Partly 11 (6.79%) No 0 Don't Know 0 Total 162

Question 12: Do the services you receive help you to feel more hopeful about the future?

Available Score Answers Did not answer 0 Yes 122 (75.31%) No 8 (4.94%) Don't Know 32 (19.75%) Total 162

In addition to the quantitative feedback above, qualitative feedback is collected from service users and carers through HYS, compliments and complaints:

For example, one service user commented about the Watford RAID service “I feel positive that I can move forward with the right help that I have been given; informative helpful and very understanding.”

A Carer complimented the Lister RAID service (via email): “I do feel that I need to contact you not only to pass on my thanks to X but also to commend him for his professionalism and understanding; - He was extremely kind and considerate when I became upset when my mum ‘disowned’ me - He explained very clearly to my Mum that it was the GP who had sent her to Lister for tests, not her daughter - He explained the term ‘mental capacity’ in details so that I could understand - I typed up some details about how Mum’s behaviour had changed over the last week and reasons why she should not be allowed home on her own. X kindly showed this to the Consultant so that they could make an informed decision - I called X following Mum’s discharge for more information and he was extremely helpful - He even made a quick courtesy call the following day to ask after my Mum.

6.1.6 System colleague feedback

Feedback from acute colleagues is shown in 6.2 Case Reviews and 6.5 PLAN below. In addition to acute colleagues, the RAID teams have received compliments from wider system colleagues. This includes:

Sandra Treacher, EOC Clinical Lead – Paramedic; Emergency Clinical Advice and Triage Centre East of England Ambulance Service NHS Trust: “I work a regional role across the East of England for the Ambulance Service leading on telephone triage and our frequent caller management. By far the RAID team have one of the best ways of working for frequent attenders and have engaged with us like no other service has. It is a brilliant set up, engagement of services and MDT approach and its success is down to the team that is led so

passionately by Dr Nikki Scheiner. Many patients have benefited from the treatment and care given by the RAID team in and out of hospital, and many patients who use our service have indirectly benefited due to the RAID team assisting us, which has meant us being able to use our ambulances appropriately. I attend many meetings around the trust and I use the RAID team as an example of a gold standard service for frequent callers and mental health patients”.

Heidi Hall, Head of Service, Integrated Discharge Team (IDT) at Lister, Herts County Council: “I would like to say a huge thank you for all your support and in particular your rapid response to requests from the IDT. The last few weeks have been particularly trying and the regular communication thorough the day has enabled both teams to support safe and timely discharge of patients. Thank you for your continued efforts and positive integrated working”.

6.2 Case Reviews

Case Reviews were conducted jointly by RAID consultants and acute hospital consultants across ED, adult and older peoples’ wards. For service users seen during Q1 – Q2 2017/18. Nine reviews were completed at Lister and eight at Watford. The results from these case reviews are summarised below.

Table 6.2.1. If RAID had not been available would this have affected the quality of care for this individual? Yes Grand Total Lister 9 9 Watford 8 8 Grand Total 17 17

100% of the case reviews reported that if RAID had not been available it would have affected the quality of care for the individual.

Table 6.2.2. What were the components of the RAID psychiatry review/input (select all appropriate) Across both Lister & Watford RAID Number selected 1. MH risk assessment 15 2. MH risk management 13 3. Treatment plan initiated 13 4. MH diagnosis 14 5. Discharge Planning 11 6. Liaison with other MH services 14

7. Advice to nursing/medical staff 15 8. Mental Capacity Assessment 12 9. Prescription/alteration of MH medication 12 10. MH observations 7 11. Deployment of MH legislation 7 12. Advice for de-escalation of situation by RAID 3 13. Multidisciplinary working 11 14. Rapid tranquilisation plan 0 15. De-escalation of situation by RAID 2 Grand Total 149

The data in 6.2.2 shows that despite the case reviews only looking at 17 people, each of these cases received a number of input from RAID, highlighting an element of complexity and need. The top reasons were MH risk assessment, MH diagnosis, Liaison with other MH services and Advice to nursing/medical staff.

Table 6.2.3. Did the RAID intervention facilitate the patient's engagement with physical health treatment? Row Labels unknown Yes Grand Total Lister 1 8 9 Watford 8 8 Grand Total 1 16 17

Excluding the “unknown” responses, 100% of the case reviews reported that the RAID intervention facilitated the patients’ engagement with physical health treatment (including “unknown” = 94%).

Table 6.2.4. In the acute consultants opinion did RAID contribute to a reduction in LoS? Yes (blank) Grand Total Lister 8 1 9 Watford 7 1 8 Grand Total 15 2 17

Excluding the “blank” responses, 100% of the case reviews reported a reduction in Length of Stay. Including the “blanks”, 88% reported a reduction in LoS. When asked a follow-up question about what the estimated reduction was in days, only two responses were received. One responded “2 days” and the other responded “less than a week”.

Table 6.2.5. In the ED consultants opinion did the RAID intervention prevent a re-attendance at A&E? Unknown / No blank Yes Grand Total Lister 1 5 3 9 Adult ward 1 1 1 3 ED - Older Person 2 2 Older Peoples ward 4 4 Watford 1 4 3 8 Adult ward 1 2 3 6 Older Peoples ward 2 2 Grand Total 2 9 6 17

Excluding the “unknown / blanks” 75% of the case reviews reported that RAID prevented a re- attendance at the ED.

Table 6.2.6. Did RAID prevent a delay in discharging the patient?

N/A No Yes (blank) Grand Total Lister 6 3 9 Adult ward 1 2 3 ED - Older Person 2 2 Older Peoples ward 3 1 4 Watford 1 1 6 8 Adult ward 1 5 6 Older Peoples ward 1 1 2 Grand Total 1 1 12 3 17

Excluding the “N/A / blanks” 92% of the case reviews reported that RAID prevented a delay in discharging the patient.

Table 6.2.7. Is there evidence in the hospital notes of a MH diagnosis? No Yes blank Grand Total Lister 1 6 2 9 Watford 8 8 Grand Total 1 14 2 17

Excluding the “blank” responses, 93% reported that there was evidence of a diagnosis in the hospital notes.

Additional comments from Case Reviews from Acute hospital consultants:

Lister hospital:

“[RAID] prevented readmission. Significant contribution to MDT meeting and conference calls and prescription/alteration of MH medications…”.

“ If RAID was not available early in the admission this would have delayed the discharge planning and also would have caused family anxiety”.

“RAID team were extremely helpful in managing this extremely complex patient with every complex social issue (& difficult family)… Overall excellent care/support from RAID team…”

“The RAID team were extremely helpful in liaising with the family and MDT to aid discharge planning process. The RAID team recognised the possibility of safeguarding concerns and appropriately escalated this…”.

Watford hospital:

“ Generally the RAID service has transformed the care of patients with severe mental illness and the service has been a shining light in preventing admission, facilitating discharge and providing good quality care”.

“ The acute trust would not have been able to assess and manage risk in this patient or deploy appropriate MHA legislation in timely manner”.

“Absolutely vital MDT working and very helpful in management of patient’s complex medical and psychiatric needs”.

“High quality easily accessible helpful service”.

“ RAID consultant input was invaluable in the management of this lady with a psychiatric history who presented to A&E several times over a 6 month period with reduced level of consciousness and acute confusional state. RAID consultant identified that reason for presenting complaint was hitherto undiagnosed epilepsy and hence contributed to need for neurology assessment and input with appropriate change in management to prevent readmission”.

6.3 Acute data:

The data below has been provided by WHHT for Watford hospital and represents activity for people with a recorded MH diagnosis during Q1 2017/18. In addition, some data is available for Q1 2011/12 pre-RAID for comparison. At the time of writing this report, ENHT data was not available.

Table 6.3a: Number of ED attendances Q1 2017/18 (ICD 10 coding not employed for ED attendances. ED national codes used, but no 'mental health' diagnosis so identified by one of the following diagnosis codes: deliberate self-harm, neurosis, psychosis, psychiatry, suicidal, panic attack, overdose, depression, hysteria, anxiety, stress. Alternatively a disposal method of 'Discharge to Psychiatry' is assumed to indicate a mental health patient.)

Number of ED Attendances Year Quarter Month 16-64 65+ Total 2017/18 Q1 Apr 65 4 69 2017/18 Q1 May 71 6 77 2017/18 Q1 Jun 83 9 92 2017/18 Q1 219 19 238

Table 6.3b Number of ED attendances Q1 2011/12 (detail as above)

Number of AE Attendances Year Quarter Month 16-64 65+ Total 2011/12 Q1 Apr 112 3 115 2011/12 Q1 May 127 7 134 2011/12 Q1 Jun 142 13 155 2011/12 Q1 381 23 404

As noted in the detail behind the data, the ED does not use ICD10 coding and therefore the informatics team have had to make assumptions regarding the diagnosis codes to use. This data will therefore not be used for comparison. It is important to note that general coding in ED is likely to improve in 2017/18 as part of CQUIN, this will aid the evidence of RAID involvement in ED.

Table 6.3c: Number of non-elective admissions in Q1 2017/18 (Number of non-elective admissions discharged in Q1 2017/18 with a Chapter V Mental Health ICD10 recorded in any of the diagnosis fields at any time before or during the spell.)

Number of Non-Elective Admissions Discharged in Period Year Quarter Month 16-64 65+ Total 2017/18 Q1 Apr 295 436 731 2017/18 Q1 May 349 431 780 2017/18 Q1 Jun 379 473 852 2017/18 Q1 1023 1340 2363

Table 6.3d Number of non-elective admissions in Q1 2011/12 (detail as above)

Number of Non-Elective Admissions Discharged in Period Year Quarter Month 16-64 65+ Total 2011/12 Q1 Apr 155 145 300 2011/12 Q1 May 163 179 342 2011/12 Q1 Jun 180 233 413 2011/12 Q1 498 557 1055

The non-elective admissions data in tables 6.3c and 6.3d show a significant increase in admissions for people with a MH diagnosis since 2011/12; a 240% rise. However it is important to recognise that this increase is likely to be due to improved MH diagnosis coding in the acute trusts as opposed to an actual increase in admissions.

The ED data in table 6.3a identifies 238 patients as having attended the ED in Q1 2017/18. However, WHHT note that ED diagnosis coding is currently incomplete since it is not required for HRG and therefore the numbers presented are likely to be an under-representation of the true numbers of mental health patients attending the ED. This data therefore has not been used in the evaluation of RAID.

Table 6.3e Average LoS Q1 2017/18 (Mean average number of non-elective admissions for people with a MH diagnosis. Excluding those discharged from the acute assessment units with a zero length of stay).

ALOS (in days) Year Quarter Month 16-64 65+ Total 2017/18 Q1 Apr 6.1 15.4 12.2 2017/18 Q1 May 4.8 14.6 10.9 2017/18 Q1 Jun 4.0 13.3 9.9 2017/18 Q1 5.0 14.4 11.0

Table 6.3f Average LoS Q1 2011/12 (detail as above)

ALOS (in days) Year Quarter Month 16-64 65+ Total 2011/12 Q1 Apr 5.1 10.7 8.1 2011/12 Q1 May 5.9 15.5 11.4 2011/12 Q1 Jun 5.2 12.9 9.8 2011/12 Q1 5.4 13.2 9.9

The average LoS data above suggests an increase in LoS for older adults between 2011/12 and 2017/18, however given the previously recognised limitation to the 2011/12 data with regards to MH diagnosis recording, this data has not been used for comparison purposes.

6.4 National evidence:

The economic evaluation of RAID in Birmingham (Birmingham City Hospital and North West London collaboration), undertaken by the London School of Economics (LSE), has demonstrated that it can achieve the following outcomes, over and above traditional liaison services:

- reduce admissions, leading to a reduction in daily bed requirement of 44 beds per day, saving the NHS £3.55 million per annum through decommissioning acute beds (in a hospital of 600 beds; Watford has circa 750 beds, Lister has circa 730 beds); - reduce discharges to institutional care for elderly people by 50%, saving local authorities £3 million per annum in contributions to residential care; - produce a consequent cost-to-return ratio of £1 to £4. Further research since the initial LSE evaluation of RAID in Birmingham has suggested that for “various reasons this is probably on the optimistic side and a more realistic assessment might take, as an upper limit, an initial return of £3 for every £1 invested, in line with the findings of the RAID roll-out study, falling over time to £2.50” (Centre for Mental Health, 2016) - In terms of hospital efficiency, waiting times for mental health patients in the ED have been reduced by 70%, which is reflected in an overall improvement in ED waiting times.

The National Confidential Enquiry into Patient Outcome and Death (NCEPOD) ‘Treat as One’ report in 2017 studied the gap between mental and physical healthcare in general hospitals. Some of the key findings relevant to this evaluation include:

- The study identified patients who refused some aspect of care. The most common challenges associated were nutrition, interventions, investigations and physiological observations. Reviewers were of the opinion that the mental health of the patient was a contributing factor to the refusal of care in 91.3% (136/149) of these challenges. - “The effect of having a liaison psychiatry team, and one which was PLAN accredited was noted. Good practice in the quality of mental healthcare was demonstrated in 40.8% of cases from hospitals with no liaison psychiatry team; in 46.1% of cases with non-PLAN accredited liaison psychiatry team and in 59.8% of hospitals with a PLAN accredited liaison psychiatry team”.6

6.5 PLAN feedback from acute colleagues:

The Psychiatric Liaison Accreditation Network (PLAN) completed a review of both RAID teams in 2015; this review informed and resulted in both teams receiving PLAN accreditation through to October 2018, upon which time the teams will be reviewed again. “Accreditation assures patients,

6 http://www.ncepod.org.uk/2017mhgh.html (p.85)

carers, frontline staff, commissioners, managers and regulators that the liaison service is of a good quality and that staff are committed to improving care”7

The summary of feedback below highlights the positive impact that RAID has had on the acute hospitals, with partnership working / dialogue and training valued by both Lister and Watford hospital staff.

Table 6.5.1: Lister feedback:

SUMMARY (1) OF THE FEEDBACK FROM ACUTE COLLEAGUES Main Areas of Achievement Acute staff gave lots of positive feedback and appreciated the work the liaison team carries out. Acute staff felt able to share differences of opinion and have a dialogue with the liaison team. Acute colleagues noted an improvement in standards in mental health care since the RAID team had been introduced. Acute colleagues appreciated the training the liaison team provides. SUMMARY (2) OF THE FEEDBACK FROM ACUTE COLLEAGUES Action Points Who will take the What action will be taken? When? action? Ward staff to be invited to attend the monthly meetings, which Team manager and 1 the liaison team has with ED staff or to organise a separate Oct-15 consultant psychiatrists meeting. to lead on this. Liaison team to discuss Liaison team to consider offering training on the standards they when and how they 2 have not provided training for yet (such as on suicide awareness Dec-15 would offer this to and mental health and stigma) acute staff. The liaison team to continue auditing the work they carry out Liaison team to discuss 3 Dec-15 with acute staff such as response times and referrals. and carry out audit. Liaison team to meet Liaison team to continue to work with medical teams to ensure a 4 Oct-15 with acute staff whole 'team approach'. regarding this.

7 http://www.rcpsych.ac.uk/workinpsychiatry/qualityimprovement/ccqiprojects/liaisonpsychiatry/plan/whygeta ccredited.aspx

6.5.2: Watford acute colleague feedback:

SUMMARY (1) OF THE FEEDBACK FROM ACUTE COLLEAGUES Main Areas of Achievement Acute staff reported that the frequent attender programme had been "phenomenal". Acute staff valued the tailored teaching sessions they receive on the wards and in the ED, particularly on dementia and end of life care. The liaison team are pro-active and go to the emergency department to seek referrals. Acute staff were very satisfied with the bleep referral procedure, access to senior opinion when required and response times. The older adult psychiatrist has close links and joint working with elderly care staff and geriatricians, and the working age consultant psychiatrist works closely with perinatal staff. SUMMARY (2) OF THE FEEDBACK FROM ACUTE COLLEAGUES Action Points What action will be taken? When? Who will take the action? 1 The service manager, team manager Dec-15 The liaison team to aim to have and consultant psychiatrists to have regular meetings with ward staff, a meeting regarding this. along with maintaining their regular ED meetings. 2 As above. Immediately Clarity is needed on who will assess 16 and 17 year olds within the liaison teams' working hours. 3 As above. The liaison team to Dec-15 consider attending ward rounds again. 4 As above. The liaison team to Dec-15 consider shadowing their acute colleagues.

7.0 Conclusion:

Conclusions are based on each of the RAID outcomes below:

 Improved quality of care for patients with mental health needs in acute hospitals: o timely access o better patient experience o improved health outcomes  Improved efficiency and patient flow in hospitals  System learning: Improved knowledge & confidence of ED & acute staff to identify and respond to MH needs  Trust & confidence in RAID team

7.1 Improved quality of care for patients with mental health needs in acute hospitals:

7.1.1 Timely access

Whilst targets are not set for RAID access times, the teams have consistently performed well against the current access times. In the last year Lister RAID has consistently achieved above 98% per quarter for ED referrals seen within an hour and 100% for ward referrals seen within 24 hours; Watford RAID achieved above 98% for ED referrals and 97% for ward referrals. Watford RAID performance is marginally lower than Lister RAID due to differing levels of demand on each service. Whilst the Watford RAID service operates later than Lister – providing 25% more operating hours - demand at Watford is 36% higher than at Lister. Therefore demand on the Watford service is greater despite the longer operating hours.

A large part of this higher demand at Watford comes from the wards and in particular the old age wards. The RAID team have worked in partnership with WHHT to develop a multi-disciplinary / agency pathway for patients suffering from a persistent delirium. This higher demand is seen in the number of ward referrals (see table 6.1a); additionally the RAID team report that patients on the old age wards often require follow-up appointments as their LoS is longer than that for adults on average (see tables 6.3e & f).

The amended access time definitions for RAID will be introduced as part of the move to Core24. It is anticipated that the revised wait time targets will be met within 2 months of the move to Core24. It is also anticipated that the introduction of Core24 will help to smooth out the current pattern of referral times, which, for Lister in particular, shows a peak at around 9am in line with RAID operating hours commencing at 08:30 and the end of the acute staff shift handover.

7.1.2 Better patient experience:

Service user and Carer feedback through HYS and from compliments consistently evidences a high level of satisfaction in their experience with RAID. The Friends and Family test score, which identifies whether someone is likely to recommend the service to friends and family if they need it, shows a large majority of service users would recommend RAID (100% at Lister and 94% at Watford) and are therefore happy with the service they received. In addition the teams regularly receive compliments directly and via HYS (see appendix 2).

Further a question in the case reviews asked “If RAID had not been available would this have affected the quality of care for this individual?” for 100% of cases “Yes” was the response given. As an example of the impact on quality of care, an acute consultant noted that without RAID “The acute trust would not have been able to assess and manage risk in this patient or deploy appropriate MHA legislation in timely manner”.

In addition to Patient Reported Experience Measures (PREMs), Patient Reported Outcome Measures (PROMs) will be implemented as part of the Core24 transformation funding in line with the RCPsych FROM-LP data. This alongside the CROM data will provide a comprehensive picture of the effectiveness of the service in improving health outcomes.

7.1.3 Improved health outcomes:

2016/17 and Q1 2017/18 data across both RAID teams shows approximately 65% of patients had a clinician rated improved outcome (where it was recorded) as a result of a RAID intervention. The core business of RAID is rapid assessment during which time many people will be at the point of starting a clinical treatment episode and are unlikely to show an immediate improvement within space of a 45 -60 minute RAID intervention (average RAID intervention time). Benefit is accrued with referral onto treating service, therefore it is expected that there will be a number of cases where there is “No Change” in the clinicians impression. It is not expected that performance against the outcome measures will significantly vary with the introduction of Core24, however as more RAID services start to measure and report CROMS (a requirement of Core24), data will become available upon which to benchmark the Lister and Watford RAID team.

7.2 Improved efficiency and patient flow in hospitals:

A reduction in length of stay is one indicator of improved efficiency and patient flow. This is demonstrated through a number of measures:

 Speed of response; compared with the psychiatric liaison service (pre-RAID), RAID respond significantly quicker and perform well against the 4 hour ED and 24 hour ward referral response times. The Psychiatric liaison service pre-RAID response times focused on the ED (due to resource limitations), with a target of 4 hours for ED referrals and 72 hours for ward referrals, however these were not always met. Lister and Watford RAID teams deliver rapid response times; in the last year consistently performing well against the 1 hour ED response time (>98%) and the 24 hour ward referral response times (>97%). As such, it is reasonable to conclude that the rapid response element of RAID (compared with pre-RAID) will have a positive impact on length of stay.  Improved service user engagement in physical health; there is evidence that RAID interventions have improved service users’ engagement in physical health treatment. The results from the case reviews showed that in 94% of the cases (100% excluding unknown), the RAID intervention facilitated the patients’ engagement with physical health treatment. This is supported by the NCEPOD findings that identified the mental health of the patient was a contributing factor to the refusal of care in 91.3% (136/149) of cases.  Positive RAID interventions; the range of inputs from RAID (including MH risk assessment, MH diagnosis, Liaison with other MH services and Advice to nursing/medical staff as evidenced in the case reviews) will have had positive benefits on the service users and will have improved recovery. This is evidenced by the CROM data showing 65% improved outcome; which recognising the fundamental business of RAID to assess rapidly, is a significant improvement for service users. Additionally, the patient experience data evidences that 88% and 75% of those service users responding to the HYS survey at Lister and Watford respectively felt that the service they received helped them feel more positive about the future.

These indicators alone build a picture of a service that is able to reduce length of stay, through; rapid response, supporting engagement in physical health and providing a range of interventions with improved outcomes. This is reinforced by two questions in the case reviews:

 “In the acute consultants opinion did RAID contribute to a reduction in LoS”? In 100% of cases where a blank response is excluded the acute consultants reported “Yes”. Including “blanks”, 88% said “Yes”.  “Did RAID prevent a delay in discharging the patient”? In 92% of cases where a “blank”/”unknown” response is excluded “yes” is given. Including “blank”/”unknowns” 71% said “Yes”.

In addition to LoS it is likely that cost savings will also result from potential reduction in ED re- attendances and admissions from ED, however it is not possible to analyse this due to data quality and data consistency issues. The ED does not use ICD10 coding and therefore the WHHT informatics team have had to make assumptions regarding the diagnosis codes to use. Indeed the WHHT admissions data identifies 2363 patients in Q1 2017/18 were admitted non-electively with a MH diagnosis recorded during the spell; ED data only shows 238 patients for the same period. It is reasonable to predict that a large number of the admissions would have come through the ED given they are non-elective and therefore whilst the data suggests that diagnosis recording increases 8 fold once admitted, it also highlights the lack of recording in ED. [It is important to note that general coding in ED is likely to improve in 2017/18 as part of the CQUIN, which should aid the evaluation of RAID involvement in ED in future years].

It is difficult to quantify a cost saving from improved efficiency and patient flow, as this evaluation cannot provide a robust analysis of the data, due to a number of factors:

1. National evaluations of RAID using acute data pre-RAID and post-RAID implementation, (primarily the LSE evaluation of the Birmingham RAID model), have accounted for a wide range of factors affecting patient flow and attempt to isolate the RAID effect; “Use was therefore made of a pair-matched control research design in which patients in the intervention group were matched individually with corresponding patients in the control group, with the matching being based on a number of criteria”8 (LSE evaluation). This evaluation is not commissioned to provide this degree of research. 2. The data available for review only accounts for one element of RAID’s impact, ie. Length of Stay. It does not enable a review of the impact of RAID on ED flow through early intervention and potential admission avoidance. Further, it does not enable a review of the influence of RAID, ie. the ability of acute staff on the wards and ED to influence patient flow, due to the RAID training. A core part of the RAID service is the MH training (formal and informal) given to acute hospital staff to help them identify and better manage patients with a MH diagnosis 3. This evaluation can only give a partial insight into a cost saving based on a large range of assumptions and caveats.

8 https://www.centreformentalhealth.org.uk/evaluation-liaison-psychiatry (p9)

As such a set of scenarios is costed using the following set of assumptions based on conclusions from the results in this paper:

 Patient numbers are taken from the RAID Q1 17/18 ward data (not acute trust data)  Impact would be seen on 88% of those patients seen by RAID on a ward (not ED) (taken from case review data 6.2.4)  Cost per bed day is calculated using total spell costs divided by number of bed days  Cost per excess bed day is calculated using number of excess bed days used  Cost per bed day for Lister Hospital is provided by ENHCCG and is averaged across all ages and disciplines  Cost per bed day for Watford Hospital is provided by HVCCG and is averaged across all ages and disciplines

Scenario 1:

In addition to the above general assumptions the following relate to scenario 1:

- A reduction in LoS for adults of 1 day - A reduction in LoS for Older People of 1 day

Table 7.2a: Potential cost saving from reduced LoS

Adult / Number Average approx Average cost Approx Older of cost per saving per per excess saving per People patients bed day Saving Q1 annum bed day Saving Q1 annum 16 – 64 120 £438 £46,253 £185,011 £179 £18,902 £75,610

65+ 111 £438 £42,784 £171,135 £179 £17,485 £69,939

Lister Total 231 £89,037 £356,147 £36,387 £145,548

16 – 64 139 £438 £53,576 £214,305 £230 £28,134 £112,534 65+ 188 £438 £72,463 £289,851 £230 £38,051 £152,205

Watford Total 327 £126,039 £504,156 £66,185 £264,739

In scenario 1, the range of cost savings for LoS alone at Lister is between £146k - £365k and the range for Watford is £265k - £504k (gross of RAID costs).

Scenario 2:

Given the LoS for adults and Older Peoples varies significantly, with older peoples LoS in excess of double the adult LoS, there is greater opportunity for a reduction in LoS in Older peoples wards. Therefore in addition to the above general assumptions the following relate to scenario 2:

- A reduction in LoS for adults of 1 day - A reduction in LoS for Older People of 2 days

Adult / Number Average approx Average cost Approx Older of cost per saving per per excess saving per People patients bed day Saving Q1 annum bed day Saving Q1 annum

16 – 64 120 £438 £46,253 £185,011 £179 £18,902 £75,610

65+ 111 £438 £85,568 £342,271 £179 £34,969 £139,878

Lister Total 231 £131,820 £527,282 £53,872 £215,487

£53,576 £214,305 £28,134 £112,534

16 – 64 139 £438 £230 65+ 188 £438 £144,925 £579,702 £230 £76,102 £304,410

Watford Total 327 £198,502 £794,006 £66,185 £264,739

In scenario 2, the range of cost savings for LoS alone at Lister is between £215k - £527k and the range for Watford is £265k - £794k (gross of RAID costs).

Scenario 3:

Scenario 3 builds further on the opportunity for reduced LoS in older peoples wards, as such, in addition to the above general assumptions the following relate to scenario 3:

- A reduction in LoS for adults of 1 day - A reduction in LoS for Older People of 3 days

Adult / Number Average Approx. Average cost Approx Older of cost per saving per per excess saving per People patients bed day Saving Q1 annum bed day Saving Q1 annum

16 – 64 120 £438 £46,253 £185,011 £179 £18,902 £75,610

65+ 111 £438 £128,352 £513,406 £179 £52,454 £209,817

Lister Total 231 £174,604 £698,417 £71,357 £285,426

£53,576 £214,305 £28,134 £112,534

16 – 64 139 £438 £230 65+ 188 £438 £217,388 £869,553 £230 £114,154 £456,614

Watford Total 327 £270,964 £1,083,857 £142,287 £569,149

In scenario 3, the range of cost savings for LoS alone at Lister is between £285k - £698k and the range for Watford is £569k - £1,083k (gross of RAID costs).

Given that the scenarios above only account for LoS cost savings based on limited evidence, this evaluation cannot give a definitive cost saving resulting from RAID.

While there is evidence that RAID has reduced LoS (see above) it has not been possible to identify from the data the extent of such a reduction. However, the scenarios above provide an insight into the possible financial effect across a range of scenarios that are consistent with other findings.

It should also be noted that these scenarios exclude the positive impact on meeting ED waiting targets; avoided admissions and reduced rate of readmissions.

Finally, the scenarios do not seek to indicate where such financial gains may be realised (by the hospital trust or by local commissioners).

7.3 System learning: Improved knowledge & confidence of ED & acute staff to identify and respond to MH needs.

Feedback from acute staff regarding the training from RAID is very positive with 99.6% of those completing a feedback form at Lister Hospital reporting that the training met their learning objectives and 95% at Watford hospital. Additional comments received are largely positive and reported that the training was relevant, helpful, informative, useful, engaging and interesting. The main area of negative feedback was that the training was too short and needed to be longer to cover the breadth of the topic. Whilst recognising this eagerness for the training to be longer and cover more, this needs to be balanced against the pressure put on the organisation by taking acute staff away from clinical duties. The longer the training the more time members of staff are away from the wards / ED impacting on Acute organisational capacity. The RAID teams feel that the current programme balances this conflict.

In addition to the formal training, at every RAID intervention members of acute staff receive informal training through the support, advice and guidance given by the RAID team. Attendance at MDTs and ward rounds also helps to improve the knowledge and confidence of staff to identify and respond to MH needs.

WHHT non-elective admissions data in tables 6.3c and 6.3d shows a significant increase in admissions for people with a MH diagnosis since 2011/12; a 240% rise. However it is important to recognise that this increase is likely to be due to improved MH diagnosis coding in the acute trusts as opposed to an actual increase in admissions. The improvement in recording is likely to be due to the training provided to acute colleagues by RAID, the presence of RAID alongside acute colleagues in assessing and reviewing service users and the ability for RAID to record diagnoses directly in the hospital notes. This improvement in MH diagnosis recording will significantly help with the evaluation of RAID in the future as the data starts to more accurately capture those with a MH diagnosis.

7.4 Trust & confidence in RAID team:

Evidence that the Acute Trusts have trust and confidence in the RAID team can be seen from the case review data and comments as well as the willingness of the acute consultants to take part in the case reviews as they regard RAID as a valuable service. 100% of the acute / ED consultants who

completed the case reviews reported that if RAID had not been available this would have affected the quality of care for this individual. Furthermore, nearly all of the case reviews involved acute consultant feedback including:

“RAID team were extremely helpful in managing this extremely complex patient with every complex social issue (& difficult family)… Overall excellent care/support from RAID team…” (Lister Consultant).

“Generally the RAID service has transformed the care of patients with severe mental illness and the service has been a shining light in preventing admission, facilitating discharge and providing good quality care” (Watford Consultant).

Further, Ruth Connolly, Assistant Divisional Manager, Unscheduled Care and Sarah Cato, Matron, WHHT have provided the following feedback:

“The RAID team provides a service which is a considerable improvement to that available before. They are based in the hospital so know the staff and processes. This has enabled us to have agreed protocols and arrangements for referrals, with agreed roles and responsibilities. They provide a consistent level of service with consistent staff who know the hospital and who have developed personal relationships with the ED and ward teams… There are good on-going relationships between the RAID team and hospital staff…

There is a Frequent Attender group which ED, RAID and other relevant staff attend, which over the last few years has developed care plans for vulnerable patients and improved their on-going care reducing attendances at ED…

One of the RAID consultants was key in setting up the specialist dementia ward and RAID staff are a key part of the team providing on-going support to this patient group.

In summary, RAID is considered an essential component of the service available at WHHT”.

In addition to acute hospital colleague feedback, the teams have received compliments from Sandra Treacher, EOC Clinical Lead – Paramedic, Emergency Clinical Advice and Triage Centre, East of England Ambulance Service and Heidi Hall, Head of Service Integrated Discharge Team, HCC (see 6.1.6). These compliments recognise the valuable role RAID play in supporting the health care system.

8.0 Recommendations

It is clear that RAID is providing a valuable, high quality service not only to service users and carers, but to the acute trusts and wider healthcare system as seen through staff feedback and the case reviews. As a result, the recommendation is for the current Watford and Lister RAID services to be recurrently funded, and for both Hertfordshire CCG’s the Core24 funding beyond the one-year NHSE transformation funding, to be recurrent.

Appendix 1: RAID Case review questions

Questions to be responded to on an individual case by case basis. NCEPOD Question Response options A&E / ward ref question 3.9 If RAID had not been available would this Yes, No, Unknown Both have affected the quality of care for this individual? 4.8 & What were the components of the RAID 1. MH risk assessment 4.15 psychiatry review / input 2. MH risk management 3. Treatment plan initiated 4. MH diagnosis 5. Discharge Planning 6. Liaison with other MH services 7. Advice to nursing/medical staff 8. Mental Capacity Assessment 9. Prescription/alteration of MH medication 10. MH observations 11. Deployment of MH legislation 12. Advice for de-escalation of situation by RAID 13. Multidisciplinary working 14. Rapid tranquilisation plan 15. De-escalation of situation by RAID (tick all that apply) Link to Did the RAID intervention facilitate the Yes, No, Unknown Both 5.2 patient’s engagement with physical health treatment? In the acute consultants opinion did RAID Yes / No Ward contribute to a reduction in LoS If yes, please quantify In the ED consultants opinion did the Yes / No ED RAID intervention prevent a re- attendance at A&E 6.5/6.7 Did RAID prevent a delay in discharging Yes / No / Unknown Both the patient? 6.11 Was the patient readmitted within 30 Ward days of discharge? Did the patient re-attend ED within 30 Yes / No / Unknown ED days of discharge from ED? Is there evidence in the hospital notes of Both a mental health diagnosis? 8.2 What is the view of the Acute Consultant Both of the quality of the RAID service in this individual case Any additional notes / comments relating Both to this case

Appendix 2: Service User / Carer feedback

Watford RAID:

 “I cannot thank you and your team enough for all your help and support you have given me over the past ten months. When I was first referred to you I had struggled both physically and mentally for over four years and generally being treated poorly by the health care professionals I saw as they did not have a proper understanding of my condition. I was at my lowest point at this time and once I had spoke to you I was reassured I was seeing the right person to help me understand and treat my condition which meant a great deal to me at that time as I had isolated myself from almost everybody. At last week’s session listening to the lady who had the failed suicide attempt and understanding how she got to that point was very sad, as I was at that point ten months ago. By what you achieve in your sessions with patients and by educating other health care professionals making them aware of what they can do to help people from the onset of their condition and getting help to them straight away, maybe we would not hear so many sad stories in your sessions. I would just like to add by what you are doing day in day out continually pushing to educate, to make everyone aware both patients and the medical profession is so very important and you have my respect and admiration your passion and energy is contagious and quiet amazing. As for myself my future is now something I look forward to as I have the tools to cope more effectively , I have found not only my old self but become a more rounded individual in the process so thank you”.  “Thank you so much for everything you have done for me. I was able to confide in you and that’s not something I do a lot. Thank you for motivating me to recover.”  “I feel positive that I can move forward with the right help that I have been given; informative helpful and very understanding.”  “Very friendly, understanding experienced and most of all supportive.”  “X has helped me with regards to helping me with a future plan and getting me the support and help that I need to get through my relapse without drinking again and also helping me with my relationship with my family and helping them understand the problems that I am currently having.”  “X is so kind and helpful. This service must continue! You are saving lives! X was fantastic today. I could ask for no more.”  “The RAID team were very good, listened carefully, and gave good advice. Delighted to be discharged.”

Lister RAID:

 Compliment from a Carer (taken over the phone): Just had phone call from the father of X to say thank you to you both. He was very grateful for your intervention and says you helped to relieve a lot of stress after his son had been in A&E overnight. He told me I have “The BEST Staff”!  Compliment from a Carer (via email): “I do feel that I need to contact you not only to pass on my thanks to X but also to commend him for his professionalism and understanding; - He was extremely kind and considerate when I became upset when my mum ‘disowned’ me - He explained very clearly to my Mum that it was the GP who had sent her to Lister for tests, not her daughter - He explained the term ‘mental capacity’ in details so that I could understand - I typed up some details about how Mum’s behaviour had changed over the last week and reasons why she should not be allowed home on her own. X kindly showed this to the Consultant so that they could make an informed decision - I called X following Mum’s discharge for more information and he was extremely helpful - He even made a quick courtesy call the following day to ask after my Mum. - If there is any way in which he can be thanked or rewarded, please do let me know. He is an excellent member of your team.  “Dear Mr Cahill I wish to draw to your attention to the care my mother X has received while patient recently, at the Lister. The professional service that consultant , X, RAID TEAM ,gave was the one stabilising factor in my mother’s physical and physiological care and it is true to say that until her involvement very little headway was being made in any respect at this hospital. It is hard for me to understand how this hospital dealt with such patients, as my mother before RAID. Dr X has shown several personal qualities, which in my experience makes such a person an invaluable staff member and trust will enjoy the trusts full support in her good work”

Item 8 Appendix 2

Title of scheme: RAID (Rapid Assessment Intervention and Discharge) CCGs covered by the scheme: Herts Valley CCG, East and North Herts CCG (only one QIA is required for each scheme even in multiple CCGs are involved) Lead CCG: Herts Valley CCG (the CCG that will coordinate the completion of the QIA in consultation with involved CCGs) Project Lead for scheme: Anna Hall, Senior Commissioning Manager, Mental Health Senior Manager/ Executive Sponsor: David Evans, Director of Commissioning Brief description of scheme: RAID is an enhanced mental health liaison service model which supports mental health and urgent care outcomes to deliver speedy mental health assessment in A&E and support flow in the acute hospital; supports admission avoidance and/or early inpatient discharge to prevent delayed transfers of care (DToC). RAID also works to build capacity within the acute setting through workforce development.

This QIA is being provided in support of the RAID evaluation paper being presented to Herts Valley Clinical Commissioning Group (HVCCG) Governing Body on 18 January 2018. HVCCG Governing Body is being asked to:

- To note the national NHS strategic direction of travel for the expansion of Mental Health Psychiatric Liaison services using the RAID model.

- To discuss the evaluation report and commissioners comments and agree RAID is providing a valuable, high quality service to service users and impacts on the acute trusts and wider healthcare system.

- To agree to ongoing funding of the existing Watford RAID services (£994,000 currently funded on a non-recurrent basis in HVCCG budget) and to funding of the extended CORE 24 service (£351,666) once NHS England pump priming funding is exhausted.

Please note if a decision is made by HVCCG Governing Body to cease RAID funding there would be negative impact on all the areas outlined below and another QIA will need to be completed to ensure the risk of decommissioning this service is understood.

Intended Quality Improvement Outcome/s:

RAID continues to be funded to provide a valuable, high quality service in terms of effective rapid care and patient experience to service users. RAID to continue to support and contribute to making an impact on acute trusts and wider healthcare system national metrics. Methods to be used to monitor quality impact:

Pos/ Risk Comments (include Full Neg Score reason for identifying Assessment or if N impact as positive, Required N/A negative or neutral) Yes/No

(Risk > 8 Stage 2 full assessment required) Duty of Quality Pos Where there is agreement with the Could the proposal impact positively or report negatively on any of the following: recommendations, the proposal will not a) Compliance with NHS Constitution impact or have a right to: positive impact on the following:

 Quality of Care and Environment Compliance with NHS  Nationally approved treatments/ Constitution drugs Partnerships – due to  Respect, consent and the continued confidentiality presence of RAID  Informed choice and involvement within the acute  Complain and redress Safeguarding children or adults b) Partnerships c) Safeguarding children or adults

NHS Outcomes Framework Where there is agreement with the Could the proposal impact positively or report negatively on the delivery of the five recommendations, the proposal will have domains (assess all separately): direct positive impact 1. Preventing people from dying on preventing people from dying prematurely prematurely as RAID core business is rapid assessment for those in mental health crisis presenting to emergency departments in acute hospitals, facilitating rapid Pos treatment/service.

Pos Where there is 2. Enhancing quality of life agreement with the report recommendations, the proposal will have direct impact on enhancing quality of life. A key function of RAID is to facilitate access onto an appropriate care pathway within

secondary care mental health services which should result in better mental health outcomes in the long– term.

Pos Where there is agreement with the 3. Helping people recover from report episodes of ill health or following recommendations, the injury proposal will have direct impact on helping people recover from episodes of ill health or following injury. RAID core business is rapid assessment for those in mental health crisis presenting to emergency departments in acute hospitals. A key function of RAID is to facilitate access onto an appropriate care pathway within secondary care mental health services which results in better mental health outcomes in the long–term.

Pos Where there is 4. Ensuring people have a positive agreement with the report experience of care recommendations, the proposal will have direct impact on ensuring people have a positive experience of care. As outlined in the main report in Appendix 2 (can be made available if required) RAID regularly receive compliments and positive feedback. Also demonstrated/evidenc ed through the case reviews that RAID positivly affects the quality of care that acute providers are able give to people in

mental health crisis in terms of rapid assessment and management of risk.

Pos Where there is 5. Treating and caring for people in agreement with the a safe environment and report protecting them from avoidable recommendations, the proposal will have harm direct impact on treating and caring for people in a safe environment and protecting them from avoidable harm. As outlined in the report case reviews RAID positively affects the quality of care that acute providers are able give to people in mental health crisis in terms of rapid assessment and management of risk. Access a) Patient Choice Could the proposal impact positively or The proposal supports negatively on any of the following: patient choice to access this mental a) Patient Choice health service. b) Access b) Access c) Integration The proposal supports patient choice to access this mental health service through acute provider ED. c) Integration

This proposal supports effective integration.

Name of person completing assessment: Anna Hall Position: Senior Commissioning Manager, Mental Health Signature: Date of assessment: 05.01.2018

Reviewed by: David Evans Position: Director of Commissioning

Signature: Date of review: 05.01.2018 Proposed frequency of review: Six monthly/ Quarterly/ Monthly/ Other please specify:______(minimum monitoring is six monthly (scores 6 or below), every 4 months (scores 8-9), quarterly (scores 10- 12) and monthly (15-20), weekly or more frequent (score 25) Use boxes below to record outcome of reviews

Date of next review: July 2018

Signed off by: Clare Saunders Position: Deputy Director of Nursing and Quality

Signature: Date of review: 9/1/18 Requires review at Quality Committee: N Date considered at Quality Committee: Logged on spreadsheet: Y Date: 10/1/18

Post Implementation Review

(use the template below to record outcomes of reviews- if more than one is required cut and paste the box below) Have the anticipated quality impacts been realised? Y/N Comments: Have there been any unanticipated negative impacts? Y/N Comments: Are any additional mitigating actions required? Y/N Comments: Do any amendments need to be made to the scheme? Y/N Comments: Reviewed by: Position:

Signature: Date of review:

NHS Herts Valleys Clinical Commissioning Group Board Meeting Date of Meeting: 18 January 2018

Title Committee chairs reports Agenda item 9 Purpose* (tick) Decision ☐ Approval ☐ Discussion ☐ Assurance ☒ Information only ☐

Author and job title Responsible director and job title Director signature Paul Smith, Alison Gardner. Stuart Bloom, Rod While Thelma Stober Head of Corporate Governance

Short summary of paper The Committee Chairs’ report summarises key discussions, areas of assurance and decisions from the most recent committee meetings:  Quality  Finance and performance  Patient and public involvement  Commissioning executive Recommendation(s) The Board is being asked to: Take relevant assurances from the work of the committees.

Engagement with Not applicable patients/public/staff and other stakeholders Links to Strategic Objectives (tick all that apply) Objective 1: We will continually improve engagement with patients, carers, the public and member practices ☒ so that they contribute to and influence our work and activities. Objective 2: We will commission safe, high quality services that meet the needs of the population, reducing ☒ health inequalities and supporting local people to stay well and avoid ill health. Objective 3: We will work with health and social care partners to transform the delivery of care through the ☒ implementation of Your Care, Your Future, the strategic review in west Hertfordshire. Objective 4: We will ensure that there is a financially sustainable and affordable healthcare system in West ☒ Hertfordshire. Board Assurance Framework Refer to assurance levels table below and latest BAF report here: N:\Nursing & Quality\8 Risk Management System\2. Board Assurance Framework\BAF 201718\Current versions for front sheet reference N.B. The executive summary for this paper explicitly points to the evidence to support the assurance level indicated above. For example: Very high – what is the evidence to support the current strong position & how will it be sustained? High – what is being done to strengthen controls and mitigate the likelihood of this risk materialising? Medium - what is being done to address gaps in assurance and how successful is this action proving? Low - what are the urgent actions planned to address the lack of assurance?

Ref. Risk Risk description Current risk Target risk Assurance Owner score and score Level movement since last month This report provides assurance on the management of a large number of risks on the Board Assurance Framework. New strategic risks identified by this report

Other significant risks related to this report (from the CRR)

Resource None CFO Signature implications

Potential conflicts None of interest Equality and Not applicable quality impact analyses (indicate the key points the analysis has identified relevant to decision required) Equality delivery Better Health Outcomes ☐ system (identify Improved Patient Access and Experience ☐ which goal your A Representative and Supported Workforce ☐ proposal / paper supports) Inclusive Leadership ☐ Report history Not applicable Which Groups or Committees have seen this report and when? Where does the report go next? Appendices

Chairs report: January 2018

Quality committee Dates of Meetings Chair Executive Lead 11 January 2018 Alison Gardner Diane Curbishley  Key assurances/risks received CHC Operational Dashboard  Sourcing patient placements remains a challenge and care home contracts are being established to support.  The CHC team is actively recruiting into vacancies and is almost at full establishment. The senior team are reviewing the staffing levels ensure the establishment is appropriate to meet the service demands.

N&Q Risk Register  Two risks were recommended for removal from N&Q Risk register, both related to Looked after Children. The Committee agreed to remove. Quality Impact Assessment (QIA) risks  Over the Counter Medicines Stage 2 QIA had been identified as not having been approved by the Quality Committee as part of the QIAs review. The Committee agreed to approve the QIA retrospectively. Assurance was given that the QIA processs is embedded within the CCG processes now.

Care Homes  EEAST Emergency Care Practitioner Care Home car schemes enhanced contract (ECP) contract has been signed, however there is a risk that the contract will not be fulfilled as the timeline for roll out of the second car has not been confirmed due to recruitment challenges. Escalation to EEAST at a senior level will occur. Safeguarding Children  Section 11 update was provided from all HVCCG providers. Risks were raised in relation to HUC and actions have been agreed to obtain assurance, including a bespoke quality assurance visit to the service. Safeguarding Children and Adult training  Assurance was provided regarding the HPFT training figures. Formal trajectories and targets have been agreed.  Levels are improving at all other providers and are being closely monitored. Monthly monitoring will continue and be reported via Quality Committee to ensure trajectories are met. Concordia  Following the cessation of the Concordia service and subsequent audit to establish whether a safe diagnostic service was provided, an error rate of 1.5% was noted. A further audit is to be undertaken, as agreed with NHS England with an increased sample size. This will look to confirm the level of error within the service. It was noted that there is no immediate safety risk; a view supported by NHSE. Quality Dashboard  RFL and WHHT have reported 5 and 4 Never Events respectively since April 2017. Further assurance is required from RFL regarding action taken and the CCG is working closely with WHHT regarding the outcomes of their findings and the assurance of embedded action.  Complaints performance at WHHT is improving in line with the trajectories set. Quality Alert System  Themes and trends remain the same. Additional assurance required regarding the support for QAS at WHHT and this will be raised through Clinical Quality Review Meeting.

Integrated Finance Dates of Meetings Chair Executive Lead & Performance 14 December 2017 Stuart Bloom Charlie Wood committee Key assurances received Presentation from the Integrated Urgent Care provider, HUC.  Three contact centres have been networked and this has led to an improvement in call answering times.  National targets for the percentage of calls handled by a clinician will increase to 60% on 31 March 2018. HUC is already achieving 66%.  Clinical assessment service targets, locally drafted, are not being achieved and need to be reviewed.  OOH performance against has improved but is still not meeting the target.  Recruitment and rota fill remain an issue - it has been difficult to attract clinical staff to the Potters Bar shifts.  The Committee noted that workforce and data remain key issues and these were not addressed by the presentation.  Clarity is required about handover during the ‘shoulder period’ between general practice and out of hours.  Patient feedback also suggests that they are not contacted responsively and this may lead to attendances elsewhere.  The Committee asked HUC to return in 6 months with a presentation focussing on the key issues identified at this meeting. Integrated Performance Report  The challenging position within A&E at WHHT has continued over the past few months and the CCG has been proactively seeking mitigation. A bi-weekly system resilience operational meeting has been instigated.  Problems with referral to treatment have continued, particularly because of current pressures at WHHT and theatre issues.  A ‘blip’ in cancer data at WHHT saw the 62 day target missed. E&NH Trust is moving slowly in the right direction with this target but still remain a challenge.  There have continued to be issues with the non-emergency patient transport service around capacity and resource across the patch, but the contract will be brought to signature soon and this will enable improvement.  HVCCG workforce dashboard shows a higher than national average turnover, although this is not a straightforward comparison. High sickness figures are largely due to long-term absences that are being addressed. The recently closed staff survey had an 80% response rate and early indicators will be available from February. Decisions taken None

Integrated Finance Dates of Meetings Chair Executive Lead & Performance 11 January 2018 Paul Smith Charlie Wood committee Key assurances received  A&E is very challenged; this is a national issue. WHHT has been very proactive in adhering to national guidance and cancelling both elective procedures and Out Patients appointments. All system partners are being held to account to support the pressures being experienced.  The A&E situation has impacted directly on the RTT targets, through cancellation of procedures.  111/OOH - It was highlighted that staff shortages are critical. Borehamwood has had to be closed due to shortfalls. Challenging to address.  HCT – There is challenge in the length of stay and delayed transfers of care position, whereby system resilience is working with the provider to address and initiate pathway changes.

Finance & Dates of Meetings Chair Executive Lead performance 14 December 2017 Paul Smith Elke Taylor (deputising committee for Caroline Hall) Key assurances received  Acute contracting position is better than plan and an improvement on the previous month.  Challenges on coding issues of £2.1m have been let go as part of the outputs of mediation, but in return WHHT has agreed to a number of other things.  GP referrals are down on 2016/17 and trending down from previous years.  A&E overall performance is similar to previous years.  At M7 the year-to-date overall performance is worse than plan, but an improvement on the previous month, with a deficit of £1.8m. The CCG is still forecasting that it will meet its control total, with adverse variances offset by non-recurrent budget underspends.  An increasing trend has been identified in the size of packages and activity for CHC rather than an increase in patient numbers. The full year potential forecast for CHC is now based on more reliable data.  Risks around primary care prescribing QIPP were noted.  Year to date QIPP achievement at M8 is ahead of plan, but the full year forecast has been revised down to 90%.  The transformation board with WHHT is now more effective.  The QIPP plan for 2018/19 will be presented to the Commissioning Executive in January.  The Chair noted the positive transformation achieved within the CCG in relation to data and negotiations. Decisions taken  The Committee approved the proposed financial envelope for Dietetics procurement, subject to some additional requirements.  The Committee approved the proposed financial envelope for a community vasectomy service.  The Committee noted the decision taken by the CEO to fund GP streaming in ED.

Finance & Dates of Meetings Chair Executive Lead performance 11 January 2018 Paul Smith Elke Taylor (deputising committee for Caroline Hall) Key assurances received  Acute contracting continues to be better than plan.  Deep dives into Royal Free London and East & North Herts Trust activity: actions being followed up with trusts.  Outcomes of mediation will provide sustainable change.  Ongoing review of CHC spend and external review to be undertaken.  Deep dive into prescribing to inform actions to be taken on implementing QIPP schemes.  Update of financial plan noted. Decisions taken  Approved updated financial plan  Approved financial envelope for ENT, subject to some additional requirements.  Approved financial envelope for Opthalmology, subject to some additional requirements.

Primary Care Dates of Meetings Chair Executive Lead Commissioning 7 December 2017 Thelma Stober David Buckle

Committee

Key assurances received  GPFV locality plans – the committee noted the update but were not yet assured that St Albans and Harpenden locality was on track to achieve the required target by March 2018.  Update on the STP plan - the committee noted the good progress but expressed concern regarding the achievability of the plan.  It was noted that for primary care, the month 7 position is an under spend to date of £69k. We are forecasting a year end underspend of £287k based on information available to the end of October.  Practice risk log reviewed and update on premises received. Decisions taken  The committee approved the extension of the West Herts Medical Centre contract from 31 March 2018 to the new expiry date of 1 October 2018.  Approved the recommendation to extend the current APMS contract for GP extended access for a further 12 months to 31 March 2019.The committee also approved the contract variation and noted that the GP streaming element had been approved by the CEO and had commenced.  Approved the revised PCCC terms of reference Areas of escalation to the board  None

Patient and Dates of Meetings Chair Executive Lead public 13 December 2017 Alison Gardner Juliet Rodgers involvement committee

Key assurances received  The Committee noted the outcome of the process for the appointment of the patient representative to the board, i.e. that both J Wigley and J Ainsworth Beardmore had been jointly appointed and were assured that the process had been robust.  Assurance in respect of financial turnaround.  Assurances around general practice following delegation including mechanisms for contractual compliance and performance and General Practice Forward View Re-procurement of adult community services and the timetable and governance processes. Areas of escalation to the board  Concerns were expressed about the lack of UTC facilities in Hertsmere and St Albans and Harpenden.

Commissioning Date of Meeting Chair Executive Lead executive 16 November 2017 David Buckle David Buckle committee Key assurances received Funding of respite provision Assurance around the processes behind the finance and performance committee’s decision to cease funding of respite provision currently provided at Nascot Lawn.

Update on QIPP Conversations were taking place outside of the QIPP transformation board to improve engagement and address the barriers to engagement and delivery.

Decisions taken Children’s community services Approved the funding of up to £30k to undertake a baseline activity and expenditure analysis of children’s community services provided by HCT and benchmarking where available with other CCGs.

Urgent Care Strategy Approved the direction of travel and the strategic plan in relation to urgent treatment centre development subject to addressing Hertsmere concerns.

Service specification for community vasectomy services Approved the clinical specification for a community vasectomy service.

Areas of escalation to the board Update on QIPP It was agreed that the strategy and approach for 2018/19 QIPP would be shared with the board. Concerns about the internal capacity to deliver the large number of schemes. Concerns about lack of pace within the main provider to deliver QIPP was noted to be a major issue.

Commissioning Date of Meeting Chair Executive Lead executive 21 December David Buckle David Buckle committee Key assurances received Adult community health services Received an update on the current and planned activity and key milestones, resource implications for the CCG, the project management processes and the key risks and mitigating actions. Decisions taken Terms of reference Subject to a minor amendment, the commissioning executive agreed the changes made to the committee’s terms of reference and recommended them to the board for approval at the next board meeting in public on 18 January 2018. QIPP schemes 2018/19 1. Approved the methodology in capturing and validating the schemes. 2. Approved the identified QIPP schemes subject to final validation. 3. Approved the process for engagement. Adult weight management in Hertfordshire Approved contribution of £17k to Tier 2 community weight management system, subject to discussions with ENHCCG and HCC/PH for a 3-way split. Procurement of nutrition and dietetics service Approval of the clinical model to launch procurement for a 3 year contract for a community nutrition and dietetics service, including a tier 3 obesity management approach. Fitness for elective surgery policy Ratified the policy. Implementation plan for fitness for elective surgery policy Approved. NICE guidance policy Approved.

Areas of escalation to the board Adult community health services Risk that the tendering, mobilisation and transition stages may require additional investment or spend. Concerns about internal capacity to deliver a procurement of this scale alongside a number of other procurements and challenging QIPP schemes.

NHS Herts Valleys Clinical Commissioning Group Board Meeting 18 January 2018

Title Integrated Performance Report Agenda item 10a Purpose* (tick) Decision ☐ Approval ☐ Discussion ☒ Assurance ☐ Information only ☐

Author and job title Responsible director and job title Director signature Matt Daly Charlie Wood Performance Lead Director of Contracting and Performance Short summary of paper The October performance report affects most areas of risk but is specifically key to risks 2.1 and 2.2 as per the Board Assurance Framework. Key performance areas to note in the report are:  A&E – performance remains below the constitutional target. This can be reviewed on page 3 of the performance pack with supporting narrative, including actions to address, on page 4.  DToCs – the 3.5% target has been exceeded currently; at 2.0% and is above the expected trajectory at both WHHT and HCT. Performance figures and supporting narrative, including actions to address, are on page 6.  RTT – Performance remains below the 92% target and can be reviewed on page 4 with supporting narrative and mitigating actions on page 5.It is anticipated that the position will worsen due to cancellations on elective procedures as directed NHSE to support A & E pressures.

Recommendation(s) The Board is being asked to:  Discuss and note the report  Full dashboards for WHHT, RFL, ENHT, L&D, Bucks, RNOH are available on the intranet: http://hertsvalleysccg.nhs.uk/documents/business-intelligence-performance- and-information-governance/performance-reports Engagement with N/A patients/public/staff and other stakeholders Links to Strategic Objectives (tick all that apply) Objective 1: We will continually improve engagement with patients, carers, the public and member practices ☐ so that they contribute to and influence our work and activities. Objective 2: We will commission safe, high quality services that meet the needs of the population, reducing ☒ health inequalities and supporting local people to stay well and avoid ill health. Objective 3: We will work with health and social care partners to transform the delivery of care through the ☐ implementation of Your Care, Your Future, the strategic review in west Hertfordshire. Objective 4: We will ensure that there is a financially sustainable and affordable healthcare system in West ☐ Hertfordshire.

Board Assurance Framework Refer to assurance levels table below and latest BAF report here: N:\Nursing & Quality\8 Risk Management System\2. Board Assurance Framework\BAF 201718\BAF Current version for front sheet reference N.B. The executive summary for this paper explicitly points to the evidence to support the assurance level indicated above. For example: Very high – what is the evidence to support the current strong position & how will it be sustained? High – what is being done to strengthen controls and mitigate the likelihood of this risk materialising? Medium - what is being done to address gaps in assurance and how successful is this action proving? Low - what are the urgent actions planned to address the lack of assurance Ref. Risk Risk description Current risk Target risk Assurance Owner score and score Level movement since last month Risk that we do not deliver on all NHS constitutional 2.1 CWo pledges, key national targets and priorities. 12↑ 8 Medium Risk that we are unable to ensure high quality, safe and sustainable services for the population and 2.2 DCu patients of west Hertfordshire. 12→ 8 Medium Resource N/A CFO Signature implications

Potential conflicts All members have completed conflict of interests’ documentation and we are not aware of any of interest risks arising. Equality and N/A quality impact analyses (indicate the key points the analysis has identified relevant to decision required) Equality delivery Better Health Outcomes ☐ system (identify Improved Patient Access and Experience ☐ which goal your A Representative and Supported Workforce ☐ proposal / paper supports) Inclusive Leadership ☐ Report history Which Groups or This paper has not been to any prior groups or committees ahead of this meeting. Committees have seen this report and when? Where does the report go next? Appendices Performance Report

Item 10a Appendix 1

Herts Valleys Clinical Commissioning Group Performance Report

October 2017

Working together for a healthier west Herts - -

- -

- Page 2 - Executive summary

Accident and Emergency HVCCG did not meet the A&E target in October 2017 and performance continues to remain challenged across the Herts Valley system. Urgent care recovery escalation meetings are held regularly with NHS England & West Herts Hospital Trust with joint CCG and WHHT performance packs (incorporating recovery plans and mitigating actions) submitted to NHS England as part of ongoing monitoring process. The Local A&E Delivery board meets monthly, with attendance at Chief Executive level and throughout winter will monitor the implementation and impact of the Winter Plan; a System Resilience Group is also in place, meetings increased to weekly and is attended by the system's operational directors to discuss key performance and operational issues. Currently the system is experiencing unprecedented challenge which is also being reported nationally.

Delayed Transfers of Care (DToC) HVCCG DToC performance shows an overall upward trend for October, rising to 9.8% the week of October 12 against a trajectory of 3.5%. The SRT review the position on a daily basis and provide proactive intervention with system partners, including regular audits of DToCs and other stranded patients and appropriate escalation and There is also ongoing escalation to system partners via the Systems Resilience Group and A & E Board. Currently the DTOC target has been exceeded and is at 2% due to additional capacity being provided through additional winter monies.

RTT HVCCG did not meet the target for RTT in September 2017 at 88.9% against a target of 92%, a 1% drop against the previous months performance. This fall in performance is due to theatre closures, restricted weekend working, pressures on emergency pathway and limited bed capacity . WHHT are unlikely to meet their trajectory of compliance in October and are in negotiation with NHSI to extend and working through mitigating the risks into November but any further increase in demand could pose a risk to achieving the standard. The Provider is actively outsourcing to Independent Providers to manage referral backlogs.

Cancer Waiting Times HVCCG achieved six out of the Eight Cancer Waiting Times (CWT) targets in October 2017. The non- compliant CWT targets being predominantly within ENHT and MVCC. This is however, the fifth consecutive month that the 62 day target has not been achieved. This is due to underperformance at RFLHT and E&NHT. The cancer network is aware of the issues and a recovery plans are in place for both E&NHT and RFLHT. A contract performance notice has been sent to E&NHT in December addressing the under performance by E&NHCCG (as the co-ordinating commissioner) which requires E&NHT to implement a remedial action plan. Two Week Wait Breast target has been achieved in October & the CCG has met the target for the third consecutive month and is now achieving target YTD.

Community Mental Health Referrals Hertfordshire Partnership NHS Foundation Trust did not meet the 98% target for September with HVCCG performance being 70.3%. An increase of 6.4% on the previous month performance of 63.9%, stopping the previous 2 month decline. There are a number of challenges faced by the Trust in this area including high levels of demand and capacity issues. The Trust is being held more rigorously to account reviewing and querying pathway performance, LOS and patient flow. There are various plans to mitigate, ranging from signposting to other services to reduce pressures, reducing clinical assessor pass on rates of outliers and additional resources to focus on assessments. HPFT continue to submit weekly performance reports to Commissioners and monthly meetings held to focus on the SPA recovery action plan.

Patient Transport Service There continues to be challenges around capacity levels for the provision of patient transport services. HVCCG continues to provide additional support via a number of local patient transport services. Due to the current pressure around A & E and the requirement for continued discharges at the Trust, transport has a vital role to play in supporting patient flow. The new patient transport contract was signed in December with EEAST enabling them to consult with staff and recruit as required. This will support a transition period move to full capacity by the end of March.

- Page 3 - Access standards

17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 IAF YTD Indicator Trend Ref. Target Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 17/18

Percentage of incomplete pathways within 18 weeks for patients on AS01 92% 89.8% 89.3% 89.0% 89.5% 90.6% 89.8% 90.4% 91.5% 91.0% 91.3% 90.9% 90.4% 89.4% 88.9% 89.1% 90.4% incomplete pathways * Number of patients waiting more than a year for treatment AS05 0 3 4 0 0 1 0 1 1 0 0 0 0 0 0 0 1 (Incomplete pathways)

AS06 Percentage of patients waiting 6 weeks or less for a diagnostic test* 99% 99.3% 99.4% 99.8% 99.7% 99.3% 98.8% 99.4% 99.7% 99.3% 99.4% 99.6% 99.4% 99.1% 98.5% 98.7% 99.1%

Percentage of patients admitted, discharged or transferred out within AS08 95% 86.8% 86.7% 84.5% 85.5% 81.5% 85.7% 85.9% 81.7% 76.6% 84.0% 89.0% 82.9% 82.3% 81.6% 83.4% 82.9% 4 hours of arrival in the dept.*

West Hertfordshire Hospitals NHS Royal Free London NHS Foundation Luton & Dunstable University Hospital IAF Trust Trust Indicator Target Ref. YTD YTD YTD Sep-17 Oct-17 Trend Sep-17 Oct-17 Trend Sep-17 Oct-17 Trend 17/18 17/18 17/18 Percentage of incomplete pathways within 18 weeks for patients on AS01 92% AS01R 88.1% 88.5% 89.6% AS01U 87.4% 86.9% 90.2% AS01W 92.0% 92.3% 92.7% incomplete pathways * Number of patients waiting more than a year for treatment AS05 0 AS05R 0 0 0 AS05U 0 0 0 AS05W 0 0 0 (Incomplete pathways)

AS06 Percentage of patients waiting 6 weeks or less for a diagnostic test* 99% AS06R 98.1% 98.6% 99.1% AS06U 98.4% 99.3% 99.8% AS06W 94.7% 96.1% 97.9%

Percentage of patients admitted, discharged or transferred out within AS08 95% AS08R 81.6% 83.4% 82.8% AS08U 84.3% 87.0% 87.4% AS08W 98.5% 98.6% 98.8% 4 hours of arrival in the dept.*

- Trolley waits in A&E no longer than 12 hours 0 AS06R 0 0 AS06U 0 0 AS06W 0 0

- Ambulance handover 30-60 min - 20.4% 20.4% 18.8% ------

- Ambulance Handover over 60 Min - AS08R 9.8% 9.8% 10.9% AS08U - - - AS08W - - -

* NHS Constitutional Standard

- Page 4 - Access Standard Narrative Key issues Mitigating actions Progress A&E A&E A&E In October 2017, WHHT achieved 83.4% against the 95% 4 hour standard. A number of immediate and future initiatives are being reviewed and This was an improvement of 1.8% on September 2017, giving a YTD position implemented to improve A&E flow. Current nurse streaming in ED includes: of 82.8% - Nurse led streaming of walk ins/self referrals An in depth, daily, action driven Emergency Access Performance Review - AAU nurse controller telephone triage of GP referrals Watford A&E attendances for the month of October year on year have meeting, held by the Trust, has led to a decrease in ED attributable - STARRing increased slightly by 2.5% Oct 2016 were 7949, compared to Oct 2017 8145, breaches for both admitted and non admitted patients. - GP streaming in ED however total year on year is marginal difference. (2016 - 70,117 2017- ED streaming for assessment where capacity allows it. 70,433) Implementation of revised internal standard for treatment time (from ARP reported to be going well handover times have improved - Oct - YTD activity analysis reveals only 20% of attendances were streamed to ACU maximum of 2 hours to 1 hour). 70% within 30 mins. or ESAU: 7216 The key intervention to improve streaming is the protection of ambulatory and assessment areas from surge / escalation. Over Christmas performance has fallen considerably; attendances Performance has been affected by protracted periods of escalation into Expansion of CDU (the capital works) will deliver an additional 10 spaces were high around 387 per day on average with a higher level of acuity. some surge areas during October 2017 and patients have been bedded in Implementation of the Ambulance Response Programme (ARP) October This has continued despite DTOC levels being at their lowest since May assessment areas resulting in all patients being seen in ED. This can be 18th 2017. evidenced by a reduced number of patients seen in ambulatory care. RTT Percentage of A&E patients seen in ambulatory care WHHT is actively outsourcing to independent providers such as Spire and October 2016 - 14% (1086) BMI to manage referral backlogs on key pressure areas such as ENT, RTT October 2017 - 12% (994) Trauma and Orthopaedics and Ophthalmology. A revised trajectory is For October 2017, WHHT's performance was slightly below the being agreed with NHSI as the Trust no longer expect to achieve national average of 89.1%. The Trust is continuing with outsourcing to RTT compliance this year. independent providers where patients are accepting the transfer for RTT performance across HVCCG continues to be marginally below the target Other Priority actions to deliver compliant performance in 2017/18 their appointments to reduce the current backlogs, with 1,346 patients of 92%, with achievement in October of 89.1%. Year to date performance, for include: treated elsewhere to date. This initiative is limited by patient choice, the financial year, is currently at 90.4%. • Continued focus on reduction of backlog through outsourcing and with only around half of patients who are offered an alternative provision of in house waiting list initiatives. provider taking the option; and also there are issues around the level The Trust has continued ventilation and site issues affecting capacity, with a • Urgent upgrade of theatre ventilation systems – now completed. of complexity that the other providers can pick up. Any further vanguard theatre in place at St Albans. The biggest pressures are in • Approval of theatre business case. limitations in capacity will pose a risk to achieving the standard. This ophthalmology, ENT and T&O, with increasing pressures in pain • Increase in-house capacity with appointment of new consultants in could also be further impacted by any unanticipated demand beyond management. The Trust continues to outsource although ENT capacity at dermatology, rheumatology, and neurology. current growth expectations. outsourced providers has decreased. • Pathway redesign to reduce variation and standardise. Other risks to progress will potentially result from further issues with infrastructure including delays to repairs and maintenance. The number of long waits (40+ weeks) dropped from 64 in September to 46 Following the direction from NHSE to postpone non-urgent procedures in in October. There were 70 on the day cancellations in October, up from 55 in January 2018 due to winter pressures, the Trust position against this target Diagnostics September. is expected to worsen further, particularly from M10. The Trust has made good progress and is nearly compliant in November, and expects to be compliant in December. Diagnostics Diagnostics Trust performance around 6-week diagnostic waits has worsened, after a The Trust has a trajectory to be compliant with 6-week waits by December. long period of compliance. This is due solely to the Trust picking up Action taken to achieve this includes additional lists and re-arranging job additional cardiology activity as a result of the Concordia decommissioning. plans. In particular demand for stress echos has exceeded capacity.

- Page 5 - DToC standards

20 21 22 23 24 25 26 27 28 29 30 31 IAF Indicator Trend Ref. Target 10-Aug 17-Aug 24-Aug 31-Aug 07-Sep 14-Sep 21-Sep 28-Sep 05-Oct 12-Oct 19-Oct 26-Oct

- No. of Delayed Transfers of Care 25 44 67 62 53 63 59 62 69 68 69 56 65

- Delayed Transfer of Care Performance (%) 3.5% 6.3% 9.5% 8.8% 7.5% 9.0% 8.4% 8.8% 9.8% 9.7% 9.8% 8.0% 9.2%

- Delayed Transfer of Care Trajectory (%) - 4.2% 3.9% 3.6% 3.5% 3.5% 3.5% 3.5% 3.5% 3.5% 3.5% 3.5% 3.5%

West Hertfordshire Hospitals NHS Trust Hertfordshire Community NHS Trust IAF Indicator Target Ref. 05-Oct 12-Oct 19-Oct 26-Oct Trend 05-Oct 12-Oct 19-Oct 26-Oct Trend

- No. of Delayed Transfers of Care - AS01R 45 39 32 41 23 30 24 24

- Delayed Transfer of Care Performance (%) 3.5% AS05R 7.7% 6.7% 5.5% 7.0% 19.7% 25.6% 20.5% 20.5%

- Delayed Transfer of Care Trajectory (%) - AS06R 3.5% 3.5% 3.5% 3.5% 3.5% 3.5% 3.5% 3.5%

Key Issues Mitigating actions Progress DToC performance continues to be challenging within Herts Valleys SRT maintaining proactive daily audits of both DToC and with overall system performance remaining above the target of 3.5% stranded patients to identify issues and remove avoidable Ongoing escalation to system partners via the in October. causes of delay. A&E Delivery Board continues, with significant resource directed to generating additional WHHT DToC performance throughout October averaged 6.7%; HCT Implementation of the winter plan actions, discussed at A+E capacity and improving discharge processes. performance for the same period also remained high, averaging Local Delivery Board which include: 21.5% Currently the DTOC position has met and •Immediate investment in additional social care assessment exceeded the 3.5% target - at 2%. System-wide, the biggest pressure on health attributable DToC was capacity – substantive recruitment complete This has been due to the improved patient flow the long wait in the community bed base for IMC and rehab •A thrice weekly check on all system delayed transfers to through capacity gained in application of winter resources. This peaked at 11 patients in October ensure appropriate escalation monies applied through bed and package •Additional ‘step-down’ capacity now in place to help CHC purchases. For Social Care attributable DToC, this was packages of care or 85% target placements, where October saw an average of 34 people delayed per Actions to be undertaken by October: day. •New D2A model agreed with HCC to provide additional resources •Additional short term bed capacity purchased - further capacity being explored.

- Page 6 - Cancer Access standards 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 IAF Indicator Ref. Target Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 YTD Sparkline

CA01 All Cancers - two week wait 93% 90.5% 91.5% 91.6% 94.5% 94.6% 94.7% 97.1% 94.8% 92.5% 96.4% 94.9% 94.8% 95.3% 95.2% 96.0% 95.1%

Two week wait for breast symptoms CA02 93% 76.0% 91.1% 88.0% 90.4% 91.5% 90.3% 90.0% 89.3% 87.7% 94.6% 91.4% 89.6% 97.6% 96.1% 96.3% 93.1% (where cancer not initially suspected) Percentage of patients receiving first definitive treatment within 31 CA03 96% 95.7% 96.2% 93.6% 98.1% 97.3% 93.3% 94.2% 99.2% 96.6% 98.0% 96.5% 96.3% 97.9% 94.5% 98.2% 96.9% days of a cancer diagnosis.

CA04 31 Day standard for subsequent cancer treatments -surgery 94% 100.0% 100.0% 95.7% 96.2% 97.0% 94.6% 100.0% 90.9% 96.6% 96.8% 94.6% 95.8% 100.0% 92.6% 97.1% 96.2%

31 Day standard for subsequent cancer treatments - CA05 98% 98.8% 96.7% 96.3% 97.6% 94.7% 95.3% 98.7% 99.0% 94.4% 100.0% 97.1% 99.0% 99.0% 98.8% 99.3% 98.4% anti cancer drug regimens

CA06 31 Day standard for subsequent cancer treatments - radiotherapy 94% 92.4% 90.1% 97.7% 92.3% 98.5% 92.8% 93.9% 94.3% 92.4% 92.1% 86.5% 89.8% 96.3% 90.9% 94.8% 91.8%

CA07 All cancer 62 day urgent referral to first treatment wait (Actual)* 85% 80.5% 85.8% 82.1% 87.9% 92.4% 74.3% 85.9% 87.0% 85.4% 91.6% 83.3% 81.5% 82.3% 75.5% 79.3% 83.0%

62 day wait for first treatment following referral from an NHS cancer CA09 90% 100.0% 96.4% 85.7% 100.0% 76.2% 95.7% 100.0% 94.9% 100.0% 100.0% 100.0% 94.4% 90.9% 86.7% 75.0% 94.0% screening service 62 day wait for first treatment for cancer following a consultant's CA10 - 75.0% 78.6% 80.0% 85.0% 76.2% 79.2% 88.9% 89.5% 95.8% 91.7% 81.8% 80.8% 88.5% 84.4% 80.8% 86.5% decision to upgrade the patients priority

West Hertfordshire Hospitals NHS Royal Free London NHS Foundation IAF East & North Hertfordshire NHS Trust Indicator Target Trust Trust Ref. Sep-17 Oct-17 YTD Trend Sep-17 Oct-17 YTD Trend Sep-17 Oct-17 YTD Trend

CA01 All Cancers - two week wait 93% CA01R 95.2% 96.4% 95.1% CA01U 95.8% 93.8% 93.5% CA01W 97.3% 97.1% 97.8% Two week wait for breast symptoms CA02 93% CA02R 97.6% 97.4% 92.9% CA02U 93.3% 95.8% 93.4% CA02W 91.3% 90.1% 93.0% (where cancer not initially suspected) Percentage of patients receiving first definitive treatment within 31 CA03 96% CA03R 96.5% 99.3% 98.6% CA03U 95.6% 99.2% 97.5% CA03W 93.9% 91.6% 91.3% days of a cancer diagnosis.

CA04 31 Day standard for subsequent cancer treatments -surgery 94% CA04R 100.0% 100.0% 99.1% CA04U 94.1% 97.8% 97.4% CA04W 92.1% 74.1% 85.0% 31 Day standard for subsequent cancer treatments - CA05 98% CA05R 100.0% 100.0% 100.0% CA05U 100.0% 100.0% 100.0% CA05W 95.5% 98.4% 95.9% anti cancer drug regimens

CA06 31 Day standard for subsequent cancer treatments - radiotherapy 94% CA06R CA06U 100.0% 100.0% 100.0% CA06W 88.5% 89.5% 89.2%

CA07 All cancer 62 day urgent referral to first treatment wait (Actual)* 85% CA07R 80.9% 86.2% 87.3% CA07U 81.5% 83.2% 81.8% CA07W 73.8% 76.8% 71.5% 62 day wait for first treatment following referral from an NHS cancer CA09 90% CA09R 86.4% 72.2% 91.1% CA09U 100.0% 86.4% 92.3% CA09W 65.3% screening service 62 day wait for first treatment for cancer following a consultant's CA10 - CA10R 86.2% 85.7% 88.9% CA10U 83.3% 87.5% 86.8% CA10W 66.7% 87.5% 69.2% decision to upgrade the patients priority CA01U * NHS Constitutional Standard

- Page 7 - Access Standards (Cancer) Narrative

Key issues Mitigating actions Progress In October, Herts Valleys CCG missed achievement on 2 out of WHHT missed the 2WW for breast at 92.9% in October but WHHT dipped slightly on their two week wait breast the 8 Cancer Waiting Times (CWT) targets. met all other targets. symptomatic, missing the target by 0.1% so will continue to work on actions in an agreed improvement plan. The missed targets were for the 62 day standards. The all WHHT: close monitoring of all patients on open pathways Cancer 62 day standard was not achieved with 79.3% against continues, including inter trust referrals. Mini RCA style Actions taken by ENHT to improve their 62-day performance a target of 85%. The 62 day standard from screening was also breach analysis is in place for all cancer pathway breaches. include additional MRI and CT capacity, restructure of not achieved, with 75% against a 90% target. These are signed off by the relevant clinical lead who is internal cancer tracking with micromanagement of each required to indicate whether there has been any clinical patient on the pathway, introduction of best practice PTL harm as a result of the delay incurred. If harm is identified, management, review of MDT efficiencies, and the Non-compliance for 62 day is due to ENHT (71.5%) and RFL this is taken through the SI process. appointment of an Interim Cancer Divisional Director and (81.8%)which has resulted in the Herts Valleys CCG level non- Interim Cancer Turnaround Manager. compliance of 79.3% for October. The CCG continues to work closely with Lead Commissioners to ensure ENHT and RFL recovery action plans are having the RFH are currently reporting their cancer recovery work to desired impact and achieving improved outcomes for Herts NHS Improvement on a weekly basis. One aim is to reduce Valleys patients. The cancer network is aware of the issues the backlog down to manageable levels by the end of and a recovery plans are in place for both E & NHT and October, which is currently ahead of trajectory. RFH are RFLHT. anticipating a return to compliance with the 62 day standard by the end of November. Work continues on the ENHT Recovery Plan. Whilst still not compliant, ENHT continues to show improvements in their all Cancer 62 day standard, achieving 76.8% for October ENHT aim to achieve compliance by January. A contract performance notice has been sent to E&NHT in December addressing the under performance by E&NHCCG (as the co- ordinating commissioner) which requires E&NHT to implement a remedial action plan. Two Week Wait Breast target has been achieved in October & the CCG has met the target for the third consecutive month and is now achieving target YTD.

- Page 8 - Patient Transport Narrative

Key issues Mitigating actions Progress HVCCG has set up an interim provision with a number of The EEAST contract has now been signed - 22nd December, Work has been ongoing to mobilise the recovery Providers to support patient transport for Outpatients and this will enable EEAST to proceed with the TUPE consultation arrangement whilst the details of the new service Trust discharges. and create permanent jobs for staff. specification and deliverable outcomes were being negotiated into the new contract. HVCCG is leading on these It has been difficult to fill the capacity gap when there have There will still be a transition period where more staff are negotiations in collaboration with the Consortia. (West Essex been shortfalls on the day from crew cancellations coupled recruited and EEAST can work towards a full complement. In has also formed part of these negotiations with a view to with the Trust making an increasing number of on the day the meantime during this mobilisation HVCCG will continue standardising their revised contract to reflect the terms and unplanned discharges. This has been met with requests for to support the capacity level with additional provision. This is conditions of the Consortia ) increased provision from existing Providers but due to short proving more essential over the winter period where the notice has not always been fulfilled. Trust is challenged to increase its discharges to enable a Some challenges faced by EEAST have been the transfer of more efficient patient flow impacting directly on A & E. staff - significant numbers have left. This has impacted on capacity and meant that the individual CCGs have needed to provide additional support through a number of other suppliers.

EEAST has also subcontracted out to UKSAS who have not proved reliable - crews have cancelled on the day and have also been selective about what journeys are covered, not adhering to the specification within the contract.

- Page 9 - Mental Health standards

17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 IAF Indicator Ref. Target Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Sparkline

MH01 IAPT Access Roll-out (Local Data) * 1.2% 1.3% 1.3% 1.4% 1.6% 1.0% 1.5% 1.5% 1.6% 0.7% 1.0% 1.3% 1.2%

MH02 IAPT Recovery rate (Local Data)** 50% 58.5% 53.6% 55.0% 52.4% 52.1% 59.2% 54.3% 55.0% 58.0% 52.4% 57.3% 51.4% 52.3% 54.7% 56.5%

The proportion of people that wait 6 weeks or less from referral to entering a MH03 course of IAPT treatment against the number of people who finish a course of 75% 89.8% 96.6% 97.2% 96.4% 97.3% 95.7% 97.4% 98.1% 97.7% 94.9% 96.1% 96.4% 94.5% 94.8% 95.1% treatment in the reporting period.

The proportion of people that wait 18 weeks or less from referral to entering a MH04 course of IAPT treatment against the number of people who finish a course of 95% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100% 100.0% 100.0% 100.0% 100.0% 100% 100% 100% 100% treatment in the reporting period.

MH05 Estimated diagnosis rate for people with dementia (65 years+) 66.7% 63.5% 64.5% 64.5% 64.5% 64.8% 64.8% 64.9% 66.1% 65.7% 65.7% 66.5% 66.8% 67.2% 67.6% 68.1%

Routine referrals to the Community Mental Health team meeting 28 - 98% 90.9% 92.7% 96.7% 87.3% 80.0% 66.5% 88.0% 96.2% 85.3% 85.6% 90.3% 91.3% 79.1% 63.9% 70.3% day wait

MH10 Early intervention Psychosis (2 week Referral To Treatment) 50% 63.2% 87.5% 57.1% 71.4% 100.0% 100.0% 75.0% 75.0% 75.0% 83.3% 72.7% 57.1% 86.7% 58.8% 50.0%

NB: IAPT figures for August are awaiting the AQN data before they can be calculated which has been delayed this month

- Page 10 - Key issues Mitigating actions Progress Dementia Dementia Dementia Following the commencement of the One Stop Pilot and 6 week Assessment waiting compliance is slightly under target Performance for the estimated diagnosis rate for people increase in Dementia Diagnostic appointments the Nurse at 87.87% October (65yrs+) was above the target of 66.7% with November diagnosis has ceased. Diagnostic appointments are delivering above target at 67 reflecting an achievement of 68.6%. The launch of the One Stop Pilot is due to commence on the appointments last week (target 42 offered per week). DNA Achievement of the target was two months in advance of the 15th January 2018 rate was very high (42%) this week due to weather conditions trajectory of 66.7% in September, achieving 66.8% in July. (heavy snow) and illness in the older population. Visits are underway to GP practices where the diagnosis rate Diagnostic appointment waiting times - Additional diagnostic is below 50% or the practice has a volume of possible appointments to enable transfer to new East One Stop undiagnosed patients. Information for GP's has gone out with pathway the news letters and tools have been uploaded to the Intranet Clinic diagnostic rates are overall stable at 75.48% for the last for detection, coding and support for Dementia Diagnosis in 6 week period. Primary Care. One Stop Pathway Pilot – Southwest plan is to commence triage process on 15 January and One Stop clinics to The Local Incentive Scheme for Dementia includes an commence on 5 March. education programme and support to GP's to maintain the SW quadrant have seen a slight dip in performance due to Dementia Diagnosis rates, first three education events have some staffing and data cleansing issues, but the trajectory is taken place. to achieve target by end of Quarter 3. The new one-stop model is also impacting on the 6 week target as the average Community Mental Health Referrals Community Mental Health Referrals wait for a diagnosis in the NW is now 8-9 weeks, mainly due to imaging waits; however this has meant that the majority of Referrals for Hertfordshire Partnership NHS Foundation Trust Reviewing current methods of collecting, and presenting, people are receiving a diagnosis within this time period as continues to be challenged in meeting the target of 98%. information captured on key areas of concern including the opposed to a previously longer wait and reflects an Performance for HVCCG stood at 70.28% for October and is review of methodology behind DNAs. This would mean the improvement in the overall quality of service. the second subsequent drop since steady back to back potential change to implementing a clock stop on the first Community Mental Health Referrals increases from the 85.3% achievement in April 2017. DNA which would lead to a reduction in breaches. SPA are now triaging within the 14 day target and there is ongoing work in community services to improve waits, Working with SPA to support the signposting to other services including consideration of IA focused workers within SW team to reduce pressures. and increased scrutiny of potential breaches across both Work with the SPA team to reduce the pass on rates of some clinical and operational leads to accelerate decision making on clinical assessors that appear to be outliers and could be actions to address. There is also ongoing work with SPA team passing on inappropriate referrals to reduce the pass on % of individual clinical assessors. Implement additional resources within the SW team to focus Discussions commenced with commissioners on how on assessments and increase scrutiny of potential breaches to repeated DNA’s are monitored and recorded, including the accelerate the decision making process on actions to address. quality of primary care referrals because of the impact this is The SW team to focus on assessments and increase scrutiny of having on the capacity of the community teams to manage potential breaches to accelerate the decision making process existing caseloads and inbound referrals. At the end Q1 and in on actions to address. Work is underway with a number of GP response to continuing capacity focus on working with SPA to practices to ensure that referrals are going to the most support signposting to other services. This has had some appropriate services. impact but is difficult to sustain with high demand. HPFT continue to submit weekly performance reports to Commissioners and monthly meetings held to focus on the SPA recovery action plan.

- Page 11 - 111 Standards

17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

Indicator Target Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Sparkline

111 Total Number of Calls Offered to 111 call centre - 25,283 24,392 28,337 27,346 35,019 32,306 27,608 32,943 31,525 36,771 33,372 28,714 24,584 24,906 26,794

111 Percentage of Abandoned Calls after 30 seconds 5% 0.6% 1.5% 1.7% 2.4% 3.4% 2.0% 2.5% 1.4% 3.7% 2.7% 3.8% 3.6% 1.3% 2.1% 1.8%

111 Average Time to Answer Call (Seconds) 60 New Metric Not Previously Reported 49 24 29 32

111 Total Number of Calls Answered 22,058 21,114 24,648 23,780 30,086 28,368 24,223 25,664 29,713 28,270 26,349 25,723 22,814 24,046 26,012

111 Calls Answered Not Needing 111 1,916 2,024 2,138 1,808 2,079 2,068 1,806 1,945 1,852 1,540 1,556 563 499 338 328

111 Percentage of Calls Triaged 89% 87% 88% 88% 88% 89% 88% 88% 87% 88% 87% 92% 95% 95% 96%

111 Percentage of Ambulance Dispatches 10% 7.5% 8.6% 8.2% 8.7% 8.0% 8.0% 8.0% 7.0% 7.0% 7.3% 7.3% 7.7% 8.0% 8.9% 8.3%

111 Percentage Advised to Attend A&E 6% 6% 7% 6% 6% 6% 6% 5% 5% 6% 6% 3% 4% 4% 7%

Percentage Advised to Make an Urgent GP Appointment in Practice 111 17% 17% 17% 18% 18% 20% 19% 19% 18% 18% 16% 18% 19% 18% 19% Hours

111 Percentage Booked in to GP Out of Hours Service 41% 40% 40% 40% 41% 41% 38% 38% 43% 38% 36% 38% 36% 34% 34%

111 Percentage Not Recommended to Attend Another Service 9% 9% 9% 10% 9% 9% 9% Change in the Reporting of the Metric - Historical Data Not Available

111 Percentage of Calls Closed as Self Care 4% 4% 4% 4%

- Page 12 - 111 Narrative

Key issues Mitigating actions Progress

111 111 111

For the month of October, the total amount of hours lost due to The attendance concerns for staff have been raised at Director Level Ongoing work on addressing the revalidation not being 100% of the sickness was higher than anticipated, which had an impact on and are a high priority area for HUC. Attendance meetings are being ED dispositions. Training requirements have been identified via performance, such as the clinical advisor call backs. carried out and there is an implementation of a new attendance auditing process and cases that are highlighted by the reporting management processes in November. team. The average wait for a call back from a Clinical Advisor for the month The backing data has now been finalised and the CCG should be of October has risen slightly compared to previous months. Recruitment has been ongoing and we have a number of new starters receiving data soon, which will support the performance figures and on the rota and back to back training courses. The rotas for future enable validation. months are almost full, which allows possible movement of experienced senior Clinical Advisors to work outside of pathways within the CAS. There will be an increase in call volumes during the Christmas and New Year period. There are plans for additional call volumes and the resources to manage these volumes. On prime dates over the winter period HUC Average Time to Answer Call (Seconds) has increased from 24 to 29 will increase staffing by up to 10% based on last year’s actual call second, however, still within the 60 second target. An increase in call volumes. Call volumes are monitored on a daily basis and changes to volumes together with the ongoing recruitment and new starters the rotas implemented to reflect the call patterns. have increased the average wait time.

The Percentage of Ambulance Dispatches of 8.9% for the month of October is below the 10% target. However, this is the highest it has been during the course of the year. Early indication of November activity shows this has reduced to 8.2%.

- Page 13 - OOH Standards

17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

Indicator Target Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Sparkline

OOH Total Number of Cases (Out of Hours Calls) - 10,318 9,756 11,376 10,993 14,572 13,360 10,526 11,036 12,781 11,106 9,871 10,055 9,336 9,613 10,061

OOH Percentage of Cases Resolved Through Advice Only 38.0% 36.0% 37.0% 39.0% 42.0% 43.0% 39.0% 40.0% 38.0% 38.0% 37.6% 38.3% 35.0% 35.0% 35.0%

OOH Percentage of Cases Advised to Come to Centre 47.0% 50.0% 49.0% 46.0% 43.0% 41.0% 45.0% 45.0% 48.0% 49.0% 48.4% 48.0% 48.0% 50.6% 49.0%

OOH Percentage of Cases Booked as Home Visits 12% 11% 12% 11% 11% 13% 13% 11% 11% 12% 11% 12% 14% 12% 13%

Percentage of Cases Where No Advice Given (Patients either refuse OOH 3% 3% 3% 3% 4% 3% 3% 3% 4% 1% 3% 2% 3% 2% 2% appointment or did not attend)

OOH Urgent Home Visits Undertaken Within 2 Hours 95% 86.9% 93.9% 87.9% 89.4% 82.7% 84.4% 90.7% 93.4% 87.4% 88.2% 81.7% 77.9% 77.6% 82.1% 87.7%

OOH Routine Home Visits Undertaken Within 6 Hours 95% 83.2% 90.8% 88.8% 88.3% 84.4% 79.0% 88.2% 89.9% 87.2% 89.7% 86.1% 84.2% 83.2% 84.0% 87.8%

OOH Urgent Consultations Undertaken Within 2 Hours (Base F2F) 95% 92.8% 90.4% 86.7% 91.6% 89.0% 91.2% 92.1% 93.0% 88.6% 87.8% 86.6% 83.1% 82.2% 91.5% 85.0%

OOH Routine Consultations Undertaken Within 6 Hours (Base F2F) 95% 98.3% 99.2% 98.3% 98.7% 91.8% 97.4% 95.6% 97.2% 97.0% 98.3% 97.9% 96.2% 95.9% 96.0% 94.1%

- Page 14 - OOH Narrative

Key issues Mitigating actions Progress

OOH OOH OOH

Total Number of Cases (Out of Hours Calls) – the number of calls has UCP recruitment is being undertaken to improve resource levels. It is 5 new GPs have been inducted in October, the rota fill for October picked up for the second consecutive month. anticipated that this should have a positive impact on being able to remains at 88%, the same as September. There will be an increased keep cars out on the road and not have GP’s return to base to see rota from the 1st October, to help with the winter pressures. This will Performance for Home Visits within 2 and 6 hours respectively patients. We have been informed that 2 UCPs started in November. be an additional 75 hours per week. remains below the target of 95%, however there seems to be an improvement. Urgent Home Visits within 2 hours achieved 82.1% Stricter processes to be put into place for cancelled shifts in that at The Service Delivery Team and Clinical Resources are continuing to whilst Routine Home Visits within 6 hours performed at 84%. least 3 weeks’ notice must be given and an alternative shift must be tweak and ensure improvement in rota fill on a daily basis. Time slots Urgent Base consultations was 91.5%, which is the first time in the booked. have been shortened to encourage more utilisation. The Service last 6 months where the performance has increased month on delivery manager will be looking at breach times for visits from month. (N.B Advance November data shows the numbers dipping In line with 111, current reporting is to be reviewed to identify 2/3/4/5/6 hours to gain further oversight to when and how many slightly, this will be discussed with this improvement being possible options to alter the current template received and improve breaches occur and at what point in the process this happens. maintained on these figures) accuracy of the reported numbers.

Rota fill for late weekend visiting shifts was low in September similar to the month of August, which has had some impact on the performance for home visits. October rota fill has greatly improved across the month and along with the breach investigations there is an expectation on an improvement on performance going forward.

The number of cancelled shifts had decreased in September. However, in October the data shows the number of cancelled shifts has increased to 275 hours. The provider has put in a stricter process to combat this issue.

As with the 111 service, there are ongoing discussions around reporting and data quality. As the OOH reporting forms part of the same template the same issues are present including the lack of supporting data to enable validation of performance.

- Page 15 - Community standards

17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 IAF Indicator Ref. Target Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Sparkline

- Average Length of Stay in HCT Community Hospital - Stroke <42 35.1 37.7 28.9 49.8 30.0 45.3 52.5 49.1 43.1 37.5 39.7 30.3 38.1 37.2 37.5

Average Length of Stay in HCT Community Hospital - Stroke (Rehab - <35 31.8 34.0 28.3 37.8 28.7 34.0 40.8 34.3 30.0 34.3 35.9 25.4 37.0 34.2 35.4 Pathway Only)

- Average Length of Stay in HCT Community Hospital - Non Stroke <21 31.2 33.0 30.3 37.7 25.9 31.4 27.2 34.8 40.6 28.5 34.4 35.6 25.4 28.0 29.5

Average Length of Stay in HCT Community Hospital - Non Stroke - <19 22.1 20.5 19.0 22.4 19.0 22.2 19.5 24.8 27.2 21.1 23.1 24.6 20.0 20.5 21.8 (Rehab Pathway Only)

Percentage of patients admitted to a bed based unit that have an - 95% 99.0% 99.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 99.0% 99.0% 100.0% 100.0% 100.0% 100.0% 100.0% estimated discharge date set within 3 days of admission

Percentage of patients discharged on, or before, the estimated - 90% 55.0% 57.0% 57.0% 48.0% 65.0% 58.0% 63.0% 38.0% 40.0% 56.0% 44.0% 50.0% 47.0% 55.0% 49.0% discharge date set upon admission

Key Issues Mitigating Actions Progress

Performance against the average length of stay targets continues to The Trust is undertaking a red to green review to look into The agreed review is due to be delivered at the end be a challenge for non-stroke activity and patients being discharged the causes behind poor performance in these areas. of October. In the after their estimated discharge date. A mini audit on IMC patient stays has been carried out to interim a workshop has been arranged with all Delayed transfers of care are impacting on the ability to discharge support forthcoming workshop. stakeholder groups on 27th Oct to closely review patients on or before their estimated dates. In September, the pathways and agree on immediate 'must dos' to percentage of patients discharged within their estimated date was improve patient flow. 47%. HCT maintain that this is linked to the DToC issues, however, even after excluding these patients from the actual figures, performance in this area would still only have reached 72% achievement for September. DToCs are impacting on the average length of stay but is unlikely to be the only reason attributable.

- Page 16 - Additional Community Narrative

Key issues Mitigating actions Progress

Musculoskeletal Musculoskeletal Musculoskeletal The service at Hertfordshire Community Trust has a number To mitigate staff shortages, overtime is being offered to staff Initial appointments continue to be prioritised to further of vacant posts along with staff members on maternity leave with the additional action of utilising agency resources to reduce waiting times within the service. and long term sickness. This is staff shortage has reduced the backfill the vacant posts. Ongoing monitoring is being The new model of delivery is now embedded within the level of activity that can be undertaken and impacted on implemented to determine the full impact. A new model of teams at HCT. waiting times. delivery has also been designed to be implemented within Waiting times are improving with the average wait the service teams. reducing from 6.3 weeks to 5 weeks over the last two Diabetes months. This has also reduced the total numbers on the There are ongoing issues with waiting times within the service Diabetes waiting list by 300 over the same period. and continuing decreases in follow up activity relating mainly Enacting ongoing monitoring for activity relating to Diabetic to Diabetic Specialist Nursing. Specialist Nursing to look at the impact of nurses reviewing Diabetes caseloads. Undertaking a deep dive to further understand Monitoring is being undertaken and will support the reasons behind the decreases in activity for Diabetic preparation for implementation of the new integrated Specialist Nursing. model of care. Implementation of a new integrated care model which should lead to an increase in activity.

- Page 17 - NHS Herts Valleys Clinical Commissioning Group Board Meeting Date of Meeting: 18 January 2018

Title Finance Report – month 8 Agenda item 10b Purpose* (tick) Decision ☐ Approval ☐ Discussion ☒ Assurance ☐ Information only ☐

Author and job title Responsible director and job title Director signature Elke Taylor, Deputy CFO Caroline Hall Julie Dean, Head of Financial Planning & Chief Finance Officer Reporting

Short summary of paper At the end of November (month 8) the CCG is reporting a year to date deficit of £1.9m (£1.8m at month 7). The deficit is due to continuing healthcare activity running at higher levels than plan. This is offset by an improvement in the year to date acute activity, which is reporting expenditure better than plan. The CCG is currently forecasting breakeven for the year, with financial risk offset by mitigations. Recommendation(s) The Board is being asked to: Note financial performance for month 8 of 2017/18

Engagement with Engagement has taken place with provider organisations stakeholders/patient/public Links to Strategic Objectives (tick all that apply) Objective 1: Effective Engagement. We will continually improve engagements with member practices, ☐ patients, the public, carers and our staff to contribute to and influence the work of Herts Valleys CCG. Objective 2: High Quality. We will commission safe, high quality services that meet the needs of the ☐ population, reducing health inequalities and supporting local people to avoid ill health and stay well. Objective 3: Transforming Delivery. We will work with health and social care partners to transform the ☐ delivery of care through the implementation of “Your Care, Your Future”, the strategic review in west Hertfordshire. Objective 4: Affordable & Sustainable Care. We will ensure that there is a financially sustainable and ☒ affordable healthcare system in west Hertfordshire. Board Assurance Framework Refer to assurance levels table below and latest BAF report here: N:\Nursing & Quality\8 Risk Management System\2. Board Assurance Framework\BAF 201718\BAF Current version for front sheet reference N.B. The executive summary for this paper explicitly points to the evidence to support the assurance level indicated above. For example: Very high – what is the evidence to support the current strong position & how will it be sustained? High – what is being done to strengthen controls and mitigate the likelihood of this risk materialising? Medium - what is being done to address gaps in assurance and how successful is this action proving? Low - what are the urgent actions planned to address the lack of assurance? Ref. Risk Risk description Current risk Target risk Assurance Owner score and score Level movement since last month 4.1 CH Risk that we do not deliver a financially sustainable 20→ 10 Medium health and social care system. 4.2a DE / Risk that we do not identify the right QIPP schemes 12↑ 8 Medium DC or decisions to commission /recommission (improving) /decommission, of sufficient value. 4.2b DE / Risk that we do not make sufficient progress on the 16↑ 8 Medium DC QIPP schemes identified. (improving) 4.3 CH Risk that we do not achieve financial balance in 20→ 10 Medium 2017/18 New risks identified by this report

Other significant risks related to this report

Resource Not applicable. This report provides a general update on key CFO Signature implications financial issues and performance.

Potential conflicts No, this report is for information and discussion. of interest Equality and There are no implications quality impact analysis (indicate the key points the analysis has identified relevant to decision required) Equality delivery Better Health Outcomes ☐ system (identify Improved Patient Access and Experience ☐ which goal your A Representative and Supported Workforce ☐ proposal / paper supports) Inclusive Leadership ☐ Report history The report was presented to the Finance & Performance Committee on 11 January 2018. Which Groups or Committees have seen this report and when? Appendices

Item 10b

Finance Report Month 8 – November 2017

Caroline Hall – Chief Finance Officer

Produced by: Elke Taylor – Deputy CFO Julie Dean – Head of Financial Planning & Reporting

1 Contents Slide ref Executive Summary 3 Finance Report: Acute Commissioning 5 Non-Acute Commissioning 7 Primary Care Commissioning 8 Other Programme Costs 9 Running Costs 10 Financial Position: Risks & Mitigations 12 Underlying Position 13 Use of Reserves 14 Resource Allocation & Budget Adjustments 15 QIPP 16 Cash & Balance Sheet: Statement of Financial Position 18 Cash Drawdown 19 Better Payment Practice Policy 20

2 Executive Summary (1)

Healthcare Programme Costs Report for eight months to 30 November 2017 At month 8 the CCG is reporting a year to date deficit of £1.9m, compared to £1.8m YTD Deficit £1.9m Worse than plan at month 7. Full Year forecast Surplus £0.1m in year In line with plan There has been a further improvement in the acute position this month, which is Cumulative forecast £0.34m surplus In line with plan now £1.3m underspent compared to £0.6m at month 7. Continuing Health Care (CHC) however is £4.5m worse than plan, compared to £3.3m at month 7. CHC continues to be closely monitored to assess the impact of any further emerging Running Costs pressures. YTD Spend £8.6m In line with plan Running costs are showing a small underspend of £22k year to date compared to Full Year Forecast Spend £12.8m In line with plan £46k underspend at month 7. Costs are expected to be in line with plan for the year.

The CCG’s net risk remains zero, the same as month 7. The likely risks to the financial Risks & Mitigations position identified to date are still expected to be offset by mitigations of the same value. The CCG continues to review its risks and any opportunities to mitigate these. Net risk nil Risk adjusted position £0.1m surplus The CCG’s underlying position is a recurrent surplus of £5.3m. This is a deterioration from month 7 due to the increasing spend in continuing care and the non-recurrent nature of mitigations. Underlying Position QIPP schemes to the full value of the £38m target have been identified however after Closing 2016/17 underlying position £8.8m deficit a detailed review this month the forecast outturn has been revised down to £33.8m to take account of slippage on various schemes. 2017/18 underlying position £5.3m surplus The CCG continues to forecast breakeven overall. The pressures of higher than planned activity in acute, and additional CHC placements, are being offset by QIPP mitigations in year. These are a combination of non-recurrent benefits from prior YTD Plan £21.5m year accruals no longer being required, and budgetary underspends in other programme areas. YTD Actual £22.3m Full Year Plan £38m Forecast Outturn £33.8m

3 Executive Summary (2)

YTD MONTH 8 ANNUAL FORECAST Commentary: VARIANCE VARIANCE Acute is reporting an underspend of £1.3m year to 2017/18 Budgets - Source & BUDGET ACTUAL favourable / BUDGET FORECAST favourable / date compared to £0.6m underspend at month 7. Application of Funds (adverse) (adverse) The underspend is due to lower levels of activity. £000 £000 £000 £000 £000 £000 Lower elective activity due to temporary theatre closures at West Hertfordshire Hospitals (WHHT) Revenue Resource Limit * 560,813 560,813 0 848,796 848,796 0 during the year have impacted on the year to date position. Activity at Spire and BMI has reduced from previous months. Acute expenditure at both WHHT APPLICATION OF FUNDS - and Luton & Dunstable continues to be worse than Programme plan with over-spends of £1.7m and £2.2m Acute Commissioning 297,801 296,481 1,320 442,741 442,741 0 respectively. The annual forecast is expected to be Non acute Commissioning 119,118 124,420 (5,302) 178,271 186,388 (8,117) breakeven and continues to be closely monitored. Primary care Commissioning 110,803 110,427 376 168,845 168,248 597 Other Programme Costs 20,209 18,546 1,663 28,116 26,494 1,622 The non-acute over-spend of £5.3m largely relates to Total Commissioned Services 547,931 549,874 (1,943) 817,973 823,871 (5,898) continuing care, which has further deteriorated this month with an over-spend of £7.3m now being forecast. There is also a £0.6m overspend at HCT, Running Costs 8,585 8,563 22 12,797 12,797 0 which relates to bed costs in quarter 1. These overspends have been offset by use of non-recurrent Reserves, Contingency & Provisions: measures such as prior year benefits and budgetary Non Recurrent Fund (0.5%) 0 0 0 3,768 3,768 0 underspends in other programme costs. Contingency (0.5%) 0 0 0 3,838 3,838 0 Other Reserves & Provisions 4,229 4,229 0 10,319 4,422 5,898 Primary Care is now showing a small underspend with Total Reserves 4,229 4,229 0 17,925 12,028 5,898 an overspend in prescribing being offset by an underspend in local enhanced services Total Applications 560,746 562,667 (1,921) 848,696 848,696 0 In-year Surplus / (deficit) 67 (1,854) (1,921) 100 100 0 Running costs continue to report in line with plan, albeit with some small offsetting variances. * Excludes brought forward surplus of £244k

4 Acute Commissioning (1)

YTD MONTH 8 ANNUAL FORECAST VARIANCE VARIANCE 2017/18 Acute Commissioning Budgets BUDGET ACTUAL favourable / BUDGET FORECAST favourable / Application of Funds (adverse) (adverse) £000 £000 £000 £000 £000 £000 MAIN TRUSTS West Hertfordshire Hospitals 164,968 166,687 (1,719) 245,661 248,057 (2,396) Royal Free London 33,028 33,372 (344) 49,231 49,758 (527) Luton & Dunstable 13,453 15,650 (2,197) 20,051 23,327 (3,276) East & North Hertfordshire 10,603 10,198 405 15,837 15,531 306 Buckinghamshire Healthcare 9,776 9,768 8 14,540 14,528 12 University College London 7,432 6,542 890 11,034 9,613 1,421 Royal National Orthopaedic Hospital 4,686 4,175 511 6,809 6,070 739 East of England Ambulance 11,804 11,747 57 17,680 17,594 86 Other Contracts 30,582 30,884 (302) 45,701 46,123 (422) TOTAL ACUTE CONTRACTS 286,332 289,023 (2,691) 426,544 430,602 (4,058) 0 OTHER ACUTE 11,469 7,458 4,011 16,197 12,139 4,058 0 TOTAL ACUTE COMMISSIONING 297,801 296,481 1,320 442,741 442,741 0

The latest available data (month 7 flex) shows a further improvement in the year to date position (£0.6m at month 7), including a small improvement at WHHT despite the re-opening of theatres. The forecast overspend at WHHT and Luton & Dunstable is expected to be managed through delivery of QIPP savings.

5 Acute Commissioning (2)

There is a recognised time lag in receiving acute data therefore the reported position for acute contracts is based on month 7 trust reports. From these, the majority of acute contracts are judged to be performing roughly in line with or better than plan. The most notable exceptions are WHHT, Luton and Dunstable University Hospital NHS Foundation Trust, Imperial College Healthcare NHS Trust and Spire, where expenditure is higher than plan. As in previous months, a CQUIN accrual has been included, which relates to trusts (including WHHT) who did not meet their control total in 2016/17 and therefore are not currently entitled to 0.5% of the CQUIN payment. The contract values (and therefore budget) for these trusts include this sum but the year to date and forecast outturn does not. NHSE require this 0.5% of CQUIN to be set aside as a local system risk reserve, which is therefore shown on a separate line in the report.

WHHT is reporting year to date overspend of £1.7m against plan (£1.8m overspend at month 7). The main variances relate to emergency admitted care (£2.6m), maternity (0.8m) and outpatients, A&E and drugs (£0.8m in total) offset by £1.6m elective admitted care, £0.8m CQUIN and £0.1m ‘other’. The position continues to be affected by temporary theatre closures, resulting in lower elective activity at the trust this year. The position includes provider accruals of £1m (i.e. estimated value of un-coded activity). These remain under detailed review and challenge with the Trust.

Luton & Dunstable University Hospital NHS Foundation Trust (L&D) is reporting performance £2.2m worse than year to date plan. Of this £0.8m relates to QIPP that was included in the contract but not yet achieved. The balance relates to over-performance across both elective and non-elective points of delivery. The final outturn for L&D for 16/17 was around £0.6m higher than the estimated outturn value which was used to set the contract value for 17/18. Some of the 17/18 overspend is therefore a carry over from 16/17.

East & North Herts under performance continues (£0.4m at month 8). The forecast underspend of £0.3m at year end assumes some increase in activity over the remaining months.

6 Non - Acute Commissioning

YTD MONTH 8 ANNUAL FORECAST VARIANCE VARIANCE BUDGET ACTUAL favourable / BUDGET FORECAST favourable / NON ACUTE COMMISSIONING (adverse) (adverse) £000 £000 £000 £000 £000 £000 Mental Health 55,089 55,063 26 82,695 82,695 (0) Community 43,364 44,143 (779) 64,800 65,577 (777) Continuing Care 20,665 25,214 (4,549) 30,775 38,115 (7,340) TOTAL NON ACUTE CONTRACTS 119,118 124,420 (5,302) 178,271 186,388 (8,117)

The Community commissioning over-spend largely relates to unplanned non-recurrent expenditure on HCT beds in quarter 1.

The Continuing Care over-spend relates to adult fully funded care packages and is due to greater volumes of packages than anticipated in the plan. The year to date position also includes a £0.5m provision for a prior year retrospective claim.

7 Primary Care Commissioning

YTD MONTH 8 ANNUAL FORECAST VARIANCE VARIANCE BUDGET ACTUAL favourable / BUDGET FORECAST favourable / PRIMARY CARE COMMISSIONING (adverse) (adverse) £000 £000 £000 £000 £000 £000 Prescribing 51,092 51,044 48 76,347 76,425 (78) Delegated Primary Care 46,760 46,761 (1) 73,079 73,079 (0) Enhanced Services 4,754 4,443 311 7,132 6,667 465 Other Primary Care 8,197 8,179 18 12,287 12,077 210 TOTAL PRIMARY CARE 110,803 110,427 376 168,845 168,248 597

GP prescribing is over-spend by £74k year to date, based on actual expenditure to September 2017 (the latest available) projected forward using the national expenditure profile. This is more than offset by savings from central drugs and vacancies within the Medicine’s Management Team. GP prescribing is forecasting a £200k overspend, due to cost pressures in Category M and NCSO (No Cheaper Stock Obtainable), and anticipated to increase to £0.7m in month 9 following further review of the cost pressures arising from Cat M and NCSO. The delegated Primary Care budget will continue to be reviewed and amended as better, more reliable expenditure and forecast information becomes available. Budget has been set aside for primary care capacity pressures, practice resilience, and a contingency reserve. Month 8 year to date and forecast outturn are reported in line with plan. Enhanced Services are underspending in the local treatment room service, which is reporting lower than expected activity.

8 Other Programme Costs

YTD MONTH 8 ANNUAL FORECAST VARIANCE VARIANCE BUDGET ACTUAL favourable / BUDGET FORECAST favourable / OTHER PROGRAMME COSTS (adverse) (adverse) £000 £000 £000 £000 £000 £000 Better Care Fund 8,937 8,937 0 13,405 13,405 0 Patient Transport 1,265 1,383 (118) 1,898 2,119 (221) NHS 111 1,129 1,129 0 1,693 1,693 0 Non Recurrent Programme 6,850 6,769 81 8,077 8,050 27 Other 2,028 328 1,700 3,043 1,227 1,816 TOTAL OTHER PROGRAMME 20,209 18,546 1,663 28,116 26,494 1,622

The Better Care Fund relates to the agreed budget for Hertfordshire County Council to support social care . The budget is not expected to under or over-spend in-year.

Non emergency patient transport is over-spending as the provider has ceased trading and alternative services have had to be put in place at short notice.

‘Other’ includes benefits arising this year from prior year accruals no longer required.

9 Running Costs

YTD MONTH 8 ANNUAL FORECAST Commentary: VARIANCE VARIANCE BUDGET ACTUAL favourable / BUDGET FORECAST favourable / Running cost expenditure is £22k RUNNING COSTS (adverse) (adverse) better than plan compared to £000 £000 £000 £000 £000 £000 £46k better than plan in month 7 Administration & Business Support 127 128 (1) 190 193 (3) YTD. Over the course of the year Assurance 202 122 80 323 204 119 Business Development 527 532 (5) 791 801 (10) expenditure is expected to Ceo/ Board Office 376 435 (59) 564 660 (96) remain within the running cost Chair And Non Execs 551 502 49 827 737 90 allocation. Clinical Support 27 27 0 40 40 0 Commissioning 530 487 43 847 755 92 Communications & Pr 236 220 16 356 333 24 Recruitment for vacant posts is Contract Management 537 561 (24) 794 861 (67) well progressed however Corporate Costs & Services 1,193 1,196 (3) 1,777 1,783 (6) additional interim support has Emergency Planning 136 148 (12) 204 208 (4) Estates And Facilities 163 154 9 245 229 15 been engaged to ensure the CCG Finance 865 844 21 1,243 1,258 (15) achieves key actions and Human Resources 222 173 49 334 305 29 priorities this year. Medical Directorate 667 758 (91) 1,000 1,115 (115) Nursing Directorate 578 519 59 868 798 70 Performance 861 971 (110) 1,222 1,457 (235) Primary Care Support 787 786 1 1,173 1,059 114 TOTAL RUNNING COSTS 8,585 8,563 22 12,797 12,797 0

10 Financial Position Analysis

11 Risks & Mitigations

Risks Comments Commentary: £m This table summarises the identified Acute 3.4 Winter Pressures, Spec Comm transfer & HRG4 risks for the CCG as at month 8. Continuing Care 1.0 Activity Prescribing 2.3 QIPP under-delivery & cost pressures Other 0.5 Risks are currently estimated at £7.2m, Total Risks 7.2 and relate largely to acute activity pressures, continuing care placements and under achievement of QIPP Upside / Mitigation Comments schemes. These risks are mainly £m recurrent in nature, and will increase Contingency 3.8 the run rate as they materialise. The Primary Care 1.1 probability adjusted mitigations are Other Mitigations 2.3 Prior year benefits and budget reviews estimated at £7.2m, but are mainly Total Mitigations 7.2 non-recurrent in nature, relating to prior year benefits and budgetary Net Risk / Headroom 0.0 reviews.

Reported Forecast Surplus 0.1 At month 8, the CCG estimates that Risk Adjusted Forecast Deficit 0.1 sufficient mitigations will be available to offset the likely risks and therefore still achieve a surplus of £0.1m.

12 Underlying Position

ANNUAL FORECAST CLOSING OPENING VARIANCE REMOVE NON- REMOVE NON- RECURRENT FULL YEAR RECURRENT 2017/18 Budgets - Source & BUDGET FORECAST favourable / RECURRENT RECURRENT OTHER NON- POSITION EFFECT OF OTHER FULL POSITION Application of Funds (adverse) ALLOCATIONS SPEND RECURRENT 2017/18 QIPP YEAR EFFECTS 2018/19 £000 £000 £000 £000 £000 £000 £000 £000 £000 £000

Revenue Resource Limit 848,796 848,796 0 (9,409) 839,387 839,387

APPLICATION OF FUNDS - Programme Acute Commissioning 442,741 442,741 0 431 462 443,634 1,500 445,134 Non acute Commissioning 178,271 186,388 (8,117) (2,268) 180 184,300 184,300 Primary care Commissioning 168,845 168,248 597 (305) (1,025) 1,500 168,418 332 168,750 Other Programme Costs 28,116 26,494 1,622 (5,797) 1,543 22,240 22,240 Total Commissioned Services 817,973 823,871 (5,898) (7,939) (1,025) 3,685 818,592 0 1,832 820,424

Running Costs 12,797 12,797 0 (60) (479) 12,258 12,258

Reserves, Contingency & Provisions: Non Recurrent Fund (0.5%) 3,768 3,768 0 (3,768) 0 0 Contingency (0.5%) 3,838 3,838 0 (3,838) 0 0 Other Reserves & Provisions 10,319 4,422 5,898 (1,410) (1,604) 1,408 1,408 Total Reserves 17,925 12,028 5,898 (1,410) (7,606) (1,604) 1,408 0 0 1,408

Total Applications 848,696 848,696 0 (9,409) (9,110) 2,081 832,258 0 1,832 834,090 In-year Surplus / (deficit) 100 100 (0) 0 9,110 (2,081) 7,129 0 (1,832) 5,297 The underlying positions at the end of 2017/18 and start of 2018/19 are arrived at by removing expenditure and income assessed to be non-recurrent in nature e.g. one-off QIPP savings and adjusting 2018/19 for the full year effect of in-year investments e.g. the new integrated urgent care contract which started at the end of June 2017.

The closing underlying position for 2017/18 is estimated to achieve a surplus of £5.3m after full year effects, based on current assumptions and expenditure reported at month 8. It assumes that none of the identified risks materialise. 13

Use of Reserves

MONTH 7 MONTH 8 MONTH 8 ANNUAL FORECAST Commentary: VARIANCE 2017/18 Running Cost Budgets TOTAL BUDGET TOTAL FORECAST favourable / The use of reserves table provides a breakdown of Application of Funds BUDGET MOVEMENT BUDGET (adverse) available reserves and any provisions included in £000 £000 £000 £000 £000 the 2017/18 budgets, movements since last Non-recurrent Fund (1%) 3,768 0 3,768 3,768 0 month and how they have been included in the Contingency (0.5%) 3,835 3 3,838 3,838 0 current forecast position. Other Reserves & Provisions:- Total Other Reserves 9,340 979 10,319 4,422 5,898 Of the 1% non-recurrent reserve, half has been 16,943 982 17,925 12,028 5,898 allocated to reduce this years QIPP requirement. The remaining half (£3.8m) must be retained and is not available to the CCG and is therefore shown separately in the table.

The Primary Care contingency and 1% non- recurrent reserve have been retained within the Delegated Primary Care budget.

Other reserves contains sums for additional allocations and expenditure planned for later months. £5.9m has been used to offset forecast over-spends in other areas.

14 Resource Allocation & Budget Adjustments

TOTAL IN MONTH TOTAL The total programme budget at month 8 is 2017/18 Running Cost Budgets BUDGET BUDGET BUDGET £836m (including delegated primary care co- Application of Funds MONTH 7 MOVEMENT MONTH 8 commissioning). The running cost allocation £000 £000 £000 is £13.25m with budget currently agreed at £12.8m. Acute 443,172 (431) 442,741

Non Acute 177,968 303 178,271 The CCG has a surplus carried forward of Primary Care 168,845 (0) 168,845 £0.2m, giving a total resource allocation of Other Programme 28,407 (291) 28,116 £849m. The table indicates how this is Reserves 16,943 982 17,925 allocated across budget headings. Planned Surplus 100 0 100 Sub-total Programme 835,435 564 835,999 Net allocations of £573k have been received Running Costs 12,788 9 12,797 in month 8, comprising £600k transformation funds, £404k perinatal Total In-year Resource Limit 848,223 573 848,796 community services development funds and a reduction of £431k relating to charge Surplus carried forward 244 244 exempt overseas visitors. TOTAL RESOURCE LIMIT 848,467 573 849,040

QIPP

YTD Plan Forecast CCG Delivery Plan Actual Variance Plan Actual Variance RAG £000s £000s £000s £000s £000s £000s Red 2,538 1,121 (1,417) 4,173 1,390 (2,782) Amber 2,186 761 (1,425) 6,481 993 (5,488) Green 16,800 20,438 3,638 27,371 31,377 4,007 Totals 21,524 22,319 795 38,024 33,761 (4,263) % Achievement 104% 89%

QIPP performance at month 8 is reported as 104% of the year to date plan and 89% of the annual plan.

The forecast outturn this month represents a drop when compared to last month. The lower figure follows a ‘deep dive’ exercise aimed to more accurately reflect the CCG’s QIPP year end position. The revised outturn is driven by three main issues. 1. Some schemes are subject to contract dispute and mediation. These schemes will not release 100% of forecast savings – new forecasts estimate a best case scenario of 25% of originally anticipated savings. This applies to AEC, first to follow up ratios and LPTP schemes. These have been subject to mediation in November and early December. 2. Transformation schemes are taking longer to develop and implement than originally anticipated. This applies to demand management schemes and non elective pathway changes. These have now been re-profiled into quarter 4 of 17/18 with a full year effect in 18/19. 3. For a number of schemes, following investigation into feasibility, it has been found they are not viable this year. These include ambulance contract, urgent care re-commissioning and outpatient procedure transition. These have been re- profiled into 18/19 QIPP. 16 Cash & Balance Sheet

17 Statement of Financial Position

30 31 October 31 March Asset /Liability November Commentary: 2017 2017 2017 The Statement of Financial Position at month £000 £000 £000 8 represents a point in time snap shot of the Non-current assets: 0 0 0 CCGs balance sheet at 30 November 2017. Current assets: Trade and other receivables 3,585 4,793 4,388 The table compares balances with the closing Cash and cash equivalents (1,276) (305) 321 Total current assets 2,309 4,488 4,709 position for 2016/17 and the previous month.

Total assets 2,309 4,488 4,709 Balances reflect the relative timing of cash Current liabilities: drawdown, amounts payable and receivable Trade and other payables (57,526) (56,829) (50,521) and reflects the impact from payment of Provisions (1,720) (1,484) (706) invoices and payroll. Total current liabilities (59,246) (58,313) (51,227)

Non-Current Assets plus/less Net Current Assets/Liabilities (56,937) (53,825) (46,518)

Financed by Taxpayers’ Equity: General Fund (56,937) (53,825) (46,518) Total taxpayers' equity: (56,937) (53,825) (46,518)

18 Cash Drawdown

Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Total £000 £000 £000 £000 £000 £000 £000 £000 £000 £000 £000 £000 £000 Forecast Drawdown including Top Slice for Drugs 69,720 69,541 65,560 69,460 68,660 69,460 73,360 70,360 70,260 70,760 70,160 80,589 847,890

Actual drawdown 64,000 63,200 59,200 63,100 53,500 63,500 73,000 439,500 Actual top slice 5,720 6,341 5,815 6,453 6,342 6,611 6,586 43,868 Total 69,720 69,541 65,015 69,553 59,842 70,111 79,586 0 0 0 0 0 483,368 Difference 0 0 545 (93) 8,818 (651) (6,226) 2,393 Undrawn balance 364,522 Proportion remaining 43.0%

Amendments to Forecast Drawdown M3 additional allocation of £1,569k (added to M12 forecast drawdown) M4 additional allocation of £339k (added to M12 forecast drawdown) M5 additional allocation of £236k (added to M12 forecast drawdown) M6 additional allocation of £6,346k added to M7, M8 and M12 forecast drawdown

The cash available for drawdown in 2017/18 is estimated to be £847.9m.

At month 7 £483.4m has been drawn down representing 57% of the total cash available. The higher than forecast drawdown of cash in October was to settle outstanding BCF invoices, and to support WHHT cash flow by paying over-performance invoices “without prejudice”, until the actual value of over-performance is agreed.

19 Better Payments Practice

Nov-17 Oct-17 NHS NON-NHS TOTAL TOTAL

Number of invoices 95% 99% 98% 97% Percentage of target achieved in month

Value of invoices 100% 100% 100% 100% Percentage of target achieved in month

Number of invoices 93% 98% 97% 97% Percentage of target achieved cumulatively

Value of invoices 100% 99% 99% 99% Percentage of target achieved cumulatively

The percentage of invoices paid within payment terms in November (15 days for NHS and 30 days for non NHS) was 98% by number and 100% by value compared to a target of 95%.

Current month and cumulative performance are similar.

The lower performance for NHS invoices by number is due to relatively large volumes of low value invoices that require validation before payment (the equivalent performance in 2016/17 was 87%).

20 NHS Herts Valleys Clinical Commissioning Group Board Meeting 18 January 2018

Title Proposal for joint appointment of two patient representatives to the Herts Valleys Agenda item 11 CCG Board

Purpose* (tick) Decision ☐ Approval ☒ Discussion ☐ Assurance ☐ Information only ☐

Author and job title Responsible director and job title Director signature Laura Abel Juliet Rodgers Approved by Corporate Governance Support Manager Associate Director Communications and J Rodgers Engagement Short summary of paper The tenure of the current patient representative to the board comes to an end on 31 March 2018. Following an open and competitive recruitment process, two candidates were of a particularly high standard and it is proposed to appoint both in order to strengthen and enhance patient representation in Herts Valleys. As part of this it is proposed that patient representation is extended to attendance at the Commissioning Executive and Primary Care Commissioning Committee.

Recommendation(s) The Board is being asked to: Discuss and support the proposal for the appointment of two patient representatives to the board: Jill Ainsworth-Beardmore and John Wigley, effective April 2018, with a division of responsibilities on a 12 month rotation. The board is also asked to approve attendance of a patient representative at the Commissioning Executive and Primary Care Commissioning Committee.

Engagement with This has been discussed at Patient and Public Involvement committee on 11 patients/public/staff and October and 13 December 2017. other stakeholders Links to Strategic Objectives (tick all that apply) Objective 1: We will continually improve engagement with patients, carers, the public and member practices ☒ so that they contribute to and influence our work and activities. Objective 2: We will commission safe, high quality services that meet the needs of the population, reducing ☒ health inequalities and supporting local people to stay well and avoid ill health. Objective 3: We will work with health and social care partners to transform the delivery of care through the ☐ implementation of Your Care, Your Future, the strategic review in west Hertfordshire. Objective 4: We will ensure that there is a financially sustainable and affordable healthcare system in West ☐ Hertfordshire. Board Assurance Framework Refer to assurance levels table below and latest BAF report here: N:\Nursing & Quality\8 Risk Management System\2. Board Assurance Framework\BAF 201718\Current versions for front sheet reference N.B. The executive summary for this paper explicitly points to the evidence to support the assurance level indicated above. For example: Very high – what is the evidence to support the current strong position & how will it be sustained? High – what is being done to strengthen controls and mitigate the likelihood of this risk materialising? Medium - what is being done to address gaps in assurance and how successful is this action proving? Low - what are the urgent actions planned to address the lack of assurance? Ref. Risk Risk description Current risk Target risk Assurance Owner score and score Level movement since last month Risk that we do not engage effectively with a range 1.1 JR of our patients, population and stakeholders. 16→ 8 High New strategic risks identified by this report

Other significant risks related to this report (from the CRR)

Resource No funding implications CFO Signature implications N/A

Potential conflicts No conflicts of interest relating to this paper of interest Equality and N/A quality impact analyses (indicate the key points the analysis has identified relevant to decision required) Equality delivery Better Health Outcomes ☐ system (identify Improved Patient Access and Experience ☐ which goal your A Representative and Supported Workforce ☐ proposal / paper supports) Inclusive Leadership ☐ Report history Report produced for board 18 January 2018 Which Groups or Committees have seen this report and when? Where does the report go next? Appendices Report follows

Herts Valleys Clinical Commissioning Group

Proposal for joint appointment of two patient representatives to the

Herts Valleys CCG Board

1. Executive summary

Under the Health and Social Care Act 2012, CCGs should ensure that the views of patients, carers and the public are utilised to inform commissioning and consider consequences of decisions. This is addressed at paragraph 6.2.3 of the CCG’s constitution: The CCG shall promote the involvement of patients, their carers and representatives in decisions about their healthcare in:  The prevention or diagnosis of illness, and  Their care or treatment.

Effective engagement with patients and the public is one of the CCG’s four strategic objectives and Herts Valleys goes further than the statutory requirements in a number of ways, including having a patient representative attending the board in a volunteer capacity. The purpose of a non-voting patient representative to sit in attendance at board meetings is to add scrutiny and constructive challenge from a patient-public perspective to board discussions. The post holder also attends the quality committee. As the patient representative to the board, the post holder is expected to act in accordance with Herts Valleys’ values, follow our code of conduct and the Nolan Principles.

The tenure of the current patient representative comes to an end in March 2018 and following a selection process, two very capable candidates have been identified. The board is asked to consider the appointment of both candidates for a two year period as outlined in the proposal below.

2. Background

Under the term of office agreed for this post, an initial term of 18 to 24 months can be followed by an additional period of two years, subject to a re-appointment process. A maximum term of four years was agreed for this role, in order to maintain objectivity and independence of the post holder. Caroline Sutherland was first appointed to the role in March 2014 and re-appointed in October 2015; consequently, Caroline’s tenure comes to an end in March 2018.

At the patient and public involvement committee on 11 October 2017 patient representatives sitting on the committee were advised about the opportunity and invited to submit their application by 1 November. Interested applicants were asked to demonstrate compliance with nine core competencies. The job description and person specification are attached at appendix 1.

Three applications were received and all three candidates were interviewed on 17 November by a panel comprising: Nicolas Small, Alison Gardner and Juliet Rodgers. Two of the candidates, Jill Ainsworth- Beardmore and John Wigley, were of a particularly high standard and it is proposed to appoint both candidates in order to strengthen and enhance patient representation in Herts Valleys.

3. Proposal

In order to build on our strong patient involvement across the CCG, it is proposed that patient representation is extended to the Commissioning Executive and Primary Care Commissioning Committee. The Chairs of both committees have been in discussion with the lay member with responsibility for patient and public involvement, the Chair of the CCG and the Head of Corporate Governance. In time, the Chair of the CCG wishes to build on our extremely good reputation for patient involvement by extending direct patient involvement into the Sustainable Transformation Partnership (STP).

The newly expanded and refreshed roles that have been defined offer us opportunities to use the skills and qualities that the two candidates demonstrated in their applications and interviews.

Outline proposal for consideration

John Wigley Jill Ainsworth Beardmore Attend board year one Attend board year two Attend quality committee year one Attend quality committee year two Attend primary care commissioning committee year Attend primary care commissioning committee year two one Attend commissioning executive year two Attend commissioning executive year one Attend urgent care and planned and primary care Attend children, young people and maternity and programme boards mental health and learning disabilities programme boards

It is proposed that both patient representatives attend the board development sessions and provide cover when their colleague is unable to attend a meeting.

4. Next Steps

Timetable until handover of responsibilities:

 11 October 2017 – launch of process at PPI committee.  1 November – expressions of interest due. 3 applications received.  17 November 2017 – interviews held. Two applicants proposed in shared role as above.  18 January board meeting discussion of proposal.  Appointment(s) confirmed by the HVCCG board (effective 1 April 2018).  John Wigley to act in shadow with current patient representative at 8 March 2018 board meeting if agreed as above.  1 April 2018 – formal start date of new patient representative(s) to the board.

This will be reviewed in January 2020.

5. Recommendation

The board is asked to support the proposal and appointment of two patient representatives to the board, Jill Ainsworth-Beardmore and John Wigley, effective April 2018, with a division of responsibilities on a 12 month rotation.

Alison Gardner – Lay board member with responsibility for patient and public involvement January 2018

NHS Herts Valleys Clinical Commissioning Group Board Meeting

18 January 2018

Title Communications and Engagement Report Agenda item 12 Purpose* (tick) Decision ☐ Approval ☐ Discussion ☐ Assurance ☐ Information only ☒

Author and job title Responsible director and job title Director signature Juliet Rodgers, Associate Director of Juliet Rodgers, Associate Director of Communications and Engagement. Communications and Engagement.

Short summary of paper This paper summarises key communications and engagement activities since the last board meeting in public

Recommendation(s) The Board is being asked to: To note communications and engagement activities for the period. Engagement with This paper summarises key communications and engagement activities since the stakeholders/patient/public last board meeting in public Links to Strategic Objectives (tick all that apply) Objective 1: We will continually improve engagement with patients, carers, the public and member practices ☒ so that they contribute to and influence our work and activities. Objective 2: We will commission safe, high quality services that meet the needs of the population, reducing ☐ health inequalities and supporting local people to stay well and avoid ill health. Objective 3: We will work with health and social care partners to transform the delivery of care through the ☒ implementation of Your Care, Your Future, the strategic review in west Hertfordshire. Objective 4: We will ensure that there is a financially sustainable and affordable healthcare system in West ☐ Hertfordshire. Board Assurance Framework Refer to assurance levels table below **and latest BAF report here: N:\Nursing & Quality\8 Risk Management System\2. Board Assurance Framework\BAF 201718\BAF Current version for front sheet reference Ref. Risk Risk description Current risk Target risk Assurance Owner score and score Level movement since last month 1.1 JR Risk that we do not engage effectively with a range 16 ↓ 8 Medium of our patients, population and stakeholders.

1.2 DB/JR Risk that member practices and other partners do 16↓ 8 Medium not see the potential positive impact of their engagement with HVCCG 1.3 JR Risk that we have an unengaged staff body 4→ 4 High

New risks identified by this report

Other significant risks related to this report

Resource Within existing resources. implications

Potential conflicts of interest Equality and quality impact Our engagement work seeks to include our diverse communities. analysis (indicate the key An equality analysis will be carried out for the communications and engagement programme points the analysis for the public consultation. has identified relevant to decision required)

Equality delivery Better Health Outcomes ☒ system (identify Improved Patient Access and Experience ☒ which goal your A Representative and Supported Workforce ☒ proposal / paper supports) Inclusive Leadership ☒ Report history None Which groups or committees have seen this report and when? Appendices

**Assurance levels Level Details Very high Taking account of the issues identified in this report, the Board can take reasonable assurance that the controls upon which the organisation relies to manage this risk are suitably designed, consistently applied and effective. High Taking account of the issues identified in this report, the Board can take reasonable assurance that the controls upon which the organisation relies to manage this risk are suitably designed, consistently applied and effective. However, we have identified issues that, if not addressed, increase the likelihood of the risk materialising. Medium Taking account of the issues identified in this report, whilst the Board can take some assurance that the controls upon which the organisation relies to manage this risk are suitably designed, consistently applied and effective, action needs to be taken to ensure this risk is managed. Low Taking account of the issues identified, the Board cannot take assurance that the controls upon which the organisation relies to manage this risk are suitably designed, consistently applied or effective. Action needs to be taken to ensure this risk is managed. N.B. The executive summary for this paper must explicitly point to the evidence to support the assurance level indicated above. For example: Very high – what is the evidence to support the current strong position & how will it be sustained? High – what is being done to strengthen controls and mitigate the likelihood of this risk materialising? Medium - what is being done to address gaps in assurance and how successful is this action proving? Low - what are the urgent actions planned to address the lack of assurance?

NHS Herts Valleys Clinical Commissioning Group Board Meeting 18 January 2018

1. Introduction and purpose of paper This paper summarises the communications and engagement activity for the previous period. Members will note that the assurance levels are indicated as mostly amber; this report outlines the activities being undertaken to address risks associated with shortfalls in engagement with our audiences.

2. Patient and public participation

Urgent care and West Herts Medical Centre contract There has been engagement with patient groups, PPI committee members and other patient representatives as part of our work to develop the west Hertfordshire urgent care strategy. Communications are in line with Your Care, Your Future messages about redesigning services to ensure that people receive the right level of care for their needs in the right place and in a timely manner.

An urgent treatment centre (UTC) at Hemel Hospital opened on 1 December. Initial communications has focused on explaining what the UTC offers, as part of wider plans to encourage take up of urgent care services, in order to alleviate pressure on A&E and help patients get the right treatment in the right place. The UTC has opened on the interim hours that were introduced for the urgent care centre in December 2016. A consultation about opening hours starts at the end of January. At the same time we will consult on procurement options for West Herts Medical Centre as the contract is due for renewal. Options for both services will be explored in the context of the urgent care strategy.

Re-procurement of adult community services We will be engaging with staff, patients and local people so that they can influence the way we re-commission adult community health services in west Hertfordshire. This is a major project that will see progress towards achieving the service transformation outlined in our Your Care, Your Future plans. This engagement will build on high level feedback from Your Care, Your Future and further engagement will be needed to get specific feedback to support the development of the new service specification. Patient representatives will be involved in the procurement process so that we have a patient perspective in all discussions. There will also be wider conversations through our PPG network and at our next PPI development session. And we will target communication with users and support groups. A market engagement event taking place over the next few weeks will also initiate discussions with and feedback from potential providers.

Health and well-being ambassadors We have worked with a group of patient representatives to develop a role within the CCG for health and wellbeing ambassadors. This role has supported engagement on Let’s Talk and Stay Well This Winter (SWTW) campaigns. During this pilot phase our current six ambassadors have helped to identify, within their local communities, opportunities to promote the national SWTW campaign on keeping well over the colder months, and using

3 services appropriately. This has included providing information at community events, dementia cafes, healthwalks and also St Albans Christmas market. We are currently reviewing the programme with a session planned for February where we will consider any lessons learnt, and look to develop the programme further, recruiting more members from our patient networks and the wider community so that we can engage better with all our local communities. The results of the review will come to the PPI committee for consideration.

GP Practice Patient Participation Groups (PPG) We continue to build our west Herts PPG network – currently we have contacts and members from the majority of practices, either staff or patients, and we are working with our locality teams to chase up on the gaps.

We are also continuing to build the network yammer platform, currently with over 130 members who include representatives from PPGs, patient groups and also patient engagement leads.

Procurement and service redesign As part of Your Care, Your Future work to develop community-centred health services that will provide people with care closer to home, we have been asking for expressions of interest from patients to be involved in the procurement and service design of a number of services. These are: Ear Nose and Throat (ENT), Ophthalmology, Dietetics, MSK, Vasectomy, Obesity, Stroke, Dermatology, Gynaecology and Diabetes. To help interested patients through the process we have an introductory session planned for the beginning of January.

3. Winter campaigns ‘Stay Well This Winter’ continues to gain momentum since its October launch. The initial focus of the campaign was centred around encouraging people to take up the offer of flu jabs, with the recent focus on s the over 65s and people with a long term condition.

During December the campaign has also included strong messaging around using NHS111, engaging with your local pharmacists for advice and support, and also providing information about health services over the holidays, including repeat prescription reminders.

The campaign has been delivered using a variety of methods such as: media releases and articles; bulletins and newsletters through our networks; social media platforms, in particular Twitter, Facebook and Yammer; leaflet drops to vulnerable patients and face- to- face sessions such as St Albans Christmas market.

We have also made excellent use of our health and welling ambassadors, who have shared the key messages through local network groups. Radio Verulam in St Albans have regularly shared the key messages during their daily ‘Health Matters’ show too.

This is a national campaign and has been promoted throughout west Hertfordshire via other partner organisations too.

4. Print and broadcast media activity There continued to be interest during November in the new policy on being fit for surgery, agreed following the ‘let’s talk’ consultation.

This subject attracted interest nationally and even in some overseas publications and digital platforms. Our approach to this level of media interest was to respond to questions and ensure, so far as is possible, that stories were accurate and we endeavoured to correct notions that surgery was being rationed or ‘banned’.

Nascot Lawn continued to feature in local media following the decision that Herts Valleys CCG would not be able to continue this discretionary funding. This included a lengthy piece on local radio station, BBC Three Counties.

We used the media to advise people about improvements to urgent care services and in particular the urgent treatment centre in Hemel Hempstead. Local MP Mike Penning was reported being critical of NHS organisations in this patch for what he termed a ‘downgrade’; he was concerned about the opening hours at the centre.

In the run up to Christmas and subsequently, A&E departments and our acute hospital in general, faced significant pressures and, alongside our partner communications team at WHHT, we issued statements encouraging patients to heed advice and to use NHS111, or the UTC for non-urgent medical assistance.

Also in relation to the Christmas and new year period, media releases were distributed locally to printed and online press, urging people who need medication for long term conditions, or who are looking after someone with a long term illness, to think ahead and contact their GP or pharmacist to get important medicines in good time for the bank holidays.

5. Social media activity and digital Our social and digital media communication continues to develop, as we steadily raise our profile within the community. Our page ‘likes’, on Facebook have grown by almost 15%, and so we are growing our access to different audiences.

We continue to use more engaging content and make more use of images, as we support national and local campaigns and initiatives (see above). Currently we are using our social media platforms to reinforce key messages around the Stay Well This Winter campaign.

Our activity on both digital and social media has supported other key campaigns such as Herts Warmer Homes, NHS111, Are You Winter Ready? And, crucially, to announce our service changes for both over-the-counter medicines and gluten free foods, following the public consultation over the summer months.

The use of social media continues to offer a vital link to the public where we can act fast in delivering messages. It also gives us an opportunity to monitor and respond to feedback in a timely fashion. It is worth noting that, to date, there has been very little feedback via social media on the implementation of the ‘let’s talk’ policies.

We are carrying out a review of our website and the intranet. We have already put in place a number of improvements to the website, for example by way of additional news categories on the home page with images and better formatting. Further changes will follow as we continue our review.

6. Staff communications and engagement The most recent round of ‘breakfast with the directors’ concluded before Christmas with a number of different themes cropping up and suggestions being made. Overall, staff are reporting really positive things about working at Herts Valleys and we know they value this particular means of giving feedback and engaging with colleagues on any topic they choose.

Recent staff briefings have covered issues such as the health and wellbeing ambassadors, plans around ‘my care record’, urgent care and at December’s session we announced the latest staff awards winners.

We expect the results of the 2017 staff survey to be with us shortly. The staff involvement group will undertake a review of staff communications and engagement once we receive these results and have had a chance to review and evaluate them.

7. Member practice communications and engagement We have continued to evaluate the practice communications and work has begun on formulating a plan for improvements. This month there will be a meeting with practice managers, giving an opportunity to present ideas and feedback information on how we can improve our communication – both in terms of the GP bulletin and the GP intranet.

8. Other Materials to announce and explain the ‘let’s talk’ policies on over- the- counter medicines and gluten- free food were produced and issued at the end of November, in line with implementation plans. We are now working with colleagues at East and North Hertfordshire CCG to develop a suite of materials on the fitness for surgery policies which come into effect in the coming weeks. We will continue to get feedback from our reader panel and PPI representatives as material is developed; this is crucial in the production of effective communications on these new policies.

Two new communications policies have been developed and are being finalised. We have updated our media policy and created a new one – a policy around how we use social media. The latter has been discussed both at our staff involvement group and PPI committee as many of our patient representatives and work colleagues are frequent users of social media and can help support our campaigns and messages. Indeed we are encouraging them to do so.

Draft minutes

Item 13

Joint Committee Meeting Thursday 12th October 2017 Focolare Centre, Meeting Room 1, Welwyn Garden City

Present: Stuart Bloom (SB) Lay Member, HVCCG Corina Ciobanu (CC) GP, Dacorum, HVCCG Dianne Desmulie (DD) Lay Member, Patient and Public Engagement, ENHCCG Linda Farrant (LF) Lay Member, Governance and Audit, ENHCCG Beverley Flowers (BF) Chief Executive (Accountable Officer) , ENHCCG Alison Gardner (AG) Lay Member, HVCCG Russell Hall (RH) GP, Stevenage, ENHCCG Kathryn Magson (KM) Chief Executive (Accountable Officer), HVCCG Hari Pathmanathan (HP) Chair, ENHCCG Richard Pile (RP) GP, St Albans and Harpenden, HVCCG Nicolas Small (NS) Chair, HVCCG Nicky Williams (NW) Deputy Chair, ENHCCG

In Attendance: Diane Curbishley (DC) Director of Nursing and Quality, HVCCG Jas Dosanjh (JD) Corporate Governance Manager, ENHCCG (Minutes) Sarah Feal (SF) Company Secretary, ENHCCG Stacey Golding (SG) Lead Pharmaceutical Adviser (Governance), ENHCCG Caroline Hall (CH) Chief Finance Officer, HVCCG Rachel Joyce (RJ) Interim Medical Director, ENHCCG Nuala Milbourn (NM) Assistant Director, Communications, ENHCCG Raj Nagaraj (RN) Consultant in Public Health, ENHCCG Juliet Rodgers (JR) Associate Director, Communications and Engagement, HVCCG Miranda Sutters (MS) Consultant in Public Health, HVCCG Pauline Walton (PW) AD and Head of Pharmacy and Medicines Optimisation, ENHCCG Rod While (RW) Head of Corporate Governance, HVCCG Penny Wylie (PW) Director, ActionPoint Marketing Solutions Ltd.

Page 1 of 15

MINUTES

Item Subject Action by

1. WELCOME AND APOLOGIES FOR ABSENCE

The meeting opened at: 14.02

The Chair of Governing Body at East and North Hertfordshire Clinical Commissioning Group (ENHCCG) welcomed all to the meeting, and advised that the meeting will be jointly chaired with the Chair of Board at Herts Valleys Clinical Commissioning Group (HVCCG).

The Chair (ENHCCG) provided an explanation of the format for the meeting and general housekeeping. It was explained that this is a special joint decision-making meeting held in public so that anyone interested (members of the public and journalists) can observe. It is the final stage in a long and considered process which has developed over a number of months, and each individual CCG governing body has discussed the proposals and the members here today are representing the views of their organisations.

The Chair advised that this is not a meeting at which the public can contribute to the debate and the Committee members have reviewed the meeting papers, which include the questionnaire results, public meeting notes and organisational responses. Representatives of the public have been invited to make three minute representations to the joint committee to reflect people’s personal experiences, as the Committee members want to ensure that the patient voice is heard by everyone involved in the decision making process today.

The Chair asked all those around the table to formally introduce themselves and state whether they are a voting member of the Committee (noted as Members on page 1).

No apologies were received.

2. DECLARATIONS OF INTERESTS

The Chair (HVCCG) invited the members to declare any declarations of interest or declarations relating to matters on the Agenda.

No declarations were made.

Page 2 of 15

Item Subject Action by 3. CHIEF EXECUTIVES’ INTRODUCTION

The Chair (HVCCG) invited the Chief Executives from both CCG’s [Beverley Flowers (BF) for ENHCCG and Kathryn Magson (KM)] to provide an explanation of circumstances which led to the consultation process being initiated.

BF and KM explained that:

 Currently this is a difficult time for the NHS due to a number of multi-faceted issues arising from the increasing demands placed on services, i.e. increase in population, but the income available to meet these needs is not growing at the same rate.

 There is a need to review the current provisions and, based on conversations with the public, advice was sought on how to run the consultation process and evaluation.

 Every attempt was made to obtain views from a range of communities, including those from hard to reach groups.

It was highlighted that the financial position of both CCG’s is different from one another and therefore may influence the outcomes of the final decisions taken.

The Chair thanked BF and KM, and introduced Juliet Rodgers (JR) and Nuala Milbourn (NM) who provided an overview of the consultation process, including how it evolved and was carried out.

JR and NM informed the Committee that:

 The consultation was approached jointly by both CCG’s in order to maximise resources and efficiency, to ensure that a common approach would be taken across the county.

 The consultation lasted 10 weeks and each CCG held their own processes for public engagement and feedback led by the Communications Teams.

 The parameters of consultation were clearly set out and the main aim was to reach as many people as possible to obtain views and feedback to inform the decision making process.

 There were 2500 responses and, although this may be a small percentage of the population, when benchmarked we have had a high response rate.

Page 3 of 15

Item Subject Action by

The Chair thanked JR and NM and asked the Committee members to comment on their experience of the consultation process.

The Committee members commented that:

 The public understand the challenges that the NHS is facing and want to get involved; this was demonstrated via the balanced views provided through attendance at planned events, with an increase in involvement from groups who do not usually attend such events.

 Some of the most effective engagement was through the unplanned events/held in locations not typically associated with health, as it allowed for views to be heard from those who don’t usually participate.

 The length of the consultation also provided greater opportunity for more people to get involved and have their views considered.

 The process was rigorous and supported by the CCGs’ Commissioning Prioritisation Framework, with all equality and quality impacts assessed.

Overall, the Committee members were in agreement that the consultation process has been robust and thorough.

4. STATEMENTS FROM INTERESTED PARTIES

The Chair (ENHCCG) invited the representatives of the public to address the Committee. The Committee heard five supporting statements.

The Chair thanked the representatives for sharing their personal experiences via these statements.

5. CONSULTATION – FINDINGS AND FEEDBACK

The Chair (HVCCG) introduced Penny Wylie (PW), Director of ActionPoint Marketing Solutions, and the company that hosted the survey, received both online and written responses and collated the results.

Page 4 of 15

Item Subject Action by

The Committee were advised that the Consultation was effectively broken down into two parts:

a) IVF and fertility services (ENHCCG, HVCCG and West Essex CCG);

 The total in favour of a reduction or stopping IVF was: 54% in ENH, 31% HV and 34% WE, with the majority of responses from those not affected.

 Responses included: - Stopping provisions could lead to mental health issues and in turn cost the NHS more, - There should be a nationally agreed approach, - There could be an increased cost to the NHS when dealing with patients who undergo IVF treatment abroad where it is available at a lower cost to private treatment in the UK.

b) Fitness for surgery, gluten-free prescribing, over the counter medicines, female sterilisation (ENHCCG and HVCCG), and vasectomy (HVCCG only);

Fitness for surgery –

 The overall majority were in favour of the proposals that those with a Body Mass Index (BMI); - Of 40+ should reduce weight before surgery: 85% in ENH and 86% in HV, - Over 30 should reduce weight before surgery: 74% in ENH and HV.

 In both ENH and HV 86% were in favour that smokers should be required to quit smoking before being referred for non- urgent surgery.

 Responses included: - Being asked to improve health before surgery is not unreasonable, - Need to take some responsibility for our own health, - Weight loss is difficult for some people due to other health issues, i.e. mobility.

Gluten-free prescribing –

 The overall majority were in favour of the proposal that gluten- free food should not be available on prescription with the

Page 5 of 15

Item Subject Action by exception of people with learning disabilities: 76% in ENH and 78% in HV.

 Responses included: - Gluten-free food is widely available in the supermarkets, - It should remain for low income families, - A lot of foods are naturally gluten free already.

RP left the meeting at 15.14

Over the counter medicines –

 The overall majority were in favour of the proposal to limit the prescribing of medicines, products and food items that are available without prescription: 90% in ENH and 89% in HV.

RP re-joined the meeting at 15.16

 Responses included: - A lot of medicines are cheaper over the counter, - Low income families should still be entitled, - Money can be saved; the NHS needs to make cuts somewhere.

Female sterilisation –

 The majority were in favour of the proposal to stop funding for female sterilisation except in exceptional circumstances: 64% in ENH and 61% in HV.

 Responses included: - Lots of alternative methods are available, - Unwanted pregnancy/children would cost more in long-run, - Should only be funded if there are medical issues/exceptional circumstances. RN left the meeting at 15.20

Vasectomy –

 This was only considered by HVCCG and 55% were in favour of the proposal to stop funding vasectomy.

 Responses included: - Better/cheaper than consequences of an unwanted pregnancy, - There are other forms of contraception available.

Page 6 of 15

Item Subject Action by The Chair thanked PW and the ActionPoint team for the coordination and analysis of the responses.

It was explained that organisational responses to the consultation are including in the meeting papers. It was also explained that a number of detailed questions were raised during the consultation process, both online and postal, in meetings and in organisational submissions. Clinicians from both organisations have provided information in response to these questions and their responses are included in the meeting papers. It was noted that all of this information was provided to Committee members in advance of the meeting. RN re-joined the meeting at 15.24

There were no questions for PW from the Committee members, and the Chair thanked all those who participated in the consultation to provide their views which will contribute to the outcomes to be reached during this meeting.

The meeting adjourned at 15.30 to 15.42

6. CONSULTATION – ISSUES AND OPTIONS

The Chair (ENHCCG) explained that the Committee will now discuss each proposal in turn, referencing the options and using the questions and responses to inform the discussion.

The Chair reminded the members of the Terms of Reference and that they have delegated authority on behalf of their board / governing body to make the decisions at this meeting and that that those decisions would be binding on the respective governing bodies.

 Fitness for surgery

The original consultation proposal was:

o Morbidly obese patients with a BMI over 40 would need to reduce their weight by at least 15% over 9 months or reduce their BMI to less than 40 (whichever is greater) before having non‐urgent surgery;

o Obese patients with a BMI over 30 will not get non‐urgent surgery until they reduce their weight by 10% over 9 months or reduce to less than 30 (whichever is the greater);

Page 7 of 15

Item Subject Action by o Smokers would be required to quit smoking before being referred for non‐urgent surgery;

There would still be individual exceptional cases where the policy would not apply - where delaying a procedure would cause harm.

The Committee discussed the proposal in relation to the responses:

 It was confirmed that the proposal in relation to routine planned surgery and exceptionality would be applied where the harm of not having surgery is high (i.e. excludes cancer patients, cardiology).

 It was highlighted that many people struggle to lose weight in line with the parameters and that this cohort of patients will require support. It was stated that support will be provided and that it has been found that ill health triggers often motivate people to act in a way to better their health. All agreed that there should be more opportunities at an early stage to highlight health concerns to patients and work with them to address these before they develop.

 It was noted that GPs should have the ability to refer any patient if they felt it was absolutely necessary.

 The use of the BMI calculator as an appropriate indicator of health concerns was queried. It was reported that all evidence and studies of patients in regards to this area have been based on BMI, but it is recognised that this is not the correct tool for all patients, i.e. those with a high muscle mass. Therefore, it will be important that the checks are reviewed correctly by the health professional in relation to the individual patients, and guidance will be provided.

The Chair (ENHCCG) reminded the Committee of the options:

1. Do nothing - retain the current BMI and smoke-free policy on non-urgent surgery;

2. Agree with the proposal with the option of exceptionality on an individual basis.

A vote was taken and counted, the Committee members agreed unanimously with option 2.

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Item Subject Action by  Over-the-counter medicines and products on prescription

The original consultation proposal was:

o Limit the prescribing of medicines, products and food items that are available without a prescription from a high‐street pharmacy, registered online pharmacy, supermarket or shop for short-term self-limiting conditions.

Exclusions to this policy would include: - Where there are safeguarding concerns - Patients with long term conditions, for example osteoarthritis and the need for regular pain relief

The Committee discussed the proposal in relation to the responses:

 It was confirmed that this proposal would only apply to short- term conditions.

 It was queried how this potential change in practice would be implemented by GP’s. It was agreed that our focus would be on significant patient education into the specific medications that are available without a prescription and utilisation of communications via GP surgeries.

 The survey results demonstrated that patients feel this would be a positive change with benefits to be reaped through other avenues, such as freeing up appointment slots in the long-run. Initially appointments may be longer where GP’s attempt to work with patients to educate patients to take responsibility for their own health.

The Chair (ENHCCG) reminded the Committee of the options:

1. Do nothing - continue to prescribe medicines, products and food items readily available over the counter;

2. Agree with the proposal and the above exclusions.

A vote was taken and counted, the Committee members agreed unanimously with option 2.

 The prescription of gluten-free foods

The original consultation proposal was:

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Item Subject Action by o No longer provide gluten-free food on prescription with the exception of coeliac patients with learning disabilities or where there are safeguarding concerns.

The Committee discussed the proposal in relation to the responses:

 The quality of gluten-free food in supermarkets was queried. It was advised that there is a lot of choice available in supermarkets, and although some brands are fortified they are not the prime source for tackling deficiencies. There needs to be patient education in relation to other food groups, i.e. dairy, that can be consumed as part of a healthy diet, without over reliance on specific gluten-free produce.

 Clarification was sought regarding what a potential safeguarding concern might entail. It was advised that these would usually involve the welfare of children and concerns that may be raised where the gluten-free requirements of the child diet are not being managed by the primary carer. It was highlighted that GP’s undergo safeguarding training and are therefore equipped to identify any such concerns.

 It was agreed that, if this proposal is to be adopted, a plan will need to be put into place to clarify the process for patients who currently have repeat prescriptions for gluten-free food.

The Chair (HVCCG) reminded the Committee of the options:

1. Do nothing - retain the current CCG policy;

2. Agree with the proposal including the exception of coeliac patients with learning disabilities.

A vote was taken and counted, the Committee members agreed unanimously with option 2.

 Female sterilisation

The original consultation proposal was:

o NHS in Hertfordshire would no longer fund female sterilisation except in exceptional circumstances, which would be assessed on a case‐by‐case basis if alternative forms of long‐ acting contraception are unsuitable.

The Committee discussed the proposal in relation to the responses:

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Item Subject Action by

 Before a decision was made to consult on this area, there was a lot of evidence gathering with regards to alternative long acting safe and effective contraception for women.

 It was acknowledged that feedback received was in relation to the money that could be saved as other cheaper options for contraception are available.

The Chair (HVCCG) reminded the Committee of the options:

1. Do nothing - retain the current CCG policy;

2. Agree with the proposal including the option of exceptionality.

A vote was taken and counted, the Committee members agreed unanimously with option 2.

 Vasectomy (HVCCG only)

It was noted that this proposal applies to the HVCCG area only.

The original consultation proposal was:

o HVCCG would no longer fund vasectomy except in exceptional circumstances.

Exclusions to this policy would include: - Where there are safeguarding concerns; - Where there are mental health issues to be taken into account; - Where the patient is unable to use other forms of contraception due to the harm they would cause and the only other clinical option is female sterilisation.

The Committee discussed the proposal in relation to the responses:

 It was noted that Herts Valleys CCG has recently adopted an interim policy, after seeking public views, which has stopped routine funding for male sterilisation (vasectomy) but allows funding in the exceptional circumstances (as listed above).

 It was noted that it had been highlighted through feedback that vasectomy is one of the minority contraceptive procedures that men take control of as most other forms of rely on women.

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Item Subject Action by  A third option was proposed based on discussions that had taken place at HVCCG’s commissioning executive committee. This option is to allow access to the service if provided in the community based on agreed criteria. If this policy is adopted by HVCCG then the criteria will be consistent with that of ENHCCG.

The Chair (HVCCG) reminded the Committee of the options:

1. Do nothing - retain current CCG policy;

2. No longer fund vasectomy except in exceptional circumstances;

3. Allow access to the service if provided in the community, based on agreed criteria..

A vote was taken and counted, the Committee members agreed unanimously with option 3.

 IVF and specialist fertility services

The original consultation proposal was:

o No longer fund IVF and other specialist fertility treatments, except in exceptional circumstances

The Committee discussed the proposal in relation to the responses:

 It was noted that each CCG has a different starting position with regards to the number of IVF cycles offered under the existing policies; - ENHCCG currently offers up to three cycles, - HVCCG have paused their current policy of offering one cycle since 16 June 2017.

 The impact that this proposal could have on the mental health of patients who are refused treatment was queried. Assurance was provided that this aspect was investigated in depth prior to commencing the consultation process, however there are very few studies regarding this and a lack of evidence to support any particular views. There is, however, evidence that suggests there are increased rates of depression and other mental health related conditions for those who undergo IVF treatment (regardless of the outcome). However the mental health aspects are not as widely published as the successes.

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Item Subject Action by

 It was queried how the work of the Consortium would be affected if the change was to be implemented. It was confirmed that ENHCCG lead the wider range of providers within the Consortium, however it is down to the individual CCG’s to have their own policy in place with regards to the number of IVF cycles to be provided and therefore the decisions made at this meeting will not directly impact the Consortium work that the CCG lead on. It was advised that there are 12 months left for the current Consortium arrangements that are in place.

 The potential issue of ‘postcode lottery’ was raised whereby there may be some social injustice as a result of the proposal being adopted. It was advised that a review has been undertaken of patients seeking IVF and social deprivation, there was no evidence to suggest that there are more applicants from low income backgrounds.

 It was acknowledged that this proposal has received feedback, from those who value NHS funded IVF and specialist fertility treatments, with great strength of emotions and feelings.

 It was advised that spending has been reviewed in depth as part of the Prioritisation Framework and decisions have to be made to widely reduce expenditure. This has been a difficult issue but the decision to consult on this area was not taken lightly, there is a need to weigh up the evidence and how money is spent and both CCG’s are in a different financial position.

 The HVCCG policy has currently been paused for those who were at the end of the eligibility review (have been identified as suitable to receive IVF treatment) to ensure that there was not a sudden influx of demand and an unsustainable backlog whilst the policy was being consulted upon.. It was advised that, if it is agreed to adopt the proposal, those who have had their treatment paused will be provided with treatment in line with the latest policy (one cycle). Patients would be expected to be re-referred by their secondary care clinician by 31 December 2017 (with treatment to be completed within 12 months).

 HVCCG is taking a number of emergency financial measures that reflect the current financial position of the CCG. Should the decision be to stop funding, the policy should be reviewed again in 12 months’ time.

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Item Subject Action by

 It was confirmed and noted that ENHCCG is not currently under the same pause as HVCCG and treatment is being provided in line with the current policy (three cycles).

The Chair (ENHCCG) reminded the Committee of the options:

1. Continue to fund the current number of cycles offered (ENHCCG = three, HVCCG = one)

2. Reduce to two cycles (ENHCCG only)

3. Reduce to one cycle (ENHCCG only)

4. Stop funding, except in exceptional circumstances

5. Stop funding altogether

A vote was taken and counted, the Committee members agreed unanimously with: - option 3 for ENHCCG, - option 4 for HVCCG reflecting the emergency financial measures that the CCG is taking. The policy would be reviewed in 12 months’ time

The discussions regarding the proposals were drawn to a close as the Committee members unanimously agreed with selected options, within voting conducted in accordance with the delegated authority.

It was agreed that clear plans would be put into place to ensure a smooth implementation of the decisions agreed today.

7. ANY OTHER BUSINESS

No other business was raised for discussion.

8. MEETING CLOSE

The Chairs thanked all members of the public and media in attendance for taking their time to attend this meeting, stating that the views and information gathered during the consultation process have been a very important part of the decision making process and will go on to inform the implementation of the decisions taken.

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Item Subject Action by

The Communications Team at both CCG’s were thanked for their hard work and approach to ensure a robust consultation took place.

The meeting closed at: 16.57

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