Primary Care Commissioning Committee Meeting Held in Public 18 May 2017, 9:30 Am – 12.30Pm Room 1, Jubilee House, Bloxwich Lane, Walsall, WS2 7JL

Primary Care Commissioning Committee Meeting held in public 18 May 2017, 9:30 am – 12.30pm Room 1, Jubilee House, Bloxwich Lane, Walsall, WS2 7JL

Agenda Items Item No Assurance

Decision Approval

Information only

9.30 1.0 Introductions and apologies for absence*

Carol Marston, Robert Freeman

9.35 2.0 Notification of any items of other business*

2.1 Declarations of interest*

9.40 3.0 Consent Agenda

9.40 3.1 To approve the Minutes of the Primary Care Item 3.1 Approval Commissioning Committee held on 20 April 2017.

9.45 3.2 IT Steering Group update Item 3.2 Information

9.45 3.3 Walsall Plan Item 3.3 Information

9.45 3.4 Public Health Transformation Fund Review Item 3.4 Information

9.45 3.5 Big Conversation Update ( full report available on Item 3.5 Information CCG internet )

9.55 4.0 Report on Matters Arising – Action log Item 4.0 Discussion

10.00 4.1 Finance Report – TG Item 4.1 Information

10.05 4.2 QIPP Report Item 4.2 Information 4.3 - GB Medicines Management presentation Item 4.3 Information 4.4 - Medicines Management Business Case Item 4.4 Approval

10.10 5.0 PCOG Update Item 5.0 Information

- Quality assurance update

10.20 6.0 Saturday Opening Evaluation Item 6.0 Information

10.25 7.0 Latent TB Screening Item 7.0 Information

10.35 8.0 Audit Response - DM Item 8.0 Information

10.40 9.0 Transformation funding bids - DM Item 9.0 Information

10.50 10.0 Risk Register Item 10.0 Information

Any other business 10:55 11.0

11:00 12.0 Date of next meeting:

15 June 2017, 9.30am – Room 1, Jubilee House

11.00 13.0 Close

*Monthly standing items on the agenda. QUORUM A minimum of 50% membership (8 members) which must include: The Chair or Vice Chair, one CCG Director, the Secondary care consultant or Director of Governance Quality and Safety.

Date Page 2 of 2

Primary Care Commissioning Committee (Public Meeting) 20 April 2017 9.30am Jubilee House

Notes Present

Mike Abel (MA), Donna Macarthur (DM), Tony Gallagher (TG), John Duder (JD), Robert Freeman (RF), Carol Marston (CM), Carsten Lesshafft (CL), John Taylor (JT), Simon Brake (SB)

In attendance Sara Hadley (SH), Sumaira Tabassum (ST), Bal Dhami (BD), Lee Dukes )LD), Alison Simmons (AS), David Johnson (DJ)

1/17 Apologies for Absence Yvonne Higgins, Dr Uzma Ahmad

2/17 Notification of any items of other business None

3/17 Declarations of Interest

General awareness that some committee members have an interest in various GP practices. Declarations of Interest Declared by: 1. JD; patient at Lichfield Street practices and member of practice PRG 2. MA; indirect conflict of interest as his wife is a patient at The Limes practice.

4/17 Consent Agenda

Minutes of the PCCC held on 30 March were agreed as a true record after amendment to remove that the group should focus on DNA’s from item 179/16 PPLG.

The group discussed the use of abbreviations: Agreed to provide a standard glossary

IT Steering Group update noted by committee.

5/17 Report on Matters Arising

180/16 Saturday Opening Evaluation – detailed report not yet received, CM to request for next Meeting: Open 176/16 Finance Report, QIPP to include Medicines Management and LCS – agenda item. 148/16 SL Handover – April 2017: Complete 148/16 Patient on Line (POL); Primary Care Facilitators worked extensively with practices; 2 months Data lag noted. Agreed proactive use of Communication was required in the form of utube, Videos, snapchat, with regular updates from CCG Chair. Communication Department to

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Lead with regular updates added as a standard agenda item HD : Open 124/16 Primary Care Finance development session – date to be agreed as soon as possible : Open 77/16 NHSE update regarding Avoiding Unplanned Admissions (AUA) DES – progressing appeals. Report to committee with regular appeal and clawback updates : Open

6/17 QIPP Report

GP Forward View Transformation Funding discussed. Proposed bids for funding are via Leadership Group against 3 elements - Access - Medicines Management - Delivery at scale

Action : DM to bring to the May meeting for a decision

Reported PCCC QIPP target is £3.6m with schemes identifies for £2.9m, £938,000 shortfall, plus additional £1.9m still to be allocated by Finance & Performance Committee.

The group discussed potential QIPP areas. Agreed ideas/suggestions should be clinically driven. Reported Leadership Group focuses on Medicines Management QIPP with limited scope in LCS’s.

Action: DM to present a report at May meeting quantifying where LCS savings can be made for Committee decision.

7/17 NHSE Update

Update report presented to Committee, main points:  Reported MOUs between CCG and NHSE are now all signed.  GPFV West Midlands lead is Sarah Rutter for the Black Country and Birmingham and Solihull.  DES service specifications will be sent out to practices by end of April for return by June.  Refresh of Primary Medical Care policy book available in July.  Tamiflu for residents of care homes, Agreed Tamiflu issue referred to Health Protection Forum.

Action: SR to refer Tamiflu issue to Health Protection forum and report back to committee.

8/17 Medicines Management Update

Report presented to the committee,  Tax Regulation IFR35 no longer applies following Medicines Management SLA revisions. Reported this is Consistent with other CCGs.  Pharmacy Hours It was proposed current vacancies are frozen, noted this may impact on QIPP savings. The opportunity to explore new staffing models such as Pharmacy Technicians was discussed. Action : ST Options paper to June PCCC  Pharmacy Incentive Scheme Business cases presented. Agreed practices already at the top 10% should be rewarded for maintaining this position. Decision: Both business cases approved by the committee.

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9/17 PCOG Update

Update report presented to committee, main points;  Agreed PCCC minutes and any development sessions are shared with PCOG. The contracting variation log will sit with PCOG and forwarded to Committee for information.  The dashboard has been further developed with new data and score. Sharing of dashboard to be discussed with LMC / GP localities.  50 Walsall practices have now received a CQC inspection; 34 are rated as good, 9 as requiring improvement, 5 as inadequate and 2 rated outstanding.  Risk register reviewed and updated; three risks removed and one relating to Primary Care Level 3 Safeguarding figures added.

10/17 Fire Services

Fire Service presentation discussed. Agreed to raise awareness of the community services offered through the Communication Department. Action: Communications to raise awareness: HD

11/17 HealthWatch Update

Update presented to committee. Reported HealthWatch alerted to cancellations of operations at the Manor Hospital; and reasons given unacceptable and HealthWatch referred to the Health and Scrutiny Panel for further investigation. Reported Walsall HealthWatch now looking at joint public meetings with Wolverhampton HealthWatch. Also talking to other HealthWatch including Dudley.

12/17 Risk Register

Audit Report recommendation to add the risk register or a version of to the public part of the meeting. Development work regarding confidential items required before it can sit within the public meeting.

Action: review risk register :DM

183/16 Any Other Business

The Chair suggested the meeting be recorded in future this was agreed by the members of the committee.

184/16 Date of next meeting

PCCC Public meeting – 18 May 2017 9.30, Room 1, Jubilee House

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In Confidence Not for Publication or Dissemination Delete if paper is for public dissemination PRIMARY CARE COMMITTEE Date of committee meeting: 18/05/2017 Agenda Item No:3.2

TITLE OF REPORT IT Steering Group Report

PURPOSE OF REPORT: Report IT Exceptions and Risks

EXECUTIVE SUMMARY: IT Exception Report

Nine exceptions reported – four relating to projects in delivery and four operational.

Risks in summary: Four operational risks identified, two RAG rated amber and two rated red.

RECOMMENDATION TO THE COMMITTEE:

COMMITTEE ACTION Assurance REQUIRED:

REPORT WRITTEN BY: Graham Westgate, Interim Strategic IT Lead

REPORT PRESENTED BY: Tony Gallagher

REPORT SIGNED OFF BY:

CONSENT AGENDA Indicate if appropriate for the consent agenda

PREVIOUS COMMITTEES Nil

There is a requirement for all members to read the papers prior to the meeting. The presenter must not go through the paper in detail. The presentation should go through

1 the executive summary and include any amendments/additional information which was not available at the time of writing the report or if there has been any discussion or challenge prior to the meeting.

The CCG Corporate Objectives.

Please indicate which Corporate Objectives this report supports Involve patients and public in decision making

Ensure value for money 

Commission high quality services 

Promote good health and sound treatment of ill health

Ensure strong leadership and good governance 

Work in partnership

Positive general duties - Equality Act 2010 The CCG is committed to fulfilling its duty under the Equality Act 2010 and to ensure its commissioned services are non-discriminatory. This report is intended to support delivery of our duty to have a continuing positive impact on equality and diversity The CCG will work with providers, communities of interest and service users to ensure that any issues relating to equality of service within this report have been identified and addressed Please indicate if there have been any equality of service issues identified in this Yes report No

All papers are subject to the Freedom of Information Act. All papers marked as ‘in confidence, not for publication or dissemination’ are sent securely to named individuals and they cannot be distributed further without the written permission of the Chair. Exemption 41, Information provided in confidence, applies.

Exceptions

Title Cause Consequences Actions Due Date 1 Universal capabilities Time lag of the national system Unable to verify the actual Escalated to NHS Digital. June 2017 project national utilisation reporting provided by NHS performance against the universal reporting frequency Digital: capabilities project real time Actions planned within the project to identify whether local reports can be developed to provide the required reports. and accuracy i. SCR – TBC

ii. EPS ‐ 3 months Variance between the actual stats Primary Care Informatics Function Work with clinical system iii. ERS – 1.5 months and estimates received from NHSE is supplier to verify whether reports can be developed that align to iv. Patient Online – 2 months not sufficiently accurate to enable national reporting queries. v. GP2GP – at least 2 weeks effective decisions to be made. E.g.

EPS stats variance for November 2016 Cost of EMIS Enterprise License for search and reporting – Variance between the actual stats and has a range difference of 30%. Year 1 ‐ £21.5k plus VAT estimated received from NHS Digital Year 2 ‐ £17k plus VAT (recurring costs per annum) – feasibility of monthly is inaccurate E.g. EPS stats Unnecessary expenditure of effort by local reporting being identified in advance of funding being variance for November 2016 has a project staff supporting practices that sought. range difference of 30%. have already met national targets

though cannot be evidenced.

2 Patient On Line (POL) 13 Walsall Practices not achieved the Pending publishing the final stats for Support the GP practices to increase utilisation by working March 2018 national 10% aim – details in year end, the NHS England POL lead through the challenges faced in meeting targets. Action plan Appendix A has estimated that nationally Walsall developed for each GP practice are average based on the level of NB It has been indicated by NHS patient on line registrations achieved. Identify additional opportunities to increase utilisation. England the following will be accepted as mitigation where practices have For practices below 10% increased Focus on realising the benefits of the national systems and the not met the 10% aim/ target work required during 2017/18 to value the systems will add to both practices and patients. The  practices in special measures achieve the 20% aim by 31st March project board meeting in May 17 will be set aside to develop  practices mergers pending  walk in centres 2018 plans with this focus.

NB March 17 final figures not yet published. Due to the time lag of

Title Cause Consequences Actions Due Date when reports are available, it is expected the status of Walsall practices against the POL March 2018 target will be available for the July 17 PCCC IT exception report 3 Docman Project – Utilisation of Docman GP is very low. Docman roll out stalled with 12 GP As an escalation to the IT Steering Group, options paper May 2017 – Product Utilisation Docman cannot receive electronic practices remaining to go live (NB at appraising the direction and next steps of the project developed for preferred documents directly from WHT. different stages of the deployment) for IT steering group. option to be identified Options paper developed being taken As April IT Steering group not held due to bank holiday and to February 17 IT steering group availability prevented quorate Extraordinary IT Steering Group to creating additional effort to transfer be arranged the preferred option will be identified at the May IT the documents into Docman. Steering Group (15/05/2017).

4 Network Walsall network infrastructure CoIN Unable to access national funding for WHT IT to update network infrastructure options paper as no May 2017 Infrastructure Costs – (Community of Interest Network) is new Health and Social Care Network longer in a contract with Virgin Media for the PSN (Public Sector for preferred CoIN (Community of not centrally funded during 2016/17 as the Public Sector Network) network infrastructure. option to be Interest Network) Network, Community of Interest identified Network (PSN COIN). Clarify the position regarding central funding levels for the Health and Social Care Network.

WHT to cost alternative infrastructure and all options within the paper.

5 GPIT and CCG IT WHT IT service has been unable to Service being delivered through WHT IT confirmed they have escalated internally to their June 2017 SLA’s not signed for provide breakdown of service costs implied contract and at potential risk Executive IT Director who is now leading on this. 2016/17 and 2017/18 and therefore CCG unable to verify of full scope of services not being are pending value for money or opportunities to provided to the expected service SLA meetings scheduled during May 17 to finalise WHT reduce SLA costs. This is also linked to levels. understanding of requirements enabling WHT’s IT service offer to exception 3 re network infrastructure be costed. Establish SLA’s/ service offer based on documented

Title Cause Consequences Actions Due Date costs. Cost of service being aligned to GPIT requirements and within cost envelope allocation. Service offer not received from WHT Once SLA’s signed, continue performance delivery through the in response to the GPIT and CCG IT monthly operational IT performance group. service specifications being sent. Longer term options for sourcing IT service to be identified. 6 Email Archive PST A default configuration within If the PC hard disk drive failed Progress preferred mitigation identified from the developed TBC files Microsoft Outlook saves Email archive mechanically or the PC was stolen, all options paper by WHT which is to relocate the email archive files files (.PST files) to the local PC hard data stored on the drive would be to a secure shared storage location on the network.

disk drive. irrecoverable due to it not being The mitigation plan is being taken to the WHT Change Advisory backed up. Board on 09/05/2017 for approval and is included for discussion Data residing on local hard disk drives at the monthly IT performance meeting on 11/05/2017. is not backed up and is not encrypted. As PC disk drives are not encrypted, Provisional completion date pending from WHT. the PST files are at risk of As PST archive files can be linked to unauthorised access. Some desktops identified with PST archive files on local drives NHS net email accounts, it is possible are in scope for replacement through the technology refresh project. Planning for this project remains underway by WHT and that PID could also reside within the Risk profiled by WHT IT – Red, score pending a start date. PST file. WHT advised that over 900 16.

have been identified within GP Additionally, all new clients deployed are to be configured practices. preventing email archive (PST) files being saved to local hard disk drives and will be included in the technology refresh project.

7 SUS Non‐Reporting Urgent care centres unable to National reporting requirement not Further to the NHSE workshop for NHS Digital and other affected TBC Type III complete SUS reporting as technical met. NHS organisations at the end of April, a follow on supplier solution not currently available. meeting is being scheduled in May for a solution to be identified. Clinical system supplier is aware of the issue. This issue is also experienced by other

CCG’s using EMIS. Provisional completion date to be confirmed once solution identified and lead time for development and deployment understood.

Title Cause Consequences Actions Due Date 8 NHS Mail 2 CQC inspection at WHT conflicts with Start of the NHS mail 2 migration Identify feasibility of CCG and GP’s to migrate first in line with October the provisionally planned date for delayed potentially until August 2017 original plan. 2017 migrating to the NHS Mail 2 platform. (pending confirmation). NHS Mail 2 migration project board to finalise the migration date and arrange communication to all stakeholders and service users.

Risks

Risk Area RAG Rationale / Impact Mitigating Actions Insufficient GP IT provider resources/ capacity to A . Delayed start of projects. Include interim project management and deliver programmes of work . Extended project delivery timescales . technical resources within the bids. . Inability to spend GP IT capital by year end resulting in funding being withdrawn. . If business as usual resources are used to delivery priority projects, operational service are at risk of being impacted. Primary Care Informatics Facilitators A One permanent primary care facilitators on extended career break. Interim resources employed. Options being Keeping in touch days and return to work intentions pending for the staff member. identified to regain control over In line with WHT policy, return to work intentions might not be confirmed until end of management of the resources including May 2017. TUPE and partnership working with another CCG. Temp staff contract extended by WHT until 30th June 2017.

Email Archive Files R Email archive files (.PST files) are at risk of loss as they reside on PC local drives. Over Options appraisal in development to 900 have been identified. Whilst the WHT IT service provider are developing the plan, mitigate, including costs insufficient resources are available to complete this in a timely manner. Efficient options for the transfer of these files are being explored. If the archive files have

Risk Area RAG Rationale / Impact Mitigating Actions archived email from NHS mail accounts, there is a risk this could include PID. Hardware Compatibility R Hardware manufacturers are upgrading chipsets within new client hardware that Windows 10 Readiness being managed by IT aren’t compatible with Windows 7. Dell (hardware manufacturer of standard service provider’s technical team. hardware deployed within Walsall) have confirmed that this will be effective in Summer 2018. Actual date to be confirmed. Meeting held on 10/04/2017 with support manager and assurance provided as to the EMIS remains unsupported on the Windows 10 platform without a date confirmed work underway. when the supported version of EMIS will be available. CCG and GP IT expectations outlined response and plan pending.

Windows 10 Readiness has been added as a recurring agenda to the monthly IT service performance review meetings to monitor progress.

Appendix A – Patient On Line, Walsall Practices Below 10% National Aim/ Target as at 31st March 2017

NB April 2017 figures not available at the time of writing this report. Future reports will include status against the 20% national patient online target to be achieved by 31/03/2018

Practice Practice Name % Achieved at 31/03/17 Challenges Experienced in Meeting 10% Code (preliminary only) M91659 BRACE STREET HEALTH CENTRE 4.19% Resistance to change and low interest from patients. Practice currently undergoing changes after joining Modality group. Practice Manager in M91028 BERKLEY PRACTICE 4.40% process of utilising good practice already undertaken at Kingfisher Practice. Practice currently having staffing issues and locum GP's currently. Practice services provided M91625 THE MANOR PRACTICE 6.08% by IntraHealth. Additional support expected for the practice once become part of The Practice Group (from 3rd April) M91025 DARLASTON HEALTH CENTRE 7.11% Low patient interest, and was suggested based on demographic. M91641 DR ALI SURGERY 7.22% Practice staff capacity and low patient interest. Y02624 THE WHARF FAMILY PRACTICE 8.09% Misinterpretation by the practice of the project objectives and costs. Patient on line service being promoted, low patient interest. CQC inspection outcomes a M91624 MOXLEY MEDICAL CENTRE 8.53% priority. Practice manager advised low patient interest based on demographic. Elderly population who M91637 BLACKWOOD HEALTH CENTRE 8.58% like visiting the practice. M91613 SAI MEDICAL CENTRE 9.01% Intrahealth Practice ‐ Practice promoting patient online service. M91628 BRACE STREET HC‐ KUMAR 9.08% Practice active in registering patients. Low patient interest. Year end. M91612 ST MARY'S SURGERY 9.10% Practice active in registering patients. Low patient interest. Year end. M91614 STROUD PRACTICE 9.34% Patients not completing the registration process Patient on line service being promoted, low patient interest. CQC inspection outcomes a M91609 NEW ROAD MEDICAL CENTRE 9.67% priority. Year end.

Agenda item 6

Health and Wellbeing Board

24 April 2017

The Walsall Plan: Our Health and Wellbeing Strategy 2017 - 2020

1. Purpose

This paper is intended to report on the process followed in developing the Walsall Plan: Our Health and Wellbeing Strategy 2017 – 20, including a workshop event on 29th March. (Feedback in appendix 1) The final version of the Walsall Plan is going to all the Partnership Boards identified in the Partnership structure for sign-up (Appendix 2). It is important that the members of the Health and Wellbeing Board (HWB) consider the Walsall Plan, the priorities identified and for which priorities the HWB will be taking the lead. In addition, the HWB obsession needs to be agreed.

Once the priorities and obsession for the HWB have been accepted, then the processes for identifying actions, audit and performance management need to be discussed (Appendices 3 and 4)

2. Recommendations

2.1 That the Health and Wellbeing Board approves, and signs up to, the final version of the Walsall Plan shown in appendix 2 and agrees that they will take the lead on the key priorities identified for the HWB within the Plan.

2.2. That the HWB agrees the Obsession upon which it will lead “To support the capacity of VCSEs in Walsall, and greater connectivity between the VCS and partners, in order to improve health and wellbeing for all, by increasing the number of Walsall residents who volunteer, in particular around loneliness and isolation and physical activity”.

2.3 That the HWB notes the next steps for developing both the Obsession action plan (appendix 3) and reporting arrangements for the HWB priorities (appendix 4).

3. Report detail

The Health and Wellbeing Strategy (HWS) is a key document for the Health and Wellbeing Board, identifying the priorities for current and future focus. These priorities should not be about work already being covered by LA and partner services, but should identify any gaps or where the connectivity between partners on the HWB can make a positive difference.

At the Health and Wellbeing Board on 27th January it was agreed that the Health and Wellbeing Strategy and the Walsall Plan would be integrated into a single plan covering the wider determinants of health.

The Walsall Plan: Our Health and Wellbeing Strategy (Appendix 2) has been developed using several key sources of information:

 Local strategic needs assessments (JSNA, Economic Needs Assessment, Strategic Assessment for the Community Safety Plan)  Work for the Strategic Partnership Group identifying cross-cutting themes within partnership and organisational plans  Current work on the Council’s Corporate Plan

The wider determinants of health are recognised, and three overarching priorities have been identified to improve the health and wellbeing of our population:

 Increasing economic prosperity through increased growth  Maximising people’s health, wellbeing and safety  Creating healthy and sustainable places and communities

A life course approach has been taken, with reducing inequalities as a key theme across all areas. Key priorities have been identified underneath each overarching priority. These priorities are the focus of work for our Partnership Boards - appendix 1 of the Walsall Plan identifies which Board is accountable for each priority. Alongside these priorities, a number of key target groups have been identified.

In addition, each Board has identified an “obsession”, a key issue where the whole Partnership can work together to make more of a difference to the outcomes for our local population. These “obsessions” are:  To support the capacity of VCSEs in Walsall, and greater connectivity between the VCS and partners, in order to improve health and wellbeing for all, by increasing the number of Walsall residents who volunteer, in particular around loneliness and isolation and physical activity (Health and Wellbeing Board)  All children are safe, happy and learning well (Children and Young People’s Partnership)  Quality apprenticeships for all ages (Walsall Economic Board)  Address the issue of homelessness / rough sleepers to improve outcomes (Safer Walsall Partnership)  “If it doesn’t feel right, then act on it” (Safeguarding Boards)

3.1 Involvement of partners and consultation

Partners have been involved throughout the development of the Walsall Plan, through individual meetings and through discussion in various partnership forums including:  Health and Wellbeing Board  Strategic Partnership Group  Council Management Team  Cabinet-Council Management Team  Borough Management Team  Walsall Economic Board

A workshop event for partners was held on 29th March where there was further opportunity to contribute to the development of The Walsall Plan and to consider its delivery. All members of the HWB were invited to attend this event. Feedback is given in appendix 1.

Engagement with the public will be crucial in shaping delivery of the specific actions identified in the plan.

3.2 Governance arrangements

The Walsall Plan will need to be approved by each partner organisation in Walsall, and also by the Walsall Partnership Boards as the overarching plan for Walsall. All Partnership Boards and partner organisations will be responsible for ensuring that their own plans reflect and deliver against the priorities in the Walsall Plan. The Walsall Plan has been developed in conjunction with the Corporate Plan.

The Partnership Boards will continue their own monitoring and performance management arrangements for their action plans to deliver the key priorities in the Walsall Plan. It is not planned to duplicate existing performance management and governance arrangements. Delivery plans will continue to be managed through the relevant Partnership Boards and partner organisations. The Partnership Boards will continue to hold individual organisations accountable for delivery of their action plans. Accountability for each organisation will be through its own governance structure - for Council this will be through Cabinet.

3.3 Next steps:

All of the Partnership Boards and partnership organisations will be asked to sign-up to the Walsall Plan and work within their existing governance arrangements to monitor progress against the priorities for which they take the lead.

Appendix 3 includes a draft template to promote discussion about the reporting arrangements for the HWB priorities. Further consultation is required on this to identify the key strategies and plans involved and agree the focus of each area of work for the HWB.

Appendix 4 is a draft action plan for the HWB obsession. This requires identification of a named lead and further development, perhaps through a small working group.

Subsequent versions of both appendices 3 and 4 need to be brought back to the next meeting of the HWB.

4. Implications for Joint Working arrangements:

The Walsall Plan (appendix 2) is the primary partnership document identifying the shared key priorities for Walsall, all of which contribute to improving the health and wellbeing of the population. Partnership discussions, influence and drive will be channelled through the Partnership Boards identified within the Plan, all of which lead on one, or more, of the key priorities. It is expected that the members of those Partnership Boards will decide how best to pool their resources to lead and support the work being undertaken to tackle priorities.

5. Health and Wellbeing Priorities:

The Walsall Plan has been developed recognising that, in order to enable people to live healthy, safe, independent, prosperous and fulfilling lives, we need to work together in partnership to co-ordinate an holistic approach to the challenges we identify, covering the socioeconomic, cultural and environmental elements determinants of health.

Within the Plan, due consideration has been given to the six Marmot objectives as listed below:

1. Give every child the best start in life 2. Enable all children, young people and adults to maximise their capabilities and have control over their lives 3. Create fair employment and good work for all 4. Ensure healthy standard of living for all 5. Create and develop healthy and sustainable places and communities 6. Strengthen the role and impact of ill-health prevention.

All the key priorities have been mapped across the life course and a review has been conducted to ensure all the Marmot objectives are represented within the key priorities identified for Walsall. All six objectives have been covered.

Safeguarding has also been a focus for consideration and it is recognised the work involved is implicit within the list of priorities. Both Safeguarding Boards (children and adults) are included in the Partnership diagram within the Walsall Plan and members have been consulted in the various drafts of the document. In addition, the Safeguarding Boards have chosen their own obsession for focus during the lifetime of the Walsall Plan. .

Authors

Cath Boneham Health and Wellbeing Programme Manager  653738  [email protected]

Rachel Chapman Specialty Registrar – Public Health  650324  [email protected] Appendix 1

Feedback from The Walsall Plan: Our Health and Wellbeing Strategy workshop (29th March 2017).

Specific responses to comments are in bold

How does The Walsall Plan fit with your organisation/partnership board? Specific Board comments:  SWP members have been instrumental in the initiation and forward drive of the development of greater coordination and alignment of priorities, funding and engaging Accenture in the first instance. Walsall Plan incorporates the SWP Plan – safety a key part of well-being.  Walsall Plan will give WEB a sense of purpose/direction and help shape its agenda. We need to ensure it adds value to WEB rather than increase burden. One of the strengths of WEB is in being non-statutory: it’s not the ‘Council’s’ board and so the private sector feels a great sense of ownership. A lot of its value is that it has 2 very basic priorities at its core – creating local jobs and helping local people get those jobs. We don’t want to lose this simplicity.  CYPP needs refresh – real opportunity to embed these priorities into the refreshed CYPP and then see any gaps.  Safeguarding Boards have an assurance role, not an operational role  Aspects of the Walsall Plan fit the Police and Crime Plan, which also takes a holistic approach General comments:  Interrelationships within Plan are vital, with many of the priorities dependent on one another. Communication + collaboration between Boards is key. Other Boards have role to play in delivering improvements to achievements. (Role for SPG in identifying synergy, challenging interrelationships and enabling information sharing). Examples identified: o Wider cultural change needed – e.g. learning and skills agenda for up to 25 years, not enough opportunities in Walsall – priority sits with WEB. o Adults emotional wellbeing and resilience sits with HWB – connected to CYP emotional health and wellbeing (do these adults have children? How are they affected? Opportunity – to position CYP issues better with HWB o Keep vulnerable people safe – early help connection to CYPP but should stay with WCSB. o Opportunity to rewrite Youth Justice plan – can build in Walsall plan – shared objectives fitting into boards o Monitoring and oversight issues falling out – CYPP e.g. teenage pregnancy and infant mortality could feed into HWB o Need to follow the whole pathway through e.g. apprenticeships through to jobs in Walsall. o Improving air quality – role of WEB – need to recognise this – local jobs in Walsall. o Tackle the harms of substance misuse – link with HWB? o Better continuity of education and skills into increase access to skills and learning

 Need for greater and appropriate information sharing – ‘permission to share’ – not be parochial (a role for SPG to ensure information sharing protocols are in place).  What is our target? Need to set ourselves some concrete targets/ambitions (e.g. help community sector to set up 25 new businesses this year) so that everyone can work towards a common goal and we can see tangible progress.  Challenge recognised of how you do all of this alongside everything else. Boards don’t do the work – lead organisations do it.  How do we deal with challenge and contradictions when there is limited funding?  Feels like business as usual – this is good thing. Helpful that Plan is based on wider determinants – link to Marmot  Obsessions are the added value of the Plan – the collective is greater than the parts. But they need to be explained in terms of outcomes.  How will we know we are successful? – balance of being ambitious enough but not too ambitious.  Health Impact Assessment should be used more to assess organisational decisions and how they contribute to the Walsall Plan  Must engage around priority actions with public. Check that they ‘own’ the priorities/actions.  Synergy in training is required across partners  Where possible use a common language and a common way of working

Are there any priorities identified for your board where you would not see your board taking a lead?  The priority around ensuring services are accessible and culturally appropriate etc. should underpin ALL delivery, but who will OWN this? How will it be measured? (This has now been made a priority for all Boards, everyone should own and report on this through the Strategic Partnership Group)  NB Safeguarding Board role is oversight rather than operational  Still need to fine-tune the specific priorities adopted by SWP to enhance clarity, especially the ‘violence’ priority (this will be done as part of the work of the SWP).  Tobacco needs to be included in the ‘drugs, alcohol, and substance misuse priority.’ (Tobacco control will be considered by SWP when appropriate, there may be overlap with other Boards eg HWB)

Do you have robust governance arrangements in place to oversee your lead priorities?  Significant work is underway to reshape SWP Board, making it more dynamic, holding people to account, performing a scrutiny focused role, maintaining stronger community links.  Need to revisit the relationship diagram – Local Resilience Forum may not need to be part of that list. We also need to develop our own for the revised ToRs. (Local Resilience Forum removed. Please note that the relationships diagram is a dynamic structure that will change and develop over time)  Need to be clear on our own accountability and our new sub groups.  Some consideration needs to be given to where sub-groups fit and the role they play– certain priorities could be owned by sub-groups, e.g. Employment & Skills Board already have activity around skills agenda  We need to be action-orientated, recognising commercial drivers. Where is the accountability and monitoring for Walsall Plan going to sit? (Accountability sits with each Partnership Board and their own action plans, oversight will be through the SPG)  Each Board needs to consider its membership (ensure that membership includes the right people that can make the decisions), balance of organisational representation, terms of reference and reporting. This includes a decision on the role of Provider organisations on partnership Boards (Each Board should review their membership, members should identify substitutes when not available)  It would be helpful to have a consistent reporting format for Boards without creating a whole industry of reporting. Need to focus on a few issues (obsessions) for long enough. Plans need to have timescales so we can see results. (Safeguarding Boards have developed a scorecard and are now revisiting their priorities)  Are reports just to SPG? Could they be shared with all Boards? (This should be co-ordinated by Board officers on the SPG)  Consider timetable of reporting to ensure partnership inputs.  Need to have locality model lead by an identified board.

What has worked well before? Are there any gaps?  Good, solid and effective partnerships are already in place  Need to have the right discussions at the right time.  Avoiding duplication is key and should be supported by the Strategic Partnership Group.  Need to develop a consistent and meaningful performance management model. (Responsibility of each Board, to be shared with SPG)  Still need to flesh out how we understand and recognise what our partners are doing. (This will be supported by 6 monthly reporting to SPG and annual partnership summit)  Risk in having a great plan – there’s a danger of lots of words, but no action  Need to try not to be all things to all people. Must be ‘impact focussed’ – asking ourselves where we can make a difference, and all focus on that.  So what is the ‘big thing’ we can do that will create change. Possible link with Social Value.  Specific gaps identified by CYPP: o Oversight for Young Carers o Connection to corporate parenting board o Toxic trio group cease broader agenda to be picked up (by) CYPP Board - part of neglect (removed from Partnership diagram)  How connected Plan is to WMCA?  Challenge to demonstrate added value of working together. How to connectively know Walsall Plan has made a difference  Need appropriate resource to deliver on priorities  Gap identified regarding housing in Partnership structure (gap in current Plan)

Table discussions on specific obsessions – to be developed into action plans by each Board Address the issue of homelessness and rough sleeping to improve outcomes  Need to promote and drive greater coordination across agencies and sectors.  Improve sustainability of support.  Support and awareness raising around safeguarding for voluntary agencies.  Channel and direct the support that’s available to those in greatest need.  Need to really UNDERSTAND the multiplicity of issues faced by the homeless and those who sleep rough – no ‘one size fits all.’  Are we sufficiently resourced to make this happen and get to know those individual stories?  Do we really know the extent of the issue? Intelligence and knowledge held in different places.  Homeless triage.  Need to work with others on early intervention.  SWP will provide a platform for partnership discussion and delivery of tasks, but the casework should be addressed at locality panel level.

Apprenticeships  Recognise that partners themselves are employers – all will have budgets and we need to think collectively about workforce development and how we spend our Apprenticeship Levy  Some people might not be ready to go into an apprenticeship – so how do we plan for pre-apprenticeships/traineeships?  How do we link to other priorities/obsessions – e.g. Looked After Children?  Proactive vs reactive – we need to be working with young children to develop their aspirations and broaden horizons, for example with effective information, advice & guidance (IAG)  Where do schools feature in the Partnership? [this is a question that was being asked 10 years ago!] Especially engagement with independent schools/academies. Schools are incentivised to encourage students to stay on at school rather than take up apprenticeships  Enterprise events could give young people an introduction into the world of work, and change mindsets. Engaging with the VCS would be really helpful in this regard.  Need to focus on people achieving their full potential – which isn’t always the same thing as a focus on qualifications.

All Children are safe, happy and learning well  Does this sit with CYPPB OR WCSB?  Strap line in presentation “safe, happy and learning well” supports / aligns with Walsall Plan priorities – is the obsession for CYPP Board?

New Obsession wording : All children are safe, happy and learning well  There is a role for all partners/boards  Obsession must be recognised by HWB, SWP, WEB, WCSB. All have a different role to play in different aspects of the obsession.  Connectivity o – e.g. Apprenticeship (economic board) – role of schools – need to change this being seen as a vulnerable pathway for CYYP – Apprenticeships need to became norm as curriculum offer. o Pathway from Youth Justice route into apprenticeships – connect to employers.  Thinking as family – some focus on adults – consider are they parents? How does fixing issues for adult’s impact on family.

Key element is early intervention What is going to be different that hasn’t happened before? ‐ Simplified governance structure ‐ Need to be willing to challenge each other and hold to account ‐ Fundamental to obsession is having a ‘home’ – connects back to economic board as well. ‐ Link of pupil place planning to housing need and provision ‐ Gaps – engagement of head teachers and young people represented ‐ Role of Head Teacher rep on CYPPB and Young Person rep – do we engage? Need to engage and listen to YP and families in right way ‐ How to utilise locality model support delivery ? ‐ Role of 6th form provision in engaging younger people e.g. Duke of Edinburgh

Cultural shift needed in schools (see earlier re apprenticeships) ‐ Ofsted inspection considers p/ships and engage in localities – schools can get on board

Strand in strategy (Walsall Plan) ‐ Engagement of ‘providers’not represented e.g. schools ‐ Capture/engage voice of C+YP

Focus on issue – track delivery + impact

Package engagement of partners for schools to encourage them in

A strong, professional and vibrant voluntary and community (VCS) sector within Walsall that meets the needs of our communities, and is supported by a credible VCS infrastructure organisation  Need to get synergy about schemes we already have – build on these. Tap into resource with skill share etc. Post resources – infrastructure.  Consider LETS/Timeshare schemes.  Timeshare between statutory partners etc.  Need to consider what people are attracted to dependant on skills to share.  Link with housing/affordable housing  Consider similarities of mission – who is best placed to deliver what? What is the IMPACT and what people want?

ACTIONS

 Orgs – supporting volunteers/3rd sector  Volunteering policy  Shadowing/working between statutory organisations.  Reviewing of commissioning process in conjunction with voluntary sector.  External funding to support voluntary sector & commissions – work in partnership. Challenge that Borough boundaries don’t mean a lot. Think about wider boundaries. Walsall needs presence, there is a “Wellbeing Board” within Combined Authority structures – could look at this.  Strong partnership to build links to help people to stay healthy & independent.  NEED TO DESCRIBE OUTCOMES WE WANT i.e. Capacity/Help individual.  Need consideration of ‘need’ rather than ‘want’.

“If it doesn’t feel right, then act on it”  To embed the message "if it doesn't feel right it may not be". "Don't assume that some is doing something". "You might just save a life, you may well change a life".  To work collaboratively with Public Heath, initially to scope the programme and to agree a communications plan.  The aim being to increase safeguarding awareness across the community of Walsall and to ensure that clear reporting routes are available.

Appendix 2

The Walsall Plan: Our Health and Wellbeing Strategy 2017-2020

Please note: This is the final version as of 12.4.17 but as it is an iterative, living document, there may be future amendments to the Walsall Plan to reflect future context and decision making.

Improving Outcomes for People of Walsall

Whether people are able to live healthy, safe, independent, prosperous and fulfilling lives depends on a number of factors including individual lifestyles, social and community networks and wider living and working conditions (the Dahlgren and Whitehead “Rainbow model”). Local partnerships are crucial to achieving this holistic approach that is needed to deliver improved outcomes. Any work to improve outcomes for individuals must also consider how to reduce inequalities across the population.

Knowing Our Needs

Assessment of need in Walsall is predominantly tackled through three key assessments, the Joint Strategic Needs Assessment (JSNA), the Economic Needs Assessment and the Strategic Assessment to inform the Community Safety Plan. The needs identified in these assessments have been used to inform the development of this Walsall Plan.

The emerging needs identified from the latest JSNA refresh are:

- Emotional health / wellbeing of children and young people, including self esteem and higher aspirations - Infant mortality, including maternity services - Obesity in children - Mental health (all ages) - Physical activity (all ages) - Health & Work– including people unable to take up employment due to ill health - Long term conditions - e.g. cancer, diabetes, asthma and respiratory diseases - Dementia - Loneliness & isolation (including carers) - Substance misuse - Domestic violence - Quality housing, appropriate for need & energy efficient - Infrastructure to encourage active leisure & travel

Emerging needs identified through the Local Economic Assessment centred around:

People ‐ Demographic change – with a shrinking proportion of working age residents ‐ Qualifications, skills and behaviours – to equip people to enter and progress in work ‐ Worklessness – especially youth and long-term unemployment ‐ Benefit dependency and ill health – particularly those on health-related out-of- work benefits

Business ‐ Economic output and productivity ‐ Size and diversity of the local business base ‐ Number and range of local jobs ‐ Support for new and existing business growth

Place ‐ Connectivity and accessibility – by road and public transport ‐ Supply of quality development sites and premises ‐ Housing offer – appropriate for existing residents and future demand ‐ Attractive natural and built environments – including vibrant town and district centres

Summary of the emerging needs identified in the Strategic assessment:

Following the comprehensive strategic assessment of 2016 – 2017, the priorities of Safer Walsall Partnership were identified under four headings: Prevention, Intervention, Reduce Demand and Strategic Themes. Responsibility for delivery

against those themes clearly cut across Adult and Children’s Safeguarding, Health and Wellbeing and Safer Walsall Partnership Boards and their sub groups. Ensuring the work delivered across the diverse services supported by this governance structure was captured and recognised, with clear lines of accountability, scrutiny and challenge was a catalyst for the work of the Strategic Partnership Group, which was formed in order to deliver these assurances and achieve better connectivity across the overall governance structure.

Extensive work has since taken place, and is continuing, to align priorities and governance in order to avoid duplication, improve efficiency and efficacy and ensure there are clear lines of accountability and scrutiny.

The strategic themes for Safer Walsall Partnership from 2017 will be:

 Violence  Contest (the UK’s strategy for counter terrorism: Pursue, Prevent, Protect, Prepare)  Substance misuse (drugs and alcohol)  Reducing reoffending.

These have been identified utilising local intelligence, risk and vulnerability, together with the knowledge, experience and demand levels of the agencies which form the Safer Walsall Partnership (SWP) Board.

It will be the responsibility of SWP Board to oversee delivery, with each theme having a designated lead who will be responsible for pulling together the work carried out by all partners to achieve the best possible outcomes for our communities.

Knowing Our Priorities

A number of strategies, based on these needs assessments, are already in place across the Partnership in Walsall. The cross cutting themes identified within partnership and organisational strategies have been used to identify three overarching priorities for The Walsall Plan where value can be added by working together in partnership:

1. Increasing economic prosperity through increased growth (table 1 below) 2. Maximising people’s health, wellbeing and safety (table 2 below) 3. Creating healthy and sustainable places and communities (table 3 below)

Reducing inequalities will be a core action within and underlying each of these priorities. The principle of “proportionate universalism” will be applied ie the scale and intensity of effort will be greatest where our need in Walsall is greatest.

A Marmot life-course approach has been applied to the three overarching priorities, and key priorities within these have been identified:

Table 1: Increasing Economic Prosperity Through Increased Growth dults Children Young People A Older People Reduce inequalities Improve school readiness Improve education outcomes Increase access to appropriate skills and training Ensure people possess the skills to enter and progress in work Increase opportunities for, and take-up of volunteering Build the business environment to create more local, added value, jobs Develop strong and sustainable infrastructure

Table 2: Maximising People’s Health, Wellbeing and Safety dults Children Young People A Older People Reduce inequalities Improve maternal and newborn health Improve emotional health and wellbeing of children and young people Enable children and young people to be better protected and safeguard themselves Enable and empower individuals to improve their physical and mental health Maximise emotional wellbeing and resilience of adults Support local people to secure and stay in employment Reduce loneliness and isolation and increase support through social networks Support independent living Remove unwarranted variation in health care and ensure access to services with consistent quality Enable those at risk of poor health to access appropriate health and care, with informed choice Keep vulnerable people safe through prevention and early intervention Ensure services recognise cultural barriers, and are inclusive and accessible for existing, new and emerging communities Protect communities and individuals from the threat caused by extremist behaviour Tackle the harm to individuals and communities caused by substance misuse Improving community safety through reducing reoffending Reduce the harm to individuals and communities caused by all types of violent behaviour

Table 3: Creating Healthy and Sustainable Places and Communities dults Children Young People A Older People Reduce inequalities Develop an environment to enable healthy lifestyles Actively support inward investment to make Walsall an attractive place to live and work Improve air quality Promote environmental sustainability Ensure access to appropriate and affordable housing Support a sustainable third sector through individual and collective engagement Empower connected, inclusive and resilient communities Deliver prevention and intervention through locality delivery models

Key Target Groups in Walsall

In order to reduce inequalities a number of key target groups in Walsall have been identified:

 Looked after children  NEETs  Teenage parents  Families on the edge of care  Individuals challenged by addictions  Individuals with mental health disorders  Offenders and ex-offenders  Carers – children and adults  Children and adults with disabilities (including learning disabilities)  People with long term conditions  People with complex needs including co-morbidities and frailty  People lacking cohesive social networks

In addition, there are geographical pockets of high need in communities. A core action underlying the Walsall Plan is to reduce inequalities which will include key target groups, communities and geographical areas.

Walsall and the wider partnership

Walsall is a key player in significant wider partnerships:

 The Black Country and West Birmingham Sustainability and Transformation Plan (STP)  The West Midlands Combined Authority  The Black Country Local Enterprise Partnership

The Black Country and West Birmingham STP is a transformational plan for local health and care systems that incorporates 5 areas: Birmingham (West), Dudley, Sandwell, Wolverhampton and Walsall. This will ensure the sustainability of quality services for the population of Walsall by working in partnership with providers across a wider geographical area. The main areas of focus are: local based care; maternity and infant health; mental health and learning disabilities services and extended hospital collaboration. The Walsall footprint of the STP is driven through the Walsall Together partnership group.

The West Midlands Combined Authority incorporates 18 local authorities (including the 7 metropolitan councils of the West Midlands) and 4 Local Enterprise Partnerships. It aims to address the wider determinants of health, in particular: economy, skills, transport and housing.

The Black Country Local Enterprise Partnership (LEP) covers the sub-regional footprint of Walsall, Dudley, Sandwell and Wolverhampton local authorities, and affords an opportunity for business communities and the public sector to effectively work together in a challenging economic climate. The LEP Board – which includes high profile business leaders and education providers, alongside local authority leaders – has set out its ambitions for the Black County in a Strategic Economic Plan (SEP). The SEP made up of a range of strategic programmes relating to one of three pillars – people, business and place – which together are designed to:

 Enable businesses to grow;  Create the economic, social and physical infrastructure to support that growth.

Our “Obsessions”: Using our partnership to make more of a difference

In developing The Walsall Plan we have mapped the ongoing work of the existing key partnership structures. This has enabled us to identify gaps where all the partners, through the existing partnership structures, can work in tandem to make a visible difference. We are calling these our “obsessions” and each Partnership Board will take a lead on a different obsession to improve outcomes for the population of Walsall. Underlying each obsession will be a 3 year action plan outlining the contributions of each partner and how success will be measured.

The obsessions are:

- To support the capacity of VCSEs in Walsall, and greater connectivity between the VCS and partners, in order to improve health and wellbeing for all, by increasing the number of Walsall residents who volunteer, in particular around loneliness and isolation and physical activity (Health and Wellbeing Board) - All children are safe, happy and learning well (Children and Young People’s Partnership) - Quality apprenticeships for all ages (Walsall Economic Board) - To improve outcomes for the homeless / rough sleepers (Safer Walsall Partnership) - “If it doesn’t feel right, then act on it” (Safeguarding Boards)

Recognising and filling the gap

As the Walsall Plan was discussed and developed, partners recognised the importance of appropriate and affordable housing provision across the Borough and the significant impact this has on many other outcomes that the partnership is pursuing. It is felt that the development of a new, strategic level board will most appropriately position housing in our partnership arrangements. It is therefore intended to establish a Walsall Housing Board which will sit alongside other key boards in its own right – i.e. alongside Safer Walsall Partnership, Walsall Economic Board etc (See Relationship diagram at end of Plan). Discussions have been held with the Chairman of the Walsall Housing Partnership (WHP) who supports the new board and is willing to offer representation to it through a nomination from the WHP. It will be made clear, however, that the WHP exists in its own right and the Walsall Housing Board is neither taking on its remit nor expecting WHP to report to the Board.

The Walsall Housing Board’s remit will be to focus on strategic housing matters, working with partners from the private and public housing sector, the Council and Walsall partners. Its work will be within the context of the emerging Land & Housing focus of the West Midlands Combined Authority for which Walsall Council Leader, Cllr Sean Coughlan, provides portfolio leadership at the regional level.

How we will make the Walsall Plan happen: governance arrangements

The Walsall Plan is the overarching strategy for Walsall, with collective ownership by partnerships and partner organisations. The Walsall Plan will need to be signed off by each partner organisation in Walsall, and also by the Walsall Partnership Boards as the overarching plan for Walsall. All Partnership Boards and partner organisations

will be responsible for ensuring that their own plans reflect and deliver against the priorities in the Walsall Plan.

It is recognised that there is significant work already happening in Walsall which will contribute to the priorities identified in the plan. Appendix 1 identifies which Partnership Board is accountable for, and provides the governance for, each priority in the plan although it should be recognised that other Partnership Boards may contribute to priorities where they are not the ‘lead’. New or refreshed strategies and plans should reflect the priorities in the Walsall Plan.

The Walsall Partnership relationship model (appendix 2) demonstrates the relationship across the Partnership Boards. This is not a hierarchical model.

However, it is important that the whole Walsall Partnership is aware of progress against the Walsall Plan and any gaps or challenges with delivery. To support this approach it is proposed that:

 A six monthly report is presented to the Strategic Partnership Group by each of the Partnership Boards on progress against their priorities, including their obsession. This will identify any issues or challenges with delivery, and highlight key successes.  A ‘Partnership Summit’ is held on an annual basis for partners to share their progress, challenges and priorities (first summit in September 2017 to review progress to date)

Oversight through Walsall Plan shared reporting

Partnership oversight Feedback to through the Strategic Contribute to Partnership Boards Partnership Group (SPG) delivery of Walsall

Plan

Feedback to own organisations

Walsall Partnership Boards: responsible for delivery of own action Contribute to action plans plan delivery

Walsall Partner Hold accountable for Organisations, with delivery against own organisational plans governance arrangements

Outcome indicators can be used to assess progress over time but change is often slow and affected by many factors, resulting in little change in an outcome within a 12 month timescale. Intermediate indicators can be used to measure process or actions eg: smoking cessation rates rather than reduction of mortality from lung cancer and COPD. This will require a shared commitment by partners on what key indicators to measure, how to collect and report these.

Delivery at a locality level: Integrated locality working

The new Locality Delivery Model will provide an opportunity to shape the delivery of The Walsall Plan priorities at a local level. A four-locality footprint has been proposed that reflects the current and emerging service delivery models of a range

of partners. Locality Plans will be developed to reflect the elements of the overarching Walsall Plan as they relate to each area. These Locality Plans will be informed by ‘top down’ strategic intelligence, while also bringing in community- informed intelligence from ‘bottom up’ local engagement, to address inequalities and secure better outcomes for Walsall’s vulnerable individuals, families and places.

The Locality Model will consist of two key elements, closely aligned and interdependent;

- Locality Panels: multi-agency operational groups, with professionals drawn from across relevant partners. Their focus will be on prevention and intervention, facilitating information sharing, identifying solutions, tasking activity, and reviewing outcomes and impact. This will extend and strengthen existing partnership arrangements that have already demonstrated successful outcomes, such as Early Help Locality Panels and Area Partnership Tasking.

- Locality Partnership Boards: strategically-focused groups, with membership drawn from elected members, other public and voluntary sector partners, community leaders and businesses in the Locality. Their focus will be on identifying how the strategic priorities for the Borough are nuanced with each Locality – and on developing and owning Locality Plans that provide a golden thread from these high level plans right down to the Locality level and below – as well as facilitating a range of community engagement processes, and identifying and supporting Active Citizens to build self-sustaining communities.

The broad elements of the model have been established through consultation with partners. However, the detail is still subject to final approval through Walsall Cabinet and Council.

Opportunities and Constraints

There are opportunities for innovation and delivering differently through the strong partnerships that are already in place in Walsall. Better alignment of our shared priorities will increase integration and reduce duplication. This will be both more efficient and more effective for our local population.

However, we also need to consider the dwindling resources which will require hard choices when looking at where we need to focus our efforts. We recognise that we have a number of vulnerable residents who require services now. Ideally we have enough resource to provide services to those who require them now but also do the preventive work to support our residents to improve their health and wellbeing sufficiently that they do not require those services in the future. In the absence of

sufficient resource, we need to be able to reduce the demand for services as quickly as possible to release resources, so that we can do the preventive work that is vital to the continued health and wellbeing of our population in Walsall.

Appendix 1: Delivering the Walsall Plan: Accountability of Walsall Partnership Boards

Walsall Economic Board Safer Walsall Partnership Children’s Safe-guarding Board Adults’ Safe- guarding Board CYP Partnership Health and Wellbeing Board Walsall Housing Board Increasing Economic Prosperity Through Increased Growth Improve school readiness Improve education outcomes Increase access to appropriate skills and training Ensure people possess the skills to enter and progress in work Increase opportunities for, and take-up of volunteering Build the business environment to create more local, added value, jobs Develop strong and sustainable infrastructure Maximising People’s Health, Wellbeing and Safety Improve maternal and newborn health Improve emotional health and wellbeing of children and young people Enable children and young people to be better protected and safeguard themselves Enable and empower individuals to improve their physical and mental health Maximise emotional wellbeing and resilience of adults Support local people to secure and stay in employment Reduce loneliness and isolation and increase support through social networks Support independent living

Walsall Economic Board Safer Walsall Partnership Children’s Safe-guarding Board Adults’ Safe- guarding Board CYP Partnership Health and Wellbeing Board Walsall Housing Board Remove unwarranted variation in healthcare and ensure access to services with consistent quality Enable those at risk of poor health to access appropriate health and care, with informed choice Keep vulnerable people safe through prevention and early intervention Ensure services recognise cultural barriers, and are inclusive and The responsibility of all Boards and partners though their accessible for existing, new and emerging communities service delivery and commissioning Protect communities and individuals from the threat caused by extremist behaviour Tackle the harm to individuals and communities caused by substance misuse Improving community safety through reducing reoffending Reduce the harm to individuals and communities caused by all types of violent behaviour Creating Healthy and Sustainable Places and Communities Develop an environment to enable healthy lifestyles Actively support inward investment to make Walsall an attractive place to live and work Improve air quality Promote environmental sustainability Ensure access to appropriate and affordable housing Support a sustainable third sector through individual and collective engagement Empower connected, inclusive and resilient communities Through Locality Delivery Model

Action Plan for Health and Wellbeing Board Obsession Appendix 3

Overall aim: To support the capacity of VCSEs in Walsall, and greater connectivity between the VCS and partners, in order to improve health and wellbeing for all, by increasing the number of Walsall residents who volunteer, in particular around loneliness and isolation and physical activity

Specific Outcomes:

1. To increase the level of understanding between partners (as represented on the HWB) and the VCS. 2. To ensure consistency and best practice in relation to volunteering. 3. To support the sustainability and capacity of VCSEs in Walsall working to deliver health and wellbeing outcomes. 4. To increase the number of VCSEs and volunteers engaged in health and wellbeing activity.

Outcome(s) Action Who is leading Year 1/2/3 How this will be measured 1 Develop a programme of skills exchange / shadowing between HWB task and finish Year 1  Programme in place partners and VCSEs. group (including both  Number of exchanges HWB members and  Survey of participants on relevant others). Leads knowledge of partner will be identified within organisations (pre/post task group engagement) 2, 4 Develop a shared Volunteering Policy that can be used to One Walsall Volunteer Year 1  Volunteering policy replace or augment partner organisation volunteering policies Centre developed (to include, for example, arrangements for workforce to engage  Number of organisations in volunteering, quality, training, support, access to facilities, that have adopted it safeguarding) 3, 4 Develop and implement a plan to support VCSEs to successfully Year 1  Development of plan bid for external funding (including sub‐regional and regional  Number of successful bids opportunities)  Number of cross‐ sector/collaborative projects securing external funding

Action Plan for Health and Wellbeing Board Obsession Appendix 3

Outcome(s) Action Who is leading Year 1/2/3 How this will be measured Carry out a needs assessment for volunteering and the voluntary Work already being sector to identify what we need in Walsall, what we already undertaken by One have and people’s preferences. Use this to inform a gap analysis Walsall, the results of and development plans which streamline and reduce which will be shared with duplication. the HWB as well as the recommendation/actions that will follow 4 Develop a framework for volunteering that includes models that The range of models Year 1  Framework developed and are community‐led as well as organisation‐led (eg LETS / should all be considered implemented timeshare schemes). This could link with the corporate social when accessing external responsibility of larger organisations as well as individuals in our funding. This may be communities. covered within that work 3 Develop a programme of health and wellbeing training to Year 2  Training programme support VCSEs to deliver impactful activities in this field. developed  Number of courses offered  Number of attendees  Evaluation of training offered 1, 3, 4 To develop and adopt a framework for working with the VCS Year 2  Number of partners that that includes how services are commissioned or grant funded, signed up to framework decommissioned, outcomes framework, how VCSEs are  No of projects developed in consulted, co‐production of projects etc. line with framework 3, 4 Develop and adopt a standard policy of social value to be used Year 2  Policy developed within organisations and in commissioning processes  Number of partners who have incorporated it  Support/resources provided to VCSE via policy

Action Plan for Health and Wellbeing Board Obsession Appendix 3

Outcome(s) Action Who is leading Year 1/2/3 How this will be measured 4 Create and fill a minimum number of volunteering opportunities Year 3  Number of volunteering within partner organisations opportunities  Number of participating partner organisations  Number of volunteer recruited/retained 1, 3, 4 Develop a communication plan to promote VCS to partners and Year 3  Communications plan volunteering opportunities to individuals and communities developed and implemented 1, 2, 3, 4 Carry out a review of the impact of the voluntary sector to Year 3  Review carried out and inform future plans disseminated

Priorities within the Walsall Plan where HWB is the lead Appendix 4

Health and Lead group / Contact name and key group How this will be delivered: Focus for HWB – Wellbeing organisation Key strategies / action plans key indicators to Board demonstrate Priorities (Exception reporting to HWB) progress (To be from the agreed) Walsall Plan Increasing Economic Prosperity Through Increased Growth Increase Partnership Partnership between PH and Paul Gordon. HWB ‘Obsession’ action plan HWB ‘Obsession’ opportunities between PH and Commission with One Walsall as provider action plan for, and take- Paul Gordon. up of Commission with volunteering One Walsall as provider Maximising People’s Health, Wellbeing and Safety Improve Public Health and Uma Viswanathan: Infant Mortality Strategy (2016- maternal and Children’s Infant Mortality Group (meets quarterly) 19) and Action Plan newborn Services health Enable and PH Team Barbara Watt Healthy Weight empower  Physical activity PH Performance Dashboard individuals to  Health and Work reported to improve their  Mental health and Wellbeing PH Programme Board physical and  Appropriate use of drugs and alcohol Green Spaces Strategy mental health

Priorities within the Walsall Plan where HWB is the lead Appendix 4

(Expected Project Launch: July) Reduce Angela Aitken: Resilient Communities Charter  Number of older loneliness and Public Health Through Healthy Resilient communities which has a number of priorities people isolation and Steering Group to Walsall Together including Directory Mapping, supported increase Improving Health Literacy, through MCW support Wellbeing Plans and Making programme through social Connections Walsall (MCW) networks Programme. Action plan in development (Expected Project Launch: July) Support Kerrie Allward: independent Better Care Fund (BCF) living

Priorities within the Walsall Plan where HWB is the lead Appendix 4

Health and Lead group / Contact name and key group How this will be delivered: Focus for HWB – Wellbeing organisation Key strategies / action plans key indicators to Board demonstrate Priorities (Exception reporting to HWB) progress (To be from the agreed) Walsall Plan Remove CCG through Paul Tulley: unwarranted Walsall Together Walsall Together variation in healthcare and ensure access to services with consistent quality Enable those CCG through Paul Tulley: at risk of poor Walsall Together Walsall Together health to access appropriate health and care, with informed choice Creating Healthy and Sustainable Places and Communities Develop an PH Team: Paulette Myers, Joe Holding environment to and Susie Gill Green Spaces Strategy enable healthy Nicola Morris with Clean and green, Tobacco Control Plan lifestyles Allotments etc

Priorities within the Walsall Plan where HWB is the lead Appendix 4

Annual Status Report 2016 http://cms.walsall.gov.uk/air_quality _annual_status_report_2016_wals all_council.pdf

Air Quality Page http://cms.walsall.gov.uk/index/envir onment/pollution/air_quality.htm

Build a Commission Commissioner: Paul Gordon HWB ‘Obsession’ action plan sustainable through PH with One Walsall third sector One Walsall through individual and collective engagement

Priorities within the Walsall Plan where HWB is the lead Appendix 4

Agenda item 13

Health and Wellbeing Board

24th April 2017

Public Health Transformation Funded services

1. Purpose

To update the Health and Wellbeing Board on the Public Health Transformation Funded services covering the period 2014/15 – 2016/17 and inform the Board that the investments are under review in light of the proposed financial savings to public health core services as part of the Council’s 4 year plan. The review process is designed to understand where the best outcomes from public health investments can be made and contribute information to understand any cumulative impact on public health outcomes as a result of partner organisation’s commissioning intentions and investment plans.

2. Recommendations

2.1 That the Health and Wellbeing Board note the investments made from the Public Health Grant across the various Council Directorates and commits to supporting the review process

3. Report detail

Walsall Council has a statutory duty to achieve population level improvements in public health (Health and Social Care Act (2012)). To achieve the statutory duty the Council receives a ring fenced Public Health Grant from Department of Health (DH) via Public Health England (PHE). Walsall’s Grant for 2016/17 is £18,577,000.

The Public Health Transformation Fund was established in 2014/15 with an initial fund of £1.0 million rising to £2.3 million in 2015/16. The fund was created by disinvesting in existing public health commissioned services, making the savings by re-commissioning and remodelling services, and investing in council services that can be transformed to deliver improved public health outcomes.

The applications for investment are made to a panel chaired by the Portfolio Holder for Health and Wellbeing and including finance representation who consider the proposals to ensure that investment are in line with JSNA and Health and Wellbeing Strategy recommendations and consistent with Public Health England guidance on use of the Public Health Grant.

The aim of the fund was twofold;

a) To embed the public health functions across the range of Council services in recognition of the contribution that many existing services make to improving the public health of individuals who live and work in Walsall whilst seeking to influence and transform those services to deliver improved health and wellbeing outcomes.

b) To support Council directorates achieve their savings targets by replacing the Council directorate’s investments with an investment from the Public Health Grant.

The services fall within two categories

 Council delivered services e.g. sports and leisure, sustainable travel, air quality monitoring, health at work, early intervention family work and Children Centres  Services commissioned with external agencies e.g. Rethink adult mental health support, Advocacy Matters adult advocacy services, drug and alcohol residential rehabilitation placements (various providers), Accord Housing domestic abuse emergency accommodation provision and Walsall Healthcare Trust Teenage Pregnancy services

The intention of the Transformation Fund investments is to work alongside the services to “transform” elements of how they are delivered to optimise the public health outcomes. There is a requirement to meet the conditions of the Public Health Grant, which requires the annual statement of assurance to be signed by the Council Chief Executive, Chief Finance Officer and Director of Public Health, with the potential for claw back arrangements if the conditions are not met.

4. Investments:

The following tables display the Transformation Fund as a proportion of all public health investments and the detail of the services investments, ranging across services covering aspects of environmental and regulatory services, universal services and services targeted at vulnerable groups.

Table 1 Transformation Fund Investment (2014/15 –2016/17) 2014/15 2015/16 2016/17

Recurrent Investment £1M £2.3M £2.2M Non-recurrent Investment to pump prime invest to save - £0.025M £0.06M programmes of work % PH allocation 6.3% 12.4% 12.3%

Table 2 Public Health Transformation Fund (£1 Million) recurrent investment across council areas Phase 1 (2014/15 – 2016/17)

Directorate £(K) Adult social care Domestic abuse: Commissioned domestic abuse 275.4 and Inclusion emergency accommodation service. Parenting: Redesign and expansion of Children’s commissioning and delivery of parenting training 150

Youth Justice: specialist drug and alcohol worker 35

Sports Development: Integration with other Public Health commissions to improve delivery of PH outcomes through increasing participation in physical 100 activity and improved wellbeing.

Physical activity and wellbeing: Community Allotments and Ranger Service - Integration with other Public Health commissions to improve delivery 329.5 of PH outcomes through increasing participation in physical activity and improved wellbeing Neighbourhoods

Sustainable travel: Delivery of A*STARs programme – a partnership programme established jointly by Public Health and the Road Safety and Sustainable Travel team Integration with other Public Health commissions to 110.1 improve delivery of PH outcomes through increasing participation in physical activity and improved wellbeing

Total 1,000

Transformation fund 2015/16 – 2016/17)

The Transformation Fund was increased in 2015/16 and proposals requesting investments were received from a number of Council service areas. Table 3 lists the additional investments approved by the panel.

Table 3: Public Health Transformation Fund (£1.3 Million) recurrent investment across council areas Phase two (2015/16)

Title Service Area £(K) Teenage Pregnancy IYPSS 137.3 Early Intervention/Children’s Early Intervention and 350 Centres Family Support Air Quality and Respiratory Health Pollution Control 99.8 Healthy Takeaway Awards, Environmental Health 284 Workplace Health and Safety, Tobacco Control Sports development Sports and Leisure 45 Services Health and work Regeneration, 21.2 Employment and Skills Community allotments/rangers Green Spaces 48.3 Drugs and alcohol rehabilitation Social Care and 74

placements Inclusion Rethink mental health support Social Care and 96.53 services Inclusion Advocacy Matters older People’s Social Care and 67.68 advocacy Inclusion Parks and Playgrounds Green Spaces 83 TOTAL 1,306.8

A public health Transformation Fund review meeting was held on the 13th September 2016 where £141,800 savings were identified to contribute to the Council savings proposals for 2017/18. The annual monitoring of the investments was completed in March 2017 where it was found not all projects are optimising the opportunities to deliver public health outcomes.

The value for money of all the Transformation Fund investments are being scrutinised in the context of the Council 4 year budget planning, Public Health in year treasury Grant cuts of £1.1M in 2015/16, £0.430M in 2016/17 and a £0.458M in 2017/18 and the proposed public health team’s £3,587,152 contribution to the council savings over the next 3 years.

The performances of all these services are jointly monitored between council and public health managers against the specification and service objectives. All investments will be jointly reviewed over the next 6 months to inform the next phase of consultation and the planning the commissioning and investment plans for 2018/19.

The priority and sustainability of these investments, in comparison to other public health commissioned services, will be decided by the Director of Public Health and the Council Health portfolio holder in consultation with other council directors and Health and Wellbeing Board partners.

5. Health and Wellbeing Priorities:

The services funded by the Transformation Fund contribute to achieving the Marmot objectives in delivering the Health and Wellbeing Board’s priorities to improve the health and wellbeing of people in Walsall.

Background papers

None

Author

Adrian Roche Head of Social Inclusion [email protected] Tel.01922 653746

Governing Body Public Meeting Tuesday 2nd May 2017 Agenda Item No:8

TITLE OF REPORT Big Conversation Public Engagement - Feedback Report

EXECUTIVE SUMMARY: NHS Walsall Clinical Commissioning Group (CCG) launched a public engagement exercise: The Big Conversation, on 24 January 2017 until 24 March 2017.

The purpose of the exercise was to engage with people in Walsall on their views and experiences of health care services and also share ideas for future healthcare delivery to ensure sustainable, high-quality services that are affordable and fit for the future.

The main areas of focus for public engagement were agreed as follows: Urgent Care, Primary Care, Stroke Services and Walsall Together.

An extensive engagement programme was put in place to ensure as many people as possible from across the diverse population of Walsall were able to participate and give their views. Prior to the exercise, the engagement plan was shared with the NHS Walsall Patient and Stakeholder Advisory Group and Walsall Health Overview and Scrutiny Committee for feedback to ensure it was robust and inclusive as possible.

A range of communication channels were used to engage with the public. These consisted of 3 face to face events, 6 days of community outreach work with ‘the Big Conversation Bus’, 10,000 copies of the engagement document which included a questionnaire were distributed throughout the borough, 63 tweets were sent out, Patient Representative Groups (PRGs) and Patient Participation groups (PPGs), newsletters, the CCG website and partner communications channels were used to raise awareness and encourage participation.

Walsall CCG also enlisted the support of Healthwatch Walsall throughout the exercise to implement the engagement plan. They used their extensive voluntary and community network to raise awareness and supported with facilitation at each of the public events. They also held 6 focus groups with 112 children from local schools to gain feedback on the CCGs behalf.

451 people participated in total: 63 people provided feedback in video recorded interviews. 176 people attended one of the three events that were held across the borough. 212 people completed the questionnaire in total.

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Questionnaire Feedback Summary

Not all respondents answered all the questions. The largest proportion of respondent were female. In terms of the age profile of respondents, the highest number was from the 14 - 24 age range followed by 65 - 75.

The majority of respondents came from the White - English/ Welsh/ Scottish/ Northern Irish/ British groups. The second biggest group of respondents were Asian/ Asian British from the Pakistani and Indian communities.

Primary Care Services The majority of respondents said GP practices should be open 8.30am - 6.30pm Monday- Friday and on Saturday mornings and that they would be willing to book GP appointments online and use both telephone and online video consultations.

The majority were also ‘very likely’ or ‘likely’ to attend an appointment at another local GP surgery if their own GP was not available, and they would be willing to accept an appointment with another member of medical staff who is not a GP.

Stroke Services Respondents were asked to rate a list of areas that the CCG should consider when commissioning future stroke services for local people. 24/7 day access to consultant care and good quality outcomes and survival rates featured top of the list. This was followed by effective after-care arrangements which are close to home. Delivery at a local hospital and good transport links were seen as being least important.

Urgent Care The main reason for using the Urgent Care Centre was urgent but not life- threatening illness or injury. This was followed by not being able to access an appointment with their GP practice. If one of the Urgent Care Centres were to close or operate reduced hours respondents said they would go to A&E, use the other Urgent Care Centre or call the NHS 111 service.

The majority of respondents said there should be an Urgent Care Centre at Walsall Manor Hospital site, which is open 24 hours each day. They also said GP appointments should also be increased during the day, evenings and weekends.

Walsall Together The majority of respondents were in support of better joining up health and social care services. Better communication and efficiency were seen as benefits and organisational budgets were seen as a barrier. The use of more health literature, advertising, GP surgeries and social media to educate patients were suggested to encourage people to make use of more preventative health and care services.

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IMPLICATIONS The recommendation is that the content of the report is carefully considered and options for formal public consultation should be agreed.

However, following the announcement by the House of Commons to hold an early election on June 8th, it has been confirmed by the Cabinet Office that the pre-election period (the PEP) began on 22nd April. No consultations should be launched by NHS organisations during the PEP unless considered essential; the case for these should be made to the Cabinet Office via the Public Affairs and Stakeholder Relations team.

RECOMMENDATIO 1. To provide assurance on the engagement process N TO THE 2. To agree on the report COMMITTEE: 3. To approve the recommendations for the next steps for public consultation CONFLICT OF N/A INTEREST MANAGEMENT COMMITTEE Approval ACTION REQUIRED: REPORT WRITTEN Hardeep Dhillon BY: Head of Communications and Engagement REPORT Sally Roberts PRESENTED BY: Director of Governance, Safety and Quality REPORT SIGNED Sally Roberts OFF BY: Director of Governance, Safety and Quality CONSENT N/A AGENDA PREVIOUS N/A COMMITTEES, DISCUSSION OR CIRCULATION

There is a requirement for all members to read the papers prior to the meeting. The presenter must not go through the paper in detail. The presentation should go through the executive summary and include any amendments/additional information which was not available at the time of writing the report or if there has been any discussion or challenge prior to the meeting.

The CCG Corporate Objectives. Ensure robust financial management for in-year and subsequent years Identify and implement QIPP Direct performance improvements to ensure compliance with NHS constitution Ensure effective quality and safety assurance of the system Ensure effective contract management of Primary Care (including QIPP contribution) Active participation in formulating the Black Country STP Active participation in formulating Walsall Together Improving CCG Governance and Capability

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Contents

Purpose 4

Background information 4

Aims 5

Timeline 5

Engagement Approach 6

7 How we have engaged - Infographic Core materials 8 Public events 8 Community Outreach – Big Conversation Camper Bus 8 Patient and Stakeholder Advisory Group 8 Patient Representative Groups (PRGs)/ Patient Participation Groups 9 Focus Groups in schools – Healthwatch 9 Walsall Health Overview and Scrutiny Committee 9 Posters/ leaflets / Publications 9 Media coverage 9 Social media 9 Website 10 10 Feedback Feedback from public events 10 Feedback from public video interviews 11 Feedback from schools 15 Feedback from questionnaire 18

Annexes Annex A Copy of Engagement Document & Questionnaire 42 Annex B Copy of Camper Van Schedule 60 Annex C Copy of flyer 60 Annex D Copy of poster 61 Annex E Press releases 62 Annex F Copy of GP Bulletin e-newsletter 62 Annex F Copy of Stakeholder e-newsletter 63 Annex G Dedicated web pages on CCG website 64

1. Purpose

On 24 January 2017, NHS Walsall Clinical Commissioning Group (CCG) launched a seven week public engagement exercise - The Big Conversation.

The purpose of the exercise was to engage with people in Walsall on their views and experiences of health care services and also share ideas for future healthcare delivery to ensure we have sustainable, quality services that are affordable and fit for the future.

This report details the feedback received during the period of engagement.

The main areas of focus for public engagement were agreed as follows

Primary Care (GP Services)

 To address the wide variation in performance, quality, demand and accessibility Urgent Care  To help those with urgent care needs to access the right advice or treatment in the right place, first time  To avoid duplication of services with the consideration of one Urgent Care Centre at Walsall Manor Hospital

Stroke services

 To consider how complex care could be delivered differently to reduce the demand for hospital services such as stroke.

Integrated Care / Community services (Walsall Together)

 To promote self-care by helping people look after themselves.  To work with partners and key stakeholders to provide responsive, personalised services in, or as close as possible to people’s homes with Integrated Health and Care Teams through the Walsall Together programme

2. Background

The NHS as a whole is facing a wide series of challenges of a growing population, an ageing population, patients living longer with increasing and multiple long-term conditions for example; heart disease, diabetes and hypertension, increasing patient expectations and cuts in local councils’ social care.

The recent government strategy (Five Year Forward View) makes the national case for change and sets out the requirement to work differently and collaboratively.

Walsall faces the same national challenges and as a result is seeing an increase in appointments, especially for older patients, and more people are using urgent care and emergency services, some local services are struggling to meet national targets and requirements leading to an overall increasing pressure.

What is clear is that improving the current system will not be enough. The CCG along with its partners and local people must look at doing things differently and reshape some services to put patients at the centre and to better meet the health needs of the future.

There are opportunities to improve the quality of services for patients whilst also improving efficiency, ensuring more integration of services and providing more care outside of hospitals. 4

Patients have already expressed that they want improved access to local GP services, with more services provided out-of-hospital, closer to homes and communities.

The future vision is that new integrated and community-based models of care are developed, that there is a reduction in duplication and where local services are struggling to meet national expectations, that alternatives arrangements for this provision are considered.

NHS Walsall CCG is committed to involving and engaging with the Walsall population to ensure they can influence decision making and be part of shaping local NHS health service for the future.

3. Aims

The aims of the exercise were as follows:

 To outline the challenges facing the local health care economy, the services currently in place and explain the need to review these  To understand which areas Walsall CCG will take forward for formal public consultation  To gather views from stakeholders, the public and patients on the case for change to some health services in Walsall  To encourage and provide opportunities for as many people as possible to get involved and ensure that a diverse range of voices are heard.

4. Timeline

Date Activity 6 October NHS Walsall CCG Governing Body meeting (OD Day) 7 December Patient and Stakeholder Advisory Group meeting 11 January NHS Walsall CCG Quality and Safety Committee meeting 19 January Walsall Health Overview and Scrutiny Committee meeting 24 January Launch event at Walsall Town Hall 9 February Primary care/ Walsall Together event at Rushall Community Centre 21 February Patient Participation and Liaison Group meeting 2 March until 8 March Big Conversation camper van community outreach 9 March Urgent Care and Stroke services event at Moxley People’s Centre 13 March Patient and Stakeholder Advisory Group meeting 21 March until 24 March Focus groups with schools 23 March Commissioning Committee meeting 30 March NHS Walsall CCG Governing Body meeting (early findings report) 2 May NHS Walsall CCG Governing Body meeting

5. Engagement Approach

The communications and engagement activity was undertaken in line with the following principles, as outlined in NHS Walsall CCG’s Communication and Engagement Strategy 2016-19:

 Accessible and inclusive, to all people in our community.  Clear and professional, demonstrating pride and credibility.  Targeted, to ensure people are getting the information they need,  Open, honest and transparent.  Accurate, fair and balanced.  Timely and relevant  Sustainable, to ensure on-going mutually beneficial relationships.  Two-way, we won’t just talk, we’ll listen.  Cost effective, always demonstrating value for money

Walsall CCG demonstrated this, by ensuring that range of techniques were used to engage with a wider audience as possible. Methods used included face to face public events, community outreach and video recorded interviews, a questionnaire, social media and the CCG website.

The CCG also enlisted the support of Healthwatch Walsall to implement the engagement plan. As well as attending all events, Healthwatch Walsall facilitated the event discussion sessions; they participated in the community outreach work and disseminated the questionnaire through their extensive networks. Healthwatch also used their network with local schools to hold six focus groups with young students.

5.2 Core engagement materials

To ensure wide access and to help people to engage with the exercise a core set of engagement materials were produced. These included:

 An engagement document and questionnaire. (Annex A). The document set out the context, the reasons for the exercise and explained how people can have their say.  A web page was included on the CCG website.  An online questionnaire for people who wished to respond electronically.  Advertising materials for wider distribution, including newspaper adverts, leaflets and posters on the different ways to have your say.  A series of press releases to publicise the engagement opportunities to a wide audience.

5.3 Public events

Three public events were held in separate venues across Walsall. In total 173 people attended. The events were advertised via GP surgeries, email newsletters, posters, leaflets, the CCG website, through the local media, social media and through partner communication networks.

The first event was held at Walsall Town hall and focused on setting the scene and updating the public on the CCGs financial situation and other local challenges. Attendees then broke away into smaller discussion groups looking at one of following areas; Walsall Together, Urgent Care, Stroke, Primary Care.

The second event was held at Rushall Community Centre and the main focus was on Walsall Together and primary care only.

The third event was held at Moxley People's Centre and the focus was on stroke and urgent care services.

5.4 Community Outreach – Big Conversation Camper Bus

A camper van was commissioned by the CCG to go out into various communities across Walsall. Staff from the CCG and Healthwatch representatives spoke to members of the public and handed out surveys. Ten venues were visited over a 7 day period, including a weekend.

Voluntary and community organisations were given the opportunity to have a visit from the Big Conversation Bus. Some of the venues that were visited include supermarkets, a place of worship, a leisure centre, libraries and markets. The full schedule is available in Annex B.

Alongside the staff, a camera crew invited members of the public to give their feedback on camera. Over sixty three people participated in total and feedback is summarised on page 14.

5.5 Walsall CCG Patient and Stakeholder Advisory Group

The main role of the Walsall CCG Patient and Stakeholder Advisory Group is to ensure that the CCG undertake meaningful engagement with patients and public. The group were invited to help shape the engagement plan and kept informed of activity throughout. They were also asked to support the exercise and share the material and messages through their own communities and networks.

5.6 Focus groups

Healthwatch Walsall held 6 focus groups with 112 children in schools across Walsall. The children completed a questionnaire and had discussions about the different areas.

5.7 Patient Representative Groups (PRGs)/ Patient Participation Groups

GP practice PRGs were also enlisted to promote the engagement document in their practices. Practice Managers and PRG/ PPG Chairs promoted it within their surgeries and helped members of the public complete the questionnaire where necessary.

Copies of the engagement document were also distributed at the Patient Participation and Liaison Group meeting with is made up of Chairs and Vice-chairs of PPG/ PRGS across Walsall.

5.8 Walsall Health Overview and Scrutiny Committee

The public engagement plan for the Big Conversation was shared with members of Walsall Health Overview and Scrutiny Committee for comments and feedback on the 10th January 2017.

All councillors were also invited to the public events and given the opportunity to complete the questionnaire via the local authority communication channels.

5.9 Posters/ leaflets / Publications

Promotional material was produced to raise awareness of the public events. (See Annex C for a copy of the flyer and Annex D for a copy of the poster).

Communication about the engagement exercise and electronic copies of the engagement survey were sent to the CCGs stakeholders list which includes local GPs, MPs voluntary sector, CCG partners and providers. (See Annex F for a copy of the e-newsletter.)

5.10 Media coverage

Regular press releases were issued to the local media (see Annex E) and the CCG secured two interviews with Made in Birmingham Television, an article in the Walsall Advertiser and a feature on local community radio station, Ambur Radio. Ambur Radio is the largest multicultural community station in the West Midlands, broadcasting in English, Hindi, Punjabi, Urdu, Bengali and Gujarati to over 200,000 live listeners and over 140,000 online each day.

Articles were also featured on websites and in newsletters from Healthwatch Walsall, Walsall Healthcare NHS Trust, Walsall Council and Dudley & Walsall Mental Health Partnership NHS Trust.

5.11 Social media

Throughout the campaign, the CCG regularly tweeted key messages, communication materials and photos from engagement events using the hashtag #Bigconversation. A total of 63 tweets were sent to over 5,500 followers, which had a potential total reach of 144,000. Messages have also been retweeted by staff, partners, local media and followers.

5.12 Website

Dedicated web pages were set up on the CCG's website: http://walsallccg.nhs.uk/be- involved/the-big-conversation . (See Annex G)

6 Feedback

6.1 A summary of what people told us at the public events:

Urgent Care The main reason patients said they use the Urgent Care Centre (UCC) in the town was because it’s seen as an easier alternative than accessing their own GP practice.

The co-location of UCC in the A&E at Walsall Manor Hospital is confusing for patients. Although it was recognised that recent changes had made it easier to differentiate between the UCC and A&E.

The consensus was that there should be one Urgent care centre which is open 24 hours. Good transport links are essential.

Patient education on how to use services appropriately including more health literature was a key theme in the feedback. In particular raising awareness of the NHS 111 service and self-care, it was felt both of these need much wider advertising for the general public.

Primary Care Overall the feedback on primary care services was positive and many attendees were happy with GP. There was general agreement that it would be acceptable to see a different GP nearby if own GP not available at a different practice, however, there was some concern about transport links and having to travelling to other practices.

Participants were supportive of using more online and telephone services to access GP appointments and advice however it was recognised that it won’t suit everyone and that traditional methods would still need to be used for more vulnerable people and those without knowledge or access to the internet.

The general consensus was that GPs should have longer opening hours for those who work. This should include evenings and weekends where possible. Abolishing half day closing was also an issue that was raised.

Patient education on when to go to your GP was seen as really important.

Confusing when multiple GPs in one building with several receptions and waiting areas. Need to work together better and reduce duplication.

Although not directly related to the questions that were posed to participants there was discussion around GPs prescribing medicines that can be bought

over the counter. It was seen as a waste of resource when these are often low value in supermarkets but at a high cost to the NHS. Stroke If a relative were to suffer from a stroke the most important main priority is fast, Services effective care with good quality outcomes.

Good value for money was also an important factor for the CCG to consider alongside the above points. Effective local rehabilitation services with consistency of care was a key theme.

It was felt the CCG need to consider more patient education on prevention of stroke and raise awareness of the national stroke campaign locally.

Stroke care does not necessarily have to be in the Walsall area however travel time, road networks and good transport links all need to be considered.

Walsall There was consensus for the collaboration of some health and social care Together services and general support for the Walsall Together model of care. There was agreement that there needs to be a major improvement in the access to social care service. For those patients that are in the community after a hospital stay, there needs to be continuity of care. It was felt this would improve patient experience and reduce hospital time.

It was recognised that many health services were not aware of each other and that one directory should be developed and made available to both public and patients. This would help patients and staff, navigate a complex system.

Participants gave lots of examples of experiencing health care that is not joined up with social care.

Support for using more preventive services such as pharmacies and the voluntary sector to educate patients on self-care.

6.2 Key themes from patient video interviews:

Urgent Care

Have you used one of the Urgent Care  Hip problem Centres in Walsall in the past 6  Walk-in dentist months? If so, what did you use it for?  Burn  Chest infection/asthma  Tetanus injection  Morning after pill  Ear syringing  Dizziness Where would you go if one or both  Manor, A&E Urgent Care Centres were to close or  GP reduce their hours?  Don’t know

 Chemist  Would try to help myself  QE Hospital  Samuel Johnson Hospital  NHS 111  Google  Birmingham Children’s Hospital

Do you have any thoughts on how we  GP home visits could provide an alternative to the  GPs open evenings and weekends Urgent Care Centres?  More GPs  Invest in A&E  GP appointments when you need them  Mobile vans/pop up surgeries  Surgeries in 24 hr supermarkets  More available community care  Webcam GP appointments, Skype  Self-care, more education on this  Cottage hospitals attached to GP surgeries  What do you value most about your  Seen quickly GP practice?  Support with lifestyle changes  They take time with you  Urgent appointments if you are really ill  See the same doctor  Easy to get an appointment  Same day prescriptions  It’s free  The quality of care  Easy to get to  Caring, friendly  Direct phone number  Text reminders

Primary Care

What would make the biggest  More GPs difference to your experience of your  Longer appointments GP practice – what would you  Prioritise when booking appointments change?  GPs in A&E  More money  See a nurse first  More receptionists  Later opening, weekend opening  Make it easier to get an appointment  More confidentiality at reception  More services located together  Children’s specialist  Phone lines open earlier to book appointments 12

 Give missed appointments to those waiting  More flexible nurse appointments  New, updated building

Have you used any of your GP  No, don't have the internet, my surgery practice’s “online services” (e.g., doesn't do this, prefer face to face booking appointments, repeat  No, but would use it if available prescriptions, accessing your medical  To make an appointment records or test results)? What was  To see part of my medical record your experience of them?  Tried to use it to make hospital appointment but didn’t work  Repeat prescription  Holiday vaccination Stroke Services

If a relative of yours required care for  Quick response a stroke, what would be the most  F.A.S.T important things you would look for?  Compassionate people to care for the patient  Appropriate care for family and friends  Look for quality care  Recovery  Prefer to go to New Cross Hospital  Expertise of staff  Physio and Rehabilitation  Speed of being treated  Concerned about aftercare and the finances that go with it  Daily care  Whether there’s a lack of support

What are the most important things  Listen to what the public are saying for the CCG to consider when buying  People want to know what’s going on stroke support services?  There’s not much in place for patients at home  Doctors being overstretched  Ensure that ambulances can accommodate all cases  Availability to those who need them  Good care for patient and families  Easy access  Ensure patients don’t feel like a statistic, be more personal  Ensure aftercare won’t fully be provided  More local services  Ensure services are easily accessible for those with mobility issues  Hospital departments to meet patients in the community 13

Walsall Together Programme- Joining up health and social care Do you have any experience of using  Amazing services services that have been joined up  Walk in centre was good (integrated)? How did you feel about  All services are under pressure the support you received from these  Budget cuts are causing problems services?  It hasn’t necessarily improved services  Support services haven’t got all the info for

the patient  Lack of support for mental care  Unaware of integrated services  A lot of pen-pushing/time wasting  Don’t feel fully cared for when in hospital with mental health issues

How do you feel about plans to join  It would be a good thing together services such as health care  Notes not being on all systems seem strange and social care? What do you think  The services can’t cope with what they’ve got would be the benefits? What would already be the barriers?  Depends on what kind of services would get help

 Help isn’t there for mental health patients  They should be kept separate  It needs to benefit and help people  It needs to ensure people are monitoring things  Hope it doesn’t become a financial issue  Services not working together could hold up help  Social services need to up their standard  Ensure there is communication across all services  If integrated, reassurance you’re being taken care of  Waiting for funding has caused delays in treatment being received  Systems need tightening up

How could we encourage people to  People have got to want to take themselves make use of more preventative health to these services and care services like pharmacies,  Extend the opening hours voluntary support groups, online  Advertise and educate information and advice?  Let people know that A&E is there for emergencies  It’s whether people want to listen to advice we’re handing out  Supply information about preventative

medicines  Make online help more accessible and less confusing  Would be tough to get advice via internet/social media across to the elderly and those who can’t afford mobile phones and computers  People prefer to see their chemist as they have as much medical knowledge as their GP

6.3 Feedback from schools: Five focus groups were held with pupils at local secondary schools including Queen Mary Grammar School, Joseph Leckie School and West Walsall EACT Academy. In total 112 students took part. A summary of the feedback is below.

School Feedback Where do you go for advice when  GP you are ill?  Walk in centre  A&E  Manor Hospital  Family member  Friends  Pharmacy  NHS 111  Google

What health condition would you use  Broken bones, sprains an Urgent Care Centre for?  Asthma attack, breathing difficulty  Mental health issue  Allergic reaction  Vomiting  Infections, ear ache  Cut that needs stiches  High temperature  Fall  Dizziness, fainting  Heart problems  Bleeding in pregnancy  Diarrhoea  Recurring nose bleeds  Burn  Bad cough 15

 Period cramps

What health condition would cause  Accident, eg car accidents you to use A&E?  Collapse, unconscious  Stroke  Cut  Head injury, stitches  Poisoning  Throw up blood  Broken bones, fractures, sprains  Shot /stabbed  Fall  Severe headache  Breathing difficulties  Sports injuries  Chicken pox  Severe viral infection  Nosebleed  Heart attack  Pregnancy problems

What do you use your pharmacy for?  Collect prescriptions, repeat prescriptions  Holiday vaccines, travel advice  Wouldn't go for advice - don't feel know they enough  Pain killers, over the counter medicine  High temperature  Rash, animal bite, wasp sting  Back ache  Cold, sore throat, earache  Sunburn  Heat pads  Flu jabs  Feminine products  Diarrhoea  Pharmacy First card - get free medication  Stop smoking  Hayfever  Nit shampoo  Vitamin deficiency  Antiseptic cream  Condoms  Morning after pill

What health concern would you visit  Sinuses your GP for?  Refer onto other services  Asthma  Headaches  Injections, travel vaccine  Infections  Emotional health, stressed, anxious  Check ups  Cervical screening  Anaemia  Contraceptive advice  Ill more than a week  Heavy periods  Constipation  Fainting  Blood tests  Rash, eczema  Sudden weight loss/gain  Hair loss  Hay fever  Asthma, inhalers  Broken bones

6.4 Questionnaire Responses

Methodology

Respondents were asked to complete a questionnaire, which was made available:

 on the CCG website  distributed to key stakeholder and organisations including voluntary and community sector, GP patient reference groups, local GP practices  sent to those registered on the Walsall Patient Voice Panel  distributed to those who attended one of the three public events held across the area.  distributed via PRGs/ PPGs at GP surgeries  distributed during community outreach work

The questionnaire focused on the views and opinions of those responding and the feedback received, therefore, provides a range of qualitative information to support the decision-making process.

In total, 212 questionnaires were returned. These form the basis of this analysis. Not all respondents answered all questions.

Section one: About you

Question 1: Please state your gender

Question 2: Please state your age

Question 3: Please state your ethnicity

Section 2: Primary Care Services

Question 1: When do you think GP Practices should be open?

Question 2: If it was available how likely would you be book GP appointments online?

Question 3: If an appointment was not available at your own GP surgery, how likely would you be to attend another local surgery if they could offer an appointment on the day you needed?

Question 4: How do you feel about practices working together to provide care? (The below “word clouds” have been produced using a website called Wordle. from text that was provided. The bigger the words, the more they were used in the feedback.)

Question 5: How likely would you be to use the following types of appointments to see your GP if they were available at your GP surgery?

Question 6: If a GP appointment was not available, how likely would you be to accept an appointment with another appropriate member of medical staff who is not a GP?

Question 7: What do you value most about your GP practice?

Question 8: What would make the biggest difference to your experience of General practice – what would you change?

Question 9: Is there any other feedback you would like us to consider?

 For weekend emergencies alternative surgeries  Peer support groups would be a good idea  I think that a penalty should be imposed on patients who miss appointments, particularly if they do it more than once. I am aware that, where there are mental health issues, this could be inappropriate. The problem and the cost to surgeries are huge and something needs to be done to remedy this  Have better doctors who have a greater understanding of conditions and are more interested in your health  The body has the capacity to heal itself up to a point. Maybe some though should be given for GP's to explain about meditation techniques, thought processes before giving out drugs straight away. I understand sometimes in certain illnesses they have to, but a lot of the time positive thinking could be used. Plus emphasise on diet and exercise  More natural remedies to treat illnesses  Make the building autism-friendly  Increase use of pharmacist time in surgery to re-direct patients who do not need GP time/assessment  Skype and telephone advice would be great. If there was a way they could issue a prescription to your pharmacy following a Skype assessment, this would be great!  Just to be able to get appointment with my own GP would be nice  I think GPs do a good job but are hampered by rules like 10 min appointments which mean that you can't properly discuss ailments and their context as a whole and how different symptoms and conditions might actually be related etc. 1 appointment- 1 condition.  Doctors’ appointments should make only up to only 3 days ahead  Designated GP for older patients, young children. Open access to nurse practitioner or pharmacist - no appointment  Please be aware many elderly patients do not have access at home to the internet. Digitalisation of services, therefore, is not ideal  Adding new technologies, everybody now has internet access & smartphones, so why not use them to make application for example.  Need to have a triage system in place for people with problems that they deem urgent instead of going to A& E they could be seen by a nurse, HCA who could make a decision to determine if they needed an appointment with DOC  Availability of appointments outside 9-6 would be great too especially for working individuals  To relieve pressure on A & E there should be at least 1/2 day opening at certain practices at weekends.  They need to be run in a more business-like fashion and have far better customer service from reception and admin staff  Advertise the urgent out of hours GP service more and encourage appropriate use of the routine and urgent services we have

Section 3: Stroke Services

Question 1: If a relative of yours required care for a stroke, what would be the most important things you would look for?

Question 2: What are the most important things for the CCG to consider when commissioning stroke services?

Question 3: Rank in order the areas we should consider in commissioning (buying) a future stroke service for Walsall patients. (1=most important, 8=least important)

Question 4: Is there any other feedback you would like us to consider?

 Separate urgent care department that deals immediately for potential or stroke victims from start of care to finish  You cannot, and should not, be expected to meet all the expectations of patients and relatives. This is totally unrealistic. The focus should be on the quality of the medical care, immediately following the stroke, whilst in hospital and during the recuperation period.  Sufficient well-qualified staff to fulfil need for treatment and aftercare good medical facilities readily available  The results of all investigations following a stroke e.g. MRI, CT Scans etc. should be given to GP and patient asap.  Have follow up with patients with other members of the specialist stroke team after 12 months to encourage patients to persist with exercises and speech to see continued improvement. Support the family as well; in the long run, it can save money if they are on-board helping to bring improvements to the patients' health, communication and mobility.

Section 3: Urgent Care

Question 1: Why do you use the Urgent Care Centres?

Question 2: Where would you go if one of the Urgent Care Centres were to close?

Question 3: Where would you go if one or both of the Urgent Care Centres were to have reduced opening hours?

Question 4: Should the Urgent Care Centre at the Manor Hospital be open 24 hours each day?

Question 5: Should we increase access for appointments with your own GP?

Question 6: Is there any other way of providing an alternative to the urgent care centres?

Question 7: Is there any other feedback you would like us to consider?

 I would not want the waiting times to visit the GPs to be so long  More appointments being available  Last time I visited urgent care was on a Sunday morning with my husband who had injured his arm. We had to wait 3 1/2 hours to be seen for assessment as there was only 1 doctor on duty. There were at least 30 patients waiting to be seen  Does Walsall need 2 urgent care centres? Would it be more practical & cost effective to expand the one at the Manor Hospital & close the one in the town centre? Is putting contracts out to tender the best way of staffing the centres? I assume that it is expensive - is it the only option?  More small centres especially for evenings + weekends due to people working office hours and cannot make GP hours  Maybe have different sections for different age groups. Separate department in A&E for elderly patients. Children's clinic for urgent cases. Reduce waiting time. Triage at A&E divert less serious cases to urgent care/mental health  Current urgent care provision at Manor Hospital is "grim". Limited waiting space, some patients really poorly, lacking in comfort. Some staff not adhering to bare below the elbow policy  I've been a few times to Walsall walk in centre. Was impressed I was seen quickly and got the treatment needed. If these places shut it would make A&E waiting time very long indeed  We accessed the urgent care centre recently for my child who had badly cut his hand. We had to wait over 3 hours (not a problem as he needed stitches) The staff were very busy and frazzled, my child has a hidden disability of emotional and behavioural difficulties because they were so busy there was little to no patience or understanding.  Health literacy for patients to schools in Walsall Use NHS 111 for education or self-care Confidence in existing services limits use of NHS 111 24hrs UCC  I feel the "telephone" consultation is dreadful. It puts you off and creates the problem to often 'worsen'. Giving antibiotics over phone I feel is dangerous and maybe unnecessary. It makes you put up with the problem which can be a problem harder to treat or even to a worse scenario - life threatening  A qualified nurse to assess the urgent need at doctors surgery to take necessary calls  I think they provide a really useful service and have always been pleased with the treatment. I would only go when necessary and if I was unable to see a GP.

Section 4: Walsall Together

Question 1: Do you have any experience of using services that have been joined up and how did you feel about the support you received from these services?

 Good advice and help  The support from different services together is very beneficial and makes you feel good  Yes. I was very fortunate in that, subsequent to hospital medical treatment. The occupational health & physiotherapy staff were very helpful & supportive.  Have found services are often not joined up. Having had a relative who recently had a stroke, departments seemed to concentrate more "on passing on" rather than whether next department/team had resources/support in place.  I have seen when elderly patient has a fall and the way the rehabilitation system works to enable them to return to their home. What I witnessed seemed to work well, but only to a point. Once the patient decided not to co-operate the system stopped and they were left to their own devices - all initial progress was wasted  Doesn't feel integrated still repeating same info to multiple people  Treated me with respect and dignity. Gave me all the right care and medication  I got support from lifestyle link for weight loss. She referred me to heart care to see specialist help  Integrated services do not have common goals. If it is nursing needs then social services have no interest  Yes. For my mother when I was her carer. Once accessed, social care was easy to contact with queries and requests  Communication is key. Some services not a high enough standard/quality safe  Disabled and paraplegic from June 15 to present time slowly learning to walk again, had the need to use the services of community teams and found that there is a lack of communication no joined up thinking-lack of visits from community nurses very spasmodic when they should have been weekly visits-care service from carers was risky due to lack of hygiene on their part -no risk assessments done by staff .  Absolutely terrible. As far as my experiences are concerned, joined up services do not exist. It is appalling. There appears to be no communication between service providers and it's extremely dangerous for the patients  I have used the Citizens Advice service in Walsall in my local health centre (Bloxwich) on a number of occasions. My GP informed me of it, as I was having issues around benefits and debt. The level of service I received was brilliant - the fact that I could access this in my local community was a 38

tremendous bonus, as I suffer from chronic anxiety and depression and this means that I struggle to travel far (such as going to Walsall) The fact that Walsall Council have removed funding for this vital service is really bad news, they should reconsider this move - the implications for me and others is going to be significant. I simply cannot believe that they have done this. It is very short-sighted and will lead GPs spending even more time on non-clinical matters. That cannot be good for anyone concerned.

Question 2: How do you feel about plans to join together services such as health care and social care? What do you think would be the benefits? What would be the barriers?

 This would be a good idea as bringing both together means more care & understanding  It sounds like a good idea theoretically but I would be very wary of creating a service that encompasses such wide ranging fields of care & so many staff. Might it not be better to ensure that systems are in place that facilitate the liaison & cooperation between the services rather than create another behemoth  I think it would be completely worthwhile. More communication and liaising will help understanding on many levels  It could be a good idea as long as everyone involved could work together and no-one felt toes were being stepped on, how would it be agreed what was best for the patient? If more opinions are involved it might make for quicker easier solutions to be put in place to benefit the patient  It would help if services could all work together. It could get things done quicker, getting information to families. A barrier might be a lack of communication messages could get lost  More communication between the healthcare and social care would be the benefit  They are both close which would be convenient. I don't see any barriers  Good idea Would give patients security when leaving hospital Prevent bed blocking Problems: Managers jealous of keeping their own "empires" + not co-operating  Help to prevent bed blocking by having better liaison & communication

 Great idea - only if it is correctly funded. It happened years ago and worked well. Has to be good communication - break down barriers between services. Breakdown - not my problem culture  Joint funding would be an advantage, better communication and a seamless service for patients Barrier. Staffs reluctant to change  I feel happy because both services of people and health will join and will be able to help both  Agree and it makes sense that health and social care should function better as one integrated service. One point of contact would hopefully be more efficient than the current complicated setup. The barriers are political, Social care is an extension of health service and should never have been split away from health.  Benefits would be that patients would be able to recover and become independent in an efficient and develop a more rapid response to needs. The barriers are different budgets, line management arrangements and differing thresholds of needs.  Joined up services has to be a way forward and a positive for the residents of Walsall.  I think it will save the resources of the government and my time without going to different clinics.

Question 3: How could we encourage people to make use of more preventative health and care services like pharmacies, voluntary support groups, online information and advice?

Annexes

Annex A - Copy of Engagement Document and Questionnaire

Annex B – Locations where the Big Conversation Camper Van visited

Date Venue Thursday 2 March Asda Bloxwich Superstore, Woodhall Street Thursday 2 March Pheasey Library, Collingwood Centre, Pheasey Friday 3 March Willenhall Market, Market Place, Willenhall Saturday 4 March Joseph Leckie Polish School, Walstead Road West Saturday 4 March Park Street, Walsall Sunday 5 March Guru Nanak Gurdwara, Sikh Temple, 127 West Bromwich St Monday 6 March Walsall College (courtyard), Littleton Street West, Walsall Monday 6 March Oak Park Leisure Centre, Coppice Road, Walsall Wood Tuesday 7 March Pelsall Library, Pelsall Village Centre, High Street, Pelsall Tuesday 7 March Bloxwich Active Living Centre, High Street, Bloxwich

Annex C - Big Conversation event flyer

Annex D - Big Conversation Event Poster

Annex E - Big Conversation Press Releases

12 January 2017: Have your say on local health services – Join The Big Conversation

30 January 2017: The Big Conversation continues – Have your say on GP and community services 27 January 2017: First Big Conversation event a success

21 February 2017: The Big Conversation Camper Van hits the road in Walsall

14 February 2017: Have your say on Urgent Care and Stroke Services as part of the Big Conversation

Annex F - GP Bulletin eNewsletter

Annex F - Stakeholder eNewsletter

Annex G - Big Conversation CCG Website Page

For more information about NHS Walsall Clinical Commissioning Group visit www.walsall.nhs.uk

Please contact 01922 603077 or email [email protected] to request this document in a

different language or format

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Our mailing address is: NHS Walsall Clinical Commissioning Group Jubilee House Bloxwich Lane Walsall WS2 7JL Primary Care Commissioning Committee Action Log ‐ Public

Complete Please check the compleled actions on the log are accurate as they will be removed after this meeting Live

Item Lead Required By Comments Action Risk Register 12/17 Review risk Register to enable it to be part of the public meeting DM May‐17 Live

Fire Service 10/17 Communication to raise awareness of community services being offered. HD May‐17 Live

Medicines Management Update 08/17 ST to develop paper outling potential future options re needs and skill mix ST May‐17 Live NHSE Update 07/17 Tamiflu issue to go to Health Protection forum SR May‐17 Live QIPP Report QIPP proposals back to May meeting. 06/17 A report for May meeting quantifying where LCS savings can be made for Committee decision. DM May‐17 Live Saturday Opening Evaluation Requested not yet received, required for 180/16 More detailed report for the next meeting DM / CB Apr‐17 next month Live Finance Report 176/16 Next meeting main item should be QIPP to include Medicines management and LCS's as main areas DM/ MH Apr‐17 On agenda Live Finance report Possible development session for Primary care finances for greater Before school hoildays, SH to send out 124/16 understanding dates add business case development to MA/DM Jun‐17 session (RF will need 6 wks notice) Live on going, still working through appeals, BD to forward report from team. 77/16 NHS England Update Regular update on appeals and An update of any specific issues for Walsall practices regarding the AUA DES BD Sep‐16 clawbacks Live SL Handover DM/SL Apr‐17 Complete suggested more Comms involvement, 148/16 More detail on POL for next meeting GW Apr‐17 reported through IT steering group Complete Primary Care Commissioning Committee Action Log ‐ Public

Decision Log Date Item Minutes Outcome 08/08/2016 71/16 ‐ Devlopment session for STP Decision

Wolverhampton CCG specification as our basis Consider 1 provider, possibly a Federation or Urgent Care Centre 08/08/2016 73/16 ‐ Zero Tolerance SchemeUse Discuss resilience arrangements with neighbouring CCG Reccommendation

Letter from Chair and AO, also Walsall Gp newsletter to all GP practices, to LMC and CCG websites and twitter 08/08/2016 75/16 ‐ Update from Quality Improvement Sub‐group regarding good news story from Beechdale CQC report Decision Committee recommendation stronger than just noting 08/08/2016 76/16 ‐ Patient Online Update report, fully support and endorse Decision Adopt Primary Care Commissioning polices and 17/10/2016 91/16 ‐ CCG Update procedure document Decision 17/10/2016 94/16 Medicine Management Update PCCC agree to go out to recruitment Decision PCCC agreed vthat LCS's and governance are the 24/11/2016 107/16 Update From Primary care Operational Group responsibility of the committee Decision 26/01/2017 129/16 Medicine Management Update Palative Care LCS Decision 26/01/2017 134/16 Patient Participation paper Requested 1 year additional funding, request agreed Decision Pharmacy LCS ‐ Pharmacy First, agreed to go for NHSE service re <16s as long as no cost involved. Commission 23/02/2017 Medicines Management Update >16s for 3 months Agreed 2017/18 Prescribing Incentive Scheme part 1 and part2 20/04/2017 Medicines Management Update business cases Approved

Primary Care Commissioning Committee (Public Meeting) 18 May 2017 Agenda Item No:

TITLE OF REPORT Financial Monitoring Report for Delegated Primary Care and other Primary Care budgets for the period to 31 March 2017

PURPOSE: This report is to inform the Primary Care Commissioning Committee of the financial position of the delegated Primary Care budgets.

KEY POINTS: At the end of March 2017, Walsall CCG’s management accounts report an underspend of £646k against a budget of £37,157k for delegated Primary Care budgets, and an underspend of £81k for CCG core commissioning budgets, giving a total underspend of £727k.

RECOMMENDATION To note for information. TO THE COMMITTEE: CONFLICT OF INTEREST MANAGEMENT COMMITTEE ACTION For information. REQUIRED: REPORT WRITTEN BY: Lorraine Gilbert REPORT PRESENTED Tony Gallagher BY: REPORT SIGNED OFF Tony Gallagher BY: CONSENT AGENDA No

PREVIOUS None COMMITTEES, DISCUSSION OR CIRCULATION

The CCG Corporate Objectives. Ensure robust financial management for in‐year and subsequent years Identify and implement QIPP Direct performance improvements to ensure compliance with NHS constitution Ensure effective quality and safety assurance of the system Ensure effective contract management of Primary Care (including QIPP contribution) Active participation in formulating the Black Country STP Active participation in formulating Walsall Together Improving CCG Governance and Capability

Page 1 of 3

1 Funding Available As at March 2017, total funding available for Primary Care Delegated Commissioning remained at £37,157k,

Funding from the CCG mainstream allocation for locally commissioned service remains at £4,214, bringing total resources available to £41,371k.

2 Performance against budget For the twelve month period to March 2017, total expenditure of £36,511k was incurred against budget of £37,157k, resulting in an underspend of £646k. The following table analyses these costs across the various elements of the contract.

Annual Budget Actual YTD Budget YTD YTD Variance £000 £000 £000 £000

Global Sum/MPIG/Contract Value 24,813 24,813 24,639 ‐174 Quality & Outcomes Framework 3,793 3,793 3,927 134 Direct Enhanced Services 1,581 1,581 1,717 136 Premises 4,884 4,884 4,864 ‐20 Dispensing Fees 203 203 227 24 Seniority/Maternity/Sickness 499 499 500 1 Other 1,174 1,174 439 ‐735

TOTAL 36,947 36,947 36,313 ‐634 GP Forward View 210 210 198 ‐12 Sub Total Delegated Commissioning 37,157 37,157 36,511 ‐646

Locally Commissioned Services 4,214 4,214 4,133 ‐81

TOTAL 41,371 41,371 40,644 ‐727

Quality and Outcomes Framework shows an overspend of £134k, based on forecast performance for practices – final achievement will be confirmed in June 2017.

Direct enhanced services show an overspend of £136k, predominantly due to variation in Learning Disability Health Checks (£61k), and Minor Surgery services (£69k).

Other services shows a year to date underspend of £735k due to slippage on central reserves which are committed in future years.

Page 2 of 3

Locally Commissioned Services The annual budget for Locally Commissioned Services is £4,214k and the final outturn was £4,133k, equating to an underspend of £81k – this variation can be attributed to non‐recurring savings from 2015‐16 creditor accruals.

3 Financial Impact of the 2017/18 Contract Changes

Following on from the previous report, the CCG has now received clarification regarding funding of CQC fees and medical indemnity fee reimbursement – initial guidance had suggested that additional funding would be received for these new contract elements, but unfortunately this is not the case – the costs will need to be met from the existing delegated allocation. Initial estimates forecast the costs of these two items at approximately £400k, and this will need to be met from reserves which were being held for future developments – the level of reserves will reduce to approximately £200k. Work is currently being undertaken to identify detailed budgets for all elements of the contract, and will be presented at the next meeting.

Page 3 of 3

Medicines Management QIPP work streams 2017/18 Medicines Management QIPP principles • Walsall CCG is keen to ensure that only treatments that are clinically effective and provide a clear health benefit to patients are prescribed on NHS prescriptions.

• This is to ensure that CCG resources provide interventions with a proven health gain for the population.

• Therefore Walsall CCG recommends that clinicians prioritise resources based on evidence of the clinical effectiveness and safety of treatments, their cost effectiveness, and on which interventions provide the best health outcomes.

• Any proposed changes must adhere to these principles, be safe, cost effective, appropriate for individual patients and be inline with the Joint Walsall Formulary “Medicines Management Team”

The CCG has an in‐house medicines management team and employs a number of sessional clinical pharmacists who work in general practice. This “team” works closely with general practice to deliver prescribing efficiencies against the key principles previously outlined What is the QIPP position for 2017/18?

2017/18 2018/19 £000 £000 GP Prescribing

50,073 48,969 Recurrent Start Point

‐770 Full year impact of Medicines of Limited Clinical Value (16/17 QIPP)

1,035 1,028 Inflation

2,662 2,155 Growth

‐1,900 QIPP Target ‐3,045

‐986 ‐979 Efficiencies

48,969 49,273 Total Prescribing Budget The team supported by the clinical leads have developed and put forward a number of schemes to deliver the QIPP challenge for 2017/18

Title Original Target

Medicines Optimisation £1,418,000

Prescribing Incentive Scheme (Part 1 & 2) £628,000 *

Repeat Ordering Hub Pilot £72,000

Wound Management Pilot £20,000*

Total £2,138,000

* This is the minimum expected saving further analysis being undertaken taken to determine position Medicines Optimisation

In this context this includes;

1. Repeat Prescription Service(RPS)‐ ‐ This involves the provision of pharmaceutical support at GP Practice level for the review of repeat prescriptions for patients. Medication will be tailored so patients will be switched to the most cost effective formulary choice of medication or even stopped if it warranted according to the NICE evidence and/or clinical guidance. This will also support a reduction in medicines waste by not issuing prescriptions for items not needed by the patient. Options to develop a repeat ordering hub are also being explored 2. Medicines of limited clinical value

Not recommended by National Institute for Not supported by local Health and Care formulary ‐ JMMC Excellence (NICE)

Medicines that can be Poor clinical outcomes provided as a “self‐ which are published in care” products brought clinical trials from a community pharmacy 3. Pain Prescribing

Develop pathways and clinician education for management of pain to: • Reduce inappropriate prescribing spend on analgesics • Optimise pain management • Protect patients from harm from analgesics • Reduce inappropriate referrals/admission Prescribing Incentive Scheme Part 1 Summary The Prescribing Incentive

The Prescribing Incentive Scheme is a voluntary system that Cost Improvement rewards practices for Entry Target Antibiotic Targets Targets high‐quality and cost‐ effective prescribing in Walsall CCG. Entry Target

Entry – Medicines Management will produce CCG policies, practices will be required to adopt these policies. Evidence of this will be required.

Practice Practice Practice paracetamol Ibuprofen VitaminD prescribing policy prescribing policy prescribing policy Antibiotic targets •ANTIBIOTIC TARGET; a 10% reduction (or greater) in the Trimethoprim: Nitrofurantoin prescribing ratio i.e. reduction in Trimethoprim prescribing compared to Nitrofurantoin. 10%

•ANTIBIOTIC TARGET; a 10% reduction (or greater) in the number of trimethoprim items prescribed to patients aged 70 years or greater (10% reduction would mean as a CCG we would see 5021 trimethoprim items 10% (June 2015‐May 2016) reduce to 4924 items in 2017/18

• ANTIBIOTIC TARGET; sustained reduction of inappropriate prescribing in primary care. Items per STAR‐PU must be equal to or below England 2013/14 mean performance value of 1.161 items per STAR‐PU. This 10% threshold will remain during 2018/19. MOLCV

Oral Nutritional Diabetes Supplements Cost Improvement targets Worth 70% tiered payments Wound Respiratory management

Pain • Cost Improvement Programme CIP (previously known as MOLCV) • Reduce spend in top 5 items for practice by 20% MOLCV (this will be individual to worth 10% each practice) • List to be supplied by Walsall CCG Medicines Management Team • Gliptins to Alogliptin (Linagliptin for renal patients) • All strips and needles to reflect formulary choice only • GLP1 face to face reviews per Diabetes practice (number of reviews per practice may vary, set as 3 worth 10% reviews per 1000 patients list size) • Practice pharmacists may support the reviews • 90% Brand prescribing • Respiratory face to face Respiratory reviews per practice min. 12 patients per practice worth 10% for step down therapy • Practice pharmacists may support the reviews • Pregabalin prescribing as per license. • 75% costs of all prescribing to be formulary branded Pain generic choice or 25% worth 20% increase in practice baseline formulary branded generic choice • Formulary Wound choice ‐ 30% decrease in dressing practice worth 10% baseline costs of non‐formulary products • 70% cost of Oral prescribed ONS to be nutritional formulary powdered supplements or a supplements 30% decrease in (ONS) practice baseline cost level of non‐ prescribing formulary products worth 10% Prescribing Incentive Scheme part 2 Summary This will be comprised of; 1. Entry target – must be completed to qualify a. Activation of Optimise Rx for the duration of the scheme

2. Overall Cost Improvement Plan targets‐ i. An overall 5% reduction in NIC/ASTRO‐PU for each practice over the CCG average NIC/ASTRO‐PU of £50.08 ii. An overall 2.5% reduction in NIC/ASTRO‐PU for each practice under the CCG average NIC/ASTRO‐PU of £50.08

Practices payments will be tiered depending on achievement. Payment will not be made where there is non‐achievement or an increase in prescribing spends. Wound Dressings – Hub pilot

Walsall CCG aims to reduce dressing wastage and improve adherence to formulary choice dressings.

The actions that have been identified are; 1. Promotion of formulary choice of dressings– this will ensure the formulary choices are known to the prescribers. 2. Development and promotion of a prescription dressing request form ‐ this will ensure that only the cost effective items that are on formulary are requested. This will enable the requesting nurse to only select formulary items in order of 1st line and 2nd line choices. This will also ensure that supplies are limited to maximum of 2 week treatment. This has now been implemented. 3. Further work to set up a central store hub for certain dressings is being explored to support waste reduction. Delivery

• The Medicines management work plans have been aligned with the QIPP objectives. • Keele University is providing support and specific reports have been commissioned to monitor and evidence delivery • The Primary care committee will oversee delivery and will receive monthly updates

• There are a range of expected savings dependent on the extent to which the individual scheme targets are met, the team is currently reviewing the proposals to exclude counting potential duplication of savings and to ensure a realistic and not over optimistic position is presented to committee

Primary Care Commissioning Committee Date of committee meeting: 18 May 2017 Agenda Item No: 5.0

TITLE OF REPORT Primary Care Operational Group – Primary Care Quality Update

PURPOSE OF To update the committee with an update from Primary Care REPORT: Operational Group and Primary Care Quality.

KEY POINTS: This report details an update for Primary Care Quality:

CQC: Currently, 54 Walsall practices have received a CQC inspection and rating since Jan 2015. 38 of Walsall practices inspected are rated as Good (70%), 9 rated as Requiring Improvement (17%), 4 practices rated Inadequate (7%) and 3 practices rated as Outstanding (6%).

Our local CQC Inspection Manager provided an update to the group on upcoming inspections and outcomes.

CQC Practice Support Visits: GP practices that receive an inadequate or require improvement rating from CQC are supported in their action plan by the CCG. However, since February 2017 due to capacity these visits have not taken place.

GP Dashboard: The Top Scoring 10 & Bottom Scoring 10 practices have been updated as of April 2017 to include new data and scores from the dashboard over the previous quarter. A number of the practices previously identified in the top & bottom ten have now changed. A proposal was put forward as to how the CCG is using the dashboard information to improve the quality of services within Primary Care and how the dashboard informs what actions the CCG takes. Action to jointly discuss and identify how intelligence from the data can be used to maximize impact. Dashboard data has been analysed and a number of themes identified for focus.

Q3 Primary Care Complaints: In Q3 there were a total of 9 formal complaints made to NHS England for Walsall CCG GP Practices. None of the complaints Page 1 of 8

Risks: The following risk relating to Quality were identified at the Primary Care Operational Group: PCOG1: review of the LCS’s not being completed on time, risk that the QIPP not be achieved for Primary Care. PCOG2: Intelligence sharing/Reporting. How is information being shared between CCG teams and externally and how the information is being used effectively. RECOMMENDATION  Note the contents of the report. TO THE COMMITTEE:

COMMITTEE Assurance / Action ACTION REQUIRED:

REPORT WRITTEN Katie Hayes, Quality & Safety Officer BY:

REPORT Sally Roberts – Director for Quality & Safety PRESENTED BY:

REPORT SIGNED OFF BY:

CONSENT AGENDA: n/a

PREVIOUS Primary Care Operational Group

There is a requirement for all members to read the papers prior to the meeting. The presenter must not go through the paper in detail and only indicate if there are any amendments or additional information which was not available at the time of writing the report. The CCG Corporate Objectives. Please indicate which Corporate Objectives this report supports Involve patients and public in decision making  Ensure value for money  Commission high quality services  Promote good health and sound treatment of ill health  Ensure strong leadership and good governance 

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Work in partnership  Positive general duties - Equality Act 2010 The CCG is committed to fulfilling its duty under the Equality Act 2010 and to ensure its commissioned services are non-discriminatory. This report is intended to support delivery of our duty to have a continuing positive impact on equality and diversity. The CCG will work with providers, communities of interest and service users to ensure that any issues relating to equality of service within this report have been identified and Addressed Please indicate if there have been any equality of service issues identified in this report All papers are subject to the Freedom of Information Act. All papers marked as ‘in confidence, not for publication or dissemination’ are sent securely to named individuals and they cannot be distributed further without the written permission of the Chair. Exemption 41, Information provided in confidence, applies.

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Contents

1. CQC: ...... 5 2. CQC Practice Support Visits: ...... 6 3. GP Dashboard: ...... 6 4. Q3 Primary Care Complaints: ...... 7 5. Primary Care Workforce: ...... 7 6. CEPN: ...... 7 7. Risks: ...... 8

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1. CQC: Currently, 54 Walsall practices have received a CQC inspection and rating since Jan 2015. 38 of Walsall practices inspected are rated as Good (70%), 9 rated as Requiring Improvement (17%), 4 practices rated Inadequate (7%) and 3 practices rated as Outstanding (6%).

Our local CQC Inspection Manager provided an update to the group on upcoming inspections and outcomes. The CQC are due to publish two more practices ratings shortly and have two more inspections planned. Due to the new registration of a practice, the last inspection is not due to be completed for six months.

Since the last report there have been a number of new ratings:

 Rushall Medical Centre – Good  Saddlers Health Centre – Good  Mossley & Dudley Fields – Outstanding  Collingwood Family Practice – Good  Harden Health Centre (Dr P Kaul) – Good  St Mary’s Surgery – Good* *St Mary’s improved from Inadequate in February 2016 to Good in March 2017.

Since January 2015 some practices have been inspected more than once. Below shows the practices that have received more than one inspection and the direction of change.

st nd Practice Name 1 Inspection Result 2 Inspection Result Dr Khan MC Requires Improvement Good Dr Saha Requires Improvement Inadequate New invention HC Requires Improvement Good St Marys Inadequate Good Ambar MC Inadequate Requires Improvement Lockfield Surgery Good Good Saddlers HC Good Good Sycamore House Good Good The Limes MC Good Good St Johns Good Good

9 out of 10 practices that have received a re-inspection since January 2015 have improved on their re-inspection.

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The table below shows a breakdown of the CQC domains for the GP practices that have had an inspection:

CQC Rating Table

Safe Effective Caring Responsive Well-led Overall

Outstanding 0 2 1 4 3 3 Good 41 40 51 45 40 38 Requires 8 10 2 4 8 9 improvement Inadequate 5 2 0 1 3 4 Total 54 54 54 54 54 54

Themes identified from the Inadequate CQC ratings under the “Safe” domain are as follows:

 Incident investigations were not robust, and actions were not being followed up. Processes for conducting investigations were not always followed.  No effective system in place to record Staff Immunisation status and no risk assessments had been completed in the absence of a record.  Concerns around medicines/prescription management was identified.

An action plan to address the common themes identified above is being developed and will be reported and monitored through Primary Care Operational Group. A quality improvement project to improve incident reporting within Primary Care is also in development.

2. CQC Practice Support Visits: GP practices that receive an inadequate or require improvement rating from CQC are supported in their action plan by the CCG. However, since February 2017 due to capacity these visits have not taken place.

The Quality and Primary Care teams are in the process of creating a Standard Operating Procedure for future CCG visits to practices that receive a result of either Requires Improvement or Inadequate rating in order for the CCG to support practices and agree an action plan for improvement. It will begin with any practice that has not received a visit from February 2017 with a rating of inadequate and requires improvement as a priority. A mechanism for peer support will also be considered.

3. GP Dashboard: The Top Scoring 10 & Bottom Scoring 10 practices have been updated as of April 2017 to include new data and scores from the dashboard over the previous quarter. A number of the practices previously identified in the top & bottom ten have now changed. A proposal was put forward as to how the CCG is using the dashboard information to improve the quality of services within Primary Care and how the dashboard informs what actions the CCG takes.

The data collated in the GP dashboard has been reviewed and the following themes have Page 6 of 8

been identified for further development:

• FFT Data – There is a large proportion of practices not submitting their Friends & Family Test returns. This has been highlighted to Primary Care to check what the contractual requirement is and what the CCG can do to support practices. A meeting with NHSE patient experience lead to discuss how data can be used most effectively is also scheduled.

• Low flu vaccination uptake from practices

• Infection Control Management – Across the GP infection control audit data that has been reviewed it is found that many practices had concerns raised around their infection control governance processes. The CCG are now receiving the infection control audits and common themes will be discussed with the Public Health infection prevention lead and areas for support identified.

4. Q3 Primary Care Complaints: In Q3 there were a total of 9 formal complaints made to NHS England for Walsall CCG GP Practices. None of the complaints were upheld.

The categories of complaints were as follows:

Complaint Categories Number of Complaints Practice Management 2

Appointment Availability/Length 2

Communications or Attitude 3

Delay in or Failure to Refer 2

Clinical Treatment 4

The CCG receive an overview of the complaints every quarter. The next quarter is due for release in August 2017.

A request to NHSE in regards for a themed synopsis of complaints received has been requested.

5. Primary Care Workforce: In April 2017 Lisa Clarke joined the CCG two days a week as the Practice Education Facilitator/Work Force Lead. This post will work closely with the CEPN and feed into the CCG’s Primary Care work stream.

6. CEPN: Walsall Alliance Ltd, a federation of 30 practices across Walsall was awarded the CEPN status by Health Education West Midlands, to support the development of the primary care workforce Page 7 of 8

for 3 years commencing 2016.

The training hub is a way of developing the primary care workforce. CEPN have four main focuses:

1. Workforce Planning 2. Training and Education 3. Growing your own staff 4. Future sustainability 5. Collaboration

Through the CEPN, HEE allocate certain funding streams annually for post registration education. Funding has now been allocated for 2017/18 which incorporates funding for:

• Specialist Practice/ Practice Nursing (Degree programme)

• Fundamentals in practice nursing (new to practice)

• Advanced clinical practice (master’s programme)

7. Risks: The following risks relating to Quality were identified at the Primary Care Operational Group:

PCOG2: A review of the LCS’s not being completed on time, risk that the QIPP not be achieved for Primary Care.

PCOG3: Intelligence sharing/Reporting. How is information being shared between CCG teams and externally and how the information is being used effectively.

The following risk was closed:

PCOG 1: 12 GP Practices have not signed up or completed the CCG Level 3 Safeguarding Training.

There is a risk that the GP’s are not receiving the training and they are not compliant with the requirement for Clinical Staff working with children, young people and/or their parents/carers and who could potentially contribute to assessing, planning, intervening and evaluating the needs of a child or young person and parenting capacity where there are safeguarding/child protection concerns.

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Palmaris Healthcare Limited Saturday Acute/Sameday Service

Feedback covering the period 25.2.17- 6.5.17

Introduction

As a result of NHS England’s provision of monies to help reduce the effect of ‘winter pressures’ on A & E Departments and Urgent Care Providers, Palmaris Healthcare Limited were granted a contract to run from 14.1.17 until 10.6.17 to provide additional acute GP and Nurse Practitioner appointments on Saturday mornings from 8am until 2pm.

This provision is delivered from two hubs based at The Keys Practice, Willenhall and Anchor Meadow Health Centre, Aldridge.

These appointments are available to all patients registered with a Walsall GP being bookable on the day by telephone or via walk-in.

The service is clinically staffed with GPs and Nurse Practitioners from across Walsall practices (not just from the host practices).

Provision Progress

The service continues to expand with an increase from an average of 45 patient attendances per week at the last report on 21.2.17 to 55 patient attendances per week over the period from 25.2.17 until 6.5.17. This represents a healthy percentage increase in attendances of 22% since 21.2.17.

A total of 998 patients have used the Palmaris Bank Holiday and Saturday Services, with 759 of those being in the period under report.

Patients have visited one or the other hub from all over the borough of Walsall including Bloxwich, Willenhall, Darlaston, Stonnall, Leamore, Brownhills, Pelsall, Coalpool, Pheasey, Central Walsall, Streetly, Aldridge, Birchills, Clayhanger, Harden, Little London, New Invention, Palfrey, Pleck, Rushall.

We are developing good links with NHS ‘111’ (indeed in the reporting period, 53 (7%) of the patients who have had an appointment, have been referred by NHS ‘111’) and the Walsall Urgent Care Centres. This involves both them referring patients to us, and the hubs telephoning them to update on capacity in an attempt to help reduce wait times that patients are experiencing elsewhere when they could be seen quicker via the Palmaris service.

The service is proving especially beneficial to patients 16 years and under and aged 65 and over with 26% and 20% of all consultations taking place in these age groups respectively. This is a positive as they are generally recognised as the most vulnerable age groups in terms of the effects and progression of acute illness.

Illness Categories Treated

As you would expect, there are a wide variety of illnesses that are being treated via the Hubs. The most significant in terms of volume are shown below:

Illness Number of Patients Percentage % Respiratory Infection 66 9% Tonsillitis 23 3% Viral Illness 37 5% UTI 29 4% Dressing of Wound 8 1% Rashes 21 3% Headache 6 1% Contraceptive Advice 6 1% Earache 6 1% Dizziness 6 1% Pain 47 6%

Recommendations

Having seen the benefit that patients are receiving from this service, and, in the light of NHS England’s drive towards wider GP Opening Times, I would encourage the CCG Board to consider investing in continued provision of the current Saturday service in the period leading up to April 2018 when Walsall receives it’s additional ‘extended hours’ funding.

There appears to be a great deal of logic in allowing the service to continue to build gradually as it has been since 14.1.17 rather than ceasing the service and have to go through the initial lead-in time again.

Accepting that as a result of this project there may be changes that would need to be effected, I would be happy to work alongside CCG officers to help re-shape the service accordingly.

Christopher Blunt Managing Director Palmaris Healthcare Limited [email protected]

In Confidence: Not for Publication or Dissemination Delete if paper is for public dissemination PRIMARY CARE COMMISSIONING COMMITTEE Date of committee meeting: 18th May 2017 Agenda Item No:7.0 TITLE OF REPORT New Entrant LTBI Test & Treat Programme

PURPOSE OF REPORT: Update and Locally Commissioned Service Approval

EXECUTIVE SUMMARY: The report updates PCC members on the New Entrant LTBI Test & Treat Programme.

RECOMMENDATION TO Agree LTBI Locally Commissioned Service THE COMMITTEE:

COMMITTEE ACTION Decision REQUIRED:

REPORT WRITTEN BY: Jacqueline Nation, LTBI T&T Project Manager

REPORT PRESENTED BY: Jacqueline Nation, LTBI T&T Project Manager

REPORT SIGNED OFF BY: Carol Marston

PREVIOUS COMMITTEES No

The CCG Corporate Objectives.

Please indicate which Corporate Objectives this report supports Involve patients and public in decision making X Ensure value for money X Commission high quality services X Promote good health and sound treatment of ill health X Ensure strong leadership and good governance X Work in partnership X

Jacqueline Nation May 2016 Page 1

Jacqueline Nation May 2016 Page 2

New Entrant Latent Tuberculosis Infection Test and Treat Programme

1.0 Background

Tuberculosis (TB) rates in England remain high and are associated with significant morbidity, mortality and costs. The onset of TB can be insidious and difficult to detect, often resulting in significant diagnostic delays. Late diagnosis is associated with poorer outcomes for the individual and in the case of pulmonary TB, with an increased risk of transmission to the public. It is likely that the majority of TB cases in England are the result of ‘reactivation’ of Latent Tuberculosis Infection (LTBI), an asymptomatic phase of TB, which can last for years. LTBI can be diagnosed by a single, validated blood test; interferon gamma release assay (IGRA). It is usually treated with antibiotics, preventing active TB disease in the future.

The Collaborative Tuberculosis Strategy for England: 2015 to 2020 published in January 2015 (https://www.gov.uk/.../collaborative-tuberculosis-strategy-for-england) by NHS England (NHSE) and Public Health England (PHE) sets out approaches to support TB prevention, treatment and control. This included the setting up of TB control boards to plan, oversee, support and monitor all aspects of local TB control. The control boards have representation from Clinical Commissioning Groups (CCGs), NHS England, PHE, local authorities, local TB service providers and other stakeholders. The Strategy identifies ten areas of action to reducing TB in the UK. This report explicitly addresses area of action number 8: to ‘systematically implement new entrant latent TB testing’. New NHS funding has been made available to support its implementation nationally.

Initial priority has been given to local authority areas with high TB incidence (≥20 per 100,000 populations or over) or a high TB case burden to implement a systematic LTBI testing and treatment programme. High incidence areas have the highest burden of disease (64% of cases in England between 2011 and 2013) and systematic LTBI testing and treatment in these areas will have the greatest impact on reducing national TB incidence.

Walsall CCG had a TB incidence rate of 20.9 average for 2011–13, this however fell to 16.9 average during 2012-14 (170 active cases during 2011–13, 121 active cases during 2013- 15). In 2016 Walsall was the only CCG in the West Midlands to have an increase in the number of active TB cases.

Over the 2012–14 period 40 practices in Walsall had at least 1 case of active TB; 9 practices carried the highest burden of active TB cases (2 practices had 11 cases each, 2 practices had 8 cases each, 1 practice had 7 cases, 1 practice had 6 cases and 3 practices had 5 cases each: total of 66 cases which is just under half of all TB cases in Walsall for this period).

2.0 Current Position

In spite of evidence supporting clinical and cost effectiveness of LTBI screening, implementation in England has been inconsistent; this situation is reflected in Walsall where screening is generally limited to the screening of TB case contacts only.

Jacqueline Nation May 2016 Page 3

Walsall CCG put in a bid to the West Midlands TB Control Board and secured an allocation of £110,000 to support testing of 500 people for latent TB during 2017/18. The funding allocation included funding for a designated project manager (0.4WTE) now in post; supported by a project officer (0.4WTE) starting on 15 May 2017.

To deliver the programme GP practices with a high incidence of TB will be targeted to carry out latent TB screening in primary care. A Locally Commissioned Service (LCS) has been developed for remunerating participating GP practices and is attached for PCCC approval. Funding for the LCS is within the NHS England allocation.

A Service specification has been submitted to Secondary Care and is awaiting approval. The Secondary Care TB team have been requested to provide (are currently working on establishing) a pathway for individuals referred through the programme.

NHS England has procured the Oxford Immunotec Laboratory provider to carry out the IGRA blood test which is paid for directly by NHS England.

The programme will be piloted with one GP Practice (Palfrey Health Centre) to test implementation processes. The remaining 8 GP Practices with 5 or more cases of active TB during the period 2012-14 will then be invited to sign up for the LCS. Further practices will be invited to sign up when the programme is established within the high burden practices subject to further NHS England funding.

3.0 Recommendations

The Primary Care Commissioning Committee is asked to:

3.1 Note the contents of the report 3.2 Support and encourage engagement with the programme 3.3 Agree the LTBI LCS Specification.

Jacqueline Nation May 2016 Page 4

SCHEDULE 2 – THE SERVICES

A. Service Specifications

Service Specification Version 1.0, 26 April 2017, DRAFT No. Service General Practice Locally Commissioned Service 2017-18 Commissioner Lead Carol Marston Clinical Lead Dr Carsten Lesshafft Period Co-terminus with Contract Date of Review May 2018 1. Population Needs

1.1 National/local context and evidence base

National context

Since 2013 there has been a year on year decline in the number of TB cases in England, down to 6,520 in 2014, a rate of 12.0 per 100,000. The recent reduction in TB cases is predominantly associated with a reduction in cases of those born outside of the UK (which make up almost three‐quarters of all TB cases in England). The majority of non‐UK born cases (86%) are now notified more than two years after entering the UK and are most likely due to reactivation of latent TB infection.

The Collaborative Tuberculosis Strategy for England: 2015 to 2020 published in January 2015 https://www.gov.uk/.../collaborative‐tuberculosis‐strategy‐for‐ england by NHS England (NHSE) and Public Health England (PHE) sets out approaches to support TB prevention, treatment and control. This included the setting up of TB control boards to plan, oversee, support and monitor all aspects of local TB control. The control boards have representation from Clinical Commissioning Groups (CCGs), NHS England, PHE, local authorities, local TB service providers and other stakeholders.

The formal responsibility for commissioning NHS TB services continues to rest with CCGs. The Collaborative TB Strategy Commissioning Guidance sets out further details, including proposing local lead CCG arrangements for TB commissioning and membership of the relevant control board.

Jacqueline Nation Latent TB Infection Test & Treat Programme LCS May 2017 1 | Page

The Strategy identifies ten areas of action to reducing TB in the UK. This LCS explicitly addresses area of action number 8: to ‘systematically implement new entrant latent TB testing’. Screening for LTBI of new entrants to England is also supported by the National Institute of Health and Care Excellence.

It is likely that the majority of TB cases in England are the result of ‘reactivation’ of LTBI, an asymptomatic phase of TB, which can last for years. LTBI can be diagnosed by a single, validated blood test; interferon gamma release assay (IGRA). It is usually treated with antibiotics, preventing active TB disease in the future. In spite of evidence supporting clinical and cost effectiveness of LTBI screening, implementation in England has been inconsistent.

Evidence shows that the effectiveness and cost effectiveness of LTBI testing depends on the accurate identification and targeting of eligible recipients. The clinical and cost effectiveness of LTBI testing is not dependent on UK geography, and it can also be effectively carried out in low incidence areas. While LTBI testing would be beneficial for all UK areas in England, particular focus is on systematic implementation in areas with high local incidence. High incidence areas have the highest burden of disease (64% of cases between 2011 and 2013) and systematic LTBI testing and treatment in these areas will have the greatest impact on reducing national TB incidence. The national strategy proposes that rolling out LTBI testing should be in stages, commencing with the high incidence areas, where local ownership and infrastructure can be established.

To support this service NHSE identified funding for development of latent TB infection identification, testing and treatment. Lead CCGs can access the additional funding on the basis of a locally developed latent TB implementation plan signed off by the relevant TB control board and approved by the national NHSE / PHE TB programme team.

The Collaborative TB Strategy for England recommends LTBI testing and treatment for 16 to 35 year olds who recently arrived in England from high incidence countries, where TB incidence is 150/100,000 population or over (Appendix 1).

Local context

Initial priority has been given to local authority areas with high TB incidence (≥20 per 100,000 populations or over) or a high TB case burden to implement a systematic LTBI testing and treatment programme. Walsall CCG had a TB incidence rate of 20.9 average for 2011–13; this fell during 2012‐14 and 2013–2015 periods but the number rose again in 2016 to 52 cases (rate not yet available) (Appendix 2).

PHE data identifies that over the 2012–2014 period 40 practices had at least 1 case of active TB; 9 practices carried the highest burden of active TB cases (2 practices had 11 cases each, 2 practices had 8 cases each, 1 practice had 7 cases, 1 practice had 6 cases and 3 practices had 5 cases each: total of 66 cases which is just under half of all TB cases for this period).

Jacqueline Nation Latent TB Infection Test & Treat Programme LCS May 2017 2 | Page

Walsall CCG has been allocated £110,000 for 2017–2018 to support the implementation of the LTBI Programme, which will cover testing of up to 500 individuals.

This LCS aims to provide a framework to support the implementation of local LTBI testing and treatment as part of a robust local and regional TB control programme.

2. Outcomes

2.1 NHS Outcomes Framework Domains & Indicators

Domain 1 Preventing people from dying prematurely  Domain 2 Enhancing quality of life for people with long‐term conditions Domain 3 Helping people to recover from episodes of ill‐health  or following injury Domain 4 Ensuring people have a positive experience of care  Domain 5 Treating and caring for people in safe environment  and protecting them from avoidable harm

2.2 Public Health Outcomes Framework 3.05i Treatment completion for TB  3.05ii Incidence of TB  4.08 Mortality from Communicable diseases  (persons)

2.3 Local defined outcomes

The LCS outcome measures will include: • Number of practices identified with the highest burden of active TB cases engaged in the LTBI T&T Screening programme. • Number of patients identified as meeting the screening eligibility criteria (see point 3.3) and offered screening (new registrants and individuals identified through EMIS searches). • Number of patients identified accepting screening. • Number of patients who have a positive IGRA test result. • Number of patients with a positive IGRA test result who are directly referred for treatment. • Number of those patients who have been identified and referred for treatment and have completed the appropriate treatment regime. Data on numbers of referrals, numbers who attended / did not attend, outcomes of

Jacqueline Nation Latent TB Infection Test & Treat Programme LCS May 2017 3 | Page

further screening and treatment outcomes will be captured and submitted to the national team by secondary care TB team.

2.4 Regional Outcome Measures

The West Midlands Regional Outcome measures include: • Evidence of CCG engagement. • Implementation of the national pathway (Algorithm Appendix 3). • Evidence of the reduction in active cases.

3. Scope

3.1 Aims and objectives of service

The scope of this LCS is to develop a service that helps to improve patient access to screening services within a primary care setting, identification and targeting those who meet the eligibility criteria set out in Point 3.3 and implementation of early intervention and management strategies to reduce the impact of undiagnosed and untreated TB.

The development of the service will also support primary care to have a better understanding of local communities; and in addition for TB services to build capacity for future demand and associated treatments and costs.

Primary care will embed a systematic LTBI Test and Treat Screening Programme supported by robust clinical templates and will receive remuneration (see point 6) for identification, screening and appropriate data capture.

The LCS has been designed to reward practices for: • Establishing a screening programme within the GP practice to identify newly registered patients who meet the national eligibility criteria for inclusion (see point 3.3). • Establishing a screening programme within the GP practice to offer screening to previously registered individuals (identified through EMIS Enterprise searches) who meet the national eligibility criteria for inclusion. • Establishing a systematic data capture process including appropriate READ coding within primary care. • Using the appropriate laboratory services to screen for latent TB identification. • Using the appropriate referral process for those patients with a positive interferon gamma release assay (IGRA) test directly to TB services for early intervention therapy.

Practices will be paid for identification and screening of patients that meet the Jacqueline Nation Latent TB Infection Test & Treat Programme LCS May 2017 4 | Page

screening criteria (as per point 3.3). Onward management and treatment will be under the care of the Secondary Care TB team.

3.2 Service description/care pathway

This LCS covers the screening of both patients who are:  New registrants to a practice who meet the screening eligibility criteria (as point 3.3)  Retrospective screening of patients already registered at practices who meet the screening eligibility criteria (as identified in point 3.3).

Practices will be required to sign a consent form under the data sharing agreement with the CCG in order that audit searches through EMIS Enterprise can be run to provide the practice with data on individuals who meet the national eligibility criteria (as identified in point 3.3).

Timely and appropriate information and awareness raising activities will take place in communities that are at high risk of TB. This will be established by:

• Setting up LTBI screening programmes within primary care settings. • Identifying and monitoring patients who have LTBI, and compliance with treatments. • Ensuring that patients who are invited for LTBI testing are provided with adequate assurance regarding the testing to ensure maximum uptake. • Understanding barriers to the uptake of the offer of LTBI testing across communities. • Collaboration and engagement across primary, community and secondary care providers. • Promoting access to screening programmes locally for our residents. • Understanding current and future activity. • Capacity building for provider services. • Wider community engagement, communication and raising the profile of the risks of unidentified and undiagnosed LTBI.

The implementation of these actions will support a consistent strategy for delivering screening in the community across Walsall. It will provide a standardized approach to tackling the problem and improve access to vulnerable people who may ordinarily not have access to appropriate services.

Delivery of the service is dependent on clear identification processes within primary care. For the service to deliver success, it is assumed that Walsall GP practices will

Jacqueline Nation Latent TB Infection Test & Treat Programme LCS May 2017 5 | Page

record activity and access and refer to the appropriate interventions using the designated READ codes.

To develop a service that is considered appropriate to satisfy all of these elements will require full engagement from general practices and clinical leads. Due to limited funding for 2017/18 the LCS will be offered to the practices with the highest burden of active TB cases (i.e. practices with five or more cases of active TB through 2012 ‐ 2014). Roll out to further practices will be dependent on additional funding in 2018. Clinical networks will be kept informed to highlight the importance of the LTBI Screening programme to encourage active participation from practices focused on improving the health of local communities. A designated project manager has been appointed and will provide support to assist in programme delivery and implementation.

A toolkit is available to assist in the delivery of the programme which can be accessed online at www.thetruthabouttb.org/professionals/ltbi‐toolkit or www.tbalert.org/health‐professionals/ltbi‐toolkit

3.3 Population covered

Individuals registered with GP practices in Walsall who meet the national eligibility criteria. National eligibility criteria for inclusion: • Aged 16‐35 • Born in or lived in for 6 months or longer, a high incidence area of the world with TB rates ≥150/100,000 or Sub Saharan Africa (Appendix 3). • Arrived within the UK in the last 5 years. • Have no history of TB either treated or untreated. • Have never undergone screening for TB in the UK.

3.4 Any acceptance and exclusion criteria and thresholds

In order to meet the terms for payment, patients for LTBI testing and treatment under the national programme must fulfill ALL of the eligibility criteria and be registered with a Walsall GP.

3.5 Interdependence with other services/providers

The interdependencies required to support delivery of this LCS include: • Consistent resource capacity within the TB team to support GP Practices. • Cross referencing of test results from laboratories/Primary Care/Secondary Care/TB programme team. • Access to the appropriate clinical templates. • Project manager support for practices with any concerns or outstanding issues.

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4. Applicable Service Standards

4.1 Applicable national standards (eg NICE)

• Practices providing the service defined within this agreement will have facilities available to enable them to provide services to the standards set out within this LCS. • Adequate and appropriate equipment will be available for healthcare professionals to undertake the service defined within this LCS. • Practice staff carrying out the initiatives within this LCS will be appropriately qualified to do so. • NICE quality standard 141 January 2017 - Statement 1 People aged 16 to 35 years who have arrived in the country within the past 5 years, from countries with a high incidence of tuberculosis (TB), are tested for latent TB infection when they register with a GP.

5. Location of Provider Premises Providers will provide the scheme from their GP practice premises.

6. Monitoring, Payment and Validation Completion of the LTBI clinical template embedded in EMIS will raise READ codes which will be captured by the CCG. Payment scales for screening:

Amount £1 Per patient (previously registered and identified through EMIS search as meeting the eligibility criteria) contacted and invited for screening (number of invitations per practice subject to discussion with the programme manager) : the EMIS screening template will need to have been populated to generate the READ codes for payment. £10 Per IGRA test performed on individuals meeting ALL of the eligibility criteria for LTBI testing: the EMIS screening template will need to have been populated to generate the READ codes for payment. £10 Per positive IGRA test / referral to secondary care: the EMIS screening template will require updating to generate the appropriate READ code to generate payment. £10 Per referral to secondary care for individuals with signs and symptoms suggestive of active TB, identified through the LTBI Test &Treat screening process, including those self‐presenting following receipt of an invitation for screening: the EMIS template will require updating to generate the appropriate READ code for payment. (Excludes individuals not meeting the criteria or those self‐presenting who have not been contacted to invite for screening). Payment will only be made for any tests performed where ALL of the eligibility criteria are met.

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Financial Year Financial Quarters Payment Month Quarter 1 (April – June 17) July 17 2017/18 Quarter 2 (July – Sept 17) October 17 Quarter 3 (Oct – Dec 17) January 18 Quarter 4 (Jan – March 18) April 18 o Quarter 1 – baseline quality standard report and CCG return o Quarter 4: run end of year report and CCG return

It is expected activity will be reported evenly during each quarter of the 2017‐18 financial year.

Participating GP practices are required to sign a consent form under the data sharing agreement with the CCG.

7. General Practice Sign Up

GP practices will be invited to provide the General Practice Locally Commissioned Service against the terms of the Standard NHS Contract for 2017‐18.

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APPENDICES

APPENDIX TITLE Page No. Appendix 1 Countries of origin eligible for LTBI 10 / 11 testing and treatment Appendix 2 TB trends in Walsall since 2000 12

Appendix 3 Latent TB Testing and Treatment 13 Algorithm

Jacqueline Nation Latent TB Infection Test & Treat Programme LCS May 2017 9 | Page

Appendix 1

Countries of origin eligible for LTBI testing and treatment (Estimated TB incidence rate≥150 per 100,000 population in 2013 or Sub‐Saharan Africa) Country Incident Country Incident

Afghanistan 189 Liberia 308

Angola 320 Madagascar 233

Bangladesh 224 Malawi 156

Benin 70 Mali 60

Bhutan 169 Marshall Islands 354

Botswana 414 Mauritania 115

Burkina Faso 54 Mauritius 21

Burundi 128 Micronesia 188

Cote d'Ivoire 170 Mongolia 181

Cabo Verde 143 Mozambique 552

Cambodia 400 Myanmar 373

Cameroon 235 Namibia 651

Central African 359 Nepal 156 Republic

Chad 151 Niger 102

Comoros 34 Nigeria 338

Congo 382 Pakistan 275

DRP Korea 429 Papua New Guinea 347

DR Congo 326 Philippines 292

Djibouti 619 Republic of Moldova 159

Equatorial Guinea 144 Rwanda 69

Eritrea 92 Sao Tome & Principe 91

Equatorial Guinea 144 Rwanda 69

Jacqueline Nation Latent TB Infection Test & Treat Programme LCS May 2017 10 | Page

Eritrea 92 Sao Tome & Principe 91

Ethiopia 224 Senegal 136

Gabon 423 Seychelles 30

Gambia 173 Sierra Leone 313

Ghana 66 Somalia 285

Greenland 194 South Africa 860

Guinea 177 South Sudan 146

Guinea‐Bissau 387 Swaziland 1382

Haiti 206 Timor‐Leste 498

India 171 Togo 73

Indonesia 183 Tuvalu 228

Kenya 268 Uganda 166

Kiribati 497 UR Tanzania 164

Laos PDR 197 Zambia 410

Lesotho 916 Zimbabwe 552

Jacqueline Nation Latent TB Infection Test & Treat Programme LCS May 2017 11 | Page

Appendix 2

TB trend in Walsall since 2000, with West Midlands / England rates for comparison.

Period Count Value Lower CI Upper CI West Midland England 2000 ‐ 02 182 23.9 20.5 27.6 ‐ 12.7 2001 ‐ 03 168 22.0 18.8 25.6 ‐ 13.1 2002 ‐ 04 168 21.9 18.7 25.5 ‐ 13.5 2003 ‐ 05 155 20.1 17.1 23.6 ‐ 14.1 2004 ‐ 06 153 19.8 16.8 23.1 ‐ 14.7 2005 ‐ 07 155 19.9 16.9 23.3 ‐ 15.0 2006 ‐ 08 166 21.2 18.1 24.7 ‐ 15.0 2007 ‐ 09 160 20.3 17.3 23.7 ‐ 15.1 2008 ‐ 10 148 18.6 15.7 21.9 ‐ 15.1 2009 ‐ 11 161 20.1 17.1 23.5 ‐ 15.2 2010 ‐ 12 166 20.6 17.6 23.9 ‐ 15.1 2011 ‐ 13 170 20.9 17.9 24.3 ‐ 14.7 2012 ‐ 14 138 16.9 14.2 19.9 ‐ 13.5 2013 ‐ 15 121 14.7 12.2 17.6 17.9 12.0

Source: Enhanced Tuberculosis Surveillance system (ETS) and Office for National Statistics (ONS) http://fingertips.phe.org.uk/profile/tb‐ monitoring/data#page/4/gid/1938132814/pat/46/par/E39000033/ati/19/are/E3800 0191/iid/91359/age/1/sex/4

Jacqueline Nation Latent TB Infection Test & Treat Programme LCS May 2017 12 | Page

Appendix 3

Jacqueline Nation Latent TB Infection Test & Treat Programme LCS May 2017 13 | Page

4. Our findings and how management has responded

System Control Objective 1: The CCGs governance arrangements have been reviewed and revised to reflect national guidance surrounding Primary Care Commissioning requirements.

System Control Objective 2: Roles, responsibilities and lines of accountability are established and clearly defined for Primary Care Commissioning.

An internal governance review was undertaken at the CCG during 2016 to review structures and reporting arrangements and committees terms of reference were revised and approved at the Governing Body meeting in September 2016.

During 2016 the CCG commissioned an independent review from the Good Governance Institute (GGI) to review the internal governance at the CCG, with a particular focus on the effectiveness of the Governing Body, decision-making processes, assurance frameworks, risk management, and the governance of quality. The findings have been discussed and actions agreed, with an action plan being approved by the Audit & Governance Committee at the March 2017 meeting.

Work has been undertaken by the CCG to produce a Primary Care Strategy and to ensure the strategy is aligned to the STP and operational plan. The draft Primary Care Strategy 2016-21 was presented to the Governing Body meeting in January 2017.

System Control Objective 3: A Primary Care Commissioning Committee has been established and its terms of reference are in line with national guidance.

The Primary Care Commissioning Committee has reviewed and revised it’s Terms of Reference during 2016 to take into account the latest NHS England guidance relating to conflicts of interest management.

Risk Area Audit Finding Risk Ranking Recommendation Response Who and when

3.1 The Primary Care Commissioning Committee Noncompliance with 4 The PCC papers should be A staff training Hardeep Dhillon PCC papers papers are not uploaded to the CCG website best practice. uploaded to the CCG requirement was First training date on CCG in a timely basis. website on a timelier basis, identified and external 12/5/17 website The CCG may be i.e. agendas prior to the training fom the CSU From June 17 In September 2016 the agendas and papers open to criticism meeting date and minutes has been arranged papers will be relating to the period April to August 2016 from the public that following each meeting. uploaded in a were uploaded to the CCG website. The it does not act in an timely manner. The agendas and papers relating to meetings open and The website should be schedule of

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Risk Area Audit Finding Risk Ranking Recommendation Response Who and when

held since September 2016 have not yet transparent way. updated to ensure only The number of meetings meetings for been uploaded to the website. We noted folders relevant to of the primary care 2017/18 will be that the website contains folder headings for committee meetings that are committee has been added to the upcoming meetings for each month of the scheduled/held are included reviewed and a return to website year, with the exception of September and to avoid any confusion by monthly meetings has December 2016, however the committee the public that a meeting been established terms of reference states the committee will was due but did not take meet six times a year in public. place. The website will be updated for 2016 and Further one of the areas reported on in the The PCC Committee 2017 meetings and the recent Good Governance Institute meetings schedule for correct folders will be governance report was that … ‘members 2017/18 should be added to established suggested that information was not always the CCG website. easily available on the CCG’s website and the The meeting schedule organisations is not supported by a good for 2017/18 will be intranet. This was reportedly causing uploaded frustrations, and perhaps also has implications for the organisations reputation as open and transparent’.

3.2 The CCG held a Primary Care Non compliance 3 Items requiring a formal The committee had Chair of PCC – PCC Commissioning (PCC) Committee with the committee decision by the PCC agreed to hold a immediate effect Committee development session in September 2016. terms of reference Committee should be development session in development We reviewed and agenda and minutes and and the CCG’s reserved for the PCC lieu of a September sessions found that it was unclear whether decisions Scheme of Committee meetings and meeting. This was the were being taken within the development Delegation for should not be undertaken first time a development session that should be reserved for the decision making. within development session session was held. A formal PCC Committee meetings. forums. number of issues had arisen in month that The PCC Committee terms of reference The CCG should set clear required an urgent state….’Meetings of the Committee shall, as guidelines for the purpose of response so were taken a general rule should be held in public, the development sessions at the meeting. including the decision making and the and to emphasize the need The committee agreed deliberations leading up to the decision for transparency when that this should not be unless the CCG has concluded it is making decisions. normal practice and a appropriate to exclude the public and or distinction needs to be where appropriate, the representatives in drawn between a formal attendance’. committee meeting and

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Risk Area Audit Finding Risk Ranking Recommendation Response Who and when

a development session Subsequent development sessions have had a clear agenda and subject focus. The development session will not replace a committee meeting

System Control Objective 4: Key risks in relation to Primary Care Commissioning have been considered and included in the Risk Register and Assurance Framework where appropriate.

Risk Area Audit Finding Risk Ranking Recommendation Response Who and when

4.1 The Primary Care Commissioning Committee Non compliance 4 The Risk Register should be The risk register had Donna Macarthur Risk Register agendas and minutes were reviewed to with best practice. included as a standing been taken in the “in Risk register on – PCC ensure the Risk Register is included as a agenda item on the public committee” part of the the public agenda Committee standing agenda item and discussed at each Not including the session of the PCC meeting as a number of from May 2017 meeting. We noted the Risk Register was Risk Register in the Committee in order for the risks on the register had included on the agenda for the following public section of CCG to demonstrate been identified in this meetings: the Committee openness and transparency. section. Some of the may be perceived risks included very  April 2016 private session by the public as a specific contractor  May 2016 private session lack of openness information which it  June 2016 private session and transparency. may not always be  July 2016 private session appropriate to put in  August 2016 private session the public domain. To  October 2016 private session respond to the risk  November 2016 public session described some names  January 2017 private session will be redacted from the public risk register 4.2 The PCC Committee draft work plan Committee roles 3 Review of the Risk Register Review of the risk Donna Macarthur PCC (schedule of reports and decisions) and responsibilities and risk management register is undertaken at July 2017 Committee presented to the June 2016 private session may not be clearly arrangements should be every meeting and risks work plan meeting and September 2016 development defined and included on the PCC are flagged to the session was reviewed and we noted that the fulfilled. Committee work plan. governing body through Risk Register is not included on the work the primary care

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Risk Area Audit Finding Risk Ranking Recommendation Response Who and when

plan. It was also noted that some items on The PCC Committee terms of assurance report. It is the work plan were incomplete and not reference should be updated accepted that a review populated with proposed meeting dates. to include a requirement to of the arrangements maintain an annual work should be included as The PCC Committee terms of reference do plan. part of the work plan not record that the Committee should have an annual work plan in place. The ToR will be Carol Marston amended to include the June 2017 requirement of an annual work plan

Within our Assurance Framework review we have identified that committee risk registers are not always fully populated with some fields being incomplete or left blank. A recommendation has been made to ensure committee risk registers are fully populated and maintained up to date.

System Control Objective 5: The CCG maintains a Register of Procurement Decisions relating to Primary Care Commissioning detailing the decision made, who was involved in making the decision, a summary of any conflicts of interest in relation to the decision, and how this was managed by the CCG.

System Control Objective 6: The CCG has a clear system for dispute resolution.

System Control Objective 7: CCG members and officers have received appropriate training on conflicts of interest specific to Primary Care Commissioning.

The CCG maintains a Register of Procurement Decisions which is published on the CCG website in line with NHS England guidance. The CCG has reviewed and revised the Disputes Resolution process during the year which was approved by the Audit & Governance Committee at the January 2017 meeting. The CCG has undertaken some training in relation to conflicts of interest management, and Governing Body and chairs development but further training is planned once the NHS England training modules have been released in April 2017. The CGG will need to put processes in place to monitor and ensure that members and staff undertake the required training. We have reviewed the detailed arrangements and compliance with guidance within our conflicts of interest management review which will be reported on separately.

System Control Objective 8: Reporting arrangements for Primary Care Commissioning to the Governing Body is established and clearly defined and includes updates on progress against the procurement of primary care services.

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There are five sub-groups which report to the Primary Care Commissioning Committee, including; the Primary Care Quality Improvement Sub Group; Primary Care Provider Committee Group; Medicines Management: Capital Review Group; and the IT Steering Group. The Primary Care Commissioning Committee provides assurance reports to each meeting of the Governing Body with a summary of the issues discussed at the committee.

In the recent governance review undertaken by the Good Governance Institute, it was reported that some issues had been noted relating to a lack of evidence and poor standard of papers for some sub-committees including the Primary Care Commissioning Committee. The CCG’s action plan to address the recommendations made has acknowledged that action is required to ensure high quality papers are delivered, that enable improved performance and evidence of decision making.

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System Control Objective 9: Appropriate handover arrangements are in place to ensure a smooth transfer of responsibilities from NHS England to the CCG.

Risk Area Audit Finding Risk Ranking Recommendation Response Who and when

9.1 We have been unable to confirm whether Arrangements may 3 A report should be provided The CCG became fully Donna Macarthur / Handover appropriate handover arrangements were in not be signed up to to the PCC Committee on delegated from April Tony Gallagher / arrangement place to ensure a smooth transfer of by all relevant the transition of Primary 2016. NHS E staff have Sally Roberts from NHSE responsibilities from NHS England to the parties. Care Commissioning from attended the primary CCG. We were informed by the Primary Care NHS England to the CCG, care committee Aug 2017 Administrator that the handover All tasks and confirming whether there is meetngs prior to arrangements had not been reported, responsibilities may assurance that the transition handover under joint assessed or approved. not been was appropriately managed commissioning appropriately and all actions have been arrangements and transferred. completed. continue to attend post delegation which has Lack of assurance facilitated handover over effectiveness of the handover A report will be arrangements. prepared which considers the handover of responsibilities for commissioning, finance and quality

Within our financial systems review we reported that there are no documented procedures specific to Primary Care Commissioning processing of payments at the CCG. Payments vary in frequency and staff need to be aware of what to check on a monthly basis. Should a member of staff leave the CCG unexpectedly, there is no trail for staff to follow and provide continuity. A recommendation was made and action has been agreed to ensure local procedures are put in place for payments to practices.

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Appendix 1: Definition of our assurance levels and our risk rankings

Opinion Assessment rationale

The audit highlighted weaknesses in the design or operation of controls that have not only had a significant impact on the delivery of key system No objectives, they have also impacted on the delivery of the organisation's strategic objectives. As a result, no assurance can be given on the operation of the system's internal controls to prevent risks from impacting on achievement of both system and strategic objectives. The audit highlighted some weaknesses in the design or operation of control that have had a serious impact on the delivery of key system Limited objectives, and could also impact on the delivery of some or all of the organisation's strategic objectives. As a result, only limited assurance can be given on the operation of the system's internal controls to prevent risks from impacting on achievement of the system's objectives. The audit did not highlight any weaknesses that would in overall terms impact on the achievement of the system's key objectives. However, the audit did identify some control weaknesses that have impacted on the delivery of certain system objectives. As a result, only moderate assurance Moderate can be given on the design and operation of the system's internal controls to prevent risks from impacting on achievement of the system's objectives. The audit did not highlight any weaknesses that would materially impact on the achievement of the system's key objectives. The audit did find some low impact control weaknesses detailed in section four of this report which, if addressed, would improve the overall performance of the Significant system. However these weaknesses do not affect key controls and are unlikely to impair the achievement of the system's objectives. As a result, significant assurance can be given on the design and operation of the system's internal controls to prevent risks from impacting on achievement of the system's objectives. The audit did not highlight any weaknesses that would impact on the achievement of the system's key objectives. It has therefore been concluded that key controls have been adequately designed and are operating effectively to deliver the key objectives of the system. As a result, Full full assurance can be given on the operation of the system's internal controls to prevent risks from impacting on achievement of the system's objectives.

Risk ranking Assessment rationale

The system has been subject to high levels of risk that have, prevented the system from meeting its objectives and also impacted on the delivery 1 of the organisation's strategic objectives. The system has been subject to high levels of risk that has, or could, prevent the system from meeting its objectives, and which may also impact 2 on the delivery of some or all of the organisation's strategic objectives.

3 The system has been subject to medium levels of risk that have, or could, impair the system from meeting its objectives.

4 The system has been subject to low levels of risk that has, or could, reduce its operational effectiveness.

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Business Case

Project Ref: Project Name: Primary Care Leadership Group Development Version: Final Author: PC Leadership Group

Clinical Lead: The Primary Care Leadership Group

Year 1 net cost : External Facilitator for 3 months = £17,550

Primary Care Leadership Groups:  Management Capacity: o 3 months = £6,000 o 9 months = £78,000  Clinical capacity = £60,000  Total Funding Requirement £161,550

Approvals:

Authorising Chair / Name Title Signature Date Body Primary Care Committee Director Lead

Clinical Lead

Financial Lead

Walsall CCG Business Case v2.0 24_11_2016

1. Executive Summary

The Primary Care Leadership Group wish to secure circa £161,550 non recurrent funding from the FYFV Development Fund for 17/18 to:

 Procure an independent facilitator to support the Primary Care Leadership Group in the development of a preferred organisational model for the proposed MCP contract.  To support and develop the existing management capacity within the 5 GP groups to facilitate the development of the business case, pathways, governance structure and attendance at appropriate meetings to support the MCP model.  To release clinical capacity for GP’s to attend the Primary Care Leadership Group meetings, Provider Board and provide clinical leadership to the development of the MCP model.  To develop & support the GP Leadership group to bring about changes in the way services are delivered based on primary care working at scale and consistently delivering a high quality , efficient and cost effective service

2. Background

Walsall CCGs Strategic Plan assumes primary care will be better placed to offer an extended range of services in the future through maximising opportunities for practices to work together, co‐location/integration of community services and opportunities for embedding the voluntary sector as part of the primary care provision. The CCG has recognised the need to support general practice to transform and the need to facilitate practices working together to create more sustainable services for the patients of Walsall. This is consistent with the FYFV and the emerging new models of care.

Walsall’s Primary Care Strategy sets out the vision for primary care and the operating model needed to respond to the challenges we face. The strategy draws on learning from new care models , both in the Black Country Sustainability and Transformation Plan (STP) area, and nationally (e.g. Multispecialty Community Providers (MCPs) and Primary and Acute Trusts (PACTS)). The stated aim is to develop a new provider‐operating model based on place/whole population, and focussed on outcomes, incorporating the voluntary sector and other primary and community services.

National guidance sets out the principle for CCGs and the need to strengthen arrangements for providing significant support for practices and federations to redesign care and build

Walsall CCG Business Case v2.0 24_11_2016

more sustainable organisations for the future. CCGs who have already been involved in provider development are finding that creating space for practices to meet and plan together, through funding backfill; and providing expert facilitation to make rapid progress on reviewing options and creating improvement plans are most effective. Walsall CCG has committed to facilitating discussions with the federations and super partnerships that have emerged in Walsall and to support them as they prepare to adopt the new models with the ultimate aim that they take on responsibility for the health care budgets for the population.

The Primary Care Leadership Group has been formed to provide a collective voice on behalf of primary care providers in Walsall. Membership consists of the five existing Federation/Super partnerships in Walsall and covers the majority of practices via Walsall Alliance, Modality, The Practice Group, Palmaris and Umbrella Partnership. The group has made rapid progress to date and shares a common vision that is based on:

 Changing old ways of working and moving towards a multi‐disciplinary approach to service provision.  Primary Care working at scale in partnerships with community, mental, social, voluntary and secondary care providers  Maximising patients accessing services within the community  Integration around place

The initial discussion has been based on a Borough wide MCP model, operating on a place based integrated team covering a 30‐50,000 GP population working together across the larger Walsall footprint to obtain economies of scale and high quality care to keep patients at their lowest point of dependency. This will be achieved through proactive collaboration working towards the fundamental principle of funding on a capitated basis to achieve better outcomes for our population.

3. Business Solution

The new models of care provides an opportunity to redesign services in a more efficient and effective way to provide better patient outcomes and improve value for money. GP’s are fundamental to the delivery of the new model and it is imperative that the GP provider community work together at scale to fulfil the ambitions of national and local policy. The Primary Care Leadership Group aims to be at the forefront of developing new models of care and has the support of all practices in Walsall.

The Group has been exploring structures to facilitate Primary Care’s leadership role in these developments. However, the details of the model, including structure, workforce, outcomes measurements, and management and governance arrangements requires detailed working up. A lack of resources to support this detailed development is seen as a major barrier to our success.

Walsall CCG Business Case v2.0 24_11_2016

Primary Care has not had the investment in the past to build the capacity required to enable working at scale and to develop clinical leadership to ensure safe and high quality services are provided to our patients. Financial support is required to build the capacity of Primary Care to turn these ambitions into reality. We have identified a funding requirement of c£162k. to support some short term external capacity and to release management and clinical time for our leads to work through the different models in partnership with all stakeholders and agree the most appropriate corporate form.

The funding requirement is broken down as follows: (Please see 8. Procurement for allocation of funding)

 External Facilitator @ £450 per day working for 39 days over 3 months = £17,550 – (The external facilitator will be retained for a 3 month period. During this period we would appraise the skills that we have within the Primary Care Leadership Group and our current position in terms of model development and assess if we need to extend this period for a further 9 months or we have the capacity within the team to facilitate this project. This additional funding is included in the Management Capacity figures below)

 Primary Care Federation Groups: o Management Capacity: . 15 days @ £400 per day over 3 months = £6,000 . 195 days @ £400 per day for 9 months = £78,000 o Clinical capacity @ £1000 per month / per Federation for 12 months = £60,000

 Total Funding Requirement £161,550

Once agreed this will enable the Group to focus on a shared vision , strategic planning, governance structures, clinical pathways and outcomes measures to facilitate the effective implementation of an MCP model in Walsall.

4. Expected Benefits

The 10 key benefits from this investment would be:

1. A collaborative voice from Primary Care as we develop an integrated solution to local health needs

2. Leadership and management capacity to support the delivery and implementation of the MCP model in Walsall

3. Clinical support and input from GP Leaders to develop Improved patient outcomes through patient centred care

Walsall CCG Business Case v2.0 24_11_2016

4. Development of Primary Care at scale and obtaining a consistent approach to service delivery.

5. More efficient service provision from integrated and multidisciplinary teams working to provide comprehensive and personalised care.

6. Further development of locality based teams and how these teams will look and operate across Walsall. 7. Collaboration with all member practices from all Walsall Federations / Super Partnerships to develop trust and one collective vision towards an MCP model.

8. Development of the Walsall Provider board to support and sustain collaborative working with WMH, DWMH, Local Authority, Public Health and the Voluntary sector. This will develop integrated working with agreed clinical priorities and pathways of care across Walsall.

9. Through effective collaboration with member practices and the Walsall Provider Board , The GP Leadership group will explore the 3 identified priority areas (Access, Demand Management and Medicines Management) and present a detailed plan to the CCG which links practice performance and financial reimbursement.

10. The future benefits beyond 12 months will be for the MCP model to align to national and local aims / priorities.

5. Expected Disbenefits

There are no disbenefits identified to this arrangement. Primary Care needs to be at the forefront of these developments and requires support to redesign models of care and create a sustainable organisation for the future. NHS England support the principles of practices benefitting from locally funded developments.

6. Timescales

We are faced with a challenging local agenda as we look to implement new models of care. Timescales are very tight and we need to continue our momentum. Funding needs to be implemented by the beginning of April as there is a finite opportunity to progress this without losing continuity.

7. Major Risks

Walsall CCG Business Case v2.0 24_11_2016

That this decision takes time and momentum and history is lost. Primary Care must be at the forefront of MCP development and this can only be achieved if it is funded appropriately to deliver.

8. Procurement

The external facilitator for 3 months will be Sarah Laing who has been working with the PC Leadership Group as it is important to continue with someone who has been involved in the development of the group and can provide continuity.

TPG will hold the funding from the FYFV Development Fund on behalf of the GP Leadership Group. TPG will employ the external facilitator on a fixed term contract for 3 months.

The management and clinical capacity will be identified by the individual GP groups from within their existing structure. Each Federation / Super Partnership will provide and be funded for x1 Management representative & x1 Clinical representative. These will be selected from Board members or Super Partnership representatives /committees.

The group will consist of a minimum of 10 members – 5 Clinical (GPs) & 5 Non‐ clinical (Management). It is expected that both the clinical and non‐clinical members from each Federation / Super Partnership will attend the monthly GP Leadership Board Meetings and monthly Walsall Provider Board Meetings.

Federations will be funded based on attendance to the above meetings. The elected Chair of the GP Leadership group will monitor attendance of meetings and allocated workflow throughout the group.

Clinical Example:

If a GP Representative of a Federation was to attend both monthly meetings and complete allocated workflow and actions the Federation/ Super Partnership would receive £1000 for monthly clinical commitment. If the GP representative only attends x1 meeting a payment of £500 will be made to the Federation / Super Partnership.

Management Example:

If a Management representative of a Federation / Super Partnership attends both monthly meetings in months 1‐3 and complete allocated workflow and actions the Federation/ Super Partnership would receive £400 for monthly Management commitment. If the Management representative only attends x1 meeting a payment of £200 will be made to the Federation / Super Partnership.

Please Note: no attendance / engagement with the above criteria will result in zero payment being made to the Federation / Super Partnership.

Walsall CCG Business Case v2.0 24_11_2016

The funding will also be used to secure meeting venues, engagement events and administrative support.

The GP Leadership Group will facilitate member practice engagement both clinical and non‐ clinical and collaboration with the larger health and social care teams to develop an integrated approach.

9. Financial Summary

Year 2017 Month Cost of FYE implementation April £12,850 May £12,850 June £12,850 July £13,667 August £13,667 September £13,667 October £13,667 November £13,667 December £13,667 January £13,667 February £13,667 March £13,667 Total £161550

Walsall CCG Business Case v2.0 24_11_2016

Business Case

Project Ref: Project Name: Walsall Alliance Super‐Partnership Version: Final Author: Waheed Saleem

Clinical Lead: Sohaib Siddiq

Year 1 net cost :  Project Management‐ £15,600

 Legal Costs: £38,000 (Incl VAT)

 Finance due diligence‐ £12,000 (incl VAT)

Approvals:

Authorising Chair / Name Title Signature Date Body Primary Care Committee Director Lead

Clinical Lead

Financial Lead

Walsall CCG Business Case v1.0 09/05/2017

1. Executive Summary

Walsall Alliance Federation is seeking support from the Primary Care Development Fund to form a super‐partnership from amoungst its 29 Walsall GP practices. The funding is one off to cover the initial costs for forming the super‐partnership, due to the number of practices forming the super partnership, the funding will accelerate the formation of the super partnership.

The development of primary care at scale fits national policy, GP Five Year Forward and the local direction of travel as set out in Walsall CCG ‘Primary Care Strategy’ and will produce benefits for the whole health economy.

2. Background

Walsall Alliance Federation was set up in November 2015 with 31 GP practices, covering a population of 130,000. Two practices have moved to other groups. Presently we have 29 practices covering a population of 126,000. Walsall Alliance Limited is a private company limited by shares with the GP partners as shareholders.

The Federation has developed and published a strategic plan and has been successful in developing projects and initiatives to support primary care. We have developed a very successful education programme, attracting clinicians from across the region; agreed a buying club and preferential rates with a locum agency for member practices; managing the CEPN for Walsall and Wolverhampton area, under contract with HEE; successful in bidding for medical education grants from pharmaceutical companies; developed a training hub for practice nurse training and development and co‐applicants in health research projects with Aston University.

Although we have been successful in several areas, members see the advantage of moving the Federation model to the next steps of forming a super‐partnership from amongst its member practices to support the continued development of primary care in Walsall.

3. Business Solution

Walsall Alliance Federation member practices consider the development of a super‐ partnership supports the future resilience of GP services in Walsall. The challenges and risks of continuing as smaller practices, with reductions in practice incomes, increased regulatory requirements, workforce challenges and modernisation of primary care necessitates a different model of primary care.

The benefits of forming a super partnership will ensure the long‐term sustainability of primary care in Walsall, improved quality of services and support the primary care

Walsall CCG Business Case v1.0 09/05/2017

workforce. The Partnership will support practices to reduce variability in service provision and improve patient and workforce satisfaction.

The development of the super partnership will be undertaken in a phased approach to ensure we are able to manage the complication of forming a partnership effectively. This is supported by the advice from our lawyers who have considerable experience in developing super partnerships in other areas.

In phase 1 we will merge 12 practices and will have subsequent phases for other members to join the super partnership.

At present, we have 12 formal Expressions of Interest from member practices to participate in Phase 1, with on‐going conversations with other member practices to join the partnership in phases 2 and 3.

The following workstreams will be developed:

 Legal due diligence

This will involve each practice providing responses to a standard (high level) due diligence questionnaire which will elicit details about the practices staff, liabilities, basic questions regarding property ownership, contractual commitments, working practices etc.

 Partnership agreement

A new partnership agreement will be put in place which will not only govern the relationship of the “first‐stage” merging practices but also will be in a form that all the other practices can sign up to when they merge.

 Staff‐ TUPE

As part of the process of merging, each practice’s staff will transfer to the newly formed partnership under the TUPE regulations. Consultations will be undertaken with the Staff and Unions.

 Property

Putting in place leases for premises that are currently owned by the GP’s, as the new partnership will not be buying the premises. Those practices that lease their building, the lease will be assigned to the new partnership with landlord’s consent.

 NHS Contracts

Walsall CCG Business Case v1.0 09/05/2017

The continuity of practice’s GMS contracts will be preserved by all the “first‐stage” merging practices becoming named as partners on each other’s contracts. CCG involvement and negotiations will be undertaken and agreement made.

 Financial and accounting due diligence

Financial due diligence on each of the practices will be undertaken by the accountants, as well as advising upon the accounts of the newly merged partnership.

The funding requirement is broken down as follows:

 Project Management@ £400 per day working for 39 days over 6 months = £15,600  Legal Costs‐ £38,000 (including VAT)  Accountant Costs‐ £12,000 (including VAT)  Total Funding Requirement‐ £65,600

4. Expected Benefits

The expected benefits will be:

 Economies of scale: Reduction in the operating and management costs for practices resulting in developing resilience for primary care, through merger of back office functions, more efficient procurement, reduction in duplication, leaner management processes, reducing demand and workload pressures on GP’s.  Quality: Improved quality resulting in increase in patient satisfaction; effective patient involvement through better patient engagement process; achieving and maintaining Good CQC rating; increase in QoF points; reduction of variability amongst practices on both primary care and commissioning indicators, through sharing good practices, providing support to challenged practices, undertaking quality reviews and mock inspections.  Service Development: Improved access, meeting the national requirements for GP Access and the local priorities of demand management and medicine optimisation to reduce pharmaceutical expenditure; development of new primary and community care services; improving service delivery in all practices; working with third sector to develop patient pathways; development of technology to improve patient experience e.g. telephone and e‐consultation.  Workforce: Improved recruitment and retention of GP’s; development of new clinical roles to support primary care e.g. clinical pharmacists, nurse prescribers, new clinical and nurse staff roles, ensuring patients see the right clinician in a timely manner; increase in satisfaction of primary care workforce; enhanced training and development opportunities; succession planning. This is in line with the HEE report ‘The future of primary care‐ Creating teams for tomorrow’ July 2015

Walsall CCG Business Case v1.0 09/05/2017

 System Leadership: Ability to lead, develop and implement New Models of Care in Walsall, working in partnership with the Provider Board and the Primary Care Leadership Group.

5. Expected Dis‐benefits

There are no disbenefits identified to this arrangement. Primary Care is facing considerable challenges and the formation of a super partnership will provide the resilience and support required to improve the delivery of primary care and provide the system leadership in the development of the New Models of Care.

6. Timescales

Practice engagement‐ May 2017 Lawyers and Accountants engaged to undertake work‐ June 2017 Consultation with staff‐ May‐September 2017 Draft Partnership Agreement completed‐ July 2017 Legal and financial Due Diligence completed‐ May‐Sept 2017 Partnership Agreement signed‐ September 2017 CCG informed and GMS contracts amended‐ October 2017 Phase 1 partnership launched – November 2017 Phase 2 practices join partnership‐ January 2018 Phase 3 practices join partnership‐ March 2018

7. Major Risks

The risks are as follows:  Practices don’t sign up to the Partnership Agreement  CCG don’t agree to the GMS contract amendments  Legal challenges  TUPE issues resulting in delays in staff transfer  Benefits don’t materialise

8. Procurement

The project management, legal and financial support will be provided through our existing contracts.

Project Management will be provided by Waheed Saleem, Managing Director Legal support: Slater Heelis LLP Accountants: Ballard Dale Syree Watson

Walsall CCG Business Case v1.0 09/05/2017

Slater Heelis LLP and Ballard have extensive experience of forming super partnerships across the country and experience of representing practices from other areas entering super partnerships. They also provide legal and accountancy support for the Federation and therefore in a good position to ensure the work is completed quickly.

9. Financial Summary

Year 2017/18 Month Cost of implementation FYE April May June £2,600‐ Project Management £9,500‐ Legal fee £4,000 Accountancy fee July £2,600‐ Project management August £2,600 Project management £9,500 Legal fee September £4,000 – Accountancy fee £9,500‐ Legal fee £2,600‐ Project management October £2,600 Project management November £2,600 Project management £9,500‐ Legal fee £4,000‐ Accountancy fee December January February March Total £65,600

Walsall CCG Business Case v1.0 09/05/2017

In Confidence Not for Publication or Dissemination Primary Care Commissioning Committee Date of committee meeting: Agenda Item No:

TITLE OF REPORT Medicines Management Pharmacist Allocation Update

PURPOSE OF REPORT: To update the Primary Care Commissioning Committee of 1. Medicines Optimisation Business Case P00030

KEY POINTS: Key points in this business case; The business case will comprise of a number work streams;  Repeat Prescribing Service  Cost improvement programme  Pain prescribing

QIPP net saving identified in the business case is £1,418,000. The business case has been approved for submission to Primary Care Commissioning Committee via the QIPP Review Board on 10th May 2017. RECOMMENDATION TO The primary care commissioning Committee are asked to; THE COMMITTEE:  Note the contents of the Business Case  Approve the Business Case COMMITTEE ACTION Decision REQUIRED: REPORT WRITTEN BY: Sumaira Tabassum, Head of Medicines Management REPORT PRESENTED BY: Sumaira Tabassum, Head of Medicines Management REPORT SIGNED OFF BY: Donna Macarthur, Director of Primary Care and Integration CONSENT AGENDA No PREVIOUS COMMITTEES TIME REQUIRED 15 minutes

The CCG Corporate Objectives.

Please indicate which Corporate Objectives this report supports Involve patients and public in decision making

Ensure value for money 

Commission high quality services 

Promote good health and sound treatment of ill health

Ensure strong leadership and good governance 

Work in partnership

Business Case

Project Ref: P00030 Project Name: Medicines Optimisation Version: Draft v0.7 Author: Rupesh Thakkar Commissioning Manager: Sumaira Tabassum Clinical Lead: Dr Sushma Manthri Director Lead: Donna Macarthur Year 1 net cost / (saving): £0 / £1,418,000 *P00034-savings will be amalgamated with P00030 and reported to PMO Overall project net cost / (saving): £0 / £1,418,000 *P00034-savings will be amalgamated with P00030 and reported to PMO

Equality Impact Assessment (EQIA) If EQIA is not applicable then please state why: Completed: Pre Screen: ☐ Full: ☒ N/A: ☐ Note: a Pre-Screen EQIA should be completed as a minimum unless a justified reason can be given for non- completion.

Is this a QIPP initiative? Yes ☒ No ☐

Approvals: Authorising Chair / Name Title Signature Date Body Primary care Mike Abel Lay Member – Commissioning Commissioning Committee & Transformation Director Lead Donna Director of Macarthur Primary Care & Integration Clinical Lead Dr S Manthri Clinical Advisor Medicines Management Financial Lead Michelle Deputy CFO Gordon Governance / Sara Saville Head of CG Quality Lead Business Andy Field Performance Information Manager Lead 1

Walsall CCG Business Case v2.0 24_11_2016

Amendment History

Modified By Date Modified Version Summary of Changes Made Rupesh Thakkar 10.04.17 0.1 Draft format Hema Patel 25.04.17 0.2 Amendments following review Rupesh Thakkar 25.04.17 0.3 Amendments following review Sumaira Tabassum 07.05.17 0.4 Amendments following review Joanne Loague 08.05.17 0.5 Amendments following review Hema Patel 09.05.17 0.6 Amendments following review Michelle Gordon 10.05.17 0.7 Final

Document Identification The latest version of this document can be found in the following location:

Document References Title Document Description Document Location

Distribution List Name Title Date of Issue Dr Sushma Manthri GP Clinical Lead Donna Macarthur Director Lead Lee Dukes PMO lead QIPP review Board

Walsall CCG Business Case v2.0 24_11_2016

1. Executive Summary

Walsall CCG is keen to ensure that only treatments that are clinically effective and provide a clear health benefit to patients are prescribed on NHS prescriptions. This is to ensure that CCG resources provide interventions with a proven health gain for the population. Therefore Walsall CCG recommends that clinicians prioritise resources based on evidence of the clinical effectiveness and safety of treatments, their cost effectiveness, and on which interventions provide the best health outcomes.

The work will comprise of a number of workstreams:

 Repeat Prescription Service(RPS) This involves the provision of pharmaceutical support at GP Practice level for the review of repeat prescriptions for patients, in doing so, patients’ medication will be optimised so they take the most effective dose with the least amount of harm and there will be better patient monitoring and reduced clinical risk. Patients will be switched to the most cost effective formulary choice of medication or even stopped if it warranted according to the NICE evidence and/or clinical guidance. This will also support a reduction in medicines waste by not issuing prescriptions for items the patient does not require.

 Cost Improvement Programme This is a list of drugs which are prescribed across the NHS that are considered low priority and poor value for money. It also incorporates drugs which can be provided as self-care, with advice and support from the community pharmacist. This will also have a positive impact on GP capacity and access.

 Pain Prescribing To develop pathways for management of pain to: o Reduce inappropriate prescribing spend on analgesics o Optimise pain management o Protect patients from harm from analgesics o Reduce inappropriate specialist’s referrals/admission

2. Reason

The reason for implementing this change is to ensure the CCG prescribing budget is utilised on evidence based medicines and interventions and patients are prescribed according to clinical need and that patients are not prescribed medicines which have a poor evidence base.

Walsall CCG Business Case v2.0 24_11_2016

The financial outturn for the prescribing budget within 2016/17 had an overspend of £297,000. Medicines Management activities implementing cost effective prescribing in the CCG produced an overall cost reduction of £2.2M.

The overspend will have been influenced by a number of factors over which we have no control, e.g. under achievement on 2016/17 MOLCV scheme, drug pricing structure, NICE guidance, winter conditions, Flu epidemic, and any new evidence base.

3. Business Solution

The project will comprise of the following three work-streams:

3.1 Repeat Prescription Service (RPS) Practice based Pharmacists will continue to be located in all general practices across Walsall.

The pharmacist will elicit any relevant information from the patient and the GP clinical system for the purposes of assessing the appropriateness of a repeat prescription request to ensure:

 Items are prescribed only for clinical need, the pharmacists will identify any changes and recommendations will be made to the GP. In the case of prescribing pharmacists, this change can be made independently.  Dosages of items prescribed will be optimised and quantities will be synchronised during the reviews.  Reduce waste by not issuing prescriptions for items the patient has not used or requested for several months or for inappropriate requests from third parties such as appliance contractors or nutritional supplement providers.  Improved patient safety by eliminating access to expired items so patients can’t accidentally take medicines they don’t need.  Delivery of efficiency savings through modifying/changing to the most cost effective formulary choice of medication or even stopped if warranted according to the NICE evidence and/or clinical guidance.  Only items listed on the joint Walsall CCG formulary are prescribed. This will be done by accessing the current formulary and selecting the formulary choice products.  Delivery of improved patient-related outcomes - this service is reviewing the practice based safety searches i.e. PINCER.

Patients will be advised to attend their GP surgery if deemed appropriate, e.g. for annual review, blood monitoring or if GP review/input is required

If the repeat prescription request is refused, the pharmacist will inform the patient on the reasons for the refusal. 4

Walsall CCG Business Case v2.0 24_11_2016

All interventions and changes that are identified and actioned will be documented on the repeat prescribing data entry form (see appendix-1). This will include any efficiency savings made as currently completed by every pharmacist working at any practice at the end of each month. This information is then sent on a monthly basis to Keele University to be evaluated. The evaluations received from Keele are monitored by the medicines management team. Keele savings are based on savings made (annualised) minus investment made. The annualised saving are then adjusted to reflect savings attributable to the relevant financial year.

3.2 Cost Improvement Programme In the case of treatments which can be prescribed on NHS prescriptions, the CCG is reviewing treatments that provide limited health benefit. They will be considered a LOW PRIORITY and not suitable for prescribing unless patients fall into an exception category.

Some medicines that are used to treat minor ailments do not require the patient to be seen by a GP or Nurse employed within General Practice. Such products are termed self-care and products can be purchased from pharmacies and supermarkets. Pharmacists and other trained staff members are experts on providing advice around minor ailments; they are easy to access without an appointment and most local pharmacies provide the Minor Ailments Scheme (MAS), known locally as the Pharmacy First Scheme.

Some other products are clinically ineffective or not cost effective. These treatments will not have undergone rigorous clinical trials to demonstrate that they are effective. It is inappropriate to direct NHS resources towards products that do not have proven efficacy or safety, i.e. unlicensed medicines.

The drugs that are termed medicines of limited clinical value or self-care are listed below and have been split into high, medium and low priority based on cost savings associated with them based on January Epact figures.

High Priority Formulary Medium Priority Formulary Low Priority Formulary status status status requiring requiring requiring review review review Liothyronine Yes Doxazosin Yes Capsaicin cream No Modified-Release (Rubefacients) (MR)

Fentanyl Yes Omega 3 No Travel vaccine not No immediate prescribable on the release NHS Co-proxamol No Eflornithine Yes Dosulepin No cream (Vaniqua®) for hirsutism 5

Walsall CCG Business Case v2.0 24_11_2016

Gluten free Yes Lidocaine plasters Yes Glucosamine/ No Glucosamine & Chondroitin Oral Nutritional Yes Oxycodone/Nalox No Complementary No supplement one (Targinact®) Therapies Vitamin B12 Yes Paracetamol/Tra No Probiotics No madol (Tramacet®) Dental products No Aliskiren (Rasilez®) No and fluoride supplements Cough and cold Yes Lutein and antioxidant No remedies vitamins for age- related macular degeneration Cannabis Sativa No Flexitol No Fusidic Acid eye No drops Orlistat No Vitamin B Yes Compound Vitamin C Yes Glyccopronium No Bromide *cost excludes prescribing for children, cancer and end of life patients

Success would be seen through reduction in the expenditure and/ or volume of prescriptions.

The work streams above will require the following actions to be completed:

 Formulary review – to include only those drugs that are deemed the most cost effective and produce the best quality outcomes. (table above indicates which items requires formulary review) https://www.walsallhealthcare.nhs.uk/formulary.aspx  Produce short prescribing guidelines for each drug on the list. Guidelines will direct pharmacists and GPs to the most cost effective choice. Including preparing patient information and letters, to support any changes that may be required. This will improve adherence to any potential changes because by understanding the reasons behind the change will provide context to the patients. See https://www.prescqipp.info/droplist  Align the practice pharmacist work plans to focus on specific medicines in a phased approach in order to ultimately cover all medicines on the list. By systematically

Walsall CCG Business Case v2.0 24_11_2016

introducing these drugs into the pharmacist work plans will ensure all the items have been reviewed. o See appendix-2: Pharmacist Work Plan  The Optimise Rx messages which appear on the GP screens will be updated for all drugs. This tool will ensure that cost effective choices are offered to the GP practices.

The outcomes will be verified by:-

 Using the outputs from the Optimise Rx system which has the facility to evidence acceptance by prescribes at practice level of the suggested drug switches.  Using validated Epact data to calculate the reduction in activity/volume since the introduction of the Cost Improvement Programme (previously referred to MOLCV) in drugs introduced to the scheme to date.  Calculating the impact of the review of the repeat prescribing component to date provided by Keele University.

Each of the schemes above provide significant further opportunities for savings which will commenced in 2017/18 and continue into 2018/19 and beyond.

3.3 Pain Prescribing

To reduce spend on chronic pain medication by £34,000.

To develop pathways for management of pain which will:  Reduce inappropriate prescribing spend on analgesics  Optimise pain management  Protect patients from harm from analgesics  Reduce inappropriate specialist’s referrals/admissions

Develop step down protocols and pathways for referring patients who are addicted to pain medication, over the next 24 months.

To educate a minimum of one primary care clinician per practice to empower those to manage patients with pain safely and appropriately within September 2017. This will be through GP and practice staff education IMPACT sessions for Pain Management and Joint Trust and CCG education sessions (MSK Commissioning manager and Clinical Lead).

To make a reduction in spend (will be minimal for the first year as this will be used for the engagement with the pain team), implementation of the education and audits. The subsequent years will see change in prescribing behaviour as a result of reviewing the pathway, the education sessions and reviewing the audits.

Walsall CCG Business Case v2.0 24_11_2016

Although the CCG may have invested in consultant time, this would increase activity for the clinic. This increase in clinic activity will further enhance quality and cost effectiveness in prescribing chronic pain medications. This investment in particular is not for this project.

This project will also deliver the NHS outcomes framework i.e. 1. Prevent people from dying prematurely by ensuring appropriate analgesics prescribed e.g. stopping Diclofenac, an NSAID, in patients with cardiovascular disease, as it is associated with worsened cardiovascular outcomes 2. Enhancing quality of life for people with long-term conditions e.g. by reviewing and optimising medication for pain management for chronic pain and also addressing the cause of the pain 3. Helping people to recover from episodes of ill health or following injury e.g. stopping NSAIDs in patients with gastrointestinal bleeds or renal failure. 4. Ensuring that people have a positive experience of care by involving patients in prescribing decisions, providing information on drugs and ensuring a holistic approach to their care 5. Treating and caring for people in a safe environment and protecting them from avoidable harm e.g. by ensuring a proton pump inhibitor is prescribed for an elderly patient to prevent gastrointestinal bleeds.

These objectives are also to improve concerns raised within the Midlands Quality Review Service (WMQRS) Quality Standards for the review of the Care of People with Chronic Pain. (See appendix-3)

4. Expected Benefits

 Prescribing behaviour change.  Educational resources including interactive guidance will be developed and distributed to GP practices and Practice Pharmacists.  Patients will only receive medicines which are evidenced based  Patient communication and education and managing patient expectation.  Patients empowered to self-care  Joint working with secondary care  QIPP savings.

Benefits would be seen through -a reduction in the expenditure / volume of prescriptions, this will be measured using EPACT data which will compare future volumes and prices against the 16/17 baseline outturn (realised from June 2017) -Keele evaluation data (realised from May 2017) -outputs from Optimise Rx (realised from April 2017)

Walsall CCG Business Case v2.0 24_11_2016

5. Expected Dis-Benefits

 Barriers to change may include GP reluctance, patient resistance (which may lead to increased patient complaints), patient questions, queries and possibly follow-ups.

 An increased reduction is difficult to implement given that secondary prescribing choices impact heavily on GP prescribing in primary care. The list of CIP drugs contains many items which are specialist initiated and continue to be prescribed within GP practices notably in the pain and palliative care specialties.

 Impact on Practice Pharmacist time and workload

 GP time to implement changes

 Potential increased demand on Pharmacy First (local commissioned service (linked to point 7. Major Risks)

6. Timescales

This project started at the end of October 2016. It will be on-going as the drugs that are in the work-plan will be added in by April 2017.

Delivery against milestones will be determined as both volume change compared to 16/17 baseline and also in a cost reduction (based upon current prices) against the baseline for the same period. Success can be measured using outputs from EPACT, Keele data, Optimise Rx, and an overall comparison to the financial performance of the prescribing budget. The budget has been set using the assumption that the QIPP target will be achieved and any overspend will indicate QIPP under achievement.

7. Major Risks - The scheme may not get approved at Primary Care Commissioning Committee

- Increased Pharmacy First activity and costs Patients use the Pharmacy First Scheme to obtain self-care items, which is still a cost burden to the NHS. This service is currently commissioned by Walsall CCG for over 16 years of age, (under 16s may access the service commissioned by NHS E, the costs of which are not recharged to the CCG).

April 2017 activity shows 318 patients accessed the scheme Cost of consultations: £1102.50 Cost of Medication: £1021.93(ex VAT)

Walsall CCG Business Case v2.0 24_11_2016

Activity that would require treatment with paracetamol; ibuprofen and cough and cold remedies i.e. MOLCV can be seen below:

Number of patients Cost of consultations Cost of medication Acute Cough 83 patients £290.50 £83.71 Acute Fever 66 patients £231.00 £113.17 Acute Headache 65 patients £227.50 £114.10 Cold and Flu 18 patients £63.00 £28.66 Earache 0 patients 0 0 Totals 262 £917.00 £339.64

Monthly Total for MOLCV= £1256.64 (ex VAT). This risk can be mitigated by educating patients to self-care and purchasing medication rather than accessing the service.

- Potential increase in patient complaints - Initiative blamed as cause of public error in self-medication resulting in harm to a patient - Perceived ‘Rationing’ of services/drugs - Lack of adherence by GP practices - Patient language difficulties resulting in GP not being able to fully explain the guidelines - Potential conflict(s) of interest - drug shortages - sudden pricing changes (e.g. category M) - increase in winter pressure demands - new NICE guidance - new licensing or MHRA guidance

8. Procurement  Existing arrangements of service level agreements with individual pharmacists would be required. Current service level agreements would continue in line with the medicines management pharmacist allocation decision which has been recently agreed by Walsall CCG Governing Body and Finance (September 2016).

 Optimise Rx £90k Per Annum

 Keele University to be commissioned to evaluate the RPS activity

These costs are recurring therefore not included in implementation costs.

9. Financial Summary

Walsall CCG Business Case v2.0 24_11_2016

Year 2017/18 Month Cost of Expected Net Savings implementation Savings April £0 £118,166.66 £118,166.66 May £0 £118,166.66 £118,166.66 June £0 £118,166.66 £118,166.66 July £0 £118,166.66 £118,166.66 August £0 £118,166.66 £118,166.66 September £0 £118,166.66 £118,166.66 October £0 £118,166.66 £118,166.66 November £0 £118,166.66 £118,166.66 December £0 £118,166.66 £118,166.66 January £0 £118,166.66 £118,166.66 February £0 £118,166.66 £118,166.66 March £0 £118,166.66 £118,166.66 Total £0 £1,418,000 £1,418,000

The RPS and CIP elements of this business case were commenced during 2016/17. The cost efficiencies have been validated by finance and represent the level of savings commenced part way through 2016/17 which will be realised in 2017/18 based upon the annualised level of savings of either: switching to more cost effective alternative medicines or the phased introduction of the CIP element or not issuing prescriptions not required. These CIP elements have the potential to expand further throughout the year which would add further to QIPP delivery (verified with finance team as and went realised).

CIP - to date there has been some progress made through promoting the self-care agenda to the public via Twitter; CCG staff; LPC and LMC. This work plan is to further support this and to enhance the development of the self-care agenda. Since the self-care launch, interactive guidelines on the following items cough and cold remedies; doxazosin MR prepartaions; eflornithine cream; Flexitol; gluten free products; lidocaine plasters; liothyronine; Omega 3 and vitamin D have been produced to support GPs and practice pharmacists in reviewing patients’ medication and to stop/switch prescribing where deemed appropriate. Messages for these products are also incorporated into Optimise Rx to ensure prescribers are offered alternative medication/actions.

Financial monitoring will be carried out by the finance team on a monthly basis and discussed within our monthly meetings.

Walsall CCG Business Case v2.0 24_11_2016

10. Appendix

Appenixdix-1: Repeat prescribing data entry form

Repeat Prescribing Data Entry Form v3 sept 16 onwards.xls

Appenixdix-2: Pharmacist work plan

Pharamcist Work Plan 2017-18.doc

Appenixdix-3: WMQRS of Care of people with chronic pain

Walsall-Chronic-Pain- report-V1-20150923_1449147278.pdf

Appenixdix-4: QEIA

QEIA Tool v1 Medicines Optimisation.xlsm

Walsall CCG Business Case v2.0 24_11_2016

PRIMARY CARE COMMISSIONING COMMITTEE RISK REGISTER Date Date risk Risk Description Inherent Detailed Action Timeline Residual Risk Treat Risk Risk reviewed Context, Cause, Policy & Risk Risk Owner* Tolerate rating Identified Consequence LXC LXC Transfer direction Terminate of travel   PCCC 01 Primary Care Operational Group has been Failure to develop Primary established with a focus on Quality and care Improvement systems Performance. and implement effective Contract monitoring process being contract management to developed based on best practice from Monthly Sept 16 Dec 16 address unwarranted or 4x4 =16 across the region. 3x4=12 DM Treat review  avoidable variations in To be ratified at the next Primary Care primary care may result in Commissioning Committee. further negative quality Action plan and or financial impact on the health system. PCCC 02 Memorandum of Understanding with Limited capacity within NHS England (NHS E) with regards WCCG Primary Care Team accessing support from the established to undertake contract NHS E HUB. monitoring and to support In‐house support from other CCG areas current and future has been specified including Quality, Monthly Oct 16 Dec 16 procurements may impact 4x4 =16 Contracting and Finance. 4x4=16 DM Treat review  on CCG to carry out its Procurement timeline being developed to duties in relation to ensure allocation of required resources. primary care services. Update Jan 17: Changes in commissioning Decision to increase residual risk structure to support following imminent departure of a staff Primary Care member supporting Primary Care from

PCCC 03 Joint LMC and CCG workforce fayre was Resilience of the General undertaken. Practitioner workforce will Establish links with local CEPN. result in pressures on Primary Care Operational Group has a current workforce and remit to review workforce issues. have a potential negative Practice Nurse strategy under Monthly May 16 Dec 16 impact on patient care in 4x4 =16 development. 3x4=12 DM Treat review  primary care. Pharmacy support for General Practice reviewed to ensure all practices have equal support. Re‐establish Workforce Group Interviews next week Lisa Clarke now appointed PCCC 04 Primary Care Strategy under Sustainability of single‐ development. handed practices may Primary Care Operational Group has been Monthly May 16 Dec 16 3x4 =12 3x4 =12 DM Treat result in sudden closure of established with a focus on Quality and review  practices placing further Performance. pressures on the system. Links with CQC have been established.

PRIMARY CARE COMMISSIONING COMMITTEE RISK REGISTER Date Date risk Risk Description Inherent Detailed Action Timeline Residual Risk Treat Risk Risk reviewed Context, Cause, Policy & Risk Risk Owner* Tolerate rating Identified Consequence LXC LXC Transfer direction Terminate of travel   PCCC 07 Medicine Management – QIPP workshop. QIPP failure to deliver, Joint PCOG and PCCC development Monthly Feb 17 4x5 =20 DM required savings required 5x5 =25 session to focus on QIPP and Finance for review  in 2017/18 17/18 & LCS’s PCCC 08 Letter sent to NHSE outlining risk to ETTF – delay of premises timeline of delivery of Town Centre Monthly Feb 17 directions, lack of clarity in 4x4 = 16 development. 4x4 =16 TG review  whether funding can be Review of building programme, GPs identified for new builds leading project PCCC 09 DJ to gain an understanding of the A Walsall Practice exploring practices concerns and to help clarify a branch closure if they are financial position Monthly March 17 unable to resolve funding 4x4=16 2x3=6 DM Review  issues with NHS Property ( 28th April – practice confirmed they services. have put on hold any potential closure)

PCCC 10 Identify commissioning lead March 17 Failure to deliver the APMS Establish APMS steering group re‐procurement on time Secure support from CSU / NHS England due to CCG capacity constraints and the 5X4 =20 4x4 DM  challenging timescale

Committee Risk Registers The committee risk register is a management communication tool.

The inherent risk is the risk rating arising from a specific risk before any action has been taken to manage it taking into account any controls i.e. policies or training that is already in place. The residual risk is the risk rating for the risk after the actions have been implemented and are effective.

Treat – residual risk requires further management. This is usually, but not exclusively, for risks that have a rating > 6

Tolerate – the residual risk requires no further management and may be closed or monitored. Any tolerated risks > 6 should be included in the committee assurance report to the Governing Body and kept on the register for monitoring

Transfer – the risk management is transferred to another party (external) either through insurance or transferring the risk to a third party. This does not relate to risks that are internally transferred to another committee

Terminate – the risk no longer exists when the organisation stops the activity that created the risk. These risks can be closed on the register.

Matrix Consequence Likelihood 1 2 3 4 5 Insignificant Minor Moderate Major Catastrophic 1 Rare < 2.5% 1 2 3 4 5 2 Unlikely 2.5 - < 10% 2 4 6 8 10 3 Possible 10 – 49% 3 6 9 12 15 4 Likely 50 – 80% 4 8 12 16 20 5 Almost certain >80% 5 10 15 20 25