Bwd CCG Part 1 Papers 081117

Questions from members of the public will be received under Item 4; if submitted in advance in line with the protocol on the CCG’s website: http://www.blackburnwithdarwenc cg.nhs.uk/about-us/governing- body-meetings/

CLINICAL COMMISSIONING GROUP (CCG)

GOVERNING BODY MEETING

Wednesday 8th November 2017 at 1 pm Meeting Rooms 1 and 2, Blackburn Central Library Town Hall Street, Blackburn BB2 1AG

A G E N D A

Item No: Agenda Item Member Responsible Report PUBLIC PARTICIPATION 1. Chair’s Welcome Mr Graham Burgess Verbal

2. Apologies for Absence and Confirmation of Quoracy Mr Graham Burgess Verbal

3. Declarations of Interest relating to items on the agenda Mr Graham Burgess Verbal Members and attendees are requested to identify any interests relating specifically to the agenda items being considered (see guide below) and inform the Chair and Governing Body Secretary in advance of the meeting.

4. Questions from Members of the Public Mr Graham Burgess Verbal

PART 1 BUSINESS (APPROXIMATELY 1.30 PM) 5. Minutes of the Annual General Meeting held on 6th Mr Graham Burgess Attached September 2017 5.1 Minutes of the Meeting held on 6th September 2017 Attached 5.2 Extract from Part 2 of the Minutes of the Meeting held on Attached 6th September 2017

6. Matters Arising Mr Graham Burgess 6.1 Action Matrix Attached

7. Clinical Chief Officer’s Report Dr Penny Morris Attached

8. Chief Finance Officer’s Report Mr Roger Parr Attached

9. Contract, Quality and Performance Report Mr Roger Parr/ Attached Dr Malcolm Ridgway 10. Blackburn with Darwen Annual Report of the Director of Professor Dominic Attached & Public Health Harrison Presentation

FOR INFORMATION 11. Sub-Committees and Groups’ Minutes Mr Iain Fletcher Attached

12. Joint Committee of Clinical Commissioning Groups Mr Graham Burgess 12.1 Agenda for the Meeting on 2nd November 2017 Attached 12.2 Draft Minutes of the Meeting Held on 2nd March 2017 Attached 12.3 Draft Minutes of the Meeting Held on 6th July 2017 Attached 12.4 Draft Minutes of the Meeting Held on 7th September 2017 Attached

13. Accident and Emergency Board Report Mr Alex Walker Attached

14. Any Other Business All Verbal

15. Date and Time of Next Meeting: Mr Graham Burgess Verbal Wednesday 17th January 2018 in Meeting Rooms 1 and 2, Blackburn Central Library, Town Hall Street, Blackburn BB2 1AG

EXCLUSION OF THE PRESS AND PUBLIC – ‘That representatives of the press and other members of the public be excluded from the remainder of the meeting having regard to the confidential nature of the business to be transacted, publicity on which would be prejudicial to the public interest’ (Section1(2)Public Bodies(Admission to Meetings)Act 1960)

PART 2 (APPROXIMATELY 3 PM) A/17 Minutes of Part 2 of the Meeting held on 6th Mr Graham Burgess Attached September 2017

B/17 Matters Arising Mr Graham Burgess B/17.1 Action Matrix Attached

C/17 Pennine Lancashire Clinical Commissioning Groups’ Dr Malcolm Ridgway Confidential Provider Update Attached

D/17 Any Other Business All Verbal

Types of Conflict of Interest

Type of Interest Description 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; • A shareholder (or similar owner 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; • In secondary employment (see paragraph 56 to 57); • In receipt of secondary income from a provider; • 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-Financial This is where an individual may obtain a non-financial professional benefit from the Professional consequences of a commissioning decision, such as increasing their professional Interests reputation or status or promoting their professional career. This may, for example, include situations where the individual is: • An advocate for a particular group of patients; • A GP with special interests e.g., in dermatology, acupuncture etc. • A member of a particular specialist professional body (although routine GP membership of the RCGP, BMA or a medical defence organisation would not usually by itself amount to an interest which needed to be declared); Page 2 of 3

Type of Interest Description • An advisor for Care Quality Commission (CQC) or National Institute for Health and Care Excellence (NICE); • A medical researcher. Non-Financial This is where an individual may benefit personally in ways which are not directly linked to Personal their professional career and do not give rise to a direct financial benefit. This could Interests include, for example, where the individual is: • 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 groups with an interest in health. Indirect This is where an individual has a close association with an individual who has a financial Interests interest, a non-financial professional interest or a non-financial personal interest in a commissioning decision (as those categories are described above). For example, this should include: • Spouse / partner; • Close relative e.g., parent, grandparent, child, grandchild or sibling; • Close friend; • Business partner.

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CLINICAL COMMISSIONING GROUP (CCG) Item 5 Minutes of the Governing Body Annual General Meeting Wednesday 7th September 2017 at 12 noon Hornby Theatre, Blackburn Central Library, Town Hall Street, Blackburn BB2 1AG PRESENT: Mr Graham Burgess Chair (Chair) Dr Chris Clayton Clinical Chief Officer (CC) Mr Roger Parr Deputy Chief Executive/Chief Finance Officer (RP) Miss Claire Jackson Director of Commissioning Operations Dr Penny Morris General Practitioner (GP) Executive Member and Vice Chair (PM) Dr Zaki Patel GP Executive Member Dr Adam Black GP Executive Member Dr Preeti Shukla GP Executive Member Dr John Randall GP Executive Member Dr Nigel Horsfield Lay Member Dr Geraint Jones Lay Member – Secondary Care Doctor (Retired) Mrs Janet Thomas Executive Nurse/Associate Director of Quality and Commissioning.

IN ATTENDANCE: Mr Iain Fletcher Head of Corporate Business Mrs Pauline Milligan Governing Body Secretary

Min No: 17.074 Chair’s Welcome

The Chair welcomed everyone to the CCG’s Annual General Meeting (AGM).

The Chair thanked stakeholders for staying for the meeting following the earlier Stakeholder Event and welcomed members of the public for joining the CCG’s AGM.

He directed proceedings to the formal part of the meeting.

17.075 Apologies for Absence and Confirmation of Quoracy

Apologies had been received in respect of:

Dr Malcolm Ridgway, Clinical Director for Primary Care and Quality; Mr Paul Hinnigan, Lay Member – Governance and Professor Dominic Harrison, Director of Public Health, Blackburn with Darwen Borough Council (BwD BC)

The AGM was confirmed as quorate.

17.076 Declarations of Interest Relating to Items on the Agenda

No declarations of interest were made with regards to items on the agenda.

17.077 Minutes of the Annual General Meeting Held on 7th September 2016

The minutes of the Annual General Meeting held on 7th September 2016 had been Page 1 of 8

approved as a correct record and ratified by the Governing Body on 2nd November 2016.

RESOLVED: That the minutes of the AGM held on 7th September 2016 were noted.

17.078 Review of the Year 2016/17

The Chair commenced the presentation with a brief outline of the CCG’s achievements over the past year.

The Chair referred to the financial challenges the CCG had faced during the year whilst ensuring quality of care for the residents of BwD.).

He continued that the Chief Finance Officer would explain the CCG’s financial challenges further later in the meeting. He stated that the CCG had been transparent in its reporting of the financial challenges it faced in terms of any changes it had to make to its services, e.g. in relation to Medicines Management, but the CCG had widely engaged with the public and many people had responded to its consultation and the variety of meetings it had held.

The Chair referred to the CCG’s achievements over the past year, which the Clinical Chief Officer would outline in the next part of the presentation.

The Chair continued that the CCG was very committed to looking at new ways of engaging and consulting with stakeholders and members of the public and these had been discussed during the Stakeholder Event prior to the AGM. The CCG did not intend to replace more traditional forms of contact with stakeholders and members of the public and continued to hold meetings with them but it was embracing new wider ways of engagement via social media and its Citizens Panel.

Dr Chris Clayton continued the presentation with a review of 2016/17.

Dr Clayton confirmed that the presentation would be available via the CCG’s website following the meeting. The link is provided below:

http://www.blackburnwithdarwenccg.nhs.uk/about-us/governing-body-meetings/

Dr Clayton highlighted key areas of work which had taken place over the past year in relation to:

• Mental Health; • Primary Care; • Medicines Management; • Integrated Care and Better Care Fund; • Scheduled Care; • Unscheduled Care; • Children and Adolescent Mental Health; • Paediatrics; • Maternity; • Changes to Constitution.

Questions and answers followed.

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Q Some years ago you, as a CCG, declined to continue Chiropody for Older People. Since then amputations in Type 2 Diabetics have increased. Could you tell me what the rate is at the moment of amputations due to Type 2 Diabetes and not looking after your toe nails properly?

A Yes you are right. At the end of the Care Trust Plus (CTP) (formerly the Primary Care CC Trust) it was facing difficult decisions. BwD has had to make efficiencies for many years and was faced with a difficult decision in relation to low level footcare and if this was something that the NHS could continue to provide. The CTP took the decision that it was not something that it could continue to provide but supported the Voluntary Sector to try and help and put a different system in place.

In terms of the link to diabetes and amputations, I do not have the figures available at this moment; however I recall that Professor Dominic Harrison, Director of Public Health, had stated that there was not an association between the two and demonstrated that, for the levels of diabetics within the BwD population, the levels of consequence, in terms of amputations, were lower than the national average.

ACTION: Dr Clayton caveated his response as he did not have actual data to hand but asked that Professor Harrison provide a response following the meeting.

Dr Geraint Jones introduced himself, informed the meeting of his former clinical role and special interest in diabetic foot problems and provided further information to assist in the response to the enquirer. Dr Jones explained that Podiatry had a major role in the prevention and management of diabetic foot problems; however diabetic patients had been exempt from the reductions in Podiatry Services. Dr Jones explained that the reduction in services was in relation to routine Podiatry Services which were reduced by the CTP, e.g. toe nail cutting services.

Dr Jones continued that amputation rates were very variable and BwD had historically performed well. He added that Professor Harrison had been correct when he stated that there were many factors involved and when these were taken into account BwD’s amputation figures were not as bad as the total numbers might appear.

Q The savings were £62k. I am confident that the cost of one or two operations is more than that.

A The CTP did exempt diabetic patients from the reduction in Podiatry Services. CC ACTION: Dr Clayton agreed to clarify the above point, which would be confirmed in the minutes of the meeting, available on the CCG’s website.

POST MEETING NOTE: At the request of Dr Clayton (see above), further clarification was provided by Professor Dominic Harrison:

The most recent Diabetes Foot Care Profile was produced by Public Health England on the 7th September 2017. This covered the data period 2013/14 to 2015/16.

An extract of the main ‘headline indicators’ of outcomes for diabetic foot disease is extracted below.

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This shows that BwD CCG population health indicators for diabetic related amputations (and related issues) remain slightly better than the average English rate – though the data Confidence Intervals (CI-below) mean that technically we can only say we are now ‘statistically similar’ when compared with England.

Dr Penny Morris continued the presentation with a case study from the Integrated Neighbourhood Teams (INTs).

Dr Morris explained that a few years ago she had given a presentation to the Governing Body following a pilot scheme which had been undertaken in the East locality. The scheme had brought together Health, Social Care, Community Services and the Voluntary Sector to look at those patients who were being admitted to hospital on a regular basis. The aim was to see if the problems faced by these patients, who often had complex issues, could be solved.

The success of the scheme was such that, even before the pilot had been fully completed and evaluated, the process was rolled out to the BwD localities. In order to achieve this, the BwD footprint was reorganised into four localities and then the neighbourhood teams were developed in each locality. The scheme was initially looking at patients who historically had high admission rates to hospital to see if they could be treated in a better and more constructive way.

Dr Morris presented and outlined a case study which demonstrated the progress made within the INTs.

Questions, answers and comments followed.

Q Are there plans to involve housing as part of the Integrated Teams?

A Yes absolutely. This will be part of the next steps that I mentioned as part of the PM organisation of health and well-being in the neighbourhoods.

Q I am glad that you are taking a holistic picture, rather than just the patient going to their GP and are looking at the problems as a whole and not just the general thing that is wrong with someone.

A Thank you, yes. That is why the East pilot was initiated in the first place because we PM realised that medical needs were not looking at patients holistically.

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RESOLVED: That the Governing Body noted the content of the review of the year 2016/17. 16.079 Financial Review 2016/17

Mr Roger Parr introduced himself as the CCG’s Chief Finance Officer and provided an overview of the financial reports for 2016/17.

Mr Parr formally thanked the CCG’s Finance and Governance Teams of the CCG and Midlands and Lancashire Commissioning Support Unit in producing the CCG’s Annual Accounts and Report and the Audit Committee who ratified the Annual Accounts and Report.

The CCG achieved each of its key financial duties in 2016/17:

Statutory Duties Target Performance Achieved CCG to remain within its revenue £248,655k £246,243k Yes allocation CCG to remain within its running £3,541k £3,484k Yes cost allocation

Better Payment Practice Code Target Number NHS Payables 95.0% 99.5% Non NHS Payables 95.0% 98.6%

Mr Parr explained that the funding that the CCG was responsible for was circa £250m.

He outlined the breakdown of costs as follows:

Funding £248,655k Commissioning Costs Staff Costs £709k

Other Costs £242,398k

Income (£348k)

Running Costs

Staff Costs £1,686k Other Costs £1,798k Net Expenditure £246,243k Surplus 2016/17 £2,412k* *National Risk Reserve

Mr Parr drew members’ attention to the investments and developments in 2016/17, which focused on out of hospital activities:

• Quality Improvement in Primary Care; • GP Access Fund; • Better Care Fund; • Mental Health; • Resilience.

Mr Parr explained that 53% of the CCG’s expenditure as spent on the acute sector, whilst 47% was spent out of the acute sector. He added that this was something that the Page 5 of 8

CCG recognised and was working to change.

Total Spend £246m £1,435 per head % Acute Care £767 53% Primary Care £318 22% Community Based Care £98 7% Mental Health £103 7% Continuing Health Care £41 3% Other £108 8%

Mr Parr looked to the future and reported that the CCG had allocations received and notified for the current and next financial year. He continued that allocations were increasing; however, demand and costs were increasing at a higher rate. This meant that the CCG would continue to be faced with a financial gap that would need to be closed in order for the CCG to deliver its business rules.

He explained that the CCG was still 2% under its ‘fair share’ allocation in terms of the formula used to calculate allocations.

In 2017/18 BwD CCG received an allocation increase of 2.0% but remained 2.08% away from its target allocation (£4,622k).

2017/18 2018/19 Programme Allocation £222,476k £226,891k Running Cost Allocation £3,518k £3,500k

Primary Care Co-Commissioning £23,719k £24,176k

Total Allocation £249,713k £254,567k

Mr Parr explained that the CCG was on track to deliver its business rules in 2017/18. A total of £6.2m of Quality, Innovation Productivity and Prevention (QIPP) savings had been delivered to date.

He added that in the first quarter of the year the CCG had achieved a year on year reduction of 5% in terms of prescribing costs (i.e. 47,000 items prescribed). He drew members’ attention to the impact of the reduction in prescribing activity.

Mr Parr highlighted an activity summary for 2016/17, which demonstrated the impact of some of the CCG’s QIPP schemes on Primary Care and Acute Services.

Primary Care Summary Impact Improving Access to Primary Care 11,369 evening and weekend attendances Acute Visiting Service 4,592 contacts Intensive Home Support 3,591

Acute Summary 2016/17 2015/16 Variance Accident and Emergency (A&E) 59,493 61,469 -3.2% Attendances Non-Elective Activity 19,546 20,409 -4.2% Out-patient First Attendances 55,771 54,082 3.1% Elective Activity 23,519 22,931 2.6% Page 6 of 8

Mr Parr concluded his presentation by commending the CCG’s financial position to members as set out in the CCG’s Annual Accounts and Annual Report and invited questions or comments on any aspect of the CCG’s finances.

Questions and answers followed.

Last year you very helpfully listed Continuing Healthcare (CHC) on the list of expenditure Q per head. CHC is one of the big problems for older people because if they get CHC its

NHS but if it’s Local Authority residential care they have to be assessed for it. Has the

CHC amount increased/decreased/changed?

CHC expenditure continues to increase. It is increasing at a greater % than many of the A CCGs’ other services. The CCG has some very expensive packages of care which it RP provides to the community. These are carried out via national framework assessments.

Mr Parr added that expenditure and the demand for CHC was increasing.

The national Courts have decided that the CCG is the arbiter not the Local Authority so Q the CCG has a very important role.

The CCG applies national frameworks to all the decisions that are made to ensure that A they are consistent, fair and equitable. RP

How can I get hold of the national frameworks? Q

The information is provided on the CCG’s website: A http://www.blackburnwithdarwenccg.nhs.uk/health/individual-patient-activity/ RP

I am sitting here trying to imagine being a member of the public and trying to understand Q what the CCG could have done with its £2.4m surplus. Please can you explain why

there is a surplus of £2.4m?

At the beginning of the financial year the financial framework was published. CCG were A mandated to set aside 1% of their resource allocations. That was to allow for potential RP transformation or to make sure that the NHS was sustainable on a national footprint.

During the course of the year the NHS’s position as a whole was assessed and was

forecast to be overspent. Therefore, the CCG’s were asked not to spend the 1% set

aside on transformation or new investments but to set it to one side to be applied to the

national deficit for the NHS Trusts across the country to ensure that the NHS as a whole

could balance.

The Chair thanked Dr Clayton, Dr Morris and Mr Parr for their presentations.

RESOLVED: That the Governing Body noted the content of the financial review of

2016/17.

17.080 Any Other Business

No further business was discussed.

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17.081 Closing Remarks

The Chair stated that, as this would be the last AGM Meeting for Dr Clayton in light of his departure from the CCG at the end of September, on behalf of the CCG and the Governing Body, he wished to formally record his thanks to Dr Clayton for the tremendous amount of hard work he had done for the CCG over the past few years. The Chair added that BwD was a high performing CCG and had good partnerships with Local Authority, its GPs and was respected across the region. He stated that this was attributable to Dr Clayton and the way he had worked by being honest, encouraging debate and responding to any crisis in a calm, solution seeking, manner.

The Chair formally thanked Dr Clayton for all his work and wished him every success for the future.

The Chair drew the meeting to a close and thanked everyone for their attendance and contribution.

Signed Date

Page 8 of 8 Subject to approval at the next meeting

CLINICAL COMMISSIONING GROUP (CCG) Item 5.1 Minutes of the Governing Body (GB) Meeting held on Wednesday 6th September 2017 at 1.30 pm in Rooms 1 and 2, Blackburn Central Library, Town Hall Street, Blackburn, BB2 1AG

PRESENT: Mr Graham Burgess Chair (Chair) Dr Chris Clayton Clinical Chief Officer Mr Roger Parr Deputy Chief Executive/Chief Finance Officer Miss Claire Jackson Director of Commissioning Operations Dr Penny Morris General Practitioner (GP) Executive Member and Vice Chair Dr Zaki Patel GP Executive Member Dr Adam Black GP Executive Member Dr Preeti Shukla GP Executive Member Dr John Randall GP Executive Member Dr Nigel Horsfield Lay Member Dr Geraint Jones Lay Member – Secondary Care Doctor (Retired) Mrs Janet Thomas Executive Nurse/Associate Director of Quality and Commissioning.

IN ATTENDANCE: Dr Gifford Kerr Consultant in Public Health (representing Professor Dominic Harrison) Mr Iain Fletcher Head of Corporate Business Mrs Pauline Milligan Governing Body Secretary

Min No: 17.082 Chair’s Welcome

The Chair opened the meeting by welcoming all attendees and members of the public and thanked those who had attended the CCG’s Annual General Meeting (AGM).

The Chair welcomed Dr Phil Huxley, Chair, East Lancashire (EL) CCG, as an observer and explained that the two CCGs were more working more closely together.

17.083 Apologies for Absence and Confirmation of Quoracy

Apologies for absence had been received in respect of Dr Malcolm Ridgway, Clinical Director for Primary Care and Quality; Mr Paul Hinnigan, Lay Member – Governance and Professor Dominic Harrison, Director of Public Health, Blackburn with Darwen Borough Council (BwD BC).

The Chair confirmed that the meeting was quorate.

17.084 Declarations of Interest Relating to Items on the Agenda

The Chair reminded Members of their obligation to declare any interest they may have on any issues arising at Committee Meetings which might conflict with the business of BwD CCG.

Declarations declared by members of the GB are listed in the CCG’s Register of Interests. The Register is available, either via the Secretary to the GB or the CCG website via the following link:

http://www.blackburnwithdarwenccg.nhs.uk/about-us/registers-interests/.

The Chair reminded members that they should, if appropriate, make a declaration should a conflict emerge during the meeting and these would be recorded against the relevant agenda item.

17.085 Questions from Members of the Public

Q There are at least three leaflets about repeat prescriptions in Boots premises in BwD and they are incorrect due to your decision about 12 months ago.

These leaflets are national leaflets but it seems Boots have not been notified of the restrictions which you placed on repeat prescriptions. Could you formally notify Boots of this slight difficulty as they are offering incorrect advice to any patient who picks one of these leaflets up?

A Community Pharmacies are independent contractors and can display whatever leaflets they choose. The CCG has no jurisdiction over Community Pharmacy and does not contract with them.

The Head of Medicines Management at the CCG has informally visited Boots in Ewood to discuss the leaflets, and they stated that they have many patients with General Practitioners outside of the BwD area where the leaflet is relevant. Should a BwD patient request to use this service, they would advise that this is not possible due to local practice policy.

Q There is also an NHS England leaflet `Ref 092015_002 Product Code RD2 with a note Crown Copyright 2005 available in Boots which is completely inaccurate in that it refers to electronic prescriptions as “will be deployed in the near future”.

Should these leaflets be available in their current form?

A Having not seen these leaflets, it is not possible to answer this question. However, there are still some GP practices where the Electronic Prescription Service (EPS) has not yet been enabled.

This question should be referred to NHS England as they hold the contract with Community Pharmacies for EPS.

Q Can I compare the spending of different CCGs and how would I do this please?

A The comparison of spend across CCGs in Lancashire and South Cumbria would have to be obtained via a Freedom of Information (FoI) request to each individual CCG.

Q I wanted to know about the expenditure on the leaflets published by Healthier Lancashire and South Cumbria, which was known as the Sustainability and Transformation Plan and is now known as something else and has now leapt forward into Accountable Care Organisations. There are a lot of things being changed without us knowing about it.

A I do not have the figure for the cost of the Healthier Lancashire and South Cumbria (L&SC) Sustainability and Transformation Partnership (STP) brochure which had been produced but this will be answered by the FoI process. The Team have done their best to produce readable documentation which describes the process by which the STP Plan is being created. There is a lot of different terminology being used and we do need to be clear about what we mean when we speak about the different terms. Hopefully I clarified the different terms during the Stakeholder Event earlier today.

17.086 Minutes of the Meeting held on 5th July 2017

The minutes of the meeting were reviewed and accepted as an accurate record.

RESOLVED: That the minutes of the meeting held 5th July 2017 were approved as an accurate record.

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17.086.1 Extract of Part 2 of the Minutes of the Meeting held on 5th July 2017

The Extract of Part 2 of the Minutes of the Meeting held on 5th July 2017 was accepted as an accurate record.

RESOLVED: That the Extract of Part 2 of the Minutes of the Meeting held on 5th July 2017 was approved as an accurate record.

17.087 Matters Arising/Action Matrix

Matters Arising

There were no Matters Arising which were not listed on the Action Matrix.

17.087.1 Action Matrix

The Action Matrix was reviewed and the following were noted:

Minute 16.096/17.023.1/17.040.1/17.059.1 – Stroke Update Dr Nigel Horsfield reported that the Pennine Lancashire Quality Committee received a very good presentation from members of the Stroke Team, which included Nursing and Management staff, who had reported a significant improvement in the figures.

ACTION: The presentation was well received and it was agreed that it would be useful for the GB to receive a similar presentation.

Minute 16.101.1/17.023.1/ 17.040.1 – Cancer Performance Update The Chair reported that he would write again to the Chief Officer of Greater Preston CCG for an update on progress in the Autumn.

Minute 17.017/17.059.1 – Intermediate Care Re-provision The Chair reported that conversations with BwD BC about future plans were ongoing and the GB would be updated accordingly.

Minute 14.041 (iii) – Chief Officer Report The Chair reported that the CCG would request that a member of the Fylde Coast attend a future meeting once the work was established.

17.088 Clinical Chief Officer’s Report

Dr Chris Clayton presented his report and highlighted the following items:

• Department of Health: o NHS Transformation;

• NHS England: o NHS Continuing Healthcare Assessment Process;

• L&SC: o Joint Committee of CCGs; o Primary Care Transformation Project.

• Pennine Lancashire: o Together a Healthier Future Programme.

• Blackburn with Darwen o 2016/17 Annual Assessment; o Accountable Officer; o Lay Member Term of Office;

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o Healthwatch; o Borough Council – Road Safety.

• Good News o National Institute for Health and Care Excellence (NICE) Learning Awards 2017; o Practice in Management Award.

There were no questions.

As this was the last meeting of the GB for Dr Clayton, the Chair stated that he wished to repeat the comments he made at the earlier AGM and, on behalf of the GB, formally record his thanks for all the work Dr Clayton had done for the CCG. The Chair added that, on a personal note, it had been a pleasure to work with him for the last few years.

RESOLVED: That the GB noted the content of the report.

17.089 Chief Finance Officer’s Report

Mr Roger Parr presented the report for month 4 and highlighted key elements.

The CCG reported a year to date surplus of £781k, which was £35k ahead of plan. The CCG was forecasting to deliver a surplus of £2,346k; £107k ahead of plan.

Mr Parr reminded members that it was still early in the financial year. He explained that the CCG was holding its 0.5% risk reserve, as per national guidance, and this was excluded from the reported financial position.

He referred to the level of performance in relation to activity within the Acute Trust at the end of the last financial year and explained that this level of activity had continued into the first part of this year. The CCG’s contract with its main provider was currently underperforming; with a slight underspend.

Mr Parr drew members’ attention to the risks within the system.

Questions and answers followed.

ACTION: Following discussion about the reasons for the reduction in activity within the Acute Trust, the Chair requested that Mr Parr and team carry out further analysis on the figures to enable the GB to understand the reasons for the reduction.

The Chair thanked Mr Parr and all the teams who were working to deliver the CCG’s finance and performance targets across the patch.

RESOLVED: That the GB noted the content of the financial summary and the financial position of the CCG at the end of July 2017.

17.090 Contract, Quality and Performance Report

Mr Parr presented the contracting section of the month 3 report and then deferred to Mrs Janet Thomas to highlight the key points related to quality and performance.

Mr Parr highlighted the following:

• Lancashire Care NHS Foundation Trust (LCFT) Mental Health Services (page 3): o Psychological Therapies – Mr Parr reported that the expected activity for Quarter 1 was slightly ahead of plan (the figures did not include the data from the Long Term Conditions pilot scheme); o Admissions – the number of admissions to mental health in patient wards was stable; o Out of Area Placements (OAPs) – the number of OAPs had reduced for BwD

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residents.

• East Lancashire Hospitals NHS Trust (ELHT) (page 5): o Accident and Emergency (A&E) – activity had significantly reduced; o Non-elective admissions – Mr Parr reported that there were currently two queries lodged at the moment in relation to activity with the Trust; o ‘Awaiting Treatment Performance’ – the figures remained stable. Primary Care (page 7) o Out of Hours – there was a reduction in activity. • Other Significant Contracts (page ): o North West Ambulance Service (NWAS) – it was noted that NWAS was piloting a new way of reporting its data and the results of this would be published in future reports.

Mrs Thomas highlighted the following:

• LCFT – Mental Health Services (page 3): o Memory Assessment Service (MAS) – the memory assessment trajectory had been met with performance of 84.48% of patients being seen within the six weeks target. • ELHT – (page 5): o A&E 4 Hour – the recovery plan was in place and continued to report an improvement in performance which was being monitored by the A&E Delivery Board (A&EDB). • Primary Care – (page 7): o Care Quality Commission – 24 out of 26 practices had been inspected and, out of the 22 reports published, 1 practice had been rated as ‘outstanding’, 20 practices had been rated as ‘good’ and 1 practice had been rated in October 2016 as ‘inadequate’. This practice had now been re-inspected and the results of the inspection were awaited. Mrs Thomas stated that Primary Care should be commended for the quality of service that had been demonstrated across its practices. • LCFT – Community Services (page 8): o Referral to Treatment (RTT) (Incomplete) – there was an improvement in the Children’s Speech and Language Therapy (SALT) Service. A recovery plan was in place.

Questions and answers followed.

ACTION: Following discussion regarding A&E 4 Hour performance, Miss Jackson agreed to ensure that the reports from the A&EDB are presented to the GB on a regular basis and the Plan on the Page is circulated to members once finalised.

RESOLVED: That the GB noted the content of the reports and supported the actions as identified.

17.091 Healthier L&SC STP Governance Proposal

Dr Clayton provided background information to the proposed new STP governance arrangements.

The proposal contained two elements:

• STP Governance; • Accountable Care (in Blackpool and the Fylde Coast).

Dr Clayton explained the two elements and drew members’ attention to two Memorandums of Understanding (MOUs) which would set out:

• the deliverables for the whole of L&SC;

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• the objectives of the national MOU for the Fylde Coast.

Dr Clayton drew members’ attention to the diagram (page 3) which outlined the proposed new STP governance arrangements and the creation of an STP Board. The STP Board would have an MOU between itself and NHS England and NHS Improvement which would allow it to operate within certain criteria.

The STP would focus and review performance on a number of areas:

• Urgent Care; • Mental Health; • Primary Care; • Cancer.

The Chair explained the link between the STP Board and the Joint Committee of CCGs (JCCCGs). The STP Board would have no statutory powers, i.e. it was a partnership and not a legal body. The decision making body remained as the JCCCG, which was accountable to the L&SC CCGs.

Questions and answers followed.

Dr Clayton referred to the section which set out the proposed membership of the STP Board (page 9) and explained the composition of the Board.

Questions and answers followed.

ACTION: The Chair invited anyone who wanted to be a representative for Pennine Lancashire to contact himself or Dr Clayton.

RESOLVED: That the GB:

i. supported the establishment of the STP Board for L&SC, in line with the explanatory information contained in this report; ii. noted that the other aspects of the governance arrangements already exist and the terms of reference for the various groups will need to be refined over time as and when the STP Board becomes fully operational; iii. supported a revised Governance structure for L&SC STP.

17.092 Healthier L&SC STP Development of Shared Decision Making for the Joint JCCCGs

Dr Clayton presented the report which put forward proposals to the GBs across L&SC CCGs for the development of shared decision-making that would:

• enable effective shared decision making on agreed STP-wide priorities; • give CCG GBs assurance on appropriate governance arrangements and confidence to delegate decision-making authority to the JCCCG; • provide a consistent framework which also supports and clarifies decision-making in local accountable systems (Local Delivery Partnerships) and neighbourhoods.

Dr Clayton reminded members of the background to the development of the proposals and drew members’ attention to the four main delegations (Appendix 1) in relation to:

• commissioning and prescribing policies; • stroke; • adult mental health and dementia; • learning disabilities.

He also highlighted future potential delegations (Appendix 2) in relation to:

• acute and specialised services; Page 6 of 10

• urgent and emergency care; • children and young people’s mental health and well-being; • adult mental health and dementia; • transforming care (learning disabilities).

Dr Clayton summarised that the GB was being asked to support the proposal in order to commence effective strategic commissioning in these areas.

Questions, answers and comments followed.

ACTION: It was agreed that a representative from the Together a Healthier Future Programme Office would be invited to a future GB Development Session to provide some options for Accountable Care System models.

RESOLVED: That the GB:

i. noted that the JCCCGs was established by the L&SC CCGs in December 2016 to facilitate effective and defensible shared decision making in support of the STP; ii. noted the expectations of national regulators for the evolution of shared decision making in this fast-track STP; iii. considered and approved the requested delegations for joint decision-making through the JCCCG for 2017/18, as described in Appendix 1; iv. noted that further delegations are likely to be requested in future around areas described in Appendix 2; v. requested that the JCCCGs reviews and strengthens the STP guiding principles for decision-making. vi. noted that CCG leaders have agreed to produce a Commissioning Development Strategy during the autumn of 2017 and this will be presented to GBs in due course.

17.093 Governing Body Assurance Framework Update

Mr Parr presented the quarterly Governing Body Assurance Framework (GBAF) for review. He explained that the GBAF was a key document which linked the CCG’s corporate objectives to risks, controls and assurances and provided assurance to the GB on the CCG’s systems of internal control.

Mr Parr informed members that a piece of work was underway with EL CCG to review the CCGs’ Risk Registers. It had been found that there some risks common to both registers but there were also some different scores on some risks and work was continuing to understand why some of the scores were different and how common scoring could be achieved across Pennine Lancashire.

Mr Parr reminded members that they had been sent documentation to complete the annual risk appetite exercise; an important exercise used to assess the risk appetite of the GB and compare the results to previous years.

Questions and answers followed.

RESOLVED: That the GB:

i. noted the content of the report; ii. reviewed the GBAF risks.

17.094 Replacement Process for the CCG’s Accountable Officer

The Chair presented the report, which briefing GB members of the proposed process to appoint a replacement for the CCG’s Accountable Officer (AO).

The Chair drew members’ attention to the short timeframe in relation to the process and the

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criteria set out in the CCG’s Constitution, i.e. that any potential applicant currently needed to be a practising GP elected to the GB.

He outlined further considerations for members and details of the role of the AO.

The Chair explained the two stage process that was being proposed:

• Stage 1

That the CCG set out to appoint an Interim AO until 31st March 2018 and would seek to do this from the current GP GB members subject to a review of suitability requirements etc.

The CCG would then go to the Membership to seek an Interim GP GB Member to maintain the clinical leadership.

If no such interim appointment was possible, then the CCG should then seek urgent change to the Constitution to allow an alternative approach to appointment in the interim period.

• Stage 2

That during the interim phase, the CCG embarked upon a conversation with the CCG Membership upon the options of AO leadership that were available in the context of the changing health and care system and associated practicalities such as the contractual mechanisms of appointment and the timescales. It was proposed to call a Senate Meeting in September to start the engagement with the Membership.

Depending upon the preferred model, any required changes to the Constitution could be agreed and ratified by the Membership during that time to allow any such future appointment to take place.

Other potential alternative options to a GP GB member undertaking the AO role included:

• Sharing an AO with another CCG; • Sharing an AO with the Local Authority; • Appointing an independent non GP AO which could include a development opportunity from within the Executive Team.

Members noted that, in addition, discussions would take place with NHS England through the Chair to gain its support and advice on the suggested proposals.

Questions and answers followed.

It was noted that the alternative options listed in the proposal were not exclusive and there were a range of options which could be considered.

RESOLVED: That the GB supported the two stages outlined in the report.

17.095 Process for 2017-18 Emergency Preparedness, Resilience and Response (EPRR) Assurance

Mr Iain Fletcher presented a suite of documents following the publication of revised EPRR core standard documentation by NHS England in July 2017.

Mr Fletcher explained that the core standards applicable to the CCG had been reviewed to produce a statement of compliance to be endorsed by the GB and submitted to NHS England by September 2017.

Mr Fletcher outlined the process in relation to the CCG’s providers and assurance of their

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compliance with the standards.

There were 38 standards to be considered this year and a requirement to complete a deep dive on elements of governance by March 2018.

Mr Fletcher reported that, following discussions with colleagues at EL CCG, it had been agreed that the Pennine Lancashire CCGs were now ‘fully compliant’ with the core statement and this was the recommendation for GB approval.

Questions and answers followed.

RESOLVED: That the GB:

i. agreed the submission of full compliance against the core standards requirements; ii. noted the proposal to submit a health economy report to NHS England within their timescales and to receive the report at the GB meeting.

17.096 Annual Report of the Audit Committee

Mr Parr presented the above report in the absence of Mr Paul Hinnigan, Audit Committee Chair.

The report had been to the Audit Committee and approved for presentation to the GB for information.

There were no questions.

RESOLVED: That the GB noted the content of the report.

17.097 Communication and Engagement Update

Mr Fletcher presented the report and explained that the report had been produced during a period of purdah and, therefore, had been subject to its restrictions on publicity.

Mr Fletcher drew members’ attention to the increase in activity in relation to the CCG’s website and social media channels.

There were no questions.

RESOLVED: That the GB:

i. noted the content of the report; ii. agreed to feedback any comments or suggestions in relation to communications and engagement activity and comment on future plans; iii. agreed to receive a further report at its meeting in October 2017.

17.098 Review of Register of Interests

Mr Fletcher presented the review of the GB’s Register of Interests for the information of members.

There were no questions.

RESOLVED: That the GB noted the content of the report.

17.099 Sub-Committees and Groups’ Minutes

Mr Fletcher presented the report, which included the minutes of the GB Sub-Committees and Groups for receipt and note by members to inform the GB of delegated and key decisions taken and provide information regarding items of particular interest or potential risk.

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There were no questions.

RESOLVED: That the GB noted the content of the report.

17.100 Any Other Business

No further business was discussed.

17.101 Date and Time of Next Meeting

The next meeting will be held on Wednesday 8th November 2017 at 1 pm in Meeting Rooms 1 and 2 Blackburn Central Library, Town Hall St, Blackburn, BB2 1AG.

The Chair thanked everyone for their attendance and input and the meeting closed.

Signed ………………………………………………. Chair ……………………………………………… Date

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CLINICAL COMMISSIONING GROUP (CCG) Item 5.2 Extract from the Minutes of Part 2 of the Governing Body (GB) Meeting held on Wednesday 6th September 2017 at 3 pm in Rooms 1 and 2, Blackburn Central Library, Town Hall Street, Blackburn, BB2 1AG

IN ATTENDANCE: Mr Iain Fletcher Head of Corporate Business Mrs Pauline Milligan Governing Body Secretary

Re-Confirmation of Apologies for Absence and Quoracy Apologies for absence had been received in respect of Dr Malcolm Ridgway, Clinical Director for Primary Care and Quality; Mr Paul Hinnigan, Lay Member – Governance and Professor Dominic Harrison, Director of Public Health, Blackburn with Darwen Borough Council (BwD BC).

The Chair confirmed that the meeting was quorate.

Re-Confirmation of Declaration of Interests The Chair reminded Members of their obligation to declare any interest they may have on any issues arising at Committee Meetings which might conflict with the business of BwD CCG.

Declarations declared by members of the GB are listed in the CCG’s Register of Interests. The Register is available, either via the Secretary to the GB or the CCG website via the following link:

http://www.blackburnwithdarwenccg.nhs.uk/about-us/registers-interests/

No declarations of interest were made with regards to items on the agenda at this point.

The Chair reminded members that they should, if appropriate, make a declaration should a conflict emerge during the meeting and these would be recorded against the relevant agenda item.

A/17 Minutes of Part 2 of the Meeting held on 5th July 2017

The Minutes of Part 2 of the Meeting held on 5th July 2017 were reviewed and accepted as an accurate record.

RESOLVED: That the Minutes of Part 2 of the Meeting held on 5th July 2017 were approved as an accurate record.

B/17 Matters Arising

There were no matters arising.

B/17.1 Action Matrix

Minute E/17 March – Acute Visiting Service (AVS) Miss Claire Jackson reported that the CCG was just awaiting formal sign off of the contract variation.

Minute B/17.1 May/B/17.1 July – Any Other Business – Bariatric Services Dr Chris Clayton reported that decisions of this nature would be picked up by the Joint Committee of CCGs going forward.

C/17 Pennine Lancashire Clinical Commissioning Groups’ Confidential Provider Update

Mrs Janet Thomas presented the report, which provided the GB members with a briefing on new provider performance/quality issues that have occurred since the last meeting.

Mrs Thomas drew to members’ attention to key issues.

Questions and answers followed.

RESOLVED: That the GB received the report for information purposes.

C/17.1 Independent Investigation Report

Mrs Thomas presented the above confidential report and explained that, as the lead commissioner for Mental Health Services, the CCG was required to approve the report for publication on its website.

Mrs Thomas provided background to the report, which was commissioned by NHS England in April 2016 in order for an independent organisation to undertake an investigation into the care and treatment of a patient and the events that led up to the death of the patient’s spouse.

The investigation concluded that that given the complexities of the case the death of the patient’s spouse was not preventable.

There were a range of actions which had been included in the report for Lancashire Care NHS Foundation Trust, Lancashire County Council and the CCG and these actions would be overseen by the Safeguarding Adults Board and monitored via the Pennine Lancashire Quality Committee.

Mrs Thomas concluded that, if the GB approved the content of the report, it would be published on the CCG’s website.

There were no questions.

RESOLVED: That the GB: i. considered the content of the Independent Report; ii. ensured that the resulting actions and outcomes addressed all areas Page 2 of 3

where lessons should be learned and actions appropriate to allow formal publication on 15th September 2017.

D/17 Joint Commissioning Arrangements

Miss Claire Jackson provided an update presentation on developments in relation to the establishment of a Joint Commissioning Committee between the two Pennine Lancashire CCGs.

Miss Jackson reminded members of the recommendations presented to the Joint Board to Board in June and the proposed governance structure.

She outlined progress to date and explained next steps.

Questions and answers followed.

RESOLVED: That the GB noted the content of the update.

E/17 General Practitioner Executive Time Commitment

Dr Chris Clayton confirmed that the current time commitments of the GP Executives remained unchanged.

RESOLVED: That the GB noted the content of the update.

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Item 6.1

GOVERNING BODY (GB) MEETING - ACTION MATRIX PART 1

Action Origins Action Owner Due Date Status GB Ref 16.096/17.023.1 Stroke Update The Chair requested that the Executive Team (ET) consider the questions and comments posed by members of the GB and produce a report in response to be presented to the appropriate forum for action and then the results reported back to the GB in early 2017.

17.040.1 Dr Chris Clayton agreed to investigate the current position related to Stroke Services and report back to the next meeting.

17.059.1 It was agreed at the June Development Session that stroke would be added to the agenda of the next Executive Team to Team Meeting with East Lancashire CCG.

17.081.1 Dr Nigel Horsfield reported that the Pennine Lancashire Quality Committee received a very good presentation from members of the Stroke Team, which included Nursing and Management staff MR/JT Future In progress. and reported a significant improvement in the figures. The Agenda presentation was well received and it was agreed that it would be useful for the GB to receive a similar presentation.

16.101.1/17.023.1 Cancer Performance Update The Chair confirmed that a response had been received from the Chief Officer of Greater Preston CCG, who attends the Cancer Alliance Meetings, which had been circulated to members and suggested that a review of progress regarding the recommendations from the Lancashire and South Cumbria Acute

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Oncology Review should take place at the end of May.

17.040.1/17.081.1 The Chair reported that he would write again to the Chief Officer GB November In progress. of Greater Preston CCG for an update on progress in the Autumn. 17.017/17.059.1/ Intermediate Care Re-provision 17.081.1 The Chair reported that conversations with BwD BC about future plans were ongoing and the GB would be updated accordingly. CJ November Completed.

17.041 (iii) Chief Officer Report The Chair referred to the content of section 3.3, which referred to the work on the Fylde Coast being highlighted as an ‘exemplar’ of good practice and requested that the Executive Team organise a briefing/presentation for the GB outlining what it means to be recognised as an ‘exemplar’.

17.081.1 The Chair reported that the CCG would request that a member of Executive Future In progress. the Fylde Coast attend a future meeting once the work was Team Meeting established. 17.083 Chief Finance Officer’s Report Following discussion about the reasons for the reduction in activity within the Acute Trust, the Chair requested that Mr Parr RP November The trend was linked to out of and team carry out further analysis on the figures to enable the hospital provision. GB to understand the reasons for the reduction. 17.084 Contract, Quality and Performance Report Following discussion regarding A&E 4 Hour performance, Miss Jackson agreed to ensure that the reports from the A&EDB are CJ November Completed. presented to the GB on a regular basis and the Plan on the Page is circulated once finalised. 17.085 Healthier Lancashire and South Cumbria (L&SC) Sustainability and Transformation Partnership (STP) Governance Proposal All September Completed. The Chair invited anyone who wanted to be a representative for Pennine Lancashire to contact himself or Dr Clayton. 17.086 Healthier L&SC STP Development of Shared Decision Making for the Joint JCCCGs It was agreed that a representative from the Together a Healthier Future Programme Office would be invited to a future GB GB December Completed. Development Session to provide some options for Accountable Care System models

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GOVERNING BODY MEETING

CLINICAL CHIEF OFFICER’S REPORT

Date of Meeting 8th November 2017 Agenda Item 7

CCG Corporate Objectives

Through better commissioning, improve local health outcomes by addressing poor X outcomes and inequalities To work collaboratively to create safe, high quality health care services X To maintain financial balance and improve efficiency and productivity X To deliver a step change in the NHS preventing ill health and supporting people to live X healthier lives To maintain and improve performance against core standards and statutory requirements X To commission improved out of hospital care X CCG High Impact Changes Delivering high quality Primary Care at scale and improving access X Self-Care and Early Intervention X Enhanced and Integrated Primary Care and Better Care Fund X Access to Re-ablement and Intermediate Care X Improved hospital discharge and reduced length of stay X Community based ambulatory care for specific conditions X Access to high quality Urgent and Emergency Care X Scheduled Care X Quality √ GOVERNOVERNING BODY MEETING Clinical Lead: Dr Penny Morris

Senior Lead Manager Mr Iain Fletcher Finance Manager Mr Roger Parr Equality Impact and Risk Assessment The report is for the information of members only. completed: Patient and Public Engagement completed: The report is for the information of members only. Financial Implications The report is for the information of members only. Risk Identified The report is for the information of members only. Report authorised by Senior Manager: Dr Penny Morris Decision Recommendations

The Governing Body is requested to receive this report and to note the items as detailed.

Report of the Clinical Chief Officer – 8th November 2017 Page 2 of 13

CLINICAL COMMISSIONING GROUP (CCG)

GOVERNING BODY MEETING

8TH NOVEMBER 2017

CLINICAL CHIEF OFFICER’S REPORT

1) Introduction

I am pleased to present my first report to the Governing Body (GB), which provides an update on national and local issues of interest to members not covered elsewhere on the agenda, and also provides an indication of where my efforts have been directed since the departure of Dr Chris Clayton, Clinical Chief Officer.

As members will already be aware, I have recently been appointed as the Clinical Chief Officer for Blackburn with Darwen CCG with effect from 30th October 2017.

2) Department of Health

2.1 Appointment

The Department of Health (DH) has confirmed the appointment of Professor Jonathan Van-Tam as the new Deputy Chief Medical Officer for England.

Professor Van-Tam took up the position on 2nd October 2017. He replaced Professor John Watson who retired after 4 years in the role.

The Deputy Chief Medical Officers are senior public health leaders who support the Chief Medical Officer – the most senior adviser on health and medicine to the UK Government.

2.2 Winter Funding

The DH announced that a further 19 hospitals across England have been given a cash injection of over £13 million for emergency care, in the latest wave of winter funding.

Around £13 million has been awarded to improve patient flow through Accident and Emergency (A&E); ensuring departments are prepared for busy times during winter. The additional funding brings the total given to hospitals since April to over £90 million, part of the dedicated funding announced in the Spring Budget.

The Minister of State for Health, Mr Philip Dunne, said that thanks to the hard work and dedication of staff, the NHS has put in place strong plans ahead of winter - ensuring patients continue to receive safe and efficient care as demand rises over the coming months.

The funding will give more hospitals the boost they need to streamline patient flow in A&E, freeing up A&Es to care for the sickest patients and helping make sure all patients get the right treatment in the right place as quickly as possible.

The funding will be used to help hospitals finalise preparations ahead of winter, particularly to handle the large volumes of patients attending A&E. By investing in the necessary equipment or infrastructure, hospitals will be able to target improvements to patient flow and relieve pressure on A&E.

Report of the Clinical Chief Officer – 8th November 2017 Page 3 of 13 The funding supports NHS England’s wider plans to improve A&E performance in England by 2018. In particular, it will help hospitals hit the target of admitting, transferring or discharging 95% of patients within 4 hours.

Members will find a report, which outlines plans for improving the performance of the Pennine Lancashire Urgent and Emergency Care system, later on today’s GB agenda.

Further information via: https://www.gov.uk/government/news/new-13-million-funding-to-help- hospital-aes-prepare-for-winter

2.3 Nationwide Digital Services

The Health Secretary, Jeremy Hunt, said during a speech at the Health and Care Innovation Expo in Manchester on 12 September that “every patient in England should be able access their medical records and book an appointment with a General Practitioner (GP) via an app by the end of 2018”. He referred to the next 10 years as ‘the decade of patient power’.

By the end of 2018 – the 70th birthday year of the NHS – the Health Secretary said he expects every patient in England to be able to do the following online through an app:

• access NHS 111; • access their healthcare record; • book an appointment with a GP; • order repeat prescriptions; • express their organ donation preferences; • express their data sharing preferences; • access support for managing a long term condition;

Pilot schemes are already underway, with ongoing evaluation before a potential national roll-out.

The Health Secretary said “if the NHS is going to be the safest, highest quality healthcare system in the world we need to do technology better. So today I am setting 7 challenges which, if we achieve them, will make the NHS a world-beater in the care of people with long term conditions.

People should be able to access their own medical records 24/7, show their full medical history to anyone they choose and book basic services like GP appointments or repeat prescriptions online.

I do not underestimate the challenge of getting there – but if we do it will be the best possible 70th birthday present from the NHS to its patients.”

Online trials of support for long-term conditions have already been successful, with apps such as MyCOPD helping patients manage their conditions with less reliance on GP and hospital appointments.

To ensure independent ‘digital doctors’ are operating at the same high standard as the rest of the NHS, the DH has launched a consultation about expanding the number of providers included in the Care Quality Commission’s (CQC) ratings system.

In his address to delegates the Health Secretary also announced:

• the launch of MyNHS open data challenge – a £100,000 fund to reward most creative apps and digital tools to improve services; • an update on the acute and mental health global digital exemplars – organisations which deliver care through world-class use of digital technology and information flows;

Report of the Clinical Chief Officer – 8th November 2017 Page 4 of 13 • which Trusts will form part of a further wave of exemplars – the ‘Fast Followers’ – which will receive up to a total of £80 million over the life of the programme (to the end of the financial year 2020 to 2021), with each Fast Follower matching funding; • £21 million of new matched funding for up to 7 mental health Fast Followers – creating fresh investment of up to £42 million.

In Blackburn with Darwen (BwD), patients are able to access NHS 111, their healthcare record, book an appointment with a GP and order repeat prescriptions. The CCG is working with practices to encourage patients to use the services which are in place.

The CCG is exploring a range of digital solutions for chronic obstructive pulmonary disease, diabetes and other Long Term Conditions. In addition, the CCG has a programme of work underway to deploy a choice of health apps to practices.

Once further guidance has been published, the CCG will support practices and patients to meet the new national requirements.

As previously reported to the GB, there is a live website in Lancashire and South Cumbria (L&SC) which gives nearly 2 million people and the clinicians that serve them access to the best health and care apps that are available.

ORCHA – which stands for Organisation for the Review of Care and Health Apps – links to a range of health apps that have received fully impartial reviews by doctors and other clinical experts, with scoring criteria added to the reviews to help make informed decisions with more confidence more quickly. Once a person has decided which app to try, ORCHA will easily allow them to download it direct from the website.

The ORCHA website can be access via: https://lancashire.orcha.co.uk

Further information via: https://www.gov.uk/government/news/health-secretary-challenges-nhs-to- deliver-digital-services-nationwide

2.4 Trainee GPs

The Health Secretary announced a package of measures to strengthen General Practice on 12th October.

From 2018, surgeries in hard-to-recruit-to areas will benefit from a new Government-backed scheme – the Targeted Enhanced Recruitment Scheme – which will offer a one-off payment of £20,000 to attract trainees to work in areas of the country where training places have been unfilled for a number of years.

The DH has also asked Health Education England (HEE) to make sure many of the 1,500 additional medical training places that will be funded from next year are located in priority areas, including rural and coastal communities.

Speaking at the Royal College of General Practitioners Conference in Liverpool, he focused on recruitment and retention across General Practice, with other measures including:

• new flexible working arrangements, including the opportunity to take on mentoring and leadership roles, for GPs considering retirement; • a new international recruitment office set up by NHS England to help local areas to recruit GPs from overseas, with plans to expand fast-track routes into general practice for Doctors trained outside the European Economic Area in countries such as Australia;

Report of the Clinical Chief Officer – 8th November 2017 Page 5 of 13 • a consultation on the regulation of Physician Associates to provide further clarity on the scope of the role, and exploring how support staff can bolster healthcare teams across the country.

Further information via: https://www.gov.uk/government/news/jeremy-hunt-announces-salary- supplement-for-trainee-gps

2.5 Grant Scheme to Improve Mental Healthcare

The DH launched a £15 million fund to better support people at risk of experiencing a mental health crisis.

The Beyond Places of Safety scheme will improve support services for those needing urgent and emergency mental healthcare. This includes conditions such as psychosis, bipolar disorder, and personality disorders that could cause people to be a risk to themselves or others.

The Beyond Places of Safety scheme will focus on:

• preventing people from reaching crisis point in the first place; • helping to develop new approaches to support people who experience a mental health crisis.

The Health Secretary said that, “as part of the Government’s commitment to improving mental health throughout society, we are determined to go further to help people who are experiencing a crisis or feel they are approaching one.

We want make sure that therapeutic and empathetic support is in place to stop people falling ill, support them through crisis and help them recover”.

The additional funding will give local areas scope to do even more, and it is hoped that there will lots of innovative ideas for improving urgent and emergency mental healthcare across the country.

The launch of the Beyond Places of Safety fund follows a £15 million investment in the Improving Places of Safety scheme, which aims to reduce the number of people who end up in a police cell following detention under the Mental Health Act.

Further information via: https://www.gov.uk/government/news/new-15-million-grant-scheme-to- improve-mental-healthcare

2.6 GP Indemnity

The Government is planning to develop a state-backed indemnity scheme for GPs, to protect them from the costs of clinical negligence claims, subject to further work on relevant issues.

The Government’s ambition is to provide a more stable and affordable system for GPs. The scheme could provide financially sustainable cover for claims arising from the delivery of NHS services.

The Government has been working with the 4 medical defence organisations that currently provide indemnity cover to GPs and with GPs on how a state-backed scheme could work. Any new scheme should:

• meet the needs of current and future GPs; • be in the interest of patients; • represent value for money for taxpayers.

Report of the Clinical Chief Officer – 8th November 2017 Page 6 of 13 Urgent discussions will take place with GP representatives on how best to engage with the sector. The scheme will need careful negotiation and will take at least 12 to 18 months to establish. GPs should continue to make sure they have appropriate indemnity cover, in line with General Medical Council (GMC) requirements, to enable them to practise.

Further information via: https://www.gov.uk/government/news/gp-indemnity-development-of-state- backed-scheme-for-england

3) NHS England

3.1 Appointment

NHS England has announced the appointment of Mr Ray James as its first National Learning Disability Director, to drive improvement across the country on services to people with a learning disability, their families and carers.

Mr James is the former national president of the Association of Directors of Adult Social Services and the long-standing executive Director of Health, Housing and Adult Social Care at the London Borough of Enfield.

He has led on significant programmes of work nationally and at Enfield he led teams who have achieved multiple award-winning services in respect of safeguarding, community involvement and independent living for disabled adults.

Further information via: https://www.england.nhs.uk/2017/10/nhs-england-appoints-senior-local- government-leader-as-national-learning-disability-director/

3.2 Innovation to Transform

At the Health and Care Innovation Expo in Manchester in September, the Chief Executive of NHS England, Mr Simon Stevens, set out an ambitious vision for the NHS as it approaches its landmark 70th anniversary – calling on health and care leaders to unleash the game changing potential of innovation for both patients and taxpayers.

Mr Stevens unveiled new plans to free up funds for the latest world class treatments by slashing hundreds of millions from the nation’s drugs bill and announce that new and cutting edge treatments will be routinely available for the first time.

Innovations include:

• Revolutionary new treatment for Hepatitis C is set to save NHS England more than £50 million as well as saving thousands more lives; • New measures to slash up to another £300 million from the nation’s medicines bill; • Trailblazing new treatment to restore sight using patients’ own teeth; • Routine commissioning of the latest technology to help deaf children hear; • An expansion of the test-bed programme testing the treatments and care models of tomorrow.

Mr Stevens revealed that investment in new oral treatments that can cure Hepatitis C more quickly and with fewer side effects has already led to a 10 per cent reduction in the number of deaths and an unprecedented reduction in liver transplants for Hepatitis C of around 50 per cent.

This is the latest in a series of innovative drug deals that has been made possible by NHS England working closely with industry to bring prices down, expand treatment options and make new treatments available rapidly – in one case within just four weeks of a treatment receiving its marketing authorisation.

Report of the Clinical Chief Officer – 8th November 2017 Page 7 of 13

Health and care leaders will also hear how new rules on the use of biosimilar medicines – cheaper but equally clinically effective to original ‘biological’ treatments –giving Doctors a choice of new treatments for thousands of patients with serious and painful conditions, such as cancer and rheumatoid arthritis, but at a significantly reduced cost.

Currently six of the top 10 drugs in the UK by cost are biological medicines – the most complex and therefore expensive used in the NHS. The plans to accelerate and widen the uptake of biosimilars will save hundreds of millions of pounds from the nation’s medicine bill, estimated to be up to £300m a year by 2021.

Mr Stevens also signalled NHS England’s intent to continue to develop the successful Test Bed Programme as the NHS goes into its 70th year. 7 sites have been working with 40 innovators, 51 digital technology products, eight evaluation teams and five voluntary sector organisations to understand which products and processes can save and transform lives, at the same or lower cost than current practice.

In the coming years, more biological medicines are set to lose patent exclusivity and more biosimilar medicines are expected to come into the marketplace. Biosimilars that are already delivering safe, effective treatment for patients and cost savings for the NHS, include:

• Biosimilar Infliximab, which is used to treat rheumatology conditions and inflammatory bowel disease, came on the market in March 2015, and is currently being used by 80 per cent of patients; • Biosimilar Etanercept, which is used to treat rheumatology conditions, became available in April 2016, and 58 per cent of patients are using it; • Switching to these two latest biosimilars has already saved the NHS approximately £160 million per annum; • In April 2017, biosimilar Rituximab, a medicine that treats cancer and rheumatoid arthritis, became available; • In 2018 biosimilar Adalimumab will become available, which is used to treat rheumatology conditions and inflammatory bowel disease – this will offer an biosimilar alternative to the current medicine which accounts for the highest spend in hospitals – more than £300 million in 2015/16.

The introduction of lower cost biosimilar medicines has the dual advantage of also driving down the cost of the original drug. For example, the cost per defined daily dose for Infliximab has fallen by nearly two-thirds from £16.80 to £6.84.

Further information via: https://www.england.nhs.uk/2017/09/as-nhs-approaches-70-it-is-time-to- unleash-the-potential-of-innovation-to-transform-patient-care-says-simon-stevens/

3.2 Winter Pressures

NHS England, Public Health England, the DH and NHS Improvement have unveiled measures to boost the uptake of flu vaccinations along with package of new contingency actions to respond to pressures on frontline services this winter. Intensified preparations include:

• Providing free flu vaccines for hundreds of thousands of care home staff at a cost of up to £10m as well as increasing the number of jabs for young children in schools and vulnerable people; • Directing NHS Trusts to ensure they make vaccines readily available to staff and record why those who choose to opt out of the programme do so; • Writing to Doctors, Nurses and other healthcare workers reminding them of their professional duty to protect patients by being vaccinated;

Report of the Clinical Chief Officer – 8th November 2017 Page 8 of 13 • Setting up a new National Emergency Pressure Panel to provide independent clinical advice on system risk and an appropriate regional and national response; • The biggest expansion in training for A&E consultants ever with hundreds more Doctors over the next four years and other healthcare staff.

Many people with flu show no symptoms, meaning healthcare workers who feel fit and healthy can unwittingly infect vulnerable patients. Getting vaccinated is the best way to stop the spread of influenza and prevent deaths. It can also ease pressures that a heavy flu outbreak would place on services such as doctors’ surgeries and busy hospital wards, like those seen recently in Australia and New Zealand.

NHS staff are already offered the vaccination for free to protect patients and the public. This winter, in recognition of how important this is, NHS England will extend free jabs to up to more than one million care home workers and has set aside £10million to fund it.

Health Chiefs have directed all Trusts to increase programmes to ensure that Nurses, Doctors and other healthcare professionals get their flu jabs – protecting themselves and their patients this winter. Although last year saw record take up more than one in three NHS staff failed to do so, with just one in five being vaccinated in some Trusts. This year, NHS Trusts have been told to make the vaccine readily available to staff without the need to disrupt their work and record why anyone who decides to opt out chose to do so. A letter has been sent to all Doctors, Nurses and other NHS staff to remind them of their professional duty to protect their patients.

The CCG has undertaken a programme of engagement to encourage patient uptake of the flu vaccination, especially in children, and BwD CCG staff received their flu injections at a session on 25th October.

Further information via: https://www.england.nhs.uk/2017/10/nhs-leaders-unveil-action-to-boost-flu- vaccination-and-manage-winter-pressures/

4) Public Health England

4.1 Stoptober

New data published in a University College of London (UCL) report shows quitting success rates at their highest for at least a decade, up to 19.8% for the first 6 months of this year, significantly higher than the average for the last 10 years (15.7%).

Success rates among the less well-off have for years remained consistently low, but in a major turnaround the sharp increase in success rates is being seen entirely among this group. For the first time, smokers in manual occupational groups have virtually the same chances of quitting as those in white collar jobs.

The report coincided with the launch of the Stoptober quit smoking challenge, which has inspired over one and a half million quit attempts since 2012. The campaign is based on research that if you stop smoking for 28 days you are 5 times more likely to stop for good.

With Stoptober now in its sixth year, the UCL report gives a number of reasons why there’s never been a better time to quit, including:

• better and more quitting aid options, with e-cigarettes now the most popular; • more restrictions on smoking; • banning the use of attractive brand imagery on tobacco packaging; • a strong anti-smoking culture in England; • effective stop smoking campaigns such as Stoptober.

Report of the Clinical Chief Officer – 8th November 2017 Page 9 of 13 E-cigarettes are the most popular quitting method in England and local stop smoking services are the most effective way to give up, with those who combine the two having some of the highest success rates. Last year over half (53%) of all those taking part in Stoptober opted to use an e- cigarette as a quitting aid. This year the campaign featured e-cigarettes in the TV ad encourage and support smokers who are keen to try e-cigarettes to help them stop smoking.

The CCG works in partnership with Lancashire County Council and NHS organisations across L&SC to encourage smokers to stop.

People who want to quit are encouraged to contact Quit Squad, Lancashire’s stop smoking service, to get the help they need. The County Council and NHS aim to reduce the percentage of people who smoke in Lancashire to 12% by 2022.

Quit Squad, which is commissioned and funded by the County Council and delivered by Lancashire Care NHS Foundation Trust (LCFT), gives people support to change their smoking behaviour and nicotine replacement therapies to help them beat the cravings.

Further information via: https://www.gov.uk/government/news/highest-smoking-quit-success-rates- on-record and http://www.quitsquad.nhs.uk/index.php

5) CQC

5.1 State of Care Report

The CQC has published its annual assessment of health and social care in England.

The report looks at the trends, highlights examples of good and outstanding care and identifies factors that maintain high quality care.

This year’s report shows that the quality of care has been maintained despite some very real challenges. Most of us are receiving good, safe care and many services that were previously rated inadequate have recognised the CQC’s inspection findings, made the necessary changes and improved.

The fact that quality has been maintained in the toughest climate most can remember is testament to the hard work and dedication of staff and leaders. However, as the system continues to struggle with increasingly complex demand, access and cost, future quality needs to be improved.

Further information via: http://www.cqc.org.uk/publications/major-report/state-care

5.2 Mental Health Services for Children and Young People

The CQC has completed an initial review of Mental Health Services for children and young people.

The report is the first phase of a major thematic review requested by the Prime Minister in January 2017. The CQC has drawn on existing reports, research and other evidence and its inspections of children and young people’s mental health services, as well as conversations with young people to identify the strengths and weaknesses of the current system.

The report confirms many of the issues raised in the Five Year Forward View (FYFV) for Mental Health published in 2016 and in particular, comments on the difficulties children and young people face in accessing appropriate support for their mental health concerns from a system that is fragmented and where services vary in quality.

Report of the Clinical Chief Officer – 8th November 2017 Page 10 of 13 During phase two of the thematic review, CQC will undertake fieldwork to identify what helps local services to achieve, or hinders them from achieving, improvements in the quality of mental health services for children and young people, as set out in the NHS’s FYFV for Mental Health.

The findings in CQC’s phase one report will inform the Government’s Green Paper on children and young people’s mental health, expected before the end of the calendar year.

By providing an assessment of the system, this report also lays the foundations for the next phase of CQC's review. Phase two will seek to identify where has there been real change in the system, where change has been slower and what was needed to drive better care. The CQC will carry out fieldwork to observe care where appropriate; speak to staff and also commissioners. Following this, CQC will make full recommendations to encourage improvement in the mental health system for children and young when we publish our thematic review in March 2018.

Further information via: http://www.cqc.org.uk/news/releases/cqc-completes-initial-review-mental- health-services-children-young-people

6) HEE

6.1 New Training Scheme

HEE and the National Institute for Health Research (NIHR) have announced a new pre-doctoral level training scheme to support aspiring non-medical clinical academics.

The Pre-doctoral Clinical Academic Fellowship (PCAF) scheme will support award holders to split their time equally between clinical service and academic training over a two year period. During this time, Fellows will undertake formal and informal clinical research training, designed around their unique training needs. One of its many benefits is that it will allow protected time for participants to develop an application for PhD funding, with support from a named supervisor and mentor.

Forming part of the HEE/NIHR Integrated Clinical Academic (ICA) programme, the PCAF scheme will contribute towards developing the future clinical academic research leaders, who demonstrate the potential to become independent researchers and lead their own research projects.

The PCAF scheme is anticipated to open for applications in February 2018 and will replace the current ICA Masters in Clinical Research Studentship scheme.

Further information via: https://www.nihr.ac.uk/funding-and-support/funding-for-training-and-career- development/training-programmes/nihr-hee-ica-programme/nihr-hee-ica-programme-pcaf.htm

7) L&SC

7.1 Joint Committee of CCGs

Members of the public are invited to observe the Joint Committee of CCGs, which is set to hold its next formal meeting in public on 2nd November 2017 at Morecambe Bay CCG, The Lecture Theatre, Moor Lane Mills, Moor Lane, Lancaster LA1 1QD.

The Joint Committee of CCGs is made up of GPs and Lay Members from each of the CCGs in L&SC. Chief Executives from Lancashire County Council, BwD Borough Council, Blackpool Council, representatives from District Councils; local Healthwatch are not members of the Committee, but attend the meetings.

Members will note that the agenda for the November meeting and revised minutes of previous meetings are included later on today’s agenda.

Report of the Clinical Chief Officer – 8th November 2017 Page 11 of 13 8) Pennine Lancashire

8.1 Together a Healthier Future (TAHF) Programme

At the Pennine Lancashire Accountable Health and Care Partnership Leaders’ Forum meeting on 18th October 2017, a discussion took place about the need to continue the development of the shadow Accountable Care System for Pennine Lancashire and future leadership arrangements for the Transformation Programme following the departure of Dr Chris Clayton, who was Chief Officer for this work between March and September 2017.

Partnership Leaders recognised the need to maintain the pace of work and were keen to ensure that the programme could continue to develop, utilising the skills and knowledge of existing leaders within Pennine. Consideration was also given to the strengths offered by developing a distributive leadership model.

It was, therefore, agreed that Mr Kevin McGee, Chief Executive of East Lancashire Hospitals NHS Trust, and Mr Mark Youlton, Accountable Officer for East Lancashire (EL) CCG, will jointly lead the transformation programme. Mr McGee will lead work on building the Accountable Care System for Pennine Lancashire and Mr Youlton will lead work on bringing together commissioning between the two CCGs.

These leadership arrangements will enable us to move towards the implementation of the new model of care, both in and out of hospital.

At the meeting Partnership Leaders also reaffirmed their commitment to becoming a shadow Accountable Care System on 1 April 2018 and a full Accountable Care System by 1 April 2019. This would include establishing a Pennine Lancashire system control total for 2018/19.

The meeting also considered and agreed the New Model of Care and work will now continue on further defining how we work together to design and deliver this.

9) BwD

9.1 CCG

9.1.1 Clinical Chief Officer

As members are aware, Dr Chris Clayton left the CCG on 29th September 2017 to take up a new role in Derbyshire. Dr Clayton was presented with gifts from CCG staff at a Staff Team Brief on 27th September; where he said that, whilst he was looking forward to a new challenge, he would miss everyone in BwD. All the CCG’s staff wished him well in his new role.

As stated at the beginning of this report, and following an interview process, I have recently been appointed as the Interim Clinical Chief Officer for the CCG. The appointment has been approved by NHS England with effect from 30th October 2017.

During my 6 month interim role, I would like to continue the ‘clinically-led’ CCG ethos, which puts patient care and experience at the very heart of everything we do and is embedded in our Constitution.

The CCG also needs to find the right long term solution to leadership in BwD. I hope to bring stability during the next 6 months and while we are in a time of great change across the landscape.

I plan to continue to support my Primary Care colleagues at a time of unprecedented demand but, whilst I am committed to supporting Primary Care, I also believe we need to work

Report of the Clinical Chief Officer – 8th November 2017 Page 12 of 13 together to address the financial pressures as we have a joint responsibility. I am aware of the pressures on the frontline and I am keen to hear ideas of how we can make improvements and face the challenges ahead.

The CCG is preparing for another potentially tough winter and all our plans are in place. The CCG will continue to work closely with its patients, colleagues and partners to ensure it keeps people healthy and safe this winter. The CCG’s population has difficult health challenges and winter can be serious; particularly for people aged over 65 and those with long term health conditions. The system also needs to be resilient and ensure that its house is in order so it can meet the high demand and complex needs of its patients.

9.1.2 Clinical Senate

The CCG held a full Membership Clinical Senate on 10th October.

At the meeting, the interim Accountable Officer appointment results were discussed with the GP Membership. A Chief Officer briefing and finance update were provided. Members also received a presentation on Primary Care Networks and discussed ways in which they wanted to develop neighbourhoods.

9.2 Healthwatch

9.2.1 Annual General Meeting

Healthwatch BwD will hold its Annual General Meeting on 8th November 2017 at Blackburn Central Library, where it will present its 2016/17 Annual Report. Attendees can also hear from Healthwatch’s Amplify Champions about what they have achieved over the last year and see the launch of Amplify’s Pennine Lancashire Young Person Engagement.

10) News and Events

10.1 Living Well Programme

A new ‘Living Well’ programme being delivered across Pennine Lancashire has been set up to help improve the mental health of people living with long term health conditions.

The programme is delivered in partnership with the CCG, LCFT, Lancashire Women’s Centre and EL CCG. The Living Well Programme is easy to access and a person does not need to be referred to it by their GP.

Research demonstrates that people with long-term conditions are two to three times more likely to experience mental health problems than the general population.

The Living Well programme offers talking therapies through groups and one-to-one sessions in GP Practices and community settings, to help people come to terms with their health condition and manage anxiety or low mood that they may have as a result of living with a long term condition.

Living Well is available across Pennine Lancashire for anyone with a long-term health condition such as asthma; cancer; diabetes, epilepsy and many others.

11) Recommendation

The Governing Body is requested to receive this report and to note the items as detailed.

Dr. Penny Morris Clinical Chief Officer 30th October 2017

Report of the Clinical Chief Officer – 8th November 2017 Page 13 of 13

GOVERNING BODY MEETING

Chief Finance Officer Report

Date of Meeting 8th November 2017 Agenda Item 8

CCG Corporate Objectives

Through better commissioning, improve local health outcomes by addressing poor outcomes and inequalities To work collaboratively to create safe, high quality health care services To maintain financial balance and improve efficiency and productivity y To deliver a step change in the NHS preventing ill health and supporting people to live healthier lives To maintain and improve performance against core standards and statutory requirements To commission improved out of hospital care CCG High Impact Changes Delivering high quality Primary Care at scale and improving access Self-Care and Early Intervention Enhanced and Integrated Primary Care and Better Care Fund Access to Re-ablement and Intermediate Care Improved hospital discharge and reduced length of stay Community based ambulatory care for specific conditions Access to high quality Urgent and Emergency Care Scheduled Care Quality GOVERG BODGOVERNING BODY MEETING

Governing Body Meeting Page 1 of 3

Clinical Lead: N/A

Senior Lead Manager Mr Roger Parr Finance Manager Mrs Linda Ring Equality Impact and Risk Assessment N/A completed: Patient and Public Engagement completed: N/A Financial Implications N/A Risk Identified See report Report authorised by Senior Manager: Mr Roger Parr Y

Decision Recommendations • The CCG Governing Body is asked to note the contents of this financial summary and the financial position of the CCG at the end of September 2017.

Governing Body Meeting Page 2 of 3

Executive Financial Summary Month 6 – Period Ending 30th September 2017

Year to Date (YTD) Full Year Forecast Budget Actual Variance Budget Actual Variance £000 £000 £000 £000 £000 £000 Funds Available 124,580 124,580 0 251,263 251,263 0

Commissioning 92,905 92,891 14 185,245 185,199 46 Primary Care 26,186 26,825 (639) 53,531 54,787 (1,256) Corporate 3,792 3,745 47 7,387 7,387 0 Reserves 578 0 578 2,861 1.651 1,210 Balance 1,119 1,119 0 2,239 2,239 0

Summary Financial Position – The CCG is reporting a year to date surplus of £1,119k which is in line with the financial plan. The CCG is forecasting to deliver an year end of surplus of £2,239k in line with the financial plan. The CCG is currently holding a 0.5% risk reserve as per national guidance.

Commissioned Services Risks

• Healthcare Commissioning is reporting a YTD underspend of £14k with • The QIPP target for the CCG is 3.4% of turnover and some schemes a year-end forecast underspend of £46k. are scheduled to come on line during the year. • Primary Care Services are reporting a YTD overspend of £639k with a • Acute activity levels continue to be a key factor in 2017/18. Schemes forecast year end overspend of £1,296k mainly from prescribing and are in place to manage demand. primary care co-commissioning. Prescribing is reporting a YTD • Continuing health care and complex packages continues to be a key overspend of £600k and a year-end forecast overspend of £1,200k. risk as these are generally high cost and low volume. The CCG • Corporate Services are reporting an underspend of £47k and a continues to closely monitor this area of expenditure. forecast breakeven position at year end. • Prescribing expenditure is volatile and is monitored closely by the Medicines Management Team. The prescribing waste scheme Capital commenced in 2016/17 and is expected to make significant savings. There is however an emerging pressure from drugs classed as no • A combined budget for hardware replacement of the GPIT estates, cheaper stock obtainable. provision of mobile working and the upgrade all practices across Blackburn with Darwen CCG to Windows 10 has been submitted by QIPP NHS England Lancashire and South Cumbria on behalf of the CCG. • The CCG has actioned £6.7m of QIPP savings to date and is ahead of plan to meet the full year savings of £8.6m. The CCG is reviewing services to identify where savings can be made to meet the target. The CCG plans to deliver the full target however there remains a risk of schemes yet to be actioned.

Recommendation: The CCG Governing Body is asked to note the contents of this financial summary and the financial position of the CCG at the end of September 2017. Governing Body Meeting Page 3 of 3

NHS Blackburn with Darwen CCG APPENDIX A

Summary Governing Body Report ‐ September 2017

Annual Forecast Budget to Date Expenditure to Date Variance to Date Annual Budget Annual Forecast Variance £000 £000 £000 £000 £000 £000

Revenue Resource Limit

Confirmed (124,580) (124,580) 0 (251,263) (251,263) 0 Anticipated 000000 Total Revenue Resource Limit (124,580) (124,580) 0 (251,263) (251,263) 0

Expenditure

Commissioning (Page 2) 119,091 119,716 (625) 238,776 239,986 (1,210) Corporate (Page 4) 2,055 2,016 39 3,869 3,939 (70) Reserves (Page 4) 578 0 578 2,861 1,651 1,210 Healthcare Sub Total 121,724 121,732 (8) 245,506 245,576 (70)

Running Costs (Page 4) 1,737 1,729 8 3,518 3,448 70 Total Expenditure 123,461 123,461 0 249,024 249,024 0

Surplus/(Deficit) 1,119 1,119 0 2,239 2,239 0

Better Payment Practice Code YTD Value (%) YTD Volume (%) FOT Value (%) FOT Volume (%) Target (%)

NHS 100.0 99.6 100.0 99.6 95.0

Non NHS 99.9 99.5 99.9 99.5 95.0 NHS Blackburn with Darwen CCG APPENDIX B

Healthcare Commissioning Report ‐ September 2017

Expenditure to Annual Forecast Budget to Date Variance to Date Annual Budget Annual Forecast Date Variance £000 £000 £000 £000 £000 £000

Acute Services

NHS contracts (includes Ambulance Services) 60,295 60,444 (149) 120,665 120,888 (223) Non NHS Providers 3,472 3,313 159 6,993 6,658 335 NHS Contract Exclusions / Cost per Case 268 289 (21) 536 578 (42) Non Contract Activity 878 948 (70) 1,756 1,897 (141) Other 41 41 0 41 41 0 Sub Total Acute Contracts 64,954 65,035 (81) 129,991 130,062 (71)

Mental Health Services

NHS contracts 7,937 7,896 41 15,693 15,652 41 Non NHS Providers 617 662 (45) 935 969 (34) IPA ‐ Complex Packages 413 560 (147) 825 1,129 (304) Non Contract Activity 104 104 0 286 288 (2) Other 314 320 (6) 436 433 3 Sub Total Mental Health Services 9,385 9,542 (157) 18,175 18,471 (296)

Community Health Services

NHS contracts 7,116 7,116 0 14,232 14,232 0 Non NHS Providers 667 683 (16) 1,248 1,267 (19) NHS Contract Exclusions / Cost per Case 162 152 10 323 305 18 Non Contract Activity 000000 Hospices 526 523 3 1,051 1,046 5 Other 000000 Sub Total Community Services 8,471 8,474 (3) 16,854 16,850 4

Total Healthcare Contracts 82,810 83,051 (241) 165,020 165,383 (363)

Continuing Care Services

Continuing Care 3,307 3,116 191 6,518 6,153 365 Free Nursing Care 508 507 1 1,031 1,031 0 Sub Total Continuing Care Services 3,815 3,623 192 7,549 7,184 365

Primary Care Services

Prescribing 12,366 12,966 (600) 24,732 25,932 (1,200) Enhanced Services 701 690 11 1,406 1,390 16 Primary Care Co‐Commissioning 11,271 11,343 (72) 23,217 23,297 (80) Out of Hours 891 891 0 1,699 1,699 0 Commissioning 625 611 14 1,812 1,795 17 Other 332 324 8 665 674 (9) Sub‐total Primary Care services 26,186 26,825 (639) 53,531 54,787 (1,256)

Other Programme Services

Other Non Acute 3,884 3,865 19 7,884 7,925 (41) Complex Cases & Individual Funding Requests 2,396 2,352 44 4,792 4,707 85 Sub Total Other Programme Services 6,280 6,217 63 12,676 12,632 44

Surplus/(Deficit) 119,091 119,716 (625) 238,776 239,986 (1,210) NHS Blackburn with Darwen CCG APPENDIX C

Main Healthcare Contracts ‐ September 2017

Expenditure to Annual Forecast Budget to Date Variance to Date Annual Budget Annual Forecast Date Variance £000 £000 £000 £000 £000 £000

Acute Contracts Main Provider

East Lancashire Hospitals NHS Trust 51,396 51,399 (3) 102,791 102,799 (8)

Other Lancashire Providers

Lancashire Teaching Hospitals NHS FT 2,622 2,957 (335) 5,245 5,914 (669) Blackpool Fylde & Wyre Hospitals NHS FT 327 267 60 703 535 168 University Hospitals Morecambe Bay NHS FT 55 61 (6) 110 121 (11) North West Ambulance Service NHS Trust (Block) 3,646 3,671 (25) 7,293 7,343 (50) Sub Total Other Lancashire Providers 6,650 6,956 (306) 13,351 13,913 (562)

Greater Manchester Providers

University Hospital South Manchester NHS FT 316 225 91 656 450 206

Salford Royal NHS FT 186 233 (47) 372 466 (94) Royal Bolton Hospitals NHS FT 152 121 31 303 242 61 Wrightington, Wigan & Leigh NHS FT 439 432 7 878 863 15 Central Manchester University Hospital NHS FT 731 750 (19) 1,463 1,500 (37) Pennine Acute NHS Trust 111 77 34 221 153 68 The Christie NHS FT 175 91 84 349 181 168 Sub Total Greater Manchester Providers 2,110 1,929 181 4,242 3,855 387

Merseyside Providers

Royal Liverpool & Broadgreen NHS Trust 82 103 (21) 165 206 (41) Sub Total Merseyside Providers 82 103 (21) 165 206 (41)

Independent Sector Contracts

BMI Healthcare (Beardwood, Beaumont, Gisburne) 2,903 2,771 132 5,807 5,573 234 Ramsay 223 197 26 495 393 102 Sub Total 3,126 2,968 158 6,302 5,966 336

Total Acute Contracts 63,364 63,355 9 126,851 126,739 112

Mental Health Contracts

Lancashire Care NHS FT (Block) 7,919 7,879 40 15,658 15,618 40 Calderstones Partnership NHS FT (Block) 000000 Greater Manchester West NHS FT 16 16 0 32 32 0 Total Mental Health Contracts 7,935 7,895 40 15,690 15,650 40

Community Health Contracts

Lancashire Care NHS FT (Block) 7,116 7,116 0 14,232 14,232 0 Total Community Health Contracts 7,116 7,116 0 14,232 14,232 0

Surplus/(Deficit) 78,415 78,366 49 156,773 156,621 152 NHS Blackburn with Darwen CCG APPENDIX D

Non Healthcare Commissioning Report ‐ September 2017

Annual Forecast Budget to Date Expenditure to Date Variance to Date Annual Budget Annual Forecast Variance £000 £000 £000 £000 £000 £000

Other Corporate Costs (Non‐Running Costs)

CSU re‐charge 261 260 1 519 519 0 NHS Property Services re‐charge 1,169 1,169 0 2,338 2,433 (95) Other 625 587 38 1,012 987 25 Sub Total Corporate Costs 2,055 2,016 39 3,869 3,939 (70)

Plan requirements & reserves

Reserves 578 0 578 2,861 1,651 1,210 Sub Total Reserves 578 0 578 2,861 1,651 1,210

Running Costs

CCG Pay 810 785 25 1,619 1,619 0 CSU re‐charge 666 666 0 1,324 1,324 0 NHS Property Services re‐charge 49 49 0 99 99 0 Other 212 229 (17) 476 406 70 Running Costs Reserve 000000 Sub Total Running Costs 1,737 1,729 8 3,518 3,448 70

Surplus/(Deficit) 4,370 3,745 625 10,248 9,038 1,210 NHS Blackburn with Darwen CCG APPENDIX E

Statement of Financial Position ‐ September 2017

September Statement of Financial Position £000

Non Current Assets Property, Plant, Equipment 0

Total Non Current Assets 0

Current Assets Trade and Other Receivables 4,515 Financial Assets 0 Inventory 298 Cash and Bank 108

Total Current Assets 4,921

Total Assets 4,921

Current Liabilities Trade and Other Payables (11,063) Other Liabilities 0 Provisions (1) Borrowings 0

Total Current Liabilities (11,064)

Total Assets less Current Liabilities (6,143)

Non Current Liabilities Trade and Other Payables 0 Provisions 0 Borrowings 0 Other Liabilities 0

Total Non Current Liabilities 0

Total Assets Employed (6,143)

Financed By General Fund (6,143) Revaluation Reserve 0 Donated Asset Reserve 0 Government Grant Reserve 0 Other Reserves 0

Total Equity (6,143)

GOVERNING BODY MEETING GOVERG BODGOVERNING BODY MEETING Contract, Quality and Performance Report

Date of Meeting 08 November 2017 Agenda Item 9

CCG Corporate Objectives

Through better commissioning, improve local health outcomes by addressing poor 9 outcomes and inequalities To work collaboratively to create safe, high quality health care services 9 To maintain financial balance and improve efficiency and productivity 9 To deliver a step change in the NHS preventing ill health and supporting people to live 9 healthier lives To maintain and improve performance against core standards and statutory requirements 9 To commission improved out of hospital care x CCG High Impact Changes Delivering high quality Primary Care at scale and improving access 9 Self-Care and Early Intervention 9 Enhanced and Integrated Primary Care and Better Care Fund 9 Access to Re-ablement and Intermediate Care x Improved hospital discharge and reduced length of stay 9 Community based ambulatory care for specific conditions 9 Access to high quality Urgent and Emergency Care 9 Scheduled Care 9 Quality 9 Clinical Lead: Dr Malcolm Ridgway – Director of Quality and Performance Mr Rogere Parr – Chief Financee Officer Senior Lead Manager Mr Rogere Parr – Chief Financee Officer Finance Manager Mrs Jill Marr – Senioro Finance Officer Equality Impact and Risk Assessment Not Required completed: Patient and Public Engagement completed: Not Required

Governing Body Meeting 1 | Pag e

Financial Implications None identified at this stage Risk Identified Fluctuating performance and potential impact on the quality of patient care Report authorised by Senior Manager: Dr Malcolm Ridgway – Director of Quality and Performance Mr Roger Parr – Chief Finance Officer / Interim Deputy Chief Executive Y Decision Recommendations To note the contents of the report and support actions as identified.

Governing Body Meeting 2 | Page

Contract & Information Quality & Performance Lancashire Care Foundation Trust (LCFT) Mental Health ‐ Executive Summary Lancashire Care Foundation Trust (LCFT) Mental Health ‐ Executive Summary Month 5 Month 5

Psychological Therapies – Blackburn with Darwen Clinical Commissioning Group (BwD Psychological Therapies – LCFT met the 50% Recovery target for BwD CCG in CCG) has a monthly access target of 275 which is required to deliver an annual access rate August (61%), and is above target in year to date data (54.4%). Trust of 16.8% of estimated prevalence during 2017/18. The CCG’s year to date (YTD) performance (All CCGs) was 56.3% in‐month and is 55.0% YTD. performance, including the Long Term Conditions (LTC) IAPT Service, is above the level required to achieve this target: The standard for 75% of patients to enter treatment within 6 weeks was met for BwD CCG in August 2017, at 83.0%, with a YTD position of 84.8% (Trust • LCFT IAPT (Core Service plus LTC): 1,253 Treatments performance, 93.9% in‐month and 94.5% YTD). The standard for 95% of patients o 15.3% annualised rate, based on year to date numbers to enter treatment within 18 weeks was also met for BwD CCG in‐month, at 100%, with a YTD position of 99.5% (Trust performance: 99.4% in‐month and • Lancashire Women’s Centre (LWC) Core IAPT: 163 Treatments 99.4% YTD). o 1.9% annualised rate, based on year to date numbers • Lancashire Women’s Centre (LWC) LTC IAPT: 90 Treatments (1.1% per annum) Long internal waits however remain an issue, particularly for high intensity o 1.1% annualised rate, based on year to date numbers interventions such as Cognitive Behavioural Therapy (CBT), 1 to 1 Psychological • Total: 1,506 Treatments Wellbeing Practitioner (PWP) sessions and Counselling. For BwD CCG, as at the o 18.4% annualised rate, based on year to date numbers end of August 2017 there were 30 patients waiting over 18 weeks for CBT. The Trust report that this relates to reduced treatment capacity within the local Referrals – At Month 5, BwD CCG referrals to LCFT Mental Health Services have increased teams, and that recruitment processes are underway to cover this operational from 2016‐17 levels by +30 (+2.5%), which is above plan by +123 (+11.2%). gap.

Admissions ‐ The number of admissions to Mental Health inpatient wards (including Out of Memory Assessment Service (MAS) ‐ The target for 70% of patients to be seen Area Placements (OAPs), is below the number admitted in the previous year i.e. 163 in by the Memory Assessment Service (MAS) within 6 weeks was met for BwD CCG 2017‐18, versus 169 in 2016‐17 ‐6 (‐3.6%). Including OAPs, BwD CCG admissions are above in August 2017, at 97.78%, with a YTD position of 61.07% (Trust performance: plan +72 (+79%). 80.4% in‐month and 64.8% YTD). To ensure that the current level of improved performance is sustainable, the Trust supported by commissioners, is looking to Bed Days ‐ Including Out of Area bed days, BwD CCG patients account for more than BwD standardise the MAS model across Lancashire. Currently there is significant CCG’s weighted population share of bed days +1,301 (+28%). variation between localities in terms of the diagnostic model, third sector utilisation and the level of post‐diagnostic support. Out of Area Placements (OAPs) – OAPs for 2017/18 year to date are 9 admissions (5.5% of all admissions) and 560 bed days (9.4% of all bed days). For both admissions and bed days, these are decreases on the same period last year, when OAPs accounted for 40 admissions (24% of all admissions) and 1,251 bed days (22% of all bed days).

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Contract & Information Quality & Performance East Lancashire Hospitals NHS Trust (ELHT) ‐ Executive Summary East Lancashire Hospitals NHS Trust (ELHT) ‐ Executive Summary Month 5 Month 5

Point of Delivery (POD) Activity Variance £ Variance A&E 4 Hour – Given underperformance nationally against the 95% 4 hour target, A&E (including MIU) ‐1642 (‐6.7%) ‐£190K (‐6.5%) NHS England has set a trajectory for 2017/18 for: over 90% of emergency Elective (Ordinary + Day Cases) ‐23 (‐0.4%) £68K (+1.1%) patients to be treated, admitted or transferred within 4 hours by September Elective Excess Bed Days ‐198 (‐63.4%) ‐£52K (‐64.6%) 2017; the majority of trusts to be meeting the 95% standard by March 2018; and Elective Costs Inc. Excess Bed Days +£16K (+0.3%) for the NHS overall to meet the 95% standard by the end of the 2018 calendar year. Locally, the 95% 4 hour waiting time target for A&E was not met in August Non Elective (NEL) Inc. Non‐Emergency (NE) ‐2 (‐0.03%) +£415K (+2.9%) 2017 at East Lancashire Hospitals Trust (ELHT). However an improvement in ‐1631 (‐47.2%) ‐£377K (‐45.0%) NEL + NEL NE Excess Bed Days performance was experienced in August 2017, at 89.20% (84.10% YTD), in Non Elective Threshold Adjustment +£25k comparison to 79.95% in July 2017. A 4 hour recovery action plan is being Non Elective Costs Inc. Excess Bed Days +£63K (+0.4%) monitored via the A&E Delivery Board. Outpatients First Attends ‐787 (‐5.6%) ‐£261K (‐8.2%) Outpatient Follow‐up Attends +734 (+2.5%) +£62K (+5.9%) Ambulance Handovers ‐ The number of delayed ambulance handovers Outpatient Procedure – New +223 (+6.0%) +£21K (+4.1%) decreased in August 2017, with 269 over 30 minutes and 30 over 60 minutes, in comparison to 446 over 30 minutes and 106 over 60 minutes in July 2017. Outpatient Procedure – Review +33 (+0.4%) +£26K (+3.2%) Performance is linked to the A&E 4 hour position and improvement with the 4 Total Outpatient +202 (+0.4%) ‐£151K (‐2.7%) hour target aligned with improved flow within the unit which has had a positive Inpatient Care is above plan on cost (+£68K, +1.1%) from below plan activity (‐23 spells, impact. ‐0.4%). This is due to Ordinary Elective activity (EL) showing higher costs, with notable shifts in the grouping of spells, towards higher levels of complications/comorbidities. Trolley Waits ‐ In August 2017, there were 7 Mental Health 12 hour A&E However, below plan Excess Bed Days (‐198 bed days), has reduced Elective Admission breaches at ELHT. A teleconference has been held for all 7 breaches in line with costs by ‐£52K, the implication being that the total over performance is +£16K (+0.3%). due process with key themes identified relating to bed availability. The root cause has been added to the fishbone tool and actions identified have been Outpatient Care is well below plan on cost (‐£151K, ‐2.7%) from slightly above plan activity included in the overarching action plan which is being monitored via the ELHT (+0.4%). This is mostly due to the more expensive Outpatient First Attendances, being well Contract Quality Review Meetings. below plan in activity, while less expensive Follow‐ups are above plan in activity. Referral to Treatment Incomplete – In August 2017, the RTT ‘Awaiting Non‐Elective Admissions including Non‐Emergency are above plan (+£440K, +3.2%) from Treatment’ standard (target 92% within 18 weeks) was achieved at ELHT for BwD close to plan activity (‐2 spells, ‐0.03%). This is again due to shifts in the grouping of spells, CCG patients, with performance at 92.7% (92.7% YTD). 11 patients are currently towards higher levels of complications /comorbidities. However, below plan Excess Bed waiting >36 weeks (of which 0 are > 52 weeks). Days (‐1,631 bed days), has reduced the Non Elective Admission costs by ‐£377K, the implication being that the total over performance is +£16K (+0.3%).

Referral to Treatment – BwD CCG patients awaiting treatment at ELHT stands at 6,990 at month 5. This is a decrease from the previous month (‐64, ‐0.9%). However, compared to the same month last year, this is a decrease of (‐468, ‐6.3%). Governing Body Meeting 4 | Page

Contract & Information Quality & Performance Primary Care ‐ Executive Summary Primary Care ‐ Executive Summary Month 5 Month 5

Out of Hours ‐ Compared to last year’s Month 5 data, total activity for the Out of Hours Care Quality Commission (CQC) – CQC have now inspected 25 out of 26 practices service is under plan YTD by ‐381 (‐4.9%). All services are underperforming as follows: Dr in Blackburn with Darwen. Pringle Street surgery is the only practice that has not Advice (‐44, ‐2.0%), Home Visits (‐63, ‐6.0%) and Primary Care attendances (‐274, ‐6.1%). had an inspection, however the inspection is imminent. Waterside Surgery’s inspection took place on 19th September and the findings have not yet been Year to date ‐ Activity Full Year Forecast ‐ Activity published. 17/18 16/17 Variance Status 17/18 16/17 Variance Status 22 practices have now received a rating of ‘Good’ and one practice ‘Outstanding’ PC 4250 4524 ‐274 ‐6.1% G 10,306 11,108 ‐802 ‐7.2% G Attends i.e. Darwen Healthcare.

Dr 2211 2255 ‐44 ‐2.0% G 5,362 5,355 7 0.1% G Nurse Forum ‐ ‘Practice makes Perfect’ ‐ The forum continues to support Advice education and offers the opportunity for engagement around quality, Home 994 1057 ‐63 ‐6.0% G 2,410 2,539 ‐129 ‐5.1% G transformation and workforce development. The session held in September Visits provided a workshop were nurses worked in their locality groups to share ideas and discuss concerns on the future of nursing within primary care. A consultant Total 7455 7836 ‐381 ‐4.9% G 18,078 19,002 ‐924 ‐4.9% G from the Pathology department in Royal Blackburn hospital will be delivering a presentation on ‘Interpreting blood results’ at the next session in November. Alternative Provider Medical Services (APMS) General Practitioner Contracts – The CCG Future sessions will focus on collaborative working with community, district and has prepared the specification and all associated documentation for the APMS contracts Care Home nurses. for Bentham Road and Waterside. These contracts have now been put out to tender. The Pennine Lancashire Primary Care Quality Group ‐ continues to meet on a Quality and Outcomes Enhanced Services Transformation (QOEST) ‐ The QOEST plan monthly basis to discuss and act upon any concerns within general practice continues to be progressed. Quarterly Quality and Performance Assurance meetings are across Pennine Lancashire. on‐going. Planning for the next cycle has commenced with greater emphasis on access and sustainability. Draft plans (1st cut) to be available in December 2017. The GP education programme continues to deliver high quality events such as the recent “Hot Topics” programme. These are highly valued by GPs and practice Estates Technology Transformation Fund (ETTF) ‐ The West Scheme has been supported staff and help improve care for our patients. in principle by NHS England, and is now subject to finalising the outline business case. This work has commenced. Referrals – Despite an aging population and the increasing burden of patients with long‐ term conditions, referrals to the CCG’s main hospital provider (ELHT) have decreased this year compared to the same period last year i.e. ‐460 (‐0.4% per working day). A reduction in referrals from GPs account for just over half of this decrease ‐231 versus 2016/17 (‐0.3% per working day).

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Contract & Information Quality & Performance Lancashire Care Foundation Trust Community ‐ Executive Summary Lancashire Care Foundation Trust Community ‐ Executive Summary Month 5 Month 5

The process for reporting against variances (+/‐10%) as agreed by Chorley and South Ribble Referral to treatment (RTT) Incomplete ‐ The 92% 18 weeks referral to CCG (CSR CCG) as lead contractor for LCFT Community Services is for the Trust to provide treatment (RTT) Incomplete target was met for BwD CCG LCFT Community an exception report in the month following the previous quarter. services patients in August 2017, with performance at 99.4% (93.0% YTD).

Adult Learning Disability Service (‐1598, ‐66.6%) – The Trust has advised that a review of The Children’s Speech and Language Therapy (SALT) service met the RTT the figures has indicated that there is a recording issue across the learning disability teams. Incomplete target for first time in 2017/18 for BwD CCG in August 2017, with The activity recording system in Adult Learning Disabilities is a dual system using paper‐ performance at 98.5%. LCFT reported that significant staffing issues were the based clinical records with the addition of Electronic Care Records for recording major contributory factor to the poor performance within the Children’s SALT contacts. The Trust has advised that this issue will be resolved as the team move onto the services in 2017/18. Recruitment processes have been completed and the team new IT system in month 12. This has been queried with the Trust as this timeframe is not is now fully established. acceptable.

Children’s Learning Disabilities (+318, +94.9%) – The Children’s Learning Disability service has had a number of groups running over the past 2 months which has increased the activity figures. The Trust has advised that these groups are set to continue throughout the year. This will be reviewed with the Commissioner and the plan rebased.

Community Stroke Service (‐639, ‐24.5%) – LCFT has advised that the underperformance is due to a combination of vacancy and sickness absence. Quality patient care is being maintained with patients receiving an initial telephone contact within 1 working day and a face to face initial assessment within 5 working days. The Trust is activity recruiting to fill the vacancies.

DESMOND (‐47, ‐34.8%) – The underperformance for DESMOND contacts is due to sickness that has affected the ability of the team to deliver the programme. The Trust has advised that they plan to deliver 3 courses in September which will improve the position.

Diabetes Specialist Nursing Service (‐595, ‐26.4%) – The underperformance has been due to staffing vacancies. Following recruitment, there is improved performance in month 5 from an average of 308 contacts for months 1 ‐ 4, to 429 contacts in month 5.

Community Intravenous Therapy (‐298, ‐39.5%) ‐ The IV team continues to see a reduced number of referrals. The service is working with East Lancashire Hospitals Trust (ELHT) to maximise referrals. From October 1st 2017, the service has been redesigned to accept step down referrals only. The purpose of this redesign is as a result of changes to the Governing Body Meeting 6 | Page decommissioning of medical oversight and step up referrals no longer being accepted. However, the impact on service will be minimal as step up activity into the service saw 4 patients being referred from April to September.

Complex Case Management (‐574, ‐24.1%) – The Trust has advised that the underperformance is due to a combination of vacancies and new starters being unable to work independently due to requirements for training. Referrals for the service have increased to 22 in month 5 which is above the average of 15 for months 1 ‐ 4. Quality patient care is being maintained and all referrals are being actioned.

District Nursing (Out of Hours) (+1404, +50.7%) ‐ Teams are responding to increased demand. More people are staying on caseloads for longer and demand for long term clinical interventions for people to stay well at home is increasing. A review of transition from day to out of hours care is being completed in month 4 and the plan will be rebased at month 6.

Rapid Assessment Team (+1468, +21.4%) ‐ Following an increase in referrals in month 4, referral rates remain high but more consistent with previous months. The service continues to over perform on activity due to a high number of referrals of patients in crisis situations at home and palliative patients who require urgent intervention from the Rapid Assessment Team.

Pulmonary Rehabilitation Service (+367, +13.3%) ‐ The current position in over plan activity is due to the number of patients attending and successfully completing their course. This is due to intensive work contacting patients, building relationships with the service which has resulted in more patients completing a six week course. Although over plan, the activity is in line with 2016/17 activity.

Treatment Room (‐8739, ‐21.1%) ‐ The treatment room overall positon has been impacted by significant underperformance in other treatment room activities (‐9490, ‐24.6%), mitigated by over performance in Non‐Serious Injury (+163, +23.6%), Tissue Viability (+158, +40.0%) and Ulcer and Vascular (+456, +54.3%). The treatment rooms respond to the needs presented and issues have been raised with commissioners regarding increased complexity of patients and the impact on contacts, as appointments are prolonged to manage multiple complex issues. The team are planning to change to a walk in service from 1st November to improve activity in this area.

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Contract & Information Quality & Performance Other ‐ Executive Summary Other ‐ Executive Summary Month 5 Month 5

BMI Beardwood + BMI Gisburne Park ‐ Total costs are below plan ‐£142K (‐6.1%). Ambulance Response Programme – Due to the Ambulance Response • BMI Beardwood: ‐£178K (‐8.3%) Programme which was implemented within NWAS on 7th August 2017, incident • BMI Gisburne Park: +£36K (+18.9%) classification and response measures have fundamentally changed. This means that any reports which were based on Reds/Greens or measuring 8/19 minute Elective Inpatient Care (EL + DC) position at month 5 shows activity +68 spells above plan response times are no longer possible to produce. At the last NWAS Contract and (+4.6%) but with costs ‐£61K below plan (‐3.6%). General Surgery, Trauma & Orthopaedics Commissioning Group, it was agreed that there would be a grace period of three and Gynaecology are the key specialties which have underperformed: months to allow completion of the Ambulance Response Standards consultation.

• General Surgery ‐£49K (‐24%) [‐59 spells, ‐23%] Referral to Treatment 18 weeks (Incomplete) – The referral to treatment (RTT) • Trauma & orthopaedics ‐£16K (‐2.2%) [‐23 spells, ‐8.4%] incomplete pathway was not achieved for BwD CCG in August 2017, with • Gynaecology ‐£26K (‐35%) [‐28 spells, ‐33%] performance at 91.23% (91.27% YTD) against a 92% target. Patient flow to Pain Management is below plan in terms of cost, but above plan in terms of activity: Lancashire Teaching Hospitals (LTHTr) continues to impact on the CCGs position • Pain management ‐£34K (‐7.8%) [+46 spells, +7.6%] with 227 patients waiting over 18 weeks (although this is a decrease from 253 in

the previous month). The main pressure is in Neurology, where there are 120 Only Gastroenterology and Ophthalmology have over performed to a notable degree: patients with a wait over 18 weeks (reduced from 142 in the previous month). • Gastroenterology +£24K (77 spells versus plan 20, +57 spells] The Trust has medical vacancies which they have not yet been able to fill. In the • Ophthalmology +£23K (173 spells versus plan 132, +41 spells] interim outsourcing capacity has been identified to deliver Neurology outpatient activity from September 2017. To aid with reducing the backlog, outpatient Outpatient Care position at month 5, shows activity ‐175 attendances/procedures below clinics are also being held at weekends. plan (‐2.8%) with costs ‐£64K below plan (‐10.9%). The key specialties below plan are as follows: Cancer – 2 weeks for an urgent GP referral for suspected cancer – In August • General surgery ‐£14K (‐18.7%) [‐181 attendances/procedures, ‐24.0%] 2017, the standard for 93% of patients to be ‘seen within 2 weeks for an urgent • Urology ‐£11K (‐29.3%) [‐41 attendances/procedures, ‐15.0%] referral for suspected cancer’ was not met for BwD CCG with performance at • Spinal surgery service ‐£8K (‐34.3%) [‐36 attendances/procedures, ‐20.8%] 92.16%. YTD the target is being met with performance at 94.12%. There were 32 • Trauma & orthopaedics ‐£17K (‐10.7%) [‐175 attendances/procedures, ‐10.0%] breaches leading to the underperformance. A high number of breaches were due • ENT ‐£11K (‐13.4%) [‐100 attendances/procedures, ‐11.7%] to patient initiated delays for various reasons, ranging from patients being on • Ophthalmology ‐£10K (‐24.0%) [‐100 attendances/procedures, ‐22.4%] holiday to patients requesting appointments at specific hospitals. To address this issue, the Cancer Team are working with GP practices to re‐emphasise to patients the importance of attending the earliest available appointment. Other breaches related to the lack of capacity within the Maxillofacial service for skin cancer patients.

Cancer ‐ patients receiving subsequent treatment for cancer within 31 days

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(Surgery) – In August 2017, the standard for 94% of patients to receive ‘subsequent treatment for cancer within 31 days (Surgery)’ was not met for BwD CCG with performance at 88.89%. YTD the target is being met with performance at 95.24%. There was 1 breach due to a patient’s treatment being delayed for medical reasons.

Cancer ‐ patients receiving 1st definitive treatment for cancer within 2 months (62 days) – In August 2017, there was underperformance against the 62 day referral to first treatment standard for BwD CCG with performance at 81.25% against an 85% target. YTD the target is being met with performance at 85.29%. There were 6 breaches leading to the underperformance ‐ 1 breach related to late referral to the tertiary provider, 2 breaches related to late referral to a treatment provider, 1 breach was due to a provider initiated delay to a diagnostic test, 1 breach was due to inadequate elective capacity, and 1 breach was due to operational capacity.

Cancer performance continues to be overseen by the Pennine Lancashire Cancer Tactical Group which monitors the delivery of the Cancer Action and Implementation Plan.

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Appendix 1

East Lancashire Hospitals NHS Trust: BwD CCG Contract 1st April 2017 – 31st August

Blackburn with Darwen Year to Date CCG's position at EAST LANCASHIRE Activity Activity Activity % Cost Cost Cost % HOSPITALS NHS TRUST Plan Actual Variance Variance Plan Actual Variance Variance

A&E (including MIU) 24,541 22,899 ‐1,642 ‐6.7% £2.943M £2.753M ‐£190K ‐6.5%

Elective 6,344 6,321 ‐23 ‐0.4% £6.080M £6.148M £68K 1.1% (Ordinary + Daycases)

Excess Bed Days (Elective) 312 114 ‐198 ‐63.4% £81K £29K ‐£52K ‐64.6%

Non Elective 7,029 7,084 55 0.8% £11.340M £11.871M £530K 4.7%

Excess Bed Days 3,118 1,710 ‐1,408 ‐45.2% £751K £425K ‐£325K ‐43.4% (Non Elective)

Non Elective Non‐ 1,167 1,110 ‐57 ‐4.9% £2.460M £2.370M ‐£91K ‐3.7% Emergency

Excess Bed Days (Non 336 113 ‐223 ‐66.4% £86K £34K ‐£51K ‐59.9% Elective Non Emergency)

Outpatient First Attends 14,025 13,238 ‐787 ‐5.6% £3.176M £2.915M ‐£261K ‐8.2%

Outpatient Follow‐up 29,011 29,745 734 2.5% £1.059M £1.122M £62K 5.9% Attends

Outpatient Procedure – 3,712 3,935 223 6.0% £511K £532K £21K 4.1% New

Outpatient Procedure – 7,392 7,425 33 0.4% £827K £853K £26K 3.2% Review

Total £29.313M £29.050M ‐£263K ‐0.9%

Contract Residual Balance £528K £0 ‐£528K ‐100.0%

Other £12.744M £13.732M £988K 7.8%

Grand Total £42.586M £42.782M £196K 0.5%

Tables Based upon Version 2 of the Contract Monitoring Pivot, updated at 05/10/2017

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Appendix 2

All Providers: BwD CCG Contract 1st April 2017 – 31st August

Blackburn with Darwen Year to Date CCG's position at ALL HOSPITAL Activity Activity Activity % Cost Cost Cost % PROVIDERS Plan Actual Variance Variance Plan Actual Variance Variance

A&E (including MIU) 25,399 23,891 ‐1,508 ‐5.9% £3.059M £2.877M ‐£182K ‐6.0%

Elective 9,104 9,110 6 0.1% £9.281M £9.280M ‐£1K 0.0% (Ordinary + Daycases)

Excess Bed Days (Elective) 446 290 ‐156 ‐34.9% £114K £71K ‐£43K ‐37.8%

Non Elective 7,347 7,444 97 1.3% £11.995M £12.668M £673K 5.6%

Excess Bed Days 3,221 1,851 ‐1,370 ‐42.5% £778K £460K ‐£318K ‐40.9% (Non Elective)

Non Elective Non‐ 1,237 1,170 ‐67 ‐5.4% £2.672M £2.506M ‐£167K ‐6.2% Emergency

Excess Bed Days (Non 348 114 ‐234 ‐67.2% £89K £35K ‐£54K ‐61.0% Elective Non Emergency)

Outpatient First Attends 17,771 16,831 ‐940 ‐5.3% £3.819M £3.528M ‐£291K ‐7.6%

Outpatient Follow‐up 38,835 39,935 1,100 2.8% £1.806M £1.895M £89K 4.9% Attends

Outpatient Procedure – 3,858 4,136 278 7.2% £535K £565K £30K 5.6% New

Outpatient Procedure – 7,785 7,975 190 2.4% £884K £930K £47K 5.3% Review

Outpatient Procedure – 883 643 ‐240 ‐27.2% £114K £79K ‐£35K ‐31.1% Unspecified

Total £35.147M £34.894M ‐£254K ‐0.7%

Contract Residual Balance £528K £0 ‐£528K ‐100.0%

Other £14.029M £15.114M £1.085M 7.7%

Grand Total £49.705M £50.008M £302K 0.6%

Tables Based upon Version 2 of the Contract Monitoring Pivot, updated at 05/10/2017

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Appendix 3

GP Referrals > +5% (above) Within 5% versus < ‐5% (below) ‐0.3% versus 16/17 versus 2016‐17 2016‐17 versus 2016‐17

Number of Referrals Referrals per Working Day GP GP 2016‐17 2017‐18 Specialty Variance Variance Variance Referrals Referrals (106 (104 Quantity % % 2016‐17 2017‐18 days) days) Cardiology 655 636 ‐19 ‐2.9% 6.2 6.1 ‐1.0% Community Paediatrics 1 169 186 17 10.1% 1.6 1.8 12.2% Dermatology 930 812 ‐118 ‐12.7% 8.8 7.8 ‐11.0% E.N.T. 1039 977 ‐62 ‐6.0% 9.8 9.4 ‐4.2% Gynaecology 945 973 28 3.0% 8.9 9.4 4.9% Medical Specialties 1152 1275 123 10.7% 10.9 12.3 12.8% General Medicine 84 88 4 4.8% 0.8 0.8 6.8% Diabetic Medicine 50 18 ‐32 ‐64.0% 0.5 0.2 ‐63.3% Elderly Medicine 56 46 ‐10 ‐17.9% 0.5 0.4 ‐16.3% Gastroenterology 666 799 133 20.0% 6.3 7.7 22.3% Respiratory Medicine 296 324 28 9.5% 2.8 3.1 11.6% Oncology 128 116 ‐12 ‐9.4% 1.2 1.1 ‐7.6% Ophthalmology 1115 1235 120 10.8% 10.5 11.9 12.9% Other Specialty group 2 308 303 ‐5 ‐1.6% 2.9 2.9 0.3% Paediatrics 3 493 436 ‐57 ‐11.6% 4.7 4.2 ‐9.9% Pain Management group 4 95 118 23 24.2% 0.9 1.1 26.6% Rheumatology 204 181 ‐23 ‐11.3% 1.9 1.7 ‐9.6% Surgical Specialties 1820 1707 ‐113 ‐6.2% 17.2 16.4 ‐4.4% Breast Surgery 609 571 ‐38 ‐6.2% 5.7 5.5 ‐4.4% General Surgery 972 950 ‐22 ‐2.3% 9.2 9.1 ‐0.4% Vascular Surgery 239 186 ‐53 ‐22.2% 2.3 1.8 ‐20.7% Trauma & Orthopaedics 979 870 ‐109 ‐11.1% 9.2 8.4 ‐9.4% Urology 616 592 ‐24 ‐3.9% 5.8 5.7 ‐2.0% Grand Total 10648 10417 ‐231 ‐2.2% 100.5 100.2 ‐0.3%

1 Community Paediatrics and Community Paediatric Neurodevelopmental Service

2 A&E, Cardiothoracic Surgery, Child & Adolescent Psychiatry, Clinical Genetics, Critical Care Medicine, Clinical Haematology, Endocrinology, Medical Oncology, Neonatology, Palliative Medicine, Radiotherapy, Rehabilitation

3 Paediatrics, Paediatric Surgery, Paediatric Cardiology, Paediatric Nephrology and Paediatric Respiratory Medicine

4 Pain Management and Anaesthetics

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Other Referrals > +5% (above) Within 5% versus < ‐5% (below) ‐0.6% versus 16/17 versus 2016‐17 2016‐17 versus 2016‐17

Number of Referrals Referrals per Working Day GP GP 2016‐17 2017‐18 Specialty Variance Variance Variance Referrals Referrals (106 (104 Quantity % % 2016‐17 2017‐18 days) days) Cardiology 346 413 67 19.4% 3.3 4.0 21.7% Community Paediatrics 1 450 373 ‐77 ‐17.1% 4.2 3.6 ‐15.5% Dermatology 123 113 ‐10 ‐8.1% 1.2 1.1 ‐6.4% E.N.T. 596 546 ‐50 ‐8.4% 5.6 5.3 ‐6.6% Gynaecology 473 448 ‐25 ‐5.3% 4.5 4.3 ‐3.5% Medical Specialties 428 548 120 28.0% 4.0 5.3 30.5% General Medicine 109 95 ‐14 ‐12.8% 1.0 0.9 ‐11.2% Diabetic Medicine 113 174 61 54.0% 1.1 1.7 56.9% Elderly Medicine 31 26 ‐5 ‐16.1% 0.3 0.3 ‐14.5% Gastroenterology 175 253 78 44.6% 1.7 2.4 47.4% Respiratory Medicine 790 592 ‐198 ‐25.1% 7.5 5.7 ‐23.6% Oncology 219 236 17 7.8% 2.1 2.3 9.8% Ophthalmology 1189 1140 ‐49 ‐4.1% 11.2 11.0 ‐2.3% Other Specialty group 2 890 851 ‐39 ‐4.4% 8.4 8.2 ‐2.5% Paediatrics 3 376 419 43 11.4% 3.5 4.0 13.6% Pain Management group 4 117 126 9 7.7% 1.1 1.2 9.8% Rheumatology 136 153 17 12.5% 1.3 1.5 14.7% Surgical Specialties 667 737 70 10.5% 6.3 7.1 12.6% Breast Surgery 154 205 51 33.1% 1.5 2.0 35.7% General Surgery 380 410 30 7.9% 3.6 3.9 10.0% Vascular Surgery 133 122 ‐11 ‐8.3% 1.3 1.2 ‐6.5% Trauma & Orthopaedics 2167 1963 ‐204 ‐9.4% 20.4 18.9 ‐7.7% Urology 256 336 80 31.3% 2.4 3.2 33.8% Grand Total 9223 8994 ‐229 ‐2.5% 87.0 86.5 ‐0.6%

Number of Referrals Referrals per Working Day Referral Type Variance 2016‐17 2017‐18 2016‐17 2017‐18 Variance % % (106 days) (104 days) 1 GP 10648 10417 ‐2.2% 100.5 100.2 ‐0.3% 2 Non‐GP Professional 5947 5617 ‐5.5% 56.1 54.0 ‐3.7% 3 Other 3276 3377 3.1% 30.9 32.5 5.1% Total 19871 19411 ‐2.3% 187.5 186.6 ‐0.4%

1 From GP 2 From non‐GP professional (e.g. Consultant, Nurse Specialist, Other Practitioner 3 From non‐GP other (e.g. Following A&E Attendance or Emergency Admission, Self, Ex Private Patient)

A Specialty level analysis can be found on pages 18 ‐ 24. Activity queries are raised with ELHT on a monthly basis via Contract Management and formal Contract Performance and Development Group (CPDG) meetings.

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Appendix 4 LCFT Community Contract ‐ LCFT: Service Line Activity Against Plan – August 2017

Year to date ‐ Activity Full Year ‐ Activity Year‐on‐Year Comparison (Planned Activity) Service Line Plan Actual Variance Var % Status^ Plan Forecast 16/17 17/18 Variance Var % Adult Learning Disabilities 2400 802 ‐1,598 ‐66.6% 5509 1913 1,320 802 ‐518 ‐39.2% Adult Speech and Language Therapy No Plan 11 N/A No Plan 26 23 11 Children's Learning Disabilities 335 653 318 94.9% 1039 1558 398 653 255 64.1% Children's Nursing No Plan 13 N/A No Plan 31 460 13 Children's Speech & Language 1950 2,604 654 33.5% 6703 6212 2,379 2,604 225 9.5% Children's Occupational Therapy 475 497 22 4.6% 1553 1186 661 497 ‐164 ‐24.8% Children's Physiotherapy No Plan 46 N/A No Plan 110 22 46 Chronic Fatigue Syndrome No Plan 0 N/A No Plan 0 49 0 Community Matrons No plan 13 N/A No plan 31 2 13 Community Neurological Service No plan 23 N/A No plan 55 31 23 Community Stroke Service 2610 1,971 ‐639 ‐24.5% 6083 4702 3,076 1,971 ‐1,105 ‐35.9% Dermatology 2160 2,108 ‐52 ‐2.4% 5251 5029 2,552 2,108 ‐444 ‐17.4% Not DESMOND (Completed Courses) 135 88 ‐47 ‐34.8% 349 210 88 N/A N/A Known Diabetes Specialist Nursing Service 2255 1,660 ‐595 ‐26.4% 5752 3960 1,989 1,660 ‐329 ‐16.5% District Nursing 37700 40,510 2,810 7.5% 88966 96642 41,428 40,510 ‐918 ‐2.2% District Nursing (Out of Hours) 2770 4,174 1,404 50.7% 6543 9958 3,672 4,174 502 13.7% District Nursing (inc. Out of Hours) 40470 44,684 4,214 10.4% 95509 106599 45,100 44,684 ‐416 ‐0.9% Falls Team No plan 9 N/A No plan 21 0 9 Heart Failure Service No plan 0 N/A No plan 0 0 0 Intermediate Care ACS 5045 4,971 ‐74 ‐1.5% 12787 11859 4,282 4,971 689 16.1%

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Year to date ‐ Activity Full Year ‐ Activity Year‐on‐Year Comparison Service Line Plan Actual Variance Var % Status^ Plan Forecast 16/17 17/18 Variance Var % Intensive Home Support 13045 13,604 559 4.3% 32234 32454 10,750 13,604 2,854 26.5% Community IV Service BwD 755 457 ‐298 ‐39.5% 2862 1090 459 457 ‐2 ‐0.4% Complex Case Management 2380 1,806 ‐574 ‐24.1% 4809 4308 1,512 1,806 294 19.4% COPD 3050 3,013 ‐37 ‐1.2% 6626 7188 2,559 3,013 454 17.7% Rapid Assessment Team 6860 8,328 1,468 21.4% 17937 19867 6,220 8,328 2,108 33.9% Nutrition & Dietetics No plan 4 N/A No plan 10 5 4 Oxygen Service 1695 1,635 ‐60 ‐3.5% 3868 3900 2,958 1,635 ‐1,323 ‐44.7% Podiatry 7735 8,318 583 7.5% 20334 19844 9,628 8,318 ‐1,310 ‐13.6% Pulmonary Rehabilitation 2760 3,127 367 13.3% 6012 7460 3,777 3,127 ‐650 ‐17.2% Treatment Rooms 41495 32756 ‐8,739 ‐21.1% 88193 78143 37075 32756 ‐4,319 ‐11.6% Treatment Room 38640 29,150 ‐9,490 ‐24.6% 81645 69541 33,605 29,150 ‐4,455 ‐13.3% Ear Care (Treatment Room) 445 379 ‐66 ‐14.8% 861 904 458 379 ‐79 ‐17.2% Healthy Legs (Treatment Room) 485 525 40 8.2% 1110 1252 463 525 62 13.4% Minor Injury (Treatment Room) 690 853 163 23.6% 1496 2035 922 853 ‐69 ‐7.5% Ulcer & Vascular (Treatment Room) 840 1,296 456 54.3% 1948 3092 917 1,296 379 41.3% Tissue Viability (Treatment Room) 395 553 158 40.0% 1133 1319 710 553 ‐157 ‐22.1% Grand Total ‐ Activity with Plans 124565 119478 ‐5,087 ‐4.1% 291176 285029 125945 119478 ‐6,467 ‐5.1%

Reporting Tolerances Under Plan <‐5% Close to Plan >‐5% to <+5% Above Plan >+5% ^ Status = change in variance to plan (year to date M5 to M4) % Variance Widened % Variance Narrowed

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Appendix 5

Inpatient Waiting List

Inpatient and Daycase Waiting List Source : ELHT Performance Report

East Lancashire Hospitals Current Month ‐ August 2017 Previous Month ‐ July 2017 0‐<6 6‐<13 13‐<20 20 + Grand 0‐<6 6‐<13 13‐<20 20 + Grand Specialty Variance %age +/‐ Weeks Weeks Weeks Weeks Total Weeks Weeks Weeks Weeks Total General Surgery 523 194 57 27 801 650 209 56 26 941 ‐140 ‐14.9% Urology 231 165 81 51 528 288 151 72 45 556 ‐28 ‐5.0% Breast Care 61 19 0 2 82 56 10 6 2 74 8 10.8% Vascular Surgery 106 31 5 2 144 Data Only Reported Separately to General Surgery From Aug‐17 +144 N/A Orthopaedics 475 440 131 116 1162 587 382 143 109 1221 ‐59 ‐4.8% ENT 147 132 52 30 361 240 101 57 19 417 ‐56 ‐13.4% Ophthalmology 377 240 65 23 705 420 194 63 16 693 12 1.7% Oral Surgery / Maxillo Facial 362 179 98 85 724 353 230 87 87 757 ‐33 ‐4.4% Dermatology 0 0 0 0 0 0 0 0 0 0 0 N/A Medical Oncology 1 0 0 0 1 0 0 0 0 0 1 N/A Clinical Oncology 0 0 0 0 0 0 0 0 0 0 0 N/A Surgical Division 2283 1400 489 336 4508 2594 1277 484 304 4659 ‐151 ‐3.2% General Medicine 660 10 0 11 681 796 5 4 10 815 ‐134 ‐16.4% Rehabilitation 0 0 0 0 0 0 0 0 0 0 0 N/A Cardiology 155 49 16 5 225 137 56 13 5 211 14 6.6% Thoracic Medicine 18 3 2 0 23 11 3 0 0 14 9 64.3% Nephrology 0 0 0 4 4 0 0 1 3 4 0 0.0% Medical Division 833 62 18 20 933 944 64 18 18 1044 ‐111 ‐10.6% Gynaecology 197 47 2 0 246 245 37 2 0 284 ‐38 ‐13.4% Family Care Division 197 47 2 0 246 245 37 2 0 284 ‐38 ‐13.4% Interventional Radiology 0 0 0 0 0 0 0 0 0 0 0 N/A Pain Management 9 7 2 3 21 5 4 4 0 13 8 61.5% Rheumatology 47 16 2 3 68 47 11 3 1 62 6 9.7% Haematology 0 0 0 0 0 0 0 0 0 0 0 N/A Diagnostic & Clinical Support 56 23 4 6 89 52 15 7 1 75 14 18.7% Grand Total 3369 1532 513 362 5776 3835 1393 511 323 6062 ‐286 ‐4.7%

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LCFT MH quality measures currently underperforming against target Appendix 6

Threshold Apr May June July Aug 2017/18 Ref Indicator Level 2017/18 17 17 17 17 17 YTD Trust 98.53% 97.13% 97.54% 94.63% 97.21% 97.01% CPA: 7 day follow up from psychiatric inpatient E.B.S.3 95% care BwD 100% 94.74% 100% 90.91% 94.74% 95.48%

NQR_1 Duty of Candour 0 Trust 0 0 0 0

IAPT: Prevalence Q1 3.75% Q2 3.96% Trust 3.87% 1.37% 1.29% 6.53% Notional Q2 Monthly 1.32% LQR_6 Notional YTD 6.39%

NB performance against notional targets are displayed as lightly shaded and are intended as an indicator of BwD 3.72% 1.27% 1.38% 6.37% current performance only. *Data is under review as detailed on page 21. Trust 68.97% 83.33% 90.91% 70.37% 78.95% 78.98% Early Intervention Psychosis: seen within 2 E.H.4 50% weeks BwD 85.71% 81.82% 83.33% 50.00% 87.50% 77.50% ADHD (Adult): seen within 18 weeks – CAMHS N/A Trust 46% 39% 36% 40% Transitions LQR_1 ADHD (Adult): seen within 18 weeks – new N/A Trust 94% 84% 85% 88% patients Trust 47.02% 52.09% 70.37% 79.75% 80.40% 64.80% LQR_5 MAS: seen within 6 weeks 70% BwD 16.67% 18.97% 84.48% 92.68% 97.78% 61.07%

Unscheduled Care: Trust 51.64% 45.88% 46.04% 40.75% 39.44% 44.79% MHLT assessment within 1 hour of referral from N/A ED BwD 53.41% 57.00% 55.56% 41.84% 26.58% 47.63% LQR_8 Unscheduled Care: Trust MLHT Assessment within 24 hours from ward N/A Expected from Q2 referral ELHT site

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Threshold Apr May June July Aug 2017/18 Ref Indicator Level 2017/18 17 17 17 17 17 YTD

Unscheduled Care: Trust 229 286 300 384 1199 All 4 hour breaches where psychiatric N/A assessment was requested ELHT site 70 69 59 80 278

Unscheduled Care: Trust 67 79 99 116 129 490 4 hour breaches where psychiatric assessment N/A was requested within 2 hours ELHT site 22 30 38 50 63 203

Unscheduled Care: Trust 3 10 29 13 17 72 12 hour breaches where psychiatric assessment N/A was requested ELHT site 1 1 12 8 8 30

OAPs Out Area of Placements (average) 0 Trust 23.48 25.52 25.67 24.23 23.68 24.52

KEY RED Under performance GREEN Achieving AMBER Under Review

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Appendix 7 ELHT quality measures currently underperforming against target

Threshold Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar YTD Ref Indicator 17/18 17 17 17 17 17 17 17 17 17 18 18 18 E.B.5 A&E 4 Hour * 95% 82.72% 84.39% 84.73% 79.95% 89.20% 84.10% Cancelled E.B.S.2 0 1 1 1 0 0 3 Operations E.B.S.4 52 week wait 0 1 0 1 2 0 4

E.B.S.5 Trolley wait 0 1 5 12 7 7 32 Ambulance E.B.S.7a Handover 0 351 332 349 446 269 1747 >30min Ambulance E.B.S.7b Handover 0 85 45 29 106 30 295 >60min Missed E.B.S.7 handover 0 161 169 123 166 124 743 stamps Clostridium E.A.S.5 28 2 4 3 2 5 16 Difficile

*KEY RED Under performance GREEN Achieving AMBER Under Review

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Appendix 8 LCFT Community quality measures currently underperforming against target

Apr May Jun Jul Aug Indicator Target 17 17 17 17 17 Referral to treatment (RTT) Incomplete (BwD CCG) 84.9% 91.7% 95.6% 96.1% 99.4% Adult Learning Disability Service 100% 100% 100% 100% 100% Adult Speech and Language Therapy 100% 100% 100% 100% Children's Occupational Therapy 100% 100% 100% 100% 95.7% Children’s Physiotherapy 100% 100% Children's Speech & Language Therapy 70.2% 81.8% 90.2% 90.9% 98.5% Community Respiratory Service 100% 100% Community Stroke Service 100% 100% 100% 100% 100% 92% Continence Service 100% 100% Falls Team 100% 100% 0% Intermediate Care 100% 100% 100% 100% 100% Nutrition & Dietetics 100% 100% 100% 100% Podiatry 100% 100% 100% 100% 100% Pulmonary Rehabilitation 100% 100% 100% 100% 100% Rapid Assessment Team 100% 100% 100% 100% 100% Rheumatology 100% Community Stroke Rehabilitation Measures (BwD CCG) Patients assessed with 72 hours of referral 95% Q1: 96.0% Due Q2 FIM/FAM: increase in at least 1 domain at point 95% Q1: 97.0% Due Q2 of discharge Mood screen: patients receiving a mood and 95% Q1: 100% Due Q2 anxiety screen Goal setting: with written goals in place 95% Q1: 100% Due Q2 PROM: improvements in more than one domain 95% Q1: 100% Due Q2

KEY RED Under performance GREEN Achieving AMBER Under Review

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NHS Constitution Appendix 9

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Year to Aug 2017 Metric Level Period Target Date Position Position

NHS Constitution support measures

HCAI

24: Number of C.Difficile infections CCG YTD 20 24 24

Activity Measures

Referral to Treatment (RTT) & Diagnostics

2015: Number of Endoscopy Diagnostic Tests/Procedures CCG YTD 2,098 2,098

2018: Number of Completed Admitted RTT Pathways CCG YTD 3,928 3,452 3,452

2016: Number of Diagnostic Tests/Procedures (excluding Endoscopy) CCG YTD 18,511 18,511

2019: Number of Completed Non‐Admitted RTT Pathways CCG YTD 13,039 12,178 12,178

Other performance measures

EMSA

1067: Mixed sex accommodation breaches ‐ All Providers CCG Aug 2017‐18 0 0 1

Referral to Treatment (RTT) & Diagnostics

1839: Referral to Treatment RTT ‐ No of Incomplete Pathways Waiting >52 weeks CCG Aug 2017‐18 0 0 0

Episode of Psychosis

2099: First episode of psychosis within two weeks of referral CCG Aug 2017‐18 50.00% 87.50% 72.22%

Increasing Access to Psychological Therapies (IAPT) Prevalence

Numbers of patients entered treatment for IAPT services (all providers) as a percentage YTD CCG 4.20% 4.30% 4.30% of estimated Prevalence (Jun 2017‐18)

Increasing Access to Psychological Therapies (IAPT) Waiting Times

E.H.1: Six week starters as a percentage of Finished course of treatment (all providers) CCG Jun 2017‐18 75.00% 81.25% 89.36%

E.H.2: Eighteen week starters as a percentage of Finished course of treatment (all CCG Jun 2017‐18 95.00% 100.00% 97.87% providers)

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GOVERNING BODY MEETING

Annual Report of the Director of Public Health, 2016/17

Date of Meeting 8 November 2017 Agenda Item 10

CCG Corporate Objectives

Through better commissioning, improve local health outcomes by addressing poor X outcomes and inequalities To work collaboratively to create safe, high quality health care services X To maintain financial balance and improve efficiency and productivity To deliver a step change in the NHS preventing ill health and supporting people to live X healthier lives To maintain and improve performance against core standards and statutory requirements To commission improved out of hospital care X CCG High Impact Changes Delivering high quality Primary Care at scale and improving access Self-Care and Early Intervention X Enhanced and Integrated Primary Care and Better Care Fund Access to Re-ablement and Intermediate Care Improved hospital discharge and reduced length of stay Community based ambulatory care for specific conditions Access to high quality Urgent and Emergency Care Scheduled Care Quality

Clinical Lead: N/A

Senior Lead Manager Dr Gifford Kerr Finance Manager N/A Equality Impact and Risk Assessment Yes completed: Patient and Public Engagement completed: The Public Health Annual Report is a professional statement of the Director of Public Health and not subject to consultation in its own right. GOVERG BODGOVERNING BODY MEETING Governing Body Meeting Page 1 of 4

Financial Implications None Q None Report authorised by Senior Manager: Professor Dominic Harrison Y

Decision Recommendations

1) Note the content of the Public Health Annual Report 2016/17

2) Support the recommendations of the report including the approach to improving health and wellbeing by supporting social movements for health

Governing Body Meeting Page 2 of 4

1. EXECUTIVE SUMMARY

The Director of Public Health has a duty to produce an Annual Report, which is traditionally a professional statement about the health of local communities and increasingly an important vehicle by which Directors of Public Health can identify local issues, flag problems and report progress. The report is publicly accessible and a key resource to inform local inter-agency action for health and wellbeing.

The 2016/17 Annual Report for Blackburn with Darwen is set out in two parts :

1. Health as a Social Movement describing the major cultural change required to address current health and wellbeing challenges and,

2. The Integrated Strategic Needs Assessment (ISNA) Summary Review setting out the environmental and social context of Blackburn with Darwen as a place and associated impact on the wellbeing of the population.

The report makes a number of recommendations to improve health and wellbeing by supporting social movements for health which were approved by Blackburn with Darwen Council Executive Board on 12 October 2017.

An electronic version of the report can be downloaded from http://www.blackburn.gov.uk/Lists/DownloadableDocuments/Public%20Health%20Annual%20Report%202016 _17%20Final.pdf

2. BACKGROUND

Under the Health & Social Care Act 2012 (section 31), the Director of Public Health has a duty to write an Annual Report on the health of the local population. Within the same section of the Act, the Local Authority has a duty to publish the report.

The Public Health Annual Report is traditionally a professional statement about the health of local communities and, increasingly an important vehicle by which Directors of Public Health can identify local issues, flag problems and report progress. The Report, which should be considered alongside the local Joint Strategic Needs Assessment and Joint Health and Wellbeing Strategy, is publicly accessible and a key resource to inform local inter-agency action for health and wellbeing,

The report this year is set out in two parts: Health as a Social Movement and the Integrated Strategic Needs Assessment (ISNA) Summary Review.

The first section of the Report highlights how social movements can energise the major cultural change required to address current health and wellbeing challenges. A social movement for health refers to “a persevering, people-powered effort to promote or resist change in the experience of health, or the systems that shape it” (Nesta 2016) and can have transformative effects on society (as has been shown by the success of the HIV and disability rights movements, for example).

A social movement for health is needed now because the existing model of health and social care service delivery is no longer fit for purpose to address the current causes and patterns of disease, and citizens are asking for much deeper involvement in choices related to their health and wellbeing. Indeed, Simon Stevens, Chief Executive of the NHS, states in the Five Year Forward View that large scale social movements are

Governing Body Meeting Page 3 of 4

‘mission critical’ for the future of the NHS. The work reflected in the report is also being developed as part of the Pennine Lancashire (health and care) Transformation Programme.

The ISNA Summary Review forms the second part of the report and documents the social and environmental context of Blackburn with Darwen as a place and the impact these factors have on the physical and mental wellbeing of the population collectively, and as individuals. This section begins with a profile of the borough’s population and local economy with subsequent sections arranged under the three themes of the Joint Health and Wellbeing Strategy: ‘Start Well’, ‘Live Well’ and ‘Age Well’. The ISNA demonstrates the scale of our challenge – doing more of what we have always done will not be sufficient to secure the improvements in health and wellbeing that people aspire to and are demanding – reinforcing the need to fully embrace the power of social movements for health.

The ISNA Summary Review was strongly commended by the Health and Wellbeing Board Peer Review team in 2015 and inclusion of an updated version in the latest Public Health Annual Report broadens its exposure.

3. Recommendations

The report makes the following key recommendations for adoption by Blackburn with Darwen CCG, Council and partners;

Recommendation 1 – Becoming a ‘Changemaking’ Place

Improve working culture and practices by adopting and encouraging the three ‘changemaking’ values:

• Creativity - ideas and initiative cannot be the sole reserve of a few senior individuals but must be encouraged and valued by everybody.

• Self-determination - freedom and willingness to respond quickly and creatively giving employees license to act on their own initiative and to try new approaches without waiting for permission

• Collaboration - effective collaboration across departments and with external partners and the public will extend changemaking values, build trust and prevent duplication of efforts.

Recommendation 2 - Work With Communities To Support The Growth Of Social Movements For Health

• Develop strong and sustained networks: recognise the importance of and support shared learning through communities of interest and other networks beyond time-limited programmes of work • Identify and support organisational and community social movement ‘champions’ to promote social movements for health within their formal and informal networks • Create learning and development opportunities in support of - and in the spirit of - social movements for health • Deliver a rolling programme of celebration and learning to include an annual Festival of Strengths

Recommendation 3: Embed Social Movements In Practice

• Identify and develop exemplar social movements, in order to create real-world examples of communities mobilised for health and care • Understand and demonstrate ‘what works’ through continuous engagement and evaluation. • Support and encourage spread of movements, by developing approaches that could be scaled, adapted and adopted in other communities. Governing Body Meeting Page 4 of 4

September 2017 v1.7

Blackburn with Darwen

Annual Report of the Director of Public Health 2016/17 Contents

Section One - Social Movements for Health Section Two - Integrated Needs Assessment Summary Review

Introduction 3 Integrated Needs Assessment Summary Review - Introduction 20 Blackburn with Darwen’s Vision 3 Setting The Scene 21 Box 1 - A system in need of an upgrade? 4 Population 21 What is a social movement? 5 Local economy 26 Box 2 - Social movement in Blackburn with Darwen 6 Welfare reforms 30 What is a social movement for health? 7 Safe & healthy homes and neighbourhoods 31 What is the role of the public sector? 8 Social mobility 33 What needs to change? 9 Start Well 34 Changemaking 10 Determinants of health for children/young people 34 Becoming a ‘changemaking’ place 11 Vulnerable groups 36 Empowering communities 12 Lifestyle factors and their consequences 37 Box 3 – Blackburn with Darwen’s ‘passionate enthusiasts’ 13 Accidents 41 Recommendation 2 - ‘Work with communities to Child & infant mortality 42 14 support the growth of social movements for health’ Live Well 43 Embedding Social Movement Approaches In Practice 15 Lifestyle factors 43 Box 4 – Adverse Childhood Experiences (ACEs) 15 Health outcomes 48 Box 5 – Substance misuse 16 Asylum seekers 56 How Will We Know If We Are Successful? 17 Age Well 57 Recommendation 3 - Embed social movements in practice 17 Issues particularly affecting older people 57 Summary of Recommendations 18 Quality and length of life 59 References 19 End of life 60 References 61

Blackburn with Darwen Public Health Annual Report 2016/17 Page 2 Social Movements for Health

Introduction There is growing recognition that if we want a health and social care system that is high quality, safe and sustainable (and we do!) then carrying on as we are isn’t an option. The current health and care service models are failing to address the wider determinants of health and wellbeing and it is clear that big institutions – like the NHS - are not able to tackle today’s health challenges on their own.

When the NHS was conceived, the most pressing health issues were infectious diseases and most of hospitals’ work was around managing short periods of acute illness. The main health issues now facing Blackburn with Darwen and the wider population are, however now very different, being predominantly long term conditions: diabetes, heart and lung disease, cancer and mental illness.

Since its inception in 1948 the collective enterprise of the NHS has proven to be amongst the most successful, efficient and effective global institutions. There is growing evidence that its operating model and service are no longer fit for purpose to address the current causes and patterns of disease (Box 1), and people are asking for much deeper involvement in choices related to their health and wellbeing. If the NHS is to continue to improve health and wellbeing it will need to extend and augment the ways in which it works to include supporting large scale social movements for health and increasing its focus and investment on the proactive generation of health. Indeed, Simon Stevens, Chief Executive of the NHS, states in the Five Year Forward View1 that large scale social movements are now ‘mission critical’ for the future of the NHS.

Our Vision: For Blackburn with Darwen to become a place where social movements are encouraged and enabled to thrive, through close collaboration between empowered residents and responsive institutions, for the improvement of health and wellbeing.

Blackburn with Darwen Public Health Annual Report 2016/17 Page 3 Social Movements for Health

Box 1 - A system in need of an upgrade? Type 2 diabetes and obesity

Diabetes In Blackburn with Darwen alone, diabetes diagnoses have nearly doubled in the last ten years and are continuing to increase. Nationally, over 600 children and young people have type 2 diabetes, a condition previously unheard of at this age. We cannot reverse this trend by relying on a purely service-driven model. As announced in the Five Year Forward View1, the NHS is implementing a national diabetes prevention programme of intensive intervention for people identified as already at high risk, which is important for these individuals, but does nothing to tackle the underlying causes of diabetes. Instead we need to address the risk conditions in society that have encouraged diabetes in the first place. These risk conditions create unhealthy environments by allowing sugar to be hidden in children’s food, advertising processed foods with high sugar content and transport policies that encourage the use of cars rather than public or active transport.

Obesity To date, attempts to tackle obesity have largely taken a pathological approach, in which the cause of obesity has been assumed to be a ‘problem’ with the individual. We then try to ‘fix’ this through individually focussed behaviour change programmes and, if this doesn’t work, then surgery is considered. However, as this and previous annual reports show, whole sections of the population, from children to older people, have shown increasing levels of obesity over the last twenty years, which contradicts a notion that obesity is simply an individual behaviourial issue. We need to ask: if certain behaviours cause obesity, then what causes these behaviours? The answer is that, as for diabetes, there has been a change in the environment so that unhealthy choices are often the easiest, or even actively encouraged.

The risk conditions for obesity are effectively the same as those for type 2 diabetes (and many other health conditions), and addressing these wider environmental factors has the potential to make a much bigger impact on public health than focussing only on individuals and their behaviour.

“We need to stop investing in the wrong end of the problem and think about addressing the underlying risk conditions”

Blackburn with Darwen Public Health Annual Report 2016/17 Page 4 Health as a Social Movement

How social movements impact health and care

1. Bring about change in the experience and delivery of health care 2. Improve people’s experience of disease, disability, or illness 3. Promote healthy lifestyles 4. Address socioeconomic and political determinants of health “When we talk of social change, we talk of movements; a 5. Democratise the production and dissemination of knowledge word that suggests vast groups of people walking together, 6. Change cultural and societal norms leaving behind one way and travelling towards another” 7. Propose new health innovation and policymaking processes Rebecca Solnit Communicating the value of movements Social Movements for Health There is no definitive definition of a social movement. Yet, it is possible to sharpen understanding and communication around the term to make it useful to a UK health and care context. Current NHS communication around social movements focuses on the NHS as a social movement and on movements supporting NHS services, fostering cultural change and driving large-scale systems Whatchange. is It ais criticalSocial to Movement?sharpen the communication around social movements to capture the Social movements can have tremendous power, leading to breadth of their potential value as well as refine it to reflect depth of understanding. Social movements involve collective action by individuals who voluntarily come together around transformational changes in both practice and culture (as the civil rights and environmental movements have, for example). According a Acommon social movementcause. They empowers often involve radical action and protest, which may lead to conflict with accepted norms and ways of doing things. They put pressure on society to change, respond to Nesta2: directlyUnderstanding to the needs how ofsocial people movements and communities behave is andcritical have to engagingthe potential with to them. spread We widely suggest across that populationsa social EMPOWERS through personal: networks. In short, a social movement EMPOWERS: “In their purest form movements are messy, vibrant, spontaneous and uncontrollable. They bubble up outside of formal institutions and from beyond established power Empathises with the issues of people, carers and communities structures. They challenge and disrupt. They are restless and determined. They often make society, elites and institutions deeply uncomfortable as they challenge accepted values, Mobilises the strengths, capabilities, resources and knowledge of people priorities and procedures”

Powers people by building leadership and agency Given this unpredictability and potential conflict with institutions and power structures, it is extraordinary and potentially unprecedented for the leader of the largest public institution in the country, the NHS, Orbits existing health, political, and societal systems to change them to call for more social movements as a way to support its ability to deliver. Yet it is social movements that can drive the adoption of new social norms that ultimately make a meaningful impact on the health Waves and recurs in intensity over time of our community, and we welcome this call for action.

Experiments with new ideas and approaches Social movements are integral to a healthy and thriving society. When successful they can enable disproportionately large, positive outcomes. High levels of social movement activity indicates that a Rages and roars for issues that matter particular set of factors are present within a community: engaged residents; a diversity of movements; mobilisation around common causes; and significant grievance with the current state of affairs. Self-governs their activities It is these societal features that enable movements to be born and to grow, and that we need to foster. The history of Blackburn with 2 (Figure from Nesta ). Darwen suggests that we already have many of the raw ingredients of social movements in place (Box 2).

Blackburn with Darwen Public Health Annual Report 2016/17 Page 5 6 7 Social Movements for Health

Box 2 - Social movements in Blackburn with Darwen

Blackburn with Darwen has many of the precursors required to start a social movement. The first is its strong connections between politicians and the public. For a small borough, we are politically influential, having borne politicians such as Barbara Castle and Jack Straw who have helped to bring about significant change. Blackburn with Darwen also has strong community networks, political engagement and representation. Representatives from all communities play an active part in Blackburn with Darwen’s local government, which helps to channel dissatisfaction into positive action.

Blackburn with Darwen also has a rich history of social movements starting here. In the 1830s, Blackburn, along with Preston, played a key role in the birth of the temperance movement in the UK, which aimed to tackle the threats of drunkenness and street drinking by addressing what we would now call social determinants. Within 50 years Blackburn had improved dramatically, with working hours reduced, education for all children and the building of a public park and library. National legislation was also passed which gave magistrates the power to close public houses by 11p.m.

When the American Civil War began in the 1860s, American cotton exports ceased. This ‘cotton famine’ had a dire impact on Blackburn, which had only just started its cotton industry. Blackburn Council responded to this issue by employing around 1,000 people from the cotton industry to build the town’s sewers. It raised the money to fund this project by subscription and without the help of national government.

Blackburn with Darwen Public Health Annual Report 2016/17 Page 6 Social Movements for Health

What is a Social Movement for Health? A social movement for health specifically refers to “a persevering, people-powered effort to promote or resist change in the experience of health, or the systems that “Developing health as a social movement is a shape it” 2. The HIV/AIDS movement has, for instance, transformed the way people process of allowing and enabling a community to experience their own condition and has created a cultural shift in how society responds to those with the illness and to issues of sexuality more generally; from cries of “gay plague” take action on the determinants of their own life and HIV being considered a death sentence in the 1980s, those living with HIV now have chances” better access to appropriate health care as well as social support and, as a result, both length and quality of life are approaching that of those without the disease.

Another example is the disability rights movement, which has fought for equal rights and against discrimination for several decades and has achieved many notable victories, including the passing of the Disability Discrimination Act in 1995. These examples show the power of advocacy and pressure through sustained social movements to transform aspects of health.

Of course, social movements are not an answer to all of our health and care concerns. They can be messy, turbulent, and risky, leading us down somewhat untried and untested paths, without immediate benefit. Yet, they represent one approach to the system-level transformation so urgently needed in health and care and, if successful, can have significant health impacts by2:

1. Bringing about change in the experience and delivery of health care 2. Improving people’s experience of disease, disability or illness 3. Promoting healthy lifestyles 4. Addressing wider determinants of health 5. Democratising the production and dissemination of knowledge 6. Changing cultural and societal norms 7. Bringing about new health innovation and policymaking processes

The potential of social movements to actively create health, and not to focus only on preventing disease, means it makes sound economic sense to invest time, effort and resources in finding local solutions to help social movements to grow and spread.

Blackburn with Darwen Public Health Annual Report 2016/17 Page 7 Social Movements for Health

Health as a Social Movement What is the Role of The Public Sector? “Political, civic and managerial leadership in public services should focus on creating the conditions in

which people and communities take control, to lead flourishing somelives, change increase (e.g. service, health solution, expectancy belief, pattern and of behaviour,reduce norm) into an organisation, disparities in health expectancy across the social gradient”. Fairsocial Society system Healthy or society Lives at large. (The One Marmotpath is illustrated Review below.) 3 Informal grassroots groups progress towards greater formalisation and institutionalisation,

The public sector is uniquely placed to help create the conditions and make thepotentially space for spawning social movements an organisation to toflourish. supportHigh itsWhether scale. Some and organisationshow social willmovements ‘dock’ into achieve Vanguards their aims depends in part on the ability of institutions to listen and effectively respond.formal NHSProgramme To services fully realise by sharing the potentialmanagement of socialresponsibilities movements, (e.g. Wellbeing institutions Enterprise’s need to be agile New Care Model Social Prescribing programme), others will remain more autonomous. Still others might form and responsive, with a commitment on both sides – community and organisations- to engageVolunteering in and create better ways of doing things. and run groupsHospital Schemes or departments within the NHS organisational structure. Movements aimed Commissioned

at changing cultural and political normscharitable activity and institutions might follow a different trajectory to Social movement theory suggests that changes are only likely to ‘catch hold’ oninstitutionalisation the ground if they and are resist consistent formalisation with and local incorporation. customs, habits,Further workaspirations is needed and to mappassions. the Movements generally do not form from a specific call to action, but from raw emotiondifferent: trajectories to institutionalisation, diffusion and scale; for initial discussion, the following diagram plots some illustrative examples along one path. “a diffuse dissatisfaction with the status quo and a broad sense that the current institutions and power structures of the society will Path to institutionalisation Wellbeing not address the problem. This brewing discontent turns into a Enterprises movement when a voice arises that provides a positive vision and (Social Prescribing) NHS Change Day Platform 4 a path forward that’s within the power of the crowd” NHS Change Fully Day Platform Vanguards

New Care Model 32 Programme It is, therefore, important for public sector organisations to truly understand what Self-funded charitable activity drives and moves local people, to listen to their concerns and to respond. Over time, Wellbeing Volunteering in

Level Groups Enterprises Hospital Schemes INTEGRATION WITH FORMAL HEALTH AND CARE this can lead a social movement to become a sustained part of formal organisations Neighbourhood (Social Prescribing) MANAGED

through a process of ‘institutionalisation’. A movement institutionalises institutionalisation to Path when it Partially BY THE NHS embeds some change (e.g. a service, solution, belief, pattern of behaviour, or Neighbourhood Grassroots cultural norm) into an organisation, social system or society at large. The figure to Level Groups social movement the right demonstrates a path to institutionalisation of movements within the NHS. None

There are of course many differences between large organisations like the NHS Fully Autonomous

Partially Grassroots Self-funded Commissioned and local government and society as a whole, but public sector leaders can and social movement charitable activity charitable activity

should learn from how social movement initiators “mobilise the masses and Autonomous 4 institutionalise new societal norms” . None High

MANAGED INTEGRATION WITH FORMAL HEALTH AND CARE

Health as a Social Movement Figure from Nesta BY THE NHS some change (e.g. service, solution, belief, pattern of behaviour, norm) into an organisation, an organisation, norm) into of behaviour, pattern solution, belief, service, some change (e.g. below. is illustrated One path large. or society at social system and institutionalisation, formalisation greater towards progress groups grassroots Informal into will ‘dock’ Some organisations support its scale. to an organisation spawning potentially Enterprise’s Wellbeing (e.g. sharing management responsibilities by NHS services formal others might form Still autonomous. more others will remain programme), Social Prescribing aimed Movements structure. or departments within the NHS organisational and run groups to trajectory a different might follow and political norms institutions changing cultural at map the is needed to Further work and incorporation. formalisation and resist institutionalisation the following initial discussion, diffusion and scale; for institutionalisation, to trajectories different along one path. examples plots some illustrative diagram

Blackburn with Darwen Public Health Annual Report 2016/17 Page 8

32 Social Movements for Health

What Needs to Change? A lot! But this isn’t about – or rather is about more than - structural reform. This is because, firstly, it is often difficult for social movements to collaborate effectively with health services without the movement either collapsing under the burden of bureaucracy or being pressured to change2. More fundamentally, and despite successive Governments persisting with the idea that major reorganisations of the health service will address many of the issues we face, structural reforms have not led to lasting improvements.

Why is this? Primarily, it is because the underlying culture, norms and expectations of organisations and the communities they serve are of far greater importance than organisational structures5. Formal organisational structures are of course necessary and useful in many ways, but even the best thought-through structures and processes can be undermined by a culture of negative behavioural norms. Meanwhile, a positive and constructive culture can deliver real impact even within the context of messy, fragmented structures (like our current health system!).

“Culture is like the wind. It is invisible, yet its effect can be seen and felt. When it is blowing in your direction, it makes for smooth sailing. When it is blowing against you, everything is more difficult”4

This is not to say that structural and organisational reform is always a bad thing; it certainly isn’t. The current reforms - devolution and health and care integration – do have potential, but concentrating solely on structures without including transformation of culture and norms runs the risk of merely continuing negative norms - territorialism, hierarchical power and inertia - under a new banner, thus reducing any potential positive impact5.

To achieve the cultural changes we are hoping for, both professionals and communities need to learn how to connect, collaborate, cooperate, co-create and co-produce 6 in much more effective ways. New working practices and models of engagement are required that take advantage of both the efficiency and scale of institutions and the dynamism and agility of movements. For this to occur, we require two things: a willingness to change the culture and working practices within our own organisations; and better connections with empowered local communities, who are capable of demanding their voice is heard.

Blackburn with Darwen Public Health Annual Report 2016/17 Page 9 “We do not become transformed alone, we become transformed when we’re in relationship with others” Hahrie Han

Social Movements for Health

Changemaking We believe that embodying a ‘changemaking’ approach is the first step to driving the necessary change in the ethos and norms of the institutions and communities that create Blackburn with Darwen, rather than their formal structures.

The New Local Government Network describes their vision of a “changemaking council” for example, as one which places a much greater focus on developing a positive working culture, shared values and shared purpose by encouraging the three changemaking values of creativity, self-determination and collaboration5.

To prevent inertia and increase innovation, creativity should be valued across the whole workforce and ideas not considered merely as something that come from senior leaders. Employees must be able to practice self-determination, a licence to act on their own initiative and to try new approaches without seeking explicit permission. Finally, effective collaboration counters fragmentation and territorialism and ensures that effort is reinforced rather than duplicated5. Social movements do not fit into the rigid structures many of us are used to working with, and to harness the agility, freedom, positivity and determination underpinning many movements we must aim to develop and share these same values in our professional lives.

It can take as few as 3% of people in an organisation to drive the conversations of 85% of other people7. If we can embed the ‘changemaking’ values of creativity, self-determination and collaboration into our own working culture, we will then be in a strong position to extend these values to our partners and ultimately to the communities we work with and for, thereby helping to create the conditions necessary for social movements to thrive.

Blackburn with Darwen Public Health Annual Report 2016/17 Page 10 Social Movements for Health

Recommendation 1 Becoming a ‘changemaking’ place Improve working culture and practices by adopting and encouraging the three ‘changemaking’ values:

» Creativity - ideas and initiative cannot be the sole reserve of a few senior individuals but must be encouraged and valued by everybody. More ideas, more insight, more impact!

» Self-determination - freedom and willingness to respond quickly and creatively is crucial if we are to benefit from a social movement; employees must have license to act on their own initiative and to try new approaches without waiting for permission.

» Collaboration - seek ways to work across organisational boundaries; there is no use in being an island of good practice! Effective collaboration with other departments, external partners and the public will extend changemaking values, build trust and prevent duplication of efforts.

Blackburn with Darwen Public Health Annual Report 2016/17 Page 11 “The public no longer wants to be led, they want to be mobilised. They want professionals on tap, not on top” Social Movements for Health

Empowering Communities It is well recognised that connected and empowered communities are healthier communities8. Communities that are involved in decision-making about their area and the services within it, that are well networked, supported and supportive, and where neighbours look out for each other, are known to have a positive impact on people’s health and wellbeing. Social movement theory suggests that building community resilience is key to achieving large scale change and successful social movements for health9.

To do this, we need to be more open and responsive to communities and work together to create change. Fundamental to this change are interpersonal relationships, including both how professionals go about their work and how we engage with communities. Therefore, we will follow the advice of Nesta and advance our own transformation “with humility and in partnership with the people who the NHS has served for over half a century” whilst developing “solutions that are created through deep engagement and collaboration” 2. We aim to mobilise communities at scale for health and wellbeing by: » Recognising people as assets, with knowledge and skills as well as needs » Developing approaches that are community-led and better at connecting people to their communities » Creating healthy places that build social capital » Commissioning in a way that reflects the concerns of local communities and values co-production We need to acknowledge that public sector organisations are more than statutory regulators and service providers by recognising and encouraging their wider role of supporting communities and enabling people to act for themselves6. To create an environment conducive to social movement development and growth, we must empower communities so that local people’s creativity is fostered, their responsibility and desire to look after themselves and each other is encouraged and supported, and collaboration and coproduction become routine.

Communities and residents themselves must also be willing to speak up, to demand more and to engage. For our part, we may need to convince our residents that their voices really will be heard, and then actively encourage them to speak out in order to generate a climate of public opinion and political conviction that change is necessary. There has been a recent culture shift that supports this in that we are increasingly seeing patients and residents demanding a say in their own health circumstances. There are several examples across Blackburn with Darwen where people have identified an issue in their communities, for instance social isolation or physical activity, and are doing something about it. Although their work is on a small scale, they are the passionate enthusiasts who can help social movements gain traction (Box 3).

Movements need local activists who will influence their peers and so form a critical mass of support for sustained change. In doing so, informal ‘communities of interest’ can form, in which groups of people who may not usually work together come together to act and learn in order to achieve a common goal. They provide a space where individual identity becomes collective identity, a powerful catalyst for change. These networks can be cultivated and are recognised to be one of the most important mobilisation mechanisms for social movements. These informal groups need to be considered as crucial partners and we should do what we can to support their growth.

Blackburn with Darwen Public Health Annual Report 2016/17 Page 12 Social Movements for Health

Box 3 – Blackburn with Darwen’s ‘Passionate Enthusiasts’

Circle of Friends Beth Gregory has been involved in community groups in one guise or another since she became a North East Lancashire Road Safety League officer when she was twelve. Around 8 years ago Beth, along with five others, started her latest community group – the Circle of Friends – which runs social events for the elderly in her local village, Guide. Eight people initially joined but news of the group soon spread by word of mouth. Within a matter of months there were over 34 members from all over the area.

The Friends receive talks from a variety of speakers, play bingo, exercise, laugh and catch up. As the group are mainly in their eighties or nineties, Beth thinks it is important that they all meet and socialise in this way so that they stay connected. She believes that without this group, most of the members would “sit at home in front of the television and ‘vegetate’”!

Beth acknowledges that there are difficulties – running costs and transport needs have made it increasingly difficult to run the group – but is pleased to see similar groups being set up across Blackburn with Darwen, and hopes that these too will reach out to other elderly people who might also be lonely and feel isolated.

Young Weavers Kevin Riddehough has been cycling for as long as he can remember. About ten years ago Kevin came across the ‘Let’s Ride’ website set up by British Cycling, which allows anyone to join organised cycle rides and/or create their own cycling group.

Kevin was inspired to set up his own group within the Blackburn area and initially organised rides during the week around his work commitments. In December 2012, Kevin, along with his wife, Vicky, then started Bus Stop Bikers, before establishing the Young Weavers in 2014 to encourage more families, rather than just adults, to take part.

Young Weavers has been up and running for nearly three years now. The activities take place on the weekend and alternate, so that on one week there is a bike ride and then the next is a walking/family activity. There are also sporadic family events, such as craft events or trips to Stonyhurst College. Young Weavers has a committee, Facebook group and dedicated website.

Kevin will keep on cycling and inspire others to become active. The reason he does this is because he loves seeing someone, who started by cycling at the back of the group, going to the head of the group and chatting on every ride. For Kevin, success is not about how many members he has, it is about reaching a variety of people and encouraging those who do not exercise to get on a bike and ride.

Blackburn with Darwen Public Health Annual Report 2016/17 Page 13 Social Movements for Health

Recommendation 2 Work with communities to support the growth of social movements for health » Develop strong and sustained networks: recognise the importance of and support shared learning through communities of interest and other networks beyond time-limited programmes of work.

» Identify and support organisational and community social movement ‘champions’ to promote social movements for health within their formal and informal networks.

» Create learning and development opportunities in support of - and in the spirit of - social movements for health.

» Deliver a rolling programme of celebration and learning to include an annual Festival of Strengths

Blackburn with Darwen Public Health Annual Report 2016/17 Page 14 Social Movements for Health

Embedding Social Movement Approaches In Practice We are beginning to put the thinking behind social movements into practice. Boxes 4 and 5 highlight how we are attempting to harness the power of social movements to address Adverse Childhood Experiences (ACEs) and substance misuse, respectively. We recognise, though, that the potential scope of social movements for health is much broader and that almost every aspect of health and wellbeing could be influenced for the better by a demand for change led by our residents, including housing, transport and education alongside traditional health systems.

Box 4 – Adverse Childhood Experiences (ACEs)

The Adverse Childhood Experiences (ACEs) movement began in response to a 1998 U.S. study which identified ten stressful or traumatic experiences that children can be exposed to whilst growing up, ranging from those that directly harm a child (such as physical, verbal or sexual abuse, and physical or emotional neglect) to those that affect the environment in which they grow up (including parental separation, domestic violence, mental illness, alcohol abuse, drug use or incarceration). There is a strong relationship between ACEs and both chronic ilness (diabetes, heart disease, etc.) and health-harming behaviours (smoking, alcoholism, violence, incarceration, etc.) in adulthood. However, it is possible to both prevent ACEs and to reduce the consequences of ACEs in those that have already experienced them.

So far, the ACEs movement has primarily been led by professionals, both locally and internationally, with no deep rooted culture change yet making ACEs a policy priority. There is then both a need and an opportunity for a health social movement around ACEs and their effects.

We believe that only a citizen-led social movement has the potential to change norms around ACEs and to create environments that nurture healthy children and families. We are committed to encouraging and fostering a social movement around ACEs and tailoring our own local programs and policies to help create safe, stable and nurturing communities.

We are working to: raise awareness and understanding of ACEs; create environments for people to share and support each other in working through their experience of ACEs; create an ACE-informed workforce across sectors (including education, health and social care, criminal justice, and voluntary, community and faith groups); engage local community members in developing effective and novel solutions; and explore the adoption of evidence-based ACEs interventions that have been successfully implemented elsewhere.

While we see ourselves as well placed to provide the initial spark for a local movement, the long-term success of ACEs prevention will rely on local people and communities taking ownership of the movement from the very beginning, in order to drive the changes that they want. We are ready to listen, to adapt and to support. Importantly, we’re also prepared to ‘let go’ and allow the movement to take its own course, however unpredictable that may prove to be!

Blackburn with Darwen Public Health Annual Report 2016/17 Page 15 Social Movements for Health

Box 5 – Substance misuse

There is strong local evidence that recovery from drugs and substance misuse is best supported by peers, allies and community action. We recognise this and have actively encouraged the growth of a social movement in relation to our substance misuse services.

When the Council tendered for a substance misuse service provider in 2014, we required bidders to adopt a Recovery Orientated Integrated System (ROIS) model, in which those with lived experience were involved in raising awareness, reducing stigma and promoting prevention. Key to this were coproduction and the development of community-based assets, including: working collaboratively with local people and wider stakeholders to ensure that services truly meet the needs of people and their families; building on individual strengths; assisting people to achieve their life goals; and promoting overall improved wellbeing for all.

The drug and alcohol third sector organisation CGL (Change, Grow, Live) was appointed and has provided substance misuse services across BwD since 2015, including education and prevention, training, treatment and recovery support through easy access support to both young people and adults. The effectiveness of the system has been enhanced by new and improved relationships between professionals, citizens and volunteers with each other and with schools and colleges, local businesses and employers, and other voluntary, community and faith sector organisations.

There have been many positives from using this model. Many service users are engaged and connected through regular sports and social activities including football, boxing, fishing, walking, choirs and family craft sessions. There is now a regular community sports day, participation in the nationwide ‘Recovery Walk’ and health and nutrition classes that provide cooking and lifestyle skills. In addition, residents are given the opportunity to learn a skill or gain further qualifications and help is provided to get users into apprenticeships and employment. All of these activities help those affected by substance misuse by encouraging them to stay clean, be more confident and sociable, stay connected and understand that they are not alone with their situation.

A key part of the model’s success has been enabling and empowering residents to take action for themselves, with some now regularly leading projects or getting involved in mentoring others. For example, some service users are involved in a furniture restoration project, whilst others lead art and craft sessions. The Step Up Buddy system also utilises peer mentors to ensure a wealth of experience and support for those leaving treatment.

As a commissioner we have not dictated what needs to be done, but instead allowed and encouraged charities and the community to mobilise and organise specific services and broader wellbeing projects which are most relevant and beneficial to them. This is a prime example of how powers can successfully be relocated away from statutory organisations and towards citizens, to empower them to take ownership of their own recovery and to tackle substance misuse more widely.

Blackburn with Darwen Public Health Annual Report 2016/17 Page 16 Social Movements for Health

How Will We Know If We Are Successful? In order to continuously improve our practice we will work with organisations and communities to develop ways of continuiously evaluating progress, by asking: • Did we accomplish the goal we were trying to accomplish? • Did our community grow stronger (through creating capacity or gaining power they didn’t have before)? • Did individuals involved in the whole effort learn, grow and develop their capacity to organise with others?

Recommendation 3 Embed social movements in practice • Identify and develop exemplar social movements, in order to create real-world examples of communities mobilised for health and care. • Understand and demonstrate ‘what works’ through continuous engagement and evaluation. • Support and encourage spread of movements, by developing approaches that could be scaled, adapted and adopted in other communities

Blackburn with Darwen Public Health Annual Report 2016/17 Page 17 Social Movements for Health

Summary of Recommendations:

Recommendation 1 – Becoming a ‘Changemaking’ Place Improve working culture and practices by adopting and encouraging the three ‘changemaking’ values: • Creativity - ideas and initiative cannot be the sole reserve of a few senior individuals but must be encouraged and valued by everybody. More ideas, more insight, more impact! • Self-determination - freedom and willingness to respond quickly and creatively is crucial if we are to benefit from a social movement; employees must have license to act on their own initiative and to try new approaches without waiting for permission. • Collaboration - seek ways to work across organisational boundaries; there is no use in being an island of good practice! Effective collaboration with other departments, external partners and the public will extend changemaking values, build trust and prevent duplication of efforts.

Recommendation 2 - Work With Communities To Support The Growth Of Social Movements For Health • Develop strong and sustained networks: recognise the importance of and support shared learning through communities of interest and other networks beyond time-limited programmes of work • Identify and support organisational and community social movement ‘champions’ to promote social movements for health within their formal and informal networks • Create learning and development opportunities in support of - and in the spirit of - social movements for health • Deliver a rolling programme of celebration and learning to include an annual Festival of Strengths

Recommendation 3: Embed Social Movements In Practice • Identify and develop exemplar social movements, in order to create real-world examples of communities mobilised for health and care • Understand and demonstrate ‘what works’ through continuous engagement and evaluation. • Support and encourage spread of movements, by developing approaches that could be scaled, adapted and adopted in other communities.

Blackburn with Darwen Public Health Annual Report 2016/17 Page 18 References

1. NHS (2014). Five Year Forward View. www.england.nhs.uk/wp-content/uploads/2014/10/5yfv-web.pdf

2. del Castillo et al. (2016). Health as a Social Movement: The Power of People in Movements. Nesta. www.nesta.org.uk/sites/default/files/health_as_a_social_movement-sept.pdf

3. Marmot et al. (2010). Fair Society Healthy Lives. The Marmot Review. www.instituteofhealthequity.org/resources-reports/fair-society-healthy-lives-the-marmot-review/fair-society-healthy-lives-full-report-pdf.pdf

4. Walker & Soule (2017). Changing company culture requires a movement, not a mandate. Harvard Business Review. https://hbr.org/2017/06/changing-company-culture-requires-a-movement-not-a-mandate

5. Lent & Studdert (2017). A changemaking vision for local government. New Local Government Network. www.nlgn.org.uk/public/wp-content/uploads/A-Changemaking-Vision-of-Local-Government.pdf

6. Knox (2017). Social movements and the future of healthcare. Reimagining Health. http://reimagininghealth.com/social-movements-and-the-future-of-healthcare/

7. Lalleman (2017). How to rethink change with the three percent rule. Innovisor. www.innovisor.com/article-rethink-change-three-percent-rule/

8. South (2015). A guide to community-centred approaches for health and wellbeing, Public Health England. www.gov.uk/government/uploads/system/uploads/attachment_data/file/417515/A_guide_to_community-centred_approaches_for_health_and_wellbeing__full_report_.pdf

9. Bate et al. (2004). The next phase of healthcare improvement: what can we learn from social movements? BMJ Quality & Safety, 13:62-66. http://qualitysafety.bmj.com/content/13/1/62.long

Blackburn with Darwen Public Health Annual Report 2016/17 Page 19 Integrated Needs Assessment Summary Review

Introduction Department of Health guidance describes the central importance in the modernised health and care system of an enhanced Joint Strategic Needs Assessment (JSNA), which should consider all the current and future health and social care needs of the area. The local authority and CCG should be guided by the JSNA when developing their Joint Health and Wellbeing Strategy.

The following 41 pages present many of the key messages from Blackburn with Darwen’s JSNA, which is known as the Integrated Strategic Needs Assessment (ISNA). It begins with a profile of the borough’s population and local economy (‘Setting the Scene’), and is then arranged under the same three themes as the Joint Health and Wellbeing Strategy itself: ‘Start Well’, ‘Live Well’ and ‘Age Well’.

The ISNA Summary Review documents the social and environmental context of Blackburn with Darwen as a place and its impact on the health behaviours, physical and mental wellbeing of the population collectively, and residents as individuals. It also demonstrates the scale of our challenge – doing more of what we have always done will not be sufficient to secure the improvements in health and wellbeing that people aspire to and are demanding. We need, therefore, to fully embrace the power of social movements.

Blackburn with Darwen Public Health Annual Report 2016/17 Page 20 2 INTEGRATED STRATEGIC NEEDS ASSESSMENT – SUMMARY REVIEW

SETTING THE SCENE

POPULATION

Figure 1 - ONS mid-2015 population estimate POPULATION ESTIMATES AND PROJECTIONS for Blackburn with Darwen Mid-2015 estimate2 (with England profile for comparison) The latest ONS mid-year population estimates for Blackburn with Darwen are for 2015, and indicate a total population of 146,846. This represents an increase of 103 people since mid-2014. The England age structure is superimposed for comparison, from which it can be seen that Blackburn with Darwen has a much younger age profile than average. 28.7% of its population is aged under 20, which is the fifth highest proportion in England.

Figure 2 - 2014-based ONS population projections, Blackburn with Darwen

Population projections3 The latest population projections from ONS are based on the 2014 population estimate, and look ahead to 2039. For Blackburn with Darwen overall, a slow almost imperceptible fall is now predicted (Figure 2). However, the 65 age-group is expected to rise by approximately 10,000 over the period (ie. by almost 50%).

SETTING THE SCENE Cross-Cutting Identification, prevention Positive mental health Poverty & financial Themes: & early intervention & wellbeing inclusion (fairness) 3 INTEGRATED STRATEGIC NEEDS ASSESSMENT – SUMMARY REVIEW

2011 CENSUS DATA Ethnicity The Census is still our best source of data on the ethnic breakdown of the borough’s population, and the relationship between ethnic group and other social characteristics. The proportion of residents who are Indian or Pakistani are the 11th highest and the 6th highest respectively of any local authority in England. Figure 3 - Ethnicity: Blackburn with Darwen v. NW and England, 2011 (showing counts for Blackburn with Darwen)

The main ethnic groups have markedly different age profiles from each other (Figure 4), and are represented in varying concentrations across the borough (Figure 5). Figure 4 - Age profiles by ethnic group, Blackburn with Darwen, 2011

Figure 5 - Blackburn with Darwen – ethnicity by ward

SETTING THE SCENE Cross-Cutting Identification, prevention Positive mental health Poverty & financial Themes: & early intervention & wellbeing inclusion (fairness) 4 INTEGRATED STRATEGIC NEEDS ASSESSMENT – SUMMARY REVIEW

Religion According to the Census, 77,599 Blackburn with Darwen residents (52.6%) identify themselves as Christian, and 39,817 (27.0%) as Muslim. 13.8% have no religion, and 5.6% did not answer the question. Religion and ethnicity are closely interlinked, with the vast majority of Christians in the borough being White, and almost all Muslims being Indian, Pakistani or members of other minority ethnic groups (Figure 6). Figure 6 - relationship between ethnicity and religion in Blackburn with Darwen Language For the first time, the Census asked about the ‘main language’ of everybody aged 3 or above. Over 86% of Blackburn with Darwen residents had English as their main language, Figure 7 - but a multitude of Main language of other languages Blackburn with are also Darwen residents represented: aged 3+

Out of 57,353 households in Blackburn with Darwen, there are just over 4,000 where nobody has English as their main language, and just over 800 more where only children have English as their main language.

Figure 8 - Main language by household

However, it is important to appreciate that many of those with a main language other than English nevertheless speak English ‘well’ or ‘very well’. Only 973 people in the borough could not speak it at all.

SETTING THE SCENE Cross-Cutting Identification, prevention Positive mental health Poverty & financial Themes: & early intervention & wellbeing inclusion (fairness) 5 INTEGRATED STRATEGIC NEEDS ASSESSMENT – SUMMARY REVIEW

DEPRIVATION The long-awaited Indices of Deprivation 2015 came out in October 2015, replacing the 2010 version. They are based on 37 indicators, mostly dating from around 2012/13. Deprivation at the Lower Super Output Area (LSOA) level Figure 9 - Index of MultipleDeprivation (IMD) 2015 The best-known output is the Index of Multiple Deprivation (IMD), which incorporates all the indicators, and is calculated for small neighbourhoods known as Lower Super Output Areas (LSOAs). Figure 9 shows IMD 2015 mapped for Blackburn with Darwen’s 91 LSOAs. 2010 National Deciles 2015 Nearly half (45 out of 91, or 49%) of the Borough’s LSOAs are in the worst two national deciles. By definition, each national decile accounts for 10% of all the LSOAs in England, so Blackburn with Darwen has well over its ‘fair share’ of deprived LSOAs. CHANGE SINCE 2010 It is natural to wonder how things have changed since 2010, but IMD scores from different years are not 91 directly comparable. What we LSOAs can do is analyse relative change – i.e. how many LSOAs have moved up or down in the rankings (Figure 10). 64 out of 91 LSOAs in Blackburn with Darwen stayed in the same decile, and only two of them moved by more than one decile. However, even staying still does not necessarily mean ‘no change’, as the whole country could have got more or less deprived since 2010. Deprivation at the Borough level Figure 10 - IMD 2010 and IMD 2015 – There are various ways of summarising the Indices of Deprivation at the borough level. In the past, we have tended movement of Blackburn with Darwen's 91 LSOAs to focus on the ‘Rank of Average Score’ method, which ranks authorities according to the average IMD score of between National Deciles their LSOAs. On that basis, Blackburn with Darwen was 17th most deprived out of 326 authorities in 2010, and now ranks as 15th most deprived in 2015. However, the summary indicator which is now most widely quoted is the proportion of LSOAs in the Borough falling within the 10% most deprived in England (i.e. in National Decile 1). In Blackburn with Darwen, that proportion fell from 34% in 2010 to 31% in 2015, moving the Borough from 11th most deprived to 12th most deprived in the rankings. SETTING THE SCENE Cross-Cutting Identification, prevention Positive mental health Poverty & financial Themes: & early intervention & wellbeing inclusion (fairness) 6 INTEGRATED STRATEGIC NEEDS ASSESSMENT – SUMMARY REVIEW

Figure 11 - Life expectancy in England and LIFE EXPECTANCY Blackburn with Darwen, 1991-93 to 2012-14 Life expectancy in Blackburn with Darwen has risen over the years, but the gap with England has not closed (Figure 11). There is also striking inequality in life expectancy within Blackburn with Darwen. To illustrate this, Public Health England has ranked the borough’s LSOAs by IMD score, divided them into ten equal groups (‘deciles’) of deprivation, and calculated the life expectancy Figure 12 - Male life expectancy by deprivation decile for each (Figure 12).4 Blackburn with Darwen, 2012-14 In 2012-14, the difference in female life expectancy between the most and least deprived deciles was 8.8 years, and for males it was 13.5 years (Figure 12). Public Health England prefers to quote the ‘Slope Index’, which is based on the slope of the fitted (red) line. This comes to 8.3 years for females and 11.9 years for males.

← Most deprived Least deprived →

PREMATURE MORTALITY The inequalities between more and Most deprived quintile of BwD less deprived parts of the borough are also illustrated in the 2015 Health Profile for Blackburn with Blackburn with Darwen Darwen.5 The gap in premature Source: PHE

death rates is particularly stark for

men, and if anything appears to be gap

growing. gap Figure 13 - Premature mortality Least deprived quintile of BwD England (under 75) for Blackburn with Darwen, England, & most/least deprived quintiles of (a) MALES (b) FEMALES Blackburn with Darwen [Directly Age Standardised Rate per 100,000. Rates are for three years pooled – e.g. ‘2012’ is actually ‘2011-13’] for (a) males and (b) females

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LOCAL ECONOMY

Any analysis of health and social care needs would be incomplete without a Figure 14 – quick introduction to the local economy, not only because it helps to set the Relationship between context, but also because so many of the wider determinants of health and employment rate and wellbeing are economic in nature. lack of qualifications SKILLS In 2015, there were estimated to be 13,500 people aged 16-64 in Blackburn with Darwen with no qualifications, or 14.9% of the working-age population. This is the 11th highest rate of any upper tier authority in England, and significantly higher than the North West (10.0%) or England (8.5%) averages. Data from the Centre for Cities provides a graphic illustration of the relationship between lack of qualifications and the employment rate in the UK’s 63 ‘Primary Urban Areas’ (Figure 14).6 Only 18.4% of people aged 16-64 in Blackburn with Darwen had a degree or equivalent and above in 2015, which is the 24th lowest rate (England 28.8%).7 However, this suggests a slight improvement on previous years. There is also an encouraging trend in the proportion of the borough’s 19-year-olds qualified to Level 3 (i.e. two A-levels or equivalent) (Figure 15)8. Blackburn with Darwen overtook England several years ago, and currently stands 2.4 percentage points ahead (Blackburn with Darwen 59.8%, England 57.4%).

Figure 15 - Level 3 qualification at age 198

ECONOMIC ACTIVITY As seen in Figure 16, an estimated 64.8% of the borough’s residents aged 16-64 are employed. This is the 12th lowest rate out of 150 upper tier local authorities (not including the City of London and Scilly Isles). Together with those who are officially unemployed (i.e. actively seeking work and available to start), it means that only 70.1% are ‘economic active’, which is the 7th lowest rate in England. The other 29.9% Figure 16 - Economic activity and inactivity & of residents are economically inactive, either through choice or circumstance. employment rate (age 16-64, year ending December 2015) SETTING THE SCENE Cross-Cutting Identification, prevention Positive mental health Poverty & financial Themes: & early intervention & wellbeing inclusion (fairness) 8 INTEGRATED STRATEGIC NEEDS ASSESSMENT – SUMMARY REVIEW

WORKLESSNESS Claimant Count Not everybody who is unemployed will claim benefits, but the Claimant Count is a useful indicator of those that do. The term now includes non-working claimants of Universal Credit as well as Job Seekers Allowance claimants, and figures are available on this basis going back to January 2013 (Figure 17). In May 2016, Blackburn with Darwen’s Claimant Count was 2745, or 3.0% of the working-age population (England 1.7%). Rates have been fairly steady since the beginning of 2015, although the gap with England appears to have widened slightly. Figure 17 - Claimant rate Jan 2013 – May 2016 At the ward level, the Claimant Count rate in May 2016 (defined as Job Seekers Allowance plus ranged from 0.5% in North Turton with Tockholes, to 5.5% non-working Universal Credit claimants) in Wensley Fold (Figure 18).

Click to download the latest ward-level Figure 18 - Claimant rate May 2016 (Wards) Claimant Count and Rate (defined as Job Seekers Allowance plus non-working Universal Credit claimants) Key out-of-work benefits ‘Key out-of-work benefits’ is usually presented in the Summary Review as a convenient measure of all those who qualify for benefits because they cannot be in full-time work. It has basically consisted of those claiming Job-Seekers Allowance, incapacity benefits, or Income Support for lone parents. However, an increasing number of those who would formerly have claimed JSA now receive Unversal Credit instead. Unfortunately, this has yet to be incorporated in the official calculation of ‘out-of-work benefits’. If we remove the JSA claimants, and add on the new ‘Claimant Count’ instead (which combines JSA claimants and non-working claimants of Universal Credit), then the total number of people on ‘Key out-of-work benefits’ in Blackburn with Darwen as at November 2015 becomes approximately 13,110, or roughly 14.2% of the 16-64 age-group. This compares with 8.9% in England and 11.7% in the North West. However, it must be stressed that this is a very rough-and-ready improvisation. If the adjustment were really this easy, it would surely have been done for us already on websites such as Nomis.9 Working-age Incapacity The largest single category of out-of-work benefits claimants are those receiving Employment Support Allowance, or some other sort of incapacity benefit. This group is considered in more detail in the ‘Live Well’ section (page 34).

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EMPLOYMENT BY SECTOR Figure 19 - Employees by sector – Blackburn with Darwen compared with Great Britain Public Administration, which includes Education and Health, accounts for more than a third of employees in (2014) Blackburn with Darwen. Figure 19 shows how the percentage of Blackburn with Darwen employees in each sector compares with the Great Britain average. PRODUCTIVITY Figure 20 – Productivity (GVA per hour worked) – Productivity describes the lowest ranking NUTS3 areas, relative to UK (2014) ability to produce outputs from a given amount of inputs such as labour. Economic output can only be increased by raising the amount of inputs (e.g. employees) or by raising their productivity, so productivity is vital to improving 10 Source: standards of living. Business Register & The preferred sub-regional measure Employment of productivity is Gross Value Added Survey (ONS) (GVA) per hour worked. On this basis, Blackburn with Darwen has the 4th lowest productivity out of Source: 173 ‘NUTS 3’ areas in the UK ONS (Figure 20), at less than 75% of the UK average.10 EARNINGS 11,12 Provisional median gross weekly earnings for Blackburn with Darwen residents in Figure 21 – Provisional Median Gross Weekly Earnings of residents - 2015 were £344.50. Although this looks like a reduction compared with last year’s Upper Tier Authorities in England (2015) Summary Review, the figure quoted there was later revised downwards. The new provisional figure puts Blackburn with Darwen in fourth lowest position out of 150 upper-tier authorities (Figure 21). Analysis by the Resolution Foundation12 shows that 25% of employees in Blackburn with Darwen stand to benefit from the introduction of the National Living Wage in April 2016, rising to 32% by 2020. Both proportions are just within the top quintile nationally.

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Figure 22 - Gross Disposable Household HOUSEHOLD INCOME Income per head – Blackburn with Darwen as a whole Highest and lowest in A recent ONS report13 shows that in 2014, Blackburn with Darwen had the second lowest each Region Gross Disposable Household Income per head in the UK, after Leicester and followed by (NUTS3 areas, 2014) Sandwell. This means it is the lowest NUTS3 area in the North West. Figure 22 shows the lowest and highest average incomes found in each region. Inequalities within Blackburn with Darwen 14 ONS also issues income estimates at the smaller Highest income Middle Super Output Area (MSOA) level14, although decile these are not quite so up-to-date. There are various versions, taking account of taxes and/or housing costs, but Figure 23 shows total gross weekly income. It is shaded according to national decile, so it can seen that seven out of Blackburn with Darwen’s 18 MSOAs fall into the lowest- income tenth of MSOAs in England. Only four are in the upper (green) half of the distribution.

Lowest income Source: Regional decile gross disposable household income 1997 to 2014 (ONS)13

Figure 23 - Estimated Total Weekly Income (MSOAs, 2011/12) £ per head Shaded according to national decile Chart taken from ONS Statistical Bulletin13 SETTING THE SCENE Cross-Cutting Identification, prevention Positive mental health Poverty & financial Themes: & early intervention & wellbeing inclusion (fairness) 11 INTEGRATED STRATEGIC NEEDS ASSESSMENT – SUMMARY REVIEW

WELFARE REFORMS Figure 24 – Impact of Welfare Reforms pre- 2015* and post-2015† (Blackburn with Darwen compared with GB)15 A new report from Sheffield Hallam University summarises the impact of the welfare reforms introduced since 2010, and the likely impact of the further reforms announced since 2015. It finds that generally speaking, they fall most heavily upon the most deprived authorities.15 The report estimates that the pre-2015 reforms have already lost Blackburn with Darwen £510 p.a. per working-age adult. Just before the 2015 Budget, the Guardian reported widespread concern in Blackburn with Darwen about the prospect of further cuts:16

The Sheffield Hallam report now predicts that by 2020-21, the further reforms announced in 2015 will have resulted in an additional loss of £560 per head in Blackburn with Darwen. Along with ESA = Employment & Support Blackpool, this is the highest equal predicted Allowance impact out of 378 local authorities. Blackburn LHA = Local Housing Allowance with Darwen’s low wages and large families make (housing benefit for private it particularly vulnerable to the planned tenants) reductions in Tax Credits, and the new Universal MIS = Mortgage Interest Support (change from payment to Credit tapers and thresholds. loan) The report does acknowledge that there are offsetting factors, such as the introduction of the National Living Wage, extension of free PIP = Personal Independence childcare, and rent and tax reforms. However, it doubts whether these will wholly compensate for the welfare reductions, or will benefit Payments the same people. It also considers the possibility that claimants may be incentivised to look for work, but considers it doubtful that the UC = Universal Credit 1% uprating = limit in annual demand for labour will expand to match. increase of most benefits

* i.e. impact by March 2016 of reforms introduced by the Coalition Government following 2010 General Election † i.e. predicted impact by 2020-21 of reforms introduced following the 2015 General Election (plus the post-2016 increases in PIP already announced before 2015). SETTING THE SCENE Cross-Cutting Identification, prevention Positive mental health Poverty & financial Themes: & early intervention & wellbeing inclusion (fairness) 12 INTEGRATED STRATEGIC NEEDS ASSESSMENT – SUMMARY REVIEW

SAFE AND HEALTHY HOMES AND NEIGHBOURHOODS

HOUSING Condition of housing stock Blackburn with Darwen’s housing stock is dominated by older terraced housing, much of it in poor condition, with 27,000 houses in the borough estimated to be ‘non-decent’. Approximately 12,300 homes contain a ‘Category 1 hazard’, which by definition means it poses a risk to health and safety. The greatest concentrations of such houses are found in Bank Top, Mill Hill and central Darwen.17 Poor management and maintenance in the growing private rented sector is a particular concern, and the Council has presented evidence to a House of Commons Select Committee arguing for tighter regulation to avert social problems and the destabilisation of communities.18 Houses in multiple occupation (HMOs) Some of the most acute social problems are concentrated in multi-tenanted ‘Houses in multiple occupation’ (HMOs), which themselves are concentrated in particular areas of the borough. The locations of the biggest private-sector HMOs in Blackburn with Darwen (those with 5 or more bedspaces) are shown in Figure 25. These alone have more than 500 bedspaces between them.19

Figure 25 - Houses in Multiple Occupation (HMOs) with 5+ bedspaces as at December 2011 (overlaid with Wards) Cold housing and fuel poverty A common reason for housing being classified as non-decent or hazardous is low energy standards and excess cold. As well as being a major contributor to excess winter deaths, cold housing adds to the burden of circulatory and respiratory disease, colds and flu, exacerbates chronic conditions such as rheumatism and arthritis, and has a negative effect upon mental health across all age-groups.20 A household is defined as being in fuel poverty only if its required fuel costs are above average, and spending that amount on fuel would leave it below the poverty line*. An estimated 7232 households in Blackburn with Darwen were in fuel poverty in 2014. This equates to 12.4% of all households in the borough, and compares with an England Source: average of 10.6%.21,22 Out of more than 300 local authorities, Blackburn with Darwen now ranks just outside the Old Dept of highest 50 for fuel poverty, which suggests a relative improvement in recent years. Energy & definition Climate Change

Figure 26 - % Households in Fuel Poverty, 2014 (modelled estimates) Lower Super Output Areas overlaid with Wards

* The Department of Energy & Climate Change no longer issues fuel poverty figures according to the old definition (the need to spend more than 10% of income on maintaining a satisfactory level of heating). SETTING THE SCENE Cross-Cutting Identification, prevention Positive mental health Poverty & financial Themes: & early intervention & wellbeing inclusion (fairness) 13 INTEGRATED STRATEGIC NEEDS ASSESSMENT – SUMMARY REVIEW

CRIME AND VIOLENCE Figure 27 - Hotspots of recorded Crime and Antisocial Crime and antisocial behaviour Behaviour (January-December 2015) Crime and fear of crime affects not only the health of individual victims, but the wellbeing of whole Overlaid with Locality boundaries communities, and public engagement has shown it to be a high priority in Blackburn with Darwen.23 Data about the type and whereabouts of every recorded incident of crime or antisocial behaviour is available from http://data.police.uk/. In Figure 27, the darkest shading denotes the areas with the greatest density of incidents in the year to December 2015. Key offences Figure 28 compares five key crime rates in Blackburn with Darwen in 2014/15 against the England & Wales average (which is scaled to equal 100 for every crime type). All except the robbery rate are higher than the national average. Violence against the person and Sexual Offences have both risen since 2013/14, but not as fast as the national average. All recorded crime figures have to be treated with caution, as they do not currently meet the standards required for National Statistics status.24,25 Violence Figure 28 - Recorded crime per 1000 population 2014/15 - The relationship with health is Blackburn with Darwen compared with England & Wales (=100). particularly direct in the case of Also showing percentage change since 2013/14. violent crime, which is the subject of three indicators in the Public Health Outcomes Framework.26 Blackburn with Darwen had 2337 recorded offences of violence against the person during 2014/15, which as a rate is almost 18% higher than the national average, and puts it in the second highest quintile. The borough is also in the second highest quintile in 2014/15 for the rate of sexual offences per 1000 population. Rates of emergency hospital admissions for violence are high across most of the urban north of England, although most places are on a downward trend. Blackburn with Darwen’s rate for the period 2012-13 thru 2014-15 is down on the year before, but stands at roughly twice the England average, and ranks 6th highest in the country.

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SOCIAL MOBILITY

THE SOCIAL MOBILITY INDEX A new index from the Social Mobility and Child Poverty Commission attempts to measure the chances that poorer children in each local authority have of doing well later in life. Data was collected reflecting their educational attainment before, during and after their school years, and also the outcomes achieved by adults in the same area (in terms of income, job status and home ownership). From these sixteen indicators was derived the overall Social Mobility Index, as well as a separate summary measure for each of the four life-stages. Overall Index On the overall Social Mobility Index, Blackburn with Darwen ranks 154th out of 324 lower-tier local authorities in England (where 1st is best) – i.e. it sits just above mid-table. The prime ‘hotspots’ of Social Mobility (red shades in Figure 29) are predominantly in London, though Ribble Valley and Rossendale are also in the best quintile. At the opposite end of the spectrum, the worst ‘coldspots’ (blue shades) are West Somerset, Norwich and Wychavon, with Blackpool ranking 9th from bottom. Although Figure 29 – there is a tendency for social mobility to be better in more affluent The Social Mobility Index areas, this is by no means always the case. (overall ranking) Life Stage Indices Blackburn with Darwen’s overall Social Mobility Index masks considerable variation in how the borough performs at each of the four life stages: Early Years School Youth Adulthood Blackburn with Darwen ranks 312th (13th Blackburn with Darwen’s poorer children The youth indicators look at how young Blackburn with Darwen’s ranking slips worst) on the Early Years indicators. make up substantial ground during their people eligible for free school meals again to 235th (90th worst) on the adult This is mainly due to the low percentage school years, particularly when it comes perform at A-level, and their success at indicators. It scores well for affordable of children eligible for Free School to GCSE performance. For entering higher education and housing, but this is offset by low Meals who achieve a 'good level of the four school-age indicators avoiding ‘NEET’ status. pay and the low proportion who development' at the end of Early Years combined, Blackburn with Darwen Blackburn with Darwen ranks 28th are in managerial and professional Foundation Stage. ranks 86th best, putting it in the top 30%. best in the country, making it one of the occupations. top 10% of authorities. The results show that Blackburn with Darwen’s more disadvantaged young people make remarkable progress on their journey from ‘Early Years’ to the ‘Youth’ life-stage. Although the borough is still a relative ‘coldspot’ on the ‘Adulthood’ indicators, there is reason to hope that this will change as the new better-equipped generation of young people enters the workforce. SETTING THE SCENE Cross-Cutting Identification, prevention Positive mental health Poverty & financial Themes: & early intervention & wellbeing inclusion (fairness) 15 INTEGRATED STRATEGIC NEEDS ASSESSMENT – SUMMARY REVIEW

START WELL

DETERMINANTS OF HEALTH FOR CHILDREN/YOUNG PEOPLE

CHILD POVERTY Figure 30 - Revised local child poverty measure, BwD wards, by The Child Poverty Act of 2010 pledges that by 2020, no more than 10% of children should be living lone parent or couple family and approx. out-of-work/in-work split in families whose income is less than 60% of median household income (before housing costs). In both 2012/13 and 2013/14, 17% of children in the UK were in poverty by this definition27, and the 2020 target is widely expected to be missed. The Government intends to replace the child poverty measure and legislation before then, but it remains in force at present.28 It is not possible to monitor local child poverty on exactly the same basis, but the HMRC provides a proxy measure based on administrative data. This has been known by several names over the years, but is currently referred to as the Children in Low-Income Families Local Measure. It counts the number of children living in families which are either receiving Income Support (IS) or means- tested Job Seekers Allowance (JSA), or else are in receipt of tax credits with an income less than 60% of the median.29 The two sub-categories give a rough out-of-work/in-work split.30 At the UK level in 2013, the Children in Figure 31 – Children in Low Low Income Families Local Income Families Local Measure works out to be 1.2 Measure 2013, percentage points higher than Blackburn with Darwen the official measure, so it is only a rough equivalent. (Lower Super Output Areas overlaid with ward On the local measure, 9105 boundaries) children in Blackburn with Darwen, or 22.5% of the total, Source: HMRC were ‘in poverty’ in 2013 (the latest year available), which is the same percentage as in 2012, and down from 26.0% in 2011. There was wide variation around the borough, as seen in both Figure 30 and Figure 31. A relatively high 41.3% of Blackburn with Darwen’s children in poverty are in couple families (see green shading in Figure 30) - the sixth highest proportion in England. This is particularly evident in wards with a high Asian population. The pale colours in Figure 30 indicate that the borough has a substantial problem of child poverty even among working families (i.e. those not receiving IS or JSA). START WELL Cross-Cutting Identification, prevention Positive mental health Poverty & financial Themes: & early intervention & wellbeing inclusion (fairness) 16 INTEGRATED STRATEGIC NEEDS ASSESSMENT – SUMMARY REVIEW Figure 32 - Foundation Stage: percentage of children achieving a good level of development, 2015 EDUCATION (overall, and broken down by ethnicity, first language, and Free School Meals status) Early Years Foundation Stage The Early Years Foundation Stage profile measures children’s development at the end of the school year in which they turn 5. Figure 32 shows that in 2015, 56% of Blackburn with Darwen children were deemed to have a ‘good’ level of development. This is an improvement on 47% in 2014, but it is the third lowest proportion in England, after Leicester and Halton. In contrast to the Summary Review of even two years ago, the inequalities within Blackburn with Darwen by ethnic group or by first language are now relatively small.31 However, there is a 20 percentage point gap between those who qualify for Free School Meals (FSM) and those who do not. Only 40% of Blackburn with Darwen’s FSM pupils have a ‘good’ level of development, which is the third equal lowest proportion in England.

Primary education – Key Stage 2 Figure 33 - Key Stage 2: % achieving Level 4+ in reading, writing and mathematics, 2015 At the end of primary education, 81% of Blackburn with Darwen (overall, and broken down by ethnicity, first language, and Free School Meals status) pupils in 2015 achieved the expected level - Level 4 or above - in reading, writing and mathematics (England 80%).32 By this age there is very little difference, either locally or nationally, in the performance of White and Asian pupils, or those with or without English as their first language (Figure 33). Children entitled to Free School Meals (FSM) still do less well, but Blackburn with Darwen’s results for this group are the 19th highest in England. Outside of London, only Rutland has better FSM attainment at Key Stage 2.

GCSE attainment GCSE attainment has been measured in a new way since 2013/14 which is not comparable with earlier results. However, during both periods, Blackburn with Darwen has been improving at a faster rate than average (Figure 34). On the key ‘5+ GCSEs at Grade A*-C including English and Maths’ measure, the gap with England is now only 0.4 percentage points (56.9% versus 57.3%).33 Asian pupils in Blackburn with Darwen are now out-performing White pupils on the ‘5+ A*-C inc English & Maths’ measure by 60.6% to 55.7%, and pupils without English as their first language are obtaining better results than those with (59.4% v. 55.8%). There is still a large gap, however, between pupils Figure 34 - 5+ GCSE Grade A*-C eligible for Free School Meals (with 37.8% achieving the standard) and all other including English & Maths pupils (60.7% achievement). A similar gap is seen both regionally and nationally. (state-funded schools only) START WELL Cross-Cutting Identification, prevention Positive mental health Poverty & financial Themes: & early intervention & wellbeing inclusion (fairness) 17 INTEGRATED STRATEGIC NEEDS ASSESSMENT – SUMMARY REVIEW

VULNERABLE GROUPS NEETS Young people who are Not in Education, Employment or Training (NEET) have been described by the Deputy Prime Minister and by Sir Michael Marmot as a ‘time bomb’ for the economy, society, and public health.34,35 In 2014, Blackburn with Darwen was estimated to have 336 NEETs aged 16-18, down from 369 in 2013 and 460 in 2012. This equates to 5.8% of the age-group, compared with an England average of 4.7%, and places the borough in the second highest quintile of upper-tier authorities.36 FAMILIES WITH MULTIPLE PROBLEMS The government estimated in 2011 that there were approximately 120,000 ‘troubled families’ in the country, each costing local and central government an estimated £75,000 per year.37 In addition to their other difficulties, an estimated 71% of these families had poor health, with 46% having an adult who suffers from a mental health problem.38 Local authorities were funded to assist such families by giving them one dedicated worker rather than a "string of well-meaning, disconnected officials".39 Blackburn with Darwen was assumed to have 465 troubled families, and by May 2015, like a lot of other authorities, it had ‘turned around’ all of them.40 The scheme is now being extended to work with 400,000 more families nationally, who are experiencing a wider range of problems.41 Figure 35 - LOOKED AFTER CHILDREN Looked-after children As at 31st March 2015, 315 children in Blackburn with Darwen were being looked after by the local per 10,000 authority.42 This gives a rate of 83 per 10,000 children under the age of 18, down from 89 per aged 0-17, 10,000 a year ago. However it is still higher than the England average of 60 per 10,000, and places March 2015 Blackburn with Darwen on the border between the highest and 2nd-highest quintiles (Figure 35).

CHILDREN IN NEED Figure 36 - Children in Need in Blackburn with Darwen, Looked after children are one category of ‘Children in Need’ – the DfE’s term for all those referred to the local by primary need at initial assessment (March 2015) authority and assessed to be in need of services. Blackburn with Darwen had 1617 Children in Need at the end of March 2015, up from 1515 a year earlier. This gives a rate of 423 per 10,000, compared with averages of 368 in the NW and 337 for England.43 Figure 36 shows the primary reason why these children were assessed as being in need. The number attributed to abuse or neglect has risen from 802 to 928 in one year. YOUNG CARERS According to the 2011 Census, Blackburn with Darwen has approximately 1543 ‘young carers’ aged under 25, or 3.1% of the age-group (NW 3.0%, England 2.6%). However, it is suspected that these are serious underestimates, and may be anything may be anything up to four times too low.44 YOUNG OFFENDERS Young offenders tend to have worse than average health for their age, particularly in terms of mental health problems.45 The number of juvenile offenders has fallen steeply in recent years, with less than a fifth as many in Blackburn with Darwen in 2013 as in 2005. The proportion who reoffend within a year is one of the government’s Social Justice Outcome Framework indicators. This rate has crept up nationally, but inevitably there is more fluctuation in Blackburn with Darwen (Figure 37).46 Figure 37 - % young offenders reoffending within 1year

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LIFESTYLE FACTORS AND THEIR CONSEQUENCES

ALCOHOL National trends The drinking habits of 11-15 year-old secondary school pupils in England are monitored by means of an annual HSCIC survey. In 2014, 38% of pupils responded that they had drunk alcohol at least once, and 8% had done so in the last week. The equivalent figures in 2003, however, were 61% and 25%, so there is a clear downward trend.47 An expert panel set up by the Cabinet Office and Department of Health has also been looking at young people’s risk behaviours.48 It acknowledges the decline in drinking rates, but cautions that there is a minority who frequently drink to excess, leading to poor outcomes for themselves and heavy demands on hospital and other public services.

“What about YOUth?” survey Figure 38 – Drinking Behaviours among 15 year-olds in 49 A major new survey carried out for the first time in 2014 provides an insight into Blackburn with Darwen, NW and England the health behaviours of 15 year-olds in every upper-tier local authority. Public Source: What About YOUth survey (2014) Health England have produced an interactive tool for exploring the results at http://fingertips.phe.org.uk/profile/what-about-youth. The three questions about alcohol were: whether the pupil had ever had an alcoholic drink; whether they were regular drinkers (i.e. usually drinking at least once a week); and whether they had been drunk in the preceding four weeks. Blackburn with Darwen emerged significantly better (i.e. lower) than average on all these questions, ranking 30th lowest in England on all three. It was also among the bottom three in the NW on all three questions - and lowest of all on the one about drunkenness. These results are likely to be assisted by the high proportion of Muslim pupils in the borough, many of whom may not drink at all. Hospital admissions Blackburn with Alcohol-specific conditions are those which are invariably due to alcohol. The most recent Darwen figures for hospital admissions in under-18s for alcohol-specific conditions are for 2012/13- 2014/15 (Figure 3950). Blackburn with Darwen’s admission rate is the sixth highest in the NW, significantly higher than England, and in the highest quintile of local authority districts overall. England Figure 39 - Alcohol-specific admissions, under-18s, crude rate per 100,000 (2012/13-2014/15) Source: http://fingertips.phe.org.uk/profile/local-alcohol-profiles

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SUBSTANCE MISUSE The ‘What about YOUth’ survey (http://fingertips.phe.org.uk/profile/what-about-youth)49 also asked three questions in 2014 about drug-taking: whether the pupil had ever tried cannabis; whether they had taken cannabis in the last month; and whether they had taken any other drugs in the last month. On all these questions, Blackburn with Darwen was not significantly different from the England average. BwD Again, however, it seems that those who do indulge in 2012/13 - 2014/15 Blackburn with Darwen have a high propensity to need BwD hospital treatment. Between April 2012 and March 2015, an England average of 43 young people aged 15-24 from Blackburn with England Darwen were admitted to hospital each year for substance misuse, giving a rate of 227.1 per 100,000 per annum. This is the second highest rate in England (average 88.8), and appears to be on a rising trend: Figure 40 - Hospital admissions due to substance abuse (directly standardised rate per 100,000 aged 15-24 years) Source: ChiMat69 SMOKING Cigarettes The 2014 ‘What about YOUth’ survey49 classifies pupils according to whether they smoke cigarettes at all (‘current smoker’), and if so whether that is at least once a week (‘regular smoker’) or less frequently (‘occasional smoker’). Blackburn with Darwen had 8.0% ‘current’ smokers ( England average 8.2%). This total is made up of 6.6% regular smokers and 1.5% occasional smokers (Figure 41). The tool at http://fingertips.phe.org.uk/profile/what-about-youth portrays the low proportion of occasional smokers as a ‘good’ thing - but that rather depends on the alternative. Obviously we would prefer pupils not to smoke at all, but if they do, then ‘occasional’ is arguably preferable to ‘regular’. Figure 41 - Proportion of 15 year-olds smoking 'Regularly' or 'Occasionally' Other tobacco products Figure 42 - Proportion of 15-year The survey also asked whether pupils had tried any other tobacco products (such as shisha), to which 16.5% of olds who have tried e-cigarettes Blackburn with Darwen pupils answered ‘yes’. This is the second highest proportion in the North West (Significantly higher than England, (average 11.3%), but not significantly different from the England average of 15.2%. Significantly lower than England, Electronic cigarettes No significant difference) 32.2% of 15-year-old pupils surveyed in Blackburn with Darwen had tried e-cigarettes, which is the second highest proportion in the country (after Blackpool). There is a pronounced north-south divide (Figure 42), with the borough sitting amid a huge swathe of authorities which are all significantly higher than the England average of 18.4%.

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TEENAGE PREGNANCY The number of under-18 conceptions in Blackburn with Darwen fell to a new low of 61 in 2014. When the government launched its Teenage Pregnancy Strategy in 1998, the number was 169.51 Expressed as a rate, this puts Blackburn with Darwen below the England average, though not by a significant amount. In terms of percentage reduction since the start of the Teenage Pregnancy Strategy, the borough is now the 11th most improved upper-tier local authority since 1998 (Figure 44). Figure 43 – Under-18 conception rate (per 1000 females aged 15-17) Figure 44 - % change in under-18 conception rate between 1998 and 2014

Under-16 conceptions involve even smaller numbers, and thus fluctuate a lot from year to year. With 13 such conceptions in 2014, Blackburn with Darwen had a rate of 4.5 per 1000, which is very close to the England average (4.4 per 1000) and not significantly different from it.26 CHLAMYDIA SCREENING 52 Chlamydia is a largely hidden condition, so cases are most often discovered through opportunistic Figure 45 – Chlamydia diagnostic rate per 100,000 15-24 year-olds 52 screening. The National Chlamydia Screening Programme aims to diagnose and treat as many (Upper-Tier LAs, 2014) cases as possible in young people, and local authorities are encouraged to aim for a ‘Chlamydia Detection Rate’ of at least 2300 per 100,000 15-24 year-olds. Latest figures for 2014 show that this target was only achieved in 29% of upper tier local authorities. Blackburn with Darwen’s detection rate was a below- average 1854 per 100,000 (Figure 45). The proportion of tests proving positive in the borough was unexceptional, but the percentage of the population tested was the Blackburn third lowest in the NW. Public Health England’s map with shows Blackburn with Darwen surrounded by authorities Darwen with a higher detection rate (Figure 46).

Figure 46- Chlamydia Detection Rates in NW (2014)

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CHILD OBESITY AND UNDERWEIGHT The National Child Measurement Programme (NCMP) undertakes an audit of the height and weight of children in Reception and Year 6 of primary school each year, and the results for 2014/15 are shown in Figure 47.* The percentage of children of healthy weight in Blackburn with Darwen is similar to the NW and England averages.53 However, just over 100 children in Blackburn with Darwen were underweight, which is a significantly higher proportion than average. The Reception rate of 2.1% underweight is the 8th highest out of 144 upper-tier local authorities in England, and the Year 6 rate of 3.1% is the highest of all. It should Figure 47 - be noted that a high proportion of Blackburn with Darwen pupils are of Asian ethnicity. National Child Nationally, children in this group were more than twice as likely as average to be undeweight.54 Measurement Programme Blackburn with Darwen does not compare badly on any of the measures of overweight or 2014-15 obesity. The proportion of Year 6 children who are above a healthy weight (i.e. overweight or obese) is significantly better than average (29.9% compared with an England average of 33.2%), and just outside the lowest quintile nationally. Work is ongoing in Blackburn with Darwen to explore the potential causes of both overweight and underweight, and develop an evidence-based action plan to address the underlying issues at both ends of the spectrum.

CHILDREN’S ORAL HEALTH Dental health of 5-year olds The latest 2015 survey of 5-year old children55 found that approximately 56% of children in Blackburn with Darwen had one or more decayed, missing or filled teeth.† This was the highest proportion in England, and compares with a national average of just under 25%. The average child in the borough had 2.4 decayed, missing or filled teeth, which was the second highest in England. Figure 48 – Hospital admissions for tooth extraction 2014/15 Hospital admissions for tooth extraction56 (with caries as primary diagnosis, as % of age-group) One consequence of a high level of decay is a high rate of hospital admission for tooth extraction. In 2014/15, there were 409 admissions of Blackburn with Darwen children to have teeth out because of dental caries. This translates to a higher than average proportion of the population in every age-group, and particularly among 5-9 year-olds (Figure 48).56 Hospital admissions are only part of the story, as in 2014/15, over 179,000 teeth were extracted in primary care from 0-9 year-old children in England. However, these figures are not available at the local authority level.57 Tackling tooth decay Interventions and health programmes aimed at addressing the problem of child tooth decay in Blackburn with Darwen include the identification of vulnerable children 58 through nurseries and children’s centres, providing free toothpaste, and educating communities about which products have high sugar content.

* Figure 47 is based on pupils living in Blackburn with Darwen, as this is now the main measure reported by Public Health England.. † Public Health England has switched to quoting this as “43.9% of Blackburn with Darwen children with no obvious decay”. START WELL Cross-Cutting Identification, prevention Positive mental health Poverty & financial Themes: & early intervention & wellbeing inclusion (fairness) 22 INTEGRATED STRATEGIC NEEDS ASSESSMENT – SUMMARY REVIEW

ACCIDENTS

Figure 49 - Children (0-15) ROAD ACCIDENTS Killed or Seriously Injured (KSI) Killed or seriously injured (KSI) in Blackburn with Darwen 2012 - 14 Over the three year period 2012-14, 42 children aged (showing ward boundaries) 0-15 were killed or seriously injured (KSI) on Blackburn with Darwen’s roads.59 This equates to the third highest crude rate of any upper-tier local authority in England - or the second highest if the very small and atypical City of London is excluded. However, it consists of injury accidents only, as there has not been a single child fatality on the borough’s roads since 2006. The locations of these accidents can be seen in Figure 49 on the left. Figure 50 –Breakdown of 157 KSI casualties aged 0-25 by age & road user type (BwD, 2010-14) Figure 50 on the right looks at a broader age-range (0-25), over a longer period (2010-14), which allows us to break the KSI casualties down by the type of road user (columns) as well as by age (light to dark shading). There was one fatality, to a motor- cyclist in the 21-25 ageband, and all the other casualties were serious injuries. Out of 157 in total, very nearly half of KSI casualties were pedestrians, most of whom (42 out of 76) were aged under 11.60

PEDESTRIAN CHILD KSI The borough’s rate of pedestrian child KSI casualties (Figure 51) is well above the national average, particularly at the youngest ages.60 For the 0-15 age-group as a whole, its pedestrian KSI rate is second only to the anomalous City of London.61

Figure 51 - Child pedestrian KSI rate All child road casualties per 100,000 (2010-2014) showing 95% confidence intervals60 If we broaden our scope to include all recorded child casualties on the road, whether serious or not, Blackburn with Darwen still compares badly. A new report from the RAC places it 3rd highest out of 378 authorities in Great Britain, for the years 2010-14 combined. The other authorities featuring in the top four are Blackpool, Hyndburn and Burnley.62

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EMOTIONAL WELLBEING OF CHILDREN AND YOUNG PEOPLE Lack of data Hard facts about the prevalence of children and young people’s mental health problems continue to be scarce and out of date, as the last national survey was in 2004. Plans are now well advanced to conduct a survey across England and Scotland during 201663, but the final results are not expected to be published until 2018.64 In the meantime, the House of Commons Health Select Committee has acknowledged that those trying to plan and run services are ‘operating in a fog’.65 In Blackburn with Darwen, the best available insight into children and young people’s emotional health and wellbeing continues to be the specialised Integrated Strategic Needs Assessment carried out in 2014.66 National policy In 2014, the Government set up a Children and Young People’s Mental Health and Wellbeing Taskforce, to consider how children and young people’s mental health services can be better organised, commissioned and provided and made easier to access. The Taskforce has called for improvements in the following areas by 2020:67  tackling stigma and improving attitudes to mental illness  establishing ‘one stop shop’ support services in the community  introducing more access and waiting time standards for services  improving access for children & young people who are particularly vulnerable Emotional wellbeing of school pupils A high proportion of Blackburn with Darwen children start school without having reached a ‘good’ level of development (see page 16). However, out of the entire school population, the proportion in 2015 who had a statement of special educational needs (SEN) because of social, emotional and mental health was close to the national average. The 2013/14 rates of exclusion due to persistent disruptive behaviour, and for drugs/alcohol use, are the lowest in the North West and among the lowest in England.68 Self-harm Blackburn with One possible consequence of emotional ill-health, particularly in children and young people, is self-harm. The scale of the Darwen problem is reflected in the rate of hospital admissions for self-harm, although this only represents a fraction of total incidents. The 2014/15 rate of self-harm admissions in the 10-24 age-group in Blackburn with Darwen was significantly higher than the England average, but unexceptional for the NW, which has many of the highest rates in England. It is encouraging to note that England the number of admissions in Blackburn with Darwen has declined from 156 in 2012/13 to 137 in 2014/15. Figure 52 - Emergency admissions for self-harm (10-24 years), Source: ChiMat Child Health Profile69 directly standardised rate per 100,000 (Blackburn with Darwen v. England) CHILD & INFANT MORTALITY

INFANT MORTALITY Unfortunately the number of infant deaths (under age 1) registered in 2014 in Blackburn with Darwen rose to 19, after having been at levels of 10-12 for several years. This meant that the rate per 1000 for 2012-14 has reverted to being significantly higher than average, and is the eighth highest out of 150 upper-tier authorities in England.69 CHILD MORTALITY The ChiMat Child Health Profile also includes a mortality rate for children aged 1-17 (i.e. explicitly excluding infants).69 This is also measured over three years, but there are very few deaths in this age-group (approximately 6 per year in the case of Blackburn with Darwen), so very few local authorities differ significantly from average. In 2012-14, Blackburn with Darwen was just outside the highest quintile, with a rate of 14.8 per 100,000, but this is not significantly different from the England rate of 12.0 per 100,000.

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LIVE WELL

LIFESTYLE FACTORS

ADULT OBESITY In 2012-14, an estimated 66.5% of Blackburn with Darwen adults were overweight or Figure 53 - obese.26 This is not significantly different from the England average of 64.6%, but that Adult excess itself is of course far from ideal. New research predicts that by 2035, this proportion weight 2012-14 will have risen to 72% across the UK. By then, the annual direct health cost arising from (Blackburn with overweight and obesity is predicted to reach over £2.5bn nationally.70 Darwen, NW ALCOHOL (ADULTS) and England) The Alcohol Harm Paradox It has been known for some time that although alcohol consumption is, if anything, higher among more affluent groups, the harms from alcohol consumption fall disproportionately upon deprived populations.71 A major national survey has now shed new light on this so-called ‘Alcohol Harm Paradox’. It found that in deprived, as opposed to non-deprived, communities, heavy (‘increased risk’) drinking was ten times more likely to be accompanied by a combination of smoking, excess weight, and inadequate diet and exercise. The researchers suggest that the ill effects of these factors may be multiplicative, rather than additive. They recommend sending out a public health message that any given level of alcohol consumption is likely to be more harmful to those who also smoke, are overweight or have an unhealthy lifestyle. Deprivation was also associated with a greater tendency to binge-drink, which may carry higher risks of injury and heart disease than spreading the same amount of consumption over several days.72

Alcohol-related admissions and mortality Figure 54 - Rate A headline indicator of the health consequences of drinking is the rate of alcohol- of alcohol- related hospital admissions. This has shown little change in the last year (Figure 54), related th and Blackburn with Darwen is still significantly above average, ranking 24 highest out admission 26 of 152 upper-tier authorities. episodes per Blackburn with Darwen had the 19th highest rate of alcohol-related deaths in 2014, 100,000 out of 152 upper-tier local authorities. It also had the 13th highest rate of mortality population from chronic liver disease in 2012-14.73 - 'narrow' Alcohol-related incapacity measure (PHOF In 2015, Blackburn with Darwen had 320 claimants of incapacity benefits (nearly all of indicator 2.18) which will be Employment & Support Allowance), whose main disabling condition was Alcohol Misuse. This equates to 355.5 per 100,000 people of working age, which is the second highest rate out of 152 upper-tier authorities, and far exceeds the England average of 136.8 per 100,000.73

LIVE WELL Cross-Cutting Identification, prevention Positive mental health Poverty & financial Themes: & early intervention & wellbeing inclusion (fairness) 25 INTEGRATED STRATEGIC NEEDS ASSESSMENT – SUMMARY REVIEW Figure 55 - Estimated smoking prevalence SMOKING (ADULTS) for adults aged 18+ Prevalence (Source: IHS via Tobacco Control Profiles) The primary source of smoking prevalence data in Public Health England’s Tobacco Control Profiles is the Integrated Household Survey (IHS), which estimates that 23.6% of adults in the borough were current smokers in 2014.74 This is the 6th highest rate in England, and significantly higher than the national average of 18.0%. Smoking rates are generally higher in the ‘Routine & Manual’ (R&M) group (light bars in Figure 55), and Blackburn with Darwen has the 10th highest rate for this group, at 35.2%. The IHS is being discontinued, so the Tobacco Control Profiles already contain prevalence data from two other sources – the Quality Outcomes Framework, and the GP Patient Survey. Whichever source is used, smoking prevalence in Blackburn with Darwen is consistently in the worst or second-worst decile nationally.75 Outcomes The borough still compares poorly on many smoking-related health outcomes, including having the third highest rate of smoking attributable deaths from heart disease in 2012-14, and the fourth highest rate of emergency hospital admissions for COPD in 2014/15. Costs Updated estimates from ASH now put the cost to society of smoking in Blackburn with Darwen at approximately £42.8m p.a.. This includes lost productivity due to smoking breaks (£19m), early deaths (£10m) and sick days (£3m). It also includes the £6.2m cost to the NHS of smoking-related disease, plus the cost of smoking-related social care, fires and waste disposal.76 Public Health England estimates that every £1 spent on smoking cessation saves £10 in future health care costs and health gains.77

Stop Smoking services Figure 56 - Blackburn with Darwen Stop Smoking Service - 78 Results for 2014/15 show a further clients setting a quit date ('Setters') & quitting ('Quitters')78 slight fall in the number of Blackburn with Darwen clients setting a quit date (‘setters’), but a slight rise in those who have quit at four-week follow-up (‘quitters’) [Figure 56]. Relative to the number of smokers, both these results are significantly better than the England average.79 Nationally, the number of setters and quitters have both continued to decline, with speculation that this may be due to the growing popularity of e-cigarettes SMOKEFREE HOMES PROGRAMME Blackburn with Darwen’s new ‘smokefree homes programme’ gathers pledges from the public to keep Figure 57 - Launch of the smokefree homes programme their homes smoke-free, in order to minimise harm to children, young people and non-smokers.

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SEXUAL HEALTH Sexually Transmitted Infections (STIs) Figure 58 - All new STI diagnoses Blackburn with Darwen INCIDENCE OF STIS (exc. Chlamydia aged < 25) (other NW authorities in blue) Interpretation of the overall rate of STI diagnoses is complicated by the fact that per 100,000 (2014) local authorities are encouraged to detect as many cases as possible of Chlamydia in young people under 25 (see page 20). An indicator has therefore been introduced which specifically excludes diagnoses of Chlamydia in the under-25s. On this basis, 547 new STIs were diagnosed in Blackburn with Darwen in 2014, giving it a rate of 576 per 100,000, which is significantly lower (i.e. better) than the England average of 829 per 100,000.80 The rate of gonorrhoea diagnoses is a useful marker for high levels of risky sexual activity. In Blackburn with Darwen (Figure England 59), it is consistently lower (i.e. better) than the England average. The 2014 rate was 26.5 per 100,000, significantly below BwD the national average of 63.3 per 100,000. Figure 59 - Gonorrhoea diagnoses STI DIAGNOSES BY ETHNIC GROUP AND COUNTRY OF BIRTH per 100,000 (2014) Out of all the new STI diagnoses made in GUM clinics on Blackburn with Darwen residents in 2014, 83.0% had ethnic group specified as ‘White’ and 11.6% as ‘Asian or Asian British’. Only around 1% did not have ethnicity recorded. Where recorded, 6.4% of new STIs diagnosed in Blackburn with Darwen were in people born overseas.81 HIV An estimated 103,700 people were living with HIV in the UK in 2014.82 The groups most affected are men who have sex with men (MSM), and men and women of black African ethnicity.82 The numbers infected through non-sexual routes (e.g. injecting drug use, or mother-to-child transmission) remain low. HIV TESTING Testing is integral to the treatment and management of HIV. Knowledge of HIV status increases survival rates, improves quality of life and reduces the risk of transmission. Uptake In 2014, an HIV test was offered at 88.9% of eligible attendances at GUM clinics among residents of Blackburn with Darwen, and 69.4% of offers were accepted. In England, it was offered at 80.1% of eligible attendances, and 77.5% of offers were accepted.81 Logically, this equates to much the same performance locally and nationally. However, attention tends to focus on the uptake – the percentage of offers accepted. On this basis, Blackburn with Darwen on 69.4% is significantly worse than England on 77.5%.80 The uptake of HIV testing among MSM in Blackburn with Darwen is of particular Figure 60 - Uptake of HIV test concern, as it is the lowest in the country. There has been a sudden deterioration England among MSM from 91.6% of test offers to MSM attendees being accepted in 2013, to only 81.6% attending GUM clinics in 2014 (Figure 60). This compares with a national average of 94.5%. (i.e. % of test offers accepted) Coverage The proportion of eligible GUM attendees who received at least one HIV test in the course of the year (perhaps Blackburn across multiple attendances) is known as the testing coverage. Blackburn with Darwen’s overall coverage of 67.3% with Darwen in 2014 is not significantly different from England (68.9%), and is significantly better than the North West average of 55.4%. However, the borough’s testing coverage for MSM is actually lower than the overall figure, at 65.1% (England 87.2%). This again puts Blackburn with Darwen bottom of the league table nationally where MSM are concerned.

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PEOPLE LIVING WITH HIV In 2014, there were 89 people living in Blackburn with Darwen who received NHS care for HIV.80 This equates to a crude rate of 1.02 per 1000 people aged 15-59, compared with an England average of 2.22 per 1000. Areas with a prevalence of more than 2 per 1000 are advised to consider routine HIV testing for all hospital admissions as well as new registrants in primary care, but Blackburn with Darwen is well below this level. England HIV DIAGNOSES Figure 61 - New HIV diagnoses There were only 3 new diagnoses in Blackburn with Darwen in 2014, giving a rate of 2.6 per per 100,000 population (2014) 100,000 (Figure 61). This is in the lowest quintile nationally, significantly below the NW and BwD England averages, and on an apparently downward trend (although numbers as small as this are subject to random fluctuation). People diagnosed with HIV late (having a CD4 count of <350 cells/mm3 within 3 months of their diagnosis) are ten times more likely to die in the following year than those diagnosed promptly.83 Between 2012 and 2014, Blackburn with Darwen had 6 late diagnoses of HIV, representing 46.2% of all diagnoses (England average 42.2%).80 REPRODUCTIVE HEALTH Reducing unwanted pregnancies is an ambition in the Department of Health’s Framework for Sexual Health Improvement in England (2013).84 LONG-ACTING REVERSIBLE CONTRACEPTION (LARC) NICE defines LARCs as methods of contraception that require administration less than once per month or cycle. These can take the form of intrauterine devices (non-hormonal) or systems (hormonal), or contraceptive implants or injections.

Figure 62 - Prescribing rates for LARC (excluding injections) The rate per 1,000 women of long acting reversible contraception Source: PHE Sexual and Reproductive Health Profiles80 prescribed by GP services (excluding injections) in 2014 was 17.9 for Blackburn with Darwen, 23.1 for North West and 32.3 per 1,000 women in England.80 The rate of LARCs prescribed in sexual and reproductive health (SRH) services (excluding injections) per 1,000 women aged 15 to 44 years was 26.7 for Blackburn with Darwen, 26.0 for North West and 17.8 for England. Therefore the total rate of LARCs prescribed (excluding injections) for BwD was 44.5 per 1,000 women which was lower than the national rate of 50.2 per 1,000 women. The indicators exclude injections because:  Injections rely on repeat visits/administration within the year and have a higher failure rate than the other LARC methods  Injections are easily given and thus do not require the resources and training that other LARC methods require  Injections are outside local authority commissioning contracts ABORTIONS The rate of abortion in Blackburn with Darwen in 2015 was 18 per 1000 women (aged 15-44), which is significantly above the England rate of 16.2 per 1000.85 35% were repeat abortions, compared with 38% in England. The Department of Health’s policy states that women who request an abortion should have early access to services if legally entitled to one.84 78% of abortions in Blackburn with Darwen took place before 10 weeks’ gestation, compared with an England average of 80.4%.85 Only 11% of abortions in Blackburn with Darwen in 2015 were surgical, and 89% medical.85 This is one of the lowest proportions of surgical abortions in the North West, and compares with an England average of 45.8%. Early medical abortion is less invasive than a surgical procedure and carries less risk as it does not involve instrumentation or the use of anaesthetic. However, women may prefer a surgical abortion for a variety of reasons such as wishing to avoid the experience of going through an induced pregnancy loss, or preferring to make only one visit to the provider site (medical abortions typically require two). PHE states that a very high percentage of medical abortions compared to other areas could be an issue for concern, so we cannot unequivocally state if these proportions are good or bad.80 LIVE WELL Cross-Cutting Identification, prevention Positive mental health Poverty & financial Themes: & early intervention & wellbeing inclusion (fairness) 28 INTEGRATED STRATEGIC NEEDS ASSESSMENT – SUMMARY REVIEW

DRUG MISUSE (ADULTS) Prevalence There have been no new estimates of the prevalence of opiate and/or crack cocaine use since 2011/12, when Blackburn with Darwen was estimated to have 1417 users. When expressed as a rate, this was almost 75% higher than the England average.86 Treatment The treatment of opiate users and non-opiate users involves very different numbers and outcomes. In Blackburn with Darwen, the percentage of those in treatment who complete it successfully (without re-presenting within 6 months) has continued to improve, and is now significantly better than average for both types of user: 87

Figure 63 – Successful completion of drug treatment (Blackburn with Darwen v. England)26

OPIATES NON - OPIATES 8.4% 42.1% 45.6% 36.8% 6.8% 6.4% 29.2% 5.1%

DRUG USERS IN TREATMENT WHO LIVE WITH CHILDREN According to the latest JSNA Support Pack from Public Health England, 40% of users in treatment in Blackburn with Darwen have a child living with them. This is down from 46% the year before, but still well above the national average of 30%.88 Value for money Public Health England has published a presentation which highlights how investment in drug treatment and recovery services not only benefits individuals, but strengthens families and makes communities safer. It estimates that every £1 spent on drug treatment saves £2.50 in costs to society.77 Even higher returns can be obtained from motivational interviewing and the development of Figure 64 - Extract from supportive networks for people with drug addiction. Each £1 spent in these ways is estimated to 'Why Invest?' presentation return £5 to the public sector in reduced health care, social care and criminal justice costs.89

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HEALTH OUTCOMES

CANCER Figure 65 – Age-Standardised Incidence Rate Incidence (All Cancers, M+F) The number of new cases of cancer diagnosed each year has been rising nationally, by almost a third in the past 20 years. Possible reasons include the growing and ageing population, their smoking, drinking and eating habits, and better detection of cancer.90 The incidence rate in Blackburn with Darwen fluctuates from year to year, but is not significantly different from the England average (Figure 65).91

Figure 66 - Premature (age < 75) mortality Mortality and Survival from all cancers (Age Standardised Rate) Even though cancer incidence has been increasing, improved survival means that premature mortality BwD from the disease has been gradually declining. Premature mortality in Blackburn with Darwen has followed the general downward trend, but the latest rate is once again significantly higher than the England average (Figure 66).26 The same applies to the portion of this England mortality considered ‘preventable’.26 Red = significantly higher than England When all patients aged 15-99 diagnosed with cancer in 2013 were followed up for a year, Blackburn with Darwen had a 1-year ‘survival index’ of 67.7%, compared with an England average of 70.2%. This puts it near the bottom of the league table, which is also true if we look at bowel or lung cancer individually.92,93 Prevalence Cancer prevalence is here taken to mean a count of the persons alive who have ever been diagnosed with cancer (also known as ‘cancer survivors’). By 2010 (the most recent year available), there were 3525 cancer survivors in Blackburn with Darwen who had been diagnosed since 1991 (Figure 67).94 Some of these survivors will experience emotional, practical, medical and financial problems which continue long after treatment has finished.95 Assuming cancer incidence continues to rise and survival continues to improve, Public Health England and Macmillan estimate that the number of survivors in Blackburn with Darwen could grow to 6,800 by 2030.96 Figure 68 shows the number of survivors in Blackburn with Darwen from Figure 67 - Cancer survivors in each of the ‘Big 4’ cancers, broken down by time since diagnosis.* Blackburn with Darwen in 2010 (all cancers, total = 3525) *NB - Individuals with more than one type of cancer may be double-counted in Figure 68 - BwD survivors of 'Big 4' cancers as at 2010 showing length of survival Figure 68, but not in Figure 67. Both charts include diagnoses since 1991 only. showing length of survival LIVE WELL Cross-Cutting Identification, prevention Positive mental health Poverty & financial Themes: & early intervention & wellbeing inclusion (fairness) 30 INTEGRATED STRATEGIC NEEDS ASSESSMENT – SUMMARY REVIEW

CARDIOVASCULAR DISEASE Cardiovascular disease, or CVD, is an umbrella term for conditions of the circulatory system, such as coronary heart disease (CHD), stroke, heart failure and rhythmic heart disorders. Together these accounted for 27.2% of all deaths in England & Wales in 201497, and 28.6% in Blackburn with Darwen. CVD mortality In 2012-14, the Borough had the second highest all-age mortality rate for CVD out of 152 upper-tier Figure 69 - CVD mortality under age 75 authorities in England.98 (directly standardised rate per 100,000 persons) PREMATURE MORTALITY (BELOW AGE 75) ●Red = significantly worse than England Blackburn with Darwen’s death rate from CVD in the under-75 age-group is consistently higher than average (Figure 69), and was the 6th highest out of 152 upper-tier authorities in 2012-14. Two-thirds of these deaths were from types of CVD from which premature death is considered to be largely preventable, either via behaviour change or through public health measures. This gives Blackburn with Darwen the 7th highest premature death rate from ‘preventable’ types of CVD.26 Coronary Heart Disease (CHD) In 2014/15, there were 6641 people in Blackburn with Darwen who had been diagnosed with CHD, and modelled estimates suggested that approximately another 1660 residents were likely to have it too without knowing.99 Out of all the upper-tier local authorities in England, Blackburn with Darwen had the 5th highest premature mortality rate for CHD in 2012-14.98 Figure 70 - CHD admissions99 There were 1096 hospital admissions for CHD in 2014/15, which gives a rate significantly above the Blackburn with Darwen England average (Figure 70).99 Stroke In 2014/15 there were 2980 people in Blackburn with Darwen who had ever been diagnosed with a stroke.99 There England were also 225 new admissions because of stroke, which is significantly above the England rate, although the gap is much less striking than for CHD. The premature mortality rate from stroke in Blackburn with Darwen in 2012-14 was 20.9 per 100,000, which ranks ninth highest among upper-tier local authorities. The mortality rate among those aged 75 and above was also significantly higher than the England average.98, 99 CVD risk factors High blood pressure is one of the leading risk factors for CVD. Public Health England’s Hypertension Profile shows that Blackburn with Darwen has approximately 22,000 paatients diagnosed with hypertension, but is suspected of having around a further 17,300 undiagnosed cases.100 The borough is in the second highest quintile on a ‘lifestyle risk factors’ index combining estimated levels of obesity, lack of exercise and excess alcohol. In 2014/15, only 10.8% of eligible residents aged 40-74 were offered an NHS Health Check, and 7.0% received one, both of which proportions are well below the national average.99

LIVE WELL Cross-Cutting Identification, prevention Positive mental health Poverty & financial Themes: & early intervention & wellbeing inclusion (fairness) 31 INTEGRATED STRATEGIC NEEDS ASSESSMENT – SUMMARY REVIEW Green / Amber / Red = significantly better than England / no significant difference / significantly worse than England Diabetes

101,102 Figure 71 - Summary of Blackburn with Darwen performance on Diabetes care pathway Data from http://www.phoutcomes.info/ & associated tools (unless otherwise stated) Background Diabetes affects around 4m people in the UK, predicted to rise to 5m by 2025, and consumes around 10% of NHS spending.103 Blackburn with Darwen’s prevalence of 8.1% (Figure 71) is the highest in the NW, and 10th highest out of 209 CCGs nationally.This may be partly for reasons amenable to preventative action (e.g. low physical activity), but also because of the inherently high risk in Asian populations. Structured education Blackburn with Darwen has one of the highest rates of referral to programmes of structured (checks on eyes, feet, cholesterol etc, which all diabetic patients should have at least annually) education, designed to help patients manage their condition and hopefully reduce the risk of complications.104 However, both locally and nationally, only a tiny fraction are recorded as actually attending.108 Several reports have drawn attention to this problem.105,108,106 When Blackburn with Darwen patients do attend, the main provider, X-pert Health, reports that they show the biggest increase in empowerment out of all its 66 client CCGs nationwide.107 National Diabetes Audit Much of the data in Figure 71 originates from the National Diabetes Audit (NDA). The NDA switched to an ‘opt-in’ model two years ago, which has led to reduced participation nationally. In 2014/15, only 15 Blackburn with Darwen practices took 102 part.108 This has obvious consequences for the * Hyperglycaemia estimates from PHE. (Red rating denotes worst quintile, rather than statistical significance) † Excess mortality data taken direct from National Diabetes Audit.101 quality of the data which the Audit can provide.

LIVE WELL Cross-Cutting Identification, prevention Positive mental health Poverty & financial Themes: & early intervention & wellbeing inclusion (fairness) 32 INTEGRATED STRATEGIC NEEDS ASSESSMENT – SUMMARY REVIEW Figure 72 - Key Mental Health Risk Factors and Indicators for Blackburn with Darwen 5 109 110 MENTAL HEALTH AND WELLBEING 109,110 (Main sources: PHE Health Profile , Common Mental Health Disorders Profile , Severe Mental Illness Profile , Public Health Outcomes Framework26 as at 20/4/16. See also other parts of this Summary Review.) Risk factors Green / Amber / Red = better than England / similar to England / worse than England The incoming arrows represent factors associated with an increased risk of mental health problems. Many of these risk factors are themselves exacerbated by mental ill-health, so there is really a two-way relationship, but this is not shown in the interests of simplicity. Prevalence Blackburn with Darwen has a higher than average proportion of patients registered with a Severe Mental Illness, and above-average rates of more common mental health problems such as anxiety and depression. However, the prevalence of these problems among social care users is well below average. Services & Quality The PHE profiles suggest a generally high level of service usage, with Blackburn with Darwen falling in the top quintile on several indicators.* IAPT services are not, however, delivering a high level of recovery or improvement, and waiting times are also disappointing. Outcomes The Borough has a high emergency admission rate for self-harm, but its suicide rate in 2012-14 was similar to the national average. It continues to have the lowest mortality levels in the NW among adults with serious mental illness, both in absolute terms and when compared with the general population.

* The PHE profiles also suggest that Blackburn with Darwen has the country’s top rate of entry to IAPT treatment. However, the stated figure equals the referral rate. This is not typical, and may be a mistake. LIVE WELL Cross-Cutting Identification, prevention Positive mental health Poverty & financial Themes: & early intervention & wellbeing inclusion (fairness) 33 INTEGRATED STRATEGIC NEEDS ASSESSMENT – SUMMARY REVIEW

Local geography of mood and anxiety disorders One of the 37 indicators in the Indices of Deprivation 2015, known as the ‘Mood and Anxiety Disorders’ indicator, attempts to summarise the level of mood and anxiety disorders among adults living in each Lower Super Output Area or LSOA (see Figure 73). This indicator is actually a composite of four other indicators − in other words, it is a mini-index in its own right. The four component indicators are:

 Prescribing data – based on types and amounts of relevant drugs prescribed by GPs  Hospital admissions data – based on inpatient spells for reasons of mental ill health  Suicide data – based on deaths between 2008 and 2012  Benefits data – based on receipt of incapacity benefits for reasons of mental ill-health Over a third (32 out of 91) of Blackburn with Darwen’s LSOAs are in the highest national decile for the Mood and Anxiety Disorders indicator, and more than half are in the top two deciles combined. None of the borough’s LSOAs are in the least-affected decile. Impact of worklessness on mental health Healthwatch Blackburn with Darwen has published a report based on research carried out with 120 local residents, drawing attention to the impact of unemployment upon mental health.111 79% of respondents felt that their work situation had negatively affected their mental health and wellbeing, often causing financial and housing problems, Figure 74 - Artwork from stress, stigma and social isolation, and 44% were not aware of local mental health Healthwatch Blackburn with and wellbeing services that they could approach for help. These issues are Darwen's report on the Impact brought to life through the use of case studies and striking graphical illustrations. of Unemployment on Mental Health and Wellbeing111 Inpatient psychiatric care: ‘out-of-area’ placements The issue of ‘out-of-area’ care, whereby mental health patients may have to travel miles to be found a hospital bed, has been the focus of much media and political attention this year. Well over 5000 patients in England were sent to out-of-area hospitals in 2015-16, and the problem is increasing year on year.112 One of the most acutely affected providers was Lancashire Care Foundation Trust, which serves Blackburn with Darwen. Out-of-area placements across LCFT as a whole rose from 331 patients in 2014-15 to 751 in 2015-16, and in January 2016 it became the first ever mental health trust to declare a major incident. This enabled it to redeploy staff to address the crisis, and develop a number of initiatives to reduce the pressure on beds. By May 2016, the number of patients in hospital beds outside of Lancashire had fallen from 94 to 20. An independent commission was set up in 2015 under Lord Crisp to investigate concerns about the provision of Figure 73 - Mood and Anxiety Disorders indicator acute inpatient psychiatric beds, and issued its report in February 2016.113 Blackburn with Darwen CCG, which is the from Indices of Deprivation 2015 lead commissioner of mental health services across the whole of Lancashire, has welcomed the report, which calls (Blackburn with Darwen LSOAs overlaid with Wards) for an end to the practice of out-of-area placements by October 2017.114 The new CCG Improvement and Assessment Framework also seeks to address the issue of out-of-area placements for mental health patients. It will require CCGs to monitor the number, duration and cost of such placements, and the reasons for them, and to put plans in place to reduce the use of out-of-area placements by the end of 2016/17.115

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WORKING-AGE INCAPACITY Incapacity benefits claimants In November 2015, 9.8% of 16-64 year-old residents in Blackburn with Darwen were receiving some sort of incapacity benefit. This gives the borough the seventh highest rate out of 152 upper-tier authorities, after Blackpool, Knowsley, Liverpool, Middlesbrough, Stoke-on-Trent and Hartlepool. It continues an established pattern of consistently higher rates in Blackburn with Darwen than in the region or England as a whole (Figure 75). Figure 75 – Proportion of residents aged 16-64 claiming Employment Support Allowance and other incapacity benefits (November each year)9 Within the borough, the proportion of the working-age population claiming incapacity benefits ranges from under 5% in six wards, to 17.0% in Shadsworth with Whitebirk and 19.1% in Wensley Fold. Conditions leading to incapacity benefit claims By far the biggest category of condition resulting in the receipt of incapacity benefits is mental health problems, which account for just over half of all claims (Figure 76): Figure 76 - Recipients of ESA and other incapacity benefits by qualifying condition (Lower Super Output Areas in Blackburn with Darwen, Aug 2015)116

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Figure 77 - Sight loss: VISUAL IMPAIRMENT risk factors and impacts Risk factors and impacts121,117,118,119,120 Sight loss is related to many of the other topics in this ISNA, often as a possible cause or consequence (Error! Reference source not found.). Several of the risk factors on the left hand side of the diagram are modifiable, and it is roughly estimated that about 50% of sight loss can be avoided.121 Blind and partially sighted residents – certified & registered In 2013/14, 94 new patients in Blackburn with Darwen were certified as blind or partially sighted.26 Registering with the council is optional, but as at March 2014, Blackburn with Darwen had approximately 545 residents registered as blind, and 800 as partially sighted.122 Approximately half of those in each category were over the age of 75. However, it is possible to have a degree of sight loss which affects daily life without qualifying for certification, so these figures are only the tip of the iceberg.

Modelled estimates The RNIB estimates that the true number of people affected by sight loss in Blackburn with Darwen may be in the order of 3,700.123 2015 2020 2030 Its Sight Loss Data Tool provides modelled estimates of how the number Early stage AMD 4910 5380 5880 Late stage dry AMD 350 380 430 of people with mild, moderate and severe sight loss is likely to change Late stage wet AMD 710 950 880 over the coming years (Figure 78). Cataract 1110 1240 1390 Figure 78 - Modelled estimates of number of The Sight Loss Data Tool also provides modelled estimates of the Glaucoma 1270 1300 1330 people living with sight loss in Blackburn with numbers of people living with specific conditions that could threaten Diabetic retinopathy 2770 2800 2840 Darwen (source: RNIB123) their sight (Table 1). Table 1 - Modelled estimates of people Cost to the local economy living with particular sight-threatening conditions in Blackburn with Darwen123 NHS spending on problems of vision in Blackburn with Darwen was £4.6m in 2013/14, but it is estimated that an additional £10.5m goes on indirect costs such as lower employment, absenteeism and the provision of informal care.123

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ROAD SAFETY Overall rates In Blackburn with Darwen in 2014 there were 553 recorded road traffic casualties (of all ages), down from 576 in 2013, and 638 the year before that. Expressed as a rate per resident, this puts Blackburn with Darwen 27th highest out of 152 upper-tier authorities in England. 477 of these injuries were slight*, 73 were serious, and three were fatal, giving a total of 76 killed or seriously injured (KSI) in 2014.124 If we look at three years combined, Blackburn with Darwen had the 24st highest KSI rate out of 151 upper-tier authorities in 2012-14, and was significantly worse than England.26 Pedestrian casualties In 2014, Blackburn with Darwen had the 11th highest overall rate of pedestrian casualties in England (per 100,000 population), and the highest of all outside London.124 If we focus on the more serious injuries, Blackburn with Darwen tends to have more pedestrian KSIs than car occupant KSIs (Figure 79).125 This is the opposite of the national picture, where there were over 1½ times as many car occupant as pedestrian KSIs in 2014.126 The rate of pedestrian KSI casualties in Blackburn with Darwen is higher than average for almost every age-group (Figure 80), and significantly so for the youngest residents (aged 0-10) and the oldest (aged 66+).

Figure 80 – Pedestrian KSI rates by age (BwD v. England, 2010-14)

Figure 79 - Number of KSI casualties (BwD, 2005-14) Alternative rates All the analysis so far relates to accidents occurring in Blackburn with Darwen, whether the casualty was local or not. Dividing by the resident population to obtain a rate may not therefore seem particularly logical. If we want to assess the risk to our own residents, we may prefer to count casualties according to where they come from, regardless of where their accident occurred. This is done in a recent report, but for constituencies rather than local authorities.127 In 2009-14, the rate of KSI casualties from Blackburn constituency was 24% higher than the Great Britain average, and for those from Rossendale & Darwen constituency it was 34% higher. When all severities of casualty are considered (not just KSI), Blackburn constituency comes 10th highest out of 632 constituencies. If we focus on pedestrian casualties of all severities, Blackburn constituency comes second highest in the country (after Tottenham), with more than twice the national average rate.127

* The recording of non-serious injuries is often less than complete. LIVE WELL Cross-Cutting Identification, prevention Positive mental health Poverty & financial Themes: & early intervention & wellbeing inclusion (fairness) 37 INTEGRATED STRATEGIC NEEDS ASSESSMENT – SUMMARY REVIEW

ASYLUM SEEKERS Asylum seekers are those who have entered the UK and applied for refugee status, and are waiting for their claim to be assessed. They are allocated Home Office accommodation on a no-choice basis, are not allowed to work for twelve months, and are reliant on cash payments to meet their ‘essential living needs’. These payments were initially set at a level of 70% of Income Support, but were frozen between 2011 and 2015. A new flat rate per person was introduced in August 2015, which represents a ‘substantial reduction’ for single parents and families with children.128,129,130,131,132 Asylum seekers are far from evenly spread around the country. Blackburn with Darwen is one of the 36 districts in the UK to have 250 or more asylum seekers as at the end of September 2015 (Figure 81). Between them, these districts account for over 80% of all asylum seekers in the country, while many other districts have none at all. The national total number of asylum seekers is much lower than a decade ago, although it has been rising again for the past three years. Blackburn with Darwen’s latest count of 278 is also well down on its previous peak (Figure 82). Figure 82 - Figure 81 - Districts with 250+ Numbers of asylum seekers asylum seekers at end September 2015 receiving support in (also Belfast, not shown) Blackburn with Darwen Source: Home Office133 Source: Home Office133 Health needs of asylum seekers Given that asylum seekers are typically fleeing conflict, politicaly upheaval and persecution, it is only to be expected that they will be suffering from anxiety, fear and loneliness. Some may have had highly traumatic experiences, including violence, torture and war, and be suffering mental distress as a result. They may also come from countries where TB, HIV and hepatitis are prevalent, or have chronic non-communicable diseases, such as diabetes, which may have gone untreated.129 Healthwatch engagement programme Asylum Seeker and Refugee drop-in sessions take place weekly at Wesley Hall in Blackburn and the United Reformed Church in Darwen. By attending these sessions to offer advice and information, Healthwatch Blackburn with Darwen has been able to build up a relationship with asylum seekers and refugees, and conduct interviews and focus groups. It has now published its findings as an online report.134 Asylum seekers reported that they often encountered communication barriers when seeking healthcare. This could bring added anxiety and confusion, and meant that conditions and treatments were often poorly understood. Children were sometimes called upon to act as an interpreter, which was an imposition on them and could inhibit the frank discussion of medical problems. Respondents also found it difficult and costly to obtain an appointment, and often needed multiple slots in order to deal with all their issues in the face of language barriers. There were also problems relating to staff attitudes, with some residents feeling they were looked down upon or not taken seriously. Others had been put off seeking healthcare because of doubts or misunderstandings about patient confidentiality.

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AGE WELL

ISSUES PARTICULARLY AFFECTING OLDER PEOPLE TRIPS AND FALLS Hospital admissions Each year, 30% of over-65s will experience one or more falls, rising to 50% of over-80s.135 The Public Health Outcomes Framework records the annual age-standardised rate of falls-related emergency hospital admissions among residents aged 65+. Blackburn with Darwen is consistently higher than average, with 515 such admissions in 2014/15, putting it just within the top quintile nationally.26 Hip fractures Following a hip fracture, only one in 3 sufferers return to their former level of independence, and another third have to leave their own home and enter long-term care.136 Blackburn with Darwen’s rates of hip fracture at ages 65-79 and 80+ were both close to average in 2014/15.26 Local initiatives and engagement Blackburn with Darwen’s ‘Fallstop’ campaign137 aims to raise awareness of some simple steps that people can take to prevent falls in their own home, and how to access professional advice and help. The Fallstop advice leaflet is widely available through GP practices, pharmacies, libraries etc as well as online.138 Local Quintiles In an engagement programme in 2015, Healthwatch Blackburn with Darwen gathered real-life stories about the circumstances of trips and falls, the risk factors leading to them, the care and treatment received, and the longer term impacts on the patient and their carers. Many experienced loss of confidence after a fall, which may in turn lead to isolation.139 LONELINESS AND ISOLATION Lonely people have a higher risk of depression and suicide, visit their GP more, have a higher use of medication, higher incidence of falls, and are at increased risk of entering long-term care.140 Key risk factors for loneliness include being in later old age (over 80 years), on a low income, in poor physical or mental health, and living alone or in deprived urban communities.141 A good source of guidance for local authorites is the updated Combating loneliness guide, from the LGA and the Campaign to End Loneliness.141 Extent of the problem Age UK has devised a way of modelling the prevalence of loneliness in the over-65 population, using data from the 2011 Census.142+143 They estimate that Blackburn with Darwen as a whole is the 39th loneliest district out of 326 in Figure 83 - England. The map on the left shows their model at the Lower Super Output Area (LSOA) level. One-fifth of the Modelled LSOAs in Blackburn with Darwen are shaded in each colour. However, the whole of the top two quintiles (i.e. prevalence of highest 40%) in Blackburn with Darwen falls within the highest-risk quintile (i.e. top 20%) nationally. loneliness in 65+ population The only official measures of social isolation are for adult carers, and those receiving social care. In 2014/15, (LSOAs overlaid 41.1% of carers surveyed in Blackburn with Darwen said they had as much social contact as they would like with Wards) (England 38.5%). This puts the borough in the second best quintile. Among adults receiving social care, 52.7% 26 Source: Age UK142 had as much social contact as they would like, which is the third best result in the country (England 44.8%).

AGE WELL Cross-Cutting Identification, prevention Positive mental health Poverty & financial Themes: & early intervention & wellbeing inclusion (fairness) 39 INTEGRATED STRATEGIC NEEDS ASSESSMENT – SUMMARY REVIEW Figure 84 – Reducing the risk of dementia - PHE infographic on DEMENTIA the role of local government and Health and Wellbeing Boards147 Research & policy Although the number of people with dementia is still predicted to rise as the population ages, recent research lends weight to the suggestion that it may not be quite such a fast- growing epidemic as was feared. One particularly influential paper from Cambridge University has reported a 22% drop in UK prevalence in a generation.144,145 The researchers suggest that these improvements may reflect better education and living conditions in the post-war era, and improved prevention and treatment of chronic conditions such as vascular disease. They recommend that the most fruitful direction for dementia research is to focus on prevention rather than cure, by improving health across the life-course. The decline in dementia incidence has been particularly striking in men, as they have adopted healthier lifestyles and cut down on smoking.146 Public Health England and NICE have both responded to this message by bringing out guidance on the actions that people in midlife can take to reduce the risk of dementia or postpone its onset, and what local authorities and other agencies can do to help them.147,148 Local prevalence ESTIMATES NHS England has concluded that the Cognitive Function and Ageing Study II (CFAS II)149 at Cambridge University provides the best scientific evidence of dementia prevalence, rather than the updated Dementia UK study.150 However, the CFAS II rates are only available for ages 65+, so the Dementia UK rates are still used below that age.151,152,153 Applied to the Blackburn with Darwen population, the approved rates suggest that there may be about 1371 residents with dementia, of whom 1280 are aged 65+.152,154 RECORDED VERSUS ESTIMATED PREVALENCE The prevalence estimates cover all people with dementia, whether diagnosed or not. NHS England’s ambition is for 66.7% of this number to have received a diagnosis, which was achieved earlier this year. At the local level, the official measure uses the number of recorded diagnoses among the registered population of each CCG, divided by the estimated number of residents with dementia. On this basis, Blackburn with Darwen scores 81.7% (April 2016).152 However, more people have a GP in Blackburn with Darwen than live in the borough, so this is probably a slight exaggeration. A recalculated version comes out about 10 percentage points lower, but still above the 66.7% threshold. Dementia-friendly communities155 For people who already have dementia, Blackburn with Darwen offers many examples of communities and services where they can feel safe, understood and respected:  A ‘dementia-friendly’ initiative at Blackburn Rovers, with special checkouts and easy-read signs both at the ground and at its stores and cafes.156  The borough’s first ‘dementia-friendly’ GP practice, with specially trained staff, extra reminders, longer appointments and improved signage.157  A pioneering dementia-friendly ward at the Royal Blackburn Hospital, developed with support from the King’s Fund, providing a calm and comforting, yet stimulating, environment. With its specially-designed layout, colour scheme, lighting effects, Lancashire photos and nostalgic furnishings, and optoinal entertainments and activities, it is now being emulated by neighbouring authorities.158  A new state-of-the-art 64-bed care-home, offering the latest in person-centred care and dementia-friendly design. It features everything from a cinema and vintage tea rooms to a special football-themed room created in partnership with Blackburn Rovers Community Trust.159

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QUALITY AND LENGTH OF LIFE

HEALTHY LIFE EXPECTANCY Everything within the Public Health Outcomes Framework is geared towards achieving two ‘overarching outcomes’, one of which is: “Increased healthy life expectancy, i.e. taking account of the health quality as well as the length of life ” 160 The importance accorded to this indicator reflects the philosophy that the public health system should be concerned not just with extending life, but with improving health and wellbeing across the life course. The calculation involves splitting total Life Expectancy into the portion spent in ‘good’ health and the remainder spent in ‘not good’ health, based on responses to a survey question such as: “How is your health in general?” (Figure 85):161

Figure 85 – Healthy Life Expectancy – Blackburn with Darwen compared with 150 upper-tier local authorities and England (2012-14) It can be seen that Healthy Life Expectancy in Blackburn with Darwen is 58.0 years for males and 60.3 years for females, both of which are significantly lower than the England average. When Healthy Life Expectancy is divided by total Life Expectancy, we find that males in Blackburn with Darwen can expect to spend 75.6% of their life in good health, and females 74.3%, which again is below average for both sexes. The 2012-14 data provides the first opportunity to compare Healthy Life Expectancy for non-overlapping time periods, as the series only started in 2009-11. However, the change over time is statistically insignificant in most local authority areas, including Blackburn with Darwen. The Public Health Outcomes Framework acknowledges that Healthy Life Expectancy is the sort of measure which can take a long time to show any marked improvements, which is why the overarching outcomes are underpinned by a large collection of supporting indicators.160

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END OF LIFE

CAUSE OF DEATH

Figure 86 - Cause of death - broad breakdown, Blackburn with Darwen 2014

It is natural to ask ‘What is the biggest cause of death in Blackburn with Darwen?’. This depends on how the causes have been grouped into categories, but if we accept the very broad classification used here, the answer is ‘CVD’ (with 353 deaths in 2014), followed by ‘Cancer’ (331). This contrasts with England as a whole, where Cancer overtook CVD in 2011, and has remained slightly higher since. There is, however, no ‘right’ or ‘wrong’ way to split up the causes. Figures from the ONS suggest that Dementia and Alzheimer’s disease is the second biggest cause of death nationally. However, this has been arrived at by combining various forms of dementia, and splitting up CVD and cancers.162

AGE WELL Cross-Cutting Identification, prevention Positive mental health Poverty & financial Themes: & early intervention & wellbeing inclusion (fairness) 42 INTEGRATED STRATEGIC NEEDS ASSESSMENT – SUMMARY REVIEW

REFERENCES

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147 Public Health England (2016). Health matters: midlife approaches to reduce dementia risk. Available from https://www.gov.uk/government/publications/health-matters-midlife-approaches- to-reduce-dementia-risk/health-matters-midlife-approaches-to-reduce-dementia-risk 148 NICE (2015). Dementia, disability and frailty in later life – mid-life approaches to delay or prevent onset. Available from https://www.nice.org.uk/guidance/ng16/chapter/1-Recommendations 149 CFAS. Cognitive Function & Ageing Study. Availble from http://www.cfas.ac.uk/ 150 Prince M, Knapp M et al (201). Dementia UK; 2nd edition. Available from https://www.alzheimers.org.uk/site/scripts/documents_info.php?documentID=2759 151 Alistair Burns (2016). Letter to all CCGs. Available from http://www.ipswichandeastsuffolkccg.nhs.uk/LinkClick.aspx?fileticket=sAjkZ_xG9gQ%3D&tabid=762&portalid=1&mid=2616 152 NHS England (2016). Dementia diagnosis monthly workbook. Available from: https://www.england.nhs.uk/mentalhealth/dementia/monthly-workbook/ 153 NHS England (2016). Technical definitions for commissioners 2016/1. Available from: https://www.england.nhs.uk/wp-content/uploads/2016/02/technical-definitions.pdf 154 Department of Health (2016). Prime Minister’s Challenge on Dementia 2020 – Implementation Plan. Available from https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/507981/PM_Dementia-main_acc.pdf 155 LGA (2015). Dementia friendly communities: guidance for councils. Available from http://www.local.gov.uk/web/guest/publications/-/journal_content/56/10180/7415470/PUBLICATION 156 The Shuttle (2016). Dementia friendly initiative for Blackburn Rovers. Available from http://theshuttle.org.uk/dementia-friendly-initiative-for-blackburn-rovers/ 157 Lancashire Evening Telegraph (2015). Blackburn health centre sets an ‘example’ on dementia care. Available from http://www.lancashiretelegraph.co.uk/news/13769821.Blackburn_health_centre_sets_an____example____on_dementia_care/ 158 The Bolton News (2015). ‘Home from home’: Pioneering ward shows how Royal Bolton could look with help from Donate £1 for Dementia campaign. Available from http://www.theboltonnews.co.uk/news/13361065._Home_from_home___Pioneering_ward_shows_how_Royal_Bolton_s_could_look_with_help_from_Donate___1_for_Dementia_campaign/ 159 The Shuttle (May 2016). One of Britain’s most pioneering specialist dementia care services opened in Blackburn yesterday. Available from http://theshuttle.org.uk/one-of-britains-most- pioneering-specialist-dementia-care-services-opened-blackburn-yesterday-19th-may-during-national-dementia-awareness-week/ 160 DH (2012). Public Health Outcomes Framework for England 2013 to 2016: Part 1A. Available from https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/216160/Improving-outcomes-and-supporting-transparency-part-1A.pdf 161 ONS (2016). Healthy Life Expectancy at birth by Upper Tier Local Authority and Area Deprivation, England: 2012 to 2014. Available from http://www.ons.gov.uk/releases/healthylifeexpectancyatbirthbyuppertierlocalauthorityandareadeprivationengland2012to2014 162 ONS (2015). What do we die from? Available from http://webarchive.nationalarchives.gov.uk/20160105160709/http://www.ons.gov.uk/ons/rel/vsob1/mortality-statistics--deaths-registered- in-england-and-wales--series-dr-/2014/sty-what-do-we-die-from.html

REFERENCES

GOVERNING BODY MEETING

SUB-COMMITTEES AND GROUPS’ MINUTES

Date of Meeting 8th November 2017 Agenda Item 11

CCG Corporate Objectives

Through better commissioning, improve local health outcomes by addressing poor X outcomes and inequalities To work collaboratively to create safe, high quality health care services X To maintain financial balance and improve efficiency and productivity X To deliver a step change in the NHS preventing ill health and supporting people to live X healthier lives To maintain and improve performance against core standards and statutory requirements √ To commission improved out of hospital care X CCG High Impact Changes Delivering high quality Primary Care at scale and improving access X Self-Care and Early Intervention X Enhanced and Integrated Primary Care and Better Care Fund X Access to Re-ablement and Intermediate Care X Improved hospital discharge and reduced length of stay X Community based ambulatory care for specific conditions X Access to high quality Urgent and Emergency Care X Scheduled Care X Quality √

Clinical Lead: N/A

Senior Lead Manager Mr Iain Fletcher Finance Manager N/A Equality Impact and Risk Assessment Report for information only completed: Patient and Public Engagement completed: Report for information only Financial Implications Report for information only GOVERNING BODGOVERNING BODY MEETING

Risk Identified Report for information only Report authorised by Senior Manager: Mr Iain Fletcher

Decision Recommendations The Governing Body is requested to receive and note the content of the report.

Governing Body Meeting Page 2 of 3

CLINICAL COMMISSIONING GROUP (CCG)

GOVERNING BODY MEETING

8TH NOVEMBER 2017

SUB-COMMITTEES AND GROUPS’ MINUTES

1. Introduction

This report presents the minutes of the Governing Body Sub-Committees and Groups for receipt and note by members.

The minutes inform members of delegated and key decisions taken and provide information regarding items of particular interest or potential risk.

2. Sub-Committees and Groups

2.1 Primary Care Co-Commissioning Committee

The ratified minutes of the meeting held on 18th July 2017 are attached as Appendix 1.

2.2 Commissioning Business Group

The ratified minutes of the meetings held on 9th August and 13th September 2017 are attached as Appendices 2 and 3.

2.3 Pennine Lancashire Quality Committee

The ratified minutes of the meetings held on 28th June, 26th July and 23rd August 2017 are attached as Appendices 4, 5 and 6.

3. Recommendation

The Governing Body is requested to receive and note the content of the report.

Iain Fletcher Head of Corporate Business 27th October 2017

Governing Body Meeting Page 3 of 3

Appendix 1

CLINICAL COMMISSIONING GROUP (CCG)

Minutes of the Primary Care Commissioning Committee (PCCC) held on Tuesday 18th July 12.00 – 2.30 p.m. Meeting Room 2 Blackburn Library PRESENT: Mr Graham Burgess CCG Chair Dr Malcolm Ridgway Clinical Director for Quality and Effectiveness Mr Roger Parr Chief Finance Officer Mr Paul Hinnigan Lay Member - Governance Dr Nigel Horsfield Lay Member Dr Geraint Jones Lay Member – Secondary Care Doctor (Retired)

IN ATTENDANCE: Mr Peter Sellars Primary Care Transformation Manager Mrs Catherine Lawless CCG Development Officer (minutes) Mrs Sarah Danson NHS England Mrs Julie Kenyon Senior Operating Officer Primary Care & Medicines Mr Stephen Toulmin Local Medical Committee Mrs Kate Pavlidou Primary Care Transformation Programme Manager Mrs Catherine Wright Primary Care Quality Lead Mr David Mehaffey Managing Consultant, PA Consulting. Dr Abdullahi Sheriff Managing Consultant, PA Consulting.

Min No: 1. Chair’s Welcome

The Chair welcomed everyone to the meeting and gave a short briefing with regards to the content of the agenda and general housekeeping. In addition the Chair welcomed Mr Toulmin to the meeting and formally invited him to stay for specific items in Part 2 of the Primary Care Co Commissioning meeting as his contributions would be of interest to PCCC members.

The Chair advised PCCC members that Item E/8 GP Services – Extended Access in Part 2 of the meeting should be moved from Part 2 for discussion in Part 1 of the meeting as he said that the PCCC are to consider agreeing an extension of a contract and should therefore be in Part 1. 2. Apologies for Absence and Confirmation of Quoracy

Apologies for absence were received in respect of:

Dr Stephen Gunn, Dr Gifford Kerr, Miss Claire Jackson, Mrs Janet Thomas and Dr Preeti Shukla 3. Declarations of Interest

The Chair asked members if they would like to declare any Conflicts of Interest (CoI) relating to items on the agenda. The Chair reminded those present that if, during the course of discussion a CoI became apparent, it should be declared at that point.

Dr Malcolm Ridgway declared a conflict of interest (Indirect Interest) with regards to Part 2 of the Primary Care Co Commissioning Committee Item C/8. The Chair noted the conflict of

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interest and asked that Dr Ridgway leave the meeting room during this item.

Declarations declared by members of the Primary care Co Commissioning Committee are listed in the CCG’s Register of Interests. The Register is available, either via the Secretary to the GB or the CCG website via the following link: http://www.blackburnwithdarwenccg.nhs.uk/about-us/registers-interests/ 4. Questions from the Public

No questions had been received from members of the public. 5. Minutes of the Meeting held on 31st May 2017

The minutes of the previous meeting were reviewed and accepted as an accurate record.

RESOLVED That the Minutes of the Meeting held on 31st May 2017 were approved as an accurate record. 6. Action Matrix / Matters Arising

The action matrix was reviewed and updates were provided.

Item 7 Primary Care Update - Estates & Technology Fund (ETTF) – Mr Hinnigan commented that he had met with members of the Primary Care Group and looked at the Project Initiation Documents (PID’s) for the West development and reported that he found the meeting very useful, although he said there are a few points that still need to be addressed.

Item 7 Primary Care Update - GP Opening Hours – Dr Ridgway commented that NHS England are reluctant to share practice data around patient non attendances with CCG’s. Mr Sellars also advised that the contract for the Apollo Toolkit Blackburn with Darwen practices signed up to has now come to an end. Nationally there is to be a new workload tool rolled out. Roll out and sign up to the new tool will be in August 2017. 7. Primary Care Update: Mr Sellars asked PCCC members to note the contents of the Primary Care Update and drew the PCCC to key pieces of information. Estates & Transformation Fund (ETTF) – It was noted that the PID’s have gone to region with a planned start (build) of summer 2018 and completion and mobilisation by 2019. GP Access Fund - The Federation are in the process of finalising the new service model but there are a few issues around indemnity cover with the Medical Defence Union (MDU). Primary Care at Scale – Monies have been set aside for Blackburn with Darwen practices from NHS England to help deliver Primary Care Networks. Mr Sellars commented that services should be started to be redesigned by Autumn 2017. It was noted that the NHS monies will go to practices for their utilisation and not to CCG’s. Practice Changes – Dr Z Patel has now joined partnership with Dr P Jagadesham. Dr Patel is also looking to provide a satellite service for his patients in association with the Family Practice at Barbara Castle Way Health Centre, for those patients who do not wish to travel. It was noted that the CCG is working with the practice to ensure the best service for patients. Dr I Zafar (Roe Lee Surgery) has now gone into partnership with Dr Marlborough’s practice (Montague Practice) and is looking to merge both practices subject to conversion of contracts (ie PMS to GMS). Mr Parr raised comment around the processes involved in the planned satellite surgery as this could impact on costs to the CCG and that it would have to go through formal governance and advised that more clarity is needed. It was noted that this is in the early stages of development and will be brought to the PCCC at a later date with more information.

ACTION: Information around the planned satellite surgery to be brought to a later meeting of the PCCC.

CONCLUSION: That the PCCC noted the Primary Care Update.

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7.1 Primary Care Work Plan: Mr Sellars briefly outlined the Primary Care Work Plan to date and asked the PCCC for their comments.

ACTION: The PCCC suggested that on the tab for the Estates Strategy in January a progress report to be added to update for the July meeting, and that the APMS tab should be expanded to include APMS/GMS/PMS, to enable the PCCC to discuss any key contractual issues. Dr Ridgway further commented that following the GP Forward View Delivery Plans there will be a lot of work around workforce and asked for this to be also added to the work plan.

CONCLUSION: That the PCCC noted the contents of the Work Plan and asked for this to be a standing item on future PCCC agenda’s.

8. General Practice Quality Monitoring: Mrs Wright asked the PCCC to note the contents of the report following NHS England developing a Quality Assurance Framework in order to strengthen and also to standardise processes nationally. Mrs Wright advised that the Pennine Lancashire General Practice Quality Group has adopted this process for monitoring the quality of general practice using the quality concerns trigger tool which has three stages:

• Routine quality assurance monitoring • Enhanced quality surveillance • Enhanced quality review

Mrs Wright advised that the tool is a welcomed process for all CCG’s to follow and allows for the monitoring of general practice which should ensure areas of concern are addressed at an early stage. Mrs Wright drew the PCCC’s attention to the Primary Care Performance Dashboard which helps to identify practices for further review. Following this and further evaluation of performance and other data, the Quality Group will arrange to visit the identified practices advising them of the areas of concern and work with them to address and resolve these in a supportive manner. Mrs Wright further commented that the dashboard is to be developed further for Pennine Lancashire. It was noted that Governance will sit with the Pennine Lancashire Quality Committee to which some Blackburn with Darwen PCCC members attend and advised that if there were any contractual issues they would then be brought to the PCCC’s attention. Dr Jones commented that the information provided was of a good standard and very useful and would help to inform future commissioning intention’s and advised that from looking at the data provided, practices with the largest number of whole time equivalent GP’s per 1,000 population have the best practice outcomes and commented that as a CCG we should be targeting practices with reduced numbers first.

CONCLUSION: That the PCCC noted the contents of the report and asked Mrs Wright to thank quality team members who have contributed to the dashboard.

9. Workforce Tools & Workforce Dashboard: Dr Ridgway gave a brief introduction with regards to the tool which has been developed by PA Consulting working with NHS England, and advised is currently being funded by NHS England for 48 practices. It was noted that the tool extracts practice appointment data from GP systems, identifies which clinician has seen which patient and can be linked with the reason for attendance. The resulting data can be used to inform future GP workforce and activity and helps to determine whether the patient could have been seen by another member of staff for example by a practice nurse. Dr Sheriff drew the PCCC’s attention to the presentation which gives the neighbourhood level summary of primary care activity for Blackburn with Darwen and advised that the document provides example scenarios of how the neighbourhood teams within Lancashire can use the tool to consider their options when developing their workforce strategy, and can also be used to identify areas under pressure, help to determine future models of care going forward and also what additional workforce will be required in future years to cope with population growth and increased multi-morbidity. PCCC members raised concern around the data supplied and the massive increase in activity to which Dr Ridgway advised could be due to demographic

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changes and also the shift from secondary care to primary care.

ACTION: Mrs Lawless to the share the presentations with PCCC members.

Dr Ridgway advised the PCCC of the international recruitment drive, which Dr Kate Pavlidou is leading, to help develop the workforce across England. Dr Pavlidou advised that this work is being carried out through the Transformation Office to support organisational development and to start thinking about workforce implications in delivering the Five Year Forward View. Mr Sellars commented that this is a great opportunity to start to develop an accountable care system. The Chair welcomed this information and asked for a Blackburn with Darwen analysis in 6 months time.

ACTION: Analysis of data for Blackburn with Darwen be brought to the September meeting

CONCLUSION: That the PCCC noted the contents of the report.

12.55 Dr Kate Pavlidou & PA Consulting left the meeting 10. End of Year Report – Prescribing, Quality, Innovation, Productivity and Prevention: Mrs Kenyon asked PCCC members to note the contents of the end of year prescribing report which details practice achievement against a number of prescribing areas:

• GP Prescribing Budget • Medicines Optimisation Scheme (MOS) • National QIPP Indicators • Prescribing Waste Scheme

Mrs Kenyon advised that the aim of the prescribing areas is to promote and increase evidence based, cost effective prescribing in line with national and local guidance, which in turn will improve prescribing quality and patient safety, reduce risk from medication errors, reduce waste and support prescribing spend within budget. Mrs Kenyon drew PCCC members to chart 3 of the Medicines Optimisation Scheme which shows a £432,065 underspend. Mrs Kenyon commented that performance against the national QIPP indicators during 2016/17 has been excellent and that for the first time shows improvement across all areas. The Prescribing Waste Scheme - by the end of March, 17 practices had implemented the scheme, 4 practices are yet to go live, 4 practices had already stopped community pharmacy ordering, with 2 practices remaining. Mrs Kenyon said whilst it is impossible to contribute the reduction in spend solely to the waste scheme, forecast outturn reduced from £26,741,824 before the scheme started in September to a final position of £26,218,330. In conclusion Mrs Kenyon asked the PCCC to note that Blackburn with Darwen CCG contributed to 0.84% to the national prescribing reduction despite having only 0.3% population and that one practice demonstrating the greatest impact has shown a reduction in spend of £193,079 between 2015/16 and 2017/18. The Prescribing waste Scheme continues to show promising results and is expected to deliver additional QIPP savings during 2017/18. Mr Parr commented that some of the performance has been outstanding and that the figures in April was the lowest since February 2013.

CONCLUSION: That the PCCC noted the contents of the report and commented that the report is very positive.

E/8 GP Services – Extended Access – Mr Sellars asked the PCCC to note the contents of the paper which outlined that since 2015 Blackburn with Darwen practices have been offering 7 day extended access through the Prime Ministers Challenge Fund and asked approval from the PCCC to extend the current contract until April 2019. Mr Sellars advised this will enable the new extended model to be embedded and also to align with other procurements to allow the remodelling of primary care. It was noted that the service is now delivered through the GP

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Access Fund which is part of the GP Forward View plan. It was noted that the current contract held by the Local Primary Care (LPC) is an APMS contract. Mr Sellars advised of the options to further extend or procure the contract and described the work to further develop primary care at scale through new models of care and delivery. Dr Ridgway advised that the date in the paper needed to be adjusted such that it aligns with other relevant contracts such as community services. This would also affect the overall costs.

CONCLUSION: That the PCCC agreed to extend the current contact until March 2019.

AOB: Primary Care Financial Summary – Mr Hinnigan commented that there is no financial report and asked Mr Parr to provide the PCCC with an update. Mr Parr advised that at month 3 there is a slight overspend in Primary Care due to an error by NHS England.

ACTION: Primary Care Financial Summary agenda item for the next meeting

Date and Time of Next Meeting

The next meeting will be held on Tuesday 19TH September 12.30 - 2.00 p.m. in Meeting Room 2, Blackburn Central Library, Town Hall St, Blackburn, BB2 1AG.

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Minutes of the Commissioning Business Group (CBG) Meeting Wednesday 9th August 2017 1.30 – 3.30 p.m. Room G10 & 11, Innovation House, Evolution Park, Haslingden Road, Blackburn BB1 2FD

Present Dr Adam Black GP Executive Member (Chair) Mr Paul Hinnigan Lay Member - Governance Ms Claire Jackson Director of Commissioning Operations Dr Chris Clayton Clinical Chief Officer Dr Malcolm Ridgway Clinical Director for Quality and Primary Care Dr Geraint Jones Secondary Care Doctor (Retired) Mrs Janet Thomas Executive Nurse/Associate Director for Quality and Commissioning Dr Penny Morris GP Executive Member Mr Roger Parr Deputy Chief Executive/Chief Finance Officer Mrs Karen Cassidy Public Health Specialist (Live Well)

In Attendance Ms Louise Shoulder Executive Support to Director of Commissioning Operations Mrs Catherine Lawless Minute Taker Mrs Julie Kenyon Senior Operating Officer Mrs Rachel Murphy Commissioning Transformational Lead Integrated Care

Item Action 08/17/01 Apologies for Absence/Agenda Sequencing Apologies for absence had been received from Dr John Randall, GP Executive Member (Chair) Dr Zaki Patel, GP Executive Member Dr Preeti Shukla, GP Executive Member Elaine Johnstone, Service Director, MLCSU Mr Neil Holt, Head of Commissioning Performance Mr Gifford Kerr, Public Health

08/17/02 Declarations of Interest & Confirmation of Quoracy

The meeting was confirmed as non-quorate due to a number of apologies.

The Chair reminded Members of their obligation to declare any interest they may have on any issues arising at Committee Meetings which might conflict with the business of Blackburn with Darwen Clinical Commissioning Group Info (CCG).

Commissioning Business Group Minutes 9th August 2017

08/17/03 Minutes of the Previous Meeting – 12th July 2017

The Minutes of the last meeting were reviewed and agreed as a true record. It was agreed that they would be approved at September CBG. LS

08/17/04 Matters Arising - Action Matrix

Miss Claire Jackson updated the meeting on the Acute Visiting Service developments (AVS) that had been presented to Senate meeting on Thursday 27th July which has prompted some constructive debate.

There was a positive discussion around the use of the Service, variation by practice and the need to engage with Localities to address this. It was suggested that two way communications would improve appropriate referrals. The cut off time for referrals into ELMS was re-iterated including the requirement for the service to be contacted directly to check capacity and appropriateness of referral after 5.30pm and prior to 6:30pm closure.

ACTION: Feedback to be provided to Senate in three months with CJ monitoring information around the risks and issues of AVS

08/17/05 Declaration of Any Other Business No declarations were made. For Discussion

08/17/06 Joint Working - Pennine Lancashire Joint Commissioning

Miss Jackson presented an update on proposals to develop a Joint Commissioning committee across Pennine Lancashire following discussion at Board to Board meeting in June. The proposal would include the merging of the CBG and East Lancashire CCG Sustainability Committee.

The proposed governance structure would maintain separate Governing Bodies with separate Finance Committees. It was agreed that more work is required to define the functionality, the risks and benefits associated with this change.

Mr Paul Hinnigan suggested that there would need to be equal membership from both constituent CCGs and raising the question around the majority membership and if that would need to be Clinicians.

Dr Chris Clayton advised that the Committee must deliver for Pennine Lancashire and he believed that there was merit in bringing these two groups

Commissioning Business Group Minutes 9th August 2017

together. There would be a need to refresh the Scheme of Delegation and the Governing Body would have to agree the new format.

Dr Malcolm Ridgway suggested that there still needs to be a ‘do nothing’ option if we cannot agree and we need to think about how we continue to ensure Blackburn with Darwen specific issues are resolved.

CBG members felt it was key to commence discussion with clinicial leads to align views where possible across the 2 CCGs as this would be fundamental to effective decision making.

ACTION: To be presented at Sustainability Committee at ELCCG on 14th CJ August to discuss proposed clinical attendance and voting members.

ACTION: An update on progress to date in relation to the development of CJ a joint committee to be discussed at Governing Body in September

08/17/07 Better Care Fund (BCF) 2017 – 2019 Plan

Chair introduced Mrs Rachel Murphy, Integrated Commissioning Transformation Lead, to the group

Miss Claire Jackson provided an overview of Better Care Fund Plan requirements for 2017-19, which is being developed in partnership with the Local Authority. Proposals will build on the original BCF plan which was approved by CBG members in 2015. The plan will align with both Pennine Lancashire and Lancashire and South Cumbria developments for integration and is reflective of the NHS 5 Year Forward View.

Miss Claire Jackson also gave an overview of the Improved Better Care Fund (iBCF) requirements, which provided additional non-recurrent resource to Social Care to support social care pressures and reducing delayed transfers of care.

CBG members supported the BCF plan which will be signed off on behalf of the Health and Wellbeing Board prior to submission on 11th September.

08/17/08 Community Dermatology

Dr A Black presented the Community Dermatology Paper for approval. A number of outcomes of the procurement process were outlined which included: Cease process and re-advertise for bidders with slightly differing terms, stop procurement and discuss with local providers via a service redesign model, or, extend the existing sustainability partner contract until 31st March 2018.

Paper could not be agreed by the members in the absence of quoracy and was 3

Commissioning Business Group Minutes 9th August 2017

recommended for chairs action.

ACTION: Passed for Chairs action AB

ACTION:

To be included as an agenda item for PL Joint Commissioning Committee LS when formed where the contract terms for extending need to be discussed and agreed. LS To be included on CBG agenda in October for update.

2:45pm - Mrs Julie Kenyon left the meeting.

Standing Item 08/17/09 Quality, Innovation, Productivity, Prevention (QIPP)/Right Care Update:

An update on QIPP progress was provided. CBG were asked to note the increase in the value of QIPP savings banked, work is continuing to support closing the gap and this receives further review by the Finance Scrutiny Group.

To date there has been £35,000 monthly savings realised from the changes to the administering of back injections and the cost reduction from high cost drugs (biosimilars).

ACTION:

Updated policy required in regard to facet joint injections. AB/MR

For Information

08/17/10 Investments Schedule

Mr Roger Parr informed the meeting that the Month 4 position remains stable and strong. Performance is strong with Providers.

Any Other Business

None.

Commissioning Business Group Minutes 9th August 2017

Date and Time of Next Meeting 08/17/11 The next meeting was scheduled for Wednesday 13th September at 1 pm Info in Room G10 & G11, Innovation Centre.

The Chair thanked everyone for their attendance and the meeting closed.

Commissioning Business Group Minutes 9th August 2017

CLINICAL COMMISSIONING GROUP (CCG)

Minutes of the Commissioning Business Group (CBG) Meeting held on Wednesday 13th September 2017 1.30 – 3.30 p.m. in Room G10 & 11, Innovation House, Evolution Park, Haslingden Road, Blackburn BB1 2FD

Present: Dr John Randall General Practitioner (GP) Executive Member (Chair) Miss Claire Jackson Director of Commissioning Operations Dr Zaki Patel GP Executive Member Dr Malcolm Ridgway Clinical Director for Quality and Primary Care Mrs Karen Cassidy Public Health Specialist (Live Well) Dr Penny Morris GP Executive Member Mr Roger Parr Deputy Chief Executive/Chief Finance Officer Dr Geraint Jones Secondary Care Doctor (Retired) Dr Chris Clayton Clinical Chief Officer Dr Adam Black GP Executive Member Dr Preeti Shukla GP Executive Member

In Attendance: Mr Neil Holt Head of Commissioning Performance Mrs Julie Kenyon Senior Operating Officer Ms Louise Shoulder Executive Support to Director of Commissioning Operations Ms Samantha Wallace-Jones Senior Commissioning Manager Ms Elizabeth Fleming Head of Urgent Care Mr Alex Walker Programme Director for Urgent Care Ms Jayne Lowthion Commissioning Manager

Item Action 09/17/01 Apologies for Absence/Agenda Sequencing

Apologies for absence had been received from Mr Paul Hinnigan – Lay Member (Governance).

09/17/02 Declarations of Interest and Confirmation of Quoracy

The meeting was confirmed as quorate.

Dr Malcolm Ridgway declared an indirect Conflict of Interest (CoI) in agenda item 09/17/06 Out of hours, GP Advice and Clinical Navigation Hub Review.

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Due to the nature of the conflict, it was agreed that Dr Ridgway would leave the room at that point and take no part in discussions.

09/17/03 Minutes of the Previous Meeting – 9th August 2017

The Minutes of the last Meeting were reviewed and agreed as a true record.

RESOLVED: That the Minutes of the Meeting held on 9th August 2017 were agreed as an accurate record.

09/17/04 Matters Arising - Action Matrix

07/17//05 Acute Visiting Service (AVS) Miss Claire Jackson informed members that changes to AVS had been approved from the 1st October 2017.

It was noted that an update would be provided at the October Senate meeting.

07/17/04 Assessment and Support for Children and Young People Requiring Ventilation Miss Jackson provided an update to members following the agreement to move to a framework process for complex and ventilated packages of care for children and the removal of the block contractual element for the Children’s Ventilated Service.

A breakdown of staffing costs on the block contract element had now been received via contracts.

There may be some elements of the block contract that were still required in order to provide assessment for these children and East Lancashire Hospitals NHS Trust (ELHT) were considering if they would still like to provide this.

The CCG was now in a position to serve 12 months’ notice on the block contract element.

09/17/05 Declaration of Any Other Business No further declarations were made. For Decision 09/17/06 Out of Hours, GP Advice and Clinical Navigation Hub Contract Review

Dr Ridgway declared an indirect CoI in this item.

Due to the nature of the conflict Dr Ridgway left the meeting and did not take part in the discussions.

Ms Elizabeth Fleming presented the paper, which provided an update to the CBG on progress towards developing an integrated urgent care specification for Pennine Lancashire.

Page 2 of 6

It was noted that the paper had already been discussed and supported at East Lancashire (EL) CCG Sustainability Committee.

Currently, all the above services were provided by East Lancashire Medical Services (ELMS) who had highlighted to the CCG a number of perceived issues:

• that there was a forecast overspend on the Out of Hours (OOHs) Service; • that activity across GP OOHs and GP Advice had increased by 46% whilst funding had only increased by 10%; • that they may have to temporarily close services on the Directory of Services (DOS) to maintain resilience of core services.

In response to this BwD and EL CCGs have undertaken a formal review of the GP OOHs, Navigation Hub and GP Advice services.

Members were asked to support a move to a single integrated service offer, with 24/7 clinical advice and consolidation of current service locations. This would require extending the current contract to March 2019 and decommissioning the Clinical Navigation Hub and GP Advice.

Following discussion, members agreed to support the recommendations in the paper and requested that a draft specification was brought to the November meeting.

ACTION: Ms Fleming agreed to bring a draft specification to the EF November meeting.

RESOLVED: That the CBG agreed to:

i. support the integrated service offer which includes 24/7 clinical advice; ii. support the consolidation of current service locations; iii. support the decommissioning of Clinical Navigation Hub and GP Advice; iv. extend the current contract to March 2019; v. support the sustainability payment until March 2019; vi. support the test for change of Primary Care streaming at Burnley General Hospital Urgent Care Centre between ELMS and ELHT GPs; vii. support the integration of the ELMS budget.

Dr Ridgway returned to the meeting.

09/17/07 Intensive Home Support Service – Intravenous Antibiotics Service

Dr Penny Morris presented the paper which provided an options appraisal for an Intravenous Antibiotic (IVAB) Service for BwD CCG as part of an Intensive Home Support Service (IHSS) offer from 1st October 2017.

Page 3 of 6

Dr Morris reported that, following a detailed review of activity and demand for IVAB over the previous 12 months, it appeared that the demand for step up Cellulitis IVAB was lower than anticipated in a community setting.

Dr Morris explained that step down activity had steadily increased.

Members discussed the two options:

1. maintain the current service as it stands; 2. change the current service to a step down only service and reduce the funding allocation from £138k to £50k.

Members considered the risks and mitigations and agreed that the current service was not cost effective, nor sustainable, and that they supported option 2; i.e. that the service should be changed to a step down only model with an associated reduction in contract value.

ACTION: The Committee requested that Mrs Lisa Kiernan report to the Executive Team regarding the pathway redesign process and Communication and Engagement Plan being undertaken before 1 LK October 2017.

RESOLVED: That the CBG agreed to Option 2, including a reduced Lancashire Care NHS Foundation Trust (LCFT) contract value.

09/17/08 Dermatology Community Service Contract

Miss Samantha Wallace-Jones and Dr Adam Black presented the paper in relation to the Intermediate Community Dermatology Service Procurement Position Update.

The purpose of the paper was to provide the CBG with:

• an update in relation to the procurement exercise that had been undertaken during August 2017; • a request for approval for an interim contract and future long term commissioning plan for the Intermediate Community Dermatology Service.

Miss Wallace-Jones updated members and provided further clarification in relation to the answers which had been received from bidders since the paper had been circulated. This offered further assurance regarding finance, activity and the proposed sub-contracting arrangements.

The Committee was requested to approve a 12 month contract with About Health, whilst a contract review was undertaken and further discussions with EL CCG regarding a Pennine Lancashire alignment of contracts.

Following discussion, members agreed to approve the awarding of a 12 month contract to About Health to enable the CCGs to review plans and agree timescales. Page 4 of 6

RESOLVED: That the CBG:

i. noted the current position with regards to the Intermediate Dermatology Service procurement; ii. noted the risks and limitations; iii. noted the outcomes of the interim procurement process; iv. agreed to approve the awarding of a 12 month contract to About Health. For Discussion 09/17/09 Joint Committee

Miss Jackson provided the Committee with an update of progress towards a Joint Committee with ELCCG.

Discussions centred on ensuring delivery of the statutory responsibilities of the 2 CCGs whilst undertaking joint working as appropriate, a review of the areas where joint posts were already in place and what worked well.

It was agreed that formal agreement of the structure, reporting and governance arrangements was required following further discussion with clinical leads.

Miss Jackson confirmed that discussions remained ongoing across the 2 CCGs.

ACTION: It was agreed that a further update would be provided at the CJ next meeting.

RESOLVED: That the CBG noted the content of the update. 09/17/10 Urgent Treatment Centre Review

Ms Fleming updated the Committee regarding the ongoing Urgent Treatment Centre (UTC) Review.

She explained that the slide set had already been presented and discussed at the Clinical and Management Executive Team (CMET).

Ms Fleming informed members that there was a national requirement that local UTC’s were designated by December 2017. The Urgent Care Team was currently undertaking a process (including a demand, affordability and workforce profile) to determine how many UTCs were required across Pennine Lancashire and where these should be best located.

She continued that national guidance directed commissioners to ask whether current Primary Care Services should be co-located with UTCs.

ACTION: It was agreed that the results of the review would be presented EF to a future CBG.

RESOLVED: That the CBG noted the content of the update.

Page 5 of 6

Standing Item 09/17/11 Right Care Update/Quality, Innovation, Productivity and Prevention (QIPP)

Mr Neil Holt presented the current position on Right Care/QIPP.

It was noted that the spend on Gluten Free prescribing had dropped to virtually nothing since the policy was agreed. CBG members were also asked to note how the quarterly percentage reduction in prescribing costs within BwD CCG was far in excess of the national position, with the gap continuing to widen.

The 2018/19 QIPP position was discussed, with a number of schemes already identified to contribute towards the delivery of a circa £5million target. Further work needs to be done to identify additional opportunities to close the gap.

Right Care plans have now been submitted in the three required areas:

• Medicines; • Musculoskeletal; • Respiratory.

RESOLVED: That the CBG noted the content of the update.

For Information

09/17/12 Investments Schedule

The investment scheduled was presented for information.

RESOLVED: That the CBG noted the content of the schedule.

09/17/13 East Lancashire Medicines Management Board Minutes

The minutes of the EL Health Economy Medicines Management Board on 19th July 2017 were presented for information.

RESOLVED: That the CBG noted the content of the minutes.

09/17/14 Any Other Business

No further business was discussed.

09/17/15 Date and Time of Next Meeting

The next meeting was scheduled for Wednesday 11th October at 1 pm in Room Info G10 and G11, Innovation Centre.

The Chair thanked everyone for their attendance and the meeting closed.

Page 6 of 6

NHS Blackburn with Darwen Clinical Commissioning Group NHS East Lancashire Clinical Commissioning Group

PENNINE LANCASHIRE QUALITY COMMITTEE Minutes of the meeting held on 28 June 2017

PRESENT: Michelle Pilling Lay Advisor: Quality and Patient Engagement, ELCCG - Chair Ryan Catlow Compliance and Resilience Manager, ELCCG Dr Stephen Gunn GP Representative, BwDCCG Jackie Hanson Director of Quality and Chief Nurse, ELCCG Dr Nigel Horsfield Lay Member, BwDCCG Dr Geraint Jones Lay Member, BwDCCG Kathryn Lord Head of Quality, Pennine Lancashire CCGs Claire Moir Governance, Assurance and Delivery Manager, BwDCCG Dr Malcolm Ridgway Director of Quality and Performance, BwDCCG Dr Richard Robinson GP Representative, Hyndburn Locality, ELCCG Lisa Rogan Associate Director of Medicines, Research & Clinical Effectiveness, ELCCG Debbie Ross Head of Safeguarding Children, Pennine Lancashire CCGs Dr Zeenat Sykes GP Representative, Rossendale Locality, ELCCG Janet Thomas Associate Director of Quality and Commissioning, BwDCCG

In Attendance: Deryn Ashby Executive Assistant, ELCCG – minutes Simon Bradley Quality and Performance Manager, M&LCSU Yvonne Jackson Specialist Safeguarding Practitioner, Pennine Lancashire CCGs Judith Johnston Head of Clinical Commissioning, ELCCG Elaine Johnstone Service Director, M&LCSU Vanessa Morris Infection Prevention & Control Lead Nurse, Pennine Lancashire CCGs David Rintoul Quality and Performance Manager, M&LCSU

Attended for Specific Items: David Brewin Head of Complaints and PALS, M&LCSU Jason Newman Head of Performance and Delivery, ELCCG Maureen Walsh Complaints Case Manager, M&LCSU Anita Watson Lead Nurse Infection Prevention and Control, LCC Lewis Wilkinson Quality and Performance Support Officer, M&LCSU

REF: RATIFIED ACTION 17.139 Welcome & Chair’s Update

The Chair opened the Pennine Lancashire Quality Committee and welcomed all attendees.

The Chair formally thanked Dr Yasara Naheed, who has stepped away from the committee, thanking her for her support and insight. She advised that Dr James Fleming will be attending future meetings to replace Dr Naheed as Burnley Locality GP Representative.

17.140 Apologies

Apologies were received from: Susan Clarke, Dr James Fleming, Dr Asif Garda, Cathy Gardener, Kirsty Hollis, Dr Gifford Kerr, Caroline Marshall, Sharon Martin, Dr Paul Taylor, Alex Walker, Collette Walsh. Page 1 of 14 Minutes Approved by the Chair: /06/2017

NHS Blackburn with Darwen Clinical Commissioning Group NHS East Lancashire Clinical Commissioning Group

17.141 Declarations of Interest

There were no interests declared by members. The Chair reminded members that they need to declare any declarations in respect of the agenda, and that guidance pertaining to Declarations of Interest had been circulated for information.

The meeting was quorate.

17.142 Minutes of the Meeting Held On 24 May 2017

Some amendments were offered for the meeting held on 26 April 2017. These were:

17.116: Presentation: Stroke Service It was agreed that the minutes should better reflect the lack of confidence from members in regards to the assurance provided to improve stroke performance.

17.136: Any Other Business Cyber-Attack: In the fifth line of the paragraph the sentence should read “…it was also recognised that primary care teams worked hard to keep their systems going with limited IT”.

With the above amendments, the minutes were formally ratified.

The minutes for the meeting held on 26 April 2017 were approved as an accurate reflection of the meeting.

17.143 Action Matrix

17.095: Memory Assessment Service This has been scheduled to return to committee in September 2017.

17.105: BwDCCG Equality and Inclusion Annual Report C Bentley has confirmed that this action has been completed. RATIFIED 17.116.1: Presentation: Stroke Service The plan has been shared with C Walsh. It was confirmed that the actions from the meeting are being taken forward, and that C Walsh has spent time at ELHT walking the Stroke pathway. A Task and Finish Group has been developed to look at the performance and plans for the future. An update has been requested for the committee in August 2017. It was also noted that this issue was raised at the BwDCCG Governing Body meeting.

17.116.2: Presentation: Stroke Service This has been scheduled for the August committee. This action can be closed.

17.122.1: Pennine Lancashire Quality and Performance Report – Month 12 The paper has been included on the agenda for today’s meeting. This action can be closed.

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NHS Blackburn with Darwen Clinical Commissioning Group NHS East Lancashire Clinical Commissioning Group

17.122.2: Pennine Lancashire Quality and Performance Report – Month 12 An update is included within the Quality Report and the agenda item pertaining to Quality Premiums.

17.128: Pennine Lancashire CCGs Safeguarding Quarterly Dashboard Report The GP bulletin has been updated in relation to CSE. This is to be distributed this week. This action can be closed.

17.129: CQC Review of Health Services for Children Looked After and Safeguarding in Lancashire: Action Plan Update This item is to be held in abeyance as there are still discussions ongoing with LCC; D Ross to contact The Chair if the Chairs Letter is required.

17.130: ELCCG Safeguarding Self-Assessment Accountability and Assurance, including Section 11 Requirements This list has been circulated within the CCG for managers to action.

17.132: 2016/17 Quality Accounts These have been scheduled for the July committee. This action can be closed.

17.144 Matters Arising

There were no matters arising.

17.145 Presentation: Complaints Presentation

D Brewin and M Walsh, CSU attended to provide an update around the complaints process and offer some highlights from the annual reports for both CCGs.

In East Lancashire, there were a total of 86 complaints and 33 MP letters received during 2016/17. Blackburn with Darwen received 32 complaints and 12 MP letters during the same period.

EL responded to all correspondence within 26 weeks, and BwD had 1 breach in this area; it was confirmedRATIFIED that this occurred following liaison with the complainant who requested that the complaint remained open whilst as IFR request was processed.

Both CCGs had breaches of the 40 working days indicator; EL had 17 breaches and BwD had 10 breaches. These were in relation to the level of investigation, and K Lord assured members that the team work hard to communicate with the family and ensure they are aware when there is a delay to an outcome. M Walsh advised that all of the 40- day breaches were in relation to CHC, as there were a lot of cases where back-dated payments were requested or where there were several aspects within the complaint that needed to be investigated.

D Ross queried whether this data captures any under-18 complaints. D Brewin advised that it is often the responsible adult replying on behalf of the child, but that he would discuss this in more depth outside of the meeting.

ACTION: D Brewin and D Ross to liaise and discuss the under-18 complainants Page 3 of 14 Minutes Approved by the Chair: /06/2017

NHS Blackburn with Darwen Clinical Commissioning Group NHS East Lancashire Clinical Commissioning Group

For ELCCG there were currently 9 cases that were referred to the Ombudsman during 2016/17 for review. Of these: 2 decision outcomes were not upheld; 3 cases were returned for local resolution; cases are still awaiting a decision on whether the Ombudsman will investigate; 1 case is awaiting a review decision.

It was noted that ELCCG received 183 PALS enquiries during 2016/17 and BwDCCG received 71 PALS enquiries. These were broken down into categories. It was noted that General Practice was the biggest enquiry through PALS for both CCGs.

D Brewin advised that the commissioning decisions regarding gluten free prescribing and facet joint injections generated a large number of enquiries and complaints, but it helped that the CCGs had participated in public engagement and communication before finalising the decisions. He noted that the complaints team can support any with any future plans for changes to services across both CCGs.

It was noted that the complaints service has evolved over the last 2 years and is more responsive. D Brewin added that there will be a change to the way that complaints are reported for both CCGs, and that in 2017/18 from Q1 there will be a joint report completed.

J Johnston noted that there had been a significant number of complaints regarding the CHC process, and there was discussion about the impact and lessons learned from these issues.

ACTION: J Johnston to speak with H Gorton, CSU, about triangulating the lessons learned from complaints and how these are applied

The Chair thanked D Brewin and M Walsh for their update.

D Brewin and M Walsh exited the meeting.

17.146 CONFIDENTIAL DISCUSSIONS – Provider Updates

K Lord presented this item; the paper was tabled for reference. The content of this item is for committee membersRATIFIED and attendees only, and is not for wider distribution.

The confidential minutes of this part of the meeting will be circulated under separate cover.

Members received and acknowledged this report.

VM entered the meeting.

17.147 Primary Care Quality Update

C Wright provided an update in relation to Primary Care. It was noted that this item had been marked confidential, but that this is not necessary. Future meetings will include this update as part of the main agenda items. Members were advised that a monthly Primary Care Quality Group has been established to review issues across both CCGs. Page 4 of 14 Minutes Approved by the Chair: /06/2017

NHS Blackburn with Darwen Clinical Commissioning Group NHS East Lancashire Clinical Commissioning Group

Across the Pennine Lancashire footprint, there are 17 practices that have been identified as delivering less than the expected level of quality. The majority of those practices identified are already working with the CCG to improve their performance, and the remaining practices will be brought into Enhanced Surveillance.

Following a CQC inspection, many of the practices who received a ‘Requires Improvement’ recommendation in just one category, and therefore ‘Good’ overall, have now been re-assessed and received good in all domains. Some are still going through this process. There are still 8 practices due to undergo a first inspection, 4 in each CCG, and all will be carried out before September 2017. There are 3 practices currently rated as ‘Inadequate’ which the CCG and RCGP are supporting.

Both CCGs are working to ensure a Pennine Lancashire approach to Quality Assurance for Primary Care.

Primary Care Audit Following the internal audit report on Primary Care Quality at BwDCCG in November 2016, the team have been working hard to ensure that all 6 recommendations were addressed. A meeting is expected with Internal Audit team in July 2017 to provide the assurance required to satisfy the audit teams concerns.

Members received and acknowledged this report.

17.148 Pennine Lancashire Quality and Performance Report – Month 01

S Bradley and D Rintoul attended to present the key points from the Pennine Lancashire Quality and Performance Report for Month 01. Full details are available within the report.

A&E There was underperformance against the 4-hour A&E target in April 2017 for both CCGs.

RTT Incomplete There was underperformanceRATIFIED against the RTT incomplete standard in April 2017 for BwDCCG. Performance at Lancashire Teaching Hospitals is having the most significant impact on the position for both CCGs. This has been shared with the Contracts Team so that they can ascertain whether any harm has come to patients awaiting procedures.

Cancer 2-Week Target (Breast) The target was not met for BwDCCG and ELCCG in April 2017. There was discussion about this as it was highlighted that there were a number of patients who repeatedly failed to attend for their initial scan. This is being further explored by the Cancer Tactical Group. IT was queried whether these were for patients undergoing 2-week rule or any patients awaiting a breast exam, as the latter should be scanned within 2-weeks as well; it was confirmed that this specifically related to patients with suspected cancer referred

Mixed Sex Accommodation BwDCCG had a mixed sex accommodation breach in April 2017, attributed to Bolton Foundation Trust. A contract query has been raised with Bolton CCG, and a further update will be provided within the next report. Page 5 of 14 Minutes Approved by the Chair: /06/2017

NHS Blackburn with Darwen Clinical Commissioning Group NHS East Lancashire Clinical Commissioning Group

E-Coli In April 2017 there were 33 E-Coli cases identified within the population of East Lancashire, and 15 cases in Blackburn with Darwen.

Quality Premium: 2016/17 Baseline data is currently being collated for the 2017/18 Quality Premium Measures.

Out of Area Treatments There was an average of 23 Out of Area Treatments in April 2017 against a target of 0 and a tolerance threshold of 15. There has been an increase in the number of out of area PICU placements in April and May 2017. A trajectory to further reduce the numbers of OATs throughout 2017/18 is in development.

52 week There was 1 patient waiting over 52-weeks in April 2017. This patient us under the speciality of Maxillofacial Surgery, which is commissioning by Spec Comm; this has been included for reference.

LCFT

MAS Seen Within 6-weeks The target was not met for either CCG, nor at Trust level for April 2017.

Members acknowledged the report

VM exited the meeting. RATIFIED

17.149 Pennine Lancashire Serious Incident Review Group Recommendations

L Wilkinson presented the paper to the committee.

ELCCG In May 2017, 9 reports were reviewed. Of these, 5 were approved for closure, 4 were rejected and returned to the provider, and 1 report required an internal CCG action before closure could be approved.

BwDCCG In May 2017, 14 reports were reviewed. Of these, 10 were approved for closure and 4 were rejected; of these, 1 report was returned to the provider and 3 reports required an internal CCG action before closure could be approved.

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NHS Blackburn with Darwen Clinical Commissioning Group NHS East Lancashire Clinical Commissioning Group

During this period, a total of 13 extension requests were submitted by ELHT; these were due to the operational pressures within ELHT. The CCG will continue to monitor the situation.

There have been 4 extension requests submitted by LCFT in May 2017. A high number of extension requests were received after the due date, and the timely submission of extension requests has been reinforced with LCFT; the situation will continue to be monitored.

In May 2017, 1 Rapid Review was outstanding from ELHT and 2 reports were received outside the 72-hour timeframe for LCFT. The requirement for timely submission of rapid reviews under the Serious Incident Framework has been reinforced with both ELHT and LCFT.

ELCCG has 75 StEIS incidents open at present and BwDCCG has 44 incidents open at present.

Dr M Ridgway raised a concern within the appendix where an incident had been described in brief, and whether this was appropriate. It was agreed that the level of detail would be reviewed.

The Committee formerly received the report for information.

L Wilkinson exited the meeting.

17.150 2016/17 CQUIN Reconciliation Q4 for EL and BwD CCG Hosted Contracts

2016/2017 CQUIN Reconciliation has taken place for Q4 for ELCCG and BwDCCG hosted contracts. S Bradley presented the outstanding Q4 milestones.

BMI Evidence has been submitted by BMI for the remaining CQUIN indicator. Therefore payment can be released; BMI achieved all 3 CAUIN indicators.

ELHT Evidence has been submittedRATIFIED by ELHT for the Sepsis indicator, and this has been reconciled. The data for the Reduction in Antibiotic Consumption indicator has not yet been published by NHS England, therefore this cannot be reconciled at this time. Payment can therefore now be released for the Sepsis indicator, in line with the 8 indicators already achieved.

LCFT Evidence has been submitted by LCFT for the 3 unreconciled CQUIN indicators. Therefore payment can be released for the outstanding CQUIN indicators; LCFT have achieved all their CQUIN indicators.

MCFT National data is required for 1 of the indicators; therefore this has not yet been reconciled.

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NHS Blackburn with Darwen Clinical Commissioning Group NHS East Lancashire Clinical Commissioning Group

IAPT Consortium Evidence has been submitted for the unreconciled schemes, with full achievement of all milestones.

About Health Evidence has been submitted by about Health for their outstanding CQUIN indicators. These have been reconciled with full achievement of the milestones.

Members were asked to support the recommendations relating to release the newly reconciled Quarter 4 monies.

Members acknowledged the report and approved the recommendations for payment of CQUIN monies as outlined in the report

17.151 Pennine Lancashire IPA / CHC Update

J Johnston presented this report to committee to update on the progress and current risks in relation to Individual Patient Activity for the Pennine Lancashire CCGs. Full details are available within the report.

Continuing Health Care There were a number of improvement workshops held at the beginning of May 2017. Nationally, the Department of Health is undertaking a review of the national framework and it is understood that a revised framework will be published by the end of 2017 with implementation from 1 April 2018.

Previously Unassessed Period of Care (PuPOC) The CSU is continuing to manage the process by responding to the disputes against decisions received. As at 30 April 2017 34 disputes have been received relating to Blackburn with Darwen cases of which 16 remain open. 66 disputes have been received relating to East Lancashire cases of which 42 remain open.

Quality Premium There is a national measure relating to CHC included in the Quality Premium for 2017- 2019: RATIFIED  Part a) worth 50%: more than 80% of cases with a positive NHS CHC Checklist, the NHS CHC eligibility decision is made by the CCG within 28 days from receipt of the Checklist (or other notification of potential eligibility).  Part b) worth 50%: less than 15% of all full NHS CHC assessments take place in an acute hospital setting.

CHC Choice and Equity Policy The CCGs commenced implementation of the CHC Choice and Equity Policy from 1st April 2017. The policy has been applied to one East Lancashire case to date. Learning from the case will be used in the development of standard operating procedures.

Transforming Care There is no further movement regarding the original Winterbourne cohort from the last update provided; Blackburn with Darwen has four CCG responsible patients remaining in hospital and East Lancashire CCG has three.

Page 8 of 14 Minutes Approved by the Chair: /06/2017

NHS Blackburn with Darwen Clinical Commissioning Group NHS East Lancashire Clinical Commissioning Group

Court of Protection East Lancashire CCG is continuing to receive section 21a challenges. The CSU is securing resource to provide timely response. This has also required engagement of legal advice and the instruction of a barrister in one case. East Lancashire cases are routinely discussed in the Complex Case Advisory Group.

There was a query around the discharge dates indicated for patients at Mersey Care NHS Foundation Trust, noting that forensic patients are detained under custody. J Johnston assured members that the professionals involved are aware of the patients that can be discharged to the community, and that the discharge dates would not be agreed until the legalities have been explored. There is 1 CCG-commissioned package of care at the Whalley site, but this has been referred to NHS England as no immediate solution can be identified. There was discussion about problems associated with discharges, and J Johnston informed members that a complaint had been received from neighbours of a complex patient in the community.

There was discussion regarding Individual Funding Requests, and it was observed that these should be referred to commissioning managers and be reviewed through sustainability and commissioning groups to help identify when there are service development opportunities.

J Johnston was thanked for her update.

Members acknowledged the report and the progress in this area.

17.152 Lancashire IPC Update

A Watson attended to present the Lancashire County Council Infection Prevention Annual Report for 2016/17.

This report details the year-end position for HCAIs that undergo mandatory surveillance, an update on anti-microbial prescribing, including any outbreaks and support provided to GPs and Care Homes. The delivery programme for 2017/18 is also included.

MRSA RATIFIED During 2016/17 there were 16 cases of MRSA across Lancashire, and 0 cases in Blackburn with Darwen. This is a reduction on the number of cases in 2015/16 which is an improvement. The report detailed the results of the Post Infection Review (PIR) outcomes for each case.

Clostridium Difficile During 2016/17 there were 306 cases of CDI reported across all 7 Lancashire CCGs; however, this is an improvement on the 2015/16 report. All CCGs met their CDI objective, with the exception of ELCCG. All Local Acute Trusts met their objectives for 2015/16, with the exception of ELHT. It was noted that the target is not based on population but on previous success.

E-Coli During 2016/17 there were 1073 cases of E-Coli reported across Lancashire (898) and Blackburn with Darwen (175). ELCCG had the highest number of E-Coli cases, but when this is converted to the number of cases per hundred thousand, Blackburn with Page 9 of 14 Minutes Approved by the Chair: /06/2017

NHS Blackburn with Darwen Clinical Commissioning Group NHS East Lancashire Clinical Commissioning Group

Darwen are an outlier. From April 2017 cases will be categorised as there is a Quality Premium associated with a 10% reduction in cases.

AMR A draft Anti-Microbial Resistance Strategy and Action Plan have been developed by the Infection Prevention Team at LCC, and are currently working with each CCG to develop and support the implementation of their localised action plan.

There was a brief discussion regarding terminology. It was noted that the term “frequent flyer” was not appropriate, and that this should be changed to “regular attender”. In addition, Dr G Jones noted that C-Diff is a common organism and not a disease.

A Watson was thanked for her update

Members acknowledged the report and the progress made in this area.

17.153 Pennine Lancashire Risk Management Update

Blackburn with Darwen CCG For BwDCCG there are 10 operational risks and 7 strategic risks held on the register. One risk was recommended for closure, but on discussion it was agreed to retain this on the register. There were no new risks added, and no risks for closure during the reporting period.

East Lancashire CCG The total number of open risks on the register is 17. All of the 9 extreme risks on the register have been reviewed and action plans updated where risk owners were present.

Full details of the risks are available within the report and on the Corporate Risk Registers

ACTION: Risk Registers to be updated to reflect whether the target risk would be met, and to ensure that there are no duplications in the report to committee RATIFIED Members acknowledged the report and the updates to the Risk Register, and approved the recommendations.

17.154 Quality Premium Performance 2016/17 and 2017/18

This report provides Quality Committee members with a review on the Pennine Lancs CCG performance against Quality Premium measures for 16/17 and a highlight of those for 17/18.

The maximum Quality Premium payment for a CCG equates to a Combined total of £2,750k. - Blackburn with Darwen CCG: £850k - East Lancashire CCG: £1,900k

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NHS Blackburn with Darwen Clinical Commissioning Group NHS East Lancashire Clinical Commissioning Group

Blackburn with Darwen CCG did not achieve financial balance, therefore will not receive Quality Premium payment despite having met a number of threshold measures. ELCCG received £142,500 of the available funding.

The Chair highlighted that both CCGs were being disadvantaged through the Quality Premium by continued poor ambulance performance, despite providing additional investment. It was suggested that this is further discussed at the joint Exec Meeting in the first instance as a substantial amount of money is being lost to both organisations by not performing against the Quality Premium targets, and that this would also be reflected in poor patient experience.

ACTION: Discussions to be held at the joint Exec Meeting regarding the poor performance against the Quality Premium targets in 2016/17 and how this correlates against loss of income and patient experience.

17.155 2016/17 Quality Accounts

This report was presented to inform the Committee of the process implemented for publication and sign off of the 2016/17 Quality Accounts for EL and BwDCCG hosted contracts. This paper presented the Quality Accounts for the organisations that had not submitted them in time for the previous committee. These were: Mersey Care NHS Foundation Trust (July 2016 – April 2017), Calderstones Partnership NHS Foundation Trust (April – June 2016) and BMI Healthcare.

Members acknowledged the report

17.156 Policy for Relations with the Pharmaceutical Industry and Other Commercial Organisations

Dr L Rogan presented this policy to members for information.

NHS organisations and staff are encouraged to consider the opportunities for joint working with the pharmaceutical industry where the benefits this could bring to patient care and the difference it can make to their health and well-being are clearly advantageous. The policyRATIFIED provides a framework to assist the organisation and NHS staff in determining when a joint working agreement or commercial sponsorship is appropriate. Specifically, it aims to assist the organisation and NHS staff in maintaining appropriate ethical standards in the conduct of NHS business.

It was noted that this policy would be consistent across Pennine Lancashire, and provide assurance about the transparency of the interactions with the pharmaceutical industry. This policy has been well received by practice nurses. The Chair asked whether Research and Development would be covered by this policy; Dr L Rogan confirmed that this is covered through the Research Policy.

ACTION: Dr L Rogan to share the contact details of Dovetail with ELHT

Members acknowledged the policy.

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NHS Blackburn with Darwen Clinical Commissioning Group NHS East Lancashire Clinical Commissioning Group

17.157 Annual Performance Report for the Prescribing and Medicines Optimisation Work Programme for 2016/17

Dr L Rogan presented this report to members. This is already discussed at the Sustainability Committee given the number of financial elements involved, and is presented at this committee for information.

This report provides a comprehensive review of the performance and outcomes delivered through the Prescribing and Medicines Optimisation Work Programme 2016- 17. The report demonstrates delivery of £2,016,332 of efficiency savings.

Dr L Rogan advised that the East Lancashire Medicines Management Board received 1.6m visits from across the globe. The Chair queried how many patients are aware of this website, and Dr L Rogan assured her that this has recently started to be publicised to them.

Dr S Gunn exited the meeting

The plan for 2017/18 will be a joint strategy for both organisations. Dr M Ridgway commended Dr L Rogan and J Kenyon for their effortd. He noted that they are each leading on different projects across Pennine Lancashire and are sharing the strategic objectives. Dr G Jones concurred, noting that this was a good report. J Hanson thanked the team for their hard work over the past 12-months.

The Chair advised that she had recently attended a Learning Disability Group where they flagged a number of issues around managing medicines; she queried the work around this. Dr L Rogan advised that additional phone lines have been installed in some practices to help them manage this system. The feedback received is that this has saved the GP work. It was noted that there are exceptions for some patients, but these are supported through trusted community pharmacists.

ACTION: Dr L Rogan to liaise with Dr R Sharma regarding repeat prescribing for community LD patients

Dr L Rogan was thanked along with her team for the quality of the work that had taken place in 2016/17. RATIFIED Members acknowledged the report.

17.158 Research Update

Dr L Rogan provided a verbal update relating to Research.

She noted that this is an area that requires greater infrastructure as the CCGs receive a number of requests for excess treatment costs for clinical trials. The Research Policy has previously been through committee and approved, but she now proposed a Research Panel, accountable to this committee, where research projects can be reviewed when they are not directly linked to Medicines Management. The outcomes can then be presented to members for approval. Dr G Jones queried whether a Pan- Lancashire Research Committee was already in existence. After debate, it was agreed that this committee was no longer held.

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Dr L Rogan advised that she had received a request in relation to Bowel Screening and requested permission for members to seek a Chair’s Action from The Chair to approve this paper. J Hanson assured members that she had discussed this in-depth with Dr L Rogan and would support this, but that robust governance is needed for future requests. J Thomas added that this case has also been discussed at BwD Execs and approved.

ACTION: Dr L Rogan to share the Bowel Screening paper with The Chair; this will then be supported via a Chair’s Action and returned to the next meeting for noting

17.159 Quality Contract Meeting Minutes May 2017: BMI, ELHT, LCFT, MCFT

These were distributed prior to today’s meeting for information. No comments were raised.

Members acknowledged the minutes.

17.160 ELCCG Risk Management and Information Governance Minutes: May 2017

These were distributed prior to today’s meeting for information. No comments were raised.

Members acknowledged the minutes.

17.161 Cancer Tactical Meeting Minutes: May 2017

These were distributed prior to today’s meeting for information. No comments were raised.

Members acknowledged the minutes.

RATIFIED 17.162 Any Other Business

Fire Safety of NHS Premises Members were advised that an update would be provided at the next meeting in relation to the fire safety of NHS buildings and estates. NHS Property Services have been asked for an update.

17.163 Items for the Risk Register

There were no new items for inclusion on the Risk Register for either CCG.

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17.164 Date & Time of Next Meeting

The next meeting has been scheduled for Wednesday 26 July 2017 in Meeting Room 1, Walshaw House.

The deadline for papers is 5pm on Monday 17 July 2017.

The meeting closed at 16:05

RATIFIED

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PENNINE LANCASHIRE QUALITY COMMITTEE Minutes of the meeting held on 26 July 2017

PRESENT: Michelle Pilling Lay Advisor: Quality and Patient Engagement, ELCCG – Chair Ryan Catlow Compliance and Resilience Manager, ELCCG Sue Clarke Head of Safeguarding, BwDCCG Jackie Hanson Director of Quality and Chief Nurse ELCCG Kirsty Hollis Chief Finance Officer, ELCCG Dr Nigel Horsfield Lay Member, BwDCCG Dr Geraint Jones Lay Member, BwDCCG Dr Malcolm Ridgway Director of Quality and Performance, BwDCCG Dr Lisa Rogan Associate Director of Medicines, Research & Clinical Effectiveness, ELCCG Dr Zeenat Sykes GP Representative, Rossendale Locality, ELCC Paul Taylor Secondary Care Consultant, ELCCG Janet Thomas Associate Director of Quality and Commissioning, BwDCCG

In Attendance: Cath Lawless Primary Care Support Assistant, Blackburn with Darwen – minutes Simon Bradley Quality and Performance Manager, M&LCSU Michael Connell Quality and performance Specialist M&LCSU Judith Johnston Head of Clinical Commissioning, ELCCG Vanessa Morris Infection Prevention & Control Lead Nurse, Pennine Lancashire CCGs Caroline Marshall Locality Lead – Quality & Performance, M&LCSU Alex Walker Performance Director, Urgent Care, BwDCCG & ELCCG

Attended for Specific Items: Anne Allison Associate Director of Quality Improvement & Experience, LCFT Joanne Bull Head of Nursing for Quality & Compliance Angela Dunne Cancer Project Lead Jane McNicholas Lead Cancer Clinician ELHT Paul Mortimer Associate Director of Clinical Services, BMI Healthcare Juliette Mottram Cancer Manager ELHT Jenny Mulloy Equality & Inclusion Business Partner David Tansley RATIFIEDDirector of Quality and Safety at East Lancashire Hospitals NHS Trust Sue Walsh Associate Director of Clinical Services, BMI Healthcare Lewis Wilkinson Quality & Performance Support Officer

REF: ACTION 17.165 Welcome & Chair’s Update: The Chair welcomed attendees to the Pennine Lancashire Quality Committee and after introductions gave a short briefing with regards to the content of the agenda and general housekeeping. The Chair advised the Committee that the presentations from providers would be presented at the start of the meeting and following this normal business would resume.

17.166 Apologies: Dr Stephen Gunn, Kathryn Lord, Clair Moir, Elaine Johnstone, Sharon Martin, Dr James Fleming, Mrs Julie Kenyon, Dr Richard Robinson and David Rintoul

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17.167 Declarations of Interest: The Chair asked members if they would like to declare any Conflicts of Interest (CoI) relating to items on the agenda. The Chair reminded those present that if, during the course of discussion a CoI became apparent, it should be declared at that point.

CONCLUSION: That there were no declarations of interest noted.

The meeting was confirmed as quorate.

17.168 Provider Quality Accounts:

BMI Healthcare Presentation Sue Walsh and Paul Mortimer attended the meeting to present the quality accounts for

BMI Healthcare and drew committee members’ attention to information relating to

performance at BMI Beardwood, BMI Gisburn and BMI Lancaster.

CQC Inspections It was noted that following the CQC inspections earlier in 2016 BMI Beardwood was confirmed as good, BMI Gisburn was confirmed as good and BMI Lancaster was confirmed as requires improvement. P Mortimer advised members that a large number of the actions and recommendations from the CQC visits have now been completed with a few remaining around corporate policies for BMI Lancaster.

Infection Prevention and Control S Walsh advised that across the cluster they share an Infection Control Nurse who ensures standardised processes are carried out across all three sites.

Risk Register/Reporting Incidents S Walsh advised of the new tool RiskMan which BMI Healthcare use to record any incidents and never events. It was noted that to date there had been no new Never Events reported.

VTE

There is now a specific risk assessment that consultants have to carry out before surgery so that patients are aware of the risks involved, both before and after surgery. RATIFIED Re-admissions P Mortimer advised in regard to re-admissions of patients the three sites look for any themes and trends per 100 discharges to help identify any lessons learned. It was noted that any learning in regard to re-admissions is fed back to the staff.

Patient Experience / Complaints Management P Mortimer advised that three sites now do a Closing the Loop Report and use the

E-Cascade System which informs all sites of reported incidents and the learning from them. It was noted that the procedure for this is via email to staff who read receipt that they have received the reports, to which compliance is monitored.

Questions and answers followed with regards to a patient who had developed complications at home following a procedure and had died. P Mortimer provided the Committee with a brief history of the patient’s journey and gave assurance that, following the patient’s death, a change in practice has been carried out to which Page 2 of 10 Minutes amended 08.09.17 Minutes Approved by the Chair: /09/2017

NHS Blackburn with Darwen Clinical Commissioning Group NHS East Lancashire Clinical Commissioning Group learning outcomes have been shared across all sites. Dr G Jones asked whether BMI carry out routine mortality reviews. P Mortimer said he would take this back for discussion.

ACTION: P Mortimer to check whether mortality reviews are carried out. PM

The Chair thanked P Mortimer and S Walsh for their update and commented that the approach to shared learning across all sites is to BMI’s credit.

CONCLUSION: That the Committee noted the presentation by BMI Healthcare.

LCFT Approach to Quality Improvement Anne Allison outlined Lancashire Care Foundation’s Trust vision to provide high quality care in the right place, at the right time, every time and advised of the quality commitment for care that is safe, effective and caring, responsive and well-led. A Allison outlined LCFT’s quality account and advised of their approach in 16/17 which was to meet all requirements, for it to be public friendly and give an accessible overview of the quality of care provided by LCFT, she also acknowledged that they do not get everything right all of the time. A Allison advised of the criteria for LCFT’s Always Events, which is a national initiative, and should be evidence based, be measurable, and affordable. She outlined some of the initiatives LCFT have carried out following the areas of improvement identified by the CQC during their inspection in September 2016. It was noted that LCFT regularly hold Always Event Programmes, looking at complaints, feedback and national survey data, and advised how the Trust deal with them. It was noted that LCFT have also implemented an initiative to install secure post boxes where people can put their comments, complaints and feedback. It was noted that LCFT’s quality plan has 16 priorities and that their overarching aspirational aim is supported by the detailed year-on-year plans, which incorporates the 13 areas of improvement identified by the CQC. It was also noted that LCFT are now using Life QI to capture their data to help drive continuous improvement. The Chair queried whether out of area treatments would be a focus, and A Allison confirmed it would be.

CONCLUSION: After questions and answers the Chair thanked A Allison for her presentation and commented that LCFT could be commended for the number of initiatives undertaken. RATIFIED David Tansley joined the meeting

Mersey Care Foundation Trust Quality Account Report 16/17 Joanne Bull asked the Committee to note that her presentation would focus on the Mersey Care Quality account from 01 June 2016. Joanne Bull outlined Mersey Care Trust’s Strategic direction which is to strive for perfect care, and a fair culture. It was noted that there are 3 priority areas which the Trust have focussed on for 2017/18 and advised of the progress to date on these areas. 1. No Force First: This has been achieved 2. Towards Zero Suicide: This has been partially achieved. 3. Improvements in Physical Health Pathways: This has been partially achieved.

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and not just at the point of failure but starting at what went well. With regards to the Mersey Care Specialist Learning Disability Services (Whalley) Joanne Bull advised that the Trust has recently been given a rating of outstanding following the CQC inspection. J Hanson commended Mersey Care and the teams involved, acknowledging the hard

work has been carried out at the Calderstones site over the last three years since the previous organisation was put in to special measures.

CONCLUSION: The Chair thanked J Bull for her presentation.

East Lancashire Hospitals Trust Approach to Quality Improvement: David Tansley advised that ELHT’s quality account is now published and provided the Committee with highlights of the quality account, commenting that the Trust are committed to delivering safe, personal and effective care. It was noted that there has been a significant level of investment available with regards to time training and resource, and advised that the Trust now have a quality improvement team who support the delivery. D Tansley advised of the successes to date from the quality account for 2016/17 and confirmed the 3 quality improvement priorities which focus upon the safety of systems and the culture of safety, both across the organisation as a whole and in specific teams. Further work is being undertaken to increase compliance with hand hygiene and infection prevention guidance. In addition D Tansley asked the Committee to note the Trust has also performed well against the pledges made to ‘sign up to safety’.

CONCLUSION: After questions and answers from Committee members the Chair thanked D Tansley for his update and commented that she found the progress made very encouraging.

Dr M Ridgway left the room

17.169 Minutes of the Meeting Held On 28 June 2017

No amendments were offered for the minutes of the meeting held on 28 June 2017.

The minutes for the meeting held on 28 June 2017 were approved as an accurate reflection of the meeting. RATIFIED

17.169 Chairs Action: Ratification: Approval of Bowel Screening Research

Members ratified the Chairs Action in relation to the Bowel Screening Research. Other actions were updated on the Action Matrix.

17.170 Matters Arising:

There were no matters arising

V Morris joined the meeting

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17.171 Confidential Discussions: Provider Updates

C Marshall presented this item: Confidential items were shared with Committee members. Papers were tabled for reference. The content of this item is for Committee members and attendees only and is not for wider distribution.

17.172 Cancer Update: GP making a Cancer Referral 14 Day Rule

J McNicholas and J Mottram, ELHT, and A Dunne, CCG Cancer Team, provided an update following the April 2017 meeting and requested approval from Committee members to make an adjustment to the cancer referral form on the point of a GP making a cancer referral (14 day rule), for patients who go on holiday. It was noted that the amendments and the referral form have been shared with the Head of Performance at Christie’s Hospital, Manchester, who have discussed their procedures. J Mottram outlined the proposal which is that the GP will still make a referral in the normal way and will write the patient’s holiday dates on the two-week proforma. She advised that the proforma is now updated to include a mandatory asking if the patient is going on holiday; the GP then sends the referral to the booking clerk and the referral is placed on the patient administration system with the appointment made for when the patient returns from their holiday. If the referral breaches they are allowed to make a waiting time adjustment for that period of holiday only, and not for the full 14-days. It was advised that this has been raised at the Cancer Steering Group and was confirmed as the approach undertaken by Christie’s Hospital, Manchester. However, J Mottram advised that she had also shared the proposal with the National Team for approval as the National Guidance states that an adjustment cannot be made. It was confirmed that if the National Team do say no, this would not go ahead.

ACTION: Further guidance to be sought from the National Team. Cancer Team CONCLUSION: After questions and answers the Committee agreed to the adjustment following further guidance and approval be given from the National Team; the Policy would also have to go to the respective Governing Bodies for final approval.

A Walker and L Wilkinson joined the meeting RATIFIED

17.173 Home of Choice Policy

A Walker asked the Committee to note the contents of the report and supporting appendices. He advised Committee members of the process of supporting patient’s choice, which is to avoid long hospital stays, and advised that nationally home of choice has been one of the reasons why patients have a delayed transfer of care which he advised locally equates to 17% of delays over the last 2 years. It was noted that the Home of Choice policy has been developed across Lancashire and South Cumbria and is in line with the National Policy and also the Urgent and Emergency Care Delivery Plan by NHS England. It was confirmed that all key staff are aware of the policy and that information materials, including factsheets, letters and easy to read patient leaflets and information packs, have been developed to support patients on admission and on discharge and explain what they can expect to happen and what they need to do. A Walker advised members that the Policy has also gone through all relevant Page 5 of 10 Minutes amended 08.09.17 Minutes Approved by the Chair: /09/2017

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Governance Boards. Comments were received from Committee members around some of the wording in the letters, and A Walker advised that this would be amended before being shared. With the agreed amendments, A Walker asked the Committee to approve the Policy and support the implementation of the Policy in East Lancashire. J Johnston asked if there are plans for the letters for patients to be in other languages, and A Walker agreed to take the query back. The Chair asked that information around admissions, discharges and re-admissions be included in future Quality & Performance Reports.

ACTION: A Walker to take back whether there are plans for the letters to AW be available in other languages.

ACTION: S Bradley to include information around admissions, discharges and re-admissions into the Quality & Performance Report.

CONCLUSION: After questions and answers from Committee members the Committee agreed to support the implementation of the Policy after revision of the letters.

17.174 Pennine Lancashire Quality and Performance Report Month 2

S Bradley and M Connell jointly presented the Month 02 Quality and Performance Report produced by the Lancashire and Staffordshire Commissioning Support Unit and drew Committee members to key pieces of information.

ELHT

A & E There was underperformance against the 4 hour A & E target with performance in May 2017 at 84.39% (ELHT)

Ambulance Calls At BwD CCG level in May 2017 there has been underperformance against all Reds at 91.69% against a target of 95%. Red 2 at 65.96% against a target of 75%. In EL CCG level in May 2017 thereRATIFIED has been underperformance against all three ambulance call targets. All Reds 86.29% against a target of 95%, Red 1 59.87% against a target of 75%m, and Red 2 58.81% against a target of 75%.

Referral To Treatment There was underperformance against the RTT incomplete standard for BwDCCG with performance at 91.61% in May 2017.

Diagnostics Waits The diagnostic waiting time target of 1% of patients waiting 6 weeks or more for a diagnostic test was not met in May 2017 with a rate of 1.20% for EL CCG.

Cancer: Breast Symptoms The 2 week target was not met in May 2017 for BwDCCG with performance at 92.16% against a target of 93%. Year to date the target is not being met with performance at 90.22%. It was noted that there were 4 breaches, 3 were due to patient cancellations to Page 6 of 10 Minutes amended 08.09.17 Minutes Approved by the Chair: /09/2017

NHS Blackburn with Darwen Clinical Commissioning Group NHS East Lancashire Clinical Commissioning Group which Simon Bradley advised that the new information leaflet for patients should start to address this area of concern.

Cancer Patients receiving First definitive treatment The 62-day target was not met at BwD in May 2017, with performance at 84.62% against a target of 85%. Year to date the target is being met at 92.45%.

The Chair drew the Committee to page 10 of the report to which she commented there were a number of initiatives that the ambulance service had introduced in 2016/17 and asked for an update on the impact on performance.

ACTION: S Bradley to provide information around the NWAS initiatives in the SB next Quality & Performance Report.

Healthcare Associated Infections: (HCAI) V Morris asked the Committee to note that there were 2 case of MRSI BSI for the population of EL. Year to date there have been 2 cases reported. In May 2017 there were 10 cases of Clostridium Difficile Infection (CDI) identified within the ELCCG population. In BwD there were 4 cases of Clostridium Difficile Infection (CDI). It was noted that lessons learned from this relate to antibiotic prescribing, but emphasised it is very difficult to make a judgment without reviewing the patient. The CCG’s across Pennine Lancashire are currently carrying out a deep dive around 20 cases of E-Coli for each CCG following NHS England publishing the E-Coli BSI Quality Premium Target for 2017/18.

LCFT

CPA 7 Day Follow Up The target for 95% of patients on a care programme approach (CPA) to be followed up within 7 days of discharge from a psychiatric inpatient care was not met for BwD in May 2017 with performance at 94.74% (2 patients).

IAPT Prevalence target of 1.25% for LCFT was not met for EL in May 2017 with performance at 1.13% and with year to date position of 2.13% against a trajectory of 2.5%. It was noted that the Trust areRATIFIED also behind trajectory with year to date performance at 2.42% against a trajectory of 2.50%.

MAS The target of 70% of patients to be seen by the service within 6 weeks was not met for both CCG’s.in May 2017 at 18.9% and 37.5% respectively. The year to date positions stands at 18.00% and 30.45%.

Out of Area Placements At Trust level there was an average of 25.52 Out of Area Placements (OAPs) in May 2017 against a trajectory range of 12 to 26, a target of 0, and a financial tolerance threshold of 15.

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The Chair drew Committee members to page 48 of the report relating to the 111 service which described a case where a patient had reportedly died, but on arrival it was clear he had not. She requested an up-to-date report on the planned changes for the 111 service.

ACTION: S Bradley to provide an update on the 111 service to the September SB meeting.

CONCLUSION: That the Committee noted the contents of Pennine Lancashire Quality and Performance Report Month 2.

J Mulloy joined the meeting and V Morris exited the meeting

17.175 Serious Incident Report Group Recommendation

L Wilkinson asked the Committee to note the contents of the report which is in line with the EL CCG Serious Incident Review Group (SIRG) and the BwD SIRG and drew Committee members to key items of information.

The Chair raised a query around how the Committee receives assurance that lessons are being learnt from the incidents. C Marshall provided assurance that they have introduced a fishbone diagram into the SIRG meetings which does captures all themes, trends and lessons learned and from this any areas that keep coming up can be identified. Dr P Taylor drew Committee members to page 4 of the document, 2016/317984 on the recommendations, and advised that it currently read ‘Hb of 74’ but it should read ‘Hb of 7.4’.

ACTION: L Wilkinson to amend the report. LW

CONCLUSION: That the Committee noted the contents of the report.

17.176 Pennine Lancashire Risk Management Update

R Catlow asked Committee members to note the content of the combined Risk Management Report forRATIFIED BwD and EL CCGs and outlined the purpose for recording, monitoring and reviewing the management of risks. It was noted that there are six risks for Pennine Lancashire:  95% A & E Emergency 4 Hour Standard  62 Day cancer target  Ambulance Performance  Initial Health Assessments for Looked after Children  Performance Against Financial Targets  Lack of Inpatient Beds for Children and Young People with Mental Health Issues

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R Catlow advised there have been 2 new risks added to the risk register for ELCCG:  Risk 253 – Ability of diagnostic provision to support 14 day cancer diagnosis,  Risk 254 – Lack of oncology provision across the Lancashire footprint including Pennine Lancashire

It was noted that there have been no new risks added to the BwD Risk Register. It was confirmed that Risk 249 – APMS Procurement has been removed from the EL CCG Risk Register.

CONCLUSION: That the Committee noted the contents of the update of the Combined Risk Register for BwD and EL CCG.

17.177 ELCCG Workforce, Race and Equality Standards Report 2016/17

J Mulloy asked the Committee to note the contents of the report and outlined the purpose of the report and gave an overview of the implications arising from the introduction of the Workforce Race Equality Standard (WRES) on 01 April 2015, and drew Committee members to Appendix 1 and asked for approval of the WRES annual report for publication on to the CCG’s website. J Mulloy drew members to the WRES indicators, and The Chair queried where the comparative population data is taken from as it seemed high compared to census data. J Mulloy advised that the information is taken from the Electronic Staff Record (ESR) but commented that she would check whether the data is correct before it is published.

ACTION: J Mulloy to check comparative population data. JM

CONCLUSION: That the Committee noted the contents of the report and agreed for the data to be published once the comparative data is confirmed as correct.

17.178 Quality Contract Meeting Draft Minutes: BMI/ELHT/LCFT X 2 June 2017 :

Members acknowledged the minutes

17.179 ELCCG Risk ManagementRATIFIED and Information Governance Group Draft Minutes June 2017:

Members acknowledged the minutes

17.180 Cancer Tactical Meeting: June 2017

Members acknowledged the minutes

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17.181 Any Other Business

M Connell advised that LCFT have offered to present their Quality Plans to CCGs and asked if the Pennine Lancashire Quality Committee would be in agreement for them to attend a meeting.

CONCLUSION: The Chair agreed that LCFT could present their Quality Account at a future meeting.

17.182 Items for inclusion on the Corporate Risk Register

None identified.

17.183 Date and Time of Next Meeting Wednesday 23rd August 2017 at 1.p.m. Meeting Room 1, Walshaw House.

RATIFIED

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PENNINE LANCASHIRE QUALITY COMMITTEE Minutes of the meeting held on 23 August 2017

PRESENT: Michelle Pilling Lay Advisor: Quality and Patient Engagement, ELCCG - Chair Susan Clarke Head of Safeguarding, Pennine Lancashire CCGs Dr Asif Garda GP Representative, Pendle Jackie Hanson Director of Quality and Chief Nurse, ELCCG Lucille Hinnigan Deputy Chief Finance Officer, ELCCG Dr Nigel Horsfield Lay Member, BwDCCG Julie Kenyon Senior Operating Officer, Primary, Community and Medicines Commissioning, BwDCCG Sharon Martin Director of Performance and Delivery, ELCCG Claire Moir Governance, Assurance and Delivery Manager, BwDCCG Dr Richard Robinson GP Representative, Hyndburn Locality, ELCCG Dr Zeenat Sykes GP Representative, Rossendale Locality, ELCCG Dr Paul Taylor Secondary Care Consultant, Non-Executive Director, ELCCG Janet Thomas Executive Nurse and Associate Director of Quality & Commissioning, BwDCCG

In Attendance: Deryn Ashby Executive Assistant, ELCCG – minutes Victoria Ainscough Specialist Safeguarding Practitioner for Children, Pennine Lancashire CCGs Simon Bradley Quality and Performance Manager, M&LCSU Michael Connell Quality and Performance Specialist, M&LCSU Judith Johnston Head of Clinical Commissioning, ELCCG Caroline Marshall Locality Lead, Quality and Performance, M&LCSU

Attended for Specific Items: Michelle Montague Assistant Business Manager, Medicines for Older People / Stroke & Community Hospitals, ELHT Vanessa Morris Infection Prevention & Control Lead Nurse, Pennine Lancashire CCGs Jennifer Mulloy Equality and Inclusion Business Partner, M&LCSU Kelly Taylor Commissioning Lead – Maternity, Children and Families, Pennine Lancashire CCGs Collette Walsh Head of Commissioning, Integrated Community Services, ELCCG Anita Watson Lead Nurse Infection Prevention and Control, LCC Hazel Whittle Assistant Director of Nursing for Older People / Stroke and Community Hospitals, ELHT Lewis Wilkinson Quality and Performance Support Officer, M&LCSU Catherine Wright Primary Care Quality Lead. RATIFIED REF: ACTION 17.184 Welcome & Chair’s Update

The Chair opened the Pennine Lancashire Quality Committee and welcomed all attendees.

17.185 Apologies

Apologies were received from: Ryan Catlow, Kerry Galloway, Dr Stephen Gunn, Kirsty Hollis, Elaine Johnstone, Dr Geraint Jones, Kathryn Lord, Dr Malcolm Ridgway, Dr Nick Roberts.

L Hinnigan has attended to represent K Hollis.

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17.186 Declarations of Interest

Dr N Horsfield advised that he had a conflict in respect of agenda item 4.1: Stroke Presentation. He has friends and former colleagues that work at East Lancashire Hospitals NHS Trust.

There were no other Declarations of Interest declared.

The meeting was quorate.

17.187 Minutes of the Meeting Held On 26 July 2017

Some amendments were offered for the meeting held on 26 July 2017. These were:

Title page The meeting was held on 26 July 2017, not 26 July 2018. Michelle Pilling is Chair of the meeting. Kirsty Hollis is a member of the committee and not in attendance. David Tansley is the Associate Director of Quality and Safety at ELHT

17.168: Provide Quality Accounts LCFT: Pg 3: The conclusion should read Anne Allison, MCFT: In the second paragraph, the sentence should read “With regards to the Merseycare Specialist Learning Disability Services (Whalley)” and to “…the Calderstones site”.

17.170: Cancer Update: GP making a referral 14-Day Rule The last sentence should read “It was noted that if the National Team do say no it would not go ahead”.

11.172: Pennine Lancashire Quality and Performance Report – Month 02 The action should read that “Simon Bradley to provide information around the NWAS initiatives in the next Quality and Performance report”.

With the above amendments, the minutes were formally ratified. RATIFIED

17.188 Action Matrix

17.129: CQC Review of Health Services for Children Looked After and Safeguarding in Lancashire: Action Plan Update S Clarke advised that a full update should be available at the next meeting.

17.145.1: Presentation: Complaints Service Further information is awaited regarding under-18 complainants. The Named Nurse for Safeguarding at ELHT is also involved in this query.

17.145.2: Presentation: Complaints Service This has been delayed due to annual leave, but the work is ongoing to triangulate the lessons learned from complaints and how these are applied. This action can be closed.

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17.153: Pennine Lancashire Risk Management Update This action has been completed.

17.154: Quality Premium Performance 2016/17 and 2017/18 This action has been completed.

17.156: Policy for Relations with the Pharmaceutical Industry and Other Commercial Organisations This action has been completed.

17.157: Annual Performance Report for the Prescribing and Medicines Optimisation Work Programme for 2016/17 This action has been completed; it was confirmed that Dr Sharma is reviewing the issue regarding repeat prescriptions for community LD patients.

17.158: Research Update This action has been completed.

17.168: Provider Quality Accounts BMI are reviewing the mortality reviews at corporate level. A further update should be available at the next meeting.

17.171.1: Provider Report: Daneshouse Medical Centre This has been included in the provider report. This action can be closed.

17.171.2: Provider Report: Laparascopic Cholecystectomy This has been included in the provider report. This action can be closed.

17.172: Cancer Update: GP Making a Cancer Referral 14-Day Rule Further guidance is still awaited from the National Team. A further update will be brought when the guidance has been received.

17.173.1: Home of Choice Policy It was confirmed that there are plans for letters to be available in other languages.

17.173.2: Home of Choice Policy S Bradley advised thatRATIFIED the data source is complex, but that data is available for the re- admissions. This is currently being worked through, and it is anticipated that a draft report will be available at the next committee meeting.

17.174: Pennine Lancashire Quality and Performance Report: Month 02 S Bradley informed members that there has been a change to the way that ambulance standards are monitored, but that this will be reflected in future reports. This action can be closed.

17.174: Pennine Lancashire Quality and Performance Report: Month 02 A further update is needed regarding the 111 service.

17.175: Serious Incident Review Group Recommendations This action has been completed.

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17.177: ELCCG Workforce, Race and Equality Standards Report 2016/17 J Mulloy has confirmed that the comparative population data is correct. This action can be closed.

17.189 Matters Arising

There were no matters arising.

17.190 Presentation: Stroke Pathway Update

H Whittle and M Montague, ELHT, attended with C Walsh to provide an update on the stroke pathway. The action plans were tabled, and members advised they were welcome to provide comments.

The purpose of the presentation was to provide assurance that there is an action plan in relation to stroke that is being implemented to effect improvements. In addition, it was noted that this is a joint presentation between commissioners and providers, to emphasise that this is a joint approach across all organisations.

C Walsh observed that 80% of strokes can be prevented, but they are the fourth biggest cause of mortality, and that the Pennine Lancashire CCGs are not performing as well as other areas. This is significant as stroke is a major contributor to long term disability in adults.

There are a number of high-risk factors, such as smoking, hypertension and Atrial Fibrillation. It was noted that secondary prevention is not as effective in this area, and that both CCGs have a high admission rate to hospital for stroke with over 700 admissions, not including TIAs.

The pathway has been split into 7 stages: 1. Primary prevention 2. Pre-hospital 3. Acute phase 4. Integrated Community Stroke Team 5. Survivorship RATIFIED 6. Secondary prevention 7. End of Life

The focus of the presentation today is the acute phase and the Integrated Community Stroke Team. There had been concerns raised by this group at the last presentation, and as a result of this the team had agreed to walk the stroke pathway in order to gain a full understanding of the pathway and issues. In addition, the team had arranged for a visit from Professor Tony Rudd, national lead on stroke, to provide further insight.

It has been identified that the community services must be robust and that early supported discharge is fully considered, with patient support available for 6 weeks.

M Montague explained that the pathway begins in the emergency department, where there is now a dedicated bay to triage patients with suspected stroke. All investigations are completed in the emergency department, including thrombolysis if it is required. Page 4 of 18 Minutes Approved by the Chair: 08/09/2017

NHS Blackburn with Darwen Clinical Commissioning Group NHS East Lancashire Clinical Commissioning Group

Input is available from a stroke Nurse Consultant and the stroke nurses. Further care is provided on the Acute Stroke Unit as long as needed, led by a stroke MDT of clinicians, therapists and nursing team. There are daily MDT meetings and extended MDT meetings twice a week to discuss patient care. If further rehabilitation is needed, the patient is transferred to a ward at Pendle Community Hospital, and follow up by community stroke teams is arranged on discharge.

Dr Garda entered the meeting

Members were advised that all data is stored on the Stroke database, and divided into 10 domains; the action plan was developed from these domains with a number of points monitored within each domain. This is then used to monitor how the service has been performing, and provide internal contemporaneous data, unverified, to highlight any immediate areas of concern. The SSNAP data is also reviewed to see what areas need improvement and to try to improve the SSNAP rating.

H Whittle advised that a full review was undertaken for the admin process and new staff were recruited. The mortality data is also being measured at stroke steering board. It was identified that the medical workforce was below recommended guidelines, so the Trust recruited a speciality doctor and nurse consultants to fill the gap. This has enabled the service to see patients in a more timely manner. The Nurse Consultant will also complete RCA reports, where identified. The therapy staffing levels were also below national guidelines, and a business case was developed and approved to support the recruitment of additional therapists.

Within the 10 domains of the action plan, 3 are focussed on, scanning, the stroke unit, and thrombolysis. Some examples of actions taken to date were highlighted to the group. C Walsh added that the intention is to plan ahead, and review the action plan on a monthly basis to see identify the next actions and where these need to be owned. This is jointly managed by the CCGs, ELHT, LCFT. It was noted that when Dr T Rudd, National Clinical Director for Stroke with NHS England, visited on 18 July 2017, he validated the plans and recognised that there was positive senior management engagement. He was also assured by the collaboration between organisations. He was pleased to note that the beds on the stroke unit were ring fenced for stroke patients, and that the Trust had employed 2 Nurse Consultants. He advised focus on sustaining these improvements. C Walsh cautioned that workforce is a significant concern, but that this was being addressed.RATIFIED The Trust is committed to reducing the length of stay for patients, and it has been recognised that this can be improved by providing further medical support at Pendle Community Hospital; there are delays to discharge from the community hospital which are being explored to understand how best to overcome these. This includes identifying any potential barriers pertaining to the CHC process that may be contributing to this issue.

The agreed next steps are continuous monitoring, a ‘Pit Stop’ workshop on 29 August 2017, and a ‘Visioning’ workshop for community services on 27 September 2017. The 0-4 hours target is being monitored, and it was noted that this was a good indicator of whether the changes are improving flow through the service. At present it is difficult to identify when the improvements will be seen and exactly how this will affect targets, but the focus is to improve the stroke care unit and achieve the highest standard possible. A robust business case will also be needed to support a possible move to an Enhanced Stroke Department in the future.

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NHS Blackburn with Darwen Clinical Commissioning Group NHS East Lancashire Clinical Commissioning Group

Dr N Horsfield queried how robust the ringfence is on the stroke beds. It was explained that the unit try to keep 5 beds available for flow and capacity. Dr P Taylor observed that there was significant progress on the action plan, and it was pleasing to note that the thrombolysis performance was improving, with an RCA completed on patients that breach this target. C Marshall queried where the RCAs were reported and the assurance that lessons were being learned. H Whittle advised that there is a weekly meeting with the stroke consultants and matrons, and that the outcomes are reported through the Stroke Steering Group. Actions are being put in place quickly, and shared with the executives and commissioners. There is also a weekly Operational Meeting.

J Thomas queried how these changes are impacting on the ability to provide long term care for patients in the community. C Walsh advised that this is being addressed in a different business case, and that work is underway to understand the patient journey, looking at the differences that the changes in care would make. It was emphasised that if the thrombolysis is not completed within 4 hours, the future care is more intense and provides pressure on the system down the line.

S Martin queried the hyper acute element of the pathway, observing that this needs to be put in place in Lancashire as improvements in other areas are where a hyper acute service has been implemented. A specification has been agreed across Lancashire and the Trust are developing a plan for the STP area, with a further update available in September / October 2017. This would look at a reduction in the length of stay, a reduction in disabilities associated with stroke, a business case for the whole pathway. H Whittle assured members that some of the work is about what would need to be in place to make ELHT a Hyper Acute Stroke Unit so that there are no future delays when that decision is made.

J Hanson observed that there has been a culture of keeping patients in hospital before discharge, and that there needs to be a reduction in the length of stay. M Montague concurred, noting that the increased medical visits to the community hospital has improved MDT decision making and confidence to discharge the patient. There is also discussion on the services delivered in the community to support an Early Supported Discharge, with a joint approach between ELHT and LCFT.

The Chair thanked the team and acknowledged the work done to date. She noted that there is a lot of scrutiny in this area, but the progress has been well articulated and staff are working hard. She RATIFIEDwas also assured by the relationship between the commissioners and multiple providers. She asked that the patient voice is included in informing future pathway change; C Walsh explained that the current work is technical, but the Visioning Workshop will include patient representation to help shape the service and ensure their voice is heard.

M Montague, L Whittle and C Walsh exited the meeting.

Dr N Horsfield advised members that workforce recruitment was also an issue, particularly in A&E and lung oncologists. He asked if commissioners were aware of which services were restricted by staff shortages. It was noted that these are discussed at the quality meetings with providers and documented in the minutes. S Martin added that staff shortages are known about, such as neurology, and that there are plans being developed to overcome these on a Pan-Lancashire basis. Commissioners need to test if these mitigation plans robust enough. J Hanson added that there are discussions at STP level where areas of concern are known about, time has been taken to overcome these; one example is the time to release the budget to recruit nurse consultants in Page 6 of 18 Minutes Approved by the Chair: 08/09/2017

NHS Blackburn with Darwen Clinical Commissioning Group NHS East Lancashire Clinical Commissioning Group

stroke to relieve the medical staffing vacancies. Dr P Taylor observed that sometimes these changes to staff structures are not fully supported at executive level, and that radical re-design is needed to help achieve the outcomes needed. The Chair noted that the improvements made to date were very encouraging.

V Morris entered the meeting.

17.191 Pennine Lancashire Risk Management Update

For BwDCCG there are 10 operational risks and 6 strategic risks held on the register. ELCCG has 17 risks on the Risk Register. With 12 escalated to its GBAF. These are detailed in full within the report. Across Pennine Lancashire there are 6 risks which are included on the Risk Registers for both CCGs. These are:  95% Accident and Emergency 4-Hour Standard  62-Day Cancer Target

 Ambulance Performance

 Initial Health Assessments for Looked after Children  Performance Against Financial Targets  Lack of In-Patient Beds for Children and Young People with Mental Health Issues (Tier 4 beds)

In addition to these, there are a number of similar risks across both organisations around workforce / capacity, diagnostic capacity, and the quality of care provided to patients.

No new risks were added for BwDCCG or ELCCG in July 2017. Three risks were revised: Ability of diagnostic provision to support 14-day cancer diagnosis; Lack of oncology provision across the Lancashire footprint, including Pennine Lancashire; Failure to achieve the stroke quality requirements for people who have had a stroke being admitted to an acute stroke unit within 4-hours.

The East Lancashire CCG Governing Body Assurance Framework has been updated to reflect the changes in the managed risks of the CCG with a risk score of 12 or above. The Blackburn with Darwen CCG Governing Body Assurance Framework risks are presented for review onRATIFIED a quarterly basis to the GB and are aligned to the CCG Improvement and Assessment Framework.

It was noted that a shared approach to the combined risk areas would be more beneficial to both CCGs. S Clarke queried why some joint issues are not reported the same, where they are included on one Risk Register but not deemed risky enough to be included on the other Risk Register.

ACTION: S Martin to discuss with J Johnston and I Fletcher why some areas, S Martin such as CHC, are identified as concerns for both CCGs but are not reflected on both Risk Registers.

Dr Horsfield advised that there had been discussion at the BwDCCG Audit Meeting as to whether the A&E risk score should reduce in line with the ELCCG risk score. C Moir advised that there have been discussions around aligning risk to the joint working approach. The Chair added that MIAA had recently completed an audit on ELCCG risk

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NHS Blackburn with Darwen Clinical Commissioning Group NHS East Lancashire Clinical Commissioning Group

management arrangements, with a rating of significant assurance and some recommendations.

ACTION: C Moir and R Catlow to review the joint risks and align risk scores, R Catlow where appropriate / C Moir

Full details of the risks are available within the report and on the Corporate Risk Registers

Members acknowledged the report and the updates to the Risk Register, and approved the recommendations.

17.192 CONFIDENTIAL DISCUSSIONS – Provider Updates

S Clarke and C Marshall presented this item; the paper was tabled for reference. The content of this item is for committee members and attendees only, and is not for wider distribution.

The confidential minutes of this part of the meeting will be circulated under separate cover.

Members received and acknowledged this report.

17.193 Domestic Homicide Review: Final Report and Action Plan

C Marshall presented this report to provide the Committee with an overview of the Serious Incident 2014/14031 and subsequent Independent Investigation report and action plan. BwDCCG GB will receive the DHR report at the meeting scheduled for 06 September 2017 and, once approved, will be published on all stakeholder websites from 15 September 2017.

Committee members were asked to consider the Independent Report and ensure the resulting actions and outcomes address all areas for action. It was noted that this report has been approved by NHS England. The action plan will be monitored, and the Safeguarding Board areRATIFIED also involved in this case. The Chair noted that that this was a detailed report that highlights the hidden problem of the dangers that some unpaid carers face from the people that they are caring for. The recommendations are timely and will help to address the issues identified, but assurance is needed on how these will be monitored and how the recommendations will be implemented. C Marshall advised that NHS England are monitoring the action plan, in liaison with LCFT, but that this case is also discussed at the BwD Safeguarding Board to identify relevant learning.

ACTION: P Chapman to be asked to ensure that the actions are taken forward P Chapman through the BwD Safeguarding Board

Members were asked to ensure that any comments were sent to C Marshall or J Thomas by the end of the week, otherwise the report would be taken as approved by the committee.

Providing there are no further comments, the report and action plan are approved.

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NHS Blackburn with Darwen Clinical Commissioning Group NHS East Lancashire Clinical Commissioning Group

17.194 Pennine Lancashire Quality and Performance Report – Month 03

S Bradley and M Connell attended to present the key points from the Pennine Lancashire Quality and Performance Report for Month 01. Full details are available within the report.

Springfield Nursing Home M Connell informed members that this provider was flagged as ‘red’ on the dashboard as they had not supplied the requested information. They are currently in a QPIP process for safeguarding.

ELHT

A&E There was underperformance against the 4-hour A&E target in July 2017 for both CCGs. The Trust must achieve the 90% target by the end of September 2017, and 95% by end of March 2018.

RTT Incomplete There was underperformance against the RTT incomplete standard in July 2017 for BwDCCG. Performance at Lancashire Teaching Hospitals is having the most significant impact on the position for both CCGs, and CSRCCG have been asked for an update on progress.

Cancer 2-Week Target (Breast) The target was met for BwDCCG in July 2017, but the year-to-date position is still failing. ELHT have an action plan in place and have assured that the target will be met by the end of the year.

Ambulance Calls There has been underperformance for both CCGs against all 3 ambulance targets. The targets for ambulance calls have been changed in-year and will be reflected on future reports. It was requested that, as part of this change, NWAS provide data to a district level to enable the CCGs to monitor response times in rural areas.

E-Coli RATIFIED In April 2017 there were 36 E-Coli cases identified within the population of East Lancashire, and 7 cases in Blackburn with Darwen. A concern has been raised by LMC regarding the collation of E-Coli data by GPs. This has been shared with LCC to provide a response, as it is a nationally mandated process.

Quality Premium NHS England has published guidance on the quality premiums for 2017/18. The premium relating to Red 1 Ambulance Calls has been removed, due to the changes in reporting and monitoring, which has affected the weighting of the associated premiums. The A&E target in the Quality Premium has been reduced in line with the national target.

52 week There was 1 patient waiting over 52-weeks in July 2017. This patient is under the speciality of Maxillofacial Surgery, which is commissioning by Specialised Commissioning; this has been included for reference. Page 9 of 18 Minutes Approved by the Chair: 08/09/2017

NHS Blackburn with Darwen Clinical Commissioning Group NHS East Lancashire Clinical Commissioning Group

LCFT

12-Hour Breaches During Q1 there was an increase in the number and proportion of 4-hour breaches across Lancashire for patients awaiting a psychiatric assessment.

Out of Area Treatments There was an average of 23 Out of Area Treatments in June 2017 against a target of 0 and a tolerance threshold of 15. There has been an increase in the number of out of area PICU placements in April and May 2017. A trajectory to further reduce the numbers of OATs throughout 2017/18 is in development.

V Morris exited the meeting.

Attention Deficit Hyperactivity Disorder There was discussion on the issues with the ADHD service, with assurance that there will be a further update following the next Quality and Performance Group meeting. M Connell advised that patients over 25 not benefitting from service as the behaviours are well established by this age. Dr N Horsfield requested figures as well as percentages to provide context to the scale of the issues being experienced.

Memory Assessment Service J Hanson noted that there had been an improvement in the performance of the Memory Assessment Service.

Members acknowledged the report

17.195 Pennine Lancashire Serious Incident Review Group Recommendations

L Wilkinson presented the paper to the committee.

ELCCG In July 2017, 10 reports were reviewed. Of these, 7 were approved for closure, and 3 were returned to the providerRATIFIED.

BwDCCG In July 2017, 5 reports were reviewed. Of these, 2 were approved for closure and 4 were returned to the provider.

During this period, a total of 6 extension requests were submitted by ELHT; 4 were made before the deadline, and 2 were received after the deadline.

There have been 3 extension requests submitted by LCFT; 1 was received before the deadline, and 2 were received after the deadline.

Two Rapid Review reports are outstanding from ELHT, but with the exception of these two all other reports were received within 72-hours. LCFT submitted 3 Rapid Review reports outside the 72-hour deadline, and the timely submission on these reviews has been discussed with them.

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NHS Blackburn with Darwen Clinical Commissioning Group NHS East Lancashire Clinical Commissioning Group

ELCCG has 67 StEIS incidents open at present and BwDCCG has 41 incidents open at present.

Members were advised that ELHT have requested permission to use the dashboard as part of their reporting process to their internal committees.

The Chair noted that the number of extension requests is decreasing, which is assuring. There was discussion on the increase in the number of pressure ulcers, but members were assured that work has already started to understand the reason for this; whether it is increased vigilance and reporting, or whether there was a deterioration in care.

The Committee formerly received the report for information.

L Wilkinson exited the meeting.

17.196 2016/17 CQUIN Reconciliation Q4 for EL and BwD CCG Hosted Contracts

2016/2017 CQUIN Reconciliation has taken place for Q1 for ELCCG and BwDCCG hosted contracts. S Bradley presented the outstanding Q4 milestones.

BMI Evidence has been submitted by BMI for the 2 CQUIN indicator; both have been fully reconciled and recommended for payment.

ELHT Evidence has been submitted by ELHT for the 4 Q1 indicators due. 2 have been fully reconciled and recommended for payment, 1 has a data lag and will be submitted separately, and 1 indicator requires further discussion and evidence. Data has also now been published for the outstanding 2016/17 Q4 indicator, and this has been recommended for payment.

LCFT Evidence has been submitted by LCFT for the 4 Q1 CQUIN indicators. These have been fully reconciled and payment can be released.

MCFT RATIFIED Evidence has been submitted for the 3 Q1 CQUIN indicators. 1 has been recommended for payment, and 2 are awaiting further information. Data has also now been published for the outstanding 2016/17 Q4 indicator, and this has been recommended for payment.

IAPT Consortium Evidence has been submitted for the Q1 indicator and this has been recommended for payment.

About Health Evidence has been submitted for 2 out of the 3 Q1 CQUIN indicators. One has been fully reconciled and recommended for payment, and 1 is awaiting further information. The third is subject to a datalag and will be reviewed in due course.

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NHS Blackburn with Darwen Clinical Commissioning Group NHS East Lancashire Clinical Commissioning Group

Age UK Evidence has been submitted for the Q1 indicator, and this has been recommended for payment.

Members were asked to support the recommendations relating to release the newly reconciled Quarter 4 monies, as specified, and the identified Quarter 1 payments.

Members acknowledged the report and approved the recommendations for payment of CQUIN monies as outlined in the report

17.197 Primary Care Quality Assurance Report

C Wright attended the meeting to present the Primary Care Quality Assurance Report.

She noted that the Quality Concerns Trigger Tool has been adopted by the Pennine Lancashire Team, and the indicators have been developed against which the GP practices will be monitored.

The annual GP Survey was published in July 2017. There is a vast range in the individual practice responses, and specific work is being undertaken in ELCCG practices through the Quality Framework. The other area of concern was that the level of satisfaction in the Out of Area Service was 5% below the national average for EL patients, and 1% for BwD patients.

Work is being undertaken to work through the complaints received regarding GP surgeries, and to identify any themes or trends across Lancashire.

There are currently 3 providers across Pennine Lancashire awaiting their first CQC inspection, and 3 practices across Pennine Lancashire that have been rated ‘inadequate’ following their CQC inspection.

The Chair queried whether the quality improvement contract had identified any shared improvement areas across Pennine Lancashire. C Wright advised that the content for both organisations was different, but that this task had been assigned to the commissioning team to pull this together across the Pennine Lancashire footprint. Dr Z Sykes reported onRATIFIED the monthly meeting to discuss shared learning that has been successfully adopted in Rossendale; C Wright advised that this was something that is being encouraged in the other localities to support practices to link together and share learning. Dr Garda queried the relevance of the quality surveillance in an evolving scenario where there was a shortage of GPs and Nurses, and whether this would be broadened to include other specialities, such as the pharmacist; he noted that this tool should be revised to reflect and quantify the input of other clinicians and the reduction on the GP workload as a result of shared provision.

The Chair noted that workload had been raised as an issue at Governing Body it would be helpful to understand if the BwDCCG scheme raised the same concerns and if there were any opportunities to share learning in regard to quality improvement approaches. J Thomas noted that support was available to practices through the federations. C Wright was thanked for her update.

Members acknowledged the report.

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NHS Blackburn with Darwen Clinical Commissioning Group NHS East Lancashire Clinical Commissioning Group

17.198 Lancashire IPC Update

A Watson attended to present the Lancashire County Council Health Care Associated Infection Report for Q1 2017/18 across the Lancashire footprint. She noted that some terminology had been changed within the report, as per a previous request by the committee.

MRSA During Q1 there were 3 cases of MRSA, 2 of which were assigned to the CCG.

Clostridium Difficile During Q1 there were 23 cases of E-Coli for ELCCG against a target of 14, and there were 11 cases for BwDCCG against a target of 10. Overall there has been an increase in cases across Lancashire, although there is not yet a clear explanation for this.

E-Coli During Q1 there were 113 cases of E-Coli for ELCCG against a target of 64, and there were 31 cases for BwDCCG against a target of 35. NHS Improvement has published a resource pack aimed at developing a health economy approach to managing and reducing E-Coli.

Klebsiella There were 41 cases of Klebsiella in Lancashire, with 29 cases apportioned to non- Acute Trusts.

Care Homes During Q1, there have been 16 referrals for Care Homes undergoing a QIPP process. There have also been 29 care homes supported to manage norovirus outbreaks.

Future Plans A Watson advised that there is focus on a Sepsis Strategy for care homes. There is also focus on a Lancashire-wide E-Coli strategy, and supporting CCGs to develop localised E-Coli Action Plans.

Dr N Horsfield queried whether other antibiotic resistant infections are recorded. A Watson advised that the gram negative infections remain in focus, with MRSA and E-Coli as the main concerns.RATIFIED V Morris noted that Public Health England are monitoring the epidemiology of antibiotic resistant strains.

Members acknowledged the report and the progress made in this area.

V Morris and A Watson exited the meeting.

17.199 Pennine Lancashire Safeguarding Dashboard

S Clarke presented the Pennine Lancashire Safeguarding Dashboard to members.

The report detailed the progress on the development of a Pennine Lancashire model for safeguarding, which now includes two Specialist Practitioners for Children’s Safeguarding, and one additional Specialist Practitioner for Adults Safeguarding. There has also been additional administrative support brought in to support the wider CCG work. Page 13 of 18 Minutes Approved by the Chair: 08/09/2017

NHS Blackburn with Darwen Clinical Commissioning Group NHS East Lancashire Clinical Commissioning Group

None of the initial health assessments for looked after children have been completed within timescales. There is a discrepancy on the risk registers between both organisations, but this may be as this is a higher risk to ELCCG. This matter is being pursued by the safeguarding team. ELHT have also reported that they have not received any requests for initial health assessments from BwD Local Authority since June 2017, despite 13 children being placed during this time. This has been escalated to safeguarding leads, with assurance that backlog of assessments will be completed. The concern with the initial health assessment performance also remains as the community specification has not been signed off by ELHT; this has been escalated by contracting and commissioning. S Clarke requested support from the committee through a Chairs Letter if the matter is not resolved. The Chair agreed, noting that particular focus should be paid to this vulnerable group of children, with assurance needed from ELHT as to when the service specification will be approved.

ACTION: J Hanson and S Martin to discuss the community paediatric specification and escalate accordingly.

S Clarke advised that the BwD process of monitoring to identify delays will be introduced into the EL safeguarding model.

The compliance against safeguarding training has increased but is still not at acceptable levels, particularly in BwDCCG. This has been raised at both exec teams, and awareness of the training is being promoted.

S Clarke advised members that there were concerns with the safeguarding standards as the CSU are not able to give assurance regarding their compliance. They have been asked for an updated self-assessment plan and action plan by the end of September 2017 to provide full assurance that they are compliant with their safeguarding responsibilities. J Hanson observed that this had been ongoing for some time and would need including on the Risk Register if it was not resolved.

ACTION: J Johnston to raise the issue of CSU non-compliance with the safeguarding self-assessment at the IPA Programme Board.

S Clarke informed members that there have been concerns raised in the multi-agency safeguarding hubs thatRATIFIED police and social care are making decisions without input from other teams. This has been raised and is being challenged.

The Chair thanked S Clarke for the detailed report.

Members acknowledged the report.

17.200 Pennine Lancashire IPA / CHC Update

Continuing Health Care CCG managers continue to work with the CSU to implement the jointly agreed action plan. The planned workshop has not been held, due to system pressures, but this will Page 14 of 18 Minutes Approved by the Chair: 08/09/2017

NHS Blackburn with Darwen Clinical Commissioning Group NHS East Lancashire Clinical Commissioning Group

be revisited in the coming months. The Department of Health is undertaking a review of the national framework, with a revised framework anticipated toward the end of 2017 for implementation on 01 April 2018. The new IPA database has had some impact on forecasting financial commitments, and the CCG Finance Teams continue to seek assurance from the CSU that this is a reflection on actual positions. There are currently 391 CHC reviews outstanding for ELCCG and 116 reviews outstanding for BwDCCG.

Previously Unassessed Period of Care (PuPOC) The CSU is continuing to manage the process by responding to the disputes against decisions received. As at 31 July 2017 36 disputes have been received relating to Blackburn with Darwen cases of which 16 remain open. 71 disputes have been received relating to East Lancashire cases of which 42 remain open. ELCCG received a letter from NHS England following consideration of a case at an Independent Review Panel, with a request that the CCG develop an action plan. Work is ongoing with the CSU to develop and implement this action plan.

Quality Premium There is a national measure relating to CHC included in the Quality Premium for 2017- 2019. The CCGs are still awaiting Q1 figures from SCU to understand the scale of the remedial action required, with work ongoing a ross Lancashire for future Discharge to Assess models.

Transforming Care BwDCCG have discharged 1 patients from the original Winterbourne cohort; both CCGs have 3 CCG responsible patients remaining in hospital. Two of these patients are complex, and have been escalated to NHS England for advice and support. NHS England have released a revised CTR policy, which has placed additional obligation on the CCGs. This is being worked through to understand the implications.

Court of Protection East Lancashire CCG is continuing to receive section 21a challenges. The CSU has secured the necessary response to ensure timely responses to these. ELCCG discuss cases at the Complex Case Advisory Group.

The Chair thanked J JohnstonRATIFIED for her update.

Members acknowledged the report and the progress in this area.

17.201 Pennine Lancashire Complaints, MP Letters and PALS Report, Q1 2017/18

C Marshall advised members that this was the first joint report between both CCGs. She noted that K Lord has requested feedback on the content to provide improvement on future reports.

The report detailed that ELCCG had received 21 complaints in Q1, and BwDCCG had received 2; this is a reduction for both CCGs on the previous quarter.

During this period, ELCCG had also received 1 compliment.

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NHS Blackburn with Darwen Clinical Commissioning Group NHS East Lancashire Clinical Commissioning Group

The report detailed an analysis on the reasons for the complaints, MP letters and PALS contact to identify themes and trends.

The Chair noted that the domains of patient experience and sub subject were to generalised to identify trends. She also noted that the inclusion of a lessons learned section was good but could be improved by including wider system learning.

Members acknowledged the report, and agreed to provide K Lord with feedback on the report.

17.202 Pennine Lancashire E&I Quarterly Update Report

J Mulloy attended to provide a joint update for both CCGs. She highlighted that the CSU will be looking at the grading on goal 4, for inclusive leadership. This will be completed across both CCGs and will be separately reported. The other area of focus is goal 1.3, pathways of care and moving between services. The CSU is currently doing some exploratory work around this goal.

The Workforce Race Equality Standard was included within the report and this is published on the CCG website.

J Mulloy advised that she has developed a tracker to monitor the Equality Impact Risk Assessments requested from different commissioners and has separated these into Pennine Lancashire, East Lancashire and Blackburn with Darwen. She advised that she had been concerned that she was not receiving information from commissioners so had arranged to attend the Senior Management meetings to explain the support offered within the EIA process. She noted that this had been successful, as she has been contacted a number of times since this presentation.

The new Equality Resource pack is available on line for primary care, and J Mulloy advised that she has linked with BwD colleagues in order to approach this jointly across both CCGs.

Members acknowledged the report.

RATIFIED 17.203 Maternity Services Update

K Taylor attended the meeting to update members regarding the Lancashire STP programme on maternity services. Changes had been implemented following the Kirkup review in Morecambe Bay, which recommended a whole system change in relation to maternity and midwifery services, and the publication of a National Maternity Review, also known as ‘Better Births’. From this, ELHT contributed to the Every Baby Counts RCOG national quality improvement programme to reduce the number of babies that die or are left severely disables as a result of an incident during labour. ELHT was also a pilot site for the Saving Babies Lives care bundle, introduced by NHS England in March 2016, and implementation of this bundle was included as a local CQUIN indicator for 2016/17.

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NHS Blackburn with Darwen Clinical Commissioning Group NHS East Lancashire Clinical Commissioning Group

As a result of these measures, over 2 years the Trust have noted a 53% reduction in avoidable stillbirths, although the review recognises that not all stillbirths are avoidable. However, there has also been an increase in scanning appointments, and an increase in induction and caesarean sections.

C Marshall noted that the RCAs completed for still births are very good at identifying the root cause, and that the Trust have a dedicated worker to support the families affected by still births. There has also been positive feedback from the genetics services where consanguinity is a contributing factor.

J Hanson observed that the level of induction rate rationale needs to be closely monitored. Dr Z Sykes queried whether the number of postpartum deaths was also included, and it was confirmed that these are StEIS reported when they occur, but they are infrequent. These will often be subject to an independent review and investigation.

The Chair thanked K Taylor for her report, noting the positive progress in this area.

Members acknowledged the report.

17.204 Clinical Coding Audit

L Hinnigan presented this report, following an audit completed by MIAA, which was commissioned by EL and BwD CCGs to help identify the reason for increase in activity and cost in the Respiratory service and Trauma and Orthopaedics departments in 2015/16. The findings of this report have been shared with ELHT.

The report identified that the overall accuracy of clinical coding was variable, with poor quality noted for orthopaedic episodes.

It was noted that accurate data quality and clinical coding was imperative to support patient care. The report provided limited assurance on the clinical coding process overall, with physical records and staffing levels identified as a high risk.

The members noted the content of this report, and observed that improvement would be difficult until the Trust moved to an electronic patient record. RATIFIED Members received the report and noted the concerns raised.

17.205 Quality Contract Meeting Minutes July 2017: BMI, ELHT, LCFT, MCFT

These were distributed prior to today’s meeting for information. No comments were raised.

Members acknowledged the minutes.

Page 17 of 18 Minutes Approved by the Chair: 08/09/2017

NHS Blackburn with Darwen Clinical Commissioning Group NHS East Lancashire Clinical Commissioning Group

17.206 ELCCG Risk Management and Information Governance Minutes: July 2017

These were distributed prior to today’s meeting for information. No comments were raised.

Members acknowledged the minutes.

17.207 ELMS Out of Hours Contract Minutes – June 2017

These were distributed prior to today’s meeting for information. No comments were raised.

Members acknowledged the minutes.

17.208 Any Other Business

None was raised.

17.209 Items for the Risk Register

As per the discussion under 17.197: Pennine Lancashire Safeguarding Dashboard, it was agreed that the issue pertaining to the CSU staff being potentially non-compliant with the Safeguarding Self-Assessment toolkit should be considered for addition to the Risk Register if the issue is not resolved.

17.210 Date & Time of Next Meeting

The next meeting has been scheduled for Wednesday 27 September 2017 in Meeting Room 1, Walshaw House.

The deadline for papers is 5pm on Monday 18 September 2017.

The meeting closed atRATIFIED 16:05

Page 18 of 18 Minutes Approved by the Chair: 08/09/2017

Joint Committee of CCGs 2nd November 2017 – 1.00pm – 3.00pm

Venue: Main Lecture Theatre, Ground Floor, Moor Lane Mills, Morecambe Bay CCG, Lancaster, LA1 1QD Agenda Timings Item Item Owner Action Format No Standing Items 1.00pm – 1 Welcome and Introductions Phil Watson Information Verbal 1.05pm 2 Apologies Phil Watson Information Verbal

3 Declarations of Interest Phil Watson Information Verbal 1.05pm – 4 • Minutes from the following meetings for Phil Watson Information Paper 1.20pm ratification: o 7th September 2017 o 6th July 2017 o 2nd March 2017

• Revised Joint Committee of CCG’s Terms Carl Support Paper of Reference Ashworth 5 Action Matrix Review Phil Watson Information Paper

For noting, the removal of items from the Action Matrix as follows: • Evaluation and Hurdle Criteria review – this is being picked up via the Care Professionals Board • Integrated Diagnostics – this is being picked up via the Provider Group as part of the work around the Carter Review 6 Any Other Business Declared Phil Watson Information Verbal For Discussion/Recommendations 1.20pm – 7 Local Maternity Services Plan Vanessa Support Presentation 1.40pm Wilson 1.40pm – 8 Transforming Care Debbie Decision Paper 2.05pm Nixon 2.05pm – 9 Urgent and Emergency Care Transformation David Support Paper 2.30pm Funding Bonson 2.30pm – 10 Capital and Estates Briefing Gary Support Paper 2.45pm Raphael 2.45pm - Formal meeting closed 2.45pm – Continue with Questions from the Public All Discussion Verbal 3.00pm For information only The next Joint Committee of CCG’s meeting will be held on: Phil Watson Information Verbal Thursday 11th January 2018 – 1.00pm – 3.00pm – venue to be confirmed

Apologies should be sent to Sue Hesketh - [email protected] or 01253 951490 Agenda Item 17404

Joint Committee of the Clinical Commissioning Groups (JCCCGs)

Minutes of the Joint Committee of the Clinical Commissioning Groups held on Thursday 2nd March 2017, 1pm – 3pm at the University of Central Lancashire, 53 Degrees Hall, Preston, PR1 7BQ

Chair Phil Watson (PW) Independent Chair JCCCGs Attended Voting Alex Gaw Chair Lancashire North CCG Apologies Members Andrew Bennett Chief Officer Lancashire North CCG Attended Chris Clayton Chief Clinical Officer Blackburn with Darwen CCG Attended David Noblett Lay Member Greater Preston CCG Attended Sumantra Mukerji Chair Greater Preston CCG Attended Doug Soper Lay Member West Lancashire CCG Attended Marie Williams GP Member Blackpool CCG Apologies Geoffrey O’Donoghue Lay Member Chorley South Ribble CCG Attended Gora Bangi Chair Chorley South Ribble CCG Attended Graham Burgess Chair Blackburn with Darwen CCG Attended Mark Youlton Chief Officer East Lancashire CCG Apologies Mary Dowling Chair Fylde and Wyre CCG Attended Paul Kingan Chief Finance Officer West Lancashire CCG Attended Phil Huxley Chair East Lancs CCG Apologies Roy Fisher Chair Blackpool CCG Attended Tony Naughton Chief Clinical Officer Fylde and Wyre CCG Apologies Michelle Pilling Deputy East Lancashire CCG Attended Adam Janjua Deputy Fylde and Wyre CCG Attended Kirsty Hollis Deputy East Lancashire CCG Attended Non-Voting Allan Oldfield Chief Executive Officer Fylde Council Apologies Members Amanda Doyle Accountable Officer Healthier Lancs & South Cumbria Attended Andrew Bibby Director for Specialised Apologies Services NHS England Andy Curran Medical Director Healthier Lancs & South Cumbria Attended Dean Langton Chief Executive Officer Pendle Council Apologies Gary Hall Chief Executive Officer Chorley Council Attended Gary Raphael Finance Director Healthier Lancs & South Cumbria Attended Harry Catherall Chief Executive Officer Blackburn Council Attended Jane Higgs Director of Operations NHS England Apologies Jo Turton Chief Executive Officer Lancashire County Council Apologies Kim Webber Chief Executive West Lancs Borough Council Apologies Lawrence Conway Chief Executive South Lakeland District Council Attended Neil Jack Chief Executive Officer Blackpool Council Apologies Samantha Nicol Programme Director Healthier Lancs & South Cumbria Apologies Sir Bill Taylor Chair Healthwatch Apologies Diane Wood Chief Executive Cumbria County Council Apologies Mike Wedgeworth Deputy Healthwatch Attended David Tilleray Deputy West Lancs Borough Council Attended Sakthi Karunanithi Deputy Lancashire CC Attended Steve Thomson Deputy Blackpool Council Attended In Jacquie Allan Exec Support Officer Healthier Lancs & South Cumbria Attended attendance Dionne Standbridge Director Pennine Lancashire Attended Peter Tinson Chief Operating Officer Fylde and Wyre CCG Attended

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ACTION 17-03-1 Welcome and Introductions Info

The Chair welcomed the members of the Committee to their second formal meeting. He explained the status of the meeting and that the Committee had invited members of the public to observe what happens at these important decision making meetings. He clarified that this was a meeting held in public but not a public meeting, although the members of the public would be allowed to ask questions relating to agenda items at the end of the meeting. He explained to the members of public the voting rules of the JCCCGs.

17-03-2 Apologies and Quoracy Info

Apologies were received from Alex Gaw, Jane Higgs, Dean Langton, Sam Nicol and Allan Oldfield. All other non-attendees sent deputies as above.

The meeting was declared quorate.

RESOLVED: The Chair noted the apologies. 17-03-3 Declarations of Interest Info

The Chair requested that the members declare any interests relating to items on the agenda. The Chair reminded those present that if, during the course of the discussion, a conflict of interest subsequently became apparent, it should be declared at that point.

RESOLVED: No declarations of interest were notified. 17-03-4 Minutes from the previous meeting held on the 2nd February 2017 Info

The minutes of the meeting were reviewed, and amendments proposed. Mary Dowling said that she had some changes to suggest and offered to do this outside of the meeting to save time. This was agreed. The Chair asked that with the changes, the Committee accept the final minutes as a true and accurate account of the meeting.

RESOLVED: The minutes of the meeting were accepted as a true and accurate record of the meeting on the 2nd February 2017. 17-03-5 Action Matrix Review Info

The Action Matrix from the previous meeting was reviewed and all of the outstanding items would be covered on the agenda, with the exception of reference 17-01-9 Evaluation and Hurdle Criteria which would be on a future agenda. The Committee also noted that the final version of the Terms of Reference for the Committee were awaited and this should remain as an action.

RESOLVED: The action matrix was reviewed and the outstanding issue noted.

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17-03-6 Any Other Business Declared: Info

The Chair asked the members of the Committee if they had any other business they wished to declare for discussion at the end of the meeting.

ACTION: Mr Doug Soper asked that the work plan for the Committee be discussed.

17-03-7 Programme Board Feedback Info

Amanda Doyle, Chief Officer for the Healthier Lancashire and South Cumbria Programme gave an update on the main topics of discussion from the recent Programme Board meeting.

The planned change to the Programme Management team had taken place and the role of the externally contracted team would now be undertaken by Carl Ashworth’s team from the Commissioning Support Unit, who were already supporting collaborative programmes across Lancashire and South Cumbria. Consequently the structure and contacts will change while the central team is being established. Once finalised the contact list will be issued to the members of the JCCCGs.

Karen Smith from Blackpool Council had been appointed as the Senior Responsible Officer for the Regulated Care Workstream. She had given a detailed presentation to the Programme Board on the workstream and had identified issues that could be influenced locally at STP level, rather than nationally.

There was also a presentation on the Third Sector. Stewart Lucas from Mind discussed how the voluntary sector can connect with the Local Delivery Plans and Sustainability and Transformation Plans. David Houston from Trinity Hospice then spoke about hospices and the opportunities that existed to engage with them. Lancashire currently has 8 hospices.

Neil Greaves gave an update on the public facing narrative for the change programme and the Senior Responsible Officers had received the latest draft, which was included on the JCCCGs’ agenda.

Declan Hadley presented a paper on integrated diagnostics and asked the Programme Board to support the proposal to create an integrated diagnostics workstream. He sought commitment from all the organisations identified to participate in the proposed collaborative arrangements. All the organisations at the meeting agreed to sign up to the proposal and Declan was tasked to put a group together to own the work, establish a clinical leader and then take their proposal to the Provider Group, prior to reporting back to the Programme Board. An update on this will be reported to the JCCCGs in August 2017.

Amanda then concluded with a brief update on the work plan which is in the process of being completed. At this point a question was asked about the current position of STPs as there had been a lot of press speculation about them being in

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different positions. Amanda confirmed that we are in a strong position and the plan we have and the work we are doing is supported nationally.

It was agreed that a more detailed discussion would be more appropriate in a development session. This led to the question about the members of the Committee receiving copies of the Programme Board Papers, which was not agreed. The Programme Board does not meet in public therefore the papers from that meeting do not go in the public domain. Once the minutes from the Programme Board have been ratified, these can be issued to the JCCCGs members for information.

ACTION: Once the Central Team has been established a contact list will be issued to the members of the JCCCGs.

ACTION: An Integrated Diagnostics Paper update to be presented at the August 2017 JCCCGs meeting.

RESOLVED: Once the Programme Board minutes have been ratified, these may be issued to the members of the JCCCGs. 17-03-8 Communications and Engagement

Neil Greaves discussed the “Delivering the Message” document, which he had distributed to the members of the JCCCGs. He confirmed that Senior Responsible Officers for each of the workstreams had also been closely involved in ensuring that the content sufficiently explained what was happening and they had indicated the changes that they wanted making to the document. He then gave the Committee the opportunity to voice any suggestions they had to improve the document.

On the whole the document was felt to be compelling, effective and well mapped out. Several members made comments to improve key elements of it and these would be reflected in the final document as far as possible. One of the main suggestions was that the documents could be more sensitively worded by emphasising that health improvements are important and can also lead to financial benefits.

The Healthier Lancashire and South Cumbria Programme was described as part of a collaborative effort among organisations across Lancashire and South Cumbria but the JCCCGs considered that it was much more and in particular had responsibilities to develop a new vision for health and care services across the region.

A request was made for an animated version to be created once the final document is produced as this would assist older adults and people with learning disabilities to understand the issues.

It was felt this was an important document to reach out and engage not only the general public but also the third sector, local councillors and our local MP’s.

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The communication and engagement teams from Lancashire and South Cumbria had all been involved in creating the document and a revised version was being taken to focus groups for final discussion. This would then be circulated to the Committee members and it was agreed that Amanda Doyle could sign off the document on behalf of the JCCCGs.

ACTION: For the Committee to forward any additional comments to Neil Greaves for inclusion in the amendments.

RESOLVED: The Committee agreed that Amanda Doyle could sign off the document once the changes had been made.

17-03-9 Local Delivery Plans (LDP) presentations from 2 areas Pennine Lancashire

Chris Clayton introduced himself as the new Senior Responsible Officer for the Pennine Lancashire Local Delivery Area, replacing Sally McIvor. He took the opportunity to thank Sally for all of the input she had put into the programme.

He outlined the programme that had been running for approximately 18 months and the similarities across the Lancashire programmes. He spoke in detail about the Pennine Lancashire Case for Change and other issues including: health and wellbeing; care and quality; and finance and efficiency.

The timeline for developing the new models of care was shown, with the scheduled consultation and implementation periods now being undertaken. He reported that significant and extensive programmes of communication and engagement were taking place with the public, workforce and politicians, including via social media. The health improvement priorities included respiratory, cardiovascular, frailty, mental health, psychological support, cancer, children and maternity, musculoskeletal and end of life.

He emphasised that Pennine Lancashire are working together to design an accountable care system, with a memorandum of understanding already signed. There is a governance framework in place and regular meetings are in progress. It had been agreed that the new model of care has to be in place before organisation structures are reviewed.

He concluded by suggesting that the ‘ask’ of the STP from Pennine Lancashire is:

a. Clarity over the District General Hospital offer for Pennine Lancashire residents a. Determining the tertiary specialist network offer for Pennine Lancashire residents b. Managing lead commissioner arrangements as we move towards “accountable care” in LDPs and deciding how services that fall outside an LDP c. How we standardise enablers such as digital, workforce – should we do them once and implement at HL&SC level?

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d. Standardisation on some elements of the programme which are implemented in LDPs – e.g. prevention / primary care?

e. Can the STP / JCCCGs provide the scale required to ask important questions nationally e.g. social care funding?

Chris Clayton stated that we cannot tackle all of the areas at once and these need to be planned.

In view of some of the work that was being led by Andrew Bennett, he was tasked with drawing-up a draft description of what Accountable Care means, for distribution to members of the Committee.

ACTION: Andrew Bennett to circulate a draft description of Accountable Care.

RESOLVED: The presentation was received and noted.

West Lancashire

Paul Kingan, Chief Finance Officer for West Lancashire LDP presented an update on the programme. He highlighted that this LDP was relatively small and included 19 GP practices, 3 neighbourhoods and had a population of 112,000. All of the 19 practices have signed up to one federation.

Due to the boundaries of the LDP, they also have to take into account both Merseyside and Greater Manchester STPs along with Lancashire and South Cumbria, because of the complicated mix of patient flows.

The acute patient flows are largely towards Merseyside and Greater Manchester, but the community and local services are provided in Lancashire. The LDPs key focus is it’s out of hospital strategy and Paul quoted the 1948 World Health Organisation definition that -“Health is a state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity.”

He displayed a slide highlighting the LDP strategy which covered:

a. Community Services Transformation b. Primary Care Transformation c. Out of Hospital strategy “Building the future together” d. Health inequalities including Well Skelmersdale

Paul discussed the links between the local delivery plan and the Healthier Lancashire and South Cumbria plan, and played a video on “Well Skelmersdale” and asked the Committee to consider the inter-relationships.

The ask of the STP from West Lancashire is: a. How can we link this with the prevention workstream? b. How can we link this with the enablers?

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c. How do we get the pace needed?

ACTION: Paul Kingan to circulate the web link for the video.

RESOLVED: The presentation was received and noted.

17-03-10 Child and Adolescent Mental Health

Peter Tinson presented the Lancashire Children & Young People’s Emotional Wellbeing & Mental Health Transformation Programme discussing the commitment to children and young people and highlighting the issue that 75% of mental health issues start by the age of 18.

The programme has been in existence for 18 months and there is a full programme board in place. The plan for the programme was signed off in January 2016. The plan for 2017/18 has recently been refreshed and the funding which is spent collaboratively across the region had been identified.

Through engagement in stakeholder workshops they had gained views on the experiences and needs of young children and currently produce a monthly bulletin to keep them informed on the work of the programme.

Recent CAMHS patient surveys show that there is a high level of satisfaction and happiness from parents, carers and children for most aspects of the services, although there are still issues to be addressed including waiting times and lack of community venues.

The programme acknowledges that although they have made a lot of progress there is still a lot more to undertake. The information presented covered Lancashire and Peter said that the scope of the programme in future has to include South Cumbria.

RESOLVED: The presentation was received and noted. 17-03-11 Any Other Business Info

The item requested by Doug Soper was covered in Amanda Doyle’s opening points and no other business was noted. Closing remarks

The Chair thanked the Committee members for their attendance and noted that he was delighted at the interest shown from the General Public and closed the meeting prior to taking questions from the gallery.

The date and venue for the next meeting are to be confirmed, but the Chair asked that the Committee members still keep the 6th April 2016 in their diaries.

Topics discussed through the Public Questions: STP documents and their clarity

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Terminology used in documents received from NHS England Minutes from meetings – availability on website PWC report issued by Lancashire County Council Bed situation and how it is being managed Social Care cut backs and impact of closure of leisure centres Federations of General Practices and accessibility Clarification of financial information provided at last meeting

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Joint Committee of the Clinical Commissioning Groups (JCCCGs)

Minutes of the Joint Committee of the Clinical Commissioning Groups held on Thursday 6th July 2017, 1pm – 3pm at the Banqueting Suite, South Ribble Borough Council, West Paddock. Leyland, Lancashire, PR25 1DH

Chair Phil Watson Independent Chair JCCCGs Attended Voting Alex Gaw Chair Morecambe Bay CCG Apologies Members Andrew Bennett Chief Officer Morecambe Bay CCG Attended Chris Clayton Chief Clinical Officer Blackburn with Darwen CCG Attended Debbie Corcoran Lay Member Greater Preston CCG Attended Sumantra Mukerji Chair Greater Preston CCG Apologies Doug Soper Lay Member West Lancashire CCG Apologies Marie Williams GP Member Blackpool CCG Apologies Geoffrey O’Donoghue Lay Member Chorley South Ribble CCG Attended Gora Bangi Chair Chorley South Ribble CCG Attended Graham Burgess Chair Blackburn with Darwen CCG Attended Mark Youlton Chief Officer East Lancashire CCG Apologies Mary Dowling Chair Fylde and Wyre CCG Attended Paul Kingan Chief Finance Officer West Lancashire CCG Attended Phil Huxley Chair East Lancs CCG Attended Roy Fisher Chair Blackpool CCG Attended Adam Janjua Clinical Lead Vice Chair Fylde and Wyre CCG Attended Non-Voting Allan Oldfield Chief Executive Officer Fylde Council Attended Members Amanda Doyle Accountable Officer Healthier Lancs & South Cumbria Apologies Andrew Bibby Director for Specialised Attended Services NHS England Andy Curran Medical Director Healthier Lancs & South Cumbria Attended Carl Ashworth Service Director Healthier Lancs & South Cumbria Attended Dean Langton Chief Executive Officer Pendle Council Apologies Gary Hall Chief Executive Officer Chorley Council Attended Gary Raphael Finance Director Healthier Lancs & South Cumbria Attended Harry Catherall Chief Executive Officer Blackburn Council Attended Jane Higgs Director of Operations NHS England Attended Dave Tilleray Deputy Chief Executive West Lancs Borough Council Attended Lawrence Conway Chief Executive South Lakeland District Council Apologies Karen Smith Chief Executive Officer Blackpool Council Attended Sir Bill Taylor Chair Healthwatch Attended Diane Wood Chief Executive Cumbria County Council Apologies Sakthi Karunanithi Deputy Lancashire CC Attended In Jacquie Allan Exec Support Officer Healthier Lancs & South Cumbria Attended attendance Neil Greaves Comms & Engagement Healthier Lancs & South Cumbria Attended Malcolm Ridgeway Primary Care NHS England Attended Jackie Forshaw Primary Care NHS England Attended Mark Spencer Primary Care NHS England Attended

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ACTION 17-07-1 Welcome and Introductions Info

The Chair welcomed the members of the Committee to the formal meeting. He explained the status of the meeting and that the Committee had invited members of the public to observe what happens at these important decision making meetings. He clarified that this was a meeting held in public but not a public meeting, although the members of the public would be allowed to ask questions relating to agenda items at the end of the meeting.

He explained to the Public that Lancashire Television would be filming the meeting. He had approved this to demonstrate our commitment openness and transparency in the JCCCGs when making decisions. 17-07-2 Apologies and Quoracy Info

Apologies were acknowledged and the meeting was declared quorate.

RESOLVED: The Chair noted the apologies and declared the meeting quorate 17-07-3 Declarations of Interest Info

RESOLVED: It was agreed that the “A vision from Primary Care Transformation” could contain items that could result in the GPs on the JCCCGs being conflicted. 17-07-4 Minutes from the previous meeting held on the 2nd March 2017 Info

The minutes of the meetings were reviewed, and amendments made.

A discussion followed on the accuracy of the Terms of Reference (ToR), highlighted in point 17-03-04. It was noted that the version of the ToRs circulated most recently was not the final version approved by the Joint Committee. Work still needs to be completed to ensure all relevant conversations and actions from separate meetings between Capsticks and the CCGs were incorporated into the ToR. It was agreed that in line with the new governance proposals, the ToR would be revisited, and a sub group would finalise and recirculate the ToRs as a matter of urgency. Further revisions thereafter could be incorporated in the review planned for March 2019. With this action the members of the JCCCG were happy to proceed.

The Chair asked that with the agreed changes and acknowledgement of the need to review the ToR, the Committee would accept the minutes of the meeting.

RESOLVED: The minutes of the meetings were accepted subject to the relevant changes being made to the 2nd March meeting.

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17-07-05 Action Matrix Review Info

The Action Matrix from the previous meeting was reviewed.

17-01-09 Evaluation and Hurdle Criteria: Prior to purdah this was discussed at the Programme Board meeting and more work is required for the exercise to be completed. This will be presented at the September JCCCG.

17-03-07 Integrated Diagnostic paper: This has been deferred to October 2017.

17-03-09: West Lancashire LDP Presentation: This has been uploaded to the HLSC Website.

17-03-09: Accountable Care Systems: A description was forwarded as requested to members of the JCCCG with the agenda for the meeting.

RESOLVED: The action matrix was reviewed and updated. 17-07-06 Any Other Business Declared: Info

The Chair asked the members of the Committee if they had any other business they wished to declare for discussion at the end of the meeting.

At this point Sir Bill Taylor reminded the Committee that it would be more helpful for the public if the Committee could refrain from using acronyms. This was agreed.

The Chair added to the public that there would be time once the formal meeting had been closed for the audience to ask questions. 17-07-07 A Vision of Primary Care Transformation Info

Dr Malcolm Ridgway presented a slide deck on the vision for Primary Care. Key messages were: • A standardised primary care offer delivered in community settings where it is safe and cost effective do so, provided by integrated teams serving a population of between 30,000 to 50,000, 8am until 8pm, 7 days per week • The hypothesis is that it is expected that the amount spent on secondary care by CCGs will remain relatively static over the next four years. CCG growth funding will be channelled into primary care to manage increased demand and there will also be a necessity to invest in prevention, self-care and community resilience • Primary Care Networks (PCNs) are the simple first steps for GPs; these are collaborations between primary care providers developing a multidisciplinary team approach. These can become business units of MCPs or other Accountable Care Systems. There are already models across the HLSC footprint in varied stages of development and maturity • The NHSE Primary Care Transformation team is working with the LDPs and CCGs, utilising their local expertise. There will be funding available to co-produce plans around the practices and other providers integrating and working at scale to manage more people in the community. • A project completed in the Pennine Lancashire area has shown that a third of

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admissions and emergency attendances could have been managed in the community

There is a need for whole systems change, including Extensivist GPs working with specialist teams managing people in their own homes and Accountable Care Systems.

Dr Mark Spencer commented that the final slide in the deck was most important referring to prevention and healthier communities. We need to focus on wellness rather than illness.

Questions and answers followed:

It was felt that training for GPs and the workforce was an important issue and should have been emphasised in the presentation. The way the workforce will have to operate going forward will be very different from what they are doing presently. There will be a need to work in an integrated way. The need to continue with GP trainers was considered central, to ensure the correct skill mix across the Lancashire and South Cumbria footprint.

The importance of finance and the flow of funding were also discussed.

Quality was stressed as the most important aspect, but efficiency, cost savings and continuity of services were also substantial issues. As there are decreasing numbers of GPs, there is a need to make changes to the model of care to mitigate this impact. Some of the current changes currently taking place within practices was likened to ‘sticking plasters’, when a whole service redesign is required to make then sustainable.

The Primary Care team is now engaging with fellow professionals and stakeholders to propose the next steps.

Sir Bill Taylor made the point that through Healthwatch any engagement events should be made available and put into the public domain Mr Neil Greaves confirmed that any events are also published on the Healthier Lancashire and South Cumbria website.

RESOLVED: The JCCCG noted the proposals and the next steps to move them forward.

17-07-08 Governance of the STP – Issues for the JCCCGs Info

Mr Gary Raphael presented a paper explaining the rationale for changes to the Sustainability and Transformation Partnership (STP) governance structure, especially with respect to the relationship between a proposed STP Board and the Joint Committee of CCGs (JCCCGs). He explained that the structure had already been taken to several different forums and discussed in detail with Chief Executives and Chief Officers.

The composition of the STP Board had been directed by NHSE and NHSI and for Lancashire and South Cumbria this had been interpreted as follows:

• An executive lead from each of the LDPs/ACS

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• Up to five non-executive/lay members drawn from CCGs and FTs/NHS Trust • A councillor representative from each of the four upper tier local authorities • The STP lead and other, interim, STP executives • A primary care provider representative • Other officers and/or observers in attendance, as required

The final governance structure will need to be considered by NHSE and NHSI, for them to accept and endorse the recommendation ns.

The Committee was asked to: note the content of the paper; endorse the proposals if possible; and note that formal proposals were to be made to boards and governing bodies within the next month to enable them to support the new governance arrangements.

Discussions followed with sections being highlighted from the report.

Point Comment 10 Mandate – is this the correct wording STP cannot make decisions – this is not in relation to the STP it is in relation to the totalities of what the STP may tale on 5 Is a presumption? 14 Is there not the same conflict for providers? Appendix 1 It was felt that the diagram was traditional and further work needed to be finalised. Greater clarity was required on the accountability and nature of relationships

In response to point 10, GR explained that there will be an element of mandate in the STP Board’s work as both NHSE and NHSI will continue to hold organisations to account even as they align their functions with the STP and NHSE/I senior managers are likely to be on the Board in officer roles.

GR thought that he had made a factual point in paragraph 5. In the current governance arrangements the JCCCGs is the focal point of decision making but in the proposed new governance structure the STP Board brings together commissioner and provider perspectives and will be expected to lead strategy development and implementation.

GR explained the reason for identifying a constraint in the membership of the STP Board’s non-executive membership: if the JCCCGs was to receive a ‘referral’ from the STP Board for a commissioning decision, it would surely be better not to have the same lay members reviewing the STPs Board’s recommendations if they were on both bodies? GR did not think that any other STP Board or JCCCGs members could be in that position.

GR confirmed to the Committee that he would welcome any discussion outside of the meeting in order to refine the proposals and asked that any further comments be sent to him for response.

A final comment was that the STP Board should not be established as ‘just another meeting’ on top of everything else currently being done. It was suggested that greater ______Joint Committee Clinical Commissioning Group Page 5 of 7

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efforts needed to be made to rationalise the number of meetings and forums across Lancashire and South Cumbria to enable us to make the new arrangements work better for us all. These sentiments were endorsed by all at the JCCCGs.

The Committee thanked GR for the paper, acknowledging that it was a welcome explanation of the plans for the new STP Board. The Committee felt that the plans could be refined and looked forward to some further discussions over the summer period alongside CCG governing bodies and provider boards being asked to support refined proposals.

ACTION: The paper was noted and following today’s discussion, the governance structure will be refined and forwarded to all Chief Executives and Accountable Officers of Trusts, CCGs and Local Authorities, so that they are able to provide formal feedback on the plans. This amendment was agreed. 17-07-09 Development of proposals for delegated decision making in the Joint Committee of CCGs

Mr Andrew Bennett presented an update to the members on the development of proposals for delegated decision making from CCG Governing Bodies.

The paper confirmed that CCG Accountable Officers are sponsoring the development of a common paper for each CCG’s Governing Body which will set out proposed areas for delegated decision making to the Joint Committee. It is essential that the delegations requested were specific enough to enable CCG Governing Bodies to understand the scope and impact of decision making both on the STP as a whole as well as local health and care systems.

The workstream leads had been asked to identify the delegated decisions and work is continuing to complete the drafting of this paper during July 2017. It is expected that a final version of the delegations paper will be available for consideration by CCG Governing Bodies during August and September.

The papers were well received and the members were appreciative of a document to take back through their respective CCGs for comment.

There were a few comments on the amount of time that was being taken to establish the committee. Mr Paul Kingan pointed out that although it sometimes felt that little progress had been made in fact the STP had already undertaken a lot of work and what we are trying to do through the decision making arrangement was to formally agree a process.

ACTION: Note the current development of proposals for delegated decision making to the Joint Committee of CCGs.

17-07-10 Any other business

There was no other business raised at this point.

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Joint Committee of the Clinical Commissioning Groups (JCCCGs)

The next JCCCG Meeting will be held on the 7th September 2017 at Chorley Town Hall, Market Street, Chorley, Lancashire.

Topics discussed through the Public Questions: Access to papers prior to the meeting – it was confirmed that these should and will be posted on the website The New STP Board Self-Diagnosis Public Health Education and new technology Use of ANPs Capturing success

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Joint Committee of the Clinical Commissioning Groups (JCCCGs)

Minutes of the Joint Committee of the Clinical Commissioning Groups held on Thursday 7th September 2017, 1pm – 3pm at Chorley Town Hall – Lancastrian Suite

Chair Phil Watson (PW) Independent Chair JCCCGs Attended Voting Alex Gaw Chair Morecambe Bay CCG Apologies Members Andrew Bennett Chief Officer Morecambe Bay CCG Attended Chris Clayton Chief Clinical Officer Blackburn with Darwen CCG Attended (One vote Sumantra Mukerji Chair Greater Preston CCG Attended per CCG) Doug Soper Lay Member West Lancashire CCG Attended Susan Fairhead GP Member Blackpool CCG Attended Geoffrey O’Donoghue Lay Member Chorley South Ribble CCG Attended Gora Bangi Chair Chorley South Ribble CCG Attended Graham Burgess Chair Blackburn with Darwen CCG Attended Mark Youlton Chief Officer East Lancashire CCG Apologies

Jackie Hanson Director of Quality and East Lancashire CCG Attended

Performance

Tony Naughton Chief Clinical Officer Fylde and Wyre CCG Attended

Mary Dowling Chair Fylde and Wyre CCG Attended

Paul Kingan Chief Finance Officer West Lancashire CCG Attended

Phil Huxley Chair East Lancashire CCG Attended

Debbie Corcoran Lay Member for Patient & Greater Preston CCG Attended Public Involvement David Bonson Chief Operating Officer Blackpool CCG Attended In Amanda Doyle STP Lead Healthier Lancs & South Cumbria Attended attendance Andrew Bibby Director for Specialised NHS England Attended Services Andy Curran Medical Director Healthier Lancs & South Cumbria Attended Carl Ashworth Service Director Healthier Lancs & South Cumbria Attended Gary Hall Chief Executive Officer Chorley Council Attended Gary Raphael Finance Director Healthier Lancs & South Cumbria Attended Jane Higgs Director of Operations NHS England Attended Lawrence Conway Chief Executive Officer South Lakeland District Council Attended Sir Bill Taylor Chair Healthwatch Attended Debbie Nixon SRO Mental Health Healthier Lancs & South Cumbria Attended Neil Jack Chief Executive Blackpool Council Attended Sakthi Karunanithi Deputy Lancashire County Council Attended Hannah Milton Business Support Healthier Lancs & South Cumbria Attended

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Joint Committee of the Clinical Commissioning Groups (JCCCGs)

ACTION 17901 Welcome and Introductions Info

The Chair welcomed the members of the Committee to the formal meeting. He explained the status of the meeting and that the Committee had, for the first time, invited members of the public to a drop-in session prior to the meeting, in order to give them the opportunity to ask questions in advance of the meeting. He added that there would still be an option to ask questions when the meeting had finished.

The Chair acknowledged Chris Clayton’s departure from the Committee and thanked him on behalf of the Committee and other colleagues for all his efforts and hard work, both in Pennine Lancashire and also the wider STP. The Committee wished him well in his future role. 17902 Apologies and Quoracy Info

Apologies were received from Alex Gaw, Roy Fisher, Marie Williams and Mark Youlton. These were acknowledged and the meeting was declared quorate.

RESOLVED: The Chair noted the apologies and declared the meeting quorate 17903 Declarations of Interest Info

RESOLVED: None declared

17904 Minutes from the previous meeting on 6th July 2017 – amendments were discussed as Info and follows: action • Page 1 – Organisation name incorrect for Dr Sumantra Mukerji - Amendment: change to Greater Preston CCG. • Page 2 - Minute from the Joint Committee meeting in March regarding the Terms of Reference – Amendment: It was noted that the version of the Terms of Reference circulated most recently was not the final version approved by the Joint Committee. It was therefore agreed that the most recent version of the Terms of Reference would be recirculated to Committee members again, noting that further comments and revisions will be incorporated in March 2018 when they will be reviewed. • Page 3 – Primary Care Transformation item – Amendment: Outcome of the discussion was that the JCCCG noted the proposals and the next steps to move them forward. • Page 5 second paragraph – governance item – Amendment: Mary Dowling suggested that the action on this item did not fully reflect the discussion that took place at the meeting and proposed that it should be as follows: ‘ACTION: The paper was noted and following today’s discussion, the governance structure will be refined and forwarded to all Chief Executives and Accountable Officers of Trusts, CCGs and Local Authorities, so that they are able to provide formal feedback on the plans.’ This amendment was agreed.

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Joint Committee of the Clinical Commissioning Groups (JCCCGs)

It was noted that there are some outstanding changes to be made to the minutes from the Joint Committee meeting in March. Mary Dowling has provided comments outside of this meeting and these will be incorporated and the minutes will be brought back to the Joint Committee in November for formal ratification.

RESOLVED: The minutes of the meetings were accepted subject to the relevant changes STP Admin being made. Team 17905 Action Matrix Review Info

The Action Matrix from the previous meeting was reviewed as follows:

1. Hurdle and Evaluation Criteria: This item has been deferred to the next meeting. 2. Integrated diagnostics update: This item has been deferred to the next meeting. 3. JCCCG Terms of Reference (ToR) - Mary Dowling commented on the ToR and suggested that the Committee should have the final agreed version available to it. The general view was that because of the changes that are taking place in the various other associated groups, such as the STP Board being established and the change in emphasis on the Programme Board and the wider governance of the programme, it makes sense to wait until the end of the financial year to review these, once the new bodies have been in operation for a few months.

Amanda Doyle agreed that the most recent ToR which are being worked to could be recirculated, accepting that these would be reviewed in March 2018.

ACTION: Recirculate the most recent version of the ToR, once Mary’s comments have STP Admin been incorporated. Team 17906 Any Other Business Declared: Info

The Chair asked the members of the Committee if they had any other business they wished to declare for discussion at the end of the meeting.

Gary Raphael stated that he would like to discuss the position on capital bids.

The Chair added that there would also be an opportunity for the public to ask questions at the end of the formal meeting. 17907 Programme Overview Info

Carl Ashworth presented a paper on the STP Outline Work Programme for 2017/18.

Amanda Doyle added that this is an STP level work programme and the purpose for the update was to provide the Committee with an understanding of the overarching programme activities and how the work in Local Delivery Partnerships (LDPs) fits with the wider STP strategy.

STP’s are expected to make progress across the following areas: 1. Establishing STP governance arrangements 2. Delivery and assurance of system performance against NHS Constitution and other

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Joint Committee of the Clinical Commissioning Groups (JCCCGs)

targets 3. Achievement of system sustainability 4. Transformed services that manage future demand in a different way 5. Designing future commissioning/provider arrangements through ACS and strategic commissioning developments

So far, Senior Responsible Officers have identified decisions for the JCCCGs in 2017/18, to sign off clinical policies, agree process and evaluation criteria and agree a strategic commissioning model.

The role of the JCCCGs in 2018/19 will be to sign off clinical policies and the short list of options for consultation.

An MOU (Memorandum of Understanding) has been agreed between NHS England and the STP, which aligns regulatory responsibilities to support the work of the STP. NHS Improvement had not yet agreed their input to the MOU.

Amanda Doyle commented that this will be a fluid piece of work, in that as people agree delegations to the Joint Committee, the work around those decisions will be added to this work plan.

Mary Dowling expressed a concern regarding the decision making role of the Joint Committee in the context of the proposed STP governance arrangements.

Amanda Doyle commented that the Committee can only be responsible for things that the individual CCGs delegate to it. She added that the role of the Joint Committee is really important in relation to some of the major issues, but unless the individual CCGs delegate the decision making around those things to the Committee, the work required cannot be progressed effectively. Amanda also suggested that as the STP matures and develops, the responsibilities for the Joint Committee are likely to increase. Mary Dowling said that it was her understanding that delegation had already occurred through the terms of reference of the Joint Committee and the Committee now awaited the proposals/business cases on the major issues it needed to decide.

Amanda Doyle and Mary Dowling agreed to discuss this further outside of this meeting.

Amanda stated that the Committee should be taking some responsibility for performance management in relation to the priority areas – including quality. At present, no CCG has led Amanda to believe that they are willing to delegate their own responsibility for this to the Committee; however, Amanda added that she would welcome CCG’s that would like to pursue a conversation about this.

Phil Huxley queried how we would enable clinicians to engage in conversations if we are dealing with things more centrally via the Committee. Amanda added that we need to widen our engagement to people at all levels and bring their comments and feedback to the process.

Mary Dowling congratulated Carl Ashworth on the work which had gone into his paper and added that it was very helpful in taking things further forward. She remained ______Joint Committee Clinical Commissioning Group Page 4 of 9

Joint Committee of the Clinical Commissioning Groups (JCCCGs)

concerned that the role of the Joint Committee was not adequately reflected particularly in relation to delivery and assurance of system priorities.

The paper was well received and members were appreciative of the clarification this provides.

RESOLUTION: The paper was noted. 17908 Urgent Care Presentation Info

Andrew Bennett introduced the presentations, highlighting the impacts of the Five Year Forward View in relation to commissioning. Lancashire and South Cumbria have an opportunity to develop new approaches to commissioning as follows:

• Collective: STP-wide e.g. through the Joint Committee. • Place-based: in local health and care “accountable care” systems. • Integrated: aligning resources and priorities with NHS England, Local Government and commissioning support services.

The next steps were outlined as follows: • A proposal has now gone to CCG Governing Bodies requesting delegated decision making into the Joint Committee for specific areas. • A Commissioning Development Strategy will now be developed – encompassing the next 2-3 years. • Two case studies to be presented today – Urgent and Emergency Care and Mental Health.

David Bonson thanked Andrew for setting the scene and commenced his presentation on Urgent and Emergency Care.

Key messages were discussed as follows: • Urgent Care is a whole system – not just A&E services. • Urgent and Emergency Care Plan – There are seven key priorities which will deliver transformation of Urgent and Emergency Care. These are: 1. NHS 111 Online – being tested and rolled out during 2017. 2. NHS 111 Calls – by the end of 2017/18 the percentage of calls receiving clinical advice will exceed 50%. 3. GP Access – by March 2019, patients will have access to evening and weekend appointments with general practice. 4. Urgent Treatment Centres – standardise approach nationally. These facilities will open 12 hours per day and will be staffed by clinicians, with access to simple diagnostics. 5. Ambulances – are currently under extreme pressure. Ensure right vehicles are despatched as quickly as possible and move to a hear and treat/see and treat model. 6. Hospitals – Emergency departments are very congested. Ensure that only patients that need to be there are there and others are screened and signposted to the most appropriate service. 7. Hospital to Home – Move on to home/more appropriate care setting at the

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Joint Committee of the Clinical Commissioning Groups (JCCCGs)

earliest opportunity. A lot of work is going on regarding delayed transfers of care (DTOC).

• Urgent Treatment Centres - national service specification was published in July 2017. The aim is to have 150 Urgent Treatment Centres in place by 2017, with full coverage by December 2019. Key components of the specification are: o GP led service as part of multidisciplinary workforce o Open at least 12hrs a day, 7/365 o Direct booking from NHS111, ambulance services, GPs and “Walk in” o Access to simple diagnostics and X-ray facilities

• Performance –The national expectation is that we achieve the standard of 90% of people seen within the 4 hour period by September 2017 and 95% by March 2018.

Amanda Doyle thanked David for the presentation and asked if he could be more specific about the action that needs to be taken immediately.

David responded by suggesting that there is a need to do a stock take of contracts for CCG’s and providers, in order to move this work forward, in terms of where we are now against the national specification. There is a deadline for the end of September 2017. This is a very specific ‘ask’. The Lancashire and South Cumbria Urgent Care Workstream is co-ordinating this piece of work.

David added that there is a need to quickly think about what the commissioning arrangements would look like to deliver the requirements described in the service specification. Lead commissioner arrangements are linked with the delegated decisions work.

There will also be a requirement to work collaboratively with providers around the function of the whole of urgent care, with an integrated approach to managing the workforce to deliver this effectively.

There is also a plan to use business intelligence to track the patient journey, to help with understanding patterns, demand and risks.

The Chair asked if there were any questions.

A discussion took place around recent A&E performance, which is currently a risk across the whole system. We are in a very challenged position and there is a need to focus on what we are going to do about it. Lancashire and South Cumbria have an opportunity to work collectively to improve performance across the system.

Geoffrey O’Donoghue asked whether the presentations could be circulated with the papers for the Joint Committee. Amanda responded to state that the NHS England Urgent Care Specification has already been cascaded and that the presentations that are used, do not always tell the full story, as they are used as a tool to aid full explanation and therefore there could be a risk of confusion and misinterpretation if they were on the website.

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Joint Committee of the Clinical Commissioning Groups (JCCCGs)

The Joint Committee is asked to agree the following:-

To proceed with the stock take of existing contracts with CCG’s and Providers to take this work forward.

RESOLUTION: The Joint Committee agreed this. 17909 Mental Health Presentation Info

Debbie Nixon and Andrew Bibby presented a slide deck, which built on David Bonson’s Urgent Care presentation.

Debbie explained that the Mental Health Five Year Forward View is very explicit and sets a complex direction of travel in the following priority areas:

• Children and young people’s mental health • Perinatal mental health • Adult mental health: common mental health problems • Adult mental health: community, acute and crisis care • Adult mental health: secure care pathway • Health and justice • Suicide prevention

In addition to the Mental Health Five Year Forward View, there is a requirement to deliver a Mental Health Delivery Plan, which is aimed at monitoring performance and delivery through one function. This is very prescriptive, particularly around workforce and the delivery of outcomes. There are some really clear milestones that need to be delivered.

There will be a consistent high quality offer for mental health services, regardless of where people live. There will be a tiered approach to services as follows: • Tier 1 services – neighbourhood level • Tier 2 services – Local Delivery Partnerships • Tier 3 services – STP level • Tier 4 services – STP or inter STP

There is currently significant variation across Lancashire and South Cumbria which needs addressing. There will be a consistency around the ‘what’ but local flexibility about the ‘how’ (taking account of incidence; population density; demography; geography).

There are also a range of services that are in the main commissioned by NHS England – including children, health and justice, secure services for adults, inpatient services and perinatal services. There will be equitable access for the whole population. The tier approach aims to deliver seamless transition for patients, irrespective of where they are from.

There is also a huge opportunity around prevention and reducing demand, supporting people in communities to play an active role in their health and care.

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Joint Committee of the Clinical Commissioning Groups (JCCCGs)

We have seen recent improvements in our performance in mental health and we have been rewarded for this, in that we have received capital resource to improve perinatal inpatient services, hospital liaison and transformation resource for improving access.

We have an opportunity for greater collaboration across the whole patch, to help us to progress at pace, improve clinical outcomes, utilise workforce effectively, manage performance through a single system and increase our overall productivity and efficiency.

Lancashire and South Cumbria are doing well against some of the performance indicators, but we are not achieving all. Step changes are required to achieve national priorities and mandates. We need to look at things to implement collectively or consistently.

Debbie suggested a slight amendment to the ‘ask’ of the Joint Committee as outlined below.

The JCCCG is asked to agree the following:

To receive a detailed proposal for a revised operating model for the commissioning of mental health services. This aims to implement the national mental health and wellbeing strategy.

RESOLUTION: The Joint Committee agreed this. 17910 Any other business

1. Capital

Gary Raphael presented a slide deck on the Capital Bid. He explained that we had been successful previously, despite the tight timescales we had to refine and submit the bids.

Wave 1 success: • Mental Health Inpatient scheme affecting Burnley and Chorley hospitals (£5m to £10m scheme) • A&E development at Blackburn Hospital (£5m to £10m scheme)

Gary explained that as part of Wave 2 (September 2017), we will be submitting a Lancashire & South Cumbria pathology scheme, covering all four acute trusts with an estimated cost of £31m. In addition to the pathology scheme, we had decided to make NHS England and NHS Improvement aware of the priority schemes for Lancashire and South Cumbria, in relation to urgent and emergency care services, in effect, the pipeline of developments that were not yet ready for wave 2 submission, but would be next in line.

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The relevant submission was still in development, but so far the benefits and costs of this could be outlined as follows: • Improvements to A&E and RTT (Referral to Treatment Time) • Improvements to cancer treatment • Patient experience improved in A&E • Costs circa £35m over next 2 years

The Joint Committee is asked to support the following:-

Submission of this bid.

RESOLUTION: The Joint Committee supported this. 2. The next Joint Committee meeting – incorrect date on the agenda

The Chair stated that the date of the next Joint Committee meeting was outlined incorrectly on the agenda. He confirmed the correct date as 2nd November 2017 – 1.00pm – 3.00pm – Morecambe Bay CCG - The Lecture Theatre, Moor Lane Mills, Moor Lane, Lancaster, Lancashire, LA1 1QD. A message will be communicated to the public via the website and via Local Delivery Partnership communication channels.

The next JCCCG Meeting will be held on: 2nd November 2017, 1.00pm – 3.00pm - Morecambe Bay CCG - The Lecture Theatre, Moor Lane Mills, Moor Lane, Lancaster, Lancashire, LA1 1QD

The Chair thanked the Committee members and members of the public for their attendance and closed the meeting prior to taking questions from members of the public.

Topics discussed through the Public Questions: 1. Access to papers prior to the meeting, difficulties accessing the website and publicising the Joint Committee meetings dates via different channels. 2. Our confidence in achieving success.

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GOVERNING BODY MEETING

ACCIDENT AND EMERGENCY POSITION UPDATE Date of Meeting 8th November 2017 Agenda Item 13

CCG Corporate Objectives

Through better commissioning, improve local health outcomes by addressing poor outcomes and inequalities To work collaboratively to create safe, high quality health care services To maintain financial balance and improve efficiency and productivity To deliver a step change in the NHS preventing ill health and supporting people to live healthier lives To maintain and improve performance against core standards and statutory requirements x To commission improved out of hospital care CCG High Impact Changes Delivering high quality Primary Care at scale and improving access Self-Care and Early Intervention Enhanced and Integrated Primary Care and Better Care Fund Access to Re-ablement and Intermediate Care Improved hospital discharge and reduced length of stay Community based ambulatory care for specific conditions Access to high quality Urgent and Emergency Care x Scheduled Care Quality GOVERG BODGOVERNING BODY MEETING

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Clinical Lead: Dr David White

Senior Lead Manager Mr Alex Walker Finance Manager N/A Equality Impact and Risk Assessment N/A completed: Patient and Public Engagement completed: N/A Financial Implications N/A Risk Identified N/A Report authorised by Senior Manager: Mr Alex Walker Y

Decision Recommendations The Governing Body is requested to consider and support the content of the report.

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CLINICAL COMMISSIONING GROUP (CCG)

GOVERNING BODY MEETING

8TH NOVEMBER 2017

ACCIDENT AND EMERGENCY POSITION UPDATE

1. Introduction

1.1 Accident and Emergency (A&E) performance has remained challenging throughout 2017/18 with the system rarely achieving the required 95% level for seeing and either treating or discharging patients. The service provides an urgent and emergency care service at a number of access points across Pennine Lancashire and patients can arrive unannounced at any time of the day or night. Ensuring that a safe and swift service is provided at all times is the priority of both the providers and commissioners.

1.2 East Lancashire Hospitals NHS Trust (ELHT) is the main provider delivering 24 hour services, 365 days per year from the hospitals at Blackburn and Burnley. In addition they provide a 12½ hour Minor Injury Unit (MIU) service every day from the Accrington Victoria Hospital (AVH) site. A private provider PDS medical deliver a similar MIU service from Rawtenstall Health Centre, for 12hrs per day. A further access point for minor illness operates from AVH in the form of the Health Access Centre; provided by East Lancashire Medical Services (ELMS).

1.3 These services are scrutinised continuously with numerous data streams coming into various parts of the CCGs as well as into the regulators, NHS England (NHSE) and NHS Improvement (NHSI). As part of assurance processes requests have recently been made to provide a system-wide recovery plan that is designed to improve the A&E performance position such that it delivers a 90% level by the end of September 2017, building up to 95% by the end of March 2018. Following this, requests were received to provide a level of assurance regarding Winter Planning for the system. As a result a combined approach was taken across the system to develop plans that initiated a number of schemes that would drive change throughout the system resulting in improved performance.

1.4 The purpose of this report is to outline to the Blackburn with Darwen CCG Governing Body the steps that the Urgent and Emergency Care system have taken locally to improve performance, to describe the improvement schemes being implemented and to report on progress to date.

2. Purpose / Background

2.1 The main aim of this report is to outline the plans for improving the performance of the Urgent and Emergency Care system. The objective is to explain the recent levels of performance that the system has delivered. It is also to explain the plans that are in process to drive improvement through a number of changes to the system. Finally it is to describe the impact that some of the changes have begun to have on the system.

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2.2 Performance of the Urgent Care system in Pennine Lancashire is presented in graphs 1 and 2 below. As can be observed, the continuous yellow average performance line runs significantly below the required performance level indicated by the dotted red line of 95%.

Graph 1 – ELHT A&E Performance Rolling 12 Month Position

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Graph 2 – ELHT A&E 4 Hour Performance 2017-18

2.3 A number of key national documents have been issued in the past couple of years that attempt to provide blueprints and drivers for sustainable improvements in Urgent Care systems nationwide. The issue of poor performance is not restricted to Pennine Lancashire. It is fair to say that it remains a considerable challenge for most Trusts up and down the country. Locally we have taken all of these national directives and combined them with local priorities to develop a Plan on a Page (POAP). This comprehensive document covers transformational change across the full range of the patient journey from ambulances, to the front door, patient flow through the hospital to discharge and recovery back out into the community. This is detailed in Appendix 1.

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2.4 During August 2017, in response to poor performance during July a recovery plan was requested by NHSE/ I. Members of the A&E Delivery Board (AEDB) worked together to develop a robust plan concentrating on schemes that would make a substantial difference to the performance of both non admitted and admitted patients. These schemes have been lifted out of the POAP and in some cases their implementation has been accelerated in order to impact positively on both A&E performance and planning for winter.

2.5 In figure 1 The 4 Hour Performance Recovery Plan and its nine programmes are detailed. For each of these schemes it can be seen that an estimate has been given of the likely impact on A&E performance once the scheme is running at full capacity which will be sometime after it first commences.

2.6 On Graph 3 trajectories are shown that illustrate how performance has been modelled for the Urgent Care system until March 2018 firstly if we ‘do nothing’; the red line. This ‘do nothing’ scenario would be expected if there is no change in the system. Secondly the green line shows the modelling of the estimated impact of phasing in the recovery schemes. This second line shows that if the impacts come to fruition and the schemes adhere to the timetable outlined then the system will be able to deliver the required 90% performance by September 2017 and 95% by the end of March 2018. Plotted in blue is the actual performance to date.

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Graph 3 – A&E 4 Hour Performance Recovery Plan Trajectory

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Figure 1 – A&E 4 Hour Performance Recovery Plan

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2.7 To date the AEDB have had generally positive feedback from NHSE/I regarding the 4 hour recovery plan and performance of the system has shown some positive signs of improvement. The system achieved a monthly performance figure during September of just over 88%, narrowly missing the 90% target. Work continues to ramp up the schemes started in the past few months whilst preparation is underway to implement those other schemes that are scheduled to start in the near future.

2.8 The Blackburn with Darwen CCG Governing Body are asked to receive this paper, note the contents, acknowledge the excellent partnership working that has taken place so far and support the work plan going forwards.

3. Conclusion

3.1 The Urgent Care system in Pennine Lancashire remains under significant pressure and performance locally has not been at the levels that organisations would want it to be at on a sustained basis. However significant work has taken place over recent months to try to move the system onto a more sustainable footing by pushing ahead with a number of changes throughout the system that will have a positive effect through the traditionally difficult winter period.

3.2 There is a coherent, consistent and robust plan in place to transform the Urgent Care system locally that has been agreed via the AEDB and regulators to move Pennine Lancashire in a positive direction. These plans will continue to be implemented over the coming months and form part of much longer term plans not detailed here, including significant capital projects to deliver a much improved urgent care system for the residents of Pennine Lancashire.

4. Recommendations

4.1 The Governing Body is requested to consider and support the content of the report.

Alex Walker Project Director Urgent Care, Pennine Lancashire CCGs November 2017

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APPENDIX 1 – PLAN ON A PAGE ACCESS (SRO ALEX WALKER, DEPUTY ELIZABETH FLEMING) The ambulance service will offer a more equitable and clinically focused r STREAMING response that meets patient needs in an appropriate time frame with the North Pennine Lancashire A&E Delivery Board (SRO DR DAMIAN RILEY, DEPUTY NATALIE BROCKIE) fastest response for the sickest patients. West ED senior leadership team to confirm roles and responsibilities of command/ q PL deliverables 2017/18: Plan on a Page – September 2017 control to reduce known unwarranted variation. A process must be developed • Sustainable 7 day falls car (March 2018) PL to monitor effectiveness and approaches taken by senior Executive leaders to AEDB 999 • Sustainable 7 day Ambulance Liaison Officer (June 2017) Winter support the team to develop a consistent model. • Sustainable 7 day pathfinder option for Pennine Lancashire (December NHS I ELHT NHS E U&EC Discharge Footprint PL PL deliverables 2017/18: 2017) report Delivery Plan High Impacts Recovery AEDB Schemes • Core nursing review RBH, UCC and ED (May 2017) Implementation of • Programme of work relating to improved handover position (October 2017) Priorities 1‐5 Priorities 1‐7 Priorities 1‐8 PL AEDB agreed model (October 2017) • Review of Healthcare professional 999 conveyance utilisation (October North West UECN 7 • ENP/Physio service review (Sept 2017)

2017) Department Improvement

• Confirm sustainable in‐reach offer from orthopaedics and anaesthetics Throughout 2017 we will be testing innovative new models of service that n (October 2017) enable patients to enter their symptoms online and receive advice online or a North • Mobilise and continuous evaluation of command and control structures PL call back. West e.g. daily breach meetings, co‐ordinator roles, consultant‐led 2 hourly AEDB PRIMARY CARE ACCESS We will continue to develop the response patients receive when they call o NW board rounds (continuous) Emergency 111. By the end of 2017/18 the percentage of calls receiving clinical advice PL AEDB (SRO SHARON MARTIN, DEPUTY COLLETTE WALSH) Continuous • Evaluate management model changes and confirm sustainable model

111 will exceed 50%. By March 2019 patients and the public will have access to evening and after 3 month test period (October 2017) weekend appointments with general practice. p PL deliverables 2017/18: PL AEDB • Programme of work to review local Directory of Services (DOS) (November Primary PL deliverables 2017/18: • 7 Delivery of extended primary care access in Hyndburn Locality Develop a whole‐system approach to identifying and managing frailty with an r 2017) Care initial focus on delivering early functional assessment in ED and commencing a • Roll out Acute Patient Assessment Services (APAS) 24/7 (October 2017) (November 2017) PL Access comprehensive geriatric assessment. AEDB • Explore opportunities to link with Airedale Vanguard (October 2017) • Progress plans to deliver extended primary care access in East Lancashire (to commence Oct 17 for March 2019 completion) PL deliverables 2017/18:

Standardise access to ‘Urgent Treatment Centres’ through booked q Phase One: appointments via NHS 111. These facilities will have an increasingly for PL AEDB • 7 Operational monitoring of primary care streaming and minor injuries standardised offer ‐ open 12 hours a day and staffed by clinicians, with access to simple diagnostics (continuous)

DISCHARGE AND RECOVERY • 7 Collaborative system partner forum to be established to develop PL deliverable 2017/18 (SRO ALEX WALKER) delivery plan for Integrated Urgent Care (September 2017) Conclude draft modelling regarding number and locations of UTCs in Pennine We will speed up the assessment process and ensure that patients are • 7 Complete options appraisal for optimising utilisation of ambulatory Redesign

National requirements UCCs t care (October 2017) Lancashire(January 18) sent home as soon as possible and if home is not the best place for their PL PL immediate care, they will be transferred promptly to the most AEDB • 7 Complete options appraisal for interim Frailty Assessment Unit AEDB Suite appropriate care setting for their needs. (October 2017) PL deliverable 2017/18: u • 7 Implement Respiratory Assessment Unit and Home Non‐Invasive Care FLOW • Enhanced Health in Care Homes. Roll out of red bag scheme in 2017‐18 PL Ventilation service (October 2017) as part of Enhanced Health in Care Homes model. Wider EHCH delivery (SRO JOHN BANNISTER, DEPUTY TONY MCDONALD) AEDB • 7 Commission and mobilise Mental Health Triage service (November overseen as part of Vanguard delivery across Pennine Lancashire. 2017) The systematic implementation of the national SAFER patient flow bundle. nn • Pilot near patient testing for Chest Pain Pathway (December 2017) The implementation of the ECIP red and green day improvement tool PL deliverables 2017‐18: o 7 PL AEDB

should be a key focus area for the organisation under the ‘model ward’ roll • 7 Discharge to Assess ‐ Home first. Agree a home first principle and Emergency t Phase Two out. deploy a ‘movement’ campaign to engage staff, patients, carers and loved ones. It is essential that behaviour and attitudes from every qs • Options appraisal for delivery of ECP transformation in 2018/19 options PL deliverables 2017/18: PL (October 2017)

Review stakeholder is focused on ‘home first’ thus preventing deconditioning

• Evaluate progress of the Model Ward work and build on this to establish associated with prolonged unnecessary inpatient stays. Starting from a AEDB a programme of work which oversee the roll out of standardised process pilot of 2 patients a day, progress to 50 patients a week across the whole Phase Three

for Red2Green and discharge processes (July 17) Management

• Options appraisal for the formation of Emergency Care Suite in 2019/20 •Review and strengthen existing Internal Professional Standards of Pennine Lancashire by October 2017 Process

PL AEDB (December 2017) framework and audit process (Aug 17) • 7 Discharge to Assess ‐ CHC pathway. Move to 85% of CHC triggers and MDTs taking place outside an acute hospital setting by 2018 through In Emergency Departments we will develop new approaches prioritising the

•Standardisation of Board/ ward round processes across all wards using s needs of the sickest patients. Our frail and elderly patients will get specialist standardised checklist approach (TBC) the delivery of Discharge to Assess pathways in alternative care setting PL Care

assessments at the start of their care and those patients who could be better •Develop standardised process for identification and monitoring of EDD Discharge for further assessment (March 2018) AEDB

Discharge treated elsewhere, will be streamed away from Emergency Departments. and link to Criteria Led discharge (TBC) UECN deliverable 2017‐18: t PL deliverables 2017/18: •Roll out of Red2Green best practice across all wards and establish • Delivery of Home of Choice policy. Agree and sign off the Home of UECN Choice policy developed across Lancashire and South Cumbria. Use the Streaming • Work with NHS England Programme Management team to understand the PL appropriate audit framework (Oct 17) Primary designation of UTCs in the context of RBH UCC and BGH UCC (September 2018) AEDB

patient documentation, undertake staff training and agree funding PL AEDB PL deliverables 2017/18: st • Implementation of priority acute standards streams to support delivery of the policy (1 October 2017) Day PL deliverable in 2017‐18: 7 Clinical Service pr ESCALATION AND SYSTEM RESILIENCE • 7 Develop a single integrated model of IDS to support the Discharge PL PL deliverables 2017/18: from Acute setting, Home First, Discharge to assess and Intermediate AEDB (SRO KEVIN MCGEE, DEPUTIES JOHN BANNISTER AND ALEX WALKER)

• 7 Progress proposal for the restructure of the current Clinical Flow and care pathway by winter 2017. Will support 7 day working across the To review organisational/ system escalation plans and create action cards to p Site Management structure across with the aim of implementation ahead Discharge pathway (November 2017) ensure a consistent approach is applied to managing internal flow across the PL

Flow

of the 2017/18 winter period (Oct 17) PL deliverable in 2017‐18: organisation. The action cards should be monitored and effectiveness evaluated to AEDB PL AEDB •Audit and improvement on compliance with agreed escalation processes • Undertake a system diagnostic against the 5 current Intermediate care support continuous improvement. Alongside this: Develop and implement a full

at a specialty and trust level (Oct 17) pathway options as part of the roll out of the Home First and Discharge capacity protocol at times of heightened escalation. PL Restructure Clinical

•Review utilisation of the discharge lounge and identify opportunities for to Assess pathway, in order to understand the capacity and activity shifts Function PL deliverable in 2017‐18: AEDB increased and timely access to aid flow (July 17) Care that should underpin a revised model of delivery (September 2017) • Review the Pennine Lancashire escalation plan ensuring alignment with national PL deliverables 2017/18: PL AEDB • Review of Intermediate care provision as part of the learning from the guidance. This escalation plan is to include the teleconference function, Standard

Intermediate

PL diagnostic (March 2018) Operating Procedures (12 Hour Breach, Diversion and Deflection) and OPEL • Review utilisation of NWAS PTS resources and reduce usage and AEDB

associated costs with private PTS ambulance (July 17 ‐ Nov 17) PL deliverable in 2017‐18: PL Framework (October 2017) Escalation • Evaluate the current models of IHSS and recommend a single model for AEDB • Review the ELHT escalation plan to ensure this incorporates a full capacity

PTS need

& protocol which is implemented at times of heightened escalation (October 2017)

Pennine Lancashire (April 2018).

Teams Unplanned PL deliverables in 2017‐18: System • Agree process for winter planning for 2017/18 (October 2017) • Undertake resilience planning and assurance for peak demand periods e.g. bank PL Service AEDB holidays, Christmas break (October 2017) Community Notes: Efficiency Page*LGA, ADASS,8 of 9 NHS E, DH, ECIP, Monitor and NHS I. Managing Transfers of Care between Hospital and Home. Integrated