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

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/

The meeting will be CLINICAL COMMISSIONING GROUP (CCG) digitally recorded in line with the GOVERNING BODY MEETING Governing Body th Terms of Reference Wednesday 11 September 2019 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

PART 1 BUSINESS (APPROXIMATELY 1.15 PM) 5. Minutes of the Meeting held on 10th July 2019 Mr Graham Burgess Attached 5.1 Extract from Part 2 of the Minutes of the Meeting held on Attached 10th July 2019

6. Matters Arising Mr Graham Burgess 6.1 Action Matrix Attached

7. Joint Chief Officer’s Report Mr Roger Parr Attached

8. Integrated Care Partnership Priorities Mrs Claire Richardson Presentation

9. Clinical Commissioning Group Annual Assessment Mr Roger Parr Attached 2018/19 10. Governing Body Assurance Framework Update Mrs Kirsty Hollis Attached

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

12. Performance Report Mr Roger Parr/ Attached Mrs Kathryn Lord 13. Quality Update Report Mrs Kathryn Lord Attached

14. Governing Body and Sub-Committees’ Terms of Mrs Debra Atkinson Attached Reference

FOR INFORMATION 15. Midlands and Lancashire Commissioning Support Unit Mrs Kirsty Hollis Attached Data Mitigation

16. Communication and Engagement Update Mrs Kirsty Hollis Attached

17. Pennine Lancashire Medical Workforce Mrs Claire Richardson/ Verbal Dr Preeti Shukla 18. Review of Register of Interests Mrs Debra Atkinson Attached

19. Annual Report of the Audit Committee Mr Paul Hinnigan Attached 19.1 External Audit Annual Audit Letter Attached

20. Blackburn with Darwen Special Educational Needs and Mrs Claire Richardson Attached Disability Inspection Main Findings

21. Governing Body Sub-Committees’ Minutes Mrs Debra Atkinson Attached

22. Any Other Business All Verbal

23. Date and Time of Next Meeting: Mr Graham Burgess Verbal

Wednesday 13th November 2019 at 1 p.m. at Walshaw House, Regent Street, Nelson BB9 8AS

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/19 Minutes of Part 2 of the Meeting held on 10th July 2019 Mr Graham Burgess Attached

B/19 Matters Arising Mr Graham Burgess B/19.1 Action Matrix Attached FOR INFORMATION C/19 Adult Community Services – Next Steps and Mr Alex Walker Attached Opportunities

D/19 End of Life Care Performance Measures – Annual Mr Alex Walker/ Attached Review Mrs Caroline Edwards

E/19 East Lancashire Medical Services: Contract Extension Mr Alex Walker Verbal for Integrated Urgent Care Update

F/19 Pennine Lancashire Clinical Commissioning Groups’ Mrs Kathryn Lord Attached Confidential Provider Update

G/19 Governing Body Sub-Committees Part 2 Minutes Mrs Debra Atkinson Attached

H/19 Pennine Lancashire Accident and Emergency Board Mr Roger Parr Attached Chair’s Report

I/19 System Update Mr Graham Burgess Verbal

J/19 Any Other Business All Verbal

Page 2 of 3

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);  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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Subject to approval at the next meeting

CLINICAL COMMISSIONING GROUP (CCG) Item 5 Minutes of the Governing Body (GB) Meeting held on Wednesday 10th July 2019 at 1 p.m. in Rooms 1 and 2, Blackburn Central Library, Town Hall Street, Blackburn, BB2 1AG PRESENT: Mr Graham Burgess Chair Dr Julie Higgins Joint Chief Officer Mrs Claire Richardson Director of Population Strategy and Transformation Dr Ridwaan Ahmed Clinical Director for Quality and Primary Care Dr Penny Morris Medical Director Dr Preeti Shukla General Practitioner (GP) Executive Member Dr Zaki Patel GP Executive Member (Part) Dr Adam Black GP Executive Member (Part) Dr Geraint Jones Secondary Care Doctor (Retired) Dr Nigel Horsfield Lay Member Mr Paul Hinnigan Lay Member – Governance Professor Dominic Harrison Director of Public Health and Well-being, Blackburn with Darwen Borough Council (BwD BC)

IN ATTENDANCE: Mr Iain Fletcher Head of Corporate Business Mrs Debra Atkinson Head of Corporate Business, East Lancashire (EL) CCG Mrs Jill Marr Deputy Chief Finance Officer (representing Mr Roger Parr, Chief Finance Officer/Deputy Chief Officer) Mr Alex Walker Director of Performance and Delivery, EL CCG Mrs Kirsty Hollis Chief Finance Officer and Deputy Chief Officer, EL CCG Mrs Kathryn Lord Director of Quality and Chief Nurse, EL CCG Mrs Anne Cunningham Public Health Intelligence Specialist, BwD BC (Item 19.064.1) Ms Tabitha Kavoi Public Health Speciality Registrar (Item 19.064.2) Mrs Pauline Milligan Governing Body Secretary

Min No. Item 19.052 Chair’s Welcome

The Chair opened the meeting by welcoming all attendees and members of the public to the meeting.

The Chair also welcomed colleagues from EL CCG, who were attending the meeting as members of the Pennine Lancashire (PL) CCGs’ single Executive Team. He added that, conversely, members of the BwD CCG GB were also now attending the GB meetings of EL CCG.

19.053 Apologies for Absence and Confirmation of Quoracy

Apologies for absence had been received in respect of the following members:

Mr Roger Parr, Chief Finance Officer/Deputy Chief Officer

Dr John Randall, GP Executive Member (Vice Chair)

The meeting was confirmed as quorate. 19.054 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.

No declarations were made at this point.

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.

19.055 Questions from Members of the Public

There were no questions from members of the public.

19.056 Minutes of the Meeting held on 8th May 2019

The draft minutes of the meeting on 8th May 2019 were reviewed.

ACTION: Following a request from Mr Paul Hinnigan, Mrs Pauline Milligan to amend Item 19.039 of the minutes to read that each member who had declared a Conflict of Interest would “leave the meeting and not take part in the discussion or decision for that item”.

RESOLVED: That, following the above amendment being made in line with discussions, the minutes of the meeting held on 8th May 2019 were approved as an accurate record.

19.056.1 Extract from Part 2 of the Minutes of the Meeting held on 8th May 2019

The Extract of Part 2 of the Minutes of the Meeting held on 8th May 2019 was approved as an accurate record.

RESOLVED: That the Extract of Part 2 of the Minutes of the Meeting held on 8th May 2019 was approved as an accurate record.

19.057 Matters Arising/Action Matrix

Matters Arising

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

19.057.1 Action Matrix

The Action Matrix was reviewed and the following were noted: Page 2 of 13

Minute 19.026 (ii)/19.042.1 – Contract, Quality and Performance Report Dr Penny Morris provided an update on this action, which was in relation to the issue of clinical feedback to GPs following a patient’s attendance at the Accident and Emergency (A&E) Department.

Dr Morris confirmed that the action referred to a specific clinical issue that had been resolved with the practice concerned.

It was also noted that there was also a wider primary and secondary care issue in relation to clinical feedback and this and other issues were being discussed in the primary and secondary care forums.

Minute 19.028/19.042.1 – Financial Report – 2019/20 Mrs Claire Richardson provided a verbal update.

Dr Preeti Shukla was working with Mrs Kate Quinn, Associate Director for Workforce and Transformation, Together a Healthier Future Programme (TAHF), in relation to medical workforce. There was a plan to get medical leads together to progress the work.

She stated, that in terms of responsibility for workforce planning, the Interim NHS People Plan had recently been published and, in line with the NHS Long Term Plan Implementation Framework, it was expected that a Healthier Lancashire and South Cumbria (HL&SC) Integrated Care System (ICS) Workforce Strategy would be developed.

It was recognised that the TAHF Programme was leading some elements in relation to workforce planning across PL with providers and this work was being developed into a PL Workforce Strategy. It was hoped to bring a report to GBs in September, aligned with the timescales of the ICS Workforce Strategy development.

Minute 19.034 (ii)/19.042.1 – Joint Committee of CCGs (JCCCG) Agenda Dr Julie Higgins informed members that she had begun to circulate the ICS programme updates to them to keep them informed of the JCCCG’s work.

She deferred to Mr Alex Walker to provide a specific update in relation to Stroke Services.

Mr Walker reported that there were two main pieces of work being undertaken across HL&SC in relation to stroke; the stroke pathway was being reviewed and a Case for Change was being developed by the JCCCG. The CCG would be asked to review the Case for Change and its investment into Stroke Services and there was currently a Business Case being developed across PL.

19.058 Chief Officer’s Report

Dr Higgins presented her report, which provided an overview of work across HL&SC and locally; along with an update on national policy issues.

Supported by Mrs Richardson and Dr Morris she drew members’ attention to:

 ICS Board – Primary Care Strategy – reviewed by the ICS Board and signed off by the JCCCG;  Lancashire Intermediate Care Review – Lancashire County Council working Page 3 of 13

with CCGs to develop a Case for Change and Strategy for Intermediate Care. Unitary Councils will also be involved in the Case for Change. A paper will be presented to the Lancashire Health and Well-being Board. Mr Walker has established an Intermediate Care Board to support.  Special Educational Needs and Disability (SEND) Inspection – the Office for Standards in Education, Children’s Services and Skills (Ofsted) and the Care Quality Commission (CQC) inspection took place during week commencing 17th June. The CCG worked closely with the Local Authority on the key lines of enquiry identified prior to the inspection. The findings of the inspection, which was not graded, would be communicated in July.  Integrated Care Partnership (ICP) – on 1st April 2019 the new GP contract for GPs in Primary Care outlined requirements for the establishment of Primary Care Networks (PCNs). In PL these developments had been taking place over the last six years; however the contract formally required GPs to sign Network Agreements by 30th June 2019. Each network was expected to be led by a local GP in a Clinical Director role. Seven national network service specifications would follow and PCNs would be accountable for their delivery.

Questions and answers followed.

Following a question from Mr Paul Hinnigan, the following BwD PCN Clinical Directors were confirmed as follows:

 Dr Helen McKeating – West;  Dr Ridwaan Ahmed – North;  Dr Pervez Muzaffar – Darwen;  Dr Thomas Accialini – East.

In addition, the GP membership and Local Medical Committee had agreed that an overarching Clinical Director of the PCNs would also be appointed and this was Dr Mohammed Umer.

The Chair highlighted all the work that had been undertaken in relation to the BwD SEND inspection by the CCG and Local Authority and, on behalf of the GB, thanked all the CCG’s staff, and its partners, that had been involved.

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

19.059 Chief Finance Officer’s Report

Mrs Jill Marr presented the report on behalf of Mr Roger Parr and highlighted key elements:

The CCG was reporting a break even position against the Financial Plan as at month 2.

 Healthcare Commissioning was reporting a year to date underspend of £21k;  Primary Care was reporting a small underspend;  Corporate Services were reporting a small underspend.

However, Mrs Marr pointed out that it was very early in the financial year and data had only been reported on one month’s acute activity. Activity appeared to be on trend with 2018/19 and, therefore, the financial position remained as break even as reported.

 A capital bid for £244k had been submitted to and approved by NHS England Page 4 of 13

for hardware replacement of GP Information Technology estates, provision of infrastructure, mobile working and operating software;  The CCG’s Quality, Innovation, Productivity and Prevention (QIPP) target was £6m. The CCG had achieved £3.4m of its annual target to date, which was on target with its QIPP plan.  The main risks were acute activity, in particular scheduled care, continuing healthcare and complex packages of care and prescribing expenditure;

There were no questions.

RESOLVED: That the GB members present noted the contents of the financial summary and financial position of the CCG at the end of May 2019.

19.060 Contract, Quality and Performance Report

Dr Ridwaan Ahmed presented the quality and performance section of the month 1 report and then deferred to Mrs Marr to highlight the key points related to the CCG’s contracts.

Dr Ahmed highlighted the following:

East Lancashire Hospitals NHS Trust (ELHT) (page 5):  A&E 4 Hour – performance remained relatively stable but still under the 95% target and recovery trajectory. A group had been establish to look at a system model for same day Primary Care and how demand could be managed to ease the pressure on the acute system.

Mrs Marr highlighted the following:

Lancashire Care NHS Foundation Trust (LCFT) Mental Health Services (MHS) (page 3):  Psychological Therapies – Mrs Marr reported that Improving Access to Psychological Therapies (IAPT) was currently below target to meet its 19% prevalence target;  Referrals – below plan;  Admissions – below plan;  Bed Days – higher than expected for the weighted population;  Out of Area Placements (OAPs) – were still high; however, additional investment in the Community Teams and 24 Home Treatment Teams was expected to have a positive impact.

ELHT (page 5):  In-patient activity – below plan;  Out-patient activity – below plan;  Non-Elective Admissions – above plan.

Mrs Marr informed members that the 2019/20 contracting agreement meant that only planned care, day cases and out-patients were now paid on a cost per case basis and other services were aligned to the cost of the service.

Primary Care (page 7):  Out of Hours – activity above plan;  Estates Technology Transformation Fund (ETTF) – the west scheme continued to develop its outline business case, including redesign and funding.

Page 5 of 13

LCFT Community (page 8): Mrs Marr reported that one of the CCG’s services lines was over performing and eight were underperforming, with the remaining six service lines operating within tolerance.

ACTION: Mr Hinnigan requested that further narrative was included in the LCFT mental health section to explain the reasons behind the high level of OAPs, when the number of referrals and admissions were down. Mrs Marr to feedback to Mr Parr.

Mr Alex Walker informed members about the establishment of a PL Scheduled Care Board, which would be monitoring areas such as Out-patients, Referrals to Treatment, etc. The Chair suggested that the GB should also closely monitor those areas in future reports.

ACTION: Mr Hinnigan requested that future reports included a breakdown of the individual provider versus the target for those patients who were on the inpatient waiting list for over 20 weeks and details of the recovery plans in place. Mrs Marr to feedback to Mr Parr.

Members discussed the ongoing issues in relation to the recruitment and retention of medical staff and how the levels could be improved.

Professor Dominic Harrison informed members that there had been a major outbreak of influenza in Australia, with double the number of cases reported so far than had been experienced in previous years. Professor Harrison circulated details of the outbreak to members at the time of reporting. He warned that this could present a major challenge to the PL system this winter.

Questions and answers followed.

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

19.061 Developing a Shared Strategy for 2019 – 2024 across the Lancashire and South Cumbria Integrated Care System

Dr Higgins provided an abridged version of the presentation circulated by the HL&SC ICS and supporting report. The report requested that the GB discuss, comment and endorse in principle the strategic narrative document, eight priorities, engagement process and further system development work.

The ICS had developed a Shared Strategy for 2019-24 and it was now undergoing a full engagement process.

The document set out the vision for HL&SC and, at the heart of the vision were the following ambitions:

 We will have healthy communities;  We will have high quality and efficient services;  We will have health and care service that works for everyone, including our staff.

The case of change referred to the actions that were needed to improve health inequalities and performance, provide consistent high quality care for patients and achieve financial balance. Page 6 of 13

Dr Higgins outlined the plans and partnership priorities on three levels (doing things once and setting standards):

 Across L&SC;  In the local area (ICPs);  In the neighbourhood and community (PCNs).

The current clinical workstreams were identified as follows:

 Cancer;  Regulated Care;  Stroke;  Mental health  Maternity and Paediatrics;  Head and Neck Cancer;  Urgent Care;  Elective Care Diagnostics;  Vascular Surgery;  Learning Disability;  Primary Care;  Prevention.

Dr Higgins drew members’ attention to and outlined the list of partnership priorities:

1. Maximise the benefits of our work in neighbourhoods; 2. Deliver an integrated health and social care workforce for the future with the capacity and capability to provide sustainable care and support to our local communities; 3. Strengthen the resilience and mental health of people and communities; 4. Establish a group model for all hospital services in L&SC; 5. Reinvigorate strategic partnerships across the public sector; 6. Establish a public sector enterprise and innovation alliance with our ICS partners, including academic partners and Local Enterprise Partnerships to deliver inward investment and support job creation; 7. Bring the entire health and social care system back into financial balance; 8. Consolidate commissioning so that our arrangements for planning and prioritising our resources improve our population’s health and the outcomes of health and social care.

She highlighted that there was more detail on each of the eight priorities in the full pack of slides, which provided more detail of the plans and ambition behind them and what would be different in the next two and five years.

Dr Higgins stated that there would be a major phase of engagement on the strategy throughout the summer so that it could be published in September, demonstrating the involvement of the public and stakeholders and how they had contributed to the strategy.

She drew members’ attention to the specific request from the ICS Board for the GB to endorse several actions to take forwards in the work set out in ‘next steps’. These were:

i. Comment on the strategic narrative which has been developed by the L&SC

Page 7 of 13

ICS; ii. Endorse the strategic narrative document as the basis for the development of the L&SC ICS five year plan; iii. Endorse in principle the eight priorities within the document, subject to the outcomes of a proposed engagement process; iv. Endorse the proposed engagement process with patients, citizens, staff and wider partners and support the actions required to deliver it effectively; v. Support the further system development work now being arranged in respect of provider collaboration, commissioning and partnership between local authorities and the NHS.

Questions and answers followed.

Professor Harrison referred to the national Annual Budget Report produced by the Association of Directors of Adult Social Care (ADASS) and highlighted some key points in the report in relation to funding.

In particular that, alongside the £7bn reduction in adult social care funding since 2010, resulting in less spending on prevention, there had been a lack of investment in primary and community health care and prevention of ill health; with fewer GPs, a 45% reduction in District Nurses since 2010 and a 10% reduction in the Government grant for Public Health since 2015/16.

He explained that some of the aspirations in the strategy needed to be expanded to indicate how funding and investment would support their implementation. Whilst agreeing that the aspirations in the strategy were correct, he stated that he would like to see more information on how they would be achieved in light of the resources available.

ACTION: Professor Harrison agreed to send details of the resources outlined in the ADASS Report to Mrs Debra Atkinson, Head of Corporate Business, EL CCG, for her to include in the feedback to the ICS.

Dr Nigel Horsfield agreed with Professor Harrison and referred to the health inequalities in the report and how many aspects of this were outside the control of the CCG.

Dr Adam Black referred to the hours and cost involved in producing the strategy and also the restructuring process and questioned if that investment would have the required impact.

Members agreed that they were, in some respects, optimistic about the implementation of the strategy.

Dr Morris referred to the recent changes in the GP Contract; in that General Practice had been formally advised that they had to sign up to the PCNs and there would be accountability in the service specifications. There was a five year plan, accompanied by the promise of resources and additional workforce, which allowed Primary Care to plan for the future better than previously.

Mr Hinnigan agreed with Professor Harrison. Whilst fully supporting the priorities and partnership working principles, he questioned the omission of information on any achievements that had taken place in the clinical workstreams since the ICS’s inception. He remarked that it would be useful to see a ‘costed plan’ on how the aspirations in the strategy would be achieved. He questioned if the CCG had received

Page 8 of 13 value for money in relation to the investment it had already made in the ICS.

Dr Geraint Jones raised a point about the incentives that may be required for the implementation of the strategy.

Dr Higgins explained some of the work that had been undertaken by the ICS with Chief Officers and Chief Executives that had set out priorities and expectations. She added that the work would be supported by legislation in the future and collaborative working was the way forward.

Professor Harrison commented that it was important to align the financial system with the aspirations declared in the strategy.

Dr Black remarked that there were already some incentives in place and it was getting the financial aspects correct that would facilitate change.

Mrs Richardson commented that there was an opportunity for PL as an ICP in the ICS to begin to deliver these plans in a quicker, more coordinated, way. The Pennine priorities were aligned to the ICS and the ICP needed to reflect its plans to deliver the priorities locally.

Mr Hinnigan remarked that there would be a period where the legislation required would not keep pace with the work that the ICP was undertaking. During this period there was a need for formal accountability and governance to keep pace with the current state.

The Chair summarised the discussion as follows:

That the GB:

 Generally supported the approach all the partnership principles listed in the presentation in in terms of neighbourhood working and integration; however: o The principles needed to be fully resourced; o There needed to be clear governance and clear lines of accountability; o There needed to be incentives to make the changes required.

Dr Black explained why outcome driven shared working had worked for the GPs creating the neighbourhoods in BwD over the last five years and could work in L&SC.

Dr Zaki Patel remarked that the CCG did face challenge with some of its providers, who were failing some targets and it was difficult to improve behaviours. However, the PCNs were small units that could implement change. The challenge with some of the CCG’s providers was that they were much bigger organisations and it was more difficult to instigate change.

Dr Morris commented that the new PCNs were the incentive required to work better together and this was not the case in General Practice two years ago. The main aim was to all work together.

Dr Higgins summarised the principles, which were agreed, subject to:

 There being a more community focus;  There being more clarity about resources and equity;  The direction of travel having a costed plan;  The accountability and governance being addressed. Page 9 of 13

RESOLVED: That the GB endorsed the principles, subject to:

i. There being a more community focus; ii. There being more clarity about resources and equity; iii. The direction of travel having a costed plan; iv. The accountability and governance being addressed.

19.062 Equality and Inclusion Annual Report 2018/19

Mr Iain Fletcher presented the Equality and Inclusion (E&I) Annual Report 2018/19 for information.

He stated that the report had been reviewed and discussed at the Pennine Lancashire Quality Committee.

He drew members’ attention to pages 6 and 7, which listed the CCG’s strengths in terms of E&I and areas for improvement.

It was noted that the report demonstrated that the CCG continued to make good progress in the way it commissioned services in line with its duties and responsibilities in relation to E&I.

There were no questions.

Mr Fletcher requested approval for the report to be published on the CCG’s website. This was agreed.

RESOLVED: That the GB:

i. received and noted the content of the report; ii. agreed that the report should be published on the CCG’s website.

19.063 360 Degree Survey

Mr Fletcher presented the report, which provided a summary of the key findings and recommendations arising from the independent 360 degree stakeholder survey, commissioned by NHS England and conducted by Ipsos MORI.

He reported that the CCG had identified 47 stakeholders to take part, of which 33 completed the survey. The overall response rate was 74%; well above the average response rate within the ICS.

He highlighted the recommendations in the report.

There were no questions.

ACTION: Following a request from the Chair, Mr Fletcher agreed to request that Mr David Rogers, Head of Communication and Engagement, to compile an appropriate media piece on the results.

RESOLVED: That the GB:

i. noted the content of the report; ii. supported the recommendations in the report.

Page 10 of 13

19.064 Blackburn with Darwen Public Health

Professor Harrison introduced these items and provided background to their instigation.

19.064.1 Neighbourhood Level Data/Mapping Tool

At a previous meeting, there had been discussions and an action to provide a detailed analysis in relation to life expectancy trends within the BwD neighbourhoods.

Professor Harrison stated that Mrs Anne Cunningham had been developing a tool that would allow Public Health to review health data within the neighbourhoods. There had been discussions about how the team would demonstrate the tool to members and it had been decided that a training session outside the GB meetings would be most appropriate.

Mrs Cunningham explained how the tool was developed and could be used. It provided a means to review small area data and pull together a range of data from that available from various reputable sources in one interface. She added that this would become clearer when demonstrated in an interactive session.

Professor Harrison informed members that the tool could, for example, be used to compare the number of patients with type 2 diabetes within each neighbourhood, or within the Borough as a whole. The information could also be drilled down even further to street level. However, there were some limitations, i.e. if the figures being analysed were very small.

Questions and answers followed.

ACTION: Professor Harrison agreed to organise a live interactive joint Pennine Lancashire GB session to demonstrate the neighbourhood mapping tool and would share the link to the tool prior to the session.

19.064.2 Low Carbohydrate Diets

Professor Harrison reminded members of the background to the report; in response to a request from the Finance Scrutiny Group for him to report back on any research or evidence that had demonstrated the potential benefits of a low carbohydrate diet (LCD) for patients with type 2 pre-diabetes and diabetes.

He introduced Ms Tabitha Kavoi, who had produced the report.

Ms Kavoi informed members that there was no definitive definition of an LCD and that there were many different types. She explained that most of the research that had taken place into LCDs was based on diets containing less than 130g of carbohydrate a day.

The paper focused on obesity and weight loss and Ms Kavoi outlined the results of some of the studies that had taken place. She commented that there was an issue with the evidence as the studies were not long enough; although some short term weight loss was evident.

Whilst the evidence showed that LCDs could improve type 2 pre-diabetes and diabetes in the short term, evidence from the longer term studies could not be used as the main way to treat and manage diabetes. It was thought that LCDs could lead to the

Page 11 of 13

improvement of health and raised mortality in the long term but they should be part of a joint individual patient approach.

The overall conclusion was that, although an LCD may be of benefit to some patients, there was currently not enough evidence to support a recommendation for the whole population. There was strong evidence, however, that a balanced diet should be recommended. A diet for individual patient needs should be supported by a Clinician, Dietician or Nutritionist.

Ms Kavoi highlighted the recommendations in the report for the GB to consider:

i. Support a Whole Systems Approach to tackling unhealthy weight and recognising a single driver in isolation cannot work. Focusing heavily on one element of the system is unlikely to successfully bring about the scale of change required; ii. Continue to support the commitment to the Joint Local Authority Declaration on Healthy Weight signed in 2017 which is designed to challenge all parts of the system to: - a. Ensure Healthy Weight is integrated into all policies and commissions thereby harnessing the assets in the wider system; b. Engage with the proposed Pennine Lancashire Healthy Weight Review which aims to map the assets, barriers, gaps and opportunities across the Integrated Care Partnership area to tackle unhealthy weight.

Questions and answers followed.

RESOLVED: That the GB:

i. supported a Whole Systems Approach to tackling unhealthy weight and recognising a single driver in isolation cannot work. Focusing heavily on one element of the system is unlikely to successfully bring about the scale of change required; ii. continued to support the commitment to the Joint Local Authority Declaration on Healthy Weight signed in 2017 which is designed to challenge all parts of the system to: - a. agreed to ensure Healthy Weight is integrated into all policies and commissions thereby harnessing the assets in the wider system; b. agreed to engage with the proposed Pennine Lancashire Healthy Weight Review which aims to map the assets, barriers, gaps and opportunities across the Integrated Care Partnership area to tackle unhealthy weight.

The Chair thanked member of the Public Health Team for their attendance and input and they left the meeting.

19.065 Governing Body 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.

There were no questions.

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

Page 12 of 13

19.066 Any Other Business

No further business was discussed.

19.067 Date and Time of Next Meeting

The next meeting will be held on Wednesday 11th September 2019 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

Page 13 of 13 Subject to approval At the next meeting

Item 5.1

Extract from Part 2 of the Minutes of the Governing Body (GB) Meeting held on Wednesday 10th July 2019 at 3 p.m. in Rooms 1 and 2, Blackburn Central Library, Town Hall Street, Blackburn, BB2 1AG

PRESENT: Mr Graham Burgess Chair Dr Julie Higgins Joint Chief Officer Mrs Claire Richardson Director of Population Strategy and Transformation Dr Ridwaan Ahmed Clinical Director for Quality and Primary Care; Dr Penny Morris Medical Director Dr Zaki Patel General Practitioner (GP) Executive Member (Part) Dr Adam Black GP Executive Member Dr Preeti Shukla GP Executive Member (Part) Dr Geraint Jones Secondary Care Doctor (Retired) Dr Nigel Horsfield Lay Member Mr Paul Hinnigan Lay Member – Governance Professor Dominic Harrison Director of Public Health and Well-being, Blackburn with Darwen Borough Council (BwDBC)

Re-Confirmation of Apologies for Absence and Quoracy

Apologies for absence had been received in respect of the following members:

Mr Roger Parr, Chief Finance Officer/Deputy Chief Officer Dr John Randall, GP Executive Member (Vice Chair)

The meeting was confirmed as 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 Blackburn with Darwen CCG.

Declarations declared by members of the GB are listed in the CCG’s Register of Interests. The Register was 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 were made 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/19 Minutes of Part 2 of the Meeting held on 8th May 2019

The Minutes of Part 2 of the Meeting held on 8th May 2019 were reviewed.

RESOLVED: That the Minutes of Part 2 of the Meeting held on 8th March 2019 were approved as an accurate record.

B/19 Matters Arising

No new matters arising were noted:

B/19.1 Action Matrix

The Action Matrix was reviewed.

There were no new actions to update.

C/19 Pennine Lancashire Clinical Commissioning Groups’ Confidential Provider Update

Dr Ridwaan Ahmed presented the report, which provided the GB members with a briefing on new provider performance/quality issues that had occurred since the last meeting.

Dr Ahmed highlighted key items.

Drs Zaki Patel and Preeti Shukla joined the meeting.

Questions and answers followed.

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

D/19 Pennine Lancashire Accident and Emergency Delivery Board Report

Mr Alex Walker presented the report and highlighted key elements in relation to:

 Hospital Handover Collaboration;  Flu Vaccination;  Mental Health – Northumberland, Tyne and Wear Report;  Mental Health – National Integrated Care System Visit;  Same Day Primary Care;  Review of Easter Activity – Lessons Learned.

Questions and answers followed. Page 2 of 4

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

E/19 Blackburn with Darwen Health Profiles – Child Mortality

Professor Dominic Harrison presented the report, which had been produced following a request following a discussion at a previous meeting where he had informed members of BwD’s child mortality rate.

Professor Harrison explained that the child mortality indicator related to deaths between the ages of 1 to 18 years. (The infant mortality indicator related to deaths from birth to 18 years).

He drew members’ attention to the data from 2015 – 2017 that was available and pointed out that there were limitations in analysing the data in relation to the small numbers involved.

Professor Harrison explained that every Local Authority area was required to have a Child Death Overview Panel, which reviewed all child deaths case by case to determine if the death was preventable. The deaths were reported in an Annual Report produced by the Lancashire Child Death Overview Panel of all child deaths in Lancashire with the causality identified.

Questions and answers followed.

Members discussed what could be defined as a preventable death. Professor Harrison suggested that he produce a report to bring back to a future meeting.

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

F/19 Governing Body Sub-Committees and Groups’ Part 2 Minutes

Mr Iain Fletcher presented the report, which included the Part 2 minutes of the Governing Body Sub-Committees and Groups.

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

There were no questions.

RESOLVED: That the GB:

i. received and noted the content of the report; ii. ratified the Minutes of the Blackburn with Darwen Clinical Commissioning Group Remuneration and Terms of Service Committee Meeting in Common with East Lancashire Clinical Commissioning Group Remuneration and Terms of Service Committee on 17th April 2019.

G/19 System Update

The Chair informed members that the GB would be taking part in a Tripartite Meeting with East Lancashire CCG and East Lancashire Hospitals NHS Trust on 31st July 2019.

Page 3 of 4

He requested that members confirm their attendance to the pre-meeting and main meeting as soon as possible.

ACTION: All members to confirm their attendance to the Tripartite pre- meeting and main meeting as soon possible.

H/19 Any Other Business

Information Technology (IT) Dr Zaki Patel raised a point about the increased number of IT issues within the GP Practices.

Mr Fletcher responded that he had reported the issues to the IT Department on a Conference Call in relation to the last outage. The IT Department were investigating the number of issues and the reason for their occurrence.

ACTION: Mr Fletcher agreed to inform members of the results of the investigation.

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

Page 4 of 4

Item 6.1

GOVERNING BODY (GB) MEETING - ACTION MATRIX PART 1

Action Origins Action Owner Due Date Status GB Ref 18.026 (ii) Contract, Quality and Performance Report Following a suggestion from Dr Zaki Patel, Dr Adam Black agreed to review the revised template for Neurology Service to see if this could be improved.

18.075.1 Dr Black reported that this was still in progress and requested that the item be deferred until the next meeting. IN PROGRESS VERBAL UPDATE 18.096.1 In the absence of Dr Black it was agreed to defer the action AB SEPTEMBER SEPTEMBER MEETING until the next meeting.

19.007.1 Dr Black stated that Dr Malcolm Ridgway was involved in the work to create a template for the whole of Lancashire, which was still ongoing and he would report back. 18.055 End of Life Care Update The Chair requested that Mrs Janet Thomas return with an SEPTEMBER annual update including performance measures in July JT JULY 2019 PART 2 AGENDA 2019. 19.050 Any Other Business – Measles Vaccination Professor Dominic Harrison agreed to discuss the issue with Dr Gifford Kerr, Consultant in Public Health, produce a DH NOVEMBER IN PROGRESS report on the uptake of vaccinations and screening and invite a representative of NHS England to attend a future meeting to discuss.

Page 1 of 2

19.056 Minutes of the Meeting held on 8th May 2019 Following a request from Mr Paul Hinnigan, Mrs Pauline Milligan to amend Item 19.039 of the minutes to record that PMILL SEPTEMBER COMPLETED each member who had declared a Conflict of Interest would “leave the meeting and not take part in the discussion or decision for that item”. 19.060 (i) Contract, Quality and Performance Report Mr Paul Hinnigan requested that further narrative was TO BE INCLUDED IN included in the Lancashire Care NHS Foundation Trust RP SEPTEMBER JOINT PERFORMANCE Mental Health Services section to explain the reasons REPORT FROM behind the high level of OAPs, when the number of referrals NOVEMBER and admissions were down. 19.060 (ii) Contract, Quality and Performance Report Mr Hinnigan requested that future reports included a TO BE INCLUDED IN breakdown of the individual provider versus the target for RP SEPTEMBER JOINT PERFORMANCE those patients who were on the in-patient waiting list for over REPORT FROM 20 weeks and details of the recovery plans in place. NOVEMBER

19.063 360 Degree Survey Following a request from the Chair, Mr Fletcher agreed to request that Mr David Rogers, Head of Communication and IF SEPTEMBER COMPLETED Engagement, to compile an appropriate media piece on the results. 19.064.1 Neighbourhood Level Data/Mapping Tool Professor Dominic Harrison agreed to organise a live interactive joint Pennine Lancashire GB session to DH NOVEMBER IN PROGRESS demonstrate the neighbourhood mapping tool and would share the link to the tool prior to the session.

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GOVERNING BODY MEETING

JOINT CHIEF OFFICER’S REPORT

Date of Meeting 11th September 2019 Agenda Item 7

CCG Corporate Objectives

Through better commissioning, improve local health outcomes by addressing X poor 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 X live healthier lives To maintain and improve performance against core standards and statutory X 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: Dr Julie Higgins

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: Is a Data Protection Impact Assessment Yes No Required? Data Protection Impact Assessment Yes No completed: Patient and Public Engagement N/A completed: Financial Implications N/A

Risk Identified N/A

Report authorised by Senior Manager: Dr Julie Higgins

Decision Recommendations

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

Report of the Joint Chief Officer – September 2019 Page 2 of 2 NHS Blackburn with Darwen Clinical Commissioning Group NHS East Lancashire Clinical Commissioning Group

PENNINE LANCASHIRE CLINICAL COMMISSIONING GROUPS’ (CCGs’)

GOVERNING BODY MEETINGS

SEPTEMBER 2019

JOINT CHIEF OFFICER’S REPORT

1. Introduction

I am pleased to present my joint report to the Pennine Lancashire (PL) Governing Bodies (GBs), which provides an update on national and local issues of interest to members.

2. System Updates

2.1 Healthier Lancashire and South Cumbria (HL&SC) Integrated Care System (ICS)

The Integrated Care System (ICS) Board provides leadership and development of the overarching strategy for Lancashire and South Cumbria, oversight and facilitation of delivery of sustainability, transformation and design of the future state of health and care.

Partners are working towards the national submission of the ICS strategic plan on the 27th September 2019. Two system wide events have been held so far with representatives from across the ICS to develop a common set of assumptions that each of the organisations plans will include. ICP leads and ICS programme leads have been drafting and compiling their responses to support the development of the plan, with ongoing fortnightly calls in place to maintain the dialogue and updates

The Clinical Congress has been confirmed for the 26th September to bring together clinical leaders from across Lancashire & South Cumbria to build upon existing engagement and plans within ICPs and neighbourhoods to consolidate the clinical element of the strategy. Invites will initially be distributed via the ICS Care Professionals Board and ICP strategic leads to cascade throughout the clinical community.

A set of recommendations following the review of the ICS governance were presented to the ICS Board in July. A subsequent meeting was held with Non-Executive Directors to review the recommendations which have been further refined in advance of a decision at the September ICS Board meeting. Additionally ICPs were asked to provide feedback to support the development of the final draft of the recommendations.

2.2 Joint Committee of CCGs

The Joint Committee of CCGs (JCCCG) held a Development Workshop on the 1st August 2019. This considered the ICS governance proposal.

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The JCCCG is made up of General Practitioners (GPs) and Lay Members from each of the CCGs in HL&SC, Chief Executives from Lancashire County Council, Blackburn with Darwen (BwD) Borough Council, Blackpool Council and representatives from District Councils. Local Healthwatch are not members of the Committee, but attend the meetings.

Further information via: https://www.healthierlsc.co.uk/joint-committee-ccgs

2.3 Lancashire Health and Wellbeing Board

On 23rd July 2019 Louise Taylor, Executive Director of Adults Services and Health and Wellbeing, presented to the Lancashire Health and Wellbeing Board on behalf of the Better Care Fund Steering Group.

Louise gained the approval of the Board to transform the Better Care Fund steering group into the Advancing Integration Board. Dr Julie Higgins chairs this board and Louise is the vice Chair. The Board will have a wider remit to manage the planning for and delivery of the BCF, to oversee the delivery of the Intermediate Care Strategy action plan and to build a common framework for the integration of Health and Social Care at all levels. The board will meet for the first time on 23rd August. An early task for the board is to establish a programme group to manage and deliver against the board’s workstreams. A comprehensive governance review will ensure that lines of accountability and reporting are clear and strong, and that best use is made of resources. These considerations will include the connections to the ICS and ICPs.

Also approved by the Health and Wellbeing Board was the approach to the use of the Winter Pressures grant that will include funding of capacity to support this transformation.

2.4 Advancing Integration

In addition to the creation of the board senior health and social care leaders have continued to work to develop the detail of how transformation will be achieved. The latest workshop saw each Integrated Care Partnership considering how integration would be applied at different levels in the system using the delivery of the Intermediate Care Strategy as its focus. Each ICP is now working up its high-level action plan for this for further development at the inaugural meeting of the Advancing Integration Board and consolidation into a single pan Lancashire plan.

2.5 Better Care Fund Planning

The BCF planning guidance was published towards the end of July. This has now enabled Lancashire BCF partners to focus on confirming detail of spending plans for 2019/20. The approach, encouraged nationally, is for there to be minimum change and for BCF to be considered business as usual.

The deadline for submission of the BCF plan is 27th September 2019 with a period of regional and national assurance to follow. A plan is in place to deliver against that deadline and includes required approvals from all partner organisations and the accountable body, the Lancashire Health and Wellbeing Board.

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While the position for the BCF is clear for 2019/20 it is not into 2020/21 and beyond. This gives increased urgency for work, underway, to manage any non-recurrence and make services sustainable from within core funding.

2.6 Lancashire Special Educational Needs and Disability (SEND) Partnership Board

On 2nd August, Blackburn with Darwen Local Authority and CCG received the letter from OFSTED in response to the Special Educational Needs and Disabilities (SEND) inspection. The letter outlined the main findings from the inspection which took place in June where inspectors for Ofsted and the CQC spoke with children and young people with SEND, parents, carers and staff from Blackburn with Darwen Borough Council, schools, education settings and Blackburn with Darwen Clinical Commissioning Group (CCG).

Inspectors reported that BwD had made considerable progress in implementing the SEND reforms since 2014. Key strengths included

 Provision for SEND is a key priority for all partners, there is a good understanding of local issues and new leadership is accelerating pace of improvement  Real enthusiasm and “can do attitude” was shown by staff who work closely together to make sure children and young people get the best possible support, making good use of Common Assessment to identify unmet needs  Evidence of clear capacity for improvement, including through emerging joint commissioning strategy across Local Authority and CCG  High quality of service delivery, with particular examples of SEND Advisory Team based within Education, support for pre-school and school age children and effective delivery of the Healthy Child Programme  The Designated Clinical Officer leading the implementation of change which has resulted in improvement in the quality of Education, Health and Care plans

Inspectors also recommended key areas for development, including:

 Areas for development include better incorporation of leaders’ and managers’ accurate knowledge of the local area into improvement plans.  More emphasis to be placed on the positive differences the SEND provision makes to the lives of children and families, rather than processes.  Some children have long waits for neurodevelopment assessments and some mental health services due to the high demand for these services.  Better use of data, in relation to patterns and trends of need, to inform and evaluate commissioning of services and strategic planning.  Opportunities for employment and independent living are limited and need to be broadened and it was acknowledged the local area’s ambitious plans for adults’ services will help to support this.  The full report of the joint local area SEND inspection is available to read here https://www.blackburnwithdarwenccg.nhs.uk/inspection-highlights-positive-outlook-for- services-supporting-children-and-young-people-with-special-educational-needs/

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 On 2nd August, Blackburn with Darwen Local Authority and CCG received the letter from OFSTED in response to the Special Educational Needs and Disabilities (SEND) inspection. The letter outlined the main findings from the inspection which took place in June where inspectors for Ofsted and the CQC spoke with children and young people with SEND, parents, carers and staff from Blackburn with Darwen Borough Council, schools, education settings and Blackburn with Darwen Clinical Commissioning Group (CCG).

The Lancashire SEND Board was in June 2019, with the next meeting being held on the 16th September, there will be a further update to the next Governing Body Meeting. 2.7 Pennine Lancashire Integrated Care Partnership

Following the publication of the NHS Long Term Plan guidance in June, the Lancashire and South Cumbria Integrated Care System (ICS) is required to develop a 5 year delivery plan. The plan is expected to include;

 System Narrative Plan: to describe how systems will deliver the required transformation activities to enable the necessary improvements for patients and communities as set out in the Long Term Plan.

 System Delivery Plan: to set the plan for delivery of finance, workforce and activity, providing an aggregate system delivery expectation and setting the basis for the 2020/21 operational plans for providers and CCGs. The system delivery plan will also cover the LTP ‘Foundational Commitments’.

 A single integrated finance, activity and workforce plan.  Focus at system level, underpinned by organisation-level breakdowns.  To include a system Financial Recovery Plan (FRP).  As far as possible, reflect contracts for 2020/21.  Plans to be fully aligned across organisations within each system: 2020/21 system plan to provide the basis for detailed operational plans in early 2020.  Performance plans out of scope of system plan, given ongoing Clinical Review of Standards.

The ICS has set out a number of planning requirements and timescales which will require an ICP response. Draft submissions are expected by end of September and final plans agreed by mid November. In response, the Pennine Lancashire Integrated Care Partnership is undertaking a refresh of narrative to move the partnership forward towards a more focussed Population Health Management approach and delivery of the Pennine Lancashire integrated model of care. The ICP developing narrative reflects:

• Full alignment of the Pennine Plan with the NHS Long Term Plan • Alignment with the key messages of the ICS narrative • The 2 pronged approach to integration for Pennine Lancashire – fully integrated commissioning and stronger alignment across health organisations • A full commitment to addressing the significant health inequalities in Pennine Lancashire, a ‘shift left’ towards prevention and social prescribing

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• Prioritising Primary Care Networks and neighbourhoods, transforming intermediate tier services, clinical strategy focussing on improving outcomes for people affected by cancer, heart disease stroke, respiratory and musculoskeletal problems • A People Strategy that will enable us to recruit the best people, with the right skills and values, to a system that supports the workforce to be the best they can be in a culture of community, compassion, inclusion, innovation and improvement to deliver care to the population it serves.

In addition to the narrative, Pennine Lancashire ICP Chief Officers have been working on developing a delivery framework, identifying four main areas of focus for the partnership which was received at Partnership Leaders Forum in July.

 System Responses – supporting partner organisations to work together to provide a system response to local issues including model of care development, finance, population health management, workforce and digital services transformation  System Improvements – Ensure delivery of tangible improvements in health and social care provision  System Coordination – supporting the delivery of integrated Care Partnership priorities, programmes, plans and engagement  System Development – Develop and management of plans for more integrated health services and commissioning across health and care within Pennine Lancashire

Programme boards are being established to co-ordinate delivery of the ICP workstreams, supporting five areas for transformation: Scheduled Care, Integrated Community Care, Prevention, Mental Health and Wellbeing and Urgent and Emergency Care, with dedicated Chief Officer level sponsorship. An annual delivery plan has been produced outlining key actions and milestones for each of the programme boards which mirrors the CCG operating plan for 2019/20. At the July meeting, ICP Partnership Leaders received an update on neighbourhood developments including a presentation on the recent Vital Signs Value Stream Analysis Event in Pendle East which supported the development of the HAPPI hub, co-locating health and care services within a local health centre. Leads from Together an Active Future, funded through Sport England also provided an overview of how the 6 districts in Pennine Lancashire are identifying priorities to ‘Test and Learn’ initiatives which will engage with local people and motivate them to get active. The process will support a bid for further funding, the outcome of which will be announced in March 2020. 2.8 Journey to Integration

A tri-partite development session between the 2 CCGs and East Lancashire Hospitals Trust was held on the 31st July 2019. The session aimed to bring together Governing Body members to commence discussions on how the 3 organisations could strengthen alignment across commissioning and provision, including development of a local health system, building

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blocks required for integration and a high level road map. The recommendations from the session will be shared with Governing Body members once collated. 3. Clinical Commissioning Group Updates

3.1 Patient and Public Involvement

I am delighted that following self-assessment and a process of assessment and validation by NHS England, Blackburn with Darwen achieved a rating of “good” in the annual Integrated Assessment Framework assessment of Patient and Public Involvement (PPI) and East Lancashire achieved a rating of “outstanding”. This follows last year’s assessment where both CCGs, along with all other CCGs in Lancashire and South Cumbria were given a rating of “requires improvement”. Members may recall that we were not happy with this assessment and submitted a request for review, given the depth and breadth of engagement that the CCGs lead, and are involved in. However, the Communication and Engagement team used this as an opportunity to review processes, and approaches to engagement, and along with a root and branch review of engagement undertaken in the CCGs, implemented improvements to our approach.

This has clearly paid off, and it is a phenomenal achievement to move from “requires improvement” to “good” and “outstanding”.

While one team supports both CCGs in communication and engagement, members may be interested as to the reasons for the difference in rating. To achieve “outstanding” BwD will need to undertake much more engagement, as well as engagement that translates into actionable change that can be evidenced. In addition, there is a need to adopt a more coproduction orientated approach and involve more patients in the working of the CCG and on projects at the planning stage. Head of Communication and Engagement, David Rogers has drafted guidance on coproduction which will be shared with Senior Managers for consideration and adoption, moving forward.

East Lancashire CCG has continued to undertake patient and public engagement around adult community services. This has included surveys of service users of treatment room services, palliative care, lower limb vascular and lymphedema services, as well as end of life and Intensive Home Support Service users. Reports of the findings and a “You Said, We did” matrix is being compiled.

Significant engagement has been undertaken in primary care, in particular focusing on Daneshouse Surgery, Briercliffe and latterly, Slaidburn.

A proposal and plan for ongoing dialogue in “community conversations” within each locality about what matters to people in their communities about health and health services has been developed. This builds on partnership work with Blackburn and Lancashire Healthwatch and will support planning in localities for future service redesign and development. The proposal, which will be signed off by senior managers and executive directors will represent a two pronged approach: firstly a look back at existing data and soft intelligence from surveys and engagement, and also allowing for continuous dialogue in each of our communities. The

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proposal, if adopted will be a significant opportunity to support the objectives of the CCGs, particularly, the move towards a “shift left”.

3.2 Clinical Strategy

The CCG Medical Directors have been working closely with the Medical Director and Clinical Leads within ELHT to develop a Clinical Strategy across Pennine Lancashire. The initial phase of the work aims to break down boundaries across primary and secondary care. Providing a consistent approach to clinical leadership will drive changes in processes, behaviours and cultures and enable delivery of the new care model for Pennine Lancashire.

4. Policy Updates

4.1 NHS England

4.1.1 Managing Safeguarding Allegations Against Staff Policy and Procedures This policy applies to all NHS England staff, and anyone working on behalf of or undertaking work or volunteering for NHS England, including those staff registered as Performers on the National Performers List, i.e. GPs, Dental Practitioners, Pharmacists, and Optometrists. The policy was updated on 19 August 2019.

It provides a framework to ensure appropriate actions are taken to manage such allegations, regardless of whether they are made in connection with an employee’s/worker’s duties with NHS England or if they fall outside of this i.e. in their private life or any other capacity.

The policy is available at: https://www.england.nhs.uk/wp-content/uploads/2015/07/managing-safeguarding- allegations-against-staff.pdf

4.1.2 Safeguarding Children, Young People and Adults at Risk in the NHS: Safeguarding Accountability and Assurance Framework

The purpose of this document is to set out clearly the safeguarding roles and responsibilities of all individuals working in providers of NHS funded care settings and NHS commissioning organisations. This policy was update on 19 August 2019.

This SAAF aims to:  identify and clarify how relationships between health and other systems work at both strategic and operational levels to safeguard children, young people and adults at risk of abuse or neglect;  clearly set out the legal framework for safeguarding children and adults as it relates to the various NHS organisations, in order to support them in discharging their statutory requirements to safeguard children and adults;

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 outline principles, attitudes, expectations and ways of working that recognise that safeguarding is everybody’s business and that the safety and well-being of those in vulnerable circumstances are at the forefront of our business;  identify clear arrangements and processes to be used to support practice and provide assurance at all levels, including NHS England and NHS Improvement Board, that safeguarding arrangements are in place.  promote equality by ensuring that health inequalities are addressed and are at the heart of NHS England’s values.

The policy is available at: https://www.england.nhs.uk/wp-content/uploads/2015/07/safeguarding-children- young-people-adults-at-risk-saaf.pdf

4.1.3 Interim Clinical Commissioning Policy – Vasectomy

This policy aims to ensure that male Armed Forces patients are able to access NHS vasectomy services wherever they live or receive their services in England. This interim policy was updated in August 2019 was first published in July 2019.

The policy is available at: https://www.england.nhs.uk/wp-content/uploads/2019/08/interim-clinical- commissioning-policy-vastectomy-1.pdf

4.2 Department of Health and Social Care

4.2.1 DHSC Group Accounting Manual 2019 to 2020 Consultation Response

All bodies within the Department of Health and Social Care accounting boundary (DHSC group bodies) must publish annual reports and accounts. Clear and transparent reporting helps the entity, as well as the users of the entity’s annual report and accounts, understand and scrutinise the year’s operations and outcomes. The consultation sought views on the DHSC group accounting manual that applies to DHSC bodies for their annual report and accounts. The consultation ran from 22 January to 22 February 2019. Responses have been analysed and summarised in the consultation response document.

This document also identifies the areas in which the DHSC group accounting manual 2019 to 2020 has been revised to better meet users’ needs.

4.3 NHSCC

4.3.1 Building Healthier Communities: The Role of the NHS as an Anchor Institution

The Health Foundation describe how, as the largest employer in the country, the NHS is a powerful ‘anchor institution’, with assets that can be used to support local communities. It notes that there is scope for CCGs to increasingly consider social value in decision-making, and includes a case study from Salford, where the CCG has developed an action plan for social value.

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This recent policy is available via the link: https://www.health.org.uk/sites/default/files/upload/publications/2019/I02_Building%20health ier%20communities_WEB.pdf

4.3.2 Change or Collapse – Lessons from the Drive to Reform Health and Social Care in Northern Ireland

The Nuffield Trust’s research report was published in July 2019 and is the second in their series, exploring what UK health systems can learn from each other. Focusing on Northern Ireland it explores barriers and enablers of efforts to improve their health and social care system.

This research policy is available via the link: https://www.nuffieldtrust.org.uk/files/2019-07/nuffield-trust-change-or-collapse-web-final.pdf

4.3.3 Place-Based Approaches for Reducing Health Inequalities

Public Health England has produced a guidance document that emphasises the importance of a place-based approach to tackling health inequalities and provides practical tools and a framework that can be used to support local action.

The main points made in this report are:

 the gap in life expectancy in England is growing, with females in the most deprived parts of the country experiencing a decline in life expectancy  health is not just about the length of life we live, but also the quality of life – the gap in healthy life expectancy (years lived in good health) between the most and least deprived areas of England was around 19 years for both males and females from 2014 to 2016  the extra costs to the NHS of health inequalities have been estimated as £4.8 billion a year from the greater use of hospitals by people in deprived areas alone  health inequalities reduce employment and productivity - which has a cost for the national and local economies  acting on health inequalities is, therefore, an investment for England’s national and local economies - with the cost of inaction running into the billions  the focus on narrowing gaps in life expectancy in the Industrial Strategy, DHSC’s vision paper for prevention, and the NHS Long Term Plan all create welcome opportunities for ambitious, coordinated, national and local level action on health inequalities  health inequalities are not caused by one single issue, but a complex mix of environmental and social factors which play out in a local area, or place - this means that local areas have an important role to play in reducing health inequalities  addressing the wider determinants of health through a life course approach is important for achieving impact at the level of population health - rather than at the individual level

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This report is available to view via the attached link: https://www.gov.uk/government/publications/health-inequalities-place-based-approaches-to- reduce-inequalities/place-based-approaches-for-reducing-health-inequalities-main-report

4.3.4 NHS Mental Health Implementation Plan 2019/20-2023/24

NHS England and NHS Improvement have published the Mental Health Implementation Plan, setting out how the challenging transformation programme for mental health will be funded, planned and delivered.

This is available via the link: https://www.longtermplan.nhs.uk/wp- content/uploads/2019/07/nhs-mental-health-implementation-plan-2019-20-2023-24.pdf

4.3.5 Realising the Value of Healthcare Data – A framework for the Future

Ernst and Young report that realising the value of healthcare data – held by organisations including CCGs and Trusts – could help the government achieve health priorities on prevention, care quality and finances, and they explore different mechanisms to value it.

This framework proposal focused on the UK’s health care ecosystem and patient records held across the NHS and is available via the link: https://assets.ey.com/content/dam/ey- sites/ey-com/en_gl/topics/life-sciences/life-sciences-pdfs/ey-value-of-health-care-data-v20- final.pdf?download&utm_source=The%20King%27s%20Fund%20newsletters%20%28main %20account%29&utm_medium=email&utm_campaign=10751364_NEWSL_DHD_2019-08- 07&dm_i=21A8,6EFT0,S965QQ,PDW6C,1

4.3.6 Health, Care and the 100 Year Life – How Policy Makers can Ensure Health and Fairness for All in an Era of Extreme Longevity

The Social Market Foundation explores the growing prospect of the “100 year life” in the UK and the impact of this demographic change on the health and care services of the future.

The Foundation’s main activity is to commission and publish original papers by independent academic and other experts on key topics in the economic and social fields, with a view to stimulating public discussion on the performance of markets and the social framework within which they operate. The publication is available via the link: http://www.smf.co.uk/wp- content/uploads/2019/07/Health-care-and-the-100-year-life.pdf

4.4 Department of Health

4.4.1 PACAC Inquiry into Eating Disorders: Government Response

This document sets out the government’s response to the Committee’s conclusions and recommendations. Eating disorders are serious, life-threatening conditions with some of the highest mortality rates of any mental health disorder. Early intervention is vital and we recognise how important it is that everyone with an eating disorder can access quick,

Report of the Joint Chief Officer – September 2019 Page 10 of 12 NHS Blackburn with Darwen Clinical Commissioning Group NHS East Lancashire Clinical Commissioning Group

specialist help when necessary. Improving eating disorder services is a key priority for the government and a fundamental part of our commitment to improve mental health services.

This policy is available via:

https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_da ta/file/824524/pacac-inquiry-into-eating-disorders-government-response-web-accessible.pdf

4.4.2 DHSC and HTA Framework Agreement: 2019-2022

How the Department of Health and Social Care (DHSC) and the Human Tissue Authority (HTA) will work together over the next three years. It sets out the roles, responsibilities, governance and accountability arrangements of the relationship, to ensure it best serves patients, the public, HTA licence fee payers and the taxpayer. It should be read alongside the annexes. The Framework is available via:

https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_da ta/file/821794/dhsc-hta-framework-2019-2022.pdf

The four annexes are: Wider Guidance, Finance and Accounting Responsibilities, Public- Facing Communication and Relationships with other Arm’s Length Bodies: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_da ta/file/821796/dhsc-hta-framework-2019-2022-annex-a.pdf, https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_da ta/file/821797/dhsc-hta-framework-2019-2022-annex-b.pdf, https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_da ta/file/821799/dhsc-hta-framework-2019-2022-annex-c.pdf https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_da ta/file/821800/dhsc-hta-framework-2019-2022-annex-d.pdf

4.4.3 Better Care Fund: How it will Work in 2019 to 2020

The Better Care Fund (BCF) will provide financial support for councils and NHS organisations to jointly plan and deliver local services.

This document sets out the agree way in which the BCG will be implemented in financial year 2019 to 2020. It includes:

 The level of funding for 2019 to 2020  Conditions of access to the fund  National Performance metrics  The assurance and approval process

The link to the policy: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_da ta/file/821676/Better_Care_Fund_2019-20_Policy_Framework.pdf

Report of the Joint Chief Officer – September 2019 Page 11 of 12 NHS Blackburn with Darwen Clinical Commissioning Group NHS East Lancashire Clinical Commissioning Group

4.4.4 Mental Health Act: Referrals to First-Tier Tribunal

The Guidance sets out when the Secretary of State can refer patients to the First-Tier Tribunal under Section 67 of the Mental Health Act and how to request a referral. Link available: https://www.gov.uk/government/publications/section-67-of-the-mental-health- act/section-67-of-the-mental-health-act-1983-references-by-the-secretary-of-state-for-health- and-social-care-to-the-first-tier-tribunal.

The Summary of Applications to First-Tier Tribunal:

https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_da ta/file/821298/applications-to-the-tribunal-list.pdf

.4.5 NHSX

Tell Us What Guidance You Need on Information Sharing

Information governance is all about how to manage and share information appropriately. Many organisations have published guidance on information sharing in health and care, including guidance on how to use and share information to support the care of individuals, as well as for planning and research.

NHSX - a new joint unit which is seeking to take forward digital transformation in the NHS - wants to bring all of this guidance together in one place, to simplify it, and to ensure that any new guidance we produce focuses on the topics that are most important to you. These topics could include answering your questions or supporting you in overcoming any barriers to information sharing that you feel are impacting negatively on patient care.

We would like to hear from anyone who is involved in making decisions about sharing information, for example patients or service users, health and care professionals, information governance specialists or interested members of the public. We would value your time in completing this short questionnaire. The survey is online via: https://www.engage.england.nhs.uk/survey/guidance-on-information- sharing/consultation/subpage.2019-08-02.2879735306/

5. Recommendation

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

Dr Julie Higgins Joint Chief Officer September 2019

Report of the Joint Chief Officer – September 2019 Page 12 of 12

GOVERNING BODY MEETING

CLINICAL COMMISSIONING GROUP ANNUAL ASSESSMENT 2018/19

Date of Meeting 11th September 2019 Agenda Item 9

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 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 Scheduled Care Quality GOVERG BODGOVERNING BODY MEETING

Clinical Lead:

Senior Lead Manager Mr Neil Holt ( Head of Commissioning Performance) Finance Manager Equality Impact and Risk Assessment completed: Is a Data Protection Impact Assessment Required? No Data Protection Impact Assessment completed: N/A Patient and Public Engagement N/A completed: Financial Implications None Risk Identified Report authorised by Senior Manager: Mr Roger Parr Y

Decision Recommendations Governing Body Members are asked receive the report and note the headline rating of Good for BwD CCG.

Governing Body Meeting Page 2 of 6

CLINICAL COMMISSIOMING GROUP

GOVERNING BODY MEETING

11TH SEPTEMBER 2019

CLINICAL COMMISSIONING GROUP ANNUAL ASSESSMENT 2018/19

1. Introduction

1.1 The Clinical Commissioning Group (CCG) annual assessment for 2018/19 provides each CCG with a headline assessment against the indicators in the CCG Improvement and Assessment Framework (IAF). The CCG IAF aligns key objectives and priorities as part of the CCG’s aim to deliver the Five Year Forward View and latterly The Long Term Plan. The headline assessment has been confirmed by NHS England’s Commissioning Committee.

2. Assessment

2.1 This report provides confirmation of the annual assessment, as well as a summary of any areas of strength and where improvement is needed from our year-end review (Annex A).

2.2 The final headline rating for 2018/19 for NHS Blackburn with Darwen (BwD) CCG is Good with the Quality of Leadership rated as Green and Finance rated as Green.

2.3 The 2018/19 annual assessments have been published on the CCG Improvement and Assessment page of the NHS England website in July. At the same time they have been published on the MyNHS section of the NHS Choices website. The dashboard with the data has also been issued with year-end ratings.

2.4 NHS England thanked the CCG for its contribution to delivering the Five Year Forward View and the focus that the CCG and its staff are making to improving health care for local people.

3. Recommendations

3.1 Governing Body Members are asked receive the report and note the headline rating of Good for BwD CCG.

Roger Parr Chief Finance Officer 5th September 2019

Governing Body Meeting Page 3 of 6

Annex A 2018/19 Summary

The CCG should be congratulated on the work undertaken in developing supportive and robust arrangements across Pennine Lancashire. There are clear opportunities in the enhanced integration of the two CCGs within Pennine Lancashire and integration of an enhanced service offer in relation to Personal Health Budgets and Continuing Health Care Budgets. Pressures continue to be apparent within cancer 62 day, cancer two week wait, urgent and emergency care and mental health which require clear focus and attention. The CCG has shown focus on financial delivery overall and should be commended for its outstanding performance in dementia and diabetes.

Key Areas of Strength / Areas of Good Practice

The CCG:

 Has developed a strong working relationship with the neighbouring CCG and the wider Pennine Lancashire health economy, including the recent appointment of a joint CCG Accountable Officer. The CCG is also contributing to the developing Lancashire and South Cumbria Integrated Care System;  Achieved an outstanding rating for the clinical priority area for diabetes and maintained the outstanding rating for dementia;  Demonstrated significant reductions in prescribing costs including work in switching to biosimilars;  Noting ongoing challenges, an improving position was seen in 2018/19 in relation to urgent and emergency care, linked to positive working with system partners and good practice around reducing LOS, DTOC and work with the Ambulance Service;  Led the ‘Lets Talk About Cancer’ initiative and is noted as a highly positive programme;  Led initiatives to improve workforce with the work in relation to Primary Care workforce being noted as innovative.

Key Areas of Challenge

 Focus is required on most of the clinical priority areas where the rating is not currently rated as good or outstanding. Particular attention should be given to improving maternity, cancer, learning disabilities and mental health indicators which are rated as requires improvement;  Sharing of opportunities across the Pennine Lancashire ICP and playing an active part of the developing Lancashire and South Cumbria ICS is key. This is specifically linked to the areas of Continuing Health Care and the wider commissioning agenda, ensuring local delivery and supporting delivery across Lancashire and South Cumbria, commissioning on a wider footprint where this is beneficial.

Key Areas for Improvement

The following areas require some focused attention and improvement:

Continuing Health Care (CHC): - Continue engagement with Blackburn with Darwen Council and consider linkages with Lancashire County Council.

Personal Health Budgets (PHBs): - Support improvements in PHBs continue to progress towards having an embedded CHC team across Pennine Lancashire.

Maternal Smoking:

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- CCG to support delivery across the Pennine Lancashire footprint by sharing the service arrangements provided across Blackburn with Darwen CCG.

Childhood Obesity - Monitor delivery against the standard, noting involvement in the national programme linked to childhood obesity and the CCG to conduct a review of their healthy weight strategies.

Cervical Screening - Support the wider Pennine Lancashire system in delivering improved performance as seen within Blackburn with Darwen CCG.

Urgent and Emergency Care: - Although noting improvements throughout 2018/19 there remains a continued need to ensure sustained improvements in the delivery against the Urgent Care standards; - Continue the work with partners to address 12 hour breaches; - Monitor and support improvement in system workforce pressures to support delivery, continuing and expanding on the work programmes in place to increase workforce capacity.

Cancer 62 day: - Ensure continued effective engagement with the Cancer Alliance; - Continue oversight and management across the Pennine Lancashire footprint; - Monitor staffing with the local provider and the impact of tertiary centres on local performance, setting follow on actions as a result of this monitoring.

Cancer Two Week Waits: - Although wider two week wait performance has shown to be positive focus is required to improve performance on the breast symptomatic standard, including the support to wider system partners; - The management of pressures caused by patient choice must be understood across the Pennine Lancashire system.

Diagnostics - Performance has been positive however the pilot work on the lung cancer pathway needs to be monitored in relation to overall diagnostics performance.

Referral To Treatment (RTT): - Monitoring of performance both locally and within the private sector needs to continue and actions taken to improve where necessary.

52 Week Waits: - Work with partners to address and eradicate 52 week waits, noting the financial implications in 2019/20.

Waiting List: - Ensure focus on reducing the waiting list size; - Ensure reporting of waiting list size is consistent with levels of activity and that additional activity, not currently included in the waiting list is clearly articulated.

Mental Health: - The CCG should continue to support local mental health providers in managing demand across the system; - Ensure escalation arrangements across organisations are understood, robust and embedded into practice; - Understand and monitor performance against IAPT recovery and EIP standards; - Monitor Children and Young People services and links with an all age service.

Sepsis: - Ensure full engagement with the continued work on the sepsis bundle to support improvements locally; - Continue to work with system partners to review and ensure early identification of sepsis.

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Primary Care: - Positive work ongoing in relation to primary care and developing the primary care workforce, however the CCG needs to monitor continued workforce demands and pressures and set actions in place to mitigate risk.

Sustainability

Key areas of strength/areas of good practice: - CCG delivered their QIPP in 18/19; - Development of a joint CCG QIPP and Trust CIP is being explored.

Key areas of challenge: - Focus needs to be on the delivery of a sustainable service offer across Pennine Lancashire, following the system support needed this year.

Key areas for improvement: - The delivery of a combined QIPP and CIP across Pennine Lancashire should be a focus for 2019/20; - Deliver plans within provided resource to ensure additional funding is not required to support delivery.

NHS England and NHS Improvement (North West) Lancashire & South Cumbria Integrated Care System

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NHS England and Improvement – North West

Assurance and Delivery

Preston Business Centre Watling Street Road Fulwood Graham Burgess, Chair, NHS Blackburn with Darwen CCG Preston [email protected] PR2 8DY

Dr Julie Higgins, Chief Officer, NHS Blackburn with Darwen CCG Telephone: 01138 254808 [email protected] Email: [email protected]

9th July 2019 Date

Dear Graham / Julie

2018/19 CCG annual assessments

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

This letter provides your annual assessment, as well as a summary of any areas of strength and where improvement is needed as discussed at our year-end review (Annex A).

Detail of the methodology used to reach the overall assessment for 2018/19 can be found at Annex B. The categorisation of the headline rating is either Outstanding, Good, Requires Improvement or Inadequate.

The 2018/19 headline rating for NHS Blackburn with Darwen CCG is Good. This rating being testament to the CCGs leadership and engagement across your health economy.

The 2018/19 annual assessments will be published on the Commissioning Regulation pages of the NHS England website in July. At the same time they will be published on the MyNHS section of the NHS Choices website. The Q4 IAF dashboard will be issued with year-end ratings in July.

NHS England and NHS Improvement

2019/20 will be a transitional year for commissioner and provider oversight arrangements, although the CCG annual assessment process remains a familiar one. I look forward to working with you and continuing to support your CCG in improving healthcare for your local population and system.

I would ask that you please treat your headline rating in confidence until NHS England has published the annual assessment report on its website. This rating remains draft until formal release. Please let me know if there is anything in this letter that you would like to follow up on.

Yours sincerely

Jane Cass Director of Strategic Transformation / Locality Director - NHS England and NHS Improvement (North West) Director of Assurance, Delivery & Performance – Lancashire & South Cumbria ICS Annex A – 2018/19 summary

Key Areas of Strength / Areas of Good Practice The CCG: • Has developed a strong working relationship with the neighbouring CCG and the wider Pennine Lancashire health economy, including the recent appointment of a joint CCG Accountable Officer. The CCG is also contributing to the developing Lancashire and South Cumbria Integrated Care System • Achieved an outstanding rating for the clinical priority area for diabetes and maintained the outstanding rating for dementia • Demonstrated significant reductions in prescribing costs including work in switching to biosimilars • Noting ongoing challenges, an improving position was seen in 2018/19 in relation to urgent and emergency care, linked to positive working with system partners and good practice around reducing LOS, DTOC and work with the Ambulance Service • Led the ‘Lets Talk About Cancer’ initiative and is noted as a highly positive programme • Led initiatives to improve workforce with the work in relation to Primary Care workforce being noted as innovative

Key Areas of Challenge • Focus is required on most of the clinical priority areas where the rating is not currently rated as good or outstanding. Particular attention should be given to improving maternity, cancer, learning disabilities and mental health indicators which are rated as requires improvement • Sharing of opportunities across the Pennine Lancashire ICP and playing an active part of the developing Lancashire and South Cumbria ICS is key. This is specifically linked to the areas of Continuing Health Care and the wider commissioning agenda, ensuring local delivery and supporting delivery across Lancashire and South Cumbria, commissioning on a wider footprint where this is beneficial

Key Areas for Improvement The following areas require some focused attention and improvement:

Continuing Health Care (CHC): • Continue engagement with Blackburn with Darwen Council and consider linkages with Lancashire County Council

Personal Health Budgets (PHBs): • Support improvements in PHBs continue to progress towards having an embedded CHC team across Pennine Lancashire

Maternal Smoking: • CCG to support delivery across the Pennine Lancashire footprint by sharing the service arrangements provided across Blackburn with Darwen CCG

Childhood Obesity • Monitor delivery against the standard, noting involvement in the national programme linked to childhood obesity and the CCG to conduct a review of their healthy weight strategies

Cervical Screening • Support the wider Pennine Lancashire system in delivering improved performance as seen within Blackburn with Darwen CCG

Urgent and Emergency Care: • Although noting improvements throughout 2018/19 there remains a continued need to ensure sustained improvements in the delivery against the Urgent Care standards • Continue the work with partners to address 12 hour breaches • Monitor and support improvement in system workforce pressures to support delivery, continuing and expanding on the work programmes in place to increase workforce capacity

Cancer 62 day: • Ensure continued effective engagement with the Cancer Alliance • Continue oversight and management across the Pennine Lancashire footprint • Monitor staffing with the local provider and the impact of tertiary centres on local performance, setting follow on actions as a result of this monitoring

Cancer Two Week Waits: • Although wider two week wait performance has shown to be positive focus is required to improve performance on the breast symptomatic standard, including the support to wider system partners • The management of pressures caused by patient choice must be understood across the Pennine Lancashire system

Diagnostics • Performance has been positive however the pilot work on the lung cancer pathway needs to be monitored in relation to overall diagnostics performance

Referral To Treatment (RTT): • Monitoring of performance both locally and within the private sector needs to continue and actions taken to improve where necessary

52 Week Waits: • Work with partners to address and eradicate 52 week waits, noting the financial implications in 2019/20

Waiting List: • Ensure focus on reducing the waiting list size • Ensure reporting of waiting list size is consistent with levels of activity and that additional activity, not currently included in the waiting list is clearly articulated

Mental Health: • The CCG should continue to support local mental health providers in managing demand across the system • Ensure escalation arrangements across organisations are understood, robust and embedded into practice • Understand and monitor performance against IAPT recovery and EIP standards • Monitor Children and Young People services and links with an all age service

Sepsis: • Ensure full engagement with the continued work on the sepsis bundle to support improvements locally • Continue to work with system partners to review and ensure early identification of sepsis

Primary Care: • Positive work ongoing in relation to primary care and developing the primary care workforce, however the CCG needs to monitor continued workforce demands and pressures and set actions in place to mitigate risk

Sustainability:

Key areas of strength/areas of good practice: • CCG delivered their QIPP in 18/19 • Development of a joint CCG QIPP and Trust CIP is being explored

Key areas of challenge: • Focus needs to be on the delivery of a sustainable service offer across Pennine Lancashire, following the system support needed this year

Key areas for improvement: • The delivery of a combined QIPP and CIP across Pennine Lancashire should be a focus for 2019/20 • Deliver plans within provided resource to ensure additional funding is not required to support delivery

Summary

Annex B – Overall assessment methodology NHS England’s annual performance assessment of CCGs 2018/19

1. The CCG IAF comprises 58 indicators selected to track and assess variation across policy areas covering performance, delivery, outcomes, finance and leadership. Assessments have been derived using an algorithmic approach informed by statistical best practice; NHS England’s executives have applied operational judgement to determine the thresholds that place CCGs into one of four overall performance categories.

Step 1: indicator selection 2. A number of the indicators were included in the 2018/19 IAF on the basis that they were of high policy importance, but with a recognition that further development of data flows and indicator methodologies may be required during the year. By the end of the year, there were three indicators that were excluded as there was no data available for the measures: Percentage of deaths with three or more emergency admissions in last three months of life, Cardiometabolic assessment in mental health environments and Children and young people’s mental health services transformation.

Step 2: indicator banding 3. For each CCG, the remaining indicator values are calculated. For each indicator, the distance from a set point is calculated. This set point is either a national standard, where one exists for the indicator (for example in the NHS Constitution); or, where there is no standard, typically the CCG’s value is compared to the national average value.

4. Indicator values are converted to standardised scores (‘z-scores’), which allows us to assess each CCG’s deviation from expected values on a common basis. CCGs with outlying values (good and bad) can then be identified in a consistent way. This method is widely accepted as best practice in the derivation of assessment ratings, and is adopted elsewhere in NHS England and by the CQC, among others. 1

5. Each indicator value for each CCG is assigned to a band, typically three bands of 0 (worst), 2 (best) or 1 (in between).2

Step 3: weighting 6. Application of weightings allows the relatively greater importance of certain components (i.e. indicators) of the IAF to be recognised and for them to be given greater prominence in the rating calculation.

1 Spiegelhalter et al. (2012) Statistical Methods for healthcare regulation: rating, screening and surveillance 2 For a small number of indicators, more than 3 score levels are available, for example, the leadership indicator has four bands of assessment. 7. Weightings have been determined by NHS England, in consultation with operational and finance leads from across the organisation, and signal the significance we place on good leadership and financial management to the commissioner system:

• Performance and outcomes measures: 50%; • Quality of leadership: 25%; and, • Finance management: 25%

8. These weightings are applied to the individual indicator bandings for each CCG to derive an overall weighted average score (out of 2).

Figure 1: Worked example

Anytown CCG has:

- Quality of leadership rating of “Green” (equivalent to a banded score of 1.33) - Finance management rating of “Green” (equivalent to banded score of 2) - For the remaining 53 indicators, the total score is 49.5. - The se scores are divided through by their denominator and weighted to prod uce an overall domain weighted score:

1.33 2 49.5 ( ) × 25% + ( ) × 25% + ( ) × 50% = ퟏ. ퟑ 1 1 53

Step 4: setting of rating thresholds 9. Each CCG’s weighted score out of 2 is plotted in ascending order to show the relative distribution across CCGs. Scoring thresholds can then be set in order to assign CCGs to one of the four overall assessment categories.

10. If a CCG is performing relatively well overall, their weighted score would be expected to be greater than 1. If every indicator value for every CCG were within a mid-range of values, not significantly different from its set reference point, each indicator for that CCG would be scored as 1, resulting in an average (mean) weighted score of 1. This therefore represents an intuitive point around which to draw the line between ‘good’ and ‘requires improvement’.

11. In examining the 2018/19 scoring distribution, there was a natural break at 1.45, and a perceptible change in the slope of the scores above this point. This therefore had face validity as a threshold and was selected as the break point between ‘good’ and ‘outstanding’.

12. NHS England’s executives have then applied operational judgement to determine the thresholds that place CCGs into the ‘inadequate’. A CCG is rated as ‘inadequate’ if it has been rated red in both quality of leadership and financial management.

13. This model is also shown visually below:

GOVERNING BODY MEETING

GOVERNING BODY ASSURANCE FRAMEWORK UPDATE

Date of Meeting 11 SEPTEMBER 2019 Agenda Item 10

CCG Corporate Objectives

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

Clinical Lead: DR PENNY MORRIS

Senior Lead Manager MRS CLAIRE MOIR Finance Manager N/A Equality Impact and Risk Assessment N/A completed: Is a Data Protection Impact Assessment No Required GOVERG BODGOVERNING BODY MEETING Governing Body Meeting Page 1 of 5

Data Protection Impact Assesment N/A completed: Patient and Public Engagement completed: N/A Financial Implications N/A Risk Identified WITHIN THE REPORT Report authorised by Senior Manager: MR ROGER PARR/MRS KIRSTY HOLLIS Y

Decision Recommendations

The Governing Body is asked to:

i. Note the contents of the report

ii. Support the work underway to align the GBAF risks across both CCGs

iii. Identify any further risks which may prevent the achievement of the CCG’s Corporate Objectives

Governing Body Meeting Page 2 of 5

NHS BLACKBURN WITH DARWEN CLINICAL COMMISSIONING GROUP (CCG)

GOVERNING BODY MEETING

WEDNESDAY 11TH SEPTEMBER 2019

GOVERNING BODY ASSURANCE FRAMEWORK UPDATE

1. Introduction

1.1 The purpose of this report is to present the CCG’s Governing Body Assurance Framework (GBAF) for review.

2. Background

2.1 The CCG is required to have in place a system of internal control that supports the achievement of the organisation’s strategic aims and objectives. The GBAF is a key document which links the corporate objectives to risks, controls and assurances and is the main tool that the Governing Body uses to discharge its overall responsibility for internal control.

2.2 The GBAF is designed to ensure the requirements of the annual reporting arrangements i.e. the Annual Governance Statement (AGS) are met and that principal risks to the CCG achieving its Objectives are managed appropriately.

3. Corporate Objective Risks – 2019/20

3.1 With the appointment of a Joint Chief Officer in January 2019 for both BwD and East Lancashire (EL) CCGs, it was agreed that shared set of Corporate Objectives (CO) for 2019/20 would be developed. At the joint Governing Bodies meeting on 12 June 2019, the following objectives were agreed:

 CO1: To commission the best quality and effective services to deliver optimal healthcare outcomes for our local population.

 CO2: Ensure the balance of our health investment reflects our population’s needs and keeps the population well.

 CO3: Deliver the 10 year strategy by engagement with the population we serve and ensure we commission services that meet local needs with a clear focus on population health management strategies.

 CO4: We will focus on population health outcomes through helping to deliver successful Integrated Care Partnerships and ensure decisions, provision and access to local services is based on the needs of our population.

 CO5: As local health leaders we will focus on increasing life expectancy across Pennine Lancashire to be at, or above the national average in the next 10 years (to be agreed).

These objectives will now be incorporated into the next update of the GBAF with the associated risks. Governing Body Meeting Page 3 of 5

3.2 The Corporate Objective risks (2018/19), and their risk ratings (as previously) held on the BwD CCG’s GBAF were:

 CO1.1: There is a risk that ineffective commissioning decisions will prevent the CCG from achieving its corporate objectives, improving health and reducing inequalities (12)

 CO2.1: System-wide capacity issues may emerge that prevent the delivery of the CCG's plans and priorities (12)

 CO3.1: Failure to effectively manage demand, activity and cost pressures across the health system may impact on the CCG delivering its financial targets (16)

 CO4.1: The local health economy may not be sustainable unless there is a programme of change (12)

 CO5.1: There is a risk that providers delivery poor quality care and do not meet standards and outcomes (12)

 CO6.1: Clinical workforce capacity is challenged across the system (20)

4. Review of GBAF Risks

4.1 In accordance with the discussion held at the joint Governing Bodies meeting in June, work is now underway to progress the implementation of a shared Risk Management Strategy and Policy across both BwD and EL CCGs. The GBAF for both CCGs will in future present all risks held by the CCG that are rated 15 and above, in support of this aligned approach.

4.2 The risks that were previously held on the BwD CCG GBAF (para. 3.2) will be reviewed to identify whether they align to the revised corporate objectives listed in paragraph 3.1. In addition, a review of the risk ratings, will determine whether under the revised risk management strategy, their rating means they are retained as GBAF risks, or are downgraded and (if relevant) held on the corporate risk register.

4.3 For completeness, the GBAF is attached at Appendix 1 which contains the risks that have been held by BwD CCG whilst the work outlined above is finalised.

6. Update on Corporate Risk Register

6.1 The Governing Body has delegated authority to the Pennine Lancashire Quality Committee (PLQC) for the management of risks on the CCG’s Corporate Risk Register (CRR). A joint risk management report between Blackburn with Darwen and East Lancashire CCG continues to be presented for review by the PLQC on a bi-monthly basis.

6.2 As previously reported the following risks are held by both CCGs (the risk rating indicates those risks which would transfer to the GBAF):

Governing Body Meeting Page 4 of 5

 95% Accident and Emergency 4 hour standard (20)

 62 day cancer target which has been revised to incorporate (16)

 Ambulance Response Performance (16)

 Initial Health Assessments for Looked After Children

 18 Week Referral to Treatment (16)

 Performance against financial targets (16/currently on GBAF)

 Lack of inpatient beds for Children and Young People with Mental Health Issues (currently being re-assessed)

 Loss of residential and nursing home beds from care home sector and impact upon system resilience

 Mental Health system pressures impacting on quality and performance of services (16)

 UK’s exit from the EU (with a ‘deal’ or ‘no deal’)

 Failure to achieve stroke quality requirements for people who have had a stroke being admitted to an acute stroke unit within 4 hours (BwD risk, but under review for inclusion on EL CCG CRR). (15)

6.3 At the PLQC meetings in May and July 2019, discussions have been held regarding the review of target risk ratings and how progress is monitored towards the achievement of these. Further support will be provided to risk owners through the Risk Management and Compliance Group (RMCG) meeting. The membership has been broadened to include BwD CCG, and will provide challenge and scrutiny for all risks held on both CCs risk registers.

7. Recommendations

7.1 The Governing Body is asked to:

i. Note the contents of the report

ii. Support the work underway to align the GBAF risks across both CCGs

iii. Identify any further risks which may prevent the achievement of the CCG’s Corporate Objectives

Claire Moir Governance, Assurance and Delivery Manager 5th September 2019

Governing Body Meeting Page 5 of 5

Appendix 1

NHS Blackburn with Darwen Clinical Commissioning Group Corporate Risk Register and Governing Body Assurance Framework 2018/19 NHS Blackburn with Darwen CCG 2018/19 Risk Summary NHS Blackburn with Darwen CCG Current Joint Risk? Register Risk ID Risk Description Risk Owner Score (Y/N) 2019/20 Corporate Objectives Ineffective commissioning decisions may prevent the CCG from achieving its corporate objectives, improving health and reducing inequalities GBAF CO1.1 Roger Parr 12 Under review (under review) STRATEGIC OBJECTIVES To commission the best quality and effective services to deliver optimal CO1 healthcare outcomes for our local population Ensure the balance of our health investment reflects our population’s needs System‐wide capacity issues may CO2 emerge that prevent the delivery of and keeps the population well the health economy's plans and Deliver the 10 year strategy by engagement with the population we serve GBAF CO2.1 Roger Parr 12 Under review priorities (under review) CO3 and ensure we commission services that meet local needs with a clear focus on population health management strategies We will focus on population health outcomes through helping to deliver Failure to effectively manage the successful Integrated Care Partnerships and ensure decisions, provision increase in demand, activity and CO4 and access to local services is based on the needs of our population cost pressures across the health GBAF CO3.1 Roger Parr 16 Under review system may impact on the CCG As local health leaders we will focus on increasing life expectancy across delivering its financial targets (under CO5 Pennine Lancashire to be at, or above the national average in the next 10 review) years. The Local Health Economy may not be sustainable unless there is a GBAF CO4.1 programme of change (under Dr Julie Higgins 12 Under review review)

There is a risk that providers deliver Dr Ridwaan GBAF CO5.1 12 Under review poor quality care and do not meet Ahmed quality standards and outcomes Clinical workforce capacity is challenged across the system Dr Ridwaan GBAF CO6.1 20 Under review (under review) Ahmed Governing Body Assurance Framework Risks 2018/19 MENU

Corporate Objective CO1: Through better commissioning, improve local health outcomes by addressing poor outcomes and inequalities (under review)

Risk Description CO1.1 Ineffective commissioning decisions may prevent the CCG from achieving its corporate objectives, improving health and reducing inequalities (under review)

Initial Current Target Risk Owner Roger Parr Likelihood Possible Possible Unlikely Financial / VFM  Consequence Major Major Major Compliance / Regulatory Level 12 12 8 Innovation / Quality / Outcomes  Date Apr‐17 Mar‐19 Reputation  Movement ↔ Controls Assurance The CCG has submitted its activity plans and assumptions for 2018/19 to NHS England. Routine Internal Assurance contract monitoring of delivery against these plans will be undertaken (Integrated Business Report, CCG Governing Body receives papers and minutes from Commissioning Business Group contract and performance meetings) Monthly Contracting and Finance report update presented to Governing Body The CCG's Plans developed in conjunction with Health and Wellbeing Board and the Integrated Strategic Monthly Quality and Performance report presented to Pennine Lancs Quality Committee Needs Assessment (ISNA). Health and Wellbeing Strategy also informs CCGs plans and local health Minutes of contract and performance meetings issues and significant barriers to improving health and reducing inequalities. Minutes of the Joint CCG Commissioning Committee CCG Governing Body receives assurance and progress updates on implementation of its annual plans External Assurance Commissioning Business Group and Primary Care Commissioning Committee established with NHS England Improvement and Assessment Framework for 2018/19 ‐ monthly performance responsibility for developing, approving and monitoring plans and business cases. review meetings are held The CCG has full delegated authority from NHS England to co‐commission primary care which enables CCG's activity plans for 2018/19 are being reviewed by NHS England. the CCG to provide a strong focus on local clinical leadership and enable optimal decision making on 360 degree stakeholder survey findings are reviewed and areas for improvement built into the investment across primary, secondary and community services CCG's commissioning processes Use of "Rightcare" metrics to support decision making. Areas for greatest potential opportunities have been reviewed and plans for 3 priority areas submitted to NHS England (MSK, Medicines, Respiratory)

Gaps in Controls Gaps in Assurance Fragmentation of the commissioning system may slow down decision making Currently limited contract information on community services, primary care or specialist The frequency and timeliness of performance monitoring data varies according to the measure e.g. commissioning plans or performance monitoring information Potential Years of Life Lost (PYLL) figures are produced annually Health outcomes in certain areas are not improving as expected

ACTION PLAN

Expected Action Assigned to Date of update Action Description Progress to Date completion date To remain in place Implement process for reviewing the effectiveness of CCG's commissioning An assurance framework/commissioning plan tracker has been throughout reporting decisions developed linked to QIPP/Cases for Change 2018/19 Roger Parr period Attend monthly review meetings with NHS England to review performance To be held jointly with East Lancashire CCG against CCG IAF indicators Neil Holt/Claire Moir Monthly Governing Body Assurance Framework Risks 2018/19 MENU

Corporate Objective CO2: To work collaboratively to create safe, high quality health care services (under review)

Risk Description CO2.1 System‐wide capacity issues may emerge that prevent the delivery of the health economy's plans and priorities (under review)

Initial Current Target Risk Owner Roger Parr Likelihood Possible Possible Unlikely Financial / VFM  Consequence Major Major Major Compliance / Regulatory Level 12 12 8 Innovation / Quality / Outcomes  Date Apr‐17 Mar‐19 Reputation Movement ↔ Controls Assurance The Pennine Lancashire Health Economy has developed a Health and Social Care Escalation Plan which Internal Assurance ensures a continuous cycle of capacity and escalation planning to ensure the position across Pennine Minutes of Pennine Lancashire Clinical Transformation Board Lancashire remains resilient during periods of increased demand Minutes of Joint Committee of Clinical Commissioning Groups Together a Healthier Future Programme Management Office function (which CCG contributes to) is now Feedback on external public engagement in place to oversee delivery of Pennine Lancashire transformational plans Lancashire Leadership Forum established by NHS England to support the Lancashire and South Cumbria External Assurance change Programme (delivery of care in and outside of hospital). NHS Accelerate Programme developed External assurance provided through the NHS England Improvement and Assessment Framework to explore innovative models of care assurance monthly review meetings A&E Delivery Board established and meets monthly Strong relationships and leadership across the health and social care economy GP Federation has established the GP Access Fund (GPAF) which is now providing 7 day access to 100% A&E Delivery Board (supported by the A&E Delivery Group) meets monthly and is overseeing of patients living in Blackburn with Darwen plans to improve the delivery of urgent and emergency care Lancashire wide forums established to review system wide capacity issues. The CCG is working to support the implementation of national guidance issued on Urgent and Emergency Care and Cancer priorities A&E Delivery Board Plan on a Page circulated to governing body members

Gaps in Controls Gaps in Assurance The frequency and timeliness of performance data varies according to the measure e.g. reducing Health economy‐wide Integrated Care System plans/new models of care still developing emergency admissions through urgent care data is produced quarterly, but the comparison of Pennine Lancashire Local Delivery Plans still developing performance is made year on year Currently aligning financial deficit to proposed Sustainability and Transformational plans for Lancashire and South Cumbria

ACTION PLAN

Expected Action Assigned to Date of update Action Description Progress to Date completion date Roger Parr Nov‐18 Commissioning Development Framework to deliver 5YFV being developed A Committees in Common meeting has been established Integrated Care System vision aligned to Pennine Lancashire plans between BwD and East Lancs Commissioning Committees which Commissioning Organisations working together to identify how common resources is proposing to meet on a monthly basis to support collaborative are governed working across both CCGs tba Governing Body Assurance Framework Risks 2018/19 MENU

Corporate Objective CO3: To deliver financial balance and improve efficiency and productivity (under review)

Risk Description CO3.1 Failure to effectively manage the increase in demand, activity and cost pressures across the health system may impact on the CCG delivering its financial targets (under review)

Initial Current Target Risk Owner Roger Parr Likelihood Likely Likely Possible Financial / VFM  Consequence Major Major Major Compliance / Regulatory Level 16 16 12 Innovation / Quality / Outcomes  Date Apr‐17 Mar‐19 Reputation  Movement ↔ Controls Assurance CCG Governing Body approved budget for 2018/19 including contingency reserves Internal Assurance Financial recovery plan submitted to NHS England Demand and activity is monitored throughout the financial year; risk score amended based on Demand management initiatives in place ; the CCG is systematically working through the Rightcare the increasing (or decreasing) likelihood that targets will be met process (wave 2 CCG) with delivery partner support; 3 priority areas for greatest potential opportunities QIPP tracker used to monitor performance against transactional and transformational initiatives. have been identified and plans submitted to NHS England Potential impacts have been quantified and these are monitored and updated on a weekly basis Referral quality improvement scheme in place to track actions undertaken and any financial adjustments. Financial plan underpinning strategic plan in place The CCG has implemented a referral quality improvement scheme which is already showing a Established budgetary control system reduction in activity and costs against a range of procedures of limited clinical value and first Monthly meetings with budget holders outpatient attendances CCG Exec Team assigned responsibilities for QIPP savings programme Finance and Scrutiny Group meet monthly and receive detailed progress reports on QIPP CCG ET considers overall performance and ensures corrective action taken as required initiatives Finance recovery plan monitored through Operational Delivery Group and Executive Team Commissioning intentions for 2018/19 are being developed and associated contract values will Finance and Scrutiny Working Group (Governing Body representation) scrutiny of CCG recovery plans be agreed with providers

External Assurance Finance and activity plans has been produced for 2018/19 and submitted to NHS England

Gaps in Controls Gaps in Assurance Continuing to experience underlying growth in activity Impact of schemes/business cases may not be realised immediately Prescribing expenditure costs are impacting on CCG's financial plans. Increasing pressure from drugs classed as No Cheaper Stock Available (NCSO)

ACTION PLAN

Expected Action Assigned to Date of update Action Description Progress to Date completion date QIPP meetings are held Continuing to progress existing QIPP schemes and develop further schemes for both BwD Work is underway identify further schemes to achieve the QIPP Roger Parr weekly and reported to ET and Pennine Lancashire to achieve stretch target in 2018/19 target 2018/19 Continue to utilise Rightcare metrics to identify areas where CCG is an outlier The BI Team have developed a sophisticated tool to support Roger Parr Review monthly on spend and activity. Regular meetings held with delivery partner colleagues explore any of the Rightcare condition metrics. PAGE 6 Latest update for April ‐ September this year is showing a 1.7% Ridwaan Ahmed Review monthly Monitor impact of referral quality improvement scheme reduction in GP referrals compared to the same period last year Governing Body Assurance Framework Risks 2018/19 MENU

Corporate Objective CO4: To deliver a step change in the NHS in preventing ill health and supporting people to live healthier lives (under review)

Risk Description CO4.1 The Local Health Economy may not be sustainable unless there is a programme of change (under review)

Initial Current Target Risk Owner Dr Julie Higgins Likelihood Possible Possible Unlikely Financial / VFM  Consequence Major Major Major Compliance / Regulatory Level 12 12 8 Innovation / Quality / Outcomes  Date Apr‐17 Mar‐19 Reputation  Movement ↔ Controls Assurance Pennine Lancashire Integrated Health and Care Partnership Leaders Forum is established with Internal Assurance responsibility for overseeing the Together a Healthier Future (TAHF) Transformation Programme. The Senior Responsible Officers from organisations released to support the development of the plans Forum consists of the Chief Officers/Chairs and leaders of the six statutory health and care organisations and systems for health and care that constitute the Transformation Programme. Updates on transformational plans presented to Joint Committee of Clinical Commissioning System Accountable Officer and Local Leadership (Senior Responsible Officer) arrangements for each Groups element of the Pennine Lancashire Cases for Change programme identified Governance review underway to clarify the roles and functions at each level across the system Outcomes of the Solution Design phase are set out in the draft Pennine Plans including the Benefits External Assurance Framework, new model of care proposals and quality standards. Lancashire and South Cumbria Sustainability and Transformation Plan End to End Overarching Timeline for completion set with milestones to monitor progress Accountable Health and Care Partnership Leaders' Forum membership includes senior leaders Resource plan developed from key organisations (BwD CCG, East Lancs CCG, East Lancashire Hospitals Trust, Lancashire External agency providing specialists support to assist in financial modelling (Deloittes Care Foundation Trust, BwD Borough Council and Lancashire County Council This has set the overarching strategic direction for the transformation programme with a key focus on developing plans for new models of care and an Accountable Care System for Pennine Lancashire

Gaps in Controls Gaps in Assurance Process to undertake gap analysis and definition of key priorities to be undertaken Scale of financial challenge and alignment of commissioner/provider plans may impact on delivery of plans

ACTION PLAN

Expected Action Assigned to Date of update Action Description Progress to Date completion date Roger Parr 20/11/2018 Joint meeting (EL and BwD CCG) held on 12 June 2018 to discuss Commissioning Both East Lancs and BwD CCG are working closely together and Development Framework have recently formed a commissioning committee in common to Integrated Care System vision aligned to Pennine Lancashire plans align decisions where appropriate Commissioning Organisations working together to identify how common resources Mar‐19 are governed Governing Body Assurance Framework Risks 2018/19 MENU

Corporate Objective CO5: To maintain and improve performance against NHS core standards and statutory requirements

Risk Description CO5.1 There is a risk that providers deliver poor quality care and do not meet quality standards and outcomes (under review)

Initial Current Target Risk Owner Dr Ridwaan Ahmed Likelihood Possible Possible Unlikely Financial / VFM  Consequence Major Major Major Compliance / Regulatory Level 12 12 8 Innovation / Quality / Outcomes  Date Apr‐17 Mar‐19 Reputation  Movement ↔ Controls Assurance Joint Pennine Lancashire Quality Committee (PLQC) established and meets monthly Internal Assurance Internal quality structures functioning well as confirmed through internal audit reports (high assurance Pennine Lancashire Quality Committee minutes on performance reporting) Integrated Quality, Performance and Effectiveness Reports and exception reports Monitoring assurance received through contractual route that provider cost improvement plans will not Contract Quality and Performance Report presented monthly to Governing Body negatively impact on quality and safety of services Minutes from Contract and Performance meetings Lancashire Quality Surveillance Group established and Provider Quality Accounts reviewed by PLQC CSU Quality and Performance Team reviewed provider quality accounts Patient experience monitored using patient surveys Quality of Primary Care Services ‐ findings of quality visits discussed at quarterly review meetings Quality and performance lead attends monthly Community Contract Quality and Performance meetings LCFT Quality Improvement Action Plan monitored through PLQC following CQC rating of Primary Care Quality Group established which will monitor primary care quality data/framework "requires improvement" Routine GP practice visits underway. External Assurance CQC inspection visits reports NHS England external assurance meetings (monthly) ‐ quality issues discussed Mersey Internal Audit Agency Review s Healthwatch reports are now received and reviewed via the CCG's Operational Delivery Group

Gaps in Controls Gaps in Assurance Availability of quality data relating to community services still needs improvement Awaiting quality and performance dashboard from NHS England to enable monitoring of general practice

ACTION PLAN

Expected Action Assigned to Date of update Action Description Progress to Date completion date Quality and performance lead from CCG now attends Contract Quality and Contracts update is now a weekly standing item at the Ops Ridwaan Ahmed Review monthly Performance meetings Delivery Group Monthly Senior Executive in attendance at Community Contract Management Meetings ‐ The CCG is working with LCFT on a joint approach to quality issues raised regarding poor quality community contract data being received assurance ‐ reports and outcomes of these visits are shared with Roger Parr the CCG Governing Body Assurance Framework Risks 2018/19 MENU

Corporate Objective CO6: To commission improved out of hospital care (under review)

Risk Description CO6.1 Clinical workforce capacity is challenged across the system (under review)

Initial Current Target Risk Owner Dr Ridwaan Ahmed Likelihood Likely Likely Possible Financial / VFM  Consequence Major Major Major Compliance / Regulatory Level 16 20 12 Innovation / Quality / Outcomes  Date Apr‐17 Mar‐19 Reputation  Movement Controls Assurance Workforce Development Group established to review opportunities for recruitment and retention Internal Assurance (short/medium term) with Health Education North West. Wider system re‐design is planned (new Primary Care Strategy is approved and finalised. 5 year Sustainability and Transformation Plan models of care/organisational form) to stimulate workforce recruitment and retention across the health covering a Lancashire and South Cumbria footprint sets out the ambitions for transformational economy. change including workforce requirements. APEX workload tool utilised which works in conjunction with INSIGHT worforce planning tool to improve Pennine Lancashire Quality Committee monitors and receives assurance of "Safer Staffing" levels efficiencies in general practice, and to help identify future skill mix in general practice and new models of across providers care. External Assurance Within the QOEST scheme there is a sustainability element which is now having an impact on developing NHS England has submitted a bid on behalf of all CCGs to assist with GP retention across the the future workforce. country. Wider system re‐design is planned (new models of care/accountable care system) to stimulate Health Education North West (HENW) has informed the CCG of the Workforce Development workforce recruitment and retention across the system. Funding Allocations for 2018/19. These will be utilised in Workforce Development upskilling CCG has full delegated authority to co‐commission primary medical care which enhances the CCGs remit which includes Vocational Learning Support, Non‐Medical Prescribing and Mentorship and to influence local GP workforce development in conjunction with NHS England including supporting Supervision. General Practice in workforce review, skill mix, and development. New roles in primary care will be A Digital Supervision Pilot is to commence in BwD in association with NHS Digital and it is encouraged to create a sustainable workforce across primary care as a whole including increasing anticipated that this will be rolled out across Lancashire and South Cumbria based on the Advanced Nurse Practitioners and Health Care Assistants to allow GPs to become Expert Generalists. evaluation. Integrated localities will support this through reducing GP workload to allow them to take on more CCG engages with both HENW and Pennine Lancashire organisations to review opportunities to complex work. QOEST scheme will allow practices to plan ahead in terms of sustainable workforce. encourage GP placements in BwD Physicians Associates have commenced their training GP Forward View Operational Plan submitted to NHS England which incorporated planning for Contractual levers used to ensure commissioned levels of activity delivered. workforce, capacity and future models of care. LCFT and ELHT are recruiting nationally and internationally using innovative recruitment strategies

Gaps in Controls Gaps in Assurance On‐going financial pressures on NHS resources 2018/19 Capacity and workforce pressures are exacerbating existing recruitment and retention problems Physicians Associates will require 2 year training programme Clinical Workforce capacity is a national issue (reported as 5.9% shortage) Cap on agency spend is exacerbating issues with safe staffing levels which is impacting on service delivery (reduction in local health services)

ACTION PLAN

Expected Action Assigned to Date of update Action Description Progress to Date completion date Engaging with both Health Education NW and Pennine Lancashire organisations to create opportunities to encourage Malcolm Ridgway Review quarterly Workforce development group established to review recruitment opportunities GP placements in BwD Collaboration with Healthier Lancashire Programme to support the development of 5 year STP including workforce requirements System Leader Forum established and workforce identified as Malcolm Ridgway/Roger Parr Review quarterly one of five key tests of the transformation programme

GOVERNING BODY MEETING

Chief Finance Officer Report

Date of Meeting 11th September 2019 Agenda Item 11

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

Clinical Lead: N/A

Senior Lead Manager Mr Roger Parr Finance Manager Mrs Linda Ring Equality Impact and Risk Assessment N/A completed: Is a Data Protection Impact Assessment Required? No GOVERG BODGOVERNING BODY MEETING Governing Body Meeting Page 1 of 3

Data Protection Impact Assessment completed: No Patient and Public Engagement N/A completed: Financial Implications As per report Risk Identified As per 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 July 2019.

Governing Body Meeting Page 2 of 3

Executive Financial Summary Month 4 – Period Ending 31st July 2019

Year to Date (YTD) Full Year Forecast Budget Actual Variance Budget Actual Variance £000 £000 £000 £000 £000 £000 Funds Available 88,869 88,869 0 271,363 271,363 0

Commissioning 68,525 68,612 (87) 203,841 204,048 (207) Primary Care 18,113 18,105 8 55,650 55,650 0 Corporate 2,178 2,152 26 6,675 6,733 (58) Reserves 53 0 53 5,197 4,932 265 Balance 0 0 0 0 0 0

Summary Financial Position – The CCG is reporting a breakeven position in line with the financial plan. The CCG is on plan to deliver its year end forecast breakeven position.

Commissioned Services Risks

 Healthcare Commissioning is reporting a YTD overspend of £87k with  The CCG has a QIPP target of £6.0m and has achieved savings of a year-end forecast overspend of £207k. 25.8% of the target. There is a risk that some schemes will not fully  Primary Care Services are reporting a small YTD underspend of £8k release the planned savings in year and the CCG continues to look for with forecast year end breakeven position. Prescribing expenditure opportunities to mitigate any shortfalls. figures have been received for April and May with June and July  Acute activity levels continue to be a key factor in 2019/20. Schemes expenditure estimated. A forecast breakeven position is reported at are in place to manage demand this time.  Continuing health care and complex packages continues to be a key  Corporate Services are reporting an underspend of £26k and a year risk as these are generally high cost and low volume. The CCG end forecast overspend of £58k. continues to closely monitor this area of expenditure.  Prescribing expenditure is volatile and is monitored closely by the Capital Medicines Management Team. The prescribing waste scheme and the prescribing hub continue into 2019/20.  A combined budget for hardware replacement of the GPIT estates, provision of infrastructure, mobility working and operating software has QIPP been approved by NHS England on behalf of the CCG. Expenditure of  The CCG has actioned 25.8% of its QIPP savings to date and is on plan £244k is expected in 2019/20. to meet the full year savings of £6.0m.

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 July 2019.

Governing Body Meeting Page 3 of 3

NHS Blackburn with Darwen CCG APPENDIX A

Summary Governing Body Report ‐ July 2019

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 (88,869) (88,869) 0 (271,363) (271,363) 0 Anticipated 000000 Total Revenue Resource Limit (88,869) (88,869) 0 (271,363) (271,363) 0

Expenditure

Commissioning (Page 2) 86,638 86,717 (79) 259,491 259,698 (207) Corporate (Page 4) 1,057 1,057 0 3,170 3,228 (58) Reserves (Page 4) 53 0 53 5,197 4,932 265 Healthcare Sub Total 87,748 87,774 (26) 267,858 267,858 0

Running Costs (Page 4) 1,121 1,095 26 3,505 3,505 0 Total Expenditure 88,869 88,869 0 271,363 271,363 0

Surplus/(Deficit) 000000

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

NHS 100.0 100.0 99.0 99.0 95.0

Non NHS 99.5 99.6 99.0 99.0 95.0 NHS Blackburn with Darwen CCG APPENDIX B

Healthcare Commissioning Report ‐ July 2019

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) 43,343 43,397 (54) 129,979 130,139 (160) Non NHS Providers 2,116 2,160 (44) 6,219 6,344 (125) NHS Contract Exclusions / Cost per Case 226 229 (3) 518 522 (4) Non Contract Activity 693 662 31 2,078 1,987 91 Other 141 163 (22) 269 335 (66) Sub Total Acute Contracts 46,519 46,611 (92) 139,063 139,327 (264)

Mental Health Services

NHS contracts 6,055 6,055 0 18,166 18,166 0 Non NHS Providers 327 384 (57) 828 828 0 IPA ‐ Complex Packages 883 814 69 2,649 2,617 32 Non Contract Activity 65 65 0 127 127 0 Other 388 386 2 672 665 7 Sub Total Mental Health Services 7,718 7,704 14 22,442 22,403 39

Community Health Services

NHS contracts 4,972 4,972 0 14,916 14,916 0 Non NHS Providers 604 617 (13) 1,644 1,696 (52) IPA ‐ Complex Packages 80 81 (1) 241 242 (1) NHS Contract Exclusions / Cost per Case 127 125 2 380 380 0 Non Contract Activity 000000 Hospices 380 380 0 1,096 1,096 0 Other 000000 Sub Total Community Services 6,163 6,175 (12) 18,277 18,330 (53)

Total Healthcare Contracts 60,400 60,490 (90) 179,782 180,060 (278)

Continuing Care Services

Continuing Care 2,545 2,566 (21) 7,636 7,698 (62) Free Nursing Care 410 367 43 1,231 1,100 131 Sub Total Continuing Care Services 2,955 2,933 22 8,867 8,798 69

Primary Care Services

Prescribing 8,411 8,411 0 25,232 25,232 0 Enhanced Services 804 808 (4) 2,491 2,491 0 Primary Care Co‐Commissioning 7,369 7,373 (4) 23,299 23,299 0 Out of Hours 455 455 0 1,365 1,365 0 Commissioning 702 696 6 2,147 2,147 0 Other 372 362 10 1,116 1,116 0 Sub‐total Primary Care services 18,113 18,105 8 55,650 55,650 0

Other Programme Services

Other Non Acute 3,086 3,107 (21) 8,939 8,943 (4) Complex Cases & Individual Funding Requests 2,084 2,082 2 6,253 6,247 6 Sub Total Other Programme Services 5,170 5,189 (19) 15,192 15,190 2

Surplus/(Deficit) 86,638 86,717 (79) 259,491 259,698 (207) NHS Blackburn with Darwen CCG APPENDIX C

Main Healthcare Contracts ‐ July 2019

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 37,186 37,186 0 111,558 111,558 0

Other Lancashire Providers

Lancashire Teaching Hospitals NHS FT 1,898 1,955 (57) 5,694 5,865 (171) Blackpool Fylde & Wyre Hospitals NHS FT 157 202 (45) 448 578 (130) University Hospitals Morecambe Bay NHS FT 46 34 12 138 103 35 North West Ambulance Service NHS Trust (Block) 2,596 2,596 0 7,787 7,787 0 Sub Total Other Lancashire Providers 4,697 4,787 (90) 14,067 14,333 (266)

Greater Manchester Providers

University Hospital South Manchester NHS FT 000000

Salford Royal NHS FT 147 170 (23) 402 470 (68) Royal Bolton Hospitals NHS FT 93 93 0 278 278 0 Wrightington, Wigan & Leigh NHS FT 348 366 (18) 1,052 1,105 (53) Central Manchester University Hospital NHS FT 693 613 80 2,078 1,838 240 Pennine Acute NHS Trust 72 68 4 224 212 12 The Christie NHS FT 70 51 19 211 152 59 Sub Total Greater Manchester Providers 1,423 1,361 62 4,245 4,055 190

Merseyside Providers

Royal Liverpool & Broadgreen NHS Trust 36 64 (28) 109 192 (83) Sub Total Merseyside Providers 36 64 (28) 109 192 (83)

Independent Sector Contracts

BMI Healthcare (Beardwood, Beaumont, Gisburne) 1,963 1,962 1 5,732 5,724 8 Ramsay 153 198 (45) 487 620 (133) Sub Total 2,116 2,160 (44) 6,219 6,344 (125)

Total Acute Contracts 45,458 45,558 (100) 136,198 136,482 (284)

Mental Health Contracts

Lancashire Care NHS FT (Block) 6,039 6,039 0 18,116 18,116 0 Calderstones Partnership NHS FT (Block) 000000 Greater Manchester West NHS FT 11 11 0 33 33 0 Total Mental Health Contracts 6,050 6,050 0 18,149 18,149 0

Community Health Contracts

Lancashire Care NHS FT (Block) 4,972 4,972 0 14,916 14,916 0 Total Community Health Contracts 4,972 4,972 0 14,916 14,916 0

Surplus/(Deficit) 56,480 56,580 (100) 169,263 169,547 (284) NHS Blackburn with Darwen CCG APPENDIX D

Non Healthcare Commissioning Report ‐ July 2019

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 000000 NHS Property Services re‐charge 875 897 (22) 2,624 2,682 (58) Other 182 160 22 546 546 0 Sub Total Corporate Costs 1,057 1,057 0 3,170 3,228 (58)

Plan requirements & reserves

Reserves 53 0 53 5,197 4,932 265 Sub Total Reserves 53 0 53 5,197 4,932 265

Running Costs

CCG Pay 579 564 15 1,777 1,777 0 CSU re‐charge 380 382 (2) 1,139 1,186 (47) NHS Property Services re‐charge 44 44 0 133 133 0 Other 118 105 13 456 409 47 Running Costs Reserve 000000 Sub Total Running Costs 1,121 1,095 26 3,505 3,505 0

Surplus/(Deficit) 2,231 2,152 79 11,872 11,665 207 NHS Blackburn with Darwen CCG APPENDIX E

Statement of Financial Position ‐ July 2019

July Statement of Financial Position £000

Non Current Assets Intangible Assets 9

Total Non Current Assets 9

Current Assets Trade and Other Receivables 2,090 Financial Assets 0 Inventory 803 Cash and Bank 191

Total Current Assets 3,084

Total Assets 3,093

Current Liabilities Trade and Other Payables (6,364) Other Liabilities 0 Provisions (113) Borrowings 0

Total Current Liabilities (6,477)

Total Assets less Current Liabilities (3,384)

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

Total Non Current Liabilities 0

Total Assets Employed (3,384)

Financed By General Fund (3,384) Revaluation Reserve 0 Donated Asset Reserve 0 Government Grant Reserve 0 Other Reserves 0

Total Equity (3,384)

GOVERNING BODY MEETING GOVERG BODGOVERNING BODY MEETING Performance Report

Date of Meeting 11 September 2019 Agenda Item 12

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  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 

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Clinical Lead: Dr Ridwaan Ahmed – Director of Quality and Performance Mr Roger Parr – Chief Finance Officer Senior Lead Manager Mr Roger Parr – Chief Finance Officer Finance Manager Mrs Jill Marr – Deputy Chief Finance Officer Equality Impact and Risk Assessment Not Required completed: Is a Data Protection Impact Assessment Required? Yes No  Data Protection Impact Assessment completed: Yes No  Patient and Public Engagement Not Required completed: 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 Ridwaan Ahmed – 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.

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Contract & Information Quality & Performance Lancashire Care Foundation Trust (LCFT) Mental Health ‐ Executive Summary Lancashire Care Foundation Trust (LCFT) Mental Health ‐ Executive Summary Month 3 Month 3

Early Intervention in Psychosis (EIP) ‐ The 56% target for treatment with a NICE Psychological Therapies – Blackburn with Darwen Clinical Commissioning Group (BwD approved care package within 2 weeks of referral was not achieved at Trust level in CCG) needs to achieve a monthly access target of 369 (22.0% p.a. of estimated June 2019, with performance at 44.44%. The target was however met for BwD CCG prevalence by Q4 2019/20). The CCG’s year to date (YTD) performance, including the with performance at 66.67%. Referral delay continues to be the main reason for Long‐Term Conditions (LTC) IAPT Service, is below the level required to achieve this breaching. target. It is also below the planned year to date level i.e. a current annualised rate of 19.0% of estimated prevalence: The RTT standard operating procedure (SOP) has been reviewed to reflect a o LCFT IAPT ‐ Core Service: 534 Patients into treatment recognition of the trusted assessment and the impact on ‘clock start’, the SOP was fully implemented from the beginning of July 2019. It is anticipated that the new o LCFT IAPT – LTC Service: 346 Patients into treatment SOP as well as several actions that have been put in place will reduce the number of o YTD Total 880 Patients (17.5% p.a. estimated prevalence) breaches. However, it was highlighted that all EIP teams nationally are experiencing o YTD Target: 954 Patients (19.0% of estimated prevalence) difficulties with the EIP service and that due to the complex nature of the service users some breaches are to be expected. Lancashire Women’s Centre (Core Service plus LTC) is now sub‐contracted via LCFT and is included in the above performance. ADHD Service ‐ There continues to be an underperformance in the ADHD service in terms of the number of people waiting more than 18 weeks from referral. For BwD Referrals – at Month 3, BwD CCG referrals to LCFT Mental Health Services have CCG in June 2019 there was 54 out of 74 people waiting more than 18 weeks with decreased on 2018‐19 levels ‐175 (‐21.3%). When compared to 2018‐19 plans, referrals the longest wait currently at 132 weeks. The current performance of the ADHD are below the expected level ‐39 (‐5.7%). This is due to below plan referrals in service was discussed at PEG on 1st August 2019 and the following points were Community Mental Health Team – Adult (‐32, ‐39%) and Hospital Liaison (‐30, ‐49%). highlighted: Only referrals to the Community Mental Health Team – Older Adult (+11, +92%) and Criminal Justice Liaison (+40, +31%) are showing substantial above plan performance. ‐ Other services nationally have an upper age range of 30 years. If this was the case for LCFT 30‐35% of patients currently in the service would be Admissions ‐ including Out of Area admissions, and against plans based on LCFT total removed. However previous guidance from procurement has suggested that capacity split by each CCG's current Mental Health weighted population, BwD CCG this could lead to potential litigation. above plan at month 3, +10 (+15%). ‐ It was also advised that over the age of 35 years there is no treatment that Bed Days ‐ including Out of Area bed days and based on plans which are calculated by would make a difference; however, a diagnosis could make a difference in taking LCFT’s total available bed days, at month 3, BwD CCG patients have accounted terms of protected characteristics but would not change the outcome. for more than the CCG’s Mental Health weighted population share of bed days +845 However other areas that have these restrictions were not necessarily (+27%). performing as well as LCFT.l

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Out of Area Placements (OAPs) Memory Assessment Service (MAS) – The target for 70% of service users to be 2018/19 2019/20 Yr on Yr Change assessed by the Memory Assessment Service (MAS) within 6 weeks was met at Trust at Month 3 at Month 3 in OAP % level in June 2019, with performance at 70.00% a decrease from May 2019 at BwD 4 out of 67 17 out of 76 71.04%. +16.4% CCG (6.0%) (22.4%) There has been an improvement in performance for BwD CCG to 34.28% in June Admissions All Lancs 36 out of 575 60 out of 552 2019 compared to 12.50% in May 2019. In M3, there has been a continued increase +4.6% CCGs (6.3%) (10.9%) in the number of referrals received and accepted by the Pennine MAS teams. There BwD 403 out of 3285 1010 out of 3978 continues to be sickness and vacancies in the team and bank staff are being utilised +13.1% CCG (12.3%) (25.4%) where possible. The additional support from other teams had to be stepped down Bed Days All Lancs 2677 out of 27811 5493 out of 37382 as they were experiencing their own resource issues. Several actions are in place to +5.1% CCGs (9.6%) (14.7%) continue to improve this position by September 2019.

OAPs account for 22% of all BwD CCG admissions and 25% of all BwD CCG bed days. Improving Access to Psychological Therapies (IAPT): Prevalence ‐ LCFT's IAPT This is high compared to all Lancashire CCGs combined, and is also a substantial reporting for June 2019 indicated that the monthly prevalence target of 1.58% was increase on the same period last year. not achieved at Trust level with performance at 1.41%. BwD CCG achieved the prevalence target of 1.58% for Month 3 with performance reported at 1.60%. At Trust level there have been 187 Out of Area Placements (OAPs) in 2019‐20, against Actions are in place to increase performance against the prevalence target: the decreasing trajectory (now 46 per month – see below). This June figure (68) is an increase on the May figure (59). There is a plan to reduce OAPs across Lancashire CCGs, ‐ A redesign of the assessment stage to improve efficiency and patient with the new trajectory set as follows: experience ‐ The screening and telephone assessment PDSA are now in progress in the Apr‐19 May‐19 Jun‐19 Jul‐19 Aug‐19 Sep‐19 Oct‐19 and onwards East locality to test out new assessment models. 57 52 46 23 18 12 11 ‐ LCFT are currently looking at a communications strategy to achieve more appropriate referrals. With an aim that more appropriate referrals will The OAPs position and the impact of admission avoidance schemes are reported reduce the number of DNAs and patients dropping out of treatment. monthly via the LCFT Operational Resilience Group. Trajectories set relate specifically to OAPs funding and monitored via the formal Risk Share Agreement. The longest wait for BwD patients is between 11‐17 weeks (4 service users awaiting CBT). The sub‐contracting framework is now in place with providers delivering services a number of different interventions.

IAPT: Recovery ‐ The 50% Recovery target was met at Trust level in June 2019 with performance at 51.8%. The target was met for BwD with performance of 51.3%. The learning from reviewing ‘non‐recovered’ patients has highlighted the following reasons for non‐recovery:

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‐ Reliable recovery is being demonstrated as well as an improvement in symptoms however patients are not reaching full threshold for recovery. ‐ Silvercloud and groups have higher rates of non‐recovery, and as previously reported actions are in place to address this. ‐ LCFT are considering whether to continue using Silvercloud as the contract is due to end.

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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 3 Month 3

Point of Delivery (POD) Activity Variance £ Variance Referral to Treatment (RTT) Incomplete – In June 2019, the 92% RTT Incomplete A&E (including MIU) +1592 (+11.2%) Cost per plan target was not met at ELHT, with performance of 89.3%. For BwD CCG the target Elective (Ordinary + Day Cases) +21 (+0.6%) ‐£265K (‐7.1%) was not met with performance reported at 88.9%. Elective Excess Bed Days ‐152 (‐55.0%) ‐£43K (‐59.1%) Elective Costs Inc. Excess Bed Days ‐£308K (‐8.1%) The main pressure at LTHTr remains in Neurology, where there are 129 BwD CCG Non‐Elective (NEL) + Non‐Emergency (NE) ‐113 (‐2.4%) Cost per plan patients with a wait over 18 weeks. Greater Preston CCG will be taking service NEL + NEL NE Excess Bed Days +164 (+14.7%) Cost per plan redesign of neurosciences forward as a programme of work in 2019/20. Outpatients First Attends +1005 (+14.3%) Cost per plan Outpatient Follow‐up Attends +3583 (+27.2%) Cost per plan A&E 4 Hour – The 95% 4‐hour waiting time target for A&E was not met in June 2019 Outpatient Procedure – New +264 (+13.1%) +£43K (+14.1%) with performance at 82.49%. Mental health attendances continue to be a pressure in June 2019. Monitoring for Delayed Transfers of Care (DTOC) has shown a slight Outpatient Procedure – Review +20 (+0.5%) ‐£26K (‐4.4%) decline on the previous month and the position for M3 is 3.5%. Longer length of Total Outpatient +4960 (+18.1%) +£17K (+0.5%) stay is currently above the NHSI trajectory. As at 24th July 2019, the position is

above trajectory with 170 patients >21 days LOS against a target of 123. An ELHT‐ Inpatient Care is below plan on cost ‐£265K (‐7.1%) from above plan activity (+21 spells, led action plan has been agreed to deliver this target and work is underway to +0.6%). Less expensive Day Case activity is above plan (+174 spells, +5.7%) [+£20K, enhance the effectiveness of all current work streams. +0.9%]; while more expensive Ordinary Elective activity (EL) is well below plan (‐154 spells, ‐30% [‐£285K, ‐20%]. Below plan Excess Bed Days (‐152 bed days, ‐55%) has Ambulance Handovers – In June 2019, there were 112 ambulance handovers over further decreased Elective Admission costs by ‐£43K, resulting in a total Elective under 30 minutes and 21 handovers over 60 minutes, which is a reduction on the previous performance of ‐£308K (‐8.1%). month. Performance continues to be impacted by the pressures within the

Emergency Department. ELHT and NWAS continue to work together to reduce Outpatient Care is well above plan, mostly due to Outpatient Follow Up Attendances handover times and release ambulance crews. (+3583 attendances, +27.2%) and Outpatient First Attendances (+1005 attendances,

+14.3%). However, cost for both these (Outpatients New and Review) have been set at 12 Hour Breaches – In June 2019, there were 8x 12‐hour A&E breaches at ELHT. Bed plan for the year (therefore there is no cost overperformance). Outpatient Procedures availability continues to be the primary cause of delay with limited patient flow. The New are also above plan, +264 (+13.1%), with a comparable cost overtrade (+£43K, Mental Health Improvement Board is holding the accountability for the combined +14.1%). Outpatient Procedures Review are slightly above plan, although there is an action plan. under performance on cost (‐£26K, ‐4.4%).

Non‐Elective Admissions including Non‐Emergency are below plan ‐113 (‐2.4%). However, no cost benefit is realised from this, as costs have been set for the year as per plan. Combined with the overperformance in Emergency excess bed days, under PbR (Payment by Results) a cost benefit of ‐£89K would have been realised.

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However, had PBR been used for Accident Emergency (costs now also set as per plan for the year), a overtrade of +£220K (+11%) would have incurred against A&E activity.

Referral to Treatment – the number of BwD CCG patients awaiting treatment at ELHT is 8,729 at M3. This is an increase from the previous month (+160, +1.9%), and an increase on the same period last year (+2,364, +37%).

Part of the growth in activity versus the same period last year, is accounted for by Trauma and Orthopaedics pathways now including MSK pathways. It is estimated that this change added an extra 1,000 pathways in relation to BwD CCG patients. As such, real growth in pathways is estimated to be +1,364 (+21%).

There are 979 waiting >18 weeks = 11.2% i.e. above the target threshold of <=8%.

Referrals – Referrals to the CCG’s main hospital provider (ELHT) have increased +1.2% this year compared to the same period last year:

 GP Referrals ‐238 ‐3.6%  Non‐GP Professional Referrals +376 +8.1%  Total +138 +1.2%

NB. Referrals via A&E, following Emergency Admission and self‐referrals, are no longer included in data flows. As such, these have been removed from previous year’s comparative data.

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Contract & Information Quality & Performance Primary Care ‐ Executive Summary Primary Care ‐ Executive Summary Month 3 Month 3

Out of Hours ‐ Compared to last year’s Month 3 data, total activity for the Out of Hours Care Quality Commission (CQC) – Limefield Surgery (P81214) was inspected on 20th service provided by ELMS is over plan overall YTD by +1138 (+23.7%). June 2019 and its report was published on 19th July 2019 with a rating of Good overall and Good in all domains. Following a Requires Improvement notice, the CQC th Year to date ‐ Activity Full Year Forecast ‐ Activity carried out a focussed visit at Hollins Grove Surgery (P81721) on 7 August 2019. 19/20 18/19 Variance Status 19/20 18/19 Variance Status Quality Visits – Olive Medical Practice (P81683) ‐ The most recent monthly quality To be 2117 1876 241 12.8% R 9294 8236 1058 12.8% R th seen review took place with the partners on 8 August 2019. It was agreed that the practice has made significant progress since April with the support of the GP Advice 3830 2933 897 30.6% R 16235 12502 3823 30.6% R Federation, Local Primary Care. The CCG is continuing to offer support through weekly progress visits. The practice is also addressing a Remedial Notice Action Plan

Total 5947 4809 1138 23.7% R 25620 20738 4882 23.5% R from the previous provider Umar Medical Centre and has made significant progress. 11 of the 21 actions are complete and the remaining are in progress.

Incidents ‐ Brownhill Surgery (P81155) reported a second incident at the Brownhill Estates Technology Transformation Fund (ETTF) ‐ The West Scheme continues to pharmacy regarding a patient who was prescribed the wrong dosage of Trulicity develop its outline business case (OBC) stage. Further work has been undertaken Ampoules. The practice has confirmed that the pharmacy is investigating, and the regarding the scheme size and cost. Presentation of the scheme is expected to take incident has been reported to NHS England. place at the September Primary Care Co‐Commissioning Committee. Complaints ‐ In Quarter 4 2018/19 5 complaints were made to NHS England; of Primary Care Neighbourhood (PCN) –The Neighbourhoods continue to meet and are these2 are ongoing and 3 were not upheld. developing service improvement projects. Discussions will be taking place regarding further PCN development now that the new Clinical Directors have been appointed to Post Payment Verification Visits ‐ PPV visits were discussed at the Primary Care prepare the PCN’s to deliver the national requirements. Group on 1st August 2019. Future reviews for the practices identified in 2019 cannot be carried out until April 2021; this will show the results from the financial year QOEST ‐The 2019/20 plan is now being implemented and operationalised. Discussions 2020/2021 and therefore demonstrate if the improvements have been made. have commenced on what the next plan should look like and how a possible Pennine approach or elements of such could be adopted Patient Experience Annual GP Patient Survey 2019 Blackburn with Darwen 2016 2017 2018 2019 Number of questionnaires sent out 8,466 8,850 8,761 9,013 Number of questionnaires returned 2,749 2,824 2,389 2,455 Response rate 32% 32% 27% 27%

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Friends and Family Test (FFT)‐ May 2019 Total List Total Percentage Percentage Not Size Responses Recommend Recommend England 59,379,578 299,063 90% 6% BwD 176,912 433 91% 5% The FFT will change from April 2020, further details are awaited from NHS England.

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Contract & Information Quality & Performance Lancashire Care Foundation Trust Community ‐ Executive Summary Lancashire Care Foundation Trust Community ‐ Executive Summary Month 3 Month 3

The process for reporting against variances (+/‐10%) as agreed by Chorley and South LCFT have advised of several data input errors and migration issues as a result of the Ribble CCG (CSR CCG) as lead contractor for LCFT Community Services is for the Trust to recent implementation of the RiO PAS system in June 2019. Issues were highlighted provide an exception report in the month following the previous quarter. during the M3/Q1 validation period when LCFT performance colleagues noted a high incidence of incorrect data. Performance and information teams have been BwD CCG has 17 service lines – 4 services are over performing and 5 are working to correct and validate the month 3 position but due to the scale and underperforming +/‐10% with the remaining 6 service lines operating within tolerance. complexity of the issues needing resolution, some of the M3 data remains 2 children’s therapy services currently have no agreed plan due to the ongoing outstanding. Refreshed data for the LCFT Community performance measures is performance issues with RTT. The host Commissioner has advised that there are on‐ currently being validated and will be included with the M4 submission. going discussions with the Trust in relation to their trajectories before baselines can be agreed.

Adult Learning Disabilities (+339, +52.7%) ‐ The service has highlighted a reporting issue due to the move to RIO within August’s data which will have impacted activity from M2. This has now been addressed and is being monitored for reporting in M4.

Community Stroke Service (+168, +22.0%) ‐ The vacancies in the team have reduced and staff have worked additional hours to reduce the patient waiting times which has resulted in activity over baseline. On‐going monthly meetings are taking place to monitor waiting lists, staffing and patient outcomes.

Dermatology Service (‐627, ‐47.7%) ‐ The reduction in contacts is due to changes in About Health (who provide the GPwSI element of the BwD Community Dermatology service). The GPwSI service now uses 'System One' to record their activity and can no longer provide LCFT with the nurse activity undertaken where nurses support or run GPwSI nurse clinics. LCFT have a meeting planned on 23rd August 2019 to meet with the CCG and About Health to work on a solution.

DESMOND (‐43, ‐53.1%) – The Trust is looking at accreditation of the 1:1 offer and from September 19, Spirit Healthcare will also be providing Diabetes Education in Blackburn with Darwen. New baselines have been agreed for groups and 1:1s based on 2018/19 outturn.

Intensive Home Support (+2069, +27.1%) – The IHSS team are working to full capacity

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and report 0 weeks wait for RAT and 3 weeks wait for Rehabilitation.

The overall contract activity total is under plan by ‐972, ‐1.4%.

Baselines for Diabetes Specialist Nursing, Podiatry, Pulmonary Rehabilitation and Tissue Viability were delayed due to clarification queries from the CCG to the Trust. Therefore, exception narrative against these baselines will be reported in month 4.

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Contract & Information Quality & Performance Other ‐ Executive Summary Other ‐ Executive Summary Month 3 Month 3

BMI Beardwood + BMI Gisburne Park ‐ Total costs are below plan ‐£91K (‐6.3%). Ambulance Response Programme – In June 2019, for Category 1 calls (time critical  BMI Beardwood: ‐£107K (‐8.2%) and life‐threatening), the 7‐minute mean target and the 90th centile measure (15  BMI Gisburne Park: +£16K (+11.6%) minutes) was achieved for BwD CCG, with performance of 6 minutes 48 seconds and 11 minutes 12 seconds respectively. Elective Inpatient Care (EL + DC) position at month 3 shows activity ‐78 spells below plan (‐8.2%), with cost below plan ‐£60K (‐5.7%). For Category 2 (emergency), the 18‐minute mean target was not achieved for BwD While the specialties ENT is above plan (+5 spells, +20%), all other specialties are below CCG, with performance of 22 minutes 55 seconds. The 90th centile measure (40‐ plan. The largest under performance is for the following minute target) was also not achieved, with performance at 47 minutes 12 seconds.  Pain Management/Anaesthetics ‐£26K (‐9.1%) [‐32 spells, ‐7.5%] This is a reduction in performance from May 2019.  Trauma & Orthopaedics including Spinal Surgery ‐£22K (‐4.4%) [‐6 spells, ‐2.9%] th In June 2019, BwD CCG did not achieve the 90 centile target for Category 3 th Outpatient Care position at Month 3 shows below plan activity ‐160 (urgent) calls with performance at 2 hours 31 minutes and did not achieve the 90 attendances/procedures (‐4.4%) with costs also below plan ‐£31K (‐8.9%). This is mostly centile measure for Category 4 (less urgent) with performance at 4 hours 15 driven by Outpatient First Attendances: minutes.  Outpatient First Attendance ‐£33K (‐21.1%) [‐182 attendances, ‐19.6%]  Outpatient Procedure +£7K (+13.8%) [+72 procedures, +20.1%] NWAS has increased provision of See and Treat, with the aim of reducing  Outpatient Follow‐Up Attendance ‐£6K (‐4.3%) [‐50 attendances, ‐2.2%] conveyance to A&E. In June 2019 27.4% of calls resulted in See and Treat. The qualified paramedic workforce is now trained in the application of the Manchester Across all Points of Delivery (PODs) combined, the only specialty above plan to a Triage System and training is scheduled for Newly Qualified Paramedics due to notable degree is: qualify in August 2019.  Gynaecology +£8K (+20%) [+32 spells/attendances/procedures, +16%] Referral to Treatment (RTT) 18 weeks (Incomplete) – This RTT measure was not achieved for BwD CCG in June 2019 with performance at 89.92%. There were 1317 patients with a wait over 18 weeks out of a total waiting list of 11,886. Of the patients with a wait over 18 weeks, 822 were at ELHT, 311 were at LTHTr and the remainder were lower numbers across multiple providers.

Cancer ‐ % of patients seen within two weeks of an urgent GP referral where cancer is suspected The 2‐week target was not met in June 2019 for BwD CCG; there were a total of 59 breaches in month, 34 of which were patient initiated. The Pennine Lancashire public campaign ‘Let’s Talk Cancer’ is highlighting the importance of attending appointments and there are plans to roll out the campaign across the Cancer

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Alliance footprint and to support GP participation in the National Cancer Diagnosis Audit process. 18 breaches were due to outpatient capacity and recruitment is currently underway to replace a Consultant Dermatologist and the service are looking to appoint a locum consultant in the interim. Capacity and demand are being modelled for skin referrals into Maxillofacial to ensure appropriate capacity for outpatient and biopsy demand to manage 2 week wait patients.

Cancer % of patients receiving subsequent treatment within 31 days The 31‐day target was not achieved for BwD CCG in June 2019 with performance at 93.8%. There was 1 breach due to elective capacity. Capacity continues to be a pressure and directorates are working to ensure sufficient capacity and exploring all options to increase the number of surgical lists provided.

Cancer ‐ % of patients receiving subsequent treatment (chemotherapy) within 31 days The 31‐day target was not achieved for BwD CCG in June 2019 with performance at 92.9%. There was 1 breach due to treatment delay for medical reasons.

Cancer % of patients receiving 1st definitive treatment for cancer within 2 months – The 62‐day target was not met for BwD CCG in June 2019 with performance at 80.7%. There were 6 breaches leading to the underperformance.

The CCG continues to work closely with the Trust on Cancer pathway efficiencies to progress the 28 Day Project, to allow compliance with the Day 28 target by April 2020. The Trust has increased workforce to support the 28‐day faster diagnosis standard and will evaluate if this will translate into achievement of the target or if other factors are impacting on performance. A workshop is planned for October 2019. ELHT have undertaken a process mapping exercise which the CCG Cancer Team attended. Pathway analysis is currently underway. A review of 62 Day patient escalation processes has been carried out on behalf of Lancashire and South Cumbria Cancer Alliance Board. The final report has been circulated and ELHT are carrying out a gap analysis against the recommendations in the report.

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Appendix 1

East Lancashire Hospitals NHS Trust: BwD CCG Contract 1st April 2019 – 30th June

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 Var

A&E (including MIU) 14,221 15,813 1,592 11.2% £2.038M £2.038M 0.0%

Elective 3,599 3,620 21 ‐55.4% £3.742M £3.476M ‐£265K ‐7.1% (Ordinary + Daycases)

Excess Bed Days (Elective) 52 122 52 100.0% £73K £30K ‐£43K ‐59.1%

Non‐Elective 4,106 3,912 ‐194 ‐4.7% £8.997M £8.997M 0.0%

Excess Bed Days 1,065 1,177 112 10.5% £279K £279K 0.0% (Non‐Elective)

Non‐Elective Non‐ 556 638 82 14.7% £1.424M £1.424M 0.0% Emergency

Excess Bed Days (Non‐ 52 104 52 100.0% £19K £19K 0.0% Elective Non‐Emergency)

Outpatient First Attends 7,056 8,061 1,005 14.3% £1.397M £1.397M 0.0%

Outpatient Follow‐up 13,184 16,767 3,583 27.2% £1.137M £1.137M 0.0% Attends

Outpatient Procedure – 2,016 2,280 264 13.1% £302K £344K £43K 14.1% New

Outpatient Procedure – 4,460 4,480 20 0.5% £587K £561K ‐£26K ‐4.4% Review

Total

Other 658 745 87 13.3% £26K £26K 0.0%

Grand Total £20.019M £19.728M ‐£291K ‐1.5%

Based upon Version 2 of the Contract Monitoring Pivot, updated at 05/08/2019

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Activity within Point of Delivery classed as “OTHER” at ELHT

Activity Cost Activity Activity Activity Cost Cost Point of Delivery (POD) Cost Plan Variance Variance Plan Actual Variance Actual Variance % %

BLOCK (Non-PBR) £3.586M £2.914M -£673K -18.8% Age Related 735 733 -2 £77K £77K -0.3% Macular Degener’n Audiology 1,252 1,204 -48 £129K £135K £6K -3.8% 4.7% Critical Care 580 560 -20 £144K £143K -£1K -3.4% -0.9% Direct Access 330 394 64 £21K £24K £3K 19.3% 14.8% Other – Cardiology Direct Access PBR 359,280 356,917 -2,363 £806K £794K -£12K -0.7% -1.5% Pathology

Direct Access (Some 6,599 6,828 229 £270K £255K -£14K 3.5% -5.3% Radiology costs Diagnostic now 5,583 6,302 719 £363K £411K £48K 12.9% 13.3% Radiology mostly set as High Cost Drugs 3 3 0 £2K £3K £0K 14.3% per Maternity Pathway 1,136 3,987 2,851 £1.123M £1.123M plan) Rehabilitation 933 1,208 275 £273K £273K 29.5% Regular Day 410 463 53 £131K £132K £1K 12.8% 0.4% Attender Therapies 10,890 12,325 1,435 £454K £454K 13.2% Ward Attender 475 578 103 £62K £61K -£1K 21.6% -1.7% Other PBR TOTAL £3.856M £3.886M £30K 8.6% 0.8% Activity Variance 23 23 £25K £25K Adjustments 655 655 Anticoagulation 1,428 1,245 -183 £229K £200K -£29K -12.8% -12.8% Other ‐ Service Non‐ AQP (NOUS) 2,381 2,381 £95K £95K PBR CQUIN £355K £355K Integrated Eye 1,028 1,116 88 £57K £62K £5K 8.6% 8.0% Service TOTAL £287K £736K £449K 156.8% Other Miscellaneous £38K £39K £1K 2.9% OTHER GRAND TOTAL £7.766M £7.574M -£193K -2.5%

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Appendix 2

All Providers: BwD CCG Contract – 1st April 2019 – 30th June 2019

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 Var

A&E (including MIU) 14,824 16,427 1,603 10.8% £2.130M £2.131M £1K 0.0%

Elective 5,482 5,403 ‐79 ‐47.1% £5.916M £5.574M ‐£342K ‐5.8% (Ordinary + Daycases)

Excess Bed Days (Elective) 54 176 51 96.3% £91K £49K ‐£42K ‐46.2%

Non‐Elective 4,402 4,112 ‐291 ‐6.6% £9.464M £9.435M ‐£29K ‐0.3%

Excess Bed Days 1,125 1,247 122 10.9% £297K £302K £4K 1.5% (Non‐Elective)

Non‐Elective Non‐ 596 673 77 13.0% £1.512M £1.498M ‐£15K ‐1.0% Emergency

Excess Bed Days (Non‐ 54 105 51 96.3% £19K £19K ‐£0.1K ‐0.3% Elective Non‐Emergency)

Outpatient First Attends 9,474 10,164 690 7.3% £1.807M £1.761M ‐£46K ‐2.5%

Outpatient Follow‐up 19,505 22,701 3,196 16.4% £1.652M £1.608M ‐£44K ‐2.7% Attends

Outpatient Procedure – 2,229 2,415 186 8.4% £335K £365K £30K 9.1% New

Outpatient Procedure – 4,863 4,865 2 0.0% £645K £617K ‐£28K ‐4.3% Review

Outpatient Procedure – 448 540 92 20.4% £68K £81K £13K 18.9% Unspecified

Outpatient ‐ Other 1,318 1,264 ‐54 ‐4.1% £43K £40K ‐£3K ‐7.5%

Total £23.979M £23.479M ‐£500K ‐2.1%

Other £8.459M £8.224M ‐£236K

Grand Total £32.438M £31.703M ‐£736K ‐2.3%

Based upon Version 2 of the Contract Monitoring Pivot, updated at 05/08/2019

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Appendix 3 ELHT Referral Data for 2019/20 – GP Referrals

Number of Referrals to ELHT GP GP Variance Trend Specialty Referrals Referrals Variance % Quantity (last 15 months) 2018‐19 2019‐20 Cardiology 755 754 ‐1 ‐0.1% Community Paediatrics 1 95 127 32 33.7% Dermatology 354 389 35 9.9% E.N.T. 538 579 41 7.6% Gynaecology 772 752 ‐20 ‐2.6% Haematology 80 61 ‐19 ‐23.8% Medical Specialties 801 704 ‐97 ‐12.1% General Medicine 181 187 6 3.3% Diabetic Medicine 26 22 ‐4 ‐15.4% Elderly Medicine 18 20 211.1% Gastroenterology 403 300 ‐103 ‐25.6% Respiratory Medicine 173 175 2 1.2% Oncology 66 80 14 21.2% Ophthalmology 633 598 ‐35 ‐5.5% Other Specialty group 2 79 90 11 13.9% Paediatrics 3 298 288 ‐10 ‐3.4% Pain Management group 4 38 10 ‐28 ‐73.7% Rheumatology10291‐11‐10.8% Surgical Specialties 1124 975 ‐149 ‐13.3% Breast Surgery 410 439 29 7.1% General Surgery 581 437 ‐144 ‐24.8% Vascular Surgery 133 99 ‐34 ‐25.6% Trauma & Orthopaedics 522 584 62 11.9% Urology 357 294 ‐63 ‐17.6% Grand Total 6614 6376 ‐238 ‐3.6%

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 4 Pain Management, Anaesthetics

Referrals via A&E, following Emergency Admission and Self Referrals, are no longer included in data flows. As such, these have been removed from the previous year’s comparative data. This also affects the next section ‘Non‐GP Referrals’.

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Appendix 3 - Cont ELHT Referral Data for 2019/20 – Other Referrals

Number of Referrals to Non-ELHT Providers Other Other Variance Trend Specialty Referrals Referrals Variance % Quantity (last 15 months) 2018‐19 2019‐20 Cardiology 1338 1346 8 0.6% Community Paediatrics 1 102 131 29 28.4% Dermatology 75 68 ‐7 ‐9.3% E.N.T. 213 177 ‐36 ‐16.9% Gynaecology 245 232 ‐13 ‐5.3% Haematology 26 40 14 53.8% Medical Specialties 593 1037 444 74.9% General Medicine 10 9 ‐1 ‐10.0% Diabetic Medicine 88 90 22.3% Elderly Medicine 15 13 ‐2 ‐13.3% Gastroenterology 149 180 31 20.8% Respiratory Medicine 331 745 414 125.1% Oncology 128 121 ‐7 ‐5.5% Ophthalmology 778 697 ‐81 ‐10.4% Other Specialty group 2 405 461 56 13.8% Paediatrics 3 86 81 ‐5 ‐5.8% Pain Management group 4 67 65 ‐2 ‐3.0% Rheumatology 125 91 ‐34 ‐27.2% Surgical Specialties 254 246 ‐8 ‐3.1% Breast Surgery 91 65 ‐26 ‐28.6% General Surgery 91 99 8 8.8% Vascular Surgery 728210 13.9% Trauma & Orthopaedics 152 144 ‐8 ‐5.3% Urology 80 106 26 32.5%

Grand Total 4667 5043 376 8.1%

Blackburn with Darwen CCG's Referrals to ELHT as at Month 3 Referral Type Trend 2018‐19 2019‐20 Variance Variance % (last 15 months) GPs Referrals to ELHT 6614 6376 -238 -3.6% Other Referrals to ELHT 4667 5043 376 8.1% Total 11281 11419 138 1.2%

Other Referrals are from non‐GP professionals e.g. Consultant, Nurse Specialist, Other Practitioner

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Appendix 4

LCFT Community Contract ‐ LCFT: Service Line Activity Against Plan – June 2019

Year to date ‐ Activity (2018/19) Full Year ‐ Activity Year‐on‐Year Comparison (Planned Activity) Service Line Plan Actual Variance Var % Status Plan Forecast 17/18 18/19 Variance Var %

Adult Learning Disability Service 642 981 339 52.8%  5509 3924 1,075 981 ‐94 ‐8.7%

Children's Learning Disability 156 149 ‐7 ‐4.5%  1039 596 184 149 ‐35 ‐19.0% Service Children's Speech & Language No Plan 1,770 N/A  6703 7080 1,968 1,770 ‐198 ‐10.1% Therapy

Children's Occupational Therapy No Plan 412 N/A  1553 1648 402 412 10 2.5%

Community Stroke Service 765 933 168 22.0%  6083 3732 761 933 172 22.6%

Dermatology Service 1314 687 ‐627 ‐47.7%  5251 2748 1,309 687 ‐622 ‐47.5%

DESMOND (Completed Courses) 81 38 ‐43 ‐53.1%  243 152 75 38 ‐37 ‐49.3%

Diabetes Specialist Nursing 1440 1,247 ‐193 ‐13.4%  5752 4988 1,306 1,247 ‐59 ‐4.5%

District Nursing (inc. Out of Hours) 23874 23498 ‐376 ‐1.6%  95509 93992 24303 23,498 ‐805 ‐3.3%

Intermediate Care ACS 3195 3,169 ‐26 ‐0.8%  12787 12676 2,604 3,169 565 21.7%

Under Plan Close to Plan Above Plan ^ Status = change in variance to plan (year to date M3 to M2) Reporting Tolerances <‐10% >‐10% to <+10% >+10%   % Variance Widened % Variance Narrowed

Revisions to the 2018/19 plan have been made. However, those Service Lines marked ‘No Plan’ are still under negotiation.

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Appendix 4 – Continued

Year to date ‐ Activity Full Year ‐ Activity Year‐on‐Year Comparison (Planned Activity) Service Line Plan Actual Variance Var % Status Plan Forecast 17/18 18/19 Variance Var % Intensive Home Support 7644 9713 2,069 27.1%  32234 38852 8100 9,713 1,613 19.9% Oxygen Service 969 879 ‐90 ‐9.3%  3868 3516 942 879 ‐63 ‐6.7% Podiatry 5082 4,410 ‐672 ‐13.2%  20334 17640 4,489 4,410 ‐79 ‐1.8% Pulmonary Rehabilitation 1503 1,205 ‐298 ‐19.8%  6012 4820 2,135 1,205 ‐930 ‐43.6% Treatment Room 21491 20248 ‐1243 ‐5.8%  85950 80992 21698 20,248 ‐1,450 ‐6.7% Tissue Viability ‐ Healthy Legs 219 217 ‐2 ‐0.9%  1110 868 287 217 ‐70 ‐24.4% Tissue Viability Service 225 254 29 12.9%  1132 1016 264 254 ‐10 ‐3.8% Grand Total ‐ Activity with Plans 68600 67628 ‐972 ‐1.4%  282813 270512 69532 67628 ‐1,904 ‐2.7%

Under Plan Close to Plan Above Plan ^ Status = change in variance to plan (year to date M3 to M2 Reporting Tolerances <‐10% >‐10% to <+10% >+10%   % Variance Widened % Variance Narrowed

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Appendix 5

Inpatient Waiting List

Source : ELHT East Lancashire Hospitals Current Month Previous Month Performance Report 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 732 158 78 44 1012 676 176 66 38 956 56 5.9% Urology 357 182 78 68 685 352 192 99 65 708 ‐23 ‐3.2% Breast Care 57 30 12 0 99 63 34 6 0 103 ‐4 ‐3.9% Vascular 101 31 11 15 158 77 39 5 15 136 22 16.2% Orthopaedics 564 389 186 101 1240 572 378 155 80 1185 55 4.6% ENT 234 140 102 86 562 251 177 106 84 618 ‐56 ‐9.1% Ophthalmology 464 331 207 120 1122 385 369 188 113 1055 67 6.4% Oral Surgery / Maxillo Facial 507 286 186 111 1090 453 268 144 104 969 121 12.5% Dermatology 0 0 0 0 0 0 0 0 0 0 0 N/A Medical Oncology 2 2 1 3 8 2 1 0 3 6 2 33.3% Clinical Oncology 1 0 0 2 3 2 0 0 2 4 ‐1 ‐25.0% Surgical Division 3019 1549 861 550 5979 2833 1634 769 504 5740 239 4.2% General Medicine 999 46 4 7 1056 956 71 7 6 1040 16 1.5% Rehabilitation 0 0 0 0 0 0 0 0 0 0 0 N/A Cardiology 164 61 18 0 243 172 60 11 0 243 0 0.0% Thoracic Medicine 47 16 1 2 66 51 11 0 2 64 2 3.1% Nephrology 6 2 0 0 8 6 0 0 0 6 2 33.3% Medical Division 1216 125 23 9 1373 1185 142 18 8 1353 20 1.5% Gynaecology 332 101 26 5 464 342 115 23 2 482 ‐18 ‐3.7% Family Care Division 332 101 26 5 464 342 115 23 2 482 ‐18 ‐3.7% Pain Management 69 42 29 31 171 48 44 23 42 157 14 8.9% Rheumatology 62 59 31 3 155 68 66 7 2 143 12 8.4% Haematology 28 9 0 3 40 32 7 0 3 42 ‐2 ‐4.8% Diagnostic & Clinical Support 159 110 60 37 366 148 117 30 47 342 24 7.0%

Grand Total 4726 1885 970 601 8182 4508 2008 840 561 7917 265 3.3%

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Appendix 6 ‐ LCFT MH quality measures currently underperforming against target Threshold 2018/19 May Jul Aug Sep Oct Nov Dec Jan Feb Mar Ref Indicator Level Apr 19 Jun 19 2019/20 YTD 19 19 19 19 19 19 19 20 20 20

NQR 1 Duty of Candour ‐ Trust 6 2 5 1

Trust 53.42% 51.43% 46.34% 44.44% 53% 2018/19 E.H.4 Early Intervention in Psychosis (EIP) BwD 60.75% 50% 100% 66.67% 56% 2019/20

EL 50.46% 16.67% 44.44% 20.00% ADHD Service 92% Trust 24.17% 23.86% 26.05% 23.37% Adults waiting <18 weeks – new referrals LQR1 ADHD Service 92% Trust 38.02% 22.35% 25.00% 24.79% Adults waiting <18 weeks – transition referrals

Trust 85.56% 81.44% 71.04% 70.00%

LQR5 Memory Assessment Service 70% BwD 84.61% 59.09% 12.50% 34.28%

EL 84.48% 48.15% 20.73% 29.24% 1.58% Trust 16.80% 1.35% 1.38% 1.41% IAPT: Prevalence 1.58% BwD 20.52% 1.42% 1.36% 1.60%

1.4% EL 15.77% 1.21% 1.41% 1.34% LQR_6

Trust 53.4% 51.9% 52.50% 51.80%

Recovery 50% BwD 51.7% 43.5% 53.80% 51.30%

EL 53.7% 53.8% 52.90% 52.50% Unscheduled Care 95% Trust 46.07% 59.87% 58.76% 66.04% MHLT: Assessed within 1 hour of referral from ED (Internal Target) LQR 8 Unscheduled Care Trust 73.71% 80.94% 67.71% 17.98% MHLT assessed within 24 hours of referral from ward ANTT LQR 13 Infection Control Trust 41% 43% 43% Compliance 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 19/20 19 19 19 19 19 19 19 19 19 20 20 20 Referral to E.B.3 Treatment 92% 90.3% 90.6% 89.3% 90.08% (Incomplete) RTT Number of underperforming 0 8 10 10 ‐ specialties Diagnostics E.B.4 within 6 weeks <1% 2% 1.8% 0.97% 2%

E.B.5 A&E 4 Hour * 95% 79.48% 79.70% 82.49% 80.50%

E.B.6 Cancer 2 week GP 93% 91.42% 92.20% 91.80%

Cancer 2 week E.B.7 93% 72.73% 89.00% 81.00% breast

Cancer 31 day E.B.9 94% 88.00% 93.00% 90.30% subsequent Cancelled E.B.S.2 0 2 6 0 8 Operations E.B.S.5 Trolley wait 0 15 13 9 37 E.B.S.7 Ambulance 0 188 153 112 453 a Handover >30min E.B.S.7 Ambulance 0 50 23 21 94 b Handover >60min Missed handover E.B.S.7 0 118 134 120 372 stamps Duty of Candour 0 1 2 0 3 Breach *Includes Rossendale MIU *KEY RED Under performance GREEN Achieving AMBER Under Review

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Appendix 8 ‐ LCFT Community current quality measure performance against target Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Indicator Target 19 19 19 19 19 19 19 19 19 20 20 20 Referral to treatment (RTT) Incomplete (BwD CCG) 58.6% 72.7% Children’s Occupational Therapy 58.6% 52.8% Children’s Speech and Language Therapy 53.4% 59.1% Community Stroke Service ‐ 100% Domicillary Physiotherapy ‐ ‐ 92% Falls Team ‐ ‐ Intermediate Care ACS 100% 100% Podiatry ‐ 100% Pulmonary Rehabilitation 100% 100% Rapid Assessment Team 100% 100%

*KEY RED Under performance GREEN Achieving AMBER Under Review

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Appendix 9 ‐ NHS Constitution

Metric Level Period Target Blackburn With Year to Date Darwen CCG Position

NHS Constitution measures

A&E waits 2123: 4‐Hour A&E Waiting Time Target (Monthly Aggregate CCG Jul 2019‐20 95.00% 80.12% 79.51% based on HES 17/18 ratio) Referral To Treatment waiting times for non‐urgent consultant‐led treatment 1291: Referral to Treatment RTT (Incomplete) CCG Jul 2019‐20 92.00% 87.39% 88.74%

Diagnostic test waiting times 1828: % of patients waiting 6 weeks or more for a diagnostic CCG Jul 2019‐20 1.00% 1.38% 1.90% test Cancer waits – 2 week wait 191: % Patients seen within two weeks for an urgent GP CCG Jun 2019‐20 93.00% 88.15% 90.77% referral for suspected cancer (MONTHLY) 1879: % Patients seen within two weeks for an urgent GP CCG Q1 2019‐20 93.00% 90.77% 90.77% referral for suspected cancer (QUARTERLY) 17: % of patients seen within 2 weeks for an urgent referral CCG Jun 2019‐20 93.00% 95.16% 83.16% for breast symptoms (MONTHLY) 1880: % of patients seen within 2 weeks for an urgent referral CCG Q1 2019‐20 93.00% 83.16% 83.16% for breast symptoms (QUARTERLY) Cancer waits – 31 days 535: % of patients receiving definitive treatment within 1 CCG Jun 2019‐20 96.00% 98.25% 97.27% month of a cancer diagnosis (MONTHLY) 1881: % of patients receiving definitive treatment within 1 CCG Q1 2019‐20 96.00% 97.27% 97.27% month of a cancer diagnosis (QUARTERLY) 26: % of patients receiving subsequent treatment for cancer CCG Jun 2019‐20 94.00% 93.75% 93.48% within 31 days (Surgery) (MONTHLY) 1882: % of patients receiving subsequent treatment for cancer CCG Q1 2019‐20 94.00% 93.48% 93.48% within 31 days (Surgery) (QUARTERLY) 1170: % of patients receiving subsequent treatment for cancer CCG Jun 2019‐20 98.00% 92.86% 97.62% within 31 days (Drug Treatments) (MONTHLY) 1883: % of patients receiving subsequent treatment for cancer CCG Q1 2019‐20 98.00% 97.62% 97.62% within 31 days (Drug Treatments) (QUARTERLY) 25: % of patients receiving subsequent treatment for cancer CCG Jun 2019‐20 94.00% 100.00% 100.00% within 31 days (Radiotherapy Treatments) (MONTHLY) 1884: % of patients receiving subsequent treatment for cancer CCG Q1 2019‐20 94.00% 100.00% 100.00% within 31 days (Radiotherapy Treatments) (QUARTERLY) Cancer waits – 62 days 539: % of patients receiving 1st definitive treatment for CCG Jun 2019‐20 85.00% 80.65% 82.42% cancer within 2 months (62 days) (MONTHLY) 1885: % of patients receiving 1st definitive treatment for CCG Q1 2019‐20 85.00% 80.21% 80.21% cancer within 2 months (62 days) (QUARTERLY) 540: % of patients receiving treatment for cancer within 62 CCG Jun 2019‐20 90.00% 100.00% 100.00% days from an NHS Cancer Screening Service (MONTHLY) 1886: % of patients receiving treatment for cancer within 62 CCG Q1 2019‐20 90.00% 100.00% 100.00% days from an NHS Cancer Screening Service (QUARTERLY) 541: % of patients receiving treatment for cancer within 62 CCG Jun 2019‐20 (N/A) 94.12% 90.38% days upgrade their priority (MONTHLY) 1878: % of patients receiving treatment for cancer within 62 CCG Q1 2019‐20 (N/A) 87.93% 87.93% days upgrade their priority (QUARTERLY) NHS Constitution support measures

HCAI 24: Number of C.Difficile infections CCG YTD 13 14 14

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Activity Measures

Referral to Treatment (RTT) & Diagnostics 2018: Number of Completed Admitted RTT Pathways CCG YTD 2860 2663 2663

2015: Number of Endoscopy Diagnostic Tests/Procedures CCG YTD 1675 1675

2016: Number of Diagnostic Tests/Procedures (excluding CCG YTD 18580 18580 Endoscopy) 2019: Number of Completed Non‐Admitted RTT Pathways CCG YTD 9756 13888 13888

Other performance measures

EMSA 1067: Mixed sex accommodation breaches ‐ All Providers* CCG Jun 2019‐20 0 2 8

Diagnostic test waiting times 1839: Referral to Treatment RTT ‐ No of Incomplete Pathways CCG Jul 2019‐20 0 0 0 Waiting >52 weeks Episode of Psychosis 2099: First episode of psychosis within two weeks of referral CCG Jul 2019‐20 56.00% 66.67% 66.67%

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GOVERNING BODY MEETING

Quality Update Report

Date of Meeting 11th September 2019 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 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 

Clinical Lead: Mrs Kathryn Lord

Senior Lead Manager Mrs Kathryn Lord Finance Manager Equality Impact and Risk Assessment completed: Patient and Public Engagement completed: Financial Implications Risk Identified

Report authorised by Senior Manager: Y Decision Recommendations Members are asked to receive the report for information purposes

BLACKBURN WITH DARWEN CLINICAL COMMISSIONING GROUP

GOVERNING BODY MEETING

11TH SEPTEMBER 2019

QUALITY UPDATE REPORT

1. Introduction

1.1 This paper outlines for Governing Body members recent national policy documents, publications and conferences along with quality improvement work underway across the local health care economy to improve the health and care of our population.

2. World Sepsis Day

World Sepsis Day is held on September 13th every year. The CCG has planned communications to raise awareness of the day.

The CCG continues to work with partners across the Health Economy on the sepsis agenda, with an ongoing programme of education and events for Regulated care.

Benchmarking has taken place across Primary Care around ‘Sepsis Champions’ for each GP Practice who take ownership for developing strategies to ensure that all staff members are trained in the recognition and management of sepsis. Further work is planned to promote the role of the ‘Sepsis Champion’ and support training and education into Primary Care.

The CCG are a member of ELHTs Mortality Steering Group, which identifies learning through Structured Judgement Reviews and continue to work with the Trust on harm free care and improving the usage of the sepsis care bundle.

A Sepsis Event is currently being planned to health and social care across Pennine Lancashire.

3. Provider Updates

3.1 East Lancashire Hospital Trust

3.1.1 Centralised Outpatients and Patient Administration Services (COAS) – Patient Portal

The service in partnership with Healthcare Communications won the Public Sector Paperless Award for ‘Best use of a digital solution’ and has also been shortlisted for ‘Special Recognition Award’.

The system allows patients to download their appointment letter and associated documents to their smart phone. The patient is sent a secure link and pass code to their phone. If the link is not activated within 24 hours then a paper copy is automatically generated.

To the end of June 2019, an average of 38% of letters have been downloaded, resulting in over 210,000 letters being downloaded rather than being printed.

3.1.2 Radiology – Getting it right first time (GIRFT)

The Radiology Department was involved in a recent ‘Getting it right first time’ (GIRFT) visit to review service provided.

GIRFT is a programme designed to improve clinical quality and efficiency by reducing unwarranted variations. The following good practice was identified from the review meeting:

- Good model of acute team having a registrar, radiographer, radiologists with mixed reporting culture - Patient flow optimised well from Emergency Department with a good inpatient and outpatient split - Patient feedback used to enable positive changes to the service - Positive feedback from GPs on how good the service is with communication; with email and a phone line in place for GPs to call - Advanced practice for bands two to four with imaging assistants carrying out cannulations to improve patient flow and Assistant Practitioners and Clinical Technologists in nuclear medicine. - Two direct access science students in sonography have taken full time posts with ongoing training programme and mentorship for new staff - Excellent GMC results with trainees coming back to the department for Consultant posts - Improved CT utilisation with 50% more CT carried out than the national average - Reduction in outsourcing usage - A higher than average (92.5%) of patient having CT and/or MR scan on the same day or the following day of admission - Fast track pathway for patient who require a CT following an abnormal x-ray with good communication with patient throughout the process - Patient access to book appointments straight from clinic - One stop clinic for prostate, head and neck.

3.2 Lancashire Care Foundation Trust (LCFT)

3.2.1 Quality Improvement

Increasing Opportunities for Feedback The LCFT experience team continue to promote opportunities to collect service user feedback with particular focus on low reporting teams such as mental health inpatient wards and district nursing teams. Feedback reviewer training has also been provided to support staff in identifying quality improvements from service user feedback and in promoting areas of good practice to share the learning.

Bespoke support to new managers and reporting to networks is ongoing and the re- establishment of mental health inpatient service user groups will assist in the collation of live feedback. Electronic devices, such as iPads are being dispatched in targeted areas to improve data collection.

Following the results of the Community Mental Health Survey, themes relating to improving communication and carer feedback were highlighted. A quality improvement project was commenced to co-produce a carer friendly information resource with East

Lancashire Carers Group, NCompass, and service users and their carers. The Trust have also signed up to the ‘Triangle of Care’ to further promote carer engagement.

Feedback from service users who have experienced seclusion at the Trust has been included in quality improvement initiatives to support service user. Consultation events have been held to enable these service users to co-design parts of the programme such as seclusion documentation and the ‘my wishes’ seclusion checklist. This will enable service users to input into their care, and provide a wish list into their care, should they require seclusion at any time during their treatment.

Triangle of Care The 'Triangle of Care' is a therapeutic alliance between service user, staff member and carer that promotes safety, supports recovery and sustains wellbeing. The scheme was initially developed by carers and staff seeking to improve carer engagement and is supported by national agencies such as the National Mental Health Development Unit, the NHS Confederation Mental Health Network and the Princes Royal Trust for Carers.

Phase 1 of the Triangle of Care Programme is now complete and LCFT have been awarded their first star (Level 1). Stars are awarded as a recognition of achievement and commitment to improving partnerships with carers, with the first star being given for completing self-assessments and improvement plans for inpatients and crisis teams.

Phase 2 has now commenced which will consist of a 2-year programme to improve carer engagement in the Community Mental Health Teams, in addition to continued progress from Wards and Crisis Teams.

3.2.2 Northumberland Tyne and Wear (NTW) Mental Health Pathway Review

Progress continues with the NTW review areas for action detailed below;

 A&E Liaison  Street Triage  Section 136/Place of safety  Frequent attenders  Bed management  Assessment wards  Delayed discharges  Bed capacity  Community Mental Health Teams  Mental Health Decision Units  Substance misuse

Significant investment has been made into the Trust’s Crisis and Home Treatment Teams and a plan to merge the Pennine teams to work as one 24/7 is being finalised.

Recruitment into the A&E Liaison team is continuing, and a range of options are being considered as to the clinical suitability of estates facilities. Requirements for Pennine Lancashire include suitable rooms to assess patients, office space, waiting areas and staff kitchen. A task and finish group is in place to progress this work and indicative timescales are around 6-7 months for design, planning and completion.

Following a number of reviews and concerns raised regarding key elements of the mental health acute care pathways, LCFT have established a small team of senior clinicians who have been tasked with offering support and challenge to clinical colleagues with liaison and 136 settings, to consider alternative strategies and options such as the greater use of home based treatment. A ‘gatekeeping assessment tool’ has been developed to support the process and aid clinicians in identifying the appropriate care and treatment for the service user in receipt of assessment. 5

An updated position was presented to the Pennine Lancashire Quality Committee on 28th August 2019.

3.3 Primary Care

3.3.1 GP Patient Survey

Results from the GP Patient Survey 2019 were published in July 2019: https://www.gp-patient.co.uk/surveysandreports

In 2018 the questionnaire was significantly redeveloped to reflect changes in the delivery of GP services as set out in the General Practice (GP) Forward View. In addition, for the first time the sample included 16-17 year olds to improve the inclusivity of the survey. These changes mean that the majority of questions are not comparable with results from previous publications.

For East Lancashire CCG (compared to the national average), 6 questions are better, 4 are the same and 5 are worse. The most notable difference is for the question relating to ‘speed of alternative care when the practice is closed’ which is 4% worse than the national average.

For Blackburn with Darwen CCG (compared to the national average), 11 questions are better, 1 remains the same and 2 are worse.

East Lancashire CCG has included a specification for ‘Improving Access’ in the Quality Framework which asks practices to review on a locality basis how they can improve access to their services for patients.

Both CCG’s are implementing Care Navigation as a way to manage demand by reducing the pressures on GPs and directing patients to a more appropriate service at the first point of contact. The results will now be reviewed on a practice by practice basis to identify any issues and also identify practices to celebrate

3.3.2 Primary Care Web Tool GP Indicators

Following the closure of the NHS England Primary Care website in March 2019, a new General Practice Indicator (GPI) and GP IT Digital Maturity Index Assurance Indictors are now available on a new portal. Some sections are currently in development; however information has been made available which categorises practices based on the number of triggers identified.

This information has been mapped onto the Pennine Lancashire GP Dashboard to allow triangulation with other sources to create a picture of each practice’s performance and outcome data and is used to identify which practices need support. The dashboard is reviewed by the GP Quality Team with two CCG Clinical Leads and discussed at the Pennine GP Quality Group quarterly.

4. Friends and Family Test

The Friends and Family Test (FFT) is a tool for capturing patient experience which enables continuous improvement in healthcare services. NHS England has announced changes to the FFT including: - A new mandatory question with 6 new response options - Removal of mandatory timescales to enable people to give feedback at anytime - Greater emphasis on use of FFT feedback to drive improvement

Revised guidance is expected to be published in September 2019 for implementation by Providers in April 2020. 6

Further details on the FFT can be found: https://www.england.nhs.uk/fft/

5. Patient Safety Strategy

The NHS Patient Safety Strategy was launched at the Patient Safety Congress on 2nd July 2019. This strategy describes how the NHS will continuously improve patient’s safety, building on the foundations of a safer culture and safer systems.

The intention of the new strategy is to emphasise the learning that takes place to prevent incidents, share safety insight and improve patient safety. There are a number of changes to the Patient Safety Incident Response Framework as a result of the refreshed strategy, with a broader scope for incident management and less of a focus on the current threshold for ‘Serious Incidents’. The intention is to develop a risk-based approach, with transparency and support for patients, relatives and staff. This will include a change in the governance and oversight provided by commissioners. The 60 working day deadline will be removed, with the adoption of timelines based on an investigation management plan, agreed with those affected. Investigations will be led by those with safety investigation training, and with the dedicated time and resource to complete the work. There will be greater involvement of patients, families, carers and other lay people.

For primary care, there will be a replacement of the National Reporting and Learning System (NRLS) with a more responsive and interactive reporting system. This will improve the dissemination and implementation of Patient Safety Alerts.

The full strategy can be found: https://improvement.nhs.uk/resources/patient-safety-strategy/

6. World Patient Safety Day

The first World Patient Safety Day is scheduled to take place on September 17th. The objective of the day is to raise global awareness about patient safety with the theme ‘Patient Safety, a global health priority’. The CCG will be promoting the day through social media.

7. First Contact Practitioner for musculoskeletal (MSK)

Within the NHS Long Term Plan is an aim for every patient with a MSK condition to have access to a First Contact Practitioner (FCP) by 2023/24. A webinar hosted by NHS England is planned for the 20th September 2019 with presentations from areas with FCP in place to outline the benefits of FCP for patients and local health systems and to allow discussion on the impact of their work to maximise the benefits an FCP can bring.

Webinar registration is available: https://zoom.us/webinar/register/WN_wBquzBqlSRONda5iY2is6Q

8. Conclusion

This paper outlines information in relation to recent national policy documents, publications and conferences and quality improvements being undertaken by commissioned Providers.

9. Recommendations

9.1 Members are asked to: 7

 Note the content of the report

Mrs Kathryn Lord Interim Director of Quality and Chief Nurse

GOVERNING BODY MEETING

GOVERNING BODY AND SUB COMMITTEES’ TERMS OF REFERENCE

Date of Meeting 11th September 2019 Agenda Item 14

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 √ GOVERNING BODGOVERNING BODY MEETING

Clinical Lead: N/A

Senior Lead Manager Mr Iain Fletcher Finance Manager N/A Equality Impact and Risk Assessment Report for information only completed: Is a Data Protection Impact Assessment Yes No Required? Data Protection Impact Assessment Yes No completed: Patient and Public Engagement completed: Report for information only Financial Implications Report for information only Risk Identified Report for information only Report authorised by Senior Manager: Mr Iain Fletcher

Y Decision Recommendations

The Governing Body is requested to receive and approve the Governing Body and Sub Committees’ Terms of Reference.

Governing Body Meeting Page 2 of 4

CLINICAL COMMISSIONING GROUP (CCG)

GOVERNING BODY MEETING

11TH SEPTEMBER 2019

GOVERNING BODY AND SUB-COMMITTEES’ TERMS OF REFERENCE

1. Introduction

This report presents the Terms of Reference (ToRs) of the Governing Body and its Sub- Committees for approval by members.

2. Amendments to the ToRs

Amendments to the ToRs that have been or were made since last review are listed below:

2.1 Governing Body

The ToR of the Governing Body has been revised to reflect the new arrangements following the appointment of a Joint Chief Officer, the move to a single Executive Team across the Pennine Lancashire CCGs on 1st June 2019 and a revision to the voting membership of the Governing Body to maintain a clinical majority (section 5, page 3).

The ToR is attached as Appendix 1.

2.2 Primary Care Co-Commissioning Committee

The ToR of the Primary Care Co-Commissioning Committee was approved by the Committee at its meeting in May 2019. It was revised to reflect the new arrangements following the appointment of the Joint Chief Officer and move to a single Executive Team across the Pennine Lancashire CCGs (section 5, page 4).

The ToR is attached as Appendix 2.

2.3 Audit Committee

The ToR of the Audit Committee was approved at its April 2019 meeting; subject to following amendments, which have been made.

Section 2.2, page 2 – Public Sector Internal Audit Standards (2013) amended to (2017).

Section 2.4, page 3:

 The Quality, Performance and Effectiveness Committee amended to Pennine Lancashire Quality Committee;  The Department of Health extended to Department of Health and Social Care.  The NHS Litigation Authority amended to NHS Resolution;  Primary Care Commissioning Committee amended to Primary Care Co- Commissioning Committee.

The ToR is attached as Appendix 3.

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3. Recommendation

The Governing Body is requested to receive and approve the Governing Body and Sub Committees and Groups’ ToRs.

Iain Fletcher Head of Corporate Business 5th September 2019

Governing Body Meeting Page 4 of 4

Appendix 1

CLINICAL COMMISSIONING GROUP (CCG) GOVERNING BODY TERMS OF REFERENCE

1.0 Purpose of the Committee The purpose of the NHS Blackburn with Darwen Clinical Commissioning Group (CCG) Governing Body is, on behalf of their population, to:

a. commission safe and effective community and secondary health care services b. continually work towards the quality improvement of health care c. work in partnership with other Clinical Commissioning Groups and agencies to secure the overall health and well-being of the population d. conduct the business in accordance with the constitution of the CCG and the NHS constitution and other NHS statutory guidance.

In discharging its obligations the CCG Governing Body will be responsible and accountable for delivering financial balance, managing risks and for achieving national and local quality, productivity and service delivery targets.

The CCG Governing Body will delegate responsibility for a range of functions to its committees and working groups, e.g. the Pennine Lancashire Quality Committee, the Primary Care Commissioning Committee, the Audit Committee, the Remuneration and Terms of Service Committee, the Commissioning Business Group, the Information Governance Steering Group, Policy Group and the Executive Joint Commissioning Group. These functions are set out in the approved Terms of Reference of each committee/group and the CCG’s Standing Orders and Schemes of Delegation.

2.0 Roles and Responsibilities 2.1 The CCG Governing Body will operate within the legal framework.

2.2 The CCG Governing Body will comply with its standing orders and standing financial instructions and the terms of reference will be reviewed at least annually.

2.3 The CCG Governing Body is subject to governance, ethical and legal guidelines. This includes requirements around ethical behaviour, conflicts of interest declarations and maintaining a register of interests.

2.4 The CCG Governing Body will establish committees and working groups as required to effectively transact the business of the Clinical Commissioning Group, approving all Terms of Reference and clearly setting out all delegated functions. 2.5 The CCG Governing Body will agree to delegate powers of budgetary responsibility to its committees and groups. A formal Scheme of Delegation will be agreed between the CCG Governing Body and its committees and groups. Page 1 of 6 Version 0.04 June 2019

2.6 NHS England will hold the CCG Governing Body to account for delivery of its delegated responsibilities / accountability. NHS England has the power to intervene in the work of the CCG should it be considered necessary.

2.7 The elected General Practitioner (GP) representatives on the Governing Body of the CCG Governing Body will, as part of a team, ensure that the CCG exercises its functions efficiently, effectively and economically with good governance and in accordance with the terms of the CCG as agreed with its members. The development of the governance arrangements is in accordance with the legal requirements in the Health and Social Care Act 2012 for the establishment of CCGs. 2.8 The CCG Governing Body will receive regular reports from its committees and groups from which to gain assurance on the delivery of the annual and strategic Operational and Financial Plans. 2.9 The CCG Governing Body will be responsible for ensuring that services for the population of Blackburn with Darwen are informed and commissioned in a way which delivers improved health and social care, improved outcomes, improved patient experience, good productivity and minimises health inequalities and that its work is in accordance with the requirements of the NHS Constitution. 2.10 The CCG Governing Body will develop the commissioning intentions and oversee the conduct of contracting negotiations for the major CCG led contracts. 2.11 The CCG Governing Body will continually review quality and performance, outcomes and efficiency and effectiveness of spend in all commissioned services that fall within the scope of the CCG. 2.12 The CCG Governing Body will be responsible for the assurance that services are safe, of a consistently high quality, value for money and sustainable. 2.13 The CCG Governing Body will ensure continuous and meaningful engagement with the public and patients in the planning, delivery and prioritisation of services. 2.14 The CCG Governing Body will work collaboratively with a range of partners to commission services which will improve health and minimise health inequalities. 2.15 The CCG Governing Body will ensure that planning, prioritisation and decision making are transparent, equitable and auditable. 2.16 The CCG Governing Body will ensure that the CCG achieves a balanced budget, whilst delivering the agreed Single Integrated Plan. 2.17 The CCG Governing Body will lead the development of the strategic planning process for the CCG. 2.18 The CCG Governing Body will be responsible for and take ownership of Quality, Innovation, productivity and Prevention (QIPP) and performance management. 2.19 The CCG Governing Body will be responsible for determining remuneration levels for Lay Members including Nurse advisor, Secondary Care Doctor.

2.20 The Governing Body will receive confirmation reports on the determined remuneration levels and conditions of service of the Executive Officers and GP Executive members from the Remuneration and Terms of Service Committee. 3.0 Deliverables 3.1 To commission a comprehensive range of appropriate, cost effective and high quality health services for the population of Blackburn with Darwen. 3.2 Create and lead the development of the system locally to ensure that the CCG remains fit for purpose. 3.3 Lead and drive the change of behaviour and culture in the NHS that is required for optimal productivity and sustainability by creating meaningful relationships across the whole system. 3.4 Ensure inclusion of all GP practices and that practices’/clinical engagement is harnessed and targeted to deliver priorities. 3.5 Ensure that the CCG Governing Body has a mandate from its constituent Page 2 of 6 Version 0.04 June 2019

practices/GPs. 3.6 Be responsible for the organisational development of the CCG.

3.7 Ensure effective and appropriate practice education development and communication in relation to CCG led commissioning. 3.8 Develop meaningful engagement/links with Local Authority/Public Health Service/ NHS England / Health and Well-Being Board / Healthwatch and other organisations as appropriate to ensure system development in line with the implementation of the Health and Social Care Act 2012. 3.9 Communication and sharing of learning locally, regionally and nationally.

3.10 Minutes recording the decisions reached and the reasons for such decisions shall be maintained. 3.11 The Publication of the Governing Body’s Annual Report.

4.0 Constraints/Risks 4.1 The CCG Governing Body will work within the constitution and legal framework of the NHS.

5.0 Membership 5.1 The membership of the CCG Governing Body is:

 Chair (v) (Lay Member)  Joint Chief Officer (v)  All elected GP Governing Body members (includes the Vice Chair) (v)  Lay Member Governance (v)  Chief Finance Officer/Deputy Chief Officer (v)  Director of Population Strategy and Transformation  Medical Director (v)  Clinical Director of Quality and Primary Care (v)  Secondary Care Doctor (v)  Lay Member  Executive Nurse

Co-opted Member:  Director of Public Health (Blackburn with Darwen Local Authority)

In Attendance:  Heads of Corporate Business  Director of Performance and Delivery  Chief Finance Officer/Deputy Chief Officer (East Lancashire)  Administration Support

Voting members of the Governing Body are those indicated by (v).

In the absence of the Chair the Vice Chair will conduct proceedings.

In the absence of the Clinical Chief Officer one of the Executive Officers will act as their deputy.

Members must comply with the requirements of the CCG’s conflict of interest policy.

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5.2 The CCG Governing Body will also invite other individuals to attend meetings as required from time to time. These individuals will not have voting rights.

5.3 The CCG Governing Body reserves the right to co-opt additional members where appropriate.

6.0 Governance and Reporting 6.1 Reporting arrangements - into The CCG Governing Body will report to NHS England. 6.2 The CCG Governing Body will make the minutes of meetings available to member practices, after each Governing Body Meeting and will keep them informed by messages from the Clinical Chief Officer as key strategic decisions are taken.

6.3 Reporting arrangements – from

The CCGs sub-committees and groups listed below will report into the CCG Governing Body:-

- Pennine Lancashire Quality Committee

- Commissioning Business Group

- Primary Care Commissioning Committee

- Remuneration and Terms of Service Committee

- Audit Committee

- Executive Joint Commissioning Group

- Information Governance Steering Group

- Policy Group

- Lancashire and South Cumbria Joint Committee of Clinical Commissioning Groups (JCCCG)

The CCG will also on occasions be required to establish other Sub-Committees in line with the CCG’s constitution.

6.4 Quorum A meeting of the Clinical Commissioning Group Governing Body shall be quorate when there are a minimum of five members, to include three GPs, one Executive Officer and one Lay Member present, unless the exceptional circumstances apply as described below:-

1. Where a decision is to be made where significant conflicts of interest exist with GP members the quorum will be achieved by five of the remaining six Governing Body members: Interim Deputy Chief Executive/CFO, Interim Director of Commissioning (Operations), Secondary Care Doctor, 2 Lay Members and the Chair (and any non-conflicted GP members) re paragraph 2.20. 2. Where a decision is to be made where a conflict of interest exists with a sitting

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Vice Chair, the role of the Chair will be deferred to a Governing Body Member. 3. Where a decision is to be made on Remuneration etc. as paragraph 2.19. for the Lay Member, Chair, Secondary Care Doctor and Registered Nurse the quorum will be achieved by a minimum of five members: Interim Deputy Chief Executive/CFO, Interim Director of Commissioning (Operations) and four GP members.

The conflicts of interest policy will be applied to both these scenarios. 6.5 Attendance Each member is expected to attend a minimum of 75% of scheduled meetings per annum. 6.6 Review The Terms of Reference will be reviewed annually by the CCG Governing Body at the first meeting in the financial year.

6.7 Recording of Proceedings

CCG The CCG will make an audio recording of proceedings. Members of the Governing Body have agreed to the recording of the meetings, as an aide-memoire for the minute taker; to ensure an accurate transcript of the meeting. The copy of the audio recording will be kept by the Governing Body Secretary. The recording will be stored in line with the terms of the CCG’s Information Governance Handbook.

Members of the Public in Attendance The CCG will accommodate members of the public who wish to film, photograph or record CCG meetings in so far as it does not disrupt business and respects the rights of individuals who may not wish to be filmed. Any member of the public wishing to film the meeting is required to make the request in writing at least 24 hours in advance.

The filming, photographing or audio recordings will only be made from the designated public seating area and may be taken from one fixed position, to prevent obstructing others from observing proceedings.

Attendees will be advised at the start that the meeting is being filmed, photographed or audio recorded, and given the name and contact details of the individual undertaking the recording.

The Chair shall instruct that filming, photographing or audio recordings is stopped:

 During those parts of the meeting when the press and public have been excluded due to the nature of the business being discussed i.e. either exempt or confidential matters;  If there is a public disturbance or suspension/adjournment of the meeting;  If to his judgement the recording has become disruptive or distracting to the good order and conduct of the meeting;  If the Chair determines that it has not been possible to obtain informed consent from a person with known learning disabilities or mental health issues or parental consent for a young person speaking.

In allowing this, the CCG requests that those recording proceedings must not edit the film/recording/photographs in a way that could lead to misinterpretation of the proceedings, or infringe the core values of the CCG. Page 5 of 6 Version 0.04 June 2019

The use of flash photography or additional lighting will not be allowed unless this has been discussed in advance of the meeting and agreement reached on how it can be done without disrupting proceedings.

Public Order The Chair may, at any time, require the public or individual members of the public or media to leave the meeting or may adjourn the meeting to a private location if he considers that those present are disrupting the proper conduct of the meeting or the business of the Governing Body.

7.0 Relationships/Interdependencies with other Bodies 7.1 The Governing Body will cooperate and collaborate with other organisations in order to achieve its objectives.

8.0 Location of shared information such as plans, or contact information 8.1 These will be stored electronically on the Clinical Commissioning Group drive.

9.0 Related Policies 9.1  Standing Financial Instructions  Standing Orders  Scheme of Delegation  Governance Framework  Risk Management Policy  Conflict of Interest Policy  Constitution

10.0 Schedule of Meetings 10.1 The Governing Body will meet a minimum of 6 times per year in public with additional meetings being scheduled as required to ensure Governing Body development and discussion.

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Appendix 2

PRIMARY CARE CO-COMMISSIONING COMMITTEE TERMS OF REFERENCE

1.0 Purpose of the Committee

NHS England has delegated to the CCG authority to exercise the primary care commissioning functions set out in Schedule 2 in accordance with section 13Z of the NHS Act 2006 (as amended). Arrangements made under section 13Z do not affect the liability of NHS England for the exercise of any of its functions. However, the CCG acknowledges that in exercising its functions (including those delegated to it), it must comply with the statutory duties set out in Chapter A2 of the NHS Act 2006 (as amended) which include:

a) Management of conflicts of interest (section 14O);

b) Duty to promote the NHS Constitution (section 14P);

c) Duty to exercise its functions effectively, efficiently and economically (section 14Q);

d) Duty as to improvement in quality of services (section 14R);

e) Duty in relation to quality of primary medical services (section 14S);

f) Duties as to reducing inequalities (section 14T);

g) Duty to promote the involvement of each patient (section 14U);

h) Duty as to patient choice (section 14V);

i) Duty as to promoting integration (section 14Z1);

j) Public involvement and consultation (section 14Z2).

The CCG will also need, in respect of the delegated functions from NHS England, to specifically exercise those set out below:

a) Duty to have regard to impact on services in certain areas (section 13O);

b) Duty as respects variation in provision of health services (section 13P).

The purpose of the Committee is to enable members to make collective decisions on the review, planning and procurement of primary care services in Blackburn with Darwen under delegated authority from NHS England.

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2.0 Roles and Responsibilities

2.1 To provide a forum, with delegated decision making powers, for approval of commissioning intentions where the recommended providers are GP practices. 2.2 Provide assurance to the Governing Body, Audit Committee, NHS England and general public that the CCG has the necessary governance arrangements in place to manage conflict of interest in regard to the procurement of services provided by GP practices. 2.3 Agree and review the Primary Care Strategy at least annually and to be assured of the Implementation of its associated action plan .

2.4 Facilitate a culture of openness and probity around the local commissioning of GP services.

2.5 Demonstrate that the CCG and member practices are acting fairly and transparently and that final commissioning decisions are made in ways that preserve the integrity of the decision making process. 2.6 Have due regard to other independent contractors (and other providers) when any commissioning or contracting decisions are made, and that the CCG will provide assistance to NHS England in the commissioning of dental, optometry, community pharmacy and public health services.

2.7 On behalf of the Governing Body, scrutinise and approve proposals ensuring that where the recommended provider of services is to be a GP practice, there is evidence that the plans:

 Clearly meet local health needs and have been developed appropriately  Go beyond the scope of the GP contract  Have been procured using the appropriate methodology  Promote improvements in the quality of primary medical care  Demonstrate the achievement of improved outcomes and value for money  Cannot be delivered by another provider to the same level of quality, specification and/or price  Include details for monitoring the quality of service provision  Include the details of any actual or potential conflict of interest having been appropriately declared and entered in the register which is publicly available  Maintain confidence and trust between patients and GP’s

3.0 Deliverables

3.1 Review of GMS, PMS and APMS contracts (including the design of PMS and APMS contracts, monitoring of contracts, taking contractual action such as issuing branch/remedial notices, and removing a contract).

3.2 Newly designed enhanced services (“Local Enhanced Services” and “Directed Enhanced Services”).

3.3 Design of local incentive schemes as an alternative to the Quality Outcomes Framework (QOF).

3.4 Decision making on whether to establish new GP practices in an area.

3.5 Approving practice mergers.

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3.6 Making decisions on ‘discretionary’ payment (e.g. returner/retainer schemes).

4.0 Constraints/Risks

4.1 The Committee will function as a corporate decision-making body for the management of the delegated functions and the exercise of the delegated powers from NHS England.

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5.0 Membership

5.1 Members (voting)

 The Chair of the meeting who will be a lay member (with the exception of the Audit Committee Chair)  Joint Chief Officer  Chief Finance Officer  Lay Member  Secondary Care Doctor (Retired)  Director of Quality & Chief Nurse  Lay Member – Governance (Chair of Audit Committee)

Each member of the Committee shall have one vote. The Committee shall reach decisions by simple majority of members present, but with the Chair having a second and deciding vote if necessary. However the aim of the Committee will be to achieve consensus decision making wherever possible.

5.2 GP Executives, Members of the Public and those in attendance (non-voting)

In addition GP Executives may be invited to discuss certain items but will have no voting rights and must not be involved in decision making. Meetings of the Committee shall be managed in accordance with the Conflicts of Interest Policy.

The following will also be invited to be in attendance but will have no voting rights:-  A clinical lead GP for primary care  CCG officers as required  A representative from local Healthwatch  A representative from Health and Well Being Board  A representative from the Local Medical Committee  A representative from the NHS England Sub Regional Team  Consultant in Public Health  Patient Participation Group’s representative member

The Committee may resolve to exclude the public and those in attendance from a meeting that is open to the public (whether during the whole or part of the proceedings) whenever publicity would be prejudicial to the public interest by reason of the confidential nature of the business to be transacted or for other special reasons stated in the resolution and arising from the nature of that business or of the proceedings or for any other reason permitted by the Public Bodies (Admission to Meetings) Act 1960 as amended or succeeded from time to time, unless requested by the Chair. Those required to remain will be notified in advance of the meeting and relevant papers sent. 6.0 Governance and Reporting

6.1 Reporting arrangements – into CCG Governing Body

6.2 Reporting arrangements – from Primary Care Group 6.4 Quorum The meeting will be quorate if a minimum of 4 voting members attend including at least one lay and one executive member.

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6.5 Attendance Deputies are acceptable by prior approval from the Chair. 6.6 Review The Committee shall review its own performance and terms of reference on an annual basis at the first meeting in the financial year. 6.7 Recording of Proceedings

CCG The CCG will make an audio recording of proceedings. Members of the Committee have agreed to the recording of the meetings, as an aide-memoire for the minute taker; to ensure an accurate transcript of the meeting. The copy of the audio recording will be kept by the Committee Secretary. The recording will be stored in line with the terms of the CCG’s Information Governance Handbook.

Attendees will be advised at the start that the meeting is being filmed, photographed or audio recorded, and given the name and contact details of the individual undertaking the recording.

The Chair shall instruct that filming, photographing or audio recordings is stopped:

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7.0 Relationships/Interdependencies with other Bodies

7.1 The Committee has delegated responsibility from the Governing Body and interdependencies with the Commissioning Business Group and the Pennine Lancashire Quality Committee.

8.0 Location of information such as plans, or contact information

8.1 Information relating to the Primary Care Co-commissioning Committee is saved electronically on the Clinical Commissioning Group drive.

9.0 Related Policies

9.1 Managing Conflicts of Interest

10.0 Meetings

10.1 Members of the Committee have a collective responsibility for the operation of the committee. They will participate in discussion, review evidence and provide objective expert input to the best of their knowledge and ability and endeavor to reach a collective view.

10.2 The Committee may delegate tasks to such individuals or sub-committees as it shall see fit, provided that any such delegations are consistent with the parties’ relevant governance arrangements, are recorded in a scheme of delegation, are governed by the terms of reference as appropriate and reflect appropriate arrangements for the management of conflicts of interest.

10.3 Minutes of meetings will be presented to NHS England’s Lancashire and Greater Manchester Area Team and the Governing Body of Blackburn with Darwen CCG each month for information.

10.4 Agendas and any papers for committee meetings will be circulated to members and published at least five days in advance. Where the Committee meets in person, a corporate team member will attend to formally minute the proceedings.

10.5 Meetings will be held at least quarterly. The Chair of the Committee may arrange extraordinary meetings at their discretion. A schedule of meetings will be circulated to all members on an annual basis.

10.6 Meetings will be held in public.

10.7 The Committee may resolve to exclude the public from a meeting that is open to the public (whether during the whole or part of the proceedings) whenever publicity would be prejudicial to the public interest by reason of the confidential nature of the business to be transacted or for other special reasons stated in the resolution and arising from the nature of that business or of the proceedings or for any other reason permitted by the Public Bodies (Admission to Meetings) Act 1960 as amended or succeeded from time to time.

10.8 Except as outlined in these terms of reference, meetings of the committee shall be conducted in accordance with the provisions of Standing Orders, Reservations and Delegation of Powers as approved by the Membership and reviewed from time to time.

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AUDIT COMMITTEE

TERMS OF REFERENCE

1.0 Purpose of the Committee

The Audit Committee (the Committee) is established in accordance with Blackburn with Darwen’s (BwD’s) Clinical Commissioning Group’s Constitution. These Terms of Reference set out the membership, remit, responsibilities and reporting arrangements of the Committee and shall have effect as if incorporated into the Constitution.

The duties of the Committee will be driven by the priorities identified by the Clinical Commissioning Group, and the associated risks.

2.0 Roles and Responsibilities 2.1 Integrated Governance , Risk Management and Internal Control The Committee shall review the establishment and maintenance of an effective system of integrated governance, risk management and internal control, across the whole of the Clinical Commissioning Group’s activities (clinical and non-clinical) that support the achievement of the Clinical Commissioning Group’s objectives.

Its work will dovetail with that of the Pennine Lancashire Quality Committee which the Clinical Commissioning Group established to seek assurance that robust clinical quality is in place and drive improvements to services.

In particular, the Audit Committee will review the adequacy and effectiveness of:

 All risk and control related disclosure statements (in particular the governance statement), together with any accompanying Head of Internal Audit Opinion, external audit opinion or any other appropriate independent assurances, prior to endorsement by the Clinical Commissioning Group.

 The underlying assurance processes that indicate the degree of achievement of Clinical Commissioning Group objectives, the effectiveness of the management of principal risks and the appropriateness of the above disclosure statements.

 The policies for ensuring compliance with relevant regulatory, legal and code of conduct requirements and related reporting and self-certification.

 The policies and procedures for all work related to fraud, bribery and corruption as set out within the relevant NHS Standard Contract Service Condition and as required by NHS Counter Fraud Authority’s Standards for Commissioners.

In carrying out this work the Committee will primarily utilise the work of Internal Audit, External Audit and other assurance functions, but will not be limited to these sources. It will also seek

V 0.09 April 2019

reports and assurances from officers as appropriate, concentrating on the over-arching systems of integrated governance, risk management and internal control, together with indicators of their effectiveness.

This will be evidenced through the Committee’s use of an effective Assurance Framework to guide its work and that of the audit and assurance functions that report to it.

As part of its integrated approach, the Committee will have effective relationships with other key committees so that it understands processes and linkages. However, these other committees must not usurp the Committee’s role.

2.2 Internal Audit

The Committee shall ensure that there is an effective internal audit function that meets the Public Sector Internal Audit Standards (2017) and provides appropriate independent assurance to the Audit Committee, Clinical Chief Officer and Clinical Commissioning Group Governing Body. This will be achieved by:

 Consideration of the provision of the internal audit service, the cost of the audit and any questions of resignation and dismissal.

 Review and approval of the internal audit strategy, operational plan and more detailed programme of work, ensuring that this is consistent with the audit needs of the organisation, as identified in the assurance framework.

 Considering the major findings of internal audit work (and management’s response) and ensuring co-ordination between the internal and external auditors to optimise audit resources.

 Ensuring that the internal audit function is adequately resourced and has appropriate standing within the Clinical Commissioning Group.

 An annual review of the effectiveness of Internal Audit. 2.3 External Audit

The Committee shall review and monitor the external auditor’s independence and objectivity, the work and findings of the external auditors, and, consider the implications and management’s responses to their work. This will be achieved by:

 Consideration of the appointment and performance of the external auditors, as far as the rules governing the appointment permit (and make recommendations to the Governing Body when appropriate).

 Discussion and agreement with the external auditors, before the audit commences, on the nature and scope of the audit as set out in the annual plan, and ensuring coordination, as appropriate, with other external auditors in the local health economy.

 Discussion with the external auditors of their evaluation of audit risks relating to both the financial statements and value for money conclusion, and associated impact on the audit fee.

 Review of all external audit reports, including the report to those charged with governance, agreement of the annual audit letter before submission to the Clinical Commissioning Group and any work undertaken outside the annual audit plan, together with the appropriateness of management responses.

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 Ensuring there is a clear policy for the engagement of external auditors to supply non audit services

2.4 Other assurance functions

The Audit Committee shall review the assurance framework and the corporate risk register as well as findings of other significant assurance functions, both internal and external and consider the implications for the governance of the Clinical Commissioning Group.

These will include, but will not be limited to, any reviews by Department of Health and Social Care, arm’s length bodies or regulators/inspectors (for example, the Care Quality Commission and NHS Resolution) and professional bodies with responsibility for the performance of staff or functions (for example, Royal Colleges and accreditation bodies).

In addition, the Committee will review the work of other committees within the organisation, whose work can provide relevant assurance to the Committee’s own areas of responsibility. In particular, this will include the work of the Pennine Lancashire Quality Committee and the Primary Care Co-Commissioning Committee.

2.5 Counter Fraud

The Committee shall satisfy itself that the Clinical Commissioning Group has adequate arrangements in place for countering fraud and security that meet the NHS Counter Fraud Authority’s standards and shall review the outcomes of counter fraud work. It shall also approve the counter fraud work programme.

The Committee shall ensure that there is effective review of the work of the Local Anti-Fraud Specialist as set out by the relevant NHS Standard Contract Service Condition and as required by NHS Counter Fraud Authority’s Standards for Commissioners, insofar as the areas delegated to CCGs are concerned. This will be achieved by:

 Approval of the appointment of a Local Anti-Fraud Specialist either directly or through the appointment of the internal audit services.

 Review and approval of the CCG’s Anti-Fraud, Bribery and Corruption Policy, operational plans (including Annual Workplan and Annual Report) and detailed programme of work, through recurring progress reports, to ensure that the Committee is satisfied with action taken throughout the year and that significant losses have been properly investigated and reported.

 Ensuring that the Anti-Fraud functions are adequately resourced and have appropriate standing within the CCG.

2.6 Management

The Committee shall request and review reports and positive assurances from Directors and Managers on the overall arrangements for governance, risk management and internal control.

The Committee may also request specific reports from individual functions within the Clinical Commissioning Group as they may be appropriate to the overall arrangements.

2.7 Financial reporting

The Audit Committee shall monitor the integrity of the financial statements of the Clinical Commissioning Group and any formal announcements relating to the Clinical Commissioning

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Group’s financial performance.

The Committee shall ensure that the systems for financial reporting to the Clinical Commissioning Group, including those of budgetary control, are subject to review as to completeness and accuracy of the information provided to the Clinical Commissioning Group.

Annual Reports and Accounts

In accordance with the CCG’s Constitution (Scheme of Reservation and Delegation) the Committee is authorised to approve the Group’s annual report and annual accounts.

The Audit Committee shall review the annual report and financial statements before submission to the Governing Body (for information), focusing particularly on:

 The wording in the annual governance statement and other disclosures relevant to the Terms of Reference of the Committee;  Changes in, and compliance with, accounting policies, practices and estimation techniques;  Unadjusted mis-statements in the financial statements;  Significant judgements in preparing of the financial statements;  Significant adjustments resulting from the audit;  Letter of representation  Explanations for significant variances  Qualitative aspects of financial reporting.

2.8 Review instances where Standing Orders / Standing Financial Instructions have been waived.

2.9 Review, at least annually, the Clinical Commissioning Group Governing Body’s schedules of losses special payments and register of gifts and hospitality and declaration of Clinical Commissioning Group members’ interests.

2.10 Whistleblowing The Committee shall review the effectiveness of the arrangements in place for allowing staff to raise (in confidence) concerns about possible improprieties in financial, clinical or safety matters and ensure that any such concerns are investigated proportionately and independently.

3.0 Deliverables 3.1 Reports of assurance to the Clinical Commissioning Group Governing Body that the functions as identified in the Audit Committee Work plan have been performed.

3.2 Minutes recording the decisions reached and the reasons for such decisions shall be maintained and be submitted to the Clinical Commissioning Group Governing Body.

4.0 Constraints/Risks 4.1 Audit reporting and publishing of annual accounts are set within pre-determined dates.

5.0 Membership 5.1 The Committee shall be appointed by the Clinical Commissioning Group as set out in the Clinical Commissioning Group’s Constitution and may include individuals who are not on the governing body.

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The Lay Member on the Governing Body with a lead role in governance will chair the Audit Committee.

As a minimum membership shall be made up of:-

Lay Member for Governance (Chair) Secondary Care Doctor One other Lay Member General Practitioner Executive

Members must comply with the requirements of the CCG’s Conflict of Interest Policy. In the event that all clinical members are excluded from decisions due to conflicts of interest clinical input may be sought from elsewhere if and when required.

The Accountable Officer will be invited to attend meetings and discuss at least annually with the Audit Committee the process for assurance that supports the Annual Governance Statement. The Accountable Officer will be invited to attend when the committee considers the draft Annual Governance Statement, the Annual Report and Accounts.

The Chief Finance Officer and other Executives from the Clinical Commissioning Group may be in attendance at the specific invitation of the Chair.

6.0 Governance and Reporting 6.1 The Audit Committee will report to the Clinical Commissioning Group Governing Body on how it discharges its responsibilities.

The Committee will report to the governing body at least annually on its work in support of the annual governance statement, specifically commenting on:  The fitness for purpose of the Assurance Framework  The completeness and “embeddedness” of risk management within the organisation  The integration of governance arrangements  The appropriateness of evidence that show the organisation is fulfilling regulatory requirements relating to its existence as a functioning business

This annual report should also describe how the Committee has fulfilled its terms of reference and give details of any significant issues that the Committee considered in relation to the financial statements and how they were addressed. 6. The Committee shall report after each meeting on all matters within its duties and responsibilities. The report should be completed in line with the agreed template and the full minutes will be submitted to the next meeting of the governing body.

6.3 Quorum Quorum shall be 2 members. 6.4 Frequency The Audit Committee shall meet at least four times per annum and at least once a year will meet with Internal Audit and External Audit with no other officers present. The Chief Finance Officer will arrange secretarial support for the committee. 7.0 Relationships/Interdependencies with other Bodies 7.1 The Audit Committee is informed by corporate business transacted by the Clinical Commissioning Group Governing Body and its Sub-Committees.

8.0 Location of information such as plans, or contact information

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8.1 Information relating to the business of the Audit Committee is saved electronically on the Corporate Drive. 9.0 Related Policies 9.1  Being Open Policy  Whistle Blowing Policy  Fraud and Corruption Policy  Conflict of Interest Policy  Standing Financial Instructions  Standing Orders 10.0 Schedule of Meetings 10.1 4 times per annum as a minimum.

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GOVERNING BODY MEETING

MIDLANDS AND LANCASHIRE COMMISSIONING SUPPORT UNIT DATA MITIGATION

Date of Meeting 11 September 2019 Agenda Item 15

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 Y 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

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Clinical Lead: N/A

Senior Lead Manager N/A Finance Manager N/A Equality Impact and Risk Assessment completed: Is a Data Protection Impact Assessment Required? Yes Data Protection Impact Assessment completed: Yes Patient and Public Engagement N/A completed: Financial Implications As per report Risk Identified As per report Report authorised by Senior Manager: Kirsty Hollis – Chief Finance Officer NHS East Lancashire CCG Y

Decision Recommendations

Note the actions of the SIRO and DPO to be able to provide the NHS Digital with the required assurance by the deadline of 31 July 2019

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CLINICAL COMMISSIONING GROUP

GOVERNING BODY MEETING

11 SEPTEMBER 2019

MIDLANDS AND LANCASHIRE COMMISSIONING SUPPORT UNIT DATA MITIGATION

1.0 INTRODUCTION

1.1 As part of the service offer to both NHS Blackburn with Darwen and NHS East Lancashire CCGs (the CCGs), Midlands and Lancashire Commissioning Support Unit (MLCSU) undertakes the function of a Data Service for Commissioners Regional Office (DSCRO). This allows NHS Digital to disseminate personal identifiable information, predominantly the Secondary User Services (SUS) data, under the Health and Social Care Act (2012), to commissioners. This allows CCGs to carry out their statutory commissioning responsibilities, in accordance with the Data Protection Act (2018), and is governed by way of a Data Sharing Framework Contract (DSFC) and a Data Sharing Agreement (DSA).

2.0 PURPOSE OF THE UPDATE

2.1 The purpose of this update is to bring to the attention of the Governing Bodies, the intention of MLCSU to change the way that the data that flows from NHS Digital is stored and that that be by way of the implementation of cloud based storage.

2.2 To bring to the attention of the Governing Bodies the assurance requirements from NHS Digital and the work undertaken by both myself as Senior Information Responsible Officer (SIRO), supported by colleagues from our Information Governance (IG) service, and Hayley Gidman as our nominated Data Protection Officer (DPO) to allow us to be able to provide those assurances.

2.2 The type and content of data shared will not change although an updated data privacy impact assessment has been completed. This has been reviewed and signed off by both myself as SIRO and our DPO.

3.0 BACKGROUND TO THE NEED TO PROCURE AN ALTERNATIVE DATA STORAGE FACILITY

3.1 MLCSU, for all its clients, currently stores SUS data on a server based system, which is currently the Microsoft Parallel Data Warehouse (PDW). In the very near future, the hardware and the technology for this will no longer be supported. Therefore PDW needs to be decommissioned. Following an options appraisal by MLCSU, a decision was taken by their IT Architecture Board to replace PDW with a Public Cloud Data Warehouse (DW) solution based on the utilisation of Microsoft Azure SQL Data Warehouse Platform as a service.

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The benefits of this being:-

 Cost effective  Highly resilient, scalable infrastructure  No downtime for upgrades and patches  No hardware issues for example disc failure  No re-write required to migrate the PDW process  Allows for a phased migration  Remains as an on-going managed service with support for design and maintenance  Network speed improvement

3.2 Whilst this is an Information Technology (IT) project and has been driven by colleagues from both MLCSU and NHS Digital, colleagues from the Information Governance (IG) service have been embedded as part of the project group to ensure that all IG matters are considered to ensure not only compliance with legislation but also NHS Digital standards appertaining to the use of cloud based services.

4.0 ASSURANCES

4.1 As part of their final sign off of the project implementation, NHS Digital required the SIRO of each of MLCSU’s customers to provide written assurance on four counts by 31 July 2019.

4.2 Following a review of all the documentation relating to the proposed migration, and fully supported by our DPO, I was able to provide NHS Digital with the following assurance.

To Whom it May Concern.

In my role as Senior Information Risk Owner for both NHS East Lancashire CCG and NHS Blackburn with Darwen CCG, I can confirm the following

 That as data controllers, we understand that public cloud services, in this case

Microsoft AZURE, are being used for our data received and managed under our Data Sharing Contract and Data Sharing Agreement with NHS Digital  I confirm we have read and understood the NHS Policy NHS and social care data: off-shoring and the use of public cloud services and guidance on public cloud services  As Data Controllers we are confident that our data processors, MLCS, have followed NHS Policy and have appropriate controls in place in line with Health and Social Care Cloud Security –Good Practice Guide  As Data Controllers we will ensure that our Governing Bodies are aware of the use of the cloud and the processing and controls in place.

I can confirm the above actions have or will be completed within a reasonable period of time

and that as a Data Controller the organisation confirms they are suitably assured regarding the controls and happy for MLCSU to start migration to the new platform.

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4.3 This report and update therefore form the final part of that assurance.

5.0 RECOMMENDATION

5.1 Governing Body are therefore asked to:-

5.1.1 As Data Controller, to be aware of the use of cloud based storage solution and the processing and controls put into place by MLCSU as our DSCRO.

5.1.2 Note the actions of the SIRO and DPO to be able to provide the NHS Digital with the required assurance by the deadline of 31 July 2019

6.0 SUPPORTING DOCUMENTATION

Annex Number Description 1 Privacy Impact Assessment – Checklist 2 NHS and Social Care data: off-shoring and the use of public cloud services guidance (11 April 2018) 3 Health and Social Care Cloud Risk Framework © 2018 NHS Digital 4 Health and Social Care Cloud Security – Good Practice Guide © 2018 NHS Digital

Kirsty Hollis Chief Finance Officer / Deputy Chief Officer – NHS East Lancashire CCG SIRO on behalf of NHS Blackburn with Darwen CCG and NHS East Lancashire CCG

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Privacy Impact Assessment – Checklist Annex 1

Key Information – please be as comprehensive as possible.

Project Name: SUS Data Processing in the Azure Cloud

Description of project: MLCSU currently have an on-premise Microsoft Parallel Data Warehouse (PDW) solution based in Jubilee House which requires decommissioning due to support reasons. It has been determined that the PDW should be replaced with a Public Cloud Data Warehouse (DW) solution based on the utilisation of Azure SQL Data Warehouse Platform as a Service (PaaS). The processing of SUS data is to be migrated and the migration is under time pressure because of the support and Microsoft licensing requirements for the existing on-premise DW.

Reasons to decommission PDW (APS) appliances and migrate to Microsoft Azure

 PDW technology is hugely expensive  PDW support contracts are very expensive  PDW appliances are not particularly resilient – v1 architecture destroyed disks  SQL Server SA licencing costs for PDW appliances doubled in 2012 – we didn’t realise this increase until current licences expired in 2018 – SA required for AU upgrades  PDW 1 Based at Lima – Compute nodes already extended EOS past August 2018  Deeply engrained within Microsoft infrastructure (PDW & SQL) with existing technical and support contracts (Office 365) – Microsoft preferred over AWS or Google  An Options Paper presented to the IT Architecture Board with 3 options: o Move to Azure o Continue without resiliency o Relicense current infrastructure / purchase another PDW and the decision was taken to migrate to Azure

Azure Migration - Pros

 Very cost effective – especially for PDW  Highly resilient, scalable infrastructure  No downtime for upgrades or patches

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 No hardware issues - disk failures  Basic elements go completely unchanged e.g. SQL Server, Windows, DSQL  No re-write required to migrate PDW processes  Phased migration – only moving what has to stay on PDW technology  ANS support for design and maintenance (ongoing managed service)  Network speed improvement as all process are based at Lima data centre

Explain what the project aims to achieve, what the benefits will be to the organisation, to individuals and to other parties.

You may find it helpful to link to other relevant documents related to the project, for example a project proposal

Will the project involve any data from which individuals could be identified Yes (including pseudonymised data)? (Yes/No)

IF NO THEN YOU DO NOT NEED TO ANSWER ANY FURTHER QUESTIONS AND A PIA IS NOT REQUIRED.

Key Contacts

Project Manager Name & Job Title: Allyson Barratt, Programme Manager (Business Intelligence)

Project Manager Email: [email protected]

Mobile: 07342 080465 Project Manager Phone: Office: 0121 612 1474

Key Stakeholder Names & Roles: Phil Rowley, Head of BI – Contracting and Data Processing

Kevin Roberts, Development Manager | Business Intelligence

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Sam Cardus, Senior Infrastructure Manager (North)

Mohammed Waeed, Infrastructure Manager (Networks) (South)

Mark Bridges, Service Delivery Manager (DCSRO)

Screening Questions YES or NO

Will the project involve the collection of new information about individuals? No

Will the project compel individuals to provide information about themselves? No

Will information about individuals be disclosed to organisations or people who No have not previously had routine access to the information?

Are you using information about individuals for a new purpose or in a new way No that is different from any existing use?

Does the project involve you using new technology which might be perceived as No being privacy intrusive? For example, the use of biometrics or facial recognition.

Will the project result in you making decisions about individuals in ways which Yes – service may have a significant impact on them? e.g. service planning, commissioning of planning, new services commissioning of new services

Is the information to be used about individuals’ health and/or social wellbeing? Yes – as is

Will the project require you to contact individuals in ways which they may find No intrusive?

If any of the screening questions have been answered “YES”, then please continue with the Privacy Impact Assessment Questionnaire (below).

If all questions are “NO”, please return the document to the Information Governance Team and do not complete a Privacy Impact Assessment. Please email the completed screening to Michelle Wiles – IG Project Manager. [email protected]

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Privacy Impact Assessment – Questionnaire

Use of personal information

1. Description of data: MLCSU currently have an on-premise Microsoft Parallel Data Warehouse (PDW) solution which requires decommissioning due to support reasons. It has been determined that the remaining PDW should be replaced with a Public Cloud Data Warehouse (DW) solution based on the utilisation of Azure SQL Data Warehouse Platform as a Service (PaaS). The migration is under time pressure because of the Support and Licensing requirements for the existing on-premise DW.

All aspects of SUS data are included (as currently processed on the PDW (physical kit), which is located in Jubilee House):

 Inpatient data  ECDS data (formerly known as A&E data)  Outpatient data  Critical care data

Please see the attached Azure migration diagrams to explain the current set-up and the future Azure vision.

e.g. name, address, date of birth, NHS number, gender, clinical or other health information, ethnicity.

You need to note the exact information which you will be recording.

Different data sets have different sensitivities. For example, If you are recording information in relation to rare diseases by geographical area, depending on the disease and how rare it is, it may be possible to identify an individual from just the disease and the first part of the post code. However, if you are looking at common diseases by geographical area, then it may be you’d be unable to identify the individual by the disease combined to the first part of the postcode.

2. What is the justification The format of the data will not be changing – it is just the location for the inclusion of of where and how the pseudonymised data will be processed. Data identifiable data rather than is pseudonymised within the RPC before it is processed in the Azure using de- cloud. identified/anonymised data? Could you use anonymised data instead? If not, what is the reason

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for this. You need to be specific for the reason.

The information is not new information. It is the way in which the 3. Will the information be data is processed and where the data is processed that is changing. new information as opposed The way in which the information is used is not changing. Data to using existing information Sharing Agreements (DSAs) are in place with commissioners for in different ways? which MLCSU provide DSCRO services.

Is the information new to the organisation?

If you are planning on using data that you already hold (and have a legal basis to do so) but if you are proposing to use the same data for a distinctly different and incompatible purpose then you will still need to consider the legal basis for doing so.

The Data Protection Act requires organisations, including those in 4. What is the legal basis for the NHS, to process personal data fairly and lawfully. NHS Digital the processing of identifiable cannot release patient level data to a commissioning organisation data? unless it has a data sharing framework contract and a data sharing agreement in place. If consent, when and how will this be obtained and NHS Digital, formally known as HSCIC, is able to disseminate data to recorded? commissioners under the Health and Social Care Act (2012). The act provides the powers for NHS Digital to collect, analyse and disseminate national data and statistical information. To access this data organisations must submit an application and demonstrate that they meet the appropriate governance and security requirements.

NHS Digital, through its Data Services for Commissioners Regional Offices (DSCROs), is permitted to collect, hold and process Personal Confidential Data (PCD). This is for purposes beyond direct patient care to support NHS commissioning organisations and the commissioning functions within local authorities.

Data regarding health care treatment can only be shared with commissioning organisations where a formal Data Sharing Framework Contract (DSFC) is in place alongside a Data Sharing Agreement (DSA).

The Data Services for Commissioners safely provides anonymised patient-level data to commissioners for use in healthcare planning and payment within the NHS.

Healthcare commissioners need information about the treatment of patients to review and plan current and future health care services. To do this they need to be able to see information about the healthcare provided to patients which can include patient level data.

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The law says commissioners are not allowed to access Personal Confidential Data (PCD) because they are not providing direct patient care. So they need an intermediary service called Data Services for Commissioners Regional Office (DSCRO), that specialise in processing, analysing and packaging patient information within a secure environment into a format commissioners can legally use; anonymised patient level data.

Anonymised patient level data allows a patients 'events' to be linked without revealing the identity of that person.

Applications for the receipt of data are usually used to support three main areas of work:  Risk stratification: is a process that uses personal data from health care services to identify and support patients with long term conditions and to help minimise unplanned hospital admissions.  Invoice validation: is a process that uses personal data to make sure health care organisations providing care are paid correctly.  Commissioning is a process using data coded to hide the identity of patients. It is used by organisations to plan and commission health care services.

National Data Opt Out (NDOP) is already applied to the data in the RPC.

A legal basis is always required. These can include: Explicit data subject consent, s251 support, statutory power.

Do you have a specific piece of legislation which clearly states you are able to process personal data for this specific purpose? If so please provide a link to the legislation and state how this relates to your project.

Will you be gaining consent directly from the patient? Who will be doing this and how will this be recorded? Who will be responsible for holding this data? You will need to provide a mechanism for any data subjects to withdraw consent if they change their mind. If consent is to be the legal basis then include a description of how this is to be achieved.

The information provided here may also be useful in answering questions 8 (Legal basis for data linkages), 12 (Governance measures for Confidentiality and security), 13 (Subject Access) and 14 (data being used elsewhere in Organisation or third party).

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5. Who will be able to access The data will be processed in the Azure cloud and then transferred identifiable data? to SQL10, before being made available via CSU servers to the following:

BI staff & contractors – as current – access to pseudonymised data.

Strategy Unit analytics staff & contractors – as current – access to pseudonymised data.

The primary region for processing data in Azure is UK South, with UK West as a secondary region.

Microsoft SLA

Azure SQL Data Warehouse database SLA from Microsoft;

https://azure.microsoft.com/en-gb/support/legal/sla/sql-data- warehouse/v1_0/

Azure SQL Database SLA from Microsoft;

https://azure.microsoft.com/en-gb/support/legal/sla/sql- database/v1_1/

Azure SLA from Microsoft;

https://azure.microsoft.com/en-gb/support/legal/sla/virtual- machines/v1_8/

Many more available;

https://azure.microsoft.com/en-gb/support/legal/sla/

This should include details of any data processors / contractors and sub-contractors and any proposed overseas transfers.

List all the organisations who will have access to the data which you will be collecting. Will it be shared in identifiable format or will you just be sharing non-identifiable information?

If you are transferring the information to an online system such as a portal for other organisations to access, where is that data stored? A lot of cloud storage providers use data servers which are located outside of the EEA and so this would be classed as an overseas transfer.

This will link to question 9 (Security or data transfers) and also to

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questions 15 and 16 (Data flows).

6. Will the data be linked There will be no change to the way the data is used. with any other data collections? If you are planning on linking the data to other information held by your organisation or another then you need to specify and provide business reason / information requirement

7. How will this linkage be There will be no change to the way the data is used. achieved? How will this be completed, who will be responsible for linking the data and what consistent identifiers will be used to ensure the accuracy of any linkages.

8. Is there a legal basis for There will be no change to the way the data is used. these linkages? i.e. is it within the terms of any prior consent? Is it within the scope of any statutory justification?

If you are using explicit consent, the process of linking any data sets should be included in the consent form.

This may be the same legal basis as question 4 (consent) or may require an additional legal basis

9. What security measures Staff who have access to the RPC and data processing in Azure are will be used to transfer the all DSCRO secondees. We have engaged ANS to provide assistance data? with the design of the Azure solution. Please see the attached document for further information.

What is the most secure method of transferring the information which can be used? Do any methods of transfer need to be risk assessed?

You need to follow safe haven principles as detailed in the

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Organisation’s IG Handbook. More information on safe haven principles can be found in the Organisation’s IG Handbook.

10. What confidentiality and We have engaged ANS to provide assistance with the design of the security measures will be Azure solution. Please see the attached document for further used to store the data? information.

i.e. contractual arrangements with data processors, contractual arrangements with their staff as well as physical and technical security measures

What contractual clauses are or will be in place with the intended data processors that cover how they are expected to store identifiable data?

The data controller retains responsibility for ensuring the data processor has sufficient processes in place.

Confidentiality measures include staff training, policies and procedures as well as compliance checks.

11. How long will the data be As per usual NHS retention rules. retained in identifiable form? And how will it be de- e.g. Data retention, redaction and disposal policy. Include identified? Or destroyed? arrangements if the project is withdrawn/ stopped.

Look to the NHS Code of Practice for retention of documents: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/ 200139/Records_Management_- _NHS_Code_of_Practice_Part_2_second_edition.pdf

What steps are in place for accidental loss or damage - link to questions 9 and 10 (Security measures for transfer and storage).

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12. What governance We have engaged ANS to provide assistance with the design of the measures are in place to Azure solution. Please see the attached document for further oversee the confidentiality, information. security and appropriate use of the data and manage e.g. oversight body / committee, security audit and risk review disclosures of data extracts procedures. to third parties to ensure identifiable data is not This should also include contingency planning against accidental disclosed or is only disclosed loss, destruction or damage to personal data. with consent or another legal basis? What steps are in place for accidental loss or damage - link to questions 9 and 10 (Security measures for transfer and storage).

13. If holding personal i.e. National Data Opt Out (NDOP) are already applied within the RPC. identifiable data, are Existing CSU subject access procedure should apply. procedures in place to provide access to records This is in relation to Subject Access provisions within the DPA. under the subject access provisions of the DPA? This should include how personal data is located and procedures for explaining the information in the record e.g. coded data, to the Is there functionality to individual. respect objections/ withdrawals of consent? How third party and seriously harmful information will be handled and how grounds for withholding information will be managed.

Who will be responsible for releasing the information? This should be covered by the Organisation’s Subject Access Request Standard Operating Procedure.

Can data easily be located and extracted? Will the data need an explanation for it to make sense to the applicant? E.g. provide a list of codes or abbreviations

Any contracting organisations should be made aware of their obligations around providing data upon request. Will the data subject be asked to contact the data controller directly and then liaise with the data controller?

14. Are there any plans to The data will be used for the same purposes as it is currently. It is allow the information to be the way in which the data is processed and where the data is used elsewhere either in the processed that is changing. CCG, wider NHS or by a third party? The data will be used for exactly the same purposes as is.

Will the data be re-used for the same purpose or for a different purpose?

If you plan to allow information be used elsewhere within the

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Organisation, wider NHS or by a third party you need to consider the legality of the transfer (question 4) and the security and confidentially arrangements in place (questions 10 and 11).

Describe the information flows

The collection, use and deletion of personal data should be described here and it may also be useful to refer to a flow diagram or another way of explaining data flows.

15. Does any data NHS and Social care providers may use cloud computing services for NHS data. flow in identifiable Data must only be hosted within the UK - European Economic Area (EEA), a form? If so, from country deemed adequate by the European Commission, or in the US where where, and to covered by Privacy Shield. where? Please see attached diagram for how the data flows currently and in the Azure cloud.

Will data be shared? If so, in what form and with who? Does it need to be shared with identifiers?

Is the recipient outside of the EEA? (This links to the information Provide in question 5 – Who has access to the data).

16. Media used for Only need to answer the question if answered yes to question 15. data flow? This links with question 9 (security measures will be used to transfer the (e.g. email, fax, data) safe haven principles should be followed as detailed in the post, courier, other Organisation’s IG Handbook. – please specify all that will be used)

Consultation requirements

Part of any project is consultation with stakeholders and other parties. In addition to those indicated “Key information, above”, please list other groups or individuals with whom consultation should take place in relation to the use of person identifiable information.

It is the project’s responsibility to ensure consultations take place, but IG will advise and guide on any outcomes from such consultations.

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Hayley Gidman, Caldicott Guardian, was briefed on 21/03/19.

Are there any engagement or participation groups who would be able to provide feedback and comments on the proposed use of data?

Are there other teams outside of the project team/organistion who should be consulted?

Has the lead organisations Caldicott Guardian been consulted?

Privacy Risks

List any identified risks to privacy and personal information of which the project is currently aware. Risks should also be included on the project risk register.

Risk Description Proposed Is the risk reduced, transferred, Further detail if required Risk or accepted? Please specify. (to individuals, solution to the CCG or to (Mitigatio wider n) compliance)

Further information

Please provide any further information that will help in determining privacy impact.

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Following acceptance of this PIA by Information Governance, a determination will be made regarding the privacy impact and how the impact will be handled. This will fall into three categories:

1. No action is required by IG excepting the logging of the Screening Questions for recording purposes.

2. The questionnaire shows use of personal information but in ways that do not need direct IG involvement – IG may ask to be kept updated at key project milestones.

3. The questionnaire shows significant use of personal information requiring IG involvement via a report and/or involvement in the project to ensure compliance.

It is the intention that IG will advise and guide those projects that require it but at all time will endeavour to ensure that the project moves forward and that IG is not a barrier unless significant risks come to light which cannot be addressed as part of the project development.

Please email entire completed document to [email protected]

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NHS and social care data: off-shoring and the use of public cloud services

NHS and social care organisations can safely locate health and care data, including confidential patient information, in the public cloud including solutions that make use of data off-shoring.

This guide explains the safeguards that must be put in place to do so, including considerations about where the data can be located.

In brief:

• NHS and Social care providers may use cloud computing services for NHS data. Data must only be hosted within the European Economic Area (EEA), a country deemed adequate by the European Commission, or in the US where covered by Privacy Shield.

• Senior Information Risk Owners (SIROs) locally should be satisfied about appropriate security arrangements (using National Cyber Security Essentials as a guide) in conjunction with Data Protection Officers and Caldicott Guardians.

• Help and advice from the Information Commissioner’s Office is available and regularly updated.

• Changes to data protection legislation, including the General Data Protection Regulation (GDPR) from 25 May 2018, puts strict restrictions on the transfer of personal data, particularly when this transfer is outside the European Union. The ICO also regularly updates its GDPR Guidance.

Use of cloud computing services

1) The UK Government introduced a ‘cloud first’ policy for public sector IT in 2013. The use of cloud services was also endorsed in the National Information Board’s Personalised Health and Care 2020 framework, published in November 2014 and, if implemented correctly, it is compliant with the National Data Guardian’s recommendations.

2) Provided that the upmost care is taken when collecting, transferring, storing and processing patient data, NHS and social care organisations are permitted to host data within the UK, EEA (countries deemed by the European Commission to have adequate protections for the rights of data subjects), or in the US where covered by Privacy Shield.

3) There are no restrictions on where in the UK data may reside, for example data from the NHS in England data may be hosted in Scotland, and vice versa. (See ‘Further detail on acceptable locations for data offshoring’ at foot of page)

What is cloud computing?

4) As defined by the National Institute of Standards and Technology: “Cloud computing is a model for enabling ubiquitous, convenient, on-demand network access to a shared pool of configurable computing resources (e.g. networks, servers, storage, applications, and services) that can be rapidly provisioned and released with minimal management effort or service provider interaction.”

5) Public cloud services, defined as cloud infrastructure provisioned for open use by the general public, offers the biggest potential benefits for the public sector. There are other deployment models available such as community, hybrid or private cloud.

6) NHS and social care organisations can safely put health and care data, including non-personal data and confidential patient information, into the public cloud. Many NHS organisations and government departments have already made this decision based on risk management assessments and having put appropriate safeguards in place.

Benefits of the cloud

7) Cloud providers have a significant budget to pay for updating, maintaining, patching and securing their infrastructure. This means cloud services can mitigate many common risks NHS and social care organisations often face.

8) Cloud services may provide other advantages for NHS and social care organisations including lower IT costs and the ability to develop, test and deploy services quickly without large capital expense. 9) As more services for patients and staff move to the Internet and the need for better data interoperability increases, it is likely that use of cloud services will become more prevalent in NHS and social care organisations.

Migrating to the Cloud: four steps to informing a risk-based decision

10) All decisions relating to the security of data are the responsibility of the local data controller within a healthcare organisation. In accordance with recommendations made by the National Data Guardian, organisations should also have a SIRO responsible for data and cyber security who should be included in making a risk- based decision.

11) Well-executed use of cloud services is appropriate for most NHS and social care information and services. However, your organisation may have different needs, dependent on your data security requirements. These requirements will be defined by the availability, integrity and confidentiality criteria of your specific data or systems.

12) However, there are some potential downsides to cloud services that need to be considered when making a risk-based decision:

a) Moving critical services to the cloud will increase the importance of Internet access to your organisation. If your Internet access is disrupted or is unreliable, you may lose access to your data and services. b) You may need to change the way you budget for technology as cloud services usually operate on a pay-as-you-go (revenue) model rather than capital expenditure. c) You may need to recruit the right capability to deliver and manage cloud services if your organisation has no prior experience of running this type of service. d) Not all systems were designed to run in the cloud, and so some may not be compatible. e) Use of the cloud increases the portability of data, meaning data can be distributed across multiple devices both within and without the boundary of your organisation. The right cultural understanding and behaviours need to be in place to manage this portability appropriately mitigate any risks.

13) You should take into account these and other relevant factors, including, but not limited to, cost, security, resilience, capability and funding when deciding whether to use cloud services. If you are unsure, seek specialist advice. 14) These are the steps you should take to ensure you select and implement a solution that is appropriate for the risk level of the specific data set or system your organisation has decided to move to the cloud.

Step 1: Understand the data

15) All data managed by NHS and social care organisations should be treated as OFFICIAL data, in line with the Government Security Classification Policy.

16) However, you shouldn’t treat all information equally. All information in your organisation will need risk-appropriate and proportionate security measures based on the service level of the system, the type of data you are dealing with, how much of it there is, and how long you will be retaining the data for.

Step 2: Assess the risks

17) Once you have gathered this information about the data or system you are considering moving into the cloud, you can use it to classify your data based on its level of risk.

18) There are a number of risk models available for classifying data and you should choose the one that is most appropriate for you and your organisation. If you are unsure of what factors the model should take into account when assessing your data, you can refer to:

a) the National Cyber Security Centre’s guidance on making risk based decisions b) the NHS Digital Health and Social Care data risk framework.

19) As an organisation, you retain Data Controller responsibility. It is possible that, once you have completed your risk assessment process, by following steps such as those outlined here, there may be some situations where cloud services are deemed not appropriate for specific systems or data. You will also want to refer to the European Union General Data Protection Regulation (GDPR), and how you can ensure privacy by design and conduct the necessary data protection impact assessments.

Step 3: Implement controls (data protection and location)

20) Assessing your data on a case-by-case basis is important because even though the cloud provider will be responsible for various elements of hosting and maintenance of a data, your organisation will retain data controller responsibilities and is therefore, ultimately, responsible for ensuring that proportionate security controls are put in place to mitigate all risks.

21) There are a number of pieces of relevant legislation and policy to help inform these proportionate decisions. These are: a) The Government Security Classification Policy; b) The Data Protection Act and EU General Data Protection Regulation (GDPR); and c) The Information Governance Toolkit v14.1, which will be superseded by The Data Security and Protection Toolkit from April 2018.

22) In general, these requirements are universal and large cloud service providers should have taken these into account when producing standard contractual terms. For example it is normal for contracts to include specific clauses relating to data availability, resilience and recovery. However, this is not a given and you may also have more specific requirements that you will want to ensure are built into the contract with your cloud provider, based on your risk assessment of the data. To help you define these requirements, you should talk to your cloud provider but also refer to:

a) The Information Commissioner’s Office (ICO) guidance for organisations considering using cloud services to process personal data; b) The ICO guidance on data protection reform (GDPR); c) NHS Digital’s Cloud Security Good Practice Guide; and d) The National Cyber Security Centre’s 14 Cloud Security Principles

23) These requirements will also influence, and be influenced by, where your cloud provider is processing or storing your data, as you may choose to take advantage of cloud solutions that conduct these functions outside of the UK.

24) Considering cloud providers that host or process data within EEA or adequate countries can be beneficial as it gives you more choice over cost, availability and resilience. To benefit from additional resilience it is highly recommended that for the data you deem to be of the highest risk you consider taking a multi-region approach; where, for example the data is stored both in and outside of the UK.

25) It is important to remember that these are legally complex considerations. It is possible to have numerous jurisdictions apply to data held in cloud services, (particularly when the cloud provider is non UK, or has a non UK parent company). Whilst Cloud providers should let you specify geographic region(s) to host or process data, you should clarify before contracting out. Furthermore, service providers sometimes use offshore technical and support staff, who are able to access data from another location. Many global service providers have a global support model that does not limit where staff can operate. You will want to understand whether this has any impact for your risk-based decision.

26) When selecting a cloud provider you should ask them to provide clarity on these complexities and their ability to meet all of your security requirements, not just those related to the National Security Centre’s 14 principles - evidence of which is detailed for each provider listed on the Digital Marketplace.

27) Finally, in addition to these quantitative measures you should explain to your service users how you are storing and managing their personal confidential data. Some people may associate ‘the cloud’ with the consumer Internet services they are familiar with (e.g. email, file sharing), rather than the securely designed enterprise cloud services used by many organisations.

28) If you are unsure about what any of this means for your organisation, seek legal advice.

Step 4: Monitor the implementation

29) As stated, whilst your cloud provider will have data protection responsibilities as a data processor, your organisation will retain data controller responsibilities and must be assured at all times that the selected cloud implementation is fit for purpose. Your organisation’s security requirements will change over time, so regular review points are recommended.

30) In accordance with the recommendations made by the National Data Guardian, your organisation should have a SIRO responsible for data and cyber security. You should ensure that this individual has access to the evidence provided by your cloud provider that they are compliant with the recognised standards, which could include third party verification of this, and the additional security controls that you may have requested. This evidence and the implementation itself should be reviewed regularly to ensure that any necessary changes to your cloud solution are made in a timely fashion.

Further detail on acceptable locations for data offshoring

Hosting data in the UK, EEA or adequate countries

Personal confidential data can be hosted in countries that provide an adequate level of protection for personal data.

Principle eight of The Data Protection Act states that: “Personal data shall not be transferred to a country or territory outside the EEA unless that country or territory ensures an adequate level of protection for the rights and freedoms of data subjects in relation to the processing of personal data.”

The European Commission provides a list of adequate countries. It is the responsibility of local organisations to monitor and take note of any future changes to this list, in the case of any future amendments.

There are other mechanisms to host personal confidential data outside the EEA while satisfying the requirements of the eighth principle of the Data Protection Act - including Model Clauses in contracts and Binding Corporate Rules.

For more information you should refer to the Information Commissioner’s guidance on sending personal data outside the EEA.

If you are planning to host data outside the EEA, or with a provider based outside the EEA, you should assess the impact of this data being subject to the legal jurisdiction of that country when making a risk-based decision.

Hosting data in the United States

NHS and social care data can be safely hosted with certain organisations in the US.

Personal confidential data can be hosted with organisations that participate in the Privacy Shield scheme agreed between the EU and US. The European Commission has issued a formal decision that the Privacy Shield provides adequate protection to allow personal data to be transferred to the US.

If you are planning to host data with an organisation in the US, you should verify whether they are part of this scheme on the Privacy Shield website, and whether the type of data you plan to transfer is covered by the organisation’s Privacy Shield commitments.

If the organisation you plan to host data with is not part of the Privacy Shield scheme, you will not be protected by the agreement. You should seek legal advice if you plan to host personal confidential data with a US provider that is not part of the Privacy Shield.

There are other mechanisms to host personal confidential data in the US while satisfying the requirements of the eighth principle of the Data Protection Act - including Model Clauses in contracts and Binding Corporate Rules.

For more information you should refer to the Information Commissioner’s guidance on sending personal data outside the EEA and transferring data to the US. Hosting data in other countries

NHS and social care organisations are not expected to host data outside of the UK, EEA, US or adequate countries as determined by the European Commission. Annex 3

Health and Social Care Cloud Risk Framework

This material is general guidance only. Recipients are responsible for exercising their own professional judgement in any use of the material.

Whilst efforts were taken to ensure that the information contained in this document is both clear and accurate at the time of publication, NHS Digital cannot guarantee that this information will be suitable for the recipient's own hosting and infrastructure requirements, or their procurement/commercial/legal context.

Accordingly, NHS Digital accepts no responsibility for any losses or damages arising from the use of this material.

1 Introduction

The purpose of this document is to present a framework for assessing and managing risk around the use of public cloud technologies in the Health and Social Care sectors in England. This framework is intended to be treated as guidance and is recommended to be used by individual Data Controller organisations as they consider the use of public cloud facilities.

There are a wide variety of potential processing activities that may be successfully undertaken with the use of public cloud services, ranging from the use of public cloud to host reports that are intended for public distribution, to data analytics environments containing anonymised data across a region, to national-scale point- of-care clinical systems processing significant quantities of sensitive personal data to support direct care. The use of public cloud to support these scenarios – and indeed the use of any hosting facilities, public or private – can never be risk-free, and the degree of risk varies across these use cases.

Whilst any risk associated with the use of public cloud facilities remains with the Data Controller, this document provides a risk framework that enables a consistent assessment of those risks. This helps organisations to understand where their use of public cloud facilities aligns with their risk appetite.

This document is in five parts:

• The first part details the scope of this paper. • The second part provides background and context around the need for this guidance. • The third part provides an overview of risk classes that should be considered as part of each organisation’s risk management process. • The fourth part describes three separate dimensions of data use that need to be considered: the type of data being processed, the scale of the data, and its persistency. The overall risk depends on the degree to which each of these dimensions is applicable to any specific proposed use of public cloud facilities. • The fifth part provides a model for assessing and managing risk.

2 Scope

This document is specifically intended to address: • The processing of electronic assets that support information systems, including: o Data relating to individuals’ contact with the health and social care system o Data processed across the health and social care sector (including, but not limited to, activities and processes carried out by NHS Digital itself)

Whilst not the primary target of this document, the risk-management principles are also relevant to: • Board, Commercial, Financial, Contractual, Legal material generated or processed by NHS Digital or other health organisations • Human Resources: personal data relating to members of staff

3 Background and Context

There is appetite across the Health and Social Care system in England to use public cloud computing. These facilities have emerged rapidly in recent years and now provide a cost-effective and agile means of provisioning infrastructure. However, uptake has been restricted, in part due to the lack of guidance on the use of such services, particularly in relation to security.

There is existing cross-government guidance1 around the use of public cloud facilities. Whilst it provides an overall “permission statement” for the use of public cloud, that guidance is not intended to provide specific approval for the health and social care sector, nor give specific guidance on how to safeguard data.

Individual organisations within the Health and Social Care system hold Data Controller responsibilities and are therefore accountable for the systems they use and for the risk-based decisions that they must take. This document provides a framework that is specifically targeted to health and social care organisations to help them assess and manage the risk of using public cloud.

The framework provided in this document describes the kinds of risk that should be considered, the ways in which risk may be affected by different processing proposals and relates these to an individual organisation’s risk appetite. This appetite may, reasonably, vary over time.

The use of this framework is intended:

• To provide more consistency in risk assessment. • To help identify low risk scenarios which are suitable for initial adoption of public cloud. Over time, we would expect to see greater use of public cloud as we accrue demonstrable experience of safe and acceptable use.

1 https://www.gov.uk/guidance/public-sector-use-of-the-public-cloud; https://www.ncsc.gov.uk/guidance/implementing-cloud-security-principles

4 Risk Classes

This section provides a high-level overview of the risks that should be taken into account when the use of public cloud is being considered. Note that these risk classes are not exclusive to public cloud facilities; rather, they are relevant to all methods of data processing. The well-executed use of public cloud facilities may well reduce some classes of risk, compared to traditional on-premise computing environments.

Risk class Description Confidentiality Data may be subject to loss of confidentiality through breach, through unauthorised access, or through unintended or accidental leakage between environments. Integrity Data may be subject to loss of integrity through data loss or unintended manipulation. Availability Ensuring that access to your data is available when required. Network connectivity to cloud becomes a critical dependency and there is a risk of introducing a Single Point Of Failure (SPOF). Public cloud cannot be assumed to be permanently available; cloud availability and SLA must match the need. Impact of breach We cannot assume there can never be any breach, so we need to consider the impact of any unintended breach (unauthorised disclosure into an uncontrolled, or less-well-controlled than intended, environment) Public perception There is some degree of public concern over the use of public cloud given that these are widely available, shared, computing environments. Lock-in Flexibility may be impacted (resulting in increased levels of lock-in) by: • the adoption of a specific public cloud provider’s unique services. • the difficulties involved in migrating large quantities of data may make it difficult, in time and/or cost, to migrate to an alternative in the event of future commercial or service changes. • an architecture that is not sufficiently tailored to a public cloud model. Table 1

5 Dimensions that affect risk

The impact of risk is considered along three dimensions: data type, data scale and data persistence.

5.1 Data Type

The type of data being processed impacts risk. At the extremes: from managing reports intended for public distribution, to maintaining extremely sensitive PKI secrets. To support the range of potential types of health and social care data, we describe a health and social care classification scheme. To take advantage of cross- governmental principles around data classification, we also provide a mapping to the Government Security Classifications policy.

The Government Security Classifications Policy2 came into force in April 2014, providing a policy that describes the classification of information assets into one of three high-level types, and provides a baseline set of security controls for each. It is intended to be used for all information assets across government departments, agencies, public sector delivery partners and the wider supply chain. The three high- level types are: OFFICIAL, SECRET and TOP-SECRET, with OFFICIAL having an additional handling caveat of OFFICIAL-SENSITIVE. Additional descriptors are possible to further classify assets. A few descriptors are provided as core (of which the main relevant to us are COMMERCIAL, PERSONAL), although it is permissible to introduce others, supported by local policies and business processes.

In addition, existing classification schemes are mostly concerned with securing various information assets, whereas we also need to consider the distinction along different axes: for example, how data can and should be shared and the legal bases for its processing. Public perception and potential concern is also heightened in the health sector, which needs to be taken into account when defining the approach to, and controls applied to the handling of health data assets. Statements as to how healthcare information is processed also exist, either as department policy (e.g. DH offshore processing policy), NHS Digital processes and practices (e.g. how Spine 2 is operated), or as part of existing commercial arrangements (both national, such as GPSoC, or local, such as Trusts’ supplier contracts).

The new scheme described in this paper provides a health and social care sector- specific framework upon which an appropriate and proportionate set of security controls can be applied, dependent on the specific needs of different kinds of health and social care data. It is required because existing data classification schemes do

2 https://www.gov.uk/government/publications/government-security-classifications

Copyright ©2018 NHS Digital Page 6 of 16 Health and Social Care Cloud Risk Framework not achieve the level of granularity required to cover the variety of different data types that are processed across the health and care system, and there are specific needs and complexities in the processing of health data.

Note that additional controls can be added to any data-type in order to reduce any associated risks. For example, to address concerns regarding the Confidentiality, and integrity of data, such data may be separately encrypted before transfer to the cloud, using strong cryptography as defined by the current version of NIST SP800- 57 and where the encryption keys are not stored with the cloud provider. In such circumstances the risk profile associated with the data being processed on public cloud is significantly mitigated.

The proposed data classification scheme is illustrated in Table 2 below:

Type Description Example Publicly available information Statistical material that is intended for The number of diabetics public distribution. Identification from in Sheffield, or location these materials, with or without any information for health-care other materials, is not feasible. providers. Synthetic (test) data Synthetic (test) data is fictional data, Fabricated dummy HES engineered to be representative of data set, used for testing real data, that is created in order to purposes, risk assessed avoid the need to use real data when to ensure that there is no developing and testing IT systems. risk of the data Synthetic data must pose zero risk of contributing to the access contributing to the revealing of any to any personal data. personal data. Aggregate data Summarised and anonymised data, Summarised records of but which is not suitable for public activity of a particular distribution, for example due to the hospital. risk that it may be used with other material to contribute to the re- identification of individuals. The risk of such re-identification is not necessarily significant, but does exist (especially in the presence of a sustained and skilled attack). Already encrypted materials Materials that are already encrypted Scanned hospital patient before they touch the cloud, using notes which are encrypted strong cryptography as defined by by an application before the current version of NIST SP800- being uploaded to the 57 and where the encryption keys cloud for archive are not stored with the cloud purposes provider. Personal Data (PID) Information about an identified individual Demographic data Information about the individual A person’s address rather than their clinical details details and NHS Number High Risk demographic data Demographic data where, in the The address details of a event of a breach, there is a high risk person under the care of includes of significant harm the UK Protected Persons

Service3, likely to be reflected in an S-flag applied to their PDS details. Personal confidential data PCD is based on the ICO definition of A person’s medication (PCD) sensitive personal data, extended history within health and social care to include:- • deceased persons • information that is given in confidence and is owed a duty of care, such as: o Social care records / child protection / housing assessments o DNA / finger prints o Bank / financial / credit card details o National Insurance number / Tax, benefit or pension records o Travel details (for example at immigration control, or Oyster records) o Passport number / information on immigration status / travel records o Work record or place of work / School attendance / records Legally-restricted PCD Sensitive personal data that are Details of a person’s subject to additional regulations or previous gender statute, under the • Gender Recognition Act 20044, • Human Fertilisation & Embryology Act 20085 Extra-delicate PCD Sensitive personal data that are Details that a person has sometimes seen to be additionally asked not to be shared delicate, but for which there are no legal restrictions. This determination

includes is often not consistent, but is commonly-held, and is often related to conditions that attract, or are considered to attract, stigma. For example, HIV status, mental health conditions, other conditions contained within the SCR “sensitive code” list. Whilst many patients see information on these kinds of condition to be particularly private

3 http://www.nationalcrimeagency.gov.uk/about-us/what-we-do/specialist-capabilities/uk-protected- persons-service 4 http://www.legislation.gov.uk/ukpga/2004/7/pdfs/ukpga_20040007_en.pdf 5 http://www.legislation.gov.uk/ukpga/2008/22/pdfs/ukpga_20080022_en.pdf

and not to be shared under any circumstances, others see them as important to share, and for any stigmas to be removed. Note that there is no legal distinction between PCD and Extra-delicate PCD. Anonymised data Sensitive personal data that has Extract from a research been subject to de-identification database where all and/or other privacy-enhancing pseudonyms have been techniques, in line with the ICO removed Anonymisation Code of Practice. Risk of re-identification is remote (and would be based on activities that are illegal and/or break contractual arrangements). No way of authorised linking with other datasets. Sensitive personal data that has HES data set been subject to de-identification and/or other privacy-enhancing techniques, in line with the ICO Anonymisation Code of Practice, containing a pseudonym that allows for linking with other data-sets where Pseudonymised data that is permitted through business justification and legal basis. Otherwise, risk of unauthorised re- identification is remote (and would be based on activities that are illegal and/or break contractual arrangements). Reversibly pseudonymised Pseudonymised data where the Data dissemination to data pseudonym is also intended to be support risk stratification used to facilitate re-identification (where individuals may where that is supported by business subsequently be usefully purpose and legal basis. re-identified to support their direct care)

includes Irreversibly pseudonymised Pseudonymised data where re- Data dissemination to data identification is not intended. support a research project that never requires re- identification Patient account data Account credentials (including any A person’s account details recovery materials) for citizen for NHS Choices accounts for patient-facing online health tools Patient choices Statements / preferences made by A person’s expressions of patients regarding the use of their their wishes recorded in data their GP’s clinical system or on the Spine Patient meta-data (identifiable) Information about how identified History of an identified patients have used patient-facing person’s use of NHS online health tools Choices’ symptom information Patient meta-data (linkable) Information about how patients have History of an unknown used patient-facing online health (but linkable) person’s use tools (not identified, but linkable of NHS Choices’ symptom across sessions) information

Professional user account data Account credentials (including any A Clinical Application recovery materials) for professional logon. user (e.g. clinician, health professional, etc) accounts that control access to any personal data (including PCD) Professional account data Account credentials (including any Authentication details to (less-sensitive) recovery materials) for professional portal providing access to user (e.g. clinician, health anonymised data. professional) accounts that control access to anonymised information Audit data Data that records the use of a system Clinical system audit trail and the provenance of the data that system manages Professional user meta-data Information about how users have History of a GP’s use of used clinical or administrative tools their clinical system, or of that process personal data SCR Audit data (personal) Data describing the use of a clinical The audit trail of a GP or administrative system that system showing all users’ processes personal data, where that interactions and use of audit data itself includes or the system

includes references PCD Audit data (non-personal) Data describing the use of a clinical History of logins to a or administrative system, where that clinical system audit data itself does not include or reference PCD Material that provide long-lived Look-up tables or linkage between reversibly- decryption keys Key Materials pseudonymised data and personal data, or provides a similarly significant security function Very short-lived One-time decryption keys A decryption key generated to support (and only usable within) a specific re-identification activity within an individual user session Rotatable Material that provide linkage between An encryption key used reversibly-pseudonymised data and by a DSCRO to re-identify personal data, that persists over time pseudonyms included in

includes and over user sessions but is many data disseminations generally rotatable Long-lived, persistent Material that provide long-lived and A root certificate private persistent linkage between key for a widespread PKI reversibly-pseudonymised data and personal data, or provides a significant security function Table 2

Table 3 below provides an agreed6 mapping between the health data types and the Government Security Classification Policy. This enables us to take advantage of cross-government policy statements and published principles (such as the 14 NCSC

6 Agreed by the Healthcare Cloud Working Group, including NHS Digital, NHS England, DH, GDS.

Cloud security principles7) around that classification, whilst treating those statements as necessary but not necessarily sufficient in a health and social care context.

Type Map to Govt. Security Notes Classification Publicly available information No applicable mapping The most obvious mapping is to something like UNCLASSIFIED but this is no longer part of the model Synthetic (test) data OFFICIAL Aggregate data OFFICIAL Already encrypted materials OFFICIAL Personal Data (PID) OFFICIAL-SENSITIVE Demographic data OFFICIAL-SENSITIVE High Risk demographic data OFFICIAL-SENSITIVE Personal Confidential Data OFFICIAL-SENSITIVE (PCD)

includes Legally-restricted PCD OFFICIAL-SENSITIVE s incl ude Extra-delicate PCD OFFICIAL-SENSITIVE

Anonymised data OFFICIAL-SENSITIVE Pseudonymised data Maximum of variants Reversibly pseudonymised OFFICIAL-SENSITIVE data Irreversibly pseudonymised OFFICIAL-SENSITIVE ncludes

I data Patient account data OFFICIAL-SENSITIVE Patient choices OFFICIAL-SENSITIVE Patient meta-data (identifiable) OFFICIAL-SENSITIVE Patient meta-data (linkable) OFFICIAL-SENSITIVE Professional user account data OFFICIAL-SENSITIVE Professional user account data OFFICIAL-SENSITIVE (less-sensitive) Audit data Maximum of variants Professional user meta-data OFFICIAL-SENSITIVE Audit data (personal) OFFICIAL-SENSITIVE

ncludes Audit data (non-personal) OFFICIAL-SENSITIVE I Key Materials Maximum of variants Very short-lived OFFICIAL-SENSITIVE Rotatable OFFICIAL-SENSITIVE Whilst we need such data to Long-lived, persistent OFFICIAL-SENSITIVE be treated to the highest standards, they do not fit into ncludes

I the government policy criteria for SECRET or TOP-SECRET. Table 3

7 https://www.ncsc.gov.uk/guidance/implementing-cloud-security-principles

Whilst we can (mostly) demonstrate an appropriate mapping from health data type to the Government Security Classification Policy, there are some limitations that emerge:

• Many data types map to OFFICIAL-SENSITIVE, but there are many kinds of data in this category that we will control, and disseminate, in different ways • We cannot, through the Government Security Classification Policy, indicate the very highly sensitive NHS materials such as PKI secrets as needing any greater control than many other kinds of information

5.2 Data Scale

There are two dimensions when considering scale: taking account of the depth (e.g. scope of data for any one individual) and the breadth (e.g. how many individuals are included).

For depth, data should be treated the same whether there is a single data item that causes a particular classification to apply, or whether there are many.

For breadth, the scale8 is:

Scale Description Example scale Extra-Small (XS) Very low volume less than 10,000 records or events Small (S) Local scale, such as an individual between 10,000 and 1m records or Trust events Medium (M) Regional scale, such as county or between 1m and 5m records or events ACO Large (L) National scale over 5m records or events Table 4

This approach recognises the difference in potential harm given the scale of breach; it provides a wider recognition of very large datasets that are commonly processed across the health system (both inside and outside of NHS Digital). However, it is recognised that this banding is still somewhat artificial, requiring a degree of judgement.

8 Note that the scale in question here is the number of patients / events, and how that is analogous to geographic indicators of scale, not the specific geographic spread of a particular data set: for example, a data-set covering 1000 individuals spread across the country represents less risk than a data-set covering 1 million individuals in a specific city.

5.3 Data Persistence

A public cloud facility can be used to process data in many ways, ranging from, at one extreme, processing that requires long-term persistence of data, to the opposite extreme where data may be purely transient (is never persisted). The range of levels that is used in Part 5 is as follows:

Persistency Description Example Persistent Data is deliberately placed into persistent physical Clinical System holding long- storage (for example using databases or file lived patient clinical stores) for long term / indefinite use. information Temporary Data is deliberately placed into persistent physical Dissemination environment storage (for example using databases or file providing access to national stores) for a short-defined period, typically for a pseudonymised data to specific project. support a specific research project Cached Data may be persisted into persistent physical Message queue storage as part of the required processing but it is kept only to support time-bound transactions, rather than long-term Transient Data transits the facility but is never intentionally Web interface capturing data persisted out-of-memory that is immediately transferred outside of public cloud Table 5

Note that transient data is not risk-free: rather, different risks exist depending on the level of data persistence. In general, the level of overall risk reduces between persistent and transient.

6 Risk Framework

Two important aspects to risk management are risk analysis and risk appetite. With those aspects measured, a consistent approach to managing risk can be taken.

6.1 Risk Appetite

Risk appetite may be influenced by a number of factors; for example:

• The degree to which an organisation believes it may be subject to challenge, perhaps as a result of public fears over the ways in which personal data is processed (see Part 3 above) • The degree to which an organisation wishes to “play safe” in its use of public cloud facilities, or alternatively is comfortable in operating at the “cutting edge” • The available budget: a constrained budget will, other factors being equal, drive additional use of elastic public cloud facilities • The degree of risk associated with an organisation’s existing infrastructure services

6.2 Risk analysis and management

This section describes a risk analysis tool that is based upon the three dimensions described in Part 4 above, to aid in a consistent approach to the assessment of risk in the use of public cloud facilities.

Note: • This is not intended to be an overly prescriptive model; rather it is to inform an organisation’s assessment and promote consistency within an individual organisation and across organisations • It is assumed that the controls in place by any selected public cloud facility satisfy the NCSC Cloud Security principles9 and that therefore such use is “well-executed” as described in recent guidance from GDS10 • When assessing processing scenarios, consider the most sensitive aspect where there is more than one involved

The Risk Framework tool is available separately. An initial impact score is assigned to each data type. That score is then scaled separately by the scaling factors assigned to each measure of scale and persistence, resulting in a “Risk Impact Score” value.

9 https://www.ncsc.gov.uk/guidance/implementing-cloud-security-principles 10 https://www.gov.uk/guidance/public-sector-use-of-the-public-cloud

The tool maps the generated Risk Impact Score to one of five “Risk Profile Levels”. This provides an overall view that reflects the “degree of risk or contentiousness” of the described use of public cloud.

In general, all potential uses – and risks – should be weighed against the benefits of public cloud facilities (for example in terms of cost, time-to-launch, flexibility, etc). The Risk Appetite Level may also be subsequently affected by a privacy-enhancing technique, or additional controls, that are added to a processing environment (at either an infrastructure or application layer, or both).

Following those steps, the table below provides an overview of the impact of the resulting level in terms of governance. This takes into account the degree to which, at present, there is relatively little use of high-profile public cloud take-up across health and care, but with the expectation that, over time, we would expect to modify these expectations given greater experience.

Risk Profile Level Governance Expectation Class I All organisations are expected to be comfortable operating services at this level. Class II Whilst there may be some concerns over public perception and lock-in, most organisations are expected to be comfortable operating services at this level. Class III At this level, risks associated with impact of breach become more significant, and the use of services at this level therefore requires specific risk management across all risk classes described in Section 4, requiring approval by CIO / Caldicott Guardian level. Class IV At this level, it is likely to become more difficult to justify that the benefits of the use of public cloud outweigh the risks. However, this case may still be made, requiring approval by CIO / Caldicott Guardian, and would be required to be made visible to the organisation’s Board. Specific advice and guidance may be provided by NHS Digital on request. Class V Operating services at this level would require board-level organisational commitment, following specific advice and guidance from NHS Digital. Table 6

In addition, the Risk Profile Level drives the level of controls that are required to be implemented by the public cloud provider. The description of these controls is provided separately.

7 Document Control 7.1 Copyright

This material is copyright protected by Health and Social Care Information Centre (known as NHS Digital) unless otherwise indicated. Material may be reproduced free of charge in any format or medium for research, private study or for internal circulation within an organisation. This is subject to the material being reproduced accurately and not used in a misleading context. Where any of the material is being republished or copied to others, the source of the material must be identified and the copyright status acknowledged.

7.2 Related References, Links and Documents

These documents will provide additional information:-

NHS and social care use of public cloud services Health and Social Care Cloud Security Good Practice Guide Health and Social Care Data Risk Model

Health and Social Care Cloud Security – Good Practice Guide

This material is for general guidance only. Recipients are responsible for exercising their own professional judgement in using the material.

Accordingly, NHS Digital accepts no responsibility for any losses or damages arising from the use of this material.

1 Introduction

The UK Government introduced a ‘cloud first’ policy for public sector IT in 2013. The use of cloud services was also endorsed in the National Information Board’s Personalised Health and Care 2020 framework, published in November 2014.

A paper jointly published by the Department of Health and Social Care, NHS England, NHS Digital and NHS Improvement on 19 January 2018 states that NHS and social care organisations can safely locate health and care data, including confidential patient information, in the public cloud including solutions that make use of data off-shoring. The paper provides advice and guidance regarding the safeguards that should be put in place to do so.

NHS Digital have built upon this advice and guidance to develop more detailed materials to enable a systematic approach to evaluate risk and applying proportionate controls. This document explains the process and provides details on what proportionate controls should be put in place.

2 Overview of the Method

This Good Practice Guideline (GPG) is a four-step process. It should be used at the start of any digital project to understand the risk of the data that needs to be stored and processed and the safeguards that must be put in place to do so. The steps are as follows:-

• Step 1 - Understand the data you are dealing with • Step 2 – Assess the risks associated with the data • Step 3 – Implement appropriate controls • Step 4 – Monitor the implementation and ongoing risks

3 Step 1 - Understand

The first step is to understand the data that you are dealing with.

1. List all the data fields/attributes that will be stored or processed by the system. 2. Quantify how much data is under consideration. 3. Consider how long the data will be held in the system.

Health and Social Care Cloud Security – Good Practice Guide

4. Understand the Service Classification1 of the system (Bronze | Silver | Gold | Platinum). This relates to the availability SLAs and will be used to determine the cloud security approach for availability and integrity. The service classification is normally agreed between the owning Programme and Service management. 5. Carefully assess the data fields/attributes and decide which Data Type(s)2 this relates to. 6. Armed with this information, use the NHS Digital Data Risk Model to calculate the risk classification of the data. 7. Ensure that you document the outputs of the above, specifically:- a. Retain the list of data types/attributes. b. Record the rationale for selecting the data type(s). c. Retain the completed risk model.

The Health and Social Care Cloud Risk Framework document lists the different Data Types, scale and persistency along with descriptions and examples. This will help you with steps 1 to 5 above.

The NHS Digital Data Risk Profile Tool calculates a score based on the type of data, the amount of data and for how long the data is held. This score is then translated into a Risk Classification and will be used in the next steps of the process. The risk classification is used to help you understand:-

• the risk profile and the associated governance that we would expect you to undertake. • the controls that are needed to be put in place to mitigate the risk.

4 Step 2 - Assess

This step is about assessing the risk and identifying governance requirements for putting the data in the cloud. At the end of this step, you should have decided as to whether you want to use public cloud to host your system.

4.1 Risk Appetite

Different organisation and programmes will have different appetites towards risk and this appetite may vary over time.

1 Refer to appendix B. 2 Refer to the document: Health and Social Care Cloud Risk Framework for details of data types.

Health and Social Care Cloud Security – Good Practice Guide

• Class I defines the lowest level of risk. • Class V defines the highest level of risk.

However, proportionate controls are available to help mitigate these risks, regardless of whether the risk is classified as Class I or Class V. These are detailed in Step 3. Understand your organisation’s risk appetite, implement controls and monitor their effectiveness as part of your ongoing governance process.

4.2 Governance

Using the Risk Classification obtained in step 1, refer to the table below to understand the governance expectation.

Risk Profile Level Expectation

Class I All organisations are expected to be comfortable operating services at this level.

Class II Whilst there may be some concerns over public perception and lock-in, most organisations are expected to be comfortable operating services at this level.

Class III At this level, risks associated with impact of breach become more significant, and the use of services at this level therefore requires specific risk management across all risk classes described in Part 3, requiring approval by CIO / Caldicott Guardian level.

Class IV At this level, it may become more difficult to justify that the benefits of the using public cloud outweigh the risks. However, a case may still be made, requiring approval by CIO / Caldicott Guardian, and be made visible to the organisation’s Board. Specialist advice and guidance should be sought.

Class V Operating services at this level would require board-level organisational commitment, following specialist advice and guidance.

4.3 Other Considerations

Security is not the only aspect that you should consider when moving to cloud. Other elements to think about include:-

Health and Social Care Cloud Security – Good Practice Guide

4.3.1 Public Perception

There is some degree of public concern over the use of computing environments that are well-known to be publicly-consumable and used for a wide variety of small and large scale uses. There may be a lack of trust as to the effectiveness of the people, technical and process controls that are intended to reduce the risks of confidentiality and breach to manageable levels. You must be comfortable with any challenge that comes from the public and the media. And if there is a security incident, then the question will be raised as to why public cloud was used.

4.3.2 Lock-in and migration

If you build your infrastructure using standard and widely available components such as virtual machines (VMs) and storage it will ease any migration to another provider. However, vendor specific components are attractive as they may provide lower cost options and facilitate faster delivery. Be conscious of any trade- off. Consider the impact of the necessity of migrating potentially large quantities of data to launch a service, and the potential future impact of increased data scale if ever you wished to, or needed to, migrate to an alternative.

4.3.3 Data Repatriation

Consider how any data within the system can be retrieved and returned to you when the contract for cloud services expires. Discuss with your intended provider how you wish your data to be transferred back into your custody. Ensure such facilities and associated timescales are agreed and included within the contract. You should also seek assurances from your cloud provider that any copies of your data will be deleted, overwritten or otherwise rendered inaccessible.

4.3.4 Existing situation

When considering moving systems into public cloud, it is worth considering the “As- Is” hosting solution. If you have an existing high risk but low security solution, then the perceived risks of moving into a public cloud may be mitigated.

4.3.5 Complex Systems

Systems may host a variety of different data types, which hold different risk profiles. It may be appropriate to consider hosting some subsystems on public cloud whilst hosting other subsystems elsewhere.

Health and Social Care Cloud Security – Good Practice Guide

4.3.6 Data residency and sovereignty

Some cloud providers may store or process data offshore, which may improve resilience and reduce costs. Processing data in cloud services is legally complex, regardless of where the data is being processed. Data must only be hosted within the European Economic Area (EEA), a country deemed adequate by the European Commission, or in the US where covered by Privacy Shield. Further guidance is available from the Information Commissioner’s Office.

4.3.7 Fair Processing

Regardless of the where services are hosted, all organisations processing personal data must do so fairly and lawfully. This is set out in the first data protection principle of the Data Protection Act 1998. Fair processing includes providing details of:

• your identity and, if you are not based in the UK, the identity of your nominated UK representative; • the purpose or purposes for which you intend to process the information; and • any extra information you need to give individuals in the circumstances to enable you to process the information fairly.

4.4 Documentation

It is important that a complete set of documentation is kept for audit purposes to prove that appropriate due diligence has been taken with regards to where and how data is hosted. Therefore, document:-

1. The governance decision to use the cloud (e.g. meeting minutes). 2. Responses to all other considerations listed above.

4.5 Contracts

All Cloud contracts need to be robust and clearly compliant with UK law. It is essential that you have documentation that details what duties and obligations have been agreed.

5 Step 3 - Implement

Having decided that you wish to utilise public cloud to host your system, you need to:-

• select a cloud provider that meets the required security standards, and

Health and Social Care Cloud Security – Good Practice Guide

• apply the security controls that are under your responsibility.

Using public cloud necessitates a joint responsibility to security. The cloud provider must ensure that their service is appropriately secure, and you must have confidence in it. Similarly, the users have a responsibility to ensure how they implement the solution is appropriately secure. This is often referred to as the joint responsibility model.

Appendix A lists the minimum standards the cloud provider must meet and how you should implement the solution. These are structured around the National Cyber Security Centre’s (NCSC) 14 Cloud Security Principles. Against each principle is the recommended approach and specific guidance, dependant on the risk classification3.

5.1 Select a cloud provider

Choose a cloud provider that meets the minimum security standards as specified in the table. Each of the 14 principles will have a section entitled “The cloud provider should:-” This lists a set of minimum standards. However, you only need to adopt the standard that corresponds to your risk score. For example, if your risk score is

3 Principle 2.6 - Physical resilience and availability uses the service category (B)ronze, S(ilver), G(old) and (P)latinum, rather than Cat I to V, to determine which minimum standards / controls that need to be in place.

Health and Social Care Cloud Security – Good Practice Guide

Class II, then in the above example the Cloud provider only needs to meet requirement 1. However, if your risk score is Class IV then they need to meet requirements 1 and 2.

You can buy cloud services through the G-Cloud Framework on the Digital Marketplace. Cloud services are listed on the Digital Marketplace alongside information and evidence submitted by vendors on how they perform against the National Cyber Security Centre’s Cloud Security Principles. You may need to request further information from the supplier to be confident that they meet the recommended standards.

5.2 Apply security controls

Similarly, you must implement controls in-line with the recommendations in the table. Each of the 14 principles will have a section entitled “The service user should:-” This lists a set of minimum implementation standards. However, you only need to adopt the standard that corresponds to your risk score. For example, if your risk score is Class II, then in the above example you have no controls to apply. However, if your risk score is Class IV then you need to meet requirements 1 and 2.

5.3 Documentation

1. Evidence that the supplier meets the standard. 2. Evidence that you have implemented the controls. 3. Cloud contract(s), showing that they are clearly compliant with UK law and what duties and obligations have been agreed.

6 Step 4 - Monitor

Like any other system, once implemented you cannot forget about security and risk. It needs to be proactively monitored and managed.

6.1 Manage known risk

If there are any residual risks, then these need to be document and pro-actively managed.

Health and Social Care Cloud Security – Good Practice Guide

6.2 Monitor cloud service

Cloud services offered by providers are most likely to continually evolve. You need to make sure that your vendor keeps you informed of any changes that may affect, in a detrimental way, the security of your system and data.

Similarly, your vendor should supply updated proof of certifications and assessments on a regular basis.

6.3 Monitor controls

The service user is responsible for implementing and maintaining certain security controls. These should be reviewed / audited on a regular basis.

Health and Social Care Cloud Security – Good Practice Guide

7 Document Control

7.1 Copyright

7.2 Related References, Links and Documents

These documents will provide additional information:-

NHS and social care data: off-shoring and the use of public cloud services Health and Social Care Cloud Risk Framework Health and Social Care Data Risk Model

Health and Social Care Cloud Security – Good Practice Guide

8 Appendix A - Detailed Advice and Guidance

The table below is based on the National Cyber Security Centre’s (NCSC) advice for Implementing the Cloud Security Principles. These principles have been examined within the context of health and social care and a recommended implementation approach has been specified. Further, guidance has also been listed against each principle, detailing what the Cloud Provider should do/provide. It also lists what the Cloud Service User should do to safeguard data.

This guidance assumes an Infrastructure as a Service (IaaS) model is being utilised and the split of responsibilities between the Cloud Provider and Cloud Service User reflects this. When a SaaS model is utilised then the split would need to be adjusted with the SaaS provider taking more of the responsibilities.

For clarity, the “Cloud Provider” is the organisation that is providing the cloud service. The “Service User” refers to the customer-side architect / developer / programmer / IT Pro / etc that is developing and maintaining the system in the public cloud.

The specific guidance is only applicable if there is a “Y” in the category field that matches the data risk category as defined by the risk tool. Section 2.6 - Physical resilience and availability – is an exception. The “Y” relates to the Service Classification4, being either Bronze, Silver, Gold or Platinum.

4 Refer to appendix B for an explanation of Service Categories.

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Ref Security Principle NHS Recommended Approach NHS Guidance Class Class Class I/II III IV/V

1. Data in transit protection TLS (Version 1.2 or above) The Cloud Provider should:-

User data transiting OR 1. Utilise strong cryptography as defined by NIST SP800-57 to encrypt networks should be communications: adequately protected IPsec or TLS VPN gateway a. Internally between Cloud Components. Y Y Y against tampering and b. Between Cloud Data Centres. eavesdropping. c. Between the Cloud admin portal and the Cloud.

2. Undertake annual assessment against a recognised standard such as ISO to test the security of the communication: a. Internally between Cloud Components. b. Between Cloud Data Centres. Y Y c. Between the Cloud admin portal and the Cloud.

Ensure that the assessment is conducted by a suitably qualified provider such as those certified under the CREST scheme.

The Service User should:-

1. Utilise strong cryptography as defined by NIST SP800-57 to encrypt Y Y communications between the Cloud and the End-user.

2. Undertake regular (minimum yearly) penetration testing of the communication between the Cloud and the End-user

Ensure that the Penetration test is well scoped such that ‘Data in Y Y transit protection’ is fully tested.

Ensure that the test is conducted by a suitably qualified provider such as those certified under the CREST scheme.

Ref Security Principle NHS Recommended Approach NHS Guidance Class Class Class I/II III IV/V

Health and Social Care Cloud Security – Good Practice Guide

2. Asset protection and resilience

User data, and the assets storing or processing it, should be protected against physical tampering, loss, damage or seizure.

2.1 Physical location and legal Known locations for storage, The Cloud Provider must:- jurisdiction processing and management 1. Provide cloud infrastructure (which includes all hardware, software, Y Y Y In order to understand the networks and the physical data centres that house it all) within the legal circumstances under UK, European Economic Area (EEA), a country deemed adequate by which your data could be the European Commission, or in the US where covered by Privacy accessed without your Shield. consent you must identify the locations at which it is 2. Provide independent validation that the data centres are actually Y Y Y stored, processed and physically located within the UK, European Economic Area (EEA), a managed. country deemed adequate by the European Commission, or in the US

where covered by Privacy Shield. You will also need to understand how data- 3. State the legal jurisdiction(s) to which your data is subject to. handling controls within Y Y Y the service are enforced, relative to UK legislation. The Service User should:- 1. Only use Cloud Infrastructures to store and process data that are physically located within the UK, European Economic Area (EEA), a Y Y Y country deemed adequate by the European Commission, or in the US where covered by Privacy Shield.

2. Review the Cloud Provider’s T&Cs to ensure they are compliant with the Data Protection Act (DPA) and the General Data Protection Y Y Y Regulation (GDPR).

Health and Social Care Cloud Security – Good Practice Guide

2.2 Data centre security Conforms to a recognised The Cloud Provider should:- standard Locations used to provide 1. Hold and maintain certification to ISO 27001. Y Y Y cloud services need physical protection against Prove that the scope of certification includes the physical security of unauthorised access, the data centres. tampering, theft or reconfiguration of systems. Demonstrate that certification was performed by a suitably qualified Inadequate protections expert party such as those certified under the CREST scheme. may result in the disclosure, alteration or loss of data.

2.3 Data at rest protection Encryption of all physical media The Cloud Provider should:-

To ensure data is not 1. Provide encryption facilities to ensure that no data is written to Y Y Y available to unauthorised storage in an unencrypted form. parties with physical access 2. Provide secure key management service providing strong Y Y Y to infrastructure, user data cryptography as defined by the current version of NIST and FIPS held within the service standards. e.g. NIST SP800-57 Part 1’. should be protected

regardless of the storage The service must provide detailed audit reporting on access of the media on which it’s held. keys. Without appropriate measures in place, data 3. Confirm that the encryption utilises strong cryptography as defined by Y Y Y may be inadvertently the current version of NIST SP800-57. disclosed on discarded, lost or stolen media. 4. Undertake annual assessment against a recognised standard such as Y Y ISO or FIPS 140-2 to test the encryption.

Ensure that the test is conducted by a suitably qualified provider such as those certified under the CREST scheme.

The Service User should:-

Health and Social Care Cloud Security – Good Practice Guide

1. Ensure that the encryption is appropriately configured when you Y Y Y implement the system on your chosen cloud provider.

2. Ensure keys are managed by the data controller. Keys can be stored Y Y Y either locally or in an HSM service provided by the cloud supplier. The key management solution should utilise strong cryptography as defined by the current version of NIST and FIPS standards. e.g. NIST SP800-57 Part 1

2.4 Data sanitisation Explicit overwriting of storage The Cloud Provider should:- before reallocation The process of provisioning, 1. Provide assertions regarding their data sanitisation approach. Y Y Y migrating and de- provisioning resources 2. Show that the specified data sanitation approach has been validated Y Y should not result in by a suitably qualified independent third party. unauthorised access to user data.

2.5 Equipment disposal A recognised standard for The Cloud Provider should:- equipment disposal is followed Once equipment used to 1. Hold certification to CSA CCM v3.0 OR ISO/IEC 27001. Y Y

deliver a service reaches OR the end of its useful life, it Prove that the scope of certification validates the secure equipment

should be disposed of in a disposal. way which does not compromise the security of Demonstrate that certification was performed by a suitably qualified the service, or user data expert party such as those certified under the CREST or CSA STAR stored in the service. scheme.

A third-party destruction service The Cloud Provider should:- is used 1. Ensure the security of the equipment and prove the chain of custody Y Y until the equipment is successfully destroyed.

2. Demonstrate that the third-party services have been Y Y assessed against a recognised standard, such as the CESG Assured Service (Destruction) scheme.

Health and Social Care Cloud Security – Good Practice Guide

Prove that the scope of the assessment validates the secure equipment disposal and chain of custody.

Demonstrate that the assessment was performed by a suitably qualified expert party such as those certified under the CREST scheme.

Health and Social Care Cloud Security – Good Practice Guide

2.6 Physical resilience and The service provider commits to a Service Classification (See appendix A): B S G/P availability Service Level Agreement (SLA) The Cloud Provider should:- Services have varying levels AND 1. Provide a contractual commitment to SLAs, with remedies available Y Y Y of resilience, which will should the SLA be missed. affect their ability to Analysis of the design operate normally in the 2. Prove that the data centres are certified to Uptime Institute Tier 2 or Y event of failures, incidents equivalent qualified provider such as those certified under the CREST or attacks. A service scheme. without guarantees of availability may become 3. Prove that the data centres are certified to Uptime Institute Tier 3 or Y Y unavailable, potentially for equivalent qualified provider such as those certified under the CREST prolonged periods, scheme. regardless of the impact on your business. 4. Provide two or more “availability zones” / Data Centres in-line with Y Y the requirements in 2.1.

The Service User should:-

1. Design for failure. Solutions should be architected for cloud such that Y Y Y they are resilient regardless of the underlying cloud infrastructure.

2. Use at least one availability zone / Data Centre. Y

3. Have resilient network links to the zone / Data Centre. Y

4. Use multiple availability zones / Data Centres. Y

5. Have resilient network links to each zone / Data Centres. Y

6. Use different cloud vendors or multiple regions from the same Y vendor.

7. Have resilient network links to each region / vendor. Y

Health and Social Care Cloud Security – Good Practice Guide

8. Ensure their system has DDoS protection. This may be provided by Y the Cloud vendor or a third party.

Ref Security Principle NHS Recommended Approach NHS Guidance Class Class Class I/II III IV/V

3. Separation between users Virtualisation technologies (e.g. The Cloud Provider should:- a hypervisor) provide separation A malicious or between users 1. Provide Supplier Assertions regarding their approach to Y Y Y compromised user of the user/customer environment separation. service should not be able OR 2. Undertake annual assessment against a recognised standard such as Y Y to affect the service or data ISO, CyberEssentials to test the ‘separation between users/ customer of another. Other software provides environment’. separation between users

Ensure that the test is conducted by a suitably qualified provider such as those certified under the CREST scheme.

3. Hold and maintain certification to ISO27017 for the Cloud Platform. Y Y

Demonstrate that certification was performed by a suitably qualified expert party such as those certified under the CREST scheme.

The Service User should:-

1. Undertake end-to-end Penetration testing of the solution. Y Y

2. Implement a GPG13 compliant Protective Monitoring solution. Y

Ref Security Principle NHS Recommended Approach NHS Guidance Class Class Class I/II III IV/V

4. Governance framework Conformance with a recognised The Cloud Provider should:- standard The service provider should 1. Hold and maintain certification to CSA’s STAR programme OR ISO/IEC Y Y have a security governance 27001. framework which Demonstrate that certification was performed by a suitably qualified

Health and Social Care Cloud Security – Good Practice Guide

coordinates and directs its expert party such as those certified under the CREST scheme. management of the service and information within it. 2. Prove that the scope of certification includes the governance Y Any technical controls framework goals set out below: deployed outside of this a. A clearly identified, and named, board representative (or a framework will be person with the direct delegated authority) who is fundamentally responsible for the security of the cloud service. This is undermined. typically someone with the title ‘Chief Security Officer’, ‘Chief Information Officer’ or ‘Chief Technical Officer’. b. A documented framework for security governance, with policies governing key aspects of information security relevant to the service. c. Security and information security are part of the service provider’s financial and operational risk reporting mechanisms, ensuring that the board would be kept informed of security and information risk. d. Processes to identify and ensure compliance with applicable legal and regulatory requirements.

Ref Security Principle NHS Recommended Approach NHS Guidance Class Class Class I/II III IV/V

5. Operational security

The service needs to be operated and managed securely in order to impede, detect or prevent attacks. Good operational security should not require complex, bureaucratic, time consuming or expensive processes.

5.1 Configuration and change Conformance with a recognised The Cloud Provider should:-

Health and Social Care Cloud Security – Good Practice Guide

management standard 1. Hold and maintain certification to CSA CCM v3.0 OR ISO/IEC 27001. Y Y

You should ensure that Prove that the scope of certification includes configuration and changes to the system have change management processes. been properly tested and authorised. Changes should Demonstrate that certification was performed by a suitably qualified not unexpectedly alter expert party such as those certified under the CREST or CSA STAR security properties scheme.

The Service User should:-

1. Maintain an accurate inventory of the assets which make up the Y Y Y service, along with their configurations and dependencies.

2. Ensure changes to the service are assessed for potential security Y Y Y impact, and the implementation of changes are managed and tracked through to completion.

5.2 Vulnerability management Conformance with a recognised The Cloud Provider should:- standard You should identify and 1. Hold and maintain certification to CSA CCM v3.0 OR ISO/IEC 27001, Y Y Y mitigate security issues in ISO/IEC 27017. constituent components Demonstrate that certification was performed by a suitably qualified expert party such as those certified under the CREST or CSA STAR scheme.

2. Manage vulnerabilities in a manner that aligns with ISO 30111 and Y Y Y show ISO / CSA compliance to validate the process.

3. Prove that mitigations for discovered vulnerabilities are implemented Y Y Y for the server-less devices, hypervisors and supporting infrastructure, within the NCSC best practice timescales set out below:- a. ‘Critical’ vulnerabilities should be mitigated within 24 hours b. ‘Important’ vulnerabilities should be mitigated within 2 weeks.

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c. ‘Other’ vulnerabilities mitigated within 8 weeks. If compensating controls are in place to reduce the vulnerability risk, the timescales can be adjusted accordingly.

The Service User should:-

1. Undertake patching or vulnerability management for the guest Y Y Y operating system and application components, within the NCSC best practice timescales set out below:- a. ‘Critical’ patches should be deployed within 24 hours b. ‘Important’ patches should be deployed within 2 weeks of a patch becoming available c. ‘Other’ patches deployed within 8 weeks of a patch becoming available

Undertake regular (min yearly) penetration testing. Y Y

Ensure that the Penetration test is well scoped such that ‘security vulnerabilities in the Operating system and components above’ are fully tested.

Ensure that the test is conducted by a suitably qualified provider such as those certified under the CREST scheme.

5.3 Protective monitoring Conformance with a recognised The Cloud Provider should:- standard You should put measures in 1. Hold and maintain certification to CSA CCM v3.0 OR ISO/IEC 27001 Y Y place to detect attacks and and ISO/IEC 27017 unauthorised activity on the service Prove that the scope of certification includes protective monitoring controls showing that:- a. The service generates adequate audit events to support effective identification of suspicious activity b. These events are promptly analysed to identify potential compromises or inappropriate use of your service c. The service provider takes prompt and appropriate action to

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address incidents

Demonstrate that certification was performed by a suitably qualified expert party such as those certified under the CREST or CSA STAR scheme.

The Service User should:-

1. Put in place appropriate monitoring solutions to identify attacks Y Y against their applications or software.

5.4 Incident management The Cloud Provider should:-

Ensure you can respond to 1. Hold and maintain certification to CSA CCM v3.0 OR ISO/IEC 27001. Y Y Y incidents and recover a secure, available service Prove that the scope of certification includes incident management controls in detail showing that:- a. Incident management processes are in place for the service and are actively deployed in response to security incidents b. Pre-defined processes are in place for responding to common types of incident and attack c. A defined process and contact route exists for reporting of security incidents by consumers and external entities d. Security incidents of relevance to the Service User will be reported in acceptable timescales and formats

Demonstrate that certification was performed by a suitably qualified expert party such as those certified under the CREST or CSA STAR scheme.

2. Demonstrate robust, well tested and rehearsed incident management Y Y Y procedures.

The Service User should:-

1. Put in place monitoring solutions to identify attacks against their Y Y applications or software.

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2. Have an incident management process to rapidly respond to attacks. Y Y

Ref Security Principle NHS Recommended Approach NHS Guidance Class Class Class I/II III IV/V

6. Personnel security Personnel screening performed The Cloud Provider should:- but does not conforms with Where service provider BS7858:2012 1. Operate a personnel screening process that aligns with BS7858:2012 Y Y personnel have access to and show ISO / CSA compliance to validate the process. your data and systems you need a high degree of Demonstrate that the assessment was performed by a suitably confidence in their qualified expert party such as those certified under the CREST or CSA trustworthiness. Thorough STAR scheme. screening, supported by The Service User should:- adequate training, reduces the likelihood of accidental 1. Ensure IT admin staff are strongly authenticated. Y Y or malicious compromise by service provider personnel. 2. Have a suitable auditing solution is in place to record all IT admin Y Y access to data and hosting environments.

Ref Security Principle NHS Recommended Approach NHS Guidance Class Class Class I/II III IV/V

7. Secure development Independent review of The Cloud Provider should:- engineering approach against Services should be designed recognised secure development 1. Hold and maintain certification to: Y Y and developed to identify standard a) CESG CPA Build Standard, OR and mitigate threats to b) ISO/IEC 27034, OR their security. Those which c) ISO/IEC 27001, OR aren’t may be vulnerable to d) CSA CCM v3.0. security issues which could compromise your data, Demonstrate that certification was performed by a suitably qualified cause loss of service or expert party such as those certified under the CREST or CSA STAR enable other malicious scheme. activity.

Health and Social Care Cloud Security – Good Practice Guide

Ref Security Principle NHS Recommended Approach NHS Guidance Class Class Class I/II III IV/V

8. Supply chain security Assessed through application of The Cloud Provider should:- appropriate standard The service provider should 1. Hold and maintain certification to: Y Y ensure that its supply chain a) ISO/IEC 27001, or satisfactorily supports all of b) ISO/PAS 28000:2007 the security principles Demonstrate that certification was performed by a suitably qualified which the service claims to expert party such as those certified under the CREST scheme. implement. 2. Prove that the scope of certification includes supply chain security Y showing:- a) How your information is shared with, or accessible to, third party suppliers and their supply chains. b) How the service provider’s procurement processes place security requirements on third party suppliers. c) How the service provider manages security risks from third party suppliers. d) How the service provider manages the conformance of their suppliers with security requirements. e) How the service provider verifies that hardware and software used in the service is genuine and has not been tampered with.

Ref Security Principle NHS Recommended Approach NHS Guidance Class Class Class I/II III IV/V

9. Secure user management

Your provider should make the tools available for you to securely manage your use of their service. Management interfaces and procedures are a vital

Health and Social Care Cloud Security – Good Practice Guide

part of the security barrier, preventing unauthorised access and alteration of your resources, applications and data.

9.1 Authentication of [admin] Strong authentication in place, The Cloud Provider should:- users to management which is subject to regular interfaces and support exercising 1. Provide Supplier Assertions regarding their approach to strong Y Y Y channels authentication.

2. List all the channels by which the service provider would accept Y Y Y In order to maintain a management or support requests from you (telephone phone, web secure service, [admin] portal, email etc.). users need to be properly authenticated before being 3. Undertake annual assessment against a recognised standard such as Y Y allowed to perform ISO, CyberEssentials to test the ‘Authentication of users to management activities, management interfaces and support channels’. report faults or request changes to the service. Ensure that the test is conducted by a suitably qualified provider such as those certified under the CREST scheme.

The Service User should:-

1. Ensure that a list of authorised individuals from your organisation Y Y Y who can use those mechanisms is maintained and regularly reviewed.

2. Use 2FA to obtain access to the system. Y Y

3. Configure logging of access attempts. Y Y

4. Regularly review the access attempts to identify unusual behaviour Y Y

9.2 Separation and access Access control implemented in The Cloud Provider should:- control within software, subject to regular management interfaces testing 1. Provide Supplier Assertions regarding how management interfaces Y Y Y

Health and Social Care Cloud Security – Good Practice Guide

are protected and what functionality they expose. Many cloud services are managed via web 2. Undertake annual assessment against a recognised standard such as Y Y applications or APIs. These ISO, CyberEssentials to test the ‘Access Control to management interfaces are a key part of Interfaces’. the service’s security. If [admin] users are not Ensure that the test is conducted by a suitably qualified provider such adequately separated as those certified under the CREST scheme. within management interfaces, one [admin] The Service User should:- user may be able to affect the service, or modify the 1. Ensure that authorised individuals from your organisation who can Y Y Y data of another. use those mechanisms are managed by the ‘principle of least privilege’, typically using a RBAC mechanism.

Ref Security Principle NHS Recommended Approach NHS Guidance Class Class Class I/II III IV/V

10. [End User] Two factor authentication The Cloud Provider should:- Identity and authentication OR 1. Allow users to authenticate with a username and either a Y Y hardware/software token, or ‘out of band’ challenge (e.g. SMS) All access to service interfaces should be 2. Provide details of the authentication scheme. Y Y constrained to 3. Undertake annual assessment against a recognised standard such as Y Y authenticated and ISO, CyberEssentials to test the ‘2FA’. authorised [end user]

individuals. Ensure that the test is conducted by a suitably qualified provider such as those certified under the CREST scheme.

TLS client certificate The Cloud Provider should:-

OR 1. Show that they use TLS 1.2 or above with an X.509v3 client certificate Y Y that identifies an individual user.

Health and Social Care Cloud Security – Good Practice Guide

2. Undertake annual assessment against a recognised standard such as Y Y ISO, CyberEssentials to test the ‘TLS 1.2+ using an X.509v3 client certificate’

Ensure that the test is conducted by a suitably qualified provider such as those certified under the CREST scheme.

The Service User should:-

1. Ensure the secure creation and management of certificates. Y Y

2. Ensure there are safeguards in place on end user devices to protect Y Y them.

3. Implement processes to revoke lost or compromised credentials. Y Y

Identity federation with your The Cloud Provider should:- existing identity provider 1. Provide support for federating to another authentication scheme, Y Y such as a corporate directory, an OAuth or SAML provider.

2. Provide details of the authentication scheme. Y Y

3. Undertake annual assessment against a recognised standard such as Y Y ISO, CyberEssentials to test the ‘identity federation’.

Ensure that the test is conducted by a suitably qualified provider such as those certified under the CREST scheme.

The Service User should:-

1. Only use this approach if their existing identity provider uses two- Y Y factor authentication.

Ref Security Principle NHS Recommended Approach NHS Guidance Class Class Class I/II III IV/V

Health and Social Care Cloud Security – Good Practice Guide

11. External interface Internet The Cloud Provider should:- protection AND/OR 1. Implement a Protective Monitoring solution. Y Y All access to service interfaces should be Community network 2. Undertake annual assessment against a recognised standard such as Y Y constrained to ISO, CyberEssentials to test the ‘external interface protection‘. authenticated and AND/OR

authorised individuals. Ensure that the test is conducted by a suitably qualified provider such Private network as those certified under the CREST scheme.

The Service User should:-

1. Ensure their system has Web Application Firewall (WAFs) protection. Y Y This may be provided by the Cloud vendor or a third party.

2. Ensure that the implemented design protects data by ensuring it is at Y Y least two ‘firewall’ hops from the external network, architected in such a way that the compromise of one firewall will not affect the other.

3. Correctly implement firewall rulesets using the "Deny All" First and Y Y Y then Add Exceptions principle.

Ref Security Principle NHS Recommended Approach NHS Guidance Class Class Class I/II III IV/V

12. Secure service Known service management The Cloud Provider should:- administration architecture 1. Provide Supplier Assertions regarding their service management Y Y Y Systems used for architecture. administration of a cloud 2. Ensure access is only available over a secure channel. Y Y Y service will have highly privileged access to that 3. Limit management actions to authorised staff. Y Y Y service. Their compromise would have significant 4. Audit all management actions. Y Y Y

Health and Social Care Cloud Security – Good Practice Guide

impact, including the 5. Regularly (daily) review the logs to identify any irregular activities. Y Y means to bypass security controls and steal or 6. Have separate user accounts for administration and normal user Y Y Y manipulate large volumes activities. They should not user their administration accounts for of data. normal business activities.

7. Not be able to browse the internet or open their external email in the Y Y Y The methods used by the same processing context as they manage systems. service provider’s administrators to manage 8. Protect the integrity of the end user devices used to manage the Y Y Y the operational service service. should be designed to mitigate any risk of 9. Undertake annual assessment against a recognised standard such as Y Y exploitation that could ISO, CyberEssentials to test the ‘secure service administration’. undermine the security of the service. If this principle Ensure that the test is conducted by a suitably qualified provider such is not implemented, an as those certified under the CREST scheme. attacker may have the means to bypass security controls and steal or manipulate large volumes of data.

Ref Security Principle NHS Recommended Approach NHS Guidance Class Class Class I/II III IV/V

13. Audit information for Data made available The Cloud Provider should:- users 1. Record system events in near real-time to provide an audit log. Y Y Y You should be provided 2. Ensure that the audit logs are tamperproof. Y Y Y with the audit records needed to monitor access 3. Ensure that the retention period for the logs can be defined by the Y Y Y to your service and the customer. data held within it. The type of audit information 4. Provide a secure facility to forward / export the logs off the cloud Y Y Y available to you will have a infrastructure.

Health and Social Care Cloud Security – Good Practice Guide

direct impact on your 5. Provide facilities to allow logs pertaining to their own systems to be Y Y Y ability to detect and human readable. respond to inappropriate or malicious activity within 6. Undertake annual assessment against a recognised standard such as Y Y reasonable timescales. ISO, CyberEssentials to test the ‘auditing facility’.

Ensure that the test is conducted by a suitably qualified provider such as those certified under the CREST scheme.

The Service User should:-

1. Use the audit data as part of an effective pro-active monitoring Y Y Y regime.

Ref Security Principle NHS Recommended Approach NHS Guidance Class Class Class I/II III IV/V

14. Secure use of the service Enterprise managed devices The Service User should:-

The security of cloud AND/OR 1. Use a security hardened master operating system image to build Y Y Y services and the data held guest servers. within them can be Partner managed devices 2. Utilise integrated security monitoring and policy management Y Y Y undermined if you use the facilities to help detect threats and weaknesses, due to poor design or service poorly. AND/OR mis-configuration. Consequently, you will have certain responsibilities Unknown devices 3. Undertake annual assessment against a recognised standard such as Y Y when using the service in ISO, CyberEssentials to test the ‘security monitoring’. order for your data to be adequately protected. Ensure that the test is conducted by a suitably qualified provider such as those certified under the CREST scheme.

Health and Social Care Cloud Security – Good Practice Guide

9 Appendix B

The IT Services that are offered by NHS Digital are assigned a Service Classification. This approach reduces the complexity of service offerings and provides guidelines to making informed service choices for new services. The following table provides summary details for each of the four Service Classifications.

Service Service Characteristics Classification

Platinum • Typically, critical national services. • Absence of system leads to complete failure of dependent systems and services with a high possibility of clinical safety issues. • Service interruption results in severe reputational damage. • 24x7x365 Support required. • Service Availability – 99.9%. • DR Recovery target 2 hours. • Monthly MI reporting. • Example service – Spine.

Gold • Predominantly transactional services. • Absence of system leads to operational difficulties that can be coped with for a limited period. • Absence of system may lead to increased risk to clinical care. • 8-6 Mon to Sat Support required. • Service Availability – 99.9%. • DR Recovery Target 4 hours. • Monthly MI reporting. • Example service – POS/DSCRO

Silver • Predominantly data capture, batch processing. • Absence of system leads to operational difficulties, but these are manageable for an extended period. E.g. 1 day. • Absence of system may lead to a slight increase in clinical risk Business Hours Support (8am-6pm) Mon-Fri (not BH). • Service Availability – 99.5%. • DR Recovery optional - dependent on outcome of business impact analysis. • Monthly MI reporting. • Existing service – SUS, HES.

Bronze • Business Hours Support (8am-6pm) Mon-Fri (not BH). • Service Availability – 98%. • DR Recovery optional- dependent on outcome of business impact analysis. • Ad Hoc MI reporting. • Existing service – Parliamentary questions/publications.

GOVERNING BODY MEETING

COMMUNICATIONS AND ENGAGEMENT REPORT JUNE 2019 Date of Meeting 11 September, 2019 Agenda Item 16

CCG Corporate Objectives

Through better commissioning, improve local health outcomes by addressing poor outcomes and x 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 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 x 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 X Quality

Clinical Lead: Penny Morris Senior Lead Manager David Rogers Finance Manager Roger Parr Equality Impact and Risk Assessment n/a completed: Is a Data Protection Impact Assessment n/a Required? GOVERG BODGOVERNING BODY MEETING Governing Body Meeting Page 1 of 6

Data Protection Impact Assessment completed: Not required Patient and Public Engagement completed: Ongoing engagement with the public on a range of commissioning activities Financial Implications None Risk Identified None Report authorised by Senior Manager: Kirsty Hollis

Decision Recommendations

The Governing Body is requested to:

 Note the contents of the report;  Feedback any comments or suggestions in relation to communications and engagement activity and comment on future plans;  Receive a further report at its meeting in November 2019.

Governing Body Meeting Page 2 of 6

CLINICAL COMMISSIONING GROUP (CCG)

GOVERNING BODY MEETING

11 SEPTEMBER, 2019

COMMUNICATIONS AND ENGAGEMENT REPORT SEPTEMBER 2019

1 Introduction

This report provides an analysis of communications and engagement activity by the CCG over the last quarter.

2 Background

The Communication and Engagement Team operates as one team with NHS East Lancashire CCG colleagues, to realise the benefits of economies of scale and avoid unnecessary duplication.

3 Communication and Engagement Report - 11 September 2019

3.1 This report provides a summary of activity on communications and engagement by Blackburn with Darwen CCG between 1 June 2019 and 30 August 2019. It covers a wide range of activity, including:

 Engagement including staff and stakeholder  Proactive and reactive media relations  Integrated communications  Design and marketing  Website and digital media  Campaigns  Future work

4 Overall assessment

4.1 This quarter has been busy in terms of preparation for the upcoming Winter period which is always the busiest time of the year for the Communications and Engagement Team. Supporting the CCG’s AGM has also been a priority this quarter.

5 Proactive and Reactive Media Management

5.1 The Communications Team have continued to be proactive in terms of media management.

5.2 Comparison over the last 12 months :

PR activity 1 June 2019 – 30 1 Feb 2019 – 30 1 Dec 2018 – 31 1 Sept 2018 – 30 August 2019 April 2019 Jan 2019 Nov 2018

Media enquiries received 12 6 9 Proactive media releases 33 31 28 22 issued Proactive Facebook posts 183 178 162 Governing Body Meeting Page 3 of 6

Proactive Twitter posts 141 154 215

5.3 Website

5.4 During the last quarter, there were 1,425 page visits. The top three most visited pages were Commissioning 224, News 183 and Latest news & events 144.

6 Integrated system communications

6.1 During the last quarter, the joint Pennine Lancashire Communication and Engagement Team (CCG and ELHT communication and engagement teams) has continued to work together across all aspects of the service. The two teams meet monthly to discuss integration and joint ways of working, while the two heads of service meet weekly to plan and review joint work, and collaborative endeavours. This collaborative approach is helping to improve communication, save time, reduce duplication of effort, improve working relationships and provide a better experience for people who use health and social care services.

7 Design and marketing

7.1 The communication and engagement team has delivered a number of design projects during the last quarter including the CCG Full, and Summary Annual Report 2019, as well as campaigns around cancer awareness, self care and PPG awareness.

8 Digital media

8.1 The Communication and Engagement Team has continued to use its digital channels effectively, particularly in relation to signposting members of the public to appropriate services, gathering soft intelligence, and building engagement. We continue to use broadcast media such as LearnLive and inhouse video production to good effect.

8.2 Facebook engagement (Likes, or followers)

Facebook engagement for the CCG has continued to increase through interaction and by posting stories of relevance and salience to our followers. The current following is 2317. The CCG continues to have a high number of followers, and when combined with East Lancashire CCG, we have one of the highest reaches in the North West for social media from a CCG.

8.4 Twitter Engagement (Followers)

Twitter engagement for the CCG has continued on its upward trajectory too and currently stands at 4,342. We continue to build engagement through interaction and by posting stories of relevance and salience to our followers.

8.5 Video

The team has continued to use video as an effective way of promoting key messages and campaigns. A number of videos have been delivered this quarter including one for Breastfeeding Awareness Week in August https://www.youtube.com/watch?v=8VRG4nAv82g and two case studies to promote the upcoming Organ Donation Week in September https://www.youtube.com/watch?v=2-1KIlb78EU https://www.youtube.com/watch?v=u_TCXwdzCDc Governing Body Meeting Page 4 of 6

9 Campaigns and marketing

9.1 Planning for the forthcoming winter season, especially around the children’s flu immunisation, is now in progress with partners across the health and social care system.

10 Engagement, Insight and Market Research

10.1 Following self-assessment and a process of independent assessment and validation by NHS England, Blackburn with Darwen achieved a rating of “good” in the annual Integrated Assessment Framework assessment of Patient and Public Involvement (PPI). NHS East Lancashire CCG achieved a rating of “outstanding”. This follows last year’s assessment where both CCGs, along with all other CCGs in Lancashire and South Cumbria were given a rating of “requires improvement”. Members may recall that we were not happy with this assessment and submitted a request for review, given the depth and breadth of engagement that the CCGs lead, and are involved in. However, the Communication and Engagement team used this as an opportunity to review processes, and approaches to engagement, and along with a root and branch review of engagement undertaken in the CCGs, implemented improvements to our approach.

This has clearly paid off, and it is a phenomenal achievement to move from “requires improvement” to “good” and “outstanding”.

While one team supports both CCGs in communication and engagement, members may be interested as to the reasons for the difference in rating. To achieve “outstanding” BwD will need to undertake much more engagement, as well as engagement that translates into actionable change that can be evidenced. In addition, there is a need to adopt a more co-production orientated approach and involve more patients in the working of the CCG and on projects at the initial planning stage. We have drafted guidance on coproduction which will be shared with Senior Managers for consideration and adoption, along with other training on engagement and consultations, moving forward.

A proposal and plan for ongoing dialogue in “community conversations” within each locality about what matters to people in their communities about health and health services has been developed. This builds on partnership work with Blackburn and Lancashire Healthwatch and will support planning in localities for future service redesign and development. The proposal, which will be signed off by senior managers and executive directors will represent a two-pronged approach: firstly a look back at existing data and soft intelligence from surveys and engagement, and also allowing for continuous dialogue in each of our communities. The proposal, if adopted will be a significant opportunity to support the objectives of the CCGs, particularly, the move towards a “shift left”.

11 Staff Engagement

11.1 The Communications Team continues to support staff messages with a weekly bulletin as well as supporting the monthly staff briefing sessions. The monthly staff brief is now delivered as a joint brief across Blackburn with Darwen and East Lancashire and delivered in person from one site whilst being web cast digitally to the other site, as well as to other sites and locations.

12 Future work

12.1 Key priorities for the coming quarter for the communication and engagement team are to: Governing Body Meeting Page 5 of 6

 Support the developing primary care neighbourhoods  Implement and mobilise “community conversations” following approval by senior managers and executives  Plan for delivery of the Pennine Winter Plan

13 Recommendation

14.1 The Governing Body is requested to:

David Rogers Head of Communications and Engagement September 2019

Governing Body Meeting Page 6 of 6

GOVERNING BODY MEETING

REVIEW OF GOVERNING BODY REGISTER OF INTERESTS

Date of Meeting 11th September 2019 Agenda Item 18

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  GOVERG BODGOVERNING BODY MEETING

Governing Body Meeting Page 1 of 3

Clinical Lead: N/A

Senior Lead Manager Mrs Claire Moir Finance Manager Mr Roger Parr Equality Impact and Risk Assessment This report is for information only completed: Is a Data Protection Impact Assessment Required? Yes No Data Protection Impact Assessment completed: Yes No Patient and Public Engagement completed: This report is for information only Financial Implications This report is for information only Risk Identified This report is for information only Report authorised by Senior Manager: Mr Iain Fletcher Y

Decision Recommendations

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

Governing Body Meeting Page 2 of 3

CLINICAL COMMISSIONING GROUP (CCG)

GOVERNING BODY MEETING

11TH SEPTEMBER 2019

REVIEW OF GOVERNING BODY REGISTER OF INTERESTS

1. Introduction

The purpose of this briefing is to provide the Governing Body with an update on its Register of Interests.

Following revised guidance from NHS England and the subsequent revision to the CCG’s Conflicts of Interest Policy, it was agreed that the CCG’s Registers of Interests would be renewed bi-annually.

2. Governing Body Register

Governing Body Members have recently been requested to review their Declaration of Interests, to ensure that the register is up to date (attached as Appendix 1). The register was presented to the CCG’s Audit Committee on 20th August 2019 and has been published on the CCG’s website in line with statutory requirements.

3. Recommendation

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

Mr Iain Fletcher Head of Corporate Business 5th September 2019

Governing Body Meeting Page 3 of 3

Appendix 1

REGISTER OF INTERESTS NHS BLACKBURN WITH DARWEN (BwD) CLINICAL COMMISSIONING GROUP (CCG) GOVERNING BODY - AUGUST 2019 Name and position within, or Type of Interest Description of Interest (including for indirect interests, Dates Interest Relates Actions to be taken to mitigate risk (to relationship with, the CCG details of the relationship with the person who has the From and To be agreed with Line Manager or a interest) Senior CCG Manager) Dr Ridwaan Ahmed, (Clinical Financial General Practitioner (GP) Partner at Brownhill Surgery, 2014 Present Would not take part in decision making or Director of Primary Care and Blackburn procurement, or other activities relating to Quality) I am a member of a General Practice which is a member of East 2014 Present this interest in accordance with the CCG Lancashire Medical Services (ELMS) and I am an Out of Hours policy. (OOHs) sessional GP for them. Non-financial Professional I am the Clinical Director for Blackburn with Darwen North 01/07/2019 Present Primary Care Network Dr Adam Black (General Financial GP Partner for Cornerstone Practice 2008 Present Would not take part in decision making or Practitioner (GP) Executive procurement, or other activities relating to Member) these interests in accordance with the CCG policy Director of Cornerstone Healthcare Community Integrated Care 2009 Present (CIC) I am a member of a General Practice which is a member of 2008 Present ELMS and I am an OOHs sessional GP for them. Non-Financial Professional Director of Cornerstone Healthcare Charity 2010 Present

Indirect Wife is Speech and Language Therapist for 'Speak Easy' 2014 Present Charity Mr Graham Burgess (Chair) Non-Financial Professional Chair of Torus Social Housing Company, Warrington and St 2014 Present Would not take part in decision making or Helens procurement, or other activities relating to Non-Financial Professional Chair of Rochdale Integrated Commissioning Board 2018 Present these interests in accordance with the CCG policy. Non-Financial Professional Chair of the Pennine Lancashire Integrated Health and Care 2018 Present Partnership Leaders’ Forum (Shadow) Professor Dominic Harrison Indirect Director of Public Health and Well-Being with the Local Authority 2009 Present Would not take part in decision making or (Director of Public Health and procurement, or other activities relating to Well-being, Blackburn with Partner is a Green Party County Councillor on Lancashire 2015 Present these interests in accordance with the Darwen Borough Council) County Council CCG policy. Visiting Professor at the University of Central Lancashire 2014 Present

Dr Julie Higgins (Joint Chief Nil Nil Nil N/A Officer)

Mr Paul Hinnigan (Lay Member - Financial Director of Northlands Consultancy Services Limited 2016 Present Health Consultancy. Projects discussed Governance) with BwD CCG Chair in advance to ensure no conflict. Would not take part in decision making/procurement or other activity relating to this interest in accordance with the CCG policy. Mrs Kirsty Hollis (Deputy Chief Indirect Close Friend is Head of Risk at Four Seasons Healthcare 2013 Present Would not take part in decision making or Officer/Chief Finance Officer - procurement, or other activities relating to East Lancashire CCG) this interest in accordance with the CCG policy. Dr Nigel Horsfield (Lay Member) Non-Financial Professional Friends and former colleagues work at East Lancashire 1981 2010 Would not take part in decision making or and Personal Hospitals NHS Trust (ELHT), Beardwood Hospital and Gisburne procurement, or other activities relating to Park Hospital this interest in accordance with the CCG policy. Mrs Claire Richardson (Strategic Non Financial Professional Strategic Director of Transformation Pennine Lancashire 2018 Present Would not take part in decision making or Director of (seconded) procurement, or other activities relating to these interests in accordance with the Transformation/Director of Governing Body Member, Blackburn with Darwen CCG 2017 Present Commissioning Operations) CCG policy.

Indirect Sister has Director role at Lancashire Women's Centre (LWC) 2018 Present

Friendships with colleagues at Blackburn with Darwen Borough 2013 Present Council and Trafford CCG Dr Geraint Jones (Secondary Non-Financial Professional Friends and former colleagues work at ELHT, Beardwood 1987 2016 Would not take part in decision making or Care Doctor (Retired)) and Personal Hospital and Gisburne Park Hospital procurement, or other activities relating to this interest in accordance with the CCG policy. Mrs Kathryn Lord (Director of Indirect Husband is the Head of Information Technology, Midlands and 2013 Present Would not take part in decision making or Quality and Chief Nurse) Lancashire Commissioning Support Unit procurement, or other activities relating to this interest in accordance with the CCG policy. Dr Penny Morris (Medical Financial GP Partner Darwen Healthcare (DHC). Dr M Ninan (Partner at TBC Present Would not take part in decision making or Director) DHC) is GPwSI in Cardiology. procurement, or other activities relating to Indirect Dr Mohammed Umer (Partner at DHC) is Chair of the Local 2017 Present these interests in accordance with the Primary Care Federation CCG policy. Non-Financial Personal Medical Advisor to the W M and BW Lloyd Trust (Charity) in 2016 Present Darwen. Indirect Dr Mohammed Umer (Partner at DHC) has been appointed as 01/07/2019 Present the Clinical Director for the Blackburn with Darwen Primary Care Networks

Mr Roger Parr (Deputy Chief Indirect Father is Chair of East Lancashire Hospice and Governor at 2014 Present Would not take part in decision making or Executive/Chief Finance Officer) ELHT procurement, or other activities relating to Non-Financial Professional Public Sector Director of East Lancashire Building Partnership 2013 Present these interests in accordance with the CCG policy. Indirect Wife is the Interim Director of Operations – Scheduled Care, 2017 Present Blackpool Teaching Hospitals NHS Foundation Trust Dr Zaki Patel (GP Executive Financial GP Principal at Olive Medical Practice 2019 Present Would not take part in decision making or Member) GP Principal at Hollins Grove Surgery, Darwen 2017 Present procurement, or other activities relating to these interests in accordance with the I am a member of a General Practice which is a member of 2016 Present CCG policy. ELMS and I am an OOHs sessional GP for them. I am an ELMS Council Member 2018 Present Director of ZNM Limited 2013 Present Non-Financial Professional Board Member of Tauheedul Islam Girls' High School 2015 Present Dr John Randall (GP Executive Financial GP at Oakenhurst Medical Practice 1992 Present Would not take part in decision making or Member) procurement, or other activities relating to GP Partner, Dr Ali, within my practice receives financial TBC Present these interests in accordance with the remuneration for conducting Phase 3 trials for Merck; Sanofi; CCG policy. Novonordisk; AstraZenica. I am a member of the Local Blackburn GP Federation TBC Present I am a member of a GP Practice which is a member of ELMS TBC Present Indirect My wife is Deputy Head of Safeguarding, Nursing Directorate, TBC Present NHS England Dr Preeti Shukla (GP Executive Financial Locum GP in Blackburn and East Lancashire area 2011 Present Would not take part in decision making or Member) procurement, or other activities relating to Director AADI ADITI Limited (private company) 2012 Present these interests in accordance with the Local Medical Committee Member 2016 Present CCG policy. British Medical Association General Practitioners' Committee Jul-18 Jul-19 Member GP Survival England Representative 2016 Present GP Partner at Ewood Medical Centre Apr-18 Present Ad hoc work carried out for the University of Central Lancashire Jul-18 Present Medical School Director of Om Aadi Limited Jun-18 Present Non-Financial Professional British International Doctors Association Executive Member 2016 Present Blackburn National GP British International Doctors Association Chair 2017 Present Financial Blog writer 2016 Present Deputy Policy Lead, British Medical Association 2017 Present Federation GP for the Spoke Hub 2017 Present I am a member of a General Practice which is a member of 2017 Present ELMS and I am an OOHs sessional GP for them. Friends and colleagues working as GPs, Consultants, Health 2011 Present Care Assistants, Nurses, Allied Health Professionals at East Lancashire CCG, Blackburn with Darwen CCG, ELHT, Beardwood Hospital and other hospitals and other areas via social media contacts. Mr Alex Walker (Director of Nil Nil Nil N/A Performance and Delivery)

AUDIT COMMITTEE MEETING GORNIN

Annual Report of the Audit Committee 2018/19

Date of Meeting 20 August 2019 Agenda Item 19

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 G BODGOVERNING BODY MEETING

Page 1 of 23

Clinical Lead: N/A

Senior Lead Manager Mr Roger Parr Finance Manager Mrs Linda Ring Equality Impact and Risk Assessment N/A completed: Is a Data Protection Impact Assessment Required? No Data Protection Impact Assessment completed: No Patient and Public Engagement completed: N/A Financial Implications N/A Risk Identified N/A Report authorised by Senior Manager: Mr Roger Parr

Y Decision Recommendations

The Governing Body is asked to note the content of this report.

Page 2 of 23

CLINICAL COMMISSIONING GROUP (CCG) GOVERNING BODY MEETING ANNUAL REPORT OF THE AUDIT COMMITTEE 11 SEPTEMBER 2019

1. Introduction

The purpose of this report is to inform the Clinical Commissioning Group (CCG) Governing Body of the role and activities of the Audit Committee during the financial year 2018/19.

2. Role of the Audit Committee

The Audit Committee has operated during the year in accordance with its agreed Terms of Reference. A summary of the audit committee’s responsibilities are set out below and the full Terms of Reference are included as Appendix A.

3. Summary of Audit Committee Responsibilities

The roles and responsibilities of the Audit Committee include the review of the establishment and maintenance of effective integrated governance, risk management and internal control systems across the whole of the CCG’s activities, both clinical and non-clinical supporting the achievement of the CCG’s objectives. It includes the review and monitoring of the internal and external audit functions, counter fraud and monitoring of the integrity of the financial statements of the CCG.

4. Membership of the Audit Committee

Membership during the year has comprised of:

Name Number of meetings % attended

Mr Paul Hinnigan (Chair) 5 100%

Dr John Randall 5 100%

Dr Geraint Jones 5 100%

Dr Nigel Horsfield 5 100%

Invitations to attend the Audit Committee are normally provided to:

 CCG Chief Finance Officer

 Internal Audit Representatives

 Counter Fraud Representatives

Page 3 of 23

 External Audit Representatives

 CCG Chief Clinical Officer

In addition, other officers from within the organisation have been invited to attend Audit Committees where it was felt that to do so would assist the Audit Committee to effectively fulfill its responsibilities.

Administrative support has been provided by the Executive Assistant to the Chief Finance Officer.

5. Appointment of External Audit

Grant Thornton were re-appointed as external auditors for Blackburn with Darwen CCG from 1st April 2017 for a five year period.

6. Meetings during the year 2018-19

During the year 5 meetings were held on the following dates:

24 April 2018

24 May 2018

21 August 2018

27 November 2018

5 February 2019

The agenda for each of these meetings are shown in Appendix B and full minutes can be accessed on the CCG website.

7. Remuneration of the Audit Committee

The fulfilment of Audit Committee responsibilities by Lay Members are expected as part of each individual Lay Member’s contracts with the organisation.

8. Financial Statements

On 23rd April 2019, the Audit Committee reviewed the draft 2018/19 Annual Accounts and Annual Report including the Annual Governance Statement. The final version of the Annual Accounts was reviewed on 23rd May 2019. The Audit Committee also reviewed the external audit report on the Annual Accounts. The Committee also approved the content of the 2018/19 Management Representation letter.

Page 4 of 23

9. Internal Control and Risk Management Systems

At each meeting the Audit Committee has considered various reports from its Internal and External Auditors and the CCG Finance Officer. A full list of the reports received and other agenda items considered by the Audit Committee is contained in Appendix B.

10. External Audit

Grant Thornton are the CCG’s appointed external auditor. The Audit Committee has reviewed the work and findings of External Audit by:

 Discussing and agreeing the nature and scope of the 2018/19 Annual Plan;

 Considering the extent of its co-ordination with and reliance on internal audit;

 Receiving and considering reports derived from the Annual Plan: and

 Receiving and considering the annual audit letter before its submission to the Governing Body.

The Audit Committee has also met in private with External Audit so as to allow the discussion of matters without the presence of executive officers.

11. Internal Audit and Anti Fraud

The Audit Committee has reviewed and considered the work and findings of Internal Audit by:

 Discussing and agreeing the nature and scope of the Annual Plan;

 Receiving and considering regular progress reports from the Director of Internal Audit at Audit Committee meetings;

 Receiving and considering reports derived from the Annual Plan;

 Receiving the 2018/19 Head of Internal Audit’s annual opinion on the system of internal control;

 Receiving the 2018/19 Internal Audit Report;

 Receiving the 2018/19 Anti Fraud Annual Report.

The Audit Committee has also met in private with Internal Auditors so as to allow discussion of matters in the absence of executive officers.

For both internal and external audit, the Audit Committee has ensured that management actions agreed in response to reported weaknesses, have either been implemented or that there has been adequate explanation for delays or non-implementation.

12. Relationships with other Committees

The Audit Committee received minutes and reports from other Clinical Commissioning Group (CCG) Committees, eg Pennine Lancashire Quality Committee and the CCG Primary Care Co-Commissioning Page 5 of 23

Committee. The Audit Committee received reports on the financial planning of the Clinical Commissioning Group, reports on the Quality Innovation, Productivity and Prevention (QIPP) programme, risk register and other corporate registers.

13. Looking Ahead

Internal and External Audit work plans have been agreed and the agreed Audit Committee work plan for 2019/20 is shown in Appendix C which covers the main areas of work to be undertaken.

14. Recommendation

The Governing Body is asked to note the content of this report.

Mr Paul Hinnigan Audit Committee Chair 6 August 2019

Page 6 of 23

Appendix A

AUDIT COMMITTEE TERMS OF REFERENCE

1.0 Purpose of the Committee

The duties of the Committee will be driven by the priorities identified by the Clinical Commissioning Group, and the associated risks.

In particular, the Audit Committee will review the adequacy and effectiveness of:

 The policies for ensuring compliance with relevant regulatory, legal and code of conduct requirements and related reporting and self-certification.

In carrying out this work the Committee will primarily utilise the work of Internal Audit, External Audit and other assurance functions, but will not be limited to these sources. It will also seek Page 7 of 23

This will be evidenced through the Committee’s use of an effective Assurance Framework to guide its work and that of the audit and assurance functions that report to it.

2.2 Internal Audit

 Consideration of the provision of the internal audit service, the cost of the audit and any questions of resignation and dismissal.

 Considering the major findings of internal audit work (and management’s response) and ensuring co-ordination between the internal and external auditors to optimise audit resources.

 Ensuring that the internal audit function is adequately resourced and has appropriate standing within the Clinical Commissioning Group.

 An annual review of the effectiveness of Internal Audit. 2.3 External Audit

 Consideration of the appointment and performance of the external auditors, as far as the rules governing the appointment permit (and make recommendations to the Governing Body when appropriate).

 Discussion with the external auditors of their evaluation of audit risks relating to both the financial statements and value for money conclusion, and associated impact on the audit fee. Page 8 of 23

 Ensuring there is a clear policy for the engagement of external auditors to supply non audit services

2.4 Other assurance functions

2.5 Counter Fraud

 Approval of the appointment of a Local Anti-Fraud Specialist either directly or through the appointment of the internal audit services.

 Ensuring that the Anti-Fraud functions are adequately resourced and have appropriate standing within the CCG.

Page 9 of 23

2.6 Management

The Committee shall request and review reports and positive assurances from Directors and Managers on the overall arrangements for governance, risk management and internal control.

The Committee may also request specific reports from individual functions within the Clinical Commissioning Group as they may be appropriate to the overall arrangements.

2.7 Financial reporting

The Audit Committee shall monitor the integrity of the financial statements of the Clinical Commissioning Group and any formal announcements relating to the Clinical Commissioning Group’s financial performance.

Annual Reports and Accounts

In accordance with the CCG’s Constitution (Scheme of Reservation and Delegation) the Committee is authorised to approve the Group’s annual report and annual accounts.

The Audit Committee shall review the annual report and financial statements before submission to the Governing Body (for information), focusing particularly on:

2.8 Review instances where Standing Orders / Standing Financial Instructions have been waived.

Page 10 of 23

3.0 Deliverables 3.1 Reports of assurance to the Clinical Commissioning Group Governing Body that the functions as identified in the Audit Committee Work plan have been performed.

3.2 Minutes recording the decisions reached and the reasons for such decisions shall be maintained and be submitted to the Clinical Commissioning Group Governing Body.

4.0 Constraints/Risks 4.1 Audit reporting and publishing of annual accounts are set within pre-determined dates.

The Lay Member on the Governing Body with a lead role in governance will chair the Audit Committee.

As a minimum membership shall be made up of:-

Lay Member for Governance (Chair) Secondary Care Doctor One other Lay Member General Practitioner Executive

The Chief Finance Officer and other Executives from the Clinical Commissioning Group may be in attendance at the specific invitation of the Chair.

6.0 Governance and Reporting 6.1 The Audit Committee will report to the Clinical Commissioning Group Governing Body on how it discharges its responsibilities.

Page 11 of 23

requirements relating to its existence as a functioning business

8.0 Location of information such as plans, or contact information 8.1 Information relating to the business of the Audit Committee is saved electronically on the Corporate Drive. 9.0 Related Policies 9.1  Being Open Policy  Whistle Blowing Policy  Fraud and Corruption Policy  Conflict of Interest Policy  Standing Financial Instructions  Standing Orders 10.0 Schedule of Meetings 10.1 4 times per annum as a minimum.

Page 12 of 23

APPENDIX B

CLINICAL COMMISSIONING GROUP (CCG)

AUDIT COMMITTEE MEETING

Tuesday 24th April 2018 at 1.30 p.m. in the Small Meeting Room, Fusion House, Evolution Park, Haslingden Road, Blackburn BB1 2FD

A G E N D A

Item Agenda Item Member Responsible Report No: 1. Chair’s Welcome Mr Paul Hinnigan

2. Apologies for Absence and Confirmation of Quoracy Mr Paul Hinnigan

3. Declarations of Interest Mr Paul Hinnigan 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 Audit Committee Secretary in advance of the meeting.

4. Review Terms of Reference Mr Paul Hinnigan Attached

5. Minutes of the Meeting held on 27th February 2018 Mr Paul Hinnigan Attached

6. Matters Arising Mr Paul Hinnigan 6.1 Action Matrix Attached

7. Risk Management Report Mrs Claire Moir Attached

8. External Audit Mr Simon Hardman 8.1 Progress Report Attached 8.2 2017/18 Audit Queries Mr Paul Hinnigan Attached

9. Internal Audit Mrs Lisa Warner 9.1 Progress Report Attached 9.2 Head of Audit Opinion and Annual Report 2017/18 Attached 9.3 Draft Audit Plan 2018/19 Attached 9.4 Charter 2018/19 Attached 9.5 Mersey Internal Audit Agency Insight Update Attached

10. Anti-Fraud Mrs Kerry Ann Wheat 10.1 Annual Report 2017/18 Attached 10.2 Annual Plan 2018/19 Attached

Page 13 of 23

11. Draft Annual Report and Financial Statements 2017/18 Mr Roger Parr To Follow 11.1 Quality, Innovation, Productivity and Prevention (QIPP) To Follow 11.2 Annual Review of Accounting Policies To Follow 11.3 2017/18 Financial Management To Follow

12. Losses and Special Payments Mr Roger Parr Attached

13. Waivers and Standing Orders Mr Roger Parr Attached

14. Corporate Registers Mr Roger Parr Attached

15. Audit Committee Work Plan 2018 Mr Paul Hinnigan Attached

16. Pennine Lancashire Quality Meeting Mr Paul Hinnigan/ 16.1 Minutes of the Meeting held on 24th January 2018 Dr Geraint Jones Attached 16.2 Minutes of the Virtual Meeting held on 28th February 2018 Attached

17. Primary Care Co-commissioning Committee Mr Paul Hinnigan 17.1 Minutes of the Meeting held on 16th January 2018 Attached

18. Any Other Business Mr Paul Hinnigan

19. Date and Time of Next Meeting Mr Paul Hinnigan The next meeting is scheduled for Thursday 24th May 2018 at 1 p.m. in the Small Meeting Room, Fusion House.

Page 14 of 23

CLINICAL COMMISSIONING GROUP (CCG)

AUDIT COMMITTEE

Thursday 24th May 2018 at 1 p.m. in the Board Room, Fusion House, Evolution Park, Haslingden Road, Blackburn, BB1 2FD

A G E N D A (REVISED)

Item Agenda Item Member Responsible Report No: 1. Chair’s Welcome Mr Paul Hinnigan

2. Apologies for Absence and Confirmation of Mr Paul Hinnigan Quoracy

3. Declarations of Interest relating to items on the Mr Paul Hinnigan agenda 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 Audit Committee Secretary in advance of the meeting.

4. Minutes of the Meeting held on 24th April 2018 Mr Paul Hinnigan Attached

5. Matters Arising Mr Paul Hinnigan 5.1 Action Matrix Attached

6. 2017/18 Annual Report and Financial Statements 6.1 Audit Findings Report 2017/18 Mr John Farrar/ To Follow/Be Tabled Mr Simon Hardman 6.2 Letter of Representation Mr Simon Hardman To Follow/Be Tabled 6.3 Annual Report and Financial Statements Mr Roger Parr To Follow/Be Tabled

7. Any Other Business Mr Paul Hinnigan

8. Date and Time of Next Meeting Mr Paul Hinnigan

August - to be confirmed

Page 15 of 23

CLINICAL COMMISSIONING GROUP (CCG)

AUDIT COMMITTEE MEETING

Tuesday 21st August 2018 at 2 p.m. in the Board Room, Fusion House, Evolution Park, Haslingden Road, Blackburn BB1 2FD

A G E N D A

Item Agenda Item Member Responsible Report No: 1. Chair’s Welcome Mr Paul Hinnigan Verbal

2. Apologies for Absence and Confirmation of Quoracy Mr Paul Hinnigan Verbal

3. Declarations of Interest Mr Paul Hinnigan 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 Audit Committee Secretary in advance of the meeting.

4. Minutes of the Meeting held on 24th May 2018 Mr Paul Hinnigan Attached

5. Matters Arising Mr Paul Hinnigan 5.1 Action Matrix Attached

6. Risk Management Report Mrs Claire Moir Attached

7. External Audit Mr Simon Hardman 7.1 Annual Audit Letter Attached

8. Internal Audit Mrs Lisa Warner 8.1 Progress Report Attached 8.2 Assurance Framework Benchmarking Report Attached 8.3 Conflicts of Interest Benchmarking Report Attached 8.4 Insight Update Attached

9. Anti-Fraud Mrs Kerry Ann Wheat 9.1 Progress Report Attached

10. Losses and Special Payments Mrs Jill Marr Attached

11 Waivers and Standing Orders Mrs Jill Marr Attached

12. Corporate Registers Mrs Jill Marr Attached

13. Draft Audit Committee Annual Report 2017/18 Mr Paul Hinnigan Attached

Page 16 of 23

14. Annual Governance Statement 2018/19 Progress Report Mrs Claire Moir Attached

15. Review of Effective of Arrangements in Place for Staff to Mrs Claire Moir Verbal Raise Concerns

16. Audit Committee Work Plan 2018 Mr Paul Hinnigan Attached

17. Pennine Lancashire Quality Committee Meeting Mr Paul Hinnigan/ 17.1 Minutes of the Meeting held on 23rd May 2018 Dr Geraint Jones Attached 17.2 Minutes of the Meeting held on 27th June 2018 Attached

18. Primary Care Co-commissioning Committee Mr Paul Hinnigan 18.1 Minutes of the Meeting held on 19th June 2018 Attached

19. Any Other Business Mr Paul Hinnigan Verbal

20. Date and Time of Next Meeting Mr Paul Hinnigan Verbal

Page 17 of 23

CLINICAL COMMISSIONING GROUP (CCG)

AUDIT COMMITTEE MEETING

Tuesday 27th November 2018 at 2 p.m. in the Small Meeting Room, Fusion House, Evolution Park, Haslingden Road, Blackburn BB1 2FD

A G E N D A Item Agenda Item Member Responsible Report No: 1. Chair’s Welcome Mr Paul Hinnigan Verbal

2. Apologies for Absence and Confirmation of Quoracy Mr Paul Hinnigan Verbal

5. Matters Arising Mr Paul Hinnigan 5.1 Action Matrix Attached

6. Risk Management Report Mrs Claire Moir Attached

7. External Audit Ms Marianne Dixon 7.1 Progress Report Attached

8. Internal Audit Mrs Lisa Warner 8.1 Progress Report Attached 8.2 Revised Internal Audit Plan 2018/19 Attached 8.3 Insight Update Attached 8.4 Assessment of Internal Audit Findings Report Mr Paul Hinnigan Attached 9. Anti-Fraud Mrs Kerry Ann Wheat 9.1 Progress Report Attached

10. Losses and Special Payments Mr Roger Parr Attached

11 Waivers and Standing Orders Mr Roger Parr Attached

12. Corporate Registers Mr Roger Parr Attached

13. Annual Governance Statement 2018/19 Progress Report Mrs Claire Moir Attached

14. Audit Committee Work Plan 2018/19 Mr Paul Hinnigan Attached

Page 18 of 23

15. Pennine Lancashire Quality Committee Meeting Mr Paul Hinnigan/ 15.1 Minutes of the Meeting held on 25th July 2018 Dr Geraint Jones Attached 15.2 Minutes of the Meeting held on 22nd August 2018 Attached

16. Primary Care Co-commissioning Committee Mr Paul Hinnigan 16.1 Minutes of the Meeting held on 24th July 2018 Attached 16.2 Minutes of the Meeting held on 18th September 2018 Attached 17. Any Other Business Mr Paul Hinnigan Verbal

18. Date and Time of Next Meeting Mr Paul Hinnigan Verbal

Page 19 of 23

CLINICAL COMMISSIONING GROUP (CCG)

AUDIT COMMITTEE MEETING

Tuesday 5th February 2019 at 2 p.m. in the Board Room, Fusion House, Evolution Park, Haslingden Road, Blackburn BB1 2FD

A G E N D A Item Agenda Item Member Responsible Report No: 1. Chair’s Welcome Mr Paul Hinnigan Verbal

2. Apologies for Absence and Confirmation of Quoracy Mr Paul Hinnigan Verbal

5. Matters Arising Mr Paul Hinnigan 5.1 Action Matrix Attached

6. Risk Management Report Mrs Claire Moir Attached

7. External Audit Ms Marianne Dixon 7.1 Audit Plan 2018/19 Attached 7.2 Progress Report Attached 8. Internal Audit Mrs Lisa Warner 8.1 Progress Report Attached 8.2 Insight Update Attached 9. Anti-Fraud Mr Darrell Davies 9.1 Progress Report Attached 9.2 Fraud, Bribery and Corruption Self-Review Toolkit Attached Submission 10. Losses and Special Payments Mrs Linda Ring Attached

11 Waivers and Standing Orders Mrs Linda Ring Attached

12. Corporate Registers Mrs Claire Moir Attached

13. Annual Governance Statement 2018/19 Progress Report Mrs Claire Moir Attached

14. Audit Committee Work Plan 2019 Mr Paul Hinnigan Attached

15. Pennine Lancashire Quality Committee Meeting Mr Paul Hinnigan/

Page 20 of 23

15.1 Minutes of the Meeting held on 2nd October 2018 Dr Geraint Jones Attached 15.2 Minutes of the Meeting held on 24th October 2018 Attached 15.3 Minutes of the Meeting held on 28th November 2018 Attached 15.4 Minutes of the Meeting held on 19th December 2018 Attached

Page 21 of 23

APPENDIX C

Audit Committee Work Plan 2019

Item Feb April May Aug Nov 2019 2019 2019 2019 2019 INTERNAL CONTROL Risk Assurance Framework & Risk Register     Annual Governance Statement     Receive the Minutes of the Pennine     Lancashire Quality Committee Receive the Minutes of the Primary Care Co-     commissioning Committee Review Audit Committee Work Plan     Review Draft Audit Committee Annual Report  for Governing Body Review effectiveness of arrangements in  place for staff to raise concerns Review of Terms of Reference  Review of Effectiveness of Internal Audit  EXTERNAL AUDIT Audit Plan 

Audit Findings Report 

Annual Audit Letter 

Progress Report   

INTERNAL AUDIT Audit Plan 

Audit Charter 

Progress Report    

Head of Internal Audit Opinion 

ANTI FRAUD Annual Plan 

Progress Report   

Internal Assessment 

Annual Report 

OTHER Losses and Special Payments    

Waivers and Standing Orders    

Page 22 of 23

Gifts and Hospitality / Registers of    Interests/Procurement Register 

Private meeting between Lay Members,  Internal Audit and External Audit FINANCIAL REPORTING Draft/Final Annual Accounts and Financial (D) (F) Statements Annual Review of Accounting Policies (D) (F)

Annual Governance Statement (D) (F)

Draft Annual Report (D) (F)

Page 23 of 23 Item 19.1

The Annual Audit Letter For NHS Blackburn with Darwen CCG

Year ended 31 March 2019

28 June 2019 Contents

Section Page 1. Executive Summary 3 2. Audit of the Financial Statements 5 3. Value for Money arrangements 8 Appendices A Reports issued and fees Your key Grant Thornton team members are:

John Farrar Engagement Lead T: 0161 2346384 E: [email protected]

Marianne Dixon Audit Manager T: 0113 200 2699 E: [email protected]

Aaron Gouldman In-Charge Auditor T: 0161 214 3678 E: [email protected]

Purpose Respective responsibilities Our Annual Audit Letter (Letter) summarises the key findings arising from the We have carried out our audit in accordance with the NAO's Code of Audit Practice, work that we have carried out at Blackburn with Darwen Clinical which reflects the requirements of the Local Audit and Accountability Act 2014 (the Commissioning Group (the CCG) for the year ended 31 March 2019. Act). Our key responsibilities are to: • give an opinion on the CCG's financial statements and regularity assertion (section This Letter is intended to provide a commentary on the results of our work to two) the CCG and external stakeholders, and to highlight issues that we wish to • assess the CCG's arrangements for securing economy, efficiency and draw to the attention of the public. In preparing this Letter, we have followed effectiveness in its use of resources (the value for money conclusion) (section the National Audit Office (NAO)'s Code of Audit Practice and Auditor three). Guidance Note (AGN) 07 – 'Auditor Reporting'. We reported the detailed findings from our audit work to the CCG's Audit Committee as those charged In our audit of the CCG's financial statements, we comply with International Standards with governance in our Audit Findings Report on 23 May 2019. on Auditing (UK) (ISAs) and other guidance issued by the NAO.

Our work

Materiality We determined materiality for the audit of the CCG's financial statements to be £5,218,000, which was 2% of the CCG's gross revenue expenditure.

Financial Statements opinion We gave an unqualified opinion on the CCG's financial statements on 24 May 2019.

As well as an opinion on the financial statements, we are required to give a regularity opinion on whether expenditure has been incurred 'as intended by Parliament'. Failure to meet statutory financial targets automatically results in a qualified regularity opinion. Based on our review of the CCG's expenditure we gave an unqualified regularity opinion.

NHS Group consolidation We also reported on the consistency of the financial statements consolidation template provided to NHS England with the template (WGA) audited financial statements. We concluded that these were consistent.

Use of statutory powers We did not identify any matters which required us to exercise our statutory powers.

Value for Money arrangements We were satisfied that the CCG put in place proper arrangements to ensure economy, efficiency and effectiveness in its use of resources. We reflected this in our audit report to the members of the Governing Body on 24 May 2019. Certificate We certified that we have completed the audit of the financial statements of NHS Blackburn with Darwen CCG in accordance with the requirements of the Local Audit and Accountability Act 2014 and the Code of Audit Practice on 24 May 2019.

Working with the CCG

We received the CCG’s draft financial statements on 23 April 2019 in accordance with the national deadline and received comprehensive working papers at the start of our audit on 29 April 2019. Regular liaison meetings were held between the audit team and key finance officers, both prior to the preparation of the financial statements and also during the fieldwork, which enabled early resolution to emerging issues. Through the value for money conclusion we provided you with assurance on your operational effectiveness. We highlighted the need for continued financial resilience in your financial position. We believe we continue to enjoy a good professional relationship with you, including: • engaging with you on key governance areas – the CCG performed well in producing draft versions of both the Annual Governance Statement (AGS) and Annual Report on a timely basis, allowing us and other relevant stakeholders appropriate time to comment and review them • sharing our insight – we provided regular audit committee updates covering best practice and emerging accounting and governance developments. We also shared our thought leadership reports.

We would like to record our appreciation for the assistance and co-operation provided to us during our audit by the CCG's staff. Grant Thornton UK LLP June 2019

Our audit approach The scope of our audit Materiality Our audit involves obtaining enough evidence about the amounts and disclosures in In our audit of the CCG's financial statements, we use the concept of the financial statements to give sufficient assurance that they are free from material materiality to determine the nature, timing and extent of our work, and in misstatement, whether caused by fraud or error. This includes assessing whether: evaluating the results of our work. We define materiality as the size of the • the accounting policies are appropriate, have been consistently applied and are misstatement in the financial statements that would lead a reasonably adequately disclosed; knowledgeable person to change or influence their economic decisions. • the significant accounting estimates made by management are reasonable; and • the overall presentation of the financial statements gives a true and fair view. We determined materiality for the audit of the CCG's financial statements to be £5,218,000, which is 2% of the CCG's gross revenue expenditure. We We also read the remainder of the Annual Report to check it is consistent with our used this benchmark as, in our view, users of the CCG's financial statements understanding of the CCG and with the financial statements included in the Annual are most interested in where the CCG has spent its allocation in the year. Report on which we gave our opinion.

We also set a lower level of specific materiality for senior officer We carry out our audit in accordance with ISAs (UK) and the NAO Code of Audit remuneration of £10,000 Practice. We believe that the audit evidence we have obtained is sufficient and appropriate to provide a basis for our opinion. We set a lower threshold of £261,000, above which we reported errors to the Audit Committee in our Audit Findings Report. Our audit approach was based on a thorough understanding of the CCG's business and is risk based.

We identified key risks and set out overleaf the work we performed in response to these risks and the results of this work.

Significant Audit Risks These are the significant risks which had the greatest impact on our overall strategy and where we focused more of our work. Risks identified in our audit plan How we responded to the risk Findings and conclusions

Operating expenses – purchase of secondary healthcare As part of our audit work we: Our audit work did not identified A significant percentage of the CCG’s expenditure is on contracts • gained an understanding of the financial reporting any issues in respect of for healthcare with NHS providers and non-NHS providers, such processes used for the purchase of secondary healthcare secondary healthcare as operations and hospital care. This expenditure is primarily and evaluated the design of the associated controls expenditure derived through block contracts that are agreed up front for a predetermined cost or level of activity. Contract variations are • agreed all significant contract annual expenditure to agreed with the supplier throughout the year to recognise demand signed annual contracts and price adjustments against the agreed contracts. Costs related • agreed, on a sample basis, invoices for variations to to contract variations are recognised when the adjustment has secondary healthcare contracts to supporting evidence been agreed with the provider, with accruals raised at the year- • investigated unmatched expenditure and payable end for completed activity for which an invoice has not been balances with other NHS bodies over the NAO £0.3m issued. threshold, corroborating the unmatched balances used by We identified the accuracy and occurrence of secondary the CCG to supporting evidence healthcare expenditure – contract variations, and the existence of associated payables and accruals, as bearing a significant risk of • agreed, on a sample basis, payable and accrual balances material misstatement. relating to secondary healthcare to supporting evidence.

Management override of internal controls As part of our audit work we: Our audit work did not identify Under ISA (UK) 240 there is a non-rebuttable presumed risk that • gained an understanding of the accounting estimates, any issues in respect of the risk of management over-ride of controls is present in all judgements applied and decisions made by management management override of entities. and considered their reasonableness controls. The CCG faces external pressures to meet agreed targets, and • obtained a full listing of journal entries, identified and this could potentially place management under undue pressure in tested unusual journal entries for appropriateness terms of how they report performance. • evaluated the rationale for any changes in accounting We therefore identified management override of control, in policies or significant unusual transactions. particular journals, management estimates and transactions outside the course of business as a significant risk, which was one of the most significant assessed risks of material misstatement.

Audit opinion We gave an unqualified opinion on the CCG's financial statements on 24 Annual Report, including the Governance Statement May 2019. We are also required to review the CCG's Annual Report and the Governance Statement included within the Annual Report. It provided these on a timely basis with As well as an opinion on the financial statements, we are required to give a the draft financial statements with supporting evidence. regularity opinion on whether expenditure has been incurred 'as intended by Parliament'. Failure to meet statutory financial targets automatically results in Whole of Government Accounts (WGA) a qualified regularity opinion. We issued a group return to the National Audit Office in respect of Whole of Government Accounts, which did not identify any issues for the group auditor to Based on our review of the CCG's expenditure we gave an unqualified consider. regularity opinion. Certificate of closure of the audit Preparation of the financial statements We certified that we have completed the audit of the financial statements of NHS The CCG presented us with draft financial statements in accordance with the Blackburn with Darwen CCG in accordance with the requirements of the Local Audit national deadline, and provided a good set of working papers to support and Accountability Act 2014 and the Code of Audit Practice on 24 May 2019. them. The finance team responded promptly and efficiently to our queries during the course of the audit.

Issues arising from the audit of the financial statements We reported the key issues from our audit to the CCG’s Audit Committee on 23 May 2019.

Background We carried out our review in accordance with the NAO Code of Audit Practice, following the guidance issued by the NAO in November 2017 which specified the criterion for auditors to evaluate:

In all significant respects, the audited body takes properly informed decisions and deploys resources to achieve planned and sustainable outcomes for taxpayers and local people.

Key findings Our first step in carrying out our work was to perform a risk assessment and identify the risks where we concentrated our work.

The risks we identified and the work we performed are set out overleaf.

Overall Value for Money conclusion We are satisfied that in all significant respects the CCG put in place proper arrangements to secure economy, efficiency and effectiveness in its use of resources for the year ending 31 March 2019.

Risks identified in How we responded Findings and conclusions our audit plan to the risk

Financial As part of our work For 2018/19: Sustainability we: • the CCG successfully achieved its targets by delivering a balanced financial position of break even again its The CCG continues • monitored the CCG’s control total, whilst delivering a QIPP saving of £6m for 2018/19. The CCG also delivered its running costs to face financial financial position target. pressures from the against the planned outturn position • the CCG delivered QIPP savings on a largely recurrent basis, but with some (£1.5m) from non-recurrent requirement to budget savings deliver a break even • reviewed the position against the achievement of QIPP For 2019/20 resource limit whilst schemes against the • the CCG’s QIPP target for 2019/20 remains at £6m but with a stretch target of £7m. planned £6 million facing increasing target • financial pressures remain in 2019/20 and the CCG recognises that there continue to be risks from prescribing contract activity and • reviewed the cost volatility, and uncertainty in patient activity as models of care change. The increase in PBR tariff, and the the need to make a activity from the CCG’s main provider will continue to be a significant risk. £6m saving robustness of the assumptions in the • the CCG works with other CCG commissioners and local providers to help retain financial stability across the 2019/20 financial plan health economy. This will be key to addressing risks going forward. including considering the QIPP plans for the We concluded that the CCG has proper arrangements to plan finances effectively and provide reliable next financial year financial reporting to support the delivery of its strategic priorities

Commissioning As part of our work The CCG recognised the need to work collaboratively and effectively with other CCG commissioners and is a Alliance we: member of the Lancashire and South Cumbria Joint Committee of Clinical Commissioning Groups (JCCCG). This Arrangements • reviewed the is a statutory mechanism to enable collective decision making across the wider health economy which is The CCG is arrangements in particularly relevant to the delivery of the Healthier Lancashire Programme. continuing to place During 2018/19 the CCG’s Commissioning Business Group (CBG) and the East Lancashire CCG’s equivalent develop closer • monitored the committee the Sustainability Committee, agreed to meet ‘in common’. Original meetings were bimonthly, strategic development of meetings have now become monthly. commissioning any further Meeting ‘in common’ has enabled the CCGs to coordinate decision making effectively on key areas of relationships through integration commissioning and strategic planning whilst retaining their separate statutory responsibilities. its ‘Committees in Common’ meetings Our review of minutes from these meetings confirm that separate decisions are made, but in a coordinated with East Lancashire manner enabling consistency in decision making approach and timing. CCG We concluded that the CCG has proper arrangements in place for working effectively with third parties to deliver strategic priorities © 2019 Grant Thornton UK LLP | Annual Audit Letter | June 2019 9 Appendix A: Reports issued and fees

We confirm below our final reports issued and fees charged for the audit and confirm there were no fees for the provision of non-audit services.

Reports issued Fees for non-audit services

Report Date issued Service Fees £ Audit Plan January 2019 None Nil Audit Findings Report May 2019

Annual Audit Letter June 2019

Fees Planned Actual fees 2016/17 fees £ £ £ Statutory audit 38,000 38,000 38,000 Mental Health Investment Standard* 10,000 TBC 0 Total fees 48,000 TBC 38,000

* The Mental Health Investment Standard audit is expected to take place in August and September with a deadline of 30 September 2019. CCG’s have received funding of £10,000 for this audit work. Guidance on the work required has not yet been issued and we will discuss with management once the guidance has been received.

© 2019 Grant Thornton UK LLP | Annual Audit Letter | June 2019 10 © 2019 Grant Thornton UK LLP. All rights reserved. ‘Grant Thornton’ refers to the brand under which the Grant Thornton member firms provide assurance, tax and advisory services to their clients and/or refers to one or more member firms, as the context requires. Grant Thornton UK LLP is a member firm of Grant Thornton International Ltd (GTIL). GTIL and the member firms are not a worldwide partnership. GTIL and each member firm is a separate legal entity. Services are delivered by the member firms. GTIL does not provide services to clients. GTIL and its member firms are not agents of, and do not obligate, one another and are not liable for one another’s acts or omissions. grantthornton.co.uk© 2019 Grant Thornton UK LLP | Annual Audit Letter | June 2019

GOVERNING BODY MEETING

BLACKBURN WITH DARWEN SPECIAL EDUCATIONAL NEEDS AND DISABILITY (SEND) INSPECTION MAIN FINDINGS Date of Meeting 11th September 2019 Agenda Item 20

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 X 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 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 Scheduled Care Quality X GOVERG BODGOVERNING BODY MEETING

Governing Body Meeting Page 1 of 3

Clinical Lead: Dr Penny Morris

Senior Lead Manager Mrs Kirsty Hamer Finance Manager Mrs Jill Marr Equality Impact and Risk Assessment No completed: Is a Data Protection Impact Assessment Required? No Data Protection Impact Assessment completed: No Patient and Public Engagement Children, parents and carers have been engaged in completed: the development of SEND plans, including commissioning strategy for Blackburn with Darwen, including the SEND inspection. Financial Implications Financial implications of the SEND inspection are currently being identified. Any business cases as a result of the recommendations will be outlined within the SEND improvement plan. Risk Identified Full compliance with SEND requirements remains a risk identified within the CCG risk register. Report authorised by Senior Manager: Mrs Claire Richardson Y

Decision Recommendations

On 2nd August, Blackburn with Darwen Local Authority and Clinical Commissioning Group (CCG) received the letter from the Office for Standards in Education, Children's Services and Skills (Ofsted) in response to the Special Educational Needs and Disabilities (SEND) inspection. The letter outlined the main findings from the inspection which took place in June where inspectors for Ofsted and the Care Quality Commission spoke with children and young people with SEND, parents, carers and staff from Blackburn with Darwen (BwD) Borough Council (BC), schools, education settings and BwD CCG.

Inspectors reported that BwD had made considerable progress in implementing the SEND reforms since 2014. Key strengths included:

 Provision for SEND is a key priority for all partners, there is a good understanding of local issues and new leadership is accelerating pace of improvement;  Real enthusiasm and “can do attitude” was shown by staff who work closely together to make sure children and young people get the best possible support, making good use of Common Assessment to identify unmet needs;  Evidence of clear capacity for improvement, including through emerging joint commissioning strategy across Local Authority and CCG;

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 High quality of service delivery, with particular examples of SEND Advisory Team based within Education, support for pre-school and school age children and effective delivery of the Healthy Child Programme;  The Designated Clinical Officer leading the implementation of change which has resulted in improvement in the quality of Education, Health and Care plans.

Inspectors also recommended key areas for development, including:

 Better incorporation of leaders’ and managers’ accurate knowledge of the local area into improvement plans;  More emphasis to be placed on the positive differences the SEND provision makes to the lives of children and families, rather than processes;  Some children have long waits for neurodevelopment assessments, therapy services and some mental health services due to the high demand for these services. Work to be undertaken to ensure the ASD pathway for Children and Young People is NICE compliant;  Better use of data, in relation to patterns and trends of need, to inform and evaluate commissioning of services and strategic planning;  Opportunities for employment and independent living are limited and need to be broadened and it was acknowledged the local area’s ambitious plans for adults’ services will help to support this.

A full copy of the letter is attached to this report. A development plan, focusing on areas of improvement is in process and will be presented to Governing Body in January 2020.

Governing Body members are requested to:

i. Note and formally receive the letter outlining the outcome of the Joint Local Area SEND inspection in Blackburn with Darwen; ii. Note areas of key strengths and areas of development, particularly in relation to long waits for neurodevelopmental pathways, therapies and some elements of mental health services, identified within the letter; iii. Receive updates in relation to SEND developments, including escalation of risk, via Quality Committee and Governing Body.

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Ofsted T 0300 123 1231 Agora Textphone 0161 618 8524 6 Cumberland Place [email protected] Nottingham www.gov.uk/ofsted NG1 6HJ [email protected]

1 August 2019

Ms J Ivory Director of Children’s Services, Blackburn with Darwen LA 10 Duke Street Blackburn BB2 1DH

Julie Higgins, Accountable Officer, East Lancashire/Blackburn with Darwen Clinical Commissioning Group Susan Hayward, Local Area Nominated Officer, Blackburn with Darwen Borough Council

Dear Ms Ivory and Ms Higgins,

Joint local area SEND inspection in Blackburn with Darwen

Between 17 June 2019 and 21 June 2019, Ofsted and the Care Quality Commission (CQC), conducted a joint inspection of the local area of Blackburn with Darwen to judge the effectiveness of the area in implementing the disability and special educational needs reforms as set out in the Children and Families Act 2014.

The inspection was led by one of Her Majesty’s Inspectors from Ofsted, with a team of inspectors including an Ofsted Inspector and a Children’s Services Inspector from the Care Quality Commission (CQC).

Inspectors spoke with children and young people with special educational needs and/or disabilities (SEND), parents and carers, local authority and National Health Service (NHS) officers. They visited a range of providers and spoke to leaders, staff and governors about how they are implementing the SEND reforms. Inspectors looked at a range of information about the performance of the local area, including the local area’s self-evaluation. Inspectors met with leaders from the local area for health, social care and education. They reviewed performance data and evidence about the local offer and joint commissioning.

This letter outlines our findings from the inspection, including some areas of strength and areas for further improvement.

Main findings

◼ Since 2014, the local area has made considerable progress in implementing the SEND reforms. Recent changes made to the leadership and governance of SEND

have accelerated the local area’s response to the reforms. The provision for children and young people with SEND is now a high priority for all key partners. An independent external review commissioned by the local area in 2018 shone a light on the effectiveness of provision across the local area. The findings from this review provided the catalyst for further change. Leaders have ensured that recent actions build on the foundations put in place following the introduction of the reforms. ◼ Leaders have an accurate view of the effectiveness of the local area in its implementation of the SEND reforms. They have paid heed to the intelligence provided by the comprehensive external review and a recent ‘stocktake’ as well as their own in-depth knowledge of the local area. This depth of knowledge is reflected in the SEND strategy. Consequently, leaders have made considerable progress in addressing the area’s most pressing issues. Parents, carers, children and young people and professionals recognise the improvements made to SEND provision since 2014. ◼ The recently-appointed director of children’s services has provided the impetus which has accelerated the local area’s pace of improvement. She has strengthened the leadership and governance of SEND. Leaders of SEND clearly understand their roles and responsibilities. They have built on existing strengths while challenging weak practice to secure a more equitable offer for children and young people. Across the local area, leaders, managers and staff share the aspirations and ambitions of their senior leaders. ◼ Leaders’ and managers’ deep and accurate knowledge of their local area is not fully reflected in improvement plans. For example, leaders have aspirations for children and young people with SEND ‘to live happy, healthy and fulfilled lives’ but plans do not make clear how leaders will know if this has been achieved. Too much emphasis is placed on parents’ and children and young people’s experience of the processes rather than the positive differences the provision makes to their lives. ◼ The strength of the local area is in the close working relationships between professionals across education, care and health. The moral purpose, enthusiasm and commitment of this group is palpable. Professionals’ ‘can do’ attitude means that most emerging issues are swiftly resolved. Professionals have rightly-placed confidence in each other’s experience and expertise. Furthermore, they do not shy away from challenging each other to ensure that children and young people get the best possible provision regardless of their needs. ◼ The local area has demonstrated a clear capacity for improvement. For example, the local area’s response to rising demand for social, emotional and mental health support has made a positive difference to children and young people. Training and support for education staff has meant that early intervention and prevention work for school-age children is available in their schools. School-age children value the wealth of easily-accessible advice and support available to them now. As a result, they report that they are more willing to seek help and support as they know and trust the adults involved.

◼ The majority of families who expressed their views, feel that their children get the help and support they need. Moreover, these families value the advice and guidance provided by professionals. These levels of satisfaction are reflected in the low incidence of tribunals and complaints. ◼ The local area has put in place opportunities for parents, children and young people to share their ideas and to give their feedback. The ‘friends of the local offer’ group has helped to make considerable improvements to the local offer website. This website now has a wealth of information about the range of provision available including nurseries, leisure activities and support groups. The website is organised well so that parents can access information which is relevant to their particular needs. ◼ Local area leaders gather comprehensive advice and guidance to inform education health and care (EHC) plans. The views of parents, children and young people are incorporated into these plans. Both parents and professionals find the planning and review meetings helpful. However, the EHC plans do not capture some of the ‘small things’ that would make a big difference to the lived experience of children and young people with SEND. For example, the provision of a library card or leisure centre pass to enable children and young people to pursue their interests or access to transport so that they could attend a sports club out of town. Furthermore, health services do not routinely receive final copies of EHC plans, so staff are sometimes working from an incomplete record. This hampers the effectiveness of these plans in improving the coordination of services to meet children and young people’s needs. ◼ The high-quality service provided by the SEND advisory team is valued by parents, children, young people and professionals. These experienced and expert advisory teachers provide effective support, training and advice. This ensures that provision effectively meets children and young people’s needs across the schools and settings in the local area. ◼ For pre-school and school-age children there is careful planning for transitions at each stage of their lives. Professionals work well together as well as with children and young people and their families so that they are well prepared for their next steps. Consequently, schools, colleges and settings report that there are very few children and young people who join with unidentified needs, and most make a successful start to their next stage of education. Where children and young people do present with unidentified needs, such as international new arrivals, the local area is quick to put in suitable support while assessments take place. Parents of very young children speak highly of the support available through groups such as ‘Little Treasures’. These groups are a lifeline for parents. For example, they help parents to meet other families facing similar challenges. Moreover, the co-location of services in local neighbourhood children’s centres makes it easier for parents to access appointments and clinics. ◼ The majority of children and young people in the local area attend good or better schools. Across most of these schools, outcomes are improving for

children and young people with SEND. Local area senior leaders have put in challenge and support to those providers where overall effectiveness is less than good. The local area makes good use of the wealth of experience and expertise from across the different types of provision. The willingness of school leaders to provide high-quality support to schools in challenging circumstances makes a positive difference. In addition, peer-to-peer SEND reviews are helping schools to accurately evaluate their strengths and weaknesses and so prioritise their actions. ◼ Strategic leaders have started to improve their use of a wide range of data to inform their decision-making. They have improved the reliability of data they collect. However, leaders do not make sufficient use of information about patterns and trends, for example where numbers of children and young people identified with a particular need are increasing, to inform and evaluate their commissioning of services. ◼ The new appointments made by the local area, including the head of education, designated clinical officer (DCO) and strategic director of transformation, have re- energised the local area’s implementation of the SEND reforms. These new leaders share the director of children’s services’ ambitious vision for the local area. Importantly, these leaders are already making a positive contribution to the realisation of the long-term vision for children and young people with SEND. ◼ Senior leaders from health, education and social care work closely together. Increasingly, they are commissioning services jointly for groups of children and young people as well as individuals. However, there are gaps in commissioning in some health services. This is linked to the lower levels of satisfaction reported by parents and carers. The neurodevelopmental assessment pathway is not fully compliant with the National Institute for Health and Care Excellence (NICE) guidelines for all age groups. Furthermore, the transition to adult health services is difficult for too many young people. ◼ Children’s needs are generally identified well before they start school. This leads to the timely assessment of needs and the provision of appropriate and effective support. However, children and young people are waiting too long for access to some therapies and mental health services.

The effectiveness of the local area in identifying children and young people’s special educational needs and/or disabilities

Strengths

◼ The healthy child programme is being delivered effectively. Over 95% of pre- school developmental assessments are conducted on time. All children and young people who move into the area receive a health assessment from a health visitor or school nurse. This helps to identify any unmet health needs at the earliest opportunity.

◼ The children’s services 0 to 19 team is alert to the early identification of SEND. For example, they recognise that SEND is more prevalent in certain ethnic minority groups. In order to ensure better identification and support, the service has employed members of staff who speak the languages of the most significant black and minority ethnic groups in the local area. This means that professionals can speak directly to parents and their children. This helps professionals to identify any speech and language difficulties more accurately. ◼ There are emerging strengths in joint commissioning in Blackburn with Darwen. The local area has a joint commissioning strategy. Services such as the youth offending team, occupational therapy and the child and adolescent mental health service (CAMHS) are commissioned jointly by health and children’s services. Local leaders are clear about the benefits of joint commissioning. There are well- developed plans to jointly commission new emotional well-being and mental health services in the area. ◼ The common assessment framework (CAF) process is used effectively across the local area to identify unmet needs. In the sample of records reviewed by inspectors, we saw that this process is used consistently well by professionals. Parents and professionals told us that this coordinated approach leads to all professionals gaining a clearer understanding of the child or young person’s needs. Consequently, identification of children and young people’s additional needs is timely, and needs are met holistically.

Areas for development

◼ The area recognises that the performance information which they use currently does not inform their strategic planning sufficiently well. The data used by leaders does not provide them with the specific information they need to identify and anticipate patterns and trends. There is a clear commitment to collect more useful data to improve commissioners’ understanding of needs better and to inform their decisions about service provision. ◼ The two-year-old health and development review is not integrated in the local area. Health visitors send a copy of the findings to the child’s nursery but do not routinely receive any information in return. Health visitors report good joined-up working with nurseries based in children’s centres but state that this can be variable with other settings. Each nursery has a link professional from the 0 to 19 team. However, not every nursery makes good use of this service. This means that opportunities for early identification through joined-up assessments are lost. ◼ Parents tell us they are not listened to when their children’s needs are less obviously visible. Parents describe having to ‘fight’ for professionals to recognise their child’s needs. Parents’ frustrations are compounded by long waits for neurodevelopmental assessments and some mental health services. This means that for this group of children and young people there can be delays in accurately identifying their needs.

The effectiveness of the local area in meeting the needs of children and young people with special educational needs and/or disabilities

Strengths

◼ Stakeholders from across the local area, including children, young people and parents and carers, are well represented and their voices are listened to. Their views are taken into account at an operational level and, to a lesser extent, at a strategic level. Parents and carers have been involved in the ‘refresh’ of the local offer and the design of the local area SEND strategic plan. The parents of children and young people who have an EHC plan value the annual review meetings and feel able to contribute fully to the process. The majority of parents who responded to our surveys, are happy with the support their child receives once their needs have been identified. ◼ Parents’ views are taken into account at strategic level via the parent carer forum, known as Blackburn with Darwen Parents in Partnership (BwD – PIP). This group has recently increased its membership to make sure that it is more representative of local parents and carers. As a result, this partnership fulfils its aim to be ‘the strong voice of parents and carers at the heart of Blackburn with Darwen’s delivery of services for children and young people 0 to 25 years with disabilities and additional needs and their families’. ◼ Local area leaders, including school leaders, are continually seeking to improve services. Strong partnership working has led to effective provision for pupils with SEND within the vast majority of schools. The SEND coordinators’ networks are highly valued. These networks enable professionals to develop their skills and share strong practice. This makes a positive difference to the effectiveness of provision for children and young people with SEND in schools. For example, in many schools, staff have worked with children and young people to involve them in setting their targets and developing their aspirations for the future. In the best examples, children and young people can make a direct link between the support they have received and the progress they have made. ◼ The local area SEND panel was established in response to the reforms in 2014. This panel decides whether children and young people should be assessed for an EHC plan. There are education, health and care professionals represented on the panel. This results in a holistic approach to making decisions about whether an EHC needs assessment is required. The panel also provides feedback to schools on the quality of their submissions. Schools have used this feedback to help them further improve their support to children and young people with SEND. ◼ Children and young people from across the local area benefit from the high- quality SEND support service. This service provides effective assessment, advice and training to schools and settings as part of its core work and is free at the point of delivery. School leaders, parents, children and young people were extremely complimentary about the positive impact of this service.

◼ Local area leaders have created a culture where professionals feel able to gather informal advice and support from one another. Inspectors found numerous examples of professionals describing how they simply ‘picked up the phone’ to expert colleagues who were only too willing to help them. This spirit of partnership working has had a positive impact on meeting the needs of children and young people with SEND. For example, professionals are quick to respond when a child or young person’s needs change suddenly. They work together to make appropriate interim support. This approach is successful in meeting children and young people’s needs in a timely fashion. ◼ The co-location of therapists in children’s centres has led to improved collaborative working. Children’s centre and nursery staff benefit from being able to gain advice from therapists on an ad-hoc basis. This leads to staff being able to provide effective support at the earliest opportunity. ◼ Effective early years support is in place for children with additional needs. Parents hold the range of early years services in high regard. They value the timely and prompt triage process used by the portage service to identify and assess children’s needs. Home visits, specialist support groups and parenting programmes provide constructive help and support to families when they most need it. Moreover, the early years support service provides good-quality advice and guidance to settings. Furthermore, early years specialist support assistants make a significant contribution to helping young children with SEND to overcome barriers to learning and get ‘school ready’. ◼ The common assessment framework (CAF) process is used highly effectively by health, social care and education professionals across the local area to identify unmet needs. Parents and professionals told us that this coordinated approach leads to all professionals having a better understanding of the child or young person’s needs and ensures there are no gaps in their care. ◼ School staff have received additional training on the identification of social, emotional and mental health issues and feel better able to identify needs. CAMHS professionals report an increase in appropriate referrals and the service now accepts 70% of referrals which demonstrates that other professionals understand their service offer. There is a mental health champion and a mental health first aider in the majority of schools in the local area. This strategy has been highly effective in meeting low-level mental health needs in school-age children. ◼ School nurses support children and young people with additional needs at transition into primary school, secondary school and college. Each young person is offered a full health assessment at each transition point, which includes a review of their physical, emotional and mental health needs. If additional support is required, this is delivered by the 0 to 19 team or appropriate referrals are made. This means that emerging physical or emotional health needs are identified at key transition points and aids the smooth transition between different settings. ◼ The DCO has a clear remit for change. She has already overhauled the EHC assessment health advice submission process. As a result of her audit, there has

been a noticeable improvement in the quality of health advice in EHC plans. Health professionals across the area describe the DCO as a valuable source of support and information.

Areas for development

◼ Sometimes the lack of clear targets in EHC plans reduces the ability of professionals, parents and children to measure, monitor and evaluate improved outcomes for children and young people with SEND. ◼ EHC plans are not fully reflective of children and young peoples’ needs. Health services have not routinely received final copies of EHC plans and have relied on schools to share plans with them. There is also no process in place to monitor receipt of EHC plans. In health records reviewed by inspectors, plans were not always readily available. This means that staff are working from an incomplete record. Further to this, health staff do not have an opportunity to review the content of the plan to check the accuracy of the health advice. ◼ The local area is aware young people can be offered multiple health assessments if they are known to several services. Currently the youth justice and children in our care (CIOC) teams talk to each to see who is best placed to deliver the health assessment. Information is shared between services. However, the EHC assessment and the CIOC health assessments are not aligned. This means that young people experience multiple appointments and no single service has a complete record of the child or young person’s needs. This may lead to delays in implementing support. ◼ Parents have concerns about their child’s transition into adulthood. Despite information being available on the local offer website and the work of the ‘New Directions’ team (the local authority’s careers information, advice and guidance service), many parents still feel anxious about their child’s future. Parents’ perception is that the range of post-16 and post-19 options open to young people with SEND is limited. ◼ The mental health needs of some young people aged 16 to 19 are not met as well as they could be. Currently, CAMHS is not available to young people between 16 and 19 years old. Some of these young people do not meet the higher thresholds set for the equivalent adult services. Funding has recently been secured to extend the CAMHS offer to this group from the end of the year. ◼ Current demand for psychological services for children and young people with lower-level mental health needs is exceeding capacity. This means that children and young people experience lengthy waits in having their needs met. This situation exacerbates the risk that children and young people’s needs escalate in the meantime. In addition, there is inequity in the offer of emotional wellbeing services across the local area. Some schools buy in additional services, but some schools do not, meaning that levels of support are variable depending on where children attend school.

◼ School staff who deliver interventions to improve children’s emotional well-being and mental health can contact mental health practitioners for advice and support. However, there is no systematic oversight by qualified health professionals to provide the local area with reassurance about its quality and suitability. ◼ Children and young people wait too long to access speech and language therapy (SaLT) and occupational therapy. Waiting times for intervention are up to 35 weeks in these services. Schools report they do not feel well supported by SaLT services. There is a recovery plan in place which is aiming to reduce waiting times, but it is too early to evaluate its impact. ◼ Children and young people wait too long to receive an autistic spectrum disorder (ASD) diagnosis. There are gaps in the commissioning of the neurodevelopmental pathway. For example, there is no commissioned pathway for 11- to 16-year-olds. Currently, paediatricians complete these assessments in isolation rather than as part of multidisciplinary arrangements. This is not compliant with NICE guidelines. The local area is in the early stages of redesigning this pathway. ◼ There are significant variations in access to health services for older young people. A smooth transition to adulthood is difficult to achieve within some paediatric services as there is no equivalent adult health team. Parents describe feeling terrified when their child is discharged from the paediatrician when they reach adulthood. Some health practitioners keep young people on their caseload beyond their commissioned age range and some do not. This gap in the commissioning process leads to ad-hoc arrangements and inequity in service provision.

The effectiveness of the local area in improving outcomes for children and young people with special educational needs and/or disabilities

Strengths

◼ The 0 to 19 team uses an outcome measurement tool which allows data collection at a service level. This means that the service can measure its effectiveness and adapt care pathways as required. ◼ The local area ensures that there is effective early intervention to support young children and their families. Practitioners have ensured that the CAF is central to ensuring that children and their families have well-coordinated and appropriate support. The number of young children who are being supported through the CAF has increased significantly in the past 12 months. As a result of this timely intervention, more of these children are ‘school ready’ when they join their Reception class. ◼ Parents who spoke with inspectors were overwhelmingly positive about the quality of their child’s educational provision. Most were generous in their praise of the positive difference that schools have made to the lives of their children and families.

◼ Increased early years identification and support are helping pupils with SEND to improve their attainment in primary schools. The proportion of Year 1 children with SEND meeting the expected standard in the phonics screening check has improved since 2014. These children’s improving success in reading continues as they move through to the end of key stage 2. ◼ At the end of key stage 2, the proportion of children with SEND reaching the expected standard in reading, writing and mathematics has increased over the past three years and is well above the national average. ◼ Outcomes are improving for young people with SEND at key stage 4. These young people make better progress than similar young people nationally. At the end of key stage 4, more young people are achieving GCSE grade 4+ in English and mathematics. This is an improving trend and is well above the national average. ◼ Many young people benefit from a curriculum that meets their needs in post-16 settings. This helps to improve their attainment. For example, the proportions of students attaining level 2 and level 3 qualifications are above the national averages for similar students. The attendance and retention rates of this group of students are also improving. ◼ Leaders have supported schools to be more inclusive. The number of fixed-term exclusions for children and young people with SEND has reduced considerably over the past 12 months. ◼ The successful work of the youth justice service has been recognised. The team has received a national award. As a result of effective support, the rate of reoffending for this group has reduced significantly over the past 12 months.

Areas for improvement

◼ Therapists use outcome measurement tools to track the progress of individual children. However, while they are able to evaluate the impact of their interventions on individual children and young people, they do not collate this data at a service level. This hampers the service’s ability to evaluate its effectiveness. ◼ Too many children and young people with EHC plans are persistently absent from school. Although some of these children and young people have complex medical needs, this frequent disruption to their education limits the effectiveness of the provision put in place and so hampers their progress. ◼ The local area’s provision for young people when they leave school is not sufficiently well developed. While the quality and range of educational provision post-16 and post-19 is improving, the opportunities for employment and independent living are limited. Consequently, young people do not benefit as well as they should from the good start they have made. The local area’s ambitious plans for adult services will benefit this group in the long term. However, for many young people with SEND, reliance on their families’ support limits their

opportunity to live the ‘ordinary lives in their local area’ that the local area expects for them.

Yours sincerely

Pippa Jackson Maitland Her Majesty’s Inspector

Ofsted Care Quality Commission

Andrew Cook Ursula Gallagher

Regional Director, North West Deputy Chief Inspector, Primary Medical Services, Children Health and Justice Pippa Jackson Maitland Louise Holland

HMI Lead Inspector CQC Inspector Phil Harrison

Ofsted Inspector

cc: DfE Department for Education Clinical commissioning group(s) Director Public Health for the local area Department of Health NHS England

GOVERNING BODY MEETING

GOVERNING BODY SUB-COMMITTEES’ MINUTES

Date of Meeting 11th September 2019 Agenda Item 21

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 √

GOVERNING BODGOVERNING BODY MEETING

Clinical Lead: N/A

Y Decision Recommendations

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

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CLINICAL COMMISSIONING GROUP (CCG)

GOVERNING BODY MEETING

11TH SEPTEMBER 2019

GOVERNING BODY SUB-COMMITTEES’ MINUTES

1. Introduction

This report presents the minutes of the Governing Body Sub-Committees 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

2.1 Primary Care Co-Commissioning Committee

The ratified minutes of the meetings held on 19th March and 21st May 2019 are attached as Appendices 1 and 2.

2.2 Pennine Lancashire Quality Committee

The ratified minutes of the meetings held on 22nd May and 26th June 2019 are attached as Appendices 3 and 4.

2.3 Audit Committee

The ratified minutes of the meetings held on 23rd April and 23rd May 2019 are attached as Appendices 5 and 6.

2.4 Blackburn with Darwen CCG Commissioning Business Group and East Lancashire CCG Sustainability Committee meeting as Pennine Lancashire Committees in Common

The ratified minutes of the meetings held on 15th May and 17th July 2019 are attached as Appendix 7 and 8.

3. Recommendation

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

Iain Fletcher Head of Corporate Business 5th September 2019

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Appendix 1

CLINICAL COMMISSIONING GROUP (CCG) Minutes of the Primary Care Commissioning Committee (PCCC) held on Tuesday 19th March 2019 in Meeting Room 2, Blackburn Central Library, Town Hall Street, Blackburn, BB2 1AG

PRESENT: Mr Graham Burgess CCG Chair Dr Nigel Horsfield Lay Member (Deputy Chair) Mr Roger Parr Deputy Chief Executive/Chief Finance Officer Mrs Janet Thomas Executive Nurse

IN ATTENDANCE: Mr Peter Sellars Primary Care Transformation Lead Mrs Catherine Lawless Primary Care Support Assistant (Minutes) Mrs Lysa Hasler NHS England Contracts Manager Dr Stephen Gunn GP Education Lead

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.

The Chair reminded members that the meeting will be digitally recorded in line with the Primary Care Co Commissioning Terms of Reference. 2. Apologies for Absence and Confirmation of Quoracy Apologies for absenceRATIFIED were received from: Paul Hinnigan, Sarah Danson, David Massey, Dr Preeti Shukla and Dr Geraint Jones

The meeting was confirmed as quorate. 3. Declarations of Interest

The Chair reminded Members of their obligation to declare any interest that they may have on any issues arising at Committee Meetings which might conflict with the business of BwD CCG. The Chair asked members if they would like to declare any Conflicts of Interest (CoI) relating to items on the agenda.

Declarations declared by members of the PCCC 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 those present that if, during the course of discussion, a CoI became

Page 1 of 3 apparent, it should be declared at that point. 4. Questions from the Public

No questions had been received from members of the public. 5. Draft Minutes of the Meeting held on 22nd January 2019

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

RESOLVED That the minutes of the meeting held on 22nd January 2019 were approved as an accurate record. 6. Action Matrix

Actions noted. 7. Matters Arising

Matters to be discussed as agenda items. 8. Primary Care Update Report

Mr Peter Sellars presented the Primary Care Update report which brought to the attention of members National and Local Primary Care news and information.

Primary Care at Scale (Primary Care Network/Neighbourhoods) PS advised that the four neighbourhoods are operating across Blackburn with Darwen and have been working on their locally agreed projects. PS advised the PCCC that the work undertaken by the North 12.25 neighbourhood in particular is consistent with the new GP Contract. In addition PS advised RP that the Apex workforce tool has now been fully accepted by all practices and will help with joined the their workforce planning. PS advised of Item 8.2 NHS Investment and Evolution document meeting. which sets out the direction for primary care for the next ten years. PS advised of the new Primary Care Network Contract Direct Enhanced Services (DES) and advised of the associated contract changes for practices which includes the changes in the Quality and Outcomes Framework (QOF) and advised that extended hours provision will be the Primary Care Network’s responsibility from 2020. PS advised that since 2015 Blackburn with Darwen has been delivering the majority of this work already. PS advised PCCC members that the extended hours DES funding that the CCG commission separately and also the GP Contract DES money will be combined going forward which will mean for Blackburn with Darwen by 2020 all of the extended hours provision will be delivered by Primary Care Networks. PS advised that Local Primary Care Federation will be asked to continue with their extended hours provision until 2020, and asked the PCCC for their approval to draft a letter outlining the extension arrangement to Local Primary Care Federation. CONCLUSION: That the PCCC approved for a letterRATIFIED be drafted to the Federation outlining the extended hours contract arrangement up until 2020. ACTION: PS to draft letter to Federation.

Questions and answers followed:

CONCLUSION: That the PCCC noted the contents of the Primary Care Update Report.

9. PMS Update: LH asked PCCC to note the contents of the paper which provides an update on the current position with regards to the funding for Blackburn with Darwen PMS practices and also the national move to equalise funding across primary care contract types. The PCCC noted that there are currently 23 GP practices in Blackburn with Darwen and that there are 3 contracts. It was noted that there are currently 13 General Medical Services (GMS) Practices, 7 Personal Medical Service (PMS) Practices and 1 Alternative Provider Medical Services (APMS) practice in Blackburn with Darwen. LH provided PCCC with historical information relating to the work undertaken by NHS England to review local PMS arrangements and to look at practices who they feel would be better off under a GMS Contract. LH drew PCCC members to the tables in the report which outlined which practices would be better off converting to a GMS practice and asked PCCC members for their approval for the practices to be informed of the current position and to ascertain whether they wish to return to a GMS Contract. Page 2 of 3 CONCLUSION: That the PCCC noted the contents of the paper and agreed for the PMS GP Practices to be contacted. ACTION: SD to contact PMS practices. 10. Oakenhurst Branch Surgery: LH advised of the current situation with regards to Oakenhurst practice who currently have a branch surgery in Mellor, Blackburn. LH advised of the historical arrangements with NHS Property Services and Lancashire County Council. The PCCC noted that after negotiations with Lancashire County Council the lease was transferred to the practice. The lease came into effect on 7th February 2017 and is for 5 years and has an end date of 6th February 2022 with a review date of 7th February 2020. It was noted that the practice has made a claim and has advised that they have not had any notional rent paid to them and are looking for back dated costs and that they are also claiming costs for clinical waste payments to the value of £14,000. LH advised of the Regulatory Framework and Contract Arrangements document which states that the contractor should make their application to the Board for financial assistance towards its rental costs, and where appropriate in consultation with the District Valuer agree that the lease is value for money. It is understood that there has not been an recent assessment made to date by the District Valuer. The practice has also advised that the surgery site at Mellor was temporarily closed from 3rd January 2018 and reopened14th May 2018 due to refurbishment of the building.

Questions and answers followed:

SG raised comment as to whether NHS England had experienced the same claim by other practices and whether if the PCCC agree to the reimbursement are they not setting a precedent for other practices to follow suit. It was agreed for LH to take this query back to NHS England. ACTION: LH to seek clarification from NHS England.

CONCLUSION: Deferred. Paper to the May PCCC.

11. Primary Care Financial Summary Month 11 – For Information – RP asked the PCCC to note the financial summary for Month 11. RP asked the PCCC to note that there is currently an underspend driven by prescribing in particular.

12. Primary Care Work Plan – That the PCCC noted the Primary Care Work Plan. AOB There was no any other business noted. 13. Date and Time of Next Meeting The next meeting is scheduled for Tuesday 21st May 12.30 – 2.00 p.m. Board Room, Fusion House.

The Chair thanked everyone for their attendance and input and stated that the meeting would now move into Part 2.RATIFIED

Page 3 of 3 Appendix 2

CLINICAL COMMISSIONING GROUP (CCG) Minutes of the Primary Care Commissioning Committee (PCCC) held on Tuesday 21st May 2019 Board Room, Fusion House PRESENT: Mr Graham Burgess CCG Chair Dr Nigel Horsfield Lay Member (Deputy Chair) Mr Roger Parr Deputy Chief Executive/Chief Finance Officer Mrs Janet Thomas Executive Nurse Dr Geraint Jones Lay Member Secondary Care Doctor (Retired) Mr Paul Hinnigan Lay Member Governance

IN ATTENDANCE: Dr Preeti Shukla General Practitioner (GP) Executive Mrs Catherine Lawless Primary Care Support Assistant (Minutes) Mrs Sarah Danson NHS England Contracts Manager Mr Peter Sellars Primary Care Transformation Manager Mrs Linda Ring Finance Manager Mrs Lysa Hasler NHS England Contracts Manager Dr Stephen Gunn GP Education Lead Mrs Sarah Johns Blackburn with Darwen Healthwatch

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.

The Chair reminded members that the meeting will be digitally recorded in line with the Primary Care Co CommissioningRATIFIED Terms of Reference. 2. Apologies for Absence and Confirmation of Quoracy

Apologies for absence were received from: David Massey

The meeting was confirmed as quorate. 3. Declarations of Interest

Declarations declared by members of the PCCC 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/

Page 1 of 5 The Chair reminded those present that if, during the course of discussion, a CoI became apparent, it should be declared at that point. 4. Questions from the Public

No questions had been received from members of the public. 5. Draft Minutes of the Meeting held on 19th March 2019

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

RESOLVED That the minutes of the meeting held on 19th March 2019 were approved as an accurate record. 6. Action Matrix

Actions noted. 7. Matters Arising

Matters to be discussed as agenda items.

Item 8 22.01.19 Primary Care Update Apex Workforce Tool – SD confirmed that the PCCC will be able to see the aggregated data.

Item 9 19.03.2019 PMS Update – SD confirmed that the two PMS practices have been contacted and given financial advice with regards to them both changing from a PMS practice to a GMS practice. Both practices are considering their options: ACTION: SD - PMS to GMS Paper to July meeting. 8. Primary Care Co Commissioning Terms of Reference – The Chair asked for the PCCCs comments with regards to whether any changes need to be made to the Primary Care Co Commissioning Terms of Reference which are due for annual review. It was noted that Dr Malcolm Ridgway no longer attends the meeting and therefore should be removed from the Terms of Reference. Discussions followed around quoracy currently standing at 2 Lay members and 2 Executive members. It was agreed that the Terms of Reference should be discussed at the CCGs Executive Team meeting as to whether another Executive member should be added. ACTION: CL - Primary Care Co Commissioning Terms of Reference to Blackburn with Darwen Executive Team Meeting. 9. Primary Care Update Report

Mrs Sarah Danson presented the Primary Care Update report which brought to the attention of members National and Local Primary Care news and information. General Practice QOESTRATIFIED – SD advised that the QOEST Plans for 19/20 were approved at the March meeting of the PCCC. The Post Payment Verification (PPV) visits have been completed . from a selection of Blackburn with Darwen Practices. Following the visits draft reports have been completed, once the reports have been approved the practices will all be written to advising them of the recommendations.

Blackburn with Darwen Primary Care Networks – Direct Enhanced Service (DES) - SD advised that all Blackburn with Darwen practices have signed up to the Network DES Agreement. The CCG has provided the necessary assurances to NHS England on 15th May 2019. It was noted that the PCN structure fits in with the Blackburn with Darwen Primary Care Strategy. Requirements on GP practices will start from 1st July 2019. The Network Contract DES is intended to remain in place until at least 31st March 2024. PS advised of an email received earlier that day that some practices have made a request to change their network footprint. It was agreed that an update will be brought to the July meeting. ACTION: PS – PCN Update – Agenda Item.

Digital Update for Blackburn with Darwen GP Practices - SD drew Committee members to the digital update and advised of the deployment of both the Apex Workforce Tool and also the deployment of the iPLATO/MyGP App for Blackburn with Darwen Practices. SD advised that Page 2 of 5 the Apex Workforce Tool is to be utilised in general practice to give a comprehensive analysis of workload and workforce to enable practices to plan for the future. The iPLATO/MyGP App meets the NHSE contract requirements for online consultation. It was noted that the tool has multiple functions to assist practices with achieving their forthcoming GMS targets for online services and includes the ability for 2- way messaging, booking and cancelling appointments and also ordering medication. SD advised of the next steps which are to discuss how the data can be best utilised for practices to help with workload pressures and challenges and to also help identify opportunities for practices to work together collaboratively.

Digital Minor Illness Referral Service (DMIRS) – GP to Pharmacy Referral – SD advised that as part of the National Pharmacy Integration Fund Programme Lancashire and South Cumbria were invited to pilot a Digital Minor Illness Referral Services (DMIRS). Darwen Primary Care Network where one of only two successful applicants chosen to pilot the scheme. The pilot is to go live from July.

Questions and answers followed:

CONCLUSION: That the PCCC noted the contents of the Primary Care Update Report. 10 Oakenhurst Branch Surgery – SD asked Committee members to note the contents of the paper and the practices request to the reimbursement of backdated clinical waste charges, and also the request for back dated notional rent. SD provided historical information with regards to the Mellor branch surgery between Lancashire County Council and NHS property Services. It was noted that at that time the practice had changed their lease arrangements but had not notified the District Valuer. It was noted that when the lease was transferred the practice also made their own arrangements for the disposal of clinical waste. It was noted that ordinarily costs for disposal of clinical waste is picked up and administered through NHSE. Costs are then charged to each individual CCG. SD advised that she has spoken to colleagues at NHS England to ascertain whether by paying the practice the back dated payments it would set precedent. NHSE have advised that they are not aware of any issues and as there was an existing arrangement in place where rent had been previously paid they could not see any issues. Questions and answers followed around responsibility for the errors that occurred which PCCC members all agreed was unclear. In conclusion the PCCC agreed to reimburse the cost of the notional rent and as a gesture of goodwill agreed to reimburse half of the clinical waste charges. ACTION: SD to contact District Valuer to assess the rent.

CONCLUSION: That the PCCC agreed to reimburse the cost of the notional rent and as a gesture of goodwill agreed to the reimbursement of half of the clinical waste charges. 11. Blackburn with Darwen Workforce Report – SD provided an update on the current work streams and national initiatives relating to workforce development in general practice across Blackburn with Darwen. SD advised that a focus of the Network Contract DES is to support the establishment of PrimaryRATIFIED Care Networks and the recruitment of new workforce. SD advised of the reimbursable roles which are Clinical Pharmacists, Social Prescriber Link Workers, Physician’s Associates, First Contact Physiotherapists and First Contact Community Paramedics. SD advised of the workforce collections undertaken by the CCG which are carried out in conjunction with the NHS England Transformation Team to help inform future workforce planning. SD advised that currently Blackburn with Darwen has a total of 123 GPs which include GP Partners, salaried GPs and long term locums (figures correct as of January 2019).

Lift 2 – It was noted that in 2016 the North West of England Foundation School piloted a number of Longitudinal Integrated Foundation (LIFT) programmes for trainee doctors. East Lancashire Hospitals Trust was one of eight acute trusts involved in the initial pilot. Health Education England and NHS England are now in the process of establishing a second scheme which will integrate Foundation Trainees and Physician Associates into longitudinal programmes. SD advised that the aim of LIFT 2 is to produce more doctors who have experience in varying care pathways. It was noted four practices in Blackburn with Darwen have expressed an initial interest in participating in the scheme.

Page 3 of 5 General Practice Nursing – The CCG continues to support the training and development of General Practice Nursing in line with the Blackburn with Darwen Primary Care Strategy. The Pennine Lancashire Enhanced Training Practice continues to provide local coordination of learning and development opportunities for primary care. There are now 23 GP practices who are accredited to offer Student Nurse Placements.

In conclusion SD advised that workforce development and education is a crucial element in the progression of a new sustainable mode of care for General Practice and as such the CCG is committed to supporting the Primary Care workforce to work differently.

Questions and answers followed.

Discussions followed around the Physician Associate positions. It was noted that the Physician Associates cannot prescribe due them not having a professional body and can just see patients with minor illnesses that don’t require a prescription. Comparison between a Physician Associate and a Paramedic was discussed to which it was noted that a Paramedic is attached to a professional body and can therefore take the necessary prescribing course. Committee members raised concern around the Physician Associates positions functionality and asked that job descriptions for both the Physician Associate role and also the job description for a Paramedic to get a better understanding of both their roles be brought to a PCCC meeting. The Chair also advised that a formal letter should be written to NHS England asking for their rational behind the training of a Physician Associate. LH made comment that perhaps if the PCCC could look at some case studies where Physician Associates have been in practice and have left and had exit interviews. This could also be brought to the PCCCs attention to get a better understanding. PH further asked that a base line assessment be developed in order to get a more up to date position on the number of GPs across Blackburn with Darwen and what Blackburn with Darwen needs for the future. The PCCC queried how many hours exactly is a whole time equivalent session for GPs as there is lack of clarity. ACTION: LH to pull together case studies/exit interviews as to why Physician Associates may have left practice. ACTION: SD – Job description for Physician Associates role and Paramedic Role. ACTION: SD - Letter to NHS England with regards to getting a better understanding of the Physicians Associate role and what impact they will have on general practice if they cannot prescribe. ACTION: SD update at the next meeting with regards to recruitment process for the new roles. ACTION: SD – Baseline Assessment on the current number of GPs needed going forward. ACTION: All Actions July meeting of PCCC.

CONCLUSION: That the PCCC noted the contents of the workforce development update. 12. Quarterly Contract Changes Summary – SD provided a summary of the Contractual changes for Blackburn with Darwen practices between January - March 2019. SD advised that there have been two partnershipRATIFIED changes:

Dr Calow has retired from Redlam Surgery and Dr Sudell has retired from Darwen Health Care.

ACTION: SD to amend the paper to read P81061 Darwen Healthcare.

SD advised the PCCC that NHS England is currently working through the Contract Variations updates for Lancashire and South Cumbria in line with National Variations.

CONCLUSION: That the PCCC noted the Contractual changes for Blackburn with Darwen practices. 13. MoU Co Commissioning Roll Over – SD advised that the MoU sets out roles, responsibilities and working arrangements for the delivery of primary medical care services across Lancashire and South Cumbria. The MoU is for the period 1st April 2-19 – 31st March 2020. It was noted that there has been discussions with NHSE and CCGs and the Co Commissioning Management Group with regards to how this is defined going forward. SD advised the PCCC there are ongoing discussions on how things are done across the ICS footprint which SD advised there may be no need for a MOU. Page 4 of 5 Questions and answers followed:

Discussions followed with regards to the MOU and Governance arrangements to which the PCCC agreed that the MOU should remain until further guidance is sought.

CONCLUSION: That the PCCC approved the continuation of the Memorandum of Understanding. 14. Primary Medical Care Commissioning & Contracting Governance Review: SD asked the PCCC to note that the findings from the Primary Medical Care Co Commissioning and Contracting Governance Review undertaken by Mersey Internal Audit Agency which was to evaluate the effectiveness of the arrangements put in place by Blackburn with Darwen CCG to exercise the primary care medical care commissioning function of NHS England as set out in the delegation Agreement. The PCCC noted that Blackburn with Darwen Primary Care Co Commissioning were given a rating following the review as per NHSE guidance of substantial assurance. PH advised that the audit will be monitored at the Audit Committee.

CONCLUSION: That the PCCC approved the Governance Review and noted the recommendations. 15. Primary Care Financial Summary Month 1 – For information - RP asked the Committee to note the contents of the financial summary and the overall position for month 1. RP in particular drew Committee members to the prescribing figures which he made comment that year on year prescribing is coming down, which he advised is impressive despite the pressures on general practice and the no cheaper stock available. RP further advised that subject to external audit the CCG has achieved its financial duties to which primary care services has played their part.

CONCLUSION: That the PCCC noted the financial summary for month 1. 16. Primary Medical Care Policy & Guidance Manual V2 – For information – SD asked the Committee to note that a summary of the changes is presented on pages 13 and 14 and a new chapter has been added on premises running costs and service charges. 17. Primary Care Work Plan – That the PCCC noted the Primary Care Work Plan. AOB There was no any other business noted. 13. Date and Time of Next Meeting The next meeting is scheduled for Tuesday 23rd July 12.30 – 2.00 p.m. Board Room, Fusion House.

The Chair thanked everyone for their attendance and input and stated that the meeting would now move into Part 2.RATIFIED

Page 5 of 5 NHS Blackburn with Darwen Clinical Commissioning Group NHS East Lancashire Clinical Commissioning Group Appendix 3 PENNINE LANCASHIRE QUALITY COMMITTEE Minutes of the meeting held on 22 May 2019 PRESENT:

Name and Title Org. 2018 2018 2018 2018 2018 2018 2018 2018 2018 2019 2019 2019 2019 2019 25/04 23/05 27/06 25/07 22/08 02/10 24/10 28/11 19/12 23/01 27/02 27/03 24/04 22/05 Clinical Representatives (two needed): Lay Advisor: Quality and Patient Engagement – Chair ELCCG ✓ A ✓ ✓ A ✓ ✓ ✓ ✓ A ✓ A ✓ ✓ Michelle Pilling Secondary Care Doctor (retired) BwDCCG ✓ A ✓ A ✓ A ✓ ✓ A ✓ ✓ ✓ ✓ ✓ Geraint Jones: Chair Chair Associate Director of Quality and Commissioning BwDCCG - ✓ ✓ A ✓ A - A ✓ A A ✓ - ✓ Janet Thomas Associate Director of Quality and Nursing / Head of Quality ELCCG ✓ ✓ ✓E A ✓ ✓ A ✓ ✓ ✓ ✓ ✓ ✓ ✓ Kathryn Lord until August 2018; Caroline Marshall from August 2018 Chief Finance Officer ELCCG ✓ ✓ ✓ A A AR AR AR ✓E AR A A AR A Kirsty Hollis Director of Performance and Delivery / Director of Commissioning ELCCG ✓ A ✓ A ✓ ✓ ✓ AR ✓E AR A A AR AR Sharon Martin until August 2018; Alex Walker from August 2018 Director of Quality & Chief Nurse ELCCG ✓ ✓ ✓ ✓ A ✓ ✓ A ✓ ✓ ✓ A AR ✓ Jackie Hanson until August 2018; Kathryn Lord from August 2018 Director of Quality and Performance BwDCCG ✓ A ✓ ✓ ✓ ✓ ✓ ✓ A ✓ ✓ ✓ ✓ ✓ Dr M Ridgway until October 2018; Dr Ridwaan Ahmed from November 2018 Governance, Assurance and Delivery Manager BwDCCG ✓ A A ✓ A ✓ A A ✓ ✓ A ✓ ✓ ✓ Claire Moir Lay Member BwDCCG ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ Dr Nigel Horsfield Chair Secondary Care Consultant ELCCG ✓ ✓ ✓ A ✓ ✓ ✓ ✓ ✓ A ✓ A ✓ A Dr Paul Taylor Medicines Management Representative (one needed): Senior Operating Officer, Primary, Community & Medicines Commissioning BwDCCG A A ------A - A - - - Julie Kenyon Associate Director of Research, Medicines & Clinical Effectiveness ELCCG ✓ ✓ ✓ ✓ A ✓ ✓ ✓ A ✓ ✓ A ✓ ✓ Lisa Rogan Safeguarding Representative (one needed): Head of Safeguarding (Adults) and MCA Leads PLCCG - ✓ - ✓ ✓ A - ✓ ✓ - ✓ ✓ ✓ ✓ Peter Chapman Head of Safeguarding (Children) PLCCG - - ✓ - - - ✓ ------Susan Clarke Head of Safeguarding (Children) PLCCG A - - - - - ✓ - - ✓ - A - - Debbie Ross Clinical Representatives: GP Quality Lead BwDCCG ✓ ✓ ✓ ✓ A A A ------Dr Ridwaan Ahmed until October 2018; VACANT from November 2018 GP Quality Lead ELCCG ✓ A ✓E ✓ A ✓ A ✓ A A ✓ ✓ ✓ ✓ Dr Umesh Chauhan GP Representative BwDCCG A ✓ A A A A A A ✓ ✓ A ✓ ✓ ✓ Dr Stephen Gunn GP Representative, Rossendale Locality ELCCG A A ✓ ✓ A ✓ A ✓ A ✓ ✓ ✓ A ✓ Dr Zeenat Sykes ✓: present A: apols L: arrived late E: left early R: representative in attendance

In Attendance: Michelle Clayton Senior Administrator, BwDCCG (Minutes) Judith Johnston Head of Clinical Commissioning, ELCCG Simon Bradley Quality & Performance Manager (Pennine), M&LCSU Vanessa Morris Infection andRATIFIED Prevention Control Nurse (Pennine) Lewis Wilkinson Quality and Performance Support Officer, M&LCSU

Quoracy shall consist of 50% of the Committee and must include 1 Non-Executive Governing Body Member / Executive Governing Body Member from each CCG, and one clinical representative from each CCG, one of whom must be a GP.

Pennine Lancashire Quality Committee 22/05/2019 Page 1 of 14 Minutes Approved by the Chair: 19/06/2019 NHS Blackburn with Darwen Clinical Commissioning Group NHS East Lancashire Clinical Commissioning Group

REF: ACTION 19.099 Welcome & Chair’s Update

The Chair opened the Pennine Lancashire Quality Committee and welcomed all attendees.

19.100 Apologies

Apologies were received from: K Hollis, A Walker, D Atkinson, P Taylor, C Locker and A Watson.

J Johnston attended to represent A Walker V Morris attended to represent A Watson.

19.101 Declarations of Interest

No declarations of interest noted. If any transpire during the meeting to be declared.

The meeting was quorate.

19.102 Minutes of the Meeting held on 24 April 2019

No amendments were offered for the minutes of the meeting held on 24 April 2019.

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

19.103 Action Matrix

19.061 Committee In Common Mental Health Update A Thornton has emailed Dr Z Sykes and has also spoken to Dr Fiona Ford, from a PCN perspective, on providing GP input within the mental health project team. This action can be closed.

19.062.1 Pennine Lancashire Quality and Performance Report Month 10 ELHT: A&E Breaches RATIFIED S Bradley has reviewed the data available with Business Intelligence. The data does not give an adequate breakdown around psychiatric and non-psychiatric conditions; however, mental health breaches are not having a significant impact on overall performance. A piece of work was undertaken by Gill Wild, which went through A&E Delivery Board, reviewing patients who breached 4 hours and what percentage went on to breach 12 hours. Work was undertaken around that pathway and implemented on the Burnley site which saw them hitting target. This action is superseded by action below.

ACTION: K Lord to obtain the report from Gill Wild for the Committee to have K Lord sight of regarding A&E breaches and the pathway implemented at the Burnley Site.

19.062.2 Pennine Lancashire Quality and Performance Report Month 10 Referral to Treatment (RTT) Incomplete A Thornton has advised that neurology is an ICS work stream therefore planning of educational events which will be led at an ICS level which C Gardener will be involved in. This action can be closed.

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19.062.5 Pennine Lancashire Quality and Performance Report Month 10 The Community Stroke Service performance data for BwDCCG is within the Quality and Performance Report for month 12. This action can be closed.

19.064.02 Pennine Lancashire Risk Management Update Following a meeting with C Moir, D Atkinson and the two Audit Committee Chairs, recommendations were offered in aligning risk management strategies for both CCGs and a proposal will be submitted to the Governing Body on 21 June 2019. Focus was on ownership and accountability through one Risk Management Group, chaired by K Hollis, and the findings reported to this Committee. The new format should be available within the next Risk Management Report in July 2019. This action can be closed.

19.076 Minutes of the Meeting held on 27 March 2019 19.061.1 Committee in Common Mental Health A Thornton advised that the final sentence should read ‘Directors of Finance are seeking to review mental health investment plan’. M Clayton has amended the minutes accordingly. This action can be closed.

19.077 Action Matrix 18.062.4 Pennine Lancashire Quality and Performance Report Month 10 Influenza (flu) A paper will be submitted to the Committee in September 2019 to test the plans for uptake of flu vaccination in frontline healthcare workers. M Clayton to add to September’s agenda. This action can be closed.

19.078 Terms of Reference M Clayton to circulate Terms of Reference for ratification. Action remains outstanding.

19.083.1 Pennine Lancashire Referral to Treatment Neurology Performance Report S Flynn, as lead commissioner of neurology, is to present a paper at the Committee in June 2019 on the neurology position. This action can be closed.

19.083.2 Pennine Lancashire Referral to Treatment Neurology Performance Report C Marshall raised workforce issues within the Quality Performance Meeting with ELHT. Ian Stanley was not in attendance; the most appropriate person to provide narrative around this. In the meantime, challenges have been put forward to ELHT and their response should be available for June’s committee.RATIFIED This action remains outstanding. 19.084.1 Pennine Lancashire Primary Care Update C Wright has taken the issue around the friends and family surveys to NHS England, LSC and locally and awaits responses.

19.084.2 Pennine Lancashire Primary Care Update C Wright to incorporate CCG data available in relation to GP telephone access and appointment availability. This will be available for June 2019. This action remains outstanding.

19.086.1 Pennine Lancashire Quality and Performance Report Month 11 Referral to Treatment (RTT) Incomplete Assurance has been sought that there is no harm to patients from treatments being delayed. Further details are contained under the Provider Report. This action can be closed.

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19.086.2 Pennine Lancashire Quality and Performance Report Month 11 52-week Waits S Bradley has confirmed with BMI Healthcare that it was a data error and this has been reported accordingly. This action can be closed.

19.086.3 Pennine Lancashire Quality and Performance Report Month 11 LCFT: IAPT J Johnston to include crisis support provisions available, such as the Transforming Care Programme, within the IPA/CHC report in June 2019. This action remains outstanding.

19.086.4 Pennine Lancashire Quality and Performance Report Month 11 The CCG are currently pursuing CQC registration with the Trust and there is an expectation that they become CQC registered. The Committee to be updated if/when the position changes. This action can be closed.

19.087 Pennine Lancashire Individual Patient Activity/Continuing Health Care Update K Lord will be the responsible director lead on the STOMP agenda for Pennine Lancashire, supported by J Johnston. A plan will be available within the next report. This action remains outstanding.

19.104 CONFIDENTIAL: Provider Update

This 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.

19.105 CONFIDENTIAL: GP Quality Group Minutes for BwD and EL CCGs: April 2019

This paper was tabled for reference. These were distributed prior to the meeting for information. No comments were raised. The confidential minutes of this part of the meeting will be circulated under separate cover. Members received these minutes.RATIFIED 19.106 CONFIDENTIAL: ICS – LCFT Mental Health Oversight Group Minutes: April 2019

Members received these minutes.

19.107 CONFIDENTIAL: NHS England – LCFT Quality Oversight Group Minutes: April 2019

This paper was tabled for reference. These were distributed prior to the meeting for information. Comments and actions are contained within the confidential minutes of this part of the meeting and will be circulated under separate cover.

Members received these minutes.

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19.108 Pennine Lancashire Quality and Performance Report Month 12

S Bradley presented key points from the Pennine Lancashire Quality and Performance Report for Month 12. Full details are available within the report.

ELHT: A&E Breaches In March 2019, Pennine Lancashire’s performance was below trajectory, which has remained a stable position. The focus of work will be on: • Flow ensuring length of stay reviews are part of ward MDR; • Capacity review of complex case management / resource to the wards; • Review of hospital dependency, including relevance of tests and investigations; • Review of external processes to support funding decisions (CHC). Ambulance Calls BwD CCG achieved category 1 target and underperformed against all other categories in March 2019. ELCCG unperformed against all response targets. There has been an increase in activity against category 1 and 2 responses, impacting on the position. NWAS and ELHT continue to work to reduce ambulance handover times to free up crews to attend more jobs. The use of ‘See & Treat’ is being maximised, however still convey high numbers of patients on a daily basis. Referral to Treatment (RTT) Incomplete The referral to treatment (RTT) incomplete pathway target was not met by both BwD CCG and EL CCG in March 2019 and YTD, with 8 x underperforming specialties at ELHT (Trust met target YTD under for Q4): • General Surgery –additional staff have been recruited to increase capacity and an action plan is in place to address the backlog. • Urology – the service have been meeting target since June 2018; this has dipped in March 2019 so will be closely monitored. • ENT – a middle grade left in mid-2018 which has caused pressures. Nurse clinics have been expanded to increase outpatient capacity. Pathways have been reviewed to identify alternative methods of follow up without reliance on the Consultant. • Ophthalmology – workforce challenges at Consultant and middle grade level. There is a national shortage of available medical staff. A full capacity and demand review at sub speciality level is taking place to identify areas for transformation. A Glaucoma audit has been undertaken to support future models for managing this condition. • Gastroenterology RATIFIED– there has been a growth in digestive diseases. Demand modelling has been completed and a business case has been approved to expand the service and recruitment is underway. The service are providing additional clinics exploring options around triage to support demand management. • Dermatology – there are workforce challengers. The department are actively trying to recruit and are utilising Specialist and Advanced Nurses by expanding the conditions they are able to review. The Trust are working with the CCG to develop and implement a single point of access and are undertaking additional clinics. • Thoracic Medicine – there is a shortage of 2 x Consultants. A Locum has started and a new Consultant came into post in April 2019. A business case has been submitted with workforce recommendations and different ways of working with a redirection of referrals to ANP’s where appropriate. • Maxillofacial – An increase in nurse led and capacity and demand modelling underway with NHS England. The main pressure continues to be neurology for LTHTr. Demand continues to outweigh clinical capacity and templates and demand management schemes are in place however with limited impact on waiting times (26 weeks). A programme business case proposal has

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been completed to ICS to request neurosciences be prioritised and led by ICS as a programme of work for 2019/20. Steve Flynn to attend next month’s committee to provide a more detailed breakdown of work. 52-week Waits In March 2019, there were 2 patients reported with a wait of over 52 weeks for EL CCG and 0 patients for BwD CCG. • 1 x Pennine Acute – the patient has now received treatment. The Trust are working with their host commissioner to agree a process of providing further assurances for 52-week waiters. • 1 x Blackpool Teaching – A Cardiothoracic patient has been seen with no reported harm from the extended wait. A response is awaited to additional queries. ACTION: C Marshall to raise a challenge in terms of potential harm caused to the C Marshall Blackpool patient and deterioration of their condition due to the extended wait.

Cancer Patients seen within 2-weeks of an Urgent Referral for Breast Symptoms where Cancer is Not Suspected The ‘Let’s Talk Campaign’ has now commenced and an updated symptomatic breast referral template launched, which appears to be having a positive impact on performance. ELHT have verbally reported that they have met cancer targets in March and April 2019.

Cancer - % of patients receiving definitive treatment within 31 days of a cancer diagnosis The standard for patients to receive definitive treatment within 31 days of diagnosis was not met by BwDCCG in March 2019. YTD the target is being met by both CCGs. There were 2 x breaches leading to the underperformance (1 x elective capacity inadequate and 1 x provider unable to make contact with the patient by telephone).

Cancer Patients Receiving First Definitive Treatment for Cancer within 2-months This 62 day target was not met by either CCG in March 2019 and is also not being met YTD.

Some ongoing issues relating to: • Endoscopy – waiting time being propped up by additional sessions. • Radiology/ Pathology – reporting time being propped up by outsourcing. • Oncology – capacity being propped up by agency, additional sessions from Lancashire Teaching Hospitals and additional sessions from BMI. • Theatre Capacity –RATIFIED being propped up by moving less urgent cases and additional sessions.

Ongoing actions to improve the position include: • Implementation of trust wide Cancer Performance Meeting (Cancer PTL). • Review of Cancer Reporting Framework – in discussions with Cancer Data Manager and Information to ensure the most up to date and robust performance data is shared with relevant stakeholders in a timely manner. • Patient education. • Collaborative working with Primary Care. • Recruitment to vacancies within Clinical service. • Capacity & Demand – initial review completed by Cancer Alliance, more detailed view being undertaken locally. • Pathway review – New alliance pathway for Prostate, Upper GI, Colorectal and Lung • Investment of Alliance Funding in pathways to improve processes and increase activity. • Additional Capacity lists being undertaken.

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• Outsourced Radiology/ Pathology Reporting. • ELHT Cancer Action Plan overseen by the Pennine Lancashire Quality Committee. • Commencement of additional Project manager to facilitate faster diagnosis. • Endoscopy review and action plan work.

The infection control section of the Quality and Performance report deferred to agenda item Lancashire Healthcare Associated Infections 2018/19 Quarter 4 Update.

LCFT: Care Programme Approach (CPA) The target of service users on CPA to be followed up within 7 days of discharge from psychiatric inpatient care was achieved at Trust level in March 2019. 8 breaches were reported at Trust level, 1 of which was at ELCCG due to lack of patient engagement.

LCFT: Early Intervention Psychosis (EIP) At Trust level, the target for treatment within 2 weeks was achieved in March 2019 and is being achieved YTD. There were 13 patients who waited over 2 weeks in March 2019. Analyses of breaches show that 8 were due to a delay in receiving the referral. LCFT’s EIP report notes a number of actions to support performance, detailed in the report.

LCFT: ADHD (Adults): Seen within 18-weeks In March 2019, there was a slight improvement on the proportion of new referrals waiting less than 18 weeks, compared with the February 2019 position. There are still considerable challenges to the service in terms of demand for the service. LCFT have instigated a procurement process to identify external support to provide clinical services that can meet demand levels.

At the Performance and Effectiveness Group Meeting on 2 May 2019, it was reported that the Leading Excellence in ADHD in Primary Care (LEAP) model was not having the impact on waiting lists as first anticipated meaning that the position should remain static. Work continues with this model and feedback will be provided accordingly.

LCFT: IAPT Mindsmatter are required to deliver 19% prevalence target in Quarter 4. It was reported that BwD CCG met the set target and EL CCG failed to achieve the Quarter 4 target. The service continues to prioritise waiting times and recognises the impact lengthy waiting times will have on a patient’s wellbeing, risk and experience. Initial welcome calls are being made promptly however actual interventions are delayed. Discussions are ongoing with Commissioners to try and makeRATIFIED a speedier pathway. Lancashire-wide areas of concern, in relation to each service - PWP, CBT and counselling are detailed within the report.

LCFT: Memory Assessment Service (MAS) In March 2019, there was a deterioration of performance linked to staffing issues. The team are currently reviewing the booking of home visits to create more capacity for initial assessments and a further clinic per week with the introduction of clinic slots at Yarn Spinners.

There was an issue with diagnostics, in terms of a delay in results being received. The radiology specification has been reviewed by Commissioners as part of the redesign to readdress diagnostic delays which should have a positive impact on timeliness. That issue has been escalated through to LCFT Contract Management.

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CQC BMI Healthcare Lancaster were notified of an expected CQC inspection. That inspection has now taken place and CQC attended last week unannounced. Initial feedback from BMI, was that it was a positive inspection; a few minor issues have been addressed and CQC have requested additional information which has been provided and the visit report is awaited.

Questions and answers followed.

The Chair referred to the table on Page 10 of the report which provides the volume of incidents with a response from NWAS. There was a significant increase in incidents in March across every category and to see an improvement in performance, with so much additional demand actually shows substantial progress. The table provides additional context in terms of performance.

Dr Umesh referred to Page 32 of the report and the RTT Incomplete and queried what the red areas where a reflection of. S Bradley advised in terms of overall performance, ELHT are one of the few Trusts locally to meet up to Q4. The red areas are a reflection of the pressures such as staffing issues in a number of key areas, compete and demand in terms of counter-activity and the pension/taxes remuneration which is having an impact on some the specialities. In certain areas redevelopment and remodelling is commencing with a systematic approach around what staffing models can be utilised; where can ANP’s be used differently and various other positions. S Bradley feels that further work could be focused within Primary Care.

ACTION: The Quality Team to obtain an outline of where the Trust are proactively Quality seeking work in the community to assist with staffing pressures. Team

ACTION: The Quality Team to look at any specific areas where the Trust are Quality looking to redesign outpatient appointments to free up capacity. Team K Lord added that following earlier conversations, this information needs to link to the priorities. In terms of capacity, rather than to focus on a large number of priorities, to focus on the top 5 or 6 priorities and do it more successfully.

ACTION: K Lord to feedback to the Committee work around the top 5 priorities. K Lord The Chair referred to PageRATIFIED 34 of the report and queried what the main themes and trends for trolley wait breaches were in quarter 4. The overarching theme is bed availability for mental health patients. A specific Corridor Nurse is still in post to attend to overflow.

The Chair referred to the significant increase for vacancy rates for nurses on Page 35 of the report which shows an increase of 9.9% in February to 17.6% in March 2019. S Bradley advised that the nurse vacancy rates have increased subsequent to a dramatic increase in establishment numbers.

The Chair drew attention to Page 48 /50 and the value of contracts for the smaller hosted providers, as Lancashire Women’s Centre and The Community Wellbeing Service are showing amber across the whole. It would be beneficial to understand what improvements need to be made.

ACTION: S Bradley to obtain further details and include further narrative around S Bradley the services showing amber.

The Committee formerly received the report for information.

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19.109 Pennine Lancashire CQUIN 2018/19 Quarter 4 Payments

2018/2019 CQUIN Reconciliation has taken place for Q4 for ELCCG and BwDCCG hosted contracts, and the quarterly report was received. Full details of the requirements of each indicator and evidence submitted are available within the report and appendices

ELHT Of the 5 indicators, 4 indicators have been fully met and national publication of data is awaited for 1 element of the reducing the impact of serious infections scheme.

LCFT Of the 5 CQUIN indicators for Q4, 4 have been fully achieved and 1 has been partially achieved relating to the staff survey.

MCFT, BMI Healthcare, The Community Wellbeing Service, About Health and Age UK have met all milestones for Q4.

Members were asked to support the recommendations relating to the payment of 2018/19 Q4 CQUIN monies.

Members acknowledged the report and approved the recommendations for payment of CQUIN monies as outlined in the report.

19.110 Serious Incident Review Group Annual Report 2018/19

This is the first annual report for Serious Incident Reviews and was presented by L Wilkinson for 2018/19. It aims to provide assurance of a robust process of scrutiny challenge, shared learning undertaken by the Quality Team and set out developments of these processes over the next year.

CCG Performance In 2018/19 187 x RCA reports have been submitted by providers hosted by EL CCG and BwD CCG. Out of those report 1 x report was reviewed outside of the review timeframe, this was due to human error within the Quality Team. No further instances have been identified to date thus providing assurance lessons have been learned. Provider Performance RATIFIED ELHT The chart exhibited on Page 2 of the report shows an increase in the total number of incidents reported in 2018/19 compared to the previous year. The increase of incidents reported in March 2019 correlates with an increase in Grade 3 pressure ulcers reported in this month. In December 2018, new guidance was released in reporting Grade 3 pressure ulcers which has had an impact. The Chair highlighted that stating ‘non-compliance’ refers to blame to the patients and some of these patients may be older/vulnerable patients who have capacity. L Wilkinson advised the terminology from the new guidance has changed. C Marshall added that a many reports show patients did have capacity but chose to decline treatment. Falls remain the highest incident type in 2018/19. ELHT have undertaken a live piece of work as part of the falls collaborative which is being rolled out across ward and departments across the Trust. There are a range of quality improvement priorities that ELHT are putting in place, detailed in table 2 on page 3.

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There have been 2 x Never Events reported by ELHT in 2018/19. ELHT have introduced a number of key changes in relation to these incidents, detailed within the report. The overall position for ELHT at the start of 2018/19 was positive and has continued to improve over the course of the year, exhibited on the dashboard in Appendix 1. ELHT have worked with the CCG to introduce a new internal process for the approval of extension requests. The current position gives assurance that incidents are being investigated and the reports submitted in a timely manner.

LCFT The chart exhibited on Page 8 of the report shows an increase in the total number of incidents reported in 2018/19 compared to the previous year. LCFT reported in March 2017 that they have a maturing safety culture where staff are encouraged to report incidents when they occur, therefore the CCG would expect to see an increase in the number of incidents reported. Apparent/actual/suspected self-inflicted harm remains the highest incident type in 2018/19. Data published by the National Confidential Inquiry into Suicide and Homicide by people with Mental Illness shows that LCFT are below the national median suicide rate. To address some of the incidents reported LCFT have introduced some measures to aid the reduction of these incident types, laid out in table 3 and 4. Measures have also been introduced to reduce key themes arising from the LCFT reports such as poor record keeping and non-completion of assessments. Throughout the year the CCG has challenged LCFT to improve their serious incident position; the Trust has shown some improvements in the areas highlighted in appendix 2 which demonstrates the improving relationship between the CCG and LCFT.

Developments for 2019/20 The incident position for ELHT has improved so focus can now move towards improving the outcomes of investigations and ensuring that learning is embedded. The plan is to introduce evidence checking visits to ELHT to assess whether learning, and action plans are being implemented successfully. The new Patient Safety Framework is due to be released later this year and will replace the current Serious Incident Framework (2015). The new framework is expected to bring in some significant changes to current processes, detailed within the report.

Conclusion The serious incident positions continue to improve for providers hosted by East Lancashire and Blackburn with Darwen CCGs, and there are a number of improvements being made internally with Trusts to improveRATIFIED patient safety and learning as highlighted in this report. Additional work is also under way with wider organisations. The Quality Team continues to work closely with providers to aid in these improvements.

The Chair thanked L Wilkinson for the excellent report, providing narrative as well as statistics. The report provides assurance that the CCG is meeting its responsibilities to ensure that serious investigations are being appropriately investigated, learning is taking place and that learning from incidents is being shared across the relevant provider organisations.

The Committee formerly received the report for information.

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19.111 Pennine Lancashire Risk Management Update and Governing Body Assurance Framework (GBAF)

C Moir presented the Pennie Lancashire Risk Management Update. The Committee receives the Corporate Risk Register (CRR) and Governing Body Assurance Framework (GBAF) from both CCGs in order to enable members to evaluate the assurance on the management of corporate risks.

Within BwDCCG there are currently 11 operational risks and 6 strategic risks held on the register. Within ELCCG there are currently 16 risks on the CCG Risk Register; 7 of these with a risk rating >15 escalated to the GBAF. Across Pennine Lancashire there are 10 risks which are included on the risk registers of both CCGs.-: • A&E 4 hour standard 2018/19 • 62 Day Cancer Waiting Times Target • Ambulance Performance • Initial Health Assessments for Looked After Children • Mental Health System Pressures • SEND • Lack of Inpatient Beds for Children and Young people with Mental Health issues (Tier 4 beds) • Loss of Residential and Nursing Home Beds from Care Home Sector and impact upon system resilience • Failing to deliver the 18 Week Incomplete Pathway (Referral to Treatment) NHS Constitutional Standard • UK’s exit from the EU (with a ‘deal’ or ‘no deal’) presents unknown risks that may adversely affect healthcare delivery across Pennine Lancashire

The Risk Management and Compliance Group met on the 7 May (minutes of that meeting awaited) in which discussion and challenges took place regarding risks and this is where assurance can be fed up to the Quality Committee.

The Audit Committee raised a challenge in relation to risks open throughout the reporting period, such as A&E which held a risk of 20 with a target risk rating of 6 and at what point it would be recognised that the risk target would not be met.

Currently, K Hollis and D Atkinson are looking at alternative systems to use in terms of how to manage and operate the Risk Register. Other CCGs have useful tools and a more dynamic risk management RATIFIEDprocess. The Chair drew attention to section 3, where combined risks had considerably different scoring, such as IHA where EL had a risk rating of 16 and BwD had a rating of 9. It was clarified that it was due to different issues between the CCGs such as timescales as there was a more robust system in BwD.

The Chair highlighted the narrative around Section 3.5 Mental Health System Pressures in which the sentence reads ‘The CCG’s are assured that there is a significant amount of work being undertaken to mitigate this risk.’ The Chair does not feel that that level of assurance has been provided to the committee. C Moir to return to the risk owner with this challenge from the Quality Committee. C Marshall will liaise with C Gardener to assist with the review of this risk as the Quality Team are heavily involved with the mental health agenda.

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The Chair would also like the risk around Tier 4 children’s beds to be returned to the risk owner as it reads within the actions that The Harbour has reduced their bed numbers to 7 and the Committee has been assured that bed numbers will not be reduced until the national position has increased. C Moir will take this risk back to the Risk Management and Compliance Group for scrutiny.

The Chair requested that future reports are readable, as the text was too small to read, with real time updates as a future ambition. The Committee will continue to scrutinise the more significant risks.

One new risk was added to each of the CCG’s Risk Registers. Wording has been approved by NHSE England which states ‘UKs exit from the EU (with a ‘deal’ or ‘no deal’) presents unknown risks that may adversely affect healthcare delivery across Pennine Lancashire’.

No risks have been closed in April/May 2019.

Two risk have been re-instated on both risk registers following the last PLQC discussions:

• 259 – Failure to Achieve A&E 4-Hour Standard • 157 – Failure of NWAS to achieve standards outlined in ARP

The Committee formerly received the report for information.

19.112 Pennine Lancashire Complaints Report 2018/19 Quarter 4

C Marshall presented this report to provide an update on the Q4 2018/19 position for Complaints, MP Letters and PALS enquiries received across Pennine Lancashire. Full details are available within the report.

Over the last 4 quarters there has been a significant increase in complaints. Analysis between the two CCGs of cases received by year, show that BwDCCG’s position in relation to complaints has remained static; MP letters and PALS enquiries have decreased, however, there is a substantial increased trend within ELCCG. There is no rationale to explain the increase in complaints for EL CCG, however this will be monitored and reported accordingly if any clear theme or trend is identified. In terms of cases closed inRATIFIED Q4, the EL figures within the report are incorrect. There were 20 Complaints closed and 12 MP Letters closed, making total complaints closed in EL as 126.

Section 4.2 categorises the complaints received in Q4. Hospital complaints (predominately ELHT) are the highest number of complaints received for EL CCG. Key themes from these complaints include communication and clinical care.

Medicines Management remains a consistent trend for BwD CCG and specifically relates to commissioning decisions in respect of self-care medication or decisions made about drugs that have been discussed at the Lancashire Medicines Management Board.

CHC remains a consistent trend for both EL and BwD CCGs and is focussed around decision making processes, lack of timely communication and decisions made in respect of eligibility for CHC funding.

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It is pertinent to note that no complaints have been received into either CCG during Q4 2018/19 relating to mental health services. The Chair challenged whether this information is accurate, as mental health patients may be too vulnerable or lack capacity in regard to how to raise a complaint, which raises concerns.

There were no new complaint cases referred to the Parliamentary Health Service Ombudsman during Q4 2018/19.

ACTION: Sarah Harrison, Head of Patient Feedback Team, to attend the C Marshall Committee and provide a presentation on wider work undertaken to capture complaints including people presenting with significant mental health distress.

There have been 10 x MP letters received during Q4 2018/19 for EL which demonstrates expected variation from previous quarters. These letters have been received from 4 x MP offices with 3 x letters relating specifically to the CHC process and outcome. J Johnston queried whether the letters relate to the actual number of letters received or the number of patients that have complained.

ACTION: C Marshall to check whether there is a duplication of complaints i.e. are C Marshall the letters in relation to the number of letters received or the number of patients that have complained.

19.113 Lancashire Healthcare Associate Infections update 2018/19 Q4 update

A Watson presented this report to provide an update on the Q4 2018/19 position for the Lancashire in regard to Healthcare Associated Infections.

MRSA During Q4 there was no case of MRSA within BwD and EL and 5 across the ICS, bringing the total to 15 for the year with 5 EL residents and 1 BwD. Thorough investigations have taken place with no significant lapses in care being identified with the majority of patients, many of whom are vulnerable due to age or have co-morbidities. Clinical reviews continue to ensure lessons are learned and shared appropriately.

Clostridium Difficile During Q4 there were 125 RATIFIEDcases of C-Diff bringing the total to 488 for the year. BwD and EL CCGs are breaching their target trajectories: BwD have a total of 47 cases against a year-to- date target of 39; and EL has a total of 78 cases against a year-to-date target of 57. The Infection Prevention Nurses within LCC support the majority of CCGs by providing management advice and performing the review for non-Acute cases.

E-Coli To date there have been 1463 cases of E-Coli across Lancashire, against a trajectory of 819. Most local CCGs are breaching their cumulative total, despite implementing health economy action plans. The trajectory is to reduce by 10% year on year which is not being achieved. Across the ICS the ‘to date’ trajectory is currently being breached by 79% which is a significant breach. There is however an issue with the E-Coli target as the trajectory is set against Health Care Associated Infections but the baseline and the data used are the total number of cases so it is not possible to determine which ones are health care associated. These are being analysed and a very small percentage are being aligned to health care, specifically with 82% of the cases so far this year identified as community onset. The majority have been reviewed and many have had no recent healthcare involvement.

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A Watson advised that a different approach will be taken next year, with a more public health role rather than surveillance and data gathering to actually try to address and have an impact on wider public health issues.

Care Homes The IP Team continue to support those homes through the Quality Improvement Programme. At the beginning of Q4 there were 21 care homes going through the process. 3 new homes have been added whilst 2 have completed the programme. IPNs have supported 55 care homes to manage outbreaks during Q4.

Members acknowledged and approved the content of the report.

19.114 Quality Contract Meeting Draft Minutes: April 2019 East Lancashire Hospitals NHS Trust BMI Healthcare

These were distributed prior to the meeting for information. No comments were raised.

Members acknowledged the minutes.

19.115 ELCCG Risk Management and Information Governance Group Draft Minutes – April 2019

These were distributed prior to the meeting for information. No comments were raised.

Members acknowledged the minutes.

19.116 Any Other Business

No other business discussed.

19.117 Items for the Risk RegisterRATIFIED No items for inclusion.

16.118 Date & Time of Next Meeting

The next meeting has been scheduled on Wednesday 26 June 2019 at 1pm in Darwin Suite, Innovation Centre, Evolution Park.

Deadline for papers is 5pm on 17 June 2019.

Pennine Lancashire Quality Committee 22/05/2019 Page 14 of 14 Minutes Approved by the Chair: 19/06/2019 NHS Blackburn with Darwen Clinical Commissioning Group NHS East Lancashire Clinical Commissioning Group Item 4 PENNINE LANCASHIRE QUALITY COMMITTEE Minutes of the meeting held on 26 June 2019 PRESENT:

Name and Title Org. 2018 2018 2018 2018 2018 2018 2018 2018 2019 2019 2019 2019 2019 2019 23/05 27/06 25/07 22/08 02/10 24/10 28/11 19/12 23/01 27/02 27/03 24/04 22/05 26/06/ Clinical Representatives (two needed): Lay Advisor: Quality and Patient Engagement – Chair ELCCG A ✓ ✓ A ✓ ✓ ✓ ✓ A ✓ A ✓ ✓ ✓ Michelle Pilling Secondary Care Doctor (retired) BwDCCG A ✓ A ✓ A ✓ ✓ A ✓ ✓ ✓ ✓ ✓ ✓L Geraint Jones: Chair Chair Chair Chair Associate Director of Quality and Commissioning BwDCCG ✓ ✓ A ✓ A - A ✓ A A ✓ - ✓ A Janet Thomas Associate Director of Quality and Nursing / Head of Quality ELCCG ✓ ✓E A ✓ ✓ A ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ Kathryn Lord until August 2018; Caroline Marshall from August 2018 Chief Finance Officer ELCCG ✓ ✓ A A AR AR AR ✓E AR A A AR A ✓ Kirsty Hollis Director of Performance and Delivery / Director of Commissioning ELCCG A ✓ A ✓ ✓ ✓ AR ✓E AR A A AR AR AR Sharon Martin until August 2018; Alex Walker from August 2018 Director of Quality & Chief Nurse (Clinical Post) ELCCG ✓ ✓ ✓ A ✓ ✓ A ✓ ✓ ✓ A AR ✓ ✓ Jackie Hanson until August 2018; Kathryn Lord from August 2018 Director of Quality and Performance (Clinical Post) BwDCCG A ✓ ✓ ✓ ✓ ✓ ✓ A ✓ ✓ ✓ ✓ ✓ A Dr M Ridgway until October 2018; Dr Ridwaan Ahmed from November 2018 Governance, Assurance and Delivery Manager BwDCCG A A ✓ A ✓ A A ✓ ✓ A ✓ ✓ ✓ A Claire Moir GP Quality Lead (Clinical Post) ELCCG A ✓E ✓ A ✓ A ✓ A A ✓ ✓ ✓ ✓ A Dr Umesh Chauhan GP Representative (Clinical Post) BwDCCG ✓ A A A A A A ✓ ✓ A ✓ ✓ ✓ A Dr Stephen Gunn GP Representative (Clinical Post) ELCCG A ✓ ✓ A ✓ A ✓ A ✓ ✓ ✓ A ✓ A Dr Zeenat Sykes Lay Member BwDCCG ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ Dr Nigel Horsfield Chair Secondary Care Consultant ELCCG ✓ ✓ A ✓ ✓ ✓ ✓ ✓ A ✓ A ✓ A ✓ Dr Paul Taylor Medicines Management Representative (one needed): Senior Operating Officer, Primary, Community & Medicines Commissioning BwDCCG A ------A - A - - - - Julie Kenyon Associate Director of Research, Medicines & Clinical Effectiveness ELCCG ✓ ✓ ✓ A ✓ ✓ ✓ A ✓ ✓ A ✓ ✓ ✓ Lisa Rogan Safeguarding Representative (one needed): Head of Safeguarding (Adults) and MCA Leads PLCCG ✓ - ✓ ✓ A - ✓ ✓ - ✓ ✓ ✓ ✓ ✓ Peter Chapman Head of Safeguarding (Children) PLCCG - ✓ - - - ✓ ------Susan Clarke Head of Safeguarding (Children) PLCCG - - - - - ✓ - - ✓ - A - - - Debbie Ross Clinical Representatives: ✓: present A: apols L: arrived late E: left early R: representative in attendance

In Attendance: Deryn Ashby Quality and Performance Officer, MLCSU (Minutes) Judith Johnston Head of Clinical Commissioning, ELCCG Simon Bradley Quality & Performance Manager (Pennine), M&LCSU Steve Flynn Commissioning Manager, Chorley, South Ribble and Greater Preston CCGs (1 item) Vanessa Morris Infection andRATIFIED Prevention Control Nurse (Pennine), PLCCGs Lewis Wilkinson Quality and Performance Officer, MLCSU Catherine Wright Primary Care Quality Lead (Pennine), PLCCGs (1 item)

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REF: ACTION 19.119 Welcome & Chair’s Update

The Chair opened the Pennine Lancashire Quality Committee and welcomed all attendees.

19.120 Apologies

Apologies were received from: D Atkinson, Kim Ciraolo, Dr Umesh Chauhan, Clair Moir, Dr Zeenat Sykes, Janet Thomas, A Walker.

J Johnston attended to represent A Walker

19.121 Declarations of Interest

No declarations of interest noted. Any that transpire during the meeting to be declared.

The meeting was quorate.

19.122 Minutes of the Meeting held on 22 May 2019

One amendment was requested for the minutes of the meeting held on 22 May 2019.

19.110: Serious Incident Review Group Annual Report 2018/19 Developments for 2019/20 The first sentence should read that “…focus now moves towards improving the outcomes of action plans and ensuring that learning is embedded”.

With the above amendment, the minutes were recommended for approval as an accurate record of the meeting.

19.123 Action Matrix

19.083.2 Pennine Lancashire Referral to Treatment Neurology Performance Report It was noted that this actionRATIFIED was around medical staffing. K Lord confirmed that she is having conversations with C Pearson, Chief Nurse for ELHT, regarding this issue so she will ensure the outcome of this discussion is fed into the Quality Team for reporting. It was confirmed that the focus is around staffing in all areas, not just neurology. This action to remain open.

19.084.1 Pennine Lancashire Primary Care Update C Marshall advised that benchmarking surveys have been sent to practices with regard to the Friends and Family Test, there has been a poor response to date. The team are working hard to contact practices and improve the engagement. Practices to be contacted about the free text question used. This action to remain open.

19.086.3 Pennine Lancashire Quality and Performance Report Month 11 LCFT: IAPT J Johnston advised that this is outstanding. She will ensure the information is shared with the quality team for inclusion in the Quality Report.

19.087 Pennine Lancashire Individual Patient Activity/Continuing Health Care Update

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The action plan has been included as an agenda item on the agenda. This action can be closed.

19.103: Minutes of the Meeting held on 27 March 2019 19.062 Pennine Lancashire Quality and Performance Report Month 10 ELHT: A&E Breaches J Wild has agreed to present her report to committee in July 2019. This action to remain open until her presentation.

19.108.1: Pennine Lancashire Quality and Performance Report Month 12 52-week Waits Conversations are being held with Blackpool and responses to queries are awaited.

19.108.2: Pennine Lancashire Quality and Performance Report Month 12 CQC The staffing pressures will be discussed at the Scheduled Care Board, once it is established. A Demand Management review is being undertaken to ascertain what services could be moved to a community setting. The outcome of this will be reported in the Quality Report when available. This is being supported with NHS Improvement. This action can be closed.

19.108.3: Pennine Lancashire Quality and Performance Report Month 12 CQC This action links with the above action. This can be closed.

19.108.4: Pennine Lancashire Quality and Performance Report Month 12 CQC It was confirmed that the top 5 areas have been identified as: Mental Health, CVD, MSK, Frailty and Respiratory. This action can be closed.

19.108.5: Pennine Lancashire Quality and Performance Report Month 12 CQC S Bradley advised that the Quality Report is being redesigned at present and that the information requested will be reflected in due course. It was agreed to leave this action open until the redesign of the report is complete.

19.112: Pennine Lancashire Complaints Report 2018/19 Quarter 4 S Harrison is scheduled to present to committee in July 2019. This action can be closed once the presentation has beenRATIFIED received. G Jones entered the meeting

19.124 Terms of Reference

It was noted that Nigel Horsfield had been omitted from the membership, which was acknowledged as a typing error. It was also stated that conflicts of interest should be referred to the Governing Bodies.

ACTION: D Ashby to circulate the ToR for virtual approval by the clinical D Ashby members

With the above amendments, the Terms of Reference were approved for ratification by members present.

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19.125 Presentation: Neurology Pathway

Steve Flynn, Commissioning Manager for Chorley, South Ribble and Greater Preston CCG attended to present this item and to discuss the neurology and neurosciences pathway.

He summarised the issues within the service, noting that a review of pathways was triggered in 2017 by a GPwSI serving notice on the CCGs. This review identified that the Referral to Treatment (RTT) performance within neurology was poor, with new referrals waiting approximately 20-weeks meaning that they would automatically breach the RTT target. To try and address this, a number of local improvements were made - Standardised Template for referrals - Triage pathway - CNS direct to test for MRI brain - Long term condition management, such as Parkinson’s, in community with specialist nurse management

However, it was identified that any local intervention was not benefitting the service as it is the specialist service for Lancashire. Therefore changes needed to be undertaken on a broader footprint. A workshop was held with CCG colleagues and Trust about the uniformity of approach across the system. At the time the STP was asked to take responsibility for this across the Lancashire footprint, but this was not agreed. In 2016/17 it has been identified that the number of GP referrals has reduced, but there has been an increase in the number of referrals through other sources, such as A&E.

Lancashire Teaching Hospitals Trust (LTHTr) provided an update on the latest position for neurology performance, which identified many patients still waiting over 18-weeks, with the longest waiting patient at 50-weeks. The service has identified that they have capacity to see 456 new patients per month but the referral rate is 890 per month. In May 2019 capacity met demand for the first time.

The Trust offer appointments at peripheral clinics, such as East Lancashire, to elderly or vulnerable patients in the first instance, with other appointments offered across Lancashire with the majority available in their main site at Preston. However, this has found that patient’s will cancel appointments close to their date and request a move to one of the peripheral sites close to their home location. These are difficult to accommodate, resulting in longer waits. LTH are currently undertaking a review of their peripheral clinics, looking at efficiency and cost of estates. They are considering offering the services in a more community-based setting. RATIFIEDHowever, one of the most immediate challenges is access to medical records as many of these are still paper-based.

It has been identified that many patients will self-present at hospital when they have been waiting more than 6-months. When this happens the default action is for clinicians to refer to neurology. There is a review of this pathway to try and generate uniformity through urgent care pathways so that it does not automatically result in an outpatient referral, particularly as many are already on the referral waiting list. These urgent care attendances are a function of the inefficiencies within the service. It also presents a challenge for primary care as patients will see a GP multiple times whilst awaiting their outpatient appointment.

The triage system for referrals was queried to understand the skill mix. S Flynn explained that triage takes place once the referral has been accepted, with review of the sub-specialty of the condition and urgency. There was discussion around the percentage rate of people discharged after the first appointment. S Flynn advised that he did not have the figures to hand but was happy to share this; however, he was aware that the number of patients discharged after the first appointment and the number of DNAs are quite high.

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In February 2019 a further workshop was held to discuss the Neurosciences service and understand the current position. The focus question was: “Why are we spending more money and getting worse outcomes than other areas?”. This workshop utilised the Right Care packs, which highlighted that LTHTr were an outlier for neurology issues and neurological problems. The aim of the workshop was to gain support from commissioners, Specialised Commissioning and the provider to review the whole of the Neurosciences service as significant concerns were being seen, particularly around patient flow. At this workshop it was identified that there was a lack of ring-fenced neurosurgical beds and issues patient flow and repatriation. There were issues around occupancy of the Neuro-rehab beds, length of stay, accessing appropriate placement and access to specialised community services. Following this workshop a case for change was developed.

Members were informed that NHS England undertook a clinical peer review on neurosurgery earlier this year, which identified no specific patient harm due to system. This raised concern with members as it was not clear if deterioration of a condition was being considered as ‘harm’. S Flynn advised that the report identified that this was an inefficient system, but agreed to share the report. He added that the review identified some clear recommendations that the Executive Board should be doing more, which has enabled challenge to be put back to the board around collaborative improvements.

ACTION: S Flynn to share the NHS England Peer Review Report on Neurosurgery S Flynn

It has been reported that North Cumbria intend to serve notice on their current Neurosciences provider and commission LTHTr, meaning an increase in referrals. Therefore it is felt that any review should be undertaken across the ICS footprint for Lancashire and South Cumbria. Any development of an ICS Neurosciences programme would mirror existing ICS programmes, such as vascular and stroke. It was recognised the Neuroscience has interdependencies with stroke and frailty, which are both included as ICS priority areas.

A programme proposal brief was presented to the Collaborative Commissioning Board on 11 June 2019 requesting that this is managed centrally by a project lead. The next steps include development of a Neurosciences Programme Board with an independent Clinical Chair and to establish a programme team. Performance will not dramatically improve until there is a centralised plan. The Chair advised that theRATIFIED committee had raised concerns about the deteriorating position at neurology, with the big numbers breaching the RTT target. She acknowledged that this presentation had helped to inform, more than assure, that efforts were taking place but had not been easy. It helps to provide perspective on the situation and asked what the Pennine Lancashire CCGs could do to help their patients by supporting the service improvements. S Flynn noted that local investment, such as a paediatric specialist epileptic nurse, rehabilitation beds at Rakehead and use of charitable sector organisations were helping local populations but not necessarily dealing with the root of the problem. He did offer to take any queries back to the provider.

It was queried what tracking and triage was offered for patients who need to be seen urgently, such as this with MS or Motor Neurone Disease. S Flynn advised that these patients should be offered urgent slots, although there is limited capacity. He was unclear of the specific timeframe, but these patients should be seen more quickly. Where they are seen may differ depending on where the appointments are available, which provides added complication for access and distance.

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Dr P Taylor assured S Flynn that he had done a tremendous piece of work given the workforce difficulties and service configuration. He observed that the centralisation of neurosciences in Salford, which happened 20-years ago, identified that adequate rehabilitation and re-ablement beds were necessary to support the service. It is clear this is not happening in Preston. He also noted that there is pressure on resource. S Flynn advised that the consultant to patient rate should be 15/16: 1000, but the rate is more like 9/10: 1000. This has been challenging as the Trust has previously been fixed on achieving the 16- consultant workforce rather than reviewing the whole pathway. However, they are now recognising that this is needed and are identifying areas of good practice in Walton and Salford. However, S Flynn advised that Walton is a Neurosciences centre. Preston is a centre for several specialties, including cancer, plastics, trauma; this has made it more generalised. Walton has more opportunities to deliver a more efficient service as a Neurosciences centre. Preston faces a number of challenges, including the need for an intermediary diagnostics service.

K Hollis noted that Neurology is listed as a fragile service, and asked about the plans to take this through as an acute workstream with the ICS. S Flynn confirmed there are currently no plans for this as it has not been accepted in the current year’s workplan. C Marshall queried whether there was a recovery plan, and S Flynn clarified that this has been in recovery for some time. He noted that CCB had agreed that Neurosciences was an area of concern, but did not commit any specific lead. S Flynn confirmed that savings in Neurosciences could be reflected in pain management, MSK or frailty services. This is why it needs to be undertaken at ICS level as it is a broader piece of work with a number of interdependencies.

S Flynn was asked why the primary care headache service originally collapsed, and he confirmed that the GPs involved in the service had to pull back; 1 retired and 1 now works at LTH as part of their service.

There was discussion about how to improve the diagnostic services locally and to upskill primary care to manage long-term patients. S Flynn noted that the direct CNS brain pathway brought an added complexity of burdening radiology with an incidental onus of no treatment pathway to follow. Therefore it has not released as much demand as hoped. There is also an impending risk of an aging workforce.

The Chair asked K Hollis and K Lord to liaise with ICS colleagues to help to influence ICS support for a centralised neurology programme. She recognised that the local Pennine ICP focus needed to be on the roleRATIFIED that primary care could undertake to support. ACTION: K Lord and K Hollis to liaise with ICS colleagues regarding a centralised ICS programme for Neurology / Neurosciences

The Chair formally thanked S Flynn for his work in this area and for attending to provide an update to committee members.

19.126 CONFIDENTIAL: Provider Update

Members received and acknowledged this report.

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19.127 CONFIDENTIAL: GP Quality Group Minutes for BwD and EL CCGs: May 2019

Members received these minutes.

19.128 CONFIDENTIAL: ICS – LCFT Mental Health Oversight Group Minutes: May 2019

Members received these minutes.

19.129 CONFIDENTIAL: NHS England – LCFT Quality Oversight Group Minutes: May 2019

Members received these minutes.

19.130 Safeguarding Adults Review: Patient H

Members received these minutes. 19.131 CCG Safeguarding SectionRATIFIED 11 Self-Assessment NHS England and the Local Safeguarding Children and Adult’s Boards require assurance from East Lancashire and Blackburn with Darwen (BwD) CCG’s that they have the necessary safeguarding arrangements in place in line with statutory guidance. This report and accompanying self-assessment provide this assurance.

The CCG safeguarding self-assessment document from 2018 was presented to the Committee in May 2018, and it outlined that further work needed to be undertaken in respect of the organisational HR policies specifically the complaints, disciplinary and whistleblowing policies to ensure clear references and links to safeguarding. This work is now complete and the policies are now compliant. Throughout the year there have been some challenges in respect to safeguarding training compliance within the two CCGs but this has been successfully addressed and compliance is now 96% and above in all categories.

The CCG’s have been subject to a BwD Child Protection and Looked after Children CQC inspection in April 2019, with the final report expected in June 2019. This inspection identified some areas for improvement, which are currently being reviewed.

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The self-assessment identifies that there are some areas where further work is required particularly in relation to safeguarding leadership within primary care; the continued development of primary care safeguarding systems; and strengthening information sharing processes to inform safeguarding assessment and planning. A summary of work was shared outlining how these are being addressed.

Work is currently being undertaken to strengthen the safeguarding accountability structure in line with the development of the Pennine team, and the closer working alignment of the two CCGs

The Chair queried one of the actions, noting that there are Safeguarding GPs in post and yet the rating was amber. P Chapman advised that named GPs are in post but are not currently working as effectively as they could. This resource is being reviewed to ensure they are able to perform in the most effective manner.

Members received the report and approved the self-assessment report.

19.132 CCG Safeguarding Strategy

This CCG Safeguarding strategy has been developed to set the direction and priorities for BwD and East Lancashire CCGs safeguarding agenda. This Safeguarding Strategy should be read in conjunction with the CCG Safeguarding Policies, Workforce Strategy, Safeguarding Annual Reports and Business Plans.

This incorporates the statutory safeguarding functions required by the CCG and a complimentary skill mix component to ensure the team can deliver on all the required functions. NHS BwD and East Lancashire CCGs have recognised that there is a need for effective joint working if vulnerable groups are to be protected from abuse. The CCGs are committed to working closely with partner CCG’s, NHS England, the Safeguarding Boards, statutory agencies and their provider organisations to ensure the effectiveness of multiagency arrangements to safeguard and promote the wellbeing of children and adults.

It is proposed that the Pennine Lancashire CCG Quality Committee will be responsible for the performance monitoring of the strategy. It is intended that the committee will receive quarterly safeguarding reports and an annual report will be provided to the CCG Governing Bodies.

RATIFIED D Ashby / ACTION: D Ashby to liaise with Safeguarding to schedule the reports into the Safeguarding agenda matrix

The Committee formerly received the report for information and agreed the monitoring proposal

19.133 Prescribing and Medicines Optimisation Annual Report 2018/19

Dr L Rogan presented this report, which provides a comprehensive review of the performance and outcomes delivered through the East Lancashire Prescribing and Medicines Optimisation Work Programme 2018-19. The report demonstrates delivery of a number of significant cost savings, outcomes from service transformation projects and a summary of the CCGs’ compliance with NICE Technology Appraisals. The areas of work have included:

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- Use of Proton Pump Inhibitors (PPI) - Opioid Clinical Audit - Safe Use of Direct Oral Anticoagulants (DOACs) - Self Care - ASTRO-PU reduction - Reducing Medicines Waste - Prescribing in line with ELMMB Recommendations

There was discussion around the use of opioids and trying to capture the patient view of those who have struggled with addiction. The Chair agree to try to contact some patient representatives for inclusion in Clinical Audits and Governing Body patient stories

ACTION: M Pilling to try to contact patient representatives that have struggled M Pilling with opioid use

Dr L Rogan advised members that a doctor in Norfolk has been undertaking some reviews of DOAC use. This has indicated that patient on warfarin had the lowest number of hospital admissions, and patients on DOACs had the highest. This is based on local data, but he had raised this with the Department of Health for a national review. It has also highlighted that use of DOACs has an increased rate of renal impairment, which should require regular monitoring. This is concerning as it means the body cannot process and remove the DOAC, leading to an increased risk of bleeding internally, which is then harder to reverse. There are also concerns that DOACS Are Marketed as medicines that do not require regular monitoring, meaning many of these patients are under primary care. Further work is needed in this area to understand the data. The Meds Man team have arranged for a template to be embedded on EMIS to aid GPs with prescribing DOACs in the interim.

There was debate around antibiotic prescribing. It was noted that dentistry was an area with a high use of antibiotics, but this contract is managed by NHS England. Work is also ongoing around improving dental health in care homes. It was also noted that out of hours and extended access clinics would prescribe antibiotics to patients rather than take a specimen sample for culture, even if this is the most appropriate course of action. It was noted that this needs a wider review to try and understand the problem.

Quality Team ACTION: Quality Team and Medicines Management Team to liaise around / Meds Man completing an antibiotic review

The chair noted that this reportRATIFIED was comprehensive, focussing on patient experience and service quality and commended the team for all of their hard work. She thanked Dr L Rogan for her update.

The Committee formerly received the report for information

19.134 Pennine Lancashire Primary Care Update

The bi-monthly Primary Care Quality Assurance update for Pennine Lancashire CCGs was presented by C Wright. Full details are available within the report.

CQC continue to visit practices across both CCGs. All Pennine Lancashire GP practices have been visited and most have a rating of either ‘good’ or ‘outstanding’. ELCCG has 1 practice with a rating of ‘requires improvement’; BwDCCG has 4 practices with a rating of ‘requires improvement’ and 1 practice rated as ‘inadequate’. Due to a partnership dissolution and new provider, Briercliffe Surgery will move into the ‘awaiting inspection’ category once

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the new registration is complete.

C Wright informed members that she had also undertaken a practice visit to Rishton and Great Harwood on 25 June 2019. They have reviewed their CQC recommendations and are confident that they have completed them; they have requested an earlier re-visit by CQC.

Both BwD and EL CCGs are due to receive the 2018/19 Q4 complaints data by the end of June 2019. The CCGs are working with the team at NHSE to consider how the learning from these complaints can be shared across practices.

The NHS England primary care website www.primarycare.nhs.uk closed on 31 March 2019. The new General Practice Indicators (GPI) and the GPIT Digital Maturity Index Assurance Indicators are not yet available and have been delayed from a May 2019 launch date, we are not aware when they will be available. This has caused a problem in accessing practice specific outcomes data.

ELCCG had 2 reports visit the National Learning and Reporting System (NRLS), 1 in April and 1 in May 2019. BwDCCG did not have any reports. The number of incidents reported is still lower than anticipated, and practices are encouraged to report to enable learning to be shared.

Members from both Hyndburn Central Primary Care Network (PCN) and Pendle East PCN attended the Introduction to Human Factors Training day on 7th May 2019 along with colleagues from Chorley South Ribble and Greater Preston. The training provided by AQUA was very well received and a further 2 days in-depth training is arranged for 24 September and 03 October 2019. The aim is to evaluate the usefulness of this approach with 4 PCN’s before rolling it out.

A detailed report analysing the Friends and Family Test (FFT) results for April 2019 was provided. The usage of FFT in General Practice will be discussed at the next Lancashire and South Cumbria Primary Care Commissioners and Quality Forum to understand what other CCGs are doing in relation to this patient experience feedback.

There was discussion regarding the response rate from practices around the FFT service. A survey was given to Practice Managers at the recent BwD Practice Manager Forum, with a plan to do the same at the forthcoming EL Practice Manager forum. The Chair clarified that her query was around the use of the free text question to ensure it is a meaningful question asked of patients that canRATIFIED then be used to inform quality improvement work within the practice. This is the issue, as it does not appear to be adequate enough, or asked clearly enough, to generate responses from patients. It had been indicated that this may be a standard question, but this has not been confirmed. She was keen to ensure the GPs use the free text question in such a way that they are able to receive meaningful responses. This could be standardised to make it more usable. C Wright queried whether this could be discussed at the Patient Participation Group (PPG) meeting for the CCG. The Chair acknowledged that this could be a useful discussion in some of the forthcoming workshops and may be used to support discussions around self-care and difficult messages to patients.

ACTION: C Wright and M Pilling to discuss FFT test discussion at PPG meetings C Wright / M Pilling The quality team are reviewing the awareness of Sepsis amongst General Practice and Care Homes following on from an event in October 2015. The usage of e-learning is being reviewed along with the utilisation and role of Sepsis champions within GP Practices. Links have been made with the Sepsis trust with the intention of launching a campaign around the national awareness day on 13 September 2019.

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Following on from discussions at Quality Committee over winter 2018/19, the quality team have developed a plan for how to improve the reporting flu vaccinations for staff working in General Practice as this is not a mandatory requirement. The plan includes promotion at Nurse and Manager forums, competitive PCN dashboards and promotion of national flu campaign materials from August 2019. It was noted that this may be pertinent given the current flu outbreak in Australia. V Morris advised that this is being monitored, but there are currently n plans to escalate the flu programme.

All practices have now formally signed up to a Network Contract Directed Enhanced Service within Primary Care Networks (PCN). Clinical Directors have been assigned to the 9 networks within East Lancashire and recruitment is underway for the 4 within Blackburn with Darwen. More detailed information regarding this is reported through the CCG Primary Care Committees.

Dr G Jones queried the Practice Manager forums, and whether there were plans to make them a Pennine forum in the future. C Wright confirmed that this is being included in the workforce discussions across the CCGs and the development of PCNs. The same review is happening with the Practice Nurse forums, which are also separate for each CCG.

Members acknowledged the report.

C Wright exited the meeting.

19.135 Pennine Lancashire Quality and Performance Report Month 01

S Bradley presented key points from the Pennine Lancashire Quality and Performance Report for Month 01. Full details are available within the report.

ELHT: A&E Breaches In April 2019 both CCGs did not achieve the 95% target. Work is focussed on reducing length of stay in the Trust to improve flow through the system and an action plan has been agreed to support this.

Ambulance Calls BwD CCG achieved category 1 target and underperformed against all other categories in April 2019. ELCCG unperformed against all response targets. NWAS has increased the provision of See and Treat,RATIFIED with the aim of reducing conveyance to A&E, and work continues with ELHT to reduce ambulance handover times. It was noted that the performance for Category 1 calls has improved overall, which is positive.

Referral to Treatment (RTT) Incomplete The referral to treatment (RTT) incomplete pathway target was not met by either CCG in April 2019, with 8 underperforming specialties at ELHT. There continues to be pressure in Neurology at LTHTr, and the ICS are taking forward a service redesign on this pathway during 2019/20. The most recent data indicates that performance at ELHT is deteriorating, which will reflect in future reports. It was queried why BwDCCG appear to have a particular decline. S Bradley noted that the deterioration at the hospital trust has resulted in a more dramatic decline on the BwD area, but no specific area. Neurology performance may be having a more dramatic impact on BwD performance.

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52-week Waits In April 2019, there were 2 patients reported with a wait of over 52 weeks for EL CCG and 0 patients for BwD CCG. Of these, 1 has now received treatment and the other has a ‘To Come In’ date on 20 June 2019.

Cancer Patients seen within 2-weeks of an Urgent Referral for Breast Symptoms where Cancer is Not Suspected In April 2019 the target was not met by either CCG, with 23 breaches for BwD and 34 breaches for EL. A new revised breast referral template has been distributed to GP practices and uploaded to EMIS to support discussion around the importance of attending appointments. There was a brief discussion around the high number of cases that are missing the 2-week deadline, as early diagnosis is key and these cases are more likely to miss the subsequent cancer targets along the pathway.

Cancer - % of patients receiving definitive treatment within 31 days of a cancer diagnosis In April 2019 the target was not met by either CCG, with 2 breaches for BwD and 5 breaches for EL. The CCG continues to work closely with the Trust on cancer pathway efficiencies.

Cancer Patients Receiving First Definitive Treatment for Cancer within 2-months In April 2019 the target was not met by either CCG, with 7 breaches for BwD and 15 breaches for EL. The CCG continues to work closely with the Trust on cancer pathway efficiencies.

Mixed Sex Accommodation There were 3 mixed sex accommodation breaches reported for BwDCCG and 3 reported for ELCCG in April 2019. All breaches were at LTHTr. The Trust had 57 cases in-month and cited issues with flow and capacity. These are going through the relevant escalation and process. It has been noted that the issues are arising from the Critical Care unit.

Diagnostics with 6-Weeks This target was not met for either CCG in April 2019. The Trust have experienced significant pressures in both CT and MRI for Cardiac work with a 10% increase in referrals compared to the previous year. In order to address the issues, the Radiology Department have asked for all requests to be re-vetted to see if they could be undertaken under another modality. The Independent Sector has been contactedRATIFIED for a variation to contract for 25 of each modality to be sent there. The Department are also looking into whether a mobile scanning van can be utilised.

MRSA In April 2019 both CCGs had 0 cases of MRSA. V Morris did advise that this would change in subsequent reports as there has been a case for ELCCG in June 2019.

C-Diff V Morris advised that the new CDI objectives were out, but carried across the Trusts. She noted that ELHT performed well once the number of unavoidable cases were discounted. This enabled a review into lapses in care, although no new issues were identified in the reviews. A repeating theme was around slow diagnosis of infectious diarrhoea and not sending samples to test. There is also a concern that all cases appeared to be on Proton Pump Inhibitors (PPI).

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LCFT: Early Intervention Psychosis (EIP) The target for treatment within 2 weeks was not achieved by the Trust of either CCG in April 2019. Analysis of the breaches have been undertaken and highlighted some key areas for focus. The Trust has also identified several supporting actions to improve performance. Visits have also been planned to the service offered by Northumberland, Tyne and Wear, to review their referral process and whether this can be utilised within the LCFT service. Due to the continued underperformance of this service and the lack of progress against improving referral delays, a remedial action plan with a recovery trajectory and timescales has been requested from the service. This is due to be submitted by 30 June 2019.

Duty of Candour There have been 2 breaches of Duty of Candour in April 2019. Both were due to a delay in receiving confirmation that contacting the service users would not be detrimental to their health.

Memory Assessment Service The target was met by the Trust in April 2019, but was not met by either CCG. A capacity and demand plan has been completed and was due to be signed off by the service lead on 10th June 2019 this will aid in developing realistic timeframes as mentioned above.

IAPT The target was not met in April by the Trust nor the CCGs. LCFT are working towards quarterly targets and therefore aim to achieve these by the end of June 2019; these targets will be same every month instead of a cumulative target as used the previous year.

CPA The target was not met by BwDCCG in April 2019. There were 3 breaches reported for BwD where service users were uncontactable or not attending the reviews.

The Committee formerly received the report for information.

19.136 Pennine Lancashire IPA and 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. Key areas were highlighted and full details areRATIFIED available within the report. CHC Local Developments An ICS model for place-based commissioning is being developed across Lancashire and South Cumbria. A revised governance structure with a delivery board is to be presented at the IPA Programme Board in November 2019 and the joint committee of CCGs in January 2020.

CHC Quality Premium In terms of quality premium, neither CCGs are achieving their quarter premium target. Although each CCG have been asked to submit a remedial action plan to NSH England, it has been agreed that the Lancashire CCGs performance will be jointly reviewed. It had previously been reported that the CCGs had agreed to fund temporary posts to support the Discharge to Asses (D2A) process and reduce backlogs, but recruitment was unsuccessful. It has now been agreed that there will be a 12-month increase in establishment, with a plan to reduce establishment as and when vacancies arise. A review of the discharge pathway has been undertaken with recommendations awaited.

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The timescale on recruitment was queried. It was confirmed that the post will be going to advert in the next few weeks, and that the funding arrangement will start once the posts is filled. There were concerns that this had been an issue for some time.

Retrospective Requests for Review The CSU are now processing retrospective claims for CHC eligibility. The total number of cases received by ELCCG is 29, with 25 cases remaining open; BwDCCG have 21 cases, with 20 remaining open. There was discussion around the impact that care home closures would have on reviews.

IPA Activity Figures produced by MLCSU have identified that in April 2019, 274 and 101 CHC reviews were outstanding for East Lancashire and Blackburn with Darwen CCGs respectively. East Lancashire CCG has allocated a resource currently being recruited to address this back log. There are discussions with commissioned services to support the CCGs to manage this pressure in addition to securing resource from social services.

Personal Health Budgets (PHBs) Both CCGs have met their PHB trajectories for 2018-19. The East Lancashire PHB partnership is currently working on the development of a personalised care personal assistant workforce. A number of providers have expressed an interest in working with the partnership and a launch event is taking place at the end of April 2019.

C Marshall advised that a high number of complaints received by the CCGs were around CHC. She has been linking with Jackie Hadwin from the CSU to improve the communication process. This should help to reduce the chances of a complaint being made.

The Committee formerly received the report for information

19.137 Learning Disability Transforming Care, STOMP and LeDeR Update

J Johnston presented this report to committee to provide an update on the current risks in relation to LD Transforming Care, Stopping the Over-Medication of People with LD (STOMP), and the LD Mortality Review (LeDeR) for the Pennine Lancashire CCGs.

Transforming Care Both CCGs are meeting theRATIFIED requirements with regard to Care and Treatment Reviews. The CCGs participated in NHS England’s C(E)TR audit in January 2019. The Lancashire & South Cumbria TCP achieved an overall amber rating for both adults and Children and Young People. The work plan for the Partnership for the coming year has been signed off by the Joint Committee of CCGs with the emphasis being developing sustainable community services to meet national specification, development of local community beds and to refocus efforts on the wider population with learning disabilities and/or autism.

Stop Over Medicating People (STOMP) Following an audit submission to NHSE with regards to progress towards STOMP, out of the 4 ratings, ELCCG were rated as ‘Not Assured’ against 3 and ‘Partially Assured’ against 1. Feedback on BWDCCG’s submission is awaited. Monies allocated to LSC for the STOMP pilot from NHS England will be used to support activity focussed on a primary care network in East Lancashire with learning shared across the ICS. An outline plan is in place for this project which will receive ongoing oversight by the committee.

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LD Mortality Review (LeDeR) Work is continuing to clear the back log reviews with additional resources identified. There remain seven cases reported in 2018/19 awaiting allocation. It is envisaged that these will be allocated once a temporary post is appointed to. There was discussion around the visit by the Learning Disability Director and his views on the development of a community service. J Johnston advised that the Transforming Care team had moved forward since the visit; she confirmed that this is reflected in the plans and that the concerns raised are being considered within developments. The action plan has allocated tasks and actions to directorate portfolios within CCG and now includes more robust timescales.

The Committee formerly received the report for information

19.138 Quality Contract Meeting Draft Minutes: May 2019 East Lancashire Hospitals NHS Trust Lancashire Care Foundation Trust Mersey Care Foundation Trust

These were distributed prior to the meeting for information. No comments were raised.

Members acknowledged the minutes.

19.139 ELCCG Risk Management & Information Governance Group Draft Minutes – May 2019

These were distributed prior to the meeting for information. No comments were raised.

Members acknowledged the minutes.

19.140 Cancer Tactical Meeting – May 2019

These were distributed prior to the meeting for information. No comments were raised. Members acknowledged theRATIFIED minutes. 19.141 ELMS Out of Hour Contract Minutes – May 2019

These were distributed prior to the meeting for information. No comments were raised.

Members acknowledged the minutes.

19.142 Any Other Business

It was noted that ELHT sepsis mortality is an outlier. It was confirmed that this related to coding issues, and that ELHT mortality performance was included within the Quality Report. It is also reviewed and discussed at the Trist Mortality Review Meetings and through Structured Judgement Reviews. This has resulted in an increase in the number of StEIS reports received as the Trust are reporting them as incidents when they think harm has occurred, but then requesting these are stood down once investigated, if appropriate.

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19.143 Items for the Risk Register

P Chapman and the Safeguarding Team will consider including closure of care homes on the CCG risk registers.

16.144 Date & Time of Next Meeting

The next meeting has been scheduled on Wednesday 24 July 2019 at 1pm in Darwin Suite, Innovation Centre, Evolution Park.

Deadline for papers is 5pm on 15 July 2019.

RATIFIED

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CLINICAL COMMISSIONING GROUP (CCG)

Minutes of the Audit Committee Meeting held on 23rd April 2019 at 2p.m. in the Boardroom, Fusion House Evolution Park, Haslingden Road, Blackburn, BB1 2FD

PRESENT: Mr Paul Hinnigan Lay Member – Governance (Chair) Dr Nigel Horsfield Lay Member Dr John Randall General Practitioner (GP) Executive Member

IN ATTENDANCE: Dr Julie Higgins Joint Chief Officer Mrs Linda Ring Finance Manager, representing Mr Roger Parr Mrs Claire Moir Governance, Assurance and Delivery Manager Mrs Liz Cardus Senior Finance Business Partner, Midlands and Lancashire Commissioning Support Unit (M&LCSU) Mr Darrell Davies Anti-Fraud Manager, Mersey Internal Audit Agency (MIAA) Mrs Lisa Warner Senior Internal Audit Manager (MIAA) Mr John Farrar Engagement Lead, Grant Thornton UK LLP Ms Michelle Clayton Senior Administrator (minutes)

Min No Item Action By 19.019 Chair’s Welcome

The Chair welcomed everyone to the meeting of the Clinical Commissioning Group’s (CCG’s) Audit Committee (AC) and introductions were made.

19.020 Apologies for Absence and Confirmation of Quoracy

Apologies had been received from Mr Roger Parr, Mrs Louise Cobain, Dr Geraint Jones and Ms Marianne Dixon.

Mrs Linda Ring attended to represent Mr Parr, Chief Finance Officer.

The meeting was confirmed as quorate.

19.021 Declarations of Interest

The Chair invited members to declare any interests they may have in relation to items on the agenda.

No declarations of interest were made.

Declarations declared by CCG staff are listed in the CCG’s Registers of Interests. The Registers are available, either via the Secretary to the Governing Body (GB), or on 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.

19.022 Review Terms of Reference

The Chair introduced the AC Terms of Reference (ToR), which was presented for its annual review.

The Chair invited comments on the content prior to approval. The following amendments were agreed:

2.2 ‘Internal Audit’  Public Sector Internal Audit Standards (2013) should be amended to (2017).

2.4 ‘Other assurance functions’  The Quality, Performance and Effectiveness Committee amended to Pennine Lancashire Quality Committee.  The Department of Health extended to Department of Health and Social Care.  The NHS Litigation Authority amended to NHS Resolution.  Primary Care Commissioning Committee amended to Primary Care Co-Commissioning Committee.

ACTION: Ms Michelle Clayton agreed to send details of the changes to Mrs Pauline Milligan, who will amend the ToR Ms Clayton/ accordingly. Mrs Milligan

RESOLVED: That, following the above amendments being made in line with discussions, the AC approved the ToR.

19.023 Minutes of the Meeting held on 5th February 2019

The minutes of the meeting held on 5th February 2019 were reviewed and agreed as an accurate record.

RESOLVED: That the minutes of the meeting held on 5th February 2019 were approved as an accurate record.

19.024 Matters Arising

There were no matters arising.

19.024.1 Action Matrix

The Action Matrix was reviewed and the following actions were noted:

Minute 18.053/18.072.1/19.005.1/19.006 – Risk Management Report Mrs Claire Moir to provide an update on the actions under agenda item Risk Management Report.

Minute 18.062/18.072.1/19.005.1 - Review of Effective of Arrangements in Place for Staff to Raise Concerns

Mr Darrell Davies advised that this action was in relation to the staff survey focused on staff awareness of understanding reporting methods to raise concerns.

32 members of staff have taken part in the survey to date and more staff have been encouraged to take part. Mr Davies has analysed the results Page 2 of 11 so far which indicate that individuals understand the correct reporting channels. The survey acknowledges the ‘freedom to speak up’ process and staff correctly reporting concerns to Mr Davies or Mr Parr.

ACTION: Mr Davies will report back to AC once the final staff Mr Davies surveys have been completed.

19.025 Risk Management Report

Mrs Moir presented the Risk Management Report, which provided the AC with an update on the management of risks held on the full Corporate Risk Register (CRR) for March – April 2019 and highlighted key points:

 Strategic Risk Management – Corporate Objectives

The Governing Body Assurance Framework (GBAF) was presented to the GB on 6th March 2019 outlining the corporate objectives and risks for 2018/19. .

A shared set of Corporate Objectives for both Blackburn with Darwen (BwD) and East Lancashire (EL) CCGs are currently being developed. Once approved, the associated risks to the achievement of those objectives will be presented to the respective CCGs’ Governing Body (GB) for approval.

 Operational Risk Management

Mrs Moir reported that the CCG’s CRR was presented to the Pennine Lancashire Quality Committee (PLQC) on a bi-monthly basis, alongside the EL CCG’s CRR, and was presented in full to the March meeting.

Mrs Moir drew members’ attention to section 3.2, which highlighted two risks held jointly by BwD and EL CCGs. The PLQC committee did not agree to the reduction of a risk rating for a quality/safety risk at year end, to facilitate the closure of that risk when there were still issues with the non-achievement against performance targets, to then re-open it in the next reporting period. Therefore these currently remain on the BwD CRR and have been reinstated on EL CCG CRR.

A review of the risk management strategies across both CCGs is scheduled to take place in order to agree whether an aligned approach is taken once the shared objectives are approved. As part of the review process, clarity can be sought on questions the AC have asked i.e. what is being done about unachieved risk rating targets?

Dr Julie Higgins informed members that she is developing a Corporate Business Plan setting out corporate objectives, milestones and deliverables and relevant risks will be identified. Regularly reviewing delivery against the risks will provide a common approach across both CCGs. The risks identified should be specific in detail i.e. what the risk is due to and the impact, which will help provide clarity in terms of finance/quality risks.

To improve the risk management system the Chair suggested outlining key issues, learning points and recommendations, not only in terms of specific risks but also processes. Dr Higgins recommended a workshop be convened between the two CCGs

Page 3 of 11 in respect of the Chair’s points. The AC agreed to this approach.

ACTION: Dr Higgins, Mrs Moir, and Ms Debra Atkinson to Dr Higgins/ hold discussions around organising a workshop between the Mrs Moir/ two CCGs’ Audit Committees to improve the system and Ms Atkinson processes on how risks are managed.

 Corporate Risk Review: March - April 2019

There were ten operational risks and six strategic risks held on the register. Full details of the risks are outlined in Appendix 1. The following risks were reviewed during the reporting period with no change in risk rating:

o 2013/05: Accident and Emergency 4 Hour Standard. o 2016/05: 18 week RTT. o 2019/01: Mental Health System Pressures impacting on quality and performance of services. o 2018/02: Failure of the North-West Ambulance Service to adhere to targets outlined in the Ambulance Response Programme (ARP). o 2016/04: Waiting Times for Suspected Cancer – 62 day wait for first treatment following an urgent GP referral. o 2018/03: Initial Health Assessments (IHA) for looked after children are not being completed within the 20 working day statutory timeframe. o 2016/03 Failure to meet the reforms for children with educational needs and disability (SEND) as set out in the Children’s Act (2014). o 2017/03: Failure to achieve the stroke quality requirements for people who have had a stroke being admitted to an acute stroke unit within 4 hours. o 2015/04: Inability of patients aged 18 years and under to access Tier 4 Mental Health In-patient beds when assessed as requiring that facility. o 2018/01: Loss of residential and nursing home beds from care home sector and impact upon system resilience.

 Risks Closed During the Reporting Period

There were no risks approved for closure during the reporting period.

 Risks Opened During the Reporting Period

Following the last Risk Management Group meeting, narrative has been approved by NHS England for a Brexit risk to be added to the CCGs risk registers.

The Chair commented that it was useful to have a common approach to risks across both CCGs.

RESOLVED: That the AC noted the content of the report. 19.026 External Audit

Mr John Farrar presented items on behalf of External Audit.

19.026.1 Progress Report

Mr Farrar presented the Progress Report and drew members’ attention to

Page 4 of 11 a summary of progress as at 15 April 2019.

The AC acknowledged that the CCG had been the first CCG to submit their draft annual accounts and annual report to the external auditors.

He confirmed that work was currently on track and the audit of the 2018/19 accounts will commence tomorrow. The findings of the audit of accounts will be provided to the AC in May 2019.

Mr Farrar referred to results of the interim audit (pages 6 and 7) which contained items of interest for information and summarised the interim audit. He also referred the AC to Sector Update (page 8) which provides an up to date summary of national issues and developments to support the CCG.

The Chair thanked internal teams for the positive findings to date.

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

19.026.2 Annual Review of Accounting Policies

Mrs Ring presented the Annual Review of Accounting Policies, which provided a high level overview of the 2018/19 accounts along with interpretation and highlights of key issues.

Process The accounts had been produced and were submitted in accordance with the national deadline.

Key Targets The draft accounts indicated that the CCG had delivered its in-year financial balance, cash limit and Better Payment Practice Code targets.

Changes in Accounting Policy During 2018/19, changes related to financial instruments where CCGs were required to report an expected credit loss were introduced. Also, revenue for contracts with customers where CCGs were required to review their revenue sources and analyse into contract and non-contract revenue.

Significant Movements Mrs Ring highlighted some of the movements compared with the previous financial year, which related to revenue received in respect of learning disabilities and prescribing rebates, and other non-recurrent revenue e.g. care home pharmacists, digital signage.

Other significant movements included operating expenses – purchase of healthcare, purchase of social care, supplies and services, establishment and premises.

The Chair informed the meeting that he had previously met with Mrs Ring and Mrs Liz Cardus and reviewed the draft accounts and was happy with the accounts and summary Mrs Ring provided. The Chair had received satisfactory answers to a range of questions he had already raised prior to the committee meeting.

There were no further questions.

RESOLVED: That the AC noted the content of the report. 19.026.3 Draft Annual Report and Financial Statements 2018/19

Page 5 of 11 Mrs Moir presented the draft Annual Report and Financial Statements 2018/19, which had been submitted in line with the national deadline.

The report was produced in accordance with the Department for Health and Social Care which describes the content and format required, reflected within the report.

The Chair and Mrs Ring both confirmed that they had reviewed the documents in detail in advance of the meeting. Ms Moir thanked the Chair for providing detailed feedback which had been incorporated where necessary.

Ms Moir commented that, as the AC were aware, this version of the document was extremely lengthy and asked the committee if they were agreeable for a public user–friendly summarised version to be produced. The AC confirmed their agreement.

Questions and answers followed.

ACTION: A detailed breakdown of the strategic priorities against Mrs Ring/ key performance measures to be included with the performance Mr Parr section of 2019/20 Annual Report.

RESOLVED: That the AC approved the content of the draft Annual Report and Financial Statements 2018/19.

19.026.4 2018/19 Audit Queries

The Chair advised that this item had already been covered in earlier discussions.

19.026.5 Quality, Innovation, Productivity and Prevention (QIPP)

Mrs Ring presented the QIPP summary for the end of the financial year 2018/19.

She was pleased to report that the CCG had completed the delivery of its planned target of £6m as at 31 March 2019. The GB and the relevant Sub-Committees had been regularly updated on the CCG’s position during the course of the year. There had been twice-weekly reviews of the progress on QIPP and this monitoring process would continue this year.

The CCG had set a QIPP target of £6m for 2019/20 and currently had schemes identified to achieve £5.4m.

Mrs Ring drew members’ attention to the appendices, which provided more detail of the plans.

At this early stage in the 2019/20 financial year the CCG was planning to meet the QIPP target in full.

Questions and answers followed.

The Chair commented that the CCG has an effective monitoring process in place with individuals focusing on achievement. Assurance is provided via the GB, the AC and Finance Scrutiny Group, which analysed the report in detail.

Page 6 of 11 The Chair, on behalf of the AC, formally commended all the work that had contributed to the CCG’s delivery of its QIPP target and thanked all the staff present and the wider staff who had been involved.

RESOLVED: That the AC noted the outturn position for the 2018/19 QIPP and progress against plans for 2019/20.

19.027 Internal Audit

Mrs Lisa Warner presented documents on behalf of Internal Audit.

19.027.1 Progress Report

Mrs Warner presented the report, which provided an update to the AC in respect of the assurances and progress against the Internal Audit Plan 2018/19.

The following reviews had been completed:

 Conflicts of interest (joint review with Fraud); Ms Moir provided context in terms of the compliance ratings. Unlike previous years, where only samples had been requested, a 100% audit had taken place in terms of declarations of interest and governance. Measures are now in place to address the recommendations going forward.  Provider Contract Management;  Primary Medical Care Commissioning – Governance;  Data Security & Protection Toolkit;  General Data Protection Regulations assessment.

The following draft reports have been issued:

 Four Post Payment verification visits had been undertaken to GP practices. Two draft reports have been issued and the reports for the other two visits were currently being drafted. One report was at final stage.

Mrs Warner gave an overview of each completed review and any recommendations.

Questions and answers were taken after each report review.

The Chair noted that the work on the delivery of the 2018/19 internal audit plan had been substantially complete, and thanked Mrs Warner for her efforts.

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

19.027.2 Head of Internal Audit Opinion and Annual Report 2018/19

Head of Internal Audit Opinion Mrs Warner introduced the above report, which was produced annually to assist the GB in the completion of the CCG’s Annual Governance Statement (AGS).

There were three specific elements to the basis of the opinion:

 Assessment of the design and operation of the underpinning Assurance Framework and supporting processes;

 Assessment of a range of individual assurances arising from risk-

Page 7 of 11 based internal audit assignments reported throughout the period;  Assessment of the CCG’s response to Internal Audit recommendations and extent of implementation.

The overall opinion for the period 1st April 2018 – 31st March 2019 (page 4) was ‘substantial’ assurance.

Annual Report 2018/19 The remainder of the document set out the work which had been completed during the course of the year and areas for consideration in production of the AGS.

Questions and answers followed.

Dr Higgins was interested in the range of ratings of the CCGs that are audited by MIAA and how many are within the ‘substantial’ assurance range.

ACTION: An anonymised graph of assurance ratings of CCGs to be Mrs Warner provided at the next AC.

The Chair commented that it was good to note that the CCG had been rated with ‘substantial’ assurance.

RESOLVED: That the AC:

i. noted the Head of Internal Audit Opinion for the CCG as ‘substantial’; ii. noted the content of the Annual Report.

19.027.3 Draft Audit Plan 2019/20

Mrs Warner presented the draft plan for 2019/20, which had been produced in consultation with Mr Parr, and drew members’ attention to section 3 that set out the proposed Internal Audit programme for the year. She highlighted the list of planned reviews and timing.

Mrs Warner referred the AC to the review for joint working arrangements with EL CCG, which was currently subject to discussion between Mr Parr and Mrs Kirsty Hollis, Chief Finance Officer, EL CCG; so was yet to be confirmed.

Dr Higgins added that work is commencing with East Lancashire Hospitals NHS Trust to discuss a tripartite board development process with the move towards Integrated Care and suggested all three organisations have a joint review on working arrangements.

ACTION: Dr Higgins, Mr Parr and Mrs Hollis to discuss the most Dr Higgins/ appropriate approach in terms of a review of joint working Ms Hollis/ arrangements across the system for 2019/20. Mr Parr

Mrs Warner confirmed that the fees for the year (of £31,680) were contained within the Executive Summary and had remained unchanged from the previous year.

Questions and answers followed.

Mr Farrar commented that he felt the Draft Internal Audit Plan had gone through the appropriate processes and he had no issues he wished to raise regarding the Plan.

Page 8 of 11 RESOLVED: That the AC approved the Internal Audit Plan 2019/20.

19.027.4 Charter 2019/20

Mrs Warner presented the Internal Audit Charter, which defined Internal Audit’s activities, purpose, authority and responsibilities. There were no changes for 2019/20.

There were no questions.

RESOLVED: That the AC approved the Internal Audit Charter 2019/20

19.027.5 Insight Update

Mrs Warner presented the update for information.

RESOLVED: That the AC noted the report.

19.028 Anti-Fraud

Mr Davies presented reports in relation to Anti-Fraud.

19.028.1 Annual Report 2018/19

Mr Davies outlined the report which provided details of the work carried out over the last year.

He drew members’ attention to the Executive Summary (page 2), which set out the main key areas of activity as outlined by the NHS Counter Fraud Authority.

He highlighted section 3 (page 3), which set out the standards for commissioners and detailed the CCG’s self-assessment against the standards. There were some ‘amber’ ratings in the assessment; further details are within the report.

He drew members’ attention to sections 4 and 5 (pages 5 and 6) which provided more details on the activity and referrals brought forward from 2018/19.

There were no questions.

The Chair noted the agreed work plan had been delivered, with no significant issues during the course of the year.

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

19.028.2 Draft Annual Plan 2019/20

Mr Davies presented the draft work plan for 2019/20, which had been produced in consultation with Internal Audit colleagues and Mr Parr.

He confirmed that the fees (of £8,000) for the year remained the same as last year. He advised the AC that there will be a new colleague joining the agency to replace Mrs Kerry Wheat.

He drew members’ attention to section 2, which outlined the planned priority areas and risk assessments.

Page 9 of 11 Mr Davies highlighted section 3, which provided more details in terms of planned activity and delivery.

Questions and answers followed.

RESOLVED: That the AC approved the Anti-Fraud Annual Plan 2019/20. 19.029 Losses and Special Payments

Mrs Ring presented the Losses and Special Payments Report for 1st April 2018 – 31st March 2019.

There had been one loss recorded in respect of Jalia Healthcare £2,644, as agreed at the AC in November 2018.

There were no other losses recorded in the period 1st April 2018 – 31st March 2019.

There were no questions.

RESOLVED: That the AC noted the Losses and Special Payments recorded for the period 1st April 2018 – 31st March 2019. 19.030 Waivers and Standing Orders

Mrs Ring presented the Waivers and Standing Orders report for the period 1st April 2018 – 31st March 2019.

There had been three single tender waivers signed during the period.

There were no questions.

ACTION: A column to be added to the Losses and Special Mrs Ring Payments to indicate when it has been reported to the AC.

RESOLVED: That the AC noted the Single Tender Waivers recorded for the period 1st April 2018 – 31st March 2019. 19.031 Corporate Registers

Mrs Moir presented the Corporate Registers Report, which provided an update on the registers held by the CCG and details of any exceptions.

There were no changes to the GB Register.

Changes to the staff register were highlighted.

Members of the Senate Meeting, held on 28th February 2019, were invited to renew their declarations. There have been no changes to the Senate Register. Due to the difficulties in ascertaining this information previously, declarations have been added as a standing item to the Senate Meeting agenda.

Mrs Moir highlighted the additions to the Gifts and Hospitality Register.

She highlighted the new entries on the Procurement Register.

There were no questions.

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

Page 10 of 11 19.032 Audit Committee Work Plan 2019

The Chair introduced the AC Work Plan 2019 and invited any comments on the content.

There were no comments.

RESOLVED: That the AC noted the content of the Work Plan 2019.

19.033 Pennine Lancashire Quality Committee (PLQC)

19.033.1 Minutes of the Meeting held on 23rd January 2019 19.033.2 Minutes of the Meeting held on 27th February 2019

The Chair introduced the minutes, presented for information, and invited Dr Nigel Horsfield to highlight any areas of concern.

Dr Horsfield referred to the disparity between the two CCGs’ Risk Registers’ strategies and processes; already discussed.

He added that the same issues, such as Accident and Emergency (A&E) attendances, were identified repeatedly at the PLQC. The A&E Delivery Board held responsibility for monitoring the situation; however, their reports did not provide assurance that a resolution appeared to be reachable. This was continuing to be followed up.

There were no other questions.

RESOLVED: That the AC noted the content of the minutes.

19.034 Primary Care Co-commissioning Committee (PCCC)

19.034.1 Minutes of the Meeting held on 22nd January 2019

The Chair introduced the minutes of the meeting held on 22 January 2019, presented for information.

There were no questions.

RESOLVED: That the AC noted the content of the minutes.

19.035 Any Other Business

No further business was discussed.

19.036 Date and Time of Next Meeting

It was agreed that the next meeting of the AC would be on 23rd May 2019 2-4pm in the Board Room, Fusion House.

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

Page 11 of 11 Appendix 6

CLINICAL COMMISSIONING GROUP (CCG) Minutes of the Audit Committee Meeting held on 23rd May 2019 at 1 p.m. in the Board Room, Fusion House Evolution Park, Haslingden Road, Blackburn, BB1 2FD

PRESENT: Mr Paul Hinnigan Lay Member – Governance (Chair) Dr Nigel Horsfield Lay Member Dr Geraint Jones Lay Member – Secondary Care Doctor (Retired)

IN ATTENDANCE: Mr Roger Parr Chief Finance Officer Mrs Linda Ring Senior Finance Manager Mr John Farrar Engagement Lead, Grant Thornton UK LLP Mrs Marianne Dixon Audit Manager, Grant Thornton UK LLP

MINUTES: Mrs Pauline Milligan Governing Body Secretary (transcription of audio recording)

Min No Item Action By 19.037 Chair’s Welcome

The Chair welcomed everyone to the meeting of the Clinical Commissioning Group’s (CCG’s) Audit Committee (AC).

The Chair explained that, due to issues within the Administration Team, the meeting would be audio recorded and then transcribed at a later date.

He added that, due to the departure of a member of temporary staff, the minutes of the last meeting would not be presented until the August meeting. 19.038 Apologies for Absence and Confirmation of Quoracy

Apologies had been received from:

Dr John Randall, General Practitioner (GP) Executive Member Mrs Lisa Warner, Senior Internal Audit Manager, Mersey Internal Audit Agency (MIAA) Mr Darrell Davies, Assistant Director, MIAA Mrs Claire Moir, Governance, Assurance and Delivery Manager

The Chair explained that, as the purpose of the meeting was to agree the final annual accounts, some members of the CCG and members of MIAA were not required to attend the meeting.

The meeting was confirmed as quorate. 19.039 Declarations of Interest

The Chair invited members to declare any interests they may have in relation to items on the agenda. No declarations of interest were made.

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.

19.040 2018/19 Annual Report and Financial Statements

19.040.1 Audit Findings Report 2018/19

Mr John Farrar presented the report and drew out key headline messages (page 3):

 There was an unqualified conclusion on the CCG’s financial statements for 2018/19;  There was an unqualified conclusion on the CCG’s Value for Money (VfM) arrangements;  The Auditors had not needed to exercise any statutory powers or duties;  Materiality calculations were as set out in the plan (page 4);  The audit was now almost complete, with a few minor checks to be carried out in relation to the receipt of the Letter of Representation and approval of the final version of the accounts and Annual Report.

Mrs Marianne Dixon reported that a late amendment had been made to the real increase on the Cash Equivalent Transfer Value (CETV) in the Remuneration Report, which had been adjusted in the Annual Report, due to an issue with the calculations. The NHS Business Services Authority had recently issued revised figures due to an error in the previous calculations.

Mr Farrar highlighted key items:

Going Concern (page 5) – Our Responsibility:

 The financial statements of the CCG were prepared on a ‘required’ basis, i.e. the CCG’s ability to continue as a going concern. The management had adopted the going concern assumption based on: o The CCG’s strong historic performance in achieving the financial targets set by the Department of Health and Social Care (DHSC); o Opening allocations being notified by the DHSC for 2019/20; o The CCG’s Financial Plan being reviewed and assessed as meeting business rules by NHS England.

Significant Findings (page 6) – Risks Identified in our Audit Plan:

 The revenue cycle included fraudulent transactions – this risk had been rebutted as: o revenue did not primarily involve cash transactions; o revenue was principally an allocation from NHS England.  Management override of controls – the audit work did not identify

Page 2 of 5 any issues in respect of management override of controls;  Operating expenses – purchase of secondary healthcare – there were no matters to bring to the attention of the AC.

Significant Findings (page 8) – Accounting Policies:

 Revenue recognition – appropriate accounting policies in place;

Other Communication Requirements (page 9):

 Matters in relation to fraud – nil return;  Matters in relation to related parties – nil return;  Matters in relation to laws and regulations – nil return.

Other Responsibilities under the Code (page 10):

 Regulatory opinion – proposed to issue an unqualified regulatory opinion;  Other information – no significant inconsistencies had been identified, minor presentation changes to the Annual Report and Governance Statement had been discussed and updated by management – proposed to issue an unqualified opinion;  Auditable elements of Remuneration and Staff Report - proposed to issue an unqualified opinion;  Matters on which we report by exception – nothing to report on these matters.  Review of accounts consolidation schedules and specified procedures on behalf of the group Auditor – proposed to issue a ‘consistent with’ report;  Certification of the closure of the audit – proposed to certify the closure of the 2018/19 audit for the CCG.

Value for Money (VfM) (page 11):

Mr Farrar provided background information to the approach in relation to VfM.

The Auditors had carried out an initial risk assessment in January 2019 and identified a number of significant risks in respect of specific areas.

The Auditors had focused their work on the significant risks that were identified in the CCG’s arrangements in relation to financial sustainability and commissioning alliance arrangements. The Auditors had gained the evidence and assurance necessary to be satisfied that the CCG did have appropriate arrangements in place for securing the economy, efficiency and effectiveness in its use of resources.

Independence and Ethics (page 13):

Mr Farrar confirmed that there were no significant facts or matters that impacted on the Auditors independence to bring to the attention of the AC.

 Audit and Non-audit Services – no non-audit work had been carried out; however, work on the Mental Health Investment Standard audit was due to take place in August and September.

Audit Adjustments (page 14):

 Impact of adjusted misstatements – there were no misstatements Page 3 of 5 identified for adjustment;  Misclassification and disclosure changes – there were no misclassifications identified for adjustment. The list of disclosure omissions had been adjusted.

Mr Farrar thanked all the Finance Team for producing a high quality set of accounts. He added that it was clear that quality assurance had taken place and there were only minor changes to be made.

Fees (page 15):

Mr Farr confirmed that the fees for the audit were in line with the Audit Plan.

Audit Opinion (draft) (page 16):

The draft audit opinion was detailed and it was anticipated that the Auditors would provide the CCG with an unmodified audit report.

Questions and answers followed.

The Chair remarked that he was pleased to receive a good report and, on behalf of the AC, thanked all the staff who, once again, worked to produce the 2018/19 Annual Report and Financial Statements on time and to a good standard; with only minor amendments to be made. Mr Roger Parr echoed the Chair’s comments.

ACTION: Mr Parr agreed to pass on the AC’s thanks to all the staff Roger involved in the production of the 2018/19 Annual Report and Parr Financial Statements.

The Chair noted that minor amendments would be checked and finalised.

ACTION: The Annual Audit Letter would be presented to a future Pauline meeting of the GB for information. Mrs Pauline Milligan to add to Milligan the GB Forward Plan.

RESOLVED: that the AC noted the content of the report.

19.040.2 Letter of Representation

Members reviewed the standard letter, requested by all auditors, which provided the CCG’s opinion as to its financial statements giving a true and fair view in accordance with International Financial Reporting Standards and the accounting policies directed by the Secretary of State with the consent of the Treasury, as relevant to the NHS in England.

Members noted that the letter would be signed by the Joint Chief Officer and Chief Finance Officer following approval.

Questions and answers followed.

RESOLVED: That the AC approved the Letter of Representation.

19.040.3 Annual Report and Financial Statements 2018/19

The Chair introduced the Annual Report and Financial Statements 2018/19, which had been reviewed at the last meeting. He was satisfied that the documents had received the necessary scrutiny at the last meeting and only minor amendments had been made.

Page 4 of 5 He enquired if a summary report would be produced for publication. Mrs Linda Ring responded that a public facing summary report would be produced in June.

There were no further questions.

RESOLVED: That the AC approved the Annual Report and Financial Statements 2018/19.

19.041 Any Other Business

Integrated Care System Dr Geraint Jones commented that the CCG had been careful, and had been audited on, ensuring that it provided VfM. He enquired how the CCG could be assured that the funding it provided to the Integrated Care System (ICS) was also used appropriately.

Mr Parr responded that the CCG was aware of how much funding was provided and where the spend was directed but it remained the responsibility of the accountable body (the CCG) as the ICS was not a statutory body.

He stated that it was the role of the Joint Committee of CCGs (JCCCG) to oversee how the ICS was operating and the commissioning decisions being made on a Lancashire and South Cumbria wide basis.

Dr Jones asked if this was monitored on an annual basis.

Mr Parr responded the JCCCG monitored and reviewed its processes throughout the year on the areas that the CCGs had delegated to it.

Dr Jones asked if members thought that the CCGs should also have a role in the monitoring and review process of the ICS.

The Chair wondered if the CCG received VfM in relation to the functions of the ICS in line with CCG spend and if the CCGs should receive details of where the spend was being directed.

Members discussed the work of the ICS and Integrated Care Partnerships (ICPs).

ACTION: The Chair requested that the AC receive a report at the Roger next meeting on the funding provided to the ICS and ICP, details of Parr where the funding was being spent and if they provided VfM. Mr Parr to action. 19.042 Date and Time of Next Meeting

It was agreed that the next meeting would be confirmed as soon as possible. Pauline ACTION: Mrs Pauline Milligan to confirm. Milligan

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

Page 5 of 5 NHS Blackburn with Darwen Clinical Commissioning Group NHS East Lancashire Clinical Commissioning Group

Appendix 7 Pennine Lancashire Committees in Common Minutes of the Blackburn with Darwen CCG Commissioning Business Group and East Lancashire CCG Sustainability Committee held on 15th May 2019 at Innovation House, Blackburn

PRESENT: Blackburn with Darwen CCG Dr John Randall General Practitioner (GP) Executive Member Dr Ridwaan Ahmed Clinical Director – Quality & Primary Care Dr Adam Black GP Executive Member Paul Hinnigan Lay Member (Governance) Dr Geraint Jones Lay Member (Secondary Care Doctor – Retired) Dr Penny Morris Medical Director Roger Parr Deputy Chief Executive/Chief Finance Officer Dr Preeti Shukla GP Executive Member Janet Thomas Executive Nurse / Associate Director Quality and Commissioning East Lancashire CCG: David Swift Lay Member Governance - CHAIR Dr Santhosh Davis GP, Clinical Lead Burnley Alex Walker Director of Commissioning

In Attendance: Jason Newman Head of Performance & Delivery Gifford Kerr Consultant in Public Health Medicine Julie Kenyon Senior Operating Officer – Primary Care & Medicines Commissioning Elaine Craven Executive Assistant - Minutes

Min Ref: ACTION 19:64 Welcome & Chairs Update

The Chair welcomed members to the meeting.

19:65 Apologies

Apologies were received from Dr Julie Higgins, Dr Zaki Patel, Dr Mark Dziobon, Kirsty Hollis, Dr Fiona Ford, Dr Vanessa Warren, Dr Tom McKenzie, Naz Zaman, Debra Atkinson and Dr Lisa Rogan.

19:66 Governance

. Declarations of Interest: Roger Parr declared an ‘Indirect’ interest in agenda item 9.3 PL Hospice Provision, the Chair and members were happy for him to remain whilst the item was discussed.

. Quoracy:  East Lancashire Clinical Commissioning Group Sustainability Committee were not quorate. The minutes will be circulated to those members not in attendance to seek support for the decisions made.  Blackburn with Darwen Clinical Commissioning Group Commissioning Business Group were quorate.

- 1 - Minutes Approved by the Committees: 17.07.19 19:67 Minutes of the meeting held on 17th April, 2019:

The minutes of the meeting held on 17th April were approved as an accurate record.

19:68 Action Matrix:

The Action Matrix was presented and updated as follows:

18:31 Pennine STEP (Succeed Thrive Empower Pennine) Service – Included on the agenda.

19:54 Contracts due to Expire – Included on the agenda.

19:58 Albion Mill and Intermediate Care Update (BwD Only) – Slight delay, will now be live Summer next year instead of January/February. Will need to keep a check on the contract extension with Springfield Care Home.

19:69 Matters Arising:

There were no matters arising.

19:70 Pennine Lancashire Clinical Commissioning Groups master contract tracker:

Jason Newman presented the item and referred to the tracker documents sent out prior to the meeting. Jason provided the committee with an overview of revised governance arrangements now in place. A schedule of Senior Managers Meetings, chaired by Roger Parr, and Joint Senior Managers & Executive Management Team meetings, chaired by Julie Higgins, is now in place.

The Contracts Department have been asked to raise any issues/renewals in plenty of time, a formal notice time has been established.

Business will be tracked through the Senior Managers Meetings to ensure papers are prepared in time for the relevant Committee meetings. A meeting/agenda tracker is the main way of collating agenda items for the relevant meetings.

Discussion then followed:

 Is this new? No both have been in place, in some form, for a while.  The timing and quality of papers, has sometimes had a last minute feel and the committee need assurance that going forward this will improve.  The idea of this update is to provide assurance that processes are now in place.  Should Committees in Common be receiving more strategic items, rather than the historic practice of bringing papers for every single contract?  The Committee need to be assured that items not brought to this Committee, will still be scrutinised in detail.  Do we have the resources in both CCGs to carry out all of the work required? Is this why papers are brought late and the quality isn’t there? Is there a time issue?  A large number of contracts were due to expire at the end of March. This impacted on the January and February Committees in Common agendas, it was recognised that this could have been better and that there needs to be a grip on this going forward.

The members agreed a willingness to review the Terms of Reference, on the

- 2 - Minutes Approved by the Committees: 17.07.19 proviso that assurance can be given that: o the detailed scrutiny of reports will still take place; o contracts not brought to Committees in Common will be taken to Senior Managers for approval; o the relevant governance is in place.

ACTION: Jason Newman to bring back an updated schedule showing which items Jason will come to Committees in Common, and which will be dealt with elsewhere in the Newman organisations.

19:71 Pennine STEP (Succeed Thrive Empower Pennine) Service update:

Alex Walker provided a verbal update in relation to the decision taken at the last Committees in Common meeting which was to:  Seek to terminate the contract at the earliest point.  Redeploy any resource during the termination period to support Primary Care Network and Integrated Neighbourhood Team delivery.

Following the meeting, advice was sought in relation to ending the contract at the earliest point. The procurement advice received was that there was a serious risk of legal challenge should the Clinical Commissioning Groups try to terminate the contract early i.e. before the end of the required 12 month notice period. The Committees in Common Chairs were then consulted with a view to returning to the original recommendation contained in the report, which was:  Agree the proposed re-negotiation of the contract level to £100k to block and £475 tariff per episode of care, for the remainder of the contract period (final 3rd year of the contract).

The next steps in place are, a meeting with the provider has been arranged on 17th June to re-negotiate the contract, following that, an outcome report will be brought to the Committees in Common meeting on 17th July.

Discussion then took place and the following points were made:

 Members present from both Committees reiterated concerns over the performance issues, but agreed with the suggested way forward.  Need to learn from this and ensure that future contracts are fit for purpose.  Robust performance monitoring needs to be in place for future contracts.  Look at options in relation to notice periods and inserting a clause regarding early termination should there be performance issues.  As this contract ends in 12 month time, it would be prudent to now start to look at an alternative model to ensure service continuity.  The main issue with this particular contract is in relation to value for money, and not the quality of the service provided by the provider to a small amount of patients.

Action: Members present from both Committees requested that a report be Alex brought to a future meeting, outlining how commissioning contracts will be drawn Walker up in the future, highlighting the changes that have been put in place to mitigate risk.

19:72 Pennine Lancashire support for Tuberculosis service review – Options paper for ICS Collaborative Commissioning Board:

Gifford Kerr presented the report which outlined that the current configuration of the Tuberculosis service in Lancashire and South Cumbria is unlikely to be sustainable or appropriate in the future.

- 3 - Minutes Approved by the Committees: 17.07.19 Gifford then provided additional information in relation to the chronology and background of the report: The proposal of a wider role for Pennine Lancashire in the Tuberculosis service, to improve quality was first discussed in the summer of 2017 with a report taken to the East Lancashire CCG Sustainability Committee in January, 2018. Due to the significant senior officer changes which have taken place there has been no further movement in relation to this. In February/March 2019 a report was taken to the ICS surveillance group regarding Tuberculosis in the Preston area. Jackie Hanson and Andrew Bennett agreed that a report should then go to the Collaborative Commissioning Board.

Gifford asked that members support the recommendations in the report.

Gifford added that:  Expertise in East Lancashire, through the legacy of Peter Ormerod and his colleagues, is a success story as Tuberculosis has dramatically reduced.  Contact tracing is key when a Tuberculosis case is discovered.  In other areas services are fragmented.  In other parts of Cumbria and Lancashire, specialist nurses are seeing less cases than in this area, this extra nursing capacity will aid our area.  Socially complex cases require additional resource – CGL are taking on some of the work previously done by specialist nurses.

Members then discussed the content of the report:  The statistics are quite shocking for the Blackburn with Darwen area, at 4 times the national average. It will take years to reduce this down to the national level.  A new screening programme is picking up cases.  Great shared capacity - the 2 Clinical Commissioning Groups have a greater share of leadership capacity to address this issue.  Has to be clinically led – this is very reassuring.  When the Tuberculosis model came in, it was based around London.  Trying to build on and maintain the service.  How can we ensure that Tuberculosis awareness continues and that expertise are going to spread across the area to where it is needed?  Tuberculosis is difficult to spot and can mimic other things.  Levelling up other areas and not levelling down.  Making effective use of financing – how do we manage that? Our area is fine as it is embedded in the East Lancashire Hospitals Trust contract, other areas will be more difficult.  Wouldn’t expect a reduction in service and there will be no extra funding. Could there potentially be a reduction in costs?

Decision:  Members present from both Committees support the recommendation that a Tuberculosis specialist hub and network is developed for Lancashire & South Cumbria through engagement with the Collaborative Commissioning board – subject to the following caveats: o The CCGs are not agreeing to any additional funding o There is an expectation that there will be no reduction of the local service in Pennine Lancashire o East Lancashire Clinical Commissioning Group Sustainability Committee members not in attendance also support this decision.

 Members present from both Committees support a leadership role for

- 4 - Minutes Approved by the Committees: 17.07.19 the Pennine Lancashire Clinical Commissioning Groups in the service review process in the context of further developing the East Lancashire Hospitals Trust Tuberculosis service leadership across the Lancashire and South Cumbria Integrated Care System.

As East Lancashire Clinical Commissioning Group Sustainability Committee was not quorate, these minutes will be circulated to those members not in attendance to seek support for these decisions.

19:73 East Lancashire Health Economy Medicines Management Board Minutes:

The minutes of the East Lancashire Health Economy Medicines Management Board for meetings held on 16th January, 20th February and 20th March 2019 were received, and it was agreed to receive these going forward.

The Chair commented that the Terms of Reference published on the East Lancashire Medicines Management Board website state that copies of minutes will be sent for acceptance and approval to each Governing Body via the Sustainability Committee for East Lancashire CCG and Commissioning Business Group for Blackburn with Darwen CCG. In the Chair’s opinion this is difficult if there are no members of the board in attendance at this committee, acknowledging that the two meetings currently clash.

The Chair also noted that the Terms of Reference were due to be revised in November 2018 and it would appear that the Pennine Lancashire GP member allocation has not been taken up, with only Dr Tom McKenzie and Dr Sheila Jackson in regular attendance.

Action: Julie Kenyon agreed to take this back to the East Lancashire Health Julie Economy Medicines Management Board, and for updated terms of reference to be Kenyon submitted for approval to a future meeting.

19:74 Any other Business:

There were no items for inclusion on the Risk Register.

There were no other items of business in this section of the meeting.

19:75 Date & Time of the Next Meeting:

The next meeting was confirmed as Wednesday, 19th June, 2018, 1 pm, Walshaw House, Nelson.

- 5 - Minutes Approved by the Committees: 17.07.19 NHS Blackburn with Darwen Clinical Commissioning Group NHS East Lancashire Clinical Commissioning Group

Appendix 8 Pennine Lancashire Committees in Common Minutes of the Blackburn with Darwen CCG Commissioning Business Group and East Lancashire CCG Sustainability Committee held on Wednesday, 17th July 2019 at Innovation House, Blackburn

PRESENT: Blackburn with Darwen CCG Dr John Randall General Practitioner (GP) Executive Member - Chair Dr Ridwaan Ahmed Clinical Director – Quality & Primary Care Dr Adam Black GP Executive Member Paul Hinnigan Lay Member (Governance) Dr Geraint Jones Lay Member (Secondary Care Doctor – Retired) Roger Parr Deputy Chief Executive/Chief Finance Officer Dr Zaki Patel GP Executive Member

East Lancashire CCG: David Swift Lay Member Governance Kirsty Hollis Deputy Chief Executive/Chief Finance Officer Alex Walker Director of Performance & Delivery Naz Zaman Lay Member Equality & Inclusion

In Attendance: Julie Kenyon Senior Operating Officer – Primary Care & Medicines Commissioning Cathy Gardener Head of Commissioning – Scheduled Care, Mental Health and Cancer Karen Henderson Lead Commissioning Support Manager – Scheduled Care Elaine Craven Executive Assistant - Minutes

Min Ref: ACTION 19:81 Welcome & Chairs Update

The Chair welcomed members to the meeting.

19:82 Apologies

Apologies were received from Dr Julie Higgins, Dr Penny Morris, Dr Preeti Shukla, Dr Santhosh Davis, Dr Mark Dziobon, Dr Tom MacKenzie, Kathryn Lord, David Rogers, Gifford Kerr, Debra Atkinson, Dr Lisa Rogan and Aidan Kirkpatrick.

19:83 Governance

The Chair reminded members of their obligation to declare any interest they may have on any issues arising during the meeting, which might conflict with the business of the Clinical Commissioning Groups. The Chair referred members to the outline definitions in relation to types of interest, now attached to the meeting agenda.

 Declarations of Interest: There were no declarations of interest made at this meeting.  Quoracy: Blackburn with Darwen Clinical Commissioning Group

- 1 - Minutes Approved by Committee 21.08.19

Commissioning Business Group was quorate. East Lancashire Clinical Commissioning Group Sustainability Committee was not quorate, the minutes will be circulated to those members not in attendance to seek support for the decisions made at this meeting.

Members raised concern and questioned the reason behind the quoracy issues that have been experienced in relation to both Committees. Points raised were:  Is the venue an issue?  Are Wednesdays too overloaded with meetings, should Committees in Common move to another day?  A combined Terms of Reference would now seem to be appropriate and should help with the issue of quoracy.  Should there be a working group to look at a plan? Kirsty Hollis offered to take this forward and members from both Committees agreed.

ACTION: Kirsty Hollis to meet with both Chairs to look at a plan. K. Hollis

Ratification of minutes was raised by the Chair, he asked if members from both Committees would support Chair’s action being used to ensure minutes are signed off in a timely manner. The members present from both Committees were in support of this.

The Chair advised that Dr Vanessa Warren has stepped down as GP Clinical Lead for Ribblesdale, to take up a role within the Primary Care Network. As a result of this, Dr Warren will no longer serve as a member of the East Lancashire Clinical Commissioning Group Sustainability Committee effective 1st July 2019.

19:84 Minutes of the meeting held on 15th May, 2019:

The meeting scheduled to take place on 19th June was stood down, therefore the minutes of the 15th May meeting were presented for ratification.

The following amendments to the minutes of the 15th May meeting were put forward by the Chair:

 Dr Penny Morris’ title be amended to Medical Director.  Minute ref: 19:66 – Roger Parr’s declaration of interest should be shown as an ‘Indirect’ Interest.  Minute ref. 19:71 – Replace 2 instances of The Committee, with Members present from both Committees….  Minute Ref: 19:72 – Replace Committee decision with Decision and add Members present from both Committees…., to each of the bullet points. Add a paragraph as follows: As East Lancashire Clinical Commissioning Group Sustainability Committee was not quorate, the minutes will be circulated to those members not in attendance to seek support for these decisions.

Members present from both Committees approved the above amendments.

The Chair confirmed that following the 15th May Committees in Common meeting, the minutes were circulated to East Lancashire Sustainability Committee members not present at the meeting. Sufficient support was received to ensure that the decisions made at the meeting were quorate and a record has been placed on file for audit purposes.

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19:85 Action Matrix:

18:31: Pennine STEP Service The owner of this action is now Cathy Gardener (CG). Alex Walker provided an update in relation to this action. Work is ongoing with the provider to refocus the service onto the Community. Some success has been achieved in reducing costs, however, the Clinical Commissioning Group are awaiting confirmation of changes before finalising. An update will be brought back to Committees in Common. The service going forward is the critical thing, this will inform regarding the type of investment needed. April 2020 the STEP contract will be revised, how the service is performing will determine the contract going forward.

19:24: Proposal for an Integrated Primary & Community Mental Health Care Model – this action has been taken over by current ongoing events and will be covered in the NTW item on this agenda. Action closed.

19:54: Contracts/meeting tracker and governance assurance – This will be an agenda item for the August Committees in Common meeting.

19:58: Albion Mill – this piece of work is ongoing and will now be brought into the wider Pennine Lancashire Intermediate Care plan, which is an item on this agenda. The Albion Mill project is running slightly behind time and Roger Parr confirmed that the Springfield Contract extension will support the revised project completion date. Action closed.

19:73: East Lancashire Health Economy Medicines Management Board - Terms of Reference are on this agenda. Action closed.

19:86 Matters Arising:

There were no matters arising.

19:87 East Lancashire Clinical Commissioning Group Sustainability Committee Terms of Reference:

David Swift presented this item, he advised that the finance section had been removed from the original East Lancashire Clinical Commissioning Group Sustainability Committee Terms of Reference and these now reflect the remit of the current committee.

Members present approved the Terms of Reference. As East Lancashire Clinical Commissioning Group Sustainability Committee was not quorate, the minutes will be circulated to those members not in attendance to seek support for this decision.

19:88 Mental Health System Improvement Plan:

Cathy Gardener attended to present this item. Cathy explained that the Integrated Care System (ICS) had commissioned an independent review, carried out by Northumberland, Tyne and Wear NHS Foundation Trust, of the Lancashire Urgent Mental Health Pathway. In response to the report findings an ICS level Mental Health System Improvement Board has been established. This board will be accountable for overseeing the implementation and delivery of a Mental Health Improvement Plan. Some elements in the plan have local responsibility for delivery and, in view of this, a Pennine Lancashire Mental Health Delivery Board will be established. This board will be responsible for

- 3 - Minutes Approved by Committee 21.08.19 implementing local actions. The Pennine Lancashire Mental Health Delivery Board will report into the Accident and Emergency Delivery Board, Pennine Lancashire Transformation Programme and ICS Mental Health System Improvement Board. Members then went on to discuss this item:

 Do we agree with the reason why the independent review was requested? An increase in demand was cited, however, there are also questions whether the provider is failing or underperforming.  Clarification was requested in relation to the term Mental Health Weighted Population referred to on Page 7 of the report. Weighting takes into account the needs of the population and is influenced by areas of deprivation. There are three higher weighted Clinical Commissioning Group areas in Lancashire & South Cumbria – both East Lancashire and Blackburn with Darwen have higher weighted mental health populations.  Clinical Commissioning Groups are accountable for Mental Health Services, but delivery is delegated to the Integrated Care System.  Committees in Common need to see the Terms of Reference for the Pennine Lancashire Mental Health Delivery Board, including details of the membership. The Terms of Reference have not been formally signed off as yet, they will be brought to a future meeting  Governance arrangements are confusing: o Joint Committee of Clinical Commissioning Groups has delegated authority. o There is mixed organisation membership on the Integrated Care System board. o Accountability sits with the Clinical Commissioning Groups. How do we get assurance regarding work agreed at ICS level? There needs to be more governance in place, but the Pennine Lancashire Mental Health Delivery Board should give the Clinical Commissioning Groups more confidence regarding local delivery. There is also an action plan in place which contains delivery targets.  There is still a need for governance to be in place, to ensure assurance, as Clinical Commissioning Groups are legally accountable.  Slides 63/64 regarding Culture and Relationships, some services are described as ‘secretive’, the system was described as ‘fragmented and power based’ – there’s a need for transparency and there needs to be responsibility.

 Who will be appointed as members of the Pennine Lancashire Mental

Health Delivery Board?

The Board will be made up of key people working in Mental Health at a

local level.

Need to ensure that the Board is properly constituted, has the correct

membership and there needs to be Key Performance Indicators identified.

 Members requested sight of overall governance. It would be helpful for

Claire Richardson to attend Committees in Common to present the work

that she is involved in.

 With regards to the Action Plan, there are various references to East Lancashire Hospital Trust and Clinical Commissioning Groups, but mainly Lancashire Care Foundation Trust people named. This will be populated as the organisations send in details of their nominated representatives.  Why was the report delayed? Data issues were given as the reason for delay.

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Action: The Terms of Reference for the Pennine Lancashire Mental Health C. Delivery Board be brought to a future Committees in Common meeting. Gardener

Action: Claire Richardson to be invited to Committees in Common to present the C. work she has been involved in regarding governance. Richardson

19:89 DVT Service:

Karen Henderson attended to present this item, key points:

 Different financial arrangements are currently in place for each Clinical Commissioning Group – Blackburn with Darwen are on a block contract and East Lancashire is a cost per episode contract.  Improved patient experience.  Managing 97% of referrals.  More cost effective and better value service.  Lots of positive work over recent months.  East Lancashire Target was 434 patients seen per annum, however the actual activity figure is over 1300.  More work required – scoping and evaluation of service. Is the model right? Is there scope for PCN working?  Not extending will have a detrimental effect on secondary care.

Members then discussed the item:  The Chair commented, in his capacity as a GP, this is the best thing that has happened for GPs and their patients in recent years.  How much money has this service saved rather than patients going to secondary care? Big gains would be if service was 24hrs instead of 9 to 5, this would be a great gain to aid secondary care.  Good example of partnership working. However, a slight downside has been that it is too easy for GPs to refer patients to this service, which has resulted in some diagnostic referral errors, this needs to be addressed in practice.  Clinically good service and financially good. Are we going to spend a lot of time re-commissioning a service that is already performing effectively?  How do we tick the boxes without spending too much time on this?  The pilot needs drawing to a conclusion, and then a light touch procurement undertaken.  Look at possibility of adding in an Out of hours service.

Decision: The members of both Committees present supported the extension of both contracts for a further 12 months to 30th September 2020, and to an increased activity target in line with intelligence, with the following caveats:  East Lancashire Clinical Commissioning Group move to a block contract.  Assess possible Out of Hours service.

As East Lancashire Clinical Commissioning Group Sustainability Committee was not quorate, the minutes will be circulated to those members not in attendance to seek support for this decision.

19:90 Intermediate Care:

Alex Walker gave a presentation in relation to a Pennine Lancashire Intermediate Care Plan.

- 5 - Minutes Approved by Committee 21.08.19

The presentation was well received by members present from both committees, the following comments and observations were made:

 Community level is key.  The concept of a bed is key, taking into account, infrastructure cost, bed blocking etc, keeping people in their own bed would reduce costs – move things down further with a strong community offer in people’s own homes.  Strong dialogue with the public will be needed to articulate changed thinking.  Assessment/diagnosis is really important. Challenges around medical oversight.  The members present were fully supportive. In short term, still need the bed base but the whole system needs to change to support staged change.  Question if Intermediate Care needs a re-brand.  East Lancashire has a lot of investment tied up that could be used for change. Greater opportunities to shift resource around.  Detailed plan now needed to assess viability.  Building on conversations already happening re: financial pressures. ICP/CCG financial strategy going forward.  ICP opportunity for different thinking.  This will be a key element of the 3 or 4 big things that will really affect change/benefit patients. PCN and Primary care is another key area.  Frames up what is being talked about by the ICP – Intermediate Care meeting has been going on for a good while and now much more about the Out of Hospital system. Now needs some socialisation and on the back of Albion Mill it was relevant to bring this to Committees in Common now.

A detailed project plan for the work will now be generated.

19:91 East Lancashire Medicines Management Board Terms of Reference:

The East Lancashire Medicines Management Board Terms of Reference were received for information. An observation was made that there needs to be Blackburn with Darwen GP attendees. Julie Kenyon to feed this back to East Lancashire Medicines Management Board.

19:92 Pennine Lancashire Diabetes Health Improvement Board Terms of Reference:

The Pennine Lancashire Diabetes Health Improvement Board Terms of Reference were received for information.

19:93 Pennine Lancashire Diabetes Health Improvement Board Minutes & Action Matrix – December 2018:

The Pennine Lancashire Diabetes Health Improvement Board Minutes & Action Matrix for the meeting held on 5th December, 2018, were received for information.

19:94 Any other business:

There were no items for inclusion on the Risk Register.

There were no other items of business in this section of the meeting.

- 6 - Minutes Approved by Committee 21.08.19

19:95 Date & Time of Next Meeting:

The next meeting was confirmed as Wednesday, 21st August, 2019 commencing at 1.00 p.m. at Walshaw House, Nelson.

- 7 - Minutes Approved by Committee 21.08.19