AGENDA
GOVERNING BODY Part I
Wednesday, 30 September 2020 14:00 – 17:00 Hrs Meeting Held Virtually
14:00 Public Meeting Welcome and Introductions - open agenda for members of the public to raise items previously shared with the Clinical Commissioning Group
14:00 Start of NHS Salford Clinical Commissioning Group Governing Body Meeting Item Time Description Lead 1 14:00 Patient Story Chair a) Apologies for absence 2 14:05 Chair b) Declarations of Interest a) Minutes of last meeting – 29 July 2020
3 14:10 b) Action Log – 29 July 2020 Chair
c) Matters arising Leadership Reports 14:15 a) Chair’s Urgent Business (verbal) Chair 4 14:25 b) Chief Accountable Officer Report (paper) Chief Accountable Officer For Assurance/Decision Strategy
14:45 a) COVID-19 Recovery and Phase 3 Planning (paper) Chief Accountable Officer
Performance
15:00 b) Assurance Framework Report, Organisational Chief Accountable Officer Planning, Performance and Risk (paper)
15:15 c) Quality of Commissioned Services (paper) Medical Director
5 15:30 d) Finance Performance (paper) Chief Finance Officer
15:45 e) Safeguarding Adults Annual Report (paper) Chief Accountable Officer
16:00 f) Medicines Optimisation Annual Report (paper) Chief Accountable Officer
16:15 g) Learning Disabilities Mortality Review (LeDeR) Chief Accountable Officer Annual Report (paper)
16:30 h) Annual Workforce Profile Data Report and Action Chief Accountable Officer Plan (paper)
Process
16:45 i) Declarations of Interest, Gifts and Hospitality Chief Accountable Officer Registers (paper) For Information Reports of Partnership Boards/Sub-Committees
a) Adults’ Commissioning Committee (ACC) (paper) Chair of ACC
b) Primary Care Commissioning Committee (PCCC) Chair of PCCC
(paper) 6 16:55
c) Audit Committee (paper) Chair of Audit Committee
d) Executive Team (paper) Chief Accountable Officer
7 17:00 Reflection Chair 8 17:00 Meeting close Chair
Date and Time of Next Meeting: 25 November 2020, 14:00 – 17:00 Hrs Venue: Meeting Held Virtually
GOVERNING BODY
Part 1 24 June 2020, 14:00-16:30Hrs Meeting Held Virtually
Present:
Dr Tom Tasker (TT) Chair Steve Dixon (SD) Chief Accountable Officer Paul Newman (PN) Lay Member for Innovation Matters Brian Wroe (BW) Deputy Chair and Senior Lay Member for Patient and Public Participation Dr Chris Babbs (CB) Governing Body Secondary Care Consultant Kate Jones (KJ) Neighbourhood Lead Dr Jeremy Tankel (JT) Medical Director Dr David McKelvey (DM) Neighbourhood Lead Edward Vitalis (EV) Lay Member for Finance and Audit Matters David Warhurst (DW) Chief Finance Officer Dr Tom Regan (TR) Clinical Director for Commissioning
In Attendance:
Jenny Noble (JN) Head of Governance & Policy Francine Thorpe (FT) Director of Quality and Innovation Karen Proctor (KP) Director of Commissioning Ross Baxter (RB) Senior Patient Services Officer (Minutes)
Apologies:
Paul Kavanagh-Fields (PKF) Governing Body Nurse Hannah Dobrowolska (HD) Director of Corporate Services Councillor John Merry (JM) Deputy City Mayor, SCC Dr Muna Abdel Aziz (MAA) Director of Public Health, SCC Dr May Moonan (MM) Assistant Director for Health Care Public Health, SCC Dr Nick Browne (NB) Clinical Director for Partnerships/Neighbourhood Lead David Flinn (DF) Neighbourhood Lead
Governing Body Page 1 of 7 29 July 2020
1. Patient Story
The patient story was presented, and highlighted the case of a patient’s experience with social care occupational therapy and equipment services.
2. Apologies and Declarations of Interest
a) Apologies
The above apologies were noted and the meeting was quorate.
b) Declarations of Interest
TT reminded committee members of their obligation to declare any interest they may have on any issues arising at the Governing Body meeting which might conflict with the business of the CCG. No interests were declared.
3. Minutes of the Meeting and Matters Arising
a) 24 June 2020 Meeting Minutes
The minutes were accepted as an accurate record of the formal meeting held on 24 June 2020. b) 24 June 2020 Action Log
The Nitrous Oxide action has been completed, subject to re-circulation. KP’s action is ongoing as there is a need to analyse local data, and this will be brought back in future. c) Matters arising
There were no matters arising.
4. Leadership Report a) Chair’s Urgent Business
No formal update as items were covered in the main agenda. b) Chief Accountable Officer Report
SD presented the Chief Accountable Officer (CAO) Report to ensure that the Governing Body remains up to date on the latest developments relevant to the organisation. The areas highlighted were;
• First Do No Harm Report – This was issued as a result of a safety review conducted. It looks at harm to individuals as a result of three separate treatments, and was prompted by patient led campaigns over a number of years. It gives a frank and honest review and report of the failings within the NHS. This is being reviewed internally.
Governing Body Page 2 of 7 29 July 2020
• Focus from COVID-19 on inequalities and diversity – Staff risk assessments have been undertaken for all members of staff, and all GP practices have been asked to do the same.
KJ noted her delight that diversity and inclusion has remained a focus, and asked whether all practice colleagues have access to Occupational Health. It was advised that the service is inconsistent but Salford Royal (SRFT) is able to offer support locally.
Action – KP to confirm what arrangements Salford Practices have
KJ asked what support there is for balancing a home and work life. SD advised that the CCG has implemented measures to help keep in touch with staff such as encouraging 1-1 conversations, and there are sessions on Virtual College on mental health and wellbeing. There are examples of people changing their working day to suit their home life. Some members of staff have asked to go back into the office, and a process is in place to identify which staff can go back first which includes a risk assessment. There are three teams that do need an office base as they are more patient facing, and there was only one other request for three individual members of staff who feel their health and wellbeing is suffering from working at home, and options are being explored as part of the next phase.
In response to a query from BW, SD confirmed that the staff risk assessments would be revisited as a part of 1-1s so that they are not just a one-off tick box exercise.
DM said he was pleased to see the Freedom to Speak Up Guardian was being highlighted, and stated the need to encourage people to speak up through appropriate channels in confidence that their concerns will be listened to.
FT noted that the First Do No Harm Report was a hard read and urged clinicians to think about their own practices and populations, and how the report is relevant to them.
Governing Body noted the update.
5. For Assurance/Decision a) COVID-19 Response, Recovery and Planning Update
The report provided members with an update on actions taken in the management of the ongoing COVID-19 pandemic, for the restarting of urgent and routine services to support non-COVID-19 health needs, and regarding integrated commissioning and CCG annual planning for the remainder of 2020/21. The priorities for system, integrated commissioning and CCG work for the remainder of 2020/21 were shared for approval.
It was highlighted that in Salford the number of people accessing healthcare had dropped, but the level of transmission in the community is increasing, going from 3 a day a few weeks ago to 9 to date. Rochdale issued communications to the public about reinforcing good hand hygiene, social distancing and face coverings. Salford is now ranked red from a Public Health England perspective as a result of localised outbreaks in schools and the Afro-Portuguese community. Track and trace identified the individuals and did the contract tracing, advising people to isolate.
Governing Body Page 3 of 7 29 July 2020
For the recovery phase and priorities in Salford, the reflection is that there is still a long list of priorities and what needs to be done, but this will all be in the context of COVID-19 and winter pressures.
In response to queries from EV, SD confirmed that the outbreaks in schools were in adults rather than children, and that the definition for an outbreak is two or more cases in one setting. He advised that all care home staff and residents are entitled to a test whether symptomatic or not, and that as of the previous day there were two homes awaiting swab results. There has been a review in Salford on what went well and what did not, and whilst this is still being collated there have been really positive messages on the system coming together. On less good areas, national guidance can come out late and the system has to react quickly, and it may cause local challenges. There has also been a mortality review on all deaths of Salford residents who died using records from the GP, hospital, 111 and 999, as well as social services. For the funds to the VCSE sector, those sums are administered by Salford CVS. GM is looking at a rehab programme, and anyone discharged from hospital has a pathway to be followed up on.
SD noted that there is an agreement to keep the AJ Bell facility in the short term (until the end of August so far), as it is fulfilling a number of areas and is proving a real asset. There is however a list of staff groups that can be tested regularly when asymptomatic, and the AJ Bell doesn’t fulfil this need, so there needs to be a more localised testing offer.
There was a query as to whether there is a direct correlation between the amount of testing and number of cases, as well as the comparison of a potential second wave to a traditional winter flu season. It was advised that more testing does lead to more positive results, and that Salford compares itself to others in this area. Inpatient numbers are coming down, and the intelligence shows new cases appear to be in the younger population. The figures for previous flu seasons are not to hand, but this can be obtained from Public Health if required.
TT noted the importance of bearing in mind the unintended consequences of more virtual appointments, as well as making sure that no group is disadvantaged by this. He also noted that the governance structure for COVID appeared quite large, and that there always needed to be a challenge on how efficient these are.
Governing Body noted the update, and approved the strategic priorities for the system, integrated commissioning and CCG work for the remainder of 2020/21. b) Assurance Framework Report, Organisational Planning, Performance and Risk
The performance monitoring and reporting regime has been amended during the COVID-19 pandemic, and these changes were highlighted within Section 2, noting that Salford CCG continues to produce activity and monitoring information in order to track performance and potential backlog to inform the next phase of recovery. Section 3 highlighted the latest performance information, and the report highlighted the waiting times and backlog that has increased over the past few months.
A&E attendances are getting back to 80% of pre-COVID-19 levels, and there was a question on what can be done to reduce people presenting at in the department where appropriate. It was confirmed that there is a national campaign to encourage people to
Governing Body Page 4 of 7 29 July 2020
phone 111 before presenting at A&E, as they can then book people into the Emergency Department if necessary or an alternative suitable service. There was also a query on how easy it is for Salford residents to see a GP. There are national instructions that GPs should operate total telephone triage where possible, and work is ongoing with colleagues in settings that people may present to if they cannot see a GP. DM also noted that patient experiences in this area need to be listened to as the change from face-to-face to telephone triage has happened. FT highlighted the work that is being done in this area.
JT noted national documents that give indication as to where different procedures fall for surgical waiting priorities, and highlighted that there needs to be a conversation with those who are less urgent as to how best to proceed. He also noted that this is a large amount of work to be done on how patients can be supported with surgery.
Governing Body noted the contents of the report c) Financial Position to June 2020
The paper provided information on the month 3 financial position and forecast outturn for the 4 months to July 2020 based on available information at the end of June 2020. The revised financial regime was detailed, with a forecast deficit of £8.9m before the national financial adjustments which should ensure the CCG has a breakeven position. Of the £8.9m, the CCG had received an additional allocation of £3m and therefore the remaining top up required equated to £5.9m, of which £2.6m relates to COVID costs and £3.3m to the shortfall of funding based on the CCG’s revised allocation.
It was noted that whilst the top up funding is subject to national scrutiny, the CCG believed that costs are justifiable. To support assurance, an extraordinary Audit Committee meeting was held in June to review the governance the CCG has put in place to capture, monitor and assure itself that COVID costs are accurate. EV noted that the Audit Committee was happy to offer further support if required.
Governing Body noted the forecast financial position, and the risks and next steps outlined.
d) Quality of Commissioned Services
The report noted that the COVID-19 pandemic has necessitated a number of changes to the provision of health and social care services to be implemented very quickly. The impact of these changes on the quality and safety of health and social care provision has been considered, any potential risks have been highlighted and where possible mitigating actions have been taken to reduce or minimise the risks.
In response to a query from BW regarding the number of serious incidents reported, and how members can be assured the information is accurate, FT confirmed that a member of her team attends the weekly meetings, and is integrated well into the work. DM noted that quality is embedded in the SRFT mechanisms, and asked whether the SRFT Oversight Group is based with the CCG or SRFT. FT advised that the members of the CCG are now going to be fully embedded in SRFT’s assurance committees, and that the specific group highlighted is an internal one.
Governing Body Page 5 of 7 29 July 2020
An anecdote was provided regarding a positive patient experience at SRFT.
Governing Body noted the contents of the report and received assurance that the CCG has adopted its approach to quality assurance to maintain oversight of providers during the pandemic and into the recovery phase e) Workforce Race Equality Standard
The report provided the Workforce Race Equality Standard (WRES) for approval, noting that this is usually accompanied by an action plan which is required to be published on the CCG website. The report is required to be submitted to NHS England by 31 August 2020, however there is an extension for the action plan to 31 October 2020 due to COVID-19.
EV noted that he was honoured to take up the role of Diversity and Inclusion Champion alongside KJ, highlighting that he can bring lived experience to the table, and noted that uncomfortable conversations may need to be had in this area. He asked what the population size was, and SD confirmed that the survey was of 152 people, and around 14 had identified as BAME.
KJ asked whether the numbers of BAME staff that have experienced bullying and harassment has increased or decreased, and what plans there are going forward. SD confirmed the idea is that the action plan will come back to Governing Body in September.
BW noted that whilst this report is specific to BAME, it is important to remember the seven protected characteristics.
Governing Body approved submission of the WRES 2019/20 Report
f) Data Security and Protection Toolkit
The paper provided an update to members regarding the final status report for the Data Security & Protection Toolkit (DSPT) for the CCG. The CCG is required to submit a DSPT annual return, and despite being provided with an option to defer due to COVID- 19, the CCG submitted the return in March as planned. The CCG met all of the 10 Data Standards, provided all 106 Mandatory Evidence items, and furthermore provided 50 of the 51 recommended evidence items. The DSPT was audited by Mersey Internal Audit Agency, and the final statement articulated “substantial assurance” of the CCG’s processes.
Governing Body noted that the toolkit was submitted ahead of the revised national deadline, and the standards, and evidence items that were achieved
6. Reports of Partnership Boards/Sub-Committees a) Primary Care Commissioning Committee Report
The report updated Governing Body on decisions and discussions at the last meetings in March 2020.
Governing Body Page 6 of 7 29 July 2020
Governing Body noted the contents of the report. b) Audit Committee Report
The report updated Governing Body Board on decisions and risks identified at the last Audit Committee meeting on 7 May 2020.
Governing Body noted the contents of the report. c) Executive Team Report
The report provided assurance relating to the Executive Team in line with the meeting’s Terms of Reference, outlining key decisions made since March.
Governing Body noted the contents of the report.
7. Reflection
TT noted the improvement in how virtual meetings are running. He highlighted discussions around COVID, the key reports including the WRES submission, and thanked members of the public for attending the AGM and staying for the duration.
8. Meeting Closed
The meeting closed at 16:30
Governing Body Page 7 of 7 29 July 2020
Governing Body Meeting 29 July 2020 Part 1: Action Log
Ref. Subject Action Responsible Status
Assurance Framework 5b Get data on cancers diagnosed from GM commissioning team KP Covered in the cancer section of this month’s Assurance Report Report
Chief Accountable 4b Confirm what arrangements Salford Practices have for Occupational Health KP Update to be provided in the meeting Officer Report
Page 1 of 1
GOVERNING BODY MEETING PART I
AGENDA ITEM NO: 4b
Item for: Decision/Assurance/Information (Please underline and bold)
30 September 2020
Report of: Chief Accountable Officer
Date of Paper: 21 September 2020
Subject: Chief Accountable Officer Report
In case of query Ross Baxter Please contact: Senior Patient Services Officer
Strategic Priorities: Please tick which strategic priorities the paper relates to:
Quality, Safety, Innovation and Research Integrated Community Care Services (Adult Services) Children’s and Maternity Services Primary Care Enabling Transformation Purpose of Paper:
This paper contains summaries of Local and National policies, strategies and relevant news to ensure that the NHS Salford Clinical Commissioning Group (CCG) Governing Body remains up to date on the latest developments relevant to the organisation.
Further explanatory information required
HOW WILL THIS BENEFIT THE This paper contains summaries of local and HEALTH AND WELL BEING OF national policies, strategies and relevant news to SALFORD RESIDENTS OR THE ensure that the NHS Salford Clinical CLINICAL COMMISSIONING Commissioning Group (CCG) Governing Body GROUP? remains up to date on the latest developments relevant to the organisation to benefit the health and wellbeing of Salford residents.
WHAT RISKS MAY ARISE AS A None identified RESULT OF THIS PAPER? HOW CAN THEY BE MITIGATED?
WHAT EQUALITY RELATED None identified RISKS MAY ARISE AS A RESULT OF THIS PAPER? HOW WILL THESE BE MITIGATED?
DOES THIS PAPER HELP None identified ADDRESS ANY EXISTING HIGH RISKS FACING THE ORGANISATION? IF SO WHAT ARE THEY AND HOW DOES THIS PAPER REDUCE THEM?
PLEASE DESCRIBE ANY None identified POSSIBLE CONFLICTS OF INTEREST ASSOCIATED WITH THIS PAPER.
PLEASE IDENTIFY ANY None identified CURRENT SERVICES OR ROLES THAT MAY BE AFFECTED BY ISSUES WITHIN THIS PAPER:
Footnote:
Members of Governing Body will read all papers thoroughly. Once papers are distributed no amendments are possible.
Document Development
Not Comments and Date Process Yes No Outcome Applicable (i.e. presentation, verbal, actual report) Public Engagement (Please detail the method i.e. survey, event, consultation) Clinical Engagement (Please detail the method i.e. survey, event, consultation) Has ‘due regard’ been given to Social Value and the impacts on the Salford socially, economically and environmentally? Has ‘due regard’ been given to Equality Analysis (EA) of any adverse impacts? (Please detail outcomes, including risks and how these will be managed) Legal Advice Sought
Presented to any informal groups or committees Sent to the Chief Accountable Officer Approved by the CAO on 23 (including partnership groups) for engagement or (CAO) for review on 23 September September 2020 2020 other formal governance groups for comments / approval? (Please specify in comments) Note: Please ensure that it is clear in the comments and date column how and when particular stakeholders were involved in this work and ensure there is clarity in the outcome column showing what the key message or decision was from that group and whether amendments were requested about a particular part of the work.
Chief Accountable Officer Report
1. Executive Summary
This paper contains summaries of local and national policies, strategies and relevant news to ensure that the Governing Body remains up to date on the latest developments relevant to the organisation.
2. National Update
2.1 NHS People Plan
On 6 August, ‘We are the NHS: People Plan – action for us all’ was officially published, alongside the ‘Our People Promise’. The new People Plan sets out what our NHS people can expect from their leaders and from each other. It builds on the creativity and drive shown by our NHS people in their response to the COVID-19 pandemic, and gives consideration to the feedback received during the programme of engagement which took place on the Interim People Plan. It focuses on how we must all continue to look after each other and foster a culture of inclusion and belonging, as well as take action to grow our workforce, train our people, and work together differently to deliver patient care.
This plan sets out practical actions for employers and systems, as well as the actions that NHS England and NHS Improvement and Health Education England will take, over the remainder of 2020/21. It includes specific commitments around:
• Looking after our people – with quality health and wellbeing support for everyone • Belonging in the NHS – with a particular focus on tackling the discrimination that some staff face • New ways of working and delivering care – making effective use of the full range of our people’s skills and experience • Growing for the future – how we recruit and keep our people, and welcome back colleagues who want to return
In response to the launch of this NHS-wide strategy, Salford CCG will review our existing local ‘People Plan’ to ensure our local workforce approach aligns with the national ways of thinking and compliments the overall objectives and key themes as listed above. The local Salford CCG People Plan will be submitted to an upcoming Governing Body meeting for formal oversight and approval.
2.2 The NHS Patient Safety Strategy
The NHS Patient Strategy was published in summer 2019 and included an ambition to introduce a new role of patient safety specialist into every NHS organisation. These individuals will be key leaders and fundamental to improving patient safety across the system. Chief Accountable Officers received a letter at the end of August from the National Director of Patient Safety asking them to identify one or more
individuals to undertake these roles within CCG’s across England, nominations are expected by the end of November.
Over the past 4 years Salford CCG, along with our partners has had a significant focus on patient safety through the Safer Salford programme that we have been leading. This puts us in a strong position to be able to implement the requirements of the Patient Safety Strategy and embed the role of patient safety specialists. The CCG’s Medical Director and Director of Quality and Innovation have been asked to consider nominations to this role on behalf of the CCG. They will discuss with partners involved in the Safer Salford programme to ensure that these roles align with our existing patient safety initiatives and further updates on this important work will be included in the quality reports to Governing Body.
3. NHS Salford CCG Update
3.1 Salford Safeguarding Children Partnership Annual Report 2019/20
The Salford Safeguarding Children Partnership has recently published their Annual Report for 2019/20. Salford CCG is one of three statutory partners along with the Council and the Police, that has equal and joint responsibility for local safeguarding arrangements for children and young people in our city. The key statistics for Salford children outlined within this report are stark, comparing a range of local indicators, the health and wellbeing of Salford children is worse than the England averages. As of the end of March 2020, there were 548 children on a child protection plan and 562 Looked After Children. These statistics illustrate the important work that partners need to do to keep children safe.
Restrictions imposed due to the national pandemic have increased the risk of neglect and abuse of children going unnoticed. The closure of schools, GPs and health professionals working remotely meant that the number of referrals to the Bridge, our local safeguarding hub reduced significantly. However our strong partnership arrangements and collaborative approach to safeguarding enabled us to quickly implement arrangements for sharing information ensuring that the children we knew were at risk were being reviewed and supported. There is some great work going on in the city to address the challenges we face in terms of tackling neglect and domestic abuse through early help and support. The impact of our work over the past year is illustrated within this report. It includes examples of system wide learning through reviews and the voices of children are highlighted.
https://safeguardingchildren.salford.gov.uk/about-the-partnership/annual-report/
3.2 The 7 Principles of Public Life
The Committee on Standards in Public Life (Nolan Committee) has set out seven principles of public life which it believes should apply to all in public service. The seven principles of conduct that underpin the work of public authorities are as follows:
1.1 Selflessness
Holders of public office should act solely in terms of the public interest.
1.2 Integrity
Holders of public office must avoid placing themselves under any obligation to people or organisations that might try inappropriately to influence them in their work. They should not act or take decisions in order to gain financial or other material benefits for themselves, their family, or their friends. They must declare and resolve any interests and relationships.
1.3 Objectivity
Holders of public office must act and take decisions impartially, fairly and on merit, using the best evidence and without discrimination or bias.
1.4 Accountability
Holders of public office are accountable to the public for their decisions and actions and must submit themselves to the scrutiny necessary to ensure this.
1.5 Openness
Holders of public office should act and take decisions in an open and transparent manner. Information should not be withheld from the public unless there are clear and lawful reasons for so doing.
1.6 Honesty
Holders of public office should be truthful.
1.7 Leadership
Holders of public office should exhibit these principles in their own behaviour. They should actively promote and robustly support the principles and be willing to challenge poor behaviour wherever it occurs.
More information can be found at https://www.gov.uk/government/publications/the-7- principles-of-public-life.
In August 2020, Governing Body members took the opportunity to consider what we already do through the way we behave and how we commission our services to demonstrate these principles. This was also an opportunity for us to think about how/what we might do to demonstrate these better.
The Governing Body is asked to re-adopt these principles as the basis for working practices across the organisation and to actively demonstrate constant adherence to the principles. These principles will be cascaded to staff asking them to recognise the importance of the principles and to uphold them at all times. Our Deputy Chair/Senior Lay Member, Brian Wroe, is the Governing Body lead to champion the principles within the CCG.
Please note that the recommendation is to re-adopt the 7 principles of public life as the basis for working practices across the organisation and to actively demonstrate constant adherence to the principles.
3.3 The Public Health Annual Report and refreshed Locality Plan for Salford
The Public Health Annual Report 2019-20 has been published and the Locality Plan 2020-25 approved. Both documents are available on the Partners in Salford website. The documents outline the work in place and the priorities for Salford pre and post COVID.
The Public Health Annual Report looks at the current situation in the city with the first section covering the response to COVID-19 and the second and third sections reviewing the previous Locality Plan and progress on the next Locality Plan and associated priorities for the next five years.
4. Recommendations
4.1 The Governing Body is asked to:
• re-adopt the 7 principles of public life as the basis for working practices across the organisation and to actively demonstrate constant adherence to the principles • note the contents of the report
Ross Baxter Senior Patient Services Officer
GOVERNING BODY MEETING PART I
AGENDA ITEM NO: 5a
Item for Decision/Assurance/Information (Please underline and bold)
30 September 2020
Report of: Chief Accountable Officer
Date of Paper: 18 September 2020
Subject: COVID-19 response, recovery and planning update In case of query Hannah Dobrowolska Please contact: Director of Corporate Services
Strategic Priorities: Please tick which strategic priorities the paper relates to:
Quality, Safety, Innovation and Research
Integrated Community Care Services (Adult Services)
Children’s and Maternity Services
Primary Care
Enabling Transformation
Purpose of Paper:
To provide the Governing Body with an update on actions taken:
• in the management of the ongoing COVID-19 pandemic • for the restarting of urgent and routine services to support non-COVID-19 health needs • regarding planning for the remainder of 2020/21 and after
This report should be read in conjunction with the quality report and the assurance framework report, for a fuller picture of the work ongoing to respond to and recover from COVID-19.
Further explanatory information required
HOW WILL THIS BENEFIT THE An effective COVID-19 response and recovery, HEALTH AND WELL BEING OF as well as longer term planning, is the vital for SALFORD RESIDENTS OR THE the people of Salford, to minimise the negative CLINICAL COMMISSIONING GROUP? impact for now and the months/years to come.
WHAT RISKS MAY ARISE AS A The COVID-19 response, recovery and annual RESULT OF THIS PAPER? HOW planning work is guided by prioritising action in CAN THEY BE MITIGATED? the areas of highest risk.
WHAT EQUALITY RELATED RISKS A section in this report details the work MAY ARISE AS A RESULT OF THIS associated with inequalities in relation to PAPER? HOW WILL THESE BE COVID-19. MITIGATED?
DOES THIS PAPER HELP ADDRESS In March 2020, COVID-19 was noted by the ANY HIGH RISKS FACING THE Governing Body as a high risk. This position ORGANISATION? IF SO WHAT ARE continues and this paper shares the work to THEY AND HOW DOES THIS PAPER minimise that risk for the people of Salford. The REDUCE THEM? annual planning element also addresses other CCG strategic risks.
PLEASE DESCRIBE ANY POSSIBLE This paper outlines priorities directly and CONFLICTS OF INTEREST indirectly associated with general practice and ASSOCIATED WITH THIS PAPER. requests approval. Governing Body members who work in general practice have a conflict of interest in this element of the paper, which will be managed accordingly within the meeting.
PLEASE IDENTIFY ANY CURRENT All CCG roles and services have been affected SERVICES OR ROLES THAT MAY BE by the COVID-19 pandemic and their work will AFFECTED BY ISSUES WITHIN THIS be guided by annual planning priorities agreed. PAPER:
Footnote:
Members of this Committee will read all papers thoroughly. Once papers are distributed no amendments are possible.
Document Development
Comments and Date Not Process Yes No (i.e. presentation, verbal, actual Outcome Applicable report) Public Engagement COVID-19 response engagement work (Please detail the method i.e. survey, event, has taken place and recovery related consultation) work is ongoing. Clinical Engagement Clinicians have been involved in service (Please detail the method i.e. survey, event, level response solutions and appropriate consultation) COVID-19 governance groups. Clinicians have been involved in shaping the annual planning priorities. Has ‘due regard’ been given to Social Value The annual plan includes social value and the impacts on the Salford socially, actions. economically and environmentally? (Please detail outcomes, including risks and how these will be managed Has ‘due regard’ been given to Equality This paper includes a specific section on Analysis (EA) of any adverse impacts? equality matters and the annual plan (Please detail outcomes, including risks and includes equality actions. how these will be managed) Legal Advice Sought
Presented to any informal groups or Paper shared with the Executive Team Amendments made as committees (including partnership groups) for for comment. Priorities shared with required. engagement or other formal governance relevant Commissioning Committees and groups for comments / approval? Advisory Boards. (Please specify in comments)
Note: Note: Please ensure that it is clear in the comments and date column how and when particular stakeholders were involved in this work and ensure there is clarity in the outcome column showing what the key message or decision was from that group and whether amendments were requested about a particular part of the work.
COVID-19 response, recovery and planning update
1 Executive Summary
This report provides the Governing Body with an update on actions taken:
- in the management of the ongoing COVID-19 pandemic - for the restarting of urgent and routine services to support non-COVID-19 health needs - regarding planning for the remainder of 2020/21
The report should be read in conjunction with the quality report and the assurance framework report, for a fuller picture of the work ongoing to respond to and recover from COVID-19.
2 Current Salford position
2.1 Public Health update
The public health picture is a rapidly changing one, and a verbal update will be provided at the Governing Body meeting to share the latest position.
2,174 COVID-19 cases in total have been reported in Salford as of Sunday 13 September (an increase of 204 cases since Sunday 7 September). The previous week the increase was 156 and the week before that 93 cases, so we are seeing exponential spread from the end of August. Salford is on the top national watch list areas, and third highest in GM. The 7 day infection rate was 88.4 per 100,000 for the week ending 8 September. We are seeing an increase in average age and this is consistent with household transmission to older people in the household and positive tests in care homes. The average age is over 40 years old. There continues to be a number of individuals testing positive across the city. The largest ethnicity category is ‘White British’. COVID related hospital admissions remain very low - new admissions average 3 per day. Sadly we have had five confirmed COVID related deaths in Salford in this second wave. The death rate from all causes in Salford remains below the average levels expected from the last five years. The virus continues to circulate and cluster in households in the city. There is relaxing of attitudes in hospitality and shopping, and in those crowded areas, there will be vulnerable people or those who are unwary. It appears that people are taking the virus home and it clusters within a household. As families are sometimes all key workers, that explains people testing positive across workplaces and settings. In addition, people have returned from holidays where we know there are high rates.
2.2 Outbreaks
All care homes have very strict measures in place which have not been relaxed since the first wave. The care home outbreaks and whole care home testing are no longer the key drivers for the numbers in Salford. There are increasing numbers of cases in workplaces and links to outbreaks that are across GM. There are increased numbers in health and care staff, hospitality, retail, leisure and a handful from education settings.
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2.3 Community engagement
We have taken our community engagement to the street level now. Initially focused on the specific communities in the outbreaks (culture, language, faith), we are now attending areas with highest footfall. We have visible messaging in places and on social media. Engagement with businesses is planned to advise settings to include sanctions for customers/clients and staff where they are breaching COVID secure requirements. Volunteers and trusted leaders in the community are joining the efforts to raise awareness and urge people to follow the hand hygiene guidance, social distancing and to wear face coverings in crowded places. The key message now is “If you think you may have the virus, you must stay at home”.
2.4 Testing
There will continue to be high demand for testing, and Salford is one of the areas prioritised due to high rates of infection. For some time now, home tests have only been available from the national portal for key workers. We are aware that people are finding it difficult to get a slot at a testing centre via NHS119 or the NHS portal. We are advising people who are symptomatic to keep trying on the national portal during the day and early evening. People who do not have symptoms are reminded not to take up slots that someone who is unwell really needs.
In the meantime, Public Health is advising that anyone with coronavirus symptoms acts as if they have tested positive for the virus and self-isolates.
Due to high level of demand, AJ Bell is currently only taking bookings for symptomatic health and care staff and patients. Only the symptomatic member of the household can be tested. We are looking to increase the capacity at AJ Bell at some point in the near future and we hope this position may be able to change.
Salford is piloting saliva testing which is in its early stages and we hope to roll out in due course.
2.5 Compliance and enforcement
We have provided written guidance to all business/persons that are subject to regulatory activity. For example 3,758 retailers have been sent two separate mailshots on reopening of businesses; 310 licensed premises have received reopening advice. 1,200 licensed taxi drivers, operators and owners have been issued advice and guidance on multiple occasions, and 1,370 visits have been conducted, 329 of which are a result of a complaint, including proactive compliance visits to 505 high risk business hospitality venues.
2.6 Health Protection Board report
The Health Protection Board was set up in July 2020 in responding to COVID-19, and the terms of reference were included in the Salford Outbreak Plan published on 30 June 2020. https://www.salford.gov.uk/people-communities-and-local- information/coronavirus/covid-19-outbreak-management-plan/
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The group have been meeting weekly every Thursday to consider the situation in Greater Manchester and the UK, and specifically the situation in Salford in terms of data, soft intelligence and the measures in place.
The Health Protection Board have focused in July on the cases and consequence management system in place and there is ongoing recruitment to the key Test and Trace roles.
In August, and in response to local restrictions, the COVID-19 action plan for August and September was produced. This followed the themes in the outbreak plan and tasked named individuals with key activities.
We have been ahead of the curve on the guidance that Public Health England (PHE) have been producing, and we have been advising care homes and other care settings, schools and workplaces. The volume of household and community transmission has meant that we need to balance a suite of measures.
Along with Greater Manchester, the focus has shifted to the suite of measures in the Contain Strategy as follows:
• Parameters within which people can live with COVID-19: A long list of restrictions is in place already. Can we give people alternatives – not just “Don’t do this” but “you CAN do this instead”? • Actions to protect the vulnerable: This is an area of more recent focus. • Health Checks • Care home take up is good but still needs to scale up • Home care staff take up of sessions at Gateways need to be further promoted • Considering extending the health checks to other staff • COVID risk assessment and long term condition reviews • Previously shielded cohort • Prioritised for medical reviews • Professionals visits to care settings • Guidance is being finalised.
2.7 Approaches to implement interventions
2.7.1 Intelligence/Data
We are now getting daily test results both negative and positive and this reflects the position of Salford along with other areas of the north and Greater Manchester as areas of national concern. We are monitoring the data daily and tracing contacts with advice to isolate. From the 8th September, it is planned for Salford to have access to the national contact tracing system (CTAS).
2.7.2 Community Engagement
Key messages were developed and translated to different languages. Street level engagement was undertaken with the help of volunteers and CVS:
• Stay at home as much as you can • Wash your hands thoroughly and regularly • Keep a safe distance from others - two metres wherever possible
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• Make sure that you follow guidance about meeting in groups • Wear face coverings in shops, indoor venues, public transport and taxis. • Book a test if you are unwell or a member of your household, and stay at Home till you get the result • Cancel your plans even at short notice if you are asked to self-isolate • Make sure you are up to date with all your vaccinations, especially those you missed and seasonal flu.
2.7.3 Outbreak management/prevention • Need to move away from responding to outbreaks and focus efforts on areas where there are no current outbreaks to prevent future outbreaks. • The focus of the next 3 months will be on supporting and gaining assurance from settings deemed ‘high risk’. This includes safely welcoming an estimated 19,000 University of Salford students into the city as well as children and young people back to schools and college. • Horizon scanning and predicting potential settings and communities with timely response. • Winter planning/ Flu vaccinations including preparing if and when a COVID-19 vaccine comes available.
3 Health and Social Care response
This section of the report outlines how the health and care sector in Salford has responded from mid-July to mid-September and follows on from the detailed reports provided to Governing Body in June and July. Much work had been undertaken up to July so below may appear limited information, but only reflects any significant changes since that report so as to avoid duplication. This includes the critical work with partners across the city. It highlights the exceptional response staff across many organisations.
The focus has now moved from ensuring that critical services continue to operate alongside the COVID-19 response, to undertaking a greater volume of urgent work and safely restarting routine services. This is a significant challenge for the system.
3.1 VCSE Sector
The VCSE COVID response group has become the Spirit of Salford Network to maintain a legacy and now meets monthly, the group’s terms of reference and membership have been reviewed with the focus now on recovery and future planning.
The COVID response funding repayment received has been reinvested into the 3rd Sector fund for the coming year this amounts to an additional £260k, £40k of which has been top sliced to support the ‘Big Reset Conversation’ and targeted engagement work. Initial ideas on how to allocate the remaining £220k include:
• Add £160k to the Recovery Fund pot, which is ‘live’ for bids now (we’ve currently allocated £200k for grants of up to £20k and I think we will be hugely over-subscribed); • Add £10k back into the Wellbeing Fund pot (we took it out to help meet COVID- 19 demand for other pots);
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• Allocate £50k for a COVID Responsiveness Fund which we can spend to address emerging need over the next 6 months.
3.1.1 Update on key areas of work:
Spirit of Salford (SOS) Stay in Touch Service the service was transferred from Salford NHS CCG to the Health Improvement Service, who have made contact with the 150 people who had been using the service to assess their ongoing support needs. Originally there were 30-40 volunteers providing support but now down to 10 reflecting the reduction in calls. Support from Health Improvement Service is still on offer and they are setting goals around emotional wellbeing and lifestyle working with Age Friendly Salford and the Beyond service making referrals where appropriate. COVID health checks are now available to everyone via the Spirit of Salford helpline.
Age Friendly Salford and SOS have seen 14 referrals, seven women and seven men and as of 24 August they have made telephone contact with five People.
As part of the initial telephone conversation to understand what is important to the individual, the following issues/concerns were raised: . • Confusion about lockdown what they can and can't do • Not being able to see family • Depression/crying all the time • Not eating well because they can't be bothered • Worried about other members of their family
3.1.2 Pharmacy Delivery Service
The pharmacy delivery service, which has delivered 500 prescriptions on behalf of pharmacies since mid/late May. There were seven Pharmacies with steady demand. The service was stood down on 14 August due to end of shielding patients and Pharmacies not receiving money for deliveries. The infrastructure is in place ready if it needs to start up again, and can be done on an ad hoc basis.
3.1.3 Salford City Council Food Hub Support
Food parcels are no longer available via the hub however, people that can’t afford food can ring SOS helpline and be referred to Salford Assist. If they physically can’t buy food they will be referred to Salford CVS for volunteer support.
3.1.4 Feeding Salford Plan
Salford CVS have circulated the draft plan; the plan was re-written before COVID and was offered to Local Authority as part of the food recovery plan. It has now been re- written to include COVID-thinking and is a recovery plan for statutory partners.
The key issues include: • Food clubs rather than food banks. • School uniform issues • Animals/pet food share • Sanitary products
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3.1.5 Key considerations for recovery remain consistent:
• Work is underway to look at the development of recovery plans – focusing on what elements we would like to keep utilising the additional £220k identified – grant rounds to support recovery are open and/or planned • Stay in Touch service will be maintained but facilitation will switch to the Health Improvement Service in the interim to release CCG staff further discussion to take place regarding the longer term stability. • SOS Network focusing on how best we sustain programmes of work in stages of recovery - short, Medium and long term • Outline plan completed for the 2021/22 3rd Sector fund – there will be an extended responsiveness fund.
3.2 Adult Social Care
The Adult Social Care (ASC) system has maintained a high degree of operational and service resilience throughout the COVID-19 crisis and as we build service back.
The two key groups established (ASC Market Strategy Group and ASC Strategy & Assurance Group) continue to meet and oversee response and recovery work
We have been progressed a co-design restart project for our day centre services and through September a number of our day centres have started to provide direct services to people. We will maintain strong Care Act and Public Health oversight as these services further build back into October, making any necessary adjustments to plans should local or national guidance require this.
The recent announcement relating to access to PPE for ASC services is welcomed and we are ensuring this national message is communicated to our local providers through our existing communication and engagement routes. By accessing the national PPE supply routes, ASC providers will be assured of supply through this next phase of the outbreak.
We also welcomed the announcement about the continuation of the Infection Control Funding for ASC services. This will provide further financial assurance to care providers, enabling them to maintain their public health prevention and protection requirements. We await specific guidance about this announcement and expect this before the end of September. As an interim support measure, the local financial support offer (known as the Salford Offer) is planned to be extended for a further month until the end of October 2020.
Over recent weeks we have seen the rise in COVID-19 cases across Salford impact on a number of our Care Homes. We have seen ten COVID related deaths in September across two homes with a further ten homes with infections across their staff/resident population. Public Health colleagues are working closely with those homes at this time. We have not seen recorded outbreaks in any other part of the Adult Social Care service system. To support safe and coordinated professional visits to care homes we published a local professional visiting guide - this guide has been approved by the Director of Public Health.
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3.3 Primary Care
Primary care continues to respond flexibly to COVID-19. All Salford GP practices remain open and operating COVID-safe models. Total triage systems remain in place with high levels of virtual and telephone consultations. All practices are offering face-to-face appointments for patients when clinically appropriate but the number of such appointments is substantially lower than pre-pandemic levels
Salford Primary Care Together continues to deliver a range of COVID-19 services, demand for these services is currently lower than the peak of the late spring / early summer. The service’s capacity has been flexed to reflect demand and to support the reform of the Urgent and Emergency Care System.
There is a focus on maintaining quality and safety as well as safely restarting routine GP services, but priorities have changed in response to the pandemic. In the first few months of the pandemic there was a significant reduction in the rates of initial diagnosis of common physical (e.g. Type 2 diabetes, cancer, circulatory system diseases) and mental health conditions. Various initiatives are underway to address this including a “catch up” of screening, immunisation and vaccination services, initiatives to improve early identification of cancer and health checks for people with learning disabilities and front line workers. Long term condition management and reviews are being re-focused to prioritise patients who are at additional risk due to COVID-19. The seasonal flu vaccination programme has commenced; in a couple of Salford’s neighbourhoods Primary Care Network schemes are being established to enhance what is being delivered at individual practice level.
Community pharmacy has remained open to the public for the duration of the pandemic. The national commissioned medication delivery service for patients on the shielded list ceased on 31st July 2020 as the national shielding programme was paused. This service will be reinstated if a decision to re-introduce shielding in a locality is taken. An announcement from the DHSC will allow community pharmacies who are based in the reintroduced shielding postcode areas to recommence the service to support shielded patients and ensure they can, if necessary, have medication delivered. This will be funded as before via the national pharmacy contractual arrangements.
3.4 Mental Health
IAPT demand is now back at pre COVID-19 levels (there was a drop of c30% during the early months of COVID-19). Evaluation of the acceptability and effectiveness of video conferencing within the GMMH service has provided assurance of the effective and acceptability of this method of delivery with people using the service and staff. Where people chose (or were unable) to access video / telephone therapy, their details have been retained for GMMH to establish contact and prioritise face to face offers as soon as possible. Where access to online / telephone offers have been unsuitable for people due to access reasons (e.g. where someone requires an interpreter or if the person has LD impacting on this method of delivery), they will again be prioritised for face to face delivery. As part of the ‘building back better’ approach, IAPT services are also exploring group and online provision to inform a blended approach in the future.
Living Well VCSE Grants have been awarded to two services to develop additional capacity to address issues of Loss and Substance Misuse. These were themes that
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were identified pre-COVID-19 as key issues for our Living Well cohort but which are all the more important since COVID-19. These services will form part of the Living Well system with referrals going via the Living Well MDT
Discussions are underway with Six Degrees regarding the development of a Bereavement Counselling service for adults in Salford which will complement the Bereavement Support Service they are commissioned to provide across GM
In July / August we were looking at a backlog of around 200 people waiting for MATS due to the service having to stop completing assessments in lockdown. It was initially thought that resolving the waiting list would take until November approx. However GMMH are currently booking the last of the waiters (approx. 65 people) into clinics for September.
3.5 Children’s Services
Impact of COVID-19 on Children and Young People – a piece of work is underway to assess both the positive and negative aspects of COVID-19 and lockdown policy. It is intended that this will help us to identify actions to mitigate negative impacts and enhance positive impacts of the policy and further inform strategies for recovery and renewal. There is acknowledgment of the impact around the wider determinants of health and well-being the document also outlines opportunities to promote and protect population health and well-being and reduce health inequity.
Summary Specific Impact of COVID-19 on Children and Young People:
• Increased mental health or wellbeing concerns • Increased loneliness and isolation missing friends, family and school • Disruption to education – impact on exams • Lack of safe space – including not being able to access their youth club/ service and lack of safe spaces at home • Challenging family relationships • Impact of an increase in the incidence of Domestic abuse • Lack of trusted relationships or someone to turn to • Increased social media or online pressure – for some digital poverty and access to technology • Higher risk for engaging in gangs, substance misuse, carrying weapons or other harmful practices • Higher risk for sexual exploitation or grooming • Impact may be higher for those already experiencing ACE’s • Not being able to access health care in the same way or independently • Reduced amount of physical activity
Children and Young People Recovery plan - the updated CYP COVID-19 recovery plan is in its 8th iteration the plan is monitored at the monthly Children's Services Extended Leadership Team (COVID-19) meeting. The current focus is around the preparation for children and young people returning to school. Work is underway to assure parents and carers that all the necessary precautions and plans are in place this will hopefully support good attendance levels. The work includes support for
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schools around visitors to school, it also provides staff with the necessary information and skills to deal with parental concerns.
Children’s Integrated Services Working Group – there are now weekly meetings with SRFT covering operational delivery of the current recovery plans, with a focus on the existing service redesign and transformation strands. The group are in the process of developing an overarching Health and Wellbeing framework. The document is built around the Start Well elements of the Salford Locality Plan and aligns with both the NHS Long Term Plan (LTP) and the GM Children & Young People Health & Wellbeing Framework. It identifies the key themes and objectives from each of these documents and outlines the Salford response.
The CCG is continuing to work with Salford Royal NHS Foundation Trust (SRFT) Safeguarding Team and Children’s Services to resolve some data quality issues and to provide assurance around support to children and young people in Salford who are looked after and / or in the youth justice service.
3.6 Community Services
All community health services continue to work through a process of reinstating services and are also planning for an enhancement of community services to manage the rehabilitant needs of those who have had COVID-19 and those who have been shielded over recent months. To assist with this Salford Care Organisation has set up a Community Recovery Cell which meets weekly.
Although virtual appointments will remain the default method of care, risk assessments to enable the resumption of face to face appointments for the most vulnerable / those with specific conditions are considered by the Recovery Cell. Since the last update to Governing Body resumption of some face to face appointments have been approved for the following areas:
• Podiatry • Audiology (Paediatric, Adult Assessment and Rehabilitation and Adult Vestibular Assessment and Rehabilitation) • Cardiovascular Rehabilitation • Speech and Language Therapy • Diabetes Outpatients • Home Oxygen Therapy Service • Lower Limb Vascular Triage • High Impact Substance Misuse Team • Urology • Orthotics • Pulmonary Rehabilitation • Musculoskeletal CATS • Parkinson’s Disease Outpatient Appointments • Complex Care of the Elderly and General Geriatrics Outpatient Clinics
On 31 July 2020 NHS England published a letter on the third phase of the NHS response to COVID-19. This letter replaced all previous guidance. In relation to community services this letter states the following:
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“General practice, community and optometry services should restore activity to usual levels where clinically appropriate, and reach out proactively to clinically vulnerable patients and those whose care may have been delayed.”
“Community health services crisis responsiveness should be enhanced in line with the goals set out in the Long Term Plan, and should continue to support patients who have recovered from the acute phase of Covid but need ongoing rehabilitation and other community health services. Community health teams should fully resume appropriate and safe home visiting care for all those vulnerable/shielding patients who need them”
“From 1 September 2020, hospitals and community health and social care partners should fully embed the discharge to assess processes.”1
The CCG will be working with colleagues at SRFT, via various routes to ensure these measures are put in place and services continue to be stepped back up to pre- COVID-19 levels, where clinically appropriate and safe to do so.
3.7 Acute Services
The Salford Care Organisation has set up a number of Recovery Cells which meet weekly. The cells have specifically focused on:-
3.7.1 Admitted Cell
Continuing the push to increase on-site theatre capacity in the short term by unblocking the barriers to re-opening all theatres on-site (this has included staffing levels, Anaesthetist cover, zoning/infection control requirements). SRFT are anticipating that a further 2 theatres are expected to be operational by the end of September.
Continuing to develop and use off-site theatre capacity (i.e. Oakland’s for Orthopaedics, the Alexander for Neurosurgery, Spire for ENT and Spinal Surgery, Fairfield Hospital for Orthopaedics and Rochdale for General Surgery, Urology and Gynae).
If all plans deliver, SRFT expect to achieve 79% of its target activity by end of September within NHS capacity across the NCA, with this increasing to 87% with the Independent Sector capacity included. This is in line with the 80% target by end of September that is included in the national Phase 3 recovery guidance.
Longer term planning is underway regarding how SRFT can further increase theatre capacity, including consideration of 7 day working.
For non-theatre work, the main area of focus is expansion of day case infusion / procedure capacity. This service has a reduced throughput due to increased spacing / social distancing requirements, so there is a need to increase capacity to off-set this as well as making up for the reduced throughput in recent months.
1 NHS England, “Third phase of NHS response to Covid-19 letter” (31st July 2020) https://www.england.nhs.uk/coronavirus/wp-content/uploads/sites/52/2020/07/Phase-3-letter-July-31-2020.pdf
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3.7.2 Non-admitted Cell
Risk assessments have been undertaken for clinics where Face to Face (F2F) appointments are required and all specialities have restarted out patients in various forms, both F2F and virtual.
Infection Prevention Control (IPC) requirements have resulted in a significant drop in physical waiting room capacity. Main Outpatient waiting area now at 27% of previous, clinic room capacity is at 75% of previous levels.
SRFT are continuing to monitor the number of virtual v F2F activity aiming for 60% of activity being delivered virtually.
SRFT are working with Four Eyes Insight around Neurology and Dermatology on demand and capacity, modelling, clinic appointments optimisation and redesign.
SRFT are also in the process of re-establishing phlebotomy provision for virtual outpatient appointments.
Recovery work is taking place via the Northern Care Alliance (NCA) System Wide Outpatient programme (SWOP). The SWOP remit has extended its focus on the wider recovery programme with establishing links to the local recovery cells. Work to support recovery has focused on the following areas:-
3.7.3 Patient Initiated Follow Up (PIFU):
A GM policy has been developed to support PIFU. Patient Initiated Follow-up (PIFU) enables patients to decide if they would like to be followed-up and when. In line with the personalised care agenda, PIFU plays a key role in enabling shared decision making and supporting patients with self-management by helping them to know when and how to access the right clinical input. This should free up much needed clinical capacity. A Standard Operating Procedure (SOP) is in development to support this work and provide consistency in delivery at specialty level. SRFT are commencing work on Patient Initiated Follow Up pilot within two specialties.
NHS E/I NW have established an outpatient adopt and adapt programme: GM Elective Reform Programme have aligned their work to reflect this NW programme of work
NHS E/I NW are establishing a number of task and finish groups to support the outpatient adopt and adapt programme and Salford CCG and NCA have been accepted onto the PIFU rapid adopter programme. This rapid adopter programme will take place from mid-August to November
3.7.4 NF2F non face to face appointments:
This work has continued to support virtual consultations where safe and appropriate. This has been supported by new / revised Community Standard Operating Procedures (SOPs) associated with the COVID-19 Response and Recovery Plan.
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3.7.5 Extended Advice and Guidance (A&G):
Advice and Guidance (allowing GPs to seek advice from secondary care consultants and enabling the management of patients in primary care) is the starting point for the whole of outpatient transformation. There is now a national requirement to accelerate both outpatient recovery and implement rapid transformation to urgently tackle the backlog of patients needing care, estimated to be up to 2 million outpatient appointments across the NW. Work at a NW level will be led by the NHSE/I Outpatient Restore & Transform Programme who will build on work already carried out. Advice and guidance is a core element of this.
The CCG is working with SRFT to roll out extended Advice and Guidance and initial engagement with Primary Care and the Primary Care Networks (PCN’s) has taken place to inform this work.
Improved utilization of A&G is being promoted locally and SRFT are continuing to work to ensure all specialties offer A&G on Electronic Referral system e-RS.
3.7.6 Diagnostics Cell
Radiology - Radiology capacity has significantly reduced across all modalities due to social distancing and decontamination requirements. Activity figures for July compared to 19/20 baseline are CT Scans 94%, MR Scans 69% and Ultrasound Scans 61% for SRFT.
There are plans in place to try and achieve the 90% for September and 100% for October targets in line with the Phase 3 recovery plan. These will be very challenging to achieve and there are limitations in terms of patient safety requirements, available capacity and workforce availability. The NCA Radiology department is working closely with the GM Imaging Cell to identify and utilise all available and suitable independent sector (IS) capacity for Salford patients across GM. There are significant backlogs of work across all modalities and this will take a significant amount of time to work through. This will mean that waiting times for Radiology exams for patients that are not on cancer pathways will be increased and will continue to be so for some time.
Cancer access and performance for Radiology has been maintained throughout the pandemic. Radiology reporting times are significantly better than pre-pandemic levels and Radiology are scoping what is required to maintain this level of reporting performance.
Endoscopy / Cross-relaxation imaging CRI – Endoscopy activity is scaling back up after being reduced to just urgent inpatients during late March and April as per Gastroenterology national guidance.
SRFT are currently at about 50% of last year’s activity with plans to increase this on a week by week basis in line with Phase 3 recovery. They are currently using independent sector capacity at the Spire and Oakland’s to deliver additional sessions, and is looking to further increase activity on the Salford endoscopy site, increasing both the numbers of sessions; and the numbers per session, safely, and in accordance with any IPC guidelines.
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Currently, cancer and urgent cases are prioritised to address the backlog of activity that had accrued during the period of inactivity, followed by the long waiters and then the next set of patients clinically prioritised.
CRI activity is back underway after a long period of inactivity due to only urgent activity being delivered on site. All CRI diagnostics are back underway, but have backlogs to contend with as the services get back up and running. This is being addressed by additional sessions being worked to bring down the waiting times. Overnight sleep studies are yet to resume due to the difficulty in ring fencing bed capacity due to the zoning that is now required to segregate COVID and non-COVID patients on site. Alternative locations are currently being discussed.
Neurophysiology – the service has been scaling back up from an urgent-only basis to start to see routine patients again. This has involved gradual increase in clinic templates, made possible by creative approaches to spacing in the waiting room and wider department, and having patients wait in their cars etc. until their appointment time. By the beginning of October, the service expects to be running at 100% of pre- COVID-19 capacity, and the service is considering ways of clearing backlogs through ad-hoc weekend extra clinics.
3.7.7 Cancer
Performance is close to on achieving key cancer standards (2ww, 31 day, 62 day) for the most recent period with complete data (June). However, this doesn’t reflect the growth in patients beyond their breach date i.e. backlog caused by delays in pathways. Key bottlenecks include certain diagnostics such as Endoscopy.
Close attention is being paid to all patients who are beyond their breach date. A new weekly cancer PTL meeting is in place at SRFT, attended by Directors of Operations and Managing Directors to review patient-level pathway details. This, along with gradual improvements in access to diagnostic and treatment capacity, is reducing the number of 104+ day waiters.
4 Equality Impact
4.1 Significant work has taken place over this last period on the planning and delivery of robust engagement with the city’s hard to reach communities in relation to the dissemination of COVID-19 public health messaging. The communities which have been focussed on to date (as informed and prioritised by public health data) have included; North African, Portuguese speaking African, South Asian, Orthodox Jewish and Young People. The engagement approach being adopted involves in-depth co- ordination of the Health Improvement Service, CVS, Healthwatch and the neighbourhood teams (who have trusted relationships with the communities already) using the messaging which has been developed and agreed by public health and the Salford Communications Cell.
4.2 Work has commenced on scoping of the contents and agreeing the direction of the new citywide Equality Strategy. Rather than creating a standalone organisational strategy, the CCG will adopt this partnership strategy, but will create a bespoke work plan, which ensures we achieve our statutory duties.
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4.3 A return was submitted to Greater Manchester Health and Social Care Partnership on Friday 4 September providing assurance that we are giving appropriate consideration to our public sector equalities duties throughout this phase of the pandemic (appendix 1). The partnership have indicated that they are happy with the contents of our submission.
4.4 Work continues on an ongoing basis to review and quality assures all staff / workforce risk assessments.
5 COVID-19 Governance
5.1 Changes to system wide COVID-19 arrangements outlined in July’s Governing Body report are shown in italics within this section.
5.2 Salford City’s response was coordinated by the Salford COVID-19 Strategic Coordination Group. The group met daily from March to early May which then reduced to weekly and has now been stood down, instead business as usual routes are being used.
5.3 Salford Recovery Group was established in early June and is a partnership meeting led by SCC. This group meets fortnightly with a topic specific focus, including on test and trace, returning to the Civic Campus, economic impact. For the CCG it is attended by Director of Corporate Services.
5.4 A Salford Health Protection Board continues to meet weekly, attended for the CCG by the Medical Director and Director of Quality and Innovation and whilst testing work continues also by the Director of Corporate Services. An update from
5.5 Partners across the city came together to design, develop and deliver our response to COVID-19 and to deliver support to our residents. This collaboration is equally important as we ease lockdown and plan recovery. Each partner has their own structures in place. SCC is formally responsible for ensuring city wide coordination of the local response and recovery. Two core groups are in place to support the city wide effort. Feedback suggests that these meetings are valued and operating well.
• COVID-19 Civic Leadership Group: chaired by the City Mayor or Deputy City Mayor, this group is now meeting fortnightly (having met weekly in the early stages of our response) and brings together chief officers from across the city’s public, private and voluntary sector organisations. The CCG’s Chair is a member of this group.
• Local Resilience Forum (LRF): chaired by SCC’s Head of Community Safety, this group brings together tactical leads from all of the critical partner organisations across the city. The LRF is a standing meeting that would normally meet twice a year to exercise our emergency response plans, however it met weekly from March to the end of May, moving to fortnightly from the beginning of June and monthly from July. The CCG’s Director of Corporate Services is a member of this group as a senior manager and a CCG on call manager.
5.6 The health and care elements of the response and recovery have been coordinated through two groups:
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• Health and Adult Social Care COVID-19 Coordination Group This group met twice weekly from March until the end of May, moving to weekly from the beginning of June and fortnightly from July. This group was stood down in mid-August, with the Health Protection Board and business as usual governance taking over. It is likely that this group will be stood up again over coming weeks as system pressure grows.
• Children’s COVID Coordination Group This group, also known as the Children’s Services Extended Leadership Team (COVID-19) Group, met weekly until June, then fortnightly and now meets monthly to monitor the Children and Young People (CYP) Recovery plan - the updated CYP COVID-19 recovery plan is in its 8th iteration. The current focus is around the preparation for children and young people returning to school. Additional work is underway to fully assess the impact of COVID on CYP and service delivery.
5.7 A range of subgroups to these two coordination groups were established, and outlined in previous reports, many of these have now ceased, returning to business as usual arrangements. The current position is that:
• The Testing Coordination Group has continued without changes. • The Tracing Coordination Group (Squad) has been stood down. • The VCSE COVID response group became the Spirit of Salford Network to maintain a legacy and now meets monthly, the group’s terms of reference and membership have been reviewed with the focus now on recovery and future planning. • The Adult Social Care Coordination Group has stood down, however the fortnightly ASC Market Strategy Group and weekly ASC Finance group remain. • The GP COVID Co-ordination Group continues to meet but its frequency has been reduced to once a fortnight. The supporting governance of Primary Care Neighbourhood leads and huddles with GP practices remains in place and their frequency has also been reduced.
5.8 The CCG continues to be involved in or receives feedback from a range of Greater Manchester level groups, most notably the Community Cell and Hospital Cell.
6 Recovery planning
6.1 Throughout this report the word recovery is used in its loosest sense, recognising the huge loss that individuals and communities have experienced during this crisis, and also recognising the community response and some service changes that have been made during this period, which provide opportunities to “build back better and fairer”.
6.2 In July’s Governing Body report our approach to recovery planning was outlined, as a reminder planning is now for three overlapping phases of recovery. The NHS COVID-19 phases are:
• Phase 1 – initial COVID-19 response • Phase 2 – restarting of urgent and some routine services • Phase 3 – easing out of lockdown to a living with COVID-19 time • Phase 4 – referred to as ‘Building Back Better’ in Greater Manchester, and in Salford as building back better and fairer.
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6.3 We are currently working on elements of all of these phases within the CCG. The overlap will increase if we experience second or third waves of the virus.
6.4 As we move from the initial response phase of COVID-19, we begin to consider how the health and care system provides the best care and treatment possible during a “living with COVID-19” phase as well as the longer term system “recovery” and transformation.
6.5 As part of phase 3 planning following on from the phase 3 letter issued by NHS England/Improvement (see appendix 2), the CCG has submitted all required activity related returns (template and narrative) to Greater Manchester in line with timeframes set, working closely as a local system across Salford to ensure that provider and commissioner planning aligned. We are aware of the discussions between the NW Regional Team and Greater Manchester colleagues, as our STP footprint, on restoring services. We are working to ensure that these plans represent ambitious but realistic levels of activity for our local patients.
6.6 We know that the NW is running below national average and required targets for restoration of services and GM is especially low for some elements. Systems continue to review plans and undertake “check and challenge” to understand organisational variation with the expectation that plans will improve. We are maximising the opportunities through NHS111 first, use of independent sector and impact of transformation/productivity maximisation - adapt and adopt (outpatients, endoscopy, theatres and imaging). To deliver the ambition within the phase 3 letter, considerable work is ongoing at provider and system level, including involvement in the adapt and adopt plans.
7 Recommendations
The Governing Body is asked to note:
• the update regarding the management of the ongoing COVID-19 pandemic, • the restarting of urgent and routine services to support non-COVID-19 health needs. • planning for the remainder of 2020/21 and after.
Steve Dixon Chief Accountable Officer
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Urgent actions to address inequalities in NHS provision and outcomes – Return Template for (NHS Salford CCG)
This piece of work needs to be completed and returned to Lisa Stack: [email protected] (GMHSCP) by 12 pm on the 4th September 2020. Summary: COVID-19 has further exposed some of the health and wider inequalities that persist in our society. The GMHSCP team have been asked to co- ordinate this return for the Regional Office. This template, provided by NHSE/I is intended to describe how we are, and intend to address the inequalities in health provision exposed by the COVID -19 pandemic against 8 key areas. This return will then form an integral part of the Phase 3 Planning return to NHSE/I.
Urgent actions to address health Please set out here your approach to implementing the urgent actions to address health inequalities inequalities specified within the guidance on Implementing phase 3 of the NHS response to the COVID - 19 pandemic. Note that the North West COVID - 19 Community Risk Reduction Framework is available to support local partnerships to reduce the risk of transmission and impact of COVID – 19 on local communities. You may
wish to cross refer to relevant sections of this template. Spirit of Salford Network 1. Protect the most The Spirit of Salford Network is a citywide response to COVID and includes partner representation vulnerable from COVID-19, from health and care and wider. The network receives regular insight from communities and with enhanced analysis develops plans to meet the needs of the most vulnerable. This has included: and community • Stay in Touch service providing regular chat and check calls. engagement, to mitigate • Help with shopping and food the risks associated with • Social needs such as dog walking, medication collection relevant protected characteristics and social Citizen Insight and economic conditions; The network carried out a COVID Insight survey between April – July 2020 which has led to a and better engage those number of actions including targeted prevention campaigns, improved information about waiting lists communities who need and priorities and exploring Salford wide COVID testing. most support. Third Sector funding A crisis fund was also set up for the network to increase action at grass roots level. Several projects were implemented by communities themselves including; improved COVID information to the Jewish community, Kosher food parcels and support for the South Asian community to stay connected during Mosque closure.
Understanding impact on equality groups NHS Salford CCG and Salford’s Equality Improvement Partnership led on an overarching equality impact assessment for health and care. Findings and recommendations have been presented across the system for action and include: • Improve data collection in relation to gaps identified • Further insight gathering with underrepresented groups (currently underway) • Engagement on recovery plans
Shaping recovery plans – Big Reset Conversation The integrated care system (Salford Together) will launch Salford’s Big Reset Conversation (health and care) on 7th September 2020. A three month partnership engagement plan to inform recovery plans. Salford CVS will lead on targeted engagement with underrepresented communities (including non-digital).
Prevention campaigns A system wide health inequalities group, Salford Time to Act meets on a weekly basis and reports directly into the health and wellbeing board. This group represents system leaders across the public sector and voluntary sector, looking at consistent messaging and joint plans and programmes.
Targeted outbreak communications and engagement The Salford Comms Cell is a partnership communications and engagement group established to oversee targeted engagement. This group receives public health data and community insight to develop tailored engagement programmes and communication materials to reduce infection and spread of COVID-19. For example, accessible information for the Portuguese speaking African community has been developed and shared with community leaders, via Whatsapp in different languages and disseminated by volunteers face to face.
Workforce Salford’s BAME Staff Risk Assessment Group, which has now evolved into Salford Time to Act, developed a Risk Assurance Framework for all health and care partners in Salford including the VCSE sector. This was to ensure we have a consistent approach in who would be assessed and being able to manage the outputs of the risk assessment across the whole health and care sector. Additional training has been developed for third sector organisations to enable them to carry out risk assessment competently.
Cold Home Assessment Service The CCG commissioned the Cold Home Assessment Service (HAS) implemented to provide additional capacity in order to support high risk or ‘shielded’ patients in their homes where there was an acute presentation.
2. Restore NHS services Interpretation & Translation Services for remote, digitally enabled Consultations. inclusively, so that they are During the initial phase of the pandemic the CCG’s monitoring highlighted that practices use of used by those in greatest interpreters fell significantly. This highlighted concerns about access to primary care services for need. This will be guided Salford’s non-English speaking BAME communities and BSL patients. The CCG commissions a by new, core performance range of interpretation, translation and BSL services for GP practices – including those which are monitoring of service use designed to support remote consultations. The Service Improvement Team is promoting these and outcomes among services to GP practices, training staff to use them and monitoring utilisation to identify and target those from the most those practices where lack of access for these groups appears to be a concern. Alongside this, the deprived neighbourhoods CCG is progressing an engagement exercise with these communities to seek to understand how and from Black and Asian they can be supported to be more confident in using the services available to them, and providing communities, by 31 reassurance that there are interpretation services in place. October. Citizen insight and equality barriers As above, an overarching EIA has been completed for health and care in Salford. Recommendations have been presented to the Adult Advisory Board for Salford Together and include the gathering of further data and insight to inform recovery plans.
The Big Reset conversation will provide regular insight in relation to barriers to accessing services for protected characteristics.
Internal datasets No systematic approach to this as of yet, but have identified the following actions: • Working with providers assess data completeness and data quality • Working with providers, develop data completeness and data quality improvement plans as needed • Potentially develop contract levers to help achieve these plans
Ideally, the above actions should be undertaken GM-wide. Other actions for Salford will be: • Pilot an approach in one/two service areas for reviewing access and outcomes for BAME/deprived/other groups • Consider our future approach based on this pilot and examples of best practice
• The overarching EIA for health and care (above) made recommendations to the Adult Advisory 3. Develop digitally enabled Board to ensure digital pathways were accessible to non-digital users e.g. face to face and care pathways in ways telephone where required which increase inclusion, • The Big Reset conversation will target non-digital users to provide insight around barriers for all including reviewing who is four pathways between September 2020 and December 2020 using new primary, • Targeted engagement with non-digital users has begun and includes insight from people with outpatient and mental learning disabilities and BAME groups who do not have internet access. Findings will be health digitally enabled reported across the system in September 2020 care pathways by 31 • EIAs and monitoring for NHS 111 First, total triage in general practice, digitally enabled mental March. health, virtual appointments • Virtual appointments is one of the five pillars for the Northern Care Alliance and will sit in the Out Patients programme. As actions emerge, the NCA will be allocating support to priority areas • Big Reset Conversation will gather insight on service use
Reviewing patient experience is built into all such programmes and any service change, transformation programmes and projects. As a lot of these examples are COVID-related, we are retrospectively developing mechanisms to do this.
Mental health • Digital pathways in place for mental health via the following: • Silvercloud: commissioned at GM level, providing open access CBT based interventions for anxiety, resilience, stress and COVID specific anxiety, in addition to offering IAPT supported pathways via Step 2. Step 3 currently being explored • Etherapy: commissioned locally via existing contract with Self Help Services as part of the IAPT pathway • Locally commissioned IAPT: services provision (GMMH / Six Degrees) has been digital / telephone delivery since the start of the national lockdown restrictions • Beyond: development of a local VCSE mental health response for COVID via self-referral through the Spirit of Salford Local Authority COVID response telephone line. Providing online / telephone interventions for people not known to GMMH • 24/7 support line for people known to GMMH • To support the work of Beyond and Living Well, a specific EIA has been undertaken which includes the action to monitor the uptake of the digital Beyond offer by demographic breakdown • IAPT services have primarily been delivered by telephone / online methods throughout the COVID response. Acceptability of this delivery method has been reviewed by Step 3 GMMH IAPT service with positive results • Further demographic analysis planned for key services to underpin additional actions • Experiences from people using IAPT / Beyond / Living Well services are currently being collected via the CCG engagement team • Recruitment is underway for 0.5wte Healthwatch post to gather lived experience of mental health services using ethnographic research. This will be particularly linked with the Living Well and Beyond elements of service provision.
Salford Royal NHS Foundation Trust/Salford Care Organisation Where clinically appropriate outpatient consultations have moved to video or telephone appointments. Patients have a direct line of communication should they need to change or be supported for their appointment type. The patient access policy including the DNA criteria is not being applied for non-face to face appointments during COVID so patients are not disadvantaged should their telephone number be wrong or not recorded.
The usage of video & telephone is collated by age profile and postcode prefix to assess any early warning signs of inequity.
Some services have surveyed patients following telephone and video consultations and have noted reduced cost and time of travel and more comfortable consultations due to the home environment.
Long Term Condition Management and Prevention 4. Accelerate preventative In line with the recommendations of the phase 3 letter, the CCG is in the process of reintroducing an programmes which adapted Long Term Condition KPI in the Salford Standard in 20/21. This will incentivise GP proactively engage those practices to undertake long term condition reviews of their patients. The KPI is to be adapted to at greatest risk of poor target GPs efforts at those at those who are most vulnerable to additional risk due to COVID-19. health outcomes; including This includes our BAME communities and front line workers, including those who condition(s) place more accessible flu them at increased risk (e.g. obese, poorly controlled diabetes or respiratory disease, etc.) Practices vaccinations, better are to be given guidance to help identify priority patients, as an interim whilst the national COVID-19 targeting of long-term risk prediction model is being developed. In addition a guide has been developed to help practices condition prevention and undertake reviews in the context of COVID-19 – the expectation is that all practices will risk asses management programmes all patients, undertake some reviews remotely and prioritise patients who need a face-to-face such as obesity reduction appointment. The revised indicator will come into effect from 1 October 2020. programmes, health checks for people with The provision of physical health checks for people with severe mental illness is an existing KPI learning disabilities, and within the Salford Standard. Practices achieve the standard if they deliver comprehensive physical increasing the continuity of health checks for 75% of people with serious mental illness each year. This indicator is to be maternity carers. reintroduced from 1 October 2020/21 with performance monitored and shared at practice level but it will not be attached to a financial incentive (as ity is unclear whether the 75% achievement level is appropriate).
Learning Disabilities On 3 March 2020 Salford’s Adult Commissioning Committee (integrated CCG and Council) took a decision to commission Empower You for a period of 5 years. Empower You is a short-term intensive programme enabling disabled people and those around them to lead active lifestyles. This is achieved through making existing community provision more accessible. The service upskills community based staff and local activity providers enabling mainstream provision to better meet the needs of disabled people. It has evidenced outcomes through measuring physical health scores before and after the programme and through use of the Outcomes Star Tool before and after the programme. The CCG is in touch with the service to understand how the service model can be adapted in the context of COVID.
Salford were successful in securing NHSE funding alongside innovation funding to address the learning from the Learning Disability Mortality Review Programme in relation to primary medical care with an overall aim to reduce health inequalities within the learning disability population. The project will align the community LD Service and GP practices with an aim to improving and maintaining LD registers, increasing uptake of annual health checks, as well as improving the quality and consistency of this health checks, increasing uptake of cancer screening programmes by supporting with training, advice and guidance on reasonable adjustments and the application of the MCA. An LD nurse is now in post, on secondment to work alongside AQUA to implement the requirements of the innovation. She is currently working with GP practices and the LD service to ensure LD registers are up to date and using the North of England support pack to help them undertake LD health checks and increase uptake of flu checks. She is scheduled to attend the next PCN Collaboration Group and CCG (GP practice) neighbourhood meetings. In order to further accelerate this work in line with the phase 3 letter the CCG is in the process of reintroducing a KPI relating to LD Health Checks into the Salford Standard for 2020/21 – by achieving the standard for LDF health checks practices will be able to attract additional Salford Standard income (in addition to DES and PCN funding).
Holistic annual health reviews for long term conditions patients have been a part of the Salford Standard (locally commissioned service from Salford CCG, provided by all Salford Practices) for many years. To support the resumption of this aspect of care we are working on data quality tools which will help practices identify their most at risk population (eg BAME patients, those with obesity, poorly controlled diabetics, etc). This will allow them to target their efforts at the most needy patients, particularly those who at most risk of suffering severe consequences of COVID infection. It is anticipated that these data sets will be available in the next few weeks and will provide a valuable resource to practices over the coming months. They will allow monitoring (at both a practice and city-wide level) of progress with our long term conditions patients.
Flu Vaccination Salford has a comprehensive flu vaccination plan for 2020/21. Local flu vaccination initiatives which can be seen as additional to the minimum requirements described in the national guidance include: • Various levels of engagement in the flu vac programme from Salford’s 5 PCNs. One PCN is planning significant PCN level vaccination initiatives, in addition to practice own efforts, with vaccinations being offered in various settings across the wide. Another PCN is putting in place a scheme to increase the number of flu vac home visits carried out by its practices • Salford’s district nursing teams are commissioned to deliver flu vaccines to housebound individuals (and their carers) on their case load • Salford’s care homes medical practice is planning to vaccinate care home residents • Salford Primary Care Together is exploring the possibility of going into nurseries to vaccinate children; they have linked with one provider who has agreed the approach. SPCT are linking in with Council colleagues to reach additional nurseries • Plans are in place to vaccinate patients in hospital band intermediate care beds.
Communications and engagement Continuing to develop social marketing campaigns to promote the prevention programmes, co- producing the materials with the target audience for maximum impact, such as providing films translated into other languages, promoting the availability of interpreters in general practice, working with community representatives to cascade messages.
Salford Royal NHS Foundation Trust/Salford Care Organisation The NCA are rapid adopters of patient initiated follow up (PIFU) which describes when a patient (or their carer) can request their own appointment as and when required. This may be triggered by a change in symptoms or circumstances. This helps patients access support when they need it (e.g. during a flare-up of their symptoms) and avoids unnecessary routine ‘check in’ appointments. This ensures patients know when and how to access the right clinical input at the right time.
The CCG have developed an action plan to address gaps in data including: 5. Particularly support those • Seeing assurance from GMMH, SRFT and IAPT providers on work to address gaps in data who suffer mental ill health, • Regular contract meetings with mental health providers to review progress as society and the NHS • Regular review of DQMI figures for ethnicity recover from COVID-19, • Development of a dashboard to monitor against an agreed local target underpinned by more robust data collection and Salford CCG’s business intelligence team will provide regular advice and information to monitoring by 31 commissioners in relation to improving data sets. December.
Salford CCG 6. Strengthen leadership and Executive board leads: accountability, with a Edward Vitalis – Governing Body Lay Member (finance and governance) named executive board Kate Jones – Governing Body Neighbourhood Lead (Eccles) [nurse] member responsible for David McKelvey – Governing Body Neighbourhood Lead (Ordsall) [GP] tackling inequalities in Hannah Dobrowolska – Director of Corporate Services place in September in every NHS organisation, Action plan: alongside action to Salford published its latest WRES in July 2020 and will publish its staff (including leadership) increase the diversity of equality report for 2019/20 and associated action plan in September. Our report and plan for senior leaders. 2018/19 was published in July 2019.
In addition Salford CCG’s Chair and Salford City Council’s Mayor have highlighted this as a priority noting they are both passionate about improving the diversity of our leadership and that now seems the right time for us to take co-ordinated action on this across our integrated organisations. This work is in its very early stage, with the initial step looked at the make up of decision making groups.
Salford Royal NHS Foundation Trust/Salford Care Organisation The CEO and Chief of People is the Northern Care Alliance lead for Equality, Diversity and Inclusion. The Director of Finance is the lead for health inequalities. The NCA is working on a 10 year plan, with trajectory to see an increase of 15% on BAME senior leaders across the organisation.
The NCA have recently advertised for Associate NED roles – targeting underserved communities in order to diversify the makeup the Board.
Salford Primary Care Together Executive board lead is Peta Stross – Chief Operating Officer.
PCNs Each primary care network (PCN) has a lead for equality: • Broughton: Dr Mahmoud Megahed • Eccles and Irlam: Dr Peter Budden • Ordsall and Claremont: Dr Deji Adeyeye • Swinton: Dr Girish Patel • Walkden and Little Hulton: Dr Sapna Tandon
7. Ensure datasets are • Linking to section 5 (above) Salford CCG’s BI Team will develop an action plan for improving complete and timely, to primary care data. This will include establishing a baseline and agreeing local targets underpin an understanding • A dashboard will be developed to review performance across primary care of and response to • The BI Team will provide regular advice and updates to commissioners inequalities. All NHS • GP practices are to be encouraged to improve recording of BAME data (and language organisations should requirements). The CCG is establishing regular monitoring arrangements, as this proactively review and information is currently available but not regularly monitored. Practice flu champions are ensure the completeness being prompted to use the opportunity of the flu vaccination programme to improve of patient ethnicity data by recording. Engagement with this priority is to form part of practice’s eligibility for the Salford no later than 31 December, Standard in 2021/22 with general practice prioritising those groups at significant risk of COVID- 19 from 1 September. Planning and delivering action to address health inequalities has been a key component in Salford’s 8. Collaborate locally in COVID response, and now recovery governance. Discussion on this can be evidenced by agenda planning and delivering items, papers, meeting notes and action. action to address health inequalities, including As an example, our COVID Health and Adult Social Care Coordination Group reported to the incorporating in plans for Salford wide COVID Coordination Group. It included representation from public health, the voluntary restoring critical services sector, Healthwatch, social care, primary care, mental health, community services and acute care. by 21 September; better The work of this group is returning to business as usual approaches, and the system-wide Adults listening to communities Advisory Board (with similar system wide representation) reviewed the COVID insight work, Equality and strengthening local Impact Assessment and agreed plans for ongoing engagement through our Big Reset Conversation. accountability; deepening partnerships with local Locally we have agreed system priorities for adults, children and primary care for the remainder of authorities and the 2020/21, which all reference tackling inequalities. voluntary and community sector; and maintaining a The CCG has provided a written COVID-19 report to each Governing Body meeting, and these continual focus on include a section on our work to address inequalities. implementation of these actions, resources and In 2019, Salford established our city wide Equalities Improvement Partnership. This is the advisory impact, including a full and operational group to Salford’s health and care system. It’s primary purpose is to provide shared report by 31 March. learning for EDI leads and develop joint actions for example in 2019 the group launched Still I Rise, an exhibition of BAME portraits and stories.
The CCG has a well-established Engagement and Inclusion Management Group, which meets quarterly and has representation from partners. This group ensures agreed annual work plans are delivered, shares learning and identifies issues to escalate. The group reports to the CCG’s Executive Team.
Salford Royal NHS Foundation Trust/Salford Care Organisation We have a System Wide Outpatient Programme that brings together primary and secondary care commissioners, clinicians and leaders from across our 5 localities. This group is looking at pathway re-design at system level considering all stakeholders so that any impact of change is controlled.
Notes for completing the table:
• At this stage we will not require you to embed documents of provide appendices of evidence. Please don’t not embed documents within this return • It may be helpful to keep any evidence that you may have in a folder in the event that any supporting information is required. We will contact you directly if this is the case. • Please can you provide a concise description supported by any bullet points of examples/ actions that your organisation is taking or is planning to implement. • Please lay out high level details of how you will achieve the action points in the table above • Once completed please ensure that the document receives approval from senior level executives prior to returning • Please use the CRRF for guidance when completing your sections to gain further insight for the requirements of the return o https://www.england.nhs.uk/wp-content/uploads/2020/08/implementing-phase-3-of-the-nhs-response-to-covid-19.pdf
Skipton House 80 London Road London SE1 6LH [email protected]
From the Chief Executive Sir Simon Stevens & Chief Operating Officer Amanda Pritchard
To: Chief executives of all NHS trusts and foundation trusts CCG Accountable Officers GP practices and Primary Care Networks Providers of community health services NHS 111 providers
Copy to: NHS Regional Directors Regional Incident Directors & Heads of EPRR Chairs of ICSs and STPs Chairs of NHS trusts, foundation trusts and CCG governing bodies Local authority chief executives and directors of adult social care Chairs of Local Resilience Forums 31 July 2020
Dear Colleague
IMPORTANT – FOR ACTION – THIRD PHASE OF NHS RESPONSE TO COVID-19
We are writing to thank you and your teams for the successful NHS response in the face of this unprecedented pandemic, and to set out the next – third – phase of the NHS response, effective from 1 August 2020.
You will recollect that on 30th January NHS England and NHS Improvement declared a Level 4 National Incident, triggering the first phase of the NHS pandemic response. Since then the NHS has been able to treat every coronavirus patient who has needed specialist care – including 107,000 people needing emergency hospitalisation. Even at the peak of demand, hospitals were still able to look after two non-Covid inpatients for every one Covid inpatient, and a similar picture was seen in primary, community and mental health services.
As acute Covid pressures were beginning to reduce, we wrote to you on 29 April to outline agreed measures for the second phase, restarting urgent services. Now in this Phase Three letter we:
• update you on the latest Covid national alert level;
• set out priorities for the rest of 2020/21; and
• outline financial arrangements heading into Autumn as agreed with Government.
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Current position on Covid-19
On 19 June 2020 the Chief Medical Officers and the Government’s Joint Biosecurity Centre downgraded the UK’s overall Covid alert level from four to three, signifying that the virus remains in general circulation with localised outbreaks likely to occur. On 17 July the Government set out next steps including the role of the new Test and Trace programme in providing us advance notice of any expected surge in Covid demand, and in helping manage local and regional public health mitigation measures to prevent national resurgence.
Fortunately, Covid inpatient numbers have now fallen nationally from a peak of 19,000 a day, to around 900 today. As signalled earlier this month, the current level of Covid demand on the NHS means that the Government has agreed that the NHS EPRR incident level will move from Level 4 (national) to Level 3 (regional) with effect from tomorrow, 1 August. This approach matches the differential regional measures the Government is deploying, including today in parts of the North West and North East. The main implications of this are set out in Annex One to this letter.
However Covid remains in general circulation and we are seeing a number of local and regional outbreaks across the country, with the risk of further national acceleration. Together with the Joint Biosecurity Centre and Public Health England (PHE) we will therefore continue to keep the situation under close review, and will not hesitate to reinstate the Level 4 national response immediately as circumstances justify it. In the meantime NHS organisations will need to retain their EPRR incident coordination centres and will be supported by oversight and coordination by Regional Directors and their teams.
NHS priorities from August
Having pulled out all the stops to treat Covid patients over the last few months, our health services now need to redouble their focus on the needs of all other patients too, while recognising the new challenges of overcoming our current Covid-related capacity constraints. This will continue to require excellent collaboration between clinical teams, providers and CCGs operating as part of local ‘systems’ (STPs and ICSs), local authorities and the voluntary sector, underpinned by a renewed focus on patient communication and partnership.
Following discussion with patients’ groups, national clinical and stakeholder organisations, and feedback from our seven regional ‘virtual’ frontline leadership meetings last week, we are setting out NHS priorities for this third phase. Our shared focus is on:
A. Accelerating the return to near-normal levels of non-Covid health services, making full use of the capacity available in the ‘window of opportunity’ between now and winter
B. Preparation for winter demand pressures, alongside continuing vigilance in the light of further probable Covid spikes locally and possibly nationally.
C. Doing the above in a way that takes account of lessons learned during the first Covid peak; locks in beneficial changes; and explicitly tackles fundamental challenges including: support for our staff, and action on inequalities and prevention.
As part of this Phase Three work, and following helpful engagement and discussion, alongside this letter yesterday we published a more detailed 2020/21 People Plan, and will shortly do the same on
2
inequalities reduction. DHSC are also expected to set out equivalent phase three priorities and support for social care.
Nationally, we will work with the wide range of stakeholders represented on the NHS Assembly to help track and challenge progress against these priorities. As we do so it is vital that we listen and learn from patients and communities. We ask that all local systems act on the Five principles for the next phase of the Covid-19 response developed by patients’ groups through National Voices.
A: Accelerating the return of non-Covid health services, making full use of the capacity available in the window of opportunity between now and winter
A1. Restore full operation of all cancer services. This work will be overseen by a national cancer delivery taskforce, involving major patient charities and other key stakeholders. Systems should commission their Cancer Alliance to rapidly draw up delivery plans for September 2020 to March 2021 to:
• To reduce unmet need and tackle health inequalities, work with GPs and the public locally to restore the number of people coming forward and appropriately being referred with suspected cancer to at least pre-pandemic levels.
• Manage the immediate growth in people requiring cancer diagnosis and/or treatment returning to the service by:
- Ensuring that sufficient diagnostic capacity is in place in Covid19-secure environments, including through the use of independent sector facilities, and the development of Community Diagnostic Hubs and Rapid Diagnostic Centres - Increasing endoscopy capacity to normal levels, including through the release of endoscopy staff from other duties, separating upper and lower GI (non-aerosol- generating) investigations, and using CT colonography to substitute where appropriate for colonoscopy. - Expanding the capacity of surgical hubs to meet demand and ensuring other treatment modalities are also delivered in Covid19-secure environments. - Putting in place specific actions to support any groups of patients who might have unequal access to diagnostics and/or treatment. - Fully restarting all cancer screening programmes. Alliances delivering lung health checks should restart them.
• Thereby reducing the number of patients waiting for diagnostics and/or treatment longer than 62 days on an urgent pathway, or over 31 days on a treatment pathway, to pre- pandemic levels, with an immediate plan for managing those waiting longer than 104 days.
A2. Recover the maximum elective activity possible between now and winter, making full use of the NHS capacity currently available, as well as re-contracted independent hospitals.
In setting clear performance expectations there is a careful balance to be struck between the need to be ambitious and stretching for our patients so as to avoid patient harm, while setting a performance level that is deliverable, recognising that each trust will have its own particular pattern of constraints to overcome. 3
Having carefully tested the feasible degree of ambition with a number of trusts and systems in recent weeks, trusts and systems are now expected to re-establish (and where necessary redesign) services to deliver through their own local NHS (non-independent sector) capacity the following:
• In September at least 80% of their last year’s activity for both overnight electives and for outpatient/daycase procedures, rising to 90% in October (while aiming for 70% in August);
• This means that systems need to very swiftly return to at least 90% of their last year’s levels of MRI/CT and endoscopy procedures, with an ambition to reach 100% by October.
• 100% of their last year’s activity for first outpatient attendances and follow-ups (face to face or virtually) from September through the balance of the year (and aiming for 90% in August).
Block payments will flex meaningfully to reflect delivery (or otherwise) against these important patient treatment goals, with details to follow shortly once finalised with Government.
Elective waiting lists and performance should be managed at system as well as trust level to ensure equal patient access and effective use of facilities.
Trusts, working with GP practices, should ensure that, between them, every patient whose planned care has been disrupted by Covid receives clear communication about how they will be looked after, and who to contact in the event that their clinical circumstances change.
Clinically urgent patients should continue to be treated first, with next priority given to the longest waiting patients, specifically those breaching or at risk of breaching 52 weeks by the end of March 2021.
To further support the recovery and restoration of elective services, a modified national contract will be in place giving access to most independent hospital capacity until March 2021. The current arrangements are being adjusted to take account of expected usage, and by October/ November it will then be replaced with a re-procured national framework agreement within which local contracting will resume, with funding allocations for systems adjusted accordingly. To ensure good value for money for taxpayers, systems must produce week-by-week independent sector usage plans from August and will then be held directly to account for delivering against them.
In scheduling planned care, providers should follow the new streamlined patient self isolation and testing requirements set out in the guideline published by NICE earlier this week. For many patients this will remove the need to isolate for 14 days prior to a procedure or admission.
Trusts should ensure their e-Referral Service is fully open to referrals from primary care. To reduce infection risk and support social distancing across the hospital estate, clinicians should consider avoiding asking patients to attend physical outpatient appointments where a clinically-appropriate and accessible alternative exists. Healthwatch have produced useful advice on how to support patients in this way. This means collaboration between primary and secondary care to use advice and guidance where possible and treat patients without an onward referral, as well as giving patients more control over their outpatient follow-up care by adopting a patient-initiated follow-up approach across major outpatient specialties. Where an outpatient 4
appointment is clinically necessary, the national benchmark is that at least 25% could be conducted by telephone or video including 60% of all follow-up appointments.
A3. Restore service delivery in primary care and community services.
• General practice, community and optometry services should restore activity to usual levels where clinically appropriate, and reach out proactively to clinically vulnerable patients and those whose care may have been delayed. Dental practices should have now mobilised for face to face interventions. We recognise that capacity is constrained, but will support practices to deliver as comprehensive a service as possible.
• In restoring services, GP practices need to make rapid progress in addressing the backlog of childhood immunisations and cervical screening through specific catch-up initiatives and additional capacity and deliver through their Primary Care Network (PCN) the service requirements coming into effect on 1 October as part of the Network Contract DES.
• GPs, primary care networks and community health services should build on the enhanced support they are providing to care homes, and begin a programme of structured medication reviews.
• CCGs should work with GP practices to expand the range of services to which patients can self-refer, freeing-up clinical time. All GP practices must offer face to face appointments at their surgeries as well as continuing to use remote triage and video, online and telephone consultation wherever appropriate – whilst also considering those who are unable to access or engage with digital services.
• Community health services crisis responsiveness should be enhanced in line with the goals set out in the Long Term Plan, and should continue to support patients who have recovered from the acute phase of Covid but need ongoing rehabilitation and other community health services. Community health teams should fully resume appropriate and safe home visiting care for all those vulnerable/shielding patients who need them.
• The Government is continuing to provide funding to support timely and appropriate discharge from hospital inpatient care in line with forthcoming updated Hospital Discharge Service Requirements. From 1 September 2020, hospitals and community health and social care partners should fully embed the discharge to assess processes. New or extended health and care support will be funded for a period of up to six weeks, following discharge from hospital and during this period a comprehensive care and health assessment for any ongoing care needs, including determining funding eligibility, must now take place. The fund can also be used to provide short term urgent care support for those who would otherwise have been admitted to hospital.
• The Government has further decided that CCGs must resume NHS Continuing Healthcare assessments from 1 September 2020 and work with local authorities using the trusted assessor model. Any patients discharged from hospital between 19 March 2020 and 31 August 2020, whose discharge support package has been paid for by the NHS, will need to be assessed and moved to core NHS, social care or self-funding arrangements.
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A4. Expand and improve mental health services and services for people with learning disability and/or autism
• Every CCG must continue to increase investment in mental health services in line with the Mental Health Investment Standard and we will be repeating the independent audits of this. Systems should work together to ensure that funding decisions are decided in partnership with Mental Health Providers and CCGs and that funding is allocated to core Long Term Plan (LTP) priorities.
• In addition, we will be asking systems to validate their existing LTP mental health service expansion trajectories for 2020/21. Further advice on this will be issued shortly. In the meantime: - IAPT services should fully resume - the 24/7 crisis helplines for all ages that were established locally during the pandemic should be retained, developing this into a national service continue the transition to digital working - maintain the growth in the number of children and young people accessing care - proactively review all patients on community mental health teams’ caseloads and increase therapeutic activity and supportive interventions to prevent relapse or escalation of mental health needs for people with SMI in the community; - ensure that local access to services is clearly advertised - use £250 million of earmarked new capital to help eliminate mental health dormitory wards.
• In respect of support for people with a learning disability, autism or both: - Continue to reduce the number of children, young people and adults within a specialist inpatient setting by providing better alternatives and by ensuring that Care (Education) and Treatment Reviews always take place both prior to and following inpatient admission. - Complete all outstanding Learning Disability Mortality Reviews (LeDeR) by December 2020. - GP practices should ensure that everybody with a Learning Disability is identified on their register; that their annual health checks are completed; and access to screening and flu vaccinations is proactively arranged. (This is supported by existing payment arrangements and the new support intended through the Impact and Investment Fund to improve uptake.)
B: Preparation for winter alongside possible Covid resurgence.
B1. Continue to follow good Covid-related practice to enable patients to access services safely and protect staff, whilst also preparing for localised Covid outbreaks or a wider national wave. This includes:
• Continuing to follow PHE’s guidance on defining and managing communicable disease outbreaks.
• Continue to follow PHE/DHSC-determined policies on which patients, staff and members of the public should be tested and at what frequency, including the further PHE-endorsed 6
actions set out on testing on 24 June. All NHS employers should prepare for the likelihood that if background infection risk increases in the Autumn, and DHSC Test and Trace secures 500,000+ tests per day, the Chief Medical Officer and DHSC may decide in September or October to implement a policy of regular routine Covid testing of all asymptomatic staff across the NHS.
• Ongoing application of PHE’s infection prevention and control guidance and the actions set out in the letter from 9 June on minimising nosocomial infections across all NHS settings, including appropriate Covid-free areas and strict application of hand hygiene, appropriate physical distancing, and use of masks/face coverings.
• Ensuring NHS staff and patients have access to and use PPE in line with PHE’s recommended policies, drawing on DHSC’s sourcing and its winter/EU transition PPE and medicines stockpiling.
B2. Prepare for winter including by:
• Sustaining current NHS staffing, beds and capacity, while taking advantage of the additional £3 billion NHS revenue funding for ongoing independent sector capacity, Nightingale hospitals, and support to quickly and safely discharge patients from NHS hospitals through to March 2021.
• Deliver a very significantly expanded seasonal flu vaccination programme for DHSC- determined priority groups, including providing easy access for all NHS staff promoting universal uptake. Mobilising delivery capability for the administration of a Covid19 vaccine if and when a vaccine becomes available.
• Expanding the 111 First offer to provide low complexity urgent care without the need for an A&E attendance, ensuring those who need care can receive it in the right setting more quickly. This includes increasing the range of dispositions from 111 to local services, such as direct referrals to Same Day Emergency Care and specialty ‘hot’ clinics, as well as ensuring all Type 3 services are designated as Urgent Treatment Centres (UTCs). DHSC will shortly be releasing agreed A&E capital to help offset physical constraints associated with social distancing requirements in Emergency Departments.
• Systems should maximise the use of ‘Hear and Treat’ and ‘See and Treat’ pathways for 999 demand, to support a sustained reduction in the number of patients conveyed to Type 1 or 2 emergency departments.
• Continue to make full use of the NHS Volunteer Responders scheme in conjunction with the Royal Voluntary Society and the partnership with British Red Cross, Age UK and St. Johns Ambulance which is set to be renewed.
• Continuing to work with local authorities, given the critical dependency of our patients – particularly over winter - on resilient social care services. Ensure that those medically fit for discharge are not delayed from being able to go home as soon as it is safe for them to do so in line with DHSC/PHE policies (see A3 above).
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C: Doing the above in a way that takes account of lessons learned during the first Covid peak; locks in beneficial changes; and explicitly tackles fundamental challenges including support for our staff, action on inequalities and prevention.
C1. Workforce
Covid19 has once again highlighted that the NHS, at its core, is our staff. Yesterday we published We are the NHS: People Plan for 2020/21 - actions for us all which reflects the strong messages from NHS leaders and colleagues from across the NHS about what matters most. It sets out practical actions for employers and systems, over the remainder of 2020/21 ahead of Government decisions in the Autumn Spending Review on future education and training expansions. It includes specific commitments on:
• Actions all NHS employers should take to keep staff safe, healthy and well – both physically and psychologically.
• Specific requirements to offer staff flexible working.
• Urgent action to address systemic inequality that is experienced by some of our staff, including BAME staff.
• New ways of working and delivering care, making full and flexible use of the full range of our people’s skills and experience.
• Growing our workforce, building on unprecedented interest in NHS careers. It also encourages action to support former staff to return to the NHS, as well as taking steps to retain staff for longer – all as a contribution to growing the nursing workforce by 50,000, the GP workforce by 6,000 and the extended primary care workforce by 26,000.
• Workforce planning and transformation that needs to be undertaken by systems to enable people to be recruited and deployed across organisations, sectors and geographies locally.
All systems should develop a local People Plan in response to these actions, covering expansion of staff numbers, mental and physical support for staff, improving retention and flexible working opportunities, plus setting out new initiatives for development and upskilling of staff. Wherever possible, please work with local authorities and local partners in developing plans for recruitment that contribute to the regeneration of communities, especially in light of the economic impact of Covid. These local People Plans should be reviewed by regional and system People Boards, and should be refreshed regularly.
C2. Health inequalities and prevention.
Covid has further exposed some of the health and wider inequalities that persist in our society. The virus itself has had a disproportionate impact on certain sections of the population, including those living in most deprived neighbourhoods, people from Black, Asian and minority ethnic communities, older people, men, those who are obese and who have other long- term health conditions and those in certain occupations. It is essential that recovery is planned in a way that inclusively supports those in greatest need.
We are asking you to work collaboratively with your local communities and partners to take urgent action to increase the scale and pace of progress of reducing health inequalities, and 8
regularly assess this progress. Recommended urgent actions have been developed by an expert national advisory group and these will be published shortly. They include:
• Protect the most vulnerable from Covid, with enhanced analysis and community engagement, to mitigate the risks associated with relevant protected characteristics and social and economic conditions; and better engage those communities who need most support.
• Restore NHS services inclusively, so that they are used by those in greatest need. This will be guided by new, core performance monitoring of service use and outcomes among those from the most deprived neighbourhoods and from Black and Asian communities, by 31 October. Develop digitally enabled care pathways in ways which increase inclusion, including reviewing who is using new primary, outpatient and mental health digitally enabled care pathways by 31 March.
• Accelerate preventative programmes which proactively engage those at greatest risk of poor health outcomes. This should include more accessible flu vaccinations, the better targeting of long-term condition prevention and management programmes, obesity reduction programmes including self-referral to the NHS Diabetes Prevention Programme, health checks for people with learning disabilities, and increasing the continuity of maternity carers including for BAME women and those in high risk groups.
• Strengthen leadership and accountability, with a named executive Board member responsible for tackling inequalities in place in September in every NHS organisation. Each NHS board to publish an action plan showing how over the next five years its board and senior staffing will in percentage terms at least match the overall BAME composition of its overall workforce, or its local community, whichever is the higher.
• Ensure datasets are complete and timely, to underpin an understanding of and response to inequalities. All NHS organisations should proactively review and ensure the completeness of patient ethnicity data by no later 31 December, with general practice prioritising those groups at significant risk of Covid19 from 1 September.
Financial arrangements and system working
To support restoration, and enable continued collaborative working, current financial arrangements for CCGs and trusts will largely be extended to cover August and September 2020. The intention is to move towards a revised financial framework for the latter part of 2020/21, once this has been finalised with Government. More detail is set out in Annex Two.
Working across systems, including NHS, local authority and voluntary sector partners, has been essential for dealing with the pandemic and the same is true in recovery. As we move towards comprehensive ICS coverage by April 2021, all ICSs and STPs should embed and accelerate this joint working through a development plan, agreed with their NHSE/I regional director, that includes:
• Collaborative leadership arrangements, agreed by all partners, that support joint working and quick, effective decision-making. This should include a single STP/ICS leader and a non- executive chair, appointed in line with NHSE/I guidance, and clearly defined arrangements for provider collaboration, place leadership and integrated care partnerships.
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• Organisations within the system coming together to serve communities through a Partnership Board, underpinned by agreed governance and decision-making arrangements including high standards of transparency – in which providers and commissioners can agree actions in the best interests of their populations, based on co-production, engagement and evidence.
• Plans to streamline commissioning through a single ICS/STP approach. This will typically lead to a single CCG across the system. Formal written applications to merge CCGs on 1 April 2021 needed to give effect to this expectation should be submitted by 30 September 2020.
• A plan for developing and implementing a full shared care record, allowing the safe flow of patient data between care settings, and the aggregation of data for population health.
Finally, we are asking you – working as local systems - to return a draft summary plan by 1 September using the templates issued and covering the key actions set out in this letter, with final plans due by 21 September. These plans need to be the product of partnership working across STPs/ICSs, with clear and transparent triangulation between commissioner and provider activity and performance plans.
Over the last few months, the NHS has shown an extraordinary resilience, capacity for innovation and ability to move quickly for our patients. Like health services across Europe, we now face the double challenge of continuing to have to operate in a world with Covid while also urgently responding to the many urgent non-Covid needs of our patients. If we can continue to harness the same ambition, resilience, and innovation in the second half of the year as we did in the first, many millions of our fellow citizens will be healthier and happier as a result. So thank you again for all that you and your teams have been – and are – doing, in what is probably the defining year in the seven-decade history of the NHS.
With best wishes,
Simon Stevens Amanda Pritchard NHS Chief Executive NHS Chief Operating Officer
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ANNEX ONE: IMPLICATIONS OF EPRR TRANSITION TO A LEVEL 3 INCIDENT
As previously signalled, effective 1 August 2020 the national incident level for the Covid19 response will change from level 4 (an incident that requires NHS England National Command and Control to support the NHS response) to level 3 (an incident that requires the response of a number of health organisations across geographical areas within an NHS England region), until further notice.
It is entirely possible that future increases in Covid demands on the NHS mean that the level 4 incident will need to be reinstated. In which case, there will be no delay in doing so. However this change does, for the time being, provide the opportunity to focus local and regional NHS teams on accelerating the restart of non-Covid services, while still preparing for a possible second national peak.
The implications of the transition from a level 4 to level 3 incident are as follows:
• Oversight: Transition from a national command, control and coordination structure to a regional command, control and coordination structure but with national oversight as this remains an incident of international concern.
• Reporting: We will be stopping weekend sit rep collections from Saturday 8 August 2020 (Saturday and Sunday data will be collected on Mondays with further detail to follow). Whilst we are reducing the incident level with immediate effect reports will still be required this weekend (1 and 2 August 2020) and we will subsequently need to be able to continue to align to DHSC requirements. Additional reporting will be required for those areas of the country experiencing community outbreaks in line with areas of heightened interest, concern or intervention.
• Incident coordination functions: The national and regional Incident Coordination Centres will remain in place (hours of operation may be reduced). The frequency of national meetings will decrease (for example IMT will move to Monday, Wednesday, Friday). Local organisations should similarly adjust their hours and meeting frequency accordingly. It is however essential that NHS organisations fully retain their incident coordination functions given the ongoing pandemic, and the need to stand up for local incidents and outbreaks.
• Communications: All communications related to Covid19 should continue to go via established Covid19 incident management channels, with NHS organisations not expected to respond to incident instructions received outside of these channels. Equally, since this incident continues to have an international and national profile, it is important that our messaging to the public is clear and consistent. You should therefore continue to coordinate communications with your regional NHS England and NHS Improvement communications team. This will ensure that information given to the media, staff and wider public is accurate, fully up-to-date and aligns with national and regional activity.
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ANNEX TWO: REVISED FINANCIAL ARRANGEMENTS
The current arrangements comprise nationally-set block contracts between NHS providers and commissioners, and prospective and retrospective top-up funding issued by NHSE/I to organisations to support delivery of breakeven positions against reasonable expenditure. The M5 and M6 block contract and prospective top-up payments will be the same as M4. Costs of testing and PPE will continue to be borne centrally for trusts and general practices funded by DHSC who continue to lead these functions for the health and social care sectors.
The intention is to move towards a revised financial framework for the latter part of 2020/21, once this has been finalised with Government.
The revised framework will retain simplified arrangements for payment and contracting but with a greater focus on system partnership and the restoration of elective services. The intention is that systems will be issued with funding envelopes comprising funding for NHS providers equivalent in nature to the current block and prospective top-up payments and a system-wide Covid funding envelope. There will no longer be a retrospective payment mechanism. Providers and CCGs must achieve financial balance within these envelopes in line with a return to usual financial disciplines. Whilst systems will be expected to breakeven, organisations within them will be permitted by mutual agreement across their system to deliver surplus and deficit positions. The funding envelopes will comprise:
• CCG allocations – within which block contract values for services commissioned from NHS providers within and outside of the system will continue to be nationally calculated;
• Directly commissioned services from NHS providers – block contract values for specialised and other directly commissioned services will continue to be nationally calculated;
• Top-up – additional funding to support delivery of a breakeven position; and
• Non-recurrent Covid allocation – additional funding to cover Covid-related costs for the remainder of the year.
Funding envelopes will be calculated on the basis of full external income recovery. For relationships between commissioners and NHS providers we will continue to operate nationally calculated block contract arrangements. For low-volume flows of CCG-commissioned activity, block payments of an appropriate value would be made via the Trust’s host CCG; this will remove the need for separate invoicing of non-contract activity.
However block payments will be adjusted depending on delivery against the activity restart goals set in Section A1 and A2 above.
Written contracts with NHS providers for the remainder of 2020/21 will not be required.
For commissioners, non-recurrent adjustments to commissioner allocations will continue to be actioned – adjustments to published allocations will include any changes in contracting responsibility and distribution of the top-up to CCGs within the system based on target allocation.
Reimbursement for high cost drugs under the Cancer Drugs Fund (CDF) and relating to treatments under the Hepatitis C programme will revert to a pass-through cost and volume basis, with adjustments made to NHS provider block contract values to reflect this. For the majority of other high cost drugs and devices, in-year provider spend will be tracked against a notional level of spend
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included in the block funding arrangements with adjustments made in-year to ensure that providers are reimbursed for actual expenditure on high cost drugs and devices. This will leave a smaller list of high cost drugs which will continue to be funded as part of the block arrangements.
In respect of Medical pay awards, on 21 July 2020 the Government confirmed the decision to uplift pay in 2020/21 by 2.8% for consultants, specialty doctors and associate specialists, although there is no uplift to the value of Clinical Excellence Awards, Commitment Awards, Distinction Awards and Discretionary Points for 2020/21. We expect this to be implemented in September pay and backdated to April 2020. In this event, NHS providers should claim the additional costs in September as part of the retrospective top-up process. Future costs will be taken into account in the financial framework for the remainder of 2020/21, with further details to be confirmed in due course.
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GOVERNING BODY MEETING PART 1
AGENDA ITEM NO: 5b
Item for Decision/Assurance/Information (Please underline and bold)
30 September 2020
Report of: Chief Accountable Officer
Date of Paper: 21 September 2020
Subject: Assurance Framework Report (Planning, Performance and Risk Update) In case of query Leanne Drury Please contact: Performance and Contract Manager
Strategic Priorities: Please tick which strategic priorities the paper relates to:
Quality, Safety, Innovation and Research Integrated Community Care Services (Adult Services) Children’s and Maternity Services Primary Care Enabling Transformation Purpose of Paper:
The purpose of this paper is to provide the Governing Body with assurance and scrutiny of Salford CCG’s latest position in relation to strategic performance indicators and strategic risks.
Further explanatory information required
This report provides a high level summary of HOW WILL THIS BENEFIT THE Salford CCG’s latest position in relation to HEALTH AND WELL BEING OF current performance and strategic risks. SALFORD RESIDENTS OR THE Further detail has been provided in relevant CLINICAL COMMISSIONING appendices (referenced in this report) for areas GROUP? of high risk and underperformance.
None WHAT RISKS MAY ARISE AS A RESULT OF THIS PAPER? HOW CAN THEY BE MITIGATED?
None WHAT EQUALITY-RELATED RISKS MAY ARISE AS A RESULT OF THIS PAPER? HOW WILL THESE BE MITIGATED?
Areas of high risk and underperformance have DOES THIS PAPER HELP ADDRESS been summarised within this report. Detailed ANY HIGH RISKS FACING THE performance recovery plans and risk treatment ORGANISATION? IF SO WHAT ARE plans are included in appendices as THEY AND HOW DOES THIS PAPER appropriate. REDUCE THEM?
None PLEASE DESCRIBE ANY POSSIBLE CONFLICTS OF INTEREST ASSOCIATED WITH THIS PAPER.
Any issues are described within the paper. PLEASE IDENTIFY ANY CURRENT SERVICES OR ROLES THAT MAY BE AFFECTED BY ISSUES WITHIN THIS PAPER:
Footnote:
Members of this Committee will read all papers thoroughly. Once papers are distributed no amendments are possible.
Document Development
Not Comments and Date Process Yes No Outcome Applicable (i.e. presentation, verbal, actual report) Public Engagement (Please detail the method i.e. survey, event, consultation) Clinical Engagement (Please detail the method i.e. survey, event, consultation) Has ‘due regard’ been given to Social Value and the impacts on the Salford socially, economically and environmentally? (Please detail outcomes, including risks and how these will be managed Has ‘due regard’ been given to Equality Analysis (EA) of any adverse impacts? (Please detail outcomes, including risks and how these will be managed) Legal Advice Sought
Presented to any informal groups or Reviewed by the CCG Executive committees (including partnership groups) for Team. engagement or other formal governance groups for comments / approval? (Please specify in comments)
Note: Please ensure that it is clear in the comments and date column how and when particular stakeholders were involved in this work and ensure there is clarity in the outcome column showing what the key message or decision was from that group and whether amendments were requested about a particular part of the work.
Assurance Framework Report (Performance and Risk Update)
1. Executive Summary
The performance monitoring and reporting regime has been amended during the COVID-19 pandemic. Section 2 of the report highlights those changes. Salford CCG continues to produce activity and monitoring information in order to track performance and potential backlog to inform the next phase of recovery.
The latest performance information (July 2020) is included in Section 3 of this report for the main NHS constitutional standards with the full dashboard included at Appendix 1. This report highlights the waiting times and backlog that has increased over the past few months. This report should be read in conjunction with the “COVID-19 Recovery and Phase 3 Planning” report that sets out the locality approach in the next phase of health and care in Salford.
2. Performance Reporting from 1 April 2020
4.1. Whilst existing performance standards remain in place, it is acknowledged nationally that the way these are managed has changed for the duration of the COVID-19 response. The performance regime had in many areas been paused and suspended for the first quarter of 2020/21. Reported within this paper is data and information that has started to be resurrected.
4.2. The CCG will not seek detailed action plans from our providers given the huge impact of the COVID-19 response. However, the CCG will continue to produce the delivery dashboard for 2020/21, reporting this to the Executive Team on a monthly basis and Governing Body bi monthly. This will track the level of performance and potential backlog as the system enters into the next phase of the year and starts to step back up some services.
3. Performance update and current issues
3.1 Reported below is the latest performance position against the main NHS Constitutional Standards. Appendix 1 reports performance against all of the other CCG indicators where information is available. Recognising that we are still living with COVID-19, stepping back up planned and routine care in the NHS will need to be flexible, balancing the need to safely recommence more routine work with the need to respond to any future COVID-19 patient demands. A separate paper on the next phases of recovery ‘COVID-19 Recovery and Phase 3 Planning ‘has been produced for Governing Body.
3.2 A&E: Urgent Emergency Care Performance in the Salford Royal Foundation Trust (SRFT) Emergency Department is below the 4 hour wait target of 95%, throughout the COVID-19 period Salford has hovered just below or above 90%. Performance is actually better than pre COVID-19 levels, when around 80% to 85% of patients were seen within 4 hours in A&E. All areas of Greater Manchester are below the 95% standard for A&E waiting times. A&E Attendances during April and May, during the peak of COVID-19, were at around 50% of pre-COVID-19 levels. The volume of patients attending A&E in August were 89% of pre COVID-19 (March 2020) volumes. Further detail and progress updates are provided in Appendix 2.
3.3 Diagnostics: Salford CCG July 2020 position for diagnostic waiting times is illustrated in the table below, including comparisions back to January 2020 and August 2019.
These breach volumes were expected as non-urgent diagnostic tests were cancelled, in line with national policy, due to the COVID-19 pandemic. In addition, referrals into providers for a diagnostic test reduced from March onwards. Referrals have started to increase but the volume of patients waiting longer than both 6 weeks and 13 weeks for a diagnostic test has also increased over this period.
Of those waiting over 6 weeks, the vast majority (81%) were awaiting a test at SRFT and of these the vast majority (also 81%) were waiting for either an imaging scan (56%) or endoscopy procedure (25%). Further detail and progress updates is provided in Appendix 2, which outlines actions being put in place to increase the capacity to reduce the number of patients on the waiting list for the dignostic test and reduce the length of time patients are waiting.
3.4 Cancer Waiting Times: Achievement of these standards was a challenge for Salford prior to the COVID-19 pandemic. Performance against some of the cancer targets has improved. Cancer treatment services were still open during the pandemic. However there are now some long waits for treatment and the number of referrals into the service significantly reduced over the past few months. The cancer pathways are a priority in the recovery phase. A detailed analysis of patients on the cancer pathway is included in Appendix 2.
3.5 Referral to Treatment (RTT):
Waiting Lists (patients waiting for first treatment following referral)
The waiting list size has increased from 24,866 in July to 26,649 in August reflecting reduced capacity to treat patients. Pre-COVID-19 Salford GP referrals were consistently around 4,100 per month, but reduced to 800 in April and 1,035 in May. GP referrals increased in June and July to 2,242 and 2,098 respectively and 2,560 in August, which is 38% below normal levels. A return to nearer 100% of anticipated referrals will further increase waiting lists if additional treatment capacity is not restored.
The reduction in hospital planned care capacity has impacted on the length of time patients are waiting for non-urgent treatment and the number of patients waiting for treatment to start continues to increase month on month.
SRFT is reviewing all patients waiting for surgery in line with Royal College of Surgeons guidance so that theatre capacity is utilised for the highest priority of patients.
Incomplete pathways: 18 weeks RTT
In August 2020, there were almost 13,000 Salford patients waiting longer than 18 weeks for treatment, which is around 52% of the total waiting list. This is compared with around 3,500 in August 2019 (12.5% of the waiting list)
Incomplete pathways: 52+ week RTT breaches
Of those currently on a waiting list in August, there were 712 waiting greater than 52 weeks, the majority of which are waiting for treatments at Salford Royal (373) or Manchester Foundation Trust (241). This compares to 26 breaches for the full financial year 2019/20. Further detailed analysis and Phase 3 planning is included in Appendix 2.
3.6 Mental Health: Improving Access to Psychological Therapies (IAPT): The latest published data is May 2020 and local data for July 2020.
• Prevalence- Published data for June shows that performance is currently at 1.9%. August local data is reported at 7.8% YTD, just below the new increased year end 25% target (2.1% per month), however this is an improving position against the May and June performance. The lower prevalence is most likely due to reduced referrals and initial appointment challenges as a result of the COVID-19 pandemic, as illustrated in the table below. It is encouraging to see that the referrals into the Six Degrees service for July 2020 are closer to the pre COVID-19 referral numbers. In addition, the numbers of patients referred to the Step 3 service at Greater Manchester Mental Health (GMMH) did not reduce significantly during the period March to May and the referrals into GMMH for July are in line with pre COVID-19 levels.
• Recovery- June published data reports that performance was 45.3% which is below the recovery target but an improving picture on April published data. Local August data reports that recovery is at 50.4% which exceeds the recovery target.
• 6 weeks – Published data for June performance is 55.7% which is below target. Local data shows performance for August at 74.9% which, whilst not quite reaching target, continues the improving trajectory from May and June. Six Degrees are showing a declining position in published and local data, however improvements are taking place in ‘on entry’ data, suggesting that there are currently no waits over 4 weeks on entry.
• 18 weeks - Published performance is showing the June position has achieved target at 95.7% with local data for August showing performance as also exceeding target at 96.6%.
The picture on performance for Mental Health services during the pandemic is encouraging. Appendix 2 highlights the Mental Health support offered to the population during the pandemic and the steps taken to support progress towards recovery. A further Mental Health summary is included within the ‘Quality of Commissioned Services’ paper, including additional information relating to the work undertaken by GMMH relating to the acceptability of video / teleconferencing methods of delivery for IAPT and the consideration of equality and diversity in building back face to face support when possible.
3.7 Clostridium difficile- as report in Appendix 1; there has been an increase in reported cases. Further detailed analysis and associated actions are report within the ‘Quality of Commissioned Services’ paper.
4. Strategic and Programme Risk Update
4.1. Since risk was last reported March 20 there have been no new risks added to the Strategic Risk Register; no risks have been closed , 1 risk has been reduced ( Failure to commission high quality, stable provision of services that meet the needs of the entire population of Salford)and 1 risk has increased (NHS and wider public sector funding ).
4.2. There are currently 16 risks on the strategic risk register, 5 of which are scored as High (Red) as outlined below. The full strategic risk register is included in Appendix 3.
4.3. Strategic Risk Register Review - On 26 August 2020 the Director of Corporate Services facilitated a workshop with Informal Governing Body to review the existing strategic risks. The session was really engaging, and several requests were put forward for improvements to our existing risk register. In particular managing strategic risks during the current “living with COVID-19” working was recognised as challenging, i.e. the need to respond to the immediate whilst keeping a clear eye on longer term ambitions. Work is now underway to address the feedback received, some of which is incorporated into today’s report and a more revised risk register will be presented as part of a future GB report
4.4. Programme Risk - Governing Body members are asked to note that there is work currently ongoing to realign programme risk registers to the new integrated commissioning governance structure for Primary Care, Adults and Children’s services. A further update will be provided once this work has been completed. COVID-19 specific risks are captured through the relevant coordination and recovery groups.
6. Recommendations
6.1 The Governing Body is asked to note the contents of this report
APPENDICES: Appendix 1- CCG Delivery Dashboard 2020-21 Appendix 2- Performance and Service Updates Appendix 3- Strategic Risk Register – Full Strategic Risk Register
Leanne Drury Performance and Contract Manager
Appendix 1 Salford CCG Delivery Dashboard 2020/21 Data collection and publication paused /no information available nationally due to Covid-19 Generated on: 22nd September 2020
1. Urgent Care
2020/21 Latest Period (Published Performance Indicator Latest Data Target Exec Lead position) Num Den Value Target
A&E Waiting Time - Seen within 4 hours (CCG) 88.10% 7,329 8,316 95% August 2020 result 88.10% 95% Karen Proctor A&E Waiting Time - Seen within 4 hours (SRFT) 89.00% 6,943 7,804 95% August 2020 result 90.00% 95% Karen Proctor NWAS Ambulance Response Programme | Category 1 - Life threatening (mean response time [07:00]) (NWAS) 07:27 07:00 August 2020 result 07:08 07:00 Karen Proctor NWAS Ambulance Response Programme | Category 1 - Life threatening (90th percentile in 15mins) (NWAS) 12:35 15:00 August 2020 result 11:55 15:00 Karen Proctor NWAS Ambulance Response Programme | Category 2 - Emergency (mean response time [18:00s]) (NWAS) 27:37 18:00 August 2020 result 21:15 18:00 Karen Proctor NWAS Ambulance Response Programme | Category 2 - Emergency (90th percentile in 40mins) (NWAS) 00:59:30 00:40:00 August 2020 result 00:43:43 00:40:00 Karen Proctor NWAS Ambulance Response Programme | Category 3 – Urgent (90th percentile in 120mins) (NWAS) 03:27:07 02:00:00 August 2020 result 02:26:04 02:00:00 Karen Proctor NWAS Ambulance Response Programme | Category 4 – Less Urgent (90th percentile in 180mins) (NWAS) 03:47:57 03:00:00 August 2020 result 03:03:37 03:00:00 Karen Proctor Trolley Waits in A&E (>12 Hours) (SRFT) 0 0 August 2020 result 0 0 Francine Thorpe GM target: Stranded patients (LoS 7+ Days) 267 2,196 May 2020 GM data Karen Proctor GM target: Super Stranded patients (LoS 21+ Days) 136 May 2020 GM data Karen Proctor GM target: Delayed transfers of care-bed days Karen Proctor Delayed transfers of care, per 100,000 population (aged 18+) Karen Proctor Inequality in unplanned hospitalisation for chronic ambulatory care sensitive and urgent care sensitive conditions (CCG) Karen Proctor Emergency admissions for urgent care sensitive conditions Karen Proctor Population use of hospital beds following emergency admission Karen Proctor
2. Scheduled Care (excluding Cancer)
2020/21 Latest Period (Published Performance Indicator Latest Data Target Exec Lead position) Num Den Value Target
Diagnostic Test Waiting Times 45.8% 3,175 6,932 1% August 2020 provisional 59.4% 1% Karen Proctor RTT: Incomplete pathways (<18 weeks) 52.6% 12,553 22,700 92% August 2020 provisional 57.9% 92% Karen Proctor RTT: Incomplete Pathways (>52 weeks) 712 0 August 2020 provisional 712 0 Francine Thorpe RTT: Incomplete Pathways Total Waits * adjusted, see main paper 26,649 24,741 August 2020 provisional 26,649 24,741 Karen Proctor Achievement of clinical standards in the delivery of 7 day services Karen Proctor Number of patients not treated within 28 days of last minute elective cancellation (SRFT) Francine Thorpe
3. Cancer
1/4 24/09/2020 Salford CCG Delivery Dashboard 2020/21 Data collection and publication paused /no information available nationally due to Covid-19 Generated on: 22nd September 2020 2020/21 Latest Period (Published Performance Indicator Latest Data Target Exec Lead position) Num Den Value Target
New: Cancer Waits - 28 Days waits (faster diagnosis standard) 74.0% 639 863 70% July 2020 result 73.9% 70% Karen Proctor Suspected cancer (Urgent GP referral)- 2 Week Wait 91.5% 742 811 93% July 2020 result 93.7% 93% Karen Proctor Breast Symptomatic – 2 week wait for breast symptoms (where cancer was not initially suspected) 44.2% 34 77 93% July 2020 result 58.6% 93% Karen Proctor Cancer Waits - 31 Days (All Cancers) 96% 96 100 96% July 2020 result 95.2% 96% Karen Proctor Cancer Waits - 31 Days (Drugs) 94.1% 16 17 98% July 2020 result 98.6% 98% Karen Proctor Cancer Waits - 31 Days (Radiotherapy) 100% 29 29 94% July 2020 result 99.10% 94% Karen Proctor Cancer Waits - 31 Days (Surgery) 95.45% 21 22 94% July 2020 result 88% 94% Karen Proctor Cancer Waits - 62 Days (Urgent GP Referral) 89.60% 43 48 85% July 2020 result 76.60% 85% Karen Proctor Cancer Waits - 62 Days (Screening Service) 0.0% 0 1 90% July 2020 result 87.50% 90% Karen Proctor Cancer Waits - 62 Days (Decision to Upgrade) 86.40% 19 22 85% July 2020 result 77.9% 85% Karen Proctor Cancer Waits - 104 or more day waits 8 0 July 2020 result 38 0 Karen Proctor Cancers diagnosed at early stage Karen Proctor One-year survival from all cancers Karen Proctor Cancer patient experience Karen Proctor
4. Mental Health and Learning Disabilities
2020/21 Latest Period (Published Performance Indicator Latest Data Target Exec Lead position) Num Den Value Target
IAPT Prevalence (CCG) - PUBLISHED 1.9% 540 36,357 2.1% June 2020 final 7.8% 25.0% Judd Skelton IAPT Prevalence (CCG) - LOCAL 1.7% 2.1% August local data 8.8% 25.0% Judd Skelton IAPT Recovery Rate (CCG) - PUBLISHED 45.3% 110 255 50% June 2020 final 42.5% 50% Judd Skelton IAPT Recovery Rate (CCG) - LOCAL 50.4% 50% August local data 50.0% 50% Judd Skelton IAPT Waiting Times - 6 Week Wait Ended Referrals (CCG) - PUBLISHED 55.7% 145 285 75% June 2020 final 54.8% 75% Judd Skelton IAPT Waiting Times - 6 Week Wait Ended Referrals (CCG) - LOCAL 74.9% 75% August local data 63.2% 75% Judd Skelton IAPT Waiting Times - 18 Week Wait Ended Referrals (CCG) - PUBLISHED 95.7% 270 285 95% June 2020 final 95.9% 95% Judd Skelton IAPT Waiting Times - 18 Week Wait Ended Referrals (CCG) - LOCAL 96.6% 95% August local data 95.9% 95% Judd Skelton People with a severe mental illness (SMI) receiving a full annual physical health check and follow-up interventions 46.7% 1,200 2,572 60% Q1 2020/21 result 46.7% 60% Judd Skelton New: People experiencing a first EIP treated within two weeks of referral (MHSDS - Rolling Quarter) 84.0% 60% April 2020 final 84.0% 56% Judd Skelton Dementia (aged 65 and over) 72.2% 1,644 2,278 77.8% July 2020 final 72.2% 77.8% Judd Skelton Mental health out of area placements Judd Skelton Patients diagnosed with dementia whose care plan has been reviewed in a face-to-face review in the preceding 12 months Judd Skelton Ensuring the quality of mental health data submitted to NHS Digital is robust (DQMI) Judd Skelton
2/4 24/09/2020 Salford CCG Delivery Dashboard 2020/21 Data collection and publication paused /no information available nationally due to Covid-19 Generated on: 22nd September 2020 Care Programme Approach (CCG) Judd Skelton IAPT Workforce - Therapist co located in primary care Judd Skelton IAPT Workforce - Therapist co located in primary care (FTEs) Judd Skelton IAPT Workforce-IAPT Trainees Judd Skelton IAPT Workforce-IAPT Trainees Judd Skelton
5. Children and Maternity 2020/21 Latest Period (Published Performance Indicator Latest Data Target Exec Lead Num Den position) Value Target
Waiting times for Routine Referrals to Children and Young People Eating Disorder Services 100% 7 7 80% Q1 2020/21 result 96.7% 80% Karen Proctor Waiting times for Urgent Referrals to Children and Young People Eating Disorder Services 100% 2 2 75% Q1 2020/21 result 100% 75% Karen Proctor Improve access rate to CYPMH 19.5% 8.8% Q1 2020/21 result 19.5% 35.0% Karen Proctor Women's Smoking Status at Time of Delivery 9.6% 83 867 10% Q1 2020/21 result 9.6% 10% Karen Proctor Proportion of children aged 10-11 classified as obese. Dr Muna Abdel Aziz Neonatal mortality and stillbirths Karen Proctor Women’s experience of maternity services Karen Proctor Choices in maternity services Karen Proctor Percentage of children waiting 18 weeks or less for a wheelchair Karen Proctor
7. Primary Care
2020/21 Latest Period (Published Performance Indicator Latest Data Target Exec Lead position) Num Den Value Target
Proportion of the population that the urgent care system 111 can directly book appointments into the contracted extended 0 100 Q4 2019/20 result 0 100% Caroline Rand access services Salford Wide Extended Access Pilot (SWEAP) (evening and weekends) at GP services 100% 100% July 20 final local data 100% 100% Karen Proctor Antibiotics prescribed in primary care 1.019 0.965 June 20 final 1.019 0.965 Francine Thorpe Proportion of broad spectrum antibiotics prescribed in primary care 10.1% 10% June 20 final 10.1% 10% Claire Vaughan Proportion of the population with access to online consultations Caroline Rand Extended Access Appointment Utilisation Caroline Rand Proportion of people with a learning disability on the GP register receiving an annual health check Karen Proctor Completeness of the GP learning disability register Karen Proctor Primary care workforce Karen Proctor % of diabetes patients have achieved all the NICE-recommended treatment targets Karen Proctor % of people with diabetes diagnosed for less than a year who attended a structured education course Karen Proctor
3/4 24/09/2020 Salford CCG Delivery Dashboard 2020/21 Data collection and publication paused /no information available nationally due to Covid-19 Generated on: 22nd September 2020 Provision of high quality care: primary medical services Karen Proctor Patient experience of GP services Karen Proctor
8. Quality
2020/21 Latest Period (Published Performance Indicator Latest Data Target Exec Lead position) Num Den Value Target
HCAI Measure CDIFF (SRFT) 17 36 Cumlative to July 20 17 36 Francine Thorpe HCAI Measure MRSA (CCG) 0 0 Cumlative to July 20 1 0 Francine Thorpe HCAI Measure MRSA (SRFT) 0 0 July 20 final 1 0 Francine Thorpe Number of injuries due to falls in people aged 65+ (rolling 12 months) 1022 1,116 Rolling 12 months to August 20 1022 1,116 Judd Skelton NHS CHC assessments take place in an acute hospital setting 0.0% 0 21 15% Q4 2019/20 0.0% 15% Karen Proctor Provision of high quality care: hospital Francine Thorpe Mixed Sex Accommodation Breaches (CCG) Francine Thorpe
Number of personal health budgets that have been in place, at any point during the quarter, per 100,000 CCG population. Francine Thorpe
8. Leadership 2020/21 Latest Period (Published Performance Indicator Latest Data Target Exec Lead position) Num Den Value Target The proportion of carers with a long term condition who feel supported to manage their condition In-year financial performance Expenditure in areas with identified scope for improvement Probity and corporate governance Staff engagement index Progress against the Workforce Race Equality Standard Effectiveness of working relationships in the local system Quality of CCG leadership Compliance with statutory guidance on patient and public participation in commissioning health and care
4/4 24/09/2020
Appendix 2-Performance and Service updates
Urgent Care: Accident and Emergency
Illustrated in the tables and graphically below are attendance figures comparing from February 2020 to August 2020, for both Salford CCG patient attending all A&E departments and all patent attending Salford Royal Foundation Trust. Patients attending A&E during April fell to less than 50% of pre COVID-19 levels. Attendances have started to increase and are currently at around 80%, when compared to pre-COVID-19 activity.
The proportion of patients admitted to hospital following an A&E attendance at SRFT was around 32.7% before the COVID-19 peak (April 2019 – Feb 2020), which was approximately an average of 95 admissions per day. During the COVID-19 peak (March – May 2020), the proportion increased to 34.6%, but the average admissions per day fell to 65 per day, as A&E attendances fell dramatically. The average daily number of non-elective admissions is currently around 82 per day. Therefore, assuming all other things were equal, the reduced number of admissions may indicate that there was a cohort of patients who should have attended A&E and been admitted during this period, who didn’t. This is being reviewed as part of the GM Safety Siren work.
COVID-19 admission numbers into the hospital have been in single figures through August 2020 but we are seeing a small increase in September 2020, as admitted COVID-19 cases have moved into low double figures.
The hospital continues to operate cold and hot areas to ensure that non COVID-19 and COVID-19 patients are kept separate. Salford CCG continues to operate a COVID-19 hub off site with 2 clinicians working from the St Andrews clinic, with a steady 12 to 15 patients being seen face to face on a daily basis. If numbers increase, there is flexibility to reopen two other COVID-19 clinics that operated at the height of the pandemic. There continues to be anecdotal evidence that patients are struggling to gain access to swabbing to test for COVID-19 and work is being carried out with our Public Health colleagues to identify the issues and establish solutions.
Salford has secured funding for a separate mental health area on the Salford Royal Hospital site which will help support patients that present at the hospital. This will reduce pressure on other hospital services while providing a more appropriate service for the patient. . Estates have identified a location and plans are being developed to deliver this programme. A timescale is in the process of being agreed but all monies must be spent by December 2020.
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In order to support Emergency Attendance going forward, in August two service test changes were carried out at the Emergency Department front door to support the implementation of Urgent Emergency Care by Appointment across Greater Manchester. The service test changes that happened on the 3rd August and the 18th August 2020, assessed self-presenting patients before they entered the Emergency Department, to establish if there were more appropriate services that could meet their needs. This resulted in over 25% of self-presenters being booked into more appropriate services than in the Emergency Department on the 3rd August and 23% on the 18th August. 88% of those patients followed up after this service, rated the service and their experience as good, very good, or outstanding.
This part of the project went fully live on the 24th August 2020 and performance and outcomes will continue to be monitored. It is intended that all localities in Greater Manchester will implement similar models but at present, Salford is the only area that is fully operational with this service.
Salford is now working on the second phase of Urgent Emergency Care by Appointment which is Call Before You Attend, within the development of the NHS 111 First service. The aspiration is that 25% of self-presenting Emergency Department patients would be encouraged to call 111 rather than self-presenting to the Emergency Department. This element of the model is scheduled to be implemented in Salford by the 20th October 2020.
Car
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Scheduled Care: Diagnostic waiting Times
Most recent performance data for August shows that more than half of Salford CCG patients waited over 6 weeks for a diagnostic test and almost a quarter over 13 weeks. A significant proportion of the long waiting times are for Non Obstetric Ultrasound Scans (NOUS). Waiting times have also increased for MRI Scans, CT Scans and Gastroscopes. Suspected cancer and other urgent referrals are prioritised.
Diagnostic waiting times are anticipated to improve as part of the national COVID-19 recovery guidance which allows for the restarting of non urgent tests, which were paused during the immediate response to the pandemic. This includes several community based providers of NOUS.
CCG diagnostic activity for August is 41% of the average monthly diagnostic activity volume when compared with the same period in 2019/20. The NHS is now in Phase 3 recovery and requires Trusts to re-establish, and where necessary re-design, diagnostic services to deliver at least 90% of their last year’s volume of tests by September for MRI/CT and endoscopy procedures, with an ambition to reach 100% by October.
Listed below are steps SRFT is taking to re-establish their diagnostic capacity in line with this Phase 3 requirement:
• Endoscopy activity is scaling back up after being reduced to just urgent in-patients as per national guidance • Endoscopy activity is currently approximately 50% of last year’s activity with plans to increase this on a week by week basis in line with Phase 3 recovery • SRFT are currently using the independent sector at the Spire and Oaklands to deliver additional endoscopy sessions, and are looking to further increase activity on the Salford endoscopy site, in accordance with national Public Health England guidelines • Currently, endoscopy for cancer and urgent cases are prioritised to address the backlog of activity that has accrued during the period of reduced activity; long waiters, non-cancer and non-urgent cases will be the next priority groups of patients to be seen • Routine CT/MRI imaging is now being undertaken after a long period of reduced activity due to only urgent activity being delivered on site; there are substantial backlogs to clear as services get back up and running • This backlog is being addressed by scheduling additional waiting list initiative sessions to bring down waiting times and waiting lists • One challenge is overnight sleep study tests which are yet to resume due to the difficulty in ring fencing bed capacity due to the zoning that is now required to segregate COVID-19 and non-COVID-19 patients on site. Alternative locations are currently being discussed.
At the time of writing, the CCG is in the process of agreeing recovery planning figures with NHSE.
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Scheduled Care: Cancer Waiting Times
Whilst cancer services have remained a priority area for the NHS during the pandemic, COVID-19 has significantly impacted on cancer waiting time standards nationwide.
Eleven national Cancer Waiting Time (CWT) indicators are monitored. In July 2020, five were not achieved for Salford CCG.
1. 2 Week Wait (following a suspected cancer GP Referral) – 93% target July performance was at 91.5% (a total of 811 patients seen of which 742 patients were seen within standard). The volume of GP suspected cancer referrals seen in July 2020 were 86% of July 2019 volume. In order to meet the target for July, 13 more patients would have needed to be seen within two weeks.
A total of 69 breaches were reported in July, of which 61 took place at Manchester Foundation Trust (MFT), with a majority being suspected breast cancer, with patients being seen with a 15 to 21 day timeframe. There was 1 suspected children cancer that waited in excess of 20 days to be seen
2. 2 Week Wait (following a GP referral for Breast Symptoms) – 93% target July performance was at 44.2% (a total of 77 patients seen of which 34 were seen within the standard). Performance has worsened compared to June (64.4% - 47/73). In order to meet the target for July, 38 more patients would have needed to be seen within two weeks.
A total of 43 breaches were reported in July, with 40 breaches taking place at MFT;. Over half of the patients waited between 15 and 21 days to be seen and the rest waited between 22 days and in excess of 119 days.
The volume of GP two week wait breast symptoms referrals seen in July 2020 was 71% of July 2019 volume.
3. 31 Days wait for subsequent cancer treatment (Drugs) – 98% target July performance was at 94.1% (17 patients seen of which 16 were within standard). The patient waited 139 days at SRFT. The YTD position is 98.6%, which meets target.
4. 62 Days wait for initial treatment (following Screening) – 90% target July performance was at 0% (one patient seen, but not within target) against the 90% target. The patient waited 125 days at Bolton FT following bowel screening, due to a delay in accessing a diagnostic procedure.
5. Waiting 104 days or more from referral to the first definitive treatment In July, Salford CCG had 8 patients treated who had waited over 104 days for their first definitive cancer treatment against a zero tolerance.
Salford CCG patients receive cancer treatment from a range of Providers. The table below shows July 2020 breaches referred to in the section above, broken down by hospital provider.
With the exception of Manchester Foundation Trust (MFT), Salford CCG breach numbers at individual Provider Trusts are small. MFT report that all cancer referrals are triaged and the most clinically urgent prioritised for assessment and treatment, meaning that those assessed as less urgent are waiting longer. In addition, despite patients being assured that the hospital site is COVID secure with strict adherence to Public Health England (PHE) hygiene requirements and social distancing measures, a proportion of patients are continuing to defer outpatient appointments due to fears about COVID-19, which has resulted in patients rebooking to a later
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date and triggering breaches. Manchester CCG has been asked for further information about capacity issues at MFT and cancer waiting times recovery plans.
Key Points: The NHS is now in Phase 3 recovery, with national guidance issued on the 31 July 2020 identifying the following areas to focus on, in respect of cancer services:
• To return to pre-pandemic levels of suspected cancer referrals • To increase the treatment numbers for cancer patients • To reduce the backlog of those waiting for treatment
Salford and GM are seeing improvements in all these areas.
The following key points provide some background to the main challenges and issues.
GP Suspected Cancer Referrals Cancer services have remained open during the COVID-19 pandemic with national and local communications encouraging patients to not delay contacting their GPs with any worrying signs or symptoms and to attend hospital settings for appointments and cancer diagnostic tests.
However, as the table below shows during the period April to June 2020 GP suspected cancer referrals were significantly lower than normal (March 2020). This has improved, with Salford GP referrals showing greater recovery than GM.
Cancer referrals are returning to normal levels for all tumour groups with the exception of lung cancer. At the end of August, suspected lung cancer referrals for GM were 50% less than normal and 25% lower for Salford CCG. Local and national work on addressing this with patient and professional facing communications is ongoing.
“Missing” Cancer Referrals It is calculated that during March – July 2020, there were 18,000 fewer suspected cancer referrals than expected made in GM. GM Cancer Alliance is working with GM CCGs and Provider Trusts to
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draw up plans to ensure sufficient capacity is in place to manage increased demand as a result of ‘missing’ patients presenting in the future and a subsequent peak in demand for cancer treatments, surgery and follow-up care.
In addition, GM Cancer Alliance is considering whether to develop active case finding to be more proactive in identifying ‘missing” referrals and encouraging patients to present.
Cancer Diagnostics Although diagnostic tests for suspected cancer patients have continued throughout the pandemic and are the highest priority, waiting times still remain longer than they were previously. Overall, GM diagnostic capacity is reduced by approximately 40% due to social distancing measures and zoning restrictions.
Of particular concern, within GM and nationally, are the numbers waiting for an endoscopy procedure to diagnose or discount upper and lower gastrointestinal cancers.
As at 15 September, a total of 826 GM cancer patients were reported as delayed awaiting diagnostic tests; 793 of these were awaiting endoscopy. Waiting times are reducing week by week and it is anticipated that it will take between 6 and 9 months to clear the GM backlog. In comparison, Salford CCG has a relatively low number of patients delayed due to diagnostics, 21 are currently delayed awaiting diagnostics of which 18 are waiting for an endoscopy procedure.
GM are operating a collective approach to managing and clearing the endoscopy waiting list with the development of a single GM system management for these procedures, utilising capacity across all NHS and Independent Sector providers.
Volume of confirmed cancer diagnoses Governing Body has previously queried if the number of diagnosed cancers has reduced as a result of reduced suspected cancer referrals. Routine cancer information systems do not report on dates of diagnosis, but focus on treatment dates and waiting times. GM Cancer Alliance colleagues are working to develop an analysis of cancer conversion rates (i.e. the rate of confirmed cancers per suspected cancer referral). A lower or the same conversion rate during April – July would indicate a risk that opportunities to diagnose cancer may be being missed by fewer patients presenting with symptoms and fewer suspected cancer referrals. This analysis is proving difficult due to the limitations of the data, but continues to be developed.
In order to partly respond to the Governing Body enquiry, presented below is a graph which shows the number of cancer diagnosed patients treated each month since April 2019. Whilst this does not provide the number of patients diagnosed during this period, it shows the number of diagnosed patients treated. Due to recent reduced diagnostics and treatment capacity, it is expected that the number of treatments will have reduced in recent months. Over time, the plan is that this will recover to expected/above expected levels. This graph will be updated and reported to the GB on an ongoing basis to help monitor cancer treatment recovery plans.
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The full impact of COVID-19 upon the presentation, identification, diagnosis, treatment and outcomes for cancer patients is not likely to be fully understood until after longer term robust quantitative analysis.
Long waiting times for cancer treatment Nationally GM has the highest number of patients waiting over 62 days and 104 days for treatment. At 20th September, GM had 2,412 patients waiting over 62 days for treatment, of these 897 were waiting in excess of 104 days. SRFT had 143 patients waiting over 62 days, of which 42 patients were waiting over 104 days.
The majority of these long waiters are on either Lower Gastrointestinal (LGI) or Upper GI (UGI) cancer pathways, their waiting time lengthened by the delays in accessing endoscopy.
GM has developed a plan to comply with the national and regional mandate to reduce, by 30 November 2020, the volumes of patients currently on active cancer pathways beyond 104 days. This plan is based on a number of assumptions, including that there is no significant second wave resulting in re-deployment of key workforce and resources.
SRFT manage all long waiters at weekly cancer patient tracking meetings. This, along with gradual improvements in access to diagnostic and treatment capacity, is reducing the number of 104+ day waiters at SRFT as shown in the table below.
Additional information relating to potential patient harm is reported with the ‘Quality of Commissioned Services’ paper. Times: July 2020 Update Report
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Scheduled Care: RTT Recovery
The NHS is now in Phase 3 recovery and requires Trusts to accelerate the return to near normal levels of non-urgent health services as follows:
• At least 80% of last year’s activity for both overnight planned care hospital admissions and for outpatient/day case procedures, by September, rising to 90% in October (while aiming for 70% in August); • 100% of last year’s activity for first outpatient attendances and follow-ups (face to face or virtually) from September (and aiming for 90% in August)
Salford CCG patient activity for July 2020 was the following proportion of July 2019 activity:
Day cases: 44% Planned overnight inpatients: 42% Outpatients first attendances: 61% Outpatient follow up attendances: 73%
Listed below are steps SRFT is taking to re-establish their elective admission and out-patient capacity in line with this Phase 3 requirement:
Admitted Patients • Continued to increase on-site theatre capacity in the short term by unblocking the barriers to re-opening all theatres on-site (staffing levels, anaesthetist cover, zoning / infection control requirements). A further 2 theatres are expected to be available by the end of September • Continued use of off-site NHS and Independent Sector theatre capacity (Oaklands for Orthopaedics, Alexander for Neurosurgery, Spire for ENT and Spinal Surgery, Fairfield for Orthopaedics and Rochdale for General Surgery, Urology and Gynaecology) • If all plans deliver, SRFT expect to achieve 79% of last year’s level of activity by end of September within NHS capacity across the Northern Care Alliance, with this increasing to 87% with Independent Sector capacity included. This is in line with the 80% target by end of September included in the national Phase 3 recovery guidance • Longer term planning is underway regarding how to further increase theatre capacity, including consideration of 7 day working
Non-admitted (Out-patients) • For non-theatre work, the main area of focus is expansion of day case infusion/procedure capacity. Day Case services have a reduced throughput due to increased spacing/social distancing requirements, so there is a need to increase capacity with 7 day working being considered to off-set this as well as making up for the reduced throughput in recent months • Out-patient services have been scaling back up to see (either virtually or face to face) an increasing number of routine patients. This has involved a gradual increase in clinic appointments, made possible by creative approaches to spacing in waiting rooms and departments and having patients wait in their cars etc. until their appointment time. By the beginning of October, out-patient services expect to be running at 100% of pre-COVID-19 capacity, and are considering ways of clearing backlogs through ad-hoc weekend extra clinics • Local service developments currently being implemented at pace for non-admitted patients at SRFT are Advice & Guidance (A&G) and Patient Initiated Follow-Up (PIFU) • These service developments are in line with the national requirement to accelerate outpatient recovery and implement rapid out-patient transformation to urgently tackle the backlog of patients needing care and are described in more detail in the Governing Body COVID-19 Recovery Report cheduled Care RTT Recovery and Pahse 3 planning
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Mental Health: Service Update
• Both Six Degrees and GMMH have been delivering therapy via telephone and / or video conferencing throughout the pandemic. Evaluation of the acceptability and effectiveness of video conferencing within the GMMH service is being undertaken. Online group delivery is also taking place in Six Degrees.
• Current waiting times for Six Degrees are 4 weeks on entry which is an improving picture; however this is not yet reflected in local on exit data. Whilst recovery against the improvement trajectory is taking slightly longer than anticipated, it is likely that the improving on entry data will be reflected in November data. There are no waits between appointments once someone has undergone their initial appointment. People are seen fortnightly unless they request otherwise.
• Six Degrees has continued to see the benefit of counselling staff, with practitioners targeting the GP surgeries with the longest waiters. The value of this staff group is widely recognised in the service and an evaluation is underway to demonstrate the impact of this workforce and will contribute to the discussions at GM and nationally relating to competencies of the IAPT workforce. Some contracts / hours for Counsellors are being extended until the end of the year to support with the recovery against the trajectory. Experienced staff on mat leave are now starting to return to the service, although this may be on reduced hours in some cases.
• Psychological Wellbeing Practitioners (PWPs) trainees are now in place and another cohort of trainees is planned for Spring 2021.
• People not wanting / able to take up IAPT via video / telephone with Six Degrees are being contacted regularly and face to face clinics are being explored in a limited capacity in line with the reopening of Gateways. GMMH have informed people who have not wanted / been able to uptake IAPT via video / telephone that they will be contacted when face to face clinics are on offer.
• Silver Cloud (online therapeutic packages supported by IAPT workers) are now integrated into Six Degrees data flow and is being operationalised as part of the service in two GP surgeries as a pilot approach to ensure that processes are embedded. Planning is ongoing for wider roll out. Public Silver Cloud packages are available without IAPT support.
• Six Degrees staff have been supporting with the triage of referrals to the new Beyond service (supporting referrals from the Spirit of Salford line for people not known to GMMH). In addition to triage, Six Degrees has supported the onward referral to CMHT where needed and the liaison between primary and secondary mental health care.
• GMMH has continued to see improvements in the monthly reporting. Silver Cloud is being explored for Step 3 to support online offers.
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Generated on: 21 September 2020
Appendix 3 - Strategic Risk Register - All Risks
1. Listen to our Member practices and partners, and keep the voice of the people of Salford at the heart of everything we do
SRR.06 Changes in patient behaviour fail to materialise resulting in ongoing health inequalities and ever increasing demand for services Risk Owner Claire Connor; Hannah Dobrowolska Changes in patient behaviour fail to materialise resulting in ongoing health inequalities and ever increasing demand Risk Sponsor Steve Dixon for services Governance Group Governing Body Locality Plan in place with significant focus on prevention and associated Communications, Engagement and Social Marketing Plan agreed across partners. This is being implemented with support of partners across Salford. Significant work programme associated with self care, particularly linked to long term conditions. Significant Existing Controls work programme associated with mental health. Regular campaigns associated with appropriate use of services. Good availability and use of health inequalities data to guide commissioning decisions. CCG Communications and Engagement Strategy in place and work ongoing. Salford and GM level public health led work ongoing. Update reports provided to EEMG which reports exceptions for action or information for assurance to Executive Team. Update reports provided to Health and Assurances Wellbeing Board for Locality Plan related activities. Gaps None. Original Risk 12 Current Risk 16 Target Risk 12 Risk Treatment: Tolerate Continue with existing controls.
High Impact 4 High Impact 4 High Impact 4 Latest Update: 10 Sep 2020 Next Assessment due: 05-Oct-2020 Likely 3 Very Likely 4 Likely 3 No change Risk Identified 10-Oct-2017 Risk Assessed 10-Sep-2020 Target Date 03-Jul-2021 Risk Movement since last Constant Risk History assessment
SRR.07 Commissioning decisions are influenced by conflicts of interest and do not represent the best solutions for the people of Salford Risk Owner Hannah Dobrowolska; Jenny Noble Commissioning decisions are influenced by conflicts of interest and do not represent the best solutions for the Risk Sponsor Steve Dixon people of Salford Governance Group Governing Body Updated Conflicts of Interest Policy approved in September 2017 in line with new national guidance and is reviewed annually. Implementation commenced. Training Existing Controls delivered to Governing Body members. Clear minuting of decisions where any real or perceived conflict of interest issues occur. Staff excluded from decision and
1 Generated on: 21 September 2020
discussion as appropriate. New NHS England on line mandatory training completed by relevant staff and will be rolled out to all staff by September 2020. Conflicts of Interest Registers for Governing Body members, relevant staff and CCG members in place. Internal Audit review of Conflicts of Interest in March 2017 gave an improvement in the level of compliance with NHSE guidance compared to previous years, and highlighted areas of good practice. Implementation of the agreed Assurances management actions in line with the audit recommendations will be completed. Conflict of Interest monitoring returns made to GM in line with requirements. Where concerns are raised, these are investigated and any required action taken. Gaps Full implementation of up to date the Conflict of Interest Registers for CCG practice members ongoing. Original Risk 6 Current Risk 4 Target Risk 2 Risk Treatment: Treat (Plan in place) Implementation of full CCG practice members Conflict of Interest Registers ongoing. Ensure the Conflict of Interest arrangements within the CCG and Salford City Council are applied appropriately to integrated commissioning decisions.
Medium Impact 3 Low Impact 2 Low Impact 2 Latest Update: 09 Sep 2020 Next Assessment due: 05-Oct-2020 Unlikely 2 Unlikely 2 Very Unlikely 1 No change. Risk Identified 10-Oct-2017 Risk Assessed 10-Sep-2020 Target Date 31-Mar-2020 Risk Movement since last Constant Risk History assessment
2. With Salford City Council plan services together, including an even greater focus on prevention, early intervention and care outside of hospital
SRR.02 Distraction from delivery of organisational objectives during organisational changes associated with integrated commissioning Risk Owner Hannah Dobrowolska If leaders and staff focus too heavily on the organisational changes associated with integrated commissioning, this programme could distract staff from delivery of their commissioning related objectives and mean that these are not Risk Sponsor Steve Dixon delivered, meaning that the ambitions set out in our Locality Plan are not likely to be achieved. Governance Group Governing Body This way of working is business as usual now, with strategic priorities and objectives set across integrated commissioning where appropriate. Staff continue to be Existing Controls engaged in the changes with clear communication and OD plans in place to minimise any staff anxiety associated with change. Partnership agreement in place to determine integrated commissioning arrangements. Colocation work ongoing. Assurances Staff survey results remain high. Feedback from Staff Forum/staff events does not indicate a significant risk in this area. Gaps None identified. Original Risk 8 Current Risk 3 Target Risk 4 Risk Treatment: Treat (Plan in place)
2 Generated on: 21 September 2020
Continue with clear staff communication and engagement. Retained as strategic risk until colocation complete, which is subject to ability to return to office working in line with COVID-19 infection prevention and control working limitation.
High Impact 4 Medium Impact 3 High Impact 4 Latest Update: 10 Sep 2020 Next Assessment due: 05-Oct-2020 Unlikely 2 Very Unlikely 1 Very Unlikely 1 No change, working arrangements becoming business as usual. Retained as strategic risk until colocation complete, which is subject to ability to return to office working in line with COVID-19 Risk Identified 10-May-2018 Risk Assessed 10-Sep-2020 Target Date 31-Mar-2020 infection prevention and control working limitation. Risk Movement since last Constant Risk History assessment
3. Play a leading role in transforming and improving the quality of health and care services across our neighbourhoods, city, sector and Greater Manchester
SRR.10 Failure to commission high quality, stable provision of services that meet the needs of the entire population of Salford. Risk Owner Harry Golby If there is a disruption in the delivery of services patients may not be able to access appropriate clinical care which may lead to patient harm and impact on wider service delivery across the system. If post-COVID service models Risk Sponsor Steve Dixon; Harry Golby develop that do not meet the needs of the entire population then health inequalities may persist and worsen. Governance Group Governing Body The Primary Care Commissioning Committee (PCCC) focuses on commissioning of primary medical services, including the Salford Standard for GP Practices and Existing Controls other enhanced services for pharmacists and optometrists. Regular reporting of regarding performance and quality of CCG commissioned services up to Priomary Care Commissioning Committee. Relationships with member Assurances practices and Local Medical Committee also provide assurance (e.g. practice visits, LMC support, neighbourhood meetings, etc.) We currently have limited collaborative working arrangements for wider primary medical care. This has been identified as a Programme Risk and is being managed as Gaps such. Limited coordination of wider primary care services which are managed across multiple organisations. Original Risk 8 Current Risk 12 Target Risk 4 Risk Treatment: Treat (Plan in place) Management through Salford Standard and neighbourhood practice visits.
High Impact 4 High Impact 4 High Impact 4 Latest Update: 02 Sep 2020 Next Assessment due: 05-Oct-2020
3 Generated on: 21 September 2020
Unlikely 2 Likely 3 Very Unlikely 1 Risk reviewed and amended to reflect all services (not solely primary care) and potential for inequalities arising from post-COVID services models in line with feedback from informal Risk Identified 10-Oct-2017 Risk Assessed 02-Sep-2020 Target Date 31-Mar-2020 governing bod. Likelihood reduced as CCG has assurance that most services have restarted following initial phase on the pandemic (i.e. period when Salford did not have stable services is Risk Movement since last Decreasing Risk History now past) and all sectors are developing post-COVID recovery plans and actions to address assessment inequalities are central to these plans.
SRR.19 Resilience of specific hospital services Workforce, funding and other issues mean some specific hospital services are not resilient. The risk is that a Risk Owner Karen Proctor change, for example loss of a key clinician, creates a gap in service or deterioration of performance or quality for Risk Sponsor Steve Dixon Salford patients which the provider is not able to manage in the short term. This is an overarching risk, specific recent local examples have been paediatric ophthalmology and breast surgery. Governance Group Commissioning Committee Transformation Theme 3 of the Greater Manchester “Taking Charge” plan aims to develop plans to reconfigure acute services. Clinical specialties have been prioritised where concerns regarding the resilience of services have been identified. This work is also being progressed at more local levels for example the North Existing Controls West Sector Partnership, the Northern Care Alliance and the Manchester Single Hospital Service will affect Salford residents. CCG clinicians and managerial staff are actively involved in the Theme 3 and North West Sector programmes, and, to a lesser extent, the Northern Care Alliance and Manchester Single Hospital Service programmes. The CCG has also established workstreams in areas outside the scope of these programmes (e.g. paediatric ophthalmology, etc.) Commissioning Committee and CCG Executive Team receive regular updates from the Theme 3 and North West Sector Partnership, as well as other local Assurances workstreams. Gaps Timescales may not match up i.e. gaps in service may appear before significant service reconfiguration is implemented. Original Risk 6 Current Risk 8 Target Risk 8 Risk Treatment: Tolerate Tolerate – continue to lead and support work at Greater Manchester and more local work to progress acute service reconfiguration
Low Impact 2 High Impact 4 High Impact 4 Latest Update: 27 Aug 2020 Next Assessment due: 05-Oct-2020 Likely 3 Unlikely 2 Unlikely 2 Strong relationships and governance, including sector & GM collaboration maintain strong resilience Risk Identified 10-Oct-2017 Risk Assessed 27-Aug-2020 Target Date 31-Mar-2020 Risk Movement since last Constant Risk History assessment
4 Generated on: 21 September 2020
4. Deliver Salford CCG’s operational plan and outcomes, which are in line with Salford’s Locality Plan, the Greater Manchester Health and Social Care Plan, the NHS Constitution and other national requirements
SRR.09 Failure to achieve national performance targets against constitutional standards Risk Owner Hannah Dobrowolska If pressures in the health and social care system are not effectively managed then we may fail to achieve national performance targets. This may result in patient harm, poor patient experience, negative media attention Risk Sponsor Steve Dixon (reputational damage), reduced patient confidence and could cause further pressures in the wider health system. Governance Group Governing Body Monthly performance breach reports produced to highlight areas of concern. Appropriate governance in place including the Urgent Care Board and Scheduled Care Board, Contract Management Group, Quality and Outcomes Group and internal performance meeting in place. Performance is also managed locally by providers. Existing Controls Regular discussion of performance at CCG Executive Team meetings, with formal reporting to Governing Body including performance recovery plans. Involvement in GM arrangements as required. Strong relationships with providers. Assessment of COVID-19 national and regional guidance to ensure working in line with requirements. Plans for recovery produced where required. Data regularly produced, shared and reviewed. Assurance Framework Report including performance, recovery plans and risk reports presented to every Governing Assurances Body meeting. The full and long term impact of COVID-19 on the NHS's ability to met constitutional standards is not yet clear. Due to the ongoing level of uncertainty, we do not yet Gaps have a clear recovery plan with our providers for all areas of our commissioning responsibilities. This is being worked on, with urgent work and work to address inequalities prioritised in line with national guidance. Original Risk 16 Current Risk 16 Target Risk 8 Risk Treatment: Treat (Plan in place) Risk will continue to be mitigated through continuous performance management practices within CCG and with providers/partners.
High Impact 4 High Impact 4 High Impact 4 Latest Update: 10 Sep 2020 Next Assessment due: 07-Dec-2020 Very Likely 4 Very Likely 4 Unlikely 2 No change in scores, position worsened as a result of COVID-19.
Risk Identified 10-Oct-2017 Risk Assessed 10-Sep-2020 Target Date 31-Mar-2020
Risk Movement since last Constant Risk History assessment
SRR.15 Cyber Security threat The risk that computer systems are accessed illegally resulting in failure to protect data and systems essential to Risk Owner David Warhurst delivery of care with the potential to disrupt services including disruption to commissioning functions. Risk Sponsor Steve Dixon
5 Generated on: 21 September 2020
Governance Group Governing Body GMSS have a number of controls to manage the risk of cyber attacks. These are documented in their IG toolkit submission. The GMSS IT managers have a dedicated sub group to IT security where threats and actions are monitored. Existing Controls The CCG has a Business Continuity Policy and detailed Business Continuity Plan (BCP). Contracts require providers to have business continuity plans. The Health Economy Resilience Group (HERG) allows the local system to maximise resilience arrangements. CCG monitors the GMSS performance. CCG sends out regular cyber security awareness messages to staff and practices. Assurances The BCP is reviewed every year as part of the GM Emergency Preparedness, Resilience and Response (EPRR) Assurance process, which also covers our main providers. Gaps The CCG does not quality assure the business continuity plans of providers. Original Risk 16 Current Risk 16 Target Risk 16 Risk Treatment: Tolerate NA - Risk is being tolerated with existing controls in place. The risk is constantly monitored and managed.
High Impact 4 High Impact 4 High Impact 4 Latest Update: 15 Sep 2020 Next Assessment due: 05-Oct-2020 Very Likely 4 Very Likely 4 Very Likely 4 Cyber security threats remain at high given the renewed bout of attacked associated with Covid related scams. However, the CCG/GPIT service GMSS has continued to develop its security Risk Identified 10-Oct-2017 Risk Assessed 15-Sep-2020 Target Date 31-Mar-2020 processes and has now achieved two externally accredited awards, namely Cyber Essentials Plus and ISO27001 (International Standard for IT Security). The CCG IG committee now receives regular Cyber security reports and the Audit Committee will receive a detailed report in Risk Movement since last Constant Risk History November 2020. assessment
SRR.23 Climate Change - Failure to reduce health and social care related carbon emissions will result in significant negative public health impact, increased inequalities and reputational damage. If Salford’s health and social care system fails to reduce carbon emissions in line with Greater Manchester/NHS Risk Owner Claire Connor Long Term Plan targets and limited time frame, with sustainable development not becoming fully embedded in Risk Sponsor Steve Dixon health and social care’s approach, structure and culture, then there will be a) a significant threat to public health which will undermine previous public health gains, b) worsened health inequalities and c) reputational damage. Governance Group Governing Body Risk Profile
Existing Controls The CCG has a Social Value Strategy and associated action plan, with a very small dedicated resource to this work and two Governing Body leads. This covers economic, social and environmental actions. Salford CCG is part of Salford’s Social Value Alliance. Salford CCG is a Carbon Literate organisation and is part of Salford’s Carbon Literacy Consortium. Part of the Greater Manchester Health and Social Care Partnership Sustainable Development Leadership Group, representing
6 Generated on: 21 September 2020
CCGs. Carbon reduction is included in the CCG’s innovation call for 2019/20.. Assurances Salford CCG has achieved silver accreditation for its Carbon Literacy work. The Executive Team receive a quarterly Social Value update report. Lack of prioritisation of carbon reduction action because of other threats to health which are perceived to be more urgent mean that the immediate action required is delayed. Clear leadership that climate change will exacerbate existing public health challenges, placing undue financial pressure on the NHS and worsening health inequalities both within the UK and globally. Adequate communication and engagement to actively promote and encourage participation in the work programme to ensure clear, evidence based messages and recommendations are produced and disseminated around threats to health from climate change and opportunities to Gaps achieve significant public health benefits by responding to these challenges. Governance and planning fail to recognise the health impacts of climate change and the role of the NHS to contribute to local/GM/national/global efforts around climate change/environmental degradation. Sufficient action within health and social care to ensure that parallel stakeholder environmental plans in GM are not undermined. Plans to action carbon reductions are not appropriately resourced (staff time and financial resource). Original Risk 16 Current Risk 16 Target Risk 9 Risk Treatment: Treat (Plan in place) Make full use of the NHS Sustainability Unit’s resources. Consider commissioning levers that could be used to encourage carbon reduction by our health and social care providers and wider supply chain. Gain gold/platinum Carbon Literacy accreditation. Prioritise and publicise more our work in this area including through directorate specific carbon reduction objectives and encouraging CCG leaders and staff to share personal pledges. Build further on our networks to take forward carbon reduction work collaboratively. Engage in the development and delivery of the GM Sustainable Development Management Plan (SDMP) for health and social care. High Impact 4 High Impact 4 Medium Impact 3 Latest Update: 03 Sep 2020 Next Assessment due: 05-Oct-2020 Very Likely 4 Very Likely 4 Likely 3 No change Risk Identified 05-Jul-2019 Risk Assessed 03-Sep-2020 Target Date 31-Mar-2021 Risk Movement since last Constant Risk History assessment
SRR.04 NHS and wider public sector funding Risk Owner David Warhurst If funding to the NHS and/or wider public sector is reduced, then the CCG and council may need to commission Risk Sponsor Steve Dixon services with less money so it may be necessary to reprioritise and potentially decommission services. Governance Group Governing Body The CCG has been notified of the financial allocation for 2018/19. A 5 year finance plan has been presented to the Governing Body for 2018/19 onwards. However, financial allocations for 2019 and beyond are indicative and the CCG has made assumptions on the level of growth funding in future years and therefore still a degree Existing Controls of uncertainty if these indicative allocations change or assumptions on growth are incorrect. However, the five year financial modelling for Salford CCG assumes a balanced financial position with a low savings target requirement. Annual refresh of the 5 year plan presented to Governing Body and financial risks updated. Assurances Informs commissioners of the likelihood of funding issues and allows them to plan services and service redesign programs accordingly. NHSE has only issued indicative allocations for 2019 onwards which are subject to change. Planning guidance, including CCG allocations, will be issued in October Gaps 2018. CCG funding formula could change.
7 Generated on: 21 September 2020
Original Risk 8 Current Risk 12 Target Risk 8 Risk Treatment: Tolerate Maintain watching brief upon funding developments and review accordingly.
High Impact 4 High Impact 4 High Impact 4 Latest Update: 15 Sep 2020 Next Assessment due: 07-Dec-2020 Unlikely 2 Likely 3 Unlikely 2 Due to the change in financial regime the CCG does not have a full year allocation for 20/21 and discussions are ongoing with Treasury nationally for allocations for the second half of the year. Risk Identified 10-Oct-2017 Risk Assessed 15-Sep-2020 Target Date 31-Mar-2020 The CCG has not been able to make the anticipated progress in investments according to its five year plan and does not have access to its historical surpluses. Planning guidance has yet to be Risk Movement since last released for 21/22 so there is some uncertainty regarding the financial regime going forward. Increasing Risk History assessment The settlement for local authorities has not yet been announced for 21/22 and this could have an impact on the CCG’s financial position.
SRR.01 Capacity and capability of provider workforce is insufficient Risk Owner Satty Boyes If we are unable to improve capacity and capability in our provider workforce, we may fail to deliver locality plan Risk Sponsor Francine Thorpe; Claire Vaughan objectives, transformation priorities and; core performance, quality and safety standards. Governance Group Governing Body There are a number of primary care workforce development schemes in place supported by CCG funding and the underpinning Primary Care Workforce Strategy. The Existing Controls Salford Locality Workforce Transformation Group has been refreshed with revised membership, terms of reference and objectives. CCG HR data and capacity/capability reviewed regularly by the Executive Team with high level information presented to Governing Body. Primary Care workforce data and developments are managed by the Primary Care Workforce Development Group and reported up the the Primary Care Assurances Commissioning Committee. Provider workforce matters escalated as necessary from contract and planning meetings. Salford Locality Workforce Transformation Group in place. Gaps None Original Risk 12 Current Risk 9 Target Risk 12 Risk Treatment: Tolerate Continue with existing controls.
High Impact 4 Medium Impact 3 High Impact 4 Latest Update: 18 Aug 2020 Next Assessment due: 05-Oct-2020
8 Generated on: 21 September 2020
Likely 3 Likely 3 Likely 3 Relevant workforce work streams have been prioritised following the Covid-19 pandemic. These have also been reviewed against the recently published priorities of the NHS People Plan and Risk Identified 10-Oct-2017 Risk Assessed 18-Aug-2020 Target Date 31-Mar-2020 are in line with the national priorities and deliverables. Risk Movement since last Constant Risk History assessment
SRR.20 Transforming Care targets and pressures, LD budget pressures Risk Owner Judd Skelton; Kerry Thornley If the number of high cost packages of care continues to rise as part of the Transforming Care Programme and Risk Sponsor David Warhurst demographic growth then the CCG may exceed its budget for Learning Disabilities. Governance Group Governing Body 1. Transforming Care – Care & Treatment Reviews (CTRs) carried out by commissioner. 2. Out of Borough meeting and Risk Register maintained. Existing Controls 3. Process developed for approving placements We maintain a dynamic risk register and this is linked to the CTR process. This is to proactively manage people at risk (and their care packages) with the aim of preventing admission. Care & Treatment Reviews (CTRs) process. This is to proactively manage people at risk (and their care packages) with the aim of preventing admission. Assurances we are audited on the CTR process and the LD strategy Board has oversight Gaps Query if any funding is available from NHSE to follow patients once secure beds are closed. Original Risk 9 Current Risk 9 Target Risk 6 Risk Treatment: Treat (Plan in place) Commission a number of new projects to accommodate complex adults being discharged from hospital placements. This will me managed and monitored by SRFT with oversight from SCCG.
Medium Impact 3 Medium Impact 3 Medium Impact 3 Latest Update: 18 Aug 2020 Next Assessment due: 05-Oct-2020 Likely 3 Likely 3 Unlikely 2 CCG Transforming Care target met, but Spec Comm target is unlikely to be met, with an increasing number of patents with MH and Autism adding to this number (5 out of 6 patients, only Risk Identified 11-Dec-2017 Risk Assessed 18-Aug-2020 Target Date 31-Mar-2020 one with LD). Some of these are under MOJ restrictions or similar that prevent discharge. Risk Movement since last Constant Risk History assessment
SRR.18 Stability of GM Shared Service If current changes to future stability of GM Shared Service associated with GM Theme 4 work are not well managed, Risk Owner Hannah Dobrowolska then there is a risk that poor support services to the CCG will impact on our ability to deliver our statutory obligations Risk Sponsor Steve Dixon
9 Generated on: 21 September 2020
and objectives. Governance Group Governing Body Communication with Greater Manchester Shared Service (GMSS) as required to escalate service delivery difficulties to CCG and agree recovery action where necessary, via CFOs and quarterly Customer Performance/Relationship Meetings. Service specifications in place. One to ones with GMSS service leads and CCG leads as required. GMSS governance arrangements in place through Chief Finance Officers, with formal reporting to the CCG's Executive Team. Where services do Existing Controls not perform, alternative provision implemented, e.g. in house resource for primary care IM&T added to GMSS resource, IG service recently brought in house. Strong change management arrangements in place with new leadership structure and project plan. Move to new delivery vehicle (SRFT/NCA) complete. Greater clarity on future of service, focusing on services best delivered at scale. Relevant reports received by the Executive Team. Internal Audit review of arrangements for management of this contract completed in 2013/14 providing significant Assurances assurance. Gaps Service issues being experienced in one service. Discussions to improve service performance are ongoing. Original Risk 12 Current Risk 8 Target Risk 4 Risk Treatment: Treat (Plan in place) Continue to work with GMSS to ensure high quality service received by CCG.
High Impact 4 High Impact 4 High Impact 4 Latest Update: 10 Sep 2020 Next Assessment due: 05-Oct-2020 Likely 3 Unlikely 2 Very Unlikely 1 No change in scores, though note GMSS delivery vehicle now through SRFT/NCA.
Risk Identified 10-Oct-2017 Risk Assessed 10-Sep-2020 Target Date
Risk Movement since last Constant Risk History assessment
SRR.08 Implementation of the Greater Manchester Health and Social Care arrangements may not deliver expected benefits for Salford patients Risk Owner Harry Golby; Karen Proctor If Greater Manchester Health & Social Care arrangements are not robust and aligned to Salford’s locality plan then there is a risk that the Greater Manchester plans will not deliver the expected benefits for Salford residents within the Risk Sponsor Steve Dixon expected timescale. Governance Group Governing Body Salford’s locality plan has been approved through agreed Greater Manchester governance arrangements. Salford is well represented at every level within the Greater Existing Controls Manchester governance structures and is able to influence any changes to the Greater Manchester arrangements and adapt local workstreams where required. Assurances Regular updates through Association of GM CCGs, Salford Health and Wellbeing Board, Salford CCG Governing Body and Executive Team. Gaps Some aspects of Greater Manchester strategy are not supported by clear implementation plans. Original Risk 8 Current Risk 6 Target Risk 3 Risk Treatment: Treat (Plan in place)
10 Generated on: 21 September 2020
Continued engagement in Greater Manchester's Health and Social Care work. Development of the Locality Plan Implementation Plan.
High Impact 4 Medium Impact 3 Medium Impact 3 Latest Update: 27 Aug 2020 Next Assessment due: 07-Dec-2020 Unlikely 2 Unlikely 2 Very Unlikely 1 Whilst Salford is not achieving all targets, this could not be attributed to a failure of the GM Health & Care arrangements. GM organisations continue to be committed to GM working Risk Identified 10-Oct-2017 Risk Assessed 27-Aug-2020 Target Date 31-Mar-2020 Risk Movement since last Constant Risk History assessment
SRR.24 Fraud Risk - all forms of fraud (staff, patient, recruitment, financial systems, performance, bribery and/or corruption) Risk Owner David Warhurst Risk of an act of fraud being perpetrated against Salford CCG. This could originate internally, externally or collusively. It could be either opportunistic or organised, isolated or ongoing, with the overarching intent to cause a Risk Sponsor Steve Dixon loss to the NHS and a personal or private gain to another. Governance Group Governing Body Established Financial Controls; Comprehensive ‘Fraud-Proofed’ Policies and Procedures; Internal and External Audits; Dedicated Anti-Fraud Specialist in post; Risk- Existing Controls assessed Anti-Fraud Work plans; NHS CFA Anti-Fraud Guidance and Alerts disseminated and actioned; Embedded Anti-Fraud Culture which has been developed over time. Assurances Internal and External Audits; Dedicated Anti-Fraud Specialist in post Gaps None identified at time of assessment. Original Risk 6 Current Risk 6 Target Risk 6 Risk Treatment: Tolerate NHS Counter Fraud Agency (CFA) Standard 1.4 for 2019-2020 requires organisations to undertake a comprehensive fraud risk assessment, including risks being recorded and managed in line with the organisations risk management policy and being included on appropriate risk registers. In working towards meeting this standard Salford CCG is currently working with Mersey Internal Audit Agency (MIAA) to assess seven thematic, strategic fraud risk types that cover all forms of fraud which might potentially occur within the CCG.
This is a generic fraud risk to be monitored at strategic level. The risk is being tolerated at an acceptable level in line with the CCG's risk appetite so there is no target risk score. Specific fraud risks have been identified and assessed across seven themes as outlined below. Details of these risks can be found within the CCG's programme risk registers here https://salfordlocality.pentanarpm.uk/portals/view/25615/programme-risk-portal Staff & Payroll Frauds Recruitment Frauds
11 Generated on: 21 September 2020
NHS Financial Systems & Performance (invoices, procurement, etc.) Bribery Risk Management NHS Asset Misappropriation Patient Frauds Other Third Party Frauds (originating externally to the CCG) Low Impact 2 Low Impact 2 Low Impact 2 Latest Update: 15 Sep 2020 Next Assessment due: 05-Oct-2020 Likely 3 Likely 3 Likely 3 Whilst the CCG has reviewed its fraud prevention and detection processes during COVID and remains vigilant, no increase in the risk score is required at this time. Risk Identified 16-Sep-2019 Risk Assessed 15-Sep-2020 Target Date 31-Mar-2020 Risk Movement since last Constant Risk History assessment
12
GOVERNING BODY MEETING
AGENDA ITEM NO: 5c
Item for Decision/Assurance/Information (Please underline and bold)
30 September 2020
Report of: Director of Quality & Innovation
Date of Paper: 18 September 2020
Subject: Quality Report
In case of query Francine Thorpe Please contact: Director of Quality & Innovation
Strategic Priorities: Please tick which strategic priorities the paper relates to:
Quality, Safety, Innovation and Research Integrated Community Care Services (Adult Services) Children’s and Maternity Services Primary Care Enabling Transformation Purpose of Paper:
This paper provides information and analysis on key aspects of the quality and safety of services commissioned by NHS Salford Clinical Commissioning Group (CCG). Information is included in relation to the impact of managing the Covid 19 pandemic on the quality and safety of services, as well as the impact of moving into the recovery phase.
The following three areas remain the main focus of the report
• Patient safety • Patient experience • Clinical effectiveness
Further explanatory information required
HOW WILL THIS BENEFIT THE By consistently raising the quality of care HEALTH AND WELL BEING OF residents of Salford receive from services SALFORD RESIDENTS OR THE commissioned on their behalf CLINICAL COMMISSIONING GROUP?
WHAT RISKS MAY ARISE AS A None RESULT OF THIS PAPER? HOW CAN THEY BE MITIGATED?
WHAT EQUALITY-RELATED RISKS None MAY ARISE AS A RESULT OF THIS PAPER? HOW WILL THESE BE MITIGATED?
DOES THIS PAPER HELP ADDRESS No ANY HIGH RISKS FACING THE ORGANISATION? IF SO WHAT ARE THEY AND HOW DOES THIS PAPER REDUCE THEM?
PLEASE DESCRIBE ANY POSSIBLE None CONFLICTS OF INTEREST ASSOCIATED WITH THIS PAPER.
PLEASE IDENTIFY ANY CURRENT Quality by its very nature is everyone’s SERVICES OR ROLES THAT MAY BE business therefore it will impact across all areas AFFECTED BY ISSUES WITHIN THIS of care planning and delivery PAPER:
Footnote:
Members of this Committee will read all papers thoroughly. Once papers are distributed no amendments are possible.
Document Development
Not Comments and Date Process Yes No Outcome Applicable (i.e. presentation, verbal, actual report) Public Engagement (Please detail the method i.e. survey, event, consultation) Clinical Engagement Clinical Lead for Quality and Informed content for (Please detail the method i.e. survey, event, Safety inclusion consultation) Has ‘due regard’ been given to Social Value and the impacts on the Salford socially, economically and environmentally? (Please detail outcomes, including risks and how these will be managed Has ‘due regard’ been given to Equality Analysis (EA) of any adverse impacts? (Please detail outcomes, including risks and how these will be managed) Legal Advice Sought
Presented to any informal groups or committees (including partnership groups) for engagement or other formal governance groups for comments / approval?
(Please specify in comments)
Note: Please ensure that it is clear in the comments and date column how and when particular stakeholders were involved in this work and ensure there is clarity in the outcome column showing what the key message or decision was from that group and whether amendments were requested about a particular part of the work.
Quality Report
1. Executive Summary
Information continues to be sought from a variety of sources to provide assurance on the quality and safety of services. The impact of changes that were implemented quickly as a result of managing the COVID-19 pandemic have been considered, any potential risks highlighted and where possible mitigating actions have been taken to reduce or minimise the risk.
As providers move into a recovery phase they further changes are required to ensure safe and effective service delivery. Regular quality assurance processes have been amended to reflect the current situation and NHS Salford CCG has continued to monitor the quality of service provision through established relationships. This paper provides a high level overview in relation to quality and safety across providers within the Salford system.
2. Introduction and Background
2.1 The CCG’s approach to quality assurance has been revised during the recent COVID-19 pandemic. Some routine quality assurance processes that were stepped down over recent months remain on hold; however other sources of data and soft intelligence have been used to maintain oversight of the quality and safety of providers. Oversight of patient safety, patient experience and clinical effectiveness remain the key lines of enquiry that are considered when reviewing data provided.
2.2 There is no doubt that in managing the COVID -19 pandemic other aspects of healthcare have been adversely affected, which has impacted quality and safety of services. The CCG along with partners is actively seeking to identify any areas of concern and put systems in place to minimise any further negative impact on the quality of care provided.
2.3 Providers are facing significant challenges in stepping routine services back up whilst still managing the risk of COVID-19 and have had to adapt service delivery models accordingly. The impact of new service models on the quality of care is being monitored as far as possible; along with ensuring that providers are compliant with new guidance. Particular attention is being paid to infection prevention and control and information is included within this report that outlines measures being taken by providers.
2.4 The CCG along with partners continues to work closely with care homes in Salford; these providers continue to face significant challenges in maintaining the safety of their residents, minimising the ongoing risk of COVID-19. Information is included that highlights the current situation in care homes along with the support that continues to be offered by partners across the Salford system.
3. Quality Oversight
3.1 The approach to quality monitoring during the period of the pandemic was amended to reflect the needs of the situation. Some areas of routine quality assurance were stepped down to ensure that staff within provider organisations remained focused on patient facing activity. In terms of quality assurance the main focus has been on
monitoring safety with less emphasis on monitoring experience. National data collection on patient experience remains on hold, however providers are using informal methods of seeking out the views of patients that have used services delivered in different ways. The CCG quality team will continue to work with our partners to maintain an overview on this aspect of quality assurance.
3.2 Systems recently put in place to maintain oversight of safety within services include the regular Situation Reports. Intelligence gained from regularly reviewing these reports is now incorporated into our quality assurance processes. This enables routine monitoring of the following indicators:
• Staffing • Availability of Personal Protective Equipment • Training of staff • Capacity • Numbers of patients affected by Covid 19 • Testing capacity and uptake
3.3 In terms of clinical effectiveness the impact of retaining revised service delivery models implemented during the pandemic, for example remote consultations need to be understood. Providers are currently undertaking quality impact assessments in relation to service changes which will be considered by the quality team as they are shared.
4. Salford Royal Foundation Trust (SRFT)
4.1 The CCG’s internal oversight group has now been established to review data gathered from attendance at SRFT’s assurance committees, key points to note are outlined below.
4.3 Patient Safety
4.3.1 Elective Procedures SRFT is implementing the Royal College of Surgeons Recovery Guidance to schedule elective surgical procedures as outlined below:
• Cat 1a: For surgery within 24 hours; • Cat 1b: For surgery within 72 hours; • Cat 2: For surgery within 4 weeks; • Cat 3: For surgery within 3 months; or • Cat 4: Can wait more than 3 months.
This ensures that patients with the most pressing need for surgery are prioritised.
4.3.2 Patients waiting over 52 weeks Prior to the COVID-19 Pandemic any patient that waited over 52 weeks for treatment to commence received a full root cause analysis to identify whether they had come to any harm. The number people now waiting over 52 weeks has increased significantly and this is no longer a viable option due to the amount of clinical time it will take. Patients that have been waiting over 52 weeks for a surgical intervention are being prioritised along with Cat 1a and Cat 1b patients to reduce the risk of
further delays. Those patients that do not need surgery are being seen as outpatients virtually wherever possible for a review of their condition.
A clinical steering group across the Northern Care Alliance to consider how reviews might be conducted more efficiently has recently been established. Updates will be provided in due course.
4.3.3 Patients with confirmed or suspected cancer diagnosis The following actions are being taken to reduce the risk of harm:
• Prioritising assessment, diagnosis and treatment of patients with suspected cancer or a confirmed cancer diagnosis • Regular tracking of patient journeys for those with a confirmed diagnosis of cancer • Outpatient consultations and non-surgical treatments taking place virtually as appropriate • Patients with a confirmed cancer diagnosis receive regular contact with a specialist nurse to provide advice and support
For patients in receipt of treatment from the Christie Hospital a comprehensive pack of information has been published on their on their website in addition to the following:
• Regular contact with a named clinician • Access to a 24 hour hotline
4.3.4 Infection Prevention and Control Measures Regular reports on compliance with new infection control guidance aimed at minimising the risk of COVID-19 transmission are reviewed by the Trust. An infection control collaborative has been established, led by the Trust’s Director of Nursing that tracks performance against a suite of indicators. As of the 10 September 2020, SRFT had gone 66 days without the incidence of any nosocomial transmission. Information from this collaborative feeds into the system- wide Infection Control Group chaired by the CCG’s Lead Nurse for Quality Assurance and Improvement.
Comparative data from April 2019 to June 2020 has identified an increase in Clostridium Difficile cases in Salford. Preliminary investigations into the increase in cases have identified the cases have been predominantly hospital onset. Emerging themes from quarter 1 (2020/21), based on intelligence from providers has included:
• Data analysed has identified that a significant proportion of positive patients are not Salford residents. • Incomplete cleaning schedules and audits • limited availability of side rooms • Reduction in oversight of antibiotic stewardship
Action plans to address these issues have been developed and will be monitored through the Salford Infection Control Group
4.4 Patient Experience
4.4.1 Hospital visiting continues to be suspended until further notice; however is allowed in certain circumstances, such as:
• Where a person is receiving end of life care • For a parent or appropriate adult visiting a child • For individuals who have dementia, learning difficulties or mental health conditions and need support
In these circumstances one visitor who is an immediate family member or a carer is able to visit and provide appropriate support. Patients continue to be supported to maintain contact with their loved ones through digital communication channels where possible.
4.4.2 Plans for the implementation of new approaches to patient and service user feedback were paused in April 2020. Actions to support this project were re- launched in August with the introduction of a system to receive “live” feedback during an inpatient stay through the bedside hospital “hospedia” terminals. Community services that previously relied on paper based surveys have been supported to implement text messaging feedback about their experience. Regular reports on both of these initiatives will be received through the Quality and People Experience Committee.
4.5 Clinical Effectiveness
4.5.1 Internal Mortality Reviews SRFT Clinicians were involved in mortality reviews as part of the Northern Care Alliance approach to assessing the potential impact of COVID-19 on patient safety. The following themes were identified and have been incorporated into improvement work:
• Use of frailty assessments and scores • Non-invasive ventilation outside Critical Care Units • Management of delirium and dementia • Communication between clinical teams • Communication with patients and families
Improvement work has been allocated to existing work programmes and reporting allocated to internal assurance committees. Lessons learned are being promoted through existing clinical forums.
4.5.2 Improving handover Information was presented at the September Quality and People Experience Committee in relation to a quality improvement project related to safer handover. This has been led by one of the Consultants in Acute Medicine and is a direct result of his involvement in the Safer Salford clinical engagement events held in 2018. The project has been monitoring the quality of discharge summaries on a number of wards and has seen improvements in those rated as ‘good’ and those rated as ‘great’ as defined by agreed criteria. The committee agreed to support the role out of this work to other clinical areas and it will be integrated into their refreshed quality improvement strategy.
4.5.3 Ward staffing levels In response to the changes necessitated by the new infection control guidance to segregate patients in order to minimise the risk of nosocomial transmission, ward staffing levels have been reviewed and where necessary revised.
4.6 Serious Incidents Table 1 outlines the current positon in relation to serious incidents report by SRFT in 2019/20 and 2020/21 to the end of August
Table 1 Serious Incidents reported by SRFT 2019/20 and 2020/21 to the end of August
2020/21 2019/20 To end of August
Total number of SIs reported (SRFT) 66 40
Number of Never Events (included in the total above) 3 0 Number closed 61 17
Number reviewed and awaiting further assurance 1 3
Number not yet due or not yet reviewed 4 20
4.6.1 A comprehensive paper focusing on themes and trends as well as learning from incidents was presented at Quality Reference Group on 23 September 2020. This included some comparative data with other organisations and trend analysis over time. Some key points to note from this report are:
• An increase in the number of grade 3 and 4 pressure ulcers reported on the District Nursing caseload from April to June. Analysis of this information indicates that measures introduced in response to COVID-19 had an impact. Action plans to address the issues identified have been shared and will be monitored. • A clinical review of incidents occurring within colorectal services prompted by thematic analysis of serious incidents relating to a locum consultant. A representative from the CCG has been involved in weekly review meetings and lessons learned will be presented at a clinical forum in the next month. • The report highlighted assurance that learning from incidents is taking place within SRFT and that action plans have been developed to address themes and trends identified.
5. Greater Manchester Mental Health Foundation Trust (GMMH)
5.1 Improving Access to Psychological Therapies (IAPT) IAPT performance is positive, with local data showing improving positions in all areas. GMMH has been delivering therapy via telephone and / or video conferencing throughout the pandemic. Evaluation of the acceptability and effectiveness of video conferencing within the GMMH service has provided assurance of the impact and acceptability of this method of delivery with people using the service and for staff. Referral rates reduced by approximately 30% throughout the lockdown period but have now returned to within range of the pre-COVID levels. People who chose not
to have or were unable to access therapy remotely are being prioritised for the re- introduction of face to face service delivery.
5.2 Living Well Living Well work was initially paused due to the national lockdown, the work restarted in July 2020 and the pilot is now underway in Broughton. This is starting with a small number of people and expanding to include all referrals in that locality which do not meet the threshold for Community Mental Health Teams. Discussions with the Primary Care Networks to explore the potential collaboration and extended reach of the Living Well model have been progressing positively. A Voluntary Community and
Social Enterprise (VCSE) grants process has been established to support three key areas identified by the individuals with lived experience of mental ill health who are co-designing the model:
• Families and Carers • Alcohol and Substance Misuse • Loss and bereavement
Recruitment for a part-time Living Well engagement post, located in Healthwatch Salford is underway. This role will ensure the continued engagement with people using the service to continuously inform the development and improvement of the model. Until this post is in place, the CCG / Council Engagement team are undertaking this work.
5.3 Crisis Care As part of the response to the pandemic, helpline offers have been put in place to support people presenting in crisis. I in addition, the Clinical Assessment Service (CAS) has been established at a Greater Manchester level to ensure that people contacting the ambulance service and 111 who require support for their mental health needs are directed to the right part of the system.
Local work is ongoing to support development of supporting offers to people in crisis and there has been further work undertaken in relation to the A and E Liaison offer, with a view to supporting diversion to a more appropriate setting where possible. This will improve the experience for patients requiring crisis services as well as minimising their risk of exposure to COVID-19 within an acute environment.
5.4 Suicide Prevention As part of the annual review of the action plan for suicide prevention, the impact of COVID has been considered and will shape the key areas of focus for the next 12 months. In addition, a ‘lived experience project’ has also been undertaken to listen to the experiences of people who have been bereaved by suicide or people who have experienced thoughts of suicide. The learning from this project is informing the revised action plan and helps to ensure that the lived experience voice is a key driver in this work.
As part of the ‘Month of Hope’ (10th September – World Suicide Prevention Awareness Day and 10th October – World Mental Health Day), Salford will be launching a VCSE grants opportunity for suicide prevention projects, with the aim to have a number of programmes running in a staggered approach over the next 18 months.
5.5 Serious Incidents (SI’s) The table below shows the number of serious incidents report by GMMH in 2019/20 and 2020/2021 to the end of August.
Table 2 SI’s reported by GMMH in 2019/20 and in 2020/21 to the end of August 2020/21 to end of 2019/20 August
Number of SIs reported (GMMH) 34 11 Number of Never Events (included in the total 0 0 above) Number closed 28 0
Number reviewed and further assurance GMMH has a number of incidents overdue. At the September1 SI panel GMMH1 gave assurance that a requested GMMHNumber has overdue not submitted any reports for review during4 the Covid-19 period;2 this is in line with NHSE b Number not yet due or not yet reviewed 1 8 e included in the next learning from incidents report to the Quality Reference Group.
5.5.1 There is a legacy theme from incidents relating to the management physical health. This is a common theme in incidents across the whole organisation and a steering group has been set up in GMMH to review progress against agreed action plans. An update on this work is scheduled for the next Quality and Performance group at the end of September
6. Care Homes
6.1 The CQC has suspended inspections during the period of the pandemic; no further inspection reports have been published since the last Governing Body report. The CQC inspection ratings for Salford Care Homes remain as outlined below:
Table 3 CQC Ratings for Salford Care Homes January 17 January 18 January 19 January 20 May 20 Outstanding 0 0 0 0 0 Good 15 26 30 34 37 Requires 22 12 9 7 5 Improvement Inadequate 2 3 0 0 0 Not - 6 5 4 3 inspected %age Good 38% 63% 77% 86% 88% Ranking in 150 138 112 72 32 England
Although the CQC have not been carrying any inspections in care homes during the COVID-19 pandemic, they have implemented an emergency support framework. This is a support call to homes to identify if they are experiencing any issues or concerns. The CQC inspection team has maintained contact with representatives from the Salford system through our fortnightly meetings. They have reported positive feedback from a number of care home managers about the support that they have received during the crisis from the Salford health and care system.
6.2 As part of our local response to COVID-19 relationships from system partners were maintained through a weekly operational group including all stakeholders within the system that regularly interface with care homes. A weekly call with care home managers remains in place so that they can raise any concerns or seek advice and guidance on a range of issues.
6.3 After a short period in July where there were no identified COVID-19 cases within care homes, the incidence of infections has started to increase again. A significant proportion of positive cases have been identified through the regular testing of staff and residents, many of whom are asymptomatic. However in the past 3 weeks more serious outbreaks have occurred.
6.4 The Situation Report reviewed at the Care Homes meeting on 16 September indicated outbreaks in 9 care homes:
• 3 homes were rated as red • 6 homes were rated as amber
Red rated homes indicate that the outbreak is of sufficient severity that no admissions can be taken by that home until the situation improves. Amber rated homes are managing their outbreak situation and could accommodate an existing resident back into the home with the appropriate precautions. Before any resident is accepted back into any home that has positive cases of COVID-19, specific advice is sought from the infection control team.
6.5 The infection control team is in daily contact with homes, providing targeted support as necessary. The following information has recently been supplied to all homes:
6.6 The CCG’s Continuing Healthcare Team and the Social Work team are in contact with families as part of their regular reviews for patients in care homes. The majority of which are completed remotely. A number of families are distressed about their inability to visit their loved ones within care homes due to national restrictions. However positive feedback has been received about innovative ways that some care homes are using to ensure contact is maintained as far as possible through digital communication.
6.7 The following information has recently been distributed to all care homes managers as part of our system-wide support:
• Version 8 of the infection prevention advice • COVID-19 newsletter for families • COVID-19 newsletter for staff • COVID-19 newsletter for care homes managers • Winter resilience pack • Updated flu vaccination guidance
7. Summary
7.1 Evidence is emerging that the quality and safety of services has been adversely affected by the COVID-19 pandemic. Information on harm; and potential harm to patients is being actively sought in an effort to learn lessons and implement actions
to minimise identified risks. NHS Salford CCG is working closely with providers to maintain oversight and support them in making improvements
7.2 The main focus of our quality assurance processes over recent months has been in the safety domain, this area will continue to be a priority. However as new models of care are implemented as a result of managing the pandemic it is important to ensure that quality impact assessments are undertaken and we will continue to work with providers to receive assurance around this.
7.3 Ongoing support continues to be provided by the Salford health and care system to the care homes sector. It is recognised that these providers remain vulnerable to the threat of COVID-19 as indicated by the recent increase in outbreaks.
8. Recommendations
8.1 The Governing Body is asked to:
• Note the contents of this report • Receive assurance that the CCG is working with our providers to identify the impact that the pandemic has had on the quality and safety of services, ensuring that appropriate action is taken to address any issues that are identified
Francine Thorpe Director of Quality & Innovation
GOVERNING BODY MEETING PART 1
AGENDA ITEM NO: 5d
Item for Decision/Assurance/Information (Please underline and bold)
30 September 2020
Report of: Chief Finance Officer
Date of Paper: 11 September 2020
Subject: Financial Position for the 5 months to August 2020 In case of query Elaine Vermeulen Please contact: Deputy Chief Finance Officer
Strategic Priorities: Please tick which strategic priorities the paper relates to:
Quality, Safety, Innovation and Research Integrated Community Care Services (Adult Services) Children’s and Maternity Services Primary Care x Enabling Transformation Purpose of Paper:
This paper provides information on the month 5 financial position and forecast outturn for the 6 months to September 2020 based on available information at the end of August 2020.
The report also provides a brief update in relation to the NHS financial regime for months 7- 12.
The Governing Body is asked to note the contents of this report, in particular the risks associated with the uncertainty regarding the future financial regime.
Further explanatory information required
n/a HOW WILL THIS BENEFIT THE HEALTH AND WELL BEING OF SALFORD RESIDENTS OR THE CLINICAL COMMISSIONING GROUP?
Risks are set out in section 9. WHAT RISKS MAY ARISE AS A RESULT OF THIS PAPER? HOW CAN THEY BE MITIGATED?
None WHAT EQUALITY-RELATED RISKS MAY ARISE AS A RESULT OF THIS PAPER? HOW WILL THESE BE MITIGATED?
Risks are set out in section 9. DOES THIS PAPER HELP ADDRESS ANY HIGH RISKS FACING THE ORGANISATION? IF SO WHAT ARE THEY AND HOW DOES THIS PAPER REDUCE THEM?
None PLEASE DESCRIBE ANY POSSIBLE CONFLICTS OF INTEREST ASSOCIATED WITH THIS PAPER.
None PLEASE IDENTIFY ANY CURRENT SERVICES OR ROLES THAT MAY BE AFFECTED BY ISSUES WITHIN THIS PAPER:
Footnote:
Members of this Committee will read all papers thoroughly. Once papers are distributed no amendments are possible.
Document Development
Not Comments and Date Process Yes No Outcome Applicable (i.e. presentation, verbal, actual report) Public Engagement x (Please detail the method i.e. survey, event, consultation) Clinical Engagement x (Please detail the method i.e. survey, event, consultation) Has ‘due regard’ been given to Social Value x and the impacts on the Salford socially, economically and environmentally? (Please detail outcomes, including risks and how these will be managed Has ‘due regard’ been given to Equality x Analysis (EA) of any adverse impacts? (Please detail outcomes, including risks and how these will be managed) x Legal Advice Sought
Presented to any informal groups or committees (including partnership groups) for x engagement or other formal governance groups for comments / approval? (Please specify in comments)
Note: Please ensure that it is clear in the comments and date column how and when particular stakeholders were involved in this work and ensure there is clarity in the outcome column showing what the key message or decision was from that group and whether amendments were requested about a particular part of the work.
Finance Report – Month 5
1. Executive Summary
This paper provides an update on the financial position of NHS Salford Clinical Commissioning Group (CCG) at the end of September 2020. Section 2 details the revised financial regime and the forecast deficit of £15.3m before the national financial adjustments to fund COVID and other overspends. The CCG has received £6.5m in respect of April to July COVID expenditure and has incurred a further £2.7m in August. The CCG has received top up funding of £3.5m and cost drivers of the remaining £0.6m of the deficit are set out in section 4.
The summarised forecast position to September for each element of the Integrated Fund is set out in section 6. Section 7 outlines the next steps and risks facing the locality.
Section 8 provides a brief update regarding the financial regime from Month 7. The CCG has been forecasting expenditure requirements for the remainder of the year, taking into account year to date expenditure and future commitments. This is in anticipation of a financial envelope for the Greater Manchester system, which has now been released. The CCG is currently awaiting confirmation of its allocation to assess whether its forecast expenditure is affordable.
2. April to September Financial Regime
2.1 The operational planning process was suspended in March 2020 due to the coronavirus pandemic. In order to manage the health and care system, NHS England introduced a new finance regime covering the period April to July 2020 which has now been extended to September 20. The main elements of the guidance are:
2.2 Overall Position - All CCGs will deliver a break-even financial position over the April – September period.
2.3 Funding - is based on the previously published 2020/21 allocations, adjusted to:
- reflect that they are only covering the period to September;
- reflect the run rate of expenditure incurred to month 11 2019/20;
- additional allocations to fund the financial impact of COVID schemes and the Hospital Discharge Programme
- ‘Top Up’ allocation to ensure all CCGs deliver a breakeven financial position
2.4 Expenditure - 2020/21 Acute Block contracts have been calculated nationally and the CCG is unable to pay anything other than the block amounts to providers during this period. This was based on the month 9 agreement of balances exercise.
All other budgets were based on costs at month 11, with a set of national growth/uplift rates applied, to give a 2020/21 cost base. All investments must be related to the
pandemic response and subject to national approval, and there is no requirement to deliver efficiency savings during this six month period.
3. Summary Financial Performance
3.1 The four financial statutory duties remain in force:
1. Revenue - delivery of a breakeven position, via the top up mechanism described above for at least months 1-6.
2. Cash management - The CCG has been allocated a maximum cash draw down limit of £489m. Current guidance requires the cash balance at the end of the month to be less than 1.25% of the cash draw down for that month (£416k at month 5) and the balance was £28k.
3. Better Payment Practice Code (BPPC) – the target is 95% of invoices paid within the agreed terms or within 30 days if there are no specified terms. Overall achievement was 99.5% for invoices by volume and 100% by value.
4. Running costs - manage within the CCG’s running cost allocation, via the top up mechanism for at least months 1-6.
3.2 The unadjusted CCG financial position to the end of month 6 reflects a forecast deficit of £15.3m. In order to deliver the breakeven financial position, the CCG requires:
- £4.1m top up allocation funding (£4m year to date) - £3.5m has been received by the CCG and therefore £0.6m is required for the CCG to achieve a breakeven position. Section 4 describes the areas driving the remaining top up.
- £11.2m cost of COVID 19 (£9.2m year to date) - £6.5m has been received by the CCG and therefore £4.7m is required for the CCG to achieve a breakeven position. Section 5 describes the areas driving the remaining top up.
This is summarised in the table below.
Table 1 – Actual deficit to August 2020 and forecast to September 2020
YTD Forecast to month 6 Plan Actual Variance Plan Actual Variance Area £'000 £'000 £'000 £'000 £'000 £'000 Defcit before national adjustment 0 (13,171) (13,171) 0 (15,270) (15,270) COVID top up received for April to July 0 6,521 6,521 0 6,521 6,521 Top up to breakeven received to July 0 3,457 3,457 0 3,457 3,457 Interim financial Position 0 (3,193) (3,193) 0 (5,292) (5,292) COVID top up - Outstanding August 0 2,698 2,698 0 2,698 2,698 COVID top up - Outstanding September 0 0 0 0 2,034 2,034 Top up to breakeven - outstanding 0 495 495 0 560 560 Anticipated financial position 0 0 0 0 0 0
Table 1 illustrates that year to date; there is a £3.2m risk relating to outstanding allocation adjustments. Of this, £2.7m relates to COVID 19 and £0.5m non COVID. The CCG should be notified regarding the top up claims by the end of September.
4. Main drivers of the financial position – non COVID
4.1 The forecast unfunded deficit of £0.6m is due mainly to the following:
- Prescribing £0.3m - A cost pressure of £0.3m in respect of prescribing, where the actual costs in 2020/21 are higher based on the year to date Business Services Authority report.
- Primary care £0.5m - An overspend of £0.1m on the CCG’s co-commissioned budgets for primary care medical services due to under achievement of savings plus locum spend and social prescribing investment. In addition, there is an overspend of £0.4m on the Salford Standard budget, due to the manner in which the budgets have been calculated nationally.
The above pressures are offset by net underspends on other services of (£0.2m) due to the national budget setting methodology
5. Main drivers of the financial position – COVID
5.1 The forecast unfunded deficit of £4.7m is due mainly to the following:
- Hospital Discharge Protocol £3.7m – National funding for the cost of new or extended out-of-hospital health and social care support packages. This includes the Salford Financial Offer for Adult Social Care.
- Services commissioned from Salford Primary Care Together £0.7m - and the voluntary sector to support the primary care and community response to COVID, such as the swabbing services and hot clinics as well as the AJ Bell testing facility.
- Other £0.3m – This relates to numerous other small areas such as Personal Protective Equipment, GP Claims and CCG claims.
6. Integrated Fund Summary
6.1 Under the integrated commissioning arrangements, the CCG is responsible for monitoring and reporting against all services that are within the Integrated Fund (c. £632m) which comprises the majority of the CCG’s allocation and adults’ social care, children’s care and public health budgets from the council. The Integrated Fund for Adults’ services, Children’s services and Primary Care is reviewed in detail at the individual commissioning committees.
6.2 The Integrated Fund is forecast to overspend by c. £2m at month 6, with £1.1m of this being attributable to the CCG when the risk share is enacted. A brief summary of the forecast position to month for the individual sections of the integrated fund is outlined below:
- Children’s services £1.3m overspend - Expenditure is in line with the previous year’s overspend of £7.5m however this year partners have mitigated £5m of this pressure. The expectation is that the children’s best value programme would deliver savings in year to meet the £2.5m gap although this has not yet materialised. The CCG’s share of the over spend on children’s services is 30% or £0.4m, which should be funded via the national top
up process. The remaining pressure of £0.9m is included as forecast income from Salford City Council.
- Adult’s services breakeven - Despite a savings target of £1m to Month 6, the nationally calculated block contracts have still resulted in a net expenditure underspend of £0.7m. This underspend has been almost entirely offset by a reduction in direct client income for Adult Social Care placements as an unfortunate consequence of COVID.
- Primary care £0.7m overspend - As per section 4, this relates mainly to locally commissioned services budgets overspend of £0.5m and prescribing overspend of £0.3m, offset by the underspend on the Salford Primary Care Together contract; the CCG has 100% share of these costs. This overspend should be funded through the national top up.
7. Financial Planning Months 7-12
7.1 CCGs have been asked to forecast their expenditure for the remainder of 2020/21, based on the run rate of actual expenditure incurred, the additional carrying costs of COVID including the Hospital Discharge Programme and committed investments. The CCG’s current forecast expenditure requirement for 2020/21 is £504.4m which includes COVID expenditure of £16.2m.
7.2 The financial plan is based on the continuation of the run rate of expenditure between month’s 1-4, with one off and COVID costs being removed, but additional expenditure planned as below:
- New Investments £7.9m - This includes the first draft financial costings of the refreshed priorities, committed developments such as funding the Real Living wage and adequate investment to deliver the Mental Health Investment Standard.
- COVID £4.8m - The CCG has forecast COVID costs on a “steady state” basis, assuming a gradual reduction in the Hospital Discharge Programme costs over the remainder of the year. No assumptions have been made regarding further surges in infection, or the impact this may have on the ability of providers to implement new investments.
- Run Rate Changes £3.8m – These are costs that have been understated in month 1- 4, primarily due to COVID and the financial regime. This includes elective services for non-nationally commissioned Independent sector and increases in Continuing Health Care and Adult Social Care as new and enhanced placements won’t be fully funded nationally.
7.3 Assurance meetings have been held with each CCG to challenge any areas where CCGs are outliers and to refine the forecasts. As a result, Greater Manchester organisations have been submitting revisions to their forecast on almost a weekly basis during August and September.
7.4 No costs have been included in the CCG’s forecasts for:
- Any Greater Manchester wide recovery initiatives such as endoscopy, mental health or critical care. - No costs for nationally commissioned Independent sector contacts, although these are expected to be commissioned locally from the 1st November. - Expansion of flu campaigns or winter pressures.
- Penalties arising from providers’ non-achievement of elective activity targets.
7.5 The CCG’s original plan included a drawdown of £9m from historical surpluses in 2020/21 and £3m in 2021/22. Whilst the CCG has included non-recurrent expenditure in its forecast that was to be funded from the historical surplus, further clarification is awaited on whether the CCG will have access to this in the current year and in 2021/22 as planned.
8. Financial Regime months 7 - 12
8.1 The national guidance for the months 7-12 financial regime has recently been issued. The integrated care system (ICS) is trying to work through the guidance and funding envelope, therefore accurately ascertaining an organisational view is difficult.
8.2 As expected, there is greater focus on ICS delivery, consequently a proportion of the GM funding envelope, c13.8% (c£391m) is allocated at a system level, with the expectation that the ICS decides how best to allocate this:
- COVID Funding (c£150m) - Nationally distributed to the ICS on a fair share basis.
- Growth funding (c£54m) - Additional growth funding based on 2020/21 anticipated CCG allocation growth rates
- Top Up Funding (c£188m) - top-up funding to bring the system to a breakeven position, using an updated version of the methodology applied in the month 1-6 financial framework.
8.3 For the CCG to breakeven against its current plan, it will potentially need c. 3-4% (£12- £15m) of the funding identified above. It should be noted, at the time of writing the report there are still a number of material unknowns, that the system is seeking clarification on which could significantly change this figure.
8.4 Whilst there are some changes to the allocation basis, primarily, it is still underpinned largely by block contracts to NHS providers and other areas of expenditure predicated on 2019/20 expenditure. Therefore, the surplus the CCG offered to support Greater Manchester in 19/20 is impacted by this methodology. If the CCG would have spent the surplus in 19/20, then the CCG financial envelope for 20/21 would be higher, owing to the fact the CCG would have had a higher 19/20 exit run rate.
8.5 There are a number of national funding streams that will sit outside of the ICS financial envelope; these include funding for Hospital Discharge Protocol, Elective Incentive monies and potentially nationally commissioned Independent sector contracts, although this is still to be confirmed.
8.6 The Greater Manchester system collectively will now use this envelope to generate a financial plan (aligned to operational plans and consistent with Phase 3 goals) for the second half of the year, and identify how to deploy system allocations of top-up and COVID-19 funding to individual organisations.
8.7 A system financial plan is due for submission by 5 October and thereafter the CCG will submit its own financial plan by 22 October. The next financial report to the Governing Body in November will include budgets set based on this plan.
8.8 Allocations for 2021/22 onwards will be issued in December/January along with updated financial planning guidance, so at that point the CCG will be able to resume planning on the usual five year basis.
9. Risks and Next Steps
9.1 The CCG is still awaiting confirmation of £5.3m of forecast allocation adjustments in order to achieve a breakeven position for the first six months.
9.2 Implications of the proposed NHS financial regime for months 7-12 and the risk the CCG doesn’t receive an adequate share of the system level funding.
9.3 The risk relating to the CCGs historic underspend, particularly recognising the implications that this has on the funding envelope for 20/21.
9.4 The risk of the locality priorities being unaffordable dependent on both the CCGs financial envelope and that of the local authorities.
9.5 The risk of national deadlines falling outside of the CCG’s governance timeframes.
10. Recommendations
10.1 The Governing Body is asked to:
• Note the CCG’s forecast financial position for the first six months of 2020/21 based on information available to August 2020.
• Note the update on the financial planning and the level of uncertainty
• Note the risks outlined in section 9.
David Warhurst Chief Finance Officer
GOVERNING BODY MEETING PART 1
AGENDA ITEM NO: 5e
Item for Decision/Assurance/Information (Please underline and bold)
30 September 2019
Report of: Chief Accountable Officer
Date of Paper: September 2020
Subject: Safeguarding Adults Annual Report (2019/20) In case of query Elizabeth Walton, Designated Nurse Please contact: Safeguarding Adults
Please tick which strategic priorities the paper relates to: Strategic Priorities:
√ Quality, Safety, Innovation and Research Integrated Community Care Services (Adult Services) √ Children’s and Maternity Services √ Primary Care Enabling Transformation Purpose of Paper:
This paper provides NHS Salford CCG Governing Body with the 2019/20 Safeguarding Adults Annual Report.
It confirms that the CCG is fulfilling its statutory duties in respect of Safeguarding Adults, including those in relation to the NHS Accountability and Assurance Framework as well as the priorities identified by Salford Safeguarding Adults Board (SSAB).
It provides an overview of the key actions taken to safeguard adults, highlights, progress, achievements and challenges in accordance with statutory responsibilities set out within the Care Act (2014), Counter Terrorism and Security Act (2015, Prevent Duty) and the Mental Capacity Act (MCA, 2005).
Further explanatory information required
HOW WILL THIS BENEFIT THE The CCG Governing Body will have an HEALTH AND WELL BEING OF increased understanding of the Safeguarding SALFORD RESIDENTS OR THE Adults agenda including the CCG Safeguarding CLINICAL COMMISSIONING Adult statutory responsibilities and actions taken to meet these and the priority areas for GROUP? 2019/20.
None WHAT RISKS MAY ARISE AS A RESULT OF THIS PAPER? HOW CAN THEY BE MITIGATED?
None WHAT EQUALITY-RELATED RISKS MAY ARISE AS A RESULT OF THIS PAPER? HOW WILL THESE BE MITIGATED?
No DOES THIS PAPER HELP ADDRESS ANY EXISTING HIGH OR EXTREME RISKS FACING THE ORGANISATION? IF SO WHAT ARE THEY AND HOW DOES THIS PAPER REDUCE THEM?
None PLEASE DESCRIBE ANY POSSIBLE CONFLICTS OF INTEREST ASSOCIATED WITH THIS PAPER.
None PLEASE IDENTIFY ANY CURRENT SERVICES OR ROLES THAT MAY BE AFFECTED BY ISSUES WITHIN THIS PAPER:
Footnote:
Members of Governing Body will read all papers thoroughly. Once papers are distributed no amendments are possible.
Document Development
Not Comments and Date Process Yes No Outcome Applicable (i.e. presentation, verbal, actual report) Public Engagement (Please detail the method i.e. survey, event, consultation) Clinical Engagement (Please detail the method i.e. survey, event, consultation) Has ‘due regard’ been given to Social Value and the impacts on the Salford socially, economically and environmentally? (Please detail outcomes, including risks and how these will be managed Has ‘due regard’ been given to Equality Analysis (EA) of any adverse impacts? (Please detail outcomes, including risks and how these will be managed) Legal Advice Sought
Presented to any informal groups or committees (including partnership groups) for engagement or other formal governance groups for comments / approval? (Please specify in comments)
Note: Please ensure that it is clear in the comments and date column how and when particular stakeholders were involved in this work and ensure there is clarity in the outcome column showing what the key message or decision was from that group and whether amendments were requested about a particular part of the work. 3
Safeguarding Adults - Annual Report 2019-20
1. Executive Summary
This 2019-20 Safeguarding Adults Annual Report on behalf of NHS Salford Clinical Commissioning Group (SCCG) Governing Body, provides an overview of the key safeguarding adult highlights, progress, achievements and challenges in accordance with statutory responsibilities set out within:
• The Care Act (2014) • Counter Terrorism and Security Act, 2015 (Prevent Duty) • Mental Capacity Act (MCA, 2005).
Safeguarding information in relation to children will be included within the Safeguarding Children’s Annual Report in November 2020. This report will also include a full overview of domestic abuse for both adults and children and therefore will not be detailed within this report to avoid duplication.
In addition to relevant safeguarding activity, the report will focus on key statutory areas including:
• Salford Safeguarding Adult Board progress • Prevent (Counter Terrorism requirements within the Prevent Duty) • Mental Capacity Act requirements
The SCCG Safeguarding Team remains committed to improving the quality of safeguarding standards across Salford and improving the lives of adults at risk. Continued opportunities to work collaboratively with the Local Authority, Salford Safeguarding Adult Board (SSAB) and Children’s Partnership (SSCP) and key partners will continue and be enhanced throughout 2019-20.
2 Introduction
2.1 This is the eighth Safeguarding Adults Annual Report presented to the NHS Salford Clinical Commissioning Group (SCCG) Governing Body. Following positive feedback in 2019, the format of the report has been maintained.
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OUR YEAR IN FIGURES 2019-20
PRIMARY CARE CARE HOMES Annual Safeguarding Assurances completed in all 12 Nursing Homes which includes a thorough review of • 35 Training sessions delivered (including Adult Safeguarding, 3727 evidence across 24 GM Safeguarding Standards MCA/ DoLS and Prevent) to staff within Primary Care 651
• 89% of all Primary Care Staff now trained in Adult Vulnerable Adult Referrals received from Greater Manchester Police and North West Safeguarding Level 2 and 71% of all GPs trained in Level 3 11 safeguarding assurance visits between Ambulance Service and shared with GPs Adult Safeguarding (new for 19/20) Specialist Nurses and Care Homes, a 22% improvement on 2018/19 • Average of 74% of GP Safeguarding Leads 58 contacts from Primary Care with represented at each GP Leads advice provided in relation to Forum in 18-19 Adult Safeguarding issues. Average of 46% of Nursing Home Managers represented at each SAINT Forum in 19-20 32 Safeguarding referrals submitted to the Adult Social Care NHS ENGLAND Contact Team by GPs, with 22 ( a 22% improvement on 18/19) 91% Compliance with training on radicalisation across North Region progressing to Section 42 enquiry 35 Named GP’s trained in Safeguarding Leadership 405 people attended safeguarding conferences planned by NHSE
SAFEGUARDING ACTIVITY LEARNING DISABILITY MORTALITY REVIEWS 731 Safeguarding Alerts received and reviewed by the CCG SALFORD SAFEGUARDING 19 referrals for Learning Disability Mortality Reviews (LeDeR) Safeguarding Team. ADULT BOARD (SSAB) referrals received
The CCG have been represented at 100% 76 Safeguarding Case Consultations, involved with 50 of statutory Safeguarding Adults Board 23 reviews have been fully completed and (SAB) meetings signed off by the Local Area Coordinator, CCG Safeguarding Adult Safeguarding Investigations and 8 Clinical Lead, Serious Incident Panel and the Serious Adult Review referrals which required agency Summary reports national LeDeR team during 2019-20 and/or chronologies (100% increase on 2018/19) and 1 progressed to a SAR and 1 to discretionary SAR.
PREVENT MENTAL CAPACITY ACT (MCA) AND DEPRIVATION OF LIBERTY SAFEGUARDS (DOLS) 88% of GPs trained in Prevent 98% of Salford CCG staff trained in Prevent 86% of GPs trained in MCA / DoLS 3 Prevent referrals submitted by GPs in Salford in 2019-20 275 DoLS applications authorised in 2019-20 and information shared with the GP 26 cases referred to Prevent in 2019-20 where GP 100% of DoLS authorisations shared with GP practices information was requested and shared 29% of referrals to Channel are from health 28% improvement of compliance with the MCA in Primary Care
3. PRIMARY CARE
Training
3.1 The CCG continue to have strong engagement with Primary Care which reflects in the outcome of training uptake and particularly within the high completion rate for Level 3 Adult Safeguarding training which was introduced on production of the adult safeguarding intercollegiate document (Adult Safeguarding: Roles and Competencies for Health Care Staff, 2018).
3.2 During 2019/20 the CCG continued to include and enhance the expectation around Adult Safeguarding training within the Salford Standard with a requirement of all practices to achieve a minimum of 80% of all practice staff trained in Adult Safeguarding (Level 2) and 80% of GPs, Practice Nurses and ANP’s to complete the additional new Level 3 Adult Safeguarding Training. These performance indicators remain in the Salford Standard for 2020/21.
3.3 In addition the CCG Safeguarding Team also offer a range of safeguarding training sessions including Prevent and Mental Capacity Act / Deprivation of Liberty Safeguards (DoLs). In 2019/20 the CCG included an expectation within the Salford Standard for a minimum of 80% of GPs (this was exceeded), Practice Nurses and ANP’s to complete Prevent and MCA / DOLS training. These performance indicators remain in the Salford Standard for 2020/21.
3.4 A full evaluation of the training delivered in 2019-20 has been undertaken. This evaluation highlights that the overall percentage of those who rated their understanding of the subject they attended training for was as follows:
• Pre-course – 52% of attendees rate their subject knowledge as Poor, Fair or had no understanding • Post-course – 96% of attendees rate their subject knowledge as Good or Excellent
Feedback from training evaluations
‘Presentation was excellent, engaging, clear and easy to concentrate on. Case discussions helped etc. clarify and embed the principles. Limited number of slides which were almost all easy to read and absorb. Very practical’ (Level 3 Adult SG)
‘Signposted to useful guidance. Some clarity on self-neglect which was very helpful and prompted useful discussion’ (Level 3 Adult SG)
‘It made me question the actions I would take in certain scenarios’ (Level 2 Adult SG)
‘The case studies were good to getting a better understanding of how to communicate with patients to knowing whether they have capacity or not’ (MCA/ DoLs)
Primary Care: Section 42 Enquiries
3.5 The Care Act (2014, Section 42) requires that each Local Authority must make enquiries, or cause others to do so, if it believes an adult is experiencing, or is at risk of, abuse or neglect. The following graph shows the total number of GP Practice safeguarding adult referrals which progressed through
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the Local Authority safeguarding assessment process in comparison to the numbers of those which met the Department of Health threshold for a Section 42 enquiry.
Safeguarding Adult Referrals from Primary Care 2017-18 to 2019-20
22 2019-20 32 Number of referrals which then met reporting threshold for a 13 2018-19 Section 42 enquiry 25 Number of referrals which progressed through Safeguarding 15 2017-18 Assessment Process 24
0 5 10 15 20 25 30 35
3.6 A further breakdown is provided within the following table. This shows the total number of Adult Social Care safeguarding contacts from GP Practices in Salford (19/20) in addition to the 32 referrals which progressed through the safeguarding process along with the recorded outcome of the contact.
Recorded outcome of contact Number / Percentage Progressed to Safeguarding 12 (32%) Inappropriate Referral 15 (41%) Managed outside of Safeguarding 9 (24%) Outside of Area 1 (3%) Total 37
3.7 The final graph breaks down the referrals into the abuse category. Most referrals relate to physical abuse (some which will be associated with adult only referrals for domestic abuse).
Abuse Categories of Referrals
Sexual 2
Self-Neglect 7
Physical Abuse 2
Neglect / Acts of Ommission 4
Financial Abuse 9
Emotional / Psychological Abuse 4
Domestic Abuse 4
0 1 2 3 4 5 6 7 8 9 10
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GP Safeguarding Leads Forum
3.8 Commitment from GP Safeguarding Leads has continued throughout the year and commitment to the GP Safeguarding Leads Forum maintained. Examples of where GP Safeguarding Leads have contributed to the Safeguarding Adults agenda include: • Review of Serious Adult Reviews (SARs) and Domestic Homicide Reviews (DHRs) and associated action plans for 19/20. • Contributed to the development of a Primary Care recording keeping audit process. • Contributed to the annual review of the Primary Care safeguarding annual quality improvement and assurance tool. • Disseminated learning from local SARs and DHRs • Supported development of the Learning Disability Mortality Review action plan • Supported the Prevent agenda by completing JIGSAW training and sharing learning from the Counter Terrorism Local Profile (CTLP). • Continued to support Multi Agency Public Protection Arrangements (MAPPA) via CCG SG team who have attended 9 meetings on their behalf.
Police Welfare Notices (PWNs) and Ambulance Welfare Notices (AWNs)
3.9 PWNs and AWNs are formal notifications from Greater Manchester Police (GMP) and North West Ambulance Service (NWAS) to Adult Social Care (ASC) where concerns for a vulnerable adult have been identified. 100% of PWNs and AWN’s continue to be shared with Practices as a response to findings from adult safeguarding investigations.
3.10 Following review of the pathways for PWNs throughout 18/19, there has been a reduction in PWN (36%). This is as a result of a twice weekly meeting where actions have been agreed and assigned to the most relevant agency for action. In contrast, there has been a 42% increase in the numbers of AWNs which is currently under review within ASC.
3.11 Awareness of the PWNs and AWNs however is vital and enables more enhanced insight around identifying vulnerable adults and provides greater opportunity for assessment/ reassessment and appropriate information sharing between agencies.
Case Example
Mrs B is a frail 89 year old lady
The CCG Safeguarding Team identified an increase in AWN’s relating to this lady and notified the relevant GP Practice.
The GP was able to discuss relevant information with the CCG safeguarding team and shared they’re concerns in relation to Mrs B suffering with anxiety, and feelings of loneliness and isolation despite receiving carers support four times daily, resulting in numerous calls to emergency services in between they’re visits.
Mrs B had said on many occasions that she felt she would benefit from being in a 24 hour care placement, but believed adult social care had rejected this and without any clear explanation
The CCG safeguarding team were able to support a connection between the GP and ASC to enable effective information sharing and confirmed that a referral hadn’t been ‘rejected’ but had been declined by this lady.
Directly working with the allocated worker within ASC meant that a clear support plan was put in place for this lady and the GP received regular ASC updates. Part of this plan developed with Mrs B encouraged her to contact ASC directly when she felt anxious between carer visits unless it was an emergency.
Where concerns were reported of a medical nature the GP would be notified and review arranged. Mrs B has also been given the contact number for the Samaritans for use out of hours should she feel anxious.
Since this intervention, Mrs B has not been on the frequent caller database. 8
3.12 The CCG Safeguarding Team have continued to offer advice and support to all GP Practices. Out of the 58 enquiries around adults at risk from Practices, 10 resulted in advice to submit a referral to adult social care and/ or safeguarding (further details of outcomes of consultations detailed within the table below). Enquiries around adult only domestic abuse and safeguarding concerns within Care Homes account for the majority of contacts with the team.
3.12 During 2020/21, the Named GP for Adult Safeguarding will be completing a full safeguarding quality review audit of all 2019/20 cases submitted via SG1 referral. The audit should help to identify and assess the current quality of referrals, accurate review against the multi-agency policies and procedures.
Outcome of Safeguarding Case Consultations with Primary Care
Advice Given Number / Percentage Refer to IRIS 2 Referral to or liaison with other agency 15 Refer to Adult Social Care / Submit SG1 12 Referred back to practitioner with actions 29
Mental Capacity Act (MCA) in Primary Care
3.13 Compliance with the MCA is monitored through the annual quality improvement and assurance tool.
3.14 In 2019/20 there has been a 28% improvement of compliance with Standard 10 (Mental Capacity Act) in the audit tool and reflects the ongoing delivery of mental capacity act training across primary care (86% of GPs trained). Additionally, recent SARs have been utilised to support lessons learnt sessions within the GP Safeguarding Leads Forum.
3.15 Training sessions are being reviewed for 2020/ 21 to include a greater focus on application of the MCA in practice and will support additional understanding around fluctuating and executive capacity.
Primary Care Safeguarding Annual Assurances
3.16 The CCG Safeguarding Team has continued to seek safeguarding assurances from Primary Care throughout 2020/ 21. The Safeguarding Quality Improvement and Assurance tool assists with the provision of assurance regarding current effective safeguarding practice as outlined within the NHSE Assurance and Accountability Framework 2019. It was devised specifically for Primary Care by NHS Salford CCG safeguarding team in order to drive safeguarding quality improvement.
3.17 All General Practices within Salford were required to complete this tool to provide assurance around their current safeguarding arrangements, in addition this is included as part of the Salford Standard contractual agreement. It highlights integral areas for learning and development across the Primary Care footprint and within individual practices
3.18 Following improvements noted in 2018/19, only 9 Practices were identified as requiring full quality safeguarding visits during 2019/20.
3.19 100% of Practices responded to the requested audit during 2019/20. Where full visits were unable to proceed due to Covid, Practices responded well to virtual discussions and support offers from the safeguarding team.
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4. CARE HOMES
Care Home Training 2019/20
4.1 The CCG has continued to recognise the Care Home sector as a crucial partner and as such have continued to offer and provide Adult Safeguarding training and Safeguarding and Record Keeping training to the whole of this sector.
4.2 A total of 57 Care Home staff were trained during this period on request or following identification of learning need.
Feedback from training evaluations
‘Enjoyed the course found it interesting and very helpful’
‘Very nice person and understood. Very good knowledge’
‘Very well delivered training’
Safeguarding Assurance (Care Home sector)
4.3 Throughout 2019/20 each Care Home with Nursing (13 in total) was offered support from a Safeguarding Specialist Nurse to enable greater improvements in developing on 2018/19 safeguarding assurance outcomes.
4.4 The Greater Manchester Safeguarding Children, Young People and Adults at Risk – Contractual Standards 2019-20 continued to be included in all Care Home with nursing contracts. For 19/20 there was a 92% return rate of evidence towards the standards (accounting for 1 care home not submitting evidence which was shared with the contracts team). All returned evidence was reviewed by the Safeguarding Specialist Nurses.
• 204 of Safeguarding Standards were RAG rated as Green (79%) • 55 of Safeguarding Standards were RAG rated as Amber (17%) • 5 of Safeguarding Standards were RAG rated as Red (4%)
4.5 Following on from audits completed in 2018/19, the points below highlight the improvements made:
• A 61% improvement on Care Homes able to demonstrate that they had a programme of internal audit and review is in place that enables the provider to continuously improve the protection of all service users from the risk of abuse and neglect • A 46% improvement on Care Homes able to demonstrate having up to date safeguarding policies/ procedures which are accessible to staff and service users. • A 38% improvement on Care Homes able to demonstrate sufficient protocols and systems for sharing safeguarding information.
4.6 Priority areas for support in 2020/21 include:
• Evidencing safeguarding responsibilities and roles within job descriptions • Identification of Mental Capacity Act leads and improving the quality of recorded evidence around the use of the Mental Capacity Act. • Uptake of training requirements outlined within the Adult Intercollegiate Document including safeguarding children awareness training.
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4.7 Throughout 20/21, Care Homes will be supported to improve upon any standards rated as amber or red and maintain all green standards. Care Homes have been supported to produce action plans which will be monitored by the safeguarding specialist nurses.
Salford SAfeguarding and Quality Provider NeTwork (SAINT)
4.8 The SAINT forum provides a network to develop, promote and raise awareness of the safeguarding adult agenda and quality issues within provider organisations in Salford. SAINT membership consists of both residential, nursing care home and domiciliary providers and sits within the sub group structure of Salford Safeguarding Adult Board (SSAB). It is chaired by the CCG Adult Safeguarding Specialist Nurses and highlights of last year’s achievements based off the priorities identified in 2018/19 include:
• Supporting the CCG Quality team to implement ‘React to Red - Train the Trainer’ programme to educate care home staff to reduce the incidence of pressure damage. This topic was identified by members as an area of interest in 2018/19. • Medicines Optimisation team and The Care Homes Practice pharmacist continue to be core members of the forum. They have provided regular updates around findings and themes from reviews including high risk medication, in addition to sharing good practice and national updates and guidance. As a result of discussions within SAINT and across ASC, standing operating procedures between Medicines Optimisation and the Safeguarding Team have been developed. • SAINT members were updated about the LeDeR programme and lessons learnt from reviews of learning disability residents within the care home sector. • The forum supported and promoted an innovation fund to bring care homes into the ‘NHS Digital Family’ which has provided IT equipment and access to secure email to support effective and safe information sharing. • Learning from cases and the annual assurance process continues to be shared in a positive way to allow providers to improve quality and safeguarding practice.
SAINT Priorities for 2020/ 21
4.9 Due to the Covid-19 pandemic and the challenges within the care home sector the SAINT forum recommenced in July 2020 via a virtual format. The following items have been identified as priorities for 2020/21:
• Information and development of the NHS ‘Red Bag Scheme’; a toolkit to facilitate effective handover of essential information and practical items between care homes and hospitals. • Establishing greater links with North West Ambulance Service safeguarding lead. • Introduction of the SSAB Manager as a core member of the group to facilitate sharing of quality data, peoples accounts of safeguarding and outcomes with Salford. • Work will continue to grow the membership of the forum to include more provider representations. • The forum plans to promote a new local initiative for care home staff to take part in an accredited Care Certificate programme.
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5. SAFEGUARDING ACTIVITY
5.1 The CCG Safeguarding Team continues to provide advice and support to all GP practices across Salford and support Adult Social Care with the provision of health expertise in relevant Section 42 safeguarding enquiries.
Number of consultations with Primary Care Number of Care Home Safeguarding Cases in 2019-20 where team has had direct involvement 58 50
Serious Adult Reviews (SARs) and Domestic Homicide Reviews (DHRs)
5.2 The Care Act (2014) statutory guidance states that Safeguarding Adults Boards must arrange a SAR when: • An adult in its area dies as a result of abuse or neglect, whether known or suspected, and there is concern that partner agencies could have worked more effectively to protect the adult. • An adult in its area has not died, but the SAB know or suspects that the adult has experienced serious abuse or neglect. In the context of SARs, something can be considered serious abuse or neglect where, for example the individual would have been likely to have died but for an intervention, or has suffered permanent harm or has reduced capacity or quality of life (whether because of physical or psychological effects) as a result of the abuse or neglect. SABs are free to arrange for a SAR in any other situations involving an adult in its area with needs for care and support.
5.3 During 2019/ 20 the CCG Safeguarding Team continued to support Primary Care colleagues to provide the relevant information to support decisions to undertake SAR’s in Salford and support completion of agreed SARs and discretionary reviews. The following table outlines the numbers of referrals the SAB SAR Panel:
Total no. of referrals to SAR Panel (2019/20) 8 (100% increase from 2018/19) No. progressing to statutory SAR 1 No. progressing discretionary review 1 Individual agency review required 2 Decision not determined/ ongoing 2 No further actions required 3
5.4 Themes emerging from the 2019/20 referrals are predominantly in relation to self-neglect, application of the Mental Capacity Act and interface with the Mental Health Act. Actions relating to these themes are included within the SAB Strategic Priorities and the individual sub group work plans and will progress throughout 2020/21.
5.5 As a result of identified learning from reviews, the following changes have been implemented:
• The SAB are currently developing a high risk model for management of our most complex self- neglect neglect cases and have commenced a review of the self-neglect procedures for Salford. • The Board have commissioned MCA (theatre production style) training on behalf of all partners. • The CCG have reviewed MCA training delivery for Primary Care to focus more directly on the challenges around executive capacity. • Self-neglect Read Code audits are now scheduled into the Salford Standard to ensure greater oversight of our cases across Salford. • SRFT have developed a non-concordant policy which also supported the revision of processes for managing patients whom fail to attend for renal dialysis. 12
• A Greater Manchester no concordant policy has been developed for Primary Care for launch in 20/21.
Safeguarding Supervision
5.6 The CCG Safeguarding Team recognised the significance of safeguarding supervision support for clinicians working within the CCG Continuing Health Care (CHC) team. This was verified with the publication of the Greater Manchester supervision policy for safeguarding alongside the recommendations outlined within the Adult Safeguarding: Roles and Competencies for Health Care Staff in 2018.
5.7 In partnership with the CHC team, a model for delivery of safeguarding supervision was agreed and sessions are held every 3 months, facilitated by the CCG Safeguarding Team. These sessions enable a safe environment and protected time for practitioners to reflect, discuss and explore decision making around some of the more complex safeguarding cases.
5.8 Throughout 2019/20, three group safeguarding supervision sessions were held with over 20 members of the team attending. In addition to this, the safeguarding team have also offered one to one case supervision sessions on request. Below is the feedback following those sessions:
Feedback from one to one safeguarding supervisions
‘’I found the supervision sessions in relation to patient x safeguarding beneficial in the ongoing case management for patient x. The sessions helped me to look at the situation from a reflective stance and this helped me to gain some clarity in moving what is a complex situation forward in a productive way in order to achieve assessed outcomes.
The sessions were well led and thought provoking and the sessions enabled me to consider different perspectives and the various dynamics within the situation. Having the protected time to discuss the care of this individual enabled me to have clearer thought processes’’
‘’I personally thought it was excellent and even in the virtual format, in fact it almost felt more personalised for me in virtual format.
Safeguarding supervision has been almost as valuable as counselling in some ways, but also allowed for some valuable reflective processes. Virtual format was absolutely no barrier to its effectiveness’’
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6. NHS ENGLAND (NHSE)
2019/20 Governance Arrangements
6.1 The regional Chief Nurse is accountable for safeguarding across NHS England North to the Chief Nursing Officer, NHS England.
6.2 The Director of Nursing for the Greater Manchester Health and Social Care Partnership (GMHSCP) is responsible for supporting and providing assurance on the safeguarding of adults at risk in conjunction with the GMH&SCP Safeguarding Lead.
6.3 The Greater Manchester Safeguarding Networks have delegated authority to act on behalf of the CCG Executive Leads in all matters relating to safeguarding and are accountable to GMHSCP Directors of Nursing (DoNs) and the Quality Board.
6.4 From January 2019 to July 2020 the CCG Designated Nurse Safeguarding Adults undertook the role of Chair for the Greater Manchester (GM) Adult Safeguarding Network. As a result, the network established clear strategic priorities and objectives for 2019/ 20 aligning to the strategic priorities for Salford. Some of the outcomes and achievements for 19/20 from the Network are outlined in the section below.
6.5 The Designated Nurse’s role is to work across the local health system to support other professionals in their agencies on all aspects of safeguarding and child protection. Designated Nurses are clinical experts and strategic leaders for safeguarding and as such are a vital source of advice and support to health commissioners in CCGs, the Local Authority, GMHSCP, NHS England, other health professionals in provider organisations, governance committees, regulators, the Safeguarding Boards, Community Safety Partnerships and Health and Well Being Boards.
GM Adult Safeguarding Network Achievements
6.6 Key achievements for the GM Adult Safeguarding Network in 2019-20 include:
• Development of a GM process for sharing Care Home Safeguarding Assurance outcomes (including out of area placements). • Developed GM guidance and minimum safeguarding competencies for healthcare staff across GM. • Finalised a GM Non Concordant Guidance document for Primary Care for roll out later in 2021. • Maintained representation at the National Safeguarding Adults Network and relevant Regional Meetings. • Reviewed the adult elements of the GM Safeguarding Contractual Standards.
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GM Adult Safeguarding Network Priorities and Objectives for 2019/20
6.7 The Designated Nurse Safeguarding Adults stepped down from the Chairs position in July 2020 to prioritise developments within Salford. A planned workshop has been established to define the three core priorities for the remained of 20/21 and moving into 21/22 which are agreed as:
Priority 1 Priority 3 Priority 2 Transitions/ Mental Capacity Act Complex safeguarding Transitional and developing in adults Liberty Protection Safeguarding Safeguards
Safeguarding Accountability & Assurance – Providers
6.8 The ‘Greater Manchester Safeguarding Children, Young People and Adults at Risk – Contractual Standards 2019-2020 is a collaborative GM document. This document contains the safeguarding audit framework used to monitor all NHS and Non NHS providers of health care including Care Homes.
6.9 These standards have continued to be included in all health care provider contracts (including Care Homes with Nursing) during 2019/20 and evidence and action plans scrutinised and monitored by the Designated Nurses on behalf of the CCG where full compliance is not achieved. There are currently no identified safeguarding concerns with our providers.
6.10 In addition, a safeguarding audit tool is included within the contract for Salford Royal Foundation Trust (SRFT) and quarterly updates fed into the provider Quality and Outcomes meetings and SRFT Safeguarding Committee.
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7. SALFORD SAFEGUARDING ADULT BOARD (SSAB)
7.1 The Chief Accountable Officer is the Accountable Officer for safeguarding adults. This duty continues to be delegated to the Director of Quality and Innovation who has been appointed with the authority to make commissioning decisions on behalf of the CCG and is the CCG Executive member of SSAB in conjunction with the Designated Nurse Safeguarding Adults.
7.2 Throughout 2019/20, the CCG has contributed to the ongoing developments outlined within the 3 year strategy (2018/ 2021) and the key priorities for SSAB. This can be found through the following link:
https://safeguardingadults.salford.gov.uk/safeguarding-adult-board/strategy-and-action-plan
Implementation and Impact Network (IIN)
7.3 During 2019/20 the CCG Designated Nurse Safeguarding Adults stepped down as Chair of the IIN to fulfil the role of Chair of the Safeguarding Effectiveness sub group (SEG). The IIN is accountable to the SAB and oversees the business of the Board, helping partners work collaboratively to progress and develop the SAB priorities and objectives across Salford. The key achievements for the year include:
• Launched the new branding for the SAB in Safeguarding Awareness Week in November 2019. • Instigated the development of a high risk model for self-neglect across Salford, identified from learning from a completed serious adult review. • Service user feedback process developed and rolled out and service user stories now form the basis of all IIN meetings. • Informed a review of the SAB website • Development and dissemination of guidance regarding fire risk and emollient products in conjunction with GMP. • Initiated a series of MCA (theatre production style) training sessions across Salford.
Safeguarding Effectiveness Group (SEG, previously Performance and Quality Sub Group)
7.4 Following a commissioned review of the Performance and Quality sub group and in conjunction with new Chairing responsibilities, the following changes have been completed:
• Alignment to the SSAB strategy • Development of a Safeguarding Effectiveness Framework (see diagram below designed by the CCG) outlining the elements of the SSAB 3 year strategy to achieve relevant safeguarding assurances. • Alignment to recording mechanisms used by the children’s partnership assurance group to create consistency and utilise the work that this group has done to develop accurate recording mechanisms. • Established a forward plan, identified areas for priority (including self-neglect, complex safeguarding and domestic abuse). • Established spot light reports to align to processes established within the children’s partnership and provide opportunity for a more focused and in depth review of priority areas identified within Salford.
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Making Safeguarding Personal (MSP) – A personal approach that enables safeguarding to be done with, not to, people.
7.5 MSP has continued to be included within all adult safeguarding training throughout 2019/20 including Level 3 adults training for Primary Care.
7.6 MSP has been the key focus of developments in LeDeR pathways and as a result, all families are approached to be included within the review, families receive one to one feedback on the reviews and are invited to contribute to suggestions around improving practice. This has led to the development of a family led bereavement support group and a nationally launched, family designed bereavement card.
7.7 In respect of safeguarding referrals, health referrals in 2019/20 accounted for 392 (42%, increase of 12% on the previous year). Referrals from Primary Care, account for 9.7% of referrals from health in Salford (including out of area referrals).
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8. LEARNING DISABILITY MORTALITY REVIEWS (LeDeR)
8.1 Salford CCG is part of the national LeDeR programme, commissioned by the Health Quality Improvement Partnership on behalf of NHSE and led by Bristol University. The LeDeR programme was established as a result of the Confidential Inquiry into Premature Deaths of People with a Learning Disability 2003, which found that people with learning disabilities are four times as likely to die of preventable causes compared with the general population.
8.2 The LeDeR Programme aims to help reduce premature mortality and health inequalities for people with learning disabilities in England through local reviews of deaths of people with learning disabilities.
8.3 In September 2020, the CCG will publish its first LeDeR Annual Report which will highlight the developments from LeDeR between 2019/20.
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9 PREVENT
9.1 In April 2015, the Prevent Statutory Duty under Section 26 of the Counter-Terrorism and Security Act 2015 was made a statutory responsibility for the health sector. The Duty stated that the health sector needed to demonstrate “due regard to the need to prevent people from being drawn into terrorism”.
9.2 Prevent is part of the UK’s Counter Terrorism Strategy known as CONTEST. Prevent works to stop individuals from getting involved or supporting terrorism or extremist activity. Radicalisation is a psychological process where vulnerable and/or susceptible individuals are groomed to engage in criminal, terrorist activity.
9.3 Salford CCG recognises that Prevent sits within the generic safeguarding process which is evident within the CCG’s commitment to the Prevent agenda across Salford.
9.4 29% of the referrals into Prevent in Salford are from health and account for 3% of referrals across GM.
9.5 The table below summarises the CCG’s statutory responsibilities for Prevent and the assurance that these requirements have been met.
Prevent Duty requirements SCCG Assurance Prevent Lead in Place • Designated Nurse Safeguarding Adults is SCCG’s Prevent Lead • The Prevent Lead is a member of the Regional Prevent Steering Group • Sits on the local Strategic Prevent/ Channel Panel Group • Approved Home Office Prevent Peer Reviewer
Embed Prevent within Local • Prevent included within the CCG and GP Safeguarding Policy and Procedures and Policies and procedures have systems and processes in • Standard Operating Procedures for Prevent referrals in place to monitor the Prevent the CCG and across health and Primary Care developed. agenda • Standard Operating Procedures for sharing information from Primary Care into the Strategic Channel Panel established. In 2018-19 26 referrals were received for patients registered with a Salford GP practice (this is a 65.5% increase from 2018/19), information was requested for each of these patients from the GP to be shared at Channel Panel and this information was received back within 5 working days for 92% of these cases (an improvement of 15% from 2018/19). • Prevent included within SRFT ¼ly reporting and provider Safeguarding contractual standards and monitoring of smaller providers has commenced from April 2020 including Care Homes with Nursing. • Salford ‘health’ account for 3% of the GM referrals into Prevent. Ensure Prevent training is • Prevent training mandatory for all CCG staff - 94% of CCG embedded within the Staff are compliant with Prevent training organisation and commissioned • Prevent included within the Salford Standard resulting in services 88% of GP’s completing this training and 3 referrals from Primary Care. 19
10 Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS)
10.1 The Designated Nurse Safeguarding Adults is responsible for leading on the Mental Capacity Act and Deprivation of Liberty Safeguards where health services have been commissioned on behalf of the CCG.
10.2 Throughout 2019/20, the MCA Lead has been a member/ contributed to developments of the following networks/forums, providing leadership, advice, support and developing strategies:
• NHS England’s National/Regional Mental Capacity Act/DoLs Network • National and GM Adult Safeguarding Networks – contributing to liberty protection safeguard developments • Local Liberty Protection Safeguards (LPS) Steering Group (paused during Covid period)
10.3 The changes outlined within the Mental Capacity (Amendment) Bill 2018 are particularly paramount within the reporting period. The Bill outlines the new provisions entitled the Liberty Protection Safeguards (LPS) which will replace Deprivation of Liberty Safeguards (DOLS) late in 2019 or early 2020. The implications for Salford CCG will include:
• New statutory responsibilities will be created as NHS trusts and CCGs will be required to issue LPS authorisations in addition to the local authority • A requirement to provide resource to support required changes that implementation of the Bill will introduce including: o Development of LPS pathways to support coordination of evidence to demonstrate the criteria set out within the pending Code of Practice, independent review (Approved Mental Capacity Professional) and Authorisation for those aged 16 years and over. o Additional training and supervision requirements o Additional advocacy resource.
10.4 In response to the anticipated changes, a locally established LPS steering group with representation from local authority, CCG and SRFT will progress implementation plans throughout 2019/20 in readiness for when the Bill becomes operationalised. The Code of Practice to support the implementation of the Bill was anticipated in December, 2019. Developments around LPS paused as per government announcements but are currently reinstated for 20/21.
10.5 During 2019/ 20 the CCG Safeguarding Team has continued to undertake the following work in respect of this agenda:
• Delivery of awareness training across Primary Care to be revised in late 2021. • Monitoring of MCA application in Primary Care via the GP Safeguarding Contractual Standards. • Review of provider arrangements in respect of the Mental Capacity Act and Deprivation of Liberty Safeguards through the Safeguarding audit and assurance framework.
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11 CHALLENGES / PRIORITIES 2020-21
11.1 The following outlines the priorities for 2020/ 21 for adult safeguarding
1. Ensure that Making Safeguarding Personal principles and the voice of our vulnerable adults remain at the heart of safeguarding processes. 2. Continue to deliver and support the CCG’s statutory responsibilities as a key strategic partner of the SSAB in line with the Care Act (2014) 3. Maintain and deliver the CCG responsibilities set out in the Assurance and Accountability Framework (2015) and subsequent revised versions. 4. Maintain effective Safeguarding arrangements with GMHSCP and fulfil priority and statutory requirements. 5. Prepare, deliver and embed the Mental Capacity (Amendment) Bill reforms on behalf of the CCG to ensure that SCCG is able to meet its statutory requirements 6. Ensure that SCCG continues to fulfil its statutory requirements for Prevent. 7. To support integration of the work within the SCCG Safeguarding Team of the children & adults agenda, including transition, domestic abuse, Mental Capacity, Prevent and complex safeguarding. 8. Define and develop integrated Safeguarding assurance processes in line with contractual safeguarding audit standards. 9. Further develop and support quality assurance and safeguarding processes across Salford in health as part of the integration agenda. 10. To continue to work with GP Practices in further developing the quality of their contributions to safeguarding processes 11. Continue to deliver the requirements for LeDeR across Salford and implement/ embed the lessons learnt across the integrated organisation and continue to manage the Primary Care Innovations. 12. Continue to provide effective leadership to support the delivery of the Greater Manchester Adult Safeguarding Network strategic priorities and objectives
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12 RECOMMENDATIONS
12.1 The Governing Body is asked to:
• Note that the statutory requirements relating to Safeguarding Adults at risk have been achieved for 2019/20 and receive assurance in respect of our activity to promote Adult Safeguarding with Salford.
• Note the anticipated legislative changes within the Mental Capacity Act and Liberty Protection Safeguards and expected additional requirements these will place upon the CCG and commissioned providers.
• Continue to support the activity of the Safeguarding Team in improving safeguarding standards across the City.
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GOVERNING BODY MEETING PART I
AGENDA ITEM NO: 5f
Item for: Decision/Assurance/Information
30 September 2020
Report of: Chief Accountable Officer
Date of Paper: 17 September 2020
Subject: CCG Medicines Optimisation Annual Report 2019/2020 In case of query Claire Vaughan Please contact: Head of Medicines Optimisation
Dr Peter Budden GP Clinical Lead Medicines Optimisation
Strategic Priorities: Please tick which strategic priorities the paper relates to:
√ Quality, Safety, Innovation and Research √ Integrated Community Care Services (Adult Services) √ Children’s and Maternity Services √ Primary Care √ Enabling Transformation Purpose of Paper:
This paper provides NHS Salford Clinical Commissioning Group Governing Body with an overview of activities and improvements made in relation to medicines optimisation in Salford; this report is aligned to the financial year 2019/2020.
Further explanatory information required
HOW WILL THIS BENEFIT THE Members of the Governing Body will be updated HEALTH AND WELL BEING OF on the medicines optimisation activity within SALFORD RESIDENTS OR THE 2019/2020 CLINICAL COMMISSIONING GROUP?
WHAT RISKS MAY ARISE AS A None RESULT OF THIS PAPER? HOW CAN THEY BE MITIGATED?
WHAT EQUALITY RELATED RISKS None MAY ARISE AS A RESULT OF THIS PAPER? HOW WILL THESE BE MITIGATED?
DOES THIS PAPER HELP ADDRESS No ANY EXISTING HIGH RISKS FACING THE ORGANISATION? IF SO WHAT ARE THEY AND HOW DOES THIS PAPER REDUCE THEM?
PLEASE DESCRIBE ANY POSSIBLE None CONFLICTS OF INTEREST ASSOCIATED WITH THIS PAPER.
PLEASE IDENTIFY ANY CURRENT None SERVICES OR ROLES THAT MAY BE AFFECTED BY ISSUES WITHIN THIS PAPER:
Footnote:
Members of this Committee will read all papers thoroughly. Once papers are distributed no amendments are possible
Document Development
Not Comments and Date Process Yes No Outcome Applicable (i.e. presentation, verbal, actual report) Public Engagement (Please detail the method i.e. survey, event, consultation) Clinical Engagement Input from GP Clinical Lead and (Please detail the method i.e. survey, event, Team Pharmacists consultation) Has ‘due regard’ been given to Social Value and the impacts on the Salford socially, economically and environmentally? Has ‘due regard’ been given to Equality Analysis (EA) of any adverse impacts?
(Please detail outcomes, including risks and how these will be managed) Legal Advice Sought
Presented to any informal groups or committees (including partnership groups) for engagement or other formal governance groups for comments / approval? (Please specify in comments)
Note: Please ensure that it is clear in the comments and date column how and when particular stakeholders were involved in this work and ensure there is clarity in the outcome column showing what the key message or decision was from that group and whether amendments were requested about a particular part of the work.
CCG Medicines Optimisation - Annual Report 2019/2020
1. Executive Summary
This report highlights the breadth of work completed during 2019/2020 in relation to Medicines Optimisation (MO). This includes supporting high quality primary care prescribing, delivering efficiencies to the budget where possible, ensuring medicines use and medicines optimisation is considered in the commissioning and contracting activities of the organisation and providing strategic direction to Greater Manchester and national level activities. The team also has a strong focus on improving the safety of medicine use in Salford.
Areas covered in this report include
• Effective organisation work streams • Outcome based use of medicines • Quality work streams • Routine medicine optimisation activity • Improving medication use in care homes • Non-medical prescribing • Supporting Salford City Council in medicine optimisation • Supporting the Salford Standard • Supporting commissioning and contract activities
The information outlined within the report highlights the contribution made by the MO team in relation to a range of CCG strategies and strategic priorities.
2. Introduction and Background
2.1 This annual report is to inform the NHS Salford Clinical Commissioning Group (SCCG) Governing Body of activities and improvements made in relation to medicines optimisation; this report is aligned to the financial year 2019/2020.
2.2 Medicines play a crucial role in maintaining health, preventing illness, managing long-term conditions and curing disease. In an era of significant economic, demographic and technological challenge, it is vital that patients get the best quality outcomes from medicine use.
Against this background, it is known that:
• Up to 50 per cent of patients do not take their medicines as intended; • Between 5 and 8 per cent of all unplanned hospital admissions are due to medication issues; • Medicines waste is a significant issue; • According to medication safety data, the NHS could do much better at reporting and preventing avoidable harm from medicines; • Resistance to antimicrobials presents a real and significant threat to modern health care.
2.3 Throughout 2019/2020, SCCG has continued to demonstrate significant commitment to medicines optimisation as outlined within the current Quality and Safety Strategy and evidenced through provision of regular medicines optimisation updates to the Primary Care Quality Group and Quality Reference Group.
2.4 Within the CCG strategic plan there is an active move to focusing on medicines optimisation. Medicines optimisation’s primary goal is maximising value; the value that a patient derives from their medicines and the value that the whole population experiences from the NHS’ investment in medicines. Optimal medicines use is a crucial step in both improving the quality of care and balancing the costs of healthcare. Medicines optimisation is, therefore, an approach to the quality use of medicines that aims to produce the best possible patient outcomes.
2.5 The CCG MO team continues to support safe and effective medicines use and works with pharmacy teams across Salford to promote an integrated approach to medicines optimisation and safety.
3. Effective Organisation Work Streams
3.1 Maintaining costs in the primary care prescribing budget remains challenging. The GP practice primary care prescribing budget for 2019/20 was £39 million. The year end spend was £40.3million, an overspend of £1.3million (3.4%). This over spend position was largely due to in year national price increases due to the medicines margin and price adjustments.
3.2 The medicine margin is the difference between the purchase price paid by the community pharmacy contractor and what they have been reimbursed by the NHS for dispensing the product against an NHS prescription. Pharmacy contractors are private businesses that provide NHS pharmaceutical services under the community pharmacy contractual framework (CPCF). CPCF funding is delivered through fees and allowances paid to pharmacy contractors by NHS England and the medicine margin.
3.3 The Department of Health and Social Care (DHSC), with the Pharmaceutical Services Negotiating Committee (PSNC) and NHS England, assesses the medicine margin achieved by pharmacy contractors (through a medicines margin survey) and adjust reimbursement arrangements, as necessary. On August 2019 it was announced that the DHSC would increase medicine reimbursement prices by £15 million each month until March 2020. The increase was made based on margin data from 2019/2020 along with predictions for delivery in 2020/2021. This equated to an increase cost to the Salford primary care prescribing budget of approximately £100,000 a month.
3.4 Other factors affecting budgetary performance include temporary price concessions, through the No Cheaper Stock Obtainable (NCSO) price adjustments to national drug tariff prices. The DHSC set price concessions using information derived from manufacturers and wholesalers, evidencing procurement prices above the national set price. Pressures from these monthly adjustments rose from an average of £30,000 per month to £113,000 in March 2020. In addition, at the start of the Covid19 pandemic an increase in prescription activity was seen, resulting in 13% more items being dispensed in March compared to February, with a corresponding increase in cost of 19% (equating to £623,000).
3.5 Although Salford’s weighted prescribing costs are above the England average, they are broadly in line with the Greater Manchester average:
Figure 1: Per capita prescribing costs
3.6 When benchmarked against its comparator ‘similar’ CCGs as defined by the Right Care Programme methodology, Salford’s weighted prescribing costs remain lower than the majority:
Figure 2: Quarterly trend of weighted per capita prescribing costs
3.7 Despite the current pressures, the spend, on primary care prescribing has been stable over recent years as the MO team cost improvement plan delivers savings which offset the growth.
Financial year Budget Spend 2015/2016 £39,134,720 £38,961,006 2016/2017 £39,624,078 £40,713,321 2017/2018 £41,194,218 £39,888,217 2018/2019 £40,199,788 £39,207,593 2019/2020 £39,037,383 £40,368,291
3.8 To offset growth in the prescribing budget, each year the MO team deliver a primary care prescribing cost improvement plan. These work streams are delivered in all Salford practices; the majority by three MO pharmacy technicians, supported by standard operating procedures, defined clinical system searches and patient information developed by the pharmacists.
3.9 The 2019/2020 primary care cost improvement plan delivered £642,803 in recurrent savings to the primary care prescribing budget. Some of the work streams with larger savings are summarised below.
3.10 A generic medicine contains the same quantity of active substance(s) as the branded medicine that was originally granted a product licence. Generic medicines are, overall, much less expensive to the NHS. Their appropriate use instead of branded medicines can deliver considerable cost savings. Reviewing the prescribing of branded medicines and switching (where clinically appropriate) to the equivalent generic medicine has generated £94,000 recurrent savings.
3.11 Ivabradine is prescribed for the symptomatic treatment of chronic stable angina. The 2.5mg tablet is 15 times more expensive than the equivalent number of 5mg tablets, which are scored so they can be halved. Reviewing and switching appropriate patients to using half a 5mg tablet has generated annual savings of £62,000.
3.12 Significant savings have been made on the appropriate cost-effective prescribing of insulin pen needles. Insulin pen needles range in price between approximately £4- £30 per box. There is no evidence that there are any significant differences between brands of needles, therefore NHS England guidance advises the prescribing of lower cost needles.
Figure 3: Cost of higher cost (≥£5/box) insulin pen needles per 1000 patients
3.13 In March 2018 (updated June 2019), NHS England published guidance for 35 conditions (plus probiotics and vitamins and minerals) where self-care by patients may be more appropriate and for which over the counter (OTC) items should not routinely be prescribed in primary care. Primary Care Commissioning Committee agreed application of this guidance in Salford in April 2019 but implementation was delayed as a GM commissioning statement was not agreed until September 2019. Reviews have also been delayed in Q4 due to the Covid19 pandemic and the refocus of team activities. As a result, the projected savings were not achieved in 2019/2020. However the work stream has now resumed and savings will be seen in 2020/2021 and recurrently thereafter.
3.14 Salford prescribing of OTC items is shown below in Figure 4. The top 5 classes of items are drugs used in the conditions below. Prescribing reviews are focusing initially on these key areas.
• Hay fever • Vitamins and minerals • Dry eyes • Minor pain conditions • Dry skin
Figure 4: GM over the counter prescribing costs April 2019-March 2020
3.15 In 2019 NHSE also issued guidelines for 18 products which fell into one or more of the following categories:
• Products of low clinical effectiveness, where there is a lack of robust evidence of clinical effectiveness or there are significant safety concerns; • Products which are clinically effective but where more cost-effective products are available, including some products that have been subject to excessive price inflation; and • Products which are clinically effective but due to the nature of the product are deemed a low priority for NHS funding.
Monthly reviews ensure Salford continues to be one of the lowest spending CCGs in Greater Manchester on these items that NHS England deems to be low priority:
Figure 5: Items which should not routinely be prescribed. Weighted net ingredient cost.
3.16 The MO team also monitors prescribing and reviews accordingly in a number of key areas on a monthly basis:
• Red drugs: Drugs considered to be specialist medicines and prescribing responsibility for these medicines should normally remain with the consultant or specialist clinician • Do Not Prescribe drugs: Products which have been deemed by the Greater Manchester Medicines Management Group as not suitable for prescribing • Grey Drugs: Items which are deemed not suitable for routine prescribing but may be suitable for a defined patient population • Special order items: an unlicensed medication which has been specifically manufactured for a specific patient for a specific need and should only be used where there is no suitable licensed alternative. Due to the nature of the manufacturing process, they are usually high-cost items. ‘Drug Tariff specials’ are special order items where the price paid has been fixed by the Department of Health and Social Care.
3.17 Salford prescribers who are unsure of any request to prescribe medicines in these categories are encouraged to check with the MO team who receive several enquiries of this nature on a daily basis. This benefits Salford patients as it ensures safety is maintained as medications deemed specialist in nature remain under secondary or tertiary care that monitor and review patients as necessary and delivers financial savings by stopping inappropriate transfer of prescribing costs from hospitals to primary care.
3.18 Salford continues to perform well on these comparators compared with other Greater Manchester CCGs:
3.19 Salford has the lowest monthly spend on specialist (Red) drugs in Greater Manchester, and has reduced prescribing costs compared with the previous year:
Figure 6: Weighted prescribing cost of specialist medications Q4 2019/2020
3.20 Salford has the second lowest monthly spend on ‘Do not prescribe’ drugs in Greater Manchester, and has reduced prescribing compared with the previous year:
Figure 7: Weighted prescribing cost of ‘Do not prescribe’ medications Q4 2019/2020
3.21 Salford has the second lowest monthly spend on Special order drugs in Greater Manchester, and has reduced prescribing compared with the previous year:
Figure 8: Weighted prescribing cost of special order medications Q4 2019/2020
3.22 Salford has the lowest monthly spend on ‘Drug Tariff’ Special order drugs in Greater Manchester, and has reduced prescribing compared with the previous year:
Figure 9: Weighted prescribing cost of Drug Tariff special order medications Q4 2019/2020
3.23 Salford has the lowest weighted prescribing cost of ‘Grey’ drugs in Greater Manchester, and is stable compared with the previous year:
Figure 10: Weighted prescribing cost of ‘Grey’ medications Q4 2019/2020
3.24 Monthly oversight and review, proactive assurance with the team by Salford practices and routine interaction with secondary care clinicians ensures that primary care prescribing in Salford remains, as far as possible, compliant with the good practice position agreed across Greater Manchester. A continued focus on specialist prescribing in 2020/2021 will ensure outpatient redesign is delivered within these existing frameworks.
4. Outcome based use of medicines
4.1 Within the CCG strategic plan there is an active move to focusing on medicines optimisation. Medicines optimisation’s primary goal is maximising value; the value that a patient derives from their medicines and the value that the whole population experiences from the NHS’ investment in medicines. Optimal medicines use is a crucial step in both improving the quality of care and balancing the costs of healthcare.
4.2 To facilitate looking not just at medicines expenditure in isolation, but in relation to the outcomes they contribute to, analysis of medicines used in diabetes, COPD management and stroke prevention are reviewed in relation to the national Quality and Outcomes Framework (QOF) outcomes and non-elective admission data. These are shown in Appendix 1. These plots show Salford to be in the low prescribing expenditure, low admissions quartiles which evidences best practice care and medicines optimisation.
4.3 These analysis comparing prescribing costs vs outcomes show Salford CCG to be performing consistently well in comparison to Greater Manchester peers in using medicines both cost and clinically effectively with the desired patient related outcomes.
4.4 The Head of MO has also led GM work in 2019/2020 to establish commissioners receiving outcome data with regard to high cost, PBR excluded drugs. Salford CCG
spent £7,000,000 on PBR excluded drugs in 2019/2020 and other than assurance on compliance with National Institute for Health and Care Excellence (NICE) technology appraisal criteria receives no further patient outcome data.
4.5 Following the NICE approval of Dupilumab, an injectable agent for atopic dermatitis the MO team led a piece of work with dermatologists and medicines management pharmacists at SRFT to measure the impact of the use of this drug and the outcomes treatment was having in GM patients. Utilising a secondary care recording system Blueteq, forms were co-produced with the dermatology team. This allowed clinicians to record the severity of the patient’s condition by recording their EASI 50 (Eczema Area and Severity Index) and DLQI (Dermatology Life Quality Index) scores prior to treatment initiation and again at 16 weeks.
4.6 Analysis of this information has, for the first time, provided commissioners with information on severity of disease and response after treatment. The data shows high average EASI score at initiation, indicating severe disease and high DLQI score at initiation indicating that their skin condition is having an extremely large effect on patients’ lives. After treatment reduction in EASI score ranges from 52% to 100%, average is 77% reduction (NICE requires a 50% reduction to continue) with some patients reporting EASI reduction in excess of 90% evidencing very significant clearance in some patients. Significant reductions in DLQI were also seen providing commissioners with assurance that the treatment was delivering significant improvement in patients' perception of the impact of skin diseases on different aspects of their health-related quality of life.
4.7 By putting in place this monitoring of patient response commissioners are able to be assured that patients receiving this drug at SRFT are achieving significant health gains and meeting the criteria set by NICE to continue treatment.
4.8 This was then taken a step further when the new GMMMG High cost drugs pathway for psoriasis in adults was approved in November 2019. As lead commissioner for SRFT the MO CCG lead developed, in conjunction with the dermatology clinical team and pharmacy team, a monitoring framework for this pathway which will provide assurance on NICE compliance, cost effectiveness and patient outcomes. This will run in shadow form and be reviewed in 2020/2021. This is currently the only GMMMG high cost drug pathway that has an associated monitoring framework.
5. Quality Work Streams
5.1 Salford CCG has identified the use of medicines within the health economy as a key area for quality improvement. This is highlighted by the safer medicines programme that is part of the overarching Safer Salford programme.
5.2 Medicines are the most common intervention and the biggest cost after staff in healthcare. Getting the most from medicines for both patients and the NHS is becoming increasingly important as more people are taking more medicines. There are also national and international drivers to use medicines in a safer and more effective way with a particular focus nationally on antibiotics and antimicrobial stewardship.
5.3 Quality Commissioning Committee approved a medicines optimisation quality and safety programme in July 2019; highlights of this programme are provided below. 5.4 Ongoing work continues to reduce inappropriate antibiotic prescribing by Salford practitioners. These include:
• Supporting the development and review of Greater Manchester guidance • Production of quarterly antibiotic practice specific reports to inform review • Antibiotic performance as a Salford standard Key Performance indicator • GP review of antibiotic prescribing in Salford Care Home Practice
5.5 Following on from the introduction of a sustained reduction in number of antibiotic prescription Key Performance Indicator (KPI) as part of the Salford standard in 2018/2019, a further KPI in relation to appropriate coding and clinical diagnosis was added to evidence antimicrobial stewardship as per NICE quality standards. Data for this parameter are currently held locally at practices and the MO team are working with the business intelligence team to move towards a centralised monitoring.
5.6 Performance at year end saw 32 practices showing a decrease from baseline in their antibiotic prescribing, with some achieving up to 39% reductions in the number of prescriptions being issued. While overall antibiotic prescribing rates saw a further decrease in 2019/2020 compared to 2018/2019, a further reduction of 8.2% is required to reach the NHS England national CCG target. GP practices not meeting the national standard have been set a three year improvement target to encourage antibiotic reduction. At year end 71% of practices have either achieved their year one improvement target or the national target.
5.7 Trimethoprim items prescribed for patients aged 70 and over have also seen a downward trend during 2019/2020. This is typically used for urinary tract infection (UTI), and was audited by the MO team in previous years in view of the national antibiotic quality premium to reduce the use of trimethoprim in patients over 70 years old. This improvement work has seen a sustained reduction as shown below.
No. of Trimethoprim items for patients aged 70yrs plus 3,200 3,000 2,800 2,600 2,400
Figure 11: Trimethoprim prescribing in patients over 70 years
5.8 In July 2019, five primary care networks (PCNs) were formed within Salford CCG. This builds on the core of current primary care services and enables greater
provision of proactive, personalised, coordinated and more integrated health and social care. To support the delivery of PCN focused medicines optimisation workstream for 2020/2021, the MO team have produced PCN data reports based on key areas outline in the NHS Long Term Plan. PCNs have been asked to agree on their areas of prioritisation, and these will be translated into KPIs to form a part of the Neighbourhood Integrated Practice Pharmacist in Salford (NIPPS) team’s work plan.
5.9 The Opioid Aware project from the Faculty of Pain Medicines seeks to improve prescribing of opioid analgesia. There is little evidence that opioids are helpful in long term pain, and the risk of harm increases at high doses without associated increase in benefit. NIPPS led reviews using the GMMMG chronic pain guide have been successfully piloted in Springfield Medical Centre showing significant improvement in their prescribing in this area. Opioid reviews have been proposed as a key area for prioritisation for PCNs to consider in 2020/2021 as the national PCN direct enhanced service which encourages PCNs to actively work with its CCG in order to optimise the quality of local prescribing of medicines which can cause dependency.
5.10 During 2019/2020 work continued on the national programme Stopping Over- Medication of People with Learning Disabilities (STOMP). The MO team facilitated a STOMP implementation group bringing together Salford partners to deliver the specific actions for general practice to review these patients. To gauge the extent of these reviews, the MO team collated baseline data and identified 917 adults and 215 children across Salford who may benefit from a specialist review.
5.11 During 2019/2020, access to GM funding has been secured and a specialist mental health pharmacist from Greater Manchester Mental Health (GMMH) has been facilitating reviews for Salford patients. The initial focus was on the four GP practice’s in the Swinton PCN, due to a high concentration of patients on the learning disability registers at these practices. 54 adults have been reviewed; 39 patients were identified as prescribed antipsychotics for challenging behaviour. 21 patients have been recommended to begin a dose reduction plan and 18 patients will be reviewed by a LD specialist consultant. If GM funding continues, the review process will be refined and scaled up in the remaining PCNs in 2020/2021. To ensure continuity in the service, the specialist mental health pharmacist will work closely with the NIPPS team and the CCG MO team facilitating this process.
5.12 There are 71 available hormone replacement therapy (HRT) products commercially available within the UK market. To streamline prescribing and encourage adherence to the GMMMG formulary, the MO team were due to develop a Salford specific HRT guide in 2019/2020. Unfortunately, this work has been interrupted by supply disruptions of 32 products throughout the year. These supply issues account for more than 50% of the GMMMG formulary. Work on this will recommence when the supply chain stabilises.
5.13 Hydroxychloroquine is a medication used to treat several inflammatory conditions prescribed under shared care agreement with specialists. Retinopathy is a side effect which has shown a higher prevalence in patients on therapy longer than five years or in those taking concomitant tamoxifen. To ensure patient safety, the Royal College of Ophthalmologist recommends an annual eye screen. Reviews across Salford have identified 168 patients who are in this at risk category and 57 of which have an
annual eye test documented. Patients without an annual eye test have been highlighted to GP practices for a referral to their local eye hospital. 5.14 The dose of the class of drugs direct oral anticoagulants (DOACs) that are used is dependent on the condition being treated and how well the patient’s kidneys are functioning. In 2018/2019, the MO team began work to improve prescribing on DOACs, to date 238 patients across four PCNs have been reviewed. Areas for improvement in prescribing have been highlighted and feedback to both primary and secondary care prescribers. These reviews have now transitioned to the NIPPS team to allow them to be scaled up. This work has been nominated for a HSJ patient safety award.
5.15 In previous years the MO team have carried out reviews of the prescribing of antidepressant in under-18s to ensure prescribing is in line with NICE guidelines. Feedback from the children’s safeguarding team and prescribing data have highlighted that performance have not been sustained and further reviews were necessary. The top quartile of practices prescribing to under-18s have been targeted for review, to date, 41 patients have been reviewed across all five PCNs. This work is due to continue in 2020/2021.
5.16 The GM Minor Ailment Scheme (MAS) is due to move towards a more evidenced based choice of therapy and refocus the scheme to be condition, not product based. In preparation for a relaunch, GP practices have been asked to feedback their experience of the service and have highlighted a desire for practices to receive notification from local pharmacies when patients have had medication supplied via the MAS. The MO team have been working with PharmOutcomes to design a notification template to ensure GP practice receives sufficient information for their patient records to facilitate ongoing care (if they choose to want this information).
5.17 CURE is an inpatient smoking cessation project which has had a successful trial at the Wythenshawe site of Manchester Foundation Trust, and is due to being rolled out across all hospitals in GM. In preparation of the roll out, at SRFT, the MO team have linked in with the Public Health team and the local health improvement team to facilitate discussions and support local smoking cessation service redesign. This will ensure on going pathways post discharge are in place to support continued smoking cessation and access to therapies.
5.18 Scriptswitch® is a prescribing decision support solution which delivers savings to the prescribing budget and improving patient care and outcomes. To ensure the system aligns with current guidelines and GMMMG formulary, the MO team have been reviewing messages on the system. There are 6,834 messages on the Salford profile and 2,152 messages have been reviewed during 2019/2020. Reviews will continue into 2020/2021.
6. Routine Medicine Optimisation Activity
6.1 The MO team offer a query answering service to all clinicians, practice staff and Salford patients and receive approximately 80-100 queries a month. These can vary from simple questions on whether a GP should be prescribing items requested from secondary care for patients, to more complex clinical queries involving drugs in pregnancy and breast feeding, drug interactions and co-morbidities, transfer of care
queries and commissioning responsibilities. These are all answered in a timely manner ensuring our clinicians are supported in their prescribing decision making.
6.2 The MO team also write and authorise local Patient Group Directions (PGD) to support the delivery of appropriate interventions in primary care e.g. spirometry and also produce annual assistant practitioner protocols to support practices deliver the influenza vaccination programme and other routine injections. A Patient Group Direction (PGD) is a written instruction for the sale, supply and/or administration of and allows specified health care professionals to supply and / or administer a medicine directly to a patient with an identified clinical condition, without the need for a prescription or an instruction from a prescriber. The use of PGDs and protocols streamlines processes in primary care and improves patient care by improving timely access to appropriate medicines.
6.3 The number of GP practices changing their clinical system continued to grow in 2019/2020. The MO Technicians support practices during this transition carrying out drug mapping, checking allergy status and that other information has transferred correctly, ensuring patient safety.
6.4 The MO technicians routinely support practices with their use of electronic prescribing and repeat dispensing aiming to increase the uptake of this option for patients in Salford. In March, early in the COVID-19 pandemic, NHS England advised that practices must use the Electronic Prescription Service (EPS) and should aim to move patients to electronic repeat dispensing unless there is a clinical reason not to do so. A focused effort from the CCG MO team saw over 22% of prescriptions in Salford being issued this way, making the CCG the highest performing CCG in the North West and well above the England average of 13%. This allowed a reduction in workload for GP practices managing repeat prescriptions, footfall to practices and allowed patients to collect their repeat medications directly from the pharmacy.
7. Improving Medicine Use in Care Homes
7.1 2019/2020 saw a successful innovation fund bid utilising a MO technician to improve medicines optimisation in care homes receive recurrent funding. This has enabled the team to sustain the improvements seen in the past financial year and expand quality improvement in medicine use in care homes in Salford. In 2019/2020 a further 26 care homes (residential and nursing) received comprehensive medication audits from the team.
7.2 During 2019/2020 the care home pharmacist and technician, working with the CCG business intelligence team, developed a bespoke audit tool for use in care homes (Appendix 2). This has streamlined the review process making it more efficient. This has now been used to review nine care homes with excellent feedback from care homes staff.
7.3 These audits help to ensure that residents are receiving safe care and treatment relating to medicines and improve compliance with Care Quality Commission (CQC) standards; specifically the ‘Safe’ domain of the inspection report. The care homes medicines management dashboard will allow the MO Team to track and monitor the medicines management performance of each care home and whether pharmacy intervention results in an improvement. It is hoped that this dashboard will also be
utilised by different partners and organisations across the Integrated Care Organisation who seek assurance relating to medicines management performance in care homes.
7.4 The medicines optimisation team has produced and distributed guidance on; medicines storage, as required medication use, stock rotation and managing expiry dates and reducing waste, enabling improvements in these areas as evidenced by improved CQC assessments.
7.5 2019/2020 saw the team start to work collaboratively with community pharmacies dispensing for residents in Salford care homes. This collaborative approach saw measurable improvements in labelling and correct container supply to ensure the homes can meet the requirements of the CQC and NICE care home medicines guidance. Allergy status was updated on MARs charts, GP and community pharmacy clinical systems. A test of change with community pharmacies also extended to supporting two homes move to original packs dispensing (as recommended by NICE) and after the success of these two tests this will be extend in 2020/2021.
7.6 All medicines related safeguarding incidents reported to the CCG safeguarding team continue to receive a MO Pharmacist review. In addition, data is being gathered in the form of Salford Adult Safeguarding Notifications (SG1 forms) to ascertain what medication incidents are most commonly occurring and in which care settings so improvements can be pro-actively made.
7.7 This work has formed part of the Salford Quality Improvement Network which is a collaboration of health and social care professionals across Salford Integrated Care Organisation. It acts as a co-ordinating body for activity in Salford that works to improve the quality of the city’s care homes. The MO pharmacist (partnerships) and MO pharmacy technician (care homes) are regular, active members of the quality improvement network since its formation in 2017.
8. Non-Medical Prescribing
8.1 The Non-Medical Prescribing (NMP) Lead supports current and prospective non- medical prescribers and provides assurance to the CCG that appropriate governance arrangements are in place.
8.2 The main functions of the NMP role are:
• Responding to enquiries from prospective students, including assessing suitability for the course and for NHS funding • Supporting students through the application process to registration and authorisation • Liaising with NHS Business Services Authority to register (and deregister) prescribers against the correct prescribing budget(s) • Maintaining a register of non-medical prescribers • Supporting practices to ensure NMPs are correctly set-up on the clinical system • Providing on-going support to prescribers including dealing with queries and sharing prescribing data for prescribers to reflect upon and support their own continuing professional development (CPD).
• Networking with other NMP Leads, the Health and Education Co-operative, Higher Education Institutions (HEIs), Greater Manchester Training Hub (GMTH), Health Education England (HEE) and others involved with NMPs to share good practice and learning • Co-operating and supporting Professional Bodies with investigations into individuals of concern
8.3 The work of the NMP lead provides assurance to the CCG in relation to governance and safety of non-medical prescribing by:
• Maintaining an up-to-date register of all non-medical prescribers • Requesting that all NMPs complete an Annual Declaration • Maintaining a record of prescription pads ordered on behalf of non-medical prescribers • Registering and deregistering prescribers with the NHS Business Services Authority • Representing NHS Salford CCG at the North West Non-Medical Prescribing Leads Network meetings to liaise with other NMP Leads and others involved with non-medical prescribing to share good practice and learning
8.4 The support provided by the NMP ensures that Salford’s primary care workforce is diverse and capitalises on alternatives to GP prescribers, facilitates access to prescription medicines for Salford residents and allows streamlining of services.
8.5 The NMP Lead has provided on-going support to over 100 Salford CCG GP practice based and St Ann’s Hospice based non-medical prescribers, including nurses, pharmacists, physiotherapists and paramedics. These consist of a combination of practice employed staff, training posts, locums, community teams (e.g. Enhanced Care Team) and those working in practices as part of a commissioned service (e.g. neighbourhood practice pharmacists).
8.6 In 2019/2020 five prospective students have been supported by the NMP Lead through the application process. This includes: three nurses, one paramedic, and one pharmacist.
8.7 The funding route for NMP courses changed in 2019/2020. The funding had previously been held by CCGs. However, the Director of Finance for HEE confirmed that the Greater Manchester Strategic Workforce Collaborative Board should determine management of funding for primary care. The Board agreed that the funding for NMP courses should be managed through the Greater Manchester Training Hub (GMTH). The process for approving NMP applications remains with the CCG NMP Leads, but the funding must be approved by the GMTH, and a funding confirmation letter issued to the student to provide to the HEI. The CCG NMP lead facilitates prospective students through this process.
9. Supporting Salford City Council in Medicine Optimisation
9.1 Salford CCG MO team took over supporting Salford City Council (SCC) in its medicines optimisation needs from April 2016. This was consolidated during 2017 with a new pharmacist post commencing January 2017; Medicine Optimisation Pharmacist (Partnerships).
9.2 This has seen the team support the SCC Public Health team in several areas during 2019/2020;
• Patient Group Directions to allow supply from pharmacies (without the need for a prescription) of emergency hormonal contraceptives have been reviewed, reauthorised and continued. • Support has been provided to the Health Protection Team when reviewing community Clostridium Difficile infection and Methicillin-resistant Staphylococcus aureus (MRSA) cases by undertaking medicines management reviews and assisting with the assessment of treatment suitability. • The team has supported SCC with prescribing data, and its interpretation, relating to contraception and smoking cessation to facilitate their commissioning reviews. • Monthly review of gram negative blood stream infections (GNBSIs) to support the learning and inform improvement plans to meet the NHS Long Term Plan ambition of a 50% reduction in Gram-negative bloodstream infections (GNBSIs) by 2024/25.
10. Supporting the Salford Standard
10.1 The MO team are responsible for writing, supporting and monitoring the medicines optimisation elements of the Salford Standard. These facilitate safe drug monitoring of high risk drugs, adherence to NICE standard of medicines use in long term conditions, a reduction in potentially risky medicines combinations of medications to improve medication safety in Salford and reduction in inappropriate antibiotic use.
10.2 Building on the work from the previous year the Salford standard 2019/2020 saw a continued focus on reducing the number of inappropriate antibiotic prescriptions. Salford CCG continues to be above the national target for antibiotic use of 0.965 items/STAR-PU. (This measure shows the amount of antibacterial drugs that have been prescribed, in relation to what would be expected given the number and characteristics of patients registered at the practice, for example, recognising some drugs are generally prescribed more for older patients. The England average is 0.879)
10.3 Two antibiotic improvement indicators were included in the standard 2019/2020
• Achieving the national prescribing standard for primary care antibiotic volume • Evidence of quality standards in NICE antimicrobial stewardship Quality standard 121, Quality statement 3: Recording information
10.4 Acknowledging achieving the national standard would be challenging for some practices who’s baseline performance was some distance from this, a three year improvement target was introduced which carried partial payment. Overall Salford’s position improved.
• 1.119 at baseline to 1.055 at year end • 32 practices reduced their antibiotic prescribing • 19 practices met national target • 10 practices met Year one improvement target
10.5 Improved coding and recording of diagnosis as part of the evidencing NICE quality standard has facilitated improvement work in practices not meeting their improvement target.
10.6 Practices to work in partnership across the healthcare system to tackle the threat of sepsis.
• Practices must identify a sepsis lead and this lead must to hold an education session in practice by the end of Q2. Attendance at this must be multidisciplinary and include non-clinical e.g. reception staff, as well as clinical staff. This education sessions must include reference to the following resources
• Recognising sepsis in primary care as documented in the NHSE guide • Think sepsis tool provided by Health Education England
• Performance at year end saw all Salford practices that were contracted to deliver the Salford standard meeting this requirement. Feedback from practice’s showed a variety of practice initiated improvements in the area of identifying sepsis in Salford patients.
10.7 This Salford standard allowed the CCG to submit a compliant return on the CCG Improvement and Assessment Framework 2019/2020 indicator 43: Evidence that sepsis awareness raising amongst healthcare professionals has been prioritised by the CCG.
11. Supporting Commissioning and Contract Activities
11.1 The team provide MO expertise at the CCG strategy groups including: Commissioning Committee, Primary Care Quality Group, Integrated Community Based Care Group, Health Care Associated Infection Group, Innovation and Research Oversight Group, Independent Funding Request Panel and Care Homes Quality Improvement Network. Attendance at providers Medicines Management Groups at SRFT and GMMH also ensures commissioner’s views are considered in their medicines management agendas.
11.2 The CCG MO team provide professional support to the Local Commissioned Services from Community Pharmacy in Salford; the Minor Ailment Scheme and the Palliative Care Drug Supply Service. They also support the delivery of the commissioned Neighbourhood Integrated Practice Pharmacist Service (NIPPS) based team commissioned from SRFT.
11.3 During 2019/2020 the Head of Medicines Optimisation has had opportunities to ensure Salford CCG is able to influence the national agenda on medicines optimisation through membership of both the NHS Clinical Commissioners medicines group and being the North West commissioning representative on the National NHS England Medicines Optimisation Clinical Reference Group (MOCRG).
11.4 This clinical reference group main objectives are listed below and membership presents significant opportunities to Salford in shaping the changes and the future development of these national programmes.
Objectives of the MOCRG include:
• to provide a forum for commissioners, providers and procurement pharmacists to share ideas about optimising the use of medicines included in the specialised commissioning ‘high cost drugs list’; • to engage with CCGs, procurement, providers and the Commercial Medicines Unit in the development and delivery of a work plan for high cost medicines; • to work in collaboration with national medicines procurement groups, National Pharmaceutical Supply Group (NPSG) and Pharmaceutical Market Strategy Group (PMSG); • to provide a forum to debate and reach consensus on issues such as the repatriation of patients to secondary care, rebate and gain share arrangements; • to support the on-going implementation of home care reforms.
12. Summary and Conclusions
12.1 This report highlights the breadth of work delivered by the CCG MO team. This includes supporting high quality primary care prescribing, delivering efficiencies to the budget where possible, and ensuring medicines use and medicines optimisation is considered in the commissioning and contracting activities of the organisation, and influencing national changes in these areas. There is also a strong focus on improving the outcomes Salford patients get from medicines and reducing, where possible, any potential harms.
12.2 The importance of medicines and their optimisation is threaded throughout the CCG and included in a wide range of work streams. Not only does medicines optimisation deliver significant financial efficiencies (to both the primary care and high cost drug budgets) but also ensures primary care prescribers are supported and that prescribing in Salford is effective, patient centred and of high quality.
12.3 In addition, the information outlined within the report highlights the contribution made by the MO team in relation to a range of CCG strategies and strategic priorities including:
• Quality and Safety Strategy • Primary Care Workforce Development Strategy • Achieving nationally mandated targets • Partnership working across the Salford locality • Partnerships within Greater Manchester • Safer Salford
12.4 The MO team will continue to support GP practices in their prescribing and over the next two years plan to focus on the areas highlighted in the Primary Care Network Direct Enhanced Service, particularly in frail or vulnerable residents and those most at risk from Covid 19. This will improve the health outcomes and reduce harms for Salford patients. Work will also continue to ensure the current focus on spend and outcomes on PBR excluded drugs continues.
12.5 The team will also continue to work with the newly developing Primary Care Networks (PCNs), building on established neighbourhood working and support. 2019/2020 saw
the team develop PCN work plans for the practice pharmacist’s team, supporting patient facing work and quality improvement. As the care system in Salford continues to evolve there will also be a continued focus on reducing variation in standards and improve the delivery of care relating to medicines in the community care setting in Salford.
13. Recommendations
13.1 The Governing Body is asked to:
• Note the contents of this report • Accept assurances that Salford CCG has a strong MO work plan that is integrated into both its support for primary care and commissioning activities
Claire Vaughan Head of Medicines Optimisation
Dr Peter Budden CCG GP Clinical Lead Medicines Optimisation
Appendix 1: Prescribing and outcomes in the clinical areas of Stroke, COPD and Diabetes
1. Anticoagulation prescribing vs stroke non elective admissions
The chart below show s the w eighted number of Stroke Non-elective admissions per CCG over the last 12 months, against the prescribing cost per patient on the QOF Atrial Fibrillation register. (Data from May 2019 to Apr 2020 inclusive and is GP practices only, it does not include services. QOF data from 2018/19) Weighting calculations are: - Total Stroke Non-elective admissions over the last 12 months divided by Atrial Fibrillation register size (2018/19) (ICD10 Codes I60 - I69 [Primary Diagnosis Only]). - Total Stroke prescribing costs over the last 12 months divided by Atrial Fibrillation register size (2018/19) (Edoxaban, Dabigatran Etexilate (110 & 150mg), Rivaroxaban (15 & 20mg), Apixaban, Warfarin Sodium).
This report includes those strengths of NOACs which have a marketing authorisation for prevention of stroke in adults with non-valvular atrial fibrillation (NVAF) The bottom left quadrant is low cost low admissions The top right quadrant is high cost high admissions The centre point is the Greater Manchester average The size of the circle represents the absolute number of admissions (relative to its peers)
High Prescribing, Low High Prescribing, High Admissions Admissions Summary: Inefficient prescribing Summary: Good patient and possible patient harms outcomes, but at high Action: Validate practice register, prescribing cost high prescribing not reducing Action: Improve prescribing admissions – prioritising patient efficiency reviews required
Low Prescribing, High Admissions Summary: Possible under- Low Prescribing, Low treatment and possible patient Admissions harms Summary: Best practice care Action: Validate practice register, Action: Maintain, share low prescribing with higher best practice with peers admissions than expected – targeted patient reviews required
2. COPD non elective admissions vs prescribing costs per patients on the QOF register
The chart below show s the w eighted number of COPD Non-elective admissions per CCG over the last 12 months, against the prescribing cost per patient on the QOF COPD register. (Data from May 2019 to Apr 2020 inclusive and is GP practices only, it does not include services. QOF data from 2018/19) Weighting calculations are: - Total COPD Non-elective admissions over the last 12 months divided by COPD register size (2018/19) (ICD10 Codes J20,J41,J42X,J43,J44,J47X [Primary Diagnosis Only]). - Total COPD prescribing costs over the last 12 months divided by COPD register size (2018/19) (BNF Sections 3.1 and 3.2).
The bottom left quadrant is low cost low admissions The top right quadrant is high cost high admissions The centre point is the Greater Manchester average The size of the circle represents the absolute number of admissions (relative to its peers)
High Prescribing, Low High Prescribing, High Admissions Admissions Summary: Inefficient prescribing and Summary: Good patient possible patient harms outcomes, but at high Action: Validate practice register, high prescribing cost prescribing not reducing admissions – Action: Improve prioritising patient reviews required prescribing efficiency
Low Prescribing, High Admissions Low Prescribing, Low Summary: Possible under-treatment Admissions and possible patient harms Summary: Best practice Action: Validate practice register, low care prescribing with higher admissions Action: Maintain, share than expected – targeted patient best practice with peers reviews required
3. Weighted number of diabetes admissions per prescribing costs per patients on diabetes QOF register
The chart below show s the w eighted number of Diabetes Mellitus admissions per CCG over the last 12 months, against the prescribing cost per patient on the QOF Diabetes register. (Data from May 2019 to Apr 2020 inclusive and is GP practices only, it does not include services. QOF data from 2018/19)
The bottom left quadrant is low cost low admissions The top right quadrant is high cost high admissions The centre point is the Greater Manchester average The size of the circle represents the absolute number of admissions (relative to its peers)
High Prescribing, Low High Prescribing, High Admissions Admissions Summary: Inefficient prescribing Summary: Good patient and possible patient harms outcomes, but at high Action: Validate practice register, prescribing cost high prescribing not reducing Action: Improve prescribing admissions – prioritising patient efficiency reviews required
Low Prescribing, High Admissions Summary: Possible under- Low Prescribing, Low treatment and possible patient Admissions harms Summary: Best practice care Action: Validate practice register, Action: Maintain, share low prescribing with higher best practice with peers admissions than expected – targeted patient reviews required
Appendix 2 CCG developed Medicines Optimisation care home audit tool
pp p g y ( pp ) T2 - Receipt, storage and 2.01 All medication storage areas are locked upon arrival. Fully met 100% disposal of medicines 2.02 All medicines are stored within a locked cupboard or trolley when not in use. Fully met 100% 2.03 A copy of all medications ordered/requested is kept at the home Not Observed 0% 2.04 Internal and external medicines kept separate/organised clearly for each resident. Fully met 100% 2.05 All medicines are in date (check cupboard, trolley) Fully met 100% 2.06 Evidence of stock rotation Not met <75% 2.07 Appropriate stock levels - should be no more than a month's supply of medicines Not met <75% 2.08 All stock stored off the floor (including supplements, dressings etc.) Fully met 100% 2.09 All medicines are labelled for individual residents Partial 75% 2.10 Items are labelled on the container as well as the outer box e.g. inhalers, eye drops, creams... Not met <75% 2.11 Date of opening written on bottled medicines e.g. eye drops, liquids, tablets with a desiccant Not met <75% 2.12 Medicines that are kept in bedrooms or any other communal areas are stored safely and an associated risk assessment has been completed. Not Observed 0% 2.13 Refrigerator is locked upon arrival Fully met 100% 2.14 The temperature of the refrigerator is between 2-8⁰C at the time of audit Fully met 100% 2.15 Fridge temperatures are monitored daily - minimum, maximum and current temperatures must be taken each day. Partial 75% 2.16 If temperature has ever gone out of range evidence that appropriate action has been taken by staff. Not Observed 0% 2.17 Medicines requiring refrigeration are stored appropriately and the refrigerator is clean, dry and with no ice build-up. Fully met 100% 2.18 Medicines returned to pharmacy/waste disposal company are recorded and disposed of correctly. Partial 75% 2.19 Medicines awaiting disposal are kept separate from current medicines Fully met 100% T3 - Handling of high- 3.01 Controlled drugs (including those provided in a MDS) are stored in an appropriately locked cupboard. Fully met 100% risk medicines 3.02 There is an individual page in the register for each resident and their controlled drug. Fully met 100% 3.03 The record of administration includes date and time of medication. Fully met 100% 3.04 The record of administration includes dosage and route of medication. Fully met 100% 3.05 The record of administration includes the remaining stock balance. Fully met 100% 3.06 The record of administration includes signatures of two responsible staff members (one as a witness). Fully met 100% 3.07 The actual stock of controlled drugs tallies with the amount recorded in the controlled drug register. Fully met 100% 3.09 Controlled drugs are being disposed of, according to current controlled drug regulations/ procedure. Not Observed 0% 3.10 If Warfarin is being administered are directions clear? Fully met 100% 3.11 Parkinson’s medicines have specific timings listed on medication records and are administered at these times. Not Observed 0% 3.12 Alendronic acid is being given pre-breakfast with appropriate time interval. Not met <75% T4 - Observations 4.01 Is the drug round completed in a reasonable time, giving enough time between doses? Partial 75% 4.03 A drink is being offered with medicines. Fully met 100% 4.04 Clean medication pots (or equivalent) are used to supply medicines to resident. Fully met 100% 4.05 Medicine label checked against medication records. Fully met 100% 4.06 Swallowing of medicines is witnessed (if necessary) before administering medicines to the next resident. Not Observed 0% 4.07 Medication records are signed immediately following administration. Not met <75% 4.11 Liquid medicines are measured and administered accurately. Not Observed 0% 4.14 Drug trolley never left open and unattended during medication round. Fully met 100% 4.15 Do not disturb tabard (or other measure to minimise risk of distraction) used during medication round. Not met <75% 4.17 Refused does are being managed and recorded correctly. Not met <75% 4.18 Covert medicines policies and procedures are in place, signed and up-to date. Not Observed 0% 4.19 Minimal interruptions during medication round. Not met <75% 4.20 All staff handling medication have undertaken the correct training and competency skills reviewed annually in line with mandatory training Fully met 100% T5 - Administration of 5.01 Is there written consent from the resident who self-administers their medication? ( As part of the consent process, residents agree to store medicines Not Observed 0% medication by a person 5.02 Are self-administered medicines being stored appropriately? Not Observed 0% other than care staff 5.03 Is a risk assessment in place for the self-administration of medication? Not Observed 0% 5.04 Is the risk assessment being repeated based on individual needs? Not Observed 0% 5.05 Is a record maintained in accordance with legal & organisational requirements of disposal of self-administered medication? Not Observed 0% 5.06 Does the care plan indicate the resident’s wishes to self-administer and make it clear whether the person needs support? Not Observed 0% 5.07 The MAR chart states that the resident is self-administering Not Observed 0% T6 - Oxygen 6.01 Does the home have a policy/ risk assesment in place for specific users requring oxygen therapy Not Observed 0% 6.02 Are appropriate hazard/ warning notices displayed? Not Observed 0% 6.03 Staff are aware that certain cream/ lotions as well as alcohol rub are not used in close prioximity of patients on oxygen. Not Observed 0% 6.04 If oxygen is used by the home is it stored upright, and securely Not Observed 0%
GOVERNING BODY MEETING PART 1
AGENDA ITEM NO: 5g
Item for Decision/Assurance/Information (Please underline and bold)
30 September 2020
Report of: Chief Accountable Officer
Date of Paper: 18 September 2020
Subject: LeDeR Annual Report (2019/20)
In case of query Elizabeth Walton, Designated Nurse Please contact: Safeguarding Adults
Please tick which strategic priorities the paper relates to: Strategic Priorities:
√ Quality, Safety, Innovation and Research Integrated Community Care Services (Adult Services) √ Children’s and Maternity Services √ Primary Care Enabling Transformation Purpose of Paper:
This paper provides NHS Salford CCG Governing Body with the 2019/20 Learning Disability Mortality Review (LeDeR) Annual Report.
It confirms that the CCG is fulfilling its responsibilities in respect of LeDeR. The report provides an overview of the key outcomes and findings from LeDeR reviews in Salford during the identified period.
In addition, the report provides assurance that the LeDeR process has been successfully embedded within Salford and that completion of reviews in a timely manner has led to improvements in service delivery for individuals with a learning disability in Salford.
Further explanatory information required
HOW WILL THIS BENEFIT THE The CCG Governing Body will have an HEALTH AND WELL BEING OF increased awareness of the key SALFORD RESIDENTS OR THE achievements and outcomes of LeDeR in CLINICAL COMMISSIONING Salford. GROUP?
None WHAT RISKS MAY ARISE AS A RESULT OF THIS PAPER? HOW CAN THEY BE MITIGATED?
None WHAT EQUALITY-RELATED RISKS MAY ARISE AS A RESULT OF THIS PAPER? HOW WILL THESE BE MITIGATED?
No DOES THIS PAPER HELP ADDRESS ANY EXISTING HIGH OR EXTREME RISKS FACING THE ORGANISATION? IF SO WHAT ARE THEY AND HOW DOES THIS PAPER REDUCE THEM?
None PLEASE DESCRIBE ANY POSSIBLE CONFLICTS OF INTEREST ASSOCIATED WITH THIS PAPER.
None PLEASE IDENTIFY ANY CURRENT SERVICES OR ROLES THAT MAY BE AFFECTED BY ISSUES WITHIN THIS PAPER:
Footnote:
Members of this Committee will read all papers thoroughly. Once papers are distributed no amendments are possible.
Document Development
Not Comments and Date Process Yes No Outcome Applicable (i.e. presentation, verbal, actual report) Public Engagement (Please detail the method i.e. survey, event, consultation) Clinical Engagement (Please detail the method i.e. survey, event, consultation) Has ‘due regard’ been given to Social Value and the impacts on the Salford socially, economically and environmentally? (Please detail outcomes, including risks and how these will be managed Has ‘due regard’ been given to Equality Analysis (EA) of any adverse impacts? (Please detail outcomes, including risks and how these will be managed) Legal Advice Sought
Presented to any informal groups or committees (including partnership groups) for engagement or other formal governance groups for comments / approval? (Please specify in comments)
Note: Please ensure that it is clear in the comments and date column how and when particular stakeholders were involved in this work and ensure there is clarity in the outcome column showing what the key message or decision was from that group and whether amendments were requested about a particular part of the work. 3
Learning Disabilities Mortality Review (LeDeR) Programme
1. Executive Summary
The 2019-20 LeDeR annual report has been prepared for NHS Salford Clinical Commissioning Group (SCCG) Governing Body and provides an overview of the key developments, progress, achievements and challenges in respect of learning from deaths in Salford.
This report is the first annual report on the learning from deaths of those with learning disabilities within Salford. The report covers the period from April 2019 up until the end of March 2020. Previous reporting has been included within the CCG Safeguarding Adults Annual Reports.
SCCG has continued to demonstrate commitment to LeDeR during 2019-20 and continues to work across the integrated network.
2. Background
2.1 Salford CCG is part of the national LeDeR programme, commissioned by the Health Quality Improvement Partnership on behalf of NHS England (NHSE) and led by Bristol University. The LeDeR programme was established as a result of the Confidential Inquiry into Premature Deaths of People with a Learning Disability 2003, which found that people with learning disabilities are four times as likely to die of preventable causes compared with the general population.
2.2 The LeDeR Programme aims to help us reduce premature mortality and health inequalities for people with learning disabilities in England through local reviews of deaths of people with learning disabilities. Reviews are conducted on those aged 4 years and above and enable us to identify positive areas of practice as well as highlighting areas for further improvement.
2.3 The CCG have provided a Local Area Coordinator (LAC) and deputy LAC within the Safeguarding Team to facilitate development of this programme. Salford CCG’s LAC also fulfils the role of Designated Nurse for Safeguarding Adults and is a member of the Greater Manchester LAC Network with links to the Regional and National Leads to ensure learning from reviews can be appropriately shared.
2.4 Salford CCG worked with Salford Royal Foundation Trust, SRFT (Adult Social Care, ASC) to identify key reviewers within the Community Learning Disability Team to utilise specialist knowledge of learning disabilities to complete reviews. In addition to this, a series of ‘buddy reviewers’ were trained to support main reviewers to add independence and additional expert knowledge. Our buddy reviewers are from a variety of backgrounds including, Continuing Health Care Nurses, Care Homes Managers and GPs with specialist interest.
2.5 NHSE and NHS Improvement (NHSI) commissioned a review of the alignment of the LeDeR process with other statutory processes (e.g. coroners’ inquests and safeguarding investigations), to inform guidance for CCGs and providers. Incorporating the LeDeR processes within the CCG Safeguarding Team has ensured that there is
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connectivity with all local statutory arrangements including Child Death Overview Panels (CDOP).
2.6 CCGs received additional support from NHSE and NHSI following a £5 million investment identified to address historical backlog cases which were over 12 months old. The money was also identified to improve the quality of reviews and the consistency of the application of the methodology. During 2019, Salford CCG received funding to provide additional administrative support to support completion of reviews.
3. LeDeR Governance arrangements
3.1 The diagram below demonstrates the local governance arrangements for LeDeR across Salford.
Salford LeDeR Steering Group
LD and Autism Strategy Board
Salford Safeguarding Adult Commissioning Salford Safeguarding Adult Board Committee Children’s Partnership
3.2 The local LeDeR Steering Group is chaired by the LAC and includes membership from:
• Designated Nurse for Safeguarding Adults, Salford NHS CCG • Clinical Lead for Mental Health and Learning Disability, Salford NHS CCG • Representatives from Continuing Health Care, Salford NHS CCG • Integrated Commissioning Manager (Learning Disabilities and Autism), Salford NHS CCG • Representatives from the Joint Adult Learning Disability Team, SRFT • ICU Consultant and Mortality Lead, SRFT • Nursing Home Manager • Lead Nurse for Learning Disabilities and Autism, NMGH • Swan Bereavement Nurse and Trainer for Children and Families, SRFT • MCA/DoLS Team Manager, Salford City Council • Engagement and Development Worker, Salford NHS CCG • Practice Manager, Salford Care Homes Practice
3.3 This steering group reviews all completed LeDeR reviews and identifies any themes / trends and develops actions to be included within the Salford LeDeR action plan. This
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action plan is then monitored by the Learning Disability (LD) and Autism Strategy Board.
3.4 In addition to the annual report, updates on LeDeR are reported within the CCG quarterly via the Safeguarding Report and updates are provided to the Safeguarding Adults Board and Children’s Safeguarding Partnership.
3.5 The LAC also sits on the SRFT Mortality Review Group meetings to ensure that feedback from reviews is shared across the wider system.
4. LEDER Review Process
4.1 The following diagram outlines the current quality assurance pathway in place for LeDeR reviews in Salford.
4.2 To ensure a level of independence to completed reviews, all reviews are submitted to the Serious Incident Panel which has both clinical and non-clinical representation to enable a rounded view on the final documents. This also means that themes and trends can be cross referenced across Salford’s Health system.
Engaging with people and their families
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4.3 Inclusion of the person’s family and friends is a significantly important part of the pathway and all attempts are made, where appropriate, to include families and friends within the LeDeR journey. The following is an example of the benefit of LeDeR reviews to families/ carers of those with a learning disability via the Salford LeDeR reviewer.
‘Following the review of a lady who had lived in an adult placement for around 7 years, the ladies carers commented that they had felt nervous and unsure about taking part in the LeDeR Review. However, by talking about Miss X as part of the review it had ‘’brought her back to us’’, which they had taken great comfort in. During the review myself and the carers spent much time talking about her as a person, her interests, personality traits, reminiscing on her old holidays and looking through photographs which helped to gain a greater picture of Miss X as a person within the final review’
4.4 Some ways in which we have engaged with and on behalf of Salford people with learning disabilities in respect of LeDeR are outlined below:
• A Salford representative sits on the North West Confirm and Challenge Group. This group contributed to the development of LD and Autism training programs to support prevention of avoidable deaths. • Three Salford representatives (people with learning disabilities, Autism or both) sit on the Greater Manchester (GM) Confirm and Challenge Group. In October 2019, this group reviewed progress against the GM LD Plan and progress towards goals set around LeDeR. • The North West ‘Being Safe’ Group (with two Salford representatives) contributed to development of a letter being sent by the National Campaigns Group and received a personal response from Simon Stevens (CEO of NHS England). • The National Campaigns group which is represented by two Salford people with LD and Autism or both, discussed the National LeDeR Annual Report and were able to contribute to developing a letter to raise concerns in respect of DNAR’s (Do not Attempt Resuscitation orders). • Salford’s ‘Listening to People’ Group (represented by 20 Salford people) and meets monthly. Areas relating to LeDeR which have been discussed include, what they felt GP’s needed to know, ideas on the best ways to respond to a bereaved family following learning from a review (condolence card design) and received information regarding updates on LeDeR and STOMP following the LD and Autism Strategy Board. • During Salford’s Big Health Day (an information and educational event for people with a learning disability aged 14 years plus) where 128 Salford people attended, a stall for LeDeR was included. Feedback from support workers was that they felt they would now take on board the information taken from LeDeR and work to ensure people have health checks and ask GPs to use available communication packs to improve communication between them and the people they are supporting. • The Salford LD information Facebook page has been utilised to share relevant messages around LeDeR.
5. Confidentiality and Data Sharing
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5.1 The National LeDeR Programme applied to the national Confidential Advisory Group (CAG) for Section 251 (of the NHS Act 2006) approval for the use of patient identifiable information, in order that reviews can be undertaken of the deaths of people with learning disabilities.
5.2 The programme has been given full approval to process patient identifiable information without consent. Specifically, this provides assurance for health and social care staff that the work of the LeDeR Programme has been scrutinised by the national CAG. The CAG is appointed by the Health Research Authority to provide expert advice on uses of data as set out in the legislation and advises the Secretary of State for Health whether applications to process confidential patient information without consent should or should not be approved. The key purpose of the CAG is to protect and promote the interests of patients and the public whilst at the same time facilitating appropriate use of confidential patient information for purposes beyond direct patient care. More information about Section 251 approval is available at: www.hra.nhs.uk/about-the- hra/our-committees/section-251/what-is-section-251/
5.3 There have been no issues in relation to sharing of information within Salford during the completion of LeDeR reviews.
6. Child Death Overview Panel (CDOP)
6.1 There has been a statutory requirement for Local Safeguarding Children Partnerships to review child deaths since 2008. The regulations are outlined in The Children Act 2004, Working Together to Safeguard Children and the Child Death Overview Panel (CDOP) statutory and operational guidance. The introduction of The Children and Social Work Act 2017 resulted in significant changes to the child death review process with statutory responsibility for these arrangements moving to the Local Authority and the CCG where the child resides.
6.2 The purpose of the child death review process is to collect and analyse information about the death of each child who normally resides in Salford with a view to identifying any matters of concern or risk, modifiable factors affecting the health, safety or welfare of children, or any wider public health concerns. The new statutory guidance emphasises the need to recognise additional factors associated with certain conditions such as learning disability. As such, CDOPs are well placed to review these types of deaths and are therefore advised to follow the child death review process rather than the LeDeR review for these cases.
6.3 All referrals for children referred into LeDeR are currently managed within the CDOP process. The Designated Nurse for Children’s Safeguarding has oversight of these reviews on behalf of the CCG.
7. Salford Activity
7.1 The following outlines the activity relating to LeDeR during the period of 2019/20 only.
7.2 During this period, Salford CCG completed 19 reviews. The table below outlines the cases received and details of rejected referrals.
REFERRAL DATA 2019-20
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Number of LeDeR Referrals Received 19 Number of LeDeR Referrals progressed to 17 Initial or Multi-Agency Review 2 Both cases were confirmed as not having a learning disability. One of the cases was referred to the Number of LeDeR Referrals Rejected Local Authority Safeguarding Serious Adult Review (SAR) Panel for further enquiries but did not meet the requirement for a SAR. Number of LeDeR referrals which were 0 already going through Safeguarding Process Number of LeDeR referrals which also heard 1 at Coroners in 2019-20
7.3 Cases are only rejected from the review process where there is clear confirmation from health and/or social care records and agreement sought from the NHSE Regional Lead. 7.4 Where it is apparent that a safeguarding investigation is underway, the reviewer will be included within the safeguarding meetings to ensure consistency of information sharing and accuracy within the review.
7.5 As of March 2020, Salford CCG was in the top two GM CCGs for highest completion of reviews.
Characteristics
7.6 The National LeDeR Annual Report (2018) highlighted that a quarter (25%) of people from Black, Asian and Minority Ethnic (BAME) groups had profound and multiple learning disabilities, which was twice the proportion (11%) of white British ethnicity. Of the 607 service users currently receiving a service in Salford, 595 have their ethnicity recorded and this represents 4% being within a BAME group in Salford, 100% of the LeDeR cases referred to date identified as White British.
7.7 The chart below highlights the gender ratio of referrals to LeDeR in Salford:
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7.8 The last published National LeDeR Annual Report presents a similar picture with 6 out of 10 cases being male.
7.9 During 2019/20, the average age of death of those referred into Salford was 58 years old (Females 60 years and Males 57years) and this is consistent with the National average (Overall 59 years, Females 59 years and Males 60 years). The disparity from the general population is therefore, 23 years for males and 23 years for females in Salford.
7.10 The chart and table below show the breakdown of age group referred into the LeDeR program in Salford. Age of LeDeR Cases 2019-20
3 5
Under 45 46 – 65 Over 65
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Under 45 3 reviews 46 – 65 9 reviews Over 65 5 reviews
Place of Death
7.11 This table outlines the place of death for all Salford LeDeR reviews in 2019/20: 10
Salford Royal Hospital 13 North Manchester General Hospital 2 St. Ann’s Hospice 2
7.12 It appears that in Salford that a large number of our LD population’s place of death is within acute trust setting rather than within their usual place of residence. This is an area identified for further focus by the LeDeR Steering Group in 20/21.
Grading of Care
7.13 On completion of reviews, reviewers are asked to provide an overall assessment of the care provided to the individual and provide a grade. This grade is then reviewed and confirmed at the CCG Serious Incident Panel. The table below shows the grading of care and the LeDeR Reviewers’ overall assessment of the care received in 2019/20:
1. This was excellent care (it exceeded expected good practice). 0 2. Good (It met expected practice) 11 3. Satisfactory (it fell short of expected good practice in some 3 areas but did not significantly impact on the persons wellbeing) 4. Care fell short of expected good practice and this did impact 2 on the person’s wellbeing but did not contribute to the cause of death 5. Care fell short of expected good practice and this 0 significantly impacted on the person’s wellbeing and/or had the potential to contribute to the cause of death. 6. Care fell far short of expected good practice and this 0 contributed to the cause of death. Case not yet signed off and therefore not graded 1 7.14 The key issues raised in the cases which did not meet the expected standard of care related to, delayed access to services following a failed attendance and application of the Mental Capacity Act (MCA).
7.15 As a result, and on recruitment of an LD Lead working across SRFT, significant training around the MCA including onsite support and development of a non- concordant policy. Throughout 2020 we have already highlighted improvements with the application of the MCA within more recent reviews.
Causes of death 11
7.16 Data within the National LeDeR Annual Report (2019) suggests that the most significant cause of death for those with a Learning Disability is from respiratory type diseases such as pneumonia. The table below outlines the cause of death (Part 1A of death certification) for all Salford reviews:
Cause of death (Part 1A death No. of individuals certification) Pneumonia 4 (24% of all Salford’s cases) Renal Failure 1 Community Acquired Pneumonia 1 Hypoxic Brain Injury 1 Cardiac Arrest 1 Sepsis 1 Hip wound infection and Osteomyelitis 1 Biventricular Cardiac Failure 1 Lung Cancer 1 Respiratory Infection 1 Epilepsy 1 COVID-19 2
7.17 Although individuals with a Learning Disability are more likely than the general population to have other conditions that increase their risk of respiratory infection, including epilepsy, this notable percentage has been identified as an area for further consideration via the LeDeR Steering Group for 20/21.
Covid related deaths
7.18 During the reporting period, there were 2 deaths where the primary cause of death was COVID – 19 in March 2020. Both of these cases were reviewed and received a grading of ‘Good’ for standard of care.
7.19 All COVID-19 deaths of those with a learning disability were initially put through a rapid review process to ensure that any learning could be highlighted immediately. Rapid reviews were completed by the community learning disabilities team and full reviews of each case completed by the LeDeR reviewer.
8. Themes Identified from Reviews
8.1 Each case presented to the LeDeR Steering Group covers four key areas.
1. Background – Detail about the person. What were there likes/ dislikes/ diagnosis 2. Events leading up to death – Provides key information outlining services involvement in the care journey 3. What went well – Outlines areas of good practice for dissemination and for monitoring improvements 4. Areas for development – Used to establish relevant actions for individual agencies as well as themes and trends.
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8.2 On review of the 2019/20 LeDeR reviews in addition to historical back log case reviews, the following table highlights the key theme areas for Salford. Detail of actions taken to date will be covered later in the report.
Overarching Theme Details Discharge Planning • Issues relating to the effectiveness of handover – acute to community and vice versus – assessment pre discharge or EOL care • Inclusion of reasonable adjustments • Issues relating to discharge planning meetings Communication/ Inclusion/ • Lack of awareness of specific health co Development –Primary Care morbidities in LD (including screening/ reasonable • Quality of referral letters for pts with a LD adjustments • Accessibility of screening – reasonable adjustments • Maintenance of LD register • Quality of annual health checks • Dementia screening Dementia • Ongoing review of dementia screening • Monitoring and ongoing assessment of those with dementia/ at risk of dementia (predominantly Downs Syndrome) Mental Capacity • Role of the IMCA • Application of the Act • Use of reasonable adjustments as part of assessment of capacity.
9. Greater Manchester (GM) Learning Disability Strategy Implementation - Putting learning into action.
9.1 As part of the Learning Disability Strategy Implementation, each locality has now submitted their draft delivery plan and ‘Good Health’ is one of the 10 priorities within the Strategy. The table below highlights some of the areas of the good health strategy and work streams underway in Salford:
Health Strategy Component Salford Workstream Consistent and quality annual health • Development of Electronic Annual checks for everyone with a learning Health Check due to be launched disability aged 14yrs+. • Primary Care Innovation Project Learning Disability Mortality Reviews • LAC within the CCG (LeDeR) carried out and findings used to • LeDeR Steering Group Established improve services to positively impact on • LeDeR Governance arrangements in the health of people with a learning place disability, and prevent premature deaths. • Primary Care Innovation Project • LD Lead recruited across the Northern Care Alliance to cover SRFT. Improve access to mainstream health • SRFT (including ASC and linking to 13
services, , including mental health the Primary Care Innovation Project) services, developing reasonably adjusted are developing pathways, such as health and social care pathways and auditory service, pathway for taking services bloods (including opportunity to purchase tickleflex/Buzzy for practices to improve access)
STOMP - reduce the use of anti- • STOMP pilot completed within psychotropic medication Primary care to review psychotropic medications. Improve cancer services and experiences • Primary Care Innovation Project - for people with Learning Disabilities and additional workstreams are currently improve the uptake of the national cancer being considered by the LeDeR screening programmes. Steering Group.
9.2 These plans will be monitored quarterly via the GM Learning Disability Delivery Group and will also provide an assurance to the wider system that as GM, we are delivering on our commitments. The plans will be scrutinized by the Confirm and Challenge Group on a regular basis. All ten of the GM localities are part of a collaborative process whereby colleagues leading on different priorities share and learn from each and actively identify an opportunity to work together on certain priority areas.
9.3 The work of the GM Health Inequalities Working Group is one of the mechanisms to provide GM solutions to problems and challenges identified in individual localities. Within Salford the LD and Autism Strategy Board have oversight of this plan.
Primary Care Innovation Bid (18 month project)
9.4 Salford were successful in securing NHSE funding alongside innovation funding to address the learning from LeDeR reviews in relation to Primary Care with an overall aim to reduce health inequalities within this population. This project runs throughout 2019/20.
9.5 The project sets out to provide improved liaison between the community LD Service and GP practices in Salford with the aim to:
• Update and maintain accurate LD registers across the Salford Care Organisation • Increase uptake and the quality and consistency of Annual Health Checks • Increase uptake of cancer screening programmes with additional support from the Community Learning Disability Team (CLDT) to enable reasonable adjustments and prevent unnecessary failed appointments. • Support a reduction of non-attended appointments. • Additional support from the CLDT to improve the quality of mental capacity assessments within Primary Care. • Increased awareness of health inequalities through delivery of LD Awareness Training throughout Primary Care.
9.6 This is in addition to an additional innovation supporting delivery of autism awareness training via Salford Autism. This will be face to face training delivered by autistic adults. The offer is extended to staff across organisations; Primary care, CCG, SRFT, the City Council and GMMH and will provide sustainable links into Primary care to ensure that once systems are put in place, they continue following the initial project. 14
Stopping Over-Medication of People with Learning Disabilities (STOMP)
9.7 Throughout 2019/20 work continued on the national programme STOMP. An implementation group came together to deliver the specific actions for general practice to review these patients identified via the Medicines Optimisation Team.
9.8 During 2019/2020, access to GM funding has been secured and a specialist mental health pharmacist from Greater Manchester Mental Health (GMMH) has been facilitating reviews for Salford patients.
Dementia Screening Pathway
9.9 Following outcomes of LeDeR reviews, there is currently a review of the Dementia Pathway within the Community LD Team. This will enable us to bring this in line with good practice for re-assessment of people with LD who are at higher risk of dementia and aims to introduce an automatic reassessment process leading to earlier recognition and improved management of Salford people with a LD.
Card of Condolence
9.10 Following a completed review which highlighted that a parent felt particularly disappointed that the local LD Community Team had not acknowledged her daughter’s death with a card of condolence, the LeDeR Steering Group worked with this young woman’s family and engaged with local service user and community groups to design a bespoke bereavement card. This was launched Nationally in Adult Safeguarding Awareness week and is being utilised by other CCG areas across the country. The following account has been provided from the mother of the young lady sadly passed away:
‘’Following the death of our daughter Nicole, taking part in the LeDeR process was our way to inform how we felt about the services she had received. We felt like she had been part of a ‘case load’ and now it was ‘case closed’. It was as if she hadn’t mattered.
Further discussions were had and the idea of the bereavement card was born. Being included in the design decisions as well as the wording made it a cathartic experience. We absolutely love the finished design and hope it helps families who have lost a person with a disability feel as though that person’s life is acknowledged’’.
9.11 The final design which was shared nationally can be seen below.
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Family Bereavement Support
9.12 As part of the LeDeR review process, Nicole’s mum also shared and explored her wishes to develop a bereavement support group for parents of people with a learning disability. During conversation she explained that the loss of a loved one with a learning disability is a unique experience and one that involves many forms of loss including role, function, routine and often the main purpose of that parent/carer’s life. As such, she felt that a unique response was required. The CCG has provided some support and advice in terms of setting up the group and advertisement. It is hoped that bereaved families can be sign posted to the group as part of the LeDeR review process in the future.
10. Next Steps in Salford
• Continue to support delivery of the requirements set out for health within the Learning Disability Strategy relating to LeDeR. • Deliver the outcomes set out within the Primary Care Innovation Bid and promote an increased awareness of LD across the Salford system. • Further develop the mechanisms for strengthening learning and understanding of data from LeDeR reviews to improve our local service offers for those with an LD including exploration surrounding the highest known causes of death. • Continue to share key learning from reviews across Salford. • Strengthening arrangements for monitoring the LeDeR action plans within the LD and Autism Strategy Board. • Maintain progress around completion of LeDeR reviews.
11. Summary
11.1 Salford has embraced the LeDeR programme and embedded robust processes to ensure that it is integrated into our systems for identification of learning and improvement.
11.2 Since the introduction of LeDeR in Salford, we have seen a significant improvement in the awareness of LD and have begun to make real improvements to the way services support our people with a LD, Autism or both.
11.3 Salford remains focused on highlighting both the positive developments achieved through LeDeR as well as being committed to identifying and resolving the inequalities
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which are highlighted through our reviews. More importantly, we want to achieve this through listening to the voice of our people with LD’s.
12. Recommendations
12.1 The Governing Body is asked to:
• Receive assurance that the LeDeR process has led to improvements in service delivery for individuals with a learning disability in Salford • Note the contents of this report and in particular the timely completion of reviews under the current pressures. • Recognise the commitment from all Agencies in Salford to drive this agenda and seek to improve services.
E. Walton Designated Nurse Safeguarding Adults / LAC for LeDeR
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GOVERNING BODY MEETING PART 1
AGENDA ITEM NO: 5h
Item for Decision/Assurance/Information (Please underline and bold)
30 September 2020
Report of: Steve Dixon Chief Accountable Officer
Date of Paper: 17 September 2020
Subject: Annual Workforce Profile Data Report and Action Plan In case of query Lindsay Kirby Please contact: Senior Communications and Inclusion Manager Strategic Priorities: Please tick which strategic priorities the paper relates to:
Quality, Safety, Innovation and Research Integrated Community Care Services (Adult Services) Children’s and Maternity Services Primary Care √ Enabling Transformation Purpose of Paper:
To present the Annual Workforce Profile Data Report and Action Plan for approval by Governing Body prior to publishing.
Further explanatory information required
The benefits of establishing and maintaining a HOW WILL THIS BENEFIT THE diverse workforce are well understood. Teams HEALTH AND WELL BEING OF are more innovative and creative and, SALFORD RESIDENTS OR THE specifically important to the NHS, it is found that CLINICAL COMMISSIONING patients have better experiences of care when GROUP? the workforce mirrors the patient population and has a better understanding of patients’ needs.
WHAT RISKS MAY ARISE AS A None RESULT OF THIS PAPER? HOW CAN THEY BE MITIGATED?
WHAT EQUALITY-RELATED RISKS None MAY ARISE AS A RESULT OF THIS PAPER? HOW WILL THESE BE MITIGATED?
DOES THIS PAPER HELP ADDRESS None ANY EXISTING HIGH OR EXTREME RISKS FACING THE ORGANISATION? IF SO WHAT ARE THEY AND HOW DOES THIS PAPER REDUCE THEM?
PLEASE DESCRIBE ANY POSSIBLE None CONFLICTS OF INTEREST ASSOCIATED WITH THIS PAPER.
PLEASE IDENTIFY ANY CURRENT None SERVICES OR ROLES THAT MAY BE AFFECTED BY ISSUES WITHIN THIS PAPER:
Footnote:
Members of this Committee will read all papers thoroughly. Once papers are distributed no amendments are possible.
Document Development
Not Comments and Date Process Yes No Outcome Applicable (i.e. presentation, verbal, actual report) Public Engagement (Please detail the method i.e. survey, event, consultation) Clinical Engagement The draft report and action plan Feedback incorporated (Please detail the method i.e. survey, event, has been shared with clinical into final report. consultation) members of EIMG Has ‘due regard’ been given to Social Value and the impacts on the Salford socially, economically and environmentally? (Please detail outcomes, including risks and how these will be managed Has ‘due regard’ been given to Equality Analysis (EA) of any adverse impacts? (Please detail outcomes, including risks and how these will be managed)
Legal Advice Sought
The action plan has been drafted Feedback incorporated Presented to any informal groups or in liaison with the CCG’s Personal, into final report. committees (including partnership groups) for Fair and Diverse (PFD) engagement or other formal governance Champions. The draft report and groups for comments / approval? action plan has been presented to (Please specify in comments) EIMG.
Note: Please ensure that it is clear in the comments and date column how and when particular stakeholders were involved in this work and ensure there is clarity in the outcome column showing what the key message or decision was from that group and whether amendments were requested about a particular part of the work.
Workforce Profile Data Report and Action Plan 2019/20
1. Executive Summary
This paper presents the Annual Workforce Profile Data Report and Action Plan 2019/20 for approval by Governing Body.
2. Background
2.1 The purpose of this report is to provide information on how Salford CCG met its legal and mandated duties in its functions with regards to diversity and inclusion over the time period 1 April 2019 – 31 March 2020.
2.2 Under the Equality Act 2010 all public sector organisations have a duty to publish information relating to employees with protected characteristics. Appendix A is the Workforce Profile Data Report 2019/20. The data within this report provides the CCG with an opportunity to review its practices and ensure that all employees are provided equal opportunities.
2.3 Appendix B is the Workforce Diversity and Inclusion Action Plan. This includes the actions resulting from the CCG’s Workforce Race Equality Standard (WRES) 2020, which was approved by Governing Body in July. The NHS Workforce Race Equality Standard (WRES) is in place to ensure employees from Black, Asian and Ethnic Minority (BAME) backgrounds have equal access to career opportunities and receive fair treatment in the workplace and we are required to publish an approved WRES Action Plan by 31 October 2020.
2.4 Instead of publishing a separate WRES action plan, the Workforce Diversity and Inclusion Action Plan incorporates the work needed to be done to support all protected characteristics amongst our workforce. The action plan has been drafted in liaison with our Personal, Fair and Diverse (PFD) Champions.
3. Recommendations
3.1 The Governing Body is asked to:
• note the contents of the report and action plan. • approve the publication of this report and action plan onto the CCG website.
Lindsay Kirby Senior Communications and Inclusion Manager
Our workforce 2019/20
Publication of information under the Equality Act 2010
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Contents
Introduction ...... 3 Workforce composition ...... 3 Age ...... 3 Ethnicity ...... 5 Gender ...... 6 Disability...... 7 Sexual orientation ...... 7 Marital status and civil partnership ...... 7 Gender reassignment ...... 7 Religion and belief ...... 8 Non-mandatory training 2019/20 ...... 8 Leavers ...... 8 Recruitment ...... 8 NHS Staff Survey 2019 ...... 9 Conclusions ...... 11
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Introduction
The Equality Act 2010 provides a legal framework to strengthen and advance equality and human rights. The Act brought together all existing equality law - such as the Sex Discrimination Act 1975, Race Relations Act 1976, Equal Pay Act 1970, Disability Discrimination Act 1995 - into one single legislative framework and covers nine protected characteristics:
• Age • Race • Gender • Disability • Marital status and civil partnership • Sexual orientation • Religion or belief • Pregnancy and maternity • Gender reassignment
Everyone has protected characteristics – we all have an age, a race or a sexual orientation, for example – so the Equality Act 2010 is for everyone to ensure they are not discriminated or treated differently because of a protected characteristic.
Under the Equality Act 2010 all public sector organisations have a duty to publish information relating to employees with protected characteristics. This data provides the CCG with an opportunity to review its practices and ensure that all employees are provided equal opportunities.
This report provides an overview of the data collated within the following sections:
• Workforce composition • Non-mandatory training • Recruitment / leavers
Workforce data is drawn from NHS Electronic Staff Records (ESR) as of 31 March 2020 and as such includes information on staff members employed directly by the CCG only on fixed or permanent contracts, not those on secondment to the CCG or in joint roles where the employer is not the CCG. Bank staff are also excluded from the data. Comparative data to the Salford population is taken from the 2011 Census and NHS Employer’s Measuring up: your community and your workforce1 tool.
Throughout the report, partial percentages are rounded to the nearest whole number e.g. 12.8% is rounded up to 13%, while 5.3% rounded down to 5%. Where numbers are small, no data is presented to avoid people be identified.
Workforce composition
The CCG has a total workforce of 152 staff, of which 70% are female and 30% male. As of 31 March 2020, 89% are White with 9% from Black, Asian and Minority Ethnic (BAME) backgrounds.
Our average age is 46 years old, 5% of staff declare having a disability and, in large part as CCGs are led by practicing local clinicians, a high proportion of the workforce (41%) is part-time.
Age
1 https://www.nhsemployers.org/your-workforce/plan/recruiting-from-your-community/measuring-up- your-community-and-your-workforce 3
The average age of both men and women working for Salford CCG is 46 years old. The breakdown by age group is:
Age group Salford CCG % Salford population % Representative Under 20 0% 7% Under 20 – 24 3% 11% Under 25 – 29 5% 12% Under 30 – 44 39% 28% Over 45 – 59 42% 24% Over 60 – 64 10% 7% Over 65+ 1% 10% Under Total 100% 100% N/A
The age breakdown per bands is:
Age group Bands 1 – 4 Bands 5 – 7 Bands 8a+ Non AfC Under 20 0% 0% 0% 0% 20 – 24 28% 0% 0% 0% 25 – 29 6% 10% 0% 0% 30 – 44 17% 37% 55% 30% 45 – 59 33% 48% 36% 44% 60 – 64 11% 5% 9% 22% 65+ 6% 0% 0% 4% Total 100% 100% 100% 100%
The age breakdown of staff working full time compared to part time is:
Age group Full time Part time Under 20 0% 0% 20 – 24 4% 2% 25 – 29 6% 3% 30 – 44 40% 37% 45 – 59 46% 37% 60 – 64 3% 19% 65+ 1% 2% Total 100% 100%
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Ethnicity
Our Workforce Race Equality Standard (WRES) 2020 is available as Appendix 1 and also via www.salfordccg.nhs.uk/about-us/how-we-do-things/publications. The WRES is an annual publication mandated by NHS England for us to demonstrate our progress against nine indicators of staff experience and the differences between White staff and BAME staff. The definitions of BAME and White used in this report and the WRES follow the national reporting requirements of ethnic category in the NHS data model and dictionary and based on 2001 Census categories for ethnicity. ‘White’ staff includes white British, Irish, Eastern European and any ‘other white’. The BAME staff category includes all others except ‘undisclosed.
The overall breakdown by ethnicity is:
Ethnicity Salford CCG % Salford population % Representative White 89% 90% Over BAME 9% 10% Fairly well Undisclosed 1% 0% Over
The ethnicity breakdown per bands is:
Ethnicity Bands 1 – 4 Bands 5 – 7 Bands 8a+ Non AfC White 89% 93% 91% 78% BAME 11% 7% 9% 15% Undisclosed 0% 0% 0% 7% Total 100% 100% 100% 100%
The ethnicity breakdown of staff working full time compared to part time is:
Ethnicity Full time Part time White 90% 89% BAME 10% 8% Undisclosed 0% 3% Total 100% 100%
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Gender
Salford CCG’s workforce is 70% women, 30% men compared to the overall Salford population of 51% women and 49% men.
The gender breakdown per bands is:
Gender Bands 1 – 4 Bands 5 – 7 Bands 8a+ Non AfC Male 11% 20% 30% 63% Female 89% 80% 70% 37% Total 100% 100% 100% 100%
The gender breakdown per employee group is:
Employee group Male Female Total Governing Body 90% 10% 100% Executive Team 50% 50% 100% Senior Managers* 30% 70% 100% Other clinical leads** 42% 58% 100% All other employees 18% 82% 100% *Staff at AfC 8a – 8d when not included in the Executive Team **Clinical leads who do not sit on the Governing Body
The gender breakdown of staff working full time compared to part time is:
Gender Full time Part time Male 30% 29% Female 70% 71% Total 100% 100%
Overall, 60% of men work full time compared to 40% who work part time, while 59% of women work full time and 41% part time.
Changes to the Equality Act, which came into force in April 2017, made it compulsory for companies with more than 250 employees to report their gender pay gap figures at the end of every financial year. The gender pay gap is the difference between the average hourly earnings of a company’s male and female employees.
While Salford CCG’s workforce total is below the mandatory reporting trigger, we still calculate our gender pay gap so we can address any issues it may raise.
When formally reporting gender pay gap figures, organisations are required to publish both mean and median figures. The mean is calculated by adding up all of the wages of employees in a company and dividing that figure by the number of employees. The median is the number that falls in the middle of a range when everyone’s wages are lined up from smallest to largest. The median is typically a more representative figure as the mean can be skewed by a handful of highly paid people.
Our median gender pay gap breaks down as follows: Overall Agenda for Change Non Agenda for Change Men £24.80 £22.40 £79.00 Women £22.40 £20.60 £79.00 % difference 10% 8% 0%
Our mean gender pay gap is: 6
Overall Agenda for Change Non Agenda for Change Men £41.83 £21.58 £75.18 Women £25.51 £21.15 £72.51 % difference 39% 2% 4%
When comparing the Salford CCG workforce as a whole, women earn 10% (median) or 39% (mean) less than men. When the comparison is made between those on the Agenda for Change payscales, women are paid 8% (median) or 2% (mean) less than men. When the comparison is made between non-Agenda for Change colleagues, there is no gender pay gap comparing the median, and a 4% pay gap using the mean.
Due to the overall low numbers against the following protected characteristics, we have limited data to publish to avoid identification.
Disability
5% of staff declare on Electronic Staff Record (ESR) to have a disability with 4% not declaring any disability status. However, we know we have an ongoing mismatch between the number of staff who record having a disability on ESR compared to those who state having a disability in the anonymous NHS Staff Survey. Our Staff Survey results for 2019 show 16% of staff report having a physical or mental health condition, disability or illness.
The highest percentage of disabled staff is within Agenda for Change Band 8a and 86% of those with a disability work full time, according to ESR data.
Sexual orientation
Sexual orientation Salford CCG % North West* % Representative Heterosexual 90% 95% Under Gay / Lesbian / Bisexual 3% 2% Fairly well Unknown 7% 3% Over *Data from the Office for National Statistics is only available at a regional level.
Marital status and civil partnership
Status Salford CCG % Salford population % Representative Civil partnership 1% 0.5% Fairly well Divorced 9% 9% Fairly well Legally separated 1% 3% Under Married 59% 37% Over Single 25% 43% Under Undisclosed 3% 0% Over Widowed 2% 7% Under
Gender reassignment
Transgender individuals have a legal right to live in their chosen gender and not record their previous gender. As such there is no monitoring of gender reassignment within the NHS.
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Religion and belief
Religion and belief Salford CCG % Salford population % Representative Atheism 17% 22% Under Buddhism 1% 0.5% Fairly well Christianity 62% 64% Fairly well Hinduism 0% 1% Fairly well Islam 3% 3% Fairly well Judaism 1% 3% Under Sikhism 0% 0.1% Fairly well Undisclosed/other 16% 6% Over
The most reported religious belief in all AfC pay bands was Christianity followed by Atheism.
Non-mandatory training 2019/20
While Salford CCG’s mandatory training is automatically recorded via our Virtual College platform, staff are encouraged to manually log any additional non-mandatory training they undertake.
During 01 April 2019 to 31 March 2020, 90 individuals made a total 161 attendances at 36 different courses:
• 55% of women and 51% of men… • 78% of White staff and 50% of BAME staff… • 71% of staff with a declared disability… • 100% of LGBT staff and 67% of heterosexual staff… • 17% of staff aged 20–29, 63% of staff aged 30-59 and 82% of staff over the aged of 60
…participated in at least one piece of non-mandatory training.
Leavers
Out of the 16 people who left the organisation during 2019/20:
• 44% were men and 56% female • 25% were BAME and 75% White • 6% were under the age of 30, 44% aged 31 to 45, 44% were 45 to 59 years old and 6% over the age of 60 • 6% had a disability • 44% were Christian, 12% Islamic and 12% atheist, 6% Hindi, 6% Jewish (19% did not declare a religious/belief) • 81% were heterosexual, 19% did not declare a sexual orientation
Recruitment
Between 01 April 2019 to 31 March 2020, 22 roles were advertised at Salford CCG with recruitment breakdown as follows:
Category Description % Applications % Shortlisted % Appointed
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TOTAL 148 36 11 Male 44% 58% 27% Gender Female 55% 42% 73% Undisclosed 0% 0% 0% Yes 8% 14% 9% Disability No 92% 86% 91% Undisclosed 0% 0% % WHITE - British 53% 69% 73% Ethnicity BAME 47% 31% 27% Undisclosed 1% 0% 0% Under 20 0% 0% 0% 20 to 24 1% 0% 0% 25 to 29 13% 11% 0% 30 to 34 12% 6% 27% 35 to 39 19% 14% 18% 40 to 44 17% 19% 18% Age Band 45 to 49 12% 17% 18% 50 to 54 5% 22% 9% 55 to 59 2% 8% 9% 60 to 64 0% 3% 0% Over 64 0% 0% 0% Undisclosed 0% 0% 0% Heterosexual 93% 94% 100% Sexual Orientation LGBT 4% 3% 0% Undisclosed 2% 3% 0% Christianity 61% 69% 54% Islam 13% 8% 0% Hinduism 6% 0% 0% Judaism 0% 0% 0% Religion and Belief Sikhism 0% 0% 0% Buddhism 0% 0% 0% Atheism 13% 14% 36% Other 4% 3% 9% Undisclosed 3% 6% 0% Married 52% 44% 82% Single 37% 39% 9% Civil Partnership 1% 0% 0% Marriage and Civil Legally separated 1% 3% 0% Partnership Divorced 7% 8% 9% Widowed 0% 0% 0% Undisclosed 1% 6% 0% NHS Staff Survey 2019
The 2019 NHS staff survey results for Salford CCG give some insight into people’s experience of working at the CCG. The survey was administered by Picker, and all staff are surveyed. The 2019 response rate for Salford CCG was 88%. The reports show results by the organisation average, by directorate and by the protected characteristics of age, ethnicity, gender and disability.
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In order to preserve anonymity of individual staff, scores where there are fewer than 11 respondents are not provided. This means that, for Salford, there is no analysis by religion or sexuality is shown.
Some headline findings are:
Age
• Older staff feel the organisation values their work more than our younger staff (82% for 51-65 year olds, 75% for 41-50 year olds and 85% for 31-40 year olds, compared to 64% for 21 – 30 year olds) • Across all age bands, over 90% say they are trusted to do their job • 64% of 21 to 30 year olds feel there are frequent opportunities to show their initiative in their role, increasing to 95% for 31 to 40 year olds and 88% of those over the age of 50 • 31 to 40 year olds felt the most pressure from managers to come into work (23%), compared to 0% for 41 to 50 year olds and 8% of staff aged 51 to 65 • Morale was scored similarly across all age groups, although slightly higher for staff aged 51 to 65 (7.6 compared to 7 for 21-30, 7.3 for 31-40 and 7.4 for 41- 50) • Quality of appraisals scored between 6 and 7 across all age groups, but was lowest for staff aged 21-30 (6.4).
Ethnicity
• 95% of White staff feel they are trusted to do their job, compared to 85% of BAME staff • 85% of BAME staff and 87% of White staff believe they receive the respect they deserve at work • 69% of BAME staff agreed they get recognised for doing good work, compared to 84% of White staff • 93% of BAME staff are satisfied with the support they get from their line managers, compared to 90% of White staff • 85% of BAME staff feel their work is valued by the CCG, compared to 80% of White staff
Gender
• Men look forward to going to work more than women (74% compared to 64%) • 93% of women and 95% of men feel trusted to do their job • 90% of men feel they get recognised for doing good work, compared to 81% of women • 81% of women and 83% of men feel their role is making a difference to patients and service users • 85% of women feel respected by colleagues and 90% of men agree • Men are more likely to work extra unpaid hours with 68% compared to 54% of women
Disability
• 52% of staff with a disability always look forward to coming to work, compared to 71% of staff without a disability • 76% of disabled staff felt they get recognition for their good work, compared to 84% of staff without a disability
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• 76% of staff with a disability felt respected at work, compared to 89% of non- disabled staff • 40% of disabled staff strongly agreed that the CCG takes positive action on health and wellbeing, compared to 63% of non-disabled staff • Morale scored similarly between people with disabilities (7) and people without disability (7.5)
Conclusions
The benefits of establishing and maintaining a diverse workforce are well understood. Teams are more innovative and creative and, specifically important to the NHS, it is found that patients have better experiences of care when the workforce mirrors the patient population and has a better understanding of patients’ needs.
Where we have the available data, as an organisation we are currently fairly reflective of Salford’s population. Similarly, where we have the data, from the staff survey, it appears staff largely feels positive about coming to work and how they are treated. However, we are not complacent and the following outlines the actions we will take over the next 12 months towards increasing the diversity of our workforce and continuing to build our reputation as a supportive, inclusive place to work.
Salford CCG has a small workforce, with a total 152 staff. Therefore it is difficult to make meaningful statistical analysis year-on-year as small staff changes can make a significant impact on the workforce composition.
Training and development
Our Personal, Fair and Diverse (PFD) Champions have become embedded into the organisation as the ‘go to’ advocates for anyone in the organisation who may experience discrimination. In developing our Diversity and Inclusion Action Plan (Appendix 2), which incorporates our WRES Action Plan, our PFD Champions are keen that we focus on raising awareness of the issues facing those with a protected characteristic and developing a workplace that feels safe and supportive – and, most of all, listens – for people to share what the challenges/solutions are. We do this by educating ourselves on the barriers some colleagues may face because of the colour of their skin, their sexuality, or gender, they are more likely to spot discrimination or the potential for it and be able to act. Therefore we will spend the next 12 months continuing to deliver diversity learning lunches and similar events to the workforce to give them a more thorough understanding of the different faiths and communities in Salford, the barriers faced by people from the LGBTQ+ communities and what living with various types of disability can be like, both for those in the workplace and accessing healthcare services. We continue to use our internal communication channels to promote inclusion and regularly share the work the PFD Champions are doing so staff understand their role and how they can help.
Through our membership with the enei – the Employers Network for Equality and Inclusion – and as alumni to the NHS Employers’ Diversity and Inclusion Partners Programme, we will continue to learn and share best practice with other organisations to ensure we are doing all we can to eliminate discrimination in the workplace.
Declaration of equality information
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We continue with the ongoing problem – not just applicable to Salford CCG – of the discrepancy between those people who declare a disability on ESR (5%) compared to the Staff Survey where 16% of respondents said they were living with a disability.
In 2019/20, we introduced an appraisal ‘checklist’ to prompt line managers to check with staff if their ESR details are up-to-date and, if not, they know how to amend them. We are encouraging staff to use ESR more regularly by moving functions over - such as accessing online payslips and recording their annual leave - which we hope, in turn, improves familiarity with the site.
Through our PFD Champions, learning lunches and regular internal communications focusing on diversity and inclusion, we will continue to raise awareness, educate and promote inclusivity to encourage staff to feel safe to disclose whether they have a disability, their sexuality or their religious beliefs, and try to understand why staff choose not to disclose certain information
Our new starter induction checklist is being revamped and we will include an explanation for new starters as to why we collect equality data and encourage them to ensure their ESR information is up-to-date.
Ethnicity
The percentage of Salford CCG’s workforce with a Black, Asian and Minority Ethnic (BAME) background is representative of the overall Salford population, which is 9.8% BAME. Although we are conscious the Salford population data is coming up to 10 years old with a new census due in 2021.
For the first time since 2016, we have had enough BAME colleagues complete the NHS Staff Survey to provide us with insight based on ethnicity. While 85% of BAME staff feel trusted, valued and respected, these numbers are still below the comparable scores for White colleagues and 69% of BAME staff agree they get recognized for doing good work, compared to 84% of White staff. Although figures have increased from last year, we also note only half of our BAME staff are accessing non-mandatory training and development opportunities.
Our Diversity and Inclusion Action Plan includes specific actions relating to WRES, which aims to continue improving outcomes and experiences for BAME colleagues. This includes participating in the Race at Work Charter survey and promoting development opportunities aimed at BAME staff, such as the NHS Leadership Academy’s Stepping Up programme.
Gender
Our workforce reflects a national trend, whereby women are more attracted to public sector employment. Women continue to dominate the CCG workforce gender split with 70% women and 30% men. However, our Governing Body is 90% male. Work had started in 2019/20 with our Governing Body and Clinical Leads towards identifying if there are any perceived barriers to joining the most senior level of the organisation and we will use these discussions to start developing an action plan on how we can address this.
We will continue to promote a culture of flexible working in the organisation by raising awareness of our flexible and agile working policies through regular staff communications, which is becoming more of a common theme through our integration with Salford City Council, but also through the impact of COVID-19 in the last few months where staff have been asked to work from home and balance work 12 with caring responsibilities. The CCG’s policies around maternity/paternity leave are also being updated with a greater emphasis on shared parental leave and, once available to staff, internal communications will promote better understanding and guidance of the scheme.
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Appendix 1: Workforce Race Equality Standard 2020
Background narrative
a) Any issues of completeness of data
On 31st March 2020, 1.3% of employees had chosen not to state their Ethnic Origin. This is a 0.8% decrease from the figure of 2.1% which we reported on the same date in 2019.
b) Any matters relating to reliability of comparisons with previous years
We are unable to provide analysis of BAME staff for indicator 7. This is because the information is taken from the NHS Staff Survey and there were fewer than 11 BAME respondents for this particular question. In order to preserve anonymity of individual staff scores, we have not been able to provide any analysis for this indicator.
Total numbers of staff
a) Employed within this organisation at the date of the report
152
b) Proportion of BAME staff employed within this organisation at the date of the report
31st March 2020: 9.2%
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Self-reporting
a) The proportion of total staff who have self–reported their ethnicity
31st March 2020: 98.7%
b) Have any steps been taken in the last reporting period to improve the level of self-reporting by ethnicity
• As part of our appraisal process, a 'Manager's Checklist' includes a prompt for managers to ask employees if their information (including ethnicity) is up-to-date on the Electronic Staff Record (ESR) • Introduced regular communications to staff through Staff News to explain why we use the data collected • Continued our programme of Personal, Fair, Diverse (PFD) Champions whose role as workforce diversity champions is to reassure the wider workforce around how this data will not be used in any kind of discriminatory way
c) Are any steps planned during the current reporting period to improve the level of self-reporting by ethnicity
• To continue the PFD champions programme • To progress from being awarded the enei silver employer award to the gold award, following their guidance on being a fully inclusive employer • As a signatory to the Race at Work Charter, work to the five principles and share guidance/best practice from other signatory organisations • Develop internal communications for staff through dedicated extranet workspace explaining why we collect data and what we use it for • To work with Salford City Council as part of integrated commissioning to share best practice
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Workforce data
a) What period does the organisation’s workforce data refer to?
31st March 2020
Workforce Race Equality Indicators
Action taken and planned including Narrative – the implication of the Data for Data for e.g. does the indicator link to EDS2 Indicator data and any additional reporting year previous year evidence and/or a corporate Equality background explanatory narrative Objective For each of these four workforce indicators, compare the data for White and BAME staff 1 Percentage of 9.2% 9.0% 2020 Our WRES Action Plan 2020 is being staff in each of the • White: 89.5% co-produced with our Personal Fair AfC Bands 1-9 and • BAME: 9.2%, Diverse Champions and will be VSM (including • Undeclared: 1.3% published www.salfordccg.nhs.uk/about- executive Board us/how-we-do-things/diversity-and- members) Non-clinical inclusion/wres by 31 October 2020 compared with the • Under AfC1: 0% percentage of • AfC1: N/A staff in the overall • AfC2: 66% white / 33% BAME workforce. • AfC3: 100% white Organisations • AfC4: 92% white / 8% BAME should undertake • AfC5: 90% white /10% BAME this calculation • AfC6: 77% white / 23% BAME separately for • non-clinical and AfC7: 100% white for clinical staff. • AfC8a: 89% white /11% BAME • AfC8b: 89% white /11% BAME 16
• AfC8c: 100% white • AfC8d: 100% white • AfC9: N/A • Non-AfC: 81% white / 9% BAME / 9% undeclared Clinical: • Under AfC1: 0% • AfC1: N/A • AfC2: N/A • AfC3: N/A • AfC4: N/A • AfC5: 100% white • AfC6: N/A • AfC7: 100% white • AfC8a: 83% white /17% BAME • AfC8b: 100% white • AfC8c: 100% white • AfC8d: 100% white • AfC9: N/A • Non-AfC: N/A • Medical and dental: 75% white / 18% BAME / 6% undeclared 2 Relative likelihood White staff are White staff are Number of shortlisted applicants: Our WRES Action Plan 2020 is being of staff being 1.4 times more 4.1 times more White: 60 co-produced with our Personal Fair appointed from likely to be likely to be BAME: 25 Diverse Champions and will be shortlisting appointed from appointed from published www.salfordccg.nhs.uk/about- across all posts. shortlisting shortlisting Number appointed from shortlisting: us/how-we-do-things/diversity-and- White: 13 inclusion/wres by 31 October 2020 BAME: 4
Ratio shortlisting/appointment: White: 13/60 = 0.22 BAME: 4/25 = 0.16
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Relative likelihood of white staff being appointed from shortlist, compared to BAME staff (0.22/0.16) is therefore 1.4 times greater. 3 Relative likelihood N/A N/A Salford CCG has experienced only a Our WRES Action Plan 2020 is being of staff entering very small number of formal co-produced with our Personal Fair the formal disciplinary procedures in the last 12 Diverse Champions and will be disciplinary months and we are therefore not able published www.salfordccg.nhs.uk/about- process, as to publish the data due to likelihood us/how-we-do-things/diversity-and- measured by entry of identification. inclusion/wres by 31 October 2020 into a formal disciplinary investigation. This indicator will be based on data from a two year rolling average of the current year and the previous year. 4 Relative likelihood White staff are White staff are Number of staff in workforce: Our WRES Action Plan 2020 is being of staff accessing 1.19 times 2.16 times White: 136 / BAME: 14 / Undeclared: co-produced with our Personal Fair non-mandatory more likely to more likely to 2 Diverse Champions and will be training and CPD. access non- access non- published www.salfordccg.nhs.uk/about- mandatory mandatory Number staff accessing non- us/how-we-do-things/diversity-and- training and training and mandatory training and CPD: inclusion/wres by 31 October 2020 CPD CPD White: 81 / BAME: 7 / Undeclared: 1
Ratio accessing non-mandatory training and CPD White 81/136 = 0.59 BAME 7/14 = 0.5
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Relative likelihood of white staff accessing non-mandatory training and CPD compared to BAME staff (0.59/0.5) is therefore 1.19 greater National NHS Staff Survey indicators (or equivalent) For each of the four staff survey indicators, compare the outcomes of the responses for White and BAME staff. 5 KF 25. Percentage White: 4.3% White: 7.8% We were unable to report our BAME Our WRES Action Plan 2020 is being of staff figure for 2019 as there were fewer co-produced with our Personal Fair experiencing BAME: 0.0% BAME: N/A than 11 respondents and therefore Diverse Champions and will be harassment, our NHS Staff Survey results were published www.salfordccg.nhs.uk/about- bullying or abuse not provided to preserve anonymity. us/how-we-do-things/diversity-and- from patients, inclusion/wres by 31 October 2020 relatives or the public in last 12 months.
6 KF 26. Percentage White: 8.5% White: 11.4% As above Our WRES Action Plan 2020 is being of staff co-produced with our Personal Fair experiencing BAME: 15.4% BAME: N/A Diverse Champions and will be harassment, published www.salfordccg.nhs.uk/about- bullying or abuse us/how-we-do-things/diversity-and- from staff in last inclusion/wres by 31 October 2020 12 months.
7 KF21. Percentage White: 92.8% White: 100% We were unable to report our BAME Our WRES Action Plan 2020 is being believing that figure for 2020 and 2019 as there co-produced with our PFD Champions trust provides BAME: N/A BAME: N/A were fewer than 11 respondents and and will be equal therefore our NHS Staff Survey published www.salfordccg.nhs.uk/about- opportunities for results were not provided to preserve us/how-we-do-things/diversity-and- 19
career anonymity. inclusion/wres by 31 October 2020 progression or promotion. 8 Q17. In the last 12 White: 1.7% White: 3.5% We were unable to report our BAME Our WRES Action Plan 2020 is being months have you figure for 2019 as there were fewer co-produced with our PFD Champions personally BAME: 7.7% BAME: N/A than 11 respondents and therefore and will be experienced our NHS Staff Survey results were published www.salfordccg.nhs.uk/about- discrimination at not provided to preserve anonymity. us/how-we-do-things/diversity-and- work from any of inclusion/wres by 31 October 2020 the following? b) Manager/team leader or other colleagues
Board representation indicator For this indicator, compare the difference for White and BAME staff. 9 Percentage 0.9% less 0.6% less 8.3% of the Governing Body voting Our WRES Action Plan 2020 is being difference membership is BAME compared to co-produced with our PFD Champions between the 9.2% of the overall CCG workforce. and will be organisations’ published www.salfordccg.nhs.uk/about- Board voting us/how-we-do-things/diversity-and- membership and inclusion/wres by 31 October 2020 its overall workforce
Are there any other factors or data which should be taken into consideration in assessing progress?
The definitions of BAME and White used in the WRES follow the national reporting requirements of ethnic category in the NHS data model and dictionary and based on 2001 Census categories for ethnicity. ‘White’ staff includes white British, Irish, Eastern European and any ‘other white’. The BAME staff category includes all others except ‘undeclared’. Applying this to the overall Salford population (2011 Census), 9.8% are BAME.
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Workforce Diversity and Inclusion Action Plan 2020/21 The following is our overarching plan to develop the diversity of the CCG workforce and incorporates our actions from the Workforce Race Equality Standard (WRES) 2019/20
Theme Aim Summary of Action Lead To be completed
To be a leading voice in Strategic developing the diversity of Co-author the Salford-wide Diversity and Inclusion Strategy, ensuring workforce inclusion is Assistant Director of Engagement, Inclusion Mar-21 direction Salford's public sector embedded and Development workforce
Continue as an alumni member of the NHS Employers Diversity and Inclusion Partners To maintain membership/ Programme 2020/21 participation in the D&I Membership Continue to participate in the Race at Work Charter Survey networks and programmes Senior Communications and Inclusion and Maintain accreditation as a Disability Confident Committed (Level 1) organisation and progress Ongoing aimed at supporting NHS Manager accreditation towards Level 2 as a Disability Confident Employer organisations to be Participate in the enei (Employers' Network for Equality and Inclusion) annual TIDE survey, inclusive building on our current silver award towards gold accreditation To continue to deliver the rolling programme of learning lunches throughout the year - allowing Engagement, Inclusion and Development staff to have a better understanding and respect for diversity within the organisation and city as a Ongoing Assistant whole To educate our workforce To continue to deliver the Key Skills for Managers training course to any new managers (which to the barriers faced by includes modules on recruitment, non-discriminatory management practice and valuing diversity), HR Mar-21 people with protected ensuring it meets best practice. characteristics so they can identify discrimination and To refresh training for existing managers every three years. HR Quarterly Training and know how to respond. Development To undertake the annual non mandatory training reporting stock take OD and Social Value Manager Mar-21 To continue promoting opportunities such as the NHS Leadership Academy's Stepping Up OD and Social Value Manager Ongoing To ensure all staff have programme, aimed at developing BAME staff towards senior levels of the NHS equal access to training To continue developing the CCG's training and development extranet workspace building content OD and Social Value Manager Ongoing and development and promoting its existence to staff via regular staff communication channels opportunities To continue communicating via Staff News eBulletins, screensavers and via line managers the importance of staff centrally recording any non-mandatory training and development they have OD and Social Value Manager Ongoing participated in OD and Social Value Manager, HR and Review how roles are advertised at the CCG and how this can be expanded, e.g. through social Senior Communications and Inclusion Jun-21 media or community groups, to encourage a range of people applying for roles Manager Provide information/guide to staff on qualifications from overseas and their UK-equivalent to make HR and Senior Communications and it easier for recruiting managers when shortlisting. Also reinforce message through comms that if Mar-21 Inclusion Manager To work towards improving unsure, speak to HR advisor the diversity of the CCG To continue to review and monitor board representation and that fair processes are in place for Recruitment Head of Governance Ongoing workforce at all levels of the recruitment of board roles. the organisation Work with cliniclal leads/execs/Governing Body to identify barriers to people applying for roles Senior Communications and Inclusion Mar-21 within senior levels of the organisation and create an action plan to implement Manager Update the new starter induction checklist to include explanation on why we collect the data, copy Senior Communications and Inclusion Mar-21 of Equal Opps form and overview to WRES Manager Review the exit process for leavers, including the exit interview, to help identify any patterns for OD and Social Value Manager/HR Jun-21 why staff may leave the organisation Assistant Director of Engagement, Inclusion To continue to participate in the annual NHS National Staff Survey. Jan-21 and Development Encourage staff to speak to PFD champions if they experience any discriminatory issues or need OD and Social Value Manager Quarterly advice Promote the work done by PFD champions to create a set of 'standards' or examples of what we To ensure our staff know OD and Social Value Manager Quarterly Our staff how to raise concerns, that would class as bullying at the CCG and promote these regularly to staff. Promote regular staff surveys focusing on the culture of the CCG to identify any areas for voice they will be listened to and OD and Social Value Manager Ongoing acted upon where relevant improvement To continue to regularly promote Dignity at Work policy using all internal communications Senior Communications and Inclusion Quarterly channels Manager Continue with regular communications to promote the various channels staff have to raise Senior Communications and Inclusion Ongoing concerns, e.g. PFD Champions, comments box, 'Ask Steve online Manager
GOVERNING BODY MEETING
AGENDA ITEM NO: 5i
Item for: Decision/Assurance/Information (Please underline and bold)
30 September 2020
Report of: Director of Corporate Services
Date of Paper: 18 September 2020
Subject: Gifts and Hospitality/Register of Interests
In case of query Gina Magson Please contact: 0161 212 4353
Strategic Priorities: Please tick which strategic priorities the paper relates to:
Quality, Safety, Innovation and Research Integrated Community Care Services (Adult Services) Children’s and Maternity Services Primary Care Enabling Transformation Purpose of Paper:
To provide an update of the entries onto the register for the Gifts and Hospitality and Register of Interests for Governing Body Members, Staff and Salford CCG Member Practices, as at the end of Quarter 4.
Further explanatory information required
N/A HOW WILL THIS BENEFIT THE HEALTH AND WELL BEING OF SALFORD RESIDENTS OR THE CLINICAL COMMISSIONING GROUP?
N/A WHAT RISKS MAY ARISE AS A RESULT OF THIS PAPER? HOW CAN THEY BE MITIGATED?
N/A WHAT EQUALITY RELATED RISKS MAY ARISE AS A RESULT OF THIS PAPER? HOW WILL THESE BE MITIGATED?
N/A DOES THIS PAPER HELP ADDRESS ANY EXISTING HIGH RISKS FACING THE ORGANISATION? IF SO WHAT ARE THEY AND HOW DOES THIS PAPER REDUCE THEM?
N/A PLEASE DESCRIBE ANY POSSIBLE CONFLICTS OF INTEREST ASSOCIATED WITH THIS PAPER.
N/A PLEASE IDENTIFY ANY CURRENT SERVICES OR ROLES THAT MAY BE AFFECTED BY ISSUES WITHIN THIS PAPER:
Footnote:
Members of Audit Committee will read all papers thoroughly. Once papers are distributed no amendments are possible.
Document Development
Not Comments and Date Process Yes No Outcome Applicable (i.e. presentation, verbal, actual report) Public Engagement (Please detail the method i.e. survey, event, consultation) Clinical Engagement (Please detail the method i.e. survey, event, consultation) Has ‘due regard’ been given to Social Value and the impacts on the Salford socially, economically and environmentally? Has ‘due regard’ been given to Equality Analysis (EA) of any adverse impacts? (Please detail outcomes, including risks and how these will be managed) Legal Advice Sought
Presented to any informal groups or committees Presented to Audit committee on 7 Noted by members of the (including partnership groups) for engagement or May 2020 for information/assurance. Audit Committee. other formal governance groups for comments / approval? (Please specify in comments) Note: Please ensure that it is clear in the comments and date column how and when particular stakeholders were involved in this work and ensure there is clarity in the outcome column showing what the key message or decision was from that group and whether amendments were requested about a particular part of the work.
Gifts and Hospitality/Register of Interests
1. Executive Summary
To provide an update of the entries onto the registers for the Gifts and Hospitality Register and Conflicts of Interests.
2. Introduction and Background
2.1 NHS Salford CCG is required to present regular updates to the Governing Body of entries made onto the registers (Appendices 1-3). The Conflicts of Interest Policy also encompasses the register for Gifts and Hospitality (Appendix 4)
2.2 The registers for quarter 4 were presented to the Audit Committee in May 2020 however, due to the response to Covid-19, elements of this work were stood down which unfortunately meant a delay in the registers being presented to Governing Body however, sight of the registers and assurance was provided to Governing Body via the Audit Committee report in June 2020. Therefore, the registers attached are as at the end of quarter 1 for this current year.
2.3 Work has been undertaken with Salford CCG Staff, and Governing Body to obtain conflict of interest forms for the current year. The return of forms for staff and Governing Body is currently 96%. Member Practices would ordinarily submit Declaration of Interest form as a performance indicator within the Salford Standard. Due to the response to Covid-19, work around the Salford Standard has been delayed.
2.4 At the CCG Executive Meeting held on 5 March it was agreed that only Module 1 of the Conflicts of Interest training would be undertaken by all CCG employees. The decision was also taken that further Modules 2 and 3 would only need to be completed by CCG decision making staff. A definitive list of decision making staff has now been agreed and the process has begun to roll out the mandatory training across the Organisation. Completion of the training will be monitored through the monthly training compliance report.
2.5 The Gifts and Hospitality Register includes both members of staff and the Governing Body. Communications and reminders are routinely shared with all staff and members via the newsletter. The register details the declarations received upto 31 March 2020.
3. Recommendations
3.1 The Governing Body is asked to:
• note the registers for all entries of Gifts and Hospitality and Register of Interests as at the end of Quarter 4.
Gina Magson, Governance and Policy Manager
Appendix 1 – Register of Interests (Staff) Appendix 2 – Register of Interests (Governing Body) Appendix 3 – Register of procurement decisions Appendix 4 – Register of Gifts and Hospitality
Conflict of Interest Register NHS Salford CCG Employees
Type of Action taken to mitigate Name Job Title Name of interest Nature of interest From To Date Signed interest risk Abbie Haye Quality and Safety Officer None 10 February 2020 Adrienne Capps Admin Assistant None 04 February 2020 Alison Bali Senior Business Support Officer None 04 February 2020 Senior Manager, Engagement Amanda Rafferty None 04 February 2020 and Inclusion Amber Galbraith OD & Social Value Manager None 24 February 2020 Anastasija Zozuila Finance Support Officer None 13 February 2020 Salford Primary Care Andrea Lightfoot Service Improvement Manager Daughter works for SPCT Indirect Ongoing Ongoing 24 February 2020 Together Designate Nurse for Andrea Patel None 19 February 2020 Safeguarding Children and LAC Sister-in-law works as Head of Salford CCG Management Accounts Senior Finance & Contracts Andy Boulter Indirect 01/04/2020 31/03/2021 05 February 2020 Manager Manchester University Brother works in Finance NHS Foundation Trust Department Specialist Nurse Adult Anna Crowther None 06 February 2020 Safeguarding Manage in accordance with Anna Ganotis Head of Service Improvement Carbon Literacy Trust Husband is a trustee Indirect Nov-19 Present 04 February 2020 COI policy Senior Service Improvement Annette Donegani None 04 February 2020 Manager Ben Waterall Information Officer None 28 February 2020 Engagement and Development Caroline Allport None 14 February 2020 Officer Specialist Nurse Safeguarding Caroline Cooper None 10 February 2020 Children Head of Business Intelligence Caroline Rand None 05 February 2020 and Information Technology Charley Gibbons Contracts Accountant None 05 February 2020 Chris Ogden Senior Contracts Manager None 05 February 2020 Chris Tyson Business Intelligence Manager None 03 February 2020 Compliance with CCG COI Lead Medicines Optimisation Manchester University policy and the General Christina Sheen Daughter works in maternity unit Indirect Ongoing Ongoing 03 February 2020 Technician NHS Foundation Trust Pharmaceutical Council standards AD for Engagement, Inclusion Claire Connor None 03 February 2020 and Development Compliance with CCG COI Greater Manchester Husband is Business Manager, policy and the General Claire Vaughan Head of Medicines Optimisation Mental Health NHS Indirect Ongoing Ongoing 20 February 2020 South Manchester and Trafford Pharmaceutical Council Foundation Trust standards Integrated Commissioning Clare Mayo None 03 February 2020 Manager Senior Information Dave Forrest None 04 February 2020 Analyst/Business Intelligence Pennine Acute Trust Member Hospital Trust Line Manager is aware and Ongoing North West Non-financial this will be noted in any David Dobson Quality Assurance Manager Trust Member Ongoing 04 February 2020 Ambulance Service professional relevant CCG meetings and Primrose Hill Primary Chair of Governors & Co-opted discussions Nov-18 School Governor David Walker Admin Team Leader None 07 February 2020 David Warhurst Chief Finance Officer None 04 February 2020 Dawn Taylor Personal Assistant None 04 February 2020 Dawn Thomond NHS Funded Care Team None 14 February 2020 Debra Wilson Finance Manager None 07 February 2020 Denise Wright Personal Assistant None 05 February 2020 Engagement and Experience Diane Critchley None 04 February 2020 Officer Partner is Head of Planning and To note in relevant Stepping Hill Hospital Indirect Sep-19 Strategic Development discussions Senior Service Improvement Eejay Whitehead Senior Manager's daughter Ongoing Do not lead on 03 February 2020 Manager 42nd Street attends the same school as my Indirect Jun-17 commissioning of children's daughter mental health services Salford Royal NHS Non-financial Elaine Redwood Personal Assistant Mother works at Chest Clinic Jul-05 Ongoing 11 February 2020 Foundation Trust professional Elaine Vermeulen Deputy Chief Finance Officer None 20 February 2020 Ellie Greene Communications Assistant None 17 February 2020 Joint Head of Planning and Emma Reid None 10 February 2020 Performance Director of Quality and Francine Thorpe The Broughton Trust Spouse is Chief Officer Indirect Ongoing Ongoing As per COI Policy 25 February 2020 Innovation Gina Magson Governance and Policy Manager None 12 February 2020 Senior Manager Innovation & Hakeel Qureshi None 24 February 2020 Research Hannah Ahle Service Improvement Manager None 03 February 2020
If a decision is being made Non-financial that might advantage that GP Practice personal practice or the wider Eccles neighbourhood over other St Andrews Medical practices/neighbourhood Hannah Dobrowolska Director of Corporate Services May-03 Ongoing 03 February 2020 Centre over other practices/neighbourhoods, declare the risk and exclude Family's GP Practice Indirect myself from any relevant decision making
Harry Walton Finance Assistant None 05 February 2020 Hazel Riley Contract Manager None 03 February 2020 Open and honest Non-financial Mount Chapel Safeguarding Coordinator 2008 communication channel with personal line manager as to roles. Should discussions arise Specialist Nurse Safeguarding Helen Platt Ongoing around commissioning of 12 February 2019 Children services, a conflict of interest Self-employed Safeguarding would be declared and no Thirty One Eight Financial Jun-18 Trainer involvement with potential contract arrangements
Finance Assistant (Placement Hiba Samra None 11 February 2020 Student) Senior Service Improvement Hilary Rothwell None 11 February 2020 Manager Acting Senior Service Ian Pattison None 06 February 2020 Improvement Manager Jacquie Purser Head of NHS Funded Care None 26 February 2020 Lead Nurse NHS Funded James Treanor None 10 February 2020 Nursing Care Senior Commissioning Officer, Janet Tomlinson None 03 February 2020 NHS Funded Care Janice Harris Nurse Commissioner None 07 February 2020 Jeanette Ainsworth Management Accounts Assistant None 03 February 2020
Manchester University Jenny Noble Head of Governance and Policy Husband is Strategy Manager Indirect Apr-16 Ongoing Adherence with CCG policy 03 February 2020 NHS Foundation Trust Integrated Commissioning Jessica Ta'ati None 03 February 2020 Manager Joanne Cookson Safeguarding Assistant None 06 February 2020 Digital Multimedia & Josie Webster None 18 February 2020 Communications Assistant Salford CCG Member Self, family and friends are Non-financial Where possible, colleagues Practices members personal to work in those practices Medicines Optimisation Jude Owens Ad-hoc working involving Ongoing Ongoing Compliance with CCG COI 12 February 2020 Pharmacist marking undergraduate policy and the General University of Bradford Financial pharmacy students OSCE Pharmaceutical Council examinations standards Julie Chadwick Nurse Commissioner None 03 February 2020 Director of a company that Specialist Nurse Adult Karen Mccormick delivers training and consultanty Financial Jan-19 Ongoing Not working in Salford area 17 February 2020 Safeguarding services in safeguarding Karen Proctor Director of Commissioning None 03 February 2020 Kate Cooper Senior Contract Manager None 05 February 2020 Integrated Commissioning Kerry Thornley None 10 February 2020 Manager Senior Business Kyle Jones None 03 February 2020 Analyst/Developer Innovation, Research and Lara-Anne Turrell None 24 February 2020 Workforce Project Officer Primary and Community Laura Hosey-Davies None 17 February 2020 Informatics Manager Lauren Fairey Service Improvement Manager None 03 February 2020 Laurence Patrick Assistant Accountant None 05 February 2020 Planning and Performance Leanne Drury None 20 February 2020 Manager Leanne Gaye Service Improvement Manager None 06 February 2020 Lesley Bates Information Officer None 03 February 2020 Lesley Lowe Personal Assistant None 04 February 2020 Medicines Optimisation Lesley Sutton None 03 February 2020 Technician Medicines Optimisation Linda Halliwell None 03 February 2020 Technician Senior Communications and Husband is a national news Lindsay Kirby i Newspaper Indirect 01-Jan-14 Ongoing 04 February 2020 Inclusion Manager journalist Engagement and Development Lindsey Brook None 10 February 2020 Officer Lindsey Fretwell None 03 February 2020 Lisa Best Quality Assurance Manager None 11 February 2020 Lisa McGlynn Commissioning Support Officer None 26 February 2020 Medicines Optimisation Lisa Pridgeon None 20 February 2020 Technician Greater Manchester Identified via the Network Adult Safeguarding Chair Jan-19 Ongoing TOR and ownership from all Network CCGs Designated Nurse Safeguarding Non-financial Liz Walton Provision of personal 10 February 2020 Adults Panel member on the professional expertise only. Non- NICE Safeguarding in Care Homes Nov-18 May-20 disclosure of Salford specific Guideline data/intelligence Take no part in any contract or financial decisions. Report COI at all relevant CCG and Non-financial Malcolm Semp Associate Director - Best Value Six Degrees Non-executive Director Apr-19 Mar-19 Six Degrees meetings. Take 06 February 2020 personal no part in discussion regarding issues relating to Six Degrees Margaret Saxton Nurse Commissioner None 24 February 2020 North West Boroughs Excluded from decision Mohammed Amin Senior Finance Manager Sibling works for Indirect Sep-19 Ongoing 25 February 2020 Foundation Trust making for this organisation
Brother-in-law works in Salford CCG contracting Highlight any necessary Manchester University Husband works as Divisional Nicola Boulter Head of Management Accounts Indirect 20/02/2020 Ongoing conflicts as and when 20 February 2020 NHS Foundation Trust Accountant Research required
Son has special education needs N/A and we are Salford Residents Deputy Designated Nurse Nicola Dugdale Safeguarding Children and None 10 February 2020 Looked After Children Nicola Howarth Primary Care Data Quality None 27 February 2020 Paul Keeling Service Improvement Manager None 17 February 2020 Head of Integrated Paul Walsh None 03 February 2020 Commissioning Phil Kemp Head of Finance & Contracting None 05 February 2020 Senior Manager - Quality Mother is senior manager for Rachel Farn Salford CCG Indirect Ongoing Ongoing 14 February 2020 Assurance children's services Rebecca Arbidans Senior Information Analyst None 04 February 2020 Named GP for Adult Rebecca Marchmont None 27 February 2020 Safeguarding Social Marketing and Projects Richard Whitehead None 18 February 2020 Manager Robin Gene Service Improvement Manager None 18 February 2020
Ross Baxter Senior Patient Services Officer None 04 February 2020 Abstain from any GP Clinical Lead for Urgent and involvement in bids/issues Ross Seaton SRFT Wife works as a renal consultant Indirect Jun-16 Ongoing 31 March 2020 Emergency Care Board regarding the renal department at SRFT Senior Service Improvement Saiqa Farooq None 03 February 2020 Officer Sally Sale Nurse Commissioner None 17 February 2020 Senior Service Improvement Sam Glynn-Atkins None 11 February 2020 Manager Samantha McDermott Nurse Commissioner None 06 February 2020 Samuel Sunter Management Accountant None 11 February 2020 Senior Service Improvement Sandra Everett None 03 February 2020 Officer Sandra Lindsay EID Assistant None 24 February 2020 Working collaboratively in the wider CCG safeguarding team to ensure decisions are not biased. Still having the same assurance requirements as other GP Named GP for Safeguarding Local GP & Practice Non-financial Sharmishtha Ghangrekar SPCT Nov-17 Ongoing practices. Regular 1-2-1 13 February 2020 Children Safeguarding Lead professional meetings with managers to discuss/manage any potential areas of conflict. Will declare conflicts of interest where required at meetings Senior Service Improvement Stephanie Pearson None 10 February 2020 Officer Senior Service Improvement Stephen Tilley None 25 February 2020 Manager Stephen Woods Head of Service Improvement None 03 February 2020 Role is part of capacity as CCG Governing Body Interim Chief Accountable Non-financial Steve Dixon NorthWest EHealth Director Nov-16 Ongoing member. This is in effect a 06 January 2020 Officer professional CCG interest. The interest is non-pecuniary Sue Hall Admin Assistant None 05 February 2020 Lead Nurse Quality Assurance & Sue Harris None 10 February 2020 Improvement Sue Marshall Personal Assistant None 04 February 2020 Suzanne Icke Nurse Commissioner None 17 February 2020 Syeed Ismail Information Analyst None 03 February 2020 Tony Fitzgerald Estates Project Officer None 03 March 2020 Mental Health Commissioning Tony Marlow None 06 February 2020 Manager Acting Head of Service Tori Quinn None 06 February 2020 Improvement Medicines Optimisation Tsz Shan Mak None 03 February 2020 Pharmacist Deputy Head of NHS Funded Victoria Hall None 06 February 2020 Care Wai Ken Chan Data Developer None 03 February 2020 Cruse Bereavement Non-financial Wendy Hodgson Service Improvement Manager Member of Committee 2016 Ongoing 06 February 2020 Care Lancashire professional Yvonne Kelly Service Improvement Manager None 03 February 2020 Pete Budden Medical Prescribing Lead SPCT Nominal Shareholder Financial 2018 Present Declare when appropriate 08 March 2020 Clinical Lead for Research and Ester Anderson None 09 March 2020 Innovation Non-financial Salaried GP May-14 Present professional GP Clinical Lead for Children SPCT Declare if any conflicting Wan-Ley Yeung Clinical Lead for Homeless Non-financial 03 March 2020 and Young People Aug-16 Present agenda items Service professional Lishi Tai Chi Coach in Salford Financial Sep-18 Present Work for homeless service and Greta Smith Clinical Care Lead SPCT Financial Feb-20 Apr-21 10 March 2020 as locum GP WWL NHS Non-executive Director 2018 Foundation Trust Health First ALW Non-executive Director Financial 2012 Westleigh Medical Partner 2016 Practice Non-financial Steven Elliot Macmillan GP and Cancer Lead NHSE&I Medical Adviser 2013 27 March 2020 professional N/A Prostate cancer sufferer 2011 Wigan GP Alliance Wife is board member 2012 Health First ALW Wife is Director Indirect 2012
Westleigh Medical Wife is Partner 2012 Practice Ruth Quinn IG Manager None 02 April 2020 Member of Salford CCG EUR Non-financial Marion Roberts Panel, & Salford Representative SRFT GPwSI Tier 2 Dermatology 2007 Present 09 March 2020 professional on GM EUR Steering Group Lead Nurse, NHS Funded Care Sarah Bannister None 03 February 2020 Team Wayne Chan Senior Information Analyst None 01 April 2020 Daniel Holmes Nurse Commissioner None 12 January 2020 Nkonyelu Chijioke Estates Project Officer None 28 January 2020 Specialist Safeguarding Nurse Victoria O'Neill None 21 January 2020 for Adults Danielle Sterling Business Support Officer None 21 February 2020 Nurse Commissioner NHS Lisa Silver None 12 May 2020 Funded Care Team Specialist Nurse Safeguarding Laura McNicoll None 04 March 2020 Children Specialist Nurse Safeguarding Jayne Barber None 08 March 2020 Children Assistant Director Integrated Manchester University Declare in meetings relating Judd Skelton Wife works in CAMHS Indirect Ongoing Ongoing 20 February 2020 Commissioning NHS Foundation Trust to MFT Nurse Commissioner NHS Rebedca Woodward None 13 May 2020 Funded Care Team Husband is a Public Health To be managed on an ad Natalie McInerney Service Improvement Manager Salford City Council Indirect Feb-17 Ongoing 02 June 2020 Strategic Manager hoc basis as the need arises
Satty Boyes Workforce Programme Manager None 24 February 2020 Assistant Director of Harry Golby None 19 June 2020 Commissionong Associate Director - GM Joint Andrea Dayson None 24 June 2020 Commissioning Team Salford and Trafford Non-financial Jenny Walton Clinical Lead Vice Chair 2019 Ongoing 24 June 2020 LMC professional Senior Service Improvement Sarah Cannon None 25 June 2020 Manager Conflict of Interest Register NHS Salford CCG Governing Body
Action taken to mitigate Name Job Title Name of interest Nature of interest Type of interest From To Date Signed risk Executive Director of Nursing Primary Care 24 Financial Oct-18 Present and Quality Paul Kavanagh-Fields Governing Body Nurse Declared as appropriate 03 March 2020 Non-financial Chester University Visiting Professor Feb-20 Present professional Health and Care Fitness to Practise Panel Chair Aug-12 Present Professions Council Non-financial To be disclosed as required Brian Wroe Deputy Chair/Lead Lay Member 26 February 2020 General Osteopathic professional at meetings Investigating Committee Chair Apr-19 Mar-23 Council If a decision is being made Non-financial St Andrews Medical GP Practice that might advantage that Hannah Dobrowolska Director of Corporate Services personal May-03 Ongoing 03 February 2020 Centre practice or the wider Eccles Family's GP Practice Indirect neighbourhood over other Karen Proctor Director of Commissioning None 03 February 2020 Director of Quality and Francine Thorpe The Broughton Trust Spouse is Chief Officer Indirect Ongoing Ongoing As per COI Policy 25 February 2020 Innovation Salford Primary Care Shareholder Financial Oct-16 Present Together Neighbourhood Lead & Clinical Nicholas Browne Price Waterhouse Non-financial Declared at meeting 13 May 2020 Director of Partnerships Brother is a Director Jul-05 Ongoing Cooper professional Non-financial Bolton Primary School Governor Jun-18 Present professional Role is part of capacity as CCG Governing Body Interim Chief Accountable Non-financial Steve Dixon NorthWest EHealth Director Nov-16 Ongoing member. This is in effect a 06 January 2020 Officer professional CCG interest. The interest is non-pecuniary Lay Member - Finance and Edward Vitalis None 30 June 2020 Governance Chris Babbs Secondary Care Clinician None 13 May 2020 Salford Primary Care Shareholder Financial Apr-19 Ongoing Together Clinical Director for St Andrews Medical To be disclosed when Tom Regan Partner is an employee Financial 01/04/2019 Ongoing 26 June 2020 Commissioning Centre 4 relevant Wife is Private Clinical N/A Indirect Apr-18 Ongoing Psychologist Governing Body Neighbourhood Newbury Green David Flinn Practice Manager Financial 01/04/2017 Ongoing 13 May 2020 Lead Medical Practice Paul Newman Lay Member Peel Group Management Team Member Indirect 2009 Ongoing 13 May 2020 GMS Contract Holder Financial Ongoing Jeremy Tankel Medical Director Declare where necessary 25 February 2020 Clarendon Surgery Financial Ongoing Angel Living Centre Financial Ongoing Conflicts acknowledged CCG Clinical Neighbourhood Advanced Practicioner - Head of Non-financial Kate Jones SPCT Apr-18 Ongoing during meetings, actions 30 May 2020 Lead Workforce professional taken as appropriate CCG Neighbourhood Clinical Non-financial To be declared if relevant to David McKelvey Extinction Rebellion Member 2019 Ongoing 20 May 2020 Lead personal agenda 2 St Andrews Medical GMS GP Partner Aug-17 Ongoing Centre Declare as a potential COI in Salford Primary Care Tom Tasker Chair Member Oct-16 Ongoing all meetings attended where 11 October 2019 Together appropriate North West Leadership Chair Representative for Greater Sep-19 Ongoing Academy Board Manchester Withdraw from any relevant Chief Accountable Officer (on Non-financial commissioning Anthony Hassall Gaddum Trustee on board Ongoing Ongoing 14 May 2020 secondment to NHS England) personal conversations involving Gaddum Register of procurement decisions and contracts awarded NHS Salford CCG
Procurement type – Decision making Contract Award Existing contract or new CCG procurement, process and Contract Contract Procurement CCG clinical Summary of conflicts of interest declared (supplier name Ref Number Contract/Service Title procurement (if existing collaborative CCG contract manager name of decision value (£) value to Description lead and how these were managed & registered include details) procurement with making (Total) CCG address) partners committee Register of Gifts and Hospitality NHS Salford CCG
Reason for Accepting or Details of Previous Name Job Title Date of Offer Accepted or Declined? Date of Receipt Name and Nature of Supplier Business Details of Gift Estimated Value Declining Gifts/Offers from Supplier
GOVERNING BODY MEETING PART 1
AGENDA ITEM NO: 6a
Item for Decision/Assurance/Information (Please underline and bold)
30 September 2020
Report of: Co-chairs of Adults’ Commissioning committee Date of Paper: 16 September 2020
Subject: Report of Adults’ Commissioning Committee In case of query Karen Proctor Please contact: Director of Commissioning
Strategic Priorities: Please tick which strategic priorities the paper relates to:
Quality, Safety, Innovation and Research Integrated Community Care Services (Adult Services) Children’s and Maternity Services Primary Care Enabling Transformation Purpose of Paper:
This is a report from Salford’s Adults’ Commissioning Committee (ACC). The report aims to provide assurance relating to the adults’ commissioning programme.
The Governing Body is asked to note the content of the report which outlines the business discussed at the committee’s September 2020 meeting.
Further explanatory information required
The Adults’ Commissioning Committee HOW WILL THIS BENEFIT THE oversees Salford’s adult commissioning HEALTH AND WELL BEING OF activities aimed at delivering the local strategic SALFORD RESIDENTS OR THE priorities. CLINICAL COMMISSIONING GROUP?
n/a WHAT RISKS MAY ARISE AS A RESULT OF THIS PAPER? HOW CAN THEY BE MITIGATED?
n/a WHAT EQUALITY-RELATED RISKS MAY ARISE AS A RESULT OF THIS PAPER? HOW WILL THESE BE MITIGATED?
n/a DOES THIS PAPER HELP ADDRESS ANY HIGH RISKS FACING THE ORGANISATION? IF SO WHAT ARE THEY AND HOW DOES THIS PAPER REDUCE THEM?
n/a PLEASE DESCRIBE ANY POSSIBLE CONFLICTS OF INTEREST ASSOCIATED WITH THIS PAPER.
n/a PLEASE IDENTIFY ANY CURRENT SERVICES OR ROLES THAT MAY BE AFFECTED BY ISSUES WITHIN THIS PAPER:
Footnote:
Members of this Committee will read all papers thoroughly. Once papers are distributed no amendments are possible.
Document Development
Not Comments and Date Process Yes No Outcome Applicable (i.e. presentation, verbal, actual report) Public Engagement Commissioning programmes (Please detail the method i.e. survey, event, include public engagement as consultation) appropriate. Clinical Engagement Commissioning programmes (Please detail the method i.e. survey, event, include clinical engagement as consultation) appropriate. Has ‘due regard’ been given to Social Value Commissioning programmes and the impacts on the Salford socially, include consideration of Social economically and environmentally? Value as appropriate. (Please detail outcomes, including risks and how these will be managed Has ‘due regard’ been given to Equality Commissioning programmes Analysis (EA) of any adverse impacts? undertake EAs as appropriate (Please detail outcomes, including risks and how these will be managed) Legal advice is sought on specific Legal Advice Sought issues as appropriate. Presented to any informal groups or committees (including partnership groups) for engagement or other formal governance groups for comments / approval? (Please specify in comments)
Note: Please ensure that it is clear in the comments and date column how and when particular stakeholders were involved in this work and ensure there is clarity in the outcome column showing what the key message or decision was from that group and whether amendments were requested about a particular part of the work.
Adults’ Commissioning Committee Report
1. Executive Summary
This report summarises the ACC’s formal business during September 2020.
2. Introduction and Background
2.1 The Adults’ Commissioning Committee has responsibility (subject to reserved matters) for all matters relating to the Adults’ Services Integrated Health and Care Fund (Pooled Budget and Aligned Budgets) as set out in the Partnership Agreement between Salford City Council and Salford Clinical Commissioning Group.
2.2 This report summarises the ACC’s formal business during September 2020.
3. Finance Report
3.1 The committee received an in-year update in relation to the financial performance of the adults’ element of the Integrated Fund at month 4 2020/21 which currently showed an overspend of £0.1m. Due to the current uncertainly in relation to the NHS financial regime the position was not currently forecast forward to the end of the financial year. At the time the report was prepared the CCG had still not formally received its allocation for month 5 and the current financial regime meant that no new investment could be made into services at this time.
3.1 The committee noted that the unfortunate number of deaths in care homes had led to an estimated shortfall in income in the region of £0.5m. In line with the commitment made by the CCG and the City Council, arrangements were currently being finalised for the move towards the Real Living Wage.
4. Adult Mental Health Update
4.1 The committee received a comprehensive update on the current mental health performance against a range of targets for mental health set out in the 5 Year Forward View for Mental Health (5YFV) and the NHS Long Term Plan, an update on the additional mental health work streams aligning with ongoing work across Greater Manchester, and an update on the Living Well UK Programme which was aimed at helping Salford focus on people’s skills, aspirations and experiences to build a different way of offering mental health support and help.
4.2 The committee heard that referral to IAPT had reduced dramatically at the peak of Covid-19, with a drop of approximately 50% across Greater Manchester and 30% in Salford. However, the committee was reassured that referrals were now back to pre- Covid rates and work was underway to establish timescales for reintroducing face to face therapy. Telephone or video appointments were not suitable for everybody and individuals who had chosen to await the return of face to face would be given priority when timescales were agreed.
4.3 In relation to adult mental health crises and urgent care services, GMMH had established a 24/7 helpline and the GM Clinical Assessment Service (CAS) was in place to divert callers to this 24/7 helpline and onto appropriate local services as required.
4.4 Following a brief pause to allow staff to be redeployed to support frontline requirements the Living Well work had resumed in June and the team was now operating a pilot approach in Broughton, supporting referrals that would otherwise not have met the criteria for Community Mental Health Teams (CMHT).
4.5 The committee was informed of a number of mental health and suicide prevention awareness raising issues during the Month of Hope which started with World Suicide Prevention Awareness Day on 10 September and ends with World Mental Health Day on 10 October.
5. Integrated Care / Community Health Care Update
5.1 The committee received an update on the integrated care programme and the work programmes of the Integrated Community Based Care Group (ICBCCG), Adults’ Advisory Board (AAB) and End of Life Services for the months March to August. This included a brief summary and overview of the current status of services taking into account the impact of the Covid-19 pandemic.
5.2 All community services were now working through a process of reinstating services and planning for enhancing services to manage the rehabilitation needs of those who had had Covid-19 and those who had been shielding. Risk assessments were being carried out for all services including the need for sufficient time between appointments and ongoing provision of telephone appointments where appropriate.
5.3 The report included a presentation to the Adults’ Advisory Board an End of Programme Evaluation of the 12 transformation ‘test of change’ projects implemented between 2017 and 2020. The evaluation, carried out by Advancing Quality Alliance (AQuA) identified a number of definitive benefits including better use of resources, improved patient experience and improved patient outcomes.
6. Adult Commissioning Report
6.1 The committee received an overview of the Urgent & Emergency Care Redesign. Transformation of these services had been a longstanding ambition but the pandemic had made the need for transformation all the more important. ‘Urgent and Emergency Care by Appointment’ had been developed to support the management of flow into A&E departments, direct patients to other services more appropriate for their condition and reduce the number of A&E attendances. Feedback from patients and clinicians on two Salford-wide test of change days in August had been positive.
6.2 An update on the Salford Lung Health Check pilot informed that, by March, 2,417 patients had accepted their invitations to attend for a Lung Health Check. From these, 16 lung cancers and five other cancers had been detected. These were cancers which might otherwise have gone undetected for some time.
7. Investing in Prevention and Covid Response
7.1 The committee received for information a copy of a report which had been considered and approved at the Health and Care Commissioning Board’s meeting on 2nd September. Members of the board had asked for it to be circulated to the Adults’ Commissioning Committee as not all members were members of both committees.
7.2 The report outlined necessary expenditure on Public Health services in Salford budgeting for the uplift in public health grant and the Test and Trace grant. It highlighted the key issues for the system regarding specialist requirements for statutory responsibilities of the council for health protection and public health, and for the city to remain COVID secure.
8. Recommendations
8.1 The Governing Body is asked to:
• note the contents of this report.
Cllr Gina Reynolds Dr Jeremy Tankel Lead Member for Adult Services, Health & Wellbeing - SCC Medical Director - CCG
GOVERNING BODY MEETING PART 1
AGENDA ITEM NO: 6b
Item for Decision/Assurance/Information (Please underline and bold)
30 September 2020
Report of: Chair of PCCC
Date of Paper: 14 September 2020
Subject: Report of Primary Care Commissioning Committee In case of query Karen Proctor Please contact: [email protected]
Strategic Priorities: Please tick which strategic priorities the paper relates to:
Quality, Safety, Innovation and Research Integrated Community Care Services (Adult Services) Children’s and Maternity Services Primary Care Enabling Transformation Purpose of Paper:
This is a report from Salford’s Primary Care Commissioning Committee (PCCC). The report aims to provide assurance relating to the primary care commissioning programme, outlining key decisions made by the PCCC.
The Governing Body is asked to note the content of the report, including decisions made in July 2020.
Further explanatory information required
HOW WILL THIS BENEFIT THE The Primary Care Commissioning Committee HEALTH AND WELL BEING OF oversees Salford’s primary care commissioning SALFORD RESIDENTS OR THE activities aimed at delivering the local strategic CLINICAL COMMISSIONING priorities. GROUP?
WHAT RISKS MAY ARISE AS A N/A RESULT OF THIS PAPER? HOW CAN THEY BE MITIGATED?
WHAT EQUALITY-RELATED RISKS N/A MAY ARISE AS A RESULT OF THIS PAPER? HOW WILL THESE BE MITIGATED?
DOES THIS PAPER HELP ADDRESS N/A ANY HIGH RISKS FACING THE ORGANISATION? IF SO WHAT ARE THEY AND HOW DOES THIS PAPER REDUCE THEM?
PLEASE DESCRIBE ANY POSSIBLE The CCG is a GP-led organisation so conflicts CONFLICTS OF INTEREST of interest are not entirely avoidable. There is a ASSOCIATED WITH THIS PAPER. potential conflict of interest associated with each decision concerning primary care. These are managed via the CCG’s policy.
PLEASE IDENTIFY ANY CURRENT N/A SERVICES OR ROLES THAT MAY BE AFFECTED BY ISSUES WITHIN THIS PAPER:
Footnote:
Members of this Committee will read all papers thoroughly. Once papers are distributed no amendments are possible.
Document Development
Not Comments and Date Process Yes No Outcome Applicable (i.e. presentation, verbal, actual report) Public Engagement Commissioning programmes (Please detail the method i.e. survey, event, include public engagement as consultation) appropriate. Clinical Engagement Commissioning programmes (Please detail the method i.e. survey, event, include clinical engagement as consultation) appropriate. Has ‘due regard’ been given to Social Value and the impacts on the Salford socially, economically and environmentally? (Please detail outcomes, including risks and how these will be managed Has ‘due regard’ been given to Equality Commissioning programmes Analysis (EA) of any adverse impacts? include clinical engagement as (Please detail outcomes, including risks and how these appropriate. will be managed) Legal advice is sought on specific Legal Advice Sought issues as appropriate. Presented to any informal groups or committees (including partnership groups) for engagement or other formal governance groups for comments / approval? (Please specify in comments)
Note: Please ensure that it is clear in the comments and date column how and when particular stakeholders were involved in this work and ensure there is clarity in the outcome column showing what the key message or decision was from that group and whether amendments were requested about a particular part of the work.
Primary Care Commissioning Committee Report
1. Executive Summary
At its July 2020 meeting the Primary Care Commissioning Committee (PCCC): • Made a decision to end the Quays Pilot in March 2021, and supported a new option for progression, and will receive an update at the next meeting • Approved The Gill boundary extension • Agreed the primary care work plan • Noted the pre-COVID-19 opening financial position and the risks associated • Noted the PCQG and PCOG reports
2. Introduction and Background
2.1 NHS England has delegated specific functions associated with the commissioning of primary medical care services to NHS Salford CCG. PCCC has been established to make decisions and oversee primary medical care commissioning under this delegated authority. In addition PCCC oversees the primary care commissioning work programme of NHS Salford CCG and Salford City Council.
2.2 This report summarises PCCC’s business at its March 2020 meeting. The purpose of the report is to provide assurance relating to Salford’s primary care commissioning programme, outlining significant decisions.
2.3 The PCCC is a meeting held in public, normally every other month. The public is excluded from those items where publicity would be prejudicial to the public interest. These Part 2 items remain confidential until such time as they become appropriate to discuss in public, and those items will be presented to Part 2 of the Governing Body
3. Decision & Assurance
3.1 Quays Pilot
An update was given to members from The Quays Practice team regarding the progress of the pilot, with two options presented for the committee’s decision. These were to end the pilot on 31 March 2021 as originally planned, or to extend the pilot to 30 September 2021 to mitigate against the impact of COVID-19 and enable further innovation to be tested.
Members discussed the details of where the costs of this would come from, and the details and purpose of the pilot so far. They also discussed the detail of the options available, noting that the recommendation was option 4, to invite expressions of interest for a branch practice from existing practices within the Ordsall and Claremont neighbourhood.
PCCC noted the update by The Quays Practice team, made the decision to end the pilot in March 2021 and supported Option 4 as a way of progressing.
3.2 The Gill Boundary Extension
PCCC was advised that the CCG had received an application from The Gill Medical Practice, to change the practice boundary. The paper provided PCCC with information on the options available to the group, the local context including the impact of new developments in the area, the benefits for people living in Walkden & Little Hulton, and the feedback received from stakeholders. SGA confirmed that there would not be an outer boundary as the proposal was that the boundary covered the entire Walkden and Little Hulton Primary Care Network (PCN) area. It was noted that, whilst in draft when the PCCC papers were circulated, the EIA had now been signed off.
Members discussed the responses from practices in the area and assurances relating to this, and noted the help of the LMC in discussing any specific issues with practices. PCCC also acknowledged that approval of the request was not a reflection on the quality or capacity at any other local practices.
PCCC approved the application to change the practice boundary.
3.3 Business Planning Update
The update noted that normally at this time of year the CCG and Council work plans are fully complete and reflected in staff objectives, and reporting on delivery has commenced. This year however the timescale has slipped due to the response to the COVID-19 pandemic. A work plan for the remainder of 2020/21 has been prepared, and a flexible approach will be required to prioritise work and adapt the plan to ensure Salford’s general practices continue to improve and modernise whilst also remaining able to respond to any new demands arising from the pandemic.
Members discussed inclusion of the ongoing work around urgent care, and how this fits into the work plans. It was also highlighted that the work plan would need to be reflected on as the situation changes. Assurance was given that all staff should have had appropriate risk assessments, and that the CCG would be explicit in how it deals with BAME issues.
PCCC agreed the primary care work plan at Appendix 1, noting that it is subject to change for the reasons outlined.
3.4 Primary Care Finance Report
The presentation recognised that a level of expenditure had been agreed pre-COVID, but there is a new financial regime. Primary Care lost £300k from the core budget, which caused pressures, and the expectation is that top-ups to the budget will be requested nationally. The overspend is significant, but the feeling is that this is justifiable, and the detail was provided within the presentation. It is likely that this will continue into months 5 and 6, with the biggest issue there being new investment, but value for money has been found through void costs.
PCCC noted the pre-COVID-19 opening financial position of the primary care element of the integrated fund, and the risks associated with COVID-19 and the next steps, including the CCG’s revised financial regime.
4. For Information
4.1 Primary Care Quality Group Report
The Primary Care Quality Group (PCQG) Report provided an overview on a number of areas that are used to measure the quality and safety of patient care within the primary care services commissioned by the CCG. It provided an update on issues that have been discussed at the regular PCQG meetings along with the associated actions taken.
The Salford Standard has had a positive impact on antibiotics prescribing, and whilst not all are achieving the target, there have been significant improvements. A significant risk has been recognised for safeguarding children, and Safeguarding have been working hard to promote within the current environment.
PCCC noted the contents of the report and the progress made in developing the mechanisms for gaining assurance on quality and safety within primary care.
4.2 Primary Care Operational Group Report
The PCOG Report provided an update on the work that is overseen by PCOG. This included an update on practice specific contractual issues, core contractual requirements, enhanced services, locally commissioned services, general practice capacity, estates and informatics projects, and governance. It was highlighted that Eccles Gateway has now closed, and all approved mergers have completed.
Members discussed an incident with removal of patients from a practice list, and received assurance that any patients who had not already registered elsewhere were being followed up by the practice involved.
PCCC noted the contents of the report.
5. Recommendations
5.1 The Governing Body is asked to note the contents of this report
Ross Baxter Senior Patient Services Officer
GOVERNING BODY MEETING PART 1
AGENDA ITEM NO: 6c
Item for Decision/Assurance/Information
30 September 2020
Report of: Chair of the Audit Committee
Date of Paper: 15 September 2020
Subject: Audit Committee Update Report
In case of query Elaine Vermeulen Please contact: Deputy Chief Finance Officer
Strategic Priorities: Please tick which strategic priorities the paper relates to:
Quality, Safety, Innovation and Research Integrated Community Care Services (Adult Services) Children’s and Maternity Services Primary Care Enabling Transformation Purpose of Paper:
This paper updates the NHS Salford Clinical Commissioning Group Governing Body Board on decisions and risks identified at the last Audit Committee meeting held on 3 September 2020.
Further explanatory information required
HOW WILL THIS BENEFIT THE Provides assurance that controls are effective. HEALTH AND WELL BEING OF SALFORD RESIDENTS OR THE CLINICAL COMMISSIONING GROUP?
WHAT RISKS MAY ARISE AS A None. RESULT OF THIS PAPER? HOW CAN THEY BE MITIGATED?
WHAT EQUALITY-RELATED RISKS None. MAY ARISE AS A RESULT OF THIS PAPER? HOW WILL THESE BE MITIGATED?
DOES THIS PAPER HELP ADDRESS Summarises the work of the Audit Committee ANY HIGH RISKS FACING THE around controls assurance. ORGANISATION? IF SO WHAT ARE THEY AND HOW DOES THIS PAPER REDUCE THEM?
PLEASE DESCRIBE ANY POSSIBLE None. CONFLICTS OF INTEREST ASSOCIATED WITH THIS PAPER.
PLEASE IDENTIFY ANY CURRENT None. SERVICES OR ROLES THAT MAY BE AFFECTED BY ISSUES WITHIN THIS PAPER:
Footnote:
Members of this Committee will read all papers thoroughly. Once papers are distributed no amendments are possible.
Document Development
Not Comments and Date Process Yes No Outcome Applicable (i.e. presentation, verbal, actual report) Public Engagement (Please detail the method i.e. survey, event, consultation) Clinical Engagement (Please detail the method i.e. survey, event, consultation) Has ‘due regard’ been given to Social Value and the impacts on the Salford socially, economically and environmentally? (Please detail outcomes, including risks and how these will be managed Has ‘due regard’ been given to Equality Analysis (EA) of any adverse impacts? (Please detail outcomes, including risks and how these will be managed) Legal Advice Sought
This report is a summary of the Minutes of the previous Presented to any informal groups or meeting of the CCG Audit meeting were approved by committees (including partnership groups) for Committee. the Audit Committee. engagement or other formal governance groups for comments / approval? (Please specify in comments)
Note: Please ensure that it is clear in the comments and date column how and when particular stakeholders were involved in this work and ensure there is clarity in the outcome column showing what the key message or decision was from that group and whether amendments were requested about a particular part of the work.
Audit Committee Update Report
1. Executive Summary
This paper updates the NHS Salford Clinical Commissioning Group Governing Body Board on decisions and risks identified at the last Audit Committee meeting held on 3 September 2020.
2. Audit Committee Minutes
2.1 The minutes of the meeting held on 17 June and 30 June 2020 were approved subject to some minor amendments.
3. Matters Arising
3.1 The log of outstanding matters arising was reviewed and progress since the last meeting was noted. It was highlighted that three matters were ongoing. The first related to the ongoing fraud investigation. The CCG’s exposure had been quantified in relation to the fraud and it was noted that the investigation is ongoing. The next outstanding action was in relation to reviewing of COVID-19 expenditure. It was fed back that this had been double-checked and the action can now be closed. The final outstanding action was in relation to the Internal Audit plan. It was agreed that this would be picked up later on the agenda.
4. Reports Presented to the CCG Audit Committee
4.1 The Deputy Chief Finance Officer presented the Proposed Audit Committee Workplan 2020/21. The committee discussed the plan and a couple of minor amendments were suggested. It was queried if an annual Quality Report should be presented to the Audit Committee and this will be discussed further outside of the meeting.
4.2 The Chair of the Audit Committee mentioned that some changes had been made to the Conflicts of Interest Policy following recommendations received from Internal Audit. The forms and registers had also been amended. It was noted that no new guidance had been issued, the quarterly assessments by NHS England had been stood down and staff training has been deferred until the Autumn. The committee recommended approval of the amended documents to Governing Body.
4.3 The Head of Governance and Policy presented the Response to the Internal Audit COVID Checklist in relation to Gifts and Hospitality. She explained that there were a number of areas which were not applicable to the CCG and therefore these had been left blank. She mentioned that the Checklist relating to the Assurance Framework had not yet been completed, but it is intended this will be done shortly.
4.4 The Assistant Director, Mersey Internal Audit Agency presented the Internal Audit Progress Report and talked through the key messages. It was noted that the CCG had requested some changes to the Internal Audit work programme for 2020/21. These changes relate to the Mental Health Investment Standards (adding in a
review) and a review of the VCSE during the recovery phase. A revised programme will be drafted and circulated to members of the committee for consideration.
4.5 The Assistant Director, Mersey Internal Audit Agency of the Internal Audit discussed the Internal Audit Follow Up Report and mentioned that there were currently 12 recommendations which were in progress. It was highlighted that the majority of these had a target completion date which had been set before the pandemic and therefore there had been a delay with them being completed. However, it was noted that these are now being picked up again by the relevant CCG managers.
4.6 The Assistant Manager – Audit, Grant Thornton presented the Annual Audit Letter for approval. She explained this was a public facing document which had been produced following the completion of their 2019/20 audit. The committee approved the Annual Audit Letter.
4.7 The Local Counter Fraud Specialist, Mersey Internal Audit Agency presented the Anti-Fraud Progress Report. The committee discussed whether there had been any impact of COVID in relation to fraud cases. There was also a discussion in relation to Salford being chosen as a pilot area for mass testing of COVID. The possible risks related to this were discussed. It was agreed that adequate controls and measures need to be put in place by the CCG once the testing kits are fully rolled out. The Chief Finance Officer agreed to take this forward.
4.8 The Deputy Chief Finance Officer presented the National Fraud Initiative 2018/19 – Update May 2020. This was an update following the National Fraud Initiative matching exercise. The report provided details of how the matches had been actioned by the CCG. The committee noted the update report.
4.9 It was noted that no amendments had been made to the Scheme of Reservation and Delegation since the last report was presented to the Audit Committee in May 2020.
4.10 It was noted that no Losses and Special Payments had been made since the last report to Audit Committee in February 2020.
4.11 The Deputy Chief Finance Officer presented the Waivers of Standing Orders report. She highlighted that the report provides details of all orders processed by the CCG over £10,000 since the last report to Audit Committee in February 2020. The committee considered the detail provided for each order and were happy that the CCG’s Procurement Policy had been followed for each.
4.12 The Deputy Chief Finance Officer presented the Progress of Audit Recommendations report. The impact of COVID on implementing the Audit Recommendations and also that managers are now picking this work back up was noted.
5. Key Issues for Governing Body Consideration
5.1 It was agreed that the following issues need highlighting to the Governing Body:
• Proposed changes to the Internal Audit Plan – this might be done via the Executive Team now if appropriate. • Make Governing Body members aware that the Audit Committee has discussed Anti-fraud and the possible risks relating to the pilot in Salford for testing for COVID.
• The revised Conflicts of Interest documentation require approval by Governing Body and are attached with this report.
6. Recommendations
7.1 The Governing Body is asked to:
• Note the contents of this report and the assurances provided. • Approve the revised Conflicts of Interest Policy attached.
Edward Vitalis Chair of the Audit Committee
Conflicts of Interest Policy
Job title of lead contact: Head of Governance and Policy Version number: Version 123.1 Group responsible for approving Governing Body the document: Date of final approval: 27 September 2019 Date for review: 03 September 2020
Version Date Author Status Comment 1 9 December Laura Siddall Draft 2013 2 19 Laura Siddall Draft Amended following comments by December Claire Vaughan, Head of 2013 Medicines Management 3 30 Laura Siddall Draft Amended following comments by December Liz Warwick, Board PA 2013 4 11 Ruth Fairhurst Draft Amended following comments by Hannah Dobrowolska, Head of February Corporate Services 2014 5 20 Ruth Fairhurst Draft Amended following comments February received from the Programme 2014 Management Group 6 26th Ruth Fairhurst Draft Amended following comments February received from the Programme 2014 Management Group 7 11th Ruth Fairhurst Draft Amended following comments November received from the Executive Team 2014 8 8th January Ruth Fairhurst Draft Amendment resultant of the 2015 publication of statutory guidance issued by NHSE 9.1 21 July 2016 Jenny Noble Draft Review resultant of the publication of revised statutory guidance issued by NHSE 9.2 15 Jenny Noble Draft Amended following comments by September Hannah Dobrowolska, Head of 2016 Corporate Services 10.1 18 August Jenny Noble Draft Review resultant of the publication 2017 of new revised statutory guidance issued by NHSE 10.2 7 September Jenny Noble Draft Amended following comments 2017 received from the Audit Committee 10.2 27 Jenny Noble Final Approved by Governing Body September 2017 11.1 16 August Gina Magson Draft Amended following 2018 recommendations made by internal audit 11.2 6 September Jenny Noble Draft Amended following comments 2018 received from the Audit Committee 12.1 27 August Gina Magson Draft Amended following
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2019 recommendations made by internal audit 12.2 27 Gina Magson Final Approved by Governing Body September 2019 13.1 24 August Gina Magson Draft Amended following comments 2020 received from the Audit Committee
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Contents
Section Contents Page
1 Introduction to the policy 5
2 Definition of an interest 6
3 Principles 6
4 Declaration of interests 6
5 Register(s) of interest 7
6 Declaration of gifts and hospitality 7
7 Maintaining a register of gifts and hospitality 8
8 Roles and responsibilities 9
9 Governance arrangements and decision making 10
10 Managing conflicts of interest throughout the commissioning cycle 13
11 Raising concerns 15
12 Breach of conflicts of interest policy 15
13 Fraud, bribery and corruption 16
Appendix 1 NHS Salford Clinical Commissioning Group Declaration of interests template 18
Appendix 2 NHS Salford Clinical Commissioning Group Declaration of gifts and hospitality form template 21
Appendix 3 NHS Salford Clinical Commissioning Group Procurement template 22
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1 Introduction to the policy
1.1 The policy describes the principles and processes which employees, the Governing Body, members of Salford CCG and contractors should follow in regard to the declaration of conflicts of interest. It also describes the principles and process that individuals of Salford CCG should follow if they are offered or given gifts, payments, hospitality and commercial sponsorships.
1.2 Salford CCG is required to make arrangements to manage conflicts of interest and potential conflicts of interest to ensure that decisions made by the CCG will be taken, and seen to be taken, without any possibility of the influence of external or private interest.
1.3 This policy applies to:
• All CCG employees, including: all full and part time staff; any staff on sessional or short term contracts; any students and trainees (including apprentices) agency staff and seconded staff • In addition, any self-employed consultants or other individuals working for the CCG under a contract for services • Members of the Governing Body. All members of the CCG’s committees, sub- committees/sub-groups, including: co-opted members; appointed deputies; and any members of committees/groups from other organisations • All members of the CCG (i.e. each practice). This includes GP partners (or where the practice is a company, each director); and any individual directly involved with the business or decision-making of the CCG.
1.4 This policy applies to those persons within the scope identified in 1.3 (above) when they are acting on behalf of the CCG e.g. when representing or speaking on behalf of the CCG at conference and meetings. It does not apply to GP members of the CCG in the daily running of their practice.
1.5 Persons within the scope of this policy should ensure that it is clear which organisation they are representing, or speaking on behalf of, when at conferences or in meetings.
1.6 For example, a GP member of the Governing Body attends a conference or meeting where services or policies that could benefit the GP Practice, of which they are a member, are discussed and decisions are made about future models of care or commissioning intentions.
1.7 In this case, the GP should ensure that he or she declares which body they are representing, or speaking on behalf of, and consider if a declaration of a perceived or actual conflict of interest should be raised, and recorded.
1.8 GMSS staff contractors should also refer to the GMSS Conflicts of Employment Interest Policy on the GMSS intranet.
1.9 To further support CCGs to manage conflicts of interest, NHS England has launched new online training. The training package has been developed in collaboration with NHS Clinical Commissioners and aims to raise awareness of the risks of conflicts of interest and how to identify and manage them. In addition, the revised statutory guidance on managing conflicts of interest for CCGs requires CCGs to undertake an annual internal
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audit of conflicts of interest management. To support CCGs to undertake the audit, NHS England has published a template audit framework. The CCG will comply with conflicts of interest audit and training requirements.
2 Definition of an interest
2.1 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.
2.2 The types of interests that should be declared include, but are not limited to:
• Financial interests: This is where an individual may get direct financial benefits from the consequences of a commissioning decision; • Non-financial professional interests: This is where an individual may obtain a non- financial professional benefit from the consequences of a commissioning decision, such as increasing their professional reputation or status or promoting their professional career; • Non-financial personal interests: This is where an individual may benefit personally in ways which are not directly linked to their professional career and do not give rise to a direct financial benefit; • Indirect interests: This is where an individual has a close association with an individual who has a financial interest, a non-financial professional interest or a non- financial personal interest in a commissioning decision (as those categories are described above).
2.3 If in doubt, it is better for an interest to be declared, and managed appropriately, than for it to be ignored.
3 Principles
3.1 All individuals within the scope of this policy working for, or with Salford CCG, must abide by the Seven Principles of Public Life (commonly known at the Nolan Principles), the Good Governance Standards of Public Services; the Seven Key Principles of the NHS Constitution and the Equality Act 2010. They must at all times comply with Salford CCG’s Constitution, and be aware of their responsibilities, as outlined in it.
3.2 Where relevant, individuals covered by the scope of this policy must also follow appropriate professional codes of conduct, and are obliged to report any misdemeanours to their professional bodies.
3.3 As a general principle, it is the responsibility of all those covered by this policy to be aware of the potential possibility for perceived and actual conflicts of interest arising, and to take steps to ensure that potential instances are identified and recorded at the earliest opportunity, by discussing the issue with their line manager or contract manager and ensuring the interest(s) are notified to the Head of Governance and Policy, and raised with the Chair of any meetings, where the perceived, or actual conflict(s) of interest should be declared.
4 Declaration of interests
4.1 The types of interest to be declared are outlined in the definition of an interest section, including: financial interests; non-financial professional interests; non-financial personal interests; or indirect interests.
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4.2 Individuals must declare any interest, on appointment, at meetings, annually, or on changing role, responsibility or circumstances, and no later than 28 days after becoming aware of the interest. The interest should be discussed with their line manager, or contract manager, then declared in writing to Head of Governance and Policy, using the template attached in Appendix 1, and notified to the Chair of any meeting where the interest is likely to be relevant.
4.3 All relevant individuals are required to complete and return a Conflicts of Interest Declaration (contained in Appendix 1) on an annual basis. A nil return should be submitted to the Head of Governance and Policy if an individual concludes that they have no interests to declare.
4.4 Where individuals are unable to provide a declaration in writing, for example, if a conflict becomes apparent in the course of a meeting, they should make an oral declaration before witnesses, and provide a written declaration as soon as possible afterwards to the Head of Governance and Policy.
5 Register(s) of interest
5.1 The CCG holds registers of interests for:
• All CCG employees • Members of the Governing Body • All members of the CCG (i.e. each practice but not all practice staff as outlined in the scope of the policy)
5.2 The registers of interests will be reviewed annually, will be published on the Salford CCG’s website (and be available upon request from Salford CCG). This frequency of review has been reduced and is in line with the requirement for CCGs to collate declarations of interest on an annual basis.
6 Declaration of gifts and hospitality
6.1 A ‘gift’ is defined as any item of cash or goods, or any service, which is provided for personal benefit, free of charge or at less than its commercial value.
Gifts from suppliers or contractors
6.2 Items with a value of less than £6, such as promotional items, may be accepted. These gifts do not need to be recorded in the register, but individuals should notify their line manager in writing.
6.3 All others gifts from suppliers or contractors doing business (or likely to do business) with the CCG should be declined, whatever their value. The person to whom the gifts were offered should also declare the offer to the team or individual who has designated responsibility for maintaining the register of gifts and hospitality so the offer which has been declined can be recorded on the register.
Gifts from other sources
6.4 Gifts with a value over £50 can now be accepted on behalf of an organisation, but not in a personal capacity.
6.5 Individuals should immediately report all offers of gifts with a value of £50 or more to their line manager, and record the offer in the register.
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6.6 If the gift arrives without warning, an individual should pass the gift to his or her head of service/team, who will decide whether the gift should be returned, and agree how to notify the gift giver of the action taken.
6.7 If gifts with a value of less than £50 are repeatedly provided by a giver, then these must be treated as collectively having a value over £50.
Hospitality
6.8 Hospitality means offers of meals, refreshments, travel, accommodation, and other expenses in relation to attendance at meetings, conferences, education and training events etc.
Meals and Refreshments
6.9 Under a value of £25 may be accepted and need not be declared.
6.10 Of a value between £25 and £75 may be accepted and must be declared.
6.11 Over a value of £75 should be refused unless (in exceptional circumstances) senior approval is given.
Travel and Accommodation
6.12 Modest offers to pay some of all of the travel and accommodation costs related to attendance at events may be accepted and must be declared.
6.13 Offers which go beyond modest, or are of a type that the CCG itself might not usually offer, need approval by senior staff (e.g. the Head of Governance and Policy), should only be accepted in exceptional circumstances and must be declared. A clear reason should be recorded on the CCG’s register(s) of interest as to why it was permissible to accept travel and accommodation of this type.
6.14 A non exhaustive list of examples includes:
• offers of business class or first class travel and accommodation (including domestic travel). • offers of foreign travel and accommodation.
Sponsored events and other forms of sponsorship
6.15 Sponsorship of NHS events by external parties is valued. Offers to meet some or part of the costs of running an event secures their ability to take place. Without this funding there may be fewer opportunities for learning, development and partnership working. However, there is potential for conflicts of interest between the organiser and the sponsor, particularly regarding the ability to market commercial products or services. As a result, sponsorship of CCG events by appropriate external bodies should only be approved by the Head of Governance and Policy who will conclude that the event will result in clear benefit for the CCG and the NHS; and staff should declare involvement with arranging sponsored events to their CCG.
6.16 For further information, please see Managing Conflicts of Interest in the NHS: Guidance for staff and organisations.
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7 Maintaining a register of gifts and hospitality
7.1 The policy sets out in which instances individuals need to make a declaration to the register. They should make their declaration to the register as soon as possible. The register is held by the Head of Governance and Policy. A declaration form is attached as appendix 2.
7.2 The register is reviewed annually by the Audit Committee, and annually by the Governing Body.
7.3 The CCG will publish the register(s) of gifts and Hospitality on the CCG’s website.
8 Roles and responsibilities
8.1 Everyone in the CCG has responsibility to appropriately manage conflicts of interest.
Appointing Governing Body or committee members and senior employees
8.2 On appointing Governing Body, committee or sub-committee members and senior staff, the CCG will consider whether conflicts of interest should exclude individuals from being appointed to the relevant role. This will be considered on a case-by-case basis and in line with the CCG’s constitution which reflects the CCG’s general principles.
8.3 The CCG will assess the materiality of the interest, in particular whether the individual (or any person with whom they have a close association as listed in the types of interest on page 5 of the policy) could benefit (whether financially or otherwise) from any decision the CCG might make. This will be particularly relevant for Governing Body, committee and sub-committee appointments, but will also be considered for all employees and especially those operating at senior level.
8.4 The CCG will also determine the extent of the interest and the nature of the appointee’s proposed role within the CCG. If the interest is related to an area of business significant enough that the individual would be unable to operate effectively and make a full and proper contribution in the proposed role, then that individual would not be appointed to the role.
8.5 Any individual who has a material interest in an organisation which provides, or is likely to provide, substantial services to a CCG (whether as a provider of healthcare or commissioning support services, or otherwise) should recognise the inherent conflict of interest risk that may arise and should not be a member of the Governing Body or of a committee or sub-committee of the CCG, in particular if the nature and extent of their interest and the nature of their proposed role is such that they are likely to need to exclude themselves from decision-making on so regular a basis that it significantly limits their ability to effectively perform that role. Specific considerations in relation to delegated or joint commissioning of primary care are set out below.
CCG Lay Members
8.6 Lay members play a critical role in the CCG, providing scrutiny, challenge and an independent voice in support of robust and transparent decision-making and management of conflicts of interest. They chair a number of CCG committees, including the Audit Committee and Primary Care Commissioning Committee.
Conflicts of Interest Guardian
8.7 To further strengthen scrutiny and transparency of the CCGs’ decision-making processes, the CGG will have a Conflicts of Interest Guardian (akin to a Caldicott Guardian). This
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role will be undertaken by the CCG audit chair, as audit chairs already have a key role in conflicts of interest management. The Conflicts of Interest Guardian will be supported by the CCG’s Head of Governance and Policy, who has responsibility for the day-to-day management of conflicts of interest matters and queries.
8.8 The Conflicts of Interest Guardian will, in collaboration with the CCG’s Head of Governance and Policy:
• Act as a conduit for GP practice staff, members of the public and healthcare professionals who have any concerns with regards to conflicts of interest; • Be a safe point of contact for employees or workers of the CCG to raise any concerns in relation to this policy; • Support the rigorous application of conflict of interest principles and policies; • Provide independent advice and judgment where there is any doubt about how to apply conflicts of interest policies and principles in an individual situation; • Provide advice on minimising the risks of conflicts of interest.
8.9 Whilst the Conflicts of Interest Guardian has an important role within the management of conflicts of interest, executive members of the CCG’s Governing Body have an on-going responsibility for ensuring the robust management of conflicts of interest, and all CCG employees, Governing Body and committee members and member practices will continue to have individual responsibility in playing their part on an ongoing and daily basis.
Primary Care Commissioning Committee Chair
8.10 The Primary Care Commissioning Committee has a lay chair and lay deputy chair. To ensure appropriate oversight and assurance, and to ensure the CCG audit chair’s position as Conflicts of Interest Guardian is not compromised, the audit chair will not hold the position of chair of the Primary Care Commissioning Committee. This is because CCG audit chairs would conceivably be conflicted in this role due to the requirement that they attest annually to the NHS England Board that the CCG has:
• had due regard to the statutory guidance on managing conflicts of interest; and • implemented and maintained sufficient safeguards for the commissioning of primary care.
9 Governance arrangements and decision making
Secondary employment
9.1 The CCG requires that individuals obtain prior permission to engage in secondary employment, and reserve the right to refuse permission where it believes a conflict will arise which cannot be effectively managed. The CCG has clear and robust organisational policies in place to manage issues arising from secondary employment. In particular, it is unacceptable for pharmacy advisors or other advisors, employees or consultants to the CCG on matters of procurement to themselves be in receipt if payments from the pharmaceutical or devices sector.
Chairing arrangements and decision-making processes
9.2 The chair of a meeting of the CCG’s Governing Body or any of its committees, sub- committees or groups has ultimate responsibility for deciding whether there is a conflict of interest and for taking the appropriate course of action in order to manage the conflict of interest.
9.3 In the event that the chair of a meeting has a conflict of interest, the deputy chair is responsible for deciding the appropriate course of action in order to manage the conflict of
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interest. If the deputy chair is also conflicted then the remaining non conflicted voting members of the meeting should agree between themselves how to manage the conflict(s).
9.4 In making such decisions, the chair (or deputy chair or remaining non-conflicted members as above) may wish to consult with the Conflicts of Interest Guardian or another member of the Governing Body.
9.5 It is good practice for the chair, with support of the CCG’s Head of Governance and Policy and, if required, the Conflicts of Interest Guardian, to proactively consider ahead of meetings what conflicts are likely to arise and how they should be managed, including taking steps to ensure that supporting papers for particular agenda items of private sessions/meetings are not sent to conflicted individuals in advance of the meeting where relevant.
9.6 To support chairs in their role, they will be given access to the declaration of interest checklist prior to meetings, which will include details of any declarations of conflicts which have already been made by members of the group.
9.7 The chair will ask at the beginning of each meeting if anyone has any conflicts of interest to declare in relation to the business to be transacted at the meeting. Each member of the group should declare any interests which are relevant to the business of the meeting whether or not those interests have previously been declared. Any new interests which are declared at a meeting must be included on the CCG’s relevant register of interests to ensure it is up to date.
9.8 Similarly, any new offers of gifts or hospitality (whether accepted or not) which are declared at a meeting must be included on the CCG’s register of gifts and hospitality to ensure it is up-to-date.
9.9 It is the responsibility of each individual member of the meeting to declare any relevant interests which they may have. However, should the chair or any other member of the meeting be aware of facts or circumstances which may give rise to a conflict of interests but which have not been declared then they should bring this to the attention of the chair who will decide whether there is a conflict of interest and the appropriate course of action to take in order to manage the conflict of interest.
9.10 When a member of the meeting (including the chair or deputy chair) has a conflict of interest in relation to one or more items of business to be transacted at the meeting, the chair (or deputy chair or remaining non-conflicted members where relevant as described above) must decide how to manage the conflict. The appropriate course of action will depend on the particular circumstances, but could include one or more of the following:
• Where the chair has a conflict of interest, deciding that the deputy chair (or another non-conflicted member of the meeting if the deputy chair is also conflicted) should chair all or part of the meeting; • Requiring the individual who has a conflict of interest (including the chair or deputy chair if necessary) not to attend the meeting; • Ensuring that the individual concerned does not receive the supporting papers or minutes of the meeting which relate to the matter(s) which give rise to the conflict; • Requiring the individual to leave the discussion when the relevant matter(s) are being discussed and when any decisions are being taken in relation to those matter(s). In private meetings, this could include requiring the individual to leave the room and in public meetings to either leave the room or join the audience in the public gallery; • Allowing the individual to participate in some or all of the discussion when the relevant matter(s) are being discussed but requiring them to leave the meeting when any decisions are being taken in relation to those matter(s). This may be appropriate
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where, for example, the conflicted individual has important relevant knowledge and experience of the matter(s) under discussion, which it would be of benefit for the meeting to hear, but this will depend on the nature and extent of the interest which has been declared; • Noting the interest and ensuring that all attendees are aware of the nature and extent of the interest, but allowing the individual to remain and participate in both the discussion and in any decisions. This is only likely to be the appropriate course of action where it is decided that the interest which has been declared is either immaterial or not relevant to the matter(s) under discussion.
Primary Care Commissioning Committees and sub-committees
9.11 NHS Salford CCG has level 3 delegated commissioning arrangements in place. This enables the CCG to assume responsibility for commissioning general practice services.
9.12 The CCG has established a Primary Care Commissioning Committee for the discharge of their primary medical services functions. The interests of all Primary Care Commissioning Committee members must be recorded in the CCG’s register(s) of interests.
9.13 Meetings of the Primary Care Commissioning Committee, including the decision-making and deliberations leading up to the decision, are held in public unless the CCG has concluded it is appropriate to exclude the public where it would be prejudicial to the public interest to hold that part of the meeting in public. Examples of where it may be appropriate to exclude the public include:
• Information about individual patients or other individuals which includes sensitive personal data is to be discussed; • Commercially confidential information is to be discussed, for example the detailed contents of a provider’s tender submission; • Information in respect of which a claim to legal professional privilege could be maintained in legal proceedings is to be discussed; • To allow the meeting to proceed without interruption and disruption.
Membership of Primary Care Commissioning Committee
9.14 The Primary Care Commissioning Committee is constituted to have a lay and executive majority. This ensures that the meeting will be quorate if all GPs had to withdraw from the decision making process due to conflicts of interest.
9.15 The Primary Care Commissioning Committee has a lay chair and lay deputy chair.
9.16 The Committee also has a GP representative to ensure sufficient clinical input, who is not in the majority and a non-voting member.
9.17 Representatives from HealthWatch and the Salford Health and Wellbeing Board are also non-voting members of the Committee.
Primary Care Commissioning Committee decision-making processes and voting arrangements
9.18 The Primary Care Commissioning Committee is a decision-making committee, which has been established to exercise the discharge of the primary medical services functions.
9.19 The quorum requirements for Primary Care Commissioning Committee meetings includes a majority of lay and officers present including the Chair or Deputy Chair.
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9.20 In the interest of minimising the risks of conflicts of interest, GPs do not have voting rights on the Primary Care Commissioning Committee. The arrangements do not preclude GP participation in strategic discussions on primary care issues, subject to appropriate management of conflicts of interest. They apply to decision-making on procurement issues and the deliberations leading up to the decision.
9.21 Whilst the CCG has established a Primary Care Quality Group to develop business cases and option appraisals, ultimate decision-making responsibility for the primary medical services functions rests with the Primary Care Commissioning Committee.
Minute-taking
9.22 It is imperative that the CCG ensures complete transparency in their decision making processes through robust record-keeping. If any conflicts of interest are declared or otherwise arise in a meeting, the chair must ensure the following information is recorded in the minutes:
• Who has the interest; • The nature of the interest and why it gives rise to a conflict, including the magnitude of any interest; • The items on the agenda to which the interest relates; • How the conflict was agreed to be managed; and • Evidence that the conflict was managed as intended (for example recording the points during the meeting when particular individuals left or returned to the meeting).
10 Managing conflicts of interest throughout the commissioning cycle
10.1 Conflicts of interest need to be managed appropriately throughout the whole commissioning cycle. At the outset of a commissioning process, the relevant interests of all individuals involved should be identified and clear arrangements put in place to manage any conflicts of interest. This includes consideration as to which stages of the process a conflicted individual should not participate in, and, in some circumstances, whether that individual should be involved in the process at all.
Designing service requirements
10.2 The way in which services are designed can either increase or decrease the extent of perceived or actual conflicts of interest. Particular attention should be given to public and patient involvement in service development. Public involvement supports transparent and credible commissioning decisions. It should happen at every stage of the commissioning cycle from needs assessment, planning and prioritisation to service design, procurement and monitoring. The CCG has a legal duty under the Act to properly involve patients and the public in their respective commissioning processes and decisions.
Provider engagement
10.3 It is good practice to engage relevant providers, especially clinicians, in confirming that the design of service specifications will meet patient needs. This may include providers from the acute, primary, community, and mental health sectors, and may include NHS, third sector and private sector providers. Such engagement, done transparently and fairly, is entirely legal. However, conflicts of interest, as well as challenges to the fairness of the procurement process, can arise if a commissioner engages selectively with only certain providers (be they incumbent or potential new providers) in developing a service specification for a contract for which they may later bid.
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10.4 Provider engagement should follow the three main principles of procurement law, namely equal treatment, non-discrimination and transparency. This includes ensuring that the same information is given to all at the same time and procedures are transparent. This mitigates the risk of potential legal challenge.
10.5 As the service design develops, it is good practice to engage with a range of providers on an on-going basis to seek comments on the proposed design e.g. via the commissioners website and/or via workshops with interested parties (ensuring a record is kept of all interaction). NHS Improvement has issued guidance on the use of provider boards in service design.
10.6 Engagement should help to shape the requirement to meet patient need, but it is important not to gear the requirement in favour of any particular provider(s). If appropriate, the advice of an independent clinical adviser on the design of the service should be secured.
Specifications
10.7 Commissioners should seek, as far as possible, to specify the outcomes that they wish to see delivered through a new service, rather than the process by which these outcomes are to be achieved. As well as supporting innovation, this helps prevent bias towards particular providers in the specification of services. However, they also need to ensure careful consideration is given to the appropriate degree of financial risk transfer in any new contractual model.
10.8 Specifications should be clear and transparent, reflecting the depth of engagement, and set out the basis on which any contract will be awarded.
Managing Conflicts of Interest in the Procurement Process
10.9 Anyone seeking information in relation to a procurement exercise, or participating in a procurement exercise, or otherwise engaging with Salford CCG in relation to the potential provision of services, or facilities to the group, will be required to make a declaration of any relevant conflict/potential conflict of interest, and must follow this policy. This requirement will be set out in the contract for services.
10.10 Salford CCG staff invited to visit organisations to inspect equipment (e.g. software or training aids) for the purpose of advising on its purchase, will be reimbursed for their travelling expenses, in accordance with the travel expenses policy laid down by Salford CCG. Such expenses should not be claimed from other organisations, to avoid compromising the purchasing decisions of Salford CCG.
10.11 Every invitation to tender to a prospective bidder for Salford CCG business must require each bidder to give a written undertaking not to engage in collusive tendering, or other restrictive practice, and not to engage in canvassing Salford CCG personnel or representatives concerning the contract opportunity tendered. Prospective bidders must declare any conflict of interests using the form attached in Appendix 2.
10.12 Offers of pro bono work from prospective bidders for Salford CCG business should be politely refused.
10.13 The National Health Service (Procurement, Patient Choice and Competition) (No. 2) Regulations (2013) regulation 6 requires the following:
• CCGs must not award a contract for the provision of NHS health services, where conflicts, or potential conflicts between the interests involved in commissioning such
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services, and the interests involved in providing them, affect, or appear to affect, the integrity of the award of that contract; and • CCGs must keep a record of how it managed any such conflict, in relation to NHS commissioning contracts it enters into; and details of this should be published by the CCG in Procurement Register of Decisions
Register of Procurement Decisions
10.14 The Deputy Chief Finance Officer, on behalf of the CCG, will maintain a Register of Procurement Decisions taken (and this will be updated whenever a procurement decision is taken) including:
• The details of the decision • Who was involved in making the decision (i.e., Governing Body or Committee Members – including Joint Committees with NHS England, other CCGs, and Local Authorities - and others with decision making responsibility); and • A summary of any conflicts of interest in relation to the decision, and how this was managed by the CCG
10.15 The Register of Procurement Decisions will be publicly available online, and at the registered offices of the CCG, and will form part of the CCG’s Annual Accounts in due course.
11 Raising concerns
11.1 It is the duty of every CCG employee, Governing Body member, committee or sub- committee and GP practice member to speak up about genuine concerns in relation to the administration of the CCG’s policy on conflicts of interest management, and to report these concerns. These individuals should not ignore their suspicions or investigate themselves, but rather speak to the designated CCG Conflicts of Interest Guardian for these matters.
11.2 Any non-compliance with the CCG’s conflicts of interest policy should be reported in accordance with the terms in this policy, and CCG’s whistleblowing policy (where the breach is being reported by an employee or worker of the CCG) or with the whistleblowing policy of the relevant employer organisation (where the breach is being reported by an employee or worker of another organisation).
11.3 Effective management of conflicts of interest requires an environment and culture where individuals feel supported and confident in declaring relevant information including notifying any actual or suspected breaches of the rules.
11.4 Anonymised details of breaches will be published on the CCG’s website for the purpose of learning and development.
11.5 Any suspicions or concerns of acts of fraud or bribery can reported online via https://www.reportnhsfraud.nhs.uk/ or via the NHS Fraud and Corruption Reporting Line on 0800 1284060.
12 Breach of conflicts of interest policy
12.1 The CCG has a clear process for managing breaches of its conflicts of interest policy. The process is detailed below:
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• The CCG’s Accountable Officer and / or Conflicts of Interest Guardian will be informed by the Head of Governance and Policy within 28 days of any individuals having taken up office or appointment, or a new office, or new appointment having not completed and returned a completed declaration of interest form, within 28 days of appointment, to her.
• In accordance with the CCG’s constitution and NHS England statutory guidance, failure to declare a perceived or actual conflict of interest either within 28 days of appointment (including contractor, executive (employee) and member roles), re- appointment; or on taking up a new role in the CCG, could lead to the removal from office or position of that individual.
• The Accountable Officer and / or Conflicts of Interest Guardian will consider any extenuating circumstances for non-compliance with the 28 day rule, and may take appropriate external advice from Hempsons, the NHS Solicitors, or the CCG’s Internal Auditors, Mersey Internal Audit Authority (MIAA), before recommending a course of action to the Governing Body or Executive Team as appropriate.
12.2 The CCG’s Chief Accountable Officer and the Chair of the Audit Committee will be required, on an annual basis, to attest to the CCG having had regard to NHS England statutory guidance concerning conflicts of interest, in its Annual Report and Accounts.
12.3 In the event that the CCG has departed from the NHS statutory guidance on conflicts of interest in any year, it will be required to account for this to its Audit Committee, and to explain this in detail in its Annual Report and Accounts.
13. Fraud, bribery or corruption Salford CCG has a zero tolerance of fraud, bribery or corruption. We are committed to protecting our assets and those of the NHS to promoting honesty and integrity in all our activities. The CCG remains determined to prevent, deter and detect all forms of fraud, bribery and corruption committed against it, whether by internal or external parties.
Failure to manage conflicts of interest could lead to legal challenge and even criminal action in the event of fraud, bribery and corruption. This could have implications for the CCG and linked organisations, and the individuals engaged by them.
The Fraud Act 2006 created a criminal offence of fraud and is mainly investigated under:
Section 2 – Fraud by False Representation Section 3 – Fraud by failing to disclose information Section 4 – Fraud by abuse of position
Fraud carries a maximum sentence of 10 years imprisonment and/or a fine and can be committed by a body corporate.
The Bribery Act 2010 makes it easier to tackle this offence in public and private sectors. The offence of bribing another person or being bribed carries a maximum prison sentence of 10 years and/or a fine.
Bribery is offering an incentive to someone to do something which they wouldn’t normally do. For example, someone advertising a job might be offered tickets to an event by one of the candidates or someone linked to them in an attempt to influence a decision. A bribe may take the form of payment, gifts, hospitality, promise of contracts or employment, or some other form of benefit or gain. The individuals engaged in the actual bribery activity do not have to be those who instigate the offence(s), or ultimately benefit
16 from it. All parties involved are potentially subject to prosecution. The bribe may take place prior, to after, the corrupt act or improper function.
All staff have a personal responsibility to ensure they are not placed in a position which risks, or appears to risk, a conflict between their private interests and their NHS duty. To limit our exposure to both fraud and bribery we have in place an Anti-Fraud, Bribery and Corruption Policy, a Code of Conduct and Conflict of Interest Policy and mechanisms for raising concerns. These apply to all staff and to individuals and organisations who act on behalf of the CCG. We also have in place local counter fraud specialist who will investigate, as appropriate, any allegations of fraud, bribery or corruption.
Any suspicions or concerns of acts of fraud or bribery can reported directly to the CCG Anti-Fraud Specialist (AFS), Lynne Doherty on 0161 743 2008 or 07551 137267. Email [email protected].
Alternatively concerns can be reported online to the NHS Counter Fraud Authority via https://www.reportnhsfraud.nhs.uk/ or via the NHS Fraud and Corruption Reporting Line on 0800 1284060. This provides an easily accessible route for the reporting of genuine suspicions of fraud, bribery and corruption within the NHS, in strictest confidence. Callers can remain anonymous if they wish to do so.
This Conflicts of Interest Policy should be read in conjunction with the CCG’s Anti-Fraud, Bribery and Corruption Policy which demonstrates the CCG’s commitment to addressing the risks of such actions and provides an opportunity for staff to ventilate their concerns with a view to them being investigated.
References: • Committee on Standards in Public Life (1995) Standards of Public Life: First Report of the Committee of Standards in Public Life London: HMSO • Department of Health (1994) The Code of Conduct and Code of Accountability in the NHS (second revision) London: Department of Health • Bribery Act (2010) London: HMSO • Managing Conflicts of Interest: Statutory Guidance for CCGs (19/12/14) • Managing Conflicts of Interest: Revised Statutory Guidance for CCGs (June 2016) • Managing conflicts of interest: Revised statutory guidance for CCGs 2017
Related Salford CCG policies, procedures and documents: • Local Anti-Fraud, Bribery and Corruption Policy • Whistleblowing Policy • Disciplinary Policy • Commercial Sponsorship Policy • Salford CCG Constitution Professional Standards Authority Standards for NHS Boards and Clinical Commissioning Group Governing Bodies in England
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Appendix 1: Declaration of interests for CCG members and employees
Name: Date: Position within, or relationship with, the CCG (or NHS England in the event of joint committees): Detail of interests held (complete all that are applicable): Type of Description of Interest (including for Date interest Actions to be Interest* indirect interests, details of the relates taken to relationship with the person who has the mitigate risk *See From & To interest) reverse (to be agreed of form with line for manager or a details senior CCG manager)
The information submitted will be held by the CCG for personnel or other reasons specified on this form and to comply with the organisation’s policies. This information may be held in both manual and electronic form in accordance with the Data Protection Act 1998. Information may be disclosed to third parties in accordance with the Freedom of Information Act 2000 and published in registers that the CCG holds.
I confirm that the information provided above is complete and correct. I acknowledge that any changes in these declarations must be notified to the CCG as soon as practicable and no later than 28 days after the interest arises. I am aware that if I do not make full, accurate and timely declarations then civil, criminal, or internal disciplinary action may result.
All staff should be aware that the information provided in this form will be added to the CCG’s registers which are held in hardcopy for inspection by the public and published on the CCG’s website. All staff must make any third party whose personal data they are providing in this form aware that the personal data will be held in hardcopy for inspection by the public and published on the CCG’s website and must inform the third party that the CCG’s privacy policy is available on the CCG’s website.
Signed: Date:
Signed/Approved By: Position: Date: (Line Manager or Senior CCG Manager)
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nd th Please return to the Head of Governance and Policy, 2 Floor, 7 Floor, St James’s Formatted: Superscript HouseUnity House, Salford Civic Centre, Swinton, Salford, M27 5AW or email to [email protected]
Type of Description Interest Financial This is where an individual may get direct financial benefits from the consequences of a Interests commissioning decision. This could, for example, include being: • A director, including a non-executive director, or senior employee in a private company or public limited company or other organisation which is doing, or which is likely, or possibly seeking to do, business with health or social care organisations. This includes involvement with a potential provider of a new care model; • A shareholder (or similar ownership interests), a partner or owner of a private or not-for- profit company, business, partnership or consultancy which is doing, or which is likely, or possibly seeking to do, business with health or social care organisations; • A management consultant for a provider; or • A provider of clinical private practice. This could also include an individual being: • In employment outside of the CCG (see paragraph 79-81); • In receipt of secondary income; • In receipt of a grant from a provider; • In receipt of any payments (for example honoraria, one-off payments, day allowances or travel or subsistence) from a provider; • In receipt of research funding, including grants that may be received by the individual or any organisation in which they have an interest or role; and Having a pension that is funded by a provider (where the value of this might be affected by the success or failure of the provider). Non- This is where an individual may obtain a non-financial professional benefit from the Financial consequences of a commissioning decision, such as increasing their professional reputation Profession or status or promoting their professional career. This may, for example, include situations al Interests where the individual is: • An advocate for a particular group of patients; • A GP with special interests e.g., in dermatology, acupuncture etc.: • An active member of a particular specialist professional body (although routine GP membership of the Royal College of General Practitioners (RCGP), British Medical Association (BMA) or a medical defence organisation would not usually by itself amount to an interest which needed to be declared); • An advisor for the Care Quality Commission (CQC) or the National Institute for Health and Care Excellence (NICE); • Engaged in a research role; • The development and holding of patents and other intellectual property rights which allow staff to protect something that they create, preventing unauthorised use of products or the copying of protected ideas; or GPs and practice managers, who are members of the governing body or committees of the CCG, should declare details of their roles and responsibilities held within their GP practices. Non- This is where an individual may benefit personally in ways which are not directly linked to Financial their professional career and do not give rise to a direct financial benefit. This could include, Personal for example, where the individual is: Interests • A voluntary sector champion for a provider; • A volunteer for a provider; • A member of a voluntary sector board or has any other position of authority in or connection with a voluntary sector organisation; • Suffering from a particular condition requiring individually funded treatment; A member of a lobby or pressure group with an interest in health and care. Indirect This is where an individual has a close association with an individual who has a financial interest, a non-financial professional interest or a non-financial personal interest in a
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Interests commissioning decision (as those categories are described above) for example, a: • Spouse / partner; • Close family member or relative e.g., parent, grandparent, child, grandchild or sibling; • Close friend or associate; or • Business partner.
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Appendix 2: Declaration of gifts and hospitality
Date Recipient Position Date Date of Details of Estimated Supplier / Details of Details of the Declined Reason for Other Name of Receipt (if Gift / Value Offeror: previous offers officer reviewing or Accepting Comments Offer applicable) Hospitality Name and or Acceptance and approving Accepted? or Nature of by this Offeror/ the declaration Declining Business Supplier made and date
The information submitted will be held by the CCG for personnel or other reasons specified on this form and to comply with the organisation’s policies. This information may be held in both manual and electronic form in accordance with the Data Protection Act 1998. Information may be disclosed to third parties in accordance with the Freedom of Information Act 2000 and published in registers that the CCG holds.
I confirm that the information provided above is complete and correct. I acknowledge that any changes in these declarations must be notified to the CCG as soon as practicable and no later than 28 days after the interest arises. I am aware that if I do not make full, accurate and timely declarations then civil, criminal, professional regulatory or internal disciplinary action may result.
All staff should be aware that the information provided in this form will be added to the CCG’s registers which are held in hardcopy for inspection by the public and published on the CCG’s website. All staff must make any third party whose personal data they are providing in this form aware that the personal data will hold in hardcopy for inspection by the public and published on the CCG’s website and must inform the third party that the CCG’s privacy policy is available on the CCG’s website.
Signed: Date:
Signed/Approved By: Position: Date:
(Line Manager or a Senior CCG Manager) Please return to the Head of Governance and Policy, 2nd Floor, Unity House, Salford Civic Centre, Swinton, Salford, M27 5AW 7th Floor, St James’s House or email to [email protected] Appendix 3: Declaration of conflict of interests for bidders/contractors
Name of Organisation: Date: Details of interests held:
Type of Interest Details
Provision of services or other work for the CCG
or NHS England
Provision of services or other work for any other potential bidder in respect of this project or procurement process Any other connection with the CCG or NHS England, whether personal or professional, which the public could perceive may impair or otherwise influence the CCG’s or any of its members’ or employees’ judgements, decisions or actions
Name of Relevant [complete for all Relevant Persons] Person
Details of interests held: Personal interest or that of a family Type of Interest Details member, close friend or other acquaintance? Provision of services or other work for the CCG
or NHS England
Provision of services or other work for any other
potential bidder in respect of this project or procurement process
Any other connection with the CCG or NHS England, whether personal or professional, which the public could perceive may impair or otherwise influence the CCG’s or any of its members’ or employees’ judgements, decisions or actions
To the best of my knowledge and belief, the above information is complete and correct. I undertake to update as necessary the information.
Signed:
On behalf of:
Date:
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GOVERNING BODY MEETING PART I
AGENDA ITEM NO: 6d
Item for Decision/Assurance/Information (Please underline and bold)
30 September 2020
Report of: Chief Accountable Officer
Date of Paper: 2 September 2020
Subject: Executive Team Report
In case of query Hannah Dobrowolska Please contact: Director of Corporate Services
Strategic Priorities: Please tick which strategic priorities the paper relates to:
Quality, Safety, Innovation and Research Integrated Community Care Services (Adult Services) Children’s and Maternity Services Primary Care Enabling Transformation Purpose of Paper:
This is a report from the Salford Clinical Commissioning Group Executive Team Meeting, which is a formal committee reporting to the Governing Body. The purpose of the report is to provide assurance relating to the functions undertaken by the Executive Team in line with the CCG’s Constitution and the Executive Team Meeting’s Terms of Reference.
The report outlines key decisions made at the Executive Team Meetings during July and August 2020 and seeks, as appropriate, ratification of decisions. There are no decisions that require ratification during this period.
Further explanatory information required
HOW WILL THIS BENEFIT THE The Executive Team Meeting conducts the day HEALTH AND WELL BEING OF to day operational business of the CCG, which SALFORD RESIDENTS OR THE allows the CCG to deliver against its Strategic CLINICAL COMMISSIONING Plan. GROUP?
WHAT RISKS MAY ARISE AS A As part of any Executive Team decision, risks RESULT OF THIS PAPER? HOW are considered. CAN THEY BE MITIGATED?
WHAT EQUALITY RELATED RISKS As part of any Executive Team decision, MAY ARISE AS A RESULT OF THIS diversity and inclusion is considered, and any PAPER? HOW WILL THESE BE associated risks. MITIGATED?
DOES THIS PAPER HELP As part of any Executive Team decision, impact ADDRESS ANY HIGH RISKS on existing high or extreme risks are considered. FACING THE ORGANISATION? IF SO WHAT ARE THEY AND HOW DOES THIS PAPER REDUCE THEM?
PLEASE DESCRIBE ANY POSSIBLE Conflicts of interest are present for the GP CONFLICTS OF INTEREST members attending the Executive Team ASSOCIATED WITH THIS PAPER. Meetings. These are inherent as clinical members are also providers of services. Any Conflicts of Interest are managed by the team in line with the CCG’s policy.
PLEASE IDENTIFY ANY CURRENT As part of any Executive Team decision, impact SERVICES OR ROLES THAT MAY BE current services or roles are considered. AFFECTED BY ISSUES WITHIN THIS PAPER:
Footnote:
Members of this Committee will read all papers thoroughly. Once papers are distributed no amendments are possible.
Document Development
Not Comments and Date Process Yes No Outcome Applicable (i.e. presentation, verbal, actual report) Public Engagement Public engagement is undertaken as (Please detail the method i.e. survey, event, necessary for the matters considered consultation) by the Executive Team. Clinical Engagement A Clinical Lead is a member of the (Please detail the method i.e. survey, event, Executive Team to provide a clinical consultation) perspective. Engagement with wider clinicians is undertaken as required for matters considered by the Executive Team. Has ‘due regard’ been given to Social Value and Consideration of social value is given the impacts on the Salford socially, economically to matters considered by the Executive and environmentally? Team. In addition, the Executive Team (Please detail outcomes, including risks and how receive a quarterly update on Social these will be managed Value work across the CCG. Has ‘due regard’ been given to Equality Analysis Consideration of equality is given to (EA) of any adverse impacts? matters considered by the Executive (Please detail outcomes, including risks and how Team. In addition, the Executive Team these will be managed) receive a quarterly update on diversity and inclusion work across the CCG. Legal Advice Sought Legal advice is sought as required for matters considered by the Executive Team. Presented to any informal groups or committees Paper shared with the Chief Amendments made as (including partnership groups) for engagement or Accountable Officer for comment. required. other formal governance groups for comments / approval? (Please specify in comments) Note: Note: Please ensure that it is clear in the comments and date column how and when particular stakeholders were involved in this work and ensure there is clarity in the outcome column showing what the key message or decision was from that group and whether amendments were requested about a particular part of the work.
Executive Team Report
1 Executive Summary
This report summarises the Executive Team meeting’s business during July and August 2020.
2 Background
2.1 The Executive Team Meeting is a subcommittee of the Clinical Commissioning Group (CCG) Governing Body, to which it is accountable.
2.2 This report summarises the business conducted at the Executive Team Meetings in line with the CCG’s Constitution and the Executive Team Meeting’s Terms of Reference.
2.3 The responsibilities of the Executive Team are:
2.3.1 To oversee the day to day running of the organisation and therefore be responsible for a range of operational matters, including but not limited to: • Human Resources • Communications • Engagement • Organisational development • Financial management and those already mentioned • Health, Safety and Risk • IM&T including Information Governance • Organisational Performance • Continuing Healthcare (operational matters) • Integrated Commissioning (operational matters) • Safeguarding (operational matters) • External commissioning support • Strategic and operational estates planning • Emergency planning, resilience and response
2.3.2 To receive reports from the: • Health Economy Resilience Group • IM&T Programme Board • Salford Strategic Estates Group • Engagement and Inclusion Management Group
2.3.3 To promote innovation in commissioned services and internal working practices.
2.3.4 To lead the development of governance frameworks with the CCG’s principal partners to support the delivery of joint commissioning priorities.
2.3.5 To prioritise the business of the CCG to meet its annual objectives, providing the programme management framework and final decision making forum to enable realisation of the operational plan.
2.3.6 To provide assurances to the NHS Salford CCG in respect of their statutory requirements associated with day to day management of the organisation and its operations, including the development and management of corporate governance arrangements.
2.3.7 Where required, due to Conflict of Interest concerns, take decisions delegated to the Executive Team by other committees or groups of the CCG where the committee or group that would ordinarily take the decision cannot appropriately manage the Conflict of Interest concerns within its own membership.
2.3.8 From April 2019 the Executive Team also has responsibility for commissioning decisions in relation to “in view” activities and services as defined in the integrated commissioning arrangements the CCG operates with Salford City Council.
3 Executive Team Meeting Summaries
3.1 At each Executive Team meeting a verbal update on COVID-19 response and recovery and the Greater Manchester Health and Social Care Partnership is noted. The only exception to this is where time pressures do not allow. In this report, to avoid repetition, these updates are not mentioned except where there are particular matters of note.
3.2 1 July 2020
The Executive Team discussed strategic and action planning. They recognised the different elements of planning which will be brought together in the coming weeks, namely:
• ongoing living with COVID-19 work requirements • new work needed to minimise the negative impacts COVID-19 has had • altered/new work to ensure the opportunities COVID-19 changes have brought are maximised • work we had planned/begun to plan as part of the annual planning workshops in January to March 2020
The Governing Body (GB) agendas (part 1 and 2) were reviewed and agreed for July. An Engagement and Inclusion Management Group (EIMG) Update was received, with an update on GB equalities leadership, discussion of interpreter services, inclusivity of the Innovation Fund and COVID-19 inequalities recommendations, in particular representation on decision making groups and completion of equality impact assessment for temporary and permanent service changes.
A Communications Evaluation Report was noted. The OD and Social Value Quarterly Updates were reviewed and optional updated appraisal paperwork approved. As part of noting the HR Quarterly Update a probationary period review was noted with the recommendations agreed. The Executive Team considered how induction may need to be adapted for our current remote working context and asked that the equality data relating to HR matters is reviewed.
Operational COVID-19 matters were considered.
3.3 8 July 2020
There was no Executive Team meeting on 8 July due to many members being required to attend the Children’s Commissioning Committee.
3.4 15 July 2020 – Integrated Leadership Team Meeting
New mass testing requirements developed at a Greater Manchester level were noted, with feedback being that these may be too healthcare focused. An implementation plan for Salford will be developed over the coming weeks. Proposals in relation to pillar 1 COVID-19 testing at the AJ Bell were considered with approval given for the remainder of phase 1 and phase 2 (up to mid-September). Options with regard to phase 3 were considered with more detail requested prior to a decision.
The draft annual plan for the remainder of 2020/21 was reviewed and approved as a working document, subject to some final amendments in relation to the children’s work and formal agreement of the strategic priorities by the CCG’s Governing Body and SCC’s Cabinet.
A review of the neighbourhood General Practice Forum’s and the CCG’s support to these was considered with the recommended changes agreed.
3.5 22 July 2020 – Executive Team Plus
Updates on GM governance and colocation were provided.
The Executive Team only then considered workspace requirements and the implementation of a pilot project for personal health budgets. A further discussion took place on COVID-19 and test and trace in particular.
3.6 29 July 2020
The Executive Team ratified infection control guidance for CCG staff which has been cascaded to staff via the newsletter and intranet. Proposed governance arrangements and future working in GM and localities were considered. There was a discussion on planning and assurance, with further guidance expected imminently. The children’s best value proposal was agreed.
3.7 5 August 2020
The Executive Team agreed £30k funding for a mortality review project to review the clinical management of patients in Salford during wave 1 of COVID-19 to help ensure lessons are learnt ahead of any future wave.
The terms of reference of the Health Protection Board were reviewed and reporting to the CCG agreed.
The recent NHS England phase 3 letter on recovery was considered, in particular how the delivery of the requirements within this letter will be managed through local governance arrangements. The positive news was shared that the CCG has received the £2.2m additional funding requested, which was initially not granted to support the local COVID-19 response and to ensure a balanced financial position for the CCG.
3.8 12 August 2020
The Executive Team discussed the step up of the Salford Standard for the rest of this financial year and scoped priorities that may be taken forward. The Executive Team also discussed the need to review the Salford Standard for the longer term. The Salford Standard income will focus on supporting primary care to get back to normal.
3.9 19 August 2020 - Integrated Leadership Team meeting
The focus of the COVID-19 recovery discussion was on preparations for children returning to school in September. The group discussed governance at a Greater Manchester level in light of the phase 3 letter, and although there may be some opportunities to do more at this level it was felt that the most important relationships to improve health were at place (locality and neighbourhood level).
The COVID-19 Equality Impact Assessment (EIA) for adults was discussed, with further analysis required as services recommence. Plans for the Big Reset Conversation were shared which will help ensure the voice of patients and the public is heard in how services change as a result of COVID-19.
A MyWork update was noted in relation to the process for priority groups returning to office working.
3.10 26 August 2020 – Executive Team Plus
Governance at a Greater Manchester level was discussed in light of the phase 3 letter, following last week’s Executive Team discussion. An update on colocation and returning to the office was provided, covering accommodation, OD and IT.
The Executive Team only continued their meeting. A GM return on the urgent actions to address inequalities in NHS provision and outcome was discussed, to ensure the examples we share are complete and submitted on time. An estates update was noted, with approval given for the break clause timing for the new Little Hulton Health Centre, the disposal of the current Little Hulton Health Centre when possible, temporary funding for preparatory costs for the Lower Broughton scheme and a site search for a Quays (branch) practice. The Governing Body agendas for September were reviewed and confirmed.
3.11 In addition there have been additional informal Executive Team meetings on Friday and Mondays where needed to manage COVID related matters on the following dates:
13 July 2020 7 August 2020 17 August 2020 24 July 2020 10 August 2020 21 August 2020 31 July 2020 14 August 2020 28 August 2020
4 Recommendations
4.1 The Governing Body is asked to:
• note the content of this report.