Joint Committee of Barking and Dagenham, Havering and Redbridge Clinical Commissioning Groups 30 November 2017 2.30Pm Boardrooms, Becketts House, Ilford, IG1 2QX

Joint Committee of Barking and Dagenham, Havering and Redbridge Clinical Commissioning Groups 30 November 2017 2.30pm Boardrooms, Becketts House, Ilford, IG1 2QX

Item Time Lead Attached, director verbal or to follow 1.0 Welcome, introductions and apologies 2.30 Chair 1.1 Declaration of conflicts of interest Attached 1.2 Minutes of the meetings held in September Attached 2017 1.3 Matters/actions arising Attached

2.0 Chair and chief officer reports 2.1 Chairs’ report 2.35 Chairs Attached 2.2 Chief officer’s report 2.45 CB Attached 2.3 Patient engagement report 2.55 SW/RC/KA Attached

3.0 Governing body assurance 3.1 Governing body assurance framework 3.05 MP Attached

4.0 Corporate strategy and planning 4.1 NEL commissioning arrangements 3.15 AS Attached

5.0 Quality and performance 5.1 Integrated performance report 3.25 GS Attached 5.2 Finance report 3.35 TT Attached 5.3 Quality report 3.45 JH Attached 5.4 Safeguarding children annual report 2016-17 3.55 JH Attached 5.5 Looked after children annual report 2016-17 4.00 JH Attached 5.6 Safeguarding adults annual report 2016-17 4.05 JH Attached

6.0 Development/governance 6.1 Integrating governance arrangements 4.10 MP Attached 6.2 FRPB Chair’s report 4.15 TT Attached 6.3 Finance & delivery committee chair’s report 4.20 KP Attached 6.4 Audit & governance committee chair’s report 4.25 KP Attached 6.5 Remuneration & workforce committee chair’s 4.30 KP Attached report 6.6 Minutes of committees and relevant fora: 4.35 Attached • Primary care committee • Quality & safety committee • Patient engagement forum • Primary Care Transformation Board

7.0 AOB 4.40 8.0 Questions from the public 4.45 9.0 Date of next meeting – 14 December 2017 4.50

Glossary of terms and abbreviations

Term Explanation

AO Accountable Officer

ACS Accountable Care System

ADL Activities of Daily Living

APC Area Prescribing Committee

ASH Accredited Safe Haven

BCF Better Care Fund

BHR Barking and Dagenham, Havering and Redbridge

BHRUT Barking, Havering and Redbridge University Trust

BPPC Better Payment Practice Code

CAPS Clinical Application Services

CCG Clinical Commissioning Group

CCS Complex Care Service

CD Clinical Director

CDOP Child Death Overview Panel

CEO Chief Executive Officer

CFO Chief Finance Officer

CHC Continuing Healthcare

CHS Community Health Services

CHSCS Community Health and Social Care Services

CIL Community Infrastructure Levies

CO Chief Officer

COO Chief Operating Officer

CQC Care Quality Commission

CQRM Clinical Quality Review Meeting

CQUIN Commissioning for Quality and Innovation

CSU Commissioning Support Unit

CTT Community Treatment Team

CVS Council of Voluntary Services

CYPP Children and Young Person Plan

DOH Department of Health

DTOC Delayed Transfer of Care

ECG Electrocardiogram

EHC Education, Health and Care

ELHCPB East London Health and Care Partnership Board

EMT Executive Management Team

EoI Expression of Interest

EOL End of Life Care

FNP Family Nurse Partnership

FRPB Financial Recovery Programme Board

FRPDM Financial Recovery, Planning, Delivery and Monitoring

FT Foundation Trust

FYE Full Year Effect

GBAF Governance Board Assurance Framework

GP General Practitioner

H4NEL Health for North East London

HCAIs Healthcare Associated Infections

HE NCEL Health Education North Central and East London

HLP Healthy London Partnership

HSC Health Scrutiny Committee

HWBB Health & Wellbeing Board

IAPT Improving Access to Psychological Therapies

ICPB Integrated Care Partnership Board

ICM Integrated Case Management

ICSG Integrated Care Joint Health and Social Care Steering Group

IFR Individual Funding Request

IRS Intensive Rehabilitation Service

IST Intensive Support Team

JAD Joint Assessment and Discharge Service

JCB Joint Commissioning Board

JEC Joint Executive Committee

JHWS Joint Health & Wellbeing Strategy

JSNA Joint Strategic Needs Assessment

KGH King George Hospital

KPIs Key Performance Indicators

LAC Looked After Children

LAS London Ambulance Service

LETB Local Education and Training Boards

LMCs Local Medical Committees

LPC Local Pharmaceutical Committee

LSCB Local Safeguarding Children’s Board

LTC Long Term Conditions

MASH Multiagency Safeguarding Assessment Hub

MLU Mid-wife Led Unit

MOU Memorandum of Understanding

MSRB Maternity Systems Readiness Board

NEL North East London

NELCSU North East London Commissioning Support Unit

NELFT North East London Foundation Trust

NHS National Health Service

NHSE NHS England

NHSI NHS Improvement

NICE National Institute for Health and Care Excellence

OFSTED Office for Standards in Education, Children’s Services and Skills

OD Organisation Development

ONEL Outer North East London

PALS Patient Advice and Liaison Service

PEFs Patient Engagement Forums

PELC Partnership of East London Cooperatives

PMCF Prime Minister’s Challenge Fund

PMO Project Management Office

POD Point of Delivery

POLCV Procedures of Limited Clinical Value

PPGs Patient Participation Groups

PSED Public Sector Equality Duty

PTL Patient Tracking List

QIPP Quality, Innovation, Productivity and Prevention

RAG Red, Amber, Green

RTT Referral To Treatment

SAB Safeguarding Adults Board

SCB Safeguarding Children’s Board

SCN Strategic Clinical Network

SDPB System Delivery Programme Board

SRO Senior Responsible Officer

STP Sustainability and Transformation Plan

TDA Trust Development Agency

TSCL The Transforming Services – Changing Lives

UCC Urgent Care Centre

UCL University College London

UCLP University College London Partners

UEC Urgent and Emergency Care

UTI Urinary Tract Infection

VFM Value for Money

WELC Waltham Forest, East London and City

WICs Walk in Centres

YTD Year to Date

Last updated: November 2017

Name Role Organisation Nature of interest Amendment and date Dr Waseem Chair Markyate Surgery Sessional GP Peartree surgery, Mohi Herts – until 09/16. Together First Limited Shareholder (May 2014)

London Wellbeing Care Ltd Director

Kensington and Chelsea CCG GP partner Added 20/4/14

Dr Ravali Clinical director Tulasi Medical Centre GP Partner. Spouse is Lilly Goriparthi practice manager (19/9/06) Pharmaceutical Company Limited- Tulasi Properties Ltd Director / Shareholder removed 1/12/16 (1/8/16)

Health & Happiness Clinic Ltd Director / Shareholder (1/8/12)

Barking, Dagenham and Member (7/9/09) Havering LMC

Royal College of General Member Practitioners

6 Name Role Organisation Nature of interest Amendment and date Together First Ltd Shareholder (June 2017)

Dr Jagan John Clinical director King Edward Medical Group GP Partner, other GPs are family members (2010)

LMC (Barking, Dagenham & Member (2013) Havering)

North East London Foundation GPwSI in Cardiology BD Trust CHS (2011)

Together First Limited (from Shareholder May 2014)

Health 1000 (December 2014) Director Prime Minister’s Challenge Lead (2015)

Healthy London Partnerships GP lead – self care

Dr Rami Hara Clinical director Urswick Medical Centre GP Principal

Pharmaceutical companies Speaker fee - Chair and speaker at educational lectures/meetings

Together First Limited (from Shareholder May 2014)

London Deanery GP registrar trainer 2

7 Name Role Organisation Nature of interest Amendment and date NHSE GP appraiser (mainly Havering)

Barts Hospital & Queen Mary’s Undergraduate Tutor University (18/10/16)

Dr Gurkirit Clinical director Thames View Health Centre GP Principal Kalkat Primary Clinical Partnership Director/owner or part owner/ Ltd Share holder

Apex Healthcare Ltd Director/owner or part owner/ Share holder

Queen Mary Medical School, Honorary Lecturer London

Together First Limited (from Shareholder May 2014)

BHR CCGs Area Prescribing Chair

Dr Anju Gupta Clinical director Abbey Medical Centre GP Principal and CCG lead for diabetes. Practice employs a GP who is the spouse of a BHRUT director

Together First Limited Member (2014) 3

8 Name Role Organisation Nature of interest Amendment and date NELFT GPwSI – Diabetes (2009)

NHSE GP appraiser (2013)

Wilson Mason PLC Spouse employed as an architect and company undertakes NHS work (2015)

Barking, Dagenham & Member (2015) Havering LMC

Dr Kanika Rai Clinical director White House Surgery GP partner. Sister is a GP a partner and is also a GPwSI dermatology. Brother is also a partner

Together First Shareholder (May 2014). Brother is also a director

MacMillan Cancer lead GP for B&D(2015-17)

London Deanery FY2 and GP trainer (2013)

Queen Mary’s University and Undergraduate tutor (2007) Imperial College

Sahdia Lay member The Forum for Health and Director (paid employee) Warraich Wellbeing 4

9 Name Role Organisation Nature of interest Amendment and date The Forum for Health and Company Director Healthwatch Wellbeing Trading Ltd Waltham Forest Removed 11/7/17 Heathwatch Redbridge Member (1/4/13) Healthy Island London Borough of Redbridge Spouse is a Councillor Partnership Removed 13/11/17 Newham Deanery Trustee

Kash Pandya Lay member - Essex Ministry of Justice Lay Member (2010-18) Hillcroft College for Governance Advisory Committee women, Surbiton – removed May Her Majesty’s Inspector of Associate Inspector (2011) 2017. Constabulary Health & Safety Brentwood Citizen’s Advice General advisor (2009) Executive – Bureau removed May 2017. Havering CCG Lay Member Berwin Leighton Redbridge CCG Lay Member Paisner (BLP) removed May PricewaterhouseCoopers Kiren Pandya (son) 2017. Management consultant (2013)

Accenture Anand Pandya (son) Solicitor

University of Essex Independent Audit 5

10 Name Role Organisation Nature of interest Amendment and date Committee member (2013- 19)

Southend on Sea Borough Independent Audit Council Committee Member (2016- 18)

Charles Associate None None North Essex Beaumont Independent Lay Partnership Voting Member for Foundation Trust – Audit Committee and removed 25/4/17 Individual Funding Request Panel

Conor Burke Accountable officer None None Your business works (not trading) - removed Jan 2017 Redbridge college – removed Jan 2017 Sharon Morrow Chief operating officer None None

Tom Travers Chief financial Officer Royal Free Foundation Trust Wife works in finance department

Jacqui Himbury Nurse director None None

11 Name Role Organisation Nature of interest Amendment and date Gina Director, Delivery & Regina Shakespeare Owner Shakespeare Performance (Interim) Consulting

Jane Gateley Director, Strategy & Hurley Group Partner is a director Integration

Sarah See Director, Primary Care NELFT Partner is an employee Transformation Churchill Medical Services, Family registered with the Chingford practice.

Last updated: November 2017

Name Role Organisation Nature of interest Amendment and date

Dr Atul Chair Maylands Healthcare GP Partner (April 2013) Saag Properties Aggarwal Services LTD – Maylands Healthcare Ltd Director and shareholder in onsite removed Jan 2017 pharmacy (April 2013) HAVCO - removed Parkview Dental Practice Sister is NHS dentist within Jan 2017 Havering (1996)

Essex Medicare LLP Part owner which owns Westland Clinic, Hornchurch. Space rented out to:- -InHealth (Diagnostic) (Jan 2014) -Nuffield Health (Brentwood) (Jan 2014) -Communitas Clinics (dermatology) (Aug 2014)

Havering Health Limited Shareholder (Sept 2014). GP Partner at Maylands Surgery – (Dr Kendall) is a director (Nov 1

13 Name Role Organisation Nature of interest Amendment and date

2014)

Barking, Dagenham & Co-opted member (2013) Havering LMC

Dr Alex Tran Clinical director Hornchurch Healthcare, Principle GP NHSE & the Cancer The Medical Centre Commissioning Board -removed Jan 2017 Hornchurch Healthcare Director Limited

Havering Health Limited Shareholder (from August 2014)

Dr Gurdev Clinical director South End Road Practice Sessional GP (sept 2015) Lynnwood medical Singh Saini centre – removed Jan National ME Charity Chair 2017

St Francis Hospice Trustee

Barking, Dagenham and Member Havering LMC

Barking, Dagenham and Director Havering LMC Limited

Dr Ochuko Clinical director Rush Green Medical Partner (May 2000) Maurice Centre Sanomi Havering CCG GP Tutor / Education Lead

14 Name Role Organisation Nature of interest Amendment and date

Practice Based Clinical Director & shareholder (2007) Services (PBCS) Ltd

Inspirehealth Ltd (not Director & shareholder (2013) trading)

Local Medical Committee Member

Havering Health Limited Shareholder & member (Aug 2014)

Dr Ashok Clinical director Wood Lane Medical General Principal & senior Deshpande Centre (WLMC) partner. Wife, daughter & son-in- law are GP partners at WLMC (1989)

Dermatology service Weekly clinic conducted from (Communitas) Wood Lane Medical Centre. GP partner (daughter) covers dermatology sessions for Communitas

Barking & Dagenham, Member Havering LMC

Havering Health Limited Shareholder. GP partner at WLMC is chair of Havering Health Federation (August 2014)

Nuffield Health Wife works in gynaecology (2017)

15 Name Role Organisation Nature of interest Amendment and date

Ann Baldwin Clinical Director The Central Park GP Partner (2009) Surgery

Barking & Dagenham, Chair (June 2015) Havering LMC

Havering Health Limited Shareholder (Aug 2014)

Havering CCG GP Appraiser (2012)

Royal College of General Member (2012) Practitioners, British Society of Rheumatology

Kash Pandya Lay member - Essex Ministry of Justice Lay Member (2010-18) Hillcroft College for Governance Advisory Committee women, Surbiton – removed May 2017. Her Majesty’s Inspector Associate Inspector (2011) of Constabulary Health & Safety Executive – removed Brentwood Citizen’s General advisor (2009) May 2017. Advice Bureau Berwin Leighton Barking and Dagenham Lay Member Paisner (BLP) CCG removed May 2017.

Redbridge CCG Lay Member

PricewaterhouseCoopers Kiren Pandya (son) Management consultant (2013)

16 Name Role Organisation Nature of interest Amendment and date

Accenture Anand Pandya (son) Solicitor

University of Essex Independent Audit Committee member (2013-19)

Southend on Sea Independent Audit Committee Borough Council Member (2016-18)

Charles Associate None None North Essex Beaumont Independent Lay Partnership Voting Member for Foundation Trust - Audit Committee and removed 25/4/17 Individual Funding Request Panel

Richard Lay member - PPI Richard Coleman Director/co-owner. Coleman Associates Ltd Spouse also a director/co-owner (April 2013)

1-2-1 Social Enterprise Associate providing mentoring on pro bono basis mentoring to the NHS (Oct 2014)

PricewaterhouseCoopers Nephew is a partner (Aug 2013)

BHR CCGs Brother in law is Independent GP

Conor Burke Chief officer None Your business works (not trading) - removed Jan 2017

17 Name Role Organisation Nature of interest Amendment and date

Redbridge college – removed Jan 2017 Alan Steward Chief operating Steward and Steward Ltd Director. Partner is also a officer Director

Tom Travers Chief financial officer Royal Free Foundation Wife works in finance department Trust

Jacqui Nurse director None Himbury

Gina Director, Delivery & Regina Shakespeare Owner Shakespeare Performance Consulting (Interim)

Jane Gateley Director, Strategy & Hurley Group Partner is a director Integration

Sarah See Director, Primary NELFT Partner is an employee Care Transformation Churchill Medical Family registered with the Services, Chingford practice.

Last updated: September 2017

Name Role Organisation Nature of interest Amendment and date

Dr Anil Mehta Chair Fullwell Cross Medical GP Partner Centre

Metropolitan Police Forensic Medical Examiner

The cleaning company Owner - Sister in law

NHS England (Feb 2015) GP Appraiser

Healthbridge Direct (from Shareholder September 2014)

Fouress Enterprises Ltd Director

Dr Sarah Heyes Clinical director The Shrubberies Medical GP Partner/Principal Centre

Healthbridge Direct Shareholder (from September 2014)

Dr Muhammad Clinical director Forest Edge practice, GP Partner Tahir Hainault Health Centre

Dagenham & Redbridge Medical adviser & club 1

19 Name Role Organisation Nature of interest Amendment and date

Football Club doctor

Redbridge local medical Member committee

Healthbridge Direct Shareholder (from September 2014)

Dr Mehul Clinical director Mathukia surgery GP Principal Mathukia Dr Chawla & Partners GP Partner from 1/5/16. Brother is a GP Principal

Valia Consultancy – Director/Owner/Shareholder Healthcare & research consultancy

PELC GP Locum

NOCLOR and NIHR GP research champion

Healthbridge Direct Share Holder (from September 2014)

Dr Shabana Ali Clinical director Southdene Surgery GP Partner/Principal. Daughter is receptionist/admin

Healthbridge Direct Shareholder. Daughter (from September 2014) works is receptionist/admin. 2

20 Name Role Organisation Nature of interest Amendment and date

North East London GP with special interest in Foundation Trust cardiology

Avicenna Ltd Director. Husband is also a director

BMA Member

RCGP Member

NHSE GP appraiser (B&D CCG, Havering CCG)

Dr Syed Raza Clinical director Seven Kings surgery GP partner (Oct 2017) Redbridge Fairness Commission – removed Raza Syed Medical Ltd Director (June 2014) Jan 2017

Healthbridge Direct Employed at surgery that is Chadwell Heath surgery (from September 2014) a shareholder. Employed – removed Sept 2017 as locum in the Hub.

PELC Locum GP

Dr Jyoti Sood Clinical director Newbury Group Practice GP Partner (2003) Redbridge GP Alliance Federation – removed ESS Wanstead GPwSI – Diabetes & April 2017 Dermatology (2011)

Ealing Hospital NHS GPwSI – Diabetes & Trust Dermatology (2010) 3

21 Name Role Organisation Nature of interest Amendment and date

Soods Limited – Locum Director. Husband is a agency partner (2005)

NHS England GP appraiser (2003)

London Deanery GP trainer (2004)

Imperial College Undergraduate GP trainer (2011)

Communitas Clinics Provide minor surgery (Havering) (2013)

Redbridge LMC Member (Sept 2016)

Care Quality Special Advisor (Sept 2016) Commission (CQC)

Healthbridge Direct Shareholder (April 2017)

DMC Healthcare (1/8/17) GPwSI – diabetes and dermatology

Health Education Associate director of England education (Ilford & Romford)

Dr Anita Bhatia Clinical director Southdene surgery GP partner

Healthbridge Direct Shareholder (Sept 2014) 4

22 Name Role Organisation Nature of interest Amendment and date

Mychem Ltd Husband is owner/director of pharmacy – Mid Essex CCG

Phoenix Medics Ltd Brother is a director – freelance GP-services to NHS/private sector

Essex Local Prescribing Husband does remunerated Committee ad-hoc work

Dr Shujah Clinical director Castleton Road surgery GP Partner Added May 2017. Hameed Partners in Healthcare Director (1/2015) Locum GP at Castleton Rd – removed 24/5/17 Healthbridge Direct Locum GP (1/2015)

PELC Locum GP (1/2015)

BHR GP Solutions Locum GP (1/2016)

Ah-Fee Chan Secondary care North Middlesex Consultant in Anaesthetics consultant University Hospital NHS and Intensive Care Trust Medicine

Nadia Medical Services Director of the company Ltd (March 2015) providing consultant services at a range of private facilities in London where practice privileges 5

23 Name Role Organisation Nature of interest Amendment and date

are given

Charles Associate None None North Essex Partnership Beaumont Independent Lay Foundation Trust – Voting Member for removed 25/4/17 Audit Committee and Individual Funding Request Panel

Conor Burke Accountable officer None Your business works (not trading) - removed Jan 2017

Redbridge college – removed Jan 2017

Louise Mitchell Chief operating officer None None

Tom Travers Chief financial officer Royal Free Foundation Wife works in finance Trust department

Jacqui Himbury Nurse director None

Khalil Ali Lay member Dr Joseph’s GP practice, Family GP Collier Row, Romford

St Francis Hospice, Spouse is donor Havering

Cancer Research Spouse is a donor 6

24 Name Role Organisation Nature of interest Amendment and date

Kash Pandya Lay member - Essex Ministry of Justice Lay Member (2010-18) Hillcroft College for Governance Advisory Committee women, Surbiton – removed May 2017. Her Majesty’s Inspector Associate Inspector (2011) of Constabulary Health & Safety Executive – removed Brentwood Citizen’s General advisor (2009) May 2017. Advice Bureau Berwin Leighton Paisner Barking and Dagenham Lay Member (BLP) removed May CCG 2017.

Havering CCG Lay Member

PricewaterhouseCoopers Kiren Pandya (son) Management consultant (2013)

Accenture Anand Pandya (son) Solicitor

University of Essex Independent Audit Committee member (2013- 19)

Southend on Sea Independent Audit Borough Council Committee Member (2016- 18)

25 Name Role Organisation Nature of interest Amendment and date

Gina Director, Delivery & Regina Shakespeare Owner Shakespeare Performance (Interim) Consulting

Jane Gateley Director, Strategy & Hurley Group Partner is a director Integration

Sarah See Director, Primary Care NELFT Partner is an employee Transformation Churchill Medical Family registered with the Services, Chingford practice.

Draft Barking & Dagenham Clinical Commissioning Group Governing Body Meeting 26 September 2017 1.30pm Maritime House Present: Dr Waseem Mohi (WM) Clinical Director and Chair Dr Gurkirit Kalkat (GK) Clinical Director Dr Anju Gupta (AG) Clinical Director Dr Ramneek Hara (RH) Clinical Director Dr Ravali Goriparthi (RG) Clinical Director Kash Pandya (KP) Lay member - governance Tom Travers (TT) Chief Finance officer Sharon Morrow (SM) Chief Operating Officer Jacqui Himbury (JH) Nurse Director Sahdia Warraich (SW) Lay member – patient and public involvement

In Attendance: Marie Price (MP) Director of Corporate Services Anne-Marie Keliris Company secretary Frank O’Neill NELCSU Ceri Jacob NHSE regional lead for north east London (for item 5 only)

Apologies: Conor Burke (CB) Accountable Officer Dr Kanika Rai (KR) Clinical Director

Item Action 1.0 Welcome and apologies The Chair welcomed members to the meeting and apologies for absence were noted.

1.2 Declarations of conflicts of interest The Chair reminded governing body members of their obligation to declare any interest they may have on any issues arising at the meeting which might conflict with the business of Barking & Dagenham clinical commissioning group.

Declarations declared by members of the governing body are listed in the CCG’s Register of Interests. The Register is available either via the secretary to the governing body or the CCG website at the following link:

27 http://www.barkingdagenhamccg.nhs.uk/About-us/Our-governing- body/register-of-interests.htm

1.3 Minutes of the last meeting The minutes of the meeting held on 18 July 2017 were agreed as a correct record.

1.4 Matters/Actions arising The governing body noted the actions taken since the last meeting and the following was discussed:

Further to item 6.1 - Integrated contract report – SM updated that Dr Kumar had met with Dr Rai to discuss concerns raised and this will also be discussed at the next PTI meeting.

2.0 Chair & Accountable Officer’s Reports 2.1 Chair’s report The Chair presented his report covering the following areas:  Annual General meeting  Financial situation

 System developments, including networks and localities  Meetings

The governing body noted the report.

2.2 Chief Officer’s report TT presented the chief officer’s report covering the following areas:  BHR System Delivery Plan

 BHR Accountable Care System and Sustainability and

Transformation Plan (STP)  CCG Development  2018/19 Commissioning Intentions Operational Resilience  Winter Planning

 Health and Wellbeing Board update

The governing body noted the report.

2.3 Patient experience report SW presented a report which provided a summary of the various feedback that has come through to the CCG from patients and stakeholders highlighting the following areas:

 The Patient Engagement Forum (PEF)  Joint PEF meeting  Procurements

 Adult inpatient survey

Discussion ensued on the future of the patient engagement forum and the MP plans to reflect the new commissioning structure. MP agreed to provide the governance structure to the Chair. MP reported that the developing

28 networks will also have patient engagement and work is underway to explore how this will be achieved.

It was noted that the Chair of the PEF was not in favour of the proposals but was willing to give them a try.

The governing body noted the report.

3.0 Governing body assurance 3.1 Governing body assurance framework SM presented a report which outlined the key risks to the clinical commissioning group in achieving its corporate objectives as identified in the governing body risk assurance framework. There are two risks on the GBAF:- 1. Risks to the delivery of the Clinical Commissioning Group’s (CCG) budget 2. Barking, Havering and Redbridge University Hospitals Trust (BHRUT) emergency care performance

It was noted that one risk was de-escalated from the GBAF in August - BHRUT cancer 62 days standard.

JJ questioned whether there will be additional financial support from NHSE for winter pressures. SM responded that there is not additional funds and the focus is to develop winter plans with feedback from NHSE, NHSI and STP colleagues.

JJ questioned how BHR performance compared across London. SM responded that there are concerns that winter pressures will make BHR and partners less resilient. Workforce issues at BHRUT continue to be an issue and for this reason BHR is considered a higher risk.

JJ asked what the mitigation is to support reducing demand on A&E. SM reported that as the SRO for the workstream which reports to the A&E delivery board there are a number of projects to support addressing this risk. The Chair reported on his attendance at the recent A&E summit.

GK referred to supporting practices that do not have access to district nursing services to immunise house bound patients with flu vaccine. SM/GK SM/GK agreed to discuss this outside the meeting.

KP commented that it was refreshing to see the reduction in risks at the governing body level and reported that the finance and delivery committee continue to review 30 risks below this level. He also suggested that the target for the financial risk of 30 March was unrealistic, TT agreed to TT review this.

The governing body noted the current risks escalated to the GBAF and levels of assurance in the controls and mitigating actions being taken.

29 4.0 Quality and performance 4.1 Integrated contract report TT presented the integrated performance report which included finance and activity, in its contracted services, to identify the key risks presented by that performance and provide assurance that those risks are being appropriately managed. The report is based on month 4 activity and month 5 finance information.

The main points of note are:

BHRUT: The BHRUT 2017/19 financial forecast across the three CCGs is £9.75m above plan. This over spend is driven by over performance in the following areas: elective, non-elective, maternity, day cases and outpatients. One of the key drivers of the projected overspend is the increased average unit cost of activity compared to last year. This is being investigated. CCGs have issued 4 notices as part of the formal contract management process. These notices reflect the CCGs concern on specific areas and have required the Trust to work with CCGs to identify and agree remedial actions. In addition to the formal notices CCGs are also working with the Trust on a number of areas in September and October (the 28 day plan) which include a joint reconciliation of quarter 1 activity to inform the M6 reported position and a refreshed demand and capacity model from the Trust which will be completed by the end of September 2017. On performance, against constitutional performance measures, the Trust reported a significant improvement in cancer performance in July with all eight cancer standards met as well as achieving 90.0% RTT compliance. The 4 hour A&E performance in July was 88.02%, slightly below the recovery trajectory of 88.5%. Early indications are that Q2 performance may also be below the recovery trajectory

Barts Health: The position reported is a forecast variance across the three CCGs of £7.5m. Referrals were 16% lower in the first quarter than the same period last year. This reduction is likely to have been influenced by the cyber-attack in month May. However, despite the recent reduction in reported referrals, outpatient and elective activity are over plan year to date. This may be a result of increased activity in July potentially indicating a catch up in lost activity as a result of the cyber-attack in May. A significant financial risk to CCGs is the level of un-coded activity, which means that activity cannot be accurately or fully costed. CCGs have raised this concern with the Trust who have committed to achieve 95% coding by 18 September 2017. As with BHRUT, formal challenges have been raised in relation to over performance in outpatient procedures. Review and resolution of this will form part of the Q1 reconciliation process.

On performance against constitutional performance measures, the 62 day Cancer wait - standard was missed at Barts Health. The Trust underperformed against the 4 hour A&E standard and achieved 88.35% against the STF target of 88.8%.

NELFT: The CCGs and NELFT are discussing the options for closing down outstanding issues relating to the 2017/18 contract following the recent offer, with the option of proceeding to mediation if necessary. Quarter 1 IAPT performance shows good achievement of recovery targets

30 but access targets not being met consistently. Against the 3.75% access target, Barking and Dagenham, Havering and Redbridge CCG performance is at 3.5%, 2.91% and 3.91% respectively.

Discussion ensued and the governing body expressed concern that Barts Health were not reporting on their RTT position and how this is being challenged. TT reported that this was being challenged through the collaborative commissioning agreement and continual dialogue with lead commissioner to drive change.

JJ commented that it would be useful to have a better understanding on the position for our financial health and reported that networks have raised confusion of clinical pathways to Barts Health. He added that a dialogue between the two trusts was required to be clear on pathways to ensure the networks are clear on the best pathway for best outcomes for patients.

KP welcomed the new report format. He agreed that it would be helpful to have lead commissioners and Barts Health in attendance at a future governing body and would work well for a future joint committee of the BHR CCGs. KP questioned how binding the results of the independent audit will be of BHRUT. TT responded that the terms of reference were currently in development, adding that the results will not be binding, unless by joint agreement, however the process had been jointly agreed.

The governing body noted the report.

4.2 Finance & activity report TT presented the month 5 finance and activity report highlighting that the CCG has a year to date deficit of £1.2m and a forecast deficit of £2.79m. This is in line with the CCG’s operating plan. However, the position contains a significant level of risk and is therefore red rated. The two largest risks continue to be acute contracts and QIPP delivery.

Acute contract over performance is a major risk and is driven by the current level of activity and cost reported against both the BHRUT and Barts contracts. Price has increased at a much higher rate than activity (refer to page 5 of the IPR). BHR CCGs have issued three Contract Performance Notices (CPN) and one Activity Query Notice (AQN) to BHRUT. The CCGs have also written to the Trust requesting Non Elective and Stroke audits. The terms of reference and timelines for these are being finalised. These actions will inform an agreed 28 day plan, including a quarter 1 reconciliation.

The unadjusted reported overspend based on Month 4 SLAM equates to £13.5m at BHRUT and £3.6m at Barts. The CCGs have made a number of adjustments to the trust’s data which include claims and challenges (of £3.4m), QIPP delivery assumptions (in excess of £3m) and other technical issues and adjustments (£4.8m). This has resulted in forecast overspends at BHRUT of £4.7m and £1.2m at Barts.

The forecast position across the entire QIPP portfolio includes QIPP delivery of £9m, a slippage of £3.5m against plan. Of this, £1.5m slippage relates to the QIPP in acute contracts and £2m relates to acute QIPP

31 schemes that are not currently in contracts. (QIPP summary - more information can be found on page 3 of the IPR and within the FRPB and Financial Recovery Programme Progress Summary).

The forecast contract costs at BHRUT and Barts would not allow the CCGs to meet their control totals. The position was discussed with NHSE who agreed that the CCG should report to plan for Month 5, to allow the system and contractual processes to be concluded such that the CCGs can report Month 6 from a robust and informed position. Depending on the outcome of current processes, the risks identified in this report may translate into a forecast deficit in the Month 6 report.

To enable reporting to plan, the CCGs have therefore assumed a forecast outturn contract settlement where activity and price growth are in alignment. This assumption equates to an adjustment of £2.1m to the forecast outturn and £1.5m to the year to date position. This adjustment contains a high level of risk and is reflected in the risk analysis below.

The other main areas of spend including Continuing Health Care (CHC), Prescribing and Primary care are broadly in line with plan.

The net risk facing the CCGs at Month 5 is £5.8m after contingencies have been fully utilised in the reported position. If the risks materialise, this will result in the CCGs deficit increasing to £8.6m.

JH questioned whether the current position reflects investments agreed at FRPB. TT explained that any investments agreed after the report was written will be reflected at the next meeting.

The governing body agreed the financial position and noted the risks within it.

4.3 Quality report JH presented a report which provided assurance that the CCG continues to measure and monitor the quality of the services we commission from all providers including:  Barts Health NHS Trust CQC inspection

 PELC CQC inspection

 NELFT CQC inspection  GP service alerts  Quality Impact Assessment (QIA) process  BHRUT Mortality Outlier Status

 BHRUT – Never Events

 BHRUT - Delayed and Missed Diagnosis  NELFT Workforce Risks - Safer Staffing  NELFT access to services  NELFT access to CAMHS

 NELFT Update on the ligature programme of work  NELFT Clinical Harm Review Panels

32 The Chair thanked the quality team for clearing the GP alerts backlog. He requested that the number of GP alerts with RAG ratings are included within the next quality report. JH reported that this would also be shared at the next PTI meeting and it was agreed to add this to the intranet for GPs who are not in attendance. JH

Discussion ensued on workforce issues at NELFT and it was noted that although the recruitment process had been shortened there were still problems and it was acknowledged that the level of transparency with NELFT was an issue.

SM commented that the housebound flu vaccine is commissioned by NHSE and if the local provider does not provide this, the CCG will need to review if this is provided differently.

JJ referred to the regulation 28 issued by the Coroner in relation to a delayed diagnosis at BHRUT and questioned whether the Coroner was satisfied with the response received and when the governing body can expect to receive a report for assurance. JH reported that the most serious risks are considered by the quality and safety committee who had reviewed the response and were assured that it was adequate. It was noted that this death was not reported as a serious incident and this will be escalated via the SPR process. Concerns had been raised with NHSE and it had also been suggested that a risk summit is convened.

The governing body noted the report.

3.45pm Ceri Jacob arrived.

5.0 NEL Commissioning arrangements The Chair welcomed Ceri Jacob, the NHSE regional lead for north east London to the meeting. The Chair presented a report which recommend to the 7 CCG governing bodies in North East London, new shared commissioning arrangements in the form of a shared single Accountable Officer and supporting governance arrangements. The proposed arrangements reflect changes in the context for commissioning and the very strong direction to building sustainable local accountable care systems. The proposals are seen as a starting point that may evolve over time to reflect progress with implementation of the local accountable care systems.

The Chair highlighted some of the potential benefits:

 a more strategic focus on those things that are better coordinated across seven CCGs rather than three or one. The AO can take a longer term strategic view and not get buried in detail  in areas such as maternity services, acute contract payment systems - there is real benefit to a common and consistent approach  a stronger voice of seven commissioners collaborating for discussion with providers

33  enable CCGs locally to focus more of our efforts on developing our local solutions - accountable care in BHR and networks/localities

 fairer distribution of resources across NE London – access to the transformation funds that this new arrangement would allow us to unlock  a larger resource base both financial and staffing.  sharing of good practice

KP commented that it can be concerning when governance arrangements change, adding that BHR CCGs were already ahead in some aspects of the proposals with a shared accountable officer. He added that the proposals will not affect the sovereignty of the individual CCGs.

The Chair reported that changes to commissioning arrangements have already happened across most of London, and have begun to across the rest of the country. He added that as a Chair he would prefer to be at the forefront of shaping the future of the CCG and any further proposals or changes regarding staffing structures, governance, budgets would need to be agreed by the governing body and will ensure that we have staff and GB members included in discussions on these issues to ensure that BHR’s and our borough’s interests are at the forefront.

JJ reported there had been concerns raised by GP membership on the availability of a single AO across a larger area. He added that the membership will require assurance on this issue. KP reported that this concern was also raised by other audit chairs and acknowledged that arrangements will need to be reviewed to ensure that this is being achieved.

MC commented that lessons from previous reorganisations need to be reviewed as the local authority felt it was not consulted. It was also noted that meetings were too large and it was difficult to see where decisions were made and the governance was problematic. MC also reported that the biggest concern the local authority have is how this will affect development of localities.

CJ acknowledged that membership engagement is crucial and reported on future stakeholder sessions planned. She added that decisions will still need governing body approval and there are no plans for a joint governing body across north east London.

RG commented that it will be helpful to develop a shared purpose across north east London and a single accountable officer could support this.

RH commented that there could be a negative effect on the population if services change, it was noted that this was not the intention of the proposals. KP commented that equality impact assessments will be important for fairness of decisions made and that regular reviews of the effectiveness of the arrangements will be required.

Discussion ensued on ensuring lessons learnt from previous reorganisations and the importance of engaging staff.

34 TT commented that structured and formalised arrangements can only be positive for equalisation and variation across the STP.

JH requested that areas for delegation need to be confirmed to ensure it is clear on the statutory function for safeguarding.

The governing body agreed it was important to keep the local population at the forefront of decisions made as Barking & Dagenham is one of the most deprived boroughs in London whose population have differing needs to other areas in the STP.

The governing body:  Approved the recommendation to appoint a single accountable officer for the CCGs in North East London;  Approved the recommendation that the single accountable officer will also act as the STP lead;  Approved the recommendation to establish the governance arrangements, including the joint committee and committees in common at system level, to provide clear direction and support for the single accountable officer, including delegated functions.  Approved the recommended scheme of delegation and job description

6.0 The meeting was abandoned due to a fire alarm.

After the meeting the following reports were re-circulated via email and approved by members.

 Accountable Care System proposals update  Integrating CCG Governance – Response to Legal Directions and Overall Strategic Direction

7.0 Date of the next meeting To be confirmed.

35 Draft Havering Clinical Commissioning Group governing body Minutes 27 September 2017 2.00pm Imperial House Present Dr Atul Aggarwal (AA) Chair/ Clinical director Dr Maurice Sanomi (MSan) Clinical director Dr Alex Tran (AT) Clinical director Dr Gurdev Saini (GS) Clinical director Dr Ashok Deshpande (AD) Clinical director Richard Coleman (RC) Lay member – PPI & Vice Chair Conor Burke (CB) Chief officer Tom Travers (TT) Chief finance officer Alan Steward (AS) Chief operating officer Jacqui Himbury (JHim) Director of nursing

In attendance Anne-Marie Keliris Company secretary Marie Price (MP) Director of corporate services Andrew Rixom (AR) Public health consultant, LBH Lee Eborall (LE) NELCSU Ceri Jacob (CJ) Ceri Jacob, the NHSE regional lead for north east London (for item 6.7 only)

Apologies Kash Pandya (KP) Lay member – governance Dr Ann Baldwin (AB) Clinical director

Item Action 1.0 Welcome and apologies The Chair welcomed members to the meeting and apologies for absence were noted.

http://www.haveringccg.nhs.uk/About-us/Our-governing-body/register-of- interests.htm

36 1.3 Minutes of the last meeting The minutes of the meeting held on 12 July 2017 were agreed as a correct record.

1.4 Matters/Actions arising The governing body noted the actions taken since the last meeting.

2.0 Chair & Accountable Officer’s Reports 2.1 Chair’s report The Chair presented his report covering the following areas: The governing body noted the report.  Annual General meeting  Financial situation  System developments, including networks and localities  Meetings

The governing body noted the report.

2.2 Chief Officer’s report CB presented his report covering the following areas:  BHR System Delivery Plan  BHR Accountable Care System and Sustainability and Transformation Plan (STP)  CCG Development  2018/19 Commissioning Intentions Operational Resilience  Winter Planning  Health and Wellbeing Board update

The governing body noted the report.

2.3 Patient experience report RC presented a report which provided a summary of the various feedback that has come through to the CCG from patients and stakeholders highlighting the following areas:  The Patient Engagement Forum (PEF)  Joint PEF meeting  Procurements  Adult inpatient survey

MP agreed to share the summary of the adult inpatient survey with MP members.

The governing body noted the report.

3.0 Governing body assurance 3.1 Governing body assurance framework AS presented a report which outlined the key risks to the clinical commissioning group in achieving its corporate objectives as identified in

37 the governing body risk assurance framework. There are two risks on the GBAF:- 1. Risks to the delivery of the Clinical Commissioning Group’s (CCG) budget 2. Barking, Havering and Redbridge University Hospitals Trust (BHRUT) emergency care performance

One risk was de-escalated from the GBAF in August:

1. BHRUT cancer 62 days standard.

The Chair expressed concern that the CCG cannot affect change on some issues within the risks.

AT questioned how much scrutiny there is on the 62 day target. AS reported that there is intense scrutiny with weekly meetings to review action and progress.

MS questioned whether there are any plans for exploring primary care supporting winter contingency plans. CB reported that there is a whole workstream around demand management which will discussed in more detail in the second part of the meeting today.

The Chair questioned where the risk at primary care level is recorded. TT responded that the budget risk includes primary care and the finance and delivery committee review the full risk register which includes significant primary care risks.

The governing body noted the current risks escalated to the GBAF and levels of assurance in the controls and mitigating actions being taken.

4.0 Corporate strategy and planning 4.1 ELHCP Programme Progress Summary Report – Q1 2017 CB presented a report which summarised progress to date of the East London Health and Care Partnership (ELHCP) programme of work.

The Chair questioned how local CDs are involved in the programmes. CB reported that most workstreams are clinically led but this needs to be strengthened further and it is the role of the clinical senate to do this.

The governing body noted the report.

4.2 Accountable Care System proposals update CB presented a report which updated on proposals to take forward the development of Accountable Care in Barking and Dagenham, Havering and Redbridge.

The governing body:  Noted the progress to take forward development of an Accountable Care System;

38  Approved the next steps  Agreed to receive a further report in December 2017

5.0 Quality and performance 5.1 Integrated contract report LE presented the integrated performance report which included finance and activity, in its contracted services, to identify the key risks presented by that performance and provide assurance that those risks are being appropriately managed. The report is based on month 4 activity and month 5 finance information.

The main points of note are:

BHRUT: The BHRUT 2017/19 financial forecast across the three CCGs is £9.75m above plan. This over spend is driven by over performance in the following areas: elective, maternity, day cases and outpatients. One of the key drivers of the projected overspend is the increased average unit cost of activity compared to last year. This is being investigated. CCGs have issued 4 notices as part of the formal contract management process. These notices reflect the CCGs concern on specific areas and have required the Trust to work with CCGs to identify and agree remedial actions. In addition to the formal notices CCGs are also working with the Trust on a number of areas in September and October (the 28 day plan) which include a joint reconciliation of quarter 1 activity to inform the M6 reported position and a refreshed demand and capacity model from the Trust which will be completed by the end of September 2017 On performance, against constitutional performance measures, the Trust reported a significant improvement in cancer performance in July with all eight cancer standards met as well as achieving 90.0% RTT compliance. The 4 hour A&E performance in July was 88.02%, slightly below the recovery trajectory of 88.5%. Early indications are that Q2 performance may also be below the recovery trajectory

39 NELFT: The CCGs and NELFT are discussing the options for closing down outstanding issues relating to the 2017/18 contract following the recent offer, with the option of proceeding to mediation if necessary. Quarter 1 IAPT performance shows good achievement of recovery targets but access targets not being met consistently. Against the 3.75% access target, Barking and Dagenham, Havering and Redbridge CCG performance is at 3.5%, 2.91% and 3.91% respectively.

TT reported that contract discussions with BHRUT will be reflected in quarter one reporting and possible arbitration. LE reported that relationships with BHRUT had been more positive recently with closer working.

The Chair questioned what the Barts Health increase in outpatient procedures relate to. LE reported that these relate to a move from day procedures as part of a contract agreement with the Trust.

The Chair reported that there were issues with NELFT stating they would Chair/TT not undertake flu vaccinations for the housebound. The Chair agreed to discuss this further with TT after the meeting.

Discussion ensued on low dementia diagnosis in Havering. CB reported that Havering have historically been challenged primarily due to population and also coding in GP practices. It was noted that work is being progressed by Sharon Morrow to improve this.

MS referred to NELFT paediatric services and long OT waiting times. TT reported that this has been a long standing issue and a business case for improvement is awaited from NELFT. JH reported that this is also being reviewed at SPR meetings and in service line reporting. NELFT has been asked to provide a remedial action plan and numbers of patients currently waiting.

The governing body noted the report and asked that the next report strengthen action taken.

5.2 Finance & activity report TT presented the month 2 finance and activity report highlighting that the CCG has a year to date deficit of £4m and a forecast deficit of £9.7m. The forecast deficit includes the 17/18 in year deficit of £4.9m and the historic deficit of £4.8 This is in line with the CCG’s operating plan. However, the position contains a significant level of risk and is therefore red rated. The two largest risks continue to be acute contracts and QIPP delivery.

40 The unadjusted reported overspend based on Month 4 SLAM equates to £15.8m at BHRUT and £4m at Barts. The CCGs have made a number of adjustments to the trust’s data which include claims and challenges (of £4.4m), QIPP delivery assumptions (in excess of £5.4m) and other technical issues and adjustments (£3.8m). This has resulted in forecast overspends at BHRUT of £3.7m and £2.5m at Barts.

The forecast position across the entire QIPP portfolio includes QIPP delivery of £12.9m, a slippage of £4.5m against plan. Of this, £2.3m slippage relates to QIPP in acute contracts and £2m relates to acute QIPP schemes that are not currently in contracts. (QIPP summary – more information can be found on page 3 of the IPR and within the FRPB and Financial Recovery Programme Progress Summary).

To enable reporting to plan, the CCGs have therefore assumed a forecast outturn contract settlement where activity and price growth are in alignment. This assumption equates to an adjustment of £2.3m to the forecast outturn and £1.3m to the year to date position. This adjustment contains a high level of risk and is reflected in the risk analysis below.

The other main areas of spend including Continuing Health Care (CHC), Prescribing and Primary care are broadly in line with plan.

The net risk facing the CCGs at Month 5 is £6.6m after contingencies have been fully utilised in the reported position. If the risks materialise, this will result in the CCGs deficit increasing to £11.5m.

The governing body agreed the financial position and noted the action taken to achieve it.

5.3 Quality report JH presented a report which provided assurance that the CCG continues to measure and monitor the quality of the services we commission from all providers including:

 Barts Health NHS Trust CQC inspection  PELC CQC inspection  NELFT CQC inspection  GP service alerts  Quality Impact Assessment (QIA) process  BHRUT Mortality Outlier Status  BHRUT – Never Events  BHRUT - Delayed and Missed Diagnosis

41  NELFT Workforce Risks - Safer Staffing  NELFT access to services  NELFT access to CAMHS  NELFT Update on the ligature programme of work  NELFT Clinical Harm Review Panels

AT questioned whether there are any concerns regarding NELFT providing CAMHS service in Kent. JH reported there are no fundamental concerns raised with regard to NELFT CAMHS service by the CCG or the safeguarding children’s board.

The governing body noted the report.

6.0 Development/governance 6.1 Integrating CCG Governance – Response to Legal Directions

and Overall Strategic Direction

MP presented a report which detailed the reasons for the proposed establishment of a joint committee with BHR CCGs.

Discussion ensued on quoracy and voting arrangements. It was noted terms of reference need to finalised and agreed at the first meeting.

The governing body agreed to establish a joint committee with fellow BHR CCGs.

6.2 Annual Audit Letter 2016/17 TT presented the annual audit letter for 2016/17 which detailed the external auditor’s findings and opinion the CCG’s governance arrangements and annual report and accounts for 2016/17.

The governing body acknowledged the external auditor’s management letter and noted the opinion given.

6.3 Finance & delivery committee chair’s report The Chair presented a report which provided key highlights of the finance and delivery committee held on 29 August 2017.

The governing body noted the report.

6.4 Audit & governance committee report KP presented a report which provided key highlights of the audit and governance committee held on 11 July 2017.

The governing body noted the report.

6.5 Work of the FRPB and Financial Recovery Programme TT presented a summary report which provided key highlights of the FRPB and financial recovery programme.

The governing body noted the report.

6.6 Minutes of sub committees:

42 The governing body noted the minutes of:  Primary care transformation programme board held on 5 April 2017  Joint executive committee held on 10 August 2017  Patient engagement forum held on 19 July 2017  Primary care commissioning committee held on 5 July 2017  Quality & safety Committee minutes held on 1 September 2017

4.00pm CB left the meeting due to a conflict of interest in the next item on the agenda. Ceri Jacob arrived.

6.7 NEL Commissioning arrangements The Chair welcomed Ceri Jacob, the NHSE regional lead for north east London to the meeting. The Chair presented a report which recommend to the 7 CCG governing bodies in North East London, new shared commissioning arrangements in the form of a shared single Accountable Officer and supporting governance arrangements. The proposed arrangements reflect changes in the context for commissioning and the very strong direction to building sustainable local accountable care systems. The proposals are seen as a starting point that may evolve over time to reflect progress with implementation of the local accountable care systems.

The Chair highlighted some of the potential benefits:

 a more strategic focus on those things that are better coordinated across seven CCGs rather than three or one. The AO can take a longer term strategic view and not get buried in detail

 in areas such as maternity services, acute contract payment systems - there is real benefit to a common and consistent approach

 a stronger voice of seven commissioners collaborating for discussion with providers

 enable CCGs locally to focus more of our efforts on developing our local solutions - accountable care in BHR and networks/localities

 fairer distribution of resources across NE London – access to the transformation funds that this new arrangement would allow us to unlock

 a larger resource base both financial and staffing.

MP reported that as Kash Pandya lay member for governance was unable to attend, she had been asked to make the following comments - although it can be concerning when governance arrangements change, BHR CCGs were already ahead in some aspects of the proposals with a shared accountable officer and that the proposals will not affect the sovereignty of the individual CCGs.

43 The Chair reported that changes to commissioning arrangements have already happened across most of London, and have begun to across the rest of the country. He added that as a Chair he would prefer to be at the forefront of shaping the future of the CCG and any further proposals or changes regarding staffing structures, governance, budgets would need to be agreed by the governing body and will ensure that we have staff and GB members included in discussions on these issues to ensure that BHR’s and our borough’s interests are at the forefront.

MS commented that Havering CCG needs assurance that all seven CCGs will be treated equally. CJ responded that as the accountable officer will be appointed by each CCG, he/she will be equally accountable for all CCGs.

TT commented that structured and formalised arrangements can only be positive for equalisation and variation across the STP.

JH requested that areas for delegation need to be confirmed to ensure it is clear on the statutory function for safeguarding.

RC commented that public challenge could point to associated costs. CJ acknowledged this and reported that the operating model needs to be finalised but it is expected to be cost neutral.

RC referred to specialist commissioning and assumed that the delegation from NHSE will not be without risk. CJ responded that this will need to be designed and agreed at a national level.

The Chair commented that as BHR CCGs are 42% of the STP, this will need to reflected in the clinical input and accountability.

7.0 Questions from the public There were no questions from the public.

8.0 Date of the next meeting To be confirmed.

Redbridge Clinical Commissioning Group Governing Body Meeting 28 September 2017 2.00pm Becketts House

Present: Dr Anil Mehta (AM) Clinical Director and Chair Dr Syed Raza (SR) Clinical Director Dr Sarah Heyes (SH) Clinical Director Dr Shujah Hameed (SHam) Clinical Director Dr Joyoti Sood (JS) Clinical Director Dr Anita Bhatia (AB) Clinical Director Dr Shabana Ali (SA) Clinical Director Dr Mehul Mathukia (MM) Clinical Director Dr Ah Fee Chan (AFC) Secondary Care Consultant Conor Burke (CB) Chief Officer Kash Pandya (KP) Lay member - governance Khalil Ali (KA) Lay Member-PPI Tom Travers (TT) Chief Finance officer Jacqui Himbury (JH) Nurse Director Louise Mitchell (LM) Transformation Director

In Attendance: Marie Price (MP) Director of Corporate Services Anne-marie Keliris (AMK) Company Secretary Lee Eborall NEL CSU Ceri Jacob NHSE regional lead for north east London (for item 6.8 only)

Apologies: Vicky Hobart (VH) LBR Director of Public Health Dr Muhammad Tahir (MT) Clinical Director

Item Action 1.0 Welcome and apologies The Chair welcomed members to the meeting and apologies for absence were noted.

Declarations declared by members of the governing body are listed in the

CCG’s Register of Interests. The Register is available either via the secretary to the governing body or the CCG website at the following link:

http://www.redbridgeccg.nhs.uk/About-us/Our-governing-body/register-of- interests.htm

1.3 Minutes of the last meeting The minutes of the meeting held on 20 July 2017 were agreed as a correct record.

1.4 Matters/Actions arising The governing body noted the actions taken since the last meeting.

2.0 Chair & Accountable Officer’s Reports 2.1 Chair’s report The Chair presented his report covering the following areas: The governing body noted the report.  Annual General meeting

 Financial situation

 System developments, including networks and localities

 Meetings

The governing body noted the report.

2.2 Chief Officer’s report CB presented his report covering the following areas:  BHR System Delivery Plan

 BHR Accountable Care System and Sustainability and Transformation Plan (STP)

 CCG Development

 2018/19 Commissioning Intentions Operational Resilience

 Winter Planning

 Health and Wellbeing Board update

CB updated that the management team had approved the draft

commissioning intentions today which will be shared with providers.

KA commented that as part of the development of the ELCHP it will be

paramount that transformation plans are also focused on. The governing body noted the report.

2.3 Patient experience report KA presented a report which provided a summary of the various feedback that has come through to the CCG from patients and stakeholders

highlighting the following areas:  The Patient Engagement Forum (PEF)  Joint PEF meeting  Procurements  Adult inpatient survey

The governing body noted the report.

3.0 Governing body assurance 3.1 Governing body assurance framework LM presented a report which outlined the key risks to the clinical commissioning group in achieving its corporate objectives as identified in the governing body risk assurance framework. There are four risks on the GBAF:- 1. Risks to the delivery of the Clinical Commissioning Group’s (CCG) budget 2. Barking, Havering and Redbridge University Hospitals Trust

(BHRUT) emergency care performance

3. Barts Health (BH) performance against key targets, A&E and RTT 4. BH quality concerns

One risk was de-escalated from the GBAF in August:

1. BHRUT cancer 62 days standard.

KP commented that it was good to see only four key risks. Referring to the financial risk, he felt it would be useful to understand if the mitigations are helping the progress made. He also commented that the target rating was optimistic and suggested reviewing this. TT agreed that this would be reviewed for the next meeting.

The governing body noted the current risks escalated to the GBAF and levels of assurance in the controls and mitigating actions being taken.

2.40pm Dr Raza arrived

KA welcomed the progress report and suggested that the governing body may want to see more detail on prevention of obesity, as this is high in some areas of Redbridge and should be recognised in reporting.

KA also commented that it will be important to communicate changes to ensure patients understand changes in workforce and new roles. The Chair reported that the role of the PPG is to communicate with the population on changes in primary care.

MM questioned what is being done to standardise care across the seven CCGs. CB responded that this is the role of the STP and the report describes the priorities of the partnership. He added that there are areas

where access is being restructured which was recently discussed at the clinical senate. It was noted that not all CCGs took part initially but this had changed in phase two and all are now working together.

CB commented that engagement mechanisms of individual schemes need to be reviewed and will need to ensure there is strong patient representation across all areas.

SAli commented that digital technology is advanced in the inner north east London CCGs and questioned whether there are plans to widen this work to outer north east London CCGs. CB responded that there are information governance issues that need to be explored, but BHR CCGs are committed to move to a consistent/common system for GP IT.

KP commented that it would be useful to include in future reporting the impact on BHR and localised schemes.

The governing body noted the report.

4.2 Accountable Care System proposals update CB presented a report which updated on proposals to take forward the development of Accountable Care in Barking and Dagenham, Havering and Redbridge.

SH commented that she supports collaborative working but is concerned for Wanstead and Woodford patients that do not go to BHRUT as Barts Health in not referred to within the report. CB acknowledged this concern CB and will ensure this is included in the next update report.

The governing body:  Noted the progress to take forward development of an Accountable Care System;

 Approved the next steps

 Agreed to receive a further report in December 2017

4.3 Redbridge Health and Wellbeing Strategy 2017-20

The Chair presented the Redbridge Health and Wellbeing Strategy for 2017-20.

KA commended the choice of priorities in the strategy. He referred to the launch of the prescribing pilot in Fairlop locality and requested that the evaluation is undertaken quickly. He also suggested that an in year draft progress report is also explored.

JS commented that obesity is not specifically mentioned, however it was pointed out that it is referred to in more detail under the diabetes and children and young people sections.

The governing body agreed the new Health & Wellbeing Strategy (subject to Council Cabinet approval on 17 October).

The main points of note are:

target, Barking and Dagenham, Havering and Redbridge CCG performance is at 3.5%, 2.91% and 3.91% respectively.

The Chair questioned when Barts Health will start reporting on RTT. LE responded that this will not happen in this financial year and the lead commissioner has requested that a robust process is in place before returning to reporting.

The Chair questioned whether there is any progress with NELFT. LE responded that this is following the contract management route.

SHam referred to double payment queries and questioned how this is being dealt with. LE responded that the Trust are being challenged on this and was confident that this would be resolved.

KP welcomed the new report format. He added that the report was concerning and the only positive position was that the community care contract was under control.

KA referred to overperformance at Barts Health and BHRUT and suggested it would be helpful to have further detail on any other acute sites which could cause problems in the future. He also requested further detail on high cost procedures and how these are performing, for example orthopaedic revisions.

LE reported that there is a robust process in place to monitor trends including referrals into independent sector and high cost patients.

CB reported that there will be further strengthening of reporting and was currently exploring including a primary care scorecard.

The governing body noted the report.

5.2 Finance & activity report TT presented the month 2 finance and activity report highlighting that the CCG has a year to date deficit of £1m and a forecast deficit of £2.5m. This is in line with the CCG’s operating plan. However, the position contains a significant level of risk and is therefore red rated. The two largest risks continue to be acute contracts and QIPP delivery.

The unadjusted reported overspend based on Month 4 SLAM equates to £7.5m at BHRUT and £7.6m at Barts. The CCGs have made a number of adjustments to the trusts data which include claims and challenges (of £3.5m), QIPP delivery assumptions (in excess of £3m) and other technical issues and adjustments (£3.4m). This has resulted in forecast

50 overspends at BHRUT of £1.4m and £3.8m at Barts.

The forecast position across the entire QIPP portfolio includes QIPP delivery of £9.9m, a slippage of £5.4m against plan. Of this, £2.6m slippage relates to QIPP in acute contracts, £2m relates to acute QIPP schemes that are not currently in contract and £0.5m relates to QIPP schemes in Community and Mental Health contracts. (QIPP summary – more information can be found on page 3 of the IPR and within the FRPB and Financial Recovery Programme Progress Summary).

To enable reporting to plan, the CCGs have therefore assumed a forecast outturn contract settlement where activity and price growth are in alignment. This assumption equates to an adjustment of £5m to the forecast outturn and £2m to the year to date position. This adjustment contains a high level of risk and is reflected in the risk analysis below.

The other main areas of spend including Continuing Health Care (CHC), Prescribing and Primary care are broadly in line with plan.

The net risk facing the CCGs at Month 5 is £7.9m after contingencies have been fully utilised in the reported position. If the risks materialise, this will result in the CCGs deficit increasing to £10.4m.

The governing body agreed the financial position and noted the action taken to achieve it.

3.30pm Dr Heyes left the meeting.

5.3 Quality report JH presented a report which provided assurance that the CCG continues to measure and monitor the quality of the services we commission from all providers including:

 Barts Health NHS Trust CQC inspection

 PELC CQC inspection

 NELFT CQC inspection

 GP service alerts

 Quality Impact Assessment (QIA) process

 BHRUT Mortality Outlier Status

 BHRUT – Never Events

51  BHRUT - Delayed and Missed Diagnosis

 NELFT Workforce Risks - Safer Staffing

 NELFT access to services

 NELFT access to CAMHS

 NELFT Update on the ligature programme of work

 NELFT Clinical Harm Review Panels

JH reported that the recent CAMHS review had identified capacity issues which are now on the NELFT risk register. She added that a business case had been received today for further investment into the service.

The Chair expressed concern at the 17 unexpected deaths recorded as suicide. JH acknowledged the concern and reported that Redbridge were not above the national average. She added that NELFT are undertaking a review of the underlying reasons and will be reporting on this shortly as suicide prevention is a national priority.

KA expressed concern at the number of deaths attributed to waiting for access to IAPT. JH agreed that this is concerning, adding that all psychology services have a danger of suicide. It was noted that NELFT have reduced the first assessment to active treatment time and have also introduced continuing contact while patients are waiting for appointments.

KP welcomed the progress in strengthening the GP alert system.

The governing body noted the report.

6.0 Development/governance 6.1 Integrating CCG Governance – Response to Legal Direction and Overall Strategic Direction MP presented a report which detailed the reasons for the proposed establishment of a joint committee with BHR CCGs.

KP supported the proposals and highlighted the importance of reviewing effectiveness of a regular basis. The Chair questioned whether members need to be consulted on proposals. MP reported that it would be good practice to share the report with members to keep them updated on governance and agree what is required.

KA commented that the size of the joint committee could cause issues. MP reported that a governing body awayday will be discussing practicalities and terms of reference in October.

Concern was expressed that Barts Health issue could be diluted. CB responded that Barts Health also affect Barking & Dagenham CCG and suggested that joint working will encourage all CCGs to take ownership and relate to STP.

The governing body agreed to establish a joint committee with fellow BHR

CCGs.

The governing body acknowledged the external auditor’s management letter and noted the opinion given.

6.3 Finance & delivery committee chair’s report The Chair presented a report which provided key highlights of the finance and delivery committee held on 29 August 2017.

KP expressed concern at the current financial position of the CCG.

The governing body noted the report.

6.4 Audit & governance committee report KP presented a report which provided key highlights of the audit and governance committee held on 11 July 2017.

The governing body noted the report.

6.5 Work of the FRPB and Financial Recovery Programme TT presented a summary report which provided key highlights of the FRPB and financial recovery programme.

The governing body noted the report.

6.6 Minutes of sub committees: The governing body noted the minutes of:  Primary care transformation programme board held on 5 April 2017  Joint executive committee held on 10 August 2017  Patient engagement forum held on 19 July 2017  Primary care commissioning committee held on 5 July 2017  Quality & safety Committee minutes held on 1 September 2017

4.00pm CB left the meeting due a conflict of interest in the next item on the agenda. Ceri Jacob arrived.

The Chair highlighted some of the potential benefits:

 a more strategic focus on those things that are better coordinated across seven CCGs rather than three or one. The AO can take a longer term strategic view and not get buried in detail

 in areas such as maternity services, acute contract payment systems - there is real benefit to a common and consistent approach

 a stronger voice of seven commissioners collaborating for discussion with providers

 enable CCGs locally to focus more of our efforts on developing our local solutions - accountable care in BHR and networks/localities

 fairer distribution of resources across NE London – access to the transformation funds that this new arrangement would allow us to unlock

 a larger resource base both financial and staffing.

KP commented that although it can be concerning when governance arrangements change, BHR CCGs were already ahead in some aspects of the proposals with a shared accountable officer and that the proposals will not affect the sovereignty of the individual CCGs.

Discussion ensued and concern was raised on the availability of a single accountable officer. CJ acknowledged the concern raised. She added that the proposed arrangements exist in other part of London and are working well. The CCG will remain a statutory body and retain borough based teams. Phase two of the proposals will decide on the base of accountable officer along with management structure and the governing body will have an opportunity to shape this.

The Chair questioned whether constitutional changes will be required. MP responded that in principle changes will not be required.

KP commented that it will important to engage staff. MP reported that staff briefings are taking place more regularly with the next meeting on Monday.

SAli questioned whether there are any plans to merge CCGs. CJ confirmed that this is not planned.

JH commented that given the significant quality issues in the STP a stronger voice will enhance and strengthen the CCGs position as commissioners.

TT commented that structured and formalised arrangements can only be positive for equalisation and variation across the STP.

JH requested that areas for delegation need to be confirmed to ensure it is clear on the statutory function for safeguarding.

SAli left the meeting at 4.15pm

7.0 Questions from the public Questions from Janet Knight: Q1: Are you still working towards closing King George's A & E in 2019? Especially relevant in the light of the massive housing proposed throughout NE London. A: It is still the intention of the local NHS to make the changes by 2019 but please be assured nothing will happen until we are fully satisfied all the necessary resources are in place, including the additional capacity at neighbouring hospitals, and we have made sure it is safe for our patients. In the meantime, the existing A&E facilities at King George will continue to operate as now.

Q2: What is the number of patients registered at a GP Practice in Ilford South, postcodes IG1, IG2 and IG3, and what is the number for the rest of the Borough? A: There are 20 practices in Ilford South with a combined weighted list size as of 1 July 2017 of 120,669. The total weighted patient list for Redbridge as of the 1 July 2017 is 275,901.

Q3: How many full time GP's are there within Ilford South, compared to the rest of the Borough, and why are they not making this information publically available. A full response to this question will be sent after the meeting.

You might have heard earlier that we are delighted to have won funding to bring 35 overseas GPs to the wider BHR area and we have introduced a number of new support roles in practices to support GPs. But recruitment and retention of GPs is a national issue – not just for us in Redbridge.

Questions from Andy Walker: Q1 Is Sterile Services staying at King George Hospital? A: The CCG doesn’t commission hospital sterile services so it was suggested that this question is directed to the Trust.

edQ2 NHS managers said at Redbridge Health Scrutiny last night that Care UK have said that the block contract has to stay in place otherwise they will walk away from the contract. So why does not the NHS manage the unit? A: We’ve checked with attendees at last night’s meeting and nobody from the CCG said that. The unit is run by Care UK and the CCG is currently consulting on proposals to change the way it pays for beds there. Currently we fund care for 14 people at the home and pay £2.4m for a further 34 empty beds. That’s not a good use of NHS resource or tax payer’s money.

So we are proposing to end our contract at Meadow Court and support those who live there to move to a different nursing home of their choice. The CCG has already held a number of meetings with patients and their families. The consultation ends on 27 October.

Q3 Inexplicably, Care UK won the contract to run the NE London Treatment Centre, rather than BHRUT. Do you agree with me that both bids must be published to maintain public confidence in the bidding process? A: The CCGs ran a lawful, robust procurement exercise for the service which was carried out in the best interests of patients, in accordance with the NHS rules on procurement, choice and competition.

In terms of publishing tenders or bids, suppliers do not expect their commercial information to be made public which is why it’s exempt under the FOI act for example.

Q4 Do you agree with me that bed numbers at KGH and QH should be published each month? A: Our teams work with BHRUT to get all the information we need to commission and monitor contracts on a regular basis.

Q5 There is an important delayed PW report coming, can I be told what it is about? A: After confirming the report was a population growth study, CB confirmed that this would be shared with the health scrutiny committee.

Q6 Would you welcome a feasibility study into the buying out of Queens PFI by local authorities? A: It was suggested that this question should be directed to hospitals Trust and the local authority, but given the sums involved, it was questioned if this would be a sensible use of limited resources and of council tax payer’s money?

8.0 Date of the next meeting To be confirmed.

Barking & Dagenham CCG action log

Action ref: Meeting date Action required Lead Required by Status

6.3 18 July 2017 Barts Health - CB advised that input to the contracting CB September To review this Quality report monitoring process via the lead commissioner has been 2017 suggestion at the next escalated. CB suggested that the Governing Body consider meeting and inviting the lead commissioner to address the Governing Body. determine whether this action is required.

4.3 26 The Chair thanked the quality team for clearing the GP alerts JH November RAG ratings not Quality report September backlog. He requested that the number of GP alerts with RAG 2017 included, however 2017 ratings are included within the next quality report. JH reported detailed report on GP that this would also be shared at the next PTI meeting and it alerts in quality report was agreed to add this to the intranet for GPs who are not in on agenda. attendance.

Havering CCG action log

Action ref: Meeting date Action required Lead Required by Status

5.3 Quality 12 July 2017 Crisis Team – JH reported that a number of serious incidents JH September Verbal update. report had highlighted access to the crisis team as a theme and this 2017 had been raised at the NELFT CQRM. A report will be presented to the quality and safety committee and governing body meeting updating on action taken to address access including a plan, timeline and learning.

Redbridge CCG action log

Action ref: Meeting Action required Lead Required by Status date

2.2 20 July CT reported that she had been receiving a number of concerns CT September Verbal update. Chief Officers 2017 from patients about access to Barts Health services and was also (HealthWatch) 2017 report concerned that patients are not receiving quality discharge information. CT agreed to write to CB with further detail.

Barking & Dagenham CCG - CLOSED ACTIONS

Action ref: Meeting date Action required Lead Required by Status

2.3 26 Discussion ensued on the future of the patient engagement MP November CLOSED Patient September forum and the plans to reflect the new commissioning 2017 Information on experience 2017 structure. MP agreed to provide the governance structure to new report the Chair. arrangements shared.

3.1 26 GK referred to supporting practices that do not have access to SM/ GK November CLOSED GBAF September district nursing services to immunise house bound patients with 2017 NHSE are 2017 flu vaccine. SM/GK agreed to discuss this outside the commissioning meeting. NELFT to provide a housebound service for people who are the district nursing caseload; the CCGs are commissioning a service from GPs for housebound

59 Action ref: Meeting date Action required Lead Required by Status

patients who are not on the district nursing caseload.

TT Revised GBAF on KP commented that it was refreshing to see the reduction in agenda. risks at the governing body level and reported that the finance and delivery committee continue to review 30 risks below this level. He also suggested that the target for the financial risk of 30 March was unrealistic, TT agreed to review this.

5.4 23 May 2017 Dr Rai raised further concerns with the GP alert process and JH September CLOSED Quality report suggested exploring different ways the process could be run. 2017 Within quality She also questioned whether CDs are aware of alerts and report on agenda. suggested that a pathway and protocol is required for GP alerts just as there are for specialities. KP reported that internal audit would be in touch with CDs who had raised concerns.

5.4 23 May 2017 Dr John raised concern at BHRUT’s CQC mortality rates for JH September CLOSED Quality report UTIs and requested an urgent GB report including what the 2017 Within quality issues are and how they are being dealt with and suggested report on agenda. that BHRUT internal audit was required. SM reported that BHRUT will be reviewing the data by 1 June.

6.1 18 July 2017 KR commented that she was unaware that IAPT will set up SM September CLOSED Integrated clinics within surgeries and suggested that this information 2017 Verbal update at contract report should be circulated to practices to ensure they are aware. SM meeting. agreed to report this at the next PTI.

60 Havering CCG CLOSED ACTIONS

Action ref: Meeting Action required Lead Required by Status date

5.2 17 May It was agreed to discuss further at a future clinical directors AS TBC CLOSED Contracting 2017 meeting and share personal experiences of the service and CB This will report agreed to challenge the urgent care board to consider programmed into approaches to improve utilisation of the urgent care centre. a future Havering CDs meeting. Our system UEC improvement plan – agreed through the A&E Delivery Board - includes measures to improve UCC use. It is monitored at each meeting and has seen improvement in Quarter 1.

5.2 17 May The Chair referred to the IAPT KPI and reported that the waiting JH September 2017 CLOSED Contracting 2017 times for the crisis team were too long and there was no Update within report indication of this in the report. JH reported that this will be part quality report. of the next quality report due to the high number of GP alerts

5.3 17 May The Chair suggested in preparation for winter a report on the JH September 2017 CLOSED Quality report 2017 review of pneumonia deaths should be escalated to the Update within governing body for review. quality report.

61 Action ref: Meeting Action required Lead Required by Status date

1.4 12 July NELFT survey – The chair reported that he had not seen this AS September 2017 CLOSED Matters arising 2017 survey and questioned whether there is an opportunity to input The Chair has into questions. He advised that there should also be a GP survey received a copy – AS agreed to investigate. of the GP survey on MH services. The questions were developed with Dr Kumar as MH GP lead. 2.2 12 July GS expressed concern that there had been no attendance from CB September 2017 CLOSED Chief officer 2017 a NELFT mental health lead at the dementia partnership board. Verbal update. report CB suggested writing to the Trust expressing disappointment.

6.3 12 July Discussion ensued on BHRUT mortality outlier status and JH JH September 2017 CLOSED Quality report 2017 reported on the action BHRUT are taking including setting up a Update within multi-agency system wide group to review 30 mortality reviews. quality report. She added that this will be reflected on the GBAF at the next meeting.

CB commented that it is the CCGs duty to improve quality. He added that system wide issues need to be adequately responded to and reflected on the GBAF with the CCG’s responsibilities and assuring the governing body.

It was agreed that a report would be presented to the next meeting addressing BHRUT and the CCG’s role of system requirement and what we are doing to address wider system issues.

2.3 27 MP agreed to share the summary of the adult inpatient survey MP November 2017 CLOSED September with members. Complete. 2017

62 Action ref: Meeting Action required Lead Required by Status date

Patient engagement report

5.1 27 The Chair reported that there were issues with NELFT stating Chair/TT November 2017 CLOSED Integrated September they would not undertake flu vaccinations for the housebound. NHSE are contract report 2017 The Chair agreed to discuss this further with TT after the commissioning meeting. NELFT to provide a housebound service for people who are the district nursing caseload; the CCGs are commissioning a service from GPs for housebound patients who are not on the district nursing caseload

Redbridge CCG – CLOSED ACTIONS

Action ref: Meeting Action required Lead Required by Status date

3.1 26 May The Chair questioned whether a sixth risk was whether the WEL MP July 2017 CLOSED GBAF 2017 proposals for multiple ACS posed any risk and a seventh was primary care risk due to lack of GPs and district nurses and the ageing current professionals. MP advised it was a technical issue

63 Action ref: Meeting Action required Lead Required by Status date

registering risk but she would discuss these proposals with the relevant directors and report back to the risk lead.

4.2 26 May The governing body noted the draft and consultation period. The VH September 2017 CLOSED Health & 2017 governing body also noted the required CCG input and On Agenda Wellbeing responsibilities and agreed to receive the agreed strategy Strategy following consultation in July. 5.3 26 May JH requested CDs provide any details of access issues re SE/JH September 2017 CLOSED Contract report 2017 CAMHS as this linked to her responsibilities around Safeguarding Update within Children and Sue Elliott would pick these up. ShH had letters quality report. transferring care from CAMHS to NELFT that he could forward on. JH would bring a report to the next meeting on any issues and explore if LBR dis-investment had an impact on provision and consider the risks.

5.4 26 May BHRUT was a CQC mortality outlier for UTI in May and fuller JH September 2017 CLOSED Quality report 2017 understanding was awaited on the cause. The CCG had been Update within monitoring the upwards trend in SHMI data as this was the highest quality report reported level in London. The Quality & Safety Committee was setting up a clinician to clinician meeting to understand this further, whilst noting a serious robust approach to mortality at the Trust was evident. 3.1 20 July KA referred to A&E performance and questioned whether any CB/AS September 2017 CLOSED GBAF 2017 thoughts have been considered on new LAS targets and what The new impact these could have. VH reported that these are focused on standards are flexibility of response time to reaching patients rather than a direct not directly impact on A&E performance. CB agreed he did not believe there linked to Trust’s was a direct impact but would ask for this to be reviewed. A&E performance. In theory, if call handlers are being given

64 Action ref: Meeting Action required Lead Required by Status date

more time to assess calls then it could be expected that more alternative care pathways are utilised which should help Trust’s manage their A&E performance. An objective of the alternative care pathways is to reduce the number of ambulance conveyances to hospital so that LAS and the Trust can focus on emergency and life- threatening calls/ needs. 6.1 20 July CB suggested that an update on ICM should be presented to the CB September 2017 CLOSED Integrated 2017 next meeting. Verbal update. contract report

6.3 20 July ShH referred to the Barts Health duty of candour target which was JH September 2017 CLOSED Quality report 2017 consistently not being met and questioned whether the Trust had

65 Action ref: Meeting Action required Lead Required by Status date

a plan for improvement. JH reported that Whipps Cross do have Email update an action plan which has been reviewed and strengthened which sent to has resulted in recent improvements and is on an upward members trajectory.

ShH also asked whether both Trusts are meeting their NHSI requirement to report serious incidents on STEIS and a follow up email. JH reported that BHRUT have a system in place and are compliant and Barts Health have a system but staff are not always using it. JH agreed to provide a status update after the meeting.

JH would provide further detail following the meeting.

6.3 20 July CB referred to the 60% of identified open alerts that are from Barts JH September 2017 CLOSED Quality report 2017 Health and asked whether the CCG can be confident that the Within quality clinical harm process will identify everyone affected. JH agreed to report. follow this up and report back.

To: Meeting of the Joint Committee of Barking and Dagenham, Havering and Redbridge CCGs

From: Dr Waseem Mohi, Chair, Barking and Dagenham CCG Dr Atul Aggarwal, Chair, Havering CCG Dr Anil Mehta, Chair, Redbridge CCG

Date: 30 November 2017

Subject: Chairs’ report

Executive summary The report provides an overview of our key activities and those of the CCG since the last governing body meetings in September.

Recommendations The Joint Committee is asked to note the report.

1.0 Purpose of the report

1.1 To provide an update on activities since the last meeting and on key CCG news. 2.0 Working collaboratively

2.1 BHR CCGs have a positive history of working together. We began as a collaborative of three CCGs with a mix of shared and local arrangements. Over the past four years we have worked increasingly closer where it makes sense to do so and where there is a clear benefit for patients. Following a series of internal and external reviews, and our own experience, we have further integrated our governance, with this being the first meeting of our joint BHR committee. We still of course retain the ability to make separate decisions and hold separate governing body meetings where we need to, but where our business is common in terms of provider quality and performance for example, then it makes sense for us to consider and address these issues collectively.

2.2 We have had a series of helpful development sessions of our governing bodies over the past few months to agree our plans for further integrating governance and the ways in which we will work together. We have recently realigned portfolios for governing body members, with a pan BHR focus for all members. The governance report later on the agenda describes this in further detail.

3.0 North East London Commissioning Developments

3.1 The key development since the last governing body meetings has been the appointment of Jane Milligan as the Accountable Officer for the seven CCGs across north east London. Jane takes up her role on 1 December 2017. We welcome Jane as our Accountable Officer for the BHR CCGs and will be working with her as we transition to the new arrangements, which are described further in paper 4.1 on the agenda. 4.0 Financial situation

4.1 Colleagues will be aware of the continued financial challenges that we face in BHR. This has been the most difficult year yet, and has led us to discussions and decisions that we hadn’t anticipated when we first became commissioners over four years ago. The financial position as reported in the finance paper on this agenda demonstrates a deterioration, so while we have made progress in delivering QIPP, there is still more to do if we are to achieve financial balance. Our future plans for accountable care provide a medium term plan for addressing some of the underlying issues that exacerbate the position in our health and care system. 5.0 System developments, including networks and localities

5.1 Work is progressing to develop our accountable care system, with a plan to test new arrangements for three pilot areas from 2018/19: intermediate care, diabetes and children with special educational needs and disabilities

5.2 Work in developing the provider alliance is progressing well, as is the CCGs and local authorities joint commissioning arrangements. We are taking part in the final development session within the current programme for the networks, as commissioning leads within a ‘dragon’s den’ format.

6.0 Meetings

6.1 In addition to the many committee meetings that we attend, below is a summary of other meetings we have been to since the last governing body meetings.

6.2 GB away days: we had a session with members from the three BHR CCG governing body members earlier this month, at which Jane Milligan, the new AO came to introduce herself. We focussed on our priorities and how we could best align our members/directors to the new system arrangements.

6.3 Informal CDs’ meetings: we have had local meetings focussing on ACS, locality and network developments, financial recovery and transformation programme performance. We agreed that we will move to collective meetings so that we are all kept informed and are communicating with each other well, as a BHR CCG community.

6.4 NEL STP and new commissioning arrangements meetings: we have been attending a range of meetings to input to strategic developments at the NEL level, most notably with regard to the new commissioning arrangements under the new AO.

6.5 Health and wellbeing boards: at the last meetings we focussed on the Mayor of London’s health inequalities strategy and heard an update on the progress with the East London Health and Care Partnership (NEL STP)

 Barking and Dagenham, 8 November: diabetes prevention and care, the Better Care Fund, health and wellbeing outcomes framework performance report and the annual report of the director of public health

 Havering, 15 November: public health outcomes framework, draft autism strategy, suicide prevention strategy and pharmaceutical needs assessment. CCG Chair unable to attend on this occasion.

 Redbridge, 20 November: annual adult safeguarding board report, safeguarding children’s annual report and business plan, progress on the new child and adolescent mental health model, annual public health report and the pharmaceutical needs assessment. 6.0 Resources/investment 6.1 There are no additional resource implications/revenue or capital costs arising from this report.

7.0 Equalities 7.1 There are no direct equality implications arising from this report.

8.0 Risk 8.1 The CCG is managing a number of serious risks which are outlined in further detail in the assurance section of this agenda.

9.0 Managing conflicts of interest 9.1 There are no conflicts of interest arising from this report.

21 November 2017

To: Meeting of the Joint Committee of Barking and Dagenham, Havering and Redbridge CCGs

From: Conor Burke, Chief Officer

Date: 30 November 2017

Subject: Chief Officer’s Report

Executive summary This report provides an overview of key activities undertaken by the Chief Officer and the BHR CCGs since the last meeting.

Recommendations The Committee is asked to:  Note the progress report

1.0 BHR System Delivery Plan 1.1 We continue to make progress on our financial recovery plan, with £42.6m of the £55m target identified, as of 30 October 2017. Further information is provided in the paper later on the agenda.

2.0 BHR Accountable Care System and Sustainability and Transformation Plan (STP) 2.1 The Integrated Care Partnership Board (ICPB) has supported the proposal to use 2018/19 to pilot test the principles of an Accountable Care System.

2.2 The Joint Commissioning Board’s recommendation to frame the pilot test around the following areas was endorsed at the October meeting of the ICPB:

 Intermediate care  Diabetes management and prevention  Children with special educational needs and disabilities (SEND)

2.3 Members of the Joint Commissioning Board (JCB), including officers from the CCGs, are now finalising the detailed propositions in each of these areas for providers to consider and respond to during November and December. In principle, it is anticipated that a contract for these services will be offered to the local alliance of providers (as below) rather than individual organisations. A financial offer will be made in return for achievement of a given number of outcome measures. Providers will need to be able to demonstrate a new integrated operating model.

2.4 In parallel to the commissioning process, local providers (Barking, Havering and Redbridge University Hospital Trust, GP networks, local authorities, North East London Foundation Trust) have begun to establish an informal alliance to consider how they may respond. A further workshop is planned for 22 November.

70 2.5 It is anticipated that the System Delivery and Performance Board will become the formal forum for the Provider Alliance from December (reporting into the ICPB as does the JCB). PricewaterhouseCoopers (PwC) continue to provide support to GP providers. Following discussion at the ICPB, providers are reviewing their delivery support requirements.

2.6 The London health and care devolution memorandum of understanding was signed on 16 November by the Mayor of London and the Secretary of State for Health, as well as health and care leaders across the capital. This is a key step forward for greater health and care integration in Barking and Dagenham, Havering and Redbridge as it will support our planned pooling of budgets to enable joint planning and delivery of services, starting from April 2018 with selected services.

3.0 CCG Development 3.1 During September and November we have held a number of governing body development sessions focussed on the new system developments, particularly with regard to the north east London commissioning arrangements and our local BHR system commissioning and provider development. We’ve agreed to further integrate our governance and leadership arrangements, and have been looking at how colleagues from across the three governing bodies lead on priority work areas and programmes across BHR. We of course still retain the ability to focus on local issues and decisions as required.

4.0 CCG Assurance 4.1 At the NHS England (NHSE) finance assurance meetings on 26 September and 3 November discussions focused on the current financial position and activity, as well as the financial outturn to 2018/19, year to date performance on delivery of QIPP schemes and further opportunities identified from the system delivery plan.

5.0 Winter Planning 5.1 The A&E Delivery Board (AEDB) has now taken on a new structure, focused on four areas of the pathway:  Pre-front door  In-flow  Through-flow  Out-flow

5.2 The AEDB now operates with a single, system-wide action plan and dashboard and each of the aforementioned workstreams has a designated senior responsible officer (SRO) and clinical leads representing the CCGs, Barking, Havering and Redbridge University Hospitals Trust (BHRUT) and the BHR local authorities.

5.3 Key actions include the development of the current Urgent Care Centre (UCC) at Queen’s Hospital to improve the performance of the service. A new trajectory for meeting the 4 hour performance metric is being developed based on these actions. In addition, contingency actions have been prepared along with trigger points. These are based on our key challenges as a system, namely Demand Management, UCC Capacity and Workforce.

5.4 All of this work has been very well received by NHSE and NHS Improvement.

6.0 Health and Wellbeing Board update 6.1 At the Barking and Dagenham Health and Wellbeing Board meeting on 8 November, discussions focused on the Mayor of London’s Health Inequalities Strategy, diabetes prevention and care update and the 2016/17 annual report of the Director of Public Health.

6.2 At the Havering Health and Wellbeing Board meeting on 15 November, discussions focused on the Mayor of London’s Health Inequalities Strategy, suicide prevention strategy and the Havering autism strategy.

6.3 At the Redbridge Health and Wellbeing Board meeting on 20 November discussions focused on the Mayor of London’s Health Inequalities Strategy, Redbridge Children and Young People’s Mental Health Transformation Plan and received 2016/17 annual reports from Public Health, the Local Safeguarding Children’s Board and Safeguarding Adults Board.

7.0 Equalities 7.1 There are no equalities implications arising from this report.

8.0 Risk 8.1 There are no risks arising from this report.

9.0 Managing of conflicts of interest 9.1 There are no conflicts of interest issues relevant to this report.

10.0 Resources/investment 10.1 There are no additional resource implications/revenue or capitals costs arising from this report and no impact on sustainability.

3 November 2017

72 To: Meeting of the Joint Committee of Barking and Dagenham, Havering and Redbridge CCGs

From: Sahdia Warraich, Lay Member PPE, Barking and Dagenham CCG Richard Coleman, Lay Member PPE, Havering CCG Khalil Ali, Lay Member PPE, Redbridge CCG

Date: 30 November 2017

Subject: Patient Engagement Report

Executive summary This joint report summarises patient and public engagement, feedback and insight gathered since the last meetings and includes a summary of key lay member activities.

Areas covered:  The Joint Patient Engagement Forum (PEF)  NHS England (NHSE) assessment against patient engagement indicator – good rating  Local updates  CQC patient experience A&E report

Recommendations The committee is asked to:  Note and comment on the contents of the report

1.0 Purpose of the report 1.1 To provide a summary of the CCGs’ engagement with patients, the public and other stakeholders since the last meeting.

2.0 Joint Patient Engagement Forum (PEF) Update 2.1 Our first Joint PEF meeting was held on 17 October with the three CCG PEFs meeting jointly, reflecting the strategic direction of the wider system and enabling us to be joined by the CCGs’ Accountable Officer, Conor Burke, and senior CCG directors for presentation and Q&As.

2.2 Marie Price, Director of Corporate Services, gave a presentation covering the recent PEF members’ survey and the future shape of engagement, while Conor Burke talked through the new north east London (NEL) commissioning arrangements and the wider strategic changes.

2.3 Sarah See, Director of Primary Care Transformation, presented on primary care improvements, the emergence of networks and the opportunities these may provide for future patient engagement.

2.4 PEF members then discussed a range of issues covering further primary care transformation and improvement including premises, feedback and actions following engagement meetings and role of the new single accountable officer and capacity given their role across the seven NEL CCGs.

2.5 Those attending said that the updates were helpful and the meeting had worked well given some of the reservations initially.

2.6 The approach to have borough then joint PEF meetings alternately was seen as a reasonable compromise, with the benefit of being able to attract senior attendees/speakers who were of common interest to all three PEF members. We agreed to monitor and review effectiveness of the meetings and this new way of working.

3.0 Joint Chairs, Vice Chairs and Lay Members meeting 3.1 The December/January PEF Chairs, Vice-Chairs and Lay Members meeting will agree the format and agenda of the next joint BHR PEF meeting scheduled for January. A date has been identified to secure the attendance of the new Accountable Officer for NEL, Jane Milligan, at the meeting.

4.0 Engagement and consultations 4.1 The CCGs have continued to engage with the public during two consultations over the past few months. The first, by Redbridge CCG through a consultation into changing the way it pays for beds at Meadow Court and more widely by the BHR CCGs during phase two of the ‘Spending NHS Money Wisely’ programme proposing further changes to prescribing and criteria for a range of procedures. Clinical directors have presented the proposals to a wide range of stakeholder, community and interest groups across BHR, answering questions and concerns and encouraging members of the public to respond formally to the consultations. An update was also provided at the November CCG PEF meetings.

5.0 NHS England Assessment 5.1 We have just received our assessment for patient engagement against the new patient and community engagement indicator and are pleased to report that all three CCGs have been rated as ‘good’. There is recognition of the positive work that we have dome and some helpful recommendations for improving arrangements in future, including broadening engagement wider than PEFs.

6.0 Borough updates

6.1 Barking and Dagenham: The PPE lay member for Barking and Dagenham has been involved in early discussions around community urgent care services across BHR and provided feedback on a range of current services.

6.2 Havering: The PPE Lay Member for Havering CCG Chaired the Havering VCS meeting on 27 September. The main agenda items were an update on the local government consultation on Adult Social Care and Support Policy. Alan Steward, System OD and Transition SRO, provided a strategic CCG update. The next meeting in December includes a GP networks update from Dr Dan Weaver.

6.3 Redbridge: The PPE Lay Member attended one of the development meetings of the four Locality Primary Care Networks, and Quality Improvement (QI) sessions. The Lay Member has suggested that in addition to the good collaborative work by members of the Practices in each Locality, the time is right for moving to the next stage of further development. This includes adopting formal Patient Involvement, initially through the Chairs of member Practices' Patient Participation

74 Groups (PPGs) for each Locality. Work has already commenced on this aspect.

7.0 CQC patient experience A&E report 7.1 The CQC 2016 patient experience Emergency Department Survey has been published. The report identifies which hospital trusts have better, or worse, than expected patient experience. Click here for the report.

7.2 The report identifies eight Trusts as achieving ‘worse than expected’ results, including BHRUT, which is rated as ‘requires improvement’.

7.3 The results for England and trust level results are available on the CQC website. There is also a technical document that describes the methodology for analysing the trust level benchmark results, and a Quality and Methodology report that discusses methodological issues. https://www.cqc.org.uk/sites/default/files/20171017_ED16_outliers.pdf

8.0 General activities 8.1 BHR Lay Members have continued to inform and support the CCGs in key developmental work regarding primary care transformation, primary care commissioning, financial recovery, governance and audit, voluntary and community sector engagement, the patient engagement fora, and in consultations regarding changes to commissioning.

8.2 The BHR Lay Members participated in the stakeholder interviews of the candidates for the role of East London's CCGs' single Accountable Officer (AO) on 31 October. Further detail on the new arrangements for the new AO and NEL commissioning are covered later on the agenda.

9.0 Resources 9.1 There are no resource issues relevant to this report.

10.0 Equalities 10.1 Engagement in the borough should contribute to reducing inequalities in access to healthcare and support the CCG in meeting its equality objectives. This work is progressed through the CCGs’ patient engagement forum structure and in collaboration with patients, the voluntary sector and other key stakeholders.

11.0 Risks 11.1 There are no identified risks in relation to this report.

12.0 Managing conflicts of interest 12.1 There are no conflicts of interest relevant to this report.

Author: Andy Strickland, Head of Communications, BHR CCGs Date: November 2017

75 To: Meeting of the Joint Committee of Barking and Dagenham, Havering and Redbridge CCGs

From: Marie Price, Director of Corporate Services

Date: 30 November 2017

Subject: Governing body risk assurance framework report

Executive summary This is the first report of the Governing Body Assurance Framework for the joint meeting between Barking and Dagenham, Havering and Redbridge CCGs (BHR CCGs). The governing body assurance frameworks (GBAF) have been reviewed to reflect the current significant risks to the three organisations. There are five risks on the GBAF which includes one risk newly escalated. Risk ratings are based on the October 2017 risk register.

The five risks on the GBAF are :- 1. Risks to the delivery of the Clinical Commissioning Groups’ (CCGs) budget 2. Barking, Havering and Redbridge University Hospitals Trust (BHRUT) emergency care performance 3. Barts Health (BH) performance against key targets, A&E and RTT 4. BH quality concerns 5. BHRUT’s mortality rate is higher than expected and indicates the number of patients dying for certain clinical conditions is higher than the expected number of patient deaths.

The BHRUT mortality risk has been escalated to the GBAF in November with a severe risk rating of 20. Full details of the actions the commissioners are taking to mitigate can found in the quality report, section 5.1

Recommendations The Committee is asked to:  Note and comment on the current risks escalated to the GBAF and that assurance, levels, controls and mitigating actions being taken are appropriate  Raise and discuss other potential risks that may require escalation to the next GBAF or, where the risk has reduced, de-escalation.

1.0 Purpose of the Report 1.1 The purpose of the GBAF is to outline the key strategic risks to the CCGs in achieving its corporate objectives and the controls in place to provide assurance that the risks are being managed.

2.0 Background/Introduction 2.1 The CCGs’ governing bodies have a responsibility to maintain sound risk management processes and ensure that internal control systems are appropriate and effective, and where necessary to take appropriate remedial action. The CCGs’ collaborative risk register consists of

76 risks that are local to the individual functions across the CCGs and risks that the CCGs have in common.

3.0 Current risks on the GBAF 3.1 There are five significant risks on the collaborative risk register that have been escalated to the GBAF. Appendix 1 shows the full detail of these risks. These fall under three of our five corporate objectives as follows:

Corporate objective 1 - Secure financial recovery.

Risk 1.1: Significant risks to the delivery of the CCGs’ financial plan - legal directions on financial delivery of our QIPP requirements in year and management of any acute over activity relating to underlying performance: a) Legal Financial directions, b) If we do not deliver against the CCGs’ QIPP plans the CCGs will be in breach of financial control totals and c) risk of over performance in acute, continuing care or prescribing activity.

Mitigation:  Implementation of our action plan from the Well Led Review  BHR CCGs developed System Delivery Framework and Plan, as a mechanism to drive system recovery  Fortnightly Financial Recovery Programme Board (FRPB) chaired by the Chief Financial Officer  Financial Recovery Planning, Delivery and Monitoring group (FRPDM) established with the responsibility for oversight of the QIPP development process and monitoring delivery against plan, reporting to the FRPB  Financial risk mitigation via our integrated financial strategy across north east London sustainable transformation plan (STP) with continued development through the STP process  Aim to overachieve the QIPP requirement to provide stretch generating schemes and therefore savings over and above the £55m target  Implementation of quarter 1 reconciliations  Implementation of 28 day action plan  Escalation to AO/CEOs  Jointly agreed independent mediation with BHRUT.

Collaborative objective 3: - Ensuring that we deliver on the objectives within our CCGs’ and system wide transformation programmes

Risk 3.1: BHRUT's on-going failure to deliver A&E performance standards will impact on the delivery of services to patients.

Mitigation:  The A&E Delivery Board is in place leading the work to improve operational delivery  BHR urgent and emergency care (UEC) programme established with four delivery work streams to deliver improvement and mandatory requirements and address all risks  BHRUT is being held to account via contract meetings including Service Performance Reviews (SPR) and Contract Quality Review meetings (CQRMs)  Fortnightly assurance calls and monthly escalation meetings with the Trust, BHR CCGs, NHS England (NHSE) and NHS Improvement (NHSI)  A ‘winter checklist’ has been completed to confirm how well progressed the BHR system is against 69 specific items that NHSE and NHSI colleagues would like to see in place.  A set of ‘winter contingencies’ have been produced which include radical actions in order to ensure good performance levels in A&E throughout winter.

Collaborative objective 5 - High quality, compassionate and safe care.

Risk 5.4a and c. Barts Health (BH) performance – this risk groups together two performance areas that BH are failing to achieve, RTT and urgent and emergency care. There are also data quality concerns that present a further challenge for commissioners. The risks could threaten the long-term viability of the Trust and could put patients at risk and cause reputational damage.

All mitigations actions for assurance against risks 5.4a, 5.4c and 5.6 are via the co-ordinating commissioner, Newham CCG.

Risk 5.4a – BH has a significant RTT backlog and the PTL is currently being validated. The attribution of increased numbers of 52 weeks wait patients is not available and BHR CCGs are not sighted on our patients. There is therefore a risk that those patients would be subject to clinical harm and the CCGs are unable to assure themselves.

Mitigation:  RTT recovery is reflected in the improvement plan work being undertaken by BH after being placed in special measures in March 2015 with oversight by the co-ordinating commissioner (Newham CCG) via the RTT and monthly performance meetings with the Trust  The Trust to return to reporting by the end of December 2017 with the continuation of real time validation of the patient target list (PTL).  Performance is reviewed at the contract review group monthly (CRG) via the co-ordinating commissioner  Assurance sought along with clarification from our co-ordinating commissioner in regard to the exact number of patients waiting over 52 weeks who are residents of BHR CCGs - an unvalidated assessment has been shared.  To have completed demand and capacity modelling by March 2018 that achieves compliance with the RTT standard by September 2019  Monthly BH (BHR CCGs) escalation and review meeting with updates on performance to take place assessed by BHR CCGs Joint meeting established by NHSE/NHSI with BH and the co-ordinating commissioner in regard to the provision of external assurance for the process of returning to RTT reporting  Attendance by BHR CCGs’ quality lead at the patient safety/harm reduction group

Risk 5.4c: Barts Health A&E - failure to deliver quality improvements in urgent and emergency care at BH (specifically at Whipps Cross hospital).

Mitigation:  UEC plan agreed but subject to assurance through NHSE.  Performance meetings including the Trust, commissioners and NHS Improvement (NHSI) with regular updates at CRG meeting.

Risk 5.6: There is a risk that patients may receive poor quality of care and or suffer harm as a result of BH's failure to achieve quality indicators (never events, levels of healthcare acquired Infections (HCAIs) and management processes for serious incidents (Sis) and complaints).

Mitigation:  Specific concerns have been formally escalated to the co-ordinating commissioner through the Quality Leads meeting  BHR CCGs' quality team attends Whipps Cross CQRM, which considers remedial action plans.

Risk 5.7: BHRUT’s mortality rate is higher than expected evidenced by summary hospital level mortality indicator (SHMI) and hospital standardised mortality ratio (HSMR) data. This indicates

the number of patients dying in BHRUT for certain clinical conditions is higher than the expected number of patient deaths.

Mitigation:  In August 2017 CCGs issued a Contract Performance Notice in respect of non- assurance of BHRUT's mortality action plan  The plan has subsequently been revised and meetings held with the Trust to understand their action plan in full  The CCGs, Trust and regulators are part-way through application of the Risk Profiling Tool and expect to complete this in November 2017.

3.0 Resources / investment 3.1 There are no additional resource implications/revenue or capital costs arising from this report. The cost of operating effective risk management arrangements is met from within existing resources.

4.0 Equalities 4.1 There are no equalities considerations arising from this report.

5.0 Risk 5.1 This report also links to the following GB papers being presented at this meeting and provide greater detail on key risks mentioned above and the organisations mitigations.

 GBAF risk ref. 1.1 relates to the Integrated Performance report, Finance report and the FRPB Chair’s report

 GBAF risks ref. 3.1 relates to the Integrated Performance report

 GBAF risk ref. 5.6 relates to the Quality report

6.0 Managing conflicts of interest 6.1 There are no conflicts of interest considerations arising from this report.

Attachments: Appendix 1 - Governing body assurance framework and summary

Author: Pam Dobson, deputy director, corporate services, BHR CCGs Date: 10 November 2017.

79 Appendix 1 – NHS Barking and Dagenham, Havering and Redbridge CCGs

Collaborative objective 1: secure financial recovery.

Risk Description: Lead director: Significant risks to the delivery of the CCGs' financial plan - legal directions on financial delivery of our QIPP requirements in year and management of any Tom Travers acute over activity relating to underlying performance: a) Legal Financial directions, b) If we do not deliver against the CCGs' QIPP plans the CCGs will be Risk ref: 1.1 in breach of its financial control total and c) risk of over performance in acute, continuing care or prescribing activity. Initial Assurances Current Gaps Target Risk Proposed Controls I = internal risk Evidence for Rating Rating actions E = external rating assurance Control Assurance 30/03/18 8/2015

1 Weekly Financial Recovery Planning, 1 Minutes of FRPDM The integrated 1. Further 1. Working with 16 Delivery and Monitoring group (FRPDM) meetings and risk log and performance schemes to providers and oversight of the QIPP development mitigations for all report finance be identified STP partners to

schemes (I) High process and monitoring delivery against report and the to cover the identify additional

FRPB Chair’s ) = plan. savings gap. schemes 2 Minutes of the FRPB report provides continues 2 Fortnightly Financial Recovery Senior Executive greater detail 2. Fully Programme Board (FRPB) Senior meetings (I) on the functioning 2. PMO project Executive meetings (revised TOR). management programme controls and 3 Minutes of the bi monthly of this risk. management monitoring 3 Formal escalation route to Finance and Finance and Delivery office (PMO) processes have Delivery Committee (F&D) committee (I) been 3. Further strengthened. Minutes of bi monthly 4 Clinical engagement and leadership activity Alignment of Governing Body meeting strengthening via the Joint Executive Likelihood (4) x Impact (4 (I) growth required resource Likelihood (4) x Impact (5) = Severe 20 Committee (JEC) monthly, FRPB and Likelihood (4) x Impact (5) = Severe 20 beyond completed by end F&D committee. 4 Minutes of the JEC (I) current September 2017. projections 5 Independent review of finances jointly 5 Report of the independent 3. Activity commissioned with NHSE review (E) management plan

to be agreed with 6 Monthly NHSE London Assurance 6 Minutes of the NHSE BHRUT by end of meeting London assurance November, meeting (E) Agreement 7 Formal contractual escalation and around a risk agreements for local mediated solutions 7 Outcome letters following reserve

mediations (E) supporting the 8 STP risk share agreement ratified and in activity place for 17/18 presented to F&D 8 As point 3. committee. management plan

Page 1 of 9 80 Corporate objective 3: Ensuring that we deliver on the objectives within our CCGs and system wide transformation programmes. 

Risk Description: BHRUT's on-going failure to deliver A&E performance standards will impact on the delivery of services to Lead director: Gina Shakespeare patients. Risk ref: 3.1 Initial Assurances Current Gaps Target Risk Controls I = internal risk Evidence for Proposed actions Rating Rating E = external rating assurance Control Assurance 30/03/18 6/2013

1. Accident and Emergency 1. Minutes of the fortnightly The integrated BHR UEC programme Delivery Board (formerly Accident and performance established with four delivery the SRG). Emergency Delivery report provides work streams to deliver Board. (E) greater detail improvement and mandatory 2. Urgent and Emergency on the requirements and address all Care (UEC) Programme 2. Minutes of the monthly management risks. Steering group. UEC Programme of this risk. Steering Group. (E) Continued liaison with NHSE

– 3. Contractual meetings 3. Minutes of monthly and the NHSI to provide SPR / CQRM – and contractual meetings – assurance on delivery, contractual levers. SPR / CQRM. (I) particularly through winter surge arrangements. 4. Winter only - daily surge 4. Notes of daily surge call. (E).

calls with the Trust and Likelihood (4) x Impact (3) = High 12

Likelihood (4) x Impact (4) = Severe 16 reassurance with NHSE. Likelihood (4) x Impact (4) = Severe 16

5. Notes of the calls (E). 5. BHRUT and BHR CCGs

fortnightly assurance calls with NHSE and NHSI. 6. Notes of the meetings 6. BHRUT and BHR CCGs (E). monthly escalation meetings with NHSE and NHSI. 7. This is written and shared with partners 7. Detailed A&E delivery including NHSE and Board governed system NHSI. Specific triggers plan with specific trigger points will be monitored points to prompt additional daily by nominated interactions based on leads from each performance and demand organisation.

Page 2 of 9 81 Collaborative objective 5: High quality and compassionate and safe care

Risk Description: (Two performance areas are grouped together here that BH are failing to achieve) Lead director: Louise Mitchell Barts Health (BH) performance. BH continues to fail operational standards, a) referral to treatment times (RTT) and c) A&E, (specifically Whipps Cross). There are also data quality concerns that present a further challenge for commissioners. This could: Threaten the long-term validity of the Risk ref: 5.4 a and c – (groups the Trust and put patients at risk and cause reputational damage. two performance risks together) Initial Assurances Current Gaps Target Risk Evidence for Controls I = internal risk Proposed actions Rating Rating assurance E = external rating Control Assurance 30/03/18 7/2014

2 1. Monthly Collaborative 1. Minutes of the The 1. Absence of 1. Absence of Co-ordinating Commissioning Committee (CCC) CCC meeting. (E) integrated an agreed agreement in commissioner continues in

meetings led by the co-ordinating performance number of 52 respect of RTT negotiation with BH on

Severe 16 commissioner, Newham CCG (Chief report weeks waiters these two matters. The ) = High 1 =

Officer) (CCGs only) provides for BH, latest commissioner 2. Minutes of the A&E greater detail breaching due proposal was sent to the 2. Monthly A&E Delivery Board Delivery Board. (E) on the to patient trust on 30 October 2017 meeting, led by BH Chief Executive, management choice attended by Newham CCG on behalf of this risk. factors. of commissioners. 2. Absence of 3. Minutes of the TSG 3. Bi-monthly Technical Sub Group agreement on and CRG. (E) (TSG) and monthly Contract Review a date for

Likelihood (3) x Impact (4 Group (CRG) meetings, led by return to Likelihood (4) x Impact (5) = 20 Severe

Likelihood (4) x Impact (4) Newham CCG, attended by BH. achieve

4. Minutes of the RTT compliance

4. Monthly RTT assurance meeting, led assurance with the 92%

by Newham CCG, attended by BH, meeting. (E) standard for

monitoring RTT performance and RTT.

recovery - site specific remedial

action plans (RAP) in place and

monitored. 5. Monthly BH

Internal Escalation 5. Monthly BH Internal (BHR CCGs) Review meeting Escalation Review meeting receiving report. (I) updates on performance (RTT, A&E, and diagnostics) and quality.

Page 3 of 9 82 Lead director: Gina Risk Description: There is a risk that patients may receive poor quality of care and or suffer harm as a result of BH's failure to Shakespeare NB: The Nurse Director retains overall achieve quality indicators (never events, levels of HCAIs and management processes for SIs and complaints). responsibility for Quality and Safety Risk ref: 5.6 Initial Risk Assurances Current Gaps Target Rating Controls I = internal risk Evidence for Proposed actions Rating 2/2015 E = external rating assurance Control Assurance 29/12/17

1. Contract performance notice 1. Remedial action 16 The Quality 1. Remedial action 1. Remedial action 12 issued. plans and recovery report provides plans for SI and plans received trajectory. (E) greater detail Duty of Candour and reviewed by

2. BH Contract Review Group, on the the lead

2. Minutes of monthly = Severe attend by the lead CRG (E) management of commissioner commissioner on behalf of this risk. and the CCGs BHR CCGs and are non- compliant and 3. Letters of escalation x Impact (4) = High 3. Monthly BH Internal (BHR the CCGs has to lead (4) x Impact (4) = High 16 (3)

CCGs) Escalation Review ) x Impact (4) escalated to the

meeting receiving updates on commissioners lead performance (RTT, A&E, and (March 2017) (E) commissioner diagnostics) and quality.

Likelihood Likelihood

4. Barts Health (Whipps Cross) Likelihood (4 4. Minutes of the

monthly Clinical Quality CQROA meeting Review and Oversight (E) Assurance (CQROA) meeting

with NHSI and NHSE.

5. Performance enforcement 5. WX to self-assess notices issued by the Care to determine if any Quality Commission (CQC) notices can be following an inspection in July closed

2016.

6. Quality reports to every Quality 6. Minutes of the Q&S and Safety (Q&S) Committee Committee detailing issues, actions taken and impact. 7. Minutes of the SI 7. Monthly SI panels including al panel meetings. (E) NEL CCGs

Page 4 of 9 83 Lead director: Gina Shakespeare Risk Description: BHRUT’s mortality rate is higher than expected (evidenced by SHMI and HSMR data) and this indicated the number of NB: The Nurse Director retains patients dying in BHRUT for certain clinical conditions is higher than the expected number of deaths overall responsibility for Quality and Safety Risk ref: 5.7 Initial Risk Assurances Current Gaps Target Rating Controls I = internal risk Evidence for Proposed actions Rating 7/2017 E = external rating assurance Control Assurance 09/2018

20 1. Bi monthly Quality and Safety 1. Minutes of the 1. Not assured of 1. Paper to be Committee Quality and Safety the robustness of presented to Committee (I) plans the Q&S

) = High 2. Monthly Clinical Quality committee 19 3) = High 6 5 Review Meeting (CQRM) 2. Minutes of the 2. 6 months lag in December CQRMs (I) published data. 2017 3. Escalation to the monthly Proxy data contract review group (CRG) 3. Minutes of the CRG developed with x Impact ( meeting (I) BHRUT 4. Joint Committee Meeting of BHR CCGs bi monthly (GB) 4. Minutes of the GB meeting (I) 5. BHRUT’s Mortality faculty

developed from September 5. Reviews presented Likelihood (2) Likelihood (4) x Impact ( 2017 and undertaking a to CQRM number of thematic mortality Likelihood (4) x Impact (5) = Severe 20

reviews 6. Mortality contract 6. Outputs of the Mortality faculty performance notice reviews informed the Trusts (CPN) bi monthly mortality improvement meetings (I) and programme and plan. point 3

7. BHRUT’s Mortality reviews 7. Learning from death presented to the Mortality policy published Assurance Group (MAG) September 2017 (E)

8. Full compliance with the National Guidance on learning from deaths issued in March 2017 by the National Quality Board.

Page 5 of 9 84

Barking and Dagenham, Havering and Redbridge CCGs Governing Body Assurance Framework - overall summary (2015 – 2017)

Current End of year Previous risk ratings Target Lead / Risk description rating forecast risk GBAF ref. (summarised) Aug Oct Dec Feb April June July Sept Nov Jan April June August Oct This Last level 2015 2015 2015 2016 2016 2016 2016 2016 2016 2017 2017 2017 2017 2017 time time T Travers Risk of failure to deliver the 1.1 20 20 20 16 16 16 20 20 20 20 20 20 20 20 16 8 16 CCGs’ budget plans. (was 6.1) Failure to deliver quality G improvement in urgent and Shakespeare 16 16 16 16 16 16 16 16 16 16 16 16 16 16 12 12 12 emergency care at 3.1 BHRUT. Failure of Barts Health G (BH) to meet a number of Shakespeare 12 operational standards, 16 20 20 20 20 20 20 20 20 20 20 20 20 16 10 15 5.4, RTT & A&E, data quality a & c and others. There is a risk that patients G may receive poor quality of Shakespeare care and or suffer harm as 20 20 20 20 20 20 20 20 20 20 20 20 16 16 12 8 12 5.6 a result of BH's failure to achieve quality indicators. BHRUT’s mortality rate is higher than expected. The G number of patients dying in Shakespeare BHRUT for certain clinical 20 20 10 6 5.7 conditions is higher than the expected number of deaths

Risk Summary Number

Total risks last report 4 New risk(s) escalated 1 Risks de-escalated this report 0 Total GBAF risk this report 5

Page 6 of 9 85

NHS BHR CCGs Governing Body Assurance Framework - overall summary (2013 – 2015)

Initial Previous risk ratings Lead / rating Risk Description May GBAF ref. (June Sept Jan Mar June Sept Nov Dec Feb 2013) 2013 2014 2014 2014 2014 2014 2014 2015 2015

G Shakespeare Failure to deliver quality improvement in urgent and 16 16 20 20 20 20 25 25 25 16 3.1 emergency care at BHRUT

G Shakespeare Failure of Barts Health (BH) to meet a number of 5.4, a, b operational standards, RTT and A/E, data quality and 20 20 16 20 20 & c others.

G Shakespeare Quality standards not being met at BH - for C.Diff, and 16 20 5.6 MRSA and FFT

Page 7 of 9 86

Page 8 of 9 87 How to interpret the CCGs governing body assurance framework (GBAF):

Lead director Risk ratings: This is the executive lead The risk rating is derived from conversation between the lead director (or with responsibility for: nominated deputy) and the risk lead. The risk score is calculated using the risk - managing the risks to the grading matrix. There are three types of risk rating used in the CCG GBAF. - initial risk rating: t corporate objectives and his grades the risk as if there were no remedial measures This is called the ‘inherent risk’ - liaising with the risk lead to in place. . - current risk rating: ensure the GBAF is up to this grades the risk taking into account the remedial date measures. The remedial measures should aim to 1, reduce the likelihood of the Reporting to the CCG risk materialising, 2, reduce the impact of the risk if it does happen and 3, governing body or other reduce both. - target risk rating: committee on progress this is the level of risk that the CCG is prepared to accept and the level of risk that must be aimed for.

Initial Gaps Target Current Risk Lead Risk Control Assurance Proposed Risk – Risk Description Controls Assurances risk Ref Director Rating actions 1/4/1 rating (June 13) 4 Commissioning 15  Our current control is we have  A regular weekly report 15  A detailed  A regular  Develop 3 Risk ref organisations issued instructions to the CSU is being developed with process for report will new Proposed actions This is a risk are not able to not to pay un-validated the CSU to report on the non contract be validati Where gaps have identifier run patient level invoices. Where we have a progress. invoicing produced on attributed to the been identified, list validations for contract we will pay in line requires for the process the actions required risk by the CCG the first quarter with the contract and monitor  The audit committee urgent audit and to put them into risk lead 3.3 MS to validate non activity. will be updated on development. governance place. contract activity performance to only pay committee Ensure they have a which will  Where there is no contract we validated invoices. named lead and present a will develop an alternative target date financial risk validation process. Until the process is developed we will not pay the invoices.

Risk description Assurance Gaps in controls Controls For each risk note down: Assurances are inevitably ‘bits of What more can be done to Who can be harmed and how What is being paper’ that act as evidence the control the risk and what can they be harmed if the risk done to reduce controls are in place. Examples controls could be improved materialises. the likelihood and include: Gaps in assurance Areas to consider are: harm/ severity of the Job descriptions /organisation charts What associated injury, objectives, claims or risk. Regular reports documentation will litigation, service disruption, One specific risk Contracts / service level agreements demonstrate that the controls staffing and competence, may be mitigated Policies and procedures are in place? morale, financial, external by a number of Minutes / agendas / terms of assessment and adverse controls reference media interest

Page 9 of 9 88

To: Meeting of the Joint Committee of Barking and Dagenham, Havering and Redbridge CCGs

From: Alan Steward, System OD and Transition SRO BHR CCGs

Date: 30 November 2017

Subject: NEL Commissioning Arrangements

Executive summary The report asks the Joint Committee to support proposals for new commissioning and governance arrangements across North East London, following the appointment of a single accountable officer.

This report updates all NEL CCG governing bodies (GBs) on the establishment of the new commissioning arrangements. It builds on the September GB report that set out the strategic direction of commissioning and its link to the development of local accountable care systems.

This report reflects feedback from the Governing Bodies of all 7 NEL CCGs given at the September governing bodies and addresses requirements for transparent governance arrangements and the importance of sovereignty, to lay a strong foundation for the development and implementation of the local accountable care systems. This paper specifically addresses:

 Local decision-making and accountability.  Resources and leadership.  Governance and structures that ensure that each CCG will be fully involved in decisions that affect their boroughs.  Proposals for a commissioning strategy that provides assurance that co-commissioning with local authorities for local services continues, but identifies and sets out services that would benefit from strategic alignment across NEL.  The initial Executive arrangements.  The potential risks arising from these proposal and the mitigating actions.  Next steps to ensure that arrangements are implemented formally for 1 April 2018 with robust transition arrangements. Detailed proposals will be brought to the December GBs for decision on the governance and the executive arrangements.

Recommendations The committee is asked to:  Note the progress made and provide any comments  Approve the recruitment of an interim Director of Strategic Commissioning

1. Purpose of the Report 1.1 This report updates all North east London (NEL) CCG Governing Bodies on the establishment of the new commissioning arrangements. It builds on the September Governing Body report that set out the strategic direction of commissioning and its link to the development of Accountable Care Systems. In September, Governing Bodies agreed to appoint a Single Accountable Officer for all North east London CCGs to provide the required leadership and focus to develop and move to the new arrangements and to use a joint committee of all CCGs to deliver decision- making at North east London level.

1.2 These new arrangements are vital to deliver North east London’s:  Strategic alignment with the NHS Five Year Forward View and in particular the commitment to develop Accountable Care Systems (ACS)  Sustainability for the whole system including providers, commissioners and partners  Improvements in outcomes, quality and performance and reducing variation across North east London.

1.3 The arrangements are built on detailed discussions with all CCGs including Chairs meeting, Board Development sessions and workstream meetings on commissioning strategy, governance and people management.

2. Background/Introduction 2.1 In discussing the proposals to establish a Single Accountable Officer (SAO) and joint decision- making arrangements, Governing Bodies sought reassurance on a number of themes including accountability, local decision-making, resources and leadership and governance.

2.2 It is important to restate that the CCGs remain responsible legally to deliver their responsibilities and these arrangements do not change that. The redesign is driven by how best to organise the commissioning arrangements to reduce fragmentation and duplication by adopting common approaches where it make sense to do so. These are set out in the design principles being adopted across North east London and advocated by all CCG Chairs. These are:  Working at scale only where it benefits residents  Delivering efficient and effective decision making  Maintains and enhances strong clinical leadership  Supports ACS development  Respects local accountability and subsidiarity  Builds engagement and strong local relationships  Fosters system collaboration and co-design  Focuses on quality improvement to reduce costs

2.3 The views and concerns expressed by Governing Bodies have been considered by the Chairs and delivery group and the responses below are being embedded into the detailed redesign of the North east London commissioning system.

2.4 Accountability  All CCG Governing Bodies remain accountable for their statutory functions  All CCG Governing Bodies will need to approve the Scheme of Delegation for both the Single Accountable Officer and Joint Committee  The SAO is the Accountable Officer for each North east London CCG  The SAO will be a member of each CCG Governing Body and will be accountable for local performance and delivery to the CCG

2.5 Local Decision-making  All CCG Governing Bodies remain accountable for their statutory functions and the use of public funds

 There will be a strong local team whose focus will continue to be on developing local relationships with key stakeholders and making progress towards delivering the ACS  The SAO, who has a responsibility for supporting the development of the ACS, will provide leadership to the local team, along with the CCG Chair and CCG Governing Body  Patient and public engagement, service delivery, service redesign must continue to take place at a local level  The CCG will need to approve any constitutional changes (Governance Workstream are leading on this)  Relationships and joint working with partners will continue as business as usual throughout and after the transition to the new commissioning arrangements  Integrated Commissioning arrangements must be maintained and led locally

2.6 Resources and Leadership  Each CCG remains responsible for its use of public funds and resources and formal allocations will remain at this level.  The North east London CCG Chairs have agreed the following principles which will shape this work: o Cost allocation should be based on existing budgets (running costs) rather than on weighted population o Management arrangements will be cost neutral at both system and CCG level o The new commissioning arrangements must support fully local system development.  There will be new Executive arrangements to support the SAO aligned to the overall delegation of responsibilities at North east London, as well as requirements with NHSE.  The local system will review its own structure in conjunction with the SAO to deliver the strong local leadership.  The North east London CCG Chairs have agreed to split of the costs of redesigning and implementing the new commissioning arrangements between the CCGs until 31 March 2018 based on weighted population.  The Chief Finance Officers are looking at how the costs are distributed fairly between all partners from April 18/19. This will come to CCG governing bodies for approval.  The risk sharing agreement is designed to ensure that there is shared equal risk across all CCGs and no one CCG is expected to bear a greater share of the risk.  Resources in North east London will predominantly sit at the local commissioning system level, where the majority of integrated commissioning and service redesign will take place.

2.7 Governance  Each CCG will remain accountable for delivering its functions and use of public funds  The proposed governance structure ensures that each CCG will be involved fully in the decision-making process affecting commissioning of services in their respective boroughs  Joint Commissioning Committee approved to cover North east London Commissioning functions as outlined in Phase 1 Board paper: o Specialist commissioning o Discussion and alignment of strategic commissioning across all functions (e.g. urgent care, planned care, mental health, primary care) o the commissioning of services common to all such London Ambulance Service (LAS) and services outside the scope of the ACSs o discussion and agreement of acute services strategy including the approaches to payment o workforce development o development of the framework for commissioning of local ACSs o Assurance to regulators on system performance and the delivery of the Five Year Forward View

2.8 The Governing Body is asked to note and endorse the design principles and approach to developing North East London commissioning arrangements

3. Phase 2 North East London Commissioning Arrangements 3.1 As set out in the September Governing Body report, the CCG Chairs are leading the development and implementation of the changes. Three workstreams – each lead by 2 CCG chairs – have been agreed. The table below sets out the leadership, support and deliverables attached to each. The Chairs and Single Accountable Officer are meeting monthly to ensure delivery.

Commissioning Strategy 3.2 North east London has a history of co-commissioning with local authorities where a detailed understanding of local people and services is required. Significant progress has been made on integrated commissioning over the last four years. These services should continue to be commissioned independently by individual CCGs with local system alignment.

3.3 It is recognised however that in commissioning services there are some areas that would benefit from strategic alignment across North east London including urgent care, mental health and planned care. In these areas there is significant variation in demand and capacity, quality and models of care. A North east London strategy will be beneficial in providing a framework for local commissioning. For a limited number of cases, CCGs have already identified the benefit of joint commissioning at a North east London level. These are for Specialist Commissioning, Integrated Urgent Care (nee NHS111) and London Ambulance Service. It is recognised that the strategic alignment of commissioning strategies may identify further areas. These will require CCG Governing Body approval. The proposed functions and services at each level are set out below. These are aligned to the proposals set out in the September Governing Body.

Local Commissioning North east London Commissioning  All Integrated Commissioning with local  Direct commissioning of Specialist authorities for example adults, children, commissioning, LAS and IUC prevention  NHSE assurance (except by exception e.g.  Provider development Primary care A&E) development, contracting, prescribing,  Discussion and alignment of North east London pharmacy Commissioning strategies (e.g. UEC, mental

Local Commissioning North east London Commissioning  Contracting and commissioning with major health, planned care) providers (hospitals, community / mental health  Provider commissioning strategy providers)  Discussion and alignment of out of hospital  Community Services contracting development and in particular primary care at  Mental health contracting scale  Acute Commissioning and contracting (local)  Access to STF, risk management and delivery of North east London control totals  ACS commissioning framework and outcomes  Workforce and other enablers

For all the services in column 1, it is proposed that the individual CCGs will undertake the following commissioning functions:  Business cases and service change requests  Needs assessment and demand and capacity planning  Procurement  Contracting and contract management  Joint work with LA  Setting outcomes for providers  Outcome monitoring  Decommissioning services  Consultation and engagement – local people, members, local organisations (providers, councils, VCS) – North east London via local arrangements

3.3 For any services commissioned directly at North east London (such as LAS or IUC) the joint committee will undertake these functions.

3.4 For the alignment of strategy (for example acute or primary care) the proposed North east London Joint Committee will undertake the following responsibilities:  Needs assessment  Demand and capacity planning  Setting outcomes for providers  Outcome monitoring

3.5 For commissioning and contracting with North east London major providers (acute / community), it is proposed to organise these at a system level and around our major providers. Commissioning requirements would be developed and agreed locally but aligned around our major providers. For the avoidance of doubt these would be Barts Health, Barking, Havering and Redbridge University Trust, Homerton University Trust, East London Foundation Trust and North East London Foundation Trust. These five providers provide the majority of hospital and community services to local people. Contracting monitoring and associated governance would be delivered at this level as well. The NELCSU will support these arrangements where relevant. Primary care commissioning will be delivered locally including any commissioning with GP Federations and Networks.

3.6 The Governing Body is asked to note the progress on the commissioning strategy proposals and provide any comments.

4. Governance 4.1 The Governance workstream is developing the detailed proposals to ensure there is robust North east London governance and the commissioning strategy arrangements described in the previous section are implemented. This is being driven through a wider group of CCG lay members and partners with detailed proposals to be presented to each CCG Governing Body in December.

4.2 This will set out how the Joint Commissioning Committee will work and integrate with CCG Governing Bodies. It includes setting out the Terms of Reference including scope, membership, scheme of delegation and constitutional changes needed by CCG. It will also include the services / functions that the North east London CCG Governing Bodies wish to delegate to the newly established JCC. This will incorporate the latest guidance on conflicts of interest and around primary care commissioning issued by NHSE and other regulators. A number of options are being considered with local government colleagues to secure their input into the Joint Commissioning Committee and an update can be provided at the meeting.

4.3 It is essential that the Joint Commissioning Committee is implemented formally from 1 April 2018. It is also proposed that North east London puts these measures into practice in shadow form from 1 January 2018. This will provide an opportunity for all CCGs and the Single Accountable Officer to ‘test’ the new arrangements and identify any changes and improvements required for April 2018. These will be reported to Governing Bodies in March 2018.

4.4 The Governing Body is asked to note the progress made under the governance workstream and provide any comments.

5. People Management 5.1 Following the agreement in phase 1 to appoint a Single Accountable Officer (SAO) a rigorous recruitment process was undertaken. This involved a stakeholder day on 31 October that was well-attended including representatives from governing bodies, local authorities, NHS trusts, Health and Wellbeing Boards and the Local Medical Council. The appointment panel was composed of all CCG chairs, NHS England, NHS Improvement, the East London Health Care Partnership (ELHCP) Independent Chair and a CCG Lay member.

5.2 The SAO was appointed unanimously and confirmed by the NHS Chief Executive on 3 November. This was communicated on Monday 6 November to all partners, stakeholders, MPs and providers and staff. A subsequent video was also released to introduce the new SAO and her ambitions for North east London.

5.3 The SAO is now looking to attend a range of North east London meetings wherever possible including CCG Governing Bodies and development sessions, also meeting local authority leaders and officers.

5.4 The governance workstream is working through the detailed implications of a SAO including the scheme of delegation, quoracy and any required constitutional changes. The detail will be submitted to Governing Bodies in December for decision.

6. Executive Support 6.1 Given the allocation of responsibilities at North east London and the need to support the SAO to fulfil her duties, it is anticipated that the following responsibilities and accountabilities will need Executive support at North east London level.  Finance – given the challenges in North east London around delivering NHS required control totals, provider sustainability and the resource challenges of need and demand outstripping resources. This post is also important in providing the financial assurance for the SAO to deliver her statutory duties.  Contracting and Commissioning – to align and manage commissioning strategies particularly with the major providers, as well specialised commissioning (anticipated delegation from NHSE for 19/20)  Assurance – for both quality and performance and delivery of constitutional and other standards  Out of Hospital – with all local commissioning systems looking to develop out of hospital services to reduce the reliance on hospitals for basic care. This will have a focus on primary care provider development at scale using networks, Federations and other models.

 These will complement the ELHCP posts that have been established around Chief Information Officer and Provider Development.

6.2 It is recognised that these could be delivered either through new posts, matrix arrangements or a combination of both. This will help ensure the sustainability of running costs.

6.3 It is proposed to fill two roles on an interim basis. 6.3.1 Firstly, to honour the commitment for strong local leadership, it is proposed that a Managing Director post is established for each CCG to provide senior leadership and support to each CCG (one for BHR). To ensure continuity and smooth transition arrangements and deliver the business as usual, Chairs’ authority has been provided to allow for filling of these roles on an interim basis as a priority from 1 December to align with the new SAO formally taking on her responsibilities. Appendix 1 provides further detail with job description in Appendix 2. Given the additional current vacancy in BHR for the Director of Delivery and Performance, it is proposed to move to immediate recruitment of the substantive post.

6.3.2 Secondly, the role of strategic commissioning requires focus and a dedicated role. This recognises the current priority to implement and align commissioner approaches and deliver the key commissioning intentions and contracting for NEL major providers. This will allow early alignment of 18/19 contracts and arrangements to deliver the NEL aspirations for improving health outcomes, reducing variation and provider sustainability.

6.4 A proposed Executive Structure will be brought to the CCG’s December Governing Body/Joint Committee. This will include the detailed financial implications of the new arrangements and demonstrate that the proposals will be cost neutral and equivalent across North east London and for individual CCGs. All posts will be formalised through the agreed North east London CCGs’ organisational change and related policies.

6.6 A detailed OD programme will be developed to support transition and the new working arrangements including a whole system away day to encourage collaboration and understanding.

6.7 The Governing Body is asked to a. Note the progress made under the people management workstream and provide any comments. b. Approve the recruitment of an interim Director of Strategic Commissioning.

7. Risks and Mitigation 7.1 It is recognised that with any change in commissioning arrangements can destabilise existing arrangements and that there are significant risks that need mitigation. The risks attached to the transition are being managed through the Chair and AO monthly meeting. Each Governing Body must however own the risk and associated mitigating action through its risk management arrangements. The risk assessment and mitigation are set out below. These should be incorporated into each CCG risk register and where necessary Governing Body Assurance Framework.

7.2 The risk review uses the standard NHS methodology that considers the likelihood of the risk alongside its severity. Both measures are scored out of 5 (with 5 being the most likely and worst impact). The risk score takes account of the mitigating action proposed. This then gives a risk score and categorisation of:

Risk rating Risk Score Low 1 – 6

Medium 7 – 15

High 15 - 25

7.3 The risk and mitigation associated with introducing the new North east London commissioning arrangements are:

Risk Mitigation Likelihood Impact Score Transition  Effective transition arrangements with clear 2 4 8 impacts on responsibilities and accountabilities Business as  LA / member and wider stakeholder engagement Usual (BAU) comms and engagement including partner  Frequent staff engagement highlighting importance of BAU and no change in statutory relationships responsibilities and staff morale Imposes  North east London level for strategic alignment 2 4 6 greater with limited direct commissioning. Most centralisation leadership and resource focused at local system / that limits ACS CCG development,  Prime responsibility for new SAO to ensure local increases commissioning remains strong duplication and  Better alignment particularly around assurance will bureaucracy reduce local system / CCG demands

7.4 The Governing Body should consider and note the risks associated with introducing the new commissioning arrangements and ensure that these are reflected in its CCG risk register.

8. Next Steps 8.1 To ensure that the North east London commissioning arrangements are implemented formally from 1 April 2018, the following timetable is proposed.

9. To allow the formal implementation of these arrangements for 2018/19, a report will be submitted to the December Governing Body /Joint Committee that sets out:  Proposed new governance arrangements including joint committee terms of reference and constitutional changes  Proposed Executive structure and posts and transition arrangements  Detailed financial implications of the proposed new commissioning structure.

10. Resources/investment 10.1 There is a commitment that the proposed changes will be cost neutral across NEL and CCGs. Detailed costings and assurance will be provided in the December paper.

11. Equalities 11.1 Any changes agreed will be delivered in line with the CCGs’ requirements in relation to equality and human rights for both the local population and affected staff.

12. Risk Agreeing the recommendations of this report will assist the CCGs to deliver on their priorities and mitigate the risks by contributing to:  An aligned commissioning strategy to improve health outcomes and support the long term viability of local NHS providers.  Delivering financial sustainability against a backdrop of increasing demand. The appointment of an AO (combined with the role of STP lead) is key to securing the transfer and application of transformation funds to North East London;  Preparing for the delegation of specialist commissioning to NEL.  Increased focus on developing local integrated commissioning and accountable care systems

13. Managing conflicts of interest 13.1 There are no conflicts of interest in relation to this paper.

Author: Alan Steward, System OD and Transition SRO BHR CCGs Date: 20/11/17

Appendix 1

APPOINTMENT OF MANAGING DIRECTOR

Introduction 1. As outlined in the update paper to the GB, to honour the commitment for strong local leadership, it is proposed that a Managing Director post is established for each CCG to provide senior leadership and support to each CCG (1 for BHR) and to ensure continuity and smooth transition arrangements and deliver the business as usual that these posts should be filled as a priority. The Chairs have agreed to move ahead with this interim appointment and the paper provides some more detail.

Managing director 2. The job description for the MD post is attached at Appendix 2. This has been developed with the 7 CCG Chairs and with Jane Milligan, SAO designate.

3. The current plans are  That each of the current CCG COs will move from December to take on special projects to support the NEL system. This date reflects the 1 December date on which Jane formally becomes the Accountable Officer for each CCG GB.  The work plan for the current COs during their notice period will be discussed and agreed between them, their current Chair and Jane.

4. It is critical that the CCG has strong leadership during this transition period to support the GBs to take forward their plans and to maintain the focus on performance and delivery

5. As the GB update paper outlines, plans for the full NEL operating model, the Joint Committee and associated management structure will be developed and brought to GBs in December. If this is agreed consultation will take place during January with recruitment to posts starting from February

6. It would not be practical to wait to fill the local MD post until then and given the business critical nature of the MD post the Chairs have agreed with Jane that these are advertised now on an interim basis (i.e. for individuals to take on these roles from 1 December through to the end of March). In BHR it is recognised that the current deputy post (Director of Planning and Delivery) is vacant. Recognising this and to allow substantive recruitment to be undertaken before implementation from 1 April 2018, it is proposed that this will go straight to full recruitment.

Interim appointments 7. The plan is to write on an individual basis to the current managers paid on VSM grades in each CCG. (There are 5 VSMs across NEL plus the 5 CFOs). They will be alerted to the posts (5 in total - 1 each in WF, C&H, TH and Newham and 1 across the 3 BHR CCGs). They will be asked if they wish to apply and to say which CCG role they are interested in.

8. Letters are planned to be sent out on 22 November with expressions of interest (letter and cv) sent back by 30 November).

9. Interviews will be held for each CCG involving the CCG Chair, Jane and another GB member if the chair proposes this - these to take place as early as possible in December (week of 4 December)

10. Once the panel has met and agreed whether to appoint the interested candidate, a discussion will take place between the CCG Chair, Jane, the candidate and the “outgoing” CCG AO to agree who will do what during the December to March period, ensuring a handover from the current CO to the interim MD during December and ensuring clarity for the system on who is doing what

11. Communication across the CCG and to partners can take place to outline roles and responsibilities after this meeting along with the GB being kept informed about the MD’s objectives

12. Each CCG Remuneration Committee will need to meet to agree whether the candidate should receive any pay increase for taking on the MD role and the individual will need to discuss with Jane and the Chair whether any backfill is needed for their current role

13. It is also expected that each MD will take on a role to support an STP area and this will be done in discussion between the individual, Jane and the CCG Chair

Future arrangements 14. As outlined the full NEL management structure, including the MD roles and how they will work across the local system, will come to GBs in December and then go to wide consultation with partners in January6

15. If the structure is agreed, recruitment to all the posts would take place from late February/March - these would be substantive appointments and will include stakeholder evaluations and formal interview panels for all posts including the MD roles

16. The current MD job description will be amended to reflect how the interim role is working and will also include more details of the scheme of delegation from Jane to the individual MD which will form part of the December GB paper

Appendix 2 CCG Managing Director – BHR CCGs

Grade Very Senior Manager

Accountable to Accountable Officer NEL CCGs

Works with and supports: CCG Chair

NEL Executive Team Member Attends the Governing Body of CCG

Line management responsibilities: CCG Staff

Base

Background and Context North East London CCGs have been successful in delivering strong clinical commissioning in collaboration with our patients and in developing strong relationships with providers and partner local authorities to jointly plan services which deliver improvements for our diverse and growing populations.

We have recognised that there are a number of areas where strong leadership is needed under our Accountable Officer (AO) and STP to coordinate our collective work to achieve our ambitions as quickly as possible but in a way that adds value to the efforts at a local level to support the move to Accountable Care Systems.

Whilst there is one Accountable Officer for all 7 NEL CCGs there is an important and critical role to support each CCG and system to commission its providers to deliver the STP, work with partners and build the local Accountable Care System. The local Managing Director will have a key working relationship with the CCG Chairs and CCG GBs to ensure that the CCGs strategies are coordinated and taken forward in partnership with patients, members and local partners (in particular the Local Authorities as fellow system commissioners) and will act as the main contact for the system linking with the individual CCGs.

Each of the 7 CCGs is a statutory organisation in its own right and has its own Governing Body, sub-committees, and wider governance structure. The Governing Bodies of the CCGs are the ultimate decision making bodies and are sovereign. To support the Governing Bodies there is a local team of CCG staff some of who work across the system, a number of staff who work across the NEL Collaborative and support the STP, and a small senior team who work across all 7 CCGs in NE L.

The local Managing Director will also be asked to take on a NEL system leadership role, leading on a particular workstream in support of the STP

Overall Purpose of the Role The Managing Director role has 3 key components:  Supporting delivery within the CCGs  Working with Local Authority commissioners to ensure the delivery of the STP and other priorities and to support the development of an ACS  Taking a system leadership role for particular NEL wide initiatives and portfolios

The Managing Director is part of the NEL Executive Team and has line management responsibility for the local CCG staff. They will be expected to work collaboratively with local partners to ensure

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the system has robust plans in place to achieve local ambitions, and to deliver the local FYFV and other STP action plans.

They will carry a particular responsibility to work with partner Local Authorities to align commissioning to best achieve the system’s ambitions and to support the development of local Accountable care arrangements and system behaviours.

It is anticipated that a matrix management arrangement will be agreed and that some staff reporting to the Managing Director will also support NEL wide initiatives.

The Managing Director provides senior management support to the NEL Accountable Officer and CCG Chairs and GBs in ensuring that the CCGs exercise their functions effectively, efficiently and economically. The Managing Director is responsible for the development and implementation of effective management systems to enable CCG leaders, together with the wider membership and partners, to deliver the CCGs’ business and strategic objectives.

A scheme of delegation will be agreed by each CCG GB to reflect the responsibilities of both the Accountable Officer and the Managing Director and the CCG/NEL operating model with the Managing Director being asked to undertake some deputising and other functions on behalf of the AO

Main Responsibilities

Senior Leadership  To contribute to the development of the vision, aims and business objectives of the CCGs and NEL as a whole.  To advise the CCGs on specific commissioning, business development and key corporate issues.  To support the clinical leaders and patients of the CCGs to maintain a systematic approach to ensuring the CCGs remain clinically led, accountable to their patients, delivering patient gain and committed to co-design.  To support the Accountable Officer to develop and implement the local organizational strategy and plan for the CCG GBs and CCG staff to ensure the effective transition to both an ACS and NEL commissioning at scale arrangements whilst ensuring that the CCGs deliver their statutory responsibilities.

Strategic and Operational Planning  To lead the development and implementation the CCGs’ annual delivery plan and ensure that this is reflected in local workstream and other plans and that there is a clear performance and accountability framework in place to ensure the delivery of performance targets, financial recovery/improvement, activity management and quality standards  To oversee the development of the CCGs’ strategic and operational plans and work with other Officers to ensure their delivery through the commissioning system.  To support the development, implementation and monitoring of the annual QIPP in line with the delivery plan, working towards a system sustainable plan and ensuring that contractual and other arrangements are in place to secure partner commitment and delivery  To develop and maintain systems for delivery and performance to ensure that progress is monitored and remedial action is taken where required to support delivery of objectives, contracts and achievement of financial balance  To ensure that all organisational resources are prioritised and targeted at delivery of organisational plans.  To provide CCG input to local statutory planning and assurance partnerships – e.g. attending HWBBs

Operational management  To manage the day to day business of the CCGs.

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 To work through the agreed quality arrangements to develop an integrated approach to patient quality, safety and continuous improvement of all commissioned services.  To maintain general oversight of all operational, commissioning and business functions.  To support the Accountable Officer to ensure that the CCGs comply with all legal requirements (including equalities and human rights legislation) and advise the Accountable Officer of any issues or risks;  To ensure that the CCGs have systems and processes in place to promote equality and prevent discrimination.  To put in place effective systems to monitor and review the implementation of decisions made by the CCGs and institute processes that facilitate effective and efficient work flow;  To keep the Accountable Officer, the Chairs and the wider governing bodies informed about potential risks and opportunities and recommend appropriate courses of action;  To ensure that systems are implemented that maintain high standards of public service, public accountability and probity, in conjunction with the AO and the Governing Bodies and the Audit Committees.  To ensure that the CCGs complete on time all returns, templates and proformas from NHSE and that these have appropriate sign-off  To ensure that the CCGs have effective Human Resource management so that they recruit and retain an effective and efficient workforce.  To ensure that the CCGs support and develop individuals to maintain motivation and commitment.

Commissioning  To develop relationships with the Local Authorities to ensure that commissioning secures effective delivery of integrated health and social care services and that ACS behaviours are developed and implemented.  To work with the CCG and NEL Chief Financial Officers and agreed quality organisational arrangements to ensure that appropriate management processes are in place for commissioned services such that the CCGs can be assured that quality standards are met and that there is full compliance with contractual expectations, financial responsibilities, statutory requirements and economic regulation and that where necessary, effective remedial action is taken swiftly.  To develop and implement the CCGs’ commissioning strategy as agreed by the GBs which reduces system costs, unwarranted variations, poor quality and health inequalities and implements new models of care in conjunction with the clinicians and patients  To ensure that robust contractual arrangements are in place to secure the CCGs and STP ambitions.  To support the Accountable Officer to ensure the effective management of the delegated commissioning functions from NHS England relating to Primary Care, ensuring robust systems are in place to manage the delegation and ensure objectives are met.  To support the NEL performance management arrangements, ensuring that the CCG can account for its actions and address areas of poor performance in support of the local assurance system and framework  To ensure that the local system has robust operational plans in place to achieve FYFV priorities, areas where improvement is needed under the IAF and other performance systems and NHS Constitutional standards and that these are backed up by clear contractual arrangements  To ensure a “you said we did” golden thread between issues raised by patients, clinicians and partners and CCGs’ contractual arrangements and plans

Governance  To deliver appropriate management, operational, administrative and developmental support for the GBs’ Sub Committees, ensuring that they are able to carry out their functions and that there is a robust flow of business;  To work with the AO to ensure that the Governing Bodies have access to timely skills, advice and information to undertake the full range of its functions effectively;

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 To work closely with other Officers and CCG Managing Directors to ensure an integrated approach to governance, taking specific responsibility for corporate, engagement and human resource governance systems.  To ensure all governance is effectively managed across the CCGs in line with the terms and requirements outlined within CCG constitutions, NHS England and statutory guidance and the Nolan principles  To attend the GB meetings and other sub Committees in line with the scheme of delegation  To ensure that risk management systems are in place that ensure risks are well managed and mitigated at both operational and corporate level. This includes ensuring the work of the Governing Bodies is informed by a corporate assurance framework that takes account of strategic risks to the delivery of the CCGs’ strategic and operational commissioning plans.  To ensure on behalf of the Accountable Officer that the CCGs are able to demonstrate that any potential or actual conflicts of interest of staff, members and contractors are identified and well managed and that these stand up to scrutiny.  To ensure that all CCG policies and the CCG constitutions are kept up to date and adhered to  To undertake all functions delegated by the Accountable Officer in line with good governance, the scheme of delegation and the CCGs constitutions  To support the Accountable Officer to ensure that the CCGs statutory responsibilities are met, particularly where the Managing Director is attending GB Committees or deputising for the Accountable Officer.  To support the Accountable Officer to ensure that the values of the CCGs are reflected in how the CCGs’ duties are exercised.

Communication and Engagement  To develop systems to support the CCGs to work collaboratively across the BHR and NEL footprints and with other partners to achieve shared outcomes, where appropriate;  To pursue opportunities to develop partnerships at all levels within the community that will promote the health and well-being of the people within the area;  To put arrangements in place to secure the support and commitment of all stakeholders, including patients, partners, the public and staff, in the strategic direction of the CCGs  To ensure that effective arrangements are in place for patient and public engagement in the CCGs’ commissioning work to ensure that it complies with its statutory duties  To ensure that a co-production operating model is in place whereby the views of patients and the public shape service plans and inform decision making within the CCGs  To act as the main point of contact for system partners and support the Accountable Officer in effective working relationships and communications.

Line Management responsibilities  Specifically, to provide line management & leadership to CCG staff in line with local HR policies and arrangements, ensuring effective systems of support development and performance management of staff, including annual objectives and appraisals

Emergency Preparedness Resilience and Response  To take charge in high-priority crises of an operational nature and ensure that suitable arrangements are in place to ensure business continuity at all times;  As the Officer responsible for Emergency Preparedness, Resilience and Response for the CCGs, ensure that the CCGs have plans in place to meet their duties as a Category 2 responders ensuring that the CCGs contribute to coordinated planning for emergency preparedness and resilience and are able to respond to and recover from disruptions, significant incidents and emergencies.  To participate in the Directors On call rota as required.

Any other reasonable duties as agreed with the NEL Accountable Officer.

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General (all VSM posts)  To ensure own actions contribute to the maintenance of a quality service provision.  To be responsible for the self-development of skills and competencies through participation in training and development activities and to maintain up to date technical and professional knowledge relevant to the post.  To participate in the CCGs Performance and Development Review and to undertake any identified training and development related to the post. • To undertake statutory and mandatory training as deemed appropriate by the CCG. • To develop and maintain effective working relationships with colleagues. • To adhere to all CCG policies and procedures.

Confidentiality All CCG staff and contractors working for the CCG have both a common law duty and a statutory duty of confidentiality to protect patient (and indeed any personally identifiable) information and only use it for the purposes for which it was intended. The disclosure and use of confidential patient information needs to be both lawful and ethical.

Information Governance CCG staff must keep up-to-date with the requirements of information governance and must follow Trust policies and procedures to ensure that Trust information is dealt with legally, securely, efficiently and effectively. Staff must appropriately manage the records they create or hold during the course of their employment with the Trust, making the records available for sharing in and

Confidentiality policies, procedures and guidelines (e.g. Freedom of Information Act 2000, Caldecott guidelines).

Safeguarding Safeguarding is everybody’s business. It is a basic human right, every child and adult should be protected from abuse, CCG’S have a fundamental part to play in this. All staff must recognise signs of vulnerability and be able to report and act on any concerns. It is imperative staff know who to contact within the organisation for further help and guidance and they are aware of all the main policies that underpin safeguarding in the organisation.

Health & Safety All staff have a duty to ensure the health and safety of themselves and others whilst at work. Safe working practices and health and safety precautions are a legal requirement. ALL accidents must be reported to your manager and you must participate in accident prevention by reporting hazards and following relevant policies and procedures including Moving and Handling guidelines.

Equality and Diversity The CCGs are committed to an Equal Opportunities Policy which affirms that all staff should be afforded equality of treatment and opportunity in employment irrespective of sex, sexuality, age, marital status, ethnic origin or disability. All staff are required to observe this policy in their behaviour to other employees and service users.

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Person Specification

Essential Desirable Education and  Educated to master level or  Postgraduate Qualifications equivalent level of experience qualification in working at a senior (Director) level in management and a specialist area. healthcare.  Evidence of continuing professional development.

Experience  Experience of recent work within an  Experience of Senior NHS Trust, CCG or Local Authority in project and Management & a senior commissioning role. programme management Leadership  – Experience of system working ie techniques and working with partners to achieve tools. collective ambitions  Experience of a multi-agency working across organisational and professional boundaries in a leadership role.  Previous experience of working in a collective decision making group such as a board or committee.  Experience of contributing to the development of strategic objectives and in particular setting direction, long term goals and planning and using commissioning to secure their delivery.  Experience of engaging service users and/or communities to effect service change.  Experience of successfully operating in and delivering priorities in a partnership/collaborative environment.  Experience of working with clinicians and supporting the delivery of clinical strategies.  Understanding of the background to and aims of current healthcare policy in London.  High level analytical and critical thinking skills and the ability to draw qualitative and quantitative data from a wide range of sources and present in a clear concise manner.  Ability to analyse numerical and written data, assess options and

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draw appropriate conclusions.  Understanding of relationship between the Department of Health, NHS England and individual providers and commissioners.  Proven Leadership experience in delivering change.  Experience of designing and maintaining internal business processes.  Experience of building and managing teams.  Experience of consensus building and working in collaboration across multiple stakeholders.  Track record of enabling good clinician/management relationships.  Track record of effective working relationships with Local Authority commissioners and Local Authority officers to maximise health gain  Experience of supporting organisational and staff development during a period of change

Knowledge, Skills &  Knowledge of NHS Commissioning Abilities policy associated with performance management.  Sound understanding of NHS principles and values as set out in the NHS Constitution.  Demonstrated capability to plan over short, medium and long-term timeframes and adjust plans and resource requirements accordingly.  Financially literate with ability to review, critically challenge and effectively utilise financial information for decision making;  Able to understand the CCGs risk environment including knowledge and understanding of the strategies that have been adopted by the CCGs and the risks inherent in any transformation strategies.  In-depth understanding of health and care and an appreciation of the broad social, political and economic trends

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influencing them.  Able to understand and analyse complex issues, drawing on the breadth of data to needed to inform CCG decision-making; able to balance competing priorities and make difficult decisions;  Understanding of current legal requirements and good practice in employment practices, equality and discrimination.  Will consider the most effective way to promote equality of opportunity and good working relationships in employment and service delivery and has the ability to take actions support and promote this agenda.

Communication  Effective communication and skills stakeholder relationship skills, with the ability to communicate on highly complex matters and difficult situations.  Effective presentation skills – used to presenting to a wide range of audiences – able to communicate complex issues effectively.  High level negotiating skills able to work with a range of providers and agree performance targets and performance improvement initiatives.  Able to communicate effectively with patients and clinicians

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To: Meeting of the Joint Committee of Barking and Dagenham, Havering and Redbridge CCGs

From: Regina Shakespeare, Interim Director of Delivery and Performance

Date: 30 November 2017

Subject: Integrated Performance Report 2017/18 (Month 6 Activity, Month 7 Finance)

Executive summary This report is provided to present the BHR Clinical Commissioning Groups Joint Committee members with an integrated view of performance, including finance and activity, in its contracted services, to identify the key risks presented by that performance and provide assurance that those risks are being appropriately managed. This report is based on month 6 activity and month 7 finance information. This report concerns the CCGs' main providers - Barking, Havering and Redbridge University Hospitals NHS Trust (BHRUT), Barts Health NHS Trust (Barts Health), North East London Foundation Trust (NELFT), Partnership of East London Cooperatives (PELC) and the London Ambulance Service (LAS).

The main points of note are: BHRUT: The BHRUT 2017/18 financial forecast across the three CCGs is £8.4m above plan. This over spend is driven by over performance in the following areas: elective, maternity, day cases and outpatients. One of the key drivers of the projected overspend is the increased average unit cost of non-elective activity compared to last year. An independent audit was commissioned to review non- elective case mix and price increases. The audit outcome is due to be finalised by the end of November. Following voluntary independent mediation entered into by the BHR CCGs and the Trust on 26 - 27 October, the mediator found in favour of the BHR CCGs on a number of items including recommending a cap on the level of unwell babies at 27% (compared with the current recorded levels of 60%), and recommending a re-basing of the Marginal Rate Emergency Tariff to reflect National Tariff Payment System (NTPS) Guidance. Based on the mediation outcome, and all other adjustments (for QIPP, metrics, penalties, automated claims and technical adjustments), the total net benefit to the BHR CCGs for quarter 1 is £6.8m. BHR CCGs wrote to the Trust on 10 November to finalise the quarter 1 reconciliation and as at 14 November, a Trust response remains outstanding. At the meeting of the Trust Board on 1 November, the Trust reported extreme pressure on its cash position and risk to liquidity due to unpaid over performance, a deterioration of creditor debt and additional supplier expenditure. BHR CCGs have paid the Trust in line with the cash profile agreed within the 2017/18 contract, and additionally supported the Trust with a £4m advance (paid on 12 October) pending conclusion of the contractual processes and an understanding of the Trust’s cash forecast. Modelling the impact of the quarter 1 mediation, and accounting for the £4m advance, BHR CCGs have a £3.36m credit due from the Trust. 4 contractual notices remain open and active with the Trust, however a period of purdah in respect of formal contract actions to support the mediation process had been agreed between Commissioners and

108 the Trust which was originally agreed to end on the 31 October 2017 but remains in discussion. On performance, against constitutional performance measures, the Trust met all 8 cancer standards in the month of September and for quarter 2. RTT performance in September was 91.5% against the 92% standard. The monthly 52 week wait reported position indicates 15 patients having waited over 52 weeks in September, down from 17 in August. The 4 hour A&E performance in September was 87%, slightly below the recovery trajectory of 90%.

Barts Health: The Barts Health 2017/18 financial forecast across the three CCGs is £7.4m above plan. Referrals are 12% lower year-to-date when compared to the same period in 2016/17. Despite the reduction in reported referrals, outpatient and elective activity are over plan year-to-date. The level of un-coded activity has reduced from 14% last month to 6.3% but still represents a financial risk of 16.3% of spend. Commissioners expect a further improvement next month. The quarter 1 reconciliation has been completed with a number of issues escalated to a Chief Officer meeting on 10 November. Unfortunately, these items were not concluded. Commissioners are due to propose that parties seek to appoint a technical mediator to help resolve the disputes relating to the quarter 1 reconciliation. On performance against constitutional performance measures, September performance against the 62 day cancer wait indicates an outturn of 95.9% and recovery of quarter 2 performance at 85.1%. The Trust underperformed against the 4 hour A&E standard and achieved 87.05% in October against the STF trajectory of 90.82%. The Trust has agreed to return to reporting in April 2018 and the Trust has confirmed that all 52 week waiters will be cleared by March 2018.

NELFT: The mediated negotiation which took place on 6 - 7 November has been completed. The mediation outcome includes a reduction to the contract value of £1.6m (community and mental health elements combined) which reflects both QIPP delivery and Commissioner investments and set out requirements for more detailed reporting of costs by the Trust in the 2018/19. Following the mediated negotiation, outstanding matters for 2017/18 are being concluded through a contract variation. Quarter 2 IAPT performance shows good achievement of recovery targets for Havering and Redbridge. Barking and Dagenham missed the target of 50% with performance of 44%. IAPT Access targets not being met consistently. Against the 3.75% access target, Barking and Dagenham, Havering and Redbridge CCG performance is at 3.5%, 2.91% and 3.91% respectively.

Recommendations The Committee is recommended to:

 review the report;  note the actions that are being taken and;  seek any further assurances they require in respect of risks and their management.

1.0 Purpose of the Report 1.1 The purpose of this report is to inform the committee members on the contract activity and performance for acute, community, mental health contracts including the LAS contract, and agree any actions required.

2.0 Background/Introduction 2.1 This is a report from Director of Delivery and Performance to inform committee members of the position of acute, community and mental health contracts including the LAS contract.

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3.0 Report Content 3.1 The Integrated Performance Report (IPR) 2017/18 (Month 6 Activity, Month 7 Finance) report (attached) is a summary of an extensive IPR which is considered at several levels within the organisations.

4.0 Resources/investment 4.1 Resources/investment in each service/provider are highlighted for each individual provider as required, under the relevant sections of this report.

4.2 The outcome of contractual performance has a profound financial impact on the CCGs’ ability to achieve financial balance.

5.0 Equalities 5.1 There are no equalities implications arising from this report.

6.0 Risk 6.1 Risks and mitigations for each area of activity and finance service are highlighted for each individual provider, under the relevant sections of this report; for each CCG individually; and at a BHR level.

7.0 Managing conflicts of interest 7.1 There are no conflicts of interest to note, related to this report.

Author: Acute and Non-acute MDT, BHR POD, NEL CSU Date: 17 November 2017

110 Joint Committee of Barking and Dagenham, Havering and Redbridge CCGs Contract Report 2017/18

Report Publication Date: November 2017 (Month 6 Activity / Month 7 Finance)

111 Executive Summary

The purpose of the report is to advise the Committee of the key risks in relation to the contract portfolio of the BHR CCGs. The key areas of risk are summarised below and the actions/recommended actions being taken are listed on the next page. Committee members are asked to: • Note the contents of the report; • Note the key risks that are being brought to their attention; and • Advise on the appropriateness of the actions being undertaken.

BHRUT • The forecast outturn (FOT) improved by £2.3m compared to the forecast last month, taking it to a total of £346.6m against a plan of £338.2m. • A total of 4.4% activity remains uncoded in the BHRUT M6 flex position, this is an improvement on the previous months’ uncoded level of 12%. • The Trust met all eight national cancer standards in September at aggregate level (although not at specialty level) including the 62 Day GP Referral standard. • 18 Week RTT Incomplete performance in September is 91.5% against the standard of 92%. The Patient Tracking List (PTL) also indicates the waiting list is growing. The monthly 52 week wait reported position shows 15 patients over 52 weeks in September which is a reduction from 17 in August. • Validated 4 hour A&E performance for September has continued to be challenged with a performance of 87% against a trajectory of 90%. • At the meeting of the Trust Board on 1 November, the Trust reported extreme pressure on its cash position and risk to liquidity due to a deterioration of creditor debt and additional supplier expenditure. BHR CCGs have paid the Trust in line with the cash profile agreed within the 2017/18 contract, and additionally supported the Trust with a £4m advance (paid on 12 October) pending conclusion of the contractual processes and an understanding of the Trust’s cash forecast. Modelling the impact of the Q1 mediation, and accounting for the £4m advance, BHR CCGs have a £3.36m credit due from the Trust.

Barts Health • The FOT remained relatively unchanged at £100.7m against a plan of £93.4m. Over performance is in unplanned care in the form of critical care (£1.3m), non-elective inpatients (£1.7m) and outpatient procedures (£1.1m). • A Chief Officer meeting was held on Friday 10 November, with a view to determine the three outstanding issues for Q1 reconciliation; post-freeze maternity additions (£171k for BHR CCGs), palliative care, and high cost drugs. Unfortunately, these items were not concluded. • The level of uncoded activity has reduced from 14% last month to 6.3% but still represents a financial risk at 16.3% of spend in the relevant PODs. • Referrals, reported through Monthly Activity Reporting (MAR) data, are 12% lower year to date when compared to the same 5 months last year. • The Trust achieved A&E performance of 87.05% in October against the monthly STF trajectory of 90.82%.

NELFT • The mediated negotiation, which took place on 6 - 7 November, has been completed. The agreed mediation outcome includes an amended contract value which reflects both QIPP delivery and Commissioner investments and set out requirements for more detailed reporting of costs by the Trust in this financial year.

LAS • The CCG Q2 position (M6 flex) is reported at 2.6% below plan (24,046 incidents against a plan of 24,677). ELHCP and pan-London positions are reported at 2.3% (59,706, incidents against a plan of 61,140) below plan and 1.4% (276,645 incidents against a plan of 272,788) above plan, respectively. • LAS successfully transitioned over to Ambulance Response Programme (ARP) protocols overnight on 31 October 2017.

QIPP • QIPP is under delivering by £6.4m YTD, with a M7 forecast under delivery of £13.5m (NB numbers are for the BHR-wide CCGs’ position). This represents a deterioration in forecasted performance from the reported position at month 6. The forecast outturn includes a prudent position on the delivery of pipeline opportunities and unidentified QIPP, which drives a higher level of assumed underperformance compared to the YTD position. • Delivery against live schemes is positive at M7, with CCGs delivering £15.0m of a planned £21.4m (70.1% achievement against plan), however this is a deterioration compared to month 6, this is due to the phasing of the unidentified. CCGs are forecasting this level of performance will continue throughout 17/18. Strong performance is noted against the Prescribing Incentive and PoLCE schemes. • Delivery against pipeline opportunities and unidentified QIPP accounts for the majority of FOT underperformance (£9.0m against the forecasted £13.5m underperformance). The112 ‘Big Ticket’ initiatives governed by the System Delivery and Performance Board continue to be developed, noting that the Referral Management System business case has been approved by the Financial GoverningRecovery Body Programme Contract Board Report (FRPB). 2017/18 - BHR CCGs 2 Executive Summary – Actions being undertaken

BHRUT • Following voluntary independent mediation entered into by the BHR CCGs and the Trust on 26-27 October, the mediator found in favour of the BHR CCGs on a number of items including recommending a cap on the level of unwell babies at 27% (compared with the current recorded levels of 60%), and recommending a re-basing of the Marginal Rate Emergency Tariff to reflect National Tariff Payment System (NTPS) Guidance. Based on the mediation outcome, and all other adjustments (for QIPP, metrics, penalties, automated claims and technical adjustments), the total net benefit to the BHR CCGs for Q1 is £6.8m. BHR CCGs wrote to the Trust on 10 November to finalise the Q1 reconciliation and as at 14 November, a Trust response remains outstanding. • Non-elective and stroke audits, which commenced on 16 October, are being finalised and a meeting to review a draft auditors’ report is scheduled for Friday 17 November. Initial findings suggest the Trust has enriched its coding practice in these two areas in comparison to 2016/17 Q1 data. The impact of this, HRG4+ changes and next steps will be outlined in the auditors’ final report. • An Information Breach Notice regarding outstanding information requested in the Critical Care and RTT CPNs, was issued on 13 October 2017 and a response from the Trust is awaited, however a period of purdah in respect of formal contract actions to support the mediation process had been agreed between Commissioners and the Trust which ended on the 31 October 2017. • Following the issuing of the AQN (16 August AQN addressing activity variances not dealt with through the audits or Q1 reconciliation), BHR CCGs and BHRUT are jointly working to put in place an Activity Management Plan (AMP) specifically to address higher than planned levels of activity within planned care and utilisation rates within the UCC (compared with A&E). • In October, NHSE raised concern that the levels of patients waiting 52 weeks and over (for admitted, non admitted and incompletes) reported nationally did not correlate with the local PTL. Further investigation is underway with the Trust. • A GP Practice Dashboard (by network) has been shared with all BHR GP practices for ongoing referral management/monitoring at practice and network level. • Work has begun on refreshing the Indicative Activity Plan (IAP) for 2018/19 and other relevant elements of the 2017/19 signed contract.

Barts Health • Commissioners are due to propose that parties seek to appoint a technical mediator to help resolve the disputes relating to Q1 reconciliation. • The Trust has agreed a return to reporting of RTT in April 2018 (March 2018 data set) and the Trust confirm that 52 week waiters will be cleared by March 2018.

NELFT • The full mediation outcome is being finalised in a contract variation (CV). BHR CCGs and NELFT are in the process of undertaking the final negotiations regarding wording of the CV.

LAS • The M6 freeze position is expected to be discussed and agreed at the Finance and Information Group meeting on 30 November 2017.

QIPP • As reported at M6, there is ongoing work to assure the delivery of existing schemes and identification of system wide ‘big ticket’ opportunities. CCGs and BHRUT have commenced initial work to align PMO processes to support enhanced reviews of QIPP performance, with a view to enable more robust interventions. • Consultation on Phase 2 of “spending money wisely” is underway and scheduled to end on the 15 of November. Assuming proposals are agreed, this will deliver a part year impact from M11 onwards. • Work continues on the ELHCP-wide Procedures of Limited Clinical Effectiveness (PoLCE) review. A Steering Group and Clinical Panel have been formed and evidence review is underway prior to formation of proposals. • Action plans are in place to remedy underperformance for the muscular-skeletal (MSK) and gastroenterology schemes with performance reviews due to be completed this month. It will be necessary to re-evaluate these measures in the light of the incentives package currently being co produced with primary care provider representatives with a view to strengthening demand management in the system. • QIPP planning for 2018/19 continues, with £29.8m of schemes identified so far (note this includes unassured schemes at an early stage of development). Transformation SROs will meet with the PMO to further articulate the scheme development pipeline. The PMO is also engaging with ELHCP colleagues as part of the QIPP planning process. • The contract due diligence process continues. CCG proposals for decommissioning, equating to £110k (2017/18 part year effect), have been identified to date.

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Governing Body Contract Report 2017/18 - BHR CCGs 3 CCG Overview – Financial Summary – Reported M6 Position Data Source: NHSE Return

Key Messages

• The BHRUT 2017/18 financial forecast outturn is £8.4m above plan. This continues to be driven by Non Elective, Emergency Admitted, Elective, Maternity, Day Cases and Outpatient activity. • Current QIPP performance at M7 indicates an achievement of £15.0m against a plan £21.4m (a variance of £6.4m). Overall deterioration in forecast outturn position at M7 compared to M6 by £1m, FOT position now stands at £31.5m. Work is underway to ensure delivery of schemes such as MSK and Gastroenterology. • Bart's Health still has a high level of uncoded activity, although significant improvements have been made between M5 and M6 to improve this position. The reported forecast is now £7.4m above plan. High cost critical care patients continue to have an impact on the position. • There is continued overspend on the Homerton contract, which relates to IVF and maternity related activity. • The Independent Sector has not seen the expected reduction in referrals which should have followed the cessation of referral redirects from BHRUT at the end of Q4 2016/17. Therefore the forecast has been adjusted accordingly to reflect current activity and referral levels. • Moorfields continue to over perform in high cost drugs. Activity is also continuing the previously reported year on year increase. • UCLH has seen a reduction in month in Redbridge CCG, which has reversed last months increase. This relates to critical care, haematology & Note . Overspends are shown in red in brackets, whilst numbers in black represent an underspend. This convention is used neurosurgery. throughout this report. All financial values are reported in £’000s.

The only exception to this convention is slide 62 (ELHCP Overview) which presents the financial position on an STP-level and therefore follows STP conventions (red text for an overspend, negative values in black text for an underspend).

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Governing Body Contract Report 2017/18 - BHR CCGs 4 Acute Contract Performance – M6 BHRUT and Barts Health

Finance BHRUT The forecast at M7 (overspend of £8.4m) is currently reported as per the BHR CCG’s assessment of the likely scenario and includes MRET at £2.7m and successful challenges at £11.5m. A possible best case scenario is an overspend of £3.3m which includes MRET at £2.7m and challenges at £17.6m. It is to be noted that these scenarios also include a number of other variables. Overspends have been identified in the unadjusted position in antenatal, day cases, elective, non-elective and outpatients. The areas of concern are: Maternity activity levels are up 8.1% and costs have increased by 9.2%. Whilst the increase in the cost of deliveries appears to be in line with other providers (and driven by changes to Guidance), analysis suggests a change in antenatal pathway case mix, with shifts from standard and intermediate pathways to intensive pathways. This is being investigated further and has been raised with the Trust. RTT-related PODs (Outpatients, DC, Elective) are all continuing to increase in line with previous months. Investigations are underway to explain the impact of the RTT-related activity return from previously redirected referrals to the independent sector and the impact of RTT compliance status at aggregate level and work to agree potential benefits from attracting out of area activity. Diagnostics activity has also increased by 1.0%. Drug Spend is increasing due to IR specialised commissioning transfers in gastroenterology and rheumatology. Costs 18.5% up. Neuro activity was incorrectly charged to CCGs and this will be corrected to NHSE. Non-elective stroke, respiratory, gynaecology, ambulatory care, vascular, general surgery and endocrinology have all seen a significant forecast increase over budget of £15.7m. Critical Care is reporting a forecast underspend of £1.8m which is 10.3% below the budget. Barts Health BHR CCGs are reporting a forecast over performance of £7.4m which is an decrease of £0.2m against last month. YTD over performance of £3.6m continues to be driven by unplanned care (inpatients of £0.9m and critical care of £0.6m) and planned care (outpatients including outpatient procedures £1.0m, and elective inpatients £0.3m. Uncoded activity in the month has a financial value of £0.7m (£1.5m last month) out of a total spend of £4.6m across the relevant PODs. While significantly reduced this is still a financial risk. In line with previous months, and based on the previous months movements and the relative levels of uncoded data, an adjustment has been made on the assumption that some of this spend to be reattributed as Specialised Commissioning at freeze. The Q1 reconciliation has been completed with a number of issues escalated. The main outstanding issue for BHR CCGs is the disputed post freeze inclusion of maternity pathway activity relating to months one and two, valued at £173k . This has been risk rated in the forecast outturn at 50%. The FYO includes £1.3m QIPP savings as proposed by the CCG. Activity BHRUT Over performance is seen in most outpatient and elective planned care areas mainly attributed to additional demand, with RTT and QIPP performance contributing to a lesser extent. Over performance continues to be seen in unplanned care primarily associated with stroke and sepsis activity, though significant increases are seen with costs. NEL and stroke audits have been completed and an initial auditors report is due to be discussed with commissioners on Friday 17 November. The impact of Sepsis national changes have been agreed as part of Q1 reconciliation as cost neutral in 2017/18. A deep dive on day case activity is underway. Barts Health Unplanned Care at 4.65% above plan is driven primarily by a 35% over performance in Critical Care. As per last month this is expected to reduce at freeze as spells are reattributed to Specialised Commissioning along with related critical care bed days. Planned inpatient care is 1.8% above plan and continues to be driven by Elective inpatients rather than Day Cases. Outpatients as a whole is 7% over YTD. First appointments are 6.4% above plan, despite a reduction in reported referrals and the potential impact of the cyber attack. Births are significantly under plan in the month, resulting in a 7% variance in the year to date. While there has been a downward trend in activity for BHR CCGs at Barts Health there also appears to be under reporting in the month. This has been mitigated in the forecast outturn. Performance

A&E - The validated 4 hour performance for September at BHRUT is 87.0% against a trajectory of 90%. Barts Health achieved 87.1% in October against the monthly STF trajectory of 90.8%. RTT – BHRUT achieved 91.5% against the 92% incomplete pathways standard. Barts Health has agreed to return to reporting in April 2018 (March 2018 data set) and the Trust confirm that 52 ww will be cleared by March 2018 across all specialities (including Trauma and Orthopaedics and Oral Surgery). Cancer – BHRUT met all eight cancer standards in September, although not at specialty level. At Barts Health, performance against the Cancer 62 Standard for September is 95.9% and recovery of Q2 performance is 85.1%. Diagnostics - Performance remains below the standard in August (96.26%) and September (97.71%), but is showing an upward trend of recovery in line with the trajectory.

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Governing Body Contract Report 2017/18 - BHR CCGs 5 Contract Performance – M6 Key associates and Independent Sector

Finance

UCLH continues to show an underspend in Electives, Maternity and ‘Other’. This is partially offset by overspends in Critical Care and Outpatients. Homerton are still seeing an increase in referrals. Maternity and IVF Treatments continue to over perform. Increases in electives, outpatients, diagnostics and non-electives have also been seen YTD. Royal Free has seen an increase in month in Non-Electives, Plastics, Gastroenterology, T&O and Nephrology. Moorfields - forecast to be 9% overspent mainly in outpatients and planned inpatient care. Guys & St Thomas' - Spend is increasing in Gastroenterology, Cardiology, Paediatric ENT & Paediatric Rheumatology. Care UK, Spire, Holly and the Roding - the redirect program ended in April though demand has not decreased accordingly. Further work is being carried out to understand why the expected demand management reductions are not being achieved.

Activity

• Associate over performance in activity continues to increase impacting mainly on non electives, inpatient planned care, outpatients and maternity. • Homerton over performing in all areas with forecasted activity 14.7% over plan. • Moorfields continues to see high number of cataract, glaucoma and retinal procedures. Over performance in High Cost Drugs is as a result of the Diabetic Eye Screening Programme (DESP - commissioned by NHSE) where more patients are being referred into Moorfields for treatment of Diabetic Macular Oedema for which the main treatment is injection therapy (CCG commissioned).

• Independent Sector over performance across all specialties. • Day cases have seen the highest increase in activity across the other PODs, over plan by 26%, followed by outpatients procedures over plan by 40%. NELTC seeing 18% over performance against last year activity, with day cases over performing by 40.5% and outpatient follow-ups by 22% • Spire Roding seeing over performance by 21% overall, with day cases over plan by 29% and outpatient procedures 36%

Performance

• NELTC has missed the standard every month this financial year except in June 2017. In M6 however, performance has improved to 98.8% from the M5 position of 98.6%. It should be noted in M6 there was 1 breach reported which caused the overall standard to not be achieved. • Guys and St Thomas’ have not met the RTT performance standard this year for BHR CCG patients. On average there have been 941 incomplete pathways waiting every month this year.

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Governing Body Contract Report 2017/18 - BHR CCGs 6 Mental Health Contract Performance – North East London Foundation Trust

Finance

The mediated negotiation which took place on 6 – 7 November has been completed. The agreed mediation outcome includes a reduction to the contract value of £1.6m (community and mental health elements combined) which reflects both QIPP delivery and Commissioner investments and set out requirements for more detailed reporting of costs by the Trust in the 2018/19. The full mediation outcome is being finalised in a contract variation (CV). BHR CCGs and NELFT are in the process of undertaking the final negotiations regarding wording of the CV. Activity

• Mental Health Tariff live trading is being applied to three clusters. M5 shows, after the application of the risk share, an overall financial benefit to the CCGs of £6,301.91.

• IAPT services are not included in mental health tariff cluster based activity plans. IAPT activity and performance are based on % access rates calculated by a monthly attainment target for each CCG of 1.25% of expected population prevalence of people with common mental health disorders. For M6, Barking and Dagenham, Havering and Redbridge IAPT services’ performance has fallen and are below access target achieving 1.00%, 1.00% and 1.09 respectively. Achievement of the IAPT access target is mainly dependent on increasing referrals to the services. The CCGs have IAPT leads working with primary care and NELFT to promote the service.

Performance

• M5 and M6 main mental health performance indicators are set out below. Q1 mental health performance was closed down at the 13 October 2017 SPR. • Q1 IAPT performance shows achievement of recovery targets. However, IAPT access targets are not being met consistently. • M5 inpatient occupancy rates at Goodmayes Hospital remain high for adults. Although there is a risk of out of area placements being required, NELFT continues to manage the risk and to avoid such placements. The inpatient occupancy rates for older adults has moderated and is now within the required threshold. • M6 dementia diagnosis rates continue below target in Havering. However, Redbridge and Barking and Dagenham maintain their consistent achievement of the target. • The M6 data is not yet available for the Early Intervention in Psychosis (EIP) target (at least 50% of patients receiving a NICE treatment within two weeks).The M5 position is set out below showing achievement in each borough. • At the 13 October SPR, the CCG, in closing down the Q1 mental health performance, accepted NELFT’s mitigation on a Redbridge CAMHS KPI failure and waived the contractual penalty. However, in respect of the Redbridge KPI failure on review of crisis plans, NELFT’s mitigation was not accepted and the contractual penalty was applied.

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Governing Body Contract Report 2017/18 - BHR CCGs 7 Community Contract Performance – North East London Foundation Trust

Finance

The mediated negotiation which took place on 6 – 7 November has been completed. The agreed mediation outcome includes a reduction to the contract value of £1.6m (community and mental health elements combined) which reflects both QIPP delivery and Commissioner investments and set out requirements for more detailed reporting of costs by the Trust in the 2018/19. The full Mediation outcome is being finalised in a contract variation (CV). BHR CCGs and NELFT are in the process of undertaking the final negotiations regarding wording of the CV.

Activity

Community Service

- Whilst the variance in contacts is above plan, the contact metric does not reflect the complexity of patient need.

- The year to date plan and variances are based on an overall performance of community services, which includes a broad range of over and under performance against annual activity plans.

- Due to the current reporting timescales, the latest month’s activity data is based on the flex position and will be adjusted to a freeze in the following month.

- NELFT is undertaking work and analysis to revise the current straight line activity plan to reflect seasonal variation where applicable. This work stream has been phased with the children's reporting to be adjusted M9. The contract activity plan will be varied for 2018/19 to reflect seasonal variation in monthly activity.

- Month 6 children's community services show a drop in activity due seasonal variation. This is related to the school summer holiday period, when health professional sessions on school sites cease until the start of the new term in September. September flex data; it is anticipated this will increase when the activity reporting is refreshed.

Performance

NELFT key performance indicators (KPI) and CQUIN performance is reported quarterly in line with contractual targets and the quarterly SPR closedown process.

Performance Management M6 performance data has been received and position will be reviewed and agreed at the Service Performance Review (SPR) meeting on 10 November 2017. The performance is summarised below:

• No reported breaches of the 18 week Referral to Treatment (RTT) across adult and paediatric pathways.

• Inpatient occupancy rates across general rehabilitation remains high at over 90% on average. Stroke ward occupancy has reduced and is showing a current level of 54.7%.

• Average length of stay across both the general rehabilitation wards (Japonica and Foxglove) highlights that Japonica is not meeting the benchmark standard of less than 21 days for the period, which is reflective of the current level of patient acuity.

• Stroke bed average length of stay (ALoS) has seen a decrease when compared to previous months at 36 days, and remains above the 28 day benchmark. NELFT state that the previously reported increase in the complexity of cases continues to be a trend. This requires a more complex discharge process. 118

Governing Body Contract Report 2017/18 - BHR CCGs 8 Contract Performance – NHS 111 and London Ambulance Service Data Source: LAS Performance Reports, LAS Monthly Activity Report

Finance NHS 111 BHR spend at M6 of £1.66m is above plan, which is based on 2016/17 actuals, by £246k.

The over performance in M6, compared to M6 in 2016/17 is not unexpected. In part the over performance is due to appropriate allocation of calls to Barking and Dagenham, Havering and Redbridge (BHR) CCGs since month 7 in 2016/17. The increase in activity has been anticipated by the Commissioners and provisions have been made in the budget to cover the cost of the over performance.

LAS The un-agreed Q2 position (based on M4/5 freeze and M6 flex) currently equates to a rebate of £128k for the BHR CCGs. Breaking this down, the rebate due to each CCG is as follows: Barking and Dagenham CCG - £88k, Havering CCG - £32k and Redbridge CCG - £8k. It should be noted that in the same period, the pan-London position is over performing by £1.2m with most of this in the North West London region. The YTD position is similar as per the above, with reported under performance of £102k for the BHR CCGs. The pan-London position is over performing by £2.9m.

NHS England provided an update to Commissioners on 7 September 2017 in regards to the paramedic re-banding funding that they allocated to CCGs for 2017/18 and 2018/19, proposing that 4 months’ worth of the 17/18 full year funding is paid to the LAS, with the remaining subject to the assessment process in November 2017. NEL and NCL CCGs have yet to provide authorisation for payment of this funding, and have raised concerns around a possible overlap with the 2017/18 £10m pan-London CQC funding that is now built into the contract on a recurrent basis. At the CPM meeting on 30 October 2017 the LAS were requested to provide a paper outlining the spend and planned spend of the CQC funding in 2017/18.

A review of the Commissioner investment of £10m for to support delivery of the Quality Improvement Programme, in response to the CQC’s assessment in June 2015 was shared at the July Strategic Commissioning Board meeting. The general consensus is that the funding has had a positive impact on all CQC areas. A report summarising the investment is available upon request.

Activity NHS 111 Activity has risen again in M6 and the YTD figure for BHR (137,957) is 23% over plan. The increase is, in part, attributable to the modification of a mobile network in M7 of the previous financial year (2016/17) to resolve the issue of incorrect allocation of BHR calls to other CCGs.

For week ending 22 October 2017, PELC achieved 38% calls directed to a GP for BHR in the Clinical Assessment Service (CAS) within NHS 111 service. This comfortably meets the Integrated Urgent Care (IUC) target of 30%, although there has been continued fluctuation is the last 4 weeks (ranging from 31 to 37%).

LAS The CCG Q2 position (based on M4/5 freeze and M6 flex) is reported at 2.6% below plan (24,046 incidents against a plan of 24,677). While total activity levels in Q2 are lower than the previous year, the proportion of Cat A activity has increased – see Fig 47.1 on the next slide. STP and pan-London positions are reported at 2.3% (59,706, incidents against a plan of 61,140) below plan and 1.4% (276,645 incidents against a plan of 272,788) above plan, respectively. The M6 freeze position is expected to be discussed and agreed at the Finance and Information Group meeting on 30 November 2017.

Performance NHS 111 PELC’s strong operational performance for key metrics has continued in M6; it has achieved 97.3% of calls answered within 60 seconds and a 1.7% call abandonment rate. These key indicators fall comfortably within contractual thresholds (>95%; <5%) for the month. PELC’s performance has remained strong and it has been one of the top performing providers compared to other providers in London and Nationally.

LAS BHR CCGs M6 Cat A8 performance is 66.3%, which is down on M5 reported performance by 1.3% but above the corresponding months in both 2015/16 and 2016/17 – see Fig 47.2. YTD performance for the BHR CCGs is 66.0%. STP and pan-London M6 Cat A8 performance is 67.6% and 68.6%, respectively. Pan-London performance was below the agreed trajectory for M6 of 71.6%. 119

Governing Body Contract Report 2017/18 - BHR CCGs 9

To: Meeting of the Joint Committee of Barking and Dagenham, Havering and Redbridge CCGs

From: Tom Travers, Chief Finance Officer

Date: 30 November 2017

Subject: Finance Report Month 7

Executive Summary

The Month 7 Risk Report should be read in conjunction with the detailed Integrated Performance Report (IPR) (Month 6 activity / Month 7 finance).

As reported in previous months the forecast acute contract costs and slippage against QIPP delivery do not allow the CCGs to meet their control totals. This was discussed and agreed with NHSE and in Month 7 BHR CCGs submitted a revised forecast deficit position of £25.2m (slippage of £10.2m against plan) and year to date slippage of £13.8m (slippage of £5m against plan). These positions include the 17/18 in year deficit and the historic deficit reported by Havering CCG. The in-year forecast deficit is £20.4m and the year to date deficit is £11m.

The revised forecast assumptions were subject to an independent review by Internal Audit and a sub group of the Audit Committee. The assumptions were signed off as a prudent view based on the latest view of contractual positions.

The forecast position reported for the BHRUT contract is based on the technical view of the independent mediation entered into for Quarter 1. However, until the CCGs receive a confirmed position from the Trust in relation to the mediation there remains an element of risk within the reported position for BHRUT. For Barts there are contractual processes in place and the forecast is based on a technical view of the latest Quarter 1 reconciliation. A number of items are still not agreed with Barts and these will be escalated. This has resulted in forecast overspends at BHRUT of £8.4m and £7.4m at Barts. For other Associate contracts and Independent Providers the reported forecasts are based on the latest activity and referral trends.

The other main areas of spend including Continuing Health Care (CHC), Prescribing and Primary care are broadly in line with plan, however B&D CCG are reporting overspends within CHC and prescribing.

The forecast position across the entire QIPP portfolio includes QIPP delivery of £31.5m, a slippage of £13.5m against plan. Of this, £5m slippage relates to the QIPP in acute contracts and £5.3m relates to acute QIPP schemes that are not currently in contracts. (For more information on QIPP delivery please refer to pages 5 and 11 of the IPR).

The two largest areas of risk continue to be acute contracts and QIPP delivery. The level of acute contract over performance reported at Month 7 is driven by the current level of activity and costs reported against the contracts. Whilst the forecast position includes a prudent view of acute performance and QIPP delivery there is a risk that activity growth will be in excess of the reported position and a risk that there will be further slippage against QIPP schemes. The revised net risk facing the CCGs at Month 7 is £6m. If the risks materialise, this will result in the CCGs in year deficit increasing to £26.4m.

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Recommendations The Committee is asked to:

Agree the financial position noting the risks within it.

1 Purpose of Report

The purpose of this report is to brief the Committee on the overall financial position as at the end of October 2017 (Month 7).

2 Background/Introduction

As at the end of Month 7 the CCG reported a deficit of £13.8m with a forecast year end deficit of £25.2m against resource limit (this includes the 17/18 in year deficit and the historic deficit reported by Havering CCG).

3 Month 7 Financial Indicators

See table on next page for detail.

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MONTH 7 FINANCIAL INDICATORS

In Year Rating this month Indicator In Year Target Actual Variance Key Messages £'000 £'000 £'000 At month 7 BHR CCGs have reported an in year deficit of £11m. This represents slippage of £5m against plan. The position is therefore red rated. The two largest areas of overspend are acute over performance and QIPP slippage. Acute contract over performance is a major risk and is driven by the current level of Financial position year to date (5,949) (10,976) (5,027) Red activity and cost reported against both the BHRUT and Barts contracts. Commissioners have had to make a large number of adjustments to trust data to achieve the current reported position. There is a risk that activity growth will continue to impact on the position.

The forecast outturn deficit has moved from the planned deficit of £10.2m to £20.4m. A number of risk mitigations are included in this position. Forecast overspends have been Financial position forecast outturn (10,200) (20,415) (10,215) Red reported againt the main contracts, £8.4m with BHRUT and £7.4m with Barts. This position includes a high level of risk as described above. These pressures have been negated by the release of the commissioning reserve, contingency and non recurrent items available to the CCG. The year to date savings position shows an under achievement of £6m. The position has Savings Year to date 21,137 15,047 (6,090) Red been calculated using month 6 flex data and proxy data. The savings forecast outturn projects a £13.6m slippage. This position is broadly in line Savings forecast outturn 45,098 31,534 (13,564) Red with the level of assured savings schemes The likely risks facing the CCGs at month 7 amount to £6m; there are no mitigating Risks and Opportunities Net Opportunity (5,998) Red reserves as they have all been entered into the reported position, resulting in a net risk of £6m. If the risk position fully materialises the CCGs will record an in year worst case forecast Worst Case Forecast outturn (10,200) (26,413) Red outturn of a £26.4m deficit

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REVENUE POSITION

Annual YTD Budget YTD Actual YTD Forecast Variance QIPP Budget Variance Outturn to FOT Variance £'000 £'000 £'000 £'000 £'000 £'000 £'000

BHRUT 338,190 198,533 201,995 (3,462) 346,574 (8,384) (2,494) Barts Health NHS TRUST 93,353 55,622 58,844 (3,222) 100,711 (7,358) (3,310) Homerton 8,214 4,866 5,673 (808) 9,387 (1,172) 24 Other Acute 127,075 74,334 79,296 (4,962) 135,372 (8,297) 746 Acute Reserves 13,246 6,873 3,031 3,842 7,971 5,275 0 Other Acute QIPP Plans (6,329) (2,752) 0 (2,752) (1,060) (5,269) (5,269) Acute Commissioning Total 573,749 337,475 348,840 (11,364) 598,956 (25,206) (10,304)

Mental Health 94,406 55,030 54,428 603 93,541 865 (201) Community 84,877 49,831 50,648 (817) 86,073 (1,197) (894) Continuing Care 58,970 34,127 34,736 (609) 59,688 (718) 412 Primary Care & Prescribing 127,426 73,707 73,687 20 127,201 225 (288) Primary Care Co-Commissioning 100,334 58,525 58,525 (0) 100,334 0 0 Other Programme Services 35,480 15,265 14,546 719 34,072 1,408 0 Programme Reserves and QIPP Investments 19,255 7,250 (1,160) 8,410 2,558 16,697 0 QIPP Disinvestments (8,240) (3,659) (1,670) (1,989) (5,950) (2,290) (2,290) Running Costs 16,819 9,810 9,810 0 16,819 (0) 0 Total BHR CCGs Expenditure 1,103,076 637,362 642,389 (5,027) 1,113,292 (10,215) (13,564)

2017/18 Allocation (1,092,876) (631,412) (631,412) 0 (1,092,876) 0

2017/18 Control Surplus / (Deficit) (10,200) (5,949) (10,976) (5,027) (20,415) (10,215)

2017/18 Allocation including historic deficit (1,088,116) (628,636) (628,636) 0 (1,088,116) 0

Control Total Surplus / (Deficit) (14,960) (8,726) (13,753) (5,027) (25,175) (10,215)

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MAIN EXPENDITURE VARIANCES

Acute Contracts

 The CCGs are reporting a forecast overspend of £8.4m with BHRUT. Unadjusted data suggests a significant underlying overspend of £37.3m. The CCGs have made a number of adjustments to the Trust’s data which include claims and challenges (£11.5m), QIPP delivery assumptions (£8.6m) and other technical adjustments (£8.8m).  The Trust and the CCG entered into voluntary mediation on 26-27 October 2017 to inform the Quarter 1 position between the organisations. The forecast reported by the CCG for the BHRUT contract is based on the technical view of the mediation outcome. The CCGs wrote to the Trust on 10 November 2017 to finalise Quarter 1 but at the time of writing the Trust has not agreed to the mediated outcome. Until agreement is reached there is a significant level of risk associated with the reported position.  The CCGs gave cash support to BHRUT while the Quarter 1 position was being progressed. The Trust are still facing challenges with regards to cash flow and it is likely that the CCGs will be asked to provide cash support for Quarter 2.  There are a number of Contract Performance Notices (CPNs) and clinical audits which are detailed in the IPR report. Further BHRUT information can be found within pages 15- 26 of the IPR.  There continues to be high levels of uncoded activity at Barts Health which represents a financial risk to the CCGs. The variance reported at Month 7 relates to non-elective, critical care, out patients, additional bed days and QIPP slippage (Further Barts information can be found on pages 27-28 of the IPR).  The CCGs are reporting a forecast overspend of £7.4m with Barts. Unadjusted data suggests an underlying overspend of £13.6m. The CCGs have made a number of adjustments to the Trust’s data which include claims and challenges (£1.8m), QIPP (£1.3m) and other technical adjustments (£3.1m).  Homerton is reporting a forecast overspend of £1.2m, relating to maternity and IVF cycles.  Other Acute areas are forecasting an overspend position of £8.3m. The largest adverse variances are reported against the Independent Providers. The Independent Providers have not seen the material reduction in referrals expected following the cessation of referral redirects from BHRUT at the end of 16/17. The forecast has been adjusted to reflect current activity and referral levels.  There is also forecast QIPP slippage of £5.3m against other acute QIPP commitments.  The QIPP slippage and acute over performance is partly mitigated by an acute reserve. This has released £5.3m into the forecast position.  The overall acute forecast position is, therefore, a £25.2m overspend, of which £10.3m is assessed to be due to QIPP under delivery.

Mental Health

 Mental Health shows a forecast underspend of £0.9m at Month 7. This relates to slippage against the Mental Health investments. A number of variables will further impact the Mental Health forecast outturn over the coming months, these include the mediated position on the NELFT contract and drug spend relating to Mental Health prescribing.

Community

 Year to date overspend of £0.8m and forecast overspend of £1.2m. The main pressures relate to QIPP slippage and pressures against the insulin pump budget.  The annual QIPP target with NELFT is £2.2m. At Month 7 It is assumed that there will be slippage against this QIPP resulting in a contribution to the total forecast overspend of £0.8m (refer to page 29 of the IPR for detail on the NELFT contract).

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Continuing Care

 The forecast position show over spends of £0.7m.  The position is driven by a range of factors - 16/17 London Borough of Redbridge creditor release and QIPP over achievement offset by use of agency staff and an activity over performance at Barking and Dagenham CCG.

Primary Care & Prescribing

 Across BHR, Primary care and Prescribing are forecast to plan. B&D CCG is forecasting a prescribing pressure, whilst Redbridge and Havering are forecasting prescribing underspends. The impact of drug concession prices is being further analysed by the Medicines management team, this may further impact outturn in future months.  Primary care is forecast to plan, this includes a number of assumptions with regard to investments. There are a number of work streams and outstanding items within Primary Care, including outstanding premises issues and the investment of Redbridge CCG growth monies. These issues may cause a change in the position in future months.

Running Costs

 The CCGs have a running cost allocation of £16.8m. The current forecast is to plan.

Annual YTD Budget YTD Actual YTD Forecast Variance to QIPP Budget Variance Outturn FOT Variance £000 £000 £000 £000 £000 £000 £000 Pay 7,328 4,274 4,274 0 7,328 0 0 Non Pay 1,781 1,039 1,039 0 1,781 0 0 CSU 7,710 4,497 4,497 0 7,710 0 0 Total Running Cost 16,819 9,810 9,810 0 16,819 0 0

Other Programme Services / Reserves / QIPP Investments and Disinvestments

 The main budgets held under “Other Programme Services” includes budgets for Better Care Fund (BCF), 0.5% uncommitted risk reserve, Property Services and other programme services. Within other programme services there is a forecast overspend of £1m relating to the corporate IT department.  In total there has been £16.7m released into the financial position from programme reserves and QIPP Investments. This relates to the release of contingency (£5m), brought forward creditors, release of provisions and savings shown against other investments.

Further detailed information across all contracts is found in the Performance Report.

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RISK ANALYSIS

Probability of risk Potential Full Risk being Risk Value realised Value £000s % £000s

RISKS Acute SLAs 5,526 50% 2,763 Continuing Care SLAs 1,605 50%803 QIPP Under-Delivery 4,865 50% 2,432

TOTAL RISKS 11,996 5,998

MITIGATIONS Contingency Held 0 100% 0

TOTAL MITIGATIONS 0 0

NET RISK / HEADROOM (11,996) (5,998)

Forecast Outturn Underspend / (Deficit) 0 (20,415) RISK ADJUSTED CONTROL TOTAL (11,996) (26,413)

The risk analysis above shows the risks to the CCG that are not reported within the Month 7 position. A full risk is estimated, with a percentage probability applied to give a risk adjusted value.

Acute SLAs

 The acute SLA risk revolves around the outcome of the Quarter 1 reconciliation process and any unplanned activity across the rest of the financial year.

Continuing Care

 The continuing care risk relates to a potential increase in costs later in the financial year as a result of the annual review of packages of care and demographic growth above planned levels.

QIPP under Delivery

 Outstanding risk is based on an estimate of further slippage in the forecast QIPP delivery assumptions.

Mitigations

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 Due to the financial position the CCGs face, the contingency has been released into the financial position. This means that no further contingencies are available to offset the financial risk

 The risk analysis will be further informed by the conclusion of the ongoing process in relation to the BHRUT contract.

If the risks detailed above materialise this will have an adverse impact on the current reported position and will result in the CCGs in year deficit increasing to £26.4m.

UNDERLYING POSITION

Remove Non Non Other Non FRP Full 2017/18 2017/18 Forecast at Recurrent Recurrent FYE of Recurrent Year underlying M07 Budget QIPP Investments Spend Impact position (b/f Schemes surplus) £m £m £m £m £m £m £m

Total Allocation 1,092.9 -5.6 0.0 0.0 0.0 0.0 1,087.3

Total Spend 1,113.3 -5.6 -6.9 5.7 -12.8 1.2 1,094.9

Surplus / (deficit) -20.4 0.0 6.9 -5.7 12.8 -1.2 -7.6

Purpose  The underlying position details the recurrent spend against the allocation received. The aim is to remove one-off items to measure the underlying position. This is different to the forecast position at Month 7. The underlying position at Month 7 has worsened compared to Month 6 and reflects the fact that the in-year forecast deficit has moved from £10.2m to £20.4m.

Methodology  The start point is the Month 7 forecast. Non recurrent budget allocations and spend of £5.6m are removed plus other non-recurrent spend of £6.9m. Other non recurrent spend includes the removal of the 1% non recurrent reserve and other non recurrent investments.  Non recurrent QIPP and the full year impact of 17/18 schemes are factored into the position to give the 2017/18 underlying position. At Month 7 it is expected that this will be a deficit of £7.6m.

Risk to the Underlying Position  Any further QIPP slippage will negatively impact the in-year and underlying position.  Furthermore, the underlying position assumes a full year impact of schemes of £12.8m. Any variations to this will negatively impact the position.  The ongoing process in relation to the BHRUT contract will impact the underlying position.  The underlying position is based on the current forecast outturn. Any changes to the forecast position will impact the underlying position.

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FINANCIAL ACCOUNTING METRICS

Cash Position at 31st October 2017

The CCGs draw down cash from the Department of Health each month to pay invoices and staff salaries.

The CCGs are required to end each month with an actual cash balance that is less than 1.25% of the main cash drawdown for that month.

Throughout October 2017, the CCGs continued to operate within their expected cash envelopes, and was not overdrawn on its bank accounts at any point. The CCGs are working closely with NEL CSU to ensure accurate and robust cash forecasts are in place, and that there continues to be appropriate cash and treasury safeguards.

A summary of the cash position for the three CCGs is shown below, and further detail is provided at Appendix 4.

Barking & Dagenham Havering CCG Redbridge CCG CCG

Closing cash balance at end of month £114k £163k £124k Closing cash balance less than 1.25%? Y Y Y

Amount drawn down to date £154,750k of a full year £211,100k of a full year £196,600k of a full year forecast of £263,500k forecast of £353,250k forecast of £334,200k

Invoice payment performance measure – Better Payment Practice Code (BPPC)

The BPPC requires the CCGs to pay all valid invoices by the due date, or within 30 days of receipt of a valid invoice, whichever is later. The CCGs are working closely with NEL CSU to ensure all valid invoices are being cleared in line with this target.

The cumulative BPPC figures for non NHS invoices have dropped due to a number of invoices uploaded onto the Oracle system with incorrect “received” dates. Correction of the date for prior months will make a significant difference to performance, and the CCGs will discuss making an adjustment for this with its external auditors.

A summary of the year to date results is shown below, and further detail can be found at Appendix 5.

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Barking & Dagenham Havering CCG Redbridge CCG CCG M7 YTD 2017/18 M7 YTD 2017/18 M7 YTD 2017/18 Number £000 Number £000 Number £000 Non-NHS Payables: Total Non-NHS trade invoices paid in the year 6,108 37,327 8,419 51,728 8,610 60,065 Total Non-NHS trade invoices paid within target 5,668 35,243 7,625 48,133 8,011 55,442 Percentage of non-NHS trade invoices paid 93% 94% 91% 93% 93% 92% within target NHS Payables: Total NHS trade invoices paid in the year 1,297 118,296 1,313 159,575 1,434 139,175 Total NHS trade invoices paid within target 1,224 116,361 1,225 150,665 1,347 139,510 Percentage of NHS trade invoices paid within 94% 98% 93% 94% 94% 100% target

Combined non NHS and NHS: Total Non-NHS trade invoices paid in the year 7,405 155,623 9,732 211,303 10,044 199,240 Total Non-NHS trade invoices paid within target 6,892 151,604 8,850 198,798 9,358 194,952 Percentage of all trade invoices paid within 93% 97% 91% 94% 93% 98% target

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OVERVIEW

No Indicator Month 2 Month 3 Month 4 Month 5 Month 6 Month 7 Month 8 Month 9 Month 10 Month 11 Month 12 1. Financial position year to date Amber Amber / Red Red Red Red Red 2. Financial position forecast outturn Amber Amber / Red Red Red Red Red 3. Savings Year to date Green Amber Amber Red Red Red 4. Savings forecast outturn Red Red Red Red Red Red 5 Risks and Opportunities Red Red Red Red Red Red

6 Worst Case Forecast outturn Red Red Red Red Red Red

 The financial position of the CCGs is extremely challenging. The forecast QIPP slippage at Month 7 and contract over performance means that the CCGs have released available contingencies into the position. The forecast position has been revised at Month 7 and a deficit of £25.2m (in-year deficit of £20.4m) was reported to NHSE. The financial position for the year to date and forecast position remain at Red. Any further QIPP slippage or increased over spends against acute contracts may impact on this further.

 The table above shows the finance dashboard on a month by month basis. All financial indicators are reported as Red. This is as a result of the risk around the BHRUT and Barts contracts. The unadjusted data from BHRUT shows a significant and unusual forecast overspend. The position reported at Month 7 includes the CCG view of the mediation panel’s decision on the treatment of claims and other challenges. Until this forecast is agreed with the Trust there is an element of risk within the financial position. Any movement on the BHRUT contract is a risk to the CCGs overall financial position.

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4 Financial Summary The financial position of the CCG is extremely challenging. The forecast QIPP slippage at Month 7 means that the CCG has released available contingencies into the position. The current reported position at BHRUT, Barts and other acute providers do not allow the CCGs to meet their control totals and a revised forecast deficit of £25.2m has been submitted to NHSE.

5 Resources/Investments n/a

6 Equalities n/a

7 Risk Financial risk is reported in section 3 of the report.

8 Managing conflicts of interest n/a

Attachments: 1. Appendix 1 – CCG Revenue Position 2. Appendix 2 – CCG Risk Position 3. Appendix 3 – CCG Underlying Position 4. Appendix 4 – CCG cash position 5. Appendix 5 – CCG Better Payment Practice Code

Author: Tom Travers, Chief Finance Officer Date: November 2017

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APPENDIX 1

CCG Revenue Position

NHS Barking and Dagenham CCG

Annual YTD Budget YTD Actual YTD Forecast Variance QIPP Budget Variance Outturn to FOT Variance £'000 £'000 £'000 £'000 £'000 £'000 £'000

BHRUT 92,230 54,142 56,345 (2,203) 96,653 (4,423) (529) Barts Health NHS TRUST 22,298 13,249 13,753 (503) 23,612 (1,315) (707) Homerton 2,231 1,327 1,600 (273) 2,678 (446) 27 Other Acute 31,533 18,413 19,277 (864) 32,916 (1,383) 247 Acute Reserves 3,266 1,886 725 1,161 1,919 1,348 0 Other Acute QIPP Plans (1,987) (1,013) 0 (1,013) (233) (1,754) (1,754) Acute Commissioning Total 149,572 88,005 91,699 (3,695) 157,545 (7,973) (2,715)

Mental Health 31,229 18,154 18,276 (122) 31,072 157 (9) Community 31,790 18,669 18,962 (294) 32,239 (449) (279) Continuing Care 15,546 9,055 9,465 (410) 16,301 (755) 112 Primary Care & Prescribing 33,178 19,178 19,572 (394) 33,928 (751) (96) Primary Care Co-Commissioning 30,048 17,527 17,527 0 30,048 (0) 0 Other Programme Services 11,069 4,610 4,723 (3,319) 11,286 (217) 0 Programme Reserves and QIPP Investments 5,918 2,275 (931) 3,207 1,115 4,802 0 QIPP Disinvestments (2,382) (1,090) (528) (562) (1,894) (488) (488) Running Costs 4,554 2,656 2,656 0 4,554 0 0

Total BHR CCGs Expenditure 310,521 179,038 181,421 (2,383) 316,194 (5,672) (3,475)

2017/18 Allocation (307,731) (177,412) (177,412) 0 (307,731) 0

2017/18 Control Surplus / (Deficit) (2,790) (1,626) (4,009) (2,383) (8,463) (5,672)

NHS Havering CCG Annual YTD Budget YTD Actual YTD Forecast Variance QIPP Budget Variance Outturn to FOT Variance £'000 £'000 £'000 £'000 £'000 £'000 £'000

BHRUT 154,421 90,655 92,211 (1,556) 158,278 (3,857) (1,295) Barts Health NHS TRUST 9,116 5,608 6,635 (1,027) 11,323 (2,206) (1,136) Homerton 1,460 866 1,021 (155) 1,668 (208) 21 Other Acute 46,807 27,412 29,213 (1,800) 49,890 (3,083) 223 Acute Reserves 6,201 3,000 1,349 1,651 3,618 2,583 0 Other Acute QIPP Plans (2,330) (965) 0 (965) (640) (1,690) (1,690) Acute Commissioning Total 215,675 126,577 130,429 (3,852) 224,137 (8,462) (3,876)

Mental Health 32,184 18,699 18,167 532 31,795 388 (6) Community 29,655 17,410 17,891 (481) 30,276 (621) (311) Continuing Care 20,609 12,007 12,105 (97) 20,743 (133) (17) Primary Care & Prescribing 47,913 27,753 27,490 262 47,194 719 (69) Primary Care Co-Commissioning 33,687 19,649 19,649 (0) 33,687 0 0 Other Programme Services 11,152 4,779 4,503 (2,570) 11,041 111 0 Programme Reserves and QIPP Investments 6,744 2,740 (106) 2,847 1,111 5,634 0 QIPP Disinvestments (2,500) (1,102) (532) (570) (1,917) (583) (583) Running Costs 5,755 3,357 3,357 (0) 5,755 (0) 0 Total BHR CCGs Expenditure 400,875 231,869 232,952 (1,083) 403,821 (2,946) (4,863)

2017/18 Allocation (395,941) (228,991) (228,991) 0 (395,941) 0

2017/18 Control Surplus / (Deficit) (4,934) (2,878) (3,962) (1,083) (7,880) (2,946)

2017/18 Allocation including historic deficit (391,181) (226,214) (226,214) 0 (391,181) 0

Control Total Surplus / (Deficit) (9,694) (5,655) (6,738) (1,083) (12,640) (2,946)

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APPENDIX 1 - CONTINUED

CCG Revenue Position

NHS Redbridge CCG

Annual YTD Budget YTD Actual YTD Forecast Variance QIPP Budget Variance Outturn to FOT Variance £'000 £'000 £'000 £'000 £'000 £'000 £'000

BHRUT 91,539 53,735 53,439 296 91,643 (105) (670) Barts Health NHS TRUST 61,939 36,764 38,456 (1,692) 65,776 (3,837) (1,468) Homerton 4,523 2,673 3,052 (379) 5,041 (518) (25) Other Acute 48,735 28,509 30,806 (2,298) 52,566 (3,831) 275 Acute Reserves 3,778 1,988 957 1,031 2,434 1,344 0 Other Acute QIPP Plans (2,012) (775) 0 (775) (187) (1,825) (1,825) Acute Commissioning Total 208,502 122,894 126,711 (3,817) 217,273 (8,771) (3,712)

Mental Health 30,993 18,178 17,985 193 30,674 320 (186) Community 23,431 13,753 13,795 (43) 23,558 (127) (303) Continuing Care 22,815 13,065 13,167 (101) 22,645 170 317 Primary Care & Prescribing 46,336 26,776 26,624 152 46,079 257 (124) Primary Care Co-Commissioning 36,599 21,348 21,348 (0) 36,599 (0) 0 Other Programme Services 13,259 5,876 5,320 (1,801) 11,746 1,513 0 Programme Reserves and QIPP Investments 6,593 2,234 (122) 2,356 332 6,261 0 QIPP Disinvestments (3,358) (1,467) (610) (857) (2,138) (1,219) (1,219) Running Costs 6,510 3,797 3,797 (0) 6,510 (0) 0 Total BHR CCGs Expenditure 391,680 226,454 228,016 (1,562) 393,277 (1,597) (5,227)

2017/18 Allocation (389,204) (225,010) (225,010) 0 (389,204) 0

2017/18 Control Surplus / (Deficit) (2,476) (1,444) (3,006) (1,562) (4,072) (1,597)

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APPENDIX 2

CCG Risk Position

NHS Barking and Dagenham CCG

Probability of risk Potential Full Risk being Risk Value realised Value £000s % £000s

RISKS Acute SLAs 1,522 50% 761 Continuing Care SLAs 397 50% 199 QIPP Under-Delivery 1,132 50% 566 Other Risks 0 100% 0

TOTAL RISKS 3,051 1,525

MITIGATIONS Contingency Held 0 100% 0 TOTAL MITIGATIONS 0 0

NET RISK / HEADROOM (3,051) (1,525)

Forecast Outturn Underspend / (Deficit) 0 (8,463) RISK ADJUSTED CONTROL TOTAL (3,051) (9,988)

NHS Havering CCG

Probability of risk Potential Full Risk being Risk Value realised Value £000s % £000s

RISKS Acute SLAs 2,135 50% 1,067 Continuing Care SLAs 689 50% 344 QIPP Under-Delivery 2,013 50% 1,006

TOTAL RISKS 4,836 2,418

MITIGATIONS Contingency Held 0 100% 0

TOTAL MITIGATIONS 0 0

NET RISK / HEADROOM (4,836) (2,418)

Forecast Outturn Underspend / (Deficit) 0 (7,880) RISK ADJUSTED CONTROL TOTAL (4,836) (10,298)

NHS Redbridge CCG

Probability of risk Potential Full Risk being Risk Value realised Value £000s % £000s

RISKS Acute SLAs 1,869 50% 934 Continuing Care SLAs 520 50% 260 QIPP Under-Delivery 1,720 50% 860

TOTAL RISKS 4,109 2,054

MITIGATIONS Contingency Held 0 100% 0

TOTAL MITIGATIONS 0 0

NET RISK / HEADROOM (4,109) (2,054)

Forecast Outturn Underspend / (Deficit) 0 (4,072) RISK ADJUSTED CONTROL TOTAL (4,109) (6,127) 134

APPENDIX 3

CCG Underlying Position

NHS Barking and Dagenham CCG

Remove Non Non Other Non FRP Full 2017/18 2017/18 Forecast at Recurrent Recurent FYE of Recurrent Year underlying M07 Budget QIPP Investments Spend Impact position (b/f schemes surplus) £m £m £m £m £m £m £m

Total Allocation 307.7 -2.0 0.0 0.0 0.0 0.0 305.7

Total Spend 316.2 -2.0 -1.8 1.9 -2.7 0.3 311.9

Surplus / (deficit) -8.5 0.0 1.8 -1.9 2.7 -0.3 -6.1

NHS Havering CCG

Remove Non Non Other Non 2017/18 2017/18 Forecast at recurrent FYE of FYE of Recurrent Recurrent underlying M07 QIPP QIPP Investments Budget / Spend position Schemes Spend £m £m £m £m £m £m £m

Total Allocation 395.9 -1.6 0.0 0.0 0.0 0.0 394.3

Total Spend 403.8 -1.6 -3.3 1.8 -3.7 0.4 397.4

Surplus / (deficit) -7.9 0.0 3.3 -1.8 3.7 -0.4 -3.1

NHS Redbridge CCG

Remove Non Non Other Non 2017/18 2017/18 Forecast at recurrent FYE of FYE of Recurrent Recurrent underlying M07 QIPP QIPP Investments Budget / Spend position Schemes Spend £m £m £m £m £m £m £m

Total Allocation 389.2 -1.9 0.0 0.0 0.0 0.0 387.3

Total Spend 393.3 -1.9 -1.8 2.0 -6.3 0.5 385.7

Surplus / (deficit) -4.1 0.0 1.8 -2.0 6.3 -0.5 1.6

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APPENDIX 4

Cash Position

NHS Barking & Dagenham CCG

Apr 17 May 17 Jun 17 Jul 17 Aug 17 Sep 17 Oct 17 Nov 17 Dec 17 Jan 18 Feb 18 Mar 18 Total Actual Actual Actual Actual Actual Actual Actual Forecast Forecast Forecast Forecast Forecast Forecast 1,800 £ £ £ £ £ £ £ £ £ £ £ £ £ 1 2 3 4 5 6 7 8 9 10 11 12 1,600 1,675 Balance bfwd 25 1,675 81 180 65 170 259 114 153 140 179 226 25 1,400 RECEIPTS Cash Drawdown 22,000 21,000 22,300 23,600 21,850 22,100 21,900 22,450 22,100 21,200 21,900 21,100 263,500 1,200 Other 389 145 749 358 357 134 49 40 0 0 0 0 2,220 VAT 28 36 46 30 98 19 17 21 0 0 0 0 294 1,000 Total Receipts 22,417 21,181 23,095 23,988 22,305 22,253 21,966 22,510 22,253 21,340 22,079 21,326 266,040 800 PAYMENTS Creditors NHS 16,277 17,082 16,391 18,639 16,825 16,589 16,650 17,560 17,009 16,157 16,674 16,157 202,012 600 Creditors BACS 4,384 5,516 6,440 5,324 5,261 5,472 5,355 4,816 5,009 4,909 5,083 4,909 62,479 Creditors CHAPS 2 58 0 22 0 0 0 0 0 0 0 0 82 400 Salary CHAPS 0 0 4 0 0 0 0 0 0 0 0 0 4 275 263 279 295 273 276 274 281 276 265 274 264 Cleared Pay Ords 7 20 66 16 8 0 3 0 0 0 0 0 121 200 Salaries & Wages 55 55 51 59 58 58 59 55 55 55 55 55 670 259 226 Pensions 12 12 13 13 14 13 13 12 12 12 12 12 150 180 170 153 140 179 165 Tax & NI 29 30 31 30 33 32 31 28 28 28 28 28 356 0 81 65 114 Other 0 0 0 0 0 0 0 0 0 0 0 0 0 Apr 17 May 17 Jun 17 Jul 17 Aug 17 Sep 17 Oct 17 Nov 17 Dec 17 Jan 18 Feb 18 Mar 18 Total Payments 20,767 22,774 22,996 24,103 22,199 22,164 22,111 22,472 22,113 21,161 21,852 21,161 265,875 Target (1.25% of main drawdown) Actual Cash Closing Balance Forecast Cash Closing Balance BALANCE CFWD 1,675 81 180 65 170 259 114 153 140 179 226 165 165

NHS Havering CCG

Apr 17 May 17 Jun 17 Jul 17 Aug 17 Sep 17 Oct 17 Nov 17 Dec 17 Jan 18 Feb 18 Mar 18 Total 1,000 Actual Actual Actual Actual Actual Actual Actual Forecast Forecast Forecast Forecast Forecast Forecast £ £ £ £ £ £ £ £ £ £ £ £ £ 900 1 2 3 4 5 6 7 8 9 10 11 12 903 Balance bfwd 32 903 124 98 75 88 67 163 225 278 245 186 32 800

RECEIPTS 700 Cash Drawdown 27,600 28,000 34,500 31,250 28,700 28,900 32,150 30,650 28,850 27,100 28,300 27,250 353,250 Other 194 129 367 75 643 -137 42 45 0 0 0 0 1,358 600 VAT 25 39 29 26 195 60 24 23 0 0 0 0 420 Total Receipts 27,819 28,168 34,896 31,351 29,538 28,823 32,215 30,719 29,075 27,378 28,545 27,436 355,060 500 431 391 402 383 PAYMENTS 400 345 350 359 361 361 339 354 341 Creditors NHS 20,588 21,812 25,366 23,982 21,940 21,688 24,695 23,226 22,090 20,375 21,067 20,375 267,204 Creditors BACS 6,236 6,778 9,327 7,258 7,419 7,060 7,304 7,328 6,606 6,656 7,190 6,681 85,842 300 Creditors CHAPS 0 218 0 37 0 0 15 0 0 0 0 0 270 278 277 Salary CHAPS 0 0 0 0 12 0 0 0 0 0 0 0 13 200 225 245 Cleared Pay Ords 28 41 131 0 54 0 2 0 0 0 0 0 256 163 186 Salaries & Wages 53 55 55 52 55 57 61 57 57 57 57 57 673 100 124 Pensions 11 11 12 12 14 7 10 12 12 12 12 12 138 98 75 88 0 67 Tax & NI 32 30 32 32 30 32 33 33 33 33 33 33 386 Other 0 0 0 0 0 0 0 0 0 0 0 0 0 Apr 17 May 17 Jun 17 Jul 17 Aug 17 Sep 17 Oct 17 Nov 17 Dec 17 Jan 18 Feb 18 Mar 18 Total Payments 26,948 28,946 34,922 31,374 29,525 28,844 32,119 30,656 28,798 27,133 28,359 27,158 354,782 Target (1.25% of main drawdown) Actual Cash Closing Balance Forecast Cash Closing Balance BALANCE CFWD 903 124 98 75 88 67 163 225 278 245 186 277 277

NHS Redbridge CCG

Apr 17 May 17 Jun 17 Jul 17 Aug 17 Sep 17 Oct 17 Nov 17 Dec 17 Jan 18 Feb 18 Mar 18 Total 1,800 Actual Actual Actual Actual Actual Actual Actual Forecast Forecast Forecast Forecast Forecast Forecast £ £ £ £ £ £ £ £ £ £ £ £ £ 1,600 1 2 3 4 5 6 7 8 9 10 11 12 1,623 Balance bfwd 11 1,623 309 148 270 133 35 124 121 278 242 187 11 1,400

RECEIPTS 1,200 Cash Drawdown 27,400 27,400 27,150 28,600 30,600 27,100 28,350 28,300 26,600 27,300 28,000 27,400 334,200 Other 1,137 1,208 1,664 742 658 968 329 24 1,600 0 0 0 8,331 1,000 VAT 101 193 214 83 507 112 39 112 0 0 0 0 1,360 Total Receipts 28,639 28,801 29,028 29,424 31,765 28,180 28,718 28,436 28,320 27,578 28,242 27,587 343,901 800 PAYMENTS Creditors NHS 19,389 20,821 17,633 20,853 21,225 19,913 19,771 20,761 20,027 19,333 20,052 19,434 239,213 600 Creditors BACS 6,948 8,389 10,737 7,685 9,922 7,624 8,022 6,956 7,303 7,291 7,291 7,253 95,421 383 Creditors CHAPS 12 191 17 17 0 0 68 0 0 0 0 0 304 400 343 343 339 358 339 354 354 333 341 350 343 Salary CHAPS 0 5 0 0 0 0 0 0 0 0 0 0 5 309 Cleared Pay Ords 1 1 62 2 7 0 3 0 0 0 0 0 76 200 270 278 242 Salaries & Wages 361 387 388 394 387 396 409 400 390 390 390 390 4,682 148 187 187 Pensions 119 122 134 133 140 132 138 112 112 112 112 112 1,478 133 124 121 0 35 Tax & NI 197 200 218 218 221 213 218 210 210 210 210 210 2,535 Apr 17 May 17 Jun 17 Jul 17 Aug 17 Sep 17 Oct 17 Nov 17 Dec 17 Jan 18 Feb 18 Mar 18 Other 0 0 0 0 0 0 0 0 0 0 0 0 0 Total Payments 27,026 30,115 29,188 29,303 31,902 28,278 28,629 28,439 28,042 27,336 28,055 27,399 343,714 Target (1.25% of main drawdown) Actual Cash Closing Balance Forecast Cash Closing Balance BALANCE CFWD 1,623 309 148 270 133 35 124 121 278 242 187 187 187

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APPENDIX 5

Better Payment Practice Code Performance

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To: Meeting of the Joint Committee of Barking and Dagenham, Havering and Redbridge CCGs

From: Jacqui Himbury, Nurse Director

Date: 30 November 2017

Subject: Quality Report

Executive summary

This report provides assurance to the joint committee that the Clinical Commissioning Groups (CCGs) continue to measure and monitor the quality of the services we commission from all providers, including for contracts where we are associate commissioners such as the London Ambulance Service (LAS).

The report is divided into two sections:

Section 1: Quality matters and issues that give an indication of how the BHR system is performing and the system wide risks that are being managed collectively in collaboration with partners. For this report this includes a detailed section on the GP Service Alert process and how this is used as a fundamental tenet of our early warning system and a section on the quality performance of the London Ambulance Service.

Section 2: Focuses on the quality priorities and performance of our main providers and the issues we are currently monitoring and managing through the Clinical Quality Review Meetings (CQRM), this includes workforce issues (including safer staffing), mortality reporting and the management of Never Events for BHRUT. For NELFT this includes the workforce risks (safer staffing), waiting times for IAPT and the Access and Assessment Brief Intervention services (which are crisis intervention mental health services), and the progress of clinical audits and implementation of the learning.

Recommendations The Committee is asked to:

 Discuss and review the quality matters outlined in this report  Suggest any additional actions that are required for further quality improvements or assurance

1.0 Purpose of the Report 1.1 This report is presented to the joint committee to ensure that members are fully briefed and assured on all the quality challenges and issues that the CCGs are addressing through our range of commissioning activities. Areas of good quality practice are also reported as it is important we recognise and celebrate achievements to have a full understanding of the quality of our commissioned services.

1.2 This covers both strategic and operational quality issues and details how they are managed so that the people we commission services for receive the best possible care, delivered in a way

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that is safe and effective while providing value for money and delivering a positive patient experience.

2.0 Introduction 2.1 Improving experience for patients continues to be a CCG priority, and many of our specific quality improvement and assurance activities are aimed at doing this, particularly our actions that deliver improved provider quality performance, which we assure and monitor through our established contract monitoring processes.

2.2 This report is divided into two sections:

 Section 1 – Quality matters and issues that give an indication of how the BHR system is performing and the risks that are being managed collectively. For this report this includes a detailed section on the GP Service Alert process and how this is used as a tenet of our early warning system and a section on the quality performance of the London Ambulance Service.

 Section 2 – Focuses on the quality priorities and performance of our main providers and the issues we are currently monitoring and managing through the Clinical Quality Review Meetings (CQRM), this includes workforce issues, mortality reporting, the continued management of Never Events and the application of the Quality Risk Profiling Tool (QRPT) for BHRUT. For NELFT this includes the workforce risks (safer staffing), waiting times for IAPT and the Access and Assessment Brief Intervention services (which are crisis intervention mental health services), and the progress of clinical audits.

3.0 Section 1: System Quality Performance

3.1 London Ambulance Service 3.2 The lead commissioner for LAS is Brent Clinical Commissioning Group and this is the organisation that leads the CQRM process. We receive and review the papers each month although we do not attend the meeting.

3.3 We are notified when serious incidents are reported if any of our residents are affected. Although we do not have responsibility for the management of the serious incident process we do review the final root cause analysis report and ensure that duty of candour compliance.

3.4 Since the last CQC comprehensive inspection LAS have reviewed and developed a very robust and detailed improvement plan and strengthened their governance arrangements to ensure delivery of this plan. This includes a review of the organisation’s internal approach to deliver and sustain delivery of the required improvements. Following a review of all the current Trust action plans and a completed gap analysis against all the newly defined areas for improvement for the well led and safe domain, LAS have compiled a single overarching quality improvement plan for the entire Trust. This combines all quality deliverables within the 2017/18 Business Plan, the Well Led Review and CQC Action Plan into the one Quality Improvement Plan (QIP).

3.5 This new QIP incorporates both impact and progression key performance indicators within a very clear monitoring and reporting framework, which is managed by a newly created Programme Board, which met for the first time on 5 October 2017. The Programme Board is also leading the work to develop a proposed framework to ensure the Trust is prepared and ready for the next CQC inspection.

3.6 The Trust’s quality priorities for delivery during 2017/18 are: 3.6.1 Safe: People are protected from abuse and avoidable harm. This will be achieved by:  Increasing the Sign Up to Safety Pledges to ensure that pathways for patients are available to provide timely and appropriate care  Improve outcomes for patients with critical conditions with a particular focus on sepsis  Improve and embed learning from incidents to reduce the risk of same theme incidents. 3.6.2 Caring: Patients are treated with compassion and dignity. This will be achieved by:

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 Ensure effective and consistent risk assessments are completed for patients presenting with mental illness or in crisis  Ensure patients are protected from avoidable infections  Ensure patients have timely and clinically appropriate access to services. 3.6.3 Effective: Care and treatment brings good outcomes. This will be achieved by:  Reporting on all ambulance quality indicators, learning from data and improving services to patients  Standardisation of hospital handovers and implementation of a process to ensure the sickest patients are prioritised  Develop and mortality and morbidity review process. 3.6.4 Responsive: Services provide timely care. This will be achieved by:  Workforce management when allocating ambulance personnel taking into account individual experience, qualifications and capabilities  To continue working with staff to address issues related to rosters and rest breaks  To develop a robust plan to tackle handover delays 3.6.5 Well Led: Leadership assures high quality care. This will be achieved by:  To support and equip managers to lead well from Board to Station by providing leadership development  Review leadership and management styles of key staff with responsibilities for managing emergency and urgent care ambulance crews  To build positive and collaborative relationships with all stakeholders  To ensure the executive team increase their engagement with staff and lead by example.

3.7 Progress and impact of the QIP will continue to be monitored by the lead commissioner who has provided positive assurance that the plan is progressing to agreed timeframes and small positive quality improvements are being delivered by the Trust.

3.8 The Quality and Safety Committee will receive a detailed progress report at the December meeting detailing our local position and priorities for assurance purposes and confirmation that any risks to patient safety have been identified and mitigating actions put in place by the Trust.

4.0 System Quality Improvement Actions

4.1 GP Service Alerts. Since April 17 year to date we have received 309 individual GP service alerts from members in all three CCGs. As of 1 November 2017 106 of these remain open. All open alerts have been clinically reviewed and given a priority rating and all are being progressed to closure. In order to meet the key performance indicator agreed by the task and finish group of 95% closed within 28 days our rate of open alerts should be at 40 open at any one time. We are currently operating with double this number.

4.2 This is an average of 42 alerts per month, with a cumulative average increasing from 40 per month in April to 43 by October. The detail behind these numbers is presented in table 1 below.

4.3 All GP alerts received, whether open or closed are recorded on the GP Service Alert data base and each one is issued with a subject code. This enables us to easily monitor and report all themes and to identify any emerging trends very early.

4.4 The main themes which have been developed into key lines of enquiry and progressed with providers between July and October is:  17 alerts have been raised relating to DMC Healthcare referrals processes and delays in getting appointments and diagnostic tests. 6 alerts have been raised about the Medefer service with similar concerns. All of these alerts have been passed to the planned care team and have or are being investigated.  21 alerts have been raised about access to and discharge from NELFT community and mental health services. These have all been shared with NELFT, and very detailed responses have been received. Assurance has been provided by the Trust that all individual patient risks related to accessing services have been mitigated and all patients

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requiring access to mental health services are receiving them. Thematic GP Service Alerts are reviewed as a standing item at each CQRM so that any arising actions are aligned with current Trust wide improvement plans.

 18 alerts have been raised concerning service delivery issues for Barts Health NHS Trust (BH). Themes from these alerts are outpatient clinic issues because of consultant holiday cover, discharge summaries being incorrect or incomplete and inappropriate referrals back to primary care. BH is providing a good to response to all alerts raised and are attempting to resolve the issues.

 90 alerts have been raised about BHRUT. These are following similar themes to those referenced above, including 5 indicate failed referrals via Medefer and 14 are about clinically inappropriate referral back to the GP. These alerts are being followed up through our contracting processes and we are working with BHRUT to resolve all the issues.

Table 1: Number of GP service alerts as of 1 November 2017.

5.0 Section 2: Operational Quality Improvements and Challenges

Provider quality performance improvements and challenges addressed through the CQRM

5.1 BHRUT. The CCGs continue to have serious concerns about some performance indicators that are used in the overall assessment of the quality of care provided by BHRUT. These concerns are about mortality and the Trust’s mortality reduction improvement plan, never events, delayed or missed diagnosis and workforce risks. Following a detailed discussion of the patient safety risks at the QSC it was agreed that these risks would be escalated to NHS England (London) as our regulator and NHS Improvement as the Trusts regulator.

5.1.1 The outcome of the escalation was a recommendation that the BHR system and the Trust use a quality risk profiling tool to assess the level of risk against 124 indicators of quality. This is a tool developed by NHSE and is called the Quality Risk Profiling Tool.

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5.1.2 The Quality Risk Profiling Tool (QRPT) is a quality risk profiling tool to assist clinical commissioners and providers in assessing risks to quality and patient safety across all domains of the CQC framework and across individual organisations. The tool provides a structured framework to ensure a consistent approach to assessing the level of risk by all stakeholders.

5.1.3 The tool enables the level of risks for specific indicators of quality to be identified using a systematic risk-based methodology, which identifies where further assurance or support may be required. It also allows and enables a basis for shared understanding, ownership and decisions to be made that are proportionate to the level of quality risk where concerns have been identified.

5.1.4 BHR CCGs and the Trust completed their individual versions of the tool during October. BHR CCGs led a process to complete the tool with stakeholder contributions being provided by NHSE, NHSI, Healthwatch, Health Education England and the CQC.

5.1.5 Following completion of the tool, a moderation meeting was held between the various stakeholders and the Trust on 8 November to review the overall level of quality risk for BHRUT and to review the areas of highest risk. The areas of high risk are those that have previously been identified through our early warning system and contract monitoring processes and include the risks that have previously been reported to QSC. These are workforce, mortality, Never Events, junior doctors’ training and financial management and deficits.

5.1.5 It was agreed at the meeting to hold a further meeting in December to agree next steps and the arrangements for ongoing quality monitoring. Although there are significant specific quality risks that the Trust are managing, the mitigating actions in place reduce the overall risks to patient safety and it was therefore unlikely that the group would proceed to a Risk Summit.

5.2 Mortality Performance. The CCGs continue to monitor and review the Trust’s mortality data on a monthly basis. This is the Hospital Standardised Mortality Ratio (HSMR) and the Summary Hospital-level Mortality Indicator (SHMI). We review the data by site and by weekday and weekend and at speciality level. The next reporting period for publically available SHMI data is December 2017. When this data is published commissioners will be able to undertake a further impact assessment of the Trust’s mortality reduction plan.

5.2.1 The Trust continues to report that they are making steady progress with the implementation of their mortality reduction plan and that the improvement actions are having a positive impact. They are using internally available data including crude mortality to make this assessment. Commissioners do not share this view and continue with the enhanced monitoring arrangements that are currently in place. This includes the gateway review process which is now in place.

5.2.2 The CQC have issued a third mortality outlier alert for biliary tract disease. The Trust have assured us that a full response will be sent to the CQC by the required submission date of February 2018. The CQC have also requested that the Trust undertakes further mortality reviews for sepsis and urinary tract sepsis.

5.3 Never Events. The Trust continue to implement their composite improvement plan developed following recent Never Events. The plan has now been assured by commissioners. The Trust have not reported any Never Events since July 2017.

5.4 Delayed and Missed Diagnosis Over the past few months we have seen an increasing number of serious incidents coming through specifically related to missed or delayed diagnosis for cancer. In addition to the SIs being declared by the Trust, the GP Alert system has also recently identified a case of potential clinical harm as a result of delayed reporting and the Trust not acting on the radiology results.

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5.4.1 Whilst we have sought and been given assurance that BHRUT are managing this quality risk and have an improvement plan in place for radiology services, at both the external clinical harm review panel and the CQRMs, from the information available the level of risk has now escalated. This risk remains on the CCGs’ risk register.

5.4.2 At the November CQRM, the Trust gave a clinically led presentation on their radiology improvement plan and the actions they are taking to improve the overall service delivery and especially this patient safety risk of missed or delayed diagnosis. This includes the development of an incidental findings pathway.

5.4.3 Following a review of the plan commissioners are partially assured that the plan will deliver the required quality improvements.

5.5 NELFT 5.5.1 Brookside Unit. The child and adolescent mental health wards known as Brookside have now been rated as “Outstanding” overall by the CQC. The unit in Goodmayes received the new upgraded rating following an inspection by the CQC in August 2017.

5.5.2 The inspection found that:  Strong and inspirational leadership at the Trust had transformed the Brookside Unit over an eighteen month period and the significant improvements put in place by the Trust had moved the rating from “Inadequate” to “Outstanding”.  Staff were fully committed to ensuring that they provided quality services and continued to improve through innovation. Young people receiving care were encouraged to become actively involved in quality improvement projects and their input was valued.  Staff treated young people and their families as partners in their care. They understood the importance of being kind and respectful.  There was genuine empathy and understanding of individual needs and wishes, which was reflected in the work undertaken with young people and their families.  There was a strong, visible person-centred culture. Staff were highly motivated and inspired to offer care that was kind and promoted people’s dignity.  Staff morale was high and they commented that this has steadily improved since the ward has re-opened in September 2016.  The leadership, governance and culture of the service drove improvement and underpinned the delivery of high quality person-centred care.

5.2.3 This is a significant achievement for NELFT and will lead to improved care for children and young people who require tier 4 inpatient mental health services. The quality of care will continue to be monitored through the CQRM process.

6.0 Resources/investment 6.1 There are no additional resource implications/revenue or capitals costs arising from this report.

7.0 Sustainability 7.1 If we achieve the quality improvements detailed in this report the positive impact will be on sustained quality improvement and an improvement in patient experience.

8.0 Equalities 8.1 This report has considered the CCGs’ equality duty and where relevant has identified relevant actions which address any likely impact on equality and human rights.

9.0 Risk 9.1 Failure to ensure that there are improvements to the quality performance of commissioned services may result in a failure to manage and mitigate risks with potential harm to patients and reputational damage to the CCGs. The CCGs’ quality surveillance and management system provides mitigation to this risk. The management of this risk is assured by the Quality and Safety Committee.

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9.2 Some patients may not be receiving the quality of care at the level which the CCG commissions, and therefore may have a poor experience of using the services we commission.

9.3 Mitigating actions for the above risks have been specified in the body of the report.

10.0 Managing conflicts of interest 10.1 There are no conflicts of interest raised in this report.

Author: Jacqui Himbury, Nurse Director

Date: 09 November 2017

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To: Meeting of the Joint Committee of Barking and Dagenham, Havering and Redbridge CCGs

From: Jacqui Himbury, Nurse Director

Date: 30 November 2017

Subject: Safeguarding Children Annual Report

Executive summary

This is the fourth safeguarding children annual report and reflects achievements, risks and all works completed in 2016-2017.

The report is written to provide assurance to the Committee that the Clinical Commissioning Groups (CCGs) are discharging its statutory responsibility to safeguard the welfare of children across the BHR health economy.

This report will address the following areas:  Safeguarding and accountability assurance framework  Strategic approaches to safeguarding children  Leadership, performance management and quality assurance  Engagement with primary care  Population overview and deprivation  Safeguarding children including current priorities within the safeguarding children agenda  Safeguarding children training  Priorities and key achievements for 2016/17  Key priorities for 2017/18

Recommendations

The Committee is asked to:  Review and discuss the safeguarding children agenda outlined in this report  Suggest any additional actions that are required for further improvements or assurance

1. Purpose of the Report 1.1 This report provides the Committee with an overview of safeguarding children across the BHR health economy during 2016/17. The report reviews the work across the year, giving assurance that each CCG has discharged its statutory responsibilities to safeguard the welfare of children across the health services it commissions.

1.2 The report will also highlight significant risks within the safeguarding children agenda and demonstrate how the safeguarding team within the CCGs are managing and mitigating the risks.

147 1.3 Additional information is included about national changes and influences, as well as local developments, Local Safeguarding Children’s Board’s (LSCB) priorities and activity.

2. Introduction 2.1 Continued development of the safeguarding children agenda will ensure that the services we deliver and commission are safe, effective and provide a positive outcome for children, young people and their families.

2.2 This report will address the following areas:  Safeguarding and accountability assurance framework  Strategic approaches to safeguarding children  Leadership, performance management and quality assurance  Engagement with primary care  Population overview and deprivation  Safeguarding children including current priorities within the safeguarding children agenda  Safeguarding children training  LSCB priorities  Performance against 2016/17 priorities  Key objectives for 2016/17  Key objectives for 2017/18

3. Safeguarding and accountability assurance framework 3.1 CCGs are statutorily responsible for ensuring that the organisations from which they commission services provide a safe system that safeguards children and adults at risk of abuse or neglect. This includes specific responsibilities for Looked-After Children as defined by the Children Act (1989) and for supporting the Child Death Overview Panel (CDOP), to include sudden unexpected death in childhood. Local authorities have the same responsibilities in relation to the public health services that they commission.

3.1.1 CDOPs are responsible for reviewing information on all unexpected child deaths. They record preventable child deaths and make recommendations to ensure that similar deaths are prevented in the future. 3.1.2 CDOPs are accountable to the local safeguarding children board (LSCB) and they are made up of representatives from social care, and the police as well as health representation. Details of how CDOPs will function in the future is outlined in section 9. 3.2 The Safeguarding Vulnerable People in the NHS Accountability and Assurance Framework (NHS England 2015) sets out the requirements necessary for CCGs to be able to demonstrate that they have appropriate systems in place for discharging their statutory duties in terms of safeguarding. These include:

 A clear line of accountability for safeguarding, reflected in CCGs’ governance arrangements, i.e. a named executive lead to take overall leadership responsibility for the organisation’s safeguarding arrangements.  Clear policies setting out their commitment, and approach, to safeguarding including safe recruitment practices and arrangements for dealing with allegations against people who work with children and adults as appropriate.  Training their staff in recognising and reporting safeguarding issues, appropriate supervision and ensuring that their staff are competent to carry out their responsibilities for safeguarding.  Effective inter-agency working with local authorities, the police and third sector organisations which includes appropriate arrangements to cooperate with local authorities in the operation of Local Safeguarding Children Boards (LSCBs), Local Safeguarding Adults Boards (LSABs) and Health and Wellbeing Boards.  Ensuring effective arrangements for information sharing.

148  Employing, or securing, the expertise of Designated Doctors and Nurses for Safeguarding Children and for Looked After Children (LAC) and a Designated Paediatrician for unexpected deaths in childhood.

4. Strategic approach to safeguarding children 4.1 Each CCG is required to provide assurance that safeguarding activity within all commissioned services meets national safeguarding standards and demonstrates a model of continuous improvement. This is reflected in the local policy and procedure and reflected in the CCGs’ governance framework and delivery plan.

4.2 Although the CCGs’ Accountable Officer holds ultimate accountability for safeguarding children, the Nurse Director holds Governing Body responsibility.

4.3 The CCGs takes a cross generational approach to safeguarding children, young people and adults. This is delivered through the CCGs’ Quality and Safeguarding Team and provides strategic leadership for safeguarding children, Looked-After Children and vulnerable adults across the local health economy. The roles provide leadership, quality assurance, training, supervision and specialist clinical advice on safeguarding to the CCGs and to provider organisations.

4.4 In 2016/17 the CCGs undertook a review of the role of the Designated Nurse for Safeguarding Children and added the responsibility for looked-after children. This had previously been a separate role covering three CCGs.

4.5 According to the intercollegiate guidance for safeguarding children (2014) and the intercollegiate guidance for looked after children (2015), each CCG should employ at least one whole time equivalent (WTE) designated nurse for safeguarding children per 70,000 child population and at least one WTE designated nurse for looked after children per 70,000 child population. Across the BHR footprint there is a total child population of 176,120, therefore there should be five WTE designated nurses to ensure intercollegiate compliance. However, as the designated nurses are co-located and provide cross cover, the CCGs can fulfil their statutory responsibilities with a smaller resource.

4.6 The CCGs currently have a contractual arrangement with NELFT NHS foundation Trust to employ the Designated Doctors for Safeguarding Children across the BHR footprint and the Sudden Unexpected Death in Infancy Consultant role in Redbridge. The Designated Doctor for Looked- After Children is directly employed by the CCGs.

4.7 The CCGs also fund the named GP role and have resources in place to cover this function in Barking and Dagenham and Havering. However, this remains a vacant post in Redbridge and therefore represents a significant risk within Redbridge CCG. This is currently on the safeguarding children risk register and a business plan has been submitted to ensure this function is covered in 2017/18.

5. Leadership, Performance Management and Quality Assurance 5.1 There is a clear vision to achieve the highest standards of quality and safety and to embed safeguarding principles across the borough. This is achieved by each of the designated professionals having particular commissioned providers to support, enabling a strengthening of supervision, training (in line with the Intercollegiate documents 2014, 2015), as well as providing safeguarding and LAC assurances.

5.2 Contractual governance ensures that compliance with core safeguarding standards are in place and assurances are given by providers. Contractual specifications for all providers are included within the schedule of all contracts and actively monitored via the CCGs’ Clinical Quality Review Meetings (CQRM).

5.3 Monitoring of serious case review recommendations is undertaken collaboratively with the LSCBs to ensure external scrutiny.

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5.3.1 A serious case review is an independent multi-agency review following the death or serious injury of a child where abuse is known or suspected and where there has been a failing by services. The requirements for a serious case review are outlined in the statutory guidance ‘Working Together to Safeguard Children’ (2015).

6. Engagement with Primary Care 6.1 The Designated Nurses for Safeguarding Children continue to work closely with the Designated Doctors/Named GP to help share information and inform the CCGs of the priorities for safeguarding work across primary care.

6.2 The Designated and Named professionals work closely with GPs to support their safeguarding functions, increase participation and offer supplementary training. The Designated Nurses for Safeguarding Children has attended PTI sessions as well as working with individual GPs on complex cases and supporting practices with CQC visits.

6.3 To further expand on this work, the 2017/18 safeguarding priorities include the development of a Safeguarding GP forum (see section 13) as well as continuing to work with GPs to increase attendance and report submissions for child protection conferences.

7. Population overview and deprivation 7.1 The most recent estimates from the Office of National Statistics (ONS) from mid-2013 show that 206,500 people live in Barking and Dagenham, 249,085 people live in Havering, and 296,800 people live in Redbridge. There is an estimated population growth of around 7.5% by 2019.

7.2 Havering and Bromley are London’s least diverse boroughs. However, of all London boroughs, Havering has had the highest percentage increase between the 2001 Census and the 2011 Census as the percentage of ethnic minority population has more than doubled, with the following ethnic groups seeing the highest increase:  Black or Black British: African  White Other  Asian/ Asian British: Indian

7.3 The unemployment rate in Barking and Dagenham is 11.5%, Havering is 5.2%, and Redbridge is 7.6%. There is also a high proportion of children under the age of 16 years living in low income families across the three boroughs.

8. Safeguarding Children 8.1 Safeguarding children remains a complex and ever evolving agenda that moves and adapts to meet the needs of its local community. As a result of this, there are a number agendas that the Committee needs to be aware of as they are key priorities across the BHR footprint. These key areas are:  Neglect  Early help  Section 47 investigations  Child protection medical examinations  Female Genital Mutilation  Child Sexual Exploitation  Gangs and County Lines  PREVENT  Child Deaths  Serious Case Reviews/Learning Reviews  LeDeR Reviews  Multi Agency Safeguarding Arrangements and Partnership Work

8.2 Neglect

150 8.2.1 According to the 2016 Pan London Safeguarding Procedures, neglect is defined as a failure to meet a child’s basic needs. These needs can be failed in a variety of ways including inadequate food, shelter, and clothing, not providing a safe environment or stimulus for the child, not accessing appropriate medical care.

8.2.2 Research has proven that the rates of identified neglect cases has significantly increased in the United Kingdom over the past five years and is the number one reason for a child becoming subject to a child protection plan or for becoming a looked after child.

8.2.3 Because neglect has become such a high priority area within England, the government has launched a series of Joint Targeted Area Inspections (JTAI) to look at service provision. The inspections are undertaken jointly by Ofsted, Care Quality Commission (CQC), HMI Constabulary and HMI Probation. In preparation for these inspections, the CCQ has been working closely with the Local Safeguarding Children’s Boards, Children’s Services and provider organisations to ensure there are robust systems in place for the identification and protection of neglected children.

8.3 Early Help 8.3.1 Neglect is the main focus of child protection plans across Barking and Dagenham, Havering, and Redbridge and therefore responses to the early signs of neglect are essential.

8.3.2 The existing Early Help Health services are aligned to the three LSCBs “Threshold” guidance. Health services have a key part to play in early help. However, further development is needed across all agencies to embed the use of the common assessment framework (CAF), this will be a priority area for all health providers.

8.3.3 During 2016/17, there have been a significant number of cases that have both been stepped up to section 47 investigations and stepped down to early help. This indicates that there is still room for improvement around professional understanding of early help and the application of correct thresholds.

8.4 Section 47 Investigations. 8.4.1 In certain circumstances, the early help offer is not the correct threshold to safeguard children and cases need to be escalated to a section 47 investigation to effectively safeguard the child/ren. Under section 47 of the Children Act (1989), the local authority has statutory powers to carry out an investigation to determine if a child has suffered or is likely to suffer significant harm.

8.4.2 There has been a continued increase in the number of referrals for child safeguarding, section 47 investigations and the number of children subject to a child protection plan within the three boroughs. The charts below outlines the safeguarding activity for 2016/17.

8.4.3 Whilst there may have been an increase in the promotion of safeguarding awareness, training and more coherent multi-agency processes implemented over the past year, multi-agency case file audits will be needed to demonstrate that these are having a positive impact on both practice and the outcomes for children.

8.4.4 Having children/young people in the wrong part of the system causes not only stress to the young people and their families but also additional workload to professionals. The impact on professionals involved in child protection functions, in attending statutory child protection meetings alone equates to an additional 12.3 hours per case, without accounting for the necessary travel time, writing reports or completing casework recording or safeguarding work with the child and family. Therefore, it is essential that safeguarding children is effectively embedded into practice to ensure that children are effectively safeguarded and their welfare is promoted.

151 Number of child safeguarding referrals for 2016/17 1400 1097 1143 1200 1042 946 939 1000 872 804 800 681 615 545 596 600 380 400 200 0 Q1 Q2 Q3 Q4

Redbridge Havering Barking and Dagenham

Children subject to a child protection plan 2016/17 378 400 357 371 350 314 283 298 296 294 300 266 265 271 266 250 200 150 100 50 0 Q1 Q2 Q3 Q4

Redbridge Havering Barking and Dagenham

8.5 Child Protection Medicals. 8.5.1 As part of a section 47 investigation, a child protection medical may be indicated to establish if significant harm has been caused to a child, the impact of such harm, and to rule out if injuries could have been caused by another mechanism.

8.5.2 NELFT has revised their service for child protection medicals (excluding child sexual assault medicals) across Barking and Dagenham, Havering and Redbridge so that all child protection medicals are now undertaken at a Barking venue.

8.5.3 Child sexual assault medicals (CSA) are commissioned by NHS England, and take place at Sexual Assault Referral Centres (SARC). It is through this process and the vigilance of multi- agency staff that serious sexual assault cases are managed as well as identifying particular types of abuse e.g. child sexual exploitation and female genital mutilation.

8.6 Female Genital Mutilation (FGM) 8.6.1 Female genital mutilation (FGM) comprises all procedures that involve partial or total removal of the external female genitalia, or other injury to the female genital organs for non-medical reasons.

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8.6.2 FGM is recognised internationally as a violation of the human rights of girls and women. It reflects deep-rooted inequality between the sexes, and constitutes an extreme form of discrimination against women. It is nearly always carried out on minors and is a violation of the rights of children. The practice also violates a person's rights to health, security and physical integrity, the right to be free from torture and cruel, inhuman or degrading treatment, and the right to life when the procedure results in death.

8.6.3 The Serious Crime Act 2015 introduced mandatory reporting requiring regulated health and social care professionals to report known cases of FGM in under 18-year olds to the police.

8.6.4 There have been no reported cases in 2016/17 of children who have been subjected to FGM but there have been 243 women with FGM who have been identified within BHRUT services.

Identified cases of FGM (adults) 2016/17

80 76 68 60 56 40 43 20 0 Q1 Q2 Q3 Q4

Used with permission of BHRUT

8.6.5 The highest concentration of identified FGM cases are within the London Borough of Southwark and by comparison the BHR footprint has a fairly low number of identified cases. However, it is important to note that BHR is above the national average and the identified cases are likely to increase as more families move out of the central London region.

8.6.6 The CCGs scrutinise the locally held FGM data to seek assurance that provider organisations are fulfilling their mandatory reporting duties in-line with the Serious Crimes Act (2015) and have sought assurance that FGM is sufficiently included in all levels of safeguarding children training delivered by commissioned provider organisations.

8.7 Child Sexual Exploitation (CSE) 8.7.1 Child sexual exploitation is a form of child sexual abuse. It occurs where an individual or group takes advantage of an imbalance of power to coerce, manipulate or deceive a child or young person under the age of 18 into sexual activity (a) in exchange for something the victim needs or wants, and/or (b) for the financial advantage or increased status of the perpetrator or facilitator. The victim may have been sexually exploited even if the sexual activity appears consensual. Child sexual exploitation does not always involve physical contact; it can also occur through the use of technology.

8.7.2 Child sexual exploitation is a crime with devastating and long lasting consequences for its victims and their families. Childhoods and family life can be ruined and this is compounded when victims, or those at risk of abuse, do not receive appropriate, immediate and on-going support. The first response to children, and support for them to access help, must be of a very high standard if there is to be a positive long-term outcome.

8.7.3 Each CCG works closely with the local authority and provider organisations to ensure that appropriate services are identified and resources are in place to meet the needs of this very vulnerable population. This is achieved by:  CCG representation on the safeguarding children’s boards  CCG representation at the Multi Agency Sexual Exploitation (MASE) panel  CCG representation at the CSE steering group 7

153  CCG representation at looked after children placement panels  Close working with the joint children’s commissioners to ensure access to prioritised health services.

8.7.4 Child Sexual Exploitation (CSE) continues to be a priority area across the BHR footprint with a large number of young people experiencing child sexual exploitation as well as being reported missing from their home or placement.

8.7.5 The local understanding of child sexual exploitation is that the most common model of abuse is peer-on-peer abuse with the ‘boyfriend’ model as the second most common. The particular vulnerable groups of children most affected by this are looked after children and children with additional learning needs.

8.7.6 Within the NHS, information regarding CSE has been disseminated across all areas and training has been provided via the Safeguarding Children’s Boards. However, safeguarding audits/practice visits will need to be undertaken in 2017/18 to ensure that training has effectively been embedded into practice.

8.8 Gangs and County Lines 8.8.1 There is a strong link between CSE and organised crime networks within the United Kingdom. The supply and distribution of illegal substances place our young people at significant risk of harm, death, or becoming involved in criminal activity.

8.8.2 The grooming process that a young person will go through with gang initiation is virtually identical to that of child sexual exploitation and these two worlds are intertwined in terms of drug use and sexual activity. For example: a young person may be expected to engage in sexual activity as part of a gang initiation process and sexually exploited young people may be encouraged to take illegal substances as a way for perpetrators to maintain control.

8.8.3 Gangs in the London area use a drug distribution model called ‘county lines’ as a way of spreading their products across the UK. The gang leaders will send gang members to rural parts of the UK to distribute drugs there with the promise of financial gain. Young people are therefore at significant risk of being caught in possession of illegal drugs and money, attack from rival gang members, and risk of attack if they attempt to leave the gang or if money and/or drugs are unaccounted for.

8.8.4 As a result of this, there are a number of young people who are placed in out-of-area foster placements to maintain their safety and to sever their connection with gang members.

8.8.5 The CCGs feed into this agenda by ensuring that health services are commissioned to meet the health needs of this population including sexual health services, CAMHS services, and commissioning effective services for looked after children placed out of area. The safeguarding children’s team also attend foster care placement panels and CSE/missing panels so they have oversight of the high risk cases within the boroughs.

8.9 PREVENT 8.9.1 In addition to CSE and gangs, an additional area of concern that affects our vulnerable child population is the risk of radicalisation.

8.9.2 In 2011 the Home Office published its anti-terrorism strategy of which there are four strands:  Prevent  Pursue  Protect  Prepare

154 8.9.3 In line with this strategy, the NHS is required to ensure its workforce is able to identify individuals who are at risk of radicilisation and take appropriate action to ensure that these individuals are not radicalised, therefore providing protection for the wider community.

8.9.4 The CCGs are supporting provider organisations in rolling out the Workshop to Raise Awareness of Prevent (WRAP) and are closely monitoring training compliance. The PREVENT agenda has been a priority area at CQRMs and provider organisations are currently compliant with WRAP and PREVENT awareness training.

8.9.5 Within the CCGs, PREVENT awareness training is embedded into mandatory training with a high level of compliance across the CCGs. However, further development is needed to ensure the CCGs have a robust policy in place and to ensure the CCGs have staff trained to deliver WRAP training.

8.10 Child Deaths 8.10.1 The Local Safeguarding Children’s Boards have responsibility for ensuring that all child deaths (where the child normally resides in their borough) are reviewed to identify any appropriate learning.

8.10.2 The panel is made up of key partners including representatives from the CCGs’ safeguarding team. The panel chair is accountable to the independent chair of the local safeguarding children’s board and are required to submit an annual report.

8.10.3 Currently the Child Death Overview Panel (CDOP) is managed by public health but this will be transferring to the CCGs following the implementation of the recommendations made by the wood review (see section 9).

8.10.4 For 2016-17 there were a total of 57 child deaths across of BHR footprint (see table below) with prematurity and sepsis being the top two causes of death. As a result of this, provider organisations have undertaken a piece of work to ensure the early identification of sepsis in children to reduce to risk of death associated with sepsis.

8.10.5 Another key responsibility of the CDOP is to make onward referrals to other review panels if there are concerns around the circumstances of the death e.g. serious case review panels and LeDeR referrals.

Number of child deaths by borough 2016/17

21 24

Redbridge Havering Barking and Dagenham

8.11 SCRs and Learning Reviews 8.11.1 The criteria for carrying out a serious case review is (a) where a child has died or has been seriously injured (b) where abuse is known or suspected (c) and where there has been a failing by the multi-agency. If the criteria is partially met, the serious case review panel may consider carrying out a learning review instead of a serious case review. 9

155

8.11.2 In 2016/17 there have been three serious case reviews and two learning reviews undertaken across the BHR footprint.

8.11.3 All reviews are now complete but are awaiting publication. Two reviews will be significantly delayed in publication due to on-going legal proceedings.

8.11.4 All reviews undertaken have made recommendations within the health economy and action plans are monitored within the LSCB sub-groups as well as at CQRMs with provider organisations.

8.11.5 The main learning points from the serious case reviews are around appropriate recognition and response to neglect and fabricated and induced illness as well as recognising the vulnerabilities of older aged children, concealed compliance, and the role of fathers.

8.11.6 In response to the serious case reviews the CCGs have worked closely with provider organisations to share the learning and implement new practices in the clinical area.

8.12 Learning Disability Mortailty Review (LeDeR) Program 8.12.1 In addition to serious case reviews, a child death may also need to be notified to LeDeR if there is a death of someone with a learning disability who is over the age of 4 years.

8.12.2 The LeDeR program launched in 2015 and is a three year program to identify learning from deaths where there is a learning disability.

8.12.3 The CCGs are coordinating the implementation of the LeDeR program but further development is needed to ensure staff across the health economy are trained to undertake the reviews.

8.13 Multi Agency Safeguarding Arrangements and Partnership Work 8.13.1 Given the high need and vulnerability within the local populations, it is recognised that safeguarding children is most effectively delivered through strategic and organisational multiagency arrangements, with partners working collaboratively to achieve a shared vision. The focus for multi-agency safeguarding is through the Local Safeguarding Children Boards (LSCBs), the Local Safeguarding Adults Boards (LSABs) and other multi agency partnerships including the Health and Wellbeing Boards, the Children’s Partnership Boards, MASH strategic Boards and Multi agency Public Protection Arrangements (MAPPA).

8.13.2 The CCGs are committed to partnership working and are key member of the LSCB/LSAB and its sub-committee’s as well as the other board meetings.

8.13.3 Under Section 11 of the Children Act (2004) all NHS organisations are required to have processes in place to safeguard and promote the welfare of children. In order to provide assurance of this to the LSCBs, the CCGs complete an annual Section 11 audit that is then scrutinised by external partners. The audit comprises of eight overall standards that each CCG will self-assess itself against. These are:

 A senior management commitment to the importance of safeguarding and promoting children’s welfare  A clear statement of the agency’s responsibilities towards children; available for all staff  A clear line of accountability within the organisation for work on safeguarding and promoting the welfare of children  Service development that takes account of the need to safeguard and promote welfare and is informed, where appropriate, by the views of children and families

156  Staff training on safeguarding and promoting the welfare of children for all staff working with or (depending on the agency’s primary functions) in contact with children and families  Safe recruitment procedures in place  Effective inter-agency working to safeguard and promote the welfare of children  Effective information sharing

8.13.4 The CCGs ‘Section 11 audit has demonstrated that the CCGs meet most of the required standards and have an action plan in place to ensure continued service development in respect of safeguarding children.

8.13.5 The biannual CCGs section 11 reports have been agreed at the appropriate sub-committee of the LSCBs. However, this is a ‘live’ document that is updated on a regular basis to reflect changes in workforce and implemented service development.

9. Impact of the wood report on LSCB 9.1 In 2016, Alan Wood CBE undertook a fundamental review of the role and functions of Local Safeguarding Children Boards and the Serious Case Review process. The review considered the effectiveness of current arrangements in holding partners to account.

9.2 The Government response to the Wood Report was published in May 2016; supporting the findings of the report. The legislative process to remove LSCBs from current statute has commenced and the arrangements for both multi-agency shared leadership and the transfer of responsibility for CDOP from DfE to DH has begun.

9.3 The revised arrangements will be set out in the Children and Social Work Bill. The statutory guidance will then be published in 2017/18 for the reforms to be implemented in April 2019.

9.4 These legislative proposals represent the most significant changes in child protection and safeguarding in 40 years. However, until new statutory guidance is issued, the LSCBs and their functions will continue in their current form.

10. Safeguarding Training 10.1 The CCGs have key performance indicators (KPIs) in place to seek assurance that commissioned services have staff who are trained at an appropriate level in-line with intercollegiate guidance.

10.2 Core contracts require that a minimum of 85% of provider staff are up-to-date with their safeguarding training and this is monitored via quality dashboards.

10.3 The CCGs are also required to ensure that their staff are sufficiently trained at an appropriate level and have set a compliance rate at 85%. The chart below demonstrates that Havering and Redbridge CCGs are currently compliant for safeguarding children training. However, further work is needed to ensure sustained compliance across the three CCGs. It is important to note that training compliance is affected by new staff coming into post and a smaller overall numbers in Havering and Barking and Dagenham CCGs.

157 CCG Safeguarding Children Level 1 training compliance 2016/17 year end

Redbridge 92% 8%

Havering 86% 14%

Barking and Dagenham 67% 33%

0% 20% 40% 60% 80% 100% 120%

Compliant Non-compliant

10.4 The designated professionals for safeguarding children within the CCGs are required to undertake additional training at level 5 as per the intercollegiate guidance. As of March 2017, all the designated professionals for safeguarding children within the CCGs are 100% compliant with level 5 training.

10.5 Further development work is needed to ensure that the safeguarding training being offered by the CCGs is up-to-date and covers all the key topics outlined in the intercollegiate guidance.

11. Looked After Children 11.1 Looked-After Children will be addressed in a separate annual report.

12. Key Objectives 2016/17 12.1 The objectives identified for 2016/17 were as follows:

 To ensure clear, robust governance for safeguarding is in place.

 To ensure the CCGs are assured that both internal and providers safeguarding systems are effective.

 To review the safeguarding resource, ensuring it is both adequate, high quality and fit for purpose.

 Increase awareness of safeguarding across professionals and public, both internally and externally.

 Support effective primary care engagement and practice in safeguarding.

 To further develop systems to protect vulnerable groups from harm.

12.2 The safeguarding children service within the CCGs have made considerable progress against these objectives including:

 Improved data quality being provided by provider organisations  Improved scrutiny at CQRM meetings  Implementation of safeguarding supervision with provider organisations  Implementation of a GP safeguarding forum in Barking and Dagenham  Compliance against most of the Section 11 standards  Delivery upon the CSE, Gangs and FGM agenda  Improved quality of multi-agency audits 12

158  Integration of LAC into the designated nurses role  Policy development for management of allegations against staff

13. Key priority areas for 2017/18 13.1 Following a safeguarding team development day, publication of the three LSCBs priorities and benchmarking against statutory and NICE guidance. The safeguarding children’s service have developed the following key priority areas.

 Development of a domestic abuse policy.  Development of a safeguarding children supervision policy.  Review of the CCG safeguarding strategy for 2017-2020.  Review of the safeguarding children training being offered to ensure that it is being delivered in-line with intercollegiate guidance.  Ensure that all commissioned safeguarding roles have up-to-date service specifications in place.  Develop stronger links with primary care through the creation of a GP safeguarding forum.  Continue to work with GPs increase attendance and report submission for child protection conferences.  Continue to work closely with the LSCBs to ensure that robust safeguarding data is being captured and scrutinised.  Continue to work closely with providers to ensure that safeguarding children is embedded into practice.  Ensure that effective safeguarding children supervision is embedded into practice.  Influence the audit plans of the LSCBs to seek assurance that national drivers have effectively been embedded into practice i.e. CSE, FGM.  Responding to the Social Care and Families Act that is due for publication in mid-2017.  Involvement in developments driven by sustainability and transformation plans (STP) e.g. development of a tri-borough child death overview panel.

13.2 These key priority areas will be closely monitored by the safeguarding assurance committee to ensure that the safeguarding service within the CCGs continues to improve.

14. Resources/Investment 14.1 There are no additional resource implications/revenue or capitals costs arising from this report.

15. Sustainability 15.1 If further improvements are made in effectively safeguarding children across the BHR footprint, this will have a positive impact on the long-term outcomes for children and families within the boroughs.

16. Equalities 16.1 This report has considered the CCGs’ equality duty but has not identified any areas that are likely to impact on equality or human rights.

17. Risks 17.1 Failure to ensure that there are constant improvements in the quality of safeguarding children activity may lead to potential harm to patients and reputational damage to the CCGs. The identification of such risks are addressed within the Safeguarding Assurance Committee and escalated to the Quality and Safety Committee when indicated.

18. Managing Conflicts of Interest 18.1 There are no conflicts of interest raised in this report.

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Authors: Paul Archer, Designated Nurse for Safeguarding Children and Looked After Children – Havering

Sue Nichols, Designated Nurse for Safeguarding Children and Looked After Children - Redbridge

Date: 10th October 2017

160

To: Meeting of the Joint Committee of Barking and Dagenham, Havering and Redbridge CCGs

From: Jacqui Himbury, Nurse Director

Date: 30 November 2017

Subject: Looked After Children Annual Report

Executive summary

This is the fourth looked after children annual report and reflects achievements, risks and all works completed in 2016-2017.

The report is written to provide assurance to the Committee that each Clinical Commissioning Group (CCG) is discharging its statutory responsibility to safeguard the welfare of children and meet the health needs of looked after children across the BHR health economy.

This report will address the following areas:  Accountability assurance framework  National and local context of looked after children  Initial health assessments  Review health assessments  Arrangements for health assessments for children placed outside the BHR footprint  Audit arrangements  Unaccompanied asylum seeking children  Access to health services  Corporate parenting panels  Adoption arrangements  Looked after children training  Priorities and key achievements for 2016/17  Key priorities for 2017/18

Recommendations

The Committee is asked to:  Review and discuss the looked after children agenda outlined in this report  Suggest any additional actions that are required for further improvements or assurance

161 1. Purpose of the Report 1.1 This report provides the Committee with an overview of looked after children (LAC) across the BHR health economy during 2016/17. The report reviews the work across the year, giving assurance that each CCG has discharged its statutory responsibilities to safeguard the welfare of children and meet the health needs of LAC across the health services it commissions.

1.2 The report will also highlight significant risks within the LAC agenda and demonstrate how the safeguarding team within the CCGs are managing and mitigating the risks.

1.3 Additional information is included about national changes and influences, as well as local developments, priorities and activity.

2. Introduction 2.1 According to the Children Act 1989 a child is looked after by an authority if he or she is in their care or if he or she is provided with accommodation for a continuous period of more than 24 hours by the authority in the exercise of its social services function. Children are taken into care for a variety of reasons, the most common being to protect a child from abuse or neglect. In other cases their parents could be absent or may be unable to cope due to disability or illness.

2.2 Continued development of the LAC agenda will ensure that the services we deliver and commission are safe, effective and provide a positive outcome for children, young people who have been placed in the care system.

2.3 This report will address the following areas:  Accountability assurance framework  National and local context of looked after children  Initial health assessments  Review health assessments  Arrangements for health assessments for children placed outside the BHR footprint  Audit arrangements  Unaccompanied asylum seeking children  Access to health services  Corporate parenting panels  Adoption arrangements  Looked after children training  Priorities and key achievements for 2016/17  Key priorities for 2017/18

3. LAC accountability assurance framework 3.1 CCGs are statutorily responsible for ensuring that the organisations from which they commission services provide a safe system that safeguards children and adults at risk of abuse or neglect. This includes specific responsibilities for Looked-After Children as defined by the Children Act (1989) Local authorities have the same responsibilities in relation to the public health services that they commission.

3.2 The Safeguarding Vulnerable People in the NHS Accountability and Assurance Framework (NHS England 2015) sets out the requirements necessary for CCGs to be able to demonstrate that they have appropriate systems in place for discharging their statutory duties in terms of safeguarding. These include:

162  A clear line of accountability for safeguarding, reflected in the CCGs’ governance arrangements, i.e. a named executive lead to take overall leadership responsibility for the organisation’s safeguarding arrangements.  Clear policies setting out their commitment, and approach, to safeguarding including safe recruitment practices and arrangements for dealing with allegations against people who work with children and adults as appropriate.  Training their staff in recognising and reporting safeguarding issues, appropriate supervision and ensuring that their staff are competent to carry out their responsibilities for safeguarding.  Effective inter-agency working with local authorities, the police and third sector organisations which includes appropriate arrangements to cooperate with local authorities in the operation of Local Safeguarding Children Boards (LSCBs), Local Safeguarding Adults Boards (LSABs) and Health and Wellbeing Boards.  Ensuring effective arrangements for information sharing.  Employing, or securing, the expertise of Designated Doctors and Nurses for Safeguarding Children and for Looked After Children (LAC) and a Designated Paediatrician for unexpected deaths in childhood.

4.2 Although the CCGs’ Accountable Officer holds ultimate accountability for safeguarding children, the Nurse Director holds Governing Body responsibility.

4.3 The CCGs take a cross generational approach to safeguarding children, young people and adults. This is delivered through the CCGs’ Quality and Safeguarding Team and provides strategic leadership for safeguarding children, Looked-After Children and vulnerable adults across the local health economy. The roles provide leadership, quality assurance, training, supervision and specialist clinical advice on safeguarding to the CCGs and to provider organisations.

4.6 The CCGs currently have a contractual arrangement with NELFT NHS Foundation Trust to employ the Designated Doctors for Safeguarding Children across the BHR footprint and the Sudden Unexpected Death in Infancy Consultant role in Redbridge. The Designated Doctor for Looked-After Children is directly employed by the CCGs.

163 4.7 The CCGs also fund the named GP role and have resources in place to cover this function in Barking and Dagenham and Havering. However, this remains a vacant post in Redbridge and therefore represents a significant risk within Redbridge CCG. This is currently on the safeguarding children risk register and a business plan has been submitted to ensure this function is covered in 2017/18.

5.3 Monitoring of serious case review recommendations is undertaken collaboratively with the LSCBs to ensure external scrutiny.

6. National and Local Context of Looked After Children 6.1 In 2017 the numbers of looked after children in England continue to increase. After small rises of 1% each year between 2014 and 2016, the rise this year has been greater at 3%. At 31 March 2017 there were 72,670 looked after children in England, an increase of 2,220 on 2016, and an increase of 4,600 on 2013. At 31 March 2017, 62 children per 10,000 of the population were looked after, up from 60 children per 10,000 in the previous four years (see table 1).

Table 1: Number of looked after children nationally at 31st March 80000 72670 70000 68070 68820 69500 70450 60000 50000 40960 40000 37490 38020 38520 39680 30000 30580 30800 30980 30770 31710 20000 10000 0 2013 2014 2015 2016 2017

Male Female Total

6.2 The national picture has not been mirrored locally within Barking and Dagenham and Havering where the number of LAC steadily decreased since 2015. However,

164 Redbridge has seen a steady increases within the same timeframe. Table two gives a ‘snap shot’ view of the number of LAC on a specific given day whereas table 3 gives an overview of the total number of LAC who have been through the care system over a 12 month period.

6.3 It is important to note that these statistics only show looked after children that originate from each of the boroughs but does not capture the number of children who have been placed in Barking and Dagenham, Havering or Redbridge by another local authority. Across the BHR footprint we currently have children placed with us from at least 15 other local authorities.

6.4 It also needs to be acknowledged that the LAC population is extremely fluid with placement changes and children coming into and leaving care on a daily basis.

Table 2: Number of Looked After Children at 31st March

500 455 450 415 415 410 400

300 240 230 245230 205 205215 215 215 185 200

100

0 2013 2014 2015 2016 2017

Barking and Dagenham Havering Redbridge

Table 3: Total number of looked after children 2013-2017

800 715 715 655 655 700 610 600 500 420 385 380400 400 320 325350 330 350 280 300 200 100 0 2013 2014 2015 2016 2017

Barking and Dagenham Havering Redbridge

6.5 Locally we have seen an overall increase in the total number of children who have begun to be LAC over the past 5 years and an increase in the overall number of

165 children who have ceased to be looked after (see table 4 and 5). The reasons for ceasing to be looked after can be for a variety of reasons including:

 Returned to the care of parents  Care leaver at age 18  Placed with another family member under special guardianship order  Adoptions

Table 4: Number of children who started to be looked after 2013-2017

350 310 300 270 245 250 220 210 195 185 200 160 145145 145135 150 115 100105 100 50 0 2013 2014 2015 2016 2017

Barking and Dagenham Havering Redbridge

Table 5: Number of children who ceased to be looked after 2013-2017 300 275 275 250 255 255

200 195 205 165 175 150 140 140 140 120 130 120 100 100

0 2013 2014 2015 2016 2017

Barking and Dagenham Havering Redbridge

7. Adoptions 7.1 The ultimate aim of children’s social care and its key partners is to work with birth families, manage risk, and reunite families with their children under close supervision. However, in certain circumstances the risks associated with family contact are either too high or birth parents wish to relinquish their parental responsibility.

7.2 Rather than have a child in the care system until they turn 18 years of age, it is more beneficial to the child to be freed up for adoption. Adoption is a legal process where

166 birth parents relinquish their parental responsibility, and parental responsibility is given to another family.

7.3 Nationally the number of looked after children ceasing to be looked after due to adoption increased between 2011 and 2015 from 3,100 to a peak of 5,360. Last year the number of adoptions fell for the first time since 2011, by 12% and in 2017 the number of looked after children adopted has fallen again, by 8% to 4,350.

7.4 This is a picture that is reflected in our local population where there has been a significant decrease in the number of adoptions when compared to 2015 (see table 6).

7.5 It is currently unclear why there has been a significant decrease in the number of adoptions given that there have been tighter timeframes introduced for the completion of adoption. However, the early help offer, the use of public law outline, smarter child protection plans and the use of guardianship orders will have all had an impact on the number of cases that progress to adoption.

Table 6: Number of looked after children who were adopted in 2013-2017 40 35 35 30 25 25 20 20 15 15 15 15 10 10 10 10 5 5 5 0 0 0 2013 2014 2015 2016 2017

Barking and Dagenham Havering Redbridge

8. Unaccompanied asylum seeking children 8.1 Another factor that has influenced our local LAC population is the number of unaccompanied asylum seekers placed across the BHR footprint.

8.2 Section 17 of the Children Act 1989 imposes a general duty on local authorities to safeguard and promote the welfare of children within their area who are in need.

8.3 Children seeking asylum (UASC) who have no responsible adult to care for them are separated or ‘unaccompanied’, and are therefore ‘in need’. The relevant local authority children’s social services department has a gateway duty to assess such children under section 17, and then, almost always, to accommodate them under section 20 of the Children Act 1989.

8.4 A child asylum seeker’s first encounter with the Home Office can be the point at which a welfare referral involves the relevant children’s services. This will, in the first instance, always be the local authority in which the child is present.

8.5 In July 2016 the national transfer scheme was introduced for unaccompanied asylum- seeking children (UASC) arriving in the UK, so that children are no longer necessarily

167 cared for in the local authority in which they first present, but instead may be transferred to an authority with greater capacity on a voluntary basis.

8.6 Locally, the number of UASC has remained fairly stable over the past four years with a peak in 2016 when the national transfer scheme was initially introduced (see table 7).

Table 7: Number of unaccompanied asylum seeking children at 31st March 2013-2017 40 35 35 30 30 25 25 25 25 20 20 20 20 15 15 15 10 5 0 0 0 2013 2014 2015 2016 2017

Barking and Dagenham Havering Redbridge

8.7 It is important to note that some of these children will have suffered persecution, genocide, civil war, death of family members, and separation from family members that will all impact on the young person’s mental health and their ability to integrate into British society.

8.8 The need for robust health assessments and health services for this population of children is also of the highest importance as there is often no or little available health histories including unknown date of birth, childhood illness history, and vaccination history.

9. Initial Health Assessments 9.1 In 2009 the department of health stated that ‘looked after children and young people share many of the same health concerns than their peers, but often to a greater degree. They often enter care with a worse level of health than the peers, in-part due to the impact of poverty, abuse and neglect.’ Therefore, it is important that all looked after children have their health needs assessed.

9.2 Following the death of Dennis O’neil in 1945, it became mandatory for all looked after children to have a medical assessment by a doctor within a month of coming into care. This was then underpinned in law following the Children Act 1989. It is now a statutory requirement that all children coming into care to have an initial health assessment (IHA) within 20 working days. In order for this process to occur, a request together with completed paperwork needs to be received by the LAC health team from the local authority.

9.3 There has been good compliance with achieving this target across the BHR footprint from when NELFT receive the IHA paperwork to final completion. There are still a number of areas that need further development to ensure continued compliance with statutory guidance. For example:

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 There can be significant delays in IHAs being completed in timeframes when LAC are placed in other local authority areas outside of the BHR footprint.  Quality issues of IHAs when completed by out of area GPs.  Staffing issues that have resulted in the unavailability of a paediatrician.  Delays in the local authority submitting paperwork to the LAC health team.  LAC refusing to engage with an IHA

9.4 The CCGs are working closely with the local authorities and the LAC health team to address some of the issues outlined above to improve the compliance of IHAs being completed within timeframes.

10. Review Health Assessments 10.1 It is a statutory requirement that all LAC receive a review health assessment (RHA) every six months for the under 5s cohort and then annually thereafter.

10.2 RHAs are generally provided by the health visiting or school nursing services and this process is overseen by a specialist LAC nurse. The provider usually has capacity to undertake high quality RHAs across the BHR footprint when requested.

10.3 There can sometimes be issues with engaging with older aged LAC for their review health assessments, therefore the LAC Health Team will spend a considerable amount of time to try and engage the young people in their health.

10.4 There are also ongoing issues with the quality of RHAs undertaken outside the BHR footprint. This will be discussed in more detail in section 9 and 10.

11. Arrangements for health assessments for children placed outside the BHR footprint 11.1 Under NHS England guidance ‘Who pays: Determining responsibility for payments to providers’ (2013) the “originating CCG” remains the responsible CCG for the services which CCGs have responsibility for commissioning, even where the child registers with another GP practice.

11.2 To fulfil this statutory duty, the CCGs will commission individual health assessments from GPs or specialist nurses for children who are placed outside of the BHR footprint.

11.3 In order to ensure quality of health assessments undertaken out of area, The Designated Doctor for Looked After Children has implemented a quality standard checklist that is sent out with IHA/RHA paperwork when a health assessment is undertaken out of area. This is to ensure that the standards of health assessments and terms and levels of payment are clear from the outset with a view to improve and maintain quality and timeliness of assessments.

11.4 If an issue arises where a poor quality IHA/RHA has been returned, the case will be escalated to the Designated Nurse/Doctor and the CCG will withhold payment until the health assessment has been updated and amended.

12. Audit arrangements 12.1 The CCGs have arrangements in place to ensure that there is consistent quality of initial and review health assessments undertaken across the health economy. The LAC health team quality assure all IHA/RHAs undertaken and request amendments as appropriate.

169 12.2 In addition to this, the CCGs conduct their own independent audits to quality assure health assessments. If concerns arise, these are addressed directly with providers using existing contractual leavers.

13. Vulnerabilities of looked after children 13.1 Although health assessments are an important aspect of the care of a looked after child, it is important the IHA/RHAs also identify any vulnerabilities that the child may have.

13.2 There is an assumption that looked after children are safe within the care system. Whilst most children living in care are kept safe from harm, a small number still remain at risk of abuse and neglect whilst they are within the care system.

13.3 Children may enter care for all sorts of reasons but the most common reasons are because they have been subjected to abuse or neglect at the hands of their birth parents. These experiences can leave children with complex physical, emotional and mental health needs. This can significantly increase their vulnerability to abuse whilst in the care system.

13.4 Many children also move repeatedly in and out of care, or between placements. This can prevent them from forming stable relationships with adults who could help protect them.

13.5 Some of the significant risk factors associated with looked after children are:

 Risk of running away  Risk of child sexual exploitation  Risk of being embroiled into gang activity  Childhood obesity  Risk of criminal activity  Risk of drug and alcohol misuse  Risk of early sexual debut which in-tern can lead to sexually transmitted infections and teenage pregnancy  Risk of poor educational outcomes

13.6 Some of the ways we manage these risks across the BHR footprint are:

 Oversight of all missing children via the corporate parenting panels  Risk management of CSE and gang cases via the Multi Agency Sexual Exploitation (MASE) panel.  Early identification of childhood obesity via review health assessments and onward management and referrals as appropriate.  Health promotion activity to promote healthy lifestyles and positive relationships.  Signposting to youth friendly sexual health services.  Oversight of LAC education via the virtual school and personal education plans (PEP).

14. Meeting the health needs of looked after children 14.1 The emerging health needs of looked after children are often complex and diverse.

170 14.2 The designated doctor for looked after children undertook an audit of IHAs across Barking and Dagenham and Havering to establish the emerging health needed of the LAC population. The audit looked at a total of 268 IHAs across the two boroughs and identified the most common emerging health needs (see table 8).

14.3 Although Redbridge was not included in this audit, we can assume that similar priority areas will be identified.

14.4 The highest priority area identified from IHAs were unmet dental needs, eye health checks, emotional wellbeing, and incomplete immunisations. Some of these unmet health needs are easily rectified once identified i.e. opticians, dentist, immunisations. However, the emotional health and well-being of a looked after child is complex and can take years to adequately address.

14.5 The CCGs are working closely with the joint children’s commissioners to ensure that the identified needs of looked after children are effectively commissioned for and that there are effective measures in place to ensure quality outcomes. This work will continue to be developed and delivered upon in 2017/18.

Table 8: Emerging health needs from IHAs 90 82 80 72 70 56 60 48 50 42 40 23 30 18 14 14 20 9 9 12 9 5 7 5 7 10 1 3 2 1 3 3 2 0

Barking and Dagenham Havering

14.6 In order to help identify the emerging emotional problems of looked after children, every looked after child between the ages of 4 and 16 years are asked to partake in a strengths a difficulties questionnaire (SDQ). The SDQ is a behavioural screening tool that assesses young people against the following areas:

 Emotional symptoms  Conduct problems  Hyper-activity/inattention  Peer relationship problems  Pro-social behaviour

14.7 The SDQ is not a diagnostic tool but is more of an indicator as to where a child may experience problems. If significant emotional problems are identified, onward referrals to CAMHS should be made to ensure appropriate diagnosis and treatment.

171 14.8 All identified health needs should be referenced in the health care plan section of initial and review health assessments and will then feed into the child’s overarching care plan that is then managed by the allocated social worker with oversight from the independent reviewing officer.

14.9 The CCGs, in partnership with the local authority, will commission services on an individual basis if the needs of a looked after child cannot be met via our standard contracts with providers. To help with this process, the CCGs are developing a complex case panel in conjunction with the local authority to ensure that the health needed of looked after children are being robustly met.

14.10 It is important to note that one of the highest risk areas associated with looked after children is access to CAMHS services. With CAMHS provision across the country being under increased pressure, there is often a large waiting list for looked after children to access an appropriate service.

14.11 This risk is currently being managed by the joint children’s commissioners and the designated nurses and cases are being escalated on an individual basis to ensure that vulnerable children are receiving an appropriate service.

14.12 There have also been identified problems with looked after children having access to community mental health services when they transition into adult services when they turn 18 years of age.

15. Ofsted Inspection 15.1 The transition of children was also an area of concern that was identified in the Havering Ofsted inspection. As a result of this, the local authority has been awarded a grant from the department for education and will be working with looked after children in 2017/18 to deliver a transition conference and look at transition delivery across the cohort.

15.2 Although the Ofsted inspection also looked at provider services in health, the overall inspection didn’t identify any major gaps in service provision. All of the provider organisation have actions plans are these are being scrutinised on a regular basis via CQRM and safeguarding operational meetings.

16. Corporate parenting panels 16.1 External to the CCGs, accountability and scrutiny for the services provided to looked after children from multiagency partners is directed through the Corporate Parenting Panel. The designated nurses and designated doctor for looked after children represent the CCGs and the local health economy at the corporate parenting panels within the local authorities.

16.2 The term corporate parent was first introduced in Care Matters Report 2006 around transforming the life for children and young people in care. A Corporate parent is all staff employed by public bodies who should advocate for looked after children and young people as if they were their own child.

16.3 In addition to this, the designated nurses co-chair with the local authority a LAC health sub-group which feeds into the corporate parenting panel and provides the panel with evidence that the local health economy it fulfilling its statutory duties for meeting the health needs of looked after children.

172 17. Looked After Children Training 17.1 The Intercollegiate Guidance (2015) for Looked after Children sets out the knowledge, skills and competencies required of health staff (at level 1-5) that work directly or indirectly with LAC. This includes primary care and allied health professionals.

17.2 The CCGs are working closely with provider organisations to ensure that there is compliance for LAC training and that it is fit for purpose. In addition to this, the specialist nurses for LAC are receiving 1-2-1 supervision from the Designated Nurses for Safeguarding and LAC.

17.3 The designated doctor and designated nurses have also participated in the GPs education program to ensure that primary care is compliant with intercollegiate guidance.

18. Key Objectives 2016/17 18.1 The identified key objectives for 2016/17 were as follows:

 Achieving statutory compliance with the LAC health assessments and to continue to improve the quality of the assessments.  Develop and agree robust arrangements for ensuring the strategic oversight and performance management of the health needs of looked after children in Barking and Dagenham.  To raise the profile of LAC within GP practices.  BHR CCGs to monitor the new LAC service specification.

18.2 There has been considerable progress against these objectives including:

 Quality assurance of health assessments using checklist.  CCG audit of initial and review health assessments.  Monitoring of KPI compliance via CQRM meetings and safeguarding assurance committee.  Development of performance on a page for LAC.  Development of a LAC development group.  Attendance of corporate parenting panels and LAC health sub groups.  Providing LAC training to GPs

19. Key priority areas for 2017/18 19.1 Following the development of a LAC strategy (see appendix 1) and undertaking a gap analysis against statutory guidance, the CCGs have identified the following key areas of development for 2017/18:  To ensure the improved quality of initial and review health assessments for looked after children.  To foster a stronger working relationship between the CCGs and providers.  To have an increased understanding of the local LAC population.  To improve the quality and scrutiny of LAC health data.  To develop a stronger working relationship with the local authority.  To improve how health services engage with looked after children and foster carers.

173 20. Resources/Investment 20.1 There are no additional resource implications/revenue or capitals costs arising from this report.

21. Sustainability 21.1 If further improvements are made in effectively meeting the needs of looked after children across the BHR footprint, this will have a positive impact on the long- term outcomes for children and families within the boroughs.

22. Equalities 22.1 This report has considered the CCGs’ equality duty but has not identified any areas that are likely to impact on equality or human rights.

23. Risks 23.1 Looked after children’s access to appropriate CAMHS services

23.2 Quality of initial and review health assessments undertaken outside of the BHR footprint.

23.3 IHA paperwork being provided to LAC health teams within a timely manner.

23.4 Meeting the health needs of looked after children outside of the BHR footprint.

24. Managing Conflicts of Interest 24.1 There are no conflicts of interest raised in this report.

Authors: Paul Archer, Designated Nurse for Safeguarding Children and Looked After Children – Havering

Dr Sophie Niall, Designated Doctor for Looked After Children

Date: 11th October 2017

174 Appendix 1: CCGs’ LAC Strategy

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To: Meeting of the Joint Committee of Barking and Dagenham, Havering and Redbridge CCGs

From: Jacqui Himbury Nurse Director

Date: 30 November 2017

Subject: Adult Safeguarding Annual Report 2016/17

Executive summary This is the fourth annual safeguarding adults report presented to the joint committee with the purpose of providing assurance on the effectiveness of adult safeguarding arrangements in the Clinical Commissioning Groups (CCGs) and across the system. The report covers the period 1 April 2016 to 31 March 2017. Safeguarding adult duties are now statutory requirements that we must adhere to, and there is also a duty placed on agencies to cooperate to help and support adults in need and their carers.

The term ‘adult safeguarding’ covers everything that assists an adult at risk of abuse and neglect to live a life that is free from harm, and which enables them to retain independence, well-being, dignity and choice. It is about preventing abuse and neglect, as well as promoting good practice for responding to concerns on a multi-agency basis. Whilst the responsibility for coordinating safeguarding adult’s arrangements lies with local authorities, effective safeguarding is based on collaboration, a local multi- agency approach and strong partnerships. The CCGs are statutory members of the local Adult Safeguarding Boards (SAB).

Adult safeguarding is extremely wide ranging, however this report focuses specifically on:  The prevention of harm and abuse through provision of safe, effective and high quality care  Effective responses to allegations of harm and abuse, responses that are in line with local multi-agency procedures: and  Using learning and the sharing of information to improve service to patients, their families, carers and members of the public.

Safeguarding adults from harm is one of the CCGs’ priorities and this report describes the arrangements that are in place to do this.

The CCGs have a commissioning responsibility to ensure that the organisations we commission from have effective safeguarding arrangements in place and that the Government approved safeguarding principles are applied in terms of how we operate as organisations and when working with our partners. This annual report details how the CCGs have fulfilled their obligations and demonstrates how the NHS Outcomes Framework informs our plans especially for:  Domain 4 - Ensuring people have a positive experience of care: and  Domain 5 -Treating and caring for people in a safe environment and protecting them from avoidable harm.

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Recommendations The Committee is asked to:  Discuss the report and advise on any further actions required  To agree the recommendations for 2017/18 safeguarding adult priorities in section 23

1.0 Purpose of the Report

1.1 To provide assurance that during 2016/17 the CCGs complied with and will continue to comply with all our statutory safeguarding duties and the best practice safeguarding standards as set out in: “Safeguarding Adults: The role of NHS commissioners (2011); pan London policy and procedures to safeguard adults (2011); Safeguarding Vulnerable People in the NHS: Accountability and Assurance Framework (2015). The Care Act (2014)”.

1.2 To provide an annual update to the committee on the 2016/17 service developments for adult safeguarding and to confirm that we have reviewed our safeguarding arrangements over the last 12 months to ensure we are working effectively.

1.3 The report also informs members of the adult safeguarding duties and responsibilities and how the organisation fulfils these. This includes partnership working with the Safeguarding Adults Board (SAB) of which we are a statutory member along with the local authority and the police.

2.0 Introduction

2.1 The CCGs are committed to working with partner agencies to ensure the safety, health and wellbeing of our patients and local people.

2.2 Protecting those at risk of harm is a key part of the CCGs’ approach to commissioning, and, together with a focus on quality and patient experience, is integral to our working arrangements.

2.3 Our approach to adult safeguarding is underpinned by quality (assessment, assurance and improvement) and contracting systems and processes that aim to reduce the risk of harm and respond quickly to any concerns.

2.4 This is the fourth CCGs Adult Safeguarding Annual Report and will provide assurance on how the CCGs are meeting their statutory requirements for safeguarding adults at risk of abuse and neglect. The report will also provide an overview of the progress made during the year 2016-17.

3.0 Safeguarding Adults within the NHS

3.1 Safeguarding adults is the responsibility of NHS funded organisations and all healthcare professionals working in the NHS have a duty to ensure that the principles underpinning adult safeguarding are applied; by delivering safe and high quality care and support. Working with the principles of the Mental Capacity Act (2005) healthcare professionals need to respect the decision making of the individual who is experiencing or is at risk of being abused and neglected.

3.2 There is a distinction between provider responsibilities and those for commissioners who need to assure themselves of the safety and effectiveness of the services they have commissioned and that the requirements of the Mental Capacity Act are embedded in the work of organisations. Good partnership working is important and healthcare commissioners and professionals should have developed relationships and collaborative working arrangements with colleagues across the

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safeguarding system. The CCGs have well developed and stable relationships with all partners and stakeholders across our systems and we will continue to do this through the Safeguarding Adults Boards (SAB).

4.0 Safeguarding National Context

4.1 The statutory safeguarding duties of CCGs have in this reporting period (April 2016 – March 2017) been clarified through a number of national documents. The impact of the 2014 Care Act requirements has generated a wide array of policy requirements and guidance in support of these new responsibilities. These documents are intrinsically linked to the ongoing developments required for 2017/18. The CCGs are compliant with the accountabilities and requirements in the following:

5.0 NHS Accountability and Assurance Framework:

5.1 Safeguarding Vulnerable People in the Reformed NHS: Accountability and Assurance Framework (NHS Commissioning Board 2013: revised NHSE June 2015).

5.2 This framework describes the safeguarding roles, duties and responsibilities of NHS England, Clinical Commissioning Groups, NHS providers and various other bodies in the health system. During 2015 NHS England announced a set of revised arrangements within the framework; these were required in order to take account of:

 The wider context for safeguarding which has changed in response to the findings of large scale inquiries, incidents and new legislation.  New and revised statutory and intercollegiate guidance.  The changes to the NHS commissioning system, with the introduction of co- commissioning from April 2015 it was seen as important that safeguarding roles were made clear.  Feedback from practitioners working across the health system.  The restructuring process in NHS England at regional and local levels.

5.3 Following consultation in early 2015 the refreshed Accountability and Assurance Framework was published in July 2015. This framework describes the relationships, legal frameworks, principles and attitudes that enable the health system to effectively safeguard adults, it also reinforces the shift in focus outlined in “Making Safeguarding Personal” in its aim.

“ to promote empowerment and autonomy for adults, including those who lack capacity, for a particular decision as embodied in the Mental Capacity Act 2005, implementing an approach which appropriately balances this with safeguarding” (July 2015 pg. 8)

5.4 This shift reinforces all agency responsibilities in focussing adult safeguarding work away from process and procedures to one of giving those people who are using safeguarding services more engagement and control in the resolution of their circumstances. The CCGs use this aim to underpin and inform their safeguarding work.

6.0 Care Act (2014)

6.1 Care Act legislation came into force in April 2015 and, at that time work was ongoing across BHR to ensure the requirements of the Act were met. These obligations are now statutory and local authorities are required to promote integration with the NHS and other stakeholders. It places a statutory duty on agencies to cooperate to help and support adults in need and their carers; it

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fundamentally aims to place people at the centre of their care and support and to maximise their involvement. The CCGs fulfil the duty to cooperate. We do this by:

 Fully cooperating with and financially contributing to the SABs in publishing a 3-5 year strategic plan that sets out how we intend to protect and safeguard people across our borough.  Meeting all of the objectives and aims within the strategic plan and contributing to the Annual Safeguarding Adults report which details the SAB’s activity during the year and describes what each member agency has achieved.  Fully participating in all Safeguarding Adult Reviews (SAR) and ensuring that any lessons learned are shared and that organisations use the learning to improve safeguarding practice.

6.2 The key legislative focus in adult safeguarding is based on who can make decisions; adults have a legal right to make their own decisions, even if they are deemed eccentric or unwise, as long as they have the capacity to make that decision and are free from coercion or undue influence. Through our commissioning framework and quality assurance systems we ensure that all providers meet this legislative requirement.

6.3 The CCGs have a Designated Adults Safeguarding Manager (DSAM) and this post is now funded substantively in our structure. The recruitment process for this post ended in February 2017 with the successful appointment of 1WTE post holder. The purpose of this role is to be the organisational expert for all adult safeguarding issues, risks and concerns and actively promote safeguarding best practice across the borough both internally and externally.

6.4 The Duty of Candour regulation was also introduced. This is a key recommendation from the Francis Inquiry into the Mid Staffordshire Foundation Trust and from 1 April 2015 all providers must comply with the Duty of Candour requirements. Our providers are monitored on delivery of this regulation through our quality contract monitoring process with performance being reported in the contracting and performance report. The purpose of this regulation is to ensure openness, transparency and trust.

6.5 The other new requirement is the Fit and Proper Persons Test for all directors or those acting in an equivalent role within any NHS service provider.

7.0 The Criminal Justice and Courts Act 2015

7.1 The Criminal Justice and Courts Act came into force 13 April 2015 (applying to offences committed after this date) and includes both individual care workers and provider organisations in offences of ill treatment or wilful neglect. This care provider offence can be committed by a range of organisations, by hospitals or by partnerships, e.g. a GP partnership.

8.0 Domestic Violence, Crime and Victims Act 2004 (updated 2014)

8.1 Places a duty on Community Safety Partnerships to make arrangements for Domestic Homicide Reviews; Health agencies including CCGs are required to participate in these. The CCGs have participated in all reviews when required to do so.

9.0 DH Best Practice Guidance for NHS Staff

9.1 In order to support and enable healthcare agencies NHSE is developing a set of essential competencies and roles for all staff working within an adult safeguarding environment. The

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CCGs’ designated professionals have had an opportunity to comment on this document as it has been developed. Final publication is expected in the summer of 2017.

10.0 Mental Capacity Act (2005) Deprivation of Liberty Safeguards (DoLS)

10.1 The Mental Capacity Act (MCA) aims to empower people to make decisions for themselves as much as possible and to protect people who may not be able to take some decisions. The MCA is supported by a Code of Practice and health staff members are specially highlighted as a category of professionals who are required to understand and work within this code of practice. The interdependencies between MCA and safeguarding can only be addressed if staff members are fully aware of their responsibilities.

10.2 NHSE expects, as a legal duty, that all NHS funded providers meet the requirements of this Act. CCGs must also be assured that the services they commission are compliant for all members of the population who are over 16 years of age. The CCGs obtains assurance from providers through its Safeguarding Standards and quality assurance processes. During 2016/17 there were no local breaches of the MCA regulations.

10.3 The Deprivation of Liberty Safeguards (DoLS) within the MCA provide a legal protective framework for those vulnerable/at risk people who are deprived of their liberty and not detained under the Mental Health Act 2005. These safeguards apply to people in hospitals and care homes (whether privately or publicly funded) and their purpose is to prevent decisions being made which deprive vulnerable people of their liberty. In the event of it being necessary to deprive a person of their liberty, the safeguards give them rights to representation, appeal and for any authorisation to be monitored and reviewed. All requests for Deprivation of Liberty Safeguards are led by the local authority and the CCGs monitor the number of applications by each provider using benchmarking data for assurance that the expected number of applications are being made.

10.4 During 2015/16 the number of DoLS applications for BHRUT was moderately below the expected number. This indicated that BHRUT was not applying the MCA/DOLS process appropriately. This was raised at the clinical quality review meetings and towards the end of 2015/16 the number of applications from BHRUT increased as an improvement plan was implemented. BHRUT successfully secured substantive funding to appoint a MCA/DOLS coordinator; with substantive 1WTE taking up employment during the period 2016/17.

11.0 Lampard Report (2015)

11.1 In February 2015 the final Lampard Report was published following an investigation into the abuse of children by Jimmy Savile. This report provided independent oversight of the NHS and Department of Health investigations into the role and activities of Jimmy Savile in health organisations. The report focussed on the findings and conclusions of NHS investigations with the intention of strengthening patient care and safety. Although this investigation and report related to child abuse the lessons learned are applicable to all health and care settings. Therefore the CCG has ensured the lessons learned and any required changes in adult health/care settings have been made.

11.2 The common themes relevant to the wider NHS are as follows:

 Security and access arrangements (including celebrities/VIPs)  Role and management of volunteers  Safeguarding arrangements

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 Raising complaints and concerns  Fundraising and charity governance  Observance of due process

11.3 There is still some concern that, although awareness amongst NHS staff of safeguarding and of their obligations to protect patients has increased markedly in recent years, staff may not necessarily recognise the implications of these issues for themselves or their organisations.

12.0 PREVENT Statutory guidance issued under section 29 of the Counter-Terrorism and Security Act (2015)

12.1 This Act came into force in February 2015 and created a new duty on certain bodies to have due regard to the need to prevent people from being drawn into terrorism. This duty applies to some NHS bodies, amongst a range of others. Associated guidance sets out the main expectations of the main bodies subject to the duty.

12.2 Key duties of the Act were also included in the 16/17 NHS Standard Contract with requirements for a Prevent Lead, Policies and Procedures and compliance with the principles contained in the Government Prevent Strategy/Guidance Toolkit. This included the need to have a programme to raise awareness amongst all staff and volunteers as supported by new Prevent Training and Competencies Framework developed in conjunction with the 2014 Intercollegiate Document (ICD).

12.3 The Core Standards for Emergency Preparedness now require Acute Trusts, NHSE,CCGs and NHS Funded Providers to define how they are meeting the Prevent Strategy’s objectives of: -

 Responding to the ideological challenge of terrorism and the threat faced from those who promote it.  Preventing people from being drawn into terrorism and ensuring that they are given appropriate advice and support.  Working with sectors and institutions where there are risks of radicalisation which need to be addressed

13.0 CCGs Safeguarding Operational Delivery

13.1 Safeguarding Leadership

13.2 The Chief Accountable Officer discharges all safeguarding accountabilities through delegation to the Nurse Director who is the Governing body Executive Lead for Safeguarding. This post holder is a member of the local Adult Safeguarding Boards (RSAB) and is supported to fulfil the required functions by the Deputy Nurse Director. The Deputy Nurse Director has delegated responsibility for safeguarding (adults & children), and has represented the CCGs within the adult safeguarding partnership arrangements. The Designated Adult Safeguarding Manager is the operational lead for adult safeguarding, and is also the MCA/DOLS and PREVENT lead.

14.0 Progress against 2016/17 Priorities

14.1 Strengthening Safeguarding Arrangements

14.2 The CCGs safeguarding arrangements fully comply with the Government’s requirements for the Care Act, to further strengthen our partnership with the SAB and to raise organisational awareness of safeguarding as everybody’s business. During this reporting period we have

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achieved this through a number of activities including further development of the Designated Adults Safeguarding Manager (DASM) role. The DASM has worked closely with all safeguarding professionals and other clinical staff groups to enable a cultural transformation from reactive working to early intervention and prevention.

15.0 Learning and Improvement

15.1 The safeguarding team have continued to champion competency based learning for all staff and practitioners across the health system and reviewed and endorsed safeguarding training modules both within the CCGs, across primary care and with providers.

15.2 Changes in the way the CCGs monitor training have led to improvements in the percentage of staff who have completed Level 1 adult safeguarding and PREVENT Awareness training. However the organisation is not yet consistently over 95% compliant despite an improvement plan being in place. As of 31 March 2017 adult safeguarding training figures were as shown below:

CCG Adult Safeguarding PREVENT Awareness

Barking & Dagenham 71% 71%

Havering 81% 95%

Redbridge 94% 94%

15.3 During 2017/18 individual members of staff/ GB members who have not completed their training will receive personal notification of the need to complete adult safeguarding training and all new members of staff are now required to complete their training within the first week of employment.

15.4 The DASM has worked collaboratively with the NHS England (London) CCG Safeguarding Leads Forum in facilitating lessons learnt sessions and ongoing personal development within safeguarding adult’s roles.

15.5 There has been ongoing support for the Primary Care Protected Learning Event (PLE) events which have prioritised safeguarding. All evaluations have demonstrated high levels of satisfaction. An ongoing training programme is in place.

16.0 Contribution to Multi Agency Safeguarding Arrangements and Multi Agency Partnership Working

16.1 Safeguarding Adult’s Boards. The Safeguarding Adult Boards have been the key mechanism for promoting and protecting the safety of adults at risk from abuse and neglect. They act as a partnership forum for agreeing how agencies should co-operate to safeguard adults at risk and ensure that local arrangements work effectively to bring about positive outcomes for the borough residents.

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16.2 The CCGs’ commitment to the work of the RSAB and its sub groups is outlined in the table below

Safeguarding Adult Boards Nurse Director Deputy Nurse Director Designated Adult Safeguarding Manager Sub Groups Designated Adult Safeguarding Manager

17.0 Safeguarding Adult Reviews (SAR)

The CCG has fully supported the processes around SARs. A Breakdown of SARs opened and closed are shown below:

CCG SAR Identifier Brief Description of Case Status

Barking & Dagenham RC Choking Death (Learning Disability) Ongoing

Barking & Dagenham JS Ineffective Hospital Discharge Opened

Barking & Dagenham SK Care Provision Failure Opened

Havering SM Child-Adult Transition Concerns Opened

18.0 Domestic Homicide Reviews (DHR) The CCG has fully supported the processes around DHRs. A Breakdown of DHRs opened and closed are shown below:

CCG DHR Identifier Brief Description of Case Status

Barking & Dagenham XX* Mercy Killing Opened

Redbridge XX* Killed by Partner Ongoing

*Anonymised as DHR Report not yet published.

19.0 Performance and Assurance

19.1 The effectiveness of the safeguarding system is assured and regulated by a number of bodies and mechanisms. These include:

 Provider internal assurance processes and Board accountability  The Safeguarding Adult Board  External regulation and inspection - CQC and Monitor (now NHS Improvement)  Effective commissioning, procurement and contract monitoring.

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19.2 All provider services, are required to comply with the Care Quality Commission Essential Standards for Quality and Safety which include safeguarding standards (Standard 7).

19.3 The CCGs performance manage each provider organisation through formal contract review meetings using a contract monitoring risk framework. . In addition the following arrangements are in place to strengthen the CCGs’ assurance processes:

 The DASM is aiming to become a member of each main providers internal safeguarding committees.  Joint commissioner/provider quality contract meetings always consider safeguarding issues/priorities and receive updates on the implementation of action plans from Safeguarding Adult Reviews/Domestic Homicide Reviews.  A programme of announced quality assurance visits continues by the quality and safety team and includes Governing Body members, across all health providers and settings to an agreed methodology.  Systematic reviews of serious untoward incident reports are routinely received from North East London Commissioning Support Unit (NELCSU) at the Quality and Safety Committee.

20.0 Care Homes with Nursing and Safeguarding 20.1 Local Context: the table below provides details of geographic data relating to each CCG area:

CCG Total Over GP Care Homes Population 65’s Surgeries with Nursing

Barking & Dagenham 201,979 20,924 48 7

Havering 253,029 44,815 52 18

Redbridge 296,800 36,200 46 12

Totals 751,808 101,939 146 37

20.2 Each Care Home with Nursing registered with the Care Quality Commission (CQC) is subject to inspection and subsequent rating. The table below shows the breakdown of ratings for homes within the BHR local economy:

Rating %

Outstanding 0

Good 66.66

Requires Improvement 33.33

Inadequate 0

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20.3 There has been an increase in the number of safeguarding incidents in care home settings within BHR during the reporting period and investigations suggest that these are often due to low staffing levels and staff training. In response to this the CCGs have developed closer working relationships with local authority colleagues and other partners including the Care Quality Commission (CQC) and Healthwatch to ensure a robust approach is in place to address concerns in the care home with nursing sector through timely information sharing.

20.4 Effective partnership working and improved intelligence sharing identified 4 local care homes with nursing where serious concerns had been identified during the reporting period:

Care Home with CCG Main Areas of Concern Nursing

Provider 1 Barking & Staffing Levels Dagenham Inadequate Care Planning Nutrition & Hydration

Provider 2 Barking & Staffing Levels Dagenham Medicines Management Issues Repositioning

Provider 3 Havering Staffing Levels Lack of Effective Management Inadequate Assessments & Care Planning

Provider 4 Redbridge Staffing Levels Medicines Management Issues Unmet Medical & care Needs

20.5 As a result, increased frequency of monitoring visits were adopted with closely monitored improvement plans put into place by the CCGs and local authorities.

20.6 The DASM holds responsibility to support the nursing homes across BHR with specific reference to safeguarding issues and the implementation and monitoring of early warning systems across the homes. When any concerns are identified an enhanced level of quality and contract monitoring is implemented using our contract monitoring framework.

20.7 The next phase of this work is to engage with providers to develop positive relationships which will ensure providers are aware of how to access support and share good practice.

21.0 Internal CCG Assurance.

21.1 The Safeguarding Assurance Committee (SAC) continues to meet monthly and provides assurance to the Quality and Safety Committee that the CCGs are fulfilling all safeguarding accountabilities and duties.

21.2 The SAC has reviewed all organisational safeguarding polices, made recommendations for the required updates and once approved, made these available to staff on the intranet.

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21.3 Further assurances relating to safeguarding for our main providers are gained from Clinical Quality Review Meetings (CQRM) held monthly with each provider.

21.4 Adult safeguarding arrangements within the local health economy were compared with the requirements of ‘Safeguarding Vulnerable People in the NHS – Accountability and Assurance Framework’ (NHSE). We continue to be fully compliant.

21.5 Work continued to strengthen the CCGs’ work as a partner organisation on the SAB and continued to actively contribute and participate in the working groups.

21.6 Working continued with the safeguarding named professionals in provider organisations to ensure that safeguarding adult arrangements across the health economy were robust and regularly reviewed.

21.7 There was formal agreement on operational safeguarding arrangements (including the ongoing quality assurance of community care providers) with Local Authority colleagues.

21.8 Safeguarding Standards were updated for NHS funded providers including primary care and implemented during this reporting period.

22.0 Conclusion

22.1 The year 2016/17 has been a period of consolidation for adult safeguarding in Barking & Dagenham, Havering, and Redbridge CCGs (BHRCCGs) with a focus in the latter quarter on the planning and developments needed to ensure that the new Care Act requirements continue to be met.

22.2 The CCGs have taken seriously the fulfilment of this new statutory duty in relation to adult safeguarding and has used its existing quality and assurance systems to ensure that both its own requirements and those of its commissioned services have met the required standards. We have effectively continued to work proactively to safeguard adults, and strengthened the already well- established partnership arrangements.

22.3 Assistance has been provided to General Practice with requirements for effective CQC registration. Primary care has been supported with the development of an effective, robust and current Adult Safeguarding Policy which includes a proactive, preventative approach to adult safeguarding.

22.4 Provision of appropriate adult safeguarding training has been provided to support GPs in ensuring their workforce has an appropriate level of competency in regard to adult safeguarding.

22.5 Increased adult safeguarding awareness amongst staff has been facilitated by the regular circulation of related legislation, guidance and articles.

23.0 Priorities and Planned Improvements for 2017/18

23.1 Continue to ensure the CCGs fulfil all statutory guidance and maintains a focus on safeguarding development and training with an emphasis and focus on domestic violence, adult neglect and the PREVENT, radicalisation agenda.

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23.2 Develop an Adult Safeguarding supervisory system and process for provider named professionals that is based on best practice and evidence. The aim of this is to ensure consistency of supervisory practice across the BHR system.

23.3 Improve the joint monitoring and quality assurance of nursing/care homes with Local Authority colleagues.

23.4 Further develop the BHRCCGs Safeguarding Strategy building on our existing framework.

23.5 Develop the systems, processes and outcomes that ensure the mandates in the Care Act are applied across BHR health services.

23.6 Support the development of a positive learning culture across partnerships for safeguarding adults and the development of competency based learning (as per the DH proposed Best Practice Guidance).

23.7 To further strengthen the safer discharge process when people are discharges from inpatient settings.

23.8 Develop a “Health Safeguarding Group” as an oversight group for safeguarding adults in the CCGs and provider health services that informs the SAB to enhance the SAB work.

23.9 Ensure service developments are informed by views of stakeholders.

24.0 Resources/investment

24.1 Failures of care are costly for the NHS as well as the patient. Safeguarding adults is a significant factor in reducing costs incurred in avoidable harm, avoidable admissions, delayed and unsafe discharges.

24.2 This report does not have any additional resource requirements.

25.0 Equalities

25.1 The continued development and strengthening of our safeguarding arrangements will promote the values of the NHS constitution and uphold the rights it confers on people; improve health outcomes; promote equality and reduce health inequalities; so that we can work with patients, the public and our partners to continue to protect vulnerable adults from abuse or neglect.

26.0 Risks

26.1 Operationally, there is one adult safeguarding lead working across BHR CCGs. Over the past twelve months as our safeguarding arrangements have become more effective, there have been occasions when resources are stretched.

27.0 Managing conflicts of interest

27.1 There are not any conflict of interest issues arising within this report.

Author: Mark Gilbey-Cross, Designated Adult Safeguarding Manager Date: 15 August 2017.

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To: Meeting of the Joint Committee of Barking and Dagenham, Havering and Redbridge CCGs

From: Marie Price, Director of Corporate Services

Date: 30 November 2017

Subject: Integrating Governance Arrangements

Executive summary Following the last meeting of the respective Barking and Dagenham, Havering and Redbridge (BHR) CCG governing bodies where it was agreed that the CCGs would establish a joint committee, colleagues attended a development session to explore how we could further integrate working and governance arrangements across our three CCGs.

Colleagues agreed that we should make all our committees joint where we are permitted to, given our positive experience of other such committees to date, and to reflect our new way of operating.

At the same time, the new north east London (NEL) commissioning arrangements have progressed, with the appointment of a new single accountable officer (AO) across the seven CCGs, and agreement in principle to establish a joint committee across NEL for a number of limited functions/responsibilities.

Given the current state of flux and development with the wider governance arrangements, it is proposed that a more detailed set of proposals come to the next meeting of this Committee for both the BHR and NEL level committees.

Recommendations The Committee is asked to:  Agree that the Finance & Delivery and Quality & Safety Committees become ‘joint’ rather than ‘in common’, with each developing revised terms of reference, to come to the next meeting of this committee for final approval.  Agree to consider final terms of reference for this committee at the next meeting, alongside the proposed terms of reference for the new NEL joint commissioning committee.

1.0 Purpose of the report 1.1 To seek agreement to the further proposals for integrating governance across BHR.

2.0 Introduction 2.1 In line with the requirements of the CCGs’ well-led review, the CCGs have further strengthened and integrated governance over the past six months, with a number of the committees meeting in common rather than separately. At the last meeting of the governing bodies, it was agreed to establish a joint committee, to meet in place of the separate governing body meetings where the business is common to the three CCGs. This is the first meeting of the new committee, which currently includes all of the members of the BHR CCGs’ governing bodies.

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2.2 The CCGs retain the ability to meet as separate governing bodies – or committees, as evidenced by a meeting of the Redbridge governing body on 30 November on a matter affecting Redbridge only.

3.0 NEL commissioning developments 3.1 Since the last meeting, there has also been progress with the new NEL commissioning arrangements, with the appointment of the new single AO. The report discussed under 4.1 on the agenda outlines the progress to date and advises of the further information and recommendations coming to the next meeting of this committee. This will include the terms of reference for the NEL joint committee. Given that this work is underway within the governance work stream, which includes a number of BHR representatives, it is proposed that the terms of reference (TORs) for this joint committee are considered in parallel with the new NEL committee, with both sets of TORs coming to the next meeting. This will ensure full alignment and consistency in approach.

3.2 The CCGs also need to consider the role of the new AO, proposed local managing director post and delegation considerations within the BHR committees’ membership, with a view to possibly revising membership.

3.3 In the meantime the draft TORs discussed at the last meeting will apply, and decisions of the committee will be on the basis of unanimity. The membership of the committee will remain as per the governing bodies, with the addition of the new post of Director of Delivery and Performance as a core member as outlined in the TORs considered at the last meetings.

4.0 Further proposals for integrated governance 4.1 The CCGs held a development session earlier in the month to discuss how best to refocus our leadership to reflect the current priorities and emerging system changes at a local, BHR and NEL level. Colleagues agreed that the CCGs should operate on an even more collaborative basis, with governing body members working for the benefit of BHR regardless of the CCG from which they originate.

4.2 It was also agreed that with the exception of the committees that CCGs are not permitted to operate as joint across organisations – namely the Audit and Governance Committee and Remuneration and Workforce Committee – that all other committees should become joint, with a refreshed membership. This would include: 4.2.1 Finance and Delivery Committee 4.2.2 Quality and Safety Committee

4.3 The CCG chairs, chief officer, lay member for governance and relevant directors met to consider the membership requirements of the CCGs’ committees, BHR and NEL meetings and wider programmes, and aligned members based on their skills, experience and interests.

4.4 It is therefore proposed that each of the above committees revise its terms of reference to reflect a joint rather than ‘in common’ approach and that these terms of reference come to the next meeting of this committee for approval. In the meantime it is suggested that the membership be revised to reflect the new portfolios and agreed virtually by the respective current committee members.

5.0 Equalities 5.1 There are no equalities implications arising from this report.

6.0 Risk 6.1 There are no risks arising from this report.

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7.0 Managing of conflicts of interest 7.1 There are no conflicts of interest issues relevant to this report.

8.0 Resources/investment 8.1 There are no additional resource implications/revenue or capitals costs arising from this report and no impact on sustainability.

Author: Marie Price, Director of Corporate Services Date: 20 November 2017

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To: Meeting of the Joint Committee of Barking and Dagenham, Havering and Redbridge CCGs

From: Tom Travers, Chief Financial Officer Chair of Financial Recovery Programme Board (FRPB)

Date: 30 November 2017

Subject: Work of the FRPB and Financial Recovery Programme Progress Summary

Executive summary During 17/18 BHR CCGs are required to deliver £45m of savings, in year. The position at the beginning of November is that £32.14m savings scheme opportunities have been approved by the CCG. A pipeline of new opportunities has been established as new schemes continue to be brought through the approval process.

Recommendations The Committee is asked to note the report

1.0 Purpose of the Report 1.1 To update the Committee on the progress of the 17/18 Financial Recovery Programme and work of the FRPB.

2.0 Background/Introduction 2.1 The financial challenges facing the BHR health system, following agreement of 2017-19 NHS contract values, are now significant, requiring BHR CCGs to save £45m to deliver a planned £10.2m deficit across BHR. Work is continuing under the direction of the Financial Recovery Program Board (FRPB) to deliver savings schemes to meet this target.

2.2 Under the FRPB’s Terms of Reference a high level summary of the progress on the financial recovery will be regularly provided to the Governing Bodies (or now Joint Committee).

3.0 Report Content 3.1 Significant progress continues to be made on the savings programme: 46 savings schemes are now approved by the CCGs and the total CCGs’ assured savings figure is £32,140,000.

3.2 It is noted that where schemes are in delivery on average between 85-90% of planned savings delivery is being achieved. This represents strong delivery against plan.

3.3 The programme of contract due diligence reviews is now drawing to a close, this has yielded £177,000 in savings from decommissioning and renegotiation of current contracts.

3.4 Work is being carried out between the CCGs and BHRUT and NELFT to develop joint savings schemes which are anticipated to have significant savings values attached to them. A business case, jointly developed with BHRUT for a referral management system which focusses on referral quality improvement was brought to the FRPB on 02.11.17. Business cases for pressure ulcers and discharge to assess are currently being jointly developed with BHRUT, a case focusing on

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end of life is being jointly developed with NELFT. The development of these schemes is being overseen by the System Delivery Programme Board.

3.5 The CCGs continue to work with clinicians to identify new savings opportunities. New savings schemes continue to be brought through the FRPB approval process. In addition work has commenced to identify the scale of the savings challenge in 18/19 and the schemes which will contribute to it. This will include an impact from some of the schemes which commenced delivery in 17/18.

3.6 The CCGs anticipate the need to deliver £35m of QIPP savings, based on existing financial modelling and 17/18 forecasted performance. To date the CCGs have identified £30m of 18/19 QIPP opportunities, of which £14m derives from part-year savings from schemes from the 17/18 programme, while the remaining £16m relates to new areas. This leaves £5m remaining as unidentified. CCGs will continue to develop schemes to mitigate this.

4.0 Resources/investment 4.1 There are no additional resource implications/revenue or capitals costs arising from this report.

5.0 Equalities 5.1 There are no additional equalities implications arising from this report. All savings scheme are required to have an Equalities Impact Assessment completed as part of the approval process.

6.0 Risk 6.1 There are no risks arising from this report. Risks to project delivery are held in individual project risk registers. It is noted that there is an overriding risk, held on the CCGs’ corporate risk register around not achieving the savings target.

7.0 Managing conflicts of interest 7.1 There are no conflict of interest in regards to this paper.

Author: Jeremy Kidd, Head of PMO Date: 18.11.17

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To: Meeting of the Joint Committee of Barking and Dagenham, Havering and Redbridge CCGs

From: Kash Pandya, Chair of BHR CCGs Finance & Delivery Committee

Date: 30 November 2017

Subject: Feedback report from the October 2017 BHR CCGs Finance & Delivery Committee meeting

Summary The Finance & Delivery Committee meeting minutes are provided to give additional assurance to this Committee and this brief feedback report provides key highlights from the meeting:-

Finance risk overview report - Committee members were given an update on the financial risks and members were advised that main drivers continue to be the over performance on the acute contracts and delays in delivering the QIPP savings plan. The Committee welcomed the updates provided on the BHRUT, NELFT and Barts Health contracts and gave full support to the actions being taken. The Committee also noted the progress being made to manage demand through the development of the Referral Management System (RMS) and Primary Care Bundle. Members agreed that the financial situation remains a matter of extreme concern with a potential worst case scenario deficit of up to £26m for 2017/18.

Integrated Performance Report (IPR) – Committee members were presented with the (IPR). The Committee welcomed the new style report and discussed its content; in particular that planned care and day cases activity are increasing. It was agreed that a deep dive on day cases should be undertaken and reported at the next Finance & Delivery sub-group meeting in November.

Financial Delivery and Performance Risk Report - Committee members were presented with a new style risk report reformatted in line with the recent restructure of the CCGs. The Committee discussed the report and the numbers of red risks on it and whether any needed to be escalated to the corporate risk register. The Committee supported the mitigations being put in place but requested more information be recorded in the register on the impact of the mitigations put in place.

Update on hospital letters not being received by patients – the CSU provided a summary of the issues raised and action being taken. It was agreed that the report would be shared with all practices and others, where appropriate.

Update on NHS standard contract – changes affecting the interface between primary & secondary care - the CSU provided a paper which informed the Committee on a number of procedures in place with BHRUT in light of the changes introduced to the new NHS standard contract. It was agreed that the paper was helpful and would be circulated to a wider audience. The CSU was asked to convert the paper into a Q&A document to go out to practices.

Recommendation:  The Joint Committee of BHR CCGs is asked to note this feedback report and the October committee minutes which provide more detail on all the matters considered.

1 November 2017

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Draft Minutes of the BHR CCGs Finance & Delivery Committee held on Wednesday 25 October 2017, Imperial Offices, Romford

Members:- B&D CCG Havering CGG Redbridge CCG Kash Pandya (KP) Kash Pandya (KP) Kash Pandya (KP) Lay Member, Governance Lay Member, Governance Lay Member, Governance and F&D Committee Chair and F&D Committee Chair and F&D Committee Chair Tom Travers (TT) Tom Travers (TT) Tom Travers (TT) Chief Finance Officer Chief Finance Officer Chief Finance Officer Dr Waseem Mohi (WM) Atul Aggarwal (AA) Dr Mehul Mathukia (MM) CCG Chair (by telephone) CCG Chair Clinical Director Gina Shakespeare (GSh) Gina Shakespeare (GSh) Gina Shakespeare (GSh) Director, Delivery & Director, Delivery & Director, Delivery & Performance Performance Performance Khalil Ali (KA) Khalil Ali (KA) Khalil Ali (KA) Lay member PPI Lay member PPI Lay member PPI Dr Alex Tran (AT) Clinical Director Dr Maurice Sanomi (MS) Clinical Director Attendees:- Dr Gurdev Saini, Clinical Director, Havering CCG (GSa) Dr Ann Baldwin, Clinical Director, Havering CCG (AB) Rob Adcock, Deputy Chief Finance Officer, BHR CCGs (RA) Lee Eborall, BHR POD Director, CSU (LE) Anna McDonald, Business Manager, BHR CCGs (AMc)

Apologies - members Dr Gurkirit Kalkat (GK) Clinical Director, B&D CCG Dr Jyoti Sood (JS) Clinical Director, Redbridge CCG Dr Sarah Heyes (SH) Clinical Director, Redbridge CCG Apologies - attendees Dr Kanika Rai (KR) Clinical Director, B&D CCG Dr Ramneek Hara (RH) Clinical Director, B&D CCG Dr Anju Gupta (AG) Clinical Director, B&D CCG Dr Ashok Deshpande (AD) Clinical Director, Havering CCG Dr Anita Bhatia (AB) Clinical Director, Redbridge CCG Ali Kalmis (AK) Director, Acute Contract Management- CSU

1.0 Welcome and apologies Action

The Chair welcomed everyone to the meeting and explained that WM would be joining by telephone and that the meeting would not be quorate for Redbridge CCG until a clinical director arrived. Apologies were noted.

1.1 Declarations of interests The Chair reminded committee members of their obligation to declare any interest they may have on any issues arising at committee meetings which might conflict with the business of BHR CCGs.

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No additional declarations of interest were declared. The register of interests held for BHR CCGs Governing Body (GB) members and staff is available from the Company Secretary.

1.2 Minutes of the last meeting The minutes of the meeting held on 29 August 2017 were agreed as an accurate record.

1.3 Matters arising/actions log

WM referred to the discussion held at the recent Primary Care Commissioning Committee about the risk share agreement between BHR CCGs and the extra money for Redbridge CCG and raised his concerns asking if primary care growth could be redistributed under the CCG Risk Share Agreement. TT advised that the Risk Share Agreement applied to direct commissioning budgets and predated the delegated commissioning arrangements. TT confirmed that further discussions are taking place with the CCG Chairs and officers. The Chair drew the discussion to a close summing up that it is an on-going issue

The actions log was reviewed:-

3.5 BHR Joint delivery arrangement review draft PwC report – The chair asked for this action to remain open on the actions log so that updates on the outcome of the recommendations continue to be given – Action open.

Management costs – GSa had raised at the last meeting that none of the management costs appeared in any of the reports presented to the Committee. It was noted that running costs were referred to in the Risk Overview report and TT confirmed they are included in the finance report TT going to the November Governing Bodies. The Chair asked for an interim report to be circulated to Committee members before the next Committee meeting in December.

The remaining actions either remained open or were related to items on the agenda.

2.0 Performance

2.1 Finance Risk Overview report – month 6 (month 5 data)

BHR CCGs reported a year to date (YTD) deficit of £12.1m in month 6 and a forecast deficit of £15m. The YTD deficit represents slippage of £4.6m against the YTD plan agreed with NHSE. TT advised that there will be a significant degree of over performance in regard to the acute contracts. The key drivers continue to be the acute contracts and QIPP delivery. An overview on the contractual levers that are being deployed was given and TT also briefed the Committee on the independent mediation process being undertaken with BHRUT. In regard to Barts Health (BH), the lead commissioner has agreed the Qtr1 position and the CCGs’ finance team is currently reviewing the detail.

The forecast position across the entire QIPP portfolio includes QIPP delivery of £32.5m, a slippage of £12.5m against plan. Of this, £5.2m slippage relates

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to QIPP in the acute contracts. B&D CCG is reporting overspends within Continuing Health care (CHC) and prescribing. The net risk facing the BHR CCGs at month 6 is £16m and if the risks materialise, it will result in the CCGs in year deficit increasing to £26m. The Chair asked what NHSE’s view is and TT confirmed that constructive dialogue is continuing and they accept that we are unlikely to hit our control target. The Chair questioned what else, if anything, could be done and added that we need to continue to demonstrate improvement in spite of the challenges being faced. KA gave his view that much more pro-active action needs to be taken in regard to the pathways.

GSh briefed the Committee on the information breach notice and the Activity Query Notice (AQN) issued to BHRUT and also the work that the two senior responsible officers (SROs) Louise Mitchell (BHR CCGs) and John Scott (BHRUT) have undertaken in putting together the Referral Management System (RMS) business case, which GSh confirmed is based on evidence of what helps to manage demand well. Alongside that, there is the primary care bundle and a good deal of other joined up work is happening to address the £16m. KA thanked GSh for her update.

WM gave his view on the RMS business case that was presented to the Clinical Cabinet saying he felt the business case was deficient. GSh asserted that the business case was an agreed process which had been to the System Delivery Programme Board (SDPB) and the Clinical cabinet and that a number of staff had worked hard on its production adding that it would be helpful if WM could clarify his concerns. AA gave his view that the primary care bundle is exactly right but the RMS needs some work. GSh outlined the principles of the business case and reiterated that it is evidence based and confirmed that it is not triaged based.

Dr Mathukia joined the meeting.

AB reminded members that a lot of time has been spent working with the Trust over recent years on referrals. GSh added that although there had been good dialogue with the Trust over RTT, the situation now is that we are in a contract dispute with them. The Chair brought the discussion to a close by summing up the discussion and reiterated that there is a potential deficit of £26m.

2.2 Integrated Performance Report (IPR)

GSh suggested that the Committee should focus on the executive summary provided at the start of the report detailing the actions being taken rather than the report as a whole, which members agreed and comments were given on how large the report was. GSh promised that primary care would be better represented the next time the report comes to the Committee. GSa referred to his request to see management costs and TT confirmed they will appear in the finance report that will be going to the November GB meetings. LE drew the Committee’s attention to slide 4 which provided details on financial performance by programme and said the Committee needs to keep focused on the predicted overspend in planned care and unplanned care. KA noted an increased pattern on the follow-up of patients and increased activity in day cases adding that day cases are a substantial and significant area. GSh confirmed that both planned care and day cases are increasing. KA said we need to understand if there is any impact on primary care. AA

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questioned whether the increase could be due to a coding issue or Patient Treatment List (PTL) management within the Trust. The Chair suggested that a deep dive on day cases could be undertaken at the Finance Committee sub-group meeting in November and asked LE to provide the LE report in advance of the sub-group meeting which is scheduled for Thursday 23 November.

AB said we need to be mindful of consultant to consultant referrals. GSh confirmed that consultant to consultant referrals have been addressed in the RMS business case and the standard is the same regardless of who makes the referral. LE drew the Committee’s attention to slide 24 of the report which provided data on referral trends.

WM welcomed the IPR but added that it provides data on what is being spent but doesn’t demonstrate the patient journey through the system. WM used the Community Treatment Team (CTT) as an example and said a better understanding of the service is needed especially in regard to integrated budgets. LE confirmed that including patient pathways in the IRP is being considered in terms of the future direction of travel. GSh reported that the Joint Commissioning Board is considering which pathways should be tested first and the most favoured areas are Intermediate Care, Diabetes and Special Educational Needs & Disability (SEND). The detail is being worked through in regard to how much is spent form the start of the pathways through to the end.

The Chair drew the Committee’s attention to slide 10 which provided data on Network performance and asked if the dashboards are being shared with the Networks. GSh confirmed that the Networks are going to be fully informed and that the GP dashboards will be shared at the end of October.

2.2.1 NELFT contract position

LE presented the high level report requested at the last meeting to update the Committee on the contract position including finance, activity and performance. LE outlined the key areas and reported that the Trust has not accepted the revised financial offer made by BHR CCGs to close down outstanding issues relating to the 2017/18 community & mental health contracts. Both parties have agreed to external mediation through CEDR which will take place on 7 November 2017. The Chair requested an update TT on the outcome of the mediation process at the next meeting. MM asked if we have the breakdown of activity and GSh responded that the principle request is for us to receive service line information.

KA referred to the Networks and asked what the process is for sharing intelligence with them. GSh said she would welcome a Clinical Director (CD) to join the regular contract meetings that are held with NELFT. AB raised a question about the future in regard to CDs and both the Chair and GSh reassured AB and the other Committee members that there are no plans to not have CDs going forward.

The Committee noted the report and confirmed their full support on the action being taken.

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2.2.2 Barts Health contract position

The purpose of the report was to provide the Committee with an update and to also to draw attention to the value of the contract adjustments made to the Service Level Agreement Monitoring (SLAM) information supplied by the Trust and the risk this creates for BHR CCGs. TT recapped on the update given earlier on in the meeting whereby the lead commissioner has agreed the Qtr1 position which his team are reviewing.

The Committee noted the report.

2.3 System delivery Framework

The Committee agreed there was nothing more to add to what had already been discussed earlier on the agenda. The Chair commented that the main consideration is the delivery of QIPP savings. KA added that it had been agreed last year that the CCGs would be looking at QIPP for 2018/19 at this point in the financial year and TT advised that the 2018/19 QIPP Plan in its current stage of development was presented to the FRPB on 5 October 2017.

3.0 Financial Delivery and Performance Risk Report

TT presented the new style risk report and explained that the format had been changed in line with the recent restructure of the CCGs. He added that it should be read in conjunction with the monthly IPR which represents a comprehensive review of performance against targets, contracted activity, finance and QIPP. The Chair welcomed the new format and thanked GSh, TT and PD. TT reported that the following two new risks have been added:-

 A high number of patients are at risk of delayed diagnosis and treatment as a result of a 'Cyber attacks' and overall Trust IT resilience status at Barts Health (BH)  There is a risk that workforce constraints at BHRUT will significantly

impair urgent care performance over the winter period.

WM commented on the high number of red rated risks and said it would be useful if the text included timelines on when they were expected to change to amber/green. TT drew attention to the target risk score included in Appendix 2 and explained that the risks are reviewed on a monthly basis by the Executive Management Team (EMT) to ensure the register is kept as up to date as possible. GSh added that she reviews the risks with her team at their regular directorate team meeting. It was suggested that it would be

helpful if the two attachments to the report were clearly named as Appendix

1 and 2 to avoid confusion. The Chair requested that a matrix is provided in GSh/PD addition to the register at the next meeting showing the progress made. He then asked the Committee to consider if there were any risks that need to be escalated to the Governing Body Assurance Framework (GBAF). GSh added that the BAF and the Delivery & Performance risk register have everything embedded.

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The Committee noted the report, accepted the assurances given and agreed the actions being taken to reduce the impact to the CCGs.

4.0 STP Risk Share Agreement

Committee members were provided with a copy of the Framework Agreement for Risk Sharing in 2017/18 and TT explained that CCGs are mandated to hold a minimum 0.5% contingency within their individual positions. A further 1% is required to be spent re-currently but only 0.5% has to be committed at the start of the financial year by CCGs party to the agreement. WM said he was happy with the agreement for now but added that it will be changed going forward. The risk share is deployed at year end. MM referred to the risk share agreement between BHR CCGs and TT explained that the 0.5% is in addition to the 0.5% contingency we have already deployed in forecast.

5.0 Procurement Oversight Group report

GSh presented the report which updated the Committee on the progress made to date and the risks and mitigations put in place to in relation to management of procurement activities. The first procurement under the new arrangement is the provision of wheelchair and postural seating for adults and children and is currently being evaluated. The Chair commented that he is very pleased with the progress made so far. WM asked if some of the procurements could be delivered in a different way and said the Networks and Federations need to be consulted. GSh confirmed that will happen where it is appropriate for the service. A further update will be given at the next meeting which will include tranche 3.

6.0 Update on hospital letters not being received by patients

LE advised that the report was provided in response to a request at the last meeting. It provided a summary of the issues raised into three main themes: appointment issues, test results and discharge summaries. The content of the report was noted and members agreed that it was very helpful. WM said the paper needs to be shared with the Networks and also discussed at the Clinical Cabinet and the Quality & safety Committee. LE to share the LE CSU paper wider as requested and bring a follow up report back to the next Committee meeting. KA agreed and said this is exactly the sort of information that needs to be shared with the Networks and others to ensure that loops are closed. AB added that we need to see behavioural changes at all levels at the Trust fairly quickly so that everyone follows the same processes.

7.0 Update on NHS standard contract – changes affecting the interface between primary & secondary care

A paper on this was first presented to the Committee at the meeting in June 2017 and members had requested a follow up. The paper informed the Committee on a number of procedures currently in place with BHRUT in light of the changes introduced to the new NHS standard contract. Progress against delivery of each of them is monitored at monthly contract meetings with the Trust and LE said he would bring an update to the December meeting. The Chair welcomed the paper but questioned if the F&D

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Committee is the most appropriate place for the update to come back to. AA said it would be more appropriate for it to be discussed at the Clinical Cabinet. MM said he found the paper really useful and said it would be helpful for the paper to be circulated to all GPs and stakeholders as well. LE to share the CSU paper wider as requested and GSh said it would be LE useful for it to be converted into a Q&A sheet for practices.

8.0 Items for noting

8.1 Payment Development Consultation

The Committee noted the paper.

8.2 Procurement Oversight meeting minutes

The committee noted the minutes.

8.3 BHR local Estates Forum minutes

The Committee noted the minutes.

9.0 Any other business

9.1 Primary care bundle – WM suggested that a three month pause and a risk share are needed in order for the Networks to be successful. TT confirmed that a paper on the primary care bundle will be discussed by a non-conflicted group at the next FRPB on 2 November 2017. AA said he understands the need for a non-conflicted group to make the decision but said some conflicted members need to be involved in the discussion. GSh confirmed that clinicians have been involved in the discussions and explained that the mandated envelope will be taken to the FRPB followed by a meeting to negotiate the best agreement and then the final sign off will take place.

8.0 Dates of next meetings:

F&D sub-group – 23 November 2017

F&D Committee – 21 December 2017

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To: Meeting of the Joint Committee of Barking and Dagenham, Havering and Redbridge CCGs

From: Kash Pandya, Chair of Audit & Governance Committees

Date: 30 November 2017

Subject: Feedback from the 10 October 2017 Audit & Governance Committee meetings

The Committee’s attention is drawn to the following key matters discussed at the Audit and Governance Committee meetings on 10 October 2017:

 The Director of Nursing gave an update on the key risks facing her team, in particular around quality issues at NELFT and the steps being taken to mitigate these risks.  The Director of Strategy outlined the progress being made in developing a BHR ACO with local partners, in particular an agreement to implement jointly managed pilot schemes from 1st April 2018 and the governance arrangements that would underpin them.  Internal Audit and Local Counter Fraud Services work plans remain on track, Their review of QIPP arrangements had received a partial assurance because of the under delivery to plan but the auditors recognised that the scale of the task facing the CCGs was very challenging. A review of the GP alerts system had also received a partial assurance but good progress had already been made in implementing the recommendations made.  The CFO updated the Committee on the CCGs financial position and the risks facing them, in particular in reaching agreement with the acute providers and NELFT on contractual over-performance and delivery of savings. The Committee remain concerned that the CCGs were unlikely to achieve their spending control targets for 2017/18 and the continued growth in demands, despite the mitigation put in place. The Committee were assured that risk management arrangements had been put in place across the STP area to manage these risks for 2017/18 and QIPP planning for 2018/19 was in progress.  The Director of IT and Innovation briefed the Committee on the implications of the General Data Protection Regulations (GDPR) which are to be implemented from May 2018 and their impact on providers, including GPs. The Committee recommended that the requirements of these regulations be included in provider contracts for 2018/19 and that the annual information governance compliance requirements also take account of this development.  The Committee welcomed a report on the Better Care Fund and the progress made in securing better joint working with partners and improved patient outcomes.  The Director of Delivery and Performance outlined the progress made in strengthening procurement arrangements and reducing the backlog of contracts requiring a review. The Committee welcomed the progress made but remain concerned about the numbers of single tender waivers that still continue to be required. A follow up report was requested for the January 2018 A&GC meeting.

Kash Pandya

BHR CCGs Audit & Governance Committee Chair

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DRAFT Minutes of the Joint Barking & Dagenham, Havering and Redbridge CCGs Audit &Governance Committee held on 10 October 2017 at Becketts House 9.30-12.00

Present –Members Kash Pandya (KP) BHR audit chair, lay member for Audit & Governance Charles Beaumont (CBe) BHR co-opted member for Audit & Governance Richard Coleman (RC) Lay member PPI Havering CCG In attendance-Officers Tom Travers (TT) BHR chief financial officer Rob Adcock (RA) BHR deputy chief financial officer Marie Price (MP) BHR director of corporate services Angela Ward (AW) BHR company secretary Jacqui Himbury(JH) Part BHR Nurse Director Jane Gateley (JG) Part BHR Director of Strategy & Integration Rob Meaker (RM) Part BHR IT & Innovation SRO Gina Shakespeare (GS) Part BHR Interim Director of Delivery & Performance Barend Henning (BH) Part Deputy Director of Procurement NELCSU Frank O’Neill (FON) In attendance-auditors Nick Atkinson (NA) Internal Auditor, RSM Charlie Nicholls (CN) LCFS, RSM Apologies Khalil Ali (KA) Lay Member PPI Redbridge CCG Sahdia Warraich (SW) Lay Member PPI B& D CCG

Action 9.00 Committee Members held a short private meeting. 9.15 Part 2 Item -Members only. BH from the CSU and TT attended to provide an update on a current procurement process and the minutes will be sent to the committee AW members.

13/17 Welcome and Apologies for absence Apologies for absence were received from Khalil Ali and Sahdia Warraich.

14/17 Declaration of Interests (DOI) No further declarations of interests were declared other than those on the three registers presented.

15/17 Minutes of meeting held on 14 February 2017. The minutes of the previous meeting were agreed and would be signed by the Chair as a correct record.

16/17 Matters Arising The log indicated a number of completed actions and updates that were being provided at the meeting, in addition;

31/17-Life Study Provision- TT confirmed that this matter was now closed and would not appear in the 2017/18 accounts. Action Closed.

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46/17-EA Mgt. Letters and delegated co-commissioning information for external audit of accounts- RA advised that a NEL group would discuss this and it would be discussed early with KPMG. The Chair would also raise this with David Slegg. Action closed.

48.1 Risk Register-TT updated on the current BHRUT cash position and difficulty in signing off the Qtr.1 period due to £6m of disputed items. With concern for patient safety, an advance of £4m support had been made whilst a business case was developed for NHSI. The finance team had discussed the facts with NHSI. It was noted NELFT were in a better position due to disposable assets. The Chair noted that the risk register would be provided to the December meeting where this would be revisited and there would be further discussion under item 21.

49.4 Tender Waivers- Clinical Effectiveness- RA confirmed that B& D were not involved as they had a different provider. Action closed.

17/17 Directorate risk briefing JH, Director of Nursing, attended to brief members on the current quality and safety risks. There were no specific risks to report for BHRUT. The Key Lines of Enquiry (KLOE) register tracked areas whether there was potential for risk to grow and these were reviewed by the Quality & Safety Team and were escalated as necessary.

There were quality concerns at NELFT and the risk of nearing a tipping point. Triangulation of data sources was underway and this would feature on the next risk register update. Bringing quality & safety into the Delivery and Performance directorate had the advantage of allowing better triangulation of data sources. The Chair questioned the impact on financial risk and JH responded that there was a cost pressure for the Serious Incident where a level 3 investigation had to be commissioned.

RC questioned NELFT risks arising from capacity and JH responded that the occupancy was high and requiring some out of area placements. Also a business case was being developed around access to CAMHS. Risk was mainly around an emerging trend of Serious Incidents involving unexpected death from self-harm/ possibly suicide. The trend over 4 years was now seeing consistently high occupancy but also higher acuity. The high acuity was also impacting on the home treatment teams and access teams. It was vital that following risk assessment, outcomes were acted upon in a more consistent way. The CQC had revisited and there was to be a Well Led Review shortly and the outcomes were awaited.

The Chair questioned whether constitutional targets could be met and JH responded that they were on the risk register e.g. dementia screening, ITT etc. JH also reported on C.Diff allocation target breaches but we were on trend to deliver by year end.

Noting we were associate commissioners for Barts Heath, the Chair questioned the status on quality. JH advised that Redbridge CCG were the bigger users and although associate members, the quality team regularly attended the WX CQRM and there were also monthly quality leads meetings and a clinical review meeting. There was also an overarching NEL quality surveillance group. JH acknowledged it was difficult to obtain good quality information and their Board reports were also reviewed to gain information. There had been some improvements and moving to collaborative arrangements would benefit. There had been a more positive CQC report on WX, moving from ‘inadequate’ to ‘requires improvement’, e.g. the End of Life Care Policy was rated as ‘good’.

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The Chair in noting NELFT quality concerns questioned if we were engaged with the Trust clinical audits. JH confirmed that these were allocated clinical presentation space at each monthly CQRM and there was robust challenge, which assisted the CCG in gaining assurance.

The Chair thanked JH for the insight she had provided to committee members and for the good work on the GP Services Alert processes.

18/17 Directorate Risk Briefing- Jane Gateley JG, Director of Strategy & Integration, attended to outline the risk in her area of work that included work on the ACS partnership and PMO support for the Delivery & Performance agenda. JG updated the committee on the development of an ACS and the current direction of developing an informal way to work as a system to deliver better quality from resources. The governance was discussed, including establishment of a partnership board, system delivery board, joint commissioning board and sub-committees. Consideration was being given to test areas from April 2018 in preparation to go live in 2019, therefore having parallel systems. All CEOs were meeting together next week and reviewing proposed test areas. To date intermediate care, diabetes and children’s services had been proposed, with public health input on the prevention side. In NEL there was work on an assurance framework and the need to ensure providers were ready. Kings Fund principles around place based commissioning, Treasury information and some other sources of information had been collated to put into that framework. Due to the good partnership working established, BHR was seen as a good pilot area. RC noted that the resource for the pilot work was currently JG and one other and JG advised that when decisions were made additional resources could kick in. The PMO was only staffed by two at present.

Members noted the risk around commitment to this general push and that October was the key milestone to gain agreement to proceed. NA added that all partners would remain accountable to their own boards and as there was no change to the statutory/legal framework but he saw finance as a potential stumbling block. JG added that for the test to run from April, partners needed to work as one and that including managing the risks. When agreement was reached there would be legal checks of the processes and any competing regulatory issues but risk management was key whether we were working in shadow or final form.

NA noted the stop/start work and an earlier lull in proceedings and understood BHR were already ahead in his way of thinking.. The Chair raised concerns for the delay and sought assurance on the governance arrangements adding the BCF was brought in to genuinely address the risks of demand management and not a re-labelling exercise.

The Chair added that payment mechanisms were required for the ACS and possibly an MOU. JG responded that the legal advice was that the MOU was not essential. TT added that day to day pressures would challenge the process when there were contractual disputes with providers requiring resolution and there would be the need for very careful balancing. JG was asked to share updates as development progressed.

JG was thanked for her briefing on the risk arising from her areas of work.

19/17 Internal Audit BHR Report NA advised that two reports had been completed, GP Alerts and QIPP-Phase 1. Both had received partial assurance. The former had been a review of a point in time, there 3 Draft Minutes BHR Audit Committee 10 October 2017 v2 204

had been an action plan, and the management actions had been followed up and all had been implemented.

For the latter there was a sense of learning and earlier preparation this year leading to more robust processes and there were easier to follow through assumptions. However, a partial assurance opinion has been given to this Phase 1 review due to current under-delivery of QIPP schemes with slippage valued at £13.4m. NA emphasised that deliverability was very challenged and noted it was NHS driven. The Chair requested that all reporting made it clear, if challenged, what we had done to address the challenges. NA added that the Phase 2 report, hopefully ready in December, would continue to focus on robustness of delivery and the review of late schemes. The Chair questioned whether our assumptions were robust. NA confirmed that the report identified 5 of the 6 PIDs had identified their assumptions, with the remaining one still in draft form.

CB questioned if we had missed any ideas and NA responded that by comparison our programme was of a large scale and size already and BHR was an efficiency saving QIPP rather than a spending/investing QIPP, as elsewhere. TT added that an independent review had been arranged with Rubicon to gain assurance that we were doing everything realistically possible and the Phase 2 work of ‘Spending Money Wisely’ was out to consultation. He requested that the auditors emphasise in their opinion the conclusion that the CCGs were delivering in excess of 70% of the required savings and BHRUT had identified no QIPP saving schemes as yet. The Chair said this would be discussed at both the Finance Committee and FRPB and requested NA NA/TT draft a statement to agree with TT. Also that NA also consider the 2018/19 QIPP plans which were currently under development..

IA had been asked to undertake a review of the CCG’s complaints process and responding to Access Requests. This was not yet concluded and there remained one individual to interview. A report would follow.

CSU Report The report was able to show positive follow up on 13 management actions. Two reports had been finalised –Cybersecurity and Recruitment. For the former some medium rated actions had been implemented and others were underway, action had been taken and there was some work to do on firewall rules. The report referred to the Wannacry ransomeware attack that impacted the NHS in May. CSU had provided a report to NHSE that identified further prevention work required and 4 of 6 actions had so far been implemented.

A recruitment review had covered 11 CCGs served by the NELCSU where one medium and one low action recommendations were issued. However, the audit found generally well designed and effective controls in place.. Due to the scale of change this year across 7 NEL CCGs it was important this was maintained. Declaration of Interest was now being embedded at the recruitment stage. Also attached for information were papers on Wannacry, Conflicts of Interest benchmarking, Health Matters, QIPP Phase 1, GP Alerts report.

The internal auditor reports were noted.

20/17 LCFS This was a progress against plan report and CN highlighted a few areas for attention. A new e-learning package on fraud, bribery and corruption had been introduced at the BHR CCGs and the uptake to date was varied. This was part of staff’s mandatory training and LCFS would continue to monitor uptake. The report detailed an emerging

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national risk by fraudsters to attempt to recover a bogus debt, particularly from large organisations and the CCGs gad covered this in the staff newsletter.

The LCFS Reactive work summary which included 1 case brought forward from last year and 3 new Havering notifications making 4 under investigation. The details of these cases were shared and Sarah See had been advised of the primary care issues.

The progress report was noted.

21/17 Governance MP’s report described how the new HMRC intermediate legislation, IR35, that came into being in April, applied to anyone contracted to work through an intermediary. All staff ‘off payroll’ required an IR35 assessment to determine if it was in the scope of the legislation. The task of identification was complete and individuals affected had received letters confirming their status, copied to relevant intermediaries. . The CCG required that all individuals who fell within the IR35 regulations were now employed through an umbrella organisation/agency. This would ensure that tax and NI were effectively dedicated.

This had led to a decision not to contract directly with GPs for their services and six clinical leads will need to be moved to the payroll system. It was noted that the legislation impacted on around 10 individuals which meant we were not an outlier. Noting there was some pension arrangements to resolve the Chair added that consideration would need to be given to GPs involved in networks and localities and payments for backfill. MP confirmed that this linked with a clinical input review currently underway.

The Committee noted the HMRC requirement had been met.

22/17 Finance 22.1 Risk Overview Report TT advised of the M5 position based on M4 Trust activity data, leading to a forecast deficit of £15m. The two key risks were acute contracts and QIPP delivery and the CCGs were still immersed in Qtr.1 reconciliation with BHRUT and Barts. The CCGs were not in a position to easily extrapolate on the data received. NHSE had supported reporting ‘to plan’ until the Qtr. 1 reconciliation differences with the providers were resolved but the Committee noted a deficit may need to be reported in M6.TT advised of an adjustment of £4.8m in the year to date and the risk had been fully shared withNHSE and the STP.

TT explained the current serious cash position at BHRUT and an imperative to close down Qtr. 1 urgently. There had been a constructive meeting with BH contract leads, Newham, and resolution was awaited. CB questioned the very high level of disputed items in Qtr.1. TT referred to the unexplained coding of some activities leading to outlier and unexpectedly high cost positions in some specialties e.g. unusually high numbers of unwell babies needing more expensive extra support. TT advised that TOR of a coding audit were shared in September with BHRUT and there would be an enforced start the following week.

KP noted that a M9 close down and account submission would be required shortly. RC was concerned at these very serious risks and questioned sanctions if the CCGs breached their Legal Directions. TT’s report concluded with the CCGs net risk of a £30.5m deficit.

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The serious risks highlighted were considered and noted by the Committee who awaited an update on progress made on reconciliation of Qtr.1 as soon as possible.

22.2 Better Care Fund (BCF) FO’N provided a report on value gained from the BCF in the last two years. New NHSE guidance required a two year Integration and BCF plan to be submitted for 2017-2019. It had been agreed that this would be a joint plan between BHR CCGs and the three local Boroughs incorporating three separate finance and activity plans. The plan was submitted in September and is currently going through an assurance process. There had been internal audit reviews of the BCF governance arrangements for both the years it has been operational, with a positive outcome and a recent ‘substantial assurance’ rating being given.

The CCG’s contributions to the pooled fund last year was around £45m and there were risk management rules in place. The BCF had a key focus of reducing non- elective activity with a target of 1.7% reduction for 2016/17 and this was surpassed at 3.6%. It was noted that finance and activity data was reviewed monthly but there FO’N was not a clear line of cause and effect and FO’N advised there would also be a focus this year on Delays Transfers of Care (DTC). It was clear partnership working had been strengthened by the BCF and areas for joint commissioning had been considered (referred to by Jane Gateley earlier). It was agreed that the report would be sent to Jane Gateley for further triangulation.

The Committee noted the recommendations in the report as requested.

22.3 General Data Protection Regulation report (GDPR) RM presented this report highlighting changes to GDPR and implications for the CCG which would be enforceable by next May. These requirements built on the earlier Data Protection Act requirements and were about storing, managing and processing personal data. The report set out a number of new rights of the individual and listed the key areas for attention. There was a mandatory breach process and the CCGs were required to nominate a Data Protection Officer.

KP noted that this was likely more familiar to the NHS than private companies and NA added that an important area of risk was going to be data flows such as on the GP side and data mapping may need to be updated. RC noted the huge task for main providers and questioned whether this needed to be updated in the NHS standard contract to assist contract management.NA added that the IG Toolkit may RM/TT need changing too. TT and RM were asked to discuss whether this was a risk to be added to the register particularly around providers/GPs.

The Committee noted the report.

22.4 Tender Waivers GS reported that some contracts had expired and were implied contracts but due diligence was being done and work was ongoing to minimise the number of tender waivers. The Chair stressed his ongoing concerns about the numbers of single tender waivers that were having to be approved. GS assured him that new procurement processes put in place would reduce the need for single tender waivers in the future.

22.4.1.Care UK- Cherry Orchard The tender waiver was noted by the Committee.

22.4.2 Care UK- Heatherbrook The tender waiver was noted by the Committee.

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The tender waiver was noted by the Committee.

22.4.4 UEC-24/7 provision of an urgent care centre The tender waiver was noted by the Committee.

23/17 Report of the Procurement Oversight Group (POG) GS’s report was in response to the Committee’s request for risk assessment of the procurement pipeline and requirements for Single Tender Waivers (STWs). The previous report had covered Tranche 1 procurements and now the team were working on Tranche 2. Procurements had been RAG rated and those amber and red had been escalated to the relevant SROs and mitigations would be reported back to the POG. GS was pleased to report that the CCG’s independent GP had now joined the POG adding a further layer of assurance.

Discussing risks, GS advised that a number of amber and red rated procurements would need to be dealt with by STW but was pleased to report both amber and red ratings had reduced.

The Chair welcomed long awaited clarity of the risk arising from the pipeline and the assurances given and set a challenge of no STWs in 2018/19. GS explained that the STWs were not usually large procurements crucial to business and would include financial materiality in the next report. NA added that the new visibility on procurement was helpful. It was agreed the next report would be at the February GS meeting.

The Committee welcomed and noted the contents of the report.

24/17 Committee Work –plan Dec-May The work-plan was updated and would continue to gain items.

The NELFT Audit Chair was attending our meeting in December and the BHRUT Audit Chair in February.

25/17 Any Other Business There was no other business.

26/17 Chair’s Key Messages for GBs The Chair advised of the key matters to be highlighted.

26/17 Items for Information The Draft IG Steering Group Minutes of 22 September 2017 were noted.

27/17 Date of Next Meeting The next meeting was arranged for 27 February 2017

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

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To: Meeting of the Joint Committee of Barking and Dagenham, Havering and Redbridge CCGs

From: Kash Pandya, Lay member and Chair of Remuneration & Workforce Committee

Date: 30 November 2017

Subject: Feedback report from the 10 October 2017 Remuneration and workforce Committee meeting

Summary Below is a summary of items considered and approved by the Remuneration & workforce committee at its meeting held on 10 October 2017.

Key items discussed and approved The Committee considered the following items:

 Restructuring update  Director of Delivery appointment  Agency staff update  Meeting attendance update  Workforce reports

Recommendation The Joint Committee is asked to note this report.

November 2017

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Draft Minutes of the Primary Care Commissioning Committee (a Committee in common) held on 5 July 2017 at Becketts House

Present B&D CCG Havering CGG Redbridge CCG

Conor Burke, Chief Officer, Conor Burke, Chief Officer, (CB) Conor Burke, Chief Officer, (CB) (CB)

Kash Pandya, Lay member Kash Pandya, Lay member (KP) Kash Pandya, Lay member (KP) (KP)

Sarah See, Director of Sarah See, Director of Primary Sarah See, Director of Primary Care, (SS) Care, (SS) Primary Care, (SS)

Dr Arnold Fertig, Dr Arnold Fertig, Dr Arnold Fertig, Independent GP (AF) Independent GP (AF) Independent GP (AF)

Dr Adedayo, GP (AA) David Derby, GP, (DD) Shabana Ali, Clinical Director (SA) Dr Kalkat, Clinical Director, Khalil Ali, Vice Chair & Lay (GK) member PPI (KA)

Sahdia Warraich, Lay member (SW)

In attendance Natalie Keefe (NK) Head of Primary Care Transformation, BHR CCGs Anne-Marie Dean Chair, Havering Healthwatch Anne-Marie Keliris (AMK) Company Secretary, BHR CCGs Allison Goodlad Head of Primary Care, NHSE Dr Terilla Bernard (TB) LMC, Havering & Barking & Dagenham Dr Atul Aggarwal (AA) Chair, Havering CCG Dr Anil Mehta (AM) Chair, Redbridge CCG Andrew Rixom (AR) Public Health Consultant, LBH Gladys Xavier (GX) Deputy Director of Public Health, LBR Rob Dickenson (RD) Senior Finance Manager, BHR CCGs Sue Elliott (SE) Deputy Director, Qulaity, BHR CCGs Tony Curtis (TC) Senior Commissioning Manager, NHSE

Apologies Richard Coleman Chair & Lay Member PPI, Havering CCG Tom Travers CFO, BHR CCGs Jacqui Himbury Nurse Director, BHR CCGs Vicky Hobart Director of public health , LBR Cathy Turland CEO, Redbridge Healthwatch

Shabnam Ali GP, Redbridge

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Item Action 1. Welcome and apologies The Chair, Khalil Ali welcomed those present and apologies for absence from those listed above were noted.

2. Declarations of conflicts of interest The Chair reminded members of their obligation to declare any interest they may have on any issues arising at the meeting which might conflict with the business of the primary care committee and clinical commissioning group.

Declarations declared by members are listed in the CCG’s Register of Interests. The Register is available via the secretary to the committee.

3. Minutes, action log and risk register 3.1 The minutes of the meeting held on 5 July 2017 were agreed as a correct record.

3.2 The committee noted the actions that had been taken and it was agreed to follow up the budget best and worst case scenarios at the RD next meeting.

3.3 The committee noted the risk register.

4. Budget update RD presented the budget report which summarised the latest financial Primary Care Co-Commissioning (PC) Financial Plan for 2017/18 and highlighted the challenging financial position faced by the CCGs.

The budgets for all three CCGs are on plan at month 4. Within this position each CCG has seen the impact of demographic growth, but this is affordable within the current budget due to utilising a combination of the remaining growth funding and contingency.

A review of the list size increases to date suggests, if continued at the same rates, this will be affordable within the current budget and therefore the forecast outturn is a break-even position for all 3 CCGs. This is only affordable in Barking & Dagenham CCG and Havering CCG by way of utilising the full growth funding and contingency. In Redbridge CCG there is significant surplus growth funding which is available for investment in Primary Care. The break-even year-end forecast assumes that this will be fully utilised.

The main risks to the forecast position is a heightened level of demographic growth, rent and rates increases, cost of named GPs and the cost implications of the PMS Review.

AA asked for clarification on the named GP requirement. RA confirmed that there are expectations on each CCG to put named GPs in place and this has been flagged as a risk until details have been clarified.

The committee noted the report and the level of financial risk.

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5. PCCC revised terms of reference SS presented the revised terms of reference for each CCGs PCCC to ensure compliance with the new guidance that recommends that the vice chair role should not be undertaken by the audit chair.

The committee(s) agreed that the lay member for PPI in Redbridge become the vice chair of the committee(s) and that the ToRs are updated accordingly.

1.25pm AMD arrived.

6. CQC pilots support programme – requires improvement SS presented an interim report that provided an update of the work to date and some of the key themes that have come out of the visits and it was noted that the final report will be presented in December.

KP welcomed the report and suggested that it would be useful to have more detail on financial stability and what work is planned. SS acknowledged this and reported that this would be crossed referenced with the PMS review.

AF questioned whether pilot practices volunteered, as these practices would be more likely to engage. SS responded that they had volunteered and places were allocated on a first come first serve basis.

TB commented that the issues raised were not surprising and was concerned that this was not addressing the real issues. She added that further one to one support within practices would be helpful and also suggested that training should be more proactive. SS acknowledged that practice manager training needs to be approached differently in the future.

AMD expressed concern at the number of practices requiring improvement and asked what plans were in place for practices that do not improve.

CB welcomed the report and what this means for primary care development. He added that the work was commissioned with an objective to move SS practices to “good” and would like to know the effectiveness of the intervention. He suggested that a workshop with the practices involved could reflect on emerging themes, findings and actions required which should be reflected in the final report.

The committee noted the interim report.

7. Special allocations scheme AG presented a report which updated on progress to develop a Londonwide Framework for Special Allocation Schemes to inform future commissioning of these services across STPs, and interim arrangements to be put in place within BHR in the meantime.

The committee noted the report.

8. Redbridge PCCC 8.1 Hainault surgery – revert to GMS contract The committee noted the return of Hainault Surgery from PMS to GMS and

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the subsequent increase in cost to the primary care budget.

8.2 The Coutlands surgery – GP resignation SS presented a report seeking approval to disperse the list of Courtland Surgery due to the retirement of the contract holder, Dr Surindar Babbar, following the cessation of his notice period on 20 January 2018.

Discussion ensued on pressures felt by practices due to requirements of the regulator and support practices need to be sustainable in the future.

CB suggested exploring the possibility of the network coming together as a provider to supply the APMS contract. SS reported that in this case due to the timeframe it would not be possible but this could be explored for future cases.

The committee approved the dispersal of Courtland Surgery patient list, subject to further engagement.

8.3 Roding Lane surgery & Clayhall surgery merger Members of the Non Conflicted Redbridge Primary Care Commission Committee approved the minutes of the meeting that took place on 10 August 2017.

The committee noted that the non-conflicted members agreed the business case from Roding Lane Surgery and Clayhall Clinic to merge and operate under a single GMS contract (with Roding Lane operating as a ‘branch site’, and requested that appropriate communication takes place with partners, local stakeholders and patients, and a review of progress and performance be brought back to the committee in six-months’ time.

8.4 Mathukia surgery & VM surgery merger update The Committee noted the content of the report and the revised timeframe to complete the merger and agreed the finalised practice catchment area.

9. Questions from the public There were no questions.

10. Any other business – There was no other business.

11. Date of the next meeting – 11 October 2017

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

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Draft Minutes of the Primary Care Commissioning Committee (a Committee in common) held on 11 October 2017 at Becketts House

Present B&D CCG Havering CGG Redbridge CCG

Sahdia Warraich, Lay Richard Coleman, Chair & Lay Khalil Ali, Vice Chair & Lay member (SW) member (RC) member PPI (KA) Sarah See, Director of Sarah See, Director of Primary Sarah See, Director of Primary Care, (SS) Care, (SS) Primary Care, (SS)

Tom Travers, Chief Finance Tom Travers, Chief Finance Tom Travers, Chief Finance Officer (TT) Officer (TT) Officer (TT) Dr Kalkat, Clinical Director, Shabnam Ali, GP, (SAli) (GK)

Shabana Ali, Clinical Director (SA)

In attendance Natalie Keefe (NK) Head of Primary Care Transformation, BHR CCGs Anne-Marie Keliris (AMK) Company Secretary, BHR CCGs Dr Terilla Bernard (TB) LMC, Havering & Barking & Dagenham Dr Waseem Mohi (WM) Chair, Barking & Dagenham CCG Dr Anil Mehta (AM) Chair, Redbridge CCG Manisha Madhvadia (MM) Officer, Barking & Dagenham Healthwatch Andrew Rixom (AR) Public Health consultant, LBH Vicki Hobart (VH) Director of public health, LBR Rob Dickinson (RD) BHR CCGs Gohan Choudhury (GC) NHSE Dr Ambrish Shah (AS) Redbridge LMC Mark Gilbey-Cross (MGC) Designated adult safeguarding manager

Apologies Dr Arnold Fertig Independent GP Kash Pandya Lay member Jacqui Himbury Nurse Director, BHR CCGs Allison Goodlad Head of Primary Care, NHSE Anne-Marie Dean Chair, Havering Healthwatch

Item Action 1. Welcome and apologies The Chair welcomed those present and apologies for absence from those listed above were noted.

It was noted that the meeting was not quorate.

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Declarations declared by members are listed in the CCG’s Register of Interests. The Register is available via the secretary to the committee.

3. Minutes, action log and risk register 3.1 The minutes of the meeting held on 13 September 2017 were agreed as a correct record subject to date change on header.

3.2 The committee noted the actions that had been taken and the following was noted: ACT72 – It was reported that other CCG are exploring localised QOF which focuses on clinical needs of an area and it was questioned whether this could be explored for BHR CCGs. SS responded that realistically, this could be explored for 2019/20. SS SS agreed to explore if there is an appetite for this locally.

3.3 The committee noted the risk register.

4. Budget update TT presented the budget report which summarised the latest financial Primary Care Co-Commissioning (PC) Financial Plan for 2017/18 and highlighted the challenging financial position faced by the CCGs.

It was noted that the budgets for all three CCGs are on plan at month 5. Within this position each CCG has seen some impact of demographic growth, but this is affordable within the current budget due to utilising a combination of the remaining growth funding and contingency. A review of the list size increases to date suggests, if continued at the same rates, this will be affordable within the current budget and therefore the forecast outturn is a break-even position for all 3 CCGs. This is only affordable in Barking & Dagenham CCG and Havering CCG by way of utilising the full growth funding and contingency. In Redbridge CCG there is significant surplus growth funding which is available for investment in General Practice. The break-even year-end forecast assumes that this will be fully utilised. The main risks to the forecast position is a heightened level of demographic growth, rent and rates increases, cost of named GPs and the cost implications of the PMS Review.

The Chair referred to the brought forward creditors review and questioned whether there are any associated risks or benefits. TT responded that there are currently no risks and it was too early for any benefits to be clear.

The committee noted the report and the level of financial risk.

5. Barking & Dagenham and Redbridge PCC Committee 5.1 Extended hours DES GC presented a report to inform the committee of the change from 1 October 2017 to the Extended Hours Access DES. New conditions have been introduced to the DES which means that practices that close for half a day after 1 October 2017 will no longer be able to participate and claim for

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the Extended Hours Access DES.

SW suggested that Ilford Lane surgery details are re-checked. GC

1.25pm Dr Mohi and Dr Mehta arrived.

MGC questioned whether early closing has affected overall patient experience. GC confirmed that further evaluation of patient experience needs to be undertaken.

MM questioned whether extended hours in practices will guarantee additional GP appointments and suggested that this information is shared with patients. SS agreed it would be useful to share once information from practices has been collected and reconciled.

The committee noted: • the practices that have confirmed they will continue to close half day • the reduction in approximately 9,550 out of core hours appointments • the associated reduction in expenditure under this DES for 2017/18 • a further update report will be submitted when NHS England clarifies the approach for practices that do not open full core hours

6. Questions from the public There were no questions.

7. Any other business – There was no other business.

8. Date of the next meeting – to be confirmed.

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

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Primary Care Transformation Programme Board DRAFT minutes of meeting of 27th July 2017 Becketts House Present: Councillor Mark Santos, Chair (MS) Cabinet Member for Health and Social Care, LBR Mateen Jiwani (MJ) Associate Medical Director for Primary Care Dr Daniel Weaver (DW) Chair, Havering Health Ltd Dr Jwala Gupta (JG) Network Lead, Havering CCG Dr Siva Ramakrishnan (SR) Chairman, Healthbridge Direct Mark Scott (MSc) Primary Care Programme Manager, NEL STP Paul Roche (PR) Primary Care Programme Manager, NEL STP Hemant Patel (HP) Secretary, NEL LPC Khalil Ali (KA) Lay Member, Redbridge CCG Richard Coleman (RC) Lay Member, Havering CCG Katy Scammell (KS) Consultant in Public Health, Redbridge Paul Olaitan (PO) Programme Manager, BHR CEPN Karen Stubbs (KS) Chief Operating Officer, Healthbridge Direct

In attendance Sarah Perman (SP) Deputy Director, Primary Care Transformation, BHR CCGs Monga Mafu (MM) Primary Care Delivery Manager Redbridge CCG Cathy Lobendan CL) Primary Care Delivery Manager Havering CCG Simon Clarke (SC) Primary Care Delivery Manager B&D CCG Jenny King (JK) Business Manager, Primary Care Transformation, BHR CCGs Apologies Dr Arun Sharma (AS) Director, Together First Dr Shabana Ali (SA) Clinical Director, Redbridge CCG Sarah See (SS) Director, Primary Care Transformation, BHR CCGs Conor Burke (CB) Chief Officer BHR CCGs Dr Gurkirit Kalkat (GK) Clinical Director, Barking and Dagenham CCG Tom Travers (TT) Chief Finance Officer BHR CCGs

Item Title Welcome and introductions The Chair welcomed all to the meeting and introductions were made. Apologies were noted. 1. Minutes and actions of the meeting 5th April 2017 The minutes of the previous meeting were reviewed and approved for accuracy. Action log SP went through the action log. She updated on outstanding actions as follows:  Item 4 - paper for noting on primary care investments  Item 5 – relates to the dashboard. SP will liaise with colleagues for an update on the STP plans. The intention is to ensure that the BHR primary care dashboard is in line with the STP dashboard indicators for primary care. The dashboard will be circulated at a later date.  Item 8 relates to testing the model for future general practice workforce which PO presented on at the last meeting.  Item 10 – progressing. A paper relating to the membership of the board was taken to the informal Joint Executive Committee (IJEC) but was not discussed as Dr Anne Baldwin had been unable to attend. DW queried whether there was a way to expedite this item and the Chair requested that this action be referred back to IJEC and be on the agenda for the next PCTPB meeting.

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Action Ensure paper relating to ‘membership of the board’ is taken to the next IJEC (action: SP)

Risk register This was noted.  Item 13 - KS suggested that provider maturity be crossed reference to ascertain the level of risk relating to GP federations and provider organisations and where they sit on the maturity dashboard that is being developed by the East London Health and Care Partnership. 2 At scale working – Network and federations status update and plans DW gave an update following the primary care workshop held on 6th July. It was noted that networks were now established and working together to overcome the significant workforce challenge and declining spend in primary care.

DW clarified the difference between federations and networks and the role of the Accountable Care system (ACS):

A primary care federation is a formal or informal alliance of general practices or general practices and other community primary care providers, coming together to achieve and deliver a range of objectives

The remit of a GP Federation is generally to share responsibility for delivering high quality, patient-focussed services for its communities.

The ACS works under a contract that specifies the outcomes and other objectives they are required to achieve within a given budget. It is a mechanism to release funds i.e., “cradle to grave” care.

DW updated on plans for a primary care investment bundle consisting of resources for provider development, pathway optimisation and enhanced services.

All agreed that the current workforce was insufficient and SP recommended to the board that the next meeting scheduled for 6th September be replaced by a workshop focused on primary care workforce issues and that invitations be extended to those who attended the primary care workshop on 6th July who are not on the Board. This was approved.

KS stated that this topic could also be covered at PTI events to not only reinforce the message but ensure everyone was working together across the boroughs.

It was agreed that in order to achieve success, more financial resource for provider development would be required and SP confirmed that this was the CCGs’ intention and a proposal for this was to be worked up over the summer.

Action: Update diary invites for the next meeting to “workforce development session” (Action – SP) Extend invite to this meeting to included appropriate attendees (Action - SP)

3. Primary care workforce update Review of General Practice Nursing in BHR A paper prepared by Aimee Fairbairns (AF), Nursing Directorate, NHSE (London) had previously been circulated to members and was discussed. SP clarified that this review had been undertaken in line with policy and funding from NHSE and was a focused piece of work commissioned by the CCGs on the current status and risks around practice nursing in BHR.

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The review found that there were clear pressures around GPNs in BHR with an older general practice nursing workforce, gaps in workforce and an increasing demand from patients. Health Education England’s Recognise, Rethink, Reform document launched recently sets out a range of recommendations to support & develop the GPN workforce.

The 10 point plan referred to in the document had been delayed due to the general election and purdah and would follow shortly. The aim of the review was to develop strategic recommendations now which would position BHR well in anticipation of the review being published.

KS expressed disappointment on behalf of the federations for not being included in the list of contributors. The federation felt that many nurses had not seen the review or had the opportunity to comment. It was suggested that they share this paper through their own federation/network and glean the opinion from all three federations to ensure as much information as possible is collated. SP replied that AF had had limited time to carry out the work. She had attended a number of network meetings and this would be made apparent in the paper.

All agreed that there is a problem in not only recruiting GPNs but also retaining them in the area after training; this is a serious issue that needs to be addressed to ensure a return for investment as it was not acceptable for training to be given to staff who then move out of our area. DW raised the suggestion of on-line training; a pilot scheme was running in one small area but long term DW appealed to the panel to investigate ways of funding this in BHR. This would not only attract nurses to the area but also instil a feeling of support, education and carer progression.

After further discussion all agreed that the disparity between GPN pay and conditions, training and career progression needs to be addressed.

JG expressed her frustration with recruitment as suitable candidates are not readily available. She suggested we defer to the next professional possibly HCAs and scale them up into a nursing associate role. It was noted that CEPN works alongside the federations to roll out nurse practitioner and nurse associate positions.

KS reported that the federations are looking into having their own provider staff bank with very low operational and running costs which would also support the nurses with a CPD programme. This would become part of a career pathway which starts at school; it is important to make nursing and primary care a more attractive career path to follow to encourage staff to apply for posts and then stay.

SP emphasised that this document had not been shared beyond this meeting. A meeting to discuss the document with lead nurses in each CCG was planned once the 10 point plan is published.

Action Include Federations on list of contributors in the report (Action – SP) Share the report with nurses once the 10 point plan is published (Action – SP) International Recruitment Bid SC presented a paper relating to the International Recruitment Bid and reported that the GP Forward View gave a commitment to attract and recruit up to 500 GPs from overseas; NHSE have allocated £20million to this programme.

BHR along with Waltham Forest and Newham CCGs had submitted a bid to recruit 35 GPs to work in practices. SC was happy to announce that an email had been received from NHSE to informally confirm that the bid has been successful.

The next step will be to engage in discussions with partner organisations to agree the plans for implementation.

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Working with recruitment agencies, the plan initially is to target candidates from Spain and Portugal together with UK returners from Canada, Australia and New Zealand.

Recruited GPs will need to go through HEE’s induction and refresher programme.

MS welcomed brief comments on how the scheme could be developed but due to time constraints requested that any in-depth comments be sent via email.

The following were noted.

 Ensure candidates meet the same standard as local GPs  If training is provided there should be a contractual obligation to stay for a certain period of time.  Share recruitment process and timescales with GPs  Ensure RTT input would form part of the induction and refresher scheme through HEE.

SC requested the board to note that a bid has been submitted and proved successful.

The paper was noted by the board CEPN update PO reported that after the CEPN board meeting on the 19th July it had been agreed that going forward they would focus on specific pathways, using all their collective resources to maximise impact. The three priorities that the CEPN board agreed were:-

1. A more targeted approach to better outcomes for local people 2. A system wide approach to workforce development 3. Ensuring CPEN is financially sustainable in supporting the workforce to develop the necessary skills in new models of care

Essentially ensuring the CPEN is set up to develop a system wide approach to workforce development keeping in line with the Accountable Care System approach.

Current CEPN activities include:  Training needs’ analysis assessment across general practice  Currently in the process of recruiting a number of posts; support through the nurse training super hub to recruit 2 x 0.5 posts which will be practice nurse educator roles.  Work is ongoing relating to the rotation of nurse associates  Working with CCGs, relevant partners, federations and the STP to look at the ‘new roles’ offered and how to make them meaningful and engaging across general practice.  Specifically CPEN are in the process of recruiting for the third phase of their new ‘practice nurse in general practice nursing’ an initiative funded by Health Education England; the aim is to recruit 10 GPNs across BHR. The advert is on NHS jobs with the closing date of 28th July. At the present time 28 applications have been received; there is an option to extend the closing date with interviews scheduled for the middle of September.  Testing the viability of an e-learning pilot for practice nurses’ immunisation update training  Work being undertaken relating to wider participation and apprenticeships  Transformation fund - QI work focussing on end of life care as a pathway and a system wide approach.  Group consultations for patients with long term conditions – engaging with several practices around interest in this project.  Non-medical prescribing for practice nurses and pharmacists  Work relating to empowering and engaging carers via training and education within practices  Work with CCGs around an approach to identify GPs with special interest

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 Specific piece of work around pharmacists across BHR

HP mentioned the disparity of BHR CCGs being a combination of 3 boroughs but only receiving funding as one borough, effectively being disadvantaged. This sentiment was agreed and it was suggested that a letter be sent from this board to HEE explaining the position and requesting additional funds. MS is happy to support PO in requesting extra resource.

Action Draft paper for support for additional funds for CEPN (Action – PO) 4. Review of primary care long term conditions schemes Diabetes prevention and improvement scheme (B&D, Havering & Redbridge) As there was limited time, this was not discussed. A presentation had been circulated giving an update on the schemes in the three boroughs.

Atrial fibrillation quality improvement programme (Redbridge) MM presented the AF Improvement Scheme paper which was supported by the BHR Medicines Management team and Redbridge Public Health team. The scheme addresses gaps in detection, assessment and treatment of patients with AF by following a specific pathway. The scheme is working well in terms of engagement from practices.

SP stated that this is an important step for long term conditions in BHR and we are already seeing significant outcomes in terms of treatment, including an increase in the numbers of high risk patients with AF who are anticoagulated.

The intention going forward is for commissioners to develop a local incentive scheme for a number of long term conditions and that this will be commissioned over a longer period from April 2018 e.g. two to three years. The recommendation is that this is an agenda item at the next board meeting

The paper was noted by the board Action Update at next meeting on proposal for a local incentive scheme for BHR practices covering a “bundle” of long term conditions (Action – SP) 5. STP Primary Care Update Provider development framework MSc gave an update on the East London Health and Care Partnership (STP) provider development framework. It was noted that the framework includes helping ‘at-scale’ providers in East London baseline their position and identify priority areas for organisational development. The STP have developed a framework to help understand the infrastructure to be able to support membership and quality improvement and also more generally a section on overall provider development. The framework has 5 sections: (1) building a culture of quality improvement, (2) building skills and capability, (3) developing networks of QI practice, (4) availability of improvement ideas, and (5) at-scale provider development. Each CCG and provider has undertaken an initial self-assessment against the main QI categories. An important next step is to put together provider selectors around organisation maturity. The paper was noted by the board Primary care acceleration investment case PR reported that the East London Health and Care Partnership’s work concentrates on quality improvement and workforce development. An investment case for £6.1m has been developed and is being considered by Dr Arvind Madan, Director of primary care, NHSE, and a GP in Tower Hamlets. An update on the outcome of this will follow at the next meeting

It was noted that the issues are very clear but the onus needs to accelerate solutions rather than focus on the problems.

The paper was noted by the board

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Action Provide an update at the next meeting on the investment case for funding for primary care. 6. Any other business None

Date of next meeting: 6th September 2017 (dedicated workforce workshop)

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BHR joint PEF actions 17 October 2017

Actions No Issue/item Action Lead

1. Accessibility Sort out hearing loop at Becketts House MP

2. Governance Look at PEF ToR and how applies to a joint MP PEF

3. Communications Pick up issue of some Redbridge people not MP receiving emails

4. Future PEFs Ensure action log is maintained for PEF ZA meetings

5. Financial recovery Share list of identified £44m savings through MP efficiencies and contract negotiations

6. Spending NHS money Feedback to PEF on decisions reached, ZA wisely consultations once made, at future PEF meeting.

7. Consultation best Share ideas about how to reach people when All practice consulting

8. Future joint PEFs Ask members for their thoughts on where is MP best to hold joint PEF meetings

9. PPG chairs A number of PPGs are struggling to recruit SS new chairs and there is concern over what will happen if they cannot find volunteers. SS to share contact details for PC borough leads and info about the contractual obligation for a PPG.

10. Patients travelling into Concerns raised about adults with long-term SS London conditions/disabilities having to travel to appointments in central London. SS to pick up with Anita.

223 11. Primary care – Advise when there will be patient SS network meetings involvement in the GP network meetings.

12. Financial recovery – Look into savings plans and if there will be a ZA medication savings strategy to protect funding for people taking biologics.

13. Agenda items Email members to ask for suggestions about MP what to discuss at future joint PEF meetings.

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Draft Minutes of the BHR CCGs Quality & Safety Committee – Part 1 Tuesday 24 October 2017 at Becketts House 1.30 – 3.30pm

Members:- B&D CCG Havering CGG Redbridge CCG Ah-fee Chan (AFC)- Chair Secondary Care Consultant Jacqui Himbury (JH) Jacqui Himbury (JH) Jacqui Himbury (JH) Nurse Director Nurse Director Nurse Director Gina Shakespeare (GSh) Gina Shakespeare (GSh) Gina Shakespeare (GSh) Director, Delivery & Director, Delivery & Director, Delivery & Performance (Interim) Performance (Interim) Performance (Interim) Dr M Tahir (MT)

Attendees:- Christine Kane (CK) Deputy Director, Quality Assurance , BHR CCGs Mark Gilbey-Cross (MGC) Designated Adult Safeguarding Manager, BHR CCGs Belinda Krishek (BK) Chief Pharmacist BHR CCGs Angela Ward (AW) Company Secretary BHR CCGs

Apologies Dr Sarah Heyes Dr Maurice Sanomi Dr Ashok Deshpande

1.0 Welcome and apologies Action The Chair welcomed everyone to the meeting and apologies were noted. It was also noted that the Committee was not quorate for B&D CCG or Havering CCG.

No additional declarations of interest were declared. The register of interests held for BHR CCGs Governing Body (GB) members and staff is available from the Company Secretary.

1.2 Minutes of the last meeting The minutes of the meeting held on 1 September 2017 were agreed as an accurate record.

1.3 Matters Arising Action Log 1.3 Quality Strategy-report on agenda. Action Closed. 1.3 NHS111- CK provided minutes of PELC SI meetings, and advised of robust processes in place with a lead (ex LAS) covering these now. Action closed.

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1.3 DN capacity- NELFT had provided an interim report at the last CQRM with a full report promised for next. MT flagged the impact on primary care due to a shortage in DN provision and questioned slow progress. JH acknowledged delay and this had been raised at CQRMs and flagged formally to NELFT and the Chair confirmed that the Committee could not accept any further extension and a breach notice would be the next step. Action open.

2.0 Clinical Harm- JH confirmed that the Clinical Harm Review process had been stood down and BHRUT was found to be fit for purpose. The BH process was still continuing and was robust but slower than BHRUT. At a recent meeting LM confirmed that the RTT recovery plan is making progress and an estimate of BHR patients waiting longer than 52 weeks was around 50.Action Open for BH

3.0 Mortality Reduction Plan- GS and JH had discussed this further and JH had written to BHRUT that the Committee had not yet received sufficient assurance. There was a Gateway meeting later this week where this would be progressed. Action Closed.

2.2 BHRUT Delayed Diagnosis-The Trust had shared a report on delayed diagnosis at the CQRM and gave a presentation on radiology advising that JH improvements were in place. For the next CQRM presentation 3 planned care clinical leads were attending to discuss progress. Action Open as ongoing

6.0 BHRUT Never Events/Maternal Deaths- Although there was JH assurance on Never Events being addressed there was still more to do. Action open as ongoing

10.0 051 Diabetic Charcot Pathway- LM had provided an update that the SI investigation was underway to be completed by the end of January when summary findings and lessons learned will be shared. This was an agenda AW item for February. Action open.

1.3 Concordia Look Back- AW updated that a Havering GP had been contacted requesting an update on the health of one patient identified. The Committee wished to know more about their current health and relationship with past scans and this was currently being reviewed by the practice. Original Action Closed but further information awaited. AW

2.0 Risk Register CK presented the Risk Assurance report and the following risks were discussed;

RTT triage services- the risk arose from patients redirected away for surgery who may not receive appropriate post-operative care e.g. physiotherapy. Queen’s acute pathway includes physiotherapy at Queens. MT advised on wound mgt. issues following treatment in the independent sector.

Mid Essex Maternity- There was a risk of local mothers being turned away due to temporary closure to out of area bookers. This was being closely monitored with involvement of the regional maternity commissioner (STP

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level) and maternity transformation board and bookings needed to be managed carefully to cope with demand and capacity issues.

Community C Diff Cases- The red rated risk was around lack of clarity as to who was funded to carry out community C Diff follow-ups. The Committee was aware of risk identified relating to overuse of antibiotics in primary and community care and actions plans were being presented under item 4. An Infection Control directive was expected to be mandated on community C Diff shortly.

Discharge Summaries not acted upon- Risk arose around some practices not accessing discharge summaries and depending on their patients bringing a copy in. Practices were being supported. A review of discharge emails had begun to be reconciled with patient records, which would be followed by clinical harm reviews and patients recalled as necessary. The matter was recorded as an SI and RCA would follow and an independent audit would be carried out. JH was pleased to advise that to date no cases of clinical harm had been found. Also that the Francis report had required early warning system and the KLOE tracker was effective in capturing emerging trends.

Quality Assurance Care Homes- The past visiting arrangements were too labour intensive and unsustainable and therefore there was collaborative work with the LA, STP and quality surveillance group. MGC would still visit if an alert was raised.

The risk assurance report was noted and red rated risks discussed.

3.0 Mental Health specialist brief for Quality Leads Qtr.1 2017/18 This regular briefing from the CSU covering Qtr1 provided SI themes across NELCSU providers which included 19 reported by NELFT. The recommendations in the report were noted.

4.0 C Diff SI implementation assurance report Arising from a review into care provided to a patient in 2013/14, NELFT had developed an action plan to mitigate similar risk. There were 4 key recommendations for NELFT to respond to and leads and timelines were noted. As commissioners BHR worked with primary care to ensure best practice around prescribing antibiotics through the medicines management team and BK was the local lead on the London wide group.

The update report was noted.

5.0 Adult Safeguarding Annual Report for BHR CCGs This was an assurance report that the CCGs complied with all statutory duties and best practice standards. Safeguarding training and Prevent awareness training had been completed as follows- B& D 71%/71%, Havering 81%/95% and Redbridge 94% for both against the 95% target. Names of those who had not completed the training were being tracked. MT added this was part of GMC requirements for GPs and part of the revalidation/appraisal process and suggested they be asked if they had completed training through another avenue of compliance. MGC did provide MGC training at PTI events and would add focus on compliance being mandatory. He would pass an update to GS to raise with CDs.

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Noting issues raised during the Meadow Court consultation, assurance was sought of the safety of services commissioned and GS would be discussing GS this with CB.

The Annual Report with its recommendations for 2017/18 was approved by Redbridge CCG Members. As both B & D and Havering CCG were AW inquorate the secretary would request their support by email.

6.0 Children’s Safeguarding Annual Report and Looked After Children Annual Reports Children’s Safeguarding Due to limited time at the last meeting, MGC requested any further commentary or questions on the 2016-17 annual report. The safeguarding training standard was 85% and Redbridge & Havering were compliant although this was impacted by staff numbers in B& D.

Looked After Children –This report provided assurance that the BHR CCGs were discharging their responsibilities to safeguard and look after the health needs of LAC. JH flagged risks around health assessments and reviews on time, noting it was improving but the area of children in care was complex as many were out of borough placements and work continued closely with Borough colleagues. This was also a very transient cohort with starters and leavers both increasing. There was evidence of differing approaches to moving children from child protection to LAC across the CCGs. The age limits of LAC are 18 but the borough had responsibilities up to 25 years if ‘children’ are in full time education. BK noted the reference to seeking effective commissioning and quality outcomes and the table identifying emerging health needs e.g. dental, eyesight and questioned gaps. MT flagged the important issue of Immunisation and a worrying trend and wished this and ‘unaccompanied children’ to be flagged in the report. MGC

The Children’s Safeguarding and Looked After Children’s report were AW approved by the Redbridge Committee members. As both B & D and Havering CCG were inquorate the secretary would request their support by email.

7.0 Quality Strategy Implementation JH advised that the current strategy was for 2015-2018 and would require updating in 2018. That revision would reflect on revised operational arrangements e.g. STP and would involve stakeholder/partner engagement. There would be updates on progress at the February Committee for the AW March Governing Body.

The briefing was noted.

8.0 Safeguarding at Risk Strategy MGC presented this joint Children and Adults Safeguarding Risk Strategy for each of the BHR CCGs. This adhered to national guidance and had already been agreed by the Safeguarding Assurance Committee

GS welcomed this comprehensive and clear document.

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Redbridge CCG Members approved the strategy and B& D and AW Havering Member would be asked to consider and approve the same.

9.0 Looked After Children (LAC) Strategy

This short strategy document, an addendum to the previous strategies, outlined how the CCGs would further develop LAC services to ensure statutory responsibilities were fulfilled. GS questioned monitoring arrangements on progress for this very vulnerable group of children and JH confirmed that we were at mid-point of implementation and this was reviewed monthly with clinicians at the Safeguarding committee, such as compliance with Ofsted, and those minutes were provided at the Q & S MGC meetings for further assurance. It was agreed there would be a further update in 6 months at his Committee.

Redbridge CCG Members approved the strategy and B& D and Havering AW Member would be asked to consider and approve the same.

10.0 PREVENT policy This was a new CCG policy that outlined how the CCG will deliver on the PREVENT agenda, ensuring staff could identify and support individuals at risk of radicalisation. The policy complied with national guidance and had been approved by the Safeguarding Assurance Committee. Attention was drawn to a Raising a Concern form relating to reporting colleagues and this was on the staff intranet. MT was aware of face to face training for locality staff, BHRCCGs, ELC, BHRUT, NELFT and independent providers.

Redbridge CCG Members approved the strategy and B& D and Havering AW Member would be asked to consider and approve the same.

11.0 Domestic Violence Abuse Policy The policy outlined how the CCG would deliver on the national agenda to ensure staff and service uses who are victims or perpetrators are identified and supported. Again the policy adhered to national guidance and had been approved by the Safeguarding Assurance Committee. Attention was to be MGC given to clarifying HR leads as this function was led by the CSU. The review date was 2020 unless new guidance was received beforehand.

Redbridge CCG Members approved the strategy and B& D and Havering AW Member would be asked to consider and approve the same.

12.0 Primary Care SI Status report Following an audit of GP practices, 6 practices were identified as not monitoring discharge summary email boxes. There had been a change of arrangements in 2014 where faxes were no longer employed and some dated back to that time. An independent audit was established to identify any patients that might have come to harm and a Task & Finish group set up to oversee the audit and minutes were provided for this Committee.

An SI investigation was reviewing events to identify root causes and learning to mitigate against further events. Resilience funding had been offered to support the tasks by way of an agreed MOU. A fuller report would be JH provided to the December Committee meeting. It was noted the NHSE were informed and LMC requested expediency. The MOU was now developed.

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The briefing report was noted.

13.0 GP Service Alerts Update An internal audit of the process had identified improvements and the process was revised as recommended, which included KPIs on response times. A Task & Finish Group was established to oversee the changes to the process and a target set of closure of 28 days. There had been an update on the revised GP Alerts process delivered to PTI events in October. The alerts received this year had increased by comparison to 294 and currently there were 105 open cases. The GP alerts newsletter was welcomed. MT added that the boundary issue for community services was still unresolved but noted it was a closed action for this Committee. JH added that this was progressing elsewhere as it had been referred to STP level as change was not within the CCG gift.

The update report was noted.

14.0 Any Other Business 14.1 Committee Attendance- Due to non-attendance two of the three CCG meetings today were not quorate and decisions could not be made on policies and annual reports that needed to be forwarded to the next Governing Body meetings.

It was noted that this had been raised a number of times since the Committee was formed and flagged by the Well Led Review. Noting the Accountable Officer and Chairs had been notified before, GS would raise GS this again and keep the Committee Chair informed. It was vital to the Committee to receive CD feedback on ‘coal face’ issues and experiences and assurance was weakened by lack of full clinical membership input.

The secretary would write to the absent members to ask them to read and AW comment on the Committee papers to allow these reports to progress.

14.2 CAMHS- MT raised concerns over referrals to Loxford Hall noting that the Local Authority had stopped providing their Here and Now service.

Criteria for referrals to children’s services had changed and only very severe cases seemed accepted. There was now a gap in the mild to moderate group of services. Children with disruptive behaviour or those with problems of a socio-psychological nature may receive ‘parental advice’ and were not being fully supported by either primary of secondary care. Lack of access was leading to quality and safety issues. GPs could not prescribe the medication some required until they were assessed.

GS advised that NELFT were making a case of extreme pressure and this was compounded by the LA decision. SM was in discussion with NELFT on demand and capacity and a business case was being developed which would demonstrate what could be achieved with additional funds. Clarity MT would be sought on entrance criteria. MT was asked to raise this via GP alerts and also raise at the next IJEC meeting.

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14.3 Never Events- The Chair questioned the Trust’s Duty of Candour around Never Events. JH confirmed that there was regular discussion with the providers on this and it was actioned.

14.4 Farewell- The Chair in noting this was the last meeting CK would attend before she left the CCGs, thanked her on behalf of the Committee for her good work and wished her well for the future.

15.0 Items for Information 15.1 Safeguarding Assurance Committee Minutes-the minutes of the meeting held on 19 September 2017 were noted.

15.2 BHRUT SI Panel Meeting Minutes- the minutes of the meeting held on 18 September 2017 were noted.

15.3 NELFT SI Panel Meeting Minutes- the minutes of the meeting held on 16 August 2017 were noted.

15.4 PELC SI Panel Meeting Minutes- the minutes of the meeting held on 11 October 2017 were noted.

15.5 BHRUT CQRM Minutes- the minutes of the meeting held on 11 September 2017 were noted.

15.6 NELFT CQRM Meeting Minutes- the minutes of the meeting held on 20 September2017 were noted.

15.7 WX CQRM Meeting Minutes- the minutes of the meeting held on 19 October 2017 were noted.

16.0 Future Meetings The next meetings were on 19 December 2017 and 27 February 2018.

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