NHS Coventry and Rugby CCG and NHS Warwickshire North CCG Governing Body Meetings in Common to be held in Public on Thursday, 12 July 2018, 2:45 pm to 4:00 pm in Endeavour Meeting Rooms, Heron House, Newdegate Street, Nuneaton, CV11 4EL A G E N D A

Time Item Presenter Enclosure No

1. Standing Items 2.45 1.1. Welcome and Apologies Received: Chris Stainforth Sarah Raistrick Verbal

1.2. Declarations of Interest: Where possible, any conflict Sarah Raistrick Enclosure A of interest should be declared to the Chair of the meeting in advance of the meeting. See guide below. 1.3. Minutes of the last Meetings held in common on 8th Sarah Raistrick Enclosure B March and 9th May 2018 1.4. Matters Arising/Action Schedule Sarah Raistrick Enclosure C

2.50 1.5. Chair’s Report a) Coventry and Rugby CCG Sarah Raistrick Enclosure D b) Warwickshire North CCG Deryth Stevens Enclosure E 2.55 1.6. Chief Officer’s Report Andrea Green Enclosure F 2. Strategy and Planning 3.00 2.1. Public Health Report a) Coventry and Rugby Liz Gaulton Enclosure G b) Warwickshire John Linnane / Enclosure H Rachel Robinson 3.05 2.2. Commissioning Intentions Jenni Northcote Enclosure I 3.10 2.3. Communications and Engagement Report Jenni Northcote Enclosure J 3. Quality, Safety and Performance 3.15 3.1. Patient Story – Diabetes Jo Galloway Presentation

3.25 3.2 Integrated Safety, Quality and Performance: • Safety and Quality Report Jo Galloway Enclosure K • Performance Report Steve Jarman- Davies 4. Financial Performance 3.30 4.1 Finance and Contract Report: Month 2 Clare Hollingworth a) Coventry and Rugby CCG Enclosure L b) Warwickshire North CCG Enclosure M 3.35 4.2 Procurement Report Clare Hollingworth Enclosure N 5. Assurance and Governance Enclosure O 3.40 5.1. Governing Body Assurance Framework Quarter 1 Maria Maltby (To Follow) Time Item Presenter Enclosure No

3.45 5.2. CCG Response to the Modern Slavery Act 2015 Maria Maltby Enclosure P a) Coventry and Rugby CCG b) Warwickshire North CCG 3.50 5.3. Annual Audit Letters: a) Coventry and Rugby CCG Clare Hollingworth Enclosure Q b) Warwickshire North CCG Enclosure R 3.55 6. Policies for Ratification 6.1 Non-Medical Prescribing in Primary Care Policy Jo Galloway Enclosure S 6.2 Gifts and Hospitality Policy Maria Maltby Enclosure T 6.3 Gluten Free Policy Steve Allen Enclosure U 7. Committee Reports - Coventry and Rugby CCG Committee Chairs Enclosure V a) Audit Committee: 10 April 2018 and 24 May 2018 Committee Reports - Warwickshire North CCG Committee Chairs Enclosure W b) Audit Committee: 2 May 2018 and 24 May 2018 Committees in Common Reports Committee Chairs Enclosure X c) Clinical Quality and Governance Committees in Common: 25 April 2018 d) Commissioning, Finance and Performance Committees in Common: 26 April 2018 and 24 May 2018 Other Enclosure Y e) Health and Wellbeing Board – Warwickshire: 2 May 2018 f) Health and Wellbeing Board – Coventry: 9 April 2018 4.00 8. Questions from Visitors Sarah Raistrick Verbal 4.05 9. Any Other Business Sarah Raistrick Verbal

Future Governing Body Meetings in Common held in Public: Date Time Venue Wednesday 12 September 2.45 pm – 4.00 pm Venue TBC, Coventry 2018 Thursday 08 November 2018 2.45 pm – 4.00 pm Heron House, Nuneaton o

Declarations of Interest

Under the Health and Social Care Act 2012, there is a legal obligation to manage conflicts of interest appropriately. Where possible, any conflict of interest should be declared to the Chair of the meeting as soon as it is identified in advance of the meeting. Where this is not possible, it is essential that at the beginning of the meeting a declaration is made if anyone has any conflict of interest to declare in relation to the business to be transacted at the meeting. An interest relevant to the business of the meeting should be declared whether or not the interest has previously been declared.

Type of Description Interest

Financial This is where an individual may get direct financial benefits from the consequences of a Interests commissioning decision. This could 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 (of more than 5% of the issued shares), partner or owner of a private or not for profit company, business or consultancy which is doing, or which is likely, or possibly seeking to do, business with health or social care organisations. • A consultant for a provider; • In secondary employment; • In receipt of a grant 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 reputation or Interests status or promoting their professional career. This may 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 CQC or NICE; • A medical researcher. Non-Financial This is where an individual may benefit personally in ways which are not directly linked to their Personal professional career and do not give rise to a direct financial benefit. This could include, for Interests 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; • A member of a political party; • Suffering from a particular condition requiring individually funded treatment; • A financial advisor. 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). This should include: • Spouse / partner; • Close relative e.g., parent, [grandparent], child, [grandchild] or sibling; • Close friend; • Business partner.

Blank Page NHS WARWICKSHIRE NORTH CCG AND COVENTRY AND RUGBY CCG - Register of Interests for Governing Bodies in Common meeting

WN / CR / Current position (s) held- i.e. Governing Declared Interest- (Name of the organisation and Title First Name Surname Type of Interest Date of Interest Both Body, Member practice, Employee or other nature of business)

Declared To Indirect Interests Professional Non-Financial Non-Financial Personal Interests Personal Financial Interests Nil Lay Member for Audit and Governance WN Mr David Allcock (previously Lay Member for Public and Patient Engagement)  1. GP at Camphill GP-Led Health currently operated WN Dr Godwin Igodo Clinical Lead Oct-10 Current by Malling Health/IMH Group

 2. Director at Ripples Healthcare (former interest - WN Dr Godwin Igodo Clinical Lead Current to be removed in October 2018)

1. GP Partner at Station Street Surgery   WN Dr Arshad Khan Clinical Lead Current

2. GP Partner at Torcross Medical Centre, Coventry   WN Dr Arshad Khan Clinical Lead Current

3. GP Locum at Khan Medical Practices Ltd  

WN Dr Arshad Khan Clinical Lead 2011 Current

1. 50% Shareholder of Graham Nuttall Associates  14/09/2015 Ltd WN Mr Graham Nuttall Lay Member for Primary Care Current

2. Trustee and Board Member at Bulkington Village 14/09/2015 Centre WN Mr Graham Nuttall Lay Member for Primary Care Current 

Lay Member for Public and Patient WN Mr Derek Pickard 1. Member of the Labour Party  1994 Current Engagement

Lay Member for Public and Patient WN Mr Derek Pickard 2. Member of the Healthwatch Steering Committee  Current Engagement  Consultant Physician for Worcestershire Health and WN Dr Chris Pycock Secondary Care Doctor Dec-14 Current Care Trust

Joint role with Warwickshire North CCG and WN Ms Rachel Robinson Associate Director of Public Health  Current Warwickshire County Council

WN Dr Imogen Staveley Clinical Lead 1. Salaried GP at Bedworth Medical Centre  04/09/2017 Current NHS WARWICKSHIRE NORTH CCG AND COVENTRY AND RUGBY CCG - Register of Interests for Governing Bodies in Common meeting

WN / CR / Current position (s) held- i.e. Governing Declared Interest- (Name of the organisation and Title First Name Surname Type of Interest Date of Interest Both Body, Member practice, Employee or other nature of business)

WN Dr Imogen Staveley Clinical Lead 2. CEO PregnaPouch (Pregnancy related app)  Current October 2015

1. Partner at Dordon and Polesworth Group WN Dr Deryth Stevens Chair  2005 Current Practice

2. Dordon and Polesworth Group Practice is a WN Dr Deryth Stevens Chair  Current member of Primary Care Warwickshire Federation

3. A business partner at Dordon and Polesworth Group Practice has a financial interest in Linden WN Dr Deryth Stevens Chair  Current Nursing Home Group (former interest - to be removed in October 2018) 4. Practice holds a contract to provide services to a  local nursing home WN Dr Deryth Stevens Chair 2015 Current

Practice Nurse at Bulkington Surgery  WN Mrs Sue Turner Practice Network Lead Jul-05 Current

 Practice Network Lead Nuneaton and WN Dr Inayat Ullah 1. GP at Woodlands Surgery Current Bedworth

2. Practice participates in the One Thing Campaign  Practice Network Lead Nuneaton and WN Dr Inayat Ullah to undertake Health Checks (former interest - to be Current Bedworth 6 Months removed in November 2018)

3. Partner at Longford Primary Care Centre,  Practice Network Lead Nuneaton and WN Dr Inayat Ullah Coventry (former interest - to be removed in Current Bedworth November 2018) 4. Urgent Care George Elliot Hospital  Practice Network Lead Nuneaton and WN Dr Inayat Ullah Current Bedworth

Clinical Director, Coventry and Rugby CCG 1. Senior Partner, Walsgrave Health Centre, CR Dr Steven Allen  Apr-15 Current Governing Body Coventry

Clinical Director, Coventry and Rugby CCG CR Dr Steven Allen 2. Practice is member of GP Alliance  Nov-16 Current Governing Body

Lay Member Public and Patient Engagment, CR Mrs Claire Forkes Nil Coventry and Rugby CCG Governing Body

Acting Director of Public Health Coventry and CR Ms Liz Gaulton Coventry and Rugby Governing Body Member Nil (Co-opted participant, non-voting)

Lay Member, Coventry and Rugby CCG 1. Senior Manager, South Central Ambulance CR Mr Ludlow Johnson  Sep-08 to date Governing Body Service

Lay Member, Coventry and Rugby CCG CR Mr Ludlow Johnson 2. Specialist Advisor, Care Quality Commission  Apr-14 to date Governing Body NHS WARWICKSHIRE NORTH CCG AND COVENTRY AND RUGBY CCG - Register of Interests for Governing Bodies in Common meeting

WN / CR / Current position (s) held- i.e. Governing Declared Interest- (Name of the organisation and Title First Name Surname Type of Interest Date of Interest Both Body, Member practice, Employee or other nature of business)

Lay Member, Coventry and Rugby CCG CR Mr Ludlow Johnson 3. Magistrate  Sep-09 to date Governing Body

Secondary Care Consultant, Coventry and 1. Consultant Anaesthetist, Northampton General CR Dr Prashant Kakodkar  Oct-02 to date Rugby CCG Governing Body Hospital

Secondary Care Consultant, Coventry and 2. Consultant Anaesthetist, Three Shire Hospital, CR Dr Prashant Kakodkar  Dec-02 to date Rugby CCG Governing Body Northampton

Secondary Care Consultant, Coventry and CR Dr Prashant Kakodkar 3. Special Advisor, Care Quality Commission  Sep-16 to date Rugby CCG Governing Body

Secondary Care Consultant, Coventry and CR Dr Prashant Kakodkar 4. Examiner, The Royal College of Anaesthetists  Oct-11 to date Rugby CCG Governing Body

Secondary Care Consultant, Coventry and 5. Local Negotiating Committee Member, CR Dr Prashant Kakodkar  Dec-16 to date Rugby CCG Governing Body Northampton General Hospital

Secondary Care Consultant, Coventry and CR Dr Prashant Kakodkar 6. Member Q - Network, Health Foundation  Nov-17 to date Rugby CCG Governing Body

Clinical Lead, InSpires Locality, Coventry and CR Dr Peter O'Brien 1. GP Partner at Forrest Medical Centre.  1987 Current Rugby CCG Governing Body

Clinical Lead, InSpires Locality, Coventry and CR Dr Peter O'Brien 2. Practice is member of GP Alliance  2015 Current Rugby CCG Governing Body

Clinical Lead, InSpires Locality, Coventry and CR Dr Peter O'Brien 3. Chairman of Trustees, The Night Shelter  Apr-18 Current Rugby CCG Governing Body

Chair, Coventry and Rugby CCG Governing CR Dr Sarah Raistrick 1. GP Partner Willenhall Primary Care Centre 1  Jul-15 Current Body

Chair, Coventry and Rugby CCG Governing CR Dr Sarah Raistrick 2. Practice is a member of the GP Alliance  Current Body

Chair, Coventry and Rugby CCG Governing 3. Husband is a leader (I am a member) of a church CR Dr Sarah Raistrick  Current Body in Coventry supporting Hope Coventry initiatives.

Chair, Coventry and Rugby CCG Governing CR Dr Sarah Raistrick 4. Practice is a member of Sowe Valley Cluster  Current Body

Lay Member Audit and Governance, Coventry CR Mr Chris Stainforth Nil and Rugby CCG Governing Body

Clinical Lead, Rugby Locality, Coventry and CR Dr Deepika Yadav 1. Salaried GP, Forrest Medical Centre  Dec-14 Current Rugby CCG NHS WARWICKSHIRE NORTH CCG AND COVENTRY AND RUGBY CCG - Register of Interests for Governing Bodies in Common meeting

WN / CR / Current position (s) held- i.e. Governing Declared Interest- (Name of the organisation and Title First Name Surname Type of Interest Date of Interest Both Body, Member practice, Employee or other nature of business)

Clinical Lead, Rugby Locality, Coventry and CR Dr Deepika Yadav 2. Husband is GP, Locum  Apr-13 Current Rugby CCG

Clinical Lead, Rugby Locality, Coventry and 3. Clinical Advisor for NHS England (on an ad-hoc CR Dr Deepika Yadav  Mar-18 Current Rugby CCG basis) for the International Recruitment Programme

Clinical Lead, Rugby Locality, Coventry and CR Dr Deepika Yadav 4. LMC Member  Apr-18 Current Rugby CCG

Chief Nursing Officer, Coventry and Rugby Both Ms Jo Galloway Nil CCG and Warwickshire North CCG

Both Ms Andrea Green Chief Officer Honary Member of the Faculty of Public Health  Mar-18 Current

Chief Finance Officer, Coventry and Rugby Both Mrs Clare Hollingworth Nil CCG and Warwickshire North CCG

Director of Acute Contracting and Both Mr Steve Jarman-Davies Nil Performance. IFR Panel Member.

Director of Public Health Warwickshire. County Both Dr John Linnane Council, Governing Body Member (Co-opted Nil participant, non-voting)

Both Mrs Maria Maltby Deputy Director of Corporate Affairs Nil

Both Ms Jenni Northcote Chief Strategy and Primary Care Officer Nil

Unconfirmed Minutes of the Governing Body Meetings in Common Held in Public on Wednesday, 9th May 2018, 1.30pm

Venue: Council Offices. Friarsgate, Eaton Road, Coventry

Present: Dr Deryth Stevens Chair - WNCCG Dr Sarah Raistrick Chair - CRCCG Mr David Allcock Lay Member for Audit and Governance - WNCCG Mr Chris Stainforth Lay Member, Audit and Governance - CRCCG Ms Liz Gaulton Director of Public Health, Coventry - CRCCG Dr Chris Pycock Secondary Care Doctor - WNCCG Ms Clare Forkes Lay Member, Public and Patient Involvement - CRCCG Dr Inayat Ullah Practice Network Lead: Nuneaton and Bedworth - WNCCG Mr Graham Nuttall Lay Member - Primary Care - WNCCG Ms Sue Turner Practice Network Lead: North Warwickshire - WNCCG Mr Derek Pickard Lay Member – Patient and Public Involvement - WNCCG Dr Prashant Kokodkar Secondary Care Specialist Consultant - CRCCG Mrs Clare Hollingworth Chief Finance Officer Ms Jo Galloway Chief Nurse Dr Imogen Stanley Clinical Lead – WNCCG

Apologies: Ms Andrea Green Chief Officer Dr John Linnane Director of Public Health, Warwickshire Dr Deepika Yadav Rugby Locality Lead - CRCCG Dr Peter O’Brien Clinical Locality Lead, Inspires - CRCCG Dr Steve Allen Clinical Director Mr Ludlow Johnson Lay Member for Patient and Public Involvement and Equality Dr Arshad Khan Clinical Lead - WNCCG Dr Godwin Igodo Clinical Lead - WNCCG

In Attendance: Mrs Maria Maltby Deputy Director of Corporate Affairs Ms Rachel Robinson Consultant in Public Health Medicine – WNCCG Mr Stan Orton Public and Patient Group Representative Mr Steven Jarman-Davies Director of Acute Contracting and Performance (From 14:02 until 14:49) Mrs Julie Seaborne Governance Officer Kay Greene Director of Clinical Services – Mary Ann Evans Hospice

1

Item Action No: 1. Standing Items:

1.1 Welcome and Apologies

Dr Stevens welcomed those present to the meeting and gave a special welcome to the new Governing Body members:

• Claire Forkes – Lay Member for Public and Patient Engagement, Coventry and Rugby CCG • Chris Stainforth – Lay Member for Audit and Governance, Coventry and Rugby CCG • Imogen Staveley – Elected Clinical lead, Warwickshire North CCG

Dr Stevens also welcomed Dr Sarah Raistrick to her first meeting as Chair of Coventry and Rugby CCG.

Dr Stevens advised that Coventry and Rugby Governing Body was not quorate due to apologies and therefore any decisions would need to be confirmed in writing by email outside of the meeting.

1.2 Declarations of Interest:

Dr Stevens reminded Members of the need to declare their interest in any items requiring a decision and to remove themselves from such decision making. declarations of interest were raised. No declarations were made.

1.3 Minutes of the Last Meeting: 8th March and 29th March 2018

The minutes of the meetings held on 8 March and 29 March were agreed as a true and accurate record of the meetings subject to a change to the minutes of 8 March of ‘Any Other Business’ to be amended to “Mr Orton reported that he had attended an Extended Access conference in Birmingham”.

1.4 Matters Arising And Action Schedule:

Matters Arising There were no matters arising.

Action Schedule Item 46 - Patient Group Forum: Provide an update regarding the re-negotiation of the NHS 111 contract to the Patient Group Forum. - Tobe carried forward to the next patient group forum meeting due to the last one being cancelled due to bad weather conditions.

Item 53 - Local Maternity System Transformation Plan - Number of live births: Mr Orton highlighted that Figure 9 on page 22 of the report stated that the change in numbers of live births between 2014 and 2039 would be 8 for North Warwickshire. Ms Robinson to review the figure and provide an update to Members. - Rachel Robinson confirmed that she had asked the Insight Team to review the figures and the number of new births had been amended. Action closed.

2

Item Action No: 1.5 Chair’s Report:

(A) Coventry and Rugby CCG: Dr Raistrick presented the Coventry and Rugby CCG Chair’s report. She confirmed that after taking up her post on 1 April 2018, she had started to develop relationships with key stakeholders and members. Dr Raistrick had attended her first meetings of the Coventry Health and Wellbeing Board and the Warwickshire Health and Wellbeing Board. She had also attended two meetings of the Clinical Design Authority along with Jo Galloway (Chief Nurse), clinical leaders of provider organisations, GP representatives and Chairs of local CCGs.

In respect of member engagement, Dr Raistrick confirmed that Coventry had made a good step forward to cluster-based working with the appointment of Cluster Lead GPs and facilitators. There had been a meeting with the leads to hear their local priorities and offer support and direction to balance their local plans with CCG priorities and planning.

Coventry and Rugby CCG Governing Body Members NOTED the report.

(B) Warwickshire North CCG: Dr Stevens presented her report and confirmed that as of 1 April 2018, Warwickshire North CCG was now fully delegated for commissioning of Primary Care GP related services.

Dr Stevens reported that the CCG supported GPs and practice staff for education on a monthly basis. In March 2018 a Coventry and Warwickshire wide event relating to cancer had been held. There had been a variety of themes including early diagnosis, prevention, referral pathways, living beyond cancer and end of life care.

Warwickshire North CCG Governing Body Members NOTED the report.

1.6 Chief Officer’s Report

In Andrea Green’s absence, Mrs Hollingworth presented the Chief Officer’s report. Key points included:

• The CCGs had participated in the end of year assurance review with NHS England on 16 April 2018, the outcome of the reviews would be known by July 2018 once all CCGs had been assessed and the national moderation process completed. • On 12 April 2018, the first workshop was held to evolve local Health and Wellbeing Partnership into a local Place based forum for the population in the boroughs of Nuneaton, Bedworth and North Warwickshire. • Warwickshire North CCG had successfully completed the final stages of delegation of commissioning from NHS England in March 2018 and so commenced commissioning primary medical services as planned from 1 April 2018.

Coventry and Rugby CCG and Warwickshire North CCG Governing Body Members NOTED the report.

2. Strategy and Planning:

2.1 Coventry Public Health Report

Ms Liz Gaulton presented the Coventry Public Health Report which provided the

3

Item Action No: following:

1. An overview of the recently launched integrated healthy lifestyle service. 2. An update on activity relating to the Coventry and Warwickshire Year of Wellbeing; 3. An opportunity for members of the Governing Body to consider how the CCG/s link in to the Year of Wellbeing work..

Coventry and Rugby CGG Governing Body Members NOTED the report.

Warwickshire Public Health Report Ms Rachel Robinson presented the Warwickshire Public Health report to update the Governing Bodies on the core offer work programme from Public Health Warwickshire with Warwickshire North CCG and the Rugby Borough areas. The report included updates on the following areas:

• Ready for School Pilot • Drug and Alcohol Service Redesign and Re-commissioning Process • Making Every Contact Count (MECC) Programme • Health Visiting & FNP Service Delivery • National Diabetes Prevention Programme • Warwickshire North Health and Wellbeing Partnership • #onething • Healthwatch • Child Sexual Exploitation (CSE) • Fitter Futures Falls pilot

Warwickshire North CCG and Coventry and Rugby CGG Governing Body Members NOTED the report.

2.3 Communications and Engagement Report

Dr Stevens introduced the Communications and Engagement written report which provided an overview of communications and engagement activity undertaken during February – April 2018.

Coventry and Rugby CCG and Warwickshire North CCG Governing Body Members NOTED the report.

3. Quality, Safety and Performance:

3.1 Patient Story - Ms Galloway introduced Kay Greene, Director of Clinical Services from Mary Ann Evans Hospice who presented a patient story in respect of the Community Rapid Response Team. This was a pilot project funded and provided by South Warwickshire Foundation Trust and the Mary Ann Evans Hospice. The project includes visiting patients and their families for end of life care in respect of symptom control and management, and also carer reassurance/support.

The patient story was well received by Governing Body members and Dr Ullah in particular praised the service which he said was a ‘brilliant’ service which was very valued.

3.2 Integrated Safety, Quality and Performance Report

Ms Galloway presented the Safety and Quality section of this report to provide assurance to the Governing Body of the performance of services commissioned by

4

Item Action No: Coventry and Rugby and Warwickshire North CCGs for the month of February unless otherwise specified. The report also provided an update on quality concerns within commissioned services that are either being investigated or are being monitored against improvement plans. Ms Galloway highlighted the following areas within her report:

University Hospital Coventry and Warwickshire:

Areas on Level 3 the Clinical Governance Framework:

Urgent Clinic Letters sent within 10 days – Despite increased Trust oversight over the last 3 months, overall performance with this standard had not improved. The CCG had issued the Trust with a formal Contract Performance Notice that would require the Trust to provide a formal recovery plan by first week of May 2018.

Accident and Emergency Department (A&E)- The Trust was not currently meeting the 4 hour target and the CCG had formally requested the Trust conduct a review of Serious Incidents reported over the past twelve months and to provide the CCG with assurance that there were no key themes or trends directly related to the clinical care. The Trust had also been requested to share the outcome of clinical audits carried out. The CCG also had plans to conduct a further unannounced visit.

Coventry And Warwickshire Partnership Trust:

Areas on Level 2 of the Clinical Governance Framework:

CQC Inspection - the final CQC inspection report was published on 8 November 2017 with an overall rating of ‘requires improvement’. A warning notice was issued to CWPT in relation to older people's services as it was identified that the Trust’s systems and processes did not effectively monitor the physical healthcare of patients and reduce identified risks. CQC revisited this service in November 2017 and the service has subsequently been re-graded from ’inadequate’ to ‘requires improvement’. The CQC action plan forms a standing item agenda at the CQRM and the CCG is assured that CWPT has robust governance arrangements in place to monitor the action plan.

George Eliot Hospital:

Areas on Level 2 of the Clinical Governance Framework:

Accident & Emergency (A&E) - The Trust was not currently meeting the 4 hour target and had also reported a number of 12 hour trolley breaches. The CCG continued to monitor the quality of care delivery in A&E through the monthly CQRM and monitoring of Serious Incidents (SIs) reported by the Trust; with no incidents of patient harm being reported to date. The Chief Nursing Officer visited the A&E department on 27 February to walk through the patient pathway for adults and children.

Fragile Services (End of Life Care (EoLC); Paediatrics; Emergency Department; and Rheumatology) - The Trust was experiencing workforce challenges within End of Life Care, Paediatrics, Emergency Department and Rheumatology services. These challenges were routinely discussed at the Trust’s Board meeting and Quality Assurance Committee. Ms Galloway reported that it was positive to note at the March 2018 CQRM that the Trust had been successful in recruiting a Consultant for the EoLC service. The Consultant was expected to take up post in August 2108 and a second Consultant position had also been advertised.

Mr Jarman-Davies presented the performance section of the report and noted the

5

Item Action No: following key points:

Referral to Treatment Times (RTT) - 84.8% of Coventry and Rugby CCG patients had been waiting less than 18 weeks from their GP referral date to be seen or treated by a hospital specialist against a target of 92%. The figure for Warwickshire North CCG was 84.1%.

Cancer waiting times - Coventry and Rugby CCG achieved all Cancer waits targets. Warwickshire North CCG underachieved against the cancer 62 day wait target from urgent GP referral to first definitive treatment, with performance at 84.4% against a target of 85%. 3 patients at UHCW and 1 patient at George Eliot Hospital had waited more than 104 days from referral to treatment.

Mixed Sex Accommodation - There were 4 Mixed Sex Accommodation breaches for Coventry and Rugby CCG of which 3 were at the Royal Berkshire NHS Foundation Trust and 1 at Dartford 7 Gravesham NHS Trust. Two Warwickshire North CCG patients breached at GEH.

Cancelled Operations - 46 patients in quarter three had operations cancelled at UHCW, on or after the day of admission for non-clinical reasons and weren’t offered another binding date within 28 days. All cancellations at GEH were offered another biding date within 28 days. The main reason for the breaches was capacity and the need to schedule urgent/cancer patients further reduced the capacity available.

Improving Access to Psychological Therapy (IAPT) - Coventry and Rugby CCG achieved against the IAPT 15% access target in December 2018 but Warwickshire North CCG underachieved at 12.9%. Both CCGs achieved against the recovery rate target.

Coventry and Rugby CCG and Warwickshire North CCG Governing Body Members NOTED the report.

4. Financial Performance

4.1 Finance and Contract Report: Month 12

Coventry and Rugby CCG Mrs Hollingwoth presented the Coventry and Rugby CCG Month 12 Finance Report which advised Members of the draft financial position of the CCG up to 31 March 2018 (Month 12 – 2017/18), and which remained subject to external audit, and advised of any other financial issues likely to impact in the next financial year.

It was noted that Coventry and Rugby CCG originally planned to achieve a £1.1m control total surplus. At Month 10, the CCG revised its year end forecast to a £0.9m deficit to recognise £2.0m of the total £3.1m cost pressure relating to the national shortage of some generic branded drugs (ie. the ‘No Cheaper Stock Obtainable’ issue). This forecast had been maintained but then adjusted for the two sums released by NHSE to result in an end of year surplus of £2.65m [£1.1m less £2.0m plus £2.95m plus £0.6m]. This was then added to the brought forward surplus of £3.35m from 2016/17 to reach a cumulative surplus of £6.0m.

Mrs Hollingworth advised that recurrent in-year QIPP delivery was reported to be 73%. The delivery of Non Recurrent schemes was reported as achieving 154%. This gave a combined achievement of 98% against the savings required for the year. The poor delivery against recurrent QIPP schemes has a negative impact upon the CCG’s underlying position.

6

Item Action No: The recurrent underlying deficit was assessed at £7.8m; this contributed to the significant financial challenge and scale of efficiency savings required in 2018/19

Coventry and Rugby CCG Governing Body Members NOTED the pre-Audit position for Month 12.

Warwickshire North CCG Mrs Hollingworth advised Members of the draft financial position of the CCG up to 31 March 2018 (Month 12 – 2017/18) which was subject to external audit and advised of any other financial issues likely to impact in the next financial year.

It was noted that Warwickshire North CCG had originally planned to achieve a £4.3m control total deficit. At Month 10, the CCG revised its year end forecast to a £5.2m deficit to recognise £0.9m of the total £1.3m cost pressure relating to the national shortage of some generic branded drugs (ie. the ‘No Cheaper Stock Obtainable’ issue). This forecast had been maintained but then adjusted for the two sums released by NHS England to result in an end of year deficit of £3.73m [£4.3m plus £0.9m less £1.17m less £0.3m]. This was then added to the brought forward deficit of £14.25m from 2016/17 to reach a cumulative deficit of £17.98m

Mrs Hollingworth advised that there had been an improvement in the CCGs underlying financial position. The recurrent underlying deficit was assessed at £6.32m.

It was noted that QIPP achievement for the year was 72%. There was significant in- year slippage against all recurrent QIPP programmes; this was partially offset by an over-delivery against Other/Cost Avoidance schemes ie. the application of non- recurrent flexibilities. Reserves had been utilised as further mitigation against the QIPP under-achievement. The underlying financial position and the consequence for the scale of savings required in 18/19 remained a significant concern on this basis. Mr Stainforth asked about processes for learning in respect of the financial challenges and Mrs Hollingworth confirmed that there had been external consultant support in respect of a cost reduction programme. Lessons learned and key themes had been explored and this including planning schemes earlier and strengthening of reporting processes.

Mr Allcock confirmed that this was an incredibly challenging financial year and he congratulated Mrs Hollingworth and her team for their efforts in hitting some significant challenges.

Warwickshire North CCG Governing Body Members NOTED the pre-Audit position for Month 12.

4.1 2018/19 Financial Plan Update

Mrs Hollingworth presented this reports for both CCGs and confirmed that at the last meeting, the Governing Bodies approved the 2018/19 Financial Plans (revenue budget). It was noted that modelled savings had been subject to a thorough assurance process; with the final savings logic clearly documented and signed off by the relevant SRO, a new Standard Operating Procedure was in place; and additional temporary posts had been approved and are being recruited to support in-year QIPP delivery. The following key points were noted for each CCG were:

Coventry and Rugby CCG • The CCG had been set a 2018/19 in-year control total of £0m; ie. it was 7

Item Action No: required to contain expenditure within its notified revenue resource limit and deliver a break even position. • The Budget Plan approved in March 2018 required that the CCG identify and deliver in-year QIPP savings of £23.0m in 2018/19. At the point of Budget approval, plans to deliver this level of QIPP were not yet fully assured and £3.0m remained Unidentified. This shortfall had now been addressed. • Whilst the potential net in-year risks faced by the CCG had been re-assessed downwards from £17.7m to £13.6m; this remains a significant issue and the CCG must continue to focus throughout the year on identifying and securing further mitigations. Mitigating actions would be agreed and monitored via the CCG’s Finance & Performance Committee.

Warwickshire North CCG • The CCG had been set a 2018/19 in-year control total of £1m deficit. • The Budget Plan approved in March 2018 required that the CCG identify and deliver in-year QIPP savings of £11.1m in 2018/19. At the point of Budget approval, plans to deliver this level of QIPP were not yet fully assured and £2.1m remained Unidentified. This shortfall had now been addressed. • Whilst the potential net in-year risks faced by the CCG had been re-assessed downwards from £7.8m to £7.7m; this remained a significant issue and the CCG must continue to focus throughout the year on identifying and securing further mitigations. Mitigating actions would be agreed and monitored via the CCG’s Finance & Performance Committee.

Coventry and Rugby CCG and Warwickshire North CCG Governing Body Members:

• NOTED that work has been completed to quantify and risk assess expected savings QIPPs. • NOTED the progress achieved in resolving the balance of unidentified QIPP.

• NOTED the reduction in the assessed value of potential in-year risks and be advised that mitigating actions will be monitored via the Finance &

Performance Committee.

4.3 Procurement Update

Mrs Hollingworth provided an overview of the procurement work programme and a progress update for each of the individual projects.

The Governing Body noted that the Out of Hospital contract was now live (for both Coventry and Rugby CCG and Warwickshire North CCG)

Warwickshire North Governing Body members:

• NOTED and confirmed that they were ASSURED as to the progress of the current procurements • NOTED the procurement pipeline and the decisions that will be required over the next few months

Coventry and Rugby Governing Body was not quorate due to apologies and therefore it was agreed to request email confirmation of Member’s support to approve a direct award of a contract (18mths + 6 mths) to the incumbent provider of the Community Eye Service on the understanding that a reduced notice period of 3 months will be negotiated.

Post Meeting Note: Members of the Coventry and Rugby CCG Governing Body unanimously supported the direct contract award for the Community Eye Service. 8

Item Action No: 5 Assurance and Governance Framework

Mrs Maltby presented the updated Assurance Framework at Quarter 4 and emphasised that this was the Governing Bodies key tool for ensuring that key risks to achievement of the CCGs’ objectives were being mitigated. Mrs Maltby advised that the Assurance Framework would be reviewed by the Senior Management Team for 2018/19.

Coventry and Rugby CCG and Warwickshire North CCG NOTED the Assurance Framework at Quarter 4.

6. Policies for Ratification

Freestyle Libre Flash Continuous Glucose Monitoring System policy

Dr Stevens presented this report to propose adoption of policy by the CCGs for the routine use of the Freestyle Libre Flash Continuous Monitoring System subject to patients satisfying criteria detailed within the report.

Mr Nuttall reported that this policy had not been considered by the CCGs’ Finance and Performance Committees and Mrs Hollingworth confirmed that there had been considerable interested by members of the public and therefore it had been felt appropriate to bring to this meeting rather than wait until the next Governing Body meeting in July 2018.

Warwickshire North CCG APPROVED the proposed policy.

Coventry and Rugby Governing Body was not quorate due to apologies and therefore it was agreed to request email confirmation of Member’s support to approve this policy to enable a written resolution for this decision.

Post Meeting Note: Members of the Coventry and Rugby CCG Governing Body unanimously supported adoption of the policy for the Freestyle Libre Flash Continuous Glucose Monitoring System.

Policy for Approving Pharmaceutical Industry Rebate Schemes

Dr Stevens presented this policy and confirmed that the purpose was that retrospective rebates were increasingly being offered by suppliers of products prescribed on FP10 in primary care. This policy provided a framework for managing rebates in a legal and ethical way, and provided transparency and governance to this area of work. Warwickshire North CCG Members APPROVED the policy for implementation.

Coventry and Rugby Governing Body was not quorate due to apologies and therefore it was agreed to request email confirmation of Member’s support to approve this policy to enable a written resolution for this decision.

Post Meeting Note: Members of the Coventry and Rugby CCG Governing Body unanimously supported adoption of the policy for Approving Pharmaceutical Industry Rebate Schemes.

7. Committee Reports for Information:

Coventry and Rugby CCG Governing Body Members NOTED the following

9

Item Action No: Committee reports: • Audit Committee: 6th February 2018; and • Finance and Performance: 26th February 2018. • Primary Care Commissioning Committee Report – Quarter 4

Warwickshire North CCG Governing Body Members NOTED the following Committee reports: • Finance and Performance Committee: 22nd February 2018 • Clinical Quality and Governance Committee: 25th January 2018 • Audit Committee:15th February 2018 • Joint Commissioning Committee Report – Quarter 4

Both Governing Bodies NOTED the following Committees in Common Reports Clinical Quality and Governance Committee in Common:28th February 2018 Commissioning Finance and Performance Committee in Common: 29th March 2018

Both Governing Bodies NOTED the following minutes: • Health and Wellbeing Board – Warwickshire: 22nd March 2018 and • Health and Wellbeing Board – Coventry: 5th February 2018.

8. Questions From Visitors: Questions from visitors were:

In relation to the Integrated Safety, Quality and Performance Report, why some of the Mixed Sex Accommodation figures quoted were not in local areas. Ms Galloway explained that it would be that the local CCG was the responsible commissioner who was commissioning care out of the locality for example if a person had fallen ill while away from home.

Why nursing homes mentioned within the report were on escalation. Ms Galloway explained that this where homes which were being monitored more closely by the CCGs due to concerns and actions plans were in place.

9. Any Other Business: There were no items of any other business reported.

Date of the Next Meeting Held in Public:

Date: 12th July 2018 Time: 12pm – 1pm Venue: Heron House, Nuneaton

Signature: (Chair CRCCG) Date:

Signature: (Chair WNCCG) Date:

10

ENC C: ACTION SCHEDULE - WNCCG AND CRCCG GOVERNING BODY - MEETINGS IN COMMON TO BE HELD IN PUBLIC

WN / CR ACTION MEETING AGENDA ACTION RESPONSIBLE COMPLETION CURRENT UPDATE REF DATE ITEM OFFICER DATE STATUS Patient Group Forum: Provide an update regarding the re-negotiation of the NHS CRCCG / 111 contract to the Patient Group Forum. 46 09-Nov-17 7 Andrea Green 12-Jul-18 In Progress Update 09/05/18: This would be carried forward to the next Governing Body meeting. WNCCG Update 02/03/18: Update to be provided at the next Patient Group Forum, March meeting postponed due to adverse weather conditions. Local Maternity System Transformation Plan Performance Report: Ms Green Andrea Green suggested that a performance report was presented to the Governing Body CRCCG / 54 08-Mar-18 2.1 meeting every 6 months, with the next report scheduled for the September 2018 Sep-18 Not Yet Due Jo Gallway / Steven WNCCG meeting. Report to the September 2018 Governing Body meeting to contain a Jarman-Davies specific update on workforce. Site Visit to CAMHS Hub: Ms Galloway confirmed that information would be CRCCG / 59 08-Mar-18 3.2 provided to the Governing Body meeting in September 2018 following the July site Jo Galloway Sep-18 Not Yet Due WNCCG visit to the CAMHS Hub. Action taken following CQC inspection of CWPT: Ms Galloway agreed to Update 03/07/18: Information is included in Quality and Performance report. A Quality Assurance visit of CRCCG / update members at the next Governing Body meeting and Ms Gaulton confirmed 62 09-May-18 3.2 Jo Galloway / Liz Gaulton 12-Jul-18 Complete the CAMHS service is being arranged for the end of July 2018 and lines of enquiry for the visit are being WNCCG that she would support her with this as there would also be report going to the developed Health and Social Care Scrutiny Board. Blank Page NHS Coventry and Rugby Clinical Commissioning Group NHS Warwickshire North Clinical Commissioning Group Enc D

Report To: Governing Body Meetings in Common

Report Title: Coventry and Rugby CCG Chair’s Report – July 2018

Report From: Dr Sarah Raistrick - Chair of NHS Coventry and Rugby CCG

Date: 12th July 2018

Previously Considered by: N/A

Action Required (delete as appropriate)

Decision:  Assurance:  Information:  Confidential 

Purpose of the Report: To advise the Governing Body of activity since the May 2018 meeting of the Governing Body.

Key Points: The Chairs Report covers the following:

• Engagement • STP Clinical Design Authority

Recommendation: The Coventry and Rugby CCG Governing Body is requested to NOTE the report.

Implications

Objective(s) / Plans supported by this IAF Leadership Domain report: Conflicts of Interest: Not applicable Non-Recurrent Expenditure: Not applicable Recurrent Expenditure: Not applicable Financial: Is this expenditure included within the CCG’s Financial Yes No N/A  Plan? (Delete as appropriate) Performance: Not applicable Quality and Safety: Not applicable General Statement: The CCG is committed to fulfil its obligations under the Equality Act 2010, and to ensure services commissioned by the CCG are non-discriminatory Equality and Diversity: on the grounds of any protected characteristics. Policies/decisions may need to be adjusted in line with any equality analysis or due regard. Any decision that is finalised without being influenced by appropriate due regard could be deemed unlawful.

Page 1 of 4

NHS Coventry and Rugby Clinical Commissioning Group NHS Warwickshire North Clinical Commissioning Group Enc D

Has an equality impact Yes assessment been undertaken? No N/A  (attached) (Delete as appropriate) Patient and Public Not applicable Engagement: Clinical Engagement: Not applicable Risk and Assurance: Not applicable

Page 2 of 4

NHS Coventry and Rugby Clinical Commissioning Group NHS Warwickshire North Clinical Commissioning Group Enc D

Coventry and Rugby CCG

Chair’s Report - July 2018

Engagement

I have been meeting with the local GP Alliance, cluster leads and Local Medical Committee (LMC) to build relationships and to encourage dialogue and drive to ensure the organisations recognise their unique viewpoint but represent themselves and their constituents to the wider population with a coherent, cohesive “voice of general practice”.

Cllr. Seacole (Leader of Warwickshire Council) invited me for a dialogue with her Councillor with portfolio for health, Health and Wellbeing representatives and Public Health consultant to discuss the current state of health and social care collaboration and the work ahead.

I have begun my round of visits to all the GP practices in Rugby to listen to staff, inform and relationship build.

The new Lead GP Tutor for Education will have been appointed by the time of this report and we have been working hard to demonstrate to members our commitment to deliver high quality education.

STP

Both as a member of the Clinical Design Authority and Health and Wellbeing Boards I am working with other clinicians to add stronger clinical leadership to the STP.

I along with others have participated in training and workshops to evaluate local achievements, foster collaboration and learn best practice from other STPs in the West Midlands and further afield. I hope to bring a clearer clinical strategy and evidence of action and delivery to my future reports.

Page 3 of 4

NHS Coventry and Rugby Clinical Commissioning Group NHS Warwickshire North Clinical Commissioning Group Enc D

Blank Page

Page 4 of 4

NHS Warwickshire North Clinical Commissioning Group Enc E

Report To: Governing Body Meetings in Common

Report Title: Warwickshire North CCG Chair’s Report – July 2018

Report From: Dr Deryth Stevens - Chair of NHS Warwickshire North CCG

Date: 12 July 2018

Previously Considered by: N/A

Action Required (delete as appropriate)

Decision: Assurance: Information:  Confidential

Purpose of the Report: To advise the Governing Body of activity since the May 2018 meeting of the Governing Body.

Key Points: The Chairs Report covers the following:

• Warwickshire North Health and Wellbeing Partnership • Warwickshire North Joint Strategic Needs Assessment (JSNA) Stakeholder Meeting • Members Council

Recommendation: The Warwickshire North CCG Governing Body is requested to NOTE the report.

Implications

Objective(s) / Plans supported by this IAF Leadership Domain report: Conflicts of Interest: Not applicable Non-Recurrent Expenditure: Not applicable Recurrent Expenditure: Not applicable Financial: Is this expenditure included within the CCG’s Financial Yes No N/A  Plan? (Delete as appropriate) Performance: Not applicable Quality and Safety: Not applicable General Statement: The CCG is committed to fulfil its obligations under the Equality Act 2010, and to ensure services commissioned by the CCG are non-discriminatory on the grounds of any protected characteristics. Policies/decisions may need to be adjusted in line with any equality analysis or due regard. Any decision that is finalised Equality and Diversity: without being influenced by appropriate due regard could be deemed unlawful. Has an equality impact Yes assessment been undertaken? No N/A  (attached) (Delete as appropriate)

Page 1 of 2

NHS Warwickshire North Clinical Commissioning Group Enc E

Patient and Public Not applicable Engagement: Clinical Engagement: Not applicable Risk and Assurance: Not applicable

Page 2 of 2

Warwickshire North CCG

Chair’s Report - July 2018

July marks a year since we held the first WNCCG and CRCCG Governing Body meetings in common. We have seen a number of changes throughout the year. We have seen some valued members either retire or leave to pastures new: Chair, Adrian Canale-Parola; and Lay Member Audit and Governance, Peter Maddock.

We have also welcomed a new Chair, Sarah Raistrick; Director of Nursing, Jo Galloway; Lay Member for Patient and Public Engagement, Derek Pickard; Clinical Lead, Imogen Staveley; Lay Member Audit and Governance, Chris Stainforth; Lay Member for Patient and Public Engagement, Claire Forkes; and most recently a new Independent Advisor for Patient Engagement, Tricia Lowe. Since the inception of the Governing Body in common we have a larger group at the board meetings but made excellent progress in getting to know each other. There have been some cultural shifts which I feel is a good thing, and I see evidence that we have a better understanding of the wider health economy Certainly from my perspective a better understanding of our main providers and a more coherent and consistent commissioning function since we started working more closely together.

July also marks the 70th anniversary of the NHS. A number of us were lucky enough to be invited to the Celebration of the 70th birthday of the National Health Service held at Westminster Abbey. We are organising a number of more local events, such as ‘CCG Stars’, for which staff are encouraged to nominate colleagues who go above and beyond their role. A Bring and Share lunch also took place on Wednesday 4th July across both CCG sites, and staff were invited to a service to celebrate the 70th anniversary at Coventry Cathedral on Thursday 5th July. The service is open to everyone from the NHS and associated services. In order to celebrate our primary care staff we are going to be canvassing votes for a variety of awards. We plan on a small celebration to hand out these awards in a few weeks.

Warwickshire North Health and Wellbeing Partnership

This is a group that has met regularly since 2012. This partnership developed a local strategy and outcomes framework in 2015 and a proportion of the meeting was dedicated look at progress and successes against the strategy. At the most recent meeting there was an update the of integrated partnership event that took place in April. A presentation and discussion relating to suicide prevention and an overview of Warwickshire's Suicide Prevention Strategy was an important item on the agenda. Warwickshire has a higher rate of suicide than the average for England and much work is being done to understand this and provide services and help for vulnerable individuals and their families.

Warwickshire North Joint Strategic Needs Assessment (JSNA) Stakeholder Meeting

I attended this event during June and the focus was to discuss health and well-being needs of people living in the North Warwickshire Borough. Once all of the information is collated I am confident that my public health colleagues will bring this information to a public Governing Body meeting in the future

Members Council

We had our first members Council of the year in June. We presented our annual report and this was well received.

The transition to delegated commissioning is going quite smoothly and I've not heard any particular concerns from general practices in relation to this

Dr Deryth Stevens Chair Warwickshire North CCG

Blank Page NHS Coventry and Rugby Clinical Commissioning Group NHS Warwickshire North Clinical Commissioning Group Enc F

Report To: Governing Body Meetings in Common

Report Title: Chief Officer’s Report

Report From: Andrea Green, Chief Officer

Date: 12 July 2018

Previously Considered by: Not applicable

Action Required (delete as appropriate)

Decision: Assurance: Information:  Confidential

Purpose of the Report: The purpose of this report is to provide members of the Governing Bodies with information on key activities undertaken by the Chief Officer since the last Governing Body meeting in common in January 2018, and any pertinent issues not covered elsewhere on the agenda.

Key Points:

The Chief Officer’s Report covers the following:

a) Sustainability and Transformation programme – building our one NHS

i. NHSE and NHSI held first Board Meetings in Common; setting the pace

ii. Centre for Public Scrutiny workshop held 6 June 2018

iii. First meeting of the reformed Warwickshire North reformed Health and Wellbeing (Integrated) Partnership

iv. Rugby Health and Wellbeing Partnership development event, participants agreed to reform

v. Commencement of the 12 week - Integrated Care System Development Programme

b) Transforming Care Programme update.

c) NHSE Q1 Assurance review undertaken.

d) CCG Revised Values

e) Participation in CQC Well led review of UHCW

Recommendation: The Governing Body is requested to NOTE the report.

Page 1 of 4

NHS Coventry and Rugby Clinical Commissioning Group NHS Warwickshire North Clinical Commissioning Group Enc F

Implications

Objective(s) / Plans supported by this Constitution, Leadership IAF Domain report: Conflicts of Interest: None identified. Non-Recurrent Expenditure: Not applicable. Recurrent Expenditure: Not applicable. Financial: Is this expenditure included within the CCG’s Financial Yes No N/A  Plan? (Delete as appropriate) Performance: None identified. Quality and Safety: None identified. General Statement: The CCG is committed to fulfil its obligations under the Equality Act 2010, and to ensure services commissioned by the CCG are non-discriminatory on the grounds of any protected characteristics. Policies/decisions may need to be adjusted in line with any equality analysis or due regard. Any decision that is finalised Equality and Diversity: without being influenced by appropriate due regard could be deemed unlawful. Has an equality impact Yes assessment been undertaken? No N/A  (attached) (Delete as appropriate) Patient and Public None identified. Engagement: Clinical Engagement: None identified. Risk and Assurance: None identified.

Page 2 of 4

NHS Coventry and Rugby Clinical Commissioning Group NHS Warwickshire North Clinical Commissioning Group Enc F

1. Sustainability and Transformation programme – building our one NHS 1.1. Nationally on 24 May, NHSE and NHSI held their first Board meetings in common, and committed to working together to create the right culture of regulation and assurance required for the future. Both Chief Executives described working together to get coherence between their assurance action with commissioners and providers, which can better support integrated care and one NHS. A link to view the meeting is https://m.youtube.com/watch?v=K9xyUx0adxk. 1.2. The Coventry and Warwickshire Clinical Commissioning Groups already work together as part of the sustainability and transformation partnership known as Better Health, Better Care, Better Value Board, with an ambition to develop this as part of a future local integrated care system. Actions In the last two months include: • A workshop on 6 July, was led by the Centre for Public Scrutiny. Local Councillors from Coventry and Warwickshire and local NHS and LA leaders were invited to participate in this nationally facilitated event aimed at improving understanding, awareness and working between STPs and Local Authorities. A key theme that emerged during the day was a need to refine the collective focus on improving services for those who are frail, as much was being done but this was not always shared simply so that front line services might co- ordinate for the best impact and improvement. The outcomes of the event will form part of the Coventry and Warwickshire Place Forum’s programme. • Warwickshire North Health and Wellbeing Partnership as newly constituted with Provider representatives, held their inaugural meeting on 20 June. The Partnership now has senior members from CAVA, GEH, CWPT, SWFT and General Practice, along with the LA and CCG. The meeting confirmed their desire to lead the local JSNA and priority discussions; shaping and enhancing community asset building; supporting integrated provision. All of which fits well with the Coventry and Warwickshire Alliance Concordat which is currently being refreshed and presented at the next Place Forum on 16 July. • Rugby Health and Wellbeing Group held a workshop on 27 June, to explore how the Partnership might be evolved to gain better collective impact of Borough and County Council, Voluntary and NHS Provider and Commissioner action. The group agreed to work with the LSP in Rugby so that they might take a lead on the local JSNA and priority discussions; shaping and enhancing community asset building; supporting integrated provision. All of which fits well with the Coventry and Warwickshire Alliance Concordat which is currently being refreshed and presented at the next Place Forum on 16 July. • A 12 week development programme supporting evolution of a local Integrated Care System (ICS) commenced in June, and senior leaders from across Coventry and Warwickshire are working to use the programme to identify a roadmap for building the future functions and capabilities of an ICS. The core components being Strategic Commissioning function, Provider Alliance function, and an architecture for the system and enabling developments such as Population Health and Population Health Management. 2. Transforming Care Programme update 2.1. Myself and the Chief Nurse as SRO for the Coventry and Warwickshire Transforming Care Programme have been to several escalation meetings to review our actions and progress. The programme has completed all the transformative action required in the national programme, namely this year opening new adult and children’s services as alternatives to long term placements so that where ever possible people can be looked after in their community; implemented new community forensic services; last year we secured 4 new local providers of specialist care using a framework agreement developed across health and LA care. We have also achieved the requirements of closing long stay beds as part of the Building the Right support work. 2.2. The programme has seen many successes for individuals who are now supported to live with support in their community, however the programme trajectory is at risk of not being achieved. The programme will be scrutinised at the July Clinical Quality and Governance Committee and a report circulated to Members after this meeting.

Page 3 of 4

NHS Coventry and Rugby Clinical Commissioning Group NHS Warwickshire North Clinical Commissioning Group Enc F

3. NHS England Assurance Review 3.1. The Executives participated in the review of Q1 with NHSE. 4. CCG Revised Values 4.1. The CCGs have agreed a revised set of Values as part of the OD plan, they are attached for information. 5. Participation in the CQC Well Led Review at UHCW 5.1. Several members of the team provided evidence and were interviewed as part of the review. No immediate concerns were raised and the full report from the CQC is expected shortly.

End of report

Page 4 of 4

Blank Page NHS Coventry and Rugby Clinical Commissioning Group NHS Warwickshire North Clinical Commissioning Group Enc G

Report To: Coventry and Rugby Clinical Commissioning Group and Warwickshire North Clinical Commissioning Group Governing Body

Report Title: Update on Public Health Intelligence at Coventry City Council

Report From: Report from the Director of Public Health and Wellbeing for Coventry – Liz Gaulton

Date: 13th July 2018

Previously Considered by: N/A

Action Required (delete as appropriate)

Decision: Assurance: Information:  Confidential

Purpose of the Report:

1. To provide an update on activity relating to public health intelligence within Coventry; 2. To provide an overview of recent key health intelligence outputs for Coventry

Key Points:

Public Health Intelligence in Coventry Public health intelligence is the generation, collection, use, synthesis and communication of information to support decision making within public health. This information includes routine and performance data, research findings and qualitative insights. Within Coventry City Council the Insight team produces intelligence to support the public health team in addition to council functions such as social care, education, and youth offending. This update provides an overview of the recent health intelligence activities within Coventry City Council and summarises the key public health intelligence outputs.

A new Intelligence Strategy for Coventry The Insight team has developed a new strategy to direct and develop the use of intelligence across the council. The strategy comprises of the following pillars: • Set and drive standards to deliver outcomes • Shape and influence a culture of evidence based action • Maximise collaboration and effective partnerships • Promote evaluation and learning to enable others • Value diversity; promote equality and cohesion The aim of this strategy is to increase the value of intelligence produced and improve the impact of evidence and intelligence on public health activity. This strategy will move the direction of health

Page 1 of 4

NHS Coventry and Rugby Clinical Commissioning Group NHS Warwickshire North Clinical Commissioning Group Enc G intelligence in Coventry towards an increased use of open source data and data warehouses, closer alignment of qualitative and quantitative insights, and a faster adoption of new data science techniques.

Coventry Joint Strategic Needs Assessment The current JSNA process was completed in 2016. The data was recently updated in January 2018 with: • refreshed data – the latest data available as of January 2018 • the addition of a colourful set of flash facts outlining data for each theme • an accompanying set of slides for partners who would like to know more about the production and content of the JSNA The key issues highlighted by the JSNA were population growth, migration and deprivation. People in Coventry die a year earlier than the England average, and a third of the city is in the 20% most deprived areas of England. For 2019, the JSNA will move from a thematic approach to a place based approached. A place-based JSNA takes a more focused look at the assets and challenges the discrete areas that make up Coventry. This gives a more in depth understanding of geographical areas within the City and can highlight the differences and inequalities that exists within the city. The move to a place based JSNA is in line with national and regional emphasis on planning health and community services for natural geographies of populations between 30,000-50,000 people, as exemplified by the work of the STPs. The new place-based JSNA will inform the development of the next joint health and wellbeing Strategy, which is due to be revised in 2019.

Coventry Household Survey Coventry conducted its biannual Household Survey in April 2018. The survey has been run in Coventry since 2003. It is used to monitor Coventry residents’ self-reported lifestyle choices, perceptions of their health and wellbeing, and views on the quality of life in the city. Provisional figures suggest that the population is consistently rating their health as good or very good (78%). The proportion of residents who rated their health as bad has decreased significantly from 7% in the last survey to only 1% in this survey. The mean score for wellbeing, using WEMWBS1, for Coventry was 52.68, which is higher than the he England average (49.9) and Coventry's score two years ago (51.48). Whilst the proportion of the adult smoking has gone down (18%, compared to 21% two years ago), the proportions of consuming fizzy drinks at least once a day or a takeaway at least once or twice a week is significantly higher (26% and 36% respectively.)

DPH Annual Report for Coventry This year's Director of Public Health's annual report focuses on older people and managing the demand for health and care services, and updates on progress against last year's recommendations. Although Coventry is seen as a young city, the growth of the older population is accelerating. The population of those over the age of 75 are projected to increase by almost fifty percent over the next 20 years. There is a worrying stalling in the gains in improving life expectancy, which is replicated nationally. The cause for this reversal of gains seen since records began in the 19th century is not completely understood, but there are suggestions that prolonged austerity and cuts to public services may be contributing.

Page 2 of 4

NHS Coventry and Rugby Clinical Commissioning Group NHS Warwickshire North Clinical Commissioning Group Enc G

In Coventry there is a large gap between healthy life expectancy and life expectance, representing a large window of need when people start to require more and more support from health and care services. This gap is in 16.2 years in men and in 19.2 years in women. The report advocates for a focus on prevention and early intervention to address the inevitable pressures on health and social care, which will only get worse as the risk factors for diseases such as low physical activity and poor diet, and household poverty increases. The report also advocates for continued efforts to bring health and social care services closer together within Coventry, in order to deliver joined up, cost effective care.

Health intelligence collaborations across the West Midlands Coventry are involved in recent developments across the West Midlands to strengthen and progress health intelligence. Work has begun to radically change the way intelligence for health and other public services is produced, visualised and disemminated, by capitalising on advances in data science and implementing the required workforce development. To achieve this, Coventry is working in partnership with other intelligence teams from local authorities in the region, the Office of Data Analytics in the West Midlands Combined Authority and the Population Intelligence Hub from Public Health England.

1 WEMWBS is the Warwick Edingburgh Mental Wellbeing Scale

Recommendation:

1. To note the recent developments in public health intelligence within Coventry City Council 2. To note the key information from recent public health intelligence outputs 3. Contribute any comments or suggestions to improve the dissemination and use of public health intelligence amongst partners

Implications

Objective(s) / Plans supported by this Health and Wellbeing Strategy report: Conflicts of Interest: Not applicable Non-Recurrent Expenditure: Not applicable Recurrent Expenditure: Not applicable Financial: Is this expenditure included within the CCG’s Financial Yes No N/A  Plan? (Delete as appropriate) Performance: Not applicable The generation of high quality health intelligence will improve the planning Quality and Safety: and review of services. General Statement: The CCG is committed to fulfil its obligations under the Equality Act 2010, and to ensure services commissioned by the CCG are Equality and Diversity: non-discriminatory on the grounds of any protected characteristics. Policies/decisions may need to be adjusted in line with any equality analysis or due regard. Any decision that is finalised without being influenced by Page 3 of 4

NHS Coventry and Rugby Clinical Commissioning Group NHS Warwickshire North Clinical Commissioning Group Enc G

appropriate due regard could be deemed unlawful. Has an equality impact Yes assessment been undertaken? No N/A  (attached) (Delete as appropriate) The Coventry Household Survey directly engages with the public in order to document current health experience and views of public services. The DPH annual report engaged with community and service users groups in Patient and Public its production. Engagement: The Coventry Insight strategy and Director of Public Health Annual Report advocates for increased engagement and co-production with the users of health and care services and their representatives. Clinical Engagement: Not applicable Risk and Assurance: Not applicable

Page 4 of 4

NHS Coventry and Rugby Clinical Commissioning Group Enc H NHS Warwickshire North Clinical Commissioning Group

Report To: Governing Body Meetings in Common

Report Title: Public Health Update

Report From: Rachel Robinson, Associate Director of Public Health

Date: 12th July 2018

Previously Considered by: Executive Group

Action Required (delete as appropriate)

Decision: Assurance: Information:  Confidential

Purpose of the Report: To update the Governing Bodies on the Core Offer work programme from Public Health Warwickshire with Warwickshire North CCG and Coventry and Rugby CCG.

Key Points: The report includes updates on the following areas for information:

• Fitter Futures Consultation • Support for Warwickshire’s unpaid Carers • Online Survey – Have your say on Warwickshire’s health and wellbeing needs • NHS Diabetes Prevention Programme • New Suicide Bereavement Support Service launch • Rugby Health and Wellbeing Partnership • Warwickshire North Health and Wellbeing Partnership • Drug and Alcohol Service

Recommendation: The Governing Body is requested to NOTE this report.

Implications

Objective(s) / Plans Business Plan 2015/16 Refresh and Forward View to 2020 supported by this report: Conflicts of Interest: Not applicable Non-Recurrent Expenditure: Not applicable Recurrent Expenditure: Not applicable Financial: Is this expenditure included within the CCG’s Financial Plan? Yes No N/A  (Delete as appropriate) Performance: Not applicable Quality and Safety: Not applicable

Equality and Diversity: General Statement: The CCG is committed to fulfil its obligations under the Equality Act 2010, and to ensure services commissioned by the CCG are non-discriminatory

on the grounds of any protected characteristics. Policies/decisions may need to be adjusted in line with any equality analysis or due regard. Any decision that is finalised without being influenced by appropriate due regard could be deemed unlawful. Has an equality impact Yes assessment been undertaken? No N/A  (attached) (Delete as appropriate) Patient and Public Not applicable Engagement: Clinical Engagement: Not applicable Risk and Assurance: Not applicable

2

Public Health Update July 2018

Fitter Futures Consultation - Have your say! - Closes 6th July

Have your say on supporting people of all ages to lead a healthier lifestyle with Fitter Futures Warwickshire, Warwickshire County Council’s Public Health team is running a consultation for Fitter Futures Warwickshire from May to July 2018.

The aim of the services is to support the population of Warwickshire to improve their health through maintaining a healthy weight, eating healthily, becoming physically more active and having a healthier lifestyle.

The services offer families, children, and adults of all ages a choice of evidence based opportunities which provide weight management and/or physical activity support.

The consultation provides an opportunity to share your views and experiences of the Fitter Futures Warwickshire service and comment on possible future provision. The findings will be used to shape the new service which will be implemented in 2020.

Support is available for Warwickshire’s unpaid carers

Carers week was an opportunity for staff to raise awareness of the different services on offer in Warwickshire to help make carers’ lives a little bit easier. A carer is anyone who regularly provides unpaid help to someone who could not cope without them. Unfortunately many people do not realise that they are carers, while many who do realise are unaware that there is support available for them.

With approximately 11% of Warwickshire’s adult population providing some sort of unpaid care every week, and the value of this contribution estimated to be between £575 million and £1.24bn per year, it is vital that we ensure carers can access the support they need to retain their own independence and wellbeing.

3

Have your say on Warwickshire’s health and wellbeing needs

A survey has launched to find out more about the unique health and wellbeing needs of Warwickshire’s various local communities.

WCC and its partners recognise that the needs of different communities throughout the county will differ greatly depending on a range of factors such as population demographics, infrastructure, community safety and many more.

As part of a larger project to gain more insight into life in Warwickshire’s communities, a survey has opened for staff and partners to let the county council know what, in their opinion, the current health and wellbeing needs of areas they are familiar with are and any ideas they have for improvement.

The responses to this survey will form part of the 2018-2020 Joint Strategic Needs Assessment (JSNA) and will help inform service delivery and development.

The JSNA is a review undertaken every few years by partners including WCC, Warwickshire Health & Wellbeing Board, the five District and Borough councils, local Clinical Commissioning Groups, third sector organisations and council- commissioned services. Working with partners to look at the current offer for different Warwickshire areas will help to reduce duplication and strengthen the evaluation of initiatives through use of a common evidence base.

The JSNA is a really useful tool which is accessed both by teams within WCC and other stakeholders to inform commissioning decisions and promote innovation and a solution-focused approach, ensuring services are well-placed to help the people who need them most.

Data from the JSNA can also be used by a range of agencies across sectors to support specific activity such as funding bids and tender applications.

The survey will close on Sunday 15 July and takes about ten minutes to complete. To have your say, go to http://bit.ly/JSNAProfessionals

Please note, if you are a resident of Warwickshire and wish to comment from that perspective, please use http://bit.ly/JSNAResidents

For more information contact: [email protected]

4

The Service The NHS Diabetes Prevention Programme is open to adults aged 18+ with non-diabetic hyperglycemia - HbA1c 42-47 mmol/mol. However, due to the limited Initial Assessment places available and implementation funding, referrals will initially be prioritised for those in the upper end of this range - HbA1c 45-47 mmol/mol.

Those patients identified opportunistically should be referred using the referral form (sample attached). These will be uploaded onto EMIS and VISION for you to access. Please note that although the referral form criteria is HbA1c 42-47 mmol/mol only those patients with non- diabetic hyperglycemia - HbA1c 45-47 mmol/mol should be referred onto the programme at this stage. Depending on uptake this may be broadened out later in the year.

Commissioning 18 practices across Coventry & Warwickshire have been identified as trailblazers from May 2018 who we are inviting to participate in the initial phase of the NHS Diabetes Prevention Programme before it is rolled out across the STP. As one of our Trailblazer practices you will have the opportunity to refer pre-diabetic patients to a structured programme where participants learn how to prevent diabetes by incorporating healthier eating, physical activity, problem-solving, stress-reduction and coping skills into their daily lives.

During the first year 2018/19, retrospective case-finding will be used in addition to opportunistic referrals to invite eligible patients with HbA1c 45-47 mmol/mol already identified on practice lists. Patients within your practice who meet this criteria should be sent a letter inviting them to participate in the Diabetes Prevention Programme along with the patient information sheet (a template of the letter is attached).

All patients referred to the programme should be given a patient information sheet (copy enclosed). These will be sent to you via the CCG.

We have agreed with the LMC that a payment of £3 per letter will be paid to the practice for retrospective patients and an admin fee of £56 per year for recording patient referrals.

Contact: Naomi Jones from ICS 'Healthier You' Healthier You Service Manager, Tel: 07442011444, [email protected]

5

New Suicide Bereavement Support Service Launch

The Kaleidoscope Plus Group are facilitating a Suicide Bereavement Support Service, across the whole county of Warwickshire. The service has been funded by Warwickshire County Council through the Public Health and Strategic Commissioning team.

The service provides a safe space for people who have been bereaved by suicide to come together and talk openly about their experience. The groups are facilitated by trained professionals who bring with them the skills and knowledge around coping with grief, loss and bereavement.

Rugby Health and Wellbeing Partnership

A development event took place in June to explore the local appetite for expanding the Rugby Health and Wellbeing Partnership to include care providers. The event was looking if we can evolve our local established partnership to integrate our working more closely with our providers and other local partners to deliver improved Health and Wellbeing for Rugby’s population.

Also to consider if, or how, this might form one element in the evolution of a future integrated care system for Coventry and Warwickshire. The event was facilitated by John Bewick. At the meeting partners agreed to review the membership and some core areas of work for the local partnership moving forward. The next meeting will be in September.

Warwickshire North Health and Wellbeing Partnership

Following the development event in April to expand the Warwickshire North Partnership, the wider group met for the first time in June. The meeting heard a presentation on the suicide prevention programme, the JSNA and End of Life Care. 6

Drug and Alcohol Service The contracts for the newly designed and re-commissioned Drug and Alcohol Services started on 1st May 2018. The new Countywide services include: • Adults (includes needle exchange)– Change Grow Live • Recovery and Well Being – Change Grow Live • Children and Young People – COMPASS are retained • New Residential Rehabilitation Facility - ESH Works (Experience, Strength, Hope) • Inpatient Detox Supplier Framework. (Warks) CC • Residential Rehabilitation Supplier Framework. (Cov/Warks/Leics CC) • Prescribing with Pharmoutcomes – Supervised consumption Adults: Change Grow Live are the new provider for both the Adult substance misuse services and the Recovery and Wellbeing Service. The Service A recovery-focused service with a full range of treatments and interventions designed to support people to take control of their recovery journey and achieve their recovery goals. Services will include harm reduction, opiate replacement prescribing, residential and community detoxes, counselling, emotional support and supported access to mutual aid. Support in accessing training, employment and housing will also be available.

Contact: CGL can be contacted on the single point of contact number 01926 353513 or queries can be addressed to [email protected] and www.changegrowlive.org. Children and Young People: The service remains with the current provider COMPASS Contact: 01788 578227 www.compass-uk.org/compass-warwickshire

Residential Rehabilitation: ESH Works, (Experience Strength Hope) have newly opened a residential rehabilitation service with practical support and guidance for people in their recovery journey. T The Service Warwickshire’s first drug and alcohol community rehabilitation centre in Warwickshire is open for business thanks to funding from Public Health England (PHE),ESH works and Public Health. The 11 bed facility, situated just outside Southam, in South Warwickshire is CQC registered with 24/7 on site support and is operated and managed by professional staff who all have their own personal experience of addiction and recovery. The property is set in 4 acres of grounds located in the beautiful Warwickshire countryside, located away from everyday distractions it provides a safe and supportive environment for residents. Contact: 01926 889 356 www.eshworks.org We will be holding two launch events on 28th June and 5th July 2018 in the North and the South of the County to introduce the new services and gain stakeholder contributions to the Drug and Alcohol Action plan. Contact: [email protected]

7

Blank Page

8

NHS Coventry & Rugby Clinical Commissioning Group Enc I NHS Warwickshire North CCG Clinical Commissioning Group

Report To: Governing Body Meetings in Common

Report Title: Commissioning Intentions 2019/20

Report From: Jenni Northcote, Chief Strategy Officer

Date: 12th July 2018

Previously Considered by: Not applicable

Action Required

Decision: Assurance:  Information  Confidential

Purpose of the Report: The purpose of this report is to outline the approach and timescales for developing the Coventry and Rugby CCG and Warwickshire North CCG Commissioning Intentions for 2019/20.

Key Points: • All Clinical Commissioning Groups (CCGs) are required to develop and publish commissioning intentions annually which articulate the annual priorities the CCG will focus on to maximise health benefits for its population and to respond to national and local priorities. • Commissioning intentions will need to be completed and published by 30th September 2018 in line with previous years and will be presented to the Governing Body Meetings in Common on 12th September for agreement and sign off. • The commissioning intentions are informed by existing themes emerging from engagement activity, alongside an ongoing process of engagement through key stakeholders. • Recognising current challenges in the system, it is proposed that the 2019/20 commissioning intentions are set in the context of the following:

A) Local population health needs as defined by the Coventry and Warwickshire Joint Strategic Needs Assessments (JSNAs) B) National deliverables for 2019/20, focusing on areas of key performance challenges for the CCGs • The commissioning intentions will need to reflect national priorities and demonstrate how the CCGs will respond to key performance challenges. As part of the commissioning intentions stocktake, a review of progress against all key deliverables from the 2018/19 NHS Operating Plan will be undertaken.

Recommendation: The Governing Bodies are requested to NOTE and ENDORSE the proposed approach to produce the 2019/20 Commissioning Intentions.

Page 1 of 2

Implications

Objective(s) / Plans Supports delivery of the key strategic objectives of the CCGs as well as responding supported by this to the priorities of the Health and Wellbeing boards and local Joint Strategic Needs report: Assessments Conflicts of Interest: None identified. Will be identified for specific projects. Unclear at present. Will be clarified as Non-Recurrent Expenditure: commissioning intentions are developed

Unclear at present. Will be clarified as Financial: Recurrent Expenditure: commissioning intentions are developed

Is this expenditure included within the CCG’s Financial Plan? (Delete Yes No N/A  as appropriate) Will support delivery of national targets as required by the 2018/19 planning Performance: guidance. Will address identified quality issues and priorities from the Health and Wellbeing Quality and Safety: Boards and JSNAs. General Statement: The CCG is committed to fulfil its obligations under the Equality Act 2010, and to ensure services commissioned by the CCG are non- discriminatory on the grounds of any protected characteristics. Policies/decisions may need to be adjusted in line with any equality analysis or due regard. Any decision that is finalised without being influenced by appropriate due regard could Equality and Diversity: be deemed unlawful. Has an equality impact assessment been undertaken? Yes No N/A  Will be undertaken for specific projects Patient and Public Commissioning intentions will be developed within an ongoing process of Engagement: engagement which is set out in the paper. Commissioning intentions will be developed within an ongoing process of Clinical Engagement: engagement which is set out in the paper. MEDIUM – This will be reassessed when commissioning intentions have been Risk and Assurance: developed.

Page 2 of 2

Coventry and Rugby CCG and Warwickshire North CCG

Commissioning Intentions 2019/20

Report to Governing Body 12th July 2018

1. Introduction

All Clinical Commissioning Groups (CCGs) are required to develop and publish commissioning intentions annually which articulate the annual priorities the CCG will focus on to maximise health benefits for its population and to respond to national and local priorities.

In line with the commissioning cycle plan for 2019/20, work has commenced to produce commissioning intentions for both CCGs so that they can be completed and published by 30th September 2018 in line with previous years. The first stage of this work will be a full stocktake of progress against existing commissioning intentions within the first six months of 2019/20, with reference to national performance requirements and local health needs.

The commissioning intentions will demonstrate how the CCGs deliver the values of the organisations through transforming and commissioning services. Our CCG values and the commitments set out in the local Health and Wellbeing Concordat provide a set of principles for delivering our commissioning intentions. These are detailed in Appendix 1.

This paper describes the approach, process and timescales for developing the 2019/20 Commissioning Intentions.

2. Governance and Timetable

In order for the CCGs’ Commissioning Intentions to be published at the end of September they will need to be approved at the Governing Body meetings in common on 12th September 2018. Prior to being recommended for approval by the Governing Body, proposed commissioning intentions will be discussed at both Clinical Executive Groups to ensure clinical oversight, and will be presented to the Finance and Performance Committee in Common. In order to meet these deadlines the following timeline is proposed.

Timetable Date Stocktake against existing intentions June – July Approval of approach by Governing Body 12th July Ongoing engagement with local patient groups and July - August stakeholders First draft completed 8th August First draft to be reviewed at Chief Executives Meeting 13th August

1

Warwickshire North Executive Group mid-August Coventry and Rugby Clinical Executive Group

Final draft completed 16th/17th August

Final version presented to Finance and Performance 23rd August Committee in Common Final draft presented to Governing Body Meetings in 12th September Common

Final draft presented to Heath & Wellbeing Boards September

Commissioning Intentions issued and available on CCG 30th September websites as final documents

3. Engagement

Our Commissioning Intentions will be informed by insights and feedback generated through engagement with local patients, public, providers, member practices and other key stakeholders. We will take account of key recommendations coming out of Health Watch reports, reflect priorities identified through local JSNA stakeholder engagement, and listen to the key themes emerging from our Local Health and Wellbeing Partnership Forums. We will acknowledge and reflect the key messages emerging from of our existing engagement and compliment this work by reaching out to specific groups that connect with our diverse local communities, to understand and reflect the specific needs of vulnerable seldom heard groups. This engagement approach will ensure we build on what patients, stakeholders and the public have already told us is important to them, and ensure that the patient voice is at the centre of our Commissioning Intentions.

High level themes emerging from our engagement activity this year:

• Patients want to be empowered to live well o “I want to be treated like a person, not just a condition” o “I want to thrive and not just survive” o “I want to be an expert in my own health so I don’t have to keep phoning the doctor”

• Patients want easy access to services they need o “I want to be able to get in and see my GP – don’t want to have to go to A&E when my GP knows my condition and can treat it.” o “I want the people who plan services to think about people living in villages, we don’t all live in a city / town centre” o “I want to be able to talk to someone quickly, before my condition gets worse” o I would be prepared to travel to get specialist care when I need it , but want get home as soon as possible, with the right support to help me recover and cope.

2

• People want better integration in health and social care o “I find it difficult to know what health care is available for me, I need help to navigate the system” o “I want services to talk to each other – I don’t want to explain my health problems all over again every time I have an appointment” o “I don’t want to have lots of appointments with different services, I want everyone to work together.”

Appendix 2 sets out additional engagement opportunities that will also be used to inform and shape our commissioning intentions.

4. Approach to 2019/20 Commissioning Intentions

The 2019/2020 Commissioning Intentions will reflect our strategic ambitions and high level priorities for driving forward transformational change through system collaboration, with a focus on outcomes that deliver accessible and high quality care. Our aim is to develop a sustainable health care system which delivers the requirements of the NHS ‘triple aim’ of improving population health, quality of care and cost control. They will also clearly demonstrate how we will both meet the health needs of our populations and continue to make progress in delivering on key performance targets.

It is recommended that commissioning intentions for 2019/20 should be developed through a collaborative approach with South Warwickshire CCG, to reflect system wide commissioning intentions, alongside place specific commissioning priorities. Having mobilised the new Out of Hospital and Warwickshire Child and Adolescent Mental Health Services (CAMHs) contracts; delivered through an outcomes based approach, we have an opportunity to articulate an intention to move away from commissioning activity to a value based commissioning approach, focused on delivering improved outcomes for our population and seek to adopt this method for our future commissioning programmes and projects; which would align with emerging discussions around the future direction of travel towards strategic commissioner arrangements.

In 2014 the three CCGs developed and approved “Transformational Change: Transforming Lives in Coventry and Warwickshire Clinical Commissioning Groups.” This strategic plan underpins “Translating our 2020 Vision into Reality” and the “Better Health, Better Care, Better Value Programme.” Although the plan ends in March 2019, it’s priorities are strongly embedded in plans that run beyond that date and our commissioning intentions will need to reflect ongoing work streams.

For 2019/20 we have the opportunity to assess what we have achieved and what we want to focus on post 2020 across Coventry and Warwickshire. This new plan will need to describe how commissioners realise the benefits of an Integrated Care System (ICS). Providers in the future need to find new ways of working with each other and other system partners. We will need to build on our Out of Hospital experience to support provider collaboration and provider alliances that support delivery of our priorities for the forthcoming year and beyond.

3

For 2019/20 it is proposed that commissioning intentions are set in the context of and framed by the following:

A. Local population health needs as defined by the Coventry and Warwickshire Joint Strategic Needs Assessments (JSNAs) B. National Health deliverables for 2019/20, focusing on areas of key performance challenges for the CCGs.

Our initial stock take on progress against 2018/2019 commissioning intentions, JSNA Health priorities, achievement against constitutional targets, National Health deliverables and Operating Plan priorities indicate that our commissioning intentions will need to focus on the areas set out in the table at Appendix 3.

5. Next Steps

The next steps in delivering the commissioning intentions for 2019/20 are:

• Completion of stocktake against existing commissioning intentions • Review of actions against key performance challenges and operating plan priorities • Commencement of engagement process as described above • Draft commissioning intentions produced beginning of August 2018.

6. Recommendations

The Governing Bodies are requested to NOTE and ENDORSE the approach being taken to produce the 2019/20 Commissioning Intentions

4

Appendix 1:

Our Commissioning Activity will be underpinned by the CCG Values and The Health and Wellbeing Concordat Commitments set out below:

Warwickshire North and Coventry and Rugby CCG Values

Caring for our population first

• Putting our patients, carers and populations’ needs first, this is why the CCG was established and at the heart of all we do. • Working together across all parts of the health and social care system to reduce inequality, improve access, remove duplication, unwarranted variation and wasted resources so that we can best meet our communities and populations’ needs.

Creating the culture for partnerships and integration

• Building and sustaining the most effective relationships, partnerships, and service integration that improves the care and outcomes for our population. • Being objective, transparent and explicit with Partners about potential barriers to improvement so that we can collectively agree how these can be overcome

Respectful and inclusive

• Ensuring access to services by valuing everyone, being mindful of others perspectives, needs and differences. • Respecting and including our staff, empowering them through information, personal development and engagement, so that they can be active advocates for delivering the CCG core objectives.

Striving for excellence

• Ensuring that our local population has access to evidence based high quality, health and care outcomes. • Being an excellent convener for system partnerships to achieve improved care outcomes. • Improving the sustainability of primary care, so that clusters/networks can be active participants, Place leaders and partners, in the future integrated care system.

5

Refreshed Health and Wellbeing Concordat Commitments (Yet to be Approved).

Communities first, not organisations We will put communities first, not any single organisation. Understanding communities and priorities will be at the heart of our actions and decisions. Together we will drive forward the change needed in our streets, towns and across Coventry and Warwickshire.

Work across sectors We will build and sustain partnerships across public, voluntary and community and business sectors. We will value all partners’ contributions and support each other as we work towards achieving our vision.

Intervene early, think protection We will work together to tackle the causes of problems, not just react to symptoms.

Build stronger, self-sufficient communities through the ways that we work We will help communities work together and with other organisations, to be stronger. We will find ways to work with the voluntary and community sector to allow us to thrive.

Provide co-ordinated, seamless services We will improve the quality and effectiveness of services, particularly for people experiencing a complex range of issues and help reduce the number of interactions people have.

Do what works best, regardless of who does it We will develop service pathways that support the lives people lead – from birth to death. We will improve the quality of services by basing our decisions on evidence and the best way to achieve outcomes, rather than worry about who delivers the service.

Learn from others as well as from what we do We will share learning across partners and sectors to help improve services for our communities.

6

Appendix 2: Opportunities to shape our Commissioning Intentions (pre-first draft)

Opportunity Date Audience Approach Healthwatch Annual Meeting 3rd July 2018 Healthwatch and stakeholders We have submitted a number of questions for table facilitation around primary care/GP access which can feed back into CI development WCAVA Rugby Community TBC Rugby community and 10-15 minute agenda slot plus Action Network voluntary sector networking opportunity to cover representatives basic topics WN People’s Commission 18th July 2018 WN community leaders Table top discussion workshop around key priorities CRCCG AGM 18th July 2018 CCG stakeholders Posters detailing each of the core commissioning intentions with: - What we know (info from JSNA, work already done) - Our priorities - Space for people to provide thoughts, ideas etc WNCCG AGM 19th July 2018 CCG Stakeholders Posters detailing each of the core commissioning intentions with: - What we know (info from JSNA, work already done) - Our priorities Space for people to provide thoughts, ideas etc WN Member engagement TBC WN member practices We can gather initial feedback against the primary care CI, check alignment of our priorities vs theirs etc CRCCG cluster groups TBC CRCCG member practices We can gather initial feedback against the primary care CI, check alignment of our priorities vs theirs etc Online survey TBC Cancer Champions Survey to replicate the Diabetes Patient engagement activities at the AGM representative to increase the reach to patients Other patient groups and Questions on each of the core contacts commissioning intentions areas, Warwickshire North Patient setting the context and with free Forum text for people to provide thoughts, Stakeholder groups ideas etc

First draft circulation for review and comment ( and any further on going engagement)

Opportunity Date Audience Approach WN Patient Group Forum TBC Member practice Patient Depending on when the next meeting Group chairs will fall, we can either table it for discussion, or send it out electronically for feedback Healthwatch Coventry and TBC Healthwatch senior staff We can send the document to both Healthwatch Warwickshire Healthwatch organisations for initial feedback and comment WN People’s Commission TBC Community leaders We can send the document to PC members for review and comment Coventry and Rugby key TBC Key stakeholders We can send the document to various stakeholders e.g. Equality trusted stakeholders for review and and Inclusion Partnership, comment Friends of St Cross, VAC WN Members Engagement TBC WN Member practices We can send for review and comment

7

Proposed Key Focus Areas for 2019/20 Commissioning Intentions (in reference to JSNA priority areas and key deliverables from the NHS operating Plan)

JSNA Priority WN Cov Rugby Operating Plan Priority Mental Health Improvement in diagnosis for people with    Dementia diagnosis rate to be delivered at maintained at 67% of dementia. prevalence

Improvement in quality of life for people with a    Maintain delivery of access target for IAPT ( 19% of prevalence in mental illness 2019/20) Maintain 2 week standard for being seen in early intervention for Psychosis Reduction in Out of Area placements Reducing Self Harm in young people in    Further develop crises response for Children and young particular including building resilience people and fully implement a ‘CAMHs 3.5 service’ model Cancer Reduction in under 75’s mortality rates from    Ensure all eight waiting time standards are met, including Cancer by supporting the following: the 62 day referral –to-treatment cancer standard. • Halt rise of obesity in children and reduction in adults who are obese • Reduction in smoking in adults • Increase in physical activity Cardiovascular Reduction in under 75’s mortality rates from    Disease Cardiovascular Disease (CVD)

Children and Reducing Teenage Pregnancy rates    Deliver improvements in safety towards the 2020 ambition Young People to reduce stillbirths, neonatal deaths, maternal death and and Maternity Vulnerable Children (including LAC)    brain injuries by 20 and by 50% in 2025

Improving levels of educational attainment Increase the number of women receiving continuity of the and employment    person caring for them during pregnancy

Reducing higher rates of child mortality Continue to increase access to specialist perinatal mental  health services 

8

Reducing higher rates of 0-4 years A&E   attendances  

Reducing higher rates of self-harm related hospital admissions for 10-24 yr olds   Reducing higher rates of admissions due to substance misuse amongst those aged 15-24  years

Reducing higher rates of under 18 conceptions   Lower rates of breastfeeding at 6-8 weeks



Physical Reducing obesity, improving diet and    wellbeing physical activity

Reducing higher rates of smoking in those   aged 35 years +

Reducing levels of substance misuse –    alcohol and smoking

Reducing levels of infectious diseases  including HIV, TB and increasing immunisation rates Planned Care Reducing higher rates of hip fractures in    Meet and maintain planned care referral to treatment those aged 60 years + waiting time standards

9

Deliver reduction in avoidable demand for elective care by tackling variations in in referrals and providing advice first options for primary care

Creation of redesigned and efficient hospital pathways, avoiding duplication and unnecessary hospital visits

Expanding cancer screening uptake – focus on bowel, breast and cervical cancer

Primary Care Providing extended access to GP services, including at evenings and weekends, for 100% of the population

Delivering their contribution to the workforce commitment to have an extra 5,000 Doctors and 5,000 other staff working in primary care

Ensuring every practice implements at least two of the high impact ‘time to care’ actions

Actively encourage every practice to be part of a local primary care network

Urgent and Higher excess winter mortality   Deliver national performance targets for A&E and other Emergency urgent care targets Care Deliver integrated urgent care services with simple access for patients

Standardise Urgent Treatment Centres in line with national

10

standards

Transforming Continue to reduce inappropriate hospitalisation of people Care for people with a learning disability, autism or both with Learning Disabilities

11

Blank Page

12

NHS Coventry and Rugby Clinical Commissioning Group NHS Warwickshire North Clinical Commissioning Group Enc J

Report To: Governing Body Meetings in Common

Report Title: Communications and Engagement Assurance Report

Report From: Jenni Northcote, Chief Strategy and Primary Care Officer

Date: 12th July 2018

Previously Considered by: N/A

Action Required (delete as appropriate)

Decision: Assurance:  Information:  Confidential

Purpose of the Report: This report provides an overview of communications and engagement activity undertaken during May – June 2018.

Key Points: NHS Coventry and Rugby CCG and NHS Warwickshire North CCG continued to undertake a full range of communications and engagement activity during the reporting period.

This report outlines how both CCGs have met their statutory obligations for communications, engagement and involvement in this reporting period

Recommendation: The Governing Bodies are requested to NOTE the report, which is provided for assurance and information.

Implications Objective(s) / Plans Supports CCG Communications and Engagement statutory obligations. Informs supported by this commissioning and service developments. report: Conflicts of Interest: N/A Non-Recurrent Expenditure: N/A Recurrent Expenditure: N/A Financial: Is this expenditure included within the CCG’s Financial Yes  No N/A Plan? (Delete as appropriate) Performance: N/A Quality and Safety: N/A General Statement: The CCG is committed to fulfil its obligations under the Equality Act 2010, and to ensure services commissioned by the CCG are non-discriminatory Equality and Diversity: on the grounds of any protected characteristics. Policies/decisions may need to be adjusted in line with any equality analysis or due regard. Any decision that is finalised without being influenced by appropriate due regard could be deemed unlawful.

Page 1 of 8

NHS Coventry and Rugby Clinical Commissioning Group NHS Warwickshire North Clinical Commissioning Group Enc J

Has an equality impact Yes assessment been undertaken? No  N/A  (attached) (Delete as appropriate) Patient and Public The report details patient and public engagement undertaken Engagement: There has been clinical engagement in a range of communications and engagement Clinical Engagement: activity detailed within this report The report provides assurance that the CCG is undertaking its duties in respect to Risk and Assurance: patient/public/stakeholder and clinical engagement.

Page 2 of 8

NHS Coventry and Rugby Clinical Commissioning Group NHS Warwickshire North Clinical Commissioning Group Enc J

NHS Coventry and Rugby CCG and NHS next week. Local patients and Warwickshire North CCG continued to community/voluntary sector reps were engaged undertake a full range of communications and at all stages of the procurement exercise, and engagement activity during December 2017 and were involved in choosing the PPI related January and February 2018. questions for the bid, scoring and evaluating the This report outlines how both CCGs have met responses and interviewing the bidders their statutory obligations for communications, themselves as a scored part of the process. engagement and involvement in this reporting They were also given the opportunity to choose period, as set out by NHS England’s Patient and the colour scheme which the practice will be public participation in commissioning health and decorated with; the group chose the colour care guidance: scheme inspired by Rugby Golf Course (other

1. Involve the public in governance options included Rugby Clock Tower, Rugby 2. Explain public involvement in School and the distinctly not-Rugby-related commissioning plans/business plans “Coastal Waves”). 3. Demonstrate public involvement in annual reports In June, a stakeholder engagement event was 4. Promote and publicise public held with local residents to update them on the involvement project. Attendees were asked to feed back their 5. Assess, plan and take action to involve thoughts, ideas, queries and concerns around 6. Feedback and evaluate four key topics: 7. Implement assurance and improvement systems - Primary care 8. Advance equality and reduce health inequalities - Engagement 9. Provide support for effective involvement - The construction process - Public Health o We invited a representative from 1. Involve the public in governance Public Health to come and speak to residents to gain local Warwickshire North Patient Group Forum feedback for the upcoming The PGF took place on Monday 14 May Brownsover Place Based Needs 2018. The main presentation was from Claire Assessment Hall (CH), Carers and Care at Home Commissioner, Warwickshire County Council to Overall, about 30 people turned up to the event raise awareness ahead of Carers Week (week and feedback was positive, with comments on commencing 11 June). how happy they were to be involved.

The Group reported that there are still issues Maternity and paediatrics with the phlebotomy service and have requested As described in the last report, we have been more information on Prescription Ordering working with a range of stakeholders including Direct. The July meeting will give the Group the health and social care partners on an opportunity to hear from Debbie Pook, Director engagement and listening exercise with of Operations, George Eliot Hospital. mothers, mothers to be, families, carers, frontline staff and voluntary and community sector workers to identify the critical success 2. Explain public involvement in factors for maternal and child services, building commission plans/business plans on insights and key themes identified from engagement conducted previously at both a Brownsover Medical Practice development national and local level as a jumping. The procurement process for Brownsover has now completed and the announcement of the new GP service provider will take place in the Page 3 of 8

NHS Coventry and Rugby Clinical Commissioning Group NHS Warwickshire North Clinical Commissioning Group Enc J

The engagement took place between May and 4. Promote and publicise public June and has seen over 500 mothers and involvement families take part across Coventry and Alongside our traditional methods of promoting Warwickshire, either through face to face and publicising public involvement, such as our workshops or via a survey. To ensure we have website, social media, complaints and representation across our diverse communities comments procedures, we have established a and stakeholder groups we are also reaching number of additional and targeted involvement out to community/voluntary staff and frontline opportunities, as outlined below: maternity and paediatrics staff to ensure we capture a holistic view of what key stakeholders Diabetes think is working well, share their experiences A press release was issued on behalf of both and understand what is needed from our future CCG’s on Wednesday 13th June about ‘Know maternity and paediatric services going forward. your risk and fight diabetes as cases soar’ this was to support Diabetes Week and raise 3. Demonstrate public involvement awareness of the local support available for in annual reports people who are living with diabetes and those Each CCG’s annual report is now live on the newly diagnosed. Voluntary group Ekta-Unity website. In response to feedback from the NHS will be hosting the West Midlands Mayor England IAF audit of last year’s report, we have Weekend Event on Monday 2nd July 2018, tried to better demonstrate the wide range of members of the team have been involved in public involvement which has underpinned the supporting the group to have a range of local commissioning activity of the CCG throughout NHS provider services at the event. 2017/18 and have sought to highlight in each People’s Commission CCGs Annual Report patient outcomes and The next Warwickshire North People’s benefits to local patients which have been Commission is due to take place on 18th July. delivered; as well as setting out how we have The focus of the session will be a tabletop involved and engaged with the public and exercise on a number of key topics, as well as stakeholders throughout the year. an update on the GP access work. Annual General Meeting (AGM) Coventry Carers event We will be showcasing our achievements from Members of the team attended this year’s the last 12 months and looking ahead to our ‘Carers Week’ event held in Coventry on priorities and how we’ll address the challenges Wednesday 13th June at the Central Methodist of the coming year. Invitations have gone out to Hall. The purpose of attending this event was to members, partner organisations, voluntary engage with local carers about the CCG’s work groups and patient representatives. programmes relating to GP extended hours, • Wednesday, 18th July 2018 diabetes and cancer, the team engaged with The Benn Hall, Newbold Road, Rugby, CV21 approximately 50 carers and members of the 2LN (Onsite parking available) public on the day and made new networks with Registration and Refreshments from 9:30 am key people from the Chinese and African Presentations from 10:00 am – 12:00 pm communities and Coventry University. We have linked up with Warwickshire Local Authority to • Thursday, 19th July 2018 promote the launch of an initiative to raise The CHESS Centre, 460 Cedar Road, awareness of support services for Carers. The Nuneaton CV10 9DN (Free parking available CCG is working closely with the L.A team to at Church opposite venue) promote access to carers support through PPGs Registration and Refreshments from 9:30 am and member practices, and to link this initiative Presentations from 10:00 am – 12:00 pm with existing sign posting support offered through Care Navigators. Page 4 of 8

NHS Coventry and Rugby Clinical Commissioning Group NHS Warwickshire North Clinical Commissioning Group Enc J

Healthwatch Practice Merger – Chapel End Surgery The Head of Communications and Engagement Two local practices in Warwickshire North provided an updated at the Healthwatch Chapel End Surgery (Dr Motala) and Chapel Coventry steering group to keep them apprised End Surgery (Dr Ganapathi) merged on 31st of the latest and upcoming engagement work, May 2018. The new merged practice will be encouraging them to be involved wherever known as Chapel End Surgery, operate from the possible. A member of Healthwatch existing shared premises at Camphill Road and Warwickshire acted as a patient rep on the will be run by Dr Motala. Dr Ganapathi retired Brownsover Patient Advisory Forum. The CCG from General Practice on 1st April 2018. Both has responded to recent Coventry Healthwatch practices were supported by their PPGs prior to report outlining actions the CCG will take in the event and the two PPG groups are due to response to recommendations on Out Patient meet again in July Appointments. The CCG also responded to the Coventry Healthwatch survey. The joining of these two practices will provide the opportunity for Chapel End Surgery to Coventry Older Voices event provide a wider range of comprehensive The Accountable Officer, supported by members services to their patients. of the communications team attended the Coventry Older Voices meeting, convened by Rugby Health and Wellbeing Partnership Coventry City Council and COV to discuss the A development event took place in June to Care Quality Commission System Review in explore the local appetite for expanding the Coventry. The CCG representatives also Rugby Health and Wellbeing Partnership to participated in facilitated table top discussions include care providers. The event was looking if on how health and social care could be we can evolve our local established partnership improved for older people living in Coventry and to integrate our working more closely with our how older people could be involved in providers and other local partners to deliver supporting healthcare. A member of the improved Health and Wellbeing for Rugby’s communications team attended the de-brief population. meeting to start to analyse and theme the feedback and the results will be shared in the Also to consider if, or how, this might form one coming weeks. element in the evolution of a future integrated care system for Coventry and Warwickshire. The event was facilitated by John Bewick. At the 5. Assess, plan and take action to meeting partners agreed to review the involve membership and some core areas of work for the local partnership moving forward. The next Termination of Pregnancy Services (TOPS) meeting will be in September The CCGs across Coventry and Warwickshire will be going out to procurement for TOPS due Warwickshire North Health and Wellbeing to the current provider serving notice. It is not Partnership considered that public engagement will be Following the development event in April to required for this procurement process as there is expand the Warwickshire North Partnership, the no proposed change in service availability or wider group met for the first time in June. The criteria. meeting heard a presentation on the suicide Practice Merger – Clay Lane Medical Centre prevention programme, the JSNA and End of The communications team has continued to Life Care which were well received and showed provide support to the Localities Team with a progress and partnership working across all 3 practice merger which is due to take place on areas. There will be a more detailed discussion th 30 June in Coventry. on the JSNA at the next meeting.

Page 5 of 8

NHS Coventry and Rugby Clinical Commissioning Group NHS Warwickshire North Clinical Commissioning Group Enc J

6. Feedback and evaluate local links into various community and voluntary groups. This has included: Improving access to GP services survey The team conducted a survey with patients and • Grapevine the public across Coventry, Rugby and • Coventry Cyrenians Warwickshire North. The survey covered topics • Warwickshire County Council such as ease of getting appointments, using Community Safety and Locality Working online services, extended access in evenings Service and weekends and transport. Over 600 responses were gathered through a combination of online and face to face engagement. Results 8. Advance equality and reduce from this survey will be coded, analysed and health inequalities shared in the coming weeks. This will feed in to the development of future extended access Supporting refugees and homeless people. service provision across both of our CCG’s Coventry and Rugby CCG are taking forward the procurement of services for refugees and the homeless at the Anchor and Meridian sites. This 7. Implement assurance and will involve engaging with these seldom heard improvement systems groups both face to face and via a survey, which will be distributed by local community groups Showcasing patient outcomes who have access to and support this patient As part of the work to prepare for the annual cohort, such as Coventry Cyrenians and the report, AGM, and the next cycle of YMCA. commissioning intentions the CCG’s have been gathering case studies, testimonials and Improving access to dementia support examples of best practice across to gain In response to recent engagement and dialogue feedback and assurance on how stakeholders with local Older peoples forum and carers have contributed to our commissioning program groups the CCG is actively focusing on raising and capture the impact this has on achieving the profile of Dementia and access to Dementia positive patient outcomes. These will be support. The CCG recently included a specific highlighted on the CCG websites and in a new session as part of the GP protected learning PPI annual report being developed (in addition time to ensure GP’s and Nurses are aware of to the CCG annual report). the full Dementia Support offer available locally and are aware of referral pathways to access Community Dermatology service support and interventions. The CCG has also Community Dermatology service was launched worked with the LA to explore options to on 30 April 2018 across Warwickshire North increase access to training and awareness for CCG. The CCG have worked closely with the carers supporting loved ones with Dementia, the provider to ensure that the practices are fully CCG will consider local requirements for informed of the availability and locality of the Dementia provision within its Commissioning community services through regular Intentions and already has plans in place to communications, updates and a newsletter. The increase dementia assessments and diagnosis. new service should reduce waiting times and enhance the patient journey. Dying Matters WN CCG was a key partner in the delivery of an Improving links into the communities innovative Dying Matters campaign which Thanks to attendance at a number of key culminated in a public event on Thursday 17 engagement sessions recently, the CCGs have May 2018 at King Edward IV College, significantly improved and further strengthened Nuneaton. At the event, students form King Edward IV College displayed art work that they

Page 6 of 8

NHS Coventry and Rugby Clinical Commissioning Group NHS Warwickshire North Clinical Commissioning Group Enc J had produced with patients from Mary Ann north version, which has been very successful Evans Hospice (MAEH) and they also performed since its launch a few months ago. a play. NHS 70 – Celebrations The event was well attended, including several As most will be aware, our NHS is officially key decision makers (counsellors, GEH turning 70 on the 5th July. A number of local management, MAEH/Myton trustees). Working celebrations have taken place in partnership with the MAEH, Myton Hospice, George Eliot with NHS Coventry and Rugby CCG and NHS Hospital, South Warwickshire Foundation Trust Warwickshire North CCG over the last few and King Edward IV College, Nuneaton, the months, nevertheless celebrations are CCG provide expert advice and support around continuing throughout the year. the communication and engagement of the event and how to get people involved. Below is a brief snapshot of internal and local celebrations coming up next week.

9. Provide support for effective CCG Stars Over the last seven weeks, the Communications involvement team have been encouraging CCG staff to recognise those colleagues and teams who go Public Health JSNA stakeholder meetings Both CCGs have contributed to Public Health above and beyond their role by living and JSNA stakeholder meetings. These engagement demonstrating the new CCG values of being meetings provided an opportunity for a wide caring, respectful, inclusive and striving for range of stakeholders to come together to excellence. understand the key health challenges our local Staff can nominate a colleague or team by communities face. This year, Public Health is completing the attached nomination form – working on a “place based” model, where also found on the intranet and shared drive. “needs assessments” will be conducted at a Once completed this is to be returned to the more local level. The CCG is working in Communications team via email. More collaboration with Public Health to ensure that information about this campaign can be found feedback and insights generated from the JSNA on the attached CCG Stars FAQ. Entries will stakeholder events is reflected in our next close on the 2nd July and CCG stars will be iteration of our Commissioning Intentions. awarded on the 6th July. Commissioning Intentions refresh NHS 70: Bring & Share lunch (all user due to As part of our annual commissioning intentions go out 27th June) cycle both CCG’s are taking stock of the On Wednesday 4th July, there will be a Bring engagement we have undertaken and reviewing and Share lunch for all CCG staff at Parkside the patient and public feedback we have House, Coventry and in Heron House, gathered over the last 12 months. We will Nuneaton. The lunch will give staff the ensure that the key themes, messages and opportunity for staff to reminisce of their time insights generated by our local population / working in the NHS with colleagues while stakeholders inform our commissioning enjoying lunch and treats. intentions. The lunch will take place from 12:30pm in Room GP Digest – newsletter 5 at Parkside House and in Endeavour at Heron The latest edition of the GP newsletter was House. Those staff based at Hunter House and issued to GPs and Practice Managers across Westgate House who may not be able to attend Coventry and Rugby, the next edition will be the Bring and Share lunch will be receiving a aligned to the same format as the Warwickshire visit from the Communications team next week.

Page 7 of 8

NHS Coventry and Rugby Clinical Commissioning Group NHS Warwickshire North Clinical Commissioning Group Enc J

Staff are encourage to contribute home cooked delights or whatever they can, to view the list of items – please approach one of the Communications team.

Coventry Cathedral Service The Dean of Coventry, Revd John Witcombe have invited CCG staff to a special service to celebrate the 70th anniversary of the creation of the NHS. Girl Choristers of the Cathedral Choir will be presenting at the service alongside Reverend Ricarda Witcombe, Chaplaincy Team Leader at George Eliot Hospital NHS Trust on

Thursday July 5th 2018, from 5.15 pm - 6.15 pm Coventry Cathedral, Priory Street, Coventry, CV1 5FB

This service is open to everyone from the NHS and associated services, including the universities which train our future staff, as well as patients, carers and the public.

Page 8 of 8

NHS Coventry and Rugby Clinical Commissioning Group NHS Warwickshire North Clinical Commissioning Group Enc K

Report To: Governing Body Meetings in Common

Report Title: Quality, Safety and Performance Report

Report From: Steve Jarman-Davies, Jo Galloway

Date: 12th July 2018

Previously Considered by: Commissioning, Finance and Performance Committee, 28th June 2018 Clinical Quality and Governance Committee 27th June 2018

Action Required

Decision: Assurance:  Information: Confidential

Purpose of the Report: To provide assurance to the Governing Body of the performance of services commissioned by Coventry and Warwickshire and Warwickshire North CCGs for the month of April (unless otherwise specified). The report also provides an update on quality concerns within commissioned services that are either being investigated or are being monitored against improvement plans.

Key Points: Performance

Referral to Treatment Times (RTT) 84.8% of CRCCG patients had been waiting less than 18 weeks from their GP referral date to be seen or treated by a hospital specialist against a target of 92%. The figure for WNCCG was 83.6%. There were 16 CRCCG patients waiting over 52 weeks. 14 were waiting at UHCW, one at Royal Free London NHS Foundation Trust and one at Imperial College Healthcare Trust. There were 6 WNCCG patients waiting over 52 weeks, of whom all were waiting at UHCW. Both CCGs achieved against the diagnostic test waiting times target with 99.5% of CRCCG and WNCCG patients receiving diagnostic tests within 6 weeks of referral.

A & E 4 hour waits A & E 4 hour waits performance was 90.4% at UHCW, remaining below the 95% target, but a significant improvement from the March position of 79.6%. GEH also underachieved, with 92.6% of patients seen within 4 hours but has improved over the course of the last month.

Cancer waiting times CRCCG achieved all Cancer waits targets in quarter 4. WNCCG underachieved against the Cancer 62 day wait target from urgent GP referral to first definitive treatment in quarter 4, with performance at 83.2% against a target of 85%. Other targets were achieved. One patient at UHCW had waited more than 104 days from referral to treatment in April. No patients breached at GEH.

Mixed Sex Accommodation There were 2 Mixed Sex Accommodation breaches for CRCCG, one at Frimley Health NHS Foundation Trust and one at University Hospitals of Morecambe Bay NHS Foundation Trust. There were no breaches for WNCCG patients.

Cancelled Operations There were 55 patients in quarter four who had operations cancelled at UHCW, on or after the day of admission for non-clinical reasons and weren’t offered another binding date within 28 days. 3 cancellations at GEH were not offered another biding date within 28 days. The main reason for the breaches was that the need to schedule urgent/cancer patients reduces the capacity available. UHCW requires Admin Managers to review the 28 day

Page 1 of 4

NHS Coventry and Rugby Clinical Commissioning Group NHS Warwickshire North Clinical Commissioning Group Enc K cancellation report on a weekly basis and identify additional lists for relevant specialties/consultants.

Dementia Diagnosis Both CCGs continue to underachieve against the 67% dementia diagnosis target, with 59.5% of the estimated dementia cases diagnosed for CRCCG and 59.0% for WNCCG.

Early Intervention in Psychosis (EIP) CRCCG underachieved at 11% and WNCCG also underachieved at 50% against the EIP target which has risen to 53% for 2018/19.

IAPT. CRCCG achieved against the IAPT access target in February, which has risen to an annualised figure of 16% for the fourth quarter. Whilst WNCCG marginally underachieved at 15.9%, it is expected to have achieved for the fourth quarter as a whole. Both CCGs achieved against the recovery rate target.

Activity Tracker

Year-on-year referrals growth figures have been distorted by the higher number of working days in April compared to last year.

CRCCG General and Acute Referrals were 8.2% above plan. The CCG was 12.6% above plan for GP referrals and 2.4% above plan for ‘other’ referrals. On the basis of SUS data, non-elective activity for was 9.5% below target.

WNCCG General and Acute Referrals were 6.3% above plan. The CCG was 11.5% above plan for GP referrals and 0.1% below plan for ‘other’ referrals and the 12 month rolling average growth figure for GP referrals remains significantly lower than in April 2017. On the basis of SUS data, non-elective activity for was 6.8% below target. Delayed Transfers of Care for both CCGs continue to run very close to the 3.5% target level.

Quality

University Hospitals Coventry and Warwickshire (UHCW) There is one area on Level 2 and four areas on Level 3 of the CCG Quality Assurance Framework: • Level 2 – There is a risk relating to Dermatology and delays for first clinic appointments; it is positive to note that waiting times have now significantly improved with a reported maximum wait of 10 weeks for June 2018. • Level 3 – The CCG continues to monitor implications associated with delays in urgent clinic letters that should be sent within 10 days. The CCG and Trust are undertaking a joint investigation to ensure a shared understanding of Trust processes, together with potential solutions. • Level 3 – The CCG has formally raised concerns with the Trust in relation to its internal management systems used to manage patient follow up appointments. The CCG is utilising formal contractual mechanisms to gain assurance and confirmation of the management plan to resolve this issue. • Level 3 – The Trust is not currently meeting the 4 hour A&E target and the CCG has requested the Trust conducts a review of Serious Incidents reported over the past twelve months and to provide the CCG with assurance there that there are no key themes or trends related clinical care delivered within the department. • Level 3 – The Trust is experiencing increased capacity issues on Ward 14 due to issues relating to children and young people in crisis being cared for on the paediatric ward. A multi-agency group is working to develop alternative solutions to alleviate system pressures on Ward 14. A business case for a CAMHS tier 3.5 service has also been developed.

Coventry and Warwickshire Partnership Trust (CWPT) There are three areas on Level 2 of the CCG Quality Assurance Framework: • Level 2 – Following the June 2017 inspection, the CQC rated the Trust as requires improvement. The Trust has an action plan in place which is monitored as part of CQRM and the Trusts’ Chief Executive and Chief Nurse and Chief Operating Officer were invited to attend the CCGs’ Clinical Quality and Governance Committee in Common meeting in April to provide assurance regarding progress with improvements to address the CQC inspection findings. • Level 2 - The Care Quality Commission (CQC) inspection identified long waiting times for access to child Page 2 of 4

NHS Coventry and Rugby Clinical Commissioning Group NHS Warwickshire North Clinical Commissioning Group Enc K

and adolescent mental health services (CAMHS). The CCG has issued a contract performance notice and also conducted a quality assurance visit. The CCG has been assured that children and families are offered a range of alternative support options whilst waiting and patients are regularly reviewed to assess risk and prioritise patients by clinical need. The CCG is planning a follow up assurance visit at the end of July. • Level 2 - In response to a serious incident, the Trust has developed an action plan and initiated a review of wound care across Integrated Community Services. The action plan was presented to the March CQRM and will continue to be monitored.

George Eliot Hospital (GEH) There are four areas on level 2 and one area on level 3 of the CCG Quality Assurance Framework: • Level 2 – Following the October 2017 inspection, the CQC rated the Trust as requires improvement. A Quality Oversight and Assurance Group has been set up to provide assurance to system stakeholders that associated clinical and quality risks are appropriately assessed and addressed. • Level 2 – End of life care was rated as inadequate by CQC in January 2018 and there have been recruitment challenges experienced within this service. The Trust has been successful in its recruitment of an End of Life Consultant and a Lead Nurse and both are expected to be in post within the next couple of months. Recruitment of a second End of Life Consultant is underway. Actions in relation to End of Life Care form part of Trust’s Overall Improvement Plan in response to the CQC inspection. • Level 2 – The Trust has ongoing recruitment and retention challenges and utilise bank and agency staff to support. The Trust presents a safer nursing staffing report and regular updates on vacancies to the CCG at each CQRM. • Level 2 –The Trust did not achieve the required 85% compliance of the total workforce to complete Workshop to Raise Awareness of Prevent (WRAP) training by March 2018. The Trust has a plan and trajectory in place which sets out to achieve compliance by the end of September 2018. • Level 3 - The Trust is not meeting the 4 hour A&E target and has also reported a number of 12 hour trolley breaches. Urgent and Emergency services were also rated as requires improvement by CQC in January 2018. Actions in relation to Urgent and Emergency services form part of Trust’s Overall Improvement Plan in response to the CQC inspection. A further assurance visit to A&E, the Clinical Decision Unit and the paediatric assessment unit will be undertaken during July in partnership with NHSI and NHSE.

Cygnet, Coventry A CQC inspection at Cygnet took place on 30 to 31 October 2017 and the final report was published on 29th January 2018. The CQC rated the service as overall requires improvement. The quality team met with Cygnet in May 2018 and gained assurance regarding the actions the provider is taking in response to the CQC report.

The Pears, RNIB The Pears is a care and education facility for children and adolescents with complex health needs, provided by the Royal National Institute for the Blind. Care Quality Commission (CQC) visited Pears in April 2018 and put five conditions on its registration. There are no CRCCG or WNCCG residents placed within the home currently. The Safeguarding Designated Professionals from CRCCG and WNCCG are supporting the newly appointed Clinical Lead and an action plan is in place.

Recommendation:

Members are asked to NOTE the contents of the attached report.

Implications

Objective(s) / Plans supported by this 1,2,3 & 4 report: Conflicts of Interest: N/A Non-Recurrent Expenditure: Not applicable [Detail recurrent financial implications including Recurrent Expenditure: time period. If not relevant state ‘not applicable’] Financial: Is this expenditure included within the CCG’s Financial Yes  No N/A Plan? (Delete as appropriate)

Page 3 of 4

NHS Coventry and Rugby Clinical Commissioning Group NHS Warwickshire North Clinical Commissioning Group Enc K

Performance: The CCG is required to meet the national NHS Constitution targets The report outlines quality and safety issues in relation to Quality and Safety: commissioned services against the Clinical Governance Framework The report provides information relating to patients with protected characteristics where care is provided by commissioned services Equality and Diversity: Has an equality impact Yes assessment been undertaken? No N/A  (attached) (Delete as appropriate) Patient and Public Not applicable Engagement: Clinical Engagement: Not applicable The following areas are identified on the CCG risk register: • A&E performance UHCW • RTT Performance • CHC Complaints Risk and Assurance: • Lack of Assurance regarding CHC Service Performance • Timely CHC assessments • CHC Transition

Page 4 of 4

July 2018 Quality, Safety and Performance Report

1 Contents

Section 1. CCG Performance Overview Introduction ...... 4 NHS Constitution, Supporting & Mental Health Measures – CRCCG ...... 9 Indicators achieved/underachieved by CRCCG in the latest period ...... 11 NHS Constitution, Supporting & Mental Health Measures – WNCCG ………………………..13 Indicators achieved/underachieved by WNCCG in the latest period ……………………… ... 15

Section 2. CCG Quality Overview Introduction ...... 18 Items on Escalation ...... 18 Other Providers ...... 21 Primary Care Update ...... 22 Care Homes ...... 22

Section 3. Provider Level Performance and Quality UHCW Performance Dashboard ...... 25 UHCW Quality Dashboard ...... 26 GEH Performance Dashboard ...... 28 GEH Quality Dashboard ...... 29 West Midlands Ambulance Services Dashboard ...... 31 CWPT Mental Health and Learning Disabilities Dashboard ...... 32 CWPT Quality Dashboard ...... 34 South Warwickshire Foundation Trust Community Services ...... 35

Section 4. Activity Tracker Activity against Plan ...... 37 GP Referrals Tracker ...... 38 Weekly Urgent Care Trackers ...... 39 Appendix 1. Provider Contract Performance Notices ...... 42 Appendix 2. Quality Assessment Framework ...... 44 Appendix 3. Abbreviations Used in the Report ...... 45

2

1 - CCG Performance Overview

3

Introduction This report focuses on the month of April unless stated otherwise.

Exception reporting, mitigating actions and, where required, Remedial Action Plans, are presented and reviewed through the Commissioning, Finance and Performance Committee and Clinical Quality and Governance Committee as formal committees to the Governing Body. These are therefore not included in this report.

Separate Provider Dashboards are included in section 3. CWPT share only limited data for Month 1 of the contract and issue no Trust Board Report so the dashboard only covers the period to March 2018.

Referral to Treatment Times (RTT)

84.8% of CRCCG patients had been waiting less than 18 weeks from their GP referral date to be seen or treated by a hospital specialist against a target of 92%. The figure for WNCCG was 83.6%.

There were 16 CRCCG patients waiting over 52 weeks. 14 were waiting at UHCW, one at Royal Free London NHS Foundation Trust and one at Imperial College Healthcare Trust. There were 6 WNCCG patients waiting over 52 weeks, of whom all were waiting at UHCW.

Both CCGs achieved against the diagnostic test waiting times target with 99.5% of CRCCG and WNCCG patients receiving diagnostic tests within 6 weeks of referral.

Actions to Improve RTT Performance

UHCW and GEH have undertaken extensive work with an intensive support team on demand and capacity for elective and outpatient activity. An action plan for RTT improvement for UHCW will be ready for the end of June 2018 identifying how RTT performance will be delivered up to March 2019. A monthly escalation meeting on RTT delivery is held with each trust, the CCG, NHSI and NHSE to agree actions and tie performance into action plans between the Trust and NHSI that match the CCG contractual plans.

A & E 4 hour waits

A & E 4 hour waits performance was 90.4% at UHCW, remaining below the 95% target, but a significant improvement from the March position of 79.6%. GEH also underachieved, with 92.6% of patients seen within 4 hours but has improved over the course of the last month.

Actions to Improve A & E 4 hour waits performance

The system is under NHSE / NHSI escalation in 20117/18. The Action plan relating to these meetings is monitored via the local A&E delivery board, and through the Coventry and Warwickshire A&E Delivery Board.

4

UHCW

Key deliverables to achieve the improvement trajectory include:

• Implementation of actions from walk around by Glen Burley (SWFT) • Achieving 98% in the Minors stream • New Rapid assessment and treatment area • Increasing use of Ambulatory Care • Increased Medical workforce, especially at weekends • Focus remains on monitoring adherence to the ED timed pathways, continued ring fencing of assessment beds. • Local A&E Board have an escalation remedial plan managed at Director level through Contracting process, but also reporting to the Coventry & Warwickshire A&E Board about progress of actions. QIPPs are set up for 2018/19 in relation to HIUs, NHS 111 clinical assessment.

GEH

Key deliverables and enablers from the Trusts RAP to achieve the improvement trajectory include:

• Achieving 95% in the Minors stream • Ring-fencing of CDU • Increasing use of Ambulatory Care • Revised SoP for Surgical assessment unit • Revised DoP for Acute medical unit (AMU) and footprint to enable GP admissions directly to AMU • Revised Medical workforce to include: medics, PAs, ENPs, Physiotherapists, Pharmacists, GPs, ANPs • Review surgical review pathways – ensuring timely access to specialty level reviews. • Implementation of revised rapid assessment and treatment model (RAT)

Cancer waiting times

CRCCG achieved all Cancer waits targets in quarter 4.

WNCCG underachieved against the Cancer 62 day wait target from urgent GP referral to first definitive treatment in quarter 4, with performance at 83.2% against a target of 85%. Other cancer waits targets were achieved.

One patient at UHCW had waited more than 104 days from referral to treatment in April. No patients breached at GEH.

Actions to Improve Cancer waits performance

There is a performance notice in place with GEH regarding failure of the quarterly cancer 62 day wait from urgent GP referral to first definitive treatment for cancer. The GEH cancer pathway review meetings have commenced in the key areas, LGI, UGI, Urology, Lung and Gynaecology.

5

These workshops review current pathways compared to recognised national pathways, identify the gaps and agree actions required to improve the pathways going forward with all stakeholders.

Mixed Sex Accommodation

There were 2 Mixed Sex Accommodation breaches for CRCCG, one at Frimley Health NHS Foundation Trust and one at University Hospitals of Morecambe Bay NHS Foundation Trust. There were no breaches for WNCCG patients.

Actions to Improve Mixed Sex Accommodation Performance

The Operational update from the NHS National Emergency Pressures Panel in January noted that the NHS has been under sustained pressure with high levels of respiratory illness, bed occupancy levels giving limited capacity to deal with demand surges and some reports suggesting a rise in the severity of illness among patients arriving at A&Es. They recommended that to ensure patient safety comes first CCGs should temporarily suspend sanctions for mixed sex accommodation breaches.

Cancelled Operations

There were 55 patients in quarter four who had operations cancelled at UHCW, on or after the day of admission for non-clinical reasons and weren’t offered another binding date within 28 days. 3 cancellations at GEH were not offered another biding date within 28 days. The main reason for the breaches was that the need to schedule urgent/cancer patients reduces the capacity available. UHCW requires Admin Managers to review the 28 day cancellation report on a weekly basis and identify additional lists for relevant specialties/consultants.

Actions to Improve Cancelled Operations performance

The CCG will be enacting the sanctions relevant to the Trust failing to achieve this indicator and have requested the information required from the Trust finance team to enable this to take place.

The sanction is “Non-payment of costs associated with cancellation and non- payment or reimbursement (as applicable) of re- scheduled episode of care”

Dementia Diagnosis

Both CCGs continue to underachieve against the 67% dementia diagnosis target, with 59.5% of the estimated dementia cases diagnosed for CRCCG and 59.0% for WNCCG.

Actions to Improve Dementia Diagnosis performance

CRCCG

• Systematic data cleanse working with practices across Coventry and Rugby to ensure that all GP practices are submitting complete and accurate data by the end of 2018/2019. • Consideration of a new model for outreach of the existing memory assessment clinic into care homes and primary care • Review the dementia pathway, to harness primary care involvement through early concerns to diagnosis and post diagnosis and increase referrals to MCI (Mild Cognitive Impairment)

6

• Establish a working group to:

a. Establish 5 poorest areas (at practice level) b. Identify 5 best performing areas c. Get demographic information on each area d. Find the best performing comparator authorities/CCGs and Trusts, research and share best practice e. Produce an action plan to work with the poorest performing practices – initially working with the poorest five before expanding.

• Continue to increase awareness amongst all key stakeholders of the post diagnostic support available across the CCG such as Dementia Navigators (Alzheimer's Society), Admiral Nurses (Dementia UK & the GP Alliance) and Dementia Assessment and Community Services (CWPT) offering a range of evidence based interventions

WNCCG

• Undertaking a scoping exercise for a potential new model for outreach services running from the existing CWPT Memory Clinic into care homes and primary care. • The CCG are in the process of recommissioning CHESS (care home enhanced support service) to ensure continued medical input to care homes, which will aid the dementia diagnosis. • The CCG are working with the Dementia Navigator Service to promote and design new referral mechanisms for General Practice across Warwickshire North, (promoting and supporting timely dementia diagnosis). • An internal review of the CWPT Memory Clinic has been undertaken to explore the referral process, referral types, waiting times and data collection for dementia diagnosis. The CCG are meeting with the STP Board to discuss the review and identify actions to improve the DDR and system processes and flow. • Ensure CWPT informs practices when patients have been identified with dementia at the memory clinic, (ongoing). • An action plan has been devised with Nuneaton and Bedworth Borough Council and stakeholders across Warwickshire North to become dementia friends and join DAA (Dementia Action Alliance). The action plan ensures and encourages people to see their Doctor if concerned about dementia in themselves, or relative, (ongoing).

Early Intervention in Psychosis (EIP)

CRCCG underachieved at 11% and WNCCG also underachieved at 50% against the EIP target which has risen to 53% for 2018/19.

Actions to Improve EIP performance

The December paper was re-presented to the CCG May F&P, outlining the details of statutory obligations and national expectations in meeting MH targets. It was agreed that this service is of clinical importance and a further discussion regarding additional investment was suggested. The contracting team requested an updated RAP for both EIP and IAPT targets, to ensure that available resource is deployed and utilised as much as possible, with detailed steps they will be undertaking to ensure that available resource is deployed and utilised as much as possible to enable the access target to be met. The plan includes actions against the following:

7

• To look at how transfers from EI to Recovery Teams are completed for patients whose clinical presentation is not in line with EI NICE guidance, although they need a psychosis service. • Waiting list – To manage the internal transfer process and capacity issues due to high caseloads. • To ensure that people who DNA are clinically assessed under the Trust’s Non-attendance Policy • There are currently three care coordinators on the CBTp training course. One has been covered by back fill but the caseloads of the other 2 in Coventry and North Warwickshire teams have to be absorbed by existing staff.

In June CRCCG committed to providing additional funding to support the recruitment of additional care co-ordinators to address these issues

IAPT CRCCG achieved against the IAPT access target in February, which has risen to an annualised figure of 16% for the fourth quarter. Whilst WNCCG marginally underachieved at 15.9%, it is expected to have achieved for the fourth quarter as a whole. Both CCGs achieved against the recovery rate target.

Activity Tracker

Year-on-year referrals growth figures have been distorted by the higher number of working days in April compared to last year.

CRCCG General and Acute Referrals were 8.2% above plan. The CCG was 12.6% above plan for GP referrals and 2.4% above plan for ‘other’ referrals.

On the basis of SUS data, non-elective activity for was 9.5% below target.

WNCCG General and Acute Referrals were 6.3% above plan. The CCG was 11.5% above plan for GP referrals and 0.1% below plan for ‘other’ referrals and the 12 month rolling average growth figure for GP referrals remains significantly lower than in April 2017.

On the basis of SUS data, non-elective activity for was 6.8% below target.

Delayed Transfers of Care for both CCGs continue to run very close to the 3.5% target level.

8

9

10

Indicators achieved by CRCCG in the latest period

Annual NHS Constitution Measures (Monthly) Target Apr-18

Patients waiting less than 6 weeks from referral for a diagnostic test 99% 99.5% %

12 Hour Trolley Waits (UHCW) 0 0

Annual NHS Constitution Measures (Quarterly) Target Q4

Cancer two week wait for first outpatient appointment for patients referred urgently with 93% 96.3% suspected cancer by a GP

Cancer two-week wait for first outpatient appointment for patients referred urgently with breast 93% 97.8% symptoms

Cancer one month (31-DAY) wait from diagnosis to first definitive treatment for all cancers 96% 99.2%

Cancer 31-day wait for subsequent treatment where that treatment is surgery 94% 100.0%

Cancer 31-day wait for subsequent treatment where that treatment is an anti-cancer drug 98% 100.0% regimen

Cancer 31-day wait for subsequent treatment where the treatment is a course of radiotherapy 94% 97.4%

Cancer two month (62-day) wait from urgent GP referral to first definitive treatment for cancer 85% 88.7%

Cancer 62-day wait from referral from an NHS screening service to first definitive treatment for all 90% 97.0% cancers

Cancer 62-day wait for first definitive treatment following a consultant's decision to upgrade the 85% 87.1% priority of the patient

Annual NHS Constitution Supporting Measures (Monthly) Target Apr-18

Operations Cancelled for a second time 0 0

Annual Mental Health Measures (Quarterly) Target Q4 Care Programme Approach (CPA): The proportion of people under adult mental illness specialties on CPA who were followed up within 7 days of discharge from psychiatric in-patient care during 95% 98.0% the period.

Annual Mental Health Measures (Monthly) Target Feb-18

IAPT 6 Weeks - First Treatment 75% 100%

IAPT 18 Weeks - First Treatment 95% 100%

IAPT Access 16% 16%

IAPT Recovery Rate 50% 51.5%

11

Indicators not acieved by CRCCG in the latest period

Compared with Annual previous NHS Constitution Measures (Monthly) Target Apr-18 month

Patients on incomplete non-emergency pathways waiting no more than 18 weeks from referral 99% 84.8% 

RTT > 52 weeks breaches - Incomplete Pathways 0 16 

Patients should be admitted, transferred or discharged within 4 hours of their arrival at an A&E 95% 90.4% department (UHCW) 

Compared with Annual previous NHS Constitution Supporting Measures (Monthly) Target Apr-18 month

Mixed Sex Accommodation Breaches 0 2 

Compared with Annual previous NHS Constitution Supporting Measures (Quarterly) Target Q4 quarter

All patients who have operations cancelled, on or after the day of admission for non-clinical 0 55 reasons to be offered another binding date within 28 days(UHCW). (Breach no.) 

Compared with Annual previous Mental Health Measures (Monthly) Target Apr-18 month

Dementia Diagnosis 67% 59.5%  Early Intervention in Psychosis 53% 11.0% 

12

13

14

Indicators achieved by WNCCG in the latest period

Annual NHS Constitution Measures (Monthly) Target Apr-18

Patients waiting less than 6 weeks from referral for a diagnostic test 99% 99.5% %

12 Hour Trolley Waits (UHCW) 0 0

Annual NHS Constitution Measures (Quarterly) Target Q4

Cancer two week wait for first outpatient appointment for patients referred urgently with 93% 98.6% suspected cancer by a GP Cancer two-week wait for first outpatient appointment for patients referred urgently with breast 93% 99.7% symptoms

Cancer one month (31-DAY) wait from diagnosis to first definitive treatment for all cancers 96% 98.1%

Cancer 31-day wait for subsequent treatment where that treatment is surgery 94% 97.0%

Cancer 31-day wait for subsequent treatment where that treatment is an anti-cancer drug 98% 100.0% regimen

Cancer 31-day wait for subsequent treatment where the treatment is a course of radiotherapy 94% 95.7%

Cancer 62-day wait from referral from an NHS screening service to first definitive treatment for all 90% 94.7% cancers

Cancer 62-day wait from referral from an NHS screening service to first definitive treatment for all 85% 87.5% cancers

Annual NHS Constitution Supporting Measures (Monthly) Target Apr-18

Operations Cancelled for a second time 0 0

Annual Mental Health Measures (Quarterly) Target Q4 Care Programme Approach (CPA): The proportion of people under adult mental illness specialties on CPA who were followed up within 7 days of discharge from psychiatric in-patient care during 95% 95.0% the period.

Annual Mental Health Measures (Monthly) Target Feb-18

IAPT 6 Weeks - First Treatment 75% 100%

IAPT 18 Weeks - First Treatment 95% 100%

IAPT Access 16% 16%

IAPT Recovery Rate 50 51..7

15

Indicators not achieved by WNCCG in the latest period

Annual Compared with NHS Constitution Measures (Monthly) Target Apr-18 previous month

Patients on incomplete non-emergency pathways waiting no more than 18 weeks from referral 99% 83.6% 

RTT > 52 weeks breaches - Incomplete Pathways 0 6  Patients should be admitted, transferred or discharged within 4 hours of their arrival at an A&E 95% 92.6%  department (UHCW)

Annual Compared with NHS Constitution Measures (Quarterly) Target Q4 previous quarter

Cancer two month (62-day) wait from urgent GP referral to first definitive treatment for cancer 85% 83.2% 

Annual Compared with NHS Constitution Supporting Measures (Quarterly) Target Q4 previous quarter

All patients who have operations cancelled, on or after the day of admission for non-clinical 3  reasons offered another binding date within 28 days(UHCW). (Breach no.)

Annual Compared with Mental Health Measures (Monthly) Target Apr-18 previous month

Dementia Diagnosis 67% 59.0% 

Early Intervention in Psychosis 53% 50.0% 

16

2 - CCG Quality Overview

17

1. Introduction

The Clinical Quality and Governance Committee in Common for Warwickshire North CCG and Coventry and Rugby CCG routinely receives comprehensive reports on the quality and safety of commissioned services based on a wide range of data and soft intelligence including contractual quality indicators, patient experience reports and learning and the impact on practice. This includes acute and community services, small providers both NHS and independent, nursing, residential homes and primary care. The committee also receives updates on safeguarding, infection prevention and control and transforming care issues.

This report provides a summary of escalated quality issues for the attention of the Governing Body. The following are also provided for information to Governing Body in the Provider Dashboard section of the main report:

. Quality Indicators Dashboards for Coventry and Warwickshire Partnership Trust (CWPT) . Quality Indicators Dashboards for University Hospitals Coventry and Warwickshire NHS Trust (UHCW) . Quality Indicators Dashboards for George Eliot Hospitals NHS Trust (GEH)

2. Items on Escalation

A new Quality Assurance Framework has been developed and this was supported by the Clinical Quality and Governance Committee in Common at the April meeting. An overview of the Quality Assurance Framework quality escalation levels is included as Appendix 2.

University Hospitals Coventry and Warwickshire NHS Trust

Items on Level 2 of the Quality Assurance Framework:

Dermatology Patients experiencing delays receiving their first Dermatology clinic appointments has significantly improved. The maximum wait for June 2018 was 10 weeks, an improvement from 17 weeks in March 2018. The Trust has confirmed that all referrals received are clinically prioritised. The Trust and the CCG continue to work collaboratively to communicate waiting times to Primary Care colleagues.

Items on Level 3 of the Quality Assurance Framework:

Urgent Clinic Letters sent within 7 days The CCG and Trust are in the process of undertaking a joint investigation to ensure a shared understanding of Trust processes and potential solutions available to support the achievement of this standard. The timescale for the delivery of the final report is the end of June 2018. The findings will be reported to the July CQRM. The CCG is assured robust processes are in place to identify any patient harm as a result of a delay in a clinic letter and no serious incidents have been reported to date.

Partial Booking System The CCG formally raised concerns with the Trust in relation to its internal management systems used to manage patient follow up appointments as a result of a serious incident. The CCG is utilising formal contractual mechanisms to gain robust assurance and confirmation of the

18

management plan to resolve this issue. An informal CQR meeting planned for July 5th 2018 has been escalated to a formal CQR meeting to facilitate a discussion in order to gain robust assurance in relation to the action plan in place, mitigation of risk, timeframe for improvement and processes in place to identify any patient harm.

Accident and Emergency Department (A&E) The Trust is not currently meeting the 4 hour target and the CCG has formally requested the Trust to conduct a review of Serious Incidents reported over the past twelve months and to provide the CCG with assurance that there are no key themes or trends directly related to the clinical care delivered within the department. This assurance is to be presented to the CCG at the end of July 2018. The department will remain on level 3 of the framework until the CCG has received robust assurance. The CCG also has plans to conduct a further unannounced visit in the next few months to validate any assurance provided by the Trust.

Ward 14 – Paediatric Ward Capacity Issues This concern has escalated to level 3 due to capacity issues relating to children and young people in crisis being cared for on the paediatric ward. A multi-agency group is working to develop alternative solutions to alleviate system pressures on Ward 14. A business case for a tier 3.5 service has also been developed.

Coventry and Warwickshire Partnership Trust

Items on Level 2 of the Clinical Governance Framework:

CQC Inspection A CQC inspection took place from 26 to 30 June 2017 and the final report was published on 8 November 2017. The CQC inspected a number of core mental health services and the overall rating given was ‘requires improvement’. A warning notice was issued to CWPT in relation to older people's services physical health. This has since been re-graded from ’inadequate’ to ‘requires improvement’ following a CQC revisit in November 2017.

The CQC action plan forms a standing agenda item at the CQRM and the CCG is assured that CWPT has robust governance arrangements in place to monitor the action plan. To test the robustness of completed actions, the Trust is planning a series of quality visits and the CCG will be invited to participate in the quality visits. The Trusts’ Chief Executive and Chief Nurse and Chief Operating Officer were invited to attend the CCGs’ Clinical Quality and Governance Committee in Common meeting in April to provide assurance regarding progress with improvements to address the CQC inspection findings.

CAMHS Waits The June 2017 Care Quality Commission (CQC) inspection found that there were long waiting times for children and young people to access treatment for mental health problems, identifying concerns relating to the triage of children and young people in mental health services and waiting times for access to treatment in neurodevelopment services. These services were rated as requires improvement by the CQC and a further announced visit to the CAMHS service is planned for the end of July 2018.

The following actions are in place:

19

o The CCG issued a contract performance notice in relation to CAMHS waiting times and also conducted a quality assurance visit. o A review of the assessment process is being undertaken. o The CAMHS element of the CQC action plan is included as a standing item for CQRM. o The CCG has been assured that children and families are offered a range of alternative support options whilst waiting and patients are regularly reviewed to assess their risk and prioritise patients by clinical need.

The percentage of routine CAMHS referrals receiving treatment within 18 weeks of referral in the fourth quarter rose above the 95% target to 97.6%, an improvement on the 94.5% for the third quarter. In the January to April 2018 period the average wait for the first appointment for CAMHS referrals ranged between 5 and 8 weeks.

Tissue Viability In response to a serious incident, the Trust has developed an action plan and initiated a review of wound care across Integrated Community Services. The action plan was presented to the March CQRM. The CCG is continuing to monitor this incident and action plan through the CQRM process. It was initially on the Quality Assurance Framework at a level three. Following receipt of the action plan this has been deescalated to level two. The CCG continues to triangulate information from complaints, serious incidents and other soft intelligence data sources.

George Eliot Hospital

Items on level 2 of the Quality Assurance Framework:

CQC Inspection A CQC inspection took place in October 2017, with the final report published on 25 January 2018. The overall rating was ‘Requires Improvement’ and three Requirement Notices were also issued by CQC. A Quality Oversight and Assurance Group has been set up to provide assurance to system stakeholders that associated clinical and quality risks are appropriately assessed and addressed. The CCG has membership of this group and also monitors the Trust’s improvement plan at CQRM.

Fragile Services - End of Life Care (EoLC) The Trust, CQC and the CCG have identified that the End of Life Care service faces particular challenges with recruitment. End of life care was rated as inadequate by CQC in January 2018. The Trust has provided assurance regarding the immediate actions in place to manage this service, together with processes in place to monitor and review the agreed actions. The Trust has been successful in its recruitment of an End of Life Consultant and a Lead Nurse and both are expected to be in post within the next couple of months. Recruitment of a second End of Life Consultant is underway. Actions in relation to End of Life Care form part of Trust’s Overall Improvement Plan in response to the CQC inspection. The CCG Quality team is planning a quality assurance visit of End of Life Care services at the Trust.

Vacancy Rates The Trust has ongoing recruitment and retention challenges and utilises bank and agency staff to support. The overall vacancy rate for the Trust has increased when compared to the previous year; with clarification provided that this is attributed to an adjustment between ESR and the Trust’s finance system. Further reconciliation between the two systems is being undertaken. The Trust

20

presents a safer nursing staffing report and regular updates on vacancies to the CCG at each CQRM.

PREVENT WRAP Training All NHS Trusts were set a target to achieve 85% compliance of the total workforce in Workshop to Raise Awareness of Prevent (WRAP) training by March 2018. GEH did not achieve this requirement and the Trust has a plan in place to achieve compliance by 30 September 2018. The CCG is represented by the Safeguarding Lead at the Trust’s Adult and Children Safeguarding Meeting where the trajectory is monitored internally. The trajectory and recovery plan is also included as a standing agenda item at CQRM.

Items on Level 3 of the Quality Assurance Framework:

Urgent and Emergency Services The Trust is not currently meeting the 4 hour target and has also reported a number of 12 hour trolley breaches. Urgent and Emergency services were rated as requires improvement by CQC in January 2018. The CCG quality team continue to monitor the quality of care delivery in A&E through the monthly CQRM and monitoring of Serious Incidents (SIs) reported by the Trust; with no incidents of patient harm being reported to date. The Chief Nursing Officer visited the A&E department on 27 February to walk through the patient pathway for adults and children. Actions in relation to Urgent and Emergency services form part of Trust’s Overall Improvement Plan in response to the CQC inspection. A further assurance visit to A&E, the Clinical Decision Unit and the paediatric assessment unit will be undertaken during July in partnership with NHSI and NHSE.

3. Other Providers

Cygnet Cygnet is a private provider of bedded specialist mental health services based in Coventry. A CQC inspection of Cygnet took place on 30 to 31 October 2017 and the final report was published on 29th January 2018. CQC rated the service as overall ‘requires improvement’. Cygnet was rated as being ‘good’ for effective and caring and ‘requires improvement’ for safe, responsive and well led. Issues were identified in relation to governance, an incident of patient absconsion and a high level of patient restraint being reported. Following the publication of the report the quality team met with Cygnet in May 2018 and gained assurance regarding the actions the provider is taking in response to the CQC report.

4. Primary Care Update

Coventry and Rugby CCG CQC has inspected the majority of Coventry and Rugby CCG practices. CQC inspection reports published within the past few months identify five practices as requiring improvement. The CCG is working with NHSE and the five practices to ensure that there are robust improvement plans in place.

Warwickshire North CCG There are currently no concerns raised at the Joint Commissioning Committee. All of the twenty- seven Warwickshire North practices have achieved an overall rating as good.

21

5. Care Homes

Coventry and Rugby CCG

There are 108 nursing and residential homes across Coventry and Rugby with a total of 3063 beds. Currently there are three Nursing Homes and one Residential Home that are on escalation. This accounts for 3% of the total provision across Coventry and Rugby.

Warwickshire North CCG

There are 67 nursing and residential homes across Warwickshire North with a total of 1583 beds. Currently there are four Nursing Homes and one Residential Home that is on escalation with a potential notice to close. The Quality team is working with the capacity and resilience lead to mitigate any quality or capacity impacts on the health system.

Pears Royal National Institute of Blind (RNIB)

Pears RNIB is a care and education facility for children and adolescents with complex health needs. Following an OFSTED inspection which provided a rating of inadequate; Ofsted issued a notice of closure to Pears for the residential component of the service. A further OFSTED inspection took place in March 2018 which satisfied OFSTED that Pears was making the required improvements and it was subsequently removed from “special measures”.

Care Quality Commission (CQC) visited Pears in April 2018 and put five conditions on its registration. There are no CRCCG or WNCCG residents placed within the home currently. WNCCG is the host for this residential provider for looked after children and is working collaboratively with Warwickshire County Council to review, support and monitor improvements. The Safeguarding Designated Professionals from CRCCG and WNCCG are supporting the newly appointed Clinical Lead and an action plan is in place.

Chasewood Lodge

Chasewood Lodge is a residential home which has two sites:

o McDonnell Drive with a total capacity of 107 beds and an overall CQC rating of “Requires Improvement” o School Lane with a total capacity of 26 beds and an overall CQC rating of “Good.”

There are concerns relating to areas of unsafe practice and Warwickshire County Council (WCC) has issued a notice of concern and a placement stop is in place. The CCG continues to work jointly with WCC and CQC.

Name Beds Details CQC Status Responsible CCG Nursing Homes Allambie Court 26 No current restrictions Inadequate WNCCG Report: Jan 2018 Coundon 74 Voluntary placement stop Inadequate CRCCG Manor Report: Dec 2018

22

Evedale 64 Voluntary placement stop Requires CRCCG Improvement Report: Jan 2018 Harmony 35 No current restrictions Requires WNCCG House Not on framework Improvement Report: Nov 2017 Haven 70 No current restrictions Requires WNCCG Improvement Report: Aug 2017 Keresley 47 Restricted admissions, two Requires CRCCG Wood per week Improvement Report: Aug 2017 Oldbury 86 No current restrictions Requires WNCCG Grange Not on framework Improvement Report: Nov 2017 Residential Homes Chasewood 107 Enforced placement stop Requires WNCCG Lodge by WCC Improvement Report: January 2018 The Langleys 15 Voluntary placement stop Inadequate CRCCG in place Report: May 2018

23

3 - Provider Level Performance and Quality

24

25

26

27

28

29

30

WMAS – Ambulance Response Programme

Category 1 Oct '17 Nov '17 Dec '17 Jan '18 Feb '18 Mar '18 Apr '18 Mean 7:00 90th 15:00 Inc Total Mean 90th Inc Total Mean 90th Inc Total Mean 90th Inc Total Mean 90th Inc Total Mean 90th Inc Total Mean 90th Inc Total Mean 90th Cov & Rug CCG 527 06:51 11:41 546 06:14 10:58 444 07:19 13:20 412 06:50 11:49 399 06:56 11:59 358 06:58 11:41 331 06:21 10:51 Warks North CCG 191 07:15 11:56 194 07:00 12:35 194 06:53 11:51 183 07:30 12:35 157 07:32 12:33 158 08:21 14:46 153 07:27 13:22 South Warks CCG 214 08:18 15:05 198 08:20 14:33 198 08:27 15:54 183 08:26 15:12 172 09:04 14:53 162 09:06 16:53 155 07:53 13:36 West Mids 6,666 06:41 11:19 7,143 06:47 11:41 6,040 07:04 12:11 5,548 06:48 11:44 4,968 07:03 12:06 5,209 07:10 12:31 4,731 06:50 12:04

Oct '17 Nov '17 Dec '17 Jan '18 Feb '18 Mar '18 Apr '18 Category 2 Mean 18:00 90th 40:00 Inc Total Mean 90th Inc Total Mean 90th Inc Total Mean 90th Inc Total Mean 90th Inc Total Mean 90th Inc Total Mean 90th Inc Total Mean 90th Cov & Rug CCG 2,550 11:42 22:18 2,497 11:36 21:21 2,986 13:35 26:10 3,049 12:43 23:51 2,718 14:28 27:40 2,970 14:33 28:29 2,602 10:22 19:06 Warks North CCG 1,127 13:55 27:11 1,093 14:28 27:48 1,264 15:37 30:27 1,323 14:06 02:14 1,232 14:48 27:49 1,272 15:22 29:54 1,070 11:52 22:02 South Warks CCG 1,281 15:21 27:43 1,217 14:45 27:38 1,471 15:36 29:18 1,457 15:06 02:52 1,412 16:43 30:44 1,478 16:31 30:57 1,249 13:20 23:38 West Mids 35,629 11:39 21:09 35,298 11:58 21:36 41,688 13:13 24:16 42,458 12:22 22:26 37,719 13:14 24:22 40,958 14:17 26:48 36,659 11:24 20:24 Category 3 Oct '17 Nov '17 Dec '17 Jan '18 Feb '18 Mar '18 Apr '18 90th 120:00 Inc Total Mean 90th Inc Total Mean 90th Inc Total Mean 90th Inc Total Mean 90th Inc Total Mean 90th Inc Total Mean 90th Inc Total Mean 90th Cov & Rug CCG 2,729 30:23 72:17 2,642 26:28 59:31 2,773 38:34 91:12 2,538 36:09 86:57 2,313 42:48 98:33 2,452 40:27 99:35 2,374 21:21 48:01 Warks North CCG 1,210 27:49:00 63:14 1,186 27:46:00 60:28 1,170 36:58 86:36 1,187 34:13 80:22 1,056 40:22 90:03 1,157 38:13 89:23 1,080 22:37 49:13 South Warks CCG 1,592 25:54:00 55:37 1,522 25:22:00 56:16 1,689 35:05 78:24 1,530 30:26 68:20 1,374 34:14 75:40 1,448 31:28 66:45 1,446 22:48 48:25 West Mids 35,850 28:40:00 64:15 34,922 29:58:00 67:16 36,405 39:51 92:57 34,914 35:19 82:49 30,876 41:35 96:47 33,150 42:53 102:21 33,298 25:37 55:17

31

32

33

34

South Warwickshire Foundation Trust: Divisional Dashboard KPIs

35

Section 4 – Activity Tracker

36

37

38

39

40

Appendices

41

Appendix 1 – Providers contract performance notices and sanctions applied

Contract Performance Date Issued Milestones Expected Recovery Date Notice George Eliot Hospital NHS Trust (GEH) Cancer 62 day wait from Remedial Action Plan urgent GP referral to has been received and March 2018 first definitive treatment 12th December 2017 is being monitored via Recovery achieved – for cancer regular monthly Performance Notice Closed meetings. Patients should be Remedial Action Plan admitted, transferred or has been received and discharged within 4 12th December 2017 is being monitored via March 2019 hours of their arrival at regular monthly an A & E department. meetings.

Contract Date Issued Milestones Expected Recovery Performance Date Notice Coventry and Warwickshire Partnership NHS Trust CAMHS waiting time 31st October 2017 Performance Notice Issued. End of July 2018 from initial Commissioners received a appointment to follow revised trajectory in May 2018 up appointments 12 and Remedial Action Plan weeks (Coventry outlining the actions being patients) taken to achieve the trajectory and deliver improvement of the target at a CCG level, which it will review. Achievement of the trajectory has been recalculated for CRCCG to the end of July 2018 and for WNCCG by the end of April 2018. Validated May 2018 data shows that 67% of patients in CRCCG are waiting less than 12 weeks against a target of 95%.

Performance against the RAP and trajectory is being closely monitored through the contractual process. A representative from CRCCG and SWCCG attends the fortnightly waiting times meetings held by the Trust. The CCG review an update on the trajectory on a monthly basis at the Contract Technical Meeting. CRCCG are working closely with WCC regarding the Warwickshire CAMHS contract (including Rugby) to monitor performance and the issuing of any Performance Notices

42

Contract Date Issued Milestones Expected Recovery Performance Date Notice University Hospital Coventry and Warwickshire NHS Trust Accident and 30th June 2017 Contract Management Meeting To be confirmed Emergency 4 hour wait took place on 11th July 2017; the trust should provide a Remedial Action Plan within 5 working days. Referral to Treatment 30th June 2017 Contract Management Meeting 2018/19. The CCG within 18 weeks - took place on 11th July 2017; a continues to work with the Incomplete Pathways Remedial Action Plan has Trust to confirm the exact been received and is being timescale for recovery and monitored via regular monthly sustainability of the target. meetings. March 2018: A revised remedial action plan and trajectory has been received from the Trust and this will be monitored via regular monthly meetings Zero tolerance RTT 30th June 2017 Contract Management Meeting 2018/19. The CCG waits over 52 weeks took place on 11th July 2017, continues to work with the for incomplete Remedial Action Plan received Trust to confirm the exact pathways and being monitored via timescale for recovery and regular monthly meetings. sustainability of the target. March 2018: A revised remedial action plan and trajectory has been received from the Trust and this will be monitored via regular monthly meetings. All Outpatient clinic 19th April 2018 Contract Management Meeting To be confirmed once Joint letters (where the took place on 1st May 2018, Investigation is complete. Service User's ongoing draft improvement plans care and treatment received 4th May 2018 to would necessitate the inform the key lines of enquiry Service User's GP for a Joint Investigation. taking prompt action) Updated improvement plans to to be sent within 10 be shared with CCG for calendar days (7 days discussion at CQRG on 31st from 1st April 2018) May 2018 following the Service User's outpatient attendance.

43

Appendix 2

Quality Escalation Matrix

Escalation Criteria Level of risk Actions for consideration Reports to level

Level Zero All KPIs are being Negligible • Monitor KPIs CCG Quality meeting achieved/within trajectory

Level One Minor concern/s Minor Level Zero, plus: Quality meeting • Risk assess Informal CQRM • Share at informal CQRM Level Two Moderate concern/s Moderate Level One, plus: CQRM • Consider quality assurance visit/deep dive CQGC • Request action plan Governing Body • Agree trajectory for improvement Risk Register • Escalate to CQRM • Exception report to CPPM

Level Three Major concern/s High Level Two, plus: CQRM • Undertake quality assurance visit / deep dive CQGC • Raise contract query Governing Body • Escalate to joint quality contracting meeting QSG • Consider performance notice Risk Register • Consider inviting executive team to CQGC to provide assurance Level Four Extreme concern/s Catastrophic Level Three, plus: CQRM • Independent review/Appreciative enquiry CQGC • Consider Risk Summit Governing Body • Inform CQC and other regulatory bodies QSG • Invite provider executive team to CQGC to provide Risk Register assurance

44

Appendix 3 – Abbreviations used in this report – alphabetical list

A&E Accident and Emergency Department

AMHs Adult Mental Health Services

AMU Acute Medical Unit

BCF Better Care Fund

CAMHs Children and Adolescents Mental Health Services

CCG Clinical Commissioning Group

Cf & P Commissioning, Finance & Performance Committee

CPA Care Programme Approach

CQGC Clinical Quality and Governance Committee

CQSG Clinical Quality, Safety and Governance Committee

CT Computed Tomography scan

C&RCCG Coventry and Rugby Clinical Commissioning Group

CWPT C Coventry and Warwickshire Partnership NHS Trust

ED Emergency Department

EMAS East Midlands Ambulance Service NHS Trust

ENT Ear Nose and Throat

F & P Finance & Performance Committee

GEH George Eliot Hospital NHS Trust

GP General Practitioner

HEFT Heart of England NHS Foundation Trust

HSMR Hospital Standardized Mortality Ratio

IAPT Improving Access to Psychological Therapies

KPI Key Performance Indicator

45

NHS National Health Service

POD Point of Delivery

PSA Prostate-specific antigen

RAP Remedial Action Plan

RCA Root Cause Analysis

ROH The Royal Orthopaedic Hospital NHS Foundation Trust

RTT Referral to Treatment

SDIP Service Development and Improvement Plan

SHMI Summary Hospital-Level Mortality Indicator

STF Sustainability and Transformation Fund

SWCCG South Warwickshire Clinical Commissioning Group

SWFT South Warwickshire NHS Foundation Trust

TRUS Transrectal ultrasound guided biopsy

UHCW University Hospitals Coventry and Warwickshire NHS Trust

WHO World Health Organization

WIC Walk-In-Centre

WMAS West Midlands Ambulance Service NHS Foundation Trust

WNCCG Warwickshire North Clinical Commissioning Group

46

NHS Coventry & Rugby Clinical Commissioning Group Enc L

Report To: Governing Body Meetings in Common

Report Title: Finance & Contracting Report – Month 2

Report From: Clare Hollingworth, Chief Finance Officer

Date: 12th July 2018

Previously Considered by: Finance and Performance Committee, 28th June 2018

Action Required (delete as appropriate)

Decision: Assurance:  Information:  Confidential

Purpose of the Report: To advise Members of the financial position of the CCG up to 30th May 2018 (Month 2 – 2018/19) and to advise of any other financial issues likely to impact in the current financial year.

Key Points: At this early stage in the year, the CCG is reporting an overall balanced position for Month 2 in line with the agreed financial plan. The key points to note are:

• Budgets have been set to reflect anticipated expenditure less the impact of QIPP schemes. At this stage in the year, it is reasonable to assume the budgets are achievable; there are, however, a range of business as usual risks to be managed and these are reflected in the reported net risk position.

• With the above caveat, at Month 2 the CCG is forecasting an in-year breakeven position against its notified allocation which is in accordance with the Plan agreed with NHS England. This is then increased by the brought forward combined surplus of £6.0m carried forward from 2017/18 to reach an anticipated cumulative surplus of £6.0m by year end.

• The overall Year to Date cumulative position is marginally underspent against the planned break even target.

• The Acute position is reported as breakeven due to the paucity of reliable monitoring data at this stage of the financial year. At the time of reporting only un-validated month 1 monitoring data is available. As always at the start of the financial year, there are numerous data issues to be resolved with Providers.

• QIPP has been identified and schemes are in place; split between 85% Recurrent and 15% Non Recurrent. The CCG is currently reporting that QIPP delivery is on target both year to date and forecast outturn. However delivery risks are being assessed through the Programme Assurance meetings and the early indication is that the CCG faces a minimum 14% underachievement prior to any mitigating action. Given the previous year’s slippage in delivery of recurrent QIPP savings there remains a significant risk of further QIPP under performance if robust mitigations cannot be implemented.

• Running costs are forecast as in balance, with a slight underspend year to date due to vacancies.

• Achievement of the current Plan should enable the CCG to exit 2018/19 with an underlying surplus of £347k.

• At this early stage in the year, the QIPP risk is being highlighted to the Governing Body by Finance & Performance Committee.

Page 1 of 2

NHS Coventry & Rugby Clinical Commissioning Group Enc L

Recommendation: Members are asked to: • NOTE the reported overall position for month 2; and • NOTE the areas highlighted that have been escalated to the Governing Body.

Implications

Objective(s) / Plans supported by this QIPP Programme Delivery; Financial Plan Delivery report: Conflicts of Interest: Not applicable

Non-Recurrent Expenditure: Variance to Plan likely to emerge at Month 3 as Recurrent Expenditure: more data becomes available. Financial: Is this expenditure included within the CCG’s Financial Yes  No N/A Plan? (Delete as appropriate) Delivery of QIPP supports the assurance and financial performance of the Performance: organisation. Risk to the statutory duty to meet control total. Quality and Safety: Not directly applicable General Statement: The CCG is committed to fulfil its obligations under the Equality Act 2010, and to ensure services commissioned by the CCG are non-discriminatory on the grounds of any protected characteristics. Policies/decisions may need to be adjusted in line with any equality analysis or due regard. Any decision that is finalised Equality and Diversity: without being influenced by appropriate due regard could be deemed unlawful. Has an equality impact Yes assessment been undertaken? No N/A  (attached) (Delete as appropriate) Patient and Public Not applicable Engagement: Clinical engagement imperative to the efficient deployment of NHS resources and Clinical Engagement: successful delivery of service redesign. HIGH – significant risk that the CCG will not be able to maintain its reported neutral Risk and Assurance: net risk position

Page 2 of 2

Finance and Contract Report Month 2

1 Contents

1. Executive Summary 3-7 Highlights Recommendations Financial Duties Trends 2. Financial and Contractual Management 8-11 Summary Financial Position QIPP – Financial Position

2 1. Executive Summary

3 1.1 Headlines

At this early stage in the year, the CCG is reporting an overall balanced position for Month 2 in line with the agreed financial plan. The key points to note are:

• Budgets have been set to reflect anticipated expenditure less the impact of QIPP schemes. At this stage in the year, it is reasonable to assume the budgets are achievable; there are, however, a range of business as usual risks to be managed.

• With the above caveat, at Month 2 the CCG is forecasting an in-year breakeven position against its notified allocation which is in accordance with the Plan agreed with NHS England . This is then increased by the brought forward combined surplus of £6.0m carried forward from 2017/18 to reach an anticipated cumulative surplus of £6.0m by year end.

• The overall Year to Date cumulative position is marginally underspent against the planned break even target.

• The Acute position is reported as breakeven due to the paucity of reliable monitoring data at this stage of the financial year. At the time of reporting only un-validated month 1 monitoring data is available. As always at the start of a financial year, there are numerous data issues to be resolved with Providers.

• QIPP has been identified and schemes are in place; split between 85% Recurrent and 15% Non Recurrent. The CCG is currently reporting that QIPP delivery is on target both year to date and forecast outturn. However delivery risks are being assessed through the Programme Assurance meetings and the early indication is that the CCG faces a minimum 14% underachievement prior to any mitigating action. Given the previous year’s slippage in delivery of recurrent QIPP savings there remains a significant risk of further QIPP under performance if robust mitigations cannot be implemented.

• Running costs are forecast as in balance, with a slight underspend year to date due to vacancies

• Achievement of the current Plan should enable the CCG to exit 2018/19 with an underlying surplus of £347k.

• At this early stage in the year, the QIPP risk is being highlighted to the Governing Body by Finance & Performance Committee.

4

Headlines

Further work is being undertaken on the following areas:

• Providing assurance on QIPP scheme achievement through the Programme Assurance Meetings. • Recruitment to funded vacancies within Delivery teams (CHC and Medicines Management). • Resolution of Month 1 data queries • CHC data quality

1.2 Recommendations

Members are asked to:

• Note the overall balanced position for Month 2; and

• Note the areas highlighted that have been escalated to the Governing Body.

5

1.3 Financial Duties

In Month YTD Description of Financial Duties Target Variance Variance RAG Explanation RAG RAG

Ensure revenue expenditure does not exceed the The CCG has an agreed annual financial plan with NHS England with a cumulative control total of £6m Statutory duty to breakeven Green Green agreed allocation surplus and an in year breakeven position. The CCG is currently on plan to achieve these control totals.

Maintain expenditure within the revenue resource limit Position greater than or equal to The overall CCG position remains in balance. The CCG has fully identified its QIPP schemes and is Green Green and deliver against NHS England agreed control total Plan reported under plan year to date and forecast to meet its control total. Cash Drawdown less than or Maintain expenditure within the allocated cash limit Green Green The CCG is within the monthly cash target, and had a remaining cash balance of £86k. equal to Plan Maintain capital expenditure within the delegated limit Expenditure less than or equal Green Green The CCG capital expenditure is within its capital allocation limits. from NHS England to Plan Expenditure less than or equal Running costs are underspent year to date. Forecast Outturn underspend to show QIPP achievement and Ensure running costs are within the agreed allocation Green Green to Plan Vacant Posts

The CCG has not utilised any of its contingency in Month 2. The total budget of £3.1m is available to offset Ensure a minimum of 0.5% contingency is held Greater than or equal to 0.5% Green Green emerging risks during the financial year. Ensure that 1% of funds are held uncommitted unless The CCG has committed half of the 1% non recurrently as directed and is no longer required the remaining Greater than or equal to 1% Green Green agreed to be released by NHS England balance uncommitted. Ensure compliance with the better payment practice Greater than or equal to 95% by The CCG continues to comply with the Better Payment Practice Code (BPPC) for both NHS and Non-NHS Green Green code (BPPC) Number/Value validated invoices.

RAG Rating Not achieving financial duty and Red unlikely to without remedial action. Based upon current information Amber there is a risk that the financial duty will not be achieved. Green Achieving financial duty

6 1.4 Trends

Annual Plan Month 2 Position Year to date (YTD) Forecast Outturn (FOT) £m % RRL £m % RRL Gross Net Gross Net Service Area Income Income Year to Date Cummulative (underspend) / deficit (1.0) (0.4%) (1.2) (0.5%) expenditure expenditure expenditure expenditure £000s £000s £000s £000s £000s £000s In-year (underspend) / deficit - forecast 0.0 0.0% 0.0 0.0% Programme Costs 106,747 (322) 106,425 670,562 (1,858) 668,704 B/f Surplus 6.0 2.5% 6.0 2.5% Running Costs 1,493 (19) 1,474 9,808 (116) 9,692 Cumulative (underspend) / deficit - forecast 6.0 2.5% 6.0 2.5% 1% Non-Recurrent Reserve 1,163 0 1,163 5,802 0 5,802 Underlying (underspend) / deficit - forecast 0.0 0.0% Grand Total 109,403 (341) 109,062 686,172 (1,974) 684,198

Monthly Cash Drawdown PLAN CCG Opening Cash Total Cash Cash Balance Drawdown CCG Cash Available Net Spend Balance Period £000s £000s Drawdown £000s £000s £000s £000s April 85 82,200 82,200 82,285 81,693 592 May 592 44,700 44,700 45,292 45,255 37 June 37 - July - - August - - September - - October - - November - - December - - January - - February - - March - - Total CCG Cash Drawdown 126,900 NHSBA Cash Drawdown 9,637 Total Drawdown 136,537 Based on year to date data there are no trend issues on

Maximum Cash Drawdown (MCD) 683,123 113,853.79 - 22,683 monthly run rate or in-year positions to highlight. - 22,683 % of MCD utilised 20.0% % of months completed 16.7% The CCG’s total cash balance at the end of May was £37k, which is below the acceptable limit of £558k

7 2. Financial and Contractual Management

8 2.2 Summary Financial Position vs Annual Plan

YEAR TO DATE FORECAST PRIOR MONTH FORECAST (Under) / (Under) / Original Annual Forecast % RAG % Budget Actual Over Over M1 Diff Budget Budget Actuals Variance Rating Variance spend spend £000s £000s £000s £000s £000s £000s £000s £000s £000s

Acute Healthcare 333,259 333,259 51,237 51,237 0 333,259 0 0.0% 333,259 0.0% Non Acute Healthcare 173,505 173,505 28,992 28,993 1 173,505 0 0.0% 173,505 0.0% Primary Care 67,988 67,988 10,790 10,790 0 67,988 0 0.0% 67,988 0.0% Delegated Co-Commissioning 68,161 68,161 11,360 11,360 0 68,161 0 0.0% 68,161 0.0% Other Programme 25,791 25,791 4,099 4,045 (54) 25,791 0 0.0% 25,791 0.0%

Total Commissioning Budgets 668,704 668,704 106,478 106,425 (53) 668,704 0 0.0% 668,704 0.0%

General Reserves 2,722 2,722 1,163 1,163 0 2,722 0 0.0% 2,722 0.0% 0.5% Contingency 3,080 3,080 0 0 0 3,080 0 0.0% 3,080 0.0%

Total Programme Budgets 674,506 674,506 107,641 107,588 (53) 674,506 0 0.0% 674,506 0.0%

Running Cost Allowance (RCA) 9,692 9,692 1,619 1,474 (145) 9,692 0 0.0% 9,692 0.0%

Total Expenditure 684,198 684,198 109,260 109,062 (198) 684,198 0 0.0% 684,198 0.0%

Total CCG Allocation 690,198 690,198 110,260 110,260 0 690,198 0 0.0% 690,198 0.0%

(Under)/Over spend (6,000) (6,000) (1,000) (1,198) (198) (6,000) 0 0.0% (6,000) 0.0%

• At Month 2, the CCG is forecasting a cumulative year-end breakeven position against its notified allocation which is in accordance with its NHS England agreed in-year deficit plan.

• The overall year to date position is delivering marginally above the planned surplus of £1.0m at Month 2.

• Due to the paucity of reliable monitoring data at this stage of the financial year, all Programme areas are reported as breakeven.

• Running Cost Allowance (RCA) forecast expenditure is currently in line with the notified allocation of £9.69m

9 2.13 QIPP – Financial Position

YTD Outturn Outturn Current Risk Plan Actual Var Plan Actual Var % Delivery

Elective Care £446,037 £446,037 £0 £4,127,996 £4,127,996 £0 100% £844,372

Urgent Care £101,004 £101,004 £0 £1,325,734 £1,325,734 £0 100% £0

CHC / Personalised Care £615,434 £615,434 £0 £4,527,516 £4,527,516 £0 100% £920,000

Prescribing £526,754 £526,754 £0 £2,975,236 £2,975,236 £0 100% £0

Primary Care £205,103 £205,103 £0 £2,952,284 £2,952,284 £0 100% £1,066,053

Other £782,500 £782,500 £0 £4,695,000 £4,695,000 £0 100% £0

GRAND TOTAL £2,676,832 £2,676,832 £0 £20,603,766 £20,603,766 £0 100% £2,830,425

• The 2017/18 QIPP target of £10.58m is allocated across five key programme areas and other transactional schemes.

• This target is as per the CCG’s financial plan submission and agreed with NHSE.

• QIPP schemes are split 85% Recurrent and 15% Non Recurrent.

Risk - 14% risk

• Elective Care – Engagement and negotiation of pathways with Trusts is causing potential slippage to most schemes. A 20% risk has been assumed for all schemes.

• Personalisation – Early data indicates that Growth has yet to be contained; with growth reported above previous outturn levels. Staff vacancies are also contributing to the risk of under-achievement.

• Out of Hospital – delays in implementation and a review of the way the scheme is to be achieved. A 30% risk has been assumed due to this.

• All other schemes have a level of assurance on initial position, but have further work to ensure delivery

10 QIPP

The graphs below show performance by each programme plan, a cumulative position and year to date QIPP performance against the QIPP profile and a straight line profile

£446,037 Elective Care Monthly £ Performance

£2,500,000 Urgent Care £101,004

PrescribingCHC£2,000,000 / Personal£615,4345 6,754

Primary Care £205,103 £1,500,000 , QIPP Programme Plan 2018/19 (£'000)

£1,000,000

£500,000 £446,037 £782,500 £0 Elective Care Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar £101,004

QIPP - plan QIPP - actual QIPP - Forecast Urgent Care

Monthly £ Performance Personalised Care / (plan in straight 12ths) £615,434 Mental Health £205,103 £2,500,000 Primary Care

£2,000,000 £526,754 Other

£1,500,000

£1,000,000

£500,000

£0 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

QIPP - plan (12ths) QIPP - actual QIPP - Forecast

11 Blank Page

12 NHS Warwickshire North Clinical Commissioning Group Enc M

Report To: Governing Body Meetings in Common

Report Title: Finance & Contracting Report – Month 2

Report From: Clare Hollingworth, Chief Finance Officer

Date: 12th July 2018

Previously Considered by: Finance and Performance Committee, 28th June 2018

Action Required (delete as appropriate)

Decision: Assurance:  Information:  Confidential

Purpose of the Report: To advise Members of the financial position of the CCG up to 30th May 2018 (Month 2 – 2018/19) and to advise of any other financial issues likely to impact in the current financial year.

Key Points: At this early stage in the year, the CCG is reporting an overall balanced position for Month 2 in line with the agreed financial plan. The key points to note are:

• Budgets have been set to reflect anticipated expenditure less the impact of QIPP schemes. At this stage in the year, it is reasonable to assume the budgets are achievable; there are, however, a range of business as usual risks to be managed.

• With the above caveat, at Month 2 the CCG is forecasting an in-year deficit of £1m against its notified allocation which is in accordance with the Plan agreed by NHS England. This is then increased by the brought forward combined deficit of £17.9m carried forward from 2017/18 to reach an anticipated cumulative deficit of £18.9m.

• The overall Year to Date cumulative position is in line with the planned deficit of £3.2m.

• The Acute position is reported as breakeven due to the paucity of reliable monitoring data at this stage of the financial year. At the time of reporting only un-validated month 1 monitoring data is available. As always at the start of the financial year, there are numerous data issues to be resolved with Providers.

• QIPPs have been identified to the required value. The CCG is currently reporting that QIPP delivery is on target both year to date and forecast outturn. However delivery risks are being assessed through the Programme Assurance meetings and the early indication is that the CCG faces a minimum 8% underachievement prior to any mitigating action. Given the previous year’s slippage in delivery of recurrent QIPP savings, there remains a significant risk of further QIPP under performance if robust mitigations cannot be implemented.

• Running costs are forecast as in balance, with a slight underspend year to date due to vacancies.

• Achievement of the 2018/19 Plan should enable the CCG to exit 2018/19 with an underlying deficit of £1.3m

• At this early stage in the year, the QIPP risk is being highlighted to the Governing Body by Finance & Performance Committee.

Page 1 of 2

NHS Warwickshire North Clinical Commissioning Group Enc M

Recommendation: Members are asked to: • NOTE the reported overall position for month 2; and • NOTE the areas highlighted that have been escalated to the Governing Body.

Implications

Objective(s) / Plans supported by this QIPP Programme Delivery; Financial Plan Delivery report: Conflicts of Interest: Not applicable

Non-Recurrent Expenditure: Variance to Plan likely to emerge at Month 3 as Recurrent Expenditure: more data becomes available. Financial: Is this expenditure included within the CCG’s Financial Yes  No N/A Plan? (Delete as appropriate) Delivery of QIPP supports the assurance and financial performance of the Performance: organisation. Risk to the statutory duty to meet control total. Quality and Safety: Not directly applicable General Statement: The CCG is committed to fulfil its obligations under the Equality Act 2010, and to ensure services commissioned by the CCG are non-discriminatory on the grounds of any protected characteristics. Policies/decisions may need to be adjusted in line with any equality analysis or due regard. Any decision that is finalised Equality and Diversity: without being influenced by appropriate due regard could be deemed unlawful. Has an equality impact Yes assessment been undertaken? No N/A  (attached) (Delete as appropriate) Patient and Public Not applicable Engagement: Clinical engagement imperative to the efficient deployment of NHS resources and Clinical Engagement: successful delivery of service redesign. HIGH – significant risk that the CCG will not be able to maintain its reported neutral Risk and Assurance: net risk position

Page 2 of 2

Finance and Contract Report Month 2 Contents

1. Executive Summary 3-7 Highlights

Recommendations Financial Duties Trends 2. Financial and Contractual Management 8-11 Summary Financial Position QIPP – Financial Position 1. Executive Summary 1.1 Headlines

At this early stage in the year, the CCG is reporting an overall balanced position for Month 2 in line with the agreed financial plan. The key points to note are:

• Budgets have been set to reflect anticipated expenditure less the impact of QIPP schemes. At this stage in the year, it is reasonable to assume the budgets are achievable; there are, however, a range of business as usual risks to be managed.

• With the above caveat, at Month 2 the CCG is forecasting an in-year deficit of £1m against its notified allocation which is in accordance with the Plan agreed by NHS England. This is then increased by the brought forward combined deficit of £17.9m carried forward from 2017/18 to reach an anticipated cumulative deficit of £18.9m.

• The overall Year to Date cumulative position is in line with the planned deficit of £3.2m.

• The Acute position is reported as breakeven due to the paucity of reliable monitoring data at this stage of the financial year. At the time of reporting only unvalidated month 1 monitoring data is available. As always at the start of the year, there are numerous data issues to be resolved with Providers.

• QIPP has been identified and schemes are in place. The CCG is currently reporting that QIPP delivery is on target both year to date and forecast outturn. However delivery risks are being assessed through the Programme Assurance meetings and the early indication is that the CCG faces a minimum 8% underachievement prior to any mitigating action. Given the previous year’s slippage in delivery of recurrent QIPP savings, there remains a significant risk of further QIPP under performance arising if robust mitigations cannot implemented.

• Running costs are forecast as in balance, with a slight underspend year to date due to vacancies.

• Achievement of the current Plan should enable the CCG to exit 2018/19 with an underlying deficit of £1.3m

• At this early stage in the year, the QIPP risk is being highlighted to the Governing Body by Finance & Performance Committee.

Headlines

Further work is being undertaken on the following areas:

• Providing assurance on QIPP scheme achievement through the Programme Assurance Meetings • Recruitment to funded vacancies within Delivery teams (CHC and Medicines Management). • Resolution of Month 1 data queries • CHC data quality

1.2 Recommendations

Members are asked to:

• Note an overall balanced position for month 2 is reported due to the paucity of reliable contract monitoring data

• Note the areas highlighted that have been escalated to the Governing Body.

1.3 Financial Duties

In Month YTD Description of Financial Duties Target Variance Variance RAG Explanation RAG RAG The CCG has an agreed annual financial plan with NHS England with a cumulative control total of £18.98m Ensure revenue expenditure does not exceed the Statutory duty to breakeven Red Red deficit and an in year deficit plan of £1m. The CCG is currently on plan to achieve these control totals agreed allocation however will not meet its statutory duty to breakeven. Maintain expenditure within the revenue resource limit Position greater than or equal to The overall CCG position remains in balance. The CCG has fully identified its QIPP schemes and is Green Green and deliver against NHS England agreed control total Plan reported under plan year to date and forecast to meet its control total.

Cash Drawdown less than or Maintain expenditure within the allocated cash limit Green Green The CCG is within the monthly cash target, and had a remaining cash balance of £86k. equal to Plan

Maintain capital expenditure within the delegated limit Expenditure less than or equal Green Green The CCG capital expenditure is within its capital allocation limits. from NHS England to Plan

Expenditure less than or equal Running costs are underspent year to date. Forecast Outturn underspend to show QIPP achievement and Ensure running costs are within the agreed allocation Green Green to Plan Vacant Posts

The CCG has not utilised any of its contingency in Month 2. The total budget of £1.2m is available to offset Ensure a minimum of 0.5% contingency is held Greater than or equal to 0.5% Green Green emerging risks during the financial year.

Ensure that 0.5% of funds are held uncommitted The CCG has committed half of the 1% non recurrently as directed and is no longer required the remaining Greater than or equal to 0.5% Green Green unless agreed to be released by NHS England balance uncommitted.

Ensure compliance with the better payment practice Greater than or equal to 95% by Amber Amber The CCG does not comply with the Better Payment Practice Code (BPPC) for Non-NHS validated invoices. code (BPPC) Number/Value

RAG Rating

Not achieving financial duty and Red unlikely to without remedial action.

Based upon current information Amber there is a risk that the financial duty will not be achieved.

Green Achieving financial duty 1.4 Trends

Year to date (YTD) Forecast Outturn (FOT) Gross Net Gross Net Annual Plan Month 2 Position Income Income Service Area expenditure expenditure expenditure expenditure £m % RRL £m % RRL £000s £000s £000s £000s £000s £000s Year to Date Cummulative (underspend) / deficit 3.2 1.3% 3.2 1.3% Programme Costs 42,555 (352) 42,203 266,624 (1,194) 265,430 In-year (underspend) / deficit - forecast 1.0 0.4% 1.0 0.4% Running Costs 639 (4) 635 3,996 (35) 3,961 B/f Deficit 18.0 7.6% 18.0 7.6% 1% Non-Recurrent Reserv 0 0 0 67 0 67 Grand Total 43,194 (356) 42,838 270,687 (1,229) 269,458 Cumulative (underspend) / deficit - forecast 19.0 8.0% 19.0 8.0% Underlying (underspend) / deficit - forecast 1.0 0.4% (Surplus)/ deficit 1,000

Monthly Cash Drawdown PLAN CCG Opening Cash CCG Cash Total Cash Cash Monthly Expenditure Run Rate Balance Drawdown Drawdown Available Net Spend Balance Period £000s £000s £000s £000s £000s £000s 25,000 April 104 21,900 21,900 22,004 21,912 92 May 92 19,300 19,300 19,392 19,372 20 20,000 June 20 22,000 - July - 21,300 - 15,000 17/18 actual August - 20,250 - 10,000 18/19 actual September - 20,235 - £000's October - 21,357 - 5,000 18/19 plan November - 20,168 - December - 20,168 - 0

January - 21,318 - Jul Oct Apr Jan Jun Mar Feb Nov Dec Aug Sep February - 20,153 - May March 14,363 - Total CCG Cash Drawdown 41,200 NHSBA Cash Drawdown 4,591 • Based on year to date data there are no trend issues Total Drawdown 45,791 on monthly run rate or in-year positions to highlight.

Maximum Cash Drawdown (MCD) 268,966 • The CCG’s total cash balance at the end of May was % of MCD utilised 17.0% £20k, which is below the acceptable limit of £241k. % of months completed 16.7%

2. Financial and Contractual Management 2.2 Summary Financial Position vs Annual Plan

PRIOR MONTH YEAR TO DATE FORECAST FORECAST (Under) / Original Annual (Under) / Forecast % RAG Budget Actual Over M1 % Variance Budget Budget Over spend Actuals Variance Rating spend £000s £000s £000s £000s £000s £000s £000s £000s

Acute Healthcare 142,330 142,330 21,655 21,674 19 142,330 0 0.0% 142,330 0.0% Non Acute Healthcare 56,262 56,262 9,371 9,378 7 56,262 0 0.0% 56,262 0.0% Primary Care 32,962 32,962 5,602 5,612 10 32,962 0 0.0% 32,962 0.0% Delegated Co-Commissioning 25,608 25,608 4,268 4,268 0 25,608 0 0.0% 25,608 0.0% Other Programme 8,268 8,268 1,289 1,269 (20) 8,268 0 0.0% 8,268 0.0%

Total Commissioning Budgets 265,430 265,430 42,185 42,201 16 265,430 0 0.0% 265,430 0.0%

0.5% General Contingency 1,215 1,215 0 0 0 1,215 0 0.0% 1,215 0.0% General Reserves 1,152 1,152 0 0 0 1,152 0 0.0% 1,152 0.0% Delegated Cross Charge (2,300) (2,300) 0 0 0 (2,300) 0 0.0% (2,300) 0.0%

Total Programme Budgets 265,497 265,497 42,185 42,201 16 265,497 0 0.0% 265,497 0.0%

Running Cost Allowance (RCA) 3,961 3,961 660 634 (26) 3,961 0 0.0% 3,961 0.0%

Total Expenditure 269,458 269,458 42,845 42,835 (10) 269,458 0 0.0% 269,458 0.0%

Total CCG Allocation 250,479 250,479 39,683 39,683 0 250,479 0 0.0% 250,479 0.0%

(Under)/Over spend 18,979 18,979 3,162 3,152 (10) 18,979 0 0.0% 18,979 0.0%

• At Month 2, the CCG is forecasting a cumulative year-end deficit of £18.98m against its notified allocation which is in accordance with its NHS England agreed in-year deficit plan.

• The overall year to date position is in line with the cumulative planned deficit of £3.2m.

• Due to the paucity of reliable monitoring data at this stage of the financial year, all Programme areas are reported as breakeven.

• Running Cost Allowance (RCA) expenditure is currently in line with the notified allocation of £3.96m

2.13 QIPP – Financial Position

YTD Outturn Outturn Current Risk Plan Actual Var Plan Actual Var % Delivery

Elective Care £178,998 £178,998 £0 £1,612,690 £1,612,690 £0 100% £355,433

Urgent Care £47,865 £47,865 £0 £716,749 £716,749 £0 100% £0

CHC / Personalised Care £139,335 £139,335 £0 £1,520,896 £1,520,896 £0 100% £160,000

Prescribing £328,683 £328,683 £0 £2,730,690 £2,730,690 £0 100% £0

Primary Care £99,233 £99,233 £0 £1,834,268 £1,834,268 £0 100% £294,110

Other £360,452 £360,452 £0 £2,162,713 £2,162,713 £0 100% £0

GRAND TOTAL £1,154,565 £1,154,565 £0 £10,578,007 £10,578,007 £0 100% £809,543

• The 2017/18 QIPP target of £10.58m is allocated across five key programme areas and other transactional schemes.

• This target is as per the CCG’s financial plan submission and agreed with NHSE.

• All schemes are identified as recurrent.

Risk - 8% risk

• Elective Care – Engagement and negotiation of pathways with Trusts is causing potential slippage to most schemes. A 20% risk has been assumed for all schemes.

• Personalisation – Early data indicates that Growth has yet to be contained; with growth above previous outturn levels reported. Staff vacancies also contribute to the delivery risk.

• Out of Hospital – delays in implementation and a review of the way the scheme may be achieved. A 30% risk has been assumed due to this.

• All other schemes have a level of assurance on initial position but have further work to ensure delivery.

QIPP The graphs below show performance by each programme plan, a cumulative position and year to date QIPP performance against the QIPP profile and a straight line profile.

£178,998 Elective Care Monthly £ Performance £1,200,000 Urgent Care £47,865

£1,000,000 CHC / Personalg £139,335 ,

£800,000 Primary Care £99,233,

£600,000

£400,000 QIPP Programme Plan 2018/19 (£'000) £200,000

£0 £178,998 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar £360,452 QIPP - plan QIPP - actual QIPP - Forecast £47,865

Monthly £ Performance £139,335 (plan in straight 12ths)

£1,200,000 Elective Care £1,000,000 £99,233 Urgent Care £800,000 £328,683

£600,000

£400,000

£200,000

£0 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

QIPP - plan (12ths) QIPP - actual QIPP - Forecast Blank Page NHS Coventry & Rugby Clinical Commissioning Group Enc N NHS Warwickshire North Clinical Commissioning Group

Report To: Governing Body Meetings in Common

Report Title: Procurement Update Report – June 2018

Report From: Clare Hollingworth, Chief Finance Officer

Date: 12th July 2018

Previously Considered Finance & Performance Committee Meetings in Common, 28th June by: 2018

Action Required

Decision:  Assurance:  Information:  Confidential

Purpose of the Report:

To provide an overview of the procurement work programme and a progress update for each of the individual projects.

Key Points:

• As detailed in the main report, the status of the procurement pipeline of each CCG may be summarised as follows:

CRCCG WNCCG Live procurements 1 1 Contract award stage 1 1 Contract mobilisation stage 1 0 Pre-procurement planning 5 3 Contract extensions enacted 0 0 Contract extensions recommended 0 0

Recommendation:

Members of BOTH Governing Bodies are asked to: • NOTE and be ASSURED as to the progress of the current procurements; • NOTE the procurement pipeline and the decisions that will be required over the next few months; and • DELEGATE authority to the Chief Officer to approve the contract award for Diabetes Structured Education.

Implications

Objective(s) / Plans Procurement activities are primarily conducted as part of business as usual and/or in supported by this support of the CCGs’ stated Commissioning Intentions. report: Conflicts of Interest: Each procurement is planned so as to manage conflicts of interest appropriately. Non-Recurrent The non-recurrent costs of undertaking procurement activity are Expenditure: contained within each CCG’s running costs allowance. It is expected that all contract awards will be contained within the Recurrent affordable cost envelope outlined at the time of agreement to Expenditure: procure. Is this Financial: expenditure included within the Yes  No N/A CCG’s Financial Plan?(Delete as appropriate) The ability of service providers to achieve key performance targets is a key Performance: consideration when awarding contracts. The ability of service providers to achieve acceptable quality standards is a key Quality and Safety: consideration when awarding contracts. General Statement: The CCG is committed to fulfil its obligations under the Equality Act 2010, and to ensure services commissioned by the CCG are non-discriminatory on the grounds of any protected characteristics. Policies/decisions may need to be adjusted in line with any equality analysis or due regard. Any decision that is finalised without being influenced by appropriate due regard could be deemed unlawful. Equality and  Diversity: Has an equality impact Requirement assessment been will be Yes No N/A undertaken? (Delete as assessed for appropriate) each individual procurement Patient and Public An appropriate approach to PPE will be planned as part of each procurement exercise. Engagement: An appropriate approach to clinical engagement will be planned as part of each Clinical Engagement: procurement exercise. Risk and Assurance: Low Risk

Page 2 of 4

NHS COVENTRY & RUGBY CLINICAL COMMISSIONING GROUP NHS WARWICKSHIRE NORTH CLINICAL COMMISSIONING GROUP

Report to: Governing Body – Meeting in Common

Report from: Clare Hollingworth, Chief Finance Officer

Title: Procurement Update – June 2018 ______

1. Purpose of Report

The purpose of this report is to provide an overview of the procurement work programme and a progress update for each of the current services that are in the live procurement phase.

2. Procurement Work Programme

2.1 Brownsover Medical Practice – Contract Award stage (CRCCG only) The CRCCG Primary Care Committee approved a contract award to the highest scoring bidder at its May meeting. Following the expiry of the statutory standstill period, the contract has been awarded to Spirit Healthcare, an established primary care provider. Work will now commence on contract mobilisation to align with the opening of the new build primary care facility.

2.2 Minimally Invasive Vasectomy Services (MIVS) – Complete (Both CCGs) A call for competition for additional provision was issued in early March. Three providers expressed an interest and all were invited to participate in the second Any Qualified Provider window. All three chose not to bid. In the absence of market interest, it is proposed that the CCGs’ continue with the three current providers until the contract expiry date in March 2020. The re-procurement of the MIVS contract will be factored into the Procurement work programme.

2.3 Extended Access in Primary Care – Contract Award stage (Both CCGs) A costed proposal has been received from the Coventry & Rugby GP Alliance and is being reviewed by the project team. Discussions are on-going with various partners to secure a solution for Warwickshire North that can be delivered within the timescales required by NHS England. The Chief Officer has been granted delegated authority from both CCGs to approve the final detail of the contract awards; it is anticipated that these should be finalised in the next few weeks.

2.4 Termination of Pregnancy Services (ToPS) – Pre Procurement (Both CCGs) This contract is due to expire 31st March 2019. The current service provider has advised that they are not prepared to extend the current contract beyond this date. A project team, led by South Warwickshire CCG, has been established to lead the re-procurement. Their recommendation is to commission via multiple Providers; the team is working with AGCSU Procurement to explore means of securing adequate access across all three CCG footprints whilst contracting on any Any Qualified Provider basis.

2.5 Anchor & Meridian APMS contracts – Pre Procurement (CRCCG) The Primary Care Commissioning Committee has approved the re-procurement of the two specialist APMS contracts that provide services for the Homeless and Refugee and Asylum Seeker populations within Coventry. The procurement team is now being formed with the expectation that an Invitation to Tender will be issued in the summer. Public Health are supporting on the re-fresh of the service specification and engagement is being undertaken with a wide range of relevant stakeholders.

2.6 Care Homes Procurement (Coventry) - Pre Procurement (CRCCG only) In order to allow time for more work to develop an appropriate joint pricing structure, the CCG and Coventry City Council have agreed to defer planned care home re-procurement until later in the year, Page 3 of 4 with new contracts and prices expected to be effective from 1st April 2019. This work is being overseen by the Adult Joint Commissioning Board.

2.7 Flu Outbreak response – Pre Procurement (Both CCGs) CCGs have been asked to ensure that they have appropriate arrangements in place to respond appropriately to out of season flu outbreaks (and particularly to care homes). Given that any contracts are likely to be low value and let for a relatively short period, the Governing Bodies have agreed to delegate authority to award to the Chief Strategy & Primary Care Officer. Discussions with SWFT and CWPT failed to secure agreement on delivery of the “swabbing” element of the pathway; both Providers stating they did not have capacity for this. In view of the initial responses from the Community Providers, it is considered a more robust solution is to now explore commissioning the whole pathway from one provider.

2.8 Diabetes Education - Live Procurement (Both CCGs) Following the award of Year 2 monies from NHSE for Diabetes structured education services, it was determined that a streamlined procurement process would be conducted to enable the identification of the best placed provider(s) to deliver the service. As a number of local providers were potentially interested in delivering the service, local market engagement was undertaken and a ‘restricted’ procurement process conducted to include local providers only. This was deemed to be the most appropriate way to facilitate the commissioning of the service (rather than direct award) to help ensure that all local providers were given the same opportunity to bid. It was felt that conducting market engagement and running a procurement process would also be effective in facilitating provider partnerships to secure the Structured Education capacity and improve capability to deliver identified targets. A contract award recommendation is expected to be available by early August, with service commencement anticipated to be September 2018. Given the desirability of demonstrating material progress to NHSE, the two Finance & Performance Committees have recommended that the Governing Body delegate authority to approve the contract award to the Chief Officer.

2.9 GP On-line Consultation Programme – Pre-Procurement (Both CCGs)

The three Coventry & Warwickshire CCGs successfully bid for national monies to implement On-line Consultation capability across their GP Practices. The non-healthcare procurement team within Arden & Gem CSU are providing support for this programme. A suppliers demonstration event was held on the 27th June to allow GPs and Practice Managers to review and assess three suppliers who currently provide systems locally, plus a new system that has come highly recommended through the NHS England conference events. All four systems are on the GP Framework and in the Dynamic Procurement Service catalogue. Following this event, AGCSU will work with the project team to develop a tailored procurement plan and implementation timeline.

3.0 Recommendations

Members of BOTH Governing Bodies are asked to: • NOTE and be ASSURED as to the progress of the current procurements • NOTE the procurement pipeline and the decisions that will be required over the next few months. • DELEGATE authority to the Chief Officer to approve the contract award for Diabetes Structured Education.

Page 4 of 4

NHS Coventry and Rugby Clinical Commissioning Group NHS Warwickshire North Clinical Commissioning Group Enc O

Report To: Governing Body Meetings in Common

Report Title: Governing Body Assurance Framework

Report From: Maria Maltby, Deputy Director of Corporate Affairs

Date: 12 July 2018

Previously Considered by: N/A

Action Required (delete as appropriate)

Decision:  Assurance: Information: Confidential

Purpose of the Report:

To present the Assurance Framework for 2018-19 for approval.

Key Points:

• The Clinical Commissioning Groups are required to have an Assurance Framework in place. This is a tool that sets out the key risks to the achievement of the CCG’s strategic aims, along with the controls in place and assurances on their operation. • The Senior Management Team undertook a review of the Corporate Risk Register and the Assurance Framework in June 2018. • The risks identified are common to both CCGs however each Governing body remains responsible for its own risks. • Each risk has been assigned ownership to a Chief, mitigating actions identified and risk scored (using the grading matrix) and then been subject to review by all Directors collectively. • The Assurance Framework will be presented to the Governing Bodies on a quarterly basis.

Recommendation:

The Governing Bodies are requested to APPROVE the Assurance Framework for 2018/19.

Implications

Objective(s) / Plans Leadership, Sustainability supported by this The Assurance Framework focuses on risks to the achievement of the CCG’s report: strategic objectives Conflicts of Interest: Not applicable Non-Recurrent Expenditure: Not applicable Recurrent Expenditure: Not applicable Financial: Is this expenditure included within the CCG’s Financial Yes No N/A  Plan? (Delete as appropriate)

Page 1 of 2

NHS Coventry and Rugby Clinical Commissioning Group NHS Warwickshire North Clinical Commissioning Group Enc O

Performance: Not applicable Quality and Safety: Not applicable General Statement: The CCG is committed to fulfil its obligations under the Equality Act 2010, and to ensure services commissioned by the CCG are non-discriminatory on the grounds of any protected characteristics. Policies/decisions may need to be adjusted in line with any equality analysis or due regard. Any decision that is finalised Equality and Diversity: without being influenced by appropriate due regard could be deemed unlawful. Has an equality impact Yes assessment been undertaken? No N/A  (attached) (Delete as appropriate) Patient and Public Not applicable Engagement: Clinical Engagement: Not applicable Risk and Assurance: Not applicable

Page 2 of 2

Governing Body Assurance Framework 2018/19 As at July 2018 BLANK PAGE Summary of Assurance Framework Risks

The Governing Body Assurance Framework (GBAF) forms part of the CCGs' risk management policy and is the framework for identification and management of strategic risks; both risks internal to the CCG' and those in the wider system in which the CCGs have a role.

The Governing Body Assurance Framework sets out a list of strategic risks, current mitigating actions and sources internal and external assurances.

The Governing Body Assurance Framework also identifies further mitigating actions to be taken for each risk area.

Coventry and Rugby CCG Warwickshire North CCG CCG RISKS IN COMMON Ref Risk Quarter 1 Quarter 2 Quarter 3 Quarter 4 Quarter 1 Quarter 2 Quarter 3 Quarter 4 Executive Lead

AF1 Delivery of NHS Constitution 4 Hour Wait in ED target 12 0 0 0 12 0 0 0 Clare Hollingworth, Chief Finance Officer

AF2 Delivery of NHS Constitution Referral to Treatment target 16 0 0 0 16 0 0 0 Clare Hollingworth, Chief Finance Officer

AF3 Effectiveness of Preparation for Transition to Integrated Care 12 0 0 0 12 0 0 0 Andrea Green – Chief Officer System

AF4 Delivery of the Financial Plan and control total 16 0 0 0 16 0 0 0 Clare Hollingworth - Chief Finance Officer

AF5 Achievement of quality and sustainability of primary care 9 0 0 0 9 0 0 0 Jenni Northcote – Chief Strategy and Primary Care Officer

AF6 Development and sustaining structures, processes, skills and 12 0 0 0 12 0 0 0 Jo Galloway – Chief Nursing Officer expertise to deliver operational and strategic objectives

AF7 Monitoring quality concerns of commissioned services 6 0 0 0 6 0 0 0 Jo Galloway – Chief Nursing Officer

AF8 Achievement of planned trajectory for Transforming Care 16 0 0 0 16 0 0 0 Jo Galloway – Chief Nursing Officer

Coventry and Rugby CCG Warwickshire North CCG COVENTRY AND RUGBY CCG ONLY RISKS Ref Risk Quarter 1 Quarter 2 Quarter 3 Quarter 4 Quarter 1 Quarter 2 Quarter 3 Quarter 4 Executive Lead

Warwickshire North CCG Warwickshire North CCG WARWICKSHIRE NORTH CCG ONLY RISKS Ref Risk Quarter 1 Quarter 2 Quarter 3 Quarter 4 Quarter 1 Quarter 2 Quarter 3 Quarter 4 Executive Lead Delivery of NHS Constitution 4 Hour Wait in ED target

Ref Owner: Risk Summary:

Clare Hollingworth, Chief Failure to deliver the required NHS Constitution standard target of 4 hours AF1 Finance Officer wait in ED for our population

Sustain the focus on delivering today’s challenges (Finance: Performance: Quality; and continue to Strategic Priority embed the single team culture in some areas) during a period of significant evolution of the local Impacted: commissioning landscape.

COVENTRY AND RUGBY CCG WARWICKSHIRE NORTH CCG Finance and Performance Commissioning, Finance and Lead Committee: Lead Committee: Committee Performance Committee Risk rating Likelihood Impact Score Risk rating Likelihood Impact Score Quarter 1 3 4 12 Quarter 1 3 4 12 Quarter 2 0 Quarter 2 0 Quarter 3 0 Quarter 3 0 Quarter 4 0 Quarter 4 0 Rationale for Score: Rationale for Score: Evidence from the end of April 2018 that pressures have eased Evidence from the end of April 2018 that pressures have eased and performance is improving however this is still a significant area and performance is improving. Need to continue to work to of risk for UHCW. Need to continue to work to ensure these are ensure these are sustainable. sustainable. Risk Rating History

25

20 15 12 10 CRCCG Risk Score Risk 5 WNCCG 0 0 0 0 1 2 3 4 Quarter

Controls (Actions in place or planned to control the risk) Assurances (How we are assured that the action Positive is having the desired impact and level of assurance Assurance ? In Place or Planned Completion Description of Control Yes, not yet Date in place Preventative Action: Daily patient flow meetings Local A&E Board meets monthly, with representation on this take place across all organisations to ensure board from Director of Delivery Assurance YES patients are being managed appropriately. in place Detective Action: Daily report of A&E performance Monthly Finance and Performance Committee meetings and activity levels YES in place Detective Action: Weekly situation report produced by RCMT (including performance and activity and DTOC levels) in place Detective Action: EMS escalation management system operated by RCMT which give twice daily situation reports of pressures in place Directive Action: Local A&E Board have an escalation remedial plan reporting both to the Coventry & Warwickshire A&E Board as well as regional Escalation meetings with NHSE / NHSI. in place Directive Action: Through contracting, a remedial action plan has been received from the Trust and is monitored through the contracting action plan meetings with the Trust at Director level planned Ongoing Ongoing work through the STP urgent care work programme looking at sharing best practice across Coventry and Warwickshire and on local plans for implementation of the Five Year Forward View designed to manage demand appropriately and improve patient flow NHS111, out of hours and A&E planned Jun-18 A&E plan on a page agreed planned Sep-18 Five work programmes; system wide audit of OPAT to be completed planned Sep-18 Audit of D2A processes to take place by end July 2018 with a point prevalence to be undertaken in September 2018 planned Sep-18 Frailty review to complete planned Jun-18 Ambulance arrivals review to complete Controls (Actions in place or planned to control the risk) Assurances (How we are assured that the action Positive is having the desired impact and level of assurance Assurance ? In Place or Planned Completion Description of Control Yes, not yet Date planned May-18 Review of AMHAT undertaken re management of Mental Health liaison service with A&E and recommendations of future shape of service taken into STP Mental Health work programme planned Sep-18 Review of tier 4 CAMHS provision to be undertaken planned ongoing Local QIPPs re reducations in demand through management high impact users and integrating services Equality and Diversity Implications:

Quality Implications

Possible inadequate patient experience, less than optimal care for patients in ED, long stays in ED prior to admission or treatment, potential unnecessary admission to hospital and patients decompensating whilst in hospital. Delivery of NHS Constitution Referral to Treatment target

Ref Owner: Risk Summary:

Clare Hollingworth, Chief Failure to deliver the NHS Constitutional target for referral to treatment time AF1 Finance Officer (92% of patients waiting on an incomplete pathway less than 18 weeks)

Sustain the focus on delivering today’s challenges (Finance: Performance: Quality; and continue to Strategic Priority embed the single team culture in some areas) during a period of significant evolution of the local Impacted: commissioning landscape.

COVENTRY AND RUGBY CCG WARWICKSHIRE NORTH CCG Finance and Performance Commissioning, Finance and Lead Committee: Lead Committee: Committee Performance Committee Risk rating Likelihood Impact Score Risk rating Likelihood Impact Score Quarter 1 4 4 16 Quarter 1 4 4 16 Quarter 2 0 Quarter 2 0 Quarter 3 0 Quarter 3 0 Quarter 4 0 Quarter 4 0 Rationale for Score: Rationale for Score: Capacity constraints experienced in 2017/18 at UHCW have in the Issues re reporting of RTT on Lorenzo have now been resolved. main been resolved. Specialties now up to full strength. Getting it Capacity planning has been undertaken through the use of the right first time improvement programme in place to improve theatre intensive support team's demand and capacity planning tools. utilisation. Full assurance will come once we have received the Elective work is being profiled to occur in the first 9 months of the recovery trajectories from the Trust in line with capacity and year so that emergency work can be protected in the final quarter. demand planning at the end of June. Profile for management of The Trust now seem to have a good grip in terms of their long waiters is progressing in line with agreed trajectory. operational planning and performance operationally. Risks still in place in terms of demand from GP referrals being managed through the quality referrals scheme which is showing a promise.

Risk Rating History 25

20 15 16

10 CRCCG Risk Score Risk 5 WNCCG 0 0 0 0 1 2 3 4 Quarter

Controls (Actions in place or planned to control the risk) Assurances (How we are assured that the action Positive is having the desired impact and level of assurance Assurance ? In Place or Planned Completion Description of Control Yes, not yet Date

GEH and UHCW Preventative Action: Staff training in place Weekly and monthly performance reporting on Access Policy delivered YES in place GEH Preventative Action: internal 'getting it right first time' actions taken by the Trust to improve Fortnightly operational group efficiency and to create extra capacity from YES reducing lost capacity in place GEH Preventative Action: Extra activity bought above outturn activity for 2017/18 Monthly reporting to Finance and Performance Committee YES in place GEH and UHCW Detective Action: Monthly monitoring of RTT performance through contracting meetings in place GEH and UHCW Detective Action: Monthly reporting of RTT performance from national statistics in place GEH and UHCW Detective Action: Weekly information on use of e-referrals and ASIs and potential long waits in place GEH Directive Action: Routinely monitored in contracting discussions after agreement with NHSI and NHSE to step down fortnightly escalation meetings in place GEH Directive Action: Joint QIPP programme for elective care to undertake specialty reviews and produce unnecessary activity so as to free up capacity for the Trust to improve and deliver RTT in place UHCW Preventative Action: New interim Operational lead within UHCW in place Jun-18 UHCW Directive Action: The Trust has undertaken extensive work with an intensive support team on demand and capacity for elective and outpatient activity to complete at end of May 2018, with an action plan for RTT improvement being ready for the end of June 2018 going through to how RTT performance will be delivered up to March 2019 in place UHCW Directive Action: Monthly escalation meeting on RTT delivery held with the Trust, the CCG, NHSI and NHSE to agree actions and tie performance into action plans between the Trust and NHSI that match the CCG contractual plans planned ongoing GEH and UHCW: STP work programme now in place, 16 planned care sub-projects being undertaken to work on reducing demand and increasing capacity for the management of patients on elective pathways. planned ongoing GEH and UHCW: Involvement of right care lead in setting priorities for work programmes by the STP planned ongoing UHCW: Local specialty workshops have been held for Opthalmology and MSK. Clinically led by Steve Allen with the Clinical Director of UHCW re pathway redesign and opportunities for increasing capacity and reducing demand.

Equality and Diversity Implications:

Quality Implications

Possible poor patient experience and poor quality of care Effectiveness of Preparation for Transition to Integrated Care System

Ref Owner: Risk Summary: Failure to adequately prepare for the transition to the integrated care system Andrea Green – Chief AF3 (ICS) in order to secure the anticipated improvements and population Officer outcomes and supporting CCG staff through change

Strategic Priority To increase the pace of the evolution of the health system towards having a single Integrated Care Impacted: System by 2020

COVENTRY AND RUGBY CCG WARWICKSHIRE NORTH CCG

Lead Committee: Governing Body Lead Committee: Governing Body Risk rating Likelihood Impact Score Risk rating Likelihood Impact Score Quarter 1 3 4 12 Quarter 1 3 4 12 Quarter 2 0 Quarter 2 0 Quarter 3 0 Quarter 3 0 Quarter 4 0 Quarter 4 0 Rationale for Score: Rationale for Score: At an early stage of ICS development and further mitigations will be At an early stage of ICS development and further mitigations will be identified as the year progresses identified as the year progresses

Risk Rating History

25

20 15 12

10 CRCCG Risk Risk Score 5 WNCCG 0 0 0 0 1 2 3 4 Quarter

Controls (Actions in place or planned to control the risk) Assurances (How we are assured that the action Positive is having the desired impact and level of assurance Assurance ? In Place or Planned Completion Description of Control Yes, not yet Date

In Place Jul-18 Preventative Action: ICS development BHBCBV Board oversight programme underway NOT YET In Place Apr-18 Preventative Action: Organisational Monitoring via quarterly NHSE reviews - overall Development plan developed assurance rating for 2017/18 yet to be NOT YET communicated by NHS England Development of place based integrated partnerships: in place Jun-18 WNCCG partnership established planned Sep-18 Rugby Partnership under establishment planned Apr-19 Coventry partnership to be determined by April 19

Equality and Diversity Implications: None identified

Quality Implications None identified Delivery of the Financial Plan and control total

Ref Owner: Risk Summary: Clare Hollingworth - Chief AF4 The CCG fails to deliver the financial plan and control total Finance Officer Sustain the focus on delivering today’s challenges (Finance: Performance: Quality; and continue to Strategic Priority embed the single team culture in some areas) during a period of significant evolution of the local Impacted: commissioning landscape.

COVENTRY AND RUGBY CCG WARWICKSHIRE NORTH CCG Finance and Performance Commissioning, Finance and Lead Committee: Lead Committee: Committee Performance Committee Risk rating Likelihood Impact Score Risk rating Likelihood Impact Score Quarter 1 4 4 16 Quarter 1 4 4 16 Quarter 2 0 Quarter 2 0 Quarter 3 0 Quarter 3 0 Quarter 4 0 Quarter 4 0 Rationale for Score: Rationale for Score: Further mitigations will be identified during the course of the year as Further mitigations will be identified during the course of the year as indicated by variances that arise. indicated by variances that arise.

Risk Rating History 25

20 15 16

10 CRCCG Risk Score Risk 5 WNCCG 0 0 0 0 1 2 3 4 Quarter

Controls (Actions in place or planned to control the risk) Assurances (How we are assured that the action Positive is having the desired impact and level of assurance Assurance ? In Place or Planned Completion Description of Control Yes, not yet Date in place May-18 Preventative Action: SROs allocated for all Monthly Financial Recovery Group meetings documented QIPP schemes in place Ongoing Preventative Action: Contract mechanisms Monthly Finance and Performance meetings in place Ongoing Detective Action: Milestone reports collated by PMO monthly Bi-monthly Governing Body meetings in place Ongoing Detective Action: Monthly review and financial reporting mechanisms in place May-18 Directive Action: Revised Governance Process and Standard Operating Procedures implemented in May 2018

Equality and Diversity Implications: No specific E&D implications identified

Quality Implications Recovery actions could lead to restricted access to services Achievement of quality and sustainability of primary care

Ref Owner: Risk Summary: Jenni Northcote – Chief AF5 Strategy and Primary Care The CCG fails to achieve the right quality and sustainability of primary care Officer

Strategic Priority To increase the pace of the evolution of the health system towards having a single Integrated Care Impacted: System by 2020

COVENTRY AND RUGBY CCG WARWICKSHIRE NORTH CCG

Lead Committee: Governing Body Lead Committee: Governing Body Risk rating Likelihood Impact Score Risk rating Likelihood Impact Score Quarter 1 3 3 9 Quarter 1 3 3 9 Quarter 2 0 Quarter 2 0 Quarter 3 0 Quarter 3 0 Quarter 4 0 Quarter 4 0 Rationale for Score: Rationale for Score: There is a workforce strategy in place for Primary Care and GP There is a workforce strategy in place for Primary Care. An clusters are in place in Coventry supporting collaborative working. options appraisal is underway to respond to housing growth and An additional GP surgery has also been commissioned in Rugby. to consider options for responding.

A number of ETTF schemes which support primary care estates The CCG is working towards meeting the national timeline for development and refurbishment are in place. improving access, including extended hours and sites for accessing GP services out of hours. Identified priority areas impacted by housing growth which have been put forward as part of STP workbook. GPFV group actively working with the CCG to identify initiatives and interventions that support the 10 high impact actions for The CCG is expanding the delivery sites for improving access to sustainable general practice. meet the 100% coverage target.

PMS schemes that are supporting quality improvements and implementation of the 10 high impact actions.

Risk Rating History 25

20 15 10 99 CRCCG Risk Score Risk 5 WNCCG 0 0 0 0 1 2 3 4 Quarter

Controls (Actions in place or planned to control the risk) Assurances (How we are assured that the action Positive is having the desired impact and level of assurance Assurance ? In Place or Planned Completion Description of Control Yes, not yet Date in place Ongoing Primary Care Committees established Quality and performance reports to committees Yes Committee minutes Primary care monthly update to committees covering resilience issues. Yes Primary care Risk Register reported to Committees Yes Regular dialogue with NHS England with escalation processes for any concerns and issues Yes in place Ongoing Primary Care Operational Group formed to As above. manage operational issues Yes in place Ongoing Regular meetings with LMCs across both Early identification of issues and shared ownership CCGs. of resilience response, eg, temporary list closures. Reports to Committees and Committee minutes Yes

In place May-18 Cluster leads appointed and attending Monitoring reports to Primary Care Commissioning Primary Care Operational Group. Also Committee and Joint Commissioning Committees regular dialogue and supervision in place. Yes Controls (Actions in place or planned to control the risk) Assurances (How we are assured that the action Positive is having the desired impact and level of assurance Assurance ? In Place or Planned Completion Description of Control Yes, not yet Date

In place Nov-17 CRCCG only - Memorandum of Bi-monthly meetings to review progress against MoU Understanding agreed with Alliance to performance criteria Yes support resilience in primary care planned Jul-18 WNCCG only - meeting organised in No specific assurance identified November to discuss Memorandum of Understanding for resilience in primary care N/A in place Dec-17 Secured funding for international recruitment Mobilisation to be monitored via PCOG and Primary to support primary care Care Committee Yes

In place ongoing Primary care Workforce Strategies Monitoring reports to Primary Care Commissioning developed and working group taking forward Committee and Joint Commissioning Committees actions in the strategy - feeds into training Yes hubs, LWAB and STP workforce Group in place Jun-18 Submission of bid for recruitment and Clusters in place at Coventry and Rugby CCG retention funds - awaiting outcome Not yet due - Aug 2018 planned Jun-18 WNCCG - Plan developed to take forward Clusters in place at Warwickshire North CCG clusters following engagement exercise with Not yet due practices. - Aug 2018 in place Dec-17 Bids for winter resilience secured Resilience funds fully allocated

Yes in place May-18 Launched transformation fund across both No specific assurance identified CCGs to test new ideas for primary care transformation and resilience in place Jun-18 Piloting online consultations and developing No specific assurance identified GP IT strategy to support primary care delivery

Equality and Diversity Implications: None identified

Quality Implications None identified Development and sustaining structures, processes, skills and expertise to deliver operational and strategic objectives

Ref Owner: Risk Summary: Jo Galloway – Chief The CCG fails to develop and sustain the right structures, processes, skills AF6 Nursing Officer and expertise to deliver our operational and strategic objectives

Sustain the focus on delivering today’s challenges (Finance: Performance: Quality; and continue to Strategic Priority embed the single team culture in some areas) during a period of significant evolution of the local Impacted: commissioning landscape.

COVENTRY AND RUGBY CCG WARWICKSHIRE NORTH CCG

Lead Committee: Governing Body Lead Committee: Governing Body Risk rating Likelihood Impact Score Risk rating Likelihood Impact Score Quarter 1 3 4 12 Quarter 1 3 4 12 Quarter 2 0 Quarter 2 0 Quarter 3 0 Quarter 3 0 Quarter 4 0 Quarter 4 0 Rationale for Score: Rationale for Score: The CCG has developed and implemented new structures. The The CCG has developed and implemented new structures. The systems and process are in place, although work is ongoing to systems and process are in place, although work is ongoing to continuously improve. The CCG is continuing to recruit to continuously improve. The CCG is continuing to recruit to vacancies as required. An Organisational Development plan and vacancies as required. An Organisational Development plan and shared values have been developed in consultation with staff. shared values have been developed in consultation with staff.

Risk Rating History

25

20 15 12 10 CRCCG Risk ScoreRisk 5 WNCCG 0 0 0 0 1 2 3 4 Quarter

Controls (Actions in place or planned to control the risk) Assurances (How we are assured that the action Positive is having the desired impact and level of assurance Assurance ? In Place or Planned Completion Description of Control Yes, not yet Date in place Ongoing Systems and processes are in place. NHSE assurance framework ratings. YES In place Apr-18 Development of an organisational Not yet - Staff Survey results development Strategy 2019 in place Jun-18 Development of an Organisational Recruitment and retention, sickness statistics are in YES Development Action Plan line with national average in place May-18 Development of shared values for both CCGs in place Ongoing Governing Body joint development sessions

in place Ongoing Staff Forum launched and working with senior management team and CCG staff to undertake Workplace Wellbeing Charter action plan Planned Jul-18 Develop a set of behaviours to support whole organisation delivery of the CCGs values

Equality and Diversity Implications: None identified

Quality Implications No quality implications identified at this time. Monitoring quality concerns of commissioned services

Ref Owner: Risk Summary: Jo Galloway – Chief CCG processes are insufficient to identify and address all material quality AF7 Nursing Officer concerns within its commissioned services Sustain the focus on delivering today’s challenges (Finance: Performance: Quality; and continue to Strategic Priority embed the single team culture in some areas) during a period of significant evolution of the local Impacted: commissioning landscape.

COVENTRY AND RUGBY CCG WARWICKSHIRE NORTH CCG Clinical Quality and Governance Clinical Quality and Governance Lead Committee: Lead Committee: Committee Committee Risk rating Likelihood Impact Score Risk rating Likelihood Impact Score Quarter 1 2 3 6 Quarter 1 2 3 6 Quarter 2 0 Quarter 2 0 Quarter 3 0 Quarter 3 0 Quarter 4 0 Quarter 4 0 Rationale for Score: Rationale for Score: Review of quality monitoring completed and a new Quality Review of quality monitoring completed and a new Quality Assurance Framework developed and agreed which is currently Assurance Framework developed and agreed which is currently being embedded. Some further work in place to address quality being embedded. Some further work in place to address quality assurance gaps identified. assurance gaps identified.

Risk Rating History 25

20 15

10 CRCCG Risk Risk Score 5 6 WNCCG 0 0 0 0 1 2 3 4 Quarter

Controls (Actions in place or planned to control the risk) Assurances (How we are assured that the action Positive is having the desired impact and level of assurance Assurance ? In Place or Planned Completion Description of Control Yes, not yet Date in place Ongoing CRCCG/WNCCG - Comprehensive range of Bi-monthly reporting to Clinical Quality and quality assurance monitoring and assurance Governance Committee papers received by Clinical Quality and YES Governance Committees. In place Ongoing CRCCG - Comprehensive review of local Bi-monthly reporting to Governing Body and national quality indicators. YES Planned Ongoing A review of quality monitoring has been completed and gaps in assurance NOT YET processes identified are being addressed In place Ongoing A new Quality Assurance Framework has Bi-monthly reporting to Clinical Quality and been developed which includes a risk based Governance Committee YES escalation process

Equality and Diversity Implications: None identified.

Quality Implications Without robust processes there is a risk that early indications of quality concerns will not be identified and addressed in a timely way. Achievement of planned trajectory for Transforming Care

Ref Owner: Risk Summary: Although we have enhanced community services in place, and have achieved many Jo Galloway – Chief life changing improvements for individuals in community placements following long AF8 Nursing Officer term care ; there is a risk the Transforming Care Programme will not achieve the planned trajectory by the end of March 2019

Strategic Priority Sustain the focus on delivering today’s challenges (Finance: Performance: Quality;) during a period of Impacted: significant evolution of the local commissioning landscape.

COVENTRY AND RUGBY CCG WARWICKSHIRE NORTH CCG Clinical Quality and Governance Clinical Quality and Governance Lead Committee: Lead Committee: Committee Committee Risk rating Likelihood Impact Score Risk rating Likelihood Impact Score Quarter 1 4 4 16 Quarter 1 4 4 16 Quarter 2 0 Quarter 2 0 Quarter 3 0 Quarter 3 0 Quarter 4 0 Quarter 4 0 Rationale for Score: Rationale for Score: Education and awareness raising actions have identified additional Education and awareness raising actions have identified Transforming Care patients and some patients have also had a additional Transforming Care patients and some patients have late diagnosis. This coupled with slower than planned discharges also had a late diagnosis. This coupled with slower than planned of people with the most complex needs now means we are at risk discharges of people with the most complex needs now means we of not achieving the planned trajectory for our Transforming Care are at risk of not achieving the planned trajectory for our Partnership. Transforming Care Partnership.

Risk Rating History 25

20 15 16

10 CRCCG Risk Score Risk 5 WNCCG 0 0 0 0 1 2 3 4 Quarter

Controls (Actions in place or planned to control the risk) Assurances (How we are assured that the action Positive is having the desired impact and level of assurance Assurance ? In Place or Planned Completion Description of Control Yes, not yet Date

In place In place Detailed recovery plan in place to address Recovery plan reviewed monthly at Clinical Quality the risks. Oversight managed by and Governance Committee Transforming Care Board reporting to CCGs/ BHBCBV and the Collaborative Commissioning Boards. Partial New action in place to establish if any additional discharges from NHSE specialised services can be identified and appropriately supported.

Planned July/ August NHSE Regional Director scrutiny of action to External assurance of actions recover Not yet

Planned End July Additional case management resources The impact will be reviewed by the Clinical Quality being sought to assist with NHSE complex and Governance Committee in August discharges Not yet

In Place All in place Community assessment and treatment beds Successful discharges from long stay facilities end April 18 in place; IST and Crisis response all age services in place; Community forensic services in place; New framework of Providers for care and Yes support in place; New joint framework for funding agreements in place to prevent delay in communty support.

Planned August Business case being developed to build on Prevent more admissions to specialist services of the current services. those who can be best supported at home with Not yet specialist CAMHS care.

Equality and Diversity Implications: This may impact on those with LD and/or ASD and challenging behaviour who could be better looked after in the community

Quality Implications This risks failing to deliver the planned improvements in the Transforming Care Programme for the full cohort of people NHS Coventry and Rugby Clinical Commissioning Group and NHS Warwickshire North Clinical Commissioning Group Strategic Priorities 2018/20 Strate gic

Sustain the focus on delivering today’s challenges (Finance: Performance: Quality; and continue to embed the single team culture in some areas) during a period 1 of significant evolution of the local commissioning landscape.

To increase the pace of the evolution of the health system towards having a single Integrated Care System by 2020, specifically:

o Building a single strategic commissioner for Coventry & Warwickshire population by 2019. 2 o To develop more sustainable primary care and develop primary care Clusters (networks) to improve resilience and integration by 2020. o To develop integrated place based health and social care partnerships, in a way which GP Members/ clusters can better engage with by 2020. o To support evolution of the Coventry & Warwickshire STP into a shadow ICS by the end of 2019, and full ICS for 2020/21. Risk Appetite (as per Risk Management Policy 2017)

The Governing Body will, where necessary, tolerate overall levels of risk that are classified as 12 or lower where action is not cost effective or reasonably practicable. The CCG will not normally accept levels of risk scored 15 or more and will therefore ensure that plans are put into place to lower the level of risk whenever an extreme risk has been identified.

Grading Matrix

Risk Level Indicator

Risk factor Risk descriptor 1-3 Green Low Risk 4-6 Yellow Moderate Risk 8-12 Amber High risk 15-25 Red Extreme risk

Likelihood Consequence Almost Certain 5 Likely 4 Possible 3 Unlikely 2 Rare 1

Catastrophic 5 25 20 15 10 5

Major 4 20 16 12 8 4

Moderate 3 15 12 9 6 3

Minor 2 10 8 6 4 2

Negligible 1 5 4 3 2 1

Likelihood x Consequence = Level of Risk

Matrix Terminology Descriptions - Likelihood (Guide only) Likelihood score 1 2 3 4 5 Descriptor Rare Unlikely Possible Likely Almost certain

Frequency (general) Do not expect it to Will probably Will undoubtedly This will probably never Might happen or recur happen/recur but it is happen/recur but it is happen/recur, possibly How often might it/ happen/recur occasionally possible it may do so not a persisting issue frequently does it happen Frequency Not expected to occur Expected to occur at Expected to occur at Expected to occur at Expected to occur at (timeframe) for years least annually least monthly least weekly least daily Probability <1% 1-5% 6-20% 21-50% >50% Will it happen or not Matrix Terminology Descriptions - Impact (Guide only) 1 2 3 4 5 Descriptor Negligible Minor Moderate Major Catastrophic Minimal injury requiring Minor injury or illness, Major injury leading to Moderate injury requiring no/minimal intervention or requiring minor long-term Incident leading to death professional intervention treatment. intervention incapacity/disability Multiple permanent injuries Requiring time off work for Requiring time off work for Requiring time off work for No time off work or irreversible health >3 days 4-14 days >14 days effects Safety of patients, staff or public Increase in length of Increase in length of Increase in length of An event which impacts on (physical/psychologica hospital stay by 1-3 days hospital stay by 4-15 days hospital stay by >15 days a large number of patients l harm) RIDDOR/agency reportable Mismanagement of patient incident care with long-term effects

An event which impacts on a small number of patients

Patient Unsatisfactory patient Unsatisfactory patient Totally unsatisfactory Mismanagement of patient Serious mismanagement Experience experience not directly experience – readily patient outcome or care of patient care related to patient care resolvable experience Below excess claim. Claim above excess level. Complaint/ Claim Justified complaint Justified complaint Multiple claims or single Locally resolved potentially Multiple justified Potential peripheral to clinical care involving lack of major claim complaints appropriate care 5-10% over budget / Insignificant cost increase/ 10-25% over budget / >25% over budget / <5% over budget schedule slippage. schedule slippage. Barely schedule slippage. schedule slippage. Objectives / Projects schedule slippage. Minor Reduction in scope or noticeable reduction in Doesn’t meet secondary Doesn’t meet primary reduction quality / scope quality requiring client scope or quality objectives objectives approval Loss/interruption of >1 Loss/interruption of >8 Loss/interruption of >1 Permanent loss of service Service/ Business Loss/interruption of >1 day hour hours week or facility Interruption/Environm Minimal or no impact on Minor impact on Moderate impact on Major impact on Catastrophic impact on ental impact the environment environment environment environment environment Late delivery of key Uncertain delivery of key Non-delivery of key objective/ service due to objective/service due to objective/service due to lack of staff lack of staff lack of staff

Unsafe staffing level or Unsafe staffing level or Ongoing unsafe staffing competence (>1 day) competence (>5 days) levels or competence Human resources/ Short-term low staffing Low staffing level that organisational level that temporarily reduces the service Low staff morale Loss of key staff Loss of several key staff development/staffing/ reduces service quality (< quality competence 1 day) No staff attending Poor staff attendance for mandatory training /key Very low staff morale mandatory/key training training on an ongoing basis No staff attending mandatory/ key training

Uncertain delivery of key Non-delivery of key Loss of 0.1–0.25 per cent Loss of 0.25–0.5 per cent Small loss objective/Loss of 0.5–1.0 objective/ Loss of >1 per of budget of budget per cent of budget cent of budget

Financial including Claim(s) between £10,000 Claim(s) between Failure to meet Risk of claim remote Claim less than £10,000 claims and £100,000 £100,000 and £1 million specification/ slippage Purchasers failing to pay Loss of contract / payment on time by results Claim(s) >£1 million Breach of statutory Single breach in statutory Multiple breaches in Enforcement action legislation duty statutory duty Multiple breaches in Prosecution statutory duty No or minimal impact or Challenging external Statutory Duties/ Reduced performance Complete systems change breach of guidance/ recommendations/ Improvement notices Inspection/Audit rating if unresolved required statutory duty improvement notice

Low performance rating Zero performance rating

Critical report Severely critical report National media coverage with >3 days service well below reasonable public Rumours Local media coverage Local media coverage – expectation. MP National media coverage concerned (questions in Adverse Publicity/ with <3 days service well the House) Reputation below reasonable public Potential for public short-term reduction in long-term reduction in expectation Total loss of public concern public confidence public confidence confidence

Elements of public expectation not being met

Damage to a services Damage to an individual’s Damage to a team’s Damage to an Damage to NHS reputation/ local media reputation. reputation. organisation’s reputation/ reputation/ coverage. Serious breach of Some local media Local and politically Possible media interest. confidentiality e.g. up to National media coverage. Information interest. sensitive media coverage. 100 people affected Governance/ Records Management Potentially serious breach. Serious potential breach & Serious breach with either Less than 5 people risk assessed high e.g. Serious breach with particular sensitivity e.g. affected or risk assessed unencrypted clinical potential for ID theft or sexual health details, or up as low, e.g. files were records lost. Up to 20 over 1000 people affected to 1000 people affected encrypted people affected NHS Coventry and Rugby Clinical Commissioning Group NHS Warwickshire North Clinical Commissioning Group Enc P

Report To: Governing Bodies Meetings in Common

Report Title: Draft CCG Response to the Modern Slavery Act 2015

Report From: Maria Maltby – Deputy Director of Corporate Affairs

Date: 12 July 2018

Previously Considered by: Clinical Quality and Governance Committee in Common, 27 June 2018

Action Required (delete as appropriate)

Decision:  Assurance: Information: Confidential

Purpose of the Report: To present the CCGs’ draft statements in response to the Modern Slavery Act 2015.

Key Points: • The Modern Slavery Act 2015 (the Act) requires commercial organisations, including all NHS organisations, to make a public statement as to the actions they have taken to detect and deal with forced labour and trafficking in their supply chains – the Transparency in Supply Chains obligation. • Organisations with a year-end of 31 March 2017 are required to publish on their website a statement within 6 months of current year end. • The CCG’s draft statements for 2017/18 are attached at Appendix 1 and Appendix 2. • The statements reflect existing practice undertaken within the business. The CCG’s approach is governed by compliance with legislative and regulatory requirements and due to the nature of its business is a relatively low risk however we will continue to ensure that, where appropriate, we seek assurances via contractual mechanisms from our providers that they comply with the Act. • The Clinical Quality and Governance Committees in Common considered the draft statements at the meeting of 27 June 2018 and recommended them to the respective Governing Bodies for approval and adoption.

Recommendation: The Governing Bodies are asked to: • APPROVE their respective Statements in Response to the Modern Slavery Act 2015 adoption, signing by the Accountable Officer and publication.

Page 1 of 2 NHS Coventry and Rugby Clinical Commissioning Group NHS Warwickshire North Clinical Commissioning Group Enc P

Implications

Objective(s) / Plans supported by this CCG Constitution, Modern Slavery Act 2015 report: Conflicts of Interest: None identified Non-Recurrent Expenditure: Not applicable Recurrent Expenditure: Not applicable Financial: Is this expenditure included within the CCG’s Financial Yes No N/A  Plan? (Delete as appropriate) Performance: Not applicable Quality and Safety: Not applicable General Statement: The CCG is committed to fulfil its obligations under the Equality Act 2010, and to ensure services commissioned by the CCG are non-discriminatory on the grounds of any protected characteristics. Policies/decisions may need to be adjusted in line with any equality analysis or due regard. Any decision that is finalised Equality and Diversity: without being influenced by appropriate due regard could be deemed unlawful. Has an equality impact Yes assessment been undertaken? No N/A  (attached) (Delete as appropriate) Patient and Public Not applicable Engagement: Clinical Engagement: Not applicable Should the CCGs not comply with the requirements of the Act, the UK Home Secretary can force the organisation (by way of proceedings for an injunction) to issue Risk and Assurance: an annual statement. A failure to comply with the provision, or a statement that the CCGs have taken no steps, may result in reputational damage.

Page 2 of 2 NHS Coventry and Rugby Clinical Commissioning Group’s Response to the Requirements of the Modern Slavery Act 2015

This statement comprises the slavery and human trafficking statement of NHS Warwickshire North Clinical Commissioning Group (the organisation) for the financial year ending 31st March 2018 in accordance with Section 54, Part 6 of the Modern Slavery Act 2015.

The organisation recognises that it has a responsibility to take a robust approach to slavery and human trafficking and is absolutely committed to preventing slavery and human trafficking in its corporate activities.

Definition of Offences

Slavery, servitude and forced or compulsory labour.

A person commits an offence if:

i. The person holds another person in slavery or servitude and the circumstances are such that the person knows or ought to know that the other person is held in slavery or servitude, or; ii. The person requires another person to perform forced or compulsory labour and the circumstances are such that the person knows or ought to know that the other person is being required to perform forced or compulsory labour.

Human Trafficking

A person commits an offence if:

i. The person arranges or facilitates the travel of another person (victim) with a view to being exploited; ii. It is irrelevant whether the victim consents to travel and whether or not the victim is an adult or a child.

Exploitation

A person is exploited if one or more of the following issues are identified in relation to the victim:

i. Slavery, servitude, forced or compulsory labour; ii. Sexual exploitation; iii. Removal of organs; iv. Securing services by force, threats and deception; v. Securing services from children, young people and vulnerable persons.

Organisational Structure

As an authorised statutory body, the CCG is the lead commissioner for health care services (including acute, community, mental health and primary care) in the North Warwickshire and Nuneaton and Bedworth areas – covering a population in excess of 345,000 in Coventry and 103,443 in Rugby. We are an NHS organisation with 169 employees and an annual budget allocation in 2017/18 of £669,928.

The Membership, Governing Body, Executive Team and all employees are committed to ensuring that there is no modern slavery or human trafficking in any part of our business activity and in so far as is possible to holding our suppliers to account to do likewise.

Our approach Our overall approach is governed by compliance with legislative and regulatory requirements and the maintenance and development of best practice in the fields of contracting and employment.

The CCG recognises safeguarding as a high priority for the organisation. In order to achieve this we ensure that we have arrangements in place to provide strong leadership, vision and direction for safeguarding. We make sure we have clear accessible policies and procedures in line with relevant legislation, statutory guidance and best practice.

The organisational structure, business and supply chain

We have a clear line of accountability for safeguarding within the CCG. The CCG’s Accountable Officer has ultimate accountability for ensuring that the health contribution to safeguarding and promoting the welfare of children and adults is discharged effectively across the whole health economy through commissioning arrangements.

The Chief Nursing Officer is the Governing Body executive lead for safeguarding, and has responsibility for providing leadership and gaining assurance in relation to safeguarding issues within the CCG and locality.

The CCG employs the expertise of a designated safeguarding doctor and safeguarding nurses for both children and adults. These roles are an integral part of the CCG’s activity and support the delivery of the safeguarding adult and children agenda.

Procurement

The CCG ensures that organisations commissioned to provide services have appropriate systems that safeguard children in line with section 11 of the Children Act (2004), and adults in line The Mental Capacity Act 2005, The Care Act 2014 and The Modern Slavery Act 2015.

With regards specifically to the Modern Slavery Act 2015, there is a specific question in our standard set in the pre-qualification questionnaire so that we can be assured of the approach of potential providers at the outset of a procurement.

In addition, the CCG’s contractual agreements (Standard NHS Contract) contain an obligation within clause SC1.2.2 for providers of services to ‘perform all of its obligations under the Contract in accordance with’:

1.1.1 the terms of this Contract; and 1.1.2 the Law; and 1.1.3 Good Practice’

Further, under SC32 Safety and Safeguarding there is a requirement upon all of our providers to have in place programmes for safeguarding and to co-operate with the Commissioner in pursuance of these.

The policies in relation to Slavery and Human Trafficking

Across the West Midlands there is a multi-agency policy and procedures for the protection of adults with care and support needs. This policy covers Modern Slavery and Trafficking. Across Warwickshire organisations will report any concerns direct to the police or into adult safeguarding.

Any concerns are directed to the police or into adult safeguarding.

The due diligence processes in relation to Slavery and Human Trafficking in its business and supply chains

The CCG is committed to ensuring that there is no Modern Slavery or Human Trafficking in our supply chains or in any part of our business.

Safe and robust recruitment principles are adhered to which includes strict requirements in respect of identity checks, work permits and criminal records. The pay structure is derived from national collective agreements and is based on equal pay principles with rates of pay that are nationally determined. The Remuneration Committee holds the organisation to account in adhering to these standards.

Systems are in place to encourage the reporting of concerns and the protection of whistle blowers.

With regards to providers and supply chains, we expect these entities to have suitable anti-slavery and human trafficking policies and processes in place. We will use our routine contract management meetings with major providers to hold them explicitly to account for compliance with the Act and we will implement any relevant clauses contained within the Standard NHS Contract for 2018/19.

All providers are contractually required to report compliance with safeguarding standards to the CCG using the agreed frameworks

The parts of its business and supply chains where there is a risk of Slavery and Human Trafficking taking place, and the steps it has taken to assess and manage that risk

The CCG is committed to social and environmental responsibility and has zero tolerance for Modern Slavery and Human Trafficking. Any identified concerns regarding Modern Slavery and Human Trafficking would be escalated as part of the organisational safeguarding process and in conjunction with partner agencies; such as the Local Authority and Police.

The effectiveness in ensuring that Slavery and Human Trafficking is not taking place in its business or supply chains, measured against such performance indicators as it considers appropriate

The CCG aims to be as effective as possible in ensuring that modern slavery and Human Trafficking is not taking place in any part of our business or supply chains by:

i. Effective interagency working with local authorities, the police and third sector organisations which includes appropriate arrangements for preventing and responding to modern slavery and Human Trafficking; ii. Signing up to the West Midlands multi-agency policy and procedures for the protection of adults with care and support needs; iii. Continuing to undertake robust NHS employment checks and payroll systems; iv. Ensuring good communication through contract management meetings, with our commissioned providers in the supply chain and their understanding of, and compliance with, our expectations in relation to the NHS terms and conditions. These conditions relate to issues including bribery, slavery and other ethical considerations. v. Requiring the CCG’s providers to provide the CCG with assurance around safeguarding compliance within the agreed framework.

Training about Slavery and Human Trafficking

Slavery and Human Trafficking is part of the organisation’s Mandatory Safeguarding Children and Adults training programme.

This statement is made pursuant to Section 54(1) of the Modern Slavery Act 2015 and constitutes our organisation’s modern slavery and human trafficking statement for the current financial year.

Andrea Green Chief Officer NHS Coventry and Rugby Clinical Commissioning Group Xx 2018

NHS Warwickshire North Clinical Commissioning Group’s Response to the Requirements of the Modern Slavery Act 2015

This statement comprises the slavery and human trafficking statement of NHS Warwickshire North Clinical Commissioning Group (the organisation) for the financial year ending 31st March 2018 in accordance with Section 54, Part 6 of the Modern Slavery Act 2015.

The organisation recognises that it has a responsibility to take a robust approach to slavery and human trafficking and is absolutely committed to preventing slavery and human trafficking in its corporate activities.

Definition of Offences

Slavery, servitude and forced or compulsory labour.

A person commits an offence if:

i. The person holds another person in slavery or servitude and the circumstances are such that the person knows or ought to know that the other person is held in slavery or servitude, or; ii. The person requires another person to perform forced or compulsory labour and the circumstances are such that the person knows or ought to know that the other person is being required to perform forced or compulsory labour.

Human Trafficking

A person commits an offence if:

i. The person arranges or facilitates the travel of another person (victim) with a view to being exploited; ii. It is irrelevant whether the victim consents to travel and whether or not the victim is an adult or a child.

Exploitation

A person is exploited if one or more of the following issues are identified in relation to the victim:

i. Slavery, servitude, forced or compulsory labour; ii. Sexual exploitation; iii. Removal of organs; iv. Securing services by force, threats and deception; v. Securing services from children, young people and vulnerable persons.

Organisational Structure

As an authorised statutory body, the CCG is the lead commissioner for health care services (including acute, community, mental health and primary care) in the North Warwickshire and Nuneaton and Bedworth areas – covering a population in excess of 190,250. We are an NHS organisation with 40 employees and an annual budget allocation in 2017/18 of £238,393

The Membership, Governing Body, Executive Team and all employees are committed to ensuring that there is no modern slavery or human trafficking in any part of our business activity and in so far as is possible to holding our suppliers to account to do likewise.

Our approach Our overall approach is governed by compliance with legislative and regulatory requirements and the maintenance and development of best practice in the fields of contracting and employment.

The CCG recognises safeguarding as a high priority for the organisation. In order to achieve this we ensure that we have arrangements in place to provide strong leadership, vision and direction for safeguarding. We make sure we have clear accessible policies and procedures in line with relevant legislation, statutory guidance and best practice.

The organisational structure, business and supply chain

We have a clear line of accountability for safeguarding within the CCG.

The CCG’s Accountable Officer has ultimate accountability for ensuring that the health contribution to safeguarding and promoting the welfare of children and adults is discharged effectively across the whole health economy through commissioning arrangements.

The Chief Nursing Officer is the Governing Body executive lead for safeguarding, and has responsibility for providing leadership and gaining assurance in relation to safeguarding issues within the CCG and locality.

The CCG employs the expertise of a designated safeguarding doctor and safeguarding nurses for both children and adults. These roles are an integral part of the CCG’s activity and support the delivery of the safeguarding adult and children agenda.

Procurement

The CCG ensures that organisations commissioned to provide services have appropriate systems that safeguard children in line with section 11 of the Children Act (2004), and adults in line The Mental Capacity Act 2005, The Care Act 2014 and The Modern Slavery Act 2015.

With regards specifically to the Modern Slavery Act 2015, there is a specific question in our standard set in the pre-qualification questionnaire so that we can be assured of the approach of potential providers at the outset of a procurement.

In addition, the CCG’s contractual agreements (Standard NHS Contract) contain an obligation within clause SC1.2.2 for providers of services to ‘perform all of its obligations under the Contract in accordance with’:

1.1.1 the terms of this Contract; and 1.1.2 the Law; and 1.1.3 Good Practice’

Further, under SC32 Safety and Safeguarding there is a requirement upon all of our providers to have in place programmes for safeguarding and to co-operate with the Commissioner in pursuance of these.

The policies in relation to Slavery and Human Trafficking

Across the West Midlands there is a multi-agency policy and procedures for the protection of adults with care and support needs. This policy covers Modern Slavery and Trafficking. Across Warwickshire organisations will report any concerns direct to the police or into adult safeguarding.

Any concerns are directed to the police or into adult safeguarding.

The due diligence processes in relation to Slavery and Human Trafficking in its business and supply chains

The CCG is committed to ensuring that there is no Modern Slavery or Human Trafficking in our supply chains or in any part of our business.

Safe and robust recruitment principles are adhered to which includes strict requirements in respect of identity checks, work permits and criminal records. The pay structure is derived from national collective agreements and is based on equal pay principles with rates of pay that are nationally determined. The Remuneration Committee holds the organisation to account in adhering to these standards.

Systems are in place to encourage the reporting of concerns and the protection of whistle blowers.

With regards to providers and supply chains, we expect these entities to have suitable anti-slavery and human trafficking policies and processes in place. We will use our routine contract management meetings with major providers to hold them explicitly to account for compliance with the Act and we will implement any relevant clauses contained within the Standard NHS Contract for 2018/19.

All providers are contractually required to report compliance with safeguarding standards to the CCG using the agreed frameworks

The parts of its business and supply chains where there is a risk of Slavery and Human Trafficking taking place, and the steps it has taken to assess and manage that risk

The CCG is committed to social and environmental responsibility and has zero tolerance for Modern Slavery and Human Trafficking. Any identified concerns regarding Modern Slavery and Human Trafficking would be escalated as part of the organisational safeguarding process and in conjunction with partner agencies; such as the Local Authority and Police.

The effectiveness in ensuring that Slavery and Human Trafficking is not taking place in its business or supply chains, measured against such performance indicators as it considers appropriate

The CCG aims to be as effective as possible in ensuring that modern slavery and Human Trafficking is not taking place in any part of our business or supply chains by:

i. Effective interagency working with local authorities, the police and third sector organisations which includes appropriate arrangements for preventing and responding to modern slavery and Human Trafficking; ii. Signing up to the West Midlands multi-agency policy and procedures for the protection of adults with care and support needs; iii. Continuing to undertake robust NHS employment checks and payroll systems; iv. Ensuring good communication through contract management meetings, with our commissioned providers in the supply chain and their understanding of, and compliance with, our expectations in relation to the NHS terms and conditions. These conditions relate to issues including bribery, slavery and other ethical considerations. v. Requiring the CCG’s providers to provide the CCG with assurance around safeguarding compliance within the agreed framework.

Training about Slavery and Human Trafficking

Slavery and Human Trafficking is part of the organisation’s Mandatory Safeguarding Children and Adults training programme.

This statement is made pursuant to Section 54(1) of the Modern Slavery Act 2015 and constitutes our organisation’s modern slavery and human trafficking statement for the current financial year.

Andrea Green Chief Officer NHS Warwickshire North Clinical Commissioning Group Xx 2018

NHS Coventry and Rugby Clinical Commissioning Group Enc Q

Report To: Governing Body Meetings in Common

Report Title: Annual Audit Letter – Coventry and Rugby CCG

Report From: Clare Hollingworth, Chief Finance Officer

Date: 12 July 2018

Previously Considered by: Audit Committees in Common, 28 June 2018

Action Required (delete as appropriate)

Decision: Assurance:  Information: Confidential

Purpose of the Report: The purpose of this annual audit letter is to communicate to Members and external stakeholders, including members of the public, the key issues arising from audit work undertaken by the CCG’s External Auditors, EY LLP, which they consider should be brought to the attention of the Clinical Commissioning Group.

Key Points:

EY LLP issued an unqualified opinion on the CCG’s financial statement for the y/e 31 March 2018.

EY LLP issued an unqualified opinion on the CCG’s regularity of income and expenditure.

They issued a qualified ‘except-for’ conclusion in respect of the CCG’s arrangements for planning finances effectively to support the sustainable delivery of strategic priorities and maintain statutory functions. This was driven primarily by the following observations: • Between April 2017 and March 2018 the CCG has been under NHS England’s legal powers of direction; and • Although the CCG achieved a £2.65million surplus for 2017/18, it did so through significant use of non-recurrent measures. The Annual Audit Letter was considered by the Audit Committee on 28 June 2018.

Recommendation: The Coventry and Rugby CCG Governing Body is asked to note the Annual Audit Letter.

Implications

Objective(s) / Plans supported by this External Audit Plan report: Conflicts of Interest: Not applicable Non-Recurrent Expenditure: Not applicable Recurrent Expenditure: Not applicable Financial: Is this expenditure included within the CCG’s Financial Yes No N/A  Plan? (Delete as appropriate)

Page 1 of 2 NHS Coventry and Rugby Clinical Commissioning Group Enc Q

Performance: None identified in relation to this policy. Quality and Safety: None identified in relation to this policy. General Statement: The CCG is committed to fulfil its obligations under the Equality Act 2010, and to ensure services commissioned by the CCG are non-discriminatory on the grounds of any protected characteristics. Policies/decisions may need to be adjusted in line with any equality analysis or due regard. Any decision that is finalised Equality and Diversity: without being influenced by appropriate due regard could be deemed unlawful. Has an equality impact Yes assessment been undertaken? No N/A  (attached) (Delete as appropriate) Patient and Public Not applicable Engagement: Clinical Engagement: Not applicable Risk and Assurance: Not applicable

Page 2 of 2 NHS Coventry and Rugby Clinical Commissioning Group

Annual Audit Letter for the year ended 31 March 2018

June 2018

Ernst & Young LLP Contents

Contents

Executive Summary ...... 2 Purpose...... 6 Responsibilities...... 8 Financial Statement Audit ...... 11 Value for Money ...... 15 Other Reporting Issues ...... 18

The contents of this report are subject to the terms and conditions of our appointment as set out in our engagement letter dated 16 December 2016. This report is made solely to the Audit Committee and management of NHS Coventry and Rugby Clinical Commissioning Group (CCG) in accordance with our engagement letter. Our work has been undertaken so that we might state to the Audit Committee and management of the CCG those matters we are required to state to them in this report and for no other purpose. To the fullest extent permitted by law we do not accept or assume responsibility to anyone other than the Audit Committee and management of the CCG for this report or for the opinions we have formed.

Our Complaints Procedure – If at any time you would like to discuss with us how our service to you could be improved, or if you are dissatisfied with the service you are receiving, you may take the issue up with your usual partner or director contact. If you prefer an alternative route, please contact Steve Varley, our Managing Partner, 1 More London Place, London SE1 2AF. We undertake to look into any complaint carefully and promptly and to do all we can to explain the position to you. Should you remain dissatisfied with any aspect of our service, you may of course take matters up with our professional institute. We can provide further information on how you may contact our professional institute.

EY ÷ i Executive Summary Annual Audit Letter for the year ended 31 March 2018 – NHS Coventry and Rugby Clinical Commissioning Group

Executive Summary

We are required to issue an annual audit letter to NHS Coventry and Rugby Clinical Commissioning Group (the CCG) following completion of our audit procedures for the year ended 31 March 2018.

Below are the results and conclusions on the significant areas of the audit process.

Area of Work Conclusion Opinion on the CCG’s: Unqualified – the financial statements give a true and fair view of the financial position of the

► Financial statements CCG as at 31 March 2018 and of its expenditure and income for the year then ended

► Regularity of income and expenditure Unqualified – financial transactions were conducted within the CCG legal framework

► Parts of the remuneration and staff report to We had no matters to report be audited

► Consistency of the Annual Report and other Financial information in the annual report and published with the financial statements was information published with the financial consistent with the annual accounts statements

EY ÷ 2 Annual Audit Letter for the year ended 31 March 2018 – NHS Coventry and Rugby Clinical Commissioning Group

Area of Work Conclusion Reports by exception:

► Consistency of Governance Statement The Governance Statement was consistent with our understanding of the CCG

► Public interest report We had no matters to report in the public interest

► Value for money conclusion We issued a qualified ‘except-for’ conclusion in respect of the CCG’s arrangements for planning finances effectively to support the sustainable delivery of strategic priorities and maintain statutory functions. This was driven primarily by the following observations:

► Between April 2017 and March 2018 the CCG has been under NHS England’s legal powers of direction; and

► Although the CCG achieved a £2.65million surplus for 2017/18, it did so through significant use of non-recurrent measures.

Area of Work Conclusion Reporting to the CCG on its consolidation We concluded that the CCG’s consolidation schedules agreed, within a £300,000 tolerance, schedules to your audited financial statements

Reporting to the National Audit Office (NAO) We had no matters to report in line with group instructions

EY ÷ 3 Annual Audit Letter for the year ended 31 March 2018 – NHS Coventry and Rugby Clinical Commissioning Group

As a result of the above we have also:

Area of Work Conclusion Issued a report to those charged with Our Audit results report was issued on 25 May 2018 governance of the CCG communicating significant findings resulting from our audit. Issued a certificate that we have completed the Our certificate was issued on 25 May 2018 audit in accordance with the requirements of the Local Audit and Accountability Act 2014 and the National Audit Office’s 2015 Code of Audit Practice.

We would like to take this opportunity to thank the CCG staff for their assistance during the course of our work.

Stephen Clark

Partner For and on behalf of Ernst & Young LLP

EY ÷ 4 Purpose Annual Audit Letter for the year ended 31 March 2018 – NHS Coventry and Rugby Clinical Commissioning Group

Purpose

The Purpose of this Letter The purpose of this annual audit letter is to communicate to Members and external stakeholders, including members of the public, the key issues arising from our work, which we consider should be brought to the attention of the Clinical Commissioning Group (CCG).

We have already reported the detailed findings from our audit work in our 2017/18 annual results report to the 24 May 2018 Audit Committee, representing those charged with governance. We do not repeat those detailed findings in this letter. The matters reported here are the most significant for the CCG.

EY ÷ 6 Responsibilities Annual Audit Letter for the year ended 31 March 2018 – NHS Coventry and Rugby Clinical Commissioning Group

Responsibilities

Responsibilities of the Appointed Auditor Our 2017/18 audit work has been undertaken in accordance with the Audit Plan that we issued on 21 January 2018 and is conducted in accordance with the National Audit Office's 2015 Code of Audit Practice, International Standards on Auditing (UK and Ireland), and other guidance issued by the National Audit Office.

As auditors we are responsible for:

Expressing an opinion:

► On the 2017/18 financial statements;

► On the regularity of expenditure and income;

► On the parts of the remuneration and staff report to be audited;

► On the consistency of other information published with the financial statements, including the annual report; and

► On whether the consolidation schedules are consistent with the CCG's financial statements for the relevant reporting period. Reporting by exception:

► If the annual governance statement does not comply with relevant guidance or is not consistent with our understanding of the CCG;

► To the Secretary of State for Health and NHS England if we have concerns about the legality of transactions of decisions taken by the CCG;

► Any significant matters that are in the public interest; and

► Forming a conclusion on the arrangements the CCG has in place to secure economy, efficiency and effectiveness in its use of resources. Reporting to the National Audit Office (NAO) any differences over £300,000 between the consolidation schedules and the audited financial statements.

EY ÷ 8 Annual Audit Letter for the year ended 31 March 2018 – NHS Coventry and Rugby Clinical Commissioning Group

Responsibilities of the CCG The CCG is responsible for preparing and publishing its statement of accounts, annual report and annual governance statement. It is also responsible for putting in place proper arrangements to secure economy, efficiency and effectiveness in its use of resources.

EY ÷ 9 Financial Statement Audit Annual Audit Letter for the year ended 31 March 2018 – NHS Coventry and Rugby Clinical Commissioning Group

Financial Statement Audit

Key Issues The Annual Report and Accounts is an important tool for the CCG to show how it has used public money and how it can demonstrate its financial management and financial health.

We audited the CCG’s Statement of Accounts in line with the National Audit Office’s 2015 Code of Audit Practice, International Standards on Auditing (UK and Ireland), and other guidance issued by the National Audit Office and issued an unqualified audit report on 25 May 2018.

Our detailed findings were reported to the 24 May 2018 Audit Committee meeting.

The key issues identified as part of our audit were as follows:

Significant Risk Conclusion Uncertainty of Continuing Healthcare (CHC) We performed all the planned procedures communicated to the Audit Committee in our 21 Position January 2018 audit plan. Notably: Over the past two years there has been both • We carried out transaction testing on the processed invoices, agreeing them back to the significant uncertainty about the accuracy of new system and Individual Patient Agreements (IPAs); information provided in respect of CHC • We reviewed the CCG’s methodology for in-year and year-end CHC accruals, including liabilities by Arden GEM CSU and a change in challenging key assumptions used; both the system used to administer (migration • We reviewed an updated accrual calculation based on invoices in respect of 2017/18 to Broadcare in 2016/17) and a transfer of received up to the end of April 2018; responsibility to the CCG in 2017/18. • We considered the accuracy of the prior year CHC accrual and the impact of that on the current year recorded expenditure and accrual.

We consider this to present a significant risk Our testing has not identified any material misstatements with respect to CHC expenditure, both in respect of the accurate recording of including the year-end accrual. care package liabilities, the prompt and accurate processing of invoices from care As in previous years, our testing identified care packages where an Individual Patient providers, and the process for estimating year Agreement signed by the CCG and provider could not be produced. This increases the risk to end accruals in respect of un-invoiced care. the CCG of contract disputes arising. These matters impact the CCGs ability to accurately identify its year-end position.

EY ÷ 11 Annual Audit Letter for the year ended 31 March 2018 – NHS Coventry and Rugby Clinical Commissioning Group

Management override of controls A risk present on all audits is that management We obtained a full list of the journals posted to the CCG’s general ledger during the year, and is in a unique position to perpetrate fraud analysed these journals using criteria we set to identify unusual journal types or amounts. because of its ability to manipulate accounting We then tested a sample of journals that met our criteria and tested these to supporting records directly or indirectly, and prepare documentation. fraudulent financial statements by overriding We considered the risk was most focussed around those items of expenditure that are non- controls that otherwise appear to be operating routine and involve more management estimation and judgement such as year-end accruals effectively. and was linked to the risk of fraud in revenue and expenditure recognition. Auditing standards require us to respond to this risk by testing the appropriateness of journals, We did not identify any material weaknesses in controls or evidence of material management testing accounting estimates for possible override. management bias and obtaining an understanding of the business rationale for any We did not identify any instances of inappropriate judgements being applied. significant unusual transactions. We did not identify any transactions during our audit which appeared unusual or outside the CCG’s normal course of business.

Revenue and expenditure recognition Auditing standards also require us to presume In order to address this risk we carried out a range of procedures including: that there is a risk that revenue and • Testing the appropriateness of journal entries recorded in the general ledger; expenditure may be misstated due to improper • Reviewing significant accounting estimates (e.g. accruals of Continuing Healthcare and recognition or manipulation. Prescribing) for evidence of management bias; We responded to this risk by reviewing and • Reviewing the treatment of revenue items to ensure that they were, where appropriate, testing material revenue and expenditure offset against the corresponding expenditure; streams and revenue cut-off at the year end. • Testing a sample of accruals for reasonableness; • Evaluating the business rationale for any significant unusual transactions; and We considered that this risk could be increased • Performing cut-off testing of transactions both before and after year-end to ensure that by the CCG’s financial position resulting in a risk they were accounted for in the correct year. that the financial statements could be manipulated to ensure that the budgeted position was achieved. Our testing did not identify any material misstatements with respect to revenue and expenditure recognition.

Overall our audit work did not identify any material issues or unusual transactions which indicated that there had been any misreporting of the CCG’s financial position.

EY ÷ 12 Annual Audit Letter for the year ended 31 March 2018 – NHS Coventry and Rugby Clinical Commissioning Group

Our application of materiality When establishing our overall audit strategy, we determined a magnitude of uncorrected misstatements that we judged would be material for the financial statements as a whole.

Item Thresholds applied Planning materiality We determined planning materiality to be £6 million, which is 1% of gross revenue expenditure. We considered gross revenue expenditure to be one of the principal considerations for stakeholders in assessing the financial performance of the CCG.

Reporting threshold We agreed with the Audit Committee in our Audit Plan that we would report to the committee all uncorrected audit differences in excess of £250k.

We evaluate any uncorrected misstatements against both the quantitative measures of materiality discussed above and in light of other relevant qualitative considerations.

EY ÷ 13 Value for Money Annual Audit Letter for the year ended 31 March 2018 – NHS Coventry and Rugby Clinical Commissioning Group

Value for Money

We are required to consider whether the CCG has put in place ‘proper arrangements’ to secure economy, efficiency and effectiveness on its use of resources. This is known as our value for money conclusion.

Proper arrangements are defined by statutory guidance issued by the National Audit Office. They comprise your arrangements to:

· Take informed decisions; · Deploy resources in a sustainable manner; and · Work with partners and other third parties.

Informed decision making

Proper arrangements for securing value for money

Sustainable Working with resource partners and deployment third parties

EY ÷ 15 Annual Audit Letter for the year ended 31 March 2018 – NHS Coventry and Rugby Clinical Commissioning Group

We identified two significant risks in relation to these arrangements. The tables below presents the findings of our work in response to the risks identified and any other significant weaknesses or issues to bring to your attention.

We therefore issued a qualified value for money conclusion in relation to the CCG’s arrangements for planning finances effectively to support the sustainable delivery of strategic priorities and maintain statutory functions.

Significant Risk Conclusion Financial Position & Sustainability

Discussions with management and review of We concluded that this provides evidence that in respect of sustainable resource deployment, the reporting to Governing Body identified that the arrangements have not been adequate during the 2017/18 year. CCG was expecting its financial position to deteriorate during the remainder of the financial year, with expenditure in all areas exceeding forecast (Acute, CHC, and Prescribing). Additionally achievement of QIPP Savings was forecast to be well below target for the remainder of the year.

Working with partners and other third parties

This risk relates to the CCG working with third Despite identifying a significant risk in respect of working with the CSU, we have seen evidence that parties effectively to deliver strategic priorities. the CCG have used contractual levers available to it in order to manage the relationship with and This manifests itself in the following ways: output of the CSU. We have also reviewed the arrangements for monitoring and reporting provider • The CCG has over the past few years performance and overall have concluded that no qualification is required on the ‘working with experienced significant service quality partners’ criterion. performance issues with respect to the CSU. The CCG had not, as at December 2017, agreed a service level agreement with its CSU; • Key providers consistently not meeting national and local performance targets.

EY ÷ 16 Other Reporting Issues Annual Audit Letter for the year ended 31 March 2018 – NHS Coventry and Rugby Clinical Commissioning Group

Other Reporting Issues

Department of Health/NHS England Group Instructions We reported to the National Audit office (NAO) on 25 May 2018 the outcomes of our review of your summarisation schedules/accounts template conducted under the group instructions issued by the NAO. We did not identify any areas of concern.

Annual Governance Statement We are required to consider the completeness of disclosures in the CCG’s annual governance statement, identify any inconsistencies with the other information of which we are aware from our work, and consider whether it complies with relevant guidance.

Referral to Secretary of State We must report to the Secretary of State any matter where we believe a decision has led to, or would lead to, unlawful expenditure, or some action has been, or would be, unlawful and likely to cause a loss or deficiency.

We did not identify any issues which required us to issue a report to the Secretary of State.

Report in the Public Interest We have a duty under the Local Audit and Accountability Act 2014 to consider whether, in the public interest, to report on any matter that comes to our attention in the course of the audit in order for it to be considered by the CCG or brought to the attention of the public.

We did not identify any issues which required us to issue a report in the public interest.

EY ÷ 18 Annual Audit Letter for the year ended 31 March 2018 – NHS Coventry and Rugby Clinical Commissioning Group

Control Themes and Observations As part of our work, we obtained an understanding of internal control sufficient to plan our audit and determine the nature, timing and extent of testing performed. Although our audit was not designed to express an opinion on the effectiveness of internal control, we are required to communicate to you significant deficiencies in internal control identified during our audit.

We have adopted a fully substantive approach and have therefore not tested the operation of controls.

The matters reported are shown below and are limited to those deficiencies that we identified during the audit and that we concluded are of sufficient importance to merit being reported.

Description Impact Our testing of Continuing Healthcare The absence of a signed contract being in place increases the risk of contract disputes. Expenditure revealed several instances where the Individual Patient Agreements were not signed by both the CCG and the care provider.

EY ÷ 19 EY | Assurance | Tax | Transactions | Advisory

Ernst & Young LLP

© Ernst & Young LLP. Published in the UK. All Rights Reserved.

ED None

The UK firm Ernst & Young LLP is a limited liability partnership registered in England and Wales with registered number OC300001 and is a member firm of Ernst & Young Global Limited.

Ernst & Young LLP, 1 More London Place, London, SE1 2AF. ey.com NHS Warwickshire North Clinical Commissioning Group Enc R

Report To: Governing Body Meetings in Common

Report Title: Annual Audit Letter – Warwickshire North CCG

Report From: Clare Hollingworth, Chief Finance Officer

Date: 12 July 2018

Previously Considered by: Audit Committees in Common, 28 June 2018

Action Required (delete as appropriate)

Decision: Assurance:  Information: Confidential

Purpose of the Report: The purpose of this annual audit letter is to communicate to Members and external stakeholders, including members of the public, the key issues arising from the External Audit work undertaken by the CCG’s External Auditors, EY LLP, which they consider should be brought to the attention of the Clinical Commissioning Group.

Key Points:

EY LLP issued an unqualified opinion on the CCG’s financial statement for the y/e 31 March 2018.

EY LLP issued a qualified ‘except for’ opinion on the CCG’s regularity of income and expenditure.

They issued a qualified ‘except-for’ conclusion in respect of the CCG’s arrangements for planning finances effectively to support the sustainable delivery of strategic priorities and maintain statutory functions. This was driven primarily by the following observations; • The CCG recorded an in-year deficit of £3.7m. • QIPP achievement for 17-18 was 72% against the stretch target and 75.6% against the original NHSE target. • In conjunction with NHS England the CCG have set a £1m deficit budget for 18-19 reflecting their view of the CCG’s continuing journey back to financial recovery. Recommendation: The Warwickshire North CCG Governing Body is asked to note the Annual Audit Letter.

Implications

Objective(s) / Plans supported by this External Audit Plan report: Conflicts of Interest: Not applicable Non-Recurrent Expenditure: Not applicable Recurrent Expenditure: Not applicable Financial: Is this expenditure included within the CCG’s Financial Yes No N/A  Plan? (Delete as appropriate) Performance: None identified in relation to this policy.

Page 1 of 2 NHS Warwickshire North Clinical Commissioning Group Enc R

Quality and Safety: None identified in relation to this policy. General Statement: The CCG is committed to fulfil its obligations under the Equality Act 2010, and to ensure services commissioned by the CCG are non-discriminatory on the grounds of any protected characteristics. Policies/decisions may need to be adjusted in line with any equality analysis or due regard. Any decision that is finalised Equality and Diversity: without being influenced by appropriate due regard could be deemed unlawful. Has an equality impact Yes assessment been undertaken? No N/A  (attached) (Delete as appropriate) Patient and Public Not applicable Engagement: Clinical Engagement: Not applicable Risk and Assurance: Not applicable

Page 2 of 2 NHS Warwickshire North Clinical Commissioning Group

Annual Audit Letter for the year ended 31 March 2018

JUNE 2018

Ernst & Young LLP Contents

Contents

Executive Summary ...... 2 Purpose...... 6 Responsibilities...... 8 Financial Statement Audit ...... 11 Value for Money ...... 15 Other Reporting Issues ...... 18

The contents of this report are subject to the terms and conditions of our appointment as set out in our engagement letter dated 16 December 2016. This report is made solely to the Audit Committee and management of NHS Warwickshire North Clinical Commissioning Group (CCG) in accordance with our engagement letter. Our work has been undertaken so that we might state to the Audit Committee and management of the CCG those matters we are required to state to them in this report and for no other purpose. To the fullest extent permitted by law we do not accept or assume responsibility to anyone other than the Audit Committee and management of the CCG for this report or for the opinions we have formed.

Our Complaints Procedure – If at any time you would like to discuss with us how our service to you could be improved, or if you are dissatisfied with the service you are receiving, you may take the issue up with your usual partner or director contact. If you prefer an alternative route, please contact Steve Varley, our Managing Partner, 1 More London Place, London SE1 2AF. We undertake to look into any complaint carefully and promptly and to do all we can to explain the position to you. Should you remain dissatisfied with any aspect of our service, you may of course take matters up with our professional institute. We can provide further information on how you may contact our professional institute.

EY ÷ i Executive Summary Annual Audit Letter for the year ended 31 March 2018 – NHS Warwickshire North Clinical Commissioning Group

Executive Summary

We are required to issue an annual audit letter to NHS Warwickshire North Clinical Commissioning Group (the CCG) following completion of our audit procedures for the year ended 31 March 2018.

Below are the results and conclusions on the significant areas of the audit process.

Area of Work Conclusion Opinion on the CCG’s:

► Financial statements Unqualified – the financial statements give a true and fair view of the financial position of the CCG as at 31 March 2018 and of its expenditure and income for the year then ended

► Regularity of income and expenditure Qualified, ‘except for’ – due to the incurrence of expenditure in excess of the specified revenue resource limit as set out in Note 23 to the financial statements.

► Parts of the remuneration and staff report to We had no matters to report be audited

► Consistency of the Annual Report and other Financial information in the annual report and published with the financial statements was information published with the financial consistent with the annual accounts statements

EY ÷ 2 Annual Audit Letter for the year ended 31 March 2018 – NHS Warwickshire North Clinical Commissioning Group

Area of Work Conclusion Reports by exception:

► Consistency of Governance Statement The Governance Statement was consistent with our understanding of the CCG

► Referrals to the Secretary of State and NHS We reported the fact that on 23 May 2017 we referred a matter to the Secretary of State England under s30 of the Local Audit and Accountability Act 2014 reporting the fact that the Governing body had approved a deficit budget for the 2017-18 financial year

► Public interest report We had no matters to report in the public interest

► Value for money conclusion We issued a qualified ‘except-for’ conclusion in respect of the CCG’s arrangements for planning finances effectively to support the sustainable delivery of strategic priorities and maintain statutory functions. This was driven primarily by the following observations;

► The CCG recorded an in-year deficit of £3.7m.

► QIPP achievement for 17-18 was 72% against the stretch target and 75.6% against the original NHSE target.

► In conjunction with NHS England the CCG have set a £1m deficit budget for 18-19 reflecting their view of the CCG’s continuing journey back to financial recovery.

Area of Work Conclusion Reporting to the CCG on its consolidation We concluded that the CCG’s consolidation schedules agreed, within a £300,000 tolerance, schedules to your audited financial statements

Reporting to the National Audit Office (NAO) We had no matters to report in line with group instructions

EY ÷ 3 Annual Audit Letter for the year ended 31 March 2018 – NHS Warwickshire North Clinical Commissioning Group

As a result of the above we have also:

Area of Work Conclusion Issued a report to those charged with Our Audit results report was issued on 25 May 2018 governance of the CCG communicating significant findings resulting from our audit. Issued a certificate that we have completed the Our certificate was issued on 25 May 2018 audit in accordance with the requirements of the Local Audit and Accountability Act 2014 and the National Audit Office’s 2015 Code of Audit Practice.

We would like to take this opportunity to thank the CCG staff for their assistance during the course of our work.

Stephen Clark

Partner For and on behalf of Ernst & Young LLP

EY ÷ 4 Purpose Annual Audit Letter for the year ended 31 March 2018 – NHS Warwickshire North Clinical Commissioning Group

Purpose

The Purpose of this Letter The purpose of this annual audit letter is to communicate to Members and external stakeholders, including members of the public, the key issues arising from our work, which we consider should be brought to the attention of the Clinical Commissioning Group (CCG).

We have already reported the detailed findings from our audit work in our 2017/18 annual results report to the 24 May 2018 Audit Committee, representing those charged with governance. We do not repeat those detailed findings in this letter. The matters reported here are the most significant for the CCG.

EY ÷ 6 Responsibilities Annual Audit Letter for the year ended 31 March 2018 – NHS Warwickshire North Clinical Commissioning Group

Responsibilities

Responsibilities of the Appointed Auditor Our 2017/18 audit work has been undertaken in accordance with the Audit Plan that we issued on 29 January 2018 and is conducted in accordance with the National Audit Office's 2015 Code of Audit Practice, International Standards on Auditing (UK and Ireland), and other guidance issued by the National Audit Office.

As auditors we are responsible for:

Expressing an opinion:

► On the 2017/18 financial statements;

► On the regularity of expenditure and income;

► On the parts of the remuneration and staff report to be audited;

► On the consistency of other information published with the financial statements, including the annual report; and

► On whether the consolidation schedules are consistent with the CCG's financial statements for the relevant reporting period. Reporting by exception:

► If the annual governance statement does not comply with relevant guidance or is not consistent with our understanding of the CCG;

► To the Secretary of State for Health and NHS England if we have concerns about the legality of transactions of decisions taken by the CCG;

► Any significant matters that are in the public interest; and

► Forming a conclusion on the arrangements the CCG has in place to secure economy, efficiency and effectiveness in its use of resources. Reporting to the National Audit Office (NAO) any differences over £300,000 between the consolidation schedules and the audited financial statements.

EY ÷ 8 Annual Audit Letter for the year ended 31 March 2018 – NHS Warwickshire North Clinical Commissioning Group

Responsibilities of the CCG The CCG is responsible for preparing and publishing its statement of accounts, annual report and annual governance statement. It is also responsible for putting in place proper arrangements to secure economy, efficiency and effectiveness in its use of resources.

EY ÷ 9 Financial Statement Audit Annual Audit Letter for the year ended 31 March 2018 – NHS Warwickshire North Clinical Commissioning Group

Financial Statement Audit

Key Issues The Annual Report and Accounts is an important tool for the CCG to show how it has used public money and how it can demonstrate its financial management and financial health.

We audited the CCG’s Statement of Accounts in line with the National Audit Office’s 2015 Code of Audit Practice, International Standards on Auditing (UK and Ireland), and other guidance issued by the National Audit Office and issued an unqualified audit report on 30 May 2017.

Our detailed findings were reported to the 24 May 2018 Audit Committee meeting.

The key issues identified as part of our audit were as follows:

Significant Risk Conclusion Uncertainty of Continuing Healthcare (CHC) We performed all the planned procedures communicated to the Audit Committee in our 29 Position January 2018 audit plan. Notably: Over the past two years there has been both • We carried out transaction testing on the processed invoices, agreeing them back to the significant uncertainty about the accuracy of new system and Individual Patient Agreements (IPAs); information provided in respect of CHC • We assessed and challenged the assumptions and calculations applied by CRCCG to the liabilities by Arden GEM CSU and a change in data from the new system; both the system used to administer (migration • We reviewed an updated accrual calculation based on invoices in respect of 2017/18 to Broadcare in 2016/17) and a transfer of received up to the end of April 2018; responsibility to the CCG in 2017/18. • We considered the accuracy of the prior year CHC accrual and the impact of that on the We considered this presented a significant risk current year recorded expenditure and accrual. both in respect of the accurate recording of care package liabilities, the prompt and Our testing did not identify any material misstatements with respect to CHC expenditure, accurate processing of invoices from care including the year-end accrual. providers, and the process for estimating year As in previous years, our testing identified care packages where an Individual Patient end accruals in respect of un-invoiced care. Agreement signed by the CCG and provider could not be produced. This increases the risk to We considered the risk was relevant to both in- the CCG of contract disputes arising. year expenditure and year-end accruals.

EY ÷ 11 Annual Audit Letter for the year ended 31 March 2018 – NHS Warwickshire North Clinical Commissioning Group

Management override of controls A risk present on all audits is that management We obtained a full list of the journals posted to the CCG’s general ledger during the year, and is in a unique position to perpetrate fraud analysed these journals using criteria we set to identify unusual journal types or amounts; because of its ability to manipulate accounting We then tested a sample of journals that met our criteria and tested these to supporting records directly or indirectly, and prepare documentation; fraudulent financial statements by overriding We considered that the accounting estimates most susceptible to bias were the accruals for controls that otherwise appear to be operating continuing healthcare costs, and prescribing. We tested these as part of our audit work. effectively. Auditing standards require us to respond to this We did not identify any material weaknesses in controls or evidence of material management risk by testing the appropriateness of journals, override. testing accounting estimates for possible management bias and obtaining an We did not identify any instances of inappropriate judgements being applied. understanding of the business rationale for any We did not identify any transactions during our audit which appeared unusual or outside the significant unusual transactions. CCG’s normal course of business.

Revenue and expenditure recognition Auditing standards also require us to presume In order to address this risk we carried out a range of procedures including: that there is a risk that revenue and • Testing the appropriateness of journal entries recorded in the general ledger; expenditure may be misstated due to improper • Reviewing significant accounting estimates (eg accruals of continuing healthcare and recognition or manipulation. prescribing) for evidence of management bias; We respond to this risk by reviewing and testing • Reviewing the treatment of revenue items to ensure that they were, where appropriate, material revenue and expenditure streams and offset against the corresponding expenditure. revenue cut-off at the year end. • Testing a sample of accruals for reasonableness; • Evaluating the business rationale for any significant unusual transactions; and We considered that this risk could be increased • Performing cut-off testing of transactions both before and after year-end to ensure that by the CCG’s financial position resulting in a risk they were accounted for in the correct year. that the financial statements could be manipulated to ensure that the budgeted position was achieved. Our testing did not identify any material misstatements with respect to revenue and expenditure recognition.

Overall our audit work did not identify any material issues or unusual transactions which indicated that there had been any misreporting of the CCG’s financial position.

EY ÷ 12 Annual Audit Letter for the year ended 31 March 2018 – NHS Warwickshire North Clinical Commissioning Group

Our application of materiality When establishing our overall audit strategy, we determined a magnitude of uncorrected misstatements that we judged would be material for the financial statements as a whole.

Item Thresholds applied Planning materiality We determined planning materiality to be £2.4 million, which is 1% of gross revenue expenditure. We consider gross revenue expenditure to be one of the principal considerations for stakeholders in assessing the financial performance of the CCG.

Reporting threshold We agreed with the Audit Committee that we would report to the Committee all audit differences in excess of £122k.

We evaluate any uncorrected misstatements against both the quantitative measures of materiality discussed above and in light of other relevant qualitative considerations.

EY ÷ 13 Value for Money Annual Audit Letter for the year ended 31 March 2018 – NHS Warwickshire North Clinical Commissioning Group

Value for Money

We are required to consider whether the CCG has put in place ‘proper arrangements’ to secure economy, efficiency and effectiveness on its use of resources. This is known as our value for money conclusion.

Proper arrangements are defined by statutory guidance issued by the National Audit Office. They comprise your arrangements to:

· Take informed decisions; · Deploy resources in a sustainable manner; and · Work with partners and other third parties.

Informed decision making

Proper arrangements for securing value for money

Sustainable Working with resource partners and deployment third parties

EY ÷ 15 Annual Audit Letter for the year ended 31 March 2018 – NHS Warwickshire North Clinical Commissioning Group

We identified two significant risks in relation to these arrangements. The tables below presents the findings of our work in response to the risks identified and any other significant weaknesses or issues to bring to your attention.

We therefore issued a qualified ‘except-for’ value for money conclusion in relation to the CCG’s arrangements for planning finances effectively to support the sustainable delivery of strategic priorities and maintain statutory functions.

Significant Risk Conclusion Financial Position & Sustainability

Discussions with management and review of The CCG recorded an in-year deficit of £3.7m. reporting to Governing Body identified that, at QIPP achievement for 17-18 was 72% against the stretch target and 75.6% against the original month 8, whilst the CCG was reporting it would NHSE target. meet its allocation, there remained a distinct In conjunction with NHS England the CCG have set a £1m deficit budget for 18-19 reflecting their possibility that the CCG may need to formally view of the CCG’s continuing journey back to financial recovery. report a net risk position to NHSE. QIPP achievement was forecast at 62% , below the 75% We considered that this is evidence of weakness in the arrangements to secure economy, efficiency threshold deemed acceptable by NHSE. and effectiveness in the CCG’s use of resources.

Working with partners and other third parties

This risk relates to the CCG working with third Despite identifying a significant risk in respect of working with the CSU, we have seen evidence that parties effectively to deliver strategic priorities. the CCG have used contractual levers available to it in order to manage the relationship with and This manifests itself in the following ways: output of the CSU. • The CCG has over the past few years Based on the results of our work we concluded that the CCG’s arrangements in respect of working experienced significant service quality with partners and other third parties for the year ended 31 March 2018 have been appropriate to performance issues with respect to the address the identified risks. CSU. The CCG had not, as at December 2017, agreed a service level agreement with its CSU. • Key providers consistently not meeting national and local performance targets.

EY ÷ 16 Other Reporting Issues Annual Audit Letter for the year ended 31 March 2018 – NHS Warwickshire North Clinical Commissioning Group

Other Reporting Issues

Department of Health/NHS England Group Instructions We reported to the National Audit office (NAO) on 25 May 2018 the outcomes of our review of your summarisation schedules/accounts template conducted under the group instructions issued by the NAO. We did not identify any areas of concern.

Annual Governance Statement We are required to consider the completeness of disclosures in the CCG’s annual governance statement, identify any inconsistencies with the other information of which we are aware from our work, and consider whether it complies with relevant guidance.

Referral to Secretary of State We must report to the Secretary of State any matter where we believe a decision has led to, or would lead to, unlawful expenditure, or some action has been, or would be, unlawful and likely to cause a loss or deficiency.

On 23 May 2017 we referred a matter to the Secretary of State under s30 of the Local Audit and Accountability Act 2014 reporting the fact that the Governing body had approved a deficit budget for the 2017-18 financial year.

Report in the Public Interest We have a duty under the Local Audit and Accountability Act 2014 to consider whether, in the public interest, to report on any matter that comes to our attention in the course of the audit in order for it to be considered by the CCG or brought to the attention of the public.

We did not identify any issues which required us to issue a report in the public interest.

EY ÷ 18 Annual Audit Letter for the year ended 31 March 2018 – NHS Warwickshire North Clinical Commissioning Group

Control Themes and Observations As part of our work, we obtained an understanding of internal control sufficient to plan our audit and determine the nature, timing and extent of testing performed. Although our audit was not designed to express an opinion on the effectiveness of internal control, we are required to communicate to you significant deficiencies in internal control identified during our audit.

We have adopted a fully substantive approach and have therefore not tested the operation of controls.

The matters reported are shown below and are limited to those deficiencies that we identified during the audit and that we concluded are of sufficient importance to merit being reported.

Description Impact Our testing of Continuing Healthcare The absence of a signed contract being in place increases the risk of contract disputes. Expenditure revealed several instances where the Individual Patient Agreements were not signed by both the CCG and the care provider.

EY ÷ 19 EY | Assurance | Tax | Transactions | Advisory

Ernst & Young LLP

© Ernst & Young LLP. Published in the UK. All Rights Reserved.

ED None

The UK firm Ernst & Young LLP is a limited liability partnership registered in England and Wales with registered number OC300001 and is a member firm of Ernst & Young Global Limited.

Ernst & Young LLP, 1 More London Place, London, SE1 2AF. ey.com NHS Coventry and Rugby Clinical Commissioning Group NHS Warwickshire North Clinical Commissioning Group Enc S

Report To: Governing Body Meetings in Common

Report Title: Non-Medical Prescribing in Primary Care Policy

Report From: Jo Galloway, Chief Nursing Officer

Date: 12 July 2018

Previously Considered by: Clinical Quality and Governance Committee in Common, 27 June 2018

Action Required (delete as appropriate)

Decision:  Assurance: Information: Confidential

Purpose of the Report: To present the updated Non-medical prescribers (NMP) Policy for practitioners in Primary Care for ratification and adoption.

Key Points: • Warwickshire North NMP policy still in date – (Expires May 2020) • Coventry and Rugby NMP policy expired in 2016 • Arden & GEM CSU manage NMP on the behalf of Warwickshire North CCG • In house ‘medicine management team’ manages NMP in Coventry and Rugby CCG. • Therefore Warwickshire North NMP policy has been merged with Coventry and Rugby NMP policy to create one policy that covers both CCG areas but also takes into account the two processes.

• The policy was considered by the Clinical Quality and Governance Committees in Common on 27 June 2018 and recommended to Governing Bodies for ratification and adoption.

Recommendation: The Governing Bodies are asked to APPROVE the policy for adoption.

Page 1 of 2 NHS Coventry and Rugby Clinical Commissioning Group NHS Warwickshire North Clinical Commissioning Group Enc S

Implications

Objective(s) / Plans supported by this Quality and safety in primary care report: Conflicts of Interest: None identified Non-Recurrent Expenditure: Not applicable Recurrent Expenditure: Not applicable Financial: Is this expenditure included within the CCG’s Financial Yes No N/A  Plan? (Delete as appropriate) The policy includes the requirement for nurses to register with the CCG and subsequently NHS Business Support Authority (BSA), as such individual nurse Performance: prescribing data will be produced so that the practitioner and their mentor and the CCG and audit prescribing activity. Performance issues may arise from this i.e. if a practitioner is prescribing outside their scope of practice. Improve patient safety so that all NMP prescribing activity is auditable and the CCG Quality and Safety: have an up to date register of all NMP’s General Statement: The CCG is committed to fulfil its obligations under the Equality Act 2010, and to ensure services commissioned by the CCG are non-discriminatory on the grounds of any protected characteristics. Policies/decisions may need to be adjusted in line with any equality analysis or due regard. Any decision that is finalised Equality and Diversity: without being influenced by appropriate due regard could be deemed unlawful. Has an equality impact Yes assessment been undertaken?  No N/A (attached) (Delete as appropriate) Patient and Public Not applicable Engagement: Policy updated by Karen Marley Lead nurse for primary care- quality, in concurrence with Altaz Dahanni ( Meds Management) , Lisa Scullion (Meds Management), Clinical Engagement: Rebecca Bartholomew (Director of nursing- Quality), Sam Collier (Clinical Governance lead), Arden Gem Meds optimising team. If policy not in place risks are that the CCG do not know who ( NMP’s) are prescribing and where on the CCG medicine budget, that practitioner may be practicing outside Risk and Assurance: their scope of practice or may not have valid and/ or current registration with their professional body as there is no audit trail.

Page 2 of 2

Policy for Non-Medical Prescribing in General Practice

NHS Warwickshire North CCG and Coventry & Rugby CCG Policy for Page 1 of 17 Non-Medical Prescribing Version V4

VERSION CONTROL

Version: 3.1

Ratified by: NHS Warwickshire North CCG Governing Body

Date ratified:

Medicines Optimisation Team, Arden & GEM Name of originator/author: CSU, NHSE Coventry and Warwickshire CCG Ratified by: NHSE Warwickshire North CCG

Date ratified: Clinical Quality, Safety and Governance Name of responsible committee: Committee

Date issued:

Review date:

VERSION HISTORY

Date Version Comment/Update February 2014 V1 Draft

17 April 2014 V1 Policy approved by Clinical Quality Safety and Governance Committee, with amendments and recommended for ratification by Warwickshire North CCG Governing Body 22 May 2014 V1 The Governing Body approved the adoption of the policy 15 October 2015 V1.1 Clinical Quality, Safety and Governance Committee requested to approve the updated Policy of Non- Medical Prescribing and recommend it to the Governing Body for approval to adopt 26 November 2015 V2 The Governing Body approved the adoption of the Policy 06 December 2016 V3 Updates to Appendices

May 2018 V4 Incorporated Coventry & Rugby CCG Update of appendices, added annual update of competency, added Electronic prescribing paragraph. GDPR responsibilities added

NHS Warwickshire North CCG and Coventry & Rugby CCG Policy for Page 2 of 17 Non-Medical Prescribing Version V4

Contents

1. Introduction and Background ...... 4 2. Purpose and Scope ...... 4 3. Responsibilities ...... 4 4. Definitions ...... 5 5. Staff Eligible to become Qualified Prescribers ...... 6 6. Registration with Professional Body on Completion of Course ...... 6 7. Registration Registering as a non-medical prescriber in primary care ...... 6 Ordering of Prescription Pads ...... 7 Prescribers Leaving Employment/Change of Role ...... 7 8. Indemnity Insurance and Legal Liability ...... 7 9. Prescribing ...... 7 10. Documentation and Record Keeping ...... 8 11. Security and Safe Handling of Prescription Pads ...... 8 12. Handling Adverse Drug Reactions and Clinical Incidents ...... 9 13. Working with the Pharmaceutical Industry ...... 10 14. Training Requirements ...... 10 15. Review of Compliance with the Policy Including Monitoring of Prescribing and Practice. 10 16. “Off Licence” or “Off Label” Prescribing by Non-Medical Independent Prescribers...... 10 17. Scope of the Role of the Independent Prescriber ...... 10 18. Prescribing for Children ...... 11 19. Supplementary Prescribing ...... 11 20. Continuing Professional Development (CPD) & Supervision for Non-Medical Prescribers 12 21. BNFs and Drug Tariffs ...... 12 22. Drug Alerts and Urgent Communications ...... 12 23. References ...... 13 Appendix 1: Approval of Non-Medical Prescriber’s Competence and Scope of Practice ...... 14 Appendix 2: Notification of change of circumstance of Non-Medical Independent Prescriber 15 Appendix 3: Leaver Notification of Non-Medical Independent Prescriber ...... 16 Appendix 4: Equality Impact Assessment ...... 17

NHS Warwickshire North CCG and Coventry & Rugby CCG Policy for Page 3 of 17 Non-Medical Prescribing Version V4

1. Introduction and Background

1.1. The proposals for non-medical prescribing were first introduced after the Review of Prescribing, Supply and Administration of Medicines, chaired by Dr June Crown CBE when district nurses and health visitors were allowed to prescribe from a limited list of medication in 1998.

1.2. In 2001 non-medical prescribing was extended and the Extended Formulary for Nurses was introduced which allowed trained nurse prescribers to prescribe for a limited list of conditions from an extended formulary. In April 2003 regulations came into force for Nurse and Pharmacist Supplementary Prescribing, so that after an initial assessment of a patient by a doctor, the non-medical prescriber (NMP) could prescribe for that patient in accordance with a clinical management plan (CMP).

1.3. In 2006 regulations allowed pharmacists and nurses to practice as Independent Prescribers and to prescribe, within their competency, licensed Prescription Only Medicine (POM), Pharmacy medicine (P) & General Sales List medicine (GSL) on FP10.

1.4. Non-medical prescribing now includes a variety of qualified and registered health professionals.

2. Purpose and Scope

2.1. This supports the practice of prescribing in primary care settings.

2.2. This includes:

• Nurse Independent Prescribers (formerly known as extended formulary nurse prescribers (EFNP) or nurse prescriber (NP) – V300) • Supplementary prescribing by nurses (SPN) • Community Practitioner Nurse Prescribers (formerly known as District Nurse or Health Visitor Prescribers – V100 or V150) • Independent or Supplementary prescribing by pharmacists • Emergency Nurse Prescribing (including emergency care practitioners) • Prescribing by other Allied Health Professionals e.g. physiotherapists, opticians, pharmacists

2.3. This policy covers the registration, practice and clinical governance of all non- medical prescribers (NMP) and it operates in conjunction with the NMP’s own provider prescribing policies and procedures.

3. Responsibilities

3.1. Prescribers must act in accordance with the standards set by their registering body for prescribing and comply with their registration requirements.

3.2. Prescribers must act within their own professional competence and expertise when prescribing.

NHS Warwickshire North CCG and Coventry & Rugby CCG Policy for Page 4 of 17 Non-Medical Prescribing Version V4

3.3. Prescribing must be a recognised function of the job role and included within the Prescribers job description.

3.4. NHS Warwickshire North Clinical Commissioning Group (WNCCG) and Coventry & Rugby CCG (CRCCG) will process and co-ordinate the new prescriber details and declaration of competence.

3.5. NHS Warwickshire North CCG and Coventry & Rugby CCG will register new prescribers with NHS Business Services Authority (NHSBSA). This can only be done by a CCG authorised signatory, please complete appendix 1 to activate registration procedure.

3.6. NHS Arden & GEM Commissioning Support Unit Medicines Optimisation Team, on behalf of NHS Warwickshire North CCG, monitors prescribing trends of all prescribers within North Warwickshire general practices. Coventry & Rugby CCG monitor prescribing trends in house through the medicine management team. For Non-medical prescribers it is important that your competency areas are clear and kept up to date. To update the CCG of any changes please use appendix 2

3.7. Other employing organisations will monitor non-medical prescribers in accordance with their internal governance processes.

3.8. Prescribers must ensure that they process data in accordance with the General Data Protection Regulation.

4. Definitions

4.1. Prescribing means ordering the use of a medicine or other treatment.

4.2. Community Practitioner Nurse Prescribers (formerly known as district nurse and health visitor prescribers) - Following training, which is incorporated into the initial preparation of district nurses and health visitors, these groups of nurses and new community prescribers who have completed V150 training can prescribe from the Nurse Prescribers Formulary for Community Practitioners Details of this formulary, which consists of appliances, dressings and some medicines are found at the back of the BNF under Nurse Prescribers’ Formulary Appendix and Part XVIIB(I) of the Drug Tariff.

4.3. Nurse Independent Prescribers (formerly known as Extended Formulary Nurse Prescribers) - Nurses and midwives who are on the relevant parts of the Nursing and Midwifery Council (NMC) register may train to prescribe any licensed medicine for any medical condition, including some Controlled Drugs (see current guidance) Independent prescribers must work within their own level of professional competence and expertise.

4.4. Independent prescribing - This term applies to a prescriber who is legally permitted and qualified to prescribe and take the responsibility for the clinical assessment of the patient, establishing a diagnosis and the clinical management required. Independent prescribers are also responsible and accountable for their own prescribing decisions. They can prescribe any licensed medicine for any medical condition including some Controlled Drugs (see current guidance).

4.5. Supplementary prescribing - Supplementary prescribing is defined as a voluntary NHS Warwickshire North Clinical Commissioning Group Page 14 of 17 Commissioning Policy – Policy for Non-Medical Prescribing Version V3

partnership between an independent prescriber (doctor or dentist) and a supplementary prescriber to implement an agreed patient-specific Clinical Management Plan, with the patient’s agreement. The key principles of supplementary prescribing emphasise the importance of communication between the prescribing partners, the need for access to shared patient records and that the patient is treated as a partner in their care.

4.6 Prescription forms (NHS England) - NHS English ‘FP10’ secure prescription forms are numbered and have anti-counterfeiting and anti-forgery features. They are purchased by CCGs and hospitals via a secure ordering system and distributed free. The range of prescription forms used by GPs, nurses, NHS dentists and other prescribers is listed on the NHSBSA website.

4.7 Electronic Prescribing Service (EPS) is a way of issuing prescriptions and electronic signing of prescriptions represents the prescriber’s authorisation. It will be important to bear in mind the following:

• Prescriptions electronically sent to the NHS spine for access by the dispensing pharmacy, must be authorised by the prescriber and this is represented by the electronic signature. • The signature must not be used by any other person than the authoriser. • The electronic signature must be stored in a password protected area. • The practice must have a robust protocol for the electronic issue of prescriptions including repeat dispensing which meets clinical governance and risk management issues.

5. Staff Eligible to become Qualified Prescribers

5.1 Practitioners who satisfy ALL the following conditions will be entitled to prescribe as non-medical prescribers, with costs allocated to the CCG’s prescribing budget:

• Works within a GP practice setting, Prescription Ordering Direct (POD) team or other approved cost centre within the CCG area. • Has successfully completed an approved prescribing / extended prescribing training course. • Is registered with the appropriate regulatory body (e.g. NMC, GPhC) as a prescriber. • Is authorised / required by the employing authority to prescribe. • Must have a statement in their job description permitting them to prescribe. • Is authorised by the CCG to register with NHSBSA (completion and submission of form appendix 1)

6. Registration with Professional Body on Completion of Course

6.1 The prescriber must register as such with the appropriate regulatory body before commencing their prescribing role. Details of the registration process are normally given by the course provider but can also be obtained from the appropriate regulatory body.

NHS Warwickshire North Clinical Commissioning Group Page 14 of 17 Commissioning Policy – Policy for Non-Medical Prescribing Version V3

7. Registering as a non-medical prescriber in primary care.

7.1 The prescriber and their line manager must update and agree the prescriber’s job description to reflect their new role and prescribing responsibilities before prescribing is undertaken

7.2 New employees should have their prescribing qualification checked at interview stage and verified before employment, if this constitutes part of their job description.

7.3 A DBS check must be undertaken by the employing practice. In addition, a relevant job description which identifies the scope of practice/prescribing and appropriate professional indemnity cover will be required.

7.4 It is essential that mechanisms for clinical mentorship, competency maintenance and second opinion referral are in place.

7.5 The NHS Business Support Authority (formally The Prescription Pricing Authorities) in the UK requires confirmation from the NMC of a registrant’s qualification to prescribe and the scope of their prescribing qualification. The prescriber’s information is printed on handwritten prescriptions and must be used to authorise computer-generated prescriptions.

7.5 Where the prescriber will be allocated to a CCG cost centre; prescribers and their employers are required to complete the Approval of Non-medical Prescriber’s Competence and Scope of Practice form (Appendix 1) The CCG quality team [email protected]

7.6 NHS Arden & GEM CSU for Warwickshire North practices and Coventry & Rugby CCG for Coventry & Rugby are responsible for preparing documentation for submission by the CCG Authorised Signatory, in order to ensure that all non- medical prescribers in general practice are registered with the NHS Business Services Authority (NHSBSA).

Ordering of Prescription Pads and EPS

7.7 Non-medical prescribers employed by general practices: Once the prescriber has been registered and authorised by the CCG and NHSBSA – a prescription pad (if required) can be ordered by the PCSE portal. For any queries regarding this please e-mail: [email protected] detailing the NMP names NMC /GPHC number (if applicable). The prescriber will be able to use their PIN number /GPHC number to use EPS.

7.8 For Non-medical prescribers employed by other providers please refer to your organisations internal governance arrangements and policies.

Prescribers Leaving Employment / Change of Role/ competency

7.9 Within general practice the practitioner must inform the CCG of any change in circumstances (e.g. change of name, end of employment, new competencies)

NHS Warwickshire North Clinical Commissioning Group Page 14 of 17 Commissioning Policy – Policy for Non-Medical Prescribing Version V3

using either Appendix 2 or 3 as appropriate. The CCG ( Coventry & Rugby) or Arden & GEM CSU (Warwickshire North) are responsible for completing the appropriate paperwork for submission to the NHSBSA , to ensure that non-medical prescribers in general practice are registered/deregistered with the NHS BSA.

7.10 The CCG must be informed of changes of circumstances contemporaneously.

7.11 It is the responsibility of the prescriber to ensure that prescription pads are securely destroyed in line with local policy. The person who destroys the forms should make a record of the serial numbers of the forms destroyed which will be kept for 18 months. This will help to resolve any queries that may be received from the NHS BSA.

7.12 Prescribers employed directly by other healthcare providers should follow their own policy and processes for ordering and managing prescription pads.

7.13 The practice should deactivate the prescriber once they leave the practice from the practice software system to ensure no further prescriptions or repeats’ can be issued under the prescribers PIN number

8. Indemnity Insurance and Legal Liability

8.1 All providers employing non-medical providers should ensure that indemnity insurance and legal liability are in place.

9. Prescribing

9.1 All non-medical prescribers hold individual clinical liability for undertaking the assessment and follow up of all patients for whom they may prescribe.

9.2 Prescribers may: • Prescribe for patients registered with GP practices for whom the clinical commissioning group has set the NHS prescribing budget • Prescribe for visitors if they are temporarily registered with a GP practice within the CCG • Prescribe for travellers where this forms part of the prescribers roles and responsibilities and is included in their job description • Prescribe for patients outside the CCG area where this has been agreed as part of a service level agreement with another organisation for service provision

9.3 The prescriber must prescribe only for the specific patient. Those prescription items belong to the patient and are not transferable.

9.4 Prescribers may prescribe the same item on more than one occasion if it is deemed clinically appropriate.

9.5 Prescriptions may be either handwritten or computer generated and must be signed and dated by the prescriber.

9.6 Controlled Drugs must only be prescribed in accordance with the current legislation and best practice where there is a clinical need. Prescribers should not routinely prescribe and administer controlled drugs. In exceptional circumstances where a non-medical prescriber is involved in both prescribing and administering a patient/client’s controlled drug, a second suitably competent person should be NHS Warwickshire North Clinical Commissioning Group Page 14 of 17 Commissioning Policy – Policy for Non-Medical Prescribing Version V3

involved in checking the accuracy of the medication provided.

9.7

10. Documentation and Record Keeping

10.1 All prescribers are required to keep records, which are accurate, unambiguous and legible in line with requirements of the registering body standards for records. Prescribers have a duty to keep up to date with, and adhere to, relevant legislation, case law, and national and local policies relating to information (including the General Data Protection Regulation) and record keeping.

10.2 Any item prescribed by a designated non-medical prescriber must be entered into all patient records within 24 hours. Where it is not possible to enter details into records directly, the information should be passed on to the appropriate person with this authority (e.g. fax a letter to a patient’s GP). If it is not possible to locate a patient’s GP (e.g. travellers) then a record should be made in the prescriber’s records and include the patient's name, date of birth, address where seen, details of prescription, date given.

11. Security and Safe Handling of Prescription Pads

11.1 It is the responsibility of each non-medical prescriber to ensure the security of the prescription pads at all times.

11.2 Prescription pads are controlled stationery (i.e. stationery which, in the wrong hands, could be used to obtain medicines and/or medical items fraudulently) and are the property of the employing organisation.

11.3 The non-medical prescriber must keep a record of the serial numbers of the first and last prescription numbers on receipt of a new pad. It is advisable that the prescriber is aware of all prescriptions used/written so that in the event of a pad being lost or stolen the number remaining can be estimated.

11.4 In the event of loss or theft of a prescription pad the following procedure should be followed.

• Prescriber to collate details of the approximate number of prescriptions lost and the prescription serial numbers.

• Prescriber to report loss immediately, to ALL of the following:

. The non-medical prescriber’s employer . The appropriate CCG . NHS Counter Fraud

• NHS England will inform all pharmacies and relevant GP practices with details of the name and address of the prescriber concerned and the approximate number of prescriptions stolen and the serial numbers of the prescriptions

• The prescriber will be advised to write and sign all prescriptions in a particular colour (usually red) for a period of two months. Computer generated prescriptions should be signed in this colour. NHS Warwickshire North Clinical Commissioning Group Page 14 of 17 Commissioning Policy – Policy for Non-Medical Prescribing Version V3

NB: Under no circumstances should blank prescription forms be pre- signed before use.

Prescription pads should not be left unattended or accessible to others. They should be locked away securely and access should be restricted to the individual prescriber.

When travelling, the prescription pad should not be visible and should be locked in the car boot. The prescription pad should be removed when the car is unattended.

The prescription pad is the property of the employing organisation and must be returned to the district administrator on termination of employment or when the prescriber ceases prescribing duties.

Further guidance is available on: https://www.nhsbsa.nhs.uk/pharmacies-gp-practices-and- appliance-contractors/prescribing-and-dispensing/prescription-forms

12 Handling Adverse Drug Reactions and Clinical Incidents

12.1 All adverse drug reactions (ADR) should be reported in accordance with Medicines Healthcare Regulatory Agency (MHRA) Yellow Card system https://yellowcard.mhra.gov.uk

12.2 All ADRs and incidents should be recorded in the patient’s clinical records.

13 Working with the Pharmaceutical Industry

13.1 Prescribers should act within their professional code of conduct and be aware of the Department of Health’s and their employer’s policy in relation to working with the pharmaceutical industry.

14 Training Requirements

14.1 To access non-medical prescribing training, you must be registered with a professional body e.g. NMC and meet certain educational requirements. Discuss with your employer in the first case as you will need their approval and a Prescribing mentor. Contact your local training hub for further details.

15 Review of Compliance with the Policy Including Monitoring of Prescribing and Practice

15.1 Practitioners should audit their own practice as part of their ongoing review of CPD needs .ePACT data will be available from the CCG and sent out to practices on a 6 monthly basis.

15.2 All Prescribing activity within GP practices is monitored by NHS Arden & GEM CSU in Warwickshire North and the CCG for Coventry & Rugby practices

16 “Off Licence” or “Off Label” Prescribing by Non-Medical Independent Prescribers NHS Warwickshire North Clinical Commissioning Group Page 14 of 17 Commissioning Policy – Policy for Non-Medical Prescribing Version V3

16.1 Nurse and Pharmacist independent prescribers can prescribe medicines outside their licensed indications (so called “off licence” or “off label” use), where this is acceptable clinical practice and there is a body of evidence to support this practice. It must be documented and signed with the prescribers PIN. They must however, accept professional, clinical and legal responsibility for that prescribing. If prescribing ‘off label’ the prescriber should explain the situation to the patient/guardian, where possible, but where a patient is unable to agree to such treatment, the prescriber should act in accordance with best practice in the given situation and within the policy of their employing organisation.

16.2 Nurse and pharmacist independent prescribers cannot prescribe unlicensed medicines (products without a UK marketing authorisation).

17 Scope of the Role of the Independent Prescriber

17.1 NMPs will prescribe in specific areas as agreed with their employers and clinical teams, and depending on their skills and expertise. All prescribers must only work within their own level of professional competence and expertise.

17.2 To define and promote the relevant competencies to prescribe, the National Prescribing Centre (NPC) has developed a competency framework, available on its

website at http://www.npc.co.uk/improving_safety/improving_quality/resources/single_comp_fra

https://www.rpharms.com/Portals/0/RPS%20document%20library/Open%20access/ Professional%20standards/Prescribing%20competency%20framework/prescribing- competency-framework.pdf

17.3 The framework establishes 3 areas of competence – Prescribing Governance, the consultation and the patient. NPC has integrated into NICE, therefore further medicines and prescribing support can be found on https://bnf.nice.org.uk/guidance/non-medical-prescribing.html

18 Prescribing for Children

18.1 Only NMPs with relevant knowledge, competence, skills and experience in nursing children should prescribe for children. This is particularly important in primary care, e.g. out-of-hours services, walk-in-clinics and general practice settings. Anyone prescribing for a child in these situations must be able to demonstrate competence to prescribe for children and refer to another prescriber when working outside their area of expertise and level of competence (NMC 2006). Prescribers should utilise the BNF for Children and relevant national guidance for paediatric services within their practice as appropriate.

19 Supplementary Prescribing

19.1 Supplementary prescribing is a voluntary partnership between an independent prescriber (who must be a doctor or a dentist) and a supplementary prescriber, to implement an agreed patient specific clinical management plan (CMP), with the patient’s agreement.

19.2 Supplementary prescribing was introduced in the UK in 2003 for nurses and pharmacists, and was extended in England in 2005 to chiropodists/ podiatrists, NHS Warwickshire North Clinical Commissioning Group Page 14 of 17 Commissioning Policy – Policy for Non-Medical Prescribing Version V3

physiotherapists, radiographers and optometrists.

19.3 It is a legal requirement for a CMP to be in place before supplementary prescribing can begin.

19.4 Following diagnosis by an independent prescriber (doctor or dentist), the CMP is drawn up with the supplementary prescriber who can then prescribe any medicines specified in the plan, or in accordance with any guidelines specified in the CMP.

19.5 The CMP is held in the patient’s medical records and must be easily accessible by both the independent and supplementary prescribers.

19.6 NHS regulations allow the prescribing of controlled drugs and unlicensed (including “off label”) medication if specified in the CMP.

19.7 The independent prescriber is responsible for determining what the CMP covers, and the limits of the supplementary prescriber’s responsibility, including for prescribing and reviews.

19.8 Supplementary prescribers must work within their professional competence and must consult and pass back prescribing responsibility to the independent \prescriber where necessary.

20 Continuing Professional Development (CPD) and Supervision for Non-Medical Prescribers

20.1 All healthcare professionals, including NMPs, have a statutory responsibility to maintain their CPD. For NMPs, it is essential to ensure that CPD is in line with their role as a prescriber. It is advised that the documents produced A competency framework for prescribers (accredited by NICE)) are used as a tool to assist in reflection on practice and identifying continuing developmental needs.

20.2 It is the responsibility of the practitioner to ensure that they regularly reflect on prescribing decisions and maintain their knowledge on prescribing matters. Individual staff appraisal, Professional Development Plans and clinical supervision/mentorship should be used as tools to support this process. In addition, all non-medical prescribers are expected to update their knowledge and skills on an annual basis in order to maintain competency and evidence this by reflecting on the learning within their professional portfolio.

20.3 Employers also have a responsibility to ensure that prescribers have access to undertake the relevant continuing professional development as identified through their staff appraisal. This must be undertaken for the practitioner to maintain registration as competent to prescribe.

21 BNFs and Drug Tariffs

21.1 BNF

21.2 Drug tariff.

22 Drug Alerts and Urgent Communications

NHS Warwickshire North Clinical Commissioning Group Page 14 of 17 Commissioning Policy – Policy for Non-Medical Prescribing Version V3

22.1 NHS England circulates drug alerts and other urgent communications. It is essential that NMPs provide NHS England with an up-to-date email address to allow this information to be cascaded promptly.

23 References

23.1 Further information on non-medical prescribing is available from:

. The Department of Health https://www.gov.uk/government/organisations/department-of-health

. Information and Guidance on Non-Medical Prescribing is available from www.dh.gov.uk/health/2012/04/prescribing-change

. The NHS Business Services Authority http://www.nhsbsa.nhs.uk/PrescriptionServices.aspx

. The Nursing and Midwifery Council www.nmc-uk.org

. NMC- Standards of proficency for nurse and midwife prescribers:

https://www.nmc.org.uk/standards/standards-for-post-registration/standards-for- prescribers/standards-of-proficiency-for-nurse-and-midwife-prescribers/

o A Competency Framework for all Prescribers- Royal Pharmaceutical society https://www.rpharms.com/Portals/0/RPS%20document%20library/Open%20access/Prof essional%20standards/Prescribing%20competency%20framework/prescribing- competency-framework.pdf

NHS Warwickshire North Clinical Commissioning Group Page 14 of 17 Commissioning Policy – Policy for Non-Medical Prescribing Version V3

Appendix 1: Approval of Non-Medical Prescriber’s Competence and Scope of Practice Non–Medical Prescriber Details

Name ..……………………………………………………………Mr / Mrs / Miss / Ms / Sister

Role…………………………………………………Work Email Address…………………………….. Work

Location …………………………………Cost/Practice Code ……………………………………

Date of Registration with the appropriate Professional Body………………………………………… (Please attach copy of Statement of entry)

NMP code (e.g. NMC /GPhC/Regulatory body code) : ………………………………………………

Start date: ………………………………………………………………………………………………… I have read and will work in accordance with the current NHS Warwickshire North CCG. Coventry and Rugby CCG Policy for Non-Medical Prescribing

Signature of Non-Medical Prescriber : Non- medical prescriber (NMP) Type Nurse/Midwife/Optometrist/Pharmacist/Physiotherapist/ (circle as appropriate) Podiatrist/Radiographer Type of Qualification Held tick Community Practitioner Nurse Prescriber Formulary (V100 or (for Nurse prescribers only) V150) Nurse Independent Prescriber Formulary (V300) Disease area to be prescribed for Evidence of competence to prescribe in these areas and /or types of drugs to be e.g. asthma diploma/experience in clinical field prescribed e.g. asthma, palliative care, mental health, controlled drugs

Use of Prescribing authority; FP10s Other (please state) (tick all that apply) These are the agreed parameters for this individual’s prescribing activity. We the undersigned have read and will work in accordance with this CCG Policy for Non-Medical Prescribing Name Signature Date Line Manager Clinical Lead/GP Principal CCG Authorised Signatory

Once verified and authorised this data will be shared with NHSBSA in order to register the applicant as a non-medical prescriber and assign prescribing activity to the workplace. The CCG will securely store the date in order to review, and audit prescribing activity and forward EPACT data to the workplace /practitioner for PDR reflection/ revalidation (if applicable). Data will be destroyed when appendix 3 is sent to the CCG. NHS Warwickshire North Clinical Commissioning Group Page 14 of 17 Commissioning Policy – Policy for Non-Medical Prescribing Version V3

Practice to forward this form email to: [email protected]

NHS Warwickshire North Clinical Commissioning Group Page 14 of 17 Commissioning Policy – Policy for Non-Medical Prescribing Version V3

Appendix 2: Notification of change of circumstance of Non-Medical Independent Prescriber

Non–Medical Prescriber Details

Name ..………………………………………………………………Mr / Mrs / Miss / Ms / Sister

Role:……………………………………………………………...…………………………………………

Work Location ………………………………… Cost/Practice Code ………………………………….

Date of Registration with the appropriate Professional Body ………………………………………. (Please attach copy of Statement of entry)

NMP code (e.g. NMC /GPhC/Regulatory body code) ………………………………

I have read and will work in accordance with the current NHS Warwickshire North, Coventry & Rugby CCG Policy for Non-Medical Prescribing

Signature of Non-Medical Prescriber:

Existing Details New Details

Details of change required (tick as appropriate):

Change of NMP Code □ Change of Surname/Title/Initials □ Change of Qualification □ Change in competency scope

Date of change:

We the undersigned have read and will work in accordance with NHS Warwickshire North CCG Policy for Non-Medical Prescribing Name Signature Date Line Manager Clinical Lead/GP Principal

Please return this form by email to: [email protected]

NHS Warwickshire North Clinical Commissioning Group Page 15 of 17 Policy for Non-Medical Prescribing Version V3

Appendix 3: Leaver Notification of Non-Medical Independent Prescriber

Non–Medical Prescriber Details

Name ..……………………………………………………………Mr / Mrs / Miss / Ms / Sister

Role:……………………………………………………………...…………………………………………

Work Location ………………………………… Cost/Practice Code ………………………………….

Date of Registration with the appropriate Professional Body ………………………………………. (Please attach copy of Statement of entry)

NMP code (e.g. NMC /GPhC/Regulatory body code) : ………………………………

The practitioner has been deactivated on the practice EPS and (if relevant) all unused prescription pads returned. Yes ………… No……….. ( please tick)

I have read and will work in accordance with the current NHS Warwickshire North, Coventry & Rugby CCG Policy for Non-Medical Prescribing

Signature of Non-Medical Prescriber:

Leaving Date:

Details of new work location: Practice Name & Address:

Date from (insert intended date of commencement at new work location):

We the undersigned have read and will work in accordance with NHS Warwickshire North CCG Policy for Non-Medical Prescribing Name Signature Date Line Manager Clinical Lead/GP Principal

Please return this form by email to:[email protected]

NHS Warwickshire North Clinical Commissioning Group Page 16 of 17 Policy for Non-Medical Prescribing Version V3

Appendix 4: Equality Impact Assessment

See separate attachment

NHS Warwickshire North Clinical Commissioning Group Page 17 of 17 Policy for Non-Medical Prescribing Version V3 NHS Coventry and Rugby Clinical Commissioning Group NHS Warwickshire North Clinical Commissioning Group Enc T

Report To: Governing Bodies Meeting in Common

Report Title: Updated Gifts and Hospitality Policy

Report From: Maria Maltby, Deputy Director of Corporate Affairs

Date: 28 June 2018

Previously Considered by: Audit Committees in Common, 28 June 2018

Action Required (delete as appropriate)

Decision:  Assurance: Information: Confidential

Purpose of the Report: To present the revised Gifts and Hospitality Policy for ratification and adoption.

Key Points: • In July 2017, NHS England published an update to the 2016 CCG statutory guidance on managing conflicts of interest to ensure that it is fully aligned with the recently published NHS-wide conflicts of interest guidance - Managing conflicts of interest in the NHS: Guidance for staff and organisations. • The key changes from the 2016 version of the guidance in relation to gifts and hospitality include: • Gifts from suppliers or contractors: In line with the NHS-wide guidance, gifts of low value (up to £6), such as promotional items, can now be accepted. • Gifts from other sources: Also in line with the wider guidance, gifts of under £50 (rather than £10) can be accepted from non-suppliers and non-contractors, and do not need to be declared; and gifts with a value of over £50 can now be accepted on behalf of an organisation, but not in a personal capacity. • Hospitality: meals and refreshments: An amendment to the thresholds to advise that hospitality under £25 does not need to be declared. Hospitality between £25 and £75 can be accepted, but must be declared, and hospitality over £75 should be refused unless senior approval is given. • Commercial Sponsorship: The previous guidance made no reference to this. The new guidance states that sponsorship is welcomed providing specific principles are followed. • The CCGs’ policy has been updated to fully reflect the updated statutory guidance and reflects joint working arrangements between the two CCGs. • The CCGs Audit Committees in Common considered the policy at its meeting on 28 June 2018 and recommended the policy to Governing Body for approval and adoption.

Recommendation:

The Governing Bodies are asked to APPROVE the Gifts and Hospitality policy for adoption.

Implications

Objective(s) / Plans This policy supports the requirement for the CCG to be compliant with NHS England supported by this Statutory Guidance in relation to managing conflicts of interest and is in line with the report: CCG’s Constitution. Conflicts of Interest: No conflicts of interest are identified in relation to this policy.

Page 1 of 2 NHS Coventry and Rugby Clinical Commissioning Group NHS Warwickshire North Clinical Commissioning Group Enc T

Non-Recurrent Expenditure: Not applicable Recurrent Expenditure: Not applicable Financial: Is this expenditure included within the CCG’s Financial Yes No N/A  Plan? (Delete as appropriate) Performance: None identified in relation to this policy. Quality and Safety: None identified in relation to this policy. General Statement: The CCG is committed to fulfil its obligations under the Equality Act 2010, and to ensure services commissioned by the CCG are non-discriminatory on the grounds of any protected characteristics. Policies/decisions may need to be adjusted in line with any equality analysis or due regard. Any decision that is finalised Equality and Diversity: without being influenced by appropriate due regard could be deemed unlawful. Has an equality impact Yes assessment been undertaken?  No N/A (attached) (Delete as appropriate) Patient and Public None relevant to this policy. The policy will be available on the CCG’s website. Engagement: No local engagement requirements identified. Clinical engagement has been Clinical Engagement: undertaken by NHS England at a national level. The CCG has a duty to ensure that it is compliant with NHS England Statutory Guidance relating to the management of conflicts of interest. Risk and Assurance: The CCG’s Assurance Rating could be impacted if there is no compliance with the statutory guidance.

Page 2 of 2 Gifts and Hospitality Policy

NHS Warwickshire North Clinical Commissioning Group and NHS Coventry and Rugby Page 1 of 14 Clinical Commissioning Group Draft Gifts and Hospitality Policy April 2018

VERSION CONTROL

Version: 1.0

Ratified by: NHS Coventry and Rugby (CRCCG) and NHS Warwickshire North CCG (WNCCG) Governing Bodies

Date ratified: To be confirmed

Name of originator/author: Maria Maltby, Deputy Director of Corporate Affairs

Name of responsible committee: CRCCG/WNCCG Audit Committees

Date issued: June 2018

Review date: June 2021

VERSION HISTORY

Date Version Comment / Update

October 2017 0.1 Previous CCG policies updated to reflect closer working between CRCCG and WNCCG following approval of the CCGs’ Managing Conflicts of Interest Policy in September 2017. TBC 0.1 Audit Committee (CRCCG/WNCCG meeting in common) reviewed and approved the updated Policy. Recommended the Policy to the Governing Body (WNCCG/CRCCG meeting in common) for approval to adopt ……………………….. ………………………………… TBC CRCCG and WNNCG Governing Bodies approved the adoption of the Policy.

NHS Warwickshire North Clinical Commissioning Group and NHS Coventry and Rugby Page 2 of 14 Clinical Commissioning Group Draft Gifts and Hospitality Policy April 2018

Contents

1. Introduction ...... 4 2. Purpose ...... 4 3. Scope ...... 4 4. Definitions ...... 6 5. Receipt of Gifts and Hospitality ...... 6 6. Provision of Internal Hospitality ...... 9 7. Equality and Diversity Statement ...... 9 8. Monitoring Compliance and Effectiveness of the Policy ...... 9 Appendix 1 - Template Declaration of Gifts and Hospitality Form ...... 11 Appendix 2 - Register of Gifts and Hospitality Template...... 12 Appendix 3 - Decision Making Staff ...... 13 Appendix 4 - Equality Impact Assessment ...... 14

NHS Warwickshire North Clinical Commissioning Group and NHS Coventry and Rugby Page 3 of 14 Clinical Commissioning Group Draft Gifts and Hospitality Policy April 2018

1. Introduction

1.1. NHS Warwickshire North Clinical Commissioning Group and NHS Coventry and Rugby Clinical Commissioning Group (CCGs) are required to have procedures and guidance in place to record the offers and receipt of gifts and hospitality made to members, staff and other individuals engaged on official business on behalf of the CCGs. A further requirement is that the CCGs maintain a register of all types of interests and relationships of those employed by or acting on behalf of the CCGs. This policy should be read in conjunction with the CCGs’ Managing Conflicts of Interest Policy.

1.2. The context of this policy is also shaped by the Bribery Act 2010 which revised the legal framework for combating bribery and corruption in the public and private sectors. This act makes it an offence to offer, seek, give or receive a financial or other advantage as a reward for an improper act, such as the award of a contract. Penalties for bribery offences can extend as far as an unlimited fine and / or up to ten years in prison. A gifts and hospitality policy is therefore a key tool in helping organisations demonstrate they have arrangements in place to discourage the offer or acceptance of such rewards.

2. Purpose

2.1. This policy sets out the standards and procedures which must be followed in respect of gifts and hospitality. It is intended to help members, staff, lay members and others working with the CCGs to understand their responsibilities in protecting themselves and the CCGs against any suggestion of impropriety or inappropriate behaviour.

2.2. This policy helps establish a culture of openness and transparency in the CCGs’ business transactions. To maintain public confidence, the CCGs must be able to demonstrate that their decision-making processes are not influenced by inappropriate inducements. Gifts and hospitality should not be accepted other than in exceptional circumstances and as set out in this policy.

2.3. The CCGs will view instances where this policy is not followed as serious and may take disciplinary action against individuals as a result, which may result in dismissal. The CCGs will refer cases of potential fraud or bribery to the CCGs’ Local Counter Fraud Specialist for investigation. Where appropriate, the Police will be involved.

2.4. Specifically the policy aims to: a) Ensure that members and staff are clear about the guiding principles for the acceptance of gifts; b) Ensure that all members and staff are clear about hospitality they are able to accept when away from the CCGs; c) Ensure that all members and staff are clear about what hospitality they should provide for meetings, both internal and external to the CCGs.

3. Scope

3.1. This policy applies to all those who are employed by the CCGs and/or act in an official capacity on their behalf. This includes: • All CCG employees, including: • All full and part time staff;

NHS Warwickshire North Clinical Commissioning Group and NHS Coventry and Rugby Page 4 of 14 Clinical Commissioning Group Draft Gifts and Hospitality Policy April 2018

• Any staff on sessional or short term contracts; • Any students and trainees (including apprentices); • Agency staff; and • Seconded staff In addition, any self-employed consultants or other individuals working for the CCG under a contract for services should make a declaration of interest in accordance with this policy, as if they were CCG employees. • Members of the Governing Body: All members of the CCGs’ committees, and any sub-groups, including: • Co-opted members; • Appointed deputies; and • Any members of committees/groups from other organisations. • All members of the CCGs (ie, partners or directors within each practice): This includes each provider of primary medical services which is a member of the CCG under Section 14O (1) of the 2006 Act. Declarations should be made by the following groups: • GP Partners (or where the practice is a company, each director); and • Any individual directly involved with the business or decision-making of the CCGs

(Note: GPs and other staff within the CCGs’ member practices are not required to declare offers/receipt of gifts and hospitality to the CCGs which are unconnected with their role or involvement with the CCGs. GP staff will however be expected to adhere to other relevant guidance issued by professional bodies.)

3.2. It is the responsibility of all individuals specified in 3.1 to familiarise themselves with this policy and comply with its provisions.

3.3. The policy should be read in conjunction with the following documents, which also set out generic guidelines and responsibilities for NHS organisations and general practitioners in relation to the receipt of gifts and hospitality conflicts of interests: a) The CCGs’ Constitutions, in particular sections relating to conflicts of interest which describe in generic terms the types of conflict of interest, as well as the CCG’s Standing Orders, Scheme of Reservation and Delegation of Powers and Standing Financial Instructions; b) Guidance issued by NHS England; c) Code of Conduct for NHS Managers1; d) General Medical Council: Good Medical Practice 20062; e) Nursing and Midwifery Council: Code of Professional Conduct.

3.4. This policy complies with ‘NHS England Managing Conflicts of Interest, Revised Statutory guidance for CCGs 2017’ and ‘Managing Conflicts of Interest in the NHS – Guidance for staff and organisations’.

1 Code of Conduct for NHS Managers, Department of Health, Feb. 2007 2 General Medical Council: Good Medical Practice 2006 Sec 73, 74, 75, 76 NHS Warwickshire North Clinical Commissioning Group and NHS Coventry and Rugby Page 5 of 14 Clinical Commissioning Group Draft Gifts and Hospitality Policy April 2018

4. Definitions

4.1. A 'gift' is defined as any item of cash or goods, or any service, which is provided for personal benefit, free of charge or at less than its commercial value.

4.2. Hospitality means offers of meals, refreshments, travel, accommodation, and other expenses in relation to attendance at meetings, conferences, education, and training events etc.

5. Receipt of Gifts and Hospitality

5.1 All individuals listed in paragraph 3.1 must not accept gifts, hospitality and benefits of any kind from a third party which might affect, or be seen to affect, their professional judgement. This is especially important during procurement exercises, as the acceptance of gifts could give rise to real or perceived conflicts of interests, or accusations of unfair influence, collusion or canvassing.

Gifts

5.2 Gifts from suppliers or contractors doing business (or likely to do business ) with the CCGs should be declined, whatever their value (subject to this, low cost branded promotional aids may be accepted and not declared where they are under the value of a common industry standard of £6). The person to whom the gifts were offered should also declare the offer to the Associate Director of Corporate Affairs so the offer which has been declined can be recorded on the gifts and hospitality register. 5.3 Gifts from other sources (eg, patients, families, service users) under a value of £50 may be accepted and do not need to be declared. A common sense approach should be applied to the valuing of gifts (using an actual amount, if known, or an estimate that a reasonable person would make as to its value), however: • CCG staff should not ask for any gifts; • Gifts valued at over £50 should be treated with caution and only be accepted on behalf of an organisation (i.e. to an organisation’s charitable funds), not in a personal capacity. These should be declared by the individuals concerned. • Multiple gifts from the same source over a 12 month period should be treated in the same way as single gifts over £50 where the cumulative value exceeds £50.

5.4 Any personal gift of cash or cash equivalents (eg, vouchers, tokens, offers of remuneration to attend meetings whilst in a capacity working for or representing the CCGs) must always be declined, whatever their value and whatever their source, and the offer which has been declined must be declared to the Associate Director of Corporate Affairs and recorded on the register.

Hospitality

5.5 Delivery of services across the NHS relies on working with a wide range of partners (including industry and academia) in different places and, sometimes outside of ‘traditional’ working hours. As a result, CCG staff will sometimes appropriately receive hospitality. However, individuals should be able to justify why it has been accepted, and be mindful that even hospitality of a small value may give rise to perceptions of impropriety and might influence behaviour.

NHS Warwickshire North Clinical Commissioning Group and NHS Coventry and Rugby Page 6 of 14 Clinical Commissioning Group Draft Gifts and Hospitality Policy April 2018

5.6 Hospitality must only be accepted when there is a legitimate business reason and it is proportionate to the nature and purpose of the event.

5.7 CCG staff should not ask for or accept hospitality that may affect, or be seen to affect, their professional judgement. Particular caution should be exercised when hospitality is offered by actual or potential suppliers or contractors, these can be accepted if modest and reasonable, but individuals should always obtain senior approval and declare these.

5.8 Offers of meals and refreshments under £25 may be accepted and need not be declared. Offers of a value between £25 and £75 may be accepted and must be declared. Offers over a value of £75 should be refused unless (in exceptional circumstances) approval from the Chief Officer (Accountable Officer) is given.

5.9 A common sense approach should be applied to the valuing of meals and refreshments (using an actual amount, if known, or an estimate that a reasonable person would make as to its value).

Travel and Accommodation

5.10 Modest offers to pay some or all of the travel and accommodation costs related to attendance at events may be accepted and must be declared.

5.11 Offers which go beyond modest, or are of a type not usually offered by the CCGs need to be approved by the Chief Officer (Accountable Officer) and should only be accepted in exceptional circumstances and must be declared. A non-exhaustive list of examples includes: • offers of business class or first class travel and accommodation (including domestic travel); and • offers of foreign travel and accommodation.

Individual Sponsorship

5.12 CCG staff, Governing Body and committee members, and GP member practices may be offered commercial sponsorship for courses, conferences, post/project funding, meetings and publications in connection with the activities which they carry out for or on behalf of the CCG or their GP practices. All such offers (whether accepted or declined) must be declared to the Associate Director of Corporate Affairs so that they can be included on the CCGs’ gifts and hospitality register.

5.13 Individuals should only accept sponsorship to fund their attendance at relevant conferences, courses or work-related visits with the prior approval of the Chief Officer, who needs to ensure there can be no perception of a conflict of interest in relation to the motives of the organisation making the offer.

Sponsored Events

5.14 Sponsorship of NHS events by external parties is valued. Offers to meet some or part of the costs of running an event secures their ability to take place, benefitting NHS staff and patients. Without this funding there may be fewer opportunities for learning, development and partnership working. However, there is potential for conflicts of interest between the

NHS Warwickshire North Clinical Commissioning Group and NHS Coventry and Rugby Page 7 of 14 Clinical Commissioning Group Draft Gifts and Hospitality Policy April 2018

organiser and the sponsor, particularly regarding the ability to market commercial products or services. As a result the CCGs will put in place safeguards to present conflicts occurring.

5.15 When sponsorships are offered, the CCGs will adopt the following principles: • Sponsored events and the sponsors must be approved in advance by both the Associate Director of Corporate Affairs and the Head of Medicines Optimisation. The Head of Medicines Optimisation will specifically check that the sponsors and the products being promoted are in line with CCG guidelines. • Sponsorship of CCG events by appropriate external bodies should only be approved if a reasonable person would conclude that the event will result in a clear benefit for the CCG and the NHS. • During dealings with sponsors there must be no breach of patient or individual confidentiality or data protection rules and legislation. • No information should be supplied to the sponsor from which they could gain a commercial advantage, and information which is not in the public domain should not normally be supplied. • At the CCG’s discretion, sponsors or their representatives may attend or take part in the event but they should not have a dominant influence over the content or the main purpose of the event. • The involvement of a sponsor in an event should always be clearly identified in the interest of transparency. • The CCGs should make it clear that sponsorship does not equate to endorsement of a company or its products and this should be made visibly clear on any promotional or other materials relating to the event. • Staff should declare involvement with arranging sponsored events to the Associate Director of Corporate Affairs.

5.16 The CCGs will maintain records regarding sponsored events in line with the above principles. The CCGs’ Commercial Sponsorship Policy sets out the authorisation process for sponsorship.

5.17 Other forms of sponsorship: organisations external to the CCGs (or NHS) may sponsor posts or research. However, there is potential for conflicts of interest to occur, particularly when research funding by external bodies does or could lead to a real or perceived commercial advantage, or if sponsored posts cause a conflict of interest between the aims of the sponsor and the aims of the organisation, particularly in relation to procurement and competition. There needs to be transparency and any conflicts of interest should be well managed. If such circumstances arise the CCGs’ Commercial Sponsorship Policy sets out how this will be managed.

Register of Gifts and Hospitality

5.18 All offers of gifts and hospitality should be notified to the Associate Director of Corporate Affairs as soon as reasonably practicable and by law within 28 days after the interest arises. The offer will be recorded on the CCGs’ Register of Gifts and Hospitality. A template Declaration of Gifts and Hospitality Form can be found at Appendix 1 and a template of the Register of Gifts and Hospitality can be found at Appendix 2.

NHS Warwickshire North Clinical Commissioning Group and NHS Coventry and Rugby Page 8 of 14 Clinical Commissioning Group Draft Gifts and Hospitality Policy April 2018

5.19 The Register of Gifts and Hospitality will be published at least annually for decision making staff (see Appendix 3 for definition) and made publicly available via the following methods:

Coventry and Rugby CCG Warwickshire North CCG

• Published on the CCG's • Published on the CCG's website: www.coventryrugbyccg.nhs.uk; website: www.warwickshirenorthccg.nhs. uk; • On request for inspection at the CCG's headquarters; • On request for inspection at the CCG's headquarters; • On request either by post to Parkside House, Quinton Road Coventry, CV1 2NJ or email to • On request either by post to NHS : [email protected] Warwickshire North CCG, Second Floor, Heron House, Newdegate Street, Nuneaton, CV11 4EL or email to: [email protected] .uk.

5.20 Offers of gifts and hospitality for decision making staff will remain on the public register for a minimum of six months after the interest has expired. The CCGs will also retain a private record of historic offers/receipt of gifts and hospitality in line with the records retentions schedule of the Records Management Code of Practice.

6. Provision of Internal Hospitality

6.1 NHS monies for hospitality and entertainment should be used sparingly and modestly and only after each case has been carefully considered. All expenditure on these items should be capable of justification as reasonable in the light of the general practice in the public sector.

6.2 Whenever possible, meetings should be arranged within CCG premises. If this is not possible, NHS establishments should be the preferred choice of venue. If rooms are not available within NHS premises, the meeting should be arranged at the most economic rate, taking into account room rates and refreshment charges.

7. Equality and Diversity Statement

7.1 The CCGs are committed to ensuring that they treat their employees fairly, equitably and reasonably and that they do not discriminate against individuals or groups on the basis of any protected characteristic. An Equality Impact Assessment has been completed for this policy and can be found in Appendix 4.

7.2 If you have any concerns or issues with the contents of this policy or have difficulty understanding how this policy relates to you and/or your role, please contact the Deputy Director of Corporate Affairs.

8. Monitoring Compliance and Effectiveness of the Policy

8.1 The policy will be reviewed three years from the date of ratification by the CCGs’ Governing Bodies or sooner if necessary. The Gifts and Hospitality register will be presented for review to the CCGs’ Audit Committees twice yearly and published on the CCGs’ websites. Staff will be reminded of the policy and register at least annually. The Deputy Director of Corporate

NHS Warwickshire North Clinical Commissioning Group and NHS Coventry and Rugby Page 9 of 14 Clinical Commissioning Group Draft Gifts and Hospitality Policy April 2018

Affairs (or nominated deputy) will review register entries on a regular basis and will address any inappropriate receipt of gifts/hospitality with the relevant person or manager.

NHS Warwickshire North Clinical Commissioning Group and NHS Coventry and Rugby Page 10 of 14 Clinical Commissioning Group Draft Gifts and Hospitality Policy April 2018

Appendix 1 - Template Declaration of Gifts and Hospitality Form

Name:

Relevant CCG: Coventry and Rugby CCG / Warwickshire North CCG / Both CCGs *Delete as appropriate

Position within, or relationship with, the CCG (or NHS England in the event of joint committees:

Recipient Position Date Date of Details of Estimated Supplier Details of Details of the Declined Reason Other Name of Receipt (if Gift / Value / Offeror Previous Offers officer reviewing or for Comments Offer applicable) Hospitality Name or Acceptance and approving Accepted? Accepting and by this Offeror/ the declaration or Nature of Supplier made and date Declining Business

The information submitted will be held by the CCGs for personnel or other reasons specified on this form and to comply with the organisations’ policies. This information may be held in both manual and electronic form in accordance with the General Data Protection Regulation. Information may be disclosed to third parties in accordance with the Freedom of Information Act 2000 and, in the case of decision making staff’ (as defined in the statutory guidance on managing conflicts of interest for CCGs) may be published in registers that the CCGs hold. I confirm that the information provided above is complete and correct. I acknowledge that any changes in these declarations must be notified to the CCG as soon as practicable and no later than 28 days after the interest arises. I am aware that if I do not make full, accurate and timely declarations then civil, criminal, or internal disciplinary action may result. [This paragraph applies to decision making staff only] I do / do not [delete as applicable] give my consent for this information to published on registers that the CCG holds. If consent is NOT given please give reasons in the box below:

Employee/Member Signature:

Print Name: Signature: Date:

Line Manager or Senior CCG Manager

Print Name: Signature: Date:

NHS Warwickshire North Clinical Commissioning Group Page 11 of 14 Gifts and Hospitality Policy

Appendix 2 - Register of Gifts and Hospitality Template

Recipient Position Date Date of Details of Estimated Supplier Details of Details of the Declined Reason Other Name of Receipt (if Gift / Value / Offeror Previous Offers officer reviewing or for Comments Offer applicable) Hospitality Name or Acceptance and approving Accepted? Accepting and by this Offeror/ the declaration or Nature of Supplier made and date Declining Business

NHS Warwickshire North Clinical Commissioning Group Page 12 of 14 Gifts and Hospitality Policy

Appendix 3 - Decision Making Staff

Each individual and their role within the CCGs will be considered individually and a decision recorded as to whether their declaration is to be published, however, the following non-exhaustive list describes who these individuals are likely to be:

• All governing body members;

• Members of advisory groups which contribute to direct or delegated decision making on the commissioning or provision of taxpayer funded services such as working groups involved in service redesign or stakeholder engagement that will affect future provision of services;

• Members of the Primary Care Commissioning Committee (PCCC)/Joint Commissioning Committee;

• Members of other committees of the CCGs ie, Audit Committees, Remuneration Committee Finance and Performance/ Commissioning Finance and Performance, and Clinical Quality and Governance Committees;

• Members of new care models joint provider / commissioner groups / committees;

• Those at Agenda for Change band 8d and above;

• Management, administrative and clinical staff who have the power to enter into contracts on behalf of the CCG; and

• Management, administrative and clinical staff involved in decision making concerning the commissioning of services, purchasing of good, medicines, medical devices or equipment, and formulary decisions.

NHS Warwickshire North Clinical Commissioning Group Page 13 of 14 Gifts and Hospitality Policy

Appendix 4 -

Appendix 5 - Equality Impact Assessment

Policy Gifts and Hospitality Person Maria Maltby, Deputy completing EIA Director of Corporate Affairs Date of EIA April 2018 Accountable Andrea Green CCG Lead

Aim of Work To provide guidance to and ensure that NHS Warwickshire North Clinical Commissioning Group (WNCCG) and Coventry and Rugby Clinical Commissioning Group (CRCCG) are aware of the implications, restrictions and requirements around accepting gifts or hospitality. Who Affected All CCG staff, workers, Governing Body members, GP Partners and all other practice staff who have a role in the CCGs’ business.

Protected Group Likely to Protected Group Likely to be a be a differential differential impact? impact? Sex No Age No Race No Gender Reassignment No Disability Yes Marriage and Civil No Partnership Religion / belief No Pregnancy and Maternity No Sexual orientation No

Describe any potential or known adverse impacts or barriers for protected/vulnerable groups and what actions will be taken (if any) to mitigate. If there are no known adverse impacts, please explain.

To ensure that individuals with specific disabilities can access the policy and its content, the document will be made available in alternative formats if required.

NHS Warwickshire North Clinical Commissioning Group Page 14 of 14 Gifts and Hospitality Policy

NHS Coventry and Rugby Clinical Commissioning Group NHS Warwickshire North Clinical Commissioning Group Enc U

Report To: Governing Body Meetings in Common

Report Title: Glute Free Prescribing Policy

Report From: Steve Allen, Clinical Director

Date: 12/07/2018

Previously Considered by: Clinical Executive Group, Executive Group

Action Required (delete as appropriate)

Decision:  Assurance: Information: Confidential

Purpose of the Report: To agree the Gluten Free Prescribing Policy for Coventry & Rugby and Warwickshire North CCGs.

The policy has been passed through the Clinical Executive Group in Coventry and Rugby CCG and at the time of writing, has not yet been passed through the Executive Group in Warwickshire North but will be on the 12th July, directly before the Governing Body meeting and a verbal update will be given to the committee following this.

Key Points: • Gluten Free (GF) foods are available in supermarkets with a wide variety of choice. Alternatively coeliac patients can alter their diet to replace bread with naturally gluten-free foods e.g. rice, potato. GF food is expensive when obtained via NHS prescription because of clinician time and dispensing costs including out of pocket expenses (e.g. special delivery charges).

• Both CCGs have decided to follow the recommendations from the report published by the Department of Health and Social Care (DHSC) on Thursday 1 February 2018 and the health minister's preferred option to restrict prescribing to certain gluten-free products (bread and mix). The report follows the DHSC’s own consultation which considered the availability of gluten free food on prescription in primary care.

Recommendation: Members of both Governing Bodies are asked to APPROVE the policy so that the significant opportunity that this scheme presents can be implemented to maximise the value of the QIPP schemes for 2018/19 and beyond.

Implications

Objective(s) / Plans supported by this QIPP report: Conflicts of Interest: N/A Non-Recurrent Expenditure: N/A Financial: Recurrent Expenditure: N/A

Page 1 of 2 NHS Coventry and Rugby Clinical Commissioning Group NHS Warwickshire North Clinical Commissioning Group Enc U

Is this expenditure included within the CCG’s Financial Yes No N/A  Plan? (Delete as appropriate) Performance: N/A Quality and Safety: N/A General Statement: The CCG is committed to fulfil its obligations under the Equality Act 2010, and to ensure services commissioned by the CCG are non-discriminatory on the grounds of any protected characteristics. Policies/decisions may need to be adjusted in line with any equality analysis or due regard. Any decision that is finalised Equality and Diversity: without being influenced by appropriate due regard could be deemed unlawful. Has an equality impact Yes assessment been undertaken?  No N/A (attached) (Delete as appropriate) Patient and Public National consultation and EIA undertaken and published February 2018 Engagement: Clinical Engagement: N/A Risk and Assurance: N/A

Page 2 of 2 Gluten Free Policy

NHS Coventry and Rugby Clinical Commissioning Group and Page 1 of 7 NHS Warwickshire North Clinical Commissioning Group VERSION CONTROL

Version: 1.0

Ratified by: Governing Body Meetings in Common

Date ratified: Altaz Dhanani - Head of Medicines Name of originator/author: Optimisation Name of responsible committees:

Date issued:

Review date:

VERSION HISTORY

Date Version Comment / Update

NHS Coventry and Rugby Clinical Commissioning Group and Page 2 of 7 NHS Warwickshire North Clinical Commissioning Group

Contents

1.0 Policy Statement ...... 4 2.0 Scope of Policy ...... 4 3.0 Background ...... 4 Appendix 1 ...... 5

NHS Coventry and Rugby Clinical Commissioning Group and Page 3 of 7 NHS Warwickshire North Clinical Commissioning Group

1.0 Policy Statement

Coventry & Rugby and Warwickshire North CCGs will only commission or fund a limited list (see Appendix 1) of gluten free bread and gluten free mix on the NHS for all patients with established coeliac disease and dermatitis herpetiformis. Prescribing is limited to 8-10 units per month.

2.0 Scope of Policy

2.1 This policy applies to all services contracted by or delivered by the NHS in Coventry & Rugby and Warwickshire North CCGs including:

GP practices Out of hours and extended hours providers Acute Hospitals Outpatient clinics NHS community providers Independent providers Community pharmacy

2.2 This policy applies to all prescribers within the contracted services; general practitioners, locum and junior doctors, trainees and community practitioners, supplementary and independent non-medical prescribers within Coventry & Rugby and Warwickshire North CCGs.

2.3 This policy applies to:

All patients registered with or attending a healthcare appointment in Coventry & Rugby and Warwickshire North CCGs. All patients, whether or not they pay for their prescriptions.

3.0 Background

3.1 Coventry & Rugby and Warwickshire North CCGs currently spend approximately a combined £330k annually on the prescribing of gluten free (GF) food.

3.2 Coeliac disease is a common digestive condition where a person has an adverse reaction to gluten. Eating foods containing gluten can trigger a range of symptoms, such as:

• Diarrhoea, which may smell particularly unpleasant • Bloating and flatulence (passing wind) • Abdominal pain • Weight loss • Feeling tired all the time as a result of malnutrition (not getting enough nutrients from food) • Children not growing at the expected rate.

NHS Coventry and Rugby Clinical Commissioning Group and Page 4 of 7 NHS Warwickshire North Clinical Commissioning Group

3.3 GF foods are available in supermarkets with a wide variety of choice. Alternatively coeliac patients can alter their diet to replace bread with naturally gluten-free foods e.g. rice, potato. GF food is expensive when obtained via NHS prescription because of clinician time and dispensing costs including out of pocket expenses (e.g. special delivery charges).

3.4 Both CCGs have decided to follow the recommendations from the report published by the Department of Health and Social Care (DHSC) on Thursday 1 February 2018 and the health minister's preferred option to restrict prescribing to certain gluten-free products (bread and mix). The report follows the DHSC’s own consultation which considered the availability of gluten free food on prescription in primary care.

Appendix 1

List of gluten free products available on NHS prescription:

Bread

Brands: Ener-G Genius Glutafin Juvela Warburtons

Mix

Brands: Glutafin Juvela

The above brands currently represent approximately 95% of items currently prescribed in each CCG.

NHS Coventry and Rugby Clinical Commissioning Group and Page 5 of 7 NHS Warwickshire North Clinical Commissioning Group

Blank Page

Equality Impact Assessment Following the consultation 'Availability of Gluten Free Food on Prescription in Primary Care'

January 2018

DH ID box

Title: Equality Impact Assessment - Following the Public Consultation on the Availability of Gluten Free Food on Prescription in Primary Care

Author: Medicines and Pharmacy Directorate/Medicines, Regulation and Prescribing Branch/PPL/17080

Document Purpose: Corporate Report

Publication date: January 2018

Target audience: Professional and representative bodies GPs Clinicians Pharmacists Patient Associations Members of the public Managers Commissioners Directors of Public Health Clinical Commissioning Groups

Contact details: Medicines, Regulation and Prescribing Branch, Department of Health, Room 2E14, Quarry House Quarry Hill, Leeds, LS2 7UE

You may re-use the text of this document (not including logos) free of charge in any format or medium, under the terms of the Open Government Licence. To view this licence, visit Open government licence © Crown copyright 2016 Published to gov.uk, in PDF format only. Department of Health & Social Care

January 2018 Contents

Contents ...... 3 Executive summary ...... 4 1. Introduction ...... 5 2. Statutory Duties...... 7 The Public Sector Equality Duty ...... 7 Secretary of States duties under the National Health Service Act 2006 ...... 8 3. Evidence...... 10 4. The Family Test ...... 22 5. Engagement and Involvement ...... 23 Annex A - Estimated Patient Numbers ...... 24

3

Executive summary

The Department of Health launched a public consultation to seek views on whether or not to make any changes to the availability of gluten free (GF) foods that can be prescribed in primary care. Staple GF foods are available on prescription to patients diagnosed with gluten sensitivity enteropathies, and have been since the late 1960s when the availability of GF foods was limited. GF foods are now readily available in supermarkets and a wider range of naturally GF food types are now available, so the ability of patients to obtain these foods without a prescription has greatly increased. Many Clinical Commissioning Groups (CCGs) now have limited types or units of GF foods available on prescription1. A number of CCGs provide only bread and flour; several have stopped prescribing all GF foods. CCGs were set up to ensure that their local populations receive the medicines and treatments they require, with locally managed resources. Differing approaches to the availability of GF foods is creating regional variations across England. A public consultation was launched on 31st March 2017 and was open for submission of responses to 22nd June. The consultation sought views on three options:  Option 1: Make no changes to the National Health Service (General Medical Services Contracts) (Prescription of Drugs etc.) Regulations 2004.  Option 2: To add all GF foods to Schedule 1 of the above regulations to end the prescribing of GF foods in primary care.  Option 3: To only allow the prescribing of certain GF foods (e.g. bread and flour) in primary care, by amending Schedule 1 of the above regulations. This report provides information about the equality issues and the analysis of the information that was provided in response to the consultation. Changes to the prescribing of GF foods could save NHS resources and reduce the primary care prescription drugs bill by up to £22.7 million in year one following changes (based on Net Ingredient Cost (NIC) and dispensing fees).2 . Although we have not identified this in every section of this document, having weighed up the various impacts, we consider that the benefits of enabling this resource to be spent elsewhere outweighs the detriment that we have identified recognising that these detriments are potentially significant particularly in relation to Option 2.

1 CCG websites and https://www.coeliac.org.uk/gluten-free-diet-and-lifestyle/prescriptions/prescription-policies/ 2 Prescription Cost Analysis (England) 2016

January 2018

1. Introduction

1.1. The Department of Health's Shared Delivery Plan 2015 - 2020 contains the Department's objectives which includes "Improving efficiency and productivity of the health and care system". This project relates to this objective through ensuring that the Department helps the NHS make effective use of the drugs bill spending in primary care. 1.2. The Department of Health launched a public consultation to seek views on whether any changes should be made to prescribing legislation on GF foods. A range of options were set out in the consultation document, which included ending the prescribing of GF foods by adding them to Schedule 1 to the National Health Service (General Medical Services Contracts) (Prescription of Drugs etc.) Regulations 2004, or by way of otherwise amending these Regulations. Schedule 1 is commonly known as the blacklist, and GPs are not permitted to prescribe products from this list at NHS expense. 1.3. Staple GF foods have been available on prescription to patients diagnosed with gluten sensitivity enteropathies since the late 1960s when the availability of GF foods was limited. GF foods are now more widely available in supermarkets, although stock can be variable, with a wider range of naturally GF food types available, meaning that the ability of patients to obtain these foods without a prescription has greatly increased. 1.4. Many CCGs have made changes to local prescribing formularies and have restricted or ended GF food3. This regional variation is leading to inequality of access. The prescribing position in CCGs in England (July 2017) is shown in Table 1. Table 1 - CCG Prescribing Status

Prescribing Arrangements (July 2017) Number of CCGs

Following Coeliac UK guidelines 78

Ended all GF foods on prescription (all patients) 25

No restrictions 4

Other restrictions; product type, quantities, or patient status 102

1.5. All people have to purchase food, including patients with a diagnosis of coeliac disease or dermatitis herpetiformis. These patients can obtain a range of staple GF foods on prescription to support adherence to a GF diet. Adherence to a GF diet is the only way to manage the condition and prevent further ill health related to coeliac disease. 1.6. The policy is not likely to impact on human rights as patients are not denied the foods that they need, naturally GF food and formulated GF food are available to purchase in

3 https://www.coeliac.org.uk/gluten-free-diet-and-lifestyle/prescriptions/prescription-policies/

January 2018 Equality Impact Assessment

supermarkets and on-line. Patients who are diagnosed with coeliac disease will continue to be advised of the importance of adhering to a GF diet and information on how to do that. Patients are entitled to an annual review with their healthcare professional who can offer advice and guidance on maintaining a GF diet.

6 2. Statutory Duties

The Public Sector Equality Duty 2.1. The Department of Health is covered by the Equality Act 2010 and specifically by the Public Sector Equality Duty (PSED). The Duty covers the following protected characteristics: age, disability, gender reassignment, maternity, race (includes ethnic or national origins, colour or nationality), religion or belief (includes lack of belief), sex and sexual orientation. 2.2. There are three parts to the Duty, and public bodies must, in exercising their functions, have due regard to them all. They are the need to:  eliminate discrimination, harassment, victimisation and any other conduct that is prohibited by or under the Equality Act  advance equality of opportunity between persons who share a relevant protected characteristic and persons who do not share it  foster good relations between persons who share a relevant protected characteristic and persons who do not share it. 2.3. Having due regard to the need to advance equality of opportunity between persons who share a relevant protected characteristic, and persons who do not share it, involves having due regard in particular to the need to: i) remove or minimise disadvantages suffered by persons who share a relevant protected characteristic that are connected to that characteristic; ii) take steps to meet the needs of persons who share a relevant protected characteristic that are different from the needs of persons who do not share it iii) encourage persons who share a relevant protected characteristic to participate in public life or in any other activity in which participation by such persons is disproportionately low. The steps involved in meeting the needs of disabled people that are different from the needs of persons who are not disabled, include, in particular, steps to take account of disabled persons' disabilities. 2.4. Having due regard to the need to foster good relations between persons who share a relevant protected characteristic and persons who do not share it involves having due regard, in particular, to the need to: a) tackle prejudice, and b) promote understanding. 2.5 Officials have considered the implications for each of the three equality objectives in relation to the proposals for GF prescribing. Overall our view is that whilst there may be impacts, these are largely mitigated by the easier access to both formulated and naturally GF foods which are now more widely available in supermarkets and online, and to some extent, in food banks for people on low or no incomes. People can also manage their conditions by choosing naturally GF foods. Our judgement is that on balance the benefits of the proposals outweigh the identified impacts, in the light of the Department of Health's objective of helping the NHS make effective use of the drugs bill spending in primary care, as mentioned in relation to the Department of Health's Shared Delivery Plan 2015 - 2020 in paragraph 1.1 above.

7 Equality Impact Assessment

Secretary of States duties under the National Health Service Act 2006 2.5. The National Health Service Act 2006 (NHSA) contains a number of overarching duties on the Secretary of State for Health which apply to every action undertaken in relation to the NHS and public health. The following duties appear to be engaged in relation to the proposals being analysed in this Equality Impact Assessment. These are - a) the Duty to continue to promote a comprehensive health service in England (section 1) b) the Duty as to improvement in quality of services (section 1A); and c) the Duty as to reducing inequalities (section 1C). Duty to continue the promotion in England of a comprehensive health service (section 1) This Duty requires the Secretary of State to continue the promotion in England of a comprehensive health service designed to secure improvement - a) in the physical and mental health of the people of England, and b) in the prevention, diagnosis and treatment of physical and mental illness. Duty as to improvement in quality of services (section 1A) 2.6. The Secretary of State must exercise the functions of the Secretary of State in relation to the health service with a view to securing the continuous improvement in the quality of services provided to individuals for or in connection with - a) the prevention, diagnosis or treatment of illness, or b) the protection or improvement of public health. In relation to this Duty, and the section 1 Duty to continue to promote a comprehensive health service in England, our view is that the section 1A duty was never intended to mean entitlement to specific products. Within providing a comprehensive health service for people diagnosed with gluten sensitivity enteropathies, including coeliac disease, there is scope for deciding how much should be provided by the health service, and how much management of the condition is something that can be reasonably and fairly be left to the patient. In striking that balance, the Secretary of State can look at resource issues, and decide that overall some particular products may be withdrawn because of a reasonable analysis that the funds would be better spent elsewhere. Where products are not realistically available commercially there may be a requirement for the NHS to step in. Where products are readily available for the self-management for the conditions, it is reasonable to take the view that NHS resources are no longer required to ensure that patients can manage their conditions effectively. The release of funds from any GF food prescribing changes would be re-deployed into other parts of the health system. It would be at the discretion of each CCG to re-invest in other areas of health care in accordance with their local priorities. Duty as to reducing inequalities (section 1C) 2.7. In exercising functions in relation to the health service, the Secretary of State must have regard to the need to reduce to reduce inequalities between the people of England with respect to the benefits that they can obtain from the health service. 2.8. It is important to emphasise that this duty is separate from the PSED duty, and is about a need to reduce inequalities that may or may not be based on protected characteristics.

8 Socio- economic impacts need therefore to be considered in terms of other socio- economic factors such as income, social deprivation and rural isolation. We have considered the various impacts of the GF proposals on various groups of people in this analysis. Socio-economic issues are dealt with in paragraphs 3.43 to 3.53. 2.9. A full impact assessment has been published alongside this document and this explores the health and other impacts and associated costs of each option. It includes information that was submitted as part of the public consultation. The key issues are summarised below.

Key equality issues that arose from the consultation responses 2.10. Families who are on low incomes are likely to feel a greater impact from any changes to the current system for the prescribing of GF foods as they may currently be eligible for exemptions from prescription charges. Some families may have multiple coeliac disease patients making an increased cost to their weekly food shopping bill likely, if GF prescribing was ended and they had to purchase GF foods. 2.11. Families or individuals on "no income", for example those who may be awaiting decisions on benefit entitlement, and who are exempt from prescription charges, may also be greater impacted. They may temporally rely on food banks for their food, where stocks of formulated GF food could be limited, which would mean that the patient/parent/carer would need to select foods that are naturally GF, such as meat, fish, rice, fruit and vegetables, as are available, to meet their dietary needs. 2.12. It is acknowledged that bread remains a staple part of many people's diet, including patients with coeliac disease. The impact of change to the availability of GF foods on prescription could be greater on those who are experiencing economic deprivation as formulated GF bread remains more expensive than its counterpart. 2.13. Although coeliac disease is not a disability, patients with limited mobility and the elderly may have problems obtaining non-prescription GF items, as they often rely on home deliveries of these items by their pharmacies. Though they can purchase GF foods on-line for home delivery by a supermarket or on-line retailer, many may not be able to quickly adapt to any changes to access formulated GF food. 2.14. People with additional autoimmune conditions could find themselves in a situation whereby their medication to treat that condition is provided on prescription, but their GF foods are not. This may impact on them visiting their GP regularly and risk detrimental ill health. 2.15. Respondents from the parent/carer group raised concerns about access to GF food for children and the elderly, as these groups were more likely to have their dietary choices and meals made for them. Elderly patients and younger children often rely on GF foods provided under prescriptions to supplement their dietary needs. Both these groups are eligible for exemption from prescription charges, meaning they would be impacted financially by changes to GF prescribing.

9 Equality Impact Assessment 3. Evidence

3.1. The public consultation allowed interested stakeholders to submit information to highlight any issues with the three presented options. 3.2. As part of the pre-consultation work, a range of evidence was collated and reviewed from a variety of sources which included; journal articles, published reports, local CCG insights and changes, the National Institute for Health and Care Excellence (NICE) guidance4 and Quality Standards5. 3.3. As part of the responses to the consultation additional evidence was requested on a range of issues, including; the link between GF prescriptions and adherence to a GF diet, data on patient impact where changes had been made at CCG level and data to support the calculations on Quality Adjusted Life Years (QALY value). This information and revised calculations have been reflected in the updated Impact Assessment published alongside this document. 3.4. In response to the consultation stakeholders provided numerous additional references in relation to the above points. This included information where patients from protected groups could be more significantly affected by any changes, the availability and cost of GF foods, and the issues faced by those on low incomes. It was emphasised that those supermarkets which stocked GF food, that stock could be variable and not consistently available. 3.5. The issues of socio-economic disadvantage were also raised, as some patients found the cost of GF food would affect their adherence to a GF diet if they had to purchase their own GF food. Some respondents stated that availability in food banks was non- existent or sparse. The Trussell Trust provides a list of frequently included products in emergency food parcels which would likely contain tinned products such as meat/vegetables/fruit, cereals, rice, tea/coffee and biscuits. Some food banks may offer a delivery service for people in rural locations.6 This service is variable and is dependent upon the food bank in the area. People requiring the services offered by a food bank would be referred by a relevant organisation such as Citizens Advice, Social Services and other welfare agencies. 3.6. Policy officials undertook a review of the information provided. This involved; accessing information contained in journal articles, reading and reviewing content, following web links and reviewing website content. These reports/papers/information sources were collated and scrutinised for relevance and factual information linking to the evidence which is also incorporated in the Impact Assessment, which additionally provides an overview of costs and calculations on health impacts for all options. 3.7. The numbers of coeliac patients is estimated to be 1% of the population.7 The English population (mid 2016) was 55,268,100, so 1% of this figure gives an estimated

4 https://www.nice.org.uk/guidance/ng20

5 https://www.nice.org.uk/guidance/qs134

6 https://www.truselltrust.org/get-help/emergency-food/ 7 https://www.nhs.uk/Conditions/Coeliac-disease/Pages/Introduction.aspx#Whos-affected

10 population with coeliac disease as 552,681. Coeliac UK estimate that only 24% of these patients have a diagnosis this gives an identified group of 132,643 coeliac diagnosed patients. This figure has been used to replicate percentages in English population to achieve an estimate of the coeliac population breakdown by; age, gender, ethnicity, disability, carers, low income, and those living in rural areas, this is detailed in Annex A.

Patient Choices and Adherence 3.8. Patients diagnosed with gluten sensitivity enteropathies, including coeliac disease, face a choice of whether to adhere to a gluten free diet. Where they are adherent, they face a reduced risk of complications. A patient presently faces the following choices:  Adhere through purchasing naturally GF food  Adhere through purchasing formulated GF food  Adhere through obtaining formulated GF food provided through NHS prescription  Not adhere 3.9. In practice, patients that adhere to a GF diet will do so through some combination of naturally GF food and formulated GF food both purchased privately and obtained through prescription. That is, through a combination of the three routes to adherence. 3.10. Under Option 2, patients would no longer be able to obtain formulated GF food through prescription. If they choose to adhere to a GF diet, they would need to do so by purchasing naturally GF food, or by purchasing formulated GF food. They would have fewer routes to adherence:  Adhere through purchasing naturally GF food  Adhere through purchasing formulated GF food  Not adhere 3.11. Under Option 3, patients are able to obtain bread and mixes through prescription. Options for adherence are:  Adhere through purchasing naturally GF food  Adhere through purchasing formulated GF food  Adhere through obtaining GF bread and mixes on prescription  Not adhere

Prescribing Data 3.12. Data detailing the prescriptions for GF, and GF and Wheat Free (WF) foods dispensed by prescription items and the associated Net Ingredient Cost (NIC) (£) is shown in Table 2. It shows a breakdown of those prescriptions that attracted a dispensing fee at point of dispensing (charged) and those exempt from prescription charges by category, including those which had a pre-paid certificate. 8 3.13. In 2016 20% of prescription items for GF and GF/WF food attracted a prescription fee at the point of dispensing, or were exempt due to having a pre-paid certificate (category F), whilst 80% of GF and GF/WF items dispensed were exempt from charges

8 Bespoke report provided by the NHS Business Services Authority for England in 2016

11 Equality Impact Assessment

under all categories (with the exception of category F - pre paid certificates) as detailed in Table 2. 3.14. In relation to all prescription items prescribed in 2016; 89.4% were exempt from prescription charges, with 4.9% being exempt due to the patient having a pre-paid certificate, and 5% attracting a charge at the point of dispensing. The majority of exemptions for both GF, GF/WF and all prescription items were those prescriptions for patients aged 60 or over, that is 39.8% and 61% respectively.

12 Table 2 - Prescription Data for Gluten Free, and Gluten and Wheat Free Foods (2016)

Prescription Exemption Category TOTAL ITEMS(%) TOTAL NIC £ (%) Charge Status

CHARGEABLE Paid (at point of dispensing) 19,047(1.29%) 443,489(1.98%)

EXEMPT A - is under 16 years of age 231,947(15.72%) 2,992,663(13.36%)

B - is 16,17 or 18 and in full EXEMPT 38,581(2.62%) 585,926(2.62%) time education

EXEMPT C - is 60 years of age or over 586,594(29.76%) 9,843,655(43.94%)

D - has a valid maternity EXEMPT 15,140(1.03%) 191,818(0.86%) exemption certificate

E - has a valid medical EXEMPT 137,603(9.33%) 1,950,699(8.71%) exemption certificate

F - has a valid prescription EXEMPT 288,314(19.54%) 4,069,882(18.17%) pre-payment certificate

G - has a valid War Pension EXEMPT 658(0.04%) 9,662(0.04%) exemption certificate

H - gets Income Support or EXEMPT Employment & Support 59,680(4.05%) 864,585(3.86%) Allowance

K - gets income-based EXEMPT 9,058(0.61%) 139,155(0.62%) Jobseeker's Allowance

L - is named on a current HC2 EXEMPT 7,268(0.49%) 106,469(0.48%) charges certificate

M - is entitled to, or named on, EXEMPT a valid NHS Tax Credit 46,891(3.18%) 671,202(3.00%) Exemption Certificate

S - has a partner who gets EXEMPT Pension Credit guarantee 1,620(0.11%) 23,708(0.11%) credit (PCFC)

X - was prescribed free-of- EXEMPT 385(0.03%) 5,915(0.03%) charge contraceptives

Z - exemption cannot be EXEMPT 32,496(2.20%) 504,353(2.25%) determined

TOTALS 1,475,282.00 22,403,188.41

13 Equality Impact Assessment

Disability 3.15. Coeliac disease is not defined as a disability under the Equality Act 2010 although it is a long term condition. It is an autoimmune disease which requires an adjustment to the diet to prevent symptoms. Some patients may have more than one autoimmune disease. People with certain conditions, including type 1 diabetes, autoimmune thyroid disease, Down's syndrome and Turner syndrome, have an increased risk of getting coeliac disease.9 3.16. If changes were made to GF prescribing then patients with additional autoimmune conditions could find themselves in a situation whereby their medication to treat that condition is provided on prescription, but their GF food requirements are not. 3.17. Some patients with an existing medical condition are exempt from prescription charges (see Table 2 - category E), this means that patients who receive GF and GF/WF food on prescription and are eligible for prescription exemptions due to having a "qualifying" medical condition, and hold a valid "medical exemption certificate".10 This accounts for 9% of all GF and GF/WF prescription items. 3.18. A substantially higher proportion of individuals who live in families with disabled members live in poverty, compared to individuals who live in families where no one is disabled.11 These patients may be impacted greater by any change to GF prescribing. 3.19. Option 1 - If no change was made to the current prescribing arrangements then patients would continue to access GF foods on prescription in accordance with their local CCG formularies. In the majority of CCGs GF foods continue to be available on prescription, which will meet the needs of the most vulnerable patients, including those with learning disabilities who may struggle to make informed choices when purchasing and preparing food. Patients with reduced mobility or those who have their prescriptions delivered will be able to continue to have staple GF delivered through pharmacies and any additional or luxury GF items required can be ordered through on-line retailers who offer home delivery. 3.20. Option 2 - If all GF prescriptions ceased then this would impact on the most vulnerable groups in society, meaning elderly and infirm patients could be adversely affected. These patient groups may have difficulty visiting a variety of supermarkets to find an adequate supply of GF foods, as stock can be variable. Patients with learning disabilities may struggle to make the correct food choices without appropriate guidance. Failure to follow a GF diet could lead to ill health for these patient groups. We have considered the GF proposals in the light of the combined impact on patients who are both disabled and elderly, and consider that any indirect discrimination that may result from the proposals will largely be mitigated by the greater availability of GF foods in supermarkets and online, and to a limited extent, in food banks for patients on low incomes. Patients will also be able to manage their condition by choosing naturally GF foods. To the extent that the proposals are likely to impact more on such patients, we

9 https://www.nhs.uk/Conditions/Coeliac-disease/Pages/Introduction.aspx#Whos-affected

10 NHS (Charges for Drugs and Appliances) Regulations 2015 11 https://www.gov.uk/government/publications/disability-facts-and-figures/disability-facts-and-figures

14 consider that any potential indirect discrimination is proportionate to the legitimate aim being pursued of helping the NHS make effective use of the drugs bill in primary care. 3.21. Option 3 - If a reduced list of staple GF products remained on prescription then all patients would have equal access to these. This means that patients who currently receive prescriptions for GF food would be able to get prescriptions for bread and mixes to support their continued adherence to a GF diet. Patients diagnosed in the future would also be able to access bread and mixes on prescriptions. Sex 3.22. Coeliac disease affects approximately one in every 100 people, although it is thought that only 24% of these will have a clinical diagnosis12. Coeliac disease can affect both men and women, but NHS Choices states that reported cases of coeliac disease are two to three times higher in women than men.13 This would mean that women could potentially be indirectly discriminated against should option 2 be pursued. We have considered the GF proposals in the light of this potential discrimination, and consider that any indirect discrimination that may result from the proposals will largely be mitigated by the greater availability of GF foods in supermarkets, and to a limited extent, in food banks for women on low incomes. To the extent that the proposals are likely to impact more on women than men we consider that any potential indirect discrimination is proportionate to the legitimate aim being pursued which is to assist the NHS make effective use of the drugs bill in primary care. 3.23. Option 1 from the consultation will not discriminate against men or women disproportionately as all patients regardless of gender would continue to access GF food on prescription. The national charity Coeliac UK recommend units of GF food based upon patients' age, sex and other factors e.g. pregnancy/breast feeding. Healthcare professionals can be guided by this and dieticians can provide tailored support to coeliac patients, providing advice based on their individual circumstances, and the recommended daily allowance (RDA) of calories, which differs for men and women.14 3.24. Life expectancy for males and females differs. Life expectancy for males is 79.2 years, and for females is 82.9 years15 . This difference would impact the length of time GF prescriptions are required for patients of different genders, meaning the impact would, in the longer term, be greater on women than on men. Race 3.25. Patients from all racial groups can be affected by coeliac disease. Estimates of patients reflecting the general population of England indicate that 87% are of "white ethnic origin".

12 Coeliac UK. https://www.coeliac.org.uk/coeliac-disease/about-coeliac-disease-and-dermatitis-herpetiformis/

13 https://www.nhs.uk/Conditions/Coeliac-disease/Pages/Introduction.aspx#Whos-affected

14 http://www.nhs.uk/Livewell/loseweight/Pages/understanding-calories.aspx

15 https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/lifeexpectancies/bulletins/nation allifetablesunitedkingdom/2014to2016

15 Equality Impact Assessment

3.26. No evidence has been found that patients from specific racial groups have higher rates of diagnosis of coeliac disease, meaning that any options from the policy will not discriminate against people from different racial backgrounds. Any changes will apply to all patients regardless of their race. It is possible that some racial groups rely more heavily on bread as part of their staple diet, whilst other groups have a preference for other staple foods which are naturally GF, for example, rice. This means that those patients in some ethnic groups could be disadvantaged if option 2 was introduced as they would need to purchase their own GF bread or source alternatives. 3.27. Patients from ethnic origins are more likely to be in lower income brackets16, therefore option 2 would therefore potentially have a greater impact on these groups. This could be mitigated by patients adjusting their diets, or purchasing their own GF formulated foods. Patients on low incomes could access naturally GF food from food banks, as formulated GF food may not be widely available. This would enable them to adhere to a GF diet and minimise the risk of ill health. 3.28. Option 3 - If a reduced list of staple GF products remains on prescription then the list of available GF staple products will still offer a degree of patient choice to suit patients from different ethnic backgrounds e.g. different bread types. Age 3.29. Coeliac disease can develop and be diagnosed at any age, and may develop after weaning onto cereals that contain gluten, in old age, or any time in between. Coeliac disease is most frequently diagnosed in people aged 40-60 years old17. Patients of all ages can access GF food on prescription, but exemption from prescription charges are available for the following age groups:  Those under 16 years of age  Those aged 16,17, and 18 and in full time education  Those aged 60 and over. 3.30. The following table (Table 3) shows the distribution of age related exemptions for GF and GF/WF food prescriptions. It provides data by the number of prescription items, compared to all prescription items in England in 2016. The largest category of patients eligible for prescription exemptions are those aged 60 and over, this group is likely to be impacted most by any changes to prescribing policy. An age related prescription exemption, or a pre-paid certificate, entitles the patient to receive all prescription items without paying an individual prescription fee for all medicines and not just for GF foods. Table 3 - Age Related Prescription Charge Exemptions

PRESCRIPTION ITEMS (2016)

16 http://www.poverty.org.uk/summary/uk.htm

17 https://www.coeliac.org.uk/coeliac-disease/myths-about-coeliac-disease/

16 GF, GF/WF All Prescriptions18 Prescriptions19

Charged - fee paid 1.3% 5.0%

Charged - pre-paid certs 19.5% 4.9%

Exempt age under 16, and 16, 17, 18 in full time education 18.3% 4.4%

Exempt age 60 and above 39.8% 61.0%

Exempt others 21.1% 24.7%

3.31. Option 1 - The policy will meet the needs of all age ranges as no age limits/exemptions would be in place nationally. Staple GF food would continue to be available on prescription and this would ensure that those who rely on prescriptions for their GF diet would continue to receive them. Coeliac UK recommends numbers of GF food units based on the patient's age. The difference in life expectancy for males (79.2 years) and females (82.9 years)20 would impact the length of time GF prescriptions are required to support a lifelong GF diet in the management of coeliac disease. 3.32. Option 2 - All patients would have to pay for all their own formulated GF food requirements, or follow a diet that is naturally GF. Patients in the prescription age exemption categories would be impacted most as they would no longer be able to access (free of charge) GF foods on prescription and would have to purchase their own GF food, or follow a naturally GF diet. 3.32.1. As 18.3% of younger patients obtain free prescriptions, this group could be impacted by any change under options 2 or 3. This could result in an increased cost to the family shopping bill if they replaced the GF staples currently on prescription with formulated GF food that they would have to purchase, in part or in entirety. 3.32.2. The impact on those in the aged 60 and above category would be greater as they receive 39.8% of all prescription items for GF food. Having to purchase their own formulated GF food could lead to financial hardship as many patients in this age group are reliant on a pension as their main source of income. GF formulated food can be more expensive than their equivalents, for example bread which is regularly consumed as part of the British diet. To mitigate the increased costs they would

18 NHS Business Services Authority (Bespoke report Sept 2017) for all GF and GF&WF prescriptions in 2016

19 NHS Digital https://digital.nhs.uk/catalogue/PUB30014

20 https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/lifeexpectancies/bulletins/nation allifetablesunitedkingdom/2014to2016

17 Equality Impact Assessment

need to adjust their diets to include more naturally GF food. If they failed to adhere to a GF diet this could lead to ill health. 3.32.3. People who are elderly may additionally have issues with mobility, this could lead to them having difficulty accessing larger stores to source their GF food requirements. They may however, be able to access delivery services offered by larger supermarkets and/or pharmacies. Paragraphs 4.45 and 4.51 evaluate the impact on those with restricted mobility. 3.32.4. We have considered the greater impact of the GF proposals on this group which may potentially result in indirect discrimination against this group, particularly in relation to older women. We consider that any indirect discrimination that may result from the proposals will largely be mitigated by the greater availability of GF foods in supermarkets and online, and to a limited extent, in food banks for older people on low incomes. Patients will also be able to manage their condition by choosing naturally GF foods. To the extent that the proposals are likely to impact more on this group than on other groups, we consider that any potential indirect discrimination is proportionate to the legitimate aim being pursued, which is to assist the NHS to make effective use of the drugs bill in primary care. 3.32.5. Both groups (children and the elderly) often have their food choices and meal preparation undertaken by a parent or carer and may be reliant upon prescriptions to assist adherence. If children consume the same meals as other members of the household (e.g. a non-GF diet) this could impact on their growth, delay puberty and make them susceptible to other auto-immune conditions21. 3.33. Option 3 - A limited range of staple GF foods would remain on prescription and changes would apply to all age groups. As stated above those in the prescription exemption categories related to age would experience a greater impact as they may have to supplement their diet with GF formulated food that they would have to purchase, if they required anything other than basic GF staple items that would remain on prescription. Gender Reassignment (Including transgender) 3.34. Patients who have changed gender or who are transgender will not be affected any differently to other patients groups as any changes would apply to all patients regardless of their gender. Sexual Orientation 3.35. Patients of differing sexual orientation will not be affected any differently to other patient groups as any changes would apply to all patients regardless of their sexual orientation. Religion or Belief 3.36. Patients with religions or beliefs, or no religion will not be affected any differently to other patient groups as any changes would apply to all patients regardless of their religion, or religious beliefs.

21 https://www.coeliac.org.uk/coeliac-disease/coeliac-disease-in-children/

18 Pregnancy and Maternity 3.37. Patients who are pregnant or new mothers who are breast feeding require additional calorie intake. They may need to obtain guidance on maintaining a healthy (GF) balanced diet to ensure they receive adequate nutrition. Patients in this group may also be affected by low incomes either before, during or after pregnancy. See paragraphs 3.43 to 3.47 below which deal with socio-economic disadvantage. 3.38. Option 1 - The policy will meet the needs of all patients as flexibility in the number of required units would be retained for those in this patient group. 3.39. Option 2 - The policy would mean that patients in this group are required to purchase any additional GF needed to supplement their calorie intake during this period of time. Those who are pregnant and on low incomes may be able to either access GF foods, or to obtain naturally GF foods in food banks 3.40. Option 3 - If a reduced list of staple GF products remained on prescription then all patients would have equal access to these. This means that patients who currently receive prescriptions for GF food would be able to get prescriptions for bread and mixes to support their continued adherence to a GF diet. Patients diagnosed in the future would also be able to access bread and mixes on prescriptions. Carers 3.41. People who care for adults or children could be impacted by any changes as they are often responsible for food choices and meal preparation for the patient. 3.42. Option 1 - Carers will continue to be able to obtain GF foods on prescription to support the patient's adherence to a GF diet. 3.43. Option 2 - Carers will have to select GF food from supermarkets, although stock can be variable and inconsistent. Carers could also be affected by issues around low incomes, and mobility limitations - see paragraphs below which deals with these issues. 3.44. Option 3 - Carers will be able to access basic GF staple items on prescription but will have to source any additional GF formulated food, or naturally GF food for the patient. Socio-economic disadvantage 3.45. Families who are on low incomes or families on no-incomes pending benefit decision outcomes, are likely to feel a greater impact from any changes as 80% of GF, GF/WF prescription items are exempt from prescription charges, and they more likely to be relying on food banks where stocks of formulated GF foods could be non-existent or limited. In the absence of formulated GF foods in food banks these patients would need to make an informed choice on eating naturally GF foods that are available via a food bank, or budget supermarket. 3.46. Those with limited transport options (e.g. non-car ownership) may struggle to access GF foods as they are not frequently stocked by smaller local retailers. The patient would have the option to obtain either naturally GF foods, or to utilise on-line ordering of formulated GF foods to mitigate the risk of ill health. 3.47. Option 1 - Patients from low income households will continue to be able to obtain GF foods on prescription to support their adherence to a GF diet. 3.48. Option 2 - Patients from lower income groups, or those with no incomes, may struggle to afford formulated GF food if this is no longer available on prescription, as GF

19 Equality Impact Assessment

foods tend to be more expensive than its counterparts. This group of patients will continue to have access to naturally occurring GF food which everyone has to buy. If they are eligible to access food from a food bank, they could source their food from there, and if there was a limited/no supply of formulated GF food, they would need to make informed choices to select naturally occurring GF food. However there is a risk that these patients will no longer continue to adhere to a GF diet and risk ill health. 3.49. Option 3 - Patients would have access to a limited range of staple GF foods on prescription, and those from lower income households often rely on budget supermarkets, which may have a more limited, or non-existent range of GF formulated foods. The British Dietetic Association (BDA) state that the provision of GF foods on prescription reduces the financial burden of the patients purchasing GF formulated foods. Families and Multiple Coeliac Households 3.50. First-degree relatives (parents, brothers, sisters and children) of people with coeliac disease are also at increased risk of developing the condition. In households where there is more than one coeliac patient, e.g. siblings, parent/child, changes to GF prescribing could have an impact on the family's food shopping bill. 3.51. Those families on low incomes or those without income may need to rely on food banks to obtain food. These may not contain formulated GF food, so the patient/parent or carer would need to make an informed choice to select naturally GF foods. People living in rural areas 3.52. Patients living in rural areas who have limited transport options may also find it difficult to source formulated GF food locally as it is may not frequently be stocked by smaller/local retailers. 3.53. Option 1 - People living in rural areas will continue to be able to obtain GF foods on prescription to support their GF diet. 3.54. Option 2 - Some patients living in rural areas may not have immediate access to larger supermarkets that are more likely to stock GF food, additionally GF food is not often stocked by small/local shops. They could therefore be significantly more impacted by any changes to GF prescribing than those not living in rural areas, and may rely on home deliveries by pharmacies for GF prescriptions to a greater extent than those not living in rural areas. Wealthier people living in rural areas are more likely to have their own transport which would make it easier for them to visit larger supermarkets to obtain formulated GF food. A patient's mobility as they age may decline, as such this could leave them with fewer options to travel to obtain GF foods. Pharmacies located in villages may stock GF foods, or could order these to meet a patient's needs, however this is likely to be a more expensive option and would not meet the needs of patients in rural areas on low incomes. If changes were made to prescribing GF foods, then patients would need to adapt their diets to rely on naturally GF foods for their nutritional requirements, or place an order for delivery by a larger supermarket for formulated GF food. Some food banks do offer a delivery service to ensure that people who live in rural areas can access foods, and avoid difficult or expensive journeys. 3.55. Option 3 - Patients in rural areas would retain access to basic GF staple foods via prescription. Most have access to a local pharmacy who may also offer home deliveries for medicines and other prescription items.

20 Summary of Impacts 3.56. In summary, any change to the prescribing of GF food on NHS prescription would have an impact on some patients who share certain protected characteristics. The main impacts would be on the elderly, those with mobility problems, and patients on low incomes.

21 Equality Impact Assessment 4. The Family Test

4.1. The family test was designed to complement the existing work of Departments to consider the three aims of the Public Sector Equality Duty. 4.2. Applying the family test when developing policy and complying with the PSED should lead to better overall outcomes for people. The test seeks to ensure that during the development of policy, particular attention is paid to its impact on supporting strong families and relationships:  Couple relationships (including same sex couples) including marriage, civil partnership, co-habitation and couples not living together.  Relationships in lone parent families, including relation between the parent and children with a non-resident parent, and with extended family.  Parent and step-parent to child relationships.  Relationship with foster children, and adopted children.  Sibling relationships.  Children's relationships with their grandparents.  Relatives or friends looking after children unable to live with their parents.  Extended families, particularly where they are playing a role in raising children or caring for older or disabled family members.

4.3. The five Family Test questions are:  What kind of impact might the policy have on family formation?  What kind of impact will the policy have on families going through key transitions such as becoming parents, getting married, fostering or adopting, bereavement, redundancy, new caring responsibilities or the onset of a long term condition?  What impacts will the policy have on all family members' ability to play a full role in family life, including with respect to parenting and other caring responsibilities?  How does the policy impact families before, during and after couple separation?  How does the policy impact those families most at risk of deterioration of relationship quality and breakdown? 4.4. Respondents to the consultation suggested an adverse impact of any change on families where there is more than one coeliac patient. This could occur on the arrival of a new child through adoption, or birth. Additional expenditure on food may impact the family food shopping budget and risk non-adherence to a GF diet, which in turn may lead to ill health. 4.5. If formulated GF foods on prescription were restricted or ended, then an adverse impact on parents could develop if a child no longer adheres to a GF diet and becomes ill. 4.6. If option 2 is implemented there may be an increased burden on the elderly or carers as they may find it harder to source formulated GF food, and this could impact on families. 4.7. Information on patients having or developing an additional long term condition was provided during the consultation. This emphasised the importance of adherence to a GF diet and regular health checks.

22 5. Engagement and Involvement

5.1. This work was subject to the requirements of the cross-government Code of Practice on Consultation 5.2. Policy officials engaged stakeholders in gathering evidence. The following activities were undertaken. 5.2.1. Conducted searches on GF policies for English CCGs. This included telephone discussions with 18 different CCG representatives to source opinions on changes and challenges faced, and the reviewing of evaluation reports on changes made and patient impact by CCGs where available from outcomes of local consultations. 5.2.2. Discussions with representative from the Pharmaceutical Advisory Group (PAG). 5.2.3. Policy officials undertook a visit to the dietetics team in Rotherham hospital to meet dieticians who assessed patients on an individual basis. Demonstration of how the voucher scheme for foods operated and the importance placed on patient annual review. 5.2.4. Web based research on coeliac disease and its management. Websites included: Coeliac UK, British Dietetic Association (BDA), British Specialist Nutrition Association (BSNA), National Institute of Health and Care Excellence (NICE), NHS Business Services Authority (NHS BSA), NHS Digital and NHS Choices. 5.2.5. Sought and reviewed impact data on changes that have been made (where available). 5.2.6. Issued an e-mail to alert key stakeholders of the launch of the consultation (25 organisations, including GF manufacturers/suppliers). 5.2.7. Updated list of stakeholders following consultation responses. 5.2.8. Search on available literature including; journal articles, press releases, reports, CCG website reviews on proposed changes to GF prescribing. 5.2.9. Face to face meetings with Coeliac UK and then BSNA (along with representatives from 2 manufacturers (Juvela and Glutafin)). 5.2.10. A review of references provided by consultation respondents, including journal reports, press articles, websites and guidance.

5.3. The engagement activity was undertaken by policy officials and the statistics were reviewed by analysts from Medicines and Pharmacy Directorate within the Department of Health (DH).  Engagement activities took place through face to face meetings, telephone discussions, e-mail exchanges and web based research.  Outputs included; obtaining and reviewing local (CCG) prescribing policies, evaluation reports, prescribing data, bespoke reports and verbal updates with Coeliac UK and BSNA.  By alerting key stakeholders to the consultation launch they were able to update their websites with a link to the DH consultation enabling a wide audience to review and respond to the public consultation.

23 Equality Impact Assessment Annex A - Estimated Patient Numbers

The numbers of coeliac patients is estimated to be 1% of the population.22 The English population (mid 2016) was 55,268,100, so 1% of this figure gives an estimated population with coeliac disease as 552,681. Coeliac UK estimate that only 24% of these patients have a diagnosis; this gives an identified group of 132,643 coeliac diagnosed patients. This figure has been used to replicate percentages, against the national splits, in the coeliac populations by; age, gender, ethnicity, disability, carers, those living in rural areas, and those on low incomes.

England Coeliac Population Estimates

Population Number in % of England English Number % of Total with CD Population Diagnosed with English England 2016 Numbers (1%) with CD CD(24%) Population

All population 55,268,100 552,681 1% 132,643 0.24%

Age Groups (Young) 10,445,671 104,457 19% 25,070 0.05%

Age Groups (Old) 9,948,258 99,483 18% 23,876 0.04%

Gender (Male) 27,247,173 272,472 49% 65,393 0.12%

Gender (Female) 28,020,927 280,209 51% 67,250 0.12%

Ethnicity (White) 48,138,515 481,385 87% 115,532 0.21%

Ethnicity (Non- white) 7,129,585 71,296 13% 17,111 0.03%

Disabled 6,411,100 64,111 12% 15,387 0.03%

Carers 6,500,000 65,000 12% 15,600 0.03%

Rural location 11,440,497 114,405 21% 27,457 0.05%

Low Incomes 12,158,982 121,590 22% 29,182 0.05%

22 https://www.nhs.uk/Conditions/Coeliac-disease/Pages/Introduction.aspx#Whos-affected

24 Coventry and Rugby CCG Audit Committee Report for the Meeting held on 10th April 2018

Achievements / Decisions Made / To Note Matters referred to lllllllllllllllll Governing Body for approval, debate or further 1. Internal Audit reports: consideration: The Committee noted the following: Policy for Approving Pharmaceutical • Off payroll & IR35 compliance – noted level of assurance Industry Rebate Schemes recommended provided – SIGNIFICANT - and the agreed action plan. for Approval. • Information Governance Toolkit - noted that the review had highlighted a number of gaps in the evidence available to support the target level of compliance for 2017/18 and that an action plan was in place to address before final submission.

2. Head of Internal Audit Opinion 2017/18

• O verall draft opinion was that Significant Assurance could be given that there was a generally sound system of internal control, designed to meet the organisation’s objectives, and that controls

were generally being applied consistently.

3. Policy for Approving Pharmaceutical Industry Rebate Schemes

The Committee heard that: Key Issues for the Governing • The potential for PCRS to help efficiently manage the prescribing Body: budget and consequently highlight significant QIPP opportunities was significant. No issues highlighted. • PCRS would only be recommended where medicines were licensed and were not on the APCs blacklist nor have had a negative decision by NICE. • There should be no directive for health professionals to prescribe a specific product, solely because a Primary Care Rebate Scheme (PCRS) was in place.

4. Corporate CCG reports: The Committee received reports confirming that: • There had been no Waivers to Formal Tendering Procedures during the period • There had been no recorded Losses or Special Payments 5. Financial Services report

• The Committee noted this report which provided key performance data on debtor, creditor and cash management, better payment compliance at month 12 (2017/18).

Key Information: • Committee Chair: Mr Chris Stainforth (Lay Member, Governance) • CCG Lead: Mrs Clare Hollingworth (Chief Finance Officer) • Date of Next Meeting: 24 May 2018 (Extraordinary meeting to approve the 2017/18 Annual Accounts) Coventry and Rugby CCG Audit Committee Report for the Meeting held on 24th May 2018

Achievements / Decisions Made / To Note Matters referred to lllllllllllllllll Governing Body for approval, debate or further 1. Report to those charged with Governance (ISA260) • Ernst Young, the CCG’s external auditors, presented there draft consideration: audit findings and detailed the work still to be concluded (minimal). None • The Committee heard that the CCG was expected to receive an Unqualified opinion in respect of both True & Fair View and Regularity but an ‘Except for’ opinion in relation to Value for Money given the deterioration in its underlying financial position.

2. Head of Internal Audit Opinion 2017/18 • Overall final opinion was that Significant Assurance could be given that there was a generally sound system of internal control, designed to meet the organisation’s objectives, and that controls were generally being applied consistently.

3. Annual Report 2017/18 • The report was received and reviewed. • With delegated authority from the Governing Body, the Committee APPROVED the report.

4. Annual Accounts 2017/18 Key Issues for the Governing • The accounts were received and reviewed. Body: • All adjustments required as a result of the statutory audit were reflected. No issues highlighted. • With delegated authority from the Governing Body, the Committee

APPROVED the Accounts. 5. Letter of Representation 2017/18 • The draft letter was received and reviewed. • The CCG had no specific issue to disclose. • The Committee authorised the CFO and the Chair of the Committee to sign the letter.

Key Information: • Committee Chair: Mr Chris Stainforth (Lay Member, Governance) • CCG Lead: Mrs Clare Hollingworth (Chief Finance Officer) • Date of Next Meeting: 28 June 2018 (Meeting in Common with Warwickshire North) Warwickshire North CCG Audit Committee Report for the Meeting held on 2 May 2018

Achievements / Decisions Made / To Note: Matters referred to lllllllllllllllll Governing Body for Internal Audit Assignment Report: Information Governance Toolkit: approval, debate or further Members were assured that the CCG met level 2 requirements which was the consideration: expected standard. Policy for Approving Internal Audit Assignment Report: Assurance Framework: Members were Pharmaceutical Industry assured that the CCG had achieved Level A assurance. Rebate Schemes: The Audit Committee approved the policy Internal Audit Assignment Report: Quality and Contract Monitoring: for recommendation to the Members were assured that significant assurance had been provided overall Governing Body. and no high level recommendations were raised.

Head of Internal Audit Final Opinion: Members heard that the Overall Head of Internal Audit Opinion was significant assurance.

Key Issues for the Governing Body:

None.

Key Information: • Committee Chair: David Allcock, Lay Member for Audit and Governance • CCG Lead: Chris Lonsdale, Director of Finance • Date of Next Meeting: 24 May 2018

Warwickshire North CCG Audit Committee Report for the Meeting held on 24 May 2018

Achievements / Decisions Made / To Note: Matters referred to lllllllllllllllll Governing Body for Report to those Charged with Governance (ISA260): Members noted that approval, debate or further the auditors issued an unqualified report in respect of the CCG’s accounts. consideration: There were no unadjusted audit differences to report, and the Value For Money conclusion was qualified ‘except-for’ on the grounds of the financial position. None.

Head of In ternal Audit Opinion 2017/18 – Final: Members heard that the report had been updated to reflect the results of the outstanding audits and the Service Auditor reports that had been received. The Committee noted the revised opinion for 2017/18.

Annual Report 2017/18: Members heard that the report had been prepared in accordance with the national guidance and NHS England template. The Committee approved the Annual Report 2017/18.

Annual Accounts 2017/18: The Committee approved the Annual Accounts 2017/18 subject to final non- substantive amendments being made as agreed with the external auditors.

Letter of Representation: Members heard that the letter was a standard requirement with no specific area requiring the attention of the Committee. The Committee noted the contents of the letter and authorised the Chief Finance

Officer and the Chair of the Audit Committee to sign it.

Key Issues for the

Governing Body:

None.

Key Information: • Committee Chair: David Allcock, Lay Member for Audit and Governance • CCG Lead: Chris Lonsdale, Director of Finance • Date of Next Meeting: 28 June 2018

Clinical, Quality and Governance Committees in Common (CQG) Committee Report for the Meeting held on 25th April 2018

Matters referred to the Governing Body for approval, debate or further consideration:

1. No matters were referred

Key Issues for the Governing Body None

Achievements/Decisions Made/Items to Note 1. Quality, Safety and Governance Provider reports:

The Committee received the reports for Coventry and Warwickshire Partnership NHS Trust (CWPT), University Hospitals Coventry and Warwickshire NHS Trust (UHCW), George Eliot Hospital NHS Trust (GEH) and Care Homes. The main issues included:

CWPT

CWPT did not meet their CAMHS (Child and Adolescent Mental Health Services) referral to treatment within 18 weeks target in February 2018, with performance of 99.4% (target 100%).

A Serious Incident (SI) was reported around Tissue Viability and work is ongoing to ensure that an action plan is being worked through to review wound care across integrated community services.

UHCW

Delays in dermatology referrals have improved and the CCG is assured that clinical triage of referrals are being conducted by the Trust.

Clinic letters are currently at level two on the framework. The CCG has begun the process of issuing formal performance notices for all Level 3 risks on the framework. We are expecting an action plan from Trust in relation to clinic letters on 1st May 2018.

GEH

A&E performance is on Level 2 of the assurance framework. The CCG has asked for further assurance around A&E and confirmed that we are carrying out a quality assurance visit to Accident and Emergency Clinical Decision Unit and Paediatrics.

Care Homes update

The CRCCG Committee noted that seven homes were on escalation and enhanced monitoring; all homes are making progress against their improvement plans. One provider has a restriction on admissions.

WNCCG Committee noted that there are currently no Elderly Care Homes closed due to quality concerns however there are five homes on enhanced surveillance where quality of care requires an improvement.

Safeguarding Assurance report

The Committees received and noted the new safeguarding dashboard. Members noted that a campaign to improve compliance for statutory and mandatory training was underway however there were still issues with training being accurately recorded within ESR. This had been escalated to IBM and a solution awaited.

The CCG is still continuing to provide a health advisory rota for the MASH until the health provision is fully up and running.

Nutritional and Hydration standards and guidelines

The Warwickshire North CCG Committee members approved the Nutritional and Hydration standards and guidelines for the use in care homes within Warwickshire North CCG.

1. Standard Operational Procedures for Discharge to Assess, pathway 2

The Committees noted the Standard Operational Procedures for Discharge to Assess, Pathway 2.

2. Quality Assurance Framework

The Quality Assurance Framework was presented to the Committee and supported. The Chief Nursing Officer outlined that discussions from the CQGC workshop in March 2018 were used to inform the development of the framework and wider engagement with system providers and stakeholders will now take place.

3. Equality and Quality Impact Assessment Policy

The Equality and Quality Impact Assessment policy was presented however not approved due to Equality Impact Assessment needing revisions. The Quality Impact Assessment element of the policy was supported by Committee members.

4. University Hospitals Coventry and Warwickshire Quality Account – CCG Response

The UHCW draft quality account and draft statement in response to this draft quality account from the CCG was presented and supported. This is an annual requirement for us to send a response and the deadline this year is 2nd May 2018

5. Information Governance Compliance Year End Reports

The committees noted that the Information Governance compliance year-end reports were successfully submitted on 31st March 2018.

6. Corporate Risk Register

The Committee noted the risk register.

7. Equality Delivery System 2 (CRCCG and WNCCG)

The Committee noted that the EDS2 reporting tools for the CCGs has been published and will be subjected to a scoring exercise prior to the end of quarter 2.

8. Workforce Race Equality Standards Action Plan

The Committees approved the respective WRES Action Plans for publication and implementation.

CRCCG / WNCCG Commissioning Finance and Performance Committee (CF&P) Report for the Meetings in Common held on 26th April 2018

Achievements/Decisions Made/Items to Note Key Issues for the Governing Body Performance Report – Month 11: The key issues for CRCCG Financial and Contracting Report Month 12: both CCGs were continued under achievement of The key concerns that need to be highlighted are: Referral to Treatment (RTT), A&E 4 hour waits, 104 day 1. Acute position cancer target and cancelled operations. WNCCG underachieved against the Cancer 62 day wait. 2. QIPP position

Procurement Report: The Committee noted and were 3. The need to use reserves and other non-recurrent assured as to the progress of the current procurements. flexibilities to offset and hence the impact on the QIPP Development, Planning, Delivery & Assurance underlying position. 2018/19: Members noted that both CCGs failed to achieve recurrent QIPP delivery against plans during 2017/18. CRCCG had achieved 98% QIPP delivery but WNCCG Financial and Contracting Report Month 12: only with the support of non-recurrent flexibilities. A root The key concerns that need to be highlighted are: and branch review had been undertaken to understand 4. Acute position the under-delivery and an action plan derived. The Committee supported the ongoing plan for enhanced 5. QIPP position delivery and assurance in relation to QIPP. 6. The need to use reserves and other non-recurrent Extended Access Contract Approval: flexibilities to offset and hence the impact on the 1. The GPs present declared an interest in the decision. 2. CRCCG Members approved the re-appointment of underlying position. the Coventry & Rugby GP Alliance for a further contract term. 3. WNCCG Members proposed the development of a local primary care solution that the Warwickshire GP Federation may be involved with, and authorised the Chief Primary Care and Strategy Officer to arrange a workshop and commence discussions. 4. Members of both Committees delegated authority to the Chief Officer to approve the final contract terms and determine whether it was in the best of interest of the CCGs to issue a transparency notice. 5. Members from both CCGs agreed for the recommendations to be circulated to all non-GP voting Members following the meeting in order for the decisions to be ratified (each Governing Body having previously delegated authority to the Committee to approve the contract award).

CRCCG Financial and Contracting Report Month 12: Members noted the release of the non-recurrent reserve Matters referred to the Governing Body for approval, and Cat M rebate. The NCSO cost pressure remained debate or further consideration: unmitigated. The Committee noted the overall position subject to Audit. CRCCG was reporting an in-year 1. CRCCG Financial and Contracting Report – Month surplus of £2.65m against its notified allocation which 12 was in accordance to the plan. This added to the brought forward surplus to reach a cumulative surplus of £6m. The recurrent underlying deficit was £7.8m. 2. WNCCG Financial and Contracting Report – WNCCG Financial and Contracting Report Month 12: Month 12 Members noted the release of the non-recurrent reserve and Cat M rebate. The NCSO cost pressure remained unmitigated. The Committee noted the overall position subject to Audit. WNCCG was reporting an end of year Key Information: deficit of £3.73m which was in line with NHSE 1. Committee Chair: Graham Nuttall (Lay Member expectations. The recurrent underlying deficit was Primary Care) £6.32m. 2. CCG Lead: Clare Hollingworth (Chief Finance Officer)

h CRCCG / WNCCG Commissioning Finance and Performance Committee (CF&P) Report for the Meetings in Common held on 24th May 2018

Achievements/Decisions Made/Items to Note Key Issues for the Governing Body Procurement Report: The Committee noted and were assured as to the progress of the current procurements. Members from both CCGs delegated authority to the Chief Finance Officer to approve the type of contract to be tendered for Termination of Pregnancy Services.

Performance Report – Month 12: The key issues for both CCGs were continued under achievement of Referral to Treatment (RTT), A&E 4 hour waits, 104 day cancer target and cancelled operations. In relation to the remaining cancer targets, CRCCG achieved all except the 2 week wait target for urgent GP referrals of patients with breast symptoms. WNCCG underachieved against the 62 day wait target from urgent GP referral to first definitive treatment, the 62 day wait target following a consultant’s decision to upgrade the priority of the patient, and the 31 day target for subsequent surgery treatment.

QIPP Report: Members heard that the CCGs were implementing a new reporting and assurance process for QIPP.Members noted that for both CCGs the QIPP projects were inherently challenging due to the number of stakeholders that needed to be influenced. Concerns was expressed that the year to date savings requirement had probably not been achieved in full and whilst action was being taken to recover implementation milestones, it was currently unclear whether slippage in cost savings could be recovered. Members of both Committees noted the report.

Matters referred to the Governing Body for approval, debate or further consideration:

None.

Key Information: 1. Committee Chair: Graham Nuttall (Lay Member Primary Care) 2. CCG Lead: Clare Hollingworth (Chief Finance Officer) th

Minutes of the Meeting of the Warwickshire Health and Wellbeing Board held on 2 May 2018

Present :-

Warwickshire County Councillors Councillor Izzi Seccombe OBE (Chair) Councillor John Holland

Warwickshire County Council (WCC) Officers Nigel Minns (Strategic Director for People Group) John Linnane (Director of Public Health and Strategic Commissioning)

Clinical Commissioning Groups (CCG) Gill Entwistle (South Warwickshire CCG) Dr Sarah Raistrick (Coventry and Rugby CCG) Dr Deryth Stevens (Vice Chair, Warwickshire North CCG)

Provider Representatives Mike Williams (Coventry & Warwickshire Partnership Trust)

Healthwatch Warwickshire Robin Wensley

NHS England Rachael Danter

Borough/District Councillors Councillor Tony Jefferson (Stratford District Council) Councillor Barry Longden (Nuneaton and Bedworth Borough Council) Councillor Andrew Thompson (Warwick District Council)

1. General

(1) Apologies for Absence

Councillors Les Caborn and Jeff Morgan (Warwickshire County Council) Dr David Spraggett (South Warwickshire CCG) Philip Seccombe (Police and Crime Commissioner) Prem Singh (George Eliot Hospital) Councillor Margaret Bell (North Warwickshire Borough Council)

Andrea Green (Warwickshire North and Coventry and Rugby CCG) Andy Hardy (UHCW and Better Health, Better Care, Better Value) Kath Kelly (George Eliot Hospital)

(2) Members’ Declarations of Pecuniary and Non-Pecuniary Interests

None

(3) Minutes of the Board Meeting held on 10 January 2018

The Minutes were agreed as a true record.

2017-07-26 HWB minutes Page 1 of 7

(4) Chair’s Announcements

The Chair welcomed new Board members in attendance, Dr Sarah Raistrick (Coventry and Rugby CCG) and Rachael Danter (NHS England). She reported that the new representative for George Eliot Hospital (GEH) would be Prem Singh, recording the Board’s thanks to Chris Spencer, the previous GEH representative. The Chair welcomed Rachel Barnes, Health and Wellbeing Delivery Manager to her first Board meeting and confirmed that Jane Coates had been appointed as the Year of Wellbeing Delivery Manager.

2. Warwickshire Pharmaceutical Needs Assessment 2018

The Committee received a report and presentation from Rachel Robinson, Associate Director of Public Health, NHS Warwickshire North/Coventry and Rugby CCGs. The Pharmaceutical Needs Assessment (PNA) provided an assessment of the pharmaceutical services currently provided in Warwickshire. In September 2017, the Health and Wellbeing Board (HWB) agreed to an update of the PNA. It then considered and made amendments to the draft document at its meeting in January 2018. The PNA subsequently went out to consultation and responses to that consultation were considered by the PNA steering group and changes incorporated where appropriate. In accordance with the authority delegated by the Board in January, the Health and Wellbeing Board Sub-Committee met on 22 March to consider and approve the final Warwickshire PNA for publication.

The HWB had approved that a Pharmacy Steering Group (PSG) be established to monitor and support delivery of the recommendations included within the PNA, updating the Board periodically. The PNA made a number of recommendations including ongoing monitoring of services and housing sites, to assess the need for supplementary PNA statements. The report highlighted a need to raise awareness, signposting and online information to promote the pharmacy services currently available. The PSG would act as a reference group for other health and wellbeing programmes working with pharmacy. The draft terms of reference were discussed at the final PNA steering group meeting on 23rd April and were submitted for consideration by the Board.

Questions and comments were submitted regarding the composition of the PSG. There would be regular updates to the HWB, to provide assurance. The importance of NHS England being represented on the group was stated. It was questioned how the health sector engaged with planning authorities, to ensure they were aware of planned residential developments and received infrastructure contributions for new or expanded services. This was applicable to both pharmacy and other primary care services. Linked to this point was ensuring that the new services were located in the correct areas. The provision of electronic rather than paper based prescriptions was also suggested.

A further presentation was provided by Anna Nicholls, Interim Deputy Head of Commissioning (Primary Care), NHS England (NHSE). This provided the Board with information about NHSE direct commissioning and its budgets. The presentation included the data for Warwickshire on service provision for dental, ophthalmic, optometry, pharmacy, Section 7A Public Health services, flu immunisation uptake and general medical services. There was discussion about the variable take up levels across Warwickshire of the flu immunisation and the negative impact that incorrect social media posts had caused. The national news relating to missed breast screening

2018-05-02 HWB minutes Page 2 of 7

was raised. It was questioned if funding for pharmacy had reduced. Satyan Kotecha, Local Professional Network (Pharmacy) Chair for the West Midlands confirmed that this was the case, adding that there was an objective for pharmacy to move from a dispensing/supply function to be more of a clinical function.

The Chair asked that NHSE provide information for the Coventry and Warwickshire area, detailing its spending on services. It would be helpful if this could be supplied in time for the September Board meeting, when it would also be considering the CCG commissioning intentions.

Resolved

That the Board notes the update on the 2018 Warwickshire Pharmaceutical Needs Assessment and agrees the terms of reference and membership of the Pharmacy Steering Group, including that NHS England is an integral part of that group.

3. Health and Wellbeing Annual Review 2017/18 and Planning Approach 2018/19

Rachel Barnes, Health and Wellbeing Board (HWB) Delivery Manager introduced this item. The Board had agreed that the current HWB strategy would conclude in March 2018 and a new strategy would be established. In 2017/18 national policy changes and local decisions had created opportunities for a ‘step change’ in the way the HWB worked, including:

• Establishment of the Place Forum and development of a ‘Place Plan’ • Commitment to Prevention and the Year of Wellbeing in 2019 • Conclusion of the 2014-19 Commissioning Intentions Plan • Development of Integrated Care Systems • Refresh of the Better Health, Better Care, Better Value programme • Commitment to Health and Housing.

The role of the Board in capitalising on this opportunity, securing the necessary alignment of across partners and drawing the respective elements together was critical. The report outlined the proposed approach to:

• Reporting on the 2014-18 HWB Strategy; • Reporting on the HWB Delivery Plan for 2017/18; and • Developing the new HWB Strategy and HWB work programme for 2018/19 for discussion.

A draft of the proposed document had been circulated for the Board’s initial consideration and feedback. It would be discussed formally at the September Board meeting. A suggestion was made to have regard to the local plans of district and borough councils. There was a need to reduce reliance on the private motor car, to encourage use of public transport and for people to take more exercise. Current transport proposals for additional roads did not contribute to this. Dr John Linnane, Director of Public Health and Strategic Commissioning confirmed that his department did work with transport colleagues. He used the example of Combined Authority schemes to encourage use of public transport and the out of hospital commissioning work which enabled a review of how services were delivered.

The format of the draft document was welcomed overall. As this would be a public facing document it was suggested that the second page, explaining how the document worked, should be reviewed.

2018-05-02 HWB minutes Page 3 of 7

Resolved

That the Board supports the direction for the Health and Wellbeing Annual Review 2017/18 and proposed planning approach for 2018/19, to enable greater strategic alignment and integration of planning and activity across the system.

4. Joint Strategic Needs Assessment

Spencer Payne, WCC Insight Service Manager provided an update on the Joint Strategic Needs Assessment (JSNA). At its meeting on 10 January 2018, the Board endorsed the delivery model for phase three of the JSNA programme with needs assessments across the County. The update described the initial work on the first wave of five place-based needs assessments. There had been targeted activity to ensure local engagement and a table in the report listed the agreed needs assessments and sponsors / leads for each area.

A working group had been established to coordinate the delivery of the programme and it met for the first time on 13th March. The programme leads were holding initial steering group meetings during April or May. Their work programme would be monitored through the JSNA Strategic Group with further updates provided to future Board meetings.

Councillor Barry Longden asked for a map to be provided showing the exact area covered for the JSNA scheme in Nuneaton Central, which would be provided. John Linnane paid tribute to the significant work undertaken by Spencer Payne and his Insight team. These sentiments were endorsed by the Chair who added that this work was being well received.

Resolved

That the Board notes the update on the Joint Strategic Needs Assessment place-based assessments.

5. Feedback from the Spring Workshop (Joint Place Forum)

John Linnane presented a report from the joint workshop held on 7 March 2018. This was the second Place Forum involving the Warwickshire and Coventry Health and Wellbeing Boards. There were over 40 attendees representing a wide range of organisations.

The main aims and outcomes from the session were reported. It provided the opportunity to update on changes in the system and to strengthen place-based working. It included a presentation on Integrated Care Systems by NHSE, the draft refreshed Concordat and system design and an update on the Year of Wellbeing. A series of actions shown in an appendix to the report would be added to the Place Plan.

The Concordat and Place Design would be updated following the feedback received at the Spring Workshop, with the aim of presenting draft versions at the next Place Forum in July 2018. Dr Linnane urged all members of the Board to attend the July Forum. The Chair spoke of the good working relationship and energy between the two boards. Councillor Holland asked whether the decision to review the Concordat after just 18 months and particularly to remove references to financial aspects would affect its transparency. The Chair noted this point and explained the rationale for revising the

2018-05-02 HWB minutes Page 4 of 7

document. In response to a further question from Dr Deryth Stevens, it was confirmed that the Place Plan rolling actions were still in progress and would be considered further in July.

Resolved

That the Board notes the feedback from the Joint Coventry and Warwickshire Place Forum held on 7 March 2018.

6. Coventry and Warwickshire CAMHS Local Transformation Plan: Year 2 Refresh

Andrew Sjurseth, WCC CAMHS Commissioner presented a report which gave background on the Local Transformation Plan (LTP) and the funding provided to improve outcomes for children and young people with mental health problems. The Coventry and Warwickshire area had been allocated annual funding of £1.7m for each of five years.

Governance and oversight of the LTP was provided by the Coventry and Warwickshire CAMHS Transformation Board. NHS England required each LTP to submit an annual refresh of their local plan. As part of this submission, NHS England expected Health and Wellbeing Boards to be sighted on the refreshed plan and act as one of the signatories to the document. It was decided that endorsement from this Board should occur following NHS England assurance of the refreshed LTP. NHS England had approved this approach and its assurance was obtained in December 2017.

The year two refresh document was submitted. It detailed the progress made in year two of the five year plan and set out priorities for year three. Year three of the LTP coincided with the start of the new Warwickshire children and young people’s emotional well-being and mental health service for 0-25 year olds, known as Rise. This new service has a two year implementation period running until August 2019. Consequently, the priority themes in year three of the LTP were aligned against the Implementation Plan for the new service.

It was noted that a joint task and finish scrutiny group had been commissioned to review the implementation of the new service and it would report its findings to meeting on 12 June. A copy of the completed review report would be supplied to the Board. A CCG representative noted that there had been a reduction in waiting times, although not as much as was hoped. On behalf of the service provider, Mike Williams referred to the increasing service demands and reducing funding allocations.

Resolved

That the Board:

1) Endorses the Coventry and Warwickshire Child and Adolescent Mental Health Services Local Transformation Plan refresh for year two.

2) Notes that a refreshed CAMHS Local Transformation Plan for year three is likely to require sign off from the Health and Wellbeing Board in October 2018.

2018-05-02 HWB minutes Page 5 of 7

7. Health and Wellbeing Board Forward Plan

The Board reviewed its forward plan for 2018/19. This listed proposed items for formal board meetings and the focus of the workshop sessions. Updates would be presented to each meeting for the Board to review. Additional items proposed for consideration in 2018/19 were updates on the Pharmacy Steering Group and LGA Upscaling Prevention. The Chair reiterated the earlier request for additional information from NHS England on its service spending across Coventry and Warwickshire.

Resolved

That the Board updates its Forward Plan as indicated above.

8(a). Better Health, Better Care, Better Value Programme

An update was presented by Brenda Howard, the Programme Director for Better Health, Better Care, Better Value (BHBCBV). She spoke about the alignment of the BHBCBV work streams with that of the Place Forum, referring particularly to the upscaling prevention work stream.

The Chair referred to locality working and endeavours to get synergy across the local health and wellbeing system. Dr Sarah Raistrick of Coventry and Rugby CCG confirmed that there was unanimous support to this approach from the Coventry HWB and John Linnane added that Coventry City Council was using the same place-based approach to its Joint Strategic Needs Assessments.

A question was asked about the Mental Health Investment Standard. This was a requirement for CCGs to increase their investment in mental health services in line with their overall increase in allocation each year. Gill Entwistle confirmed that all CCGs were required to send to NHSE an estimate their anticipated spending at the start of the year and then send details of actual spending for comparison. She offered to circulate this information for her CCG to the Board. Rachael Danter of NHSE confirmed this, adding that there was an increased focus nationally on mental health, so it was expected that there would be a shift in targeting of expenditure.

Resolved

That the Board notes the report.

8(b). Warwickshire Better Together Programme

John Linnane provided an update on the Warwickshire Better Together Programme. This included a review of performance during 2017/18. Locally the focus sought to improve performance in the four key areas measured against national performance metrics, being:

• Reducing Delayed Transfers of Care • Reducing Non-Elective Admissions (General and Acute) • Reducing admissions to residential and care homes; and • Increasing effectiveness of reablement

Detailed data was provided for each of these areas. Further sections of the report set out the 2018/19 targets and an update was provided on the additional funding

2018-05-02 HWB minutes Page 6 of 7

allocation for Disabled Facilities Grants, with £400,000 allocated to district and borough councils across Warwickshire.

The Board discussed the progress on reducing delayed transfers of care, the overall improving position and the impact of winter pressures. It was noted that Warwickshire’s population had more elderly people than the national average. There was an increasing number of residents aged over 85 which presented additional challenges for some services. A particular point was the number of frail elderly people arriving at acute hospitals by ambulance. Related to this, reference was made to the NHS 111 service and the potential for some people to use ambulance services inappropriately. It was suggested that this could be an area for reference to the health scrutiny committee or the specialist blue light collaboration group. The Chair of the health scrutiny committee, Councillor Wallace Redford was in attendance. He spoke of the previous difficulty in getting requested information from the West Midlands Ambulance Service (WMAS). Councillor Holland considered there was the potential for ambulance staff to undertake additional roles, reducing the impact for other parts of the health system. A brief explanation was given of the commissioning arrangements for WMAS.

Resolved

That the Board notes:

1) The progress of the Better Together Programme in 2017/18 to improve performance against the four national Better Care Fund (BCF) areas of focus.

2) The performance targets for 2018/19.

3) The additional funding relating to the Disabled Facilities Grant.

9. Any Other Business (considered urgent by the Chair)

Dr John Linnane referred to the recent increase in cases of measles in the region and nationally. There had been 11 cases in Warwickshire and this was an area for further Board discussion. Vaccinations were available from GPs and there was an assurance role for Public Health.

Rachel Barnes advised that a presentation would be provided at the September Board meeting on the work of the Warwickshire North Health and Wellbeing Partnership. She publicised a series of development network sessions for leaders in health and social care across the West Midlands. Those wishing to attend should email [email protected].

The meeting rose at 3.20pm

.... Chair

2018-05-02 HWB minutes Page 7 of 7

Coventry City Council Minutes of the Meeting of Coventry Health and Well-being Board held at 2.00 pm on Monday, 9 April 2018

Present:

Board Members: Councillor Abbott Councillor Caan (Chair) Councillor Taylor Rob Allison, Voluntary Action Coventry Professor Guy Daly, Coventry University Rachael Danter, NHS England Liz Gaulton, Acting Director of Public Health Simon Gilby, Coventry and Warwickshire Partnership Trust Andrea Green, Coventry and Rugby CCG Andy Hardy, University Hospitals Coventry and Warwickshire Ruth Light, Coventry Healthwatch John Mason, Coventry Healthwatch Mike O’Hara, West Midlands Police Dr Sarah Raistrick, Coventry and Rugby CCG

Employees (by Directorate):

Place: L Knight People: A Agbebiyi S Chun Lam P Fahy S Frossell R Nawaz T Wukics

Apologies: Councillors Duggins and Ruane Steve Banbury, Voluntary Action Coventry Ben Diamond, West Midlands Fire Service Professor Caroline Meyer, Warwick University Gail Quinton, Deputy Chief Executive (People) Martin Reeves, Chief Executive

Public Business

43. Declarations of Interest

There were no declarations of interest.

44. Minutes of Previous Meeting

The minutes of the meeting held on 5th February, 2018 were signed as a true record. There were no matters arising.

– 1 – 45. Dr Sarah Raistrick and Rachael Danster

The Chair, Councillor Caan welcomed Dr Sarah Raistrick, Coventry and Rugby CCG and Rachel Danster, NHS England who were attending their first formal meeting of the Board.

46. Ben Diamond and Adrian Stokes

The Chair, Councillor Caan informed the Board that Ben Diamond, West Midlands Fire Service, was moving to a new role within the Fire Service in the Black Country and that Adrian Stokes NHS England had also moved to a new role. He placed on record his thanks to both members for all their work in support of the Board. In particular, he paid tribute to the work undertaken by Ben in his role of Co-Chair of the Marmot Steering Group.

47. Chair's Update

The Chair, Councillor Caan reported on Coventry’s application to be awarded the European City of Sport for 2019. Sport had an important part to play in improving the health and wellbeing of local residents and the city had invested heavily in sports and physical activity facilities. He thanked Professor Guy Daly for all his support when hosting the delegation to the city and indicated that he was hopeful for a positive outcome which would tie in with the Year of Wellbeing and support the work in the lead up to Coventry 2021.

Councillor Caan informed that a Norwegian health delegation were due to visit Coventry the following day as part of a two day visit to the UK. The team of health professionals and policy makers wanted to look at practical examples of the Councils’ work on social determinants of health and reducing health inequalities. Coventry was chosen being the only Marmot city in the UK. The Chair reminded Members that they were invited to the lunch to meet with the delegates.

48. Towards a Place Based Approach for the Joint Strategic Needs Assessment

The Board received a report of Liz Gaulton, Acting Director of Public Health, and a presentation from Si Chum Lam, Coventry Council, which set out a proposal for a place-based approach for refreshing the Coventry Joint Strategic Needs Assessment (JSNA).

The report indicated that the publication of a JSNA, along with a Joint Health and Wellbeing Strategy (JHWBS), was a statutory requirement placed on the Board under the Health and Social Care Act 2012. It was a means by which local leaders across health and care worked together to understand and agreed the needs of Coventry residents, and was owned by the Board. It brought together data, information and key health and social care issues and supported the planning and commissioning of health, wellbeing and social care services. The Coventry JSNA had been updated for 2018 with refreshed data; the addition of a colourful set of flash facts outlining data for each theme; and an accompanying set of slides.

The current JHWBS covered 2016-19 and was due for a refresh for the 2019-22 period, which would necessitate a further refresh of the JSNA. It was the intention to move towards a place-based approach for the JSNA to inform the development

– 2 – of the next JHWBS. This reflected recent research evidence, developments and policy direction nationally which had seen a move towards recognising that health and care services based around natural geographies of populations between 30,000-50,000 people would offer populations a much more complete and less fragmented services.

The Board were informed that Warwickshire County Council had developed a placed based approach to their JSNA which had been positively received. This was a significant departure to the traditional whole population, thematic approach. Learning from Warwickshire, developing a place-based JSNA for Coventry would involve the following:  identification of suitable geographies to be the local area building blocks. Warwickshire had 22 JSNA geographies which were profiled in stages over several years;  each area to have an average population of 25,000, defined by geospatial software and stakeholder consultation;  boundaries designed to meet stakeholder needs as far as possible with partners being committed to using these areas for strategic planning purposes;  producing data at the local geography level through a profiling tool developed by the Insight team at Warwickshire; and  creating locally focussed profiles each with a local champion or sponsor and lead officer. Work to be owned by a local stakeholder group and supported by an analyst.

This move would benefit the services that worked jointly with Coventry and Warwickshire, particularly the Place Forum, the Coventry and Rugby CCG and the acute hospital trusts. It would also create new opportunities including providing support towards increased joint working between the two public health teams.

The Board noted that the footprint of the eight recently formed Family Hubs in the City could possibly act as a suitable geography for Coventry. Based on Warwickshire’s experience, a profiling tool could be made flexible enough to allow partners to access data and create statistical profiles to support multiple needs including commissioning decisions, family hubs, out of hospital localities, and the transformations of children’s social care.

The presentation provided an explanation of what the JSNA was and how it related to the JHWBS; informed of the forthcoming refresh of the JSNA and JHWBS; and provided information on the key facts and figures from the latest JSNA on population and migration, housing, skills and education, economy and business, crime and violence, life expectancy, vulnerable children and young people, mental health and wellbeing, physical wellbeing, long-term conditions, demand for care, and infectious diseases.

Members raised a number of issues in response to the report and presentation including:  Support for the inclusion of community information and community assets within the JSNA  Support for the place based approach to the JSNA with a request for clarity  A concern that different organisations used different geographical areas when using the place based approach

– 3 –  The importance of taking community opinions on board when determining geographical locations  Further information about what was included in the data relating to quality of housing and the causes of poverty  Clarification about how the design phase would determine the places which would also consider service delivery  A concern that some of the statistics covered the period three years old  Clarification that the approach to keeping the latest up to date information on the website would include relevant dates.

RESOLVED that, having reviewed the updated JSNA with 2018 data:

(1) The work towards a place-based JSNA to inform the next refresh of the Joint Health and Wellbeing Strategy (JHWBS) be endorsed.

(2) Local sponsors and lead officers in each geographical area be identified so that areas for development identified through the JSNA can be developed into local priorities and action plans.

49. Coventry and Rugby Clinical Commissioning Group (CCG) Commissioning Intentions 2018/19

The Board received a presentation from Andrea Green, Coventry and Rugby Clinical Commissioning Group (CCG) concerning the CCG’s commissioning intentions for 2018/19. All CCGs were required to develop and publish commissioning intentions, setting out their priorities, on an annual basis.

The presentation set out the background to the CCG reminding that the CCG was responsible for planning, organising and buying NHS funded healthcare on behalf of 448,000 people across both Coventry and Rugby. They were a clinically led organisation consisting of 73 GP member practices across the two areas. The CCG were currently six months into a two year programme of work for 2017-19, and work had been undertaken to align to the other priorities across the local health economy.

The presentation detailed the challenges and pressures faced locally by the NHS along with the national drivers for the next two years. The Commissioning intentions for 2018/19 were set within the contest of significant financial and workforce challenges across health and social care which would require new models of care characterised by:  Putting patients’ needs and system sustainability before organisations needs  Commissioning of services that supported people to live independently for longer, stayed well and recovered quicker closer to home, where appropriate  Commissioning services that encouraged and supported patients to be active participants in their own care  Commissioning at the scale where this delivered improved outcomes and achieved best use of resources  Commissioning in local community settings where it was safe, sustainable and achieved improved outcomes and patient experience

– 4 –  Holistic care co-ordinated around the patient, delivered by interdisciplinary teams working around groups of GP practices.

The system integration priorities were the development of clinical networks across Coventry and Warwickshire; to support providers in working together to maximise outcomes for the population; and to develop a collaborative commissioning approach across Coventry and Warwickshire to deliver the Better Health, Better Care, Better Value initiative.

The presentation referred to the engagement with the local population and provided detailed information on the commissioning intentions for the following workstreams: preventative and proactive care - primary care and out of hospital; maternity and paediatrics; urgent and emergency care; planned care; mental health. Information was also provided on how the intentions aligned to the Coventry Health and Wellbeing key priorities. It was highlighted that engagement with the local population would continue in order to receive feedback against the proposals to check that the priorities will deliver the best health, best care and best value.

Members expressed support for the work on mental health; enquired about staffing implications including the issue of Brexit; and raised the issue of the positive impact of new technology. Reference was made to the work of the universities who were responding to the challenges presented by Brexit while working closely with the health partner organisations.

RESOLVED that:

(1) The content of the presentation be noted.

(2) Copies of the presentation slides be circulated to Board members.

50. Update from Place Forum

The Board received a presentation from Liz Gaulton, Acting Director of Public Health, concerning the Coventry and Warwickshire Place Forum which took place on 7th March, 2018.

The Board were informed that there were over 40 attendees at the event which provided the opportunity to update on key changes in the system and inform a number of key products to strengthen place-based working. The actions agreed at the Forum were set out and these were to be added to the Place Plan. The presentation included an update on the rolling actions contained in the Place Plan.

The Forum agreed to update the Coventry and Warwickshire Health and Well- being Alliance Concordat to reflect the priorities for improved well-being and ways of working. The requirements from the discussion on the concordat were highlighted. The Board noted that the updated Concordat would be submitted to the next meeting of the Board in the new municipal year for ratification.

The presentation referred to the agreement reached to set out a holistic design for the health and care system which showed what everyone was working to and the

– 5 – roles the partners played. The model provided a framework for working which was to be applied sensitively to each place.

The Forum agreed that 2019 was to be the Year of Wellbeing. It was to be a flagship activity of the Forum with all partners championing, investing in and prioritising this. Planning and engagement with partners would take place during 2018. The Board noted that the Wellbeing Deliver Manager had now been appointed and would manage and implement the Year of Wellbeing.

RESOLVED that:

(1) The contents of the presentation be noted.

(2) The updated Coventry and Warwickshire Health and Wellbeing Alliance Concordat be submitted to the next meeting of the Board for ratification.

51. Better Health, Better Care and Better Value Programme Update

The Board considered a report of Andy Hardy, University Hospitals Coventry and Warwickshire (UHCW) which provided an update on the Better Health, Better Care, Better Value programme and workstreams.

The report highlighted that the programmes of work would reflect the priorities of one strategic, place-based plan being developed across Coventry and Warwickshire by the Health and Wellbeing Alliance. A refreshed concordat had been drafted which had been discussed by the Place Forum earlier this month. The report highlighted that the Upscaling Prevention pilot was to be used as a catalyst for place-based care, putting prevention and self-help at the heart of all change programmes.

The report set out progress with the following transformational and enabling programmes of work:

Transformational Upscaling Prevention Maternity and Paediatrics Mental Health and Emotional Wellbeing Planned Care Productivity and Efficiency Urgent and Emergency Care

Enabling Estates Digital Transformation Workforce

Liz Gaulton, Acting Director of Public Health reported on the Upscaling Prevention workstream. This work programme was to focus on two core elements: (i) Local Government Association (LGA) Upscaling Prevention and (ii) Community Capacity. The Proactive and Preventative Programme position statement which outlined the revised role and purpose of the workstream was set out at an appendix to the report. The year 2019 was to be a Year of Wellbeing. Work

– 6 – aligned to Upscaling Prevention included the NHS Diabetes Prevention Programme which was being rolled out across Coventry and Warwickshire from April. Targeted support for people identified as at high risk of developing Type 2 diabetes would include education on healthy lifestyle, help to lose weight and physical exercise programmes.

The report indicated that Coventry and Warwickshire had successfully bid to be one of eight areas to take part in three days of action learning organised by the National Council for Voluntary Organisations (NCVO) and the Kings Fund. The local partner groups who participated were detailed. The programme included overviews of system leadership and the behaviours required to work across a system; coaching skills; and presentations from all the areas represented at the event. Taking part in the programme confirmed the importance of making an impact at the operational level. The Board were informed that Voluntary Action Coventry (VAC) had been working with CWPT on a piece of co-design around anxiety and depression pathways within the mental health workstream. Reference was made to a very productive workshop which resulted in a better joint understanding of the reasons for blockages within referral pathways and the need for better cross-sector partnership workings to address the causes of poor mental health.

Andrea Green, Coventry and Rugby CCG, provided the Board with an update on the proposals for Improved Stroke Services. Local clinicians and commissioners had been working on proposals to improve stroke services locally. A proposal was shared with the public over six weeks from 15th June to 28th July, 2017. The feedback from this engagement had been fed back into the proposals and the commissioners would shortly be seeking assurance from NHS England as to whether the pre-consultation work was robust enough to progress to the next steps which would involve public consultation later in the year.

RESOLVED that the content of the report and the updates provided at the meeting be noted.

52. Care Quality Commission Local System Review

The Board considered a report of Pete Fahy, Director of Adult Services, which summarised the outcome of the Care Quality Commission (CQC) local system review and sought approval of the action plan arising from the identification of areas for improvement by the CQC as a result of the review. A copy of the action plan was set out at an appendix to the report.

The report indicated that the CQC required the review, its outcomes and resulting action plan, was owned and monitored by the Health and Well Being Board. The review took place between 4th December 2017 and 14th March 2018, with a whole system approach being taken focusing on how people moved between health and social care, with a focus on people over 65 years of age. The review was formally completed with a Health and Well-being Board summit which discussed the findings and commenced action planning for the next steps. The final report was published on 15th March 2018.

In summary, in the course of the review the CQC found that there was a system wide commitment to serving the people of Coventry well and that Coventry was at

– 7 – the beginning of its journey in ensuring all services worked well in a ‘joined up way’. However, the review also highlighted some areas where further work was needed to ensure all those responsible for providing health and care services worked effectively together. These areas were described in the Areas for Improvement section of the CQC report.

The action plan contained seven sections which group together the areas for improvement arising from the CQC review as follows:  Vision and strategy  Engagement and involvement  Performance, pace and drive  Flow and use of capacity  Market development  Workforce  Information sharing and system navigation.  The action plan had been developed in a manner that was intended to give clarity and focus to the existing work groups and programmes in place as opposed to creating a separate and standalone set of activities. Some of the work within the action plan was complex, required input from a range of stakeholders and could also require resources for implementation that would only become clear as the work progressed. Therefore, many of the dates for completion were uncertain and/or indicative at this stage.

The Board were informed that the action plan was required for submission by 10th April, 2018. The Director of Adult Services placed on record his thanks to members of the Board for their support during the course of the review.

Members expressed their thanks to all the officers/ representatives who took part in the review process and in particular to the lead officer Pete Fahy. Clarification was sought about the arrangements for reporting back on progress with the action plan since a number of Boards had responsibility for various elements of the action plan including what would be reported to this Board. The requirement to keep all Board members up to date with progress was highlighted.

RESOLVED that:

(1) The submission of the action plan, set out at the appendix, which addresses the areas identifies for improvement in the review grouped into the seven themes agreed at the Health and Wellbeing Board summit held on 14th March, 2018 be approved.

(2) It be noted that as the action plan is not a standalone piece of work, and complements work already underway across the system, that updates and progress reports will be sought from the relevant existing body and brought to the Health and Wellbeing Board in a co-ordinated way.

53. The Year for Suicide Safer Coventry - One Year Update Report from the Suicide Prevention Strategy

– 8 – The Board received a report of Jane Fowles, Consultant in Public Health, and a presentation from Adeola Agbebiyi, Public Health Registrar, which provided an update on the progress of the Suicide Prevention Strategy previously endorsed by the Board at their meeting on 28th November, 2016; informed of the proposed year two implementation actions for the Coventry Suicide Prevention Multi-Agency Steering Group; and outlined the progress and proposals for NHS England funding for suicide prevention in the Coventry and Warwickshire STP footprint.

The report indicated the following approval of the Suicide Prevention Strategy for 2016-19 titled ‘Not One More/One is Enough’, the key highlights for year one strategic priorities were the establishment of an active multi-agency steering group; hosting two workshops to share best practice, local data and local excellence; supporting an event at a Wasps Home match for World Suicide prevention day; and facilitating the training of 50 champions and volunteers in level one suicide prevention.

The multi-agency steering group operated through priority workstream Task and Finish Groups. There were currently six Task and Finish groups covering the following year 2 priorities: Training, Higher Education, Children and Young People; Acute Health Provider Liaison; Communications and Data and Evaluation.

The Board were informed that suicide was now the biggest killer of men aged 15- 55, higher than road traffic accidents. It was also the biggest killer of women aged 15-35 and was preventable. Coventry and Warwickshire NHS Trust and local CCGs were contacted by NHS England to bid for funding to reduce suicide among middle aged men and to improve the suicide prevention service quality in the Coventry and Warwickshire STP footprint. The bid was submitted at the end of February and was currently being updated in the light of feedback and questions from Public Health England and NHS England. The bid proposals sought to: i) Increase the activity and strength of It Takes Balls to Talk, a community interest group which trained volunteers to engage men at sporting events in meaningful conversations about mental health and suicide. They also carried out training in suicide awareness and level one prevention among male culture occupations. ii) Additional training was proposed to increase the depth of skill on frontline for gatekeeper and sentinel roles especially in primary and secondary care. iii) Support for community initiatives for middle aged men and supporting organisations with delivery and evaluation.

The presentation set out why suicide mattered; informed of the strategic vision which included ‘zero suicide goal in a suicide safer city’; highlighted the priority actions; provided local data statistics for the city; and informed of how Coventry was doing including activities and successes.

Members discussed a number of issues in response to the report and presentation including the support provided by the Police; how the issue impacts on higher education institutions and an offer of support from the two universities; the importance of challenging stigma; the important role played by front line staff; how to have important conversations with people; and the inclusion of the suicide prevention work as an action for the Year of Wellbeing. It was suggested that mental health training would be useful for elected Members.

RESOLVED that:

– 9 – (1) The progress update for the Suicide Prevention Strategy endorsed in November 2016 be noted and the Board continue to support ongoing delivery of the Suicide Prevention Strategy.

(2) The proposed priority actions for year two of the strategy be endorsed.

(3) The proposals outlined for the NHSE bid funding for suicide prevention among middle aged men in Coventry and Warwickshire be noted and supported.

(4) Arrangements be put in place for mental health training to be offered to the elected members.

54. Coventry Parenting Strategy 2018 - 2023

The Board considered a report of Sue Frossell, Consultant in Public Health, concerning the Coventry Parenting Strategy 2018-2023, a copy of which was set out at an appendix to the report. The progress made to strengthen parenting provision in the city was also detailed.

The report indicated that there was clear evidence that supporting parents and carers to develop effective parenting skills was an important part of maximising their children’s potential. Coventry’s vision for parenting was to have ‘more Coventry children and young people grow up within supportive families and communities’. In order to achieve this, a multiagency steering group had been established to develop a new Parenting Strategy for the city. There was to be a Coventry-wide approach to supporting parenting, where everyone working within this area understood where their support fitted into the overall parenting support system.

The report set out the consultation process used to develop the strategy. Through the Coventry Parenting Steering Committee, a review of the current parenting provision in the city was completed. 21 agencies responded highlighting 55 different parenting projects in the city. A consultation with parents confirmed that access to parenting support needed to be strengthened. Consultation was also undertaken with young people.

The Board were informed that areas for improvement and key recommendations had been identified bringing together the views of parents and stakeholders and the evidence. The key recommendations of the strategy were: i) Strengthen availability and accessibility of general information and advice to parents ii) Harness technology and the developing digital systems across agencies to strengthen the parenting offer iii) Ensure there is a systematic approach to ensuring the quality and effectiveness of the parenting offer across the whole system iv) Ensure that this system wide parenting offer is delivered in a way which progressively provides more support across the social gradient and level of need v) Ensure there is a clear focus on early help and prevention vi) Improve cohesiveness of parenting support across Coventry vii) Building parenting capacity in specific areas where gaps have been identified.

– 10 – The multi-agency task and finish group had been set up to take forward the first four recommendations with the remaining recommendations acting as cross- cutting themes. Detailed delivery plans for each of the work streams were to be developed through the multi-agency Task and Finish groups. Parenting would also be strengthened in the future through the Family Hubs.

The Parenting Strategy would be owned and monitored by the multi-agency Coventry Parenting Steering Group and driven by the Task and Finish Sub- Groups.

Members discussed a number of issues arising from the report including support for the strategy; the financial implications and whether there was adequate resource to deliver these aspirations; the importance of destigmatising the need for help ensuring Coventry residents could ask for help at an early stage; the support provided by health workers and the family hub workers to families with young children experiencing problems; and the inclusion of the parenting strategy work as an action for the Year of Wellbeing.

RESOLVED that the Parenting Strategy recommendations be supported.

55. Any other items of public business

There were no additional items of public business.

(Meeting closed at 3.50 pm)

– 11 –