Barking and Dagenham, Havering and Redbridge Clinical Commissioning Groups Governing Bodies Meeting in Common

24 September 2020

3.00pm to 5:45pm

Via Microsoft Teams

MS Teams etiquette: could people keep their cameras off and sound on mute when they are not speaking. The Chair will keep his camera and sound on all the time along with the person presenting or commenting. People can indicate to the Chair when they would like to speak via the chat screen and the chair will invite them into the conversation.

Item Time Lead Attached, Director verbal or to follow 1.0 Welcome, introductions and apologies 3.00 Chair 1.1 Declaration of conflicts of interest Attached 1.2 Minutes of the Joint Committee of BHR CCGs meeting held on 30 July 2020 Attached 1.3 Matters/actions arising Attached

2.0 Chair and chief officer reports 2.1 Chairs’ report 3.35 Chairs Attached 2.2 Accountable officer’s report 3.40 JM Attached 2.3 Patient engagement report 3.45 RC Attached

3.0 Assurance 3.1 Governing Bodies assurance framework update 3.50 MP Attached 3.2 Quality report 4.00 SH Attached 3.3 Adult safeguarding annual report 2019-20 4.10 MGC Attached 3.4 Safeguarding children annual report 2019-20 4.15 MGC Attached 3.5 Looked after children (LAC) annual report 2019-20 4.20 MGC Attached

4.0 Corporate strategy and planning 4.1 Proposal to create a single CCG for north east London 4.25 JM Attached 4.2 BHR Integrated Care Partnership development 4.35 CJ Attached 4.3 Winter plan – 2020/21 4.45 SR Attached

5.0 Finance and performance 5.1 Finance risk overview report 4.55 HB Attached 5.2 Integrated performance report 5.05 SR Attached

6.0 Development/governance 6.1 Variation to BHR Infertility Policy on IVF 5.15 TW Attached 6.2 Use of the clinical commissioning groups’ seals 5.20 MP Attached 6.3 Finance committee chair’s report 5.25 KP Attached

1 Item Time Lead Attached, Director verbal or to follow

6.4 Minutes of committees and relevant fora: 5.30 Attached • NEL CCGs Governing Body meeting in common • Patient engagement forum • Quality & performance committee

7.0 AOB 5.30 8.0 Questions from the public 5.35 Date of next meeting – 26 November 2020 5.45

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Glossary of terms and abbreviations

Term Explanation

A&E Accident and Emergency

AF Atrial Fibrillation

AO Accountable Officer

ADL Activities of Daily Living

APC Area Prescribing Committee

APMS Alternative Provider Medical Services

AQP Any qualified provider

BCF Better Care Fund

BCP Business Continuity Plan

BHR Barking and Dagenham, Havering and Redbridge

BHRUT Barking, Havering and Redbridge University Hospitals NHS Trust

BMA British Medical Association

CAMHS Children and Young People Mental Health Services

CCG Clinical Commissioning Group

CCS Complex Care Service

CCU Critical Care Unit

CD Clinical Director

CDOP Child Death Overview Panel

CEG Clinical Effectiveness Group

CEO Chief Executive Officer

CEPN Community Education Provider Network

CFO Chief Finance Officer

CHC Continuing Healthcare

CHS Community Health Services

CHSCS Community Health and Social Care Services

CIL Community Infrastructure Levies

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CIP Cost Improvement Plan

CQC Care Quality Commission

CQRM Clinical Quality Review Meeting

CQUIN Commissioning for Quality and Innovation

CSU Commissioning Support Unit

CTT Community Treatment Team

CVS Council of Voluntary Services

CYPP Children and Young Person Plan

DES Direct Enhanced Service

DoH Department of Health

DSPG Data Security & Protection Group

DToC Delayed Transfer of Care

ECG Electrocardiogram

ED Emergency Department

ELHCP East London Health and Care Partnership

EMT Executive Management Team

EOL/ EOLC End of Life/ End of Life Care

EPR Electronic Patient Record

FOI Freedom of Information

FRPB Financial Recovery Programme Board

FRPDM Financial Recovery, Planning, Delivery and Monitoring

FYE Full Year Effect

GLA Greater London Authority

GMC General Medical Council

GMS General Medical Services

HCAIs Healthcare Associated Infections

HEE Health Education England

HLP Healthy London Partnership

HSC Health Scrutiny Committee

HWBB Health & Wellbeing Board

IAPT Improving Access to Psychological Therapies

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ICPB Integrated Care Partnership Board

ICS Integrated Care System

ICM Integrated Case Management

ICSG Integrated Care Joint Health and Social Care Steering Group

IG Information Governance

IFR Individual Funding Request

IRS Intensive Rehabilitation Service

IST Intensive Support Team

ITU Intensive Therapy Unit

JAD Joint Assessment and Discharge Service

JCAF Joint Committee Assurance Framework

JCC Joint Commissioning Committee

JHWS Joint Health & Wellbeing Strategy

JSNA Joint Strategic Needs Assessment

KGH King George Hospital

KPIs Key Performance Indicators

LAC Looked After Children

LAS London Ambulance Service

LAs Local Authorities

LCFS Local Counter Fraud Specialist

LD Learning Disability

LES Local Enhanced Service

LETB Local Education and Training Boards

LMC Local Medical Committee

LPC Local Pharmaceutical Committee

LSCB Local Safeguarding Children’s Board

LTC Long Term Conditions

MASH Multiagency Safeguarding Assessment Hub

MD Managing Director

MLU Mid-wife Led Unit

MOU Memorandum of Understanding

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MPIG Minimum Practice Income Guarantee

MSK Musculoskeletal

MSRB Maternity Systems Readiness Board

NEL North East London

NELCA North East London Commissioning Alliance

NELCSU North East London Commissioning Support Unit

NELFT North East London Foundation Trust

NHSE NHS England

NHSI NHS Improvement

NICE National Institute for Health and Care Excellence

OD Organisation Development

ONEL Outer North East London

OOH Out of hours

OPD Outpatient department

PALS Patient Advice and Liaison Service

PCCC Primary Care Commissioning Committee

PEF Patient Engagement Forum

PELC Partnership of East London Cooperatives

PHE Public Health England

PMCF Prime Minister’s Challenge Fund

PMO Project Management Office

PMS Personal Medical Services

POD Point of Delivery

POLCE Procedures of Limited Clinical Effectiveness

PPGs Patient Participation Groups

PPI Patient and Public Involvement

PSED Public Sector Equality Duty

PTL Patient Tracking List

QIPP Quality, Innovation, Productivity and Prevention

QOF Quality Outcome Framework

RAG Red, Amber, Green

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RTT Referral To Treatment

SAB Safeguarding Adults Board

SCB Safeguarding Children’s Board

SCN Strategic Clinical Network

SDPB System Delivery Programme Board

SEND Special Educational Needs and Disability

SLAM Service Level Agreement Monitoring

SPA Single Point of Access

SRO Senior Responsible Officer

STP Sustainability and Transformation Plan

TDA Trust Development Agency

ToR Terms of Reference

UCC Urgent Care Centre

UCL University College London

UCLP University College London Partners

UEC Urgent and Emergency Care

UTC Urgent Treatment Centre

VFM Value for Money

WELC Waltham Forest, East London and City

WICs Walk in Centres

WTE Whole Time Equivalent

YTD Year to Date

7 Joint Committee of Barking and Dagenham, Havering and Redbridge (BHR) CCGs Conflicts of Interest Register, which includes BHR CCGs Governing Body members and other decision makers Date - 06 August 2020 Conflics of interest will remain on the register for a minimum of 6 months following expiry Date of Interest Type of Interest Current position Declared Interest- Is the (s) held- i.e. (Name of the interest First Name Surname Governing Body, Nature of Interest Action taken to mitigate risk organisation and direct or From To Member practice, nature of business) indirect? Employee or other Interests Interests Interests Personal Personal Financial Professional Professional Non-Financial Non-Financial Barking & Dagenham CCG Jagan John Governing Body Aurora Medcare X Direct GP partner Jan 2020 current No immediate action required. Member - CCG (Previously known as (Jun 2010 for Declarations made at the Chair King Edwards Medical King beginning of meetings. Will not Group and Polaris Edwards) be involved in any decision Medicare) making regarding the conflict. Aurora Medcare X Indirect Other GPs are family members Jan 2020 current No immediate action required. (Previously known as (Jun 2010 for Declarations made at the King Edwards Medical King beginning of meetings. Will not Group and Polaris Edwards) be involved in any decision Medicare) making regarding the conflict. Personalised Care, X Direct Clinical Lead Mar-17 current No immediate action required. Healthy London Declarations made at the Partnerships, NHS beginning of meetings. Will not England be involved in any decision making regarding the conflict. North East London X Direct GPwSI - Cardiology service, Aug-11 current No immediate action required. Foundation trust Barking & Dagenham Declarations made at the Community Cardiology Service beginning of meetings. Will not be involved in any decision making regarding the conflict. Together First X Direct Shareholder May-14 current No immediate action required. (Barking & Dagenham Declarations made at the GP Federation) beginning of meetings. Will not be involved in any decision making regarding the conflict. Harley Fitzrovia X Direct Director and Shareholder Jan-18 current No immediate action required. Health Ltd Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Monifieth Limited X Direct Director and Shareholder Mar-18 current No immediate action required. (Property and private Declarations made at the healthcare) beginning of meetings. Will not be involved in any decision making regarding the conflict. Barking & Dagenham X Direct Deputy Chair of the Board 2018 current No immediate action required. Health and Wellbeing Declarations made at the Board beginning of meetings. Will not be involved in any decision making regarding the conflict. Anglia Ruskin X Direct Lecturer 2019 current No immediate action required. University Medical Declarations made at the School beginning of meetings. Will not be involved in any decision making regarding the conflict. Barking & Dagenham X Indirect Dr Gurkirit Kalkat, Clinical Apr-19 current No immediate action required. CCG Director, is also a GP partner in Declarations made at the Aurora Medcare beginning of meetings. Will not be involved in any decision making regarding the conflict. Historic - Health 1000 X Direct Director. PMCF lead Dec-14 Nov-18 Historic

Gurkirit Kalkat Governing Body Aurora Medcare X Direct GP principal Jan-20 current No immediate action required. Member - Clinical (previously known as Declarations made at the Director Thames View Health beginning of meetings. Will not Centre) be involved in any decision making regarding the conflict. Primary Clinical X Direct Director/Shareholder Apr-17 current No immediate action required. Partnership Ltd Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Apex Healthcare Ltd X Direct Director/Shareholder Apr-17 current No immediate action required. (who own Declarations made at the Knightswood beginning of meetings. Will not Residential Care be involved in any decision Home for the Elderly making regarding the conflict. Ltd) Queen Mary Medical X Direct Honorary Lecturer Apr-17 current No immediate action required. School-London Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Together First X Direct Shareholder May-14 current No immediate action required. (Barking & Dagenham Declarations made at the GP Federation) beginning of meetings. Will not be involved in any decision making regarding the conflict. BHR CCGs Area X Direct Chair Mar-15 current No immediate action required. Prescribing Declarations made at the Committee beginning of meetings. Will not be involved in any decision making regarding the conflict. Harley Fitzrovia X Direct Director and Shareholder Jan-20 current No immediate action required. Health Ltd Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Barking & Dagenham X Indirect Dr Jagan John, Chair, is also a Jan-20 current No immediate action required. CCG GP partner in Aurora Medcare Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Ramneek Hara Governing Body St Albans Surgery X Direct GP Principal May-16 current No immediate action required. Member - Clinical (Urswick MC) Declarations made at the Director beginning of meetings. Will not be involved in any decision making regarding the conflict.

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Together First Ltd X Direct Shareholder May-14 current No immediate action required. (Barking & Dagenham Declarations made at the GP Federation) beginning of meetings. Will not be involved in any decision making regarding the conflict. NHS England X Direct GP appraiser Dec-16 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. London Deanery X Direct GP registrar and GP appraiser Apr-17 current No immediate action required. mainly in Havering Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Barts Hospital & X Direct Under-graduate tutor Oct-16 current No immediate action required. Queen Mary's Declarations made at the university beginning of meetings. Will not be involved in any decision making regarding the conflict. Network East One, X Direct St Albans Surgery is a member May-19 current No immediate action required. Barking and practice Declarations made at the Dagenham PCN beginning of meetings. Will not be involved in any decision making regarding the conflict. Medimmune X Indirect Spouse is medical director Apr-11 current No immediate action required. (Astrazeneca) Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Anju Gupta Governing Body Abbey Medical Centre X Direct GP Principal. Apr-16 current No immediate action required. Member - Clinical Declarations made at the Director beginning of meetings. Will not be involved in any decision making regarding the conflict. BHR CCGs X Direct Diabetes lead Sep-15 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Together First Ltd X Direct Shareholder and member Apr-17 current No immediate action required. (Barking & Dagenham Declarations made at the GP Federation) beginning of meetings. Will not be involved in any decision making regarding the conflict. NELFT X Direct GPwSI -Diabetes Mar-10 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. NHSE X Direct GP Appriaser Sep-13 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. London Deanery X Direct GP Trainer Nov-17 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Abbey Medical Centre X Indirect Spouse is the Practice Manager 2017 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Kanika Rai Governing Body White House surgery, X Direct GP principal 01/09/2006 current No immediate action required. Member - Clinical Barking Declarations made at the Director X Indirect Sister is a GP partner and 2010 beginning of meetings. Will not GPwSI-dermatology 2017 be involved in any decision making regarding the conflict. X Indirect Brother is a GP partner 2008

X Indirect Father is a GP Principal 1998 Castleton Road Health X Direct GP principal April 2018 current No immediate action required. Centre, Redbridge Declarations made at the X Indirect Sister is a GP partner April 2018 beginning of meetings. Will not be involved in any decision X Indirect Brother is a GP partner April 2018 making regarding the conflict.

X Indirect Husband is a GP Sept 2019

B&D CCG X Indirect Brother-in-law is a B&D GP and April 2018 current No immediate action required. Clinical director. Declarations made at the beginning of meetings. Will not X Indirect Sister is a B&D network lead 2018 be involved in any decision making regarding the conflict. Together First Ltd X Indirect Brother is a director Apr-18 current No immediate action required. (Barking & Dagenham Declarations made at the GP Federation) beginning of meetings. Will not be involved in any decision making regarding the conflict. MacMillan X Direct GP for Barking and Dagenham 01/06/2015 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Health Education X X Direct FY2 Superviser and GP trainer 2013 current No immediate action required. England Declarations made at the X Indirect Sister is a GP trainer and FY2 2013 beginning of meetings. Will not trainer be involved in any decision making regarding the conflict. X Indirect Husband is a GP trainer NHS London X Indirect Sister is clinical lead 2018 current No immediate action required. Workforce Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Patient First Social X Indirect Sister is a dermatology GPwSI 2019 current No immediate action required. Enterprise Newham Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

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Queen Mary X Direct Under-graduate tutor 2007 current No immediate action required. University & Imperial Declarations made at the Medical School X Indirect Sister is an under graduate tutor beginning of meetings. Will not be involved in any decision making regarding the conflict. Amit Sharma Governing Body Tulasi Medical X Direct Salaried GP and medical Jul-13 current No immediate action required. Member- Practice director Declarations made at the Clinical Director beginning of meetings. Will not be involved in any decision making regarding the conflict. St Albans Surgery X Direct Salaried GP - one session May-17 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Becontree Medical X Direct Salaried GP and medical Sep-19 current No immediate action required. Centre director Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. B&D CCG X Direct Macmillan GP Apr-14 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. B&D CCG X Indirect Sister-in-law is a B&D Clinical Nov-11 current No immediate action required. Director Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. B&D CCG X Indirect Wife is a B&D GP and Network Aug-18 current No immediate action required. Clinical Director Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Barking, Dagenham & X Direct Member Sep-14 current No immediate action required. Havering LMC Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Care Quality X Direct GP specialist adviser Nov-14 current No immediate action required. Commission Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Veda Solutions X Direct Director Aug-13 current No immediate action required. (Providing medical Declarations made at the solutions to OOH/ beginning of meetings. Will not Macmillan/ Locum be involved in any decision pay) making regarding the conflict. Care City X Direct Test best Clinical Lead Nov-18 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Uzma Haque Governing Body Gables Surgery - X Direct GP partner Oct-15 current No immediate action required. Member - Dagenham Declarations made at the Clinical Director beginning of meetings. Will not be involved in any decision making regarding the conflict. Together First X Direct Shareholder Oct-15 current No immediate action required. (Barking & Dagenham Declarations made at the GP Federation) beginning of meetings. Will not be involved in any decision making regarding the conflict. Queen Mary's College X Direct Physician associates tutor May-19 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. BHRUT X Indirect Husband is head of department Jul-05 current No immediate action required. for care of the elderly and Declarations made at the elderly care consultant beginning of meetings. Will not be involved in any decision making regarding the conflict. Babylon GP on-line X Indirect GP partner is lead for women's Oct-15 current No immediate action required. system health Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Health Education X Direct NHS London HEE tutor - not yet Apr-19 current No immediate action required. England employed, but approved as GP Declarations made at the registrar beginning of meetings. Will not be involved in any decision making regarding the conflict. B&D and Havering X Direct LMC Member Jan-12 current No immediate action required. LMC Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Historic - Astra X Direct Chaired a meeting. Apr-18 N/A as one Historic. Zeneca off. Sahdia Warraich Governing Body Tower Hamlets GP X Direct Social Prescription Manager 18/06/2018 current No immediate action required. member - Lay Care Group CIC Declarations made at the member, PPI beginning of meetings. Will not be involved in any decision making regarding the conflict. Newham Deanery X Direct Trustee 01/06/2016 current No immediate action required. CIO Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Redbridge X Direct Member 01/04/2013 current No immediate action required. Healthwatch Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. NELFT X Indirect Sister is a chaplain/ spiritual Mar-19 current No immediate action required. advisor Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

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Doctor's House GP X Indirect Brother is employed as Practice 09/09/2019 current No immediate action required. practice, Redbridge Manager Declarations made at the CCG beginning of meetings. Will not be involved in any decision making regarding the conflict. Doctor's House GP X Indirect Daughter provides sessional Jul-20 current No immediate action required. practice, Redbridge receptionist support at the Declarations made at the CCG practice beginning of meetings. Will not be involved in any decision making regarding the conflict.

Havering CCG Atul Aggarwal Governing Body Maylands Healthcare X Direct GP Partner Apr-13 current No immediate action required. Member - CCG Declarations made at the Chair beginning of meetings. Will not be involved in any decision making regarding the conflict. Maylands Healthcare X Direct Director and shareholder in on- Apr-13 current No immediate action required. Ltd site pharamcy Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Parkview Dental X Indirect Sister is NHS dentist within 1996 current No immediate action required. Practice Havering Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Essex Medicare LLP X Direct Part owner which owns 2014 current No immediate action required. Westland Clinic, Hornchurch. Declarations made at the Space rented out to Inhealth beginning of meetings. Will not (Diagnostic),Nuffield Health be involved in any decision (Brentwood), Communitas making regarding the conflict. Clinics (Dermatology & Gynaecology) Havering Health Ltd X Direct Shareholder. GP partner (Dr Sep-14 current No immediate action required. Kendall) is a director Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Barking, Dagenham X Direct Co-opted member 2013 current No immediate action required. and Havering LMC Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Westlands Clinic X Indirect Spouse is a dentist who has an May-18 current No immediate action required. (Langton Dental) outsourced contract with Declarations made at the BHRUT for oral surgery. beginning of meetings. Will not be involved in any decision making regarding the conflict. Havering CCG X Direct Registered as a patient at a GP 1990 current No immediate action required. practice in Havering. Full details Declarations made at the provided on DOI form beginning of meetings. Will not be involved in any decision making regarding the conflict. Havering Health & X Direct Vice Chair 2013 current No immediate action required. Wellbeing Board Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Anglia Ruskin X Direct Lecturer 2019 current No immediate action required. University Medical Declarations made at the School beginning of meetings. Will not be involved in any decision making regarding the conflict. Alex Tran Governing Body Hornchurch X Direct GP principal 2007 current No immediate action required. Member - Clinical Healthcare Declarations made at the Director beginning of meetings. Will not be involved in any decision making regarding the conflict. Havering Health Ltd X Direct Shareholder 2015 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Hornchchurch X Direct Director 2015 current No immediate action required. Healthcare Ltd Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Hornchchurch X Indirect Partner's SIPP is the landlord of 2016 current No immediate action required. Healthcare Ltd the Hornchurch Healthcare Declarations made at the premises beginning of meetings. Will not be involved in any decision making regarding the conflict. Maurice Sanomi Governing Body Rush Green Medical X Direct GP partner 2000 current No immediate action required. Member - Clinical Centre Declarations made at the Director beginning of meetings. Will not be involved in any decision making regarding the conflict. Practice Based X Direct Director/Shareholder abd 2007 current No immediate action required. Clinical Service Ltd GPwSI Declarations made at the (ENT service) beginning of meetings. Will not be involved in any decision making regarding the conflict. Havering CCG X Direct GP Tutor & education lead 2000 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Havering Health Ltd X Direct Shareholder 2014 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. ROWSANO Medical X Direct Director Oct-19 current No immediate action required. Services Limited Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

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Barking, Dagenham X Direct Member 2003 current No immediate action required. and Havering LMC Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Ann Baldwin Governing Body Central Park surgery, X Direct GP partner 2009 current No immediate action required. Member-Clinical Harold Hill Declarations made at the Director beginning of meetings. Will not be involved in any decision making regarding the conflict. Havering Health Ltd X Direct Shareholder Aug-14 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Royal College of GPs X Direct Member 2012 current No immediate action required. and British Society of Declarations made at the Rheumotology beginning of meetings. Will not be involved in any decision making regarding the conflict. Havering CCG X Direct GP Appraiser 2012 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Mary Burtenshaw Governing Body Hornchurch X Direct GP partner Apr-19 current No immediate action required. Member - Clinical Healthcare Declarations made at the Director beginning of meetings. Will not be involved in any decision making regarding the conflict. North East London X Direct Education lead Feb-19 current No immediate action required. faculty of RCGP Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Barking, Havering and X Indirect Spouse is a consultant 2013 current No immediate action required. Redbridge University oncologist and Chair of safe Declarations made at the Hospitals Trust medicines practice group beginning of meetings. Will not be involved in any decision making regarding the conflict. Squirrels Heath Infant X Direct Governor with responsibility for Mar-18 current No immediate action required. School special education needs Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Gemma Barrett Governing Body Hornchurch X Direct Salaried GP Oct-17 current No immediate action required. Member - Clinical Healthcare Declarations made at the Director beginning of meetings. Will not be involved in any decision making regarding the conflict. Havering CCG X Direct Registered as a patient at a GP Oct-07 current No immediate action required. practice in Havering. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Richard Coleman Governing Body 1-2-1 Social X Direct Associate 01/10/2014 current No immediate action required. member - Lay Enterprise (Provides Declarations made at the member, PPI mentoring to the NHS) beginning of meetings. Will not be involved in any decision making regarding the conflict. PriceWaterhouse X Indirect Nephew is a partner 01/08/2013 current No immediate action required. Cooper Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. MC Consulting X Direct Mentor to individuals within NHS Apr-19 current No immediate action required. bodies outside of North East Declarations made at the London beginning of meetings. Will not be involved in any decision making regarding the conflict. Redbridge CCG X Direct Registered as a patient at a GP 2013 current No immediate action required. practice in Redbridge. Full Declarations made at the details provided on DOI form beginning of meetings. Will not be involved in any decision making regarding the conflict. Historic X Indirect Brother-in-law is Independent 01/10/2017 31/08/2019 No immediate action required. BHR CCGs GP on the Primary Care Declarations made at the Commissioning Committee beginning of meetings. Will not (resigned wef 31 August 2019) be involved in any decision making regarding the conflict.

12 Redbridge CCG Anil Mehta Governing Body Fullwell Cross Medical X Direct GP partner Apr-13 current No immediate action required. member - CCG Centre Declarations made at the Chair beginning of meetings. Will not be involved in any decision making regarding the conflict. Metropolitan Police X Direct Forensic examiner Nov-15 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. The Cleaning X Indirect Sister-in-law is the owner 2013 current No immediate action required. Company Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. NHSE X Direct GP appraiser Feb-15 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Healthbridge Direct X Direct Shareholder Sep-14 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Fouress enterprises X Direct Director 2015 current No immediate action required. Ltd (Property Declarations made at the Services) beginning of meetings. Will not be involved in any decision making regarding the conflict. Prescan (Healthcare X Direct Ad-hoc screening work Jan-18 current No immediate action required. screening) Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. London Healthwise X Direct Director 2009 current No immediate action required. Ltd (non-trading) Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. General Medical X Direct GMC Associate Jan-19 current No immediate action required. Council Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Redbridge CCG X Direct Registered as a patient at a GP 2000 current No immediate action required. Practice in Redbridge CCG. Full Declarations made at the details declared on DOI form beginning of meetings. Will not be involved in any decision making regarding the conflict. Ernst & Young X Indirect Brother is employed as 2017 current No immediate action required. Associate Director Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Redbridge Health and X Direct Vice Chair 2013 current No immediate action required. Wellbeing Board Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Anglia Ruskin X Direct Lecturer 2019 current No immediate action required. University Medical Declarations made at the School beginning of meetings. Will not be involved in any decision making regarding the conflict. Sarah Heyes Governing Body The Shrubberies X Direct GP partner Oct-15 current No immediate action required. member - Clinical Medical Centre Declarations made at the Director beginning of meetings. Will not be involved in any decision making regarding the conflict. Healthbridge Direct X Direct Shareholder Sep-14 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Jyoti Sood Governing Body Newbury Group X Direct GP partner 2003 current No immediate action required. Member - Clinical Practice Declarations made at the Director beginning of meetings. Will not be involved in any decision making regarding the conflict. DMC Healthcare X Direct GPwSI - Dermatology & minor Jul-17 current No immediate action required. surgery Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Excellence in Skin X Direct GPwSI - Dermatology 2011 current No immediate action required. Science (ESS) Declarations made at the Wanstead beginning of meetings. Will not be involved in any decision making regarding the conflict. NELFT X Direct GPwSI - Diabetes 2007 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Soods Ltd (Locum X Direct Director and husband is a 2005 current No immediate action required. agency) partner. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. NHSE X Direct GP appraiser 2003 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Health Education X Direct GP trainer and NHS London 2004 / Nov- current No immediate action required. England HEE Associate Director 2017 Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

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Imperial College X Direct GP trainer 2011 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Royal College of GPs X Direct GPWSi assessor 28/02/2018 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Care Quality X Direct Special adviser Sep-16 current No immediate action required. Commission Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Healthbridge Direct X Direct Shareholder Apr-17 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Metrolaw Solicitors X Indirect Husband's firm 2002 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Patient First Social X Direct GPwSI - Dermatology Aug-19 current No immediate action required. Enterprise Newham Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. BHR CCGs X Direct International graduate lead 01/08/2019 current No immediate action required. Declarations made at the X Training hub lead June 2020 beginning of meetings. Will not be involved in any decision making regarding the conflict. NEL STP X Direct Training Hub clinical lead for Jul-20 current No immediate action required. NEL Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Historic Ealing X Direct GPwSI - Dermatology 2010 Jul-20 Historic Hospital Trust

Shujah Hameed Governing Body Fullwell Avenue X Direct Salaried GP Oct-18 current No immediate action required. member - Clinical Surgery Declarations made at the Director beginning of meetings. Will not be involved in any decision making regarding the conflict. Healthbridge Direct X Direct Shareholder and locum doctor at Apr-16 current No immediate action required. urgent care centre and BHR GP Declarations made at the solutions beginning of meetings. Will not be involved in any decision making regarding the conflict. PELC X Direct Locum doctor Apr-16 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Partners in Healthcare X Direct Director Apr-16 current No immediate action required. Ltd Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. S.I.R Tech Enterprise X Direct Director Nov-18 current No immediate action required. Ltd Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Historic Castleton X Direct GP Partner Apr-17 Jun-18 Historic Road Health Centre

Syed Raza Governing Body Seven Kings surgery X Direct GP partner Oct-17 current No immediate action required. member - Clinical Declarations made at the Director beginning of meetings. Will not be involved in any decision making regarding the conflict. Raza Syed Medical X Direct Director Jun-14 current No immediate action required. Ltd Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Healthbridge Direct X Direct Shareholder and employed as a Sep-14 current No immediate action required. locum at the hub Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. London Deanery X Direct GP Trainer 2017 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Wellbeing Group of X Indirect Brother is a pharmacist Dec-18 current No immediate action required. Pharmacy Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Historic X Direct Locum GP current Oct-19 Historic PELC Shabana Ali Governing Body Southdene Surgery X Direct GP partner/principal 2008 current No immediate action required. member - Clinical Declarations made at the Director beginning of meetings. Will not be involved in any decision making regarding the conflict. Healthbridge Direct X Direct Shareholder 2015 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

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NELFT X Direct GPwSI - cardiology 2008 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Avicenna Ltd X Direct Director 2012 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Avicenna Ltd X Indirect Husband is a director 2012 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. British Medical X Direct member 2004 current No immediate action required. Association (BMA) Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. PCGP X Direct member 2006 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. NHSE X Direct GP appraiser (B&D and 2016 current No immediate action required. Havering) Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Historic Healthbridge X Indirect Daughter works in 2015 Jul-18 Historic Direct reception/admin Mehul Mathukia Governing Body Mathukia Surgery X Direct GP principal. Brother is also GP 2010 current No immediate action required. member - Clinical principal Declarations made at the Director beginning of meetings. Will not be involved in any decision making regarding the conflict. Healthbridge Direct X Direct Shareholder Sep-14 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Valia Consultancy X Direct Director & Shareholder 2014 current No immediate action required. (Healthcare Declarations made at the Consultancy) beginning of meetings. Will not be involved in any decision making regarding the conflict. NOCLOR & National X Direct GP research champion 2015 current No immediate action required. Institute of Health Declarations made at the Research (NIHR) beginning of meetings. Will not be involved in any decision making regarding the conflict. NHS England X Direct GP Appraiser Oct-19 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Babylon Direct Remote working doctor Mar-20 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Historic X Direct GP Locum 2010 Oct-19 Historic PELC Khalil Ali Governing Body Havering CCG X Direct Registered as a patient at a GP Apr-17 current No immediate action required. member - Lay Practice in Havering CCG. Full Declarations made at the member, PPI details declared on DOI form beginning of meetings. Will not (amendment made Aug 2019) be involved in any decision making regarding the conflict. St Francis Hospice X Indirect Spouse is a regular donor Apr-17 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Cancer Research UK X Indirect Spouse is a regular donor Apr-17 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

15 Members representing BHR CCGs Jane Milligan Employee - NEL Commissioning X Indirect Partner is employed 2014 current No immediate action required. Governing Body Support Unit substantively Declarations made at the Executive Member - beginning of meetings. Will not Accountable Officer, be involved in any decision NEL CCGs making regarding the conflict. NHSE X Indirect Partner on secondment to Apr-18 current No immediate action required. Central London Community Declarations made at the Healthcare as Director of beginning of meetings. Will not Primary Care Development be involved in any decision making regarding the conflict. Action for stammering X Indirect Partner is a Trustee Oct-13 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Peabody Housing X Direct Non-executive director Jan-17 current No immediate action required. Association Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. House of St X Direct Member Oct-19 current No immediate action required. Barnabas; charity Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Historic X Direct Ambassador Oct-14 Sep-19 Historic Stonewall (charity) Henry Black Governing Body Barking & Dagenham, X Indirect Wife employed as the Assistant Dec-18 current No immediate action required. Member - NELCA Havering and Director of Finance Declarations made at the Chief Finance Redbridge University beginning of meetings. Will not Officer Trust be involved in any decision making regarding the conflict. Tower Hamlets GP X Indirect Daughter employed as Social Jan-20 current No immediate action required. Care Group CIC Prescriber Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. NHC Clinical X Member Jul-18 Jul-21 No immediate action required. Commissioners Board Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Ceri Jacob Employee - Ruislip Gardens X Direct Chair of Governors Feb-18 Current No immediate action required. Managing Director Primary School Declarations made at the BHR CCGs beginning of meetings. Will not be involved in any decision making regarding the conflict. Jacqui Himbury Employee - Nurse Health Incidents X Direct Director Oct-19 current No immediate action required. Director, BHR Investigation Declarations made at the CCGs Consultancy Ltd (not beginning of meetings. Will not trading) be involved in any decision making regarding the conflict. Kash Pandya Governing Body NHS Barking and X Direct Lay member, Governance and 2013 current No immediate action required. Member - Lay Dagenham CCG Audit Chair Declarations made at the member, beginning of meetings. Will not Governance be involved in any decision making regarding the conflict. NHS Havering CCG X Direct Lay member, Governance and 2013 current No immediate action required. Audit Chair Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. NHS Redbridge CCG X Direct Lay member, Governance and 2013 current No immediate action required. Audit Chair Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. University of Essex X Direct Independent Audit Committee 2014 current No immediate action required. member Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Southend-on-Sea X Direct Independent Audit Committee 2016 current No immediate action required. Borough Council member Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Brentwood Citizen's X Direct General Advisor 2009 current No immediate action required. Advice Bureau Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Metro Bank X Indirect Son is employed as 2019 current No immediate action required. Procurement Manager Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Accenture X Indirect Son is employeed as Legal 2017 current No immediate action required. Counsel Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Historic X Indirect Son is employeed as a 2013 2019 No immediate action required. PriceWaterhouse management accountant Declarations made at the Cooper beginning of meetings. Will not be involved in any decision making regarding the conflict. Historic X Direct Lay member, Governance and 2010 2018 Historic Essex Ministry of Audit Chair Justice Advisor Committee Stephen Rubery Employee - Director BHR CCGs X Indirect Co-habiting partner is Director Aug-18 current No immediate action required. of Commissioning & of Transformation & Delivery Declarations made at the Performance BHR within BHR CCGs beginning of meetings. Will not CCGs be involved in any decision making regarding the conflict.

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Redbridge CCG X Direct Registered as a patient at a GP current No immediate action required. Practice in Redbridge CCG. Full Declarations made at the details declared on DOI form beginning of meetings. Will not be involved in any decision making regarding the conflict. Other decision makers Rob Adcock Deputy Chief None Finance Officer Adedayo Adedeji Barking & Halbutt Street Surgery X Direct GP 1995 current No immediate action required. Dagenham CCG Declarations made at the GP and member of beginning of meetings. Will not BHR CCGs Primary be involved in any decision Care making regarding the conflict. Commissioning PELC X Direct Council Member Dec-13 current No immediate action required. Committee Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Together First Ltd X Direct Board Member & shareholder Apr-14 current No immediate action required. (Barking & Dagenham Declarations made at the GP Federation) beginning of meetings. Will not be involved in any decision making regarding the conflict. Primary Care Clinical X Direct Shareholder 2017 current No immediate action required. partnership Ltd Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Shabnam Ali Redbridge CCG GP Loxford Primary Care X Direct Clinical Director Jul-19 current No immediate action required. and member of Network Declarations made at the BHR CCGs' beginning of meetings. Will not Primary Care be involved in any decision Commissioning making regarding the conflict. Committee Ilford Medical Centre X Direct GP partner current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Charles Beaumont Independent Lay None Member of BHR CCGs Audit & Governance Committee Alison Blair Director of Hunter Healthcare X Direct Employed under contract to Oct-17 current No immediate action required. Transition NHS in North East London Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Kirsty Boettcher Employee - Deputy None Director of Delivery, Unplanned Care Richard Burack Havering CCG GP, North Street Medical X Direct GP senior partner Sep-01 ongoing No immediate action required. Named GP lead in Care Declarations made at the Safeguarding for beginning of meetings. Will not B&D and Havering be involved in any decision CCGs, clinical making regarding the conflict. children's lead for RCGP Adolescent X Direct Member 2018 ongoing No immediate action required. BHR CCGs Working Group Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Primary Care Child X Direct Chair Sep-17 ongoing No immediate action required. Safeguarding Forum Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Havering Health Ltd X Direct Clinical Director 2016 ongoing No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. BHR GP Solutions X Direct Clinical Director 2017 ongoing No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Marshall's Primary X Direct North Street Medical Care 2019 ongoing No immediate action required. Care Network representative Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. NHS National X Direct Member 2019 ongoing No immediate action required. Safeguarding Steering Declarations made at the Group beginning of meetings. Will not be involved in any decision making regarding the conflict. Julia Cory Employee - Deputy None Director, Primary Care Transformation David Derby Havering CCG GP Rosewood Medical X Direct GP Partner 2011 current No immediate action required. and member of Centre Declarations made at the BHR CCGs Primary beginning of meetings. Will not Care be involved in any decision Commissioning making regarding the conflict. Committee Havering Health Ltd X Direct Shareholder/Director and 2014 current No immediate action required. company secretary. Rosewood Declarations made at the Medical Centre is also a beginning of meetings. Will not shareholder be involved in any decision making regarding the conflict. PELC X Direct Council member 2013 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Forest Community X Direct Director (part of PELC council 2019 current No immediate action required. Health Limited member role) Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

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BHRUT X Indirect Wife is an employee 2017 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Health Education X Direct GP Trainer 2013 current No immediate action required. England Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Rob Dickenson Employee - Senior None Finance Manager Pam Dobson Employee - Deputy None Director Corporate Services Mark Eaton Director of System Amnis Ltd X Direct Shareholder and Director 2004 current Amnis Ltd will not provide any Recovery (Management services within NEL. Consultancy) Mark Gilbey-Cross Employee - Deputy None Nurse Director (Acting) Paul Hunt Employee - Finance None Manager Amanda Jameson Employee - BHR CCGs X Indirect Husband works for Redbridge Apr-18 current No immediate action required. Planning and CCG in GP IT Declarations made at the Control Lead, beginning of meetings. Will not Finance be involved in any decision making regarding the conflict. BHR CCGs X Direct Registered patient at a GP Apr-18 current No immediate action required. practice in Havering CCG. Full Declarations made at the details provided on form beginning of meetings. Will not be involved in any decision making regarding the conflict. Mohammed Kanji Employee - Crescent X Direct Paid work - pharmacist. Full Sep-93 current No immediate action required. Prescribing Adviser; Pharamcy,Romford details including remuneration - Declarations made at the APC Member provided on declaration form beginning of meetings. Will not be involved in any decision making regarding the conflict. Beta Pharmaceuticals X Direct Director. Full details including Dec-04 current No immediate action required. Ltd remuneration provided on Declarations made at the declaration form beginning of meetings. Will not be involved in any decision making regarding the conflict. Eaglebond Ltd X Direct Superintendant Pharamcist and Mar-10 current No immediate action required. (Pharmacy) director. Full details including Declarations made at the remuneration provided on beginning of meetings. Will not declaration form be involved in any decision making regarding the conflict. Carebright Limited - X Direct Director. 2009 current No immediate action required. shareholding Declarations made at the company beginning of meetings. Will not be involved in any decision making regarding the conflict. Beta Charitable Trust X Direct Trustee 2007 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Imran Khan Employee - Ilford Medical Centre X Direct Paid work as specialist Aug-16 current No immediate action required. Pharmaceutical pharmacist. Full details Declarations made at the Advisor/QIPP including remuneration - beginning of meetings. Will not Pharmacist; APC provided on declaration form be involved in any decision Member making regarding the conflict. Diabetes UK X Direct Professional member 2017 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. BHR CCGs X Direct Registered as a patient at a GP current No immediate action required. practice in Redbridge CCG. Full Declarations made at the details declared on form beginning of meetings. Will not be involved in any decision making regarding the conflict. Jeremy Kidd Employee - Deputy None Director, Planned Care Vicky Kong Employee - QIPP Havering CCG X Direct Registered patient at a GP current No immediate action required. Programme practice in Havering CCG. Full Declarations made at the Pharmacist; APC details provided on form beginning of meetings. Will not Member be involved in any decision making regarding the conflict. Pharmacist Guide - X Direct Owner of self-funded website. Sep-19 current No immediate action required. website Further details provided on DOI Declarations made at the form beginning of meetings. Will not be involved in any decision making regarding the conflict. Ahmet Koray Employee - Director None of Finance, BHR CCGs Belinda Krishek Employee - Chief North East London X Indirect Husband is an employee Apr-18 current No immediate action required. Pharmacist; APC Local Pharmaceutical Declarations made at the Member Committee (NEL LPC) beginning of meetings. Will not be involved in any decision making regarding the conflict. Fontus Health X Indirect Daughter undertakes work with Apr-18 current No immediate action required. them. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Raj Kumar Havering CCG GP, Berwick Surgery, X Direct GP Principal Apr-17 current No immediate action required. GP clinical lead for Rainham Declarations made at the BHR CCGs - Mental beginning of meetings. Will not Health be involved in any decision making regarding the conflict. Havering Health Ltd X Direct Member Apr-17 current No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict.

18 Mathukia Vaibhav Redbridge CCG Mathukia Surgery X Direct GP Principal. Brother is also a 2017 Ongoing No immediate action required. GP, GP Clincal GP at the practice Declarations made at the Lead -Macmillan beginning of meetings. Will not GP be involved in any decision making regarding the conflict. Redbridge CCG X Indirect Brother is a Clinical Director 2016 Ongoing No immediate action required. Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Robert Meaker Employee - Vertergi Limited X Direct Holder of 100% of the company Sep-14 current No immediate action required. Innovation & shares Declarations made at the Information beginning of meetings. Will not Technology Senior be involved in any decision Responsible Officer making regarding the conflict. BHR CCGs MCB Software X Direct Holder of 100% of the company 01/06/2016 Current No immediate action required. shares Declarations made at the beginning of meetings. Will not The software produced has Amendment be involved in any decision been purchased by BHR CCGs August-18 making regarding the conflict. and is currently in use by the Continuing Healthcare Team The Network Group X Direct Vertergi Ltd is a member of the Aug-18 current No immediate action required. Network Group and I am a Declarations made at the named member of the beginning of meetings. Will not leadership be involved in any decision MCB Software Services is an making regarding the conflict. associate member of the Network Group The Network Group was formed to enable small organisations to compete for larger consulting assignments. No work has been secured, but has secured a place on a framework agreement. Diginex Ltd - X Direct Shareholder Sep-19 current No immediate action required. technology company Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Sharon Morrow Employee - Director None of Transformation & Delivery (Unplanned Care & Mental Health)

Saiqa Mughal Employee - BHR CCGs X Direct Registered as a patient at a GP 2011 ongoing No immediate action required. Prescribing Advisor; practice in Redbridge CCG. Full Declarations made at the APC Member details provided on declaration beginning of meetings. Will not form be involved in any decision making regarding the conflict. Olubunmi Olajide Havering CCG GP Macmillan X Direct Macmillan GP lead in Havering Mar-18 current No immediate action required. Partner and CCG Declarations made at the Macmillan GP beginning of meetings. Will not be involved in any decision making regarding the conflict. BxNoma Limited X Direct Company director Apr-08 current No immediate action required. (healthcare company) Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Havering Health GP X Direct Director Nov-18 current No immediate action required. Federation Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Reema Patel Employee - Greenwood Practice, X Indirect Husband is a salaried GP 01/05/2019 ongoing No immediate action required. Prescribing Advisor, Havering CCG Declarations made at the Havering CCG beginning of meetings. Will not be involved in any decision making regarding the conflict. The New Surgery, X Direct Paid work as a Clinical 31/05/2019 ongoing No immediate action required. Brentwood Pharmacist. Full details Declarations made at the including remuneration and list beginning of meetings. Will not of GP practices provided on be involved in any decision declaration form making regarding the conflict. Rohpharm Pharmacy X Direct Paid work as a locum at 01/05/2019 ongoing No immediate action required. branches owned by family Declarations made at the members. Full details including beginning of meetings. Will not remuneration provided on be involved in any decision declaration form making regarding the conflict. Sanjay Patel Employee - Deputy DSP Health Solutions X Direct Director Jun-15 current No immediate action required. Chief Pharmacist; (DSPHS) Ltd Declarations made at the APC Member Financial beginning of meetings. Will not (Consultancy/ be involved in any decision Training). making regarding the conflict. DSP Health Solutions X Indirect Wife is a shareholder in the Jun-15 Current No immediate action required. (DSPHS) Ltd company Declarations made at the Financial beginning of meetings. Will not (Consultancy/ be involved in any decision Training). making regarding the conflict. Sterling Anglian X Shareholder (less than 1% of Dec-15 current No immediate action required. Pharamceuticals stockholding) Declarations made at the (SAP) beginning of meetings. Will not be involved in any decision making regarding the conflict. DSP Health Solutions X Direct Paid work as locum pharmacist. Oct-00 current No immediate action required. (DSPHS) Ltd Further details and remuneration Declarations made at the Financial declared on DOI form beginning of meetings. Will not (Consultancy/ be involved in any decision Training). making regarding the conflict. BHR CCGs X Direct Registered patient at a GP current No immediate action required. practice in Redbridge CCG. Full Declarations made at the details provided on form beginning of meetings. Will not be involved in any decision making regarding the conflict. Marie Price Employee - Greater London X Indirect Husband is area regeneration 2017 on-going No immediate action required. Corporate Services Authority (GLA) manager for North East London Declarations made at the Director BHR CCGs beginning of meetings. Will not be involved in any decision making regarding the conflict.

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City & Hackney CCG X Direct Registered patient at a GP 2008 current No immediate action required. practice where City & Hackney Declarations made at the CCG Chair is based. Full details beginning of meetings. Will not declared on form be involved in any decision making regarding the conflict. Sarah See Employee - Primary NELFT X Indirect Partner is an employee working 1986 current No immediate action required. Care within Redbridge CAMHS Declarations made at the Transformation beginning of meetings. Will not Director BHR CCGs be involved in any decision making regarding the conflict. Waltham Forest CCG X Direct Registered as a patient a GP 2001 current No immediate action required. practice in Waltham Forest Declarations made at the CCG which is part of NELCA. beginning of meetings. Will not Full details provided on DOI be involved in any decision form making regarding the conflict. Julia Summers Employee - Head of Camden & Islington X Indirect Husband is an employee 2016 Current No immediate action required. Finance Mental Health Trust Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Muhammad Tahir Employee - CCG Fairlop Primary Care X Direct Co-Chair Jul-19 Current No immediate action required. Clinical Lead Network Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Healthbridge X Direct Director on board Dec-19 Current No immediate action required. Federation Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Forest Edge GP X Direct GP Partner Oct-93 Current No immediate action required. practice Declarations made at the beginning of meetings. Will not be involved in any decision making regarding the conflict. Dagenham and X Direct Medical Doctor 1999 Current No immediate action required. Redbridge Football Declarations made at the Club beginning of meetings. Will not be involved in any decision making regarding the conflict. Julia Taylor Employee - Springfield Hospital, X Direct Paid bank work - Pharmacist. 01/04/2018 current Declared in line with CPOI Prescribing Advisor; Chelmsford Remuneration declared on DOI policy. Will be excluded from APC Member form. any related comissioning or decision making. BHR CCGs X Direct Registered as a patient at a GP 01/02/2018 current No immediate action required. practice in Havering CCG. Full Declarations made at the details declared on form beginning of meetings. Will not be involved in any decision making regarding the conflict. Tracy Welsh Employee - Director BHR CCGs X Indirect Co-habiting partner is Director 01/07/2018 current No immediate action required. of Transformation & of Commissioning and Declarations made at the Delivery (Planned Performance at BHR CCGs beginning of meetings. Will not Care) be involved in any decision making regarding the conflict. Redbridge CCG X Direct Registered as a patient at a GP April 2018 current No immediate action required. Practice in Redbridge CCG. Full Declarations made at the details declared on DOI form beginning of meetings. Will not be involved in any decision making regarding the conflict. Hanh Xuan-Tang Employee - Deputy None Director of Recovery and Planning Historic Kate Langford Governing Body Guy's and St Thomas X Direct Full time employee and Medical 31/10/2019 Historic Historic member - NHS Foundation Trust Director of GSTT Healthcare Secondary Care Alliance. Seconded to NHSI two Consultant, Barking days per week as part of this & Dagenham and role. Havering CCGs Faculty of Leadership X Direct Appraiser 31/10/2019 Historic and Management NHS Professionals X Direct Non-executive director Apr-19 31/10/2019 Historic Jane Gateley Employee - None 31/03/2020 Historic Historic Director, Strategy & Integration BHR CCGs

20 Draft minutes of the Joint Committee of Barking and Dagenham, Havering and Redbridge Clinical Commissioning Groups (BHR CCGs)

Part 1

30 July 2020 - 2.15pm

Virtual meeting via MS Teams

Barking & Dagenham CCG Dr Jagan John (JJ) Clinical Director/Chair Dr Amit Sharma (ASh) Clinical Director Dr Anju Gupta (AG) Clinical Director Dr Uzma Haque (UH) Clinical Director Dr Ramneek Hara (RH) Clinical Director (from 2.33pm) Dr Kanika Rai (KR) Clinical Director Dr Gurkirit Kalkat (GK) Clinical Director Sahdia Warraich (SW) Lay member – PPI

Havering CCG Dr Ann Baldwin (AB) Clinical Director Dr Maurice Sanomi (MS) Clinical Director Dr Mary Burtenshaw (MB) Clinical Director Richard Coleman (RC) Lay member – PPI

Redbridge CCG Dr Anil Mehta (AM) Clinical Director/Chair Dr Shabana Ali (SA) Clinical Director Dr Syed Raza (SRa) Clinical Director Dr Jyoti Sood (JS) Clinical Director Dr Shujah Hameed (SHam) Clinical Director Khalil Ali (KA) Lay Member – PPI

BHR CCGs Jane Milligan (JM) Accountable Officer, NELCA Ceri Jacob (CJ) Managing Director Henry Black (HB) Chief Finance Officer, NELCA (from 3.05pm) Kash Pandya (KP) Lay Member – Governance Steve Rubery (SR) Director of Delivery and Performance, BHR CCGs Mark Gilbey-Cross (MGC) Deputy Nurse Director (Acting) Ahmet Koray (AK) Interim Director of Finance

In attendance Gladys Xavier (GX) Interim Director, Public Health (LBR) Sharon Morrow (SM) Director of Transformation & Delivery (Unplanned Care & Mental Health), BHR CCGs Tracy Welsh (TW) Director of Transformation & Delivery (Planned Care), BHR CCGs Marie Price (MP) Director of Corporate Affairs, NELCA Anne-Marie Keliris (AMK) Governance & Emergency Planning Lead, BHR CCGs

Anna McDonald (AMc) Business Manager (secretary to the meeting), BHR CCGs

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Rachel Penney (RP) NEL Learning Disabilities & Autism Strategic Lead

Apologies Dr Atul Aggarwal (AA) Clinical Director/Chair, Havering CCG Dr Gemma Barrett (GB) Clinical Director Dr Alex Tran (AT) Clinical Director Dr Sarah Heyes (SH) Clinical Director Dr Mehul Mathukia (MM) Clinical Director Jacqui Himbury (JH) Nurse Director, BHR CCGs Lee Eborall (LE) Director, CSU Cathy Turland (CT) Healthwatch, Redbridge Matthew Cole (MC) Director, Public Health (LBBD) Manisha Modhvadia (MMo) Healthwatch, Barking and Dagenham

1.0 Welcome and apologies Action Dr Jagan John, the Chair of the meeting welcomed members to the meeting and apologies for absence were noted.

1.1 Declarations of conflicts of interest The Chair of the meeting reminded members of their obligation to declare any interest they may have on any issues arising at the meeting which might conflict with the business of the CCGs.

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

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

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

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

No additional declarations were declared.

1.2 Minutes of the last meeting The minutes of the Governing Bodies meeting-in-common held on 11 June 2020 were agreed as a correct record.

1.3 Matters/actions arising The Joint Committee noted the actions taken since the last meeting.

All actions were complete.

2.0 Chair and chief officer reports 2.1 Chairs’ report The Chair presented the report which covered the areas below:-

• Covid-19 • BHR Collaborative working • Integrated partnership

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• NEL commissioning developments • London collaborative work • Health & Wellbeing Boards

• Approval of a direct award for the digitisation of patient records • Diabetes work across BHR shortlisted for prestigious HSJ Value Award • Whipps Cross Hospital redevelopment

There were no comments.

The Joint Committee noted the report.

2.2 Accountable Officer’s report JM presented her report which covered the following areas:-

• Covid-19 update • Recovery programme • Inequalities • NELCA Diversity and Inclusion

• Bringing together our CCGs across north east London

JM referred to the work undertaken to develop the NELCA diversity and inclusion strategy focussing on ensuring our workforce is inclusive and equal.

A number of new staff networks have been established over recent months which include a BME network that has a detailed workplan and remit and growing membership. In addition, a women’s network, LGBT+ network and a disability network are also being developed and there will be a follow up workforce, race, equality standard (WRES) workshop organised during the coming months.

KP commented on recent news that the Chair of the NEL Integrated Care

System (ICS) has been confirmed as the first chair of the newly created NHS

Race and Health Observatory. The Joint Committee members agreed that the appointment will benefit NEL as a whole in terms of the learning that will gained from best practice across the country.

KA referred to the proposed move to a single NEL CCG in April 2021 and commented on the need to ensure that the progress made by the seven individual NEL CCGs over previous years is not lost and also that patients and service users continue to be at the heart of the new CCG and are involved in the changes so that they feel assured that they will benefit the local population. JM fully supported KA’s points adding that communicating the message that the changes will strengthen, support and deliver better outcomes for the population is key.

The Joint Committee noted the report.

2.3 Quality report MGC presented the report which highlighted the quality issues relating to patient safety, patient experience, clinical effectiveness and safeguarding in regard to the CCGs’ two main providers: BHRUT and NELFT. The report focussed on:-

Quality improvement across providers:

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BHRUT • CQC inspection • Never events • Cancer and incidental finding pathway clinical concerns

• Quality Review meeting

NELFT

• Initial Health Assessments for Looked After Children • Review Health Assessments for Looked After Children PELC • Queen’s Hospital Urgent Treatment Centre CQC Inspection Regulation 28 (Prevention of Future Deaths) Reports

The key points were outlined by MGC and KA commented on two positive sections in the report; BHRUT has no declared Never Events for the period April 2020 to date; no significant concerns were reported by the CQC following the inspection of the UTC based within Queen’s Hospital. MGC advised however, that since writing the report, BHRUT has declared a Never Event’ relating to a swab pack.

JJ suggested it would be helpful for quality issues relating to Barts Health Trust to be included in the report. CJ clarified that the focus of the report is on the providers where BHR CCGs are the host commissioners but agreed that it would be helpful to include a section on Barts Health Trust in the report MGC going forward.

The Joint Committee: • Noted the report and agreed the actions being taken to date to

mitigate the identified quality risks.

2.4 Patient engagement report SW presented the report which provided a summary of the CCGs’ engagement with patients, the public and other stakeholders since the last meeting highlighting the following areas:-

• Response to the pandemic

• Lay members supporting Transformation work • Working closely with the NEL team • Patient engagement forum (PEF) updates • Engagement on interpreting services

• Children and Young people’s survey

• BHR interfaith group • Impact of Covid-19 on planned engagement work

The Chair thanked all the patient groups and lay members on behalf of the Joint Committee for their help and support during the pandemic. MP advised work is being undertaken across NEL looking at ways to improve how we currently use the intelligence gathered at PEF and other patient group meetings in regard to quality and patient safety issues with a particular focus now on Covid-19 working with Healthwatch. MP to discuss this further with MGC and lay member colleagues outside of the meeting. JM referred to the MP data tool used by Healthwatch in other parts of NEL which will be considered for wider use across NEL as part of the work referred to by MP. The lay

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members welcomed the plan for even closer alignment with patient groups to enhance the patient voice.

JJ asked whether health inequalities is something the PEF could consider at a local level in order to feed into the wider work being undertaken across NEL. SW responded that lay members are very keen to encourage more people from BAME groups to join patient groups to improve engagement with BAME communities and advised that various different ways of doing that are being discussed at PEF meetings. KA added that more proactive work is needed in regard to connecting with BAME groups in order to capture the views of people who are excluded from discussions. GX reported that Redbridge Local Authority recently held a community engagement session which was attended by AMe. Members of the community were asked how they want to engage and some good suggestions were put forward. Work is underway with ‘health buddies’ from the voluntary sector and in addition, a public health engagement officer and a communications officer are being appointed with a particular focus on Covid-19.

AG commented on the need to work collaboratively with public health, schools and communities as a whole to refresh obesity strategies. It was noted that Local Authorities were updating obesity strategies pre-Covid-19 and GX advised that Redbridge Public Health is leading on the work and the overall plan is for the working group to share all the learning with Barking & Dagenham and Havering to ensure there is a system-wide approach.

The Joint Committee noted the report.

3.0 Joint committee assurance 3.1 BHR recovery and restoration planning CJ presented the report which provided a summary of activities being undertaken both at a BHR and NEL level. An overview of how health and social care partners who provide services to local residents have been working together on Covid-19 recovery and restoration. The restoration and recovery programme is led at a chief executive level across NEL and in BHR, the response is overseen by a BHR System Operational Command Group (SOCG) with the participation of all health and care partners.

The four keys areas of focus in BHR are; capturing and reviewing the lessons learnt from the changes so far, particularly in regard to patient views; working as a system on the things that we need to do collaboratively for recovery and restoration; Community Based Care model- initially on a place- based model to support the vulnerable, care homes and discharge; Integrated Care Partnership resilience and planning for future peaks. All of which will feed into the work being undertaken across NEL. There has been particular concern about the disproportionate impact on BAME communities and those living in challenging socio-economic circumstances and how the longer-term impact of the pandemic may increase inequalities. Immediate action has been taken locally in the work that the BHR system has been undertaking and a key theme of the longer-term work will be to build on this and make a difference to those who are hardest hit.

All the service changes made in response to the pandemic have been shared with Local Authorities through the Health & Wellbeing Boards, Health Scrutiny Committees as well as other partners. None of the service changes

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have been made permanent as there needs to be a clear understanding of what they mean from the patient perspective.

The importance of sharing patient views with primary care colleagues on the new ways of working both in primary care and secondary care was emphasised. CJ responded by clarifying that the two key communication routes for that in BHR are the SOCG and the Transformation Boards where acute, community and primary care providers meet together.

KA referred to the role that patients and the wider public have in terms of responsibility for self-care, self-management of obesity and preventative actions and asked for this to be identified as a specific element in the recovery plan as part of public engagement. CJ agreed and added that at a BHR and wider NEL level we are all working very closely with Local Authorities on different ways of engaging and gave virtual meetings as an example.

KP suggested looking at the local population by profession might be helpful in order to see areas where people are more at risk of Covid-19. KP also asked what is being done to rebuild public confidence to return to hospital sites and the cafes based on the hospital sites, pointing out that many people need to rely on public transport to get to hospital. JJ responded that a communications strategy is being worked on at a national level and messages will be communicated nationally and locally. He added that work is being undertaken by the Mayor of London and Transport for London (TFL) in regard to re-building confidence in terms of using public transport. CJ confirmed that all Trusts are ensuring that their sites are as safe as they can possibly be by following the guidance in terms of segregating all areas and added that in terms of the public areas within hospital sites such as cafes, all the rules in regard to social distancing and the use of masks apply. BHRUT has produced videos and the CCGs’ communications team is working closely with the Trust to promote the videos.

JJ referred to mental health investment in terms of recovery planning and CJ highlighted the impact that the pandemic has had on all the investments that were planned for 20/21. The mental health investment standard must be achieved and we have been assured that the expected investment monies for that this year are still going to be provided. Discussions are already underway with NELFT to determine where the priority areas are.

The Joint Committee: • Considered and noted the actions being taken on recovery and restoration in BHR and north east London.

3.2 Joint Committee assurance framework (JCAF) update MP presented the report which provided an update on the current position of the CCGs’ JCAF and continued focus and management of the CCGs’ highest rated risks. In order to respond to the Covid-19 pandemic, many business as usual activities and meetings were suspended and the overriding priority for the CCGs was to manage the risks associated with the pandemic.

The key risks for the CCGs on the JCAF relate to achievement of our constitutional targets:

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• A&E for Barking, Havering and Redbridge University Hospitals Trust and Barts Health • Referral to treatment times (RTT) for BHRUT and BH • Increasing access to psychological therapies (IAPT) in Barking and Dagenham and Redbridge • The CCGs’ financial position.

All of these areas were impacted by the pandemic and standard monitoring of performance was suspended. As services begin to restart, such as elective care, performance monitoring is also being restarted. As we begin to recover from the first wave of the pandemic and prepare for any subsequent waves, the CCGs’ are reassessing their corporate priorities and associated risks. As part of the Restoration and Recovery Programme, directors and workstream leads are maintaining risk registers from which key risks (and those which affect NEL) are pulled together so the that the most significant risks are escalated to the relevant Assurance Framework.

KA commented that as we move towards an integrated system and begin identify risks across the system as a whole, we need to be mindful that there may be some risks that affect organisations in different ways and cited continuing healthcare (CHC) as an example. SM assured the Joint Committee that the CCGs are working closely with the BHR Local Authorities to plan for the return of CHC assessments which were suspended due to Covid-19. Concern has been raised by the Local Authorities about managing the financial risk when we return to business as usual and SM advised that this may feature as a risk on the register going forward.

KP asked if stress testing in regard to recovery, restoration and resilience planning is taking place. JM responded advising that there is a comprehensive dashboard across the whole NEL system which enables stress testing to be undertaken. CJ elaborated confirming that we are also planning collaboratively as a system for a surge. Workforce implications are a significant risk for the system as a whole and that is being closely looked at.

ASh referred to St Francis Hospice explaining that it is an integral part of palliative care and made the committee aware that the organisation has lost a lot of its funding due to the pandemic. ASh was thanked for flagging the important point and it was noted that although hospices did receive some national funding to address the risk, it is not on-going.

The Joint Committee: • Noted the position of the JCAF and the management of the CCGs’ risks in the context of Covid-19.

4.0 Corporate strategy and planning 4.1 Corporate objectives 2020/21 CJ presented the report and advised that the CCGs’ corporate objectives had not been agreed as usual in March given the suspension of meetings due to the pandemic. The CCGs’ objectives for 2020/21 build on those agreed last year but have been refreshed in light of the Covid-19 pandemic as this year our health and care system has faced an unprecedented challenge in response to the Covid-19 pandemic and an additional objective has been

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added to reflect that relating to the recovery and restoration of services in BHR;

The objectives for 2020/21 are:-

• High quality, safe and compassionate care for all commissioned services – delivering better outcomes for local people • Recovery and restoration following the impact of Covid-19, also ensuring that we are fully prepared for winter and any potential further waves of Covid-19 • Establish our BHR Integrated Care Partnership within the NEL ICS, with primary care as the foundation of a system delivering improved health and wellbeing and tackling inequalities, through strong borough partnerships • Transform the way that care is delivered and secure financial sustainability through the work of our multi-agency transformation boards and delivery of our joint NHS system financial plans including the recovery of positions where they are at risk

RC referred to the BHR ICS finance group mentioned in the report and AK provided clarity that the group had been established pre Covid-19 and has met recently. Progress is being made in regard to how we plan collectively as a system to address the financial position in BHR.

The Joint Committee: • Considered, discussed and agreed the corporate objectives.

4.2 North East London (NEL) LeDer annual report 2019/20 JS presented the report which informed the Joint Committee of the findings of the NEL Learning Disability Mortality Review programme in 2019/20, and set out the recommendations from the review for consideration. The findings of the first 32 rapid reviews undertaken into the deaths of people with a learning disability where Covid-19 was a factor were also included.

KP asked whether a review is being undertaken to establish the reasons why so many people have died in hospital. SM responded by explaining that one of the findings from the rapid reviews was that people with Learning Disabilities (LD) and Covid-19 symptoms appear to have presented quite late and that is something that will be considered as part of the action plan. JS added that the action plan is aimed at providing care in the right place and referred in particular to Community Based Care to reduce preventable admissions. KP also asked whether any of the expected mental health investment standard monies will be used to support the recommendations in the report and SM clarified that neither LD or autism are covered by the mental health investment standard but added that there is another funding stream through the Funding Transfer Agreement (FTA) with NHS England and the NEL Learning Disabilities and Autism Board will be responsible for agreeing the appropriate use of transformation funding that is received via the FTA route.

JS responded to a question raised about the annual health check and confirmed that it is something that will be explored and developed further.

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KA asked whether there is enough capacity in the system in order to be able to deliver on the recommendations and SM explained that the reviewers are generally clinicians from NELFT and ELFT who have been focussed on frontline services during the pandemic and as such, consideration will need to be given as to how additional capacity can be supported in order to complete the remainder of the reviews. KA also noted that 75% of the patients lived in residential and supported living accommodation where there were difficulties in securing PPE and asked if that situation has improved. SM confirmed the situation has improved significantly following a mutual aid programme put in place across BHR and it will be focussed on in regard to winter planning.

MGC informed the committee that the number of deaths of people with LD has returned to the expected level that would have been seen pre Covid-19 following the spike seen during April and May.

The Chair drew the discussion to a close by thanking JS and her colleagues, in particular RP, for the comprehensive report and members were asked to note the risks outlined in the report.

The Committee: • Noted the contents and the findings of the NEL LeDeR Annual Report 2019/20. • Agreed the recommendations and the action plan included in the NEL LeDeR Annual Report 2019/20. • Noted the findings of the first 32 rapid reviews undertaken into the deaths of people with a learning disability where Covid-19 was a factor, and agreed the recommendations made.

5.0 Quality and performance 5.1 Finance risk overview report AK presented the report and gave an overview of the key points on behalf of HB. Covid-19 expenditure includes £6m for the hospital discharge pathway and primary care response to Covid-19, most of which will be recovered through top-up arrangements with NHSE. The expectation is that the temporary finance arrangements will remain in place until the end of August 2020 when updated national guidance is expected. There are a number of issues that remain outstanding at month 3 including the investment requirements in relation to meeting national standards, in particular mental health services. KP advised in his capacity as Chair of the CCGs’ finance committee that the committee intends to convene an additional meeting once the updated guidance the finance regime for the remainder of the year has been received in order to consider the implications.

The Joint Committee agreed the financial position, noting the risks within it.

5.2 Integrated Performance report (IPR) SR gave an overview of the key message in the report and began by commending BHRUT for its response to the pandemic and for continuing to protect patients and staff going forward. The biggest impact seen over the past few months has been activity reduction at BHRUT. The Trust has needed to re-configure capacity at both Queen’s Hospital and King George Hospital in response to the pandemic. Performance against all constitutional standards had to be suspended or significantly reduced. BHRUT is

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continuing to triage all referrals and focus on clinical prioritisation and is also continuing to utilise the independent sector for its elective services recovery. Recovery action plans are in place for cancer and diagnostics which have been significantly impacted by Covid-19. In regard to mental health, a significant reduction in IAPT access referrals has been seen. The numbers are beginning to increase and they are expected to be significantly higher than the numbers seen pre-Covid-19.

KA asked whether an improvement in the reluctance of patients wanting to attend hospital appointments is beginning to be seen. SR responded that there is still a significant number not wanting to return but added that progress is being made and that a national and local communications programme is being undertaken to address the concerns.

The Joint Committee: • Reviewed the report • Noted the actions being taken.

6.0 Development/governance 6.1 Annual audit letter 2019/20 KP explained that the annual audit letter is a summary of the CCGs’ external auditor’s work for the past financial year. The BHR CCGs received a very positive report from the external auditor, who issued an un-qualified audit opinion on the annual accounts for 2019/20 for each CCG together with an un- qualified value for money conclusion. The recommendations are being followed up by the Audit & Governance Committee.

The Joint Committee noted the report.

6.2 Finance Committee chair’s report The Joint Committee noted the report provided by the Chair of the Finance Committee which highlighted the key points discussed at the two meetings held in June 2020.

6.3 Audit & Governance (A&G) Committee Chair’s report The Joint Committee noted the report provided by the Chair of the Audit & Governance Committee which highlighted the key points discussed at the meetings held in June and July 2020.

6.4 Minutes of Committees and relevant fora:- The Joint Committee noted the minutes of the following:

• NEL joint commissioning committee • Primary care commissioning committee • Quality & performance committee

7.0 Any other business Covid-19 local restrictions - GX reported that the Public Health Teams across BHR have produced local outbreak management plans which are being tested locally and also by the STP. System-wide scenario testing is also being planned across NEL. A programme offering Covid-19 tests to people living in supported and residential care has also been set up. The Chair thanked GX for the assurance.

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8.0 Questions from the public No questions from the public had been received.

Date of next meeting – 24 September 2020

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Joint Committee of BHR CCGs’ actions log

Action ref: Meeting Action required Lead Required Status date by

2.3 Quality 30 July Quality issues relating to Barts Health Trust to be MGC Sept 2020 Complete. report 2020 included in the report going forward.

2.4 Patient 30 July Discussion to be held between Lay Members and the MP Sept 2020 Discussions re patient engagement engagement 2020 Quality Lead looking at ways to improve how and experience are being picked report intelligence currently gatherthered at PEF and other up in the development of new patient meetings in regard to quality and patient safety arrangements for the proposed is used. NEL CCG. The Covid-19 intelligence work has now been commissioned from NEL Healthwatches and is underway. Findings will be shared with all, including quality and lay colleagues.

BHR CCGs Joint Committee- CLOSED ACTIONS

Action ref: Meeting Action required Lead Required Status date by

2.0 BHR CCGs’ June MGC to follow up on the CQC questionnaire sent to MGC July Complete – response provided by annual reports 2020 GP practices in order to address the wider response the Quality & Safeguarding team. and annual to the CQC’s questions in regard to safeguarding. accounts 2019/20

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

4.0 External June BHR CCGs’ Audit & Governance Committee to follow- KP July Complete – followed up by the Auditor’s 2020 up the recommendations made in the report. Audit &Governance Committee. report to those charged with governance HB to follow up on whether the Capita report has been HB July Complete – report has been (ISA260) received. received.

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To: Meeting of the NHS Barking and Dagenham, Havering and Redbridge CCGs’ Governing Bodies (meeting in common)

From: Dr Jagan John, Chair, Barking and Dagenham CCG Dr Atul Aggarwal, Chair, Havering CCG Dr Anil Mehta, Chair, Redbridge CCG

Date: 24 September 2020

Subject: Chairs’ report

Executive summary The report provides an overview of our key activities and those of the CCGs since reporting to the BHR CCGs Joint Committee meeting held in July 2020.

Recommendations The Barking and Dagenham, Havering and Redbridge CCGs’ Governing Bodies are asked to note the report.

1.0 Purpose of the report 1.1 To provide an update on activities since the last meeting and on key CCG news.

2.0 Getting back to health 2.1 We would like to reassure our local population that that health services are back up and running. A whole range of measures are in place to protect against Covid-19 to keep people safe. It is essential that people attend their appointments when requested whether this be by phone, video or face to face. The winter flu vaccination programme will also commence soon and we encourage all those eligible to make their appointment when it becomes available.

3.0 BHR collaborative working 3.1 We are widening our system working with our local partners and have recently established the BHR system quality and performance committee with members of the CCG, BHRUT and NELFT in attendance.

3.2 Integrated partnership: Following the workshop held by the BHR Integrated Care Partnership Board (ICPB) in July the vision, principles and governance were refreshed. The board received a report on the review of transformation boards which included recommendations from the Carnall Farrar review as well as learning from the Covid 19 pandemic. BHR Partners recognised the essential need to address inequalities through a joint approach with health, care, and wider partners and the ambition is to embed this in everything we do and this will be progressed through a sub group of the partnership. A more detailed report on progress is presented later on the agenda.

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4.0 North East London (NEL) commissioning developments 4.1 The future of health and care for the people of north east London – the direction of travel in the NHS Long Term Plan is one CCG per integrated care system (ICS) by April 2021. We have taken more time than others to ensure development of our local arrangements and wider ICS and we are currently sharing our proposal and seeking views from our stakeholders through to end September. More detail is shared later on the agenda.

4.2 The NEL Chairs continue to hold twice weekly virtual early morning meetings working together to resolve issues and provide support where needed, with a particular focus on Covid-19.

5.0 Health and wellbeing boards (HWBB) 5.1 In July the Barking and Dagenham HWBB reconvened. The Director of Public Health gave an overview of the pandemic in the borough and highlighted the relevant local aspects such as the geographical spread and the different groups of people at higher risk of admission to hospital and of deaths. He also gave the latest position and implementation of NHS Test and Trace Programme. The role, values and priorities of the Barking and Dagenham Delivery Group have been reviewed to ensure that it is best placed to support the borough’s recovery following the Covid-19 pandemic. We also provided an update on the recovery and restoration of NHS services.

5.2 At the Havering HWBB held in August we were given a presentation on Borough Partnerships and discussed the proposed approach regarding the establishment of a Havering Borough Partnership. We also received a verbal update to members about rates of coronavirus infection in the borough and progress with the development and implementation of the outbreak control plan.

5.3 The Redbridge HWBB held their meeting in July where we provided an update on Recovery and Restoration of NHS services. Public Health presented on the impact of Covid and local actions agreed which are designed to help BAME communities understand how they can mitigate their risk, to understand the related health risk factors and to promote the NHS Test and Trace system. The Board approved the Local Outbreak Plan which is the localised plan for management of the Covid-19 Pandemic and outlines the development of a partnership response to local outbreaks, community clusters, and the potential for localised social restrictions. We also noted how Healthwatch Redbridge had responded to the pandemic across Redbridge.

6.0 Resources/investment 6.1 There are no additional resource implications/revenue or capital costs arising from this report.

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

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

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

Author: Keeley Chaplin, Business Manager, Governance, BHR CCGs Date: 9 September 2020

2 35 To: Meeting of the NHS Barking and Dagenham, Havering and Redbridge CCGs’ Governing Bodies (meeting in common)

From: Jane Milligan, Accountable Officer

Date: 24 September 2020

Subject: Accountable Officer’s Report

Executive summary This report provides an overview of key activities undertaken by the Accountable Officer since the last meeting, with a specific focus on the developments within the North East London (NEL) Commissioning Alliance.

Recommendations The governing bodies are asked to: • Note the progress report

1.0 A single CCG for north east London 1.1 Work is ongoing to engage our members and partners on our plans to bring together the seven north east London CCGs into one by April 2021. We have taken more time in NEL than other areas to ensure development of our local arrangements and wider ICS. The vast majority of our health and care delivery will continue to be delivered at our local place and borough level, working together as partners with our local population. Our single CCG would continue to be clinically led, with a clinical majority and include lay members. GP members’ forums and representative bodies will be essential to making this successful, working with their local GP chair to make decisions about health and care in local communities.

1.2 A formal vote will take place in early October with the outcome expected by mid-October. Alongside the voting, we will also submit an application to NHS England.

1.3 This is substantive item on the agenda today and will be discussed in more detail.

2.0 Covid 19 response update 2.1 The work of the north east London Incident Control centre continues at pace and we are in the process of finalising the review of wave one and sharing, disseminating and putting in place our learning from this.

2.2 Additionally, we are looking to support the testing regime and any work we can do in preparation for a future vaccination programme.

2.3 We anticipate that we will begin to refresh our planning for EU transition in October alongside our ongoing COVID-19 response.

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3.0 Recovery programme – phase three 3.1 The NEL system response to the NHSE/I Phase 3 planning letter was submitted on 21 September, including a template modelling the system trajectories and a supporting narrative. The overall focus for phase 3 has been on restoring activity in a safe and sustainable way, while ensuring equity and tackling health inequalities.

3.2 A key part of the recovery work is restoring our elective, non-elective and diagnostics services and this will be shaped in part by the work of our acute alliance which brings together the three acute Trusts in North East London, Barts Health NHS Trust, Homerton University Hospital Foundation Trusts and Barking Havering and Redbridge University Trust

3.3 As well as enabling delivery of the requirements from phase three, the Acute Alliance lays the foundation for a longer-term, strategic partnership to support a resilient hospital sector in North east London

3.4 NEL has been developing plans that are ambitious, but aim to be deliverable and further work is underway to consider what else can be done to recover services further and faster with a particular focus on increasing elective and diagnostic activity in a safe and sustainable way.

4.0 NELCA Diversity and Inclusion

WRES workshop 4.1 We are holding a second WRES workshop this month, hosted by our newly formed BME staff network, to discuss our WRES data and engage staff in developing the BME staff network action plan for 2020-21.

4.2 The virtual event will be opened by Marie Gabriel, who as well as being our ICS Chair is the new chair of the NHS Race and Health Observatory, which is hosted by the NHS Confederation and will identify and tackle the specific health challenges facing people from BAME backgrounds.

4.3 We will also hear from Julie Dublin, about the network’s vision, there will be an opportunity to discuss last year’s action plan and outcome and I will be discussing NELCA’s commitment to our WRES work.

Developing the anchor approach in north east London – virtual event 4.4 We held the first of two virtual events this month focused on establishing our anchor charter for north east London. Recognising the economic impacts of Covid-19 on our population we have developed an inequalities framework and as part of this we are considering how we can use our positions as anchor organisations drawing on our roles as major employers and procurers to support financial recovery and reduce health inequalities.

4.5 The event brought together partners from across local authorities, health, the voluntary sector and patient groups and focused on discussions about social mobility, what a charter for NEL might look like and good examples of anchor ways of working. I joined a range of speakers including Marie Gabriel, our ICS Chair, Jason Strelitz Director of Public Health for Newham as well as Julia Slay one of our lay members with a special interest in anchor organisations.

4.6 A follow up event will be held later on in the autumn.

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5.0 AGMs 5.1 This year we are holding all of our AGMs virtually in light of the ongoing pandemic. All three will have taken place by the end of September and include an overview of our 2019-20 achievements, a run through of the financial picture and a look ahead to the next twelve months. The AGMs are public facing events and have been advertised to our local residents and partners.

6.0 International year of the nurse celebration event 6.1 2020 is Florence Nightingale’s bicentennial year and has been designated by World Health Organisation as the first ever global Year of the Nurse and Midwife. Nurses and midwives make up the largest numbers of the NHS workforce and are highly skilled, multi-faceted professionals from a host of backgrounds that represent our diverse communities. 2020 is our time to reflect on these skills, the commitment and expert clinical care they bring, and the impact they make on the lives of so many. This year has also been one of unprecedented times and a year in which all clinicians worked in new and innovative ways to ensure patients received the best and highest quality of care

6.2 The senior management team across NEL want to celebrate and recognise the fantastic achievements of nurses and midwives across the system and we are holding a virtual celebration event on 28 September for all nurses and midwives in the NEL system, particularly focusing on those working in CCGs, primary care and the CSU.

6.3 Speakers include Ruth May, the NHSE/I Chief Nursing Officer, Jane Clegg and Martin Machray, the NHS London join Chief Nurses and Oliver Shanley, former regional Chief Nurse who is now the Chief Executive of NELFT.

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

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

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

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

16 September 2020

38 To: Meeting of the NHS Barking and Dagenham, Havering and Redbridge CCGs’ Governing Bodies (meeting in common)

From: Sahdia Warraich, Richard Coleman and Khalil Ali, Lay Members (PPE)

Date: 24 September 2020

Subject: Patient Engagement Report

Executive summary

This report summarises patient and public engagement, feedback and insight gathered since the last meeting.

Areas covered: • Our response to the pandemic • Patient engagement forum updates • Children and Young people’s survey • BHR CYP Transformation Board • Supporting the NEL CYP workstream • BHR Health and Faith Network • Impact of Covid-19 on our planned engagement work

Recommendations The governing bodies are asked to: • Note and comment on the contents of the report

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

2.0 Our response to the pandemic 2.1 The engagement team has continued to work hard with North east London NHS and local authority partners by sharing important messages via their channels. The team has continued to make connections in the community with key organisations such as Sight Action, Action on Hearing Loss and a Polish and European Group based in Havering.

2.2 Feedback from Sight Action around ‘what to expect if you go into a hospital and you are blind or partially sighted’ was fed back to BHRUT and has sparked a project within the Trust to look at what support is needed for a whole range of people with different needs when arriving and navigating the hospital.

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2.3 The CCGs are working with local partners to share updates on the restart of local health services including those at our local hospitals. Work is underway with providers to develop robust plans to support those patients whose treatment was affected by the impact of the pandemic, and the CCGs will support this by sharing information with patients, the public and the community and voluntary sector.

2.4 GP practices are also open for business, and we are providing patients and the public with information to encourage them to go to their GP if they have any health concerns. We will continue this work to help local people understand that while most appointments will be by telephone or video consultation, safety measures are in place to enable patients are able to go in surgeries for appointments with GPs and other health professionals.

2.5 Havering Council has recently launched their public health campaign #DoingMyBit which is encouraging residents to work together to minimise the spread of coronavirus. The CCG has supported by sharing the campaign with stakeholder groups, patients and GPs. It has also been included on the home page of the Havering CCG website.

2.6 The communications and engagement team is also be working to support the annual flu vaccination programme by encouraging eligible residents to take up the offer a free flu jab. This will be particularly vital as we continue to meet the challenge of COVID-19 this year. The CCGs will work with GPs and local partners to ensure we share messages and information with all our communities, targeting those at highest risk.

2.7 Havering Council recently supported the CCG and shared our north east London flu survey in their e-newsletter to residents. This attracted 300 responses to the survey and the responses will inform the flu campaign for this year. The is a direct result of building good relationships with local authority colleagues.

3.0 Patient Engagement Forum (PEF) updates 3.1 We invited members to a Joint PEF in July to come and talk to us about our recovery plans. Many questions were submitted before the meeting, mostly about access to primary care. Ceri Jacob gave an overview of the work the CCGs have been doing led a Q&A session. 17 members were in attendance - the same amount that we had at the physical Joint PEF meeting in November – which shows us that the online reach, so far, is the same as at a physical meeting.

3.2 PEF members continue to receive regular updates between meetings, with opportunities to get involved in local projects as well as information on specific requested topics of interest and opportunities. This has included information about forming a single CCG, blood testing, Whipps Cross redevelopment, support and opportunities for young people, how to get tested for coronavirus, our vaccines and asthma campaign and details about the Reconnections Service. They have also received an invite to the AGM, a diabetes webinar, a Q&A with Redbridge Council, various Healthwatch events and the recent NEL mental health summit.

4.0 Children and Young People’s survey 4.1 During lock down the CCG initiated a project with the three youth councils and ran a survey to find out how the pandemic had impacted young people. A report for this survey is now available on our website.

4.2 The project is being viewed as an example of good practice and shows how working with young people in this way is really rewarding and can really help them make their voices heard. The children’s mental health leads are viewing the report and considering how this can help shape their plans for the CAMHS service, as it provides a depth of understanding of the impact of lockdown on young people.

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4.3 A further report will be developed to show the impact of this piece of work.

5.0 BHR CYP Transformation Board 5.1 A mapping exercise of organisations and support for children and young people and their families has been carried out to underpin future engagement work for the board.

5.2 Discussions are now underway to provide engagement support for specific workstreams such as the autism diagnosis model and the Paediatric Integrated Nursing Service.

6.0 Supporting the NEL CYP workstream 6.1 Annie Robertson, communications and engagement manager, has recently been assigned as the north east London engagement lead for CYP. She is now attending the STP meetings and supporting by giving advice and helping to provide an overview of engagement that is happening across the seven boroughs.

7.0 BHR Health and Faith Forum 7.1 In response to COVID-19, the CCGs set up a BHR interfaith group to support our faith communities throughout the pandemic.

7.2 Members have expressed their enthusiasm to continue and grow this work. The group decided on a number of objectives for the network which have a focus on health and contribute to the north east London equality plans.

7.3 A draft terms of reference has been developed which help to ‘relaunch’ the group (as they decided to take a break throughout August) and they are hoping to attract new members to represent more faith communities across the three boroughs.

8.0 Whipps Cross Redevelopment Programme 8.1 The government has endorsed the Strategic Outline Case (SOC), and the next stage of the Outline Business Case (OBC) has commenced. Marie Clough has been appointed as the Patient Experience and Engagement Lead for Whipps Cross, and patients, and user representatives are being invited to engage in the development of the OBC.

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

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

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

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

Author: Melissa Hoskins, Head of Communications and Engagement, BHR CCGs Date: 9 July 2020

3 41 To: Meeting of the NHS Barking and Dagenham, Havering and Redbridge CCGs’ Governing Bodies (meeting in common)

From: Marie Price, Director of Corporate Affairs, NELCA

Date: 24 September 2020

Subject: Barking and Dagenham, Havering and Redbridge CCGs’ Governing Bodies’ Assurance Framework (Joint Committee Assurance Framework – JCAF)

Executive Summary The joint committee assurance framework (JCAF) reflects the current significant risks to the three organisations. In responding to the Covid-19 (CV19) pandemic, many business as usual activities and meetings were initially suspended with the overriding priority for the CCGs being to manage the risks associated with the pandemic. With several BAU activities now back up and running the JCAF has been reviewed in light of the current priorities. However, throughout the pandemic and currently the most significant risks remain as detailed below:

• A&E for Barking, Havering and Redbridge University Hospitals Trust and Barts Health • Referral to treatment times (RTT) for BHRUT and BH • Children and Adolescent Mental Health Services (CAMHS) access standard – not met in Barking and Dagenham and Redbridge • The CCGs’ financial position.

The above areas were impacted by the pandemic and standard monitoring of performance was suspended for a short period and is now back in place.

As we continue to recover from the first wave of the pandemic and prepare for any subsequent waves, we have reassessed our corporate priorities and the associated risks. As part of the Restoration and Recovery Programme directors and workstream leads have been maintaining risk registers from which key risks (and those which affect north east London) are pulled together so that the most significant risks are escalated to the relevant Assurance Framework.

Recommendations The governing bodies are asked to: • Note and comment on the current risks escalated to the JCAF and that assurance, levels, controls and mitigating actions being taken are appropriate • Raise and discuss other potential risks that may require escalation to the next JCAF

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

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1.2 In addition to highlight to the committee any significant on-going risks associated with the CV19 pandemic.

2.0 Background 2.1 The CCGs’ joint committee has a responsibility to maintain sound risk management processes and ensure that internal control systems are appropriate and effective, and where necessary to take appropriate remedial action. The CCGs’ collaborative risk register consists of risks that are specific to the individual functions across the CCGs and risks that the CCGs have in common.

2.2 Risks are recorded by directorates and functional areas within a collaborative risk register that details the risks that are common across the health economy for Barking and Dagenham, Havering, and Redbridge Clinical Commissioning Groups (BHR CCGs. The highest rated risks from the risk register are escalated to the JCAF and a report provided to the Joint Committee at each meeting.

3.0 Joint Committee Assurance Framework Risks (JCAF) 3.1 As at 1 September 2020 the highest rated risks across BHR that had been escalated to the JCAF remain as follows: - • Performance against the A&E standard for Barking, Havering and Redbridge University Hospitals Trust’s (BHRUT) with a risk rating of 16 • Performance against the A&E standard for Barts Health (BH) with a risk rating of 12 • Performance against the 18 weeks Referral to Treatment Times (RTT) standard for BHRUT with a risk rating of 20 • Performance against the 18 weeks Referral to Treatment Times (RTT) standard for BH with a risk rating of 20 • Children and Adolescent Mental Health Services (CAMHS) access standard – not met in Barking and Dagenham and Redbridge CCGs with a risk rating of 12 • The Clinical Commissioning Groups’ (CCGs) budget/control total with a risk rating of 16

3.2 Reviews of all the risks on the CCGs’ collaborative risk register is underway with relevant directors. Risk descriptions are being revised and mitigating actions updated that also consider the impact of CV19. Our significant risks that currently remain on the JCAF, detailed above, were all impacted by the pandemic and monitoring of these performance standards was temporarily suspended. However, several business as usual activities and patient services have restarted and Trusts have recommenced performance monitoring. Any emerging new risks of a significant level will be escalated to the next JCAF.

4.0 Resources / investment 4.1 There are no additional resource implications/revenue or capital costs arising from this report. The cost of operating effective risk management arrangements is met from within existing resources.

5.0 Equalities 5.1 There are no equalities considerations from this report.

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6.0 Risk 6.1 This report also links to the following GB papers being presented at this meeting and provide greater detail on key risks mentioned above and the organisations mitigations.

• JCAF risks ref. 3.1, 3.2, 3.3, 3.4 and 3.7 relates to the Integrated Performance report (IPR) • JCAF risk ref. 3.6 relates to the IPR and Finance Overview report

7.0 Managing conflicts of interest 7.1 There are no conflicts of interest considerations arising from this report.

Attachment: Appendix 1 – NHS Barking and Dagenham, Havering and Redbridge CCGs’ Joint Commissioning Assurance Framework

Author: Pam Dobson, deputy director, corporate services, BHR CCGs. Date: 1 September 2020

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Appendix 1 – NHS Barking and Dagenham, Havering and Redbridge CCGs’ Joint Commissioning Assurance Framework

Corporate Transform the way that care is delivered and secure financial recovery; Risk Ref. 3.1 Objectives Recovery and restoration following the impact of CV19

Risk If A&E standards and the agreed trajectory is not achieved at BHRUT, this could impact on the Risk Owner Steve Rubery, Director of Commissioning & Performance Description delivery of services to patients, could cause clinical harm and present a reputational risk.

Date of last B&D CCG Hav CCG Red CCG New CCG WF CCG TH CCG CH CCG Lead BHR Health System Quality CCGs Impacted committee 20 August 2020 Committee & Performance Committee    update

Score history and targets Initial Rating Initial Date Rationale Following a CQC visit, there are continued concerns with urgent and emergency care at BHRUT with risks to patient care and viability of the Trust. Failure to deliver quality improvement in urgent and emergency care could threaten the 4x4 = 16 June 2013 long-term viability of the Trust; put patients at risk; cause reputational damage and delay the implementation of acute reconfiguration programmes. Target Rating Target Date Rationale The Urgent and Emergency Care Transformation Board has been established with 3 clinically led working groups (Ambulance and Community pathways; Front door; Secondary Care). The Discharge Improvement Working Group continues and links in via the SOCG. In August the Trust developed a ‘Whole Hospital Recovery Plan’ which has 7 streams of work and the core focus is to improve ED performance by improving systems and flows across the hospital. The UEC TB supports 2 of these streams and the others are internal. A system winter plan is in 3x4 = 12 31 Mar 2021 development which focuses on both preparation for winter but also the risk of a second wave of CV19. Staffing continues to be a major risk for the Trust, along with physical capacity. Bed numbers and space if affected by the need to have both CV19 and non CV19 capacity. This affects bed flow and therefore performance. The transformation Board was established in June and the whole hospital plan was established in August and it is expected that the work through these plans will address performance. Latest review Rationale Current Rating date BHRUT has not met the trajectory in any month of 2020 / 21. Performance has been affected by CV19 – while 4x4 = 16 14 Sept 2020 activity was lower during the outbreak performance was affected by staff and bed flow. As attendance numbers started to increase performance worsened due to space and staffing issues. Assurances Date Received Controls Evidence for assurance I= internal, E= external 1. Urgent & Emergency Care Transformation Board (UETB) 1. Minutes of the monthly UETB (I) 2.09.2020 The integrated performance 2. BHRUT A&E Performance monthly assurance 2. Minutes of the monthly meeting (I) 19.08.2020 report provides greater detail on 3. Report to the BHR Health System Quality & Performance Committee monthly 3. Minutes of the BHR Health System Q&P Committee (I) 20.08.2020 the management of this risk Gaps Proposed actions Target Date Controls Assurance None reported. Mitigations 1. Urgent & Emergency Care Transformation Board with 3 workstreams 2. King George Hospital has deferred the implementation of the UTC until 15 September, with UTCs at Queens’s hospital, Harold Wood and Barking now in place with the phasing in of more diagnostics with PELC delivering the injury component. 3. Winter plan is being developed and led by director of commissioning and performance and to be completed by 30 September 2020 4. The A&E trajectory is being reviewed monthly and monitored by BHRUT A&E Performance assurance meeting 5. The 111 service is now able to make appointment bookings to stagger patient arrival times and improve the use of available capacity 6. Improved collaboration via daily discharge calls with the system partners, BHRUT, NEL, LAS and BHR including liaison with the BHR CHC team

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Corporate Transform the way that care is delivered and secure financial recovery; Risk Ref. 3.2 Objectives Recovery and restoration following the impact of CV19

Risk If A&E standards and the agreed trajectory is not achieved at Barts Health (BH), this could impact on Risk Owner Steve Rubery, Director of Commissioning & Performance Description the delivery of services to patients, could cause clinical harm and present a reputational risk.

B&D CCG Hav CCG Red CCG New CCG WF CCG TH CCG CH CCG BHR Health System Date of last CCGs Impacted Committee Quality & Performance committee 20 August 2020       Committee update

Score history and targets Initial Rating Initial Date Rationale Performance at the Trust has been poor overall with performance rarely hitting the required national standard (95% of those attending being seen in four hours). Poor flow through the hospital – both into wards and other services, as well 4x5 = 20 March 2015 as discharge back home and into community or other settings. The Barts Health position on A&E is unachievable by the 2014/15 year end. The A&E target is of most concern at the Whipps Cross and Royal London sites where failure of the required standards continues. Target Rating Target Date Rationale Whipps Cross undertook Perfect Month in April and learning from this has been added to the action plans which will be 3x4 = 12 31 Mar 2021 updated to focus on the areas that will have the greatest impact.

Latest review Current Rating date Rationale In February 2019 the risk was decreased to 12 following the positive impact of mitigating actions. This position has 3x4 = 12 14 Sept 2020 been maintained but the hospital performance did deteriorate during CV19 but they had a good recovery and have been meeting their trajectory Assurances Date Received Controls Evidence for assurance I= internal, E= external 1. Quarterly A&E Delivery Board (A&EDB) meeting, attended by Tower 1. Minutes of the A&EDB (E) 19.06.2020 Hamlets CCG on behalf of commissioners The integrated performance 2 Weekly NEL system level Restoration and Recovery Board with work-steams 2. Weekly summary of the daily performance reports 09.09.2020 report provides greater detail on reporting in from the Acute Alliance on UEC and winter planning the management of this risk 3. Monthly A&EDB urgent care working group at Whipps Cross hospital jointly 3. Minutes of the working group meeting (E) 19/08/2020 chaired by BH and Waltham Forest CCG attended by BHR CCGs’ UC lead Gaps Proposed actions Target date Controls Assurance None reported Mitigations 1.BH contract managed by Tower Hamlets CCG with support via NELCSU 2.AEDB working group (Whipps Cross) attended by BHR CCGs representative monthly

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Corporate Transform the way that care is delivered and secure financial recovery Risk Ref. 3.3 Objective

Risk If BH fails to deliver the operating plan trajectories in relation to RTT (WL size and 52 weeks wait) by Risk Owner Steve Rubery, Director of Commissioning & Performance Description 31 March 2021, this could impact on patient experience and could cause clinical harm.

B&D CCG Hav CCG Red CCG New CCG WF CCG TH CCG CH CCG BHR Health System Date of last CCGs Impacted Committee Quality & Performance committee 20 August 2020    Committee update

Score history and targets Initial Rating Initial Date Rationale Barts Health is non-compliant with the national referral to treatment (RTT) waiting time standards at specialty, as well as 4x5 = 20 July 2014 Trust aggregate level. In light of the large-scale data quality issues at the Trust, the Trust Board have taken the decision to suspend the monthly mandatory reporting of referral to treatment waiting times data. Target Rating Target Date Rationale If the Trust achieves its trajectory for 19/20 and is able to sustain performance for Q1 20/21 it is anticipated that the risk 3x3 = 9 31 Mar 2021 level could be reduced.

Latest review Current Rating date Rationale The Trust has not achieved its trajectory for 52 week waits which are at 50 against a target of 11. RTT incomplete performance has not improved albeit the PTL target has been achieved. However, it has been confirmed that the 4x5 = 20 9 Sept 2020 majority of the appointment slot issue (ASI) list drop off (highlighted in the last report) is attributed to Whipps Cross and therefore is likely to affect Redbridge CCG patients. Assurances Date Received Controls Evidence for assurance I= internal, E= external

1. Weekly Acute Alliance - Operational Elective Restart (AAOER) Meeting 1 Notes of the AAOER meeting (E) 9.09.2020 The integrated performance report provides greater detail on 2. Review of performance monthly, with a deep dive on a quarterly basis at the the management of this risk 2. Minutes of the Q&P committee (I) 20.08.2020 BHR Health System Quality and Performance (Q&P) committee Gaps Proposed actions Target Date Controls Assurance None reported Mitigations 1. Collaborative development of draft trajectory to achieve reduction in the number of 52 weeks waits in line with phase 3 letter requirements. Final draft due 21 September. 2. Acute Alliance - Operational Elective Restart Meeting attended by the director of performance and assurance at NELCA.

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47 Corporate Transform the way that care is delivered and secure financial recovery: Risk Ref. 3.4 Objectives Recovery and restoration following the impact of CV19

Risk If BHRUT fails to deliver the operating plan trajectories in relation to RTT (WL size and 52 weeks wait) Risk Owner Steve Rubery, Director of Commissioning & Performance Description by 31 March 2021, this could impact on patient experience and could cause clinical harm.

B&D CCG Hav CCG Red CCG New CCG WF CCG TH CCG CH CCG BHR Health System Date of last CCGs Impacted Committee Quality & Performance committee 20 August 2020    Committee update

Score history and targets Initial Rating Initial Date Rationale In February the position deteriorated across several specialties from the previous month. RTT performance is below the 4x4 = 16 April 2018 agreed trajectory of 91%, the waiting list size and the 52 weeks wait position has increased since January 2018.

Target Rating Target Date Rationale Given the impact of CV19 on the waiting times position and the challenges this has created, if the Trust do not get back 3x3 = 9 31 Mar 2021 on track to achieve the required reduction during the remainder of the current financial year, in order to be fully assured of the sustained delivery the target risk rating date has moved to March 2021 Latest review Current Rating date Rationale With the impact of CV19 the over 52 waits position has deteriorated to a current forecast of 736 patients at the end of March 2021. This is across a number of specialties, although mostly in acute pain and trauma and orthopaedics. A 4x5 = 20 9 Sept 2020 draft trajectory to reduce the number of 52ww patients from the July position of 1,261 to 736 has been submitted as part of the Phase 3 responses, with final submission due on 21/09/20. Assurances Date Controls Evidence for assurance I= internal, E= external Received 1. Fortnightly Performance Touch Point Meeting with CSU colleagues to The integrated performance 1. Notes of the fortnightly touch point meeting (E) 2.09.2020 covering RTT, diagnostics and cancer report provides greater detail on 2. Review of performance monthly, with a deep dive on a quarterly basis at the the management of this risk. 2. Minutes of the Q&P committee (I) 20.08.2020 BHR Health System Quality and Performance (Q&P) committee 3. Weekly Acute Alliance - Operational Elective Restart (AAOER) Meeting 3, Notes of the AAOER meeting (E) 9.09.2020 Gaps Proposed actions Target Date Controls Assurance None reported mitigations 1. Fortnightly “deep dive” meetings with BHRUT’s deputy chief operating officer and the CCGs’ director of transformation and delivery (planned care) 2. Advice and guidance (A&G) scheme now implemented to increase the number of patients that can be managed within primary care. Data reports have shown this has been successful. With the onset of CV19, access to A&G was increased along with the introduction of some advice lines to enable GPs to manage patients more within primary care. A survey has been completed and shows these were well received by GPs 3. The CCGs receives fortnightly status reports from the Trust and oversees any significant changes in position. 4. The Trust are addressing capacity issues within specific specialties by in and out sourcing of activity and undertaking other initiatives, e.g. enhanced triage 5. Collaborative development of draft trajectory to achieve reduction in the number of 52 weeks waits in line with phase 3 letter requirements. Final draft due 21 September. 6. Acute Alliance - Operational Elective Restart Meeting attended by the director of performance and assurance at NELCA.

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Corporate Transform the way that care is delivered and secure financial recovery; Risk Ref. 3.6 Objectives Recovery and restoration following the impact of CV19 Risk Failure to deliver the CCGs statutory financial responsibility to break-even Risk Owner Ahmet Koray, Interim Director of Finance Description Date of last B&D CCG Hav CCG Red CCG New CCG WF CCG TH CCG CH CCG Lead CCGs Impacted Finance Committee committee 30 July 2020 Committee    update

Score History and Targets Initial Rating Initial Date Rationale • The CCG’s draft Operating Plan was set to deliver an in year £6m surplus to allow an element of historic debt to be repaid. However, implementation of national processes as part of the CV19 response has placed all CCGs under revised financial management arrangements. The CCGs are now required to deliver a minimum break-even position, whilst achieving the required Mental Health Investment Standard (MHIS) expenditure. • Revised funding and block payments to NHS providers have been nationally mandated and set at values agreed during 2019/20. For the period month 1 to 6, NHS providers and CCGs are able to request additional top-up funds where legitimate expenditure has exceeded agreed funding, for example CV19 response related costs. NHSE is due 3x4 = 12 April 2020 to release detailed guidance for the remaining six months of the year and in the meantime robust in-year financial management arrangements continue to ensure the validity and reasonableness of expenditure, including those arrangements where upfront financial support has been provided to non-NHS providers or where the CCGs are temporality responsible for the cost of care packages that would otherwise be the responsibility of local authorities. • A further consequence of these revised financial arrangements is that CCGs are currently unable to invest in transformation plans and particularly those that were due to deliver savings. This poses a future risk as the savings strategies that were built into the in-year and medium-term financial plans will need investment that may not be readily available, thus leaving the local health economy facing a period of economic pressure and recovery. Target Rating Target Date Rationale • The current emergency financial regime allows the CCGs to draw additional funding to meet costs that were not covered by the original funding allocation. This is supported by the NHSE mandate that no NHS organisation will be in financial deficit during the CV19 response period. • This arrangement covers the first six months of the year and further guidance along with an allocation for the 31 March remaining months of the year is expected by the end of September 2020. The funding allocation for the second half 3x4 = 12 2021 of the year is expected to deliver a number nationally set activity targets, meet the Mental Health Investment Standard and clear the significant backlog of Continuing Healthcare (CHC) case assessments. This may expose the CCGs to an element of financial risk that will no longer be covered through requests for additional funding and therefore put an element of emphasis back on delivery savings in a climate where restoring activity to pre-CV19 levels is a priority. Latest Rationale Current Rating Review Date • During the first four months of the financial year the CCGs have recorded a small underspend against the funding allocation, but incurred an additional £10m on CV19d related expenditure. The net value has been recovered through an NHSE funding top-up allowing the CCGs to report a break-even position. • The top-up arrangements are expected to cease by the end of September 2020 and depending on the allocation to be notified, may leave the CCGs facing a financial gap. The size of the gap may be further exacerbated if activity 4x4 = 16 10 Sept 2020 recovery requires additional service provision to be commissioned or existing services to be delivered differently and possibly more expensively than previously. In addition to the risk with clearing the backlog of CHC case assessments and quantifying the ongoing costs of these, there is also the risk of the new early discharge arrangements where CCGs are required to cover the cost of the first six weeks of patient care whilst social care packages are put in place. Assurances Date Received Controls Evidence for assurance I= internal, E= external 1. Weekly Financial Recovery Planning, Delivery and Monitoring group (FRPDM) oversight 1. Minutes of the FRPDM 8.09.2020 of the QIPP development process and monitoring delivery against plan meeting (I) 2. Minutes of the monthly 30.07.2020 The integrated performance report, finance risk overview report 2. Formal escalation route to Finance Committee Finance committee (I) and strategic overview of NHS financial recovery report provide greater detail on the management of this risk 3. Minutes of bi monthly Joint 3. Reporting to the Joint Committee Committee (I) 30.07.2020

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49 A regular report setting out all CV19 related CCG expenditure. NEL Audit Committee Chairs receive and review the content the 4. NEL Audit Committee Chairs meeting to review CV19 related expenditure 4. Minutes of meeting (I &E) 28.08.2020 report for assurance that expenditure is reasonable and committed within governance arrangements. 5. Minutes and actions of 7.08.2020 Financial planning decisions to support provider commissioning 5. NEL Operational Delivery Group (ODG) weekly meeting (I&E) arrangements. Controls Assurances None reported Mitigations 1. First four months financial performance against agreed plan presented to NHSE. Feedback received and no further actions required. 2. Open Book approach to costs and contract values with non-NHS providers through the first part of the financial year. 3. Joint Committee of BHR CCGs to receive latest financial position, including risks and mitigations. 4. Revised financial procedures and delegation have been agreed through committee to enable financial delivery and control through the CV19 response period. 5. The Integrated Care Executive Group (ICEG) continues to meet and explore opportunities to deliver a sustainable local system. 6. Triangulation of financial plans with STP providers to ensure consistency across the health economy. 7. Development of a Financial Recovery Plan to be prioritised. This will allow input into the planning process for next year (2020/21) and support delivery of activity and constitution targets when transformation funds are made available. 8. QIPP plans continue to be developed as a rolling programme of work with oversight provided through the various joint transformation boards. These support the ongoing aspirations of the Long-Term Plan, draft Operating Plan and the supporting financial plans, the details of which have previously been presented to the Finance Committee for review and oversight.

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Corporate Transform the way that care is delivered and secure financial recovery Risk Ref. 3.7 Objective Recovery and restoration following the impact of CV19 Risk CAMHS access standard - with current performance this standard may not be met in Barking and Risk Owner Steve Rubery, Director of Commissioning and Performance Description Dagenham and Redbridge CCGs BHR Health System Date of last CCGs B&D CCG Hav CCG Red CCG New CCG WF CCG TH CCG CH CCG Lead Quality and Performance committee 20 August 2020 Impacted Committee   Committee update Score History and Targets Initial Rating Initial Date Rationale

With current performance this standard is now on track to be met in Barking and Dagenham with a forecast out turn of 4x3 = 12 April 2018 36.0%. Redbridge however continue to underperform against the 34% target with a forecast out turn of 25.9%. Under achievement of the standard in 18/19 suggests that it will be challenging to deliver the target in 19/20.

Target Rating Target Date Rationale CV19 adversely affected the timetable for existing recovery action plans including a Redbridge data ‘deep dive’ as previously 30 beneficial in Barking and Dagenham and pathway reviews. NELFT internal systems are reviewing future models of service 3x9 = 9 September delivery arising from CV19 and these will have medium term effects on activity. The existing model of CAMHS services was 2021 severely affected during quarter one and two through staff absence, shielding and redeployment and this prevented any meaningful integrated working around target attainment during this period. Current Latest Rationale Rating Review Date • Since March 2020 CV19 has affected the trajectory of CAMHS referrals and the manner in which services have been delivered and a full assurance report on recovery and potential ‘surge’ planning was delivered to System Operational Command Group in September 2020. NELFT as the main provider are conducting internal reviews to permanently adopt CV19 working practices • CV19 adversely affected the delivery timetable of work being done with NELFT to replicate in Redbridge the improved data collection demonstrated with B&D. It is intended to resurrect this workstream in quarter three. A similar interruption took place around the work to ensure all third sector providers were fully recoding their activity into the relevant dataset for 15 access target purposes and this significant activity is yet to be fully recorded. 4x3 = 12 September • The on-line provider KOOTH delivered additional contacts during CV9 and there is an expectation that recorded activity 2020 will exceed the stated trajectory once the data is passed through the access dataset systems • The revised Phase 3 Operating Plan trajectories are as shown however these are still non-compliant: Barking and Dagenham 28.53% and Redbridge 24.72% • The mitigations around the delivery of the Primary Mental Health (PMH) model and significant investment into Eating Disorder Services are relevant for additional activity being recorded within quarter four There is a CAMHS Operating Group within the Children and Young Peoples Transformation Group and Neuro-disability has been confirmed as a strategic priority by the Board. Assurances Controls Date received Evidence for assurance I= internal, E= external 1. Action notes of the SOCG meeting and assurance via CAMHS 10.9.2020 1. Weekly System Operational Command Group (SOCG) Recovery and Surge report (I) 22.07.2020 The integrated performance 2. Every 6 weeks’ Children and Young People Transformation Board 2. Actions notes and submitted papers (I) report provides greater detail 3. Daily North East London (NEL) CAMHS Phase 3 Planning meetings (time 15.9 2020 on the management of this 3. For agreement of the NEL Phase 3 Trajectories (E) limited) risk. 4. Monthly CAMHS Operational Board (Task and finish group of the Children and 2.07.2020 4 Action notes from the meeting (I) Young People Transformation Board) Gaps Proposed actions Target Date Controls Assurance None reported Mitigations

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51 1. Redbridge CAMHS has now received full parity funding with Havering and B&D in accordance with the NELFT Fundamental Service Review (FSR) of July 2017. The full capacity gap was agreed at £550,000 and a Part Year Effect for 20/21 has been agreed with NELFT. This additionality will remove obstacles to contacts based on capacity funding 2. Funding for the Eating Disorder Service (EDS) business case submitted by NELFT has been agreed adding additional contacts and aiming to meet the revised national standard 3. The Transformation Board has supported the move to establish a Primary Mental Health (PMH) model supporting lower level interventions across primary care, emergency / crisis within acute provision, autism pre and post diagnosis. This additional provision will deliver additional access contacts within year 4. A potential reduction in CV19 related extraordinary requirements will create capacity to source additional access activity reporting from all providers including significant 3rd sector activity

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Barking and Dagenham, Havering and Redbridge CCGs Governing Body Assurance Framework - overall summary (2018 – 2020)

Previous risk ratings Current risk End of year forecast Lead / rating Target Risk description (summarised) JCAF ref. risk rating Feb Apr Jun Aug Oct Dec Feb Apr June Aug Nov Jan Mar Sept This Last time 2018 2018 2018 2018 2018 2018 2019 2019 2019 2019 2019 2020 2020 2020 time

If A&E standards and the agreed trajectory is not S Rubery achieved at BHRUT, this could impact on the 16 16 12 12 12 12 16 16 16 16 16 16 16 16 16 16 12 3.1 delivery of services to patients, could cause clinical harm and present a reputational risk. If A&E standards and the agreed trajectory is not S Rubery achieved at BH, this could impact on the delivery of 16 16 12 12 12 12 12 12 12 12 12 12 12 12 3.2 services to patients, could cause clinical harm and 16 16 12 present a reputational risk. If BH fails to deliver the operating plan trajectories in

S Rubery relation to RTT (WL size and 52 weeks wait) by 31 16 16 12 12 16 16 16 16 12 12 16 16 16 20 12 16 9 3.3 March 2020, this could impact on patient experience and could cause clinical harm.

If BHRUT fails to deliver the operating plan S Rubery trajectories in relation to RTT (WL size and 52 weeks 16 16 16 12 12 12 12 16 16 16 16 20 20 1166 16 9 3.4 wait) by 31 March 2020, this could impact on patient experience and could cause clinical harm.

A Koray Failure to deliver the CCGs statutory financial 16 16 16 12 8 6 16 12 6 12 3.6 responsibility to break-even

S Rubery CAMHs access standard - with current performance this standard may not be met in Barking and 12 12 12 12 12 12 12 12 9 9 9 9 12 12 9 9 3.7 Dagenham and Redbridge CCGs

Risk Summary Number Total risks last report 6 New risk(s) escalated 0 Risks de-escalated 0 Total JCAF risks this report 6

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BHR CCGs Joint Committee Assurance Framework - overall summary (2016 – 2017)

Previous risk ratings Lead / Initial rating Risk Description JCAF ref. (June 2013) Apr June Jan April June Aug Oct Dec Feb 2016 July 2016 Sept 2016 Nov 2016 2016 2016 2017 2017 2017 2017 2017 2017

S Rubery Failure to deliver quality improvement in urgent 16 16 16 16 16 16 16 16 16 16 16 16 16 3.1 and emergency care at BHRUT

Failure of Barts Health (BH) to meet a number of S Rubery operational standards, RTT and A/E, data quality 20 20 16 20 20 20 20 20 20 20 16 16 3.2 and others (now split into two risks).

S Rubery Failure of Barts Health (BH) to meet a number of 20 20 20 20 20 16 16 3.3 operational standards – RTT.

BHR CCGs Joint Committee Assurance Framework – de-escalated risks (2018-2019)

Lead / Target Risk description (summarised) Date risk de-escalated Initial risk rating Risk rating at de-escalation JCAF ref. risk level

T. Travers Risk of failure to deliver the CCGs’ budget plans. (This risk has been reviewed and 1 April 2019 16 6 10 2.1 (was 1.1) revised for April 2019 but remains on the JCAF)

S. Rubery Risk of clinical harm to patients as a result of missed or delayed diagnosis at 28 March 2019 16 8 12 1.2 BHRUT due to lack of robust systems and processes to report radiological scan.

S Rubery KGH UCC service provided by PELC has been placed in special measures by the 28 March 2019 12 9 6 3.5 CQC following a quality review as "Inadequate".

S Rubery BHRUT’s mortality rate is higher than expected. The number of patients dying in 1.1 26 July 2018 20 12 6 BHRUT for certain clinical conditions is higher than the expected number of deaths. (was 5.7)

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55 How to interpret the CCGs’ Joint Committee Assurance Framework (JCAF)

– for each risk note who can be Risk Owner – this is the CCGs Impacted – this demonstrates Risk Description harmed and how can they be harmed if the risk Risk Ref – this is a risk executive lead with which CCGs across NEL are, or could responsibility for be, affected by the causes and effects materialises. identifier attributed to the − managing the risks to the of the risk Areas to consider are: harm/ injury, objectives, claims or risk by the CCG risk lead litigation, service disruption, staffing and competence, corporate objectives and morale, financial, external assessment and adverse − liaising with the risk lead to media interest. ensure the JCAF is up to date − reporting to the CCG GB or other committee on Score history and targets progress – the graph will illustrate the trend the risk has taken over time, highlighting how scores have/ haven’t Risk Ratings – the risk rating changed as well as previous is derived from conversation and current targets. between the risk owner (or nominated deputy) and the risk lead. The risk score is calculated using the risk grading matrix. There are three types of risk rating used in the CCGs’ JCAF: Controls – what is being − Initial Rating: this done to reduce the grades the risk as if there likelihood and severity of were no remedial the risk? measures in place. This One specific risk may be is called the “inherent mitigated by a number of risk”. controls. − Target Rating: this is the level of risk that the CCGs are prepared to accept and the level of risk that must be aimed for. − Current Rating: this Gaps in controls – grades the risk taking what more can be into account the remedial done to control the measures. risk and which controls can be Each rating is accompanied improved? with a date and the rationale behind the scoring. Gaps in assurance – what associated documentation will demonstrate that the controls are in place? Assurance – assurances are Proposed actions – where gaps inevitably ‘bits of paper’ which have been identified, list the Mitigations – these are the steps and evidence the controls in place. actions required to put them into processes being taken to reduce the risk score Ensure they include the received place. Ensure they have a named date. lead and target date

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56 To: Meeting of the NHS Barking and Dagenham, Havering and Redbridge CCGs’ Governing Bodies (meeting in common)

From: Sarah Heyes, Clinical Director, Redbridge CCG

Date: 24 September 2020

Subject: Quality Report

Executive summary This purpose of this report is to provide a detailed overview to the Governing Bodies of quality issues and updates across the BHR system.

Recommendations The Governing Bodies are asked to:

• Note the detail of the report • Agree actions being taken to date to mitigate the identified quality risks • Suggest any further actions to address quality and patient safety risks for local people.

1.0 Purpose of the Report This report is presented to the Governing Bodies to ensure members are fully briefed and assured in respect of quality work streams.

2.0 Introduction As agreed, the Governing Bodies will receive a quality report at each meeting that will over time appraise members of quality updates and issues.

3.0 Quality improvement across providers 3.1 BHRUT

3.1.1 Governance within Emergency Department (ED) at Queen’s Hospital 3.1.2 Further to the CQC inspection of the ED’s at BHRUT, the CQC requested further information and assurance as they are not currently visiting sites to conduct inspections. Further to the provision of the information, BHRUT have highlighted concerns they have regarding governance arrangements within ED at Queen’s Hospital. These concerns relate to the management of red and serious incidents and related governance arrangements such as identification and sharing of learning.

3.1.3 As a result, the management and oversight of ED governance arrangements have been aligned to the corporate quality and patient safety team under the leadership of the Director of Nursing (Quality & Patient Safety). Changes have also been made to the senior team within ED including a new Divisional Director and Director of Nursing.

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3.1.4 In response to the concerns, BHRUT have devised an action plan to address the concerns including the commissioning of an external organisation to investigate a number of serious incidents to ensure the appropriate identification of lessons to be learnt and shared.

3.1.5 In addition, fortnightly calls are taking place between BHRUT, CQC and BHR CCGs to maintain oversight of progress made.

3.2 Never Events 3.2.1 On 29 May 2020, the NHS National Patient Safety Team circulated a patient safety update to clinical governance and patient safety heads which included reference to nasogastric tube safety. The update outlined that the professional bodies for nutrition, anaesthetics and intensive care have produced an aide-memoire to help prevent nasogastric tube Never Events. It includes special considerations for the safety of patients with COVID-19 in critical care. Governance leads should note that nasogastric tube guidewires do not meet the Never Event list definition of a retained object as there are legitimate reasons for not removing them immediately on completion of the procedure.

3.2.2 Following review of this guidance, further clarity was sought from the NHSE London Regional Patient Safety Team regarding the nasogastric tube Never Events as declared by BHRUT. Following a further review within the NHS central team, advice was given that nasogastric tube incidents do not meet the criteria for Never Events and should be classed as Serious Incidents only.

3.2.3 As a result of this guidance BHRUT have been advised to submit de-escalation requests to have all nasogastric tube never events reclassified as Serious Incidents.

3.2.4 Since the last reporting period BHRUT have declared one Never Event related to a retained foreign object following a surgical procedure.

3.3 Cancer and incidental finding task and finish group – 3.3.1 Following presentation of the cancer and incidental finding pathway clinical concerns paper at the Quality & Performance Committee of November 2019, the paper and recommendation was discussed at the BHRUT CQRM held on 4 December 2019.

3.3.2 Following this discussion, BHRUT agreed to the development of the Task & Finish Group to address the concerns raised. This Task & Finish Group, chaired by BHR CCGs continues to meet regularly where work continues as aligned to the group’s action plan.

3.4 BHRUT Quality Review Meeting 3.4.1 Further to ongoing quality and safety concerns highlighted prior to Covid-19 a quality review meeting was convened 25 June 2020; attended by colleagues from BHRUT, Health Education England (HEE), Care Quality Commission (CQC), NHSE/I and BHR CCGs. As part of the meeting BHRUT presented updates around the following areas: • Core Services Announced CQC Inspection (Sep/Oct 2019) • ED Unannounced CQC Inspection (Jan 2020) • Clinical Information System Serious Incidents (SI) • Radiology Quality Review Update

3.4.2 Despite the huge amounts of work BHRUT have done and continue to carry out as a result of Covid-19 it was agreed by all attendees the Trust had made significant improvements in the areas where there had previously been concerns.

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3.4.3 It was also recognised that further work continues around these areas to ensure that all required actions are completed.

4.0 NELFT 4.1 Initial Health Assessments (IHA) and Review Health Assessments (RHA) for Looked After Children (LAC)

4.1.1 The BHR CCGs Designated Doctor for LAC conducts regular audits to ensure that IHA’s are of a good standard of quality, outlining health requirements and appropriate actions to address any inequalities.

4.1.2 These audits have identified the quality and processes for conducting IHA’s in Havering to have been excellent with improvements required in both Barking and Dagenham and Redbridge.

4.1.3 Several discussions have taken place at Clinical Quality Review Meetings (CQRM) to address these concerns and to seek assurances that improvements would be made. In addition, a specific meeting took place with NELFT in August 2019 to address the quality of IHA’s.

4.1.4 Due to the Covid-19 pandemic no further updates have been requested from NELFT.

4.1.5 On 30 June 2020 a meeting was convened with representation from NELFT, the three local authorities and staff from BHR CCGs’ Quality and Safeguarding team. The meeting discussed the quality of IHA’s within Havering and Redbridge, and the timeliness of RHA’s in Barking and Dagenham.

4.1.6 Discussion took place regarding IHA quality improvements that have taken place in Barking and Dagenham and Redbridge, with further work being conducted.

4.1.7 Named Doctor colleagues present (NELFT) requested additional support regarding the conducting, completion and review of IHA’s. BHR CCGs’ Designated Doctor has agreed to form a supervision type meeting with the Named Doctors at which terms of reference (ToR) will be developed, revision of the audit tool and a review of 3 recently completed IHA’s for peer support and development. This work is under way with further assurances still to be gained regarding the quality of IHA’s.

4.1.8 The development of the supervision meeting with the Named Doctors has been paused whilst further oversight and assurance is sought regarding the quality of IHA’s across BHR. This oversight and assurance will be discussed between senior leaders from BHR CCGs and NELFT at a meeting planned for 11 September 2020.

5.0 Whipps Cross (Barts Health) 5.1 The following quality updates have been provided my NEL quality lead colleagues who sit on the Whipps Cross internal quality and safety meeting (virtual).

5.2 Hospital Acquired Pressure ulcers:

5.2.1 In June 2020, there were 148 patients admitted with pressure ulcers and 54 with moisture lesions form the community. There were 6 category 1; 12 category 2; 3 category 3 and no category 4 HAPU for the month of June. The wards with the highest number of hospital acquired pressure ulcers were on AAU and syringa. There has been a significant reduction on sycamore ward which was a previously hot spot ward. The HAPU steering group has been revised and its membership, governance and data has also been strengthened. A workshop has been planned

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for band 7s to drive local ownership and accountability. The group will also be looking at celebrating good practices and learning events.

5.3 Falls:

5.3.1 There were 4.8 falls per occupied bed days for June but 5.4 for July. Medicine and in particular AAU have seen a rise in number of falls. This accounts for 53 falls (same number of falls as last month) with all bar one low or no harm. One patient fractured her ankle. The patient was independently mobilising. The steering group is progressing onto developing improvement plans with nursing colleagues and will be supported by senior nurses.

5.4 Dementia Screening:

5.4.1 Barts internal committee was pleased to note 100% dementia referral rate. It is understood that national reporting remains on hold.

5.5 Perfect Ward Audit:

5.5.1 The Well Led inspections were suspended during the COVID-19 peak period and restarted in July 2020. The Quick COVID Assessment replaced the Well Led series during the peak COVID- 19 period. This is still available for wards to complete but a date on when this will be removed was not confirmed.

5.5.2 It was noted that in June, 12 wards completed the assessment, scoring 97.1% for Whipps Cross. The teams are working on establishing QR codes refresh and the use of recently donated iPads.

5.6 Patient Safety Alerts:

5.6.1 The site (and Trust) currently has one overdue EFA alert in relation to a fire risk with Zebra printers. WXH are due to complete work in relation to this by 23/08/20.

5.6.2 There are 3 NatPSA alerts open. Plans are in place for 2 of these alerts to ensure timely closure. A new NatPSA alert was issued on 13 August in relation to issuing alert cards to prevent adrenal crisis in adults. This alert is currently under corporate review to determine management approach.

6.0 Level 3 Independent Investigations 6.1 As part of the NHS Serious Incident Framework (2015) Level 3 Independent Investigations may be commissioned where the integrity of an internal investigation and its findings are likely to be challenged or where it will be difficult for an organisation to conduct a proportionate and objective investigation internally due to the size of organisation or the individuals or number of organisations involved. Independent investigations avoid conflicts of interest and should be considered if such conflicts exist or are perceived to exist.

6.2 Across Barking and Dagenham, Havering and Redbridge two such independent investigations have been completed with the emphasis now on review and monitoring of related action plans.

6.3 The first relates to an 8-year-old boy who died as a result of an underlying, undetected cardiac issue. During the patient’s journey he passed through the care of PELC, BHRUT and London Ambulance Service (LAS).

6.4 A comprehensive action plan was developed as a result of this investigation; a review of updates during July showed that a number of actions have been completed and closed with remaining

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actions having been delayed to the system-wide response to Covid-19. Ongoing review will be conducted by the quality and safeguarding team.

6.5 The second investigation relates to 54-year-old gentleman that died as a result of a ligature incident whilst an inpatient at Sunflowers Court, Goodmayes Hospital (NELFT).

6.6 A comprehensive action plan was developed as a result of this investigation; a review of updates during July showed that a number of actions have been completed and closed with remaining actions having been delayed to the system-wide response to Covid-19. Ongoing review will be conducted by the quality and safeguarding team.

7.0 Regulation 28 (Prevention of Future Deaths) Reports 7.1 The Coroners and Justice Act 2009 allows a coroner to issue a Regulation 28 Report to an individual, organisations, local authorities or government departments and their agencies where the coroner believes that action should be taken to prevent further deaths.

7.2 Any full response to a Regulation 28 Report should be made within 56 days of the date of the report. Extensions can be granted at the discretion of the individual coroner who issued the report.

7.3 BHR CCGs Quality and Safeguarding Team have not been made aware of any Regulation 28 Reports issued to any BHR commissioned service since the outbreak of Covid-19.

7.4 On 6 August 2020, a Regulation 28 Report was issued to a GP practice within Barking and Dagenham.

7.5 The report relates to the death of a person known to mental health services with particular reference to the prescribing and dispensing of high quantities of mental health related medication.

7.6 The GP practice are required to respond to the Coroner by 1 October 2020; colleagues from the CCGs medicines management and primary care teams are supporting the practice to ensure an effective and appropriate response is made.

7.7 Once the response has been finalised, details of the Regulation 28 Report and associated actions will be shared with all BHR GP practices and NEL primary care leads.

8.0 Care Homes with Nursing 8.1 The BHR Local Quality Surveillance Group is chaired by the Designated Nurse for Adult Safeguarding (BHR CCGs) with representation of quality and safeguarding teams from local authorities within BHR and Newham; the Care Quality Commission (CQC) local area inspector also attends.

8.2 The QSG continues to monitor quality assurance and safeguarding issues in Care Homes with Nursing across the three boroughs.

8.3 Since the identification of Covid-19 colleagues from NELFT with support from nurses from the Continuing Healthcare (CHC) Team (BHR CCGs) have been providing infection prevention and control (IPC) training to care homes across BHR, this offer included residential homes, and supported living schemes. In addition, colleagues from NEL CSU provided web-based IPC training and expert support to all care homes. As a result of this work we were able to offer IPC training to 100% of all care homes (178) across BHR.

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8.4 Following the success of this training offer, a request was made for the provision of ongoing and sustainable IPC training for care homes. Colleagues from NELFT and CSU have developed a business case which has been presented to local leaders for discussion on available options and funding arrangements. The BHR CCGs have approved funding to continue funding to the end of March. During this time the BHR Care Homes Group will develop a broader offer of nursing support to care homes.

9.0 Learning Disability Mortality Reviews (LeDeR) 9.1 The current position with local LeDeR reviews as of end July 2020 is that there have been 115 cases allocated to BHR CCG over the previous 3 years of which:

• 70 have been completed • 11 are in progress • 34 are currently unallocated (due to shortage of reviewers and increase in death notifications during April 2020).

9.2 This is a significant improvement compared to our position in July 2019 when there were 55 cases of which:

• 13 were completed • 21 were progress • 21 were unallocated (due to shortage of reviewers).

9.3 However, the significant rise in number of deaths reported has resulted in a further backlog of unallocated reviews to be completed.

9.4 There was a disproportionate number of deaths amongst the Learning Disability population reported since the outbreak of the Covid19 Pandemic across London and nationally. During the early stages of the Pandemic LB Barking & Dagenham, Havering & Redbridge reported 16 deaths where the cause of death was reported to be Covid related, but during May, June and July 2020 there have been no further Covid19 related LeDeR deaths reported. This would suggest that protective measures put in place for residents living in Care Homes and Supported Living accommodation have reduced this risk.

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

10.2 If we achieve the quality improvements detailed in this report the positive impact will be on sustained quality improvement and an overall improvement in patient experience.

11.0 Equalities 11.1 This report considered the CCGs’ equality duty and where relevant has identified appropriate actions which address any likely impact on equality or human rights.

12.0 Risk 12.1 Failure to ensure that there are improvements to the quality performance of commissioned services may result in a failure to manage and mitigate risks with potential harm to patients and reputational damage to the BHR Health System.

12.2 Some patients may not be receiving the quality of care at the level which the CCGs commission, and therefore may have a poor experience of using the services we commission.

12.3 Mitigating actions for the above risks have been specified in the body of the report.

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13.0 Managing conflicts of interest 13.1 There are no conflicts of interest raised in this report.

Author: Mark Gilbey-Cross, Deputy Nurse Director (Acting) Date: 7 September 2020

7 63 To: Meeting of the NHS Barking and Dagenham, Havering and Redbridge CCGs’ Governing Bodies (meeting in common)

From: Mark Gilbey-Cross, Deputy Nurse Director (Acting)

Date: 24 September 2020

Subject: Adult Safeguarding Annual Report 2019-2020

Executive Summary Barking & Dagenham, Havering and Redbridge Clinical Commissioning Groups (BHR CCGs) have a range of statutory duties, including safeguarding adults. And are committed to working with partner agencies to ensure the safety, health and well-being of the local population. Protecting adults at risk of abuse or neglect is a key part of the Clinical Commissioning Groups (CCGs) approach to commissioning and, together with a focus on quality and patient experience, is integral to our working arrangements. Our approach to adult safeguarding is underpinned by quality and contracting systems and processes that aim to reduce the risk of harm and respond quickly to any concerns.

An adult at risk is a person aged 18 or over who is in need of care or support regardless of whether they are receiving them, and because of those needs are unable to protect themselves from abuse or neglect. Adult safeguarding means protecting a person’s rights to live in safety, free from abuse and neglect.

Clinical Commissioning Groups (CCGs) have a duty to take measures to safeguard patients who are unable to protect themselves from abuse and neglect in their commissioned services and across the local health economy. This includes working within a multi-agency framework to take measures to reduce the risk of neglect and abuse and responding where abuse has occurred or is suspected of occurring. CCGs also have duties to take additional measures in establishing effective structures for safeguarding within their organisation. This includes the development of a clear strategy, robust governance arrangements and leadership.

Recommendations The Governing Bodies are asked to: • Review and discuss the adult safeguarding agenda outlined in this report • Suggest any additional actions that are required for further improvements or assurance

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1.0 Purpose of the Report

The purpose of this report is to:

• Assure the Governing Bodies that there are robust and effective adult safeguarding processes in place which reflect national legislation and statutory guidance and demonstrate the organisation’s commitment to embedding adult safeguarding. • Demonstrate how the health contribution to safeguarding and promoting the welfare of adults is discharged across the Barking & Dagenham, Havering and Redbridge health economies through our commissioning arrangements. • Inform the Governing Bodies of the progress made on the key priorities of the year and identify the main issues, risks, and key priorities relating to safeguarding adults at risk within the boroughs of Barking & Dagenham, Havering and Redbridge for the year pending. • Provide information about national changes which influence, local developments and activity, including safeguarding inspections.

2.0 Key National changes during year 2019/20

The London Multi-Agency Adult Safeguarding Policy and Procedures were updated April 2019. The Mental Capacity (Amendment) Act 2019 recived Royal Assent in May 2019. The purpose of this is to reform the process under the Mental Capacity Act 2005 ("MCA") for authorising arrangements enabling the care or treatment of people who lack capacity to consent to the arrangements, which give rise to a deprivation of their liberty.

NHS England updated the ‘Safeguarding Children, Young People and Adults at Risk in the NHS: Safeguarding Accountability and Assurance Framework’ in August 2019.

The Revised Prevent duty guidance: for England and Wales statutory guidance was updated in April 2019. It specifies that in the exercise of their functions, to have “due regard to the need to prevent people from being drawn into terrorism”. This guidance is issued under section 29 of the Act. The Act states that the health specified authorities which must have regard to this guidance when carrying out the duty outlined in Schedule 6 of the Act are as follows: • NHS Trusts • NHS Foundation Trusts.

Towards the end of the financial year, the World Health Organisation (WHO) declared a global pandemic on 4th March 2020. The Department of Health in the UK response included a number of easements to UK Legislation and Guidance relating to Safeguarding. The ‘Coronavirus Act’ came into effect on 25th March 2020 and is intended to remain in force until the end of the Coronavirus Pandemic.

The Safeguarding Adult Boards (SAB) continued to comply with legal requirements and followed the advice provided in the ‘Coronavirus Act’.

BHR CCGs Safeguarding team were advised as were the majority of staff to ‘work from home’ whilst continuing to fulfil Safeguarding requirements. BHR CCGs provided updates to commissioned agencies on the implications of rapidly changing regulations and how to prepare for emerging threats.

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3.0 BHR CCGs key Deliverables and achievements in 2019-2020

• Ensuring that internal CCGs staff are compliant with Adult Safeguarding level 1 and Prevent training compliance requirements. • Ensuring that commissioned services were compliant with safeguarding adult, mental capacity, Prevent and domestic abuse training. • Ensuring GP training was rolled out across the 3 boroughs in the areas of the Safeguarding Adults, Mental Capacity and Deprivation of Liberty Safeguards, Prevent, Modern Slavery and Domestic Violence. • Scoping the potential Court of Protection, Liberty Protection Safeguards (LPS) community deprivation of liberty cases that the CCG commissions care for and to follow up any work preparations required to ensure that BHR CCGs are adequately resourced and trained in preparation for the implementation of LPS in 2020/2021. • Developing a robust monitoring system for Care Homes with Nursing and ensure that the Local Quality Surveillance Group oversees the quality monitoring of care homes with nursing in 2019/20. • Working collaboratively with key stakeholders and commissioned services to reduce the number of community acquired pressure ulcers. • Working with contemporary safeguarding challenges e.g. domestic abuse, online threats, homelessness, self neglect, suicide and social isolation. • Working to improve systems for support in transitional safeguarding from adolescence to adulthood. • Reviewing development against the Safeguarding Adults at Risk Audit Tool which is completed in order to monitor providers compliance with the Care Act 2014.

4.0 BHR CCGs key priorities for 2020-2021

• Ensure robust pathways and collaboration between statutory and other provider services. • Improve multi agency working in line with Making Safeguarding Personal (MSP). • Ensure CCGs staff compliance with safeguarding adults and Prevent training and that all Continuing Heath Care staff are trained in Safeguarding Adult Level 3, Mental Capacity and Deprivation of Liberty Safeguards and Liberty Protection Safeguards by October 2020. • Introduce a robust process to monitor that Continuing Health Care patient care is provided in accordance with MCA Code of Practice for clients who are CCG funded. • Robust mechanisms for monitoring quality, safeguarding, mental capacity assessments and Deprivation of Liberty Safeguards and LPS in Care Homes with Nursing. • Ensure action plans are progressed to embed learning within Provider Services and GP Practices from Safeguarding Adults Reviews (SARs) and Domestic Homicide Reviews (DHRs). • Further develop existing processes to ensure that mental capacity and transition from DoLS to LPS processes are robustly embedded within the CCG and provider organisations. • Address workforce issues in relation to the shortfall in staffing levels for Adult Safeguarding meet the Royal College of Nursing standards outlined in the Adult Safeguarding: Roles and Competencies for Health Care Staff Intercollegiate Guidance (2018). • Support for GP practices and the primary care sector in all activities relating to adult safeguarding.

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5.0 Safeguarding Framework

This annual report is also set within the context of safeguarding responsibilities as defined by the Care Act 2014 which sets out how partner agencies should work together to keep adults at risk of harm, safe from abuse and the governance underpinning adult safeguarding.

The Care Act directs organisations to make appropriate enquiries if it believes an adult is subject to, or at risk of, abuse or neglect. An enquiry should establish whether any action needs to be taken to stop or prevent abuse or neglect, and if so, by whom.

The Care Act 2014 sets out a clear legal framework for how the local system should protect adults at risk of abuse or neglect. Section 3 of the Act sets out statutory responsibility for the local authority to integrate care and support between health, local authority and other partners to promote the wellbeing of adults with care and support needs or of carers in its area. For example: • Pooled budgets, the Better Care Fund • Development of joint commissioning arrangements • Integrated management or provision of services

Under Section 43 of the Act each local authority must have a Safeguarding Adult Board (SAB) with an Independent Chair. The CCGs are statutory members of the safeguarding adult board.

BHR CCGs are guided by the 6 safeguarding principles set out within the Care Act 2014: • Empowerment • Prevention • Proportionality • Protection • Partnership • Accountability

The Care Act 2014 came into effect from 1st April 2015 and highlighted the fact that abuse and neglect can take many forms including: • Physical abuse • Psychological abuse • Financial or material abuse • Sexual Abuse • Domestic abuse • Neglect and acts of omission • Organisational abuse • Discriminatory abuse • Modern slavery • Self-neglect

Key legislation relating to Safeguarding Adults includes: • The Care Act 2014 • Mental Capacity Act 2005 • Human Rights Act 1998

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• Modern Slavery Act 2015 • Counter-Terrorism and Security Act 2015 • Mental Health Act 1983 • The Coronavirus Act 2020

6.0 Making Safeguarding Personal (MSP)

Making Safeguarding Personal (MSP) is described as a Department of Health and Social Care funded, long-term change programme, which was conceived in 2009 -10 and led by the Association of Directors of Adult Social Services (ADASS).

The focus is on change to the culture and practice of adult safeguarding – with the aim of improving outcomes for adults thought to be at risk of harm or who have experienced harm in the form of abuse or neglect (Manthorpe et al., 2015).

MSP focuses on developing practitioners’ understanding of what people want to happen or wish to achieve, and encourages practitioners’ to habitually record these desired outcomes. This is a step change from the approach outlined in the earlier ‘No Secrets’ guidance (DH and Home Office, 2000), which was felt by many practitioners to have become rather process-driven and care-management focused. All this resonates with personalisation and its ideas of empowerment, choice and control as outlined in the Care Act 2014 and its guidance (see Cooper and White, 2017).

7.0 Accountability and Assurance

NHS England Accountability and Assurance Framework (2015) sets out responsibilities of each part of the system and key individuals who work within it. The main implications of these documents for the CCG include: • Responsibility to secure the expertise of Designated Professionals on behalf of the local health system. • To gain safeguarding assurance from all commissioned services, both NHS and independent health care providers. • Ensure appropriate representation on the local Safeguarding Adult Board. • As a core member of the Tower Hamlets Safeguarding Adult Board, THCCG to have a Designated Adult Safeguarding Lead and Mental Capacity Act (MCA) Lead.

In BHR CCGs the Managing Director is the executive lead for adult safeguarding in Barking & Dagenham, Havering and Redbridge CCGs.

The Deputy Nurse Director and Designated Nurse Adult Safeguarding for BHR CCGs represents the Managing Director at the three local Safeguarding Adult Boards and their sub-groups and provide updates to the monthly Safeguarding Adult report to the CCG’s Intergrated Safeguarding Adult Board (ISAB).

The CCG does not have a General Practitioner (GP) Clinical lead for adult safeguarding across the BHR. A GP clinical lead for safeguarding adults would be a valued member of the local safeguarding adults and safeguarding network to support with the following: • support all activities, inclusive of training, necessary for GP practices to meet their safeguarding responsibilities • champion issues for GPs in the wider health and multiagency economy across the boroughs of Barking & Dagenham, Havering and Redbridge

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• be a member of the Barking & Dagenham, Havering and Redbridge Safeguarding Adult Boards (SABs) to which they can bring issues from GPs • take information from the Board to the wider general practice community • work closely with the managing director, the CCG Designated Nurse Adult Safeguarding, the Designated Safeguarding Professionals and the Named Professionals and develop relationships with all key partners.

National guidance and research is clear that GPs have an important role to play in all aspects of safeguarding. The learning from SARs and Domestic Homicide Reviews (DHRs) invariably points to the need for all agencies to work more collaboratively. It is this need for improved communication and multiagency working that makes such a post vitally important.

As part of North East London Commissioning Alliance (NELCA) and Sustainability and Transformation Plan work streams, the designated safeguarding professionals for these CCGs meet together bi-monthly to review safeguarding processes and documents. The aim is to standardise safeguarding processes across NELCA where possible.

8.0 Primary Care

As part of BHR CCGs delegated commissioning responsibilities, it is responsible for supporting and ensuring that the GP services have effective adult safeguarding arrangements and that they are compliant with the Mental Capacity Act 2005 and Care Act 2014.

CPD approved GP PTI training is being rolled out by the Designated Nurse for Adult Safeguarding to cover a range of topics relating to adult safeguarding in order to support GP knowledge and skills. The Prevent Regional Coordinator (London) NHS England delivered Prevent training to an audience of over 100 GPs in Barking and Dagenham in February 2019.

There is partial assurance on GP Adult Safeguarding training compliance.as GP training in Safeguarding Adults has been limited. In order to cover this gap, the Designated Nurse Adult Safeguarding facilitated GP PTI training sessions on Safeguarding Adults and Prevent in Redbridge on 21/11/2019 and the session was well attended.

Training relating to Domestic Violence took place for GP’s in the London Borough of Barking & Dagenham at their monthly PTI training session on 01/10/19. Safeguarding Adult and Domestic Violence training for Havering GPs took place on 11/02/2020 as part of their PTI training sessions.

9.0 Care Homes with Nursing

The Local Quality Surveillance Group (LQSG) is chaired by the Designated Nurse for Adult Safeguarding which continues to monitor quality and assurance and safeguarding issues in Care Homes with nursing input across the three boroughs.

The CQC is represented at this meeting and regular updates are provided about provider concerns. Healthwatch members are also present at these meetings.

Updates on Care Homes with nursing input are provided in adult safeguarding reports and details of specific homes where there are concerns or where restrictions

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are imposed are reported at the monthly CCGs Integrated Safeguarding Assurance Board (ISAB).

10.0 Safeguarding Training Compliance 2019 – 2020

The ‘Adult Safeguarding: Roles and Competencies for Health Care Staff Intercollegiate Document’, was published by the Royal College of Nursing in August 2018. The document is designed to be used in all healthcare organisations and provides a point of reference to help identify and develop the knowledge, skills and competence in safeguarding of the health care workforce. The CCGs have adopted this framework and monitors compliance with training requirements within commissioned services.

BHR CCGs have set health care providers a target of achieving 90% compliance with all Safeguarding adults training.

Safeguarding adult training is mandatory for all BHR CCGs staff. The training delivered is face to face and online and is tailored for a commissioning organisation.

Table 1: Barking and Dagenham CCG*:

Training Level Quarter 1 Quarter 2 Quarter 3 Quarter 4 SA Level 1 88% 96% 100% 90% Prevent level 1 68% 58% 79% 100%

Table 2: Havering CCG*:

Training Level Quarter 1 Quarter 2 Quarter 3 Quarter 4 SA Level 1 75% 83% 87% 85% Prevent level 1 80% 62% 83% 62%

Table 3: Redbridge CCG*:

Training Level Quarter 1 Quarter 2 Quarter 3 Quarter 4 SA Level 1 87% 88% 93% 91% Prevent level 1 79% 83% 90% 90%

The safeguarding training compliance for CCG commissioned health care providers of Barking & Dagenham, Havering and Redbridge Adult services from April 2019 – March 2020 was as shown in Table 4 - 6.

Table 4: Barking & Dagenham, Havering and Redbridge University Trust:

Training Level Quarter 1 Quarter 2 Quarter 3 Quarter 4 SA Level 1 98% 97% 99% 99% SA Level 2 97% 95% 95% 94% SA Level 3 93% 89% 94% 94% MCA & DoLS 98% 97% 92% 94% Prevent level 1 96% 93% 97% 97%

Table 5: North East London Foundation Trust:

Training Level Quarter 1 Quarter 2 Quarter 3 Quarter 4 SA Level A 99% 97% 97% 96% SA Level B 97% 97% 98% 93%

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MCA & DoLS 97% 96% 98% 96% Prevent level 1 96% 97% 98% 99%

Table 6: The Partnership of East London Cooperatives (PELC)*:

Training Level Quarter 1 Quarter 2 Quarter 3 Quarter 4 SA level 1 93% 98% 95% 81% SA level 2 69% SA level 3 48% Prevent level 1 & 2 100% 99% 93% 65% Prevent level 3 41%

* MCA and DoLs training is embedded within safeguarding adults training.

Assurance on compliance with mandatory training requirements is provided in Safeguarding Adult reports which are submitted to at the monthly CCGs ISAB.

11.0 Safeguarding Adults Audit and Assurance

The Safeguarding Adults Partnerships audit tool was developed at the request of the London Safeguarding Adults Board (London SAB) in 2019. The London SAB programme 2018/19 included an action to undertake a fundamental review the Safeguarding Adults at Risk Audit Tool (SARAT).

This audit tool has been updated and it is envisaged that the tool will enable SABs to demonstrate more clearly what their contribution has achieved and where there are strengths and challenges in how agencies work together and to explore and provide evidence to address the following questions:

• how effective has the partnership been? • what would make the partnership more effective?

The focus of the audit is to review organisational compliance with:

• the application of Making Safeguarding Personal • the application of the Mental Capacity Act and use of mental capacity assessment frameworks. • follow up actions from recommendations from SARS.

The CCG’s submitted their completed SARAT return in December 2019 to Barking & Dagenham and Havering Safeguarding Adult Boards. The BHR CCG’s submission was shared at an event facilitated by Havering SAB on 11th March 2020 where all partner submissions were discussed. There was positive feedback from the SAB Board Chairs from both Boroughs.

12.0 Mental Capacity Act (MCA) 2005 and Deprivation of Liberty Safeguards (DoLS)

The Mental Capacity Act is a vital piece of legislation to protect patients’ human rights. The Act seeks to ensure that any decision made, or action taken, on behalf of someone who lacks capacity to make a decision or act for themselves is made in their best interests. The Act provides a legal framework for health and social care professionals to safeguard a person when they lack capacity to make a specific decision.

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BHR CCGs hold responsibility for seeking assurance that the Act is central to the work of each health care provider organisation.

In order to meet BHR CCG’s responsibilities there are assurance processes to monitor that all health care providers have a named lead professional for MCA, there are up to date policies and procedures in place, and MCA/DoLS is a mandatory training requirement for appropriate staff.

DoLS are an amendment to the MCA 2005. DoLS under the MCA allows restraint and restrictions that amount to a deprivation of liberty to be used in hospitals and care homes if they are in a person’s best interests.

DoLS applications are submitted to the local authority and assessed and approved by a qualified independent best interest assessor.

The Mental Capacity (Amendment) Act 2019. The Mental Capacity Act 2005 includes the Deprivation of Liberty Safeguards (DoLS), which protect people who do not have the mental capacity to consent to treatment. Under the Mental Capacity (Amendment) Act 2019, the DoLS will be replaced by the Liberty Protection Safeguards (LPS).

Planned milestones for implementation of LPS:

The tri-borough LPS Task and Finish Group have undertaken an assessment of the potential impact that this will have across the boroughs of LB Barking & Dagenham, Havering and Redbridge.

Whereas the DoLS currently mainly applies to hospitals and care homes, the LPS can be used in other settings, for instance supported living, shared lives and private and domestic settings. The LPS are also not tied to accommodation or residence; they could be used, for example, to authorise day centre and transport.

Currently LBBD, LBH, and LBR hold the responsibility for the co-ordination and authorisation under DoLS. One of the key changes of the Liberty Protection Safeguards (LPS) is the removal of ‘Supervisory Body’, which is replaced with the ‘Responsible Body’, the relevant responsible body will be charged with authorising arrangements.

The ‘Responsible Body’ will depend on who pays for or who authorises the care and support arrangements that amount to a deprivation of liberty.

The community LPS will also include 16 to 18 year olds which will result in an increase in assessments for all responsible Bodies.

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The Continuing Health Care (CHC) Team facilitated a Joint Task-and-Finish group on LPS to consider the workforce & financial implications for the CCG CHC Team over the coming year.

BHR CCGs Board Report and LPS Action Plan which was submitted in early March 2020 to highlight the actions that need to be progressed and addressed.

CHC team have scoped the requirements for potential Approved Mental Capacity Professionals (AMPCs) and a dedicated LPS administrative role to manage database and case records requirements for their team to support the implementation of LPS.

13.0 Safeguarding Adult Reviews (SARs)

Section 44 of the Care Act requires SABs to carry out a SAR when cases involving an adult with care and support needs if particular criteria are met. The SAR process is only relevant to an adult with care and support needs in the area if:

• there is reasonable cause for concern about how the Safeguarding Adult Board members or other persons with relevant functions worked together to safeguard the adult and either of the following conditions are met:

• the adult has died, and the SAB knows or suspects that the death resulted from abuse or neglect (whether or not it knew about or suspected abuse or neglect before the adult died)

or

• the adult is still alive, and the SAB knows or suspects that the adult has experienced serious abuse or neglect

The purpose of a SAR is to:

1. Establish what lessons are to be learnt from a particular case in which professionals and organisations work together to safeguard and promote the welfare of adults at risk 2. Identify what is expected to change as a result to improve practice 3. Improve intra-agency working to better safeguard adults at risk 4. Review the effectiveness of procedures, both multi-agency and those of individual organisations

On conclusion of a SAR, an action plan is drawn up to ensure that the recommendations of the findings are implemented. The CCGs have complied with requests from Safeguarding Adult Boards for contributions to multi-agency actions plans and updates across the three boroughs.

Updates on SARs are provided in Safeguarding Adult reports which are submitted to at the monthly CCGs ISAB.

14.0 Domestic Abuse and Domestic Homicide Reviews

Domestic violence and abuse is any incident or pattern of incidents of controlling, coercive, threatening behaviour, violence or abuse between those aged 16 or over who are, or have been, intimate partners or family members regardless of gender or sexuality. This definition includes violence such as female genital mutilation (FGM),

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so-called ‘honour’ crimes, forced marriage, and acts of gender-based violence. Domestic abuse happens across all communities, faiths and cultures.

The CCG is committed to improving the health and wellbeing of their communities and staff and recognise that domestic abuse is a crime, which is an abuse of human rights, is a major public health problem and has severe health consequences for individuals, families and communities.

The CCG recognises the devastating impact of domestic abuse on the physical and emotional health of those exposed to domestic abuse, the majority of whom are women and children. The organisations are therefore committed to ensuring that domestic abuse is recognised and that both patients and staff are provided with information and support to minimise risk.

The Violence Against Women & Girls (VAWG), Domestic Abuse (DA) and Hate Crime team (HC) work developing a community response to prevent domestic abuse and hate crime, protect and support victims and bring offenders to justice.

Domestic Homicide Reviews (DHRs)

Community Safety Partnerships are responsible for undertaking domestic homicide reviews where the death of a person aged 16 or over has, or appears to have, resulted from violence, abuse or neglect by a relative, household member or someone he or she has been in an intimate relationship with.

There were five DHRs commissioned between April 2019 and March 2020 and these were ongoing at the time of writing this report.

Updates on DHRs which are currently being reviewed are provided in Safeguarding Adult reports which are submitted to at the monthly CCGs ISAB.

15.0 Prevent

The Government’s counter-terrorism strategy is known as CONTEST. Prevent is part of the strategy and its aim is to stop people becoming terrorists or supporting terrorism.The 4 key principles of CONTEST are:

• Pursue: to stop terrorist attacks • Prevent: to stop people becoming terrorists or supporting terrorism • Protect: to strengthen our protection against a terrorist attack • Prepare: to mitigate the impact of a terrorist attack.

The Revised Prevent duty guidance: for England and Wales statutory guidance was updated in April 2019.

NHS health providers in the boroughs of Barking & Dagenham, Havering and Redbridge provide assurance to the CCGs that they are compliant with Prevent training and reporting requirements in their Safeguarding reports.

16.0 Learning Disabilities Mortality Review (LeDeR)

The Learning Disabilities Mortality Review (LeDeR) Programme is commissioned by the Healthcare Quality Improvement Partnership (HQIP) on behalf of NHS England. It aims to guide improvements in the quality of health and social care service delivery

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for people with learning disabilities and to help reduce premature mortality and health inequalities faced by people with learning disabilities.

A key element of the LeDeR Programme is to support local areas to review the deaths of people with learning disabilities. The programme is developing and rolling out a review process for the deaths of people with learning disabilities, helping to promote and implement the new review process, and providing support to local areas to take forward the lessons learned in the reviews in order to make improvements to service provision.

The purpose of the LeDeR reviews is not to hold any individual or organisation to account as there are other mechanisms that exist for that as needed, including criminal proceedings, disciplinary procedures, employment law and systems of service and professional regulation. It is essential that reviews are trusted and safe experiences that encourage honesty, transparency and sharing of information to obtain maximum benefit from them.

The LeDeR programme responsibility at a borough level is devolved from NHS England to CCGs, with the establishment of a Local Area Contact role within each CCG identified.

In the period covering 2019/20 the BHR CCGs LeDeR programme progress is shown in the graph below:

Within the context of national progress with LeDeR reviews, the Boroughs of Barking & Dagenham, Havering and Redbridge are progressing well with LeDeR reviews overall.

Of the 87 cases allocated to BHR CCG over the previous 3 years:

• 67 have been completed • 6 are in progress • 14 are currently unallocated (due to shortage of reviewers).

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This is a significant improvement compared to our position in January 2019 when there were 55 cases of which:

• 13 were completed • 21 were progress • 21 were unallocated (due to shortage of reviewers).

Updates on progress with LeDeR case reviews are provided in Safeguarding Adult reports which are submitted to at the monthly CCGs ISAB.

17. Progress against 2019-2020 CCG Safeguarding Adult Priorities and Key Achievements

Priority Status Additional information Ensure that internal CCG staff are Partially Although overall training compliance has compliant with Safeguarding Adult Achieved improved for staff working in all three CCGs level 1 and Prevent training towards the end of the financial year, compliance compliance requrements. has not improved for some CCG staff, particularly in Havering CCG. Ensure that commissioned Partially Overall training compliance has improved for staff services are compliant with Achieved working in commissioned units such as BHRUT, safeguarding adult, mental and PELC but NELFT will need to undertake a capacity, Prevent and domestic review of their training programme as they are still abuse training. not compliant with the requirements of the RCN Framework for training competencies for Safeguarding Adults https://www.rcn.org.uk/professional- development/publications/pub-007069 issued in August 2018

Ensure GP training is rolled out Achieved The Designated Nurse Adult Safeguarding has across the 3 boroughs in the delivered CPD approved GP PTI training for areas of the Safeguarding Adults, Safeguarding Adults, MCA / DoLS, Prevent and Mental Capacity and Deprivation Domestic Abuse in all three boroughs during of Liberty Safeguards, Prevent, 2019/20 Modern Slavery and Domestic Violence.

Scoping the potential Court of Achieved The tri-borough LPS Task and Finish Group have Protection (LPS) community undertaken an assessment of the potential impact deprivation of liberty cases that that this will have across the boroughs of LBBD, the CCG commissions care for LB Havering and Redbridge. and to follow up any work preparations required to ensure The CCGs CHC team have scoped the that the CCGs are resourced and requirements for potential AMPCs and a trained for implementation of LPS. dedicated LPS administrative role to manage database and case records requirements for their team to support the implementation of LPS. Develop a robust monitoring Achieved LQSG continues to monitor quality and assurance system for Care Homes with and safeguarding issues in Care Homes with Nursing and ensure that the Local Nursing across the three boroughs with Quality Surveillance Group representation from CQC and regular updates (LQSG) oversees the quality provided about provider concerns.

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monitoring of care homes with nursing in 2019/20. Updates on Care Homes with Nursing have been provided in Safeguarding at ISAB meeting each month. The Designated Nurse Adult Safeguarding has worked closely with local authority colleagues in conducting quality assurance and safeguarding visits to care homes with nursing providers.

Work collaboratively with key Achieved Assurance is provided via Safeguarding Adult stakeholders and commissioned performance reports from commissioned services to reduce community providers. acquired pressure ulcers.

Working with contemporary Achieved The CCGs have an up to date Domestic Violence safeguarding challenges e.g. and Abuse Policy which provides advice and domestic abuse, online threats, guidance for staff members who are victims of homelessness, self neglect, Domestic Abuse. A section on Domestic Violence suicide and social isolation. was added to the BHR CCG’s GP intranet and main CCGs websites in April 2019.

The Designated Nurse Adult Safeguarding attends the Redbridge Violence Against Womenand Girls (VAGW) Strategy Group which focusses on prevetion and support to Domestic Violence and Modern Slavery victims.

Domestic Violence Training took place for GP’s in the LB Barking & Dagenham at their monthly PTI session on 1st October 2019 and for LB Havering GPs on 11th February 2020.

The Designated Nurse Adult Safeguarding is a member of the Havering homelessness and self neglect task force group and the Redbridge Violence Against Women (VAGW) Strategy Group which focusses on Domestic Violence and Modern Slavery.

Work to improve systems for Achieved The CCGs Designated Nurse Adult Safeguarding support in transitional has participated in a number of workshops and safeguarding from adolescence to workstreams to support local inititiaves in adulthood. transitional safeguarding for younger people.

Review development against the Achieved Audits completed as part of the Safeguarding Safeguarding Adults at Risk Audit Adults Board assurance processes. The CCG Tool which is completed in order completed this as a partner agency. A gap to monitor providers compliance identified was the absence of a safeguarding lead with the Care Act 2014. GP.

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18. 2020/21 CCG Safeguarding Adults Priorities

The following are the priorities set for 2020/21 for safeguarding adults:

Outcomes / Priority Rationale Action being taken Timescales deliverables Ensure robust Integrated health and care BHR CCGs is represented at the The Deputy Nurse Ongoing pathways and system should be a priority for Safeguarding Adult Boards in the Director and Designated collaboration between the CCGs. Boroughs of Barking & Dagenham, Nurse Adult statutory and other Havering and Redbridge and their Safeguarding represents provider services. The BHR CCGs are required subgroups. Each of the SABs have the CCGs at local SAB to ensure there is CCG produced Safeguarding Adult Annual and all the relevant sub representation at the tri- Reports which are available on their groups of the SAB. borough Safeguarding Adult respective websites which provides a Boards (SABs) and all the summary of national and local The Designated Nurse relevant sub groups of the developments and priorities in the Adult Safeguarding SAB. safeguarding of adults at risk. BHR represents the CCGs at CCGs sent contributions to each of Prevent and Modern the SABs for their annual reports Slavery forums, 2019/20. homelessness and self- neglect working groups. LeDeR review process in place and reviews the LD patients journey – monitored via LD commissioning.

Improve multi agency This is a statutory requirement This should be monitored via the The CCGs comply with Ongoing working in line with under the Care Act 2014. monthly Integrated Safeguarding th requirements of MSP. Making Safeguarding Adult Board monthly meetings in the Personal (MSP). CCG.

The The Designated Nurse Adult Safeguarding also attends the SAB and all sub groups of it where MSP is central to practice.

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Outcomes / Priority Rationale Action being taken Timescales deliverables Ensure CCGs staff Safeguarding Adults, Prevent The Designated Nurse Adult All staff to be trained to October 2020 safeguarding adults (Safeguarding Adult Level 3, Safeguarding provides updates on required required level in and Prevent training Mental Capacity and BHR CCGs training compliance in all mandatory compliance and that Deprivation of Liberty monthly ISAB reports. Safeguarding Adult all Continuing Heath Safeguards for Clinical staff) is subjects. Care staff are trained mandatory training for the in: CCGs. • Safeguarding Adult Level 3. • Mental Capacity and Deprivation of Liberty Safeguards • Liberty Protection Safeguards. Introduce a robust This a statutory requirement The CHC team have been asked to CHC to adopt a suitable Jan 2021 process to monitor under the Care Act 2014. provide assurance that monitoring is monitoring / audit tool to that Continuing Health in progress for mental capacity and provide assurance that Care patient care is DoLS assessments, as required. monitoring is being provided in progressed for CCG accordance with MCA funded patients Code of Practice for (including out of area clients who are CCG placements and those in funded. sheltered accommodation) Robust mechanisms MCA and DoLS are statutory The Local Quality Surveillance Updates on Care Homes End March for monitoring quality, requirements for patients who Committee is chaired by the with Nursing are 2021 safeguarding, mental lack capacity and where Designated Nurse for Adult provided in Safeguarding capacity assessments restricted practice is deemed Safeguarding and continues to Adult reports and details and Deprivation of necessary. monitor quality and assurance and of specific homes where Liberty Safeguards safeguarding issues in Care Homes there are concerns or and LPS in Care with Nursing across the three where restrictions Homes with Nursing. boroughs. imposed are reported in the monthly CCGs

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Outcomes / Priority Rationale Action being taken Timescales deliverables Updates on Care Homes with Nursing Integrated Safeguarding are provided in Safeguarding Adult Assurance Board (ISAB) reports and details of specific homes where there are concerns or where restrictions imposed are reported in the monthly CCGs ISAB meetings. Ensure action plans Both SARs and DHRs are The Designated Nurse Adult Annual updates on End March are progressed to statutory functions for the Safeguarding works with the progress with action 2021 embed learning within SABs and Community Safety Safeguarding Adult Boards to plans are requested from Provider Services and Partnerships. CCGs are develop, disseminate and monitor relevant provider GP Practices from expected to share the learning recommendation relating to organisations and Safeguarding Adults and action plans with relvant Healthcare organisations. Action followed up to provide Reviews (SARs) and provider organistions. plans are shared with relevant assurance that learning Domestic Homicide provider organisations and annual has been disseminated Reviews (DHRs). updates are requested to provide into practice for front line assurance that learning is being staff. disseminated into practice for front . line staff. . Further develop The LPS will require the CCGs The Designated Nurse Adult CHC team resourced October 2020 existing processes to to become Managing Safeguarding attends the tri-borough and train to undertake ensure that mental Authorties for CCG funded LPS Task and Finish Group which has comlex LPS capacity and clients and to undertake undertaken an assessment of the assessments for an transition from DoLS complex case assessments. potential impact that the Liberty increased numcer of to LPS processes are Protection Safeguards will have clients. robustly embedded There are training and across the boroughs of Barking & within the CCGs and workforce implications as the Dagenham, Havering and Redbridge. provider new statutory framework will organisations. extend the scope and numer of CHC team have scoped the clients who will require requirements for potential AMPCs complex assessments and (Approved Mental Capacity Court of Protection Professionals) and a dedicated LPS authorisations. administrative role to manage

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Outcomes / Priority Rationale Action being taken Timescales deliverables database and case records Whereas the DoLS currently requirements for their team to support mainly applies to hospitals and the implementation of LPS when they care homes, the LPS can be come into force in October 2020. used in other settings. e.g: • supported living Business case to justify additional • shared lives and private staff training and workforce and domestic settings. implications has been progressed.

The LPS will apply to 16 – 18 year olds and are also not tied to accommodation or residence; they could be used, for example, to authorise day centre and transport. Address workforce The Royal College of Nursing A business case for further staffing Recruit 2 wte Designated July 2020 issues in relation to Adult Safeguarding: Roles and resources to cover this workstream Nurses Adult shortfall in staffing Competencies for Health Care has been submitted and approved by Safeguarding levels for Adult Staff Intercollegiate Guidance the BHR CCGs Management Team. Safeguarding meet (2018) states: as a minimum the Royal College of the staffing resource for Nursing standards designated safeguarding role outlined in the Adult should be based on population Safeguarding: Roles or on NHS Digital safeguarding and Competencies for figures/levels of area Health Care Staff deprivation/country specific Intercollegiate formula”. Guidance (2018). The ratio should not fall below 1:220,000 population in a borough commissioning footprint.

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Outcomes / Priority Rationale Action being taken Timescales deliverables The staffing requirements are not met in BHR CCGs as there is currently 1 wte post holder to cover three boroughs which have a total population of 773,666, making the ratio 1:773,666, and this is therefore a risk to the CCG.

Support for GP The CCG must prioritise the The Designated Nurse Adult GP practices staff to be End March practices and the need for GP practices to be Safeguarding has delivered CPD trained to respond to 2021 primary care sector in sufficiently skilled to respond approved GP PTI training for safeguarding adult all activities relating to to adult safeguarding Safeguarding Adults, MCA / DoLS, concerns and engage in adult safeguarding. concerns. Prevent and Domestic Abuse in all enquires as required. three boroughs during the previous Designated Nurse Adult Regular programme of year. Safeguarding to deliver mandatory Safeguarding Adult training to GPs across training provided for GPs in the borough pending relation to: appointment of a Named • Safeguarding Adults GP who can train GP • Domestic Abuse Practice staff across the • Mental Capacity tri-borough footprint and Assessments support them with • LPS assessment Safeguarding Adult • Prevent. knowledge and expertise.

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19. Summary

This report demonstrates that BHR CCGs continue to meet statutory obligations to safeguard adults at risk in the borough. Our aim is to keep the people we serve safe in our health and social care services. We are committed to partnership working and a key objective is to work as collaboratively as possible with the people we provide services for, with stakeholders and commissioned services.

It is our priority to ensure that the safeguarding message is at the top of the agenda across health and social care. Additionally, we want members of the public to understand what safeguarding is and how to report any issues and concerns they may have.

The Governing Bodies is asked to receive the safeguarding adults report for information and assurance that effective safeguarding systems and processes are in place for BHR CCGs. The priorities for 2020/21 focus on where improvements will further ensure that there are effective systems in place to safeguard people in Barking Dagenham, Havering and Redbridge.

20. References

ADASS (2019). The London Multi-Agency Adult Safeguarding Policy and Procedures.– updated April 2019. https://londonadass.org.uk/safeguarding/review-of-the-pan-london- policy-and-procedures/

Department of Health and Social Care (2020). The ‘Coronavirus Act’ http://www.legislation.gov.uk/ukpga/2020/7/contents

Home Office (2019). Revised Prevent duty guidance: for England and Wales updated April 2019 https://www.gov.uk/government/publications/prevent-duty- guidance/revised-prevent-duty-guidance-for-england-and-wales

The Care Act 2014: http://www.legislation.gov.uk/ukpga/2014/23/contents/enacted

Coronavirus Act 2020 http://www.legislation.gov.uk/ukpga/2020/7/contents/enacted

Human Rights Act 1998: https://www.health-ni.gov.uk/articles/human-rights-act-1998

Manthorpe J, Klee D, Williams C, Cooper A (2014). Making Safeguarding Personal: developing responses and enhancing skills. The Journal of Adult Protection, 16(2), 96-103.

ADASS (2017). Making Safeguarding Person (MSP) - Support for boards in Making Safeguarding Personal across the Safeguarding Adults Partnership https://www.adass.org.uk/media/6137/msp-resources-2017-for-safeguarding-adults- boards.pdf

Legislation.co.uk (2019). Mental Capacity (Amendment) Act 2019. http://www.legislation.gov.uk/ukpga/2019/18

Mental Capacity Code of Practice 2007: The Stationery office Norwich

NHS England (updated 2019). Safeguarding Children, Young People and Adults at Risk in the NHS: Safeguarding Accountability and Assurance Framework: https://www.england.nhs.uk/publication/safeguarding-children-young-people-and- adults-at-risk-in-the-nhs-safeguarding-accountability-and-assurance-framework/

Royal College of Nursing (2018). Adult Safeguarding: Roles and Competencies for Health Care Staff https://www.rcn.org.uk/professional-development/publications/pub- 007069

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Appendix 1 Performance Indicator Key

Not Assured There is no evidence to suggest that Red services are performing at the expected level of compliance in line with statutory guidance, local policy or KPIs Partially assured There is limited evidence that services Amber are performing at the expected level of compliance in line with statutory guidance, local policy or KPIs Assured There is sufficient evidence that services Green are performing at the expected level of compliance in line with statutory guidance, local policy or KPIs Fully assured There is sufficient and consistent Blue evidence that services are performing at the expected level of compliance in line with statutory guidance, local policy or KPIs

Page 21 84 To: Meeting of the NHS Barking and Dagenham, Havering and Redbridge CCGs’ Governing Bodies (meeting in common)

From: Mark Gilbey-Cross, Deputy Nurse Director (Acting)

Date: 24 September 2020

Subject: Safeguarding Children Annual Report 2019-2020

Executive summary This is the seventh safeguarding children annual report and reflects the work undertaken to ensure deliver of the safeguarding children priorities that were agreed for 2018-2020.

The report is written to provide assurance to the Governing Bodies of BHR CCGs that the Clinical Commissioning Groups (CCGs) are fully discharging their statutory responsibilities to safeguard and promote the welfare of children across the Barking and Dagenham, Havering, and Redbridge (BHR) health economy.

This report will address the following areas: • Key priorities for 2018-2020 • Identified risks • Mitigating actions • Additional priorities identified

Recommendations

The Governing Bodies are asked to: • Review and discuss the safeguarding children agenda outlined in this report • Suggest any additional actions that are required for further improvements or assurance

1.0 Purpose of the Report 1.1 This report provides the Governing Bodies of BHR CCGs with an overview of safeguarding children activity across the BHR health economy during 2019/20. The report reviews the work completed throughout the financial year, providing assurance that the CCGs have discharged their statutory responsibilities to safeguard the welfare of children across the health services that it commissions.

1.2 The report also highlights risks within the safeguarding children agenda and demonstrates how the safeguarding team within the CCGs are managing and mitigating the risks.

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1.3 Additional information is included about national changes and legislation, as well as local developments in relation to proposed safeguarding children partnership arrangements and Child Death Review processes.

2.0 Background/Introduction 2.1 In 2018 seven key priorities were agreed for 2018-2020. These are: • To support the transition to the new Child Death Review (CDR) process • To support the CCGs in the transition arrangements from Local Safeguarding Children Boards to Safeguarding Partnerships within an Integrated Care System (ICS) • To continue to support the Named GP/Consultant Nurse in ensuring continued leadership and engagement with primary care (GP practices) to deliver safeguarding functions • To ensure the CCGs meet their Key Performance Indicators for safeguarding children mandatory training • To continue to work closely with providers to support the embedding of the new legislation and statutory guidance • To support the CCGs in the implementation of the Child Sexual Abuse (CSA) hub within the BHR footprint • To support provider Clinical Quality Review Meetings in relation to safeguarding children compliance with statutory functions.

2.2 Each of these priorities will be discussed in detail in their respective sections and will provide a narrative on the work undertaken by the CCGs to deliver these priorities during 2019/2020.

3.0 To support the transition to the new statutory Child Death Review (CDR) process 3.1 In 2016 the Wood report was published, which outlined proposed changes to the safeguarding children system including significant changes to the child death review process.

3.2 Following the enactment of the Children and Social Work Act (2017) new statutory guidance was published in 2018. The published documents are “Working Together to Safeguard Children” (2018) and the “Child Death Review Process” (October 2018). These documents mandated the statutory responsibility and guidance for the introduction of the new Child Death Review processes.

3.3 The new legislation transferred the statutory responsibility for child death reviews from the Department for Education to the Department of Health and Social Care. The child death review partners are identified as the local authority and the CCG.

3.4 To ensure that the BHR footprint effectively moved towards the new system, an executive meeting for child death reviews was established in November 2018. The purpose of this meeting was to bring together the relevant partners to progress the work-stream. It was agreed that going forward BHR CCGs would host the Child Death Overview Panel element of the new CDR process.

3.5 In ensuring that the new CDR processes were delivered within the statutory timeframes, an interim joint funded project lead was recruited by the CCGs. This role was supported by the Designated Doctor for Child Death and Designated Nurse for Safeguarding Children and Looked After Children to provide clinical leadership and expert technical support. However, due to financial constraints this post ceased prior to the submission of the CDR plan on the 29th June 2019.

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3.6 A steering group was established with key operational partners to progress the implementation of the new CDR arrangements.

3.7 To support the new statutory requirements NHSE commissioned a web-based system for the collection of the child death review information. This system, known as the eCDOP platform supports the collation and data-handling of child deaths which feeds into the National Child Mortality Database. The eCDOP platform was introduced across the BHR footprint in 2018 and was funded by Healthy London Partnership (HLP) for both 2018/2019 and 2019/2020. Funding for eCDOP has been identified for 2020/2021 from local CDR partners.

3.8 The CCG submitted a business case for the creation of a CDOP manager and CDOP coordinator. These posts are to be joint funded equally between the CCGs and the three local authorities as outlined in published CDR plans.

4.0 To continue to support the Named GP/Consultant Nurse in ensuring continued leadership and engagement with primary care (GP practices) to deliver safeguarding functions 4.1 To ensure that there was an equitable service across the BHR footprint in the support of safeguarding children within Primary Care, the CCG and NHS England agreed for the Redbridge Named GP function to be provided by a Consultant Nurse. This post has now been recruited to on a substantive basis.

4.2 The designated nurses supported primary care by participating in PTI events across the BHR footprint and have supported the development of safeguarding children GP safeguarding forum meetings to provide ongoing support and learning around the safeguarding agenda in conjunction with the Named GP/Consultant Nurse.

4.3 These meetings were suspended due to Covid-19 but plans have been put in place to hold these meetings virtually from April 2020 whilst lockdown restrictions are in place.

5.0 To ensure the CCGs meet their KPIs in terms of safeguarding children mandatory training 5.1 In line with statutory guidance, all CCG staff are required to undertake safeguarding children level 1 training on a three-yearly basis. The CCG have an internally set KPI of 90% of all staff.

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5.2 The chart above demonstrates that by year end Barking and Dagenham had achieved and maintained the set KPI. However, Havering and Redbridge are still below the required level of compliance with 46% and 89% compliance.

5.3 The designated nurses have reviewed the different staff groups whose training remains outstanding and have escalated appropriately that several Governing Bodies members remain non-compliant with their mandatory training requirements.

6.0 To support the CCGs in the transition arrangements from LSCBs to Safeguarding Partnerships 6.1 Under the Children Act 2004, as amended by the Children and Social Work Act 2017, LSCBs, set up by local authorities, will be replaced. Under the new legislation, the three safeguarding partners (local authorities, chief officers of police, and clinical commissioning groups) must make arrangements to work together with relevant agencies (as they consider appropriate) to safeguard and protect the welfare of children in the area.

6.2 The three local authority areas published their safeguarding arrangement plans on the 29th June 2019 and implemented on the 29th September 2019 when the LSCBs were dissolved and replaced by the new safeguarding partnership arrangements.

6.3 Ongoing development is being progressed to determine how the strategic partners will work together across the BHR footprint in the future and how operational functions could be discharged at a local/tri-borough level.

7.0 To continue to work closely with providers to support the embedding of the new legislation and statutory guidance 7.1 This priority has been partially addressed in section three and six (see above).

7.2 To continue to strengthen the working relationship between the CCGs and the major provider organisations, the designated nurses attend regular meetings to seek assurance and to ensure that the new safeguarding arrangements are being adequately considered.

7.3 BHRUT and NELFT each hold an assurance/engagement meeting to which the CCG participates. In addition to this the CCG attends and scrutinises the papers presented by the providers at the Clinical Quality Review Meeting (CQRM) for further assurance. These platforms are used to share audit results, compliance data, learning from serious incidents and for joint policy development.

7.4 Information from these meetings is fed into the CCGs Integrated Safeguarding Assurance Board (ISAB) to provide assurance and to mitigate and manage identified risks.

7.5 To further support the embedding of the new legislation and guidance, the designated professionals provide safeguarding supervision to the named professionals within NELFT and BHRUT which further strengthens working relationships and provides case-based assurances around safe and effective safeguarding practice. Specialist safeguarding supervision is a mandatory requirement for all health professionals working in safeguarding.

7.6 Following lockdown due to Covid-19, various assurance meetings were suspended. However, plans were implemented to hold these meetings virtually from April 2020.

8.0 To support the CCGs in the implementation of the CSA hub within the BHR footprint. 8.1 It was proposed by the Healthy London Partnership that there would be two additional north east London hubs for historic child sexual abuse, with one of the sites within the BHR footprint.

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The rationale for this was to meet the anticipated increase in demand. The recommended site was at the Horizon Clinic in Chadwell Health.

8.2 As the Horizon Clinic was not open for use for CSA purposes, interim arrangements were made for the Wood Street Health Centre in Waltham Forest to host the outer London clinic in the first instance.

8.3 Following on from this, it has been identified that there was an inadequate pool of doctors across the NELFT footprint who were suitably qualified to undertake CSA examinations and it was also deemed that the wood street clinic was not fit for purpose.

8.4 This has now resulted in all historic CSA examinations being undertaken at the Royal London where they have adequate medical cover and is in an appropriate environment.

9.0 To support provider CQRMs in relation to safeguarding children compliance 9.1 To continue to support the quality agenda, the designated nurses review all the CQRM papers for BHRUT, NELFT and a selection of the major independent providers. Once reviewed, formal feedback is given and requests are made, where appropriate, for further clarification and/or assurances

9.2 The designated nurse for Havering attends the NELFT CQRM as a substantive member and has been able to address identified quality issues in relation to safeguarding children and looked after children.

9.3 Representation at the BHRUT CQRM meeting is not currently possible due to capacity within the designated professional’s team. However, this absence is mitigated by substantial assurance papers are reviewed as part of the BHRUT operational group meeting and safeguarding strategic and assurance group meeting which is attended by the designated nurse for Barking and Dagenham.

9.4 The designated nurse for Redbridge attends the CQRM meetings for The Holly, Spire, PELC, Care UK and the wheelchair service to ensure that safeguarding children is effectively embedded into practice. This is a priority area for the CCGs as it has been identified that independent sector providers require considerable support to become fully compliant with all safeguarding statutory functions and responsibilities.

9.5 To strengthen the quality agenda, provider organisations across the health economy are discussed at the weekly safeguarding and quality team meeting, reported at ISAB, and briefings papers provided to the Quality and Performance Committee if escalation is indicated.

9.6 Following lockdown due to Covid-19, the CQRM meetings were stood down and the quality team are exploring alternative arrangements for 2020/2021.

10.0 Intercollegiate guidance 10.1 On the 31 January 2019 the Royal College of Nursing published the updated ‘Safeguarding Children and Young People: Roles and Competencies for Healthcare Staff’ which replaces the previous 2014 version.

10.2 A copy of the guidance can be accessed here: https://www.rcn.org.uk/professional-development/publications/007-366

10.3 This intercollegiate guidance provides a clear framework which identifies the competencies required for all healthcare staff. Levels 1-3 relate to different occupational groups, while level 4

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and 5 are related to specific roles. This version of the framework also includes specific detail for chief executives, chairs, board members including executives, non-executive and lay members.

10.4 The guidance also outlines clear role descriptions for specialist safeguarding/child protection professionals including the required resources to fulfil these functions.

10.5 This guidance relates to safeguarding children only and does not include looked after children, which has its own intercollegiate guidance. The looked after children intercollegiate guidance is currently being updated but has not been published yet.

10.6 The tables below outline the current provision of the safeguarding children resource within the CCGs benchmarked against the intercollegiate document.

Table 1: Designated Doctor for Safeguarding Children

CCGs Child Population Current Resource Resource according to intercollegiate guidance Barking and 66,270 3 PAs per week 4.5 – 5 PAs per week Dagenham CCG Havering CCG 67,100 2 PAs per week on an 4.5 – 5 PAs per week interim basis Redbridge CCG 82,600 3 PAs per week 4.5 – 5 PAs per week

Table 2: Named GPs for Safeguarding Children

CCGs Total Borough Current Resource Resource according to Population intercollegiate guidance Barking and 209,000 2 PAs per week 2 PAs per 220,000 total Dagenham CCG population Havering CCG 254,300 2 PAs per week 2 PAs per 220,000 total population Redbridge CCG 304,200 3 PAs per week provided 2PAs per 220,000 total by consultant nurse population

Table 3: Designated Nurses for Safeguarding Children

CCGs Child Population Current Resource Resource according to intercollegiate guidance Barking and 66,270 0.5 WTE (1 WTE shared 1 dedicated WTE Dagenham CCG between safeguarding designated nurse per children and looked after 70,000 child population children) Havering CCG 67,100 0.5 WTE (1WTE shared 1 dedicated WTE between safeguarding designated nurse per children and looked after 70,000 child population children) Redbridge CCG 82,600 0.5 WTE (1WTE shared 1 dedicated WTE

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between safeguarding designated nurse per children and looked after 70,000 child population children)

Table 4: Administrative support

CCGs Child Population Current Resource Resource according to intercollegiate guidance Barking and 66,270 1 WTE admin post shared 0.5 WTE for safeguarding Dagenham CCG across safeguarding and 0.5 WTE for LAC per children, safeguarding 70,000 child population adults, and looked after children across the three boroughs Havering CCG 67,100 As above 0.5 WTE for safeguarding and 0.5 WTE for LAC per 70,000 child population Redbridge CCG 82,600 As above 0.5 WTE for safeguarding and 0.5 WTE for LAC per 70,000 child population

10.7 The Accountable Officer has completed a scoping exercise across NELCA focusing on the resources for safeguarding children, looked after children, and safeguarding adults across the north east London footprint. This exercise demonstrated that BHR CCGs has less safeguarding resource compared to the rest of north east London.

10.8 To mitigate risk, it is important to note that all the designated professionals across the BHR footprint work closely together and function as a fully integrated team. This enables work to be streamlined and restricts the amount of duplication across the BHR footprint.

11.0 Local Developments 11.1 The designated professionals continue to contribute to the work with the local safeguarding children partnerships (SCP) to ensure that safeguarding is effectively embedded across the BHR health economy. There remains a significant contribution from the designated professionals at the SCP sub-groups with focus on multi-agency audit, learning from serious case reviews, learning reviews, contextual safeguarding, and child sexual exploitation.

11.2 Barking and Dagenham: 11.2.1 Due to significant concerns in relation to child exploitation it was agreed by Barking and Dagenham Safeguarding Children Partnership that a Criminal Exploitation Group (CEG) be established to monitor all aspects of child exploitation (trafficking, modern slavery, county lines, NRM referrals etc). The Multi-Agency Sexual Exploitation (MASE) working group is well established in Barking and Dagenham. CEG and MASE report into the Contextual Safeguarding and Exploitation Strategic group on a monthly basis.

11.2.2 Contextual Safeguarding is an approach to understand and respond to young people’s experience of significant harm beyond the family. Barking and Dagenham were successful in their bid for support from the University of Bedfordshire and are now part of the scale up programme for the next three years.

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11.2.3 An Ofsted inspection took place in February 2019 and the report was published on 1 April 2019. The CCG and health partners have actively supported the Barking and Dagenham Ofsted Improvement Plan through agreed workstreams.

11.2.4 The Independent Chair of the BDSCB convened meetings to discuss what independent scrutiny should look like going forward in the new safeguarding children partnership. The first meeting was held in October 2019 where the role, responsibilities and outcomes were discussed. This work is ongoing under the direction of the safeguarding children strategic partners.

11.3 Havering: 11.3.1 Following the identification of serious knife crime being a significant problem in Havering, Havering Safeguarding Children Partnership (HSCP) decided to develop an adolescent strategy alone with the development of an adolescent service within children’s services.

11.3.2 Work remains ongoing in relation to the deliver of the adolescent strategy, but the adolescent team have now been recruited to and work in underway in relation to aligning services.

11.3.3 The local authority is in the process of launching a new Multi-Agency Safeguarding Hub (MASH) e-portal to enable an improved quality of information sharing of safeguarding concerns across the multi-agency partnership. This has yet to go live but it is anticipated it will launch in spring 2020.

11.4 Redbridge: 11.4.1 At the October 2019 meeting of the Redbridge Safeguarding Children Partnership (RSCP) a proposal to establish a single strategic group to oversee and co-ordinate work to address both the criminal and sexual exploitation of young people – the Multi-Agency Sexual and Criminal Exploitation Panel (MASCE) was endorsed. The operational group met in November 2019 and January 2020 and is beginning to develop a multi-agency overview of the current position. A presentation from Rescue and Response, a London-wide project funded by MOPAC to support young people involved in county lines activity was delivered at the operational group. The first meeting of the strategic MASCE took place on 27 January 2020. The development of the Mapping Exploitation Tool will be key to the work of this group.

11.4.2 A new service initiative, Families are Forever in Redbridge, was launched on 28 January 2020. This is a project which will use a family therapy approach to work with young people at risk of gang exploitation and involvement in county lines. It is funded by the Youth Endowment Fund and delivered in partnership with Family Psychology Mutual, a not for profit social enterprise.

11.4.3 The Redbridge Learning and Improvement Sub Group have concentrated on developing an effective model for multi-agency Learning Reviews – reviewing cases which do not meet the threshold for notification as a serious incident or for a Child Safeguarding Practice Review, but which nevertheless offer important opportunities for learning and improvement. A draft tool has been developed and was piloted in two Learning Reviews, both considering cases of teenage suicide. The learning from both the reviews and the piloting of the tool will be reported to the RSCP meeting.

12.0 Key Priorities for 2020-2022 12.1 In partnership with the local safeguarding children partnerships, the CCG have developed the following priorities for the period April 2020 – March 2022:

• Supporting the GP federations in discharging their statutory functions for safeguarding children.

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• Ensuring that safeguarding children is adequately considered in moving towards a single ICS. • Ensuring that the CCG understands the impact that Covid-19 has had on safeguarding children and effectively manages these impacts. • Strengthen how the health economy contributes to the local safeguarding children partnerships • To provide strategic oversight and scrutiny on the delivery of the child death review requirements.

13.0 Resources/Investment 13.1 There are no additional resource implications/revenue or capitals costs arising from this report.

14.0 Sustainability 14.1 Further improvements are required to effectively safeguard children across the BHR footprint, this will have a positive impact on the long-term outcomes for children and families within the boroughs.

15.0 Equalities 15.1 This report has considered the CCGs’ equality duty but has not identified any areas that are likely to impact on equality or human rights.

16.0 Risks 16.1 There is a risk that the CCGs’ workforce and officeholders will not understand their responsibilities for safeguarding children if mandatory training compliance is not met.

16.2 The CCG is not currently compliant with intercollegiate guidance as highlighted in section 10.

17.0 Managing Conflicts of Interest 17.1 There are no conflicts of interest raised in this report.

Authors: Paul Archer, Designated Nurse for Safeguarding Children & Looked After Children – Havering Kate Byrne, Designated Nurse for Safeguarding Children & Looked After Children – Barking & Dagenham Sue Nichols, Designated Nurse for Safeguarding Children & Looked After Children - Redbridge

Date: 21st July 2020

9 93 To: Meeting of the NHS Barking and Dagenham, Havering and Redbridge CCGs’ Governing Bodies (meeting in common)

From: Mark Gilbey-Cross, Deputy Nurse Director (Acting)

Date: 28 September 2020

Subject: Looked After Children (LAC) Annual Report 2019/20

Executive Summary This is the seventh looked after children annual report which reflects the challenges and achievements in the 2019-2020 reporting period.

The report will provide assurance to the Governing Bodies that the Barking and Dagenham, Havering and Redbridge Clinical Commissioning Groups (BHR CCGs) are discharging their statutory responsibilities to safeguard and promote the welfare of children and are meeting the health needs of looked after children (LAC) across the local health economy.

This report will review the priorities set for 2018-2020 and will provide a narrative on how these priorities have been met, any barriers to delivery identified, and the mitigating actions in place.

The report will also highlight the priorities for 2020-2022 and any risks the Governing Bodies need to be cognisant of.

Recommendations The Governing Bodies are asked to endorse this report and note the progress made, challenges identified, and the mitigating actions.

1.0 Purpose of the Report 1.1 This report provides BHR CCGs Governing Bodies with an overview of LAC across the BHR health economy during 2019/20. The report reviews the work across the year, giving assurance that the CCGs have discharged their statutory responsibilities to safeguard and promote the welfare of children and meet the health needs of LAC across the health services that it commissions.

1.2 Although safeguarding children is comprehensively discussed in the safeguarding children annual report, it is important to acknowledge that LAC and safeguarding are intertwined as children move between different parts of the child protection system.

1.3 The report will also highlight risks within the LAC agenda and demonstrate how the safeguarding and LAC team within the CCGs are managing and mitigating the risks working closely with system partners.

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2.0 Key priority areas for 2018-2020 2.1 During 2018/19 the following priorities were set for the next two years: • Working in partnership with the local authorities and health providers to further strengthen the ‘zoning meetings’ (meetings where individual children are reviewed) across the BHR footprint to ensure an equitable LAC health service. • To work with LAC health providers to develop, agree and implement a LAC audit plan to demonstrate how the health needs of the LAC population have been assessed and addressed. This will include a tri-borough audit of the health passport. • Foster a stronger working relationship with the CSU contracting team and children’s commissioners to ensure that data and service quality issues are identified and addressed within acceptable timeframes. • Develop a standardised dataset across the BHR footprint for LAC focusing on key information. • Strengthen the LAC Quality Improvement Group within the CCGs to ensure that the CCGs continue to meet their statutory duties for looked after children. • To work with the children’s commissioning team to refresh the service specification for looked after children. • Work closely with the North East London Commissioning Alliance (NELCA) to explore developing standardised practice across the STP footprint.

2.2 In addition to these, an additional priority was set in 2019/2020: • The CCG will support the local authorities and NELFT in ensuring the timeliness of initial health assessments.

2.3 Each priority area will be discussed in detail below and provide the Quality and Performance Committee with assurance as to how that priority has been addressed within the financial year.

3.0 Working in partnership with the local authorities and health providers to further strengthen the ‘zoning meetings’ across the BHR footprint to ensure an equitable LAC health service.

3.1 Havering - It was highlighted to the CCG in March 2018 that there were a significant number of Review Health Assessments (RHA) that were overdue in Havering and were unlikely to be achieved by 2017/18 financial year end. Following on from this, the CCG worked closely with NELFT and the local authority children’s services to ensure that a turnaround action plan was implemented. There were a number of young people who had refused their RHAs which affected the overall number of completed RHAs. By the end of April 2018 there were only 3 RHAs not accounted for – these were in relation to children placed out of area, and it is recognised that ensuring children who are placed out of the originating borough receive RHAs on time is an added complexity.

3.2 The CCG, NELFT and the Local Authority implemented a “zoning” meeting in Havering to RAG rate all LAC cases to ensure that RHA due dates were highlighted and escalated within statutory timeframes. This pilot was so successful that by 2018/19 year end the total number of Havering LAC with an up-to-date health assessment was 91%. The outstanding 9% related to either LAC who had refused their health assessment, missing from care, or had been placed in an out of borough placement where there was a delay from the provider.

3.3 In the financial year 2019/2020 this was a similar picture with 90.8% of health assessments being completed within the financial year. Similarly, to the previous year, the remaining 9.2% relate to children who have either refused their health assessments or are currently missing from care.

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3.4 Barking and Dagenham - It was recognised in January 2018 that there was a backlog of 83 RHAs. This backlog was cleared by August 2018 and in October 2018 Barking and Dagenham introduced the “zoning” meeting as this was seen as best practice. In November 2018 the CCG became aware that there was a backlog of 35 Initial Health Assessments (IHA) which was escalated through the appropriate governance routes. Turn-around meetings were established and continue between the CCG, NELFT and the Local Authority to address the significant concerns and identify system barriers. By January 2019 the backlog was cleared, however performance in relation to looked after children having their IHA within statutory time frames remains poor. The system barriers identified included a delay in the Local Authority providing paperwork within acceptable time frames, interpreter availability, and community paediatrician availability.

3.5 Throughout 2019, there were ongoing concerns with delays in undertaking IHAs and RHAs in Barking and Dagenham. In October 2019 it was agreed at the Members Corporate Parenting Group Meeting that a monthly LAC Health Subgroup should be established. The purpose of the group was to oversee all aspects of LAC health and to support the Barking and Dagenham Ofsted Improvement Plan. Group membership is from across the CCGs, local authority and NELFT. Exceptions from the zoning meetings are escalated to the meeting. By March 2020 progress was made in addressing the RHA backlog and timeliness of IHA had improved.

3.6 To ensure that there is adequate oversight of this risk and to measure improvement, the poor compliance of IHA completion in Barking and Dagenham was added to the CCGs collaborative risk register. The collaborative risk register continued to be monitored on a bi-monthly basis.

3.7 Redbridge - During 2018/19 Redbridge local authority implemented the introduction of the IHA paperwork onto their computer system to enable the efficient handling of the IHA medical requests. This has resulted in improved timeliness of requests made to NELFT by the local authority as the NELFT LAC administrator was given access to the local authority’s computer system to access the requests.

3.8 Redbridge local authority have decided not to implement the zoning meetings as existing processes between the local authority and NELFT appear to be effective.

3.9 During 2019/20 a delay in the return of completed IHA documentation to Redbridge Local Authority was noted and the necessary action taken to introduce practice within the service to improve returns within the specified timeframes.

4.0 To work with LAC health providers to develop, agree and implement a LAC audit plan to demonstrate how the health needs of the LAC population have been assessed and addressed. This will include a tri-borough audit of the health passport.

4.1 In order to ensure the quality of health assessments is of the required standard, audits have been undertaken across the three boroughs for IHAs and RHAs.

4.2 The IHA audits have identified improvements in the quality of IHAs in Havering but further work is required to ensure improved quality in Barking and Dagenham and Redbridge. This has been addressed with the provider via the Clinical Quality Review Meetings (CQRM) and has been discussed at the IHA task and finish group to ensure continued improvement in quality standards.

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4.3 The RHA audits undertaken have shown that there is generally a high standard of health assessments being undertaken with some minor areas of improvement identified within each borough. These audits have been presented within each locality and areas for improvement shared with individual teams.

4.4 Through undertaking the audits for RHAs it has been identified that a new audit tool is required to improve the capturing of qualitative data. This will be set as a priority for 2020-2022.

5.0 Foster a stronger working relationship with the CSU and children’s commissioners to ensure that data and service quality issues are identified and addressed within acceptable timeframes.

5.1 This priority is addressed in section seven of this report.

6.0 Develop a standardised dataset across the BHR footprint for LAC.

6.1 Due to the past poor performance identified around the timeliness of IHAs and RHAs, the designated professionals have sought to implement a standardised dataset across the BHR footprint. This measures the timeliness of health assessments undertaken by NELFT.

6.2 The new dataset looks at the following five domains: • Date the child became looked after • Date the local authority issued IHA paperwork to NELFT • Date an assessment appointment was issued by NELFT • Date the health assessment took place • Date the health assessment paperwork was returned to the Local Authority.

6.3 By undertaking this exercise, the designated professionals are able to establish where the system blocks occur and are able to provide a robust narrative to the CCG, Local Authority and Corporate Parenting Panels as to why there has been a delay in undertaking health assessments.

6.4 The focus for 2019/20 has been on IHAs. However, there was an identified issue in Barking and Dagenham around the timeliness of RHAs which resulted in a task and finish group to ensure effective turnaround. This methodology has been effective and by March 2020 the backlog had been cleared.

6.5 To support a standardised dataset, the CCG now receive LAC notifications for all children who become LAC (within BHR) and are notified of relevant placement moves. This enables the designated professionals to have up-to-date information regarding the demographics of the caseloads and therefore can provide a stronger narrative around this group of children and young people.

6.6 There remains a risk that the information pertaining to other local authorities placing children within the BHR footprint is outdated information. The CCG is reliant on being notified by other local authority areas when a child is placed in area. Although local authorities are consistent in meeting the statutory requirement by notifying when in-borough placements start, there are inconsistencies in notifying when these children cease to be looked after or have been moved outside of the BHR footprint. This is not a statutory requirement.

6.7 Due to the impact of Covid-19, all provider reporting was suspended on a temporary basis. However, reporting will recommence in agreement between NELFT and the CCGs.

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7.0 Strengthen the LAC Quality Improvement Group within the CCGs to ensure that the CCGs continue to meet their statutory duties for looked after children.

7.1 The LAC Quality Improvement Group frequency has been increased to monthly to ensure sustained improvements and traction on actions.

7.2 The membership of this group has been widened to include membership from the CSU contracting team and the children’s commissioning team. In addition to this, the designated professionals have oversight of the performance data presented at the Service Performance Review Meeting.

7.3 Challenges remain around performance data quality from the provider. However, to address this the designated nurses are triangulating data held by the local authority to better understand system barriers and accurate reporting. The CSU are supporting this work-steam by requesting exception report from the provider where an area of concern is identified.

7.4 Identified challenges are escalated and managed through the Integrated Safeguarding Assurance Board, Quality and Performance Committee, and the CQRMs held with the provider.

7.5 Following Covid-19 all non-essential meetings were suspended. However, plans have been made to reinstate the LAC improvement quality group in 2020/2021 via a virtual platform.

8.0 To work with the children’s commissioning team to refresh the service specification for looked after children.

8.1 In 2019/20 the designated professionals have worked closely with the children’s commissioning team and the provider to undertake a refresh of the LAC service specification.

8.2 A series of meetings have taken place in support of the Service Line Review programme to ensure that the service specification is supporting all the work around quality and timeliness. The revised specification is also addressing the shared resource requirements with Local Authority services and the move towards integrated care.

8.3 There is an expectation that the revised service specification will be fully signed off once contract processes return to business as usual post Covid-19.

9.0 Work closely with the North East London Commissioning Alliance (NELCA) to explore developing standardised practice across the STP footprint. 9.1 In March 2018 NHS England’s safeguarding team facilitated a meeting to ensure that CCG safeguarding teams across the east London STP area were coming together to work in a more aligned way. Out of this initial meeting the NELCA safeguarding meeting was developed which brought together the safeguarding children, looked after children, and safeguarding adult designated professionals from the seven CCG areas. The meeting takes place on a six weekly basis and reports directly to the CCGs Accountable Officer.

9.2 The main priority of the group is to ensure there is a consistent approach to safeguarding (adult and children) and LAC across the STP footprint and to align policies, strategies, and declarations where possible.

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9.3 The key work stream in relation to LAC has been a refresh of the service specifications. Due to there being different models of delivery and different providers of the LAC service across the STP, an overarching service specification could not be agreed upon. However, a good practice template has been designed for future reference and will form a benchmark for service specifications across the NELCA footprint.

10.0 The CCG will support the local authorities and NELFT in ensuring the timeliness of initial health assessments. 10.1 Following a review of the data outlined in section 6.2 it was identified that across the three boroughs statutory time frames were not being met for the completion of IHAs within 20 working days of coming into care.

10.2 To address this issue and to understand the system barriers, and IHA task and finish group was established in November 2019. The group met on three occasions and information was shared jointly between the CCGs, Local Authorities and NELFT to establish where in the system there were blockages and to put mechanisms in place to unblock these.

10.3 Initial work started in relation to the following:

• Ensuring that IHA consent is obtained from parents at the point of a child coming into care • Ensuring that the local authorities send IHA requests to NELFT within 5 working days of a child becoming looked after • Streamlining administration processes to ensure that completed paperwork is returned to the local authorities within statutory timeframes • Review commissioning arrangements to free up community paediatrician capacity

10.4 Due to the impact of Covid-19, future meetings have been suspended. However, the meetings will be reinitiated in quarter 1 of 2020/2021 to ensure continued improvement.

10.5 This item will remain on the 2020-2022 priorities until there is evidence of sustained improvement in the compliance of IHAs within statutory timeframes.

11.0 2020-2022 priorities 11.1 The following priorities have been set for the next two-year period. • The CCG will support the local authorities and NELFT in ensuring the timeliness of initial and review health assessments. • To refresh the RHA audit tool to ensure informative, qualitative data is captured. • To continue to support providers in improving the quality of health assessments. • To understand the impact of Covid-19 on the LAC population • To ensure the CCG continues to meet its statutory responsibilities for looked after children

12.0 Resources/Investment 12.1 There are no additional resource implications/revenue or capital costs arising from this report.

13.0 Sustainability 13.1 If further improvements are made in effectively meeting the needs of looked after children across the BHR footprint, this will have a positive impact on the long-term outcomes for children and families within the boroughs.

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14.0 Equalities 14.1 This report has considered the CCG’s equality duty but has not identified any areas that are likely to impact on equality or human rights.

15.0 Risks 15.1 Risks have been highlighted in the main body of the report and mitigating actions discussed.

16.0 Managing Conflicts of Interest 16.1 There are no conflicts of interest raised in this report.

Authors: Paul Archer, Designated Nurse for Safeguarding Children and Looked After Children – Havering

Kate Byrne, Designated Nurse for Safeguarding Children and Looked After Children – Barking and Dagenham

Sue Nichols, Designated Nurse for Safeguarding Children and Looked After Children – Redbridge

Dr Sophie Niall, Designated Doctor for Looked After Children (BHR CCGs)

Date: 30 July 2020

100 To: Meeting of the NHS Barking and Dagenham, Havering and Redbridge CCGs’ Governing Bodies (meeting in common)

From: Jane Milligan, Accountable Officer and BHR CCG Chairs, Dr Aggarwal, Dr Mehta and Dr John

Date: 24 September 2020

Subject: Proposal to create a single CCG for north east London

Executive Summary

In line with the Long-Term Plan and the development of an Integrated Care System for north east London, the seven CCGs in north east London have been working more closely together for the last few years to create a single strategic commissioning approach, supported by strong local integration and decision-making.

It is proposed that the seven CCGs now take the final step to merge into one CCG from April 2021. There is a strong case for this change and the CCGs have been engaging widely with member practices and other stakeholders to explore how the new commissioning landscape will work to improve local population health.

Our programme to merge the seven CCGs was paused in March 2020 by the arrival of Covid-19 and was not restarted until July 2020. This has resulted in a tighter timescale to engage to meet the application deadline of 30 September, with a final deadline for member votes of 19 October.

A verbal update with the latest feedback on engagement will be provided at the meeting.

The attached slides and papers set out further detail about the proposals for change.

Recommendations The governing bodies are asked to approve: 1. the submission of a single CCG application to NHSEI on 30 September 2020; and 2. taking the proposal to merge to a vote of members in October 2020.

Author: Antek Lejk, Programme Director and Marie Price, Director of Corporate Affairs Date: 18 September 2020

101 The future of health and care for the people of north east London

102 Overview - creating an ICS and one CCG for NEL by April 2021 • Direction of travel in the NHS Long Term Plan is one CCG per integrated care system (ICS) by April 2021 • We have taken more time in NEL than other areas to ensure development of our local arrangements and wider ICS • Shared our proposal ‘The future of health and care for the people of north east London’ early August and engaged extensively through to late September. This builds on engagement over the past year on our CCG and ICS plans • Our document can be found here: https://www.eastlondonhcp.nhs.uk/ourplans/the-future-of-health-and-care- for-the-people-of-north-east-london.htm

103 A locally led system approach • The vast majority of our health and care delivery will continue to be delivered at our local place and borough level, working together as partners with our local population. We call this the 80:20 principle – in recognition of the fact that decisions about health and care will take place as close to local people as possible. • Local partnerships will decide how best to use resources in the best interests of patients • Our single CCG would continue to be clinically led, with a clinical majority and include lay members. GP members’ forums and representative bodies will be essential to making this successful, working with their local GP chair to make decisions about health and care in local communities. • Primary care will be represented throughout the system with GP leaders on the ICS board, local multi borough (BHR) and borough level partnerships – and leading transformation programmes, continuing our good work. 104 How we will create one CCG for NEL

Key workstreams • Communications and engagement – three stages • Engagement with members and wider stakeholders in advance of the vote in October - Aug - Oct 2020 • Internal communications with our CCG staff about what this change will mean for them – Aug – March 2021 • Once the vote outcome is clear, ongoing engagement with stakeholders as we develop our plan for NEL and wider ICS development – Oct 2020 – April 2021 (but there will be an ongoing approach to engagement beyond April as we develop our ICS) • Governance • New constitution to be drafted and agreed. Positive working with LMC colleagues on this. • A membership vote. Election window to open in early October for up to a week and to be run independently by Civica Election Services. • Governance handbook – will include detail on how our decision making will work. Initial draft for end of September and to be developed over next few months. • Governance at NEL level to be limited to key requirements, with focus on place and ICPs. • People • HR – develop structure of one CCG, align people policies and transfer of staff • OD – produce plan and support colleagues to work in a more integrated way, building on what we have been doing • Enablers • Finance – allocation model, single ledger and finance operating model being developed to support maximum delegation

• Digital – IT transfer 105 Benefits

• Benefits for people • Closer partnership working will enable people at all stages of their life • Working together with local councils, providers and the voluntary sector across north east London, we will address health inequalities and ensure we do everything possible to stop people getting ill to begin with • We will ensure that wherever you go in the system you won’t have to tell your story again if you don’t want to. • Benefits for staff • We are committed to supporting our workforce to grow and develop and to creating a wider pool of opportunities for career progression and development for everyone • Reduced bureaucracy, fewer meetings and a reduction in duplication • Together we will build on our own local plans to develop a single consistent plan for the future, helping us to improve services and reduce variation • Financial benefits • Ensure every single pound is spent to the benefit of every single person in north east London

106 What we’ve heard

Engagement is ongoing, which is why we have taken as much time as possible in the run up to the vote to speak with and listen to our GP members, partners and other colleagues. We’ve heard: • There is a good understanding of why we need to do this now and the broader context for these proposed changes. • LMC colleagues have welcomed the engagement and learning applied from other mergers in London to help us get this right here. Their suggestions on the constitution have been incorporated. • There is more to do and we must continue to work together as we get into the detailed design of our place and ICP arrangements – we have stated our intention to do this. • Stakeholders have expressed local is the priority and decisions must be made as close to people as possible and relationships strengthened. We’ve provided reassurance that these trusted local relationships and teams will be maintained. • Clinical leadership must be protected and strengthened in our local systems. We have committed to this. • That this is an opportunity to focus on levelling up and reduce any historic inequities in funding – maintaining current projected budgets and targeting new funding to address these issues and population need. Our financial strategy will enshrine this principle. A Declaration of Principles: Our current CCG chairs, based on feedback from member colleagues and stakeholders have developed a set of principles to inform and guide the way the new CCG will operate. These are included with the main paper.

107 Next steps with vote • The current vote will be conducted in line with current constitutions, which vary slightly across NEL. These are on a practice rather than all GP basis, with some areas having weighted voting. All of this will be made clear to members. • An independent organisation, Civica, which specialises in running elections has been commissioned to conduct the vote across NEL. We have used them before (under their name Electoral Reform Society, now part of Civica) and they have run several CCG merger votes across the country. • The vote will be conducted electronically rather than in person at a meeting as we usually do given the current restrictions on meetings given Covid-19. • We will send information packs to members from 28 September and open a window for electronic voting for a week from 5 October. • We will track progress on the vote during the voting window to ensure that practices are responding and that we meet the quorum required, and to help us understand the way in which practices are voting. • We are working with LMC colleagues and have heard their feedback on the specific merger question (based on their experience elsewhere in London) and have ensured that the question we ask in NEL is transparent and clear.

108 Designing our local arrangements • Each of our CCGs has been working with local stakeholders to design borough/place and wider system arrangements in line with our principle of 80:20 delegation. • The diagrams on the following pages show the high level arrangements for each ICP area.

109 BHR

NEL (20%) BHR SYSTEM (80%) Improvement and Delivery Havering Havering PCN North Co and Planning - Co ordination Havering Havering PCN - South production & Engagement & production Assurance and Oversight Havering Havering PCN Crest Marhsall’s Havering Borough Partnership PCN Barking and Dagenham What will theBHR System look like in April2021? Cranbrook Children and Young People, Mental Health, Planned Care, Urgent and Urgent Planned Care, Health,Mental andChildren People, Young PCN Integrated Care Executive Group; Group; Integrated Care Executive Emergency Care, Cancer, Primary Care, Long Care,Cancer, Primary Term Care, Conditions Emergency Supported by key enablers; workforce, digital, finance, estates finance, digital, enablers; workforce, key Supported by Woodford Wanstead Wanstead PCN Partners at all levels of the BHR system BHR the of levels all at Partners Integrated Care Partnership Board; Partnership Care Integrated North East London ICS and single single and ICS London East North BHR TRANSFORMATION BOARDS TRANSFORMATION BHR BOROUGH PARTNERSHIPS BOROUGH withHealth andCabinet Care Community Based Care Based Community Borough Partnership PCN North East London CCG London East North Seven Kings Havering . . Loxford PCN Commissioners and Providers Providers and Commissioners PCN Fairlop PCN North B&D Our patients, residents and local communities and local residents Our patients, Borough Partnership B&D North North B&D Redbridge PCN West B&D West PCN One B&D New New B&D PCN West PCN B&D East B&D East PCN One ...... BHR system: of the levels all at Partners housing etc. housing police, Barts Health, Others e.g. PELC sector voluntary and Community x3 Federations GP x15 Networks Primary Care NELFT BHRUT Redbridge Borough London Havering Borough London Dagenham Barking and Borough London 110 7 City and Hackney Integrated Care Partnership: Model

System Chief Officer & Clinical Leadership

111 WEL ICP leadership and governance operating model This graphic includes the PCNs to show them as the focus of delivery and improvement

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A proposal to create a single North East London NHS Clinical Commissioning Group

September 2020

NHS City and Hackney Clinical Commissioning Group NHS Tower Hamlets Clinical Commissioning Group NHS Newham Clinical Commissioning Group NHS Waltham Forest Clinical Commissioning Group NHS Havering Clinical Commissioning Group NHS Barking and Dagenham Clinical Commissioning Group NHS Redbridge Clinical Commissioning Group

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113 Contents

CONTENTS 2

1 INTRODUCTION 4

2 OUR POPULATION 5

3 OUR CONTEXT 10

3.1 Track record of working collaboratively across north east London 10

3.2 The Long Term Plan 13

3.3 Local challenges 13

3.4 The future of commissioning 14

3.5 Changes in NHS England and NHS Improvement 15

4 OUR VISION 16

4.1 Creating a new vision for North East London 16

4.2 Local delivery 17

4.3 The 80:20 principle 17

5 OUR NEW OPERATING MODEL 18

5.1 Overview 18

5.2 Strengthening our local focus 18

5.3 A single CCG 19

6 BENEFITS 23

7 ENGAGING WITH OUR PARTNERS 28

8 CLINICAL LEADERSHIP 29

9 TACKLING INEQUALITIES 29

10 OUR DELIVERY APPROACH 30

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APPENDICES

APPENDIX 1: The future of health and care in north east London APPENDIX 2: Draft declaration of principles APPENDIX 3: Financial and commissioning framework

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115 1 Introduction

The seven CCGs in north east London (NEL) have been collaborating more and more over the last few years. That collaboration has been strengthened through the pandemic as we have worked as a single system to tackle the unprecedented challenges of Covid-19. As we build a new Integrated Care System with partners across north east London, we believe now is the time to merge our seven CCGs into a single body from April 2021. This will help us to:

• Accelerate the development of news ways of working across the system. • Create a more efficient and effective operating model. • Make better use of our resources and achieve economies of scale, whilst maintaining local decision-making through borough-based partnerships and primary care networks. • Reduce variation in services and target health inequalities. • Reduce bureaucracy and focus energy on working in partnership with providers, local authorities and the voluntary sector. • Create a more resilient organisation, with better opportunities to attract and retain the skills we need. This document explains what we are proposing to do and why.

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116 2 Our Population

Population growth1 North east London currently has an estimated population of just over 2 million which is projected to rise by over 13% in the next 10 years. This is faster than London as a whole, which is predicted to grow by less than 10%. However, this growth is not uniform across the area with Newham expected to have the largest increase in numbers, rising by 72,280 by 2028 and other NEL boroughs increasing from between 6.6% to 20.5% as per table 1 below.

Table 1- Population increase over the next 10 years

Area Population Increase

2018 2023 2028 5 10 years years Barking & 212773 226988 248727 6.7% 16.9% Dagenham City of London 7681 8408 9075 9.5% 18.1% Hackney 281740 296175 299493 5.1% 6.3% Havering 257509 276651 294663 7.4% 14.4% Newham 353245 372516 425525 5.5% 20.5% Redbridge 305909 323304 333590 5.7% 9.0% Tower Hamlets 317205 341358 370712 7.6% 16.9% 283525 297438 302285 4.9% 6.6% Waltham Forest

2019587 2142838 2284070 6.1% 13.1% ELCHP

London 9006352 9479611 9889687 5.3% 9.8%

This is driven by a number of regeneration initiatives. Across NEL there are seven GLA designated housing zones2 and five opportunity areas3 as detailed below. Table 2 - Housing Zones Designated By GLA

Housing Zone New Homes Barking Riverside Gateways 1902 Rainham and Beam Park 3457 Havering 3304 Barking Town Centre 2319 Ilford Town Centre 2189 Poplar Riverside 4368 Blackhorse Lane & Northern Olympic Park 2608 Total 20,147

1 GLA 2017, 2016-based Demographic Projections – Housing led; accessed at https://data.london.gov.uk/dataset/projections/ 2 GLA, https://www.london.gov.uk/what-we-do/housing-and-land/increasing-housing- supply/housing-zones 3 GLA, https://www.london.gov.uk/what-we-do/planning/implementing-london-plan/opportunity- areas

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Table 3 - Opportunity Areas Designated By GLA

Opportunity Area Housing Target London Riverside 26,500 Ilford 5,000 City Fringe 8,700 Olympic Legacy Supplementary Planning Guidance 39,000 Upper Lea Valley 21,000 Total 100,200 Note: only some Upper Lea Valley is in NE London area Growth is heavily concentrated with the 10 wards having increase of over 40% and accounting for over two thirds of all the population increase in the STP area.

Figure 1 - Map of population growth by ward. 2018 to 2028

Population change The proportion of young people is rising slightly slower than the overall population increase at less than 10%. The numbers of people 80 years and over is projected to rise at 19% to just under 100,000 people, a faster rate than the general population. The STP is ethnically highly diverse with four of the 10 most diverse local authorities in England and Wales including the most diverse borough - Newham4. The

4 Census 2011

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118 proportion of the population characterised as BAME (Black and Minority Ethnic) is likely to increase slightly over the next 10 years rising from 51.8% to 53.5%.

Deprivation and Health Inequalities North east London is a highly deprived area with five CCGs in the 20 most deprived CCGs in England as measured using the summary measure of the rank of average.5

Clinical Commissioning Group Index Of Multiple Deprivation - Rank 2015 of Average Barking and Dagenham 4 City and Hackney 7 Havering 125 Newham 11 Redbridge 93 Tower Hamlets 9 Waltham Forest 19

As with population growth, the deprivation is not uniform across the area, as shown in the map below

There are significant health inequalities across the area. When looking at healthy life expectancy (HLE) which is an estimate of the number of years lived in “very good” or

5 DHCLG 2015, Indices of Multiple Deprivation 2015; accessed at https://www.gov.uk/government/statistics/english-indices-of-deprivation-2015

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119 “good” general health, based on how individuals perceive their general health6, there is a gap of 8.0 years for men and 9.4 years for women. Details are in the table below

Table 4 - Healthy Life Expectancy in years

Males Females Barking and Dagenham 62.8 62.3 Hackney 57.5 64.0 Havering 65.5 64.5 Newham 60.6 61.3 Redbridge 63.7 63.0 Tower Hamlets 61.9 57.2 62.4 66.5 Waltham Forest

Gap between longest and shortest. 8.0 9.4

Major Long-Term Conditions Improving the health and care management of people with long term conditions (LTCs) is a key aspiration for north east London.

The unique demographics of NEL correlate directly to the prevalence of LTCs within the local population. Diabetes is six times more common amongst the south Asian community and there are an estimated 129,000 people living with diabetes across NEL. Also linked to the same population are increased risks of developing cardiovascular disease, it is fifty percent higher in first generation South Asian people in comparison to the white European population.

There are 9,400 premature deaths in London per year due to poor air quality and the projected population increase will also lead to further rises in traffic and the potential for increased respiratory related disease.

Stroke modelling across NEL has identified that approximately one in every five people who have atrial fibrillation will go on to develop a stroke and it is estimated that 15,500 have atrial fibrillation in NEL.

According to the latest data, overall new HIV diagnoses in London have declined by 42% between 2015 and 2018 (from 2,585 down to 1,504), however London is still a high prevalence area and continued efforts to address this, including recognition of HIV as a LTC, is part of this journey. It is recognised that better management of those with long term conditions within the community promotes stable conditions and an improved quality of life, especially among deprived communities.

6 ONS 2019, Health state life expectancies, UK: 2015 to 2017; accessed at https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/healthandlifeexpectancies/bulletins/healthstat elifeexpectanciesuk/2015to2017#healthy-life-expectancy-at-birth-showed-a-gap-of-215-years-across-the-uk-local-authority- areas

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121 3 Our context

If we look at the context in which we are operating, there are five strong drivers for change. These are:

1. Track record of working collaboratively across north east London 2. The Long Term Plan 3. Local challenges 4. The future of commissioning 5. Changes to NHS England and Improvement

These are explained in more detail below: 3.1 Track record of working collaboratively across north east London

There is a strong and consistent history of collaborative working amongst the health and care organisations in north east London. The BHR CCGs have worked together under a single management structure since CCGs were established. In 2019, the three WEL CCGs (Newham, Tower Hamlets and Waltham Forest) came together under a joint management structure and City and Hackney has been working in an integrated way with local providers for a number of years including as a devolution pilot in 2015. Further steps to formalise integrated care and commissioning arrangements across the NEL footprint began to accelerate following the announcement of Sustainability and Transformation Partnerships (STPs) in early 2016. Key progress made to date includes:

The establishment of the East London Health and Care Partnership (ELHCP) in 2016. The ELHCP brings together the London boroughs, NHS trusts and clinical commissioning groups to oversee system development. It focuses on service and infrastructure change that would be best planned and delivered once for the circa two million people living in north east London. For example, maternity and cancer services.

Creation of the North East London Commissioning Alliance (NELCA) in 2017. This aligned the seven CCGs in north east London (Barking and Dagenham, City and Hackney, Havering, Newham, Redbridge, Tower Hamlets and Waltham Forest) with one accountable officer and chief finance officer. By working together, the CCGs have been able to share best practice, begin to address variation across NEL and streamline some corporate activities while also building up their local system and borough partnerships.

NEL Joint Commissioning Committee (JCC), a committee within NELCA, is one forum where this joint work is being undertaken. The JCC was established in 2018 and consists of representatives from each of the seven north east London CCGs, local authority colleagues and a number of NELCA senior officers. It focuses on issues that are common to all CCGs, and for a limited set of areas where the CCGs have agreed to delegate authority, takes decisions about some

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122 services that are commissioned once for north east London (e.g. London Ambulance Service and integrated urgent care, specialist commissioning). The JCC was responsible for the development of a joint commissioning strategy for 2018/19 to 2021/22, which includes an agreed set of commissioning principles and priorities aligned to those areas it has agreed to act collectively on. These are: urgent and emergency care, mental health, cancer, outpatients and primary care. A high-level common framework for integrated care delivery and planning has also been developed, which is being used to frame place-based and locality arrangements in local systems within north east London. There are also a range of more informal gatherings of Chairs, Audit Chairs, PPI lay members and clinicians and managers across NEL, which have helped build relationships. The Covid-19 pandemic has accelerated and strengthened the joint working to a major extent, with a new approach to rapid decision-making and delivery strengthening organisational and personal relationships and, in particular, putting clinical leadership at the front of that change.

Integrated working at a local level Through developing our local Integrated Care Partnerships, we have already shown what can be achieved by working together more closely at a local level. The examples on the next page show what is being achieved already through working together in our local systems. We will be able to build on these and deliver so much more by moving to our new way of working - a NEL ICS and single CCG. This is because it will enhance our abilities of local systems to innovate and respond to local needs, freeing up resources for where they really matter: to support local people.

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3.2 The Long Term Plan

The NHS Long Term Plan, published in January 2019, is a national document that sets out the ambitious vision for the NHS over the next ten years and beyond as medicines advance, health needs change and society develops. It outlines how the NHS will give everyone the best start in life; deliver world-class care for major health problems such as cancer and heart disease, and help people age well. We submitted our draft response to this in November 2019. The north east London Long Term Plan sets out what we plan to do in the City of London, Barking and Dagenham, Hackney, Havering, Newham, Redbridge, Tower Hamlets and Waltham Forest to work together to meet the challenges we face, and improve the quality of health and care services. It sets out how we will all work together to deliver improvements in areas like caring for our older and vulnerable residents, helping people live healthier and more active lives, and giving our children the best possible start in life. Our Long-Term Plan for north east London can only be achieved if we work more effectively right the way across the health and care spectrum and key to this is developing our Integrated Care System.

3.3 Local challenges

Across north east London we face a number of key challenges that are driving the NEL Integrated Care System development programme:

• Growing population and increasing demand – 13% projected growth in the next 10 years, we need to respond to demand differently if we’re going to manage this successfully, as we do not have unlimited capacity to deal with this, especially at a local level

• We need to ensure we deliver modern, fit for purpose infrastructure and property in order to meet the capacity challenges we face from a growing population

• We have a demographic of higher than average younger people whilst people are living longer with more than one condition – their clinical needs are very different

• Health and social inequalities– in north east London the most deprived will die significantly earlier than those in the least deprived areas unless we make significant changes

• An unbalanced system– we are set up to respond to illness and need to refocus towards prevention and population wellness

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125 • Workforce – we currently have an average of 20% vacancies across our system putting pressure on the existing workforce

• Challenges in attracting and retaining staff

• The need to develop greater partnership working across and between providers

Developing an Integrated Care System for north east London and a single CCG will enable us to better tackle these local challenges, as working collectively will help us address these issues together and for the benefit of the whole population of NEL. A single NEL CCG and ICS, with our local Integrated Care Partnerships and place- based borough partnerships, will give us the best of both worlds: stronger focus locally on local needs and greater resources to collectively tackle the challenges we face across north east London. 3.4 The future of commissioning

Change is something we are used to in the NHS, as we continually strive to improve the quality of care for our patients, delivered in the most efficient way possible. This is certainly true in the area of commissioning. Over the last few years the NHS across the country, working closely with local authorities and other partners, has been moving away from the internal market towards a much more collaborative population health focused approach where people and organisations work more closely together to provide integrated care and support improvements. Nationally, and to a degree locally, commissioners and providers have not always worked or been incentivised to work in the most collaborative way. Over recent years we have made positive steps through the STP and our local partnerships to address this. Being part of a new NEL system will further enhance this with providers and commissioners working together with a shared responsibility for the way finances are managed, contracts delivered and most importantly outcomes successfully delivered for our patients. The recently published Long Term Plan reinforces these changes and all health systems are expecting to become Integrated Care Systems by April 2021. The LTP describes how the commissioning environment will continue to evolve and it is in this context that CCGs will operate in future. It states that: ‘Every ICS will need streamlined commissioning arrangements to enable a single set of commissioning decisions at system level… CCGs will become leaner, more strategic organisations that support providers to partner with local government and other community organisations on population health, service redesign and Long Term Plan implementation.’

NHSEI has set a very clear direction for the future of commissioning. The intention is that: ‘by April 2021 all of England will be covered by Integrated Care Systems, involving CCGs working together with partners to ensure a streamlined and single set of commissioning decisions at a system level’.

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126 3.5 Changes in NHS England and NHS Improvement

Change is also taking place at our regulator, NHS England, which has come together with NHS Improvement. It provides us with some great opportunities to radically change what we do for the benefit of local people. We will have the opportunity to take on more responsibility for governance and assurance, previously undertaken at an NHS England level, so that we can ‘self-monitor’. This places more responsibility for oversight on the ICS, rather than NHSE/I carrying out this role. This will give us more autonomy and support us to concentrate on the areas that really matter to our local people, as well as be more responsive and proactive where additional local challenges arise. We’ll be better informed and better placed to direct the right resources to the right place at the right time.

Integrated working at a north east London level Across the whole of north east London, we are also seeing the benefits of more joined up working, which demonstrate that we have already been making progress in developing our ICS - and that it is the right thing to do. These include:

• NEL-wide integrated clinical assessment services (CAS) NHS111 have been rolled out across NEL. This involves a multidisciplinary team of GPs, pharmacists, dentists, nurses, paramedics and health advisors providing expert advice over the phone

• a system wide estates strategy has been developed with a prioritised capital investment programme

• the ability to progress the redevelopment of Whipps Cross hospital, which is a once-in-a-lifetime opportunity to design a new hospital from scratch

• the East London Patient Record has been rolled out across WEL and C&H and is underway in BHR. Usage has doubled in one year (currently 112,000 views per month). It allows hospital consultants and social care workers to view an individual’s medical record.

• The delivery of an electronic records programme and paper switch off achieved for outpatient referrals to hospitals across NEL

• £5.2m secured for the first rapid access diagnosis centre in England

• significant improvements in the CQC ratings for our hospitals and GP practices.

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127 4 Our Vision

4.1 Creating a new vision for North East London

The new CCG will be a core building block of our new north east London ICS. We decided to take more time than other areas in developing our merger proposals so that we could consider how our ICS and local systems would work as a whole. To help guide the new CCG the current CCG Chairs have developed a declaration of principles which provide clarity about what is important and how we wish to work in the future. This is attached as an appendix.

We want to create a new way of working together in north east London across all health and care provision, which gives local people more options, better support and properly joined-up care at the right time in the best care setting. This will help to improve the long-term health of the local population. In doing this we are aiming to:

• Invest in local integrated primary and community services to help people stay well for longer and support them at home when they need it

• Use information we have about our population to direct resources and action where it is most needed

• Create integrated services – a new way of working together with our partners and communities to make sure that we provide the right services in the right place at the right time

• Take advantage of advances in technology to change the way we access and provide care

• Support our staff to work differently, make sure they have the skills we need for the future and consider how we attract and retain staff

This means:

• Patients will have access to more services locally (for example, blood tests undertaken at your local GP), access to better records and patient data, ability to take more control over their health and care management and consistency of service, removing the postcode lottery.

• GPs will be able to provide more services locally, closer working relationships with other GPs and community partners and continued involvement in clinical decisions in their local area.

• Providers and local authority partners will be more heavily involved in local decision-making, contribute more directly to maintaining and improving the health of the local population.

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128 • Staff will have greater opportunities for career progression and training, a better work life balance through agile working practices, and improved support from combined central resources, while at the same time working even more closely on achieving local goals.

4.2 Local delivery

Local delivery is critical to the success of this new way of working. The creation of an ICS and single CCG covering a population of around two million is not a move to centralise power, it is a move to free up the statutory requirements and devolve more power to a local level. The overriding principle underpinning these changes is local accountability and the desire to see power sit as close to local people as possible. There is a strong tradition within north east London of integrated working with our partners in local authorities and other community groups at a local level. We want to see strong integrated delivery at a local neighbourhood level and we want these neighbourhoods to sit inside strong place-based borough partnerships and local Integrated Care Partnerships. Our aspirations are to work with local patient, partner and community groups to co- design and co-produce services, systems and pathways and we will continue to work with Health and Wellbeing Boards at a local level. The North East London ICS and CCG will support this local delivery and provide strategic leadership where appropriate, for example around financial sustainability, enablers like workforce, estates and digital as well as some specialist services.

4.3 The 80:20 principle

Our basic principle of 80:20 is in recognition of the fact that decisions about health and care will take place as close to local people as possible.

Decision-making will sit as close to local people as possible and will take place across a larger area if there is a strong benefit to doing so.

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129 5 Our new operating model

5.1 Overview

To deliver our long term plan, we need to change the way commissioners, providers, clinical leaders, GP members, local authorities, partners and voluntary organisations work together. The ICS and single CCG will help us do this through:

• driving forward more partnership working in a truly integrated way • enabling commissioners and providers to share responsibility for the way finances are managed and contracts delivered, as well as manage population health for the benefit of local people • reducing the statutory burden to free up resources at a local level • providing the resources to support challenges across the whole of north east London, such as population growth and homelessness

There is a shift of emphasis away from treating people when they are unwell towards helping people stay healthier for longer and supporting them in their communities. This is being supported by increased investment in primary and community care services and the creation of much more integrated working across health, social care and the voluntary and community sectors at a neighbourhood level. There will be a new focus on population health, and this will become the responsibility of all partners. Providers will not just be responsible for the people they treat but have a collective responsibility for the whole population’s health alongside commissioners. This will be a challenge to all organisations, to shift our mind set towards a different operating model. People and organisations will need to change systems, processes, behaviour and culture to maximise their chance of achieving the benefits that will come from these new ways of working. We also believe that there will need to be some changes to organisational form to support this stripping out of processes and bureaucracy, which are duplicative and don’t add value and ultimately undermine trust between partners. As part of this, there will be a change to how providers receive their money. Instead of payments per activity, there will be new arrangements within their alliances to help them focus on providing the best care for their patients and communities. To deliver this we need a fundamental shift in the way the NHS operates. The old ways of working, with the separation of commissioners and providers, independent organisations following their own agendas and competition between providers is being replaced by a new culture of co-operation, collaboration, integration and system-based working. 5.2 Strengthening our local focus

We want to create one ICS across north east London, underpinned by one NEL CCG, three strong local systems (Integrated Care Partnerships: BHR, C&H and

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130 WEL), seven place-based borough partnerships and primary care networks, which will be the focus for delivery. We are not making this change for its own sake, but to deliver our primary objective of transforming the health of our local populations. This new way of working will not happen overnight, but we believe that, as trust builds and new leadership behaviours become established, this more collaborative system approach will lead to improved population health outcomes. Supporting all of this change is an expectation that we will strengthen our clinical leadership, build on our strong partnerships with local authorities and ensure that patient and public engagement is embedded into the ICS at a local level. The NEL CCG will, with partners, be responsible for:  Improving outcomes, reduce inequalities and increase quality of care for citizens, patients and their families

 Achieving financial sustainability across the system and making the best use of tax payers’ money

 Creating a rewarding and satisfying place to work for staff across all partner organisations 5.3 A single CCG

• As part of developing the ICS, our plans are to move to a single CCG by April 2021. The single CCG will interface with NHS England and there will be a single governing body.

• However, it is important to note that our local Integrated Care Partnerships (City and Hackney, BHR and WEL) will remain in place, as will our place- based borough partnerships with our local authorities across north east London to ensure we meet the needs of local people.

• By maintaining these local systems and place-based partnerships, we will keep our focus at a local level and retain people with a passion for making a difference to local people.

• This means that staff will continue to support local people, working more closely with our local partners. We will continue to develop our local Integrated Care Boards and will continue to work with our local Health and Wellbeing Boards and Overview and Scrutiny Committees.

Why a single CCG? • The statutory and governance burdens can be undertaken at a single CCG level, rather than replicated seven times which will free up resources to meet the needs of local people and front-line services.

• Removes the barriers to true integration through the opportunity of changing and improving governance structures, so that key decisions can be made at a local level by local partners.

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131 • It will speed up decision-making in key areas. For example, improvements to the neuro rehab service (which is a NEL/LTP piece of work) and involved all seven CCGs.

• Opportunity for savings through more efficient use of back-office and administrative resources, freeing up budgets for frontline services, locally.

• More opportunities for staff as well as a better learning and development offer and fully embracing diversity through better supporting Black, Asian and Minority Ethnic (BAME) staff and other staff networks.

What will single CCG mean in terms of budgets and finance?

• Budgets will continue to be devolved to a local level – tracking what is currently forecast for each of the seven local CCG areas. Allocations were published by NHS England two years ago for the next five years. This means that each borough will continue to receive the same proportion of resources as the current CCG allocation profile, so no borough will be worse off by CCGs coming together.

• With a more integrated approach, budgets will be used more effectively. The governance to enable delegation and provide assurance across the system is to be devised through engagement with CCG leads and GP members.

• Savings through more efficient use of back-office and administrative resources will free up budgets for frontline services locally.

• The LTP signals a shift in how finances are operated throughout the system. Previously, providers and commissioners were operating on different sides with different goals. The key difference is that in our future way of working across north east London, providers and commissioners (including health and local authority) will work together and share responsibility for the way finances are managed and contracts delivered.

Financial balance across NEL • In north east London, we have a history of working collaboratively and managing risk through existing governance, which means we have experience of working in this way to achieve balance across our area, without being to the detriment of any individual CCG. Our proposals to merge would strengthen this further.

• It is a requirement for all CCGs to meet their financial duties and we have a strong track record of good financial management across north east London. The BHR CCGs, through strong local system partnerships have significantly improved their financial position over the past 2 years.

Governance Overview • We are designing governance arrangements that support collective decision making at a range of levels through our ICS. The development of one CCG will remove some of the barriers to joint decision making.

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• There will be more effective decision-making at a local level through the delegation of budgets and responsibilities to local integrated care partnership and borough boards. Current arrangements hinder the degree to which we do this currently.

• Our new ICS Chair, Marie Gabriel, is engaging with non-executive directors, lay members and lead councillors from local authorities, CCGs and NHS providers in discussions about how the NEL ICS board and associated governance will work. The design and evolution of NEL governance will be though a collaborative approach.

Risk Sharing • In terms of risk sharing, there is clear benefit for sustainability across NEL to manage risk collectively. We already use the risk-share through existing governance where there is a clinical commissioning and business rationale to do so under current arrangements, so this will not be a change.

• Working across seven local CCG areas will not only provide a risk-share but also enable resource and opportunities to be shared or mobilised where they are most needed, for example in areas around workforce or sharing expertise. Again, this will not be to the detriment of any CCG, but an opportunity to share and support each other.

Statutory Responsibilities • If there is a new NEL-wide CCG, the current statutory responsibilities of the seven CCGs will transfer to this new CCG, which will cover the same population as the existing seven CCGs. The single CCG will delegate to or share aspects of these with local systems, where it makes sense to do so.

• This means that the CCG will be able to administer some of the statutory functions in a more efficient way. This will free up local systems to work in a more integrated way, free up some of the statutory constraints and be able to focus resources to the benefit of local people in each borough in north east London.

• Through developing the Primary Care Networks, Borough Partnerships and local Integrated Care Partnerships, the bulk of delivery will continue to take place at a local level. As mentioned, we are developing the appropriate governance arrangements to support this.

Legislation • We do not require changes in legislation to implement our proposals. Our timeline is aiming to become a single CCG by April 2021, with our application to NHSE submitted in September 2020 and a members’ vote in October 2020.

• The Long Term Plan does set out the expectation that Integrated Care Systems will involve stronger partnerships and typically be covered by one

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133 CCG and legislation is planned to support this, but this legislation is not required for CCGs to merge.

• The new legislation is intended to make integration and partnership working simpler through removing some of the limitations for joint governance arrangements.

The responsibilities, finances and decision-making at each level are shown below:

Level and Definition Responsibilities are to: Money Decision-making Neighbourhoods: usually Work together with other GP Receives income from Makes decisions jointly with covering 30,000 to 50,000 practices and with community, NHS according to the local system people. Includes Primary mental health, social care, services provided and borough-based Care Networks (PCNs) and pharmacy, hospital and voluntary partnerships brings GP practices services in their local areas together with community services and social care to Takes a proactive role in create multi-disciplinary population heath and prevention teams to provide more access and better support for local people Place-based Borough Bring health and social care Works with the local Makes decisions jointly with Partnerships: integrates services together with other system budget the local system health and social care to partners so that the local allocation provide better services for authorities are working in Challenges where required local people in each local partnership with the health through borough Overview borough in north east service, patients, partners and and Scrutiny Committees London the local population as a whole.

Integrated Care Provide integrated planning and Receives a local Maintains local Integrated Partnerships: The model delivery to meet the needs of budget from NEL Care Boards to tackle local for working with local local people which matches health issues health and care existing agreed local commissioners, clinicians, Take on responsibility for budgets Removes the barriers so that providers and partners to delivering the strategic plan at a commissioners, clinicians, enable the right decisions local level Manages finances providers and partners can to be made at a local level locally come together to make join to best meet the needs of Lead on the redesign of priority decisions without conflicts of the local population. services at a local level such as Ensures financial interest diabetes decisions are made jointly with partners Engages with local stakeholders, including formal consultation where required NEL Level, including a Undertake strategy, oversight and The CCG receives Tackles the big health and single CCG: a partnership risk sharing and is a place for funds from NHS care challenges and reduces of all the key organisations partners to come together to England and passes inequalities that impact on health. shape the vision for north east down budgets to the Brings together seven London local systems in line Establishes a single Clinical Commissioning with current agreed governing board for key Groups into a single Achieve savings through allocations decisions across north east organisation under a new providing administrative functions London operating model, whilst more effectively and reduces the Maintains a central maintaining and managing burden of statutory reporting and budget too Ensures that local decisions the local systems. governance from the existing 7 are passed down to the local CCGs Manages financial risk systems, with all local ICS includes all partners Take on the responsibility for partners involved from local authorities, quality assurance previously providers and CCGs. undertaken by NHS England

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134 6 Benefits

This move to commissioning at a larger scale brings with it a whole range of advantages, both for the NHS and, more importantly, for local people. Working at a larger geography, covering populations of over 1 million, means more collaboration between partner organisations including health providers and local government to join up care and transform health and aligning commissioning policies across an area to reduce variation. It means that clinical commissioners can focus on population health – an approach which helps commissioners to plan for and intervene in long-term health conditions, target groups with common characteristics and address inequalities in care using a sophisticated knowledge of people’s needs. Working at this level also means that CCGs reduce their management costs, they can benefit from economies of scale and do things once in the patch instead of replicated seven times. A summary of some of the key benefits is shown below and more detail is provided throughout the rest of this section.

The development of one CCG has specific benefits in a number of key areas, which are explained in more detail below.

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Quality and safety • For residents of north east London, the creation of a single, more strategic commissioning organisation enables real progress to be made on tackling the complexity and fragmentation found in some care pathways, enabling care to be integrated across traditional care settings, improving the quality and experience of care for our patients and citizens.

• Operating across a north east London footprint, NEL CCG, working closely with local authorities, will be better able to identify and address inequalities across the patch. Its scale will also allow best practice for addressing health inequalities, promoting wellbeing and preventing ill health to be spread and scaled up more rapidly. This will be facilitated by greater integration of health and social care services, supported by co-commissioning and pooling/aligning of budgets where appropriate.

• The move to a single, more strategic commissioning body will support the development of a more dispersed model of clinical leadership, which will mean that more clinical leadership time will be focused on transforming health and care at a local system level and on delivering health and care differently at a PCN level than on statutory and administrative duties.

• Working closely with place-based borough partnerships and PCNs in local systems, we will be better able to bring together an alliance of providers wrapped around geographic communities to deliver new integrated care service models.

• Creating a more strategic commissioner will help to remove structural boundaries between organisations, reducing competing priorities and aligning objectives around what matters most: improving the quality of care and outcomes for our citizens and patients.

Financial • Operating seven separate statutory organisations is costly. While the seven CCGs have developed and are beginning to deliver plans to reduce running costs by April 2020, further efficiencies would be challenging in the current configuration.

• Moving to one NEL CCG is an opportunity to reduce the administrative and financial burden associated with running seven separate organisations. For example, the statutory and governance burdens can be undertaken at a single CCG level, rather than replicated seven times which will free up resources to meet the needs of local people and front line services.

• Budgets are being devolved to a local level – tracking what is currently forecast for each of the seven local CCG areas. Allocations were published by NHS England two years ago for the next five years. This means that each CCG will continue to receive the same proportion of resources compared to the other boroughs as the current CCG allocation profile, so no CCG will be disadvantaged by merging.

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136 • Contracts will still be held between the CCG and providers but there will be less focus on contractual discussions and more on transformation and collective processes to improve services. This will free up precious resources at a local level to really focus on delivering what is best for local people.

• There is already a financial risk-share mechanism in place, but this would be strengthened by operating within one financial regime.

• With a more integrated approach, budgets will be used more effectively. The governance to enable delegation and provide assurance across the system is to be devised through engagement with CCG leads and GP members.

• Savings through more efficient use of back-office and administrative resources will free up budgets for frontline services, locally. For example, there will be efficiencies in undertaking our statutory reporting duties once, rather than seven times.

• The LTP signals a shift in how finances are operated throughout the system. Previously, providers and commissioners were operating on different sides with different goals. The key difference is that in our future way of working across north east London, providers and commissioners (including health and local authority) will work together and share responsibility for the way finances are managed and contracts delivered.

• There is an opportunity to streamline overall management costs. Any savings delivered through moving to a single CCG will be reinvested in local improvement initiatives, ICS and integrated care development.

CCG Operational Changes • By reducing the duplication required from operating seven separate administrative and governance systems, NEL CCG will be able to streamline operations and allow resource (both people and money) to be focused on the core task of delivering clinically and financially sustainable services and the best possible healthcare for our population.

• While in the short term there may be uncertainty and disruption for staff, in the long term, NEL CCG will become a more attractive place to work for staff, with fewer transactional roles and more transformational roles, which are more interesting, developmental and fulfilling for staff. Equally, there will be opportunities for staff to transfer into roles in the NEL ICS and in the local BHR, City & Hackney and WEL systems.

• A single CCG will be able to bring together a pool of specialist support or expertise that can be accessed by the local systems including data analytics, business case preparation or areas requiring legal or technical knowledge

Strategic

• At a NEL level, we will undertake strategy, oversight and risk sharing and it is a place for partners to come together to shape the vision for north east London. However, the bulk of activities, including strategy at a system level,

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137 will take place locally, through the three local Integrated Care Partnerships and place-based borough partnerships.

• In north east London we are reaching the limits of what can be achieved through collaborative commissioning. Moving from seven small CCGs to one larger strategic commissioner would help to create the scale required to deliver benefits. In particular, NEL CCG would have the influence and leverage to address wider system challenges, such as provider quality and performance and system financial sustainability.

• The move to one single CCG will provide the NEL infrastructure to support the devolution of specialised commissioning from NHSE to north east London.

• Creating a single statutory commissioning body will help remove many of the technical and legal barriers to integration that exist at a local system level. Local systems will be free from a number of statutory and regulatory constraints that currently exist at a borough level and will be able to more freely share resources (e.g. joint posts and joint committees).

• NEL CCG will be aligned to the same footprint as NEL ICS and will therefore be a key enabler for the delivery of the commissioning strategy for 2018/19 – 2021/22 and the development and delivery of future integrated care and commissioning plans in north east London.

• A larger more strategic commissioner will also be better placed to support changes happening nationally to devolve more powers to CCGs for specialised commissioning, supporting the integration of care along the full breadth of the pathway. This will be particularly important for contracting relationships with Barts Health NHS Trust and Barking, Havering and Redbridge University Hospitals NHS Trust, which both have significant levels of specialised services.

• Additionally this will help deliver the oversight, assurance and improvement approach being co-developed with regulators at a regional level.

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138 Addressing key concerns We have articulated the benefits outlined above, but through our engagement to date we have picked up some key concerns from a number of stakeholders. The key ones are summarised below, along with the steps we are taking to minimise the impact and maximise the benefits. We will add to this as we continue to engage with stakeholders.

Topic You told us you are concerned What we are doing… that… Money Budgets may be held centrally Ensuring that budgets are fully devolved to a local and not passed on at a local level to match existing budget allocation, so there is level no impact at a local level. Decision- We may lose influence on key Putting in place new governance arrangements to making decisions at a local level ensure that local decisions are made at a local level by local partners – our intention is to strengthen this Clinical This may weaken as a result of Building on our existing relationships with our Leadership moving to a single CCG clinical leaders and getting their input to shape a new way of working. Clinical leadership will exist at every level within the ICS and will be key to our success. Clinical leadership budgets for each CCG will be maintained, with clinical leaders freed up to lead clinical transformation of services rather than some of the current bureaucratic focus.

Impact on A single CCG may also mean Existing hospitals, NHS trusts, GP surgeries and services reducing services for patients community services will continue with no impact. What we are doing is changing the way we work so that we can deliver a better patient experience with access to more services more easily. By working collectively, we are able to attract transformation funds to improve services for local people where they are needed most. We will address variation for patients across NEL, with a focus on the highest standards. Impact on There may be impact on CCG We are aiming to minimise the impact on staff and jobs staff as a result of the merger. maximise opportunities for career progression and training (especially from BME backgrounds). We are assuming that requirements to reduce or restructure posts will be minimal.

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139 7 Engaging with our partners

We have developed a detailed communications and engagement strategy to engage on the proposal to merge. This includes a comprehensive activity plan which sets out how we will communicate and engage with each stakeholder group.

The aims of the communications and engagement strategy are: • Ensure all identified stakeholders have been briefed on the programme • Reassure internal and external stakeholders about the purpose, timelines, benefits and opportunities • Develop core materials to support activity and ensure consistency of messaging • Gather greater understanding of perceived potential risks and issues in moving forward • Build support from partners to take forward our plans • Understand how to continue to involve stakeholders in future stages of the programme

The delivery approach of the communications and engagement plan

The production and execution of the strategy and plan has been overseen by the NEL Merger Oversight Group and delivered by senior communications and engagement leads from the local systems. Success in delivering the plan has been dependent on local level engagement led by the communication and engagement leads. Central advice, support and key materials to support the leads has been co- designed with the relevant workstream leads and comms and engagement leads, with approval by Oversight Group.

Timing of implementation Due to the advent of covid-19, the implementation of the strategy and plan has been delivered in two stages. A great deal of foundation work took place between October 2019 and March 2020, providing key messages on the emerging integrated care system and the new CCG. The strategy and plan were refreshed in July 2020 as we focused activity in preparation for the vote in October.

Communications and Engagement activities Following the approval of our strategy and key messages and stakeholder mapping, there have been a variety of engagement and listening exercises with all our stakeholders (including CCG governing body members, local authorities, clinicians, staff and Healthwatch. This has occurred in the form of meetings, special workshops and events, regular bulletins and strategic one to ones with key leaders. Activities have been recorded at a system level and coordinated by the NEL Communications and Engagement Group. We have captured learning and used feedback from the engagement sessions to create and maintain a frequently asked questions document and activity tracker. This evidence will be made available in our submission.

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140 Communications and Engagement documentation Our application will include a communication and engagement strategy, plans, public facing engagement documents, activity tracker summary and minutes from Joint Commissioning Committees to demonstrate the breadth of engagement and wealth of information and feedback from our stakeholders. The outcomes of that engagement will be included in our submission to NHS London.

8 Clinical leadership

One of the great strengths of CCGs is the role of clinical leaders, who understand their patients, in shaping the future of health services. We are committed to, at least, maintaining the current level of investment in clinical leadership and ensuring it is directed towards improving services.

One of the advantages in moving from seven CCGs to one will be the opportunity for our clinical leaders to spend more time on service improvement and less on the administration of seven organisations.

We also recognise the need for local member practices to know that they still have a voice in the CCG and there will be a seat on the governing body for a lead GP from each of the seven local systems. For the first year we would, through a transition agreement, look to the existing chairs taking on this role to ensure continuity, particularly given the current pandemic.

9 Tackling inequalities

We will fulfil our duty to reduce inequalities in accessing services and in clinical outcomes, and to ensure that services offer the same outcomes and the same experience to patients regardless of their background as stipulated by the Health and Social Care Act 2012. Furthermore we will take a positive approach to eliminate discrimination, harassment, victimisation; foster good relations and advance equality of opportunity between persons who share a relevant protected characteristic and persons who do not share it, as mandated by the Equality Act 2010. Due regard is demonstrated by considering the likely impact of merging the 7 CCGs on different groups in our community, in particular the nine protected characteristics as defined under the Equality Act 2010. We have produced a document for this application that presents the results of a desktop review of some of the 9 protected characteristics across the 7 CCGs. We have shared this document within our NEL collaborative to agree how to reduce any disproportionate impact the merger may have on the local population. The document list actions already planned to reduce inequalities which are a feature of our emerging NEL Inequalities Strategy that is being developed as a part of the NEL Recovery and Restoration plan and submitted to NHSE. The broader Inequalities Strategy highlights the improvements we plan to make on generating and using data,

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141 addressing inequalities caused by wider determinants and undertaking national actions. The final part of our document for application provides details of our approach for conducting a full CCG merger Equality Impact Assessment from October-December 2020. This will allow more time to incorporate new staff structures into our analysis and response and ensure maximum influence on the overarching NEL Inequalities Strategy. The CCG Merger EIA work is overseen by a reference group that is made up of representatives from our integrated care partnerships, local authority and NEL senior leadership.

10 Our delivery approach

The NEL Integrated Care Development Programme We have established an Integrated Care Development Programme to support the development of the Integrated Care System and oversee the creation of a single CCG as the two are closely linked. Its purpose is to: • Define the approach for the development of integrated care and commissioning in NEL, which will support the delivery of our Long Term Plan.

• Understand the current status and direction of travel of integrated care and commissioning in north east London using the NHSE ICS Maturity Matrix and CCG Merger checklist as assessment tools to do so.

• Articulate and deliver plans to help NEL to develop into a “thriving” ICS and CCG.

Design Principles of the ICS Development

• A pluralistic leadership body will help set the vision and provide guidance to teams across health and social care to create a new structures and way of working through local delivery and programme work steam plans. This will not be a top down programme.

• A place based and local systems model will be developed that is owned and driven locally, but is coherent as a whole across NEL

• The programme will work effectively with key partners (providers and local authorities) so that arrangements are developed as a system

• The work will include as a priority, engagement and communication with wider partners, patients and staff so they are involved and informed and their views taken into account as the proposals develop

• Good governance and decision-making mechanisms as required locally and across NEL

• Focus on culture, new ways of working, leadership and wider development to support the changes

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142 • Ensure local accountability remains by maintaining local system based budgets

• Maintain stability and continuity with existing financial planning by tracking budgets to published allocations

Programme Guiding Objectives 1. Creating the vision: painting a shared picture of our new system that will transform the way we work to deliver the ten year plan, and place resources to solve population health issues in the hands of health and social care services at a local level

2. Principles for collaboration: increased partnership working so that systems recognise the need to invest time and resource to build a new way of working in a complex system. Each partner is a valued member in the development (CCGs, CSU, NHSE/I, Local Authorities, Primary Care, community and mental health providers and voluntary partners)

3. Clarifying the problem to be solved: Transformation has been inhibited by structures and process that have not supported or incentivised true collaborate working. To see improvements to services for patients we will work together to, ‘do the right things with the right partners at the right footprint’ and going further/ faster together by supporting the delivery of system-wide objectives.

4. Agreeing definitions: The old way of working and defining the system will disappear. We will agree new definitions to describe our structures, relationships and the milestones we will meet to achieve our plans an vision

5. Using tools, governance and structures to make decisions: We will design and follow programme management tools and process to keep our delivery on track. Making use of a range of data driven and evidence-based tools to support decision making and good practice. We will establish programme and system governance to support decisions that may be contentious and enable traction and resolution where disagreement may otherwise have prevailed.

6. Leading and engaging a truly co-designed co produced future: Relationships and taking a journey together are key to achieving success. There will be extensive engagement with people across all three systems, with different approaches applied in each (e.g. bilateral discussions, workshops, engagement events).

7. Being pragmatic: The programme will always seek to make progress on agreed vision and plans. We may proceed without complete consensus on the detail, but we will adhere to our approved framework building on ‘quick wins’ and laying foundations for more fundamental transformation. There may not be a clear model for an ‘end-state’, initially but systems can still progress on early stages. All systems recognise that the work to date is part of a longer-term and broader piece of work (e.g. OD, development) and the need to maintain momentum on the longer term issues while delivering in the short term.

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143 8. Identifying dedicated resource and support: All systems recognise the need to provide a dedicated group of individuals with responsibility for driving mobilisation and implementation of the programme, and to clarify everyone’s role in contributing to its delivery. Systems should support the programme governance by ensuring they put forward suitable individuals with the authority and power to take decisions and steer implementation

Process for decision-making • The move to a single CCG requires the support of the Governing Bodies and members of the existing statutory organisations, with members voting on the merger in October 2020.

• The assurance process as articulated by the NHS London Regional Team is as follows:

In accordance with the legal requirements and the NHS Long Term Plan, NHS England will consider a range of criteria in deciding whether to approve a proposed merger

• Alignment with (or within) the local STP/ICS • Co-terminosity with local authorities • Strategic, integrated commissioning capacity and capability • Clinical leadership • Financial management • Joint working • Ability to engage with local communities • CCG Governing Body approval • GP members and local HealthWatch engagement • Local authority support

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144 Timeline

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145 The future of health and care for the people of north east London

Waltham Redbridge Forest

Havering

Hackney n Barking & Dagenham Newham Tower Hamlets City of London

Produced by: North East London Commissioning Alliance

146 Contents 2

Executive summary 3 Overview of health and care in north east London 4 A locally led system approach 8 Why create an integrated care system for north east London? 10 Our collective vision for north east London 12 Have your say 14 Appendix: What we have heard so far 15

August 2020

147 Executive summary 3

This is an overview of how we are changing the way we work across north east London (NEL) to improve the health of our communities. By strengthening our already established local partnerships, streamlining our Clinical Commissioning Group (CCG) administrative and other functions into one joined up organisation and bringing together our partners as an integrated care system for NEL, we will have the infrastructure we need to provide the best health and care for our local populations.

148 Overview of health and care in 4 north east London

North east London (NEL) has a population of 2.3 million people and is a vibrant, diverse and distinctive area of London steeped in history and culture. The 2012 Olympics were a catalyst for regeneration across Stratford and the surrounding area, bringing a new lease of life and enhancing the reputation of this exciting part of London. This has brought with it an increase in new housing developments and improved transport infrastructure and amenities. Additionally the area is benefiting from investment in health and care facilities with a world class life sciences centre in development at Whitechapel and confirmed funding for the Whipps Cross Hospital redevelopment and a new health and wellbeing hub on the site of St George’s Hospital in Havering, making it an exciting time to live and work in north east London.

At the heart of NEL are its people and together as health and care partners we have a collective vision of enabling our population to live healthy lives. This vision is reliant on a wide set of determinants beyond just health and which include: access to education, job opportunities and creating a healthy environment at all stages of a person’s life, ensuring they have the best chances possible. To achieve this we need to make sure patients, clinicians and managers are working together in a way that ensures they can all reach their maximum potential.

Locally led successes across NEL We have a number of fantastic examples of local leadership and achievements across our local areas. Together we can learn from each other and share our innovations and successes for the benefit of all our local populations. Some of these include:

• Working together across primary care – across our local areas we have led the way in supporting primary care to work differently. Through Primary Care Networks GP practices are working together across neighbourhoods and with community, mental health, social care, pharmacy, hospital and voluntary services.

• Social prescribing – is at the heart of our work and we have a variety of models in place across our area including link workers who facilitate social prescriptions between clinicians and patients.

• Supporting our diverse population – as part of our recovery from Covid-19 we are collectively committed to supporting local people, training, volunteering, education and creating apprenticeships at a local level, to support the recovery of our local economies, which have been significantly impacted by the pandemic.

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Overview of health and care in north east London

• Promoting a healthy start in life – across north east London children benefit from our healthy schools programme which supports children, families and adults to be more active and eat healthily.

• Acute partnerships across NEL – we are developing an acute alliance across NEL which brings together Barts Health NHS Trust, Homerton University Hospital Foundation Trust, Barking, Havering and Redbridge University Hospitals NHS Trust to set an overarching strategy for acute services to the benefit of all our people.

• Urgent care – to ensure that the Urgent and Emergency Care (UEC) needs of our population are met, we are working together to to ensure that we have staff with the right skill mix at the right place and time to care for our people.

• Mental health – we are committed to supporting people with severe mental health difficulties and one way of doing this is ensuring they have access to employment opportunities. Across all our partnerships we have rolled out our individual placement and support service which provides tailored support including job placements and guidance for both the employer and the employee.

• End of life care – through our multi-disciplinary teams we are able to support patients to die at home or in the community surrounded by their loved ones.

• Enhancing our local estates – the regeneration of Whipps Cross, the Barking riverside development and new health and wellbeing hub at St George’s will benefit our local populations

• Digital progress – we know that patients want to access their own information and only to tell their story once so are committed to improving access to patient records. As a result of Covid-19 patients can engage with services in many more ways: online, telephone, video as well as face to face.

• Maternity - across north east London, we work together as the East London Local Maternity System. This benefits staff as they are able to work across the whole patch and also allows us to ensure equal access to services. One priority for us is ensuring more choice and control for women and their families and we are prioritising personalised care plans for vulnerable women.

• Major long term conditions – we are working together to improve prevention of diabetes through education and training; running community based enhanced services to support and improve the care of those living with long term conditions and working to ensure services and support are joined up.

• Ageing well – we are committed to ensuring our workforce are trained to support our ageing population to support them to age well and maintain their independence, one example is our joined up teams consisting of physiotherapists, occupational therapists, social workers and consultant geriatricians.

• Homelessness – during the Covid-19 period we have worked closely with local authorities to provide support and care to rough sleepers. The pandemic offered a unique and powerful opportunity to address the needs of thousands of London’s rough sleepers. Charity partners have worked intensively with hotel residents to assess their needs and agree the next steps. Across north east London we are committed to building on what has been achieved so far, working in partnership with local authorities and our voluntary sector colleagues.

150 6

Overview of health and care in north east London

NEL is not without its challenges, with a high level of deprivation and inequality requiring us to work together in the best interests of patients. The Covid-19 pandemic has been a once in a lifetime challenge for all of us, testing us in every way possible not just as health and care providers but as a wider population too. Newham has been particularly impacted with the highest number of deaths in the country and more than ever before we have needed to draw on our strengths and experiences across NEL to respond to this, to learn from it and to ensure that everyone has equal opportunity to health in their lifetime.

As we continue to respond to our challenges and build on our partnership working to date, we are formalising this by coming together as an Integrated Care System (ICS). This will be how we come together as a partnership to strategically manage the health of the whole of our population and future proof ahead of any further legislative changes. Our NEL ICS and single CCG for NEL will provide support to our local places/boroughs, and in BHR's case its local system, where the vast majority of delivery and leadership will take place. We call this the 80:20 principle, placing most of our focus on delivery where it is best placed – closest to the individual. At a local level we will bring together an integrated partnership of local authorities, local acute trusts, local community services, local mental health services, local primary care, voluntary sector and most importantly local residents.

NEL – who we are

2m population Population expected to grow by around 250,000 in the next ten years

North East London

60 different ethnic groups

151 7

Overview of health and care in north east London

152 A locally led system approach 8

The vast majority of our health and care delivery will continue to be delivered at our local place and borough level, working together as partners with our local population.

The 80:20 principle Our basic principle of 80:20 is in recognition of the fact that decisions about health and care will take place as close to local people as possible.

Local partnerships will decide how best to use resources in the best interests of patients.

on Integra ond ted t L Ca as re e Care P S th ted art y r ra ne st o eg rs e N nt h m I u ip oro gh s 3 B Pa d r e t s n a e b rhood n r - ou e s e b tw h c h i o p a g l i r s k P e

s N

Local people

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A locally led system approach

Local integrated care partnerships and local delivery Local delivery is critical to the success of this way of working. A key feature of our north east London partnership is our distinct population-focused collaborative systems or integrated care partnerships (ICPs): Barking and Dagenham, Havering and Redbridge (BHR); Waltham Forest, Tower Hamlets and Newham; City of London and Hackney.

Each of these systems has developed local priorities based on the needs of their populations, developed collaboratively across organisations and through working together with local communities. In some instances these priorities are place based and in some areas like BHR they have chosen to work together to develop priorities across a wider area and will continue to collaborate closely as we develop our new arrangements.

None of this is possible without the leadership of the local authority and without involvement from our voluntary sector, patients and the wider public.

At an even more local level we bring together our services to support patients with complex care needs such as frailty, those who are housebound, those who require terminal care and those with learning disabilities.

We remain committed to demonstrating collaborative leadership, this means leadership 'with’, rather than leadership 'over'. An example being clinicians working with managers and with patients on developing pathways of care.

A clinically led CCG for north east London One CCG for NEL would continue to be a clinically led organisation with strong clinical leadership and a GP voice at all levels. There would be one NEL CCG governing body and an ICS partnership board at a NEL level. Most decisions will take place through local governance arrangements. Each place will be represented by a GP chair on the NEL governing body and ICS partnership board.

GP members’ forums and representative bodies will be essential to making this successful, working with the GP chair to make decisions about health and care in our local communities.

Involving lay members We know that lay members bring a diverse range of expertise that augments the best of how we collectively work as clinicians, managers and patients. Their independent input ensures we focus on outcomes, patient voice, value for money and good governance.

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155 Why create an integrated care system 11 for north east London?

We believe that creating an ICS across north east London will allow us to collectively respond to the challenges we face across NEL and benefit our local population in the following ways:

Benefits for people • Closer partnership working will enable people at all stages of their life e.g. whether you are pregnant, have a long term condition, require trauma treatment or end of life care, you will have equal access to all services across the whole system. • The amazing energy of health and care partners will be better shared so that we can keep you healthy. • Working together with local councils, providers and the voluntary sector across north east London, we will address health inequalities and ensure we do everything possible to stop people getting ill to begin with. We will be truly responsible for the health of all our communities, not just managing health services. • By working together across our organisations we will make sure that even if you have a complex condition requiring specialist care, you will be supported by all our services. • We will ensure that wherever you go in the system you won’t have to tell your story again if you don’t want to.

Benefits for staff • We are committed to supporting our workforce to grow and develop and to creating a wider pool of opportunities for career progression and development for everyone. We want north east London to be the place you want to live and work in. • We want to ensure staff work in an environment with reduced bureacracy, fewer meetings and a reduction in duplication. • We want everyone to be a leader no matter where they sit in the organisation • Our focus will be on relationships and solving problems together. • Together we will build on our own local plans to develop a single consistent plan for the future, helping us to improve services and reduce variation.

Financial benefits • Our overriding priority is to make sure every single pound is spent to the benefit of every single person in north east London. This means we can focus on where we can get the best value in terms of outcomes for patients and wider social value outcomes for our communities and neighbourhoods.

156 Our collective vision for 12 north east London

What do you want to achieve for our communities in the next few years?

“We support people with long term conditions to take control of their own health and care management allowing them to live full and happy lives”

Dr Atul Aggarwal, Chair, NHS Havering CCG

“Working in partnership to ensure that people are supported to age well and that quality of care is improved within our existing acute and community services”

Dr Ken Aswani, Chair, NHS Waltham Forest CCG

“Ensuring all our children in north east London have the best possible start in life, with their parents experiencing the best possible pregnancy and birth, right through to supporting schools to maximise the health of all children”

Dr Sam Everington, Chair, NHS Tower Hamlets CCG

“Making sure people have choice and control over the way they live their lives, and access to local resources and opportunities”

Dr Jagan John, Chair, NHS Barking and Dagenham CCG

“People with mental health conditions are able to live good lives – to be employed, have good relationships, somewhere comfortable to live, and to feel part of their community”

Dr Anil Mehta, Chair, NHS Redbridge CCG

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Our collective vision for north east London

“By working together we address the causes of inequality and poor health in NEL, drawing on our collective strengths and experience to improve the lives of our local people”

Dr Muhammad Naqvi, Chair, NHS Newham CCG

“Grow our neighbourhood way of working, with thriving primary care networks an essential element, to ensure that across north east London our teams are working together to support local people”

Dr Mark Rickets, Chair, NHS City and Hackney CCG

“We make every pound count and invest our health and care resource so it improves population outcomes”

Henry Black, Chief Finance Officer, NELCA

“Engaging and involving our local populations continues to be at the heart of everything we do”

Marie Gabriel, Independent Chair, NEL ICS

“The benefits of working in partnership will give everyone the best start in life, deliver world-class care for major health problems, such as cancer and heart disease, and help people age well”

Jane Milligan, Accountable Officer, NELCA

158 Have your say 14

In September 2020 we will produce a report on our proposal to merge, including feedback from stakeholders for consideration by NHS England who will need to approve our application later in the year.

How can I have my say?

Each CCG will engage with all its partners and members over the coming months. Engagement will continue through the summer, autumn and beyond. As questions come in we will develop a questions and answers document.

We also want to hear from anyone who wishes to share their views on the proposal set out in this document.

You can either email us at [email protected] Write to us at NELCA, 4th floor Unex Tower, Station Street, Stratford, E15 1DA Visit www.eastlondonhcp.nhs.uk

159 Appendix: What we have heard so far 15

As part of our work to create an Integrated Care System over the last 18 months we have undertaken engagement with a wide range of stakeholders. We have listened to feedback and already taken in to account the following:

Topic You told us you are What we are doing… concerned that…

Money Budgets may be held Ensuring that budgets are devolved to a local level to centrally and not passed match existing budget allocation, so there is no impact at on at a local level a local level

Decision- We may lose influence Putting in place new governance arrangements to ensure making on key decisions at a that decisions are made at a local level local level

Clinical Clinical leadership may Building on our existing relationships with our clinical leadership weaken as a result of leaders and getting their input to shape a new way of moving to a single CCG working. Clinical leadership will exist at every level within the ICS and will be key to our success. Clinical leadership budgets for each CCG will be maintained, with clinical leaders freed up to lead clinical transformation of services rather than some of the current bureaucratic focus

Impact on A single CCG may mean Existing hospitals, NHS trusts, GP surgeries and services reducing services for community services will continue with no impact. What patients we are doing is changing the way we work so that we can deliver a better patient experience with access to more services more easily. By working collectively, we can attract transformation funds to improve services for local people where they are needed most. We will address variation for patients across NEL, with a focus on the highest standards

Impact on There may be impact on We are aiming to minimise the impact on staff, maximise jobs CCG staff as a result of opportunities for career progression and training, and the merger to tackle inequalities across our system. We are assuming that requirements to reduce or restructure posts will be minimal

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Declaration of Principles North East London CCG

1. Continuous quality improvement. Develop a culture and ways of behaving and working that promote continuous improvement in the health, care and wellbeing of the whole population.

2. Transparent and accountable. Act transparently with and between provider organisations - planning, decision making, accountabilities and spend (£) for whole population health outcomes. We will ensure contracts involving the spend of public money are made publicly available.

3. Reducing inequalities. Focus on outcomes in terms of quality of care, performance, safety, reducing health inequalities and experience for both patients and staff. The delivery of these outcomes will be the focus of provider organisations (statutory, voluntary and community).

4. Delivery, delivery, delivery. Focus will be on delivery by provider organisations, including statutory bodies and the voluntary and community sector and the CCG.

5. Holding each other to account and actively seeking local accountability. Working as an ICS, establish a robust assurance framework that clearly shows where accountabilities and responsibilities sit for delivering high performing services and meeting national standards. Within this ensure local providers and systems hold NEL to account and NEL holds the local systems and providers to account.

6. Distributed leadership. Provide strategic commissioning leadership, lead strategic planning with partners and support the development of the ICS for north east London.

7. We are all commissioners. When making commissioning decisions, ensure all hospital and out-of-hospital organisations work together in the planning of services (including the adoption of commissioning behaviours).

8. Being led by our communities. Ensure there is the relevant skill set and appropriate balance on the partnership boards to deliver population health gains. This will include hospital/out of hospital representation, users and diversity of staff.

9. Out of hospital care. Ensure year on year an increase (in absolute and relative terms) in the quantum of financial resource (across NEL) for out-of-hospital health services.

10. Equity. Ensure equity of funding systems within all the providers.

11. Co-production and power devolved to communities. Ensure user involvement, co- production and clinical engagement throughout the CCG and our wider ICS.

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12. GP member voice. NEL CCG to be formed by the membership of each of the current seven CCGs, electing a local clinical chair (during the period of transition the current CCGs will assume this role) who will sit on the single CCG Governing Body to reflect the membership voice (as part of a democratic process) and act to connect local systems with the NEL CCG and with the NEL ICS.

13. Localising personalised services. Support place and local authority-based integrated care partnerships (ICPs) to flourish in accordance with the 80:20 principle of CCG resource distribution.

14. Decisions and delivery close to people. Governance structure characterised by delegating: planning, accountability and financial decisions consistent with the 80:20 principle. Budgets will be devolved to a local level in accordance with the national allocation formula.

15. Integration. Support all provider organisations to work in integrated systems at the place/local authority and multi borough level (where locally agreed) and to come together at NEL STP level as a single ICS.

16. Levelling up. Act to reduce unwarranted variation and reduce inequity across NEL, ensuring that decisions, including those for new investments, are taken based on population health need, are supported by outcome data and seek to address legacy issues from the previous seven CCGs.

17. Acting as leaders across our communities. Support all partners’ roles as anchor institutions (working collaboratively with one another in forming an ‘anchor system’).

18. Prevention. Enhance opportunities to prevent ill health; address the wider determinants of health; promote the development of self-supporting communities with increasing social capital.

19. Local focus. Ensure placement of CCG employed staff and sessional clinical leads will adopt the 80:20 principle of resource distribution, so that the vast majority of staff time will be managed and directed in local systems. However everyone will have a responsibility to deliver for the whole population. Local trusted contacts and relationships will be respected and built upon.

20. Speaking up and being heard. Invest in staff recruitment, retention, wellbeing, development and career progression to ensure high standards of care are delivered by a workforce that is healthy and feels able to speak up when things aren’t going as well as they should.

21. Growing our own. Support at all levels a focus on promoting equality and the ambition of “growing our own” workforce that better reflects the populations we serve - recruiting and retaining people from our local communities.

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22. Our people. Support year on year improved diversity of leadership to ensure diversity of protected characteristics, population representation and different clinical professions.

23. Working as teams together making the most of our expertise. We describe this as the triumvirate leadership model of a patient, a clinician and a manager shaping and leading change. Benefit from promoting a strong Lay Voice on the Governing Body and throughout the committee structures that support the governing body.

24. Co-production. Support clinicians and practitioners to work with managers when planning services and care pathways, with patients and the public involved throughout the process – continuing to make co-production a reality.

25. Making it easier for patients. Facilitate structural integration between all organisations across NEL ICS including enhanced communication; simplified record keeping; and joint executive posts and shared non-executives to make interfaces between organisations as seamless as possible.

26. Systems that work for patients and staff. Develop high functioning and responsive IT systems across the whole of NEL which support integrated working and improved care.

27. Modern healthcare facilities. Ensure all estates, particularly new developments, are designed around a holistic approach to health improvement.

28. Making every contact count. Ensure that everyone working in the system holds a responsibility to improve the physical, mental and social health of the population.

29. Social and environmental sustainability. Ensure that sustainability is core to everything we do and that this is the responsibility of everyone within the system.

30. Our people supported to grow and thrive. On the merger, staff of the seven CCGs will be employed by the North East London CCG. We will enable our staff to work on CCG and ICS priorities across organisational boundaries, ensuring that they have opportunities to develop professionally and maximise delivery of health and health care outcomes. We can do that for example by using ‘honorary contracts’ to enable full access to different organisation’s systems.

31. Clinical leadership budgets for each CCG will be maintained for all seven local systems, with no cut to the clinical leadership budget in any local system. The single CCG will lead to a reduction in bureaucratic processes, freeing clinical leaders up to lead clinical transformation of services. Clinical leadership will exist at every level within the ICS and will be key to our success.

163 A One NEL CCG System Financial and Commissioning Regime

September 2020

An alliance of North East London Clinical Commissioning Groups 164 City and Hackney, Newham, Tower Hamlets, Waltham Forest, Barking and Dagenham, Havering and Redbridge CCGs Implementing the LTP – CCG merger as an enabler for integration

• Creating ICPs at borough / sub-system level – integrated governance to support system wide joint decision making • Closer collaboration between provider / commissioner / Local Authorities • Potential over time to transition to formal joint committees (subject to future legislation) • More opportunity for joint posts with equal accountability back to sovereign boards

• Moving the statutory CCG body to NEL level frees up the ICP to operate with greater degree of integration whilst maintaining overarching legal framework and controls environment

• Changing the language of commissioning: • Away from commissioning as a statutory function discharged by a CCG through contract - transactional • Towards a system of value based resource allocation driven by clinical quality and return on investment (best possible outcomes derived form the finite resource we have) – supporting clinical transformation

165 North East London Commissioning Alliance 2 Overarching approach • Single CCG will be the statutory body receiving a single set of NEL allocations • Programme allocation (commissioning budget), • primary care • Running costs (RCA) • Budgets will be devolved to borough based partnerships – NHSE will not set allocations at a borough level through the national formula, however • We will track published CCG allocations, so the principle of population based capitation will remain • This will maintain stability of existing plans and ensure no one is made worse off by the merger • Circa 98% of commissioning budgets will be devolved to place • The single CCG will retain a corporate budget for head office costs, based on the functions that have been agreed • 0.5% contingency + 0.5% risk reserve held centrally to manage risk in areas of financial pressure and support overall sustainability • NOTE: • The values set out overleaf are based on pre-pandemic data, are subject to national policy and are for ILLUSTRATIVE PURPOSES ONLY

166 North East London Commissioning Alliance 3 Devolution of resource to ICPs NHS Barking and NHS Havering NHS Redbridge NHS Newham NHS Tower NHS Waltham 2021/22 Allocation BHR WEL C&H NEL Total Dagenham CCG CCG CCG CCG Hamlets CCG Forest CCG £'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000s Core Allocation 332,208 429,364 414,794 1,176,366 512,564 436,387 415,508 1,364,459 459,898 3,000,723 Primary Care 35,816 39,742 43,824 119,382 60,586 52,687 45,433 158,706 52,892 330,980 Running Costs 4,061 5,100 5,799 14,960 6,721 5,701 5,557 17,979 5,516 38,455 Total 372,085 474,206 464,417 1,310,708 579,871 494,775 466,498 1,541,144 518,306 3,370,158

Central NEL CCG Team NELCA Element Programme 355 458 443 1,255 547 466 443 1,456 491 3,202 Admin 589 740 841 2,170 975 827 806 2,608 800 5,577 STP Element Programme 302 390 377 1,068 466 396 377 1,239 418 2,725 Admin 53 66 75 193 87 74 72 232 71 497 Central NEL CCG Team Total 1,298 1,654 1,735 4,687 2,074 1,762 1,699 5,535 1,780 12,001

Central CCG Areas Centrally Commissioned 5,905 7,079 4,097 17,081 4,313 3,888 4,108 12,309 3,525 32,916 0.5% Contingency 1,661 2,147 2,074 5,882 2,563 2,182 2,078 6,822 2,299 15,004 0.5% Risk Share Reserve 1,661 2,147 2,074 5,882 2,563 2,182 2,078 6,822 2,299 15,004 Central NEL CCG Areas Total 9,227 11,373 8,245 28,845 9,438 8,252 8,263 25,954 8,124 62,923

Residual Budget Local ICPs Core Allocation 322,325 417,143 405,730 1,145,198 502,113 427,273 406,424 1,335,810 450,865 2,931,873 Primary Care 35,816 39,742 43,824 119,382 60,586 52,687 45,433 158,706 52,892 330,980 Running Costs 3,420 4,294 4,883 12,597 5,659 4,801 4,679 15,139 4,645 32,381 Total 361,560 461,179 454,437 1,277,177 568,359 484,760 456,536 1,509,655 508,402 3,295,234

Residual Budget % Local ICPs Core Allocation 97.0% 97.2% 97.8% 97.4% 98.0% 97.9% 97.8% 97.9% 98.0% 97.7% Primary Care 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% Running Costs 84.2% 84.2% 84.2% 84.2% 84.2% 84.2% 84.2% 84.2% 84.2% 84.2% Total 97.2% 97.3% 97.9% 97.4% 98.0% 98.0% 97.9% 98.0% 98.1% 97.8%

167 North East London Commissioning Alliance 4 New Long Term Plan Investment 2019/20 2020/21 2021/22 2022/23 2023/24 £000 £000 £000 £000 £000 Mental Health 2,586 2,793 9,569 19,301 25,996 Children and Young People - 136 2,935 4,556 7,532 Adult and older adult CRHTTs and Crisis Alternatives - 2,658 1,365 1,836 2,403 SMI - - 5,268 12,908 16,061 Primary Medical and Community Services 17,345 19,750 21,305 26,570 31,429 a) Primary Care 17,345 18,674 18,791 19,235 19,081 b) Ageing Well - 1,075 2,514 7,335 12,348 Cancer 4,080 3,262 2,549 2,445 2,448 Other 1,320 1,412 3,383 4,925 14,847 LTP funding allocation, total 25,331 27,217 36,806 53,241 74,720

• New LTP investment worth £75m recurrently for NEL by 2024 • Funding allocated to NEL at ICS level – investment framework based on targeting areas of need and historic inequity • Decisions on prioritisation of investment made by single NEL CCG – crucial to have representation from GP members across all 3 ICPs / 7 boroughs (+ CoL)

168 North East London Commissioning Alliance 5 To: Meeting of the NHS Barking and Dagenham, Havering and Redbridge CCGs’ Governing Bodies (meeting in common)

From: Alison Blair, Director of Transition, Barking and Dagenham, Havering and Redbridge Clinical Commissioning Groups

Date: 24 September 2020

Subject: Barking and Dagenham, Havering and Redbridge Integrated Care Partnership Development

Executive summary This report provides an update on development of the Barking and Dagenham, Havering and Redbridge (BHR) Integrated Care Partnership (ICP) development in the context of the wider north east London (NEL) Integrated Care System development.

Recommendations The Governing Bodies are asked to: • Note the progress and comment on the work to further strengthen the BHR Integrated Care Partnership • Receive an update at the November meeting on the design of the Integrated Care Partnership Governance arrangements and terms of reference

1.0 Purpose of the Report 1.1 This report provides an update on development of the Barking and Dagenham, Havering and Redbridge (BHR) Integrated Care Partnership (ICP) development in the context of the wider north east London (NEL) Integrated Care System development.

2.0 Background/Introduction 2.1 There are three key system streams of work underway, focussing on; 2.1.1 the development of the north east London (NEL) Integrated Care System (ICS) 2.1.2 the plans to develop a single north east London Clinical Commissioning Group (CCG) from the current seven (this is covered by a separate paper) 2.1.3 ongoing development of the BHR Integrated Care Partnership

2.2 These are interconnected and the latter two of the above both feed up into and form part of the overarching NEL ICS development.

2.3 A significant amount of work has taken place to refresh and strengthen the BHR Integrated Care Partnership within the context of the wider developing north east London Integrated Care System. As well as setting out the engagement that has taken place to date in BHR and future engagement plan around the Single CCG for north east London proposal, this paper summarises the progress to date, key risks, and next steps for the BHR Integrated Care Partnership development within the context of the wider north east London Integrated Care System.

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3.0 Single NEL CCG proposal 3.1 The proposal to develop a single CCG for north east London to replace the seven existing CCGs (Barking and Dagenham, Havering and Redbridge, Newham, Tower Hamlets, Waltham Forest and City and Hackney) is set out for Governing Body members under a dedicated agenda item and will therefore not be described in detail here to avoid duplication.

4.0 Development of the BHR Integrated Care Partnership 4.1 A significant amount of work is ongoing to refresh and strengthen the BHR Integrated Care Partnership.

4.2 Development of the Principles and vision: It was agreed at the July 2020 Integrated Care Partnership Board (ICPB) workshop that the ‘vision’ for the Partnership needs to act as a ‘call to action’ that is inspiring, memorable, and which galvanises stakeholders and staff to drive forward the integrated care agenda to ultimately improve outcomes for the residents of BHR. It should also reflect the need to address inequalities across the system. Building on the previous vision, the partnership agreed that ‘Better care, better lives, together for all’ articulates our ambition accurately and achieves the criteria above. Further detail of the vision and principles is set out in Appendix 1.

4.3 Initial priority areas for the BHR Integrated Care Partnership: The BHR Partnership has seven key priorities which are set out below. Within each of these, addressing inequalities, being more community based/facing with better access to services for local people, ensuring that we have the ability to act effectively and quickly and addressing the wider determinants of health in health and care provision is key and there is a need to embed these in our ways of working at every level. The seven key priorities identified for the BHR Partnership to focus on include: 4.3.1 Workforce Development 4.3.2 Developing Borough Partnerships 4.3.3 Children and young people prevention, and children and young people and adults safeguarding 4.3.4 Developing the BHR Integrated Care partnership 4.3.5 Addressing inequalities and embedding prevention in every interaction 4.3.6 Winter Planning 4.3.7 Organisational Development; building trusting relationships

4.4 A Senior Responsible Officer from the Integrated Care Partnership has been identified to drive forward progress around each area. Further detail of these key areas is set out in Appendix 2.

5.0 Strengthening BHR ICP governance in the context of the wider ICS development 5.1 As illustrated in Appendix 3, Borough Partnerships will be key to taking forward development of Community Based Care which will integrated health and care, along with the wider determinants of health at a local level, tailoring service delivery to the needs of local people. Appendix 4 sets out the proposals to take forward Community Based Care through Borough Partnerships in more detail.

5.2 Alongside this a review of the BHR Transformation Boards is underway to ensure that, learning from the COVID response, they are agile, above to drive forward improvement of outcomes for local people, and make best use of clinician’s time; detail of this can be found in Appendix 5.

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6.0 Next steps 6.1 Progress the engagement plan with key stakeholders around the single NEL CCG. 6.2 Progress establishment of the BHR Borough Partnerships. There will be a focus in October on reviewing the initial plans that the Partnerships are developing to take forward Community Based Care. 6.3 Progress the recommendations set out in the BHR Transformation Board review. 6.4 Develop detailed design of Integrated Care Partnership governance arrangements including terms of reference, which will be shared with members for review at their November meeting.

7.0 Resources/investment 7.1 This report provides an update on the development of the BHR Integrated Care Partnership, there are therefore no resource/investment implications for this report.

8.0 Equalities 8.1 There are no direct equalities implications arising from this report; however, as we move to closer integration through the proposals set out in this paper, and have a stronger focus on reducing inequalities and developing care tailored to our local populations at a Primary Care Network level, there are positive implications for equalities arising from this programme of work.

9.0 Risk 9.1 There is a comprehensive BHR System risk log which is overseen by the BHR System Operational Command Group and is reviewed on a weekly basis. This was initially intended to monitor and mitigate risks of the COVID pandemic response and subsequent Restoration and Recovery but is being expanded to include all key system / partnership risks. The top red rated risks on the register currently are: 9.1.1 Financial situation of BHR Partners, particularly in relation to the financial situation of Local Authority partners as a result of the pandemic response 9.1.2 Winter planning, particularly as this winter has the potential to see a peak in COVID cases alongside increased winter pressures 9.1.3 Risk that our staff will experience burn out as a result of the COVID response 9.1.4 Potential impact of the UK leaving the EU, on our ability to recruit to particularly care roles 9.1.5 Potential significant increase in the need for mental health support and growing demand for mental health inpatient beds

9.2 Each of these key red rated risks has been escalated to north east London.

10.0 Managing conflicts of interest 10.1 There are no anticipated conflicts of interest arising from this report.

Attachments: 1. What will the BHR System look like in April 2021? 2. BHR ICP Vision and Principles 3. BHR ICP Key Priority Areas 4. Establishing Borough Partnerships in BHR 5. BHR Transformation Boards Review

Author: Emily Plane, Programme Lead, BHR System Development Date: 1 September 2020

3 171 Better care, better lives, together for all

BHR Integrated Care Partnership APPENDICES to support Governing Body Paper on Integrated Care System Development

September 2020

172 APPENDICES

Appendix 1 BHR ICP Vision and Principles

Appendix 2 BHR ICP key priority areas

Appendix 3 What will the BHR System look like in April 2021?

Appendix 4 Establishing Borough Partnerships in BHR

Appendix 5 BHR Transformation Boards Review

173 Appendix 1

Better care, better lives, together for all

BHR Integrated Care Partnership Vision and Principles Refresh Following ICPB Workshop

August 2020

174 The proposed BHR Integrated Care Partnership Vision and Principles

BARKING AND DAGENHAM, HAVERING AND REDBRIDGE INTEGRATED CARE PARTNERSHIP

OUR VISION BETTER CARE, BETTER LIVES, TOGETHER FOR ALL

OUR PURPOSE To pool our resources to support residents

. .

STARTING WELL KEEPING WELL AGEING WELL We believe that every child should We will ensure our services are as We will improve the experience and have the best possible start in life. We simple and streamlined as possible, wellbeing of older residents supporting will develop integrated health and linking with the community and them to remain stable and care services with an embedded voluntary sector to ensure that local independent, at home, for as long as preventative approach linked to the people know how to access the right possible. When an acute admission is wider determinants of health to services and support, at the right time, required, we will ensure that they are ensure that every person has the same embedding a preventative approach supported to return back to their 175 opportunities to thrive. which seeks to address inequalities original place of residence as4 quickly and improve wellbeing and safely as possible. BHR Principles Refresh

Revised ICPB principles with the inclusion of prevention and addressing inequalities: . All the participants of the BHR system will work together as a partnership to improve the health and care of our local residents . Together we will devote our capacity and capability to resolve our biggest challenges . Addressing inequalities will be a key priority for all partners, and alongside embedding prevention and supporting residents around the wider determinants of health . We will use our collective power to lobby for resources to bring into BHR . All our collective resource is public money and will be used to best meet the needs of residents alongside our staff, carers and volunteers . We will embed an approach of ongoing collaboration with people who use health and care services . We will make decisions as locally as possible working with residents . We will support our workforce to deliver more joined up models of care for individuals and populations . We will be open and transparent in the ways we work . We will work together to address risks as they arise across the system . Whilst the statutory frameworks we all work within may remain, we will change our systems, processes, behaviour and culture to support the way we work collectively. 176 5 Appendix 2

Better care, better lives, together for all

BHR Integrated Care Partnership Priority Areas

August 2020

177 BHR Key Priority Areas The BHR Partnership has seven key priorities which are set out below. Within each of these, addressing inequalities, being more community based/facing with better access to services for local people, ensuring that we have the ability to act effectively and quickly and addressing the wider determinants of health in health and care provision is key and there is a need to embed these in our ways of working at every level.

We have seven key priorities 1. Workforce Development through establishment of a BHR Health and Social Care Academy 2. Developing Borough Partnerships; each borough is in the process of establishing their Borough Partnership arrangements 3. Children and young people prevention, and children and young people and adults safeguarding 4. Developing the BHR Integrated Care partnership, including a refresh of the Transformationn Boards 5. Addressing inequalities and embedding prevention in every interaction, with a focus on; obesity, communications and key messaging, mental health support, embedding an approach to addressing inequalities through the community based care model development 6. Winter Planning 7. Organisational Development; building trusting relationships for the BHR Integrated Care Partnership

Enabling priorities: . Digital is an enabler for a number of our key streams of work.

In addition: . We need to be explicit about how we improve health outcomes for our young people. . Need to support carers and volunteers . Collectively recognise our power together in terms of lobbying and the resources that we can bring to our area as a collective . There is a need to be realistic about what we can achieve so that we don’t over promise. 178 7 NEL (20%) BHR SYSTEM (80%) Appendix 3 Improvement and Delivery Havering Havering PCN North Co and Planning - Co ordination Havering Havering PCN - South production & Engagement & production Assurance and Oversight Havering Havering PCN Crest Marshall’s Havering PCN and WellbeingBoard Dagenham Health Delivery Group Delivery Delivery: B&D Delivery: B&D Scrutiny: HSC Scrutiny: Barking and What will theBHR System look like in April2021? Children and Young People, Mental Health, Planned Care, UnplannedPlanned Care, Cancer,Mental Health, Care,Children Young and People, Cranbrook PCN Integrated Care Executive Group; Group; Integrated Care Executive PrimaryConditions, Care,LongTerm Older People/Frailty, Autism and LD Supported by key enablers; workforce, digital, finance, estates finance, digital, enablers; workforce, key Supported by Woodford Wanstead Wanstead PCN Partners at all levels of the BHR system BHR the of levels all at Partners Integrated Care Partnership Board; Partnership Care Integrated North East London ICS and single single and ICS London East North BHR TRANSFORMATION BOARDS TRANSFORMATION BHR Partnership DesignGroup Delivery:Havering Borough BOROUGH PARTNERSHIPS BOROUGH BoroughPartnership (which withHealth andCabinet Care Community Based Care Based Community PCN North East London CCG London East North Seven Kings links the to Health and Wellbeing Board) Scrutiny: HSC Scrutiny: Havering . . Loxford PCN Commissioners and Providers Providers and Commissioners PCN Fairlop PCN North B&D Our patients, residents and local communities and local residents Our patients, Redbridge Healthand Delivery: Redbridge Delivery: Redbridge Operational Group Wellbeing Board Scrutiny: HSC Scrutiny: B&D North North B&D PCN West B&D West PCN One B&D New New B&D PCN West PCN B&D East B&D East PCN One 179 ...... BHR system: of the levels all at Partners housing etc. housing police, Barts Health, Others e.g. PELC sector voluntary and Community x3 Federations GP x15 Networks Primary Care NELFT BHRUT Redbridge Borough London Havering Borough London Dagenham Barking and Borough London Appendix 4

Establishing Borough Partnerships in Barking and Dagenham, Havering and Redbridge

August 2020

180 Developing Borough Partnerships Borough Partnerships are a key element of the BHR Integrated Care Partnership bringing together delivery of health and care services around the needs of local people. This will include input around the wider determinants of health, at a community/place based level.

One of the key aspirations for the BHR, is to support people to improve their physical and mental wellbeing before they deteriorate and require significant and/or long term, high costs interventions, supporting them to maintain a healthy life expectancy for as long as possible. We want to direct people to the right service and support that they need, first time, aiming to achieve the very best value for local people from every interaction that they have with health and care, local authority or community and voluntary sector staff across the system.

This pack sets out guidance to support the establishment of Borough Partnership Boards in each of the three BHR boroughs, to ensure that they are comprehensive, focussed on delivery, and that there is some consistency where appropriate across the three.

Borough Partnership Boards will be led by the respective Local Authority Chief Executives in each area, who will also link them into the work of the Wellbeing Boards to deliver the aspirations of more integrated care, closer to home, supporting local people to remain well for as long as possible, and drawing in support for the wider determinants of health (e.g. housing, debt management, employment) as required.

181 BHR System – Outline Operating Model

Role and Activities Population Primary Care • Targeted interventions aimed at individuals and families who have increased risk of developing needs, where the provision of 31-106k Networks/localities services, resources or facilities may restore independence, slow down or reduce any further deterioration or prevent other needs developing • Focused interventions aimed at maximising independence and minimising the effect of disability or deterioration for residents CO-ORDINATES with established or complex health problems DELIVERY OF CARE • Through multi-disciplinary and multi-agency working, provides the ability to better manage or coordinate the care of FOR LOCAL individuals RESIDENTS • Form partnerships with community groups to support and develop interventions that fill gaps in care • Empower and prepare residents to manage their care • Residents will be at the centre of care and will be equal partners in the design, delivery and monitoring of services • Deliver at scale services which serve populations larger than individual GP practices • Lead on improvement of quality and performance across partners Borough • Shapes and ensures delivery of health and care transformation plans including implementation of new models of care and 200-300k Delegate partnerships pathways tailored to local population within framework set by BHR system • Enhanced sharing of data to undertake population care management of demand and early intervention • Removes barriers and shifts resources to produce greater value and better outcomes LEADS PLANNING • Supports the development of PCN/localities and mobilise community resources to meet the needs of residents AND DELIVERY FOR • Delivers at scale services which serve borough wide population LOCAL POPULATION • Focus on wider determinants of health and care including housing, business, leisure and employment • Escalate issues and risks to BHR system for resolution or wider learning

BHR • Overall responsibility for how BHR system works in practice 800k • Overall strategy development supported by Health and Care Cabinet and Transformation Boards • Set outcomes framework, quality and performance standards • Receives full NHS allocation for BHR and develops financial strategy, resource allocation to boroughs, collective risk management approaches within NEL framework Delegate • Assures borough partnerships and their delivery of effective, efficient care and support SETS SERVICE AND • Custodian of partnership approach – involvement of all partners including wider community, clinical engagement and co- FINANCIAL production • Ensures BHR system efficiency through new commissioning and payment models STRATEGY • Cross cutting BHR wide programmes where need to work together e.g. workforce

182 11 Approach to developing Community Based Care in BHR through Borough Partnerships

It's been agreed that the focus of borough partnerships post Covid should be on the development of community based care models.

Current Position (June – July) Priority to address ongoing challenges of responding to COVID19 in the community. Work focussing on discharges, care homes and shielded population (task and finish pieces of work overseen by SOCG). Plus outbreak management/test and trace. Lessons learnt for how we work as a partnership are informing planning for the next phase of community based care development Model for Community Based Care (CBC) Now need to build on community services response and pre-Covid work to develop a CBC model which provides coherent support for local residents.

What? Build on Previous Work: Future model for BHR covering: community services, social care, primary care, mental health, • Devolution Business Case mobilising community assets, working with the voluntary sector, residents and user co- • OP Frailty Model production. • LTC pathways Including complex care, children and the healthy • Developing Primary Care Focus on prevention, tackling inequalities, meeting needs of most vulnerable, linking physical Networks and mental health plus broader areas which impact on health and well-being (e.g. housing, • Social Prescribing employment).

How? Main vehicles are the three Borough Partnerships (B&D, Havering and Redbridge), whose role will be to design, plan and deliver for all local populations across local partners within a BHR framework including outcomes and enablers. Overseen by SOCG and then ICEG/ICPB.

When? Model developed at Borough level by October for more formal engagement and sign up including implementation plan. 183 Appendix 5

BHR Integrated Care Partnership Transformation Board Review

August 2020

184 Context

The Transformation Boards are a key part of the current and future system architecture. Transformation Boards will be responsible for the development of care models for their particular care group within the overall strategic framework set by the Integrated Care Partnership Board. They are made up of all partners across health and care in BHR and have strong clinical representation. They will continue to develop plans through co-production with residents, patients and their families. As they develop, Borough partnerships and providers will then be responsible for delivering those models for their local populations.

There are currently nine Transformation Boards in BHR comprising: . Cancer . Children and Young People . LD and Autism . Long Term Conditions . Mental Health . Planned Care . Older People/ Frailty . Unplanned Care . Primary Care

A Carnall Farrar review of the BHR Integrated Care Partnership and supporting governance including the Transformation Boards in autumn 2019 recommended a review of the number of boards and their membership to ensure that resource is targeted to greatest effect. Responding to Covid and the NHS Long Term Plan, work streams have been established at north east London level when it makes sense to plan across a larger footprint with greater potential economies of scale.

This pack sets out the key Carnall Farrar recommendations, and how each is/has been taken forward, including proposals for Transformation Board leads. This report also covers the learning as a result of the Covid pandemic and poses changes to the TBs operating model, as supported by ICEG.

A review of the Primary Care Transformation Board is being undertaken separately and as such it is not focused on 185in this update. Recommendations from the Carnall Farrar review In the autumn 2019, the CCGs commissioned a piece of work from Carnall Farrar to look at the role and capacity of the nine Transformation Boards so we can take a view of their preparedness for the future. Recommendations included: Recommendation How this is being taken forward Reaffirm key role for Transformation Boards in the Agreed by ICEG, November 2019 BHR system architecture Confirm the current care group approach Agreed by ICEG, November 2019 The BHR system should provide a strategic framework Commissioned from CF and received by within which TBs should operate ICEG, January 2020 This was agreed as a direction of travel by ICEG in November 2019 but it was acknowledged that this needs to be a Confirm role and remit of TBs should focus on phased transition. planning for their particular care group (e.g. defining Some of the TBs currently also focus on pathways to improve outcomes) and that delivery performance and delivery and, whilst should be through borough partnerships with TB borough partnerships and BHR system support when needed. The roles of TBs in delivery performance arrangements are being should be of oversight on progress and for boroughs developed, it needs to be a staged to escalate issues when advice and support is needed. approach to relinquishing these roles so not to hold up progress. We have asked each SRO to consider the role of their particular board and come up with a plan for changing focus if needed. 186 Recommendations from the Carnall Farrar review

Recommendation How this is being taken forward Over the past couple of months there have The CF report recommended that there is a more been discussions with partners to change the dispersed for the TBs. Up to date leadership model following lead arrangements: they have tended to be CCG led with some exceptions Transformation Lead e.g. CYP and Cancer which have a LA lead. Lead/Sponsor In terms of the leadership model we are suggesting Board organisation Children and Elaine Allegretti (no that the lead organisation should identify the following: LBBD . A sponsor – who is responsible for high level oversight Young People change) Redbridge of the particular TB, driving their priorities, working Long Term Borough TBC across the system with all participants so will need to Conditions Partnership have system leadership qualities and the ability/resources to get things done. A member of Mental Health NELFT Oliver Shanley TBC ICEG. Havering Older People / . A convenor – who will in most cases be a senior person Borough TBC Frailty in the current structure who will be responsible for Partnership programme planning and oversight, identifying, Planned Care BHRUT Tony Chambers TBC managing and mobilising resources etc. Urgent and . Organisational ‘champions’ – dependent on the care BHRUT Tony Chambers TBC group, these will be leads from key partners Emergency Care organisations responsible for engagement and input. LD and Autism NEL led programme . Clinical leadership – which could be an overall leader NEL led programme (led by Matthew supported by other clinicians as required or a range of Cancer Cole in BHR – no change) clinicians. . PMO – support will be provided from the current system PMO (located in the CCGs) who will also run the reporting mechanism taking into account the The review of the sponsor / convenor and suggestions in the CF report. supporting resource is set out on the following slide 187 Recommendations from the Carnall Farrar review

Recommendation How this is being taken forward

TBs will formally report to ICEG and the ICPB through a monthly report highlighting issues that require escalation/decision for senior The CF report highlighted the need to firm up system support/ determination. The Health reporting arrangements. and Care Cabinet will be asked for views on proposals for significant changes to clinical models prior to them coming to ICEG/ICPB. The structure is set out in the following slides

Enabling work streams have been established at a NEL level but we need a local process to The CF report mentioned the need for TBs to link pull together the ‘asks’ of the transformation with cross cutting enablers (estate, IT and boards. The proposal is that each enabler is workforce). supported by a member of the shared PMO with a BHR lead also identified The BHR Directors of Public Health have recently Each of the Transformation Boards is presented JSNAs in a common format for each of undertaking a review of their work the boroughs. These have been discussed at the programme against the JSNAs to inform this Health and Care Cabinet. going forward.

The work of CF developed a maturity matrix to With ICEGs agreement we will ask each of the determine the maturity of each board based on TBs to undertake a self-assessment against the stage of the transformation cycle they have the matrix on a quarterly basis a summary188 of achieved. This was included in their report. which will be presented to ICEG. To: Meeting of the NHS Barking and Dagenham, Havering and Redbridge CCGs’ Governing Bodies (meeting in common)

From: Steve Rubery, Director of Commissioning and Performance

Date: 24 September 2020

Subject: Winter plan – 2020/21

Executive summary The ongoing pandemic, the potential for a second peak of Covid 19 and the risk of a concurrent flu outbreak mean that this winter could bring unprecedented challenges. On that basis, this paper proposes an approach and a set of priority areas for winter preparedness in 2020/21.

The development of the plan commenced in August 2020 and good progress has been made. This has been developed with system partners and has been regularly reviewed through the SOCG.

The plan is being brought to the Governing Bodies (meeting in common) to provide assurance on planning for winter and also to highlight both risks and investment requirements.

Recommendations The Governing Bodies are asked to:

• Note the report • Receive a further report in 2 months

1.0 Purpose of the Report 1.1 The ongoing pandemic, the potential for a second peak of Covid 19 and the risk of a concurrent flu outbreak mean that this winter could bring unprecedented challenges. On that basis, this paper proposes an approach and a set of priority areas for winter preparedness in 2020/21. The process will be co-ordinated by the Urgent care team in the CCG, and has had input from all system partners. This plan aims to assure the Governing Bodies that plans are in place to manage this risk.

2.0 Background/Introduction 2.1 Historically winter planning has been a discrete exercise involving mainly urgent and emergency care (UEC) services/partners, based predominately on a template and approach set by NHSE. This year, we need a whole system approach to planning for and minimising the risks from the coming winter.

3.0 Report Content 3.1 There is a summary of the winter plan actions as an attachment to this paper but the winter ‘plan’ will not be a single detailed plan for winter. Because the range of actions are vast and

189

held by a wide range of organisations and groups, the ‘plan’ provides an assurance document that identifies the key winter risks, outlines all of the areas that we need to address for winter preparedness and provides assurance (or not) that these are in hand.

3.2 We are proposing the following continuations and changes from previous years’ winter planning processes:

3.2.1 Things we want to keep • System plan – includes input from a wide range of system partners and has sign off through system groups • Focuses on admission avoidance, discharge and community services as well as acute capacity

3.2.2 Things we want to change • We need to consider winter preparedness across all of our programmes of work – rather than just with UEC partners. • Needs to be driven by our local system needs rather than criteria set by NHSE • Should consider wider community-based support – beyond just admission avoidance or discharge • Needs a stronger focus on flu to really tackle the challenges in this area.

3.3 We are expecting that there will be an NHSE led winter planning process and this is expected to start in September and require each STP to provide assurance to NHSE (through a set template and follow up meeting/s) that they are addressing a number of priority areas defined by NHSE.

3.4 These priority areas are not yet known, however, as an example, in 2019/20 the priorities set by NHSE were: • Same day emergency care • Reducing long length of stay • Reducing LAS hand-over delays • Increasing flu immunisations • Minors patient breach reduction

3.5 At the point that NHSE define their process, and we have agreed with STP partners how this will be completed in NEL, we will have to do some work to retro-fit our local plan into their template/requirements. We will also have to address any priorities that NHSE set that we had not already addressed locally.

4.0 Resources/investment 4.1 Investment requirements have been highlighted within the plan but the CCG has not yet received any confirmation of additional winter funds.

4.2 There may also be opportunities to bid for winter monies for specific pressure areas and we are developing our plans so that we will be well placed to put forward bids rapidly.

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

6.0 Risk 6.1 The following are the proposed critical risks relating to winter 20/21 – many of these are already included in the risk register, but are specific to the winter months: • Risk of increased mortality, morbidity and increased demand on services from a seasonal flu outbreak

2 190

• Risk of increased mortality, morbidity and increased demand on services from a second peak in Covid-19 infections • Risk of increased mortality, morbidity, deterioration and crises resulting from people not receiving or accessing the care that they need to manage their conditions. • Risk that we cannot support our vulnerable residents to stay well through winter and that changes to service provision as a result of the pandemic exacerbates this • Risk that we cannot discharge patients quickly and safely when they are medically optimised, resulting in sub-optimal care for patients and reduced flow through the acute site. • Risk that people walk or are conveyed to hospital when a different community based service would better meet their health and care needs • Risk of increased mental health crisis over winter 20/21 arising from the pandemic and resultant social and economic implications.

7.0 Managing conflicts of interest 7.1 There are no conflicts of interest

Attachments: 1. Winter plan summary

Author: Kirsty Boettcher, Deputy Director of Unplanned Care Date: 10/9/2020

3 191 BHR WINTER PLAN SUMMARY - draft 16/9/20

Area of focus Objective Actions Summary Meeting Monitoring of effectiveness New investment CCGs BHRUT NELFT LBs PELC LAS St Francis required (£) nb: no funding source R H B&D identified Workforce Maximise staff coverage for the flu Encourage all staff to be BHR wide flu group in place with all providers represented (see below under primary care) BHR flu group Uptake rates by organisation M Gilbey-Cross W Taylor J Rutter A Imakumbili K Ezeoke-Griffiths Y Enum vaccination in line with the national vaccinated, through early comms BHRUT - Operational planning to launch our annual campaign began in August. Our model to be brought to SOCG - target and accessibility to vaccination and plan has been reshaped to reflect increasing targets and the impact on Covid-19. An frequency to be agreed. outline flu plan has been developed and will be shared with JSC and TEC to gain approval for the new model of delivery, before progressing to Silver and Gold commands. The nationally mandated self-assessment will be tabled at the next board meeting and will be referenced in the minutes which are available to the public.

Workforce plan Plan to cover: response to second Detail to be shared at provider level David Amos to be asked to set up a wave; Christmas and NY cover; We also need organisations to confirm how they will collaborate / provide mutual aid to BHR wide group support to staff to manage support workforce shortages (particularly those who can't provide front line services). May exhaustion, sickness, MH etc. require some reference to NEL work within the alliances Plans also need to reflect NHS People Plan and health and well being support

Suggestion made that Military should be approached to understand any potential support offer

BHRUT Daily SitReps to remain in place to track and monitor sickness absence, temporary staffing fill rates. Centralised workforce Hubs to continue for Medical and nursing staff to support redeployment. Past initial surge increased capacity of medical rotas to improve cover ‘out of hours’ Recruitment pipeline for nursing and unqualified staffing very positive with reduction in vacancy rates; Student recruitment/International recruitment continues. Management of annual leave in place and planning for Xmas period commencing.

Primary care Maximise flu vaccination/ national Creation and delivery of BHR wide flu group established to provide oversight of vaccination programme delivered: BHR flu group Monitoring by patient cohort J Cory W Taylor J Rutter A Imakumbili K Ezeoke-Griffiths Y Enum target population vaccination plans for through PCNs (each will nominate a lead); for staff by organisation; public heath for schools. S Clarke the groups determined by national The programme commences on 1/9/20 and the group will also need to consider where best M Gilbey-Cross policy - this will need to cover to provide vaccinations for core patient groups. e.g. on discharge from hospital; respiratory both primary care and public outpatients etc. health led programmes

Maximise primary care availability as Clarify winter offer - what will be Practices will be open during core hours 8am-6.30pm on all normal working days (i.e. PCCC S See first line for patients different? What is available over including Christmas eve and NYE and days between Christmas and NYE). The operating model Christmas/ New Year? has shifted and all practices are now offering online consultations via e-consult and video consultations as well as an open door policy and seeing those patients that need to be seen face-2-face.

A duty doctor scheme is in development – more detail to be added. PCCC J Cory

111 to improve utilisation GP slots Proposal for slots to be opened up for use by 111, paramedics and UTC redirections. Primary care UEC group (STP) Monitoring by practice - TBC C Morgan Discussion through STP primary care group for agreement in September 2020. as part of STP metrics J Cory

GP hot hub plans in case of second Delivery plan developed for hot hubs and a suspected covid home visiting service (1 in each PCCC COVID fund? J Cory wave borough) and can be mobilised in 1 week. This will need to fit as part of escalation triggers. N Keefe J Hamburger

Primary care support to care homes to Care Homes DES From October a DES + for care homes support is being commissioned. This will aim to PCCC N Keefe avoid admission ensuring all care home patients have care plans and have rapid access to a GP. The contract will include the use of CMC ensuring that care plans are uploaded for other professionals to use.

GP registration Support to patients to register In development through Primary Care - update in September 2020 PCCC N Keefe with a GP

Safe management of vulnerable and Primary care offer For LTC LIS’s practices asked to risk stratify those at greatest need and ensure review prior to PCCC J Cory shielded patients winter and next phase of the pandemic. PCN HV services for non covid patients, and N Keefe housebound, to ensure LTC reviews take place. Those at greatest need reviewed and access to J Hamburger PC when required.

Pharmacy offer During COVID there were issues in getting medications to people who were shielding. We B Krishek need to develop an agreement with LPC/ pharmacies to provide support to this patient J Cory cohort.

Community care offer TBC Council offer Redbridge M Byrne B Nicholls S Knoerr The Adult social Care and integrated health service in LBR will continue to offer information and advice, care and support during the winter pressure period. Extensive information is available on the Councils website to support people with Covid19 related guidance and the Council will continue to add useful Public Health information to support residents health and wellbeing during the winter months. The Wellbeing service no longer receives government funding but a reduced service is being maintained and residents who contact the number are being provided will continue to receive information, advice, signposting and support as appropriate.

Havering Havering has stood down its Shielded Patient response, however it is included as part of our Outbreak Management response, to step this back up as required, particularly if there is a local lockdown or other changes to national guidance.

192 B&D B&D has stood down its Shielded Patient response, in line with the national move to pause the scheme, but (previously) shielding and vulnerable patients who require ongoing support can receive this from our Floating Support service. This can be stepped back up in response to a local lockdown or changes to national guidance. Our Intake Team continues to offer information, advice and guidance and signposting/connections to support within the community and through our Community Solutions service. This includes a welfare support check-in service. Contingency capacity has been retained in the Intake Team in the event of scaling the service up should local lockdown / national shielding guidance change. Extensive information to support health and well-being and wider Covid-19 related information is available on the council's website. The council's central food hub has retained a stock of food should the need to rapidly provide emergency food parcels arise

Urgent care offer - Initial screening of shielded and vulnerable patients is completed by PELC at the front door. Front door (UTCB sub-group)/ STP C Morgan G Shipley S Munshi Email inbox has been set up and process already underway. 111 group - Masks will be provided for all patients; - Following triage for shielded patients the dept will provide an area of isolation i.e. cubicle if available (or procedure room).

111 Detail to be added - NEL commissioned C Morgan services

UTC Reduce walk in activity on acute sites Bookable pathways for illness Increased bookable slots through mobilisation of two community UTCs - 2 slots available per Front door (UTCB sub-group) 111 monitoring TBC as part of C Morgan S Munshi hour. STP metrics. Bookable pathways for injury PELC developing injury virtual assessment proof of concept pathway. This would reduce Front door (UTCB sub-group)/ STP Monitoring in development C Morgan S Munshi queueing and waiting on site and face to face contacts. This also enables redirection of Secondary Care Group activity from acute to community UTCs.

Maximise community UTC PELC/ NELFT to have Point of Care testing in place in Harold Wood and Barking Community UTC Contract mobilisation group - K Boettcher S Elliott utilisation by the end of August. ACPs will be updated to increase opportunities for LAS conveyance to CCGs/ PELC/ NELFT Monitor illness and injury community UTCs. attendances by site - weekly summary. Monitor ambulance conveyances by site - weekly.

Direct care and support Access to CMC Needs further discussion Front door (UTCB sub-group) C Morgan/ M Williams S Elliott T Reeve

Access to community services Needs further discussion UTC Contract mobilisation group - K Boettcher M Williams S Elliott CCGs/ PELC/ NELFT Support to patients to register In development through Primary Care - update in September 2020 UTC Contract mobilisation group - K Boettcher/ H Mason with a GP CCGs/ PELC/ NELFT J Cory

Ambulances Maximise use of alternative to Use of star lines 5/6/7 Publicise *6 for care providers to increase usage in order to try and reduce conveyance Conveyance by home K Boettcher L Hussein J Green/ L Hider-Davies conveyance Care home Forum/ Ambulance and B Campbell community pathways (UTCB sub-gp)

Increase usage of ACPs Agree monitoring with LAS C Morgan J Niner Pilot on using *5 for paramedics to contact to be directed to most appropriate ACP or book appointment in GP hub/ UTC - agree start date with 111.

Increase ACP options ACP for MH signed off and implemented in September 2020. Ambulance and community Monitor use of ACP K Boettcher Ola C Prior pathways (UTCB sub-gp)

ACP for community UTCs to be refreshed in September with POC testing in place. Monitor use of ACP K Boettcher H Mason K Bate

HALO at Queens - This would provide appropriate challenge at the front door and ensure all alternative care Ambulance and community Agree monitoring £3k per week - £36,000 K Boettcher G Shipley K Bate pathways have been considered. pathways (UTCB sub-gp) for 12 weeks - Attendance at trust site ops meetings / huddles will facilitate flow and support unforeseen ambulance surge periods.

Maximise K466 through 111 CTT nurse based with 111 CHUB - pilot ends on 31/8/20. Evaluate impact and consider Ambulance and community £57,000 K Boettcher J Jarvis J Niner extension of funding. pathways (UTCB sub-gp) (7 months)

LAS ePr pilot EpR will be fully functioning by November 2020. It is not expected to have a significant Ambulance and community K Bate impact for winter and therefore other plans are in place to support use of ACPs pathways (UTCB sub-gp)

MH car MH TB to confirm position and learning from pilot Mental Health TB TBC S Mlambo

RAFTIng - BHRUT has recently undertaken a clinically led pilot to improve the current RAFT area and Ambulance and community K Boettcher G Shipley K Bate ambulance handover times. pathways (UTCB sub-gp) -This project has included reviewing all parts of the handover process - so the team attend the patient all at once on arrival and the defined roles of each member of the team are completed. - This has resulted in reducing the time the patients remain in RAFT area. Reducing handover times on average at Queens from 42minutes to 18 minutes. When there is flow from the ED, this is even quicker. This new process will continue for Winter 2020/21.

ED/ hospital flow Reduce ED demand Hot clinic capacity There are hot clinics for respiratory and cardiology based in ambulatory care in place. There K Boettcher J Barrett/ N Willoughby are two clinics per week for respiratory and cardiology patients which can be directly referred to through ambulatory care from ED. Reducing demand and numbers in ED by using ambulatory and hot clinic pathways. Number of appointments Ophthalmology has eye casualty with direct access for emergencies, Monday – Friday, 9am – booked 5pm. ENT, Max Fax and General Surgery hot clinics accessible through the on call team, Monday – Friday.

193 SDEC/ ambulatory care - The SDEC unit is a new unit at the Queens site, implementation continues to ensure K Boettcher G Shipley capacity is maximised. - Emphasis is on pulling appropriate patients through from the ED. A senior nurse/ACP will be allocated to support with 'pulling' patients through from the ED. -Clinical care pathways will be developed and reviewed to support with flow from ED. - To support with this through winter 2020/21, regular checks on both medical and nursing staff levels will be assessed against demand levels. Ensuring staffing well-being is paramount. - Estates reconfiguration plans to support staff well-being areas are currently going through the Trust's approval processes. - Consultant cover will be increased when required to increase the capacity for post take both in ED and SDEC - to improve flow up to the wards. - The triage pathway will be monitored, allowing fast pace in seeing patients and maintaining flow. - To support with the above, the bedded areas need to be kept free from inpatients. With bed space being used for cat B or SDEC patients. There needs to be an agreement with bed and site that the admitted patients in SDEC get same priority as ED admissions so that it operates Secondary care (UTCB sub-group)/ as SDEC and not a ward. STP Secondary Care group - Implementation project workstreams will continue to become more efficient. - Plan to upskill nurses to cover both SDEC and AECU and put on more clinics in AECU and put more patients through virtual ward.

Direct to specialty (advice and Urology advice and guidance service on ERS and answers queries via email. Daily checks with K Boettcher J Barrett/ N Willoughby referral) 48hr response time.

ED advice The GP Advice line pilot commences 24/08 C Morgan G Shipley - The purpose of this advice line is primarily to avoid attendances and admissions to secondary care relating to the Emergency Department. - It will also provide improved working between primary and secondary care and ensures that patients are put into the right stream first time; this includes Same Day Emergency Care and other appropriate patient care pathways. Number of contacts with ED The advice line will be used to support the following; consultant • Patient deterioration since discharge- unsure whether needs readmitting Number of attendances • Advice on pathway for patient- unclear avoided • Multiple symptoms- unclear where to send patient • Chasing results of ED tests, unclear of ED advice/request on discharge • Diagnostic queries- urgent requests in A&E • Shielded patients- need flagging if sending to ED Access to urgent care plans and/or - A review of frequent attenders is in place with fortnightly MDT meeting in place with LAS / Secondary care (UTCB sub-group) T Reeve G Shipley EoLC advanced care plans via CCG / NELFT / police / homeless person unit / social services and local boroughs. CMC - Ambulance crews have CMC access to records which can support decision making if patient needs conveyance, i.e. End of Life care.

Minimise LOS to maximise flow Red to green on all wards 5 Workstreams for red2green going in to winter - Discharge Improvement Working K Boettcher K Peters n/a n/a S. Knoerr 1. SDEC - supporting SDEC To increase flow through unit, using digital solution to monitor group KPIS's, performance, demand and capacity. Use data to inform changes for improvement workstreams to maximise flow through the unit. respond to increased demand.

2. Discharges - daily conference calls with system partners. Daily review of external delays. K Boettcher K Peters Shangle Khanom Annette Kinsella / S. Knoerr working with Divisions to implement 'right to reside" discharge guidance to ensure only C Morgan Christina De Heere Sophie Webster patients that require an acute bed remain in hospital. CCG to remain on site to enhance G Sud collaborative working . Streamlining of discharge paperwork and process to support CHC assessments taking place in the community. Ensure efficient use of community capacity and provide escalation triggers to enable system partners to respond.

3. Red2Green - Continued development of red2green to ensure robust escalation and delays K Peters n/a n/a S. Knoerr are reduced at ward level using 'right to reside' to drive decision making Monitoring of 4 key metrics 7+,21+day LOS, pre 12 and pre 5 discharges - developing triggers and action plan to respond to triggers. Weekly 21 day LOS review with Gold oversight. . Potential Los Blitz weeks early December and beginning of January based on last year peaks

4. Discharge Pathways- review of pathways 1-3 with system partners to ensure they deliver J Chapman K Peters Shangle Khanom Annette Kinsella / S. Knoerr as per national discharge guidance, Home first to be delivered in all 3 boroughs, Pathway 3 K Boettcher Christina De Heere Sophie Webster D2A process with rehab support to enhance pathway 2 and improve long term outcomes for /John Green / Laura patients. Osborne 5. Medway Flow/care flow - Implementation of Medway flow and electronic whiteboards K Peters n/a n/a S. Knoerr across all wards - This will enhance and support live bed state and discharge predictions.

K Peters Shangle Khanom Annette Kinsella / S. Knoerr Hospital Flow - change to format of meeting to ensure senior oversight of 4 key metrics 7+, Christina De Heere Sophie Webster 21+ day LOS, Pre 12 and pre 5 discharges

Demand and capacity assessment BHRUT - Demand and capacity exercises have been undertaken and we are working closely Discharge Improvement Working B Conway for beds with the STP Demand and capacity exercises have been undertaken and we are working group closely with the STP to develop a set of triggers to alerts us to a second wave. System wide modelling assumes that the same reduction in Non-Covid emergency demand seen in April will recur and offset any Covid related admission increase, alleviating any bed pressures. Our starting point for estimating the maximum exposure is to model the impact of Covid demand in addition to the typical winter-run rate, considering the impact of each demand management scheme separately. A challenge or us will be to provide sufficient 'green' capacity to manage elective demand whilst also preparing for winter with sufficient beds to manage emergency demand including a second wave. Further modelling will be undertaken in response to the phase 3 letter to develop a set of triggers to alerts us to a second wave. System wide modelling assumes that the same reduction in Non-Covid emergency demand seen in April will recur and offset any Covid related admission increase, alleviating any bed pressures. Our starting point for estimating the maximum exposure is to model the impact of Covid demand in addition to the typical winter-run rate, considering the impact of each demand management scheme separately. A challenge or us will be to provide sufficient 'green' capacity to manage elective demand whilst also preparing for winter with sufficient beds to manage emergency demand including a second wave. Further modelling will be undertaken in response to the phase 3 letter.

194 COVID response BHRUT reconfiguration of ED for - The ED will review the demand or any surge in COVID presentations and when required re- G Shipley COVID allocate the use of the footprint to accommodate / manage the patients in inline with the First wave incl changing the signage to and in the dept for both staff and patients.

BHRUT reconfiguration of wards The profile of our patient requirements have changed from what we would expect and has D Bays had to evolve as the COVID response has progressed. The Trust has developed a protocol document that will provide a guide to how we would change our capacity profile in the event of future surges. Demand and capacity has been review to ensure planned bed model can sustain BAU based on winter 19/20 activity. The Trust is assuming that elective activity is BAU plus COVID 19 backlog clearance

Discharge Minimise hospital LOS to maintain bed Hospital Discharge Service - pull Number of patients £525,138 K Boettcher K Peters C White flow - confirm capacity in each scheme from wards Business case in development to support this and will require 6 WTE band 7 therapists/ supported to discharge by (7 months) and address any findings from first nurses to support pull into HDS from the wards HDS wave of COVID. Mobilisation timelines Reduction in LOS Community beds K Boettcher K Peters C White for any response services Options in development Triggers for bed capacity in K Boettcher K Peters C White L Hussain B Nicholls L Hider-Davies community NELFT have developed triggers for community capacity but we need to align these with T Challinor S Knoerr triggers across the system both for winter surge and COVID

Discharge to assess J Chapman K Peters L Hussein L Neilson L Hider-Davies/ Havering: New pilot pathway is due to mobilise mid November - this will use 2 homes for S Knoerr D2A discharge and the revised process will support patient flow and will ensure swift discharge for people on this pathway. The 2 homes commissioned will support COVID positive and negative referrals. The new discharge decision tool will be implemented which ensures that 'home' is considered for all patients prior to referral on this pathway. In the Discharge Improvement Working interim period the current pathway will be used but the checklist process will be moved into Group the community - there will be minimal paperwork required prior to discharge. Also need to determine where we will hold patients that are ready for B&D Awaiting outcome of the Havering pilot to inform next steps discharge, but needing a care home who are either Covid Redbridge will continue to support the D2A pathway from hospital under the current symptomatic/positive or status arrangements. Following the Havering pilot Redbrudge will be looking at developing the D2A unknown model further to ensure people recieve support to promote their independence, health and wellbeing following discharge from hospital.

Home first J Chapman K Peters L Hussein L Neilson L Hider-Davies/ Havering: Phase 2 of the Home First pilot commences on 21st September - this pilot is S Knoerr predominantly for people that require reablement and essentially shifts the therapy assessment from the acute setting into the community reducing the amount of time the person spends in hospital. Phase 1 of the pilot demonstrated that assessing at home resulted in a reduction in the amount of care required which should release some capacity. It is expected there will be approx. 16 people per week discharged via this pathway

Redbridge is fully committed to a Home First stage 1 pilot and is engaged in discussions with community health and reablement to realise this pilot with BHRUT partners in coming months.

Trusted assessors Trusted assessors in place for care homes in Havering and can now restart visits. Trusted J Chapman K Peters L Hussein J Green L Hider-Davies Assessors are in place in some B&D homes and discussions are being undertaken tto increase this. Need to establish TA for Redbridge.

CHC capacity Confirm plans for block booking of beds for winter J Chapman K Peters

Address training needs in care homes to Actions swift deployment of Proposal in development for senior nurse to visit care homes and provide training to nursing Discharge Improvement Working Number of homes supported £75,000 K Boettcher K Peters C White L Hussein J Green L Hider-Davies T Smith support discharge needed education Syringe drivers, staff to support discharge. SFH already do this upon discharge from SFH - SFH could extend Group Number of patients (7 months) VOED etc that service discharged based on this support

Care provider support Minimise IC risk IPC team support IPC business case has been developed and funding is being discussed between system BHR Care provider forum - in place Number of homes supported £240,000 S Morrow/ C White A Loades B Nicholls E Allegretti (residential, nursing partners. This service will be essential support for the home care providers. from September 2020 (6 months) M Gilbey-Cross and home care)

Protect staff and 'patients' Home testing BHR Care provider forum - in place A Pardoe Matthews T Han Y Enum To be confirmed from September 2020

PPE Central government has confirmed flow and capacity of ongoing PPE A Pardoe Matthews J Green L Sheldrake

Assurance on care capacity at borough LBs to confirm care capacity plans Havering: A COVID specific homecare service has been commissioned which will take all LB care provider groups A Pardoe Matthews J Green L Hider Davies/ level including support to maintain homecare discharges - this streamlines the process. All placement team processes have been Stephan Liebrecht homes revised to support same day discharges. Determine where patients that There are plan to commission additional homecare capacity over the winter months should are ready for discharge, but be required. Additional reablement capacity will also be commissioned. needing a care home who are Contingency plans also in place - the wider homecare market has been consulted regarding either Covid symptomatic/ their ability to accept referrals directly from hospital, should demand require it. positive or status unknown are 10 beds have been blocked booked in The Lodge care home for all residential placements - cared for. service users will remain there until they have a negative test result (or 14 days if they were Consider support plans for homes positive) before moving onto their home of choice. where vacancy rates are high - to avoid risk of closure, loss of B&D: We are confident that we have enough homecare capacity within the market to capacity and movement of support through the Winter period. residents We have a hot and cold pathway in place for positive and negatie discharges from hospital. We are monitoring the market on a weekly basis on a Borough level and a BHR basis on a monthly level to monitor vacancies, voids and risk of closure.

Redbridge: All homecare providers have accepted COVID positive - and have already used local bubble approach to care to minimise potential infection. These plans need to be revisited to assess longer term capcity to operate over an extended period should infection rates continue to rise. In terms of care home capacity discussion are underway with our key residential provider who has identified a wing of 11 beds specifically to accept covid positive and we are currently exploring whether this home culd become dual registered for nursing. This wing is also geared up and able to accept patients with dementia.

Mental wellbeing for home residents Space for family visits to care many small homes do not have space to enable social distanced visits between care home LB care provider groups A Pardoe Matthews J Green L Hider-Davies home residents residents and their families. Any changes will be subject to LBs receiving additional care home funds in order to be able to support homes to make adjustments

195 Enable information flow to best support Access to digital platforms All care providers have been contacted to register with nhs.net. This is being followed up at a BHR Care provider forum - in place resident care and well being Borough level to ensure 100% coverage. from September 2020

STP bid submitted for team to increase digital usage across the care provider sector STP Care home Forum

Training Agreed sessional access for Care Homes to SFH education support T Smith/ B Moss

Older people Reduce admission and risk of Acute frailty model - KGH Beech Frailty Hub at KGH - Reduced attendances and admissions for people 75 and over. Ambulance and community K Boettcher/ P Thorp C White deconditioning/ infection control Support improve patient flow. Ambulance pathway agreed for crews to call unit prior to pathways (UTCB sub-gp) T Fowler conveyance - aim is also to pick up appropriate patients who would otherwise have gone to Queens Acute frailty - community Victoria frailty Unit; Create community hub to move to a preventative model of practice. Older Peoples Transformation Board K Boettcher/ P Thorp C White development Keep people ‘living well’ in the community. In development and target for November T Fowler opening.

Address loneliness and isolation Orange Line serves for those frail, lonely and isolated and work to support navigate and try to DIWG T Smith avoid their dependence on acute services - could be a social prescription outcome?

Mental Health Understand and prepare for post COVID Community crisis response NELFT to confirm current provision and any variation for winter S Mlambo W Maskala demand and winter Home Treatment Team (HTT) The need to provide a family therapy element to the HTT offer to deal with patients for Proposed Measures: 1x staff grade (9am to S Mlambo W Maskala whom relationships are a key element (two different options costings being considered: with Domestic abuse, 5pm mon-fri) 1 x family 1 or 2 doctors) Bereavement issues therapist (9am to 5pm Service would operate 9am-5pm Monday to Friday mon-fri). Total weekly Astrid to look back at the cost: £5,465 team activity to evidence Total for 5 months need for family therapist. £118,408 Have seen increases in divorce -

ACAT Detail to be added Proposed Measure: 1 x band 6 (7am to 3pm S Mlambo W Maskala Impact on breaches mon-sun) 2 x band 6 (1pm to 9pm mon-sun) (baseline - to be confirmed) Total weekly cost: Response time from referral £6,696 Total for 5 to ACAT - dealt with months £145,080 MH Transformation Board - feedback ED Diversion/ Liaison Proposal to establish a HUB in Goodmayes to receive walk in, ambulance and police transfers expected from meeting on 19/8/20 Impact on frequent 1 x band 7 (9am to 5pm, S Mlambo W Maskala with MH crisis (patients 18+) with no physical health presentation. This would act as a attenders/ High Intensity mon-fri) 2 x band 6 per diversion from A+E and walk-facility (crisis), safely staffed. Also allows for reduction of users (HIUs). Percentage of shift (early, late & night ambulance conveyance to and waits for S136 in ED. diversions (how many would mon-sun) 1x band 3 per Service would operate 7 days - 9-5pm (additional hours to be confirmed) have gone to ED or other shift (early, late & night areas) mon-sun) Total weekly Alternative to S136 cost: £22,829 Total for 5 months £495K

ED response Crisis funding received for core 24 in psychiatric liaison on both sites. Proposed Measure: Funded through S Mlambo W Maskala Full service to be in place on both sites by December 2020 but recruitment has commenced Impact on breaches transformation funding and service capacity will build over the next 2 months. Capacity and response times to be Response times confirmed. Bed capacity Additional 18 beds have been commissioned in Picasso Ward and these are in place. Reduction in ECRs S Mlambo W Maskala Direct agreement between NELFT and ELFT to utilise additional capacity in ELFT beds. Alternatives to ED conveyance MH ACP in place from September Proposed Measure: S Mlambo W Maskala Existing S136 Impact on breaches

CAMHS MH Assessments Additional behaviour based investment to cover non MH assessments and supported BHRUT / NELFT / CCG meet revising Rolling audit on existing and Part of revised MHIS/ D Tanner Melody Williams Claire Dibsdall Claire Alp Clare Brutton Suggestion but TBC discharges crisis pathway via audit and revised CAMHS ED crisis Transformation funding collaborative system solutions pathways to reduce IP bed usage and facilitate community discharge

CAMHS beds From 1/10/20 tier 4 bed management across NL and NEL moves to a provider collaborative LDA Partnership Board Out of area placements seeking to maximise local use for local population and to reinvest in community provision to Delays in hospital prevent escalation. Intention is to minimise out of London placements in NEL

CAMHS crisis response Additional investment in behaviour based crisis support. LDA Partnership Board Requirement to increase crisis support to 24/7 by March 2022.

Learning disabilities Ensure all patients with an outstanding Develop guidance and AHC Project Plan is in place for BHR, supported by the LDA clinical lead and primary care. AHC Project Group/LDA Number and % of AHCs R Penney K Sole A Kinsella C Brutton T Smith learning disability health check receives communication to support GPs Guidance has been developed with NHSE and a comms plan is in place to support its launch Transformation Board delivered one, particularly those with Covid-19 with implemented a blended SFH have a LD group special interest for any of those living with LD diagnosis and EOL needs risk factors (virtual/face to face) health check

Host Annual Health Check Two webinars are planned to support GPs to implement new guidance AHC Project Group/LDA Number and % of AHCs R Penney K Sole A Kinsella C Brutton webinars Transformation Board delivered Increase uptake of flu vaccinations Develop additional support offer LD Pharmacist will support with vaccinations at home and providing reasonable adjustments AHC Project Group Number of flu vaccinations R Penney K Sole A Kinsella C Brutton from LD pharmacist Can SFH offer OPC to aid the FLU vaccination programme? We are looking at delivering our in delivered own in conjunction with BHRUT OH so have an on site clinic set up

Circulate easy read flu vaccination Offer to be shared with patients AHC Project Group Number of flu vaccinations R Penney K Sole A Kinsella C Brutton guidance with AHC invites delivered

Minimise admissions into MH acute Continue to implement enhanced New risk thresholds and increased case monitoring were introduced at the start of the NEL Adult LDA Steering Group/NEL Adults and CYP net inpatient R Penney K Sole A Kinsella C Brutton services case monitoring and adults and pandemic; these will continue to ensure people are receiving early intervention CYP LDA Steering Group numbers for LDA CYP

Increase numbers of C(E)TRs Toolkit has been developed, training to launch alongside this to support teams in CAMHS and NEL Adult LDA Steering Group/NEL Number of community R Penney K Sole A Kinsella C Brutton delivered through community social care working with LDA cases. CYP LDA Steering Group C(E)TRs delivered webinar training

196 Promote PBS training offer to Level 1, Level 2, PBS trauma and 121 support sessions will continue to be promoted across NEL Adult LDA Steering Group/NEL PBS training take up and % R Penney K Sole A Kinsella C Brutton support services and families BHR to support management of behaviours that challenge in the community CYP LDA Steering Group pass rate

Implement learning from LeDeR and Implement LeDeR Annual Report Annual Report agreed by SMT in June 2020; a shared learning event will take place with NEL LAC Group/LDA Transformation R Penney K Sole A Kinsella C Brutton rapid reviews recommendations NELFT/ELFT and an action plan produced. This will also include the learning from the Covid- Board 19 rapid reviews, which captured learning from deaths of people with learning disabilities from Covid-19

Clear LeDeR backlog by December Business case to be developed to clear outstanding reviews; the majority of these are cases NEL LAC Group/LDA Transformation LeDeR case backlog Business case currently R Penney K Sole A Kinsella C Brutton 2020 related to Covid-19 Board under development

Paediatrics Understand urgent care demand and Education and support for parents A booklet was developed in 2019 across primary care secondary care. PDF to be widely K Boettcher/ implement plans to manage care in the carers in management of shared and proposal to send the link to all parents via primary care. Also looking to see how M Hoskins most appropriate setting childhood illnesses this can be shared through schools.

Link to SFH and work in schools around bereavement, safeguarding etc

Support to primary care to Paediatric advice line is in place (9am-5pm). This is a virtual service and the details will be manage patients publicised to GPs. UEC TB and CYP TB Hot clinic attendances

Primary care acess to phlebotomy Booking of bloods - currently a telephone service but proposal to move to online. Timescale services to be confirmed.

UTC response Referral access to CCNT do be defined so that patients can be directed to the most D Tanner/ N Abbotts M Williams S Edwards R South C Bush S Elliott appropriate service. PELC/ NELFT to consider paediatric staffing over the winter across all K Boettcher sites. Staffing and coverage of UTCs to be added for all 4 sites

Acute response A permanent Paediatric Assessment Unit (PAU) is planned to open in November which will support in managing the appropriate attendances (BHRUT) 'PELC will continue to see Paeds on each site and refer to Paeds ED as required. In the absence of a paediatric inpatient ward at KGH, patients will be assessed, stabilised and transferred to Queen's as required. Consultant and junior medical support to KGH CED in place A Paediatric Assessment Unit (PAU) is planned to open on the Queen's site for this winter, which will support Children's ED's on both sites in managing the appropriate attendances. Tropical Lagoon children's ward remains fully operational on the Queen's site

EOL Avoiding hospital admission for EOL Admission agreement to hospice/ Requires further work Separate discussion to be arranged K Boettcher K Peters C White T Smith NH/ community beds in September 2020

Support people to die in their preferred Increase number and access to Target NELFT to increase number of staff registered to use CMC; continue to promote to Ambulance and community T Reeve J Odunoye Annette Kinsella / M Fowler T Smith place of care CMC plans primary care; encourage staff to check for CMC - flag for ACP on systems pathways (UTCB sub-gp) Sophie Webster

For a repeat of the EOL palliative support offered by SFH medic phoning care homes each week to support/advice on any known patients. Care homes found that really beneficial esp. as the EOL facilitators who they might usually have turned to were redeployed away from their usual supporting role in care homes and primary care. Suggest for the winter plan/2nd wave – that this should be funded i.e.: 1-2 session per week delivered by phone/call by SFH medical team as a response to winter and or 2nd wave for duration of winter and/or second wave.

Also a focused support for palliative care / EOL planning for those with dementia both in home and care homes – this feels like a gap and was a population where the steering group feels have been impacted greater esp. with social distancing and reduced visiting by family at care home and also individual homes

Digital road map Detail to be added L Sheldrake

Homelessness Provide primary care service offer Confirm capacity and locations To be confirmed J Cory

Provide LB offer Confirm offer and discharge flow To be confirmed S Martin D Alexander S Knoerr chart by LB D Alexander T Smith/ SFH have a grant to work with issue of homelessness and access to EOLC - links to be made L Burrows

Communications BHR Communications Leads meeting M Hoskins Yvonne Lamothe F Laker Comprehensive public (next date 25 August ) communications & engagement NEL Heads of Communications plan to be delivered across BHR. meeting (fortnightly) This will cover flu, the national BHR flu steering group (CCG Head of 'Help us to Help You' winter plan Comms attends) and healthy living in winter. NELCA primary care comms meeting Children and young people (fortnightly) - flu focus M Hoskins Yvonne Lamothe F Laker signposting - engagement supported by CY P transformation board Flu - alongside public campaign, M Hoskins Yvonne Lamothe F Laker all partners to deliver local staff campaigns Ongoing COVID comms and M Hoskins A Pardoe Matthews Yvonne Lamothe L Hider-Davies engagement, coordinated across partners. LBs to lead on outbreak plans Ongoing engagement through M Hoskins Healthwatch, CVS and other VCS partners Increase population numbers who BHR-system to support the cascade of appropriate public myth-buster” comms developed for NEL joint comms M Hoskins have a documented (on CMC) ACP pan-London/NEL-wide public comms relating to end of life planning. discussion with their family and healthcare provider.

197 SFH comms link to ensure T Smith/ professionals and public J Knowler understand services and reach of the hospice

Estates Plans for COVID/ non COVID pathways Additional oxygen resilience undertaken at QH site. VIE no longer single point of failure and in event of second wave, including additional capacity available from extra oxygen stabbing connections. critical care Capital funding for additional Critical Care capacity of 15 Beds secured. Design currently in development.

All ward changes would be based on the data and daily sit reps which identify increasing number of cases and the mobilisation SOP would be implemented which includes training needs, fit testing requirements, workforce etc.

As per wave one the Trust will adopt yellow and blue critical care areas based on demand and will have the ability to flex up/down. Queen's ground floor will turn to blue to meet demand and then if required Sky A. King George Clover Ward will become blue to meet demand.

PPE Identify leads in each organisation and BHRUT - Significant demand planning and buffer stock collation has already been undertaken clear supply process with a sufficient stock level to provide coverage in an emergency for a period of one month. This is in addition to the daily stocks that we currently receive and anticipate continuing to receive. Regular fortnightly engagement is in place with NHSSC to ensure that continuity of supply continues to be in place. A new warehousing facility has been signed off at Bates in Harold Wood which will house the buffer stock.

Key Red Requires more work Yellow More COVID specific focus Blue Needs focus/ support Green Leads to be added

198 To: Meeting of the NHS Barking and Dagenham, Havering and Redbridge CCGs’ Governing Bodies (meeting in common)

From: Henry Black, Chief Finance Officer

Date: 24 September 2020

Subject: Finance Overview Report – August 2020 (Month 5)

Executive Summary

As reported to previous meetings, the NHS has a temporary set of financial management rules in place until the end of September 2020.

Existing financial arrangements for CCGs and Trusts will remain in place for August and September. This means that block payments and retrospective top-up of funding will continue, with revised financial arrangements for the second half of the year expected before October 2020.

In the meantime, the temporary finance regime requires all CCGs to break-even during this period and NHSE have been retrospectively allocating additional funds for legitimate expenditure over and above the level of funding provided. Examples of expenditure the CCG has recovered through the top-up process includes the increased primary care costs associated with the covid response and the hospital discharge programme, where the cost individuals’ packages of care post admission are being covered by the NHS irrespective of where the labiality would have previously fallen.

After the top-up allocation for Months 1 to 4 (£9.1m), at Month 5, the CCGs reported a year to date over spend of £3.6m against the five-month reporting period. The CCG has therefore requested an additional £3.6m extra funds to allow the year to date position to be reported as break-even. At the time of writing his report, the additional allocation had not yet been received.

The total top-up requested by the CCGs for Months 1 to 5, and the year to date covid spend both equal £12.7m. This means that the CCGs have achieved a break-even position once covid related expenditure is excluded.

An analysis of covid expenditure is provided within the report and in the main, it covers the costs of the hospital discharge pathway (CCG and local authority) of £10.4m and primary care of £1.7m.

The CCGs have received prescribing data for April to June. At Month 5 the CCGs have reported a year to date prescribing overspend of £1m with a forecast overspend of £1m. As there is limited data available it is likely that this position will change in future months.

In summary, the year to date pressure is currently the result of covid related expenditure that was not covered in the original CCG allocation set by NHSE.

Recommendations The governing bodies are asked to:

• Note the Month 5 reported position and drivers of the reported position.

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1.0 Purpose of Report

The purpose of this report is to brief the Finance Committee on the financial position as at the end of August 2020 (Month 5).

2.0 Background/Introduction

At Month 5 BHR CCGs undertook a full financial reporting cycle. Budgets have been allocated to the CCGs for the first six months of the financial year. All NHS payments are made via a block payment and Non-NHS contracts are reported in line with invoices and activity information received.

3.0 Month 5 Financial Position and Covid Spend

See table on next page for detail.

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FINANCIAL POSITION

Annual YTD Budget YTD Actual YTD Budget Variance BHR CCGs Month 5 £'000 £'000 £'000 £'000 BHRUT 183,069 152,548 156,219 (3,671) Barts Health NHS TRUST 57,630 48,025 48,025 (0) Homerton 4,842 4,035 4,035 0 Other Acute 63,124 52,612 50,449 2,164 Acute Commissioning Total 308,665 257,221 258,728 (1,507)

Mental Health 52,688 43,907 44,091 (184) Community 54,297 46,470 50,383 (3,913) Continuing Care 34,221 28,517 28,246 272 Primary Care & Prescribing 63,609 53,268 53,713 (445) Primary Care Co-Commissioning 56,144 46,787 46,787 0 Other Programme Services 20,685 17,269 15,112 2,157 Running Costs 7,481 6,234 6,234 (0) Total BHR CCGs Expenditure 597,791 499,673 503,293 (3,621)

20120/21 Allocation (597,791) (499,673) (499,673) 0

2020/21 Control Surplus / (Deficit) 0 0 (3,621) (3,621)

Top Up Requested 3,621

Adjusted Surplus / (Deficit) 0 Please note budgets have been set on a specific range of allocations that have been notified by NHSE. These cannot be changed, so variances are appearing between different categories of expenditure. This is especially the case with NHS providers where the variances above are a result of budget allocations rather than any performance related issue.

• Based on NHSE notified budgets, BHRUT is reporting an overspend of £3.7m. This is as a result of the notified block contract payment made to the Trust being different to the national budget setting process. However, this is offset by a corresponding underspend on other acute and programme services. There are zero variances reported against other Trusts where a block contract payment has been made.

• Mental Health shows a small year to date overspend. NELFT is being paid via the block contract regime. There are variances driven by cost and volume activity and relates to individual packages of care and PICU placements.

• Community Services is showing a year to date over spend of £3.9m. A portion of the retrospective top up budget was added to the Community Services budget (£7.6m). This offset the first four months of the covid costs associated with the hospital discharge pathway (HDP). As reported previously, local authorities have contributed to the pooled budget for the HDP but the total cost for months 1 to 5 is in excess of the pooled value by £4.9m. CCG costs in relation to this scheme are £5.4m.

• Primary Care Co-Commissioning is reporting a year to date breakeven position. Page | 3

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• Primary Care and Prescribing is reporting a year to date over spend of £0.4m, mainly as a result of an increase in prescribing price concessions.

• Other programme services are reporting a year to date underspend of £2m. This largely relates to the allocation of budgets as part of the NHSE process and offsets the overspend reported in acute.

• The overall position at Month 5 shows a year to date over spend of £3.62m. As outlined above this is driven by costs incurred for the covid response. The CCGs have reported the over spend to NHSE and it is expected that this value will form part of the retrospective reimbursement process.

COVID RESPONSE EXPENDITURE

• The current guidance requires CCGs to include covid related expenditure on their monthly NHSE returns and should only relate to the incremental cost over and above the usual cost base. They have been defined as costs incurred as a result of a national policy/directive or as a direct consequence of the covid response.

• NHSE provided information on BHR CCG’s covid expenditure is as follows:

Remote Hospital NHS 111 Management Discharge additional Bank Other Total Covid Costs - to 31 August 2020 of Patients Programme capacity Holidays Covid-19 Total £ £ £ £ £ £ NHS Barking and Dagenham 40,450 2,017,604 55,057 139,726 445,698 2,698,535 NHS Havering 69,600 4,807,028 66,054 169,814 364,473 5,476,969 NHS Redbridge 60,300 3,624,702 109,289 201,659 563,976 4,559,926 Grand Total 170,350 10,449,334 230,400 511,199 1,374,147 12,735,431

• The majority of covid related expenditure relates to the Hospital Discharge Programme (HDP) and Primary Care costs (which is split across the bank holiday, additional capacity and other category). Within the other category there is also expenditure with hospices relating to step down facilities.

• Hospital Discharge Programme (HDP). This relates to CCG and local authority commissioned new or extended care packages for patients discharged from hospital. Local authorities have been asked to pool existing funding already allocated for care and support packages from their social care budget.

• The table below shows the gross expenditure and the net Local Authority contribution to the Hospital Discharge Programme once the pooled value is taken into consideration.

Hospital Discharge Pathway - to 31 August 2020 B&D Havering Redbridge Total £ £ £ £

CCG spend 1,059,745 2,712,188 1,785,555 5,557,488 Local Authority spend 1,342,859 2,690,596 2,331,148 6,364,603 Total Gross Spend 2,402,604 5,402,784 4,116,702 11,922,090 Local Authority contribution to the Pooled Budget 385,000 595,756 492,000 1,472,756 Total Net Spend 2,017,604 4,807,028 3,624,702 10,449,334

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RISKS

• The CCGs face a varied set of financial risks during the Covid response period. Significant risks will be reflected in the Board Assurance Framework and reviewed further in the monthly finance report to the committee. a. Risk of Overspend

All overspend risks should be reviewed against the backdrop that all CCGs are expected to break-even each month, however the new financial arrangements allow the CCG to request a top-up of funding on a monthly basis should it incur expenditure over and above the allocated budget. The process is subject to review and if concerns with CCG requests are identified, these are challenged by NHSE b. CHC & Hospital Discharge Programme

CHC and hospital discharge arrangements costs have been volatile and a consistent pressure across the BHR system for a number of years. This remains the case and with the current system where the CCGs are financially responsible for all care package costs, the risk exposure is significant. This will become a greater risk post the top-up regime and particularly when the responsibility for care packages costs will need agreement between partners. c. Prescribing

• The CCG has only received three months of prescribing data. This has resulted in a reported overspend at Month 5, driven by price concessions. Therefore, a risk of activity increases and price inflation is very apparent. d. Covid Costs

• The CCGs are incurring costs relating to the Covid response and in particular for those extra services and commissioned capacity to support primary and social care. Whilst these financial pressures are currently being covered by the top-up from NHSE, there is a risk that significant financial decisions may continue to be required post this regime which without the necessary input from the CCG, may present a financial risk that will be difficult to manage. e. Investments

• The CCGs are currently unable to make planned investments so there may be a delay in the achievement of planned outcomes and possibly those related to mental health services, where the investment standard is still expected to be delivered.

• It should be noted that some of the original transformation aspirations have been delivered as part of the Covid response, for example virtual outpatient appointments. Transformation Boards will review how these operational changes could continue become more embedded in business as usual.

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Financial Summary

This report details spend incurred by the CCGs to Month 5 and Covid cost detail. Further detail will be given in future months once the guidance for Months 7 to 12 has been received.

4.0 Resources/Investments n/a

5.0 Equalities n/a

6.0 Risk n/a

7.0 Managing conflicts of interest n/a

Attachments: 1. Appendix 1 – CCG specific revenue position

Author: Ahmet Koray, Director of Finance Date: September 2020

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Appendix 1: CCG Specific Revenue Return

Barking and Dagenham CCG Annual YTD Budget YTD Actual YTD Budget Variance BARKING AND DAGENHAM CCG Month 5 £'000 £'000 £'000 £'000 BHRUT 50,796 42,330 45,193 (2,863) Barts Health NHS TRUST 12,767 10,640 10,640 0 Homerton 1,297 1,081 1,081 0 Other Acute 15,681 13,068 12,291 777 Acute Commissioning Total 80,542 67,118 69,205 (2,086) Mental Health 17,341 14,451 14,562 (111) Community 18,217 15,398 16,319 (920) Continuing Care 8,984 7,487 7,209 278 Primary Care & Prescribing 16,140 13,530 13,546 (16) Primary Care Co-Commissioning 16,808 14,007 14,007 0 Other Programme Services 8,052 6,710 4,786 1,925 Running Costs 2,031 1,693 1,692 0 Total BHR CCGs Expenditure 168,115 140,394 141,325 (932)

2020/21 Allocation (168,115) (140,394) (140,394) 0

2020/21 Control Surplus / (Deficit) 0 0 (932) (932)

Top Up Requested 932

Adjusted Surplus / (Deficit) 0

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Havering CCG Annual YTD Budget YTD Actual YTD Budget Variance HAVERING CCG Month 5 £'000 £'000 £'000 £'000 BHRUT 77,558 64,631 64,059 572 Barts Health NHS TRUST 6,990 5,825 5,825 (0) Homerton 833 694 695 (0) Other Acute 23,363 19,470 18,988 482 Acute Commissioning Total 108,744 90,620 89,566 1,055 Mental Health 16,915 14,096 14,961 (865) Community 20,048 17,289 19,504 (2,216) Continuing Care 12,638 10,531 10,477 54 Primary Care & Prescribing 24,105 20,158 20,264 (106) Primary Care Co-Commissioning 18,689 15,574 15,574 (0) Other Programme Services 6,310 5,259 4,637 622 Running Costs 2,550 2,125 2,125 (0) Total BHR CCGs Expenditure 210,000 175,653 177,108 (1,455)

2020/21 Allocation (210,000) (175,653) (175,653) 0

2020/21 Control Surplus / (Deficit) 0 0 (1,455) (1,455)

Top Up Requested 1,455

Adjusted Surplus / (Deficit) 0

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Redbridge CCG Annual YTD Budget YTD Actual YTD Budget Variance REDBRIDGE CCG Month 5 £'000 £'000 £'000 £'000 BHRUT 54,716 45,588 46,968 (1,380) Barts Health NHS TRUST 37,873 31,561 31,561 0 Homerton 2,711 2,259 2,260 (0) Other Acute 24,079 20,074 19,170 904 Acute Commissioning Total 119,378 99,482 99,957 (475) Mental Health 18,432 15,360 14,568 792 Community 16,033 13,783 14,560 (777) Continuing Care 12,599 10,499 10,560 (60) Primary Care & Prescribing 23,364 19,580 19,903 (323) Primary Care Co-Commissioning 20,646 17,205 17,205 0 Other Programme Services 6,323 5,300 5,689 (389) Running Costs 2,900 2,417 2,416 0 Total BHR CCGs Expenditure 219,676 183,626 184,860 (1,234)

2020/21 Allocation (219,676) (183,626) (183,626) 0

2020/21 Control Surplus / (Deficit) 0 0 (1,234) (1,234)

Top Up Requested 1,234

Adjusted Surplus / (Deficit) 0

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207 To: Meeting of the NHS Barking and Dagenham, Havering and Redbridge CCGs’ Governing Bodies (meeting in common)

From: Steve Rubery, Director of Commissioning and Performance

Date: 24 September 2020

Subject: Integrated Performance Report – Published M4 and M5 Position.

Executive Summary This report provides the Governing Bodies of Barking and Dagenham, Havering and Redbridge CCGs (BHR CCGs) with an integrated view of activity and performance. This covers planned care, unplanned care and mental health This report concerns the CCGs’ main providers, Barking, Havering and Redbridge University Hospitals NHS Trust (BHRUT) and North East London Foundation Trust (NELFT), with performance data for Accident and Emergency at Whipps Cross Hospital and benchmark activity comparisons. Key points this month include: 1 The block contract arrangements mandated by NHS England at the beginning of the COVID-19 pandemic will remain in place until the end of month 6 and arrangements for Q3 and Q4 have not yet been confirmed. 2 The continued change to reporting requirements means that CCGs still do not get costed activity data from Providers and as such detailed financial analysis of contracts cannot be undertaken as Secondary Uses Service (SUS) data has to be used for activity analysis and this cannot assign locally agreed prices. 3 The impact of the COVID-19 pandemic has led to a continued significant reduction in activity for all Points of Delivery (PODs) at all Providers when compared to 2019/20. This level of reduction is also seen in other North East London (NEL) providers. 4 COVID-19 has continued to adversely impact on performance against all Constitutional Standards, both acute and mental health.

Recommendations. The Governing Body in Common is recommended to: • review the report; • note the actions that are being taken; • seek any further assurances they require in respect of risks and their management.

1.0 Purpose of the Report 1.1 The purpose of this report is to inform the Governing Bodies of Barking and Dagenham, Havering and Redbridge CCGs on activity and Constitutional Standards performance relating to the CCGs’ main Providers – BHRUT and NELFT. Site data relating to Accident and Emergency performance at Whipps Cross is also included, noting that approximately 30% of Redbridge residents access

208

services on this site. It is not possible to extract site level data for any of the other Constitutional Standards for Barts Health hence these not also being covered in this report. 2.0 Background/Introduction 2.1 This is a report from the Director of Commissioning and Performance to inform the Governing Bodies of Barking and Dagenham, Havering and Redbridge CCGs on the contract activity and performance for acute, community and mental health contracts, and agree any actions required. 3.0 Report Content 3.1 As reported to the July meeting of the Joint Committee of BHR CCGs, contracts with NHS Providers were put in place at the beginning of the COVID-19 pandemic on a block basis under the instruction of NHSE/I, using nationally issued guidance to calculate the values. These arrangements will remain in place until the end of Month 6 (September) and arrangements for quarters 3 and 4 are yet to be confirmed. 3.2 The continued change to reporting requirements means that Providers are still not required to provide detailed contract monitoring files containing activity costed at locally agreed tariffs. As such the CCGs have continued to monitor activity which Providers upload to the Secondary Uses Service (SUS), but cannot accurately assign prices to this data so year on year comparisons of contract cost are not possible. Additionally, due to the mandated arrangements regarding Provider contracts, there is no contract plan to monitor activity/financial performance against. 3.3 The impact of the COVID-19 pandemic has led to a significant reduction in activity for all PODs for BHR CCGs when compared to 2019/20, ranging from 84% to 32% less activity:

3.4 Activity at BHRUT has fallen by similar levels and this level of reduction is also seen in other NEL Providers:

3.5 Independent Sector providers have seen material reductions in CCG commissioned activity due to the pandemic and the subsequent national arrangements for funding capacity to support elective recovery.

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3.6 COVID-19 has continued to have a significant adverse impact on performance against all Constitutional Standards. Whilst services are being re-started, it will take some time for headline performance against the Constitutional Standards to recover due to the backlogs that have inevitably accumulated. 3.7 BHRUT published performance against the 4-hour A&E standard in August 2020 was 73.8%, a significant deterioration from 82.3% in May 2020. Performance has been deteriorating month on month from May to August and this is largely driven by Queen’s Type 1 performance (which has fallen from 64.9% in May 2020 to 46.0% in August. 3.8 BHRUT have made significant changes to the Accident and Emergency recovery plan, re- launching this as a whole hospital improvement plan. This plan contains seven key workstreams – out of hospital; first 4, 12, 24 hours; 24-72 hours; Red to Green, discharge, step down, rehabilitation; workforce, rotas, wellbeing, accountability; hearts and minds; and information, digital transformation, technology and IT infrastructure. Each of these workstreams is sponsored by one of the Trust’s Executive Directors and the workstreams are overseen by a newly created 4-hour Access Board which meets weekly. 3.9 There continues to be a significant deterioration in performance against the 52 week wait standard with the number of patients waiting over 52 weeks increasing to 1245 in July 2020. The bulk of these patients continue to be in in the Pain specialty. 3.10 BHRUT’s Cancer and Diagnostics Performance continues to be significantly challenged in July 2020, however a revised recovery action plan has been put into place and performance has started to improve since the report to Joint Committee in July 2020. 3.11 There continues to be a weekly meeting between the Trust’s Planned Care Deputy Chief Operating Officer, the CCGs’ Clinical Lead for Planned Care and CCGs’ Director of Transformation and Delivery for Planned Care to oversee progress around elective, cancer and diagnostics recovery. 3.12 The IAPT Access standard continues not to be met by any of the BHR CCGs, with average performance across BHR at 2.78% for June 2020 against a planned trajectory of 5.25%. Unpublished July data shows a marginally improved performance at 3.69%, however the local trajectory also increases to 5.41%. Referrals into the service have been lower during the COVID- 19 pandemic which by default makes the target harder to achieve and the CCGs are working with NELFT to achieve an improvement to 5.5% by Quarter 4 2020/21. This is still lower than the national standard of 6.25% but represents an appropriately challenging target given the low start point. 3.13 The IAPT recovery rate standard was met in Barking and Dagenham and Havering CCGs and there has been improvement in Redbridge with unpublished data showing performance at 48.7% in July against the 50% standard. Aggregate performance across BHR is at 50.6% in the latest published data (June 2020) and 53.4% in July’s unpublished data. 3.14 All three CCGs underperformed the CAMHS access target against the estimated July plan. The overall numbers children and young people (CYP) entering treatment during July 2020 across BHR were 13% (60 CYP service users) down on the same period last year, and 28% (162) below estimated July 2020 plan. The impact of COVID-19 upon CYP performance is that there is a 39% (1315 service users) gap between year-to-date activity and plan at end July 2020. BHR CCGs are currently working with NELFT to agree a revised 2020/21 CYP Access plan for the NHSE/I Phase 3 operating plan submission on the 21st September 2020. 3.15 The CCGs and NELFT continue to work together to understand current (post-COVID) levels of demand for Mental Health services and to agree what needs to be put in place to meet this and recover the operating plan positions 4.0 Resources/investment 4.1 Contracts with all NHS providers are currently operating under a block arrangement as mandated by NHSE at the onset of the COVID-19 Pandemic. The detail of this is provided in the Finance Report.

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5.0 Equalities 5.1 Specific performance indicators address performance against the needs of those with Protected Characteristics (as defined by the Equalities Acts) and these are included in the report. 6.0 Risk 6.1 Risks and mitigations for each area are highlighted for each individual Provider under the relevant sections of the report; for each CCG individually; and at a BHR level. 7.0 Managing conflicts of interest 7.1 There are no conflicts of interest to note, related to this report.

Attachments: Integrated performance report

Author: Steve Rubery, Director of Commissioning & Performance Date: 16/09/2020

211 Integrated Performance Report – Published M4 and M5 Position

Governing Body in Common 24th September 2020

Produced by:212 POD Performance Team RTT, Diagnostics & Cancer July 2020 Performance

213 Activity Trends – Outpatient First and Follow-up Attendances

Outpatient Activity Trends BHRUT 40,000

35,000

30,000

25,000

20,000

15,000

10,000

5,000

0 April May June July August September October November December January February March April May June July 2019/20 2020/21 OPFA OPFU

Outpatient attendances dramatically reduced from the onset of the COVID-19 pandemic as BHRUT ceased all bar urgent activity for a period before moving to a new model of virtual clinics and triage. Attendances are now increasing again and BHRUT have submitted a trajectory to return to 90% of BAU activity levels by November 2020

214 Activity Trends – Outpatient Procedures, Elective and Daycase

Outpatient Procedure, Elective and Daycase Activity Trends BHRUT 4,500

4,000

3,500

3,000

2,500

2,000

1,500

1,000

500

0 April May June July August September October November December January February March April May June July 2019/20 2020/21

EL DC OPPROCFA OPPROCFU Surgical activity dramatically reduced from the onset of the COVID-19 pandemic as BHRUT ceased all bar urgent activity. Activity has now re-started and BHRUT have submitted a trajectory to return to 90% of BAU activity levels by October 2020

215 Activity Trends – Referrals

BHR CCGs Total Referrals Trends BHRUT 50000 45000 40000 35000 30000 25000 20000 15000 10000 5000 0 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul 2019/20 2020/21

PTL Referrals SUS

Referral levels have started to recover from the significant decrease seen during the COVID peak although are still only around 70% of pre-COVID levels

216 RTT

BHRUT failed to achieve its RTT trajectory in July-20 by 32.61% which represents continuing under performance at the Trust.

RTT Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Apr-20 May-20 Jun-20 Jul-20 RTT (%) - Trajectory 82.10% 82.30% 82.80% 83.40% 84.06% 84.61% 85.13% 85.80% 86.30% 86.94% 87.51% 88.11% 75.71% 76.06% 76.48% 76.91% RTT (%) - Actual 82.11% 82.67% 80.59% 78.86% 77.88% 76.38% 76.07% 77.16% 75.70% 75.63% 75.89% 72.90% 64.66% 56.92% 48.33% 44.30% Variance 0.01% 0.37% -2.21% -4.54% -6.18% -8.23% -9.06% -8.64% -10.60% -11.31% -11.63% -15.22% -11.05% -19.15% -28.14% -32.61% RTT Target 92% 92% 92% 92% 92% 92% 92% 92% 92% 92% 92% 92% 92% 92% 92% 92% • There was a deterioration in RTT performance by (4.03%) when compared to the previous month. • As at 30th August 2020, unvalidated data flows highlights a slight improvement in performance (50.0%) as Trust implements Covid-19 recovery initiatives. However, this remains significantly lower 217 than Trajectory. (Source: NHSE Published RTT Performance) RTT- PTL

BHRUT has exceeded the RTT PTL trajectory of 36,990 in Jun-20 by 8,519 pathways.

BHRUT Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Apr-20 May-20 Jun-20 Jul-20 PTL published (Actual) 39,575 40,494 42,206 42,551 42,564 41,334 41,023 41,392 41,392 40,358 40,837 40,827 40,447 41,614 42,792 45,509 PTL Trajectory (Plan) 38,989 38,596 38,247 37,360 36,854 36,551 36,023 35,644 35,290 34,937 34,603 34,153 37,857 37,600 37,302 36,990 Plan vs Actual (Var) 586 1,898 3,959 5,191 5,710 4,783 5,000 5,748 6,102 5,421 6,234 6,674 2,590 4,014 5,490 8,519

• BHRUT continues to triage all referrals and focus on Clinical Prioritisation of the P2 lists. • BHRUT working through the requirements of the NHSE/I Covid Phase-3 recovery letter to return to 80% of last year’s activity in Sept-20 for both overnight electives and for outpatient/ daycase procedures, rising to 90% in October. Also return to 100% of last year’s activity for first outpatient attendances and follow-ups by Sept-20 • Unvalidated data flows as of 30th August 2020 indicates the PTL further increasing to 49,070 and backlog

position decreasing to 24,554 Pathways. 218

(Source: NHSE Published RTT Performance) RTT- 38+ Weeks

38+ Wks Performance Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Apr-20 May-20 Jun-20 Jul-20 No. of Pts waiting 38+ Wks 791 747 760 689 747 701 820 909 1254 1278 1321 1622 2,301 3,235 4,229 5,496 Total PTL Size 39,575 40,494 42,206 42,551 42,564 41,334 41,023 41,392 41,392 40,358 40,837 40,827 40,447 41,614 42,792 45,509 % waiting 38+ Wks 2.00% 1.84% 1.80% 1.62% 1.76% 1.70% 2.00% 2.20% 3.03% 3.17% 3.23% 3.97% 5.69% 7.77% 9.88% 12.08%

• BHRUT’s 38+ week position has been growing since the start of the 2018/19 Financial year with acceleration observed from April-20 onwards. • The 38+ week position further deteriorated in Jul-20 with an increase of 1,267 pathways to 5,496 when compared to the previous few months. The added pressure from Covid-19 has posed a significant risk to the sustained delivery of a zero 52week wait position. • Unvalidated data flows from the Trust provides the 40+wks PTL Position. As at 30th August 2020, 219 the 40+ weeks PTL is 5,765. (Source: NHSE Published RTT Performance) RTT – 52+ Weeks

• Published Jul-20 data indicates BHRUT had (1,245) 52+ week waiters spread across a number of specialties: General Surgery (130), Urology (125), T&O (143), ENT (101), Ophthalmology (19), Neurosurgery (90), General Medicine (1), Cardiology (5), Dermatology (5), Thoracic Medicine (3), Neurology (17), Rheumatology (9), Gynaecology (112) and Other (485). • Pain Management specialty remains challenged and contributes a significant proportion of the overall 52+ week waiters at the Trust, included in the ‘Other’ category above. • The impact of Covid-19 meant the Trust failed to achieve the 52WW recovery trajectory agreed for Jul-20. • Bi-Weekly meetings between the Trust and the CCG to monitor progress against the Covid-19 elective recovery plan continues and BHRUT also join the NEL STP Elective recovery meetings. • BHR CCGs continue to receive detailed weekly reporting and a copy of the pseudonomised PTL for all patients waiting over 40 weeks which allows tracking at patient/specialty level. • As of 30th August 2020, unvalidated data flow shows the Trusts 52+WW PTL has increased to 1,539 with majority of the waits being attributed to Pain Management (15.5% of Total 52+WW PTL). • Phase- 3 RTT 52+ Weeks Plan submitted by BHRUT to NHSE/I is to achieve 736 52+WW in Mar-21.

RTT Sept-20 Oct-20 Nov-20 Dec-20 Jan-21 Feb-21 Mar-21 The total number of incomplete RTT pathways at the end of the RTT Waiting List E.B.3a 49000 49500 50000 49500 49250 48750 48250 month The number of incomplete RTT pathways (patients waiting to Number of 52+ Week RTT waits E.B.18 start treatment) of 52 weeks or more at the end of the reporting 1430 1193 1019 1041 956 816 736 period

220 (Source: NHSE Published RTT Performance) Diagnostics

BHRUT failed to achieve the DM01 standard > 99.0% for July-20 with a performance of 66.60% although a improvement noted from previous couple of months with recovery steps taking place from initial Covid-19 phase. The impact of Covid-19 has resulted in rapid deterioration in performance with increased 6+Week waiters.

Month Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Apr-20 May-20 Jun-20 Jul-20 Diagnostics Performance (Actual) 89.37% 89.96% 93.35% 93.19% 92.99% 98.38% 99.20% 99.34% 98.84% 99.05% 99.11% 92.49% 62.93% 38.84% 51.64% 66.60% Diagnostics Performance (Trajectory) 91.90% 93.50% 95.10% 96.80% 98.50% 99.10% 99.80% 99.80% 99.80% 99.80% 99.80% 99.80% 99.00% 99.00% 99.00% 99.00% Diagnostics Actual vs Plan (Variance) -2.53% -3.54% -1.75% -3.61% -5.51% -0.72% -0.60% -0.46% -0.96% -0.75% -0.69% -7.31% -36.07% -60.16% -47.36% -32.40% • There were no compliant modalities in Jul-20 attributed to the impact of Covid-19. • As of 30th August, unvalidated data flows from the Trust indicates a slight improvement in performance to 70.37% with 6+ Week Waiters backlog slightly improving, currently at 2,801. • An additional CT scanner still running at KGH site and some of the urgent CT/MRI cases sent to the

independent sector. 221

(Source: NHSE Published Diagnostics Performance) Cancer – 2 Week Wait

BHRUT failed to achieve the Cancer 2WW Standard in Jul-20 with performance of 62.65% against the 93% standard and trajectory. The Trust has now been non-compliant for four consecutive months.

Cancer Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Apr-20 May-20 Jun-20 Jul-20 2WW Performance (Actual) 92.60% 88.36% 84.64% 80.45% 91.50% 83.31% 86.17% 86.30% 90.16% 90.70% 98.12% 98.67% 58.77% 67.66% 54.51% 62.65% 2WW (Trajectory) 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 2WWTarget 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 2WW variance from Trajectory -0.4% -4.6% -8.4% -12.6% -1.5% -9.7% -6.8% -6.7% -2.8% -2.3% 5.1% 5.7% -34.2% -25.3% -38.5% -30.3%

• The Trust’s recovery trajectory indicated sustained compliance against the standard across 2020/21. • Some signs of recovery is being observed, Jul-20 saw an improvement with the Trust still reeling in from the rapid deterioration due to Covid-19 impact with the Trusts 2WW Cancer Performance222 remaining significantly below the 93% Target. Cancer – 62 Day

BHRUT failed to achieve the 62 Day standard in Jul-20 with performance of 60.59% against the 85% target. However is showing signs of recovery compared to Q1 downs.

Cancer Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Apr-20 May-20 Jun-20 Jul-20 62 Day Performance (Actual) 86.36% 76.21% 85.65% 84.06% 84.60% 84.32% 75.95% 70.33% 76.54% 70.36% 75.47% 70.89% 56.69% 40.94% 44.97% 60.59% 62 Day (Trajectory) 85.7% 85.7% 85.7% 85.7% 85.7% 85.7% 85.7% 85.7% 85.0% 85.0% 85.7% 85.7% 85.0% 85.0% 85.0% 85.0% 62 Day Target 85% 85% 85% 85% 85% 85% 85% 85% 85% 85% 85% 85% 85% 85% 85% 85% 62 Day variance from Trajectory 0.7% -9.4% 0.0% -1.6% -1.1% -1.3% -9.7% -15.3% -8.5% -14.6% -10.2% -14.8% -28.3% -44.1% -40.0% -24.4% • The Trust’s recovery trajectory anticipated delivery of the standard from March 2020. • However due to the impact of Covid-19, the Trust performance has deteriorated significantly. • The Trust has worked up a new Cancer Recovery Action Plan (RAP) which is due internal sign off

and will be shared with commissioners. 223 Cancer – PTL

BHRUT saw a significant increase in the 62 Day and 104+ Day PTL’s between April and May-20. The 62 Day PTL’s has seen a reduction from Jun-20 onwards.

Trust Data Anomaly noted

• The Trust’s 62 Day PTL position is well above the sustainable backlog estimates and London Average. • This increase in the PTL in April and May was attributed to the impact of Covid-19 • Unvalidated data flow from the Trust as of 30th August 2020 indicates a rapid increase in Cancer PTL

from the previous week. 224 No Update Available Cancer – FDS (28 Day)

BHRUT is currently achieving lower than required for the FDS 28-day standard. In January-20, % of data completeness was 53.83% against the proposed initial threshold of 75.0% which every Trust is to delivery on from 1st April 2020.

NEL Providers Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 BHRUT Total Patients 1,292 1,924 2,105 2,435 2,216 2,096 2,509 2,288 2,088 2,368 BHRUT (Breaches) 415 729 880 1,217 1,042 859 1,107 1,003 892 1,046 BHRUT Performance 67.88% 62.11% 58.19% 50.02% 52.98% 59.02% 55.88% 56.16% 57.28% 55.83%

FDS Target (from Apr-20 >) 75.0% 75.0% 75.0% 75.0% 75.0% 75.0% 75.0% 75.0% 75.0% 75.0% • FDS Performance was monitored in shadow format across 2019/20. 225 • There has not been any published performance for the months of February and March 2020. Accident & Emergency August 2020 Performance

Produced by:226 POD Performance Team Activity Trends – A&E Attendances

A&E Trends BHRUT 18,000 16,000 14,000 12,000 10,000 8,000 6,000 4,000 2,000 0 April May June July August September October November December January February March April May June July 2019/20 2020/21

Total

A&E attendances decreased significantly at the onset of the COVID-19 pandemic and have only started to recover in June, but are still below pre-COVID levels

227 Activity Trends – Non-Elective Admissions

Emergency Admission Trends BHRUT 5,000 4,500 4,000 3,500 3,000 2,500 2,000 1,500 1,000 500 0 April May June July August September October November December January February March April May June July 2019/20 2020/21

Total

Non-elective admissions fell significantly following the onset of the COVID-19 pandemic but recovered to more normal levels by June

228 4 Hour Performance

• A local trajectory for the 4 hour target was agreed for 2020/21 but this has been impacted by the Covid-19 challenges in the Trust. • The local trajectory has not been met in any month since August 2018 albeit the two months (May-20 and Jun-20). Trust performance has shown an improving position since Dec-19. This is due to reduced activity seen at the Trust over the Covid-19 period. Performance has however deteriorated from May-20 onwards as activity levels at both Trust sites gradually increased. • ED performance is affected by both admitted and non-admitted pathways. The admitted pathway performance is most significantly affected by bed availability. • The factors significantly affecting performance are: staffing – both volume and specialty response in ED; beds (hospital flow); profile and volume of both ambulance and walk in patients. 229 (Source: NHSE Published A&E Performance) 4 hour performance - Queens

Avg. Attendances = Sum of Total Attendances in Month / No. of days in Month

• Type 1 activity is ED , Type 2 is Eye casualty and Type 3 is the Urgent Treatment Centre (UTC). • The chart shows a drop in activity in March and April due to the impact of Covid-19. This has since been increasing from May-20 with services gradually resuming back to normal. • The chart shows improvement in Type 1 and All Types performance due to reduced activity between March and May attributed to the Covid-19 impact. However, Performance for the last three consecutive months has since deteriorated. • ED Performance at the Trust remains somewhat lower than other Trusts across London when benchmarked.

230 BHRUT Queen’s Avg. A&E attendances per day vs 4-Hour Performance (Source: A&E Daily) 4 hour performance – King George

Avg. Attendances = Sum of Total Attendances in Month / No. of days in Month • The chart above shows that type 3 activity, in the urgent care centre (UCC) provided by PELC, had significantly reduced due to the impact of Covid-19. With gradual increase noted from May-20 onwards with services gradually resuming back to normal. • Type 1 performance has been better and more consistent on the KGH site than at Queens. The variation is due to the difference in ambulance conveyances and complexity. August-20 has seen a deterioration in performance for both Type 1 and All Types. • Minor injuries are managed in ED at KGH, which contributes to a better type 1 performance as all patients are seen in 4 hours. Minor injury patients are seen in the UTC at Queens. 231 BHRUT King George Avg. A&E attendances per day vs 4-Hour Performance (Source: A&E Daily) Ambulance Conveyances - BHRUT

Caveat: Due to data anomaly recorded on SMART for EoE on 14/01/2020, the figure has been averaged to show a more realistic value as a sum for Jan-20 • LAS Conveyances to the Queens site have been lower than the same period last year. The impact of Covid-19 has seen a significant decrease in Ambulance Conveyances (LAS & EoE) to the Queens site between March and April 2020 with a increase being observed from May-20. QH has recorded its second highest number of EoE conveyances in August-20 with July-20 holding the highest recorded to date.

• LAS Conveyances to the KGH site have been lower than the same period last year. The impact of Covid-19 has seen a significant decrease in Ambulance Conveyances (LAS & EoE) to the KGH site between March and April 2020 with increases being observed from May-20. 232 BHRUT Ambulance conveyances by site (Source: HAS Portal (LAS), SMART Portal (EoE)) 4 hour performance – Whipps Cross

Avg. Attendances = Sum of Total Attendances in Month / No. of days in Month

• Whipps Cross are also not meeting their locally agreed trajectory. Deterioration continued for the second consecutive month in WX’s Type 1 and All Types performance in August-20 which can be attributed to a increase in activity as services gradually resume back to normal from Covid-19 affects.

• Minor injury activity is included in their type 1 performance which does improve this.

233 Barts Whipps Cross Avg. A&E attendances per day vs 4-Hour Performance (Source: A&E Daily) Total average attendances - all types BHRUT and PELC

Avg. Attendances = Sum of Total Attendances in Month / No. of days in Month Avg. Seen within 4hrs = Sum of Total No. of pts seen within 4hrs in Month / No. of days in Month

• The chart above suggests that there has been an increase in attendances from August 2019 onwards. • The increase has been in the UTCs rather than ED. Significant drop in attendances observed in March and April 2020 due to Covid-19 impact. However, a steady increase can be seen from May 2020 onwards with services gradually returning to some degree of normality. August-20 seen some reduced Activity. • Some patients are counted both in ED and the UTC which in result inflates the attendances figures.

234 (Source: A&E Daily) ED Breach reasons – (Admitted + Non-Admitted) Top breach reason for both Queens and KGH sites and Trust as whole is Clinical breach reasons, Bed Management and the wait for first clinician (not triage). Clinical breaches are related to patients who require treatment and/or await investigation results who cannot be moved to observation ward either due to capacity issues (including single sex accommodation on KGH site) or they do not meet the clinical criteria.

Based on latest Intelligence th th *Prev. 4 Weeks represents 16 August 2020 to 6 September 2020 235

(Source: Trust weekly Breaches Report) Hospital flow

Hospital Flow – Queen’s Hospital

• This chart shows 4 hour performance at Queens against stranded patients.

• The no. of Stranded patients has seen a increasing trend from April onwards for both 7 and 21 days.

• Type 1 performance has seen a declining trend in 4hr Performance with the Time to Treatment % also slightly declining.

Hospital Flow – King George Hospital

• 4 hour performance at KGH has remained steady with a marked reduction in 21 days stranded patients.

• The number of patients waiting >21days has been decreasing in recent weeks.

236

Data Source: NHSE UEC Dashboard (Chris Green) Mental Health July 2020 Performance

Produced by:

POD Performance Team 237 Constitutional Performance – Mental Health

Improving Access to Psychological Therapies (IAPT)

Published data Local data

IAPT Access rate (Rolling 3 mths) Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Apr-20 May-20 Jun-20 Jul-20

Barking and Dagenham 3.82% 3.77% 3.77% 4.16% 4.16% 3.99% 3.80% 3.94% 4.21% 4.41% 4.75% 4.51% 3.53% 2.79% 2.82% 3.83% Havering 4.00% 4.00% 4.10% 4.48% 4.58% 4.60% 4.52% 4.52% 4.34% 4.36% 4.10% 4.32% 3.41% 3.02% 2.96% 3.93% Redbridge 3.59% 3.76% 4.12% 4.38% 4.45% 4.47% 4.66% 4.64% 3.95% 3.73% 3.73% 3.92% 3.02% 2.47% 2.61% 3.38% BHR 3.79% 3.84% 4.02% 4.35% 4.42% 4.38% 4.37% 4.41% 4.15% 4.13% 4.13% 4.21% 3.29% 2.74% 2.78% 3.69% Operating plan target 4.75% 4.75% 4.75% 4.75% 4.75% 4.75% 4.75% 4.75% 4.75% 5.50% 5.50% 5.50% 5.25% 5.25% 5.25% 5.41%

IAPT Nos entering treatment (each Published data local data month) Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Apr-20 May-20 Jun-20 Jul-20 Barking and Dagenham 225 260 285 305 260 250 265 290 305 305 360 255 105 210 260 313 Havering 305 345 360 400 370 365 380 370 320 385 305 375 160 210 360 398 Redbridge 365 370 465 440 390 470 495 385 270 430 385 325 170 225 365 395 BHR CCGs (Total) 895 975 1110 1145 1020 1085 1140 1045 895 1120 1050 955 435 645 982 1106

Published data Local data

IAPT Recovery rate (Rolling 3 mths data) Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Apr-20 May-20 Jun-20 Jul-20

Barking and Dagenham 48.1% 51.7% 47.1% 52.3% 55.1% 58.2% 58.2% 52.5% 52.6% 51.9% 53.2% 54.3% 51.1% 52.3% 50.8% 54.1% Havering 56.6% 56.7% 56.7% 53.6% 54.2% 53.8% 51.9% 49.5% 47.2% 48.8% 49.6% 49.6% 48.1% 51.0% 54.9% 57.7% Redbridge 51.7% 51.4% 50.0% 48.9% 48.7% 49.2% 51.2% 50.0% 47.5% 45.6% 45.9% 50.7% 48.6% 48.1% 46.3% 48.7% BHR CCGs (Total) 52.7% 53.5% 51.7% 51.5% 52.4% 53.1% 53.2% 50.5% 48.6% 48.1% 48.8% 51.2% 49.0% 50.4% 50.6% 53.4% Operating plan target 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50%

IAPT: Local management data for end of July 2020 (latest data) reported that: • IAPT Access Rate: Across BHR, approximately 1106 service users entered treatment during July. The numbers entering treatment have shown a continued monthly improvement (top graph) since the reduction in activity in March-April due to covid. Activity is now broadly in line with the levels reported this time last year, as well as closed the gap against plan. The impact of covid upon IAPT performance is best demonstrated by looking at ytd figures for Apr-Jul20 (middle graph). This shows a 39%(2044 service user) gap between ytd activity and plan at end July. BHR CCGs are currently working with local providers to explore revised IAPT 2020/21 plan for the NHSE/I Phase 3 operating plan submission on the 21 September. 238 • Recovery Rate: Both B&D, and Havering achieved the 50% recovery rate operating plan target at the end of July. Constitutional Performance – Mental Health

Improving Access to Psychological Therapies (IAPT)

Published data local data IAPT Waiting Times: % patients waiting Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Apr-20 May-20 Jun-20 Jul-20 over 90 days bet 1st to 2nd appt Barking and Dagenham 23.1% 21.6% 14.8% 12.9% 11.1% 19.2% 16.1% 13.0% 21.1% 15.2% 17.1% 19.5% 30.0% 32.4% 20.0% 15.4% Havering 23.4% 29.7% 23.4% 30.4% 27.3% 23.5% 26.8% 22.6% 26.8% 35.6% 25.6% 38.9% 27.5% 13.0% 10.2% 4.1% Redbridge 72.7% 73.6% 60.0% 45.1% 42.1% 52.1% 48.5% 38.2% 41.4% 58.4% 50.0% 27.3% 16.0% 16.2% 15.3% 8.6% BHR CCGs (Total) 37.0% 45.7% 36.3% 32.0% 28.6% 35.2% 34.8% 28.5% 30.3% 42.6% 33.8% 28.0% 24.9% 19.2% 14.9% 9.2%

Published data local data IAPT Waiting Times: Total number Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Apr-20 May-20 Jun-20 Jul-20 waiting over 90 days bet 1st to 2nd appt Barking and Dagenham 45 40 20 20 15 25 25 15 20 25 30 40 75 55 40 33 Havering 55 55 55 70 45 40 55 60 55 80 50 70 95 35 25 9 Redbridge 120 195 150 115 80 125 160 130 60 225 140 75 40 30 45 25 BHR CCGs (Total) 220 290 225 205 140 190 240 205 135 330 220 185 210 120 110 67

IAPT: Local management data for end of July 2020 (latest data) reported that: • Waits between 1st to 2nd appt: This indicator looks at the percentage of service users who waited over 90 days between their first and second IAPT appointment. At the end of July 2020, 9.2% (67) service users across BHR waited over 90 days for a 2nd appointment; a 29%(27 service user) reduction on the previous month. The majority of these long waits are in B&D, and Redbridge.

239 Constitutional Performance – Mental Health

Children and Young People (CYP)

CYP Access data Indicative cumulative position: published data prevalence rate CCG Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Apr-20 May-20 Jun-20 Jul-20 Jul20 Target 2019/20

Barking & Dagenham 6331 5.4% 9.5% 11.7% 14.5% 16.3% 19.3% 21.9% 25.7% 29.1% 33.8% 39.0% 41.9% 3.3% 5.9% 8.0% 9.8% 18.6%

Havering CCG 4972 6.9% 12.4% 16.6% 19.8% 21.6% 24.4% 27.0% 30.8% 33.3% 36.2% 39.2% 42.0% 5.4% 10.1% 13.9% 17.7% 18.6%

Redbridge CCG 6926 3.7% 6.3% 8.7% 10.8% 12.8% 14.9% 17.5% 19.5% 21.2% 22.7% 24.5% 26.2% 2.8% 4.5% 6.6% 8.3% 18.6%

Q4 target 34% 34% 34% 34% 34% 34% 34% 34% 34% 34% 34% 34% 35% 35% 35% 35%

CYP Nos entering treatment (cumulative) Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Apr-20 May-20 Jun-20 Jul-20 Barking and Dagenham 340 600 740 915 1030 1225 1385 1630 1845 2255 2470 2650 210 375 505 620 Havering 345 615 825 985 1075 1215 1340 1530 1655 1805 1950 2090 270 500 690 880 Redbridge 255 435 605 750 885 1035 1210 1350 1465 1575 1695 1815 195 310 460 575 BHR CCGs (Total) 940 1650 2170 2650 2990 3475 3935 4510 4965 5635 6115 6555 675 1185 1655 2075

Children and Young People (CYP) Access: Local management information for end of July 2020 (latest data) reported that: • All three CCGs underperformed against estimated July plan. During the financial year to date, a total of 2075 CYP entering treatment across BHR. The majority (42%, 880 service users) were seen in Havering, with 30%(620) of BHR total were seen in Barking and Dagenham, and 28%(575) seen in Redbridge. • Overall numbers CYP entering treatment during July across BHR were 13%(60 CYP service users) down on the same period last year, and 28%(162) below estimated July 2020 plan (top graph). The impact of covid upon CYP performance is best demonstrated by looking at ytd figures for Apr-Jul20 (bottom graph). This shows a 39%(1315 service user) gap between ytd activity and plan at end July. BHR CCGs are currently working with local providers to explore revised 2020/21 CYP Access plan for the NHSE/I Phase 3 operating plan submission on the 21 September.

240 Constitutional Performance – Mental Health

Dementia

Dementia: Estimated diagnosis rate (patients aged 65 yrs +)

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

Barking & Dagenham 65.6% 69.3% 70.8% 70.7% 67.6% 67.8% 66.8% 66.5% 66.1% 65.5% 63.2% 62.2% 62.3% 62.2% Havering 64.5% 63.7% 63.2% 63.0% 61.9% 62.1% 61.5% 61.4% 61.1% 60.0% 57.2% 56.0% 55.8% 56.3% Redbridge 68.0% 68.4% 68.8% 69.3% 67.3% 68.1% 68.2% 68.2% 68.0% 69.4% 67.0% 64.4% 63.7% 63.6% NEL STP 69.3% 69.6% 69.6% 69.6% 67.6% 67.9% 67.4% 67.4% 67.4% 66.9% 64.0% 62.5% 62.2% 62.4% National standard 66.7% 66.7% 66.7% 66.7% 66.7% 66.7% 66.7% 66.7% 66.7% 66.7% 66.7% 66.7% 66.7% 66.7%

Distance from target Jul-20 position Organisation Prevalence Patients with Distance CCG Target Rate dementia from target Performance Barking & Dagenham 1186 737 54 62.2% 66.7% Havering 3408 1917 368 56.3% 66.7% Redbridge 2484 1579 75 63.6% 66.7% NEL STP 12991 8108 578 62.4% 66.7%

Dementia: Latest published NHS Digital data is for the end of July 2020. August data will be available on 24 September 2020. • All three BHR CCGs underperformed against the national standard. • B&D was 54 patients from target, Redbridge was 75 patients from target, and Havering was 368 patients from target. • Work is being undertaken with primary care services to explore how best to enable this population (aged 65 years and over) receive diagnosis and support.

241 Constitutional Performance – Mental Health Early Intervention Psychosis (EIP)

Early Intervention in Psychosis (EIP) Organisation KPI Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Apr-20 May-20 Jun-20 Jul-20 No. within 2 weeks 3 3 1 5 5 10 10 15 15 15 15 15 10 Barking and Total 3 3 1 5 5 10 10 20 15 20 15 15 15 Dagenham CCG % within 2 weeks 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 75.0% 100.0% 75.0% 100.0% 100.0% 66.7% No. within 2 weeks 2 3 6 15 15 10 10 15 10 15 15 20 20 Havering CCG Total 3 3 6 20 20 15 10 15 15 15 20 20 25 % within 2 weeks 66.7% 100.0% 100.0% 75.0% 75.0% 66.7% 100.0% 100.0% 66.7% 100.0% 75.0% 100.0% 80.0% No. within 2 weeks 5 3 3 10 10 10 10 10 10 10 10 15 15 Redbridge CCG Total 6 3 3 15 15 15 15 10 10 15 15 20 15 % within 2 weeks 83.3% 100.0% 100.0% 66.7% 66.7% 66.7% 66.7% 100.0% 100.0% 66.7% 66.7% 75.0% 100.0% No. within 2 weeks 10 9 10 30 30 30 30 40 35 40 40 50 45 BHR CCGs Total 12 9 10 40 40 40 35 45 40 50 50 55 55 % within 2 weeks 83.3% 100.0% 100.0% 75.0% 75.0% 75.0% 85.7% 88.9% 87.5% 80.0% 80.0% 90.9% 81.8% National standard 56% 56% 56% 56% 56% 56% 56% 56% 56% 56% 56% 56% 56%

Early Intervention in Psychosis (EIP): provider level Organisation KPI Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Apr-20 May-20 Jun-20 Jul-20 No. within 2 weeks 52 27 31 95 110 125 130 135 120 115 105 125 145 ELFT Total 67 34 37 115 135 150 155 170 160 150 145 165 195 % within 2 weeks 77.6% 79.4% 83.8% 82.6% 81.5% 83.3% 83.9% 79.4% 75.0% 76.7% 72.4% 75.8% 74.4% No. within 2 weeks 14 20 16 55 50 45 35 45 45 55 65 75 65 NELFT Total 15 20 18 65 60 55 50 55 55 75 80 95 80 % within 2 weeks 93.3% 100.0% 88.9% 84.6% 83.3% 81.8% 70.0% 81.8% 81.8% 73.3% 81.3% 78.9% 81.3% National standard 56% 56% 56% 56% 56% 56% 56% 56% 56% 56% 56% 56% 56%

Early Intervention in Psychosis: NHS Digital has updated the June and July 2020 data, this showed that: • During July 2020, all three BHR CCGs achieved the 56% operating plan target, which they achieved throughout the financial year 2019/20. • NELFT achieved the 56% operating plan target at end of July 2020.

242 Constitutional Performance – Mental Health

Inappropriate Out of Area Placements

published data Number of inappropriate OAP Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Apr-20 May-20 Jun-20 bed days in period Barking and Dagenham CCG 145 235 120 175 105 40 55 85 65 65 145 130 30 25 20 Havering CCG 70 110 85 160 85 65 20 20 15 110 135 90 5 0 0 Redbridge CCG 135 225 165 200 180 75 0 0 5 45 80 170 5 0 15 BHR CCGs 350 570 370 535 370 180 75 105 85 220 360 390 40 25 35

Sending Provider: inappropriate Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Apr-20 May-20 Jun-20 OAP days in period NELFT 610 865 575 735 480 225 80 130 95 335 460 525 60 0 70

Inappropriate out of area placements (bed days): Published NHS Digital data for the end of June 2020 (latest data) showed that: The total number of inappropriate out of area placement bed days remain relatively low; they increased slightly in Redbridge, and fell in Barking and Dagenham. Havering reported zero inappropriate out of area placements for the second consecutive month. NELFT reported an increase in the number of inappropriate out of area bed days that it sent to another provider to take the numbers just about the April level.

243 Constitutional Performance – Mental Health

Serious Mental Illness (SMI) Physical Healthchecks Serious Mental Illness Physical Health Checks: six physical health checks undertaken in primary care (%) Organisation Q1 2019/20 Q2 2019/20 Q3 2019/20 Q4 2019/20 Q1 2020/21 Barking & Dagenham CCG 32.2% 29.1% 34.1% 44.4% 38.8% Havering CCG 23.1% 24.4% 29.0% 38.1% 32.8% Redbridge CCG 33.4% 30.8% 39.2% 49.2% 45.3% BHR CCGs 30.1% 28.5% 34.8% 44.6% 39.8% BHR Plan Target 31.7% 38.7% 47.9% 60.0% 31.6%

Serious Mental Illness Physical Health Checks: six physical health checks undertaken in primary care (%): Q1 2020/21 Barking & Indicator Havering Redbridge BHR Dagenham

Patients nos on SMI GP registers (excluding patients ‘in remission): 1845 1864 2871 6580

Of the above, % patients who have had following test in last 12 months

1. measurement of weight (BMI or BMI + Waist circumference) 85.4% 80.4% 87.5% 84.9%

2. blood pressure and pulse check (diastolic and systolic blood pressure recording or diastolic and systolic blood pressure + pulse rate) 78.1% 72.7% 74.1% 74.8% 3. blood lipid including cholesterol test (cholesterol measurement or QRISK measurement) 60.4% 58.9% 70.5% 64.4%

4. blood glucose test (blood glucose or HbA1c measurement) 53.4% 48.6% 59.2% 54.6%

5. assessment of alcohol consumption 67.2% 56.9% 71.8% 66.3%

6. assessment of smoking status 91.2% 85.6% 91.4% 89.7%

All six physical health checks undertaken 38.3% 32.8% 45.3% 39.8%

SMI Physical Healthchecks: • This indicator looks at the numbers of patients on the GP Serious Mental Illness (SMI) register who have had all six physical health checks over a rolling 12 months reporting period: • Latest data for the end of Q1 2020/21 showed that the three BHR CCGs achieved their Q1 plan target. Performance across all three CCGs has probably been affected by covid-19 in terms of primary care data recording, and patient access to treatment. Nonetheless improving testing levels of blood lipid and blood glucose across BHR GP practices to match the percentage levels of smoking status assessment is likely to improve overall performance significantly. Local CCGs have commissioned CEG to support them with work to deliver this standard. 244 Constitutional Performance – Mental Health

Children and Young People Eating Disorders

Eating disorders urgent Q1 20/21 Eating Disorders: Urgent Referrals (seen within 1 week) Actual Organisation operating Q1 2019/20 Q2 2019/20 Q3 2019/20 Q4 2019/20 Q1 2020/21 plan target Seen in 1 wk 2 2 0 0 0 Barking and Dagenham Total seen 2 2 0 0 0 95.0% CCG % 100.0% 100.0% no patients shown no patients shown no patients shown Seen in 1 wk 5 5 7 14 14 Redbridge CCG Total seen 5 5 7 14 15 95.0% % 100.0% 100.0% 100.0% 100.0% 93.3% Seen in 1 wk 2 2 4 5 6 Havering CCG Total seen 3 2 4 5 6 95.0% % 66.7% 100.0% 100.0% 100.0% 100.0% Seen in 4 wks 9 9 11 19 20

BHR CCGs Total seen 10 9 11 19 21 95.0% % 90.0% 100.0% 100.0% 100.0% 95.2%

Eating disorders routine Q1 20/21 Eating Disorders: Routine Referrals (seen within 4 weeks) Actual Organisation operating Q1 2019/20 Q2 2019/20 Q3 2019/20 Q4 2019/20 Q1 2020/21 plan target Seen in 4 wks 14 17 0 0 0 Barking and Dagenham CCG Total seen 16 18 0 0 0 95.0%

% 87.5% 94.4% no patients shown no patients shown no patients shown Seen in 4 wks 19 23 22 17 20 Redbridge CCG Total seen 28 29 28 23 26 95.0% % 67.9% 79.3% 78.6% 73.9% 76.9% Seen in 4 wks 21 21 16 20 25 Havering CCG Total seen 27 26 18 22 27 95.0% % 77.8% 80.8% 88.9% 90.9% 92.6% Seen in 4 wks 54 61 38 37 45

BHR CCGs Total seen 71 73 46 45 53 95.0% % 76.1% 83.6% 82.6% 82.2% 84.9%

Eating Disorders: • Latest published NHS Digital data is for the end of Q1 2020-21. This national data covers a rolling 12 month reporting period. It is reported where there are two or more ‘Urgent Referrals’ and two or more ‘Routine Referrals’. • Urgent referrals seen with 1 week: Havering achieved the 95% target at end of Q1 2020/21, and Redbridge underperformed – although this reflects the very small numbers involved. There was no national data shown for Barking and Dagenham which may reflect the secondary suppression of data which is applied by NHS Digital to protect patient confidentiality. • Routine referrals seen with 4 weeks: Both Redbridge and Havering underperformed against the 95% target at end of Q1 2020/21. There was no national data shown for Barking and Dagenham which may reflect the application of NHS Digital’s secondary suppression of data.

245 To: Meeting of the NHS Barking and Dagenham, Havering and Redbridge CCGs’ Governing Bodies (meeting in common)

From: Tracy Welsh, Director of Transformation and Delivery (Planned Care and PMO)

Date: 24 September 2020

Subject: Variation to BHR Infertility Policy on IVF

Executive summary This paper sets out a proposal for varying the Infertility policy for BHR CCGs. This is in response to the pausing of IVF services as a result of the response to COVID-19. Current policies in north east London stipulate an age criteria of up to 40 on the offer of IVF treatment. This paper sets out a proposal that the age criteria is lifted by 1 year to 41 in BHR.

This would be a temporary measure and this variation in policy will be reviewed as part of the process of aligning treatment policies across north east London in preparation for one CCG from April 2021.

Recommendations

The Governing Bodies are asked to:

Approve the temporary lifting of the current upper age criteria for women accessing IVF treatment from 40 to 41 in the BHR policy.

1.0 Purpose of the Report 1.1 This paper seeks agreement to a proposal for varying the infertility policy for BHR CCGs. This is in response to the pausing of IVF services as a result of the response to COVID-19.

2.0 Background/Introduction 2.1 Current policies in north east London stipulate an age limit on the offer of IVF treatment. BHR policy currently offers IVF to women under the age of 40 following a consultation as part of the Spending Money Wisely Programme in 2017. Below is an extract from the current BHR Policy (Appendix A) in relation to the age criteria. • IVF is offered to women aged under 40 years. • Referring clinicians should be aware of the work up time required by the provider, and ensure that referrals are made in time for women to start their embryo transfer treatment before their 40th birthday.

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3.0 Proposal and next steps 3.1 In response to the pause in treatments resulting from COVID- 19, it is proposed to extend the age limit by one year to 41. Following ratification, the policy will come into immediate effect for all new referrals. Women already in a planned fertility treatment pathway who have turned 40 (the former upper age limit) can continue their treatment up to the new age limit within the constraints of the existing policy. 3.2 There is a process of aligning treatment polices across north east London and this variation will be superceded by the new standard policy worked up as part of the preparations for the single CCG from April 21. 3.3 This proposal was supported by NEL SMT and NEL CAG with a recommendation that this should go to Governing Bodies for approval. 3.4 City and Hackney and WEL CCGs are also proposing an age extension of one year subject to agreement by their governing bodies. 3.5 If agreed, providers and GPs will be informed of the changes.

4.0 Resources/investment 4.1 This change has no financial implications as, under the current financial regime, these services are provided under the nationally set block contracts. In addition, in normal circumstances, these patients would have already been treated.

5.0 Equalities 5.1 This change aims to address the adverse impact on access resulting from the pausing of IVF treatment as a result of COVID -19.

6.0 Risk 6.1 No risks arising from this change have been raised.

7.0 Managing conflicts of interest 7.1 There have been no conflicts of interest arising

Attachments: 1. Appendix A - BHR Infertility Policy

Author: Alison Glynn, Deputy Director Transformation Delivery, NEL CSU Date: 17/09/20

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Fertility Policy

10 July 2017

Note: This updated policy supersedes all previous fertility policies and reflects changes agreed by BHR CCGs’ governing bodies in June 2017.

Introduction BHR CCGs are responsible for commissioning a range of health services including hospital, mental health and community services for the local population. The CCGs have a statutory duty to maintain financial balance, which means that it must make judgements about the affordability of any proposed service for local patients. This clinical policy is intended to support individuals and couples who want to have a baby, but who have a clinical problem which means that they are potentially infertile. The CCGs aim through this policy is to offer the opportunity to have a baby to as many patients as possible within the context of its overall financial position. This policy has been developed following discussions with stakeholders, including local GPs and lead clinicians from fertility units in local hospitals. In developing this policy, the CCGs have also considered and adopted relevant NICE guidance wherever feasible. However, the need to balance service access demands with affordability has meant that in some sections the policy varies from the full recommendations made by NICE. The NICE Clinical Guidance 156, Fertility can be accessed here: www.nice.org.uk/guidance/CG156

Individual Funding Requests (IFR) This policy cannot anticipate every possible individual clinical presentation. Clinicians are invited to submit IFR for patients who they consider to have exceptional clinical circumstances and whose needs are not fully addressed by this policy. The CCGs will consider such requests in accordance with its policy on IFR. Patients accessing IVF should be fully informed of likely success rates and alternative approaches to parenting, including fostering and adoption.

Eligibility criteria Couples will only be referred for assisted conception if they meet the eligibility criteria below and when all appropriate tests and investigations have been successfully completed in primary and secondary care in line with NICE guidelines.

248 1. Definition of a For the purposes of this policy, an IVF cycle will be defined as the treatment cycle process which starts with ovulation stimulation and ends with the implantation of either a fresh embryo/ blastocyst or the implantation of a frozen embryo/ blastocyst. This may include the transfer of two embryos where this is clinically appropriate (see 7 below)

2. GP registration Patients should be registered on the medical list of Barking and status Dagenham, Havering or Redbridge CCGs.

3. Age of the IVF is offered to women aged under 40 years. female patient Referring clinicians should be aware of the work up time required by the provider, and ensure that referrals are made in time for women to start their embryo transfer treatment before their 40th birthday.

4. Lifestyle The woman must have a body mass index (BMI) of between 19 and factors 30 at the time treatment begins. Patients must be non-smokers in order to access any fertility treatment and continue to be non-smokers throughout treatment.

5. Children from IVF will not be offered to couples who have a child together or single previous applicants who already have a child. relationships IVF will be offered to couples where one of the partners has a child from a previous relationship, but the other does not. Both partners must confirm they have NOT previously undergone a sterilisation procedure. Foster children are not included in these restrictions.

Number of cycles funded NICE guidance argues that there is limited evidence for continuing to offer IVF to women who do not achieve pregnancy beyond a third cycle of fresh/ frozen embryo transfer. The guidance recommends that all cycles, whether funded by the NHS or privately be considered. The CCGs, therefore, will not fund additional treatment to a patient who has already had three fresh cycles of IVF.

6. Number of BHR CCGs will support patients to have a single embryo transfer. cycles to be This would normally be the transfer of a single fresh embryo, but a funded for frozen embryo may be used where clinical circumstances dictate women aged up that this is the best clinical option for the patient. to 39 years old who have Treatment will not be funded for patients who have previously had previously had no any NHS funded treatment cycles. more than one Treatment will not be funded for patients who have previously had cycle of ovarian three cycles of IVF including privately funded cycles. stimulation

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249 leading to an BHR CCGs require providers to adhere with the HFEA multiple birth embryo transfer restriction strategy. One child at a time guidance Fertility service providers will be expected to follow the HFEA’s guidance on minimising multiple births. Providers are be expected to observe the following rule when considering the number of fresh or frozen embryos to transfer in IVF treatment:  Use single embryo transfer if there are one or more top- quality embryos.  Consider double embryo transfer only if there are no top- quality embryos.

7.Cancelled and NICE guidelines define a cancelled cycle as occurring when egg abandoned collection is not undertaken following ovarian stimulation. cycles An abandoned cycle is not defined by NICE but is defined by this policy as including treatment leading to a failed embryo transfer. Occasionally there may be good clinical or non-clinical reasons why a cycle needs to be cancelled or abandoned. For this reason the first two abandoned/ cancelled cycles will not count towards the total number of funded cycles in section 6 above.

Treatment pathway This policy is intended, as per NICE guidance, for people who have a possible pathological problem (physical or psychological) to explain their infertility. BHR CCGs will fund investigation and treatment for all individuals and couples provided there is evidence of subfertility. The process for demonstrating subfertility will necessarily be different for heterosexual couples than for same sex couples or single people and these differences are reflected in the sub clauses below.

8. Subfertility Individuals/couples with a known cause of infertility should be referred without delay for appropriate assisted conception Heterosexual assessment. couples Women who have not become pregnant after one year of regular

unprotected vaginal intercourse two to three times per week should be referred with their partner for further assessment and possible treatment. If the woman is aged 36 or over then such assessment should be considered after six months of unprotected regular intercourse. If a cause for infertility is found, the individual should be referred for appropriate treatment without further delay. IVF treatment can be offered to women with unexplained infertility who have not conceived after two years (this can include up to one

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250 year before their fertility investigations) of regular unprotected sexual intercourse (or 12 months for women aged 36 and over).

8.1 Subfertility Female same sex couples and single women who have not become pregnant after six cycles of IUI undertaken in a clinical setting should Same sex female be referred for further assessment and possible treatment. couples and single women If a cause for the infertility is found, the individual should be referred for appropriate treatment without further delay. Where no cause of infertility can be identified women should be offered access to assisted conception if they have subfertility demonstrated by a further six cycles of IUI (12 in total) If the woman is aged 36 or over then such assessment should be considered after six cycles of IUI. As per section 9 below, the CCGs will not routinely fund the IUI cycles described above. As per section 14 below, the CCGs will not routinely fund the use of donated sperm used in the IUI cycles described above.

8.2. Subfertility Male same sex couples and single men will be referred for infertility Same sex male investigation if no pregnancy results following six cycles of IUI for couples and which the man’s donated sperm has been used. single men

9. Intra Uterine BHR CCGs will not routinely fund the use of unstimulated IUI. Insemination (IUI) IUI will, however, be offered as a treatment option for the following groups as an alternative to vaginal sexual intercourse:  people who are unable to, or would find it very difficult to, have vaginal intercourse because of a clinically diagnosed physical disability or psychosexual problem who are using partner or donor sperm

 people with conditions that require specific consideration in relation to methods of conception (for example, after sperm washing where the man is HIV positive) As per section 14 below, whilst paying for the IUI procedure, BHR CCGs will not fund the use of donor sperm. A woman who has not become pregnant following six cycles of IUI carried out within a clinical setting should be referred for further assessment and appropriate treatment for infertility.

10. Ovarian Low Ovarian Reserve reserve testing Women with low ovarian reserve are less likely to achieve pregnancy through IVF. Women referred for IVF assessment shall be offered an ovarian reserve test as per NICE guidance to identify and exclude those with low chance of conception.

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251 NICE guidance describes three tests which may be used:  Total Antral Follicle count(AFC)  Anti-Müllerian hormone (AMH)  Follicle-stimulating hormone (FSH) BHR CCGs will fund IVF only for women who have demonstrated that they have sufficient ovarian reserve on one of these three tests described in the NICE fertility guidance. This means that the patient must have either: • Total antral follicle count (AFC) of greater than 4 or • Anti-Müllerian hormone (AMH) of greater than 5.4 pmol/l or • Follicle-stimulating hormone (FSH) less than 8.9 IU/l Ovarian reserve testing should only be conducted within the overall context of a fertility assessment carried out by a specialist centre. GPs should not order these tests prior to referral to a Fertility Unit.

12. Fertility BHR CCGs will fund the collection and storage of eggs, embryos preservation and sperm for individuals with cancer or other illnesses which may impact on their future fertility with the following conditions:

 BHR CCGs will fund the storage for first five years only

 BHR CCGs will not fund for the continued storage of eggs/embryos for a woman aged 40 years and over

 BHR CCGs will not fund for the storage of sperm for a man aged over 55. The eligibility criteria set out in this policy must be applied to any subsequent use of the stored material.

13. Egg donation BHR CCGs will not fund the use of donated eggs but will fund the associated IUI/IVF/ICSI treatment in line with the criteria in this policy. Patients wishing to use donor eggs treatments must make their own arrangements to access these and are advised to check with the treating provider unit to ensure compliance with best practice guidelines.

14. Sperm BHR CCGs will not fund the purchase of donor sperm but will fund donation the associated IUI/IVF/ICSI treatment in line with the criteria in this policy. Patients wishing to access donor sperm treatments must make their own arrangements to access these and advised to check with the

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252 treating provider unit to ensure compliance with best practice guidelines.

15. Reversal of BHR CCGs will not fund treatment for couples where subfertility is sterilisation / the result of a sterilisation procedure in either partner. surgical sperm BHR CCGs will not fund the surgical reversal of either male or retrieval female sterilisation. BHR CCGs will not fund treatment where sub fertility remains after a reversal of sterilization treatment. Surgical sperm retrieval will be funded in appropriately selected patients, provided that the azoospermia is not the result of a sterilisation procedure.

16. Sperm BHR CCGs will fund sperm washing for IUI/IVF/ICSI for couples washing where the male partner is HIV positive and the female partner is HIV negative in order to prevent the transmission of HIV to an unborn child.

17. Surrogacy IVF using a surrogate mother will not be funded by BHR CCGs

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253 To: Meeting of the NHS Barking and Dagenham, Havering and Redbridge CCGs’ Governing Bodies (meeting in common)

From: Marie Price, Director of Corporate Affairs, NELCA

Date: 24 September 2020

Subject: Use of the Clinical Commissioning Groups’ seals

Executive summary The Clinical Commissioning Groups’ constitutions include guidance for the use of each Group’s seal and authorisation of documents (section 10). In line with this guidance and our requirements, this report includes the details of the use of the Groups’ seals during 2019/20.

The seals were applied three times during the year for three lease agreements relating to the relocation of the CCGs’ offices.

Recommendations The governing bodies are asked to: • Note the contents of the report

1.0 Purpose of the Report 1.1 To advise the committee on the use of the seal during 2019/20

2.0 Application of the seals 2.1 Barking and Dagenham CCG’s seal was not applied during 2019/20.

2.2 Havering CCG’s seal was not applied during 2019/20.

2.3 Redbridge CCG’s seal was applied to the following: • Lease of one unit at Lyon Road, Romford which was authorised by Henry Black, CFO and Dr Anil Mehta, Chair on 17 May 2019 • Lease of the tenth floor at Angel Way car park which was authorised by Henry Black, CFO and Dr Anil Mehta, Chair on 6 June 2019 • Lease of the ninth floor at Angel Way car park which was authorised by Henry Black, CFO and Dr Anil Mehta, Chair on 19 July 2019

3.0 Resources/ investment 3.1 Resources associated with the cost of the CCGs’ office relocation were agreed by the Joint Committee on 29 November 2018.

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

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5.0 Risk 5.1 There are no risks arising from this report.

6.0 Managing conflicts of interest 6.1 There are no conflict of interest implications in relation to this report.

Author: Anne-Marie Keliris, Company Secretary Date: 18 August 2020

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To: Meeting of the NHS Barking and Dagenham, Havering and Redbridge CCGs’ Governing Bodies (meeting in common)

From: Kash Pandya, Chair of BHR CCGs Finance Committee

Date: 24 September 2020

Subject: Feedback report from the Finance Committee

The Finance Committee considered the following key matters at its meeting in July: -

• Overall financial position for BHR CCGs at month three • Review of non-NHS block payments • Transvaginal ultrasound activity in 2019/20 • Prioritisation of Transformation and QIPP schemes • Deep dive into Improving Access to Psychological Therapies (IAPT) • Business cases requiring approval

The Committee discussed the reports in detail and supported the actions being taken, requesting further assurance where necessary in regard to risks and their management.

Kash Pandya Finance Committee Chair, BHR CCGs

25 August 2020

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NEL CCGs Governing Body meeting in common - virtual webinar Date and time: 12.30-2pm Wednesday 13 May 2020 Chair: Dr Anil Mehta Attendees: governing body members for all seven CCGs and regular attendees invited

Item Note

1. Welcome, introductions, apologies

2. Chairs’ report Dr Anil Mehta presented the Chairs’ report, summarising the CCGs’ work over the past two months in responding to the Covid-19 pandemic, on behalf of the NEL CCG Chairs. Key points included: i. Much of the business as usual activities have been suspended while we’ve focussed our efforts on the response ii. A warm welcome our new Integrated Care System Chair, Marie Gabriel OBE iii. We have worked in partnership across organisational boundaries in ways not seen before and which will want to continue. As Chairs, we’ve worked collaboratively for some time now, but the current crisis has intensified this as we’ve come together to support the system working even more closely across NEL iv. With some of our boroughs the worst affected in the country, as well as BME staff and patients more severely affected by the virus, we must tackle the health inequalities that persist in NEL. To do so we need to work together, with regional and national support v. As we have rapidly moved to new channels for consultations, with much more happening by phone or video, we would like to thank all of our Primary Care teams, as well as our patients, for embracing the changes. As we focus on recovery, we will be seeking further feedback on how we maintain a good balance of virtual and face to face options for patients to access our services vi. Our focus, as we appear to have passed the peak of current outbreak, is now on how we recover as a system, while we ensure we are prepared for any further peaks. Some of the innovations we’ve developed will continue. We will engage with local stakeholders on our plans as they develop vii. We have lost dear and valued colleagues as a result of this virus and our thoughts are with their families, friends and those they worked closely with. It is important that we remember these staff, the contributions they have made over the years and ensure that we commemorate them all viii. We want to remind our public in north east London that the NHS is open, and that it is important and safe to still seek help they have any medical concerns ix. Finally, we thank all of our CCG staff, many of whom have taken on new responsibilities, been redeployed to support our local providers and others who have worked to maintain business critical activities or step-up essential services over the past few months.

3. AO’s report Jane Milligan, Accountable Officer and SRO ELHCP, updated on the work over the past two months with system partners, in particular provider chief executives, system managing directors and local authorities, to implement a single operating model for our NEL Covid-19 response working as part of the chain of command from NHSE/I and Public Health. Key points included: i. NHSE has declared the pandemic a Level Four national incident and imposed a command and control structure on the NHS

257 ii. The focus on stepping back anything that has not been business critical and putting in place the Covid-19 operating model and structure to respond to the pandemic, and to ensure our response focusses solely on the right thing to do to keep our residents and staff safe iii. We have been working very closely with our boroughs, through our local resilience forums iv. Our Incident Control Centre has been working with Trusts, primary care and community health to manage the daily operational demands throughout the pandemic. We are now looking at how we operate our ICC and Covid-19 issue management over the longer term in light of the recovery and restoration work v. It is important that we provide support in the community post covid-19 illness, to support people through the whole pathway vi. There has been a lot of learning, including around the national challenges with PPE supply and staff testing. vii. Simon Stevens, Chief Executive of NHS England, has outlined in a letter to health leaders, the approach we must take across the NHS to ensure services get back to pre-Covid-19 capacity to meet need and reduce backlog. As a system we are now working through responding to these asks, as well as the asks from NHS London ahead of submitting a system plan for recovery on 11 May viii. Finally, I would like to thank all of our staff, clinicians and system partners for the immense effort and commitment they have given over this incredibly difficult and intense time. I am in no doubt that what we have achieved would not have been possible without our workforce and I am extremely proud of everyone.

4.1 North East London: responding to Covid-19 as one system Marie Gabriel, NEL ICS Chair, introduced North East London: responding to Covid-19 as one system.

Marie reiterated the need to be able to respond to further peaks of Covid-19, as well as resuming and maintaining our normal NHS services, an ensuring that the needs of our NEL community are met. It is also important that we look at how our community has been differently impacted, given its diversity

Jane Milligan then presented on the NEL response to Covid-19, setting out how we have worked together as a NEL system through a single operating procedure, as part of the chain of command from NHSE/I and Public Health England. Key points included: i. Critical to this is how we have coordinated the response, working with borough and local authority colleagues though the system operating control groups, cross cutting and bringing together key people across the systems ii. There has been a strong focus on ensuring that general practice, and community care providers, have appropriate support to enable digital and remote working iii. It is likely that we will continue now to have peaks and troughs, so we need to ensure that we have the capacity to meet the demand as we move to recovery and restoration.

Dr Jagan John added some points of reflection on behalf of the NEL Chairs: i. We have seen greater collaborative working across the STP than ever before, and the innovation across NEL has been incredible ii. The guidance has changed daily, and due to the hard work of Charlotte Fry and the ICC team, we have been able to act on it straightaway. I would like to thank Charlotte and the team for ensuring we are kept up to date iii. Our staff across NEL have been incredibly flexible in responding to the pandemic, and the leadership has been fantastic. I would like to thank everyone.

4.2 North East London Integrated Care System: Covid-19 Recovery & Restoration Programme Dr Mark Rickets and Ceri Jacob, BHR MD, presented on the Covid-19 Recovery & Restoration Programme for NEL, setting out our approach to responding to the 8 tests and 12 expectations set out by NHS England to guide the response of London ICSs to recovery and restoration. Key points included: i. The Covid-19 pandemic has had an unprecedented impact and will continue to do so for at least the next 18 months to two years

An alliance of North East London Clinical Commissioning Groups 258 City and Hackney, Newham, Tower Hamlets, Waltham Forest, Barking and Dagenham, Havering and Redbridge CCGs ii. The infection prevention and control programme will be key in ensuring that we do not do further harm and spread this infection iii. Our system has achieved a level of agility and cohesion in its response to the pandemic that had previously only been aspired to, along with the innovations across NEL, we do not want to lose this progress iv. The system operational command groups have been key to the response, and will continue to oversee and support the recovery and restoration, as well as to drive the equalities work. We need to ensure that we do not exacerbate any inequalities as a result of our new ways of working v. We need to ensure we have everything in place to respond to the 8 tests and 12 expectations, with most of the work to be delivered at a local level vi. Public and stakeholder engagement will be key, and we will be using our existing channels and patient groups, as well as exploring new deliberative formats as we discuss our plans vii. Our clinical leaders, managers and all of our staff are absolutely key to recovery, as they were to the initial response. We will need to help them to recover, and to help shape our services going forward.

5. Finance report Henry Black, Chief Finance Officer, presented the month 12 position for the 2019/20 financial year, reporting a surplus of £16.8m overall for NEL CCGs.

5.1 COVID-19 Pandemic Financial governance arrangements Henry Black presented on the proposed financial governance arrangements that have been developed to enable decision making to continue and to ensure a swift response to Covid-19 requirements, and to streamline authorisation limits across the seven CCGs.

These proposals are in line with NHSE/I guidance, NHS best practice and have been reviewed by our internal auditors.

Henry Black assured the group in response to a question submitted regarding procurement and quality that in relation to the proposals regarding procurement it would not change any of the requirements for quality control to be met. A contract would need to be placed with a fully compliant and regulated supplier.

Governing body members had been asked to advised of any questions or concerns regarding the proposals in advance of the meeting. There were no objections received in the week since papers were circulated, none on the call and none in the days following the meeting. Therefore, the recommendations set out in the paper were approved, and agreed as a pragmatic way forward during the current pandemic.

6. Questions from the public: None received.

7. AOB: None.

An alliance of North East London Clinical Commissioning Groups 259 City and Hackney, Newham, Tower Hamlets, Waltham Forest, Barking and Dagenham, Havering and Redbridge CCGs

Barking and Dagenham Patient Engagement Forum

28 January 2020 Committee Room 2, Barking Town Hall

Attendees CCG staff in attendance Nicholas Hurst – NELFT Marie Price – BHR CCGs Pam Dumbleton – PEF Annie Robertson – BHR Val Shaw – PEF CCGs Ron Wright - PEF Apologies Ken Humphries – PEF Sahdia Warraich – B&D David Elliott – PEF CGG Miriam Greenwood - PEF Manisha Modhvadia – Healthwatch Surinder Singh Kalsi – Local Pharmacy Committee

Items 1. Introduction and Apologies Nicholas (the Chair) welcomed members to the meeting and listed those who sent their apologies. 2. Minutes and action log The previous meeting minutes were recorded as accurate. 3. CCG update Marie recognised that it has been longer than it should have been since the last meeting and now with Annie Robertson with the CCG permanently, this should no longer be an issue. Now that the CCG is out of deficit we are also pleased to be able to provide sandwiches for the meeting.

Marie told the group that BHR CCGs has been rated green by NHSE/I and has been praised for its partnership working. The CCGs have formed transformation boards for priority areas of work (urgent care, children and young people, long term conditions, planned care, primary care, older people and frailty, and cancer) which involve our local authorities and other partners.

It’s the worst time of year for A+E, Queens is particularly struggling. Tony Chambers, the new interim CEO is making A+E recovery a priority. Marie explained that both BHRUT and NELFT have interim CEOs and that they are exploring the option of a ‘group model’ with one joint CEO for both organisations in the future.

The latest draft of the north east London Long Term Plan is available on the website – this is being called the Strategy Delivery Plan and sets out how we will work together to respond to our known challenges. The East London Health and Care Partnership (ELHCP) also has a newsletter, you can sign up here

Marie updated on the north east London Integrated Care System (ICS) – the main objective of this is to stop the divide between commissioners and providers and work together better. Marie Gabriel has just been announced at the new independent chair for the ICS and brings a wealth of experience and knows the patch very well.

As part of the development of a NEL ICS, in April 2021 we are aiming to become North East London (NEL) CCG which will bring together all of the CCGs (Barking and Dagenham,

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Havering, Redbridge, Waltham Forest, Newham, Tower Hamlets and City and Hackney) and will see a new way of doing things.

Following our consultation on urgent care in 2018 the CCG has now commissioned PELC and NELFT to deliver urgent care services. There will be four new urgent care treatment centres.

There was a discussion about rumours that some mobile phone providers were now charging for calls to 111 and 101.

Action 3.1: CCG to follow up to see if some mobile phone providers were charging for calls to 111.

Members raised concerns that PELC don’t have patient engagement arrangements and this is now a bigger concern now they are growing as providers.

Action 3.2: Annie to see what patient engagement arrangements PELC has

There was a discussion about the work in primary care to improve the standards of buildings and how the NHS will cope with the huge increase of people. Marie mentioned that we had a representative from estates at the Joint PEF meeting and that it might be helpful to recirculate this information and include any updates.

Action 3.3: Annie to circulate update information from Estates.

There is a new service coming to Barking and Dagenham and Havering for over 65s to help with loneliness and isolation which is being provided by Independent Age and commissioned by the CCGs, local authorities and Care City.

A new service providing health checks for homeless and rough sleepers is now in place in partnership with the local authorities.

4. BHRUT Clinical Strategy

Carnall Farrar, a management consultancy, has been brought in to lead this work, including to look at what may need to change in order to meet the huge population growth and changing needs.

A question was asked if the hospital has reached its limit and if so, is that why services are being moved. Marie highlighted that A+E, for example, sees several hundred more people daily than it was intended for but equally we know that there are many people there who don’t need to be and would be better served elsewhere. Theatres were given as an example of an area which is not at full capacity. Changes in how some services are delivered will be trying to respond to a wide range of issues, including medicine and technological developments.

A conversation was had around primary care being at full capacity as there are lots of vacancies so people are using urgent care because they can’t get an appointment.

A member said that often people include the Urgent Care Centre when they are talking about A+E and in fact they don’t have the same four-hour wait target as A+E. People think they’ve been to A+E and they haven’t. Hopefully having an appointment system in Urgent Care will have a positive impact. Maternity services are at capacity at the Trust so not able to accept routinely from a wider catchment area. There appears to have been an impact on

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demand partly due to poorer CQC rating for Newham, leading to an increase in those wishing to have their babies at BHRUT.

A query was raised around the desire to move things out of hospital but the community facilities don’t exist to support this. Marie talked about how the development of primary care networks as a positive. They will be thinking about the best way to deliver services for their local populations.

A discussion was had around retaining and recruiting clinical staff in the north east London area and the work that is going on to support this, for example, the GP Spin scheme which helps staff to have more flexible careers in different providers.

Marie said to achieve our ambitions we have need to look at a range of evidence and factors, including our current and forecast populations, existing buildings, what’s planned, the workforce and change the way we are doing things.

Members felt that this needs more engagement and that people need to know more.

The case for change for the BHRUT clinical strategy is on the website: https://www.bhrhospitals.nhs.uk/clinical-services-strategy/

5. Community Pharmacy

Surinder arrived earlier than expected so this item was moved up the agenda.

Surinder talked about his 36 years’ experience working as a pharmacist on one of the most deprived housing estates in the country, the Gascoigne Estate. He explained to the group that pharmacists are an integral part of primary care, offering long opening times in the heart of communities. He is part of the North East London Local Pharmacy Committee which covers Barking and Dagenham, Havering, Redbridge, Waltham Forest, Newham, Tower Hamlets and City and Hackney, which has 180 pharmacists as members. He talked about the qualifications that various pharmacy staff have and the breadth of topics they have to learn. Surinder runs an anticoagulation clinic in B+D and his patients are typically seen within five minutes and within half a mile from their homes. The role of the pharmacist is changing to more of a clinical role and pharmacies have private consulting rooms to see their patients. They offer a new medications service which means they can monitor people on new medications and prevent them from having to see the GP. Pharmacists are gaining lots of new skills so that they can help to reduce the pressure on A+E. NHS 111 have recently started referring people with minor ailments to pharmacies.

A conversation was had around opening times and that it is likely that the pharmacies that close for lunch periods or on Thursday afternoons are likely to be part of a corporate group and it could be company policy or only have one pharmacist so they close for lunch while this person takes a break.

6. Engagement update and planning Annie introduced herself and talked about her experience in north east London. She told the group that she is committed to attending these meetings and wants to ensure that the members have continuity and a single point of contact. She told the group about the networking she has been doing in the borough and what she is planning in the future. She asked members to have a think about what questions or issues they’d like to raise relating to the transformation boards. Some of the members wrote on post-it notes. Action 6.1: Members to give further feedback over email.

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7. Tabled items, future agenda items and local issues A member raised an issue about a specific practice that is being let down by locum GPs. Marie advised for them to contact our primary care team who should be able to support with this. 8. Meeting close

Next joint PEF meeting – TBC. Agenda items: TBC.

Action log Date Action Lead CCG to follow up to see if some mobile phone providers were 28/01/2020 3.1: AR/MP charging for calls to 111. Annie to see what patient engagement arrangements PELC has 28/01/2020 3.2: AR Annie to circulate update information from Estates. 28/01/2020 3.3: AR 28/01/2020 6.1: Members to give further feedback over email. All

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Havering CCG Patient Engagement Forum

Wednesday 29 January 2020 North House, St. Edwards Way, Romford

Minutes and action log (DRAFT)

Attendees CCG staff in attendance Vikki Kamm, Chair Melissa Hoskins – BHR CCGs Richard Coleman Annie Robertson – BHR CCGs Roy Carter Helena Cowin Apologies Ashley Doctors Jim Crouch Ian Buckmaster – Healthwatch Carole Loveday Nigel Bloor Anita Thomas Gwen Kirby-Dent Alan Surtees Kay Alexander Doreen Surtees Surinder Singh Kalsi – Local Pharmacy Committee

1. Introduction and apologies VK welcomed everyone.

2. Minutes and action log The minutes were agreed as accurate and Vikki went through the actions:

1. Low PPG members at Western Road. Could the CCG support with sharing information etc? AR explained that she is developing a list of PPG chairs so that we can share information with them more frequently. Action to be closed. 2. Tracy to find out how parents can get involved in the Havering CYP transformation board (early years transformation academy). MH advised transformation boards are in their early stages - the CYP board is particularly keen to involve patients. We will come back to another meeting about how we will involve patients more generally. Added to forward planner and action closed. 3. Andy to send members a single email with the details of how to respond to the aligning commissioning policies consultation. Actioned and closed 4. Andy Strickland to send link to PCN animation. Actioned and closed 5. Sarah See to be invited to attend future meeting to take part in with PPG discussions around contracts/engagement. Added to forward planner and closed action.

A member raised an issue about a practice that might not have a PPG -details to be passed to AR so this can be raised with primary care. MH mentioned that the CCG are working with primary care on a project that will look at PPGs in the primary care network (PCN) setting and work with them to develop an engagement framework and toolkit to support them to do engagement well.

3. CCG update

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MH recognised that things have been a little unsettled but permanent staffing is now in place which means this should run more smoothly.

We are now out of financial directions. NHS England has been complimentary about our financial planning and leadership.

Everyone is working together try and relieve the pressure on A+E over the winter months.

Complaints around urgent care. MH advised members to try to raise concerns on the day. The group were reminded there is a 24 hours PALs service, and a formal complaints process. Raising issues is important, it’s where learning comes from.

There was a discussion about how busy it is at the moment and people are having to make do with being in corridors. Members suggested that they could do with a mediator/advocate for people waiting in the queue to the triage desk to give some sort of reassurance of what is happening. Also someone should be assessing people in the queue. Members also talked about the communication issues between departments and that that staff are visibly stressed.

Action 3.1: MH to feed this back and to find out if this is happening.

The north east London (NEL) response to the Long Term Plan is being called the ‘Strategy Delivery Plan’ and the latest draft was issued on 15 November and is a live document. A summary document with an easy read version will be produced. Formal engagement with stakeholders has begun. We will be asking the PEF for their ideas about the proposal and plans within the document and discuss what this looks like locally.

Integrated Care System (ICS) update: work is continuing to plan what that will look like and what it means. Marie Gabriel has been recruited into the independent chair position is very well placed to lead the work going forward. There is work to develop an accountability framework looking at what will be delivered and who will deliver it.

Patient involvement in urgent care: following the public consultation in 2018 we have successfully completed the procurement of the GP led Urgent Treatment Centres (UTC) to be run by PELC and NELFT. We are working on a communications and engagement plan and will be coming back to get your help to share information when this is launched.

A member asked if St Georges is going to be a UTC. MH explained that it’s going to be a health and wellbeing hub including primary care and community services. We will come back and talk to PEF members about this.

There is a new service coming to Barking and Dagenham and Havering for over 65s to help with loneliness and isolation which is being provided by Independent Age and commissioned by the CCGs, local authorities and Care City.

A new service providing health checks for homeless and rough sleepers is now in place in partnership with the local authorities.

Action 3.2: Annie to share link to homelessness and rough sleepers consultation from the Council.

4. BHRUT Clinical Strategy MH talked to the group about the BHRUT clinical strategy - looking at what services they need to provide in their hospitals, where and why etc. We want to provide services closer to home and in community settings where possible. Clinicians have been involved in

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265 developing these plans. They have been holding listening events and are asking for feedback from patients and the public.

The key elements are: • Urgent and emergency care • Planned care • Maternity care • Cancer care • Care for people with ongoing needs – for example he care of people with long term conditions, and the care of people with complex needs.

There’s lots of information on their website and they are really keen to hear back from PEF members.

Some of the members have been to these events, but there were concerns that organisers didn’t have a good understanding of how services are functioning now, they also felt that the clinicians could look from their perspective.

Action 4.1: MH to confirm what services have been planned for the St George’s site

Some of the feedback included:

• PALs has been first class • NHS111 has been very, very good. • I’ve had some really good experiences in the NHS, when it’s working well it’s working really really well - but this doesn’t happen enough. • When you have a long term condition it’s very important that there should be someone who understands and works with you all the time. It’s wrong that an adult with a learning disability should have to go further afield. It’s difficult to travel and we need local consistency. • This also applies to children or any other disorder. It seems that support is inappropriate in the early days. • For long term conditions, if you are dealing with different people you often get conflicting advice from different consultants.

There is a new interim CEO at BHRUT, Tony Chambers who is working with the NELFT interim CEO, Oliver Shanley – they are working out how there will be a joint CEO for the two organisations in the future.

Action 4.2: CCG to share feedback with BHRUT and invite Tony Chambers to a future meeting.

5. Lay Members Report RC spoke about his involvement with primary care and some of the key changes that are happening; investment in primary care within the PCNs more nurse prescribers and clinical pharmacists. Next year we’ll see social prescribers and also investment in mental health.

There’s lots of creativity coming from networks – one of the chairs has asked for a small sum of money to have a ‘Chairs Den’ for the stroke service for early identification.

Looking at joining up services across BHR and local authorities. The homeless project is a great example of multi-agency work. Looking at how we work with Public Health colleagues - MMR is an issue at the moment.

The outcome from the Moorfields Eye Hospital consultation is being discussed at a north east London level.

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Seeing really good co-operation with hospitals – collaboration between Barts and BHRUT.

Funding: The Long Term Plan is taking a view across NEL but looking at what we need in individual boroughs and if there is enough money to deliver.

Phlebotomy: advised there’s a review at present and that this can be brought back to a future meeting.

6. Engagement update and planning AR talked about her experience in north east London and advised she is committed to attending these meetings and wants to ensure that the members have continuity and a single point of contact. She told the group about the networking she has been doing in the borough and what she is planning in the future. She asked members to have a think about what questions or issues they’d like to raise relating to the transformation boards. Action 6.1: Members to give further feedback over email.

7. Tabled items and local issues The chair felt that most issues had been raised under previous items and owing to time, no further issues were raised.

8. Community Pharmacy SSK, part of the North East London Local Pharmacy Committee talked about his experience working as a pharmacist on one of the most deprived housing estates in the country. He explained how pharmacists are an integral part of primary care, offering long opening hours in the heart of communities and advise on a whole range of topics and helping to reduce the pressure on GPs and A&E. SSK runs an anticoagulation clinic in B&D and his patients are typically seen within five minutes and within half a mile from their homes. Since December NHS 111 have started referring people with minor ailments to pharmacies.

A member asked why there are no checks when drugs are being taken for any length of time. SSK advised that patients should have an annual review of long term medication with their GPs.

With regard to waste, SSK advised that they can tell if drugs are not being used correctly ie as asthma inhalers running out too quickly. When this happens it can be reported to the GP so that the patient can be brought in for a review.

9. Close Meeting close. Action Log: 29 January 2019

Date No. Action Responsible Status January 3.1 MH to find out what support is being MH 2020 given to people waiting in the queue for urgent care centre 3.2 AR to share link to homelessness AR Closed and rough sleepers consultation from the Council.

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4.1 MH to confirm what services have MH been planned for the St George’s site

4.2 CCG to share feedback with BHRUT AR Closed and invite Tony Chambers to a future meeting.

6.1 Members to give further feedback on AR Closed things they are interested in relating to the transformation boards over email.

Future meetings: • Next meeting will be a Joint PEF – date tbc

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268

Redbridge Patient Engagement Forum

4 February 2020 York Room, Redbridge Central Library

Attendees CCG staff in attendance Dee Singh Datta, Chair Marie Price Howard Clarke-Melville Annie Robertson Swati Vyas Michelle Greene Apologies Shaan Ali, Redbridge Youth Council Lorraine Silver Yakya Jahaly, Redbridge Youth Council Raina Gee, Redbridge Youth Council Vivien Nathan, Vice-Chair Khalil Ali, Redbridge CCG Lay Member David Lyon Jean Cowie Abbas Mirza, Barts NHS Health Trust James Chapman, BHR CCGs

1. Introduction and apologies

DSD welcomed the members and changed order of agenda.

2. Whipps Cross Hospital Redevelopment

AM is the community engagement lead for the Whipps Cross Hospital (WXH) redevelopment programme who talked through why change is needed.

In September, the government committed funding to the hospital. There are four main strands to the redevelopment; health and care services, scope of a new hospital, masterplan for the site and the strategic outline case

The Trust is working together with East London Health and Care Partnership (ELHCP) to deliver the NHS Long Term Plan (LTP). This sees an increased focus for more joined up care outside of hospital. The new models of care aim to improve quality of care and access to services.

AM described the proposed options.

Details of these plans can be found on the website: https://bartshealth.nhs.uk/future-whipps

The timeline for the redevelopment project was discussed and the plan is for the construction to start in 2022/23 and it will take around four years to build.

AM has spoken to around 80 groups, approx. 1000 people, collecting views and feeding them into the plans. It’s a new hospital and a new opportunity and they are keen to keep patients and service users involved.

Navigating hospitals: AM reassured members that accessibility is important the building will be compliant with accessibility standards.

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A changing population: AM explained that things like predicted demographic and disease data has all been considered.

Future-proofing: Barts are working on future proofing the hospital for the next 30-50 years. There’s lots of work going into integrated care and services in the community.

Smaller hospital concerns: AM said the square footage would be similar to the current provision at Whipps Cross.

Primary care unit on site: AM said this is being considered as there will be a new community and new neighbourhood in the area so the infrastructure needs to be there to support this.

A carbon neutral hospital: AM explained that they are looking at how the hospital is built, there’s a number of building standards that it has to meet, and they will look at things like natural light, heating, car charging etc.

The Margaret Centre: AM said that the building could possibly go but the great work that happens there and the staff that go along with it will be moved into the new hospital. This goes for all the existing services such as the eye treatment centre that are doing great work.

Bed numbers: AM said there’s lots of work happening to keep people out of hospital so the new models of care should mean that people can be treated in the community where possible. The number of beds will be down to clinical need and capacity and this is still being decided on.

Discharge: members agreed that things need to be more integrated.

Key worker housing: AM stated there is going to be 18,000 new homes in the borough and a portion of these have to be affordable housing ad key worker housing.

Send any more feedback via Annie.

3. Public Health Budgets (PHBs)

JC is head of individualised care for the BHR CCGs. Individualised care includes continuing healthcare (CHC) which is where patients are assessed of having levels of needs – this could be people with brain injuries, severe learning disabilities, supporting people at end of life and in some cases, mental health and autism– and includes adults and children.

PHBs is where patients that receive a care package for clinical and social needs can now decide what care they need, rather than a health professional saying what they need. If one patient costs £800 per week, for example, they can now decide what elements of care they need and they can even decide who they want to employ. They can also make decisions about when they receive the care so if they need more care at the weekend, they can make this choice.

JC confirmed this not new money – it doesn’t cost the NHS more and they work within the allocation of money that’s been allotted to the patient – they can build a package for themselves which is exactly what they want.

JC explained that CHC and health pathways are not means tested.

Budget reductions: JC said in some cases it has when someone recruits their own carers for example there’s a 10% reduction but it is still held back for that person and it can be used for training.

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PHBs are also available to people who access wheelchair service and those eligible for section 117 aftercare services (people who require care when they have been discharged after being sectioned).

People with autism and learning disabilities are also eligible but it’s slightly more complicated as parts of their care package can be tied up in services that have already been paid for. This is currently being looked at.

When someone decides what care they need it has to be approved by the CCG and then it is monitored to ensure that there are health benefits and it affecting their outcomes.

Numbers: 230 CHC patients in Redbridge – half of which in nursing homes.

Exercise on referral: This is not CHC but is under the umbrella of personalisation.

Size of personal budget: JC said there is a spreadsheet which will tell you how much someone will get.

Is something is over-budget: JC said a case could be made and it would have to have required health outcomes. This would have to be pre-agreed with the CCG.

Members were asked to divert any further questions to Annie.

4. Minutes and matters arising including PEF action log

AR went through the action log and updated it. There was a discussion around actions having not been dealt with since the last meeting, in particular the action about inviting all PPG chairs to the meeting. AR and MP explained that there is a lot of planning happening at the moment and that we will look to do this in the future once we have the meetings in order.

AR talked about a project which will be looking at engagement within PCNs and this will assist the PCNs to do better engagement which will include the PPGs.

Howard Clarke-Melville was elected as the vice-chair for the Redbridge PEF.

5. News round up (MP)

MP said that BHR CCGs have been rated green by NHSE/I and have been praised for its partnership working. The CCGs have formed transformation boards for priority areas of work (urgent care, children and young people, long term conditions, planned care, primary care, older people and frailty, and cancer) which involve our local authorities and other partners.

Action 5.1: AR to circulate the names of the transformation boards

It’s the worst time of year for A+E and this is the case across the country. Tony Chambers, new interim CEO is making A+E recovery a priority. Both BHRUT and NELFT have interim CEOs and that they are looking to have one joint CEO for both organisations in the future.

Action 5.2: Invite Tony Chambers to a future meeting.

The latest draft of the north east London Long Term Plan is available on the website – this is called the Strategy Delivery Plan and sets out how we will work together to respond to our known challenges. The East London Health and Care Partnership (ELHCP) also has a newsletter, you can sign up here

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North east London Integrated Care System (ICS): main objective of this is to stop the divide between commissioners and providers and work together better. Marie Gabriel is the new independent chair for the ICS and brings a wealth of experience and knows the patch very well.

MP explained there will probably be a population budget and that it is likely that this will still be regulated by NHS England.

In April 2021 we will become North East London (NEL) CCG which will bring together all of the CCGs (Barking and Dagenham, Havering, Redbridge, Waltham Forest, Newham, Tower Hamlets and City and Hackney) and will see a new way of doing things.

Action 5.3: AR to circulate updated estates slides from the joint PEF meeting.

Following our consultation on urgent care in 2018 the CCG has now commissioned PELC and NELFT to deliver urgent care services. There will be four new urgent care treatment centres.

KA was joint chair of programme board throughout the procurement. They have ensured that patient’s views were taken into account and the views have been developed as part of the outcome measures for the contract performance.

The urgent care brand needs work and will come back to the PEF at a later date.

A new service providing health checks for homeless and rough sleepers is now in place in partnership with the local authorities. Lots of work going on in Redbridge. Please connect rough sleepers to the Welcome Centre so they can receive their health checks etc.

The CCG has recently supported two practices to relocate to Kenwood Gardens in portakabins on a temporary basis.

Action 5.4: AR to share more details about the UTCs with the group.

Discharge: British Red Cross gave leaflets when leaving the hospital but they were for services in Havering and B+D and not Redbridge.

Action 5.5: CCG to look at the leaflets and how they are funded.

6. AOB

Members agreed the library is a good location for the meeting going forward.

Question about carers and if they are reorganising.

Action 6.1: CCG to look into whether there are changes happening.

A member raised that David Hall, who used to be a member, is not very well

Action 6.2: Letter to be sent on behalf of the PEF to say thank you for everything he has done.

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Action Log

Date Number Action Status Responsible 25/06/2019 N/a Provide a breakdown of how the Open Matt Henry 716 affected treatments in Redbridge compares to the 180,000 day case, inpatient and outpatients procedures commissioned by BHR CCGs last year 25/06/2019 N/a Send PEF members information Open CCG on how the virtual fracture clinic works 25/06/2019 N/a Investigate whether there is a Open CCG rheumatologist at Barts and update PEF members 25/06/2019 N/a Each PPG/GP practice to be Open AR/MP emailed to invite representatives to attend PEF meetings 04/02/2020 5.1 Annie to circulate the names of Closed AR the transformation boards 04/02/2020 5.2 Members would like to invite Closed AR/MP Tony Chambers to a future meeting. 04/02/2020 5.3 Annie to circulate updated Open AR estates slides from the joint PEF meeting. 04/02/2020 5.4 Annie to share more details Open AR about the UTCs with the group. 04/02/2020 5.5 CCG to look at the leaflets and Closed AR how they are funded. 04/02/2020 6.1 CCG to look into whether there Open AR are changes happening to carer coordination in Redbridge 04/02/2020 6.2 Letter to be sent on behalf of the Open CCG PEF to say thank you for everything he has done

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273 Barking and Dagenham Patient Engagement Forum catch up 6 May 2020

Attendees Sahdia Warriach Peter Hopper Manisha Modhvadia (Healthwatch) Annie Robertson (CCG) Melissa Hoskins (CCG)

Apologies Ken Humphries Miriam Greenwood

Notes from the meeting

• Melissa gave a CCG update: o It’s a busy time in the NHS at the moment and all partners are working closely together. o The CCG office at North House is formally closed with only a few ‘skeleton’ staff including the IT team. All other staff are working from home or have been redeployed. o All partners have had to adapt to different ways of working very quickly. o BHRUT changed how they operate within 24 hours including rapidly discharging patients and ensuring they had the correct care and support at home. o Over one thousand COVID patients have been discharged o The Trust has been providing people with ipads so they can keep in touch with loved ones and also started an online messaging service. o NELFT has also changed how they operate and have been providing services over the phone or via video. o When people need to be seen in person they are. o Practices are open as ‘business as usual’ and have been coping really well by working together and enabling remote working for staff who are isolating, for example. o A local GP, Dr Zishan Haider, sadly lost his life from COVID-19. o Practices will continue to triage people over the phone so that this limits risks to patients and to practice staff. o Now that people are returning home we are looking at what service we can bring back safely. o Lots of great work has been happening and the world has changed so we need to look at what we will continue to do as we move into the ‘new normal’.

• Annie told members about a faith project where we are engaging with the faith communities across the whole of north east London to find out what we can do to support them during the pandemic. There’s a Barking and Dagenham, Havering and Redbridge weekly call which includes faith leaders, faith forums, BHRUT chaplaincy and NELFT chaplaincy and this has created a helpful network for now and in the future.

• Annie also updated the group on a joint project with the Youth Councils in Barking and Dagenham, Havering and Redbridge which will be looking at how young people are feeling with an aim to come up with some innovative ideas of how we could support people.

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• A general discussion was had about how everyone is feeling at the moment.

• An issue was raised about continuing healthcare provision that has been paused due to shielding and concerns that retainer will be stopped. Annie will help with the specific query offline.

• A question was asked about the urgent care services and GP hubs and whether they are operating. The services are running but you are unable to walk in. People will be treated differently if they have COVID-19 symptoms. People should contact NHS111 first, either online or by phone.

• A discussion was had around the impact on mental health and how services are coping.

• Manisha updated the group on her work with BD CAN which is supporting people in the community to get food supplies, medication and support. Healthwatch will also be looking into people’s health and social care experiences.

• Everyone agreed that this is a good way to communicate but potentially we should be offering this as a phone option as well to make it more accessible – this is possible within the parameters of Zoom. Annie is going to contact the PEF members who didn’t attend the meeting and find out why. Annie will also have a discussion with all of the PEF chairs to discuss the next meeting.

275 Havering Patient Engagement Forum catch up 5 May 2020

Attendees Vikki Kamm Carole Loveday James Crouch Ashley Doctors Helena Cowin Ian Buckmaster (Healthwatch) Annie Robertson (CCG) Melissa Hoskins (CCG)

Apologies Richard Coleman

Notes from the meeting

Annie introduced the meeting and explained it’s an informal meeting as it is the first time to meet using Zoom.

• Melissa gave a CCG update: o It’s a busy time in the NHS at the moment and all partners are working closely together. o The CCG office at North House is formally closed with only a few ‘skeleton’ staff including the IT team. All other staff are working from home or have been redeployed. o All partners have had to adapt to different ways of working very quickly. o BHRUT changed how they operate within 24 hours including rapidly discharging patients and ensuring they had the correct care and support at home. o Over one thousand COVID patients have been discharged o The Trust has been providing people with ipads so they can keep in touch with loved ones and also started an online messaging service. o NELFT has also changed how they operate and have been providing services over the phone or via video. o When people need to be seen in person they are. o Practices are open as ‘business as usual’ and have been coping really well by working together and enabling remote working for staff who are isolating, for example. o A local GP, Dr Zishan Haider, sadly lost his life from COVID-19. o Practices will continue to triage people over the phone so that this limits risks to patients and to practice staff. o Now that people are returning home we are looking at what service we can bring back safely. o Lots of great work has been happening and the world has changed so we need to look at what we will continue to do as we move into the ‘new normal’.

• Annie told members about a faith project where we are engaging with the faith communities across the whole of north east London to find out what we can do to support them during the pandemic. There’s a Barking and Dagenham, Havering and Redbridge weekly call which includes faith leaders, faith forums, BHRUT chaplaincy and NELFT chaplaincy and this has created a helpful network for now and in the future.

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• Annie also updated the group on a joint project with the Youth Councils in Barking and Dagenham, Havering and Redbridge which will be looking at how young people are feeling with an aim to come up with some innovative ideas of how we could support people.

• A question was asked about the hospitals’ policies relating to discharging Covid patients into care homes. Melissa explained that each trust will have a different policy and the local trusts are working with the care homes to ensure safe discharge for these patients – this could be that the care home are able to accept the patient back safely or that they are discharged into different care in the community until it is safe to return to their normal residence. There’s a lot of work going on to ensure peoples’ safety.

Action: Ian is going to share the Havering Healthwatch death statistics report with everyone. Action: Melissa is going to share some more information about discharge into care homes.

• Generally feedback about GP practices was good and people feel that they are coping really well. Members were asked to let Annie know if any issues with their practices so that this could be fed back to the primary care team.

• A discussion was had around whether people should attend routine blood tests now. We have been doing blood testing via appointment throughout the pandemic and if you are due a blood test, please speak to your GP.

• There was some really good praise to services that were received virtually.

• Concerns around how to move forward with issues with children with special educational needs or disabilities (SEND). Queens are looking at how to get these appointments back online.

• There was a general theme of missing seeing loved ones but also being very grateful for having gardens.

• Issues with shopping was raised and it being very difficult to get delivery slots.

Action: Annie to send round a list of what’s available from the large supermarket chains and also clarify the support from the Council and Havering Volunteer Centre.

• Ian from Healthwatch told members about their ‘Friends Network’ (which you can join by clicking here) and also a befriending service that they are offering to volunteers.

• Everyone agreed that this is a good way to communicate but potentially we should be offering this as a phone option as well to make it more accessible – this is possible within the parameters of Zoom. Annie is going to contact the PEF members who didn’t attend the meeting and find out why. Annie will also have a discussion with all of the PEF chairs to discuss the next meeting.

277 Redbridge Patient Engagement Forum catch up 7 May 2020

Attendees Dee Datta Khalil Ali Michelle Greenwood Swati Vyas Raina Gee Howard Clarke-Melville Cathy Turland (Healthwatch) Annie Robertson (CCG) Melissa Hoskins (CCG)

Notes from the meeting

• Melissa gave a CCG update: o It’s a busy time in the NHS at the moment and all partners are working closely together. o The CCG office at North House is formally closed with only a few ‘skeleton’ staff including the IT team. All other staff are working from home or have been redeployed. o All partners have had to adapt to different ways of working very quickly. o BHRUT changed how they operate within 24 hours including rapidly discharging patients and ensuring they had the correct care and support at home. o Over one thousand COVID patients have been discharged o The Trust has been providing people with ipads so they can keep in touch with loved ones and also started an online messaging service. o NELFT has also changed how they operate and have been providing services over the phone or via video. o When people need to be seen in person they are. o Practices are open as ‘business as usual’ and have been coping really well by working together and enabling remote working for staff who are isolating, for example. o A local GP, Dr Zishan Haider, sadly lost his life from COVID-19. o Practices will continue to triage people over the phone so that this limits risks to patients and to practice staff. o Now that people are returning home we are looking at what service we can bring back safely. o Lots of great work has been happening and the world has changed so we need to look at what we will continue to do as we move into the ‘new normal’.

• Khalil talked about his work in north east London (NEL) to do with social prescribing where there is a lot of things happening. He said plans are still going ahead to form integrated care systems within NEL. He said he’s concerned that people are struggling with food poverty and that moving forward we need to involve our faith groups and community and voluntary sector as an integral part of the system and ensure they are supported in every way possible.

• A discussion was had around staff health and wellbeing as the current situation is putting pressure on people and they need the correct rest, advice and support. Barts and BHRUT has offered staff significant support and now the CCGs are doing the same as they recognise this is a very stressful time for most people.

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• Swati gave an update on the work of the CVS. They have had around 600 people with various skillsets sign up as volunteers via the Volunteer Centre and 200 of those have been placed in health and social care settings. They are continuing to support the 1000+ community and voluntary groups and have been helping them to access emergency funding where needed. They are also providing the social prescribing service remotely by phone and video and a new service is opening to support the health and wellbeing of carers.

• Annie told members about a faith project where we are engaging with the faith communities across the whole of north east London to find out what we can do to support them during the pandemic. There’s a Barking and Dagenham, Havering and Redbridge weekly call which includes faith leaders, faith forums, BHRUT chaplaincy and NELFT chaplaincy and this has created a helpful network for now and in the future.

• Annie also updated the group on a joint project with the Youth Councils in Barking and Dagenham, Havering and Redbridge which will be looking at how young people are feeling with an aim to come up with some innovative ideas of how we could support people.

• Concerns were voiced around the prevalence of COVID-19 in the BAME communities and a discussion was had around the lockdown restrictions changing and people who are shielding might need further clarification as many people have made their own interpretations of the rules. Annie is happy to try and help clarify anything following the announcement on Sunday.

• Raina gave a helpful update about the youth council and how they are feeling. They will be looking at what their priorities will be going forward. Young people are worried about school (some have had lots of contact from their schools – others have had little), some are worrying about their parents for the first time as they are key workers and others have taken on caring responsibilities. Other issues have included running out of data, not having wifi and issues with having to share computers with other family members.

The Youth Council has made some videos: https://www.youtube.com/watch?v=bOkrugkdvqk&t=2s https://www.youtube.com/watch?v=AeMqaNertvU

• Healhtwatch is continuing to work closely with the CVS. They are looking into the discharge process back into care homes and have started conversations with them to gather insight. Melissa is going to link Cathy with the correct person at the CCG to share this information with as care homes are a key concern for CCGs, local authorities and trusts.

• Everyone agreed that this is a good way to communicate but potentially we should be offering this as a phone option as well to make it more accessible – this is possible within the parameters of Zoom. Annie is going to contact the PEF members who didn’t attend the meeting and find out why. Annie will also have a discussion with all of the PEF chairs to discuss the next meeting.

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Minutes of the Joint PEF 15 July 2020

Attendees Apologies Nicholas Hurst (chair) Carole Loveday Richard Coleman Alan Surtees Sahdia Warraich Doreen Surtees Khalil Ali Christine Brand Vikki Kamm Miriam Greenwood Dee Datta Harjit Sangha Ron Wright Raina Gee Swati Vyas Ian Buckmaster Val Shaw Anita Thomas Lorraine Silver David Lyon Gwen Kirby-Dent Vivien Nathan Jiwain Jain CCG staff Howard Clarke-Melville Ceri Jacob, Managing Director Chandrakant Patel Alison Blair Ken Humphries Melissa Hoskins, Head of Communications Jim Crouch and Engagement Michelle Green Annie Robertson, Communications and Engagement Manager

1. Welcome and introductions

2. Minutes, matters arising and action log There were no issues raised about the previous minutes. Members were asked to email any comments and if none received these would be signed off as accurate. No matters arising.

3. Our Recovery Plan Ceri Jacob, Managing Director of the BHR CCCs gave a brief update. She praised the fantastic work that had happened on all levels; individuals, teams and the joint working across the system. It’s been an incredibly intense time for all staff and many have been personally affected by the pandemic – she’s very proud of everyone. She talked about how we have tackled the pandemic as a system in four ways by: 1. Building capacity 2. Preventing infection 3. Developing a flexible workforce 4. Putting patients first. Some service changes had to be made to respond to the pandemic – these have been shared with PEF members. We now need to find out what this feel like for patients now that’s it’s virtual and services are being provided in different ways. North East London has recently commissioned some work to gather feedback from patients. Nothing is considered as permanent until we have consulted with the public. Although we seem to be much quieter now, staff are still working incredibly hard. Restarting services safely is tough and complex and people are still very busy. Ceri went through the questions submitted before the session.

Q. What has the uptake and continued use of tech been like with GPs? In particular, video calling in place of in-person appointments?

A. GPs generally embraced the technical solutions - this had to happen very quickly. The digital offer is something we have tried to encourage for the past few years. Some use video less and telephone more but it is available in all practices. It will need to stay there and for the vast majority of patients it will be a phone call or video call that is offered to them to ensure patient and staff safety.

Q. I’m unsure about how GPs are working, particularly given that we have had at least one GP death.

A. There is a requirement for all providers to do risk assessments and the staff, particularly black, Asian and minority ethnic (BAME) staff and older staff. The staff at most risk will work remotely with patients. For some practices all of the staff have fallen under an at-risk category and this is where working in Primary Care Networks (PCNs) has come into play. During the Covid-19 response, practices have been working much more closely together to be able to deliver care safely.

Q. How are the patients triaged as to if they need to be seen in person?

A. Patients are triaged by telephone or video and if they do decide that they need to see the patient then they will be seen. Either the patient will be seen at the practice (as a rule, practices are kept clean and covid-free, known as a ‘green’ site) and all of the infection control measures are in place (PPE, hand sanitisers etc). If someone is potentially covid- symptomatic, someone will either go out to them or they go to a ‘hot hub’. There were hot hubs in each borough during the height of covid and one team of people dealing with people who are covid-symptomatic.

Q. How are new patients being screened by GP surgeries?

A. There is a new approach to this now and people no longer need to go to the surgery to do this unless they absolutely need to.

Q. How are older patients who are unable to utilise virtual consults/video able to access services?

A. These patients are still being offered face-to-face appointments. There are two groups of patients; those who need hands on examination and those who using technology is not possible. Consideration has also been given to those who may not be able to have the initial telephone consult, for example, people with learning disabilities or homeless people. All practices are open, the door might be locked, but someone will be able to come the door and speak to you.

Q. How long is this system in place for - has this become the new normal?

281 A. The digital offer is will continue post-covid but nothing is permanent until we’ve found out how patients have found this, and there will have to be tweaks. Digital is something we have wanted to move towards and this also increases capacity within the workforce.

Q. Do we need as much physical space? A. Possibly not, however, we need extra space to ensure infection control and we do have a growing population. We wouldn’t expect to see us closing any capacity in terms of building space but we are still understanding the impact of what has happened.

Q. We all know there is a risk of a surge of undiagnosed conditions as people aren’t seeking treatment either because they are reluctant to go to hospital or they don’t know how to access the GP. What is being put in place to deal with that anticipated surge?

A. GPs are proactively seeking out patients that they would usually see, people with long term conditions, for example. The GPs are working together and have already seen a steady increase of people following the ‘NHS open for business campaign’ which was about encouraging people to seek help if they need it.

Q. How are GPs screening for cancer? A. We are expecting to see an increase of late presentations – this is a real concern. In BHR cancer treatment did not stop – this got moved to a covid-free area. GPs will still do a two- week referral. We are increasing/improving blood testing services which is also a pathway for cancer detection. GPs can still call in patients to physically examine them – although they are more likely to make the two-week referral straight away if they have concerns.

Q. Are the PPGs having an involvement in the changes to primary care? A. The picture is different in practices – they can’t come into the practice to have their PPG meeting now so it needs to be virtual. Practices should still be involving them and we could go out and give them some further prompts.

ACTION 3.1: Annie and Melissa to work with primary care on a message to practices regarding PPGs

Q. Families with SEND children have been impacted in different ways and in many cases, medical care has been halted so as we come through this there will be more families in need - are GPs ready for these families? Will there be additional capacity?

A. If there is a health element it would be around assessing the person’s needs. All GPs are quite a long way through the process of seeing people that should have been seen. We have children and young people’s board led by the director of people at Barking and Dagenham Council. They are also looking at actions that we need to take to support young people post-covid. Local authorities will also be looking at other sorts of support for parents with SEND children.

ACTION 3.2: Share more information about these plans with PEF members. ACTION 3.3: Schedule an update from CYP board for future PEF. Q. Has the operational relationship between Redbridge CCG and the hospital trusts changed over the last 6 months?

A. It was already quite good with the acute trusts, we’ve done a lot of work together over the past few years - we had an integrated financial recovery plan which was the only one in

282 London that crossed with CCG and provider. Our transformation boards also meant we were already working together. To support the trusts throughout covid we did deploy some of our staff into the trust to help with some of the back-office functions. There has been lots of collaboration.

Q. How is the backlog of elective care going to be reduced?

A. The number they can see is less because of infection control. King George Hospital is a mainly ‘green’ site and separated out areas so that they can get through the back log. There is still a number of patients declining to come forward because patients have to self-isolate two weeks before the procedure and then two weeks after – self isolating for one month feels too much for some people. There will be risk stratification of waiting lists so those at a clinical risk of waiting will be brought forward.

Q. What is the capacity at Queens? A. It’s still slightly more than it was pre-covid – we had to increase capacity due to covid. You will see this in the list that Annie sent.

Q. How is the referral pathway to see a consultant? Same as normal – it’s sent electronically from GP. Most appointments are over the phone where possible. However, referrals are down as people are choosing not to come in.

Q. What does the development of the PCNs look like at present given the virus situation and its impact on everything?

A. PCNs are doing all the mutual support – covering sickness and staffing, and sharing PPE and equipment. The pandemic has helped them to gel even more and see the benefits. The GP Federations have also stepped up to the mark and worked well together creating the hot hubs. The PCN development work has shown resilience. The next surge is expected during flu season. We will be doing everything we can to maximise uptake on the flu vaccine. Some of the symptoms are similar to covid and it’s the same people that are at risk. Practices are looking at church halls and car parks to run flu clinics in the community.

Q. What are the waiting times for IAPT? A. There is a back log that they are working their way through this. They have increased capacity for KOOTH which is a counselling service for young people. Figures are indicating up to a 30 percent increase in referrals. The mental health trusts have adapted the way they work and have been using video appointments. Some people liking this so they will continue some of this in the future. The statistics are showing that the number of young men experiencing their first psychotic episode has increased. We have been building capacity within the system to deal with this. We are working very closely with the local authorities as poverty is a big driver. For many people coming out of lockdown will bring anxiety.

ACTION 3.4: CCG to send round IAPT waiting times Q. There has been lots of concerns expressed about the blood testing services. What’s the current position?

283 A. During the height of the pandemic, phlebotomy was suspended, however services are opening again with the exception of the service at the former Wanstead hospital site (although we hope this will reopen by the end of July), and the hospital settings are running a very limited service. All blood testing is currently by appointment only and there is now an online booking for this which is an offer we have never had before. Pre-covid we were planning on moving some of these services into community settings and we plan to have blood testing available in practices – at least one service in every PCN.

4. Open conversation: your experiences of services Below are is the feedback from PEF members. “I didn’t get my shielding letting until 17 June.” “I have a friend who was put on the shield list later on in the pandemic – they were at risk by going out and this could have been far more serious.” The letters were initially sent from specific data from the national system. It might be that they didn’t fall under the specific criteria set out. These people were put on the shielded list which triggered a range of support. The list was then shared with GPs and consultants to see what had been missed so other people were added later. “I was on the shielded list from the GP so it was a bit later than it would have been done. It did happen fairly quickly and quite well.” “I’m the chair of the welfare committee at my synagogue and have been coordinating ring rounds to isolated members. There has been lots of confusion around where people have received letters or not but they are over 70 and must shield. A lot of them are reluctant to leave the house now as they’ve been at home 3 or 4 months. There’s going to be a lot of mental health issues for people who have had to shield.”

ACTION 4.1: CCG to share latest national guidance for shielded patients. “It took ages to get onto the shield list and then it took about six or seven weeks before there was any support.” “I’ve been told by Queens that ordinarily their waiting list would be towards the end of June but they are about a month behind – I’m hoping a video call or phone call instead will be possible” We are not sure of waiting times but they will almost certainly provide the appointment by phone call or video if this is appropriate. “At my surgery we’ve had a PPG meeting on Zoom – it was the largest attendance and lots of people who were unable to come in the past could join in as this made it more accessible for them.” “My surgery had two PPG meetings at the beginning of the year and the practice manger has left. We’ve had no contact from the main partner about who the new practice manager is. I’m disappointed that the practice hasn’t made any contact.”

Action 4.2: CCG to follow this up with the primary care team. “There are good people and good systems out there.” “There’s no drop off point for Barts in our areas for samples. Where can I drop off a sample?”

284 ACTION 4.3: CCG to send more guidance and advice to GPs about where to send patients. 5. Upcoming communications and engagement The communications and engagement team has been very busy sharing information, building up networks and working alongside our voluntary sectors. We have developed a new BHR Faith Forum where we’ve been talking about specific issues such as death and bereavement and the reopening of worship places. We’ve also been working the three youth councils and developed a questionnaire to find out how young people have been feeling throughout the lock down. The survey in Redbridge has received over 900 responses and we presenting our findings from all three boroughs to this children and young people transformation board. We had identified changes to be made to:

• Blood testing • Community diagnostics • Community diabetes • Anticoagulation • Wound care These proposals are being looked at again. We need to hear about the experience of services from patients. We have a lot of work to do going forward and we want to do it in a way that works for patients. We’ve also been working on the interpreting service provided at GP practices. Healthwatch had started some work before the lockdown and they have now finished and supplied the reports. We’re now looking at what this has been telling us but we will also need to build in the covid experiences. For urgent care services, some of the changes have progressed but things have had to adapt due to the pandemic. Loxford is now a bookable GP hub. We need to get feedback from people about how people have found accessing the service. We have a much better connection with PPG chairs whom we now regularly communicate with and we will be initiating some work with PCNs around how we can help them to engage better with patients.

Q. Is Barking Hospital now walk in and bookable? A. There is access for people to walk in however, we are trying to encourage people to call 111 first so that they can manage people going there.

Q. Is this going to have a knock-on affect at King George and Queens? A. The plans are that there will be lots more capacity in the community. Hubs and urgent treatment centres are now available to patients.

Q. How are we allaying fears of potential local lockdowns such as Leicester?

285 A. We work closely with the councils and there is work going on so if we get to that point we know how will we reach out. Our engagement work is also looking at making messaging clear and easy to understand for everyone.

6. AOB There was no other business.

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DRAFT

Barking and Dagenham, Havering and Redbridge CCGs; Barking, Havering and Redbridge University Hospitals NHS Trust; North East London Foundation Trust Minutes of the BHR Health System Quality and Performance Committee 20 August 2020 - 12:30 – 14:00 By video conference

Members: Dr Sarah Heyes (SH) - CHAIR Clinical Director, Redbridge CCG Mark Gilbey-Cross (MGC) Deputy Nurse Director – Acting, BHR CCGs Dr Jagan John (JJ) Chair, B&D CCG Dr Atul Aggarwal (AA) Chair, Havering CCG Dr Anil Mehta (AM) Chair, Redbridge CCG Khalil Ali (KA) Lay Member, Redbridge CCG Sahdia Warraich (SW) Lay member, B&D CCG Lorraine Bess (LB) Director of Nursing (Quality & Patient Safety), BHRUT Jacqui van Rossum (JvR) Executive Integrated Care Director (London), NELFT Jacky Hayter (JHa) Director of Performance and Business Intelligence NELFT Dr Vincent Perry (VP) Deputy Medical Director, NELFT Dr Magda Smith (MSm) Chief Medical Officer, BHRUT Steve Rubery (SR) Director of Commissioning and Performance, BHR CCGs Tracy Welsh (TW) Director of Transformation & Delivery – Planned Care, BHR CCGs

In Attendance: Ceri Jacob (CJ) Managing Director, BHR CCGs Keeley Chaplin (KC) Business Manager, Governance Team, BHR CCGs Jeremy Kidd (JK) Deputy Director of Delivery (Planned Care) BHR CCGs Hilary Shanahan (HS) Interim Head of Quality and Clinical Governance, BHR CCGs Richard Pennington (RP) Deputy Chief Operating Officer, BHRUT Aleks Hammerton (AH) Deputy Chief Operating Officer, BHRUT Carol White (CW) Integrated Care Director (Havering), NELFT Raju Rahim (RR) Provider Performance Improvement Manager, NELCSU John Flood (JF) NEL Provider Performance Director, NELCSU Alison de Metz (AdM) Head of IFR & HPSU, NEL – for item 6 Margaret Benbow (MB) IFR Team Manager, NEL - for item 6

Apologies: Kathryn Halford OBE (KH) Chief Nurse and Deputy Chief Executive, BHRUT Shelagh Smith (SS) Chief Operating Officer, BHRUT Stephanie Dawe (SD) Chief Nurse, NELFT Caroline Allum (CA) Medical Director, NELFT Diane Searle (DS) Director of Nursing (Patient Safety), NELFT Jacqui Himbury (JH) Nurse Director, BHR CCGs Susan Smyth (SS) Director of Nursing (Clinical Effectiveness), NELFT Bob Edwards (BE) Integrated Care Director (Redbridge), NELFT Melody Williams (MW) Integrated Care Director (B&D), NELFT Sharon Morrow (SM) Director of Transformation & Delivery – Unplanned care, BHR CCGs

Item Action 1.0 Welcome, introductions and apologies The Chair welcomed all to the virtually held meeting 1.1. Declaration of conflicts interest The Chair reminded committee members of their obligation to declare any interest they may have on any issues arising at committee meetings which might conflict with the business of BHR CCGs.

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No further conflicts of interest were declared other than those on the CCGs register.

The register of interests held for BHR CCGs Governing Body (GB) members and staff is available from the Company Secretary.

1.2. Minutes of the meeting held on 23 July 2020 The minutes of the meeting held on 23 July 2020 were agreed as an accurate record.

Performance 2.0 Performance against Constitutional Standards 2.1. BHRUT RP gave an overview of performance as presented to the Trust Board. RP highlighted that both sites have continued to see an increase in attendances which had reduced in April due to the Covid19 pandemic. All specialties are producing a recovery plan. Queens’ hospital theatres will be operational from September 2020. This will enable surgery for complex cases as well as general day cases to re-commence. Diagnostics have seen a reduction in overall breaches.

The Committee noted the performance report.

2.2. NELFT JHa presented the Integrated Performance Report which shows the NELFT BHR final position for Quarter 4 and the latest Quarter 1 figures. BHR IAPT actual v target for Q1 was 99.3% with 982 people entering treatment against target of 989 for that quarter. Waltham Forest compliance was Q1 86.1% 408/474.

Referral to Treatment (RTT) waiters for Community Paediatricians has increased across NELFT following earlier national guidance for service closures therefore Q1 compliance declined. Focus is now on recovery. Access to children’s services has seen a slight dip, although safeguarding continued to be prioritised.

Across London and nationally there has been a huge surge for mental health services and daily escalation calls are being held due to the pressure for beds. NELFT have worked closely with colleagues across the healthcare system and have continued discussions on priorities and preparation in the event of a surge.

NELFT have secured dedicated beds with ELFT.

KA thanked NELFT for their report and asked if there had been any improvement in safeguarding one to one supervision. JHa will arrange to JHa provide the position on this.

The committee noted the report.

2.3. Other providers JF provided the Committee with a view of performance against constitutional standards for Barts Health with CCG level performance data for the Mental Health standards.

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Performance in the 4-hour A&E target has significantly improved with Whipps Cross at 92% in June and 91.93% in July. Attendances are not far from pre-covid levels compared to last year but performance is holding up.

While referrals are starting to increase they remain well below the pre Covid level and despite the reduction in PTL size, performance has deteriorated significantly due to the national pause in elective activity, with only 54% achievement against the 92% 18-week Referral to Treatment (RTT) standard as at May 2020. RTT recovery is being led at NEL level in line with the NEL Elective Re-start Strategy. The NEL Operational Elective Re-start Group has also been established to support delivery of the overarching strategy.

IAPT access demand could increase when schools go back and this is being monitored. NELFT are keeping a close track on numbers and have an agreement with ELFT to manage the numbers within the STP. There has also been an adverse performance impact on dementia mainly due to access to care during lockdown. Pressures on out of area placements will be ongoing into winter.

The Chair asked if NELFT will do some proactive work with schools so they know they can refer directly and not try to send children to their GP. NELFT agreed that they can arrange a communication on this. JVR/CW

The committee noted the report.

3.0 A&E recovery deep dive MSm reported that members are aware of the emergency access performance challenges. Attendances experienced a significant decline during Covid but is now coming back to pre-Covid type 1 attendances.

BHRUT have reviewed each point of the pathway and how patients are assessed and have ensured escalation processes are in place and patients in the Emergency Department (ED) receive regular senior reviews. Frailty wards have now moved back in Queens, with KGH already set up. Regular patient safety discussions are held in ED. An emergency access task force has been set up to review all actions and put in additional support and additional actions if needed. The 7/21 days stranded are similar pan London. BHRUT are also working with the integrated care system (ICS) for peer review of plans and processes.

SR added that the CCG also has a weekly discussion on any current issues. NEL CCGs AO joins this discussion monthly.

KA thanked MSm and the team for their hard work especially under the current circumstances and would be interested to know how well the GP advice and guidance is working. KA queried the diagnostics data. RP advised the diagnostics overall breaches was around 67% at end of June but this is coming down slightly as CT activity is back up to pre-Covid levels and MRI is at 70-80% of what it was before. BHRUT are working across all imaging and endoscopy modalities with NHS England. Endoscopy commenced earlier and is on track to recover its position at end October, with imaging on a similar track but is contingent upon weekend and extra clinics as well as the use of the independent sector. SH suggested a communication is sent out to all GPs on how the Trust is operating to TW/RP

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reduce the backlog.

Barts Health is doing well on the 8 key cancer standards.

Regarding the Barts Health PTL there is some work being undertaken with general practices regarding patients being discharged to GPs too soon, CJ therefore this will be logged as a concern and CJ will pick up with the WEL CCGs MD who lead on the contract for Barts.

The committee noted the update.

4.0 Cancer Recovery Action Plan update RP reported that while the volume of Two Week Wait (2ww) referrals it receives has returned to pre-Covid levels as lockdown eases and patient confidence returns, there continues to be a significant proportion of patients who are refusing to attend Cancer appointments. This, and access to diagnostics, which are running at lower capacity then pre-Covid remain as particular challenges to recovery. However, the Trust anticipates reporting a compliant position for August.

For the 62-day cancer performance standard, performance for June was 45% against a target of 85%, primarily due to diagnostics capacity and patient choice due to Covid. Performance is expected to be below the target with July provisional position at 54.4%.

The one stop clinic for breast cancer patients has been restored and during July saw 200 more patients than the average which is helping to reduce the backlog. In the skin pathway, the service saw an additional 100 patients during July.

Performance reduced in upper and lower GI as endoscopy ceased during the pandemic, which was based on national guidance. This could culminate in late diagnosis and breaches but the Trust have increased capacity as much as possible and is expecting to be back on course by the end of the year.

The committee noted the update.

Quality 5.0 Quality and Safeguarding 5.1. BHRUT LB advised the CQC have recently requested information relating to patient deaths including Root Cause Analyses (RCA), as they are not yet visiting sites. The Trust has taken a number of actions on learning and management of these to provide additional assurance to the CQC. The Trust Executive team are aware on the positions of each and the team have weekly calls with the CQC with MGC invited to join from the CCG. An external company has been commissioned to review some Serious Incidents (SIs). The governance of SIs has transferred from acute medicine into corporate with an internal team to support this work. The BHRUT Infection Prevention and Control Board Assurance Framework (BAF) has been submitted to the CQC who have reported there are no significant gaps but actions are being taken to address the gaps identified. MGC noted that from a CCG perspective we have been given full oversight on governance on ED and are assured on the work being taken forward.

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The Committee noted the verbal update.

5.2. NELFT JVR gave a briefing on quality and safeguarding in NELFT with a formal report being available from September which will report by exception. During July the safeguarding team supported staff via the safeguarding advice service for children and adult queries. The Safeguarding Partnership Board has reconvened. NELFT are reporting on trends on Covid related incidents, and in addition are looking at pressure ulcerations including deep tissue. All patient incidents have been uploaded onto the national reporting and learning system. It was noted there has been an increase of suicide in young people across the organisation which includes Kent, Essex and London. The NELFT Infection Prevention and Control BAF has also been submitted with evidence to the CQC and they advised they have no concerns.

The committee noted the verbal update.

5.3. System quality and safeguarding report MGC gave an overview of the system quality and safeguarding report highlighting the following:

Since the last report BHRUT have declared one Never Event related to a retained foreign object following a surgical procedure.

Across BHR two independent investigations have been completed with the emphasis now on review and monitoring of related action plans. The first one relates to a patient who passed through the care of PELC, BHRUT and London Ambulance Service (LAS). The second investigation relates to a patient whilst an inpatient at NELFT and an update will be provided at the next meeting.

During the Covid-19 pandemic all BHR CCG safeguarding functions have continued. Team members supported the Nightingale LDN Hospital with input into all safeguarding functions from a strategic and operational perspective. All NEL designated professionals (adults & children) worked together on a system-wide safeguarding risk log which identified Covid specific risks which was fed back to CCG system safeguarding leaders and has been shared at all Safeguarding Adult Boards and with Safeguarding Children Partnerships with BHR designated professionals using the risk log as a basis of an ongoing Covid related work plan

Two additional members of the CCG’s safeguarding adults’ team have been recruited and this will enable BHR CCGs to have a dedicated Designated Nurse for Adult Safeguarding allocated to each borough.

The Liberty Protection Safeguards (LPS) will replace the current Deprivation of Liberty Safeguards (DoLS) arrangements and is expected to come into force in early 2022.

The BHR Quality Surveillance Group (QSG) continues to monitor quality assurance and safeguarding issues in Care Homes with Nursing across the three boroughs.

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The BHR Child Death Overview Panel (CDOP) chairs and Local Safeguarding Children Board (LSCB) chairs endorsed to combine the three existing CDOPs and child death review process into a single arrangement.

This year’s winter plans will have a greater emphasis on preventing hospital admissions and attendances and initial conversations have begun with CSU IPC colleagues to review current support arrangements into community-based services such as care homes around such elements as nutrition, hydration and effective skin care management to prevent pressure ulcers.

The Acting Deputy Nurse Director has proposed a BHR System Flu Oversight Group. It is expected that membership will be made up of provider flu leads, Directors of Public Health and colleagues from the three local authorities. Further updates will be provided at future Quality & Performance Committee meetings.

CJ noted the flu vaccination campaign in primary care is extensive and with the expanded flu plan for this year it should be clear who is included the group and who is funded. Primary Care are working with practices, PCNs and Federations to order adequate supplies and practices have been asked to order their PPE through normal routes. The SOCG are working with community and acute trusts to vaccinate as many people as possible. NHS staff will also be offered the flu vaccination. However, GPs are anxious there may not be enough supplies and will initially vaccinate their most vulnerable patients before vaccinating the new cohort of over 50-year olds.

The committee noted the August report.

Other issues 6.0 Policies 6.1. BHRUT Once for London IFR Policy The launch date for the Once for London IFR service was 1 April 2020 with implementation phased over April - June 2020. However, these plans were put on hold while resources were prioritised to tackle Covid-19. Implementation has now resumed with a revised ‘Go Live’ date of 1 October 2020.

The policy includes all the relevant documentation such as proposed IFR panel and appeals panel terms of reference and membership, ethical framework and checklists to guide decision making, IFR process summary flowchart, IFR governance arrangements, patient information leaflet, equality screening outcome

The committee approved the draft Once for London IFR policy.

6.2. Managing safeguarding allegations against staff - adults MGC presented the policy and procedure to provide a framework for managing cases where safeguarding allegations are made against CCG staff, regardless of whether they are made in connection to duties within the CCG or if they fall outside of this such as in their private life or any other capacity. Concern may also be raised if the staff member is behaving in a way which demonstrates unsuitability for working with adults at risk, in their present position, or in any capacity.

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The committee approved the Managing Adult Safeguarding Allegations Against Staff Policy & Procedure.

6.3. Managing safeguarding allegations against staff - children MGC presented the policy and procedure to provide a framework for managing cases where safeguarding allegations are made against CCG staff, regardless of whether they are made in connection to duties within the CCG or if they fall outside of this such as in their private life or any other capacity. Concern may also be raised if the staff member is behaving in a way which demonstrates unsuitability for working with children and young people, in their present position, or in any capacity.

The committee approved the Managing Safeguarding Children Allegations Against Staff Policy & Procedure.

7.0 Frailty update The frailty unit in King George Hospital has reopened and the service has been re-advertised to GPs. With effect from 17 August, paramedics are able to directly convey patients to the unit. BHRUT, NELFT and CCGs are working on the frailty unit in the community and a potential site has been identified. The aim is to have this in place by the end of November in readiness for winter.

The length of stay (LoS) and readmissions review was paused due to Covid but this is being picked up again in preparation for winter planning and managing demand and a potential second wave of Covid and will report on this in October.

An issue has been identified on the pathway for Wanstead and Woodford and we are linking with Whipps Cross for frailty services and is also being picked up at the Whipps Cross meeting held in August.

SH requested a discussion with SR, CJ and KB on the Whipps Cross SR, CJ, KB redevelopment.

CW agreed to share the engagement pack that is being prepared for PCNs with committee members for information.

The committee noted the verbal update.

8.0 Any other business None raised.

Items for noting 9.0 Minutes of the Area Prescribing sub-committee The minutes of the meeting held on Tuesday 28th January 2020 were duly noted.

10.0 Da te of next meeting 17 September 2020

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