St Helens Clinical Commissioning Group Governing Body Meeting Part I (Public)
Date: Wednesday, 8th July 2020
Time: 10.00 am
Venue: Virtual meeting – via MS Teams
Part 1 of this meeting will be held in public
Mission Statement:
‘Making a difference – right care, right place, right time’
NHS St Helens Clinical Commissioning Group fully support and abide by the pledges set out within the NHS Constitution and we work to ensure we portray the values and behaviours expected of all NHS organisations.
Handling Conflicts of Interest during meetings
A guide for Chairs and attendees
At any meeting where the subject matter leads a participant to believe that there could be a conflict of interest, this interest must be declared at the earliest convenient point in the meeting. This relates to their personal circumstances or anyone that they are aware of at the meeting.
1. Declarations of interests must be clearly identified within the minutes of the meeting, including any need to withdraw and reasons for not doing so.
2. As a rule, those with pecuniary interests should withdraw from the meeting and those with non-pecuniary interests could be allowed to stay, depending upon the circumstances. The Chair will determine whether there could be a matter of bias (any unfair regard with favour, or disfavour) in the matter. Members allowed to stay in the meeting may not be allowed to vote on the subject matter.
3. The Chair of the meeting must take a decision as to the need for the member of the meeting to withdraw or not from the proceedings. Where this may involve the Chair, the Deputy Chair/Vice Chair will take the decision.
4. If the Chair of a meeting is the person to whom the declaration of interests relates, the chair should vacate the seat and the meeting for that item. If there is no Deputy/Vice Chair present at the meeting, the meeting must first elect a chair from within their number by a show of hands.
5. Members of meetings who are employed by the NHS are subject to the existing NHS Codes of Conduct.
Meeting of the NHS St Helens Clinical Commissioning Group Governing Body Public Meeting to be held on Wednesday, 8th July 2020 at 10.00 am Virtual meeting via MS Teams
AGENDA
Apologies for absence:
Declarations of Interest:
Item Time Agenda Item Purpose Presented by
PB20/07/01 10.00 am Welcome and Apologies To Note Chair
To PB20/07/02 Declarations of Interest Note/Action Chair
PB20/07/03 10.05 am Minutes and Actions of the Previous For Page 5 Meeting held on 13th May 2020 Ratification Chair
PB20/07/04 Matters Arising For Chair Discussion
PB20/07/05 CHAIR AND CLINICAL ACCOUNTABLE OFFICER’S REPORTS
1. 10.15 am Chairs Report For Chair (verbal update) Information
2. 10.20 am Clinical Accountable Officer’s Report For Clinical Page 13 Information Accountable Officer Director; 3. 10.30 am Patient Story For Commissioning, Page 16 Information Primary Care and Transformation PB20/07/06 STRATEGY
1. 10.35 am Overview of CCG Reset & Recovery For Clinical Page 21 Information Accountable Officer
PB20/07/07 KEY ISSUES OF BOARD SUBCOMMITTEES 1. 10.50 am (a) Key Issues of the Quality Committee For Chair of the Page 115 held on 3rd June 2020 and 1st July Information Quality 2020 Committee
2. (b) Key Issues of the Finance and For Chair of the F&P Page 127 Performance Committee held on 27th Information Committee May and 24th June 2020 Clinical 3. (c) Key Issues of the Executive For Accountable Page 131 Leadership Team Governance Information Officer Committee held on 3rd June 2020 Clinical 4. (d) Key Issues of the Executive For Accountable Page 133 Leadership Team meetings since the Information Officer last update Chair of the 5. (e) Key Issues of the Primary Care For Primary Care Page 139 Commissioning Committee held on Information Commissioning 20th May 2020 Committee
6. (f) Key Issues of the GP Members For Chair of the GP Page 141 Council held on 1st July 2020 Information Members Council
7. (g) Key Issues of the virtual Remuneration For Chair of the Page 143 Committee held on 1st June 2020 Information Remuneration Committee 8. (h) Minutes and Key Issues Audit For Committee and presentation of Annual Page 145 rd Information Chair of the Audit Report 23 June 2020 Committee
PB20/07/08 GOVERNANCE
1. 11.05 am Governing Body Assurance Framework For Approval Associate Page 155 (GBAF) Director; Corporate Governance
PB20/07/09 FINANCE
1. 11.15 am Finance Performance Update For Chief Finance Page 201 Information Officer
PB20/07/10 PERFORMANCE
1. 11.25 am Covid-19 : Impact on Long Waiters and For Director; Page 211 assuring safety Information Commissioning, Primary Care and Transformation
2. 11.35 am Performance Report For Chief Finance Page 225 Information Officer
PB20/07/11 QUALITY
1. 11.40 am Annual Adult and Children For Chief Nurse Page 231 Safeguarding report Information
PB20/07/12 COMMISSIONING Director; 1. 11.50 am Continuous Glucose Monitoring (CGM) For Approval Commissioning, Page 253 Policy Primary Care and Transformation PB20/07/13 ANY OTHER BUSINESS
12 noon Chair
NHS St Helens CCG Annual General Meeting will take place from 12.30 pm to 1.30 pm
REFLECTION: What difference have we made to local people with the decisions we made in the meeting today?
Date and time of next meeting: The next meeting of the NHS St Helens CCG Governing Body will take place on Wednesday, 9th September 2020, Pilkington Suite (Conference Room A), St Helens Chamber, Salisbury Street, St Helens WA10 1FY
NOTE: Enclosures are sent to Board Members only – copies will be available from the St Helens CCG Office: 01744 457237 or on the website: www.sthelensccg.nhs.uk
“The Trust hereby resolves that the remainder of the meeting be held in private, because publicity would be prejudicial to the public interest, by reason of the confidential nature of the business to be transacted.” (Section 1 (2) 0f the Public Bodies (Admission to Meetings) Act 1960)
If you are unable to attend this meeting, please send your apologies to Cathy Edge on 01744 457237 or e mail [email protected]
The Public Bodies (Admission to meetings Act 1960) permits the CCG to pass a resolution at the meeting to exclude the public and press from part of the meeting by reason of the confidential nature of the business or for other special reasons stated in the resolution. Whenever a resolution to conduct business in private is passed, the resolution itself will be made public.
NHS St Helens CCG Governing Body
Meeting held on Wednesday, 13th May 2020 at 10.15 am in Virtual meeting via Skype Part I (Public Meeting) Minutes
Members Present Initials Role Geoffrey Appleton GA Lay Chair (Chair) Iain Stoddart IS Chief Finance Officer Dr Mike Ejuoneatse ME GP Governing Body Member/Deputy Chair Tony Foy TF Lay Member - Audit, Governance & Finance Sue Forster SF Director of Public Health Rachel Cleal RC Director of Adult Services Julie Ashurst JA Director of Commissioning, Primary Care and Transformation Dr Hilary Flett HF GP Governing Body Member Dr Omar Shaikh OS GP Governing Body Member Mark Weights MW Lay Member, Patient and Public Involvement Lisa Ellis LE Chief Nurse Val Davies VD NED, St Helens and Knowsley NHS F Trust Leanne Binns LB Registered Nurse Dr David Reade DR GP Governing Body Member Dr Sue Hyde SH GP Governing Body Member In Attendance Angela Delea AD Associate Director; Corporate Governance Andy Woods AW Senior Governance Manager (Merseyside CCGs Equality & Inclusion Service) (in part) Members of the Public 1 Minute-taker Cathy Edge CE PA to the Chair
Agenda Action Item PB200501 INTRODUCTION & WELCOME
The Chair welcomed the attendees and members of the public to the meeting.
APOLOGIES
Apologies were received from:
Professor Sarah O’Brien, Clinical Accountable Officer James Catania, Secondary Care Consultant
The Chair declared the meeting quorate.
PB200502 DECLARATIONS OF INTEREST The Chair reminded the Governing Body 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 the CCG.
All declarations are listed in the CCG’s Register of Interests; which is available on the CCG website at the following link:
5 http://www.sthelensccg.nhs.uk/Library/public_info/St%20Helens%20CCG%20Regis ter%20of%20Declaration%20of%20Interest%2031%2003%2017.pdf
There were no declarations of interest received.
PB200503 MINUTES OF THE PREVIOUS MEETING
1. The minutes of the previous meeting held on 8th April 2020 were agreed as a true and accurate record of proceedings.
The NHS St Helens CCG Governing Body: • Ratified the minutes of the previous meeting
PB200504 MATTERS ARISING
PB200505 Matters arising from the previous meeting held on 8th April 2020 PB200210 Quality -Safeguarding Report
The Chair had requested the Out of Borough trajectory for Looked After Children which had been reported to the Part II (Private) meeting and the action was closed.
There were no further matters arising.
PB200505 CHAIR AND CLINICAL ACCOUNTABLE OFFICER’S REPORTS
1. Chair’s Report
The Chair reported on the following:-
• Attendance at the North West Chairs virtual meeting • Teleconference with Richard Fraser, Chair of St Helens and Knowsley Trust • Teleconference with Tom Tasker, Chair of Salford CCG • Teleconferences with the Lay Members and the Clinical Accountable Officer
The NHS St Helens CCG Governing Body:- • Noted the Chair’s reports
PB200506 STRATEGY
Covid 19 Update
The Chief Nurse presented the Covid 19 update. She reported the close work across the Health and Care system in St Helens with the emergency level still at level 4 and likely to remain so until the end of the year. She reported that the Covid trajectory in the North West is not falling as rapidly as some other areas and that the Pandemic Team were meeting daily.
The Director; Commissioning, Primary Care and Transformation provided an update on the testing across the North West with mass testing sites located at Haydock Racecourse, Manchester Airport and Preston College available to book through gov.uk and the availability of self swabbing kits that can be ordered at home for those eligible. She reported that the sites were busy nationally and that St
6 Helens hoped to get additional testing in the form of a mobile testing unit within the borough which is hoped to be available for eligible residents in the next 2 weeks.
The Chief Nurse reported that the CCG continue to receive reports from St Helens and Knowsley NHS Trust on Covid patients with the numbers starting to decline. She confirmed that the CCG are supporting care homes with Ipads and pulse oximeters etc to facilitate virtual clinical assessments. The CCG are also supporting care homes with training in infection control, PPE and swabbing.
The Chief Nurse referred to a letter received from Simon Stevens, Chief Executive, NHS, outlining the expectations for business as usual during the Covid pandemic period with the Pandemic Group and Executive Leadership Team working to facilitate this. The Director; Commissioning, Primary Care and Transformation, confirmed that meetings were being held with St Helens and Knowsley NHS Trust to discuss the re-start of routine out-patient appointments in some specialties when it is safe to do so. She noted the issues associated with social distancing requirements and finding additional estates, and the use of additional technology to enable video conferencing appointments. She reported that some physiotherapy services would be available from next week.
The Director; Commissioning, Primary Care and Transformation confirmed that the Primary Care Team were working with the Communications Team on public messages highlighting the changes and the new “normal” services. She also assured that information on any changes would be communicated directly to Primary Care and through the Clinical Directors.
The NHS St Helens CCG Governing Body:- • Noted the update
PB200507 KEY ISSUES OF THE BOARD SUBCOMMITTEES
1. a. Key Issues of the Virtual Quality Committee held on 6th May 2020 – The Chief Nurse, Chair of the Quality Committee, presented the Key Issues. The Governing Body noted the Key Issue as outlined within the report. 2. b. Key Issues of the Finance and Performance Committee held on 29th April 2020 – The Chair of the Finance and Performance Committee presented the Key Issues. The Governing Body noted the Key Issues as outlined within the report. 3. c. Key Issues of the Extra Ordinary Primary Care Commissioning Committee held on 22nd April 2020 – The Chair presented the Key Issues. The Governing Body noted the Key Issues as outlined within the report. 4. d. Key Issues of the Executive Leadership Team meetings held since the last update – The Chief Finance Officer presented the Key Issues from ELT. The Governing Body noted the Key Issues as outlined within the report. He informed the Governing Body that ELT are keeping separate log 5. of decisions made during the pandemic period. e. Key Issues of the Informal Audit Committee held on 29th April 2020 – The Chair of the Informal Audit Committee presented the Key Issues. He noted the key points reported in relation to the Annual Accounts and that the Committee was satisfied with the draft submitted. With regard to the draft Annual report, some areas were to be improved and positive examples included. The Committee was satisfied with the process and awaiting feedback from NHSE. The Governing Body noted the Key Issues as outlined within the report.
7
The NHS St Helens CCG Governing Body:- • Noted the Key Issues
PB200508 GOVERNANCE
1. Equality and Inclusion and Covid 19
The Associate Director; Corporate Governance presented the Equality and Inclusion and Covid 19 report. The purpose of the report was to update Governing Body on a number of issues that need to be considered, from an equality perspective, around their response to the current emergency measures, in addition to the core standards for Emergency Preparedness, Resilience and Response (EPPR).
The Senior Governance Manager (Merseyside CCGs Equality & Inclusion Service) reported that the CCG Equality and Inclusion (E&I) Service had developed a local Covid-19 Equality Brief (Appendix 1 of the report) to highlight legal duties to the CCG and its NHS Providers. The brief included equality considerations for people with protected characteristics and also information sources for Providers and CCGs to access. He noted that the equality briefing was a live document being update and share across the system to enable the CCG to pay ‘due regard’ to its legal duty during the pandemic and to support recovery. The latest version of the report will be issued imminently. The Senior Governance Manager informed the Governing Body of the changes within the revised version 5 document.
The Senior Governance Manager reported on the work with SHAP and other voluntary organisations in order to spread key messages out to the community in terms of shielding and access to harder to reach communities. He noted the key risks identified within the BAME (Black, Asian and Minority Ethnic) communities and the interim measures to be taken for staff. The revised version 5 of the report will be circulated to Governing Body for their consideration and acceptance via e-mail. AD
NHS St Helens CCG Governing Body: • Noted the update
Andy Woods left the meeting.
PB200509 FINANCIAL PERFORMANCE Financial Covid-19 response and budget for 2020/21
The Chief Finance Officer presented the Financial Covid-19 response and budget for 2020/21.
The purpose of the report was, in the absence of a finalised 2020/21 operational and financial plan for the CCG, required to support the CCG Governing Body in its duty to maintain financial probity, stewardship, governance and value for money in relation to the anticipated £364m allocation for 2020/21.
He reported that, as a result of the system response to the Covid-19 pandemic, there had been a number of changes to the financial and contracting arrangements nationally. He confirmed that contract arrangements being replaced with mandated block arrangements and arrangements were in place for a system response fund.
8 The financial implications of the Covid-19 response were outlined within the report.
The Chief Finance Officer confirmed that the Finance Business Continuity Plan had been initiated and that there were no budgets within the financial ledger. The team were working with interim rules and regulations from NHSE/I during the pandemic period. He reported that the CCG continued tracking and reporting of additional expenditure related to Covid 19, and that all contract negotiations with Providers had been paused with payment being made as set out within Appendix 1 of the report.
The Chief Finance Officer confirmed that further guidance was still awaited on budget monitoring for the year and the Director; Commissioning, Primary Care and Transformation reported that the current guidance advised CCGs to withhold investments and transformations at this time which had a direct impact on the CCG’s ability to deliver QIPP. She informed the Governing Body that this did not relate to investment in IAPT and mental health services.
The Governing Body was asked to confirm their understanding of the financial implications and acceptance: a) That an expenditure budget will be proposed that is not able, at this stage, to include a system recovery or mitigation plan for the £26.5m deficit and therefore the CCG will operate with a significant deficit whilst the current situation endures b) That QIPP efficiency measures may pose additional financial risk during the interim period whilst Covd-19 arrangements exist c) That the approvals process for specific COVID-19 related expenditure is likely to continue to require use of procurement waivers for significant values across partner organisations. These will be reported to the Audit Committee. d) To note the impact on the budgets for the 2020/21 financial year e) The need to review the interim budget by the Governing Body as a minimum at the end of each quarter.
The NHS St Helens CCG Governing Body:- • Noted the report • Confirmed and Accepted the financial implications as outlined above
PB200510 QUALITY 1. Safeguarding Update including the Learning Disability Mortality Review
The Chief Nurse presented the Safeguarding Update. The purpose of the report was to provide an update to the Governing Body Members in relation to Safeguarding Children, Adults and Looked After Children.
She reported that in accordance with NHSE/I guidance, formal Safeguarding KPI reporting is stepped down at Q4 in favour of position statements and reporting by exception.
The Chief Nurse provided updates from commissioned services on the following:-
St. Helen’s and Knowsley Teaching Hospitals NHS Trust Bridgewater Community NHS Trust (St Helens) North West Boroughs Healthcare NHS Foundation Trust
9
She confirmed that the staff at the Urgent Treatment Centre were engaging positively following the transfer from Bridgewater to St Helens and Knowsley Teaching Hospitals NHS Trust.
The Chief Nurse provided an update on Safeguarding Adults on the following:-
• Learning Disabilities Mortality Review (LeDeR) - the NHS St Helens CCG Annual LeDeR Report 2019-20 had been submitted to the CCG Quality Committee for approval and was attached for information. The Chief Nurse reported on the national recognition of St Helens work on the LeDeR. • Liberty Protection Safeguards (update) • Domestic Homicide Review (DHR) • Prevent • Support for GPs
The NHS St Helens CCG Governing Body:- • Noted the report • Noted the LeDeR Report
PB200510 ANY OTHER BUSINESS
There was no other business.
The difference made to local people were reported as:-
Equality and Inclusion work being undertaken during the Covid pandemic ensuring access to information and services. CCGs response to the Covid Pandemic and the identification of risks and opportunities to improve services. Assurance received regarding adult and children’s safeguarding during the pandemic
DATE OF NEXT MEETING
The next meeting of the Governing Body will be held on Wednesday, 10th June 2020 at 10.30 am via Skype for Business.
Minutes Ratified as Accurate Record Name: Geoffrey Appleton Signature: Date:
10 ACTION POINTS FROM CCG GOVERNING BODY PART I MEETING HELD ON 13.05.20
Action Due From: Action Required: Required by: Completed: Number 72. PB190111 Performance Sarah O’Brien/ Research, Innovation and Development Report Sue Forster The Governing Body agreed that the CCG should be more proactive in 17th April 2019 research, innovation and development and the Clinical Accountable Deferred to Officer and the Director of Public Health agreed to progress this, in Sept 2020 particular with St Helens and Knowsley NHS Trust 84. PB190506 Strategy - Annual Report Presentation
Rachel Cleal The Chief Nurse to consider contact cares response time and capacity. 10th July 2019 - Update: 10.07.19 - RC reported on a valuation being undertaken of peer deferred to review feedback on Contact Cares to be presented to a future meeting. Sept 2020 98. PB200107 Key Issues of the Integrated Finance and Performance Board Iain Stoddart A summary of the integrated performance dashboard to be presented to 11th March 2020 Governing Body in March 2020 Deferred to Sept 2020 99. PB200108 Governance Governing Body Assurance Framework Lisa Ellis Sue Forster The Chief Nurse and Director of Public Health to seek information from 8th April 2020 surrounding CCGs on their experiences of health visitor recruitment and Deferred to report back. Sept 2020 101. PB200206 Key Issues of the People’s Board held on 22nd January 2020 Cathy Edge 8th April 2020/ The Governing Body requested a presentation on the Pause Programme. 13th May 2020 Deferred to Sept 2020
11 103. PB200209 Performance Iain Stoddart Performance Update 8th April 2020 St Helens Cares targets to be included in the regular performance Deferred to update. Sept 2020 104. PB200210 Quality Lisa Ellis Safeguarding Report The Chair requested the Out of Borough trajectory and how far from 13th May 2020 Closed home the children were (further away being a greater risk).
105. PB200307(1) Key issues of the Quality Committee 04.03.20 Julie Ashurst A further update report on CAMHS was requested for the Part II (private) 10th June 2020 meeting on 10th June 2020.
JA reported that due to Covid 19 all transformations were put on hold nationally to ensure that the NHS could adequately respond to the crisis. However, work has been undertaken in the background to bring a Deferred to business case together for implementation post crisis which is now ready Sept 2020 for ELT approval. This item therefore will be delayed for at least 2 months.
106. PB200805(1) Equality and Inclusion and Covid 19 Angela Delea Local Covid-19 Equality Brief version 5 to be circulated to Governing Body 10th June 2020 for their receipt.
12 Report to NHS St Helens CCG Governing Body Date of meeting: 8th July 2020 Governing Body Member Clinical Accountable Officer Lead: Accountable Director: Clinical Accountable Officer
Report title: Clinical Accountable Officer’s Report
Item Decision Assurance Information x (Please insert X as appropriate) for:
This report supports the following CCG Strategic Objectives. Please insert ‘x’ as appropriate.
1. To deliver financial stability x 2. To integrate health within the place of St Helens through system redesign x 3. To deliver improved outcomes for people x Strategic Objectives 4. To be recognised as good system leaders x 5. To support and transform primary care to be a system leader in St Helens Cares x
Does this report provide assurance against any of the risks identified in the Assurance Framework? (please specify)
What level of assurance does it provide? (List levels i.e. Limited/Reasonable/Significant)
Risk N/A Is this report required under NHS guidance or for statutory purpose? (please specify) No Governance and
Purpose of this paper The purpose of this report is for the Clinical Accountable Officer to inform and update Governing Body on the key strategic areas of work for the CCG since the last report.
Further explanatory information required:
Does this paper link to any of the It provides a general update on progress with the whole key themes of the CCG’s improvement Plan Operational Plan & Improvement Plan.
How will this benefit the health and wellbeing of St Helens residents or N/A this report is an information update only the Clinical Commissioning Group?
Please describe any possible Conflicts of Interest associated No conflicts of interest with this paper.
13
Please identify any current services N/A the paper is an information update only or roles that may be affected by issues within this paper.
What risks may arise as a result of N/A the paper is an information update only this paper? How can they be mitigated?
Clinical Accountable Officer Update to Governing Body (July 2020)
The purpose of this report is to inform and update the Governing Body on the key areas of strategic work since the last Governing Body meeting.
NHS St Helens CCG
COVID Pandemic:
The coronavirus pandemic has created an unprecedented challenge for the NHS and all key partners and whilst infection levels and death rates associated with the virus have fallen locally the infection remains in circulation and the NHS remains in level 4 Emergency command and control and there are new decision making structures in place (Cells) during this time. The CCG have remained focused since March on playing a key leadership role in the Place of St Helens to ensure residents are supported and kept safe during this time and in supporting our partners and practices to deliver the ask of them from NHSE. The St Helens Borough Council Covid 19 Outbreak Management Plan can be found on the Council website at https://www.sthelens.gov.uk/omp. In addition as lockdown has eased we have also started to reflect on lessons learned and ‘recovery’ phase and a report on this is on the agenda today.
Staff have been involved in key forums for the Mersey Resilience Forum, the NHS Cells, local groups etc and we have responded well to all asks of us and demonstrated a high level of resilience and flexibility across the organisation. Member practices and Primary Care Networks have also responded in an effective way, worked well together and with other partners and worked closely with the CCG.
The NHS is currently in phase 2 which refers to maintaining capacity to cope with further outbreaks of the virus whilst getting other Business As Usual activity up and running whilst maintaining new infection control guidance.
We are waiting for guidance on ‘phase 3’ which was expected by now but has been delayed centrally.
Whilst the 2 NHS cells are driving the plans and decisions regarding hospital services and out of hospital capacity CCG staff are being kept in the loop on this and NHSE have been clear that we retain our statutory duties especially in relation to quality of service therefore the Chief Nurse is working closely with providers to ensure we retain this oversight. We are also monitoring waiting lists (especially long waits and cancer waits) as these are at risk of growing because of the impact of COVID.
Local Integration We have worked very closely with all our St Helens Cares partners during the pandemic and a key learning is that integration at Place is essential to ensure joined up services are effective at
14 supporting local people. The crisis has demonstrated how effective our St Helens Cares approach is and we are now looking to embed the learning from the pandemic & review the integration arrangements with a view to establishing a formal ICP (Integrated Care Partnership) in the future.
St Helens Cares Executive and The Peoples Board are meeting in the next few weeks as we re- start some activity that was paused in March.
As reported to the Governing in previous months, work on exploring CCG integration was scaled back during COVID-19.
During June, interviews have been completed with all Governing body members across Halton, St Helens and Warrington, and a draft feedback report has been prepared for the Accountable Officers.
Work in July will focus on what CCG functions should continue to delivered at a Local Authority “place” level, and which would benefit from being consistently commissioning on a larger scale. Further engagement with key stakeholders will also be planned during this period as appropriate.
A Joint Governing body workshop has been provisionally scheduled for the 16th September subject to local lockdown rules permitting.
Cheshire and Mersey Wide The HCP Partnership Board have continued to meet and a weekly coordination group has also met (The Accountable Officer sits on both groups) to connect and communicate between different parts of the system during the crisis and this has been very helpful. The partnership are now reviewing their structures and there is a plan for a large meeting in September and they are also ‘taking stock’ of existing programmes and priorities in light of COVID and reassessing where they need to focus. It is evident that the concept of Place remains paramount and will be a key part of the partnership strategy as they move to an ICS.
A growing concern across C&M is the impact of the pandemic on already deprived and vulnerable communities and a growing recognition and evidence base that inequalities will widen and the CCG and the partnership are continuing to have conversations regarding this and it will be paramount in future planning and activities.
15 Report to NHS St Helens CCG CCG Governing Body Date of meeting: 8th July 2020 Julie Ashurst – Director of Commissioning, Primary Care and Governing Body Member Lead: Transformation Julie Ashurst – Director of Commissioning, Primary Care and Accountable Director: Transformation Report Author: Julie Ashurst
Report title: Patient stories IAPT
Item for: Decision Assurance Information (Please insert X as appropriate)
This report supports the following CCG Strategic Objectives. Please insert ‘x’ as appropriate.
1. To deliver financial stability 2. To integrate health within the place of St Helens through system redesign 3. To deliver improved outcomes for people x Strategic Objectives 4. To be recognised as good system leaders x 5. To support and transform primary care to be a system leader in St Helens Cares
Does this report provide assurance against any of the risks identified in the Assurance Framework? (please specify)
What level of assurance does it provide? (List levels i.e. Limited/Reasonable/Significant) Reasonable Risk Is this report required under NHS guidance or for statutory purpose? (please specify) No- Information only Governance and
Purpose of this paper To share two patient stories from IAPT Think Wellbeing Service that North West Boroughs took over from Nov 2019.
16 Further explanatory information required:
Mental Health. Does this paper link to any of the key themes of the CCG’s Operational Plan & Improvement Plan. If yes, please specify.
How will this benefit the health and The paper shares positive patient’s stories highlighting the wellbeing of St Helens residents or benefit that our residents are getting from this service. the Clinical Commissioning Group?
Please describe any possible None identified Conflicts of Interest associated with this paper.
Please identify any current services IAPT services (Improving Access to Psychological Therapies) or roles that may be affected by – known as St Helens Think WellBeing issues within this paper.
None highlighted What risks may arise as a result of this paper? How can they be mitigated?
1. Executive Summary
Two patients from the St Helens Think Wellbeing Service have shared their stories about their experiences with the service and felt strongly about sharing their experiences.
The stories are from different elements of the service and are in the patient’s own words.
They are attached to the report.
2. Recommendations
The Governing Body are asked to note the Contents of the Report
17 DOCUMENT DEVELOPMENT
Process Yes No N/A Comments & Date Outcome (i.e. presentation, verbal, actual report) Public Engagement (please detail x the method i.e. survey, event, consultation)
Clinical Engagement (please x detail the method i.e. survey, event, consultation)
Has ‘due regard’ been given to x Equality Analysis (EA) and any adverse impacts? (Please detail outcomes, including risks and how these will be managed)
Legal Advice Sought x
Presented to any other groups x or committees including Partnership Groups – Internal/External (please specify in comments)
Note: Please ensure that it is clear in the comments and date column how and when particular stakeholders were involved in this work and ensure there is clarity in the outcome column showing what the key message or decision was from that group and whether amendments were requested about a particular part of the work.
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Patient Stories – St Helens Think Wellbeing Service
Patients were asked by the treating therapist whether they would be happy to share their experience of the service. Both patients agreed to this and were subsequently contacted and were asked to tell their story in their own words.
Patient A – treated at Step 2 in St Helens Think Wellbeing Service - RECOVERED
Start of treatment Patient Health Questionnaire (PHQ) score – 22 – measures depression levels Start of treatment Generalised Anxiety Disorder (GAD) score – 12 - measures anxiety levels End of treatment Patient Health Questionnaire (PHQ) score – 4 End of treatment Generalised Anxiety Disorder (GAD) score – 3
“I self-referred to the Service after my GP suggested I might be suffering from depression and anxiety. I constantly worried about things, couldn’t work because of how I felt, my sleep was affected, and I rarely spent any quality time with my two children.
I initially felt stressed and embarrassed about referring to the service, but I knew I needed help. I contacted the service by phone and provided my details, and was dealt with in a friendly and professional manner and was very quickly offered an assessment for later that week.
During my assessment, I felt like it was the first time someone asked how I really was and allowed me to tell my story. I felt listened to and that the therapist took their time to understand what mattered to me. Talking about it made me realise how much I worried about everything, even things I couldn’t control and my mind was jumbled.
At the end of my assessment I was provided with a couple of options. I decided group therapy would be the best option for me, I think at that stage it was because I felt in a group I could probably avoid talking about myself. It took a lot of courage to go to the first session, but the staff were warm, welcoming and sympathetic towards the fact I was anxious, and they genuinely made me feel like I had achieved something just by turning up. So I sat at the back, and listened to the staff and the other members of the group. By the end of that first session I realised I was not the only one who felt like that and I actually felt stronger.
The second week was about wellbeing and sleep, and this session stands out to me as I honestly believe it changed my life. Sleep was a huge problem for me, I would lie awake worrying all night but then would nap in the day as my life passed me by. They explained a variety of simple steps that I could try at home to help put me back in control of my “body clock”, and it really worked. I started to get a bit of routine back in my life, sleeping at night and feeling like I could cope with the day.
Through the course I have learnt to de clutter my mind, so it wasn’t full of what were unhelpful thoughts. I still have some bad days, which is to be expected, but I feel that I now have the skills I need to cope with these so that I don’t go in to a downward spiral.
I found every week of the course useful and actually I was a little sad when it finished. From talking to a couple of others in the group, I realised I wasn’t the only one that felt like that, so we have kept in touch. We go for coffee and have a chat. I could not have imagined doing this before.
19 I feel like I am human again and living my life, instead of existing from crisis to crisis. I have returned to work, and feel like I have something to give, whereas before I felt like I couldn’t cope with anything. My colleagues have said they have noticed a huge difference. I now take breaks when I need to, and have the confidence to say when I can and cannot do something. I am now back in control. But more importantly I feel like my kids have got their Mum back”.
Patient B – treated at Step 3 in St Helens Think Wellbeing Service - RECOVERED
Start of treatment Patient Health Questionnaire (PHQ) score – 21 – measures depression levels Start of treatment Generalised Anxiety Disorder (GAD) score – 14 - measures anxiety levels End of treatment Patient Health Questionnaire (PHQ) score – 3 End of treatment Generalised Anxiety Disorder (GAD) score – 4
“I am 34, married, have a professional job and good physical health. From the outside, what was there to worry about. I thought things like this just don’t happen to me. I felt like I was just being silly and weak, and couldn’t understand why I couldn’t cope. I thought everyone gets anxious from time to time.
One day it came to a head and I felt physically unwell and went to see my GP who diagnosed me with a panic attack. This really worried me and added to my growing sense of unease and I feared another. That is where the vicious cycle started I think. I battled on, but it got worse. I became forgetful, and at times confused, I couldn’t sleep, I was exhausted, I felt upset and out of control. I felt like I was losing my mind so I went to see my GP again, who started me on medication but suggested I may benefit from CBT. So I referred myself to the service.
My CBT therapist allowed me to explain how I felt and what was happening. They then helped me to explore why it was happening and that my inner critic had created a series of unrealistic and harsh rules that I lived my life by – I was never good enough. I felt that at times discussing these was like a light bulb moment and that things made sense, other times I found addressing these deep held beliefs upsetting. However, the support from my therapist meant that we worked through these at my pace and gradually things started to make sense.
I feel like I now understand my anxiety and have the tools to live with it. I have learnt to challenge my negative thoughts, take things less personally, and have been able to share my feelings with those close to me, instead of pretending everything is ok all the time.
Now I am in control of my thoughts, I don’t experience the same physical symptoms of anxiety that I used to. I feel like I can enjoy things again.
This would not have been possible without the patience and support of Therapist Z. Thank you”.
20 Report to NHS St Helens CCG Governing Body Date of meeting: 8th July 2020
Governing Body Member Lead: Clinical Accountable Officer
Accountable Director: Associate Director; Corporate Governance
Report Author: Associate Director; Corporate Governance
Report title: NHS St Helens Reset and Recovery – Covid 19
Item for: Decision Assurance X Information X (Please insert X as appropriate)
This report supports the following CCG Strategic Objectives. Please insert ‘x’ as appropriate.
1. To deliver financial stability 2. To integrate health within the place of St Helens through system redesign X 3. To deliver improved outcomes for people X Strategic Objectives 4. To be recognised as good system leaders X 5. To support and transform primary care to be a system leader in St Helens Cares X
Does this report provide assurance against any of the risks identified in the Assurance Framework? (please specify)
What level of assurance does it provide? (List levels i.e. Limited/Reasonable/Significant) Risk Is this report required under NHS guidance or for statutory purpose? (please specify) N/A Governance and
Purpose of this paper To inform the Governing Body of the work undertaken by the CCG’s Reset and Recovery Group as part of the CCG’s business continuity planning arrangements.
21 Further explanatory information required:
Does this paper link to any of the This paper reflects the early outcomes of the CCG response to key themes of the CCG’s Covid-19 and will inform priorities for the CCG refresh of its Operational Plan & Improvement operational & improvement plan Plan. If yes, please specify.
How will this benefit the health and There are a number of initiatives identified throughout each wellbeing of St Helens residents or theme that have been agreed with the aim of improving the the Clinical Commissioning Group? health and wellbeing of residents. The new working environment theme is specifically focussed on improving health & wellbeing of the CCG workforce
Please describe any possible Conflicts of Interest associated N/A with this paper.
Please identify any current services All services & roles were affected by covid-19. This paper or roles that may be affected by provides detail of impact on services during this period and issues within this paper. identifies areas for change or improvement going foward
What risks may arise as a result of Risks associated with individual themes will be identified as this paper? How can they be part of individual project plans and managed through the CCG mitigated? risk management framework
1. Executive Summary The CCG Reset & Recovery Group was established in May 2020 to support the CCG to return to business as usual and/or adapt and transform operating models to restore a ‘new normal’, as part of business continuity planning. Its purpose is to identify recovery issues, taking into account an impact assessment on our community, staff, and providers and determine the overall recovery strategy for the CCG.
1.1 APPROACH
The group consists of representation from all areas of the CCG, primary care, and the Governing Body lay representation. CCG teams were issued with a template entitled sustaining the gains from covid-19 experience asking to describe changes, benefits, risks, barriers etc in their specific work areas. The data was analysed by the Group and categorised into 5 key themes, with theme leads identified:
Primary Care – Julie Ashurst Infection Control/Quality – Karen Edwardson IT and Governance – Iain Stoddart Future Working Environment – Angela Delea Integration/St Helens Cares – Wayne Longshaw/Sarah O’Brien
Using a simple model (Table 1) to review our crisis response measures, each theme was presented to the Group for critical review.
22
Table 1
The Group was asked to make recommendations on which aspects should progress into project plans. The CCG PMO was then tasked with creating an overall CCG Reset & Recovery Work Programme.
1.2 THEMES
• Primary Care
This impact of Covid-19 has been significant in primary care, provider group collaboration was highlighted as a key success in helping to reduce variation across the networks and the role of PCN Clinical Directors has been invaluable. A wide range of initiatives including triage system, remote consultations, drop boxes, STHK advice & guidance to primary care, and joined up work with frailty, community and primary care were all identified as successful and areas that should be amplified moving forward. Key areas that will be required to restart at part as reset plans is Face to Face consultation, regaining public confidence in visiting GP premises, on-line booking, and the impact on primary care when acute trusts resume elective care must be considered.
• Infection Control
The critical role of the Infection Prevention and Control was clearly evidenced in this theme and the stretch required in providing expertise to community, primary, and social care. The ongoing requirement for delivery of training and continued input into the public health agenda was emphasised. A number of initiatives will require restart in addition to amplifying seven day working, advice to care homes, and input to test, track & trace.
• IT & Governance
This focus of this theme related to Information and Finance. The urgent need for development of a digital strategy was highlighted. The importance of business intelligence, its value in supporting covid- 19 activity and its further development; impact of stopping financial and contracting processes, and the use of COPI (control of patient information) on longer term Information Governance processes was considered. The sign up to N365 and the approach to use of Microsoft products to support new ways of working.
• Future Working Environment
The main focus of this theme related to Agile Working and the wide range of considerations to ensure the workforce is able to adapt longer term to a new model of working. Staff health & wellbeing is a key feature and how the CCG will adapt to embrace a new ways to communicate & engage with all of its stakeholders.
23 • Integration
This theme provided ample evidence of way that the St Helens care system had been able to operate effectively during the pandemic to deliver safe and effective care to the borough as a result of integrated working and strong relationships. There were many examples given of initiatives that should be amplified as part of a programme of reset and recovery. These included enhanced discharge pathways (contact cares, discharge to assess, technology enabled solutions); the integrated approach to support local response to vulnerable patients, swabbing and care home support. Vertical integration of acute, community and primary care, nursing and therapy support for long terms conditions and options for virtual pulmonary rehabilitation were cited as successful as well as the 24/7 mental health crisis line. The work to support care homes had resulted in a much closer working relationship with health. An enhanced population health module to support BI will be important moving forward. A restart of the St Helens Cares Programme and focus on the development of an Integrated Care Partnership are seen as priorities.
Each theme presentation and areas approved are attached in Appendices A-E.
1.3 PUBLIC SECTOR EQUALITY DUTY AND HEALTH INEQUALITIES
The Equality Act 2010 is a statutory act. Public Sector Equality Duty (also known as the ‘equality duty’ or ‘PSED’) remains active. This means all service changes, even in emergency circumstances such as responding to COVID-19, must still be given ‘due regard’ to the objectives of: • Eliminating discrimination, harassment and victimisation • Advancing equality of opportunity • Fostering good relations between different protected characteristics. Evidence continues to emerge in relation to protected characteristics of ‘older age, disability (long term underlying illness), sex, Black Asian Minority Ethnic (BAME) communities and people who live in poverty being disproportionately affected by COVID-19. The Merseyside CCGs Equality and Inclusion Service has developed a COVID-19 Equality Brief V.6 (Appendix F), which is an ‘open document’ so it can track the ongoing impact of COVID-19. As part of our work on Reset and Recovery, the Equality Brief has been utilised to identify equality considerations against the five work areas. Supported by Merseyside CCGs Equality Lead, the Group had a focussed discussion, on potential unintended consequences of commissioner and provider actions / decision-making during Covid-19 and considered the broader impact across the health care system in St Helens from initiatives that had been highlighted from each theme. A report produced by CHAMPS which was a rapid evidence briefing of the direct and indirect impacts of Covid-19 on health and wellbeing was also referenced during the discussion. Key work that has been progressed include: 1. The CCG decision making log has been reviewed against Public Sector Equality Duty. 2. The Equality Brief has been shared with NHS providers and has been discussed at quality forums 3. Equality implications and mitigations have been identified across five work areas and will be incorporated into the Reset & recovery Project Plan 4. Ongoing engagement has taken and will continue to take place across organisations who represent the views of communities negatively impacted by COVID-19 5. Dr Mike Ejuoneatse, our Lead Governing Body GP, has been nominated to join and been
24 accepted on to the NHS England North West BAME advisory group. Further work required includes:
• Version seven of the COVID-19 Equality brief will be available w/c 6th July and the Group will action and provide assurances across the organisation on how it is mitigating against disproportionate impact.
• A specific brief is being developed to highlight risks around PSED, other public law duties and requirements on Provider Plans around recovery and the Group with request this is discussed at the C&M Hospital and Out of Hospital Cells.
• Equality brief (Version 7) and ‘Direct and indirect impacts of COVID-19 on health and wellbeing’ - Rapid evidence briefing by the Health & Equity in Recovery Plans Working Group (Version 1) to be shared with the Peoples Board and support SHC Executive Board partners to understand impacts and develop responses.
• Equality considerations across the five work areas will be incorporated into the Reset and Recovery project plan.
• Engagement will continue to take place with communities and organisations across the borough on the impact of COVID-19 1.4 COMMUNICATION & ENGAGEMENT
All themes identified a communication and/or engagement strand to progress their individual work plans. This requirement has been incorporated into the PMO against individual work plans. Furthermore, it was agreed that the CCG Communication & Engagement Strategy would require refreshing to address the impact of Covid-19. A revised strategy for approval by Governing Body can be found at Appendix G.
1.5 NEXT STEPS
A full Reset & Recovery Work Programme has been agreed. Theme Leads have been assigned responsibility for specific action plans within the overall programme. This will include completion of Quality and Equality Impact Assessments and development of individual comms & engagement plans. The Reset & Recovery Group will monitor progress against the Work Programme through regular meetings and the CCG Executive Leadership Team will consider / approve business cases that require investment or changes to service delivery.
The Governing Body will receive a further update on progress against the Reset & Recovery Work Programme.
2 Recommendations
Governing Body is asked to: • note the progress made in developing a CCG Reset & Recovery Work Programme • note the content of V6 Equality Briefing and actions required (Appendix E) • approve updated CCG Communications & Engagement Strategy (Appendix F)
25 DOCUMENT DEVELOPMENT
Process Yes No N/A Comments & Date Outcome (i.e. presentation, verbal, actual report) Public Engagement (please detail • The primary care slide the method i.e. survey, event, X deck was presented to consultation) the SHC Stakeholder Forum at its June meeting Clinical Engagement (please • Clinical representation detail the method i.e. survey, event, X on the Reset & consultation) Recovery Group • Primary Care slide deck discussed at GP Members Council at its July meeting Has ‘due regard’ been given to • E&D Governance Areas for further Equality Analysis (EA) and any Lead reviewed consideration adverse impacts? (Please detail X presentation from all highlighted, all outcomes, including risks and how themes theme leads to these will be managed) complete EIAs as part of project plans Legal Advice Sought X
Presented to any other groups • Presentations shared Integration slide or committees including X with Local Authority deck to be updated Partnership Groups – Reset & Recovery with SHC Exec Internal/External Group and C & M Board feedback to Health Care present to Peoples Partnership. Board July meeting • Integration slide deck discussed at SHC Executive Board June meeting • All staff teams contributed to identification of themes
26 Appendix A
Reset and Recovery Understanding Crisis Response Measures
Primary Care
20th May 2020
27 END We have done these things to respond to the immediate demands but they are specific to the crisis End of Life/Covid Service – Commissioned to support increased deaths and management of patients with Covid. Consider how long we need to commission for and how this could be incorporated back in to general practice in the longer term.
Additional AVS Car – Manages FTF visits for ‘hot’ patients where this is necessary in their own homes. Consider how long we need to commission for and how this could be incorporated back in to general practice in the longer term.
Hot hubs – GPs have coordinated their work to cohort patients to be seen at a separate hub where they need FTF appointment with suspect Covid symptoms. Minimises risk to GP and patients. Not all practices in this arrangement and costs being incurred by practices directly for ongoing running of hubs. Practices to consider whether this is their preferred option going forward or whether they continue to operate this model.
28 AMPLIFY We have been able to try these new things and they show some signs of promise for the future
Triage systems – Allows patients to be directed to right service and only seen by GP where necessary – as additional roles become more prevalent, triage will remain vital to ensure patient gets signposted to right type of appointment
Remote consultations – Telephone and Video consultations have been a huge success and can be used on an ongoing basis where appropriate. Practices must consider which type of appointments are suitable for remote consultations and which type must be FTF. Consider circumstances where routine management of conditions (eg ongoing management of clinically vulnerable, chronic disease or virtual group consultations) can become the norm. There is an ongoing requirement for good IT kit at all practices to enable this.
Drop boxes – whilst introduced as a way of doing observations on a patient remotely, the technology introduced could be used for further remote consultation, avoiding need for home visit where technology could be expanded further. Could consideration could be given to purchase of equipment for housebound patients who are seen regularly by practices?
29 AMPLIFY We have been able to try these new things and they show some signs of promise for the future
Advice and Guidance – continue with the advice and guidance lines that have emerged with STHK specialists to avoid hospital admission.
Joined up working with frailty, community and primary care teams – links between these teams have become stronger and this should be maintained, particularly as we work towards the Care Home DES as these teams will be an invaluable part of the MDT.
Collaboration between providers – GPs have worked together very well as part of their provider group and developed strong relationships across the borough. The strong links between CDs will help reduce variation between Networks as they share good practice between themselves.
Regular communication between CDs and CCG – The introduction of Skype meeting has allowed CD/CCG meetings to take place more frequently as the time commitment is reduced for CDs to attend calls. This collaboration has been effective and will remain so for the future
30
AMPLIFY We have been able to try these new things and they show some signs of promise for the future
Daily Bulletin – Introduced as a way of managing volume of communication to primary care. This has had really good feedback and should be carried on, although it may move to less than daily.
Home working – As practices have the ability to work from home, they can start to consider how they work allowing some staff to work from home on a regular basis, maintaining a presence for those who need FTF but allowing staff to work remotely where possible.
Care Plans – A lot of good work was done on this to support patients in care homes, this can be built on and maintained as part of Care Home DES.
Cancer advice line – STHK have introduced this as the public are not going to see GPs for potential cancer systems. As long as links with communication links with GPs are strong and STHK have clinical capacity to continue the service should be kept running.
31 LET GO We’ve been able to stop doing these things that were already/are now unfit for purpose
100% FTF – We should not move back to a system of 100% FTF appointments – the new norm will be somewhere between where we were pre Covid and now – will require good public communication
Access to a GP for all appointments – use the current change in public expectation of primary care to embed the culture of not always seeing a GP for a visit, alternative clinicians become the new norm where appropriate and triage system introduced means that processes are in place to enable this.
32 RESTART We’ve had to stop these things to focus on the crisis but they need to be picked up in some form
FTF appointments where appropriate – practices to consider now how they can manage FTF appointments appropriately. Will need to consider how to manage things like Flu vaccs, baby clinics, LD health checks etc as these will be necessary and many appointments will need to be FTF. This includes not only relevant PPE but also space requirements for social distancing as waiting rooms become more widely used again
Impact of public regaining confidence in visiting NHS premises – practices to consider how to manage any surges in demand as people have not visited practices for a while but start to gain confidence to do so again as these patients are likely to require FTF appointments eg the potential cancer appointments etc
Impact of follow up primary care required when acute trusts resume elective care – CCG will keep primary care briefed on the plan for this and practices will need to be aware and able to deal with ongoing demands.
33 RESTART We’ve had to stop these things to focus on the crisis but they need to be picked up in some form
On line booking – Practices to consider at what point this may be introduced whilst maintaining triage system . Could possibly be reintroduced if linked to e- consultation - until then this may have to stay switched off.
34 Primary Care Reset and Recovery
Criteria Project/Service Retain Comments END End of Life/Covid Keep until the end of At present Service Covid emergency commissioned until measures – can stop end of June. and re-start if necessary. END Additional AVS Car Keep until the end of Covid emergency measures – can stop and re-start if necessary END Hot hubs Some practices Need to share managing without experience of using the hot hubs. managing without AMPLIFY Triage systems To be continued.
AMPLIFY Remote consultations To be continued but Framework to be need to give drawn up for consideration and conditions/symptoms balance to type of to be considered for appointment. Face to Face appointments versus remote, including impact analysis. AMPLIFY Drop boxes This element will end Remote observations but do not want to lose to be pursued by a the technology Working Group from element. Primary Care and IT. AMPLIFY Advice and Guidance To be continued – To be confirmed with believe the Trust will the Trust and Caroline also want to continue Lees as the lead if they have capacity. Commissioner. System my need to be developed rather than a single telephone number and could be extended to include advice for GPs. AMPLIFY Joined up working To be continued Excellent collaborative with frailty, work facilitated by community and CCG. primary care teams
AMPLIFY Collaboration Has been facilitated by Proposed that OD the CCG but needs to Leadership sessions be
35 between providers be led by the Clinical arranged for the Directors and Network Clinical improved Network Directors. relationships. It was highlighted that no To be followed up with additional pharmacy the Trust support had been provided/tuped to support these health professionals. Trust to engage and scope this and also scope the integration of community nursing teams. AMPLIFY Regular To be continued The introduction of communication Skype meeting has between CDs and CCG allowed CD/CCG meetings to take place more frequently. AMPLIFY Daily Bulletin To be continued Expect to be reduced to weekly as required and will become an amalgamation of this and the Commissioning Bulletin. AMPLIFY Home working To be continued – will Health and Safety for link to a Framework of home working to be which patients require considered and work Face to Face to be undertaken by consultation. the CCG to be shared with practices to ensure safety of staff. Working practices of pharmacists linking to practices also to be considered. AMPLIFY Care Plans To be continued – will be maintained as part of Care Home DES. AMPLIFY Cancer advice line To be continued – will Data to be shared with be reviewed when other CCGs with clinical appointments significant number of return to a normal cases identified as a level. result of this service. Proposed access for advice for GPs too. LET GO 100% Face to Face All appointments will Good public continue to be triaged communication required LET GO Access to a GP for all All appointments will Good public
36 appointments continue to be triaged communications required
RESTART Face to Face To be continued To be managed against appointments where Framework to be appropriate developed with the Networks
RESTART Impact of public A communications regaining confidence plan is being in visiting NHS developed to support this, including the premises changes to access to GPs RESTART Impact of follow up Working with the Trust primary care required to limit the impact on when acute trusts Community and Primary Care. resume elective care
37 Appendix B
Reset and Recovery Understanding Crisis Response Measures
Infection Prevention and Control
June 2020
38 AMPLIFY We have been able to try these new things and they show some signs of promise for the future
1. Seven day working The team have been providing a limited advice and support service at weekends and bank holidays within existing staffing resource. This should carry on for care home and Liaison with other Health professionals i.e. Frailty team, Community Matrons, District Nurses, GP’s going forward, to accommodate new ways of working around IPC. This will need a an agreement from the current team, a formal rota, increased staffing resource and on call payment set up.
2. Daily COVID response telephone calls with all care homes. Focusing on COVID has given the time resource to be able to do this, it has proved invaluable for the homes and for the team to have a deeper understanding of issues or concerns in a proactive approach. All aspects of COVID management and advice: • Outbreaks • PPE • Staff and resident swab testing • EoL family advice However this is an approach the team exercise for all outbreaks of diarrhoea and vomiting, flu, TB, IGAS anyway but will have COVID additional. 39 AMPLIFY
3. Test Track and Trace Implementation of the new test, track and trace will fall heavily on the IPC team. 3 Borough PH commissioners are looking for investment for staffing. However this will fall back to CCG to manage as we host the team.
40 RESTART We’ve had to stop these things to focus on the crisis but they need to be picked up in some form • Liaising and informing Public Health England health protection regarding new outbreaks in all areas of public health. • Collection , reporting and monitoring of key care home data set to Public Health England and partners. • F lu programme • Advice line for health and social care staff and the general public. • Infection Control Training for Primary care, Dental and Care home staff • I nvestigation and analysis of infections e.g flu, measles, scarlet fever etc. • Follow up of patients with a HCAI • Quarterly Forums across services • Communication – website, single point lessons, newsletters • Audit programme for all care homes and GP surgeries • Advice on new builds and refurbishments • Health Protection forum meetings and Public Health infection control meetings. • Mycobacterium Tuberculosis (TB) – Warrington only • AMR prescribing • Action plan delivery of IPC reduction measures in MRSA, C-Diff and GNBSIs
41
END We have done these things to respond to the immediate demands but they are specific to the crisis 1. Seven day working and support at weekends if added resource cannot be found.
42 LET GO We’ve been able to stop doing these things that were already/are now unfit for purpose
43 Infection Prevention Control Reset and Recovery
Criteria Project/Service Retain Comments END No Areas to End AMPLIFY Seven day working Agreed 3 boroughs have agreed to fund 4 band 7 nurses to allow this work to continue AMPLIFY Daily COVID response Agreed To continue to telephone calls with all increase focus on care homes Infection, Prevention, Control (IPC) AMPLIFY Test, Track and Trace Agreed Working 8 am to 8 pm 7 day service – need may continue to grow RESTART Liaising and informing Agreed Public Health England health protection regarding new outbreaks in all areas of public health RESTART Collection, reporting Agreed and monitoring of key care home data set to Public Health England and partners RESTART Flu programme Agreed RESTART Advice line for health Agreed and social care staff and the general public RESTART Infection Control Agreed Training for Primary Care, Dental and Care Home staff RESTART Investigation and Agreed analysis of infections e.g flu, measles, scarlet fever etc RESTART Follow up of patients Agreed with a HCAI RESTART Quarterly Forums Agreed across services RESTART Communication – Agreed website, single point lessons, newsletters RESTART Audit programme for Agreed all care homes and GP surgeries RESTART Advice on new builds Agreed
44 and refurbishments RESTART Health Protection Agreed forum meetings and Public Health infection control meetings RESTART Mycobacterium Agreed Tuberculosis (TB) – Warrington only RESTART AMR prescribing Agreed RESTART Action plan delivery of Agreed IPC reduction measures in MRSA, C- Diff and GNBSIs
45 Appendix C
Reset and Recovery Understanding Crisis Response Measures
IT and Governance (Information & Financial)
27th May 2020
46 END We have done these things to respond to the immediate demands but they are specific to the crisis
Taken stock of CCG legal responsibility as Cat 2 responder – what this means for CCG governance
Stopped all Operational Planning processes for 20/21 financial year and amended approach to 2019/20 annual report and accounts.
Introduced short term financial system that focusses on cash flow to providers and enabling provider organisations to function e.g. attempt to pay suppliers within 7 days.
Not entered into contracts with NHS and IS providers (No standard contract in place)
Entered into some short term contracts relating to Commissioned services eg EOL/AVS/Hot Hubs where services are not to be continued OR are incorporated into new requirements
Used COPI (Control of Patient Information) in IG domain as key method to fast-track decisions.
Generally “Geared Up” to respond to the crisis and pump primed several areas of the CCG and partners in integrated working eg reactive response on agile working, IT kit distribution and communications.
47 AMPLIFY We have been able to try these new things and they show some signs of promise for the future
Development of vulnerable & shielding list using BI analysis and integration within SCR. Future development of population health and risk stratification to support commissioning decisions and PCN focus & development.
Receipt, storing, processing and sharing of Covid +ve data from STHK for CCG registered population at patient level. Ability to set flag in GP clinical systems.
Medical Interoperability Gateway (MIG) “version 2” contract signed. Provides some GP data to acute systems but will also extend EOL data into SCR. Feeder systems in place to support C&M Share2Care (Shared Care Record)
Used E Consult, Accur Rx, Skype, MS Teams, WhatsApp. Opportunity to determine best Video conferencing platform.
Short term changes in ways of working allow us to determine an effective digital strategy covering electronic care plans, discharge summaries, virtual MDT and use of telemedicine/telecare.
48 AMPLIFY We have been able to try these new things and they show some signs of promise for the future Difficulty with data extracts from Billinge practice allows move to common EMIS platform across all practices and from that “EMIS Web Enterprise”; thus benefiting from instant access to GP data at CCG or PCN level using EMIS Web Enterprise Search & Reports.
Recent CCG/LA work in Care Homes – opportunity to develop the underpinning digital capability of Care Homes and align the same eg MS Teams, pilot use of EMIS.
NHS Digital centralised procurement and at scale purchasing of eg laptops, could be modelled across wider localities and ICS footprint.
In principle sign up to N365 - allow consistent approach to Microsoft products and to deploy their functionality in a common manner eg MS Teams, MS Office.
Digital support has been variable in quality – review and strengthen SLAs.
Directive work required of BI support – need to develop SLA prior to formal transfer 49 AMPLIFY We have been able to try these new things and they show some signs of promise for the future Use of Independent sector contracts being driven by acute hub as part of a wider capacity planning approach. Potential alignment as sub contractor model within the St Helens Cares lead provider approach once C&M live capacity modelling ceases.
Commissioning/de-commissioning process – review internal processes to support fast track decisions
Roll out of Laptops & Tablets to facilitate flexible and agile working. Enhance to create digital asset strategy including replacement cycle.
Flexible working – we need to improve the balance between home / office working and core hours, but recognise 1) the need to maintain team working and the positive interactions from working in the office together and 2) the ergonomic / health issues associated with working at home
Financial – block contracting and national top ups.
50 LET GO We’ve been able to stop doing these things that were already/are now unfit for purpose
PbR as a payment mechanism
? Some wider consolidation/re-purposing of back office should current arrangements continue over the next 18mths
51 RESTART We’ve had to stop these things to focus on the crisis but they need to be picked up in some form
NHSX Cyber Resilience – continue rollout of Windows 10.
IG - Review & strengthen DPIA and DSA agreements to substitute any short term (COPI) arrangements as necessary.
Provider review meetings for main NHS providers and work out roles between hubs and commissioners.
Key developments in MH, community, primary care and integrated services eg LAC. Need to identify range of developments and
Flow of information from hubs and what has changed in service models. Need to consolidate into BAU and into contract specifications/monitoring.
Contract monitoring and robust processes for paying for healthcare when the block arrangements cease – subject to any changes to the national tariff model
QIPP development and delivery – plan and use of PMO to review processes and robustness for the changed service/commissioned ‘norm’ 52
IT and Governance Reset and Recovery
Criteria Project/Service Retain Comments END All Operational No Operational Planning Planning processes for will restart 20/21 financial year and amended approach to 2019/20 annual report and accounts END Introduced short term No financial system that focusses on cash flow to providers and enabling provider organisations to function END Not entered into contract arrangements contracts with NHS will be reviewed by and IS providers NHSE/I END Entered into some No short term contracts relating to Commissioned services END Used COPI (Control of Would like this to Patient Information) in continue and may be IG domain as key able to work more method to fast-track closely with Medicines decisions Management END “Geared Up” to No respond to the crisis and pump primed several areas of the CCG and partners in integrated working eg reactive response on agile working, IT kit distribution and communications AMPLIFY Development of Continue - Using Shielding list may not vulnerable & shielding information better to be continued list using BI analysis drive forward services, and integration within particularly Primary SCR. Future Care Networks, if data development of usage is allowed population health and risk stratification to support commissioning decisions and PCN focus & development
53 AMPLIFY Receipt, storing, Continue Covid data is expected processing and sharing to be sent to GP of Covid +ve data from records in the near STHK for CCG future as part of the registered population Testing, Tracing and at patient level. Ability Tracking programme to set flag in GP clinical systems - using information better to drive forward services, particularly Primary Care Networks, if data usage is allowed AMPLIFY Medical Continue Provides some GP data Interoperability to acute systems but Gateway (MIG) will also extend EOL “version 2” contract data into SCR. Feeder signed systems in place to support C&M Share2Care (Shared Care Record) AMPLIFY Opportunity to Continuer Used E Consult, Accur determine best Video Rx, Skype, MS Teams, conferencing platform WhatsApp AMPLIFY Short term changes in To be discussed further ways of working allow at ELT us to determine an effective digital strategy covering electronic care plans, discharge summaries, virtual MDT and use of telemedicine/telecare AMPLIFY Use of Independent Potential alignment as sector contracts being sub contractor model driven by acute hub as within the St Helens part of a wider Cares lead provider capacity planning approach once C&M approach live capacity modelling ceases – to note, cannot be amplified at this point AMPLIFY Commissioning/de- review internal To be discussed further commissioning process processes to support at ELT fast track decisions AMPLIFY Roll out of Laptops & Continue Enhance to create Tablets to facilitate digital asset strategy flexible and agile including replacement working cycle AMPLIFY Financial – block Continue contracting and
54 national top ups LET GO PbR as a payment Continue NHSE Decision mechanism RESTART NHSX Cyber Resilience Continue – continue rollout of Windows 10 RESTART IG - Review & Continue Need to await NHSE/I strengthen DPIA and Guidance DSA agreements to substitute any short term (COPI) arrangements as necessary RESTART Need to identify range Continue Update to be provided of key developments in to next Governing MH, community, Body Private meeting primary care and to be held in June on integrated services eg the process for restart LAC and Flow of of provider monitoring information from hubs and what has changed in service models RESTART Contract monitoring Continue Awaiting NHSE/I and robust processes Guidance for paying for healthcare when the block arrangements cease RESTART QIPP development and plan and use of PMO Need to restart the delivery to review processes integration and and robustness for the collaboration PMO changed processes for STHK. service/commissioned ‘norm’
55 Appendix D
Reset and Recovery Understanding Crisis Response Measures
Working Environment 3rd June 2020
56 END We have done these things to respond to the immediate demands but they are specific to the crisis 1. Pandemic Meeting Group – 7/7 access to command centre
2. 100% Home Working
3. Redeployment of staff for pandemic specific purposes
4. Use of Personal telephone (mobile or landline) for business purposes
57 AMPLIFY We have been able to try these new things and they show some signs of promise for the future
1. Blend of working options – Agile working, home based, office based – identifying hub (HQ) and satellite work spaces / drop in facilities
2. IT enabled home working, determine full kit requirement (IT, phone, furniture) and agree funding
3. Upgrade of CCG Vodaphone contract – issue to all staff
4. Health & Well-being Group
5. Staff engagement - use of technology, intranet refresh, video-communication
6. Public Engagement - introduction of free phone number to enable access public meetings, and other virtual communication platforms
7. Refresh of Comms & Engagement Strategy to determine new ways of stakeholder engagement – using social media platforms relevant to ‘joe public’ 58
LET GO We’ve been able to stop doing these things that were already/are now unfit for purpose
1. Gamble Building – CCG HQ
2. All meetings/Committees face-to-face
3. Room Hire in range of buildings/facilities for corporate meetings / public events
4. Paper Packs for Committee / Governing Body
5. Car Parking contract
59 R&R Task & Finish Group RESTART We’ve had to stop these things to focus on the crisis but they need to be picked up in some form
1. Risk Assessment for new ways of working (home based / agile working)
2. OD Plan – with focus on Development Sessions GB/CCG/Teams
3. Refresh of Strategic Objectives & Risk Assurance Framework
4. Forward planning for shape of CCG & Place going forward
5. On-boarding of new staff into the organisation
6. HR modernisation plan, use of ESR capability, accessing L & D offer, support for managers – effective staff management in new world, HR surgery
7. Restart plan of roll out of N365 / Windows 10
8. Talkfest
9. Revisit decision making to ensure robustness of QIA/EIA processes
60 Working Environment Reset and Recovery
Criteria Project/Service Retain Comments END Pandemic Meeting No Group – 7/7 access to command centre END 100% Home Working No END Redeployment of No staff for pandemic specific purposes END Use of Personal No telephone (mobile or landline) for business purposes AMPLIFY Blend of working Agreed An HQ/Hub where options the Leadership Team will be based with satellite workspaces to be identified AMPLIFY IT Enabled home Agreed Standard package to working be drawn up lead by Angela Delea and Lisa Roberts AMPLIFY Upgrade of CCG Agreed To be issued to all Vodaphone contract staff AMPLIFY Health and Wellbeing Agreed Will continue to work Group with LA as they restart their Health and Wellbeing Group but will retain a CCG only element while the changes are rolled out. AMPLIFY Staff Engagement Agreed Refresh of intranet/continue with video messages AMPLIFY Public Engagement Agreed renewed virtual communications platforms AMPLIFY Refresh of Agreed Communications and Engagement Strategy LET GO The Gamble Building Agreed Possible financial as HQ/Hub implications associated with an external venue LET GO All Agreed Draft meeting/Committees principles/criteria for face to face face to face meeting to be agreed by ELT LET GO Room Hire in range 5 premises to be
61 of buildings considered by ELT LET GO Paper meeting packs Agreed Some staff may need access to a monitor to allow Skype/MS Team interaction whilst viewing papers on ipad LET GO Car parking contract Agreed RESTART Risk Assessment for Agreed new ways of working RESTART OD Plan Agreed Focus on Development Sessions GB/CCG/Teams RESTART Refresh of Strategic Agreed Objectives & Risk Assurance Framework RESTART Forward planning for Agreed shape of CCG & Place going forward RESTART On-boarding of new Agreed staff into the organisation RESTART HR modernisation Agreed Use of ESR plan capability, accessing L & D offer, support for managers – effective staff management in new world, HR surgery RESTART Restart plan of roll Agreed out of N365 / Windows 10 RESTART Talkfest Agreed RESTART Revisit decision Agreed making to ensure robustness of QIA/EIA processes
62 Appendix E
Reset and Recovery Understanding Crisis Response Measures
Integration
18th June 2020
63 END, AMPLIFY, LET GO, RESTART
64 END We have done these things to respond to the immediate demands but they are specific to the crisis Pausing of St Helens Cares Programme – Activities suspended due to partners responding to COVID pandemic, see restart slides
65 AMPLIFY We have been able to try these new things and they show some signs of promise for the future
Enhanced discharge pathway implementation: • Contact cares: Supporting all Discharges via an SPA – Previously, CC supported St Helens. By moving to them supporting other boroughs, the discharge process has worked well - may need additional capacity in IDT teams as winter approaches. Ongoing system collaboration to standardise processes that improve discharge quality and times • Discharge to assess process principles implementation. Ongoing review and improvement via Strategic Discharge Group. • Technology enabled solutions to support MDT assessment processes in and out of hospital. (CL) NB: all of the above form part of an existing system improvement plan aiming to offer continuous improvement in health and social care pathways across boroughs.
CCG/LA Integration - This has ensured an ongoing and integrated approach to Covid. Many examples of how this has helped (vulnerable patients, swabbing, care home support etc). Local response has been made so much easier due to integration. Where next? (SOB)
Teleworking – Weekly/daily calls with: operational teams; dom care managers, nursing/care homes, mental health providers. Normally these meetings would take place face to face however the current arrangements have worked really well 66 AMPLIFY We have been able to try these new things and they show some signs of promise for the future
Vertical Integration – Acute, Community & Primary Care • Community Optometrists – Triage: treat and refer on urgent eye care patients. Primary eye care services would be the gateway into urgent care services. Would reduce the number of people seen by urgent care and provide community treatment option for patients. Need to embed system before COVID ends (CL/TMcL) • Nursing and Therapy support for LTCs including – 1) Heart failure, 2) Continence/ colostomy , 3) Tissue viability , 4) TB, 5) Parkinsons 6) Respiratory/ COPD. 7) Stroke, 8) MS, 9) MND, 10) Falls, 11) Lymphoedema, 12) Diabetes. Increase the use of telemedicine options wherever clinically safe. (AH/TMcL) • Options for Virtual Pulmonary Rehabilitation - More convenient for patients (traveling time, opportunities to segment patients that can use this mode v F2F (AH/TMcL)
Primary Care Networks – PCNs starting to mature, seeing the benefits of this, what next? (JA)
67 AMPLIFY We have been able to try these new things and they show some signs of promise for the future
24/7 Mental Health Crisis Line and Crisis Resolution Home Treatment Team – Service mobilised within about 5 working days. The 24/7 helpline is part of the wider Crisis Resolution and Home Treatment Team expecting to be fully operational by April 2021. There will be a funding gap, NWB to advise (JA)
Care Homes – relationships and close working with care homes, Primary Care, STHK. Consideration of whether : • Share Care Records should be rolled out to care homes? • Care Homes should be represented on the Provider Board? (WL)
BI and Enhance Population Health – A new module to the shared care records has been implemented (technical solution) need to use this module for future population health management , case finding and risk stratification of our most vulnerable residents (DH) (note LA taking stock of their BI requirements)
Enhanced Testing Offer - NWBs are supporting community swabbing for test and trace which is vital part of the ongoing plan
68 LET GO We’ve been able to stop doing these things that were already/are now unfit for purpose
Face to Face Meetings – We should not move back to a system of 100% FTF meetings, we could re-define which meetings or at least the frequency of F2F v videoconference meetings are required in the future
Assurance Meetings and Reporting – Need to consider the proportionality of the requirements going forward post COVID environment
69 RESTART We’ve had to stop these things to focus on the crisis but they need to be picked up in some form
St Helens Cares Programme: Resume the work programme and meetings • St Helens Cares Executive Board - 30 June or sometime in July • Provider Board - 22 July • Localities Steering Group – 13 July or 10 August • Stakeholder Forum met 2 June (discussed Primary Care) • Links to the People’s Board Opportunity to Reset our approach following the review from Hill Dickenson (AD/WL)
Refresh of s75 - making formal the shadow Integrated Finance & Performance Board
Integrated Care Partnership: Develop proposals to move towards an Integrated Care Partnership for St Helens Cares (SOB/WL)
NHS Long Term Plan/STP 5 Year Strategy/St Helens Plan: Taking stock of our approach and priorities in a post COVID world. Council have identified gaps in strategies, need to consider alignment and fit (SOB/WL)
Mid Mersey: Determine how St Helens will play its part in the development of a wider system partnership on a Mid Mersey or wider footprint (SOB) 70 RESTART We’ve had to stop these things to focus on the crisis but they need to be picked up in some form
Pulmonary Rehabilitation Service Suspended - All team members moved from delivering PR service to supporting patients who have been discharged from the hospital (AH)
71 Integration/St Helens Cares Reset and Recovery
Criteria Project/Service Retain Comments END St Helens Cares Agreed Pausing of Programme Programme to end AMPLIFY Enhanced discharge Agreed By moving to them pathway supporting other implementation: boroughs, the Contact cares: discharge process has Supporting all worked well - may Discharges via an SPA – need additional Previously, CC capacity in IDT teams supported St Helens. as winter approaches. Discharge to assess Ongoing system process principles collaboration to implementation. standardise processes Ongoing review and that improve discharge improvement via quality and times Strategic Discharge Group. Technology enabled solutions to support MDT assessment processes in and out of hospital AMPLIFY CCG/LA Integration Agreed
AMPLIFY Teleworking – Agreed Calls with: operational Weekly/daily calls teams; dom care managers, nursing/care homes, mental health providers AMPLIFY Vertical Integration – Agreed Acute, Community & Primary Care Community Optometrists – Triage: treat and refer on System to be urgent eye care embedded before patients. Nursing and COVID ends. Therapy support for LTCs - including Increase the use of 1) Heart failure telemedicine options 2) Continence/ wherever clinically safe colostomy 3) Tissue viability 4) TB 5) Parkinsons
72 6) Respiratory/ COPD 7) Stroke 8) MS 9) MND 10) Falls 11) Lymphoedema, 12) Diabetes AMPLIFY Primary Care Agreed PCN Development Networks work to be undertaken AMPLIFY 24/7 Mental Health Agreed Funding required. Crisis Line and Crisis Resolution Home Treatment Team
AMPLIFY Care Homes – Agreed Explore roll out of relationships and close Shared Care Record to working with care Care Homes. homes, Primary Care, STHK Secure a Care Home representative on the Provider Board. AMPLIFY BI and Enhance Agreed Population Health – A new module to the shared care records has been implemented (technical solution) need to use this module for future population health management AMPLIFY Enhanced Testing Agreed NWBs are supporting Offer community swabbing for test and trace which is vital part of the ongoing plan LET GO Face to Face Meetings Agreed should not return to 100% FTF meetings LET GO Assurance Meetings Agreed to re-consider Need to consider the and Reporting requirements proportionality of the requirements going forward post COVID environment RESTART St Helens Cares Agreed St Helens Cares Programme: Resume Executive Board the work programme Provider Board and meetings Localities Steering Group
73 Stakeholder Forum Links to the People’s Board Opportunity to Reset our approach following the review from Hill Dickenson
RESTART Refresh of s75 Agreed Formalise the shadow Integrated Finance & Performance Board RESTART Integrated Care Agreed Develop proposals to Partnership move towards an Integrated Care Partnership for St Helens Cares RESTART NHS Long Term Agreed Taking stock of our Plan/STP 5 Year approach and priorities Strategy/St Helens in a post COVID Plan RESTART Mid Mersey: Agreed Determine how St Helens will play its part in the development of a wider system partnership on a Mid Mersey or wider footprint RESTART Pulmonary Agreed Rehabilitation Service
74 APPENDIX F Merseyside CCG Equality and Inclusion Service
COVID-19 Equality Briefing Briefing Date : Author of the Paper: Version (3): 30th March 2020 Andy Woods Version (4): 20th April 2020 Senior Governance Manager Version (5): 14th May 2020 Merseyside CCGs Equality and Inclusion Service This Version (6): 2nd June 2020 Email: [email protected]
Jo Roberts Merseyside CCGs Equality and Inclusion Service Manager Email: [email protected] Title: COVID-19 Equality Briefing
Background COVID-19 outbreak means that the NHS has been operating under unprecedented emergency measures.
From an equality perspective there are a number of issues that all NHS organisations needed to consider as part of their response to COVID-19 in addition to the core standards for Emergency Preparedness, Resilience and Response (EPPR). There are a number of issues that NHS organisations will now need to consider as part of their recovery plans.
The restrictions extended by the emergency coronavirus legislation are designed to protect those in vulnerable situations and safeguard futures. They have significant implications for all, but as they come into effect it will be important to consider carefully the specific impacts they may have on groups who are already disadvantaged in other ways. Organisations must ensure these groups are not left further behind. https://www.equalityhumanrights.com/en/our-work/news/human-rights- and-equality-considerations-responding-coronavirus-pandemic
The Equality Act 2010 is a statutory act. Public Sector Equality Duty (known as the ‘equality duty’ or ‘PSED’) remains active. This means all service changes, even in emergency circumstances such as responding to COVID-19 and recovery planning, must still be given ‘due regard’ to the objectives of: • Eliminating discrimination, harassment and victimisation • Advancing equality of opportunity • Fostering good relations between different protected characteristics. There continues to be a legal requirement for NHS organisations to publicly make available equality analysis reports on how ‘due regard to PSED’ was made when changing services.
NHS Commissioners and Service Providers are still required to comply with legislation that covers: Equality, Human Rights, Duty of Care, Health and Safety and Employment.
75 Barriers for People The enclosed differential table provides NHS Commissioners and with Protected Service Providers with equality considerations to incorporate in their Characteristics and response and recovery of COVID-19. Mitigations have been provided mitigations along with further recommended actions for NHS organisations. Further equality related publications are available in Appendix 1. Key Issues • Prompt decision making without fully considering equality impacts. • Disproportionate impact of COVID-19 on particular groups. • Accessible Communications to meet information and communication needs for people with a disability or sensory loss on latest COVID-19 guidance and changes to services. • The need for local targeted campaigns and information giving; for those at risk (broader than the national highest risk groups) on key information across protected characteristic and other vulnerable groups. Recommendations 1. Review this Equality specific brief alongside local and national guidance. 2. Distribute COVID-19 Equality Brief to all relevant teams across organisation. For Provider colleagues including but not limited to: Executive Team, Nurse Specialists’ e.g. learning disability, sickle cell. All relevant services e.g. ophthalmology, oncology, CAMHS/ IAPT etc. Provider workforce including but not limited to human resources (workforce), patient experience, patient engagement etc. 3. Providers and CCGs to ensure that when they are reviewing services they develop existing internal documentation to evidence Public Sector Equality Duty ‘Due Regard’. PSED is still active. 4. CCGs and Providers to ensure Governing Bodies and Organisation Boards respectively are sighted on Equality Duty and associated risks by sharing the latest version of the Equality Brief and PSED brief v3 (Appendix 2). 5. CCGs and Providers to continue to seek assurance of service provision from interpreter agencies (language and BSL). 6. Ensure communications are inclusive 7. Develop targeted campaigns to vulnerable people e.g. people with sickle cell anaemia 8. Ensure patient data of COVID-19 cases and deaths are recorded by protected characteristic e.g. ethnicity and disability in addition to the standard age and sex characteristics. 9. Ensure workforce risk assessments updated in line with National recommendations around BAME staff. 10. Commissioners and Providers to resume Workforce reporting; Workforce Race Equality Standard (WRES) and Workforce Disability Equality Standard (WDES) in line with NHS England letter dated 19th May 2020. (Enclosed in Appendix 1) 11. Further to national advice that EDS2 reporting is for local determination; Commissioners and Providers should publish EDS2 summary reports on external websites. It is acceptable to re-publish existing summary reports if it has not been possible to update due to current organisational pressures. 12. Commissioners and Providers to work collaboratively on Quality and Equality considerations for recovery plans. Access advice and support from Provider Equality Leads and Merseyside CCGs Equality and Inclusion Service.
76
Protected Issue Remedy/ Mitigation Recommended Actions Characteristic Age Over 65 (and also Disability) The challenge for local health Ensure processes are in place to Guidelines developed in other commissioners and services if cases communicate guidance with clinical staff countries responding to continue to rise on current projections is to and ensure methods auditable. COVID-19 state that priority develop a consistent approach, based should be given to those who on an understanding and have, first, “greater likelihood communication of risk on a case-by- of survival and, second, who case basis and to avoid a blunt ageist have more potential years of approach. life meaning that pressures on beds and access to respiratory equipment could result in Refer to Publications approval reference: younger, otherwise healthy 001559 Maintaining standards and quality patients being prioritised of care in pressurised circumstances treatment over older patients https://www.england.nhs.uk/coronavirus/pu or those with pre-existing blication/maintaining-standards- conditions. pressurised-circumstances/
Human Rights and BMA ethical issues guidance note: Article 2 would relate to https://www.bma.org.uk/advice-and- rationing of services and the support/covid-19/ethics/covid-19-ethical- ethical decision making in who issues receives recourses in life/death situations.
Vulnerable People – All Ages Ensure Communications/ Engagement CCGs and Providers to work collaboratively Vulnerable people (broader Teams access national and local with networks e.g. Voluntary Organisations, than Government list) being information sources. Local Authority, Police, Fire Service, made aware of specific Healthwatch etc. to ensure communications services available to them via https://www.gov.uk/government/publication are shared with communities. targeted campaigns. s/guidance-on-shielding-and-protecting- extremely-vulnerable-persons-from-covid- 19
77 https://www.gov.uk/government/publication s/covid-19-guidance-on-social-distancing- and-for-vulnerable-people People living in Care Homes/ Commissioners to ensure that national and Commissioners and Providers to ensure Other Housing local information is shared with Care Home that collaborative work is ongoing with COVID-19 poses a higher risk colleagues. Local Authority, Care Quality Commission to populations that live in close (CQC) and Care Home colleagues to proximity to each other. monitor and review capacity and share information with relevant parties. Disability Sensory; D/deaf people
D/deaf, Deaf blind Ensure there is access to British Sign Language for D/deaf people
Commissioners of BSL interpreter services Commissioners of interpreter services to (CCG and Provider organisations) to collate review contract requirements to ensure any information on interpreter agency provision, revisions include Quality Standards for capacity and Business Continuity Plans Translation and Interpretation services. escalating any potential gaps as appropriate through organisation’s internal Commissioners of interpreter services to escalation process. monitor usage and use intelligence / activity data to share with CCG Equality and D/deaf people may require Consider use of Relay UK (previously Next Inclusion Service. additional support to Generation Text) to support communication understand national / local with patients. https://www.relayuk.bt.com/ guidance on COVID-19 and Explore access to video-conferencing changes to service. facilities available free during COVID-19 to support non Face to Face healthcare appointments via Sign Health. Sign Health continues to publish BSL https://www.bslhealthaccess.co.uk/ videos on their website to update D/deaf people on the latest COVID-19 guidelines. https://www.signhealth.org.uk/coronavirus/ CCGs and Providers to work collaboratively with networks e.g. Voluntary Organisations, Deaf Charities, etc. to ensure communications are shared with communities.
78
CCGs and Providers to ensure they respond to any recommendations from Healthwatch surveys undertaken during COVID-19 on patient access/ experience etc.
CCG Equality and Inclusion Service to work with Healthwatch colleagues to identify/ support any gaps in feedback from specific communities. Sensory; Visual Impairments Ensure Communications/ Engagement CCGs and Providers to work collaboratively People with visual impairments Teams access national and local with networks e.g. Voluntary Organisations, may require additional support information sources: Sight Charities, etc. to ensure to understand national / local communications are shared with guidance on COVID-19 and RNIB: communities. changes to service. https://www.rnib.org.uk/campaigning/priority -campaigns/accessible-health- information/coronavirus-and-accessible- CCGs and Providers to ensure they online-information respond to any recommendations from Healthwatch surveys undertaken during RNIB COVID-19 on patient access/ experience https://www.rnib.org.uk/news/campaigning/ etc. accessible-covid-19-information
Public Health England: (Audio, Large Print) CCG Equality and Inclusion Service to work https://campaignresources.phe.gov.uk/reso with Healthwatch colleagues to identify/ urces/campaigns/101-coronavirus- support any gaps in feedback from specific /resources communities.
Guidance is now available in easy read and in a range of community languages see https://www.gov.uk/government/publication s/covid-19-stay-at-home-guidance
79 All NHS organisations to review accessibility tools on websites Neurodiversity, Learning Ensure Communications/ Engagement Ensure monitoring arrangements in place Disabilities, low levels of Teams access national and local for Care Plans and personalised care. literacy information sources: People with neurodiversity or https://www.mencap.org.uk/advice-and- learning disabilities may support/health/coronavirus-covid-19 CCGs and Providers to ensure compliance require additional support to with Accessible Information Standard; e.g. understand national / local information available in easy read. guidance on COVID-19 and changes to service. CCGs to ensure resources are shared with General Practice colleagues to share with families who may need additional support.
Difficulty reported by people CCGs to seek assurance from NHS 111 using NHS 111 online service provider on mitigations in place to services. support people who have difficulty using the online function. Disability: Children Ensure parents/ carers/ guardians are Ensure monitoring arrangements in place involved in any changes to care plans. for Care Plans and personalised care.
CCGs and Providers to ensure compliance with Accessible Information Standard; e.g. information available in easy read.
CCGs to ensure resources are shared with General Practice colleagues to share with families who may need additional support. Cancer https://www.macmillan.org.uk/coronavirus/c Continue to keep patients informed of any People undergoing cancer ancer-and-coronavirus changes to service delivery. treatment may need support to understand any changes to treatment plans. Mental Health: All Organisations to link with Equality Leads, Commissioners and Providers to ensure Redeployment of other care Organisation Development (OD) colleagues recovery plans include priorities as professionals to respond to for access to local and national support highlighted in Simon Stevens letter dated
80 coronavirus will help save agencies for both staff and patients. 29th April 2020. Letter included in Appendix lives. But it also risks leaving 1. already vulnerable older https://www.gov.uk/government/publication people and those living with s/covid-19-guidance-for-the-public-on- mental health conditions mental-health-and-wellbeing/guidance-for- exposed. the-public-on-the-mental-health-and- wellbeing-aspects-of-coronavirus-covid-19 The impact of COVID-19 is likely to increase demand for https://www.mind.org.uk/information- mental health services e.g. support/coronavirus-and-your-wellbeing/ PTSD frontline staff, bereavement, BAME, domestic https://www.mentalhealth.org.uk/coronaviru violence, isolation etc. s Race People whose first language Commissioners of language interpreter Commissioners of interpreter services to is not English may need services (CCG and Provider organisations) review contract requirements to ensure any support to understand national/ to collate information on interpreter agency revisions include Quality Standards for local guidance and service provision, capacity and Business Continuity Translation and Interpretation services. changes. Plans escalating any potential gaps as appropriate through organisation’s internal Commissioners of interpreter services to escalation process. monitor usage and use intelligence / activity data to share with CCG Equality and Commissioners of language interpreter Inclusion Service. services (CCG and Provider organisations) to identify if interpreter agencies provider Video provision. Explore access to video-conferencing facilities. Ensure Communications/ Engagement Teams access national and local information sources: CCGs and Providers to work collaboratively https://www.doctorsoftheworld.org.uk/coron with networks e.g. Voluntary Organisations, avirus-information/# BAME Community Development Projects, etc. to ensure communications are shared Guidance is now available in easy read and with communities. in a range of community languages see https://www.gov.uk/government/publication s/covid-19-stay-at-home-guidance CCGs and Providers to ensure they respond to any recommendations from
81 Ensure organisations connect with BME Healthwatch surveys undertaken during CDW Projects where appropriate to support COVID-19 on patient access/ experience any targeted communications. etc.
Liverpool: Liverpool Community Development Service (LCDS) CCG Equality and Inclusion Service to work http://psspeople.com/whats- with Healthwatch colleagues to identify/ happening/news/introducing-liverpool- support any gaps in feedback from specific community-development-services communities. Sefton: Sefton CVS https://seftoncvs.org.uk/projects/bme/ Halton, St Helens and Knowsley: SHAP Ltd http://www.shap.org.uk/housing- support/knowsley/bme-community- development-service/
Ensure organisations can signpost people to Migrant Help. https://www.migranthelpuk.org/contact
Gypsy and Romany Further support is available through Irish Organisations to ensure communication is Travellers Community Care effective and clear, through trusted Largely mobile populations http://iccm.org.uk/contact/ organisations and individuals, in a culturally and populations with lower appropriate and sensitive way. literacy are more likely to miss accurate public health messages. Sickle Cell Anaemia Sickle Cell Society: Organisations to ensure communication is Not specified as high risk https://www.sicklecellsociety.org/coronaviru effective and clear, through trusted under national guidelines but s-and-scd/ organisations and individuals. are a vulnerable group. UK Thalassemia Society: https://ukts.org/heads-up/coronavirus- information/ Black, Asian and Minority Ethnic CCG and Providers to amend staff risk
82 BAME people disproportionally NHS Employers has now provided assessment templates to include BAME impacted upon by COVID-19. guidance and support to employers on and concerns on physical and mental Refer to statistical reviews creating proactive approaches to risk health. available in Appendix 1. assessment for BAME staff, including physical and mental health CCGs and Providers to review https://www.nhsemployers.org/covid19/heal organisational process which supports staff th-safety-and-wellbeing/risk-assessments- to raise concerns. for-staff CCGs and Providers to ensure communication is shared across staff networks.
Implement national recommendations to support BAME workforce and patients. Religion and A person’s religion or belief Refer to information resources in Appendix Ensure access to religious and spiritual Belief may impact treatment options 1. networks, Provider Lead Chaplain or Spiritual Teams.
A person may have specific Guidance relating to issues around death Ensure each patient is treated as an religious or spiritual need that and burial for faith communities individual following local guidance and with they may need you to support https://www.gov.uk/government/publication support of local infection teams to ensure them with during the End of s/covid-19-guidance-for-care-of-the- that where possible religious and spiritual Life phase or after deceased needs are met and undertaken in the safest death. Current Infection manner. control issues may impact on achieving those needs. Providers to work collaboratively with Inability for family/ friends to be families/ friends. with a dying person may breach Human Rights Articles 3 and 8. Pregnancy and Pregnant women are National Guidelines are available to support Ensure pregnant staff and patients are Maternity considered in the 'vulnerable' service providers in their response to aware of how to access support. group of people at risk of COVID-19. coronavirus https://www.rcog.org.uk/en/guidelines- Local resource to support pregnant people: research-services/guidelines/coronavirus- https://www.improvingme.org.uk/ pregnancy/covid-19-virus-infection-and- pregnancy/
83 Fertility Services
Storage limit for embryos and The Government has confirmed that the Service Providers to ensure patients are gametes current 10-year storage limit for embryos informed of Government guidelines. and gametes will be extended by two years.
Local Commissioning Policy Individual cases can be discussed between Service Provider to consider Age when Age criteria to commence GP, CCG, Service Provider and Individual clinically triaging existing and new cycle/s means that delays in Funding Request leads. appointments. access to services (either for existing or new patients) may impact on patients aged 40-42. NB refer to local policy Sex (M/F) During periods of confinement National programme and resources Ensure any communications provide domestic abuse (a crime available signposting to Voluntary Organisations and mostly impacting women and https://www.gov.uk/government/publication referrals to Safeguarding Team or Human girls) tends to increase, and s/coronavirus-covid-19-and-domestic- Resources Team as appropriate. that the health care that offers abuse/coronavirus-covid-19-support-for- a way of identifying this issue victims-of-domestic-abuse will be under unprecedented pressure. Women, including those who Ensure guidance on shielding, self-isolation Ensure group are included in staff are pregnant and on maternity is followed. communications. leave, should not be disadvantaged in their careers by following government advice to stay at home. Women are more likely to work Ensure guidance on shielding, self-isolation Ensure organisation response considers in higher risk and low paid key is followed and Health and Safety actions to improve protection and health worker roles. procedures. and well-being of key workers. https://www.theguardian.com/ world/2020/mar/29/low-paid- Ensure organisation monitors adherence women-in-uk-at-high-risk-of- with PPE, Infection Control and procedures coronavirus-exposure to support staff to raise concerns.
Sexual Access to key and supportive National information available to support Ensure communications from Stonewall Orientation information LGB people to access healthcare services. and any other LGB community group are
84 https://www.stonewall.org.uk/about- distributed. us/news/covid-19-%E2%80%93-how-lgbt- inclusive-organisations-can-help
Less likely to seek medical Organisations to link with Equality Leads for attention due to poor access to local and national support experience and discrimination agencies for both staff and patients. and experience higher levels of health inequality. Gender Access to key and supportive National information available to support Ensure communications are from Stonewall Reassignment information people who are/ have transitioned to and other Transgender community groups access healthcare services. are distributed. https://www.stonewall.org.uk/about- Less likely to seek medical us/news/covid-19-%E2%80%93-how-lgbt- Organisations to link with Equality Leads for attention due to poor inclusive-organisations-can-help access to local and national support experience and discrimination. agencies for both staff and patients. Marriage and Refer to Mental Health –All Resources available in Appendix 1. Ensure family members are included in Civil Partnership Refer to Religion and Belief individual care planning as appropriate. Refer to Sex (M/F) Domestic Violence Other Health Inequalities and Resources available in Appendix 1. Communications and Engagement Teams Poverty to ensure information is accessible to all Migrant workers who are staff with a view to signposting patients. vulnerable and unable to access public funds.
From Migrant Help key info re access to
People within the criminal National guidance available for responding Ensure organisation response includes justice service and prisons to COVID-19 within prison services. information sharing with those delivering COVID-19 poses a higher risk services within prisons. to populations that live in close proximity to each other. CCGs to liaise with General Practice to (NHSE commissioned ensure people leaving prison are able to services) access General Practice services.
85 Health Inequalities and Resources available in Appendix 1. CCGs and Providers to work with local Poverty communities to support Safeguarding E.g. Unhealthy behaviours; people in poorer communities. smoking, excessive consumption of alcohol, poor Organisation recovery plans to include the diet and low levels of physical continued communication of information to activity. support people different communities.
Difficulty reported by networks in engaging with certain communities. All Decision Making CCGs and Providers have established Wherever possible current equality The normal course of action, of Governance arrangements in place. processes around meeting PSED must be writing and submitting Equality maintained , however if this is deemed too Analysis reports (EIAs) to impractical in an emergency situation then committees, and then acting, actions that need to be taken; may be too slow a process for Use a methodology to record decisions and rapidly changing acknowledge PSED responsibilities. environments. However, the The Courts will understand the ‘time Courts follow precedent and crunch/ delivering at pace’ to fighting the deviation from the precedent epidemic, but they will want to see how implies risk. PSED has been incorporated into that process, even if that process has been temporarily abridged. Refusing to meet PSED is not an option.
Recovery Planning Human Rights Review service change log. Any restrictions must be carefully thought What dependencies are there to resume through, so that restrictions are rights- service, equality considerations and any respecting rather than breaching the very mitigation needed. Engage with relevant standards that we all need to maintain our stakeholders. Applicable to all NHS safety and dignity Organisations including CCGs for General Practice.
Ensure staff are treated as an individual if returning to work ensuring local guidance is followed in relation to Health and Safety
86 and local infection prevention and control measures.
Continue to work with sub-contractors in relation to Response and Recovery plans.
Share best practice across system, e.g. digital inclusion; use of telephone and video consultations between patients and clinicians.
Ensure organisation representation at Community Advisory Group (Co-ordinated by Merseyside Police).
Ensure ongoing Monitoring of Safeguarding referrals. Contact Details of a number of support agencies for people with Protected Characteristics or specific disabilities are available from Provider Equality Leads (via Best Practice Guidance for Reasonable Adjustments).
All advice to the public about what to do during the pandemic is issued by Public Health England (PHE) and published at https://www.gov.uk/coronavirus There is also supporting information on https://www.nhs.uk/conditions/coronavirus-covid-19/ This is the only official source of advice.
Local, Regional and National information sources is provided as follows:
200409 Accessible Information about CO
87 Appendix 1 COVID-19 Equality Related News Articles/ Statistical Reports/ Guidance/ Resources
COVID-19 Equality Specific documents.xl
Appendix 2 COVID-19 Public Sector Equality Duty (PSED) Briefing to CCG Governing Bodies and Provider Boards
COVID-19 and PSED briefing for GB and Pr
88
Version Change Log 1 2 Additions to barriers matrix 3 *Over 65’s added to Age in relation to bed pressures and access to respiratory equipment. *Recommendations updated to include target audience for brief. *Provider Lead Chaplain or Spiritual Teams added to Religion or Belief. *Safeguarding and Human Resources added to mitigations on Sex (M/F) issue relating to domestic abuse. *End of Life Care needs added to Religion or Belief. 4 *Recommendations updated to include: Providers and CCGs to note that the Equality and Human Rights Commission has suspended reporting on specific equality duties for this year. The General Duty is still in force. *Guidance relating to issues around death and burial for faith communities added to Religion or Belief *easy read and community languages government information source added to Disability and Race *Web links added to Age: Vulnerable (All Ages) *Web links added to the end of the barriers matrix to include Public Health England official sources of advice *NHS England collated information sources list embedded at the end of the barriers matrix. *Reference to NICE guidance replaced with national guidance on maintaining quality on Age (Over 65 and disability). *BMA ethical guidance added to Age (Over 65 and disability). 5 *Dates added to Briefing Date to highlight version control. *Equality Legal Duty added to Background section *Reference to recovery, recommended actions and additional appendices added to Barriers Matrix section *key issue added: disproportionate impact of COVID-19 on particular groups. *key issue removed: translation and interpretation provision *key issue: wording added: “changes to services” to third bullet point. *key issue: wording added “the need to” to opening sentence of last bullet point. *recommendations: wording added “and CCGs” and “PSED is still active” to recommendation 3. *recommendation added: CCGs and Providers to ensure Governing Bodies and Organisation Boards respectively are sighted on Equality Duty and associated risks by sharing the latest version of the Equality Brief and PSED brief v3 (Appendix 2). *recommendation added: CCGs and Providers to continue to seek assurance of service provision from interpreter agencies (language and BSL). *recommendation removed: reporting requirements suspension. *recommendation added: Ensure patient data of COVID-19 cases and deaths are recorded by protected characteristic e.g. ethnicity and disability in addition to the standard gender, sex characteristics. *recommendation added: Ensure workforce risk assessments updated in line with National recommendations around BAME staff. *Structural/ formatting changes made to barriers matrix to include recommended actions column. Recommended actions added to each Protected Characteristic and Issue. *Disproportionate impact on BAME people added to Race protected characteristic. *Human Rights issue added to Religion and Belief protected characteristic. *Additional consideration added to barriers matrix: Health Inequalities and Poverty. *Additional consideration added to barriers matrix: Decision Making. *Additional consideration added to barriers matrix: Recovery. *Appendix 1 added: includes statistical reports, guidance, national letters, health journal articles and newspaper articles linked to relevant protected characteristics and patient / staff groups. *Appendix 2 added: PSED brief for CCG Governing Bodies and Provider Boards.
6 *background narrative updated to reference the need to consider equality issues in recovery planning. *recommendation 8: age added and reference to gender removed. *recommendation added: Commissioners and Providers to resume Workforce reporting;
89 Workforce Race Equality Standard (WRES) and Workforce Disability Equality Standard (WDES) in line with NHS England letter dated 19th May 2020. *recommendation added: Further to national advice that EDS2 reporting is for local determination; Commissioners and Providers should publish EDS2 summary reports on external websites. It is acceptable to re-publish existing summary reports if it has not been possible to update due to current organisational pressures. *recommendation added: Commissioners and Providers to work collaboratively on Quality and Equality considerations for recovery plans. Access advice and support from Provider Equality Leads and Merseyside CCGs Equality and Inclusion Service. *Disability: issue added to neuro-diversity of people reporting difficulty using NHS 111 online services. Recommended action also added. *Race: BAME: narrative amended to reflect that NHS Employers has now published guidance. *Pregnancy and Maternity: issue added to barriers matrix specific to fertility services; services resuming and storage limits. Mitigations and Recommended Actions added. *Other: Health Inequalities and Poverty: Narrative reworded in the issue section and now includes low level of physical activity and difficulty reported by networks in engaging with certain communities. *Appendix 1 updated with further publications. Publications added since the last issue of the Equality Briefing are highlighted in yellow for ease of reference.
90 Appendix G
UPDATED RESET AND RECOVERY POST COVID-19 Communications and Engagement Strategy 2020-2022
91 Message from our Lay Member for Patient and Public Involvement NHS St Helens Clinical Commissioning Group is committed to carrying out meaningful engagement and communicating effectively with the local community giving people, our patients, public and stakeholders the opportunity to be involved in and influence healthcare in their local area, ensuring their voices are heard and their thoughts and experiences are taken into consideration.
Following the Covid-19 pandemic, which is ongoing and will continue to impact on our work for some time, the CCG has had to relook at how we communicate with its stakeholders and the public, and how it will ensure that local communities and key stakeholders are still able to help shape local health and care services as before.
As the Patient and Public Involvement Lay Member, my role is to ensure that, in all aspects of the CCG’s business the public voice of the local population is heard, fully represented and that opportunities are created and protected for patient and public empowerment in the work of the CCG. In particular, they will ensure that:
• Public and patients’ views are heard and their expectations understood and met as appropriate; • The CCG continues to maintain an effective relationship with Healthwatch, the voluntary sector and community groups/forums within St Helens and draws on existing patient and public engagement and involvement expertise; and • The CCG has appropriate arrangements in place to secure public and patient involvement and engagement in an effective, timely and representative way to feedback recommendations from patients, carers and the public
We have therefore updated this strategy for 2020-2021, highlighting the different means we will use to ensure that our community, patients, stakeholders, member practices and employees will be both kept informed of the work of the CCG and still have the opportunity to influence it.
Mark Weights Patient and Public Lay Member You can get in touch with me by calling 01744 627596 or by email [email protected]
92 1.0 Who we are 5.5 Social Marketing 1.1 Introduction 1.2 St Helens Integrated Peoples 6.0 Reputation Management Service (SHIPS) 6.1 Public Relations 1.3 Our Vision 6.2 Local Media 1.4 Our Values 6.3 NHS Brand 1.5 Our Duty 6.4 Crisis Management 1.6 Equality and Diversity 1.7 Our Audiences and Stakeholders 7.0 Health and Social Care is 1.8 Purpose of this Strategy Changing 1.9 Strategy Aims 7.1 St Helens Cares 7.2 St Helens Cares Engagement 2.0 What is Engagement and Group Communications and why is it 7.3 St Helens cares Brand important 2.1 Communications 8.0 Established patient/ public 2.2 Engagement and Involvement groups 2.3 How we enable patient/public 8.1 Patient Experience and engagement and Involvement Involvement Group 2.4 Messaging 8.2 Patient Participation Group 2.5 Campaigns 8.3 Stakeholder Forum 8.4 Children’s and Young people 3.0 Membership Communications Network and Engagement 3.1 Our Membership 9.0 Political Communications and 3.2 Membership Communications and Engagement Engagement channels 9.1 Public Affairs 3.3 Membership Engagement 9.2 Parliamentary Briefings Principles 3.4 Membership Communications 10.0 Statutory Duties Principles 10.1 Governing Bodies 3.5 Primary care committee 10.2 Annual Report 10.3 Annual General Meeting 4.0 Patient / Public Engagement and 10.4 Freedom of Information Involvement 4.1 Improvement and Assessment 11.0 Internal Communications and Framework Engagement 4.2 Patient and Community 11.1 Importance of Internal Engagement Indicator Communications and Engagement 4.3 Listening and learning 11.2 Internal Channels 11.3 Internal Engagement Principles 5.0 Digital Communications and 11.4 Internal Communications Engagement Principles 5.1 The Benefits of digital Communication 12.0 Evaluating our work 5.2 Plan for digital communications 12.1 Evaluation 5.3 Website 5.4 Social Media 13.0 Governance and Accountability 13.1 Working arrangements and reporting
93 1.0 Introduction NHS St Helens Clinical Commissioning Group is responsible for commissioning (or ‘buying’) health and care services for the local community, using our budget of around £226.3 million to ensure high quality, sustainable healthcare that meets the needs of our population of 197,000.
The CCG is committed to working with our colleagues at the local authority and our local acute, community and mental health trusts to make a difference and improve the health of local people.
We are a membership organisation comprised of 34 GP practices. We cover the geographical area of St Helens which includes the areas of Sutton, Town Centre, Earlestown, Rainhill, Eccleston, Clock Face, Haydock, Billinge, Rainford and Newton-le-Willows.
1.1 St Helens Integrated Peoples Services (SHIPS) The CCG is fully integrated with the People’s Service directorate within the local authority. As part of this integration a joint role has been developed - the CCG’s Accountable Officer is also the Strategic Director of People’s Services to lead the integrated team to ensure health and social care are fully aligned and deliver the best services for our community. SHIPS have set a number of priorities as a way of measuring our success by 2021:
• We will support a higher proportion of our people to stay well in their own community • We will increase the number of children and families receiving early help and reduce the numbers requiring statutory intervention • By school heads and the council working in partnership, every child will attend a ‘good’ school and the gap between vulnerable students and their peers will be decreased • We will improve healthy life expectancy and decrease the gap between the best and worst wards for healthy weight, physical activity, wellbeing and community support • We will improve the lives of people experiencing poor mental health • We will have a financially sustainable medium term integrated budget strategy without putting the population of the borough at risk
1.2 Our Vision In St Helens, our People’s Board was established to bring together the necessary membership, responsibilities and policy intention of the St Helens Health and Wellbeing Board and ‘Safer St Helens’, the local Community Safety Partnership. The membership of both groups was similar and both had a cross-over focus on some issues such as alcohol. The St Helens People’s Board creates a borough based partnership to collectively achieve our vision:
94 1.3 Our Duty NHS commissioning organisations have a legal duty under the NHS Act 2006 (as amended) to ‘make arrangements’ to involve the public in the commissioning of services for NHS patients (‘the public involvement duty’). For CCGs this duty is outlined in Section 14Z2 of the Act and for NHS England the duty is outlined in Section 13Q. To fulfil the public involvement duty, the arrangements must provide for the public to be involved in: a) The planning of services b) The development and consideration of proposals for changes which, if implemented, would have an impact on services c) Decisions which, when implemented, would have an impact on services.
1.4 Equality and Diversity The NHS has clear values and principles about equality and fairness, as set out in the NHS Constitution. In St Helens we ensure that whenever people need healthcare, they not only have the right to access it but also to be treated fairly and not to be discriminated against. As well as working with service partners to ensure that people with protected characteristics (defined by Equality Act 2010) are not discriminated against, we actively carry out targeted engagement to ensure that their voices are heard and their experiences are captured and acted upon. We also ensure that we communicate and engage with them in the most appropriate way using a variety of engagement methods and language and formats suitable for them. All engagement carried out links in with the organisation’s equality objectives, as well as reflecting the Reset and Recovery Plan around E&D and inequalities.
1.5 Our Audiences and Stakeholders Building supportive and trusting relationships with our key stakeholders is critical to our success. It is crucial to understand who our key stakeholders are and their importance to the delivery of our vision and priorities.
We also work closely with organisations which have similar objectives to help address gaps, reduce duplication, successfully implement integration and build sustainable, high-quality services. By working in partnership, we will bring together support for pressing health issues more effectively and promote the reputation of the NHS.
We have many stakeholders who we must communicate with, listen to, engage and work with. Our key audiences and stakeholders include:
• Local community
95 • Patient representatives and groups • Voluntary and community sector organisations/representatives • Healthwatch St Helens • St Helens Cares Partners • Our GP membership - the member practices and practice staff • Our staff • Local elected members • Press and media
1.6 Purpose of this Strategy This communication and engagement strategy is designed to support the CCG to realise its objectives and achieve its vision. It sets out our approach to communications and engagement, both within the CCG and externally with our many stakeholders. It also sets out how we will: m• Co municate effectively with our members • Help build public confidence in and manage the reputation of the St Helens CCG and St Helens Cares • Develop close working relationships with our stakeholders, which will allow them meaningful opportunities to influence decision making.
This strategy has now been updated to reflect the changes in how we will communicate and engage with our audiences going forward with Covid-19 restrictions in place for the foreseeable future governing how we will work.
1.7 Strategy Aims Raise Awareness: Ensure NHS St Helens CCG is a ‘recognisable face’ within NHS St Helens
Create Understanding: Clarify who NHS St Helens CCG is and what we do
Develop Partner Buy-in: Ensure all partners feel a sense of ownership and pride towards NHS St Helens CCG
Build Reputation: Raise the profile of the CCG and its members by maximising confidence levels in both GPs and the NHS overall.
Listen to Partners: Ensure the public/patient voice really is at the centre of all business decisions and that there are appropriate structures in place to all partners to feedback comments, questions, criticisms or concerns
Talk to Partners: Ensure that regular, clear, timely messages are given to our partners, letting them know what is going on within the CCG and our plans for the future
96
Manage Expectations: Confirm that some things won’t change quickly – although over time the CCG will bring about continuous improvements that benefit service users. Remind partners of the limitations to resources with respect to communications and engagement
Provide Co-ordination and Consistency: Ensure that the organisational key messages are interlinked into all messages. Ensure that all partnership communications and engagement activities are integrated into our work wherever possible
Integrate Communications and Engagement: Communications and engagement should be at the heart of all business decisions and the ethos of commitment to good communications and engagement should therefore be the responsibility of all CCG partners, not just that of the communications and engagement team.
2.0 What is Communications and Engagement and why is it important? Communication and engagement is more than an exchange of information. It achieves organisational credibility, promotes reputation and reassures people in times of crisis. It involves two-way written, verbal and non-verbal communication but also involves managing relationships. It is as much about attitude and behaviour as it is about delivering messages. Good and bad communication or the decision to communicate (or not) can have a serious impact on public confidence, staff morale and the reputation of the organisation and brand.
Our vision is to commission high quality services to enable people to live longer and healthier lives. The only way we can do this is by putting the people of St Helens at the heart of all of our communications and engagement activities. This involves working with, talking to, listening and learning from our public, patients, families and carers to fully understand what matters to them and improve things in response to their views and needs.
Similarly, greater emphasis needs to be placed upon equipping officers, GP members and other partners who have regular contact with the people of St Helens to create a well-informed network who are capable of passing on our messages effectively. Effective communication and engagement has the power to manage, motivate, influence, explain and create conditions for change.
2.1 Communications Communications is a tool used to share information and deliver key messages to the local community, stakeholders and partners. Communications can be delivered ion a number of formats to suit the audience such as email, newsletter etc. Communication is also used as a way of gaining feedback from our community on the services we commission. When developing messages, the Communications team follow the principles of the 7 Cs:
97 • Clear (what is the purpose and goal of the message? Is there a call to action?) • Concise (is the message straight to the point and brief?) • Concrete (is the message solid? Will all promises definitely be delivered upon?) • Correct (is the message error free? Are we using the best channels for the audience?) • Coherent (is the message easy to understand by all?) • Complete (is there anything missing from the message? Can we pre-empt what questions or issues may arise from the message?) • Courteous (is the message friendly, open and honest? Does it empathise with the audience’s needs?).
2.2 Engagement and Involvement Engagement and involvement refers to giving people the opportunity to shape and influence the commissioning and delivery of local health and social care. It is vital to ensure that local people’s voices are heard and their thoughts and experiences are taken into consideration i.e. ‘no decision about me without me’. Listening to our local community is key. Capturing and sharing patient experiences and stories provide us with insight and influence decision making. This gives us the opportunity to achieve a greater understanding of the needs of our community and to buy the services that our communities really need. When undertaking engagement and involvement activity, the team follow the following engagement principles. They ensure that all processes:
• Make a difference (not tokenistic) • Are transparent and are delivered with integrity • Involve the right number of participants, are fit for purpose and are tailored to their needs • Are an integral part of the mainstream commissioning and planning process • Are owned by all CCG colleagues and partners • Make clear from the start what is ‘on offer’ (i.e. what can and cannot be influenced, how the results will be used and what feedback will be given) • Involve people at the earliest stages in the planning, not just consulting them once decisions are made • Appreciate that people, communities may wish to engage at different levels and some may not wish to become fully involved • Involve participants being kept informed of what changes occurred as a result of their input • Ensure evaluation, monitoring and feedback are built into plans at the outset. This year work will continue to work with the above principles taking into account the current situation and adapt working practices to ensure the community continue to be involved adapting new technology and ways of working.
2.3 How we enable patient/public engagement and Involvement
98 Effective communication, engagement and involvement of patients and the public in the work of the CCG is the day-to-day responsibility of all our staff and members. However, to support the effective communication, engagement and involvement of patients and the public (and wider stakeholders) across the organisation and its programmes of work, we have a small dedicated communications and engagement team
The communications and engagement team are responsible for monitoring, delivering, evaluating and reporting on communications and engagement activity and how successful it has been in delivering the organisation’s objectives.
They have a key role in supporting others within the organisation to maximise the effectiveness of their communications and engagement with stakeholders. This organisation-wide communications and engagement strategy is underpinned by programme and project-level communications and engagement planning for each of CCG’s priority programmes as well as the wider work of St Helens Cares.
Patients and the public are encouraged and supported to get involved with the work of the CCG and its areas of work. This involvement can either be in an patient advisory capacity - through invitation to specific meetings, workshops or events led by programme and clinical leads, or through regular input to specific ‘task and finish’ work at project level.
2.4 Messaging
Consistent messaging gives a clear voice to the organisation. Our overarching key messages are:
• We are clinically-led, by local GPs, and work together to improve the health of the people of St Helens • We plan and buy high-quality healthcare services for the people of St Helens • We work with our patients to help prevent them becoming ill and support them to live longer, better quality lives • We are committed to working with our partners across the NHS, social care and third sector to improve the health and wellbeing of the people of St Helens • We continually work hard to safeguard the quality of healthcare services • We always encourage feedback from local people and will act on it wherever possible • We make our best efforts to use the funding and resources we have wisely to ensure we achieve value for money.
2.5 Campaigns
We will continue to develop and support campaigns aimed at promoting the appropriate use of local services and have developed a local campaign working in partnership with local CCGs and providers across the Mid Mersey footprint –
99 ‘Let’s Do It Together’ to highlight the need for appropriate use of NHS services across Cheshire and Merseyside.
3.0 Membership Communications and Engagement
3.1 Our Membership As a membership organisation, how we communicate with our 34 GP member practices is a key part of everything we do. An effective CCG must work with its membership and be committed to the same vision and to delivering shared objectives. To achieve this, two way communication is critical to ensure GP member practices feel confident that they are able to work with us to develop plans and take ownership of commissioning.
3.2 Membership Communications and Engagement channels GP Bulletin – Our fortnightly bulletin is published and distributed to all GP Practice staff via email. This bulletin is also uploaded onto the CCG intranet. The bulletin provides important updates in terms of commissioning decisions as well as key information and updates from partner organisations e.g. change to service number, pathways etc. This has been changed to a daily email update direct from the primary care team to practices due to the frequently changing situation and information needing to be cascaded.
Intranet – The intranet is specifically for CCG staff and GP members. It contains a range of information including podcasts, vlogs, details of events, policy updates and resources to support GP practices.
GP governing body member update – this is filmed following governing body with a GP governing body member sharing what is discussed at the meeting for their peers.
Accountable Officer Blog – The CCG’s Accountable Officer produces a monthly blog and ad hoc filmed updates relevant to staff and GP member practices
GP Members Council – These meetings bring together senior Clinical Commissioning /staff with GP representation from all practices across St Helens
3.3 Membership Engagement Principles There are a variety of ways in which our members are engaged with CCG business. These include our regular GP Forum and GP Members Council; ad-hoc topic specific events; and one to one practice visits with CCG senior leaders. It is vital that our members fully appreciate that the CCG is theirs, that the success of the organisation is in their gift and then subsequently take full ownership of it.
100 As with all membership organisations, there needs to be ongoing monitoring of the feelings and attitudes of members during engagement activities to assess whether attitudes are neutral, friendly, hostile or apathetic. We then adopt our approach accordingly. We know that our GPs are more likely to get and stay involved if they can clearly see how the CCG’s work will benefit them and consequently what will improve.
3.4 Membership Communications Principles In order for each of our GP members to fully appreciate what potential value the CCG could bring to them (at primary care network, practice level, and as an individual clinician), they must fully understand what the organisation actually is, it’s objectives and their own personal role within the system. By working collectively as members of one commissioning organisation, the GPs have considerably greater power than should they commission / provide independently.
Strong membership communications is essential for building robust and meaningful relationships between our GP community and the officers working on their behalf. The GPs must recognise that the CCG belongs to them and is therefore their organisation if they are to take a sense of ownership towards it. Successful membership communications will ensure that we create one unified primary care health economy, sharing local and clinical knowledge and skills and all working for the greater good, i.e. to ensure the people of NHS St Helens live longer, healthier lives.
In order to fit alongside their busy daily schedules, the CCG recognises that member communications must be succinct, relevant and not disseminated in a ‘scatter-gun’ approach. A commitment has been made to members that non-urgent, ad-hoc messages will be published collectively by a fortnightly commissioning bulletin. Alongside this digital tactic, the communications team also provide GP practices with printed communications when relevant.
3.5 Primary Care Committee The Primary Care Committee has been established to enable members to make collective decisions on the review, planning and procurement of primary care services as part of the CCG’s statutory commissioning responsibilities in St Helens under delegated authority from NHS England
4.0 Patient/ Public engagement and involvement 4.1 Improvement and Assessment Framework
NHS England has implemented an approach to the assessment of patient and public participation as part of the statutory annual assessment of performance.
The ‘Patient and Community Engagement Indicator’ is a standalone indicator within the Improvement and Assessment Framework (IAF). The assessment will therefore,
101 form part of the overall IAF assessment for CCGs.
The domains and criteria within the ‘Patient and Community Engagement Indicators’ include:
A. Governance B. Annual Reporting C. Day to Day Practice D. Feedback and Evaluation E. Equalities and Health Inequalities.
4.2 Public Consultation
We have a statutory duty where any of the CCG’s plans or proposals represents a substantial development or variation of service, to notify the local authority via the Health and Wellbeing Scrutiny Committee and formally consult with local people and wider stakeholders on our plans.
We undertake equality analysis in line with the Equality Act 2010 (and section 149 of the Public Sector Equality Duty) and pay due regard to the Gunning Principles in our approach to consultation by;
• Consulting when proposals are at a formative stage • Clearly outlining proposals and the reasons for them so local people can understand the changes • Allowing adequate time for consideration and response • Taking responses into account and ensuring they inform decision making.
Communication and engagement is vital to carrying out effective public consultation activity and therefore, each consultation carried out by the CCG will be supported by a detailed communication and engagement plan.
However, as a result of the Covid-19 pandemic and ongoing restrictions to public gatherings, it is clear we need to reassess how we carry out our statutory duties to consult. This will include going forward:
• Expanding our use of digital channels
• Sense checking with communities, and strengthening our partnership with the Voluntary & Community sector
• Demonstrating we have made the utmost effort to consult with our vulnerable groups.
4.3 Listening and learning
We want to understand the needs of our communities and the priorities for
102 reducing health inequalities in our population. We need to ensure that the most vulnerable in our society have a voice and that we listen to their experiences to ensure that they are able to access appropriate care, services and support to help bring about improvements in their health and wellbeing.
We want patients and the public to know that we listen to them and design local healthcare with them, not just for them. In order to achieve this, we need to appropriately and effectively involve patients and the public and record all feedback to help inform our commissioning.
The CCG triangulates and analyses feedback, insight and intelligence provided by patients and the public via communication and engagement activity.
This review of evidence from patient and public feedback is used as commissioning intelligence to help develop programme and project plans that address the needs identified and also to target future communication and engagement activity. Patient experience information is gathered from a range of sources, including:
Local NHS Providers - Patient feedback from providers who have direct contact with patients is crucial to the commissioning process. We collect results from both local and national patient satisfaction surveys.
Local GP Practices - Results from the annual national GP patient satisfaction surveys provide us with information about how satisfied local people are with their local GP Practice.
Patient Advice and Liaison Service (PALS) and Complaints - Complaints and PALS information provides us with a valuable insight into how patients experience local services. We look closely at the themes from complaints, concerns, enquiries and compliments. Complaints, in particular, can provide powerful lessons for improving local services.
Consultations - When carrying out our public consultations, we take the opportunity to listen to peoples’ experiences of care, and ensure we record and use them to improve Health and Social Care services.
Talkfest - Feedback from those who attend our Talkfest public engagement events provides us with valuable data on patient experience.
Patient Stories - Regular feedback from patients is vital to service redesign and development. We take the time to meet with patients and carers, listen to their stories, take careful notes and learn from these.
Focus Groups / Drop in sessions - We invite local people to attend focus groups / drop in sessions where they can share their patient experiences and meet others in similar positions to themselves. These will, in the main, be virtual going forward using a wide range to technology and new methods of engagement.
Healthwatch St Helens - We work closely with our local Healthwatch, who share feedback they have collated about local patient experiences. This gives us a rich
103 source of patient feedback which is then presented to our patient experience and Involvement Group, reviewed, analysed and added to our patient experience reporting module.
Friends and Family Test - The aim of this test is to provide all NHS patients and carers with an opportunity to give us feedback using a simple question, that is, would you recommend this service to your friends and family? We use this to help make service improvements.
Patient Websites - People are increasingly turning to websites to report on their patient experiences, and we regularly monitor these and add them to our patient data repository. Of particular note is the feedback posted on the NHS Choices website and Patient Opinion websites. Feedback posted on social media sites such as Twitter and Face book are also regularly checked for patient feedback on local services.
5.0 Digital communications and engagement
5.1 The benefits of digital communications
We recognise the need to continually develop and build new ways of communicating and engaging with our stakeholders to help develop strong, mutually beneficial relationships. It is important that we communicate with people in the way that is most convenient and accessible for them, in the way which makes it easiest for them to engage and respond.
This is more important than ever in the light of the Covid-19 pandemic. The CCG is now using Microsoft Teams to enable virtual meetings, webinars and events and will continue to shift the majority of our engagement to this channel until the pandemic is over.
Using a multimedia approach will enable us to:
• Reach a wide audience • Help to improve health and local healthcare through targeted messages • Encourage people to share our news to enhance our reach • Engage with our partners and ensure that we are approachable. The informal nature of social media encourages more people to have a conversation with us, challenge us or make their own views known.
5.2 Our plan for digital communications
We will effectively manage our digital media communication methods by linking them to our strategic objectives. Our main objectives will be to:
• Build a strong community of stakeholders online • Engage stakeholders in a two-way conversation about our work
104 • Encourage stakeholders to support our work • Share partners’ health and social care messages • Encourage staff and members to support promote and take part in our online activities.
5.3 Website
Increasingly, people use the internet to seek information about an organisation, where to obtain help and advice and how to access services. Equally websites are being used more as a means of providing feedback. As an organisation we acknowledge the importance of having a fit for purpose website.
The CCG has a quality, easy to navigate website and is accessible to the whole of the community. We ensure the website is maintained regularly and all information is up to date with latest policies, procedures as well as engagement and involvement opportunities.
5.4 Social Media
We recognise the increasing importance of social media as a way to engage and communicate with our community, partners and stakeholders. We use popular social media platforms including Facebook, Twitter, blogs and vlogs. These platforms allow us to communicate our key messages, engage with the community on our work, and obtain feedback from patients and the public as well as promoting engagement opportunities.
The nature of social media makes it responsive and constantly adapting to its environment which can provide a good opportunity for excellent two-way engagement and communications.
We also use other social media platforms such as YouTube and Instagram with the aim of further expanding our social media platforms and reach, especially with a younger audience.
5.5 Social Marketing Although we do not actively develop our own social marketing campaigns, we access regionally and nationally developed campaigns, such as ‘Be Clear on Cancer’. We also work with our local public health team and neighbouring CCGs and trusts to develop joint campaigns across our local areas to ensure consistent messages.
6.0 Reputation management
6.1 Public relations
105 Every organisation, no matter how large or small, relies on its reputation for success. If we establish and maintain a good reputation as an NHS organisation, then our patients will feel confident that we are doing the best job on their behalf and will be more likely to work with us.
One role of the communications and engagement team is to help protect and enhance the reputation of the NHS in St Helens by promoting the work the CCG does.
This can be achieved through effective public relations and media approach to:
• Raise the profile of the CCG • Strengthen relationships with GP member practices and partner organisations by showcasing how the clinical commissioning group is making a difference • Tell the story of health and social care in St Helens – sharing our successes
6.2 Local media
How the local media perceive and portray us can be highly influential in forming public and other stakeholders’ perceptions of the organisation’s credibility and standards. Careful handling of all media enquiries and identifying proactive media opportunities to talk about the improvements we have made to patient care will help us to build a mutually supportive relationship.
6.3 NHS Brand
Effective management of our identity and corporate house style is an important element in protecting the organisation’s reputation and in ensuring that our vision and values are clearly visible within all our communications.
We work with staff to ensure that the brand and the corporate house style are applied appropriately at all times. To support staff with this, the communications team have developed a series of corporate templates and guidelines about how the NHS and corporate identity should be applied.
6.4 Crisis management
The provision of healthcare is, by its very nature, risky. Incidents can occur which can quickly become a focus for the media with the potential of impacting on the reputation of the CCG. Often these can spring up without warning and require prompt, careful and effective communication management to provide the public with accurate information and reassurance – as well as limiting reputational damage. For all crisis management situations, an appropriate spokesperson will be identified and fully supported by the communications and engagement team.
106 7.0 Health and Social Care is Changing 7.1 St Helens Cares We are changing the way that healthcare and social care services are organised in St Helens. Moving forward, clinicians, managers and planners will work together and will engage with patients/service users, the public and staff to develop plans for a better healthcare and social care system for St Helens residents.
We aim to ensure that this local system of care will be organised in the most effective way to provide safe, effective, person centered and sustainable care to meet the current and future needs of our population. This will also support the vision of the St Helens People’s Board which is improving people’s lives together, by tackling the challenge of cost and demand.
The local care system, St Helens Cares, is being developed through locality working. This will see a core team of multidisciplinary health care and social care clinical and managerial staff from across St Helens working collaboratively. They will work in partnership with our local hospital providers, the ambulance service, local police and fire services, community and voluntary services, the local housing trust and education providers. They will engage with the full range of people1 in an open, transparent and accessible way and use their feedback to support the implementation of the transformational St Helens Cares Strategy.
7.2 St Helens Cares Communications and Engagement Group
To support the work of the wider St Helens Cares work, a communications and engagement group has been established to bring together all organisations to support the delivery of this work across their local communities and staff.
7.3 St Helens Cares Brand
The St Helens Cares branding guidelines have been produced to support all organisations on the effective use across the local care system. As this work evolves, work will continue across the St Helens Cares communications and engagement group to further develop the branding.
8.0 Established patient / public groups
8.1 Patient Experience and Involvement Group
The Patient Experience and Involvement Group is a sub group which reports directly to the CCG’s Quality Committee, in line with the quality strategy. The group supports and advises on borough-wide engagement, consultation and communication activity
107 and initiatives relevant to the delivery of the CCG’s Commissioning Strategy and St Helens Health and Wellbeing Strategy. Members of the PEIG promote engagement and consultation work through their groups, in line with the communications and engagement strategy. This enables the CCG to ensure that they are exhausting all channels of communication and engagement and are able to reach seldom heard or vulnerable groups. A large part of the PEIGs role is to make sure that the CCG follows their consultation and engagement processes which have been developed alongside commissioners. The PEIG also uses the best practice consultation timeline to refer to when reviewing proposals.
8.2 Patient Participation Group Forum We host a PPG Forum bringing together patients and representatives from each of the 34 GP member practices. The group is used as a two way communication tool between the CCG and practices to ensure patients are up to date on development within the CCG and primary care as well as us finding out what happening within our primary care services.
The forum will also allow us to involve patients and members of the public in the review, development and planning of services commissioned by NHS St Helens CCG and to influence the wider development of health and wellbeing services in St Helens.
We continue to work Primary Care Networks to develop new ways of working for PPGs and how we can continue to support this work across a bigger footprint. This will include working with the groups virtually using digital channels until all restrictions are relaxed.
8.3 Stakeholder Reference Forum The Stakeholder Reference Forum (SRF) has been established to build and sustain meaningful engagement with people across all communities within St Helens, enabling them to have a voice in improving their health and in shaping services as part of St Helens Cares. As such, the SRF will play a key role in providing feedback to the St Helens Cares Provider Board and the St Helens Cares Executive Board, as well as other governance groups within St Helens Cares, on proposals for service change. This Forum is made up of patients, service users and carers, and representatives from groups and organisations that represent them or that have an interest in this area. They will offer their perspectives on how St Helens Cares can inform and engage with people on its programmes of work.
We firmly believe that to be properly engaged, people must feel included and valued. Our Stakeholder Reference Forum will promote a culture where inclusiveness is our baseline not an initiative. We will be diverse in age, gender identity, race, sexual orientation, physical or mental ability, ethnicity, and perspective and we will create an environment where everyone, from any background, can participate fully in our work.
108 To this end, the aims of this Forum are to:
• Act as a sounding board for testing early plans, and information materials • Share insights to influence / inform areas requiring redesign • Offer perspectives on how individual work programmes can engage more widely with people • Advise on the development of information for wider public use • Strengthen and play a significant role in wider public communication.
This Forum does not supersede any individual organisation’s legal duties to undertake public and patient involvement as may be required, although it can be used as one option to discharge and support such involvement duties as appropriate.
The forum continues to meet virtually to ensure members are kept up to date and involved in our work, the forum have been involved in the development of the St Helens place plan and other engagement opportunities.
8.4 Children’s and Young People’s Participation Network This network was established to provide an opportunity for participation leads from range of services to share resources, opportunities and best practice in respect of the voice of the child and to improve standards of participation across the borough. This group will capture feedback / experiences triangulate and trends identified and feedback to health and social care providers.
9.0 Political Communications and Engagement
9.1 Public affairs
It is important to understand the political landscape, both locally and nationally, and work within that to deliver the best healthcare possible for the people of St Helens. It is not realistic to expect support from politicians at all times, however transparent and proactive engagement will help the CCG to deliver its objectives.
We continue to develop productive relationships with local politicians, engaging fully with formal structures and committees and liaise regularly with local MPs and local councillors.
We greatly value the local scrutiny process and continue to work closely with the Health and Adult Social Care Overview and Scrutiny Panel Committee to increase engagement in and scrutiny of our commissioning activity, plans and proposals.
9.2 Parliamentary briefings
We will respond to all Parliamentary briefing requests in a timely way, ensuring a
109 consistent, high-quality response. We will also continue to invest resource to compile a database of:
• Complaints, Freedom of Information (FOI) requests, MP and councillor briefings, comments and complaints • Serious untoward incidents, including suggestions from patients and the public • Feedback from patients, engagement and consultation events, social media and other digital platforms.
10.0 Statutory duties
10.1 Governing Body meetings
Our Governing Body is a monthly public meeting. We publish the papers and information about how to access the meeting on our website. This meeting will take place virtually via Microsoft Teams while restrictions continue with members of the public able to access the meeting via a weblink as an observer.
10.2 Annual reports
We will produce a formal annual report, as required by NHS England, to meet our statutory requirements. This is published in an electronic format. We also produce a public-friendly summary version, written in plain English.
10.3 Annual General Meeting
We organise an Annual General Meeting open to members of the public each year to share our progress as an organisation and present the challenges we face in an interactive and engaging way.
10.4 Freedom of Information
Freedom of Information (FOI) requests are frequently made by interested parties, including the media, and are collected by the CCGS governance team. As an organisation that firmly believes in openness and transparency. We respond to Freedom of Information requests in line with legal requirements.
11.0 Internal Communications and Engagement
11.1 The importance of internal communications and engagement
Achieving the vision of St Helens Cares and managing the challenge of change requires a robust internal communications function. Effective employee communications and engagement will also help to build committed staff members, focused on achieving the Clinical Commissioning Group’s goals and objectives.
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We will: • Promote clear, consistent messages • Be accessible, honest and open • Ensure that staff understand the organisation’s priorities, take ownership of them and understand progress against them • Ensure staff members are well informed, well supported and valued • Find a balance in our tone to ensure people can relate.
11.2 Internal communications channels
Our internal communications channels include:
Face to Face communications:
Face to face stand up team brief – A weekly briefing takes place for all staff across St Helens Integrated Peoples Services led by the Executive Leadership Team.
Team Meetings – regular team meetings take place across the integrated team.
These two channels are currently paused due to the Covid-19 pandemic with a longer term view to combine Team meetings and Stand Up briefs into one virtual meeting with the integrated leadership team with live Q&A function and also recorded so all staff who are unable to join live can watch in their own time
It is planned that the quarterly / bi-monthly CCG all staff meetings will continue to take place via Microsoft Teams keeping to the current schedule
Digital internal communications:
Staff Newsflash – Email bulletin to all CCG members of staff giving the latest news on the CCG, HR issues. This can be escalated to daily or every other day when the need arises, as has been the case during the Covid-19 pandemic, but is aimed to issued twice a week.
Primary Care Bulletin – Our fortnightly bulletin is circulated to our GP practices and published on our website. This can be escalated to daily, as has been the case during the Covid-19 pandemic.
Blog and Vlog – The CCG Accountable Officer / Strategic Director of People’s Services writes a monthly blog which is posted across both CCG and local authority intranet sites and films ad hoc videos when messaging is needed to be shared with staff on particular issues
SHIPS bulletin – a monthly email bulletin rounding up news of work that has been taking place across the whole SHIPS directorate. This has been paused during the Covid-19 pandemic as much work has been paused but as the organisation returns to business as usual, this bulletin will resume.
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11.3 Internal Communications Principles We strive to foster a culture in which the sharing of general information, lessons learned and good news is an expectation for staff at all levels. We know that effective internal communications is essential for the smooth running of the organisation as it ensures that everyone understands what is expected of them, what the CCG is and what it is trying to achieve enabling all to work towards the same purpose.
Although the communications team takes responsibility for managing the corporate channels (including digital, face to face and printed channels) and for facilitating the regular dissemination of centralised messages - internal communication in its broadest sense remains the responsibility of all staff.
All senior managers and clinical leads within the CCG know and understand that communicating effectively to their team and colleagues is a matter of priority - ensuring that any message, news or update issued by the CCG is appropriately circulated and explained using language that will be understood by all. There are a variety of ways in which regular face to face communication takes place including all staff sessions, team sessions and one to one meetings.
11.4 Internal Engagement Principles
Feedback has demonstrated that involving staff in making decisions that affect their professional lives increases their self-esteem and self-confidence - in turn improving their working life experience and their health and wellbeing. All staff must feel as though they have a voice within the organisation, therefore, it is vital that we maintain a constructive dialogue with staff.
Going forward, as all staff move to being agile/remote workers, we will put in place a channel for staff engagement to ensure we can address the health and wellbeing of our workforce as a priority.
Actions to date since the Covid-19 pandemic have included establishing an internal virtual health and wellbeing group with representation from across the organisation to share advice, guidance and good practice during the transition period.
In the longer term, this group will be key to establishing a more permanent and easily accessible staff engagement site –such as an enhanced intranet site or ‘Workplace by Facebook’ to enable staff members to engage and support each other virtually.
For more information on our approach to internal engagement, please refer to the CCG’s Organisational Development Plan.
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12.0 Evaluating our work
12.1 Evaluation
On-going evaluation of our communications and engagement activity will help us to:
• Learn how well our communications and engagement systems work and how they can be improved • Be held to account by internal and external stakeholders • Test and demonstrate that the feedback we receive from patient and public involvement and engagement has a direct and positive impact in shaping and influencing decision making • Develop measures for the effectiveness of stakeholder engagement activities to demonstrate continuous improvement in patient outcomes and experience
13.0 Governance and accountability We hold patient and public involvement and the relationships with our stakeholders in the highest regard. We want to enable everyone to have a voice in shaping and influencing the provision of local health and social care services.
The Merseyside CCGs Equality and Inclusion Service acts in an advisory capacity, and provides a critical review of our patient & public engagement activity.
The Governing Body retains overall accountability for the delivery of effective communications and meaningful engagement, with a dedicated Lay Member responsible for ensuring public and patient involvement is considered and demonstrated at all stages of the commissioning cycle.
13.1 Working arrangements and reporting
The communications and engagement team works closely with the Quality team and Programme Management Office to support the management of interdependencies, risks and challenges to the benefit of operational delivery.
The Project Management Office ensures that no new project or initiative can be introduced in any of our programmes of work unless plans are in place to ensure the effective communication, engagement and involvement of patients and the public
The Engagement and Involvement Lead provides regular reports to the Quality Committee to highlight any communication and engagement activities and identifies issues/risks that require further exploration
Our communications and engagement strategy and an annual communications and engagement report is presented to the Governing Body for approval and sign off.
113 114 KEY ISSUES REPORT
Quality Committee Meeting Date: Wednesday 3rd June 2020 Agenda Item Improvement or Key Issue Decision/ Action Corporate Risk/ Ref: Operational GBAF Reference - Plan Theme Mitigation QC200604 Clinical Effectiveness Report The Committee received and noted the current position statements Noted. and updates in relation to all Providers. The Quality and Contracting Team are In-line with issued guidance on ‘Revised arrangements for NHS currently reviewing the future quality Contracting and Payment during the COVID-19 Pandemic’ and assurance reporting requirements. ‘Reducing Burden and Releasing Capacity at NHS Providers and Discussions are taking place in Commissioners to manage the COVID-19 Pandemic’, the CCG, from collaboration with other CCGs to ensure March, stood down all Contract Quality Monitoring meetings. consistency across all Providers and an update on decisions and actions will be Trust Board & Quality Committee meetings were required to provided to Quality Committee once continue (virtually), the CCG therefore requested Providers to record known. and inform any areas for noting and/or escalating to commissioners - no risks have been reported to the CCG via this route. Further guidance is awaited to inform actions beyond 31st July 2020.
Issues in relation to lack of referral information received for those patients included on the ADHD referral waiting list. This risk has been included within the CCG risk register.
QC200606 Care Home Update The COVID-19 pandemic has posed a significant challenge to care Noted. homes. In addition to national guidance and support St Helens CCG and St Helens Council; in partnership with providers have worked hard to support all frontline services including care homes.
The CCG Quality team have been redeployed into various support mechanisms in this period and the implementation of the care home 115 Agenda Item Improvement or Key Issue Decision/ Action Corporate Risk/ Ref: Operational GBAF Reference - Plan Theme Mitigation quality action plan has been suspended during this time. QC200606 However, quality in care homes has continued to be monitored; cont... particularly in relation to ensuring staff within care homes received the correct PPE and IPC training outlined by the Prime Minister. St Helens CCG were required to deliver training to over 103 care home staff within a two week timeframe, however St Helens CCG exceeded this figure within 10 days being the only CCG in the North West to achieve a 100% target with St Helens receiving national recognition.
As part of the reset and recovery of normal working the Quality in Care homes action plan will be revisited to align with work that has happened as part of COVID responses. In addition the Deputy Chief Nurse is part of an integrated Support in Care Homes weekly group, and the Designated Adult Safeguarding Nurse and Quality Lead Nurse are part of an integrated Safeguarding and Quality in Care Homes sub group.
QC200607 SEND Annual Report The Committee noted the update and approved the SEND 2020-21 Noted and approved. work plan.
QC200608 Corporate Risk Register There are a total of 17 risks; of these 12 are assigned to Quality and 5 Noted and approved. assigned to Medicines Management.
Since the last update in February there have been: • 2 new risks added • 4 risks have decreased • 3 risks are suggested for closure • 11 risks have remained static
116 Agenda Item Improvement or Key Issue Decision/ Action Corporate Risk/ Ref: Operational GBAF Reference - Plan Theme Mitigation QC200609 Safeguarding Childrens & Adults Updates inc. Provider KPI Assurance In accordance with NHSE/I guidance, as a response to the Covid-19 Noted. crisis formal Safeguarding KPI reporting has been stepped down at Q4 in favour of obtaining only necessary activity data or position statements and reporting by exception.
St Helens & Knowsley Teaching Hospitals Trust Acute, Community and Paediatric Services Contracts Bi-weekly assurance templates are being completed and we are receiving assurance from the Trust from a Safeguarding perspective.
Following the transition of the UTC from Bridgewater to StHK; work is required to address the gaps in safeguarding practice identified through a series of audits carried out by the Bridgewater Safeguarding Team, shared with StHK. Work to progress the action plans required will be resumed by StHK, with a particular focus on supervision arrangements, as the COVID -19 crisis allows. Risk due to this period of instability is reflected in the CCG Risk Register.
Bridgewater Community NHS Trust Safeguarding Adults & Children Similarly to Safeguarding Adults, Safeguarding Childrens training compliance data collection continues to present a challenge to the Bridgewater Team, due to longstanding ESR issues. This is acknowledged by the Trust; however work to reconcile the data is on hold amid the Covid-19 crisis.
Looked After Children During Q4 there has been an increase in compliance with Initial Health Assessments with 82% of the in borough assessments completed within timescale (Q3-57%). All of the Initial Health Assessments outstanding from the previous quarter were also undertaken. Late assessments were due to either non-attendance at 117 Agenda Item Improvement or Key Issue Decision/ Action Corporate Risk/ Ref: Operational GBAF Reference - Plan Theme Mitigation QC200609 the appointment or late notifications. Noted. cont… The CCG Risk Register has been updated to reflect risks associated with the transition of services from Bridgewater Community NHS Trust to St Helens and Knowsley Teaching Hospitals NHS Trust.
North West Boroughs Healthcare 0-19 Service The need for further work remains around some aspects of the safeguarding children activity particularly requests for services from the LA and conversation rates, safeguarding children supervision being undertaken to support practitioners and the child, the level of strategy meetings being invited to and discrepancies in the data submitted around ICPC/RCPC. In addition the 0-19 workforce includes a proportion of practitioners who are inexperienced in relation to safeguarding children work. In particular, the new band 5 workforce.
Domestic Homicide Review (DHR) It was noted that there are 2 reviews in progress; one of which has been presented to the Peoples’ Board prior to submission to the Home Office. One further DHR is nearing completion and action plans/recommendations for all relevant agencies are currently being agreed. Safeguarding Adult Reviews (SARs) There is 1 statutory SAR is currently in progress; this is St Helens first SAR the report will continue in line with agreed timescales in order to ensure that findings are not delayed amid the Covid-19 crisis.
Liberty Protection Safeguards (LPS) Update
Reported as on hold due to the Covid-19 crisis. The Governing Body
will be updated when information regarding future plans is released.
118 Agenda Item Improvement or Key Issue Decision/ Action Corporate Risk/ Ref: Operational GBAF Reference - Plan Theme Mitigation QC200609 Learning Disabilities Mortality Review (LeDeR) Noted. cont….. The programme still continues amid COVID-19, and particularly with an increased focus ensuring equity of services and treatment.
NHSE/I have introduced a ‘Rapid Review’ process a rapid review must be completed and submitted to NHSE prior to a formal LeDeR review. There have been 2 confirmed learning disability COVID related deaths in St Helens. Rapid reviews have been completed.
Multi-Agency Safeguarding Hub (MASH) Empirical reports from MASH Specialist Nurse identifies a reduction in the number of referrals towards the end of March/ beginning of April 2020 at the initial lockdown period. Referrals are beginning to increase particularly in relation domestic abuse and the emotional impacts on children, and lack of supervision during isolation.
Signs of Safety It was noted that a 5 year implementation plan has been mapped of which we are in year 2. The SOS co-ordinator will provide Quality Committee with an update in Q1 Quality Committee.
QC200611 COPD Hub Pilot – Service Specification Approved. The Committee approved the COPD Hub Pilot Service Specification.
QC200612 QIA’S & EIA’s for Specification Approved as follows: The following QIA’s and EIA’s were submitted for review and approval: COPD Hub Pilot - Approved subject to suggested amendments. a) COPD Hub Pilot b) Phoenix Medical Centre Phoenix Medical Centre - Approved.
QC200613 Medicines Management Update and Committee Key Issues Since the COVID 19 pandemic Medicines Management Committee Noted. 119 Agenda Item Improvement or Key Issue Decision/ Action Corporate Risk/ Ref: Operational GBAF Reference - Plan Theme Mitigation has been paused therefore there are no Key Issues for Quality Noted. Committee to approve. The next Medicines Management Committee is scheduled to take place virtually on 17th June 2020.
The Medicines Management Team have provided additional support where required as a result of the COVID-19 pandemic; this includes commissioning new pharmacy services to support the delivery of end of life medication and IV antibiotics. The Team are currently focussing on the care home national mandate in relation to medication reviews within care homes and the realignment of care homes to pharmacists and technicians.
QC200614 Pan Mersey Area Prescribing Committee Recommendations Since the COVID 19 pandemic the Pan Mersey Area Prescribing Noted - The Committee will reconvene Committee has been paused therefore there are no when it is safe for clinicians to do so. recommendations for Quality Committee to approve.
QC200618 Safeguarding Annual Report The Committee received the Annual Safeguarding Report. Item listed Approved in principle pending as information only rather than approval. Committee Members to comments to be received by the Chair review and feedback any comments before Friday 12th June 2020. no later than Wednesday 17th June 2020. QC200619 2019/20 CQUIN Performance Report Noted. The Committee noted the 2019/20 CQUIN performance report circulated for information.
QC200621 Never Events STHK A total of 3 Never Events have occurred at STHK since early March Noted. 2020. Of these; 2 relate to “Theatres” and 1 relates to “Interventional Radiology”. None of the patients have suffered any serious harm and discussions have taken place between the Deputy Chief Nurse and the Assistant Director of Safety at the Trust who has provided 120 Agenda Item Improvement or Key Issue Decision/ Action Corporate Risk/ Ref: Operational GBAF Reference - Plan Theme Mitigation QC200621 assurance that the events have been taken seriously. The Trust has cont… implemented short term actions, with long term actions to be implemented following the Trusts internal reviews.
Key Issues Report Date Prepared by: Claire Holtby, PA to Chief Nurse – Director of Quality 04.06.20 Verified by: Lisa Ellis, Chief Nurse – Director of Quality 05.06.20 NOTE: A copy of any papers referenced in this Key Issues Report will be made available on request to the Committee Chair. A copy of this report will be sent to Governing Body. Formal Minutes, once approved, will be made available to the Governing Body on request. Audit Committee will receive ratified minutes of all committees for information.
121 122 KEY ISSUES REPORT
Quality Committee Meeting Date: Wednesday 1st July 2020
Agenda Item Improvement Key Issue Decision/ Action Corporate Risk/ Ref: or GBAF Reference Operational - Mitigation Plan Theme QC200704 Clinical Effectiveness Report The Committee received and noted the current position statements and Noted. updates in relation to all Providers.
St Helens & Knowsley Trust CQSG (Clinical Quality & Safety Group) meetings will re-commence virtually from 21 July 2020. The Trust will also re-instate the Community Quality Contract meetings for the Acute contract.
North West Boroughs have reconvened their QSSG (Quality, Safety & Quality Committee to prepare a briefing Safeguarding Group) meeting. The first meeting took place on 26 June paper and escalate concerns via the 2020 and concerns were raised at Quality Committee, particularly Executive Leadership Team. around staffing and leadership.
QC200705 Workforce Strategy and Update The Committee note the first reiteration of the workforce strategy. Noted.
Further consultation required with key partners.
QC200706 Evaluation of the Intensive Support Team (IST) Function within Leaning Disabilities. Noted. The Committee noted the positive outcomes from the evaluation report of the Intensive Support (IST) function within LD services and the
123 Agenda Item Improvement Key Issue Decision/ Action Corporate Risk/ Ref: or GBAF Reference Operational - Mitigation Plan Theme significant reduction in inpatient admissions. As a result of the reduction this will enable the CCG to reduce the number of commissioned bed nights to reinvest funding to this service on a recurrent basis once a revised inpatient service is agreed and in place.
Funding for this service through the Transforming Care bid has now been extended until September 2021.
QC200708 Serious Incident Report Q3 & Q4(2019-20) The Committee noted the updates on serious incidents. Noted.
StHK - Top 3 themes relate to self-inflicted harm, diagnostic incidents and slips/ trips and falls.
Primary Care - Top 2 themes relate to medication and confidentiality/ information security.
QC200709 LeDeR Programme & Updates The Committee noted the LeDeR programme updates. St Helens have Noted. recently provided support across Cheshire & Merseyside and have received recognition for our robust reviewing processes.
During Q4 (2019-20) there were a total of 3 deaths reported, and 5 reviews completed, during Q1 (2020-21) there were a total of 3 deaths reported and 4 reviews completed.
QC200710 Pinnaplasty Policy Update Approved. The Committee approved the Pinnaplasty policy update.
124 Agenda Item Improvement Key Issue Decision/ Action Corporate Risk/ Ref: or GBAF Reference Operational - Mitigation Plan Theme
QC200712 Medicines Management Update and Committee Key Issues The Committee noted the Medicines Management Committee key Noted. issues and updates.
Anaphylaxis Policy – Amendments suggested by Quality Committee at the May Committee were not agreed with by Medicines Management Committee, therefore further work needs to take place outside of the meeting.
The Team are currently focussing on:
• Medication reviews within care homes. • Review of DOAC (Direct Oral AnticoAgulant) medications • Prescribing Incentive Scheme • Review of high risk medications
QC200713 Gluten Free Food Prescribing Policy The Committee noted the revisions and approved the Gluten Free Food Noted and approved. Prescribing policy.
QC200714 CCG Cold Chain Policy The Committee noted the minor revisions and approved the CCG Cold Noted and approved. Chain policy.
QC200715 Pan Mersey Area Prescribing Committee Recommendations Since the COVID 19 pandemic the Pan Mersey Area Prescribing Noted. Committee has been paused until at least October 2020 therefore there
125 Agenda Item Improvement Key Issue Decision/ Action Corporate Risk/ Ref: or GBAF Reference Operational - Mitigation Plan Theme are no recommendations for Quality Committee to approve.
QC200718 Healthwatch COVID-19 Interim Survey Feedback The Committee received the interim survey feedback from Noted - A full report will be available later Healthwatch. The purpose of the survey was to understand what in the year. members of the public were experiencing when trying to access health care for long-term conditions and any other health concerns not related to Covid-19 during the pandemic.
Key Issues Report Date Prepared by: Claire Holtby, PA to Chief Nurse – Director of Quality 01.07.20 Verified by: Lisa Ellis, Chief Nurse – Director of Quality 02.07.20 NOTE: A copy of any papers referenced in this Key Issues Report will be made available on request to the Committee Chair. A copy of this report will be sent to Governing Body. Formal Minutes, once approved, will be made available to the Governing Body on request. Audit Committee will receive ratified minutes of all committees for information.
126 of £3m”
KEY ISSUES REPORT
Finance and Performance Committee Meeting Date: 27th May 2020 Agenda Improvement Key Issue Decision/ Action Corporate Item Ref: or Risk/ GBAF Operational Reference - Plan Theme Mitigation F&P Finance update – COVID Expenditure 200505(a) The Committee noted the financial update received around COVID-19 expenditure incurred as part of the system response to the pandemic. It is expected that the CCG will receive additional funding to cover this expenditure.
£739k of COVID-19 costs were incurred in April, with over half relating to the hospital discharge programme to free up capacity for COVID patients. ELT have reviewed the values and signed off the submission to NHSE/I. The CCG is awaiting feedback.
Risks were recognised in relation to reclaiming for COVID expenditure in line with process.
F&P Financial Management 200505 (b) The Committee noted the requirement to use a mandated budget for months 1-4 and the financial gap that will need to be addressed.
The Committee noted that the new block arrangement has reduced the level of financial risk to the CCG but has still left a financial gap of £397k per month. The finance team are working to identify where this gap can be closed.
127 Key Issues Report Date Prepared by: Dawn Mellan, PA to CFO and Deputy 30.06.20 Verified by: Iain Stoddart, CFO 30.06.20 NOTE: A copy of any papers referenced in this Key Issues Report will be made available on request to the Committee Chair. A copy of this report will be sent to Governing Body. Formal Minutes, once approved, will be made available to the Governing Body on request. Audit Committee will receive ratified minutes of all committees for information.
128 of £3m” KEY ISSUES REPORT
Finance and Performance Committee Meeting Date: 24th June 2020 Agenda Improvement Key Issue Decision/ Action Corporate Item Ref: or Risk/ GBAF Operational Reference - Plan Theme Mitigation F&P200605(a) The Committee noted the mandated budgets for the CCG and (b) and the budget book narrative that would be sent to all budget holders outlining the budget position for this 4 month reporting period (April to July 2020)
The Committee noted the cumulative financial position at month 2, being an overspend against the mandated budgets of £2,039k, which included £1,385k of Covid-19 related spend and the balance being attributed to Business As Usual (BAU) additional costs. These costs related to issues identified and flagged to NHSE relating to the differences in budget setting assumptions between NHSE/I and the CCG. Expectation is that these costs are reimbursed as part of a monthly process between the CCG and NHSE/I.
The Committee also noted the expected forecast of c£4m additional costs for the 4 month reporting period that would require reimbursement to ensure a balanced financial position and delivery of financial duties April to July 2020.
F&P 200605 The Committee noted the final reports for 2019/20 (d) & (e) expenditure relating to the pooled budget and the better care fund and financial pressures that arose over the
129 financial year.
F&P 200606 The Committee received the constitutional performance for March 2019, noting the ongoing issues with respect to A&E 4 hr waits, ambulance performance and cancer 62 days which had arisen for the majority of 2019/20. Committee also noted the deterioration in RTT incomplete pathways, Cancer 31 day waits for surgery and ambulance performance times all of which were impacted due to the Covid-19 service response.
Key Issues Report Date Prepared by: Alan Howgate, Deputy CFO 29 6 20 Verified by: Iain Stoddart, CFO 29.6.20 NOTE: A copy of any papers referenced in this Key Issues Report will be made available on request to the Committee Chair. A copy of this report will be sent to Governing Body. Formal Minutes, once approved, will be made available to the Governing Body on request. Audit Committee will receive ratified minutes of all committees for information.
130 KEY ISSUES REPORT EXECUTIVE LEADERSHIP TEAM GOVERNANCE COMMITTEE Meeting Date: 3rd June 2020
Agenda Improvement Key Issue Decision/ Action Corp Item Ref: or Risk/ Operational GBAF Plan Theme Ref ELT200602 Effective CCG Decision Making Log ELT reviewed and approved the log as an accurate Obj 4 Organisation CCG Decision Making Log, capturing all record of decisions made. Log to be maintained by ELT decisions made by ELT since March 2020 Governance Committee. created, currently with Equality & Diversity Lead for review.
ELT200605 Effective IG Bi-Monthly Report ELT noted the report – no issues/ concerns as at May Obj 4 Organisation IG Bi-Monthly report presented to Committee as 2020. at May 2020.
ELT200606 Effective Health & Safety and EPRR Annual Reports ELT reviewed and noted the two reports – no issues/ Obj 4 & Organisation Health & Safety and EPRR Annual reports, concerns. ELT200607 authored by Midlands & Lancashire CSU presented for noting.
Key Issues Report Date Prepared by: Hilary Southern, Governance & Corporate Services Manager 03/06/20 Verified by: Sarah O’Brien, Clinical Accountable Officer 03/06/20 NOTE: A copy of any papers referenced in this Key Issues Report will be made available on request to the Committee Chair. A copy of this report will be sent to Governing Body. Formal Minutes, once approved, will be made available to the Governing Body on request. Audit Committee will receive ratified minutes of all committees for information.
131 132 KEY ISSUES REPORT
Executive Leadership Team Meeting Dates: 11.05.20 to 22.06.20
Agenda Improvement Key Issue Decision/ Action Corporate Item Ref: or Risk/ GBAF Operational Reference - Plan Theme Mitigation 11.05.20 Counselling Service for Primary Care Agreed to trial for 12 months. ELT200513i To use Qwell (Adults) to provide a holistic online community 7 days a week, 365 days a year, with access to peer created content, peer to peer communities and direct access to qualified counsellors and mental health professionals.
11.05.20 Proposed merger between Haydock MC and Lime Grove Approved ELT200513ii Surgery
To obtain final approval of the proposed merger for Haydock Medical Centre and Lime Grove Surgery. This was approved in principle by Primary Care Commissioning Committee in March, pending the outcome of patient engagement and equality impact assessment.
11.05.20 GPs are having to implement care home DES – meetings have Agreed to enhance payment until taken place re assigning care homes to each network. CCG is September as additional roles following national guidance, expect delivery in line with cannot be in place so needs funding national DES and payment to be made in line with DES. to support this until they can recruit
133 Agenda Improvement Key Issue Decision/ Action Corporate Item Ref: or Risk/ GBAF Operational Reference - Plan Theme Mitigation 18.05.20 Looked After Children Nursing Team Agreed to fund 1 permanent and 1 ELT200523ii fixed term 2 year contract. Requesting to recruit 2 additional band 6 nurses to the team. Will have caseload of 75 -80 (allows to go up to 100) and specialist cases would move over from 0-19 Team, which would then give capacity to 0-19 Team which has seen an increase in numbers being referred to the service.
18.05.20 Redesign of Children and Young People’s (CYP) Mental Health Approved the model but need to ELT200523iii delivery in St Helens look at developing the CYP Board to ensure tight scrutiny. Early help offer to prevent young people going on CAMHS waiting list – currently no early help offer so the waiting times should reduce.
19.05.20 COVID-19 Urgent Eye care Service – CUES (NHS England Approved Publication approval reference: 001559)
Primary Eye Care Service will re-use its existing capacity (as routine eye care is not being undertaken) and become an urgent eye care service. The specification is a national one, and there is no impact on cost as it uses current capacity, but approval is required as it is a change to the commissioned service.
20.05.20 Visors – formal approval for spend by ELT. Putting up visors Approved across reception desks and lifts in CHP buildings to protect
134 Agenda Improvement Key Issue Decision/ Action Corporate Item Ref: or Risk/ GBAF Operational Reference - Plan Theme Mitigation staff and patients. Will be classed as Covid costs.
27.05.20 Adult ADHD Services and Prescribing Approved ELT200523i Proposed changes to the RAG status of medicines used in the treatment of adult ADHD from ‘red’ (specialist only) to ‘purple’ (shared care where the GP shares the care with the specialist).
27.05.20 Funding ADHD Waiting List Approved ELT200523ii One off funding to reduce the waiting list. There are more on the list than previously thought - NWB were unclear who was on the list.
27.05.20 Infliximab IV to sub cut Approved ELT200523iii Change from IV to sub cut with the benefit for patients being that they can self administer / or have the sub cut administered to them in their own homes removing the need for them to attend hospital for an IV.
27.05.20 Future Funding of Merseyside Child Death Overview Panel Approved ELT200523iv CDOP review – funding had not been agreed for this year. Costs to be split between the LA and CCG (in line with the rest of the country) as it is a joint responsibility. This is a statutory service.
135 Agenda Improvement Key Issue Decision/ Action Corporate Item Ref: or Risk/ GBAF Operational Reference - Plan Theme Mitigation
29.05.20 QOF Year End Payment Process for 2019-20 Approved
Instructions given by NHSE/I to CCGs that, where the points difference between 2018/19 and 2019/20 is minimal i.e. a fall of less than 30 points, they are expected to offer income protection to 2018/19 payment values. This should be done in a timely manner with any one-off payments being made in June 2020.
03.06.20 Andexanet Alfa for DOAC Anticoagulant Reversal Approved ELT200603i Pan Mersey CCGs were asked to consider the use of andexanet alfa for DOAC anticoagulant reversal pre-NICE outside of the APC process. This was approved at ELT in January 2020. The NICE TA publication date has been pushed back and is currently expected to be 19/08/2020. Recommendation is to approve until receive final version. No further stock will be ordered until final approval received.
03.06.20 Auto Enrolment for Pension 2020 Approved ELT200603ii The CCG must put any staff who have opted out of the NHS Pension Scheme back into a pension scheme within six weeks of the third anniversary of the CCG’s original staging date. It is recommended that the CCG choses a re-enrolment date of
136 Agenda Improvement Key Issue Decision/ Action Corporate Item Ref: or Risk/ GBAF Operational Reference - Plan Theme Mitigation 1st August 2020.
10.06.20 Commissioning / Decommissioning Strategy Agreed to suspend the strategy. ELT200619 This Policy was created whilst in recovery mode and needs refreshing. Discussed the options: i. Making the necessary minor amendments and then extending the strategy ii. Suspending the strategy for the time being
17.06.20 Vedolizumab Approved ELT206032 ii Move to sub cut from oral medication which exposes patients to risks of contracting COVID in the hospital environment. By switching to subcut, patients can be treated at home much more safely and reduce this risk as much as possible. It is expected SC vedolizumab will become the standard care in the future.
17.06.20 Office 365 Licencing Recommendation 1: Approved - to ELT206032 go ahead with Office N365. iii Office 2010 is currently used which will no longer be supported from October 2020 leaving the CCG at risk with no updates to Recommendation 2: Not approved protect against cyber threats. – Options to be discussed further and explore how this works with either a local or NHS tenant. Recommendations:
137 Agenda Improvement Key Issue Decision/ Action Corporate Item Ref: or Risk/ GBAF Operational Reference - Plan Theme Mitigation 1) The CCG will buy Office 365 licences for all CCG and member practices through the N365 discounted agreement; and 2) That the local tenant is used to maintain local identity and flexibility.
Key Issues Report Date Prepared by: Michelle Birchall, Exec PA to the Executive Director/Accountable Officer 24.06.20
24.06.20 Verified by:
NOTE: A copy of any papers referenced in this Key Issues Report will be made available on request to the Committee Chair. A copy of this report will be sent to Audit Committee – please highlight any specific issues to be escalated. Formal Minutes, once approved, will be made available to the Audit Committee and Governing Body on request.
138 KEY ISSUES REPORT
Primary Care Commissioning Committee Meeting Date: 20.05.20
Agenda Key Issue Decision/ Action Strategic Item Ref: Objective/ Risk or GBAF Reference PC20/05/05 New Ways of Working in Primary Care The Primary Care Commissioning Committee The Committee received a summary of the changes within noted the associated risks:- Primary Care as a result of the Covid 19 Pandemic. The • PPE changes were reported as critical for the ongoing safety of • Workforce patients and clinicians and provide an update on the • IT following:- • Lack of referrals • Triage and remote consultations • Acute Visiting Service (AVS) Capacity The Committee congratulated Primary Care and • End Of Life/Covid Positive Service the Primary Care Team for their rapid response • Hot Hubs to the current ways of working. • Shielded and vulnerable patients • Remote working • Staff Swabbing
PC20/05/06 Primary Care Risk Register The Committee agreed that risk 122 relating to The Committee approved the risk Primary Care Risk the CCG failing to have appropriate planning for Register with 6 current risks and no new risks identified. primary care to manage the Coronavirus (Covid- 19) pandemic should be focused on the delivery of safe and quality care, rather than a reputational risk and it was agreed that this would be amended.
139 PC20/05/07 Primary Care Finance The Primary Care Commissioning Committee noted the report. The Primary Care Commissioning Committee received:- • the full year expenditure incurred against both the devolved primary care allocation received for 2019/20 and the additional local CCG investment in primary care medical services. • an update on the proposed devolved budgets being set for 2020/21 based on the allocations the CCG will receive and the associated risk.
Key Issues Report Date Prepared by: Cathy Edge, PA to the Chair 01.07.20 Verified by: Geoffrey Appleton, Primary Care Commissioning Committee Chair 01.07.20 NOTE: A copy of any papers referenced in this Key Issues Report will be made available on request to the relevant Committee Chair. A copy of this Key Issues report will be sent to Governing Body and Audit Committee. Formal Minutes, once approved, will be made available to the Governing Body and Audit Committee on request.
140 KEY ISSUES REPORT
GP Members Council Meeting Date: 01.07.20
Agenda Key Issue Decision/ Action Strategic Item Ref: Objective/ Risk or GBAF Reference MC200705 2019/2020 NHS St Helens CCG Annual Report The GP Member’s Council noted the Annual The GP Member’s Council received the Annual Report Report presentation which is available to view presentation including:- on the CCG website.
• Leadership and Integration • Key Partnerships • Constitutional Performance Year to Date • Challenges and Responses • Key Achievements • 19/20 Financial Plan • 19/20 Financial Outturn (Delivery) • Key pressure points and actions taken
MC200706 Primary Care Reset and Recovery The GP Member’s Council noted the analysis The GP Member’s Council were presented with the results and confirmed that all service areas had been of the recent Primary Care Reset and Recovery analysis in captured. categories to END, AMPLIFY, LET GO and RESTART. MC200709 GP Governing Body Election Process The GP Member’s Council approved the The GP Member’s Council were informed of the GP election proposal and confirmed their approval Governing Body Election proposal for undertaking a to continue with 5 GP Governing Body nominations and elections process, supported by the LMC, members. with regards to two GP Governing Body Member positions which are due to end 30th September 2020.
141
Key Issues Report Date Prepared by: Cathy Edge, PA to the Chair 01.07.20 Verified by: Dr Mike Ejuoneatse, Chair of the GP Members Council 01.07.20 NOTE: A copy of any papers referenced in this Key Issues Report will be made available on request to the relevant Committee Chair. A copy of this Key Issues report will be sent to Governing Body and Audit Committee. Formal Minutes, once approved, will be made available to the Governing Body and Audit Committee on request.
142 KEY ISSUES REPORT Remuneration Committee Meeting Date: Papers Issued 1st June 2020, Virtual Approval Confirmation, 8th June 2020
Agenda Key Issue Decision/ Action Strategic Obj/ Item Ref: Risk or GBAF Ref RC20/06/02 Reappointment of Secondary Care Doctor Remuneration Committee agreed to recommend to Objective 4 Committee considered request to reappoint Dr James Governing Body the reappointment of Dr Catania on the Catania as Secondary Care Doctor to Governing Body for a same Terms & Conditions for a further period to further three year period. 31/05/2023. RC20/06/03 Annual Review of CCG Remuneration Framework Remuneration Committee approved the revisions to the Objective 1 Committee reviewed the 2019 Remuneration Framework, 2019 Remuneration Framework Objective 4 noting proposed minor amendments to the following sections: • Section 8.7 – Clinical Leads: Include reference to non-GP clinical leads and subsequent remuneration • Appendix 1 – Comparison Table: Include reference to non-GP clinical leads and subsequent remuneration
Key Issues Report Date Prepared by: Hilary Southern, Governance & Corporate Services Manager 09/06/2020 Verified by: Angela Delea, Associate Director Corporate Governance 30/06/2020 NOTE: A copy of any papers referenced in this Key Issues Report will be made available on request to the relevant Committee Chair. A copy of this Key Issues report will be sent to Governing Body and Audit Committee. Formal Minutes, once approved, will be made available to the Governing Body and Audit Committee on request.
143 144 St Helens Clinical Commissioning Group AUDIT COMMITTEE
Minutes of the meeting held on Tuesday 23rd June 2020 at 10.00am Virtual Meeting
Present: Members Audit Committee Chair / Tony Foy (Chair) TF Lay Member - Audit, Finance and Governance Mark Weights MW Lay Member - Patient and Public Involvement Alan Whittle AW Independent Lay Member In Attendance Iain Stoddart IS Chief Finance Officer, St Helens CCG Alan Howgate AH Deputy Chief Finance Officer, St Helens CCG Angela Delea AD Associate Director – Corporate Governance, St Helens CCG Lisa Roberts LR Principal Accountant, St Helens CCG Gary Baines GB Assistant Director, MIAA Nigel Woodcock NW Senior Internal Audit Manager, MIAA Karen McArdle KMc Anti-Fraud Specialist, MIAA David Johnson DJ Audit Manager, Grant Thornton Mark Heap MH Director, Grant Thornton Minute Taker Dawn Mellan DM PA to CFO and Deputy CFO, St Helens CCG
Agenda Details Action Item By AC APOLOGIES FOR ABSENCE 20 06 01 Welcome and Apologies
The Chair welcomed members to the meeting and noted apologies for Dr Hilary Flett.
The Chair recorded his thanks on behalf of the committee to the Finance and Governance Teams and Internal and External Audit for the exceptional levels of support and challenge received throughout the year.
The Chair reminded members that the main focus of the meeting is to approve the Annual Report and Accounts. He thanked the committee for its diligence in reading and feeding back on the draft report.
AC DECLARATIONS OF INTEREST 20 06 02 There were no declarations of interest.
AC MINUTES OF MEETING – 18th MARCH 2020 (RATIFIED) 20 06 03 The following minor amendments were noted to the last minutes: DM
AC 20 03 01 – amend attendance to reflect that auditors were not required to attend the meeting, rather than noting as apologies. 145 AC 20 03 13 – remove reference to external auditors, Grant Thornton on the Internal Audit Progress Report item.
AC RECEIPT OF HEAD OF INTERNAL AUDIT OPINION AND INTERNAL 20 06 04 AUDIT ANNUAL REPORT 2019/20 Gary Baines, Assistant Director for MIAA presented the above report which summarises the internal audit work completed for the year and provides an overall opinion on the systems of control, governance and risk management.
The CCG’s response to COVID-19 is referenced in the report and a number of governance considerations were noted.
The 2020/21 Audit Plan has been agreed taking into account the new/interim working practices for both organisations during the current pandemic.
The internal audit opinion is assessed against 3 elements, with feedback against each of these areas noted below:
Assurance Framework and process – good robust process in place which meets NHS requirements.
Individual risk-based assignments throughout the year – 5 rated high, 2 rated substantial and one rated moderate.
Response to internal audit recommendations - good progress made against actions.
Conclusion Internal Auditors, MIAA confirmed an overall opinion for the period 1st April 2019 to 31st March 2020 of ‘Substantial Assurance’ in that there is a good system of internal control designed to meet the organisation’s objectives and that controls are generally being applied consistently.
The Committee was invited to feedback:
The Chair thanked MIAA for a good clear report.
IS concurred and accepted the report as a very balanced and positive review which reflects the hard work carried out in year. He added that the CCG is looking to conduct a piece of internal audit work to validate the methodology for COVID-19 expenditure to provide some assurance going forward.
IS noted the reference to a potential move to a ‘Requires Improvement’ rating in the Assurance Framework. He added that this is not yet validated as those assessments have not been carried out by NHSE/I. He added that the CCG is also awaiting the Assurance Framework to be merged with the Trust’s Single Oversight Framework for systems moving forward.
The Chair referred to the extract from the NHSE/I letter ‘Reducing the burden and releasing capacity’ and the suggestion to continue with Quality Committee but consider streamlining other committees (including Audit Committee). He noted the importance of quality as a focus. However he added that Business Continuity also remains a focus given the current challenges. It was agreed that further consideration and discussion is needed around the role of Audit Committee. The Chair will take this forward. TF
The Audit Committee received and noted the Head of Internal Audit Opinion and Annual Report 2019/20.
146 AC REVIEW OF ANNUAL REPORT AND ACCOUNTS INCLUDING 20 06 05 GOVERNANCE STATEMENT 2019/20 The Chair noted the extensive work carried out by CCG colleagues and also Audit Committee to review and update the Annual Report and Accounts prior to this meeting. He handed over to Angela Delea, Associate Director, Corporate Governance.
AD presented the final draft Annual Report and Accounts 2019/20 to the committee for approval, prior to the submission date of 25th June 2020. NHSE/I carried out an initial review and provided interim certification on 15th May 2020. The Annual Report is presented in the usual format with the exclusion of detailed performance analysis as per the amended GAM.
AD identified a few minor typos in the report which will be amended and the AD number of COI breaches will be updated from one to two to reflect the year- end position.
Information Governance
No serious incidents were recorded and ‘Substantial Assurance’ was received around information governance. There were no control issues to report.
The committee was invited to feedback:
AW felt the report read very well and noted some significant areas of improvement in the narrative and presentation from the previous year. The Chair and MW concurred.
The Chair conveyed his thanks to the Governance Team and in particular, Jeanette Livings for her work on the report.
The Chair raised a point of accuracy with regard to the 3 VSM roles which AD agreed to double-check. IS was confident that the number of roles is accurate and AD will confirm the detail direct with the Chair after the AD meeting.
Iain Stoddart, Chief Finance Officer presented the Annual Accounts section which links to the constitutional elements for finance and aligns with the Group Accounting Manual (GAM). The report outlines several challenges faced in year by the CCG, including acute demand activity which impacted the financial position. The CCG reported a revised year-end forecast position of almost £18m deficit which is a variation of £16.2m from the control total.
IS noted a few minor typos in the annual accounts section and these will be IS/AD amended.
The Audit Committee received the draft Annual Report and Accounts 2019/20 and noted some minor amendments.
AC REVIEW OF LETTER OF MANAGEMENT REPRESENTATION 2019/20 20 06 06 IS presented the Letter of Management Representation dated 23rd June 2020 to external auditors, Grant Thornton. The letter is presented on behalf of the Governing Body and in accordance with International Financial Reporting Standards (IFRS) and the Department of Health and Social Care Group Accounting Manual 2019/20 and applicable law.
The letter represents the opinion of the Accountable Officer and Chief Finance Officer in connection with the audit of financial statements of 147 St.Helens CCG for the year ended 31st March 2020.
The committee was invited to feedback:
A small observation was made in relation to the letter which references that the unadjusted misstatements are attached. LR agreed to add this detail to LR the back of the letter.
The Audit Committee received and noted the Letter of Management Representation 2019/20.
AC RECEIPT OF AUDIT FINDINGS REPORT (ISA260) AND RECEIPT OF 20 06 07 AUDIT OPINION ON THE FINANCIAL STATEMENTS, REGULARITY OPINION, VALUE FOR MONEY CONCLUSION AND WGA ASSURANCE Mark Heap presented the Audit Findings Report for year ended 31st March 2020. The report acknowledges the COVID-19 pandemic and the significant impact on the normal operations of the CCG during this challenging period.
On behalf of external audit, MH conveyed thanks to Lisa Roberts - Principal Accountant, Iain Stoddart - Chief Finance Officer and other finance team colleagues for their assistance in the audit process.
Key points from the Audit Findings Report are noted below:
Financial Statements – the outstanding matters noted at the time of writing are being brought to a conclusion, with no other issues anticipated. Therefore, External Auditors - Grant Thornton will issue an Unqualified opinion.
Value for Money arrangements – Grant Thornton concluded that St Helens CCG has proper arrangements in place to secure economy, efficiency and effectiveness in its use of resources, except for in relation to sustainable resource deployment. Therefore, External Auditors - Grant Thornton will issue a Qualified ‘except for’ opinion, (i.e. except for sustainable resource deployment). The auditors recognised the financial challenges, not only for the CCGs but for the wider health system.
Statutory Duties – External Auditors - Grant Thornton (in accordance with the value for money conclusion above) have issued a Section 30 letter to the Secretary of State in respect of the CCG’s financial position.
Going Concern – No indications of material uncertainty or other events were identified in relation to the going concern assessment.
COVID-19 was noted as a significant risk in the Audit Plan in terms of the production and audit of the financial statements for the year ended 31st March 2020. The subsequent audit work did not identify any significant issues in respect of the identified risk.
A recommendation was noted in relation to QIPP savings and is included in the Action Plan (Appendix A). Progress against this area will be tracked during the course of the year.
Closing comments from External Auditors – Grant Thornton:
• MH commented on the “usual standard of high quality financial statements received from St Helens CCG”.
• Thanks were reiterated to the CCG Finance Team for their co- operation through the audit process during challenging and unprecedented times. 148
• Additional costs to Grant Thornton due to the COVID-19 pandemic and new ways of working were noted by MH and may impact on the fee. A full and open discussion will follow prior to the final fee being issued.
The Chair thanked Grant Thornton for a good readable report and made particular mention to the Value for Money section which provides an independent view on some of issues faced by the CCG, whilst trying to deliver value for money. Governing Body will be sighted on this.
AW added that the audit findings were testament to the hard work of the Finance Team. He mentioned the reference to a “weak control system in SAR information” and suggested a further report to the next Audit Committee to provide some understanding of where the problems lie in relation to SAR information. The Chair noted as a consideration. TF
IS agreed to follow up on the SAR for Capita PCSE which has not yet been IS received.
As a point of accuracy, IS will double-check the figure stated in relation to IS unadjusted misstatements for prescribing.
The Audit Committee received and noted the External Audit Findings Report and Opinion.
AC APPROVAL OF AUDITED ANNUAL ACCOUNTS AND GOVERNANCE 20 06 08 STATEMENT 2019/20 The Chair concluded that the committee has now received all relevant reports and supporting documentation in respect of the Annual Report and Accounts for 2019/20 and asked members to confirm their approval of these reports prior to submission.
Following a review of all relevant documents received under Agenda Items AC200604 to AC200607, the Audit Committee formally approved the Audited Annual Accounts and Governance Statement 2019/20.
The Chair continued with the standard business items.
AC RECEIPT OF ANTI-FRAUD ANNUAL REPORT 2019/20 20 06 09 Karen McArdle, MIAA presented the Anti-Fraud Annual Report for information. The report outlines the work completed in year as agreed within the Work Plan approved by Audit Committee and in line with the NHS Counter Fraud Authority’s Standards for Commissioners in relation to fraud, bribery and corruption.
KMc thanked Lisa Roberts, Principal Accountant and the Finance Team for their hard work in relation to the National Fraud Initiative.
The CCG self-assessment relating to compliance with the Standards for Commissioners was duly completed by the CFO and Audit Chair and showed an overall rating of “green” against the required standards.
The committee was invited to feedback:
The Chair felt this was a very good and detailed report.
The Audit Committee received and noted the Anti-Fraud Annual Report 2019/20.
149 AC NHSCFA’s Thematic Assessment – Fraud Threats to the NHS from 20 06 10 COVID-19 Karen McArdle, MIAA made reference to the above report which provides a comprehensive list of fraud threats across the NHS.
The Chair noted the restricted circulation of the report and asked the Anti- Fraud Specialist if she was confident that the CCG were fully sighted on all fraud threats including in this report. KMc assured Audit Committee that all relevant fraud threats within the report have been highlighted separately to the CCG via Fraud Alerts over the last few months.
The Chair asked for the Governing Body to be sighted on the changing threats to the organisation as per MIAA’s updates, e.g. agile and home working, COVID expenditure etc. IS confirmed that this will also be picked up in the GBAF as part of a wider risk assessment around COVID.
The Audit Committee noted the verbal update around fraud threats to the NHS.
AC RECEIPT OF CFO BRIEFING/UPDATE 20 06 11 Iain Stoddart, Chief Finance Officer provided a brief verbal update around the temporary finance regime as a result of the COVID pandemic. Short term budgets have been allocated by NHSE/I on the basis that the CCG would have a balanced position in the first 4 months. Arrangements for month 5 onwards have not yet been confirmed and discussions are ongoing with NHSE/I.
AC Conflict of Interest Annual Report 2019/20 20 06 12 Angela Delea, Associate Director of Governance presented the report to update Audit Committee on the COI activity during 2019/20. Key points are:
• The CCG’s “Management of Conflicts of Interest, Gifts and Hospitality” Policy has been updated twice in year to provide more clarity and understanding around COI breaches. This followed updated guidance and also a deep-dive by Audit Committee.
• The tender waiver sign off process has been improved.
• The CCG had two identified COI breaches in year – both were found to be non-material.
• COI training and compliance rates are included in the report and the governance team will continue to monitor this and chase up any outstanding training.
The Audit Committee gave positive feedback to the report which they DM found useful and it was agreed to continue with this annual update on add to policy changes going forward. Work Plan AC AGREE KEY ISSUES FOR GOVERNING BODY 20 06 13 The following were agreed as key issues to be reported to Governing Body:
• Internal and External Audit Findings – acknowledgement of outstanding effort and co-operation between all parties despite extraordinary challenges due to the COVID-19 pandemic.
• Approval of Annual Report and Accounts 2019/20 including explanation around Auditor opinions. 150
• MIAA Anti-Fraud Services Annual Report and CCG rating.
• Raise awareness of Fraud threats to the NHS (MIAA’s report).
DATE AND TIME OF NEXT MEETING
To be confirmed.
Minutes Ratified as Accurate Record.
Name: Tony Foy Signature: Date: 30.06.20
151 152 Audit Committee Meeting Date: 23rd June 2020
Agenda CCG Key Issue: Decision / Corporate Item Improvement Action: Risk / Ref: Plan Theme GBAF Reference: - Mitigation AC Annual Report and Accounts 2019/20 – the CCG Annual Report and Accounts were Positive feedback 20 06 08 approved by the Audit Committee. The Committee received the following information received from before they made the decision to approve: Internal and External Auditors • CCG Annual Report and Accounts 2019/20 with acknowledgement • Head Of Internal Audit Opinion – “Substantial Assurance” was received in of outstanding that there is a good system of internal controls designed to meet the efforts and organisation’s objectives. co-operation between all • Letter Of Management Representation - The Committee approved the letter to parties and high External Auditors and has received assurances from Governing Body to confirm quality reporting, that they were not aware of any issues that may affect the accounts that they despite had not declared. extraordinary challenges due to • The External ‘Audit Findings Report’- no material mis-statements were found. the COVID-19 pandemic. An “Unqualified Audit Opinion” was received in relation to Financial Statements, i.e. on the true and fair view – the Financial Statements are an The Annual accurate reflection of the financial position of the CCG. Report and Annual Accounts A “Qualified, Except For Audit Opinion” was received for Value for Money 2019/20 were due to financial sustainability. This is consistent with other CCGs in a similar approved subject position. to a few minor amendments. 153 Agenda CCG Key Issue: Decision / Corporate Item Improvement Action: Risk / Ref: Plan Theme GBAF Reference: - Mitigation AC MIAA Anti-Fraud Services Annual Report 2019/20 - the Anti-Fraud Specialist (AFS) Members noted 20 06 09 has completed work across the main key areas and fully delivered the workplan and approved the approved by the Audit Committee. Overall the perceived level of compliance by the Anti-Fraud CCG in relation to the required standards has been assessed as a “green rating”. Services Annual Report 2019/20.
AC Fraud Threats to the NHS – the committee received assurance from the Anti-Fraud Members to be 20 06 10 Specialist that the CCG were fully sighted on all relevant Fraud Threats. This followed vigilant to reference to the NHS Counter Fraud Authority Thematic Assessment which was potential fraud brought to the attention of Audit Chair but had limited circulation. threats.
Attention was drawn to the current and ongoing threats to the organisation in relation to the COVID situation, e.g. agile/home-working and COVID expenditure. Detail will be included in the GBAF as part of a wider risk assessment around COVID.
Key Issues Report Date Prepared by: Dawn Mellan, PA to CFO and Deputy 29th June 2020 Verified by: Alan Howgate, Deputy CFO 30th June 2020 NOTE: A copy of any papers referenced in this Key Issues Report will be made available on request to the Committee Chair. Formal Minutes, once approved, will be made available on request.
154 Report to NHS St Helens CCG Governing Body Date of meeting: 8th July 2020 Strategic Director People’s Services/ CCG Governing Body Member Lead: Clinical Accountable Officer Accountable Director: Associate Director Corporate Governance
Report title: GBAF Update: End of Quarter 1 2020/21
Item for: Decision X Assurance X Information X (Please insert X as appropriate)
This report supports the following CCG Strategic Objectives. Please insert ‘x’ as appropriate.
1. To deliver financial stability X 2. To integrate health within the place of St Helens through system redesign X 3. To deliver improved outcomes for people X Strategic Objectives 4. To be recognised as good system leaders X 5. To support and transform primary care to be a system leader in St Helens X DoesCares this report provide assurance against any of the risks identified in the Assurance Framework? (please specify) ALL
Significant What level of assurance does it provide? (List levels i.e. Limited/Reasonable/Significant) Risk Is this report required under NHS guidance or for statutory purpose? (please specify) Yes. The GBAF is part of the CCG’s Risk Monitoring Assurance in line with the
Governance and Risk Management Strategy and details the current strategic risks to the organisation.
Purpose of this paper To provide the Governing Body with a summary of the GBAF position at the end of Quarter 1 (June) 2020/21; to provide assurance that the CCG has in place robust Risk Management arrangements.
1. Executive Summary
GBAF Activity at the end of Quarter 1 (June 2020/21) For the end of Quarter 1 (June) 2020/21 the overall Assurance Rating remains ‘Significant’, as controls are robust and evidence on controls have been validated. The CCG’s Risk Management Strategy was reviewed and updated by ELT Governance Committee in December 2019 and is available on the CCG’s website; and during January/ February 2020 Mersey Internal Audit Agency (MIAA undertook a review of the CCG’s Assurance Framework (in relation to financial reporting assurance) and rated it as providing Substantial Assurance in regards to having a robust system of internal control.
A deep dive review of the CCG’s Strategic Objectives and subsequent strategic risks for 2020/21 and longer term is to be arranged, originally scheduled for the start of 2020/21 financial year; this was postponed due to Covid-19 priorities.
There are currently 15 risks on the GBAF; since the report to the Governing Body in January 2020:
1 new risk has been added: 155
4.7 – Reputational risk to CCG in failing to have appropriate planning and partnership working in place to manage the Coronavirus (Covid-19) pandemic - consequence scored as major (Criticism or intervention by NHSE, risk of adverse national media/ adverse public reaction and significant membership dissatisfaction) 4 x 3 (possible) = 12
1 risk has increased in score: 3.4 – Failure to support an effective approach to public health & prevention – the impact of the COVID-19 pandemic on the residents of St. Helens has been significant; whilst we have been focusing on the measures to protect the population from COVID-19 there have been significant other impacts e.g. MH and trauma.
5 risks have decreased in score (or risks reset for new financial year at lower risk rating): 1.1 – Failure to deliver to financial control total/non-achievement of statutory financial duties – the risk in relation to the in-year deficit risk for 2020/21 has been re-set in accordance with the current financial regime. 1.2 – Excessive demand not being managed – for months 1-4 of the 2020/21 financial year, NHS providers are being funded via a fixed mandated block payment and therefore there is no financial risk associated with patient activity during this period, and risk has been reduced. 3.1 – Failure to gain assurance on quality of commissioned services – Looked After Children’s (LAC) Service transferred in November 2019, as did Safeguarding UTC; therefore consequence reduced from 5 ‘catastrophic’ to 4 ‘major’, bringing overall risk down to 12, and target scores reset at 4 (4x1). 3.6 – Risk to provision and quality of service delivery to mental health patients in St Helens due to merger between North West Boroughs (NWB) and Merseycare - a lot of unknown surrounding the merger currently. Context of detail not available yet until more detail is available, risk is reset as possible rather than likely, therefore risk score reduced. Covid has taken emphasis off merger in quarter 1. 5.6 – Risk that Primary Care Networks will be unable to deliver key work programmes due to their maturity at the time of contract implementation – significant progress in the development of the Networks, therefore risk reduced for 2020/21.
8 risks have remained static in score: 2.2 – Failure to deliver health & care infrastructure (in relation to workforce) which enables transformation 2.5 – Risk of St Helens and Knowsley Accident and Emergency Department 4 hour target being breached (Failure to treat patients in a timely manner) 3.2 – Lack of appropriate and/or effective arrangements in place to secure patient and public involvement in the planning, development and delivery of health and social care services 3.3 – Failure to tackle unwarranted variation across the borough 3.5 – Failure to deliver estates strategy 4.5 – Failure to protect IT systems from threats emerging from cyber security 5.2 – Unrealistic demand and expectations of patients leading to an inability to address legitimate clinical need 5.3 – Without effective Primary Care engagement and support St Helens will compromise its ability to deliver the St Helens Cares strategy
Please see individual risk summaries for detailed updates (Appendix 1). (1. Recommendations The Governing Body is asked to review the GBAF as at end of Quarter 1 (2020/21), and assure itself that appropriate risks have been identified, and those risks are being managed effectively and risk scoring is appropriate.
156 NHS St Helens CCG BAF Heat Map – As at end of June 2020 (End of Quarter 1, 2020/21)
25
20
15 2.2
1.2 12 2.5 10 25 8 20 25 15
20 12 1.1 5 10 15 12 10 4 8 3.1 8 5
5 4 4 3.2
5.6 1 3.3
4 4 3.4
5 3.5 5.3 4 5
8 5 8 10 10 3.6 12 5.2 8 12 15 4.5 10 15 20 4.7 20 25 12 25 15
20
KEY 25 4.7: NEW
Initial Rating (Inherent Risk)
1.1 Current Rating (Mitigated Risk)
1.1 Current Rating (Mitigated Risk) – shaded in purple where initial rating is same as current rating
Reset Target (For 2020/21)
Final Target (To Close Risk)
157
GBAF Record – Risks Closed 1.3 – Merged with 1.1 after GB Development Session October 2018 2.1 – Failure to deliver transformational initiatives as specified in Improvement Plan – risk reviewed and closed in May 2019 – new risk around A&E added to GBAF June 2019 in its place 2.2 – Agreed for closure at GB Development Session October 2018 – Reopened June 2019 2.3 – Met its target and was closed in June 2018 2.4 – Merged with 2.1 after GB Development Session October 2018 4.1 – Met its target and was closed in June 2018 4.2 – Transferred to 5.1 in March 2018 4.3 – Met its target and was closed in March 2019 4.4 – Agreed for closure at GB Development Session October 2018 4.6 – (A1) There is a risk that a no-deal Exit from the EU will adversely affect the ability of the Health & Social Care system to safely and efficiently deliver Health & Social care Services Closed January 2020 5.1 – Agreed for closure at GB July 2019 5.4 – Merged with 5.3 after GB Development Session October 2018 5.5 – Agreed for closure at GB October 2019
158 BOARD ASSURANCE FRAMEWORK (BAF) 2020/2021 OVERALL RISK APPETITE: “The CCG recognises that the long term sustainability of services in St Helens depend upon the delivery of the Improvement Plan, strategic objectives and its relationships with partners and the public. Therefore, whilst the CCG will not accept risks that materially impact on the safety or constitutional requirements of patient care, it has a greater appetite to take considered risks in terms of their impact on organisational issues, within our required frameworks. The CCG’s highest risk appetite relates to its transformational objectives”. STRATEGIC OBJECTIVE: DIRECTOR LEAD: DATIX ID: 1. To deliver financial sustainability Chief Finance Officer 388 OBJECTIVE SPECIFIC RISK APPETITE: DATE OF REVIEW: NEXT REVIEW: OPEN - We will encourage new thinking and ideas that could lead to improved financial and operational July 2020 Sept 2020 performance. BAF RISK: 1.1 – Failure to deliver to financial control total/non-achievement of statutory financial duties. RATIONALE FOR IDENTIFIED RISK: The CCG reported an in-year deficit of £18m for the financial year 2019/20 and therefore the achievement of the statutory financial duty was not met. The cumulative deficit for the CCG at the year end is therefore £31.5m.
The risk in relation to the in-year deficit risk for 2020/21 has been re-set in accordance with the current financial regime. At present the CCG has been issued with a fixed budget for the first 4 months of the financial year. The budget is mandated by NHS England as part of the NHS response to the coronavirus pandemic and the financial regime beyond month July-20 is not certain.
It is expected that additional funding will be provided during this 4 month period to cover costs associated with the pandemic and reasonable financial challenges arising from the mandated budgets however long term financial sustainability continues to represent a key risk for the CCG. RISK RATING & MOVEMENT:
End of Score at Score at Score at Score at 2020/21 Final Risk 30 Year Q1 Q2 Q3 Q4 Risk Target 25 (19/20) (20/21) (20/21) (20/21) (20/21) Target 25 6 6 N/A 20 Risk Score (5 x 5) (3 x 2) (3 x 2) 15 10 Target Score RATIONALE FOR CURRENT RISK SCORE: 5 Delivery of the financial duties for the CCG necessitates a break even financial position in year 0 Final Risk and delivery of a 1% cumulative surplus. The cumulative deficit brought forward is £31.5m and Target 8.7% of our total resources. Whilst the operational planning has been suspended the approach to resolution of this target is still being worked through.
The scores therefore reflect the CCG in-year break even delivery against the NHSE mandated budget for the first 4 months of 2020/21. Based on the assigned budget, an initial estimate highlighted a potential £1.2m shortfall in funding before any reclaim of Covid related expenditure. Based on current actual expenditures the CCG reported an adverse variance of £2m (including £1.4m of Covid expenditure) as at the end of May 2020. Additional funding is anticipated to offset this deficit in full. The score at Q1 reflects any potential challenge over the nature of expenditure across the first 4 month period.
For the remainder of the financial year the financial regime beyond July 2020 is currently uncertain until the CCG receives further guidance expected mid 159 July 2020. The Risk Target is based on the assumption that additional allocations may not continue in the same manner and fully balance monthly expenditure requirements; therefore the risk to a financial deficit is increased.
KEY WORK PROGRAMMES: F&P Committee Recovery Meetings with NHSE Executive Leadership Team System Wide Recovery Plan Initiatives PMO (for Improvement Plan & Specific Work Programme areas e.g. Local link to wider system planning for the Acute and Out of Hospital cells Unscheduled Care) KEY ACTIONS/ TIMESCALES: 1. Await confirmation of retrospective funding to offset the month 2 variance 2. Await clarification from NHSE on the finance regime beyond July-20 3. Ensure budget holders are cognisant of the temporary budget arrangements for months 1-4 4. Seek to develop QIPP schemes and efficiency savings in preparation for the financial regime beyond July-20 OPERATIONAL RISK EXPOSURE SUMMARY (Corporate Risks scoring 15 or above): 52MM - Risk of GP Prescribing Budget Overspend (16) 47F&P - Elective demand needs to be constrained to generate QIPP savings (15) 115F&P - Failure to identify/ deliver system wide QIPP savings required for 2019/20 (20) 116F&P - QIPP plan contains unidentified savings required to be addressed at a system level (20) 117F&P - Failure to deliver overall breakeven control total for 2019/20 (20)
The above risks predominantly relate to 2019/20 and will be revised to take account of the 2020/21 interim financial regime moving forward. This will also take into account the controls and assurances at the various organisational levels. CONTROLS: ASSURANCES: Actions taken e.g. policies, processes, tasks, behaviours put in place to Sufficient appropriate evidence that a control is resulting in the desired outcome. mitigate/ manage a risk. LEVEL 1 Delegated spending limits in place LEVEL 1 Internal audit of financial systems & controls – 2019/20 audit Operational Principal & detailed financial policies in place Operational provided high assurance. (Management) (Management) Contractual Levers - to manage demand Current financial regime aims to ensure that the CCG reports a CFO is now recovery lead balance position during the 4 month period April to July 2020 CFO & Director Commissioning, Primary Care & Transformation have executive leadership for QIPP plan (system of programme meetings to drive delivery) PMO structure revised – alignment with acute Trust underway OPRAG meetings held regularly across organisation delivery levels, reports into F&P Committee Non recurrent schemes addressed e.g. pregabalin LEVEL 2 ELT Committee approval of IVA's for QIPP schemes LEVEL 2 Effective challenge and discussion held at Governing Body Oversight and regular QIPP discussion Oversight level, Committee level and local NHSE level – documented (Committees) (Committees) GB Oversight of Recovery Plan within minutes and action plans 160 Monthly reporting of QIPP delivery against planned Clear accountability re QIPP/Plan delivery - identified clinical & trajectory to GB at high level and detailed level to managerial leads Finance & Performance Committee ELT Committee/Programme Delivery Group CFO & Deputy SD/ AO will oversee delivery of QIPP reporting to GB GB and Officer sessions held to discuss other measures to be taken if QIPP is not met. Monthly financial reporting to NHSE/ NHSI LEVEL 3 ISFE rules and controls LEVEL 3 External audit of financial systems & controls Independent Peer benchmarking and best practice comparison Independent Alignment with NHSE Financial Resilience tools (Audit/ Reviews/ (Audit/ Reviews/ Inspections etc.) Engagement with key stakeholders & providers Inspections etc.) Quarterly assurance meetings with NHSE/ NHSI NHSE/I Protocol (revision to financial forecast) MIAA Audit of GBAF – Integrity of financial information provided to various groups (Governing Body, F&P Committee, F&P Board) GAPS IN CONTROLS: GAPS IN ASSURANCES:
LEVEL 1 QIPP Delivery – No QIPP programmes in place – LEVEL 1 Check and challenge ‘deep dive’ of schemes requires review in Operational suspended due to Covid response Operational line with changes in PMO arrangements to ensure CFO/ ELT (Management) (Management) Demand Management – clarity of responsibility involvement. between the CCG and acute hospital cell LEVEL 2 Change in PMO arrangements has resulted in the LEVEL 2 Due to significant risk, gaps can arise in the availability of time Oversight regular monthly meetings with CFO and Deputy Oversight afforded to specific areas of concern. (Committees) (Committees) Strategic Director no longer taking place LEVEL 3 None identified LEVEL 3 None identified Independent Independent (Audit/ Reviews/ (Audit/ Reviews/ Inspections etc.) Inspections etc.)
161 BOARD ASSURANCE FRAMEWORK (BAF) 2020/21 OVERALL RISK APPETITE: “The CCG recognises that the long term sustainability of services in St Helens depend upon the delivery of the Improvement Plan, strategic objectives and its relationships with partners and the public. Therefore, whilst the CCG will not accept risks that materially impact on the safety or constitutional requirements of patient care, it has a greater appetite to take considered risks in terms of their impact on organisational issues, within our required frameworks. The CCG’s highest risk appetite relates to its transformational objectives”. STRATEGIC OBJECTIVE: DIRECTOR LEAD: DATIX ID: 1. To deliver financial sustainability Dir Commissioning, Primary 389 Care & Transformation OBJECTIVE SPECIFIC RISK APPETITE: DATE OF REVIEW: NEXT REVIEW: OPEN – We will encourage new thinking and ideas that could lead to improved financial and July 2020 Sept 2020 operational performance. BAF RISK: 1.2 – Excessive demand not being managed. RATIONALE FOR IDENTIFIED RISK: Risk of demand for scheduled and unscheduled care not staying within contracted levels and at a level to deliver the full range of QIPP, leading to pressures on CCG budgets in 2019/20. For months 1-4 of the 2020/21 financial year, NHS providers are being funded via a fixed mandated block payment and therefore there is no financial risk associated with patient activity during this period. Key risks remain around the demand for CHC services, prescribing and other variable budgets. The financial regime beyond July-20 is uncertain and therefore the risk reflects the potential scenario that trust contracts may again revert to payment by results later in the financial year.
RISK RATING & MOVEMENT:
End of Score at Score at Score at Score at 2020/21 Final Risk 30 Year Q1 Q2 Q3 Q4 Risk Target (19/20) (20/21) (20/21) (20/21) (20/21) Target 25 25 12 9 N/A 20 (5x5) (4x3) (3 x 3) 15 10 Risk Score RATIONALE FOR CURRENT RISK SCORE: 5 Target Score The CCG experienced extremely high levels of demand across a range of services during 0 2019/20. Despite the number of non-elective admissions remaining within planned levels, the cost of that activity was significantly greater than planned leading to significant financial pressures.
The risk has been reset for the 2020/21 financial year and the risk score of 12 reflects current demand pressures in prescribing CHC. It is currently looking unlikely that the normal payments to providers will return in the coming months, so financial pressures from secondary care demand are low likelihood, but there is the underlying increases to waiting lists which will have a significant impact when normal operating resumes. While the CCG expects that COVID costs and current underspends will be funded up to the end of July-20 at least, the ongoing impact of the pandemic is captured in the risk assessment also.
KEY WORK PROGRAMMES: F&P Committee PMO (for Improvement Plan & Specific Work Programme areas e.g. Unscheduled Executive Leadership Team Care)162 STHK Collaborative Commissioning Forum Activity triangulation meetings (FARG & IM&T sub group of contract review board) System Wide Recovery Plan Initiatives Local link to wider system planning for the Acute and Out of Hospital cells KEY ACTIONS/ TIMESCALES: 1. Await clarification on the financial regime beyond July-20 and whether block payments to NHS Trusts will continue 2. Work ongoing to forecast future demand pressures due to the pandemic including the impact on prescribing, CHC and elective demand. 3. Continued development of QIPP schemes and long term recovery plan 4. Operational Performance Reporting and Assurance Group to restart in July 2020
OPERATIONAL RISK EXPOSURE SUMMARY (Corporate Risks scoring 15 or above): 10F&P - Over performance to CHC/ Complex Care Budgets (15)
CONTROLS: ASSURANCES: Actions taken e.g. policies, processes, tasks, behaviours put in place to Sufficient appropriate evidence that a control is resulting in the desired outcome. mitigate/ manage a risk. LEVEL 1 Contract monitoring meetings linked to Acute/ LEVEL 1 Contract Monitoring Minutes & Contract query notices placed Operational Community/ MH Operational where necessary (Management) (Management) CHC demand monitored through the LA pooled Regular reporting to F&P/ Quality Committee/ ELT budget arrangement STHK Collaborative Commissioning Forum oversight Regular budget monitoring processes – monitoring the financial impact of demand increases Contractual levers can be operated to support management of demand New contractual models and financial flows to meet newly developed service models Internal group meets monthly - led by Deputy Finance Officer - looking at variance analysis with colleagues from BI, Finance , Commissioning and Contracting A&E Delivery Board system plans for emergency care, and working group Evidenced Based Clinical Interventions controls in place for elective care between CCG and providers Re-mapped information flows and governance structure for St Helens Cares, including CCG areas of focus and contracts LEVEL 2 Regular updates provided through F&P, Quality LEVEL 2 Effective challenge and discussion held at Governing Body Oversight Committee and Governing Body Oversight level, Committee level and local NHSE level (Committees) (Committees) NHSE monthly reporting of financial position including demand impacts NHSE reporting on Improvement Plan progress LEVEL 3 LEVEL 3 Independent Independent (Audit/ Reviews/ (Audit/ Reviews/ Inspections etc.) Inspections163 etc.) GAPS IN CONTROLS: GAPS IN ASSURANCES:
LEVEL 1 National Gateway Letter reference 05342 removing LEVEL 1 Current contract monitoring arrangements suspended through Operational controls on Non-Elective Readmissions Operational the pandemic response. Internal Operational Performance and (Management) (Management) Inability to control the growth in hospital consultant to Reporting Assurance Group (OPRAG) planned to restart in July consultant referral rate increases 2020. Robust evidence being developed on the impact of demand management schemes LEVEL 2 LEVEL 2 Oversight Oversight (Committees) (Committees) LEVEL 3 LEVEL 3 Independent Independent (Audit/ Reviews/ (Audit/ Reviews/ Inspections etc.) Inspections etc.)
164 BOARD ASSURANCE FRAMEWORK (BAF) 2020/2021 OVERALL RISK APPETITE: “The CCG recognises that the long term sustainability of services in St Helens depend upon the delivery of the Improvement Plan, strategic objectives and its relationships with partners and the public. Therefore, whilst the CCG will not accept risks that materially impact on the safety or constitutional requirements of patient care, it has a greater appetite to take considered risks in terms of their impact on organisational issues, within our required frameworks. The CCG’s highest risk appetite relates to its transformational objectives”. STRATEGIC OBJECTIVE: DIRECTOR LEAD: DATIX ID: 2. To integrate health within the place of St Helens through system redesign Chief Nurse 392 OBJECTIVE SPECIFIC RISK APPETITE: DATE OF REVIEW: NEXT REVIEW: OPEN – We will seek creative ideas for improving and broadening care delivery through integration July 2020 Sept 2020 and encourage a similar attitude to risk amongst our partners. BAF RISK: 2.2 – Failure to deliver health & care infrastructure (in relation to workforce) which enables transformation RATIONALE FOR IDENTIFIED RISK: Risk of not having the necessary workforce in place across the place of St Helens (St Helens Cares) to enable transformation of services.
RISK RATING & MOVEMENT:
End of Score at Score at Score at Score at 2020/21 Final Risk 20 Year Q1 Q2 Q3 Q4 Risk Target 15 (19/20) (20/21) (20/21) (20/21) (20/21) Target 10 16 16 12 8 Risk Score (4 x 4) (4 x 4) (4 x 3) (4 x 2) 5 0 Target Score RATIONALE FOR CURRENT RISK SCORE: End of Score at Score at Score at Score at Final Risk Target Risk did not meet it’s in year target during 2019/20, as none of the workforce targets Year Q1 Q2 Q3 Q4 were ‘quick wins’ therefore target deemed more suitable for a final target. In year (19/20) target refreshed for 2020/21 to 12 (major, 4 x possible, 3). Risk needs reviewing for Position 2020/21 as very generic currently; some areas the CCG has no control/ influence over e.g. 0-19 Healthcare Workers and PH Commissioned services.
Currently no joined up workforce plans in place across St Helens; there needs to be integrated workforce planning and the ability to think differently in regards to developing new roles across both health and social care. There remain multiple known vacancies across St Helens in various directorates/ teams adding pressure into the system including Primary Care (GPs, Clinicians), Children’s Services (health visitors, school nurses and FNPs), Social Workers and Mental Health services – however evidence not always clear where vacancies are needed/ having a negative impact. Data often delayed coming into the CCG. Risk remains 16 at start of year, but request risk to be fully reviewed by GB and refined/ closed.
KEY WORK PROGRAMMES: Primary Care: Releasing Time for Care Programme/ International GP Recruitment Programme/ BMJ Local GP Recruitment Campaign/ Clinical Pharmacist Programme, General Practice Nurse Collaborative. KEY ACTIONS/ TIMESCALES: Draft workforce plan to go to Quality Committee in July 2020 Meeting with Higher Education Institutes (HEIs) to look at workforce redesign once possible due to Covid 165 Meeting SHK re: contracts as soon as possible (delayed due to Covid-19)
OPERATIONAL RISK EXPOSURE SUMMARY (Corporate Risks scoring 15 or above): There are currently no 15 or above risks associated with this Strategic risk. CONTROLS: ASSURANCES: Actions taken e.g. policies, processes, tasks, behaviours put in place to Sufficient appropriate evidence that a control is resulting in the desired outcome. mitigate/ manage a risk. LEVEL 1 APEX Insight software roll out across practices to LEVEL 1 Operational monitor workforce data Operational (Management) (Management) New Network DES contracts include ‘Additional Role Reimbursement Scheme’ – funding expected to create up to 20k additional jobs within PC LA rolling recruitment drive for Social Workers & APs LEVEL 2 Joint Transformation Workshops held between PH LEVEL 2 Oversight Commissioners, CCG Strategic Leads and SMT Oversight (Committees) (Committees) within NWBH to define a service improvement plan Paper presented to ELT, CCG Quality Committee and Safeguarding Board to ensure transparency & accountability re: the current 0-19 vacancy situation
LEVEL 3 Partnership working with Edgehill University – funding LEVEL 3 Advisory Board representation at Institute of Health Visiting – Independent provided for the role of Multi-disciplinary Workforce Independent brings back best practice guidance (Audit/ Reviews/ (Audit/ Reviews/ Inspections etc.) Coordinator, to support local students into health & Inspections etc.) Chief Nurse is lead for Cheshire & Merseyside Primary Care social care placements Workforce Group – soft intelligence gathering On-going ‘grow your workforce’ alongside John Moores University to ensure the 0-19 workforce is compliant with national models of practice GAPS IN CONTROLS: GAPS IN ASSURANCES:
LEVEL 1 No joined up workforce plans in place – in addition no LEVEL 1 30% of St Helen’s GPs are aged over 55 – strong indication as Operational local primary care workforce plan in place. Operational to numbers expected to retire in next 5-10 years (Management) (Management) APEX reporting not in place yet, therefore no real-time data in use. LEVEL 2 X Due to Covid, many aspects of business as usual work LEVEL 2 Oversight has been stepped down which has delayed progress Oversight (Committees) (Committees) LEVEL 3 CCG has no control over the vacancies in Social LEVEL 3 GP retention & recruitment is a growing area of concern Independent Work, 0-19 service etc. Independent nationally – vacancy rates at highest levels for 15 years (Audit/ Reviews/ (Audit/ Reviews/ Inspections etc.) Inspections etc.) Uncertainty of Brexit impacting on expected interest in International GP Recruitment Programme Multi-disciplinary Workforce Coordinator not in post yet
166 BOARD ASSURANCE FRAMEWORK (BAF) 2020/2021 OVERALL RISK APPETITE: “The CCG recognises that the long term sustainability of services in St Helens depend upon the delivery of the Improvement Plan, strategic objectives and its relationships with partners and the public. Therefore, whilst the CCG will not accept risks that materially impact on the safety or constitutional requirements of patient care, it has a greater appetite to take considered risks in terms of their impact on organisational issues, within our required frameworks. The CCG’s highest risk appetite relates to its transformational objectives”. STRATEGIC OBJECTIVE: DIRECTOR LEAD: DATIX ID: Objective 2 – To integrate health within the place of St Helens through system redesign Dir of Commissioning/ 700 Primary Care/ Transformation OBJECTIVE SPECIFIC RISK APPETITE: DATE OF REVIEW: NEXT REVIEW: OPEN - We will seek creative ideas for improving and broadening care delivery through integration July 2020 Sept 2020 and encourage a similar attitude to risk amongst our partners. BAF RISK: 2.5 – Risk of St Helens and Knowsley Accident and Emergency Department 4 hour target being breached. Failure to treat patients in a timely manner. RATIONALE FOR IDENTIFIED RISK: Need to ensure the timely access to treatment in A and E is fundamental to patient safety and broader system flow into and out of the St Helens and Knowsley Hospital Trust. RISK RATING & MOVEMENT:
End of Score at Score at Score at Score at 2020/21 Final Risk 18 Year Q1 Q2 Q3 Q4 Risk Target 16 (19/20) (20/21) (20/21) (20/21) (20/21) Target 14 16 16 8 8 12 (4 x 4) (4 x 4) (4 x 2) (4 x 2) 10 8 Risk Score 6 RATIONALE FOR CURRENT RISK SCORE: 4 Target Score The score remains the same. The reasons for not achieving the A&E 4 hour standard 2 0 Final Risk Target are multifactorial and performance is interdependent with a number of other factors and pressures such as staffing levels, acute bed occupancy and demand, community End of Score at Score at Score at Score at Year Q1 Q2 Q3 Q4 alternatives and the fact that St Helens has many challenges in relation to the (19/20) prevalence of co-morbidities and an ageing population. A number of strategies have Position been put in place in 19/20 to support system pressures such as additional resource in social care to support discharge planning and projects targeting admissions avoidance in relation to respiratory and frailty both in the Acute Trust and Community, this is in addition to ongoing system service improvement approaches within pathways to improve productivity and efficiency. Further cases had been developed to support population based approaches to proactive care and risk stratification working with community teams and primary care based upon successful pilots however this has been brought to a pause to focus upon the COVID response. Enhanced health in care homes and progress with this is also another key factor in improving A&E performance. The Integrated performance report provides further narrative and detail on progress and achievements in year. Implementation of the National IUC standards with the development of the Urgent Treatment Centre, direct booking and increased resource to support clinical triage linked to 111 and general A&E avoidance. St Helens remains one of the best in the country for DTOC a key factor attributed to non-achievement of A&E performance.
The system is operating within the emergency planning Command and Control governance. March 20 – May 20 to date has seen an improvement in performance due to the reduced attendance in A&E, bed capacity in the Acute Trust and the public responses to stay at home. During this time, much reconfiguration and redeployment of staff has taken place to prioritise the local capacity and capability to respond in line with national guidelines. 167
95% performance and over has been achieved on some days, with some consistent days over 90%. The 95 % standard is not being achieved and will still remain a challenge whilst the system applies safety measures on social distancing within clinical environments and across social care settings and deals with the changing nature of staffing capacity and COVID outbreaks. There is still a high risk that a consistent 95% performance will not be achieved. The system reset and recovery planning approach is also key to further support sustained performacne in year and beyond. The Hospital and Out of Hospital Cells will be key in deterining approaches to recovery and sustainability across the whole of Cheshire and Merseyside.
Current projects and strategy for urgent care contained within the system five year plan will continue to be progressed as much as possible and will be further influenced by the new planning guidance expected in the Autumn. Winter planning is expected to commence as part of phases 2 and 3 of COVID expectations. Existing commissioning intentions will be reviewed further also as part of reset and recovery.
KEY WORK PROGRAMMES: CCG Improvement Plan 8. Same Day Emergency Care (SDEC) working group A and E Improvement Plan agreed at Urgent Care Operational Group 9. Frailty Team redesign. Including urgent care medical care visits. Urgent Care Strategy agreed as part of St Helens Clinical and Support Proactive and reactive crisis response Strategy 10. NWAS direct referral to avoid patient attendance at A and E. Emergency Care Improvement Programme (ECIP). Whole system review. 11. Admission Avoidance Car Implementation of Venn capacity and demand action plan 12. Respiratory admissions avoidance service in A&E Winter Plan development (2019/20) 13. Community Respiratory Car All the listed programmes include: 14. NART tool in care homes 1. Extended GP access 15. Additional intermediate care community beds 2. Integrated Urgent Care, CAS and 111 16. Trusted Assessor 3. Proactive Care model 17. Additional Reablement capacity 4. Core 24 liaison 18. Contact Cares review 5. GP streaming in A&E 19. EoL/Covid service via St Helens Rota supporting COVID 6. Improved Access for primary care arrangements 7. Transition of the UTC to STHK 20. Primary Care, community and frailty team support to care home
KEY ACTIONS/ TIMESCALES: 1. New GP Sustainability LES approved at PCC which is linked to reducing attendances at A&E for minor conditions to be implemented before winter – Whilst some good actions came from this, Covid has meant that full embedding of these plans has been delayed. 2. Respiratory Hub model in primary care being developed, business case expected June 2020. 3. IV Therapy Heart Failure Pilot Case being developed – expected July 2020. 4. IV service review looking at admissions avoidance and early supported discharge opportunities – improved access to medicines in the community recently established. 5. UTC – next phase project group established, links to reset and recovery discussions. Aim for DVT pathway implementation before Winter 2020. Cellulitis pathway review commenced and aligns with IV review. 6. Frailty action plan for St Helens Cares in development following workshop – June 2020 7. Await further direction from Hospital and Out of Hospital Cells 8. Contact cares review commenced – on hold. 9. Enhanced health in care homes progression. 10. Frailty and community team support to care homes. 168 OPERATIONAL RISK EXPOSURE SUMMARY (Corporate Risks scoring 15 or above): Risk 3F&P - Risk of SHK Trust AED 4 hour target being breached (16) CONTROLS: ASSURANCES: Actions taken e.g. policies, processes, tasks, behaviours put in place to Sufficient appropriate evidence that a control is resulting in the desired outcome. mitigate/ manage a risk. LEVEL 1 Daily reporting and associated operational action LEVEL 1 Operational performance group meet and review progress – Operational (A and E attendance and waits, Delayed Transfer Operational temporarily suspended due to Covid – meetings minuted and (Management) (Management) of Care patients, stranded and super stranded reported to F&P patients, available community bed capacity, EMS) Contract review Board with STHK – A&E performance regular PMO approach to all QIPP schemes agenda item. Weekly MADE to discuss patient specific issues Monthly Executive MADE to discuss service and system issues SDEC working group Public campaign launched Dec 2019 about awareness raising of alternative services to A&E Urgent Treatment Centre aligned to St Helens and Knowsley Hospital Trust - can better manage capacity by utilising the UTC effectively and UTC activity also now counts to the 4 hour wait targets. NHSE Operational Escalation Framework implementation and use of EMS system to monitor operational pressures across the system Weekly operational teleconferences to support patient flow and manage pressures during periods of high demand 2019/2020 Winter Plan developed Ongoing communications with the public LEVEL 2 A and E Board LEVEL 2 Regular reporting to AED Board and UCOG on performance of Oversight STHK Urgent Care Operational Group (UCOG) Oversight admission avoidance scheme. (Committees) (Committees) C&M Urgent and Emergency Care Network F&P Committee review performance monthly and get a detailed CCG Constitutional Dashboard monitoring report Contract meetings & associated action plans (CRM and CQPG) Quality Committee performance monitoring. IAF monthly reporting Full update given to Finance and Performance Committee in Aug 19 as part of operational plan updates and ongoing performance updates monthly Health and Care Partnership governance linked to command and control.
169 LEVEL 3 Ambulance Response (ARP) Improvement Plan LEVEL 3 NHSE annual reviews of winter plans. Independent VENN capacity and demand review Independent Ongoing ECIST review and support as needed (Acute). (Audit/ Reviews/ (Audit/ Reviews/ Inspections etc.) HCP Hospital Cell capacity planning ongoing in Inspections etc.) response to COVID response GAPS IN CONTROLS: GAPS IN ASSURANCES:
LEVEL 1 Whilst targets are not met for reasons noted above, this LEVEL 1 Whilst targets are not met for reasons noted above, this is not due Operational is not due to lack of control or assurance. Operational to lack of control or assurance. (Management) (Management) LEVEL 2 LEVEL 2 Oversight Oversight (Committees) (Committees) LEVEL 3 LEVEL 3 To be identified in collaboration with providers. Independent Independent (Audit/ Reviews/ (Audit/ Reviews/ Inspections etc.) Inspections etc.)
170 BOARD ASSURANCE FRAMEWORK (BAF) 2020/2021 OVERALL RISK APPETITE: “The CCG recognises that the long term sustainability of services in St Helens depend upon the delivery of the Improvement Plan, strategic objectives and its relationships with partners and the public. Therefore, whilst the CCG will not accept risks that materially impact on the safety or constitutional requirements of patient care, it has a greater appetite to take considered risks in terms of their impact on organisational issues, within our required frameworks. The CCG’s highest risk appetite relates to its transformational objectives”. STRATEGIC OBJECTIVE: DIRECTOR LEAD: DATIX ID: 3. To deliver improved outcomes for people Chief Nurse 395 OBJECTIVE SPECIFIC RISK APPETITE: DATE OF REVIEW: NEXT REVIEW: AVERSE – We will endeavour to eliminate all but very lowest levels of risk that could jeopardise July 2020 Sept 2020 patient safety and experience BAF RISK: 3.1 – Failure to gain assurance on quality of commissioned services RATIONALE FOR IDENTIFIED RISK: Risks identified in relation to quality concerns raised around the provision of a number of services: CYP/ CAMHS, CN/ OOH Services, SEND, Care Home Provision and ADHD/ Autism Services. RISK RATING & MOVEMENT:
End of Score at Score at Score at Score at 2020/21 Final Risk 20 Year Q1 Q2 Q3 Q4 Risk Target 15 (19/20) (20/21) (20/21) (20/21) (20/21) Target 10 15 12 8 4 Risk Score 5 (5 x 3) (4 x 3) (4x2) (4x1) 0 Target Score End of Score at Score at Score at Score at RATIONALE FOR CURRENT RISK SCORE: Final Risk Target Year Q1 Q2 Q3 Q4 Concerns in relation to both the quality of a number of services and also around (19/20) the wider integration of community services within the St Helens Cares approach Position to integrated provision to ensure service stability to patients. Consequence reduced from 5 ‘catastrophic’ to 4 ‘major’, bringing overall risk down to 12, and target scores reset at 4 (4x1). Looked After Children’s (LAC) Service transferred in November 2019, as did Safeguarding UTC. KEY WORK PROGRAMMES: Community Transition Project Board – to undertake process of transfer of Bridgewater Community Services through STH Provider Lead arrangements. KEY ACTIONS/ TIMESCALES: 01/12/19 – Stage 1 Community Services Transfer completed 31/03/20 – Stage 2 Community Services Transfer to be completed 01/04/20 – Business as usual for services retained by Bridgewater (Equipment Store & Wheelchair Services) OPERATIONAL RISK EXPOSURE SUMMARY (Corporate Risks scoring 15 or above): 96QC – Risk of sub-optimal quality of care/ poor patient experience in CYP MH services due to demand and waiting lists (16) 102QC – Limited assurance around Safeguarding within Bridgewater Community Healthcare (20) 107QC – A number of quality and safety concerns have been identified within care home provision for St Helens (16) 109QC – Number of active cases on the Neurodevelopmental Pathway awaiting or receiving assessment for diagnosis of a developmental disorder such as Autism or ADHD (16) 112QC – Risk of the CCG failing to deliver on the Learning Disability Annual171 Health Checks 75% target (15) 107MM – Failure to support GPs to reduce antibiotic prescriptions (15) CONTROLS: ASSURANCES: Actions taken e.g. policies, processes, tasks, behaviours put in place to Sufficient appropriate evidence that a control is resulting in the desired outcome. mitigate/ manage a risk. LEVEL 1 Review of LAC Service currently underway LEVEL 1 Designated Nurse for LAC meeting LAC team quarterly and Operational Issue escalated internally within Bridgewater Operational available for reactive supervision. Also attending the 0-19 (Management) (Management) Community Healthcare NHS Foundation Trust. Healthy Child Programme Contract meetings. KPI data/ exception report monthly submissions from Provider workshops held/ progress made towards implementing the organisation to contracting team. an integrated model of delivery under LA leadership. Bi- monthly Quality and Contracting meeting with the Bi monthly submission/review of quality & safety reports and organisation and the CCG. assurance report focuses discussion on top 3 org. risks. Wider governance group to review realignment of Quarterly review and discussion of any concerns. Bridgewater services Review of soft intelligence and ad hoc information triangulated Named Nurse for LAC in post with performance data, safety and patient experience reports. LEVEL 2 Regular updates provided through Quality Committee LEVEL 2 Effective challenge and discussion held at Governing Body level Oversight and Governing Body Oversight and Committee level (Committees) (Committees) Monthly Bridgewater Commissioning Collaborative Clear notes and action logs from Community Transition Project attended by all CCG, LA’s, Health and Justice, NHSI Board used to feed back to ELT & Governing Body. and CQC - Representation from St Helens CCG includes Deputy Chief Nurse, Associate Director of Contracting and Integrated Commissioner. Community Transition Project Board mthly meetings LEVEL 3 LEVEL 3 Independent Independent (Audit/ Reviews/ (Audit/ Reviews/ Inspections etc.) Inspections etc.) GAPS IN CONTROLS: GAPS IN ASSURANCES:
LEVEL 1 Unclear line of accountability within org. for LAC LEVEL 1 CQC report published as “Requiring Improvement” – awaiting Operational Operational for revised CQC reports. (Management) Gaps within the 0-19 Healthy Child Programme (Management) (Health Visitors and School Nurses) but performance Realignment of services not highlighted to market place around review health assessments for LAC is good. Delays in implementing the shared central LAC Nursing Team in partnership with North West Boroughs Healthcare NHS Foundation Trust. LEVEL 2 CRB Community Services – no reports being LEVEL 2 Oversight received by CCG. Oversight (Committees) (Committees) Due to Covid- regular reporting has been stepped down, due to a number of staff TUPE transferring to STHK from NWB on 1/4/20, there is a lack of data and evidence to assure the work undertaken LEVEL 3 LEVEL 3 Independent Independent (Audit/ Reviews/ (Audit/ Reviews/ Inspections etc.) Inspections etc.) 172 BOARD ASSURANCE FRAMEWORK (BAF) 2020/2021 OVERALL RISK APPETITE: “The CCG recognises that the long term sustainability of services in St Helens depend upon the delivery of the Improvement Plan, strategic objectives and its relationships with partners and the public. Therefore, whilst the CCG will not accept risks that materially impact on the safety or constitutional requirements of patient care, it has a greater appetite to take considered risks in terms of their impact on organisational issues, within our required frameworks. The CCG’s highest risk appetite relates to its transformational objectives”. STRATEGIC OBJECTIVE: DIRECTOR LEAD: DATIX ID: 1. To deliver improved outcomes for people AD: Corporate Services 396 OBJECTIVE SPECIFIC RISK APPETITE: DATE OF REVIEW: NEXT REVIEW: AVERSE – We will endeavour to eliminate all but very lowest levels of risk that could jeopardise July 2020 Sept 2020 patient safety and experience BAF RISK: 3.2 – Lack of appropriate and/or effective arrangements in place to secure patient and public involvement in the planning, development and delivery of health and social care services. RATIONALE FOR IDENTIFIED RISK: Risk of there being a lack of appropriate and/or effective arrangements in place securing patient and public involvement in the planning, development and delivery of health and social care services. RISK RATING & MOVEMENT:
End of Score at Score at Score at Score at 2020/21 Final Risk Year Q1 Q2 Q3 Q4 Risk Target 7 (19/20) (20/21) (20/21) (20/21) (20/21) Target 6 6 6 4 4 5 4 (3 x 2) (3 x 2) (3 x 1) (3 x 1) 3 Risk Score 2 RATIONALE FOR CURRENT RISK SCORE: 1 Target Score Risk remains 6 (moderate impact, 3 x unlikely, 2); with the recent impact of Covid-19, 0 Final Risk Target and the inability to engage in traditional ways this has posed some challenges; it is End of Score at Score at Score at Score at suggested to monitor closely over the coming months with a view to increasing risk in Year Q1 Q2 Q3 Q4 Qtr 2 if alternative measures do not prove effective. Currently ongoing discussions (19/20) 2020/2021 taking place with our local community around how engagement will work going Position forwards, following the impact of the pandemic. Engagement conversations taking place with third sector and voluntary organisations to develop plans and pathways around how we can ensure the community continue to be involved and engaged in the work of the CCG; and ensure we continue to meet our legal duty to involve. Talkfest will continue to be our main engagement forum/ tool and plans currently in place to continue to run this during 2020 – making use of a wide range of tools including virtual technology. The Stakeholder Forum did continue to meet (virtually) during the pandemic, bringing together members to identify any lessons learnt during Covid-19. Work also continues with key CCG and LA teams (Primary Care, LA St Helens Together Team), around providing key messages and updates to the community on changes to services as well as gaining community feedback on worked well/ didn’t work well. Target for 2020/21 remains 4 (moderate impact, 3 x rare likelihood, 1). KEY WORK PROGRAMMES: Patient Engagement & Involvement Group (PEIG) Let’s Do It Together Campaign (Ongoing) St Helens Cares Stakeholder Forum St Helens Together Project Group (Ongoing) Community Talkfest (Quarterly Events) Individual Engagement/ Consultation 173 Working to the engagement and communications work plan Key areas of St Helens Cares KEY ACTIONS/ TIMESCALES: 1. Full utilisation of Insights Module including reporting – ongoing and will continue once transitioned to Ulysses. Delayed due to Covid-19, expected completion Quarter 4. 2. Internal discussions with members around how to capture external feedback (in place of the 360 Survey).
OPERATIONAL RISK EXPOSURE SUMMARY (Corporate Risks scoring 15 or above): There are currently no 15 or above risks associated with BAF risk 3.2
CONTROLS: ASSURANCES: Actions taken e.g. policies, processes, tasks, behaviours put in place to Sufficient appropriate evidence that a control is resulting in the desired outcome. mitigate/ manage a risk. LEVEL 1 Comms & Engagement Strategy in place (on website) LEVEL 1 Updates of strategy implementation progress to PEIG, and PEIG Operational PEIG oversee strategy implementation – Healthwatch Operational review of C&E Plans (Management) (Management) is a member Specific C&E plan to support CCG recovery programme. These Public & Patient Engagement through Talkfest Events plans have been drawn up with Commissioners and other engagement activities being used to Patient & Public Involvement in Commissioning Decisions – fed capture patient experience through PEIG before, during & after work completed Quality Strategy strengthened to include section on Patient & Public involvement in CCG’s Engage newsletter PPI, and use of patient stories Insights ‘Patient Experience’ module training delivered to PPI PMO process capturing all commissioning work Lead streams C&E plans Insights System has been rolled out across the CCG working on Staff training available around EIA/QI a number of difference modules. The patient experience Partnership working with neighbouring CCGs on a module is now in use, with Healthwatch data and other patient number of engagement/ consultation work experience feedback being captured. CCG website reviewed and updated for IAF submission – in addition to regular day-to-day review LEVEL 2 Regular updates provided through Quality Committee LEVEL 2 Ongoing engagement activity reporting to Quality Committee, Oversight and Governing Body Oversight and summary of PEIG action notes (Committees) (Committees) Stakeholder Forum established and meeting 6-weekly Strategy progress reports to Governing Body Level and quality of stakeholder engagement undertaken by CCG reviewed annually by NHSE via 360 survey – report to GB Healthwatch representation on Primary Care Committee LEVEL 3 Patient & Community Engagement Indicators within LEVEL 3 Feedback from last IAF submission (June 2019) fed into work Independent IAF and assessment – submitted Feb 2020 Independent streams and lessons learnt – Green rating awarded 2019. (Audit/ Reviews/ (Audit/ Reviews/ Inspections etc.) Inspections etc.) GAPS IN CONTROLS: GAPS IN ASSURANCES:
LEVEL 1 3600 Stakeholder Survey ended in 2018, no LEVEL 1 360 Survey provided a holistic view of stakeholder feedback on Operational alternative has been issued. Operational working with the CCG; no alternative method in place to capture (Management) (Management) this information. 174 LEVEL 2 LEVEL 2 Oversight Oversight ( (Committees) LEVEL 3 Awaiting IAF feedback (expected June/ July LEVEL 3 Independent 2020). Independent (Audit/ Reviews/ (Audit/ Reviews/ Inspections etc.) Inspections etc.)
175 BOARD ASSURANCE FRAMEWORK (BAF) 2020/21 OVERALL RISK APPETITE: “The CCG recognises that the long term sustainability of services in St Helens depend upon the delivery of the Improvement Plan, strategic objectives and its relationships with partners and the public. Therefore, whilst the CCG will not accept risks that materially impact on the safety or constitutional requirements of patient care, it has a greater appetite to take considered risks in terms of their impact on organisational issues, within our required frameworks. The CCG’s highest risk appetite relates to its transformational objectives”. STRATEGIC OBJECTIVE: DIRECTOR LEAD: DATIX ID: 3. To deliver improved outcomes for people Director of Public Health 397 OBJECTIVE SPECIFIC RISK APPETITE: DATE OF REVIEW: NEXT REVIEW: AVERSE – We will endeavour to eliminate all but very lowest levels of risk that could jeopardise July 2020 Sept 2020 patient safety and experience BAF RISK: 3.3 – Failure to tackle unwarranted variation across the borough. RATIONALE FOR IDENTIFIED RISK: Risk of there being unwarranted variation across the borough, and the CCG failing to commission services that contribute towards reducing health inequalities within the local economy. RISK RATING & MOVEMENT:
End of Score at Score at Score at Score at 2020/21 Final Risk 14 Year Q1 Q2 Q3 Q4 Risk Target 12 10 (19/20) (20/21) (20/21) (20/21) (20/21) Target 8 12 12 6 6 6 Risk Score (3x4) (3x4) (3 x 2) (3 x 2) 4 2 0 Target Score RATIONALE FOR CURRENT RISK SCORE: End of Score Score Score Score Final Risk Target There has been no significant improvement in variation based on current JSNA’s Year at Q1 at Q2 at Q3 at Q4 therefore the risk should remain at the current level. Early indications are that (19/20) Liverpool City region are likely to be hard hit by Covid and St Helens in particular may Position be affected, which could lead to further variation. As this evidence is clarified, this risk may increase. Life Expectancy both within the borough and with the borough and England as a whole has not significantly closed. Morbidity levels are still high for example high levels of depression, hypertension, diabetes, however some of this is positive as we are identifying people early and therefore can treat effectively. In relation to primary prevention we still have some way to reduce high levels of obesity, alcohol misuse, improve physical activity. However, there are some good outcomes and outputs being achieved around CVD, in relation to hypertension where St. Helens is proactive in identifying people with high blood pressure so they can be measured, identifying people pre diabetic and effectively managing and general positive management of people with CVD. There is still variation in outcomes across general practice and potentially could be variation across PCNs as each Network revises pathways. KEY WORK PROGRAMMES: Rightcare St Helens Cares Locality development and profiles PCN Clinical Director meetings RCP/AQUA work on obesity. Healthy Living programmes targeted by need KEY ACTIONS/ TIMESCALES: 1. Development of Locality Hubs – Underway but delayed due to Covid 2. Implementation of risk stratification business case discussed with Primary Care to fit in with the PCN pathways – June 2020 176 3. Development of community hub in Four Acre to improve – business case was underway in March 2020 but delayed due to Covid. 4. New work to use quality improvement methods in a geographical area to tackle obesity – March 2020 – delayed due to Covid 5. RightCare focus where packs highlight variation – ongoing as packs are issued – pathway changes are currently limited due to Covid and command/ control which means that no transformational pathway changes can take place 6. Primary Care Networks have had data shared about their highest risk patients. CCG met with CDs about risk strategy as noted in point 2 7. To produce a JSNA to examine the impact COVID on health inequalities in the Borough (Oct 2020) OPERATIONAL RISK EXPOSURE SUMMARY (Corporate Risks scoring 15 or above): There are currently no 15 or above risks associated with BAF risk 3.3 CONTROLS: ASSURANCES: Actions taken e.g. policies, processes, tasks, behaviours put in place to Sufficient appropriate evidence that a control is resulting in the desired outcome. mitigate/ manage a risk. LEVEL 1 The People’s Plan – action plans (5YF view plan) LEVEL 1 Annual Public Health Report Operational CCG Operational plans Operational Rightcare data highlights areas where CCG is not an outlier. (Management) (Management) Service redesign, reduction and cessation framework Equality impact reports and action plans produced for service changes Development of locality hubs and population risk stratification key projects within the St Helens Cares work programme Development of social prescribing model tackling wider social issues Ongoing working with Primary Care Networks Rightcare packs – processes in place to review packs LEVEL 2 Regular updates provided through Quality Committee LEVEL 2 HWBB Oversight (The Peoples Board) Oversight and Governing Body Oversight Constitutional Performance monitoring via CCG Quality and (Committees) (Committees) Performance Committee Scrutiny LEVEL 3 Cheshire & Merseyside Healthcare Partnership Plans LEVEL 3 Independent Independent (Audit/ Reviews/ (Audit/ Reviews/ Inspections etc.) Inspections etc.) GAPS IN CONTROLS: GAPS IN ASSURANCES:
LEVEL 1 Strategies and Policies need to systematically LEVEL 1 Current lack of ability to change pathways due to Covid. Operational reference degree to which health inequalities will be Operational (Management) (Management) reduced LEVEL 2 LEVEL 2 Oversight Oversight (Committees) (Committees) LEVEL 3 LEVEL 3 Independent Independent (Audit/ Reviews/ (Audit/ Reviews/ Inspections etc.) Inspections etc.)
177 BOARD ASSURANCE FRAMEWORK (BAF) 2020/21 OVERALL RISK APPETITE: “The CCG recognises that the long term sustainability of services in St Helens depend upon the delivery of the Improvement Plan, strategic objectives and its relationships with partners and the public. Therefore, whilst the CCG will not accept risks that materially impact on the safety or constitutional requirements of patient care, it has a greater appetite to take considered risks in terms of their impact on organisational issues, within our required frameworks. The CCG’s highest risk appetite relates to its transformational objectives”. STRATEGIC OBJECTIVE: DIRECTOR LEAD: DATIX ID: 3. To deliver improved outcomes for people Director of Public Health 398 OBJECTIVE SPECIFIC RISK APPETITE: DATE OF REVIEW: NEXT REVIEW: AVERSE – We will endeavour to eliminate all but very lowest levels of risk that could jeopardise July 2020 Sept 2020 patient safety and experience BAF RISK: 3.4 – Failure to support an effective approach to public health & prevention. RATIONALE FOR IDENTIFIED RISK: Risk of to being unable to change or influence the culture with respect to patients approach and responsibility to own health care.
RISK RATING & MOVEMENT:
End of Score at Score at Score at Score at 2020/21 Final Risk 14 Year Q1 Q2 Q3 Q4 Risk Target 12 (19/20) (20/21) (20/21) (20/21) (20/21) Target 10 Risk Score 9 12 6 6 8 (3x3) (3x4) (3 x 2) (3 x 2) 6 4 Target Score RATIONALE FOR CURRENT RISK SCORE: 2 With the COVID-19 pandemic the impact on the residents of St. Helens has been significant; 0 Final Risk whilst we have been focusing on the measures to protect the population from COVID-19 there Target have been significant other impacts – some of this is not yet realised. Mental Health and trauma are likely to have an impact, however social cohesion has increased. In order to understand the true impacts we need to collate intelligence and information to benchmark ourselves from previous years and against our neighbours.
Existing plans remain in place, some of which have been on pause; as part of recovery we will need to reset some of these plans and look at how we deliver interventions and engage with our communities with a COVID-19 lens
KEY WORK PROGRAMMES: Public Health Recovery/service Plans CCG long term plan and operational plan Prevention and Early intervention work stream, specifically social prescribing and development of community assets The People’s Plan – the priorities for the People’s Board have been approved as Mental health, Children and Young People’s Confidence and Resilience, Domestic Abuse and Cancer
178 KEY ACTIONS/ TIMESCALES: 1. Healthy Weight Strategy and development of a systems approach to obesity using the RCP QI team complete and being implemented but with delay 2. Alcohol Misuse Action Plan is being implemented with need to be refreshed in relation to service delivery and action impacted by COVID-19 3. Social Prescribing Model has been developed and implemented, however ongoing work is to embed the model with development of Primary Care Networks – continued support virtually throughout COVId 4. Review of Alcohol Liaison Service and implementation of new model based on national guidance – paused due to COVID 5. New Integrated Wellbeing Service – review of service delivery in light of COVID-19 OPERATIONAL RISK EXPOSURE SUMMARY (Corporate Risks scoring 15 or above): There are currently no 15 or above risks associated with BAF risk 3.4 CONTROLS: ASSURANCES: Actions taken e.g. policies, processes, tasks, behaviours put in place to Sufficient appropriate evidence that a control is resulting in the desired outcome. mitigate/ manage a risk. LEVEL 1 Integrated Commissioning plans LEVEL 1 Healthy Living Programmes have key performance monitoring Operational Public Health Service Plan Operational Key Local Care System Work Stream in place with Exec Lead (Management) (Management) Public Health contracts are in place and robustly assigned monitored Suicide Prevention Action Plan and social prescribing model are being actioned
LEVEL 2 Regular updates provided through Quality Committee LEVEL 2 HWBB Oversight (The Peoples Board) Oversight and Governing Body Oversight Performance monitoring via CCG Quality and Performance (Committees) (Committees) St Helens Cares priorities, plans and assurance Committee through St. Helens Cares Exec Board Scrutiny committee Updates to the People’s Board LEVEL 3 HWB Strategy (Peoples Plan) and actions to deliver LEVEL 3 JSNA Independent on key prevention priorities Independent (Audit/ Reviews/ (Audit/ Reviews/ Inspections etc.) Inspections etc.) GAPS IN CONTROLS: GAPS IN ASSURANCES:
LEVEL 1 There is little data on the population impacts of LEVEL 1 Prevention is not just about health care but the wider Operational behaviour change Operational determinants some of the impact is out of our control and (Management) (Management) Links with the wider determinants and economy relates to government policy, wider economic issues board Links back to primary care. LEVEL 2 LEVEL 2 Oversight Oversight (Committees) (Committees) LEVEL 3 LEVEL 3 Independent Independent (Audit/ Reviews/ (Audit/ Reviews/ Inspections etc.) Inspections etc.)
179 BOARD ASSURANCE FRAMEWORK (BAF) 2020/2021 OVERALL RISK APPETITE: “The CCG recognises that the long term sustainability of services in St Helens depend upon the delivery of the Improvement Plan, strategic objectives and its relationships with partners and the public. Therefore, whilst the CCG will not accept risks that materially impact on the safety or constitutional requirements of patient care, it has a greater appetite to take considered risks in terms of their impact on organisational issues, within our required frameworks. The CCG’s highest risk appetite relates to its transformational objectives”. STRATEGIC OBJECTIVE: DIRECTOR LEAD: DATIX ID: 3. To deliver improved outcomes for people Director of Commissioning 399 and Primary Care OBJECTIVE SPECIFIC RISK APPETITE: DATE OF REVIEW: NEXT REVIEW: AVERSE – We will endeavour to eliminate all but very lowest levels of risk that could jeopardise July 2020 Sept 2020 patient safety and experience BAF RISK: 3.5 – Failure to deliver estates strategy. RATIONALE FOR IDENTIFIED RISK: Risk of failure in achieving identified Estates strategy. Risk of premises in community and Primary Care not being fit for GP and community service needs.
RISK RATING & MOVEMENT:
End of Score at Score at Score at Score at 2020/21 Final Risk 10 Year Q1 Q2 Q3 Q4 Risk Target 8 (19/20) (20/21) (20/21) (20/21) (20/21) Target 6 9 9 6 6 4 Risk Score (3 x 3) (3 x 3) (3 x 2) (3 x 2) 2 0 Target Score RATIONALE FOR CURRENT RISK SCORE: End of Score at Score at Score at Score at Final Risk Target The risk did not achieve its 2019/20 target score of 6 (3x2); therefore that will remain Year Q1 Q2 Q3 Q4 the target score for 2020/21. However the risk did remain static throughout the year at (19/20) 9 (Possible, 3 x Moderate, 3). Lack of access to capital makes delivery of target Position difficult and whilst significant progress has been made on utilisation of buildings, there remain some buildings that need investment.
Strategic Estates Group is chaired by the CCG Chair, and attended by Director of Commissioning and Primary Care and partners of the Local Care System are represented at this group. The SEG has a mapped estate on a geographical information system and work has been completed to get updated utilisation information on buildings so that the SEG can have a clear understanding of what capacity the buildings have to support the transformation agenda of St Helens. Clear objectives within the Strategic Estates Plan have been developed that support the transformation required to deliver the St Helens Clinical Model. The ongoing work at St Helens is viewed as best practice by the CCG estates partner Renova, who own the LIFT sites. The CCG are now also represented on the Mid Mersey SEG. KEY WORK PROGRAMMES: Key estates work programmes include the development of Lowe house as midwifery led birthing unit which will provide improved services within St Helens and increase utilisation of the buildings. Funding has been sourced through CHP to adapt premises to support this development. Four Acre hub is also in development. The SEG are also considering Rainhill as an option for a hub and looking at use of the Millennium Centre and also better utilisation of all NHSPS and CHP sites. Some of these programmes have been held due to Covid 19, and the use of estate will change dramatically as a result. Initially, the 180 space requirements must meet social distancing guidelines, but longer term, the agile working that has developed throughout the pandemic will change the way we use estate. The SEG must now revise the Strategic estates Plan to consider this. KEY ACTIONS/ TIMESCALES: 1. Workshop with NAPC and CHP to support network estates strategies in Oct 19 and Dec 19 – estates strategy document launched nationally in Mar-20. 2. SEG to be re started post Covid – July 2020 3. Estates Strategy to be revised – Sept 2020 OPERATIONAL RISK EXPOSURE SUMMARY (Corporate Risks scoring 15 or above): There are currently no 15 or above risks associated with BAF risk 3.5 CONTROLS: ASSURANCES: Actions taken e.g. policies, processes, tasks, behaviours put in place to Sufficient appropriate evidence that a control is resulting in the desired outcome. mitigate/ manage a risk. LEVEL 1 Strategic Estates Group in place in St Helens LEVEL 1 Monitoring of progress against Strategic Estates Plan will be fed Operational Strategic Estates Strategy developed. Was reviewed Operational to Strategic Estates Group, evidenced by minutes of SEG (Management) (Management) at C&M HP level and incorporated into a Cheshire Notes from Renova GB meeting wide strategy that was assessed nationally as Good Minutes of Mid Mersey SEG CCG Director of Commissioning is NHS Public Sector Director of LIFT partner(Renova) to ensure appropriate support for development of estate is in place Utilisation studies have been done on key condition premises and are now being used to improve utilisation and used as a basis to develop Lowe House. NAPC led work to develop network estates strategies Project group on Lowe House is set up and meets regularly. Funding secured through CHP but work delayed due to Covid LEVEL 2 Regular updates provided through Finance & LEVEL 2 Performance monitoring via CCG Finance and Performance Oversight Performance Committee & Governing Body Oversight Committee and Governing Body (Committees) (Committees) St Helens Cares priorities, plans and assurance through St. Helens Cares Exec Board LEVEL 3 LEVEL 3 JSNA Independent Independent (Audit/ Reviews/ (Audit/ Reviews/ Inspections etc.) Inspections etc.) GAPS IN CONTROLS: GAPS IN ASSURANCES:
LEVEL 1 Building usage information for some NHSPS sites LEVEL 1 Funding to be secured for any estate transformation. Operational Operational (Management) Bridgewater estates costs are an ongoing dispute (Management) Lack of control re: GP owned premises Need to establish better links with LA Strategic Asset Group 181 LEVEL 2 LEVEL 2 Oversight Oversight (Committees) (Committees) LEVEL 3 LEVEL 3 Independent Independent (Audit/ Reviews/ (Audit/ Reviews/ Inspections etc.) Inspections etc.)
182 BOARD ASSURANCE FRAMEWORK (BAF) 2020/2021 OVERALL RISK APPETITE: “The CCG recognises that the long term sustainability of services in St Helens depend upon the delivery of the Improvement Plan, strategic objectives and its relationships with partners and the public. Therefore, whilst the CCG will not accept risks that materially impact on the safety or constitutional requirements of patient care, it has a greater appetite to take considered risks in terms of their impact on organisational issues, within our required frameworks. The CCG’s highest risk appetite relates to its transformational objectives”. STRATEGIC OBJECTIVE: DIRECTOR LEAD: DATIX ID: Objective 3: To deliver improved outcomes for people Dir of Commissioning/ Primary TBC Care/ Transformation OBJECTIVE SPECIFIC RISK APPETITE: DATE OF REVIEW: NEXT REVIEW: AVERSE - We will endeavour to eliminate all but very lowest levels of risk that could jeopardise July 2020 Sept 2020 patient safety and experience BAF RISK: 3.6 - Risk to provision and quality of service delivery to mental health patients in St Helens due to merger between North West Boroughs (NWB) and Merseycare – date of merger to be confirmed RATIONALE FOR IDENTIFIED RISK: The impact on provision and quality of service delivery to mental health patients in St Helens associated with this merger could potentially lead to both financial and quality concerns. RISK RATING & MOVEMENT:
End of Score at Score at Score at Score at 2020/21 Final Risk 20 Year Q1 Q2 Q3 Q4 Risk Target 15 (19/20) (20/21) (20/21) (20/21) (20/21) Target 10 16 12 8 4 Risk Score 4 x 4 4 x 3 4 x 2 4 x 1 5 Target Score 0 RATIONALE FOR CURRENT RISK SCORE: End of Score at Score at Score at Score at Final Risk Target The potential impact on service delivery associated with this merger leading to financial Year Q1 Q2 Q3 Q4 and quality concerns – including potential changes to service provision, changes to (18/19) (19/20) (19/20) (19/20) (19/20) staffing and management/ leadership, changes to patient quality of care, finance Position implications (around NWB current contract) and estates. A lot of unknown surrounding the merger currently. Context of detail not available yet, until more detail is available, risk is re-assessed as possible rather than likely. Covid has taken emphasis off merger in quarter 1 KEY WORK PROGRAMMES: The merger is at its very early stages. At this point the intention to merge has been shared but not detail of when and the project plans behind the merger. The CCG will ensure that it is fully sighted on all plans as they evolve and will continue to liaise closely with NWB Execs in the meantime. KEY ACTIONS/ TIMESCALES: As noted above, once the details on timescales are clear and project plans established, the CCG will establish actions and milestones
OPERATIONAL RISK EXPOSURE SUMMARY (Corporate Risks scoring 15 or above): The level of risk will only be fully clear when the CCG are sighted on project plans and timescales. They will be more fully reported at that time.
183 CONTROLS: ASSURANCES: Actions taken e.g. policies, processes, tasks, behaviours put in place to Sufficient appropriate evidence that a control is resulting in the desired outcome. mitigate/ manage a risk. LEVEL 1 Project plans to be shared with CCG as developed LEVEL 1 Project plans will include EIA and QIA Operational Ongoing liaison with NWB Exec team Operational (Management) (Management)
LEVEL 2 GB to be appraised of plans as they develop LEVEL 2 GB will be appraised of impact assessments as developed Oversight Oversight (Committees) (Committees) LEVEL 3 HSJ article published (indicates merger associated LEVEL 3 Independent with needing to be financially viable), to become Independent (Audit/ Reviews/ (Audit/ Reviews/ Inspections etc.) largest MH Trust in the country. Inspections etc.) GAPS IN CONTROLS: GAPS IN ASSURANCES:
LEVEL 1 No plans or timescales yet in place LEVEL 1 No timescales or detailed project plan in place yet to be able to Operational Operational fully assess impact (Management) (Management)
LEVEL 2 LEVEL 2 Oversight Oversight (Committees) (Committees) LEVEL 3 LEVEL 3 No impact assessment undertaken yet – so impact of merger Independent Independent unknown (Audit/ Reviews/ (Audit/ Reviews/ Inspections etc.) Inspections etc.) Timescales not clarified yet
184 BOARD ASSURANCE FRAMEWORK (BAF) 2020/2021 OVERALL RISK APPETITE: “The CCG recognises that the long term sustainability of services in St Helens depend upon the delivery of the Improvement Plan, strategic objectives and its relationships with partners and the public. Therefore, whilst the CCG will not accept risks that materially impact on the safety or constitutional requirements of patient care, it has a greater appetite to take considered risks in terms of their impact on organisational issues, within our required frameworks. The CCG’s highest risk appetite relates to its transformational objectives”. STRATEGIC OBJECTIVE: DIRECTOR LEAD: DATIX ID: 4. To be recognised as good system leaders Chief Finance Officer 429 OBJECTIVE SPECIFIC RISK APPETITE: DATE OF REVIEW: NEXT REVIEW: CAUTIOUS – We will take low risk options to enhance our standing as a system leader across July 2020 Sept 2020 Cheshire & Merseyside, though none that could threaten our financial position. BAF RISK: 4.5 – Failure to protect IT systems from threats emerging from cyber security. RATIONALE FOR IDENTIFIED RISK: The IT services and systems run by the HIS are coming under increased risk regarding service disruption as a result of potential cyber security attacks. A successful cyber-attack could result in the loss of data or system outage (including primary, secondary and community systems as well as local CCG IT systems) resulting in significant service disruption, harm to patients and financial loss. RISK RATING & MOVEMENT:
End of Score at Score at Score at Score at 2020/21 Final Risk 14 Year Q1 Q2 Q3 Q4 Risk Target 12 (19/20) (20/21) (20/21) (20/21) (20/21) Target 10 12 12 8 8 8 (4 x 3) (4 x 3) (4 x 3) (4 x 3) 6 Risk Score 4 2 Target Score RATIONALE FOR CURRENT RISK SCORE: 0 Final Risk Target Through national work following the cyber security incident in May 2018, cyber-attack End of Score at Score at Score at Score at processes have been put in place to enhance protection from these attacks. This Year Q1 Q2 Q3 Q4 work has continued to evolve in line with known threats and risk mitigation strategies. (19/20) It is recognised that it is not possible to totally eliminate the risk posed by cyber Position threat. The strategy is to minimise potential threats and disruption caused by these threats to the lowest possible level.
The CCG’s assessment of this risk is lower than STHK who provide our IT services as we do not have the same range and breadth of IT services as the trust. This CCG has established its target risk score of 12 (Consequence Major 4 x Likelihood Possible 3). The risk target for 2019/20 has remained at that level all year and will remain at 12 due to the key consequences being related to the principal data held in GP systems. Cyber security session undertaken in February 2020 by the CCG SIRO and senior managers, GB Awareness session undertaken in January 2020. Continued liaison with HIS partners over the wider cyber agenda in line with Cheshire & Merseyside colleagues.
Covid-19 has emphasised a greater degree of agile working and with it the technological controls and security aspects to be assessed in terms of cyber security. As a consequence the risk score has been kept at its year end level for Quarter 1 (2020/21). KEY WORK PROGRAMMES: Team of specialist (HIS) staff (including Cyber Resilience) & HIS plan in place to manage Cyber Security Risk; actively continuing to strengthen its cyber resilience through investment in new technologies/ dedicated HIS cyber response185 plan that was successfully tested during the ‘wanna cry’ attack (2017). Robust process in place for acting on CareCERT alerts providing the appropriate level of assurance to the Information Security Assurance Group which reports into the HIS Operational Group and HIS Board monthly (includes CCG representation)/ HIS have had an assessment of where they are up to in terms of cyber security and is developing a business case to reduce the chances of being affected by a cyber threat. Investment funding was awarded in 17/18 towards key priorities and this has been supplemented subsequently by the move towards Windows 10 platform and technology refresh of desktops and laptops. Regular updates provided by Director of Informatics at the HIS.
KEY ACTIONS/ TIMESCALES: 1. CCG secured funding for cyber security related investment over the last 3 years and this has been used to enhance systems of control at user end and in core IT infrastructure 2. Continued communications to all staff and practices on dangers regarding cyber threats
OPERATIONAL RISK EXPOSURE SUMMARY (Corporate Risks scoring 15 or above): There are currently no 15 or above risks associated with BAF risk 3.5 CONTROLS: ASSURANCES: Actions taken e.g. policies, processes, tasks, behaviours put in place to Sufficient appropriate evidence that a control is resulting in the desired outcome. mitigate/ manage a risk. LEVEL 1 Cyber Security Response Plan LEVEL 1 Report is sent to HIS Ops Board and HIS Board monthly Operational Dedicated staff responsible for cyber resilience Operational Care Cert collect data on security and patch management which (Management) (Management) Network Monitoring tools is reported to all partners Pact management Process Director of Informatics at HIS reports annually to F&P User communications informing users on potential Committee threats and how to stay safe CCG SIRO linked into operational elements of cyber threats Cyber essentials accreditation monitoring Information Security Assurance Group Increased understanding and awareness of SIRO, Board and Cyber security session for SIRO and senior managers Senior Managers held in Feb 2020 and GB Awareness session Jan Cheshire & Merseyside group set up in line with NHS Digital 2020 requirements to discuss issues on a monthly basis, attendance Continued communications to all staff and practices includes Trusts, CCGs, CSU and IT providers within Cheshire & on dangers regarding cyber threats Merseyside.
LEVEL 2 Regular updates provided through Finance & LEVEL 2 Performance monitoring via CCG Finance and Performance Oversight Performance Committee & Governing Body Oversight Committee and Governing Body (Committees) (Committees) HIS receive Care Cert alerts from NHS Digital and act on them in line with allowable timescales. This is reported to HIS Operational Group and HIS Board monthly LEVEL 3 Multiple, in place – further information can be LEVEL 3 Independent obtained via the SIRO as appropriate. Independent (Audit/ Reviews/ (Audit/ Reviews/ Inspections etc.) Inspections etc.)
186 GAPS IN CONTROLS: GAPS IN ASSURANCES:
LEVEL 1 New threats emerging that cannot always be guarded LEVEL 1 None identified Operational against Operational (Management) (Management) The system is reliant on awareness of users to not adopt unsafe practices Some patches are resource intensive and take time to apply fully and there are capacity issues to deal with all of the patches. They are prioritised on basis of potential impact. Interoperability means that networks are linked across the NHS. As seen in the threat in 2017, the system is only as strong as its weakest partner and one organisation being infected can quickly infect other linked systems LEVEL 2 None identified LEVEL 2 None identified Oversight Oversight (Committees) (Committees) LEVEL 3 None identified LEVEL 3 None identified Independent Independent (Audit/ Reviews/ (Audit/ Reviews/ Inspections etc.) Inspections etc.)
187 BOARD ASSURANCE FRAMEWORK (BAF) 2020/21 OVERALL RISK APPETITE: “The CCG recognises that the long term sustainability of services in St Helens depend upon the delivery of the Improvement Plan, strategic objectives and its relationships with partners and the public. Therefore, whilst the CCG will not accept risks that materially impact on the safety or constitutional requirements of patient care, it has a greater appetite to take considered risks in terms of their impact on organisational issues, within our required frameworks. The CCG’s highest risk appetite relates to its transformational objectives”. STRATEGIC OBJECTIVE: DIRECTOR LEAD: ULYSSES ID: Objective 4: To be recognised as good system leaders Clinical Accountable TBC Officer OBJECTIVE SPECIFIC RISK APPETITE: DATE OF REVIEW: NEXT REVIEW: CAUTIOUS: We will take low risk options to enhance our standing as a system leader across Cheshire & July 2020 Sept 2020 Merseyside, though none that could threaten our financial position BAF RISK: 4.7 – Reputational risk to CCG in failing to have appropriate planning and partnership working in place to manage the Coronavirus (Covid-19) pandemic
RATIONALE FOR IDENTIFIED RISK: Continuing increase in number of suspected and confirmed Covid-19 cases across the country, CCG needs to ensure it has in place appropriate plans, including business continuity arrangements to manage a pandemic, should it happen. RISK RATING & MOVEMENT:
End of Score at Score at Score at Score at 2020/21 Final Risk 14 Year Q1 Q2 Q3 Q4 Risk Target 12 (19/20) (20/21) (20/21) (20/21) (20/21) Target 10 12 4 4 8 (4x3) (2x2) (2x2) 6 Risk Score
4 Target Score RATIONALE FOR CURRENT RISK SCORE: 2 Risk scored around reputational impact – consequence scored as major (Criticism or 0 Final Risk Target intervention by NHSE, risk of adverse national media/ adverse public reaction and significant membership dissatisfaction) 4 x 3 (possible) = 12. Controls in place as below and numerous key work programmes in place to ensure up to date, consistent messages are being sent out. Corporate level risks added to Quality Committee, Primary Care Commissioning Committee, Finance & Performance Committee and ELT Governance Committee to provide overview of each risk area.
KEY WORK PROGRAMMES: Integrated Executive Leadership Team (SHIPS) Integrated Comms & Engagement Sub Group CCG Pandemic Management Team Knowsley & St Helens Integrated Comms & Engagement Sub Group Integrated Incident Management Team Weekly Covid-19 webinars (operational) Knowsley & St Helens Incident Management Team (Knowsley CCG & LA, Bi-weekly NW & National Comms & Engagement webinars/tele- St Helens CCG & LA, North West Boroughs and STHK) conferences Local Resilience Forum Meetings Regular C&M Chief Nurses tele-conferences
188 KEY ACTIONS/ TIMESCALES: Completion of NHSE Scenario Exercises & SitRep reporting as required
OPERATIONAL RISK EXPOSURE SUMMARY (Corporate Risks scoring 15 or above): N/A CONTROLS: ASSURANCES: Actions taken e.g. policies, processes, tasks, behaviours put in place to Sufficient appropriate evidence that a control is resulting in the desired outcome. mitigate/ manage a risk. LEVEL 1 Integrated Executive Leadership Team (SHIPS) LEVEL 1 Integrated approach established – enabling joint decision Operational Integrated Incident Management Team convened (LA Operational making and consistent actions/ messages (Management) (Management) Director of PH, CCG EPRR Lead (AD: Corporate Key actions identified and owners assigned, timescales set Governance) and representatives from Comms & Business Continuity Plan has been reviewed and assurance Engagement, Primary Care, Commissioning and PH, received that covers potential pandemic meeting weekly Oversight across local and neighbouring areas, plus national CCG Pandemic Management Team control centre & oversight meetings to complete NHSE Scenarios Consistent messages across the patch Knowsley & St Helens Incident Management Team Local Testing Capacity enabled within St Helens (St Helens (Knowsley CCG & LA, St Helens CCG & LA, North Hospital), and with partners Knowsley CCG (Community West Boroughs and STHK) Service) Integrated Comms & Engagement Sub Group Knowsley & St Helens Integrated Comms & Engagement Sub Group Weekly Covid-19 webinars (operational) Bi-weekly National Comms & Engagement webinars Bi-weekly North West Comms & Engagement teleconferences Covid-19 action plan developed CCG Business Continuity Plan in place LEVEL 2 ELT Committee (weekly) LEVEL 2 Integrated team ensures consistent messages/ actions across Oversight Oversight CCG & LA for population of St Helens (Committees) (Committees) LEVEL 3 NHSE Sitrep returns being completed as required LEVEL 3 Cheshire & Merseyside statistics fed into national data sets Independent Suite of webinars/ teleconferences underway (NHS, Independent Webinars providing updates around processes and guidance (Audit/ Reviews/ (Audit/ Reviews/ Inspections etc.) PHE) around comms, provider assurance and system Inspections etc.) Oversight across local and neighbouring areas, plus national working oversight Partnership working between St Helens and Knowsley around drawing up the specification for community testing NHSE/I returns on workforce risk assessments
189 GAPS IN CONTROLS: GAPS IN ASSURANCES:
LEVEL 1 LEVEL 1 Operational Operational (Management) (Management) LEVEL 2 LEVEL 2 Oversight Oversight (Committees) (Committees) LEVEL 3 No vaccine currently in place LEVEL 3 Independent Independent (Audit/ Reviews/ (Audit/ Reviews/ Inspections etc.) Inspections etc.)
190 BOARD ASSURANCE FRAMEWORK (BAF) 2020/21 OVERALL RISK APPETITE: “The CCG recognises that the long term sustainability of services in St Helens depend upon the delivery of the Improvement Plan, strategic objectives and its relationships with partners and the public. Therefore, whilst the CCG will not accept risks that materially impact on the safety or constitutional requirements of patient care, it has a greater appetite to take considered risks in terms of their impact on organisational issues, within our required frameworks. The CCG’s highest risk appetite relates to its transformational objectives”. STRATEGIC OBJECTIVE: DIRECTOR LEAD: DATIX ID: 5. To support and transform primary care to be a system leader in St Helens Cares To be Dir of Commissioning/ 454 recognised as good system leaders Primary Care/ Transformation OBJECTIVE SPECIFIC RISK APPETITE: DATE OF REVIEW: NEXT REVIEW: HUNGRY – We will actively support innovative and pioneering approaches that may lead to July 2020 Sept 2020 demonstrable transformation of primary care services in St Helens BAF RISK: 5.2 – Unrealistic demand and expectations of patients leading to an inability to address legitimate clinical need RATIONALE FOR IDENTIFIED RISK: Still some lack of patient and public awareness and education around alternative options to General Practice e.g. self-care, social prescribing, care navigation etc. RISK RATING & MOVEMENT:
End of Score at Score at Score at Score at 2020/21 Final Risk 10 Year Q1 Q2 Q3 Q4 Risk Target 8 (19/20) (20/21) (20/21) (20/21) (20/21) Target 6 8 8 6 6 4 Risk Score (4 x 2) (4 x 2) (3 x 2) (3 x 2) 2 Target Score 0 RATIONALE FOR CURRENT RISK SCORE: End of Score at Score at Score at Score at Final Risk Target Risk met it’s 2019/20 target score of 8; as whilst there is still some lack of patient and Year Q1 Q2 Q3 Q4 public awareness and education around alternative options to General Practice e.g. (19/20) self-care, social prescribing, care navigation etc., there has been a significant increase Position in patient on line activity. This may have been impacted positively by COVID 19 and the changes practices had to introduce. Public awareness and Education to alternative skill mixes and Digital initiatives will continue during 20/21. Overall target lowered to 6. KEY WORK PROGRAMMES: Patient on-line programme CCG Public Engagement campaign Q3 and Q4 Year 19/20 On-Line Consultations project Signposting Website for practices Reception & Clerical staff training Sustainability LES with practices KEY ACTIONS/ TIMESCALES: 1. Promotion via Signposting Website of NHS app and other Digital initiatives such as Video and on-line consultations. Q1 20/21 2. Support to Practices in the Recruitment of Additional Roles as part of the Additional Role Reimbursement Scheme 20/21 3. PPGs to move to Network footprint Q2 20/21 4. Increase Digital initiatives, On-line consultations/Video Consultations Q2 20/21 OPERATIONAL RISK EXPOSURE SUMMARY (Corporate Risks scoring 15 or above): There are currently no 15 or above risks associated with BAF risk 5.2 191 CONTROLS: ASSURANCES: Actions taken e.g. policies, processes, tasks, behaviours put in place to Sufficient appropriate evidence that a control is resulting in the desired outcome. mitigate/ manage a risk. LEVEL 1 Care Navigation/Signposting Training in place for LEVEL 1 Annual Public Engagement programme in place Operational Reception & Clerical staff – event held Nov 19 PLT Operational Training delivered to Reception staff to increase numbers of (Management) (Management) New Contract awarded for the implementation of patient on line usage and effective signposting to appropriate On-Line Consultations – All Practices now live services. Practices have been issued new IT kit to support Practices conducting a total triage system (whether by phone Remote working. This also allows practices to or online minimise face to face appointments as far as Communications and Engagement work on-going to promote possible utilising remote technology. NHS choices available to residents Each practice has access to remote working and New Contract awarded for the implementation of On-Line Video consultations Consultations – All practices now live Signposting Website currently 31 practices live with Funding available to include video consultations signposting website Social Prescribing – working with public health to get social St Helens Cares early Intervention & Prevention prescribers in each network work programme Four Networks signed up to participate in Network DES for Promotion through social media, ensuring 20/21 consistent messages are sent. Increased knowledge/ understanding of Reception staff to Communication plan in place to promote access to increase numbers of patient on line usage and effective on-line services and Communications and signposting to appropriate services. Engagement work on-going to promote new ways of Implementation of signposting website indicates 9480 phone working in General Practice calls avoided, 6242 visits avoided and 1374 appointments Annual Public Engagement programme in place and avoided engagement events to promote topics including, Additional Roles will be reimbursed at 100% of actual salary, self- care/staywell, using the right urgent care up to the maximum reimbursable amounts services at the right time Additional Roles include, Clinical Pharmacists, Social Link Working in Partnership with Healthwatch and VCA Prescriber, First Contact physiotherapist, Physician Associate, PPG Forum, and Practice PPG’s Pharmacy Technician, Occupational therapist, Dietician, A&E Board & STP Level Comms & Engagement Podiatrists, Health and Wellbeing Coaches programmes linked in 2 Networks have appointed Clinical Pharmacists, 1 Network Work on-going to support Social Prescribing appointed Social Link Prescriber GP sustainability LES Integrated Urgent Care System Direct Booking from NHS 111 now a Contractual requirement. – Practices subject to KPIs Community Pharmacy Consultation Service - Pilot in Newton & Haydock ended March 2020 Additional Role Reimbursement Scheme enhanced for 20/21 to include a further 6 roles – work on-going to support Networks with Contracts and Recruitment LEVEL 2 Regular updates provided through Primary Care LEVEL 2 Performance monitoring via CCG Primary Care Commissioning Oversight Commissioning Committee & Governing Body Oversight Committee and Governing Body (Committees) (Committees) Four Networks participating in 20/21 Network 192 Directed Enhanced Service LEVEL 3 None identified LEVEL 3 None identified Independent Independent (Audit/ Reviews/ (Audit/ Reviews/ Inspections etc.) Inspections etc.) GAPS IN CONTROLS: GAPS IN ASSURANCES:
LEVEL 1 Effectiveness of individual PPG’s LEVEL 1 Operational Operational (Management) Unrealistic demand during Out of Hours (Rota) (Management) Slow progression to recruit Additional Roles
LEVEL 2 None identified LEVEL 2 None identified Oversight Oversight (Committees) (Committees) LEVEL 3 None identified LEVEL 3 None identified Independent Independent (Audit/ Reviews/ (Audit/ Reviews/ Inspections etc.) Inspections etc.)
193 BOARD ASSURANCE FRAMEWORK (BAF) 2020/21 OVERALL RISK APPETITE: “The CCG recognises that the long term sustainability of services in St Helens depend upon the delivery of the Improvement Plan, strategic objectives and its relationships with partners and the public. Therefore, whilst the CCG will not accept risks that materially impact on the safety or constitutional requirements of patient care, it has a greater appetite to take considered risks in terms of their impact on organisational issues, within our required frameworks. The CCG’s highest risk appetite relates to its transformational objectives”. STRATEGIC OBJECTIVE: DIRECTOR LEAD: DATIX ID: 5. To support and transform primary care to be a system leader in St Helens Cares To be Dir of Commissioning/ 455 recognised as good system leaders Primary Care/ Transformation OBJECTIVE SPECIFIC RISK APPETITE: DATE OF REVIEW: NEXT REVIEW: HUNGRY – We will actively support innovative and pioneering approaches that may lead to May 2020 July 2020 demonstrable transformation of primary care services in St Helens BAF RISK: 5.3 – Without effective Primary Care engagement and support St Helens will compromise its ability to deliver the St Helens Cares strategy. Additionally lack of clinically led involvement in the design of transformational programmes in Primary Care will impact on the long term sustainability of practices. RATIONALE FOR IDENTIFIED RISK: Practices remain unable to sustain without transformation and collaborative working at scale. Networks not yet all working at scale and at early stages of maturity in terms of new models of care and alternative workforce. RISK RATING & MOVEMENT:
End of Score at Score at Score at Score at 2020/21 Final Risk 15 Year Q1 Q2 Q3 Q4 Risk Target (19/20) (20/21) (20/21) (20/21) (20/21) Target 10 12 12 8 8 Risk Score 5 (4 x 3) (4 x 3) (4 x 2) (4 x 2) Target Score 0 Final Risk Target RATIONALE FOR CURRENT RISK SCORE: In recognition of the significant progress made with the development of Networks and Network Leads actively engaging with NAPC to look at designing their workforce around Health Population Needs, the risk was reduced to 12 (4x3) for end of March 2020, falling short of its target score of 8 (4 x 2). Practices remain unable to sustain without transformation and collaborative working at scale. KEY WORK PROGRAMMES: St Helens Cares Programme Board Development of Locality Model GP Members Council Improved Access CCG Primary Care strategy Clinical Director and PCN Development support KEY ACTIONS/ TIMESCALES: 1. Locality Steering group set up to develop locality model 2. NHSE Funding available for Primary Care Networks, Four Networks signed to participate in the 20/21 DES 3. The CCG will continue to provide clinical support in the Recruitment process for the International GP Recruitment Programme. 4. CCG will continue to support networks. Networks also receiving support from NAPC on population health and estates. 5. Networks scheduled to meet every 6 weeks to streamline processes and policy’s and share working across the Networks 6. PCN Maturity matrix completed by networks and evaluated – Development Funding available upon submission of plans 194 7. All Networks signed up to participate in Network DES 20/21 8. CCG represented on PCN Development Fund Board to ensure support is used effectively for networks. OPERATIONAL RISK EXPOSURE SUMMARY (Corporate Risks scoring 15 or above): No risks scoring 15+ identified. CONTROLS: ASSURANCES: Actions taken e.g. policies, processes, tasks, behaviours put in place to Sufficient appropriate evidence that a control is resulting in the desired outcome. mitigate/ manage a risk. LEVEL 1 Engagement and active learning at PLT’s LEVEL 1 Maturity matrix completed by each network and evaluated Operational PCN network maturity matrix completed and Operational Additional Roles will be reimbursed at 100% of actual salary, (Management) (Management) evaluated up to the maximum reimbursable amounts CCG link with Clinical directors of each network. The Clinical Director from North is a member of the St Shared/Collaborative Working (at scale), Primary Helens Cares Executive Board, ensuring that PCNs are Care Networks represented in system wide discussions. Funding for Primary Care Networks through network Additional Roles include, Clinical Pharmacists, Social Link DES Prescriber, First Contact physiotherapist, Physician Funding from NHSE for Network transformation and Associate, Pharmacy Technician, Occupational therapist, development plans Dietician, Podiatrists, Health and Wellbeing Coaches Clinical Directors agreed to Lead on Integration with 2 Networks have appointed Clinical Pharmacists, 1 Network Community Stakeholders appointed Social Link Prescriber Additional funding allocated to ICS/STP for in-year Shared Records in place delivery of PCN development support. CCG Work on-going through St Helens Cares to strengthen and represented on the PCN development fund board remodel local community services delivered in partnership Localities steering group set up to develop locality by integrated teams working across the system and model. embracing new ways of working Additional Role Scheme Enhanced 6 more roles Locality Model progressing introduced for 20/21 Networks established & funding available from NHSE to Network Managers supporting Clinical Directors support their development Shared Records in place Localities structured with a Primary Care Network Manager Work on-going through St Helens Cares to and GB GP assigned to each. strengthen and remodel local community services Networks signed up to participate in Network Directed delivered in partnership by integrated teams working Enhanced Scheme for 20/21 across the system and embracing new ways of New clinical model of support implemented for Care Homes working Two St Helens Networks participated in the development of Networks aligned to all Care Homes an estates strategy - Critical thinking in developing an estates strategy. This was launched by NHSE/I/CHP/NAPC in March 2020 LEVEL 2 Engagement with Primary Care at Members Council LEVEL 2 Performance monitoring via CCG Primary Care Commissioning Oversight Regular updates provided through Primary Care Oversight Committee and Governing Body (Committees) (Committees) Commissioning Committee & Governing Body LEVEL 3 None identified LEVEL 3 None identified Independent Independent (Audit/ Reviews/ (Audit/ Reviews/ Inspections etc.) Inspections etc.) 195 GAPS IN CONTROLS: GAPS IN ASSURANCES:
LEVEL 1 Practices in early stages of working at scale LEVEL 1 All Practices need to commit to transformation and the work Operational Operational being driven by St Helens Cares. (Management) Low participation/uptake of Additional Roles (Management)
LEVEL 2 None identified LEVEL 2 None identified Oversight Oversight (Committees) (Committees) LEVEL 3 None identified LEVEL 3 None identified Independent Independent (Audit/ Reviews/ (Audit/ Reviews/ Inspections etc.) Inspections etc.)
196 BOARD ASSURANCE FRAMEWORK (BAF) 2020/21 OVERALL RISK APPETITE: “The CCG recognises that the long term sustainability of services in St Helens depend upon the delivery of the Improvement Plan, strategic objectives and its relationships with partners and the public. Therefore, whilst the CCG will not accept risks that materially impact on the safety or constitutional requirements of patient care, it has a greater appetite to take considered risks in terms of their impact on organisational issues, within our required frameworks. The CCG’s highest risk appetite relates to its transformational objectives”. STRATEGIC OBJECTIVE: DIRECTOR LEAD: DATIX ID: 5. To support and transform primary care to be a system leader in St Helens Cares Dir of Commissioning/ Primary 699 Care/ Transformation OBJECTIVE SPECIFIC RISK APPETITE: DATE OF REVIEW: NEXT REVIEW: HUNGRY – We will actively support innovative and pioneering approaches that may lead to July 2020 Sept 2020 demonstrable transformation of primary care services in St Helens BAF RISK: 5.6 - Risk that Primary Care Networks will be unable to deliver key work programmes due to their maturity at the time of contract implementation.
RATIONALE FOR IDENTIFIED RISK: Primary Care Networks are an essential building block of every Integrated Care System, and under the Network Contract DES, General Practice takes the leading role in every PCN. Clinical Directors will play a critical role in shaping and supporting their Integrated Care System and historic divide between primary and community services – without effective Primary Care engagement and support, St Helens Networks may compromise its ability to deliver the St Helens Cares strategy. On-going Development and support to the Networks is essential to transform primary care and enable them to be system leaders in the St Helens Cares model. RISK RATING & MOVEMENT:
End of Score at Score at Score at Score at 2020/21 Final Risk 15 Year Q1 Q2 Q3 Q4 Risk Target 10 (19/20) (20/21) (20/21) (20/21) (20/21) Target 12 8 4 4 5 Risk Score (4 x 3) (4 x 2) (4 x 1) (4 x 1) 0 Target Score
End of Score at Score at Score at Score at RATIONALE FOR CURRENT RISK SCORE: Final Risk Target Year Q1 Q2 Q3 Q4 While there has been significant progress in the Development of the Networks, (19/20) due to the maturity of Networks at the time of contract implementation, concerns Position regarding ability of networks to deliver key work programmes. Slow to progress with Integration with Community Teams.
KEY WORK PROGRAMMES: Network Contract Directed Enhanced Service CCG & Network Clinical Director meetings Regular Network Meetings NHSE support programmes in Network Development NAPC support in developing the maturity of the Networks Support on Data Sharing Agreements St Helens Cares Programme Board Maturity matrix completion and review Quality Improvement Audits
197 KEY ACTIONS/ TIMESCALES: PCN Development Support Guidance and a support prospectus was shared with all Clinical Directors and each network submitted its Maturity Matrix to NHSE/I by the deadline of 29th November 2019. Since then further funding has now been released to support the continued development of the networks. Details have been shared with the 4 Clinical Directors, who will now be required to submit plans showing how the funding will be used. Recruitment Plans to be submitted to the CCG by the end of August CCG to confirm the estimated underspend for redistribution to other PCNs Following the national consultation a number of changes have been made to the national service specifications and only the following 3 will be introduced in 20/21: Structured Medication Reviews and Optimisation (Deferred until October 2020) Enhanced Health in Care Homes Supporting Early Cancer Diagnosis, The Anticipatory Care and Personalised Care specifications have been deferred until 21/22. QOF Quality Improvement Domain 20/21 - The Quality Improvement Indicators for 20/21 are: Early Cancer Diagnosis and Learning Disability Health Checks OPERATIONAL RISK EXPOSURE SUMMARY (Corporate Risks scoring 15 or above): There are currently no 15 or above risks associated with BAF risk 5.6 CONTROLS: ASSURANCES: Actions taken e.g. policies, processes, tasks, behaviours put in place to Sufficient appropriate evidence that a control is resulting in the desired outcome. mitigate/ manage a risk. LEVEL 1 Regular Network meetings - CCG Support offered LEVEL 1 All Networks signed up to participate in 20/21 DES Operational Network Agreements & Contract Schedules in Operational Issues/ areas of support identified during Network meetings (Management) (Management) place Clear framework in place through agreements/ schedules/ Clinical Directors and nominated Payee agreed boundary maps/ identified leads (Directors) for each Network 2 Networks have appointed Clinical Pharmacists Boundary Maps agreed for each Network 1 Network appointed Social Link Prescriber Network Managers supporting Networks. Priority Population Health areas agreed for two Networks Roll out of Apex/ Insight workforce/ workload tool Maturity Matrix completed for each Network and Evaluated enabling sharing of Data across Network Additional Roles will be reimbursed at 100% of actual salary, PC Team providing support in determining up to the maximum reimbursable amounts workforce additional roles reimbursement scheme Additional Roles include, Clinical Pharmacists, Social Link NAPC support provided Two Networks have had Prescriber, First Contact physiotherapist, Physician Population Health Workshops with NAPC and Associate, Pharmacy Technician, Occupational therapist, have agreed priority areas Dietician, Podiatrists, Health and Wellbeing Coaches Sustainability Local Enhanced Service offered to Networks signed up to participate in Network Directed Networks for 19/20 – All submitted action plans Enhanced Scheme for 20/21 Quality Improvements required this year are New clinical model of support implemented for Care Homes supporting early cancer diagnosis and improving All Care Homes aligned to Networks care of people with a learning disability Two St Helens Networks participated in the development of 2 Networks expressed an interest in Productive an estates strategy - Critical thinking in developing an GP estates strategy. This was launched by NHSE/I/CHP/NAPC Additional Role Scheme Enhanced 6 more roles in March 2020 198 introduced for 20/21 Signposting Websites on a locality footprint Clinical Directors agreed to Lead on Integration Development plans for spend of population share received with Community Stakeholders for two Networks Workforce planning template shared with Clinical Directors
LEVEL 2 Regular updates provided through PCCC and GB LEVEL 2 Effective challenge and discussion held at Governing Body Oversight 2nd October meeting - Director of Commissioning, Oversight level, Committee level and local NHSE level (Committees) (Committees) Primary Care and Transformation, Clinical Directors, Assistant Director of Primary Care and GB GPs LEVEL 3 NHSE Legislation and Guidance LEVEL 3 Independent Peer benchmarking and best practice comparison Independent (Audit/ Reviews/ (Audit/ Reviews/ Inspections etc.) Engagement with key stakeholders & providers Inspections etc.) GAPS IN CONTROLS: GAPS IN ASSURANCES:
LEVEL 1 Practices in early stages of working at scale LEVEL 1 Operational Operational (Management) Low participation/uptake of Additional Roles (Management) Slow progress on Development of Network due to impact of COVID 19 on practices
LEVEL 2 None identified LEVEL 2 None identified Oversight Oversight (Committees) (Committees) LEVEL 3 None identified LEVEL 3 None identified Independent Independent (Audit/ Reviews/ (Audit/ Reviews/ Inspections etc.) Inspections etc.)
199 200 Report to NHS St Helens CCG Governing Body Date of meeting: 8th July 2020
Governing Body Member Lead: Iain Stoddart – Chief Finance Officer
Accountable Director: Iain Stoddart – Chief Finance Officer
Report title: Financial Performance – May 2020
Item for: Decision Assurance Information X (Please insert X as appropriate)
This report supports the following CCG Strategic Objectives. Please insert ‘x’ as appropriate.
1. To deliver financial stability X 2. To integrate health within the place of St Helens through system redesign
Strategic 3. To deliver improved outcomes for people Objectives 4. To be recognised as good system leaders 5. To support and transform primary care to be a system leader in St Helens
Does this report provide assurance against any of the risks identified in the Assurance Framework? (please specify)
Objective 1: To deliver financial sustainability
1.1 Failure to meet statutory financial duties 1.2 Excessive demand not being managed 1.3 Failure to identify and deliver QIPP & Recovery Programme
What level of assurance does it provide? (List levels i.e. Limited/Reasonable/Significant)
Significant
Governance and Risk Is this report required under NHS guidance or for statutory purpose? (please specify)
The CCG has a responsibility to adhere to statutory financial duties and in-year financial control duties set by NHS England.
Purpose of this paper
To inform the Governing Body of the CCG financial performance for the first two months of the financial year under the current financial regime.
201 Further explanatory information required:
Does this paper link to any of the key themes of the CCG’s N/A – as operational planning has been suspended at this Operational Plan & Improvement time Plan. If yes, please specify.
How will this benefit the health Any potential changes to services as a result of and wellbeing of St Helens information contained within this paper are subject to the residents or the Clinical equality impact assessment and quality impact Commissioning Group? assessment of the CCG.
Please describe any possible Conflicts of Interest associated None with this paper.
Please identify any current Existing services will be impacted by the need to prioritise services or roles that may be interim and emergency services in response to the affected by issues within this COVID-19 virus. paper.
What risks may arise as a result Specific risks are detailed in the report. The CCG has of this paper? How can they be assumed full reimbursement of COVID related costs and mitigated? additional expenditure incurred through allocation adjustments.
1. Executive Summary
The CCG reported a deficit of £17.977 million against a total allocation of £358.847 million for the 2019/20 financial year
In March 2020 the Governing Body agreed to a plan of £26.8m deficit for 2020/21 as part of a 4 year approach to financial recovery.
Following the COVID-19 crisis, the financial regime for 2020/21 was put on hold nationally and a system introduced to ensure all Trusts and CCGs remained in financial balance for an initial period of four months from April to July 2020. All PBR payments to Trusts have been replaced with block payments with any additional expenditure requirements reimbursed by NHSE/I as a retrospective top up including costs relating to COVID. A similar position of retrospective top ups exist for CCGs.
The CCG received centrally calculated income allocations and expenditure assumptions for the 4 month period April to July 2020 which it has used to form its operational budgets.
The CCG mandated budgets, in comparison to local expenditure assumptions for Business As Usual (BAU) operations, highlighted additional financial requirements of £309k per month requiring top up. In addition Covid-19 specific expenditure, predominantly relating to the cost of hospital discharges, has cost £1,385k as at month 2.
Overall for April and May there have been £2,039k in top-ups requested from NHSE/I to ensure the
202 CCG breaks even. This position is expected to continue into June and July.
Further information on the continuation of the current financial regime, post July, is expected as part of Phase 3 Planning Guidance to be published by NHSE/I.
2. Recommendations
The Governing Body is asked to note: a. the mandated budget position and the financial performance to May 2020; b. the Covid-19 related expenditure reported as at month 2. c. the forecast position for this 4 month period, and the additional financial risks;
203 DOCUMENT DEVELOPMENT
Process Yes No N/A Comments & Date Outcome (i.e. presentation, verbal, actual report) Public Engagement (please detail N/A the method i.e. survey, event, consultation)
Clinical Engagement (please N/A detail the method i.e. survey, event, consultation)
Has ‘due regard’ been given to N/A Equality Analysis (EA) and any adverse impacts? (Please detail outcomes, including risks and how these will be managed)
Legal Advice Sought N/A
Presented to any other groups Yes Detailed finance position or committees including has been noted and Partnership Groups – reviewed by: Internal/External (please specify • Executive Noted in comments) Leadership Team
17/6/20
• Finance & Noted Performance
Committee 24/6/20
Annual accounts and Approved Annual Report presented to Audit Committee 23/6/20
Note: Please ensure that it is clear in the comments and date column how and when particular stakeholders were involved in this work and ensure there is clarity in the outcome column showing what the key message or decision was from that group and whether amendments were requested about a particular part of the work.
204 Finance Performance Update May 2020
1. 2019/20 Final Accounts 1.1. The audit of the final accounts and annual report for 2019/20 has now concluded, and were approved by the Audit Committee on 23 June 2020.
1.2. From the drat accounts position there were no adjustments made and the final reported position was a deficit of £17.977 million against a total allocation of £358.847 million. The audit concluded that there were no unadjusted material misstatements and thus gave an unqualified opinion on the financial statements and annual report
1.3. As part of their Value for Money review, Audit concluded that the CCG has proper arrangements to secure economy, efficiency and effectiveness in its use of resources, “except for” in relation to sustainable resource deployment. This is a positive response bearing in mind the challenging financial position, but due to the deficit position breaching the budget and control total the auditors had to give a qualified opinion Equally auditors were required to submit a section 30 report to the Secretary of State for Health.
2. 2020/21 Budgets
2.1. Following the COVID-19 crisis, the financial regime for 2020/21 was put on hold nationally and a system introduced to ensure all CCGs remained in financial balance for an initial period of four months from April to July 2020.
2.2. The CCG received centrally calculated income allocations and expenditure assumptions for the 4 month period April to July 2020 which it has used to form its operational budgets. Finance & Performance Committee have discussed these budget allocations at their May and June meetings.
2.3. These budgets are based on the CCG reported expenditure forecast as at month 11 in 2019/20 and uplifted by nationally calculated assumptions for cost and growth increases. They are further adjusted to take account of the block arrangements currently in place for NHS providers and also for the temporary changes to Independent Sector contracts.
2.4. The aim of these mandated budgets is to ensure that the CCG is able to present a balanced budget on the basis that expenditure levels experienced throughout 2019/20 will continue for this period. In their calculation, NHS England identified a shortfall between their estimate of the CCGs expenditure requirements and existing national allocations. This was adjusted within the 4 month allocated budget to ensure the CCG could plan for a balanced financial position. This was a positive adjustment of £518k per month; £2,072k across the period April to July.
2.5. However a review of the national methodology compared with local expenditure needs has identified a further financial shortfall estimated at £309k per month; a total of £1,234k over this four month period. This has been raised with NHS England for further consideration as part of the monthly additional expenditure reclaim.
2.6. Specific expenditure related to the Covid-19 response is reported separately to NHS England. The CCG is expecting that this expenditure will also be reimbursable in addition to the monthly financial shortfalls outlined in 2.5 above.
2.7. It should be noted that for the first 4 months of operation, NHSE/I have not allowed for local service developments or for any contingency provision.
205
3. Month 2 Position
3.1. The cumulative net financial position as at the end of May (Month 2) is largely in line with expectations after taking account of the additional costs associated with the Covid-19 response:
£'000s Expected “additional expenditure” [NHSE vs Local assessment] 618 Covid-19 related expenditure incurred 1,385 Residual issues from 2019/20: Prescribing actual cost in March higher than year-end accrual 703 Provider actual cost in March less than year–end accrual -469 Other Operational budget net variances -198 36
Month 2 Reported & Requested Top Up 2,039
1.1. The CCG now anticipates that a retrospective allocation adjustment will be made by NHSE to fund the total £2,039k additional expenditure.
1.2. This position includes the residual issues from 2019/20; most significantly the higher than expected final position for GP prescribing. The CCG is reviewing why the March prescribing figure was significantly higher than expected and if it is identified that it purely relates to Covid-19 costs then the expenditure will be reclassified as such. The high level financial dashboard and the Month 2 budgetary position is included at appendix 1.
2. Covid-19 Related Expenditure
2.1. The CCG has reported £1,385k revenue costs for the current financial year to date, and detailed at appendix 2. The majority of costs incurred relate to the freeing up of acute hospital capacity by accelerating discharges. A forecast of £2.7m to the end of August is based on the assumption that months 3 and 4 will be in-line with month 2 expenditure, although it is recognised that the forecast is largely dependent on external factors and influenced by demand.
2.2. Covid capital costs – In dialogue with commissioning colleagues there has been no requirement for increased capital capacity to ensure ongoing Covid-19 secure provision. Joint work has been undertaken in understanding the capital elements for Seacole bed provision, but there are no specific St Helens schemes in those plans.
3. Forecast Position for the 4 month reporting period (April to July)
3.1. The CCG is forecasting expenditure to be £4m greater than the initial 4 month allocated budget. This includes £2.7m of Covid related expenditure and the identified £1.3m shortfall in BAU additional costs.
206 Forecast (M1 - M4) £'000s £'000s BAU Overspending M1 & 2 653 Forecast BAU M3 & 4 618 1,271
Covid -19 Cost reclaim M1 & 2 1,385 Expected Covid -19 Cost reclaim M3 & 4 1,313 2,698 3,970
3.2. It is expected that CCG allocations will be adjusted by NHSE/I to fund the above expenditure requirements and allow the CCG to report a breakeven position for the 4 month period; subject to any specific audit requirements.
4. Risk
4.1. A significant element of the financial risk facing the CCG in 2020/21 has been mitigated through the imposition of the temporary financial arrangements for the period April to July. Whilst the risk of NHS contract over-performance is removed through the block payment arrangements with providers, the risk in other areas of expenditure remain a concern:-
• CHC and prescribing
• the ongoing impact of COVID-19 and future planning requirements
• Outstanding financial disputes from previous years
• Required developments in key areas of Primary Care, MH and Children’s Services
• Uncertainty over the level of resources to be made available to the CCG from August.
4.2. Key to mitigating risk is through maintaining our understanding of the detailed monthly financial position and requirements of the CCG aligned to that of our key partners. Financial forecasts and assumptions are compiled on a transparent basis and compared with the ‘reasonableness’ of expenditure expected from the regulators.
5. Month 5 onwards
5.1. The temporary financial regime and mandated budgets are currently only confirmed until the end of July 2020, although there is an indication that temporary measures are likely to continue to some extent from month 5.
5.2. Further information on the basis of the post July financial regime is expected as part of Phase 3 Planning Guidance to be published by NHSE/I.
6. Recommendations
The Governing Body is asked to note: a. the mandated budget position and the financial performance to May 2020; b. the Covid-19 related expenditure reported as at month 2. c. the forecast position for this 4 month period, and the additional financial risks
207
Month 2 High level financial dashboard 2020/21
Description Year To Date 4 Month Reported Forecast Risk to Delivery Comments on Risk In addition to the overspend position being Allocation £61,716k Allocation £123,432k addressed through temporary allocation Expenditure against total Expediture £63,755k Expenditure £127,402k adjustments, there are risks asociated with Revenue Allocation pressures on CHC and prescribing which could see Variance £2,039k Variance £3,970k costs increase.
It is expected that retrospective allocation Plan Deficit £0k Planned Deficit £0k adjustments will cover the CCG overspend under PerformancePerformanceagainstagainst 20/21 Actual Deficit £0k Forecast Deficit £0k the temporary financial regime therefore the CCG financial17/18 plan/control financial plantotal Variance £0k Variance £0k will report a balanced position. There is a low risk that this overspend will be covered in full.
Budget £578k Budget £1.156k Expenditure against The running cost overspend is a factor in the wider Expenditure against Running Cost Expenditure £621k Expenditure £1,236k issues reproted to NHSE as part of their budget Running Cost budget Allocation Variance £43k Variance £80k setting methodology
Budget £0k Plan £0k No QIPP target within this 4 month planning Achieved £0k period, however the CCG will continue to secure Delivery of QIPP Target Expenditure £0k Variance £0k Variance £0k value for money and reduce costs where possible
Month 2 budgetary position and Identification of variance
208
Covid-19 Related Expenditure
Expenditure related to Covid- 19 Response 2020 Year To April May Date £'s £'s £'s Hospital Discharge Programme Purchase of capacity in care homes for hospital discharge 296,510 361,044 657,554 COVID related care packages for hospital discharge 72,191 112,657 184,848 Individual placements to Prevent Hopsital care 12,940 12,940
Primary Care Easter opening 68,019 0 68,019 Practice purchases 39,435 17,055 56,490 Texting service 11,628 0 11,628 Medical inter-operability gateway 33,110 0 33,110 Remote management of patients - IT costs 75,567 0 75,567
Other Covid-19 support services Acute Visiting Service - additional car 30,940 26,829 57,769 End of life service - additional hours 52,068 106,124 158,192 Remote management of patients - IT costs 27,150 0 27,150
Other CCG costs Remote working for non patient activities - IT costs 30,790 0 30,790 Other CCG costs 1,887 9,907 11,794
739,295 646,556 1,385,851
209 210 Report to NHS St Helens CCG Governing Body Date of meeting: 8th July 2020
Governing Body Member Lead: Dr Hilary Flett, Clinical Lead
Accountable Director: Director of Commissioning, Transformation & Primary Care Assistant Director, Urgent, Planned and Community Health Report Author: Commissioning Report title: Assurance Report; Waiting Times Performance
Item for: Decision Assurance x Information (Please insert X as appropriate)
This report supports the following CCG Strategic Objectives. Please insert ‘x’ as appropriate.
1. To deliver financial stability 2. To integrate health within the place of St Helens through system redesign 3. To deliver improved outcomes for people x Strategic Objectives 4. To be recognised as good system leaders 5. To support and transform primary care to be a system leader in St Helens Cares
Does this report provide assurance against any of the risks identified in the Assurance Framework? (please specify)
What level of assurance does it provide? (List levels i.e. Limited/Reasonable/Significant) Risk Is this report required under NHS guidance or for statutory purpose? (please specify)
Governance and N/A
Purpose of this paper To appraise the Governing Body on the position with regards to Referral to Treatment Times, specifically long waiters across elective and cancer services. The report also updates with regards to the current governance arrangements across the system.
211 Further explanatory information required:
Does this paper link to any of the key themes of the CCG’s Yes, constitutional performance and risk. Operational Plan & Improvement Plan. If yes, please specify.
How will this benefit the health and It is a statutory obligation to ensure patients are treated in line wellbeing of St Helens residents or with the NHS constitution. The COVID-19 Pandemic has the Clinical Commissioning Group? impacted upon the NHS ability to maintain performance across most services. The paper provides the Governing Body with an update of the current position and approach to waiting list management.
Please describe any possible None Conflicts of Interest associated with this paper.
Please identify any current services None or roles that may be affected by issues within this paper.
What risks may arise as a result of Refer to paper. this paper? How can they be mitigated?
1. Executive Summary
Appendix A provides an update of performance in relation to 52 week waits for St Helens including cancer 62 day standard performance. The Data reports to the period of May 2020.
Total patients waiting have shown a decrease over the last 3 months, patients waiting 18+, 40+ and 52+ weeks have all shown a significant increase due to the COVID-19 pandemic. 40+ week waiters are mainly in T&O, Gen Surgery, Plastic Surgery & Gynae. 52+ week waiters are mainly in T&O, Plastic Surgery, Neuro & Gynae. The CCG main provider St Helens & Knowlsey Hospitals reported 99 40+ week waiters and five 52+ week waiters as of May 2020. Exception reporting is contained within Appendix A.
Under the interim governance arrangements, the ‘Hospital Cell’ has also collected the current Independent Sector Provider (ISPs) NHS waiting list information and as part of the planning for the next three months, are asking the ISPs to start to work through the NHS outpatient waiting list. The surgical waiting lists will need planning in alongside the Acute NHS waiting lists and will need to be treated based on clinical prioritisation and waiting times. The Cell’s aim is to also develop as a priority, a waiting list ‘overview’ to support and facilitate this process.
It is expected that the Referral to Treatment (RTT) weekly reporting will be commenced again from 29/06/2020 which will further support this.
212
Governance
Hospital activity planning during COVID is managed through NHSE/I with providers, regularly meeting as the Cheshire and Merseyside ‘Hospital Cell’ in line with National Command & Control arrangements for emergency planning. Contracting governance has been stood down during the COVID Period with an interim framework in place reflecting the emergency planning governance.
During this period, the CCG has been kept sighted of performance and waiting list trends through the integrated BI team and commissioning teams who are in liaison with providers during this period.
In July, the CCG Operational Performance, Reporting Operational Group (OPRAG) will be re- established to enable cross departmental internal review and oversight of ongoing trends during COVID.
Quality and Safety reporting is being re-introduced from July. Critical review of long waiters will be undertaken in collaboration with providers. An updated process with regards to reviews is expected from NHSE/I.
The CCG has established a Reset and Recovery Committee to ensure oversight of key priorities and forward planning during this period.
The CCG is meeting fortnightly with its main provider in relation to Elective recovery.
Operational Management.
All Trusts are taking a clinical risk prioritisation approach to referrals and waiting list management review. The independent sector capacity is also being used to support diagnostic capacity across key specialties. Below providers an overview in relation to St Helens & Knowsley Hospitals Trust.
Long waiters
• All patients are being clinically reviewed. • All patients are being contacted with updates on the Trust position • There is a list of patients who are declining to come in due to Covid • Not all theatres are up and running at this point in time. There are 10 elective theatres. They are currently being used for Cancer and Urgent cases, this will be dependent upon the need of each individual service. Orthopaedics are the initial priority for long waiters • Numbers waiting and plans are reviewed at the twice weekly Trust internal meeting
Cancer breaches
• All referrals are tracked by the cancer information team and are clinically reviewed by the teams according to pathway milestones • All patients are being reviewed at the weekly cancer patient treatment list (PTL) meetings and escalated as appropriate. When appointments / diagnostics are declined due to COVID, this is captured on SCR the agreed re-contact date with the patient • There are some patients who have refused to attend an appointment due to shielding. The Trust continues to make numerous contacts and attempts to persuade patients to attend • All services are up and running for cancer referrals, as the time of writing the Trust not aware of any backlogged cases in any specialty except those patients who will not come in • Cancer performance, issues and plans are discussed at the Cancer MDT and twice weekly PTL meetings • The Trust have supported cancer and Primary Care by setting up the cancer hotline for local residents
In addition, the St Helens & Knowlsey Trust Finance and Performance meetings are recommencing
213 from July which will enable ongoing discussions at specialty and care group level to review waiting list issues and performance.
2. Recommendations
The Governing Body is asked to note performance as of May 2020 and the current governance an assurance arrangements in place.
Appendix A
St Helens CCG - RTT Waiters Summary
Jan-20 Feb-20 Mar-20 Apr-20 May-20 Trend Notes:- Total Waiters 12,541 12,478 12,039 12,019 11,979 Total waiters have shown a decrease over the last 3 months, 18+, 40+ and 18+ 927 945 1,235 2,019 3,044 52+ waiters have all shown a significant increase due to the COVID-19 40+ 21 31 47 98 165 pandemic. 40+ week waiters mainly in T&O, Gen Surg, Plastic Surg & Gynae. 52+ 0 0 0 2 10 52+ week waiters mainly in T&O. Plastic Surg, Neuro & Gynae. Main Provider StH&K reported 99 - 40+ week waiters and 5 - 52+ week waiters. Chart below show May RTT Waiters by wait band:-
May Over 40 Weeks by Treatment Function:- May Over 52 Weeks by Provider and Treatment Function:-
52 Week Exceptions at StH&K (Comments still need updating):- Provider Speciality Practice Seen or TCI date Reason Patient listed at week 31 of 18 week pathway, Patient booked for surgery 25/03/2020 StH&K T&O N83008 Awaiting TCI (week 45) but was cancelled due to COVID-19. Currently on hold due to COVID-19 Patient listed at 31 weeks into 18 week pathway. Patient booked for surgery 26/02/2020 (42 weeks) Hospital cancelled due to interpreter issues therefore TCI rebooked for 25/03/2020 (46weeks) TCI hospital cancelled due to COVID-19. Surgery StH&K T&O N83060 Awaiting TCI on hold due to COVID-19. Patient listed at week 1 of 18 week pathway. Patient booked for surgery on 11/03/2020 StH&K T&O Y02510 Awaiting TCI (week 41) hospital cancelled. Currently on hold due to Covid-19 Cancelled due to COVID-19. Unable to do Co2 laser treatments for safety reasons. No StH&K Plastic Surg N83053 Awaiting TCI planned start date. Patient listed at week 36 of 18 week pathway. Patient booked for surgery 25/03/20 StH&K Plastic Surg N83022 Awaiting TCI (week 43). Hospital cancelled due to COVID-19. Currently on hold due to COVID-19 52 Week Exceptions at Wirral:- Provider Speciality Practice Seen or TCI date Reason Pt is a complex joint case with Gynaecology and Colorectal. She has a telephone consultation booked for the 29th June 2020 with the Gynae consultant. We are starting up elective surgery from 1st July, which will be massively under usual capacity initially and the priority is with the cancers and clinically urgent, however the 52 week patients Wirral Gynae N83027 Awaiting TCI will be prioritised within the first cohort of routine patients that we book.
214 St Helens CCG - 62 day Cancer Summary
Jan-20 Feb-20 Mar-20 Apr-20 Trend % of patients receiving 1st definitive treatment for cancer within 2 months (62 days) 84.1% 75.5% 94.9% 76.6% Target 85.0% 85.0% 85.0% 85.0%
100.0% St Helens CCG failed the target for April with 76.6%. In April there were 11 breaches 90.0% from a total of 47 patients seen, details as follows: - 80.0% 70.0% Provider Tumour Grp Reason No. breaches 60.0% Other Reason 1 50.0% Urological Inadequate elective capacity 1 40.0% Patient Choice 1 30.0% StH&K 20.0% H&N Other Reason 2 10.0% LGI Other Reason 3 0.0% UGI Other Reason 2 Jan-20 Feb-20 Mar-20 Apr-20 LUHFT Haem Other Reason 1
Jan-20 Feb-20 Mar-20 Apr-20 Trend % of patients seen within 2 weeks for an urgent referral for breast symptoms 92.5% 96.7% 94.0% 90.5% % Patients seen within two weeks for an urgent GP referral for suspected cancer 93.4% 96.0% 95.7% 88.2% % of patients receiving definitive treatment within 1 month of a cancer diagnosis 96.0% 97.8% 98.4% 96.0% % of patients receiving subsequent treatment for cancer within 31 days (Drug Treatments) 93.5% 90.9% 100.0% 94.1% % of patients receiving subsequent treatment for cancer within 31 days (Radiotherapy Treatments) 97.1% 100.0% 100.0% 100.0% % of patients receiving subsequent treatment for cancer within 31 days (Surgery) 100.0% 100.0% 91.7% 91.3% % of patients receiving treatment for cancer within 62 days from an NHS Cancer Screening Service 83.3% 50.0% 80.0% 100.0% % of patients receiving treatment for cancer within 62 days upgrade their priority 75.0% 78.6% 87.5% 77.8%
215 DOCUMENT DEVELOPMENT
Process Yes No N/A Comments & Date Outcome (i.e. presentation, verbal, actual report) Public Engagement (please detail x the method i.e. survey, event, consultation)
Clinical Engagement (please x detail the method i.e. survey, event, consultation)
Has ‘due regard’ been given to x Equality Analysis (EA) and any adverse impacts? (Please detail outcomes, including risks and how these will be managed)
Legal Advice Sought x
Presented to any other groups x The paper has been or committees including prepared in collaboration Partnership Groups – with St Helens & Internal/External (please specify Knowlsey Hospital Senior in comments) Management.
Note: Please ensure that it is clear in the comments and date column how and when particular stakeholders were involved in this work and ensure there is clarity in the outcome column showing what the key message or decision was from that group and whether amendments were requested about a particular part of the work.
216 217 218 Patients waiting over 62 and 104 days on cancer pathways
Cheshire and Merseyside has the second highest number of patients waiting over 62 days per 100k pop in England, and the highest number waiting over 104 days.
219 Cancer waits >62 days
The number of patients waiting over 62 days has risen by 410% Trust 62+ Day Waiters Countess Of Chester 284 East Cheshire 132 Mid Cheshire 242 Liverpool University Hospitals 641 Southport and Ormskirk 66 St Helens and Knowsley 113 Warrington And Halton 167 Wirral University 282
Bridgewater 7 Clatterbridge Cancer Centre 18 Liverpool Heart and Chest 1 Liverpool Womens 30 Walton Centre 0
CMCA 1983 220 Cancer waits >104 days
The number of patients waiting over 104 days has risen by 663% Trust 104+ Day Waiters Countess Of Chester 119 East Cheshire 42 Mid Cheshire 112 Liverpool University Hospitals 239 Southport and Ormskirk 5 St Helens and Knowsley 50 Warrington And Halton 44 Wirral University 111
Bridgewater 0 Clatterbridge Cancer Centre 5 Liverpool Heart and Chest 1 Liverpool Womens 20 Walton Centre 0
221 CMCA 748 Classification: Official
Publications approval reference: 001559
18 May 2020
Dear colleague,
COVID-19 weekly NHS activity collection
As part of our COVID-19 response, NHS England and NHS Improvement are running daily COVID-19 sitreps for all NHS providers. While this information is essential for the continued monitoring of occupancy and utilisation of resources with regards to COVID-19, further information is now required as part of the recovery of critical services. As part of a dynamic incident response, it is essential that we have access to data regarding the throughput of activity in critical areas, in order to report quantitatively on what is being delivered, adjust strategy where needed, and identify where support is required. The information required cannot be obtained with the timeliness and completeness necessary through other routes (such as SUS). Therefore, a new weekly NHS activity collection is required. This will run in addition to the daily sitreps. This weekly return will collect more detailed aggregate information regarding the following:
• Elective activity • Outpatients • Cancer • Diagnostic tests
Full definitions for each section can be found in the guidance document accompanying this letter. Please ensure all activity taking place on behalf of the trust is recorded in the return – this should include activity which is taking place on behalf of the trust within the independent sector. Independent sector activity should be recorded in both this return and the weekly IS activity return. The collection will launch for the first time on Tuesday 19 May, covering the week ending Sunday 17 May. The deadline for submission will be 14.00 on Wednesday 20 May.
222 Classification: Official
In addition, we require an initial submission of all periods from 30 March until 10 May. The collection period for this back series will also open on Tuesday 19 May, and will close at 14.00 on Friday 22 May. Following this, the collection will run from 08.00 each Tuesday until 14.00 every Wednesday, collecting data from the previous Monday to Sunday. A full timetable for the next two weeks can be seen below.
Submission window Submission window Data start date Data end date opens closes Tuesday 19 May Wednesday 20 May Monday 11 May Sunday 17 May (0800) (1400) Tuesday 19 May Friday 22 May (1400) Monday 30 Sunday 5 April (0800) March Monday 6 April Sunday 12 April Monday 13 April Sunday 19 April Monday 20 April Sunday 26 April Monday 27 April Sunday 3 May Monday 4 May Sunday 10 May Tuesday 26 May Wednesday 27 May Monday 18 May Sunday 24 May (0800) (1400) Tuesday 2 June Wednesday 3 June Monday 25 May Sunday 31 May (0800) (1400)
Submitters for each provider will shortly receive invitations for the collection from SDCS. If any additional submitters are required, or if you do not receive a notification by the time the submission window opens, please contact [email protected]. For definitional enquiries, please contact the data team at england.covid- [email protected].
Kind regards,
Professor Keith Willett NHS Strategic Incident Director (COVID-19) NHS England and NHS Improvement
2
223 224 Report to NHS St Helens CCG Governing Body Date of meeting: 8th July 2020
Governing Body Member Lead: Iain Stoddart
Accountable Director: Iain Stoddart
Report title: NHS Constitution-CCG Performance
Item for: Decision Assurance X Information X (Please insert X as appropriate)
This report supports the following CCG Strategic Objectives. Please insert ‘x’ as appropriate.
1. To deliver financial stability 2. To integrate health within the place of St Helens through system redesign X 3. To deliver improved outcomes for people X Strategic Objectives 4. To be recognised as good system leaders 5. To support and transform primary care to be a system leader in St Helens Cares
Does this report provide assurance against any of the risks identified in the Assurance Framework? Improved outcomes for patients
What level of assurance does it provide? Reasonable Risk
Is this report required under NHS guidance or for statutory purpose?
Governance and No
Purpose of this paper The purpose of this paper is to: • Summarise the 2019/20 CCG year to date performance against the NHS Constitution targets.
225 Further explanatory information required:
There is alignment between the Operational Plan objectives Does this paper link to any of the and the NHS Constitution key themes of the CCG’s Operational Plan & Improvement Plan. If yes, please specify.
Addressing the measures reported as “underperforming” How will this benefit the health and should result in an improvement in clinical services delivered to wellbeing of St Helens residents or patients. the Clinical Commissioning Group? None identified in compiling this report Please describe any possible Conflicts of Interest associated with this paper. Addressing the measures reported as “underperforming” Please identify any current services should result in an improvement in clinical services delivered to or roles that may be affected by patients issues within this paper.
There is a continued risk to the reputation of the CCG where What risks may arise as a result of poor performance is highlighted and then not improved upon. this paper? How can they be mitigated?
1. Executive Summary
The NHS Constitution clarifies what people can expect from the NHS and what to do if they do not get it.
The Constitution also sets out the responsibilities that patients and the public should uphold to help the NHS work effectively and to ensure that NHS resources are used responsibly. The Constitution is accompanied by a Handbook which sets out patient, public and staff rights, values, responsibilities and pledges.
It is therefore not surprising that the Constitution is inherent in the operational plan and strategic focus of the CCG. Performance is tightly monitored and regulated with NHS England against set standards and in line with the delivery of partner organisations.
The CCG produces a dashboard each month for those rights and pledges which have a target assigned to them. This report focuses solely on the constitutional standards as they apply to St Helens CCG. The latest dashboard is included at Appendix A.
Overall performance against the constitutional targets was good and improving in most areas. Three key residual performance risks are still facing the CCG. These relate to A&E waiting times, ambulance responsiveness and cancer 62 day waiting times after referral from GP or screening services.
In terms of A&E and Ambulance performance there are system wide plans to improve on performance and the flow of patients through the unscheduled care system. These are actively managed through the local A&E Delivery Board and with dialogue with NHS England/Improvement North West and NHS England/Improvement at a national level. Whilst performance is below the levels we expect, it is recognised that there are unprecedented demands on the NHS unscheduled care system across the country, which have been further challenged due to the Covid-19 pandemic.
226 Regarding waiting times related to cancer there have been specific challenges over the year with respect to radiology capacity, national changes to certain treatment pathways for head and neck cancer and urology capacity impacted by robotics. Equally referrals for some cancers have increased.
An overall improvement from the early part of the year has been evidenced but more focussed work is being undertaken to reinforce improvement, especially in line with the impact of Covid-19 on demand and people undertaking treatment.
Due to the Emergency nature of Covid and the required response of providers, aligned to the suspension of the usual operational planning and contracting arrangements, the CCG has not undertaken the same level of performance management and reporting of its core NHS and IS providers to date. This has also impacted upon the update of recovery action plans during this emergency situation.
A revised approach to constitutional monitoring and management aligned with performance management of commissioned services is being developed. In terms of quality issues a wider QSG (Quality Surveillance Group) approach through the Chief Nurses is being undertaken on a Cheshire & Merseyside basis.
A separate report to this committee focuses on constitutional issues relating to 52 week waits, RTT and cancer performance.
2. Recommendations The Committee is requested to note the cumulative constitutional performance levels for the CCG,
227 DOCUMENT DEVELOPMENT
Process Yes No N/A Comments & Date Outcome (i.e. presentation, verbal, actual report) Public Engagement (please detail X the method i.e. survey, event, consultation)
Clinical Engagement (please X detail the method i.e. survey, event, consultation)
Has ‘due regard’ been given to X Equality Analysis (EA) and any adverse impacts? (Please detail outcomes, including risks and how these will be managed)
Legal Advice Sought X
Presented to any other groups X Yes – reviewed at F&P or committees including 24th June 2020 Partnership Groups – Internal/External (please specify in comments)
Note: Please ensure that it is clear in the comments and date column how and when particular stakeholders were involved in this work and ensure there is clarity in the outcome column showing what the key message or decision was from that group and whether amendments were requested about a particular part of the work.
228 Appendix 1 – Constitutional Dashboard
KPI Area KPI Name Target Trend Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar YTD RTT Incomplete Pathways 92% 92.65% 93.18% 93.17% 93.71% 92.26% 92.45% 92.64% 92.79% 92.58% 92.61% 92.43% 89.74% 92.53% Referral to Treatment 52 Week Waiters 0 1 1 1 0 0 0 0 0 0 0 0 0 3 Patients waiting for a diagnostic test should have Diagnostics Below 1% 0.61% 0.85% 1.33% 1.38% 1.37% 0.52% 0.46% 0.43% 1.04% 1.21% 0.97% 2.15% 1.00% been waiting less than 6 weeks from referral Patients should be admitted, transferred or discharged within 4 hours of their arrival at an A&E 95% 83.23% 83.56% 79.28% 82.42% 84.74% 86.65% 84.16% 78.72% 76.04% 80.39% 83.20% 84.15% 82.16% A&E Waits department Number of waits from decision to admit to 0 000000000000 0 admission (trolley waits) over 12 hours STHK ONLY Maximum two-week wait for first outpatient appointment for patients referred urgently with 93% 93.2% 88.4% 86.1% 88.4% 89.7% 89.5% 93.1% 94.7% 94.0% 93.4% 96.0% 95.7% 91.8% suspected cancer by a GP Cancer - 2 Weeks Maximum two-week wait for first outpatient appointment for patients referred urgently with 93% 82.0% 68.6% 65.0% 87.0% 90.0% 92.9% 97.1% 89.7% 96.0% 92.5% 96.7% 94.0% 87.6% breast symptoms (where cancer was not initially suspected Maximum one month (31-day wait from diagnosis to 96% 94.1% 98.2% 95.4% 96.1% 96.8% 96.8% 98.4% 100.0% 97.0% 96.0% 97.8% 98.4% 97.2% first definitive treatment for all cancers) Maximum 31-day wait for subsequent treatment 94% 100.0% 86.7% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 91.7% 97.8% where that treatment is surgery Cancer - 31 days Maximum 31-day wait for subsequent treatment where that treatment is an anti-cancer drug regimen 98% 100.0% 96.6% 100.0% 94.7% 94.1% 100.0% 100.0% 100.0% 100.0% 93.5% 90.9% 100.0% 97.6%
Maximum 31-day wait for subsequent treatment where the treatment is a course of radiotherapy 94% 97.1% 95.7% 96.8% 96.2% 100.0% 87.5% 97.5% 97.1% 100.0% 97.1% 100.0% 100.0% 97.3% Maximum two month (62-day wait from urgent GP 85% 82.1% 84.0% 81.1% 83.9% 84.5% 83.3% 89.2% 87.7% 84.4% 84.1% 75.5% 94.9% 84.9% referral to first definitive treatment for cancer) Maximum 62-day wait from referral from an NHS screening service to first definitive treatment for all 90% 100.0% 33.3% 100.0% 100.0% 100.0% 50.0% 100.0% 100.0% 100.0% 83.3% 50.0% 80.0% 81.3% Cancer - 62 days cancers Maximum 62-day wait for first definitive treatment 85% (local following a consultant’s decision to upgrade the 92.9% 76.9% 77.8% 93.3% 100.0% 81.8% 93.3% 87.5% 86.7% 75.0% 78.6% 87.5% 86.7% target) priority of the patient (all cancers) The number of Mixed Sex Accommodation breaches MSA <5 cases 0 0 0 2 2 0 0 0 0 1 1 - 6 Care Programme Approach (CPA: The proportion of people under adult mental illness specialties on CPA Mental Health who were followed up within 7 days of discharge 95% 95.41% 100.00% 98.06% - 97.87% from psychiatric in-patient care during the period)
STHK ONLY: All patients who have operations cancelled, on or after the day of admission (including Cancelled the day of surgery, for non-clinical reasons to be 100% 0 0 2 - 2 Operations offered another binding date within 28 days, or the patient’s treatment to be funded at the time and hospital of the patient’s choice) Category 1: Mean Performance (minutes) Time critical and life threatening events requiring 00:07:00 00:07:58 00:07:31 00:08:37 00:07:46 00:07:41 00:08:15 00:09:09 00:08:28 00:08:32 00:07:38 00:08:07 00:08:26 00:08:12 immediate intervention Category 1:90th Centile Performance (minutes) Time critical and life threatening events requiring 00:15:00 00:12:40 00:11:53 00:14:24 00:13:03 00:13:27 00:13:20 00:14:14 00:13:16 00:14:18 00:12:10 00:13:35 00:13:43 00:13:24 immediate intervention. Category 2: Mean Performance (minutes) Potentially serious conditions that may require rapid 00:18:00 assessment, urgent on-scene clinical 00:24:57 00:21:37 00:23:05 00:24:37 00:25:20 00:24:40 00:31:18 00:31:50 00:41:20 00:25:12 00:27:50 00:43:32 00:28:57 intervention/treatment and / or urgent transport Category 2: 90th Centile Performance (minutes) Potentially serious conditions that may require rapid 00:40:00 00:51:13 00:45:23 00:47:51 00:52:16 00:52:32 00:49:27 01:05:58 01:06:51 01:33:08 00:50:18 00:57:57 01:41:20 01:00:55 NWAS Ambulance assessment, urgent on-scene clinical intervention/treatment and / or urgent transport Category 3: 90th Centile Performance (minutes) Urgent problem (not immediately life- threatening)that requires treatment to relieve 02:00:00 02:31:02 01:56:42 02:29:53 03:15:43 02:48:33 02:49:42 04:03:03 04:05:57 05:21:51 04:12:55 03:33:39 05:45:22 03:16:06 suffering (e.g. pain control) and transport or assessment and management at scene Category 4:: 90th Centile Performance (minutes) Non urgent problem (not life-threatening) that requires assessment and possibly transport 03:00:00 02:57:05 02:28:42 03:56:31 03:51:17 03:21:31 03:20:23 03:34:21 03:35:30 03:59:57 03:41:52 03:18:13 04:25:38 03:29:12
229 230 Report to NHS St Helens CCG Governing Body Committee Date of meeting: 8th July 2020 Clinical Accountable Officer St Helens CCG/ Executive Director Governing Body Member Lead: Peoples Accountable Director: Chief Nurse
Report Author: Designated Nurses
Report title: CCG Safeguarding Annual Report 2019/20
Item for: Decision x Assurance Information (Please insert X as appropriate)
This report supports the following CCG Strategic Objectives. Please insert ‘x’ as appropriate.
1. To deliver financial stability 2. To integrate health within the place of St Helens through system redesign 3. To deliver improved outcomes for people x Strategic Strategic Objectives 4. To be recognised as good system leaders x 5. To support and transform primary care to be a system leader in St Helens Cares
Does this report provide assurance against any of the risks identified in the Assurance Framework? (please specify)
What level of assurance does it provide? (List levels i.e. Limited/Reasonable/Significant) Risk Is this report required under NHS guidance or for statutory purpose? (please specify) Statutory Purpose Governance and and Governance
Purpose of this paper To provide Governing Body with oversight of safeguarding activity in the year 2019/20 in relation to Safeguarding Children, Adults and Looked After Children.
231 Further explanatory information required:
Does this paper link to any of the key themes of the CCG’s Operational Plan & Improvement Plan. If yes, please specify.
How will this benefit the health and wellbeing of St Helens residents or the Clinical Commissioning Group?
Please describe any possible Conflicts of Interest associated with this paper.
Please identify any current services or roles that may be affected by issues within this paper.
What risks may arise as a result of this paper? How can they be mitigated?
1. Executive Summary The Safeguarding annual report 2019/20 provides an overview with regards to how NHS St Helens CCG and its commissioned services are fulfilling statutory duties in relation to safeguarding children and adults. The draft report has been approved by Quality Committee.
2. Recommendations Governing Body to approve the report.
232 DOCUMENT DEVELOPMENT
Process Yes No N/A Comments & Date Outcome (i.e. presentation, verbal, actual report) Public Engagement (please detail X the method i.e. survey, event, consultation)
Clinical Engagement (please X detail the method i.e. survey, event, consultation)
Has ‘due regard’ been given to X Equality Analysis (EA) and any adverse impacts? (Please detail outcomes, including risks and how these will be managed)
Legal Advice Sought X
Presented to any other groups x Actual report to be or committees including provided to Governing Partnership Groups – Body Internal/External (please specify in comments)
Note: Please ensure that it is clear in the comments and date column how and when particular stakeholders were involved in this work and ensure there is clarity in the outcome column showing what the key message or decision was from that group and whether amendments were requested about a particular part of the work.
233 Safeguarding Annual Report 2019/20
Authors: CCG Safeguarding Professionals
234 CONTENTS PAGE 1. Foreword 3
2. Executive Summary 4
3. Introduction 5
4. National Context 5
5. Local Context 6
6. Governance Arrangements 11
7. Incidents and Risk Management 12
8. Effectiveness of Safeguarding Arrangements 12
9. Training 13
10. Challenges 13
11. Business Continuity 14
12. Priorities 2020/21 14
13. Conclusion 15 Appendix 1 - Progress against the 2019/20 CCG Business 16 Priorities
235 Foreword
It is my pleasure to introduce the safeguarding adults and children annual report of NHS St Helens CCG for 2019-20. Safeguarding remains fundamental to the work of the CCG. This report provides assurance to the Governing Body that the CCG is fulfilling its statutory safeguarding responsibilities and demonstrates a strong commitment to safeguarding from the CCG as a statutory partner.
The work of safeguarding adults and children from abuse and neglect is an increasing and challenging agenda. However, the strong partnership arrangements we have in St Helens makes this more manageable as this helps protect the most vulnerable and at risk individuals.
In the last quarter of this reporting year there have been additional challenges for the health economy in relation to COVID-19; the impact of which was not fully understood. The government sanctioned legislative changes as part of a rapid response to reacting to this pandemic, all Health providers within the Borough responded to the challenges faced including that of safeguarding children and Adults.
The CCG has robust governance and accountability arrangements which ensures that safeguarding is core to business and that there is continued commitment to the priorities of the safeguarding agenda from executive level and throughout all CCG employees. This report demonstrates both the challenges and the commitment of the CCG to this agenda.
Lisa Ellis Chief Nurse/Director of Quality
236 2. Executive Summary
This is the fourth joint Annual Safeguarding Adults, Children and Looked after Children Report to NHS St Helens Clinical Commissioning Group (CCG) Governing Body. It outlines the responsibilities of the CCG in respect to safeguarding adults and children. The report covers the period of 1st April 2019 to the 31st March 2020 and provides both the national and local context to safeguarding developments.
All NHS organisations have a statutory duty to make arrangements to safeguard and promote the welfare of children under Section 11 of the Children Act 2004. The local coordination of Safeguarding Adults at risk was strengthened with the introduction of The Care Act (2014) in April 2015, which placed Safeguarding Adults Boards on a statutory footing.
CCGs are statutorily responsible for ensuring that the organisations from which they commission services have safe and effective systems that safeguards adults and children at risk of abuse, neglect or exploitation. This includes specific responsibilities for Looked After Children (LAC) and Care Leavers (CL) and for supporting the Child Death Overview process including sudden unexpected death in childhood. The Child Death Overview Panel (CDOP) annual report is available on request for information and through the Safeguarding Children Partnership Website.
CCGs are responsible for securing and employing the expertise of Designated Safeguarding Professionals, including for Looked After Children, on behalf of the local health system. These statutory roles undertake a whole health economy perspective. It is crucial that Designated Safeguarding Professionals play an integral role in all parts of the commissioning cycle, from procurement to quality assurance if services are to be commissioned that support adults and children at risk of abuse or neglect, as well as effectively safeguard their wellbeing.
The CCG has continued to make a significant contribution to the work of the St Helens Safeguarding Boards: St Helens Safeguarding Children Partnership (SCP) and Safeguarding Adult Board (SAB) and to the Corporate Parenting Forum. The Peoples Board, with responsibility for safeguarding, has Executive CCG representation.
The purpose of the joint report is to assure the Governing Body and members of the public that NHS St Helens Clinical Commissioning Group (CCG) is fulfilling its statutory duties in relation to safeguarding adults, children and looked after children in St Helens. It takes account of National changes to influence local developments and activity and has an overview of any significant issues or risks with regard to safeguarding and the actions being taken to mitigate these.
Our approach to safeguarding is underpinned by quality, a performance management culture and contracting systems and processes that aim to reduce the risk of harm and respond quickly to any concerns.
The report highlights key achievements against the CCG’s agreed safeguarding priorities for 2019/20 (see Appendix 1) and outlines the priorities for 2020/21.
237 Key Risks 2019/20:
Within the 2019/20 reporting period NHS St Helens CCG met, in the main, its statutory requirements in respect of Safeguarding and Looked after Children. As per previous reporting the role of Designated Doctor remains vacant despite an ongoing recruitment drive. As this position is a statutory requirement the vacancy remains on the NHS St Helens CCG risk register with mitigation actions in place.
Financial Impact on the CCG:
No financial impact has been identified.
Implications/Actions for Public and Patient Engagement:
No additional implications or actions for Public and Patient engagement have been identified.
3. Introduction
The purpose of this report is to ensure that NHS St Helens Clinical Commissioning Group Governing Body is informed of the progress and developments in the national and local safeguarding agenda during the year 2019/20; that it is apprised of how the CCG, the NHS organisations from whom it commissions services and Primary Care addressed their responsibilities and fulfilled their statutory duties under Section 11 of the Children Act 2004 and the Care Act 2014.
The CCG works in partnership with St Helens Local Authority and partner agencies including the Local Safeguarding Children Partnership and Safeguarding Adult Board, to safeguard children and adults at risk of abuse and harm.
This report will summarise and provide information about national and local changes and influences, governance arrangements, activity undertaken in 2019-20 and the challenges to business continuity. The report highlights the areas where further development is required and indicates potential risks.
Finally, the report’s authors seek to assure the CCG Governing Body that where gaps were identified in commissioned organisations, that these organisations were held to account via the governance processes of the CCG, St Helens Safeguarding Children Partnership and St Helens Safeguarding Adult Board.
4. National context:
4.1. Safeguarding Children The underpinning legislation for safeguarding children arrangements in England is contained within the Children Acts 1989, 2004, the Children and Adoption Act 2002 and more latterly the Children and Social Work Act 2017 (enacted 2018).
Section 11 of the Children Act 2004, (amended by the Health and Social Care Act 2012, but unchanged by the Children and Social Work Act 2017) outlines the responsibilities and duties of Clinical Commissioning Groups, as statutory partners, as well as commissioners of services to ensure they, as well as those who work on their behalf, carry out their duties in such a way as to safeguard and promote the welfare of children.
238
Looked After Children The responsibilities of CCGs to Looked after Children are outlined in Promoting the health and well-being of Looked after Children (2015). CCGs in collaboration with other NHS commissioners and local authority partners have a responsibility to ensure the timely and effective delivery of health services to looked-after children. In fulfilling those responsibilities, CCGs contribute to meeting the health needs of looked-after children in three ways:
• commissioning effective services, • delivering through provider organisations, and • through individual practitioners providing coordinated care for each child.
CCGs need to work in partnership with other commissioners of health services to ensure there are appropriate arrangements and resources in place to meet the physical and mental health needs of looked-after children. Services for individual children placed out of the CCG area should be consistent with the responsible commissioner guidance.
4.2. Safeguarding Adults The legislation relevant to arrangements for safeguarding adults at risk of abuse or neglect is found within the Care Act 2014. The Safeguarding Vulnerable Groups Act 2006 also has relevance as it does in safeguarding children arrangements.
The Mental Capacity Act 2005 became legislation in 2007 and addressed the way in which individuals who may lack mental capacity to make certain decisions are protected and supported. The Deprivation of Liberty Safeguards (DoLS) were introduced in 2007 to remedy the incompatibility between English law and the European Convention on Human Rights identified in HL v UK, the “Bournewood” case. The aim of the DoLS framework was to protect people who lack mental capacity, to be lawfully detained in a hospital or care home when this is deemed to be necessary in their best interests. The DoLS framework, however, has been criticised for being excessively bureaucratic. This led to a review of the framework, by the Law Commission, in 2014, resulting in the Mental Capacity (Amendment) Bill. The Bill was given Royal Assent on 16 May 2019 and aims to reform the current DoLS system with a new approach termed ‘Liberty Protection Safeguards (LPS). At the time of this report, plans to fully implement LPS by October 2020 have been placed on hold by the Government, due to the Covid-19 emergency.
5. Local Context: Adults and Children -
As part of the borough Integration agenda, the Designated Nurses for Children have remained within the Local Authority Safeguarding and Quality Assurance Unit under the management of the Assistant Director for Safeguarding Children. The childrens team has strong links with the quality team and are an integral part of the CCG Governance systems. The Designated Nurse Safeguarding Adults is part of the wider Quality Team and reports to the Deputy Chief Nurse. Safeguarding, as a whole, remains within the Chief Nurse’s portfolio.
239 5.1 Safeguarding Children and Looked after Children
Governance
The Peoples Board, comprising of all strategic partners, maintains responsibility for safeguarding within the Borough; the Accountable Officer provides the CCG’s representation. The St Helens Safeguarding Children’s Partnership provides the challenge and scrutiny of safeguarding practice across the system as a whole and has Executive Representation from the CCG.
Demographics
Recent ONS data (2018) reports that St Helens has approximately 40,500 children. Children and young people make up approximately 23% of the borough’s population. The rate of child poverty is worse in St Helens than our statistical neighbour’s rate with 26.3% of children under 16 years living in poverty.
With regard to vulnerable children and young people, at the time of writing this report the following data is relevant:
• The number of children subject to statutory Child in Need procedures on 31st March 2020 was 600. St Helens is an outlier numbers being above statistical, regional and national data.
• The number of children subject to a Child Protection plan on 31st March 2020 was 205 which is a slight increase from previous year (203). St Helens numbers now reflect that of statistical neighbours.
• The number of looked after children on 31st March 2020 was 496, of these 242 were placed out of borough. St Helens remains an outlier both regionally and nationally with the numbers of children in the care system. Additionally, there were 107 children placed in St Helens from other local authorities
Within St Helens, the CCG is responsible for commissioning health services for children from: Northwest Boroughs Healthcare NHS Foundation Trust, Alder Hey Children’s NHS Foundation Trust and St Helens and Knowsley Teaching Hospital NHS Trust. Support is given by the CCG Safeguarding team to childrens services commissioned by Public Health These services must as part of the commission safely discharge service delivery with regard to safeguarding. The data above demonstrates the level of demand on service throughout the year and in comparison to regional and national statistical neighbours.
A total of 7 deaths were reported through the CDOP arrangements during this business year within the St Helens Borough; 6 of which had modifiable factors. Factors identified within reviews to support learning and practice included high maternal BMI; high maternal BMI + non- compliance with medication; alcohol misuse, unsafe sleep, neglect; service provision, temperature control issues and smoking leading to prematurity.
One serious case review* was concluded and ratified through the SCP arrangements during the reporting period and an action plan is imminent.
240 (* the review was conducted under the older LSCB arrangements due to the timing of the incident which was prior to the publication of the MASA arrangements).
The issues reported above reflect a number of the borough priorities; the CCG will expect in 2020 -2021 that commissioned services will take account of these findings and further develop their service response accordingly. To note the four key priority areas agreed by the Partnership were domestic abuse, neglect, criminal exploitation and Descriptions of Need
The Local Authority (Childrens Social Care) was subject of an Inspection by their regulatory body, Ofsted, which found them to be Inadequate. This has implications for the Partners and service delivery across the Borough.
There is a requirement for health professionals across CCG commissioned provider services to initiate and contribute to Early Help assessments. This work needs to continue to ensure help for children and families is provided at the earliest opportunity which will then support improved outcomes for them negating the need for statutory intervention. Data through the year demonstrates that early help interventions have not always been offered as a significant number of request for statutory social work do not require this level of service further to an assessment being completed. This is further evidence that thresholds within the Borough are not yet consistently applied.
To support this ‘The Descriptions of Need’ document has been reviewed, updated and implemented during the reporting year. These have been adopted by the partnership. The Neglect strategy was also launched during the reporting year which will support a consistent approach to neglect in the area.
The numbers of children subject to child protection plans is and will continue to be an area for scrutiny for the partnership in 2019/2020, as data has demonstrated that there is a lack of a consistent understanding, analysis and management of risk across the partnership. This means that families are subject to statutory intervention either needlessly or for too long a periods of time.
All children subject to care proceedings are required by statute to receive health assessments. The initial assessment being required within 20 working days of coming into care, review health assessments are conducted annually for children aged 5 years and above and twice yearly for those aged under 5. The data from these assessments also contributes to the statutory return for the DfE.
Health Plans are completed from the result of the health assessment and used to inform multi- agency care planning for the child. The CCG has responsibility for the commissioning of these arrangements and to ensure that interventions are timely and of good quality.
In 2019/20 93% of children of children who had been in care for 12 months or more had their statutory health assessments within the reporting year.
The compliance and quality of this work will continue to be monitored as part of the quality schedule. The redesign of the LAC health team has progressed throughout 2019/20. The LAC health team (since December 2019) have been commissioned through North West Boroughs Healthcare NHS Foundation Trust. There has been additional funding for the team and a Named Nurse for Looked after Children was appointed in February 2020 which has reduced the risk on the CCG risk register.
241 • Partnership Working
The CCG is a key partner agency in safeguarding within the St Helens Borough. This is achieved through membership of the Safeguarding Children Partnership and its sub groups. The arrangements for the SCP were developed within the year and formally published in June 2019 in accordance with the statutory guidance and timescale defined by the DfE. Child Death arrangements have been agreed in line with the new Child Death Regulations (2018). Further amendments in relation in relation a Pan-Mersey approach are in the process of being agreed.
The CCG has continued to support and develop safeguarding practice within Primary Care. Examples of the developments are; safeguarding policies, level three safeguarding training, child protection conference and a Primary Care Forum.
The Designated Nurses are represented on the Cheshire and Mersey Designated Professionals Forum.
The CCG is a key partner on the Corporate Parenting Forum which is chaired by the portfolio holder for children’s services and the Care Leavers Board; representation is from the Designated Nurse for Looked after Children.
The CCG continues to commission the MASH nurse who contributes to partnership working to promote the timely and robust assessments for children deemed to be a risk. During quarter 4 of this reporting year additional funding has been agreed by the CCG to increase the resource to cope with the additional demand on the MASH service due to a redesign of the service which has increased demand.
• Safeguarding Children’s Partnership The Clinical Accountable Officer is the Chair of the Safeguarding Partnership Board and there is representation from the Chief Nurse, Senior Assistant Director for Safeguarding and the Designated Nurse Safeguarding Children. This group is responsible for setting priorities for the borough and holding organisations to account regarding their safeguarding responsibility.
• Subgroups of the Partnership, undertake specific pieces of work which involve all agencies working to achieve the identified priorities of the board and provide information and data in relation to the boroughs safeguarding activity. The CCG is represented (by the Designated Nurses and Named GP) on the Child at Risk of Exploitation Group, Audit, Review and Learning Group, the Health Forum, Rapid Review Panel and Pan Mersey Policy and Procedures Subgroup.
5.2 Safeguarding Adults
St Helens has an increasing population and faces challenges reflective of the national picture, in relation to financial pressures and a growing elderly population with increasing health and social care needs. There are marked inequalities amongst residents of the Borough and particular challenges locally, in relation to alcohol and substance misuse, homelessness, self- harm, mental health and domestic abuse
242 • St Helens Multi-Agency Public Protection Arrangements (MAPPA) - The Designated Nurse Safeguarding Adults represents the CCG as a core member of the St Helens Multi- Agency Public Protection Arrangements (MAPPA Panel). MAPPA is the process through which the Police, Probation and Prison Services work together with other agencies to manage the risks posed by violent and sexual offenders living in the community in order to protect the public. MAPPA is not a statutory body in itself but is a mechanism through which agencies can better discharge their statutory responsibilities and protect the public in a co- ordinated manner. Agencies at all times retain their full statutory responsibilities and obligations. The CCG shares information within primary care as required and as per the information sharing agreement.
• The Learning Disabilities Mortality Review (LeDeR) Programme was established to support local areas to review the deaths of people with learning disabilities, identify learning from those deaths and to translate the learning into service improvement initiatives. It was implemented at the time of considerable spotlight on the deaths of patients in the NHS and the introduction of the National Learning from Deaths Framework, in England, in 2017.
The programme has developed a review process for the deaths of people with learning disabilities aged 4 and upwards. A significant challenge to the delivery of the programme nationally, has been the timeliness with which mortality reviews have been completed, largely driven by the limited resources available to undertake reviews and the low proportion of people trained in LeDeR methodology who have gone on to complete a mortality review. This led to a national backlog of cases requiring review.
In January 2019, St Helens CCG had a backlog of 17 LeDeR reviews outstanding. As at 31.3.20; we have completed 27 reviews, our backlog is complete and we are progressing business as usual reviews well within NHSE timescales. Our success is largely due to the decision to employ an internal Project Lead/Reviewer.
The past year has been both challenging and rewarding. St Helens CCG has worked hard to successfully achieve the completion of back log reviews and to progress our business as usual caseload. We have established our Local LeDeR Steering Group, to oversee the LeDeR work programme and to take forward local improvements based on the evolving national and local picture. The group is well represented by Health, Social Care, Experts by Experience and 3rd Sector Agencies.
We are now in a position to implement a system-wide approach to improving the health and social care experience of patients with learning disabilities. Going forward, we plan to develop the Local LeDeR Steering Group into a wider Learning Disability Stakeholder Forum which will have oversight of all key Learning Disability work streams across the Borough. The aim of the group will be to drive improvement in the quality of health and social care service delivery for people with learning disabilities and to help to reduce inequalities in this population through working collaboratively to embed learning and identify key recommendations for improvement.
243 The first NHS ST Helens CCG LeDeR Annual Report 2019-20 has now been approved and published on the CCG website. The report can be accessed at https://www.sthelensccg.nhs.uk/your-health/learning-disabilities/
• Prevent - The Prevent Strategy is a key part of CONTEST, the Government’s counter terrorism strategy. The strategy aims to respond to the ideological challenge of terrorism and those who promote it, prevent people from being drawn into terrorism, and work with sectors and institutions where there are risks of radicalisation. St Helens has not been identified as one of the high priority areas, although it is in close proximity to several high priority regions. All health agencies must comply with the Prevent Duty Framework and reporting requirements. The Designated Nurse Safeguarding Adults is the CCG Prevent lead and ensures that relevant guidance has been implemented both within the CCG and commissioned providers; this includes access to relevant training for all staff and accessible policies and procedures. The Designated Nurse Safeguarding Adults is a core member of the St Helens Multi-Agency Channel Panel which is now well established.
• Refugee Resettlement Programme - In accordance with national policy the Designated Nurse Safeguarding Adults continues to work collaboratively with key partner agencies and in conjunction with the CCG Primary Care Team to enable the successful implementation of a refugee resettlement programme for St Helens.
• Partnership Working - St Helens CCG is a statutory partner of the St Helens Safeguarding Adults Board (SAB); a partnership of agencies with responsibility for protecting adults in St Helens from abuse, and promoting their welfare. The St Helens SAB sets priorities for the Borough and holds organisations to account regarding their safeguarding responsibility. This is achieved through membership of the SAB and its sub groups. The Chief Nurse and Designated Nurse for Safeguarding Adults represent the CCG at the Board and are members of the Strategic Leads and Safeguarding Adult Review sub-groups. The Designated Nurse Safeguarding Adults chairs the Practice and Performance sub-group which has multi-agency membership.
The Designated Nurse Safeguarding Adults works closely with the Local Authority Safeguarding Adult Unit and a robust process is in place to support Social Work colleagues in accessing timely clinical input to safeguarding enquiries and quality monitoring concerns.
• Safeguarding Adult Review (SAR) – At the time of this report, there is one statutory SAR in progress in St Helens. Recommendations learning will be formally shared with partnership agencies when the report is published.
6. Governance Arrangements
The CCG is required to have in place arrangements which ensure the provision of the expertise of Designated Professionals including; Designated Nurses (children and adult), a Designated Doctor (Safeguarding and Looked After Children) and Named GP. These professionals act as clinical advisors to the CCG on safeguarding matters and support the Chief Nurse to ensure that the local health system is safely discharging safeguarding responsibilities.
Accountability for the safe discharge of safeguarding responsibilities remains with the Clinical Accountable Officer; executive leadership is through the Chief Nurse who represents the CCG at the St Helens Safeguarding Children Partnership and Safeguarding Adult Board.
244 Safeguarding reports are presented, as a minimum, to the Quality Committee on a quarterly basis to apprise members of current safeguarding activity, including performance reports for commissioned services against the specific safeguarding Key Performance Indicators (KPIs). The reports also provide updates on national and regional safeguarding developments and outline expectations of the CCG in response to them.
Reports are also provided to the Governing Body to provide a level of assurance that safeguarding responsibilities are being safely discharged. This will comprise of key safeguarding updates from a local, regional and national perspective about initiatives, the quality of safeguarding services delivered and risks that are apparent in the system.
The CCG continues to work in partnership with statutory agencies and the third sector to support safe and effective delivery of services against the safeguarding agenda.
NHS St Helens CCG is required to provide assurance that safeguarding activity within all commissioned services meets national safeguarding standards and demonstrates a model of continuous improvement. This is reflected in local policy and procedure and is reflected in the CCG safeguarding accountability framework and contractual standards.
7. Incident and Risk Management
In accordance with national guidance there is requirement for areas of risk to be recorded on the CCG Risk register, safeguarding being no exception. At the end of the reporting period March 2020, two risks remained on the register and that was in respect of Designated Doctor capacity for St Helens and a Gap in the provision of the Named Nurse for Looked After Children (LAC) within the Community Paediatric and LAC contract and sickness within the team which is impacting on the provision of the service. This risk has been reduced by the appointment of a Named Nurse for Looked after Children however it remains on the register until the positive impact of this appointment can be evidenced.
The CCG has oversight of provider serious incidents via STEIS and all incident investigation reports are reviewed by the CCG Serious Incident Review Group. This is a multi-agency group aimed at supporting learning. The Designated Nurse Safeguarding Adults is a core member and the group Terms of Reference incorporate consideration of safeguarding issues and the process for escalation to the Safeguarding Board, with the aim of ensuring that safeguarding is threaded through investigations and the wider subsequent learning.
8. Effectiveness of Safeguarding Arrangements
The CCG has a statutory requirement under Section 11 of the Children Act 2004 to actively demonstrate that safeguarding duties are safely discharged. The current arrangements require the CCG to submit evidence of safeguarding compliance to St Helens Safeguarding Children Partnership for scrutiny; a full assessment against the Section 11 standards was submitted within this reporting year and feedback of assurance was received from the St Helens Safeguarding Children Partnership. The CCG were reported as fully compliant against the standards and this was reported to the CCG Quality Committee in February 2020.
As reported previously the CCG has a statutory duty to ensure that that all health providers from whom services are commissioned promote the welfare of children and protect adults from abuse or the risk of abuse; and are able to demonstrate that outcomes for children, young people and adults at risk are improved. The CCG remains committed to working collaboratively
245 with commissioned services and utilises a number of approaches including quarterly meetings and supervision with Provider Organisations to ensure that there is an acceptable level of assurance provided within the system to demonstrate safe, efficient and quality services are being delivered and that safeguarding responsibilities are safely discharged. Where the level of assurance has not been demonstrated and agreed recovery / progress has not been achieved, then contractual levers can be evoked, all of which is agreed and monitored via the CCG Quality Committee. In more exceptional circumstances, the CCG will work collaboratively with NHS England and other regulatory partners within the Quality Surveillance Group to gain a shared view of risks to quality through sharing intelligence. There has been no requirement for the CCG to evoke such levers in this financial year.
9. Training:
The CCG continues to promote the learning and development of staff and safeguarding training is part of the mandatory schedule for all CCG employees to ensure compliance with national guidance for health professionals. The CCG is required to ensure that all staff undertake safeguarding training in accordance with requirements for their role and responsibilities.
The Table below provides the 2019/20 end of year uptake. Mandatory Training compliance is monitored:
2019/20 Training Training CCG Staff Safeguarding Children Level 100% 1 Safeguarding Children Level 100% 2 Safeguarding Adults Level 1 98% Safeguarding Adults Level 2 100% Prevent Basic Awareness 88% Prevent Level 3-5 100% Governing Body / Board TBC training
CCG training compliance is managed by the NHS Midlands and Lancashire Commissioning Support Unit.
The CCG Training Strategy is a stepped approach to training and requires staff to work through the each mandated level of training assigned to role.
10. Challenges for 2019-20
Many of the challenges from last year remain in that both the local and regional structures; governance and reporting across health and social care continue to change across Cheshire/Merseyside and the surrounding boroughs.
Progress was made against the integration agenda and the model of St Helens Cares; this has continued to present opportunities to review and strengthen the safeguarding arrangements
246 within the Borough. Challenges remain to make sure that there is no negative impact on vulnerable children and adults within the Borough at this time of change; it is essential to ensure that strong risk management arrangements are in place.
Progress has been made against all of the agreed priorities for the CCG for 2019/20, with 6 being completed. Those that remain incomplete will be transferred into 2020/21.
During Quarter 4 of the reporting year there were additional challenges in relation to COVID-19. The impact of this is not fully understood as the Country remained in crisis at the end of the reporting year. The COVID surge and reset plan will be a priority for 2020/21.
11. Business Continuity 2019-20
The Designated Doctor role for Safeguarding Children (DDSC) remains vacant. The role has been further advertised during the reporting period however the CCG has been unsuccessful in recruitment. In the main, business has not been affected as contingency arrangements were utilised and support from within the Partnership to carry out the DDSC functions required. The CCG have been fully apprised of safeguarding activity in relation to the DDSC function within the Borough and this has been reported via the wider governance arrangements. The CCG recognises that in the absence of a current DDSC there is a need for formal arrangements in the interim and funding has been available as those functions have arisen.
Throughout the reporting period the CCG have been fully apprised of all other safeguarding activity within the borough via the wider governance arrangements.
12. Priorities for 2020-21
Priorities identified for the year 2020-21 will be monitored through the CCG Quality Committee. The key priorities for the forthcoming year are:
• Recruitment to the statutory post of Designated Doctor.
• As a key partner the CCG will continue to contribute to the safeguarding children’s partnership and multi- agency safeguarding arrangements in line with local and national guidance.
• To support the recovery and reset of the safeguarding agenda following COVID-19 pandemic within the Borough.
• To contribute to preparedness for potential surge of safeguarding issues as a result of the COVID-19 pandemic.
• Continued partnership work with the Local Safeguarding Adult Board and support with the implementation and development of national and local safeguarding arrangements in accordance with guidance, learning from reviews and LSAB strategic plan.
• Continued contribution to the integration of the work of the CCG with partner agencies within the local safeguarding arena.
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• To improve the quality of safeguarding activity and support within primary care on a locality footprint.
• To commission enhanced health contribution within the MASH service.
• To ensure the Looked after Children’s health team deliver against the service specification in its entirety
• Continued monitoring of commissioned Providers to deliver assurance of their continued engagement with the safeguarding work and agenda.
• Ensure that the CCG is compliant with statutory safeguarding responsibilities requirements; including the oversight and management of progression against action plans for section 11 scrutiny, NHSE assurance and other safeguarding frameworks to include training.
• Continue to work closely with NHSE and with Provider organisations to support the implementation of the Safeguarding Adults Intercollegiate Document (2018).
• Continue to work closely with the Local Authority and with Provider organisations to support implementation of the Mental Capacity (Amendment) Bill, in line with anticipated guidance and revised Codes of Practice.
• Continue to make progress to ensure that the voice of the adult at risk and their carers is captured in line with Making Safeguarding Personal.
13. Conclusion
This annual report provides a summary of progress against the safeguarding priorities set for 2019/20. The report demonstrates the contribution to multi agency partnerships across the borough and provides assurance to the Governing Body that the CCG is fully committed to ensuring it meets the statutory duties and responsibilities for safeguarding children and adults at risk of harm.
The CCG is actively involved in improving safeguarding arrangements for children, young people and adults at risk and works closely with multi-agency partners. It is represented at senior level on all key forums providing specialist health advice and leadership and pro-actively contributes to the safeguarding of children, young people and adults at risk.
The CCG has in place robust governance arrangements for safeguarding that are under constant review to ensure that they reflect any emerging requirements.
248 Appendix 1: Progress against the 2019/20 CCG Business Priorities
Business Priority Actions narrative Completed / on target 1 Recruitment to the statutory posts of Advertised via BMJ with varying Post remains vacant. NHSE Designated Doctor. opportunities, liaison with recognise that there is NNDHP to promote the post. emerging evidence that this is Consideration for post to be a National theme with maintained via CCG or Provider recruitment difficulties 2 The CCG will contribute to the implementation SCP has been in place since Fully achieved during of the new children’s partnership and multi- June 2019. The CCG are a key 2019/20 agency safeguarding arrangements in line with partner and represent the health local and national guidance. economy. Multi agency safeguarding arrangements have been published. A health forum has been established to support the SCP 3 Continue partnership work with the Local The CCG are a key partner of Fully achieved during Safeguarding Adult Board and support with the the Safeguarding Adults Board 2019/20 implementation and development of national and are represented at all sub- and local safeguarding arrangements in groups of the Board. accordance with guidance, learning from reviews and LSAB strategic plan. 4 To contribution to the integration of CCG and Designated Nurses for Children partner agencies within the local safeguarding remain within the safeguarding arena. unit and continue to strengthen professional relationship and support and develop multi- agency systems and processes. The Designated Nurse Safeguarding Adults works in
249 Business Priority Actions narrative Completed / on target close collaboration with the Local Authority Safeguarding Adult Unit. 5 To drive improvements in relation to the quality Level 3 training delivered on a Remains ongoing for 2020/21 of safeguarding activity and support within twice yearly basis. primary care. Introduction of the Safeguarding Health Forum, chaired by the Chief Nurse. Regular liaison with Named GP’s for Safeguarding. Safeguarding Support Sessions offered to Primary Care. Primary Care Strategy drafted Bespoke training/support in relation to Domestic Abuse 6 To support the implementation of the Looked Funding resourced for Named Remains ongoing as after Children’s health team Nurse and post recruited to development required for the Service transferred to alternate team and service delivery Provider Service specification refreshed 7 Continued monitoring of commissioned Quality schedules and Key Performance Indicators Providers to deliver assurance of their performance management are monitored and reported continued engagement with the safeguarding frameworks for safeguarding are on quarterly and feedback agenda monitored and reported on a provided to Provider quarterly basis Organisations and Co Commissioners 8 Ensure that the CCG is compliant with statutory Section 11 audit submitted to Assurance gained regarding safeguarding responsibilities requirements; SCP Section 11 audit including the oversight and management of Training compliance monitored progression against action plans for section 11 via HR processes and
250 Business Priority Actions narrative Completed / on target scrutiny, NHSE assurance and other escalated via managers as safeguarding frameworks to include training. appropriate Attendance at the Peoples Board which monitors improvement plans 9 To work collaboratively with key partner Continue to maintain Fully achieved during agencies in relation to the Refugee relationships with key partners 2019/20 Resettlement Programme. and with the CCG Primary Care Team. 10 To work closely with NHSE and with Provider Toolkit development is being led organisations to support the implementation of by an NHSE Task and Finish the Safeguarding Adults Intercollegiate Group. The Designated Nurse Document (2018). Adults is linked into the ongoing work through the Regional network. 11 Continue to work closely with the Local A CCG Working Group is The implementation, Authority and with Provider organisations to established to work towards originally planned for October support implementation of the Mental Capacity implementation. 2020, has been put on hold (Amendment) Bill, in line with anticipated A draft action plan is in place. by the Government, amid the guidance and revised Codes of Practice. The Designated Nurse Covid-19 crisis. Safeguarding Adults attends a Multi-Agency MCA Group chaired by the Local Authority. 12 Implementation of a robust assurance Initial consultation identified both A Small Contracts framework for all CCG commissioned small CCG and LA small contracts Safeguarding Assurance Tool contracts and development of an assurance required oversight. Initial is incorporated into the framework for individual placements i.e. OOA discussion with the LA agreed a Fairfield Independent placements and CHC. joint approach. Hospital Contract. Work in relation to other small contracts continues.
251 252 Report to NHS St Helens CCG Governing Body Date of meeting: 8th July 2020 – Governing Body Member Lead: Julie Ashurst Director Commissioning, Primary Care & Transformation – Accountable Director: Julie Ashurst Director Commissioning, Primary Care & Transformation Report Author: Debbie Lowe, Service Lead, IFR, Prior Approval & Policy Development, Midlands and Lancashire CSU Report title: CGM Commissioning Policy Review
Item for: Decision X Assurance Information (Please insert X as appropriate)
This report supports the following CCG Strategic Objectives. Please insert ‘x’ as appropriate.
1. To deliver financial stability X 2. To integrate health within the place of St Helens through system redesign
bjectives 3. To deliver improved outcomes for people X Strategic O 4. To be recognised as good system leaders 5. To support and transform primary care to be a system leader in St Helens Cares Does this report provide assurance against any of the risks identified in the Assurance Framework? (please specify) As per above
What level of assurance does it provide? Significant
Risk (List levels i.e. Limited/Reasonable/Significant)
Is this report required under NHS guidance or for statutory purpose? (please specify) Governance and No
Purpose of this paper Revised CGM commissioning policy, covering 6 Cheshire & Mersey CCGs, has been reviewed and recommended amendments presented to Governing Body for discussion and approval.
Does this paper link to any of the Out of Hospital Care and Hospital Care – Planned. key themes of the CCG’s Operational Plan & Improvement Plan. If yes, please specify.
How will this benefit the health and The proposal of the CBCT suite of policies will ensure that care wellbeing of St Helens residents or is given based on need rather than any subjective judgements the Clinical Commissioning Group? which can exacerbate health inequalities. Policies have been reviewed and updated with the latest clinical guidance from NICE to ensure that the right patients get the care which will benefit them Please describe any possible None identified at present. Conflicts of Interest associated with this paper.
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Please identify any current services GPs will need to work to the new criteria for care. The CCG or roles that may be affected by will ensure that there is a robust Communication Strategy for issues within this paper. raising awareness of the new policy in primary care and that GPs are specifically made aware where a policy has changed.
What risks may arise as a result of Reputational risk this paper? How can they be Changes to eligibility criteria for services can generate disquiet mitigated? amongst the public. The CCG will be aware that it may receive negative publicity once the proposed changes are implemented.
Mitigation The policies have been amended via consensus and with a group across Cheshire and Merseyside so that this CCG’s position is consistent with that of others and should not be singled out negatively for its proposals. The participating CCGs are Knowsley, Warrington, Halton, South Sefton, Southport and Formby, Liverpool and St Helens.
Wide reaching auditable engagement and consultation exercises have been undertaken demonstrating that the CCG has been transparent in its work and met all of its obligations.
Financial risk The financial impact of the policy changes has not been calculated in detail by the CSU, there is a small risk that the CCG could incur additional costs due to the changes.
Mitigation A preliminary analysis of the impact of the changes before consultation and engagement has been carried out.
1. Executive Summary Following on from Governing Body’s approval of the Phase 3 Suite of CBCT policies in March 2020, the Continuous Glucose Monitoring (CGM) policy has been reviewed and recommended amendments presented to Governing Body for approval (see section 7 of report). 2. Recommendations Governing Body is asked to consider the following: The evidence to support the commissioning of standalone CGM The proposed revision of the policy criteria to include stand-alone CGM for people with type 1 diabetes who, in the opinion of the specialist, cannot use an insulin pump for genuine reasons. Should this proposed amendment apply to both adults and children? Should CGM be offered to all women with type 1 diabetes who are pregnant? The request that CGM be considered for isolated patients with type 1 diabetes who are planning pregnancy.
Governing Body is asked to review and approve the proposed amendments.
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DOCUMENT DEVELOPMENT
Process Yes No N/A Comments & Date Outcome (i.e. presentation, verbal, actual report) Public Engagement (please detail X CSU led policy the method i.e. survey, event, development programme. consultation)
Clinical Engagement (please X CSU led policy detail the method i.e. survey, event, development programme consultation) – clinical input from Diabetes Specialists/ Clinicians. Has ‘due regard’ been given to X CSU led policy Equality Analysis (EA) and any development programme. adverse impacts? (Please detail outcomes, including risks and how these will be managed)
Legal Advice Sought X CSU led policy development programme.
Presented to any other groups X Stakeholder engagement or committees including 5 other C&M CCGs Partnership Groups – Internal/External (please specify in comments)
Note: Please ensure that it is clear in the comments and date column how and when particular stakeholders were involved in this work and ensure there is clarity in the outcome column showing what the key message or decision was from that group and whether amendments were requested about a particular part of the work.
255 Policy Development Programme: Suite 3 policies
CGM Commissioning Policy Review
Helen Dingle, Senior Prescribing Adviser, NHS Midlands and Lancashire Commissioning Support Unit (MLCSU)
Lead Author Paul Tyldesley, Medicines Commissioning Pharmacist, NHS Midlands and Lancashire Commissioning Support Unit (MLCSU)
Please tick as appropriate For Information Purpose of the Report For Discussion
For Decision The revised CGM commissioning policy is currently undergoing ratification in the 6 CCGs that have worked collaboratively to oversee this review as part of Suite 3 in the Policy Development programme.
St Helen’s CCG have requested a review of the CGM policy Executive Summary criteria, specifically that the commissioning of stand-alone CGM for people with type 1 diabetes who are not using an insulin pump is considered.
A subsequent query about the commissioning of CGM in pregnancy has also been considered.
That CCGs consider the following: i. The evidence to support the commissioning of stand- alone CGM ii. The proposed revision of the policy criteria to include stand-alone CGM for people with type 1 diabetes who, in the opinion of the specialist, cannot use an insulin pump for genuine reasons. Recommendations iii. Should this proposed amendment apply to both adults and children? iv. Should CGM be offered to all women with type 1 diabetes who are pregnant? v. The request that CGM be considered for isolated patients with type 1 diabetes who are planning pregnancy.
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1. Introduction
1.1 The purpose of this paper is to review the evidence to support the use of stand-alone CGM and consider if the criteria in the CGM policy should be revised to include it.
1.2 Proposed revised criteria are included in Appendix 1 and 2.
1.3 The intention is for all 6 CCGs involved in the collaborative policy development programme to have sufficient information to be able to consider this request for the revision of the criteria.
1.4 CCGs are also asked to consider if all women with type 1 diabetes who are pregnant should be offered CGM and should this also be available to women who are planning a pregnancy.
2. Background
2.1 Version 1 of the CGM commissioning policy was developed in 2014. A comprehensive evidence review was conducted by a public health specialist who then developed the commissioning criteria with support from a consultant diabetologist. The review concluded that the evidence to support CGM was questionable in terms of low patient numbers, the open nature of the trials, the short-term outcomes and heavy industry sponsorship. The agreed policy criteria stated that the patient should currently be on an insulin pump that would integrate with CGM before starting CGM.
2.2 The CGM policy was revised as part of the suite 3 work in the policy development programme. The public health specialist who had worked on the original policy conducted a second evidence review in 2017 which noted that the new tranche of articles added little to the current body of knowledge and, with support from the same consultant diabetologist, made recommendations which included the commissioning of only integrated CGM and pump. Medicines Management further developed the criteria so that they would be clear and quantifiable, and fine-tuned the details following an informal consultation amongst Cheshire and Merseyside specialist diabetologists. The new criteria provided specific guidance for pregnant women and for children, expanded the criteria for patients with hypoglycaemia and, although it still stated that patients should be currently using an insulin pump, the CGM no longer needed to integrate with the pump.
2.3 The draft CGM policy was circulated to provider organisations in September 2018 and the feedback was considered by the working group in November 2018. Clinicians in two trusts had noted that isolated patients may benefit from CGM but be clinically unable to use an insulin pump. The working group agreed that as these numbers were so small, and the conclusions of the review suggested that patients would derive more benefit from using both an insulin pump and CGM, these requests should be managed as IFRs. The Diabetes Technology Special Interest Group also agreed that the priority was to move the current draft of the policy through the ratification process as soon as possible.
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2.4 This draft policy was adopted as an interim policy by CCGs early in 2019 as the pump and CGM market was rapidly changing and the 2014 policy was no longer fit for purpose. 11 of the 12 Cheshire and Merseyside CCGs have adopted version 2 of the policy and 5 of the 6 CCGs who participated in the policy development working group have now formally ratified the policy.
3. Current situation
3.1 St Helens CCG recently received a complaint regarding the interim CGM policy. The complaint was made by Dr Gardner, on behalf of the patient’s parents, in his role as the Chair of the Children and Young People’s North West Diabetes Network.
3.2 Consequently, St Helens CCG have requested a review of the CGM policy criteria, specifically that the commissioning of stand-alone CGM for people with type 1 diabetes who are not using an insulin pump, is considered.
3.3 In 2018 there were two IFRs for stand-alone CGM, six in 2019 and two so far in 2020. When there were clinical reasons for the patient to be unable to use an insulin pump, the requests were considered at panel meetings. When there was no clinical reason for the patient to not use an insulin pump, they were declined on the basis they did not meet the policy criteria and were not demonstrated to be clinically exceptional.
3.4 St Helens CCG have received a second complaint relating to the criteria for CGM access for pregnant women, specifically the potential lack of access during the pregnancy planning stage.
4. Evidence review for stand-alone CGM
4.1 A literature search on Embase using the terms “continuous glucose monitoring” or “CGM” yielded several thousand studies therefore it was not possible to conduct a full evidence review post 2017. A separate search combining the above terms with terms relating to ‘paediatrics’ did not find any additional studies in children and young people since 2017.
4.2 However, a systematic review was published in February 2020 by Pease et al1. This review identified 16,772 publications, of which 52 eligible studies compared 12 diabetes management technologies comprising 3,975 participants. It includes four additional studies published since 2017, for standalone CGM use. The review compared insulin pump with either integrated or non-integrated CGM, flash glucose monitoring or self-monitoring of blood glucose (SMBG) plus multiple daily insulin injections (MDI) with either stand-alone CGM, flash glucose monitoring or SMBG.
4.3 The review reported that integrated insulin pump and continuous glucose monitoring (CGM) systems resulted in greater reduction in HbA1c levels than multiple daily injections with either flash glucose monitoring or blood glucose monitoring strips. Technologies by reduction of HbA1c values were ranked as follows: Integrated systems, insulin pump with standalone CGM, MDI with CGM and insulin pump with bolus calculators. It also notes that treatment effects were non-significant for severe hypoglycaemia or quality of life but simultaneous evaluation of outcomes in cluster analyses appeared to favour integrated insulin pump and continuous glucose monitors. They felt there was a high risk of bias and that certainty of evidence was low.
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4.4 The review concludes that integrated insulin pump and CGM systems with low-glucose suspend or hybrid closed-loop capability appeared best for HbA1c reduction, severe hypoglycemia, and possibly quality of life.
4.5 A Cochrane review of monitoring of blood glucose during pregnancy for women with pre-existing diabetes was updated in 20192. The updated review concluded: “Additional evidence from large well‐designed randomised trials is required to inform choices of other glucose monitoring techniques and to confirm the effectiveness of CGM.”
4.6 There is also an additional 3 year follow up study published in Diabetes Care in 2020 which followed 94 patients with type 1 diabetes3. In this study, 22 patients had CGM with multiple daily insulin doses and 26 had CGM with an insulin pump. 25 had an insulin pump plus self-monitoring of blood glucose (SMBG) and 21 had multiple daily insulin doses plus SMBG. This study concluded that CGM was superior to SMBG in reducing HbA1c, hypoglycaemia and other end points in individuals regardless of their insulin delivery method.
4.7 NICE NG174 states the following in section 1.6.23: “For adults with type 1 diabetes who are having real-time continuous glucose monitoring, use the principles of flexible insulin therapy with either a multiple daily injection insulin regimen or continuous subcutaneous insulin infusion (CSII or insulin pump) therapy.”
4.8 Although the evidence suggests concomitant use of an insulin pump with CGM is preferable, NICE NG185 discusses insulin pumps and CGM separately and does not specifically state at any point that they must be used together.
5. Evidence for CGM in pregnancy
5.1 Evidence for CGM in pregnancy comes from the CONCEPTT trial6. 325 women who were pregnant (≤13 weeks and 6 days' gestation) or planning pregnancy from 31 hospitals in Canada, England, Scotland, Spain, Italy, Ireland, and the USA were followed for 12 months. The results showed a small improvement in HbA1c but there was a significant improvement in neonatal health outcomes. The study found no apparent benefit of CGM in women planning pregnancy.
5.2 The NHS Long Term plan which was published in January 2019 stated that by 2020/21, all pregnant women with type 1 diabetes will be offered continuous glucose monitoring, helping to improve neonatal outcomes. A subsequent press release recommended that STPs should update local prescribing guidelines to match with the Long-Term Plan target for all pregnant women with type 1 diabetes by 2020/21.
5.3 NICE NG3 considers pre-conception management of pregnancy in type 1 diabetes7. In section 2 it says they don't know if CGM is effective before conception or in early pregnancy, so they need a randomised trial in women with diabetes who are planning pregnancy.
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6. Conclusion
6.1 There is an absence of good quality evidence to support the use of stand-alone CGM although NICE has said CGM could be used with either insulin delivery method for adults. While NICE has not made a similar recommendation for children, it has not specifically stated that children must be using an insulin pump to be able to access CGM.
6.2 There are several limitations with the additional studies published since 2017 and there is no additional data to inform the use of CGM devices in children and young people.
6.3 The trials are short term in nature, except for the 3-year study, with small patient numbers.
6.4 Due to the nature of the CGM intervention, there is no blinded data to support its use.
6.5 The systematic review concluded that integrated insulin pump and CGM systems with low-glucose suspend or hybrid closed-loop capability appeared best for A1c reduction, severe hypoglycemia, and possibly quality of life.
6.6 Since the available evidence supports the use of an insulin pump plus CGM, stand- alone CGM should only be considered for commissioning when, in the opinion of the specialist, the patient is unable to use a pump for genuine reasons.
6.7 The evidence to support the use of CGM in all women with type 1 diabetes who are pregnant comes from one small clinical trial, but NHS England has directed that STPs should review CGM guidance by 2020/21.
6.8 There is no evidence to support the use of CGM pre-conception for women with type 1 diabetes.
7. Recommendations
7.1 CCG Commissioning Leads are asked to:
i. Consider an amendment to the CGM policy to say ‘When, in the opinion of the specialist, a patient is unable to use an insulin pump for genuine reasons, stand- alone CGM may be considered alongside multiple daily doses of insulin only when all the other criteria for CGM in children or adults are met’. See Appendix 1.
ii. If any amendment is agreed, consider if this applies to both adults and children.
iii. Should a further amendment to the policy to say that CGM should be offered to all women with type 1 diabetes who are pregnant be considered now or should we wait for the direction from the STP?
iv. As there is no evidence to support the use of CGM pre-conception, consider if funding requests for these isolated patients should come through the IFR route, and only approved if the clinical exceptionality criteria is met; and that the policy should not be amended to include planning for pregnancy.
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v. If the point above is agreed, consider if these requests should be approved by Medicines Management IFR team on behalf of the CCG if the request is clinically appropriate.
MLCSU Policy Development Team May 2020
References
1. Pease A, Lo C, Earnest A, Kiriakova V, Liew D, Zoungas S. The Efficacy of Technology in Type 1 Diabetes: A Systematic Review, Network Meta-analysis, and Narrative Synthesis. Diabetes Technology and Therapeutics. 2020; vol 22, 6
2. Jones LV, Moy FM, Ray A, Buckley BS. Techniques of monitoring blood glucose during pregnancy for women with pre-existing diabetes (Update). The Cochrane database of systematic reviews. 2019;6:CD009613.
3. Soupal J, et al. Glycaemic Outcomes in Adults with T1D are Impacted More by Continuous Glucose Monitoring than by Insulin Delivery Method: 3 Years of Follow Up from the COMISAIR Study. Diabetes Care 2020; 43: 37-43 4. NICE NG17 Type 1 diabetes in adults: diagnosis and management. August 2015. NICE NG17 5. NICE NG18 Diabetes (type 1 and type 2) in children and young people: diagnosis and management. August 2015. NICE NG18 6. Feig DS et al. Continuous glucose monitoring in pregnant women with type 1 diabetes (CONCEPTT): a multicentre international randomised controlled trial. Lancet 2017 Nov 25;390:2347-2359 7. NICE NG3 Diabetes in pregnancy: management from preconception to the postnatal period. February 2015. NG3
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Appendix 1. Interim CGM commissioning policy with proposed amendments
Intervention Continuous Glucose Monitoring Policy Statement Restricted Minimum Adults with type 1 diabetes eligibility criteria CGM is only commissioned in the following circumstances.
CGM will only be considered for patients when the following criteria are met: • Already established for at least 3 months on a continuous subcutaneous insulin pump of high specification in strict accordance with NICE appraisal TAG 151 and the local insulin pump policy. OR • When, in the opinion of the diabetes specialist, a patient is unable to use an insulin pump for genuine clinical reasons, stand-alone CGM may be considered, alongside multiple daily insulin injections, only when all the other criteria for CGM in adults are met. The evidence suggests that whenever possible, the preferred option of combined insulin pump and CGM should be considered. AND • Managed by a recognised adult specialist centre of expertise. This will have a multidisciplinary team comprising a trained diabetes nurse specialist, physician and dietician with all patients trained to count carbohydrates. AND • Willing to commit to using CGM at least 70% of the time and to calibrate it as needed. PLUS • HbA1c ≥75 mmol/mol (9%) that persists despite blood glucose testing at least 10 times a day** **Where CGM is initiated due to hyperglycaemia in adults, it should only be continued longer-term if HbA1c can be sustained at or below 53 mmol/mol (7%) and/or there has been a fall in HbA1c of 27 mmol/mol (2.5%) or more, in accordance with NICE CG17. OR • Experiencing more than one severe hypoglycaemic episode a year with no obviously preventable precipitating cause. (Severe hypoglycaemia is generally recognised as hypoglycaemia involving convulsions/ unconsciousness) OR • Experiencing more than 2 episodes of hypoglycaemia per week that the patient has been unable to manage themselves and are causing problems with daily activities. OR • Complete loss of awareness of hypoglycaemia OR • Inability to recognise or communicate about symptoms of hypoglycaemia e.g. because of cognitive or neurological disabilities where other forms of glucose monitoring are not appropriate.
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Pregnancy
CGM is only commissioned in pregnancy when all criteria for CGM in adults are met. Where CGM in pregnancy is used, funding is only for the duration of the pregnancy. Insulin doses are reduced to pre-pregnancy levels as soon as the baby is delivered and CGM should not be continued beyond this point.
FOR ALL PATIENTS
A CGM system with a low Mean Absolute Relative Difference (MARD) value should be chosen.
Where there is a CGM system with alarm function that will integrate and communicate directly with the patient’s established insulin pump, then this CGM system should generally be used. However, an appropriate real-time Dexcom CGM system with alarm function may be considered for patients using other insulin pumps, or those individuals where the integrated system is not the most clinically appropriate CGM system.
The device should be withdrawn from patients who fail to achieve a clinically significant response after 6 months*.
There should also be an annual review to assure the clinically significant response is maintained and that CGM is still the most appropriate method of glucose monitoring for the patient. Consideration should be given to switching to an integrated insulin pump/CGM system when seeking to replace the insulin pump at warranty expiry, if appropriate.
Children and young people with type 1 diabetes
CGM is only commissioned in the following circumstances.
CGM will only be considered for patients when the following criteria are met:
• Already established for at least 3 months on a continuous subcutaneous insulin pump of high specification, in strict accordance with NICE appraisal TAG 151 and the local insulin pump policy. OR • When, in the opinion of the diabetes specialist, a patient is unable to use an insulin pump for genuine clinical reasons, stand-alone CGM may be considered, alongside multiple daily insulin injections, only when all the other criteria for CGM in children are met. The evidence suggests that whenever possible, the preferred option of combined insulin pump and CGM should be considered. AND • When provided by a specialist centre with a multidisciplinary team including an active member who attends at least 67% (2/3) of the North West children and young people's diabetes network meetings. In addition, the specialist centre is achieving best practice tariff in paediatric diabetes and is also engaged with the national peer review programme in paediatric diabetes, to monitor the quality of its service. AND
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• Willing to commit to using CGM at least 70% of the time and to calibrate it as needed. PLUS • Experiencing more than 2 episodes per week of severe hypoglycaemia. This is defined as having low blood glucose levels that require assistance from another person to treat and that are happening often enough to have a significant impact on schoolwork or quality of life. OR • Inability to recognise or communicate about symptoms of hypoglycaemia e.g. because of cognitive or neurological disabilities, or less than 4 years of age. OR • Impaired awareness of hypoglycaemia which is associated with significant adverse consequences e.g. seizures or severe anxiety.
Prior to transition to adult services, the child should be counselled on the transition process and advised that their CGM will be reviewed as part of the transition and their ongoing adult diabetes care. On transition to adult services there should be a review to assure there is still a clinically significant response* and that CGM is still the most appropriate method of glucose monitoring for the patient.
Ongoing continuation of CGM
* A clinically significant response is considered to be: • When the patient demonstrates wearing the sensor for at least 70% of the time. PLUS • A reduction in the frequency and/or severity of hypoglycaemic episodes. OR • A reduction in the need for third party intervention during hypoglycaemic episodes. AND/OR • Achievement of a clinically significant reduction in HbA1c, that demonstrates the patient is moving towards their individually agreed HbA1c target.
264 GLOSSARY of TERMS
A&E Accident & Emergency ACMS/ ACS Accountable Care Management System/ Accountable Care System AED Accident & Emergency Department AQP Any Qualified Provider BCF Better Care Fund BPT Best Practice Tariff BSA Business Services Authority C&B Choose and Book C&M Cheshire and Merseyside CAO Clinical Accountable Officer CCG Clinical Commissioning Group CCSP Clinical Commissioning Strategic Plan C-Diff Clostridium Difficile CFO Chief Finance Officer CHC Continuing Health Care CHP Community Health Partnership CQA Clinical Quality and Approvals CQC Care Quality Commission CQUIN Commissioning for Quality and Innovation CSU Commissioning Support Unit DCO Designated Clinical Officer DH Department of Health DOF Director of Finance DOLS Deprivation of Liberty Safeguards E&D Equality & Diversity EHCP Education Health and Care Plan EIA Equality Impact Assessment ESD Early Supported Discharge ETTF Estates & Technology Transformation Fund FARG Finance and Activity Review Group F&P Finance & Performance Committee FIH Fairfield Independent Hospital FT Foundation Trust GB Governing Body HIS Health Informatics Service IAPT Improved Access to Psychological Therapy IASH Integrated Access St Helens ICDG Integrated Commissioning Delivery Group IPC Infection Prevention & Control ISFE Integrated Single Financial Environment JSNA Joint Strategic Needs Analysis KLOE Key Line of Enquiry KPI Key Performance Indicators LA Local Authority
265 LAT Local Area Team LCS Locally Commissioned Services LMC Local Medical Committee LSP Local Strategic Partnership MCA Mental Capacity Act MIAA Mersey Internal Audit Agency MM Medicines Management MRSA Methicillin-resistant Staphylococcus aureus NCA Non-Contracted Activity NEL Non Elective NHSE NHS England NHSI NHS Improvement NHSPS NHS Property Services NPFIT National Programme for Information Technology NWAS North West Regional Ambulance Service NWB North West Boroughs PbR Payment by Results PIA Privacy Impact Assessment (Change to DPIA from April) PMO Programme Management Office PPA Prescription Pricing Authority QIA Quality Impact Assessment QIPP Quality, Innovation, Productivity and Prevention QOF Quality & Outcomes Framework QSG Quality Surveillance Group RLBUHT Royal Liverpool & Broadgreen University Hospital Trust RMS Referral Management System RTT Referral to Treatment SBS NHS Shared Business Services SEND Special Education Needs and Disability SIRG Serious Incident Review Group StH&KHT St Helens & Knowsley Hospitals Trust STP Sustainability and Transformation Plans SUI Serious Untoward Incident TFA Tripartite Formal Agreement W&H Warrington & Halton Foundation Trust WWL Wrightington Wigan and Leigh Foundation Trust
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