To Be Held in Public on Wednesday, 20Th May 2020, 2.15Pm – 5Pm Via Microsoft Teams a G E N D A

NHS Coventry and Rugby CCG and NHS Warwickshire North CCG Governing Body Meetings in Common to be held in Public on Wednesday, 20th May 2020, 2.15pm – 5pm Via Microsoft Teams A G E N D A

No Time Item Presenter Enclosure 1. Standing Items 1.1 2.15 Welcome and Apologies Received Chair Verbal 1.2 Confirmation of Quoracy Chair Enclosure A 1.3 Declarations of Interest: Where possible, any conflict Chair Enclosure B of interest should be declared to the Chair of the meeting in advance of the meeting. See guide below. 1.4 Minutes of the last Meeting held in common on Chair Enclosure C 18th March 2020 1.5 Matters Arising/Action Schedule Chair Enclosure D Sarah Raistrick/ 1.6 Joint Chair’s Report Enclosure E Sharon Beamish 1.7 Accountable Officer’s Report Adrian Stokes Enclosure F 2. Strategy and Planning Liz Gaulton / 2.1 2.25 Public Health Update Verbal Dr Shade Agboola 3. Quality 3.1 2.35 Reports from Clinical Quality and Governance Committees in Common: 26th March 2020 and 23rd Ludlow Johnson Enclosure G April 2020 3.2 2.40 Clinical Quality and Governance Committee Annual Ludlow Johnson Enclosure H Report 2019/20 3.3 2.45 Quality Report Jo Galloway Enclosure I 3.4 3.00 Child Death Overview Panel Annual Report Jo Galloway Enclosure J 4. Finance and Performance 4.1 3.05 Reports from Finance and Performance Committees Graham Nuttall Enclosure K in Common: 5th March, 9th April and 7th May 2020 4.2 3.10 Finance Reports: Month 10 Chris Lonsdale a) Coventry and Rugby CCG Enclosure L b) Warwickshire North CCG Enclosure M 4.3 3.40 Performance Report Andrew Harkness Enclosure N 5. Assurance and Governance 5.1 3.55 Report from Audit Committees in Common: 2nd April Chris Stainforth Enclosure O 2020 Sarah Raistrick / 5.2 4.00 Governing Body Annual Report 2019/20 Enclosure P Sharon Beamish No Time Item Presenter Enclosure 5.3 4.05 Assurance Framework Andrew Harkness Enclosure Q

6. Primary Care 6.1 4.20 Reports from Primary Care Commissioning Committee: Ludlow Johnson Enclosure R a) Coventry and Rugby CCG Graham Nuttall b) Warwickshire North CCG Enclosure S 6.2 4.25 CRCCG Annual Report of Primary Care Ludlow Johnson Enclosure T Commissioning Committee 2019/20 6.3 4.30 WNCCG Annual Report of Primary Care Graham Nuttall Enclosure U Commissioning Committee 2019/20 7. Policies for Decision 7.1 4.35 Commissioning Policies Enclosure V 8. For Information 8.1 4.45 Communications and Engagement Report Jenni Northcote Enclosure W 9. 4.50 Questions from Visitors Chair Verbal 10. 4.55 Any Other Business Chair Verbal

Future Governing Body Meetings in Common held in Public: Date Time Venue 08-Jul-20 2:15pm to 5:00pm TBC

23-Sep-20 2:15pm to 5:00pm TBC

25-Nov-20 2:15pm to 5:00pm TBC

13-Jan-21 2:15pm to 5:00pm TBC

17-Mar-21 2:15pm to 5:00pm TBC o

Declarations of Interest

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

Type of Description Interest

Financial This is where an individual may get direct financial benefits from the consequences of a Interests commissioning decision. This could include being:

• A director, including a non-executive director, or senior employee in a private company or public limited company or other organisation which is doing, or which is likely, or possibly seeking to do, business with health or social care organisations; • A shareholder (of more than 5% of the issued shares), partner or owner of a private or not for profit company, business or consultancy which is doing, or which is likely, or possibly seeking to do, business with health or social care organisations. • A consultant for a provider; • In secondary employment; • In receipt of a grant from a provider; • In receipt of research funding, including grants that may be received by the individual or any organisation in which they have an interest or role; and • Having a pension that is funded by a provider (where the value of this might be affected by the success or failure of the provider). Non-Financial This is where an individual may obtain a non-financial professional benefit from the Professional consequences of a commissioning decision, such as increasing their professional reputation or Interests status or promoting their professional career. This may include situations where the individual is: • An advocate for a particular group of patients; • A GP with special interests e.g., in dermatology, acupuncture etc. • A member of a particular specialist professional body (although routine GP membership of the RCGP, BMA or a medical defence organisation would not usually by itself amount to an interest which needed to be declared); • An advisor for CQC or NICE; • A medical researcher. Non-Financial This is where an individual may benefit personally in ways which are not directly linked to their Personal professional career and do not give rise to a direct financial benefit. This could include, for Interests example, where the individual is:

• A voluntary sector champion for a provider; • A volunteer for a provider; • A member of a voluntary sector board or has any other position of authority in or connection with a voluntary sector organisation; • A member of a political party; • Suffering from a particular condition requiring individually funded treatment; • A financial advisor. Indirect This is where an individual has a close association with an individual who has a financial Interests interest, a non-financial professional interest or a non-financial personal interest in a commissioning decision (as those categories are described above). This should include: • Spouse / partner; • Close relative e.g., parent, [grandparent], child, [grandchild] or sibling; • Close friend; • Business partner.

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GOVERNING BODY MEETINGS IN COMMON

Coventry and Rugby CCG Membership Warwickshire North CCG Membership

• Chair (Clinician) - Dr Sarah Raistrick • Chair – Mrs Sharon Beamish

• Accountable Officer – Mr Adrian Stokes (Interim) • Three (3) Lay Members (one of whom, as long as not the Chair, shall be the Deputy Chair where the • Clinical Director – Vacant Chair is a GP or other Healthcare Professional): - One to lead on Audit, Conflicts of Interest and • Chief Finance Officer – Mr Chris Lonsdale (Interim) Governance matters – Mr David Allcock (or deputy) - One to lead on Patient and Public engagement matters - Ms Gemma Nistorica-David • Chief Nursing Officer – Ms Jo Galloway (or deputy) - One to lead on primary care matters – Mr Graham Nuttall • Secondary Care Specialist – Dr Jonathan Timperley • Two (2) Practice Network Leads – • Lay Member (Audit and Governance) (Deputy Chair) - Ms Susan Turner – Mr Chris Stainforth - Dr Inayat Ullah

• Lay Member (Public and Patient Engagement and • Four (4) Clinical Leads- Health Inequalities) – Mr Ludlow Johnson - Dr Arshad Khan - Dr Godwin Igodo • Lay Member (Public and Patient Engagement) – Ms - Dr Imogen Staveley Gemma Nistorica-David • A registered nurse – Ms Jo Galloway (or deputy) • Godiva Clinical Lead - Dr Alastair Bryce • A secondary care specialist doctor – Dr Jonathan • InSpires Clinical Lead - Vacant Timperley

• Rugby Clinical Lead - Dr Deepika Yadav • Accountable Officer – Mr Adrian Stokes (Interim)

• Chief Transformation Officer – Mr Andrew Harkness • Chief Finance Officer – Mr Chris Lonsdale (Interim) (Non-voting) (or deputy) (or deputy)

• Chief Strategy and Primary Care Officer – Ms Jenni • Chief Transformation Officer – Mr Andrew Harkness Northcote (Non-voting) (or deputy) (Non-voting) (or deputy)

• Co-opted Participants Chief Strategy and Primary Care Officer – Ms Jenni Northcote (Non-voting) (or deputy) • Coventry Public Health (Non-voting) – Ms Liz Gaulton (or deputy) Co-opted Participants

• • Warwickshire Public Health (Non-voting) – Dr Shade Warwickshire Public Health (Non-voting) – Dr Agboola (or deputy) Shade Agboola (or deputy)

• TBC – independent director • TBC – independent director Quorum = seven members Quorum = not less than one third of the Members of the Governing Body present • Either the Chair or the Deputy Chair • Accountable Officer or Chief Finance Officer • One Independent Member • 1 Lay Member • One an employee of the Group • At least 4 clinicians (which may include the Chair • Two (2) clinical Members (save that where all the and Accountable Officer) Practice Network Leads are disqualified from participating in discussions or decision making, only one clinical member shall be required). Minimum quoracy across both CCGs = three members • 1 CCG Executive Member • 1 Lay Member co-opted across both CCGs • 1 Clinical Member co-opted across both CCGs

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

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

Declared To Indirect Interests Professional Non-Financial Non-Financial Personal Interests Personal Financial Interests Financial

Nil Mr David Allcock Lay Member for Audit and Governance

Mrs Sharon Beamish Chair, Warwickshire North CCG Governing Body 1. Director Align Performance Ltd. 100% shareholder.  Apr-12 Current

Mrs Sharon Beamish Chair, Warwickshire North CCG Governing Body 2. Daughter is a Matron at UHCW  Apr-19 Current

 Dr Alistair Bryce Godiva Clinical Lead GP Partner at Woodend Surgery 2009 Current

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

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

Mr Andrew Harkness Chief Transformation Officer 1. Member of the Faculty of Public Health  2011 Current

Mr Andrew Harkness Chief Transformation Officer 2. Member of the UK Public Health Register  2014 Current

3. Spouse is Managing Director of East Staffordshire Mr Andrew Harkness Chief Transformation Officer  2017 Current CCG

 GP at Camphill GP-Led Health currently operated by Dr Godwin Igodo Clinical Lead Oct-10 Current Malling Health/IMH Group

Director of Acute Contracting and Performance. Mr Steve Jarman-Davies Nil IFR Panel Member. NHS WARWICKSHIRE NORTH CCG AND COVENTRY AND RUGBY CCG - Register of Interests for Governing Bodies in Common Meeting

Lay Member, Coventry and Rugby CCG Mr Ludlow Johnson 1. Senior Manager, South Central Ambulance Service  Sep-09 to date Governing Body

Lay Member, Coventry and Rugby CCG 2. Specialist Advisor, Care Quality Commission (no Mr Ludlow Johnson  Apr-14 to date Governing Body longer current, to be removed in August 2020)

Lay Member, Coventry and Rugby CCG Mr Ludlow Johnson 3. Magistrate  Sep-08 to date Governing Body

3. GP Partner at Torcross Medical Centre, Coventry   Dr Arshad Khan Clinical Lead 2011 Current

1. GP Locum at Khan Medical Practices Ltd   Dr Arshad Khan Clinical Lead 2011 Current

2. GP Partner at Station Street Surgery   Dr Arshad Khan Clinical Lead 2011 Current

 Dr Mark Lawton Inspire Clinical Lead 1. Partner in Kenyon Medical Centres 1991 Current

 Dr Mark Lawton Inspire Clinical Lead 2. Shareholder Contego Solutions Ltd 2017 Current

3. Wife is a CQC inspector for  Dr Mark Lawton Inspire Clinical Lead mental health services in the 2016 Current midlands

Ms Gemma Nistorica-David Lay Member (Public and Patient Engagement) – TBC

Ms Jenni Northcote Chief Strategy and Primary Care Officer Jointly appointed - George Eliot Hospital Nov-19 Current

14/09/2015 1. Trustee and Board Member at Bulkington Village Mr Graham Nuttall Lay Member for Primary Care Current Centre 

Chair, Coventry and Rugby CCG Governing Dr Sarah Raistrick 1. GP Partner Willenhall Primary Care Centre 1  Jul-15 Current Body NHS WARWICKSHIRE NORTH CCG AND COVENTRY AND RUGBY CCG - Register of Interests for Governing Bodies in Common Meeting

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

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

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

Chair, Coventry and Rugby CCG Governing 5. Former employer and mentor (2010-14) is bidding Dr Sarah Raistrick  Jul-15 Current Body for a contract with CCG – Online consultations.

Chair, Coventry and Rugby CCG Governing 6. Met once with Rugby interest group for coffee to Dr Sarah Raistrick  Current Body discuss NHS in Rugby.

Chair, Coventry and Rugby CCG Governing Dr Sarah Raistrick 7. Non-voting Member of Coventry GP Board  Jan-19 Current Body

Chair, Coventry and Rugby CCG Governing Dr Sarah Raistrick 8. Member of West Midlands Clinical Senate  Dec-19 Current Body

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

Dr Imogen Staveley Clinical Lead 1. Salaried GP at Bedworth Medical Centre  04/09/2017 Current

2. CEO PregnaPouch (Pregnancy related app - Dr Imogen Staveley Clinical Lead  Current business is not live) October 2015

3. Role as Clinical Lead for transforming primary care Dr Imogen Staveley Clinical Lead  Jan-17 Current team, health London Partnership

Mr Adrian Stokes Interim Accountable Officer Director of Flexible Health Solutions  2014 Current

Consultant at Northampton General Dr Jonathan Timperley Secondary Care Doctor  Hospital NHS WARWICKSHIRE NORTH CCG AND COVENTRY AND RUGBY CCG - Register of Interests for Governing Bodies in Common Meeting

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

 Mrs Sue Turner Practice Network Lead Practice Nurse at Cole House Surgery Apr-19 Current

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

 Dr Inayat Ullah Practice Network Lead Nuneaton and Bedworth 2. Urgent Care George Elliot Hospital Current

Mother works part time at Bedworth Health Centre Associate Director of Governance and Mrs Anita Wilson and is employed via NHSP as Band 7 ED Nurse at  Jul-18 Current Corporate Affairs GEH

Clinical Lead, Rugby Locality, Coventry and Dr Deepika Yadav 1. Salaried GP, Forrest Medical Centre  Dec-14 Current Rugby CCG, Pathology Services Lead

Clinical Lead, Rugby Locality, Coventry and Dr Deepika Yadav 2. Husband is GP, Locum  Apr-14 Current Rugby CCG, Pathology Services Lead

Clinical Lead, Rugby Locality, Coventry and Dr Deepika Yadav 3. NHSE Medical Advisor for Workforce Development  Mar-18 Current Rugby CCG, Pathology Services Lead

Clinical Lead, Rugby Locality, Coventry and Dr Deepika Yadav 4. Member of Coventry LMC  Apr-17 Current Rugby CCG, Pathology Services Lead

Clinical Lead, Rugby Locality, Coventry and 5. Resident in local area with children who go to Dr Deepika Yadav  Mar-04 Current Rugby CCG, Pathology Services Lead school locally

Clinical Lead, Rugby Locality, Coventry and 6. Director future aesthetics LTD, providing aesthetics Dr Deepika Yadav  Jul-19 Current Rugby CCG, Pathology Services Lead treatments

Clinical Lead, Rugby Locality, Coventry and Dr Deepika Yadav 7. RCGP Midlands tutor  Sep-19 Current Rugby CCG, Pathology Services Lead

Unconfirmed Minutes of the Governing Body Meetings in Common Held in Public on Wednesday, 18th March 2020 at 2.15pm

Venue: Heron House, Nuneaton

Dr Sarah Raistrick Chair – CRCCG Mr Adrian Stokes Interim Accountable Officer Mr Chris Lonsdale (via Interim Chief Finance Officer teleconference) Ms Jo Galloway Chief Nurse and Deputy Accountable Officer Dr Deepika Yadav Rugby Locality Lead – CRCCG Mr Chris Stainforth Lay Member – Audit and Governance - CRCCG Dr Imogen Staveley Clinical Lead - WNCCG Ms Sue Turner Practice Network Lead: North Warwickshire – WNCCG Mr Graham Nuttall Lay Member - Primary Care – WNCCG Dr Arshad Khan Clinical Lead – WNCCG (until 14:59) Dr Jonathan Timperley (via Secondary Care Doctor – WNCCG/CRCCG teleconference) Dr Inayat Ullah (via Practice Network Lead: Nuneaton & Bedworth Network - WNCCG (until 14:56) teleconference)

Apologies: Dr Alistair Bryce Clinical Lead - CRCCG Ms Claire Forkes Lay Member – Patient and Public Involvement – CRCCG Dr Shade Agboola Director of Public Health, Warwickshire Mr David Allcock Lay Member – Audit and Governance - WNCCG Mr Ludlow Johnson Lay Member - Patient and Public Involvement and Equality - CRCCG Mr Mark Lawton Clinical Lead - CRCCG Ms Sharon Beamish Chair – WNCCG Mr Andrew Harkness Chief Transformation Officer

In Attendance: Ms Jenni Northcote Chief Strategy and Primary Care Officer Mr Stan Orton Public and Patient Group Representative Steve Jarman-Davies Director of Intelligence, Planning and Performance

Mrs Rose Uwins Senior Communications & Engagement Manager Ms Gemma Nistorica-David New Lay Member for Patient and Public Engagement, starting April 2020 Mrs Anita Wilson Associate Director of Governance and Corporate Affairs Mrs Victoria Scholes Governance and Corporate Affairs Officer (Minutes)

Item Action No: 1. Standing Items:

1.1 Welcome and Apologies

Dr Raistrick welcomed Members of both NHS Coventry and Rugby CCG and NHS Warwickshire North CCG Governing Bodies and members of the public to the meetings in common.

In the absence of Ms Beamish, Dr Staveley was in attendance as Deputy Chair for WNCCG.

Dr Raistrick aimed to keep the meeting as brief as possible and items for noting would be assumed read. Members would have an opportunity to raise any pertinent questions but prolonged discussion would be saved for a few important agenda items.

1.2 Declarations of Interest:

Members were reminded of the need to declare their interest in any items requiring a decision and to remove themselves from such decision making.

Dr Yadav declared that she had started in a new role as Director for Integration across University Hospitals Coventry and Warwickshire (UHCW) and the CCG.

No other declarations of interest were made.

1.3 Minutes of the Last Meeting: 22nd January 2020

Members AGREED the minutes as a true and accurate record of the meeting.

1.4 Matters Arising And Action Schedule:

Matters Arising:

There were no matters arising.

Action Schedule:

Members noted that Action 83, 85, 86, and 87 were complete. The remaining actions were in progress.

1.5 Chair’s Report:

CRCCG Chair’s Report

Dr Raistrick highlighted the outcome of the Membership vote on the future of healthcare commissioning, which was for the CCG to merge with the two Warwickshire CCGs in the Health and Care Partnership (STP).

Dr Raistrick thanked Ms Forkes for her service to the Governing Body in her Lay Member role and wished her well as she continues with her business ventures and family life.

CRCCG Governing Body Members NOTED the report.

WNCCG Chair’s Report

In the absence of Ms Beamish, Dr Raistrick confirmed that the WNCCG Chair’s report also highlighted the outcome of the Membership vote. The report also announced that Ms Nistorica- David had been appointed as the new Lay member for Patient and Public Engagement to cover both Warwickshire North CCG and Coventry and Rugby CCG and should hopefully start in April 2020. Ms Nistorica-David was observing at the meeting.

WNCCG Governing Body Members NOTED the report.

Item Action No: 1.6 Accountable Officer’s Report

Mr Stokes reported that a letter had been shared with the CCGs from Sir Simon Stevens, Chief Executive Officer of the NHS, outlining the next steps on the NHS response to COVID-19 following the declaration of a Level 4 National Incident. The next steps included freeing-up the maximum possible inpatient and critical care capacity, postponing all non-urgent elective operations and utilising NHS staff to support clinical practice.

Mr Stokes explained that the CCGs needed to support NHS staff through this period. He also explained that the expectations on the CCG as a healthcare organisation were greater than non-healthcare organisations. The system would need to stress test the operational readiness for a large number of patients going into critical care and scope private sector capacity. The NHS would need to change the way it does business in order to facilitate the response, for example, Care Quality Commission (CQC) visits had been cancelled and cost saving would be a reduced priority in the first quarter of the new financial year.

Mr Stokes highlighted that the Governing Body meeting marked the end of the Stroke Business Case. He explained the importance of Governing Body Members providing full scrutiny of the report as it was the last opportunity for challenge. Mr Stokes reported that the CCGs had received a petition from Keep Our NHS Public in regards to the model and the consultation.

The Governing Bodies NOTED the report.

2.0 Strategy and Planning:

2.1 Public Health Update

Dr Raistrick presented the report in the absence of a Public Health representative. In relation to the Year of Wellbeing, she suggested that the Governing Bodies agree the following: • To thank the staff who have been actively involved in the project; • To ensure that the CCG Staff Forum and the Wellbeing Warriors are utilised to ensure that actions that were beneficial for CCG staff are not stopped; and • To be assured by her representation on the Health and Wellbeing Board, alongside Mr Stokes.

The Governing Bodies: • NOTED the outputs and evaluation headlines from the Year of Wellbeing; and • CONSIDERED the legacy recommendations from the final report of the Year of Wellbeing; and • AGREED the actions to maintain activity as outlined above.

2.2 CCGs’ Merger Programme Update

Mr Stokes presented the report, explaining that he was seeking agreement of the approach outlined.

Governing Body members NOTED the progress to date and AGREED the approach.

2.3 Decision Making Business Case - Improving Stroke Outcomes

Dr Raistrick explained that the Stroke Business Case was a key item for the Governing Bodies to scrutinise.

Mr Stokes formally noted that the CCGs had received a petition from Keep Our NHS Public. He read the petition to Members as follows:

We the undersigned protest at the cuts planned in stroke care in Coventry and Warwickshire.

There will be a net loss of 30 acute stroke beds by closure of existing facilities in Nuneaton and Warwick. The transfer of all emergency care to University Hospitals Coventry and

Item Action No: Warwickshire at Walsgrave will put further pressure on an already overstretched hospital. Additional ambulance travel times bringing patients from Warwickshire to Coventry, could put lives at risk.

We are also concerned to learn that 70% of Coventry Stroke patients will be discharged to at home care when community health and social care services are already overstretched and under- funded.

Travel times will be increased for families visiting those Coventry patients relocated to facilities in Leamington or Nuneaton.

We demand a full and proper public consultation and a stroke service designed around the needs of patients and communities not financial targets.

Mr Stokes confirmed that a proper consultation had been undertaken, the business case represented a £3m investment and a clinical senate had designed the model.

In relation to the process followed, Mr Stokes highlighted the following: • 9 engagement events had been held with fairly good attendance from a wide range of people, including a significant number of people who had suffered from a stroke themselves. • 4 Health and Overview Scrutiny Committees had taken place, the outcomes of which were very positive. • A panel reviewed all evidence from the consultation events and the engagement opportunities. The panel determined that there had been fair representation.

In relation to the balance of opinions, Mr Stokes explained that the issues mainly related to travel, parking and ambulance travel times. The business case explained the actions being taken to mitigate these. Mr Stokes reported that the evidence demonstrated that the model saves lives and improves quality of life for patients.

In relation to the clinical closing argument, Mr Stokes explained that the model had been clinically designed and the CCGs had responded exactly as requested by the clinical group. The business case represented a £3m investment for the three CCGs and was an investment in quality for patients.

Mr Stokes confirmed that the business case had been through a significant amount of scrutiny from NHS England/Improvement and that he believed additional benefits would accrue over and above those identified in the Business Case, particularly in relation to ongoing care costs in social care. He also felt it needed to be weighed against the cost of not progressing given the length of time and consultation that had happened to date. He was confident this represented good value for money.

Dr Staveley confirmed that she supported the business case. She highlighted that it referred to primary prevention through management of atrial fibrillation, but did not include monitoring of hypertension or lipid management. Mr Stokes agreed that the system should do everything possible in terms of prevention. Dr Raistrick agreed that primary prevention should play a key role.

Dr Staveley thought that the Implementation Team should include a primary care element.

Dr Yadav asked whether the general rehabilitation beds at Hospital St Cross could be used for stroke rehabilitation. Mrs Uwins confirmed that the beds were now part of a wider general rehabilitation ward and that there were not enough patients to safely sustain a third bedded rehabilitation ward.

Ms Galloway confirmed that she was supportive of the business case and thought that it was a very clinically effective model for patients. She noted the issues that had been raised in relation to the consultation, confirming that the CCGs should ensure that all issues were monitored through the overall governance of the process. She thought that the CCGs’ message to the public should be that we have listened, we are acting and we are going to continue to monitor.

Item Action No: Dr Ullah asked about the bedded rehabilitation ward at George Eliot Hospital (GEH). Mr Stokes confirmed that the acute stroke unit at GEH would cease providing acute stroke care, with the ward being repurposed to provide Bedded Stroke Rehabilitation.

Dr Staveley highlighted that the outcome measures were process orientated. She hoped that workforce measures such as staff satisfaction were also going to be used.

Dr Staveley asked how the community rehabilitation would join up with Out of Hours to provide a complementary service. Mr Stokes confirmed that an Operational Director had oversight of both services and the CCGs would ensure that this was fed into the steering group that would continue to meet.

Mr Stainforth through that the CCGs’ response to the petition should be sympathetic but strong due to the strength of evidence behind the model.

Dr Raistrick shared the following from Ms Beamish: ‘Whilst in support of the business case, I would welcome comments on the level of financial risk to the funding with the CCGs’ financial outlook in future years.’ Mr Stokes confirmed that the business case had been through a significant amount of scrutiny from NHS England/Improvement and that the benefits of the investments far exceed the cost. There were also additional benefits such as closer working with the local government.

Ms Northcote highlighted that it was important to recognise that good practice had been followed in relation to the consultation process and this should be robustly outlined in the response to the petition.

Dr Raistrick shared the following question from Ms Beamish: ‘Has the business case met the NHS Five Tests for Change?’ Ms Northcote confirmed yes.

Members considered each recommendation outlined in the report, highlighting the following: • Recommendation 3- Members noted that there may be a delay due to the response to COVID-19, however, the recommendation to start as soon as possible was appropriate. • Recommendation 5- This should be expanded to include earlier comments regarding primary care input.

Dr Raistrick confirmed that Governing Body Members had taken due consideration of all work and the consultation process. Following scrutiny of the Decision Making Business Case, Members approved the recommendations within the report.

Mr Stokes wanted to thank everyone who had been involved in the business case. Members noted the leadership of the CCGs’ previous Accountable Officer, Ms Andrea Green, and acknowledged Mr Lonsdale’s hard work.

Ms Galloway acknowledged that this was a great decision for the CCGs’ local patients.

The Governing Bodies: • CONSIDERED the recommendations detailed in the Decision Making Business Case; and • APPROVED the CCGs to proceed to implementation of the future pathway and clinical model for stroke services.

2.4 Annual Operating Plan

Dr Raistrick explained that the plans outlined in the report may change due to the current circumstances.

Mr Stokes explained that further information would be presented to the Finance and Performance Committee.

Governing Body Members: • NOTED the activity planning template submission was made on the 5th March 2020; and • NOTED the requirement for annual contracts to be agreed and signed by 27th March 2020.

Item Action No: 2.5 Development of the CCGs 2020-2021 Corporate Objectives

Mrs Wilson presented the final revised 2020-2021 annual corporate objectives for NHS Coventry and Rugby and NHS Warwickshire North for approval. Future reports to Governing Body and Committees would be aligned against the objectives, in addition to the Assurance Framework and the Corporate Risk Register.

Governing Body Members APPROVED the corporate objectives for the year 2020-21.

3. Quality:

3.1 Reports from Clinical Quality and Governance Committees in Common: 23rd January and 27th February 2020

Governing Body Members NOTED the reports.

3.2 Quality Report

Ms Galloway presented the report, confirming that no new concerns had been added to the Quality Assurance Framework (QAF) in relation to GEH, UHCW and Coventry and Warwickshire Partnership Trust (CWPT).

The report was based on the information presented to the Clinical Quality and Governance Committee in January 2020, with the next Committee meeting taking place on the 26th March. The Committee meeting dates were being reviewed to ensure that the Governing Bodies receive the most up to date information.

Ms Galloway reported that UHCW had received an overall rating of ‘Good’ from CQC. She noted that congratulations should be fed back to the Trust.

Ms Galloway highlighted that Cygnet Coventry had been issued a section 31 notice from CQC. The CCGs were working closely with CQC regarding this and regular risk meetings were taking place.

Two additional concerns added to the QAF with regard to St Matthew’s and St Andrews, both were independent mental health care providers based within Northamptonshire: • CQC had placed a restriction on admissions to St Matthew’s mental health facility in response to reported safeguarding concerns. The CCGs and CWPT initiated an immediate response and have completed reviews of patients that CWPT and the CCGs have placed at the facility. • St Andrews Healthcare Adolescents Service has received an overall rating of ‘Inadequate’ from CQC. The CCGs were ensuring that reviews of all patients placed within St Andrews were taking place.

Ms Galloway reported that all GP practices within the CCG areas had been rated overall as either ‘Good’ or ‘Outstanding’.

Mr Stokes highlighted that the report focused on providers and explained that the CCGs were looking to strengthen the reporting of quality from an internal perspective.

Members of BOTH Governing Bodies NOTED the contents of the report.

Dr Ullah left the teleconference at 14:56.

3.3 Warwickshire Safeguarding Children and Adults Board Annual Report and Strategic Priorities for 2019-2021

Ms Galloway presented the report, confirming that it had previously been received by the Clinical Quality and Governance Committee.

Dr Raistrick explained that she had received the following question from Ms Beamish: ‘What

Item Action No: assurance had the Safeguarding Children and Adults Board had received on the proposed criteria for Safeguarding Adults Reviews (SARs) referrals to ensure that vulnerable people were not excluded?’ Ms Galloway explained that a multiagency team and Committee review the referrals with wider engagement from the safeguarding community. She offered assurance that SARs were monitored and there were mechanisms in place to raise awareness.

The Governing Bodies were ASSURED of the Annual report and Strategy 2019 – 2021.

3.4 Coventry Safeguarding Children’s Board Annual Report 2018/2019

Ms Galloway presented the report, confirming that it had previously been received by the Clinical Quality and Governance Committee.

The Governing Bodies RECEIVED the Coventry Safeguarding Children’s Board Annual Report 2018/19 were ASSURED.

4. Finance and Performance:

4.1 Reports from Finance and Performance Committees in Common: 9th January and 6th February 2020

Governing Body Members NOTED the reports.

Dr Khan left the meeting at 14:59.

4.2 Finance and Performance Committee Annual Report

The Governing Bodies RECEIVED the report and were ASSURED that the Finance and Performance Committees in Common were satisfied that they have adequately discharged their remit in the year to 31 March 2020.

4.3 Finance and Contract Reports: Month 10

Mr Stokes reported that a final position had been agreed with UHCW and the CCGs were hoping to imminently agree a position with GEH.

Mr Stokes explained that the new operating principles in relation to COVID-19 would be presented to the next Finance and Performance Committee.

CRCCG Governing Body Members NOTED that the CCG had improved its forecast by £2.9m to £5m in-year surplus;

WNCCG Governing Body Members NOTED that the CCGs position had deteriorated to a £14.1m in-year deficit

Members of BOTH CCGs REQUIRED assurance from the Committee on the work programme to be undertaken to ensure delivery: • Ms Northcote and Mr Harkness to support work on mitigation and planning at place during the first quarter of 21/22 • Chief of Transformation as part of planning for 21/22 QIPP to ensure opportunities for early delivery are taken • Chief of Transformation to ensure that transformation opportunities to be sought throughout the financial year • Execs to focus on early mitigations during Q1 before performance is known • Internal efficiency opportunities around Prescribing and Packages of care to be optimised with support from Mr Soden and Mr Dhanani. • Contract forecasts are finalised and reported to committee on.

Item Action No: 4.4 Financial Plans and High Level Budgets

The update from Mr Stokes was outlined as above.

4.5 Performance Report

Dr Raistrick highlighted that some performance measures outlined in the report would now be viewed differently in the current circumstances.

Mr Stainforth highlighted that the contract performance notice for Looked After Children Health Assessments had an expected recovery date of December 2019. He requested assurance that this would be followed up. Ms Galloway confirmed that she would ensure information was JG presented to the next Clinical Quality and Governance Committee.

Ms Galloway reported that Transforming Care would continue to be a priority for the CCGs. To date the CCGs were not achieving the trajectory for this year and were not expecting to achieve this, however, Ms Galloway offered assurance that there was a lot of focus on Transforming Care. Modelling had been undertaken and the CCGs expected to achieve the trajectory by the end of Quarter 2 2020/21.

The Governing Bodies SCRUTINISED and were ASSURED of the contents of the report.

4.6 QIPP 2020/21 Report

Mr Stokes explained that QIPP work would be redirected in relation to the response for COVID- 19.

In the context of Mr Stokes’ explanation above, Governing Body Members: • NOTED the contents of the QIPP report; • NOTED the approach being taken to develop and deliver QIPP proposals for 2020/21; and • NOTED the progress made to-date towards the overall QIPP requirement for 2020/21.

5. Assurance and Governance:

5.1 Report from Audit Committees in Common: 30th January 2020

Mr Stainforth explained that an action in relation to the GP IT stock control system had been outstanding for some time. Mrs Wilson explained that she had reported to the January 2020 Audit Committee meeting that assurance had been received from the GP IT lead that the action had been completed and would be formally closed off at the April meeting.

Governing Body Members NOTED the report.

5.2 Information Governance Toolkit

Mrs Wilson explained that the report provided assurance on the plans and processes in place to support the CCGs’ submission of the Information Governance Toolkit. NHS Digital were relaxing the submission date, however, the CCGs were still planning on submitting on the 31st March 2020.

The Governing Bodies: • RECEIVED the report and note for assurance; and • DELEGATED AUTHORITY to Senior Information Risk Owner (Associate Director of Governance and Corporate Affairs) to submit the completed Data Security and Protection Toolkit on 31 March 2020 as recommended by the Clinical Quality and Governance Committees in Common.

Item Action No: 5.3 Modern Slavery Statement

Mrs Wilson explained that the CCGs were required to prepare a statement in response to the Modern Slavery Act. The statements had been agreed by the Clinical Quality and Governance Committees.

The Governing Bodies APPROVED their statements for adoption, signing by the Accountable Officer and publication on respective CCG websites.

5.4 Timetable for Annual Report Production and Publication

Dr Raistrick highlighted that the report was requesting a decision as the CCGs’ constitution states that the Governing Bodies need to approve the CCGs’ Annual Report and Accounts.

Mrs Wilson explained that the report had previously been received by the Audit Committee. The deadline for submission of the Annual Report was currently the 28th May 2020.

Dr Staveley thought that the response to COVID-19 should take priority over the submission deadline. Mr Stokes explained that discussions were ongoing regarding whether the year end could be delayed.

Dr Raistrick suggested that the Governing Bodies approve the dates, noting that they were likely to change.

Mrs Wilson confirmed that any changes to the timetable would be reported to the Audit Committee.

The Governing Bodies: • APPROVED the Timetable for production of the Annual Report and Accounts 2019 – 2020; and • APPROVED the recommendation to delegate to the Audit Committee, at its meeting on the 27 May 2020, the authority to make and approve any final amendments to the CCGs Annual Report and Accounts 2019-2020.

6. Primary Care

6.1 Reports from Primary Care Commissioning Committee:

Dr Yadav asked whether which providers had won the Alternative Provider Medical Services (APMS) contract had been made public. Ms Northcote confirmed that she would look into this. JN

Members NOTED the reports.

7. Policies for Decision:

7.1 Whistleblowing Policy

The Governing Bodies APPROVED the policy for adoption and publication on CCG websites.

7.2 Freedom of Information Policy

The Governing Bodies APPROVED the policy for adoption.

8. For Information

8.1 Communications and Engagement Report

Ms Northcote presented the report, highlighting that the CCGs had received public interest regarding the estates programme. An estates stakeholder briefing had been instigated.

Item Action No: Mr Stokes highlighted that a question regarding the Weddington site had been received from a member of the public in advance of the Governing Body meeting. Dr Raistrick confirmed that a written response to the question would be prepared and would be shared with Governing Body Members if requested.

Governing Body Members NOTED the report.

9. Questions From Visitors:

In addition to the question outline above, Dr Raistrick confirmed that the same member of the public had asked for an update on COVID-19 testing in Warwickshire. A written response would be provided.

Dr Raistrick added that a question had been received regarding whether the CCG would be putting arrangements in place to let the public know the proportion of COVID-19 patients receiving intensive care at GEH. She confirmed that a written response would be provided, however, the level of detail shared would need to protect patient confidentiality.

10. Any Other Business

Mr Nuttall highlighted that the work of the Governing Bodies and the information they receive may need to change to enable the CCGs to respond to COVID-19.

The meeting was closed at 15:17.

11. Date of the Next Meeting Held in Public: Date: 20th May 2020 Venue: Parkside House, Coventry Time: 2:15pm to 5:00pm

Signature: (Chair CRCCG) Date:

Signature: (Chair WNCCG) Date:

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

WN / CR ACTION MEETING AGENDA ACTION RESPONSIBLE COMPLETION CURRENT UPDATE REF DATE ITEM OFFICER DATE STATUS Director of Public Health Annual Report Coventry: There was a 6 minute video Update 04/03/20: Ms Northcote confirmed that the action is in progress. The Primary which had been made about the report which Ms Gaulton recommended in terms Care team will make a request to practices that have the infrastructure and capability to of learning at primary care network meetings and wider teams etc. Dr Yadav upload the video onto waiting room screens, will ensure GPs have seen the video, play suggested this video could be shown in GP waiting rooms. Dr Raistrick asked for Liz Gaulton/ it at the next Protected Learning Time session and review whether it could be made CRCCG 82 20-Nov-19 2.1 this to be an action and for this to be taken through the Primary Care Jenni Northcote 28/04/2020 Complete available on the CCG website. Development Network Group. Update 28/4/20: The video link was provided / circulated and promoted. Update 22/01/20: Ms Gaulton confirmed that she had sent the video to Ms Northcote and was awaiting her views on whether this was suitable to share. To remain on the Action Schedule. Clinical leadership within the Joint Transformation Programme: Ms Beamish Update 05/03/20: A review of plans and governance is currently being undertaken. CRCCG/ 88 22-Jan-20 4.3 asked for the CCGs to review the clinical input into the system discussion. Andrew Harkness In Progress Ensuring appropriate clinical leadership and input will be central to discussions and WNCCG decisions to support effective transformation in the future. Looked After Children Health Assessments: Mr Stainforth highlighted that the A paper will be presented to the Clinical Quality & Governance committees in Common contract performance notice for Looked After Children Health Assessments had on 28th May 2020. CRCCG/ an expected recovery date of December 2019. He requested assurance that this 89 18-Mar-20 4.5 would be followed up. Ms Galloway confirmed that she would ensure information Jo Galloway May-20 Complete WNCCG was presented to the next Clinical Quality and Governance Committee.

Alternative Provider Medical Services (APMS) contract: Dr Yadav asked Update 28/4/20: whether which providers had won the Alternative Provider Medical Services CRCCG: All 4 contracts are now in mobilisation phase. CRCCG/ (APMS) contract had been made public. Ms Northcote confirmed that she would WNCCG: There was no market interest, we have suspended during COVID-19 90 18-Mar-20 6.1 Jenni Northcote Complete WNCCG look into this. pandemic, and we have extended contracts with existing providers for continuity. We will be relaunching revised tender at an appropriate time in respect to COVID-19 recovery. NHS Coventry & Rugby Clinical Commissioning Group NHS Warwickshire North Clinical Commissioning Group Enc E

Report To: Governing Body Meetings in Common

Report Title: Joint CCG Chair’s Report – May 2020

Report From: Sharon Beamish – Chair of NHS Warwickshire North CCG Sarah Raistrick – Chair of NHS Coventry & Rugby CCG

Date: 20th May 2020

Previously Considered by: N/A

Action Required (delete as appropriate)

Decision: Assurance: Information:  Confidential

Purpose of the Report: To advise the Governing Bodies of activity since the March 2020 meeting of the Governing Bodies.

Key Points:

• Covid-19 Pandemic

• Recruitment and Retention

Recommendation: Members of both Governing Bodies are requested to NOTE the report.

Implications

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

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(Delete as appropriate) Patient and Public Not applicable Engagement: Clinical Engagement: Not applicable Risk and Assurance: Assurance Framework Risks – AF9

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Covid-19 Pandemic

The arrival of Covid-19 had a significant impact on the working arrangements for staff and the Governing Bodies and we would like to thank everyone for the tremendous response and flexibility shown within a fast moving timeframe which was impressive. We have experienced an unprecedented pace of change in the way we have transformed healthcare locally through embracing technology at a time when many of our staff return to front line clinical practice across Coventry & Warwickshire and beyond with some volunteering to work within the Nightingale Hospital Birmingham.

Our contribution to ensuring that Covid-19 surge capacity would be sufficient to meet anticipated demand was consistently met and demonstrates what can be achieved when partners, health and Local Authority, across Coventry & Warwickshire work together for the same aim. The benefits achieved during this period have been immense and there should be no turning back. We have discussed at length the growing trends over recent years in the number of people attending Accident and Emergency Departments and hospital admissions. A number of initiatives have been deployed to reduce this trend with a minimum impact and we should take this opportunity harness our approach through the pandemic to continue the pace of change and improvement. An initial review comparing Accident and Emergency attendances during late March 2019 and March 2020 shows a significant reduction, around fifty percent. Most noticeable was the reduction of children presenting at A&E and adults with conditions such as coronary heart disease and stroke. This reflects the national trend and communication campaigns have taken place to inform the general public that the NHS is still accessible for urgent treatment and care for non Covid-19 conditions.

At the appropriate time the Clinical Quality & Governance Committees in Common will review what happened, the benefits identified from the new ways of working and potential risks to provide assurance to the Governing Bodies that lessons have been learnt and reflected in local policies and practice.

Sir Simon Stevens, NHS Chief Executive, set out in his letter of 29 April 2020 the priorities for the second stage of dealing with Covid-19 focused on restoration of urgent services beyond Covid-19 capacity. The system plan will be developed through the Partnership Executive Group for Coventry & Warwickshire and the Governing Bodies will receive progress reports from the Accountable Officer.

We will continue to respond to national policy and contribute to the execution of the local response. For Warwickshire North CCG we would like to say a massive thank you to Dr Imogen Staveley, Deputy Chair, WNCCG for her clinical leadership role working alongside the Coventry CCG Chair and GP representatives from South Warwickshire, and to all our GP clinical leads who in various forms have led on Hot Hub set-up and integration work with secondary care and communication with the public and primary care colleagues.

Recruitment and Retention

During a time of constant change, we are pleased to confirm that we are able to maintain a level of consistency in the Governing Bodies’ membership and executive leadership. We have agreed to extend Adrian Stokes, Interim Accountable Officer current contract until March 2021 or until the appointment of a substantive Accountable Officer if that were to be sooner, and Sue Turner, Elected Practice Network Lead will also remain a Governing Body member (WN) until March 2021. We are currently out to advert for a new GP Clinical Lead (CR).

Following the mandate from Practice Members to progress a programme of work to merge the three CCGs across Coventry & Warwickshire the next step is to progress the recruitment of a single Accountable Officer for all three CCGs to lead us through the transitional period into the authorisation of a new single CCG. This process has been delayed due to Covid-19 pandemic but we are now in a

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NHS Coventry & Rugby Clinical Commissioning Group NHS Warwickshire North Clinical Commissioning Group Enc E position to be able to communicate the process and timeline for this appointment to our Practice Members shortly.

Welcome to Gemma Nistorica-David, Lay Member for Public & Patient Involvement to her first Governing Body meeting. She will be representing both CCGs. Gemma qualified as a social worker and will provide valuable insight from her experience of working with children, young people and adults affected by disability. She is passionate about supporting her local community and keen to build on her experience as an advocate for the voices not always prominent in the Governing Bodies discussions.

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

Report To: Governing Body Meetings in Common

Report Title: Accountable Officer’s Report

Report From: Adrian Stokes, Interim Accountable Officer

Date: 20th May 2020

Previously Considered by: Not applicable

Action Required (delete as appropriate)

Decision: Assurance: Information:  Confidential

Purpose of the Report: The purpose of this report is to provide members of the Governing Bodies with information on key activities undertaken by the Accountable Officer since the last Governing Body meetings in common in March 2020, and any pertinent issues not covered elsewhere on the agenda.

Key Points: The following items are for the attention of Governing Body Members:

• Second Phase of NHS Response to Covid-19 • Approach to Risk Management • Merger Update • Look back at CCG engagement in Phase 1

Recommendation:

The Governing Bodies are requested to NOTE the report.

Implications

Objective(s) / Plans Constitution, Leadership IAF Domain supported by this report: Conflicts of Interest: None identified. Non-Recurrent Expenditure: Not applicable. Recurrent Expenditure: Not applicable. Financial: Is this expenditure included within the CCG’s Financial Yes No N/A  Plan? (Delete as appropriate) Performance: None identified. Quality and Safety: None identified. General Statement: The CCG is committed to fulfil its obligations under the Equality Equality and Diversity: Act 2010, and to ensure services commissioned by the CCG are non-discriminatory on the grounds of any protected characteristics. Policies/decisions may need to be adjusted in line with any equality analysis or due regard. Any decision that is

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finalised without being influenced by appropriate due regard could be deemed unlawful. Has an equality impact Yes assessment been undertaken? No N/A  (attached) (Delete as appropriate) Patient and Public None identified. Engagement: Clinical Engagement: See Key priorities and issues Risk and Assurance: Risks on the Assurance Framework- AF3, AF9

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The following items are for the attention of Governing Body Members:

• Second Phase of NHS Response to Covid-19 • Approach to Risk Management • Merger Update • Look back at CCG engagement in Phase 1

Second Phase of NHS Response to Covid 19

The CCG plays a crucial role in response to the Simon Stevens letter of 29th April. The following sets out a shortened version of the key responsibilities that are key at each level of our system, Andrew Harkness will add more granular detail in his report;

• System level (Through Partnership Executive Group) – Strategic assessment of covid/non covid facilities and pathways, optimal use of private sector capacity, working across other Integrated Care System (ICS) areas in response to Specialised Service reviews, review vulnerable services in the light of ongoing covid numbers, ensure ongoing mutual aid on key issues (Personal Protective Equipment (PPE), drugs, equipment), testing strategy to avoid second peak and embedding the enhanced working relationships that have developed further during phase 1. Lead Adrian Stokes

• Place Level (Through Place Boards) – Strong infection prevention and control (IPC) measures to avoid transmission, safe restart to services where possible, backlog assessment and planned recovery, embedding positive changes made during covid and enhance where possible, particular focus on maintaining stronger discharge arrangements, ensuring Place governance captures views of all partners in pathway enhancements and embedding the enhanced working relationships that have developed further during phase 1. Leads Andrew Harkness and Jenni Northcote

• CCG Level (Through internal Board reporting through to Governing Body) – Resetting working arrangements in light of ongoing social distancing, embedding positive process changes, restarting critical CCG services and safe withdrawal of some mutual aid and most importantly facilitating the CCG role in supporting our places. I am determined to ensure that we use the opportunity of reset to deliver things better in the future that we did before. Lead Andrew Harkness

All of this has to be done within a governance structure that leads on from the strong governance in phase 1, has a strong public and patient engagement strategy at the heart of it and has staff welfare as a crucial element of everything we do.

Approach to Risk Management

As an Executive team we have been reviewing our approach to risk management for a number of months and would like to use the reset to fast track some of those developments, the following are key in our approach;

• Utilising our new objectives in risk profiles as agreed in recent Governing Body meetings and using the reset to go further and faster on delivery (eg our technology advancements have been rapid in phase 1), • Raising the profile of our risk assessments by putting risk registers at the start of each Committees Agenda so that it drives the right conversations within meetings, • Stronger Executive ownership of those risks, the responses to risks and keeping the risk registers a live document that supports our overall governance.

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

I would encourage the Governing Body to run with this over forthcoming meetings as this embeds and hopefully we will have the same impact as we did when we brought forward the flash reports from individual committees in focussing debate and discussion even further.

Merger Update

Whilst the response to Covid has certainly reduced the level of time invested to date and the ability to respond to some of the key components of the Business Case (eg suspension of financial processes, ability to engage actively etc.) I wanted to inform the Governing Body that we have been in constant discussion with NHS England/Improvement and it is still our intention to fully proceed for a merger from April 1st 2021 and we are working closely with them on how we can do this and recognise that this could involve a modification of the ask within the application. The process of Accountable Officer recruitment is ongoing and is a crucial next step.

Look back at CCG engagement in Phase 1

I would like to finish with a massive thank you to all staff and all Governing Body members, the list of things we have achieved, the support we have given, the services we have maintained and the way we have adapted as an organisation has been very impressive. There are countless people who have gone above and beyond what their current role is, they have done this without question and have done the CCG proud. I would like to find a moment and a way once a level of normal returns to mark these achievements and find a way of recognising what people have done more formally. I would encourage Governing Body members to get involved in that process (whatever that may be).

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CRCCG and WNCCG Clinical Quality and Governance Committee in Common Report for the Main Meeting held on 26th March 2020

Achievements/Decisions Made/Items to Note Commissioning Policies - The Committee approved the draft policies relating to Cataract Surgery, Integrated Provider Quality Report – The Complementary and Alternative Therapies, Hallux Committee scrutinised and was assured of the Valgus, Male circumcision, Treatments for content of the report and noted the areas identified for Hyperhydrosis, Complex and Specialised Obesity improvement. surgery, Endoscopic Thoracic Sympathectomy and withdraw the Carotid surgery policy and recommended Safeguarding Assurance Report – The Committee these decisions for ratification by Governing body. scrutinisedlllllllllllllllll the report and was assured subject to recognising there are some areas of concern which Risk Register - The Committee received the Corporate were noted in relation to Covid-19 challenges around Risk Register noting the mitigations in place and was; safeguarding. assured that adequate actions are being taken by risk owners to mitigate the risks and that the assurances Research Update - The Committee noted the content provided are satisfactory. of the report and agreed to suspend any new research projects until September 2020 with the Grievance Policy - The Committee approved the policy exception of research requests relating to Covid-19 for adoption by both Coventry and Rugby, and Warwickshire North CCGs. Coventry and Warwickshire Health Care Partnership approach to system quality - The Professional Registration Policy – The Committee Committee noted the system wide approach to quality approved the policy for adoption by both Coventry and and progress made with the development of a Rugby, and Warwickshire North CCGs. system -wide approach for quality and a system quality assurance framework. The Committee noted CQG Schedule of Business for 2020/21- This item was that the CCG Quality Assurance Framework will be deferred to the April agenda. updated once the System Quality Assurance Framework has been ratified by QSG, in order to Information Governance Report - The Committee ensure alignment and consistency. approved the framework for adoption by the CCGs.

CDOP Annual Report – The Committee noted the report and supported presentation to the Governing Body.

ASD Waiting Times - The Committee noted the Key Issues for the Governing Body content of the report and endorsed the recommendations made to the Learning Disabilities • Safeguarding concerns with Covid-19 challenges and Autism Transformation Board and supported that • A new CCG Quality hub has been set up in a Task and Finish Group is set up to progress. response to Covid-19. National guidance is

Datix Reporting System in Primary Care - The expected regarding expectations for quality Committee was assured regarding the use of Datix monitoring during the Covid-19 period. and of actions and proposed re-delivery of system • Challenges around ASD waiting times benefits. • Court of Protection application position,

associated levels of assessed risk and actions in CHC update – The Committee received and supported the newly adapted CAPT Integrated place to address • Quality, Performance and Contracting Report and Transforming Care trajectory noted actions taken.

Court of Protection Backlog - The Committee noted the position regarding the Court of Protection applications backlog; assessed the level of risk and Matters referred to the Governing Body for approval, debate or further consideration: the actions in place to recover the position and ensure sustainability. • Commissioning Policies

Transforming Care Update - The committee noted the report and was assured that Arden TCP has the necessary governance, system wide commitment and Key Information: delivery plan in place to achieve trajectory by the end • Committee Chair: Ludlow Johnson of Quarter two 2020/21. rd • Date of Next Meeting: 23 April 2020 (Main)

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Enc G CRCCG and WNCCG Clinical Quality and Governance Committee in Common Report for the Main Meeting held on 23rd April 2020

Achievements/Decisions Made/Items to Note Key Issues for the Governing Body

Risk Register - The Committee received the • Safeguarding concerns with Covid-19 challenges Corporate Risk Register noting the mitigations in • Delay in publication of provider Quality Accounts place and were assured that adequate actions are due to Covid-19. being taken by risk owners to mitigate the risks and that the assurances provided are satisfactory.

Integratedlllllllllllllllll Provider Quality Report – The Committee scrutinised and was assured of the content of the report and noted the areas identified for improvement.

Report of The Independent Peer Review of Decision Support Tool (DST) Process (July 2019) - The Committee accepted the report; noted and discussed the actions taken and noted the assurance given and new integrated Quality, Performance and Contracting Report which will be presented to monthly CAPT Business Meetings.

Safeguarding Assurance Report – The Committee scrutinised the report and was assured subject to recognising there are some areas of concern which were noted in relation to Covid-19 challenges around safeguarding.

SEND Action Plan – The Committee noted the Matters referred to the Governing Body for approval, overarching SEND partnership action plan, and the debate or further consideration: specific health actions within this report, to address • Clinical Quality and Governance Committee the identified areas for development. Annual Report

Serious Incident Post Assurance Visit Action Plan - The Committee scrutinised and was assured regarding the actions taken to address the recommendations.

Complex Case Panel – Terms of Reference- The Committee approved the Terms of Reference for the Complex Case Panel.

Governance Update – The Committee noted the changes to the CCGs’ governance programme of work due to Covid-19 and was assured that actions are ongoing to meet requirements.

- The Committee noted Communications Update the work of the Communications and Engagement Team in response to Covid-19.

Schedule of Business 2020/21- The committee reviewed and approved the 2020/21 Schedule of Business. Items deferred due to Covid-19 are being recorded and rescheduled to future agendas.

Clinical Quality and Governance Annual Report – The Committee received the report and was assured that it had adequately discharged its remit in the year to 31 March 2020.

Key Information: • Committee Chair: Ludlow Johnson

• Date of Next Meeting: 28th May 2020 (Main)Page 1 of 2

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

Report To: Governing Body Committees in Common

Report Title: Clinical Quality and Governance Committees in Common Annual Report

Report From: Ludlow Johnson, Chair of CQG Committees in Common

Date: 20th May 2020

Previously Considered by: Clinical Quality and Governance Committees in Common – 23rd April 2020

Action Required (delete as appropriate)

Decision: Assurance:  Information: Confidential

Purpose of the Report: To present to the Governing Body the Annual Report of the Clinical Quality and Governance Committees in Common detailing how the Committees have discharged their functions over the year 2019/20.

Key Points: • The Clinical Quality and Governance Committees in Common have met 9 times in 2019/20. • The Clinical Quality and Governance Committees in Common are generally satisfied with the quality of information they receive for meetings. • Functions and duties of the committees include: o Monitor the reporting of Serious Incidents. o Oversee governance arrangements for safeguarding children and vulnerable adults o To review and monitor the performance and quality of primary care • Business Transacted this year includes: o Considering Integrated Provider Quality Reports at every formal meeting. o Thematic meeting focussing on the Corporate Risk Register o Thematic meeting on mortality • During 2020/21, business will include: o Reviewing information the committees receive regarding the quality of maternity and neonatal services for mother and babies; o Review of the impact on A&E waiting times for people aged over 85. Recommendation: The Governing Body is asked to RECEIVE the report and be ASSURED that the Clinical Quality Governance Committees in Common have adequately discharged their remit in the year to 31 March 2020.

Implications

Objective(s) / Plans supported by this Quality Assurance, Quality Improvement, achievement of statutory duties, report: Conflicts of Interest: Not applicable Financial: Non-Recurrent Expenditure: Not applicable

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

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

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NHS Coventry and Rugby CCG & NHS Warwickshire North CCG Annual report of Clinical Quality and Governance Committee

1 Introduction

This document represents the report of the Clinical Quality and Governance Committee of NHS Coventry and Rugby CCG & NHS Warwickshire North CCG for the period 1st April 2019 to 31st March 2020. The report is intended to provide the Committees with an opportunity to reflect on and document its performance during the year.

2 Membership and Meetings

The Clinical Quality and Governance Committees in Common met 9 times out of a possibility of 11 meetings during 2019/20. The Committees meet bi- monthly with themed meetings held alternate months as required. The Committees held 6 formal meetings, 3 themed meetings and 2 meetings were stood down in 19/20. The dates of meetings and attendance of members is shown in the Appendix.

The Clinical Quality and Governance Committee is chaired by Ludlow Johnson, Lay Member.

The Committee has ‘Declaration of Interests’ as a standing item on its agenda and records any interests declared in its minutes.

The performance of the Chair is reviewed by the Chairs of NHS Coventry and Rugby CCG & NHS Warwickshire North CCG.

3 Administration and Communication

The is Clinical Quality and Governance Committee were satisfied with the quality of the information that it receives for its meetings and with the administration of meetings with the majority of papers being available one week in advance of the meeting. Papers for meetings are sent electronically and posted in hard copy to members where required. During 2020/21 we anticipate expanding our use of technology to ensure that all members have access to ‘paperless’ versions of the Committee’s papers.

The agenda, minutes and papers of all Clinical Quality and Governance Committee meetings are available to staff on request.

4 Discharge of the Functions of the Committee

The functions of the Clinical Quality and Governance Committee are set out in the Terms of Reference and may be discharged directly which is then reported back to the Governing Body at every public meeting. The table overleaf sets out how the Clinical Quality and Governance Committee

1 believes it has effectively discharged its functions/duties during the year; more information about the business that the Board has transacted is contained at section 5.

Function/Duties Discharge Quality and Safety Governance

To monitor the reporting of Serious Incidents An overview of serious incident themes and and National Alerts and to provide assurance trends are reported to CQGC every two- to the Governing Body that Never Events months within the integrated provider report. and Serious Incidents are being effectively and appropriately managed and that learning from these is shared across the Group and with relevant partners.

To oversee the governance arrangements The Clinical Quality Governance Committees for safeguarding children and vulnerable in common receive safeguarding updates 6 adults and monitor the implementation of times a year related to the CCG’s compliance action plans following Serious Case Reviews with its safeguarding duties. and Adult Protection investigations. Both CCG’s work closely with the

Safeguarding partnerships across Coventry and Warwickshire to ensure that assurance arrangements are in place to monitor all action plans in relation to Safeguarding Learning Reviews and Domestic Homicide Reviews.

To review compliance with the CCG’s The medicines optimisation team (CRCCGs controlled drugs responsibilities. in-house team and ArdenGEM CSU for WNCCG) report monthly on practice CD

prescribing in accordance with the CD monitoring requirements as set out by NHS England. EPACT 2 is utilised to measure and benchmark practices against recognised prescribing indicators. This data is analysed, any prescribing trends that are cause for concern are raised with the practice. To oversee the development of quality In line with the CCG’s Quality Assurance dashboards, CQUIN schemes and Quality Framework the CQG committee in common Accounts of local providers. regularly received and scrutinised reports and updates in relation to the CQUIN schemes

and local providers quality accounts

To review and monitor the performance and The CQG Committees in common receives quality of primary care and support the work routine updates and scrutinises the of NHS England in this area. performance and quality of primary care

2 To receive and scrutinise reports from The CQG Committee has received, reviewed external agencies and groups and and monitored reports from a range of internal investigation reports relating to patient safety and external investigation reports relating to and quality issues (e.g. the Care Quality patient safety and quality issues. Commission and Monitor and independent It has acted on identified trends and has held investigation reports relating to patient safety themed meetings in order to further scrutinise and quality issues) to agree publication plans and monitor issues of concern. for investigation reports where appropriate.

Review and agree commissioning The Committee regularly reviews and agrees policies for approval by the Governing commissioning policies for approval by the Body Governing body.

To ensure that there are effective systems in The Committee has endorsed the Quality place to provide early warnings of failing and Assurance Framework which provides a unsafe services in order to identify patient mechanism to assure the CCGs’ Governing safety and quality issues and secure Bodies regarding the quality of service improvement in clinical practice; delivery in commissioned services; identifying early warnings so that potential failings in provider health services are avoided.

To receive and scrutinise reports from During 19/20 the committee received reports external agencies and groups (e.g. the Care from external agencies including an overview Quality Commission and Monitor and of provider CQC reports, Looked After independent investigation reports relating to Children reports and Ofsted inspections. patient safety and quality issues) to agree publication plans for investigation reports where appropriate. Corporate Governance and Risk Management

To ratify and recommend approval of the The CQG Committee has received and Group’s strategies and policies relating to approved a number of policies for approval the work of the Committee including the Risk during 19/20 including leave and absence Management Strategy and Policy, Incident management policies and has been assured Reporting Policies, the Complaints Policy of compliance with such policies through and Human Resources Policies. regular HR, complaints and risk reports.

To approve relevant clinical and non-clinical The CQG Committee has received HR, policies and ensure that there are Corporate, Information Governance, IT, and arrangements in place for implementation commissioning policies and others as and periodic review. necessary for approval or recommendation to the Governing Body.

To monitor complaints received and seek During 19/20 the Committee has received assurance that complaints are responded to quarterly complaints reports which detail in a timely and appropriate manner, trends trends and themes of complaints and has held and themes in complaints are monitored and a themed meeting on CAPT complaints to that learning from these is shared across the gain further insight and assurance on

3 CCG and with relevant partners. complaints processes.

To monitor and review sources of patient The committee regularly reviews a range of feedback (e.g. outcomes of provider patient patient feedback mechanisms. It has acted on surveys; net promoter scores; PALS queries identified trends and has held themed meeting and Patient Reported Outcome Measures in order to further scrutinise and monitor (PROMS) feedback) to identify potential issues of concern trends or action that may require escalation. To oversee the implementation of In line with best practice guidance the CCG accreditation and revalidation arrangements has robust governance processes in place to for relevant professional groups. oversee and monitor the accreditation and revalidation arrangement for all relevant

professional groups.

To receive and review the Corporate Risk The Committee has regularly reviewed the Registers and to ensure that there are plans Corporate Risk Register and additionally held in place for the effective management of risk. a themed meeting on risk to look at the highest rated risks in more detail and

scrutinise the measures in place to mitigate the risk. To review compliance with the Data Security Information Governance Reports are provided and Protection Toolkit. to the committee on a quarterly basis and include updates and assurance around the

DSPT work plan and audit. To ensure that there are effective The Committee has regularly received arrangements in place for Emergency updates on Emergency Preparedness Planning and Business Continuity; Resilience and Response (EPRR) in relation to the NHS England core standards process

and were fully compliant for 2019 Core Standards.

To ensure compliance with national research The CCG has robust governance processes in governance frameworks. place to monitor research contracts (hosted by the CCG) that reflect national best practice

guidance and research governance frameworks.

A Research and Development Strategy and operational action plan has been developed and scrutinised by the CQG Committee. The CQG committee will receive, scrutinise and agree bi monthly reports outlining the management and monitoring of research contracts hosted by the CCG. To oversee and ensure compliance with The CQG Committee received equality equalities legislation and associated updates including the CCGs’ response to the regulations and requirements. Modern Slavery Act. To support the development of and oversee The Committee received regular updates from the Group’s approach to Patient and Public the Communications and Engagement Team Involvement ensuring that patient feedback and met the statutory obligations for patient is incorporated within the decision making, and public involvement, as set out in section

4 commissioning and performance review 14z2 of the NHS Act 2006, as amended by process. the Health and Social Care Act 2012.

To monitor key Human Resources indicators Quarterly HR reports are presented to the (included completion of statutory and committee which include details of sickness mandatory training). absence and other HR activity such as development of policies and procedures.

5 Business Transacted During the Year

The agendas are structured to cover Quality and Safety, Safeguarding, complaints and Governance items.

The Clinical Quality and Governance Committee met formally on 6 occasions during 2019/20.

Within the Quality and Safety Governance section of its agenda, the Committee received and considered an Integrated Provider Quality Report at every formal meeting.

The formal meeting agenda is split into two sections (1) Quality and Safety and Governance and (2) Corporate Governance. The following reports are considered integrated provider reports, safeguarding reports, LAC reports, SEND reports, CQC system reports, research and development reports.

Thematic committee discussions focused on the following areas:

Risk Management and Assurance Processes – July 2019

A presentation was given outlining the processes in place for the Corporate Risk Register. This included:

• Overview, definition of risk and policy definition • The role of the CQGC in relation to Risk Management • Identifying the risks • Assessing the risks • De-escalating the risks

The Risk Improvement Plan identified the following areas of focus for 2019/20:

• CCG Risk Maturity • Assurance mapping and framework • Increase knowledge and skill • Move from Excel to Datix • Review policy and procedures

5 Thematic Discussion on Mortality – October 2019

George Eliot Hospital gave a presentation including a focus on:

• HSMR and SHMI • Crude Mortality Trend Analysis • Mortality Strategy and Improvement Plan 2018-2020

The Trust outlined their action plan including associated systems, processes and governance.

CAPT Complaints Management – February 2020

A Clinical Quality and Governance Thematic discussion took place focusing on complaints concerning the Clinical Assessment and Placement Team (CAPT) in 2019/20.

The committees received an update on best practice in complaint management together with information on the data and themes of complaints concerning the CAPT.

Agreed outcomes were noted as: - Committees to receive an assurance report on the Continuing Healthcare process - Increased quality monitoring arrangements for services the CCG provide with regular reporting into CQGC; - Greater qualitative information to be provided in the quarterly complaints report received by the committees and for information on complaints to be reported to Governing Body on a regular basis. - An independent learning event will be arranged regarding the serious complaint

In all the above discussions, Lay members of the Clinical Quality and Governance Committee provided constructive challenge and support, drawing on their own experiences, to plans being developed by the Executive Directors.

6 Development of the Committee a whole

A process of self-assessment in 2018-19 recommended that the Committee focus should include:

1) Considering whether the length and content of the agenda is appropriate and consider whether the duration and frequency of meetings is appropriate for fulfilling the committee’s terms of reference. 2) Considering items at the Committee in context of the Quality Assurance Framework (Appendix 1)

6 3) Supporting the development of guidance for standardising the completion of committee front sheets.

7 Look Forward to 2020/21

The Clinical Quality and Governance Committees in common to consider:

• What assurance can the committees receive regarding the quality of maternity and neonatal services for mother and babies? • What impact, if any, have long waiting times in A&E had on outcomes for people over 85 years of age, including mortality rates over recent years. • What impact has the introduction of Sepsis and acute kidney injury pathways had for acute patients and how does this compare to best in class

8 Conclusion and Recommendation

The Clinical Quality and Governance Committee is satisfied that it has adequately discharged its remit in the year to 31st March 2020.

7 Appendix 1 25th 23rd 27th 25th 22nd 2nd 24th 28th 23rd 27th 26th Members Designation Role April May June July August October October Novemb January February March 2019 2019 2019 2019 2019 2019 2019 er 2019 2020 2020 2020 Main Themed Main Themed Main Themed Main Themed Main Themed Main

STOOD STOOD

DOWN DOWN

Jo Galloway Chief Nurse Chief Nurse     

Chief Officer Andrea Green Executive Team    (Accountable Officer) Chief Officer Adrian Stokes Executive Team  (Accountable Officer) WNCCG Chair, David Allcock Lay Member Governing Body   Member Senior Manager Rebecca Director of Nursing Responsible for Quality Bartholomew and Quality         and Safety Inayat Ullah GP (Woodlands) Practice Network Lead

Arshad Khan GP (Station Street) Practice Network Lead        

Jon Timperley GP Secondary Care Doctor      

Patient and Public Sharon Beamish Lay Member     Engagement Independent Advisor for Tricia Lowe  Patient Engagement Senior Manager Anita Wilson / Governance Responsible for Laura Whiteley          Governance CRCCG Chair, Sarah Raistick GP Governing Body       Member Deepika Yadav GP Rugby Clinical Lead       

Alistair Bryce GP Clinical Lead

Public and Patient Ludlow Johnson Lay Member Engagement and Health       Inequalities Prashant Secondary Care Secondary Care  Kakodhar Consultant Consultant Claire Forkes Lay Member

8 NHS Coventry and Rugby Clinical Commissioning Group NHS Warwickshire North Clinical Commissioning Group Enc I

Report To: Governing Body Meetings in Common

Report Title: Quality Report

Report From: Jo Galloway – Chief Nursing Officer and Deputy Accountable Officer

Date: 20th May 2020

Previously Considered by: Clinical Quality and Governance Committees in Common, 23rd April 2020

Action Required (delete as appropriate)

Decision: Assurance:  Information:  Confidential

Purpose of the Report: The quality overview report provides information and assurance regarding quality issues that are on the CCG Quality Assurance Framework (QAF). An overview of new risks and level three risks is provided, together with a list of level two quality issues.

Key Points: Coventry and Warwickshire Partnership Trust (CWPT) Since the previous report, no additional concerns have been added to the QAF. There is one area of concern at level three and five areas of concern at level two.

George Eliot Hospital NHS Trust (GEH) Since the previous report, no additional concerns have been added to the QAF. There is one area of concern at level three and six areas of concern at level two.

University Hospitals Coventry and Warwickshire NHS Trust (UHCW) Since the previous report, Children and Young People in Crisis (System wide) has de-escalated to level two on the QAF. There are no areas of concern at level three on the QAF and there are six concerns at level two.

Other providers Since the previous report no additional concerns have been added to the QAF. There are two concerns at level three.

Recommendation: Members of BOTH Governing Bodies are asked to:

• NOTE the contents of the report.

Implications

Constitution targets and CCG legal and regulatory responsibilities. Objective(s) / Plans Strategic Objective One - We will work collaboratively with our partners to supported by this continuously improve quality of care report:

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Conflicts of Interest: None identified Non-Recurrent Expenditure: Not applicable Recurrent Expenditure: Not applicable Financial: Is this expenditure included within the CCG’s Financial Yes No N/A  Plan? (Delete as appropriate) Performance: The CCGs are required to meet the national NHS Constitution targets The report outlines quality and safety issues in relation to commissioned services in Quality and Safety: relation to the CCG’s Quality Assurance Framework General Statement: The CCG is committed to fulfil its obligations under the Equality Act 2010, and to ensure services commissioned by the CCG are non-discriminatory on the grounds of any protected characteristics. Policies/decisions may need to be adjusted in line with any equality analysis or due regard. Any decision that is finalised Equality and Diversity: without being influenced by appropriate due regard could be deemed unlawful. Has an equality impact Yes assessment been undertaken? No N/A  (attached) (Delete as appropriate) Patient and Public Not applicable Engagement: Clinical Engagement: Not applicable Risks on the Assurance Framework – AF5, AF7, AF8, AF9 Risk and Assurance: The report provides information and assurance regarding quality issues on escalation on the CCG Quality Assurance Framework

Page 2 of 6 NHS Coventry and Rugby Clinical Commissioning Group NHS Warwickshire North Clinical Commissioning Group Enc I

CCG Quality Overview

1. Introduction The Clinical Quality and Governance Committees in Common for Coventry and Rugby CCG (CRCCG) and Warwickshire North CCG (WNCCG) receive reports on the quality and safety of commissioned services. Reports are based on a wide range of data and soft intelligence, including contractual quality indicators, patient experience reports and learning and the impact on practice. This includes acute and community services; small providers, both NHS and independent; nursing homes; residential homes; and primary care. The committee also receives updates on safeguarding, infection prevention and control and Transforming Care.

This report provides a summary of escalated quality issues for the attention of Governing Body. The information provided in this report primarily relates to that which was presented to the March 2020 Clinical Quality and Governance (CQG) Committees in Common meeting.

2. Items on Escalation An overview of the Quality Assurance Framework (QAF) and escalation levels is included as Appendix 1.

This report provides information and assurance regarding quality issues that are on the CCG Quality Assurance Framework (QAF). An overview of new risks and level three risks is provided, together with a list of level two quality issues. A more comprehensive overview of quality issues at level two and above is provided for assurance and discussion at Clinical Quality Governance Committee meetings in common.

Quality Team Covid 19 Response The CCG Quality Team has established a Quality Hub in response to the Covid-19 pandemic. The hub aims to ensure that the CCGs’ quality and patient safety assurance mechanisms continue and are responsive to meet the challenges associated with the level four national emergency. The Quality Hub meets daily to review information and intelligence and has agreed revised interim monitoring mechanisms with commissioned providers. Weekly calls are in place with all main NHS providers which provide an opportunity for both parties to raise and discuss any quality concerns.

The Coventry and Warwickshire System Quality Surveillance Group has increased the frequency of meetings to monthly, in order to share information and ensure system oversight of quality.

Safeguarding Partnership Executive Group meetings have continued to take place in both Coventry and Warwickshire during the Covid-19 pandemic to ensure oversight and assurance of safeguarding risks.

Coventry and Warwickshire Partnership Trust

Since the previous report no additional concerns have been added to the QAF.

There is one area of concern at level three on the QAF:

• Tissue Viability – this relates to a serious incident that resulted in patient harm. CWPT has developed an action plan in response to the learning identified from the incident. The CCGs continue to monitor the associate action plan and will be undertaking a quality assurance visit to provide additional assurance.

There are five areas of concern at level two on the QAF:

• Adult Neurodevelopmental Service (ANDS) waiting times • Child and Adolescent ASD and ADHD Service waiting times • Children's Therapy waiting times, Coventry • Looked after Children health assessments, Coventry

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

• Substantive Versus Temporary Nursing Staff

George Eliot Hospital

Since the previous report no additional concerns have been added to the QAF.

There is one area of concern at level three on the QAF:

• Emergency Department – The CQC issued a section 29A warning notice to GEH in December 2019. The Trust’s has an action plan in place and the CCGs are monitoring the action plan to ensure actions are embedded.

There are six areas of concern at level two on the QAF:

• Clostridium Difficile Infection (CDI) • Care Quality Commission (CQC) Inspection • Mortality • Ophthalmology - Treatment Delays • Safeguarding – Named Safeguarding Doctor position • Serious Incidents – Recognition of the Deteriorating Patient

University Hospitals Coventry and Warwickshire NHS Trust

There are no areas of concern at level three on the QAF.

Since the previous report, Children and Young People in Crisis (System wide risk) has been de- escalated to level two on the QAF.

There are now six concerns at level two on the QAF:

• Urgent Clinic Letters sent out within seven days • Clostridium Difficile Infection (CDI) • CQC Inspection • Emergency Department (ED) - sepsis management • Gynaecology - referral and treatment waits • Children and Young People in Crisis (System wide)

Other Providers

Since the previous report no additional concerns have been added to the QAF. There are two concerns at level three on the QAF and no concerns on Level 2:

Items on Level Three of the QAF:

Cygnet – CQC Section 31 conditions of registration Following an inspection in July 2019, CQC issued a section 31 notice to Cygnet Coventry. The full inspection report was published on November 1st 2019 and rated the hospital as overall Inadequate. The Section 31 notice restricts admission or readmission of any patients and mandated that Dunsmore Ward, the Psychiatric Intensive Care Unit, closed. The unit closed and all patients transferred appropriately. The CCGs chair monthly formal clinical quality risk summit meetings with Cygnet as geographical host CCG. The CCGs also hold informal progress meetings to ensure that actions are being completed in between formal meetings. The CCGs continue to work closely with CQC.

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

St Matthew’s Healthcare– Restriction on admissions CQC placed a restriction on admissions to St Matthew’s mental health facility in Broomhill, Northamptonshire, in response to reported safeguarding concerns. Coventry and Warwickshire CCGs and CWPT initiated an immediate response and have completed reviews of patients that CWPT and the CCGs have placed at Broomhill. Nene CCG is co-ordinating clinical quality risk summit meetings and the CCGs are represented at these meetings.

3. Primary Care Update

Coventry and Rugby CCG and Warwickshire North CCG

CQC has suspended all routine inspections to Primary Care due to the Covid-19 situation. There are no current concerns of note and all Practices are currently rated by CQG as overall good.

4. Care Homes

The CCGs’ Quality, Care Home and Infection Prevention and Control teams, in conjunction with both Local Authorities and other partners, are working closely with and supporting Nursing and Residential Care Home providers with Covid19 related issues.

Coventry There are 86 nursing and residential homes across Coventry with a total of 2017 beds. There are two residential homes and two nursing homes that are currently on escalation and working to improvement plans. There are two nursing homes with placement stops in place.

Rugby There are 31 nursing and residential homes across Rugby with a total of 1025 beds. There is one Nursing Home currently on escalation with a voluntary placement stop in place.

Warwickshire North There are 20 nursing and residential homes across Warwickshire North with a total of 1348 beds. There is one Nursing Home currently on escalation with no placement stop in place. There are two residential homes on escalation and working to an improvement plan. One of the residential homes on escalation is on an enforced placement stop and the other is on restricted admissions. All providers are working towards an improvement plan.

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

Blank Page

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Appendix 1 Quality Escalation Matrix Escalation Criteria Level of risk Action Reports to level

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

Level One Minor concern/s Minor Level Zero, plus: Quality meeting • Risk assess Informal CQRM • Share at informal CQRM

Level Two Moderate concern/s Moderate Level One, plus: CQRM • Consider quality assurance visit/deep dive CQGC • Request action plan Governing Body • Agree trajectory for improvement Risk Register • Escalate to CQRM • Exception report to CPPM

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

Report To: Governing Body Meetings in Common Child Death Overview Panel Annual Report - Coventry, Warwickshire Report Title: and Solihull, 2018-2019 Report From: Jo Galloway – Chief Nursing Officer and Deputy Accountable Officer

Date: 20th May 2020

Previously Considered by: Clinical Quality and Governance Committees in Common – 26 March 2020

Action Required (delete as appropriate)

Decision: Assurance:  Information:  Confidential

Purpose of the Report: The Child Death Overview Panel (CDOP) Annual Report 2018/19 outlines the analysis of cases and the main conclusions derived from panels held in Warwickshire, Solihull and Coventry during the period from 1 April 2018 to 31 March 2019. It provides a summary of the learning themes that emerged from reviews, and resultant actions taken for the purpose of reducing avoidable child death.

Key Points: The Child Death Overview Panel (CDOP) review is intended to be the final scrutiny over a child’s death. This involves multiagency panels and core competency professionals that assess the information supplied. The aim is to provide a complete picture of the child’s death and living circumstances for all child deaths (birth to 18th birthday) within the locality, identify possible modifiable factors, and make recommendations with the aim of reducing potentially preventable deaths in children in the UK.

The report outlines that during this reporting year there were a total of 13 panels held and 55 cases reviewed. 48% of all deaths reviewed during 2018-19 occurred in under one year olds with 27% occurring in the neonatal period (<28 days old). Neonatal deaths were less likely than later deaths to have modifiable factors.

The main learning from this reporting year can be summarised into the following points:

• In infant deaths, maternal smoking, BMI of over 30 and domestic violence were the most frequently noted as modifiable factors.

• In older children, factors relating to early identification of sepsis and agency response to road traffic deaths were identified as the main modifiable factors.

Actions taken include: • Antenatal providers were contacted and given feedback and advice about smoking cessation and the identification and questioning relating to domestic violence.

• Identified learning was used to reinforce the current guidelines for sepsis recognition and treatment, and contributed to developments in the new Sudden Unexpected Deaths in Infants and Children under18 (SUDC) protocol.

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

Transformative Changes During this reporting year CDOP was tasked with enacting the changes required within the Working Together to Safeguard Children (2018) Statutory Guidance. The CDOP report identified the actions needed to implement the new guidance and set a timescale for the implementation.

CDOP Coventry, Solihull and Warwickshire set itself 3 main overriding outcomes:

- To deliver high quality panels that recognise the need to support families who have been bereaved, are compliant with National guidance and focus on learning from cases.

- To increase the output of learning from cases and implement effective change.

- To establish networks of accountable and dedicated professionals to show rigour and quality within the child death review process.

A working group was established, to develop new arrangements in the region. This CDOP has adopted and published its new arrangements within the statutory timescale. Access to this CDOP’s strategic change can be found at: https://www.warwickshirenorthccg.nhs.uk/mf.ashx?ID=37a674de-606b-4784- baa4-bbc25332ceae.

Recommendation:

The Governing Bodies are requested to NOTE the Child Death Overview Panel Annual Report - Coventry, Warwickshire and Solihull, 2018-2019

Implications

Objective(s) / Plans We will work collaboratively with our partners to continuously improve quality supported by this of care report: Conflicts of Interest: Not applicable Non-Recurrent Expenditure: Not applicable Recurrent Expenditure: Not applicable Financial: Is this expenditure included within the CCG’s Financial N/A  Plan? (Delete as appropriate) Performance: Not applicable To identify possible modifiable factors, and make recommendations with the Quality and Safety: aim of reducing potentially preventable deaths in children.

Equality and Has an equality impact assessment been Diversity: Yes No N/A  undertaken? (Delete as appropriate) Patient and Public The report has been shared by CDOP across the partnership Engagement: Clinical Engagement: Not applicable Risk and Assurance: Not applicable

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Child Death Overview Panel Annual Report Coventry, Warwickshire and Solihull 2018-2019

Version Author/Editor Date V1 Helen Green V2 Caroline Lamming-Chowen 21/11/2019 V3 Caroline Lamming-Chowen 02/12/2019 V4 Liz Gaulton and Jo Galloway 23/12/2019 V5 Caroline Lamming-Chowen 24/12/2019 V5 CDOP working group and Caroline Lamming-Chowen 06/12/2020

Contents

Title Page Introduction 3 Annual Overview 6 Demographic Data Analysis 8 Place of Death 10 Generic Themes Across the Sub-region 11 Additional Information on Modifiable Deaths 16 CDOP Actions 19 Consolidated Learning 21 Upcoming Changes and Next Steps for CDOP 22 Appendix Data 23

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Introduction Child Death Overview Panels (CDOP) were created in 2011 by the Government as a final process for reviewing the deaths of all children from birth to their 18th birthday who resided within the UK. The main functions of CDOP are to collate information from the services involved in the life and death of a child and to review the circumstances of the child’s death. This involves reviewing the support and services provided to the child and their family in order to identify possible modifiable factors 1 and ultimately, to reduce the potentially preventable deaths in children in the UK. CDOP does not review still births or legal terminations of pregnancy. The overarching aim of CDOP is to deduce learning that will reduce childhood mortality; this is specified within section 5 of this report.

This CDOP report outlines the analysis of cases and the main conclusions derived from panels held in Warwickshire, Solihull and Coventry during the period from 1 April 2018 to 31 March 2019. It also examines the actions and learning that has been undertaken as a result of CDOP working over the given period.

Executive Summary During this reporting year there were a total of 13 panels held and 55 cases reviewed. Of the 13 panels, 5 were held in Warwickshire, 5 in Coventry and 3 were held in Solihull. All the panels were chaired by the Public Heath Lead for the respective local authority.

48% of all deaths reviewed during 2018-19 occurred in under one year olds; 27% occurred in the neonatal period (<28 days old) and 21% occurred after the neonatal period (28-364 days). In deaths reviewed with modifiable factors, there was a more even split between age groups (25% neonatal <28 days and 30% between 28 days and 364 days), while in deaths without modifiable factors there was a higher proportion occurring in the neonatal period (28% vs. 16%). A modifiable factor is defined as that where, if actions could be taken through national or local interventions, the risk of future child deaths could be reduced.

Out of 55 deaths reviewed, 67% recorded an acute hospital as the place of death, 21% occurred at the home of normal residence, 10% in a public place and 2% occurred in a private residence other than the home of normal residence.

The core learning from this CDOP reporting year is highlighted in section 7. The majority of CDOP learning comes from when modifiable factors within the death are identified and actions are set by the panel to address this. The main learning from this reporting year can be summarised into the following points:

- Maternal smoking, BMI of over 30 and domestic violence were the most frequently noted as modifiable factors. In some cases these modifiable factors were considered to have contributed to the neonatal and perinatal deaths, however, they varied in their assessed contribution; an overview of this can be found at section 4.2. Actions were taken to contact antenatal providers and give feedback and advice about smoking cessation and the identification and questioning relating to domestic violence.

- In older children, factors relating to early identification of sepsis and agency response to road traffic deaths were identified as the main modifiable factors. Identified learning will reinforce the current guidelines for sepsis recognition and treatment and contribute to the new Sudden Unexpected Deaths in Infants & Children under18 (SUDC) protocol developments.

1 Those in which modifiable factors may have contributed to the death. These are factors defined as those, where, if actions could be taken through national or local interventions, the risk of future child deaths could be reduced. 3 | Page

During this reporting year CDOP was tasked with reflecting on and subsequently enacting the changes required within the “ Working Together 2018” Statutory Guidance. In the section entitled ‘Transformative changes’ there is a brief synopsis of some of the changes that CDOP has undergone.

CDOP Aims and Purpose The CDOP review is intended to be the final scrutiny over a child’s death. This involves multiagency panels and core competency professionals that assess the information supplied. The aim is to provide a complete picture of the child’s death and living circumstances.

Once the information is collated and processed, panel members can analyse, discuss and identify factors that can be altered to prevent future child death. The overarching purpose is to use professional scrutiny to identify actions and learning to reduce child mortality.

CDOP aims to review deaths through an independent and enquiry-based method where learning based actions can be taken, if possible. During the year 2018-2019 the aims of this CDOP sub-region were to continue in the same methodology focusing on timely review, involvement of families and improving the process as a whole.

The aims for 2019-2020 will be as follows; • Set and apply measurable actions within a panel setting, which can be scrutinised in their effectiveness, by setting specific, measurable, achievable, realistic and time sensitive (SMART) targets. • Engage with further regional action groups and panels to improve the wider impact of action and learning. Specifically, to work with the West Midlands Regional CDOP network to form a larger themed panel approach for specialist cases. • Partnership working with West Midlands regional CDOP network to form a larger themed panel approach for more complex cases that require further explanation. • Review the transition process through the CDOP executive working group to meet with the statutory duties set out in Working Together (2018) and evaluate the effectiveness and compliance of the new approach. • To effectively use sub-regional data, analyse and share learning to benefit the safeguarding and wellbeing of children living within Coventry, Warwickshire and Solihull. • To expand and set up new ‘single point of contact’ networks with child death review meetings being effectively managed by individual providers through the electronic child death overview panel platform. • To review, scope, outline and establish the fixed membership quotas for themed panels.

CDOP Partnerships This Warwickshire, Coventry and Solihull CDOP is comprised of seven statutory partners, all contributing and benefiting from the CDOP panel process. The statutory partners are: Warwickshire County Council, Coventry City Council, Solihull Metropolitan Council, Warwickshire North Clinical Commissioning Group, South Warwickshire Clinical Commissioning Group, Coventry and Rugby Clinical Commissioning Group and Birmingham and Solihull Clinical Commissioning Group.

This Warwickshire, Coventry and Solihull CDOP is also a member of the West Midlands Regional CDOP group and a part of the National Network of CDOP, enabling participation in regional developments and national learning.

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Transformative Changes In this CDOP year a full scoping of existing processes and services was undertaken by Coventry, Solihull and Warwickshire CDOP. This scoping involved examining compliance of CDOP with the old Working Together 2015 and then a gap analysis of the new guidance in Working Together 2018. From this analysis CDOP identified the actions needed to implement the new guidance and set a timescale for the implementation. When the changes were decided CDOP Coventry, Solihull and Warwickshire set itself 3 main overriding outcomes:

- To deliver high quality panels that recognises the need to support families who have been bereaved, are compliant with National guidance and focus on learning from cases.

- To increase the output of learning from cases and implement effective change.

- To establish networks of accountable and dedicated professionals to show rigour and quality within the child death review process.

During this reporting year CDOP worked closely with its statutory partners to examine the new roles that were required in Working Together 2018 and how all partners should be involved. A working group was established, to develop new arrangements in the region. This CDOP has adopted and published its new arrangements within the statutory timescale. Access to this CDOP’s strategic change can be found at: https://www.warwickshirenorthccg.nhs.uk/mf.ashx?ID=37a674de-606b- 4784-baa4-bbc25332ceae

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1. Annual Overview 1.1. Number of panels and reviews A total of 13 panels were held across Coventry, Solihull and Warwickshire during 2018-19 in which 55 deaths were reviewed as summarised in the table below. Of these 55 deaths reviewed, 20 (36.4%) were assessed as having modifiable factors. This proportion was higher in Solihull (70%), although there were smaller numbers in total. None of the child deaths reviewed by Warwickshire, Coventry and Solihull CDOP in this year, were recommended for a serious case review.

Modifiable factors Area Panels held Deaths reviewed identified (%) Coventry 5 26 9 (35%) Solihull 3 10 7 (70%) Warwickshire 5 19 4 (21%) Total 13 55 20 (36%)

Table 1 CWS CDOP Report 2018-2019

1.2. The Timing of Reviews When looking at reviews where modifiable factors were identified, there was a higher proportion of children whose deaths had occurred prior to the period of review (i.e. 01 April 2018 to 31 March 2019,). The main reasons for this disparity is that for a case to be brought to panel all prior processes including investigations need to be completed. In many of the cases that were brought at a later date, i.e. in years prior to this period of review, there were significant investigations or processes. In cases where there are significant investigations, there is a much higher chance that modifiable factors will be identified.

100%

90%

80%

70%

60%

50%

40%

30%

20%

10%

0% Without MF With MF Without MF With MF Without MF With MF Without MF With MF Coventry Solihull Warwickshire Total 04/2018 to 03/2019 04/2017 to 03/2018 04/2016 to 03/2017 04/2015 to 03/2016

Figure 1 CWS CDOP Report 2018-2019

When looking at how long after death the review was completed, 50% of deaths assessed as having modifiable factors occurred over a year before the review was completed compared to 34% without

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modifiable factors. It should be noted that reviews of two deaths in Warwickshire and one death in Solihull could not rule out the possibility of modifiable factors.

60% Under 6 months 6 or 7 months 8 or 9 months 10 or 11 months 12 months Over a year

50%

40%

30%

20%

10%

0% Modifiable No modifiable Modifiable No modifiable Modifiable No modifiable Modifiable No modifiable factors factors factors factors factors factors factors factors Coventry Solihull Warwickshire Total

Figure 2 CWS CDOP Report 2018-2019

A total of 82 deaths were reported as having an ongoing review on 31 March 2019 across the area (27 in Coventry, 9 in Solihull and 43 in Warwickshire). The majority of these deaths (91%) occurred in the same period as the current review (01 April 2018 to 31 March 2019). One death occurring in the period between 01 April 2015 to 31 March 2016 has not yet been reviewed at CDOP.

In 2018/19, there were no deaths discussed or subsequently reviewed where the child was not normally resident in the area.

CDOP reviews deaths when all of the investigatory processes have been completed. In the majority of deaths awaiting a review for nine months or over, there was a requirement to await the cases investigatory stage completion prior to panel.

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2. Demographic Data Analysis 2.1. Age 48% of all deaths reviewed during 2018-19 occurred in under one year olds: 27% occurred in the neonatal period (<28 days old) and 21% occurred after the neonatal period (28-364 days). In deaths reviewed with modifiable factors, there was a more even split between age groups (25% neonatal <28 days and 30% between 28 days and 364 days), while in deaths without modifiable factors there was a higher proportion occurring in the neonatal period (28% vs. 16%).

Deaths in 1-4 year olds accounted for 23% of those reviewed and deaths in 5-9 year olds for 15% of all deaths reviewed. In these age groups, there was a higher proportion of deaths where no modifiable factors were identified (44%) compared to those with modifiable factors (30%).

Of the 12 deaths in the age range of 1-4 years old, 2 were found to have modifiable factors and 6 had no modifiable factors. In the 15-17 year old age range those with modifiable and non-modifiable factors were evenly split with 3 deaths in each group.

For Solihull and Warwickshire, the majority of deaths with no modifiable factors were in <28d olds whereas in Coventry it was 1-4-year olds, though generally the deaths were more evenly distributed. For deaths where modifiable factors were identified, in Coventry the majority were in 28-364d olds, while in Solihull and Warwickshire it varied (although numbers are small).

Age at death (%)

0-27 days 28-364 days 1-4 years 5-9 years 10-14 years 15-17 years With modifiable 5 (25%) 6 (30%) 4 (20%) 2 (10%) 0 (0%) 3 (15%) factors Without 9 (28%) 5 (16%) 8 (25%) 6 (19%) 1 (3%) 3 (9%) modifiable factors Total 14 (27%) 11 (21%) 12 (23%) 8 (15%) 1 (2%) 6 (12%)

Table 2 CWS CDOP Report 2018-2019

2.2. Gender Of the 55 deaths reviewed, 20 were male, 32 were female and 3 were gender unidentifiable2. The proportion by gender was fairly consistent throughout the localities in which the cases were reviewed.

2.3. Ethnicity In total, 62% of deaths were reported to be in White children (44% English/Welsh/Scottish/Northern Irish/British and 17% White other). 15% of deaths were in Asian or Asian British children 19% of the child deaths reviewed were in Mixed/Multiple ethnicity, 13% were in Black or Black British ethnic group and 3% reported to be Other or Unknown.

This pattern was generally consistent by area accounting for the background difference in population ethnicity.

2 All three cases concerned extremely premature babies where the gender was not overtly apparent, and at parental request no further investigation/identification was undertaken. Cases such as these may be reported to the national mortality database as gender ‘unidentifiable’. 8 | Page

60 Modifiable factors No modifiable factors

Number 30

0 Irish Other Other Other Indian African Chinese Pakistani Caribbean Bangladeshi White & Asian White & Black African Black & White Irish/British Gypsy orGypsy Irish Traveller White Black & Caribbean Any OtherAny White background English/Welsh/Scottish/Northern White Mixed Asian (British) Black (British) Arab

Figure 3 CWS CDOP Report 2018-2019

2.4. Vulnerability Status Across all 55 reviews completed, none of the cases were seeking asylum at the time of death. No children were subject to a child protection plan at the time of death or prior to their death. No children were reported to be under a statutory order either previously or at the time of death. The statutory orders that CDOP requests information about are: Police Powers of Protection Emergency Protection Order, Interim Care Order, Care Order, Supervision Order, Residence Order, Section 20 (Children Act 1989) , Antisocial behaviour order or other court order.

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3. Place of Death Across all 55 deaths reviewed, 67% had Acute Hospital recorded as the location at the time of the event/condition which led to the death. 25% were in a neonatal unit, paediatric intensive care unit or a paediatric ward while 42% were in another location in the hospital (including delivery suites, labour wards and transplant units). There were fairly equal proportions of deaths with modifiable factors and deaths with no modifiable factors throughout the aforementioned locations. Of deaths occurring in Acute Hospital, a higher percentage were found to have no modifiable factors (72%). Children who died in other places were more likely to have modifiable factors identified (60%).

21% of reviews recorded the home of normal residence as the place of death, 25% of these deaths were recorded with modifiable factors compared to 19% of deaths with no modifiable factors.

10% of deaths were recorded in a public place including roads, railways, parks, restaurants and beaches. 15% of these deaths had modifiable factors compared to 6% of deaths with no modifiable factors.

The remaining 2% of total deaths occurred in a private residence other than the home of normal residence and had no modifiable factors.

50% 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% Paediatric Neonatal Paediatric Other Ward Unit Intensive Care Unit Acute hospital Home of Other private Public place normal residence residence Modifiable factors No modifiable factors All

Figure 4 CWS CDOP Report 2018-2019

A similar distribution of location of death was reported in Coventry, Solihull and Warwickshire.

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4. Generic themes across the sub-region 4.1. Category of death

Figure 5 below shows the categories of death for the CDOP cases for the period 1st April 2018 to 31st of March 2019, while the text below examines the relationship between the modifiable/non- modifiable factors and the category of death.

Figure 5 CWS CDOP Report 2018-2019 4.1.1. Chromosomal, genetic and congenital anomalies Across all deaths reviewed, the majority were categorised as chromosomal, genetic and congenital anomalies (31%), with a higher proportion in deaths with no modifiable factors (34%) than in deaths with modifiable factors (25%). Modifiable factors identified were two cases of consanguinity and a single case with modifiable factors related to service provision factors. This resulted in panel recommending that the family was referred for genetic counselling.

4.1.2. Perinatal/neonatal event A total of nine deaths categorised as a perinatal/neonatal event were reviewed across the sub- region in 2018/19 (17 %). Of the three deaths reviewed where modifiable factors were identified, the key factors were a late booking of pregnancy, maternal or household smoking, drugs and/or alcohol abuse, mental health issues and domestic violence.

4.1.3. Trauma and other external factors Nine of the deaths reviewed across the sub region were a result of trauma and other external factors. This category had the highest ratio of modifiable: non-modifiable death factors. Out of the five modifiable death factors, two related to road traffic accidents, two were linked to unsafe sleeping arrangements and one was linked to a sudden and unascertained illness.

The modifiable factors identified in the cases involving unsafe sleeping arrangements related to issues of co-sleeping and non-recommended modifications made to travel cots. One of the road traffic accidents occurred during the commission of a crime and had modifiable safeguarding factors; the other identified modifiable factors related to the working agreements of bus drivers. Actions taken for these cases were: raising workplace health awareness, sharing national learning about travel cots and developing a road traffic SUDC protocol. 11 | Page

4.1.4. Acute medical/surgical condition Of the four deaths reviewed that resulted from an acute medical or surgical condition, two had modifiable factors linked to smoking within the household. There were other factors reported relating to domestic violence and/or mental health challenges. These factors were present and modifiable, but did not directly contribute to the death.

4.1.5. Chronic medical condition Of the four deaths resulting from a chronic medical condition, one had maternal smoking as a modifiable factor. The other deaths were concluded to be non-modifiable. These factors were present and modifiable, but did not directly contribute to the death.

4.1.6. Malignancy Of the four deaths reviewed as resulting from malignancy, one modifiable factor related to expert learning in diagnosis of a very rare form of cancer.

4.1.7. Sudden unexpected unexplained death Of the four sudden unexpected deaths, two had smoking, alcohol and drug use within the family home identified as modifiable factors. Both of these deaths occurred in children below the age of two.

Modifiable factors (%) No modifiable factors (%) Total (%) Chromosomal, genetic and congenital anomalies 5 (25%) 11 (34%) 16 (31%)

Perinatal/neonatal event 3 (15%) 6 (19%) 9 (17%)

Trauma and other external factors 4 (20%) 5 (16%) 9 (17%)

Acute medical or surgical condition 2 (10%) 2 (6%) 4 (8%)

Chronic medical condition 1 (5%) 3 (9%) 4 (8%)

Malignancy 1 (5%) 3 (9%) 4 (8%)

Sudden unexpected, unexplained death 2 (10%) 2 (6%) 4 (8%)

Infection 1 (5%) 0 (0%) 1 (2%)

Suicide or deliberate self-inflicted harm 1 (5%) 0 (0%) 1 (2%)

Table 3 CWS CDOP Report 2018-2019

4.2. Factors contributing to death Having assessed factors in death, there is a subdivision between ‘factors that are present but did not contribute to the death’, ‘ factors that were present that may have contributed to the death’ and ‘factors that provide a complete explanation of the death’.

Across all deaths reviewed in 2018/19, the factors providing a “complete and sufficient explanation” for deaths reviewed were in the acute/sudden onset illness and chronic long-term illness categories. 12 | Page

Figure 6 CWS CDOP Report 2018-2019

For factors which “may have contributed”, the contributing factors included family and environment; of which the main factor was smoking in the household/by the mother during pregnancy. This was followed by domestic violence, alcohol/substance misuse by a parent/carer, emotional/behavioural/mental health condition in the parent/carer and acute/sudden illness.

Figure 7 CWS CDOP Report 2018-2019

Factors “present but unlikely to have contributed to the death”, included chronic long-term illness (other than asthma or epilepsy), acute illness, and disability and impairment. A breadth of factors in death were identified, although those listed below were not found to have contributed to the deaths of the children reviewed. Acute and sudden onset factor was the greatest non-contributing factor present. This column can include illnesses in children with an underlying condition, for example chest infections within immuno-compromised children.

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Figure 9 CWS CDOP Report 2018-2019

Examining the data by age group and “factors providing a complete and sufficient explanation for the death” showed that the primary factor in children aged 0-27 days old was listed as an acute cause. There was a more even split between acute and chronic long term health problems for age groups between 28 days to 17 years.

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10 0-27 days 28 days-364 days

8 1 year-4 years 5-9 years Number 6 10-14 years 15-17 years

0 Acute/Sudden onset Chronic long term Disability or Family and Parenting capacity Service provision illness illness impairment envirornment

Figure 10 CWS CDOP Report 2018-2019

For “factors that may have contributed to the death”, in children under one year old, the main identified factors were family and environment, other factors like service provision and parenting capacity were also noted. The older age groups had a number of different “factors that may have contributed to the death”.

14 0-27 days 28 days-364 days

12 1 year-4 years 5-9 years

10 10-14 years 15-17 years 8 Number 6

0 Acute/Sudden onset Chronic long term Disability or Family and Parenting capacity Service provision illness illness impairment envirornment

Figure 11 CWS CDOP Report 2018-2019

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5. Additional information on deaths with modifiable factors 5.1. Deaths with modifiable factors A total of nine deaths with modifiable factors were reviewed in Coventry during 2018/19. Two deaths with modifiable factors were reviewed in Solihull during 2018/2019. Four deaths with modifiable factors were reviewed in Warwickshire during 2018/19.

5.1.1. Sudden and unexpected death There were six sudden unexpected deaths where modifiable family and environmental factors were identified.

One child could not have a cause of death established by a post-mortem and this was recorded as unascertained. There was evidence of a number of parental actions in this case which, while not directly impacting on the death, may nevertheless have affected their parental responsiveness. These include alcohol consumption, drug use and possible drug dealing in the home, a history of domestic violence and smoking in the household. The death was referred to and discussed by the Serious Case Review sub group of the Coventry LSCB which concluded the criteria for a Serious Case Review was not met.

The second child died from an unascertained acute/sudden onset illness. Smoking in the household and issues around co-sleeping were reported factors. The parents had not followed advice from health professionals.

There was one traumatic death in a child in which modifiable factors were identified. The cause of death was a road traffic collision and the child died at the scene. There was learning around SUDIC procedures, and new SUDIC guidance around road traffic collisions were created by the West Midlands Police. There was an action for the CDOP panel to obtain a copy of this, which was shared with the developers of the upcoming West Midlands SUDC protocol.

Another death involved a child who was involved in a road traffic collision. There were no modifiable factors identified within this particular case directly linked to the death, although a number of actions linked to multi-agency services were disseminated following its review.

One child died from blunt head injuries as a result of road traffic injuries. Recommendations made by the CDOP panel included a need to raise awareness of workplace health issues locally, with a letter written to both a Member of Parliament and a bus company to draw attention to this case. The GP was also advised about appropriate communication with the Driver and Vehicle Licensing Agency in similar instances in the future.

Finally, a child died with an unascertained cause of death. A travel cot had been adapted during a period of temporary residential change. Modifiable factors identified were the arrangement of the bedding, along with a combination of the physical environment and age-related vulnerability of the infant, contributing to death. A recommendation was made by the CDOP panel to raise awareness amongst parents of young children around the dangers of modifying travel cots as this can cause an unsafe sleeping environment. The panel recommended that parents should also be made aware that travel cots should always be used following the manufacturer’s instructions. The CDOP Chair wrote to the regional community nurses asking them to add the learning identified in this review to a national campaign and the learning was shared with the local safeguarding structures. Advice around the use of travel cots was also disseminated via the Warwickshire Safeguarding Children Board newsletter.

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5.1.2. Perinatal/neonatal event There were two perinatal/neonatal deaths with modifiable factors identified. In both cases, they resulted from acute/sudden onset illnesses and maternal smoking was reported. Both were extremely premature.

In the death of one child there were additional environmental factors recorded, including mental health factors and domestic violence reports.

The second child also died in the neonatal period following preterm labour. The mother had accessed healthcare late and was failing to attend healthcare appointments. Furthermore, there were concerns over the impact of domestic abuse. Although this was reported to be historic, there remained concerns that there was undisclosed ongoing domestic abuse.

5.1.3. Infection There was one death resulting from infection where modifiable factors were identified. The child died after presenting at a Walk in Centre. Modifiable factors identified included access to healthcare and smoking in the household. At the CDOP panel a decision was made to feed back to the CCG the importance of the awareness of the screening process in line with the Sepsis Strategy.

5.1.4. Chronic medical condition There were two deaths resulting from a chronic medical condition where modifiable factors were identified:

One child died as the result of a neurodegenerative disorder. Maternal smoking during pregnancy was identified as a modifiable factor although it was clearly stated that this would not have contributed to the death.

The second death was in a child who was suffering from a malignancy where modifiable factors were identified. This was a very complex, rare case with several questions raised by the parent through the CDOP process. It was noted by the review panel that in the future, parents must be supported to understand the new arrangements and the role of CDOP as this will be helpful when dealing with complex cases such as this. A review of the new literature being sent to parents was undertaken and suitability agreed. Feedback was given to parents through the use of collaborative professionals who were involved in the child’s treatment; a meeting to answer questions directly was facilitated.

5.1.5. Chromosomal/genetic/congenital There were three deaths resulting from a genetic condition where modifiable factors were identified:

The first child died following a cardiac arrest and had a congenital heart condition. The parents were reported to be consanguineous.

The second child died from a mitochondrial disease which was complicated by sepsis. The parents were identified as consanguineous. There was an action for CDOP to check if they had had genetic counselling, which was passed onto the relevant provider who confirmed that this had been offered.

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The third case occurred in a child who died after being diagnosed with multiple congenital abnormalities in the antenatal period. Maternal smoking and alcohol consumption during the pregnancy were identified as modifiable factors.

5.1.6. Acute medical or surgical condition There was one death resulting from an acute medical condition where modifiable factors were identified. The child died from streptococcal pneumonia and a rare kidney condition. Smoking in the household by the mother and another relative was identified as a modifiable factor, but would not have affected the death of the child. Depression in a family member and domestic violence were also identified as factors. Again, these did not relate to either the infection or the kidney condition. There was a recommendation made by the CDOP panel to ensure clarity in the SUDIC process in initial communications between paediatricians and the police. This will be addressed in the West Midlands SUDIC protocol.

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6.0 CDOP Actions During this CDOP reporting year there were a total of 74 completed actions. These actions were divided into categories such as recognition, advice, change, clarity requests and extraordinary actions. Below is the overview of these actions.

6.1 Recognition of good service provision 17 letters of recognition of good service or appreciation were sent out this year to recognise the contributions to the child death process. These included thank you letters and communications to parents who contributed to the reviews of their children. Considerable recognition was given to the ambulance service, schools and community/palliative care.

6.2 Provision of Advice and Guidance 14 communications and actions were performed in terms of developing and adding to the provision of advice and guidance. Of the aforementioned actions, many involved feedback on the services provided and suggestions for improvement in individual cases.

One case resulted in the development of a case study to improve midwifery training and processes. This case study was used by one of the hospitals within this CDOP area.

Shared knowledge on bereavement services and national learning/sharing was also a key action within the provision of advice and guidance provided by CDOP this year. This included sending bereavement information to parents as protocol as well as informing partners in the CDOP process of bereavement services available.

A further notable communication involved the sharing of SUDIC protocol developments and a particular focus on the developments for road traffic protocols. Clarity was also gained on the Kennedy Guidance, which allowed for better understanding on when a SUDIC rapid review may not need to be fully instigated.

Further communications included engaging with the coroner’s officers serving Coventry, Warwickshire and Solihull. In addition, hospitals were supported to implement sepsis identification protocols.

6.3 Recommended Change 5 actions were undertaken regarding recommending change. The majority of these actions directly related to the protocols that are associated with rapid response to children involved in road traffic collisions and the development of a new response. This action contributes to the wider West Midlands protocol and CDOP has made recommendations. Other acts of recommended change involved amending internal death certification processes and reviewing the way child death decision-making is processed within multi-agency services.

6.4 Further information 35 actions involved the process of requesting further information. These were usually requests by panel to ensure that they had a complete picture so that their analysis of the case was complete.

It should also be noted that CDOP sends a letter to every parent of a child who dies, informing them that their child’s death will be undergoing a CDOP review. This letter offers parents the opportunity to contribute to the review but also supplies them with information on the process and provides information on how to access bereavement support.

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6.5 Extraordinary Actions There were 3 extraordinary actions: 1) A referral to the Serious Case Review sub-committee for a case to be considered.

2) The movement of the annual reporting procedures for CDOP.

3) Publication of training to identify children at risk of mental health crisis in schools. The mental health publication also involved an article supplied to head teachers on where to obtain quality first- aid mental health training for staff in schools.

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7. CDOP Consolidated Learning 20 of the cases CDOP reviewed had modifiable factors contributing to death. These cases with modifiable risk factors are the focus of learning from child deaths.

The most pertinent modifiable factors in neonatal and perinatal deaths were as follows: - Maternal smoking during pregnancy or in the household with young children - Domestic violence - Mothers with Body Mass Indexes over 30

Within the neonatal and perinatal age group there were also modifiable factors relating to consanguinity and alcohol and drug abuse of a parental figure. Actions aiming to disseminate learning were taken with regards to these factors including: - Correspondence with ante-natal teams regarding smoking cessation; recording smoking in pregnant mothers; and promoting referral to smoking cessation services. - Communication with GP practices relating to the identification of and support for victims of domestic violence. - Hospital communications regarding improving the way domestic violence questions were asked. - A warning about modifying travel cots was also sent around the National Network of CDOPs (NNCDOP) to be distributed nationally as well as to local authority leads.

In older children, the main modifiable factors identified were:

- Modifications to the road traffic elements of the SUDIC protocol and questions regarding development and sharing of this protocol. - Identification of sepsis in the early stages

CDOP is currently working on reviewing its SUDIC protocol.

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8. Plans for 2019-2020 In 2019-2020, CDOP shall be continuing to put in place the new arrangements in line with both Working Together (2018) and its revisions of its operational policy. The CDOP executive working group has continued to meet on a monthly basis and the upcoming actions are as follows:

- Secure the CDOP chid death review network to ensure a smooth communication between medical reviews and CDOP reviews. This includes providing training and support to providers and working together to establish effective and compliant procedures relating to information sharing and timelines of reporting.

- Review the new method of thematic panels to assess effectiveness, burden on professionals, and compliance with the new statutory guidelines. Share this report within a discussion forum of the CDOP executive board and plan for improvement.

- Securing the arrangements of a Designated Doctor for Child Death and agreeing and establishing their role as per statutory guidance.

- To work in partnership with CCGs and partners to review the SUDIC process alongside the review of the West Midlands protocol.

- Review the compliance of CDOP with the new guidance in place and provide quarterly assurance updates to the CDOP Board.

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APPENDIX Figures 1. Demographics

1.1. Age Coventry Solihull Warwickshire

MF No MF Total MF No MF Total MF No MF Total n 2 2 4 2 2 4 1 5 6 0-27 days % 22 12 15 29 100 44 25 38 35 n 5 4 9 0 0 0 1 1 2 28-364 days % 56 24 35 0 0 0 25 8 12 n 1 6 7 2 0 2 1 2 3 1-4 years % 11 35 27 29 0 22 25 15 18

n 1 4 5 0 0 0 1 2 3 5-9 years % 11 24 19 0 0 0 25 15 18 n 0 1 1 0 0 0 0 0 0 10-14 years % 0 6 4 0 0 0 0 0 0 n 0 0 0 3 0 3 0 3 3 15-17 years

Age atAge death (%) % 0 0 0 43 0 33 0 23 18 Table 4 CWS CDOP Report 2018-2019

1.2. Gender Coventry Solihull Warwickshire MF No MF Total MF No MF Total MF No MF Total Male 6 11 17 6 1 7 3 7 10

Female 3 6 9 1 0 2 1 6 7 Unknown/not stated 0 0 0 0 1 1 0 0 0

Gender Male/female sex ratio 2.0 1.8 1.9 6.0 NA 3.5 3.0 1.2 1.4 Table 5 CWS CDOP Report 2018-2019

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1.3. Ethnicity Coventry

6 Modifiable Not modifiable 5 4 3

Number 2 1 0 Irish Other Other Other Indian African Chinese Pakistani Caribbean Bangladeshi White & Asian White & Black African Black & White rn Irish/British Gypsy orGypsy Irish Traveller White Black & Caribbean Any OtherAny White background English/Welsh/Scottish/Northe White Mixed Asian (British) Black (British) Arab Other Unknown

Solihull

6 Modifiable Not modifiable 5 4 3

Warwickshire

6 Modifiable Not modifiable 5 4 3

Figure 12 CWS CDOP Report 2018-2019

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2. Place

Coventry Solihull Warwickshire

MF No MF MF No MF MF No MF

Emergency Department 0 0 0 0 0 0 Paediatric Ward 0 0 0 0 0 1 Neonatal Unit 2 3 0 0 0 2 Paediatric Intensive Care Unit 1 3 1 0 0 0 Adult Intensive Care Unit 0 0 0 0 0 0 Other1 4 7 2 2 2 5

Acute hospital Unknown 0 0 0 0 0 0 Home of normal residence 1 3 3 0 1 3 Other private residence 0 0 0 0 0 1 Foster home 0 0 0 0 0 0 Residential Care 0 0 0 0 0 0 2

Public place 1 1 1 0 1 1 School 0 0 0 0 0 0 Hospice 0 0 0 0 0 0 Mental health inpatient unit 0 0 0 0 0 0 Abroad 0 0 0 0 0 0

Location at the time of the event/condition which which event/condition of the time the at Location death the to led Other 0 0 0 0 0 0 Table 6 CWS CDOP Report 2018-2019

1 including delivery suites, labour wards, transplant units, etc. 2including roads, railways, parks, restaurants, beaches, etc

3. Category of death

Coventry Solihull Warwickshire MF No MF MF No MF MF No MF Deliberately inflicted injury, abuse or neglect 0 0 0 0 0 0 Suicide or deliberate self-inflicted harm 0 0 1 0 0 0 Trauma and other external factors 1 3 1 0 2 2 Malignancy 0 1 1 0 0 2 Acute medical or surgical condition 1 1 1 0 0 1 Chronic medical condition 1 2 0 0 0 1 Chromosomal, genetic and congenital anomalies 1 8 2 0 2 3 Perinatal/neonatal event 2 2 1 2 0 2 Infection 1 0 0 0 0 0 Sudden unexpected, unexplained death 2 0 0 0 0 2 Unknown category 0 0 0 0 0 0 Table 7 CWS CDOP Report 2018-2019

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4. Causative event

Coventry Solihull Warwickshire MF No MF MF No MF MF No MF Neonatal death 2 3 1 2 1 5 Known life limiting condition 2 9 1 0 1 4 Sudden unexpected death in infancy 5 4 4 0 2 4 Road traffic accidents/collision 0 0 0 0 0 0 Drowning 0 0 0 0 0 0 Fire and burns 0 0 0 0 0 0 Poisoning 0 0 0 0 0 0 Other non-intentional injury/accident/trauma 0 0 0 0 0 0 Substance misuse 0 0 0 0 0 0 Apparent homicide 0 0 0 0 0 0 Apparent suicide 0 0 0 0 0 0 Other 0 1 1 0 0 0 Table 8 CWS CDOP Report 2018-2019

5. Factors contributing to death Level of contribution to death Coventry Solihull Warwickshire  ?   ?   ?  Acute/Sudden onset illness TOTAL 6 5 11 2 5 6 5 3 12 Asthma 0 0 0 0 1 0 1 0 0 Epilepsy 1 0 0 0 0 0 1 0 0 Chronic/long term illness Other chronic illness 11 2 8 0 3 4 3 0 7 TOTAL 12 2 8 0 4 4 5 0 7 Learning disabilities 5 0 0 0 0 0 2 0 0 Motor impairment 3 0 0 0 0 0 3 0 0 Disability/impairment Sensory impairment 0 0 0 0 0 0 1 0 0 Other disability of impairment 0 0 0 0 0 0 2 1 0 TOTAL 8 0 0 0 0 0 8 1 0 Emotional/behavioural/mental health condition in the parent/carer 1 3 0 0 1 0 3 0 0 Alcohol/substance misuse by a parent/carer 0 1 0 0 2 0 0 1 0 Smoking by the parent/carer in a household 0 6 0 0 1 0 3 1 0 Smoking by the mother during pregnancy 0 4 0 0 0 0 1 1 0 Emotional/behavioural/ mental health condition in the child 0 0 0 0 1 0 0 0 0 Alcohol/substance misuse by the child 0 1 0 0 0 0 0 0 0 Family and environment Housing 1 1 0 0 0 0 1 1 0 Domestic violence 2 3 0 0 0 0 0 1 0 Co-sleeping 0 1 0 0 0 0 0 0 0 Bullying 0 0 0 0 1 0 0 0 0 Consanguinity 0 1 0 0 0 0 0 1 0 Total 4 21 0 0 6 0 8 6 0 Poor parenting/supervision 2 2 0 0 1 0 0 1 0 Parenting capacity Child abuse/neglect 0 1 0 0 2 0 0 1 0 Total 2 3 0 0 3 0 0 2 0 Access to health care 1 2 0 0 2 0 3 0 0 Prior medical intervention 3 1 0 0 0 0 3 0 0 Service provision Prior surgical intervention 2 0 0 0 0 0 0 0 0 Total 6 3 0 0 2 0 6 0 0

 No factors identified/unlikely to have contributed to the death ? Factors identified that may have contributed to vulnerability, ill-health or death by age  Factors identified that provide a complete and sufficient explanation for the death Table 9 CWS CDOP Report 2018-2019

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Glossary

CDOP Child Death Overview Panel

ECDOP Electronic platform for Child Death Overview Panel

SUDC Sudden and Unexpected Deaths in Infancy or Childhood

CDRM Child Death Review Meeting

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Blank Page Enc K CRCCG / WNCCG Finance and Performance Committee (F&P) Report for the Meetings in Common held on 5th March 2020

Achievements/Decisions Made/Items to Note Finance and Performance Committee Schedule of CRCCG Finance and Contracting Report – Month 10: Business: Members noted that the CCG had improved its forecast by Members Approved the 2020/21 Schedule of £2.9m from Month 9 following discussions with NHSE/I. This Business for the Committee. was before agreement on a variation note with UHCW has been accounted for. A number of risks would need pro- Any Other Business active management throughout the year to secure this Members requested regular performance updates position. from Child and Adolescent Mental Health Services lllllllllllllllll (CAMHS). WNCCG Finance and Contracting Report – Month 10: Members noted that the CCG’s positon had deteriorated to £14.1 m deficit. This was before agreement on a variation note with GEH has been accounted for. A number of risks would need pro-active management throughout the remainder of the year to secure the forecast position.

WNCCG Financial Recovery Plan: Key Issues for the Governing Body When reviewing the updated planning position members noted the approach being taken on the 20% admin savings CRCCG/WNCCG Finance and Contracting Report and the scale of the challenge for the year ahead. – Month 10: There were no areas of concern that needed specific Budget Setting Financial Plan Update: escalation to the Governing Body. The update advised that the STP plans had not been signed off and contracts were not finalised therefore an update Budget setting Update would need to come to April’s Committee. Due to contracts not being finalised and non sign off of STP Plans the Budget setting process has been F&P Committee Annual Report delayed. This report gave Members an opportunity to reflect on and document its performance during the year and they agreed that the committee had adequately discharged its remit in the year to 31st March 2020.

Annual Operating Plan – Process for Completion & Key Targets: Matters referred to the Governing Body for Members received assurance on the delivery of identified approval, debate or further consideration: actions and milestones in respect of the current status of the organisational activity planning template submission. Procurement Update – March 2020: The report was discussed and the decisions have been detailed in Performance report – Month 9: the Procurement Report which has been submitted as The report highlighted A&E 4 hour waits, Cancer 62 days, part of confidential Governing Body papers. Out of Area Mental Health Placements and Transforming Care.

Strategic Planning Assurance – March 2020 - April 2020: Members received assurance on the delivery of identified actions and milestones in respect of the year to April 2020.

A&E Deep Dive – GEH and UHCW: Members noted the initial analysis of a Deep Dive of urgent care activity which they had requested and a proposal of what other information could be useful in relation to how understanding of how patients are accessing urgent care.

Out of Hospital Update: The committee approved deferral of a decision on the procurement process and award of new contracts for six months to enable the following key workstreams to be completed to inform a final decision: Key Information: • Committee Chair: Graham Nuttall (Lay Member) Corporate Risk Register: • CCG Lead: Chris Lonsdale (Interim Chief Finance Members were assured that the adequate actions were Officer) being taken by risk owners to mitigate the risks and that the th • 9 April 2020 assurances provided were satisfactory. Date of Next Meeting: Enc K Blank Page Enc K

CRCCG / WNCCG Finance and Performance Committee (F&P) Report for the Meetings in Common held on 9th April 2020

Achievements/Decisions Made/Items to Note Key Issues for the Governing Body

CRCCG Finance and Contracting Report - Month 11: • Progress of financial performance. Members noted the continued improvement to the forecast • Opportunities for transformation during COVID-19. position of £2.9m subject to agreement with University • Financial Bridge Analysis – It was requested that Hospitals Coventry and Warwickshire (UHCW) on year-end an analysis on how things have moved from the position. It was also noted that the CCG had the contingency original forecast financial position to the current remaining to offset potential costs at month 12. position to be presented to the May 2020 lllllllllllllllll Governing Body meeting. WNCCG Finance and Contracting Report - Month 11: Members noted that the CCGs position had deteriorated to Corporate Risk Register: The impact of COVID-19 £14.1m as per reported at month 10 and is subject to outbreak on quality and safety of patient care agreement with George Eliot Hospital (GEH) on year-end position. It was also noted that the CCG had a level of contingency remaining to offset potential risks at month 12.

NHS England /Improvement (NHSE/I) Letter on next steps on NHS response to COVID-19: The CCG had received a letter from NHSE/I on 17th March related to the COVID-19 level 4 national incident. Further guidance continued to be received and was informing the CCGs’ response. Members were assured that the CCG was applying the guidance.

COVID-19 Financial Implications: Members received the report which set out the important financial framework actions the CCGs are looking to implement that will allow for swift decisions, provider sustainability and stewardship. Members noted and scrutinised the progress to date and approach taken; and approved the process adopted for sign off of related costs.

Performance report – Month 10: The report highlighted A&E 4 hour waits, Cancer 62 day waits, Out of Area Mental Health Placements, Referral to Treatment, Dementia Diagnosis and Improving Access to Psychological Therapies (IAPT) as key performance issues for both CCGs.

NHSE/I letter on Reducing burden and releasing capacity at NHS providers and commissioners to manage the Covid-19 pandemic: Members noted the report which provided additional guidance dated 28th March 2020 to support NHS commissioners to manage the COVID-19 pandemic. The aim was for commissioners to free up as much capacity as possible and prioritise workload to focus on what is necessary to manage the response to COVID-19. Matters referred to the Governing Body for approval, debate or further consideration: Corporate Risk Register: Members heard that the impact of COVID-19 outbreak on quality and safety of patient care had Procurement Update – April: The report was been added to the risk register. It was agreed that the risk discussed and the decisions have been detailed in register would be moved to the beginning of the agenda for the Procurement Report which has been submitted as future meetings, and the front sheet would refer to the part of confidential Governing Body papers. relevant agenda items. Members were assured that adequate actions were being taken by risk owners to mitigate the risks and that the assurances provided were satisfactory.

Key Information: • Committee Chair: Graham Nuttall (Lay Member) • CCG Lead: Chris Lonsdale (Acting Chief Finance Officer) • Date of Next Meeting: 7th May 2020 Enc K

Blank Page Enc K

CRCCG / WNCCG Finance and Performance Committee (F&P) Report for the Meetings in Common held on 7th May 2020

Achievements/Decisions Made/Items to Note Key Issues for the Governing Body

Corporate Risk Register: Members heard that two new CRCCG Finance and Contracting Report - Month risks regarding Court of Protection application delays and the 12: impact of Covid -19 on the CCG financial position had been The CCG ended the financial year on a £0.1m in-year added. Members were assured that adequate actions were surplus. This missed the control total but achieved the being taken by risk owners to mitigate the risks and that the CCG’s statutory duty to break-even. assurances provided were satisfactory. lllllllllllllllll • A variation note has been concluded with Performance report – Month 11: The report highlighted University Hospitals Coventry and Warwickshire A&E 4 hour waits, Cancer 62 day waits, Out of Area Mental (UHCW) which has led to an additional £6m of Health Placements, Transforming Care, Referral to support for in-year pressures. There were Treatment, Dementia Diagnosis, Improving Access to originally a number of conditions to this Psychological Therapies (IAPT) and Delayed Transfers of agreement that were made by the Governing Care (DTOC) as key performance issues for both CCGs. Body, however these could no longer all be met and discussions have had to continue to support Restoration Planning 2020/21: The Committee received the Trust given the response to COVID-19. information on the organisational approach and planning for • The CCG did not receive £0.9m of ICES Cap to recovery from Covid -19. Members were assured with the Rev. The CCG has been able to mitigate the progress of the CCG Restoration Plan 2020/21 and agreed impact of this and maintain break-even. with the approach.

F&P Committee & Assurance Framework - Risk Review: WNCCG Finance and Contracting Report - Month Members received feedback from a desktop review of the 12: risks listed on the Committee risk register and on the Board The CCG ended the financial year on a £17.9m Assurance Framework. Members noted the contents of the deficit. report and agreed to the recommendations and actions • A variation note has been concluded with George stated. Eliot Hospital (GEH) which has led to an additional £4m of support for in-year pressures. COVID-19 Finance Update: Members heard the CCGs There were originally a number of conditions to progress from a finance perspective on the Covid-19 issue. this agreement that were made by the Governing Members noted and scrutinised the progress to date and Body, however these could no longer all be met approach taken. and discussions have had to continue to support the Trust given the response to COVID-19. • The CCG did not receive £1.1m of ICES Cap to Rev. If this had been received the CCG would have be able to record an improvement on its position.

Matters referred to the Governing Body for approval, debate or further consideration:

• Procurement Update – May: The report was discussed and the decisions have been detailed in the Procurement Report which has been submitted as part of confidential Governing Body papers.

• Assurance Framework

• COVID-19 Finance Update

Key Information: • Committee Chair: Graham Nuttall (Lay Member) • CCG Lead: Chris Lonsdale (Acting Chief Finance Officer) • Date of Next Meeting: 4th June 2020 Enc K

Blank Page NHS Coventry & Rugby Clinical Commissioning Group Enc L

Report To: Governing Body – Meetings in Common

Report Title: Finance Report – Month 12

Report From: Chris Lonsdale, Acting Chief Finance Officer

Date: 20th May 2020

Previously Considered by: Finance & Performance Committee 7th May 2020

Action Required(delete as appropriate)

Decision: Assurance: Information:  Confidential

Purpose of the Report:

To advise Members of the financial position of the CCG up to 31st March (Month 12 – 2019/20).

Key Points:

• The CCG has ended the financial year on a £0.1m in-year surplus. This misses the control total but achieves the CCG’s statutory duty to break-even.

• As agreed at Governing Body a variation note has been concluded with University Hospitals Coventry and Warwickshire (UHCW) which has led to an additional £6m of support for in-year pressures. There were originally a number of conditions to this agreement that were made by the Governing Body, however as highlighted to the Governing Body these could no longer all be met and discussions have had to continue to support the Trust given the response to COVID-19.

• The CCG did not receive £0.9m of ICES Cap to Rev. The CCG has been able to mitigate the impact of this and maintain break-even. However, if the CCG had received this it would have been able to record an improved position.

Recommendation:

Members are asked to: • NOTE the overall position for month 12 subject to audit.

Implications

Objective(s) / Plans Financial Plan Delivery, achievement of statutory financial duties, QIPP Programme supported by this Delivery report: Conflicts of Interest: Not applicable Financial: Non-Recurrent Expenditure: Variances to agreed Plan are as reported.

Page 1 of 2 NHS Coventry & Rugby Clinical Commissioning Group Enc L

Recurrent Expenditure:

Is this expenditure included within the CCG’s Financial Yes  No N/A Plan? (Delete as appropriate) Performance: Failure to deliver agreed Plan will impact negatively upon the CCG’s assurance rating Quality and Safety: Not directly applicable General Statement: The CCG is committed to fulfil its obligations under the Equality Act 2010, and to ensure services commissioned by the CCG are non-discriminatory on the grounds of any protected characteristics. Policies/decisions may need to be adjusted in line with any equality analysis or due regard. Any decision that is finalised Equality and Diversity: without being influenced by appropriate due regard could be deemed unlawful. Has an equality impact Yes assessment been undertaken? No N/A  (attached) (Delete as appropriate) Patient and Public Not applicable Engagement: Clinical engagement imperative to the efficient deployment of NHS resources and Clinical Engagement: successful delivery of service redesign. Associated risks on the Assurance Framework – AF4 Risk and Assurance: HIGH – a number of risks will need pro-active management throughout the year if the CCG is to deliver its agreed control total.

Page 2 of 2 Finance and QIPP Month 12

1.3 Financial Duties

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

Ensure revenue expenditure does not exceed the Statutory duty to breakeven Green Green The CCG has delivered against the revenue resource limit. agreed Revenue Resource Limit

Maintain expenditure and deliver against NHS Position greater than or equal The CCG has a surplus control total of £2.1m. The CCG has failed to achieve this control total. £0.1m Red Red England agreed control total to Plan surplus has been achieved.

Cash Drawdown less than or Maintain expenditure within the allocated cash limit Green Green The CCG is within the monthly cash target, and had a remaining cash balance of £56k. equal to Plan

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

Ensure running costs are within the agreed Expenditure less than or equal Green Green Running costs are within the agreed allocation. allocation to Plan

Ensure a minimum of 0.5% contingency is held Greater than or equal to 0.5% Green Green The CCG has utilised its contingency in month 12

The CCG continues to comply with the Better Payment Practice Code (BPPC) for Non-NHS validated Ensure compliance with the better payment Greater than or equal to 95% Ambe r Ambe r invoices in month and on a cummlative basis, but NHS is below the 95% target for NHS validated practice code (BPPC) by Number/Value invoices on a cummlative basis.

Increase of 7.1% against Achivement of Mental Health Investment Standard Green Green The CCG has achieved the MHIS standard previous year outturn

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

Notes: Description of Financial Duties updated for point 1 & 2 Mental Health Investment Standard included

2 1.4 Trends

Year to date (YTD) Forecast Outturn (FOT) Monthly Cash Drawdown Plan CCG Gross Net Gross Net Income Income Opening Ca sh CCG Cash Total Cash Ca sh expenditure expenditure expenditure expenditure Service Area Period Balance Drawdown Drawdown Available Net Spend Balance £000s £000s £000s £000s £000s £000s £000s £000s £000s £000s £000s £000s In Year Allocation 746,681 746,681 April 155 89,600 89,600 89,755 89,735 20 May 20 43,300 43,300 43,320 43,315 5 Programme Costs 740,384 (2,586) 737,798 740,384 (2,586) 737,798 June 5 60,978 34,900 34,905 34,887 18 Running Costs 8,890 (109) 8,781 8,890 (109) 8,781 July 18 60,191 93,000 93,018 93,011 7 Reserves 0 0 0 0 0 0 August 7 60,416 47,000 47,007 47,000 7 Grand Total 749,274 (2,695) 746,579 749,274 (2,695) 746,579 September 7 60,079 39,500 39,507 39,483 24 October 24 61,779 85,800 85,824 85,719 105 Surplus / (deficit) 102 102 November 105 59,738 46,800 46,905 46,886 19 December 19 60,762 35,200 35,219 35,213 6 Movement on underspend/(deficit) 2018/19 2019/20 January 6 60,152 87,300 87,306 87,283 23 Brought forward underspend/(deficit) 6,000 6,000 February 23 57,447 51,000 51,023 51,006 17 In-year change from plan/In-year deficit 0 102 March 17 74,048 27,800 27,817 27,761 56 Balance carried forward 6,000 6,102 Total CCG Cash Drawdown 681,200 Underspend/(Deficit) % 1.0% 1.6% NHSBA Cash Drawdown 63,214 Total Drawdown 744,414

Monthly Expenditure Run Rate Maximum Cash Drawdown (MCD) 748,490 697,040.48 20,240 20,240 80,000 % of MCD utilised 99.5% 70,000 % of months completed 100.0%

60,000

50,000 19/20 plan 40,000 19/20 actual 30,000 18/19 actual

20,000

10,000

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

3 1.1 Headlines

The purpose of this report is to advise members of the draft (i.e. unaudited) financial position of the CCG up to 31st March 2020 (Month 12 2019/20) and to advise of any other financial issues likely to impact in the current financial year. The key points to note are: • The CCG has ended the financial year on a £0.1m in-year surplus. This misses the control total but achieves the CCG’s statutory duty to break-even. • As agreed at Governing Body a variation note has been concluded with UHCW which has led to an additional £6m of support for in-year pressures. There were originally a number of conditions to this agreement that were made by the Governing Body, however as highlighted to the Governing Body these could no longer all be met and discussions have had to continue to support the Trust given the response to COVID-19. • The CCG did not receive £0.9m of ICES Cap to Rev. The CCG has been able to mitigate the impact of this and maintain break-even. However, if the CCG had received this it would have been able to record an improved position.

The main points areas of expenditure variance are: • As at month 12 the CCG is reporting in line with the CCG Revenue Resource Limit. This maintains the cumulative surplus position of £6m to be carried forward into 2020/21, plus an in-year position of £0.1m surplus. • The CCG has an agreed annual financial plan with NHSE/I with a cumulative control of £8.1m surplus and an in year position of £2.1m surplus. The CCG has not achieved the in year surplus of £2.1, resulting in a failure to deliver against the NHSE/I control total. The overall CCG position remains in balance. • The impact of Covid-19 in 2019/20 is limited and expenditure has been offset by funding from NHSE/I. Where funding has not been received evidence of actual payments will be submitted to NHSE in 2020/21. • The MH, LD and Community portfolios have performed under plan. A year end position have been agreed with CWPT – Mental Health and Out of Hospital. This has included in-year adjustments to the Price Activity Matrix and the in-year assessment of KPI performance levels. These are reflected within month 12 position. • The growth in CHC packages has been below the expected levels with non CHC packages above expected levels. This has resulted in an over performance of £1m at year end. • The £5m over spend on prescribing is driven by national NCSO and Category M pressures as well as growth within IPP. • An underspend of £1.5m against running costs is reported.

4 Headlines

• As reported previously, £14.3m of the £21.0m efficiency requirement was secured through budget setting and contract negotiations. Available Prescribing data suggests over achievement against the agreed efficiency plan mainly due to POD and an under achievement against Primary Care. The Running Cost target has been achieved with over performance at £0.5m. CHC / S117 is reported as under achieving based on over performance of the budget at Month 12. Non recurrent elements have been excluded from the calculation in order to ascertain QIPP performance, however recurrent mitigations have been included. • The contingency has been utilised to offset expenditure within Acute and Prescribing. • The recurrent underlying position is reported as £1.66m surplus after taking into consideration all non recurrent elements utilised to report the month 12 position.

1.2 Recommendations

The members of the Governing Body are asked to:

• NOTE the overall position for month 12 subject to audit.

5 2.1 Summary Financial Position

Underlying PRIOR MONTH Revised YEAR T O D AT E Annual Position VARIANCE Annual Budget (Under) / Budget Recurrent M11 Budget Actual Over M11 Diff M12 Exp spend £000s £000s £000s £000s £000s £000s £000s £000s In Year Allocation 729,423

Acute Healthcare 372,990 373,158 373,158 375,806 2,648 370,468 (3,213) 5,860 Mental Health & LD 72,567 73,350 73,350 71,875 (1,475) 62,788 (487) (987) Community Services 63,859 63,859 63,859 62,738 (1,121) 60,877 (2,341) 1,220 Continuing Healthcare 68,097 68,097 68,097 69,059 962 69,686 869 93 Primary Care 71,215 71,506 71,506 76,450 4,944 73,952 4,639 305 Delegated Co-Commissioning 71,164 71,164 71,164 71,164 (0) 71,164 (0) (0) Other Programme 10,739 11,251 11,251 11,884 633 11,475 734 (101)

Total Commissioning Budgets 730,630 732,384 732,384 738,975 6,591 720,409 201 6,389

General Reserves (1,296) (1,737) (1,737) (1,177) 560 (1,177) (1,740) 2,300 0.5% Contingency 3,659 3,659 3,659 0 (3,659) 0 0 (3,659)

Total Programme Budgets 732,993 734,306 734,306 737,798 3,492 (1,177) (1,539) 5,030

Running Cost Allowance (RCA) 10,273 10,273 10,273 8,781 (1,492) 8,532 (1,359) (133)

Total Expenditure 743,266 744,579 744,579 746,579 2,000 727,764 (2,898) 4,897

Planned 19/20 Surplus 2,102 2,102 2,102 102 (2,000) 2,898 (4,898) B/f Surplus 6,000 6,000 6,000 6,000 0 0 0

Cumulative RRL 751,368 752,681 752,681 752,681 (0) 1,659 0 (1) Summary – Financial Position (Movements)

• At month 6 the forecast position included a budget shortfall and enough non recurrent items and contingency to enable CRCCG to maintain a forecast on plan. • At month 12 the CCG reported an in year deficit position to NHSE/I of £2m against the CCGs control total. Although this is £0.1m in year surplus. • Performance issues and risks over the intervening period have reduced overall when excluding the additional support for UHCW. • Prescribing pressures have risen and then been mitigated to within £0.4m of the original forecast. • CHC & S117 forecast has increased, although there is recognition that this includes an assumed error rate for prudence. • Recovery actions have been developed totaling £14m (up from £7.4m) excluding contingency which has been utilised for this position and still leaves a level of prudence within the position.

7 2.12 Efficiency The table below details the planned efficiencies and forecast for 2019/20.

Forecast Year Forecast Finance Programme Annual plan Plan YTD Actual YTD Variance YTD YTD % End Forecast % Year End RAG Variance

18/19 Full Year Effect £1,900,000 £1,900,000 £1,900,000 £0 100% £1,900,000 £0 100% Delivered

Provider Facing £5,469,000 £5,469,000 £5,594,000 £125,000 102% £5,594,000 £125,000 102% Delivered

CHC/S117 £1,278,018 £1,278,018 £838,138 (£439,880) 66% £838,138 (£439,880) 66%

Prescribing/Primary Care £2,503,000 £2,503,000 £2,859,971 £356,971 114% £2,859,971 £356,971 114%

Running Costs £1,000,000 £1,000,000 £1,492,432 £492,432 149% £1,492,432 £492,432 149%

Other Cost Avoidance £8,900,000 £8,900,000 £8,900,000 £0 100% £8,900,000 £0 100% Delivered

Total - Current - Month 12 £21,050,018 £21,050,018 £21,584,541 £534,523 102.5% £21,584,541 £534,523 102.5%

Total - Current - Month 11 £21,050,018 £19,354,433 £20,014,582 £660,149 103.4% £21,479,989 £429,971 102.0%

• The Month 12 forecasted achievement is 102.5%. • Provider Facing marginal over achievement is uncommitted planned investment. • CHC / S117 under achievement is a result of over performance of the budget at Month 12. • Prescribing / Primary Care – Medicine Optimisation is achieving against the QIPP target. Low value medicines and Over the Counter Medicines are under performing, with POD over performing. Primary Care investments have achieved £300k against the £640k target. Care Homes and Formulary Optimisation will yield a FYE in 20/21 currently at £678k. • Running Cost Allowance - shows a £492k over performance at 149% achievement due to slippage on vacant posts and non-pay budgets. • Other Cost Avoidance - The CCG started 2019/20 with an opening budget shortfall of £4.8m. Within QIPP planning for 2019/20, £8.9m QIPP was included relating to cost avoidance. The cost avoidance schemes included reserves which had been put aside for agreement of contracts, counting and charging plus a general reserve. A review of the plan and agreement of contracts resulted in the reserves not being required. The assumption made was QIPP had been achieved through cost avoidance. The budget shortfall deteriorated due to a change in the control total; however significant mitigations have been identified to offset the risk.

8 NHS Warwickshire North Clinical Commissioning Group Enc M

Report To: Governing Body - Meetings in Common

Report Title: Finance Report – Month 12

Report From: Chris Lonsdale, Acting Chief Finance Officer

Date: 20th May 2020

Previously Considered by: Finance & Performance Committee 7th May 2020

Action Required(delete as appropriate)

Decision: Assurance: Information:  Confidential

Purpose of the Report:

To advise Members of the financial position of the CCG up to 30th March (Month 12 – 2019/20).

Key Points: The purpose of this report is to advise members of the draft (i.e. unaudited) financial position of the CCG up to 31st March 2020 (Month 12 2019/20) and to advise of any other financial issues likely to impact in the current financial year. They key points to note are:

• The CCG has ended the financial year on a £17.9m deficit.

• As agreed at Governing Body a variation note has been concluded with George Eliot Hospital (GEH) which has led to an additional £4m of support for in-year pressures. There were originally a number of conditions to this agreement that were made by the Governing Body, however as highlighted to the Governing Body these could no longer all be met and discussions have had to continue to support the Trust given the response to COVID-19.

• The CCG did not receive £1.1m of ICES Cap to Rev. If this had been received the CCG would have be able to record an improvement on its position.

• As outlined to the Governing Body the CCG has moved the financial position to reflect a number of challenges within year; namely opening budget shortfall, budget reviews and in-year performance.

• In-year mitigations are identified at £3.3m. The actions for these mitigations are complete and the improvement to the financial position for the actions are secure.

Recommendation:

Members are asked to: • NOTE the overall position for month 12 subject to audit.

Implications

Objective(s) / Plans Financial Plan Delivery, achievement of statutory financial duties, QIPP Programme supported by this Delivery report: Conflicts of Interest: Not applicable

Page 1 of 2 NHS Warwickshire North Clinical Commissioning Group Enc M

Non-Recurrent Expenditure: Expenditure higher than planned for Acute Care. Recurrent Expenditure: Financial: Is this expenditure included within the CCG’s Financial Yes  No N/A Plan? (Delete as appropriate) Performance: Failure to deliver agreed Plan will impact negatively upon the CCG’s assurance rating Quality and Safety: Not directly applicable General Statement: The CCG is committed to fulfil its obligations under the Equality Act 2010, and to ensure services commissioned by the CCG are non-discriminatory on the grounds of any protected characteristics. Policies/decisions may need to be adjusted in line with any equality analysis or due regard. Any decision that is finalised Equality and Diversity: without being influenced by appropriate due regard could be deemed unlawful. Has an equality impact Yes assessment been undertaken? No N/A  (attached) (Delete as appropriate) Patient and Public Not applicable Engagement: Clinical engagement imperative to the efficient deployment of NHS resources and Clinical Engagement: successful delivery of service redesign. Associated risks on the Assurance Framework – AF4 Risk and Assurance: HIGH – unless all known and emerging financial can be mitigated, there is a real risk that the CCG will not be able to deliver the statutory breakeven duty.

Page 2 of 2 Finance and QIPP Report Month 12

1.3 Financial Duties

In Month FOT Description of Financial Duties Target Variance Variance RAG Explanation R AG R AG

Ensure revenue expenditure does not exceed the The CCG has failed to deliver against the revenue resource limit of £284.72m with a 6% over Statutory duty to breakeven Red Red agreed Revenue Resource Limit performance.

The CCG has a surplus control total of £0.136m. The CCG have failed to achieve this control total. The Maintain expenditure and deliver against NHS Position greater than or equal budget shortfall (as reflected in the negative General Reserve) has increased since the start of the year Red Red England agreed control total to Plan and the CCG was unable to mitigate. This has contributed to the deficit in year position movement of £17.8m.

Cash Drawdown less than or Maintain expenditure within the allocated cash limit Green Green The CCG did achieve its monthly cash target, and had a remaining cash balance of £23k. equal to Plan

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

Ensure running costs are within the agreed Expenditure less than or equal Green Green Running costs are within the agreed allocation. allocation to Plan

Ensure a minimum of 0.5% contingency is held Greater than or equal to 0.5% Ambe r Ambe r The CCG has utilised its contingency in month 12

Ensure compliance with the better payment Greater than or equal to 95% The CCG continues to comply with the Better Payment Practice Code (BPPC) for Non-NHS validated Green Green practice code (BPPC) by Number/Value invoices. NHS validated invoices are below the target of 95%

Increase of 6% against Achievement of Mental Health Investment Standard Green Green The CCG has achieved the MHIS standard previous year outturn

Notes: Description of Financial Duties updated for point 1 & 2 Mental Health Investment Standard included

2 1.4 Trends

Year to date (YTD) Forecast Outturn (FOT) Monthly Cash Drawdown Plan CCG Gross Net Gross Net Income Income Opening Ca sh CCG Cash Total Cash Ca sh expenditure expenditure expenditure expenditure Service Area Period Balance Drawdown Drawdown Available Net Spend Balance £000s £000s £000s £000s £000s £000s £000s £000s £000s £000s £000s £000s In Year Allocation 284,687 284,687 April 23 20,300 20,300 20,323 20,319 4 May 4 21,800 21,800 21,804 21,793 11 Programme Costs 298,799 (219) 298,580 298,799 (219) 298,580 June 11 21,000 22,000 22,011 22,005 6 Running Costs 3,918 (16) 3,902 3,918 (16) 3,902 July 6 23,406 21,000 21,006 20,977 29 Reserves 0 0 0 0 0 0 August 29 23,323 21,200 21,229 21,228 1 Grand Total 302,717 (235) 302,482 302,717 (235) 302,482 September 1 22,916 24,800 24,801 24,765 36 October 36 24,479 20,500 20,536 20,498 38 Surplus / (deficit) (17,795) (17,795) November 38 24,026 19,400 19,438 19,437 1 December 1 22,965 27,200 27,201 26,802 399 Movement on underspend/(deficit) 2018/19 2019/20 January 399 22,573 21,700 22,099 22,096 3 Brought forward underspend/(deficit) (17,979) (17,979) February 3 23,483 20,900 20,903 20,829 74 In-year change from plan/In-year deficit 0 (17,795) March 74 43,261 23,400 23,474 23,451 23 Balance carried forward (17,979) (35,774) Total CCG Cash Drawdown 264,200 NHSBA Cash Drawdown 29,332 Total Drawdown 293,532

Monthly Expenditure Run Rate Maximum Cash Drawdown (MCD) 293,532 697,040.48 20,240 35,000 20,240 % of MCD utilised 100.0% 30,000 % of months completed 100.0%

25,000

20,000 19/20 plan 19/20 actual 15,000 18/19 actual

10,000

5,000

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

3 1.1 Headlines

• The CCG has ended the financial year on a £17.9m deficit. • As agreed at Governing Body a variation note has been concluded with GEH which has led to an additional £4m of support for in-year pressures. There were originally a number of conditions to this agreement that were made by the Governing Body, however as highlighted to the Governing Body these could no longer all be met and discussions have had to continue to support the Trust given the response to COVID-19. • The CCG did not receive £1.1m of ICES Cap to Rev. If this had been received the CCG would have be able to record an improvement on its position. • As outlined to the Governing Body the CCG has moved the financial position to reflect a number of challenges within year; namely opening budget shortfall, budget reviews and in-year performance. • In-year mitigations are identified at £3.3m. The actions for these mitigations are complete and the improvement to the financial position for the actions are secure.

The main points areas of expenditure variance are:

• At month 12 the CCG reported an in year deficit position to NHSE/I a position of £17.9m. The cumulative deficit position to be carried forward in to 2020/21 is £36m. • The impact of Covid-19 in 2019/20 is limited and expenditure has been offset by funding from NHSE/I. Where funding has not been received evidence of actual payments will be submitted to NHSE in 2020/21. A separate paper is provided on the Covid-19 impact that gives a current assessment related to 20/21 predominantly. • The MH, LD and Community portfolios have performed under plan. A year end position have been agreed with CWPT – Mental Health and Out of Hospital. This has included in-year adjustments to the Price Activity Matrix and the in-year assessment of KPI performance levels. These are reflected within month 12 position. • The growth in CHC packages and non CHC packages has been below the expected levels. This has resulted in an under performance of £0.6m. • The £3m over spend on prescribing is driven by national NCSO and Category M pressures as well as growth within IPP. • Running Costs budgets are reported on plan.

Headlines

• As reported previously, the Provider Facing efficiencies are shown as undelivered due to the level of Acute over performance. Other cost avoidance schemes are also showing under delivery due to insufficient mitigations identified to cover the budget shortfall. CHC/S117 expenditure currently below plan, therefore it is assumed that the embedded efficiencies are achieving. Available Prescribing data suggests an under achievement of £0.26m against the agreed efficiency plan and a slight under achievement against Primary Care. • The contingency has been utilised to offset expenditure within Acute and Prescribing. • The recurrent underlying deficit is now reported at £12m deficit after taking into consideration all non recurrent elements utilised to report the month 12 position.

1.2 Recommendations

The Committee are asked to:

• Note the overall position for month 12 subject to audit

5 2.1 Summary Financial Position

In Month Allocation and Underlying PRIOR MONTH YEAR T O D AT E Revised Budget Adjustments Revised Position VARIANCE Annual Annual Allocation Budget (Under) / Budget Budget Recurrent Adjustments Adjustments Budget Actual Over M11 Diff M11 M12 Exp spend £000s £000s £000s £000s £000s £000s £000s £000s £000s £000s In Year Allocation 282,740 282,742

Acute Healthcare 156,381 70 0 156,451 156,451 164,918 8,467 158,986 4,673 3,795 Mental Health & LD 21,801 0 21,801 21,800 21,444 (356) 21,204 (507) 151 Community Services 22,676 0 22,676 22,676 22,591 (85) 21,909 32 (117) Continuing Healthcare 24,387 0 24,387 24,387 23,833 (554) 23,787 (568) 14 Primary Care 31,652 0 31,653 31,653 34,851 3,198 34,381 3,430 (232) Delegated Co-Commissioning 26,351 0 26,351 26,351 26,351 0 26,351 0 0 Other Programme 4,389 6 196 4,591 4,591 4,591 0 4,347 (223) 223

Total Commissioning Budgets 287,637 76 196 287,910 287,909 298,579 10,671 290,965 6,837 3,834

General Reserves (8,450) (225) (8,675) (8,675) 0 8,675 0 8,685 (10) 0.5% Contingency 1,414 0 1,414 1,414 0 (1,414) 0 (1,386) (28)

Total Programme Budgets 280,601 76 (29) 280,649 280,648 298,579 17,932 0 14,136 3,796

Running Cost Allowance (RCA) 3,903 0 3,903 3,903 3,903 0 3,759 1 (1)

Total Expenditure 284,504 76 (29) 284,552 284,551 302,482 17,932 294,724 14,137 3,795

Planned 19/20 Surplus 136 0 136 136 (17,796) (17,932) (14,136) (3,796) B/f Deficit (17,979) 0 (17,979) (17,979) (17,979) 0 0 0

Cumulative RRL 266,661 76 (29) 266,709 266,708 266,707 (0) (11,984) 1 (1)

At Month 12 the CCG is reporting a cumulative year-end deficit of £35.8m. Brought forward deficit of £18m and £17.8m in year deficit. Summary – Financial Position (Movements)

• At month 6 the forecast position included a budget shortfall and not enough non recurrent items and contingency to enable WNCCG to maintain a forecast on plan. • At month 12 the CCG reported an in year deficit position to NHSE/I of £17.9m against the CCGs control total. • The gross risk position over the intervening period is an average of £18m excluding GEH support. • Additional support to GEH of £4m has led to an increased deficit position to that reported at month 11. • Prescribing pressure have risen over the period. • CHC & S117 has reduced due to packages below expected levels. • Recovery actions have been developed totaling £3.1m (up from £1.3m) excluding contingency which has been utilised for this position.

7 2.13 Efficiency

• The table below details the planned efficiencies and forecast for 2019/20.

Forecast Year Forecast Programme Annual plan Plan YTD Actual YTD Variance YTD YTD % End Forecast % Finance RAG Year End Variance

18/19 Full Year Effect £1,145,708 £1,145,708 £1,145,708 £0 100% £1,145,708 £0 100% DELIVERED Provider Facing £2,104,000 £2,104,000 £0 (£2,104,000) 0% £0 (£2,104,000) 0%

CHC/S117 £456,162 £456,162 £456,162 £0 100% £456,162 £0 100%

Prescribing/Primary Care £1,803,000 £1,803,000 £1,508,762 (£294,238) 84% £1,508,762 (£294,238) 84%

Running Costs £200,000 £200,000 £200,000 £0 100% £200,000 £0 100%

Other Cost Avoidance £3,604,000 £3,604,000 £3,060,629 (£543,371) 85% £3,060,629 (£543,371) 85%

Total - Current - Month 12 £9,312,870 £9,312,870 £6,371,261 (£2,941,609) 68% £6,371,261 (£2,941,609) 68%

Total - Current - Month 11 £9,312,870 £8,462,132 £6,089,415 (£2,372,717) 72% £6,371,261 (£2,941,609) 68%

• The 2018/19 full year effect schemes mainly relate to Medicine Optimisation schemes. The 2019/20 savings trackers provided by the Medicine Optimisation team outline the POD 2018/19 roll over savings in order to determine achievement against the FYE target. The other targets were highlighted within the 2018/19 savings tracker which detailed the PYE achievement expected in 2019/20. • Provider Facing under achievement is due the increase in within Acute. An agreed block contract with GEH but over performance in emergency activity and under performance in Elective activity has resulted in the above activity transfer to providers outside of Arden. A non-recurrent prior year brought forward balance has created a cost pressures. The joint transformation between WNCCG and GEH required £2m to be saved for each organisation as part of the block contract arrangement between parties. The underlying over performance of GEH and the significant slippage on schemes has meant that the Transformation schemes for 19/20 have considerably underperformed with £0 realised in 2019/20. • CHC / S117 QIPP performance is based on under performance of the budget at month 12. • Prescribing / Primary Care - Medicine Optimisation is under delivering against the original QIPP target, with Formulary Optimisation and Over the Counter Medicines accounting for the majority of under delivery. Low Value Medicines are over achieving against plan. It should be noted that despite the overall QIPP programme achieving performance levels have been high and some of this is due to levels of prescribing within the CCG’s control. Further work needs to be undertaken to assure budgets can be achieved in future years on this basis. Primary Care Investment - reported at £35k below plan with the assumption that £365k is achieved through reduction in Extended Access contract. • Running Cost Allowance shows 100% achievement of the £0.2m QIPP target; this has been achieved by slippage on vacant posts and non-pay budgets. • Other - The CCG started 2019/20 with an opening budget shortfall of £3.8m. Within QIPP planning for 2019/20, £3.6m of QIPP was included relating to Cost Avoidance. The cost avoidance schemes included reserves which had been put aside for agreement of contracts, counting and charging plus a general reserve. A review of the plan and agreement of contracts resulted in the reserves not being required. The assumption made was that QIPP had been achieved through cost avoidance. The budget shortfall has since increased due to change in control totals, reduction in PMC cross charges, income for ICES Cap to REV and CHC budget review. Over performance within Acute and Prescribing has added to these pressures and whilst a number of mitigations have been identified there remains insufficient mitigations to offset the risk. 8

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

Report To: Governing Body Meetings in Common

Report Title: Performance Report

Report From: Andrew Harkness, Chief Transformation Officer

Date: 20th May 2020

Previously Considered by: Finance and Performance Committee 7th May 2020

Action Required

Decision: Assurance:  Information: Confidential

Purpose of the Report: To provide assurance to the Governing Body of the performance of services commissioned by Coventry and Rugby and Warwickshire North CCGs for the month of February (unless otherwise specified).

Key Points: Focus is being given to the priorities identified as key performance issues for both CCGs by NHS England / Improvement, as well as the wider performance areas identified locally as issues important to raise with F&P Committee from across the total portfolio of the two CCGs:

This report therefore focuses on the following areas, and gives a summary of the actions being taken to address delivery:

• A&E 4 hours • Cancer 62 day waits • Out of Area Mental Health Placements • Transforming Care

Other areas are covered where there are ongoing issues .These include the following:

• Referral to Treatment (RTT) 18 weeks • Dementia Diagnosis • Improving Access to Psychological Therapies (IAPT) Access

A & E 4 hours A & E 4 hour waits performance deteriorated slightly in March at University Hospitals Coventry and Warwickshire (UHCW) to 81.3% but improved at George Eliot Hospital (GEH) to 76.1%, still significantly below the 95% target. There were no 12 hour trolley breaches in March. However Covid 19 is now impacting across the system (NHS 111, Primary Care, West Midlands Ambulance Service (WMAS) 999, Out of Hospital and Acute providers).

A & E 4 hour waits performance has improved due to lower demand. However, whilst there are many examples of new ‘best practice’ funded with Covid-19 monies, the sustainability of these measures could be an issue. The CCG will assess what has changed and whether this needs to be consolidated into normal practice, and included in the contracts with the trusts.

Page 1 of 4 NHS Coventry and Rugby Clinical Commissioning Group NHS Warwickshire North Clinical Commissioning Group Enc N

Cancer 62 Day Waits • In February CRCCG performance was slightly below the 85% target at 83.1%, but the year to date position remains above target. WNCCG deteriorated significantly falling to 57.9%. There were 20 breaches (Lung: 2, Gynaecology: 2, Urology: 12, Lower GI: 2, Upper GI:1, Haematology:1). • Since the onset of Covid-19 there has been a reduction in two week wait referrals. Messages are being relayed to the public to encourage patients to continue to see their GP for an initial presentation and Q&A advice and support is hosted on the HC partnership website. • All trusts have implemented triage, a follow-up with patients and communications with primary care, together with an assessment following triage. • Cervical Screening daily collections have been suspended, and further advice is expected soon. Bowel and breast screening has also been suspended. Trusts are prioritising the use of private sector facilities (eg BMI) to treat cancer patients currently. This is being managed through SCG and is nationally funded.

Out of Area Mental Health Placements In January the rolling quarter figure for the number of new inappropriate Mental Health Out of Area Placements starting in the month increased to 55 patients who had started in the month and 1700 bed days. A comprehensive list of recovery actions is included in the report.

IAPT Access Performance improved in January to 21.1% for CRCCG and 20.8% for WNCCG. The impact of Covid-19 with social distancing and staff/ patient sickness, initial demand for IAPT is expected to fall. However post the pandemic there is a strong expectation for an increase in therapies for general and health anxiety, depression, Post-traumatic stress disorder (PTSD) from experiences of the Intensive Care Units and Obsessive compulsive disorder (OCD). The impact of Covid-19 is unknown at this time on future needs for patients and the population. The CCG is working with Coventry and Warwickshire Partnership Trust (CWPT) who are pulling together their assessment for the needs going forward and supporting data quality improvement requirements.

Transforming Care The cohort of people who have been admitted to CCG funded adult beds remained at above trajectory levels in March at 27 compared with a target of 13. The figure for NHS England (NHSE) funded adults was 17 (target 13) and the figure for children was 10 (target 7).

CCG Adults: CCG adult numbers remain over trajectory. Covid-19 has played a factor in this in the last 5 weeks, with some planned discharges from March 2020 have been pushed back to April and May 2020 due to impact of Covid-19 on staffing within the provider market. However, this has increased planned discharges for April and May, which have been planned with a high level of scrutiny to ensure that there are no avoidable delays to discharging these patients..

NHSE Children: 2019/20 Q4 saw unusually high number of children diagnosed with Autism following admission to hospital for their mental health presentation. The review of these diagnoses in hospital indicated no themes or trends appear to have contributed to this across Coventry and Warwickshire, but did highlight a process issue where children were added to Arden Transforming Care Partnership (TCP) numbers by NHSE/I before sufficient assurance had been received by Arden TCP to add them on to our risk registers and inpatient numbers. This is being addressed directly with NHSE/I as a process issue by the TCP programme manager, but does apply to at least 2 current NHSE Child and Adolescent Mental Health Services (CAMHS) inpatients, and inflates the performance figures. Despite this, we are currently meeting our trajectory for NHSE Children.

NHS England Adults: There is an identified area for improvement in the communication, as well as clarity around roles and responsibilities between NHSE Case Managers for these patients and CCG Clinical Commissioners. This has been raised by the new Programme Manager with Regional NHSE/I colleagues to address jointly and solve. This should improve the quality and clarity of data and information for these patients, allowing us to more effectively plan for their discharge in collaboration with

Page 2 of 4 NHS Coventry and Rugby Clinical Commissioning Group NHS Warwickshire North Clinical Commissioning Group Enc N

NHSE Case Managers.

RTT 18 weeks In February 80.6% of CRCCG patients and 77.2% of WNCCG patients had been waiting less than 18 weeks from their GP referral against a target of 92%. One CRCCG patient breached 52 weeks at Guys and St Thomas' NHS Foundation Trust. Further information has been requested from the Trust as to the reasons for the breach.

Covid-19 essentially over-rides all activity to improve RTT performance and the restriction of all non- urgent elective work will impact dramatically on delivery of RTT up to the end of July 2020 as a minimum. There has been a reduction in both referrals and activity and there will be a significant backlog to recover once restrictions are lifted on elective activity. Recovery options depend on decisions being taken on priority for restoration work, and separation of Covid-19 capacity from non-Covid capacity.

The impact of outpatients is complicated, as activity overall has reduced. There could therefore be backlog issues, but several new clinics are being run as virtual clinics, which could help going forward. However these were introduced in the last week of March so assessing the impact is difficult, until April data is available.at the end of May

Chronic Conditions Management There is a risk of increased morbidity for patients living with long term conditions as a result of Covid-19. The impact is currently difficult to assess, however there is a risk of increased utilisation of healthcare services (and costs) in the future and an increase in mortality.

Restoration of performance The CCG restoration plan for 2020/21 will set out how as a CCG we will restart, recover and reset performance across all the Key Performance Indicators (KPIs). Access to timely data / information is vital in supporting this restoration process and we are working with partners to get access to unvalidated data to support planning and understand. Additionally, we are utilising place to create joint plans and actions to drive through change, maintain opportunities, minimise risks and improve performance and value.

Dementia Diagnosis At 60.6% for CRCCG and 57.8% for WNCCG, performance in March continued at below the 66.7% target. A comprehensive list of recovery actions is included in the report.

Recommendation: The Governing Body is asked to: • SCRUTINISE and; • BE ASSURED of the contents of the report.

Implications

Objective(s) / Plans supported by this 1,2,3 & 4 report: Conflicts of Interest: None identified Non-Recurrent Expenditure: Not applicable Recurrent Expenditure: Not applicable Financial: Is this expenditure included within the CCG’s Financial Yes  No N/A Plan? (Delete as appropriate) Performance: The CCG is required to meet the national NHS Constitution targets

Page 3 of 4 NHS Coventry and Rugby Clinical Commissioning Group NHS Warwickshire North Clinical Commissioning Group Enc N

The report outlines quality and safety issues in relation to commissioned services Quality and Safety: against the Clinical Governance Framework The report provides information relating to patients with protected characteristics where care is provided by commissioned services Equality and Diversity: Has an equality impact Yes assessment been undertaken? No N/A  (attached) (Delete as appropriate) Patient and Public Not applicable Engagement: Clinical Engagement: Not applicable Risks on Assurance Framework - AF1 and AF2

The following areas are identified on the CCG risk register: • A&E performance UHCW • RTT Performance Risk and Assurance: • CHC Complaints • Lack of Assurance regarding CHC Service Performance • Timely CHC assessments • CHC Transition

Page 4 of 4 Month 11 19/20 Performance Report May 2020 Contents

Section Page Summary of Under-Performing Areas 1 Exception Report summary 2 Exception Reports 4

Summary of key under-performing areas

Target/ Performance Improvement required to hit target Change since previous month Indicator Period Trajectory CRCCG WNCCG CRCCG WNCCG CRCCG WNCCG

A & E : Percentage seen within 4 hours * 95% Mar-20 81.3% 76..1% 2,869 1,359  

Cancer: Percentage commencing treatment within 85% Feb-20 83.1% 57.9% 2 13   62 days of referral from GP

Jan 2020 0 at year Out of Area Placements - beddays** (Rolling 1700 -1700  end Quarter) TCP - Inpatient admissions for those with a Learning Disability and/or Autism/Learning 7 10 -3  Disabilities - Children*** TCP - Inpatient admissions for those with a Learning Disability and/or Autism/Learning 13 Mar-20 17 -4  Disabilities - NHS Adults*** TCP - Inpatient admissions for those with a Learning Disability and/or Autism/Learning 12 27 -15  Disabilities -CCG Adults***

Patients On Incomplete Non-Emergency Pathways 92% Feb-20 80.6% 77.2% 2,482 2,070   Waiting No More Than 18 Weeks From Referral

Dementia Diagnosis Rates 66.7% Mar-20 60.3% 57.8% 332 191  

IAPT access - Finished Courses of Treatment 22% Jan-20 21.1% 19.7% 35 16  

Delayed Transfers of Care (average weekly per 3.5% Jan-20 5.2% 3.4% -17   occupied bedday)

KEY Deteriorated  Improved  No Change  * Data is based on main provider (GEH for WNCCG & UHCW for CRCCG) ** Data is for Cov & Warks STP 1 *** Data is for WNCCG & CRCCG Coventry and Rugby CCG/ Warwickshire North CCG Exception Report Summary - May 2020

Priority KPIs

Expected Indicator Trend Comments Recovery A & E 4 hour waits performance deteriorated slightly in March at UHCW to 81.3% but improved at GEH to 76.1%, still significantly below the 95% target. There were no 12 hour trolley Consitutional Target UHCW Actual GEH Actual breaches in March. However COVID19 is now impacting across the system (NHS 111, Primary Care, WMAS 999, Out of Hospital and Acute providers). 100% Key actions: A & E 4 hour BCP/ EPPR implemented: Incident Management Teams established. 80% Sep-20 waits PCN, Out of Hospital and Acute Trusts implementing CV19 clinical guidance e.g. Primary Care, Discharge, Critical care Commissioning CV 19 Hubs (Primary Care) and additional PTS to meet the 2 hour discharge requirement across C&W. 60%

Consitutional Target CRCCG WNCCG . In February CRCCG performance was slightly below the 85% target at 83.1%, but the year to date position remains above target. WNCCG deteriorated significantly falling to 57.9%. There 90% were 20 breaches (Lung: 2, Gynaecology: 2, Urology: 12, Lower GI: 2, Upper GI:1, Haematology: 1 ). . Remedial actions include: 80% Cancer 62 Days Additional tracker post and 2 cancer posts funding agreed and recruitment in place;Implement process for straight tests for Urology & Colorectal; Review of Gynaecology capacity, additional 70% outsourcing capacity commissioned;Pathway co-ordinator across the HCP has commenced;Pathology - Working with CWPS to agree actions to improve service and have separate KPIs for Jul-20 Waits 60% patients on a cancer pathway; Additional urology capacity being sources. Locum has been recruited to increase activity and support cystoscopy capacity and fourth consultant post has been 50% approved

Inappropriate Out of Area Placements In January the rolling quarter figure for the number of new inappropriate Mental Health Out of Area Placements starting in the month increased to 55 patients who had started in the month and (Rolling Quarter) 1700 bed days.

4000 60 Actions include: 3500 50 3000 40 Out of Area 2500 •Introduction of new, strengthened admission gatekeeping arrangements led by CWPT’s Crisis Team and maximise use of alternatives to admission 2000 30 Improving inpatient patient flow . Mar-20 Placements Beddays 1500 20 1000 10 • Introduction of discharge planning for all admitted patients from the first day of admission.; Implement a daily “Red to Green” regime across all CWPT inpatient wards and equivalent in 500 OoAPs ;Develop and implement a refreshed multi-agency pathway to deliver improved support to “high intensity” service users, including those with Emotionally Unstable Personality Disorder; 0 0 Implement a refreshed CWPT inpatient bed configuration arrangements and refreshed bed capacity, reflecting an updated clinical model ; Implement strengthened daily / weekly multi-agency Placements started in periodin started Placements operational arrangements to avoid delays to discharges Jan-20 Oct-19 Sep-19 Dec-19 Aug-19 Nov-19

CCG Adults

40 30 20 10 The cohort of people who have been admitted to CCG funded adult beds remained at above trajectory levels in March at 27 compared with a target of 13. The figure for NHSE funded adults 0 was 17 (target 13) and the figure for children was 10 (target 7). Inpatient numbers Inpatient Jul-19 Jan-20 Jun-19 Oct-19 Apr-19 Sep-19 Feb-20 Dec-19 Aug-19 Nov-19 Mar-20 May-19 CCG Adults: CCG adult numbers remain over trajectory. COVID-19 has played a factor in this in the last 5 weeks, with some planned discharges from March 2020 have been pushed back to April and May 2020 due to impact of COVID-19 on staffing within the provider market. However, this has increased planned discharges for April and May, which have been planned with a high level of scrutiny to ensure that there are no avoidable delays to discharging these patients.. NHSE Adults 30 Transforming NHSE Children: 2019/20 Q4 saw unusually high number of children diagnosed with Autism following admission to hospital for their mental health presentation. The review of these diagnoses 20 Care for people in hospital indicated no themes or trends appear to have contributed to this across Coventry and Warwickshire, but did highlight a process issue where children were added to Arden TCP Detailed in with Learning 10 numbers by NHSE/I before sufficient assurance had been received by Arden TCP to add them on to our risk registers and inpatient numbers. This is being addressed directly with NHSE/I as a Recovery Plan Disabilities 0 process issue by the TCP programme manager, but does apply to at least 2 current NHSE CAMHS inpatients, and inflates the performance figures. Despite this, we are currently meeting our Inpatient numbers

Dec-… trajectory for NHSE Children. Aug-… Nov-… Mar-… May-… Jul-19 Jan-20 Jun-19 Oct-19 Apr-19 Sep-19 Feb-20 NHS England Adults: There is an identified area for improvement in the communication, as well as clarity around roles and responsibilities between NHSE Case Managers for these patients NHSE Children and CCG Clinical Commissioners. This has been raised by the new Programme Manager with Regional NHSE/I colleagues to address jointly and solve. This should improve the quality and

15 clarity of data and information for these patients, allowing us to more effectively plan for their discharge in collaboration with NHSE Case Managers. 10

0 Inpatient numbers Inpatient Sep-… Feb-… Dec-… Aug-… Nov-… Mar-… May-… Jul-19 Jan-20 Jun-19 Oct-19 Apr-19 2 Coventry and Rugby CCG/ Warwickshire North CCG Exception Report Summary - May 2020 Ongoing Issues

Expected Indicator Trend Comments Recovery

In February 80.6% of CRCCG patients and 77.2% of WNCCG patients had been waiting less than 18 weeks from their GP referral against a target of 92%. Covid-19 essentially over-rides all Consitutional Target CRCCG WNCCG activity to improve RTT performance and the restriction of all non-urgent elective work will impact dramatically on delivery of RTT up to the end of July 2020 as a minimum. One CRCCG patient breached 52 weeks at Guys and St Thomas' NHS Foundation Trust. Further information has been requested from the trust as to the reasons for the breach. 90%

85% As a Coventry and Warwickshire system there is a 26 week choice pilot in place across the STP moving patients between providers, for Ophthalmology. In light of Covid-19 roll out of the pilot Referral To has been stopped until urgent care pressures reduce significantly. Treatment 18 80% Sep-20 weeks 75%

70%

Target CRCCG 68% 66% At 60.6% for CRCCG and 57.8% for WNCCG, performance in March continued at below the 66.7% target. Proposed actions to improve performance include: 64% Dementia 62% Review capacity issues in MAS and identify how to increase diagnosis rates, such as improving the quality of referrals, increasing the use of shared care and reviewing how follow ups are 60% Sep-20 Diagnosis 58% conducted; Consider employing on a short-term basis a Psychology Assistant to ensure consistent data cleansing and a doctor to support with clearing the backlog of cases from the cognitive 56% assessment scheme. 54% 52%

Trajectory CRCCG WNCCG 26% Performance improved in January to 21.1% for CRCCG and 20.8% for WNCCG. There are a number of interdependent reasons: changes in the calculations for the prevalence levels has had 24% greatest negative impact upon providers in the West Midlands; despite increases in trainees/ staffing levels, the footfall of patients and declining availability of space available within GP 22% practices increases the need to mobilise digital provision of IAPT therapies (anticipated 1st April). Additional pressures have arisen from emerging third-sector services offering provision 20% similar to IAPT and most recently the impact of COVID-19 with social distancing and staff/ patient sickness, initial demand for IAPT is expected to fall. However post the pandemic there is a IAPT access 18% strong expectation for an increase in therapies for general and health anxiety, depression, PTSD from experiences of the Intensive Care Units and OCD. Apr-20 16% 14% The national team have confirmed that they are suspending assurance performance process of IAPT access, recovery waits for a minimum period of the next 3 months of 2020/21, to allow 12% time for services to mobilise digital/ telephone based support and facilitate WFH with outcomes reported through remote delivery. Data submissions will continue. 10%

Target UHCW 6% In January delayed transfers of care (DTOC) at GEH were below the 3.5% target level of occupied beds at 3.4% UHCW continued to breach with DTOC at 5.2%. 5% Delayed 4% There continue to be a number of complex patients requiring specialist high cost placements. The stranded patient and DTOC numbers at UHCW continues to be above target despite a real Transfers of 3% commitment and drive of the hospital teams supported by the Emergency Care Intensive Support Team (ECIST). There has been an increase in Delayed Transfers of Care attributable to the Jul-20 2%beds NHS at UHCW possibly due to a high level of referrals to Pathway 3 beds resulting in capacity issues and delays. Care 1% 0% DTOC as a % of occupied occupied of % a as DTOC

3 Patients Admitted, Transferred Or Discharged Within 4 Hours Of Their Arrival At An A&E Department - March 2020 Operational Lead: Rob Fontaine / Jenni McLaren

Latest Performance Benchmarked Nationally* Trend Performance History Consitutional Target UHCW Actual UHCW STF Trajectory GEH Actual A & E Patients waiting more than 12 hours from decision to Month Prev Month Q 3 19/20 YTD GEH STF Trajectory admit to admission - GEH UHCW  81.3% 81.9% 77.8% 82.5% 100% 35 33 95% 30 90% 25 21 85% 19 20 80% 15 15 75% 10 GEH  76.1% 74.4% 75.6% 78.3% 70% 6 5 65% 0 1 1 0 0 0 0 60% 0 *The red zone represents CCGs in the worst performing quartile Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Reasons for being off track

COVID19 impact across the system (NHS 111, Primary Care, WMAS 999, Out of Hosp and Acute providers). https://www.gov.uk/government/publications/covid-19-track-coronavirus-cases

Recovery Actions

Original Date of Expected Existing Actions Anticipated Impact Date Impact Ongoing monitoring of access rates, incident rate per 1000 population for WMAS ambulance service. This includes both NHS 111, 999 and HCP requests for ambulances. A&E analysis by site, type and age provided to STP/CWAEDB. Ongoing To track impact across the system for resilience Ongoing Regional analysis to develop for CV19 indicators. BCP/EPPR implemented. Incident Management structures and goverannce updated end Mar/early Apr to meet active Feb-20 System resilience Oct-20 covid response needs. Mutual aid ask/offer arrangements implemented

PCN, Out of Hospital and Acute Trusts implementing CV19 clinical guidance e.g. Primary Care, Discharge, Critical care Mar-20 System resilience, quality of care. Oct-20

Covid-19 Primary Care Hot Hubs deployed. NHS 111 Covid CAS service scaling up w/c 13/04 Mar-20 Additional capacity to support NHS 111 and primary care. Better initial triage of ?covid patients Apr-20

PTS: Additional 224 hours per week from 08/04 across all acute hospitals for 6 weeks. Equivalent of 4 extra shifts. Mar-20 Additional capacity to help achieve 2 hour discharge guidance and social distancing requirements Apr-20 WMAS coordinating.

New and Proposed Actions

As above - with daily EPPR structure in place.

CCG Specific Actions

Non-essential work stood down to release provider capacity. BCP underway for CCG resource.

4 62 Days Wait From Urgent GP Referral To First Defined Treatment For Cancer - Feb 2020 Operational Lead: Paul Stevenson

Latest Performance Benchmarked Nationally* Trend Performance History Consitutional Target CRCCG WNCCG GEH Actual/ Plan Month Prev Month Q3 19/20 YTD CRCCG  83.1% 85.6% 85.6% 85.2% 90% 85% 50% 100% 80% 75% 70% 65% WNCCG  57.9% 73.0% 68.2% 72.1% 60% 50% 100% 55% 50% Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 *The red zone represents CCGs in the worst performing quartile

Reasons for being off track

WNCCG

Recovery Actions

Existing Actions Date Anticipated Impact Date of Expected Impact Improvement in delays for radical prostectomy (RARP) at tertiary provider- work has commenced with HCP to review GEH -Additional tracker post and 2 cancer posts funding agreed and recruitment in place Mar-20 Apr-20 pathways across the three trust

GEH - Implement process for straight to test for Urology & Colorectal Feb-20 Improved patient pathway Apr-20

GEH - Review of Gynae capacity, additional outsorcing capacity commissioned and review of insource some daycases Jan-20 Improved patient pathway Apr-20

GEH - Pathway co-ordinator across the HCP has commenced - starting to review, support and establish agreed optimal pathways across Apr-20 Improved patient pathway Apr-20 all trusts

GEH Pathology - Working with CWPS agree actions to improve the service and have separate KPIs for patients on a cancer pathway . Ongoing Improved patient pathway Apr-20 Weekly escalation to Director of Operations on delays

GEH - Additional urology capacity being sources. Locum has been recruited to increase activity and support cystoscopy capacity and Ongoing Improved patient pathway Apr-20 fourth consultant post has been approved

New and Proposed Actions

GEH - Comprehensive list included in Trust Cancer Recovery Plan. Key areas include:

Colorectal -Straight to test for CT Colonoscopy from consultant request to OPS to Radiology (no vetting required). Urology -Review flexi cystoscopy diagnostic capacity to meet the TWW demand. - Scoping the possibility of Direct access for MRI for Prostate. - Direct access to USS for TWW by February 2020. Upper GI: Provide advice to GP’s on referral criteria Gynaecology - Outsource/Insource routine diagnostics and daycases to support delivery of the cancer standard and reduce delays by January 2020. Lung: Additional respiratory consultant to be recruited to by May 2020

CCG Specific Actions

The CCG will continue to liaise closely with GEH and to request regular updates on progress agains the Cancer Recovery Plan. 5 Total number of inappropriate Out of Area placement (OAP) bed days for adults requiring non-specialist acute mental health inpatient care Operational Eleanor Cappell - Jan 2020 Lead:

Benchmarked Nationally (Sept 2019)* Trend Performance History (Rolling quarters) Inappropriate Out of Area Placements (Rolling Quarter)

4000 60 Month Prev Month 3500 50 3000

40 1700 1305 2500  2000 30

Beddays 1500 20 *The red zone represents CCGs in the worst performing quartile 1000 500 10 0 0 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 in Placements startedperiod Reasons for being off track

• Reduced bed capacity due to anti-ligature works on wards. This impacts upon 10 MH beds, which has been a long-standing historic issue. To mitigate the risks, the Trust are actively seeking support from NHSE to resolve the PFI issues associated with estates. • Lack of community based services for people in crisis outside of CRHT provision - leading to increased admissions and readmissions. • There is no dedicated acute service pathway for patients with Personality Disorders resulting in a disproportionate use of inpatient services for patients with PD, characterised by frequent stays, longer admissions and occasional specialised PD placements. It is estimated that behaviours associated with behavioural difficulties account for a significant number of all adult admissions. • In the past, there has been a lack of consistent ownership of the OoA numbers and issues, subsequent actions have been ad hoc and ineffective in the medium/long term. • No centrally owned management system from point of admission and discharge, governance and oversight - people spending too long phoning round to expedite admission and discharge

Recovery Actions

Date of expected Existing Actions Date Anticipated Impact impact Admission avoidance Introduce new, strengthened admission gatekeeping arrangements led by CWPT’s Crisis Team and Maximise use of alternatives to admission through: Procuring beds in close proximity to Coventry / Warwickshire will improve patient flow in acute beds, maintain active patient case management and reduce length a) Compilation of a list of all currently available alternatives to admission; of stay. These steps will help to ensure that acute beds are available for patients who need them. b) Raise awareness in all key staff and stakeholders; c) Scope new alternatives; d) Set up a crisis house

Improving inpatient patient flow • Introduction of discharge planning for all admitted patients from the first day of admission. • Implement a daily “Red to Green” regime across all CWPT inpatient wards and equivalent in OoAPs March OOA • Number of patients avoid admission; • Develop and implement a refreshed multi-agency pathway to deliver improved support to “high intensity” service users, including high impact TBC post review of • Increase in staff awareness of alternatives to admission against baseline levels; those with Emotionally Unstable Personality Disorder. system action COVID-19 impact • Increased use against baseline levels in utilisation of alternatives to admission • Implement a refreshed CWPT inpatient bed configuration arrangements and refreshed bed capacity, reflecting an updated clinical plan model • Implement strengthened daily / weekly multi-agency operational arrangements to avoid delays to discharges

• 95% of all patients admission have a discharge plan in place within 72 hours of admission • Reduction in OoAP numbers by xx & OBDs by xx Enablers / infrastructure • Reduction in re-admissions by xx for client group • Implement revised definitions to clarify inappropriate / appropriate, acute / sub-acute out of area / in area placements, to enable • Improved clinical outcomes accurate reporting. • Improved service user and carer experience • Implement monthly processes for refreshing the OoAP trajectory which reflects the impact of key actions • Updated clinical model in place • Reduced numbers of and lengths of delayed discharges by xx

New and Proposed Actions

The Out of Area Action plan details the existing and most recent actions and includes the anticipated impact on bed days and an action risk overview.

CCG specific actions

Development of a refreshed OOA trajectory, split by CCG and HCP capturing number of patients OOA, Occupied Bed Days and Discharges (captured in the above trajectory). The CCGs are also reviewing LOS split by wards and have requested via CTM and QCRM a RAP to outline steps being taken to mitigate risks of bed closures (impacting a total of 16 beds) due to a long standing loss of 10 beds as a result of fire-stopping work and a recent loss of 6 beds at Willowvale ward in St Michaels due to concerns on clinical safety.

6 Transforming Care Partnership - Inpatient admissions for those with a Learning Disability and/or Autism - Mar 2020 Operational Lead: Jamie Soden/Sherryl Gaskell/Adrian Hutchins

CCG Adults NHSE Adults NHSE Children 35 25 12 30 20 10

25 8 20 15 6 15 10 4

Inpatient numbersInpatient 10 Inpatientnumbers Inpatient numbers Inpatient 5 5 2

0 0 0 Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20

Reasons for being off track

CCG adult numbers remain over trajectory. COVID-19 has played a factor in this in the last 5 weeks, with some planned discharges from March 2020 have been pushed back to April and May 2020 due to impact of COVID-19 on staffing within the provider market. However, this has increased planned discharges for April and May, which have been planned with a high level of scrutiny to ensure that there are no avoidable delays to discharging these patients. Following an external review and diagnostic of the Transforming Care position and contributing factors; The key elements identified as contributing to the system being off track when compared to the NHSE/I trajectory for Coventry and Warwickshire. These are: 1. The absence of an Autism Pathway 2. Limited capability within the core Mental Health services to work with those who have a co-morbid Mental Health issue and either mild learning disabilities and / or autism 3. Change in legislation which prevents people with elevated risk and capacity to be supported within the community with 1-1 care. 4. Programme management capacity issues reducing the effectiveness of the resource utilisation and co-ordination. This has now been addressed with the appointment of Adrian Hutchins as TCP Programme Manager. 5. Commissioning: The CWPT contract requires improved specifications for Learning Disability Services, with clearer targets for management of the patient pathway, a tighter specification for the Assessment and Treatment Unit, tighter management of length of stay, the specification of the Intensive Support Team to fit more closely with that of the ATU, so to better manage complexity, intensity and frequency of challenging behaviour in the community.

For NHSE Children, 2019/20 Q4 saw unusually high number of children diagnosed with Autism following admission to hospital for their mental health presentation. The review of these diagnoses in hospital indicated no themes or trends appear to have contributed to this across Coventry and Warwickshire, but did highlight a process issue where children were added to Arden TCP numbers by NHSE/I before sufficient assurance had been received by Arden TCP to add them on to our risk registers and inpatient numbers. This is being addressed directly with NHSE/I as a process issue by the TCP programme manager, but does apply to at least 2 current NHSE CAMHS inpatients, and inflates the performance figures. Despite this, we are currently meeting our trajectory for NHSE Children.

NHS England Adults – There is an identified area for improvement in the communication, as well as clarity around roles and responsibilities between NHSE Case Managers for these patients and CCG Clinical Commissioners. This has been raised by the new Programme Manager with Regional NHSE/I colleagues to address jointly and solve. This should improve the quality and clarity of data and information for these patients, allowing us to more effectively plan for their discharge in collaboration with NHSE Case Managers.

Recovery Actions

Existing Actions Date Anticipated Impact Date of Expected Impact

Unsure - dependent on The problem of change in legislation which has resulted in the inability to discharge some patients who have capacity but present risks in the community, has Potential positive impact on the discharge of individuals who have capacity with risky behaviour who cannot currently be discharged from hospital. Will also have a positive impact on morale of CCG Apr-20 legislation change or NHSE/I been escalated with NHSE/I for support. Clinical Commissioners who feel that they have no further avenues to pursue for these patients to get them discharged. guidance. CCG Moral boost immediate. Following the completion of a diagnostic review of the system delivery and programme work streams, an Arden TCP delivery plan was developed and signed Apr-20 This plan is galvanising the recovery actions across the system partners and provides structure and governance to the interventions. Feb 2020 onwards off by the Learning Disability and Autism Transformation Board. Completed

Improved commissioning and management of the LD patient pathway, tighter specification and management of the CWPT Contract with regard to the Assessment and Treatment Unit, the Intensive Support Team and CLDT. More patients could be effectively managed in the community, rather than being May-20 Reduce the high numbers of CCG managed inpatients. inpatients.

The Accommodation Sub Committee has been established: • To provide assurance that Arden TCP has a robust framework for pathway management of patients in the Transforming Care Cohort. • To identify appropriate accommodation and care in the community for patients moving up and down the patient pathway. • Develop the Transforming Care Housing Plan (2020-2024) to outline the various options required to ensure people remain in the least restrictive and most appropriate setting for their condition. • To address the needs of children and young people, as well as adults. Improved patient pathway management through early planning with accommodation and care providers at community level, making appropriate preparations ample time before complex patient The Accommodation Sub Committee of the Transforming Care has been established: Mar-20 April 20 onwards discharge dates. • To provide assurance that Arden TCP has a robust framework for pathway management of patients in the Transforming Care Cohort. • To identify appropriate accommodation and care in the community for patients moving up and down the patient pathway. • Develop the Transforming Care Housing Plan (2020-2024) to outline the various options required to ensure people remain in the least restrictive and most appropriate setting for their condition. • To address the needs of children and young people, as well as adults.

Development of the all age Coventry and Warwickshire Autism strategy is being concluded and final comments recived from partner organisations. It is One of the key contributory factors identified for our challenge in meeting the NHSE/I trajectory is the lack of a defined pathway for those with Autism only. The Strategy will provide direction and anticipated that the LD and Autism Transformation Board will receive the final version for review in March 2020. Once signed off the Board will recommend to Mar-20 galvanise the commitment of all parties to address this issue. whilst the impact will not be immediate the formal sign up of all parties to a single vision will provide traction in moving forward with April 20 onwards partner organisations they formally ratify the policy and commit to implmentation of the delivery plan sustainable transformation.

Implementation of a pilot to provide Autism only Intensive Support Team style intervention targeting those most at risk of admission to hospital who, due to the Mar-20 This pilot is expected to support admission avoidance and reduce the number of people admitted with Autism only Feb-20 nature of their diagnosis, do not have recourse to support from core services such as the community Learning Disability and Mental Health teams

Implementation of a pilot to co-ordinate and lead across adult services to improve the impact of existing service deployment. Mar-20 This pilot is expected to support early intervention and reduce the escalation of people who require CTR’s and high intensity support. Mar-20

CCG Specific Actions

A Transforming Care Programme Lead – Adrian Hutchins - has been appointed to provide dedicated leadership and co-ordination to the work stream with a specific responsibility for timely completion of the delivery plan. The Programme Manager is working proactively with NHSE/I to give assurance that the programme has grip on our inpatients.

Each CCG, alongside colleagues in Local Authorities and CWPT are undertaking targeted work to ensure that the 12 point discharge plan is followed, and robust, sound and detailed discharge plans are in place for all Q1 patients. More detailed information is being shared with regional leads on escalation calls to give assurance of our grip on performance, which results in NHSE/I having increased confidence in the discharges for Q1.

The Delivery Plan is being overseen by the Transforming Care Committee and is being effectively implemented. Each area has been reviewed by the committee in light of additional COVID-19 pressures, and focus has been given to the areas that can proceed. The dashboard and central database has been developed and is in use. The key areas being addressed in the Delivery plan are:

Admission Prevention; Timely Discharge;- Governance and Ways of Working;- Resource and Workforce; Data Intelligence;- Housing and Care Market. Additional areas have been added to the delivery plan in April 2020, which add additional areas of work around the transition between childrens and adult services, as well as work around the care and accommodation market specicially for children and young people.

7 Kate Cogman / Patients On Incomplete Non-Emergency Pathways Waiting No More Than 18 Weeks From Referral - Feb 2020 Operational Lead: Jo Evans

Latest Performance Benchmarked Nationally* Trend Performance History Consitutional Target CRCCG WNCCG GEH Actual/ Plan UHCW Actual/Plan Month Prev Month Quarter 3 19/20 YTD

90% CRCCG  80.6% 81.7% 83.7% 84.6% 85%

80%

75% WNCCG  77.2% 78.7% 81.6% 82.8% 70% Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 *The red zone represents CCGs in the worst performing quartile

Reasons for being off track

Both CCGs in agreement with both UHCW and GEH set plans for RTT in 2019/20 to not meet the national RTT standard of 92%, but that the outturn position for 2018/19 should be maintained in 2019/20, that total number of waiters should be at the March 2019 position by the end of March 2020, and that there would be no over 52 week waiters. This is containted with the Contract SDIPs wit providers, and provider trajectories agreed with NHS E/I linked to SFT funding by NHS E/I.

Overall in year RTT has fallen slightly below that at the start of the year, this is consistent also with the national position for England as a whole. However total incompletes (total waiters) have risen significantly driven in the main by providers delivering less activity in year than was the case in 2018/19, plus referrals have grown overall (although in part as new providers are reporting through national RTT reporting i..e Newmediac who did not report figures in 2018/19).

Long waits have fallen and the number waiting over 40 weeks has fallen considerably for both CCGs.

UHCW is part of the national Pilot for average waiting times, and as such currently has an average waiting time of 10.3 weeks, but was working before the latest guidance on restricting activity to free beds for Covid-19 to reduce this to 9.5 weeks by the end of March 2020 - this is consistent with maintaining RTT as it was. UHCW is no longer required by NHS E/I to publish its RTT performance nationally. It is working internally to have no over 40 week waiters across all specialties by the end of March 2020 as part of its work on reducing average waiting times.

As a Coventry and Warwickshire system there is a 26 week choice pilot in place across the STP moving patients between providers, for Ophthalmology. In light of Covid-19 roll out of the pilot has been stopped until urgent care pressures reduce significantly.

For both systems there are transformation board activities looking to reduce referrals though Advice and Guidance, MSK FCPs, and reductions in Follow Up activity to free capacity for new patients (Patient initiated follow Up). This will have a limited impact and the expectation is that RTT will continue to remain at its current position, with both Trusts expecting to have no 52 week waiters. Total incompletes falling back to Match 2019 levels however looks unlikely for both Trusts, by March 2020.

One patient breached 52 weeks at Guys and St Thomas' NHS Foundation Trust. Further information has been requested from the trust as to the reaons for the breach.

Existing Recovery Actions

Date of Existing Actions Date Anticipated Impact Anticipated Impact

26 week choice pilot - moving patients from UHCW/GEH to SWFT - Ophthalmology. Stopped This has stopped due to Covid-19, will increase total numbers and lengthen waiting times. Mar-20

Joint work between CCGs / Providers to ensure LPP/PLCV policies are being managed effectively. In Place Reduces levels of clinically ineffective activity being undertaken, freeing capacity for clinical effective procedures, reduces additions of patients onto waiting lists, and helps reduce growth in total lists. Mar-20

Providers recruiting to vacancies and moving away from reliance on locums and waiting list initiatives. Ongoing Addresses inbalance between demand and capacity, so moves to stopping growth in total waiting lists and helps to move to a sustainable level of provision over time. Mar-20

Place based Forums developing local elective care transformation work programmes, MSK single point of access, First Reduces demand for acute care, improves efficiency through use of new technologies for Outpatient appointments, transfer of activity away from costly acute services, to more community located Contact Practitioners, greater proprotion of non face to face apppintments, patient initated follow up, work programmes for Ongoing services, increase in thrughput by providers to increase physical capacity. Helps to move to sustainable levels of provision. Evidence that growth in total incompletes has started to level off in last 3 Sep-20 Dermatology/Ophthalmology to develop community alternatives. Greater effieciny by providers fewer DNAs, improved theatre months. utiisation utilising GIRFT.

Helps to ensure patients are referred only when necessary and worked up appropriately in primary care first. Reduces bounce back at first OP appointment, and frees capacity for acute provider to Advice and guidance, Consultant Connect, RSS triage. In place Ongoing see exisiting patients.

New and Proposed Actions

The potential impact of actions around management of Covid-19 will affect both the delivery in the future against these targets. It also impacts on the ability to deliver the identified action plans as capacity to deliver these both within the CCG and by the provider will be reduced to deal with emergency planning and resilience.

We cannot let go of all monitoring of performance. Once, after we get through this epidemic, we will need to refocus on recovering against the negative impact of having to deal with Covid-19. We will maintain the focus on clinically urgent and critical targets such as extreme long waits, as well as cancer delivery needs to remain in place, and will work on contingency plans for sustaining these have to be put in place at the same time as planning for how to deal with the next 3 to 4 months with urgent care cases arising from Covid-19 infections.

There will be in addition the need to add new monitoring to be in place over the next few months that allow us to review and see what has happened in relation to Covid-19 locally as well.

8 Estimated diagnosis rate for people with dementia - GP Practice Registers - March 2020 Operational Lead: Lexi Ireland/ Sharon Atkins

Latest Performance Benchmarked Nationally Trend Performance History Target CRCCG WNCCG

Month Prev Month Quarter 319/20 YTD 68% 66% CRCCG  60.6% 60.5% 60.5% 62.1% 64% 62% 60% 58% 56% WNCCG  57.8% 58.6% 58.3% 60.0% 54% 52% Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 *The red zone represents CCGs in the worst performing quartile Reasons for being off track

Despite positive activities to promote early diagnosis in Dementia, there are a number of reasons why performance is off track: 1. Within primary care more work can be done to overcome cultural/organisational challenges preventing a greater uptake of early dementia assessments. Simultaneously, we need to ensure GPs have access to specialist support or training to make a positive impact upon the early diagnosis standard. 2. Recognition that no ‘magic bullet’ exists and no single model or approach has been championed and promoted by NHSE and therefore the challenge is multi-faceted. 3. Dementia prevalence rates continue to rise due to increasing life expectancy, and the dementia register is fluid due to dementia being a terminal condition, so numbers required to meet the target continue to increase. 4. Capacity issues exist wthin Memory Assessment Service.

It is estimated that there could be around 160 miscoded cases across Warwickshire North practices and 283 across Coventry and Rugby. This is based on the number of cases coming through MAS which are not reflected in reported figures which come from GP systems, and is supported by the significant increase in March 2019 figures following a small number of practices carrying out data cleansing (147 list size increase in Coventry and 26 in Warwickshire North). Should this be the case, it would bring both CCGs close to their targets by the end of the six month activity period. If these numbers of miscoded cases are not found, it will indicate that further work is required with MAS to increase capacity to meet the target, and plans will be developed with CWPT. This will be reviewed three months after the start of the activity.

New challenges now exist due to Covid-19; currently, there is uncertainty around the impact that this will have on the Memory Assessment Service however, both MAS and GPs (that have previously been undertaking diagnoses) will have to focus on other priorities , in addition to this being a particularly vulnerable/at risk cohort and therefore we anticipate a further decline in rates over the coming weeks.

Recovery Actions

Expected Date Existing Actions Date Anticipated Impact of Impact

Data cleansing between MAS caseloads and GP practice lists. Practices have been asked to carry out this Nov 2019 It is estimated that there could be around 160 miscoded cases across Warwickshire North practices and 283 across Coventry and Rugby. This is based on the number of cases coming through MAS March - exercise with limited uptake. We propose employing a Psychology Assistant to carry out data cleansing on - July which are not reflected in reported figures which come from GP system, and is supported by the significant increase in March 2019 figures following a small number of practices carrying out data August MAS data and with all practices. Funding has been agreed and this is now being finalised with CWPT. 2020 cleansing. 2020 Clear backlogs of positively screened but undiagnosed patients from the Cognitive Assessment in Primary Care scheme. Practices have been asked to confirm numbers outstanding and support required to clear by Feb 2020 March - July w/c 24th February. Tailored support offers will be developed following this as required. Update 26/03/20 - - June Of the 200 cases currently outstanding it is estimated that 75 could be converted into positive diagnoses. 2020 support packages have been paused due to the Covid-19 pandemic, but outstanding assessments are 2020 mainly concentrated in a small number of practices.

Continuing the Cognitive Assessment in Primary Care scheme as part of the MH Enhanced Services offer from April 2020. Continuing support to practices around this. a. Closely monitoring the performance of practices involved and offering individual support and challenge where required. Dec 2018 Increasing involvement and relauching this will hopefully increase takeup amongst practices. The specification for this has been tightened to ensure patients move through the system faster and Ongoing b. The GP Lead and a Commissioning Manager have been carrying out individual visits to practices to onwards impacts are seen more quickly. gain feedback, understand challenges and success and support them in trouble-shooting. Practices have fed back that these visits have been beneficial in targeting concerns, and they have enabled us to identify and resolve issues affecting performance.

New and Proposed Actions

Review capacity issues in MAS and look at ways of supporting the service to increase diagnosis rates, such as improving the quality of referrals, increasing the use of shared care and reviewing how follow ups are conducted.

Consider employing a Psychology Assistant on a short-term basis to ensure data cleansing happens consistently across all practices.

Consider employing a doctor on a short-term basis to support with clearing the backlog of cases from the cognitive assessment scheme.

CCG Specific Actions

1. Supporting the inclusion of the cognitive assessment scheme into the Mental Health Enhanced Services offer. It is anticipated that coverage and sign up to the scheme would be vastly increased across both C&R & WN CCG’s as a result. 2. Targeting practices with unexpectedly low dementia registers to support with data cleansing. 3. Developing “Dementia on a Page” support leaflets ensuring GPs, patients and other stakeholders understand the range of support available. These are being developed via the STP. 4. Making use of PLT and CCG lunchtime talks to promote dementia diagnosis and support amongst primary care colleagues. 5. Arranging webinar for GPs with the national support team at NHSE for early 2020. 6. Ensure we are maximising the impact of all patient-facing staff. 7. Investigating the role of CWPT in increasing DDR. 8. Considering whether a care homes dementia assessment programme would be feasible and beneficial.

9 Improving Access to Psychological Therapy- Access Rate (Annualised) - Jan 2020 Operational Lead: Eleanor Cappell

Trend Latest Performance Benchmarked Nationally Performance History Trajectory CRCCG WNCCG

(Q1)* 26% Month Prev Month Quarter 3 19/20 YTD 24% CRCCG  21.1% 17.6% 18.8% 18.5% 22% 20% 18% 16% 14% WNCCG  20.8% 17.8% 19.3% 20.8% 12% 10% Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20

*The red zone represents CCGs in the worst performing quartile Reasons for being off track

Based on front-end data, CWPT have confirmed that it is highly likely that the IAPT service will not met the year-end 22% access rate for either CCGs. There are a number of interdependent reasons: changes in the calculations for the prevalence levels has had greatest negative impact upon providers in the West Midlands; despite increases in trainees/ staffing levels, the footfall of patients and declining availability of space available within GP practices increases the need to mobilise digital provision of IAPT therapies (anticipated 1st April). Additional pressures have arisen from emerging third-sector services offering provision similar to IAPT and most recently the impact of COVID-19 with social distancing and staff/ patient sickness, initial demand for IAPT is expected to fall. However post the pandemic there is a strong expectation for an increase in therapies for general and health anxiety, depression, PTSD from experiences of the Intensive Care Units and OCD.

Recovery Actions

Date of expected Existing Actions Date Anticipated Impact impact

NEW ACTION: The national team have confirmed that they are suspending assurance performance process of IAPT access, recovery waits for a minimum period of the next 3 months of 2020/21, to allow time for services to mobilise digital/ telephone based support and facilitate WFH with outcomes reported through remote delivery. Data submissions will continue. Q2 2020/21 NEW ACTION: • IAPT have moved to telephonic work and exploring use of “skype type” technology Services have been instructed by the national team to switch, immediately, to • Vulnerable groups have been identified for patients staff. online/telephone/digital modes of service delivery, offering a choice to people where • The national and local team are looking at measures to support the general population with mild/moderate possible. anxiety related to Covid19. Post the pandemic there is a strong expectation for an increase in therapies for general On-HOLD due to COVID-19: Shared positive evaluation of IAPT-LTC evaluation with Acute trusts and and health anxiety, depression, PTSD and OCD. requested a steering group to be developed between health care clinicians for COPD, Diabetes and Asthma and IAPT HITs to ensure IAPT can offer system support to meet the psychological needs arising from poor physical health.

ONGOING: explore offer by LAs to map interface between IAPT and community resilience/ emotional wellbeing services.

New and Proposed Actions

As a CCG we are assured all efforts are being undertaken to meet the access rate, however there is concern and a risk over whether the target will be met by year end.

CCG Specific Actions A performance Notice was issued on the 8th July against the performance of this KPI, which remains in place. Both the CCGs and CWPT have agreed that the IAPT system steering group needs to be refreshed with revised TORs to explore a strategic review of IAPT to scope the role of CWPT and MIND to reduce overlap/ duplication; increase footfall/access and re-set strategic priority for IAPT with representation from commissioners, IAPT service leads (for CWPT and MIND) and contracting colleagues. We will now also need to include a COVID-19 system response for anxiety, depression, OCD, PTSD 10 Delayed transfers of Care (As a percentage of occupied beds) - Jan 2020 Operational Lead: Sue Davies

Latest Performance Benchmarked Nationally* Trend Performance History Target UHCW GEH Month Prev Month Quarter 3 19/20 YTD 6%

UHCW  5.2% 4.9% 4.5% 4.5% 5%

3.4% 3.8% 2.7% 2.9% 1% GEH  beds occupied of a % as DTOC 0% Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20

*The red zone represents CCGs in the worst performing quartile Reasons for being off track

The stranded patient and DTOC numbers at UHCW continues to be above target despite a real commitment and drive of the hospital teams supported by ECIST.

Increase in NHS attributable DTOC at UHCW possibly due to a high level of referrals to Pathway 3 beds resulting in capacity issues and delays.

Recovery Actions

Date of Expected Existing Actions Date Anticipated Impact Impact Long Length of Stay (LLOS/Stranded patients) executive support & challenge reveiws taking place 3 times weekly Ongoing Reduction in LLOS Mar-20 Coventry & Warwickshire system wide point prevelance analysis shared at C&W A&E Delivery Board - each trust to review and Mar-20 Update from each trusts on addressing any issues raised in the report Ongoing respond to outputs Development of action plan following MADE at GEH with 5 themed priorities monitored by local A&E Delivery Group Jan-20 Improved discharge maintaining DTOC figure & reducing LLOS Mar-20 Same Day Emergency Care Unit opened at GEH inlcuding acute frailty pathway Feb-20 Reduced admissions and LOS for frailty patients May-20 3 day MADE at UHCW supported by partners to further support existing improvement plans took place early Feb 20 Feb-20 Reduction in LLOS & DTOC Mar-20 Work on complex discharge using Virginia Mason Improvement methodology Mar-20 Improved discharge pathways, reduction in LLOS & DTOC May-20

CCG Specific Actions

CCG Capacity Manager to completing a Pathway 3 audit at UHCW with a view to more patients being offered P2 & P1 (part of the LLOS recovery plan supported by ECIST) to commenced on 27th Jan 20 outcomes of the audit will be presented to C&R A&E Delivery Board in March. Daily presence of CCG Capacity Managers at both trusts supporting the community hub discussions and resolving issues relating to discharge and flow. Changes to D2A pathways in WN resulting in additional capacity for therapy led P2 D2A pathway. Deep Dive into NHS related DTOC at UHCW to identify what other actions are required to improve the position.

11 Blank Page Enclosure O

Audit Committees Report for the Meeting held on 2 April 2020

Achievements / Decisions Made / To Note: Remuneration Committee Annual Report: This report was lllllllllllllllll presented to the Committees to provide assurance that the Internal Audit Progress Report: The Committees reviewed an Remuneration Committee have discharged their functions correctly throughout the 2019/20 year. Members confirmed update of progress against the Internal Audit Plan for 2019/20 and noted that 3 reports had been finalised and there are 8 they were assured. recommendations due for implementation in progress. CRCCG Financial Services Report/WNCCG Financial Services Report Month 11: The Committees reviewed and The Committees were asked to approve this Internal Audit Plan: noted these reports which outlined key performance data for report which provided an outline work plan for the Internal Audit the CCGs covering debtor and cash management, better Team for 2020/21. The report was written prior to the pandemic, payment compliance at Month 11 2019/20. and after a short discussion the Committees Approved the plan subject to flexing due to COVID-19. Compliance with Standing Orders and Standing Financial Instructions: No known compliance issues with the CCGs The Internal Audit Review Reports – DSPT compliance review: standing orders and SFIs during the period January 2020 Committee noted the report confirming that the action plan is in through to March 2020. There have been two approved place, the CCG’s report was submitted to original timescale, Procurement Exemptions during the period January 2020 despite an extension being offered and confirmation that the report through to March 2020 as outlined and the Committees were was helpful for completing the submission documents. also advised of the need to secure additional staffing at pace Significant assurance Internal Audit Review Reports – S117: and that the additional capacity is being raised on an was given overall for both CCGs. exception basis. Members were assured of the contents of Internal Audit Review Reports – Financial Performance the report. Reporting & QIPP Delivery: Members received the Final Internal Gifts and Hospitality and Commercial Sponsorship Audit report in respect of Financial Performance Reporting & QIPP Registers: The Committees noted that the report headings Delivery and were assured that it provided Significant assurance seem inaccurate and possible duplication across CCGs had overall for CRCCG and Moderate assurance overall for WNCCG. occurred on the Commercial Sponsorship Register. It was Due to differing levels within the report, members requested the confirmed this would be looked into. The Committees report had a sectioned breakdown just prior to the final assurance confirmed Assurance for both papers. rating. Write off of Bad Debts: The Committees Approved the write Internal Audit Review Reports – Draft Head of Internal Audit off of two bad debts totalling £69,3446.05. Opinion CRCCG : The Committees noted the report which provided Significant Assurance overall. Schedule of Losses and Special Payments: Members were assured there had been no losses or special payments Internal Audit Review Reports – Draft Head of Internal Audit and that salary overpayments were currently being recovered The Committees noted the report which Opinion WNCCG: for the period January – March 2020. provided Significant Assurance overall. The report also noted there are two outstanding recommendations. Going Concern Assessment: The report requested the External Audit - Planning Reports Y/End 31/03/20: Members Committees to agree that the CCGs should be reported as a reviewed and noted this report, taking into account it was prepared going concern and the accounts should be prepared on this prior to the COVID-19 pandemic. The report confirmed that basis. The Committees Agreed and Recommend the WNCCG is presented as a VfM risk and it is intended to report the Governing Body to declare. CCGs as a Going Concern.

Counter Fraud Progress Report 2019/20: The Committees were advised this report summarises the counter fraud work completed in 2019/20. It confirms there are no current investigations being Key Issues for the Governing Body: progressed and two local issues which are being addressed. It was also noted that the pandemic is bringing about more personal • Quoracy is to be suspended down to minimal levels for scams and prescribing scams, both of which are likely to remain the duration of the pandemic. small, but it was requested to pass warnings to all staff to be • Further requests to suspend standing orders were to be cautious. Finally it was confirmed that Kay Speed-Andrews is the discussed at Remcom. new fraud champion across both CCGs. • Bad Debt write off of £69,3446.05 has been agreed. Local Security Management Progress Report: Members noted work has progressed with CHC teams in relation to lone working and ensuring current policies are understood correctly for the safety of all staff. Matters referred to Governing Body for approval, debate or further consideration: Annual Governance Statement 2019/20: Members received this report for noting, with it being highlighted that COVID-19 has been • Going Concern Assessment added as a significant control risk. • Annual Governance Statement • Decisions made on standing orders, quoracy and SFI’s Conflicts of Interest Compliance Assessment: The Committees were assured that the returns have been completed and approved, ready to send off, and that the CCGs have the required number of Lay Members. It was confirmed a new Lay Member for Patient and Public Engagement has been recruited and will be co-opted across Key Information: both CCGs from April 2020. • Committee Chair: Chris Stainforth, Lay Member for Audit and Governance Finance and Performance Report to the Audit Committee: This • CCG Lead: Kay Speed-Andrews, Deputy Chief Finance report was presented to the Committees to provide assurance that Officer the Finance and Performance Committee have discharged their th • Date of Next Meeting: 27 May 2020 – Annual functions correctly throughout the 2019/20 year. Members Accounts. confirmed they were assured.

Enclosure O Blank Page NHS Coventry and Rugby Clinical Commissioning Group NHS Warwickshire North Clinical Commissioning Group Enc P

Report To: Governing Body Meetings in Common

Report Title: Governing Body Annual Report 2019/20

Report From: Dr Sarah Raistrick, Chair CRCCG Ms Sharon Beamish, Chair WNCCG

Date: 20 May 2020

Previously Considered by: N/A

Action Required (delete as appropriate)

Decision: Assurance:  Information: Confidential

Purpose of the Report: To present the Annual Report of the Governing Bodies of NHS Coventry and Rugby CCG and NHS Warwickshire North CCG detailing how the Governing Bodies have discharged their functions over the year 2019/20.

Key Points: • The Governing Body of each of the CCGs met in common and in public 6 times formally during the period. • The Governing Bodies are satisfied with the quality of the information that it receives for its meetings and with the administration of meetings • The functions of the Governing Body are set out in the Standing Orders and may be discharged directly by the Governing Body alone or by delegation to one of the sub – committees. • Business Transacted this year includes: o Receipt of regular Finance Reports and ‘flash’ reports from its sub-committees; o Consideration of the future of healthcare commissioning; and o Receipt of updates in relation to Public Health across Coventry and Warwickshire. • During 2020/21, business will include: o Focus on the developments outlined within the sub-committee annual reports; and o Expand the use of technology to allow for further streamlining of papers and for virtual meetings to continue as required.

Recommendation: The Governing Bodies are asked to RECEIVE the report and be ASSURED that they have adequately discharged their remit in the year to 31 March 2020.

Implications

Duties of the Governing Body as detailed in the Standing Orders. Strategic Objectives- Objective(s) / Plans • supported by this We will work collaboratively with our partners to continuously improve quality of report: care; • We will inspire people to increase their confidence to manage their own health; • We will optimise the use of technology to transform patient experience and Page 1 of 2 NHS Coventry and Rugby Clinical Commissioning Group NHS Warwickshire North Clinical Commissioning Group Enc P

workforce effectiveness; • We will enable our local health and care system to deliver a sustainable, integrated response to the needs of our Places, reducing health inequalities through our commissioning strategy; • We will focus our resources to secure services that are value for money and promote a financially sustainable health economy; and • We will empower our diverse and motivated workforce to work in partnerships to improve population health. Conflicts of Interest: Not applicable Non-Recurrent Expenditure: Not applicable Recurrent Expenditure: Not applicable Financial: Is this expenditure included within the CCG’s Financial Yes No N/A  Plan? (Delete as appropriate) Performance: Report details the assessment of performance of the Governing Bodies. Quality and Safety: Not applicable General Statement: The CCG is committed to fulfil its obligations under the Equality Act 2010, and to ensure services commissioned by the CCG are non-discriminatory on the grounds of any protected characteristics. Policies/decisions may need to be adjusted in line with any equality analysis or due regard. Any decision that is finalised Equality and Diversity: without being influenced by appropriate due regard could be deemed unlawful. Has an equality impact Yes assessment been undertaken? No N/A  (attached) (Delete as appropriate) Patient and Public Not applicable Engagement: Clinical Engagement: Not applicable Risk and Assurance: Provides assurance on the Governing Bodies’ management of risks.

Page 2 of 2 NHS Coventry and Rugby CCG & NHS Warwickshire North CCG Annual report of the Governing Bodies

1 Introduction

This document represents the report of the Governing Bodies of NHS Coventry and Rugby CCG and NHS Warwickshire North CCG for the period 1 April 2019 to 31 March 2020 and provides the Governing Body with an opportunity to reflect on, and document its performance during the year.

2 Membership and Meetings

The Governing Body of each of the CCGs met in common and in public 6 times formally during the period. The dates of meetings and attendance of members are shown in Appendix B as well as attendance at a sub-committee level.

There were a number of changes to Governing Body members in 2019-2020 and these are detailed at Appendix A.

The Governing Body has ‘Declaration of Interests’ as a standing item on its agenda and records any interests declared in its minutes. The performance of Executive directors is reviewed on an annual basis by the Accountable Officer against agreed objectives. The performance of Lay members is reviewed by the Chair. The performance of the Chair is reviewed by NHS England.

3 Administration and Communication

The Governing Bodies are satisfied with the quality of the information that it receives for its meetings and with the administration of meetings with the majority of papers being available one week in advance. Papers for meetings are circulated electronically and posted in hard copy to members where requested. During 2020/21 we will expand our use of technology to ensure that all Governing Body members have access to improved ‘paperless’ versions of papers.

The agenda, minutes and papers of all public Governing Body meetings are available to staff and to the public via the CCG websites. Following a meeting a briefing is also prepared for staff and distributed internally to all staff members.

4 Discharge of the Functions of the Governing Body

The functions of the Governing Body are set out in the Standing Orders and may be discharged directly by the Governing Body alone or by delegation to one of the sub - committees, which then report back to the Governing Body. The Annual reports of the sub-committees have been received by the Governing Body and have detailed how the sub-committees have effectively discharged their functions as described in their terms of reference.

1 5 Business Transacted During the Year

The Governing Body agendas are structured to cover Strategy and Planning, Governance, Finance and Performance and Quality. In addition the Governing Body receives a report from the Accountable Officer and the Chair at every meeting which provides a general update for the Governing Body and covers any developments or issues which have arisen during the last period.

The Governing Body received and considered a Finance Report at every meeting and ‘flash’ reports from its sub-committees: the Audit Committee, the Clinical Quality and Governance Committee, the Remuneration Committee, the Finance and Performance Committee and the Primary Care Committee. Alongside the reports from its Finance and Performance Committee members also received a report covering the performance of its Provider organisations against key targets and deliverables at every meeting.

The strategic items considered by the Board included consideration on the future of healthcare commissioning, the Operating Plan 2019/20, Primary Care Strategy, Coventry Health and Wellbeing strategy, Commissioning Intentions, improving stroke outcomes and the CCGs research and development strategy.

In addition the Governing Body received updates in relation to; Public Health across Coventry and Warwickshire, an update on the Joint Strategic Needs assessment work across Coventry , Rugby and Warwickshire and Annual reports in respect of LeDeR and Safeguarding as well as updates on the CCGs response to equality and diversity and modern slavery.

The Governing Bodies also met every other month in a workshop format. In these sessions members discussed the developing approach to Integrated Care Systems, developing strategic objectives and also took one session to have a substantive discussion on risks ,opportunities and assurance. In the period the Governing Bodies also had two sessions with the Governing Body of NHS South Warwickshire CCG.

In all the above discussions, in both formal and informal sessions, Lay members and clinical leads of the Governing Body provided constructive challenge and support, drawing on their own experiences, to plans being developed by the Executive Directors.

6 Risk Management

The Governing Body receives quarterly updates of the Corporate Risk Register as part of the Assurance Framework updates. The Governing Body also takes the opportunity on an annual basis, and in workshop format, to carry out some horizon scanning, and to consider the risk and opportunities environment within which the Board operates.

7 Development of the Governing Body as a whole

A process of self-assessment in December 2019 resulted in agreement that further Governing Body development should focus both on what the Governing Body delivers and how it carries out its business. It was also agreed that the priority for development moving forward would focus on

2 ensuring the refreshed 2020/21 strategic objectives were embedded across both CCGs and that papers to Governing body and Sub-committees would be focussed around these. In light of the COVID-19 Pandemic Development sessions have been temporarily stood down.

8 Look forward 2020/21

The Governing Body welcome the developments outlined within the sub- committees annual reports and in considering these the focus of the Governing Body for 2020-21 will be to ensure time is allocated for discussion on the key priority papers, aligned with the strategic objectives. The use of technology will be expanded to allow for further streamlining of papers and for virtual meetings to continue as required. A focus of the CCGs will be a merger application to NHS England and ensuring the robustness of that application will require Governing Body member’s attention and focus in terms of the CCG’s new operating model and associated finance and quality strategies.

Conclusion and Recommendation

The Governing Body of NHS Coventry and Rugby CCG is satisfied that it has adequately discharged its remit in the year to 31st March 2020.

The Governing Body of NHS Warwickshire North CCG is satisfied that it has adequately discharged its remit in the year to 31st March 2020

3 APPENDIX A - Governing Body Members NHS Warwickshire North CCG

David Allcock Sharon Beamish Chair (until 30 November 2019) Chair (from 1 December 2019) Lay Member for Audit and Governance (from 1 December 2019)

Andrea Green Adrian Stokes Accountable Officer (until 31 August 2019) Interim Accountable Officer (from 16 September 2019)

Clare Hollingworth Chris Lonsdale Chief Finance Officer Interim Chief Finance Officer (until 29 September 2019) (from 30 September 2019)

Jo Galloway - Chief Nursing Officer

4 Clinical Leads

Dr Imogen Staveley Dr Arshad Khan Dr Godwin Igodo Sue Turner Clinical Lead & Clinical Lead Clinical Lead Practice Network Deputy CCG Chair Clinical Lead (from December 2019)

Dr Jonathan Timperley Dr Inayat Ullah Secondary Care Specialist Practice Network Lead

Lay Members

David Allcock Sharon Beamish Graham Nuttall Chris Stainforth Audit and Patient and Public Primary Care Lay Member for Governance Involvement (until Audit and November 2019) Governance (Co-opted from NHS Coventry and Rugby CCG until 30 November 2019)

5 Public Health

Shade Agboola Director of Public Health (Warwickshire)

Non-Voting Members

Jenni Northcote Andrew Harkness Chief Strategy and Primary Care Officer Chief Transformation Officer

6 NHS Coventry and Rugby CCG

Dr Sarah Raistrick Chair

Andrea Green Adrian Stokes Accountable Officer (until 31 August 19) Interim Accountable Officer (from 16 September 19)

Clare Hollingworth Chris Lonsdale Chief Finance Officer Interim Chief Finance Officer (until 29 September 2019) (from 30 September 2019)

Jo Galloway Dr Steve Allen Chief Nursing Officer Clinical Director

7 Clinical Leads

Dr Deepika Yadav Dr Mark Lawton Dr Alastair Bryce Dr Jonathan Clinical Lead Clinical Lead (from Clinical Lead Timperley June 2019) (from June 2019) Secondary Care Specialist (from 1 June 2019)

Dr Prashant Kakodkar Secondary Care Consultant (until 31 May 2019)

Lay Members

Ludlow Johnson Chris Stainforth Claire Forkes Lay Member for Primary Lay Member for Audit and Lay Member for Patient and Care, PPI & Equality Governance Public Involvement

Public Health

Liz Gaulton Shade Agboola Acting Director of Public Health (Coventry) Director of Public Health (Warwickshire)

8 Non-Voting Members

Jenni Northcote Andrew Harkness Chief Strategy and Primary Care Officer Chief Transformation Officer

Appendix B- Meeting Attendance Governing Primary Care Audit Finance and Clinical Remuneration Individual Body Commissioning Performance Quality and Funding Name (Meeting Committee Governance Request held in (Meeting held Panel Public) in Public)

Number of 6 6 5 12 9 4 6 meetings

Governing Body

Members

Mrs Sharon Beamish 5 out of 6 4 out of 4 9 out of 12 4 out of 8 4 out of 4

Mr Adrian Stokes 4 out of 4 4 out of 6 3 out of 3

Ms Andrea Green 2 out of 2 4 out of 5 3 out of 4 1 out of 1

Mr Chris Lonsdale 3 out of 3 2 out of 3 12 out of 12

Mrs Clare 3 out of 3 3 out of 3 6 out of 6 Hollingworth

Ms Jo Galloway 6 out of 6 0 out of 6 7 out of 12 6 out of 9

1 out Mr David Allcock 3 out of 6 8 out of 12 1 out of 4 of 5 1 out Mr Graham Nuttall 4 out of 6 5 out of 6 10 out of 12 4 out of 4 4 out of 6 of 5

Ms Susan Turner 6 out of 6 9 out of 12

Dr Inayat Ullah 2 out of 3 3 out of 5 0 out of 5

Dr Arshad Khan 5 out of 6 5 out of 6 8 out of 9

Dr Godwin Igodo 1 out of 6 2 out of 6 1 out of 6

Dr Imogen Staveley 4 out of 4 6 out of 7

Dr Jonathan 2 out 5 out of 6 4 out of 8 Timperley of 5

Others

Dr Helen King (or 2 out of 4 deputy) Dr Shade Agboola 0 out of 2 (or deputy)

Ms Jenni Northcote 4 out of 6 4 out of 6

Mr Andrew Harkness 3 out of 6 11 out of 12

Ms Tricia Lowe 1 out of 1 1 out of 2

10 NHS Coventry and Rugby Clinical Commissioning Group NHS Warwickshire North Clinical Commissioning Group Enc Q

Report To: Governing Body Meetings in Common

Report Title: Assurance Framework

Report From: Executive Lead - Andrew Harkness , Chief Transformation Officer Author - Laura Whiteley, Governance and Corporate Affairs Manager

Date: 20 May 2020

Previously Considered by: N/A

Action Required (delete as appropriate)

Decision: Assurance:  Information: Confidential

Purpose of the Report: The Assurance Framework is presented to the Governing bodies to outline the Q4 2019-20 position with regards to managing risks to the CCGs achieving its principle strategic objectives. The Assurance Framework details the key risks to achieving the strategic priorities of the organisations along with current risk ratings and mitigating actions in place.

Key Points:

Assurance Framework • The Assurance Framework is an integral part of the system of internal control and enables the Governing Body to focus on the strategic risks, which may impact on delivery of the organisation priorities. The Assurance Framework summarises the controls and assurances that are in place, or are planned, to mitigate against them. • The Assurance Framework is updated quarterly to reflect the latest position. Changes made to risks scores since the last quarter are listed below.

AF CCG Risk Previous Score Current Score No

AF2 CRCCG Failure to deliver the NHS Constitutional 16 25 target for referral to treatment time WNCCG 16 25 (92% of patients waiting on an incomplete pathway less than 18 weeks)

AF4 CRCCG Failure to deliver the financial plan and 20 16 control total WNCCG 12 16

AF9 CRCCG Risk to quality and safety of patient care N/a - new Risk 25 due to Covid-19 WNCCG N/a - new Risk 25

• Highest rated risks (16+) at the end of Q4 are;

o AF1 Failure to deliver the required NHS Constitution standard target of 4 hours wait in ED for

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

our population

o AF2 Failure to deliver the NHS Constitutional target for referral to treatment time (92% of patients waiting on an incomplete pathway less than 18 weeks)

o AF4 Failure to deliver the financial plan and control total (WNCCG and CRCCG) o AF8 Risk the Transforming Care Programme will not achieve the planned trajectory. o AF9 (New Risk) Risk to quality and safety of patient care due to Covid-19 • The risks identified are common to both CCGs however each Governing body remains responsible for its own risks. • Each risk has been assigned ownership to an Executive, mitigating actions identified and risk scored (using the grading matrix) and then been subject to review by the Directors. • The Assurance Framework is presented to the Governing Bodies on a quarterly basis. • The Assurance Framework for 2020-21 is being refreshed and aligned with the new organisational objectives.

Recommendation: The Governing Body are asked to: • RECEIVE the Assurance Framework NOTING the updates and determine whether they are; • ASSURED that adequate actions are being taken by the Executives to mitigate the risks and that the assurances provided are satisfactory.

Implications

• We will enable our local health and care system to deliver a sustainable, integrated Objective(s) / Plans response to the needs of our Places, reducing health inequalities through our supported by this commissioning strategy. report: • We will focus our resources to secure services that are value for money and promote a financially sustainable health economy. Conflicts of Interest: None identified Non-Recurrent Expenditure: Not applicable. Recurrent Expenditure: Not applicable. Financial: Is this expenditure included within the CCG’s Financial Yes No N/A  Plan? (Delete as appropriate) Performance: None identified Quality and Safety: As detailed within the Assurance Framework and Risk register General Statement: The CCG is committed to fulfil its obligations under the Equality Act 2010, and to ensure services commissioned by the CCG are non-discriminatory on the grounds of any protected characteristics. Policies/decisions may need to be adjusted in line with any equality analysis or due regard. Any decision that is finalised Equality and Diversity: without being influenced by appropriate due regard could be deemed unlawful. Has an equality impact Yes assessment been undertaken? No N/A  (attached) (Delete as appropriate) Patient and Public N/A Engagement: Clinical Engagement: N/A Risk and Assurance: Failure to have adequate systems of risk management and assurance could have a

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

material impact on the achievement of the CCG strategic and corporate objectives and NHS Constitutional targets.

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Governing Body Assurance Framework 2019/20 As at April 2020 Summary of Assurance Framework Risks

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

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

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

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

AF1 Delivery of NHS Constitution 4 Hour Wait in ED target 16 12 16 16 16 12 16 16 Andrew Harkness - Chief Transformation Officer

AF2 Delivery of NHS Constitution Referral to Treatment target 16 16 16 25 16 16 16 25 Andrew Harkness - Chief Transformation Officer

AF3 Effectiveness of Preparation for Transition to Integrated Care 12 12 12 12 12 12 12 12 Adrian Stokes, Chief Officer System

AF4 Delivery of the Financial Plan and control total 12 12 12 16 16 20 20 16 Chris Lonsdale - Interim Chief Finance Officer

AF5 Achievement of quality and sustainability of primary care 6 6 6 6 6 6 6 6 Jenni Northcote – Chief Strategy and Primary Care Officer

AF6 Development and sustaining structures, processes, skills and 12 12 12 12 12 12 12 12 Andrew Harkness - Chief Transformation Officer expertise to deliver operational and strategic objectives

AF7 Monitoring quality concerns of commissioned services 6 6 6 6 6 6 6 6 Jo Galloway – Chief Nursing Officer & Deputy Accountable Officer

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

AF9 Quality and Safety of patient care due to Covid-19 - - - 25 - - - 25 Adrian Stokes, Chief Officer Delivery of NHS Constitution 4 Hour Wait in ED target

Ref Owner: Risk Summary:

Andrew Harkness, Chief Failure to deliver the required NHS Constitution standard target of 4 hours AF1 Transformation Officer wait in ED for our population

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

COVENTRY AND RUGBY CCG WARWICKSHIRE NORTH CCG Finance and Performance Finance and Performance Lead Committee: Lead Committee: Committee Committee Risk rating Likelihood Impact Score Risk rating Likelihood Impact Score Quarter 1 4 4 16 Quarter 1 4 4 16 Quarter 2 3 4 12 Quarter 2 3 4 12 Quarter 3 4 4 16 Quarter 3 4 4 16 Quarter 4 4 4 16 Quarter 4 4 4 16 Rationale for Score: Rationale for Score: The impact of Covid-19 has had a dramatic effect on the level of demand in The impact of Covid-19 has had a dramatic effect on the level of terms of A&E attendances and associated admissions. A&E attendances demand in terms of A&E attendances and associated have fallen to around 45% of normal levels, and admissions have fallen by admissions. A&E attendances have fallen to around 35-45% of 25%. This together with a refocusing of clinical areas for dealing with Covid normal levels, and admissions have fallen by 40%. This together patients separate from non-covid patients, has seen an improvement in with a refocusing of clinical areas for dealing with Covid patients A&E performance with the Trust having reached over 95% in the two separate from non-covid patients, has seen an improvement in weeks. This means the target itself is less at risk, but there are concerns over the sustainability of this once demand from Covid reduce and normal A&E performance with the Trust having reached over 90% in the A&E demands increase, there is also a concern referenced in the overall two weeks. This means the target itself is less at risk, but there risk around Covid of patients who need urgent treatment, avoiding going to are concerns over the sustainability of this once demand from hospital - this may lead to increased morbidity for these patients in due Covid reduce and normal A&E demands increase, there is also a course. concern referenced in the overall risk around Covid of patients who need urgent treatment, avoiding going to hospital - this may Risk Rating History 25 20 15 16 16 16 12 10 CRCCG Score Risk 5 WNCCG 0 1 2 3 4 Quarter

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

Actions for both CRCCG and WNCCG: in place complete STF Trajectories agreed with NHS Picked up in contracting meetings, and escalated as improvements, set as SDIP within contracts. necessary requiring RAPs if necessary. Ties in Trusts performance to contract and yes NHS I regulatory action. in place ongoing Normal contractual meetings - technical Allows for issuing of PN against non delivery of meeting, contract review and escalation trajectory, and associated remedial action plans. meeting at Director level. F&P and GB Reported through F&P and through to GB. Meetings. yes Controls (Actions in place or planned to control the risk) Assurances (How we are assured that the action Positive is having the desired impact and level of assurance Assurance ? In Place or Planned Completion Description of Control Yes, not yet Date in place ongoing System review meetings - joint with NHS Agreement of recovery actions across the system, I/E, CCG and Trust around performance, signed off and assured by NHS I/E across allows for escalation at Regional and AO Commissioner and Provider. level. yes

in place ongoing Local A&E delivery board to oversee Feeds into STP UEC Board, and through to STP progress and to agree system actions to Board, also feeds into Place based transformation address operational issues, impacting board, and place based boards therefore escalated yes performance. at CO/AO level.

Actions for CRCCG only (none) Actions for WNCCG only (none) Equality and Diversity Implications: None identified

Quality Implications

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

Ref Owner: Risk Summary:

Andrew Harkness, Chief Failure to deliver the NHS Constitutional target for referral to treatment time AF2 Transformation Officer (92% of patients waiting on an incomplete pathway less than 18 weeks)

COVENTRY AND RUGBY CCG WARWICKSHIRE NORTH CCG Finance and Performance Finance and Performance Lead Committee: Lead Committee: Committee Committee Risk rating Likelihood Impact Score Risk rating Likelihood Impact Score Quarter 1 4 4 16 Quarter 1 4 4 16 Quarter 2 4 4 16 Quarter 2 4 4 16 Quarter 3 4 4 16 Quarter 3 4 4 16 Quarter 4 5 5 25 Quarter 4 5 5 25 Rationale for Score: Rationale for Score: Covid-19 has impacted on this target immediately, as all non- Covid-19 has impacted on this target immediately, as all non- routine inpatient activity has been stopped for the next 3 months, routine inpatient activity has been stopped for the next 3 months, this will lead to an increase in total incompletes and will worsen this will lead to an increase in total incompletes and will worsen the RTT delivery, reducing to below 70% by the end of June, the RTT delivery, reducing to below 70% by the end of June, based on latest projections. There has also been a reduction in based on latest projections. There has also been a reduction in GP referrals, but once Covid pressures reduce, this will lead to a GP referrals, but once Covid pressures reduce, this will lead to a large increase in referrals, and with the majority of available large increase in referrals, and with the majority of available capacity being focused on dealing with urgent cases, and the capacity being focused on dealing with urgent cases, and the longest waiters improvements to RTT will take a considerable longest waiters improvements to RTT will take a considerable amount of time. amount of time.

The impact on RTT from Covid will be long lived, and the CCG The impact on RTT from Covid will be long lived, and the CCG should not expect to see delivery even at pre-covid levels for should not expect to see delivery even at pre-covid levels for many months ahead. many months ahead.

Risk Rating History 25 25 20 15 16 16 16 10 CRCCG Score Risk 5 WNCCG 0 1 2 3 4 Quarter

Actions for both CRCCG and WNCCG: in place complete STF Trajectories agreed with NHS Picked up in contracting meetings, and escalated as improvements, set as SDIP within contracts. necessary requiring RAPs if necessary. Ties in Trusts performance to contract and yes NHS I regulatory action. in place ongoing Normal contractual meetings - technical Allows for issuing of PN against non delivery of meeting, contract review and escalation trajectory, and associated remedial action plans. meeting at Director level. F&P and GB Reported through F&P and through to GB. Meetings. yes in place ongoing System review meetings - joint with NHS Agreement of recovery actions across the system, I/E, CCG and Trust around performance, signed off and assured by NHS I/E across allows for escalation at Regional and AO Commissioner and Provider. level. yes

in place ongoing Local Place based transformation board to Feeds in Place based boards therefore escalated at oversee progress of elective care CO/AO level, as well as into STP Planned care yes transformation and impact on RTT and to Board, and STP Board. agree system actions to address operational

Actions for CRCCG only (none) Actions for WNCCG only (none) Equality and Diversity Implications: None identified

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

Ref Owner: Risk Summary: If the CCGs fail to adequately prepare and transition to an integrated care system (ICS) there is a risk that the design, development and implementation Adrian Stokes – Chief AF3 of integrated care will not be achieved by 2021 impacting on the ability to Officer improve population health outcomes and effectively support staff through change.

Strategic Priority To increase the pace of the evolution of the health system towards having a single Integrated Care System Impacted: by 2021

COVENTRY AND RUGBY CCG WARWICKSHIRE NORTH CCG

Lead Committee: Governing Body Lead Committee: Governing Body

Risk rating Likelihood Impact Score Risk rating Likelihood Impact Score Quarter 1 3 4 12 Quarter 1 3 4 12 Quarter 2 3 4 12 Quarter 2 3 4 12 Quarter 3 3 4 12 Quarter 3 3 4 12 Quarter 4 3 4 12 Quarter 4 3 4 12 Rationale for Score: Rationale for Score: From 2019/20 for CRCCG There has been realignment of From 2019/20 for WNCCG there has been realignment of incentives incentives through the agreed contract with UHCW which will help through a risk sharing agreement with George Eliot Hospital (GEH) to contribute to the achievement of the ICS by 2021. for the contract which will help to contribute to the achievement of the ICS by 2021. Coventry Health and Wellbeing Board sets priorities with Coventry Place Partnership established to lead on the delivery of planning WN Partnership established leading on planning priorities and priorities for Coventry as a Place. assurance for WN as a Place. WN Place Executive is meeting and Coventry Place Health and Care Executive is meeting and both the has identified priorities for joint working at Place for 2019/20. The Partnership and the Executive as well as Rugby Place Partnership Partnership and the Executive are supporting the design are supporting the design development and implementation of development and implementation of integrated care at WN Place and integrated care at Coventry and Rugby Places. subsequently the formation of the ICS and the Accountable Officer is the Chair of the Transformation Board.

Risk Rating History 25 20 15 12 12 12 12 10 CRCCG Score Risk 5 WNCCG 0 1 2 3 4 Quarter Controls (Actions in place or planned to control the risk) Assurances (How we are assured that the action Positive is having the desired impact and level of assurance Assurance? In Place or Planned Completion Description of Control Yes, not yet Date

Actions for both CRCCG and WNCCG: In Place Jul-18 ICS development programme underway and 2nd line - Healthcare Partnership Board oversight, being driven at the Healthcare Partnership CCG membership of the Board, receipt of minutes Board Level (Formerly STP Board) into CCG Joint Executive Team Meetings yes

In Place Nov-19 Single Commissioner for Mental Health 1st line - Staff member hold a joint post seconded from CR CCG to work across all 2nd line - Membership of system wide Mental Health three Coventry and Warwickshire CCGS on and Commissioning Boards/Meetings yes Mental Health In place Jul-19 Development of place based integrated 1st Line - agreed suite of Place principles partnerships: 2nd Line - CEO update at Governing Body yes

Actions for WNCCG only In Place 1st line - Joint post established to drive Chief Primary Care and Strategy Officer transformational programmes for WN WN/CR CCGs is now a joint post working across the George Eliot Hospital at Director Nov-19 of Strategy and Transformation Yes in Place Jun-18 WNCCG Place partnership established 2nd Line: meeting minutes; yes

Actions for CRCCG only In Place Sep-18 Rugby Partnership established 2nd Line: meeting minutes/notes; Yes

In Place Apr-19 Coventry Partnership established 2nd Line: meeting minutes/notes; Yes

In Place Jul-19 Chief Transformation Officer WN/CR CCGs 2nd Line: attendance at Coventry Place meetings named Executive CCG Lead Yes

Equality and Diversity Implications: EQIAs are completed for any revised policies and completed as part of business case proposals

Quality Implications Failure to design , develop and implement an integrated care system may affect the provision of high quality effective health and care services for the local population. Quality Impact Assessments are carried out and implications considered. Delivery of the Financial Plan and control total

Ref Owner: Risk Summary: If the CCG fails to deliver the financial plan and control total there is a risk that Chris Lonsdale - Interim AF4 NHSE/I impose special measures and/or legal directions on the CCGs Chief Finance Officer resulting in reputational damage and loss of autonomy

Sustain the focus on delivering today’s challenges (Finance: Performance: Quality; and continue to embed Strategic Priority the single team culture in some areas) during a period of significant evolution of the local commissioning Impacted: landscape and during Covid-19 Level 4 Incident.

2525 2020 16 1515 16 1212 1212 1212 1010 CRCCG Score Risk Score Risk 5 5 WNCCG 0 0 1 1 22 33 44 QuarterQuarter Controls (Actions in place or planned to control the risk) Assurances (How we are assured that the action Positive is having the desired impact and level of assurance Assurance?

In Place or Planned Completion Description of Control Yes, not yet Date

Actions for both CRCCG and WNCCG: in place Mar-20 Directive Action: Payment for NHS Providers Processes in place in line with NHS requirements. not yet in place Mar-20 Directive Action: Process in place for sign off of additional Covid-19 related costs daily by CFOs with escalation to AOs. Processes in place not yet

Preventative Action: Mechanisms to be put in place as Covid-19 approach changes phases Still too early in current phase not yet in place Ongoing Detective Action: Monthly review and Reports to F&P financial reporting mechanisms not yet

Equality and Diversity Implications: None identified

Quality Implications Will be assessed as remedial actions are identified. Achievement of quality and sustainability of primary care

Ref Owner: Risk Summary: Jenni Northcote – Chief Due to the increase in demand for General Practice, there is a risk that the AF5 Strategy and Primary Care CCG fails to achieve the right quality and sustainability of primary care Officer resulting in poor patient experience and care

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

COVENTRY AND RUGBY CCG WARWICKSHIRE NORTH CCG

Lead Committee: Governing Body Lead Committee: Governing Body

Risk rating Likelihood Impact Score Risk rating Likelihood Impact Score Quarter 1 2 3 6 Quarter 1 2 3 6 Quarter 2 2 3 6 Quarter 2 2 3 6 Quarter 3 2 3 6 Quarter 3 2 3 6 Quarter 4 2 3 6 Quarter 4 2 3 6 Rationale for Score: Rationale for Score: There is a workforce strategy in place for Primary Care and There is a workforce strategy in place for Primary Care. An Primary Care Networks are in place in Coventry and Rugby options appraisal is underway to respond to housing growth and supporting collaborative working. An additional GP surgery has to consider options for commissioning additional general practice also been commissioned in Rugby. medical provision for the population. A number of ETTF schemes which support primary care estates The CCG has met the national timeline for improving access, development and refurbishment are in place and have applied for including extended hours and sites for accessing GP services out additional ETTF funding. Identified priority areas impacted by of hours. housing growth which have been put forward as part of STP GPFV group actively working with the CCG to identify initiatives workbook. The CCG is expanding the delivery sites for improving and interventions that support the 10 high impact actions for access to meet the 100% coverage target. PMS schemes that sustainable general practice. are supporting quality improvements and new scheme developed MOU to support practice resilience across both CCGs and going to may PCC for approval. Paramedic visiting service Clinical Pharmacist partnership agreement with SWFT, staff operating across CRCCG. PCN's progressing with reimbursable recruited. Agreement with GEH for partnership to recruit FCP. role recruitment . Work continues with OOH provider to support Work continues with OOH provider to support integrated working integrated working and establishing MDT's and establishing MDT's. All practices have good or better CQC There are currently no practices with closed lists and no practices rating. CCG has introduced practice resilience escalation during Risk Rating History f CO 25 20 15 10 CRCCG 66 Score Risk 5 6 6 6 WNCCG 0 1 2 3 4 Quarter

Actions for both CRCCG and WNCCG: in place Ongoing Primary Care Committees established Quality and performance reports to committees Yes

PrimaryC itt care monthlyi t update to committees covering resilience issues. Yes Primary care Risk Register reported to Committees Yes

Regular dialogue with NHS England with escalation processes for any concerns and issues Yes in place Ongoing Primary Care Delivery Group formed to As above. manage operational issues across CR and GP FV group formed in WN Yes Controls (Actions in place or planned to control the risk) Assurances (How we are assured that the action Positive is having the desired impact and level of assurance Assurance ? In Place or Planned Completion Description of Control Yes, not yet Date in place Ongoing Regular meetings with LMCs across both Early identification of issues and shared ownership CCGs. of resilience response, e.g., temporary list closures. Yes Reports to Committees and Committee minutes In place May-18 Cluster leads appointed in CR and attending Monitoring reports to Primary Care Commissioning Primary Care Operational Group. WN in the Committee and Joint Commissioning Committees process of appointing. Also regular dialogue Yes and supervision in place. in place Dec-17 Secured funding for international Mobilisation to be monitored via PCOG and Primary recruitment to support primary care Care Committee. Yes

In place ongoing Primary care Workforce Strategies Monitoring reports to Primary Care Commissioning developed and working group taking forward Committee and Joint Commissioning Committees actions in the strategy - feeds into training Yes hubs, LWAB and STP workforce Group in place Jun-18 Submission of bid for recruitment and Clusters in place at Coventry and Rugby CCG retention funds successful and another bid Yes has been submitted in place May-18 Schemes mobilised using transformation reported and monitored through Primary Care fund across both CCGs to test new ideas for commissioning Committee primary care transformation and resilience Yes in place Jun-18 Piloting online consultations and developing PCC GP IT strategy to support primary care Digital Transformation Board established with full IT delivery programme Yes in place Sep-19 PCNs actively undertaking recruitment of Proactive engagement with PCNs through a weekly new reimbursable roles as per national conference call to ensure that the process is guidance followed. A reimbursement claim process has been Yes developed which meets national guidance. in place Sep-19 PCN development fund to support A collaboration with the Primary Care Delivery development of PCNs working with local Group (for CRCCG) and the GP Forward View providers to support primary care Group (for WNCCG). Overseen on behalf of the Yes sustainability three CCGs by the Primary Care Programme Board. in place Sep-19 In the process of commissioning APMS APMS Assurance Board which feeds into the contracts Primary Care Commissioning Committee Yes

Actions for CRCCG only In place Nov-17 CRCCG only - Memorandum of Bi-monthly meetings to review progress against Understanding agreed with Alliance to MoU performance criteria support resilience in primary care Yes

Actions for WNCCG only In place Jul-18 WNCCG only - meeting organised in PCC monitoring and assurance November to discuss Memorandum of Understanding for resilience in primary care N/A

In place Jun-18 WNCCG - Plan developed to take forward Clusters in place at Warwickshire North CCG clusters following engagement exercise with practices. Yes

Equality and Diversity Implications: None identified

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

Ref Owner: Risk Summary: Due to uncertainty regarding the CCGs' future, there is a risk that there is not Andrew Harkness - Chief enough capability and capacity at all levels resulting in the CCG failing to develop AF6 Transformation Officer and sustain the right structures, processes, skills and expertise to deliver our operational and strategic objectives

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

COVENTRY AND RUGBY CCG WARWICKSHIRE NORTH CCG

Lead Committee: Governing Body Lead Committee: Governing Body

Risk rating Likelihood Impact Score Risk rating Likelihood Impact Score Quarter 1 3 4 12 Quarter 1 3 4 12 Quarter 2 3 4 12 Quarter 2 3 4 12 Quarter 3 3 4 12 Quarter 3 3 4 12 Quarter 4 3 4 12 Quarter 4 3 4 12 Rationale for Score: Rationale for Score: Considerable work has been undertaken to harmonise a number of key Considerable work has been undertaken to harmonise a number of key HR policies which have been approved and adopted by the Governing HR policies which have been approved and adopted by the Governing Body. The Outcome of the vote on the merger proposals resulted in a Body. The Outcome of the vote on the merger proposals resulted in a vote for Merge to a single CCG. vote for Merge to a single CCG. Refreshed CCG strategic objectives signed off in March 2020 for the Refreshed CCG strategic objectives signed off in March 2020 for the 2020/21 year. 2020/21 year.

Actions for both CRCCG and WNCCG: in place Ongoing Systems and processes are in place. NHSE assurance framework ratings. Yes

In place Apr-18 Development of an organisational Monitoring of strategic objectives in OD plan at development Strategy CQGC and progressed with Staff through Staff forum. CRCCG and WNCCG OD Strategy 2018-2021 in yes place. This is currently being refreshed and revised to support proposed requirements in 2019-20 in place Jun-18 Development of an Organisational Monitoring of Action against OD plan at CQGC and Yes Development Action Plan progressed with Staff through Staff forum in place May-18 Development and circulation of shared Values were refreshed, agreed and adopted in values for both CCGs 2018/19. Values on CCG websites, publicised in yes CCG buildings, incorporated in staff appraisals. in place Scheduled Governing Body joint development sessions GB development sessions held throughout 2018/19. throughout the Staff engagement and support (including retention) yes year incorporated in the development priorities. in place Feb-18 Staff Forum launched and working with Very positive feedback has been received regarding senior management team and CCG staff to the staff wellbeing programme and wellbeing matters yes undertake Workplace Wellbeing Charter newsletters delivered by the CCG Wellbeing action plan Warriors. in progress Dec-19 Strategic and Operational review process is A Governing Body development session has taken in progress. place to review and revise the strategic objectives. Objectives will now go through organisational governance for sign off in March 2020. yes

Actions for CRCCG only (none) Actions for WNCCG only (none) Equality and Diversity Implications: Equality and Diversity implications were reviewed as part of the review of objectives and no further implications were found.

Quality Implications Quality implications were reviewed as part of the review of objectives and no further implications were found. Monitoring quality concerns of commissioned services

Ref Owner: Risk Summary: Due to variability in reporting processes within commissioned services, there Jo Galloway – Chief is a risk that the CCG may not identify and address all material quality AF7 Nursing Officer & Deputy concerns resulting in the potential for service failure and reputational and Accountable Officer patient harm.

COVENTRY AND RUGBY CCG WARWICKSHIRE NORTH CCG Clinical Quality and Clinical Quality and Governance Lead Committee: Lead Committee: Governance Committee Committee Risk rating Likelihood Impact Score Risk rating Likelihood Impact Score Quarter 1 2 3 6 Quarter 1 2 3 6 Quarter 2 2 3 6 Quarter 2 2 3 6 Quarter 3 2 3 6 Quarter 3 2 3 6 Quarter 4 2 3 6 Quarter 4 2 3 6 Rationale for Score: Rationale for Score: Review of quality monitoring completed and a new Quality Review of quality monitoring completed and a new Quality Assurance Assurance Framework approved by Governing Body in January Framework approved by Governing Body in January 2019. A period 2019. A period of embedding has taken place together with steps of embedding has taken place together with steps to reduce to reduce identified quality gaps. identified quality gaps. Quality lead in post for 'other providers' to close quality gap. Quality lead in post for 'other providers' to close quality gap. Annual Annual review of QAF is in progress and will be aligned with review of QAF is in progress and will be aligned with system QAF system QAF and presented to CQGC for ratification. Quality hub and presented to CQGC for ratification. Quality hub set up and set up and revised assurance arrangements implemented in revised assurance arrangements implemented in response to COVID- response to COVID-19. 19. Risk Rating History 25 20 15 10 CRCCG Score Risk 5 6 6 6 6 WNCCG 0 1 2 3 4 Quarter Controls (Actions in place or planned to control the risk) Assurances (How we are assured that the action Positive is having the desired impact and level of assurance Assurance? In Place or Planned Completion Description of Control Yes, not yet Date

Actions for both CRCCG and WNCCG: in place Completed in CRCCG/WNCCG - Comprehensive range of 2nd line assurance - Bi-monthly reporting to Clinical place and quality assurance monitoring and assurance Quality and Governance Committee. ongoing papers received by Clinical Quality and 3rd Line of Assurance - external reviews/deep dives yes Governance Committees. presented to CQGC as necessary

In Place Completed in A review of quality monitoring has been 1st line - Quality Lead 'other' in post to ensure place and completed and gaps in assurance processes effective quality monitoring and reporting. ongoing identified are being addressed 2nd Line - Reports to CQGC as part of provider yes Quality report In place Completed in Quality Assurance Framework in place that 2nd line Bi-monthly reporting to Clinical Quality and place and includes a risk based escalation process Governance Committee yes ongoing In place Completed in Clinical Quality Review Meetings with 2nd line - CCG Oversight of contractual quality place and providers indicators and standards ongoing yes In Place Completed in Coventry and Warwickshire System 2nd line - System QSG includes place and Quality Surveillance Group (QSG) representation from Heathwatch, NHSE/I, ongoing CQC main NHS providers and both Local Yes In place Ongoing Comprehensive monitoring of local and 2nd line - reporting F&P, CQGC and Bi-monthly national quality and performance indicators. reporting to Governing Body yes

Actions for WNCCG only (none)

Equality and Diversity Implications: EQIA considered where required

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

Ref Owner: Risk Summary: If we are unable to prevent adults with a learning disability and/or autism from being admitted to hospital, and reduce lengths of stay there is a risk that the CCG will not Jo Galloway – Chief achieve the planned trajectory for the Transforming Care Programme by the end of AF8 Nursing Officer March 2020 resulting in some patients not receiving care in the most appropriate setting impacting on individual outcomes together with reputational risk for the CCG.

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

COVENTRY AND RUGBY CCG WARWICKSHIRE NORTH CCG Clinical Quality and Governance Clinical Quality and Governance Lead Committee: Lead Committee: Committee Committee Risk rating Likelihood Impact Score Risk rating Likelihood Impact Score Quarter 1 4 4 16 Quarter 1 4 4 16 Quarter 2 4 4 16 Quarter 2 4 4 16 Quarter 3 4 4 16 Quarter 3 4 4 16 Quarter 4 4 4 16 Quarter 4 4 4 16 Rationale for Score: Rationale for Score: The Transforming Care Programme Trajectory for 2019/20 for The Transforming Care Programme Trajectory for 2019/20 for Arden Transforming Care Partnership was not achieved. Arden Transforming Care Partnership was not achieved.

Risk Rating History 25 20 15 16 16 16 16 10 CRCCG Score Risk 5 WNCCG 0 1 2 3 4 Quarter

Actions for both CRCCG and WNCCG: In place In place Detailed recovery plan in place to address Recovery plan progress reported to Clinical Quality the risks. Oversight managed by and Governance Committee Transforming Care Board reporting to CCGs/ BHBCBV and the Collaborative Commissioning Boards. New action in place to establish if any yes additional discharges from NHSE specialised services can be identified and appropriately supported.

In Place Ongoing NHSE Regional Director scrutiny of action to External assurance of actions recover yes

In Place in place Additional case management resources Positive impact on reduction in NHSE patients being sought to assist with NHSE complex achieved discharges yes In Place All in place Community assessment and treatment beds Successful discharges from long stay facilities end April 18 in place; IST and Crisis response all age services in place; Community forensic services in place; New framework of Providers for care and Yes support in place; New joint framework for funding agreements in place to prevent delay in community support. in place in place funding for CAMHS three plus service Prevent more admissions to specialist services of agreed. Service is currently being those who can be best supported at home with yes implemented. specialist CAMHS care. In Place Ongoing The CCG has established strategic External consultant review commissioned jointly with oversight via the Learning Disability and NHSE phase 1 scoping complete and updated Autism Transformation Board, is working recovery plan established closely with NHSE and has committed Programme manager post now in place. significant increased resources to recover Monitoring via the Admission Avoidance sub group yes the position. The CCG has agreed a which reports to the LDATB who provide oversight revised trajectory for that we expect to meet by September 2020.

(none) Actions for WNCCG only (none)

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

Quality Implications This risks failing to deliver the planned improvements in the Transforming Care Programme for the full cohort of people COVID-19 Pandemic

Ref Owner: Risk Summary: If COVID-19 continues to spread there is a risk that the CCG and its provider Adrian Stokes - AF9 organisations will not be able to meet the demand on its services, Accountable Officer compromising business continuity and quality and safety of patient care. 1) We will work collaboratively with our partners to continuously improve quality of care. 2) We will enable Strategic Priority our local health and care system to deliver a sustainable, integrated response to the needs of our Place, Impacted: reducing health inequalities through our commissioning strategy.

COVENTRY AND RUGBY CCG WARWICKSHIRE NORTH CCG Clinical Quality Governance Clinical Quality Governance Lead Committee: Lead Committee: Committee Committee Risk rating Likelihood Impact Score Risk rating Likelihood Impact Score Quarter 1 0 0 0 Quarter 1 0 0 0 Quarter 2 0 0 0 Quarter 2 0 0 0 Quarter 3 0 0 0 Quarter 3 0 0 0 Quarter 4 5 5 25 Quarter 4 5 5 25 Rationale for Score: Rationale for Score: Extremely likely to occur and will almost certainly have a large Extremely likely to occur and will almost certainly have a large scale scale impact on the delivery of our services and that of our impact on the delivery of our service and that of our providers providers resulting in the potential for patient harm and significant resulting in the potential for patient harm and significant loss of loss of business continuity business continuity

Risk Rating History 2525 25 2020 1515 1010 CRCCG Score Risk Score Risk 5 5 WNCCG 0 0 0 0 0 1 1 2 2 3 3 4 4 QuarterQuarter Controls (Actions in place or planned to control the risk) Assurances (How we are assured that the action Positive is having the desired impact and level of assurance Assurance?

In Place or Planned Completion Description of Control Yes, not yet Date

Actions for both CRCCG and WNCCG: In place Directive - CCG business continuity plan. Weekly review of business continuity arrangements at Directors meeting. Yes In place Preventative - Business Impact Assessments 1) Regular review of business continuity arrangements at completed across the CCGs to identify risks to Directors Meeting with escalation to Executive Meeting business continuity. as required. 2) Monthly reporting of business Yes continuity arrangements at Governing Body Meeting.

In place Detective - Escalation reporting and logging of 1) Level of usage monitored 7 days per week. 2) incidents across Coventry and Warwickshire via Feedback from providers. 3) Monitoring incidents via dedicated reporting inbox. Clinical Quality Review Meetings. yes

In place Preventative - Coventry and Warwickshire Wide 1) Regular review of business continuity arrangements at Incident Management Team for the co- Directors Meeting with escalation to Executive Meeting ordination and planning of CCG business as required. 2) Monthly reporting of business yes continuity, including Primary Care. continuity arrangements at Governing Body Meeting.

In place Monitoring - Weekly review of business Regular performance report to Directors Meeting with continuity at Directors Meeting and Executive Yes Meeting. escalations to Executive Meeting as required. In place Monitoring - reporting to Governing Body on Regular performance report to Directors Meeting with Monthly basis. yes escalations to Executive Meeting as required.

In place Monitoring - NHSE Regional Incident Control Ongoing monitoring of the clarity and quality of Room - Escalation as required and weekly call to instructions received to aid local decision making and receive updates and instructions. delivery of services. yes

In place Preventative - Weekly Strategic Coordination Feedback from participants and regular reporting of Group for all health providers and Local business continuity arrangements to Executive Authorities across Coventry and Warwickshire. Meeting and Governing Body. yes

Actions for WNCCG only Nil

Actions for CRCCG only Nil

Equality and Diversity Implications: The elderly , pregnant , vulnerable (LD , BAME) are at greater risk of harm.

Quality Implications Significant Quality Implications with a high risk of patient harm. NHS Coventry and Rugby Clinical Commissioning Group and NHS Warwickshire North Clinical Commissioning Group Strategic Priorities 2018/20 Strat egic

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

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

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

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

Grading Matrix

Risk Level Indicator

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

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

Catastrophic 5 25 20 15 10 5

Major 4 20 16 12 8 4

Moderate 3 15 12 9 6 3

Minor 2 10 8 6 4 2

Negligible 1 5 4 3 2 1

Likelihood x Consequence = Level of Risk

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

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

Patient Unsatisfactory patient Unsatisfactory patient Totally unsatisfactory Mismanagement of patient Serious mismanagement Experience experience not directly experience – readily patient outcome or care of patient care related to patient care resolvable experience

Below excess claim. Claim above excess level. Complaint/ Claim Justified complaint Multiple claims or single Locally resolved potentially Justified complaint involving Multiple justified Potential peripheral to clinical care major claim lack of appropriate care complaints 5-10% over budget / Insignificant cost increase/ 10-25% over budget / <5% over budget schedule slippage. >25% over budget / schedule slippage. Barely schedule slippage. Objectives / Projects schedule slippage. Minor Reduction in scope or schedule slippage. Doesn’t noticeable reduction in Doesn’t meet secondary reduction quality / scope quality requiring client meet primary objectives scope or quality objectives approval Loss/interruption of >8 Loss/interruption of >1 Permanent loss of service Service/ Business Loss/interruption of >1 hour Loss/interruption of >1 day hours week or facility Interruption/Environme Minimal or no impact on the Minor impact on Moderate impact on Major impact on Catastrophic impact on ntal impact environment environment environment environment environment Late delivery of key Uncertain delivery of key Non-delivery of key objective/ service due to objective/service due to objective/service due to lack of staff lack of staff lack of staff Unsafe staffing level or Unsafe staffing level or Ongoing unsafe staffing Human resources/ Short-term low staffing competence (>1 day) competence (>5 days) levels or competence Low staffing level that organisational level that temporarily Low staff morale Loss of key staff Loss of several key staff reduces the service development/staffing/ reduces service quality (< 1 quality No staff attending competence day) Poor staff attendance for mandatory training /key Very low staff morale mandatory/key training training on an ongoing basis No staff attending mandatory/ key training Uncertain delivery of key Non-delivery of key Loss of 0.1–0.25 per cent Loss of 0.25–0.5 per cent Small loss objective/Loss of 0.5–1.0 objective/ Loss of >1 per of budget of budget per cent of budget cent of budget Claim(s) between £10,000 Claim(s) between Failure to meet Financial including Risk of claim remote Claim less than £10,000 claims and £100,000 £100,000 and £1 million specification/ slippage Purchasers failing to pay Loss of contract / payment on time by results Claim(s) >£1 million Breach of statutory Single breach in statutory Multiple breaches in Enforcement action legislation duty statutory duty Multiple breaches in Prosecution No or minimal impact or statutory duty Statutory Duties/ Challenging external breach of guidance/ Reduced performance Complete systems change Inspection/Audit recommendations/ Improvement notices statutory duty rating if unresolved required improvement notice Low performance rating Zero performance rating Critical report Severely critical report National media coverage with >3 days service well Rumours Local media coverage Local media coverage – below reasonable public National media coverage expectation. MP concerned Adverse Publicity/ with <3 days service well (questions in the House) Reputation below reasonable public short-term reduction in long-term reduction in expectation Total loss of public Potential for public concern public confidence public confidence confidence Elements of public expectation not being met Damage to a services Damage to an individual’s Damage to a team’s Damage to an Damage to NHS reputation/ local media reputation. reputation. organisation’s reputation/ reputation/ coverage. Serious breach of Local and politically Information Possible media interest. Some local media interest. confidentiality e.g. up to National media coverage. sensitive media coverage. Governance/ Records 100 people affected Management Potentially serious breach. Serious potential breach & Serious breach with either Less than 5 people risk assessed high e.g. Serious breach with particular sensitivity e.g. affected or risk assessed unencrypted clinical potential for ID theft or over sexual health details, or up as low, e.g. files were records lost. Up to 20 1000 people affected to 1000 people affected encrypted people affected Enclosure R CRCCG Primary Care Committee Flash Report for the period March 2020 – May 2020

Achievements/Decisions Made/Items to Note Key Issues for the Governing Body MARCH – meeting stood down. There were no specific issues APRIL Closed raised or escalated to the Governing Covid updates to be provided monthly with additional updates to Body. Under delegation the Committee has a decision making Committee Chair as needed. Committee was updated on IMTs in place remit under the Terms of Reference with daily calls, weekly place meetings, Hot Hubs, dedicated email and for the Committee as set out in the website, shielded patients, practice resilience, acute care, technology, delegation agreement with NHSE. PPE, Funding package, staff testing and welfare support.

APRIL Public Finance Report – delegated primary medical care budget forecast to breakeven, adjustment made for list size growth, projects being developed to utilise PMS premium underspend or will carry over, usual overspend reported due to prescribing, Cat M drugs and GP IT.

Planning for next year currently suspended due to Covid.

Quality Report – Routine CQC inspections stood down due to Covid. Datix reporting system has been updated. Friends Family Test has been suspended due to Covid. Cytology screening stood down due to Covid but recovery plan being developed. Practice quality monitoring and patient safeguarding support being reviewed and increased in line with new ways of working (remotely) and isolating.

MAY Closed PMS Scheme Proposal – PCN level proposal to utilise PMS monies for Covid recovery and to accelerate new working models. NHSE welcomed the scheme, monitoring and reporting will be incorporated. This will not duplicate funding from any other source. Committee approved the scheme put forward from PCDG.

APMS Transitional Funding – Outline of applications received against the 4 contracts awarded for the incoming Provider to access additional funding in order to facilitate the transitional phase of the mobilisation of these contracts. This is in line with the percentage total contract value capped limit which was previously supported by The Committee, so report was for noting and assurance.

Risk Register – Primary Care risks are logged in a local risk register and Covid related risks are captured indaily IMT meetings. All primary care risks to be reviewed and re-graded and recorded on the local risk register and the Corporate Risk Register as appropriate.

Matters referred to the Governing Body for approval, debate or further consideration: • N/A in this reporting period

Key Information: • Committee Chair: Ludlow Johnson, Lay Member, CRCCG • CCG Lead: Jenni Northcote, Chief Strategy and Primary Care Officer Enclosure R Blank Page Enclosure S

WNCCG Primary Care Committee Flash Report for the period February - April 2020

Achievements/Decisions Made/Items to Note Key Issues for the Governing APMS Contracts: There is an APMS Assurance Board 19th May to discuss the WN re- Body st procurement and agree the timeline. Leicester Road successfully closed on the 31 March There were no specific issues raised or 2020. escalated to the Governing Body. Under delegation the Committee has a decision Primary Care Contract Report: There have been no applications to add or remove Partners making remit under the Terms of Reference to GMS contracts during this period. Paper being presented to WNPCC on 14th May 2020 to for the Committee as set out in the delegation agreement with NHSE. close practice registrations at The Old Cole House surgery as a direct impact of the Leicester Road Surgery dispersal. No applications to reconsider registration boundary areas and no applications to consider for mergers of practices. M84618 Rugby Road Surgery has informed the CCG that as of 10th April 2020 their branch site at Bedworth Health Centre has been closed temporarily due to Covid 19. The practice staff are working from the main Rugby Road site and remotely, as it was felt to be much safer for staff. The phones have been diverted to the Rugby Road site and patients will be seen face to face if required as staff are limited at present.

Estates: February Closed – STP Wide estates strategy was presented and noted with request that Coventry and South Warwickshire estates developments also be included for assurance regarding boundary developments and whole system strategy. April closed meeting – request for approval of Weddington FBC, financial appraisal of revenue, growth and affordability was explained, also justification of building size and capacity based on local population needs. Committee approved the FBC subject to clarification of any adjustments to timelines and funding release due to Covid.

Warfarin: All Warwickshire North practices have signed up to and commenced the Warfarin Enhanced Service. This practice is working collaboratively with the CCG to support the delivery of this service. General work can continue to ensure quality and systems are robust

Shared Care: All Warwickshire North practices have signed up to and commenced the shared care enhanced service. This practice is working collaboratively with the CCG to support the delivery of this service. The SC Clinical Development Group continue to meet and will work on embedding in first year and resolving any outstanding issues or issues that arise.

GPIT: Warwickshire North practices continue to migrate to the Health Shared Care Network (HSCN) fibre broadband. The work plan has been revised due to the impact on engineer staffing resource during Covid19. Completion date has been delayed from April 2020 to June 2020 as previously stated. Completion is still ahead of the N3 termination date in August 2020.

The CCG has been awarded additional technology equipment to support remote working for general practice. The equipment is being deployed and strengthened to ensure that patients are able to remote access to a GP for an initial audio or video consultation before a decision is made for a face to face clinical assessment. SWFT IT has provided the technology software to remote access to the GP IT Clinical system. This remote triage service complies with the NHSE Covid 19 Primary Care Preparedness Letter 27th March.

Medical Interoperable Gateway (MIG). This technology software works in “real time” so there is no delay in patient GP information being made available to view when the patient is receiving direct care. This software is currently going through end to end testing in readiness to deploy across Warwickshire North (GEH, WMAS, 111, Hospices, Community services and Extended Access). This system will be the first stage towards a system wide Integrated Care record.111-Direct GP Appointments 1:3,000 registered patients. This service is now being deployed across the Warwickshire North practices.

Matters referred to the Governing Body for approval, debate or further consideration: • N/A in this reporting period

Key Information: • Committee Chair: Graham Nuttall, Lay Member, WNCCG • CCG Lead: Jenni Northcote, Chief Strategy and Primary Care Officer Enclosure S

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Report To: Governing Body Meetings in Common

Report Title: Annual Report of Coventry & Rugby Primary Care Commissioning Committee meetings 2019/20

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

Date: 20 May 2020

Previously Considered by: N/A

Action Required (delete as appropriate)

Decision: Assurance:  Information: Confidential

Purpose of the Report: To provide Governing Body Meetings in Common with assurance that both the CCG Chief Officer responsible and the Lay Member Chair of Coventry and Rugby Primary Care Commissioning Committee have considered the function of the Committee during the financial year 2019/20, as documented in the following report, and are satisfied with the performance of the Committee with no further actions being recommended.

Key Points: The following report documented the performance of the Primary Care Committee under the following format: • Membership and Meetings • Appendix 1: Meeting Dates and attendance. • Administration and Communication - The level of satisfaction with the quality of information received for meetings, and timeliness of circulating papers. • Discharge of the Functions of the Committee as reflected in the Terms of Reference for the Committee. • Business Transacted During the Year – the structure of agendas to cover standing items and other business matters as they arise. • Development of the Committee as a whole • Look Forward to 2020/21

Recommendation: Governing Body Meetings in Common Members are asked to: • NOTE the contents of this report and be ASSURED that the Coventry and Rugby Primary Care Commissioning Committee Lay Member Chair and CCG Chief Officer responsible have considered the Annual Report of the Committee’s performance for 2019/20 and are satisfied with its level of performance.

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Implications

CCG Constitution. Strategic Objectives- • We will work collaboratively with our partners to continuously improve quality of care; • We will inspire people to increase their confidence to manage their own health; • Objective(s) / Plans We will optimise the use of technology to transform patient experience supported by this report: and workforce effectiveness; • We will enable our local health and care system to deliver a sustainable, integrated response to the needs of our Places, reducing health inequalities through our commissioning strategy; • We will focus our resources to secure services that are value for money and promote a financially sustainable health economy; and • We will empower our diverse and motivated workforce to work in partnerships to improve population health. Conflicts of Interest: None identified Non-Recurrent None Expenditure: Recurrent Expenditure: None Financial: Is this expenditure included within the Yes No N/A  CCG’s Financial Plan? (Delete as appropriate) This report considers the effectiveness of the committee in monitoring Performance: performance. This report considers the effectiveness of the committee in monitoring quality Quality and Safety: and safety. General Statement: The CCG is committed to fulfil its obligations under the Equality Act 2010, and to ensure services commissioned by the CCG are non- discriminatory on the grounds of any protected characteristics. Policies/decisions may need to be adjusted in line with any equality analysis or due regard. Any decision that is finalised without being influenced by Equality and Diversity: appropriate due regard could be deemed unlawful. Has an equality impact assessment been Yes No N/A  undertaken? (Delete as appropriate) Patient and Public N/A Engagement: Clinical Engagement: N/A This report considers the effectiveness of the Committee for the period Risk and Assurance: 2019/20.

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NHS Coventry and Rugby CCG

Annual report of Primary Care Commissioning Committee (Closed & Public) 2019/20 for Governing Body

1 Introduction

This document represents the report of the Primary Care Commissioning Committee of NHS Coventry and Rugby CCG for the period 1st April 2019 to 31 March 2020. The report is intended to provide the Committees with an opportunity to reflect on and document its performance during the year.

2 Membership and Meetings

The Primary Care Commissioning Committee met 12 times (Closed) and 6 times (Public) formally during 2019/20 as a Committee. The dates of meetings and attendance of members is shown in the Appendix 1.

The Primary Care Commissioning Committee Meeting was chaired by Ludlow Johnson - Lay Member, Public and Patient Involvement/Equality, or Claire Forkes (part year), the Lay Member Vice-Chair in the absence of the Chair. A new PPI Lay Member and Vice Chair for the Committee is in the process of being recruited.

Quoracy was achieved at 100% for all meetings in 2019/20, and after adjusting for relevant absences, Committee members achieved an average attendance rate average of 93% for all meetings from April 2019 to March 2020.

The Committee has ‘Declaration of Interests’ as a standing item on its agenda and records any interests declared in its minutes.

The performance of the Committee Chair is reviewed by the Chair of NHS Coventry and Rugby CCG.

3 Administration and Communication

The Primary Care Commissioning Committee is generally satisfied with the quality of the information that it receives for its meetings and with the administration of meetings with the majority of papers being available one week in advance of the meeting. Papers for meetings are sent electronically and can be posted in hard copy to members where required. During 2020/21 we anticipate expanding our use of technology to ensure that all members have access to ‘paperless’ versions of the Committee’s papers in line with IG approved secure methods.

The agenda, minutes and papers of all Primary Care Commission Committee meetings are available to staff on request and to the public (for public meetings) on the CCGs websites.

4 Discharge of the Functions of the Committee

The functions of the Primary Care Commission Committee are set out in the Terms of Reference (Appendix 2) and may be discharged directly which is then reported back to the Governing Body at every public meeting. The table below sets out how the Primary Care Commissioning Committee believes it has effectively discharged its functions/duties during the

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year; more information about the business that the Board has transacted is contained at section 5.

Function/Duties (as per TOR) Meeting Discharge Date To meet 6 times per annum or The committee met 12 times (Closed) and 6 times more frequently if required. (Public). All meetings were declared quorate and all declarations of interest were noted. To make collective decisions on Bi-monthly Assurance Report bi-monthly (Public) the review, planning and 03.04.19 APMS Re- Procurement Interim Information and procurement of primary care Engagement Report (Closed) services in Coventry & Rugby. 03.04.19 PMS Investment Proposal (Closed) 03.04.19 Special Allocation Scheme (SAS) (Public) 01.05.19 APMS – Brownsover Medical Centre Mobilisation Review (Closed) 01.05.19 Primary Care Strategy STP, emerging ICS’s, integrated working (Closed) 05.06.19 PMS Scheme – PCN Reimbursable Roles (Closed) 02.10.19 Special Allocation scheme (SAS) (Public) 02.10.19 PMS Scheme – Adult Safeguarding (Closed) To promote increased co- 21.05.19 Coventry & Rugby Primary Care Networks Registrations commissioning to increase (Closed) quality, efficiency, productivity 21.05.19 Primary Care Contract Crisis Management Process and value for money and to (Closed) remove administrative barriers. 04.09.19 PCN Clinical Pharmacists Proposal (Closed) To carry out the functions relating Bi-monthly Assurance Report bi-monthly (Public) to the commissioning of primary 03.04.19 Various Contract Variations – Contract Report (Public) medical services under Section 02.10.19 Rugby Homeless Service (Public) 83 of the NHS Act. Decision in relation to Enhanced 03.04.19 Enhanced Service Review (Public) Services. 07.08.19 Network directed Enhanced Services (Closed) 02.10.19 Enhanced Service Review (Closed) Decisions in relation to Local 04.12.19 Shared Care Pathway (Closed) Incentive Schemes (including the 05.02.20 Flash Freestyle Libre Glucose Monitoring Policy design of such schemes) Decisions in relation to the 05.06.19 Time Limited APMS Contract Assurance Report (Closed) establishment of new GP 05.06.19 Foleshill Business Case – Development of Premises practices (including branch (Closed) surgeries) and closure of GP 13.06.19 Time Limited APMS Contract Assurance Report (Closed) practices. 03.07.19 Contract Report (Closed) 06.11.19 S106 Application Status Report (Closed) Decisions about discretionary 05.02.20 APMS contract offer – Alternative Provider Medical payments. Services (Closed) 01.05.19 Financial Plan & Funding: Discretionary Funding (Public) GP Services Allocation Growth (Public) 2019/20 GP Services Allocations The approval of practice mergers Primary Care Contract Report (Closed) 01.05.19 M86016 Godiva Group Practice Addition of Dr K Mandhyan to the GMS Contract of newly merged Godiva Group Practice. (Public) M86030 Kensington Road Surgery addition of Dr Shiraz Akhtar Butt (Public) 21.11.19 M86035 Henley Green Medical Centre – request to alter the location for delivery of services (Closed) Planning primary medical care 03.04.19 Paramedic Acute Visiting Service (PAVS) (Closed) 4 NHS Coventry and Rugby Clinical Commissioning Group Enc T services in the area, including 02.10.19 Estates ETTF (Public) carrying out needs assessments. Brownsover Surgery Foleshill Development 02.10.19 Houlton Procurement (Closed) Undertaking reviews of primary bi-Monthly Quality Report bi-monthly (Public) medical care services in the area. Incident Reporting (Public) Infection Control (Public) 03.04.19 CQC Ratings (Public) 03.04.19 Speak Up Guardians (Closed) 05.06.19 Friends & Family Test Patient Surveys (Public) Immunisation Take Up Rates (Public) 07.08.19 Atrial Fibrillation Pathway (Closed) 02.10.19 Quality Care in GP Practices: Cytology Update (Public) Patient Safety, GP reporting of external incidents 07.01.20 Coventry Navigation PCN Dissolution of Partnership (Closed) 05.02.20 GP Patient Feedback Survey (Public) Decisions in relation to the Bi-monthly Quality Report bi-monthly (Public) management of poorly reforming GP practices. Management of the Delegated bi-monthly Finance Report bi-monthly (Public) Funds in the area. 03.04.19 Delegated GP Services Budget 2018/19 (Public) 01.05.19 2019/20 Financial Plan & Budget Approval (Closed) 02.10.19 Delegated GP Service Budget (Public) Premises Costs Directions 01.05.19 Foleshill Business Case for New Build Development Functions. (Closed) 03.07.19 George Eliot Medical Centre Rent Review Co-ordinating a common 03.04.19 Committee Effectiveness Review (Closed) approach to the commissioning of 03.04.19 Committees in Common (Closed) primary care services with other 03.07.19 Primary Care Strategy (Public) commissioners in the area where 02.10.19 Committee Effectiveness Review (Closed) appropriate Other ancillary activities that is bi-monthly Assurance Report bi-monthly (Public) necessary in order to exercise the Quality Report bi-monthly (Closed) Delegated Functions. 03.04.19 Quality Report NHSE Alert Circumcision 05.06.19 Asylum Seeker & Refugee Services (Public)

5 Business Transacted During the Year

The Primary Care Commissioning Committee met formally 6 times for Public meetings and 12 times for Closed meetings.

This Committee receives formal minutes of the CCG’s Primary Care Development Group for noting.

Other discussions: - As per agendas which are structured to cover standing items Finance, Quality, Primary Care, Contracts, Risk Register items. - Reporting of outcomes of Internal Audits in PCC regarding governance and in progress contracting and procurement and the status of assurance. - New Warfarin pathway oversight reporting on the management of the risk identified. - Oversight of status of shared care through appropriate reporting and logging of any risk.

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- Oversight of process for recording and reviewing of patients on the Special Allocation Scheme.

In all the above discussions, Lay members of the Primary Care Commissioning Committee provided constructive challenge and support, drawing on their own experiences, to plans being developed by the Executive Directors.

6 Training

The Primary Care Team has provided regular briefings for Member practices on the new PCN DES contract. Implications for the PCC in terms of delegation are discussed through appropriate reporting.

7 Development of the Committee as a whole

The Committee undertook a process of self-assessment in 2019 and overall the responses showed a high agreement rate with the effectiveness statements showing that respondents perceive the committee to be working effectively. Some considerations for the Committee were: 1. Relevant attendance to ensure effective scrutiny and decision making. 2. Review of timescales to ensure sufficient notice is given to report writers and distribution of papers. 3. The committee yearly plan is followed so that papers are reviewed at appropriate times. 4. Report front sheets to be clear in terms of the purpose of the paper.

Going forwards, the Committee will have oversight of work stream highlight reports and operating plan for assurance purposes.

8 Look Forward to 2020/21

The Primary Care Commissioning Committee will develop the reporting and oversight of the General Practice Digital work stream and seek assurance that the governance process is robust and the technology supports the delivery of the Long Term Plan and the GP Forward View to increase patient access to primary care services.

We look forward to presenting the PCC with the internal auditors assurance findings on their annual review of our delegated function; we are awaiting verbal confirmation that we have achieved fully assured status for the third year running.

9 Conclusion and Recommendation

The Primary Care Commissioning Committee is satisfied that it has adequately discharged its remit in the year to 31st March 2020.

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Appendix 1 Coventry and Rugby Primary Care Commissioning Committee

21/05/19 Total Committee Percentage Members 03/04/19 01/05/19 05/06/19 03/07/19 07/08/19 04/09/19 02/10/19 06/11/19 04/12/19 07/01/20 05/02/20 04/03/20 EX meetings attended Attendance Ludlow Johnson 7 58% Claire Forkes 8 67% Jenni Northcote 8 67% Clare Hollingworth Left Organisation Stood Chris Lonsdale Not yet acting Chief Finance Officer 7 58% Down Jo Galloway 1 8% Dr Deepika Yadav 10 83% Dr Mark Lawton 4 33% Dr Alastair Bryce 1 8% The above table shows actual attendance by Member

21/05/19 Total Committee Members + Deputies 03/04/19 01/05/19 05/06/19 03/07/19 07/08/19 04/09/19 02/10/19 06/11/19 04/12/19 07/01/20 05/02/20 04/03/20 EX meetings covered Ludlow Johnson Claire Forkes 12 Jenni Northcote Nikki Temperley-Smith 12 Chris Lonsdale Clare Hollingworth Left Organisation 12 Kay Speed-Andrews Stood Jo Galloway Down Rebecca Bartholomew 8 Sarah Wier-Smith Dr Deepika Yadav Dr Mark Lawton 12 Dr Alastair Bryce Dr Madeleine Wells

The above table shows number of meetings covered in the year by Members and Deputies

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Appendix 2

Schedule 18: NHS Coventry and Rugby Clinical Commissioning Group Primary Care Commissioning Committee Terms of Reference

Introduction 1. Simon Stevens, the Chief Executive of NHS England, announced on 1 May 2014 that NHS England was inviting CCGs to expand their role in primary care commissioning and to submit expressions of interest setting out the CCG’s preference for how it would like to exercise expanded primary medical care commissioning functions. One option available was that NHS England would delegate the exercise of certain specified primary care commissioning functions to a CCG. 2. In accordance with its statutory powers under section 13Z of the National Health Service Act 2006 (as amended), NHS England has delegated the exercise of the functions specified in Schedule 2 of the Delegation Agreement to these Terms of Reference to Coventry and Rugby CCG. The delegation is set out in Schedule 1. 3. The CCG has established the Coventry and Rugby CCG Primary Care Commissioning Committee (“Committee”). The Committee will function as a corporate decision making body for the management of the delegated functions and the exercise of the delegated powers. 4. It is a committee comprising representatives of the following organisations: • Coventry and Rugby CCG • Attendees from other organisations who are not members of the CCG Governing Body have observer status

Statutory Framework 5. NHS England has delegated to the CCG authority to exercise the primary care commissioning functions set out in Schedule 2 of the Delegation Agreement in accordance with section 13Z of the NHS Act. 6. Arrangements made under section 13Z may be on such terms and conditions (including terms as to payment) as may be agreed between the Board and the CCG. 7. Arrangements made under section 13Z do not affect the liability of NHS England for the exercise of any of its functions. However, the CCG acknowledges that in exercising its functions (including those delegated to it), it must comply with the statutory duties set out in Chapter A2 of the NHS Act and including: a) Management of conflicts of interest (section 14O); b) Duty to promote the NHS Constitution (section 14P); c) Duty to exercise its functions effectively, efficiently and economically (section 14Q); d) Duty as to improvement in quality of services (section 14R); e) Duty in relation to quality of primary medical services (section 14S); f) Duties as to reducing inequalities (section 14T); g) Duty to promote the involvement of each patient (section 14U); h) Duty as to patient choice (section 14V); i) Duty as to promoting integration (section 14Z1); j) Public involvement and consultation (section 14Z2). 8

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8. The CCG will also need to specifically, in respect of the delegated functions from NHS England, exercise those in accordance with the relevant provisions of section 13 of the NHS Act. 9. The Committee is established as a committee of the Coventry and Rugby CCG Governing Body in accordance with Schedule 1A of the “NHS Act”. 10. The members acknowledge that the Committee is subject to any directions made by NHS England or by the Secretary of State.

Role of the Committee 11. The Committee has been established in accordance with the above statutory provisions to enable the members to make collective decisions on the review, planning and procurement of primary care services in Coventry and Rugby, under delegated authority from NHS England. 12. In performing its role the Committee will exercise its management of the functions in accordance with the agreement entered into between NHS England and Coventry and Rugby CCG, which will sit alongside the delegation and terms of reference. 13. The functions of the Committee are undertaken in the context of a desire to promote increased co- commissioning to increase quality, efficiency, productivity and value for money and to remove administrative barriers. 14. The role of the Committee shall be to carry out the functions relating to the commissioning of primary medical services under section 83 of the NHS Act. 15. This includes the following: • GMS, PMS and APMS contracts (including the design of PMS and APMS contracts, monitoring of contracts, taking contractual action such as issuing branch/remedial notices, and removing a contract); • Newly designed enhanced services (“Local Enhanced Services” and “Directed Enhanced Services”); • Design of local incentive schemes as an alternative to the Quality Outcomes Framework (QOF); • Decision making on whether to establish new GP practices in an area; • Approving practice mergers; and • Making decisions on ‘discretionary’ payment (e.g., returner/retainer schemes).

16. The CCG will also carry out the following activities: a) To plan, including needs assessment, primary [medical] care services in Coventry and Rugby; b) To undertake reviews of primary [medical] care services in Coventry and Rugby; c) To co-ordinate a common approach to the commissioning of primary care services generally; d) To manage the budget for commissioning of primary [medical] care services in Coventry and Rugby. e) To provide assurance on the quality and safety of primary care services.

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Geographical Coverage

17. The Committee shall be responsible for decisions relating to the commissioning of primary care services for the geographical area covered by Coventry and Rugby CCG.

Membership 18. The Committee shall consist of: • Lay Member (Chair) • Chief Finance Officer • 2nd Lay Member • Three CCG GP representatives who have been elected to the CCG Governing Body • Chief Nursing Officer • Chief Strategy and Primary Care Development Officer 19. The Chair of the Committee shall be a Lay Member. 20. The Vice Chair of the Committee shall be a Lay Member. 21. Non-voting attendees. There will be a standing invite to a HealthWatch representative and a Health and Wellbeing Board representative and a Coventry Local Medical Committee (LMC) representative and a Warwickshire LMC representative.

Meeting and Voting 22. The Committee will operate in accordance with the CCG’s Standing Orders. The Secretary to the Committee will be responsible for giving notice of meetings. This will be accompanied by an agenda and supporting papers and sent to each member representative no later than 7 days before the date of the meeting. When the Chair of the Committee deems it necessary in light of the urgent circumstances to call a meeting at short notice, the notice period shall be such as she/he shall specify. 23. Each member of the Committee shall have one vote. The Committee shall reach decisions by a simple majority of members present, but with the Chair having a second and deciding vote, if necessary. However, the aim of the Committee will be to achieve consensus decision-making wherever possible. 24. A quorum will be three members, to include at least one Lay Member, one elected GP member and one CCG management member (and GP Members cannot be in the majority). 25. Meetings will be held at least six times per annum, with more frequent meetings held if required. 26. Meetings of the Committee shall: a) be held in public, subject to the application of 26(b); b) the Committee may resolve to exclude the public from a meeting that is open to the public (whether during the whole or part of the proceedings) whenever publicity would be prejudicial to the public interest by reason of the confidential nature of the business to be transacted or for other special reasons stated in the resolution and arising from the nature of that business or of the proceedings or for any other reason permitted by the Public Bodies (Admission to Meetings) Act 1960 as amended or succeeded from time to time. 27. Members of the Committee have a collective responsibility for the operation of the Committee. They will participate in discussion, review evidence and provide objective expert input to the best of their knowledge and ability, and endeavour to reach a collective view. 10

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28. The Committee may delegate tasks to such individuals, sub-committees or individual members as it shall see fit, provided that any such delegations are consistent with the parties’ relevant governance arrangements, are recorded in a scheme of delegation, are governed by terms of reference as appropriate and reflect appropriate arrangements for the management of conflicts of interest. 29. The Committee may call additional experts to attend meetings on an ad hoc basis to inform discussions. 30. Members of the Committee shall respect confidentiality requirements as set out in the CCG’s Constitution. 31. The Committee will present its minutes to NHS England and the Governing Body of Coventry and Rugby CCG quarterly for information, including the minutes of any sub-committees to which responsibilities are delegated under paragraph 27 above. 32. The CCG will also comply with any reporting requirements set out in its constitution. 33. It is envisaged that these Terms of Reference will be reviewed from time to time, reflecting experience of the Committee in fulfilling its functions. NHS England may also issue revised model terms of reference from time to time.

Accountability of the Committee 34. Delegated responsibility will be to oversee the Primary Care Budget as transferred by NHS England under delegated powers and to include other budgets the Governing Body determines as appropriate, including: a) General Medical Services (GMS); b) Premises; c) Direct Enhanced Services (DES); d) Local Enhanced Services (LES); e) Quality and Outcomes Framework (QOF); f) GP Information Technology.

Decisions and Reporting 35. The Committee will make decisions within the bounds of its remit. 36. The decisions of the Committee shall be binding on NHS England and Coventry and Rugby CCG. 37. The Committee will produce an executive summary report which will be presented to NHS England and the Governing Body of Coventry and Rugby CCG on a quarterly basis.

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Report To: Governing Body Meetings in Common Annual Report of the Warwickshire North Primary Care Report Title: Commissioning Committee 2019/20 Report From: Jenni Northcote, Chief Strategy & Primary Care Officer

Date: 20 May 2020

Previously Considered by: Warwickshire North Primary Care Committee 12 March 2020

Action Required (delete as appropriate)

Decision: Assurance:  Information: Confidential

Purpose of the Report: To provide Governing Body Meetings in Common with assurance that the Warwickshire North Primary Care Commissioning Committee has considered its function during the financial year 2019/20, as documented in the following report, and is satisfied with its performance with no further actions recommended.

Key Points: The following report documented the performance of the Primary Care Committee under the following format: • Membership and Meetings • Appendix 1: Meeting Dates and attendance for the period: 01/04/19 - 31/03/20 • Administration and Communication - The level of satisfaction with the quality of information received for meetings, and timeliness of circulating papers. • Discharge of the Functions of the Committee as reflected in the Terms of Reference for the Committee. • Business Transacted During the Year – the structure of agendas to cover standing items and other business matters as they arise. • Development of the Committee as a whole • Look Forward to 2020/21

Recommendation: Governing Body Meetings in Common Members are asked to: • NOTE the contents of this report and be ASSURED that the Warwickshire North Primary Care Commissioning Committee has considered the Annual Report of its performance for 2019/20 and is satisfied with its level of performance.

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Implications

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NHS North Warwickshire CCG

Annual report of Primary Care Commissioning Committee (Closed & Public) 2019/20 for Governing Body

1 Introduction

This document represents the report of the Primary Care Commissioning Committee of NHS Warwickshire North CCG for the period 1st April 2019 to 31 March 2020. The report is intended to provide the Committees with an opportunity to reflect on and document its performance during the year.

2 Membership and Meetings

The Primary Care Commissioning Committee met 13 times (Closed) and 6 times (Public) formally during 2019/20 as a Committee. The dates of meetings and attendance of members is shown in the Appendix 1.

The Primary Care Commissioning Committee Meeting is chaired by Graham Nuttall - Lay Member, Primary Care, or Sharon Beamish (part year), the Lay Member Vice-Chair in the absence of the Chair. A new PPI Lay Member and Vice Chair for the Committee is in the process of being recruited.

Quoracy was achieved at 100% for all meetings in 2019/20. All Committee members achieved an attendance rate average of 67% for all meetings from April 2019 to March 2020.

The Committee has ‘Declaration of Interests’ as a standing item on its agenda and records any interests declared in its minutes.

The performance of the Committee Chair is reviewed by the Chair of NHS Warwickshire North CCG.

3 Administration and Communication

The Primary Care Commissioning Committee is satisfied with the quality of the information that it receives for its meetings and with the administration of meetings with the majority of papers being available one week in advance of the meeting. Papers for meetings are sent electronically and posted in hard copy to members where required. During 2020/21 we anticipate expanding our use of technology to ensure that all members have access to ‘paperless’ versions of the Committee’s papers in line with IG approved secure methods.

The agenda, minutes and papers of all Primary Care Commission Committee meetings are available to staff on request and to the public on the CCGs websites.

4 Discharge of the Functions of the Committee

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Function/Duties (as per TOR) Meeting Discharge Date To meet 6 times per annum or The committee met 13 times (Closed) and 6 times more frequently if required. (Public). All meetings were declared quorate and all declarations of interest were noted. To make collective decisions on Assurance Report bi-monthly (Public) the review, planning and 09.05.19 APMS (IMH Practices) (Closed) procurement of primary care 09.05.19 APMS Contract Re-procurement (Public) services in Coventry & Rugby. 11.07.19 APMS Contract Risk (Closed) 11.07.19 APMS Potential Cash Flow Issues (Closed) 10.10.19 Primary Care Strategy 10.10.19 PCN Development Offer (Closed) To promote increased co- 21.05.19 Warwickshire North CCG PCN Registrations commissioning to increase 09.05.19 PC Networks (Public) quality, efficiency, productivity 09.01.20 Primary Care Network New Specification (Public) and value for money and to remove administrative barriers. To carry out the functions relating Assurance Report bi-monthly (Public) to the commissioning of primary 11.04.19 M84627 Old Cole House (Closed) medical services under Section 09.05.19 New DES Contracts (Public) 83 of the NHS Act. 13.06.19 PC Contract Crisis Management (Closed) 11.07.19 Contact Variations Bedworth Health Centre/Arbury Medical Centre (Public) 08.08.19 M84011 Bedworth Health Centre (Closed) 08.08.19 GMS Contract Variation GP Network DES (Closed) 12.09.19 Galley Common Branch Surgery Temp Closure Closed) Galley Common Christmas Closure (Closed) 12.12.19 Contract Variations Rugby Road & Queens Road 09.01.20 Surgeries (Public) Decision in relation to Enhanced 10.10.19 Enhanced Service and Incentive Scheme Review Services. (Closed) Decisions in relation to Local 11.04.19 Warfarin Pathway Redesign (Closed) Incentive Schemes (including the 11.04.19 Shared Care Pathway Redesign (Closed) design of such schemes) 09.05.19 GP NSP Safeguarding Project (Public) 09.05.19 New Warfarin Pathway (Public) 11.07.19 Warfarin and Shared Case revised pathway (Public) 13.02.20 Shared Care (Closed) Decisions in relation to the 13.06.19 Time Limited APMS Contracts (Closed) establishment of new GP practices (including branch surgeries) and closure of GP practices. Decisions about discretionary 09.01.20 APMS contract offer payments. The approval of practice mergers None Planning primary medical care 09.05.19 Estates ETTF (Public) services in the area, including 13.06.19 Camp Hill Surgery Boundary App (Closed) carrying out needs assessments. 10.10.19 Hartshill Outline Business Case (Closed) Scope, assessment, JSNA (WCC public health), Estates (ETTF) Undertaking reviews of primary bi-Monthly Quality Report bi-monthly (Public) medical care services in the area. CQC Ratings (Public) Friends & Family Test Patient Surveys (Closed) 4 NHS Warwickshire North Clinical Commissioning Group Enc U

Immunisation Take Up Rates (Closed) Infection Control (Public) Incident Reporting (Public) Patient Complaints (Public) Cytology Update (Public) Patient Safety, GP reporting of external incidents Decisions in relation to the Quality Report bi-monthly (Public) management of poorly reforming 13.06.19 Remedial Notices for GP Contracts (Closed) Chaucer GP practices. Surgery and Leicester Road Surgery Management of the Delegated Finance Report bi-monthly (Public) including: Funds in the area. 11.04.19 Delegated Budget Setting Report (Closed) 09.05.19 2019/20 Financial Plan & Budget Approval (Public) Premises Costs Directions 09.05.19 APMS Rent Reimbursements (Closed) Functions. 11.07.19 Atherstone Surgery Planning App (Closed) 12.09.19 Section 106 Submissions (Closed) 14.11.19 Estates 106 applications Status Report (Closed) Co-ordinating a common 09.05.19 Committees in common discussed (Closed) approach to the commissioning of 08.08.19 Primary Care Strategy primary care services with other 13.02.20 Estates Strategy (Closed) commissioners in the area where appropriate Other ancillary activities that is Assurance Report bi-monthly (Public) necessary in order to exercise the 11.07.19 Number of GP Appointment by Practice (Public) Delegated Functions. bi-monthly Oversight of Primary Care Risk Register related to delegated functions.(Closed) 14.11.19 Vision IT and Emis IT Systems (Closed) 13.02.20 CCG Merger Vote (Closed) 09.01.20 Estates Strategy & Position Reporting (Closed) 13.02.20 Primary Care Highlight Reports (Closed)

5 Business Transacted During the Year

The Primary Care Commissioning Committee met formally 6 times for Public meetings and 13 times for Closed meetings.

This Committee has not received or considered any Reports or minutes to note from other groups within the Primary Care Trust.

Discussions: - As per agendas which are structured to cover standing items Finance, Quality, Primary Care, Contracts, Risk Register items. - Reporting of outcomes of Internal Audits in PCC regarding governance and in progress contracting and procurement and the status of assurance. - New Warfarin pathway oversight reporting on the management of the risk identified. - Oversight of status of shared care through appropriate reporting and logging of any risk. - Oversight of process for recording and reviewing of patients on the Special Allocation Scheme. - Assurance in terms of supporting practices regarding PCN formation and new contract DES requirements. - Managing guidance and conflicts of interest for the APMS reprocurement.

6 Training

The Primary Care Team has provided regular briefings for Member practices on the new PCN DES contract. Implications for the PCC in terms of delegation are discussed through appropriate reporting.

7 Development of the Committee as a whole

The Committee has not yet undertaken a process of self-assessment. Going forwards, the Committee will have oversight of work stream highlight reports and operating plan for assurance purposes.

8 Look Forward to 2020/21

9 Conclusion and Recommendation

The Primary Care Commissioning Committee is satisfied that it has adequately discharged its remit in the year to 31st March 2020.

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WNPCCC Committee Attendance Record

21/05/19 Total Committee Percentage Members 11/04/19 09/05/19 13/06/19 11/07/19 08/08/19 12/09/19 10/10/19 14/11/19 12/12/19 09/01/20 13/02/20 12/03/20 EX meetings attended Attendance Graham Nuttall 8 67% Sharon Beamish No longer a member 8 80% Clare Hollingworth Chris Lonsdale 11 92% Jo Galloway 1 8% Jenni Northcote 10 83% Dr Arshad Khan 13 100% Dr Godwin Igodo 5 42% Average 67% The above shows actual attendance by Members.

21/05/19 Total Committee Members + Deputies 11/04/19 09/05/19 13/06/19 11/07/19 08/08/19 12/09/10 10/10/19 14/11/19 12/12/19 09/01/19 13/02/20 12/03/20 EX meetings covered Graham Nuttall Sharon Beamish No longer a member 12 Ludlow Johnson Clare Hollingworth Clare Hollingworth Chris Lonsdale 11 Kay Speed-Andrews Jo Galloway Rebecca Bartholomew 11 Mary Mansfield Sarah Wier-Smith Jenni Northcote Roma Holland 12 Nikkie Temperley-Smith Rebecca Young Dr Arshad Khan 12 Dr Godwin Igodo 4

The above table show only meeting coverage for quoracy. Deputies may attend meeting regularly. Page 7 of 11 11 NHS Warwickshire North Clinical Commissioning Group Enc U

Appendix 2

PRIMARY CARE COMMISSIONING COMMITTEE

NHS Warwickshire North Clinical Commissioning Group

Terms of Reference Introduction 1. Simon Stevens, the Chief Executive of NHS England, announced on 1 May 2014 that NHS England was inviting CCGs to expand their role in primary care commissioning and to submit expressions of interest setting out the CCG’s preference for how it would like to exercise expanded primary medical care commissioning functions. One option available was that NHS England would delegate the exercise of certain specified primary care commissioning functions to a CCG.

2. In accordance with its statutory powers under section 13Z of the National Health Service Act 2006 (as amended), NHS England has delegated the exercise of the functions specified in Schedule 2 of the Delegation Agreement to these Terms of Reference to Warwickshire North CCG. The delegation is set out in Schedule 1.

3. The CCG has established the Warwickshire North CCG Primary Care Commissioning Committee (“Committee”). The Committee will function as a corporate decision making body for the management of the delegated functions and the exercise of the delegated powers.

4. It is a committee comprising representatives of the following organisations:

• Warwickshire North CCG

• Non-voting attendees from the organisations specified in paragraph 21 below who are not members of the CCG Governing Body have observer status.

Statutory Framework

5. NHS England has delegated to the CCG authority to exercise the primary care commissioning functions set out in Schedule 2 of the Delegation Agreement in accordance with section 13Z of the NHS Act.

6. Arrangements made under section 13Z may be on such terms and conditions (including terms as to payment) as may be agreed between the Board and the CCG.

7. Arrangements made under section 13Z do not affect the liability of NHS England for the exercise of any of its functions. However, the CCG acknowledges that in exercising its functions (including those delegated to it), it must comply with the statutory duties set out in Chapter A2 of the NHS Act and including:

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

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

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

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

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

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

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

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

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

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

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8. The CCG will also need to specifically, in respect of the delegated functions from NHS England, exercise those in accordance with the relevant provisions of section 13 of the NHS Act.

9. The Committee is established as a committee of Warwickshire North CCG Governing Body in accordance with Schedule 1A of the “NHS Act”.

10. The members acknowledge that the Committee is subject to any directions made by NHS England or by the Secretary of State.

Role of the Committee

11. The Committee has been established in accordance with the above statutory provisions to enable the members to make collective decisions on the review, planning and procurement of primary care services in the geographical area covered by Warwickshire North CCG, under delegated authority from NHS England.

12. In performing its role the Committee will exercise its management of the functions in accordance with the agreement entered into between NHS England and Warwickshire North CCG, which will sit alongside the delegation and terms of reference.

13. The functions of the Committee are undertaken in the context of a desire to promote increased co- commissioning to increase quality, efficiency, productivity and value for money and to remove administrative barriers.

14. The role of the Committee shall be to carry out the functions relating to the commissioning of primary medical services under section 83 of the NHS Act.

15. This includes the following:

a) decisions in relation to the commissioning, procurement and management of Primary Medical Services Contracts, including but not limited to the following activities: • decisions in relation to Enhanced Services; • decisions in relation to Local Incentive Schemes (including the design of such schemes); • decisions in relation to the establishment of new GP practices (including branch surgeries) and closure of GP practices; • decisions about ‘discretionary’ payments; • decisions about commissioning urgent care (including home visits as required) for out of area registered patients; b) The approval of practice mergers; c) Planning primary medical care services in the Area, including carrying out needs assessments; d) Undertaking reviews of primary medical care services in the Area; e) Decisions in relation to the management of poorly performing GP practices and including, without limitation, decisions and liaison with the CQC where the CQC has reported non-compliance with standards (but excluding any decisions in relation to the performers list); f) Management of the Delegated Funds in the Area; g) Premises Costs Directions Functions; h) Co-ordinating a common approach to the commissioning of primary care services with other commissioners in the Area where appropriate; and i) Such other ancillary activities that are necessary in order to exercise the Delegated Functions.

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Geographical Coverage

17. The Committee shall be responsible for decisions relating to the commissioning of primary care services for the geographical area covered by North Warwickshire and Nuneaton and Bedworth Boroughs

Membership

18. The Committee shall consist of:

VOTING MEMBERS

• Two Lay Members

• Chief Finance Officer (or suitable deputy)

• Chief Nursing Officer (or suitable deputy)

• Chief Strategy and Primary Care Officer (or suitable deputy)

NON- VOTING MEMBERS

• Two GP representatives.

19. The Chair of the Committee shall be a Lay Member and shall not be the Lay Member for Audit and Governance.

20. The Vice Chair of the Committee shall be a Lay Member.

21. Non-voting attendees. There will be a standing invite to a HealthWatch representative and a Health and Wellbeing Board representative and a Warwickshire LMC representative.

Meeting and Voting

22. The Committee will operate in accordance with the CCG’s Standing Orders. The Secretary to the Committee will be responsible for giving notice of meetings. This will be accompanied by an agenda and supporting papers and sent to each member representative no later than 7 days before the date of the meeting. When the Chair of the Committee deems it necessary in light of the urgent circumstances to call a meeting at short notice, the notice period shall be such as she/he shall specify.

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

24. A quorum will be three voting members, to include at least one Lay Member and at least one CCG management member. GP attendees cannot be in the majority of attendees at the meeting.

25. Meetings will be held at least six times per annum, with more frequent meetings held if required.

26. Meetings of the Committee shall:

a) be held in public, subject to the application of 26(b);

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

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

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29. The Committee may call additional experts to attend meetings on an ad hoc basis to inform discussions.

30. Members of the Committee shall respect confidentiality requirements as set out in the CCG’s Constitution.

31. The Committee will present its minutes to NHS England and the Governing Body of Warwickshire North CCG quarterly for information, including the minutes of any sub-committees to which responsibilities are delegated under paragraph 28 above.

32. The CCG will also comply with any reporting requirements set out in its constitution.

33. These Terms of Reference will be reviewed annually or more frequently as required.

Accountability of the Committee

34. Delegated responsibility will be to oversee the Primary Care Budget as transferred by NHS England under delegated powers and to include other budgets the Governing Body determines as appropriate, including:

a) General Medical Services (GMS); b) Premises - in relation to Premises Costs Directions Functions. c) Direct Enhanced Services (DES); d) Local Enhanced Services (LES); e) Quality and Outcomes Framework (QOF); f) GP Information Technology. Conflicts of Interest 35. Due to the nature of work undertaken by the Committee, there is a risk of actual or perceived conflicts of interest arising. To mitigate against this risk the CCG has taken the following actions to ensure that the CCG and the Committee continue to comply with the NHS England Conflicts of Interest Guidance

a) Reviewing Membership of the group to include relevant individuals from external organisations and ensuring that the Committee does not have a majority of GP members. b) Holding and Publishing a recording of Conflicts of Interest for individuals who are members of the Committee. c) The Chair shall take necessary action during meetings, for example to remove conflicted individuals as necessary. d) The Chair shall ensure that the following information is recorded in the minutes of the meeting: • Who has the interest • The nature of the interest and why it gives rise to a conflict including the magnitude of any interest • The item on the agenda to which the interest relates • How the conflict was agreed to be managed; and • Evidence that the conflict was managed as intended (for example, recording the points during the meeting when particular individuals left or returned to the meeting. Decisions and Reporting 36. The Committee will make decisions within the bounds of its remit.

37. The decisions of the Committee shall be binding on NHS England and Warwickshire North CCG.

38. The Committee will produce an executive summary report which will be presented to NHS England and the Governing Body of Warwickshire North CCG on a quarterly basis.

11 NHS Coventry and Rugby Clinical Commissioning Group NHS Warwickshire North Clinical Commissioning Group Enc V

Report To: Governing Body Meetings in Common

Report Title: Commissioning Policies – Various

Report From: Dr Sarah Raistrick – Chair CRCCG

Date: 20th May 2020

Previously Considered by: Policy Development Group Clinical Quality and Governance Committees in Common 26th March 2020

Action Required (delete as appropriate)

Decision:  Assurance: Information: Confidential

Purpose of the Report: To obtain approval from the Governing Body for seven existing policies to be renewed and one policy to be withdrawn.

Key Points: Existing Policies – Cataract Surgery, Complementary and Alternative Therapies, Hallux Valgus, Male circumcision, Treatments for Hyperhydrosis, Complex and Specialised Obesity surgery, Endoscopic Thoracic Sympathectomy, Carotid surgery.

• Reviews have fallen due on the above 8 existing CCG commissioning policies.

• The policies have been reviewed by the Coventry and Warwickshire Policy Development Group with input from Public Health, with the following outcomes:

o Carotid surgery Withdraw policy as no restrictive measures required

o Cataract Surgery Renew with no amendments.

o Male Circumcision Renew with additional “Background” section added, to provide clarification

o Complementary and Alternative Therapies Renew with no amendments.

o Complex and Specialised Obesity surgery Renew with no amendments

o Endoscopic Thoracic Sympathectomy Renew with no amendments

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

o Hallux Valgus Renew with no amendments to criteria but revised layout to policy with support of public health consultant.

o Treatments for Hyperhydrosis Renew with no amendments.

The policies have been reviewed by the Policy Development Group and they recommend approval of the attached draft policies and withdrawal of the Carotid surgery policy.

Recommendation:

The Governing Body is asked to:

RATIFY the policies relating to Cataract Surgery, Complementary and Alternative Therapies, Hallux Valgus, Male circumcision, Treatments for Hyperhydrosis, Complex and Specialised Obesity surgery, Endoscopic Thoracic Sympathectomy and withdraw the Carotid surgery policy as recommended by the Clinical Quality and Governance Committees in Common

Implications

Objective(s) / Plans supported by this Continuation of CCGs’ commissioning policy position report: Conflicts of Interest: None Non-Recurrent Expenditure: N/A Recurrent Expenditure: N/A Financial: Is this expenditure included within the CCG’s Financial Yes No N/A  Plan? (Delete as appropriate) Performance: N/A Quality and Safety: N/A General Statement: The CCG is committed to fulfil its obligations under the Equality Act 2010, and to ensure services commissioned by the CCG are non-discriminatory on the grounds of any protected characteristics. Policies/decisions may need to be adjusted in line with any equality analysis or due regard. Any decision that is finalised without being influenced by appropriate due regard could be deemed unlawful. Equality and Diversity: Has an equality impact assessment been Yes X No N/A undertaken? (Delete as (attached) appropriate) Patient and Public N/A Engagement: Through Policy Development Group/ Clinical Quality and Governance Committees Clinical Engagement: in Common Risk and Assurance: N/A

Page 2 of 2 Introduction

The rationale and scope of this policy is contained within the overarching LPP policy which sets out CRCCG approach to Low Priority Procedures.

This document refers specifically to Carotid Surgery.

Commissioning Policy: Coventry and Rugby CCG (CRCCG)

Treatment Carotid surgery

Indication Asymptomatic carotid artery disease

Treatment: Carotid surgery for patients with no recent symptoms (<12weeks) is restricted to patients with a life expectancy >5 years; patients with evidence of embolic phenomena on retinoscopy; and patients prior to major surgery who have a severe unilateral stenosis >70%. NB. There is an absence of evidence from randomized trials that patients aged greater than 75 benefit from surgery from asymptomatic lesions.

Ref: ACST. Lancet 2004. May 8:363(9420) 1491-502.

Equality See EIA attached Impact

VERSION CONTROL

Version 2.0 Ratified by Governing Body Date ratified 13th July 2016 Name of originator/author Joint CCG Clinical Commissioning Policy Development Group

Name of responsible Clinical Development Group committee Date issued 14th July 2016 Review date July 2019

Coventry and Rugby Clinical Commissioning Group Asymptomatic carotid artery disease December 2015

EQUALITY ANALYSIS FORM

TITLE (service/ plan/ Policy for Asymptomatic carotid artery disease project/ policy/ decision):

AUTHOR / LEAD: EIA Lead

DATE ANALYSIS December 2015 UNDERTAKEN:

STAGE 1: SCREENING FOR ADVERSE IMPACTS (X PLEASE CHECK): Age X Religion or Marriage Disability Belief and Civil Partnership Sexual Carers (inc. Sex (men & X Gender Orientation young women) Reassignment/ carer’s) Transgender Race/ Pregnancy, Multiple Human Rights Ethnicity Maternity, Social (FREDA) Perinatal Deprivation fairness, respect, equality, dignity & autonomy Describe any potential or known adverse impacts or barriers for protected/ vulnerable groups: (if there are no known adverse impacts, please state who has been involved in the screening and explain how you have reached this conclusion, then move to Stage 6 sign off) This is a harmonised policy across three Clinical Commissioning Groups – Coventry and Rugby CCG, South Warwickshire CCG and Warwickshire North CCG.

Since CCGs operate within finite budgetary constraints the policy detailed in this document make explicit the need for the CCGs to prioritise resources and provide interventions with the greatest proven health gain. The intention is to ensure equity and fairness in respect of access to NHS funding for interventions and to ensure that interventions are provided within the context of the needs of the overall population and the evidence of clinical and cost effectiveness.”

The impact of this policy has been considered against all protected characteristics and Human Rights values. By not being routinely commissioned it is likely to have a positive impact as the procedure is highlighted as being less effective (potential to miss significant amounts of pathology). The policy provides a consistent clinically based criteria for decision making, benefitting patients within the CCG area by providing consistency and equity of service provision. The policy provides an avenue through the ‘Individual Funding Requests’ policy to seek funding in exceptional clinical circumstances. No potential or known adverse impacts or barriers for protected and/or vulnerable groups were identified.

STAGE 6: SIGN OFF (you should arrange for an appropriate Chief Officer/ Governing Body Member to sign off this EA before sending it to the Manager for Equality & Diversity) ROLE NAME SIGNATURE DATE Chief Clinical Officer Steve Allen

Guidance:

A summary guidance sheet can be found overleaf.

STAGE 1: Screening STAGE 2: Data and Information This stage involves an initial analysis of any adverse impacts or potential adverse This stage involves looking at the available data for the service/ plan / policy/ impacts for protected groups. The author should draw on their knowledge and project/ decision and any of the equality groups that have been identified. It is experience of the service/ plan / policy/ project/ decision and the people that are known that equality data may be limited so it is acceptable to use proxy data. The affected. It is therefore beneficial to seek the views of a range of people at this following quantitative and qualitative data and feedback can be used: early stage. E.g. you may wish to involve the E&D Manager or relevant working  Joint Strategic Needs Assessment group. You should consider the following when undertaking screening:  National data / trends  Integrated Plan  Is there a higher prevalence of any group(s) in relation to the  LCN Profile Data Sets Talk to clinical leads and experts prevalent conditions?  Existing equality consultation feedback Ensure any patient engagement  Are there any concerns about the participation of any group(s) in  Service participation and outcomes data  Patient feedback activity includes the groups that the service or any aspect of the service?  Complaints have been adversely impacted  Are there any known barriers or potential barriers to access for any  Public involvement feedback group?  Demographic profile data  Service reviews and QOF data You will need to record your explanation of any adverse impacts or no impacts. If New consultation is not always necessary, especially when there is existing feedback adverse impacts or potential adverse impacts are identified you will need to from target groups. Speak to the Public Involvement Team and the E&D manager complete the rest of the impact assessment. Defining the scope of your Equality about any existing consultation feedback. Record the findings of your analysis of Analysis (EA) will help to establish the specific aspects of the service/ plan / policy/ data, information, and feedback and what it has told you about the service and project/ decision that require further examination. how it can be improved for the adversely impacted groups. Be succinct - use bullet points if you can. Attach any additional information to the EA or record in the seeing things through an equality lens Supplementary Notes section below.

STAGE 3: Critical Challenge STAGE 4: Changes This stage asks to you critically consider the service/ plan / policy/ project/ decision This stage asks you to record any changes you will make to the service design /plan and how equality considerations are being taken into account. Some of the / policy/ project/ decision to improve access for the adversely impacted group(s), questions may not be applicable. and outcomes for patients and the patient experience. This may include If the assessment relates to a commissioned service consider whether any enhancements to existing care pathways or protocols for how things are done. Any improvements can be made through the design of the service or monitoring of the changes should be realistic and feasible. contract. ANY CHANGES NEED TO BE REFLECTED IN THE DOCUMENTED SPECIFICATION / Record any explanations or evidence in relation to your response. POLICY / PLAN

STAGE 5: Monitoring and Evaluation STAGE 6: Sign-Off This stage asks you to consider how the changes that have been identified will be The completed Equality Analysis form should be sent to the Equality and Diversity monitored in the contract /plan /policy. Specifically state what will be recorded in manager for Sign-off, and then presented to the appropriate Chief Officer / the contract/ plan /policy and whether there is any associated key performance Governing Body Member, and where relevant the Business Case Panel. indicator. How will you know the change or proposals are working?

EQUALITY ANALYSIS -

SUPPLEMENTARY NOTES / RECORDS

Cataract Surgery

Coventry and Rugby CCG/Warwickshire North CCG

VERSION CONTROL

4.0 Version: Governing Body Ratified by: TBC Date ratified: Joint CCG Clinical Commissioning Policy Name of originator/author: Development Group

Clinical Quality and Governance Name of responsible committees: Committees in Common

TBC Date issued: TBC Review date:

VERSION HISTORY

Date Version Comment / Update

March 2016 3.0 Approved by Governing Body.

May 2020 4.0 Renew with no amendments.

Coventry and Rugby CCG/Warwickshire North CCG

Commissioning Policy: Coventry and Rugby CCG (CRCCG)

Warwickshire North CCG (WNCCG)

Treatment Cataract Surgery Indication Cataracts Treatment: • Cataract surgery will be commissioned for patients who, after correction (e.g. with glasses), have 6/12 or worse in their cataract affected eye • Referrals for cataract surgery should not be based simply on the presence of a cataract • Cataract surgery will not be commissioned solely for the purpose of correcting longstanding pre-existing myopia and hypermetropia • In certain situations cataract surgery will be commissioned for patients with a visual acuity better than 6/12, for example, where there are issues associated with significant problems with glare or significant multiple vision. • Cataract surgery will be supported where there is binocular disparity/imbalance (anisometropia) • Treatment will also be commissioned for the second eye where it is not 6/12 or worse but not treating would have a significant effect on the patient’s vision • Cataract surgery will also be funded in situations where it is indicated for screening or management of other ocular co-morbidities e.g. for control of glaucoma, or for adequate view of diabetic retinopathy

Quality & See QEIA attached Equality Impact

Coventry and Rugby CCG/Warwickshire North CCG

Quality and Equality Impact Assessment

Scheme Title: Cataract Surgery Policy

Project Lead: Clive Campton, IFR Manager Senior Responsible Officer: Dr Sarah Raistrick, Chair Kate Cogman, Contracts Manager Quality Sign Off: March 2020 Intended impact of The Cataract Surgery policy supports the objective to prioritise resources and provide interventions with the greatest proven scheme: health gain, within CCG budgetary constraints. The intention is to ensure equity and fairness in respect of access to NHS funding for interventions and to ensure that interventions are provided within the context of the needs of the overall population and the evidence of clinical and cost effectiveness. How will it be achieved: The Governing Body adopts the policy.

Name of person completing assessment: Clive Campton Kate Cogman Position: IFR Manager Contracts Manager Date of Assessment: November 2019

Quality Review by: Mary Mansfield

Position: Deputy Director of Nursing and Quality

Date of Review: March 2020

Coventry and Rugby CCG/Warwickshire North CCG

Stage 1a: High level Quality and Equality Questions

The risk rating is only to be done for the potential negative outcomes. We are looking to assess the likelihood of the negative outcome occurring and the level of negative impact. We are also seeking detail of mitigation actions that may help reduce this likelihood and potential impact.

OUTCOME ASSESSMENT Evidence/Comments for Risk rating Mitigating actions (Please tick one) answers (For negative outcomes) AREA OF ASSESSMENT Risk Risk Risk Positive Negative Neutral impact likelihood Score (I) (L) (IxL) Duty of Quality Effectiveness – clinical  Policy based on NICE Could the scheme outcome guidance impact positively or Patient experience  Adopting the policy will not negatively on any have an impact. of the following:  Patient safety Adopting the policy will not have an impact. Parity of esteem  Adopting the policy will not have an impact. Safeguarding children or  Adopting the policy will not adults have an impact. NHS Outcomes Enhancing quality of life  Policy based on NICE Framework guidance, aimed at preventing Could the scheme ill health. impact positively or Ensuring people have a  Adopting the policy will not negatively on the positive experience of have an impact. delivery of the five care domains: Preventing people from  Adopting the policy will not dying prematurely have an impact. Helping people recover  Adopting the policy will not from episodes of ill health have an impact. or following injury Treating and caring for  Adopting the policy will not people in a safe have an impact. environment and protecting them from avoidable harm

Patient services A modern model of  Adopting the policy will not Could the proposal integrated care, with key have an impact. Coventry and Rugby CCG/Warwickshire North CCG

impact positively or focus on multiple long- negatively on any term conditions and of the following: clinical risk factors Access to the highest  Adopting the policy will not quality urgent and have an impact. emergency care Convenient access for  Adopting the policy will not everyone have an impact. Ensuring that citizens are  Adopting the policy will not fully included in all have an impact. aspects of service design and change Patient Choice  Adopting the policy will not have an impact. Patients are fully  Adopting the policy will not empowered in their own have an impact. care Wider primary care,  Adopting the policy will not provided at scale have an impact. Access Patient choice  Adopting the policy will not Could the proposal have an impact. impact positively or Access  Adopting the policy will not negatively on any have an impact. of the following: Integration  Adopting the policy will not have an impact. Compliance with Quality of care and  Policy based on NICE NHS Constitution environment guidance, aiming to improve quality of care and services Nationally approved  Policy adopts NICE guidance. treatment/drugs Respect, consent and  Adopting the policy will not confidentiality have an impact. Informed choice and  Adopting the policy will not involvement have an impact. Complain and redress  Adopting the policy will not have an impact. *Risk score definitions are provided in the next section.

Coventry and Rugby CCG/Warwickshire North CCG

Risk rating score definition

Likelihood Impact 1 – Rare 1 – Negligible 2 – Unlikely 2 – Minor 3 – Moderate 3 – Moderate 4 – Likely 4 – Major 5 – Almost certain 5 – Catastrophic

Likelihood

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

Catastrophic (5) 5 10 15 20 25

Major (4) 4 8 12 16 20

Moderate (3) 3 6 9 12 15

Minor (2) 2 4 6 8 10

Negligible (1) X-1 2 3 4 5

How will a successful implementation of quality indicators be measured?

Quality Outcome Measured By Positive Health Outcome Triangulation of Incidents Complaint and Patient Experience trends

Coventry and Rugby CCG/Warwickshire North CCG

Stage 1b: Equality Questions

The Public Sector Equality Duty requires us to eliminate discrimination, advance equality of opportunity and foster good relations with protected groups. Consider how this policy / service will achieve these aims.

Other partners/stakeholders involved in scheme: N/A

Who will be affected by this piece of work? CCG registered patients

Is there likely to be a Evidence/Comments for answers. differential impact? (Please tick one) Where available please share any baseline data and research on the population that this PROTECTED GROUP piece of work will affect. YES NO UNKNOWN Include any consultations with service users that have been carried out.

Gender  Adopting the policy will not have an impact. Race  Cataracts are associated with diabetes, which is more prevalent in Asian and Black populations. Activity to be monitored to ensure treatments carried out and appropriate action to be taken if not. Disability (including mental  Cataracts lead to visual impairment. Activity to be monitored to ensure treatments carried out and impairment, learning appropriate action to be taken if not. difficulty) Religion/belief  Adopting the policy will not have an impact. Sexual orientation  Adopting the policy will not have an impact. Age  Cataracts are more common in older age groups. Monitor compliance with safe guarding policies. Ref: 1 & 2 Social deprivation  Adopting the policy will not have an impact. Carers  Adopting the policy will not have an impact. Human rights  Adopting the policy will not have an impact. Pregnancy and Maternity  Adopting the policy will not have an impact.

Coventry and Rugby CCG/Warwickshire North CCG

References

1. http://cks.nice.org.uk/cataracts#!backgroundsub:1 2. http://cks.nice.org.uk/cataracts#!backgroundsub:2.

Stage 1c: Post Implementation Review

Use the template below to record outcomes of reviews – if more than one is required cut and paste the box below:

Has there been a differential Evidence/Comments for answers Mitigations impact? Quality Impact (Please tick one) YES NO UNKNOWN

Coventry and Rugby CCG/Warwickshire North CCG

Male Circumcision

Coventry and Rugby CCG/ Warwickshire North CCG Male Circumcision policy

VERSION CONTROL

4.0 Version: Governing Body Meetings in Common Ratified by: TBC Date ratified: Joint CCG Clinical Commissioning Policy Name of originator/author: Development Group

Clinical Quality and Governance Name of responsible committees: Committees in Common

TBC Date issued: TBC Review date:

VERSION HISTORY

Date Version Comment / Update

September 3.0 Approved by Governing Body 2016

May 2020 4.0

Coventry and Rugby CCG/ Warwickshire North CCG Male Circumcision policy

Commissioning Policy: Coventry and Rugby CCG (CRCCG)

Warwickshire North CCG (WNCCG)

Treatment Male circumcision Indication Clinical requirement for circumcision Background This commissioning policy is needed because male circumcision (defined as the surgical removal of all or part of the foreskin of the penis) may be done for certain medical reasons, but is often sought for cultural or religious reasons. Circumcision is not routinely commissioned by the Clinical Commissioning Groups (CCG) unless medically necessary. NB. Circumcision refers to male circumcision only. Female circumcision is prohibited in law by the Female Genital Mutilation Act 2003 and is the subject of multi-agency guidelines from the Department of Health . Treatment: Male Circumcision Male Circumcision for cosmetic, social, cultural and religious reasons - not funded

Male Circumcision under 16 years of age Male Circumcision for clinical indications funded with following clinical indications:

Recurrent episodes (more than three) of severe and pathological phimosis (inability to retract the foreskin due to a narrow prepucial ring) OR Severe and recurrent episodes (more than three) of paraphimosis (inability to pull forward a retracted foreskin) and balanitis (chronic inflammation leading to a rigid fibrous foreskin) OR Severe and recurrent episodes (more than three) of balanoposthitis (recurrent bacterial infection of the glans and foreskin)

Male Circumcision over 16 years of age Male Circumcision for clinical indications funded with following clinical indications:

Pathological phimosis OR Three documented episodes of balanoposthitis OR Relative indications for circumcision or other foreskin surgery include the following: • Prevention of urinary tract infection in patients with an abnormal urinary tract • Recurrent paraphimosis • Trauma (e.g. zipper injury) • Tight foreskin causing pain on arousal/ interfering with sexual function • Congenital abnormalities

Absolute indications for circumcision • Penile malignancy • Traumatic foreskin injury where it cannot be salvaged

Prior approval from the Clinical Commissioning Group will be required

Coventry and Rugby CCG/ Warwickshire North CCG Male Circumcision policy

before any treatment proceeds in secondary care.

Quality and See QEIA attached Equality Impact

Coventry and Rugby CCG/ Warwickshire North CCG Male Circumcision policy

Quality and Equality Impact Assessment

Scheme Title: Male Circumcision Policy

Project Lead: Clive Campton, IFR Manager Senior Responsible Officer: Dr Sarah Raistrick, Chair Kate Cogman, Contracts Manager Quality Sign Off: Intended impact of The Male Circumcision policy supports the objective to prioritise resources and provide interventions with the greatest proven scheme: health gain, within CCG budgetary constraints. The intention is to ensure equity and fairness in respect of access to NHS funding for interventions and to ensure that interventions are provided within the context of the needs of the overall population and the evidence of clinical and cost effectiveness. How will it be achieved: The Governing Body adopts the policy.

Name of person completing assessment: Clive Campton Kate Cogman Position: IFR Manager Contracts Manager Date of Assessment: November 2019

Quality Review by: Mary Mansfield Position: Deputy Director of Nursing and Quality Date of Review: March 2020

Coventry and Rugby CCG/ Warwickshire North CCG Male Circumcision policy

Stage 1a: High level Quality and Equality Questions

Helping people recover  Adopting the policy will not from episodes of ill health have an impact. or following injury

Treating and caring for  Adopting the policy will not people in a safe have an impact. environment and protecting them from avoidable harm Patient services A modern model of  Adopting the policy will not Coventry and Rugby CCG/ Warwickshire North CCG Male Circumcision policy

Could the proposal integrated care, with key have an impact. impact positively or focus on multiple long- negatively on any term conditions and of the following: clinical risk factors Access to the highest  Adopting the policy will not quality urgent and have an impact. emergency care Convenient access for  Adopting the policy will not everyone have an impact. Ensuring that citizens are  Adopting the policy will not fully included in all have an impact. aspects of service design and change Patient Choice  Adopting the policy will not have an impact. Patients are fully  Adopting the policy will not empowered in their own have an impact. care Wider primary care,  Adopting the policy will not provided at scale have an impact. Access Patient choice  Patient choice does not apply Could the proposal to alternative therapies impact positively or  negatively on any Access Adopting the policy will not of the following: have an impact. Integration  Adopting the policy will not have an impact. Compliance with Quality of care and  Adopting the policy will not NHS Constitution environment have an impact. Nationally approved  Adopting the policy will not treatment/drugs have an impact. Respect, consent and  Adopting the policy will not confidentiality have an impact. Informed choice and  Adopting the policy will not involvement have an impact. Complain and redress  Adopting the policy will not have an impact. *Risk score definitions are provided in the next section

Coventry and Rugby CCG/ Warwickshire North CCG Male Circumcision policy

Risk rating score definition

Likelihood Impact 1 – Rare 1 – Negligible 2 – Unlikely 2 – Minor 3 – Moderate 3 – Moderate 4 – Likely 4 – Major 5 – Almost certain 5 – Catastrophic

Likelihood

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

Catastrophic (5) 5 10 15 20 25

Major (4) 4 8 12 16 20

Moderate (3) 3 6 9 12 15

Minor (2) 2 4 6 8 10

Negligible (1) X-1 2 3 4 5

Coventry and Rugby CCG/ Warwickshire North CCG Male Circumcision policy

How will a successful implementation of quality indicators be measured?

Quality Outcome Measured By Positive Health Outcome Triangulation of Incidents Complaint and Patient Experience trends

Coventry and Rugby CCG/ Warwickshire North CCG Male Circumcision policy

Stage 1b: Equality Questions

Other partners/stakeholders involved in scheme: N/A

Who will be affected by this piece of work? CCG registered patients

Gender  Adopting the policy will not have an impact. Race  As policy excludes male circumcision on religious or cultural grounds there is the potential for there to be a barrier in terms of protected characteristics. Disability (including mental  Adopting the policy will not have an impact. impairment, learning difficulty) Religion/belief  As policy excludes male circumcision on religious or cultural grounds there is the potential for there to be a barrier in terms of protected characteristics. Sexual orientation  Adopting the policy will not have an impact. Age  Male circumcision is mostly done in babies and young children but can be undertaken at any age for clinical reasons. Social deprivation  Adopting the policy will not have an impact.

Coventry and Rugby CCG/ Warwickshire North CCG Male Circumcision policy

Carers  Adopting the policy will not have an impact. Human rights  Adopting the policy will not have an impact. Pregnancy and Maternity  Adopting the policy will not have an impact.

Stage 1c: Post Implementation Review

Use the template below to record outcomes of reviews – if more than one is required cut and paste the box below:

Has there been a differential Evidence/Comments for answers Mitigations impact? Quality Impact (Please tick one) YES NO UNKNOWN

Coventry and Rugby CCG/ Warwickshire North CCG Male Circumcision policy

Complementary and Alternative Therapies

VERSION CONTROL

Version: 3.0 Governing Body Meetings in Common Ratified by: TBC Date ratified: Joint CCG Clinical Commissioning Policy Name of originator/author: Development Group

Clinical Quality and Governance Committees in Name of responsible committees: Common

TBC Date issued: TBC Review date:

VERSION HISTORY

Date Version Comment / Update

November 2019 2.0 Approved by Governing Body

May 2020 3.0 Renew with no amendments.

Commissioning Policy: Coventry and Rugby CCG (CRCCG)

Warwickshire North CCG (WNCCG)

Treatment Complementary and Alternative Therapies Indication Various medical conditions Background This commissioning policy has been produced in order to provide and ensure equity, consistency and clarity relating to the approach to complementary and alternative therapies by the Clinical Commissioning Groups.

The policy reflects the relative lack of high quality research data available to support the use of these therapies.

Commissioning Complementary and alternative therapies are not commissioned by the position CCG as “stand-alone” treatments due to a paucity of information on clinical effectiveness.

In certain circumstances some of the procedures are commissioned as part of a broader contract with a mainstream provider (for example specialist pain management, oncology, palliative care and musculoskeletal [MSK] services) in a multi-disciplinary approach to symptom control.

The alternative and complimentary therapies and alternative disciplines covered by this policy include:

• Acupuncture • Alexander Technique • Anthroposophical medicine • Aromatherapy • Bach and other flower remedies • Chinese herbal medicine • Chiropractic • Crystal therapy • Dowsing • Eastern medicine • Healing Nutritional medicine • Herbal medicine • Hypnotherapy • Iridology • Kinesiology • Maharishi Ayurvedic medicine • Massage • Meditation • Naturopathy • Neutralising Antigens/clinical ecology/environmental medicine • Osteopathy • Pilates • Radionics • Reflexology • Shiatsu • Traditional Chinese medicine • Yoga

N.B. The alternative and complementary therapies/disciplines listed above are not exhaustive. 3

Quality & See QEIA attached Equality Impact

Quality and Equality Impact Assessment

Scheme Title: Complementary and Alternative Therapies Policy

Project Lead: Clive Campton, IFR Manager Senior Responsible Officer: Dr Sarah Raistrick, Chair Kate Cogman, Contracts Manager Quality Sign Off: Intended impact of The Complementary and Alternative Therapy policy supports the objective to prioritise resources and provide interventions with scheme: the greatest proven health gain, within CCG budgetary constraints. The intention is to ensure equity and fairness in respect of access to NHS funding for interventions and to ensure that interventions are provided within the context of the needs of the overall population and the evidence of clinical and cost effectiveness. How will it be achieved: The Governing Body adopts the policy.

Name of person completing assessment: Clive Campton Kate Cogman Position: IFR Manager Contracts Manager Date of Assessment: November 2019

Quality Review by: Mary Mansfield

Position: Deputy Director of Nursing and Quality

Date of Review: March 2020

Stage 1a: High level Quality and Equality Questions

OUTCOME ASSESSMENT Evidence/Comments for Risk rating Mitigating actions (Please tick one) answers (For negative outcomes) AREA OF ASSESSMENT Risk Risk Risk Positive Negative Neutral impact likelihood Score (I) (L) (IxL) Duty of Quality Effectiveness – clinical  Adopting the policy will not Could the scheme outcome have an impact. impact positively or Patient experience  Adopting the policy will not negatively on any have an impact. of the following:  Patient safety Adopting the policy will not have an impact. Parity of esteem  Adopting the policy will not have an impact. Safeguarding children or  Adopting the policy will not adults have an impact. NHS Outcomes Enhancing quality of life  Adopting the policy will not Framework have an impact. Could the scheme Ensuring people have a  Adopting the policy will not impact positively or positive experience of have an impact. negatively on the care delivery of the five domains: Preventing people from  Adopting the policy will not dying prematurely have an impact.

Helping people recover  Adopting the policy will not from episodes of ill health have an impact. or following injury

Treating and caring for  Adopting the policy will not people in a safe have an impact. environment and protecting them from avoidable harm

Patient services A modern model of  Adopting the policy will not Could the proposal integrated care, with key have an impact. impact positively or focus on multiple long- negatively on any term conditions and of the following: clinical risk factors Access to the highest  Adopting the policy will not quality urgent and have an impact. emergency care Convenient access for  Adopting the policy will not everyone have an impact. Ensuring that citizens are  Adopting the policy will not fully included in all have an impact. aspects of service design and change Patient Choice  Adopting the policy will not have an impact. Patients are fully  Adopting the policy will not empowered in their own have an impact. care Wider primary care,  Adopting the policy will not provided at scale have an impact. Access Patient choice  Patient choice does not apply Could the proposal to alternative therapies impact positively or  negatively on any Access Adopting the policy will not of the following: have an impact. Integration  Adopting the policy will not have an impact. Compliance with Quality of care and  Adopting the policy will not NHS Constitution environment have an impact.

Nationally approved  Adopting the policy will not treatment/drugs have an impact. Respect, consent and  Adopting the policy will not confidentiality have an impact. Informed choice and  Adopting the policy will not involvement have an impact. Complain and redress  Adopting the policy will not have an impact. 7

*Risk score definitions are provided in the next section

Risk rating score definition

Likelihood Impact 1 – Rare 1 – Negligible 2 – Unlikely 2 – Minor 3 – Moderate 3 – Moderate 4 – Likely 4 – Major 5 – Almost certain 5 – Catastrophic

Likelihood

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

Catastrophic (5) 5 10 15 20 25

Major (4) 4 8 12 16 20

Moderate (3) 3 6 9 12 15

Minor (2) 2 4 6 8 10

Negligible (1) X-1 2 3 4 5

How will a successful implementation of quality indicators be measured?

Quality Outcome Measured By Positive Health Outcome Triangulation of Incidents Complaint and Patient Experience trends

Stage 1b: Equality Questions

Other partners/stakeholders involved in scheme: N/A

Who will be affected by this piece of work? CCG registered patients

Gender  Adopting the policy will not have an impact. Race  Adopting the policy will not have an impact. Disability (including mental  The policy may impact on people with a disability seeking alternative treatments. Patients will be impairment, learning supported by other routine therapies. difficulty) Religion/belief  Adopting the policy will not have an impact. Sexual orientation  Adopting the policy will not have an impact. Age  The policy may particularly impact on older people (though not limited to) who may seek treatment for age related ailments. Patients will be supported by other routine therapies. Social deprivation  Adopting the policy will not have an impact. Carers  Adopting the policy will not have an impact. Human rights  Adopting the policy will not have an impact. Pregnancy and Maternity  Adopting the policy will not have an impact.

Stage 1c: Post Implementation Review

Use the template below to record outcomes of reviews – if more than one is required cut and paste the box below:

Has there been a differential Evidence/Comments for answers Mitigations impact? Quality Impact (Please tick one) YES NO UNKNOWN

Complex and Specialised Obesity Surgery

VERSION CONTROL

Version: 2.0 Governing Body Meetings in Common Ratified by: TBC Date ratified: NHS England/Policy Development Group Name of originator/author: Clinical Quality and Governance Name of responsible committees: Committees in Common

TBC Date issued: TBC Review date:

VERSION HISTORY

Date Version Comment / Update

September 1.0 Approved by Governing Body 2017

May 2020 2.0 Renew with no amendments

Commissioning Policy: Coventry and Rugby CCG (CRCCG)

Warwickshire North CCG (WNCCG)

Treatment Complex and Specialised Obesity Surgery (Bariatric Surgery)

Indication Severe and complex obesity

Treatment: NHS England policy (attached) adopted by CCGs

The purpose of the adoption of the NHS England policy is to provide guidance for the commissioning and funding of bariatric surgery

With the commissioning responsibility passing to CCGs, following the same policy as NHS England (in line with NICE guidance CG43) ensures continuity of evidence based care

Quality and Part of NHS England policy Equality Impact

Clinical Commissioning Policy: Complex and Specialised Obesity Surgery

April 2013

Reference : NHSCB/A05/P/a

NHS Commissioning Board

Clinical Commissioning Policy: Complex and Specialised Obesity Surgery

First published: April 2013

Prepared by the NHS Commissioning Board Clinical Reference Group for

Severe and Complex Obesity

Severe and Complex Obesity Surgery policy – Severe and Complex Obesity CRG NHSCB/A05/P/a

Contents

Policy Statement ...... 4

Equality Statement ...... 4

Plain Language Summary ...... 4

1. Introduction ...... 5

2. Definitions ...... 6

3. Aim and Objectives ...... 7

4. Criteria for commissioning ...... 8

5. Patient pathway ...... 10

6. Governance arrangements...... 11

7. Epidemiology and needs assessment ...... 12

8. Evidence Base ...... 14

9. Rationale behind the policy statement...... 15

10. Mechanism for funding ...... 16

11. Audit Requirements ...... 16

12. Documents which have informed this policy...... 16

13. Links to other policies ...... 17

14. Date of Review ...... 17

References ...... 17

Severe and Complex Obesity Surgery policy – Severe and Complex Obesity CRG NHSCB/A05/P/a Policy Statement

The NHS Commissioning Board (NHS CB) will commission complex and specilaised surgery as a treatment for selected patients with severe and complex obesity that has not responded to all other non-invasive therapies, in accordance with the criteria outlined in this document.

In creating this policy the NHS CB has reviewed this clinical condition and the options for its treatment. It has considered the place of this treatment in current clinical practice, whether scientific research has shown the treatment to be of benefit to patients, (including how any benefit is balanced against possible risks) and whether its use represents the best use of NHS resources.

This policy document outlines the arrangements for funding of this treatment for the population in England.

Equality Statement

The NHS CB has a duty to have regard to the need to reduce health inequalities in access to health services and health outcomes achieved as enshrined in the Health and Social Care Act 2012.The NHS CB is committed to ensuring equality of access and non-discrimination, irrespective of age, gender, disability (including learning disability), gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, sex (gender) or sexual orientation. In carrying out its functions, the NHS CB will have due regard to the different needs of protected equality groups, in line with the Equality Act 2010. This document is compliant with the NHS Constitution and the Human Rights Act 1998. This applies to all activities for which they are responsible, including policy development, review and implementation.

Plain Language Summary

People whose weight to height ratio (or Body Mass Index, BMI) is significantly high are more likely to suffer from a range of illnesses (e.g. type-2 diabetes) and have a lower life expectancy.

Programmes designed to support people in losing weight include lifestyle changes such as diet, exercise and behavioural change. Low and very low calorie diets, drug treatments, psychological support and specialist weight management programmes are also available. Bariatric (or weight-loss) surgery (e.g. gastric bypass) is a highly specialised intervention used in appropriate, selected patients with severe and complex obesity that have not responded to all other non-invasive therapies.

Within these patient groups bariatric surgery has been shown to be highly cost effective in reducing BMI and the associated illnesses, promoting longer term health.

Patients need to be motivated and adequately prepared for surgery and for the post surgical treatment and monitoring which is necessary for success.

Severe and Complex Obesity Surgery policy – Severe and Complex Obesity CRG NHSCB/A05/P/a 1. Introduction

Obesity and being overweight is a global epidemic. The World Health Organisation (WHO) predicts that by 2015 approximately 2.3 billion adults worldwide will be 1 overweight and more than 700 million will be obese.

The prevalence of obesity in England is one of the highest in the European Union. In England just over a quarter of adults (26% of both men and women aged 16 or 2 over) were classified as obese in 2010 (Body Mass Index (BMI) 30kg/m2 or over).

Using both BMI and waist circumference to assess risk of health problems, 22% of men were estimated to be at increased risk; 12% at high risk and 23% at very high risk in 2010. Equivalent figures for women were: 14%, 19% and 25%. There has been a marked increase in the proportion (doubling) that are obese, a proportion that has gradually increased over the period from 13.2% in 1993 to 26.2% in 2010 2 for men and from 16.4% to 26.1% for women.

Obesity is directly associated with many different illnesses, chief among them insulin resistance, type 2 diabetes, metabolic syndrome, dyslipidaemia, hypertension, left atrial enlargement, left ventricular hypertrophy, gallstones, several types of cancer, gastro-oesophageal reflux disease, non alcoholic fatty liver disease (NAFLD), degenerative joint disease, obstructive sleep apnoea syndrome, psychological and psychiatric morbidities. It lowers life expectancy by 5 to 20 years. Direct costs of 3 obesity are estimated to be £4.2 billion.

As BMI increases the number of obesity-related comorbidities increases. The number of patients with ≥ 3 comorbidities increases from 40% for a BMI of < 40 to more than 50% for BMI 40-49.9 to almost 70% for BMI 50-59.9 and ultimately to 89% for BMI > 59-9.

The treatment of obesity should be multi-component. All weight management programmes should include non-surgical assessment of patients, treatments and lifestyle changes such as improved diet, increased physical activity and behavioural interventions. There should be access to more intensive treatments such as low and very low calorie diets, pharmacological treatments, psychological support and specialist weight management programmes.

Surgery to aid weight reduction for adults with morbid/severe obesity should be considered when there is recent and comprehensive evidence that an individual patient has fully engaged in a structured weight loss programme; and that all appropriate non-invasive measures have been tried continuously and for a sufficient period; but have failed to achieve and maintain a clinically significant weight loss for the patients clinical needs (NICE CG43 recommendations).4 The patient should in addition have been adequately counselled and prepared for bariatric surgery.

This surgery, which is known to achieve significant and sustainable weight reduction within 1-2 years, as well as reductions in co-morbidities and mortality, is commonly known as bariatric surgery. The current standard bariatric operations are gastric banding, gastric bypass, sleeve gastrectomy and duodenal switch. These are usually undertaken laparoscopically.

Bariatric surgery is the most effective weight-loss therapy and has marked therapeutic effects on patients with Type 2 diabetes. The economic effect of the

Severe and Complex Obesity Surgery policy – Severe and Complex Obesity CRG NHSCB/A05/P/a clinical benefits of bariatric surgery for diabetes patients with BMI 35 kg/m has been estimated in patients aged 18-65 years. Surgery costs were fully recovered after 26 months for laparoscopic surgery. The data suggest that surgical therapy is clinically more effective and ultimately less expensive than standard therapy for diabetes patients with BMI 35 kg/m. Other groups have been less well studied but bariatric surgery is reported to be cost effective against a wider range of co-morbidities.

2. Definitions

Table 1: Body Mass Index (BMI) categories

Definition BMI range (kg/m2)

Underweight Under 18.5

Normal 18.5 to less than 25

Overweight 25 to less than 30

Obese 30 to less than 40

Obese I 30 to less than 35

Obese II 35 to less than 40 Morbidly obese 40 and over Overweight including obese 25 and over Obese including morbidly obese 30 and over

Gastric banding

The gastric band (or sometimes referred to more fully as laparoscopic adjustable gastric band – LAGB) helps reduce the amount of food eaten. It acts like a belt around the top portion of the stomach, creating a small pouch. Patients feel full after eating only a small quantity of food. It is adjustable and reversible.

Gastric bypass

There are a number of variations of gastric bypass operation but the most popular one conducted in the UK is called a Roux–en–Y gastric bypass (RNY). At surgery, the top section of the stomach is divided off by a line of staples, creating a small 'pouch' stomach. A new exit from this pouch is made into a 'Y' loop from the small intestine so that food bypasses your old stomach and part (about 100-150cm) of the small intestine. The size of stomach pouch and the length of small intestine that is bypassed are carefully calculated to ensure that patients will be able to eat enough for their body's needs at normal weight.

Sleeve gastrectomy

The sleeve gastrectomy reduces the size of the stomach by about 75%. It is divided vertically from top to bottom leaving a banana shaped stomach along the inside

Severe and Complex Obesity Surgery policy – Severe and Complex Obesity CRG NHSCB/A05/P/a curve and the pyloric valve at the bottom of the stomach, which regulates the emptying of the stomach into the small intestine, remains intact. This means that although smaller, the stomach function remains unaltered.

Duodenal switch

The duodenal switch (DS) works primarily by malabsorption. The operation can be performed as an open operation through a midline incision from the base of the breastbone, or laparoscopically. Technically it is a complex operation which can take 5–7 hours to complete, and will usually require a post–op hospital stay of 4–6 days.

Following a sleeve gastrectomy a short segment of the duodenum at the base of the stomach is left but the remainder cut and the second half of the small intestine bought up and joined to the duodenum (this part of the operation is very similar to a RNY gastric bypass but is slightly lower down in the digestive tract). The bypassed section of small intestine is then rejoined to carry bile and pancreatic juices to the latter part of the small intestine near where it joins the large intestine (colon).

Digestion and absorption of fat depends on it mixing with bile (from the liver and normally entering the duodenum). As this mixing does not occur until much further on in the intestine after a DS, the body's ability to digest and absorb calories from fat is severely reduced. As a result weight drops, even when eating quite normally. 5 Definitions adapted from BOSPA

Models of care

A typical model for managing obesity is outlined as follows:

 Tier 4 - Specialised Complex Obesity Services (including bariatric surgery)  Tier 3 - A primary/community care based multi-disciplinary team (MDT) to provide an intensive level of input to patients.  Tier 2 - Primary Care with Community Interventions  Tier 1 - Primary Care and Community Advice.

From: South East Coast Specialised Commissioning Group, 2010

3. Aim and Objectives

To define eligibility criteria for NHS commissioned complex and specialised obesity surgery.

Severe and Complex Obesity Surgery policy – Severe and Complex Obesity CRG NHSCB/A05/P/a

4. Criteria for commissioning

Bariatric surgery is a treatment for appropriate, selected patients with severe and complex obesity that has not responded to all other non-invasive therapies. Within these patient groups bariatric surgery has been shown to be highly cost effective.

Bariatric surgery is recommended by NICE as a first-line option for adults with a BMI of more than 50kg/m2, in whom surgical intervention is considered appropriate. However, it will be required that these patients also fulfil the criteria below.

Selection criteria of patients for bariatric surgery should prevent perverse incentives for example patients should not become more eligible for surgery by increasing their body weight. Similarly the selection criteria should not forbid bariatric surgery for patients who have lost weight with non-surgical methods

Eligibility for bariatric surgery

Surgery will only be considered as a treatment option for people with morbid obesity providing all of the following criteria are fulfilled:

 The individual is considered morbidly obese. For the purpose of this policy bariatric surgery will be offered to adults with a BMI of 40kg/m2 or more, or between 35 kg/m2 and 40kg/m2 or greater in the presence of other significant diseases.  There must be formalised MDT led processes for the screening of co-morbidities and the detection of other significant diseases. These should include identification, diagnosis, severity/complexity assessment, risk stratification/scoring and appropriate specialist referral for medical management. Such medical evaluation is mandatory prior to entering a surgical pathway.  Morbid/severe obesity has been present for at least five years.  The individual has recently received and complied with a local specialist obesity service weight loss programme (non surgical Tier 3 / 4), described as follows: This will have been for duration of 12-24 months. For patients with BMI > 50 attending a specialist bariatric service, this period may include the stabilisation and assessment period prior to bariatric surgery. The minimum acceptable period is six months. The specialist obesity weight loss programme and MDT should be decided locally. This will be led by a professional with a specialist interest in obesity and include a physician, specialist dietician, nurse, psychologist and physical exercise therapist, all of whom must also have a specialist interest in obesity. There are different models of local MDT structure. Important features are the multidisciplinary, structured and organised approach, lead professional, assessment of evidence that all suitable non invasive options have been explored and trialled and individualised patient focus and targets. In addition to offering a programme of care the service will select and refer appropriate patients for consideration for bariatric surgery.

The non-surgical Tier 3 / 4 service may be community or hospital-based but will have as their role

Severe and Complex Obesity Surgery policy – Severe and Complex Obesity CRG NHSCB/A05/P/a  Education  Dietary advice/support (which may be delivered through specialist obesity dieticians, or slimming clubs – Weight Watchers, Slimming World etc.)  Enabling access to appropriate level of physical activity where not limited due to obesity related problems such as osteoarthritis, cardio respiratory disease  Exclusion of underlying contributory disease e.g. hypothyroidism, Cushing’s  Evaluation of co-morbidities (diabetes, sleep disorder breathing, etc) and instigation of appropriate management plans  Evaluation of patient’s engagement with non-surgical measures  Evaluation of psychological factors relevant to obesity, eating behaviour, physical activity and patient engagement.  There is evidence of attendance, engagement and full participation in the above non surgical Tier 3 / 4 service Engagement can be judged by attendance records and achievement of pre-set individualised targets (for example steady and sustained weight loss of 5-10%, or maintaining constant weight whilst stopping smoking).  The patient has been assessed and referred by the lead physician/ clinician for the specialist obesity weight loss MDT.  The patient has been unable to lose clinically significant weight (i.e. enough to modify co-morbidities) during the period of intervention. Patients who lose sufficient weight to fall beneath the NICE guidance should not be considered appropriate for surgery.

The final decision on whether an operation is indicated should be made by the specialist hospital bariatric MDT. For all bariatric surgery candidates, an individual risk benefit evaluation will be done by the Bariatric Surgery MDT, this will be informed by their own clinical assessment and information provided by primary care and by non-surgical Tier 3 / 4. In some locations there may be close liaison (and perhaps even overlap of personnel) between non-surgical Tier 3/4 and Bariatric Surgery MDT. For example, a specialist bariatric physician would be on both MDTs.

The risk:benefit evaluation will consider:

 Existing co-morbidities and their reversibility  Risk of future co-morbidities and their reversibility  Patients age and general level of health  Anticipated weight reduction  Alternatives if bariatric surgery is not undertaken  Peri-operative mortality  Post-operative complications of bariatric surgery

The Bariatric Surgery Team will satisfy itself that:

 Bariatric surgery is in accordance with relevant guidelines  There are no specific clinical or psychological contraindications to this type of surgery  The individual is aged 18 years or above.  The patient has engaged with non-surgical Tier 3 / 4 Services.

Severe and Complex Obesity Surgery policy – Severe and Complex Obesity CRG NHSCB/A05/P/a  The anaesthetic and other peri-operative risks have been appropriately minimised  the patient has engaged in appropriate support or education groups/schemes to understand the benefits and risks of the intended surgical procedure  the patient is likely to engage in the follow up programme that is required after any bariatric surgical procedure to ensure  Safety of the patient,  Best clinical outcome is obtained and then maintained.  Change eating behaviour  Change physical behaviour as advised  The overall risk:benefit evaluation favours bariatric surgery

Revisional procedures will only be considered electively for clinical reasons due to complications and will require prior approval unless they are required on an acute emergency basis. (A separate policy will need to be developed for revisional procedures).

Any new/novel bariatric surgery procedures outside of this policy will not be routinely commissioned. Where a clinician wishes to make a request for a new device/procedure, an application for exceptional funding through the NHS CB Individual Funding Request (IFR) process should be made in the first instance. The latter should be free to seek advice from the CRG leads. This request will then serve as an indicator for the CRG to undertake an evidence based review prior to developing a policy agreed by the CRG for the device/procedure requested.

5. Patient pathway

Non surgical and intensive management

The non surgical and intensive management of morbidly obese patients in Tier 3/4 settings to optimise risk and subsequent referral process of eligible patients is an integral part of this pathway. This has already been described in section 4.

Pre-operative preparation

As it is an elective procedure it is critical that individuals being considered for bariatric surgery are carefully selected, appropriately referred, fully evaluated and their medical condition optimised in order to achieve the best operative, post operative and long term outcomes. This is best done by MDTs at Tier 3 / 4 services and also after referral to the Bariatric Surgical Centre.

This patient population has unique and challenging issues including an extensive range of medical and psychological and potentially psychiatric comorbidities. Often patients have unrealistic expectations of the surgery. Therefore a multidisciplinary, comprehensive and timely assessment pre-operatively is of great importance.

The diagnostic work up, pre operative evaluation, risk stratification and provision of counselling, education and information is best undertaken by a dedicated hospital

Severe and Complex Obesity Surgery policy – Severe and Complex Obesity CRG NHSCB/A05/P/a multidisciplinary team specialising in the management of morbidly obese patients including:

 Surgeons

 Anaesthetists

 Physicians

 Psychologists – will provide assessments and targeted interventions e.g. Cognitive Behavioural Therapy and also post operative support

 Dieticians

 Nurses

 Radiologist

 Dedicated administrative support

 Access to Psychiatry*

 Access to Pharmacists*

 Access to Physiotherapists or sports and exercise medicine specialists*

* with special interest in bariatric surgery

This team should also have links to independent patient support groups and also provides in-house patient support groups.

The surgical provider will have robust arrangements for surgical follow up and for receiving, assessing patients with post-operative complications and their emergency management by bariatric surgeons. This includes access to a fully staffed emergency theatre on a 24 hour basis. There will also be a contact point for advice on queries.

Structured, systematic and team-based follow up should be organised by the surgical provider for 2 years after surgery. Life long specialist follow up is also advocated although will usually be provided by the Tier 3 / 4 services. Such an approach will monitor weight loss outcomes, complications, adherence to iron, vitamin D/Calcium and Vitamin B12 supplementation, facilitate clinical suspicion of specific or combined micronutrient deficiencies leading to appropriate laboratory tests for confirmation. Psychological input, management of comorbidities, dietary and lifestyle advice and liaison with general practice will also be other functions of the follow up process. (A separate policy including consideration of automated annual recall systems will need to be developed for this).

6. Governance arrangements

 Providers, surgeons, premises, on site services and bariatric surgery throughput should at least meet the IFSO Guidelines6 for Safety, Quality, and Excellence in Bariatric Surgery.

Severe and Complex Obesity Surgery policy – Severe and Complex Obesity CRG NHSCB/A05/P/a  However, it is recognised that the IFSO hospital and surgeon volume standards were meant to imply minimum volumes only (125 per hospital and 50 per surgeon). There is clear data show that mortality and complication rates, both for bypass and banding are better with greater volumes, and the data are a continuum, so the more cases that are done the better the outcomes are likely to be, just as for all other examples of elective surgery. In addition there are two benefits of commissioning only high volume providers: higher volumes bring in more funding to support the infrastructure (nurses, dieticians, psychologists), and they allow several surgeons to take part in an on call rota e.g. 1 in 4 is practical whereas 1 in 2 is not.7 Thus major centres should be built up and other centres started only when capacity is reached. There are no hospital or surgeon volume data for sleeve gastrectomy or duodenal switch but there is no reason to doubt that the same relationship exists and therefore the same governance rules should apply.

 Appropriate MDT composition, professional inputs and process design for all stages of the pathway. Organisational arrangements for patient safety (elective and emergency) should be risk assessed, regularly tested and improved. Protocols should be audited especially the use of questionnaires for clinical assessment, generic interdisciplinary roles and substitution / expansion of professional roles i.e. use of GPs or other therapists for band-fills as an alternative to consultant radiologists; use of Skype, telephone etc. for consultations.

 The surgical service should be seamless both pre- and post operatively with the medical Tier 3 / 4 service and decided by local arrangements,

 The mandatory collection and submission of data to the National Bariatric Surgical Register. Audit timeliness and completeness of data submitted.

 The bariatric surgical provider will be responsible for the organisation of structured, systematic and team based follow up for 2 years. Just before this period is finished the surgical provider will make arrangements to hand over care to the tier 3 service.

7. Epidemiology and needs assessment

The Health Survey for England8 shows that the proportion of adults (aged 16+) who are morbidly obese with a BMI 40kg/m2 or more has risen from 0.9% in 1993-95 to 1.9% in 2006-08. Over this period, the prevalence of morbid obesity was consistently higher in women (increasing from 1.5% in 1993-95 to 2.6% in 2006-08) than in men (increasing from 0.3% in 1993-95 to 1.3% in 2006-08), although the rate of increase in recent years has been higher in men. Based on these figures, the number of adults with morbid obesity in England would be around 800,000; in a CCG covering a population of 500,000, one would expect around 8,000 adults with morbid obesity.

Predicting future trends in morbid obesity has proven difficult. Two different models

Severe and Complex Obesity Surgery policy – Severe and Complex Obesity CRG NHSCB/A05/P/a have estimated markedly different prevalence figures. The first predicts a prevalence of almost 3% in men and 6% in women by 2030; the second predicts a prevalence of 1% for men and 4% for women by 2050. Straight-line extrapolation of the prevalence of adult men with BMI greater than 40 kg/m2 predicts a level of around 3% by 2050.

Estimated NHS Commissioning Board Population Estimated Population Region Obese (‘000) Morbidly Obese (‘000)

London 1,286 122

Midlands & East of England 2,689 202

North of England 2,528 231

South England 2,331 165

Grand Total 8,836 722

Notes:

% Obese and Morbidly obese taken from Table 2.10; HSE 2007 (NHS IC 2009)

Population Statistics taken from PCO Population Estimates 2010 (Release September 2011)

Severe and Complex Obesity Surgery policy – Severe and Complex Obesity CRG NHSCB/A05/P/a

In 2006 the National Institute for Health and Clinical Excellence (NICE) estimated a total prevalence of patients, meeting NICE BMI threshold criteria, of approximately 2.22% of the population, or approximately 1.1 million people. NICE further adjusted this figure to allow for those patients who may not be considered clinically eligible for surgery and again to allow for patient choice of treatment and those who would not accept surgery even if offered.

Applying the NICE algorithm indicates that there is a potential cohort of patients who may be eligible for, and who wish to take up, bariatric surgery of approximately 0.53% of the adult population in England or 257,000 people.

2010/2011 SUS data indicates that less than 9,000 patients were admitted in that year.

Analysis of the Health Survey for England data suggest that, of those recorded as having Morbid Obesity, 7% have a BMI of 50 kg/m2. Therefore there is a population, estimated at 51,000 people, in England who are eligible for bariatric surgery as first- line treatment for their obesity. For the remainder surgery is only considered after all other forms of medical management have been attempted, but adequate, clinically beneficial weight loss has not been achieved or maintained.

8. Evidence Base

In the short term, providing bariatric surgery as a solution to weight loss is significantly more expensive than conservative management and this cost has often been used as a reason for not commissioning surgical services, or limiting access. However the remission of co-morbidities as a result of surgery or the associated weight-loss means that the overall cost of managing a patient on a care pathway that includes surgery is more cost effective in the long term than one without. , 9, The Canadian and New Zealand Health Technology Assessment (HTA) agencies 10 both reported the cost per quality-adjusted life year (QALY) for bariatric surgery compared to non-surgical interventions for obesity to be within acceptable cost- effectiveness thresholds and concluded that bariatric surgery is cost effective. However, they also reported the relative paucity of data on cost effectiveness, the poor quality of the economic evaluations undertaken to date and inability to make recommendations for bariatric surgery techniques. In 2009 a UK National Institute for Health Research (NIHR) HTA11 updated the economic review on bariatric surgery for obesity, broadening its scope to include obese as well as morbidly obese people. The HTA reviewed five original economic evaluations (including four economic models) and undertook a primary economic evaluation adopting an NHS and personal social services perspective to develop a state-transition model comparing surgical to non-surgical interventions with a time horizon of 20 years. The UK HTA authors concluded that bariatric surgery appears to be a cost-effective treatment for obesity compared with non-surgical interventions. However, their findings suggested that bariatric surgery is likely to be

Severe and Complex Obesity Surgery policy – Severe and Complex Obesity CRG NHSCB/A05/P/a less cost effective in less obese subjects and there was limited evidence to enable conclusions to be drawn on the relative cost effectiveness of different bariatric procedures. Quality Improvement Scotland (2010)12 noted that economic analyses to date have typically assumed observed weight loss lowers both the severity and incidence of obesity-related comorbidities and associated treatment costs which, while reasonable assumptions, remain to be verified.

In 2011 the NHS South East Coast Health Policy Support Unit released a policy recommendation incorporating an economic analysis with a time-horizon of10 years.13 This showed bariatric surgery is cost-effective in the medium term, reaching a break-even point within 3-years of surgery. This analysis supported the UK HTA conclusions that surgery is less cost effective in less obese patients. A study of cost-utility of bariatric surgery for morbid Obesity in Finland14 was published in 2011, showing similar results

9. Rationale behind the policy statement

Bariatric surgery for the morbidly obese is an increasingly available intervention. However, surgical intervention is not the whole solution and appropriate clinical selection of fully informed patients is important.

It is also important to ensure that surgery is not offered prematurely in a patient’s weight loss pathway. Bariatric surgery is only one component of the multimodal lifetime treatment pathway: multidisciplinary medical assessment, pre operative management of comorbidities, conservative treatments and life-long follow–up care.

Patients need to be informed of the benefits and risks as well as the life- long implications of bariatric surgery.

With informed choice patients are better able to cope with the eating restrictions of a post surgically altered gastrointestinal anatomy and mandatory follow up for nutritional supplementation and monitoring to prevent nutritional deficiencies; the management of comorbidities; and adjustment of medications and dosage post operatively.

Preparation will improve patient awareness of their role in following a healthy lifestyle to consolidate surgically achieved weight loss and resolution of comorbidities.

Patients also need information about when and where and from whom to seek help, advice and to attend for regular follow up and the actions to take in the event of the onset of surgical complications as well as gastrointestinal symptoms/ side effects arising from an altered anatomy.

Morbid obesity is a complex syndrome for which bariatric surgery is a highly specialised intervention reserved for patients with a high clinical case of need and in whom all prior efforts of intensive weight reduction have failed. Patients should also

Severe and Complex Obesity Surgery policy – Severe and Complex Obesity CRG NHSCB/A05/P/a be motivated and adequately prepared for surgery to ensure their post surgical compliance which is necessary for success. Patient selection processes should ensure that only those patients who stand to benefit the most from surgery are offered it. As a highly specialised intervention, bariatric surgery should only be undertaken by appropriately specialist trained and experienced surgeons with appropriately high caseloads working within multidisciplinary specialist teams in hospitals where these operations are commonly performed and who have the requisite institutional experience.

10. Mechanism for funding

Specialised Complex Obesity services, including bariatric surgery pre-assessment, perioperative management, postoperative and longer term follow up where it occurs within the specialised service will be funded by the NHS Commissioning Board.

Tier 1, 2, 3 services will be commissioned and funded by Clinical Commissioning Groups (CCGs). Population prevention / health promotion measures and strategies will be funded from local authority budgets.

11. Audit Requirements

Mandatory compliance by Bariatric Surgery providers with National Bariatric Surgery Registry15 requirements, including 100% provision of required data.

12. Documents which have informed this policy

Association of Upper Gastrointestinal Surgeons of Great Britain and Ireland (AUGIS). Provision of Services document 2011). Available from: http://www.augis.org/pdf/reports/AUGIS_Provision_of_Services_Document.pdf Accessed 21/08.2012.

South East Coast Specialised Commissioning Group. Obesity management model for adults.2010

North West Specialised Commissioning Group. Evidence Based Commissioning of Specialist Morbid Obesity Services: Commissioning Standards and Summaries of Relevant Studies. November 2007.

National Institute for Health and Clinical Excellence. Bariatric surgical service commissioning guide. 2010. Available from: http://www.nice.org.uk/usingguidance/commissioningguides/bariatric/BariatricSur

Severe and Complex Obesity Surgery policy – Severe and Complex Obesity CRG NHSCB/A05/P/a gicalService.jsp?domedia=1&mid=87F5267C-19B9-E0B5-D47104E7147082E9 Accessed 12/08/2012.

National Institute for Health and Clinical Excellence. Obesity: the prevention, identification, assessment and management of overweight and obesity in adults and children. CG43, 2006. Available from: http://guidance.nice.org.uk/CG43 Accessed 12/08/2012. Accessed 12/08/2012.

13. Links to other policies

Primary care commissioning policies on cosmetic plastic surgery procedures Policies on referral to private sector providers The mechanism operated by the NHS CB for funding requests outside of the clinical criteria in this policy is yet to be finalised

14. Date of Review

This policy will be reviewed in April 2014 unless data received indicates that the proposed review date should be brought forward or delayed.

References

1. World Health Organisation. Obesity and overweight. Fact sheet N°311. September 2006. Available from: http://www.mclveganway.org.uk/Publications/WHO_Obesity_and_overweight.pdf Accessed 16/08/2012.

2. Association for the Study of Obesity. Statistics – England 2012. Available from: http://www.aso.org.uk/useful-resources/statistics-england-2012/ Accessed 16/08/2012.

3. Department of Health. Obesity General information 2011. Available from: http://webarchive.nationalarchives.gov.uk/+/www.dh.gov.uk/en/Publichealth/Obes ity/DH_078098 Accessed 16/08/2012.

4. National Institute for Health and Clinical Excellence. Obesity: the prevention, identification, assessment and management of overweight and obesity in adults and children. CG43, 2006. Available from: http://guidance.nice.org.uk/CG43 Accessed 12/08/2012.

5. British Obesity Surgery Patient Association. Available from: http://bospa.waxwing.co.uk/Default.aspx Accessed 20/08/2012

6. International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO). IFSO guidelines for safety, quality and excellence in bariatric surgery,

Severe and Complex Obesity Surgery policy – Severe and Complex Obesity CRG NHSCB/A05/P/a 2007. Available from: http://www.eac-bs.com/eacbs/en/4/58.html Accessed 12/08.2012 . Accessed 20/08/2012.

7. Association of Upper Gastrointestinal Surgeons of Great Britain and ureland (AUGIS). Provision of Services document 2011). Available from: http://www.augis.org/pdf/reports/AUGIS_Provision_of_Services_Document.pdf Accessed 21/08.2012.

8. The Health Survey for England. Available from: http://www.ic.nhs.uk/hsee Accessed 21/08/2012.

9. Boudreau R, Hodgson A. Laparoscopic adjustable gastric banding for weight loss in obese adults:clinical and economic review. Ottawa: Canadian Agency for Drugs and Technologies in Health (CADTH), 2007:38. Available from: http://www.cadth.ca/en/products/health-technology-assessment/publication/739 Accessed 21/08/2012.

10. New Zealand Health Technology Assessment (NZHTA). The safety, effectiveness and cost‐effectiveness of surgical and non‐surgical interventions for patients with morbid obesity. Christchurch: New Zealand Health Technology Assessment (NZHTA).2007. Available from: http://www.otago.ac.nz/christchurch/otago014009.pdf Accessed 21/08/2012.

11. Picot J, Jones J, Colquitt J L, Gospodarevskaya E, Loveman E, Baxter L, et al. The clinical effectiveness and cost-effectiveness of bariatric (weight loss) surgery for obesity: a systematic review and economic evaluation. Health Technol Assess 2009;13(41).

12. Quality Improvement Scotland Bariatric surgery in adults. Evidence note 28, 2010. Available from: http://www.healthcareimprovementscotland.org/previous_resources/hta_report/ev idence_note_28.aspx Accessed 21/08/2012.

13. NHS South East Coast Health Policy Support Unit. 2011

14. Mäklin S, Malmivaara A, Linna M, et al. Cost-utility of bariatric surgery for morbid Obesity in Finland. Br J Surg. 2011 Oct;98(10):1422-9.

15. National Bariatric Surgical Registry. Available from: http://hostn3.e- dendrite.com/csp/bariatric/FrontPages/nbsrfront.csp Accessed 12/08/2012.

Severe and Complex Obesity Surgery policy – Severe and Complex Obesity CRG NHSCB/A05/P/a

Endoscopic Thoracic Sympathectomy

Coventry and Rugby CCG/ Warwickshire North CCG Endoscopic Thoracic Sympathectomy policy

VERSION CONTROL

Version: 4.0 Governing Body Ratified by: TBC Date ratified: Joint CCG Clinical Commissioning Policy Name of originator/author: Development Group

Clinical Quality and Governance Name of responsible committees: Committees in Common

TBC Date issued: TBC Review date:

VERSION HISTORY

Date Version Comment / Update

September 3.0 Approved by Governing Body 2016

May 2020 4.0 Renew with no amendments

Coventry and Rugby CCG/ Warwickshire North CCG Endoscopic Thoracic Sympathectomy policy

Commissioning Policy: Coventry and Rugby CCG (CRCCG)

Warwickshire North CCG (WNCCG

Treatment Endoscopic Thoracic Sympathectomy

Indication Facial blushing and/or sweating

Treatment: • Treatment not funded

Facial blushing is often a result of social phobia and is encouraged by an over-active sympathetic nervous system. There is limited evidence suggesting Endoscopic Thoracic Sympathectomy can control the occurrence of facial blushing and sweating, however, the patient may experience adverse side effects.

Quality and See QEIA attached Equality Impact

Coventry and Rugby CCG/ Warwickshire North CCG Endoscopic Thoracic Sympathectomy policy

Quality and Equality Impact Assessment

Scheme Title: Endoscopic Thoracic Sympathectomy Policy

Project Lead: Clive Campton, IFR Manager Senior Responsible Officer: Dr Sarah Raistrick, Chair Kate Cogman, Contracts Manager Quality Sign Off: Intended impact of The Endoscopic Thoracic Sympathectomy policy supports the objective to prioritise resources and provide interventions with the scheme: greatest proven health gain, within CCG budgetary constraints. The intention is to ensure equity and fairness in respect of access to NHS funding for interventions and to ensure that interventions are provided within the context of the needs of the overall population and the evidence of clinical and cost effectiveness. How will it be achieved: The Governing Body adopts the policy.

Name of person completing assessment: Clive Campton Kate Cogman Position: IFR Manager Contracts Manager Date of Assessment: November 2019

Quality Review by: Mary Mansfield

Position: Deputy Director of Nursing and Quality

Date of Review: March 2020

Coventry and Rugby CCG/ Warwickshire North CCG Endoscopic Thoracic Sympathectomy policy

Stage 1a: High level Quality and Equality Questions

OUTCOME ASSESSMENT Evidence/Comments for Risk rating Mitigating actions (Please tick one) answers (For negative outcomes) AREA OF ASSESSMENT Risk Risk Risk Positive Negative Neutral impact likelihood Score (I) (L) (IxL) Duty of Quality Effectiveness – clinical  Adopting the policy will not Could the scheme outcome have an impact. impact positively or Patient experience  Adopting the policy will not negatively on any have an impact. of the following:  Patient safety Adopting the policy will not have an impact. Parity of esteem  Adopting the policy will not have an impact. Safeguarding children or  Adopting the policy will not adults have an impact. NHS Outcomes Enhancing quality of life  Adopting the policy will not Framework have an impact. Could the scheme Ensuring people have a  Adopting the policy will not impact positively or positive experience of have an impact. negatively on the care delivery of the five domains: Preventing people from  Adopting the policy will not dying prematurely have an impact. Helping people recover  Adopting the policy will not from episodes of ill health have an impact. or following injury

Treating and caring for  Adopting the policy will not people in a safe have an impact. environment and protecting them from avoidable harm

Patient services A modern model of  Adopting the policy will not Coventry and Rugby CCG/ Warwickshire North CCG Endoscopic Thoracic Sympathectomy policy

Could the proposal integrated care, with key have an impact. impact positively or focus on multiple long- negatively on any term conditions and of the following: clinical risk factors Access to the highest  Adopting the policy will not quality urgent and have an impact. emergency care Convenient access for  Adopting the policy will not everyone have an impact. Ensuring that citizens are  Adopting the policy will not fully included in all have an impact. aspects of service design and change Patient Choice  Adopting the policy will not have an impact. Patients are fully  Adopting the policy will not empowered in their own have an impact. care Wider primary care,  Adopting the policy will not provided at scale have an impact. Access Patient choice  Adopting the policy will not Could the proposal have an impact. impact positively or Access  Adopting the policy will not negatively on any have an impact. of the following: Integration  Adopting the policy will not have an impact. Compliance with Quality of care and  Adopting the policy will not NHS Constitution environment have an impact. Nationally approved  Adopting the policy will not treatment/drugs have an impact. Respect, consent and  Adopting the policy will not confidentiality have an impact. Informed choice and  Adopting the policy will not involvement have an impact. Complain and redress  Adopting the policy will not have an impact. *Risk score definitions are provided in the next section

Coventry and Rugby CCG/ Warwickshire North CCG Endoscopic Thoracic Sympathectomy policy

Risk rating score definition

Likelihood Impact 1 – Rare 1 – Negligible 2 – Unlikely 2 – Minor 3 – Moderate 3 – Moderate 4 – Likely 4 – Major 5 – Almost certain 5 – Catastrophic

Likelihood

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

Catastrophic (5) 5 10 15 20 25

Major (4) 4 8 12 16 20

Moderate (3) 3 6 9 12 15

Minor (2) 2 4 6 8 10

Negligible (1) X-1 2 3 4 5

How will a successful implementation of quality indicators be measured?

Coventry and Rugby CCG/ Warwickshire North CCG Endoscopic Thoracic Sympathectomy policy

Quality Outcome Measured By Positive Health Outcome Triangulation of Incidents Complaint and Patient Experience trends

Coventry and Rugby CCG/ Warwickshire North CCG Endoscopic Thoracic Sympathectomy policy

Stage 1b: Equality Questions

Other partners/stakeholders involved in scheme: N/A

Who will be affected by this piece of work? CCG registered patients

Gender  Adopting the policy will not have an impact. Race  Adopting the policy will not have an impact. Disability (including mental  Adopting the policy will not have an impact. impairment, learning difficulty) Religion/belief  Adopting the policy will not have an impact. Sexual orientation  Adopting the policy will not have an impact. Age  Adopting the policy will not have an impact. Social deprivation  Adopting the policy will not have an impact. Carers  Adopting the policy will not have an impact. Human rights  Adopting the policy will not have an impact. Pregnancy and Maternity  Adopting the policy will not have an impact. Stage 1c: Post Implementation Review

Use the template below to record outcomes of reviews – if more than one is required cut and paste the box below:

Has there been a differential Evidence/Comments for answers Mitigations impact? Quality Impact (Please tick one) YES NO UNKNOWN

Hallux Valgus (Bunions) Surgery

Coventry and Rugby CCG/Warwickshire North CCG Hallux Valgus (Bunions) Surgery Commissioning Policy 1

VERSION CONTROL

4.0 Version: Governing Body Meetings in Common Ratified by: TBC Date ratified: Joint CCG Clinical Commissioning Policy Name of originator/author: Development Group

Clinical Quality and Governance Committees in Name of responsible committees: Common

TBC Date issued: TBC Review date:

VERSION HISTORY

Date Version Comment / Update

September 2016 3.0 Approved by Governing Body

Renew with no amendments to criteria but revised layout to policy May 2020 4.0 with support of public health consultant.

Coventry and Rugby CCG/Warwickshire North CCG Hallux Valgus (Bunions) Surgery Commissioning Policy 2

Commissioning Policy: Coventry and Rugby CCG (CRCCG)

Warwickshire North CCG (WNCCG)

Treatment Hallux Valgus (Bunions) Surgery

Indication Hallux Valgus (Bunions)

Background Requests for the removal of symptomatic bunions will only be considered if specific criteria are met, as detailed below.

Age, gender, smoking, obesity and co-morbidity should not be barriers to referral.

Patients with significant co-morbidities (systemic or local) should have treatment, which optimises these before referral.

Treatment Criteria Refer to Secondary Care based on the following criteria: • Deteriorating symptoms; AND/OR • Failure of appropriate conservative measures after 3 months; AND/OR • Persistent pain and disability, not responding to up to 12 weeks of non-surgical treatments; AND • Patients must be prepared to undergo surgery;

Prior approval from the Clinical Commissioning Group will be required before any treatment proceeds in secondary care.

Information Conservative Measures are defined as: • Ice and elevation for pain and swelling AND • Optimum analgesia.

Non-surgical treatments are defined as: • Wearing wide cut or specially altered shoes with increased medial pocket to minimise deforming forces AND • Externally fitted devices to improve alignment and reduce irritation, e.g. orthoses and bunion pads AND • Stretching exercises to improve / maintain joint flexibility.

Patient MUST not be referred for surgery based on cosmetic reasons alone. References Royal College of Surgeons England – British Orthopaedic Association Commissioning Guide: Painful Deformed Great Toe – 2017

NICE Interventional Procedural Guidance IPG 332

NICE Interventional Procedural Guidance IPG 140 Coventry and Rugby CCG/Warwickshire North CCG Hallux Valgus (Bunions) Surgery Commissioning Policy 3

Diagnostic This policy applies to acquired hallux valgus (“bunion’) for which the ICD-10 and code is: M20.1.4. Procedure Codes A number of procedure codes may be used for bunion operations. Relevant OPCS codes (where used for surgery for hallux valgus) include:

• W79.1 Soft tissue operations on joint of toe, Soft tissue correction of hallux valgus • W79.2 Soft tissue operations on joint of toe, Excision of bunion nec • W79.9 Soft tissue operations on joint of toe, Unspecified • W15.1 Division of bone of foot, Osteotomy of neck of first metatarsal bone • W15.2 Division of bone of foot, Osteotomy of base of first metatarsal bone • W15.3 Division of bone of foot, Osteotomy of first metatarsal bone nec • W15.4 Division of bone of foot, Osteotomy of head of metatarsal bone • W15.5 Division of bone of foot, Osteotomy of midfoot tarsal bone • W15.6 Cuneiform osteotomy of proximal phalanx with resection of head of first metatarsal • W15.8 Division of bone of foot, Other specified • W15.9 Division of bone of foot, Unspecified • W59.1 Fusion of joint of toe, Fusion of first metatarsophalangeal joint and replacement of lesser metatarsophalangeal joint • W59.2 Fusion of joint of toe, Fusion of first metatarsophalangeal joint and excision of lesser metatarsophalangeal joint • W59.3 Fusion of joint of toe, Fusion of first metatarsophalangeal joint nec • W59.4 Fusion of joint of toe, Fusion of interphalangeal joint of great toe • W59.5 Fusion of joint of toe, Fusion of interphalangeal joint of toe nec • W59.6 Fusion of joint of toe, Revision of fusion of joint of toe • W59.8 Fusion of joint of toe, Other specified • W59.9 Fusion of joint of toe, Unspecified • T70.2 Tenotomy NEX • W12.1 Biosseus angulation periarticular osteotomy and internal fixation HFQ • W12.2 Angulation periarticular osteotomy and internal fixation NEC • W12.3 Biosseus angulation periarticular osteotomy and external fixation HFQ • W12.4 Angulation periarticular osteotomy and external fixation NEC • W12.5 Biosseus angulation periarticular osteotomy NEC • W12.6 • W12.7 • W12.8 Other specified angulation periarticular division of bone • W12.9 Unspecified angulation periarticular division of bone

Coventry and Rugby CCG/Warwickshire North CCG Hallux Valgus (Bunions) Surgery Commissioning Policy 4

• W13.1 Rotation periarticular osteotomy • W13.2 Displacement osteotomy • W13.8 Other specified other periarticular division of bone • W13.9 Unspecified other periarticular division of bone • W14.1 Angulation diaphyseal osteotomy and internal fixation HFQ • W14.2 Angulation diaphyseal osteotomy and external fixation HFQ • W14.3 Angulation diaphyseal osteotomy NEC • W14.4 Rotation diaphyseal osteotomy and internal fixation HFQ • W14.5 Rotation diaphyseal osteotomy and external fixation HFQ • W14.6 Rotation diaphyseal osteotomy NEC • W53.2 Conversion to prosthetic replacement of articulation of bone not using cement NEC • W54.2 Conversion to prosthetic replacement of articulation of bone NEC • W54.3 Revision of prosthetic replacement of articulation of bone NEC • W54.4 Attention to prosthetic replacement of articulation of bone NEC • W57.3 Revision of excision arthroplasty of joint • W57.4 Conversion to excision arthroplasty of joint • W03.1 Excision of heads of multiple lesser metatarsals • W03.2 Osteotomy of multiple metatarsals • W03.3 Total correction of claw toe • W03.4 Transfer of extensor hallucis longus tendon to head of first metatarsal and fusion of interphalangeal joints • W03.5 Localised fusion of joints of midfoot and forefoot • W03.2 + W28.1 Osteotomy of multiple metatarsals and fixation HFQ • W03.8 Other specified complex reconstruction of forefoot • W03.9 Unspecified complex reconstruction of forefoot

Quality and See QEIA attached Equality Impact Analysis

Coventry and Rugby CCG/Warwickshire North CCG Hallux Valgus (Bunions) Surgery Commissioning Policy 5

Quality and Equality Impact Assessment

Scheme Title: Hallux Valgus (Bunions) Surgery Policy

Project Lead: Clive Campton, IFR Manager Senior Responsible Officer: Dr Sarah Raistrick, Chair Kate Cogman, Contracts Manager Quality Sign Off: Intended impact of The Hallux Valgus (Bunions) Surgery policy supports the objective to prioritise resources and provide interventions with the scheme: greatest proven health gain, within CCG budgetary constraints. The intention is to ensure equity and fairness in respect of access to NHS funding for interventions and to ensure that interventions are provided within the context of the needs of the overall population and the evidence of clinical and cost effectiveness. How will it be achieved: The Governing Body adopts the policy.

Name of person completing assessment: Clive Campton Kate Cogman Position: IFR Manager Contracts Manager Date of Assessment: November 2019

Coventry and Rugby CCG/Warwickshire North CCG Hallux Valgus (Bunions) Surgery Commissioning Policy 6

Quality Review by: Mary Mansfield

Position: Deputy Director of Nursing and Quality

Date of Review: March 2020

Stage 1a: High level Quality and Equality Questions

impact positively or Ensuring people have a  Adopting the policy will not negatively on the positive experience of have an impact. delivery of the five care domains: Preventing people from  Adopting the policy will not dying prematurely have an impact.

Helping people recover  Adopting the policy will not from episodes of ill health have an impact. or following injury

Treating and caring for  Adopting the policy will not people in a safe have an impact. environment and protecting them from avoidable harm

Coventry and Rugby CCG/Warwickshire North CCG Hallux Valgus (Bunions) Surgery Commissioning Policy 8

Patient Choice  Adopting the policy will not have an impact. Patients are fully  Adopting the policy will not empowered in their own have an impact. care Wider primary care,  Adopting the policy will not provided at scale have an impact. Access Patient choice  Adopting the policy will not Could the proposal have an impact. impact positively or Access  Adopting the policy will not negatively on any have an impact. of the following: Integration  Adopting the policy will not have an impact. Compliance with Quality of care and  Policy based on NICE NHS Constitution environment guidance, aiming to improve quality of care and services Nationally approved  Policy adopts NICE guidance. treatment/drugs Respect, consent and  Adopting the policy will not confidentiality have an impact. Informed choice and  Adopting the policy will not involvement have an impact. Complain and redress  Adopting the policy will not have an impact. *Risk score definitions are provided in the next sectionReferences:

Royal College of Surgeons England – British Orthopaedic Association Commissioning Guide: Painful Deformed Great Toe – 2017

NICE Interventional Procedural Guidance IPG 332

NICE Interventional Procedural Guidance IPG 140 Coventry and Rugby CCG/Warwickshire North CCG Hallux Valgus (Bunions) Surgery Commissioning Policy 9

Risk rating score definition

Likelihood Impact 1 – Rare 1 – Negligible 2 – Unlikely 2 – Minor 3 – Moderate 3 – Moderate 4 – Likely 4 – Major 5 – Almost certain 5 – Catastrophic

Likelihood

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

Catastrophic (5) 5 10 15 20 25

Major (4) 4 8 12 16 20

Moderate (3) 3 6 9 12 15

Minor (2) 2 4 6 8 10

Negligible (1) X-1 2 3 4 5

Coventry and Rugby CCG/Warwickshire North CCG Hallux Valgus (Bunions) Surgery Commissioning Policy 10

How will a successful implementation of quality indicators be measured?

Quality Outcome Measured By Positive Health Outcome Triangulation of Incidents Complaint and Patient Experience trends

Coventry and Rugby CCG/Warwickshire North CCG Hallux Valgus (Bunions) Surgery Commissioning Policy 11

Stage 1b: Equality Questions

Other partners/stakeholders involved in scheme: N/A

Who will be affected by this piece of work? CCG registered patients

Gender  Adopting the policy will not have an impact. Race  Adopting the policy will not have an impact. Disability (including mental  Adopting the policy will not have an impact. impairment, learning difficulty) Religion/belief  Adopting the policy will not have an impact. Sexual orientation  Adopting the policy will not have an impact. Age  Adopting the policy will not have an impact. Social deprivation  Adopting the policy will not have an impact. Coventry and Rugby CCG/Warwickshire North CCG Hallux Valgus (Bunions) Surgery Commissioning Policy 12

Carers  Adopting the policy will not have an impact. Human rights  Adopting the policy will not have an impact. Pregnancy and Maternity  Adopting the policy will not have an impact.

Stage 1c: Post Implementation Review

Use the template below to record outcomes of reviews – if more than one is required cut and paste the box below:

Has there been a differential Evidence/Comments for answers Mitigations impact? Quality Impact (Please tick one) YES NO UNKNOWN

Coventry and Rugby CCG/Warwickshire North CCG Hallux Valgus (Bunions) Surgery Commissioning Policy 13

Treatments for Hyperhydrosis

Coventry and Rugby CCG/Warwickshire North CCG Treatments for Hyperhidrosis (excess sweating) of the palms or axillae policy

VERSION CONTROL

4.0 Version: Governing Body Ratified by: TBC Date ratified: Joint CCG Clinical Commissioning Policy Name of originator/author: Development Group

Clinical Quality and Governance Name of responsible committees: Committees in Common

TBC Date issued: TBC Review date:

VERSION HISTORY

Date Version Comment / Update

September 3.0 Approved by Governing Body 2016

May 2020 4.0 Renew with no amendments.

Coventry and Rugby CCG/Warwickshire North CCG Treatments for Hyperhidrosis (excess sweating) of the palms or axillae policy

Commissioning Policy: Coventry and Rugby CCG (CRCCG)

Warwickshire North CCG (WNCCG)

Treatment Treatments for Hyperhidrosis (excess sweating) of the palms or axillae

Indication Hyperhidrosis (excess sweating) of the palms or axillae

Treatment: Botulinum Toxin Therapy, Iontophoresis and surgical interventions for the treatment of Hyperhidrosis are not funded on the grounds of insufficient evidence of cost-effectiveness for them to be provided routinely to all patients

Quality and See QEIA attached Equality Impact

Coventry and Rugby CCG/Warwickshire North CCG Treatments for Hyperhidrosis (excess sweating) of the palms or axillae policy

Quality and Equality Impact Assessment

Scheme Title: Treatments for Hyperhidrosis (excess sweating) of the palms or axillae Policy

Project Lead: Clive Campton, IFR Manager Senior Responsible Officer: Dr Sarah Raistrick, Chair Kate Cogman, Contracts Manager Quality Sign Off: Intended impact of The Treatments for Hyperhidrosis (excess sweating) of the palms or axillae policy supports the objective to prioritise resources scheme: and provide interventions with the greatest proven health gain, within CCG budgetary constraints. The intention is to ensure equity and fairness in respect of access to NHS funding for interventions and to ensure that interventions are provided within the context of the needs of the overall population and the evidence of clinical and cost effectiveness. How will it be achieved: The Governing Body adopts the policy.

Name of person completing assessment: Clive Campton Kate Cogman Position: IFR Manager Contracts Manager Date of Assessment: November 2019

Quality Review by: Mary Mansfield

Position: Deputy Director of Nursing and Quality

Date of Review: March 2020

Coventry and Rugby CCG/Warwickshire North CCG Treatments for Hyperhidrosis (excess sweating) of the palms or axillae policy

Stage 1a: High level Quality and Equality Questions

OUTCOME ASSESSMENT Evidence/Comments for Risk rating Mitigating actions (Please tick one) answers (For negative outcomes) AREA OF ASSESSMENT Risk Risk Risk Positive Negative Neutral impact likelihood Score (I) (L) (IxL) Duty of Quality Effectiveness – clinical  Adopting the policy will not Could the scheme outcome have an impact. impact positively or Patient experience  Adopting the policy will not negatively on any have an impact. of the following:  Patient safety Adopting the policy will not have an impact. Parity of esteem  Adopting the policy will not have an impact. Safeguarding children or  Adopting the policy will not adults have an impact. NHS Outcomes Enhancing quality of life  Adopting the policy will not Framework have an impact. Could the scheme Ensuring people have a  Adopting the policy will not impact positively or positive experience of have an impact. negatively on the care delivery of the five domains: Preventing people from  Adopting the policy will not dying prematurely have an impact. Helping people recover  Adopting the policy will not from episodes of ill health have an impact. or following injury

Treating and caring for  Adopting the policy will not people in a safe have an impact. environment and protecting them from avoidable harm

Patient services A modern model of  Adopting the policy will not Coventry and Rugby CCG/Warwickshire North CCG Treatments for Hyperhidrosis (excess sweating) of the palms or axillae policy

Could the proposal integrated care, with key have an impact. impact positively or focus on multiple long- negatively on any term conditions and of the following: clinical risk factors Access to the highest  Adopting the policy will not quality urgent and have an impact. emergency care Convenient access for  Adopting the policy will not everyone have an impact. Ensuring that citizens are  Adopting the policy will not fully included in all have an impact. aspects of service design and change Patient Choice  Adopting the policy will not have an impact. Patients are fully  Adopting the policy will not empowered in their own have an impact. care Wider primary care,  Adopting the policy will not provided at scale have an impact. Access Patient choice  Adopting the policy will not Could the proposal have an impact. impact positively or Access  Adopting the policy will not negatively on any have an impact. of the following: Integration  Adopting the policy will not have an impact. Compliance with Quality of care and  Adopting the policy will not NHS Constitution environment have an impact. Nationally approved  Adopting the policy will not treatment/drugs have an impact. Respect, consent and  Adopting the policy will not confidentiality have an impact. Informed choice and  Adopting the policy will not involvement have an impact. Complain and redress  Adopting the policy will not have an impact. *Risk score definitions are provided in the next section

Coventry and Rugby CCG/Warwickshire North CCG Treatments for Hyperhidrosis (excess sweating) of the palms or axillae policy

Risk rating score definition

Likelihood Impact 1 – Rare 1 – Negligible 2 – Unlikely 2 – Minor 3 – Moderate 3 – Moderate 4 – Likely 4 – Major 5 – Almost certain 5 – Catastrophic

Likelihood

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

Catastrophic (5) 5 10 15 20 25

Major (4) 4 8 12 16 20

Moderate (3) 3 6 9 12 15

Minor (2) 2 4 6 8 10

Negligible (1) X-1 2 3 4 5

How will a successful implementation of quality indicators be measured?

Coventry and Rugby CCG/Warwickshire North CCG Treatments for Hyperhidrosis (excess sweating) of the palms or axillae policy

Quality Outcome Measured By Positive Health Outcome Triangulation of Incidents Complaint and Patient Experience trends

Coventry and Rugby CCG/Warwickshire North CCG Treatments for Hyperhidrosis (excess sweating) of the palms or axillae policy

Stage 1b: Equality Questions

Other partners/stakeholders involved in scheme: N/A

Who will be affected by this piece of work? CCG registered patients

Use the template below to record outcomes of reviews – if more than one is required cut and paste the box below:

Has there been a differential Evidence/Comments for answers Mitigations impact? Quality Impact (Please tick one) YES NO UNKNOWN

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

Report To: Governing Body Meetings in Common

Report Title: Communications and Engagement Assurance Report

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

Date: 20th May 2020

Previously Considered by: N/A

Action Required (delete as appropriate)

Decision: Assurance:  Information:  Confidential

Purpose of the Report: This report provides an overview of communications and engagement activity undertaken during March – May 2020.

Key Points: The NHS Coventry and Rugby CCG and NHS Warwickshire North CCG Communications and Engagement team have adapted to continue supporting the organisation and local population during the Covid-19 pandemic.

The team have done what they can to continue to meet the statutory obligations for communications, engagement and involvement in this reporting period, as set out by NHS England’s Patient and public participation in commissioning health and care guidance:

Recommendation:

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

Implications

Objective(s) / Plans Supports CCG Communications and Engagement statutory obligations. Informs supported by this commissioning and service developments. report:

Conflicts of Interest: N/A Non-Recurrent Expenditure: N/A Recurrent Expenditure: N/A Financial: Is this expenditure included within the CCG’s Financial Yes  No N/A Plan? (Delete as appropriate) Performance: N/A Quality and Safety: N/A General Statement: The CCG is committed to fulfil its obligations under the Equality Equality and Diversity: Act 2010, and to ensure services commissioned by the CCG are non-discriminatory on the grounds of any protected characteristics. Policies/decisions may need to be

Page 1 of 4 NHS Coventry and Rugby Clinical Commissioning Group NHS Warwickshire North Clinical Commissioning Group Enc W

adjusted in line with any equality analysis or due regard. Any decision that is finalised without being influenced by appropriate due regard could be deemed unlawful. Has an equality impact Yes assessment been undertaken? No  N/A  (attached) (Delete as appropriate) Patient and Public The report details patient and public engagement undertaken Engagement: There has been clinical engagement in a range of communications and engagement Clinical Engagement: activity detailed within this report The report provides assurance that the CCG is undertaking its duties in respect to Risk and Assurance: patient/public/stakeholder and clinical engagement.

Page 2 of 4 NHS Coventry and Rugby Clinical Commissioning Group NHS Warwickshire North Clinical Commissioning Group Enc W

The NHS Coventry and Rugby CCG and NHS Warwickshire North CCG Communications and Below is a brief snapshot of how some of the groups Engagement team have adapted to continue who have benefited from the information and how the supporting the organisation and local population CCG has kept in touch with those groups: during the Covid-19 pandemic. Organisation Involvement activity The team have done what they can to continue to meet the statutory obligations for communications, The Carers Our healthcare services update engagement and involvement in this reporting period, Trust has supported local carers as as set out by NHS England’s Patient and public some of them have been participation in commissioning health and care struggling throughout this difficult guidance: time and found it difficult at the beginning of the lockdown as Covid-19 some of them were not aware of The whole Communications and Engagement team is what was happening or what involved in the COVID-19 response in one way or services were available for people. another and is understandably very busy as a result. The CCG’s resource and information pack that was shared For patients and the public and as a result of the with the service has provided pandemic and the impact that it has had on our local carers with key information about healthcare services, we saw a significant reduction in what services are available and the number of people attending A&E and other how to get in touch with them healthcare services. The CCG in partnership with should they require additional public health teams developed a local flyer to help support. people understand that NHS services are still open to everyone but the access might be slightly different Ekta-Unity The CCG has continued to share compared to what we have been used to. The healthcare service updates with attached flyer will be sent out to the local food banks, over 200 vulnerable women from community and voluntary groups who are supplying the BAME community across the food parcels to those people who are shielding, the city. Volunteers from the charity flyer will be included in the food box/parcel as a way included printed copies of the of getting this crucial information directly to those resource in a ‘community care people who are at clinical risk of developing severe pack’ that was posted to all of the health complications due to contracting the women. Additional updates about coronavirus disease. local health services and the latest updates about Covid-19 were The team have worked with colleagues in the local shared in a ‘WhatsApp’ group hospitals to update local people on which services message, including videos and are currently being affected by the pandemic and information in different languages. how this might affect people’s care.

EQUiP The CCG closely worked with staff The team have continued to engage with community, at EQUiP (Equality and Inclusion voluntary and charity organisations by sharing Partnership) in the run up towards information about the latest situation regarding Ramadan to make sure that community and hospital healthcare services. people from the muslim

community were aware the All of our face to face community engagement activity services available to them. Health in Coventry and Warwickshire has been postponed information was included in an since the start of the lockdown, however we have updated resource that was shared continued to keep in touch with some community across the muslim communities in contacts through various communication channels, Coventry and Warwickshire. such as; email, Facebook, Twitter and WhatsApp.

The CCG developed a local health and community Grapevine – Staff at Grapevine found the services resource in partnership with the Public Coventry and information useful and welcomed Health teams across Coventry and Warwickshire and Warwickshire the updates, they shared them the Local authorities, the aim of this resource was to with their service users/clients as let people know about the healthcare and community and when they received them. services available, such as foodbanks, charity GNP Gurdwara The congregation at the GNP support lines, mental health support, governmental Gurdwara in Coventry took quick guidance in a variety of different languages and action to share the latest advice more. and information that was shared

Page 3 of 4

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

by the CCG through a number of The team has been adapting to the rapidly changing WhatsApp groups, including; a circumstances, including changes to national singing group, young people, over messaging and branding and a campaign to remind 65’s and mums and toddlers. people to use emergency services in an emergency – we are aware that people are delaying seeking CRASAC Coventry Rape and Sexual Abuse urgent medical help due to confusion/worry over Centre welcomed the information which services are available and which they should received and requested to be be accessing – this took the form of a press release listed in the resource as a key and social media, which community and voluntary contact. sector organisations such as Healthwatch helped spread into the communities, particularly over the bank holiday weekends during the period. Some other community, voluntary and charity groups who have received updates from the CCG We have used social media to promote local and are: national guidance throughout the lockdown period, • Voluntary Action Coventry including signposting to local community support • Warwickshire Community and Voluntary organisations to help people struggling with Action lockdown, whether that be due to food shortages, domestic violence or mental health concerns. • Nepalese Community

• African Caribbean Community - Lead We are supported our local Healthwatch • Chinese Community - Lead organisations in gathering the views of local people • Roma Community - Lead on their experiences during the lockdown period via a • Polish Community - Lead survey. This will be coupled with our own existing • Muslim Community – Lead patient intelligence to help feed into future NHS • Langar Aid planning and prioritisation, particularly as we look to • Foodbank volunteers begin restoration of NHS services. • Diabetes Community Champions • Age UK – Coventry and Warwickshire Finally, we’re supporting a number of the Incident • Warwickshire Pride Management Teams, including the Coordinating • Coventry Pride Incident Control Centre, Primary Care and CCG IMTs • The Tamarind Centre • For primary care, a daily update brief is being Additional note: collated and sent to all GPs and other practice staff across Coventry and

Warwickshire on behalf of the three CCGs. BAME Some of the local community This is through a new, central COVID-19 volunteers groups have gone the extra mile primary care inbox set up by the CCGs to supporting and been actively supporting the help coordinate all communication to and the NHS: NHS by getting involved in making PPE equipment to support the from practices related to coronavirus. The frontline NHS staff to keep them process is working well, and a website is also safe during this pandemic. A group being developed to support GPs, practice of local volunteers in Coventry who nurses etc with the latest information and have sewing machines and fabric at guidance in addition to the daily updates. • home have made, face masks, The team have also supported the creation of laundry washbags and ear a primary care facing Covid-19 website protectors for NHS staff at UHCW continuing all the latest guidance for GPs and and GEH. nurses etc. • For the CCGs, daily staff briefings are being sent to update people and include latest The team have put together a resource pack for all information, stories of how staff are local comms professionals (e.g. providers, local supporting the covid-19 response, as well as authorities) to use which details a number of the some fun updates to try and keep staff groups we liaise with regularly, how to get in touch morale high during lockdown – “co-worker of with them to spread messaging out across our whole the day”, which sees staff sending photos of population, not just those with immediate access to their new co-workers (mostly pets and small the internet. We have put particular focus on those children!) have proven particularly popular. with English as a second language and our transient Staff briefings are being planned, new IT populations (students, gypsy and traveller, refugee systems and video conferencing facilities and asylum seekers) to help them navigate health permitting, and the staff forum has adapted services during these trying times. brilliantly to lockdown and is now operating virtually. Page 4 of 4