NHS WEST LANCASHIRE CLINICAL COMMISSIONING GROUP GOVERNING BODY MEETING

28 July 2015, 9.30 am – 11.30 am

Boardroom, Hilldale, Wigan Road, Ormskirk, Lancashire, L39 2JW

15 minutes to be allocated for questions from members of the public based on agenda items. Item Time Agenda item Action Presenter WLCCGB 07/15/1 09.30 Welcome John Caine 07/15/2 09.35 Declaration of Interests All 07/15/3 09.40 Minutes of previous meeting held on 26 May 2015 DR John Caine 07/15/4 09.45 Matters arising - Action sheet DR John Caine Communication 07/15/5 10.00 Chair’s update I John Caine 07/15/6 10.10 Chief Officer’s Update DR Mike Maguire Governance 07/15/7 10.20 Declarations of interest for members register update I Katie Wightman 07/15/8 10.25 Board Assurance Framework and risk register I Katie Wightman 07/15/9 10.35 Budget update DR Paul Kingan Operational Management Section 07/15/10 10.50 Integrated business report D Paul Kingan 07/15/11 11.05 Stroke service specification DR Mike Maguire 07/15/12 11.15 Procurement of Community services DR John Caine Consent items 07/15/13 11.25 Minutes of sub-committees: I John Caine - Quality Improvement Committee – May and June 2015 - Executive Committee – 12 May – 7 July 2015 - Audit Committee – May 2015

Other minutes: - Lancashire CCG network – April 2015 - Merseyside CCG network – May and June 2015 - Care Closer to Home Board – May 2015 - Health and Wellbeing Board – June 2015 - West Lancashire Community Safety Partnership – April 2015 Other Business 07/15/14 11.30 Any other business I John Caine Date and Time of Next Meeting – 22 September 2015, 9.30 – 11.30 am, tbc

I – Information D – Discussion DR – Decision Required

Members of the governing body will be available after the close of the meeting for informal discussion, time permitting Minutes D R A F T Meeting Title: West Lancashire Clinical Date: 26 May 201 5 Commissioning Governing Body Meeting Time: 10 .00 – 12.00 noon Venue: Boardroom, Hilldale Present: In attendance: Dr John Caine, Chair Katie Wightman , Head of Corporate Affairs Mike Maguire, Chief Officer Karen Thompson , Public Health Specialist Paul Kingan, Chief Finance Officer/Deputy Chief Lucinda McArthur , Senior Operating Officer Officer David Ashley, Healthwatch Lancashire Dr Adam Robinson , Secondary Care Consultant Cathy Ashcroft, Executive Assistant Dr John (Jack) Kinsey, GP Executive Lead Ian Crabtree , Head of Services Policy Greg Mitten, Lay Member information and commissioning, Lancashire Douglas Soper, Lay Member County Council

Apologies: Claire Heneghan , Chief Nurse Dr Simon Frampton, GP Executive Lead Dr Peter Gregory , GP Executive Lead Dr Bapi Biswas, GP Executive Lead

Agenda Summary of Discussion Action Item WLCCGB/ 05/15/01 Welcome and apologies for absence John Caine opened the meeting of the West Lancashire Clinical Commissioning Group Governing Body. Introductions were made by the governing body to the two members of the public present. No questions had been received from the public in respect of the agenda.

Apologies for absence were received from the above and noted.

05/15/02 Declarations of interests No declarations of interests pertinent to the agenda items were raised.

05/15/03 Minutes of previous meeting held on 24 March 2015 The minutes of the meeting held on 24 March were agreed as an accurate and correct record.

The governing body: Approved the previous minutes 05/15/04 Matters arising The action sheet was updated.

ANNUAL ACCOUNTS 05/15/05 Annual report Paul Kingan confirmed that the audit committee had met this morning and agreed to recommend the approval of the audited annual accounts, and the submission of the requested letter of representation by the governing body. The audit findings report had provided a clean opinion on the financial statements. Praise was given to Katie Wightman and Meg Pugh in producing the annual report, which includes strategic, membership and remuneration reports; statement of accountable officer’s responsibilities; annual governance statement; auditor’s report containing the, “Director of

West Lancashire Clinical Commissioning Group Governing Body meeting - 26 May 2015 Page 1 of 6 internal audit statement of opinion“. Only one audit review carried out in 2014-15 had not achieved significant assurance.

The governing body were asked to approve the annual accounts, annual report and the management representation letter. The management representation letter is a standard letter and essentially gives confirmation that the CCG governing body members have fulfilled their responsibilities around preparation of the accounts in accordance with International Financial Reporting Standards and accounting policies directed by the NHS Commissioning Board. On approval, the letter will be signed by the chair and chief officer of the CCG on behalf of the governing body .

The Governing Body thanked Paul Kingan, Katie Wightman and the finance team for their good work in producing the reports in a timely manner to a high standard. It was noted that the financial challenge the CCG faces next year is significant and the level of financial risk is much higher going forward. Doug Soper commented on the CCG’s excellent relationship with the external auditors.

The governing body: approved the audited annual accounts, annual report and the letter of representation. It was agreed that Mike Maguire, chief officer and Dr John Caine, chair will sign the letter of representation on behalf of the governing body.

COMMUNICATION 05/15/06 Chair’s update The report provided members with an update on both strategic and operational issues since the last meeting. John Caine highlighted key areas of interest: • Facing the Future Together update – in conjunction with Southport and Ormskirk Hospital NHS Trust, work continues on Facing the Future Together (FtFT). The Trust board had met with the CCG and membership council to discuss current issues including FtFT and will return in July to discuss the gateway. The final gateway is in June, when progress against key milestones is reviewed. • Results of 360 degree stakeholder survey – as the CCG is required to undertake an external 360 degree survey as part of the annual assurance, Ipsos MORI conducted a survey on behalf of NHS England. The results of the survey were very positive and reflected that the stakeholders feel engaged,, listened to and confident that the CCG effectively monitor the quality of services commissioned. Thanks were expressed to all who completed the survey. • Macmillan update – further updates on progress of the survivorship project include: a consultant led cancer event for practice nurses and GPs; the Macmillan Steering Group meets bi-monthly; a Macmillan project manager will be appointed; engagement with Lancashire Cancer network will take place; and negotiations around the location of the Macmillan Information Centre are taking place. • Advanced community paramedic – in liaison with North West Ambulance Service (NWAS), the advanced community paramedic commenced in post in West Lancashire on 27 April. The paramedic will focus on improving the local community infrastructure to provide safe care closer to home and look at NWAS standards.

Doug Soper commented that the board to board meeting with the Trust had been useful and more frequent meetings would be beneficial. The general feeling from the meeting had been that positive listening had taken place,

West Lancashire Clinical Commissioning Group Governing Body meeting - 26 May 2015 Page 2 of 6 with a commitment from Rob Gillies to turnaround some of the red indicators in the FtFT programme within the six-week period prior to the next gateway. Different feedback was received following the Trust board’s meeting with the membership council and a further meeting will take place in July. The general consensus from the CCG senior managers is that the ICO is beginning to move in the right direction although there is still a lot to do to hit the June gateway requirements. Greg Mitten commented that the Trust board had recognised that engagement with the public was required around Facing the Future Together, Better Care Fund and action to be taken in response to the CQC report, which will require patient involvement. This commitment will be monitored. David Ashley had raised monitoring exercises and improvements made at a recent patient summit.

The governing body: Noted the content of the report

05/15/07 Chief Officer’s update The report provided members with an update on both strategic and operational issues since the last meeting. Mike Maguire highlighted key areas of interest: • England’s Chief Inspector of Hospitals – Southport and Ormskirk Hospital NHS Trust – following the inspection in November 2014, the CQC report was published on 13 May. The report rated the Trust as ‘requires improvement’. The two areas rated as ‘inadequate’ are maternity and spinal injuries. Areas receiving good ratings included end of life care, children’s and young people’s services and community services for children and young families. The CCG expect improvements in all areas and progress will be monitored through the quality and safety committee in the coming months. • Quarter 3 assurance with NHS England – the assurance meeting took place on 13 April. The meeting reviewed whether the targets in the CCG plans were achievable. The meeting went well overall and the CCG achieved ‘assurance with support’. Five of six domains achieved ‘assurance’ and the remaining domain achieved ‘assurance with support’, which is due to cancer target issues. These issues are being addressed by Dr Jack Kinsey and Carol McCabrey. • Commissioning policies – the CCG had originally adopted legacy PCT policies. A policy development group had updated a number of policies with four received today for approval: Policy for exceptionality; statement of principles; policy for the reversal of sterilisation; and policy for varicose veins. All policies have been to the clinical executive committee. • IM&T update – a number of key elements from the IM&T strategy delivered to date including: summary care record project, Electronic Prescription Service; Patient online; EMIS Web; removed 0845/44 telephone numbers; first phase of EMIS community (goes live in June); Telehealth to be implemented in September; improved referral management and saved costs; reduced IT hardware and operating costs. Praise was given to Dr Bapi Biswas and Chris Russ for implementing the strategy. • Better Care Fund update – in partnership with Lancashire County Council and five Lancashire CCGs, the first draft of the workplan has been completed with the governance arrangements also being developed . Paul Kingan is leading the work to ensure that the Better Care Fund arrangements dovetail with local programmes. • Patient online – all practices have now signed up to Patient Online, which provides patients with access to their records, repeat prescribing and booking appointments. Dr Jack Kinsey confirmed that policies must be implemented at practices before the service is available to patients. One

West Lancashire Clinical Commissioning Group Governing Body meeting - 26 May 2015 Page 3 of 6 practice, where the service has been in place for a number of years, confirmed that it works well for the patients who use it.

The governing body: noted the content of the report and approved the policies, with minor amendments regarding the policy titles being highlighted on the front cover.

GOVERNANCE 05/15/08 Raising a concern (Whistleblowing) policy Katie Wightman explained that this policy is on the agenda independently to reflect the governing body’s responsibility to provide a confidential and supportive process for staff, embedded staff and members of the public to raise concerns. The revised policy is much clearer with a list of designated officers to contact should a concern not be satisfied at the line manager level. The CCG and governing body will protect and respect the anonymity of whistleblowers.

The governing body: Approved the raising a concern (whistleblowing) policy.

OPERATIONAL MANAGEMENT SECTION 05/15/09 Integrated Business Report The report provided summary information on the financial position and activity performance of the CCG to March. It also included quality and performance analysis for community based targets for Southport and Ormskirk Hospital NHS Trust. Paul Kingan highlighted key financial information from the report as follows: • The CCG has achieved its financial duties and surplus required by NHS England. • There is an underspend on urgent care, with a significant overspend on planned care. A 10% increase in referrals may be in part due to data issues in respect of the new PAS system at Southport and Ormskirk Hospital NHS Trust and work is taking place to address this. • Trauma, orthopaedics and outpatient procedures are areas for concern in terms of a high level of activity. This will be addressed through the contract review group meetings. • High cost packages of care incurred an overspend of £500 thousand at the end of year and there was discussion over individual cases. The CCG is liaising with Lancashire County Council to try to find solutions and Commercial Clinical Solutions are assisting the CSU. • Targets missed included – 62 day cancer, A&E 4 hour waiting, MRSA and C. Difficile. RTT admitted targets have been met. • QIPP target narrowly missed - but reductions in urgent care costs have been encouraging. • Better Care Fund – Lancashire’s activity position for the first month is 5% over and not 3% under as required.

• Three letters sent to Southport and Ormskirk Hospital NHS Trust are

appended to the report for information: a letter from the quality and safety

committee containing a list of quality issues and two contract change

letters.

Dr Jack Kinsey raised one quality issue for concern which is the significant

increase in the number of pressure ulcers and their severity. It is unclear if

the rise is due to more accurate reporting or an actual increase in occurrence.

Combined with the occurrence of MRSA and C. Difficile infections this raised

a question around nursing issues and the quality committee is pursuing this

matter. Greg Mitten explained the letter from the quality and safety

committee is a summation of quality issues identified by the committee from

West Lancashire Clinical Commissioning Group Governing Body meeting - 26 May 2015 Page 4 of 6 last year. The letter was submitted prior to the CQC report but mirrors the findings. Simon Featherstone, director of nursing, and Gill Brown, chief executive of Healthwatch Lancashire, will attend future meetings. Simon Featherstone is looking into the risk issues and is working closely with Claire Heneghan and Ann Butler.

Paul Kingan confirmed the areas which are covered by individual packages of care as: highly complex elderly and children; out of area mental health packages; and learning disability. The data will be shared with Ian Crabtree. PK

The NWAS response times have improved since April and the advanced community paramedic can have an impact on this area. NWAS are also working with local services, including the fire service and the advanced community paramedic is looking at first responders.

Paul Kingan confirmed the current position of the Quality, Innovation, Productivity and Performance (QIPP) plan for 2015-16. Work is taking place on the plan to reflect national and local initiatives. The CCG need to engage with membership and feed into practices. Trauma and orthopaedic pathways are being reshaped. Doug Soper questioned the degree of risk around delivery. Paul Kingan confirmed that there is a risk, but there are further schemes in the pipeline as part of a dynamic process. As the CCG have moved from a cost certainty contract to a payment by results contract with Southport and Ormskirk Hospital NHS Trust, there is more volatility this year too and a stronger need for timely information. Sustaining changes in activity as a result of the Acute Visiting Service, will continue to support the underspend in urgent care. The CCG’s QIPP is built on realistic expectations, but the governing body recognise there is a risk next year in delivering financial targets.

The governing body: Noted the performance to date and the actions in place to improve performance.

CONSENT ITEMS 05/15/10 Minutes of sub -committees: The minutes from the following meetings were noted by the governing body:

- Quality Improvement Committee – March and April 2015 - the Dr Foster report on stroke had made a number of recommendations and confirmed that the Trust is not complying with all stroke care guidance. - Executive Committee – 10 March – 12 May 2015 - Audit Committee – 21 April 2015

Other minutes: - Lancashire CCG network – February and March 2015 - it was reported that a presentation from the Lancashire Constabulary on early intervention fitted well with Skelmersdale work. The Lancashire Constabulary had attended a recent membership council and the CCG are linking into their meetings as they are implementing their early action model. Lancashire County Council are working with the constabulary. Paul Kingan confirmed that the Healthier Lancashire plans are being aligned to achieve a picture of the Lancashire landscape to identify target areas before engaging with the public. Enabling schemes being worked on include workforce and cultural transformation issues. The balance of input was discussed as the CCG flow is mostly to Mersey and our health economy must focus on local programmes. As to Healthier Lancashire’s sustainability, money and resources have been contributed but the CCG

West Lancashire Clinical Commissioning Group Governing Body meeting - 26 May 2015 Page 5 of 6 have been open in terms of their limited finances and resources in attending meetings, given the size of the CCG and its small patient flow to Lancashire. Mike Maguire is meeting with Graham Urwin to discuss the CCG’s input to Lancashire. - Merseyside CCG network – March and April 2015 – As Merseyside’s CSU did not achieve accreditation on the lead provider framework, Lancashire and Midland CSU are currently providing associate support. - Care Closer to Home Board – March and April 2015 - West Lancashire Community Safety Partnership – February 2015

The governing body: noted the papers.

Other business 05/15/11 Any other business No other items were raised.

Meeting closed at 11 .20 pm Date and time to next meeting: 28 July 2015, 9.30 – 11.30 am, tbc

West Lancashire Clinical Commissioning Group Governing Body meeting - 26 May 2015 Page 6 of 6

Agenda item no: WLCCGB 05/15/04

West Lancashire CCG Governing Body meeting Action sheet

Action Lead Date required by Action completed 03/15/5 Chairs update - Cardiology update - Confirmation Jackie Moran 26 May 2015 Follow up appointments have all that the clinic on 20 March, to see cardiology patients for been seen. New patients are follow-up appointments, took place will be sought. being seen upto June when Southport will commence to see patients again. 03/15/6 Chief officers update - Concerns about the LCC Mike Maguire / Lucinda 26 May 2015 Letter to Tony Pounder, who structure have been sent to the authority leader and a McArthur attended the executive committee. follow up letter will be sent to Tony Pounder prior to his Concern remains over portfolios. attendance at the executive committee in April. Ian Crabtree will provide a copy of the structure – received and circulated 03/15/8 Register of interest update - Further amendments Doug Soper and Greg 26 May 2015 The shadow governor positions from Doug Soper and Greg Mitten will be made when their Mitten have ceased. An update on the shadow governor positions at Southport and Ormskirk declaration of interest register will Hospital NHS Trust cease. be made in July.

03/15/14 Integrated Business Report - A small number of Dr Peter Gregory and 21 July 2015 Work has commenced on coding orthopaedic patients will be selected and their patient Mike Maguire and orthopaedic patients journey journey will be followed to provide assurance to the of those who have not had an governing body of correct coding. MRI. This will be complete by the visioning event on 1 July. 03/15/15 Care Closer to Home Strategy 2013-18 - A Mike Maguire 26 May 2015 stronger reference to Facing the Future Together is Complete required at the start of the document.

Board changed name to Strategic A Strategic Partnership Board workshop next month with Mike Maguire 26 May 2015 Transformation Partnership Board stakeholders will discuss the future structure. and will change membership and

focus on facing the future together.

Page 1 of 2

03/15/17 Minutes of other committees - A request to Katie Wightman 26 May 2015 The most recent notes available receive more recent minutes from certain meetings was are placed on the agenda. Some made. meetings circulate minutes one week prior to the next meeting. Members of these meetings will suggest this. Ian Crabtree confirmed that Clare Platt is working to increase the pace of the health and wellbeing board. New action: Claire Heneghan 28 July 2015 Work is ongoing. Commercial and Safeguarding: looking at alternative commissioning Clinical Solutions is assisting and options for patients with continuing healthcare needs. A liaising with the CSU. window of 3 months has been agreed.

Page 2 of 2

Agenda item no: WLCCGB 07/15/5

WEST LANCASHIRE CLINICAL COMMISSIONING GROUP GOVERNING BODY REPORT

DATE OF BOARD MEETING: 28 July 2015

TITLE OF REPORT: Chair’s Update

BRIEFING POINTS:

Does this report / its recommendations have implications and impact with regard to the following: A. Commissioning Board’s Aims and Objectives 1. Quality (including patient safety, clinical effectiveness and patient Yes experience) – please outline impact

2. Commissioning of hospital and community services – please outline Yes impact

3. Commissioning and performance management of GP Prescribing – No please outline impact

4. Delivering Financial Balance – please outline impact No

5. Development of the commissioning group as a commissioning No organisation – please outline impact

B. Governance – 1. Does this report: No • provide the Commissioning Board with assurance against any of the risks identified in the assurance framework (identify risk number) • have any legal implications • promote effective governance practice

2. Additional resource implications No (either financial or staffing resources)

3. Health Inequalities No

4. Human Rights, Equality and Diversity Requirements No

5. Clinical Engagement Yes

6. Patient and Public Engagement Yes

REPORT PREPARED BY: Katie Wightman, Head of Corporate Affairs

REPORT PRESENTED BY: Dr John Caine, Chair

Chair’s Update 1 West Lancashire Clinical Commissioning Group Governing Body Meeting – 28 July 2015

WEST LANCASHIRE CLINICAL COMMISSIONING GOVERNING BODY CHAIR’S UPDATE

PURPOSE

1. This report provides an update on both strategic and operational issues of interest to governing body members in the months since the last meeting.

ISSUES ARISING

Engagement events

Since my last report the CCG has held two key engagement events:

Musculoskeletal

2. In order to progress the Musculoskeletal Scheme referenced in the NHS West Lancashire CCG Strategic Plan 2015/2016, the CCG along with Southport and Formby CCGs hosted a Musculoskeletal Visioning Event on 1 July 2015.

3. The event was well attended with over 55 attendees in the form of key individuals and organisations such as current and past service users, Southport & Ormskirk Hospital NHS Trust, NHS Southport & Formby CCG, Wrightington, Wigan and Leigh NHS Foundation Trust, Liverpool University, North West Coast Academic Health Science Network (NWC AHSN), Liverpool CCG, Ramsay Health and West Lancashire Musculoskeletal Rehabilitation Clinic.

4. The CCGs have been looking at national benchmark data (Better Care, Better Value) to understand where spend varies from the norm and where we can achieve better value for money. This event acted as an initial discussion as this cannot be planned or implemented in isolation, and everyone’s viewpoint must be considered.

5. A paper containing the emerging thoughts as a result of the visioning event will be presented to the CCG’s Clinical Executive Committee on 11 August. The NWC AHSN's have agreed to work with the CCGs to identify jointly key objectives, a work plan and a timeline for each theme. The CCGs have also been invited to have a role in shaping and informing the AHSN’s Musculoskeletal Health work stream.

Cancer

6. A Macmillan Primary Care Cancer Education Event was held on the 24 June. The event was open to GPs and practice nurses and the lead cancer nurse/manager from Southport and Ormskirk NHS Trust also attended. Dr Jack Kinsey Macmillan and Executive GP for West Lancashire CCG chaired the event.

7. Speakers were: • Dr Chris McManus, lead for Lung Cancer, Southport and Ormskirk NHS Trust • Mr Rahul Mistry, lead for Urological Cancer, Southport and Ormskirk NHS Trust/St Helens and Knowsley NHS Trust • Mr Mike Zeiderman, lead for Colorectal Cancer, Southport and Ormskirk NHS Trust

Chair’s Update 2 West Lancashire Clinical Commissioning Group Governing Body Meeting – 28 July 2015

• Dr Karen Groves, Consultant in Palliative Care Medicine, Southport and Ormskirk NHS Trust

8. The aim of the event was to raise awareness with regard to referral criteria, pathway, improvements /challenges in the pathway and future developments.

9. Overall the event was evaluated excellent or very good with the majority scoring that it would help them perform their job more effectively. It is planned to run another event in 6 months on survivorship.

Early Action

10. Lancashire Constabulary have recently been successful in securing Police Innovation Funding (PIF) to develop the Early Action Public Service Lancashire project. The project is a ground-breaking and innovative project aimed at transformation of services which will deliver early interventions to children, families and adults consistently and equally across the whole of Lancashire.

11. The project will involve a collaboration of public services both statutory and non-statutory who will collectively provide the most appropriate, quality support, at the earliest point possible in that individuals life. The aim is to prevent problems occurring in the future rather than all services eventually responding to them. The CCG is fully engaged with the project.

12. The funding from the PIF bid will dramatically advance the development of Public Service Lancashire. Current planning in relation to Public Services Lancashire is transformation over the next 5 - 10 years, this bid will reduce this timescale down to 2 years during which time the Constabulary along with partners will set out to mainstream the services and develop community step down.

13. Progress to date includes:

• On 15 June mental health triage was established in each of the Constabulary’s 3 divisions ie South, East, West. Three mental health nurses are working alongside three police officers in each division, working late shift on a three week rota, to respond to mental health type incidents. Early indications are that this is going very well.

• Cross collaborative initiatives with both Northwest Ambulance Service/Lancashire Fire and Rescue Service. The first initiative went live on 1 June and involves the fire service responding to requests from the ambulance service to force entry to premises where they need to gain access to a patient. Previously the police would have responded, again this is going well.

• A strategic meeting was held on 30 April at which it was agreed to progress Early Action models ie multi agency integrated teams and panels across Lancashire. Preston will be set up first. It was also agreed to consider pan Lancashire outcomes and evaluation and commissioning. Since April meetings with respect to each initiative have taken place. The next meeting of the “Oversight” group is on 3 July.

14. Lancashire Constabulary are also working closely with the CCG in support of Well North, integrated locality teams and the Edge Hill initiative re Neighbourhood Learning Network. Chair’s Update 3 West Lancashire Clinical Commissioning Group Governing Body Meeting – 28 July 2015

NHS Statement of Support for Tobacco Control

15. The NHS Statement of Support for Tobacco Control was developed as an auxiliary to the Local Government Declaration on Tobacco Control which commits local authorities to take comprehensive action to address the harms caused by smoking. In Lancashire, as of February 2015, the Declaration had been signed by Lancashire County Council, Preston City Council, Chorley Borough Council and South Ribble Borough Council.

16. The NHS Statement of Support for Tobacco Control has been developed to enable the health community to support colleagues in local Government in their tobacco control work. Aimed at local NHS organisations, including trusts and CCGs, the Statement is a public commitment to; • Work towards further reducing smoking prevalence • Demonstrate a commitment to take action • Publicise the NHS’s dedication to protect local communities from the harm caused by smoking.

17. It also reinforces the signatory’s commitment to protect tobacco control work from the bested interests of the tobacco industry.

18. The Statement includes a number of specific commitments to play a key role in tackling the harm caused by tobacco: • Actively support local work to reduce smoking prevalence and health inequalities • Develop plan with partners and local communities • Play a role in tackling smoking through appropriate interventions such as “Make Every Contact Count” • Protect tobacco control work from the commercial and vested interested of the tobacco industry • Support Government action at national level • Participate in local and regional networks for support • Join the Smokefree Action Coalition

19. The CCG is already committed to a number of these work areas. Our strategic forward plan outlines how we will work with partners on the tobacco agenda particularly in relation to primary prevention and supporting the commissioning of stop smoking services by Lancashire County Council. The CCG also supports delivery of “A Three Year Tobacco Control Strategy for Lancashire 2014-2016 - Making tobacco less desirable, acceptable and accessible in Lancashire”.

20. It is in this context that the CCG Executive endorsed organisational sign up to the Statement which I signed in May 2015.

Public listening events

21. In June and July we held another series of listening events for the public, taking place mid-week at different times in each our five localities. Attendance was mixed in terms of numbers across the events, and attendees were from a large range of ages i.e. 20-60 years and over.

22. Our focus was on hearing about local community services to further support our strategy for joined up care (Facing the Future Together). Various services and topics were

Chair’s Update 4 West Lancashire Clinical Commissioning Group Governing Body Meeting – 28 July 2015

discussed at the events but the insight gathered touched on some common themes such as communication issues, delays/cancellations/lengths of appointments of various services and the dissatisfaction with the availability of GP appointments. A full update on the events will be delivered to our quality and safety committee this month.

23. Thank you to both Southport & Ormskirk Hospital NHS Trust and Lancashire Care NHS Foundation Trust for attending and supporting our events. A report of the findings and associated actions will be published on our website in the near future.

Chair’s action

24. On 17 June 2015 I, on behalf of the governing body, approved the submission of the Well North Partnership Proposition focussed on Skelmersdale.

Recommendation

25. Members are asked to note the content of the report.

Dr Caine Chair July 2015

Chair’s Update 5 West Lancashire Clinical Commissioning Group Governing Body Meeting – 28 July 2015

Agenda item no: WLCCGB 07/15/6

WEST LANCASHIRE CLINICAL COMMISSIONING GROUP GOVERNING BODY REPORT

DATE OF MEETING: 28 July 2015

TITLE OF REPORT: Chief Officer’s Update

BRIEFING POINTS:

Does this report / its recommendations have implications and impact with regard to the following: A. Commissioning Board’s Aims and Objectives 1. Quality (including patient safety, clinical effectiveness and patient Yes experience) – please outline impact

2. Commissioning of hospital and community services – please outline Yes impact

3. Commissioning and performance management of GP Prescribing – No please outline impact

4. Delivering financial balance – please outline impact No

5. Development of the commissioning group as a commissioning No organisation – please outline impact

B. Governance – No 1. Does this report: • provide the Commissioning Board with assurance against any of the risks identified in the assurance framework (identify risk number) • have any legal implications • promote effective governance practice

2. Additional resource implications No (either financial or staffing resources)

3. Health Inequalities Yes

4. Human Rights, Equality and Diversity Requirements Yes

5. Clinical Engagement No

6. Patient and Public Engagement No

REPORT PREPARED BY: Katie Wightman, Head of Corporate Affairs

REPORT PRESENTED BY: Mike Maguire, Chief Officer

Chief Officer’s Update 1 West Lancashire Clinical Commissioning Group Governing Body Meeting – 28 July 2015

WEST LANCASHIRE CLINICAL COMMISSIONING GOVERNING BODY CHIEF OFFICER’S UPDATE Purpose

1. This report provides an update on both strategic and operational issues of interest to governing body members in the months since the last meeting.

2014/15 Quarter 4 assurance with NHS England

2. The CCG attended the quarter 4 assurance meeting at the CSU on 25th July 2015.

3. A major topic of discussion was how the CCG is performing and NHS England focussed on the key lines of enquiry (KLOE) as part of the assurance process. The CCG representatives who attended were able to give assurance in respect of work and actions being undertaken to address specific areas of concern. Overall the feedback from NHS England was that the CCG is performing well and has a capable and dedicated team. Particularly, NHS England highlighted how well our patient engagement and involvement was undertaken and how well this was presented on our website.

4. Of all the issues discussed there were two that caused some concern - these were

• Signing off the Cost improvement Plans of the CCG’s main hospitals ensuring that these do not impact on the range of services in terms of the quality and safety of patient care. The CCG is awaiting copies of minutes from the hospital board where the chief nurse and medical director has signed off these CIPs ensuring that the quality of patient care and the range of services are not affected.

• Personal health budgets. The CCG was asked to increase the use of personal health budgets wherever appropriate. The CCG is working with the other Lancashire CCG’s to develop its approach so that more patients are aware and have access to personal health budgets.

5. NHS England also related how well the CCG’s updated plan has been received and that it had been graded as good. Few other CCGs across Lancashire had achieved this level of assurance.

Well North Partnership Proposition focussed on Skelmersdale

6. The CCG has worked with a broad range of partners on undertaking a diagnostic exercise for the Well North programme. This Public Health England funded programme is focussed on tackling health inequalities at the local level. This relates to work that the CCG has been doing focussed on better understanding health and wellbeing outcomes at ward level across West Lancashire to gain a richer understanding of health inequalities, the burden of which is experienced predominantly in Skelmersdale. The CCG will know the outcome of the Well North proposal around September time and, if successful, should see a start date of this three year programme, in October.

Shaping the future of care in Southport, Formby and West Lancashire

7. The CCG along with its local health economy partners wants everyone who lives in Southport, Formby and West Lancashire to continue to have the best possible health services, which meet the highest standards of quality both now and in the future.

8. The local health economy partners know that our services must be capable of meeting the changing healthcare needs of local residents in the years ahead. Demands on NHS services

Chief Officer’s Update 2 West Lancashire Clinical Commissioning Group Governing Body Meeting – 28 July 2015

are increasing and the challenges faced locally are not unique. However, these localities have a much higher number of older residents than other parts of the country and their healthcare needs are becoming more and more complex.

9. Southport & Ormskirk Hospital NHS Trust, working together with NHS Southport and Formby Clinical Commissioning Group (CCG) and NHS West Lancashire CCG, has jointly commissioned a review to look at how services could be shaped in the future so they can better respond to the local challenges, as demands on resources increase across the health and social care sector.

10. This will draw on clinical expertise from the Trust, CCGs and external medical experts. Alongside this, both CCGs will continue to work with key partners, patients, carers and the public for their views about future healthcare.

11. Healthcare commissioners are committed to providing services locally whenever it is medically safe, effective and feasible to do so. The review will identify options and recommendations to strengthen future arrangements and we expect it to report its findings early in 2016.

Neighbourhood Learning Network

12. This 18 month project is funded by Health Education North West and will be delivered through a collaborative approach between West Lancashire CCG, Southport and Ormskirk NHS Trust and the Faculty of Health and Social Care at Edge Hill University.

13. The first meeting of this group took place at the end of May where the scope and milestones of the project were agreed. The aim of the project is to support the development of the workforce to meet the needs of the local population within Skelmersdale, with an emphasis on the delivery of integrated care provision that promotes health and wellbeing. It was acknowledged that the specific content and structure of the learning will emerge through discussion and engagement with key stakeholders and leaders from Skelmersdale.

14. An initial communication and engagement meeting has therefore been arranged for Thursday 16 July. Currently, over 30 local leaders have confirmed their attendance from a range of organisations within the public, private and voluntary sector as well as members of the public who are seen as leaders within their community. The outcome of this meeting is to begin to identify and prioritise local issues that can be addressed by educating front line staff and ask for approximately 6 volunteers/ nominations to make up a local leadership group. This leadership group will be supported to develop learning through participation within a series of 4 Action Learning sets that will take place between September and December.

2015/16 Emergency Preparedness, Resilience and Response assurance

15. As in 2014/15 NHS England have asked all NHS organisations to undertake a self- assessment against the NHS England Core Standards for Emergency Preparedness, Resilience and Response (EPRR). The results should be reported to NHS England Lancashire & Greater Manchester by 31 August. CCG’s with lead commissioner responsibilities have to submit a health economy assurance report. As we are not lead commissioner for any services this latter requirement does not impact us.

16. We have undertaken a self-assessment. The self-assessment indicates full compliance. It is recognised that the CCG is required to undertake test of the major incident plan and take part in a multi-agency exercise as appropriate. Discussions are taking place with Midlands and Lancashire commissioning support unit over a table-top test of the major incident plan which should be taking place in the near future.

Chief Officer’s Update 3 West Lancashire Clinical Commissioning Group Governing Body Meeting – 28 July 2015

17. Attached is the statement of compliance following the self-assessment which will be submitted to NHS England on approval form the governing body.

NHS Workforce Race Equality Standard statement

18. Further to information included in my report to the January 2015 meeting of the governing body outlining the introduction of the NHS Race Equality Standard for NHS organisations I can confirm that the CCG now has a document on our website containing the information. This can be found at http://www.westlancashireccg.nhs.uk/wp-content/uploads/WRES- webpage-content-WL-CCG-Jun-20152.docx

Recommendation

19. Members are asked to note the content of the report and approve the emergency preparedness, resilience and response assurance self-assessment.

Mike Maguire Chief Officer July 2015

Chief Officer’s Update 4 West Lancashire Clinical Commissioning Group Governing Body Meeting – 28 July 2015

Emergency Preparedness, Resilience and Response (EPRR) Assurance 2015-16

STATEMENT OF COMPLIANCE

West Lancashire CCG has undertaken a self-assessment against the NHS England Core Standards for EPRR (v3.0).

Following self-assessment, and in line with the definitions of compliance stated below, the organisation declares itself as demonstrating Full compliance against the EPRR Core Standards.

Compliance Level Evaluation and Testing Conclusion

The plans and work programme in place appropriately address all the Full Core Standards that the organisation is expected to achieve.

The plans and work programme in place do not appropriately address one Substantial or more Core Standard that the organisation is expected to achieve.

The plans and work programme in place do not adequately address Partial multiple Core Standards that the organisation is expected to achieve.

The plans and work programme in place do not appropriately address Non-compliant several Core Standards that the organisation is expected to achieve.

The results of the self-assessment were as follows:

Number of Standards rated as Standards rated as Standards rated as applicable Red1 Amber2 Green3 standards 30 0 0 30

Acute providers: 47 2 1 Not complied with but Specialist providers: 38 Not complied with and not in evidence of progress and in 3 Community providers: 38 an EPRR work plan for the Fully complied with an EPRR work plan for the Mental health providers: 38 next 12 months next 12 months CCGs: 30

Where areas require further action, this is detailed in the attached EPRR Core Standards Improvement Plan and will be reviewed in line with the organisation’s EPRR governance arrangements.

I confirm that the above level of compliance with the EPRR Core Standards has been or will be confirmed to the organisation’s board / governing body.

______Signed by the organisation’s Accountable Emergency Officer

______Date of board / governing body meeting Date signed

Chief Officer’s Update 5 West Lancashire Clinical Commissioning Group Governing Body Meeting – 28 July 2015

Emergency Preparedness, Resilience and Response (EPRR) Assurance 2015-16

STATEMENT OF COMPLIANCE

West Lancashire CCG has undertaken a self-assessment against the NHS England Core Standards for EPRR (v3.0).

Following self-assessment, and in line with the definitions of compliance stated below, the organisation declares itself as demonstrating Full compliance against the EPRR Core Standards.

Compliance Level Evaluation and Testing Conclusion

The plans and work programme in place appropriately address all the Full Core Standards that the organisation is expected to achieve.

The plans and work programme in place do not appropriately address one Substantial or more Core Standard that the organisation is expected to achieve.

The plans and work programme in place do not adequately address Partial multiple Core Standards that the organisation is expected to achieve.

The plans and work programme in place do not appropriately address Non-compliant several Core Standards that the organisation is expected to achieve.

The results of the self-assessment were as follows:

Number of applicable Standards rated as Standards rated as Standards rated as standards Red1 Amber2 Green3 30 0 0 30

Acute providers: 47 2 1 Not complied with but Specialist providers: 38 Not complied with and not in evidence of progress and in an 3 Community providers: 38 an EPRR work plan for the next Fully complied with EPRR work plan for the next 12 Mental health providers: 38 12 months months CCGs: 30

Where areas require further action, this is detailed in the attached EPRR Core Standards Improvement Plan and will be reviewed in line with the organisation’s EPRR governance arrangements.

I confirm that the above level of compliance with the EPRR Core Standards has been or will be confirmed to the organisation’s board / governing body.

______Signed by the organisation’s Accountable Emergency Officer

______Date of board / governing body meeting Date signed

Agenda item no: WLCCGB 07/15/7

WEST LANCASHIRE CLINICAL COMMISSIONING GROUP BOARD REPORT

DATE OF BOARD MEETING: 28 July 2015

TITLE OF REPORT: Declaration of Members’ Interests - Update

BRIEFING POINTS: To record the declared interests of the members of West Lancashire Clinical Commissioning Governing Body Does this report / its recommendations have implications and impact with regard to the following: A. Commissioning Board’s Aims and Objectives 1. Quality (including patient safety, clinical effectiveness and patient No experience) – please outline impact

2. Commissioning of hospital and community services – please outline No impact 3. Commissioning and performance management of GP Prescribing – No please outline impact 4. Delivering Financial Balance – please outline impact No 5. Development of the commissioning group as a commissioning Yes organisation – please outline impact Will provide the commissioning board and commissioning group with practical experience of implementing good governance practices

B. Governance – please outline impact Yes 1. Does this report: • provide the Commissioning Board with assurance against any of the risks identified in the assurance framework (identify risk number) • have any legal implications • promote effective governance practice The report promotes good governance practices. It provides a summary of the declared interests of members. Since the register was first presented to the governing body additional posts have been recruited to. 2. Additional resource implications No (either financial or staffing resources) 3. Health Inequalities No 4. Human Rights, Equality and Diversity Requirements No 5. Clinical Engagement No 6. Patient and Public Engagement No

REPORT PREPARED BY: Katie Wightman, Head of Corporate Affairs

REPORT PRESENTED BY: Katie Wightman, Head of Corporate Affairs

Declaration of members’ interests West Lancashire Clinical Commissioning Group Governing Body Meeting – 28 July 2015 1 WEST LANCASHIRE CLINICAL COMMISSIONING GROUP BOARD

DECLARATION OF MEMBERS’ INTERESTS - UPDATE

BACKGROUND

1. The purpose of this report is to record the declared interests of the members of West Lancashire Commissioning Governing Body.

2. The register was updated in July 2015 to provide an up to date position of declarations of interest for the members of the Governing Body.

ACTIONS

3. The Governing Body is asked to:

a. note the declared interests of its members

Declaration of members’ interests West Lancashire Clinical Commissioning Group Governing Body Meeting – 28 July 2015 2 REGISTER OF INTERESTS AT JULY 2015

Name Date Position / Role Potential or actual area where interest could occur Dr J Caine * 12.3.15 Chair GP partner: Parbold Surgery Dr B S Biswas * 11.3.15 GP executive • Partner Beacon Primary Care lead • Wife – practice nurse and family planning nurse for the ICO (family member interest) • Director of Aspire pharmacy • 14% shareholding in Aspire pharmacy 50% shareholding in Barbonel – services company 50% partner in Beacon Primary Care • Practice pays into OWLs • Enhanced services: Anticoagulation, Dermatology and sexual health.

Dr S Frampton * 3.3.15 GP executive • GP Partner at Ormskirk Medical Practice lead providing clinical and business management roles.

Dr J Kinsey * 12.3.15 GP executive • General practice at Parbold surgery, 4 lead The Green, Parbold WN8 7DN (4 sessions per week) • Owner, director and shareholder (approx. 30%) in Mednostic Solutions Ltd. o Diagnostic provider (osteoporosis Dexa scanning) o Weight loss services • Owner, director and shareholder (70%) of JPK medical Ltd o Private company offering private medical services, out of hours care. Wife is a shareholder (30%) in JPK medical ltd. Brother in law – co-owner and director shareholder (30%) of Mednostic solutions ltd (family members) • Medical Consultant for Pharmaco- vigilance at Ayrton Saunders Ltd • Macmillan GP – employed by West Lancashire CCG • Primary care medical educator for Manchester postgraduate Deanery as an educator at Preston • GP appraiser – carry out appraisals on other GPs for NHS England • Out of hours provider – work for OWLS Declaration of members’ interests West Lancashire Clinical Commissioning Group Governing Body Meeting – 28 July 2015 3 CIC Ltd as independent practitioner for GP services in West Lancashire. • Wife works as Macmillan upper GI cancer nurse specialist at Aintree NHS Foundation Trust. Sister in law works at Southport and Ormskirk Hospital NHS Trust as staff nurse. Mother in law works in pharmacy at Ormskirk hospital (family members interests) Paul Kingan 12.3.15 Chief finance Nil officer Douglas Richard 6.3.15 Lay member Nil Soper and audit and 16.6.15 governance Greg Mitten 1.3.15 Lay member • Chief Officer, West Lancashire and patient and Community for Voluntary Services 16.6.15 public Director Lancashire Association of CVS involvement (Charity). Director Third Sector Lancashire (Voluntary position - Charity). Director One Lancashire (Voluntary position - Charity) Chair of One West Lancs -strategic partnership. (Voluntary position). Chair – Lancashire West LAG (RDPE) Board (Voluntary position) Member Governing Body – Hilldale Primary School Wife (Dierdre Mitten) is project director of Skelmersdale Food Initiative – Charity. (family member interest) Adam Robinson 10.3.15 Secondary • Consultant physician and clinical director care doctor at Salford Royal Foundation Trust

Michael Maguire 11.3.15 Chief officer • Daughter is undertaking work experience and at: Ormskirk Medical Centre in July 11.6.15 2015; Stocks Hall Nursing Home; and Beacon Medical Centre. Daughter is a student at Winstanley College and is a member of the Medical, Dental and Vets society. Dr R Bonsor* 10.3.15 GP executive • GP partner at Beacon Primary Care lead General Practice, Ormskirk and Skelmersdale. • Husband is emergency physician at Whiston Hospital (family member interest). • Part-ownership as Director of Aspire Pharmacy 14% shareholder • Director of Barbonel services - 45% shareholder

Declaration of members’ interests West Lancashire Clinical Commissioning Group Governing Body Meeting – 28 July 2015 4 • Fundraising for Lancashire Defibrillator Campaign • Chair of 30th Ormskirk Scout Group • Ambassador for Twinkle House Charity Skelmersdale, is a personal friend. Claire Heneghan 12.3.15 Chief Nurse Nil Dr Peter 6.3.15 GP executive • Partner at Parkgate surgery Gregory* and lead • Director of OWLs 16.6.15 • Brother is a fellow of AQUA (family member interest) • Provide minor surgery / contraception at practice. • GP Appraiser to NHS England, Lancashire and Greater Manchester.

*As agreed at the Governing Body meeting on 28 January 2014, please note that all principal GPs in West Lancashire are default members of the Out of Hours service.

Declaration of members’ interests West Lancashire Clinical Commissioning Group Governing Body Meeting – 28 July 2015 5 NHS West Lancashire Clinical Commissioning Group Declaration of interests - members

This form is required to be completed in accordance with the CCG’s Constitution and section 14O of The National Health Service Act 2006, the NHS (Procurement, Patient Choice and Competition) regulations 2013 and the Substantive guidance on the Procurement, Patient Choice and Competition Regulations.

Name ……………………………………………….. (BLOCK CAPITALS)

Position within or relationship with, the CCG or NHS England

……………………………………………………………………………………………….

I hereby declare my interests as follows: Type of interest Details Personal interest or that of a family member, close friend or other acquaintance? Role and responsibilities held within member practices

Membership of any GP provider organisation holding or seeking to hold CCG contracts

Membership of the Operating Board of such organisations

Directorships, including non-executive directorships held in private companies or PLCs

Ownership or part- ownership of private companies, businesses or consultancies likely or possibly seeking to do business with the CCG and/or NHS England

Declaration of members’ interests West Lancashire Clinical Commissioning Group Governing Body Meeting – 28 July 2015 6 Share holdings (more than 5%) of companies in the field of health and social care

A position of authority in an organisation (eg. Charity or voluntary organisation) in the field of health and social care.

Any connection with a voluntary or other organisation contracting for NHS services.

Research funding/grants that may be received by an individual or any organisation in which they have an interest or role

Interests in pooled funds that are under separate management (any relevant company included in this fund that has a potential relationship with the CCG must be declared)

Any interests in relation to the CCG’s Enhanced Services Review

Any other role or relationship which the public could perceive would impair or otherwise influence the individual’s judgment or actions in their role within the CCG and/or with NHS England.

Any other interests

Declaration of members’ interests West Lancashire Clinical Commissioning Group Governing Body Meeting – 28 July 2015 7 To the best of my knowledge and belief, the above information is complete and correct. I undertake to update as necessary the information provided and to review the accuracy of the information provided regularly. I give my consent for the information to be recorded in a formal Register of Interests, a public document which will be published on a quarterly basis and available for inspection upon request by the general public.

Signed: …………………………………………………… Date: ……………………

Please complete and return to: Katie Wightman, head of corporate affairs, West Lancashire CCG

Declaration of members’ interests West Lancashire Clinical Commissioning Group Governing Body Meeting – 28 July 2015 8 Agenda item no: 07/15/8

WEST LANCASHIRE CLINICAL COMMISSIONING GROUP GOVERNING BODY

DATE OF MEETING: 28 July 2015

TITLE OF REPORT: Risk Register & Governing Body Assurance Framework

BRIEFING POINTS: Outlines key risk areas Does this report / its recommendations have implications and impact with regard to the following: A. Commissioning Board’s Aims and Objectives 1. Quality (including patient safety, clinical effectiveness and patient experience) No – please outline impact

2. Commissioning of hospital and community services – please outline impact No

3. Commissioning and performance management of GP Prescribing – please No outline impact

4. Delivering Financial Balance – please outline impact No

5. Development of the commissioning group as a commissioning organisation – Yes please outline impact Part of governance arrangements

B. Governance – please outline impact 1. Does this report: Yes • provide the Commissioning Board with assurance against any of the risks identified in the assurance framework (identify risk number) • have any legal implications • promote effective governance practice Provides overview and updates on all strategic and operational risks 2. Additional resource implications No (either financial or staffing resources)

3. Health Inequalities No

4. Human Rights, Equality and Diversity Requirements No

5. Clinical Engagement No

6. Patient and Public Engagement No

REPORT PREPARED BY: Elizabeth Hill, CSU Corporate Governance & Risk Manager on behalf of Katie Wightman, Head of Corporate Affairs

REPORT PRESENT BY: Katie Wightman, Head of Corporate Affairs

Board Assurance Framework 1 West Lancashire Clinical Commissioning Group Governing Body – 28 July 2015

Risk Register & Governing Body Assurance Framework

Introduction

A Board Assurance Framework (BAF) is a key part of the CCG’s governance arrangements. These arrangements include a requirement for the Governing Body to review the documents.

The CCG Risk Register has been reviewed to reflect the up to date position as at 10 July 2015. The Clinical Executive Committee reviewed the Register on 14 July.

Board Assurance Framework

The CCG’s integrated risk framework requires the Governing Body to review all risks on the risk register and the BAF.

Below is a summary of developments in the key areas.

Delivery

The main risks in relation to delivery remain safeguarding. In particular patients in receipt of NHS funded care potentially at risk of harm as their healthcare needs may not be addressed due to gaps in the commissioning of the continuing health care service in respect of care planning and case management. A number of reviews have been commissioned over the past 15 months to establish the scale of the backlog across Lancashire, this was raised at the IPA Board July meeting. A paper has now been prepared by the CSU taking account of all reviews undertaken to give an overall picture and recommend a way forward, the paper is expected by the CCG within the next few weeks for consideration of options.

In relation to the other risk in this area Quality, Innovation, Productivity and Prevention (QIPP) schemes continue to be developed and a QIPP dashboard is being populated to monitor and report progress against identified schemes. The risk remains on the register in order to ensure focus on delivery of QIPP targets.

The risk in relation to patient safety issues in relation to the cardiology services at Southport and Ormskirk Trust has been reduced from a risk score of 16 to 12 due to the appointment of an alternative provider and on-going positive discussions with the Provider.

As the safeguarding concerns are still on-going the overall assurance rating for delivery remains Red.

Engagement

The lack of clarity from NHS England regarding Primary Care co-commissioning level remains at a risk score of 8 and conference calls with new chief executive of Manchester and Lancashire Area Team are still taking place. There has been now further progress with this issue.

Given the current situation the overall risk rating for engagement has increased to Amber.

Contracts

The main issues in relation to this element remain the risk to the CCG managing the financial position. A finance plan is in place for the overall allocation and discussions are taking place to arrive at a balanced running cost position for 2015/16.

Board Assurance Framework 2 West Lancashire Clinical Commissioning Group Governing Body – 28 July 2015

Given the current situation the overall risk rating for contracts is Green.

Operational Systems

Implementation of the new IT system at Southport and Ormskirk NHS Trust is a concern as it may affect the delivery & quality of health services. Data checks are being maintained.

Given the current situation the overall risk rating for operational systems is Amber.

Recommendations

The Governing Body is asked to note the board assurance framework and corporate risk register and continue to support the risk management arrangements.

Katie Wightman Head of Corporate Affairs July 2015

Board Assurance Framework 3 West Lancashire Clinical Commissioning Group Governing Body – 28 July 2015

West Lancashire Clinical Commissioning Group Governing Body Assurance Framework 15/07/2015 Assurance Framework 2014/15

2014/15 Critical Outcome TEAM RESIDUAL ASSURANCE

LEAD RISK STATUS RATING (overall) DIRECTOR Delivery - Failure to Deliver CCG Service Priorities MM 16 RED

Engagement - Failure to Engage Effectively with Stakeholders Dr SF (Comm) Amber Dr JK (Clinical) Contracts - Failure to effectively manage contracts to ensure Dr BB high quality services Green

Operational Systems PK Amber

Assurance Status Key: Green Complete Amber On track Red Off target NB: where there is more than 1 risk relating to a key objective the higher of the risk ratings will be shown on the summary sheet

Page 1 of 5 West Lancashire Clinical Commissioning Group Governing Body Assurance Framework 15/07/2015

EXEC MM 2014/15 Delivery - Failure to Deliver CCG Service Priorities LEAD:

Level of Principle Areas of Risk Key Controls Assurance on Controls Gaps in Control Gaps in Assurance Key actions Status

Assurance (LxC) Actions Register) LeadOfficer TargetDate for Completion of Key of Completion CurrentRatingRisk Risk IDRisk Risk to (Link Initial Risk RatingRisk (LxC) Initial These are the specific areas Processes and plans in place or Internal or external reporting Areas where controls are Areas of insufficient Must state Key actions being taken to Colour indicates where failure will risk a actions being taken to mitigate arrangements that provide not in place or are evidence to assure the either mitigate the risk current status of critical outcome risk in principle areas assurance to the Governing ineffective Governing Body that None principle risk area Body that controls are controls are being effective Limited RED = off track effective Significant AMBER = on track Full GREEN = completed

A number of reviews have been commissioned over the past 15 Patients in receipt of NHS months to establish the scale of funded care potentially at the backlog across Lancashire, risk of harm as their health issue raised at July 2015 IPA and care needs may not be CSU commissioned to manage Board meeting. Paper has now addressed due to: CHC process. been prepared by the CSU taking - Gaps in the commissioning Monthly exception reporting care Monthly Exception Report account of all reviews Not all contracts are in undertaken to give an overall 15 32 of the CHC service in 20 (5x4) homes from CSU Quarterly reports received Lack of service specification Limited CH RED place picture and recommend a way (5x3) respect of care planning and Quarterly reporting on CHC from from CSU forward, the paper is expected case management. CSU by the CCG within the next few - Lack of capacity in CHC weeks for consideration of team resulting in routine options. reviews behind scheduled. CHC team involved in safeguarding reviews. On-going monitoring to continue.

Page 2 of 5 West Lancashire Clinical Commissioning Group Governing Body Assurance Framework 15/07/2015

EXEC LEAD: Dr SF (Comm) 2014/15 Engagement - Failure to Engage Effectively with Stakeholders Dr JK (Clinical)

Principle Areas of Level of Key Controls Assurance on Controls Gaps in Control Gaps in Assurance Key actions Status

Risk Assurance (LxC) Actions Register) LeadOfficer TargetDate for Completion of Key of Completion CurrentRatingRisk Risk IDRisk Risk to (Link Initial Risk RatingRisk (LxC) Initial These are the Processes and plans in place Internal or external Areas where controls are Areas of insufficient Must state either Key actions being Colour specific areas or actions being taken to reporting arrangements not in place or are evidence to assure None taken to mitigate indicates where failure will mitigate risk in principle that provide assurance to ineffective the Governing Body Limited the risk current status risk a critical areas the Governing Body that that controls are Significant of principle risk outcome controls are effective being effective Full area RED = off track AMBER = on track GREEN = completed

None Identified. Lower ranked risks are shown on the risk register

Page 3 of 5 West Lancashire Clinical Commissioning Group Governing Body Assurance Framework 15/07/2015

Contracts - Failure to effectively manage contracts to ensure high quality services EXEC Dr BB 2014/15 LEAD:

Principle Areas of Level of Key Controls Assurance on Controls Gaps in Control Gaps in Assurance Key actions Status

Risk Assurance (LxC) Actions Register) LeadOfficer TargetDate for Completion of Key of Completion CurrentRatingRisk Risk IDRisk Risk to (Link Initial Risk RatingRisk (LxC) Initial These are the Processes and plans in place Internal or external Areas where controls are Areas of insufficient Must state either Key actions being Colour specific areas or actions being taken to reporting arrangements not in place or are evidence to assure None taken to mitigate indicates where failure will mitigate risk in principle that provide assurance to ineffective the Governing Body Limited the risk current status risk a critical areas the Governing Body that that controls are Significant of principle risk outcome controls are effective being effective Full area RED = off track AMBER = on track GREEN = completed

None Identified. Lower ranked risks are shown on the risk register

Page 4 of 5 West Lancashire Clinical Commissioning Group Governing Body Assurance Framework 15/07/2015

EXEC PK 2014/15 Operational Systems LEAD:

Principle Areas of Level of Key Controls Assurance on Controls Gaps in Control Gaps in Assurance Key actions Status

Risk Assurance (LxC) Actions Register) LeadOfficer TargetDate for Completion of Key of Completion CurrentRatingRisk Risk IDRisk Risk to (Link Initial Risk RatingRisk (LxC) Initial These are the Processes and plans in place Internal or external Areas where controls are Areas of insufficient Must state either Key actions being Colour specific areas or actions being taken to reporting arrangements not in place or are evidence to assure None taken to mitigate indicates where failure will mitigate risk in principle that provide assurance to ineffective the Governing Body Limited the risk current status risk a critical areas the Governing Body that that controls are Significant of principle risk outcome controls are effective being effective Full area RED = off track AMBER = on track GREEN = completed

None Identified. Lower ranked risks are shown on the risk register

Page 5 of 5 Status Key: West Lancashire CCG – Risk Register 10.07.15 Green – Complete Amber – On track Red - Off target West Lancashire CCG Risk Register

No. Lead Description Controls Score Risk Action Plan (AP) Updates Status Residual of AP risk Link to BAF C L R A G

Matrix designed to monitor impact of Monitoring of QIPP QIPP and assist

linked into financial redistribution of Cross reference QIPP reporting system resources. programme to redesign CSU support for programme comms, finance and QIPP outcomes

Failure to deliver business intelligence clarified and plan Continuously refresh 7 service priorities to plan Strategic Partnership amended assumptions around QIPP including QIPP targets Board (SPB) (6 key accordingly programme outcomes and Moderate BAF Theme: PJ/KT notably Facing the priorities agreed) 3 3 9 embed services. Future Together National reporting Improvement in

Delivery on assurance systems being QIPP strategy established established. Q1 -Q4 maintained with for 15/16 and operational assessment on-going scrutiny. delivery detail being completed with full No change to risk developed now assurance received score at present

time.

July 15.

Issues with Choose and Book and discharges New meeting is in being discussed with the place to engage Trust Trust Lack of engagement of clinicians with GPs. 8 providers in the quality JC attends on our No change to Regular feedback of new agenda leading to a behalf. action plan at this BAF Theme: “op forum” to lack of understanding time. JM 4 2 8 membership under Moderate and consistency CCG attends Trust Engagement chairman’s update between partners quality Committee July 2015

regarding outcomes of and vice versa Continued engagement of specific schemes. trust staff with GPs in our

membership and FTFT events

West Lancashire CCG Risk Register 1 Update – July 2015 West Lancashire CCG – Risk Register 10.07.15

No. Lead Description Controls Score Risk Action Plan (AP) Updates Status Residual of AP risk Link to BAF C L R A G i) Monitoring of Risk added Moderate performance and 28.3.14. quality metrics for all metrics so Data checks still any changes can being performed as be identified there are still data ii) Updates on issues with the PK implementation new PAS system. going to SPB The latest issue iii) Contract penalties relates to GP Implementation of the for non- Emergency 22 Monitoring of new IT system at S&O submission of Assessment unit performance & quality as it may affect the data patients that are BAF Theme: metrics. CCG IT lead delivery of health 4 2 8 not admitted to a obtaining a status report. services or the quality bed. This activity Op systems of those may have been under-reported during 2014/15 and checks are currently being done to assess the size of the issue going forward.

July 2015

Safeguarding issue Risk added on Children being investigated -learning and 15.8.14 discharged from Additional expertise actions agreed and CAMHS too early at 16 brought in to advise discussed. Lancashire System when they should & assist. Board: remain with service Lancashire wide system Wide range of until 18. Leading to Eating Disorder board will consider the attendees, risk of no services 23 contract has been service model to be including health, being received when extended - improved implemented across social care, child needs it – BAF Theme: CW serviced commenced Lancashire education Moderate safeguarding issue 3 2 6 25th February 2015 - Shared Vision voluntary sector. transition into adult Delivery meeting with the Short, Medium, Long Shared Vision up to service where staff are service leads to take term outcomes and age 25 – not trained to provide place. actions integrated joined an age appropriate System Lead to be up seamless service, inappropriate appointed system from all placement of children Develop High Level Plan commissioners on adult mental health (includes improving ward information, Risk emotional

West Lancashire CCG Risk Register 2 Update – July 2015 West Lancashire CCG – Risk Register 10.07.15

and Issues wellbeing and MH. Register, Communications Describe what , Finance and Contracting Good Looks Like – and Accountability of pre- aim to capture existing structures) good practice and define July 2015 minimum standard. Facilitated Away Day Friday 26th June 2015.

July 2015

West Lancashire CCG Risk Register 3 Update – July 2015 West Lancashire CCG – Risk Register 10.07.15

No. Lead Description Controls Score Risk Action Plan (AP) Updates Status Residual of AP risk

Develop plan to achieve Risk added July Consideration being running cost target for 2014. 25 Running costs outstrip given to how to 2015/16 Maintaining an on- available resources in PJ achieve 2015/16 going review of Moderate BAF Theme: 2015/16 3 3 9 running costs target Requirements reviewed running costs. Contracts as and when vacancies arise July 2015

Implementation and rollout plan developed Engagement made and updated with the National Risk added July C&B2 Team. New e-referral manager in 2014. strategy developed to post

move away from RMC Regular feedback and move to C&B2. S&F tie in confirmed to Executives at

27 least once per Lack of a Referral New project structure Choose and book month. Management Centre developed with clear programme board taking BAF Theme: JM Moderate Strategy TOR for groups 3 3 9 place 09.01.2015 Contract extended therein Delivery with CSU for extra DOS compiled by CCG three months to Regular feedback to cover some delay. Executives at least Alternative options are

once per month on being sought for services July 2015. how this project is supported by RMC

performing i.e. podiatry, gastroenterology etc.

West Lancashire CCG Risk Register 4 Update – July 2015 West Lancashire CCG – Risk Register 10.07.15

No. Lead Description Controls Score Risk Action Plan (AP) Updates Status Residual of AP risk Link to BAF C L R A G About to begin reviews of high cost complex cases Undertake reviews and

complete training for GPs Risk added July Undertaking review on process. 2014. of internal CSU

process around the CCG scrutinising the CCG scrutiny of IPA process - financial information CSU 29 accuracy of the financial CSU Broadcare instability, increasing sends to CCG forecast produced by the data being costs, and assurances BAF Theme: PJ CSU maintained. Moderate on quality of Undertaking further 3 3 9

assessments training for GPs on Delivery Developing new Development of process commissioning processes new commissioning

in partnership with CSU processes. Report on IPA and CCS. expenditure received July 2015 from CSU

IPA Programme Board

- CSU to report on Risk added October timeliness of CHC/FNC 2014 Patients in receipt of reviews with exception NHS funded care reporting where care Risk reduced in Jan potentially at risk of needs not being 15 from 20 to 15 harm as their health addressed. as various and care needs may - Contracts to be in place meetings and not be addressed due - CSU commissioned for all patients under action taken place; to to manage CHC 32 individual of care (IPA) A number of - Gaps in the process. CCG to ensure service reviews have been commissioning of the - Monthly exception Medium / BAF Theme: CH 5 3 15 specification in place with commissioned over CHC service in respect reporting care high CSU re CHC includes the past 15 months of care planning and homes from CSU Delivery commissioning/care to establish the case management. Quarterly reporting planning and case scale of the - Lack of capacity in on CHC from CSU managements and backlog across CHC team resulting in contribution to Lancashire, this routine reviews behind safeguarding was raised at the scheduled. enquiries/investigations IPA Board July

as outlined in the national meeting, a paper

CHC framework has now been prepared by the CSU taking account

West Lancashire CCG Risk Register 5 Update – July 2015 West Lancashire CCG – Risk Register 10.07.15

of all reviews undertaken to give an overall picture and recommend a way forward, the paper is expected by the CCG within the next few weeks for consideration of options. CHC team involved in safeguarding reviews. On-going monitoring to continue

West Lancashire CCG Risk Register 6 Update – July 2015 West Lancashire CCG – Risk Register 10.07.15

No. Lead Description Controls Score Risk Action Plan (AP) Updates Status Residual of AP risk Link to BAF C L R A G Decisions taken on referrals into MASH not informed by relevant health information and - Interim funding for potential therefore that 2wte band 7s and harm and risks not fully Awaiting outcome 1wte admin has - Options paper to recognised leading to of options paper. been made safeguarding poorer outcomes for available until collaborative and CCG children/families and 31.03.15. on future commissioning 33 vulnerable adults. No 12 month funding - Options paper of health contribution to agreement for the on- agreed for a MASH currently being MASH BAF Theme: CH / JR going funding of the 3 2 6 service manager to Low developed which - CCG/ AT/ PH agree Lancashire multi- coordinate across will make future funding of Delivery agency safeguarding organisations. Long recommendations health’s contribution Hub (MASH). Term options still for future - Procure service Insufficient health to be agreed. commissioning of contribution will impact health service on timeliness of July 2015 contribution to information sharing and MASH decision making and may result in poorer outcomes for children and adults at risk. Service specification LCFT have in place with LCFT acknowledged which requires them blocks in to co-ordinate the administrative Statutory health Service specification with health assessment processes assessments for LCFT to be amended to process and to impacting on children looked after reflect the needs of the quality assure timeliness of are not undertaken CCG in respect of PbR assessments. assessments and 34 within statutory action plan now in timescales and may Development of S&O community place. BAF Theme: CH / JR result in the child not 2 2 4 Lancashire wide service Low paeds commissioned achieving their full specification for children to undertake initial LCC to provide full Delivery potential as individual 16-18 under auspices of health assessments access to their health needs not multi-agency steering and adoption recording systems identified and group re commissioning medicals for children (Liquid Logic) to addressed in a timely of health services for 0-18 years CLA nurses in LCFT manner. looked after children. Health visiting and which will improve school nursing accurate data service specifications inputting. include the

West Lancashire CCG Risk Register 7 Update – July 2015 West Lancashire CCG – Risk Register 10.07.15

requirement for LCC and LCFT services to undertake recovery plan in statutory review place with assessments. oversight by LSCB. Improved scrutiny Contract query being and accountability issued with LCFT re structure now in uptake and place, assessment timeliness of review figures improving. assessments Further LCFT have put in improvement in place action plan to timeliness of address l issues review assessments will monitor for a further month and recommend removing the risk.

July 2015

West Lancashire CCG Risk Register 8 Update – July 2015 West Lancashire CCG – Risk Register 10.07.15

No. Lead Description Controls Score Risk Action Plan (AP) Updates Status Residual of AP risk Link to BAF C L R A G Seek assurance that the care and treatment plans for CCG commissioned packages of care for individuals lacking capacity to consent have been reviewed and where a DoLs is identified full exploration Risk added October of alternative ways of 2014. providing care/treatment

have been undertaken to - Pan Lancashire Services users are enable the least action plan in place Further update potentially at risk of restrictive option of care. with LCC being received in respect harm due to unlawful 35 bench marked of action plan July deprivation of liberty Seek assurance from against national plan 2015 progress within hospital care care homes where there Medium BAF Theme: CH / LE held by NHS 3 4 12 being made against home and supported are CHC funded patients /High England the actions to be living following the that DoLs applications Delivery - MCA/adult leads of considered at Cheshire West have been made or are CCGs providing Quality and safety Judgement in March in the process of being training to CSU staff committee in July, 2014, authorised. on DoLS. risk potentially to

be reduced. CCG to determine which

service is best placed to July 2015 be commissioned to case manage CHC patients residing in their own homes and supported tenancy to ensure compliance with Cheshire West recommendations.

West Lancashire CCG Risk Register 9 Update – July 2015 West Lancashire CCG – Risk Register 10.07.15

No. Lead Description Controls Score Risk Action Plan (AP) Updates Status Residual of AP risk Link to BAF C L R A G Develop a new suite of policies. The CCG needs to establish clear governance arrangements Risk added October for adopting polices and 2014. needs to engage in a

work stream (either in On-going review of conjunction with the work 36 Lack of commissioning commissioning in Greater Preston and policies to drive Existing legacy policies –Feb 15. Chorley and South Ribble Medium BAF Theme: PJ/JM individual patient policies being 3 3 9 CCGs with which there is /High funding decisions. utilised. Continual review of an offer of engagement, Delivery commissioning or in conjunction with policies is being county wide work being undertaken. promoted by the CSU, or

by designating its own July 2015. officers) to develop a suite of robust and up to date policies.

Risk added 3.12.14

Inability to deliver CCG is in regular corporate objectives as contact with LCC a result of Lancashire 38 over the financial County Council (LCC) Meeting with LCC to impact. A senior budget cuts impacting understand impact BAF Theme: Ensure partnership officer from LCC Medium MM on CCG in terms of LCC of cuts 3 3 9 arrangements are robust attends the /High service provision and Delivery governing body the reduction in meetings to capacity and knowledge provide any and relationships with updates. key stakeholders.

July 2015 Inappropriate placement of individual 39 learning disability patients following No progress with this BAF Theme: Learning Disabilities – issued – risk unchanged. Risk added Further discussion at Medium MM/JM Enhanced Support 3 3 9 4.12.14. CCB meeting \High Delivery Service (LD ESS) being July 2015 transferred to CCGs as a result of CCG not having the expertise in this area .

West Lancashire CCG Risk Register 10 Update – July 2015 West Lancashire CCG – Risk Register 10.07.15

No. Lead Description Controls Score Risk Action Plan (AP) Updates Status Residual of AP risk Link to BAF C L R A G Urgent cases have appointments but the majority are still be have

their appointments made Patient safety issues in

relation to the Risk added 11.2.15 40 Cost of the alternative cardiology services at provision is rising and Southport and Alternative provider Risk rating reduced BAF Theme: needs to be managed. Medium JM Ormskirk Trust having commissioned to 4 3 12 July 2015 as the \High a significant backlog of resolve backlog. discussions have Delivery Detail of discussions with follow up patients not taken place. the provider is still not being offered clear and needs to be appointments confirmed.

July 2015 Risk added June 2015.

The CFO is monitoring the situation via the Lancashire CFO Group. This group has representatives who are involved in 41 2015/16 will be the national group Increasing financial risk about preparation Action plan need looking at in relation to the CCG BAF Theme: and transition to developing as likelihood transferring taking on specialist PK establish 4 1 4 that financial risk will specialist service Low services co- Delivery understanding and increase as April 2016 contracts and commissioning and the controls. approaches. budgets to CCG’s. associated budget Any key risks will be flagged up to the CCG Executive as part of the regular finance update and appropriate actions will be discussed.

July 2015

West Lancashire CCG Risk Register 11 Update – July 2015 West Lancashire CCG – Risk Register 10.07.15

No. Lead Description Controls Score Risk Action Plan (AP) Updates Status Residual of AP risk Link to BAF C L R A G Robust financial controls (ledger) and budget setting Risk added June Continuous monitoring of 2015. 42 financial position. Failure to Achieve Some budget holders Successful Maintaining an on- PJ Financial Balance assigned BAF Theme: 4 2 8 implementation of QIPP going review of Moderate 2015/16 Contracts Budget allocation schemes financial position. agreed by DoH for 2015/16 July 2015

Lancashire Health & Wellbeing Board the Board to have discussion to determine what it will mean for the future of Risk added 18.6.15 Reduced services Public Health. 43 provision leading to CCGs are waiting increase demand on Chair of HWN Board to for outcome from

BAF Theme: MM/LM NHS services as a 3 4 12 write to the Secretary of discussions at the High result of £4M cut in State on behalf on the Health & Wellbeing Delivery public health funding in Board Board. Lancashire That any soft evidence on July 2015 the impact of local authority cuts should be forwarded to Director of Public Health

Status Key: Green – Complete Amber – On track Red - Off target

West Lancashire CCG Risk Register 12 Update – July 2015 West Lancashire CCG – Risk Register 10.07.15

CLOSED RISKS Risks removed from the active register

No. Lead Description Controls Score Risk Action Plan (AP) Updates Status Residual of AP risk Link to BAF C L R A G Robust financial controls (ledger) and Risk added July budget setting 2014. Risk Continuous monitoring of removed 26 financial position. Failure to Achieve Some budget holders Maintaining an on- from Successful PJ Financial Balance assigned going review of register on BAF Theme: 4 2 8 implementation of QIPP 2014/15 financial position. 8.6.15. Contracts schemes Budget allocation No change to risk

agreed by DoH for score at present Moderate 2014/15 time – Feb 15.

Risk added July 14. Facing the future together (FtFT) 5 year plan finalised Risk transformation & submitted removed programme in 5 year plan submitted and from place. Outcome of 28 Strategic partnership feedback received. Risk register on Uncertainty of future of Gateway 1 resulted in place reduced from (4x3) 12 to 8.6.15. Risk CCG affecting ability to in RAG Rating of BAF Theme: KT (3x3) due to potential around plan long term 3 3 9 Red / Amber. Governing body political impact delivery of Letter and Gateway Delivery development on FFT remains Report sent to S&O strategic positioning on register. Trust outlining the held current position. Moderate Second Gateway is scheduled for March 2015. Risk added July Lack of Engagement 2014 with NHS England Significant issues arising Primary care issues Risk Primary Care Teams to from conference calls with 24 raised at CCG and Merger of NHS removed ensure W Lancs are chief executive of area LAT quarterly England Area from close to the changing team to be reported to MM assurance meeting Teams has taken register on co-commissioning 4 2 8 the governing body within BAF Theme: place with top 8.6.15 agenda and to the Chief Officers Report Engagement management tier influence the shape and as from July 2014 appointed. Moderate the management of

primary care. Conference calls with new chief execut ive Concerns continue

West Lancashire CCG Risk Register 13 Update – July 2015 West Lancashire CCG – Risk Register 10.07.15

of Manchester and in relation to Lancashire Area capacity to fulfil Team take place. any co- commissioning requirements. Decision taken by Membership Council in January 2015 to operate at level 1 co- commissioning of primary care. Feb 15

Inform Chorley and JM Failure to maintain South Ribble CCG Risk 19 equipment asset (host CCG) and Network Director CSU seeking to removed register by Lancashire request they discuss contacted to discuss procure new from BAF Theme: Teaching Hospitals for issue at contract procedure. Issue to be equipment asset register on equipment issued re meeting re incident raised with CSU. Ensure and maintenance 8.6.15 Op Systems complex packages of reporting and 3 3 9 procedure reviewed with system. The CCG is care informing the CSU regard to incidents where progressing this immediately so CSU needs to be issue with the CSU Low investigation can be informed. – Jan 15. undertaken.

i) KPIs are agreed and monitored for Establish clarity of each contract. reporting activity Quality Improvement arrangements Committee collecting Risk The business information from removed 3 intelligence information Feedback to CSU various data streams Data flows are established from provided by the CSU is on the areas that but still not yet register on BAF Theme: insufficient for the CCG we require making ii) Direct feedback embedded. 8.6.15 JM to make informed 3 2 6 more robust reports from Contracts/ decisions. Monitoring of secondary providers Low/ Delivery key performance Quality dashboard re trends Moderate indicators inc resilience being redefined

& recovery planning. Sui dashboard iii) Informal GP being redesigned – sharing Feb 15

iv) Lead Nurse in post

The Central Support i) Regular discussion Continue to manage on a Regular liaison with Low

West Lancashire CCG Risk Register 14 Update – July 2015 West Lancashire CCG – Risk Register 10.07.15

1 KW Unit (CSU) do not the with CSU regarding 3 1 3 week by week basis CSU maintained. BAF Theme: have the capacity the ongoing position during transition /capability to ensure Operational the CCG can fulfill ii) CSU seeking Maintain contract for Interim specialist Systems statutory duties specialist advice to specialist cover in the staff recruited by address gaps in interim CSU for health and service offer safety, fire and risk Development of suite of management. ii) CCG have policies. contracted specialist Robust CSU support directly in Inspections completed support now in short term and reported to Audit place Committee. No significant issues Development of suite of policies nearing completion

2 JW Impact of shortfall in i)Good liaison with 3 1 3 Continue to manage on a Embedded team is Low recruitment to the CSU CSU regarding gaps week by week basis now fully BAF Theme: in terms of specific in recruitment established and

support posts When vacancies arise any residual issues Op Systems short term pressures are regarding hub covered functions are resolved

Planned 4 improvements to Planned improvements to communication BAF Theme: communications pathways to i) Specific GP pathways to improve improve efficiency. OP Systems/ Limited GP capacity to portfolios supported efficiency, Ongoing Engagement the CCG results in by CCG managers development of

increased management Ongoing development of engagement Low/ KW 3 2 6 costs and/or limited ii) Planning of GP engagement strategy will strategy will target Moderate involvement in local engagements to target better use of GP better use of GP meetings and groups ensure maximum capacity capacity – Facing benefit for CCG the Future Continue watching brief Together has produced a strategy – Risk Closed – Jan 15

5 PJ 2013/14 Financial i) Ongoing verbal 4 1 4 Regular dialogue and CCG confident of Low shortfall possible due assurances regarding updates on a weekly basis operating within to: the system wide budget for 2013/24 BAF i) Reduction in allocation issues Lancs wide agreement

West Lancashire CCG Risk Register 15 Update – July 2015 West Lancashire CCG – Risk Register 10.07.15

Theme: allocation following achieved regarding Status reduced to redefinition of ii) Agreement with allocation for 2013/14 low for this specialised services Chorley and Gtr. financial year Contracts may compromise ability Preston CCGs / to meet contract costs regarding reallocation Delivery iv) Disaggregation of resources of budgets from CLPCT

6 PJ Limit on running costs i) Establishment is 3 1 3 Regular monitoring of Finance team fully Low resulting in lack of considered staffing levels and established flexibility to manage appropriate to meet capacity BAF staff shortages in current needs No current Theme: financial dept. Examine development of pressures status ii) Staff encouraged matrix working to remains to work flexibly to mitigate impact of staff satisfactory OP ensure adequate shortages Systems cover Risk reduced to low Continue watching brief For 2013/14 only Additional target group contacts obtained via AGM and ongoing engagement work. Websi8te & Media Contacts continue 9 Coverage. Public Co-ordination of to be gathered for Board Meetings & Ongoing pressure from information flow between the stakeholder BAF Theme: joint networking. MM MPs and interested key stakeholder groups database. Patient Participation 3 2 6 Moderate (KW) parties to provide needs improving Stakeholder Engagement Groups information Database Patient Focus Groups established and MP My View Group relationship good at present time – Risk Closed Jan 15

10a JM Unclear system and i) Existing systems 3 1 3 Increase understanding of Information flow Low process to ensure the established in existing structures & arrangements CCG receives critical providers for systems within agreed BAF timely information management of commissioning and Theme: relating to SUIs. SUIs. providers Chief Nurse and ii) Handover Quality Assurance meetings in place Establish systems to Manager now in Contracts ensure appropriate post

West Lancashire CCG Risk Register 16 Update – July 2015 West Lancashire CCG – Risk Register 10.07.15

/ information flows and Op governance arrangements are in place Systems

10a JM Individual Funding i) Existing systems 3 3 9 Ensure appropriate data Information flow Low/ Request and Continuing established for is in place for IFRs and arrangements need Moderate BAF Theme: Healthcare Requests management of IFRs CHCs so that the CCG can to ensure adequate involving WL patients & CHRs appropriately monitor data regarding Contracts/ (REPLACED WITH RISK process and performance IFRs and CHRs. Op Systems 29)

10b JM Lack of nursing input i)Development of 4 1 4 Link with Chief Nurse Chief Nurse and Low into quality, robust quality to from neighbouring CCG to Quality Assurance safeguarding and SUI identify gaps ensure links re SUIs Manager now in BAF operational systems ii) Regular reporting post Theme: to Quality Committee Advertisement for of safeguarding/SUI additional nursing/quality Reduce risk to low and all quality posts in process Contracts metrics / Op Systems

11 KW Ability to manage the i) attendance at 3 1 3 Maintain contacts with Issues relating to Low gap in knowledge transition/closedown PCT, services and other knowledge transfer transfer during the group agencies during and after have now been BAF Theme: transition process from transition resolved and no PCT to CCG ii) Handover new issues have Delivery/ meetings scheduled Maintain broader been raised. Contracts/ overview of developments Op Systems iii) Legacy document to avoid unexpected Risk reduced to low re. service/agency problems specific knowledge & contacts

12 KW Lack of CCG business i) Currently linked to 3 1 3 Develop CCG specific CSU Business Low continuity plan PCT continuity and continuity and recovery Continuity Plan recovery plans plans in liaison with now received and BAF partners and stakeholders both plans Theme: circulated to all relevant parties

Op Systems

West Lancashire CCG Risk Register 17 Update – July 2015 West Lancashire CCG – Risk Register 10.07.15

13 JW Managing the demands i) Established links 2 2 4 Develop open culture with Continuing Low of the Local Area Team with LAT LAT regarding dialogue current (LAT) regarding the performance issues relationship is very BAF performance of CCG ii) Agreement with positive. Theme: contracted services LAT regarding CCG Ensure strong links with Annual Plan other CCGs is maintained Status remains satisfactory Contracts Seeking to improve data / around quality of GP Delivery/ services Engagem ent

14 JW Possible breaks in i) Comprehensive 3 1 3 Ongoing verification of All contracts now in Low continuity of contracted database of contracts data relating to all place and any BAF services during and in place contracts during transition issues Theme: post transition transition resolved Contracts ii) PCT support to / ensure all contracts are handed over to Delivery plan

15 JW Inherited risk from i) Issues being 3 1 3 CCG have fully Any issues have Low PCT- Lack of investigated by investigated the issues. been resolved and BAF governance in the Brief former CL PCT CCGs sound governance Theme: Therapy Support arrangements are Services. in place Contracts / Delivery

16 KW Potential impact on i) CCG fully 4 2 8 Robust prioritization New risk added Moderate delivery of corporate established with process to be developed December 2013) BAF Theme: and legal clearly defined roles in relation to key responsibilities arising priorities Prioritisation for Op Systems from pressures on ii) Matrix working 2014/15 needs to capacity. principles established Time management and be progressed. resilience training to be Links to No. 21 iii) PDP process in developed to embed 1-1 process in (Risk closed as relates place effective working place.

West Lancashire CCG Risk Register 18 Update – July 2015 West Lancashire CCG – Risk Register 10.07.15

to 2013/14) practices iv) Informal staff and PDR process about senior team meetings to commence for 2014/15

17 i) Hosted Services in Hosted Services proposals Chief Nurse is now Low/ place considered via Lancs CCG leading in this moderate BAF Theme: Chairs network – no area. ii) CSU proposals agreement yet reached Contracts/ Multi CCG task and Op Systems CH CSU proposals via CCG finish group has

managers meeting – no been established. Failure of the CSU and agreement yet reached Chief Nurse hosted services to attends. provide robust Multi CCG task and finish arrangements for 4 2 8 group to be established Draft Safeguarding meeting statutory Policy received and duties relating to awaiting approval safeguarding. at next quality committee. Processes now in place. Risk mitigated and closed.

23 CMC The Oyygen Service 1)Monthly review 2 3 6 To continue with controls Meeting 22.7.14 provided by Southport meetings with nurse Trust to provide and Ormskirk Hospital specialist paper of up to date Trust has a waiting list 2)Bi monthly meeting activity and risk. of existing patients to With senior team be reviewed 3)Process map September 4)Review Spec in August

20 PJ Not achieving financial i) Financial system 4 1 4 Financial plan in draft Risk added 13.3.14 Low balance in 2014/15 to take corrective BAF Theme: action as required RISK IS DUPLICATE OF Contracts/ 26 SO CLOSED Delivery

18 Reduced prescribing Low capacity due to Letter sent to LAT 2 3 6 To monitor LAT’s New Risk added BAF Theme: MM Lancashire Area Team requesting they response to letter sent 23.1.14 (LAT) having no establish standard Op Systems process in place to operating procedures Awaiting LAT authorise practice for registering new response as at based non-medical NMP with the 6.3.14

West Lancashire CCG Risk Register 19 Update – July 2015 West Lancashire CCG – Risk Register 10.07.15

prescribers (NMP) to prescription pricing have prescription pads division and implementing the required checks prior to issuing prescriptions.

21 v) Current position Cost allocation plan Low/ PJ on running costs 4 2 8 Plan for 15/16 being being prepared for moderate Potential impact of 10% BAF Theme: known prepared 2015/16 – Risk Reduction in running vi) Plan for 15/16 removed as cost allocation from OP Systems being prepared incorporated into 2015/16 Risk 25

IM&T strategy agreed To review all feedback in principle by CCG. from circulation of Strategy has been Risk added July 30 Strategy with partner Lack of approval/ circulated to partner 2014. organisations prior to full implementation of an organisations. PK implementation. Strategy Moderate IM&T Strategy Each member 2 3 6 Strategy approved BAF Theme: being presented to practice has an at November 2014 Op Systems governing body for formal agreed programme GB adoption in November. plan

Receive information via the CSU on all incidents reported in nursing homes. Incident dashboard Southport & Ormskirk Risk added July 31 being developed. Trust to amend Policy to 2014. Limited assurances on Chief nurse attends ensure staff report nursing home issues, - RADAR meeting with incident relating to Risk can now be CH potential Safeguarding Moderate local authority 3 3 9 Nursing Home patients. closed as process issues not identified BAF Theme: Regular attendance Awaiting confirmation strengthened in

Op Systems at Safeguarding Adult that this has been done relation to care Board meetings. homes. Chief nurse meets fortnightly with safeguarding team.

37 Provider has given Provider has duty of The CSU IPA team are formal notice to CSU care to patient. responsible for placing Risk added October Medium BAF Theme: PJ (28 day standard NHS 4 3 12 patients on behalf of the 2014 /High Contract) re patient on CSU and provider CCG. CCG to ascertain Delivery Sec 3 MHA as unable to meetings taking from the CSU IPA team Request made to

West Lancashire CCG Risk Register 20 Update – July 2015 West Lancashire CCG – Risk Register 10.07.15

meet patient's needs. place. why there have been a the CSU IPA team Vulnerable patient, risk delay and when will they in relation to this of absconding risk to source a more suitable new incident. CSU self and others as well placement for the patient. have stated that as a risk of self-harm. they have no concerns regarding the safety of this patient but are working with the provider to resolve.

Identified Risk now Closed – Jan 15.

West Lancashire CCG Risk Register 21 Update – July 2015 WLCCGB 07/15/09

WEST LANCASHIRE CLINICAL COMMISSIONING GROUP GOVERNING BODY REPORT

DATE OF BOARD MEETING: 28 July 2015

TITLE OF REPORT: Budget update

BRIEFING POINTS: Does this report / its recommendations have implications and impact with regard to the following: A. Commissioning Board’s Aims and Objectives 1. Quality (including patient safety, clinical effectiveness and patient No experience) – please outline impact 2. Commissioning of hospital and community services – please outline Yes impact The budgets reflect the contractual commitment 3. Commissioning and performance management of GP Prescribing – Yes please outline impact The budgets reflect the agreed prescribing budget 4. Delivering Financial Balance – please outline impact Yes The Governing Body approved the CCG’s financial plan in March 2015. This was based on the best available knowledge of allocation and financial commitments at that time. This report now contains the revised budgets, based on final contractual commitments and revision to financial assumptions. An explanation of the changes is provided. The Governing Body is asked to approve the revised budgets. 5. Development of the commissioning group as a commissioning No organisation – please outline impact

B. Governance – please outline impact 1. Does this report: • provide the Commissioning Board with assurance against any Yes of the risks identified in the assurance framework (identify risk number) • have any legal implications • promote effective governance practice Risk of not achieving financial balance is budgets are not set realistically. 2. Additional resource implications No (either financial or staffing resources) 3. Health Inequalities No 4. Human Rights, Equality and Diversity Requirements No 5. Clinical Engagement Yes The delivery of the budget plan requires clinical engagement to deliver the commissioning programme, QIPP schemes and to help manage demand in the health economy. 6. Patient and Public Engagement Yes The budget supports the CCG’s commissioning programme which includes a number of schemes that have involved patient and the public from their inception. REPORT PREPARED BY: Paul Jones, Head of finance REPORT PRESENTED BY: Paul Kingan, Chief finance officer

Budget update 1 West Lancashire Clinical Commissioning Group Board Meeting – 28 July 2015

West Lancashire CCG 2015/16 Budgets – Update Paper

1. Introduction

West Lancashire CCG’s 2015-16 Financial Plan was presented to the Governing Body on the 24th March. This was based on the CCG’s 2015-16 Activity and Finance Plan as submitted to NHS England. This paper updates the Governing Body on developments and how they have been translated into operational budgets for 2015/16.

2. Methodology

The planned expenditure figures in the Financial Plan were based on knowledge and assumptions as they stood at the time on the following parameters: • 2014/15 forecast outturn expenditure • Efficiencies generated by the application of the tariff deflator on Provider contracts • Growth in activity volumes • Cost Pressures • QIPP savings • Planned investments (both recurrent and non-recurrent)

In the intervening period between the 24th March and the Month 3 reporting period the CCG has refined the figures contained in the Financial Plan. The proposed budgets now reflect: • Actual signed contract values NB: a small number of contracts remain unsigned, including those with Southport and Ormskirk Hospital NHS Trust and Lancashire Care Foundation Trust. In the absence of a signed contract the CCG has set a budget based on a reasonable expectation of the contract value. • The finalised Prescribing budget as presented to the Medicines Management Committee • An enhanced understanding of the CCG’s expenditure commitments following the conclusion of the 2014/15 financial year.

3. Revised 2014/15 Budgets

The table overleaf details the updated budgets and the changes when compared to the Financial Plan, followed by explanatory notes on selected movements. These budgets have been uploaded into the CCG’s financial reporting system (ISFE).

Budget update 2 West Lancashire Clinical Commissioning Group Board Meeting – 28 July 2015 2015/16 2015/16 Budget Financial Plan Revisions (at Month 3) Note £000 £000 £000 Revenue Resource Limit a 145,664 804 146,468 Expenditure

Acute services Acute contracts -NHS (includes Ambulance services) b 74,097 (1,756) 72,341 Acute contracts - Other providers (non-nhs, incl. VS) b 3,256 589 3,845 Acute - Other 412 (38) 374 Acute - NCAs 829 231 1,060

Sub-total Acute services 78,594 (974) 77,620

Mental Health services MH contracts - NHS 10,570 15 10,585 MH - Other 389 (8) 381

Sub-total MH services 10,959 7 10,966

Community Health Services CH Contracts - NHS c 9,350 368 9,718 CH - Other 2,277 (265) 2,012

Sub-total Community services 11,627 103 11,730

Continuing Care Services 8,751 310 9,061 Local Authority / Joint Services 796 45 841 Free Nursing Care 994 14 1,008

Sub-total Continuing Care services 10,541 369 10,910

Primary Care services Prescribing d 18,516 269 18,785 Community Based Services 963 74 1,037 Out of Hours 942 50 992 Primary Care (Other) e 1,930 445 2,375

Sub-total Primary Care services 22,351 837 23,188

Other Programme services GP IT Costs f 242 207 449 NHS Propery Services 1,055 70 1,125 Other CCG reserves 175 122 297 Other Programme Services 4,195 0 4,195

Sub-total Other Programme services 5,667 399 6,066

Total - Commissioning services 139,739 742 140,481

Running Costs 2,307 90 2,397

Non Recurrent Schemes g 1,428 (34) 1,394 Contingency 729 3 732

Total Application of Funds 144,203 801 145,004 Surplus/(Deficit) h 1,461 3 1,464

Budget update 3 West Lancashire Clinical Commissioning Group Board Meeting – 28 July 2015 Notes a. Revenue Resource Limit – The overall resources available to the CCG have increased by £804k since the Financial Plan was issued. The CCG has received an allocation of almost £450k to assist with the cost implications of the Enhanced Tariff Option (ETO), adopted by most local NHS Trusts. This is in addition to a non-recurrent allocation of £358k for GP IT.

b. Acute Contracts (NHS & Other Providers) – The figures in the financial plan have been superseded by actual contract values. The reduction in the NHS figure reflects the fact that the CCG’s contract offer to Southport & Ormskirk Hospitals NHS Trust incorporates the underperformance in non-elective activity experienced in the later months of 2014/15. Additionally the Fairfield Hospital contract is now categorised within Other Providers, hence explaining the increase in this figure.

c. Community Contracts (NHS) - The proposed additional investment in the Community Respiratory team has contributed to the increase in this figure.

d. Prescribing - The 2015/16 budget represents a 2% uplift on outturn expenditure for the previous financial year. This is higher than previously envisaged as evidence from 14/15 indicates significant increase in Prescribing volumes. Offsetting this are planned QIPP savings of £808k. The delivery of these efficiencies will be crucial in the CCG successfully meeting its 1% surplus target.

Following confirmation of the overall Prescribing budget, individual Practice level budgets have now been agreed.

e. Primary Care (Other) – In 2014/15 the CCG invested in allocating £5/head of population on a Practice footprint to fund initiatives within Primary Care that will help deliver care for the over 75 population with complex needs. Continued investment in these schemes beyond the initial tranche of funding are now reflected in the revised budgets. f. GP IT costs – The budget is now aligned to the allocation received from NHS England, with additional provision also made for project support.

g. Non Recurrent Schemes – The CCG is required to set aside 1% of its programme allocation for these. The largest element of this (£529k) is the CCG’s contribution to the national risk pool (and associated assessment costs) to settle continuing care retrospective cases relating to periods prior to the inception of the CCG. The remainder supports a number of transformational schemes.

h. Surplus – This is the difference between the Revenue Resource Limit and budgeted expenditure (£1.464m). This equates to 1% of the CCG’s resources, as required by NHS England.

Budget update 4 West Lancashire Clinical Commissioning Group Board Meeting – 28 July 2015 4. Conclusion

The Governing Body are requested to approve the revised budgets as detailed in this paper.

Paul Jones Head of Finance 17th July 2015

Budget update 5 West Lancashire Clinical Commissioning Group Board Meeting – 28 July 2015 Agenda item no: WLCCGB 07/15/10

WEST LANCASHIRE CLINICAL COMMISSIONING GROUP GOVERING BODY REPORT

DATE OF BOARD MEETING: 28 July 2015

TITLE OF REPORT: Integrated Business Report

BRIEFING POINTS: This report provides summary information on the financial and activity performance of West Lancashire Clinical Commissioning Group for May 2015 and a financial position for June 2015. Quality and performance analysis is also provided for community based targets and for the Southport and Ormskirk Hospitals. Does this report / its recommendations have implications and impact with regard to the following: A. Commissioning Board’s Aims and Objectives 1. Quality (including patient safety, clinical effectiveness and patient Yes experience) – please outline impact

The report outlines quality and performance issues relevant to the CCG and describes key actions to address these. 2. Commissioning of hospital and community services – please outline Yes impact The report includes financial and activity information in relation to commissioned services and highlights areas of risk and actions. 3. Commissioning and performance management of GP Prescribing – No please outline impact 4. Delivering Financial Balance – please outline impact Yes The report summarises the financial position of the CCG and highlights areas of financial risk. 5. Development of the commissioning group as a commissioning Yes organisation – please outline impact This report will support the CCG in developing clear and credible plans.

B. Governance – please outline impact 1. Does this report: Yes • provide the Commissioning Board with assurance against any of the risks identified in the assurance framework • have any legal implications • promote effective governance practice Links to financial risks. 2. Additional resource implications No (either financial or staffing resources) 3. Health Inequalities Yes Links to health outcomes framework (all five domains) 4. Human Rights, Equality and Diversity Requirements No 5. Clinical Engagement No 6. Patient and Public Engagement No REPORT PREPARED BY: Paul Kingan, Chief finance officer

Integrated Business Report West Lancashire Clinical Commissioning Group Governing Body meeting – 28 July 2015

West Lancashire Clinical Commissioning Group

Integrated Business Report

July 2015

(Reporting Period May 2015)

1 | P a g e

TABLE OF CONTENTS

1 Executive Summary 3 2 Financial Position 4 3 QIPP 7 4 Planned Care: Referrals 8 5 Planned Care: e-Referrals Service 9 6 Planned Care: Acute Contract 10 7 Unplanned Care: Acute Contract 12 8 Prescribing 13 9 Lancashire Care Foundation Trust (LCFT) Activity 14

10 Quality and Performance a WL CCG Performance dashboard 18 b Southport & Ormskirk hospitals NHS Trust Urgent Care Performance Dashboard 22 c Southport & Ormskirk Hospitals NHS Trust Planned Care Performance Dashboard 23 d Southport & Ormskirk Hospitals NHS Trust Wide Performance Dashboard 24 e Areas of Under-Performance 25 f Patients Waiting by weeks 27 g CCG Outcomes Indicator Set 29 h AQC Update 30 i Friends and Family 31 J Safety Thermometer 32

11 Complaints A West Lancashire Complaints 33 B GP Issues with Southport & Ormskirk Hospitals Trust 34 c Southport and Ormskirk Compliments and Complaint 35

12 Serious and Untoward Incident reporting A New Incidents in August 35 B On-going investigations 35 C On-going investigations – Nursing & Care Homes 37

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1. Executive Summary Key information from this report

This report provides summary information on the activity NHS West Lancashire CCG performance of West Lancashire Clinical Commissioning As at June 2015 the CCG is forecasting a surplus of £1.463m, Group for May 2015 and a financial position for June 2015. in line with the 1% target (£1.441m) required by NHS Quality and performance analysis is also provided for England. community based targets and for Southport and Ormskirk Indicative performance to the end of May 2015 against the Hospitals NHS Trust. planned care element of all contracts is over plan by £289k.

CCG position highlights: The performance over the same period against the planned care element of the Southport and Ormskirk contract only is OVERALL POSITION Footprint over plan by £27k.

CCG CCG delivery of financial duties Indicative performance to the end of for May 2015 against CCG forecast CCG the unplanned care element of all contracts is under plan by DEMAND £104k.

GP referrals CCG Unplanned care performance for the same period against CCG Other referrals the Southport and Ormskirk Hospital contract is under plan PLANNED CARE by £177k. Total planned care PBR CCG UNPLANNED CARE

CCG Total unplanned care PBR Performance issues

PRESCRIBING Prescribing Budget CCG 62 day cancer performance decreased slightly in May to CCG key performance indicators YTD: 80.00%, YTD performance is still under target at 81.48%. This is mainly attributable to The Clatterbridge Cancer Centre NHS Foundation Trust who has only seen 5 out of 8 of our NHS Constitution indicators Footprint patients YTD. The Cancer 62 day’s consultant decision to RTT 18 Weeks wait (admitted) CCG upgrade their priority status is currently only 76.19% which is below the target. This is mainly due to small numbers A&E 4 hours CCG whereby there have been 5 breaches, 3 of which are Cancer Waits 62 days CCG attributable to S&O Ambulance Category A Calls CCG NWAS under achievement of category A call outs for West

Other key targets Lancashire continued however is on a upward trend as both Friends and Family CCG R1 <8 mins and R2 <8 mins performance improved. MRSA attributable to CCG CCG The annual trajectory for MRSA cases is zero and this failed C. difficile CCG in April at S&O Trust with 1 case, both the CCG and Public Cancer 14 day urgent target –breast CCG Health England have been informed.

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2. Financial Position The following table summarises the financial position for West Lancashire CCG at Month 3 2015/16.

Table 1 NHS West Lancashire CCG Financial Position as at Month 3 2015/16

Year to Date Full Year

Forecast Forecast Budget Expenditure Variance Budget Expenditure Variance

£000 £000 £000 £000 £000 £000

Acute services Acute Services 18,469 18,654 185 73,876 74,061 185 Ambulance services 738 738 - 2,951 2,951 - Sub-total Acute Services 19,207 19,392 185 76,828 77,013 185

Mental Health Services Mental Health 2,688 2,689 0 10,754 10,754 - Learning Difficulties 205 205 - 820 820 - Sub-total Mental Health Services 2,893 2,894 0 11,574 11,574 -

Community Health Services Community 3,516 3,516 (0) 14,063 14,063 - Sub-total Community Services 3,516 3,516 (0) 14,063 14,063 -

Continuing Care Services Individual Packages 2,390 2,390 0 8,855 8,855 - Funding Nursing Care 252 248 (4) 1,008 993 (15) Sub-total Continuing Care Services 2,642 2,638 (4) 9,863 9,847 (15)

Primary Care Services Primary - Local Enhanced Services 280 284 4 1,121 1,136 15 Urgent Care 759 759 - 3,035 3,035 - GP IT 112 112 (0) 449 449 - Prescribing 4,696 4,758 62 18,785 18,847 62 Sub-total Primary Care Services 5,847 5,913 66 23,389 23,466 77

Other Budgets/Reserves Running Costs 599 599 0 2,397 2,397 (0) NHS Property Services 264 264 - 1,055 1,055 - Other Corporate Costs 190 190 0 761 761 - Other Programme Services 158 158 - 632 632 - Seasonal Resilience ------Non Recurrent Schemes 290 290 - 1,160 1,160 - Contingency 247 - (247) 732 485 (247) Other Budgets/Reserves 398 398 - 2,552 2,552 - Sub-total Other Programme Services 2,146 1,899 (247) 9,289 9,042 (247)

Total - Commissioning services 36,251 36,251 (0) 145,005 145,005 (0)

Planned Surplus 366 - (366) 1,463 - (1,463) Grand Total 36,617 36,251 (366) 146,468 145,005 (1,463)

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As at Month 3 the CCG has a year to date underspend of £366k, which is forecast to increase to £1.463m by the end of the financial year. This is consistent with the delivery of a 1% surplus as required by NHS England.

Key points to note are:

Acute Services – Initial Month 2 activity monitoring information indicates significant overperformance in planned care, most notably at Aintree Hospitals NHS Trust where a £217k variance above plan has arisen in only two months. This additional activity is spread over a number of specialties with the largest being Breast Surgery (£36k) and Acute Medicine (£23k). Activity at Alder Hey NHS Trust (£84k), St Helens and Knowsley NHS Trust (£52k) and Wrightington, Wigan and Leigh NHS Trust (£22k) is also in excess of planned levels for April and May.

As data for only two months is available at this stage in the financial year, the forecast represents the year to date position and is not based on an extrapolation. Performance information will be closlely scrutinised in the coming months for evidence of developing trends that may have a material financial implication.

Prescribing – The performance of the Prescribing budget, and the delivery of planned QIPP savings of £808k, will be key to the CCG delivering its financial targets in 2015/16. Although a forecast for the 2015/16 financial year has not yet been produced by NHS Prescription Services, expenditure for April shows a 6.4% increase when compared to the same period last year. This is broadly consistent with the seven other Lancashire CCGs. Given that the budget has only been uplifted by a net 2%, this represents an area of concern. The £62k overspend has been included in the position but, as with Acute Services, this has not been extrapolated whilst additional iterations of the data are awaited.

Non Recurrent Schemes – The CCG is required to set aside 1% of its programme allocation for these. The largest element of this (£529k) is the CCG’s contribution to the national risk pool (and associated assessment costs) to settle continuing care retrospective cases relating to periods prior to the inception of the CCG. The remainder supports a number of transformational schemes.

Other Budgets/Reserves – Within this figure are resources set aside for items such as the allocation £5/head of population on a Practice footprint to fund initiatives within Primary Care and investment in Community Respiratory and Community IV schemes. These will be moved to operational budgets as and when required.

Contingency – The CCG is holding 0.5% of its allocation as a contingency (as per NHS England’s 2015/16 Business Rules). Given the year to date pressures on Acute Services and Prescribing, £247k of this contingency has already been deployed to deliver a balanced financial position as at Month 3.

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02G WEST LANCASHIRE CCG FOR GRAPH MONTH IN MONTH YTD TARGET NHS BPPC Stats 2015/16 APR 100.0 100.0 95.0 MAY 95.7 96.9 95.0 100.0 JUN 97.9 97.3 95.0 JUL 97.3 95.0 95.0 AUG 97.3 95.0 SEP 97.3 95.0 90.0 IN MONTH OCT 97.3 95.0 YTD NOV 97.3 95.0 85.0 The CCG’s annual budget at Month 3 is £146.793m. This is derived as follows: TARGET DEC 97.3 95.0 JAN 97.3 95.0 80.0 Table 2 FEB 97.3 95.0 % % Number of Invoices compliant MAR 97.3 95.0 75.0 APR MAY JUN JUL AUG SEP OCT NOV DEC JAN FEB MAR £'000 Opening Programme Allocation 139,385 Opening Running Cost Allocation 2,397 Return of 2014/15 Surplus 1,442 BCF 2015/16 2,442 GP IT Allocation 287 ETO/DTR Funding 444 GPIT - Transition FundingNon NHS BPPC Stats 2015/16 71 MONTH IN MONTH YTD TARGET Total resources100.0 ( as at Month 3) 146,468 APR 99.2 99.2 95.0 MAY 99.8 99.6 95.0 In addition to its duty on95.0 delivering a 1% surplus the CCG has other financial responsibilities: JUN 96.8 98.6 95.0 JUL 98.6 95.0 AUG 98.6 95.0 Better Payment Practice90.0 Code (BPPC) IN MONTH SEP 98.6 95.0 YTD The Better Payment Practice85.0 Code requires the CCG to aim to pay valid invoices by the due date or OCT 98.6 95.0 TARGET NOV 98.6 95.0 within 30 days of receipt of a valid invoice, whichever is later. The CCG’s target is for 95% of 80.0 DEC 98.6 95.0

invoices (both by value and volume) to be paid within this criteria. Table 3 shows the 2015/16 JAN 98.6 95.0 % % Number of Invoices compliant cumulative performance75.0 against these requirements: FEB 98.6 95.0 APR MAY JUN JUL AUG SEP OCT NOV DEC JAN FEB MAR MAR 98.6 95.0 Table 3 Cumulative On Target for Target Performance Year End to date Value 95% 99.98 NHS Volume 95% 97.31

Value 95% 98.89 Non-NHS Volume 95% 98.61

Cash Management

The CCG must not utilise more cash than it has available, both on a monthly and annual basis. It has to manage its cash flow accordingly whilst ensuring there are sufficient funds available to pay suppliers and meet the BPPC targets listed above.

Table 4

£000 Maximum Cash Drawdown 2015/16 144,763 YTD Cash Drawdown 29,950 CHC Risk Pool Contribution 235 YTD Oxygen and Prescribing 4,513

Cash Available for Remainder of Year 110,065

NHS England has issued the CCG with a Maximum Cash Drawdown (MCD) for 2015/16 of £144.763m.

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3. QIPP

Each year the CCG is faced with balancing the rising demand for hospital activity with a finite amount of financial resource. Therefore the CCG seeks to negotiate the best value for money it can achieve from its contracts, whilst also seeking to achieve Quality, Innovation, Productivity and Performance (QIPP) gains. These savings maybe either cash releasing or non-cash releasing but need to have a recurrent effect if the CCG is to see a sustainable financial benefit.

14 QIPP schemes have been identified for 2015/2016, although details of the expected savings, confidence levels and metrics are yet to be established in detail. Each of the schemes can be categorised into specific themes, which are shown in the table below together with the current indicative position regarding savings, confidence intervals and likely savings.

WL CCG 2015/2016 QIPP Scheme Summary Expected Confidence Likely Savings QIPP Theme Savings (£k) Interval (%) (£k) Improved pathway / patient experience 925 81% 748 Admissions avoidance 783 80% 626 Reduction in CCG/RMC running costs 252 75% 189 Prescribing 808 89% 717 Inappropriate referrals avoidance 103 67% 69 Other 140 100% 140

TOTALS 3,011 83% 2,489

The figures shown in the table above will continue to be refined and updated as further analysis of supporting data is carried out and the schemes are improved & developed over time. Consideration will also be given to the interdependencies between similar schemes in order that performance can be accurately monitored over the lifetime of the project.

The main schemes identified for 2015/2016 include:

. Reduction in NEL admissions / Acute Visiting Service (proposed savings of £783k) . Prescribing efficiencies (proposed savings £808k) . Review of high cost packages of care and redesigned commissioning processes (proposed savings £490k) . WLHP charging (proposed savings £150k)

Once the metrics for each scheme have been identified and agreed a QIPP ‘dashboard’ will be developed and included as part of future integrated business reports, providing further details of performance against all of the schemes identified in the current year.

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4. Planned Care: Referrals

The following section provides an overview of referrals to secondary care to May 2015.

Chart A (below) shows the numbers of referrals for the CCG across all Lancashire providers and Merseyside providers apart from Fairfield Hospital; this Trust has been omitted as we only started to receive data from July 2014 and therefore would be unable to compare to the previous year. Overall there has been an 11.9% increase in all sources of referrals YTD from the same period last year; GP referrals have increased 16.6%, this is an increase of 857 GP referrals.

Chart A: Referrals 2015/16 Compared to 2014/15 (Including Mersey Trusts)

Our main provider Southport & Ormskirk Trust has seen referrals grow by 10.2% in all sources (582 referrals); 409 of these referrals are attributable to GPs which is an increase of 11.2% compared to the same period last year. When analysing the data for this Trust caution must be taken as there are some data quality issues such as the implementation of a new Patient Administration System from October 2014 and also the use of speciality codes. For example when looking at specialty level data for GP referrals; General Medicine data has been split out from April 2015 onwards to Clinical Physiology as the average for 2014/15 for General Medicine was roughly 43 a month but for 2015/16 the average is 9, Clinical Physiology average has changed from 32 to 69 for the first two months. As previously mentioned this Trust has also had a new Patient Administration implemented in October 2014 which brought its own issues around coding as for this month only Physiotherapy referrals were coded under Allied Health Professional specialty code but reverted back to Physiotherapy specialty from November YTD. There are some speciality codes which have been used consistently which we can compare across both periods such as Dermatology which has seen 7.1% increase in GP referrals (35 referrals), ENT specialty which has seen a 9.9% increase in GP referrals (29) and Trauma & Orthopaedics which has increased by 31.8% (28).

Our Second main provider Wrightington, Wigan & Leigh NHS Foundation Trust has seen a 38.3% increase in GP referrals; Breast Surgery has increased by 77 referrals after the closure of Southport & Ormskirk Breast Services in September 2014 and there have been 21 extra GP referrals to Trauma & Orthopaedics when comparing April and May 2015 to the same period last year.

Due to the closure of Breast Services at Southport & Ormskirk there has been an increase in GP referrals to not only Wrightington as mentioned above but also to Aintree which has seen an increase in 82 GP

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Referrals comparing the same time period to last year and also 14 extra GP referrals to St Helens & Knowsley. 5. Planned Care: e-Referrals Service (previously Choose & Book)

Choose and Book was replaced by the e-Referral Service on Monday 15 June 2015. It was hoped that the new e-Referral Service (e-RS) would be a like for like replacement of its predecessor Choose and Book, with minor visual changes so that uses wouldn’t need training. Since e-RS went live there have been a number of issues affecting the use of the service with periods where the service has been unavailable in order that essential maintenance could be undertaken.

Because of the issues during the first month of the new e-RS the usual reports are not yet available, and when the information for June and July is available it is likely to be outside the expected range as both providers and referrers adapted contingency plans reverting to paper and faxing referrals in some instances.

As West Lancashire CCG practices moved away from the Referral Management Centre (RMC) who added referrals to Choose and Book on behalf of referrers, the number of referrals via Choose and Book declined. The Choose and Book Utilisation report shows the percentage of referrals via Choose and Book generally decreasing from September 2014 to January 2015 as practices started to send referrals directly to services rather than to the RMC. From the lowest percentage of 47.2% of referrals being submitted via Choose and Book in January 2015, 70% of referrals were being submitted during May 2015.

Work continues with practices to ensure all referrals possible are submitted via the new e-RS. Work also continues with local providers to ensure their services are available on the e-RS.

Below is current performance illustrating North West position utilising E-Referrals system for May 2015, which shows that all 22 West Lancashire CCG practices are using the CaB system.

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6. Planned Care: Acute Contract

All providers

Performance at month 2 against the planned care element of the contract is shown below in table 2a. This shows the planned care element of the contracts is over plan by £289k. The most significant variations are in Elective POD at Aintree University Hospitals with the following specialties over plan 103:Breast Surgery (£9.5K), 120:ENT (£10k) and 361:Nephrology (£10k).

Table 2a: Month 2 Planned Care – All Providers

Activity 2015/16 Cost 2015/16 Point of Delivery Plan Actual Variance Plan Actual Variance DC 2,448 2,595 147 £1,698,270 £1,749,261 £50,991 EL 407 422 15 £1,118,009 £1,229,965 £111,955 ELXBD 147 176 29 £32,721 £39,741 £7,020 OPFA 4,885 4,815 -70 £727,765 £715,198 -£12,568 OPFUP 10,647 11,690 1,043 £960,213 £1,039,756 £79,543 OPPROC 3,634 3,956 322 £639,828 £687,975 £48,148 OPNFTF 170 294 124 £4,730 £8,962 £4,232 Grand Total 22,340 23,948 1,608 £5,181,538 £5,470,858 £289,320

Southport and Ormskirk Hospitals NHS Trust

Performance to month 2 against the planned care element of the contract is shown below in table 2b. This shows the planned care element of the contract is over plan by £27k. The most significant variance appears to be in the OPPROC POD in 110:Trauma and Orthopaedics which is £41k over plan and Daycase POD in 502:Gynaecology which is £21k over plan.

Table 2b: Month 2 Planned Care at Southport and Ormskirk Hospitals

Activity 2015/16 Cost 2015/16 Point of Delivery Plan Actual Variance Plan Actual Variance DC 1,540 1,635 95 £901,309 £914,308 £12,999 EL 201 199 -2 £489,482 £482,668 -£6,814 ELXBD 37 2 -35 £8,058 £410 -£7,648 OPFA 2,680 2,422 -258 £409,564 £359,911 -£49,653 OPFUP 6,026 6,728 702 £562,886 £612,798 £49,912 OPPROC 2,594 2,780 186 £472,431 £498,554 £26,123 OPNFTF - 103 103 £0 £2,369 £2,369 Grand Total 13,078 13,869 791 £2,843,729 £2,871,018 £27,289

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All Other Providers

Performance to month 2 against the planned care element of the contract is shown below in table 2c. This shows the planned care element of the contract is over plan by £262k. This is largely down to the over performances already noted at Aintree University Hospitals. There is also an over-performance at Wrightington, Wigan and Leigh (£71k) and Alder Hey (£46k).

Table 2c: Month 2 Planned Care at All other Providers*

Activity 2015/16 Cost 2015/16 Provider Plan Actual Variance Plan Actual Variance Wrightington, Wigan & Leigh 2,797 2,962 165 £656,703 £727,801 £71,098 Ramsay Operations (UK) 1,562 1,562 0 £511,889 £511,889 £0 Aintree University Hospitals 1,410 1,861 451 £270,469 £372,522 £102,053 Lancashire Teaching Hospitals 485 507 22 £94,514 £113,260 £18,746 St Helens and Knowsley Hospitals 668 844 176 £154,031 £177,288 £23,257 Royal Liverpool and Broadgreen Hospitals 1,120 1,125 5 £246,783 £263,779 £16,996 Other Providers 1,219 1,218 -1 £403,420 £433,301 £29,881 Grand Total 9,262 10,079 817 £2,337,809 £2,599,840 £262,031

*Includes points-of-delivery as per Tables 2a and 2b

Key Risks and Actions

Overview

We are seeing a significant shift of activity to providers other than Southport & Ormskirk NHS Trust, particularly to Aintree, Wrightington, Wigan & Leigh, St Helens & Knowsley, Royal Liverpool & Broadgreen and Lancashire Teaching Hospitals. The CCG would have expected a reduction in financial activity at Southport & Ormskirk Hospitals Trust to offset this shift however, to date this cannot be seen. This will need more detailed analysis to understand what the underlying issues are.

Breast

Due to the closure of Breast Services at this Southport & Ormskirk NHS Trust from September 2014, activity for this specialty has shifted to Aintree, Wrightington, Wigan & Leigh Trust and St Helens & Knowsley Trust. The main elective over performance for Breast surgery at Aintree is in Outpatient First attends which is £14,646. St Helens & Knowsley is similar with the main over performance of Breast Surgery in outpatients First’s however there is also an over performance in Follow-up attends. Wrightington, Wigan & Leigh have a real over performance in Elective Inpatients for Breast Surgery also which is £19,340 above plan. Southport & Ormskirk NHS Trust are still currently seeing Follow-up patients for this specialty although numbers have reduced to 40 attendances by month 2.

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All Providers

Performance for month 2 against the unplanned care element of the contract is shown below in table 3a. Overall the unplanned care element of the contract is under plan by £104K. This is caused by significant under performances in NEL POD which is £115k under plan.

Table 3a: Month 2 Unplanned Care at All Providers

Activity 2015/16 Cost 2015/16 Provider Plan Actual Variance Plan Actual Variance Accident and Emergency 5,204 5,383 179 £566,674 £617,167 £50,493 Non-Elective Short Stay 234 206 -29 £165,177 £147,092 -£18,086 Non-Elective 1,564 1,515 -49 £2,726,469 £2,611,435 -£115,033 Non-Elective Excess Beddays 669 799 130 £141,027 £175,535 £34,508 Non-Elective Non-Emergency 230 347 117 £391,129 £383,876 -£7,253 Non-Elective Non-Emergency Excess Beddays 79 82 3 £21,230 £17,289 -£3,941 Non-Elective Same Day Emergency Care 154 107 -47 £125,504 £85,734 -£39,770 Non-Elective Threshold Adjustment - - - -£1,847 -£6,767 -£4,920 Grand Total 8,133 8,439 306 £4,135,363 £4,031,361 -£104,001

Southport and Ormskirk Hospitals NHS Trust

Performance for month 2 against the unplanned care element of the contract is shown below in table 3b. Overall the unplanned care element of the contract is under plan by £178k. This is largely due to an under-performance in NEL 300: General Medicine which is £210k under plan and NEL 100: Gen Surgery which is £47k under plan.

Table 3b: Month 2 Unplanned Care at Southport and Ormskirk Hospitals

Activity 2015/16 Cost 2015/16 Provider Plan Actual Variance Plan Actual Variance Accident and Emergency 4,089 4,223 134 £449,613 £488,997 £39,383 Non-Elective Short Stay 174 141 -33 £125,112 £104,031 -£21,081 Non-Elective 1,260 1,180 -80 £2,144,641 £1,952,035 -£192,606 Non-Elective Excess Beddays 571 672 101 £119,639 £142,668 £23,029 Non-Elective Non-Emergency 205 322 117 £330,552 £340,116 £9,564 Non-Elective Non-Emergency Excess Beddays 36 44 8 £12,132 £9,407 -£2,724 Non-Elective Same Day Emergency Care 125 85 -40 £101,869 £68,784 -£33,085 Grand Total 6,460 6,667 207 £3,283,558 £3,106,038 -£177,519

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Performance for month 2 against the unplanned care element of the contract is shown below in table 3c. Overall the unplanned care element of the contract is over plan by £74k. The most significant variations are general over-performance at Aintree University Hospitals which is £81k Over plan.

Table 3c: Month 2 Unplanned Care at All Other Providers*

Activity 2015/16 Cost 2015/16 Provider Plan Actual Variance Plan Actual Variance Wrightington, Wigan & Leigh 753 716 - 37 £362,329 £338,417 -£23,912 Aintree University Hospitals 246 330 84 £144,158 £224,792 £80,634 Lancashire Teaching Hospitals 197 180 - 17 £83,466 £77,378 -£6,088 Royal Liverpool and Broadgreen Hospitals 134 140 6 £59,742 £60,857 £1,115 St Helen's & Knowsley Hospitals NHS Trust 98 80 - 18 £46,816 £52,594 £5,778 Other Providers 245 326 81 £155,295 £171,285 £15,991 Grand Total 1,674 1,772 98 £851,805 £925,323 £73,518

*Includes points-of-delivery as per Tables 3a and 3b

Key Risks and Actions

Unplanned care is currently under performing financially against plan; however activity is over plan. There is some evidence to show that the financial shift from Southport & Ormskirk Hospitals Trust is being offset by increases at other providers.

Southport & Ormskirk Trust A&E attendances are in line with those in May 2014 however admissions are higher in May than in the same period over the last two years. The financial under-performance in Non Elective POD can be attributed to the General Medicine specialty which is £209k under plan.

8. Prescribing

In order to address the West Lancashire CCG Medicines Management duties as defined by the National Prescribing Centre’s Medicines Management Competency Framework, West Lancashire CCG has set up a Medicines Management Committee (MMC). The MMC’s remit encompasses all systems, policies and procedures designed to ensure the safe, secure and cost-effective use of medicines.

Due to lack of forecast outturn and budget data available from ePact at the beginning of the financial year, the summary below has been created to show the cost growth and list size growth for April 2015 v April 2014. West Lancashire CCG is currently showing cost growth of 6.44% for this period.

Prescribing position April 2015 Total Spend for Previous Previous YTD Current YTD Spend Cost Growth % Cost Growth % List Size Growth Current YTD Spend CCG Year (14/15) Spend (14/15) (15/16) (Apr 15 - Apr 14) Apr 15 - Apr 14 (APU Apr15 v Apr14) per APU (15/16) WEST LANCASHIRE £17,787,900 £1,397,224 £1,487,243.16 £90,019 6.44% 0.95% £3.49

* Due to lack of forecast outturn and budget data available from ePact at the beginning of the financial year this summary has been created to show the cost growth and list size growth for April 2015 v April 2014.

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9. Lancashire Care Foundation Trust Contract Activity

The contract value for Lancashire Care Foundation Trust (LCFT) mental health services is £9.7m. A brief summary of monthly and year-to-date activity will be reported through the IBR each month. The LCFT contract is for a range of mental health services such as rehabilitation, community mental health teams, hospital liaison, memory assessment, CAMHS and child psychology and prison in-reach. Below is activity for 2015-16 compared with the previous year.

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Metric Year Activity Activity Activity Activity Activity Activity Activity Activity Activity Activity Activity Activity YTD Caseload CCTT Teams - Accepted Referrals 2014/15 27 23 24 36 23 24 24 25 16 25 28 22 297 CCTT Teams - Accepted Referrals 2015/16 26 27 ------53 Community Restart Teams - Accepted Referrals 2014/15 2 1 3 1 3 - - 1 - 1 - - 12 Community Restart Teams - Accepted Referrals 2015/16 ------CRHT Teams - Referrals 2014/15 45 39 23 49 38 46 46 44 36 53 52 39 510 CRHT Teams - Referrals 2015/16 42 50 ------92 Eating Disorder Service - Referrals 2014/15 3 7 1 5 3 3 5 3 2 3 3 5 43 Eating Disorder Service - Referrals 2015/16 8 7 ------15 MAS Teams - Referrals 2014/15 37 31 30 34 39 38 33 35 41 45 46 45 454 MAS Teams - Referrals 2015/16 1 ------1 IST Referrals - Older Adult (Dementia) 2014/15 5 6 3 3 - 2 - 2 - - - - 21 IST Referrals - Older Adult (Dementia) 2015/16 1 2 ------3 IST Referrals - Older Adult (Functional) 2014/15 6 5 2 7 3 3 2 3 4 1 1 2 39 IST Referrals - Older Adult (Functional) 2015/16 1 2 ------3 Older Adult Liaison Teams - Referrals 2014/15 4 ------1 - - - - 5 Older Adult Liaison Teams - Referrals 2015/16 ------Contacts CMHT Dementia - Contacts 2014/15 144 149 175 193 147 158 173 171 180 178 147 174 1,989 CMHT Dementia - Contacts 2015/16 224 117 ------341 CMHT Functional - Contacts 2014/15 227 183 200 253 205 227 225 203 212 188 155 156 2,434 CMHT Functional - Contacts 2015/16 160 98 ------258 CRHT Face to Face Contacts - 18 to 65 2014/15 144 237 216 222 281 271 241 184 149 223 166 180 2,514 CRHT Face to Face Contacts - 18 to 65 2015/16 240 190 ------430 CRHT Face to Face Contacts - Below 18 2014/15 15 22 10 19 12 1 9 22 15 31 32 27 215 CRHT Face to Face Contacts - Below 18 2015/16 22 14 ------36 CRHT Face to Face Contacts - Over 65 2014/15 5 6 2 3 4 - - - 5 26 19 9 79 CRHT Face to Face Contacts - Over 65 2015/16 ------CRHT Telephone Contacts - 18 to 65 2014/15 10 24 26 32 32 20 23 14 11 15 14 18 239 CRHT Telephone Contacts - 18 to 65 2015/16 36 19 ------55 CRHT Telephone Contacts - Below 18 2014/15 1 2 2 - 1 - - - - - 1 1 8 CRHT Telephone Contacts - Below 18 2015/16 ------CRHT Telephone Contacts - Over 65 2014/15 - - - - - 1 - - 1 1 1 2 6 CRHT Telephone Contacts - Over 65 2015/16 - 1 ------1 Eating Disorder Service - Contacts 2014/15 19 8 22 16 11 14 7 13 6 20 19 24 179 Eating Disorder Service - Contacts 2015/16 20 24 ------44 Older Adult Liaison - Contacts 2014/15 73 35 31 56 39 7 2 4 5 9 6 2 269 Older Adult Liaison - Contacts 2015/16 2 ------2 Criminal Justice Liaison - Contacts 2014/15 17 7 7 15 8 13 8 11 11 4 - 2 103 Criminal Justice Liaison - Contacts 2015/16 ------EIS EIS: New EIS Patients in Year - VSMR 5378 2014/15 ------1 - 1 EIS: New EIS Patients in Year - VSMR 5378 2015/16 1 1 ------2 Inpatient Adult/PICU Ward Admissions 2014/15 13 10 9 17 13 11 14 12 8 17 17 6 147 Adult/PICU Ward Admissions 2015/16 9 11 ------20 Adult Inpatient 28 Day ReAdmissions 2014/15 - 2 - - 1 2 1 5 - 1 1 1 14 Adult Inpatient 28 Day ReAdmissions 2015/16 2 ------2 Adult Inpatient 90 Day ReAdmissions 2014/15 1 3 - - 3 2 4 6 - 6 1 2 28 Adult Inpatient 90 Day ReAdmissions 2015/16 2 ------2 Adult Ward Occupied Bed Days 2014/15 436 413 374 320 371 232 190 276 224 327 367 255 3,785 Adult Ward Occupied Bed Days 2015/16 331 329 ------660 Older Adult (Functional) Inpatient Ward Admissions 2014/15 - 3 1 - 1 1 - - - 1 2 1 10 Older Adult (Functional) Inpatient Ward Admissions 2015/16 1 ------1 Older Adult (Functional) Ward Occupied Bed Days 2014/15 134 154 159 64 82 79 62 60 31 29 21 66 941 Older Adult (Functional) Ward Occupied Bed Days 2015/16 168 129 ------297 Older Adult (Dementia) Inpatient Ward Admissions 2014/15 - - - - - 1 - - 1 1 - 1 4 Older Adult (Dementia) Inpatient Ward Admissions 2015/16 2 ------2 Older Adult (Dementia) Ward Occupied Bed Days 2014/15 - - - - - 5 31 30 40 46 28 25 205 Older Adult (Dementia) Ward Occupied Bed Days 2015/16 67 62 ------129 PICU Ward Occupied Bed Days 2014/15 29 24 5 5 24 25 27 12 3 21 14 25 214 PICU Ward Occupied Bed Days 2015/16 84 22 ------106

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9a CPA follow up within 7 days

The proportion of eligible patients who are followed up within 7 days is one of the performance measures on which the CCG will be monitored by the Local Area Team. The Table below shows current West Lancashire performance which is better than the LCFT average.

% Successful Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 West Lancashire CCG 66.7% 100.0% 8 CCGs 94.9% 96.0%

% Successful Q1 Q2 Q3 Q4 15-16 West Lancashire CCG 90.0% 90.0% 8 CCGs 95.5% 95.5%

As you can see above we only have two months’ worth of data and we are currently below the quarterly target. The reason for the low performance in April is due to the small number of patients; in April there were only 3 patients who required a 7 Day follow up and unfortunately one patient missed the target as they were transferred to a private PICU and follow-up with ward only given patient's clinical presentation.

9b IAPT Waiting Lists

Below is the waiting list over the last 13 months for people who have already received their welcome call but are actually waiting for a regular treatment slot with a PWP, CBT therapist or Counsellor up to May 2015. These patients represent the true patient experience, a short wait for a welcome call, followed by a long wait into actual treatment

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WEST LANCASHIRE WAITING LISTS AND WAITING TIMES Sourced from IAPT performance reports Times into treatment (post welcome call) for West Lancashire Psychological Numbers Wellbeing into Practitioners 0<4 weeks 4<7weeks 7<11 weeks 11<17weeks 17<26weeks 26+ weeks Profile treatment May-14 126 62 14 8 210 Jun-14 121 24 4 1 150 Jul-14 169 35 1 205 Aug-14 140 40 3 183 Sep-14 162 47 12 221 Oct-14 173 57 14 244 Nov-14 149 23 4 176 Dec-14 139 49 9 1 198 Jan-15 203 38 25 3 1 270 Feb-15 181 60 41 12 1 295 Mar-15 207 61 61 11 4 344 Apr-15 189 90 50 14 343 May-15 156 51 50 26 1 284

Cognitive Numbers Behavioural into Therapists 0<4 weeks 4<7weeks 7<11 weeks 11<17weeks 17<26weeks 26+ weeks Profile treatment May-14 27 41 28 96 Jun-14 23 20 40 8 91 Jul-14 40 32 32 33 137 Aug-14 36 23 46 40 4 149 Sep-14 20 30 29 59 14 152 Oct-14 15 18 28 46 17 124 Nov-14 7 9 23 18 18 75 Dec-14 11 11 27 17 2 68 Jan-15 11 4 6 19 22 62 Feb-15 10 3 7 8 18 1 47 Mar-15 9 4 8 6 6 2 35 Apr-15 17 9 11 11 1 49 May-15 32 13 4 9 58

Numbers into Counsellors 0<4 weeks 4<7weeks 7<11 weeks 11<17weeks 17<26weeks 26+ weeks Profile treatment May-14 17 16 21 3 2 59 Jun-14 17 8 16 6 47 Jul-14 29 12 5 4 50 Aug-14 30 17 11 1 1 60 Sep-14 30 28 4 1 63 Oct-14 25 19 20 1 65 Nov-14 25 14 27 12 78 Dec-15 11 19 24 21 75 Jan-15 18 11 24 25 5 83 Feb-15 22 15 14 32 3 86 Mar-15 16 15 9 8 13 61 Apr-15 18 15 16 20 9 78 May-15 6 14 17 22 6 65

There are a number of issues which have been identified which can explain the current waiting list issues such as; MindsMatter currently share a phone line with the Single Point of Access for Mental Health which has made contacting clients difficult – resulting in treatment slots going to the person they can contact, rather than the person who has waited longest. The original

16 | P a g e administrative team also struggled with the logistics of separation of the SPA from IAPT. Several members of the team have left the service as a result. New administrative staff will come into post over the autumn and the service hopes to make a fresh start with a training programme designed to consistently deliver waiting times that are broadly in turn. There are also issues around clinical capacity and also around sourcing venues for patients to be seen. LCFT and the CCG are currently looking at potentially adding the ‘Welcome Call’ appointment onto the E- Referrals system so that it can release capacity on the administrative process and all them to concentrate on getting the patients into service.

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10. Quality and Performance

9a West Lancashire CCG Performance Dashboard

Re porting 2015-16 Me tric Q1 Q2 Q3 Q4 YTD Le ve l A pr M ay Jun Jul A ug Sep Oct Nov D ec Jan F eb M ar Preventing People from Dying Prematurely

Cancer Waiting Times

% Patients seen within two weeks for an urgent GP referral for RAG G G G West Lancashire suspected cancer Actual 95.41% 95.15% 95.28% CCG Target 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% % of patients seen within 2 weeks for an urgent referral for breast symptoms RAG G G G West Lancashire CCG Actual 97.06% 94.87% 95.89% Target 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% % of patients receiving definitive treatment within 1 month of a RAG G A G West Lancashire cancer diagnosis Actual 98.41% 95.52% 96.92% CCG Target 96.00% 96.00% 96.00% 96.00% 96.00% 96.00% 96.00% 96.00% 96.00% 96.00% 96.00% 96.00% 96.00% % of patients receiving subsequent treatment for cancer within 31 RAG G G G West Lancashire days (Surgery) Actual 100.00% 100.00% 100.00% CCG Target 94.00% 94.00% 94.00% 94.00% 94.00% 94.00% 94.00% 94.00% 94.00% 94.00% 94.00% 94.00% 94.00% % of patients receiving subsequent treatment for cancer within 31 RAG G G G West Lancashire days (Drug Treatments) Actual 100.00% 100.00% 100.00% CCG Target 98.00% 98.00% 98.00% 98.00% 98.00% 98.00% 98.00% 98.00% 98.00% 98.00% 98.00% 98.00% 98.00% % of patients receiving subsequent treatment for cancer within 31 RAG G G G West Lancashire days (Radiotherapy Treatments) Actual 100.00% 100.00% 100.00% CCG Target 94.00% 94.00% 94.00% 94.00% 94.00% 94.00% 94.00% 94.00% 94.00% 94.00% 94.00% 94.00% 94.00% % of patients receiving 1st definitive treatment for cancer within 2 RAG A A A West Lancashire months (62 days) Actual 83.33% 80.00% 81.48% CCG Target 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% % of patients receiving treatment for cancer within 62 days from an RAG G G G West Lancashire NHS Cancer Screening Service Actual 100.00% 100.00% 100.00% CCG Target 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% % of patients receiving treatment for cancer within 62 days upgrade RAG G R A West Lancashire their priority Actual 100.00% 76.19% 84.85% CCG Target 86.00% 86.00% 86.00% 86.00% 86.00% 86.00% 86.00% 86.00% 86.00% 86.00% 86.00% 86.00% 86.00% 18 | P a g e

2015-16 Re porting Me tric Q1 Q2 Q3 Q4 YTD Le ve l A pr M ay Jun Jul A ug Sep Oct Nov D ec Jan F eb M ar

Ambulance

Category A calls responded to within 19 minutes RAG R A R West Lancashire Category A calls responded to within 19 minutes Actual 85.32% 92.40% 88.93% CCG Target 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00%

NORTH WEST RAG A G A AMBULANCE SERVICE NHS TRUST Actual 93.28% 96.38% 94.86% Target 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% Category A (Red 2) 8 Minute Response Time RAG R R R West Lancashire Number of Category A (Red 2) calls resulting in an emergency Actual 57.30% 68.70% 63.08% response arriving at the scene of the incident within 8 CCG Target 75.00% 75.00% 75.00% 75.00% 75.00% 75.00% 75.00% 75.00% 75.00% 75.00% 75.00% 75.00% 75.00% minutes

NORTH WEST RAG A G G AMBULANCE SERVICE NHS TRUST Actual 72.12% 79.43% 75.84% Target 75.00% 75.00% 75.00% 75.00% 75.00% 75.00% 75.00% 75.00% 75.00% 75.00% 75.00% 75.00% 75.00%

Category A Calls Response Time (Red1) NORTH WEST RAG A G G Number of Category A (Red 1) calls resulting in an emergency AMBULANCE Actual 71.22% 81.55% 76.46% response arriving at the scene of the incident within 8 SERVICE NHS TRUST Target 75.00% 75.00% 75.00% 75.00% 75.00% 75.00% 75.00% 75.00% 75.00% 75.00% 75.00% 75.00% 75.00% minutes RAG R A R West Lancashire CCG Actual 45.45% 70.80% 58.68% Target 75.00% 75.00% 75.00% 75.00% 75.00% 75.00% 75.00% 75.00% 75.00% 75.00% 75.00% 75.00% 75.00%

Helping People to Recover from Episodes of Ill Health or Follow ing Injury

Emergency Re-admissions

Emergency Re-admissions within 30 days of discharge RAG G G G West Lancashire Actual 8.89% 9.10% 8.99% CCG Target 10.90% 10.90% 10.90% 10.90% 10.90% 10.90% 10.90% 10.90% 10.90% 10.90% 10.90% 10.90% 10.90%

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2015-16 Re porting Me tric Q1 Q2 Q3 Q4 YTD Le ve l A pr M ay Jun Jul A ug Sep Oct Nov D ec Jan F eb M ar

Referral to Treatment (RTT) & Diagnostics

Referral to Treatment RTT (Adjusted Admitted) RAG A G A West Lancashire Actual 87.40% 90.61% 89.04% CCG Target 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% Referral to Treatment RTT (Non-Admitted) RAG A G G West Lancashire Actual 94.63% 95.62% 95.11% CCG Target 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% Referral to Treatment RTT (Incomplete) RAG G G G West Lancashire CCG Actual 95.32% 95.20% 95.26% Target 92.00% 92.00% 92.00% 92.00% 92.00% 92.00% 92.00% 92.00% 92.00% 92.00% 92.00% 92.00% 92.00% Referral to Treatment RTT - No of Incomplete Pathways Waiting RAG G G G West Lancashire >52 weeks Actual 0 0 0 CCG Target 0 0 0 0 0 0 0 0 0 0 0 0 0 % of patients waiting 6 weeks or more for a diagnosic test RAG G G G West Lancashire CCG Actual 0.46% 0.29% 0.38% Target 1.00% 1.00% 1.00% 1.00% 1.00% 1.00% 1.00% 1.00% 1.00% 1.00% 1.00% 1.00% 1.00%

Treating and Caring for People in a Safe Environment and Protect them from Avoidable Harm

HCAI

Number of MRSA Bacteraemias RAG R G R West Lancashire Incidence of MRSA bacteraemia (Commissioner) YTD 1 - 1 CCG Target 0 0 0 0 0 0 0 0 0 0 0 0 0 Number of C.Difficile infections RAG G G G West Lancashire Incidence of Clostridium Difficile (Commissioner) YTD 3 7 7 CCG Target 3 7 11 14 18 22 26 30 34 38 42 46 7

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2015-16 Re porting Me tric Q1 Q2 Q3 Q4 YTD Le ve l A pr M ay Jun Jul A ug Sep Oct Nov D ec Jan F eb M ar

Accident & Emergency

4-Hour A&E Waiting Time Target (Monthly Aggregate for Total WRIGHTINGTON, RAG G G G WIGAN AND LEIGH Provider) Actual 97.54% 98.47% 97.95% NHS FOUNDATION TRUST Target 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00%

LANCASHIRE RAG A G G TEACHING HOSPITALS NHS Actual 94.07% 97.18% 95.44% FOUNDATION TRUST Target 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% SOUTHPORT AND RAG A A A ORMSKIRK Actual 92.69% 93.96% 93.26% HOSPITAL NHS TRUST Target 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 12 Hour Trolley waits in A&E SOUTHPORT AND RAG G G G ORMSKIRK Actual 0 0 0 HOSPITAL NHS TRUST Target 0 0 0 0 0 0 0 0 0 0 0 0 0

WRIGHTINGTON, RAG G G G WIGAN AND LEIGH NHS FOUNDATION Actual 0 0 0 TRUST Target 0 0 0 0 0 0 0 0 0 0 0 0 0 LANCASHIRE RAG G G G TEACHING Actual 0 0 0 HOSPITALS NHS FOUNDATION TRUST Target 0 0 0 0 0 0 0 0 0 0 0 0 0

Activity

Activity

1934: GP Written Referrals RAG R G R West Lancashire GP written referrals for a first outpatient appointment in G&A YTD 2,565 4,903 4,903 specialties CCG Target 2,176 4,544 6,855 9,316 11,350 13,720 16,264 18,650 20,980 23,526 26,170 28,208 4,544 69: Other Referrals for First Outpatient Appointments Number of other referrals for a first outpatient appointment RAG R R R West Lancashire in G&A specialties CCG YTD 1,246 2,517 2,517 Target 1,003 2,000 3,003 4,147 5,208 6,309 7,444 8,555 9,580 10,717 11,803 12,866 2,000 1936: Total Referrals (MAR) RAG R R R West Lancashire Total number of referrals (GP written referrals made & other YTD 3,811 7,420 7,420 referrals - MAR) CCG Target 3,178 6,544 9,858 13,463 16,558 20,029 23,708 27,204 30,560 34,243 37,974 41,074 6,544 21 | P a g e

10b Southport & Ormskirk Hospitals NHS Trust Urgent Care Performance Dashboard

Target Subject Indicator Description Data May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 2015-16

Urgent care HQU12: Timeliness: Time to Target 15 15 15 15 15 15 15 15 15 15 15 15 15 initial assessment - 95th Month Actual 3 4 4 2 1 3 3 11 10 11 12 11 10 15 centile (arrival by ambulance) Month RAG G G G G G G G G G G G G G HQU13:Timeliness: Time to Target 60 60 60 60 60 60 60 60 60 60 60 60 60 treatment in department – Month Actual 42 48 45 39 43 44 44 50 43 42 53 46 45 60 median Month RAG G G G G G G G G G G G G G HQU10: Timeliness: total time Target 240 240 240 240 240 240 240 240 240 240 240 240 240 spent in A&E department - Month Actual 237 238 237 238 239 238 239 373 258 295 329 345 283 240 Accident and 95th centile – Month RAG G G G G G G G R R R R R R emergency Target YTD 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% targets Timeliness: A&E 4 Hour Target YTD Actual 97.43% 97.63% 97.87% 97.38% 96.95% 93.33% 94.23% 89.22% 86.66% 94.10% 92.60% 92.66% 93.94% 95.0% YTD RAG G G G G G A A A A A A A A HQU11: Patient Impact: Left Month Actual 1.5% 1.8% 2.0% 1.9% 1.7% 2.6% 2.4% 3.2% 2.3% 1.8% 2.5% 2.8% 1.9% department without being Target YTD 5.0% 5.0% 5.0% 5.0% 5.0% 5.0% 5.0% 5.0% 5.0% 5.0% 5.0% 5.0% 5.0% 5.0% seen rate YTD RAG G G G G G G G G G G G G G HQU09: Patient Impact: Target 5.0% 5.0% 5.0% 5.0% 5.0% 5.0% 5.0% 5.0% 5.0% 5.0% 5.0% 5.0% 5.0% unplanned re-attendance at Month Actual 1.7% 1.8% 1.8% 1.6% 1.8% 1.1% 0.5% 0.8% 0.7% 0.6% 1.1% 0.8% 0.9% 5.0% A&E within 7 days of original Month RAG G G G G G G G G G G G G G attendance SQU06: % stroke patients Target 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% spending 90%+ time on a Month Actual 86.2% 94.3% 79.3% 57.7% 68.3% 72.4% 72.7% 77.3% 84.0% 62.1% 75.0% 88.2% 70.6% 80% stroke unit Stroke Month RAG G G A R R R R A G R A G R SQU06: % TIA (mini stroke) Target 60% 60% 60% 60% 60% 60% 60% 60% 60% 60% 60% 60% 60% patients assessed and treated Month Actual 64.3% 42.9% 83.3% 47.1% 50.0% 42.9% 50.0% 45.5% 72.7% 40.0% 84.6% 72.7% 33.3% 60.0% <> 24 hrs Month RAG G R G R R R R R G R G G R Target YTD 0 0 0 0 0 0 0 0 0 0 0 0 0 PHQ26: Mixed Sex Month Actual EMSA Accommodation - Numbers of 0 0 6 0 0 0 0 0 0 0 0 0 0 0 unjustified breaches YTD Actual 24 24 30 30 30 30 30 30 30 30 30 0 0 YTD RAG R R R R R R R R R R R G G Month Actual 0 0 1 0 1 0 0 0 0 0 0 1 0 PHQ27: Number of MRSA Target YTD 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Bacteraemias YTD Actual 0 0 1 1 2 2 2 2 2 2 2 1 1 HCAI YTD RAG G G R R R R R R R R R R R Target YTD 5 7 9 12 14 16 18 20 22 24 27 2 4 PHQ28: Number of C. Difficile YTD Actual 6 10 13 18 21 24 26 29 30 31 35 6 9 27 infections YTD RAG R R R R R R R R R R R R R

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10c Southport & Ormskirk Hospitals NHS Trust Planned Care Performance Dashboard

Target Subject Indicator Description Data May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 2015-16

Planned care Target 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% PHQ19:RTT - Admitted Target Month Actual 94.7% 93.0% 91.5% 90.1% 92.6% 90.1% 87.0% 86.8% 82.4% 81.2% 80.4% 79.7% 83.1% 90.0% Month RAG G G G G G G R A R R R R R Target 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% PHQ20: RTT - Non Admitted RTT - 18 weeks Month Actual 98.1% 98.5% 98.5% 98.3% 98.3% 97.3% 95.3% 95.4% 93.6% 94.1% 93.9% 93.0% 94.1% 95.0% Target Month RAG G G G G G G G G A A A A A Target 92.0% 92.0% 92.0% 92.0% 92.0% 92.0% 92.0% 92.0% 92.0% 92.0% 92.0% 92.0% 92.0% PHQ21: RTT - 92.0% IncompleteTarget Month Actual 97.9% 98.1% 97.9% 97.5% 96.9% 96.1% 95.5% 94.4% 94.1% 95.1% 93.0% 93.6% 93.3% Month RAG G G G G G G G G G G G G G Target 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% PHQ24: 2 weeks (urgent GP Month Actual 98.2% 96.9% 95.6% 95.5% 95.3% 94.3% 95.5% 96.5% 96.3% 94.4% 93.6% 92.5% NA 93.0% referral) Month RAG G G G G G G G G G G G A Target 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% PHQ24: 2 weeks (urgent Month Actual 97.3% 93.2% 98.0% 96.4% 75.0% 100.0% NA NA NA NA NA NA NA 93.0% referral breast symptoms) Month RAG G G G G R G Target 96.0% 96.0% 96.0% 96.0% 96.0% 96.0% 96.0% 96.0% 96.0% 96.0% 96.0% 96.0% PHQ06: 1 month (definitive Month Actual 100.0% 100.0% 100.0% 100.0% 97.5% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 98.5% NA 96.0% treatment of cancer diagnosis) Month RAG G G G G G G G G G G G G Target 94.0% 94.0% 94.0% 94.0% 94.0% 94.0% 94.0% 94.0% 94.0% 94.0% 94.0% 94.0% Cancer waiting PHQ06: 1 month (subsequent Month Actual 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% NA 94.0% times surgery for cancer) Month RAG G G G G G G G G G G G G Target 98.0% 98.0% 98.0% 98.0% 98.0% 98.0% 98.0% 98.0% 98.0% 98.0% 98.0% PHQ06: 1 month (subsequent Month Actual 100.0% 100.0% 100.0% 100.0% 100.0% NA 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% NA 98.0% anti-cancer drug regime) Month RAG G G G G G G G G G G G PHQ03: 62 days (first definitive Target 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% treatment from urgent GP Month Actual 83.2% 82.8% 87.5% 80.3% 87.7% 81.8% 91.0% 82.0% 93.1% 91.5% 87.0% 83.5% NA 85.0% referral) Month RAG A A G A G A G A A G G A PHQ03: 62 days (first definitive Target 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% treatment from Cancer Month Actual NA 100.0% 0.0% NA 100.0% 80.0% 75.0% NA 0.0% 50.0% 100.0% NA NA 90.0% Screening Service) Month RAG G R G A R R R G

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10d Southport & Ormskirk Hospitals NHS Trust Trust Wide Performance Dashboard

Target Subject Indicator Description Data May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 2015-16

Trust wide Community acquired Target N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A pressure sores grade 2-4 Month Actual 6 11 14 15 6 17 15 12 22 13 16 44 36 Pressure sores Target 2.3 2.3 2.3 2.3 2.3 2.3 2.3 2.3 2.3 2.3 2.3 2.3 2.3 2.3 hospital acquired pressures Month Actual 3 4 1 0 1 1 5 6 8 4 2 4 6 sores grade 2-4 Month RAG G R G G G G R R R R G R R Target 100 100 100 100 100 100 100 100 100 100 HSMR YTD - Trust Month Actual 107.2 107.8 104.8 104.5 103.8 101 98.8 100.9 105.8 NA NA NA NA Month RAG R R A A A A G A R Mortality Target 100 100 100 100 100 100 100 100 100 100 HSMR monthly - Trust Month Actual 94.7 121.5 71.8 98.2 98.3 79.9 90.0 90.0 101.4 NA NA NA NA Month RAG G R G G G G G G R Target 98% 98% 98% 98% 98% 98% 98% 98% 98% 98% 98% Rapid Access Chest pain Month Actual 100 100 100 100 100 100 100 100 100 100 NA NA NA seen within 2 weeks Month RAG G G G G G G G G G G Target TBA TBA TBA TBA TBA Staff sickness Absence Month Actual 4.02% 3.88 4.1% NA 4.2 NA NA 5.1 NA NA NA NA NA TBA Month RAG G G G G G

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10e Areas of under- performance

A number of areas of underperformance are reported to end of May 2015; the detail below is presented by indicator for each of these areas with actions identified as required and on-going, seeking to improve performance.

‘Direction of travel’ of performance against indicator from previous reporting period is provided to demonstrate if performance is deteriorating.

Indicator: 62 days receiving treatment and upgrade to priority status – CCG

Target: Current Performance Direction of travel Forecast 86% 76%

Current Issues: For the priority upgrade after a consultant’s decision indicator there were 5 patients who breached in May, 3 of which occurred at Southport & Ormskirk Trust, 1 patient at Aintree and 1 patient at Lancashire Teaching Hospital.

Improvement Plans: A Situational Breach Analysis Report (SBAR) is executed each month for all breaches at Southport & Ormskirk, the main themes are around an administrative error by another provider who incorrectly uploaded a paused patient as a breach, this will be corrected for the quarter upload but has been reported nationally in month and there were also patients who would have been treated compliantly but were unfit for treatment. Discussions have begun with a local provider regarding improvements to pathways and a revised SLA is to be developed and signed between the Trusts. There is also approval at S&O for a head and neck Clinical Nurse Specialist post to support co-ordination both internally and across external providers involved in pathways.

Indicator: Ambulance category call outs – CCG

Target: Current Performance 69% Direction of travel Forecast 75% (red 2)

Current Issues: The Performance of Category A Red 2 callouts has increased this month which is in line with the trend as North West Ambulance Service figures increased from the previous month on the whole. All CCGs improved their performance when comparing from the previous month however there are still 3 CCGs under the monthly target with our CCG being one of them. Improvement Plans: Crew clear times have improved at Southport District General Hospital, there were none over 60Mins and >30Mins has dropped to below 1%, previous months performance was over 2%.

Handover times have also improved at Southport District General from the previous month dropping from 17.3% over 30mins to 12.8% over 30mins this month.

Indicator: Timeliness: Total time spent in A&E department and A&E 4 Hour Target - S&O

Minutes in A&E target: Current Performance 283 Direction of travel Forecast 240

Current Issues: May attendances at Southport A&E are in line with those in May 2014 however the admissions from A&E are higher than in the same period in the last two years. There has been an increase in the proportion of A&E attendances classes as major which highlights the complexity and acuity of patients presenting

Improvement Plans: The Trusts wider urgent care action plan is addressing significant health economy issues, many of which are long-term objectives. Site compliance continues to remain a challenge however the Trust as a whole is compliant with the four hour target for June.

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Indicator: Stroke: % Stroke patients on Stroke Unit & % TIA assesed – S&O

Target:

80% (% Unit) 71% Current Performance Direction of travel Forecast 60% (TIA 33%

assessed)

Current Issues: The Trust failed the standard for TIA in month, 4 patients breached the target out of a total of 6 treated. 2 patients were offered clinic slots within 24 Hrs but declined; they were seen at a mutually agreed clinic after the 24 Hr period. 1 patient attended A&E on a Saturday of the first bank holiday weekend where there was no consultant capacity, and 1 patient was seen in A&E at 08:15 and seen the following day in clinic at 10:00. Improvement Plans: Due to low numbers within the service a small number of breaches affect the Trusts compliance; the trust has increased capacity however patient choice and weekend presentations pose a risk to the Trust.

Indicator: MRSA Bacteraemia– S&O

Target: 0 Current Performance 1 YTD Direction of travel Forecast

Current Issues: The Trust annual target was zero for the year however there was a case in April and therefor the Trust has failed the target and will do for the remaining months of the year. Improvement Plans: A Patients Infection Review (PIR) was completed in collaboration with the CCG and reported to Public Health England. Primary Care and Secondary Care issues had been identified and will be reported back to SEMT in a formal de-brief to ensure lesson have been learnt and embedded.

Indicator: C.difficile – S&O

Target: 36

(annual Target) Current Performance 9 YTD Direction of travel Forecast 3 Cases per

Month

Current Issues: The Trust annual target is 36 cases for the year i.e. an average of 3 cases per month. There was 6 cases in April and 3 cases in May. A root cause analysis has taken place and 6 cases are to be appealed, 3 in April and 3 in May, the appeals are to be scheduled at the end of June. Improvement Plans: Antimicrobial prescribing remains good and the focus remains on early isolation of patients with diarrhoea and close liaison with the infection prevention control team particularly when side rooms are unavailable.

Pseudomonas in Critical Care Template. Initial testing after replacing pipes and taps negative. 2 week follow up tests negative. Plan to test again in 3 months. Water flow and water temperature in critical care rebalanced to reduce stagnation growth risk. Tap flushing enhanced to above national minimum standards to reduce stagnation growth risk. No patients came to harm.

Indicator: RTT - Admitted Target–S&O

Target: 90% Current Performance 83.1% Direction of travel Forecast

Current Issues: The Trust has failed the RTT Admitted pathway target for May.

Improvement Plans: The Trust continues to assign resources to the validation process, and a comprehensive training programme has been delivered by the organisation that owns the Medway system. Weekly RTT data meetings continue with an emphasis on delivering against the comprehensive action plan. The Trust is revising all standard operating procedures including RTT and MIAA has been recruited to work with the Trust to understand issues

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10f West Lancashire CCG patients waiting

There is currently a consultation on an in-year National Variation to change Referral to Treatment (RTT) sanctions in which NHS England are expecting responses by 24th July 2015. The variation is a proposal to remove the existing financial implications for the two completed RTT pathways and retain financial sanction in respect of performance against the incomplete RTT standard, increasing the value of the sanction from the current level of £150 per excess breach to £300 per excess breach.

To understand how many patients were still waiting for procedures or outpatient appointments, the numbers of patients waiting for all in-completed pathways for all trusts has been included in the graph below. More detailed reports on RTT waiters are available via Aristotle spotlight reports.

For the Lancashire footprint there are 3,612 patients with an incomplete complete pathway who are waiting over 18 weeks for May; of the 3,612 patients there are 342 patients attributable to our CCG which is 9.5 % of the Lancashire footprint. The table below shows the top 5 highest number of breaches by provider for May 2015 for our CCG.

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Provider Under 18 Weeks Over 18 Weeks The Total % in 18 Weeks RAG SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST : (RVY) 4,351 294 4,645 93.7% ROYAL LIVERPOOL AND BROADGREEN UNIVERSITY HOSPITALS NHS TRUST : (RQ6) 185 15 200 92.5% WRIGHTINGTON, WIGAN AND LEIGH NHS FOUNDATION TRUST : (RRF) 564 9 573 98.4% LANCASHIRE TEACHING HOSPITALS NHS FOUNDATION TRUST : (RXN) 179 5 184 97.3% CENTRAL MANCHESTER UNIVERSITY HOSPITALS NHS FOUNDATION TRUST : (RW3) 34 4 38 89.5%

Although Southport & Ormskirk are above the 92% national target of Incomplete Pathways when drilling down into the data Gastroenterology speciality performance is 59.6% within 18wks which is 97 patients currently waiting over 18 weeks of 240 overall waiters for this speciality; this is 33% of all waiters over 18wks. Cardiology speciality has 15 waiters over 18wks of a total of 132 waiters for this specialty and is also below the 92% target. Other specialties which are under performing are Rheumatology (12 waiters over 18wks) and General Medicine (7 waiters over 18wks).

Royal Liverpool has 15 patients currently waiting over 18 weeks. The specialty which is underperforming the most is Trauma & Orthopaedics as there are 5 waiters over 18wks of a total of 24 waiters overall for this specialty. Other specialties below the 92% target are General Surgery, ENT and Plastic Surgery.

Wrightington, Wigan and Leigh are above the 92% target for incomplete pathways , the Trust is currently running at 98.4% compliance for Incomplete Pathways, the highest number of waiters over 18wks are Trauma & Orthopaedics with 4 people over 18wks of 242 waiters overall for this specialty.

Lancashire Teaching Hospitals NHS Foundation Trust has 5 waiters overall over 18wks and overall the Trust is 97.3% compliance, there is 1 specialty which is under the target and this is Neurology with 2 patients waiting over 18wks or 11 total waiters for this specialty.

Central Manchester University Hospitals NHS Foundation Trust may not be one of our main providers and not have a large number of our patients waiting, however of the 38 patients currently waiting there are 4 patients currently waiting over 18wks which puts the Trust below the 92% target with 89.4%, the 4 waiters are over 18wks are spread over Dermatology, General Surgery, Trauma & Orthopaedics and Unknown specialty.

Conclusion

The main waiting times problems at Southport & Ormskirk Hospitals Trust need to be taken up with the Trust management of Gastroenterology, Cardiology Rheumatology and General Medicine.

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10g CCG Outcomes Indicator Set

The Health & Social Care Information Centre (HSCIC) published updated figures for 12 measures within the CCG Outcomes Indicator Set since the last report. A summary of these changes has been provided in the table below together with details of West Lancashire CCG’s position and variance since the last reporting period. Notable points in this report include;

1.14 – Smoking status at time of delivery

The percentage of women who were smokers at the time of delivery has increased since the last reporting period, from 10.8% to 12.9% during Q3 2014/2015. This now ranks WL CCG 120 of 211CCG’s.

2.6 Unplanned hospitalisation for chronic ambulatory care sensitive conditions

The direct standardised ratio (DSR) for West Lancashire CCG patients has increased for the second period running, and is now recorded as 1004.0 (per 100,000) during the period January 2014 to December 2014. The CCG ranking has improved slightly, which is confirmed by the national average following the same trend, increasing from 784.1 to 801.1 during this period.

3.1 Emergency admissions for acute conditions that should not usually require hospital admission

Similarly, the DSR for emergency admissions for acute conditions that should not usually require hospital admission has also increased slightly to 1682.7 (per 100,000) during the period January 2014 to December 2014. This again follows the national picture, with the average also rising to 1249.9 during this timeframe.

3.4 Emergency admissions for children with lower respiratory tract infections

A significant improvement on previously reported data, with the DSR for under 19 years falling from 470.9 to 357.3 (per 100,000) during the period January 2014 to December 2015. This is in contrast to the national trend which has slowly been increasing during the last 3 reporting periods, with the average now standing at 392.7 (per 100,000).

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CCG Outcomes Indicators

Latest reported Ref Indicator Description Reporting period CCG Ranking Trend Next data due Data data

Domain 1: Preventing people from dying prematurely

 1.8 Emergency admissions for alcohol related liver disease Jan-14 to Dec-14 37.0 171 out of 211 Sep-15 DSR (per 100,000) (improving)

 The percentage of women who were smokers at the time of delivery, out of the number of 1.14 Smoking status at time of delivery Q3 2014/2015 12.9% 120 out of 211 Sep-15 (declining) maternities

 The percentage of infants who are breastfed at 6-8 weeks of age, out of the number of 1.15 Breast feeding prevalence at 6 - 8 weeks Q3 2014/2015 33.1% 96 out of 122 ** Sep-15 (declining) infants due a 6-8 week check.

 1.22 Hip fracture: incidence Jan-14 to Dec-14 454.4 129 out of 211 Sep-15 DSR (per 100,000) (improving)

Domain 2: Preventing people from dying prematurely

 2.6 Unplanned hospitalisation for chronic ambulatory care sensitive conditions Jan-14 to Dec-14 1004.0 164 out of 211 Sep-15 DSR (per 100,000) (declining)

 2.7 Unplanned hospitalisation for asthma, diabetes and epilepsy in under 19s Jan-14 to Dec-14 411.5 163 out of 211 Sep-15 DSR for under 19 yrs (per 100,000) (improving)

Domain 3: Helping people to recover from episodes of ill health or following injury

Emergency admissions for acute conditions that should not usually require hospital  3.1 Jan-14 to Dec-14 1682.7 182 out of 211 Sep-15 DSR (per 100,000) admission (updated methodology) (declining)

 3.4 Emergency admissions for children with lower respiratory tract infections Jan-14 to Dec-14 357.3 85 out of 211 Sep-15 DSR for under 19 yrs (per 100,000) (improving)

 3.16 Readmissions to mental health services within 30 days of discharge Jan-14 to Dec-14 96.9 134 out of 210*** Sep-15 Indirectly Standardised Ratio (improving)

The percentage of working age adults aged 18 to 69, who have an open spell at the end of  3.17 Proportion of adults in contact with secondary mental health services in employment Jan-14 to Dec-14 8.6% 61 out of 211 Sep-15 March for the relevant financial year, whose record of employment indicated that they (improving) were employed. Domain 5: Treating and caring for people in a safe environment and protecting them from avoidable harm

Incidence of Healthcare Associated Infection (HCAI) – Methicillin-resistant  5.3 Apr-14 to Mar-15 3 83 out of 211 Sep-15 Actual count Staphylococcus aureus (MRSA) (declining)

 5.4 Incidence of Healthcare Associated Infection (HCAI) – C. difficile Apr-14 to Mar-15 47 70 out of 211 Sep-15 Actual count (not adjusted for population) (declining)

* - Not all CCG's met the minimum number of maternities requirement. % calculated compares bookings for mothers having assessments at a trust to the number of maternities at the point of delivery at that trust 2 quarters later. ** - The percentage of infants whose breastfeeding status was recorded may fall short of the data quality standard of 95%, so data not available for all CCG's. *** - TheSome percentage data suppressed of infants due whose to small breastfeeding numbers. status was recorded falls short of data quality standard of 95% in this quarter, so no data available. - Newly available indicator - Refreshed data since last report

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10i Friends and Family Test – Southport and Ormskirk NHS Trust

The table below provides a summary of Friends and Family Test response rates and results for Southport and Ormskirk Hospitals NHS Trust to April 2015. The England mean results have been included to put the ICO’s performance into context. More detailed information can be found in sections 2.0 and 3.0 of this report.

The percentage of Inpatients who would recommend the service they have received to friends and family who need similar treatment or care was maintained at 94% in April 2015, which is the highest recorded over the last 12 month period however, the response rate fell significantly from 29.5% to 13.1%, which is below the target of 15%.

The A&E response rate also followed national trends by falling significantly in April 2015. The rate of 4.3% is the lowest recorded by the ICO during the last 12 months, and remains well below the minimum response rate target of 15%, meaning it has been difficult to draw any reliable conclusions from the indicated result of 83.3%.

Similarly, it is difficult to draw any conclusions from the results for questions 1, 3 and 4 of the Maternity element of the test as not all response rates have been published by NHS England, so the minimum level expected may not have been met. The response rate for question 2 fell significantly from last month's figure of 16.0% to 8.8% in April 2015.

Quarter 4 results for the Staff Friends & Family Test have now been published, and show that the percentage of staff who would recommend their service as a place to work has fallen from the figures recorded in previous surveys, whilst the percentage who would not recommend their service has correspondingly risen. In contrast, the percentage of staff who would recommend their service to friends & family who need similar care or treatment has risen during this timeframe.

Southport & Ormskirk NHS Trust Friends & Family Summary - April 2015 Response rate England mean result Trust result Result trajectory Response rate Trust response Clinical area trajectory from (% would (% would from previous Comments target rate previous month recommend) recommend) month Result was maintained at 94% in April 2015, which is the highest recorded over the last 12 month period however, the response rate fell Inpatients 15% 13.1% 95.5% 94.0%   significantly from 29.5% to 13.1%, which is below the target of 15%.

The response rate of 4.3% is the lowest recorded by the ICO during the last 12 months, and remains well below the minimum response rate A&E 15% 4.3% 87.5% 83.3%   target of 15%, meaning it has been difficult to draw any reliable conclusions from the indicated result of 83.3%. Result fell from the previous month's figure of 97.2%, but unable to draw reliable conclusion as response rate not published by NHS England. Antenatal 15% *32 * n/a 95.3% 87.5% 

The response rate for fell significantly from last month's figure of 16.0% to 8.8% in April 2015 which is below the target of 15%, meaning it is Birth 15% 8.8% 97.2% 84.2%   difficult to draw any conclusions from the indicated score of 84.2%.

Indicated result has fallen compared to previous month (94.3%), but

Maternity unable to draw reliable conclusion as response rate not published by Postnatal 15% 17.0% * n/a 93.7% 88.2%  NHS England.

Indicated result has fallen from 100% last month , but unable to draw reliable conclusion as response rate not published by NHS England. Postnatal community 15% 28.0% * n/a 97.7% 96.4% 

The percentage of staff who would recommend their service as a place to work has fallen from the figures recorded in previous surveys, whilst Work (Q2 results) No target set 2.0% 61.7% 30.0%   the percentage who would not recommend their service has correspondingly risen.

Staff In contrast, the percentage of staff who would recommend their service to friends & family who need similar care or treatment has risen over the Care (Q2 results) No target set 2.0% 77.2% 51.4%   course of these surveys.

* Number of eligible responses not published by NHS England in April 2015. Number of actual responses received included for information only.

- Response rate or score more than 5% or 5 points below target or national mean. - Response rate or score within 5% or 5 points of target or national mean. - Response rate or score level with or better than target or national mean.

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10j Safety Thermometer

On one day each month hospital trusts are required to check to see how many of their patients suffered certain types of harm whilst in their care. This measure is known as the safety thermometer. The safety thermometer looks at four harms: pressure ulcers, falls, blood clots and urine infections for those patients who have a urinary catheter in place. This helps Trusts to understand where they need to make improvements. The table below shows the percentage of patients who did not experience any of the four harms in the Trust(s).

Safety Thermometer - May 2015 Trajectory from Trust Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 previous month Southport & Ormskirk NHS Hospitals Trust 98.1% 97.9% 98.3% 98.5% 98.7% 98.7% 97.6% 97.6% 98.9% 98.0% 98.9% 98.9% 

Wrightington, Wigan & Leigh NHS Foundation Trust 99.8% 99.6% 98.9% 99.5% 98.5% 99.1% 99.3% 99.3% 98.8% 99.5% 99.3% 98.0% 

Aintree University Hospitals NHS Trust 98.0% 98.3% 97.3% 96.7% 98.2% 97.6% 98.8% 98.5% 98.7% 97.6% 98.5% 99.4%  Royal Liverpool & Broadgreen University Hospitals 96.3% 94.1% 98.2% 97.3% 96.8% 97.3% 97.6% 97.9% 98.0% 97.3% 97.8% 97.1% NHS Trust 

Lancashire Teaching Hospitals NHS Foundation Trust 97.8% 97.7% 97.7% 98.3% 98.3% 97.8% 98.1% 98.4% 98.2% 98.4% n/a n/a

St Helens & Knowsley Hospitals NHS Trust 99.4% 98.9% 97.7% 98.4% 98.5% 98.8% 98.8% 98.2% 98.2% 98.3% 98.8% 98.5% 

- Score more than 5% lower than previous month - Score lower than previous month but within 5% - Score equal to or higher than previous month

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11. Complaints

10a West Lancashire: Complaints

During May 2015, three patients contacted the customer care team at NHS Midlands and Lancashire Commissioning Support Unit (CSU) regarding NHS services in the West Lancashire area. One (33%) of the contacts received was recorded as a concern / enquiry / comment and two (66%) were classed as a formal complaint. No compliments were received during the period. This now brings the year-to-date total to 6 contacts, which can be categorised into the themes shown below:

* Please note some contacts received may contain issues regarding more than one service area.

Other / miscellaneous themes may include multi-agency issues, CSU service, LCFT matters and compliments.

CCG related issues include Choose and Book services and retention of GP patients who are out of area.

Formal Complaints: One of the formal complaints received in May 2015 came from a patient who was unhappy with the service provided by the Ear, Nose and Throat (ENT) department at Southport and Ormskirk Hospital Trust (SOHT). The patient was signposted by the customer care team to the SOHT complaints team, and the case has since been closed. The second formal compliant came from a patient who was unhappy that their GP Practice does not currently use the Choose and Book service as part of the clinical referral process. The customer care team forwarded the issue to the CCG for a response, and the case is ongoing. Concerns / Comments: One enquiry was received from a patient who was unhappy with the treatment received by her and her husband when she was admitted to the Maternity Unit at Ormskirk Hospital. The patient highlighted a number of negative experiences. The patient was signposted to SOHT to investigate and the case has since been closed.

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11b GP Issues with Southport & Ormskirk Hospitals Trust

There were 8 complaints/comments copied to the CCG from GP’s to Southport & Ormskirk Hospitals Trust during June 2015. The most common issue related to correspondence being sent to the wrong GP Practice which raised concerns about information governance and poor communication. The chart below summarises the trends/themes of comments and complaints over the last 12 month period.

Themes & trends will continue to be monitored & reported against on a monthly basis, and raised with the Trust through the contract and quality monitoring process as appropriate.

11c Southport & Ormskirk Hospitals Trust Compliments and Complaints

The ICO report complaints on a quarterly basis and the next update included in this report will now be available in August 2015.

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12. Serious Untoward Incidents

This section provides details of the new and on-going STEIS reportable Serious Untoward Incidents (SUIs) involving West Lancashire CCG patients for the period up to end June 2015 . A Serious Untoward Incident (requiring investigation) has a nationally set definition but fundamentally is defined as an incident that occurred in relation to NHS-funded services and care resulting in ‘avoidable harm or unexpected death’ or ‘adverse media coverage, severe impact on service provision or loss of person identifiable data’.

12a. New Incidents `

During June 2015, no new StEIS incidents were reported involving WL CCG patients.

11b. On-going investigations 2

The table below shows the numbers of open SUIs for West Lancashire residents broken down by the reporting organisation, as at end June 2015.

Root cause analysis reports and action plans will be considered by the lead commissioner in conjunction with West Lancashire CCG and will be agreed as acceptable or if not, additional information will be requested. An update on progress with these cases will be presented each month as part of this report. Most of these SUI’s are expected to be closed once this information is received.

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StEIS Incidents by reporting organisation and type

Provider Organisation StEIS Number Incident Type Date New/On- Reported going/ Closed Mersey Care NHS Trust (performance managed by 2014/31998 Suicide by inpatient ( not in 02/10/14 On-going Liverpool CCG) receipt) TOTAL= 1 Lancashire Teaching Hospitals ( performance 2014/10431 Child Death 28/03/14 On-going managed by Chorley & South Ribble CCG) TOTAL = 1 Lancashire Care NHS Foundation Trust- Mental 2013/33720 Safeguarding Vulnerable Child 15/11/13 On-going Health (performance managed by Blackburn with 2014/5439 Admission of under 18s to 17/02/14 On-going Darwen CCG) adult MH ward 2014/16378 Admission of under 18s to 20/05/14 On-going adult MH ward 2015/6680 Unexpected Death of 19/02/14 Closed Community patient (not in receipt TOTAL = 3 Lancashire Care NHS Foundation Trust- 2014/10316 Child Death 28/03/14 On-going Community (performance managed by Chorley & 2015/6504 Confidential Information Leak 18/02/14 On-going South Ribble CCG) TOTAL = 2 Ramsay Healthcare E05 Scheme (performance 2012/28728 Other 14/11/12 On-going managed by NHS England) TOTAL = 1 Southport & Ormskirk Hospitals NHS Trust 2014/12082 Radiology/Scanning incident 11/04/14 On-going (performance managed by Southport & Formby 2014/23350 Delayed diagnosis 17/07/14 On-going CCG) 2014/27995 Adverse media coverage or 28/08/14 On-going public concern 2014/29145 Adverse media coverage or 08/09/14 On-going public concern 2014/31956 Attempted suicide by inpatient 01/10/14 On-going 2014/32953 Pressure Ulcer Grade 3 09/10/14 On-going 2014/34582 Delayed diagnosis 23/10/14 On-going 2014/39288 Unexpected death ( General) 02/12/14 On-going 2014/40591 Pressure Ulcer Grade 4 12/12/14 On-going 2014/40745 Screening issues 15/12/14 On-going 2014/41003 Pressure Ulcer Grade 3 17/12/14 On-going 2014/41011 Pressure Ulcer Grade 3 17/12/14 On-going 2015/9075 Communicable Disease and 09/03/15 On-going Infection issue 2015/10569 Delayed Diagnosis 19/03/15 On-going 2015/11177 Pressure Ulcer Grade 3 24/03/15 On-going 2015/12495 Pressure Ulcer Grade 3 02/04/15 On-going 2015/12501 Pressure Ulcer Grade 3 04/04/15 On-going 2015/12893 Pressure Ulcer Grade 3 08/04/14 On-going 2015/12894 Pressure Ulcer Grade 3 08/04/15 On-going 2015/12896 Pressure Ulcer Grade 4 08/04/15 On-going 2015/13164 Sub-optimal care of the 10/04/15 On-going deteriorating patient 2015/13691 Pressure Ulcer Grade 4 15/04/15 On-going 2015/13701 Pressure Ulcer Grade 3 15/04/15 On-going 2015/13704 Pressure Ulcer Grade 3 15/04/15 On-going 2015/13705 Pressure Ulcer Grade 3 15/04/15 On-going 2015/13707 Pressure Ulcer Grade 3 15/04/15 On-going 2015/13834 Unexpected Death of Inpatient 16/04/15 On-going ( not in receipt) 2015/13837 Pressure Ulcer Grade 4 16/04/15 On-going 2015/14041 Pressure Ulcer Grade 3 17/04/15 On-going 2015/14043 Pressure Ulcer Grade 4 17/04/15 On-going 2015/14047 Pressure Ulcer Grade 3 17/04/15 On-going TOTAL = 31 West Lancashire Nursing Homes ( performance *2014/20504 Pressure ulcer Grade 3 24/06/14 On-going managed by West Lancashire CCG and NHS 2014/24528 Pressure ulcer Grade 4 28/07/14 On-going England) 2015/12064 Slips/Trips/Falls 31/03/15 On-going TOTAL = 3 36 | P a g e

*Knowsley CCG patient

Closed StEIS April 2015

During the month, 1 StEIS incident was closed.

StEIS No Reporting StEIS Category Lessons Learned Organisation 2015/6680 LCFT mental Unexpected Lessons learned: health Death of Inpatient • The good and timely communication between PCMHT and CRHTT ( not in receipt) needs to be highlighted to the teams as an example of how this can ensure that service users presenting to services can received timely and appropriate assessments and interventions to address their identified needs.

• At the time the Service User self-presented to the PCMHT on 22 September 2014 there was no guidance on how services should respond to service users presenting without being referred or without arranged appointments. There is now guidance for the team based at Bickerstaffe House on how they should respond to further similar cases of individuals attending without any referral being received or a planned appointment. Consideration should be given as to how this guidance might be shared with other community based Mental Health teams within LCFT to enable them to develop local guidance for managing similar occurrences within their locality.

Root cause(s): • The investigation was unable to identify any root causes or contributory factors in Care or Service Delivery Problems that contributed to the Service User apparently taking their own life on 14 January 2015.

12c. On-going investigations - Nursing and Care homes

During the month, there have been no new serious incidents reported by Nursing Homes in West Lancashire.

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WLCCGB 07/15/11

WEST LANCASHIRE CLINICAL COMMISSIONING GROUP GOVERNING BODY REPORT

DATE OF BOARD MEETING: 28 July 2015

TITLE OF REPORT: End to End Stroke Pathway Service Specification

BRIEFING POINTS: Governing Body to: • Consider and agree the draft service specification noting the requirement for seven day access to service provision across the whole stroke pathway • Provide any feedback/ comments on the specification

Does this report / its recommendations have implications and impact with regard to the following: A. Commissioning Board’s Aims and Objectives 1. Quality (including patient safety, clinical effectiveness and patient Yes experience) – please outline impact

The end to end stroke pathway service specification is an aspirational best practice service specification which aims to standardise and improve the quality of stroke services across Lancashire and South Cumbria. 2. Commissioning of hospital and community services – please outline Yes impact The service specification outlines the required service outcomes and performance standards in relation to both hospital and community service aspects of the stroke pathway, as part of the full end to end pathway. 3. Commissioning and performance management of GP Prescribing – No please outline impact

4. Delivering Financial Balance – please outline impact Yes Work is being undertaken at a Lancashire level to understand the impact of implementing the service specification. Chief Finance Officers have agreed to the formation of a finance group to consider the options around finance including consideration of tariff unbundling in order to make recommendations to the Collaborative Commissioning Board. 5. Development of the commissioning group as a commissioning No organisation – please outline impact

B. Governance – please outline impact 1. Does this report: • provide the Commissioning Board with assurance against any of the risks identified in the assurance framework (identify risk number) • have any legal implications • promote effective governance practice

End to End Stroke Pathway Service Specification 1 West Lancashire Clinical Commissioning Group Board Meeting – 28 July 2015 2. Additional resource implications Yes (either financial or staffing resources) See comments above in relation to finance. 3. Health Inequalities Yes The service specification supports reduction in health inequalities as it addresses variation in service provision. 4. Human Rights, Equality and Diversity Requirements Yes Pre-PEAR assessment carried out, full EIA required, being undertaken by CSU. 5. Clinical Engagement Yes Clinical input into all workstreams during service specification development process; CCG Clinical Leads for Primary/Secondary Prevention, stroke consultants/specialist nurses/therapists for acute and rehab pathway phases. 6. Patient and Public Engagement Yes Patients involved in specification development via workstream groups and Steering Board. Wider patient engagement carried out during May through attendance at Stroke Association support groups to seek further input and comments on draft specification.

REPORT PREPARED BY: Claire Kindness-Cartwright, Service Redesign Senior Manager - Midland and Lancashire Commissioning Support Unit

REPORT PRESENTED BY: Mike Maguire, Chief Officer, West Lancashire CCG

End to End Stroke Pathway Service Specification 2 West Lancashire Clinical Commissioning Group Board Meeting – 28 July 2015 1) Introduction and Purpose

1.1 Purpose

The following Service Specification document sets out the criteria, as recommended by the Lancashire and South Cumbria Stroke Review Steering Board, that different parts of the stroke pathway need to meet to deliver high quality care to patients and achieve the step change improvement sought by the Lancashire and South Cumbria Stroke Review. These are the expected standards commissioners should adopt when commissioning stroke care services.

This service specification has been developed by the Lancashire and South Cumbria Stroke Review workstream groups in consultation with stakeholders, including primary care clinicians, clinical staff working in stroke and other associated services, patients and carers who have experienced NHS services, Stroke Association, commissioners, Public Health and clinical/research networks. The document aims to build on clinical best practice and provide clarity on the system requirements for stroke services without prescribing the service model to be adopted locally.

1.2 Overview

The National Stroke Strategy (2007) provides the foundation for defining stroke services and outlines what is needed to create the most effective stroke services in England. The strategy identifies major stages in the stroke patient’s pathway and stresses a need to reorganise the way in which stroke services are delivered, from prevention through to support for those who have experienced a stroke.

A whole pathway approach to the provision of stroke services is crucial to maximising the clinical outcomes for patients, the resultant quality of life and their experience of stroke services. The first 72 hours of care is vital to ensure the optimum clinical outcome for stroke survivors. This needs to be underpinned by an effective whole system pathway for assessment, treatment, rehabilitation and subsequent discharge into longer term support.

Improving outcomes and quality of care in stroke services are key ambitions for the population of Lancashire and South Cumbria. Although there have been significant improvements in stroke services across the region over the last few years, there remains scope for further improvement; outcomes are currently worse than national average for patients with cerebrovascular disease, stroke mortality is higher than the national rate and variation exists between different services providing care to stroke patients.

1.3 Lancashire and South Cumbria Vision for Stroke Services

Lancashire and South Cumbria Clinical Commissioning Groups (CCGs) wish to achieve a step change improvement in the quality of stroke and TIA services, which will in turn improve outcomes. The overarching vision for stroke services across the area is to ensure:

• That all patients who experience a stroke have access to high quality care 24/7, • TIA patients have 7 day access to TIA services • High quality life after stroke rehabilitation is available for those patients who need it

These will all be provided as part of a stroke pathway focused on providing patient and carer-centric care, empowerment and facilitation of self-management leading to meaningful participation in daily life.

For those patients at the end of life, they will be placed on the most appropriate end of life care pathway to ensure their choice of preferred place of death.

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1) Introduction and Purpose

1.4 Objectives and Expected Outcomes

The objectives are to: • Develop an end-to-end stroke service for the population of Lancashire and South Cumbria • Implement the recommendations of the National Stroke Strategy • Meet the service standards and specifications set by the Royal College of Physicians and NICE guidelines • Ensure that stroke services deliver: - Improved stroke prevention and increased public awareness of stroke/TIA signs and symptoms - Improved clinical outcomes e.g. reduced mortality - Improved quality of life outcomes e.g. reduced level of disability following a stroke - Reduced length of stay for stroke patients in hospital - A seamless transfer of care from acute to community care - Better support for stroke survivors - Better support for patients at the end of life - An excellent patient and carer experience across the whole pathway, including improved access - Ensure equity of outcomes and experience across the region

In meeting the above objectives, the expected outcomes will be that any patient presenting with acute stroke symptoms will receive the most appropriate care for their condition. Placing patients on the correct pathway (TIA, hyper acute or acute) will maximise the likelihood of best possible outcomes and allow Lancashire and South Cumbria CCGs to use resources effectively within the local area. The specific performance standards are listed in each section, but the expected outcomes are:

NHS Outcomes Framework Domains and Indicators Domain 1 Preventing people from dying prematurely x

Domain 2 Enhancing quality of life for people with long-term conditions x

Domain 3 Helping people to recover from episodes of ill-health or following injury x

Domain 4 Ensuring people have a positive experience of care x

Treating and caring for people in safe environment and protecting them from Domain 5 x avoidable harm

CVD Outcomes Strategy Ambitions Ambition 1 Manage CVD as a single family of diseases Ambition 2 Improve prevention and risk management x Ambition 3 Improve and enhance case finding in primary care x Ambition 4 Better identification of very high risk families/individuals x Ambition 5 Better early management and secondary prevention in the community x Ambition 6 Improve acute care x Ambition 7 Improve care for patients living with CVD x Ambition 8 Improve end of life care for patients with CVD x Ambition 9 Improve intelligence, monitoring and research and support commissioning x

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1) Introduction and Purpose

1.5 Evidence Base

Stroke is the fourth biggest killer in the UK and the main cause of adult complex disability. Stroke killed more than 40,000 people in 2013 in the UK and over 1,400 in Lancashire and South Cumbria. Around three quarters of people will survive their stroke, but half of stroke survivors are left with long term disability and one third of stroke survivors are dependent on others for everyday activities. Up to 80% of all strokes could be prevented.

Stroke care costs the NHS and the economy about £9 billion a year – about £4.38 billion in direct costs to health and social care, £2.42 billion in informal care costs (costs of nursing home care and care borne by the patients‟ families) and £2.17 billion in income lost to mortality and morbidity and benefit payments.

This service specification is based upon a comprehensive and current evidence base and agreed best practice, including:

1. The NHS Outcomes Framework 2014/15 (2013) Department of Health 2. A Public Health Outcomes Framework for England 2013-2016 (2012) Department of Health 3. The 2015/16 Adult Social Care Outcomes Framework (2014), Department of Health 4. Quality and Outcomes Framework for 2014/15 (2014) NHS Employers 5. National Stroke Strategy (2007) Department of Health 6. London Stroke Strategy. Healthcare for London. (2008) 7. Cardiovascular Disease Outcomes Strategy (2013), Department of Health 8. National Clinical Guidelines for Stroke (2012) Royal College of Physicians 9. Quality Standards Programme: Stroke (2010) National Institute for Clinical Excellence. 10. Stroke Service Standards (2014) British Association of Stroke Physicians 11. Diagnosis and Initial Management of Transient Ischaemic Attack, (April 2010), RCP 12. Cumbria & Lancashire Out of Hours Telestroke Service Specification (Oct 2014) Draft v.2 13. A consensus on stroke: Early Supported Discharge, Fisher et al (2011) 14. The implementation of evidenced based rehabilitation services for stroke survivors in the community: the results of a Delphi consensus process. Fisher et al (2013) 15. Community Stroke Resource review of CST models nationally: NHS Improvement Stroke, (2012) 16. Stroke rehabilitation in the community: Commissioning for Improvement (2012), NHS Improvement 17. NICE Clinical Guideline 162: Stroke Rehabilitation Long term Rehabilitation after stroke, (2013) 18. NICE Clinical Guideline IPG 278: Functional electrical stimulation for drop foot of central neurological origin (2009) 19. Services for reducing duration of hospital care for acute stroke patients: Cochrane Review (2012) Cochrane Collaboration Group 20. Implementing Evidenced based early supported discharge services: a qualitative study of challenges, facilitators and impact. Clinical Rehabilitation (2014), Vol 28 (4) 370-377. 21. Evidence Based community Stroke Rehabilitation. Walker et al. Stroke; 2013 43:293-297. 22. Intercollegiate Stroke Working Party. National Clinical Guideline for Stroke. 3rd ed. London: Royal College of Physicians; (2008) 23. Supporting Life after stroke (2011), Care Quality Commission 24. State of the Nation; Stroke Statistics (2015), Stroke Association 25. Stroke Association Manifesto 2010 – 2015 26. End of Life Care Strategy: promoting high quality care for adults at the end of their life, Department of Health, (2008) 27. The North West End of Life Care Model, January (2015) 28. Advance Care Planning: A Guide for Health and Social Care Staff NHS End of Life Care Programme, Published February (2007), revised August (2008)

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1) Introduction and Purpose

29. Making the case for change: Electronic Palliative Care Co-ordination Systems, November (2012) 30. Amber Care Bundle: http://www.ambercarebundle.org/homepage.aspx 31. The route to success - transforming end of life care in acute hospitals, 20 June 2010 - National End of Life Care Programme 32. Priorities for Care of the Dying Person, Leadership Alliance for the Care of Dying People, June (2014) 33. Final Recommended Core Education Standards for Care and Support for the Dying Person in the Last Days and Hours of Life, October 2015 - http://www.gmlscscn.nhs.uk/end-of- life/information-for-health-and-social-care-professiona/resource-library.php 34. http://www.elcqua.nhs.uk/index.php

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2) Service Specification

The service specification is divided into phases of the care pathway for stroke patients

D) Integrated A) Primary B) Pre- C) Acute E) F) Secondary Community G) End of Life Prevention Hospital Phase Survivorship Prevention Stroke Team

This document is structured according to the stroke pathway phases below. In addition, expectations that apply across the whole pathway are described at the outset.

A. Primary prevention B. Pre-hospital C. Acute phase i. Hyper Acute Stroke care 0-6 hours ii. Acute Stroke care 6-72 hours iii. Acute care and inpatient rehabilitation 72 hours – 7 days iv. Transient Ischaemic Attack (TIA) services v. Specialist Support Services (e.g. neuro and vascular surgery referrals) D. Integrated Community Stroke Team E. Survivorship F. Secondary Prevention G. End of Life

The performance standards specified for each pathway stage are defined according to the data definitions of the stated data collection audit (e.g. ASI, SSNAP, QOF etc.)

The diagram overleaf summarises the pathway according to the patient movement across the phases since they are not necessarily linear and not all phases or services are applicable to all patients.

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2) Service Specification

6

2) Service Specification

In order to improve quality of care for stroke patients and their experience of stroke services the following components need to be embedded across the whole pathway;

• Communication and Information • Collaboration • Data Collection • Monitoring, Data Transfer and Information Sharing • Innovation, Research and Development.

These components are described in greater detail below.

1. Communication and Information

Patients and their carers will receive a key contact on admission to the acute stroke unit and will be kept informed throughout the care pathway on a regular and timely basis of: • Their prognosis and situation • What is likely to happen to them next e.g. how soon they will be seen, frequency of contact, contact information for the new team, how goals will be carried over • Who is taking care of them and who is responsible for their care • What they need to be doing to facilitate their care and recovery e.g. advice and information about exercises or other activities that they can practice independently

Patients and their families/carers: • Are able to access information provided to them i.e. provided in an appropriate format/ medium, and in relevant community languages other than English and that is specific to the phase of recovery and their needs at that time • Receive instruction and guidance regarding any prescriptions; verbally and supported by written information • Are actively involved in day to day care, rehabilitation and decisions about the planning and delivery of their care • Are directed to relevant voluntary service organisations • Are encouraged to provide information on their experience of the service through the Friends and Family test and any other locally developed patient satisfaction surveys. This information will be utilised to inform quality improvement and/or service developments

Clinical teams: • Proactively communicate between themselves and with anyone who takes over responsibility for a patient’s care, e.g. discharge from acute to community or primary care, • Communicate regularly with patients and carers in appropriate ways for their condition and needs

Awareness raising activities are proactive and ongoing e.g. FAST awareness across primary care, care homes, providers and the general public.

2. Collaboration

All organisations ensure that the processes used to manage care involve all relevant people and support seamless transitions between services along the pathway. Providers of stroke services are actively engaged with their local stroke networks e.g. to ensure that each stroke unit is linked to a regional neurosciences centre for emergency review of local brain imaging.

All organisations ensure that formal links exist with patient and carer organisations e.g. local users’ forums, Stroke Association Groups, Community Stroke Clubs, as appropriate.

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2) Service Specification

3. Data Transfer and Information Sharing

Accurate and explicit records of patients are recorded and shared using agreed protocols between all hospital, community and social care practitioners and individuals in accordance with the Lancashire IT Strategy.

4. Data Collection and Monitoring

All organisations shall: • Submit data for the DH stroke and TIA IPMRs • Take responsibility for all aspects of data collection, keeping stroke registers, monitoring prevalence and management of associated conditions and participating in national stroke audits, including QOF and SSNAP either directly or via upload of equivalent local data such as GRASP that enables comparison with regional and national peers • Ensure continuously improving real time data collection and effective transfer of information between health care professionals and agencies • Ensure that a sustainable system of coding is in place for stroke patients • Ensure that processes are in place to support the collection of data across service providers • Develop a robust system for collection and validation of reliable and accurate stroke data with a lead responsible individual to approve and sign off the data. This may involve investment in data systems and personnel to avoid the burden of data collection responsibility on clinical staff • Capture patient and carer experience across the stroke pathway at regular intervals. This information should be used to inform the improvement of local services and the results should be submitted to inform commissioners on progress in improving patient experience

5. Innovation and Research & Development

All providers should: • Be part of a research network • Have a dedicated stroke research lead and actively participate in recruiting patients to national and international clinical trials and other well designed research studies (e.g. on the role of interventional radiology in treatment of acute ischaemic stroke or whether the increased intensity of therapy results in improved outcomes) • Be open to performing and participating in national and international trials • Work with Stroke Research Networks to ensure that research findings are fed into onward plans and inform clinical practice e.g. stopping doing things where there is no evidence • Work collaboratively to improve services through innovation and research

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A) Primary Prevention

Lack of awareness of stroke and TIA – lifestyle causes, risk factors, prevention and symptoms – can be a significant challenge to the realisation of a successful outcome for someone who goes on to experience a stroke or TIA. However, its “Everyone’s challenge to improve public and professional awareness of the risk factors and symptoms of stroke and what action to take” (Stroke Strategy) A proactive approach by all healthcare professionals to recognise patients at risk of stroke or TIA and subsequent mitigation against those risks will support the challenges set for us, to prevent people from dying prematurely (NHS Outcomes Framework) and to improve prevention and risk management (CVD Outcomes Strategy)

Service Identification, diagnosis and evidence–based management of AF & Hypertension Outcomes All Primary Care professionals shall develop and maintain their knowledge in stroke prevention and managing the risk factors associated with it and are proactive and effective in: • Identifying patients at risk of stroke or TIA through the NHS Health Check Programme • Ensuring that an annual pulse rhythm check is mandatory in all patients >65 or in patients attending for review of a long term condition, through prompts within clinical templates • Identifying diagnosing and managing atrial fibrillation and hypertension and reducing the risk of stroke or TIA e.g. through anticoagulation, and/or other appropriate medications as per NICE guidance • Utilising tools and technologies that can support the identification, diagnosis and management of AF and hypertension, e.g. GRASP casefinder and care management tools • Individuals screened or tested by any qualified provider shall be referred to appropriate services, e.g. primary care, as necessary, to confirm diagnosis of AF or hypertension • Making every patient contact count; carrying out manual pulse, weight and BP checks at every opportunity. This will include contact within other healthcare settings, e.g. secondary care, as an inpatient or outpatient. Any cases of new AF or raised blood pressure shall be communicated to the individual’s primary care provider within 24 hours of discharge/outpatient appointment • Accurately recording and coding patient diagnosis to enable effective treatment and monitoring • Recognising when a referral to emergency care is needed

Anticoagulation services shall be responsible for initiating anticoagulation within 14 days of referral and shall manage patients’ anticoagulation safely and adequately as per NICE guidance. They shall: • Identify patients for whom self-testing is appropriate • Advise patients who are poorly controlled • Advise and inform primary care of poorly controlled patients, as appropriate

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A) Primary Prevention

Nursing home staff are effectively trained to: • Regularly check BP, temperature, pulse rhythm • Understand the importance of patients taking their medication • Recognise the signs and symptoms of stroke and TIA and are aware of the importance of dealing with stroke as rapidly as possible • Recognise when a patient is unwell and contact emergency services when needed

Social care staff in domiciliary care, care homes and day centres, together with personal assistants purchased through Direct Payments are effectively trained to: • Carry out pulse checks • Recognise the signs and symptoms of stroke and TIA and are aware of the importance of dealing with stroke as rapidly as possible • Recognise when a patient is unwell and contact emergency services when needed

Patient/Public Awareness, Education and Training

All Primary Care professionals are proactive and effective in: • Promoting the FAST campaign, “Know your Pulse” campaign and other national/ regional campaigns increasing awareness of stroke and the need for urgent diagnosis and treatment • Raising patient awareness of AF, hypertension and their association with increased risk of stroke and the treatments for these conditions • Providing education/training to appropriate patients to enable self-pulse checking, e.g. through pulse check apps • Advising and educating patients that high blood pressure may not have any symptoms and to attend for checks as appropriate • Advising patients of lifestyle choices and treatments to minimise the risk of stroke and TIA • Advising and educating patients on how to identify signs & symptoms of stroke and TIA to enable effective early intervention/ treatment

As a result of the above, members of the public are able to recognise and identify the main symptoms of stroke and TIA and know it needs to be treated as an emergency.

The local health economy, including voluntary, community and faith sector organisations shall communicate basic information to patients on the symptoms, emergency treatment, risk factors, lifestyle factors and treatments of Stroke and TIA. This will be through a range of media including information communicated verbally by health professionals, patient information leaflets,

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A) Primary Prevention

promotion of web based information and awareness campaigns provided in a variety of formats, i.e. different languages, large print, braille, dysphasia friendly, and will be tailored for a variety of ages, ethnicities and lifestyles.

End of Life Care

• Dying matters campaign should be promoted by all health and social care settings (including third sector community based organisations) (including find your 1%) • GPs shall include patients in the Gold Standards Framework Register/Supportive Care Register if they are identified to be in their last year of life (NICE Quality Statement 1: People approaching the end of life are identified in a timely way.) • Health and Social Care professional shall identify when there is an opportunity to offer an Advance Care Planning discussion and/or refer to: o Advance Decisions To Refuse Treatment o Preferred Place of Care o Mental Capacity Act 2005 o Do Not Attempt Cardiopulmonary Resuscitation o Emergency Health Care Plan o Lasting Power of Attorney Registration o Making a will Health and Social Care professionals shall complete expressed preferences for care information on the Electronic Palliative Care Co-ordination System (EPaCCS)

• Sensitive Communication Skills Training for End of Life Care shall be provided to all staff

Performance Threshold Points Standards

AF001 The contractor establishes and maintains a register of patients with Atrial Fibrillation 5

The percentage of patients with AF in whom stroke risk has been assessed using the CHA2DS2-VASc score risk stratification scoring system in the preceding 12 months AF006 40-90 12 (excluding those patients with a previous CHADS2 or CHA2DS2-VASc score of 2 or more)

11

A) Primary Prevention

In those patients with AF with a record of a CHA2DS2-VASc score of 2 or more, the AF007 40-70 12 percentage of patients who are currently treated with anticoagulation drug therapy

The contractor establishes and maintains a register of patients with established HYP001 6 hypertension

The percentage of patients with hypertension in whom the last blood pressure reading HYP006 45-80 20 (measured in the preceding 12 months) is 150/90mmHg or less

GP practices undertake an annual audit of AF and Hypertension prevalence compared 100% of GP to expected prevalence Practices

No. and percentage of patients who are initiated on anticoagulation within 14 days of See note from date of referral Jeannie (Email)

No. and percentage of patients who are initiated on anticoagulation 15 days or more As Above from date of referral

No. and percentage of patients with time in therapeutic range of >65% 75%

No. and percentage of patients with time in therapeutic range of <65% 25%

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B) Pre-Hospital

A fast response to stroke reduces the risk of mortality and disability – “Time is Brain”. The identification of potential stroke and TIA patients and their timely admission to an appropriate stroke centre is a critical stage of the care pathway. Promotion amongst healthcare professionals, the public and carers of stroke symptom awareness (e.g. FAST) that prompt emergency treatment can improve health outcomes through timely access to stroke care and specialist treatments such as thrombolysis, which must be administered within a few hours of the onset of symptoms.

Service Clinical assessment by ambulance staff: Outcomes • All calls regarding possible strokes shall be treated as a medical emergency • All people seen by ambulance staff outside hospital, who have sudden onset of neurological symptoms, are screened using a validated tool to diagnose stroke or transient ischemic attack (TIA). Those people with persistent neurological symptoms who screen positive using a validated tool, in whom hypoglycemia has been excluded and who have a possible diagnosis of stroke are transferred to a hospital providing hyper-acute stroke services within 1 hour • All patients with suspected acute stroke are immediately transferred by ambulance to a hospital providing hyper-acute stroke services. Includes, Face, Arms, Speech, Time (FAST) positive patients and suspected stroke by paramedics even if FAST negative • Higher risk TIA patients (ABCD2 score > 4, on anticoagulation or with crescendo TIA) will be treated as a medical emergency, being at greater and imminent risk of stroke • All suspected stroke patients are assessed and managed in accordance with best clinical practice and monitored for atrial fibrillation (AF) and other dysrhythmias

Ambulance transfer to hospital:

• All patients with suspected acute stroke are immediately transferred by ambulance to a hospital providing hyper-acute stroke services within 1 hour • All suspected stroke cases are assigned “Category A” 999 response and meet Category A ambulance service standards • The Ambulance Paramedic service shall link with the receiving hospital when they have a suspected stroke patient, providing a system of pre-alert to enable all potential stroke patients (FAST positive) to be met on arrival

End of Life Care:

• Ambulance staff shall check Advance Care Plan and consider patient’s wishes where identified: o Mental Capacity Act 2005 (Advance decisions to refuse treatment) o Do Not Attempt Cardiopulmonary Resuscitation o Preferred place of death

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B) Pre-Hospital

• Needs of those identified as important shall be explored, respected and met as far as possible • Sensitive Communication Skills Training for End of Life Care shall be provided to all staff • All staff shall have an understanding of the Mental Capacity Act 2005

Education & Training • All ambulance and triage staff shall follow best practice clinical guidelines in the recognition of and handling of stroke patients‟ e.g. FAST • All Ambulance crews and paramedics are trained in stroke recognition using validated tools (e.g. FAST) • Stroke experience shall be included in paramedic training, North West Ambulance Staff (NWAS) are able to prepare patient appropriately for admission to hyper acute stroke service according to agreed protocols. • In-house communication training shall be provided to help manage patients with aphasia • Ongoing stroke specific training is included as part of Continuous Professional Development (CPD) • Ambulance service shall have an established method of obtaining and implementing new guidance for stroke care • Ambulance service shall participate in local Stroke Research Network trials and studies • Workforce • There is sufficient and appropriate stroke skilled capacity (see above for necessary skills) in the ambulance service to provide the in accordance with the performance standards set. • There is an identified clinical lead for stroke within the ambulance service • Skill mix supports supervision of junior and trainee ambulance personnel

Performance Target

Standards

1. Percentage of suspected stroke patients transferred by ambulance where a validated tool 100% (e.g. FAST) was used to determine stroke (SSNAP)

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B) Pre-Hospital

2. Percentage of patients admitted to hyper acute services within 4 hours of symptom onset

(SSNAP)

3. Percentage of FAST positive patients with a “call to door” time of <60 mins (SSNAP) 60%

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C) i. Acute Phase – Hyper Acute Stroke Care 0-6 hours

For the purposes of this specification hyper acute stroke care refers to the first six hours and acute care to the following 72 hours. There are clearly overlaps in the care received during these two phases. During this period a hyper acute stroke unit provides physiological monitoring, expert specialist clinical assessment, intensive level nursing care, rapid imaging and the ability to deliver intravenous thrombolysis 24/7. The remainder of the care up to 72 hours can be considered as acute care. All stroke services should be organised to treat sufficient volume of patients to ensure skills are maintained. Depending on volume of cases these services may be in a specialist Hyper Acute Stroke Unit (HASU) or in a dedicated area on a stroke unit.

People with stroke will receive an early specialist assessment, including swallow screening and, for those that continue to need it, have prompt access to high-quality stroke care.

Measurement of the success or otherwise of hyper acute and acute stroke care should be through the stroke sentinel national audit plan (SSNAP) run by the Royal College of Physicians. This audit comprises 44 key indicators divided into 10 domains. All stroke units are scored every three months encouraging improvements in stroke care nationally and allowing comparison between different stroke care pathways. Units around the country receive a total score and are ranked in quintiles A to E from top 20% to bottom 20%. Units in Lancashire and South Cumbria must aim as a minimum to progress upwards by one quintile within 12 months and for all Trusts to aim to achieve an overall SSNAP score of C or above.

Service Clinical assessment: Outcomes • NWAS crew shall pre-alert the hyper- acute service prior to patient arrival • All patients (including self/ GP referrals) with suspected stroke shall be admitted to a hospital with hyper acute services and seen immediately by the stroke team to receive immediate structured assessment (within 30 minutes) by appropriately trained staff in a stroke trained consultant led team to determine likely diagnosis and suitability for thrombolysis and ongoing care needs • All suspected stroke patients will be seen and assessed by a member of the specialist stroke team (Stroke Specialist Nurse / Stroke Consultant) without delay and within 30 minutes of arrival

All patients with stroke symptoms shall receive early assessment, which shall include:

Encompasses o Eligibility for thrombolysis and other relevant hyper acute treatment National o Blood Sugar measurement to exclude hypoglycaemia / hyperglycaemia and other relevant blood tests Outcome o Electrocardiogram (ECG)to assess for abnormalities (e.g. Atrial Fibrillation) Framework o Need for immediate brain imaging (Computed Tomography (CT) radiographer on site 24/7, see access to acute Domains 1-5 services for definition of immediate.) o Swallow screening (within 4 hours of admission) o Hydration assessed on admission and managed so that normal hydration is maintained o Assessment and management of other causes of stroke: intracerebral haemorrhage, subarachnoid haemorrhage,

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C) i. Acute Phase – Hyper Acute Stroke Care 0-6 hours

acute arterial dissection, cerebral venous thrombosis

• All stroke patients shall be admitted to a specialist Stroke Unit within 4hrs of arrival at hospital • The Hyper acute service shall have sufficient capacity for all stroke admissions; there shall be a ring fenced bed on the stroke unit for continuous assessment and monitoring • Ensure all patients with stroke are given an antiplatelet (e.g. aspirin 300mg) immediately after scanning unless contraindicated • Diagnosis discussed with patient and carer and plan of care clearly written in patient notes • Palliative / end of life pathway must be implemented for appropriate patients • All high risk TIAs shall undergo a specialist assessment within 24 hours of presentation to a healthcare professional

Thrombolysis:

• Patients identified as potentially eligible for thrombolysis treatment shall be scanned within next available CT slot • Treatment options to be discussed with patients and carers regardless of face to face or telemedicine assessment • If eligible, all patients shall receive thrombolysis, ideally within 30 mins and certainly within 60 mins of admission (door to needle time) • Thrombolysis shall be conducted within the criteria specified within the RCP National clinical guidelines for stroke

Monitoring:

• Protocols or pathways shall be in place that ensure appropriate monitoring of stroke patients in the hyper acute phase of care:

o All hyper acute patients shall be monitored for 24 hours according to agreed protocols and then according to patient’s needs o Any thrombolysed patient shall be closely monitored according to agreed protocols by stroke-trained staff for the first 24-72 hours post-thrombolysis in a monitored bed

Access to support services where indicated:

• Hyper acute services shall have onsite access to the following support services and clinical interpretation:

o Brain imaging (Magnetic Resonance Imaging (MRI) and CT) – patients are scanned in the next scan slot within

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C) i. Acute Phase – Hyper Acute Stroke Care 0-6 hours

usual working hours, and within a maximum of 60 minutes of request out-of-hours with skilled radiological or clinical interpretation being available 24/7 o Vascular imaging (e.g. ultrasound, Magnetic Resonance Angiogram (MRA), Computed Tomography Angiogram (CTA)), within 24 hours

• Access (onsite or off-site) to specialist services will be available with agreed referral criteria to provide:

o Neurosurgery o Vascular surgery o Diagnostics and Interventional Neuro-radiology Patient transfer:

• A system shall be in place to reduce delays in patient transfers.

End of Life Care:

• The initial clinical assessment will identify patients who are dying and staff will then initiate palliative/end of life care • Staff shall have access to an identified contact regarding queries they may have and who can support them with sensitive conversations • Access to a designated End of Life Care discharge planning nurse shall be provided

Education & • All hyper acute service staff shall have comprehensive knowledge of the stroke pathway: Training o Clinical staff assessing stroke admissions shall be trained in thrombolysis and interpretation of brain imaging o In-house hyper acute stroke training programmes shall be provided (to include stroke specific communication training to assist in the management of aphasic patients) o External stroke training shall be available, stroke physicians and non-medical specialist/ expert practitioners must achieve stroke specific competencies as detailed in the Telestroke Governance policy (provided in accordance with the Stroke Specific Education Framework) o All staff shall be trained in the Mental Capacity Act and its implications o The stroke service shall hold regular meeting between stroke Physicians and expert radiologists o All staff shall be trained in palliative and end of life care processes such as the Amber Care Bundle and Sensitive Communication Skills Training for End of Life Care shall be provided to all staff

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C) i. Acute Phase – Hyper Acute Stroke Care 0-6 hours

Workforce Consultant Stroke Specialist led:

• There will be access to consultant stroke specialist decision making for all hyper acute stroke related issues, including thrombolysis 24/7:-

o This shall be delivered in person or via telemedicine o A sustainable on-call rota of no more than1:6 o There will be at least 1 x daily senior medical ward round, the senior clinical decision maker will be stroke specialist trained

Recommended Staffing Numbers (Hyper Acute)

National Recommendation: 6 BASP thrombolysis trained physicians on a rota 24/7 2.9 WTE nurses per bed to comply with 80:20 trained vs. untrained skill mix 0.73 WTE Physiotherapist per 5 beds (respiratory & neuro) 0.68 WTE Occupational Therapist per 5 beds 0.68 WTE S< per 10 beds Access to social worker

Identified clinical leads (i.e. one A&E Clinical Stroke Lead and one Radiology Stroke Lead)

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C) ii. Acute Stroke Care 6-72 hours, iii. Acute Care & Inpatient Rehab 72hrs-7days

Acute stroke care: 6 -72 hours after admission. Acute stroke care services provide continuing specialist day and night care, with daily multidisciplinary care, continued access to stroke trained consultant care, access to physiological monitoring and access to urgent imaging as required.

In-hospital rehabilitation should begin immediately after a person has had a stroke, patients will be assessed by all the relevant members of the stroke specialist rehabilitation team (physiotherapist, occupational therapist and speech & language therapist) within 72 hours and all appropriate patients will have documented multidisciplinary goals agreed within 5 days

Continued Stroke Care: post 72hrs, for those sites which have combined acute and rehab stroke units, the patient’s stay could be significantly longer, therefore stroke specific care will continue for the length of the patient’s stay.

Rehabilitation services should continue for as long as required, to ensure the best recovery and the minimisation of any disabilities though these are likely to extend beyond time in-hospital.

Rehabilitation goals will be agreed between the multidisciplinary team, stroke patients and carers. The carer of every person with a stroke should be involved with the management process from the outset, specifically as an additional resource of important information about the patient both clinically and socially. They should be given accurate information about the stroke, its nature and prognosis, and what to do in the event of a further stroke or other problems for example post-stroke epilepsy as well as emotional and practical support.

Service Acute stroke care: Outcomes All Stroke Patients shall have access to high quality stroke care (as listed below) and spend the majority of their time in hospital under specialist stroke care, which will include:-

• Assessment and management care plan by a stroke trained nurse and at least one member of the specialist rehabilitation team within 24 hours of admission to hospital • Any patients who failed their 4hr swallow screen will be assessed by Speech and Language Therapist for repeat swallow assessment within 24 hours • Assessment for hydration and nutrition using a validated tool and referral to Dietician for appropriate patients • Discussion regarding the need for nasogastric tube or gastrostomy within 24 hours of admission and continued re- assessment where indicated • Assessment for the promotion of bladder and bowel continence including a policy to avoid urinary catheters and prevention of pressure sores • Daily manual pulse check and/or continuous monitoring of heart rate and rhythm for 48/72 hrs for identification or confirmation of atrial fibrillation • Assessment of risk for venous thromboembolism and appropriate treatment offered, within 24hrs

20

C) ii. Acute Stroke Care 6-72 hours, iii. Acute Care & Inpatient Rehab 72hrs-7days

• Implementation of palliative / end of life pathway for appropriate patients • Mobilisation out of bed on day of admission unless contra- indicated and offered frequent opportunity to practice functional activities with a trained healthcare professional • Daily consultant or specialist middle grade ward rounds at least 5 days a week • Stroke Multidisciplinary Team (MDT) which will include stroke consultant, relevant therapists, stroke nurse, shall meet at least once per day to exchange information about individual patients • Stroke Trained MDT shall be available 7 days a week • Stroke Specialist Rehabilitation will commence as soon as possible following admission into the stroke service • A Social work assessment shall be performed within a maximum of 3 days from referral • Protocols shall be in place for receiving and discharging patients 7 days a week • Patients and carers shall receive a named contact and number for a member of the stroke specialist team • Patients and carers shall be involved in all aspects of patients care and management • Comprehensive secondary prevention advice and treatment shall be provided (see secondary prevention element)

Rehabilitation in hospital:

• Rehabilitation programmes shall be built around the patient’s individual needs with patient agreed goals:

o A personalised, patient-centred, goal-led care plan agreed by relevant therapists, patient and carer, shall be implemented from admission o Stroke survivors shall be offered relevant active therapy, at a level appropriate for obtaining rehabilitation goals, for as long as they are continuing to benefit from the therapy and are able to tolerate it (target for 45 mins per discipline, 7 days a week) o All eligible patients shall receive a cognitive and mood assessment within 7 days, and re-screening as appropriate, using a validated screening tool by an appropriate therapist o Stroke survivors with continued loss of bladder control 2 weeks after diagnosis shall be reassessed and an ongoing treatment plan involving both patients and carers agreed o Referral to Specialised neuro-rehabilitation services(e.g. spasticity, orthotics, continence, driving, vocational etc) shall be done prior to discharge o Multidisciplinary meetings shall be held at least once a week to plan patient care o The expected date of discharge shall be planned and worked towards and plans shared with patient and carers

Preparation for discharge:

21

C) ii. Acute Stroke Care 6-72 hours, iii. Acute Care & Inpatient Rehab 72hrs-7days

• Planning for care after discharge shall be undertaken with appropriate stroke patients and their carer/s, as soon as possible, to enable domiciliary care support and adaptations to be arranged in a timely manner • Protocols shall be in place to ensure patients and families are fully informed and participate in the process of transfer of care • Discharge planning protocols shall be in place to ensure information handover with clear direction for community rehabilitation requirements, discharge destination (e.g. home, care home) with full participation of the Integrated Community Stroke Rehabilitation Team where indicated • All equipment and aids (e.g. wheelchairs, continence equipment etc.) shall be reviewed and ordered before discharge • Stroke survivors shall receive a joint health and social care plan on discharge where applicable • Carers shall be offered a carers assessment to support patient discharge in line with the Care Act 2015. • A formal discharge summary report shall be shared with the GP, community stroke team and stroke survivor within 24hrs of discharge

End of Life Care:

• The MDT shall identify patients who are dying and initiate palliative/end of life care • Staff shall have access to an identified contact regarding queries they may have and who can support them with sensitive conversations • Access to a designated End of Life Care discharge planning nurse shall be provided

Education & Training • All staff of the MDT shall be knowledgeable on the care standards and protocols of the stroke pathway • Staff shall be released for in-house and external training as required, including a stroke specific in-house induction training programme. • Staff skill mix supports supervision of junior and trainee personnel • All registered nursing staff in stroke units shall be trained in urinary and bowel continence, dysphagia screening, communication and end of life care • Specific education and training shall be developed and provided in accordance with the Stroke-Specific Education Framework or recognised competency framework. This education could be accessed in-house and via external courses. • Health and social care professionals shall ensure that they are up to date with the current guidance from the DVLA • All staff shall be trained in the Mental Capacity Act and its implications • All staff shall be trained in palliative and end of life processes such as Amber care.

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C) ii. Acute Stroke Care 6-72 hours, iii. Acute Care & Inpatient Rehab 72hrs-7days

Workforce Staffing numbers:

National Recommendations:- The service provider shall ensure that Acute and rehabilitation services have a multidisciplinary team comprising of: • Nurses: 1.35 WTE per bed (65:35 trained to untrained skill mix) • Physiotherapists: 0.84 WTE per 5 beds • Occupational Therapists: 0.81 WTE per 5 beds • Speech & Language Therapists: 0.81 WTE per 10 beds • Psychologists • Dieticians 60 • Social workers

Access shall be available to a range of additional professionals including those in: • Clinical Psychology • Oral health • Orthoptics • Orthotics • Pharmacy

Note: where combined stroke units are used, it is expected that beds are designated as hyper acute and acute, then staffed according to the hyper acute service and acute service standards outlined.

Performance Level A Level B Level C Standards  48% scanned within 1 hr  43% scanned within 1hr  30% scanned within 1hr Domain 1.  95% scanned within  90% scanned within 12hrs  85% scanned within 12hrs

Scanning 12hrs  Median scan time less than  Median scan time less than  Median scan time less 75mins 90mins than 60mins Domain 2.  Directly admit 90% of  Directly admit 75% of  Directly admit 60% of

Stroke Unit patients to SU within patients to SU within 4hrs patients to SU within

23

C) ii. Acute Stroke Care 6-72 hours, iii. Acute Care & Inpatient Rehab 72hrs-7days

4hrs  Median SU time less than 4hrs  Median SU time less 3hrs  Median SU time less than 2hrs  85% of patients spend at than 4hrs  90% of patients spend least 90% of stay on SU  80% of patients spend at at least 90% of stay on least 90% of stay on SU SU

 Thrombolyse 20% of  Thrombolyse 12% of  Thrombolyse 15% of patients patients patients  Thrombolyse 90% of  Thrombolyse 80% of  Thrombolyse 85% of eligible patients eligible patients eligible patients according according to RCP according to RCP to RCP minimum threshold minimum threshold minimum threshold  Thrombolyse 50% within  Thrombolyse 55%  Thrombolyse 40% Domain 3. 1hr within 1hr within 1hr Thrombolysis  Directly admit 60% of  Directly admit 65% of  Directly admit 50% of patients to SU within 4hrs patients to SU within patients to SU within AND assess for 4hrs AND assess for 4hrs AND assess for Thrombolysis Thrombolysis Thrombolysis  Median clock start to  Median clock start to  Median clock start Thrombolysis is less Thrombolysis is less to Thrombolysis is than 50mins than 40mins less than 60mins

 90% of patients seen by a  85% of patients seen by a Stroke  80% of patients seen by a Stroke Consultant within Consultant within 24hrs Stroke Consultant within 24hrs  Median clock start to Consultant 24hrs  Median clock start to time less than 9hrs  Median clock start to Domain 4. Consultant time less than 6hrs  85% of patients seen by a Stroke Consultant time less than Specialist  90% of patients seen by a Nurse within 24hrs 12hrs Assessments Stroke Nurse within 24hrs  Median clock start to Stroke Nurse  80% of patients seen by a  Median clock start to Stroke less than 2hrs Stroke Nurse within 24hrs Nurse less than 60mins  75% of applicable patients given  Median clock start to Stroke  85% of applicable patients swallow screen within 4hrs Nurse less than3hrs given swallow screen within  75% of applicable patients given  75% of applicable patients

24

C) ii. Acute Stroke Care 6-72 hours, iii. Acute Care & Inpatient Rehab 72hrs-7days

4hrs formal swallow assessment within given swallow screen within  85% of applicable patients 72hrs 4hrs given formal swallow  75% of applicable assessment within 72hrs patients given formal swallow assessment within 72hrs

 80% of patients reported as  75% of patients reported as  70% of patients reported as requiring OT requiring OT requiring OT  Median number of minutes  Median number of minutes per  Median number of minutes per day on which OT is day on which OT is received per day on which OT is Domain 5. received greater than 32mins greater than 28mins received greater than Occupational  Median % of days as an  Median % of days as an inpatient 24mins Therapy inpatient on which OT is on which OT is received is greater  Median % of days as an received is greater than 70% than 70% inpatient on which OT is  80% of the minutes of OT  75% of the minutes of OT required received is greater than 55% required is delivered is delivered  65% of the minutes of OT required is delivered

 85% of patients reported as  80% of patients reported as  75% of patients reported as requiring PT requiring PT requiring PT  Median number of minutes  Median number of minutes per  Median number of minutes per day on which PT is day on which PT is received is per day on which PT is Domain 6. received is greater than greater than 28mins received is greater than

Physiotherapy 32mins  Median % of days as an inpatient 24mins  Median % of days as an on which PT is received is greater  Median % of days as an inpatient on which PT is than 60% inpatient on which PT is received is greater than 75%  80% of minutes of PT required is received is greater than 60%  90% of minutes of PT delivered  75% of minutes of PT required is delivered required is delivered

25

C) ii. Acute Stroke Care 6-72 hours, iii. Acute Care & Inpatient Rehab 72hrs-7days

 50% of patients reported as  40% of patients reported as  45% of patients reported as requiring SALT requiring SALT requiring SALT  Median number of minutes  Median number of minutes  Median number of minutes per Domain 7. per day on which SALT is per day on which SALT is day on which SALT is received is Speech & received is greater than received is greater than greater than 28mins Language 32mins 24mins  Median % of days as an inpatient Therapy  Median % of days as an  Median % of days as an on which SALT is received is inpatient on which SALT is inpatient on which SALT is greater than 60% received is greater than 70% received is greater than 55%  75% of the minutes of SALT  90% of the minutes of SALT  55% of the minutes of SALT required is delivered required is delivered required is delivered

 80% of applicable patients  90% of applicable patients  85% of applicable patients assessed by OT within 72hrs assessed by OT within 72hrs assessed by OT within 72hrs  Median clock start to OT  Median clock start to OT  Median clock start to OT assessment less than 18hrs assessment less than 12hrs assessment less than 12hrs  85% of applicable patients  90% of applicable patients  85% of applicable patients assessed by PT within 72hrs assessed by PT within 72hrs assessed by PT within 72hrs  Median clock start to PT  Median clock start to PT Domain 8  Median clock start to PT assessment less than 18hrs assessment less than 12hrs Multidisciplinary assessment less than 12hrs  80% of applicable patients  90% of applicable patients Team  85% of applicable patients assessed by SALT within assessed by SALT within Working assessed by SALT within 72hrs 72hrs 72hrs  Median clock start to SALT  Median clock start to SALT  Median clock start to SALT assessment les than 12hrs assessment les than 18hrs assessment les than 12hrs  65% of applicable patients have  65% of applicable patients  80% of applicable patients rehabilitation goals agreed within 5 have rehabilitation goals have rehabilitation goals days agreed within 5 days agreed within 5 days  50% of applicable patients are  50% of applicable patients  60% of applicable patients are assessed by nurse, therapist and are assessed by nurse, assessed by nurse, therapist have rehab goals therapist and have rehab and have rehab goals goals

26

C) ii. Acute Stroke Care 6-72 hours, iii. Acute Care & Inpatient Rehab 72hrs-7days

 Screen for nutrition and seen  Screen for nutrition and seen  Screen for nutrition and seen by a by a dietician if deemed high by a dietician if deemed high dietician if deemed high risk of risk of malnutrition 95% of risk of malnutrition 60% of malnutrition 75% of applicable applicable patients by applicable patients by patients by discharge Domain 9 discharge discharge  Draw up a continence plan within Standards by  Draw up a continence plan  Draw up a continence plan 3 weeks for 80% of applicable discharge within 3 weeks for 95% of within 3 weeks for 75% of patients applicable patients applicable patients  Screen for mood and cognition by  Screen for mood and  Screen for mood and discharge for 85% of applicable cognition by discharge for cognition by discharge for patients 95% of applicable patients 75% of applicable patients

 90% of applicable patients  75% of applicable patients receive joint health and social  80% of applicable patients receive receive joint health and care plan on discharge joint health and social care plan on social care plan on  40% of patients treated by discharge discharge stroke skilled ESD  36% of patients treated by stroke  30% of patients treated by Domain 10  95% of applicable patients in skilled ESD stroke skilled ESD

Discharge AF discharged on  90% of applicable patients in AF  80% of applicable patients in Process anticoagulation or with plan to discharged on anticoagulation or AF discharged on start with plan to start anticoagulation or with plan  95% of patients who are  80% of patients who are to start discharged alive have a discharged alive have a named  70% of patients who are named contact contact discharged alive have a named contact

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C) iv. Acute Phase – Transient Ischaemic Attack (TIA) Services

The risk of a stroke is high following a TIA – approximately 10 to 20 percent of patients who have a TIA will go on to have a stroke within seven days. Specific TIA services provide rapid diagnostic assessment and access to specialist care for high risk patients thereby lowering the risk of a subsequent stroke.

Service TIA Identification: Outcomes • All healthcare professionals who identify a patient with suspected TIA e.g. paramedics, GPs, A&E staff, shall use the ABCD2 score to risk stratify the patient • Any patient who has a risk stratification of >4 or have a history of crescendo TIA’s (more than 1 in a week or are in atrial fibrillation) are identified as being as high risk and shall be treated as a medical emergency. • All TIA patients shall be referred to a TIA service immediately (accepting direct referral from primary care and A&E). The prioritisation of patient appointments will be dependent upon their risk stratification score, clinical features if in atrial fibrillation or recurrent TIAs.

TIA Service:

• All organisations providing TIA services shall ensure: o Access to the service 7 days a week, 365 days a year o The service has both the facilities to diagnose and treat people with confirmed TIA, plus the facilities to identify and appropriately manage (which may include onward referral) people with conditions mimicking TIA o All high risk patients receive specialist assessment and investigation within 24 hours of referral receipt and are started on an antiplatelet and a statin immediately if not already initiated by the referrer o That information and advice is provided to patients regarding measurement and control of blood pressure, stroke risk and secondary prevention

• The TIA service shall have access to:- o Blood tests o ECG o Brain scan (if vascular territory or pathology uncertain) – MRI Diffusion-weighted imaging (DWI) is the preferred mode of imaging; urgently in high risk and within one week in low risk TIA o Carotid imaging (where indicated) o Referral for carotid surgery where indicated, referral shall be done via telephone conversation with Vascular Surgeon and Stroke Consultant. Carotid surgery shall be undertaken within 7 days of onset of TIA as per NICE guidance o Provision of aspirin, clopidogrel, anticoagulation or statins as appropriate

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C) iv. Acute Phase – Transient Ischaemic Attack (TIA) Services

o Lower risk TIA patients shall receive specialist assessment as soon as possible, but definitely within one week of symptoms, whichever is the sooner o Patients who have had a TIA who present late (more than 1 week after their last symptom has resolved) shall be treated as though they are at low risk of stroke

Follow Up

• All patients with confirmed TIA shall have their risk factors assessed and documented by primary care within one month of diagnosis and information provided regarding risk factor management, for example AF

End of Life Care:

Pre-hospital: • Patient shall be included in the Gold Standards Framework Register/Supportive Care Register if they are identified to being in their last year of life (NICE Quality Statement 1: People approaching the end of life shall be identified in a timely way) • Holistic assessment shall be undertaken and shared appropriately: o This shall cover physical, psychological, social, spiritual, cultural and financial needs and provides the foundation for co-ordinated care by establishing an understanding of the individual’s needs, preferences and priorities for care. It can open discussion around advance care planning (ACP) between patients and health care professionals. TIA Clinic: • Advance Care Planning discussions shall be initiated • The GP shall be informed to add patient to GSF Register/Supportive Care Register

• Sensitive Communication Skills Training for End of Life Care shall be provided to all staff

Education & Training • All providers shall ensure that specialist stroke practitioners assessing TIA patients have training, skills and competence in the diagnosis and management of TIA. • All health care professionals shall maintain and update their knowledge of the recognition and management of TIA patients • Specific education and training shall be developed and provided in accordance with the Stroke-Specific Education Framework or recognised competency framework.

29

C) iv. Acute Phase – Transient Ischaemic Attack (TIA) Services

Workforce • The service shall be led by a specialist stroke consultant or specialist stroke nurse with appropriate specialist competency (where appropriate) • Access to Vascular surgeon which could be on-site or off-site.

Performance Target Standards

1. No. of TIA cases with a higher risk of stroke who are assessed and treated within 24 hours

of presenting to a healthcare professional (ASI 5/ IPMR)

2. TIA cases with a lower risk of stroke who are assessed and treated within 1 week of

presenting to a healthcare professional

3. Number and percentage. of patients requiring Carotid Intervention/surgery receiving

intervention/surgery within 7 days of referral

4. Percentage of TIA cases who have AF and are anti-coagulated

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C) v. Acute Phase – Specialist Support Services

Specialist neurosurgical, vascular and interventional neuro-radiological procedures are sometimes necessary to prevent further damage following a stroke, or prevent stroke altogether. Effective and timely referrals are necessary to ensure that patients suffering a stroke or TIA receive the most appropriate care as quickly as possible to improve their long term outcome.

Service Access to specialist services: Outcomes All organisations providing specialist services shall ensure that: • Specialist services are provided as early as possible through early recognition of the need for surgical intervention • All patients with a suspected non-disabling stroke or TIA, or otherwise clinically indicated, have urgent access (this could be determined as hyper-acute referral to hyper-acute specialist service, meaning immediate transfer) to comprehensive neurovascular services.

Neurovascular services include: • Neurosurgical services • Vascular surgical services • Diagnostic interventional neuroradiology

Access to specialist services may be on site or off-site. For offsite services, providers must ensure that clear protocols for referral and transfer are in place, agreed and adhered to

Neuro surgical services:

There are relatively few indications for neurosurgical intervention in patients with stroke; however specific cases of stroke may require urgent management. For example:

• Cases of middle cerebral artery territory infarction shall be referred within 24 hours of symptom onset and treated (e.g. decompressive hemicraniotomy) within 48 hours of symptom onset • Treatment for aneurysm (endovascular embolisation or surgical clipping) shall be available, whenever possible within 48 hours, subject to local service configuration Vascular surgical services:

Carotid intervention (e.g. carotid endarterectomy (CEA)) for recent (within the previous 4 weeks), symptomatic severe carotid stenosis (>70% stenosis) shall be regarded as an emergency procedure in patients who are neurologically stable, and be performed within 7 days of a TIA or minor stroke

31

C) v. Acute Phase – Specialist Support Services

Urgent carotid intervention shall be managed at the clinician’s discretion, the risks and benefits of carotid endarterectomy will be discussed with the patient by the referring clinician

Diagnostic interventional neuroradiology

Intra-arterial treatments are currently limited to trial patients, treated on clinical grounds subject to availability of intervention/facilities/staff. All such treatments shall be entered onto the appropriate registry as per NICE guidance. Subsequent rollout of this service will be subject to separate commissioning by NHS England.

Education Staff shall be trained to recognise when specialist referral is required & Training

Workforce Stroke physicians shall provide input to the multi-disciplinary management of appropriate cases

Performance Target Standards

1. Percentage of patients receiving carotid surgery within 7 days of symptom onset that 95% triggered referral (UK Carotid Interventions Audit)

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D) Integrated Community Stroke Team

Early supported discharge (ESD) enables appropriate stroke survivors to leave hospital early‟ through the provision of intense rehabilitation in the community at a similar level to the care provided in hospital. An ESD team of nurses, therapists, doctors and social care staff work collaboratively as a team with patient and families to provide intensive rehabilitation at home for up to 6 weeks thereby reducing the risk of re-admission into hospital for stroke related problems and increasing independence and quality of life with support from the carer and family. Criteria for early supported discharge is mild to moderate disability (barthel 10/20 – 17/20), medically stable, transferring safely with one or a carer and able to live safely and practically at home. “Early supported discharge is a distinct, high intensity intervention specifically suited to mild-moderate stroke patients that can be offered as part of a community stroke service”.

Stroke patients who do not fit the criteria for ESD including those stroke survivors who go home or into nursing or residential homes who have lower Barthel disability scores also would benefit from access to specialist community stroke rehabilitation in a timely manner post discharge. These patients can also be discharged earlier once medically stable, safe and practical for them to live at home and have access to specialist community rehabilitation without delay. The integrated community stroke service will provide early effective community stroke rehabilitation to all stroke patients leaving hospital to ensure the earliest discharge in conjunction with the acute stroke unit staff and family.

Service The integrated community stroke team: Outcomes People with disability after stroke shall receive rehabilitation in a dedicated stroke inpatient unit and subsequently from a specialist stroke team within the community. Stroke specialist care is defined by the RCP in the stroke clinical guidelines as that provided by health care professionals with necessary knowledge, skills, and experience of management of stroke, evidenced by a suitable qualification and training.

The Integrated Community Stroke Team (ICST) shall be multidisciplinary including psychologists, occupational therapists, physiotherapist, speech and language therapists, nursing and sufficiently staffed to be able to commence treatment as set out below.

All patients shall be referred to the ICST following discharge from acute/rehab/hyper acute centres for assessment of need and management planning in the community post discharge.

The integrated community stroke service shall provide early effective community stroke rehabilitation to all stroke patients leaving hospital to ensure the earliest discharge in conjunction with the acute stroke unit staff and family.

All patients shall be effectively discharged into the community at the earliest point once medically stable and the appropriate pathway 1-4 of rehabilitation identified with rehabilitation in the community provided without delay.

The ICST shall provide in reach to contribute to pathway selection 1-4 with the acute stroke team via locally agreed pathway by

33

D) Integrated Community Stroke Team

telephone daily, attendance at MDT or board rounds including social worker to set up the intermediate care or reablement provision in a timely manner. Age appropriate provision shall be made for the social care requirements of stroke survivors prior to discharge.

The ICST shall attend home visits as needed to support coordination of pathways and discharge planning.

A single point of contact for the integrated community stroke team shall be provided when patients leave hospital in the joint health and social care plan by the acute stroke team.

The GP shall be informed of admission to the team by the ICST within a week of admission to the team and a discharge summary sent to the GP within a week post discharge from the team with a summary of functional ability, progress and any recommendations following the ICST intervention.

A range of services are in place and easily accessible to support the long term needs of individuals, their carers and families, encouraging self-management where appropriate which are accessed/coordinated by the ICST as needed to ensure holistic coordinated care planning with other services.

Decision to refer on to other generic community rehabilitation teams should only be made by the ICST; and when it is deemed specialist ICST management and treatment is no longer needed and needs’ can be met by a generic rehabilitation service or life after stroke exercise pathways.

Carer assessment shall be completed for each carer with links to carer support groups made and family support organisations may be invited to the MDT meetings to discuss new referrals and on-going patients on the caseload.

Hospital pathway

All patients shall be contacted by telephone by a member of the ICST within 24 hours of discharge to triage and arrange an assessment date.

Response and treatment timescales:

Pathway 1: All patients shall be assessed at home to determine a management plan within 24-72hours of discharge based on clinical judgement from the information provided during discharge planning in the acute in reach phase and telephone triage within 24 hours post discharge.

34

D) Integrated Community Stroke Team

ESD patients: Treatment begins no later than 24 hours from assessment date or as per clinical judgement/patient choice. Non-ESD: Treatment begins no later than 7 days from assessment date or earlier if needed based on clinical judgement and patient choice.

Pathway 2 or 3: All patients shall be assessed at home or in the intermediate care unit within 24 hours of discharge as per clinical judgement/patient choice.

All disciplines in the ICST shall carry out the assessments needed OT/PT/SLT/Nurse within the first week of admission onto these pathways and put treatment plans in place.

A joint rehabilitation management plan with reablement shall be put in place following the initial assessment at home.

The ICST shall have responsibility for supporting the staff in the intermediate care unit and reablement service to carry out the practice of the rehabilitation treatment plans.

The ICST shall attend the MDT meetings at the intermediate care unit and reablement planning meetings to coordinate, review and plan care.

Pathway 4: patients discharged to a nursing or residential home shall have a call from the ICST with 24 hours of discharge for triage with assessment carried out within 72 hours of discharge.

Assessment shall include review of swallow, spasticity, seating, pain, upper limb management, mobility/transfer methods, continence, diet, pressure management.

Treatment shall begin for those patients who require therapy no later than 7 days from assessment or earlier based on clinical judgement.

Community referrals

Any patient living in the community who has been identified as having a stroke related problem within the scope of the ICST skill set shall be triaged by the ICST and contact made with the patient within 48 hours to determine need and management pathway. Treatment shall begin within 7 days of assessment date and intervention provided for up to six months.

The ICST will triage the referral to make a decision if the patient is to be treated by the ICST or referred onto generic pathways for management

35

D) Integrated Community Stroke Team

Medical support

The team shall seek medical support from the team nurse, GP and Stroke consultant as necessary to ensure arising medical problems are reviewed.

Intensity

Intensity shall be provided at a level based on individual need that enables the patient to meet their rehabilitation goals. Intensity levels guide: 3 hours 45 minutes per week within the first two weeks (ESD pts) and/or 2 hours 15 minutes for the first 4 weeks (non ESD/post ESD) of individual sessions of OT,PT and SLT (weeks start when treatment starts; to enable patients to reach goals in prime phase of rehabilitation recovery

The ICST shall meet weekly as a minimum to plan and manage patient care working closely with the family and carer support service or equivalent to assist in the management of emotional/financial support/life after stroke issues.

Goals shall be incorporated into a personalised plan that allows the patient to take ownership of their rehabilitation and shall be reviewed regularly (every 4-6 weeks) with the patient throughout the treatment period which will promote and support the well- being principle.

Therapy shall be offered with the ICST for a maximum of 6 months with extensions for patients with cases for exception. All outcome measures shall be recorded one week upon arrival and one week following discharge from the ICST.

The planning process for any service development should include active involvement of stroke patients and carers, with particular consideration of the views of patients who are unable to participate in the planning process directly.

Hours of Service

The hours of service shall be 08:30-16:30 6 days a week. The days over the weekend should be worked flexibly depending on the up-coming discharge planning from the acute/hyper acute over the weekend. Priorities for the weekend working should be to support hospital discharge or transfer to intermediate care unit, reablement and continuation of high priority rehab patients already on the caseload or newly discharged on a Thursday or Friday for continuity of treatment.

Stroke Rehabilitation Management

Specialist stroke rehabilitation, support and any appropriate management plans shall address the following issues either directly

36

D) Integrated Community Stroke Team

or by seamless onward referral where required

• Mobility and movement (including exercise programmes, gait retraining, mobility aids and orthotics) • Upper limb rehabilitation • Management of spasticity and tone • Sensory impairment screening and sensory discrimination training • Falls prevention (including assessment of bone health, progressive balance training and aids) • Cognitive rehabilitation (including addressing impairment in attention, memory, spatial awareness, perception, praxis and executive function) • Communication (including aphasia support twice weekly during the first 20 weeks, techniques or aids for dysarthria and apraxia, information about local groups) • Everyday activities including provision of daily living aids and equipment (e.g. dressing, washing, meal preparation) • Emotional and psychosocial issues (e.g. depression, adjustment difficulties, changes in self-esteem or efficacy, emotionalism) • Swallowing (including swallowing rehab, maintenance of oral and dental hygiene, nasogastric tube feeding, gastrostomy) • Skin integrity ( i.e. pressure care and positioning) • Nutrition (including specialist nutritional assessment, nutritional support) • Visual disturbance • Continence (bladder and bowel) • Social interaction, relationships and sexual functioning (including psychosocial management or medications) • Pain (assessed regularly using validated score, referred to specialist where indicated) • Home assessment (including need for larger scale equipment or adaptation) • Return to work (including referral to specialist in employment or vocational rehabilitation) • Driving • Financial management and accessing benefits

Joint working with stakeholders to develop pathways from ICST into community leisure and exercise classes which are promoted to stroke survivors, who are then supported to attend as part of the rehabilitation process

Stroke survivors are aware of and offered options to promote wellbeing, including peer-led support groups, engagement in community activities and professional psychological therapies including IAPT and community mental health services.

The ICST will work with the person with stroke and their family or carer, identify their information needs and how to deliver them, taking into account specific impairments such as aphasia and cognitive impairments. Pace the information to the person's

37

D) Integrated Community Stroke Team

emotional adjustment.

Referral to IAPT services should be coordinated by the ICST with advice from the psychologist as to most appropriate patients for this support

Referral should be made to Functional Electrical Stimulation for Foot drop services for those patients who fit the criteria

The team shall promote the practice of skills gained in therapy in the patient’s daily routine in a consistent manner and patients shall be enabled and encouraged to practise that activity as much as possible.

Carers are offered a carers assessment tailored to their individual needs to support well-being during the rehabilitation process

Carers are appropriately educated and trained to recognise and report causes of illness that could result in avoidable admission e.g. constipation, urinary tract infection, swallowing problems

Discharge

Maximum service provision is 6 months with extension for exceptional cases

Discharge when patient’s goals are met or patient declines service.

Patients shall be able to re refer themselves back to the ICST at any point post discharge for assessment of need and decisions about most appropriate pathway or referral to generic services.

Discharge summary sent to the GP and hospital consultant within a week of discharge from the team

Data/Audit

Agree on standard sets of data that should be collected and recorded routinely including the data required for the SSNAP.

Have an agreed protocol with the acute trust on the transfer of patient records to the ICST on the SSNAP system to ensure compliance with the audit.

All patients’ outcomes are entered onto the SSNAP database and locked to transfer at the appropriate SSNAP deadlines for quarterly reporting.

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D) Integrated Community Stroke Team

Annual report is collated presenting the outcomes of the service in terms of service delivery, patient’s outcomes and satisfaction with action plans for service improvement.

Relationships with stakeholders

Members of the ICST shall:

• Actively attend any stroke specific meetings, task groups or special interest groups to contribute towards the improvement of the whole stroke pathway • Work collaboratively with the acute/hyper acute staff to improve the SSNAP data collection process and inputting of SSNAP throughout the pathway from acute to community and 6 month review • Actively work with stakeholders to review SSNAP data/NICE quality standards performance and local data to inform priorities for whole pathway improvement • Agree local pathways for management of spasticity linking with consultants/spasticity clinics for support with complex patients, Botox and spasticity management • Agree pathways for the referral for functional electrical stimulation for foot drop service post stroke

6 month Review

There shall be a process in the ICST to record stroke survivors 4-6 month review date and a letter sent to the individual with an appointment time with at least two weeks’ notice.

Reviews shall be carried out in the clinic setting, patient’s home or alternative care depending on the individual’s ability to attend a clinic.

The Greater Manchester Stroke Assessment Tool (GM-SAT), which is an evidence-based assessment tool designed specifically for the six month post-stroke reviews, should be used as the basis of the health and social care review.

Problems should be identified and managed appropriately signposting for appropriate support or re referral back for ICST intervention if needed.

The outcomes of the 6 month review shall be recorded on a database and a report produced annually on the outcomes of the assessment including number of patients offered appointment, number of people taking up the review, outcomes of the review identifying problems seen.

39

D) Integrated Community Stroke Team

Outcome of the review shall be summarised and sent to the GP and stroke consultant.

End of Life Care – MDT recognises patient is dying: • Effective, fast and where necessary, rapid systems for discharge processes shall be in place to meet individual's preferences, including to their preferred place of care and death (e.g. Rapid Discharge Pathway) • Advance Care Planning shall be Initiated and/or reviewed • The North West End of Life Care Model shall be adopted and applied to ensure: o Holistic needs assessment o Advance Decisions To Refuse Treatment o Benefits review of patient and carer including Grants/prescription exemption o Provision of information on Blue Badge (disabled parking) scheme o On-going monitoring and support agreed to avert crisis o Referral to other services e.g. Specialist Palliative Care

• Sensitive Communication Skills Training for End of Life Care shall be provided to all staff Workforce There shall be established stroke skilled, multidisciplinary community rehabilitation team working in partnership with local authorities and other health and third sector providers. Composition of the team shall include as a minimum:

• Physiotherapist • Occupational therapist • Speech and language therapist • Nursing • Social care • Rehabilitation assistants/assistant practitioners • Clinical psychology

Staffing levels: A Integrated stroke multidisciplinary team composition should include as a minimum (WTE per 100 cases per year) over 5 days with additional staff to support weekend working as per local demand with sufficient capacity to provide the service to the performance standards set. Recommended minimal level on weekend is one qualified and one un qualified member of staff to carry out new assessments and high priority rehabilitation (based on consultation across GM, Lancs, Cumbria)

• Occupational Therapy (1)

• Physiotherapy (1)

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D) Integrated Community Stroke Team

• Speech and Language Therapy (0.4) • Nurse (0- 1.2) • Social worker (0- 0.5) • Rehabilitation assistants/Assistant practitioner (1) • Clinical Psychology (see document inset for options of levels of psychology) (1 day a week per 100 referrals)

The community rehabilitation team shall have access to support from:

• Reablement service or equivalent Psychology provision • Intermediate Care Unit for community stroke • GP • Dieticians • Orthotics • Orthotics • Vocational rehabilitation • Spasticity clinic/Consultant review for Botox, splinting for management of spasticity • FES foot drop service • Consultant review • Specialist inpatient neuro rehab centre • Return to work services • Long term conditions services with self-management/expert programme • Befriending/peer support/respite • Voluntary services/carer support

Education & Specific education and training shall be developed and provided in accordance with the Stroke-Specific Education Training Framework

Staff shall be aware of the Mental Capacity Act and it implications

Staff shall be aware of the Social Care Act 2014 and its principles

Carers shall receive training in care, for example, moving, handling and dressing; receive written information on management plan and point of contact for stroke information

41

D) Integrated Community Stroke Team

ICST shall provide on-going training and support to the support staff in the intermediate care unit and reablement to enable practice of set treatment plans by the ICST

Performance Target Standards

1. Percentage of stroke patients supported by a skilled Integrated community stroke service 95% of total discharges (SSNAP and*)

2. Percentage of stroke survivors contacted by a member of community rehabilitation team 100% within one working day and assessed within 72 hours, post discharge

3. Percentage of appropriate patients who treatment programme started within 24 hours of 100% assessment (ESD pts) or 7 days for non-ESD pts.(SSNAP and *)

4. Percentage of patients who demonstrated improvement on the MRS (SSNAP) Barthel Index Baseline first year and NEADL*

5. Percentage of appropriate patients receiving 3 hours 45 mins per week within the first two weeks (ESD pts) and/or 2 hours 15 mins for the first 4 weeks (non ESD/post ESD after 6 Baseline first year weeks) of individual sessions of OT,PT and SLT (SSNAP and *)

6. Percentage of patients with outcome measures completed within one week of arrival and 95% one week discharge from the ICST

7. Percentage of patients with a discharge summary sent to the GP within one week of 95% admission and week of discharge from the ICST *

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D) Integrated Community Stroke Team

8. Percentage of patients screened within 6 weeks post discharge for mood and cognition * 95%

9. Percentage of patients requiring specialist psychologist intervention who received the 100% specialist intervention from the team’s psychologist.

10. No increase in 28 days re admission rates with possible reduction in re admission rates due Baseline on current 28 day to early intervention and support from the CST. readmission rate

11. percentage of patients remaining in their own home following intervention from the ICST Baseline for first year (SSNAP)

Benchmark national 12. Reduction in length of hospital stay (SSNAP) proportion of patients who were discharged average or below from hospital 2 weeks post admission. Benchmark for first year

13. Proportion of patients who are still at home 91 days after discharge from hospital following Baseline assessed first ICST and Reablement pathway support.* year

14. Percentage of stroke patients that are offered and received health and social care review four- six months after leaving hospital (SSNAP). (exceptions for DNA, had another stroke, 100% declined assessment)

15. Percentage of patients and carers reporting a positive experience through a survey 90%

*Requires a separate data collection exercise. These metrics are believed to be important components of the care pathway, but at the moment there is not an existing data source to provide a standard means of collection and thus would require local collection.

43

E) Survivorship

Stroke survivors and their carers should be enabled to live a full life in the community. Support is required from local services to ensure appropriate, tailored support is provided to assist re-integration into the community and maximise the quality of life experienced by stroke survivors, their carers and families.

Service Access to stroke specific exercise programmes: Outcomes

Domain 2 (2) • All eligible stroke survivors shall have access to an exercise programme tailored to the needs of each stroke survivor, Domain 3 (3.4) designed to improve balance, endurance, strength, flexibility function and wellbeing. • Exercise programmes shall be delivered by a specialist exercise instructor who has completed the Later Life Training Exercise after Stroke (EfS) course. • All participants shall have an initial assessment prior to the programme then a further assessment following each block of intervention. • Providers shall ensure there is a clear referral pathway back into the service to enable stroke survivors to re-access exercise in the community if their condition changes or deteriorates.

Domain 2 (2.1, Access to long term communication support: 2.2,2.6ii) Domain 3 (3.4) • All stroke survivors with communication difficulties following their stroke shall have access to long term communication support in the community. • All referrals shall be contacted within five working days of referral and then seen within two to four weeks of initial contact to create an individual support plan which will assess baseline levels, identify desired goals/outcomes and to agreed support they will receive, which may include: o One-to-one support to work on desired goals o Participation in 8-10 week supported communication group o Access to peer support groups o Access to communication partner scheme

• A review shall take place at the end of each block of intervention to assess progress and update their individual support plan.

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E) Survivorship

Domain 2 (2; 2.1; Access to a key worker (named contact) for long-term support and : 2.2; 2.4; 2.6 ii) Domain 3 (3.4) • All stroke patients and their carers/families shall be provided with the contact details of a named point of contact at discharge from hospital • All stroke survivors shall be contacted by their key worker within 1 – 5 working days from the receipt of the referral. • All stroke survivors shall receive a 1-1 assessment by the patient’s keyworker to agree a personal support plan within 2- 4 weeks of referral. This plan shall identify stroke survivors desired goals/outcomes and the support which will be provided which may include:

o Provision of information on secondary prevention and healthy lifestyle measures o Provision of information about stroke and the effects of stroke o Provision of emotional support o Provision of practical advice/support, including benefits, housing, aids and adaptations o Referral/signposting into services to address unmet needs o Provision of support for self-care and support in managing the effects of stroke o Access to peer support groups and befriending services o Sign posting to a range of services in the community and support with accessing them if required o Support to participate in community life o Support with return to work or leisure activities. o Provision of practical and emotional support to the carer and family, including clear guidance on how to find help if problems develop. o Referral to health care professionals if needs changes, eg. Continence service, orthoptics,

• Key worker shall attend the weekly community stroke team MDT • All stroke survivors and their carers shall have access to education sessions on healthy lifestyles to reduce stroke related risk factors • All stroke survivors shall receive a review and onward referral to appropriate MDT members at six weeks, six months and 12 months after stroke that facilitates a clear pathway back to further specialist review, risk factor screening, advice, information, support and rehabilitation where required. Reviews shall be undertaken by the most appropriate professional according to local models of care. • Those responsible for undertaking stroke survivor reviews shall ensure that information is shared across the team, including the stroke survivor, carer, Stroke Physician and their GP.

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E) Survivorship

End of Life Care: • Recognise the deteriorating patient and refer to primary care services (ED) • Advance Care Planning shall be initiated and/or reviewed to include Advance Decisions To Refuse Treatment • The North West End of Life Care Model shall be adopted and applied • A key worker shall be identified • Expressed preferences for care information shall be completed on the Electronic Palliative Care Co-ordination System (EPaCCS) by the primary care team

• Sensitive Communication Skills Training for End of Life Care shall be provided to all staff Education and Staff working in survivorship services shall have access to training, support and guidance to ensure competence in working with Training stroke:

• Later Life Exercise after Stroke Training Course • Staff are trained to work with people with aphasia and other communication disabilities • Staff seeing stroke survivors shall have access to the Lancashire and South Cumbria directories of services, which contain information on local services and charities in the area including how the stroke survivor may access financial, emotional, social, and vocational support • Staff have the details of local services referral and acceptance criteria to ensure appropriate referral and signposting • Staff are aware of the Mental Capacity Act and its implications • Staff are trained to understand local and national Children and Adults Safeguarding procedures • Health and social care professionals should ensure that they are up to date with the current guidance from the DVLA on returning to driving • Service should include staff with expertise and competence in assessing, treating and monitoring people with behavioural and cognitive disturbance

Workforce Service providers shall have sufficient capacity to provide the service in accordance with the performance standards set.

Performance Target Standards

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E) Survivorship

1. Percentage of eligible stroke survivors (as assessed by ESD, ICST or primary care) offered 100% access to a stroke specific exercise programme.

2. Percentage of stroke survivors undergoing both an initial assessment and an evaluation assessment following referral into the exercise programme using appropriate outcome 100% measures (see below).

3. Percentage of stroke survivors with an agreed support plan and personal goals related to 100% exercise within 2 weeks of their initial assessment.

4. Percentage of stroke survivors achieving at least one personal goal related to exercise 95% whilst accessing the service.

5. Percentage of stroke survivors demonstrating an improvement in their condition following the exercise programme (local agreement of appropriate outcome tools, such as 6 min walk To be agreed locally test or 10m walk test; timed up and go; stroke impact scale; personal goal attainment or appropriate equivalent)

6. Percentage of stroke survivors with communication difficulties offered long term 100% communication support.

7. Percentage of stroke survivors referred into communication support service undergoing an initial assessment and evaluation following a block of intervention (using appropriate agreed 100% outcome measures, see below).

8. Percentage of stroke survivors with an agreed support plan and personal goals for 100% communication support within 2 weeks of initial assessment.

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E) Survivorship

9. Percentage of stroke survivors who have achieved at least one personal goal related to their 95% communication whilst accessing the service.

10. Percentage of stroke survivors showing an improvement in outcomes following communication support intervention (local agreement of an appropriate outcome tools such To be agreed locally as Self-efficacy in managing long-term health condition, PROM, TOMs or appropriate equivalent)

11. Percentage of stroke survivors offered a named key worker for information, navigation and 100% long term support.

12. Percentage of known carers provided with a named key worker for information, navigation 100% and long term support.

13. Percentage of stroke survivors and carers contacted by the key worker within 3 working 100% days from the point of referral.

14. Percentage of stroke survivors undergoing an initial assessment followed by further assessments at 6 weeks, 6 months and 12 months from point of referral into the service 100% and/or at the end of a block of intervention on their ability to manage their stroke and personal goal attainment.

15. Percentage of stroke survivors and carers referred into the service receiving an agreed 100% support plan and agreeing personal goals within 2 weeks of initial assessment.

16. Percentage of stroke survivors and carers achieving at least one personal goal in relation to 95% their recovery whilst accessing the service.

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E) Survivorship

17. Percentage of stroke survivors reporting an improved quality of life and feeling better able to manage their condition (according to appropriate outcome tools implemented at 6 week, 6 month, 12 month after referral; and/or at the end of a block of intervention eg. Self-efficacy To be agreed locally in managing long-term health conditions or the EQ-5D-5L quality of life indicator for long term conditions)

18. Percentage of stroke survivors and carers reporting a positive experience of survivorship 90% services through patient questionnaire or survey (as agreed locally)

49

F) Secondary Prevention

Healthy lifestyles and management of specific risk factors reduce the risk of an initial stroke and the risk of a subsequent stroke. For those who have already had a stroke or TIA, prevention advice is even more important. This means assessing individuals for their risk factors and giving them information about possible strategies to modify their lifestyle that can reduce their risk in addition to the prescribing of secondary prevention therapies. GPs need to actively manage major stroke risk conditions in line with national guidelines.

Service Assessment and review: Outcomes • All stroke survivors shall have their risk factors assessed and documented within one week and a personal care plan for secondary prevention developed as part of the stroke teams’ assessment which is passed on to primary care in a standardised format • Assessment for the presence of AF shall be undertaken in secondary care for both inpatients and outpatients and if diagnosed, a personalised package of care (as per NICE guidance) and information shall be offered and subsequently communicated to primary care within 24 hours of discharge/outpatient appointment • Stroke survivors and their carers shall be offered a review of their health, social care and secondary prevention needs by primary care services, within six weeks of discharge and again before six months after leaving hospital by the most appropriate professional according to local models of care • This shall be followed by an annual check of their health and social care, including review and monitoring of their stroke risk factors by the most appropriate health professional e.g. GP or practice nurse • All patients who present to primary care or A&E with symptoms of stroke that have resolved within 24hours (i.e. TIA) shall be assessed upon initial presentation for risk of subsequent stroke using the ABCD2 scoring system and referred to a neurovascular disease clinic as appropriate by the first attending qualified professional • All patients with confirmed TIA shall have their risk factors assessed and documented by primary care within one month of diagnosis and information provided regarding risk factor management, for example AF • All Stroke and TIA patients shall be routinely invited for review of secondary prevention needs on a yearly basis as a minimum • Participating GPs shall routinely audit both primary and secondary prevention of stroke and produce and maintain a register of patients who have had a stroke or TIA

Initiation and Management of Secondary Prevention:

• An individualised and comprehensive strategy for secondary prevention shall be introduced in the acute phase as soon as the diagnosis is confirmed and will be continued in the long-term by primary care, including discussion of individual risk factors. • Managing hypertension so that blood pressure is below 130/80 mmHg; treatment shall be initiated in secondary care prior

50

F) Secondary Prevention

to discharge or at two weeks, whichever is the sooner, with long term management being the responsibility of primary care. Note - gold standard target post-stroke based on RCP and NICE guidance which is tighter than QOF -150/90 • Anticoagulation shall be standard treatment for individuals with ischaemic stroke in paroxysamal, persistent or permanent atrial fibrillation and where not contraindicated • Taking into consideration patient choice, the most appropriate form of anti-coagulation therapy shall be initiated in secondary care and continued in primary care. Where there are plans to anti-coagulate as an out-patient, this shall be communicated to primary care • All patients with ischaemic stroke, not in atrial fibrillation, shall be prescribed anti- platelet medication unless contraindicated, as per NICE guidance • All patients who have had an ischaemic stroke or TIA shall be offered a statin drug as appropriate, according to NICE guidance • Information shall be communicated to patients and clinicians upon discharge by all health professionals providing care to enable appropriate ongoing care, e.g. discharge management and review information as per any standard proformas in place locally

Risk management:

• Risk factors, including hypertension, weight management, smoking, high cholesterol, atrial fibrillation and diabetes, shall be managed according to NICE clinical guidelines and appropriate action is taken to reduce overall vascular risk • Smoking cessation, safe alcohol intake, tailored exercise programmes and healthy lifestyle advice shall be offered to all stroke/TIA survivors by all appropriate health professionals providing care • Lifestyle modifications shall be discussed with patients, supported by written materials, alongside the setting of patient- centred goals by all appropriate health professionals providing care • Patients shall be made aware of risks related to high salt intake by all appropriate health professionals providing care • As part of their annual cardiovascular disease review by Primary Care patients shall have their risk factors reviewed and monitored at least annually and information and advice reinforced at every opportunity Information and advice:

• Stroke survivors shall be given a named contact on admission to the stroke unit to help them plan and manage their long- term care including physical, social and psychological needs. Further named contacts will be provided upon discharge and will be reviewed by each care provider as the patient moves through the pathway • People who have had a stroke and their relatives and carers shall be assessed by their named contact to establish and document the most appropriate format in which to receive information. They shall have access to practical, clear and consistent verbal and written information and advice provided in a variety of formats (i.e. different languages, large print,

51

F) Secondary Prevention

braille, dysphasia friendly ) throughout the care pathway which will meet individual needs and be tailored for a variety of ages, ethnicities and lifestyles • Stroke survivors shall be given information about risk factors and lifestyle management (exercise, smoking, diet, weight and alcohol), and shall be advised and supported in possible strategies to modify their lifestyle and risk factors by all appropriate health professionals providing care • TIA patients shall be given lifestyle advice and information regarding risk factors for Stroke/TIA by all appropriate health professionals providing care upon diagnosis and at annual review in Primary Care as a minimum • Patients shall receive verbal and written information regarding their medications and the importance of compliance. Health professionals shall reinforce these messages on an ongoing basis at review appointments (provision of compliance aids and the cognitive needs of the patient should be considered) • A Directory of services for survivorship shall be made available to and used by primary care to support signposting/referral of patients to appropriate services

Education and Training:

All primary care professionals shall maintain and update their knowledge of stroke prevention through CPD and are able to demonstrate the relevant skills and competencies as appropriate.

All primary care professionals shall maintain and update their knowledge of the recognition and management of TIA patients.

Nursing home staff shall be effectively trained to: • Regularly check BP, temperature, pulse rhythm • Understand the importance of patients taking their medication • Recognise the signs and symptoms of stroke and TIA are aware of the importance of dealing with stroke as rapidly as possible • Recognise when a patient is unwell and contact emergency services when needed

Social care staff in domiciliary care, care homes and day centres, together with personal assistants purchased through Direct Payments shall be effectively trained to:

• Carry out pulse checks • Recognise the signs and symptoms of stroke and TIA and are aware of the importance of dealing with stroke as rapidly as possible • Recognise when a patient is unwell and contact emergency services when needed

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F) Secondary Prevention

End of Life Care:

• Dying matters campaign should be promoted by all health and social care settings (including third sector community based organisations). (including find your 1%) • GPs shall include patients in the Gold Standards Framework Register/Supportive Care Register if they are identified to being in their last year of life (NICE Quality Statement 1: People approaching the end of life are identified in a timely way) • Health and Social Care professional shall identify when there is an opportunity to offer an Advance Care Planning discussion and/or refer to: o Advance Decisions To Refuse Treatment o Preferred Place of Care o Mental Capacity Act 2005 o Do Not Attempt Cardiopulmonary Resuscitation o Emergency Health Care Plan o Lasting Power of Attorney Registration o Making a will Health and Social Care professional shall complete expressed preferences for care information on the Electronic Palliative Care Co-ordination System (EPaCCS)

Performance Threshold Points Standards

Percentage of patients with stroke or TIA who smoke whose notes record smoking SMOK002 50-90% 25 status within the previous 12 months (QOF)

STIA001 The contractor establishes and maintains a register of patients with stroke or TIA 2

Percentage of patients with a history of TIA or stroke in whom the last blood pressure STIA003 40-75% 5 reading (measured in the previous 12 months) is 150/90 or less (QOF)

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F) Secondary Prevention

Percentage of patients with stroke or TIA who are recorded as current smokers who SMOK005 56-96% 25 have a record of an offer of support and treatment within the preceding 12 months

Percentage of patients with a stroke shown to be non-haemorrhagic, or a history of TIA, STIA007 who have a record in the preceding 12 months that an anti-platelet agent or an 57-97% 4 anticoagulant is being taken Percentage of patients with a stroke or TIA(diagnosed on or after 1 April 2014) who STIA008 have a record of a referral for further investigation between 3 months before or 1 month 45-80% 2 after the date of the latest recorded stroke or the first TIA

Percentage of patients with stroke or TIA who have had influenza immunisation in the STIA009 55-95% 2 preceding 1 August to 31 March

No. and percentage of patients who are initiated on anticoagulation within 14 days of 100% of GP date of referral Practices

No. and percentage of patients who are initiated on anticoagulation 15 days or more See note from from date of referral Jeannie (email)

No. and percentage of patients with time in therapeutic range of >65% 75%

No. and percentage of patients with time in therapeutic range of <65% 25%

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G) End of Life

Stroke is the UK’s third biggest killer. Patients having a stroke can have a rapidly changing outlook taking place in a variety of care settings; this change is reflected by The North West End of Life Care Model. To deliver high quality end of life care, systems and processes need to be in place throughout the stroke pathway. Education and training is crucial to the workforce to deliver on the 5 Priorities for Care of the Dying Person set out by NHS England Leadership Alliance for the Care of Dying People (LACDP/ Alliance). It is important that this decision is made by the appropriate skilled and experienced individual, taking account of the needs and choices of the patient, carer and family

Service End of Life Care: Outcomes • Patient shall be included in the GSF Register/Supportive Care Register if they are identified as being in their last year of life (NICE Quality Statement 1: People approaching the end of life are identified in a timely way.) • People in the last days of life shall be identified in a timely way and have their care coordinated and delivered in accordance with their personalised care plan, including rapid access to holistic support, equipment and administration of medication. • Recognition shall be given to patients whose potential for recovery is uncertain, supporting shared decision making with them to enable choice, making sure their clinical uncertainty is well managed by their team including planning ahead if their condition deteriorates further (e.g. the AMBER care bundle for patients whose recovery is uncertain) • The 5 Priorities for Care of the Dying Person shall be delivered:

1. Recognise: The possibility that a person may die within the next few days or hours is recognised and communicated clearly, decisions made and actions taken in accordance with the person’s needs and wishes, and these are regularly reviewed and decisions revised accordingly. Always consider reversible causes, e.g. infection, dehydration, hypercalcaemia, etc. 2. Communicate: Sensitive communication takes place between staff and the dying person, and those identified as important to them. 3. Involve: The dying person, and those identified as important to them, are involved in decisions about treatment and care to the extent that the dying person wants. 4. Support The needs of families and others identified as important to the dying person are actively explored, respected and met as far as possible. 5. Plan & Do: An individual plan of care, which includes food and drink, symptom control and psychological, social and spiritual support, is agreed, co-ordinated and delivered with compassion

• Effective, fast and, where necessary, rapid systems for discharge processes to meet individual's preferences, including to

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G) End of Life

their preferred place of care and death (e.g. Rapid Discharge Pathway) shall be provided. • There shall be co-ordination of care with GPs and community services, using Electronic Palliative care co-ordinations systems (EPaCCs) where these exist in the hospital's catchment area • Monitoring of ‘Just in Case’ drugs and anticipatory prescribing shall take place.

Education & Training • All staff shall be trained in palliative and end of life care processes such as the Amber Care Bundle • All staff shall receive the training outlined in the ‘Minimum Training and Education Standards document for End of Life Care • End of Life Care Quality Assessment (ELCQuA) Tool shall be used for staff personal development plans (PDP) • Sensitive Communication Skills Training for End of Life Care shall be provided to all staff

Workforce • Staff shall have access to an identified contact regarding queries they may have and who can support them with sensitive conversations. • Access a designated End of Life Care discharge planning nurse shall be provided • End of Life Care Quality Assessment (ELCQuA) Tool shall be used to support the implementation of the End of Life Care Strategy through assessment against the NICE Quality Standard for end of life care for adults

Performance Target Standards

1. Percentage mortality of stroke patients at 1 month following a stroke (SSNAP) N/A

2. Percentage mortality of stroke patients at 6 months following a stroke (SSNAP) N/A

3. Percentage mortality of stroke patients one year following a stroke (SSNAP) N/A

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G) End of Life

4. Deaths in Usual Place of Residence (Stroke Diagnosis) N/A

5. Implementation of EPaCCS N/A

6. Monitoring of ‘Just in Case’ drugs and anticipatory prescribing

7. It is an expectation that the National Quality Markers for End of Life Care are met, with data

collected to support achievement.

8. 1% of GP Practice population appearing on the Gold Standards Framework /Supportive Care 100% of GP practices Register

9. Evidence of availability of End of Life information in a variety of formats and languages

10. EPaCCS data reporting

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The North West End of Life Care Model Supporting the people of the North West to live well before dying with peace and dignity in the place of their choice

The North West End of Life Care Model

1 2 3 4 5

Increasing Last Days of First Days Advancing Bereavement decline Life after Death Disease

1 year/s Months Weeks Death 1 year/s

End of life care

Is about the individual and those important to them Is about meeting the supportive and palliative care needs for all those with an advanced progressive incurable illness or frailty, to live as well as possible until they die’. Support may be needed in the last years, months or days of life.

It should include: Key recommended Training for health and care staff:

Communication skills

Holistic assessment

Symptom control Care which is coordinated Advance care planning

Caring for carers

Priorities for care of the dying person

Bereavement support

The model supports the assessment and planning process for patients from the diagnosis of a life limiting illness or those who may be frail. The model comprises 5 phases and the Good Practice Guide (overleaf) identifies key elements of practice within each phase.

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End of Life Care Good Practice Guide

LAST YEAR OF LIFE INCREASING DECLINE LAST DAYS OF LIFE CARE AFTER DEATH Year/s Months/Weeks Days 1 year/s

Patient identified as Medical review Medical review Nurse verification of deteriorating despite effective death where indicated management of underlying All reversible causes of medical condition(s) All reversible causes of deterioration explored deterioration explored Certification of death

Multidisciplinary Team agree Clear, sensitive communication Clear, sensitive communication patient is in the last days of life with patient and those Clear sensitive with patient and those identified identified as important to them communication as important to them Clear, sensitive communication with patient and those identified as important to them Person and agreed others are Person and agreed others are Relatives supported involved in decisions about involved in decisions about treatment and care as they Dying person and agreed others treatment and care as they want are involved in decisions about want Department for Work treatment and care as they want & Pensions 011 Needs of those identified as Booklet; What to do Needs of those identified as important are explored, Agree on-going monitoring and after a death or similar important are explored, respected and met as far as support to avert crisis respected and met as far as possible possible Post death Significant Prioritised as appropriate at Gold Advance Care Planning discussion Patient included on Supportive event analysis Standards Framework meeting offered or reviewed

Care Record /GP Gold Standards Framework register and their care reviewed On-going District Nurse support Update Supportive On-going District Nurse support Care Record/ Gold regularly ICD discussion and deactivation if Standards Framework not previously initiated Register/EPaCCS with Agree on-going monitoring and Request consent to share date and place of support to avert crisis information and create EPACCS death Decisions made are regularly record reviewed and revised accordingly

Holistic needs assessment Inform all relevant Individual plan of care for the Holistic needs assessment dying person including holistic agencies ; social care, assessment, review of hydration Allied Health Ongoing communication with Keyworker identified and nutrition, symptom control Professional, Keyworker etc. is agreed, coordinated and ambulance service,

delivered with compassion OOH, Specialist Identify when there is an Palliative Care Team, opportunity to offer an Review or offer advance care equipment store Anticipatory medication plan, share information with Advance Care Planning prescribed and available patients consent discussion and/or refer on. to prevent a crisis ADRT/PPC/MCA/ Funeral attendance if DNACPR/making a will able and to include Needs of those identified as Consider Continuing Health Care carer permission if important are explored, funding/DS1500 appropriate or respected and met as far as Benefits review of patient and applicable possible carer including Grants/prescription exemption Equipment assessment OOH/NWAS updated Follow up bereavement Provide information on Blue Anticipatory medication Update EPaCCS Record as and assessment to those Badge (disabled parking) prescribed and available when necessary identified as important scheme Review package of care if DNACPR considered, outcome necessary Referral of those Agree on-going monitoring and documented, information shared identified as important support to avert crisis appropriately including Referral to other services e.g. to bereavement ambulance service Specialist palliative care counselling services as required Referral to other services e.g. Specialist Palliative Care Out of Hours/NWAS updated including DNACPR status and Staff supported OOH/NWAS updated including Advance Care Plan Advance Care Plan/DNACPR

Referral to other services e.g. ICD discussion if applicable Specialist Palliative Care 59

ADRT - Advance Decision to Refuse Treatment ICD - Implantable Cardioverter Defibrillator DNACPR - Do Not Attempt Cardio Pulmonary Resuscitation NWAS – North West Ambulance Service EPaCCS - Electronic Palliative Care Coordinating System OOH – Out of Hours GP - General Practitioner PPC - Preferred Priorities of Care Jan 2015

Lancashire & South Cumbria Directory of Services

Copy of Lancashire and South Cumbria Di

60

WLCCGB 07/15/12

WEST LANCASHIRE CLINICAL COMMISSIONING GROUP GOVERNING BODY REPORT

DATE OF BOARD MEETING: 28 July 2015

TITLE OF REPORT: Procurement of Community Services

BRIEFING POINTS: This paper puts forward the proposal of West Lancashire CCG membership to tender adult community services for ratification by the Governing Body

Does this report / its recommendations have implications and impact with regard to the following: A. Commissioning Board’s Aims and Objectives 1. Quality (including patient safety, clinical effectiveness and patient x experience) – please outline impact This paper proposes to the GB for ratification the decision to tender Community Services. The tendering exercise will need to specify accurately the quality requirements of the new service. It is expected that the metrics included in the new tender will be a range of process, quality and outcome to ensure the desired results are achieved. 2. Commissioning of hospital and community services – please outline impact x This paper proposes to the GB for ratification the decision to tender Community Services. These services for West Lancashire could be in the region of £10m, (The scope of the procurement is not yet fixed and so this is an estimate.) 3. Commissioning and performance management of GP Prescribing – please outline impact

4. Delivering Financial Balance – please outline impact x £10m represents 7% of West Lancashire CCGs commissioning budget and so there is still a significant proportion of services which will need to be managed alongside this procurement.

West Lancashire CCGs financial position is incredibly tight over the coming years and so the financial risk in this programme needs to be well managed. A risk register will be established and the form of the contract will be such that it will look to mitigate or share risk wherever it may arise. 5. Development of the commissioning group as a commissioning organisation – please outline impact

B. Governance – please outline impact 1. Does this report: • provide the Commissioning Board with assurance against any of the risks identified in the assurance framework (identify risk number) • have any legal implications x • promote effective governance practice The CCG has taken legal advice with regard to the position of this contract which states that unless the CCG can demonstrate sufficiently the benefits of remaining with the incumbent provider, legally the CCG should tender these services as they have come to end of their contractual life. Thus the proposed decision of the membership is in line with legal advice. 2. Additional resource implications (either financial or staffing resources) 3. Health Inequalities x This paper proposes to the GB for ratification the decision to tender Community Services. The tendering

Procurement of Community Services 1 West Lancashire Clinical Commissioning Group Board Meeting - 28 July 2015 exercise will need to specify accurately the necessity to help to bridge the health inequalities gap with the new service. It is expected that the metrics included in the new tender will be a range of process, quality and outcome to ensure the desired results are achieved. 4. Human Rights, Equality and Diversity Requirements x This paper proposes to the GB for ratification the decision to tender Community Services. The tendering exercise will need to specify accurately the necessity to help to meet human rights, equality and diversity requirements with the new service. It is expected that the metrics included in the new tender will be a range of process, quality and outcome to ensure the desired results are achieved. 5. Clinical Engagement 6. Patient and Public Engagement x

The CCG has been talking about its vision for new services entitled Facing the Future Together for some time. The Communications team has documented patient and public compliments, concerns, and complaints and these have been used to refine the model and the delivery of services. Our Communications team have advised the CCG that given the amount of engagement already undertaken and the fact that that model is not changing services significantly we have engaged sufficiently to meet our statutory requirements.

l REPORT PREPARED BY: Jackie Moran - Head of Quality, Performance & Contracting

Procurement of Community Services 2 West Lancashire Clinical Commissioning Group Board Meeting - 28 July 2015

NHS West Lancashire Clinical Commissioning Group Governing Body

Title: Procurement of Community Service

Paper presented by: Jackie Moran

Paper prepared by: Carole Read

Date: 28 July 2015

Summary As Governing Body will be aware, community services transferred under the Transferring Community Services initiative to Southport and Ormskirk Hospitals nearly five years ago. The contract for community service is due to expire in March 2016 and as such the CCG needs to make a decision in line with NHS procurement rules, as to what it wants to do with regard to these services in the future.

The CCG took legal advice which was communicated to its members, which resolved that given the contract had already been extended by two years over the original contract date, the CCG should legally tender these services. These services would only be able to remain with the incumbent provider on the production of a business case which demonstrated the clear benefits of so doing.

The CCG has a vision for the shape of its services entitled Facing the Future Together (FtFT). In order to inform the decision making process regarding the future of community services West Lancashire CCG along with Southport and Formby CCG set up projects with metrics and milestones based on the Vision of FtFT to demonstrate progress towards this model of care and to show how well services could be delivered in an integrated way. The milestones have been in place since November 2014.

Not only was information considered regarding the progress towards the vision of Facing the Future Together (FtFT) but also CCG members were furnished with information regarding legal advice, performance and quality information as well as a presentation by Southport and Ormskirk Hospitals Trust. A discussion took place at the CCGs membership meeting on 9th July as to what the CCG would want to do to deliver the community services required as part of FtFT.

The CCG membership then took a vote based on weighted practice populations as to what approach they wanted to take with regard to community services. The vote indicated that the membership wanted to tender adult community services. This decision is now proposed to the Governing Body for its consideration.

The Governing Body is asked to: consider the decision by membership

• choose to ratify or not the decisions to go out to tender for adult community services

Carole Read Jackie Moran Management Support Head of Quality Performance & Contracting

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Minutes

Quality and Safety Committee

Venue: Boardroom, Hilldale, Ormskirk Date & Time: Tuesday 2 June 2015 at 1.00 – 3.00 pm

Attendees: In attendance: Mr G Mitten – Chair Mrs J Rollinson – Head of safeguarding Dr J Kinsey – GP lead for safeguarding Miss C Ashcroft – Executive assistant Mrs J Moran – Head of quality, performance and Mr P Kaura – Business analyst contracting Mrs A Lumley – Primary care nursing Dr R Bonsor – Clinical lead development lead Mrs J DeBacker – Practice manager Mrs C Heneghan – Chief nurse

Apologies: Ms G Brown – Chief executive of Healthwatch (In attendance) Mr S Featherstone – Director of nursing, Southport and Ormskirk Hospital NHS Trust (in attendance) Mrs A Butler – Quality assurance manager (in attendance) Miss M Pugh – Head of communications and engagement

Agenda Summary of Discussion Lead Item CCGQIC/ 06/15/1 Welcome and apologies for absence Greg Mitten welcomed the members of the quality and safety committee to the meeting.

06/15/2 Minutes from the previous me eting on 28 April 201 5 The notes from the previous meeting were approved as a correct record of the meeting.

06/15/3 Matters arising – action sheet The action sheet was updated.

06/15/4 Declaration of interest There were no declarations of interest raised which were pertinent to the agenda. Members will raise any relevant declarations of interest as each item is discussed.

06/15/5 Quality Improvement (general)

a. Quality account for Southport and Ormskirk Hospital NHS Trust The report is based on data from January 2015 for Southport and Ormskirk Hospitals NHS Trust as published on their website. The draft report’s contents were discussed along with the status of its links to quality, safety and contracting. The report will be considered by Southport and Formby CCG in the first instance and their response co-ordinated with ours for onward transition to the Trust re: assurance of their quality position reflected in the accounts. It was agreed that West Lancashire Quality and Safety Committee – 2 June 2015 Page 1 of 4

Agenda Summary of Discussion Lead Item CCGQIC/ cannot endorse the report until a response is received from the Trust to its letter listing quality issues. This will be raised at the contracting meeting with the Trust on Wednesday 3 June. It was agreed that further analysis of data was required to identify the full information / reason for the quality issues. CH

This report will be revisited following the Single Item Quality Surveillance Group (QSG) meeting on 15 June. Claire Heneghan will take this issue to the meeting to ascertain whether the endorsement can be made given the current quality concerns and inform the executive committee and quality and safety committee of the feedback from the meeting.

06/15/6 Primary care quality

a. Primary care dashboard

i. Referrals Jackie Moran confirmed that as primary care is now the CCG responsibility, part of the work taking place in this area is looking at practice data on referrals. Puneet Kaura presented the dashboard which is available to practices on sharepoint under the dashboard tab. Practices can view referrals by specialities with outlying practices displayed on a graph and funnel chart. This data accounts for list size and shows the Taxonomies. Once a specific practice is selected, a deeper analysis shows a specialty average. The quality of a practice’s referral levels can be tested to identify any training needs. The Local Area Team wants practices to write their own quality reports with explanations as to why the practice is an outlier. It was agreed that an internal quality assurance exercise for practices can identify why they are outliers in specific areas and what can be done to improve this.

The primary care dashboard will be circulated in the GP newsletter and JM /PK taken to a membership council meeting to demonstrate its use , either by a demonstration on prescribing, referrals and A&E data or by one speciality to see if genuine quality assumptions can be made. The numbers of patients by which a practice becomes an outlier needs to be PK identified along with where GPs are referring to.

Jackie Moran identified prescribing, numbers of registers and exclusion rates from registers as other areas for the committee to address under its responsibility to lead on quality issues. Greg Mitten confirmed the equal importance of quality in primary care and provider services plus mental health representation.

b. Nursing in primary care Alison Lumley outlined her role as primary care nursing development lead and some of the work being undertaken: • The workforce profile will be presented at the executive committee on 9 June. • Protected time has been agreed with practice nurses to meet and engage with membership meetings. Three meetings have already been well-attended. • Two practices will undergo an educational audit to enable student

Quality and Safety Committee – 2 June 2015 Page 2 of 4

Agenda Summary of Discussion Lead Item CCGQIC/ placements. • Alison Lumley provides a resource available to practice nurses, GPs and practice managers. • Support for the introduction Nurse and Midwifery Council (NMC) revalidation has been provided.

Funding is available for continuing professional development training. The funding is for registered nurses only and cannot be used for backfilling roles.

The area of concern around non-registered nurses was discussed, including the timeliness of the NMC’s process to re-register which can result in a delay of up to 6 months.

Greg Mitten requested Alison’s assistance to act as a link to provide relevant information to practices nurses.

06/15/7 Safe ty

a. Serious incident report

The report listed new, ongoing and closed StEIS incidents as at 30 April that involved West Lancashire patients. Further information is required to demonstrate progress against the ongoing StEIS. The high number of pressure ulcers was discussed at the previous contract meeting with the Trust.

b. Serious incident framework This item will be deferred to the meeting on 23 June meeting.

c. Incident reporting in primary care Jackie Moran had met with Linda Ward, who has agreed to meet with the GPs to explain the definition of serious incidents and to raise awareness of the national reporting and learning system, which GPs should use to report patient safety issues. This will ensure that a standardised process is in place for all practices. Most serious incidents are managed in-house and escalated if unresolved. Linda Ward will be invited to the membership JM council meeting.

Ros Bonsor will share a link which explains what GPs should be doing around serious incident reporting and the audit process form. A RB framework could be developed for the GPs.

06/15/8 Effectiveness

a. CQUIN / other incentive schemes Puneet Kaura had met with Jo Simpson and Mike Maguire. The weighting in CQUINs has now been agreed and included in the schedule to be sent to Jo Simpson. The quality schedule now includes the alternative quality contract indicators to be met. There are national and local measures in the schedule and penalties will be implemented if the targets are not met.

b. Dr Foster reports on cardiology and stroke Dr Foster has been working with the CCG for 18 months. Some areas of the stroke report are concerning. The acute cerebrovascular standardised

Quality and Safety Committee – 2 June 2015 Page 3 of 4

Agenda Summary of Discussion Lead Item CCGQIC/ mortality rates demonstrate that the Trust were above the expected rate of mortality. The relationship between the location of the rehabilitation ward and the mortality rate in acute cerebrovascular was discussed. Also, the number of times patients are moved around between wards was highlighted. The report was felt to be beneficial.

At the single item QSG meeting on 15 June, an item on mortality will be raised, as the Trust had been identified as one of the nine Trusts in the country with the highest mortality rates. This has been raised with the Trust and it was suggested that a further letter be sent to Rob Gillies about this issue and a reminder about a response to the first letter. JM

06/15/9 Experie nce

a. GP issues, comments and complaints Information governance issues had increased and are occurring in one particular practice. There is an increase in the level of reporting, which is positive.

b. Learning from the public, My View etc This item will be deferred to the next meeting.

06/15/10 Other

Any other business A response to the letter containing the summation of quality issues sent to Simon Featherstone and Rob Gillies by Claire Heneghan on 7 May, will be requested. The lack of response will be formerly escalated to Mike Maguire JM and Dr John Caine.

The CCG reports to both the Lancashire and Mersey QSG, but in the future Lancashire will refer to the Mersey QSG for acute issues. Claire Heneghan and Debbie Fagan have agreed the meeting of the QSG with the Cheshire and Mersey team on 15 June will focus on one single item – Southport and Ormskirk Hospital NHS Trust. The meeting will include representation from the TDA and Monitor with quality leads from both CCGs. The single item QSG Enhanced Surveillance Trigger Template for the Trust will be circulated CA with the committee minutes.

Greg Mitten will discuss the increasing workload with Mike Maguire. Discussion took place about the form of replacement of the quality assurance manager role as Ann Butler will be leaving the CCG. Claire Heneghan and Jackie Moran were praised for the guidance and mentoring provided to Ann. Jackie Moran highlighted that previously the CSU had provided support to the CCG on certain quality issues and the need to find alternative support. Greg Mitten asked that the committee endorse the work being undertaken.

Date and time of the next meeting –

Tuesday 23 June at 1 pm, Boardroom, Hilldale, Ormskirk

Quality and Safety Committee – 2 June 2015 Page 4 of 4

Minutes

Quality and Safety Committee

Venue: Boardroom, Hilldale, Ormskirk Date & Time: Tuesday 23 June 2015 at 1.00 – 3.00 pm

Attendees: In attendance: Mr G Mitten – Chair Mrs L Elliott – Lead nurse for safeguarding adults Dr J Kinsey – GP lead for safeguarding and mental capacity act Mrs J Moran – Head of quality, performance and Miss C Ashcroft – Executive assistant contracting Mrs A Butler – Quality assurance manager Dr R Bonsor – Clinical lead Mrs N Baxter – Head of medicine optimisation Mrs J DeBacker – Practice manager Mr R Gillies – Medical director Mrs C Heneghan – Chief nurse

Apologies: Ms G Brown – Chief executive of Healthwatch (In attendance) Mr S Featherstone – Director of nursing, Southport and Ormskirk Hospital NHS Trust (in attendance)

Agenda Summary of Discussion Lead Item CCGQIC/ 06/15/1 Welcome and apologies for absence Greg Mitten welcomed the members of the quality and safety committee to the meeting. The apologies above were relayed.

06/15/2 Declaration of interest Drs Jack Kinsey and Ros Bonsor declared an interest in item 10b. GP issues. Not action was required in terms of this declaration.

06/15/3 Minutes from the previous meeting on 2 June 2015 The notes from the previous meeting were approved as a correct record of the meeting, with the following amendment: Page 3. 06/15/7c. Ros Bonsor will share a link which explains what GPs should be doing around serious incident reporting and ‘the audit process form.’

06/15/4 Matters arising – action sheet The action sheet was updated.

06/15/5 Extract from the integrated business report As there is limited data available at month one, the full IBR has not been produced this month, but the following three extracts were presented:

Alternative Quality Contract (AQC) – this data reflects the year-end position and is shared with the Trust. It demonstrates the level of funding withheld at end of year due to targets which have not been met by the Trust, eg e- discharge letters. The national target is still October 2015 for the changes. There is no AQC between the CCG and Trust this year, but many of the indicators now appear in the quality or information schedules. There is a national expectation that penalties will apply if targets are not achieved in Quality and Safety Committee – 23 June 2015 Page 1 of 5

Agenda Summary of Discussion Lead Item CCGQIC/ year. Rob Gillies felt that the Trust would be compliant by the end of quarter 4.

Choose and Book (CAB) – 63% of referrals received are e-referrals, with the remainder as paper referrals. Discussion took place around ways to encourage e-referrals and to cease paper referrals. This data applies to consultant clinic referrals but will eventually apply to all service referrals. Dr John Caine had discussed this with Dr Paddy McDonald and co-operation is needed from consultants. In terms of communication between GPs and consultants, it is important to understand if a referral or a query should be used, but progress is being made.

Currently some slots are not released to CAB, but reserved to accommodate paper referrals or to defer to the provider. Cath Thompson is in discussion with Darren Hunter about implementing a full e-referrals process. There is a risk that if patients cannot attain an appointment with the Trust they will go to another provider and may choose to remain with that provider. This is an area in Facing the Future Together.

Patient waiting – in terms of referral to treatment (RTT) data, there have been some issues with the new Medway system. Rob Gillies declared an interest in terms of his role in implementing Medway and confirmed that from experience with other Trusts, there is a six-months bedding in period for new systems. Medway is working well and the issues were due to the training of staff, which has now been completed by McKesson. RTT will be reported accurately from July. Richard McCarthy checks the data on a regular basis.

06/15/6 Quality Improvement (general)

a. Review of Wigan, Wrightington and Leigh Trust AB This item was deferred to the next meeting.

06/15/7 Primary care quality

a. Primary care prescribing data Nicola Baxter reported on Quarter 4 2014-15 prescribing data, which covers national and local QIPP areas. The medicines management committee analyses the data to inform the medicines optimisation workplan for 2015-16 and identify outlying practices. The current plan includes the following areas; antimicrobials, enteral feeds and strong opioids, these areas have also been agreed by the membership. The workplan will be supported by education sessions at membership, for example at a recent membership council the dieticians attend to support the work on enteral feeds and food first, and discussion took place around the community dieticians not being involved in a patients discharge into the community. Some of the QIPP areas such as long acting Insulins and pregabalin are directly influenced by secondary care. There is currently no joint prescribing meeting between the ICO and the CCG to discuss prescribing issues. The lack of joint working will be brought up through the contracting route. Currently the Pan-Mersey Area prescribing committee makes recommendations on new medicines and these are adopted by CCGs and Trusts independently of each other, including the ICO.

Quality and Safety Committee – 23 June 2015 Page 2 of 5

Agenda Summary of Discussion Lead Item CCGQIC/ The medicines optimisation team, work with the practices to develop medicines optimisation workplans and encourage the practices to work on their red QIPP areas, where they are not at target. Part of the medicines optimisation team’ workplan is to support the membership through education sessions. The plan for membership will be circulated through JM the GP newsletter, along with the quarterly QIPP report.

06/15/8 Safety

a. Serious incident report – May 2015 The report listed new, ongoing and closed StEIS incidents as at 31 May that involved West Lancashire patients. Further information is required to demonstrate progress against the ongoing StEIS incidents. There are issues in closing down StEIS incidents within 20 days and how the CCG receive assurance prior to their closure. It was suggested that the CCG have representation on the Southport and Formby CCG meeting to jointly oversee and manage SUI closure. The CCG now receive feedback from Blackburn and Darwen and attend their StEIS closure meetings in relation to Lancashire Care incidents. Future resources to attend the meetings will be discussed in light of Ann Butler leaving.

b. Serious incident framework Ann Butler presented the report which reflected changes made on 1 April and lists the definition of SUI’s which now includes ‘possible’ harm, eg. MRSA infections. Trusts now have 60 days to complete a root cause analysis as levels of reporting no longer apply. As CCGs have only 20 calendar days to report back on a root cause analysis, joint working with Southport and Formby CCG will take place to meet the new deadline for meetings which are infrequent. Ann Butler is attending a meeting on 26 June to take forward and will feed back to the committee. AB

c. Lancashire Quality Surveillance Group A meeting has not taken place to report at this meeting. Claire Heneghan CH will report at the next meeting following Lancashire Quality Surveillance Group which is to be held later in the week.

d. Merseyside Quality Surveillance Group – single item agenda meeting Rob Gillies provided feedback on the meeting. It was felt that the meeting followed a process with challenging questions received from West Lancashire CCG. No feedback has been received following the meeting.

e. Safeguarding children and vulnerable adults Lorraine Elliott reported that an annual report will be available for the next committee meeting. The CCG have an action plan for the Cheshire West ruling and current problems in accessing data will be discussed with Claire Heneghan. MPA media resource has produced a video for YouTube accessible by nursing / care homes, which will be available in September and October. Best practice pressure ulcer guidance for West Lancashire patients, will be ratified in July. There are currently no care homes on QIP. Safeguarding adults review board received 13 referrals for adult reviews and additional support will be sought to process the reviews.

Dr Ros Bonsor raised the lengthy response time for the independent metal

Quality and Safety Committee – 23 June 2015 Page 3 of 5

Agenda Summary of Discussion Lead Item CCGQIC/ health capacity assessment (IMCA) process. Lorraine confirmed that this is commissioning by the local authority with funding expected to provide the resources currently required. Lorraine Elliot asked that specific cases of concern for IMCA be forwarded to herself to reassess the risk. GPs need to be informed. This will be raised at the pan-Lancashire review meeting.

New guidance from the Department of Health in April states that patients at the end of life, who have already consented to treatment, are not under the deprivation of liberty (DoL) judgement.

Lorraine Elliot will provide a link to the Lancashire Adults Safeguarding LE Board e-learning guidance. Also, to be circulated are the training requirements for the different levels of childrens, adults and mental capacity act training.

06/15/9 Effectiveness

a. Prescribing from secondary care Nicola Baxter covered this item in item 7a.

06/15/10 Experience

a. Open and Honest report – April 2015 This item was discussed earlier in the agenda.

b. GP issues, comments and complaints This item was discussed earlier in the agenda.

c. Learning from the public, My View etc This item will be deferred to the next meeting. CA

06/15/11 Other

Any other business

Southport and Ormskirk Hospital NHS Trust’s action plan – Rob Gillies provided feedback on the report which identified issues of infection prevention control, medicine management, equipment (a medical device committee is now embedded. The capital equipment bids are the urgent bids for unanticipated purchases. There is a three-year plan for equipment replacement, servicing and the asset register have been updated.), adequate medical and nursing staff (staff are being sought abroad and posts will not commence until March 2016), maternity and obstetrics (Dr Jack Kinsey and Carol McCabrey to meet on 16 July with the Trust about an audit), community services. Kate Fallon has produced a report on community services which contain a series of options for the ICO to take forward in the next 12 months. A balanced focus between community and acute at board meeting level is required and in support of this a job description for a community lead director will be presented to the Trust board on 24 June. The Spinal injuries unit has appointed a new matron following the CQC report issued in May which highlighted concerns. Claire Heneghan raised the quality committee’s letter to Simon Featherstone highlighting a number of quality issues. Simon has suggested that the issues have been addressed in a number of other Quality and Safety Committee – 23 June 2015 Page 4 of 5

Agenda Summary of Discussion Lead Item CCGQIC/ responses to the CCG. Committee members will consider information received to ensure all areas have been addressed.

Date and time of the next meeting – Tuesday 28 July at 1 pm, Boardroom, Hilldale, Ormskirk

Quality and Safety Committee – 23 June 2015 Page 5 of 5

West Lancashire CCG Clinical Executive Committee Action and Notes – 12.5.15

Due Responsible Discussion and Decisions This week’s actions RAG Date officer Attendees Adam Robinson - Secondary Care Consultant Bapi Biswas – GP Executive Lead Claire Heneghan – Chief Nurse Debbie Dobson - Practice Manager Doug Soper – Lay Member Jack Kinsey – GP Executive Lead Jackie Moran - Head of Contracting, Performance and Quality Jo Debacker – Practice Manager Joanne Kane – Admin Assistant John Caine – Chairman Katie Wightman - Head of Corporate Affairs Lucinda McArthur - Senior Operating Officer Mike Maguire – Chief Officer Paul Kingan – Deputy Chief Officer and Director of Finance, Contracting and Corporate Affairs Peter Gregory - GP Executive Lead Ros Bonsor - GP Executive Lead Greg Mitten – Lay Member

Apologies Simon Frampton – GP Executive Lead

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IPA Issue Discussion took place on the ethics relating to funding of high cost IPAs.

Lucinda McArthur and Katie Wightman presented further advice on the legal responsibility of WLCCG in regard to this.

The CCG is expected to demonstrate that a patient’s best interests have been fundamental in consideration of such decisions.

The ethical framework has been approved at the Exec Committee but is still to be ratified by the Governing Body at the next meeting.

It was agreed that the CCG needs to have robust policies and procedures in place. It was noted that further work around complex needs would be required.

Policy Update Katie Wightman presented three policies for approval. The major changes are • Whistleblowing within the Whistleblowing policy, which • Claims now addresses issues identified in the • Bomb Threat Francis Report.

Exec members discussed the policies including any possible risk associated with any changes.

In particular the Claims policy was examined in order to fully understand

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what this policy could mean for the CCG.

Permission was also sought to remove certain polices, the responsibility for which will now sit with NHS England. It was agreed to remove these as appropriate.

It was noted that the Research and Development policy which was un- adopted at a previous Exec committee may need to be revised and re-instated in light of the current partnership working with Edgehill University.

Katie will update and add policies to the Website accordingly.

Quality Premium Charlotte McAllister presented slides on the Quality Premium payment. These are indicators to improve quality and have awards which could equate to £5 per head if indicators are met.

Although some indicators are mandatory the Exec Committee were asked to consider a menu of choices and decide which indicators the CCG should submit on 14 May.

Discussion followed on which may be most effective and produce the best outcomes for the population.

The improvement expected is defined

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loosely as being either a reduction of something or an increase in something. However it was noted that some may be difficult to measure.

Discussion then took place regarding which options to choose according to local need, Charlotte had filtered down an extensive list to a shorter menu which aligned with current CCG priorities.

Due to time constraints the clinical Executive agreed that Mike Maguire and John Caine have delegated authority to look at the detail and to finalise which indicators to support.

Wrap up

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West Lancashire CCG Clinical Executive Committee Action and Notes – 19.5.15

Due Responsible Discussion and Decisions This week’s actions RAG Date officer Attendees Adam Robinson - Secondary Care Consultant Bapi Biswas – GP Executive Lead Debbie Dobson - Practice Manager Jack Kinsey – GP Executive Lead Jackie Moran - Head of Contracting, Performance and Quality John Caine – Chairman Katie Wightman - Head of Corporate Affairs Lucinda McArthur - Senior Operating Officer Mike Maguire – Chief Officer Paul Kingan – Deputy Chief Officer and Director of Finance, Contracting and Corporate Affairs Simon Frampton – GP Executive Lead Joanne Kane – Admin Assistant Greg Mitten – Lay Member Doug Soper – Lay Member Jo DeBacker – Practice Manager Apologies and Lucinda McArthur assign ADP Roles Peter Gregory - GP Executive Lead for the meeting Claire Heneghan – Chief Nurse Ros Bonsor - GP Executive Lead

Declaration of All GPs declared an interest in Item 6 – Interest Minor Surgery.

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Notes from The notes were approved as a correct 5 May & 12 May record. Community Carole Read led a discussion about Procurement Community Procurement the first issues that would need to be addressed if the community services went to procurement after the June gateway. The pros and cons with regard to re- 17.6.15 JM procurement of community services will Following discussions it was agreed that be presented at the June Membership further work was required. Council.

Minor Surgery All GPs declared an interest in this item.

Jack Kinsey passed chair of the meeting to Mike Maguire for this item.

The chair decided that Bapi Biswas’s interest was fundamental and Bapi should not take part in the discussion or vote. Bapi was therefore asked to leave the room for this item. Bapi left the meeting at 12.35pm.

The chair decided that the interest was significant but not fundamental for other GPs. All GPs were allowed to take part in the discussion but not vote.

At present the LES is under the Area Team however this discussion was intended to look at the benefit of re- shaping provision. It was reported that some practices have requested that the CCG consider this.

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Discussion then took place around what the process was if the CCG were to go ahead with this and how best to enforce the policy around procedures of limited clinical value.

It was agreed that more work is required Work will continue in regard to minor 2.6.15 JM to approve thresholds and further clarity surgery and this will be brought back to is needed on the present process for Exec at a future date. claims in minor surgery.

Bapi Biswas returned to the meeting at the close of the item.

CQC Update / Although there is little new to report on Discussions with the CQC, the Exec Committee was S&O Board invited to give feedback on the Trust’s response to the CQC report and subsequent interactions between the CCGs and the Trust.

Following the May Membership, the Exec committee acknowledged that S&F Membership seemed to receive the recent presentation from the ICO much more favourably than the WL Membership had done.

AOB Paul Kingan reported that the IBR was circulated yesterday and requested that the Exec members provide comments on Exec Committee to email comments on 19.5.15 All the IBR directly to Cathy Ashcroft as IBR asap. soon as possible today. Wrap up

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West Lancashire CCG Clinical Executive Committee Action and Notes – 2.6.15

Due Responsible Discussion and Decisions This week’s actions RAG Date officer Attendees Bapi Biswas – GP Executive Lead Becky Cope – Admin Officer Claire Heneghan – Chief Nurse Debbie Dobson - Practice Manager Doug Soper – Lay Member Jack Kinsey – GP Executive Lead Jackie Moran - Head of Contracting, Performance and Quality Jo DeBacker – Practice Manager John Caine – Chairman Lucinda McArthur - Senior Operating Officer Mike Maguire – Chief Officer Ros Bonsor - GP Executive Lead Simon Frampton – GP Executive Lead Apologies and Adam Robinson - Secondary Care assign ADP Roles Consultant for the meeting Greg Mitten – Lay Member Katie Wightman - Head of Corporate Affairs Nicola Baxter - Head of Medicines Optimisation Paul Kingan - Deputy Chief Officer and Director of Finance, Contracting and Corporate Affairs Peter Gregory - GP Executive Lead Declaration of Item 7 – Direct access to diagnostic tests Interest for GPs – Jack Kinsey

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Item 15 – Tier 2 Minor Surgery service - All GPs declared an interest in this item

Notes from The notes were approved as a correct 19 May record.

Headline items for Health & Wellbeing Board – Lucinda AOB McArthur

Quality Surveillance Meeting – Mike Maguire

Membership Council Agenda – Jackie Moran

Review progress of This item has been deferred until 30 actions vs weekly June. action log Direct access to Jack Kinsey declared an interest in this diagnostic tests for item. The chair of the meeting was GPs passed to Mike Maguire for this item.

The chair decided that the interest was significant but not fundamental. Jack was allowed to take part in the discussion but not vote.

Mike brought a paper which outlined the proposal for a 12 month pilot for increased levels of direct access to diagnostic tests for GPs within primary care facilities.

The proposal is in response to a number of concerns raised by Practices within

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West Lancashire CCG area.

Following a group discussion it was agreed that this should be pursued as a proof of concept but further discussions are needed to take place with Membership to determine potential usage and then contracting methodology to be agreed.

Innovations with Mike Maguire passed the chair back to Impact Funding Jack Kinsey.

Chris Russ was invited to the meeting to discuss the opportunity for the CCG to submit applications to the North West Academic Health Science Network application for Innovations with Impact Funding.

The closing date for applications is 17 June 2015.

A number of suggestions have been made and these were circulated prior to the meeting.

One idea was for funding for FLO telehealth, which is to be discussed as a separate agenda item.

360 Survey This item was discussed within item 14.

FLO Business Case Chris Russ was invited to the exec committee to provide an overview of the

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FLORENCE telehealth project.

Slides were presented and the advantages of using this package were discussed.

Chris also showed the committee a patient story video that explained the advantages to using this system. There is evidence that the system works well and has reduced hospital admissions.

Following a group discussion it was A sub-group to be set up to involve 30.6.15 Jackie Moran agreed that a separate sub-group Lucinda, Jackie and Claire to discuss the / Lucinda meeting was to be set up to discuss the innovation of the FLO telehealth McArthur / innovation further, Jackie, Claire and programme. Claire Lucinda will be involved in this. Heneghan

Chris will forward the link for the patient story video to the group, for information.

AOB Health & Wellbeing Board Lucinda asked the committee if anyone could attend the next Health and Wellbeing board meeting that is taking place on 5 June at County Hall.

Dr Biswas offered to attend and then feedback to the exec committee.

Quality Surveillance Meeting Mike advised that discussions have taken place with Cheshire & Mersey with regards to a quality standing item to be included on the agenda.

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It was noted that WLCCG have provided details with regards to current quality issues, and these will be discussed at the meeting on 15 June.

Membership Council Agenda The agenda was discussed and amendments made.

Update on progress Gill Dolan and Mark Selwyn from against VFM action Commercial and Clinical Solutions were plan invited to provide an update to the exec committee.

An interim report was presented to update on specific progress and to propose the priorities for the remaining 4 weeks of the project.

Following a brief discussion Mike thanked Gill and the team for all of the work that the team had done for this project.

It was mentioned that it would be beneficial for a quarterly report to be produced and brought to exec committee to provide an update on high cost cases.

Integrated Janet Walton from Lancashire County Wellbeing Service Council was invited to the meeting to update the members with regards to the development of the new Integrated Wellbeing Service.

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This will replace Help Direct and other related services such as Connect 4 Life, Social Prescribing and Health Trainers.

It was noted that the new service will be more streamlined and available across the whole of Lancashire, all existing services will continue until the end of August.

Procurement is currently taking place, the contract will be awarded on 7 July.

Janet requested views and comments from the committee with regards to current and future services.

Bapi stated that the Connect 4 Life service works well and would recommend keeping the referral process and the email address as it currently is.

Following discussions it was agreed that Janet would meet with Chris Russ and Jackie Moran to discuss potential synergies with the FLO telehealth project.

Janet agreed to share the specifications and will continue to circulate further briefings to the CCG for information.

Community Eyecare Imran Rahman and Amanda Dainty from Community Eyecare Health Ltd, were invited to discuss the service they

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currently provide.

They reported that the service is working well and with referrals increasing over the last three years and supportive feedback from GPs.

It was noted that the current specification and service has grown over time and this requires updating.

A comment was made with regards to scoping for an emergency eye clinic, it was noted that they are looking to put this into the specification.

It was noted that this service is not available on Choose and Book, however it does have an nhs.net email address that can be used.

Following a discussion it was agreed that further discussions were required and to bring back to exec.

360 Survey & Mike Maguire updated the members on Engagement and the 360 survey that was sent to Relationship stakeholders to complete. Summary It was noted that the results received for West Lancashire CCG have increased since the previous year and feedback was very positive.

Mike discussed the verbatim comments

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that West Lancashire CCG had received and the majority of which were positive.

There are a few things that are still outstanding and are currently being reviewed, including discharge letters.

The group decided that it would be useful Compile a list of what we have done and 30.6.15 Katie to review each comment and respond on where we are up to for each comment Wightman what we have done and where we are up received from the 360 stakeholder to with these. survey.

Tier 2 minor surgery All GPs declared an interest in this item. service Jack Kinsey passed chair of the meeting to Mike Maguire for this item.

The chair decided that Bapi Biswas and Ros Bonsor interest was fundamental and Bapi and Ros should not take part in discussion or vote. Bapi and Ros were therefore asked to leave the room for this item. Bapi and Ros left the meeting at 12.30pm.

The chair decided that the interest was significant but not fundamental for other GPs. All GPs were allowed to take part in discussion but not vote. Jackie Moran reported that a number of practices have declared an interest in providing the tier 2 minor surgery service.

Following a group discussion it was agreed that as a contract has already

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been signed for this service at one practice, the CCG could offer this to other practices that would be interested in providing this service.

However, if another practice would be interested in taking this on, it would run alongside the existing contract and would be reviewed regularly.

Simon Frampton offered to be the clinical John to brief Simon on benchmarking for 30.6.15 John Caine lead for minor surgery and John Caine tier 2 minor surgery service, as Simon would brief him with regards to has offered to be the clinical lead for this benchmarking. service.

The proposal would be required to go to Governing Body for final approval.

Wrap up

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West Lancashire CCG Clinical Executive Committee Action and Notes – 16.6.15

Due Responsible Discussion and Decisions This week’s actions RAG Date officer Attendees Adam Robinson - Secondary Care Consultant Bapi Biswas – GP Executive Lead Debbie Dobson - Practice Manager Jack Kinsey – GP Executive Lead Jackie Moran - Head of Contracting, Performance and Quality Katie Wightman - Head of Corporate Affairs Lucinda McArthur - Senior Operating Officer Mike Maguire – Chief Officer Paul Kingan – Deputy Chief Officer and Director of Finance, Contracting and Corporate Affairs Simon Frampton – GP Executive Lead Doug Soper – Lay Member Jo DeBacker – Practice Manager Ros Bonsor - GP Executive Lead Joanne Kane – Admin Assistant Apologies and Claire Heneghan – Chief Nurse assign ADP Roles Greg Mitten – Lay Member for the meeting Peter Gregory - GP Executive Lead Nicola Baxter – Head of Medicines Management John Caine – Chairman Declaration of None. Interest

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Notes from 2 June The notes were approved as a correct meeting record.

Lucinda McArthur gave an update on item I2 Integrated Wellbeing Service which will be circulated to the Exec Committee.

Headline items for Meeting with Rosie Cooper MP – Mike AOB Maguire Quality Surveillance Group (QSG) with Southport and Ormskirk – Mike Maguire Visioning Event 1 July – Mike Maguire Deloitte S&O Sustainability - Mike Maguire EPR – Simon Frampton Health Visitor Service – Debbie Dobson Declaration of Interest – Katie Wightman

Well North proposal Lucinda McArthur gave a brief background on the Well North proposal. There followed an update to the Exec Committee on the diagnostic exercise so far, which will be submitted to the Well North team.

Some slides regarding hotspots in Skelmersdale were presented and the Exec Committee then discussed how this could inform effective targeting to improve health outcomes in the most marginalized populations in West Lancashire.

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In addition Lucinda reported back from a meeting at the Skelmersdale group last Tuesday. While there is widespread support for the Well North programme, the support of Lancashire County Council has not yet been confirmed. Perter Continue to progress the Well North 14/07/15 PG Gregory will be having further discussion proposal and secure support from LCC. with LCC will take place on 17 June.

Discussion centred on correspondence received recently and how best to secure the support of Lancashire County Council.

The Exec Committee was requested to give approval for WLCCG to underwrite the investment in this programme.

Detailed discussion followed on any risks, including the financial risk. Following this the Exec Committee agreed to support this in principle, subject to the submission being ratified at the next Governing Body. Reflecting the Well North deadline a Chairman’s action will be taken for submission.

Membership The draft agenda was discussed briefly Agenda – 17 June and further discussion will take place (for info) later in the meeting during item 9 Facing the Future.

Membership The draft agenda was discussed and will Agenda – 9 July (for be amended accordingly. amendments)

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It was noted that the LARC item that Paula Briggs was to present could instead be given at a separate sexual health training event. This will be raised as AOB at the Membership to gage interest.

AOB Meeting with Rosie Cooper MP Mike Maguire gave an update from the meeting with Rosie Cooper held on the 12 June.

Quality Surveillance Group (QSG) with Southport and Ormskirk Mike Maguire provided the committee with brief information regarding this meeting.

Visioning Event 1 July Mike requested that clinical members of the Exec Committee attend this event to support the ongoing MSK redesign project.

Deloitte S&O Sustainability Mike Maguire stated that there are two dates 10 and 17 July when GPs are invited to speak to Deloitte regarding Circulate details of the Deloitte listening 19.6.15 CA S&O sustainability. Full details will be event. circulated.

EPS Simon Frampton raised an issue regarding multiple items on EPS reported by a local pharmacist. The Exec

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Committee agreed the pharmacist should speak to Medicines Management or to Refer pharmacist to Medicine 23.6.15 SF/NB the pharmacies own relevant authority for Management Team or pharmacy body. a solution.

Health Visitor Service Debbie Dobson reported a potential issue with staff shortage in the Health Visiting service. This will be flagged to Claire Heneghan, as a potential safeguarding Flag issue to Claire Heneghan re 23.6.15 DD/CH/LMcA issue. A letter will be drafted to LCC and safeguarding, draft letter and consult with Lucinda McArthur will also discuss with LCC. Karen Thompson.

Declaration of Interest Katie Wightman reminded the Exec Committee to update conflict of interest statements.

Facing the Future Carol Read attended to present slides on the pros and cons of Procurement of Community Services and asked for feedback on the presentation prior to tomorrows Membership meeting, so that the Membership would be fully briefed prior to voting on the issue on 9 July.

There was detailed discussion on the Amend the FtFT presentation 17.6.15 CR/JM/CH information contained within the slides accordingly. and further consideration on the best way to present clear options.

The Exec Committee agreed it was paramount to have clarity so Membership will understand the process fully before

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the decision is taken in July. In order to do this the Committee requested a paper Produce paper to present full information 2.7.15 JM/CH/CR is produced to give Membership all the regarding the process and options in information well in advance of the regard to potential re-procurement. meeting on 9 July.

It was agreed to simplify the presentation down to just the pros and cons of a procurement process.

The Exec Committee asked for this to be included in Practice meetings. Jo Ask Practice Managers to raise at weekly 18.06.15 JDB/DD DeBacker and Debbie Dobson will take practice meeting. to Practice managers.

Katie Wightman will also draw up guidance on the constitutional requirements of a vote and emphasis will be placed on the importance of Member practices engaging in the decision making process and attending to vote

Wrap up

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West Lancashire CCG Clinical Executive Committee Action and Notes – 30.6.15

Due Responsible Discussion and Decisions This week’s actions RAG Date officer Attendees Adam Robinson - Secondary Care Consultant Bapi Biswas – GP Executive Lead Becky Cope – Admin Assistant Claire Heneghan – Chief Nurse Debbie Dobson - Practice Manager Doug Soper – Lay Member Greg Mitten – Lay Member Jack Kinsey – GP Executive Lead Jackie Moran - Head of Contracting, Performance and Quality Jo DeBacker – Practice Manager John Caine – Chairman Lucinda McArthur - Senior Operating Officer Mike Maguire – Chief Officer Nicola Baxter – Head of Medicines Management Paul Kingan – Deputy Chief Officer and Director of Finance, Contracting and Corporate Affairs Peter Gregory - GP Executive Lead Ros Bonsor - GP Executive Lead Simon Frampton – GP Executive Lead

Apologies and Katie Wightman - Head of Corporate assign ADP Roles Affairs for the meeting

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Declaration of Enhanced Training Practice & Interest Physician Associates – Dr Bapi Biswas and Dr Ros Bonsor.

Notes from 16 June This item was deferred. meeting

Headline items for Gastroenteritis Service – Jackie Moran AOB Wrightington, Wigan & Leigh – Jackie Moran

Assisted Conception – Lucinda McArthur

Review progress of This item was deferred. actions vs weekly action log Review Finance and Paul Kingan reported that the financial contract update position is still very tight.

Jackie informed the members about signed contracts and advised that we are still awaiting a contract from Wrightington, Wigan and Leigh. It was noted that Paul Kingan will escalate this today.

Paul advised that at a future exec meeting in July he will bring the current financial position and will go through QIPP plans.

Paul advised that the updated budget

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figures will be taken to the Governing Body on 28 July.

FtFT Update from A Clinical Gateway Panel took place on Clinical Panel 30 June, where the milestones for Facing the Future Together Programme were discussed.

Following an update to the committee it was agreed that further discussions will need to take place at the next Membership Council meeting, which is due to take place on 9 July, at this meeting the members will decide whether to go out to procurement.

If members agree to go out to procurement, it will be recommended and ratified at the Governing Body on 28 July.

AOB Gastroenteritis Service – Jackie Moran informed the members about the Gastro service that is provided at a practice in West Lancashire. There is currently an issue with regard to referring via Choose and Book.

Following a group discussion it was Jackie to review tariff costs for Gastro 7.7.15 Jackie Moran agreed that Jackie would review the tariff services and bring back to exec. costs and bring back to exec.

Wrightington, Wigan & Leigh – Jackie Moran advised that she had met with WWL and S&O on 29 June to discuss some of the process issues for referrals

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in and discharges out of hospital.

It was noted that it was a positive meeting and agreed that pathways would be reviewed with regards to referrals and discharges and that Wigan would be will willing to work more closely with WLCCG.

Jackie mentioned that consultants from Wigan would be interested in attending future educational events that we may hold.

Assisted Conception – Lucinda Lucinda to circulate online survey to exec 30.6.15 Lucinda McArthur reminded the group about an committee re assisted conception. McArthur online survey that has been circulated, via email and newsletter. The closing date for completion is close of play 30 June.

Enhanced Training Enhanced Training Practice Practice and Dr Bapi Biswas and Dr Ros Bonsor Physician declared and interest in this item. Associates – EOI The chair decided that the interest was significant but not fundamental. Dr Bapi Biswas and Dr Ros Bonsor were allowed to take part in the discussion but not vote.

Alison Lumley was invited to the meeting to discuss future training programmes.

An expression of interest paper was

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circulated prior to the meeting which briefly outlined the criteria for this model.

Following a group discussion it was agreed that West Lancashire CCG are not in the position at the moment to sign up to this model, however the CCG will continue to support the development of this programme.

Physician Associates Papers have been circulated to practices requesting interest in PA placements.

A number of practices have responded, however the feedback received is that they are not in a position to provide internships.

Following a group discussion it was agreed that the CCG would not submit an expression of interest for this programme, however West Lancs CCG would contact Health Education North West, and provide feedback as to possible future interest.

CCGs ‘traffic light This item was deferred. rated’ on GP access & long-term conditions

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Absence This item was deferred. Management Policy

Medicines A Medicines Optimisation Strategic Management Principles and a forward plan for 2015 – Function Workplan 2016, paper was presented to the group for information.

The purpose of this paper is to outline the strategic principles that will underpin the medicines optimisation function of the CCG and that will support the delivery of medicines optimisation objectives throughout the CCG where the right patient receives the right choice of medicine at the right time.

Within the paper there is a Medicines Optimisation work plan, which outlined action plans and timescales.

Following a discussion with regards to making prescribing savings, Jackie added that a paper was presented to the Quality Committee and following this, it was agreed to create a monthly pack for each West Lancs practice, outlining their prescribing costs.

It was agreed that Nicola would consider Nicola Baxter to consider how to reduce 21.7.15 Nicola Baxter how to reduce prescribing wastage and prescribing wastage and how to what would be the best way advertise advertise publically, also how to educate this publically and how to educate good good practice. practice.

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Stroke specification A draft Stroke specification document was circulated to the committee, and within this objectives and expected outcomes were recommended.

The service specification has been developed by Lancashire and South Cumbria Stroke Review workstream groups in consultation with stakeholders, including primary care clinicians and clinical staff.

Following a group discussion the executive committee agreed to take this specification to Governing Body on 28 July to agree in principle. Wrap up

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West Lancashire CCG Clinical Executive Committee Action and Notes – 7.7.15

Due Responsible Discussion and Decisions This week’s actions RAG Date officer Attendees Adam Robinson - Secondary Care Consultant Claire Heneghan – Chief Nurse Debbie Dobson - Practice Manager Doug Soper – Lay Member Greg Mitten – Lay Member Jack Kinsey – GP Executive Lead Jackie Moran - Head of Contracting, Performance and Quality Jo DeBacker – Practice Manager Joanne Kane – Admin Assistant John Caine – Chairman Katie Wightman - Head of Corporate Affairs Michelle Sage – Admin Assistant Paul Kingan – Deputy Chief Officer and Director of Finance, Contracting and Corporate Affairs Peter Gregory - GP Executive Lead Ros Bonsor - GP Executive Lead Simon Frampton – GP Executive Lead

Apologies and Bapi Biswas – GP Executive Lead assign ADP Roles Lucinda McArthur - Senior Operating for the meeting Officer Mike Maguire – Chief Officer Nicola Baxter – Head of Medicines Management

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Declaration of None Interest Notes from 16 and The notes from 16 June were approved 30 June meeting as a correct record.

The notes from 30 June were amended as the AOB item Gastroenteritis should have read Gastroscopy.

Headline items for Children’s Community Nursing AOB Outreach Team (CCNOT) - Claire Heneghan

Prescribing Audit – Katie Wightman

Facing the Future Together at Membership – Doug Soper

Introduction to Martin Clayton

Review progress of Updates on action were noted and will be actions vs weekly updated live action log which is on action log SharePoint.

Review Finance and It was noted that some aspects of finance contract update were discussed within the review of the live action log.

Paul Kingan gave the Exec Committee an update on the current finance position, reported that this remains tight as expected.

Sara Daulby has been recruited to the role of Finance and Commissioning

2 manager. Sara’s role combines finance and commissioning, covering Mental health and Learning Disabilities. A replacement from the CSU will be provided to cover Sara’s former post.

Jackie Moran confirmed the current position of contracts, reporting a few issues around Commissioning for Quality and Innovation (CQUIN). Brief updates were then given for diagnostics and cardiology.

Paul Kingan reminded the committee of the current collaborative projects that the CCG is involved with and gave a brief update. These are as follows;

Better Care Fund (BCF), which meets fortnightly for a steering group, in addition Karen Tordoff attends a BCF programme managers group.

Healthier Lancashire - Ernst & Young have now begun work to align plans across Lancashire. This is a diagnostic piece of work which will help inform discussion regarding where Lancashire can work more closely together.

Well North application is progressing following approval for submission from the Exec Committee.

It was noted that Quality, Innovation,

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Productivity and Performance (QIPP) and finance plans will be brought to the Executive Committee at a future date.

Absence Katie Wightman presented two refreshed Management Policy CCG policies, these being the Absence Management and Volunteer Policy.

The Exec Committee was asked to approve both and discussion followed on the changes. The main difference in the Volunteer policy is that reimbursements are now aligned to those given to staff.

Claire Heneghan requested that this policy is also amended to reflect the findings of the Lampard report.

The main change in the absence management is in regard to paternity leave and the protected time following organisational change is now five years instead of two. Katie will also clarify further detail around the triggers.

The policies were adopted subject to the Exec Committees suggested amendments.

AOB Children’s Community Nursing Outreach Team (CCNOT)

Claire Heneghan raised issues which have followed the Trust’s decision to stand down the CCNOT for West

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Lancashire.

It was noted that no contingency plan for the care of the children supported by CCNOT has been received from the Trust. Carol McCabrey is currently dealing with alternative provision.

Discussion then took place on the business case and the original contractual obligations set out in this document. A smaller group from the Exec 14.7.15 CH/PK/JM It was agreed to set up a meeting to Committee will meet with Trust discuss further with Trust to establish a representatives to discuss CCNOT issue. replacement pathway.

Prescribing Audit

Katie Wightman reported on the possibility of carrying out prescription audits, the aim being to help identify wastage in the system.

It was agreed that the four practices represented at the Exec meeting could undertake some audits. After securing permission from a sample of 10 patients, the practice will ask the patients to feedback on what they have received from the pharmacy. Nursing homes will be asked to provide a 14.7.15 NB Nicola Baxter and the Medicines log for one week to monitor returned Optimisation team will be involved and stock. following on the results can be taken to

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Membership to inform practices on the Medicines team to work with practices to 14.7.15 NB potential merits of carrying out progress prescribing audit. prescribing audits.

Facing the Future Together at Membership

Doug Soper requested details on the information that has been circulated to the Membership prior to the 9 July Membership Council. Update Membership voting cards 8.7.15 Admin Team Jackie Moran clarified what had been accordingly and provide additional admin sent, following this there was detailed support on 9 July. discussion on the process.

In addition it was agreed that Claire Heneghan will attend the Joint Oversight Group (JOG) sustainability meeting tomorrow to set out the Facing the Future Together vision.

Introduction - Martin Clayton

Martin Clayton attended the Exec Committee and gave a brief introduction regarding the work he is currently undertaking for the CCG.

Lancashire Care Paul Kingan presented an update briefing Foundation Trust – paper regarding the reconfiguration of MH Funding specialist mental health services.

The exec committee was asked to discuss the proposed findings and

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consider whether to continue further non- recurrent funding of the schemes.

Discussion followed focusing on the figures presented in the current position summary.

Ros Bonsor requested that the CCG make sure that local schemes such as the Alternative Therapy Service (Bickerstaff House) pilot where possible as part of this year’s contract agreement.

It was also suggested that Paul discuss the paper with Catherine Webster to further inform negotiations with LCFT/BwDCCG.

The Executive agreed for Paul Kingan to negotiate the final settlement on behalf of the CCG.

CCG’s traffic light This item was deferred. rated on GP access & long-term conditions

Wrap up

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Minutes DRAFT Meeting Title: West Lancashire Clinical Date: 26 May 2015 Commissioning Group Audit Committee Time: 9.00 – 10.00 am Venue: Boardroom, Hilldale, Ormskirk Present: Apologies: Douglas Soper, Lay Member (Chair) Claire Heneghan, Chief Nurse Greg Mitten, Lay Member Dr Bapi Biswas, GP Executive Lead Dr Jack Kinsey, GP Executive Lead Dr Adam Robinson, Secondary Care Doctor

In attendance Paul Kingan, Chief Finance Officer Katie Wightman, Head of Corporate Affairs Fiona Blatcher, Associate Director, External Audit (Grant Thornton) Mike Maguire, Chief Officer Dr John Caine, Chair Lucinda McArthur, Senior Operating Officer Cathy Ashcroft, Executive Assistant

Agenda Summary of Discussion Action Item 1. Welcome, Introductions and apologies for absence Doug Soper welcomed all present to the meeting of the Audit Committee and introductions were made. Apologies were noted as above.

2. Declarations of interests No declarations of interests pertinent to agenda items were raised.

3. External Audit

Audit findings report for the annual accounts Fiona Blatcher presented the audit findings report for the annual accounts, which provided a clean opinion on the audit of the accounts and value for money. A few final checks are required to ensure the annual accounts are consistent with the national ledger. No significant issues had been identified in the annual accounts and this was reflected in the audit findings report presented by external audit.

In terms of value for money (VFM), Fiona Blatcher confirmed the feedback for the CCG was a similar picture to other CCGs. There will be greater financial challenges in 2015–16 which will require close work with partners. An early understanding of the financial position will be required to manage this as soon as possible in the financial year. It was recognised that the CCG has had to work harder to achieve its financial targets than other larger CCGs. No specific recommendations were made and the work with partners and the Trust were found to be positive. Paul Kingan confirmed that the target financial position had been achieved in part through non-recurrent funding and negotiations with NHS England around use of the continuing care risk share funding reimbursement.

Management representation letter The representation letter requested by the external auditors is the standard

Page 1 of 2 West Lancashire Clinical Commissioning Group Audit Committee – 26 May 2015

letter requested from NHS bodies. The letter essentially gives confirmation that the CCG governing body members have fulfilled their responsibilities around preparation of the accounts in accordance with International Financial Reporting Standards and accounting policies directed by the NHS Commissioning Board. On approval, the letter will be signed by the Chair and Chief Officer on behalf of the CCG governing body.

The audit committee: noted the audit findings report for the annual accounts and recommended the management representation letter be submitted as requested. The audit committee recommends the governing body to authorise the Chairman and Chief Officer to sign the letter of representation.

4. Annual report Doug Soper commented that the annual report was excellent overall.

Annual Governance Statement The annual governance statement contains all the governance arrangements and details the audits carried out in this year, all of which have received significant assurance with one exception. The Committee felt the relationship between the CCG and external audit was excellent and very positive.

The audit committee: Recommended the annual governance statement and annual report to be approved by the governing body.

The annual report and accounts will be signed by the chief officer on Thursday 28 May for submission.

Financial statements Doug Soper thanked those involved for their hard work in producing the annual report and accounts including Katie Wightman, Meg Pugh, Paul Jones and Sara Daulby.

The audit committee: Recommended the annual accounts be approved by the governing body.

ANY OTHER BUSINESS

5. Date and time of next meetings Tuesday 15 September, 1.30 – 3 pm, in the Meeting room 1, Hilldale.

Page 2 of 2 West Lancashire Clinical Commissioning Group Audit Committee – 26 May 2015

Meeting held on Thursday 30 April 2015, 09:00 to 12:30 Meeting Room 253, Second Floor, Preston Business Centre, Watling Street Road, Fulwood, Preston PR2 8DY

Present: In Attendance: Dr Chris Clayton (Chair) – Blackburn with Darwen Mr Roger Parr – Blackburn with Darwen Dr Dinesh Patel – Greater Preston Mr Iain Crossley – Chorley & South Dr Alex Gaw – Lancashire North Ribble/Greater Preston Dr Tony Naughton – Fylde & Wyre Mr Paul Kingan – West Lancashire Dr Mike Ions – East Lancashire Mr Mark Youlton – East Lancashire Mr Andrew Bennett – Lancashire North Mrs Linda Riley – LCSU Mrs Jan Ledward – Greater Preston/Chorley Mr Carl Ashworth - LSCU and South Ribble Dr Umesh Chauhan (item 3) Mr Peter Tinson – Fylde and Wyre Mrs Jill Truby – Lancashire CCGs Network Mr Mike Maguire – West Lancashire Mr David Bonson – Blackpool

1. Welcome, Apologies for Absence and Declarations of Interests Dr Chris Clayton welcomed everyone to the meeting. Apologies for absence were received from Dr Amanda Doyle, Dr Gora Bangi, Dr John Caine and Mrs Debbie Nixon.

2. Appointment of Chair Dr Clayton, the current chair of the Network, left the room whilst Mr Peter Tinson, vice-chair, took the chair for this item, which was to elect a clinical lead as Chair of the Network. The current term of office was at an end. Expressions of interest had been requested and one nomination received. Following agreement, Dr Chris Clayton was duly elected to continue as Chair of the Lancashire CCGs Network for the next 12 months. Dr Clayton returned to room.

Dr Clayton was congratulated on this appointment.

3. Clinical Research plan for Lancashire Dr Umesh Chauhan gave a presentation detailing a proposed plan for Lancashire in relation to clinical research. Highlights of the presentation included: • Research paths: o ASHN: Academic Health Science Network o CRN: Clinical Research Network o CLAHRC: Collaborations for Leadership in Applied Research and Care • Geography, membership and strategic partnerships • ASHN: 6 clinical priorities – cancer, cardiac, child and maternal health, long term conditions, mental health and stroke. National lead for: telehealth/telecare/telemedicine, infection and tropical disease, personalised medicine, neurological conditions. • Priorities for 15/16, three areas of safety, cross cutting work streams and clinical. • Medicines Optimisation very important area of work for the AHSN • CRN Funding – majority of funding is given to Trusts, significant reduction in funding from last financial year • Proposed NHS support funding 2015/16 • Research Site Incentive Scheme (RSI) – The network team will support practices new to research by providing help and time with the set-up and delivery of research studies. New practices will be offered entry level studies (which have been reviewed by local GPs) that are less labour intensive in order to support and build confidence in research. Practices

Lancashire CCGs Network Minutes 30 April 2015 Page 1 of 3

will be further incentivised for their time by receiving a per patient payment recruited into research studies. • Network Governance Structures. The Host organisation with the LCRN Leadership & Management Team will develop structures, systems, terms of reference and local working practices for the LCRN. The CRN NWC reports to the Host Trust Executive which in turn reports to the Host Trust Board. • East Lancashire CCG o Member of the NWC CLAHRC o Successful in funding for projects from ASHN o Increased funding from CRN o Funding an Academic Clinical Fellow post in collaboration with Health Educational England and UCLAN • ASHN Funding in East Lancashire • CCG Ambitions o Reducing premature mortality in people with a learning disability o Prevention and health promotion o Cancer o Respiratory disease o Reducing mortality for people with serious mental illness o Maternal and neonatal paediatric interventions It was agreed that a collective approach be taken by all 8 Lancashire CCGs. Dr Chauhan proposed that a representative from CRN attend the Network meeting on a ½ yearly basis. To a suggestion that some of the research should be non-disease related, Dr Chauhan confirmed that the CRN was public health related. It was considered that it was important to have a representative on this group from the CCGs to identify priorities and influence where funding is devolved. There needed to be clinical leadership supported by an infrastructure. A proposal was put on the table to create an associated medical director role, hosted by the Network.

4. Healthier Lancashire Dr Ions updated members in relation to Healthier Lancashire. Priorities have been agreed and the team have developed the specification for trauma and orthopaedics. There have been some issues around the specification which has created a slight delay but this has now been resolved. All CCGs had signed up to procurement work. Monitor had expressed an interest and would be willing to provide resources to help. It was agreed the directors of finance and chief finance officers need to have discussions with Sam Nicol. Carl Ashworth agreed to circulate the orthopaedic review with the finance officers. Membership of the Lancashire Leadership forum was discussed and agreed that Jan Ledward and Chris Clayton would continue to be executive representatives. The items for the May meeting would include position statement of where we are and what we’re doing now. A request had been received from the voluntary sector to showcase CCGs at a ‘Lancashire Health Expo’ which follows on from one organised at Blackburn Cathedral, which showcased what the third sector does in the health and wellbeing field. This time, it was proposed that CCG’s and the 3 local authorities should be the exhibitors, and the audience would be the third sector and the general public.

5. Feedback from financial pressures and solutions workshop Following on from the financial pressures and solutions workshop held on 1 April 2015, a summary had been produced by Carl Ashworth of the agreed actions. The summary was split into two areas: tactical actions leading to contract sign off, and other tactical actions. Mr Mark Youlton presented an update. NWAS – Mr Allan Jude had now written to all CCGs with levels for setting budgets Specialised Commissioning – CSU continue to work on consultant referrals Property services – Mr Youlton was meeting up with the Area Director that afternoon. Dr Bangi was reported as being on a committee which was currently looking at NHS premises. Dr Bangi is to be asked to feedback. Workforce – still an issue with some Trusts recruiting from abroad for nurses. Mrs Riley reported that there was a specific workforce lead in the CSU at Birmingham who is currently putting together a workforce plan. Mrs Riley agreed to share information. Mr Raphael reported that Lancashire CCGs Network Minutes 30 April 2015 Page 2 of 3

QUIP to be linked to five year plan. Mrs Riley agreed to take to CCB.

6. May agenda As had been agreed at the March meeting of the Lancashire CCGs Network, the May agenda would be extended to 1 pm to allow time to be spent to develop plans for Primary Care, Workforce, and Reconfiguration. The first item on the agenda would be discussions with Mr Graham Irwin, NHS England and Mr Warren Heppolette from Central Manchester CCG, attending on behalf of Mr Ian Williamson, to discuss Devo Manc.

Time would then be allocated agreeing cases for the three areas. Dr Amanda Doyle, Mrs Debbie Nixon, and Mr Andrew Bennett had agreed to work on the case for Reconfiguration. Mike Maguire, Alex Gaw and Linda Riley volunteered around workforce, and Peter Tinson, David Bonson and Gora Bangi around Primary Care.

7. Royal Liverpool & Broadgreen Trust letter re NIHR CRN NWC CCGs had received a letter from the Royal Liverpool University Hospital regarding the National Institute Research Clinical Research Network North West Coast requesting representation on various networks. Mrs Jan Ledward had asked for this item to be included on today’s agenda to discuss a Lancashire approach, rather than individual CCGs, due to resource capacity. Following the presentation received from Dr Chauhan where this request was also discussed it was agreed to ask Dr Simon Wetherell to be the representative from Lancashire. It had also been suggested that a representative from the research network should attend Network meetings on a ½ yearly basis to update members on current research etc.

8. Minutes of the CCG Network Meeting held on 26 March 2015 The minutes of the meeting held on 26 March 2015 were accepted as an accurate record.

9. Matters Arising and Action Sheet Dr Clayton sought and obtained confirmation that the actions from the previous meeting were either complete or in hand.

10. Minutes from Other Meetings The draft minutes from the Collaborative Commissioning Board held on 14 April 2015 were noted. Stroke update – Mrs Jan Ledward updated members on work currently being undertaken. A paper had been agreed for Governing Bodies to consider acute/stroke element collaboratively and to commission other areas locally by the end of May. Stroke steering group to develop implementation plan. JL/CA to update CCB in June. CAMHS update – Mr Ashworth updated members. CAMHS steering group to establish and mobilise system board and commence work on pathway/model of care development. Dr Bowman agreed to liaise with Heather Tierney Moore to approach national team re flagship status. CA/JR to put proposal on system leadership to the May CCB.

11. Invitation to be involved in Aligning the Plans Phase An invitation had been received from Healthier Lancashire notifying CCGs that the Aligning the Plans phase was commencing and extending an invitation to be directly involved by attending the Healthier Lancashire Executive Group meetings for the duration of this phase (May to June). Again, it was considered that this could be undertaken on a Lancashire basis due to lack of resources within each individual CCG.

12. Any Other Business Dr Clayton has received a request from LCFT for the associate medical director to attend a future meeting of the Network. It was considered that the contract forum would perhaps be more appropriate. Mrs Debbie Nixon to be asked to action.

Date of next meeting: Thursday 28 May 2015 9 am to 1 pm, venue Taylor-Coleridge meeting room, Jubilee House, Lancashire Business Park, Centurion Way, Leyland, PR26 6TT.

Lancashire CCGs Network Minutes 30 April 2015 Page 3 of 3

MINUTES OF THE MERSEYSIDE CCG NETWORK MEETING

Held on Wednesday 6th May 2015 at 1.00pm - 4.00pm In the Boardroom, 3rd Floor, Merton House, L20 3DL

Present Simon Banks Chief Officer, Halton CCG Paul Brickwood Chief Finance Officer, Halton, Knowsley & St Helens CCGs Dr John Caine Chair, West Lancashire CCG Dr Rob Caudwell Chair, Southport & Formby CCG Fiona Clark (Chair) Chief Officer, South Sefton & Southport & Formby CCGs Dr Nadim Fazlani Chair, Liverpool CCG Tom Jackson Chief Finance Officer, Liverpool CCG Dianne Johnson Chief Officer, Knowsley CCG Dr Andrew Pryce Chair, Knowsley CCG Dr Cliff Richards Chair, Halton CCG Katherine Sheerin Chief Officer, Liverpool CCG In Attendance Bob Ricketts, CBE Director of Commissioning Support Services Strategy, NHS England Paul Mount Head of Risk and Regulation, NHS England Liz Gaulton Director of Public Health, St Helens Council Dawn Leicester CHAMPS Public Health Collaborative Seamus McGirr Director of Clinical Development, NWCSU Apologies Linda Bennett Associate Director of Commissioning, Warrington CCG Dr Steve Cox Clinical Accountable Officer, St Helens CCG Dr Andy Davies Chair, Warrington CCG Dr Craig Gillespie Chair, South Sefton CCG Sarah Johnson Head of Commissioning, St Helens CCG Martin McDowell Chief Finance Officer, South Sefton & Southport & Formby CCGs Mike Maguire Chief Officer, West Lancashire CCG Jan Snoddon Chief Nurse, Safeguarding Service, Halton Andrew Thomas Director of Governance, Knowsley CCG Minutes Jayne Byrne PA to Chief Officer, South Sefton CCG

No Item Action 15/78 NWCSU Transition Bob Ricketts updated the meeting on current status. Merseyside and Cheshire CCGs have made good progress in outlining their requirements and he was looking to support CCG networks in going out to the Lead Provider Framework as soon as possible. NHS England has committed to turning bids around in 4 weeks. A target transition date of November is now likely which can’t be delayed any further. NHS England needs to work with finance leads to work out costs (premises, staff redundancy costs, etc) as they will pay for those stranded costs. BR was concerned about fragmentation of core services such as BI and would want CCGs to use a minimum service specification.

KS asked why Manchester (‘Devo Manc’) was being treated differently. BR/SB confirmed Manchester was not as coherent as Merseyside CCGs and had not worked through their business cases. v:\wl ccg\meetings\board meetings\2015\july\item 13.f mersey ccg network - minutues - may 2015.docx

No Item Action BR stated common sense should prevail – a business case would not be required for every service; where the service was small (eg ambulatory) a business case would not be needed, but would be required for a core service such as finance.

Derek Rothwell confirmed a meeting was scheduled for Thursday 7th May with Debbie Bywater of NWCSU to work through intentions and firm up numbers.

BR stated there should be a people progress tracker.

Presentation on CSU proposal May 2015.pp

CCGs need to be clear on governance arrangements so implementation was not held up, therefore decisions needed to be ratified at either May or June Governing Body meetings unless delegated authority was in place.

FLC believed small services could be worked through as soon as possible and a clear specification of commissioning intentions taken to Governing Body meetings.

BR confirmed NHS England would help with mobilisation and could direct CCGs to help in writing specifications.

It was agreed an outline of commissioning intentions would be sent to Paul Mount as DR soon as possible – DR believed that could be done after the meeting with Debbie Bywater the following day, 7th May. 15/78a Hyper Tension & Mental Health – presentation by Liz Gaulton, Director of Public Health, St Helens Council

Champs presentation to Merseyside CCG Ne Dr Richards commented this was the continuation of the work initiated by Gary O’Hare.

It was agreed some clinical involvement on the board would be beneficial and it ALL would be more appropriate for CVD clinical leads rather than CCG Network GPs to attend meetings and feed back to the network – inform Dawn Leicester (CHAMPS) of any interest. 15/79 Apologies for Absence were received from Dr Steve Cox, Sarah Johnson, Andrew Thomas, Dr Andy Davies, Linda Bennett, Dr Craig Gillespie, Martin McDowell and Mike Maguire. 15/80 Minutes/Actions from the Previous Meeting The minutes were accepted as a true and accurate record of the previous meeting (once the date of the next meeting had been changed). Action Log 141008 - Collaborative Stroke – leave on tracker. 141102 - EPRR – completed – remove from tracker. 141108 - CHC Restitution Claims – remove from tracker. MMcD 141205 - Neuro-Rehab – update to come back to meeting in July. SB 151103 – AQUA – David Fillingham to be invited back to meeting in July. 15/12 – Improving Maternity Experiences Across C&M – remove from tracker. v:\wl ccg\meetings\board meetings\2015\july\item 13.f mersey ccg network - minutues - may 2015.docx

No Item Action 15/31 – Termination of Pregnancy (TOP) Procurement – remove from tracker. 15/32 - Safeguarding Update – standing item – remove from tracker. 15/33 – Developing Common Standards to Facilities Change & Pathway Improvement – remove from tracker 15/35 - Education and Workforce – remove from tracker. 15/41 - Specialised Commissioning – Devolved Services – remove from tracker. 15/44 – CCG Workshop on Future Commissioning Support Options – remove from tracker. 15/67 – NWCSU Transition Board – remove from tracker. 15/68 – EPRR and On-Call Arrangements – remove from tracker. 15/70 – LWEG (LETB) – remove from tracker. 15/81 Improving Maternity Experience Update SB updated the meeting on highlights from his report and will provide another update after the next programme board. 15/82 Safeguarding Update Reviews are complete, posts advertised and incumbents are expected to start within the next 6 to 12 weeks. 15/83 Provider Update Southport & Ormskirk Hospital NHS Trust (S&O) – a CQC report has just been issued and a risk summit is scheduled for 7th May. Board to Board meetings are being held by both Southport & Formby CCG and West Lancashire CCG as a result of increasing concerns. Deloitte’s have been commissioned as a third party. Warrington Hospital – SB reported similar issues as S&O. Liverpool Women’s Hospital – the Board has agreed they can apply for distress funding from Monitor around emergency relief but not planned support, as they don’t have a plan in place. Royal Liverpool University Hospital – KS to meet with Monitor. Ernst & Young are doing the processes. RLUH presented to the last Liverpool CCG’s Governing Body meeting and a paper will go to May’s Governing Body to decide whether or not to support RLUH. Liverpool CCG will support FT in principle to enable other changes to happen, but will make a statement in relation to the changes. Liverpool Community Health – are going through a sustainability process and on are track. 15/84 LWEG (LETB) There is a possibility of reduced numbers entering general practice as the training changed. NF is not yet sure yet what implications are on applications. 15/85 NWAS A contract settlement was reached within the £10m window without the need to go to arbitration. 15/86 Clinical Networks Smith Review – need to see/review report. Take off agenda. 15/87 NHS Clinical Commissioners KS reported there had been a discussion regarding the burden of lay reporting of insurance. Running Costs – will be reviewed after the election. A commissioner forum for learning disabilities is being established and looking for people to be involved - Geraldine O’Carroll has been nominated from South Sefton CCG. A meeting on 11th May will discuss CQC processes in relation to inspecting GP practices.

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No Item Action 15/88 Specialised Commissioning SB met with Andrew Bibby on 30th to move forward C&M collaborative approach. There is a workshop in July to discuss current commissioning arrangements. NF has FLC/SB volunteered to lead (FLC to inform Dr Leonard). Tom Jackson’s finance paper is to be submitted. 15/89 Clinical Senate 15/89 Andy Cole is the NW lead as part of the Smith Review. 15/89a Utilisation Management – presentation by Seamus McGirr SB to discuss as part of the CSU transition BI discussion/UCAT discussion. SB No Item Action 15/90 Any Other Business No other business. 15/91 Date of Next Meeting Wednesday 3rd June 2015 1pm to 4pm 3rd Floor Boardroom, Merton House, Stanley Road, Bootle, L20 3DL

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MINUTES OF THE MERSEYSIDE CCG NETWORK MEETING

Held on Wednesday 3rd June 2015 at 1.00pm - 4.00pm In the Boardroom, 3rd Floor, Merton House, L20 3DL

Present Fiona Clark (Chair) Chief Officer, South Sefton & Southport & Formby CCGs Paul Brickwood Chief Finance Officer, Halton, Knowsley & St Helens CCGs Dr Rob Caudwell Chair, Southport & Formby CCG Dr Steve Cox Clinical Accountable Officer, St Helens CCG Martin McDowell Chief Finance Officer, South Sefton & Southport & Formby CCGs Mike Maguire Chief Officer, West Lancashire CCG Dr Andrew Pryce Chair, Knowsley CCG In Attendance Chrissie Cooke Executive Nurse Consultant, Niche Patient Safety & Mental Health Strategies Apologies Simon Banks Chief Officer, Halton CCG Dr John Caine Chair, West Lancashire CCG Dr Nadim Fazlani Chair, Liverpool CCG Dr Craig Gillespie Chair, South Sefton CCG Tom Jackson Chief Finance Officer, Liverpool CCG Dianne Johnson Chief Officer, Knowsley CCG Sarah Johnson Head of Commissioning, St Helens CCG Dr Cliff Richards Chair, Halton CCG Katherine Sheerin Chief Officer, Liverpool CCG Andrew Thomas Director of Governance, Knowsley CCG In Attendance Jane Lunt Chief Nurse, Liverpool CCG Minutes Jayne Byrne PA to Chief Officer, South Sefton CCG

No Item Action 15/091 Apologies for Absence were received from Simon Banks, Dr John Caine, Dr Nadim Fazlani, Dr Craig Gillespie, Tom Jackson, Sarah Johnson, Dr Cliff Richards, Katherine Sheerin and Andrew Thomas. 15/092 Minutes / Actions of Previous Meeting were received as a true and accurate record of the last meeting, once the following amendment was made ‘15/89 Andy Cole is the NW lead as part of the Smith Review’. Actions 141008 – Collaborative Stroke – ongoing – leave on tracker. 141205 – Neuro-Rehab – update to come back to meeting in July. MMcD 151103 – AQuA Update – SB to invite David Fillingham back to meeting in July. SB 15/78 – NWCSU Transition – commissioning intentions have been made known to NHSE – remove from tracker. 15/78a – Hyper Tension & Mental Health Presentation - CCG Network leads to inform Liz Gaulton, Director of Public Health, St Helens Council, of any interest from CVD clinical leads – remove from tracker. 15/093 Provider Update (FLC) Southport & Ormskirk (S&O) – Board to Board meetings are being held with the Trust regarding ongoing concerns around leadership, culture and delivery. Currently reporting high level of pressure ulcers – SC recalled a similar issue at Whiston, where an old scoring system was being used – check what S&O using? FLC Aintree – slowly improving. There is some concern around review of clinical pathways, need to understand exactly what the issue is. g:\haltonccg\meetings & briefings\ccg network\1. july 15\mccg mins_jun 15_draft.docx

No Item Action LCH – the first of four workshops organised by KPMG was held on Monday 1st June to work through a process for determining the future home of services that LCH are currently providing. Mersey Care – currently being inspected by CQC. Results will be published in early September, but hoping to get feedback before then. RLUH – LCCG has agreed to support RLUH’s application for FT status in principle, with conditions attached (future changing economy, etc). LWH – following a report in the Liverpool Echo in relation to the petition around the closure of the hospital, NF has been trying to publicise it’s not about closing the LWH ‘brand’, rather providing safe, viable services. It was agreed Merseyside CCGs/clinical leads need to be kept close to developments. Alder Hey – a CQC follow up inspection is due in the next few weeks. CQC is currently contacting local commissioners to gather information regarding specific concerns. If the commissioner is responsible for 45% of DGH business do we need to clarify our expectations? JL confirmed Liverpool CCG/Alder Hey discussions had taken place to review the CQC action plan and changes are slowly taking place. 5 Boroughs – there will be a full CQC inspection in August, no new issues to report. Whiston – nothing major to report. The TDA are happy with progress being made compared to peers, however, there are some concerns in relation to key members of the exec team who will be leaving in the next few months. Bridgewater – new members of exec team having a positive impact. There is an agreement with Wigan to review community nursing/pathways. Warrington – is a challenged Trust at the moment. 15/093a CSU Transition All commissioning intentions are now known. NHS England has approved the review and the specifications are being progressed. Stranded Costs – MMcD has confirmed both South Sefton CCG and Southport & Formby CCG have the existing volume of stranded costs as part of this year’s SLA; however it is expected these costs will come down further. The end of November position is giving momentum to bring down stranded costs. Mersey Prescribing (APC) – SC raised concerns in relation to the group’s decision not to keep the current format. CHC Restitution – FLC has asked Clare Duggan to raise the issue nationally as it is more of a technical process. 15/094 Safeguarding Update Governance - Steering Group meetings are now well established and MOU and Service specification review is completed and signed off. The next steering group meeting will receive a full year work programme and final set of service KPIs for sign off and agree reporting. Staffing - Review fully completed. All recruitment now completed for adult and children’s team posts/vacancies. LAC designated nurse has commenced in post and is completing induction, second member of staff starts mid-July. Adult team staff should be in place mid /end August. HR issues - Stress and sickness levels in the children’s team remain an issue. A support structure is in place and HR processes have commenced. An away day development session for the children’s team has been completed with some good outcomes. A follow up session is planned for July. An away day session with the adults’ team has been completed with agreement of a team charter and behaviours. Some relationship issues remain but appear to be managed. CCG facing working - appears to be working fairly well in the children’s team and for the adults team is being embedded but due to vacancies is not as well established. Agreement on reporting for Chief Nurse/Lead Nurses with regular 121s, etc is not in place. g:\haltonccg\meetings & briefings\ccg network\1. july 15\mccg mins_jun 15_draft.docx

No Item Action Accommodation – the Safeguarding team was likely to outgrow their current accommodation and Liverpool CCG would be willing to look at accommodation to support them. 15/095 LWEG (LETB) Practice Nurse Programmes - are expanding through higher education establishments and as a result we are seeing a higher number of trained nurses. Pilot sites for practice nurse/district nurse specific training are currently being SB/HB investigated. SC to report back in August – add to work programme. Workforce Symposium - the next symposium will be held on 11th June at Aintree Racecourse. 15/096 Specialised Commissioning Nothing to report. PB suggested inviting Andrew Bibby to the meeting in August to SB discuss some of emergent issues. 15/097 Clinical Senate – nothing to report. 15/098 Presentation: Mersey Specialist Rehab Review

15.98 Presentation_Mersey Specialist Rehab Review Final Report.pptx FLC thanked Chrissie Cooke, Michelle Urwin and Martin McDowell for their hard work and tenacity in producing a really important and much needed piece of work. The report would need to be presented to Governing Bodies. It was agreed the specialised rehabilitation pathway would be continued for the foreseeable future; It was agreed Liverpool CCG would act as lead commissioner, to be reviewed on an annual basis. What did being lead commissioner mean? Did it include SIs, etc? A way round it would be to have a memo of understanding outlining duties. Non-Mersey usage would be recharged to relevant CCG. It should cover everyone, not just Oakvale Gardens. The meeting agreed to invite a proposal capped at £20,000. Chrissie Cook would speak to Michelle Urwin and report back to MMcD. MMcD MMcD to check the figure of £16.3m for hyper acute as we don’t commission that service. We will need to discuss with our providers that we are going to new model. 15/099 Any Other Business Maternity Review – SB to be asked to provide update by email/for next meeting. SB Stroke – KMcC believes we need to be doing more collaborative work. Mike Maguire to email report to Jayne Byrne for onward distribution. MM/JB Liverpool City Region – Need to positively influence it as a network. Steve Cox asked for it to be put on a future CCG Network agenda. SB 15/0100 Date of Next Meeting Wednesday 1st July 2015 at Daresbury Park Hotel, Warrington, WA4 4BB 1230 hrs – 1330 hrs – Working Lunch with Cheshire CCG Network 1330 hrs to 1600 hrs – Merseyside CCG Network Meeting

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Care Closer to Home Programme Board Minutes (RATIFIED)

Date: Wednesday 20th May 2015, 0930 hrs to 1130 hrs Venue: Clinical Education Centre, Southport & Formby Hospital, Southport, PR8 6PN

Attendees Fiona Clark (Chair) Chief Officer, Southport & Formby CCG FLC Kate Burgess Lancashire County Council KB Dr John Caine Chair, West Lancashire CCG JC Billie Dodd Head of CCG Development, Southport & Formby CCG BD Sheilah Finnegan Chief Operating Officer, Southport & Ormskirk Hospital NHS Trust SF Charlotte McAllister Urgent Care Commissioning Lead, West Lancashire CCG CMcA Holly Middleton Acting Director of Operations for Urgent Care HM Karl McCluskey Chief Strategy & Outcomes Officer, Southport & Formby CCG KMcC Pat McGuinness Operational Director, Mersey Care NHS Trust PMcG Mike Maguire Chief Officer, West Lancashire CCG MM Tina Wilkins Head of Service, Vulnerable People, Sefton Council TW Apologies Carol Bernard Director of Commissioning, Mersey Care NHS Trust CB Dr Rob Caudwell Chair, Southport & Formby CCG RC Penelope Fell Chief Operating Officer, New Directions PF Michael Gray Information Team, Southport & Ormskirk Hospital NHS Trust MG Claire Heneghan Chief Nurse, West Lancashire CCG CH Tom Knight Head of Primary Care, NHS England TK Judith Malkin Assistant Director of Operations, Community & Continued Care, Southport & Ormskirk JM Hospital NHS Trust Joanna Stark Assistant Director of Transformation & Women & Children’s Services, Southport & JS Ormskirk Hospital NHS Trust

No Item Action CCtHPB Welcome, introductions and apologies 15/01 Introductions were made and apologies were received from Carol Bernard, Dr Rob Caudwell, Penelope Fell, Michael Gray, Claire Heneghan, Tom Knight, Judith Malkin and Joanna Stark. CCtHPB Minutes and Action notes of the previous meeting 15/02 The minutes of the last meeting were accepted as a true and accurate record. Action Tracker 15/23 – Resilience issues – final winter resilience report to be shared with programme board – completed – can be removed from tracker. 15/23 – Resilience issues – link to the operational resilience document will be circulated with the minutes – completed – can be removed from tracker. 15/25 - CCtH dashboard – flu prevalence to be included and attendance levels compared - Michael Gray to do for next meeting (17th June). MG 15/25 - CC2H dashboard presentation - to be circulated with minutes - completed - can be removed from tracker. 15/15 - Diabetes update – Terry Hill to bring to next meeting 17th June. BD/TH CCtHPB Review Terms of Reference and Membership 15/03 The Terms of Reference and membership were reviewed and amendments FLC agreed. Updated version to be circulated with minutes of meeting. CCtHPB Risk Register 15/04 No additional risks were identified, although SF believed there may be some risks related to SRG. FLC asked board members to give it consideration and email All Jayne Byrne (FLC’s PA) with any risks before the next meeting. An updated register will be brought back to the next meeting on 17th June for review. FLC 1

No Item Action CCtHPB Resilience Issues 15/05 view of Easter Performance Additional thought and capacity was given to what was required and pressures were managed, although additional pressures came the week after Easter. As a result of lessons learnt, additional resource had also been planned for the forthcoming Bank Holiday. It was acknowledged there was a knowledge gap in terms of social worker support provided over the bank holiday which needed to be TW reviewed going forward. West Lancs also reported busier periods the week after Easter. The operational group should look at trends to see if it was always busier the week FLC following Easter. To be brought forward for June’s meeting - review 2 bank hols and look forward to August. CCtHPB Feedback from CCtH Dashboard 15/06 The dashboard will come back to the next meeting so we can have some clinical input - making it work is a separate issue which we have picked up as a CCG. BD FLC was hoping to utilise the CCG BI group to populate dashboard. CCtHPB Winter Planning 2015/16 (standing item) 15/07 SF was concerned about removing schemes which helped to manage risks over winter this year; where would capacity be created to manage that demand? FLC believed a random sample of approximately 5/10 patients should be taken to see where they were coming from and whether they were known to community nursing. If they were all coming from nursing homes we would possibly need to pass funding over to nursing homes, or mental health, etc. SF to look at type of A&E admittances to see if any trends appear. SF Discharge to Assess Model – SF queried whether we should be taking the same approach. The risks and implications related to that needed to be fully understood. Tina Wilkins has spoken to Clare Heneghan in relation to using the Trafford Model. It was agreed to invite Clare to the next meeting on 17th June. Billie to lead with Clare and Charlotte, Mark Waterhouse and Kate. BD/JB Allocation of SRG funding – Pat McGuinness asked how it worked. FLC confirmed Mersey Care had been allocated non-recurrent £800K to Mersey Care by Southport & Formby CCG. Pat McG to send evaluation to KMcC as it needs to link in with Care Home Liaison team (CHIPS) PMcG CCtHPB RTT (standing item) 15/08 KMcC suggested the meeting should review elective planned and non-elective unplanned care, which may lead to seasonality. Clinical questions also need to be asked regarding outcomes and procedures, which may liberate resource to help in another way. SF queried whether the CCtH was the right group to do that. MM asked what the main drivers were in elective care. FLC urged caution as RTT wasn’t a problem with waiting times creeping up. BD to circulate components BD parts of our role. CCtHPB Trajectory of Recovery in A&E 15/09 S&O has confirmed a projected trajectory of 1% per month to NHS England. CCtHPB Breakout Sessions 15/10 Individuals to get flip chart papers typed up for next time. ALL CCtHPB Any Other Business 15/12 No items raised. CCtHPB Date of Next Meeting 15/13 Wednesday 17th June 2015, 9.30am – 11.30am, Board Room, Trust Management Office, Southport Hospital NHS Trust, Town Lane, Kew, Southport, PR8 6PN

2

Lancashire Health and Wellbeing Board

Minutes of the Meeting held on Friday, 5th June, 2015 at 1.00 pm in Cabinet Room 'C' - The Duke of Lancaster Room, County Hall, Preston

Present:

Chair

County Councillor Azhar Ali, Cabinet Member for Health And Wellbeing (LCC)

Committee Members

County Councillor Tony Martin, Cabinet Member for Adult and Community Services (LCC) County Councillor Matthew Tomlinson, Cabinet Member for Children, Young People and Schools (LCC) County Councillor David Whipp, Lancashire County Council Dr Sakthi Karunanithi, Director of Public Health, Public Health Lancashire Louise Taylor, Corporate Director of Operations and Delivery (LCC) Bob Stott, Director of Children's Services Tony Pounder, Director of Adult Services Dr Gora Bangi, Chorley and South Ribble CCG Dr Mike Ions, East Lancashire Clinical Commissioning Group (CCG) Councillor Tony Harrison, Burnley Borough Council Councillor Bridget Hilton, Central Lancashire District Councils Lorraine Norris, Lancashire District Councils (Preston City Council) Michael Wedgeworth, Chair Third Sector Lancashire Professor Heather Tierney-Moore, Chief Executive of Lancashire Care Foundation Trust

1. Welcome, introductions and apologies

Apologies were received from:  Dr Tony Naughton (FWCCG)  Dr Dinesh Patel (GPCCG)  Dr Alex Gaw (LNCCG) – Andrew Bennett had been due to attend on behalf of Dr Gaw but subsequently provided his apologies

Replacements  Dr Vasudev replaced Gail Stanley (Healthwatch)  Carole Spencer replaced Karen Partington (Lancashire Teaching Hospitals Trust)  Dr Bipi Biswas replaced Dr Simon Frampton (WLCCG)

The Board were informed of a number of new members as follows:  Dr Dinesh Patel (Greater Preston CCG)  Dr Tony Naughton (Fylde & Wyre CCG)  Jane Higgs (NHS England)

1 The Board was asked to note that Dr Tony Naughton has been appointed as the Deputy Chair. CC Ali took the opportunity to ask the Board to formally thank Dr Ann Bowman for all her hard work in her capacity as the previous Deputy Chair.

2. Disclosure of Pecuniary and Non-Pecuniary Interests

None noted

3. Minutes of the Last Meeting.

The minutes of the meeting held on 29 January were agreed as a correct record

4. #lifesupsanddowns - Children and Young People's Wellbeing Promotion Video

Prior to the showing of a short video Bob Stott, Director of Children's Services provided members with a brief introduction. He explained that on Saturday 26 April, 50 children and young people from PULSE (Lancashire's Children and Young People's Health and Wellbeing Board) performed a flashmob in the Fishergate Shopping Centre, Preston.

The flashmob launched PULSE's emotional health and wellbeing campaign which aims to raise awareness of the emotional health and wellbeing issues faced by children and young people and reminding them that there are little things they can do to help improve their mood.

The campaign promotes the following five ways to wellbeing, under the umbrella of 'Coping with life's ups and downs':

 Take Time Out  Keep Connected  Try Something New  Give  Be Active

The video is the story how the flashmob came about and the impact it has created.

It was resolved that i. The Board welcomed the engaging way that emotional health & wellbeing issues had been addressed by the children and members asked for a copy of the video so that could share it amongst their individual organisations. It was agreed that Richard Cooke would provide members with a link to the video. ii. The Board consider future opportunities to engage with PULSE

5. Health and Wellbeing Board - Refreshed Governance and Approach

Richard Cooke presented this item.

2 There is a strong commitment from partners to ensure that the Health and Wellbeing Board (HWBB) is an effective forum to deliver improved health and wellbeing outcomes through collaboration. Through the engagement of Board members in a recent workshop a number of areas of focus have been identified that would enhance the approach and effectiveness of the Board. The thinking around these areas was further developed through a one off meeting of partners, which, supported by examples of good practice in other authorities, has informed a refreshed approach in Lancashire.

A number of proposals were identified which related to the following areas:  Clarity of purpose  Meetings  Strategy  Synergy and coherence  Evidence  Communication  Strategic fit

A revised Terms of Reference was also presented for consideration by the Board. The main proposed changes referred to:  Outcomes – a clearer focus on health and wellbeing outcomes for the people of Lancashire  Membership – that the leader of the County Council would become Chair of the Board and other additional members would include the five chairs of the local Health and Wellbeing Partnership, the Constabulary Chief Constable and the independent chair of the Lancashire Safeguarding Children Board.  Meeting Arrangements – hold meetings bi-monthly with alternate meetings being delivered as a workshop with a thematic focus. The Quorum of the meeting would a quarter of the membership (8) with at least one Cabinet Member

Richard explained that following a frank discussion it was recognised that there were lots of challenges but also opportunities. There was a passion and strong commitment which had resulted in a number of key themes. He stated that there was a danger that the focus of the Board would be on the differences between the organisations represented but a better starting point would be to focus on the similarities.

A discussion took place and the main points were:

 CC Martin agreed with overall thrust of the proposals and wondered whether the Board should consider including a representative from the Lancashire Care Association (LCA) be added to the membership. LCA represent over 350 care homes across the county  The trigger for this review was on the back of the Better Care Fund (BCF), the initial difficulties encountered in developing this work and the now positive engagement and collaboration across organisations.  Cllr Harrison expressed concerns of resourcing the new ways of working and was keen to develop links with other strategic partners. Can LCC also review the other partnerships? They all need looking at.  Mike Wedgeworth felt that any changes should be considered changes (rather than just for the sake of it) and wondered about linking in with Healthier Lancashire. Maybe the Board should also be looking to what is happening in Greater

3 Manchester – we need to get our act together (all of Lancashire). He expressed caution on the number of members.  Dr Biswas stated that at his CCG a number of issues had been highlighted as areas requiring further clarity and they included how the Board would provide effective challenge, particularly in light of an increased membership; reaching out to GPs to increase their involvement; including a CCG representative when determining a quorum and responsibility of BCF reporting  Dr Ions welcomed the refresh of the Terms of Reference and was keen to see the Board becoming more proactive and felt it was essential that the local health partnership were included in the membership of the Board  Cllr Hilton felt that it should be made clear to the Board what had been achieved against performance targets and that a summary sheet of the resolutions of the Board should be provided to members as soon as possible after each meeting  It was acknowledged that any changes to the terms of reference and format of reports needed to be subject to compliance with the County Council's constitution and required formal approval from Full Council.

It was resolved that i. the Board agreed the proposals presented ii. the Board agree the new Terms of Reference and subsequent comments from members for further consideration by officers prior to formal approval by Full Council iii. a summary sheet of resolutions be produced for each meeting and circulated to members at the earliest opportunity

6. Better Care Fund

The report was presented by Mark Youlton.

The purpose of this quarterly report is to inform the Lancashire Health and Wellbeing Board on the progress of the delivery of the Lancashire Better Care Fund (BCF) Plan. This report is in support of the national reporting template (Appendix A) which the Health and Wellbeing Board is required to receive, approve and submit to the Department of Health. This submission relates to the first national template completed for Quarter 4 2014/15. In June 2013 the Department for Communities and Local Government announced £3.8 billion worth of pooled budgets between health and social care, starting from April 2015. This is a multi-year fund and was launched as a financial incentive for councils and local NHS organisations to jointly plan and deliver services so that integrated care becomes the norm by 2018. While it was recognised that many places were already working collaboratively and redesigning services to meet the needs of users and communities, faster and more widespread change was required to help to meet the increasing demand for care services into the future.

The BCF is intended to provide a means for joint investment in integrated care, which ought to reduce the pressure on social care and hospitals by providing treatment before a crisis. CCGs are expected to make significant efficiencies to generate the money to invest in the BCF, and there is a risk that if BCF plans do not deliver the anticipated results (e.g. reductions in residential care admissions or reductions in emergency hospital admissions) additional resources will be needed to meet the demand (e.g. funding care packages or extra staff for A&E).

4 In January 2015, the Lancashire BCF Plan was re-submitted to the Department of Health and was approved. In 2015/16 the BCF pooled budget is agreed at £89 million which is hosted and managed through a Section 75 agreement by Lancashire County Council who also contribute to the BCF through the Section 256. The Lancashire BCF covers 21 schemes focussed on community based integrated services aimed at reducing non- elective activity (NEL) by 3.1%.

A discussion took place and the main points were:

 Significant rise in activity during the last quarter of 2014/15 which impacted on all services. Affected every BCF in the country in terms of performance target achievements and level of savings to be made.  Challenge to see how to get back on track. Important to acknowledge that it doesn't detract from the overall outcomes of BCF  Government task force may have an impact. A number of offers still being made centrally – there is an offer of support to us through a critical review. Mark stated he would welcome some external scrutiny and challenge. Will express an interest to NHSE for an external challenge  The role of the two vanguards in the County? Challenge is to how the reporting of those is connected (or not) to the reporting around the BCF  Overall confusion regarding how the vanguards align with BCF – often similar approach but possibly working with a different set of partners.

It was resolved that the report be noted and an expression of interest be forwarded to NHSE requesting an external review

7. Children and Young People's Emotional Health and Wellbeing Services

The report was presented by Shirley Waters and Carl Ashworth

The report is a high level review of all Children & Young People’s Emotional Wellbeing and Mental Health Services (C&YP EWMH), 0 – 25 years, in Lancashire. It was built on the recent service reviews conducted by local authorities and CCGs. The findings of this first phase have highlighted that there are pockets of excellence throughout Lancashire which could be developed, shared and implemented in some or all CCGs. Commissioning and services are fragmented leading to inequalities from one commissioned area to another with several providers delivering services in different ways depending on where the service user lives. CCGs are developing specific areas of provision without cognisance of activity in other areas. .

As presented in the update report to the January HWB meeting the Commissioning Support Unit was tasked with undertaking the review and taking a fresh look at the services across the pan-Lancashire system. The review was conducted in collaboration with CCGs, Local Authorities in addition to the three Health and Wellbeing Boards, Strategic Clinical Network and in cognisance of local and national drivers for change

The Programme Board for the C&YP’s EWMH submitted phase one, a whole system review, to the Collaborative Commissioning Board in April 2015 and was agreed with the

5 caveat requiring a description of a system leader which was submitted in May and also agreed.

A discussion took place and the main points were:

 It was clarified that specialised commissioning was also included in the review  A member queried the engagement of schools in developing the review – wants easy access to services. Officers responded that the review group will look at the pathway including access points.  Regarding the difference in provision of service, it was felt that there needs to be a balance depending on the community but a standardised approach to quality.  It was acknowledged that this was an important piece of work as many mental health problems begin in childhood however concerns were expressed that there has been the awareness of the issues for sometime and we are no nearer a resolution..  It was felt that we don’t want a uniform service but the expectation is to be a minimum level of service instead – how do we address these underfunded areas of service. Officers responded that it's not just about spend, it's about the quality of the service and the different models of care and best practice models of care  It was clarified that Lancashire Mind were consulted in the production of this report. It important that they are seen as key players. Shirley Waters added that the 3rd sector would be represented on the review board  Members expressed concerns that a further review was due to be undertaken as they felt that they know what the problems are. If it's about investment we should look at using existing resources smarter. Shirley stated it wasn't another review, more a 'what can be done about it' and feels confident that there is now relevant representation to make things happen  Focusing on service delivery models rather than reviewing what's already being (or not being) done  One member felt that the Board needs to take a stronger line in terms of outcomes and timescales – it's about public accountability and improving outcomes  The Board requested that officers come back to the Board in September with recommendations that need to be agreed and signed off.  The Chair asked for a plan and timeline/actions to be presented to the September Board prior to the implementation of the services (possibly also present it to the Health Scrutiny Committee)

It was resolved that i. The report be noted ii. A report be presented to a meeting of the Board in September identifying a set of recommendations to begin implementation of a new model, including a plan of the milestones and actions to be taken

8. Joint Strategic Needs Assessment - Health Behaviours

The report was presented by Mike Leaf.

This work formed part of the JSNA bespoke analysis work programme 2013/14, agreed by the Health and Wellbeing Board in October 2013. The input of the Joint Officer Group into the work

6 programme has been instrumental in the production of this JSNA. Following input from the HWB the health behaviours JSNA was undertaken to identify the prevalence of multiple health-enabling and health-compromising behaviours of Lancashire's residents. It has also provided an understanding of the relationship between these behaviours and their impact on the health of people in Lancashire.

Following extensive analysis (including the survey findings) and engagement with partners a final report has been produced

A discussion between members and the main points were:  It was suggested that in the past the JSNA hasn't been embedded into the strategic plans of partners and members were asked to consider that work on prevention should take on board the JSNA data. This could be put into an action plan for the Board to agree  General concerns were expressed regarding topics such as alcohol and also obesity and whilst some issues can be addressed locally, many are national issues

It was resolved that a report be presented to the Board that demonstrates how evidence from this JSNA is informing plans, strategies and priorities

9. Joint Strategic Needs Assessment - Six Shifts

This report was presented by Mike Leaf.

Through its Health and Wellbeing Strategy, the Lancashire Health and Wellbeing Board identified a number of important shifts in the way partners across Lancashire work together. These shifts in behaviour would fundamentally challenge the way that the wider health economy currently works and would improve health and wellbeing within the resources that will be available to us. The six shifts are: 1. Shift resources towards interventions that prevent ill health and reduce demand for hospital and residential services 2. Build and utilise the assets, skills and resources of our citizens and communities 3. Promote and support greater individual self-care and responsibility for health; making better use of information technology and advice 4. Commit to delivering accessible services within communities; improving the experience of moving between primary, hospital and social care 5. Make joint working the default option 6. Work to narrow the gap in health and wellbeing and its determinants

After extensive engagement with partners, a full report has been produced

Members made a number of comments and the main points were:  Can't argue against any of the six shifts but the issue is how do we get movement on them and develop an action plan to produce a range of outcomes  Many of the initiatives are already being integrated into other programmes (such as Better Care Fund) and we must not lose sight of that and don't try to produce something duplicated or in isolation

7  Referring to the refocus of the Board, it was suggested that the Board needs to see impact information. Base line information and progress against it to identify what areas need to be addressed and need further action/support.  Members were reminded that overall this has been going on over the last 3 years and therefore the Board should agree that we need to move it forward  It was felt that this is a good example of where the local health partnerships can be engaged with the challenge and respond to actions

It was resolved that the report be noted, shared with the local health partnerships and used to inform future priorities

10. Urgent Business

Sakthi informed the Board of a very recent announcement by the DoH stating that a £3b reduction would be made which included £200m cut to ring fenced Public Health (PH) funding – the rationale was based on redirecting the funding to front line NHS services. The reduction equates to approximately £4m per year of PH spending in Lancashire and will be made in year.

He wanted the Board to be aware that this reduction to local authority PH funding will have a significant impact on all partners e.g. CAMHS. A&E departments. Often, in situations such as this there are hidden impacts as we will not see the consequences of less people being screened for sexually transmitted diseases, or less children immunised until much later

In the Five Year View there is a strong emphasis on prevention and partners so there appears to be a mismatch between achieving the overall vision and practical delivery of services

He explained that a consultation has begun and suggested that the Board have a discussion to determine what it will mean for the future of Public Health and he can then facilitate a response to be provided on behalf of the Board.

CC Ali also offered to write to the Secretary of State on behalf on the Board

Mike Ions acknowledged the potential impacts on the NHS, and informed members that there is soft evidence of the effect of local authority cuts in social care that have already impacted on NHS partners. CC Ali suggested that Mike provide Sakthi with information on this soft evidence

It was resolved that i. a co-ordinated response to the consultation be provided on behalf of the Board ii. That any soft evidence on the impact of local authority cuts should be forwarded to Sakthi Karunanithi

11. Date of Next Meeting

The date of the next meeting of the Health & Wellbeing Board is Thursday 16 July at 2.00pm in Cabinet Room C, County Hall, Preston.

8 12. Pharmaceutical Needs Assessment

Pharmaceutical Needs Assessment (PNA) It was noted that a Transaction of Urgent Business to approve the PNA had been undertaken on behalf of the Board. The Chair and Deputy Chair of the Board were consulted prior to approval granted by the Executive Director of Adult & Community Services

I Young Director of Governance, Finance and Public Services

County Hall Preston

9 WEST LANCASHIRE COMMUNITY SAFETY PARTNERSHIP

HELD: 29th April 2015 Commenced: 6.00 pm Finished: 7.50 pm

PRESENT: David Tilleray - WLBC (CSP Chairman) Andrew Hill - WLBC Gareth Dykes - West Lancashire PACT Steve Mahon - WLBC Lyn Hall - Lancashire & Cumbria CRC Councillor Julie Gibson - Lancashire County Council Tracie O’Gara - Lancashire Constabulary Christine Rourke - Chair Ormskirk Magistrates June Chessell - Lancashire Constabulary Councillor Sudworth - West Lancashire BC Frank Robinson - Lancashire Fire and Rescue Mel Grice - IDVA, West Lancashire Kate Sutton - Lancashire & Cumbria CRC Alec Grimshaw - Discover Geraldine Martin - Lancashire & Cumbria CRC

IN ATTENDANCE: Cliff Owens - WLBC

1. WELCOME AND INTRODUCTIONS

The Chairman welcomed colleagues to the meeting and introductions were made.

2. APOLOGIES

Apologies for absence were received from:

Councillor Atherley, Gill Rowe, Bill Hancox, Jan Tyrer, Greg Mitten, Eleanor Maddocks, Sue Hogan, Katie Wightman, John Fillis, Robert Ruston

3. RESTORATIVE JUSTICE INITIATIVE

Geraldine Martin provided the Partnership with an introduction to the Restorative Justice Initiative on behalf of Lancashire and Cumbria Community Rehabilitation Company. Geraldine provided copies of the Restorative Justice Scrapbook which is a collection of thoughts on the restorative justice experience. Geraldine continued by introducing a short film on the process of restorative justice. The film was very impactive and provided a much personalised view of the restorative justice process from both the victims and perpetrators perspectives.

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Frank Robinson commented that it was clearly a very difficult process for the individuals involved and a very good piece of work that can benefit the victim and offender.

Chief Inspector Tracie O’Gara stated that the police have used restorative justice for a number of years and have seen the benefits of this approach at the lower end crimes to assist in preventing more serious offending but also to provide the victim with closure.

The short film generated very positive discussion and Geraldine concluded by stating that the general public don’t know enough about restorative justice, adding that the CRC would like to promote it more to the public and to help promote funding through the Office of the PCC.

The Chairman thanked Geraldine and Kate for a very informative presentation.

4. MINUTES OF LAST MEETING/MATTERS ARISING

The minutes of the last meeting were agreed as a true and accurate record.

The Chairman advised that strategic partners from across the County are part of the community safety strategic agenda and the Chief Executives Group must now manage the process of taking this agenda forward.

The Chairman advised that the Chief Executive’s Group community safety role is still at an embryonic stage but will be aiming to set out plans to progress this agenda. The Chairman stated that he will keep the Partnership updated on progress.

5. PERFORMANCE MONITORING

The Chairman, David Tilleray, invited partner agencies to provide a verbal overview of current performance.

Chief Inspector Tracie O’Gara provided the Partnership with an overview of police performance. C.I. O’Gara advised that West Lancashire has recorded a significant decrease in crime numbers for the 2014 / 15 period compared with the previous year but added that she would prefer to look at crime categories and parameters rather than just focus on numbers. C.I. O’Gara highlighted the continuing threat of cross border crime and also acquaintance related crime within the estates. C.I. O’Gara stated that the focus will continue to be on risk and threat but welcomed the excellent performance achieved in West Lancashire.

Frank Robinson provided the Partnership with an overview of performance on behalf of Lancashire Fire and Rescue. Frank referred the Partnership to the comprehensive report contained within the meeting pack and provided a brief overview of each of the key performance areas. Frank highlighted that a Page No: 2 of 8 downward trend against accidental fires is recorded but cautioned that this performance is plateauing out and we need to be mindful of vulnerable people and support them as much as possible.

Frank advised that the vast majority of deliberate fires continue to be in the Skelmersdale area and work is on-going with the police to identify perpetrators of ASB and deliberate primary fires. Frank highlighted the positive work the service continues to roll out through the ‘Wasted Lives’ package. Frank also stated that the ‘Kicks’ project which is delivered by Wigan Athletic Community Trust continues to be a success with significant engagement from local young people.

Steve Mahon provided an overview of performance on behalf of the ASB Team. Steve advised that during quarter 4 the team had opened 8 new cases and closed 14 cases. Steve added that 3 tenants were evicted for drug offences and a further 4 had given up the properties before court hearings. Steve stated that during the quarter West Lancashire Housing Team opened up 56 complaints with the year-end total being 277. Steve added that the team continue to publicise outcomes when appropriate to deter ASB and promote community confidence.

Alec Grimshaw provided a brief overview of performance on behalf of Discover Drug and Alcohol Services. Alec advised that over the quarter there have been some new presentations and some returns to service. Alec confirmed that opiate usage continues to reduce with it being rare for a young people to present for opiate usage. Alex confirmed that there had been a spike recorded for alcohol presentations particularly in the 40-44 age range. Alec stated that commissioned projects for supporting people in recovery in the community continue to progress positively.

Mel Grice provided an overview of performance on behalf of the Liberty Centre. Mel also advised that the Liberty Centre floating support service has been decommissioned and will cease in May 2015. Mel also advised that the West Lancashire Women’s refuge provision is also due to go out to tender and we will receive further information on this work in June 2015. Mel advised that she is currently the only IDVA in West Lancashire and is currently working with 62 families. The part time position has been filled and the IDVA is currently undertaking training.

The Chairman, Dave Tilleray thanked colleagues for providing an update against their performance indicators.

6. CSP FUNDING UPDATE 2015 / 2016

Andrew Hill, Environmental Protection and Community Safety Manager provided the Partnership with an update against the CSP’s funding allocation for 2015 / 16.

Andrew Hill advised that West Lancashire Borough Council have committed £5,000 to fund key local priorities including Bright Sparx and the Fresher’s multi-agency action plan. Andrew also advised that the Office of the PCC had Page No: 3 of 8 also agreed for £4,000 funding from the 2014/15 allocation to be rolled over to 2015/16 to support delivery of Community Action and Engagement Days which are coordinated by the Community Safety Team. Andrew advised that the Office of the PCC have indicated that CSP’s will receive a further £10,000 allocation this year but added we are currently awaiting official confirmation.

Cliff advised that the CSP has been asked by the CSE Divisional strategic Group to consider committing £1,000 funding towards a CSE bid developed by South Ribble and Chorley to provide training to front line staff on CSE. Preston CSP has also agreed to support the bid which has been agreed by the Office of the PCC.

The Partnership agreed to support the joint Divisional CSE Strategic Group bid.

7. ASYLUM SEEKERS ACCOMMODATION

David Tilleray, CSP Chairman advised the Partnership that most large towns and cities are currently used as dispersal areas for temporary accommodation for asylum seekers. The Chairman continued by advising that many areas are now reaching saturation point and Serco who manage this service on behalf of the Home Office are looking at other locations, including West Lancashire. Asylum seekers will be housed in private accommodation secured by Serco for potentially up to one year whilst they await a decision on their request for asylum.

The Council and Police are working together to assess proposed addresses from Serco within the Borough to ensure that no current issues exist and the council do have the right of veto if potential community tensions are identified during the assessment.

The Home Office through Serco are looking at relatively urban areas but not in the most socially deprived areas. Serco are currently looking at up to 30 properties in West Lancashire with a proposed average of three people in each property. It’s currently proposed to begin with six to eight properties followed by a pause for review. Support mechanisms will be identified by Serco and put in place. The Chairman advised that both the Council and police are mindful of the potential for community tensions and will work with Education and Social Services to address issues. The Chairman continued by adding that hopefully we can ease asylum seekers into indigenous communities.

Chief Inspector O’Gara stated that community cohesion is a priority and added that we would want to ensure we deliver effective public sector services as asylum seekers will be part of our community.

Councillor Julie Gibson commented that the points have been well made by the Chairman and added that she is aware of the potential impact on services. Councillor Gibson added that a key consideration is private landlords and we must ensure that standards of housing in the borough are kept up to a good level. The Chairman stated that he is conscious of this issue and added that Page No: 4 of 8 the councils Private Sector Housing Manager is represented on the working group. The Chairman continued by adding that Serco are very well resourced and are looking at entering into 5 year deals and will ensure that properties are in good condition. The Chairman concluded that it is good that Serco have approached the council on this subject and added that generally West Lancashire is always open to people and can’t see this becoming a significant issue but cautioned that it must be managed sensitively.

8. OPERATION NEMESIS

Inspector June Chessell, Lancashire Constabulary, provided the Partnership with a brief overview of the background of Operation Nemesis which was set up over 12 months ago in South Division in response to gun and gang crime in Preston and Skelmersdale.

Inspector Chessell advised that the Chief Superintendent has agreed to extend Nemesis following significant success in dealing with organised crime issues in Skelmersdale. Over 300 search warrants and numerous arrests have been made supported by significant partnership working. Inspector Chessell advised that civil injunctions have been secured against nine individuals and with 16 breaches to date significant sentences have been secured. The orders also significantly restrict movement and associations of organised crime members in the West Lancashire and Merseyside area.

Inspector Chessell cautioned that although a lot of success has been achieved we must be mindful of gap fillers coming in and deal with them effectively.

9. LANCASHIRE FIRE AND RESCUE SERVICE CSP BRIEFING

Frank Robinson, LFRS Service Delivery Manager for West Lancashire provided the Partnership with an update on several issues including the launch of the Water Safety Education Package, LFRS Emergency Cover Review and the impact on Skelmersdale Fire Station and the North West Ambulance Service 'First Responder' pilot.

Frank advised from April 2016 as part of the Emergency Cover Review the Skelmersdale team will have 50% less staff but the fire appliances will remain. The teams will be moving to a new roster with approximately £400,000 savings made. An accommodation block is being built at the back of the station and outwardly the service will remain the same.

Frank provided the Partnership with an overview of the Lancashire Fire and Rescue led water safety campaign. The campaign was formally launched on the 14th April 2015. The water safety education package ‘Dying for a Dip’ was launched alongside two new video case studies in an attempt to raise awareness around the dangers of swimming in open water in the forthcoming summer months.

Page No: 5 of 8 The education package targets teens and young adults and will initially be delivered to schools across West Lancashire. Lancashire Fire and Rescue Service would like the key messages from the education package to be promoted by partner agencies.

The package contains information slides covering various elements such as the effects of cold water on the body, the hidden dangers of water, tomb- stoning, the seaside and what to do if you see someone struggling. Another key element to the water safety campaign is the two new emotionally- charged case study videos. The videos have been released via social media. Further information can be found on the Lancashire Fire and Rescue website through the following link: -

http://www.lancsfirerescue.org.uk/2015/04/dying-for-a-dip-water-safety- campaign/

Frank also provided a brief overview of the North West Ambulance Service 'First Responder' pilot. Frank advised that fire crews will respond to Red 1 and Red 2 calls were someone is suffering from a risk to life. First Responder schemes are up and running across the country and provide additional capability before paramedics arrive. Frank advised that the scheme will not compromise fire cover and the pilot will last for six months.

10. GIVE AND GAIN DAY

Chief Inspector Tracie O’Gara provided the Partnership with an overview of the aims of Give and Gain Day which is scheduled to take place on the 15th May. Give & Gain Day is an opportunity for businesses and community organisations to celebrate what can be achieved through the power of volunteers. Employee volunteering is a win-win; the experience builds skills and motivates employees, whilst helping meet community needs.

C.I. O’Gara advised that his year will be the first year the police have participated in Give & Gain Day. C.I. O’Gara continued by adding that the police and volunteers from the Special Constabulary will be conducting high visibility work on a variety of initiatives and will be working in partnership with other agencies to promote wider aspects of volunteering.

11. THROUGH THE GATE RESETTLEMENT SERVICE

Lyn Hall, Seniour Probation Officer provided the Partnership with an overview of the ‘Through the Gate Resettlement Service’. Lyn covered a number of elements including local ‘Through the Gate’ arrangements, the ‘Offender Journey’, women offenders and the ‘Offender Manager Role’.

Lyn provided an overview of the universal resettlement service for all those received into custody, regardless of status (CRC and NPS). Lyn advised that the Cumbria and Lancashire CRC is contractually obliged to deliver services that include accommodation and employment brokerage, finance and debt advice, support for sex workers and support for victims of domestic abuse Page No: 6 of 8

Lyn added that a network of 89 resettlement prisons has been established to support TTG including HMPs Preston, Kirkham, Haverigg and Lancaster Farms.

Lyn continued by providing an overview of the offender journey advising that pro-active resettlement support commences 12 weeks prior to release. Lyn advised that the assumption is that 80% of offenders will be relocated to a resettlement prison in their home CPA, three to six months prior to release. For the remaining 20%, services to be purchased via the rate card from the Lead Host or Host in resettlement prisons. In non-designated resettlement prisons including HMP Wymott & Garth it is the home CPA’s responsibility to offer a resettlement service.

Lyn concluded by adding that the Trough the Gate Service is scheduled to commence on the 1st May 2015.

The Chairman thanked Lyn for her update.

12. COMMUNITY ACTION AND ENGAGEMENT EVENT

Cliff Owens, Community Safety Officer provided the Partnership with an overview of the plans to deliver a multi-agency Community Action and Engagement Event.

The aim of the event is to support Give and Gain Day and to improve working relationships between local residents, the voluntary sector and statutory agencies, as well as increase community confidence and reduce the fear of crime.

A skip will be provided and funded by West Lancashire Community Safety Partnership and will be available from 9.30am on Friday the 15th May 2015 in Little Digmoor. Other activities planned by the Community Safety Partnership will include: -

• The Council’s Environmental Enforcement Team will be providing information to residents on environmental issues and conducting joint visual audits with the Council’s Estates Management Team and the police. • The environmental clean-up will also be assisted by the Lancashire Probation Community Payback Team. • The Police will be holding a street surgery and welcome engagement from local residents. • Fire Service personnel will be around the estate encouraging people to have free fire safety checks on their homes and giving information about other fire safety issues. • The Dog’s Trust will be supporting the event and will be offering a limited supply of free microchips for dogs. The Council’s Environmental Enforcement Team will be there to discuss free neutering of all status dogs.

Page No: 7 of 8 • Wigan Athletic Community Trust will be promoting the ‘Kicks’ soccer project.

13. ANY OTHER BUSINESS

Councillor David Sudworth advised the Partnership that he would be leaving the council and stepping down from politics. He added that during his 3 years on Cabinet West Lancashire has prided itself in punching above its weight on the community safety agenda and is considered extremely highly across the County as a result of its strong partnership working. Councillor Sudworth added that all members support the good work of the Community Safety Partnership.

The Chairman, on behalf of the Partnership, thanked Councillor Sudworth for his support for the Partnership and for his support for the Council’s work on the anti-social behaviour agenda. The Chairman wished him well for the future.

Andrew Hill advised the Partnership that the Council will be launching a 4 week consultation on the installation of 3 new public open space CCTV cameras. The consultation will commence at the beginning of May and finish on the 1st June 2015.

Frank Robinson advised the Partnership that from the 1st July he will be starting a new temporary 6 month role in the North of the County. He added that for awareness, SDM Phil Jones will be taking over from him as LFRS Service Delivery Manager for West Lancs with effect from the 1st of July 2015.

It is anticipated that Phil will be here for a period of approximately six months and added that he is aware partners will know Phil from his previous time here some three years ago which should go some way to ensure we have a relatively seamless transition.

The Chairman stated that Frank has been a very good friend to the Partnership and wished him well in his new role.

C.I. O’Gara also advised that this would be her final Partnership meeting as she would be retiring in June 2015. The Chairman thanked Tracie for her support and wished her the best for her retirement.

14. DATE OF NEXT MEETING

The next meeting of the West Lancashire CSP will be held on Wednesday the 15th July 2015 at 6.00pm in the Council Chamber, at the Main Council Office, 52 Derby Street, Ormskirk, L39 2DF

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