NHS Herts Valleys Clinical Commissioning Group Board Meeting 12 January 2017

Title Integrated quality performance and finance report Agenda Item: 11 Purpose (tick one only) Decision or Approval ☐ Discussion ☒ Information ☐ Responsible Director(s) and Charles Allan- Director of Contracts and Resilience Job Title Caroline Hall - Chief Finance Officer Diane Curbishley –Director of Quality and Nursing Author and Job Title Stephanie White – Performance Lead Short Summary of Paper This report provides an overview of performance across a number of domains, namely; contract performance, quality, finance and programme performance. An integrated approach to performance involves coordinating all monthly data collections, producing a standard list of dashboards that are presented to the Quality and Performance Committee for a full discussion and assurance before a subset of this standard list is presented at the HVCCG Board and Commissioning executive committee. The executive summary dashboards reflect the high priority key performance indicators identified which includes the recovery action plan/ trajectories (where applicable) and progress updates. Also included below is the Quality and Performance Committee Chair’s report for the meeting held on 5 January. Recommendation(s) The Committee is being asked to discuss and note the report

Engagement with Engagement has taken place with provider organisations. Stakeholders/Patient/Public Links to Strategic Objectives (tick all that apply) 1. Effective Engagement. We will continually improve engagements with member practices, patients, the ☒ public, carers and our staff to contribute to and influence the work of Herts Valleys CCG. 2. High Quality. We will commission safe, high quality services that meet the needs of the population, reducing ☒ health inequalities and supporting local people to avoid ill health and stay well. 3. Transforming Delivery. Work with health and social care partners to transform the delivery of care through ☒ the implementation of “Your Care, Your Future”, the Strategic Review in west Hertfordshire. 4. Affordable & Sustainable Care. We will ensure that there is a financially sustainable and affordable ☒ healthcare system in west Hertfordshire. Board Assurance Framework Yes, this contributes evidence of assurance for the Board Assurance Framework in (BAF) and Corporate Risk relation to: Register (CRR) 1.1 “Risk that we do not engage effectively with a range of our patients, population and stakeholders” What current risks does this 1.2 “Risk that our member practices and other partners do not see the potential report align to? positive impact of their engagement with HVCCG” 2.1 “Risk that we do not deliver on all NHS Constitutional pledges, key national targets and priorities” 2.2 “Risk that we are unable to ensure high quality, safe and sustainable services for the population and patients of west Hertfordshire” 2.3 “Risk that we do not close the health inequalities gap between the most and least deprived communities” 3.1 “ Risk that the joint submission to obtain additional capital resource to successfully transform the delivery of care in west Hertfordshire is unsuccessful” 3.2 “Risk that there will be insufficient support from local bodies and key stakeholders to transform the delivery of care in west Hertfordshire.” 3.3 “Risk that workforce issues will prevent us from transforming the delivery of care across the health and social care system” 4.1 “Risk that we do not deliver a financially sustainable health and social care system” 4.2“Risk that we do not deliver best value from the total CCG budget” 4.3 “Risk that we do not achieve financial balance for 2016/2017 This report mitigates risks on the Corporate Risk Register in relation to the following references: S01/24 Risk that public and stakeholders are not informed effectively S02/01 Risk of a lack of proportionate and effective controls on the use, sharing and publication of information SO2/15 Risk that the continuing healthcare (CHC) retrospective cases process is not able to deliver a desired outcome in a timely way S02/25 Risk of failure to deliver specific national targets n relation to dementia diagnosis S02/26 Risk to the CCG of not implementing the recommendations of Winterbourne View via the Transforming Care programme S02/30 Risk that patients are not assessed with a management plan and exited/admitted or discharged out of ED within 4 hours SO2/31 Risk that delayed transfers of care (DTOCs) are not reduced to the target of 2.5% SO2/32 Risk that the constitutional pledge to refer to treatment with 18 weeks at WHHT is not being met for our patients SO2/33 Risk that priority ambulance KPIs are not delivered for our patients. S03/02 Risk that localities will not be aligned with CCG strategic objectives S03/03 Risk of failure to ensure that Public Health is sufficiently embedded within the CCG programmes and localities S03/05 Risk that we fail to successfully transform health and social care through use of the Better Care Fund (BCF) S03/08 Risk that lack of available workforce in primary care prevents delivery of services identified as key to transformational change SO3/09 Risk that there will be a reduced level of provision for social care services S04/03 Risk that QIPP savings are not achieved as planned S04/22 Risk that there are higher levels of hospital activity than planned/anticipated S04/23 Risk that additional expenditure will occur that is not budgeted for. Risks (e.g. patient safety, The executive summary dashboards reflect the high priority key performance financial, legal) indicators identified which includes the recovery action plan/ trajectories (where What risks have been identified applicable) and progress updates. as a result of this report? How are they being mitigated? Resource Implications Not applicable. This report provides a general update on key quality, performance and finance issues Equality Impact Analysis There are no implications (indicate the key points the analysis has identified relevant to decision required) Equality Delivery System Better Health Outcomes ☒ (identify which goal your Improved Patient Access and Experience ☒ proposal / paper supports) A Representative and Supported ☒

Workforce Inclusive Leadership ☒ Report History 01 December 2016 quality and performance committee Which Groups or Committees have seen this report and when? Appendices 10) Quality premium 2016-2017 quarter 2 11) Workforce: quarter 2 13) Environmental report- quarter 2 14) Better care fund- quarter 2 15) Safe staffing- quarter 2 16) Learning disability report including transforming care – quarter 2 18) System resilliance progress report 19) Continuing health care – quarter 2 Glossary of terms

Chair’s report of Quality and Perforamnce Committee meeting held on 5 January

Month 8 Finance report

 The report is based on M7 activity.  Forecasts are based upon historic trends, but there is a risk that activity will differ from that predicted for the rest of the year.  Recovery actions still present an element of risk but a deficit position of £8M is still considered achievable.

Transformation and QIPP report

 The Committee noted that QIPP is just one indicator of financial grip among a number of others in a complex dashboard.  The Committee welcomed a simpler method of reporting QIPP in the future.  £33M QIPP has been identified so far for 2017/18 with £5M still to be scoped. Over and above the target of £38M additional schemes will be worked up to mitigate against the risk of less than 100% delivery and/or other factors so far unseen.

Integrated quality, performance & finance report 30 November 2016

 All contracts were signed by 23 December 2016.  WHHT A&E target is not currently in line with the revised trajectory.  Issues with RFL 62 week cancer waits are being looked at in detail.  There has been a deterioration in HUC performance. There is still a need for patient education on usage.  Two never events have been reported by WHHT and are being investigated.

Safeguarding adults & safeguarding children 6 month reports

 Both staffing and training at HPFT in relation to safeguarding adults need to improve.  Both Safeguarding Boards are operating effectively and joint working is being developed.

CQUINs 2016/17 Q2

 There will be no local CQUIN schemes next year: all are nationally mandated schemes from 2017/18.

Equality & Diversity Annual Report

 HVCCG is compliant with no big issues to report.  The report will be published before 31 January 2017.

Quality Improvement 6 month report

There are some care homes with concerns raised by the CQC, all of which are being monitored in joint visits by HVCCG and HCC. The Quality Improvement team is working effectively with the information available now a significant improvement on previous years. 12 January 2017 integrated, quality, performance and finance Board report

1) Sections in this report. The integrated quality, performance and finance report is a standardised set of dashboards with selected sections going to different groups, as described below: Available Quality and performance Ref. via HVCCG Board Section committee intranet 1 Introduction to the report   Key constitutional standards dashboard – funded via the Sustainability and transformation fund 2 (replacing the top 5 priority report as of October  2016 report ) and executive highlight exception  reports (priority key performance indicator dashboards ) Performance against key national indicators (CCG view, acute and community Trusts) full Full CCG 3 dashboards and CCG patients view for the all acute dashboard patients CCG patients view providers view

Quarterly stand-alone report Quality and monthly dashboard/ 4 Quality dashboard /narrative exception narrative / quality (verbal) exception verbal update Finance overview: As of January 2017 stand-alone 5  report  Appendices  6 Performance against CCG outcomes framework 6 monthly 6 monthly -appendix

7 Transformation / QIPP progress report Quarterly Stand-alone report

8 Digital road map Half yearly- appendix 9 Health and wellbeing Annual- appendix 10 Quality premium Quarterly- appendix 11 Workforce Quarterly- appendix 1 page 12 Freedom of information Quarterly - appendix summary Quarterly- appendix 13 Environmental of

14 Better care fund quarterly Quarterly- appendix

15 Safe staffing reports - Quarterly- appendix 16 Learning disability including transforming care appendix Quarterly -appendix 17 Everyone counts Annual -appendix 18 System resilience progress update report Monthly - appendix

19 Continuing health care (as of October 2016 report) Quarterly - appendix

20 WHHT quality improvement plan Monthly- appendix

CCG assurance framework 2016-2017 including the Quarterly 21 highlight report Quarterly - appendix six clinical priorities

A note about data 1.3. The integrated quality performance and finance report includes a disparate range of indicators supported by a wide range of activity, finance, epidemiological and survey data and information. Whilst some metrics are related to short- term operational activity (e.g. A & E performance against the 4 hour target) others relate to longer term changes in outcomes. Consequently, not all metrics are updated monthly, partly due to data availability but also because a particular metric will not change significantly over the period of a month.

The majority of the data is downloaded from the Unify 2 website; this is where providers upload their data. Cancer waits data comes from the open exeter system, the databases are live, so are constantly updated by the provider; therefore the data presented will reflect the position at the time of the data extraction. Sentinel stroke national audit programme (SSNAP) data is available quarterly; however current monthly stroke data comes from the provider performance reports. There is the development of monthly stroke metrics directly from SSNAP to develop Trust internal reporting database so that indicators can be reported on a monthly basis.

The East of England Ambulance Service sends their data to the HVCCG acute generic nhs.net email. 111 data source comes from sesui system that logs calls and Herts urgent care (HUC) data comes from the adastra system.

1.4 Finance reports are typically more contemporaneous than other performance reports and, as a consequence, there will often be a 1 month disparity between the period covered by finance reports and contract performance reports. Consequently, when compiling key performance messages it may be necessary to refer to previous monthly finance report as well as the ones included in this report.

1.5 As with performance reports in recent months the Herts valleys clinical commissioning group (HVCCG) are hampered by non-availability of patient identifiable data.

2. Executive summary: key constitutional standards dashboard For 2016/17 NHS Improvement has allocated additional funding from the sustainability transformation funds (STF) that will give the NHS the resources it needs as part of the five year forward view to sustain services.

Trusts have agreed with NHS England and NHS Improvement a credible plan for maintaining delivery of core standards for patients, including the 4 hour A&E standard, the 18 week referral to treatment standard and for appropriate providers, the ambulance access standards.

Key constitutional standards dashboard table below summarises the plan against actual performance for all of HVCCG main acute providers:

West Hertfordshire Hospital Trust

For 2016/17 NHS Improvement has allocated additional funding from the sustainability transformation funds (STF) for trusts to deliver against the agreed target recovery trajectories. The table below summarises the plan against actual performance at Trust level view.

Last 12 months Comments Trusts Standards Threshold Jul-16 Aug-16 Sep-16 Oct-16 YTD trend A&E Plan 91.0% 93.0% 87.5% 88.6% A&E 4 hour Performance in October deteriorated further to 82.4% and WHHT are not currently in line with our revised trajectory to meet compliance. 95% standard Both ambulance turnaround standards have deteriorated again in October .This is due to surges in ambulance arrivals both on individual days and at particular times of day. Actual 83.2% 85.0% 85.2% 82.4% 83.7% The number of patients coming by ambulance has increased this year. Whilst there has been problems recruiting a full compliment of HALOs the 4th HALO is now is in the process of being recruited 18-weeks RTT Plan No trajectories 88.90% 90.40% Performance in November for A&E shows a slight improvement to 83% as does ambulance turnaround standards Incomplete 92% Front door flow, including acute assessment units update: Pathways Actual 87.20% 87.20% 86.60% 87.40% 87.80% • The GP service in A&E agreement that more patients need to go through this service. •Twilight service – the first substantive staff are now in post and working on the shop floor 18-weeks RTT Plan 0 0 0 0 •Plan to trial Rating (rapid assessment and treatment) in emergency department (ED) (w/c 5/12) and a relocation of the clinical decisions unit (CDU). West Hertfordshire Volume of 52 0 .- The frailty consultant 6 day service commenced week of the 5/12/16 Hospital Trust weeks breaches Actual 0 1 0 0 4 •A Clinical champion and programme Lead has been identified for SAFER and training is going well. (WHHT) The system has undertaken a ‘perfect (red to green ) week w/c 5th Dec and lessons learnt are being aggregated and shared. 99% of Diagnostic Plan 99% 99% 99% 99% •The trust continues to work closely with the emergency care and improvement programme (ECIP) and system partners to improve Pathways to be 99% Seen within 6- Actual 100.0% 100.0% 99.9% 99.9% 99.9% RTT :October’s performance against the 92% incomplete pathway standard was 87.4%,(against the sustainability and transformation fund (STF) plan of 90.44%) up from 86.6% in weeks September and the best position Plan 85% 85% 85% 85% since June 2016. The total patient tracking lists (PTL) size reduced again (by 504 pathways) and the total backlog decreased (by 291 pathways) to 2959. Referrals from HVCCG GPs continued to fall, by 2.6% since September although ear nose and throat (ENT), ophthalmology and pain all received more referrals than the previous Cancer 62 days 85% month. from GP referral Actual 90.10% 88.70% 92.90% 87.00% 87.90% Outsourcing is underway, with 396 patients currently considered appropriate, of which 224 have agreed to treatment with an alternative provider and 74 have been dated. Aim for compliance by Dec 2016

2) Key constitutional standards dashboard table below summarises the plan against actual performance for all of HVCCG main acute providers (continued):

Royal free London: For 2016/17 NHS Improvement has allocated additional funding from the sustainability transformation funds (STF) for trusts to deliver against the agreed target recovery trajectories. The table below summarises the plan against actual performance at Trust level view.

Trusts Standards Threshold Jul-16 Aug-16 Sep-16 Oct-16 YTD Last 12 months trend Comments A&E :In October2016 the combined trust out turned at 85.48% against the 95% standard. Plan 95% 95% 95% 92% The major trend this year has been a continued increase in the volume of A&E arrivals. This is illustrated by the trend in A&E 4 hour standard 95% the year to date compared to last year, where arrivals at the Royal Free Hospital A&E department has increased 3.6% Actual 91.30% 90.00% 87.90% 85.50% 90.40% compared to the corresponding period of last year. A similar trend is observed at Barnet Hospital (which increased 1.8% ).Attendances to the Urgent Care Centre at Chase Farm show a 1% increase on the comparative period of last year. Plan 92.0% 92.0% 92.0% 92.0% 18-weeks RTT 92% RFL are working hard to achieve the 95% standard and are taking action to achieve this under the “Safer, Faster, Better” Incomplete Pathways Actual 92.2% 92.0% 92.1% 92.2% 91.8% programme. The salient schemes are listed below: • Creation and opening of a new medical short stay unit at Barnet Hospital 18-weeks RTT Volume of Plan 5 5 5 0 0 • Standardising board rounds on every ward to avoid unnecessary in-patient stay delays. 52 weeks breaches Royal Free London (RFL) Actual 2 3 5 2 20 • Monitoring every patient on every ward each day to confirm they have had the intervention as planned in a timely way to get them home. • Working with primary, community, CCG and local authority partners to ensure the right care and services at the right 99% of Diagnostic Plan 99% 99% 99% 99% time is available outside of hospital Pathways to be seen 99% • Working across all specialties to develop new pathways so that patients from ED can be treated in a planned and swift within 6-weeks Actual 99.80% 99.60% 99.80% 99.80% 99.70% way without them having to wait in the ED. • Continuing to reconfigure the medical rotas at BH to increase weekend senior clinical Plan 77.4% 78.1% 74.0% 78.0% Cancer 62 days from GP 52 week :Significant progress has also been made in the reduction of 52 week breaches since the resumption of national 85% referral Actual 75.8% 77.5% 78.0% 73.7% 79.2% reporting. RFL anticipate to find long-waiting pathways which have been supressed by the Intensive support team (IST) approved exclusion rules.

East and North Hospital Trust For 2016/17 NHS Improvement has allocated additional funding from the sustainability transformation funds (STF) for trusts to deliver against the agreed target recovery trajectories. The table below summarises the plan against actual performance at Trust level view.

Comments- Last 12 months Trusts Standards Threshold Jul-16 Aug-16 Sep-16 Oct-16 YTD trend A&E : ENHT did not achieve the four hour standard in October, but did over achieve against the STF improvement trajectory, delivering 88.04% against a trajectory of 85.5%. Plan 81% 83% 85.00% 86% ENHT is forecasting achievement of the trajectory in November A&E 4 hour 95% standard 52 week : ENHT has declared 40 patients waiting over 52 weeks during October; these patients are a consequence of the current validation exercise. Each patient is being Actual 84.20% 82.50% 82.80% 88.00% 83.40% reviewed for any potential harm as a result of the delay in treatment and as yet none has been found.

18-weeks RTT Plan 92.40% 92.50% 92.60% 92.60% RTT: Incomplete 92% The RTT open pathway position has been delivered in October despite a rise in the size of the backlog. The primary reason for the increase in the backlog is the ongoing Pathways Actual 92.80% 92.60% 92.10% 92.10% 92.60% validation of historic clock stops. This validation is adding patients back into the open pathway report with waiting times of over 18 weeks. This has been offset in this reporting period by the addition of the audiology waiting list into the open pathway. 18-weeks RTT Plan 6 3 3 2 As the majority of these patients are waiting less than 18 weeks it allowed ENHT to maintain a compliant position with the standard. Volume of 52 0 ENHT anticipate further additions to the open pathway data and are still predicting that the net effect of these will result in the failure of referral to treatment (RTT) in the East and North Weeks Breaches Actual 5 12 23 40 49 coming months. Hospital Trust (ENHT) ENHT is also predicting a very challenging position in November 99% of Diagnostic Pathways to be Plan 99.50% 99.50% 99.50% 99.50% 99% 62 day cancer : October 62 day performance is under pressure as ENHT are treating more backlog patients (patients that have already exceeded the 62 day standard). Seen within 6- Corrective actions weeks Actual 99.70% 99.50% 99.60% 99.70% 99.70% • Cancer patient tracking list (PTL) reviews – now 2-3 times a week instead of monthly, and more detailed, including escalation Plan 85% 74% 77% 77.88% • Multidisciplinary Team (MDT) and patient tracking processes now reviewed. Cancer 62 days • Work underway to have enabling more robust reporting and monitoring of the stages of the patients 85% from GP Referral treatment pathway. • Each service has clearly articulated capacity requirements for 2ww patients and treatments needed Actual 76.50% 86.40% 63.90% 58.90% 73.10% per month to achieve the standard.

2) Key constitutional standards dashboard table below summarises the plan against actual performance for all of HVCCG main acute providers (continued):

Luton and Dunstable University Trust For 2016/17 NHS Improvement has allocated additional funding from the sustainability transformation funds (STF) for trusts to deliver against the agreed target recovery trajectories. The table below summarises the plan against actual performance at Trust level view. Last 12 months trend

Standards Threshold Jul-16 Aug-16 Sep-16 Oct-16 YTD Comments Plan 95.0% 95.0% 95.0% 95.0% A&E 4 hour standard 95% Actual 99.1% 99.1% 99.1% 98.9% 99.0% 18-weeks RTT Incomplete Plan 92.0% 92.0% 92.0% 92.0% 92% Performance compliant Pathways Actual 93.7% 92.9% 92.6% 92.2% 93.8% Above trajectories. 18-weeks RTT Volume of 52 Plan 0 0 0 0 0 Weeks Breaches Actual 0 0 0 0 0 99% of Diagnostic Pathways Plan 99.0% 99.0% 99.0% 99.0% 99% to be Seen within 6-weeks Actual 99.1% 99.0% 99.3% 99.6% 99.2% Cancer 62 days from GP Plan 85% 85% 85% 85% 85% Referral Actual 94.0% 87.5% 86.5% 88.0% 85.5% Buckinghamshire Healthcare Trust: For 2016/17 NHS Improvement has allocated additional funding from the sustainability transformation funds (STF) for trusts to deliver against the agreed target recovery trajectories. The table below summarises the plan against actual performance at Trust level view.

Last 12 months Trusts Standards Threshold Jul-16 Aug-16 Sep-16 Oct-16 YTD trend Comments A&E : Plan 97.1% 96.3% 95.5% 95.5% The Trust delivered a performance of 90.2% for all types in October, against the national 4 hour standard of 95%. Attendances for all types during this month was a 10% increase on the expected level of attendances for October. A&E 4 hour 95% Ambulance attendances for October continuing to be over 30% increase on the previous year average. standard This month acuity remained high with the intensive treatment unit ( ITU) at full capacity on several occasions. At the beginning of the month, trauma and orthopaedic demand Actual 91.8% 92.6% 91.9% 90.1% 91.8% increased, resulting in trauma & orthopaedics (T&O) outliers. The trust however continued to reduce medical outliers and utilised a 4 bedded ward area to act as a transit/discharge lounge. In order to meet demand this month, the trust did utilise escalation areas on both surgical assessment unit (SAU) and day surgery for patients with an estimated date of discharge within 24 hours . Plan 92% 92% 92% 92% 18-weeks RTT Incomplete 92% Action plan agreed to improve performance managed through A&E delivery board. New completion date: Q4, 2016/17 Pathways Actual 92.1% 91.7% 90.2% 89.5% 91.8% Buckinghamshire Cancer 62 day: Healthcare Trust Plan 0 0 0 0 Actions: (BHT) 18-weeks RTT • Implementation of Thames Valley Cancer Network Breach policy – support from commissioners Volume of 52 0 to reinforce non engagement pathways. Weeks Breaches Actual 0 0 1 0 2 • Additional urological surgery capacity from November onwards. • Joint patient tracking meetings with Oxford University Hospital (OUH) – fortnightly. 99% of Diagnostic Plan 99% 99% 99% 99% • Continued implementation of fast track lung diagnostic pathway. Pathways to be 99% Seen within 6- Risks: Actual 99.9% 99.5% 99.3% 100.0% 99.7% weeks • Continued capacity issues at tertiary providers. Plan 89.06% 85.25% 90.77% 88.06% • Demand pressures – urological surgery. Cancer 62 days Compliance forecast: BHT forecasting return to compliance in October 16 85% from GP Referral Actual 79.5% 88.6% 79.2% 83.8% 83.9%

2) Key constitutional standards dashboard table below summarises the plan against actual performance for all of HVCCG main acute providers (continued):

Royal National Orthopaedic Hospital (RNOH):

Comments

Trusts Standards Threshold Jul-16 Aug-16 Sep-16 Oct-16 YTD Last 12 months trend RTT: Plan RNOH have agreed a revised trajectory to compliance by 28/02/17 with NHS England and NHS Improvement at the A&E 4 hour standard 95% No A&E department escalation meeting12/10/16. Actual The revised trajectory is heavily dependent on much higher rates of outsourcing to the independent sector. A narrative agreed with commissioners to offer choice is being used, however less than 5 in ten patients are opting to be seen by the 18-weeks RTT Plan 87.6% 88.2% 92% outsourced provider. November data will be available in January (2 month time lag for reporting) Incomplete Pathways Actual 87.5% 87.1% 87.6% 88.2% 87.3% Cancer: Plan 0 0 0 0 Improvements in the 62 day and 31-day diagnosis to first treatment standard. Very low numbers of patient breaches lead Royal National Orthopaedic 18-weeks RTT Volume of 0 to non-compliance on the cancer treatment standards as do lower than anticipated numbers of patients diagnosed with Hospital (RNOH) 52 Weeks Breaches Actual 0 1 0 0 2 malignancy. Root cause analysis is undertaken on every breach and used for learning and improvement. RNOH believed that the actions in place would enable delivery by November 2016 (data available in January, 2 month 99% of Diagnostic Plan 96.3% 97.4% time lag). However, RNOH is experiencing an overall 13% - 20% increase in referrals for Sarcoma alone, from the same time Pathways to be Seen 99% last year. within 6-weeks Actual 96.3% 95.2% 96.3% 95.4% 96.6%

Plan 57% 71% Cancer 62 days from GP Diagnostics 85% Surge in referrals means that plans for compliance are at risk. RNOH has increased the numbers to outsource to the third Referral Actual 38.5% 88.6% 84.6% 56.5% 58.5% sector for MRIs.

2) Key issues/ challenges and planned actions: West Hertfordshire Hospital Trust (WHHT) cancer 2 week waits and breast: 2016/2017 Accountable Responsible Indicator Trust Threshold 2015/2016 Jul-16 Aug-16 Sep-16 Oct-16 Last 12 Months October data comments- Clinical Lead YTD Director Manager

Cancer 2 week waits following Patient choice represented 50% of the breaches. In the audit ,68% of 2ww patients were told they had to be seen in 2ww (15% were not) but 59% of urgent GP referral for WHHT - actual 93% 91.5% 81.0% 89.4% 90.8% 89.1% 89.3% patients were not told anything about their appointment. suspected cancer Capacity issues in colorectal represented 28% of the 2ww breaches for October. Avni Charles Allan Shah/Gemma Dr Phil Sawyer

Cancer 2 week waits - breast Patient choice represents 72% of the breaches. An audit has been conducted to assess what information the patients are given from their GPs. This Thomas symptomatic where cancer not WHHT - actual 93% 91.6% 44.8% 68.6% 88.3% 83.5% 74.6% demonstrated that in the audit sample 48% of breast symptomatic patients were not told they had to be seen in 2 weeks and 44% were not told suspected anything about the appointment. This information has been broken down by practice and passed to the CCG.

East of England Ambulance Trust (EEAST) 2016/2017 Indicator Trust Threshold 2015/2016 Jul-16 Aug-16 Sep-16 Oct-16 Last 12 Months October data comments- Accountable Director Responsible Manager Clinical Lead YTD Remedial action plan (RAP)- summary update

East of England Agreement on sustainability transformation funds (STF) principles: Trajectories are on a monthly basis and a quarterly basis. The monthly trajectory Ambulance category A - red 2 (life threatening ambulance trust (EEAST )- 75% 60.5% 58.9% 62.2% 63.5% 63.6% 58.5% which is used to monitor performance whilst funding payments is driven by quarterly performance. but less time critical than red 1) response actual Quarterly trajectories for red 1 have been agreed with tolerance levels. arriving <8 mins-EEAST

Mitigation on performance: EEAST Plan The STF methodology builds in tolerances on achievement yet performance could be further affected by system factors including unpredictable changes in activity profiles and handover delays. Charles Allan Sharon Kember Dr Keith Hodge

EEAST - plan Q2= 69.2% 72.8% Ambulance category A - red 1 (immediate life Contract and recovery action plan (RAP) management: In order for this agreement to be delivered there needs to be clear accountability for assuring all threatening and most time critical) response 75% parties deliver by the following : arriving within 8 mins-EEAST -Weekly performance and improvement meetings (PIAG) The PIAG meeting is now called OPG meetings and this has now been stepped down to fortnightly meeting until the new year, in line with contract negotiation’s taking place EEAST - actual 71.3% 66.7% 68.5% 70.0% 70.20% 65.4% - Finance working group - Service level agreement

Herts Urgent Care: Hertfordshire wide

Herts urgent care - Hertfordshire wide view Accountable Responsible 2015/2016 Jul-16 Aug-16 Sep-16 Oct-16 Last 12 Months October comments Clinical Lead Indicator Threshold Director Manager An increase of home visits for October 2016, acute in hours visiting services (AIVS) impacted performance on some weekday evenings as 124 visits were passed into the out of hours (OOH) period, reduced visiting across some weekends due to lower rota fill and 277 hours of sickness and 249 cancelled shifts. Urgent home visits within 2 hours ›95% 89.9% 90.2% 86.9% 93.9% 87.9% Actions: Ongoing work with CCG for remodelling of AIVS service to reduce the impact of passing visits into OOH, continuing to work on improved rota fill which was especially challenging due to half term school holiday Contract manager has requested the latest action plan Steve Dr Vipal Marshman See above Charles Allan Parbat/ Dr The key reasons are multifactorial but a large contributory factor is inadequate shift fill by GP’s. Higher GP indemnity costs and a as of October Routine home visits within 6 hours ›95% 90.7% 87.7% 83.2% 90.8% 88.8% Keith Hodge reduction in the GP workforce are contributing to this. The referrals to A&E and ambulance have remained stable and revalidation 2016 of these dispositions by a GP during Friday evening and weekends has helped maintain this. We have seen an increase in come to centre cases during October which Oct-16 had an impact on our urgent come to centre % for the month. 86% of the GP rota was filled this month although there were 277 hours of sickness and 249 cancelled shifts. Urgent face to face consults within 2 ›95% 89.3% 87.4% 92.8% 90.4% 86.7% Actions: Continuing to work on rota fill which is still a challenge, Gp performance is still hours being closely monitored .

2) Key issues/ challenges and planned actions Hertfordshire Partnership Foundation Trust (HPFT)

Hertfordshire Partnership Foundation Trust

Accountable Responsible Clinical Indicator Threshold Jul-16 Aug-16 Sep-16 Oct-16 Last 12 months October comments Director Manager Lead

Waiting times

Although there has been an improvement of 4% in HVCCG, there are a number of issues affecting the current position in single point of access (SPA) and ability to offer service users within in 28 days. There has been a significant increase in referrals to SPA and subsequent pass on to the SW quadrant. This Routine referrals to community mental ≥98% 91.75% 90.87% 92.66% 96.69% figure has doubled since June 15 and HPFT are operating with the same resource. There has also been a health team meeting 28 day wait significant increase in the number of urgent referrals into SPA which take priority over the routine Dr Mark Charles Allan Simon Pattison referrals increasing the routine referral wait time. Allen

Early memory diagnosis and support service ≥90% 96.33% 91.67% 93.97% 95.59% Please refer to the dementia progress update for narrative referrals meeting 6 week wait

Child and adolescent mental health services - Dr Mark percentage of referrals meeting assessment ≥95% 92.59% 80.36% 100.00% 100.00% Charles Allan Simon Pattison Allen waiting time standards - routine (28 DAYS)

Patient safety

% of service users with an up to date risk assessment (including learning disability & forensic (LD&F) & child and adolescent 95% 95.00% 94.77% 100.00% 94.61% mental health services (CAMHS) from April 2015

People with severe mental illness who have received a list of physical checks (in-patients 98% 100.00% 100.00% 97.92% 100.00% Dr Mark only) Charles Allan Simon Pattison Allen

Number of people entering Improving access HPFT data is reported as a cumulative figure 629 795 842 849 to psychological therapies (IAPT) treatment Therefore from Jan 2017 to explore reporting approach for this KPI

13% per annum 0.9% Prevalence target 13% per annum 0.87% 1.10% 1.17% 1.18 August 1.10%

Any qualified provider (AQP) data for improving access to psychological therapies (IAPT ) access and recovery

2% patients 1441 /12 GPs IAPT referral pathway and integrated health care and commissioning team (IHCCT) are working months = per month 120 120 120 120 closely with them, by attending their forums and visiting individual GP practices to ensure they now access to IAPT via AQP/ IAPT counsellors plan 120 have a clear understanding to refer patients into the IAPT service. HPFT anticipate an increase from quarter 3. Actual - numbers 109 114 87 no data Dr Mark Charles Allan Simon Pattison Allen 50% 50% 50% 50% HPFT are currently investigating with NHS digital the reason for a major discrepancy regarding the Plan 50% recovery rates which details that the CCG is underperforming on IAPT recovery. Initial investigation by Recovery via AQP/ IAPT counsellors HPFT indicates the issue is due to the coding of AQP data. IHCCT are working with HPFT and any qualifying provider (AQP) under the new and existing contracts to ensure any remedies are put in place Actual - numbers 50.00% 45.45% 42.47% no data to ensure this is resolved and mitigated against going forward.

2) Key issues/ challenges and planned actions Dementia Dementia progress update : Accountable Responsible Diagnosis: where are we now? Clinical Lead Director Manager 65+ Only (CFAS 30 - 64 (AS- Total Update: II) 2014) Performance reporting - 100% of patients are being seen within six weeks in the north-west and 97% in the Estimated dementia prevalence in Herts south-west. This focus on the initial assessment time has caused secondary delays in the number of people who 6,778 364 6,990 Valleys have received an initial assessment, but are waiting to see a consultant. At the end of October, 287 people were waiting. HPFT have increased the diagnostic sessions offered in excess of 30% per week in order to bring this 67% target 4,519 244 4,683 number of people waiting down to a manageable level. Of the diagnostic sessions undertaken, 81% are Current estimated number diagnosed receiving a diagnosis (Alastair Burns letter dated 15th 4,371 107 4,484 December 2015) Practice visits : dementia estimated prevalence and diagnosis rate dashboard by practice to support to inform engagement with practices - progress to date means 13 practices have received a visit with a mental health Additional diagnoses required to meet lead, locality support and mental health commissioner and on-going regular communications via normal routes. Simon Dr Mark 148 137 285 Charles Allan target Action plan progress update: Implementation of the action plan has continued with respect of primary care Pattison Allen Estimated percentage diagnosed based engagement actions. The planning round has impacted capacity toward the end of Q3 with some discrete on new prevalence figures as of 1st April 64.49% packages of work deferred until Q4 2015 We will continuously monitor performance against the following trajectory of improvement: This trajectory has now been updated using the dementia mortality rate from Public Health England for Herts Valleys and the diagnostic capacity and rates from the new EMDASS service model. Month Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Monthly diagnosis ambition (%) 60.9% 61.6% 62.3% 61.11% 61.83% 62.86% 64.10% 65.33% 66.66% 66.70% Actual reporting via Alistair Burns letter 60.90% 61.10% 61.70% 61.40% 61.60% 61.80% 62.80% 63.51% 64.5% 64.5% Revised trajectories from April 2016 61.11% 61.83% 62.86% 64.10% 65.33% 66.66% 67.05

3) Herts Valleys CCG: all acute providers at CCG patients view: Performance against key national indicators - CCG patients view for all Acute providers

TRUST VIEW: Last 12 Indicator Plan 2015/16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 YTD months

Cancer 2 week waits following urgent GP referral for suspected cancer 93% 95.1% 95.2% 93.1% 89.8% 84.3% 90.5% 91.5% 91.6% 90.7%

Cancer 2 week waits - breast symptomatic where cancer is not suspected 93% 91.3% 95.3% 90.7% 78.9% 56.5% 76.0% 91.1% 88.0% 81.6%

Cancer 31 day - 1st definitive treatment from diagnosis 96% 98.1% 95.5% 97.1% 95.6% 97.7% 95.7% 96.2% 93.6% 96.3%

Cancer 31 day - subsequent treatment for cancer - surgery 94% 96.1% 96.2% 100.0% 100.0% 96.3% 100.0% 100.0% 95.7% 98.3%

Cancer 31 day - subsequent treatment for cancer - drugs 98% 98.7% 98.8% 100.0% 97.1% 100.0% 98.8% 96.7% 96.3% 98.2%

Cancer 31 day - subsequent treatment - radiotherapy 94% 95.8% 92.2% 92.5% 91.4% 93.7% 92.4% 90.1% 97.7% 92.9%

Cancer 62 days - 1st treatment following an urgent GP referral 85% 83.6% 83.9% 78.5% 83.3% 86.0% 80.5% 85.8% 82.1% 82.9%

Cancer 62 days - 1st treatment following referral from screening service 90% 94.1% 100.0% 93.3% 90.9% 89.5% 100.0% 96.4% 85.7% 93.7%

Cancer 62 days - 1st treatment following consultants decision to upgrade 85% 86.2% 81.8% 94.1% 100.0% 82.4% 75.0% 78.6% 80.0% 84.6%

18 week referral to treatment -incomplete pathway 92% 92.1% 91.0% 91.5% 90.8% 90.0% 89.8% 89.3% 89.0% 89.3%

Number of patients waiting more than 52 weeks on incomplete pathways 0 3 3 5 4 3 4 0 22

Diagnostic tests - % of patients waiting 6 weeks or less 99% 98.6% 99.7% 99.6% 99.5% 99.6% 99.3% 99.4% 99.8% 99.8%

A&E total time in department - less than 4 hours 95% 88.4% 83.1% 87.8% 86.1% 86.0% 86.8% 86.7% 84.5% 86.1%

4) Quality key points: verbal update 5) Finance on a page month: stand-alone report 6) Performance against CCG outcomes framework: n/a 7) Transformation and quality innovation, productivity & prevention (QIPP) progress report: n/a 8) Digital road map: n/a 9) Health and wellbeing– annual report: n/a

10) Quality premium 2016/2017 quarter 2 report:

Quality premium 2016-2017 - Quarter 2 report

% of quality £ equivalent Achievement Q2 Measure Baseline Target Time frame Comments RAG premium available 16/17

2013 = 51.1%, 2014 = Improve by 4 percentage increase from 2015 Next release due Jun-17 - chasing Proportion of cancers diagnosed at stages 1 and 2 20% £587,508 n/a 54.6% points to 58.6% to 2016 quarterly data from NHS England

GP patient survey - percentage of respondents who said they had a good experience of making an Increase by 3 percentage increase from July 20% £587,508 July 15 = 77%, July 16 = n/a Next release July 2017 appointment. points to 81.3% 16 to July 17 78.3% Increase by 20 percentage increase from Mar Increase in the proportion of GP referrals made by e-referrals. 20% £587,508 March 16 = 39% 37% July data points to 59% 16 to Mar 17

Improving antibiotic prescribing in primary and secondary care - number of antibiotics per weighted 2015/16 = 1.03 per 1.16 1.04 antibiotic population. weighted antibiotic pop no reduction Latest 4 Quarters 10% £293,754 needed from 15/16 (OCT 15 - AUG 16, Sep n/a) Improving antibiotic prescribing in primary and secondary care - number of co-amoxiclav, to 16/17 2015/16 = 7.7% 10.0% 7.7% cephalosporins and quinolones as % of the total selected antibiotics .

increase from LOCAL: % of patients aged 17+ with diabetes, as recorded on practice disease registers. 10% £293,754 2014/15 = 5.08% 5.2% 5.27% 14/15 to 16/17 2015/16 LOCAL: Reported prevalence of chronic obstructive pulmonary disease (COPD) on GP registers as % of increase from (2016/17 results n/a till Sep 2017) 10% £293,754 2014/15 = 57.36% 60% 60% estimated prevalence. 14/15 to 16/17 2014/15 = 67.4%, increase from LOCAL: % of patients returning to usual place of residence following hospital treatment for stroke. 10% £293,754 72% 70.7% 2016/17 year to date 2015/16 = 68.6% 14/15 to 16/17 TOTAL AWARD AVAILABLE £2,937,538 = £2,937,538 our weighted pop 1st April 2016 * £5 TOTAL MINUS AMBER RAG £881,261 **This may change if a provider meets its planned trajectory throughout the year TOTAL AFTER BREACHES** £0

Reason to deduct from award - current progress at CCG Target 2015/16 breach 14/15? £ reduction if breach reduction if breach Q2 2016/17 breach? deficit/audit no £2,897,897 100% Maximum 18 weeks from referral to treatment – incomplete standard 92% 92.1% yes £724,474 25% 90.4% yes Maximum four hour waits in A&E departments 95% 88.4% yes £724,474 25% 86.1% yes Maximum two month (62-day) wait from urgent GP referral to first definitive treatment for cancer 85% 83.6% yes £724,474 25% 83.0% yes Maximum 8 minute response for Category A (Red 1) ambulance calls - CCG residents this year 75% 65.3% yes £724,474 25% 67.9% yes

11. Workforce: quarter 2 report

11. Workforce: quarter 2 report (Continued)

Workforce narrative – Quarter 2 report

Appraisal and mandatory training At the end of quarter one the appraisal rate was 49.33%. This increased to 83.65% by the 31st August 2016 due to the following actions that were put in place:  Appraisal awareness sessions were delivered during the appraisal window;  Regular reports broken down by Directorate tabled at (senior leadership team) SLT;  Updates provided in the staff weekly news promoting the importance of high return rates; The information from returns has now been used to produce the first draft of the appraisal, training plan and talent and succession plan reports. Staff whose appraisal documents were not received during the appraisal period has since been contacted including their directors to request this information.

Mandatory training compliance for this quarter is 89.27%, this has improved on quarter 1 and the following steps have been put in place to maintain continuous improvement in compliance.  Monthly reports are communicated with directors.  Individuals with outstanding modules are contacted with details of due modules to be completed.  Given the number of platforms via which staff currently access mandatory courses; ODL is continuing to appraise all the platforms and as of August 2016, platforms have been reduced by one. Conversations are still ongoing with the view to reducing this further.

Other ODL activities Education, Training & Development Policy was developed, approved in May 2016 and launched.

GP development programme 3 GPs were recruited to the 2 year GP development programme in 2015. June 2016 one GP resigned from the programme as they moved out of the area. August 2016 following the completion of one year on the programme a GP resigned from the programme due to personal reasons. The success of the recruitment is that the GP remains working at the practice they were recruited to in 2015.

In 2016 eight GPs were recruited to the 2016 GP development programme. One GP withdrew from the programme in October 2016 due to problems finding a suitable practice leaving a total of 7 GPs on the 2016 programme.

Practice nurse (PN) development programme The practice nurse development programme has successfully recruited 10 practice nurses (PN) s onto the programme. All PNs have contracts with a GP practice and have registered onto the accredited 'fundamentals development programme' at Herts university. As a result the planned model to recruit 10 PNs to the 2016 programme has been achieved.

HR update

Turnover for the quarter; 15 employees left in Q2 and 18 employees joined the organisation. The reasons for leaving were given as:  Not known (4)  Work/life balance (3)  Promotion (3)  Better Reward Package (3)  End of Fixed Term Contract (1)  Relocation (1)

11. Workforce: quarter 2 report (Continued) Analysis of reasons for leaving between 1 October 2015 to 23 September 2016 showed:

Note: one individual cited child dependents as reason for leaving; may wish to class this as work life balance too. It is recommended that the following areas are reviewed:

 Lack of promotional opportunities (highly cited by leavers in contracts and pharmacy)  Work life balance issues on increase  72% of redundancies were in continuing health care (CHC)  72% of HR left due to work life balance, this excludes numbers who left when first TUPE’d in Oct 2014.  75% of leavers in pharmacy left due to promotion  59% of leavers in contracts left for promotion

Recruitment has been continuing for vacant posts and phase 2 of the CHC re-organisation has begun in preparation for implementation next year, this means that the vacancy rate is at 20%. All band 8 and higher appointments made were from the white British ethnic origin group.

Agency and interim spend continues to be monitored and has reduced during August and September after having increased from June to July. Total spend to date is £608,298. However, this is expected to increase in quarter 3 due to two interim appointments at Associate Director level in system resilience and in contracting.

The sickness absence rate has dropped slightly; there is a long term sickness absence case in workforce which has now been resolved. Plans are in place to address other areas where there are high sickness absence rates.

12. Freedom of information report- n/a 13. Environmental report- quarter 2

key progress in 2016-2017 quarter 2

 Reduction on the overall carbon footprint compared to last quarter  Reduction in gas usage (although based on summer usage)  Increase in recycling  Although paper usage has increased from last quarter it is still a reduction on the same quarter last year and we have seen an overall reduction since the beginning of this year  For the first quarter since we have been recording details of catering costs (i.e. 2014) we have seen a reduction, rather than an increase, on the previous quarter’s costs key issues in quarter 2 Actions / timescales / learning

 The overall organisational carbon footprint is still  The trend for increasing catering costs each quarter expected to be significantly above target by the end of continues to be closely monitored. the year.  Office Efficiency has been amalgamated into the Waste  General waste increased significantly (in fact it was Management policy and the amended policy is now almost half this quarter to that for the whole of 2015/16 going through the approval process  The staff commute remains the main single contributor  Various initiatives to take place to encourage a of all the areas we regularly monitor to the overall reduction in landfill waste, paper usage and electricity, carbon footprint as well as an increase in recycling (2016/17) – Energy A decision has been made to reduce the work done on efficiency was promoted as part of Energy Efficiency the Good Corporate Citizen toolkit in order to week (w/c 31 October 2016) concentrate on other priorities. This means that we are  Staff travel survey is due to be carried out in February unlikely to meet targets in relation to the Sustainability 2017. This will show whether there have been any Action Plan going forward. changes to staff commuting patterns  It has still not been possible to make any progress in  To be raised with the new AD for Contracting whether it relation to the Commissioning KPIs might be possible to make any progress with the Commissioning KPIs

Environmental Dashboard:

APPENDIX A - HVCCG ENVIRONMENTAL DASHBOARD 2016/2017 Quarter 1 Quarter 2 Quarter 3 Quarter 4 Original 2014/15 2015/16 Apr-Jun Jul-Sep Oct-Dec Jan-Mar Category Key Performance Indicators 2014/15 - 2019/20 Threshold Trend Comments STATUS (tCO2e) (tCO2e) 2016 2016 2016 2017 (tCO2e) (tCO2e) (tCO2e) (tCO2e) (tCO2e)

A target reduction of 3% for 14/15 and 5% per annum from Annual equivalent measurement of 164,902 tCO2e so not currently meeting targets and carbon foot print continues to increase. Slight Overall Carbon 15/16 onwards 137,177 144,118 153,897 41,558 40,893 reduction in carbon foot from Q1 data highlighted in red due to correction of previous estimated electricity invoice Footprint Plan 133,062 126,203 124,448 122,772 121,059 119,344 ↓ A target reduction of 3% for 14/15 and 5 % per annum from Annual equivalent measurement of 9.02 tCO2e so currently meeting targets. However, this is not an accurate end of year reflection as 15/16 onwards 17.76 29.04 22.78 3.23 1.28 is based on summer months usage. Gas Plan 17.23 16.35 16.12 15.9 15.68 15.46 ↓ A target reduction of 3% for 14/15 and 5 % per annum from Annual equivalent measurement of 33.3 tCO2e so currently meeting targets. Increase on Q1 figure highlighted in red due to the 15/16 onwards 81.29 41 47.88 7.27 9.38 correction of estimated invoice for that quarter although this indicates Summer usage. Electric Plan 78.85 74.85 73.83 72.81 71.8 70.79 ↓ A target reduction of 3% for 14/15 landfill and 5 % per annum Annual equivalent measurement of 1.24 tCO2e, including an increase on Q1, so currently not meeting targets, although current from 15/16 onwards 0.51 0.98 0.88 0.22 0.4 reduction on last year. Plan 0.5 0.48 0.47 0.46 0.45 0.45 ↑ A target increase of 3% for 14/15 recycling and 5 % per annum from 15/16 onwards 0.07 0.11 0.14 0.02 0.03 Annual equivalent measurement of 0.1 so currently on target. Waste Plan 0.07 0.08 0.08 0.09 0.09 0.09 ↑ A target reduction of 3% for 14/15 and 5 % per annum from 15/16 onwards 1.52 1.56 0.62 0.05 0.55 Annual equivalent measurement of 1.2 so currently on target. Water & Sanitation Plan 1.47 1.4 1.38 1.36 1.34 1.32 ↑ A target reduction of 3% for 14/15 and 5 % per annum from Annual equivalent measurement of 12.06 tCO2e so not currently meeting targets. However, this is a reduction on last quarter. Food & Catering 15/16 onwards 5.72 13.97 10.14 3.77 2.26 Plan 5.55 5.26 5.19 5.12 5.05 4.97 ↓ Information and A target reduction of 3% for 14/15 and 5 % per annum from Annual equivalent measurement of 24.32 tCO2e so currently on target. Increase on Q1 but reduction on same quarter last year. Communication 15/16 onwards 128.44 87.72 30.85 3.89 8.27 Devices Plan 124.59 118.17 116.56 114.95 113.35 111.75 ↑ A target reduction of 3% for 14/15 and 5 % per annum from Annual equivalent measurement of 1.24 wte so currently on target. Slight increase on last quarter but reduction on the same quarter 15/16 onwards 2.65 1.88 2.71 0.31 0.41 last year. Paper products Plan 2.48 2.35 2.31 2.28 2.25 2.22 ↑

A target reduction of 3% for 14/15 and 5 % per annum from Annual equivalent measurement of 486 tCO2e so significantly above target. Business mileage has increased this quarter but the carbon Travel 15/16 onwards 34.62 407.76 496.88 474 476 footprint is mostly made up of staff commute. Currently showing a small reduction on last year. Plan 33.59 31.86 31.43 31 30.57 30.13 ↑ A target reduction of 3% for 14/15 and 5% per annum from Annual equivalent measurement of 9.34 tCO2e but based on spring/summer energy usage. Slight reduction to data for Q1 highlighted Energy well to tank 15/16 onwards 23.59 14.27 14.74 2.21 2.46 in red due to reduction in electricity usage for that quarter. and transmission Plan 22.88 21.68 21.38 21.08 20.79 20.5 ↑ Increase in the proportion of providers that have sustainable development plans in place to 100% by 2015/16* 80% 80% 80% 80% 80% RNOH added to portfolio of providers wef 1/4/16. Reported annually. Plan 80% 100% 100% 100% 100% 100% Increase in the proportion of providers that have completed Commissioning the Good Corporate Citizen Assessment to 100% by 2015/16* 40% 40% 80% 80% 80% RF and RNOH added to portfolio of providers wef 1/4/16. Reported annually. Sustainability Plan 40% 100% 100% 100% 100% 100% Development Action 75% compliance with current SDAP to be achieved. 15 55 134 143 160 Currently above target. However, work will slow considerably as we reduce work on the GCC toolkit. Plan Plan 21 137 147 157 167 177 ↑

* Calculated based on the following organisations: Barnet & Chase Farm Acute Hospital Trust; East of England Ambulance Service; Hertfordahire Community NHS Trust; Hertfordshire Partnership University NHS Trust; West Hertfordshire Hospitals NHS Trust ** No information has been provided by HCT in relation to the Avenue Clinic, therefore data for this site has been estimated based on that for Apsley 2

14. Better care fund- quarter 2 report

Key Target met Target not met

Baseline (2014- Whole year Indicator 2016-17 Q1 Q2 Q3 Q4 Comments 15) outturn Note: Q2 performance figure does not currently include Sept data - actual rate therefore has been calculated based on July and Aug data only. So far, there has been an increase in admissions from Plan 2268.0 2290.0 2326.0 2248.0 2283.0 last year with a sharper rise in June (2769 for Herts Valleys CCG). Hertfordshire total remains below 2015-16 and 2016-17 national average. Total emergency admissions (average per Following data access, BCF (better care fund) intends to move to using SUS (secondary uses service) quarter) BCF1 rather than MAR (monthly activity return) data to measure this metric in line with a method of data (composite measure) 2305.0 used by Herts Valleys CCG's QIPP (quality innovation productivity prevention) plan. * rate per 100,000 example calculation Herts Valleys CCG's rapid response service has seen 134 more people this year than for the same 100000 x 27,785 / 1150545 Performance 2442.2 2474.2 period last year. For this quarter, 98% of referrals were seen within 60 minutes. Other schemes = 2,415 for the 3 months include enhanced medical support (GP/specialist consultant geriatrician) across the community to support the core integrated community nursing and therapy teams, building therapy capacity in core integrated nursing teams, recommissioning community bed pathways and continuation of the MS (multisystemic therapy) approach which has received positive feedback from professionals so far. Whole year Indicator Target 2016/17 Q1 Q2 Q3 Q4 Comments outturn

Note: because of the complexity, a significant number of admissions will be added after quarterly Plan Long-term support of the performance has been reported - this means the Q1 rate figure will increase. Also, note that 2016-17 610.00 610.00 610.00 610.00 BCF2 needs of older people performance is measured according to a slightly different definition from 2015-16 which will result in (aged 65 or over) met by higher numbers of admissions into care homes being reported than for the same level of performance 610.00 admission to residential reported last year according to the 2015-16 definition. and nursing care homes, Performance All residential placements are closely monitored with senior managers overseeing and auditing all per 100,000 population placements that have been made. Work continues with our health care partners to review discharge pathways and promote alternative forms of care. 521 370

Whole year Target 2016/17 2016-17 Q1 Q2 Q3 Q4 Comments outturn

Plan Q2 data to be available during Q3. Proportion of older people Q1: The performance reported for April, May and June relates to people discharged from hospital to (65 and over) who were 87.10% 87.10% 87.10% 87.10% enablement in January and February 2016, i.e. into the old service before the new specialist care at still at home 91 days after BCF 3 home model was introduced. During Q1, health & community services launched the new specialist discharge from hospital care at home model which includes 3 different providers delivering a range of different services. The into reablement / 87.10% implementation involved changes to the recording of the activity in the social care system called rehabilitation services ACSIS (adults care services information system). Commissioners are working very closely with Performance providers in order to manage and support the provision of all the data required to support this new model. It is envisaged that a full set of data for these indicators will be available for quarter 2. Change in performance is attributable to both the effectiveness of the reablement service and the No data complexity in the needs of the cohort receiving reablement services in the quarter. 85.90% yet

whole year Target 2016/17 2016-17 Q1 Q2 Q3 Q4 Comments outturn

Note: Q2 performance figure does not currently include Sept data - actual rate therefore has been calculated based on Jul and Aug data only. DToC (delayed transfer of care) levels remain higher than last year's activity and national Plan performance. Rise is in referrals in Aug from WHHT (West Hertfordshire Hospital Trust) and HCT (Herts Community Trust) (1331 and 1261 respectively). For the social care element of delayed days, homecare capacity continues to cause the majority of delays along with temporary staffing capacity issues in specific areas. 713 713 713 713 The BCF (better care fund) target level has been set in order to reflect CCG targets, to reduce Delayed transfers of care numbers of delayed days below a specified proportion of all in-patient bed days - this means the (delayed days) from target rate is much lower than the 'holding target' included in the BCF plan submission while the hospital per 100,000 system-wide target was being agreed (this was based on a 10% reduction in 2015-16 actual activity population (per quarter) resulting in a target rate of 1212). BCF 4 *Rate per 100,000, example Partnership work with HCC (Herts Community Care) includes sharing of real time data to identify pressures, the introduction of the new specialist care at home service and commissioning activity calculation Q4 2014/15: 713 (100,000 x 9,236 [Jan-Mar]) aimed at increasing homecare and rehabilitation beds. Work with individual hospitals includes the / 897,668 = 1028.9 recruitment of trusted assessors to lister hospital, consideration of introducing an integrated discharge team at Princess Alexandra Hospital, and additional health care assistants recruited in the Performance Herts Valleys region. A system-wide coordinating group has also been established with both commissioner and provider output - this group first met in July and will coordinate a range of operational activity related to system flow and the delayed transfer of care (DToC) position. Herts Valleys recovery plan takes a system wide perspective and is leading on a range of patient flow improvement activity. Therefore, rather than duplicating, any Herts Valleys specific work to improve patient flow and the DTOC position will be delivered through the recovery plan.

1545 1443.7

Patient / service user experience - ' Having your Target 2016/17 2016-17 2015/16 Q1 Q2 Q3 Q4 Whole year outturn Comments say questionnaire to Goldsborough Homecare 2016-17 Q1 or Q2 data not yet available - the introduction of new Q2 report BCF report arrangements for specialist care at home, which replaces the previous enablement clients' Plan enablement service, has resulted in data not being immediately available for sampling service users receiving one of the new types of service. The 90% 90% 90% 90% 90% new service is anticipated to increase the range of people to whom a reablement type service is planned to be delivered, compared to the enablement service in 2015/16. The set of service providers is also different to the previous enablement service. BCF 5 The 2015-16 outcome reflects a questionnaire with responses in based around 5 categories: respect, understanding, choice, information and 90.00% outcome. Satisfaction measured cumulatively from quarter 1 to quarter 4 was highest in relation to staff being respectful and courteous (94.4%); Performance and lowest in relation to being offered choices about the ways needs could be met (84.7%). A revised questionnaire is to be used in 2016-17 but will maintain the above 5 categories as core questions to ensure consistency but also including additional questions aimed at increasing understanding of service user experience.

No data 89.60% yet

Whole year Target 2016/17 2016-17 Q1 Q2 Q3 Q4 Comments outturn Actual quarterly performance is an average rate of 63.76%, with figures gradually rising quarter on Plan quarter. Diagnosis rates continue to build on progress made last year (from 60%). 67% 67% 67% 67% Herts Partnership Foundation Trust continue to run evening and weekend clinics, operate a combined nurse and consultant appointment where a diagnosis has been triaged and has held a 'one stop shop clinic' from the cheshunt home first office. The early memory diagnostic assessment support service NHS Outcomes Framework - (EMDASS) performance has improved significantly averaging 39.5 diagnosis per week for the last four 2.6i estimated diagnosis weeks, up from 34.5 per week in February's update and up from 23 per week average in October BCF 6 rate for people with 2015. dementia 67.00% Each clinical commissioning group (CCG) continues to hold bi-weekly teleconference calls, with a set of key messages consistently communicated using GPs CCG communications, locality meetings and Performance mental health forums. These include the benefits of diagnosis (e.g. post-diagnosis support, carer support) and focussing on MCI (mild cognitive impairment) in primary care in order to support a prompt diagnosis of dementia as functioning decreases. Engagement will continue using dual methodologies to identify practices who are likely to have the largest gains in the number of undiagnosed patients in their practice. In April, there was an uplift to estimated dementia prevalence nationwide and for both CCG's, this resulted in an increase in the target of 210 diagnosis to reach 66.7%. 62.40% 63.76%

15. Safe staffing- quarter 2 report

Safer Staffing Report Quality & Performance Committee December 2016

The below table sets out the performance of HVCCG providers in relation to Safer Staffing levels. The data relates to Safer Staffing levels in July, and August 2016, unfortunately, at the time of writing this report the data for September 2016 was unavailable;

2016-17 2016-17 Data available from May 2015 Purely Indicative Less than 95% JULY threshold only - No Less than 90% or greater standards have been JULY than 150% set for this data

Source: Nurse staffing return - Unify2 - Published (NHS Choices) Data available from May 2014 Day Night Registered Registered Overall Org midwives/n HCA Staff midwives/ HCA Staff Trust Fill Rate DCO Team code urses Fill Fill Rate nurses Fill Fill Rate (Click down arrow to select DCO Team) Rate Rate Central Midlands RWH East & North Hertfordshire 100.00% 100.00% 100.00% 100.00% 100.00% Central Midlands RY4 Hertfordshire Community NHS Trust 102.10% 132.78% 98.39% 168.86% 117.73% Central Midlands RWR Hertfordshire Partnership NHS Foundation Trust 101.69% 93.46% 100.00% 100.00% 98.70% Central Midlands RC9 Luton & Dunstable Hospital FT 80.18% 72.36% 78.69% 84.42% 78.38% Central Midlands RWG West Hertfordshire Hospitals 67.90% 60.17% 97.85% 87.10% 79.61% Other Trust HVCCG Commissionned RXQ Buckinghamshire Healthcare NHS Foundation Trust 73.50% 106.45% 71.89% 83.87% 75.93% RAL Royal Free London NHS Foundation Trust 95.10% 90.44% 97.19% 94.13% 95.51% RAN Royal National Orthopaedic Hospital NHS Trust 93.93% 98.24% 98.91% 100.00% 96.43%

2016-17 2016-17 Data available from May 2015 Purely Indicative Less than 95% AUGUST threshold only - No Less than 90% or greater standards have been AUGUST than 150% set for this data

Source: Nurse staffing return - Unify2 - Published (NHS Choices) Data available from May 2014 Day Night Registered Registered Overall Org midwives/n HCA Staff midwives/ HCA Staff Trust Fill Rate DCO Team code urses Fill Fill Rate nurses Fill Fill Rate (Click down arrow to select DCO Team) Rate Rate Central Midlands RWH East & North Hertfordshire 84.40% 83.51% 100.61% 103.80% 91.67% Central Midlands RY4 Hertfordshire Community NHS Trust 94.27% 94.23% 96.95% 96.53% 95.23% Central Midlands RWR Hertfordshire Partnership NHS Foundation Trust 103.23% 177.89% 120.87% 129.85% 134.23% Central Midlands RC9 Luton & Dunstable Hospital FT 86.54% 98.47% 97.10% 97.47% 93.58% Central Midlands RWG West Hertfordshire Hospitals 94.28% 98.39% 97.85% 100.00% 97.18% Other Trust HVCCG Commissionned RXQ Buckinghamshire Healthcare NHS Foundation Trust 76.50% 100.00% 74.65% 100.00% 76.81% RAL Royal Free London NHS Foundation Trust 86.97% 91.76% 96.77% 98.39% 92.25% RAN Royal National Orthopaedic Hospital NHS Trust 98.02% 99.14% 99.25% 98.39% 98.58%

All providers have actions in place to ensure they achieve safer staffing levels. Any accompanying exception reports will be detailed in the Q2 Quality Report.

16. Learning disability report including transforming care – quarter 2 report key progress in quarter 1

Background summary: In order to streamline action planning and measuring progress for learning disabilities (LD) in Hertfordshire it was decided to initiate an overarching learning disabilities delivery plan. This amalgamates actions from: the annual learning disability self-assessment framework which checks and rates the effectiveness of health, social care and community services for people with learning disabilities; Hertfordshire’s 2014 – 2019 joint commissioning strategy for LD and transforming care programme the national programme of work in response to winterbourne view. key issues in quarter 2 Actions / timescales / learning

 Transforming Care: o Children and young people and adult leads in post leading on CTR’s and o Care and treatment review (CTR) admission avoidance work. Focus on community CTR’s support and all age avoidance admission admission avoidance and development of risk register – now known as admission avoidance register. o Housing/accommodation/housing o Continue to cause delays to discharge, escalated regionally and benefit Issues nationally. Locally Integrated accommodation commissioning team leading work to respond. Information received re capital bid funding NHS England/DoH (department of health) to be submitted in October. Work with providers to reconfigure decommissioned community hospital for people with learning disabilities and autism is in progress. o Discharge trajectories o Herts remains on target in Q2 for quarterly discharge targets. Child and adolescent mental health services (CAMHS) inpatient numbers increased from 3 to 5.

o Inpatient outcomes reduction in PRN (medication as needed) and o Fast Track pilots: recorded incidents of challenging behaviour. Community pilot . Creative therapy in-patient and underway with 2 providers. Mid-point review in September and work community pilot going well. In Q3 HPFT service development improvement plan will be . Circles updated for their new contract to ensure implementation in the . HPFT pilot services commenced service. Volunteer recruitment commenced. Service user assessment for offender and behavioural work in progress. Offending behaviour team working well to brief. invention and support Early Intervention & practice development team challenges with . Social care crisis team and recruitment. Need to revisit focus of team meeting planned in Q3. community crash pad – delayed Brief revised. Agreed to explore ‘proof of concept’ ideas with creative as market unable to respond to practitioners (creative therapies, application of positive behaviour the brief supports) and shared lives.  Specialist residential services (SRS)  New governance arrangements in place: Commissioners’ governance forum and pan-regional oversight group to commence in Q3.  Children’s accommodation services  Capital monies secured for Wynchlands  Health checks:  *(This figure differs from that reported in Q1 as there was a o Total number of health checks 2015/16 miscalculation) 1,265 (QoF register 2,207) = 57.2% *  All localities have been visited re health check uptake Comparable 2015/16:  DXS pathway being developed to assist practices 1,150 (QoF register 2259) = 50.9%  Health action plan component of template being improved There are a further 28 claims outstanding.  Monthly emails to lead GP in each practice with LD information This is as a result of practices not submitting  Community learning disability nurses continue to visit practices to offer claims correctly. The % number of health support. checks completed does not reflect that the  Checking and refreshing quality and outcomes framework (QOF) health check figure is based on the QOF registers and acute trust flagging systems for LD continues to take figure which is all age. This issue has been place. raised nationally.  Awaiting Q1 and Q2 data for 2016/17 – will report in Q3 o CCG has set 70% uptake target for health checks in 16

16. Learning disability report including transforming care – quarter 2 report (Continued)

key issues in quarter 2 Actions / timescales / learning  Annual Self-Assessment :  Second quarter meeting took take place in order to monitor the No requirement to complete a self- business as usual. The self-assessment will now be completed every 2 assessment for 2014/15. years. Further information as to the process expected in Q3.  An element of the meeting involved reviewing the current annual questionnaire that is sent to 1,000 people with an LD. The group intend to expand the questionnaire in order to receive more detailed quantitative data and qualitative information from people with a LD. Questionnaire to then be distributed in Q3.

 Dementia project:  Pathway to be shared with key stakeholders NHS England funded a project to develop a  Address how pathway can link in with mainstream provision – pathway for diagnosis and management of workshop being organised. dementia in the learning disability  Procurement exercise is active to identify post diagnosis provision. population. Services will be expected to be able to support people with LD. o Review of ‘as is’ situation  ‘Memory problems and dementia, an introductory guide’ brochure is underway – utilising self- currently being put into easy-read. assessment from RCPSYCH 2014 document on dementia in LD. o Developed pathways to support practioners identify pre & post diagnosis support. o Workshop held to finalise LD pathway. Commissioning managers, GP lead, psychiatrist, intensive support team (IST) nurses leader and community learning disability nurses (CLDN) covering cross county delivery were in attendance.  IAPT  HPFT Wellbeing Team has met with LD commissioners and lead Improving access to IAPT for people with a strategic nurse to consider how service can be more readily available to learning disability people with LD.  HPFT have developed tools and identified reasonable adjustments to support individuals receiving IAPT.

 Flu Immunisation:  Packs have been distributed to all practices with easy read invite for Working with NHS England to improve immunisations, explanation leaflet re value of immunisations for LD uptake of flu immunisation in LD population. population, information about capacity and consent/best interests.  Searches will be done in November and January to monitor uptake. 17) Every one counts: n/a

18) System resilience group progress report: LDB BACK Work Recovery Project stream Project name: Frailty Team Number of project tasks/milestones: 5 Project ref: RP 1 Project owner: WHHT Programme start date (Monday): 03/03/16 Clinical lead: Dr Tammy Angel This week and next week : u

Planned Planned Actual Max End Comment I Sect. Ref. Tasks & Milestones Days Complete Comment / Constraints / Remedial actions Start complete complete Date Date N 1 1 Target = 3% of improvement to 95% 03/03/16 24/07/16 The frailty service continues to meet targets and is Y 1 1.05 Milestone 1 - 0.75% achieved 17/05/16 18/05/16 18/08/16 93 Yes 18/05/16 consistently achieving over 40% discharge. We have now ceased the frailty bed provision and have agreed to re-invest Y 1 1.06 Milestone 2 - 1.5% achieved 17/06/16 18/06/16 20/08/16 64 Yes 18/06/16

1. Streaming at A&E at Streaming1. the remaining allocation to provide a 6 day service. This Y 1 1.07 Milestone 3 - 2.25% achieved 17/07/16 18/07/16 27/08/16 41 Yes 18/07/16 project is now business as usual. Y 2 1.08 Milestone 4 - 3% target achieved 17/08/16 18/08/16 05/09/16 19 Yes 18/08/16

Project name: ED Controller Number of project tasks/milestones: 0 Project ref: RP 6 Project owner: Programme start date (Monday): 03/03/16 Clinical lead: This week and next week : u Planned Planned Actual Max End Comment Sect. Ref. Task / milestone Days Complete Comment / Constraints / Remedial actions Start complete complete Date Date Project monitoring continues while the project will be moved 6 6 Target = 1% of improvement to 95% into maintenance and business as usual (BAU) as there is no 14/04/16 07/05/16 23 Yes 07/05/16 6 6.04 Milestone 1 - 0.2% achieved further project work to do at this stage in this area Good progress is being made. Teams continuing to work 08/05/16 07/07/16 04/06/16 27 Yes 07/07/16 together to keep assessment areas free of inpatients and 1. Streaming at A&E at Streaming1. 6 6.05 Milestone 2 - 0.5% achieved maximise flow Milestone 3 - 1% target achieved 08/07/16 07/09/16 61 Yes 07/09/16 6 6.06 07/09/16 An operational controller is being trialled to see if this helps during particularly pressured periods and this had achieved 90.6% for October.

Project name: Speciality In reach Number of project tasks/milestones: 0 Project ref: RP 9 Project owner: Programme start date (Monday): 03/03/16 Clinical lead: This week and next week : u Planned Planned Actual Max End Comment Sect. Ref. Task / milestone Days Complete Comment / Constraints / Remedial actions Start complete complete Date Date 9 9 Target = 1% of improvement to 95% Project to be continued to demonstrate effective impact with 2 13/03/16 13/04/16 14/05/16 62 Yes 13/04/16 of 3 milestone targets achieved via reduction of waits for 9 9.05 Milestone 1 - 0.2% achieved specialist assessment ‘0’ medical and ‘3’ surgical. System Milestone 2 - 0.5% achieved resilience group (SRG) agreement to continue funding for 1. Streaming at A&E at Streaming 1. 9 9.06 13/04/16 14/05/16 14/05/16 31 Yes 14/05/16 9 9.07 Milestone 3 - 1% target achieved 14/05/16 16/07/16 16/07/16 63 Yes 16/07/16 respiratory consultant, confirmed.

18. System resilience progress report (continued):

Project name: Mental Health Street Triage Number of project tasks/milestones: 0 Project ref: RP 12 Project owner: Programme start date (Monday): 03/03/16 Clinical lead: This week and next week : u Planned Planned Actual Max End Comment Sect. Ref. Task / milestone Days Complete Comment / Constraints / Remedial actions Start complete complete Date Date 12 12 Target =0.5 % of improvement to 95% Following governance issues around suitable vehicles, paramedic input has resumed from Wed 7 December 2016 Programme Programme Milestone 1 - 0.1% achieved 24/10/16 31/10/16 7 Yes 31/10/16 12 12.07 and key performance indicators (KPIs) will follow in due 12 12.08 Milestone 2 - 0.25% achieved 00/01/00 course. (DoD and coding pilots) coding (DoDand

3. Ambulance Response Response Ambulance3. 2 12.09 Milestone 3 - 0.5% target achieved 00/01/00

Project name: Directory of Service (DOS) development Number of project tasks/milestones: 0 Project ref: RP 14 Project owner: Programme start date (Monday): 03/03/16 Clinical lead: This week and next week : u Planned Planned Actual Max End Comment Sect. Ref. Task / milestone Days Complete Comment / Constraints / Remedial actions Start complete complete Date Date 14 14 Target =0.5 % of improvement to 95% Directory of Service development is underway with the deployment of the mobile app in planning.

Programme Programme 14 14.07 Milestone 1 - 0.1% achieved 15/08/16 01/10/16 01/10/16 Yes 01/10/16 An interim support officer has been recruited and is due to 14 14.08 Milestone 2 - 0.25% achieved 12/10/16 12/10/16 12/10/16 Yes 12/10/16 start on 12 December. 2 14.09 Milestone 3 - 0.5% target achieved 05/11/16 15/11/16 15/11/16 (DoD and coding pilots) coding (DoDand 3. Ambulance Response Response Ambulance3.

Project name: 4th HALO Number of project tasks/milestones: 0 Project ref: RP 16 Project owner: Programme start date (Monday): 03/03/16 Clinical lead: This week and next week : u Planned Planned Actual Max End Comment Sect. Ref. Task / milestone Days Complete Comment / Constraints / Remedial actions Start complete complete Date Date 16 16 Target =0.5 % of improvement to 95% This project has been agreed and recruited to and is awaiting a start date. Programme Programme 16 16.07 Milestone 1 - 0.1% achieved 01/08/16 31/08/16 30 no 31/08/16 16 16.08 Milestone 2 - 0.25% achieved 00/01/00 Milestone 3 - 0.5% target achieved

(DoD and coding pilots) coding (DoDand 2 16.09 00/01/00 3. Ambulance Response Response Ambulance3.

Project name: Local Escalation & Response Plan (LERP) Number of project tasks/milestones: 0 Project ref: RP 15 Project owner: Programme start date (Monday): 03/03/16 Clinical lead: This week and next week : u Planned Planned Actual Max End Comment Sect. Ref. Task / milestone Days Complete Comment / Constraints / Remedial actions Start complete complete Date Date 15 15 Target =0.5 % of improvement to 95% The local escalation & response plan (LERP) has now been completed and adjusted to the NHSE framework 15 15.07 Milestone 1 - 0.1% achieved 15/08/16 31/08/16 31/08/16 Yes 31/08/16 which came out in November 2016 15 15.08 Milestone 2 - 0.25% achieved 01/09/16 01/10/16 01/10/16 Yes 01/10/16 2 15.09 Milestone 3 - 0.5% target achieved 00/01/00 4. Improved Patient Flow Patient Improved 4.

18. System resilience progress report (continued): Project name: Ambulance turnaround Number of project tasks/milestones: 0 Project ref: RP 4 Project owner: EEAST / HVCCG / WHHT Programme start date (Monday): 03/03/16 Clinical lead: Dr David Gaunt This week and next week : u Planned Planned Actual Max End Comment Sect. Ref. Task / milestone Days Complete Comment / Constraints / Remedial actions Start complete complete Date Date 4 4 Target = 2.0% of improvement to 95% The turnaround figure had improved significantly with a 4 4.07 Milestone 1 - 0.5% achieved 18/07/16 31/07/16 31/07/16 13 Yes 31/07/16 performance that has been as high as 50% dropping to 25% which is 10% short of the trajectory. This project is currently 4 4.08 Milestone 2 - 1.25% achieved 18/08/16 31/08/16 31/08/16 13 Yes 31/08/16 on Amber. 2 4.09 Milestone 3 - 2.5% target achieved 19/09/16 30/09/16 11 No 30/09/16 4. Improved Patient Flow Patient Improved 4.

Project name: Lead Consultant / Early Discharge Number of project tasks/milestones: 0 Project ref: RP 7 Project owner: Programme start date (Monday): 03/03/16 Clinical lead: This week and next week : u Planned Planned Actual Max End Comment Sect. Ref. Task / milestone Days Complete Comment / Constraints / Remedial actions Start complete complete Date Date 7 7 Target = 0.5% of improvement to 95% This project is underway and now links with the SAFER project. 7 7.05 Milestone 1 - 0.1% achieved 10/03/16 10/04/16 10/03/16 0 Yes 10/04/16 7 7.06 Milestone 2 - 0.25% achieved 10/04/16 10/06/16 10/04/16 0 Yes 10/06/16 7 7.07 Milestone 3 - 0.5% target achieved 10/06/16 10/08/16 61 TBC 10/08/16 4. Improved Patient Flow Patient Improved 4.

Project name: Twilight Team Number of project tasks/milestones: 0 Project ref: RP 8 Project owner: Programme start date (Monday): 03/03/16 Clinical lead: This week and next week : u Planned Planned Actual Max End Comment Sect. Ref. Task / milestone Days Complete Comment / Constraints / Remedial actions Start complete complete Date Date 8 8 Target = 0.5% of improvement to 95% The directors group was given assurance that this team will 8 8.05 Milestone 1 - 0.1% achieved 30/03/16 30/04/16 30/04/16 31 Yes 30/04/16 be re-launched with an expected impact against the agreed 8 8.06 Milestone 2 - 0.25% achieved 30/04/16 30/05/16 30/05/16 30 Yes 30/05/16 trajectory. This team was now in place and had seen some 8 8.07 Milestone 3 - 0.5% target achieved 30/05/16 30/07/16 61 No 30/07/16 success. 4. Improved Patient Flow Patient Improved 4.

Project name: Stranded Patients Number of project tasks/milestones: 0 Project ref: RP 5 Project owner: WHHT / HVCCG / HCT / HPUFT / HCC Programme start date (Monday): 03/03/16 Clinical lead: Dr Tammy Angel This week and next week : u Planned Planned Actual Max End Comment Sect. Ref. Task / milestone Days Complete Comment / Constraints / Remedial actions Start complete complete Date Date 5 5 Target=2.5% of improvement to 95% While there is social work presence on site 7 days a week, 5 5.12 Milestone 1 - 0.5% achieved 06/05/16 14/07/16 69 14/07/16 there is still no formal 7 day team. The implementation of this is now delayed until Feb '17 5 5.13 Milestone 2 - 1.5% achieved 07/05/16 14/08/16 99 14/08/16 decision to admit (DTA) approach is expected to be in place 145 30/09/16 by Dec'16

5. Improved Discharge Improved 5. 5 5.14 Milestone 3 - 2.5% target achieved 08/05/16 30/09/16 Continuing health care (CHC) review to be completed with actions by Dec '16 although increase in staffing not expected until March '17.

18. System resilience progress report (continued): Project name: HCT in reach to IDT Number of project tasks/milestones: 0 Project ref: RP 10 Project owner: Programme start date (Monday): 03/03/16 Clinical lead: This week and next week : u Planned Planned Actual Max End Comment Sect. Ref. Task / milestone Days Complete Comment / Constraints / Remedial actions Start complete complete Date Date 10 10 Target =0.5 % of improvement to 95% Impact has been sustained with a reduction in queries on referrals received from 60% to 40%, an increase in the Milestone 1 - 0.1% achieved 12/03/16 16/04/16 16/04/16 35 Yes 16/04/16 10 10.07 number of queries resolved within two hours from 30% to 10 10.08 Milestone 2 - 0.25% achieved 16/04/16 18/06/16 16/04/16 0 Yes 18/06/16 60%, and a reduction in the number of referrals withdrawn 5. Improved Discharge Improved 5. 2 10.09 Milestone 3 - 0.5% target achieved 18/06/16 20/08/16 16/04/16 -63 Yes 20/08/16 from 40% to 25%,. Long term input against the directors

Project name: Delay transfer of care (DToC) Reduction Number of project tasks/milestones: 0 Project ref: RP 11 Project owner: Programme start date (Monday): 03/03/16 Clinical lead: This week and next week : u Planned Planned Actual Max End Comment Sect. Ref. Task / milestone Days Complete Comment / Constraints / Remedial actions Start complete complete Date Date 11 11 Target = % of improvement to 95% Social care DToCs are at 1.5% for this reporting week which is an improvement on last week and health DToCs have Milestone 1 - 0.1% achieved 11 11.05 30/06/16 30/06/16 30/06/16 0 Yes 30/06/16 increased and are now at 2% 11 11.06 Milestone 2 - 0.25% achieved 30/06/16 01/08/16 01/08/16 32 Yes 01/08/16

5. Improved Discharge Improved 5. 11 11.07 Milestone 3 - 0.5% target achieved 01/08/16 01/09/16 31 TBC 01/09/16

Project name: Trusted Assessor for Care Home Placement Number of project tasks/milestones: 0 Project ref: RP 17 Project owner: Programme start date (Monday): 03/03/16 Clinical lead: This week and next week : u Planned Planned Actual Max End Comment Sect. Ref. Task / milestone Days Complete Comment / Constraints / Remedial actions Start complete complete Date Date 17 17 Target =0.5 % of improvement to 95% This project is being run by Herts County Council (HCC ) 17 17.07 Milestone 1 - 0.1% achieved 01/11/16 30/11/16 30/11/16 17 17.08 Milestone 2 - 0.25% achieved 00/01/00

5. Improved Discharge Improved 5. 2 17.09 Milestone 3 - 0.5% target achieved 00/01/00

19. Continuing health care – quarter 2 report

The national framework for NHS continuing healthcare and NHS funded nursing care sets out the principles and processes for determining eligibility; the table below provides an overview of the framework and the progress update on the relevant standards- CHC assessment and decision making framework Assessment and decision making; lawful, high quality and timely Standard Comment Action Lead Status Standard A1- ensuring policies are Commissioning policy and redress policy are Tracey Green compliant with the national compliant with the national framework for NHS CHC. Brown framework Standard A2: Assessment process to A daily tracker is in place to manage all referrals Lucia Green facilitate timely discharge from received. A commissioning process is in place to Contrino hospital and specialist centres ensure timely placements. Standard A3: Transition between The process for managing transition between Tracey Green children and adults well managed children and adults is articulated in the Brown Standard A4: Trained & competent Bespokecommissioning training policy. for clinical and non-clinical staff to Work is in progress to Tracey Amber be commissioned. identify a suitable Brown provider. Fast track Standard Comment Action Status Standard F1-funding agreed on the The process for agreeing funding on receipt of an F1.2 and 1.3 of Lucia Amber receipt of an appropriate fast track appropriate fast track is articulated in the standard F1 require Contrino commissioning policy additional work and an action plan needs to be devised for the same. Standard F2: CCGs should carefully Regular audits are undertaken to ensure that fast Beau Klusko Green monitor use of the fast track tool and track referrals are appropriate. raise any specific concerns with clinicians, teams and organisations Care and support Standard Comment Action Status Standard C1- all individuals in receipt All patients have a written care plan saved locally Tracey Green of NHS CHC have a written care plan with the CCG in instances where the patient remains Mushawa in their own home.

We are compliant on 2 of the indicators however Commissioning Tracey Amber Standard C2: Care Planning is person work is in progress to meet C2.2. strategy yet to be Brown centred completed. The process for timely authorisation of care packaged C3.2(iii) of Standard Tracey Amber is articulated in the commissioning policy however C3 requires additional Brown there is insufficient capacity re providers. work and work is in Standard C3: Timely plan I package progress in put in place once decision is reached developing the market across Hertfordshire. Work is in progress to Lucia Red develop a Contrino Standard C4: Appropriate specialist procurement strategy package in place to support the commissioning of specialist packages. Standard C5: Case Management To be developed. Tracey Red arrangements in place Brown

Commissioned review of historic fast tracks and A programme of Tracey Amber Standard C6: Annual reviews to prioritised review for those packages that are more annual reviews to be Brown include care package is appropriate than £1,500.00 per week. developed.

19. Continuing health care – quarter 2 report

The dashboard below highlights the priority key performance indicators for continuing health care:

Continuing health care key performance quarterly report. Quarter 1 Quarter 2 Last 12 Months 2016/201 Accountable Responsible Clinical Indicator Threshold Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 To add Comments 7 YTD Director Manager Lead trend graphs

At present this data is collated manually however going forward we have requested support from the business intelligence (BI) team to review the internal tracker to make reporting easier and more transparent, there has Eligibility decision needs been vacancies within the clinical validation function which has contributed to the delays in decision making, The to be made within 28 100% 83.0% 87.0% 76.0% 88.0% 60.0% 68.0% 77.00% CCG is also reliant on satellite centres sending referrals in a timely manner in order to meet the 28 day target. days Phase 2 of the restructuring will enable this to be met from April 2017.

Falls below the national threshold for fast tracks in month 1 and month 3 can be attributed to staffing levels as Fast track decision within National well as high volumes of referrals received. 92.0% 97.0% 88.0% 97.0% 86.0% 97.0% 93.00% 48 hours 93% Falls below the national average in month 5 can be attributed to unforeseen staff absences and problems with IT structure. Q1 Reviews : There were 14 cases that had a review; further clarification is required to determine the calculation Dr figure of 14.5% that was previously reported within a stand-alone continuing health care (CHC) report presented Diane Tracey at the quality and performance committee on the 6/10/16 David Reviews should be Curbishley Brown Indicator 3 has not been measured for quarter 1 but work is in progress for performance to be measured in Buckle undertaken after 3 quarter 2. months from the initial 100% Not Measured 5.40% 6.60% 5.00% There have been a number of reviews undertaken as part of the CHC quality improvement productivity and decision and annually prevention (QIPP) in Q2 (reported %'s are based on 500 CHC patients and exclude FNC patients) - these are the thereafter first reviews and may not necessarily be within 3 months of eligibility but would form the basis of a 3 month review with an annual review or further MDT assessment scheduled as per framework guidance.

All applicants are being Indicator 4 has not been measured for quarter 1 but work is in progress for performance to be measured in notified of the outcome quarter 2. following eligibility 100% Not Measured TBC 80% 76% Previous figure reported against month 4 was calculated as an average over a 4 month period and work is now decision within 48 hours underway to separate this out to be reported on in quarter 3 of decision being made

20) WHHT quality improvement plan: n/a

22) CCG assurance year end 2015-2016: n/a

21 and 23) CCG assurances framework 2016-2017, including the six clinical priority areas: n/a

APPENDIX Glossary of terms for the integrated quality performance and finance report (IQPFR)

Acronym Stands for Brief Definition

AD Assistant director Responsible for strategic and operational management for a department/division. They will be responsible for compiling business plans, developing strategy for their area of activity, ensuring implementation and that performance targets and strategic objectives are met. AQN Activity query notice A notice setting out a query in relation to levels of referrals and/or activity to the provider. AQP Any qualified provider A list of accredited providers that NHS patients can use. AIVS Acute in hours visiting service Herts urgent care scheme providing a fast, efficient service that aims to keep people out of hospital and avoid the need to call 999 ambulances. Runs across east and north Hertfordshire. BCF Better care fund A local single pooled budget to incentivise the NHS and local government to work more closely together around people, placing their well-being as the focus of health and care services. CATT Crisis assessment and treatment team Mental health measured indicator (for number of referrals meeting a 4 hour wait). CDU Clinical decisions unit An inpatient ward for emergency department patients, who require on-going observation and treatment, following assessment; who are expected to be discharged within 24 hours, once their treatment plan is completed. CHC Continuing health care NHS continuing healthcare is the name given to a package of care that is arranged and funded solely by the NHS for individuals who are not in hospital and have been assessed as having a "primary health need". CLO Chief locality officer Responsible to manage locality wide issues. CPN Contract performance notice If the co-coordinating commissioner believes that the provider has failed or is failing to comply with any obligation on its part under this contract it may issue a contract performance notice to the provider. CQC Care quality commission The regulator for all health and social care services in England. CQN Contract query notice Contract query notice: a notice setting out in detail, the nature of a query either by the commissioner or the provider in relation to performance or non-performance of a contractual obligation. CQRM Clinical quality review meeting A meeting between the commissioner and provider of health services to review all the quality measures CQUIN Commissioning for quality and The key aim of the CQUIN framework is to secure innovation improvements in the quality of services and better outcomes for patients, a principle fully supported at all levels of the hospital DNA Did not attend When a patient does not attend an appointment. DQIP Data quality improvement plan Allows the commissioner and the provider to agree a local plan to improve the capture, quality and flow of data to support both the commissioning and contract management process. DTOC Delayed transfer of care Refers to delays in transfer of care of acute and non-acute (including community and mental health) patients. DXS DXS care pathways DXS care pathways are structured plans of care; designed to support the implementation of CCG designated clinical guidelines and protocols. They provide detailed NHS best evidence guidance for each stage in the management of a patient with a specific condition and are built around diagnostic codes.

Glossary of terms for the integrated quality performance and finance report (IQPFR) (Continued)

Acronym Stands for Brief Definition

EEAST East of England ambulance trust The trust covers the six counties which make up the east of England - Bedfordshire, Cambridgeshire, Essex, Hertfordshire, Norfolk and Suffolk and provides a range of services, but is best known for the 999 emergency services. ECIP Emergency care and improvement Clinically led programme that offers intensive practical help and programme support to 28 urgent and emergency care systems leading to safer faster and better care for patients. ECPs Emergency care practitioner Allows patients to be treated at home or in their home surrounds, without being transported to a hospital emergency department if it is not necessary. EIP Early intervention in psychosis Early intervention in psychosis is a clinical approach to those experiencing symptoms of psychosis for the first time. It forms part of a new prevention paradigm for psychiatry and is leading to reform of mental health services, especially in the united kingdom. EMDASS Early memory diagnosis and support Mental health measured indicator (for number of referrals service meeting a 6 week wait). ENHT East and north Herts NHS trust A large provider of acute health care services to HVCCG patients. ENHCCG East and North Hertfordshire clinical The organisation responsible for commissioning (planning, commissioning group designing and paying for) NHS services. The CCG serves over half a million people (580,000) registered at 60 GP practices across east and north Hertfordshire. FNC Funded nursing care Care provided by a registered nurse for people who live in a care home. FOI Freedom of information The Freedom of information Act 2000 provides public access to information held by public authorities. It does this in two ways: public authorities are obliged to publish certain information about their activities; and members of the public are entitled to request information from public authorities. GCC Good corporate citizen A corporation that accepts the importance of being collectively responsible for its local community and environment as an integral part of their core business. HALO Hospital ambulance liaison officer Post in place to support pressures in the west Herts hospitals NHS trust ambulance service. HCA Health care assistant Healthcare assistants help with the day-to-day care of patients, either in hospitals or in patients' homes. HCAI Healthcare associated infection Includes MRSA and clostridium difficile. HRG Healthcare resource group Healthcare resource groups (HRGs) are standard groupings of clinically similar treatments which use common levels of healthcare resource. HRGs help organisations to understand their activity in terms of the types of patients they care for and the treatments they undertake.

HCT Hertfordshire community trust Provides a wide range of care in people's homes, community settings and in its community hospitals. HSCIC Health and social care information The national provider of information, data and IT systems for centre (now known as NHS Digital) commissioners, analysts and clinicians in health and social care. HUC Herts urgent care Delivers urgent health care services in Hertfordshire. HVCCG Herts valleys clinical commissioning The NHS organisation responsible for commissioning (planning, Group designing and buying) health services on behalf of people who live in Hertfordshire’s council districts of Dacorum, Hertsmere, St Albans, Three Rivers and Watford. 28

Glossary of terms for the integrated quality performance and finance report (IQPFR) (Continued)

Acronym Stands for Brief Definition

IAPT Improving access to psychological The improving access to psychological therapies (IAPT) therapies programme supports the frontline NHS in implementing national institute for health and clinical excellence (NICE) guidelines for people suffering from depression and anxiety disorders. ICO Information commissioner’s office Office responsible for the enforcement of the data protection act 1998, and also responsible for freedom of information. IDAT Involuntary drug and alcohol The IDAT program is a structured drug and alcohol treatment treatment program that provides medically supervised withdrawal, rehabilitation and supportive interventions for identified patients. IST Intensive support team A small core team who manage the programme and assignments and provide the NHS with specialist advice in the delivery of operational standards. ITP Inter trust referral policy Inter trust referral policy for transfers. IHCCT Integrated health care and Commissions services for adults and children with mental commissioning team health problems and adults with learning disabilities in Hertfordshire. IPA Integrated point of access The integrated point of access is a single point of contact for Hertfordshire GP’s and other health and social care professionals to access adult community health and social care services and refer for either community nursing or social care referrals . This portal is for professional referrals only.

JCT Joint commissioning team Procures and monitors a range of health and social care support services KPI Key performance indicator Measure by which success or failure is determined. L&D Luton and Dunstable University A large provider of acute health care services to HVCCG Hospital NHS Foundation Trust patients. LAS London ambulance service The London ambulance service (LAS) is a national health service trust that is responsible for answering and responding to medical emergencies in Greater London. LOS Length of stay Refers to a patient’s length of time in hospital. MCI Mild cognitive impairment A condition in which someone has minor problems with cognition - their mental abilities such as memory or thinking Monitor Health sectors regulator that works Monitor helps hospitals and other providers to develop and closely with the care quality improve performance, respond better and faster to changing commission (CQC) patient needs and challenges. MSA Mixed sex accommodation Unjustified mixing in relation to sleeping accommodation. NEPTS Non-emergency patient transport provides transport for patients who have a medical reason service which means they are not able to travel for treatment by another method. NHSE NHS England The main aim of NHS England is to improve the health outcomes for people in England. NHSI National health service improvement Responsible for overseeing foundation trusts and NHS trusts, as well as independent providers that provide NHS-funded care. NHSI offers the support the providers need to give patients consistently safe, high quality, compassionate care within local health systems that are financially sustainable NICE national institute for health and NICE's role is to improve outcomes for people using the NHS excellence and other public health and social care services by providing national guidance and advice.

Glossary of terms for the integrated quality performance and finance report (IQPFR) (Continued)

Acronym Stands for Brief Definition

OOH Out of hours Outside normal surgery hours. POD Point of delivery Hospital or health care facility that is designated to support disaster situations in a specific geographic area.

PTL Patient tracking lists A PTL contains the data required to manage patients’ pathways, by showing clearly which patients are approaching the maximum waiting time so operational staff (e.g. staff booking appointments or admissions for patients) can offer dates according to clinical priority and within maximum waiting times. PTS Patient transport service Provides pre-planned non-emergency transport for patients who have a medical condition that would prevent them from travelling to a treatment centre by any other means, or who require the skills of an ambulance care assistant during the journey.

QIPP Quality, innovation, productivity and A large-scale programme developed by the department of prevention health to drive forward quality improvements in NHS care, at the same time to provide efficiency savings. QN Queue nurse Assists with the offloading of ambulances particularly in times where there are capacity pressures in the A&E department. The patient can be cared for by the queue nurse in a designated area and the crew can be released, once a cubicle becomes available the patient can then be transferred. RAID Rapid assessment, interface and This service is delivered by Herts partnership foundation trust discharge (HPFT) and enables faster identification of mental health needs among hospital inpatients of all ages – as well as benefitting people arriving at accident and emergency. This will help to reduce the time that some people need to stay in hospital, prevent unnecessary re-admission and encourage faster recovery from mental and physical illness. RAP Remedial action plan A recognised action plan implemented to tackle identified areas of concern. RFL Royal free London A large provider of acute health care services to HVCCG patients. RNOH Royal l national orthopedic hospital A specialist orthopedic hospital. RTT Referral to treatment time National 18 week referral rate to treatment target. SBU Strategic business unit Building firm foundations of clinical quality and maximising operational effectiveness without compromising the trust’s financial position. SCN Strategic clinical network Bring together those who use, provide and commission the service to make improvements in outcomes for complex patient pathways. SDIP Service development improvement The development of an SDIP for a department ensures that a plan department is continuously addressing the improvement of service delivery. SDMP Sustainable development management A document that clarifies objectives on sustainable plan development helps to set out a plan of action. SI Serious incident An incident where one or more patients, staff members, visitors or member of the public experience serious or permanent harm, alleged abuse or a service provision is threatened.

Glossary of terms for the integrated quality performance and finance report (IQPFR) (Continued)

Acronym Stands for Brief Definition

SIRI Serious incident requiring investigation Serious incidents requiring investigation are usually but not exclusively within a hospital. SLA Service level agreement Agreement between a service provider (either internal or external) and the end user that defines the level of service expected from the service provider.

SLT Senior leadership team HVCCG senior management team that meet fortnightly. SMART Specific, measurable, achievable, Method used to ensure project/performance goals meet these realistic and time related. objectives.

SOP Standard operating procedures Step by step instructions to assist staff to carry out routine operations/ specific pieces of work. SPA Single point of access A central place, site or phone number (e.g., 999, NHS direct, GP out-of-hours, NHS 111) which provides a gateway to a range of health and social services.

SQPR Service quality performance report Report highlighting key performance indicators.

SRIG System resilience implementation (SRIG) will ensure accountability is taken by the owner group (SRIG has been superseded by organisation for projects to be implemented and ensure the programme board) escalation to system resilience group when any of the above schemes are showing high risk. SRG System resilience group SRG will follow up areas identified via the programme board in relation to system resilience schemes. SSNAP Sentinel stroke national audit Single source of stroke data in England, Wales and Northern programme Ireland. STF Sustainability and transformation fund NHS funding which will support financial balance, the delivery of the five year forward view, and enables new investment in key priorities. TCI Treatment come in date Relates to 52+ week waiters and TCI refers to patients receiving an appointment. TCP Transforming care partnership Tasked with transforming care for people with a learning disability and/or autism. It is made up of people who use the services, their families, providers of services, clinical commissioning groups, local authorities and NHS England specialised commissioning hubs. TDA Trust development authority The NHS trust development authority provides support, oversight and governance for all NHS Trusts to deliver high quality services. TEC Technology enabled care Use of technologies such as telehealth, telecare, telemedicine, telecoaching and self-care to transform the way patients engage in and control their own healthcare and empowering patients to manage it. VTE Venous thromboembolism A disease that includes both deep vein thrombosis (DVT) and pulmonary embolism (PE). WHHT West Herts Hospitals NHS Trust A large provider of acute health care services to HVCCG patients. WRES Workforce race equality standard Tool to measure improvements in the workforce with respect to black and minority ethnic (BME) staff with many of the methods being transferable to focusing on other groups.

NHS Herts Valleys Clinical Commissioning Group Board Meeting 12 January 2017

Title Finance Report 2016/17 – Month 8 Agenda Item: 11b

Purpose* (tick) Decision ☐ Approval ☐ Discussion ☒ Information ☐

Responsible Director(s) and Caroline Hall, Chief Finance Officer Job Title Author and Job Title Julie Dean, Head of Financial Planning & Reporting

Short Summary of Paper At month 8 the CCG is reporting a deficit against plan of £10.2m (£9.5m at month 7). It is now acknowledged that in-year break-even is no longer possible and a revised control total of £8m variance from plan has been agreed. This remains a challenging target and relies on recovery actions being achieved.

Recommendation(s) The Board is being asked to: Note financial performance for 2016/17. Engagement with Engagement has taken place with provider organisations Stakeholders/Patient/Public Links to Strategic Objectives (tick all that apply) Objective 1: Effective Engagement. We will continually improve engagement s with member practices, ☐ patients, the public, carers and our staff to contribute to and influence the work of Herts Valleys CCG. Objective 2: High Quality. We will commission safe, high quality services that meet the needs of the ☐ population, reducing health inequalities and supporting local people to avoid ill health and stay well. Objective 3: Transforming Delivery. We will work with health and social care partners to transform the delivery ☐ of care through the implementation of “Your Care, Your Future”, the Strategic Review in west Hertfordshire. Objective 4: Affordable & Sustainable Care. We will ensure that there is a financially sustainable and ☒ affordable healthcare system in west Hertfordshire. Board Assurance The report is aligned specifically to the following risks on the 2016/17 Board Framework (BAF) and Assurance Framework: Corporate Risk Register 4.1 Failure to deliver a financially sustainable health and social care system (CRR) 4.2 Failure to deliver best value from the total CCG budget 4.3 Failure to achieve the agreed control total for 2016/17. What current risks does this report align to? This report provides an update on risks relating to finance and identifies mitigating actions where applicable in relation to: S04/03 S04/22 S04/23 (these risks relate to achievement of financial targets)

Risks (e.g. patient safety, Emerging risk: financial, legal) There is a risk that the CCG may exceed the revised control total. What risks have been identified as a result of this report? How are they being mitigated? Resource Implications Not applicable. This report provides a general update on key finance issues and performance.

Equality Impact Analysis There are no implications. (indicate the key points the analysis has identified relevant to decision required)

Equality Delivery System Better Health Outcomes ☐ (identify which goal your Improved Patient Access and Experience ☐ proposal / paper supports) A Representative and Supported Workforce ☐

Inclusive Leadership ☐ Report History Headline messages about month 8 have been shared with the Executive Team on 6 Which Groups or December 2016 and with the Financial Effectiveness Group on 15 December 2016. Committees have seen this report and when? Appendices Appendix 1 – Annual Budget Appendix 2 – Acute Expenditure Appendix 3 – Non Recurrent Reserves Appendix 4 – Underlying Recurrent Surplus Appendix 5 – Better Payments Practice Code Summary Analysis Appendix 6 – Statement of Financial Position Appendix 7 – Cash Appendix 8 – Recovery Plan

Finance Report 2016/17 – Month 8

1. Executive Summary and Purpose of the Report

This paper provides a 2016/17 finance report as at the end of November 2016 (month 8). The CCG is currently reporting an in-year deficit of £9.9m (£10.2m variance from plan), which reflects significant over-performance in acute services and continuing care partially offset by underspends elsewhere. The cumulative deficit (including the surplus carried forward from 2015/16) is £5.2m year to date, compared with a planned surplus of £5.0m. A recovery plan has been implemented however it is clear that the CCG will not achieve breakeven in year despite additional efforts to identify further mitigations. The CCG has therefore agreed a revised adverse forecast variance from plan of £8m. This remains a challenging target to achieve.

2. Financial Position as at November 2016 (month 8)

2.1 The CCG revenue The CCG revenue allocation has decreased by £0.2m in month allocation at 8 in relation to a reduction for Charge Exempt Overseas Visitors month 8 is (£0.6m) offset by additional funding of £0.4m for mental health £757.5m (IAPT and Perinatal).

2.2 Reporting £10.2m At month 8 the CCG has recorded an in year deficit of £9.9m adverse variance year to date compared to a planned in year surplus of £0.3m year to date (variance £10.2m). The cumulative deficit at month 8, which takes the brought forward surplus into account, is £5.2m, compared to a planned surplus of £5m. Appendix 1 gives a breakdown by service line.

2.3 £8m forecast The CCG is now forecasting a deficit variance from plan of variance from £8m. Appendix 1 provides a breakdown by service line. plan Additional mitigations have been identified to get to this revised control total (see below for further details) however this remains a challenging target to achieve.

2.4 Acute Contracts Appendix 2 shows the acute budget and expenditure broken are over- down by provider. The expenditure is based on month 6 freeze performing by and month 7 flex data where this is available. Based on this £12.5m data, the CCG is estimating over-performance of £12.5m on acute services year to date. QIPP savings are included in provider budgets where agreed in contracts but £12.1m has not been attributed to individual providers and is shown towards the bottom of the table. The contract value for West Herts Hospital NHS Trust (WHHT) does not include expected annual QIPP savings of £9.5m. The Trust’s monitoring data is indicating contract under-performance of £1.6m year to date when we might expect under-performance due to QIPP of around £6.3m. This position suggests that QIPP schemes are not currently achieving the required level of saving at WHHT, or planning assumptions were too optimistic, or there are other factors responsible for the recorded over-performance. The CCG’s internal recovery plan addressed these themes however QIPP performance has failed to improve sufficiently and other actions have had to be found.

2.5 Continuing care Continuing care is over-spending by £4.8m year to date. The is over- position reflects current commitments on the continuing performing by healthcare database together with the above anticipated £4.8m increase in the NHS funded nursing care (FNC) rate and a further £1.1m relating to the prior year that has recently come to light.

2.6 QIPP QIPP performance is not available at the time of writing. An achievement is update will be provided at the meeting. not available

2.7 The CCG has The table in appendix 3 shows planned expenditure from non- non-recurrent recurrent budgets and reserves. For completeness, the table reserves of includes £3.6m of winter resilience funding that has been £29.6m, of which transferred to the acute budget and is reflected as such in £21.8m is appendix 1. Reserves, including contingency but after budget committed or transfers total £29.6m, of which £21.8m is either committed or earmarked and earmarked for specific purposes. The CCG 0.5% contingency of £7.3m is to £3.8m is offsetting the £3m impact from repayment of system mitigate wider risk share with the balance supporting the in-year position. NHS financial risk The 1% non-recurrent requirement of £7.5m remains uncommitted and must remain so at this stage to mitigate financial risk across the wider NHS and will only be released on a decision by HM Treasury. This is not anticipated until later in the financial year, if at all in 2016/17. The forecast outturn assumes this funding is not available to mitigate the CCG in- year deficit.

2.8 The CCG The underlying deficit is currently assessed as £5.1m, which recurrent under- equates to -0.68% of the recurrent revenue allocation (see lying deficit is appendix 4). This is based on the assumption that mitigations £5.1m (-0.68%) will now be largely non recurrent in nature. This metric is important in demonstrating the extent to which the CCG is using non-recurrent funding sources to meet recurrent costs and thereby undermining its underlying financial health.

2.9 The number of The table in Appendix 5 shows the CCG’s performance against invoices paid the Better Payments Practice Code. The cumulative number of within payment invoices paid within payment terms (15 days for NHS and 30 terms is 96% days for non NHS) is 96%. The number of NHS invoices paid within 15 days is below target at 84% but payment of Non NHS invoices remains above target at 98%.

2.10 The current CCG The current CCG Statement of Financial Position (SOFP) or Statement of Balance Sheet is attached at Appendix 6 for information. The Financial Position CCG has no fixed assets or long term liabilities so the SOFP shows net only includes information on current assets and liabilities. Note liabilities of 1 to the appendix provides more detail for Trade & Other £47.3m Payables.

2.11 £498m of cash The CCG cash summary for the year is provided at Appendix 7. has been drawn This report shows cash utilisation year to date and an expected down to date cash profile for the remainder of the year. It shows that £498m of the £760m expected to be available (65.6%) has been drawn-down to date, leaving £262m (34.4%) undrawn balance.

The drawdown in November was £1.3m more than forecast.

2.12 £8m unmitigated The recovery plan developed in August has proved insufficient risk to in-year to achieve breakeven and therefore further actions have been breakeven developed to address the financial challenge. In particular, the recovery plan relied on an improvement in QIPP delivery but this is proving difficult to achieve. A revised recovery plan is provided at Appendix 8, showing current unmitigated risk of £8m. There is acceptance that the position is unlikely to improve further and therefore the CCG is now forecasting an adverse variance compared to plan of £8m. This will still be challenging to achieve and performance will need to be closely monitored.

3. Risks and mitigating actions

3.1 Risks The current forecast of an £8m variance from plan is based on current performance, various assumptions including how activity may change over the remaining months of the year and recovery actions. There is a risk that these assumptions prove inaccurate.

3.2 Mitigations The current unmitigated forecast is a deficit of £16.5m. Mitigations totalling £8.5m are set out in appendix 8 leaving current net risk of £8m. Additional mitigations may be required if these savings do not materialise.

4. Recommendation and conclusion

Board members are asked to note the 2016/17 financial position, which shows that at the end of November the CCG has an in-year adverse variance against plan of £10.2m and is therefore £10.2m behind the planned year to date surplus target and significantly behind the recovery plan trajectory. It is now clear that the CCG will not achieve breakeven in year despite additional efforts to identify further mitigations. The CCG has therefore agreed a revised deficit variance from plan of £8m. This remains challenging to achieve and performance will need to be closely monitored over the remaining months of the year.

Appendices Appendix 1 – Annual Budget Appendix 2 – Acute Expenditure Appendix 3 – Non Recurrent Reserves Appendix 4 – Underlying Recurrent Surplus Appendix 5 – Better Payments Practice Code Summary Analysis Appendix 6 – Statement of Financial Position Appendix 7 – Cash Appendix 8 – Recovery Plan

Appendix 1- Annual Budget as at November 2016 (month 8)

Annual budget Forecast YTD budget YTD Actual YTD Variance Forecast Description (ISFE) Variance (£000) (£000) (£000) (£000) (£000) (£000)

Programme Allocation 737,287 487,486 487,486 0 737,287 0

Programme Costs Acute 418,682 278,340 290,797 (12,457) 433,417 (14,735) Mental Health / LD 82,349 54,653 53,337 1,316 79,900 2,449 Community Services 66,635 44,423 44,353 70 66,647 (12) Continuing Care / FNC 27,692 18,461 23,303 (4,842) 33,192 (5,500) Prescribing 76,972 51,649 49,064 2,585 73,580 3,392 Other Primary Care 16,230 10,898 10,269 629 14,587 1,643 Reserves 25,989 13,906 12,004 1,902 22,000 3,989 Other Programme Costs 22,711 15,141 14,408 733 21,601 1,110 Total costs 737,260 487,471 497,535 (10,064) 744,924 (7,664)

Programme Surplus / (Deficit) 27 15 (10,049) (10,064) (7,637) (7,664)

Running Cost Allocation 13,203 8,802 8,802 0 13,203 0 Running Costs 12,703 8,467 8,622 (155) 13,039 (336)

Running Cost Surplus / (Deficit) 500 335 180 (155) 164 (336)

TOTAL IN YEAR SURPLUS / (DEFICIT) 527 350 (9,869) (10,219) (7,473) (8,000)

Prior Year Surplus brought forward 7,011 4,674 4,674 0 7,011 0

TOTAL CUMULATIVE SURPLUS 7,538 5,024 (5,195) (10,219) (462) (8,000)

Negative variances are adverse

Appendix 2 – Acute Expenditure as at November 2016 (month 8)

ANNUAL YTD POSITION (£'000) PROVIDER BUDGET BUDGET ACTUAL VARIANCE VAR. % TOP 6 CONTRACTS: West Hertfordshire Hospitals 243,406 164,171 162,578 1,593 1% Royal Free London 48,243 32,162 32,419 (257) (1%) Luton And Dunstable 19,500 13,000 13,768 (768) (6%) East And North Hertfordshire 14,678 9,785 9,859 (73) (1%) Buckinghamshire Healthcare 14,316 9,544 9,728 (184) (2%) Royal National Orthopaedic 8,321 5,547 5,098 449 8%

OTHER CONTRACTS: University College London 9,109 6,073 6,835 (762) (13%) Imperial College Healthcare 6,895 4,597 5,152 (555) (12%) The Hillingdon Hospitals 5,227 3,485 3,949 (464) (13%) Royal Brompton & Harefield 4,236 2,824 2,874 (50) (2%) Moorfields Eye Hospital 3,990 2,660 2,902 (242) (9%) London North West Healthcare 4,477 2,984 2,902 82 3% Guys And St Thomas 2,207 1,471 1,513 (42) (3%) Great Ormond Street Hospital 1,023 682 598 84 12% Barts Health 2,046 1,364 1,418 (54) (4%) Oxford University Hospital 799 533 591 (59) (11%) Chelsea And Westminster 650 434 540 (106) (25%) Kings College Hospital 662 441 298 143 32% Cambridge University Hospitals 583 388 544 (155) (40%) The Royal Marsden 289 193 234 (41) (21%) Frimley Health 417 278 318 (40) (14%) North Middlesex University 329 219 254 (35) (16%) The Whittington Hospital 309 206 361 (155) (75%) Bedford Hospital 225 150 122 28 19%

SUB-TOTAL NHS CONTRACTS 391,935 263,190 264,853 (1,662) (1%)

AMBULANCE SERVICES: East Of England Ambulance 17,076 11,384 11,745 (361) (3%)

INDEPENDENT SECTOR CONTRACTS: Bmi Healthcare 5,626 3,751 4,056 (306) (8%) Spire Healthcare 3,378 2,252 3,236 (984) (44%) Paul Strickland 357 238 257 (19) (8%) Ramsay Health Care 204 136 91 45 33%

OTHER ACUTE HEALTHCARE: Non Contracted Activity 4,969 3,313 3,087 226 7% Urgent Care Centre 2,275 1,517 1,505 11 1% In Vitro Fertilisation 756 504 633 (129) (26%) Individual Funding Request 455 303 324 (21) (7%) Ambulance Cost Per Case Services 16 11 22 (11) (104%)

ACUTE RESERVES/QIPP: Winter Resilience 3,628 2,419 2,419 0 0% Health & Justice 303 202 173 29 14% Overseas Visitors 94 63 136 (74) (118%) Qipp Unspecified (12,102) (8,068) 0 (8,068) 100% Prior Year (Benefit)/Cost Pressure 0 0 (821) 821

GROWTH & PERFORMANCE RESERVE: (288) (2,874) (919) (1,955) 68%

GRAND TOTAL 418,682 278,340 290,797 (12,457) (4%)

Appendix 3 – Non recurrent reserves as at November 2016 (month 8)

Strategic Readmissions Winter Uncommitted Funds Available Provider Review Credit Resilience MRET other 1% Contingency TOTAL

Non Recurrent Funds Available 5,000 4,900 3,628 2,646 4,132 7,336 3,769 31,411 Transfer to HCT contract:- 0 Integrated Discharge Assessment Team (IDAT) & Therapy Team -664 -664 Watford Rapid Response - 2nd tranche -447 -447 St Albans & Harpenden Rapid Response (full year) -1,203 -1,203 Home First -1,018 -1,018 Watford Rapid Response -720 -720 7 day bed bureau -21 -21 Transfer to acute contracts - Royal Free -479 -479 Royal Free Vanguard Q1 & 2 (pass through) 6,258 6,258 Commissioner support to Royal Free -500 -500 Repay system risk share -3,000 -3,000

Funds Available for Investment 5,000 2,107 3,628 887 9,890 7,336 769 29,617

Application of Funds Transforming Adult Services:- 0 Dacorum Rapid Response 785 785 Enhanced Medical Support 320 320 Hertsmere Locality Enhanced Clinical Case Management Service 176 176 Rollout MST care coordination 200 200 Physio & OT capacity in ICT teams 423 423 15 IMC beds at Willow Court 1,006 1,006 Continuation of support - St Peter's Ward (5 step up) HCT 111 111 Continuation of additional 10 non weight bearing beds 426 426 Continuation of 15 discharge to assess beds HCC 560 560 Other investments:- Care Homes 300 300 Stroke (incl. 2 additional HCT beds) 275 275 Protection of Social Care 2,500 2,500 RAID HPFT 994 994 Discharge to Assess /Integrated Discharge Team HCC 100 100 Postural Stability Classes HSP 350 350 IPA HCT 303 303 CHC Risk Share contribution 1,111 1,111 Primary Care Capacity Primary Care 1,500 1,500 CHC Retrospective Claims Process GEM 127 127 CHC Retrospective Claims Process - extended to Sept 16 GEM tbc 0 Adults with complex needs HCC 128 128 Get Active, Get healthy HCC 50 50 Royal Free Vanguard Royal Free 6,258 6,258 Community navigator to work in WHHT HVCCG 35 35 T24 Support T24 120 120 Janet Moorhouse- Inreach 6 weeks HCT 11 11 Contracts manager role HVCCG 0 HPCA (Trusted Assessor) HCPA 30 30 Respiratory consultants WHHT 97 97 Frailty pathway (4 x HCT beds) HCT 410 410 DTA patients from 15/16 (22 beds spot purchased) HCC 46 46 In-reach service to IDT HCT 182 182 HCA team Carebyus/Abbots 500 500 GP front end set-up HUC 435 435 Carer friendly Hospital PM 21 21 Community Surge beds 150 150 Transport Coordinator 21 21 Clincial Outlier team (6mth) 239 239 Pilot GP Nav - dedicated GP practice 9 9 4th Halo 30 30 DOS Additional 6mth staff 12 12 BUPA 10 10 Used to support in-year breakeven 713 769 1,482

Total Commitments 4,979 2,100 3,344 764 9,887 0 769 21,843

Uncommitted Reserves 21 7 284 123 3 7,336 0 7,774

Appendix 4 – Underlying recurrent surplus

2016/17 - month 8 Recurrent Forecast Underlying Non Surplus/ NHS Herts Valleys CCG Surplus/ Recurrent (Deficit) (Deficit) (£000) (£000) (£000)

16/17 published allocation 733,574 733,574 Post Mth07 Recurrent Transfers 9 9 Running Cost Allocation 13,203 13,203 - - NR: - Return of Surplus/(Deficit) 7,011 7,011 Co-Commissioning NR Allocation - Other Non Recurrent allocations 3,704 3,704

TOTAL ALLOCATION 746,786 10,715 757,501

Acute services 435,545 (2,128) 433,417 Mental Health Services 80,235 (335) 79,900 Community Health services 65,582 1,065 66,647 Continuing Care services 33,075 117 33,192 Prescribing 74,710 (1,130) 73,580 Other Primary Care 14,882 (295) 14,587 Other Programme services 6,623 (608) 6,015 BCF Expenditure 18,085 (2,500) 15,585 Reserves & Non Recurrent Programmes 9,979 12,022 22,001 Running costs 13,139 (100) 13,039 Contingency - - -

TOTAL APPLICATION OF FUNDS 751,855 6,108 757,963

CUMULATIVE SURPLUS/ (DEFICIT) (5,069) (462) (0.68%) (0.06%) Surplus/(Deficit) In-Year Movement: (7,473) Surplus/(Deficit) b/f: 7,011

Appendix 5 – Better Payments Practice Code performance

Invoice Invoice Count Invoice Amount % Amount % Passed BPPC Amount BPPC Paid Period Count (Passed) (Passed) Passed Apr-16 2,178 2,120 97% 55,471,278.90 54,195,602.43 98% May-16 1,739 1,668 96% 55,253,792.19 51,852,176.75 94% Jun-16 2,432 2,332 96% 53,988,666.31 55,225,098.39 102% *foot note Jul-16 2,036 1,941 95% 55,560,725.42 54,397,676.83 98% Aug-16 2,068 2,023 98% 58,999,300.99 58,505,250.72 99% Sep-16 1,949 1,791 92% 56,645,642.30 54,857,181.41 97% Oct-16 2,228 2,151 97% 53,780,432.86 53,201,631.39 99% Nov-16 2,051 1,942 95% 58,639,995.44 57,598,404.56 98%

YTD 16,681 15,968 96% 448,339,834.41 439,833,022.48 98%

Year To Date Period Covered Apr-16 to Nov-16

Number of Bills Paid Value of Bills Paid In Total Within In Total Within Period Target % Period Target % £'000 £'000 Non NHS 13,937 13,657 98% 120,879,680.97 118,552,935.57 98% NHS 2,744 2,311 84% 327,460,153.44 321,280,086.91 98% Total 16,681 15,968 96% 448,339,834.41 439,833,022.48 98%

*foot note The "total passed value" of invoices (in column G) is greater than the "total value" of invoices (in column F) because of credit note(s) that have failed the BPPC criteria. If the credit note(s) had passed, it would therefore have reduced the "total passed value" and a result of less than 100 % would have been recorded instead.

Appendix 6 Statement of Financial Position (Balance Sheet)

Statement of Financial Position 30 November 31 March 2016 2016

£000 £000 Non-current assets: 0 0

Current assets: Trade and other receivables 2,256 4,889 Cash and cash equivalents -1,397 163 Total current assets 859 5,052

Total assets 859 5,052

Current liabilities Trade and other payables (note 1) -47,685 -44,796 Provisions -523 -652 Total current liabilities -48,208 -45,448

Non-Current Assets plus/less Net Current Assets/Liabilities -47,349 -40,396

Financed by Taxpayers’ Equity General fund -47,349 -40,396 Total taxpayers' equity: -47,349 -40,396

Note 1 - Trade and other payables 30 November 31 March 2016 2016 £000 £000 Interest payable 0 0 NHS payables: revenue 11,314 12,371 NHS payables: capital 0 0 NHS accruals and deferred income 6,799 4,563 Non-NHS payables: revenue 11,026 6,511 Non-NHS payables: capital 0 0 Non-NHS accruals and deferred income 18,052 18,099 Social security costs 115 95 VAT 0 0 Tax 102 96 Payments received on account 0 0 Other payables 277 3,061 Total Trade & Other Payables 47,685 44,796

Appendix 7 Cash

Cashflow Forecast Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Total £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 Forecast Drawdowns inc Top Slice for Drugs @ M6 61,327 62,759 59,251 61,983 64,903 63,965 61,065 62,531 64,065 63,216 64,365 70,435 759,865

Actual drawdown 55,500 56,500 53,000 56,000 58,500 57,400 54,500 57,800 449,200 Actual top slice 5,827 6,259 6,251 5,983 6,403 5,999 6,122 6,049 48,893 61,327 62,759 59,251 61,983 64,903 63,399 60,622 63,849 0 0 0 0 498,093 Diff 0 0 0 0 0 566 443 -1,318 -309 Undrawn balance 261,772 Proportion remaining 34.4%

Amendments to Forecast Drawdown M6 - Additional 526k allocation to be drawn down in Jan M7 - Additional 1,466k allocation (3,091k actual less forecast 1,625k) to be drawn down in Nov M8 - Additional 8m central support provided as part of ACF1 exercise to be drawn down in M9, M11 and M12 M9 - Additional 1,256k allocation resulting from ACF1 (M6) exercise to be drawn down in M12

CASH DRAWINGS November Rolling actual / Forecast forecast (M8) Diff £'000 £'000 £'000 Cash Funding b/f 391,400 391,400 0 Drawings 57,800 55,966 1,834 Cash Funding c/f 449,200 447,366 1,834

Top Slice b/f 42,844 43,853 -1,009 Home Oxygen and Drugs 6,049 6,565 -516 Top Slice c/f 48,893 50,418 -1,525

Total reconciled to BSA report 498,093 497,784 309

Balance to draw down 261,772 251,533 10,239

TOTAL AVAILABLE CASH

Opening Cash b/f 173 -123 296

From Drawings 57,800 55,966 1,834 Other income 660 200 460

Total cash 58,633 56,043 2,590

TOTAL PAYMENTS

Payroll -795 -780 -15 Blocks and other NHS payments -44,067 -39,408 -4,659 Other NON NHS Payments -15,168 -14,516 -652 -60,030 -54,704 -5,326

Closing cash book position -1,397 1,339 -2,736

Appendix 8 – Recovery Plan

Herts Valleys CCG - Financial Risk Assessment Likely As at 9 December 2016 - based on M08 finance report £m

Current Forecast Variance to plan 16.46-

Recovery Plan (1) RAG Rating Non-STF related contract penalties and sanctions 0.25 Additional CCG allocation (Quality premium) 0.72 Increase programme budget underspends 0.25 Service restrictions 0.10 Review of enhanced services in primary care 0.15 National Prescribing Profile changes 1.00 2.47 Recovery Plan (2) Programme slippage 0.46 Programme slippage 0.25 NHS Property Services adjustment 0.40 Scheme underspends 2.00 Running costs recovery 0.10 EEAST Remedial Action Plan not achieved in full 0.20 Palliative care - improved use of EPaCCs 0.10 Waiting list activity 0.10 Further reduction in outpatient referrals 0.25 Other contracts reducing activity / slipping activity 0.50 GP IT underspend 0.40 Resolution of disputed items 0.20 Additional contract challenges 0.50 CHC review 0.53 5.99

Remaining Risk 8.00-

SPACER PAGE

NHS Herts Valleys Clinical Commissioning Group Board Meeting 12 January 2017

Title Medical Directorate Report Agenda Item: 12 Purpose* (tick) Decision ☐ Approval ☐ Discussion ☒ Information ☒

Responsible Director(s) and David Buckle, Medical Director Job Title Author and Job Title Lynn Dalton, Assistant Director of Localities and General Practice Development Sanjeet Johal, Head of Pharmacy & Medicines Optimisation Team (Interim) Short Summary of Paper This paper provides the Board with an update on the work being undertaken in both the Primary Care and Pharmacy and Medicines Optimisation Teams within the Medical Directorate

Recommendation(s) The Board is being asked to: Note the contents of the paper

Engagement with None Stakeholders/Patient/Public Links to Strategic Objectives (tick all that apply) Objective 1: Effective Engagement. We will continually improve engagement s with member practices, ☒ patients, the public, carers and our staff to contribute to and influence the work of Herts Valleys CCG. Objective 2: High Quality. We will commission safe, high quality services that meet the needs of the ☒ population, reducing health inequalities and supporting local people to avoid ill health and stay well. Objective 3: Transforming Delivery. We will work with health and social care partners to transform the delivery ☒ of care through the implementation of “Your Care, Your Future”, the Strategic Review in west Hertfordshire. Objective 4: Affordable & Sustainable Care. We will ensure that there is a financially sustainable and ☒ affordable healthcare system in west Hertfordshire. Board Assurance BAF: Framework (BAF) and 1.1 Risk that we fail to engage effectively with our patients, population and Corporate Risk Register stakeholders (CRR) 1.2 Risk that member practices do not see the potential positive impact of their engagement with HVCCG What current risks does this 2.2 Risk that we are unable to ensure high quality, safe and sustainable services for report align to? the population and patients of west Hertfordshire 4.1 Risk that we do not deliver a financially sustainable health and social care system 4.2 Risk that we do not deliver best value from the total CCG budget 4.3 Risk that we do not achieve financial balance for 2016/17

SO1/04 Failure to engage and communicate effectively with member practices could lead to lack of support, poor performance and threat to reputational risk, also a failure to meet organisational objectives SO4/23 Risk that additional expenditure will occur that is not budgeted for SO4/03 Risk that QIPP savings are not achieved as planned

Risks (e.g. patient safety, Financial risks identified in both Primary Care and PMOT areas financial, legal) What risks have been Mitigation: identified as a result of this - Monthly monitoring of all activity and expenditure against PCPlus and PMOT report? How are they being budgets mitigated? - Additional PMOT QIPP areas will be identified if existing QIPP is not on track to be delivered Resource Implications None

Equality Impact Analysis (indicate the key points the N/A analysis has identified relevant to decision required) Equality Delivery System Better Health Outcomes ☒ (identify which goal your Improved Patient Access and Experience ☒ proposal / paper supports) A Representative and Supported Workforce ☒

Inclusive Leadership ☐ Report History None Which Groups or Committees have seen this report and when? Appendices

*Purpose – definitions

For decision This is where the board, committee or group is presented with a range of options and is asked to decide which one to accept following discussion. For approval A specific recommendation, plan or document is presented, which the board, committee or group is requested to approve. Discussion is not essential. For information Information is provided and it is important that the board, committee or group is aware of, and understands the information and no decision is required. These items do not require discussion, except for questions of clarification. For discussion The board, committee or group is asked to debate an issue, provide views, challenge and discuss as appropriate. A decision may be made following the discussion although this is not always required. An example is a progress report on a particular pathway. In this case the Board or Committee will be asked to discuss and note the paper

Introduction

The Medical Directorate report provides the Board with a brief overview of the work of the two teams that form the directorate – The Pharmacy and Medicines Optimisation teams and Localities and Primary Care Development. The main workstreams discussed below illustrate some of the ways our teams and clinical colleagues are taking forward the strategic priorities of the organisation. The report covers the above for the months of November and December 2016.

Pharmacy and Medicines Optimisation Team (PMOT) Report

NHS Herts Valleys CCG (HVCCG) is keen to ensure that only treatments that are clinically effective and provide a clear health benefit to patients are prescribed on NHS prescriptions. This is to ensure that NHS HVCCG resources provide interventions with a proven health gain for the population.

Equally, to ensure financial sustainability within Herts Valleys CCG, it is vital that the CCG and its member practices, supported by the Pharmacy & Medicines Optimisation Team (PMOT), maintain control of prescribing costs without comprising patient outcomes.

The CCG’s strategy Your Care, Your Future describes the ambitions for our population. The PMOT has developed a specific work programme that cover the key clinical areas articulated in the strategy document as priority areas of focus for the team for the financial year ahead. The strategy offers significant opportunities to improve patient outcomes through better working with GP practices to increase the effectiveness of prescribing behaviour and by optimising the use of medicines across the local health economy by collaboratively working with our system partners.

The work areas discussed below set out both work underway and future areas of work where the PMOT will seek to optimise medicines use to deliver specific outcomes for our patients and clinicians:

1. QIPP Plan for 2017/18

HVCCG faces a significant QIPP challenge. The PMOT’s quality, innovation, productivity and prevention (QIPP) plan for 2017-18 comprise of 22 sub-schemes that are made up of quality, safety and cost savings interventions which could successfully deliver £1.8 million worth of savings to the local health economy to reinvest in other parts of the system.

The QIPP schemes are listed below:-

1 Branded generics 2 Respiratory 3 Supporting appropriate prescribing of pregabalin 4 Vitamin D pathway 5 Oral nutrition 6 Implementation of PrescQIPP Drop List for Medicines 7 Diabetes 8 Dermatology 9 Patent expiry savings 10 Stoma 11 Continence 12 Woundcare 13 Primary care rebates 14 Cardiovascular 15 Biosimilars 16 Reducing waste 17 Redesign of musculoskeletal pathway 18 Generic savings 19 Care homes 20 Specials 21 Implementation of PrescQIPP Drop List for Devices 22 FYE QIPP 16/17

The schemes have been identified and informed by:

• using a range of benchmarks to compare local and national prescribing against quality measures • alignment with key CCG clinical priority areas as articulated within HVCCG Your Care, Your Future strategy document. • Current evidence-base and initiatives successfully implemented elsewhere that could be replicated within HVCCG.

The QIPP schemes can only be delivered by gaining wide clinical engagement. Each QIPP scheme will be owned and implementation enabled by the PMOT working alongside GP clinical leads who will facilitate change with front line clinicians.

2. Co-proxamol prescribing

The CCG recently (November 2016) issued a letter to all GP practices and community pharmacies reinforcing HVCCG’s current position with regards to co-proxamol prescribing. The co-proxamol license was withdrawn from the market in 2005 on the advice from the Committee on Safety of Medicines (CSM) due to serious safety concerns. Despite good progress being made to reduce the number of items issued on prescription across the CCG, prescribing of co-proxamol is still occurring for a small number of patients and the serious risk posed from taking co-proxamol remains the same. The current average cost per pack of co-proxamol charged to the NHS is £210 and in some cases the cost is significantly more. It is imperative for the CCG to demonstrate value for money and that our resources are being invested in high quality, safe clinical and cost effective prescribing. The PMOT are supporting GP practices to review those remaining patients prescribed co-proxamol and to switch to an alternative, licensed pain management regime.

3. Branded to generic prescribing

A generic medicine contains the same quantity of active substance(s) as its branded medicine equivalent that originally received marketing authorisation. When a generic medicine is granted a license from the regulatory authority, the generic medicine is considered equally safe and clinically equivalent to the branded medicine. Generic medicines are, overall, much less expensive to the NHS. Their appropriate use instead of branded medicines can deliver considerable cost savings and importantly do not impact on delivery of care.

Data from the NHS Information Services Portal indicates that across HVCCG, the annual cost to the local health economy is approximately £260,000 for drugs that are currently prescribed by brand but could be prescribed generically. This presents a significant financial risk to the CCG where an expensive product is prescribed on an NHS prescription when there is an alternative generic cost- effective equivalent product available. In order for the CCG to deliver its statutory obligations, appropriate financial stewardship measures such as switching from branded to generic prescribing must be considered. As such, cost effective, evidence based prescribing, both for improving health outcomes and achieving financial balance, is a key priority for HVCCG.

As part of PMOT’s 2017-18 QIPP plan, the switch from branded to generic medicines has been identified as a potential prescribing efficiency. Data on these potential efficiencies has been available for many years, but there still remains reluctance to changing resistant patients. In order to support practices in making those changes, the CCG will be issuing a directive to GP practices highlighting the benefits of generic prescribing, setting out the current financial position of the CCG, why switching is

5 necessary, and an information letter to hand to patients explaining why generic prescribing is being promoted.

4. Tackling waste

Reducing medicines waste has been a priority focus area for HVCCG and will continue to form a key component of the PMOT’s work plan for 2017-18. Evidence from various parts of the country show current mechanisms and processes relating to the generation of repeat medicines are generally unfit for purpose with resulting patient safety concerns and can incur significant financial losses to the NHS.

HVCCG is committed to improving the patient journey in respect of the prescription ordering process and overall management of repeat prescribing systems in primary care.

The PMOT will be seeking to build on the existing work achieved to date to formulate a multi- faceted strategy jointly with key stakeholders to addressing medicines waste within Herts Valley CCG.

Three core areas will feature as part of this strategy:

Patients - the PMOT will develop and disseminate a patient guide to repeat medicines to support patients’ understanding of how to order, use and dispose of medicines safely. Empowering patients by increasing their awareness and understanding of what to expect when ordering their regular medicines will help encourage patients to take ownership for ordering of their prescriptions. We want every patient who can, to take responsibility for ordering their own prescriptions and not use third parties who are not best placed to know the patient’s requirements .

GP practices – the PMOT will continue to support our 68 GP practices to have safe and robust repeat prescribing systems in place. The development and dissemination of best practice guidance for repeat prescribing will ensure essential standards are met across our practices. Additionally, the CCG will support practices to promote the uptake of online ordering to their patients (in line with national policy).

Community pharmacies – Community pharmacies and their teams have a key and valued role to play in supporting patients to ensure they understand the medication they are taking and to provide further advice and support where needed. The CCG will work with local community pharmacies to promote the availability and uptake of current NHS commissioned services such as Medicines Usage Reviews and New Medicines Services.

Improved systems and processes will help to reduce wastage across the system and importantly bring benefits to patients. In the vast majority of cases, the patient is the best person to order their medicines. HVCCG will work with stakeholders to ensure the necessary supporting infrastructure is in place to deliver the strategy.

Primary Medical Services (GP services) Report

1. Delegated Commissioning i.e. taking commissioning responsibility for commissioning GP contracts from April 2017. An update is provided in the Accountable Officers Board report.

2. CCG commissioned services from GP practices

The CCG is utilising £1.5million pounds to provide increased capacity in primary care. This is funding for additional appointments during core hours (8am to 6.30pm) for the period of October 2016 to March 2017. This additional funding provides support to practices and enables them to offer their staff additional hours or secure locum cover to provide the additional appointments. The aim of increasing capacity funding is to support practices but also assist in reducing A&E attendances.

Eleven GP practices in Watford are a wave one pilot of the Prime Ministers Challenge Fund, subsequently known as the GP Access Service (GPAS) pilot. The pilot is centrally funded by NHS England (NHSE) who has confirmed the pilot will continue to be funded until 31 March 2019. It offers patients registered with the practices increased access to additional appointments outside core GP contractual hours. (6.30pm to 8pm Monday to Friday, 9-1 and 3-8 on Saturdays and bank holidays and 9-1 on Sundays. ) The service is run through two hub sites close to the participating practices. The recent national evaluation of GPAS pilots has reported an overall reduction of 14% for minor self-presenting attendances at A&E with Watford representing a 47% reduction on the previous year before the pilot was introduced. The Clinical Chair for Watford locality and CCG managers agreed with the remaining fifteen practices in Watford to utilise part of the increased capacity funding to roll out the GPAS service across their practices. This commenced in October 2016 and will run to March 2017. It provides access to the additional appointments for the same time period and provides an increase in hub sites from two to five, and thus enabling patients to access services closer to home. The roll out of the programme will be evaluated and depending on the CCG finances we will consider extending the service to include all Practices in HVCCG.

3. Procurements and consultations

HVCCCG is supporting NHSE (Central Midlands) in the procurements of two GP contracts for Meadowell Surgery in Watford and The New Surgery in Tring. The CCG is waiting for the competitive tendering of the services to commence. NHSE has to ensure it complies with procurement law and competitively tenders the service using the Alternative Provider of Medical Services (APMS) contracting route to do so. The CCG is providing local clinical expertise to support the development of the specifications and take part in the evaluation of tenders whilst ensuring that conflicts of interest guidance is met and maintained.

NHSE (Central Midlands) currently commissions the contract for West Herts Medical Centre, which his co-located with the Urgent Care Centre in Hemel Hempstead Hospital site. The centre was opened in May 2009 from 8am to 8pm every day of the year. The contractor has a time limited Alternative Provider of Medical Services (APMS) contract. The centre has a small list of registered patients circa 1,800 but sees un-registered patients. (These are patients who are not registered with West Herts Medical Centre but are registered with other GP practices.) When un-registered patients attend the premises at Hemel Hempstead hospital they are streamed at reception into either the medical centre or the Urgent Care Centre. The process is seamless and patients will not necessarily know which service they have been seen by.

Prior to an APMS contract coming to an end the commissioner in this case NHSE (Central Midlands) has two contractual options they can consider. This is to competitively re-tender the service using the APMS contracting route to seek a contractor to run the service for a further agreed contractual time period. Alternatively, to end the contract, close the centre/practice and support registered patients to re-register with another GP practice. NHSE (Central Midlands) has extended the current West Herts Medical Centre contract to the end of October 2017. This is to enable NHSE and the CCG to jointly consult on the future of the service. The consultation is planned to commence at the end of January 2017. The outcome of the consultation will be reported to the NHSE/CCG joint primary medical care commissioning committee in April 2017 for a decision on the future of the service. If the decision is to retain the service it will be competitively tendered and the incumbent provider will be able to bid for the service again. If the decision is to close the centre, NHSE (Central Midlands) supported by the CCG will work with patients and local practices to assist on the re-registration. It is worth noting that two similar centres opened on the same day: - West Herts Medical Centre in Hemel Hempstead and Spring House Medical Centre in Welwyn Garden City. Spring House has successfully established itself with a list size of circa 9,000 patients. West Herts Medical Centre has unsuccessfully tried to establish itself in the local community and has been unable to expand its list of registered patients beyond 1,800.

It is widely recognised that General Practice has struggled in the last few years as the effects of staffing and financial pressures have increased. Many small practices have disappeared and nationally a small number of partnerships have chosen to hand back their contracts. The CCG believes that very small practices are particularly vulnerable and therefore would require a new provider to clearly demonstrate sustainability.

4. GP Forward View

NHSE published the GP Forward View (GPFV) in April 2016 which outlines its plan to support and improve primary medical services through a number of actions outlined in the GPFV. The CCG Operational Planning Guidance for 2017-2019 has for the first time published a requirement for CCGs to write a GPFV plan outlining its plan to support the delivery of the GPFV. The CCG plan is required for submission in March 2017 (date to be confirmed). In future Board reports the Medical and General Practice Development directorate will provide update on progress of the GPFV. This subject is covered in more detail elsewhere on the agenda.

We can confirm a first draft GPFV plan has been submitted to NHSE (Central Midlands) we are waiting for NHSE to provide their feedback but also their proposed trajectories to assist the planning process.

Our practices were informed in August 2016 of the new GP Resilience Programme (GPRP) launched by NHSE. We supported our practices to submit expressions of interest to access a range of options under the programme. Twenty seven of the sixty eight practices submitted expressions. The CCG and Hertfordshire Local Medical Committee supported NHS England to review the expressions of interest. Practices have subsequently been informed of the outcome of their application. NB it should be noted this is not always in the form of additional funding but support to undergo a diagnostic review to consider new ways of working.

We can confirm that NHSE (Central Midlands) informed the CCG that it has launched wave 2 of the co-funded clinical pharmacist programme in General Practice. As outlined in the GPFV this is an extra 1,500 clinical pharmacists that NHSE is going to co-fund with GP practices for three years. The

8 guidance and application process has been issued to all GP practices. The portal for practice applications opens on 9 January 2017, but it is a rolling programme for applications.

5. DXS

DXS is a clinical decision support software programme that has been installed in all 68 HVCCG practices and is now ready for use. It is aimed to provide simplicity and ease of access to local (primary care) information in face to face patient appointments.

DXS promotes localised CCG care pathways and locally commissioned services to drive uptake and compliance, improving patient outcomes, reducing inappropriate referrals and improving efficiencies.

DXS is updated centrally on a regular basis eliminating the need for stand-alone intranets, websites and other referral and care pathway solutions.

5.1 DXS -current position

November 2016 reporting indicates that DXS is actively being used in 61 practices with 776 individual users. Uptake is increasing at a steady rate.

We have identified a resource to provide face to face training, and have currently provided one to one or group sessions in 12 practices, and are booking sessions over the coming months.

56 individuals have completed DXS e-Learning and 115 individuals have participated in the virtual classroom sessions.

5.2 DXS - content

We currently have 30 care pathways developed by our Clinical Leads live on DXS, with another 20+ close to completion for uploading.

Herts Valleys Care Pathways Hand surgery and ganglion Individual funding request Knee arthroscopy Oral anti-coagulation for patients Total hip replacement Bronchiolitis<2 with AF Cataracts Acute asthma2-16Years Grommets and adenoidectomy Benign skin lesions FeverishIllness<5 Tonsillectomy Total knee replacement Gastroenteritis Spinal injections Prolonged jaundice in babies Suspected lung cancer BMI smoke-free Chest pain Physical activity Anxiety and depression Community ophthalmology Ankyglossia (tongue tie) End of life Heart failure Abdominal hernia Hip pain Community gynaecology Varicose Veins Knee Pain

There are currently 262 live documents on DXS, consisting of care pathways, referral forms, patient information leaflets, and guidance documents.

These documents support the care pathways, and include referral forms for the providers most commonly used by the practices in the CCG: West Hertfordshire Hospitals, Royal Free, East and North Hertfordshire, Luton and Dunstable and Buckinghamshire Healthcare Trust as well as our community services, public health commissioned services and mental health providers.

The 20 most accessed documents currently available on DXS are

Unique Article Views Users

2WW Cancer Referral Landing Page 356 131

IPA West Referral Form 308 57

Concordia 24hr Ambulatory ECG and Echocardiogram Referral Form 196 74

WHHT Breast Suspected Cancer Referral Form 194 87

WHHT Suspected Skin Cancer Referral Form 179 73 WHHT Rapid Access Chest Pain Clinic Referral 175 67 West Herts Community Rheumatology Orthopaedics and Pain 165 43

Services (CROPS) Referral Form

WHHT Lower GI Suspected Cancer Referral Form 159 78

IAPT HPFT Referral Form 148 43

Dacorum Integrated Community Services Referral 127 17

WHHT Urology Suspected Cancer Referral Form 122 64

Diabetes SPoC Referral Form 110 46

WHHT Gynae Suspected Cancer Referral Form 110 52

Cataract Surgery Referral Form 97 38

IAPT Lea Vale Referral Form 87 44

West Herts Podiatry Referral Form 85 41

WHHT Upper GI Suspected Cancer Referral Form 84 38

IAPT The Counselling Foundation Referral Form 80 31

Breast Cancer Local Providers Landing Page 76 45

Community Respiratory Clinic Referral Form 63 29

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NHS Herts Valleys Clinical Commissioning Group Board Meeting 12 January 2017

Title Communications and Engagement Report Agenda Item: 13 Purpose (tick one only) Decision or Approval ☐ Discussion ☐ Information ☒ Responsible Director(s) and Juliet Rodgers, Associate Director of Communications and Engagement. Job Title Author and Job Title Juliet Rodgers, Associate Director of Communications and Engagement. Short Summary of Paper This paper summarises key communications and engagement activities since the last board meeting in public Recommendation(s) The Board is being asked to: To note communications and engagement activities for the period. Engagement with The report includes a key section on how patients, carers and public are involved in Stakeholders/Patient/Public the work of the CCG. Links to Strategic Objectives (tick all that apply) Objective 1: We will continually improve engagement with patients, carers, the public and member practices ☒ so that they contribute to and influence our work and activities. Objective 2: We will commission safe, high quality services that meet the needs of the population, reducing ☐ health inequalities and supporting local people to stay well and avoid ill health. Objective 3: We will work with health and social care partners to transform the delivery of care through the ☒ implementation of Your Care, Your Future, the strategic review in west Hertfordshire. Objective 4: We will ensure that there is a financially sustainable and affordable healthcare system in West ☐ Hertfordshire. Board Assurance Activities reported here provide evidence of work to engage with public, staff and Framework (BAF) and membership – key issues on Board Assurance Framework. Corporate Risk Register (CRR)

What current risks does this report align to? Risks (e.g. patient safety, Work reported here mitigates risk in the corporate register around engagement with financial, legal) the public in e.g. service re-design; relationships; and reputational risk. What risks have been identified as a result of this report? How are they being mitigated? Resource Implications Within existing resources. Equality Impact Analysis Our engagement work seeks to include our diverse communities. An Equality (indicate the key points the Analysis was completed for the public participation strategy. analysis has identified relevant to decision required) Equality Delivery System Better Health Outcomes ☐ (identify which goal your Improved Patient Access and Experience ☐ proposal / paper supports) A Representative and Supported Workforce ☐

Inclusive Leadership ☐ Report History Which Groups or Committees have seen this report and when?

Page 1 of 4

NHS Herts Valleys Clinical Commissioning Group Board Meeting 12 January 2017

1. Introduction and purpose of paper This paper summarises the communications and engagement activity for the previous period.

2. Public facing campaigns We continue to support the national Stay Well This Winter campaign using local information that we promote via digital communications and social media. Outdoor advertising using bus-shelters has started locally with colleagues reporting that they have seen this in Hemel Hempstead and Watford. Initially our messages were focussed on getting the flu jab; we have now moved into phase two of the campaign which is about encouraging people – especially those with long term health conditions and the over 65s – to talk to their pharmacist at the first sign of illness.

Our activities have also included three “roadshows” one each at Watford, Hemel Hempstead and St Albans City Hospital giving out leaflets encouraging people to stay well this winter and where to get the help they need if they are feeling unwell.

We have also supported national public health campaigns such Movember, antibiotic awareness month and patient online, encouraging people to use GP online services.

In December, in joint work with West Hertfordshire Hospitals Trust (WHHT), we announced the temporary closure of the urgent care centre in Hemel Hempstead during night time hours. We then undertook some intensive promotion about this, using a wide range of methods to ensure that this information was cascaded far and wide; this included posters, GP communication, local print media and social media such as community facebook groups.

3. Patient and public participation In line with our participation strategy we are focussing on the need to broaden engagement with an ever growing group of patients who have already expressed an interest in getting involved through their GP practice patient group.

This will be achieved by offering support to practices to develop their groups and bringing representatives, both staff and patients, together to share good practice through our west Herts PPG network. This will also help to develop and expand our locality patient groups and provide an opportunity to broaden participation on our PPI Committee from a wider network of patients.

We will also develop better connections with a range of community groups to encourage membership of PPGs whilst also enabling community representatives to influence health services for those not wishing to join established groups.

This proposal was presented and discussed at the PPI Committee meeting in December and the approach was fully supported by members.

We are similarly looking to broaden engagement through the Your Care, Your Future programme. During 2017 engagement will focus on the development of new community services. Events are taking place in each of the four localities to update people on Your Care,

Page 2 of 4

NHS Herts Valleys Clinical Commissioning Group Board Meeting 12 January 2017

Your Future and hospital options and to start a conversation about the community assets and resources that we can build on in developing new local health and care services as well as the changes patients will need to make in their lifestyles and the way they access health services. The first event will be in Dacorum at Hemel Hempstead School on 31 January and other events will follow in February. These will be evening meetings to give working age people an opportunity to attend.

To reach a broader range of people, particularly young people, the Your Care, Your Future programme will look to take the conversation to existing meetings such as youth councils and carers forums.

4. Media coverage We have received a higher than usual number of media enquiries recently. These have been about:  Social care funding and the decision not to repeat discretionary funding for Hertfordshire County Council  Our financial position more generally  The temporary overnight closure of the urgent care centre at Hemel Hempstead.

These issues generated significant local interest and there has been some national trade press interest in our financial position, with a piece appearing in the Health Service Journal (HSJ). We worked closely with colleagues at WHHT to announce the temporary overnight closure of the urgent care centre and to handle the subsequent media and political interest which needed some clarification following some media broadcasts and online commentary.

There has also been some continued local media interest in plans for reconfiguration of acute hospital services.

Just before the new year weekend, we issued information to local media and through networks to explain the pressures Watford General was under, urging people to use NHS 111 and other services if their situation wasn’t an emergency. We worked with WHHT colleagues to promote this message.

We have issued media releases on antibiotic awareness month, carers strategy being shortlisted for an HSJ award, self-care week, see your pharmacist at the first sign of feeling unwell, where to get health help over Christmas and the new year including pharmacy opening times, the announcement of the appointment of our new chief executive. The latter was reported in the HSJ.

5. Staff communications and engagement Our second round of staff awards were presented at the December staff briefing. Individual awards went to Selina Jassal and Moira Kelly and team awards went to the planned and primary care and planning and transformation teams.

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NHS Herts Valleys Clinical Commissioning Group Board Meeting 12 January 2017

We held an all staff session where we learned more about what we could do to continually improve the way we do things. Teams considered a range of topics, held discussions round their tables and shared their suggestions at the feedback session. A team of continuous improvement champions has been set up to take this initiative forward in 2017.

Recent topics of discussion at our staff involvement group meetings include the proposal to change notice periods, activities to raise funds for our charities, issues around retention and making better use of exit interview feedback and the impact of financial recovery on staff morale and recruitment.

In the run up to Christmas we held an event in the office and raised £280 for our local charity, Hector’s House.

6. Other Sustainability and Transformation Plan (STP) The STP for Hertfordshire and west Essex, A Healthier Future was published in December. The full plan and a summary document are available to view on a newly created microsite, www.healthierfuture.org.uk.

A Healthier Future includes some of the excellent examples of good practice that Herts Valleys CCG has helped to put in place which are already making positive differences to people’s health and wellbeing. There will be further opportunities to highlight local case studies through the microsite.

Website/intranet update We have transferred the material from the Your Care, Your Future website onto a new area of the Herts Valleys CCG web site, www.hertsvalleysccg.nhs.uk/your-care-your-future and this is now where we direct people to find documents and information. The STP material is also available through this new section – linked from the STP microsite.

Social media On social media we have been tweeting reminders for people to get requests for repeat prescriptions in early so they have sufficient medication for the Christmas and new year period; the temporary overnight closure of the urgent care centre in Hemel Hempstead; where to get health help and advice if you need it over Christmas; Christmas and new year pharmacy opening hours; and increased weekend GP appointments in Watford and Three Rivers.

We now have more than 3800 followers on Twitter.

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[Type text]

NHS Herts Valleys Clinical Commissioning Group Board meeting 12 January 2017

Title Board Assurance Framework 2016/17 Agenda Item: 14 End of Q3 position

Purpose (tick one only) Decision or Approval ☐ Discussion ☒ Information ☐

Responsible Director(s) and Rod While, Head of Corporate Governance Job Title Author and Job Title Katy Patrick, Risk Manager Short Summary of Paper The paper presents in summary the Board Assurance Framework (BAF), with assurances and actions updated to the end of Q3 2016/17.

Recommendation(s) The Board is being asked to: Review and discuss the BAF 2016/17 Q3. Engagement with N/A Stakeholders/Patient/Public Links to Strategic Objectives (tick all that apply) Objective 1: Effective Engagement. We will continually improve engagement s with member practices, ☒ patients, the public, carers and our staff to contribute to and influence the work of Herts Valleys CCG. Objective 2: High Quality. We will commission safe, high quality services that meet the needs of the ☒ population, reducing health inequalities and supporting local people to avoid ill health and stay well. Objective 3: Transforming Delivery. We will work with health and social care partners to transform the delivery ☒ of care through the implementation of “Your Care, Your Future”, the Strategic Review in west Hertfordshire. Objective 4: Affordable & Sustainable Care. We will ensure that there is a financially sustainable and ☒ affordable healthcare system in west Hertfordshire. Board Assurance All of the risks on the Board Assurance Framework (BAF) and Corporate Risk Register Framework (BAF) and (CRR) are relevant. Corporate Risk Register (CRR) Risks (e.g. patient safety, N/A financial, legal) What risks have been identified as a result of this report? How are they being mitigated? Resource Implications There are no additional funding implications.

Equality Impact Analysis N/A (indicate the key points the analysis has identified relevant to decision required)

Equality Delivery System Better Health Outcomes ☒ (identify which goal your Improved Patient Access and Experience ☒ proposal / paper supports) A Representative and Supported Workforce ☒ Inclusive Leadership ☒

1 Report History The Audit Committee will also receive the Q3 report on 12 January 2017. Which Groups or Q3 position to October was presented to Q&P Committee on 3 November 2016. Committees have seen this This paper presents the position at end of December 2016, and has also been shared report and when? with the Senior Leadership Team (SLT). Appendices Appendix 1 BAF Summary presentation Appendix 2 CRR Summary presentation

1. Introduction

1.1 The Board Assurance Framework (BAF) as part of the fundamental core of HVCCG’s internal control systems identifies all risks which potentially threaten achievement of the CCG’s four Strategic Objectives. The nature and relative sizes of these threats are set out in Section 2.1 below.

1.2 This paper provides the Committee with a summary of the updated BAF for 2016/17 and the end of December 2016 position (Q3), following meetings with individual risk owners, the Executive team and Assistant Directors. Changes made to the BAF since Q2 are set out in Section 2.2 below.

1.3 The BAF Summary at Appendix 1 outlines specific control measures that the CCG has put in place to manage the identified risks and the independent assurances relied upon by the Board to demonstrate that these are operating effectively. This report includes graphs showing individual risk movements over time.

1.4 Whilst this framework identifies the significant potential risks which may threaten achievement of the CCG’s Strategic Objectives, any related risks requiring specific mitigating actions are cross- referenced and documented fully within the CCG’s Corporate Risk Register. A summary of the Corporate Risk Register (CRR) at the end of Q3 is included at Appendix 2.

1.5 The BAF and CRR are reviewed monthly with individual risk owners and reported at least quarterly through the Board and its Committees.

2 2. Strategic risks at 30 December 2016. 2.1 Relative positions of threats to strategic objectives. Effective Engagement High Quality 1.1 Public 1.2 Members 2.1 National targets 2.2 Quality & Safety

12 12 12 16 Target 8 Target 8 Target 8 Target 8

1.3 Staff 2.4 System IM&T 2.3 Inequalities 8 20 Target 4 16 Target 16 Target 8

Transforming Delivery Affordable and Sustainable Care 3.1 Capital resource 3.2 Local support 4.1 Sustainable system 4.2 Best value 12 12 16 16 Target 8 Target 8 Target 10 4.3 Financial balance Target 8 3.3 Workforce

16 20 Target 10 Target 8

3 2.2 Summary of change over time (Q4 2015/16 to Q3 2016/17)

Q3 position at 30 December 2016 shows any movement in the current (mitigated) risk score, by strategic objective, since Q4 2015/16. Individual graphs embedded in the BAF summary document (Appendix 1) show movement of inherent (unmitigated) and current (mitigated) risk scores in relation to their target risk score. The target score is the level of risk to the achievement of that strategic objective that the Executive Team considers to be tolerable and justifiable.

Risk Deteriorating ↓ Risk Improving ↑ No Movement → *N.B. Risk descriptions amended STRATEGIC OBJECTIVE 1: Effective Engagement. We will continually improve engagements with member practices, patients, the public, carers and our staff to contribute to and influence the work of HVCCG Q4 15/16 Q1 16/17 Q2 16/17 Q3 16/17 Risk Ref Risk Risk Score Risk Score Risk Score Risk Score Owner (Residual) (Residual) (Residual) (Residual) 1.1 JR Risk score unchanged at 12 “Risk that we do not engage effectively with a range of our 8 8 12 12 → patients, population and stakeholders” 1.2 DB Risk score unchanged at 12 “Risk that member practices and other partners do not see the 12 12 12 12→ potential positive impact of their engagement with HVCCG” 1.3 JR Risk score unchanged at 8 “Risk that we have an unengaged 12 8 8→ staff body.” STRATEGIC OBJECTIVE 2: High Quality. We will commission safe, high quality services that meet the needs of the population, reducing health inequalities and supporting local people to avoid ill health and stay well Q4 15/16 Q1 16/17 Q2 16/17 Q3 16/17 Risk Ref Risk Risk Score Risk Score Risk Score Risk Score Owner (Residual) (Residual) (Residual) (Residual) 2.1 CA Risk score unchanged at 12 “Risk that we do not deliver on all 12 12 12 12→ NHS Constitutional pledges, key national targets and priorities” 2.2 DC Risk score unchanged at 16 “Risk that we are unable to ensure high quality, safe and sustainable 16 16 16 16→ services for the population and patients of west Herts ” 2.3 SE Risk score unchanged at 16 “Risk that we do not close the 12 16 16 16→ health inequalities gap between the most and least deprived.” 2.4 AW Risk score unchanged at 16 “Risk of lack of adequate system capability in the management and 20 16 16→ security of information, data and technology” 4 STRATEGIC OBJECTIVE 3: Transforming Delivery. Work with health and social care partners to transform the delivery of care through the implementation of “Your Care, Your Future”, the strategic review in west Hertfordshire Q4 15/16 Q1 15/16 Q2 16/17 Q3 16/17 Risk Ref Risk Risk Score Risk Score Risk Score Risk Score Owner (Residual) (Residual) (Residual) (Residual) 3.1 CA Risk score unchanged at 12 “Risk that the joint submission to obtain additional capital resource 12 12 12 12 → to successfully transform the delivery of care in west Hertfordshire is unsuccessful.” 3.2 CA Risk score unchanged at 12 “Risk that there will be insufficient support from local bodies and key 12 12 12 12 → stakeholders to transform the delivery of care in west Hertfordshire.” 3.3 SE Risk score unchanged at 16 “Risk that workforce issues will prevent us from transforming that 12 12 16 16 → delivery of care across the local health and social care system.” STRATEGIC OBJECTIVE 4: Affordable & Sustainable Care. We will ensure that there is a financially sustainable and affordable healthcare system in West Hertfordshire Q4 15/16 Q1 15/16 Q2 16/17 Q3 16/17 Risk Ref Risk Risk Score Risk Score Risk Score Risk Score Owner (Residual) (Residual) (Residual) (Residual) 4.1 AW Risk score unchanged at 16 “Risk that we do not deliver a 20 16 16→ financially sustainable health and social care system. 4.2 AW Risk score unchanged at 16 “Risk that we do not deliver best value from the total CCG budget” 16 16 16 16→

4.3 AW Risk score unchanged at 20 “Failure to achieve agreed control 16 15 20 20→ * total for 2016/17”

3. Recommendation

The Board is asked to review and discuss the BAF 2016/17 Q3 position.

1. BAF 2016/17 Summary presentation Q3 2. Corporate Risk Register 2016/17 Summary presentation Q3

5 STRATEGIC OBJECTIVE 1: Effective Engagement. We will continually improve engagement with member practices, patients, the public, carers and our staff to contribute to and influence the work of Herts Valleys CCG. BAF RISK 1.1 Risk that we do not engage effectively with a range of our patients, population and stakeholders. Inherent Risk Residual Risk Target Risk CAUSES: (A) Lack of commitment, (B) Unclear approach and absence of strategy, (C) Availability of funding, (D) Limited workforce capacity and capability. ASSURANCE SUMMARY Q3 2016/17: Executive summary of the Sustainability & Transformation Plan has been published and circulated both internally and externally. HVCCG's financial position has been discussed at a Board meeting in public and at the PPI Committee. Two stakeholder letters have also been 20 16 12 circulated. PPI Committee has agreed a new approach to expanding involvement via the PPGs at practice level. RISK OWNER: Associate Director of Communications & Engagement RISK LEAD: Associate Director of Communications & Engagement CONTROLS ASSURANCES ACTION PLAN & UPDATES COMPLETION DATE 1. Public Participation Strategy and Implementation Plan 1.Public Participation Strategy approved by Commissioning Executive 1.Implementation of the updated 1. March 2017 provides consistency of process (B) and HVCCG Board (+) strategy produced by the Your Care, 1.Each Public Participation & Involvement Committee receives a Your Future Communications & report on progress against the Implementation Plan (+) Engagement Group for the current 1. 2014/15 NHS England Stakeholder Survey (+) phase of the programme. 2. Joint Commissioning Teams helps engagement with 2. Progress reports to Public Participation & Involvement Committee 2. Engagement over next phase is 2. from Nov 2016 stakeholders (A), (B) and HVCCG Board (+) underway with a focus on local 2. 2014/15 NHS England Stakeholder Survey (+) services. 3. Patient representatives at Locality Meetings (A) 3. Progress reports to Public Participation & Involvement Committee and HVCCG Board (+) 4. Patient & Public Involvement Representative attends 4. Communication & Engagement Report to HVCCG Board (+) HVCCG Board; Lay Board Member with Lead for Patient Engagement in place.(A) 5. Public Board meetings (A) 5. Part 1 Board Meeting open to public with papers online (+) 6. Communications and Engagement Strategy in place (B) 6. Updates on stakeholder and public participation provided to Public Participation & Involvement Committee and HVCCG Board (+) 7. Engagement with key public groups and monitoring at 7. Public Participation & Involvement Committee reporting to HVCCG Public Participation & Involvement Committee. (Chaired Board (+) by Lay Member) (A), (B) 8. Monitoring at Commissioning Executive and HVCCG 8. Commissioning Executive and Board fully assured that Board (A), (B), (C), (D) transformation of services has taken into account a fair representation of stakeholders (+) 9. Your Care, Your Future (A), (B), (C), (D) 9. Clinical Engagement Subgroup and Your Care, Your Future feeds into the Commissioning Executive Meeting and each HVCCG Board Meeting (+) 10.Your Care, Your Future Clinical Engagement Subgroup 10. Clinical Engagement Subgroup and Your Care, Your Future feeds (A), (B), (D) into the Commissioning Executive Meeting and each HVCCG Board Meeting (+) 11. Planned and Primary Care Network chaired by Health 11. Planned and Primary Care Network agendas set by Healthwatch Watch meets bi- monthly (A), (B) and HVCCG jointly. The Network reports to the Planned and Primary Care Programme which reports to the Commissioning Executive. (+) 12. Local Medical Committee, Local Pharmaceutical 12. Programme Board has extended attendance invitation to all main Committee and West Herts Clinical Engagement Group providers for Part 2 Programme Board (+) feeds into HVCCG Programme Board (A), (B) 13. Service redesign/ transformation groups have 13. Stakeholders involved in redesigning of services from relevant patient and other stakeholder representatives development to procurement. E.g. enhanced respiratory services, who are involved in the redesigning of services (A), (B) ongoing engagement with public and stakeholders on Gynaecology and Cardiology and all Your Care, Your Future work streams. (+) 14. All business cases are presented to highlight time and 14. Business case submissions reviewed by Commissioning Executive resource required in order to ensure objectives of (+) transforming services are delivered (A), (C), (D) 15. Re-launched Equality and Quality Impact Assessment 15. All policies and policy revisions include the EQIA (+) (A) 16. Senior Managers attend Health Scrutiny Meetings and 16. Reports to the Commissioning Executive and HVCCG Board from Health & Wellbeing Boards (A), (B) Health Scrutiny Meetings and Health Wellbeing Boards (+) 17. Enhanced monitoring and reporting mechanisms 17. Quality Alert System; Locality and GP briefings; Performance Packs developed (A), (B) (+) 18. Your Care, Your Future intensive engagement over 18. Public Participation & Involvement Committee, GP Forum, HVCCG hospital options appraisal has taken place (A), (B) Board (+) 19. Exec summary of STP plan published and circulated 19. Intranet, STP Website, stakeholder comms both internally & externally (A), (B) 20. Update on HVCCG financial situation was discussed at 20. Public Participation & Involvement Committee, HVCCG Board a Board meeting in public and at the Patient & Public stakeholder comms, Participation Committee and communicated in two stakeholder letters (A), (B) 21. New approach to expanding involvement via practice 21. PPI minutes participation groups agreed by PPI CORPORATE RISK REGISTER LINKS RISK MOVEMENT 25 SO1/24 Risk that public and stakeholders are not informed effectively.

15 Inherent Current 10 Target

0 Q4 15/16 Q1 16/17 Q2 16/17 Q3 16/17 STRATEGIC OBJECTIVE 1: Effective Engagement. We will continually improve engagement with member practices, patients, the public, carers and our staff to contribute to and influence the work of Herts Valleys CCG. BAF RISK 1.2 Risk that member practices and other partners do not see the potential positive impact of their engagement with HVCCG Inherent Risk Residual Risk Target Risk CAUSES: (A) Failure to communicate effectively, (B) Pressures in general practice, (C) Unclear approach and absence of strategy ASSURANCE SUMMARY Q3 2016/17: Intensive period of engagement with member practices and clinical leads through, for example, GP Forum and Clinical Leads Forum in Q3 in preparation for the member practice vote about delegated commissioning and the system consultation on urgent care reconfiguration. Results are a 'yes' vote for a move to delegated commissioning and broad support expressed for the urgent care reconfiguration preferred option. Chief locality officers (CLOs) are the interface with localities, attending locality boards and writing locality plans. Clinical leads, CLOs 20 12 8 and members of the senior leadership team conduct joint practice visits. Clinical leads attend the Joint Commissioning Committee and clinical locality chairs are on the JCC working group. Operational planning for 2017/19 will include a GP Forward View plan and workforce plan. Practice Managers’ Forum is engaged to test new specifications. Next GP Forum February 2017. RISK OWNER: Medical Director RISK LEAD: Associate Director of Communications & Engagement CONTROLS ASSURANCES ACTION PLAN & UPDATES COMPLETION DATE 1. Your Care, Your Future has been developed with 1.The Member Practices' Commissioning Agreement (MPCA) 1. To work with localities and GPs as 1. Ongoing from Apr 2016 significant engagement through programmes of care, has been revised for 2016/17 and is under consultation to providers to find alternative models of enablers and localities (A), (B), (C) ensure Membership engagement at locality, practice and CCG care. level (+) 2. To work closely with the LMC to help 2. Ongoing from Apr 2016 1. Annual NHS England 360° Stakeholder Survey (+) inform alternative models of care. 3. To plan for 2017/18 and the option of 3. Mar 2017 2. Member Practice Engagement Plan and Communications 2. The Member Practices' Commissioning Agreement (MPCA) delegated commissioning. & Engagement Strategies in place (A), (B), (C) has been revised for 2016/17 and is under consultation to ensure Membership engagement at locality, practice and CCG level (+) 2. InterLoc meetings discuss concerns and share good practice with GP practices (+) 2. Annual NHS England 360° Stakeholder Survey (+) 2. Amber/Green Internal Audit Opinion for Member Practice Engagement

3. GP Forums, weekly bulletins, GP intranet and Practice 3. Practice Manager Forum introduced following engagement Managers Forum all facilitate two-way discussion and with GPs (+). Six monthly feedback from GPs was positive (+) information sharing (A), (B)

4. Locality Board structure and management arrangements 4. All work undertaken on the Plan on a Page is reported in place to increase engagement. Monthly locality briefings monthly to Locality Board Meeting and reported for capture highlights from meetings (A), (B) information to HVCCG Board quarterly. Locality Chairs are also members of the Commissioning Executive (+)

5. Bi-monthly Training, Education, Research and Learning 5. Practice Nurse and GP Education Programme secured funding Group in place chaired by HVCCG Chair (A), (B), (C) through the Health Education Programme 2015/16 (+)

6. Joint commissioning of primary medical services with 6. All clinical programmes led by a clinician who has extensive NHS England (B), (C) clinical engagement and a representative from all localities. This strengthens the synergy with the Strategy (Your Care, Your Future) (+)

7. Annual practice visits to engage member practices and 7. Practice visit from May 2015 gave in-depth insight into the enhance quality of Primary Care led by Executives, Locality 'real' pressures in primary care. This led to action on how Officers and Locality Clinical Leads (A), (B), (C) HVCCG can support member practices during CQC visits through the sharing of best practice to raise standards (+) 8. Investment of £1.5m over three years to increase 8. Evaluation of year one has shown positive outcomes (+) capacity in primary care (supporting additional appointments) and a holistic assessment team in Dacorum (B), (C)

9. Stakeholder engagement activity reported separately 9. Accountable Officer’s reports to Board (+) through the Accountable Officer report to the Board on a monthly basis (A), (C)

10. Quality Alert System (A) 10. QAS quarterly reports to Quality & Performance Committee (+) 11. Weekly GP bulletin (A) 11. Communications Team emails (+)

12. Periodic QIPP briefings (A) 12. Communications Team emails (+)

13. Plan developed for joint practice visits with NHSE 2016/17 (A), (B)

14. GP intranet overhauled (A)

15. Localities bulletin reviewed (A) CORPORATE RISK REGISTER LINKS RISK MOVEMENT SO1/24 Risk that public and stakeholders are not informed effectively. 25

15 Inherent Current 10 Target

BAF RISK 1.3 Risk that we have an unengaged staff body. Inherent Risk Residual Risk Target Risk CAUSES: Failure to implement internal communications strategy (A) Failure to adhere to specific timetables for circulation (B) ASSURANCE SUMMARY Q3 2016/17: There is a whole range of different activities in place to ensure that we communicate and engage with our staff. We continue to develop those activities and to listen to suggestions about how we can improve. We have increased the frequency of all-staff face-to- 16 8 4 face briefings and they are now monthly.

RISK OWNER: Associate Director of Communications & Engagement RISK LEAD: Associate Director of Communications & Engagement CONTROLS ASSURANCES ACTION PLAN & UPDATES COMPLETION DATE 1. Staff involvement group 1. Minutes of Staff Involvement Group 1. Staff involvement group working on 1. On-going 2. All staff meetings & staff briefings 2. Standard staff communications channels staff suggestions. 3. Team briefing 3. OneBrief delivered at team meetings, feedback collated and 2. Staff involvement group inputting into 2. Dec 2016 reported on, published on intranet development of managers’ training. 4. Staff wellbeing and social activities 4. Wellbeing noticeboards and displays, publicity for activities 3. Continuous improvement project being 3. from Nov 2016 via standard staff communications channels taken forward with staff involvement 5. Director breakfasts 5. Standard staff communications channels group. 6. Staff surveys 6. Standard staff communications channels 7. Refreshing internal communications plan 7. Minutes of Staff Involvement Group 8. Intranet overhauled and re-launched 8. New intranet site 9. Updated internal communications & engagement plan 9. Minutes of Staff Involvement Group has been discussed and agreed at the staff involvement group and includes actions following NHS staff survey 2016. CORPORATE RISK REGISTER LINKS RISK MOVEMENT 18

10 Inherent 8 Current 6 Target 4

0 Q1 16/17 Q2 16/17 Q3 16/17 STRATEGIC OBJECTIVE 2: High Quality We will commission safe, high quality services that meet the needs of the population, reducing health inequalities and supporting local people to avoid ill health and stay well BAF RISK 2.1 Risk that we do not deliver on all NHS Constitutional pledges, key national targets and priorities Inherent Residual Target CAUSES: (A) Availability of funding, (B) Limited workforce capacity and capability, (C) Competing priorities in the west Herts health and social Risk Risk Risk care economy (D) Increased attendance at A&E (E) Delays in progressing through ED (F) Demography ASSURANCE SUMMARY Q3 2016/17: A&E 4 hours at WHHT: There has been a steady improvement, mostly maintained month-on-month with November data showed performance at 84% MTD. NHS Improvement (NHSI) has agreed a revised trajectory with WHHT, to be signed off by the A&E programme board, for performance compliance at 95% by early March 2017. A number of additional actions are being put in place to support delivery of this trajectory. DTOCs at WHHT: HVCCG is collaborating WHHT to undertake a detailed analysis of DTOCs. There has been movement towards the target of 2.5%, average DToCs for November is 10.25% WHHT has now implemented the new national schemes which are included within their 16 12 8 recovery plan. Further to a recent meeting with NHSE this is priority issue for the local delivery board, monitored weekly. WHHT missed RTT target: The missed target is being addressed with a recovery plan, including a combination of further outsourcing and a revised theatre schedule. Some significant underlying issues have been identified and this is subject to weekly monitoring in the meantime. The Trust has identified over 200 patients to be directly outsourced and HVCCG are overseeing the tracking and monitoring of the progress. December 2016 deadline was not met by the Trust and an extension until end of March 2017 has been agreed by NHSE and NHSI. Ambulance KPIs: New national A&E plan has ambulance as one of the key priorities. Revised recovery action plan discussed at the September consortium meeting but remains work in progress. Original action plan was achieved in Q2. RISK OWNER: Director of Contracting & Resilience RISK LEAD: Associate Director Contracting & Procurement / Programme Director for System Resilience CONTROLS ASSURANCES ACTION PLAN COMPLETION DATE 1. Robust monthly performance reporting (B) 1. Performance dashboard and reports to Quality 1.A&E 4 hours 1. Mar 2017 & Performance Committee and HVCCG Board.(+) Continuation of existing actions: 1. Weekly performance teleconferences between 1.1 Frailty pathway increased to 6 day West Herts Trust, NHS Improvement and NHS cover/week England (+) 1.2 Improved Directory of Services 1. System Resilience Group and System (DOS) to provide alternatives to A&E Resilience Plan (+) attendance. 1. Workforce vacancy rate improving in Nursing 1.3 Mental Health Street Triage to & Midwifery. A&E is at full nursing reduce section 136 attendances for establishment. Reduction in bank and agency place of safety. staff at West Herts Hospital Trust (WHHT) (+) 1.4 Increase number of ambulance 1. CHC Amber-Red rated internal audit Jan 2016 HALO staff to 4 to improve (-) turnaround performance and new 2. Contracts and Quality Meetings. Regular monthly 2. Monthly face to face contract meetings (+) escalation plans to provide load challenges form part of the contracting process. Contract levelling and reduce ambulance Managers have clarity on information required for 2. Monitoring of progress against CQC batching. monitoring purposes. Recovery Plans are also monitored Improvement Plan through oversight committee, 1.5 GP service in ED to take minor at Contract and Quality Meetings (A), (B) led by NHS Improvement, with WHHT, CQC, CCG cases and release staff in minors for and the Deanery (+) more effective flow through majors. 2016: 3. Monitoring by the RTT Programme Board and HVCCG 3.Audit activity and assurance demonstrates that 1.6 Review of co-ordinated discharge Quality & Performance Committee (B), (C) the system is working (+) services. 4. Financial policies, data sharing and data access policies 4. Internal Audit Plan monitoring and review as 1.7 Route cause analysis across in place. (B) part of the internal audit cycle(+) organisations to understand flow 5. Integrated Plan. (HCC and partnership CCGs) (A), (B), (C) 5. Acute Contracting & Performance blockages. Management Green rated Internal Audit January 1.8a Respiratory in-reach consultant to 2016 (+) facilitate on site assessment in ED. 6. System Resilience Group monitoring Urgent and 6. Reports to, and monitoring from the Quality & 1.8. Improved performance against Planned Care dashboard. (A), (B) Performance Committee (+) target of 5 patients per hour. 7. Fortnightly performance meetings with NHS 7. Reported to SRG Group and in summary to 1.9 Re-establishment of discharge to Improvement and NHS England. (B) Integrated Quality, Performance and Finance assess in social care. Report (IQPFR) 1.10 Establishment of community bed 8. Collaborative work on workforce planning: both short- 8. Reporting to SRG. discharge resource to allow for closure term fixes and longer-term plans are being worked up. (B), of surge areas in acute trust. (C) 2. DTOCs 2. Mar 2017 9. CQC Improvement Plan for West Herts Hospital Trust. 9. NHS Improvement led multi-partnership 2.1 7 day working is part of the (A), (B), (C) Oversight Group established to gain assurance recovery plan that the CQC improvement action plan is robust 2.2 Care home trusted assessor is to be and that appropriate actions are in place to employed to reduce delays caused by deliver agreed outcomes and demonstrate waiting for care homes to assess improvement. (Chaired by the NHS 2.3 Discharge to assess (DTA) model Improvement Portfolio Director and attended by being re-introduced on a multi- HVCCG Accountable Officer and Director of disciplinary level to effect greater flow Nursing & Quality). Membership also includes and remove surge areas currently in NHSE, Healthwatch, Health Education England constant operation in the acute trust. and the GMC/ LMC. 2.4 Establishment of a community bed discharge resource to allow for closure of surge areas in the acute trust. 2.5 Increasing specialist care at home resource. 2.6 Frailty pathway increased to 6 day cover/week 2.7 Route cause analysis in train to understand reason for continued under-performance 3. RTT 18 weeks 3. Mar 2017 Dip in RTT performance being addressed with recovery plans agreed with the Trusts. 4. Ambulance KPIs (Red 1 & Red 2) Revised recovery action plan 4. Nov 2016 – agreed by ambulance consortium no change Dec 2016 CORPORATE RISK REGISTER LINKS RISK MOVEMENT SO2/01 Risk of a lack of proportionate and effective controls on the use, sharing and publication of information. 18

16 SO2/15 Risk that the Continuing Health Care (CHC) retrospective cases process is not concluded in a timely way manner. 14 SO2/25 Risk of failure to deliver specific national targets in relation to Dementia Diagnosis. 12 10 Inherent SO2/30 Risk that patients are not assessed with a management plan and exited/admitted or discharged out of the Emergency 8 Current Department (ED) within 4hrs. 6 Target

S02/31 Risk that we do not reduce delayed transfers of care (DTOCs) to the target of 2.5%. 4

2 SO2/32 Risk that we do not deliver on the constitutional pledge to refer to treatment within 18 weeks at WHHT. 0 SO2/33 Risk that we do not deliver on priority ambulance KPIs. Q4 15/16 Q1 16/17 Q2 16/17 Q3 16/17 STRATEGIC OBJECTIVE 2: High Quality We will commission safe, high quality services that meet the needs of the population, reducing health inequalities and supporting local people to avoid ill health and stay well BAF RISK 2.2 Risk that we are unable to ensure high quality, safe and sustainable services for the population and patients of west Hertfordshire. Inherent Risk Residual Risk Target Risk CAUSES: (A) Poor systems for monitoring and escalating provider quality issues, (B) Responsiveness of HVCCG, (C) Ambiguity over quality assurances required from partners, (D) Poor quality of assurances from providers commissioned directly and indirectly, (E) Availability of funding, (F) Limited workforce capacity and capability ASSURANCE SUMMARY Q3 2016/17: Monthly oversight group meetings and quality assurance visits continue. There are however, positive assurances that the Trust is maintaining safe services with positive outcomes. Mortality rates are lower than the national average and improvement has been made in targets around 20 16 8 cancer and diagnostics. Oversight group will re-commence until outcome of inspection is known (The meetings were paused during the inspection period). Clinical review completed 24 June 2016 – positive verbal feedback from NHSI. CQC re-inspection of WHHT 6-9 September 2016. Initial feedback positive with improvement acknowledged. No major concerns identified. Issues identified during the visit have been immediately addressed to the CQC's satisfaction. Final report expected January 2017. RISK OWNER: Director of Nursing & Quality RISK LEAD: Head of Quality Assurance CONTROLS ASSURANCES ACTIONS & PROGRESS COMPLETION DATE Following West Herts Hospital Trust's CQC serious concerns report: 1. Monthly report to the Quality & Performance Committee by 1. WHHT CQC Improvement Plan monitored 1. Ongoing weekly milestone 1. NHS Improvement led multi-partnership Oversight the Acting Director of Nursing and programme of quality at NHSI oversight committee. monitoring. Group established to gain assurance that the CQC assurance visits implemented. (+) Monthly reports to Q&P on progress. improvement action plan is robust and that appropriate actions are in place to deliver agreed outcomes and 1. Monitoring of progress against CQC Improvement Plan 2. WHHT CQC report expected early 2017. 2. Jan 2017 demonstrate improvement. (Chaired by the NHS through oversight committee, led by NHSI, with WHHT, CQC, Improvement Portfolio Director and attended by HVCCG CCG and the Deanery. Positive verbal feedback from NHSI (+) Accountable Officer and Acting Director of Nursing & Quality). Membership also includes NHSE, Healthwatch, Health Education England and the GMC/ LMC.) (A) - (F) 2. TDA Improvement Director in place at WHHT to provide 2. Monthly report to the Quality & Performance Committee by support, clear direction and to ensure adequate progress the Acting Director of Nursing and programme of quality is made in line with CQC recommendations. (A) - (F) assurance visits implemented. (+) 3. Monitoring of quality and safety of services through the 3. Recent SSNAP data (Sentinel Stroke National Audit monthly integrated Quality and Contract Review meetings Programme) show significant qualitative improvement. (+) chaired by the Director of Nursing & Quality (A), (B), (C), 3. Performance report on national and local KPIs to Executive (D) Team, Quality & Performance Committee and HVCCG Board (quarterly). Exception reports to the bi-monthly Local Area Team Quality surveillance group (bi-monthly). (+) 3. Workforce vacancy rate improving in Nursing and Midwifery. A&E is at full nursing establishment. Reduction in bank and agency staff at WHHT (+) 4. CQUINS in place (B), (D) 4. CQUIN overall achievement 2016/17 Q1 92% (-) 5. The CCG Infection Control Nurse attends the West Herts 5. Infection control action plan in place monitored by Infection Infection Control Committee and West Herts link to the Control Committee attended by CCG (monthly). Infection Herts Health Economy Infection Control Group (A), (B) (C), control cases monitored against national KPI (monthly) (+) (D) 6. Programme of quality/assurance visits agreed and 6. Quality Report to Quality & Performance Committee.(+) planned for 2016/17 (A), (B), (C), (D) 7. HVCCG working with WHHT to implement 7. Monthly report to the Quality & Performance Committee by recommendations from the review of SI governance.(A), the Director of Nursing and programme of quality assurance (B), (C), (D) visits implemented. (+) 7. Slight improvement in training figures for safeguarding children. L1 is slightly below target at 93% & L2 now 96% which is within target. 8. Monitoring of Serious Incidents and Never Events to 8. Serious incident overdue backlog reduced from 45 in July horizon scan by identifying trends and themes across 2015 to zero in January 2016. October 2016 no backlog but providers. Close liaison with providers through the some RCAs not within national time frames due to request Integrated Quality Lead for JCT ) (A), (B), (C), (D), (F) from WHHT for extensions. (+) 8. Herts & Beds-wide workforce programme in place. (+) 8. 2016/17 Q1 & Q2 WHHT no never events. (+) 9. Review of governance structure at WHHT and 9. Herts & Beds-wide workforce programme in place. (+) recruitment to the majority of new governance posts 9. 2016/17 Q1 & Q2 WHHT no never events (+) including Serious Incident management. (F) 10. New Associate Medical Director in post at WHHT leading on Maternity (A), (C), (D), (F) 11. CQC Improvement Plan for West Herts Hospital Trust. 11. Monthly report to the Quality & Performance Committee by (A) - (F) the Acting Director of Nursing and programme of quality assurance visits implemented. (+) 11. HSMR at WHHT has fallen from 120 to 63 (below national average). A review of this published data has begun by the TDA. (+) 12. TDA clinical review conducted on 12th February 2016. (A), (D) 13. Clinical review completed 24 June 2016 (A), (D) 14. CQC re-inspected Sept 2016 - report expected Jan 2017 14. Monitoring through CQRM (+) Following Hertfordshire NHS Community Trust’s (HCT) CQC requires improvement report: 15. CQC re-inspected Q1 2016/17 - HCT rated 'Good'. 15, 16. Monitoring through CQRM (+) All Trusts 16. Data Quality Improvement Plans include requirements around accuracy of data and reporting. RISK MOVEMENT CORPORATE RISK REGISTER LINKS 25

SO4/22 Risk that there are higher levels of hospital activity than planned/anticipated. 20

SO4/23 Risk that additional expenditure will occur which is not budgeted for. 15 Inherent Current 10 Target

Inherent Risk Residual Risk Target Risk BAF RISK 2.3 Risk that we do not close the health inequalities gap between the most and least deprived communities. CAUSES: (A) Lack of focused investment on strategies for prevention, early intervention and diagnosis, (B) Limited workforce capacity and capability for implementation ASSURANCE SUMMARY Q3 2016/17: Increased focus on prevention development ongoing. 16 16 8

RISK OWNER: Director of Contracting & Resilience RISK LEAD: Programme Director, Planned & Primary Care CONTROLS ASSURANCES ACTION PLAN & UPDATES COMPLETION DATE 1. Clinical Strategy focuses on prevention identifying 1. Clinical Strategy monitored by the clinical programmes and 1.Implementation of identified areas and 1.Apr 2017 groups at risk and approaches for increased intervention reported quarterly to the Clinical Executive. Clinical Executive end to end pathways with a focus on (A), (B) reports to the HVCCG Board. (+) prevention: 1. Increase in number of deprived wards in the CCG area. (-) 2. Your Care Your Future Strategy and programme in place 2. Prevention is a key feature of the Case for Change in Your Care 2. Focus of hub development is on areas 2a. Q3 2016/17 (A), (B) Your Future Strategy. Strategic outline case agreed by all parties of deprivation: 2b. Q4 2016/17 (+) a) Borehamwood 2. Partnership working. (+) b) South Oxhey 2. Increase in number of deprived wards in the CCG area. (-) 3. All localities have a Local Commissioning Plan which 3. Local Commissioning Plan updates and progress reported to highlights health inequalities (A), (B) HVCCG Board. (+) 3. Increase in number of deprived wards in the CCG area. (-) 4. Business Cases completed and agreed (A), (B) 4. Prevention is one of the priorities in the business cases agreed for 2016/17 (+) 4. Increase in number of deprived wards in the CCG area. (-) 5. HCC Prevention Strategy (A) 5. Reports to Health & Wellbeing Board (+) 6. Primary Care & Community Implementation Plan (A), (B) 6. Reports to Programme Board (+) 7. Hub Strategy focuses on areas of health inequalities and 7. Fortnightly team meetings with all providers, reported to the hubs will play a key role in prevention within localities (A) Estates Strategy Group (+) 8. Locality plans and Member Practice Commissioning 8. Locality Plans on a page and MPCAs. Agreements (MPCAs) and future models of care have been developed using the Your Care Your Future (YCYF) eight identified population groups and ‘tartan rug’ locality profiles which identify priority issues against national benchmarking. RISK MOVEMENT

CORPORATE RISK REGISTER LINKS 18

SO2/09 Risk to CCG in relation to resourcing delivery of joint co-commissioning of primary medical services. 16

SO2/15 Risk that the continuing healthcare, retrospective cases, process is not able to deliver a desired outcome in a timely 14 way. 12 SO2/25 Risk of failure to deliver specific national targets in relation to dementia diagnosis. 10 Inherent 8 Current S02/26 Risk to the CCG of not implementing the recommendations of Winterbourne View via the Transforming Care 6 Target Programme. 4

0 Q4 15/16 Q1 16/17 Q2 16/17 Q3 16/17 STRATEGIC OBJECTIVE 2: High Quality. We will commission safe, high quality services that meet the needs of the population, reducing health inequalities and supporting local people to avoid ill health and stay well. BAF RISK 2.4 Risk of lack of adequate system capability in the management and security of information, data and technology Inherent Residual Risk Target Risk CAUSES: (A) Historic under-investment in IT, (B) Historic lack of vision of using IT to support clinical services (C) Lack of joined up Risk approach across providers. ASSURANCE SUMMARY Q3 2016/17: All providers are meeting regularly to discuss this risk. There is an understanding that funding is limited and there is a need to collaborate. The Local Digital Road Map Implementation Group has been established. Hertfordshire Digital Integrated Care Programme Board comprises a core delivery board and an extended board of wider stakeholders. Target risk 20 16 8 score of 8 has an expected achievement date of March 2019. The programme is on track with in-year milestones and plans are being progressed around the shared care record with a local pilot using the “medical information gateway” that will commence in Q1 2017/18. RISK OWNER: Chief Finance Officer RISK LEAD: Head of IM &T CONTROLS ASSURANCES ACTION PLAN COMPLETION DATE 1. IM&T Strategy (A), (B), (C ) 1. Chief Finance Officer & Head of 1.From Apr 2016 IM&T to work with Executive and 2. Local Digital Roadmap with inter-operability as a 2. Digital Road Map submitted as part of STP providers to secure further key deliverable (C ) 2. Digital Road Map is signed up to by all providers information and assurances. 2. Monitoring of Digital Maturity Index 2. Oct 2016 2. Current digital road map 3. IT systems reviewed as part of tender process 5. Reports to the Hertfordshire Chief Executives Group extended to include west Essex (STP for new providers (A), (B) Feedback on the project to HVCCG through the wide) 4. Contracts (A), (B) Accountable Officer’s report. 5. Hertfordshire Digital Integrated Care 3. Business case for interoperability 3.Mar 2017 Programme Board (C ) to be drawn up for agreement by all 6. Head of IM&T meets with WHHT (A), (B), (C ) Chief Execs. 7. WHHT has a new datacentre (A), (B), (C) 4. Project plan to be drawn up to 4. Nov 2016 formalise plans for west Herts shared care record, plus project group to be established for implementation.

5. IG certification process required 5. As necessary. Draft to for new providers. be agreed with IG team by end Nov 2016. 6. A shared care record is currently 6. Update included in being developed, a local pilot will Accountable Officer’s commence in Q1 2017/18 and local report to HVCCG Board providers are signed up to make Nov 2016. progress on this. CORPORATE RISK REGISTER LINKS RISK MOVEMENT SO2/01 A lack of proportionate and effective controls on the use, sharing and publication of information. Chart Title 25

0 Q1 Q2 Q3

Inherent Current Target STRATEGIC OBJECTIVE 3: Transforming Delivery. We will work with health and social care partners to transform the delivery of care through the implementation of “Your Care, Your Future”, the Strategic Review in west Hertfordshire. BAF RISK 3.1 Risk that the joint submission to obtain additional capital resource to successfully transform the delivery of care in west Inherent Residual Target Hertfordshire is unsuccessful. Risk Risk Risk CAUSES: (A) Failure to make a compelling case for transformation, (B) Failure to communicate effectively with national bodies, key stakeholders and patients, (C) Limited workforce capacity and capability, (D) Requirement for an Estates Strategy 20 12 8 ASSURANCE SUMMARY Q3 2016/17: Initial feedback 15 November 2016 does not include any decision about capital funding RISK OWNER: Director of Contracting and System Resilience RISK LEAD: Programme Director Your Care, Your Future CONTROLS ASSURANCES ACTION PLAN COMPLETION DATE 1.Clear prioritisation mechanisms in place for 1. Funds for transformation are enhancing primary and 1. Strategic outline implementation 1.April 2017. the STP process - revenue and capital (A), (B), community services (+) starting from April 2016. (C) 1. Increased engagement and partnership from all partners across the health and social care health economy evidenced by signing of Strategic Outline Case. (+)

2. CCG is developing a draft Estates Strategy 2. The development of an Estates Strategy (+) together with the Estates Group which reports to the Commissioning Executive and Board (D)

3. Accountable Officer attends the Chief 3. Minutes from the Group (+) Executives Sustainability & Transformation Plan (STP) Group (A), (B)

4. Quality Assurance meetings with NHSE (A), 4. Outcomes reported (+) (B), (C), (D)

5. Chief Finance Officer attends FARG (A), (B) 5. Minutes from the Group (+)

6. Submission 21 Oct 2016 6. Report on the Pt 1 process and key outline to the Board in Public for 10 Nov to the Board in Public

7. Plan for Pt2 will be shared in closed Board 10 Nov RISK MOVEMENT

CORPORATE RISK REGISTER LINKS 25 SO3/02 Risk that localities will not be aligned with CCG objectives. 20 SO3/03 Risk of failure to ensure that Public Health is sufficiently embedded within the CCG programmes and localities. 15 SO3/05 Risk that we fail to successfully transform health and social care through use of the Better Care Inherent Fund. Current 10 SO3/08 Risk that we are unable to deliver the services identified as key to transformational change due to Target lack of available workforce in primary care. 5 SO3/09 Risk that there will be increased pressure on health services due to a reduced level of provision for social care services 0 Q4 15/16 Q1 16/17 Q2 16/17 Q3 16/17 STRATEGIC OBJECTIVE 3: Transforming Delivery. We will work with health and social care partners to transform the delivery of care through the implementation of “Your Care, Your Future”, the Strategic Review in west Hertfordshire. BAF RISK 3.2 Risk that there will be insufficient support from local bodies and key stakeholders to transform the delivery of care in west Inherent Residual Target Hertfordshire Risk Risk Risk CAUSES: (A) Failure to make a compelling case for transformation, (B) Failure to communicate effectively with national bodies, key stakeholders and patients, (C) Limited workforce capacity and capability, (D) Requirement for an Estates Strategy 20 12 8 ASSURANCE SUMMARY Q3 2016/17: Significant public and political support for plans locally. Health Scrutiny Committee also supported the preferred option for acute reconfiguration. STP Executive Summary document published December 2016 and circulated internally & externally. RISK OWNER: Director of Contracting & System Resilience RISK LEAD: Programme Director Your Care, Your Future CONTROLS ASSURANCES ACTION PLAN COMPLETION DATE 1.Regional Engagement Strategy is being taken forward 1.Frequent briefings to the Board including reports to 1. Using STP process as far as able to 1. Ongoing with District & County Councillors and local MPs (A), (B) Public Board meetings. manage.

2. Continue to bring Your Care, Your Future sponsoring 2. Feedback from NHSE November 2. Feb 2017 Boards together to oversee the terms of reference (A), (B), 1.Frequent briefings to the Board including reports to 2016 analysed and responded to (C) Public Board meetings. prior to public discussion.

3. Partnership Board chaired by HVCCG Chair (A), (B) 1.Frequent briefings to the Board including reports to 4. Stakeholder event on preferred option for acute and Public Board meetings. planned care reconfiguration (A), (B)

CORPORATE RISK REGISTER LINKS RISK MOVEMENT 25

20 SO3/02 Risk that localities will not be aligned with CCG objectives.

15 SO3/03 Risk of failure to ensure that Public Health is sufficiently embedded within the CCG programmes and localities. Inherent Current SO3/05 Risk that we fail to successfully transform health and social care through use of the Better Care Fund. 10 Target SO3/08 Risk that lack of available workforce in primary care prevents delivery of services identified as key to transformational change. 5 SO3/09 Risk that there will be increased pressure on health services due to a reduced level of provision for social care services 0 Q4 15/16 Q1 16/17 Q2 16/17 Q3 16/17 STRATEGIC OBJECTIVE 3: Transforming Delivery Work with health and social care partners to transform the delivery of care through the implementation of “Your Care, Your Future”, the Strategic Review in west Hertfordshire BAF RISK 3.3 Risk that workforce issues prevent us from transforming the delivery of care across the local health and social care system. Inherent Residual Target CAUSES: (A) Unclear approach and absence of strategy, (B) Limited workforce capacity and capability, (C) Workforce culture not congruent Risk Risk Risk with required changes, (D) Poor communication with health and social care partners ASSURANCE SUMMARY Q3 2016/17: Aligning to all strategic plans for the implementation of Your Care, Your Future from April 2016. WPEG has identified current new ways of working and hard to recruit areas. This work will be developed by the new Local Workforce 20 16 8 Action Board (LWAB). To be taken forward within the CCG by Director of Workforce in consultation with Director of Contracting & Resilience and team. RISK OWNER: Programme Director Your Care, Your Future RISK LEAD: Associate Director of Workforce CONTROLS ASSURANCES ACTION PLAN & UPDATES COMPLETION DATE 1. A new HR&ODL Strategy developed with 1. HR&ODL Strategy approved at the Board 1. Further work is required to develop 1. Mar 2017 four strands: Leadership Culture; Workforce Development meeting on 26 May 2016 workforce changes alongside pathway design: Planning, Recruitment & Retention; Learning Accountable Officer or Director of Nursing & Quality in particular providing clarity over roles and & Development; Policies, Procedures & will evaluate KPIs defined at quarterly 3 CCG AOs changes in competencies. Initial report from Systems. (A), (B), (C), (D) Tripartite meetings (+) the WPEG to be taken forward in new LWAB 1. Progress against the HR & ODL Strategy is to be (Local Workforce Action Board). reported quarterly via Q&P and bi-monthly to the 2. Local workforce action board (LWAB) will 2. From Dec 2016 Accountable Officers’ Forum develop WPEG work that identified 2. A new Service Level Agreement has been 2. Monitored via Q&P and the Accountable Officers’ recruitment hotspots to improve further signed by the AOs of HVCCG, BCCG and LCCG, forum. recruitment and retention. First meeting that sets out the HR&ODL services, which is December 2016 implemented via the approved HR&ODL 3. Director of Workforce to collaborate with 3. Jan 2017 Strategy. Director of Contracting & Resilience to draw 3. The CCG partakes in the local workforce 3. Progress reported to local workforce action board up a specific action plan for Q4 2016/17 that action board (LWAB). This has replaced the (LWAB) bi-monthly (+) defines the new models of care, pathways and former group, WPEG. The focus is on four 3. National Primary Care workforce data highlights workforce requirements in detail. strands, being: Trainees; Recruitment & gaps amongst nurses and GPs (-) Retention; Our People; New Ways of Working. 3. The Integrated Care Boards are not clear what the The Director of Workforce is the SRO for new impact on the workforce would be following ways of working across Beds & Herts. (A), (B), integration or the creation of new models of care (-) (C), (D) 4. Current new ways of working locally, regionally and nationally were identified by WPEG in a report tabled on 17.11.16. 5. Workforce strategy reviewed. CORPORATE RISK REGISTER LINKS RISK MOVEMENT

SO3/02 Risk that localities will not be aligned with CCG objectives. 25

SO3/03 A failure to ensure that Public Health is sufficiently embedded within the CCG programmes 20 and localities.

15 SO3/05 Risk that we fail to successfully transform health and social care through use of the Better Inherent Care Fund. Current 10 Target SO3/08 Risk that we are unable to deliver the services identified as key to transformational change due to lack of available workforce in primary care. 5

SO3/09 Risk that there will be increased pressure on health services due to a reduced level of 0 provision for social care services Q4 15/16 Q1 16/17 Q2 16/17 Q3 16/17 STRATEGIC OBJECTIVE 4: Affordable & Sustainable Care We will ensure that there is a financially sustainable and affordable healthcare system in West Hertfordshire. BAF RISK 4.1 Risk that we do not deliver a financially sustainable health and social care system. Inherent Residual Target CAUSES: (A) Reliant upon the engagement of partners in a common financial strategy for both STP (5 years) and Your Care Your Future (10 Risk Risk Risk years), (B) Additional financial uncertainty related to the requirement that utilisation of 1% of CCG non-recurrent spend remains fully uncommitted to create a system risk reserve with spending subject to HM Treasury approval. ASSURANCE SUMMARY Q3 2016/17: It is now clear how the ST Fund plays into year 5 STP share, but initial feedback on submission 25 16 10 review received 15.11.16 does not include any decision about capital funding. 1% non-recurrent requirement of £7.5m remains uncommitted pending decision by H M Treasury. Forecast outturn assumes this funding is not available to mitigate the CCG in-year deficit. RISK OWNER: Chief Finance Officer RISK LEAD: Director of Development CONTROLS ASSURANCES ACTION PLAN COMPLETION DATE 1.CFO membership of STP Finance Group 1. Minutes from new STP Finance group will 1. YCYF implementation risk report to the Audit 1. Jan 2017 meeting for Your Care Your Future be reported to HVCCG Board. Committee in January 2017. 2. STP draft plan submitted 30 June 2016 2,3,5. Feedback in letter from NHSE November 3. STP “do nothing” finance template 2016 did not include decision about capital submitted 30 June 2016 funding (-) 4. STP Lead appointed 5. STP updated plan submitted 21 Oct 2016 6. Separate work streams established for acute, community, primary care and prevention. CORPORATE RISK REGISTER LINKS RISK MOVEMENT SO3/09: Risk that there will be increased pressure on health services due to a reduced level of provision for social care services. 30

25 S04/03: Risk that QIPP savings are not achieved as planned.

20 Inherent 15 Current

10 Target

0 Q1 16/17 Q2 16/17 Q3 16/17 STRATEGIC OBJECTIVE 4: Affordable & Sustainable Care We will ensure that there is a financially sustainable and affordable healthcare system in west Hertfordshire. BAF RISK 4.2 Risk that we do not deliver best value from the total CCG budget. Residual Inherent Risk Target Risk CAUSES: (A) Lack of engagement, (B) Lack of prioritisation (C) Ineffective schemes - difficulty in finding genuine and quantifiable Risk savings. ASSURANCE SUMMARY Q3 2016/17: £8.46m of recovery actions have been identified in the Financial Recovery Plan to (FRP) 20 16 8 M8. QIPP delivery for M8 is up to 71.46% (£8.59m) against plan (£12.02m). Weekly escalation meetings review both the financial recovery plan and individual QIPP schemes with delivery leads and directors. RISK OWNER: Chief Finance Officer RISK LEAD: Assistant Director of Transformation & Planning CONTROLS ASSURANCES ACTION PLAN & UPDATES COMPLETION DATE 1. Clinical and Programme Leads are in 1.Monthly feedback to Executive Board 1. Assurance on Macpherson report requested by Audit 1. Jan 2017 place to ensure that schemes are and Quality & Performance Committee Committee for Jan 2017. monitored with BI Data regarding provider performance (+) 2. Additonal QIPP, decommissioning in-year and delaying 2. Ongoing (A), (C) 1. Monthly NHS England assessment of non-committed expenditure to provide headroom to mitigate CCG QIPP (+) financial risk and meet obligations 1. Internal Audit Opinion for CHC 3. Transformation projects are continually under review to 3. Ongoing Amber/Red (-) ensure delivery of savings. 1. Providers who have accepted a control 4. Programme of weekly escalation meetings to review FRP 4. From Nov 2016 total giving them access to the and QIPP with delivery leads and directors from November Sustainability & Transformation Fund are 2016. not subject to 'double jeopardy' (-) 5. Review of QIPP processes conducted. A more streamlined 5. Jan 2017 2. Transformation/QIPP & Planning Lead in 2. Monthly progress reporting on projects template has been produced for new schemes. Further place including QIPP to Quality & Performance development required. (A), (B), (C) Committee (+) 6. Review of business cases is in train. Decision-making flow 6. Jan 2017 2. NHS England quarterly comparisons of chart has been produced. Template and written process Midlands & East CCGs QIPP achievement under development. (+) 3. Monthly reporting of both activity and 3. Annual Internal Audit review (+) financial cost to identify areas of further 3. Green-rated Internal Audit Opinion for concern (B), (C) Key Financial Controls, Financial Planning & Reporting and Acute Contracting & Performance Management. Amber/Green Opinion for Governance & Payroll (+) 4. Monitored by the Quality & 4. Monthly QIPP report showing the status Performance Committee (A), (B), (C) of all schemes is in place (+) 4. NHS England QIPP review 16.6.2016 (+) – awaiting feedback

5. Internal and external QIPP meetings (A), 5. External review (by ex CFO) of CCG (C) expenditure compared with peer group 6. Monthly financial reporting on QIPP to CCGs, expected by July 2016 NHS England (C) 5. Financial Effectiveness Group scrutiny 7. Project Monitoring Team (A), (C) from November 2015 (+) 8. Monthly meetings between Accountable Officer and QIPP Programme Clinical Leads (A), (B), (C) 9. Risk Mitigation Plan (A), (B), (C) 10. Internal PMO process for monthly checking of transformation and QIPP project milestones (C) 11. Introduction of GP performance data packs so any areas of concern can be highlighted and support given in primary care (A) 12. Close monitoring of all contracts (C) 12. Financial Effectiveness Group scrutiny 13. Line by line review of expenditure from from November 2015 (+) April 2016, benchmarked against other 13. Financial Effectiveness Group scrutiny CCGs (A), (B), (C) from November 2015 (+) 14. NHSE sharing QIPP data from other 14. Financial Effectiveness Group scrutiny CCGs in the region (B), (C) from November 2015 (+) 15. Rationale for business cases is evidence-based, using e.g. Right Care data sets (B), (C) CORPORATE RISK REGISTER LINKS RISK MOVEMENT 25 S04/03: Risk that QIPP savings are not achieved as planned 20

15 Inherent Current 10 Target

0 Q4 15/16 Q1 16/17 Q2 16/17 Q3 16/17 STRATEGIC OBJECTIVE 4: Affordable & Sustainable Care. We will ensure that there is a financially sustainable and affordable healthcare system in west Hertfordshire. BAF RISK 4.3 Risk that we do not achieve the agreed control total for 2016/17 Inherent Residual Target CAUSES: (A) Acute activity levels and/or (B) Financial values of activity above those detailed in the 2016/17 financial plan. Risk Risk Risk ASSURANCE SUMMARY Q3 2016/17: Acute over-performance is estimated as £12.5m to date. Continuing healthcare over performance is at £4.8m. This is being partially managed by the Financial Recovery Plan and proactive oversight of activity flows. Further analysis is being undertaken to understand the causes of increased activity. However, NHS England have acknowledged that the CCG is unlikely to achieve a year end position better than £8m variance to plan and the control total has been revised accordingly. At month 8 £8.46m of recovery actions have been identified in the Financial Recovery Plan. Month 8 finance report shows £10.2m deficit against plan and QIPP delivery to 20 20 10 date is estimated as 71.46%. An Investment Committee of the HVCCG Board has been established and a Turnaround Director appointed. The Accountable Officer has created a programme of weekly escalation meetings to review both the financial recovery plan and individual QIPP schemes with delivery leads and directors. Further financial plan submitted on 23 December 2016. Two escalation meetings have taken place with NHS England with further meetings to be managed by the NHSE local team. Return to in-year balance is forecast in the financial plan for 2017/18 with QIPP delivery of £38m required. RISK OWNER: Chief Finance Officer RISK LEAD: Deputy Director Contracting and Procurement CONTROLS ASSURANCES ACTION PLAN COMPLETION DATE 1. NHS Standard Contracts for 2016/17 (A), (B) 1. Meeting monitoring activity and financial 1. Further analysis is being undertaken to understand 1. Ongoing performance (Monthly) (+) the causes of increased activity 1. Penalties more acknowledged by providers 2. Review of QIPP processes conducted. A more 2. Jan 2017 1. NHS England routine monitoring of financial streamlined template has been produced for new position (Monthly) (+) schemes. Further development required. 3. Jan 2017 1. Internal Audit Opinion on CHC Amber-Red(-) 3. Review of business cases is in train. Decision- 1. CHC expenditure volatile and difficult to making flow chart has been produced. Template and predict (-) written process under development.

2. Activity and Finance schedules (A), (B) 2. Reports to Quality & Performance Committee (Monthly) (+) 2. Internal audit review (Annual) (+) 2. Reports of provider Trusts to their own Boards (WHHT - monthly. Others are a mixture of monthly, bi-monthly and quarterly) (+) 2. Green-rated Internal Audit Opinion for Key Financial Controls, Financial Planning & Reporting and Acute Contracting & Performance Management. Amber/Green Opinion for Governance & Payroll (+)

3. CCG Financial Plan 2016/17 (A), (B) 3. Internal audit of commissioning plans (Annual) (+)

3. NHS England Regional deep dive process. (+)

4. Monitored by the Quality & Performance 4. Contract performance report regularly to Committee (A), (B) Executive Team (Monthly) (+)

5. Internal monthly meetings between 5. Financial Effectiveness Group monitoring of Accountable Officer and Contract Leads (A), B) QIPP schemes (Monthly) (+) 6. External monitoring meetings and activity reports (A), (B)

7. Provision of activity reports to localities and 7. Sent monthly by email (+) practices (A), (B)

8. Strategic outline business case for Your 8. Financial Effectiveness Group monitoring of Care Your Future signed by all parties 21st mitigation plan (Monthly) (+) October 2015 (A), (B) RISK MOVEMENT

9. Monthly review of Running Cost Allowance 9. Reported in monthly finance reports (+) and individual programme budgets (A), (B) CORPORATE RISK REGISTER LINKS 25 S04/22: Higher levels of hospital activity than planned/anticipated. 20

15 Inherent Current S04/23: Risk that additional expenditure will occur which is not budgeted for. 10 Target

0 Q4 15/16 Q1 16/17 Q2 16/17 Q3 16/17

CORPORATE RISK REGISTER SUMMARY REPORT Q3 2016/17 (to December) STRATEGIC OBJECTIVE 1: Effective Engagement. We will continually improve engagement with member practices, patients, the public, carers and our staff to contribute to and influence the work of Herts Inherent Risk Residual Risk Target Risk Valleys CCG. SO1/24 Risk that public and stakeholders are not informed effectively. ASSURANCE SUMMARY Q3 2016/17: There has been a significant increase in media interest in and coverage of some recent issues including the CCG's financial 20 12 8 position and service changes. Liaison and close working with WHHT communications team has been working very well. STRATEGIC OBJECTIVE 2: High Quality We will commission safe, high quality services that meet the needs of the population, reducing health inequalities and supporting local people to avoid ill health Inherent Risk Residual Risk Target Risk and stay well. SO2/01 Risk of a lack of proportionate and effective controls on the use, sharing and publication of information. ASSURANCE SUMMARY Q3 2016/17: 6 monthly IG update sign-off by SIRO on 7 December 2016. IG toolkit audit w/c 12th December. Both Information Asset 16 12 8 register and Data Flow mapping is currently being completed by staff. CEfF folders have been set up for finance staff. Plan being put in place for management of security controls for commissioning data to prepare for the removal of section 251 ASH status.. SO2/09 Risk to CCG in relation to resourcing delivery of joint commissioning of primary medical services. ASSURANCE SUMMARY Q3 2016/17: Outcome of member practices vote on 14 November 2016 was in favour for a move to delegated commissioning in April 2017. National guidance advises a response from Central NHS England expected by HVCCG early-mid January 2017. If approved we will enter into a joint 20 12 8 delegated agreement with NHSE including formalising the staffing resources from NHSE. HVCCG Board has agreed to resource the move to delegated commissioning. SO2/15 Risk that the Continuing Health Care (CHC) retrospective cases process is not concluded in a timely manner. ASSURANCE SUMMARY Q3 2016/17: Retrospective cases by GEM have been completed but the process of appeals and complaints is to be agreed with GEM in 16 12 6 January 2017. Risk Manager to meet with Deputy Director, Nursing & Quality and AD CHC in January to review all CHC risks following internal investigation. SO2/25 Risk of failure to deliver specific national targets in relation to Dementia Diagnosis. ASSURANCE SUMMARY Q3 2016/17: All current quality and safety concerns are being addressed and regularly reported on. Since April solid progress has been made towards the 66.7% diagnosis rate target for dementia. Increase from 55.05% in April to 64.5% in October 2016 against a revised trajectory of 67.05%. 12 12 8 Wait times for EMDASS are now excellent with 95%+ being seen within six weeks. 13 practices have received a visit with a mental health lead, locality support and mental health commissioner and on-going regular communication via normal routes. SO2/26 Risk to the CCG of not implementing the recommendations of Winterbourne View via the Transforming Care Programme. ASSURANCE SUMMARY Q3 2016/17: Transforming Care partnership project continues and is reported monthly to NHSE. All elements are on track to deliver. 16 12 6

SO2/30 Risk that patients are not assessed with a management plan and exited/admitted or discharged out of the Emergency Department (ED) within 4hrs. ASSURANCE SUMMARY Q3 2016/17: There has been a steady improvement, mostly maintained month-on-month with November data showed performance at 16 12 8 84% MTD. NHS Improvement (NHSI) has agreed a revised trajectory with WHHT, to be signed off by the A&E programme board, for performance compliance at 95% by early March 2017. A number of additional actions are being put in place to support delivery of this trajectory. SO2/31 Risk that we do not reduce delayed transfers of care (DTOCs) to the target of 2.5%. ASSURANCE SUMMARY Q3 2016/17: HVCCG is collaborating WHHT to undertake a detailed analysis of DTOCs. There has been movement towards the target of 16 12 8 2.5%, average DToCs for November is 10.25%. WHHT has now implemented the new national schemes which are included within their recovery plan. Further to a recent meeting with NHSE this is priority issue for the local delivery board, monitored weekly. SO2/32 Risk that we do not deliver on the constitutional pledge to refer to treatment within 18 weeks at WHHT. ASSURANCE SUMMARY Q3 2016/17: The missed target is being addressed with a recovery plan, including a combination of further outsourcing and a revised theatre schedule. Some significant underlying issues have been identified and this is subject to weekly monitoring in the meantime. The Trust have identified 16 12 8 over 200 patients to be directly outsourced and HVCCG are overseeing the tracking and monitoring of the progress. December deadline was not met by the Trust and an extension until end of March 2017 has been agreed by NHSE and NHSI. SO2/33 Risk that we do not deliver on priority ambulance KPIs. ASSURANCE SUMMARY Q3 2016/17: New national A&E plan has ambulance as one of the key priorities. Revised recovery action plan discussed at the 16 12 8 September consortium meeting but remains work in progress. Original action plan was achieved in Q2.

STRATEGIC OBJECTIVE 3: Transforming Delivery. We will work with health and social care partners to transform the delivery of care through the implementation of Your Care, Your Future, the Strategic Inherent Risk Residual Risk Target Risk Review in west Hertfordshire. SO3/02 Risk that localities will not be aligned with CCG strategic objectives. ASSURANCE SUMMARY Q3 2016/17: GP Forum has endorsed commitment to reducing bureaucracy in three steps. EMIS Enterprise funding formally approved 20 9 6 to extrapolate data from GP practices, reducing time spent searching, collating and reporting data. SO3/03 Risk of failure to ensure that Public Health is sufficiently embedded within the CCG programmes and localities. 12 6 4 ASSURANCE SUMMARY Q3 2016/17: Public Health continues to be involved in the implementation of Your Care, Your Future with a named locality lead. SO3/05 Risk that we fail to successfully transform health and social care through use of the Better Care Fund. ASSURANCE SUMMARY Q3 2016/17: Final Plan has received approved status from NHS England. Reporting to non-executives at CCG has been improved. 16 12 8 Review of governance arrangements underway, to be discussed at Joint Committee in October 2016 and reported to the Audit Committee in January 2017. SO3/08 Risk that lack of available workforce in primary care prevents delivery of services identified as key to transformational change. ASSURANCE SUMMARY Q3 2016/17: Resource risks anticipated in relation to GP Forward View - NHSE may give CCGs responsibility for recruitment of all 20 12 12 clinicians identified in the GP Forward View. Implications being considered by Director of Workforce and Assistant Director, Localities and Primary Care Development. SO3/09 Risk that there will be increased pressure on health services due to a reduced level of provision for social care services. ASSURANCE SUMMARY Q3 2016/17: The HVCCG Accountable Officer has requested that HCC provide a breakdown of areas from social care most likely to be 20 16 8 affected so that solutions can be agreed between the partners. STRATEGIC OBJECTIVE 4. Affordable & Sustainable Care. Inherent Risk Residual Risk Target Risk We will ensure that there is a financially sustainable and affordable healthcare system in West Hertfordshire. SO4/03 Risk that QIPP savings are not achieved as planned. ASSURANCE SUMMARY Q3 2016/17: QIPP delivery for M8 is up to 71.46% (£8.59m) against plan (£12.02m). Weekly escalation meetings review both the financial recovery plan and individual QIPP schemes with delivery leads and directors. Review of QIPP processes conducted. A more streamlined template has 20 16 8 been produced for new schemes. Further development required. Review of business cases is in train. Decision-making flow chart has been produced. Template and written process under development. SO4/22 Risk that there are higher levels of hospital activity than planned/anticipated. ASSURANCE SUMMARY Q3 2016/17: Acute over-performance is now estimated as £12.5m year-to-date. This is being partially managed by the Financial Recovery Plan and proactive oversight of activity flows. Further analysis is being undertaken to understand the causes of increased activity. However, NHS 20 16 8 England have acknowledged that the CCG is unlikely to achieve a year end position better than £8m variance to plan and the control total has been revised accordingly. SO4/23 Risk that additional expenditure will occur which is not budgeted for. ASSURANCE SUMMARY Q3 2016/17: Month 8 finance report shows £10.2M adverse variance and QIPP delivery of 71.5%. Further financial plan submitted 23 20 20 10 December 2016. NHS England has acknowledged that the CCG is unlikely to achieve a year end position better than £8m variance to plan and the control total has been revised accordingly.

SPACER PAGE

NHS Herts Valleys Clinical Commissioning Group Board Meeting Date of Meeting 12 January 2017

Title Sustainability – Annual report for Information and Sustainable Agenda Item: Development Management Plan for Approval 15

Purpose (tick one only) Decision or Approval ☒ Discussion ☐ Information ☒

Responsible Director(s) and Caroline Hall – Chief Finance Officer Job Title Author and Job Title Amanda Yeates – Head of Corporate Support Short Summary of Paper The paper outlines the CCG’s progress against the current sustainability work plan which has culminated in an increased score from 29% to 44% this year against the Good Corporate Citizen Toolkit. The paper also includes an updated Sustainable Development Management Plan (SDMP) with a 2 year action plan for 2017/19 which will ensure further progress. Recommendation(s) The Board is being asked to:  Note the progress made by the CCG in relation to Sustainability  Agree the SDMP and 2017/19 action plan

Engagement with All staff and the Sustainable Development Working Group have been engaged Stakeholders/Patient/Public throughout last year with the progression of the 2016 work plan and the Good Corporate Citizen Toolkit assessment. It is a statutory requirement that the CCG has an SDMP and the Sustainable Development Working Group will continue to be involved with the progression of the 2017/19 action plan. However work around sustainability has been scaled back for this period to allow staff to focus on other priorities, although all staff will still continue to be engaged with various Sustainability initiatives between 2017 and 2019. Links to Strategic Objectives (tick all that apply) Objective 1: We will continually improve engagement with patients, carers, the public and member practices ☒ so that they contribute to and influence our work and activities. Objective 2: We will commission safe, high quality services that meet the needs of the population, reducing ☐ health inequalities and supporting local people to stay well and avoid ill health. Objective 3: We will work with health and social care partners to transform the delivery of care through the ☐ implementation of Your Care, Your Future, the strategic review in west Hertfordshire. Objective 4: We will ensure that there is a financially sustainable and affordable healthcare system in West ☒ Hertfordshire. Board Assurance  Risk that we are unable to ensure high quality, safe and sustainable services for Framework (BAF) and the population and patients of West Herts (SO4/22) Corporate Risk Register (CRR)

What current risks does this report align to?

Risks (e.g. patient safety,  Risk of not meeting national targets for the NHS for an overall reduction in financial, legal) carbon emissions by 2020 and 2050 What risks have been  Progress against the Good Corporate Citizen Toolkit for the next 2 years will be identified as a result of this minimal due to the scaling back of the work plan for this period report? How are they being mitigated?

Resource Implications  Staff time in relation to progression of the work plan and attendance at quarterly Sustainable Development Working Group meetings

Equality Impact Analysis N/A (indicate the key points the analysis has identified relevant to decision required) Equality Delivery System Better Health Outcomes ☐ (identify which goal your Improved Patient Access and Experience ☒ proposal / paper supports) A Representative and Supported Workforce ☒

Inclusive Leadership ☐ Report History The Board approved the 2016 SDMP in February 2016. The Commissioning Which Groups or Executive also agreed the KPIs and baseline measurements which would be used to Committees have seen this measure the CCG’s carbon emissions in January 2016. report and when? Senior Leadership Team and Sustainable Development Working Group have already been consulted in relation to the SDMP. Appendices SDMP and 2017/19 action plan for approval.

1. Executive summary

The Climate Change Act commits the UK to reducing carbon emission by at least 80% from 1990 levels by 2050. A Sustainable Development Management Plan (SDMP) was subsequently agreed by the Board in June 2014 to enable to CCG to work towards this target. A work plan was then put into place which included the actions on the SDMP as well as those required under the “Getting Started” section of the Good Corporate Citizen Toolkit assessment. Significant progress has been made against the work plan and the CCG’s Good Corporate Citizen Toolkit baseline assessment in November 2015 has now increased from 13% to 44%.

Quarterly reporting via the Integrated Quality Performance Report against agreed KPIs however, show that while the CCG is making significant progress in reducing carbon emissions in many areas, overall the reported organisational carbon emissions continue to rise. This is mainly due to travel – caused by the CCG’s increasing workforce (from 75 wte in 2013/14 to 146 wte in 2015/16) and the associated increased staff commute as interestingly, while the organisational carbon footprint continues to rise, the carbon footprint per employee is reducing as shown below.

2013/14 2014/15 2015/16 Carbon footprint per 1829 tCO2e 1501 tCO2e 1054 tCO2e employee

A new SDMP and associated action plan has been devised for 2017/19 (see appendix). This action plan will be driven forward by the members of the Sustainable Development Working Group. The Board are asked to approve this plan.

2. Background

Sustainable Development and carbon management are corporate responsibilities. Taking action to become more sustainable can lead to cost reductions and immediate health gains. It helps us to develop a health system that is sustainable by reducing inappropriate demand, reducing waste and incentivising more effective use of services and products. In practice this means we need to:

 Focus on preventative, proactive care  Involve patients in the planning and design of services  Build resilience while protecting and developing community assets and strengths  Make the best use of scare resources  Improve efficiency and reduce waste  Minimise carbon emissions

NHS policy drivers include:

 NHS Carbon Reduction Strategy “Saving Carbon, Improving Health” which sets an ambition for the NHS to help drive change towards a low carbon society; setting a pledge

for the NHS to become one of the leading sustainable and low energy organisations by aligning NHS targets in accordance with the Climate Change Act

 NHS Constitution 2013 establishes seven key principles to guide NHS organisations. Principle six from this constitution states “The NHS is committed to providing best value for tax payers’ money and the most effective, fair and sustainable use of finite resources.”

The NHS Carbon Reduction Strategy (2009) and the Sustainable Development Strategy for the Health, Public Health and Social Care System launched in January 2014 reinforce the need for all NHS organisations to reduce carbon emissions and targets have been set for a 34% reduction by 2020 and an 80% reduction by 2050.

The Commissioning Executive agreed measureable KPIs against which the CCGs progress could be monitored in January 2015. Since then reporting has taken place on a quarterly basis via the environmental dashboard in the Integrated Quality Performance report which is presented to the Quality and Performance Committee and the Board. Performance against KPIs is available on request.

In addition to the KPIs, we use the Good Corporate Citizenship (GCC) Toolkit to measure the sustainability of the organisation. This is a methodology for NHS organisations to measure and monitor their progress towards sustainable development. The tool provides organisations with the means to monitor progress on the less easily quantifiable aspects of sustainable development in financial, social and environmental terms. Using the GCC toolkit is one of the four requirements of the NHS Carbon Reduction Strategy.

The GCC tool encourages users to assess their performance over 9 sections and scores progress in three categories; “getting started,” “getting there” and “excellent.” The GCC toolkit is designed to be used annually for monitoring and reporting on progress. The areas assessed under the GCC toolkit are:  Corporate Approach (39% compliance)  Travel (32% compliance)  Procurement (24% compliance)  Facilities Management (45% compliance)  Workforce (52% compliance)  Community Engagement (56% compliance)  Buildings (81% compliance)  Models of Care (59% compliance)  Adaptation (49% compliance)

*Compliance data includes those areas marked as n/a. However, currently only 10% of answers can be marked as n/a and this is not a sufficient number for CCG’s who do not own buildings or engage in capital projects.

The CCG uses the GCC toolkit in conjunction with their carbon footprint as the key metrics by which it measures the impacts from the implementation of the SDMP and therefore its progress towards sustainable development. The most recent GCC toolkit score in November of 2016 had increased to 44% compliance from 29% in November 2015. Our SDMP this year is again based mainly on some of the requirements of the GCC toolkit.

It is important to note that the CCG will never achieve a score of 100% against the GCC toolkit as there are areas of this which do not apply to us or are simply not cost-effective for an organisation of our size to pursue. However, we will continue to work to improve our score year on year.

3. Issues

The key issue currently for the organisation is the increasing carbon footprint in relation to travel – more specifically the staff commute.

4. Resource implications

Financial implications are not quantifiable at this time but using resources more efficiently should ultimately result in future savings for the organisation. An element of staff time will be required to drive forward the work plan and for attendance at quarterly Sustainable Development Working Group Meetings.

5. Risks/mitigation measures

The biggest risk is non-compliance with the national targets for the NHS for a reduction in the overall organisational carbon footprint. This is due to estimated baselines and the increasing size of the organisation. It is therefore important that we continue to work towards the ambitions outlined in the Good Corporate Citizen Toolkit as the scores from this will indicate quantifiable progress.

6. Recommendations

It is recommended that the Board agree the proposed SDMP and associated action plan for 2016/7.

7. Next steps

The Sustainable Development Working Group will progress the action plan during 2017/19 and quarterly reporting to the Quality and Performance Committee/Board against agreed KPIs will continue. A further report to the Board on the current position will be made following the GCC toolkit assessment in November 2017.

Item 15

SUSTAINABLE DEVELOPMENT MANAGEMENT PLAN

Version Number 1.0 Ratified By Exec Team Date Ratified Name of Originator/Author Amanda Yeates Responsible Director Chief Finance Officer Staff Audience All staff Date Issued Jan 2017 Next Review Date Jan 2020

Sustainable Development Management Plan v.1.0 January 2017 1

DOCUMENT CONTROL

Plan Page Details of amendment Date Author Version 1.0 New Plan Oct 16 AY

Sustainable Development Management Plan v.1.0 January 2017 2

CONTENTS

Section Page 1. INTRODUCTION

2. PURPOSE

3. DEFINITIONS

4. ROLES AND RESPONSIBILITIES

4.1 Roles and Responsibilities within the Organisation

4.2 Consultation and Communication with Stakeholders

5. CONTENT

6. MONITORING COMPLIANCE

7. EDUCATION AND TRAINING

8. REFERENCES

9. ASSOCIATED DOCUMENTATION

APPENDICES (TO INCLUDE GLOSSARY FOR ABBREVIATIONS AND ACRONYMS AND AN EQUALITY IMPACT ASSESSMENT)

Appendices:

Each appendix will be numbered to follow on from the policy document.

Sustainable Development Management Plan v.1.0 January 2017 3

1. INTRODUCTION

The UK Government has committed to take action to improve sustainability nationally through the introduction of the UK Climate Change Act (2008), with a target to cut carbon emissions by at least 80% by 2050, with a minimum reduction of 36% by 2020 across the UK.

The NHS Carbon Reduction Strategy for England sets an ambition for the NHS to help drive change towards a low carbon society; setting a pledge for the NHS to become one of the leading sustainable and low carbon organisations by aligning NHS targets in accordance with the Climate Change Act.

The cornerstones of this strategy are for NHS organisations to:  Establish a Board approved Sustainable Development Management Plan  Sign up to the Good Corporate Citizenship Assessment Model  Monitor, review and report on carbon  Actively raise carbon awareness at every level of the organisation

At the same time, the NHS faces challenging times with increasing demand for services. We need to work smarter and more efficiently to achieve more, with less resources, while maintaining and improving the quality of care in order to improve the health and wellbeing of people who live in West Hertfordshire. Being sustainable will help us meet the following changes facing the NHS:  An increasing number of older people with multiple health problems  The rising cost of new medical technology  Higher expectations around clinical outcomes and user experience  Working within financial restraints  Using diminishing resources wisely  Climate change which brings more extreme weather and has an impact on health  Legal responsibilities to cut carbon emissions under the Climate Change Act (2008)

2. PURPOSE

HVCCG is committed to improving health services for everyone who lives in West Hertfordshire and ensuring that we get the best value for money. To achieve this we have a responsibility to ensure that we behave in a sustainable way, making the most of our existing resources and taking into account longer term impacts. This plan sets out how we plan to operate in a sustainable way over the next 2 years. The plan will also:  Confirm HVCCG’s commitment to sustainability and carbon reduction in line with national guidance and statutory obligations

Sustainable Development Management Plan v.1.0 January 2017 4

 Outline HVCCG’s organisational ambitions in relation to sustainability and carbon reduction  Underpin and inform the content of HVCCG’s Sustainable Development Action plan  Demonstrate our progress towards the achievement of the cornerstones of the NHS Carbon Reduction Strategy

Sustainable development is about meeting the needs of today without compromising the needs of tomorrow. In the health and care system, this means working within all the available resources to protect and improve health now and for future generations.

Being sustainable will help us meet the challenges being faced by the NHS, locally and nationally. There are an increasing number of people with multiple health problems, the cost of new technology is rising and people have higher expectations around clinical outcomes and experience. However, the NHS budget is not rising in line with increasing costs. By delivering healthcare in a more sustainable way, for example using integrated models of care, promoting prevention and supporting people to stay in their own homes as long as possible, we can reduce emergency admissions and ensure that our resources are focussed on delivering the best possible health outcomes. In practice, this requires us to:  Focus on preventative, proactive care  Involve patients in the planning and design of services  Build resilience whilst protecting and developing community assets and strengths  Make the best use of scarce resources  Improve efficiency and waste  Minimise carbon emissions  Protect our environment

Being sustainable will help us to make the most of our existing resources – money, supplies, buildings and energy – without compromising the needs of future generations.

4. ROLES AND RESPONSIBILITIES

4.1 Roles and Responsibilities within the Organisation

4.1.1 The Chief Finance Officer is the lead Director responsible for Sustainable Development within the organisation. The Board have also identified a lay member and a clinician lead to oversee the organisation’s sustainable development.

4.1.2 The Head of Corporate Support will be responsible for day to day management of sustainability within the organisation and of the Sustainable Sustainable Development Management Plan v.1.0 January 2017 5

Development Action Plan (SDAP); reporting progress to the Board via the Quality and Performance Committee; and appropriate and timely review of the Sustainable Development Management Plan (SDMP).

4.1.3 The Sustainable Development Working Group (SDWG) is a Group of the Commissioning Executive Group and is responsible for assisting with and coordinating the implementation of the Sustainable Development Action Plan (SDAP). The group is made up of a cross section of representatives from the organisation, many of whom have been allocated actions within the SDAP and they will meet on a quarterly basis.

4.1.4 All staff are responsible for ensuring that they demonstrate exemplar sustainable and low carbon behaviours within the workplace and assisting with the completion of the SDAP when requested.

4.2 Consultation and Communication with Stakeholders

The following stakeholders have been consulted in relation to this policy:  Sustainable Development Working Group  Staff Involvement Group  Pharmacy and Medicine’s Management Team  Programme Director, Your Care, Your Future  Local Counter Fraud Officer  Senior Leadership Team  HVCCG Board

5. CONTENT

5.1 Strategic Goals

The CCG will adopt the goals set out in the Sustainable Development Strategy for the Health, Public Health and Social Care System 2014 – 2020.

Goal 1: A Healthier Environment

A healthier environment can contribute to better outcomes for all. This involves valuing and enhancing our natural resources, whilst also reducing harmful pollution and significantly reducing carbon emissions.

Goal 2: Communities and Services are Ready and Resilient for Changing Times and Climates

When periods of heat, cold, flooding and other extreme events occur it is vulnerable people and communities that suffer the worst. Those communities and their services bear the responsibility of addressing the consequences of these events. Multi-agency planning and organisational collaboration, underpinned by local plans and assurance mechanisms, Sustainable Development Management Plan v.1.0 January 2017 6

provide a better solution to these events than working independently, individually and ineffectively.

Goal 3: Every Opportunity contributes to healthy lives, health communities and healthy environments

Every contact and every decision taken across the health and care system can help build the immediate and longer term benefits of helping people to be well and reduce their care needs. There are multiple mechanisms that can support this approach from improved information, more integrated approaches and smarter, more aligned incentives that help minimise preventable ill-health, health inequalities and unnecessary treatment. A sustainable system cannot be achieved without taking every opportunity to support communities and people to be independent and self-manage conditions and events.

5.2 Adaptation

Adaptation is to respond to both the projected and current impacts of climate change. Adaptation for the health system is two-fold:  Climate change will negatively impact the health and wellbeing of the UK population. The health system needs to be prepared for different volumes and patterns of demand.  Climate change could impact the operational delivery of the NHS. The health system infrastructure (buildings, emergency services vehicles, models of care) and supply chain (e.g. fuel) need to be prepared for, and be resilient to, adverse weather events.

The key health risks from climate change are:  Heat (increased summer temperatures / heat wave events)  Cold (continued risk of cold snaps and related increase in deaths and illness)  Flooding and storms (resilience and continuity of health and social care services, mental health impacts and injuries)

 Incidence and exposure to marine and freshwater pathogens

 UV risk

HVCCG recognises that adapting to climate change will, in the long term:

 Reduce the costs and damages of a changing climate from extreme weather events such as flooding, droughts and heat waves, thereby minimising the risks of service failure with knock-on impacts for the wellbeing of the local population  Identify the most cost-effective and innovative solutions, allowing the organisation the flexibility to act rather than being forced to act urgently and reactively. Early action will avoid being locked-in to long- term assets such as buildings and infrastructure which are not resilient to changing climate. Sustainable Development Management Plan v.1.0 January 2017 7

 Encourage a better use of resources

Therefore, adapting to climate change is a necessary strategy as it means the organisation will be able to respond to both the projected and current impacts of climate change, ensuring that:  High quality services are maintained when the NHS has to cope with an influx of patients during critical climate events  The organisations’ infrastructure and supply chains are prepared for, and resilient to, adverse weather events.

An adaptation plan has been included as part of the overall SDMP.

5.3 Current Position

HVCCG set a 5% reduction target for 2015/16 against the 2013/14 baseline calculated. Unfortunately, this was not achieved, mainly due to increasing staffing numbers and the subsequent effect this has had on business travel and the staff commute (from 75wte in April 2014 to 146wte in March 2016).

The number of staff working for our organisation significantly affects our travel carbon footprint which is much higher than the national average baseline. It is not just business travel that is measured, but also staff commuting distance, and the CCG has a large number of staff that commute quite some distance to work. A Green Travel plan was introduced in April 2016 but has, so far, had little effect on the associated carbon footprint.

Again, possibly partly attributable to the increasing size of the organisation, levels of waste produced have increased since the 2013/14 baseline was calculated. As we occupy shared buildings and our waste is calculated on a proportion of that produced by the building as a whole, it is a real challenge to reduce this without support from the landlords and other tenants that we have been trying to secure at Hemel One. Rates of recycling though, have increased against the 2013/14 baseline in line with set targets and we will continue to promote efficient waste management amongst staff.

HVCCG has greatly reduced electricity and water usage since the baseline was calculated in 2013/14 and gas usage has reduced from 2014/15. This has been achieved through relocation to more modern and fuel efficient premises, consolidating the majority of staff on one site and promoting energy efficiency to raise staff awareness. There is likely to be little more that we can do to make any significant reduction to our fuel carbon footprint, other than continuing to promote this to staff, as both of our current premises are leased and therefore we are unable to instigate any change of fuel supplier or transfer to renewable energy.

Paper usage within the organisation is just starting to reduce as we begin to implement less paper-intensive ways of working, and we will build on this

Sustainable Development Management Plan v.1.0 January 2017 8

going forward.

During 2015/16 HVCCG engaged with local stakeholders around necessary processes and procedures to reduce the pharmaceuticals and medicine’s wastage. We wanted to identify the issues, assess how best we might address these and calculate a baseline against which we could measure progress. Subsequently, a 3-4 year plan will be introduced for 2016/17 to achieve a reduction of pharmaceutical and medicine’s wastage. . The latest climate risks to the organisation are registered on the Emergency Planning Risk Register, along with the mitigating actions which have been taken, with links to the relevant organisational and multi-agency emergency preparedness and business continuity plans. HVCCG will continue to be an active participant of the Local Health Resilience Forum and the associated subgroup, as well as the Response and Planning Sub Committee of the Hertfordshire Local Resilience Forum. This will enable the organisation to link with emergency preparedness and business continuity plans of partners within the local health economy and therefore strengthen our own emergency preparedness. HVCCG has recently been assured by NHS England of full compliance with the Core Standards for Emergency Preparedness, Resilience and Response.

The organisation is currently in the process of implementing “Your Care, Your Future,” a 5 year strategy designed to change the way that services are delivered to patients and service users in West Hertfordshire. This strategy will ultimately ensure that care services are delivered which place a greater emphasis on people staying healthy, rather than treating people when they get ill. It will involve better education on how to stay well and advice about the services on offer.

At the heart of the “Your Care, Your Future” strategy lies the principle that care should be integrated and closer to home. This will be achieved through the use of virtual and physical hubs in the different, larger communities of HVCCG’s four localities, enabling patients to travel shorter distances and less frequently to larger hospitals. Hubs may also allow health care and social staff to reduce the amount of time they travel. These developments will be positive from a sustainability perspective, in addition to the use of modern, up to date, physical hubs built to contemporary specifications.

One of the ways in which we measure our impact as an organisation on corporate social responsibility is through use of the Good Corporate Citizen (GCC) toolkit. Our overall score increased from 13% in 2014 to 29% in 2015 and we will continue to work towards increasing our level of compliance.

Sustainable Development Management Plan v.1.0 January 2017 9

5.4 Being a Sustainable Organisation

As a CCG we can improve on the current position by:  Reducing carbon by making sure we don’t waste energy or supplies; reducing staff travel (both business and commute); and improving our business processes  Making sure that our Board members and staff are aware of the importance of sustainability  Making sure we have robust plans in place to deal with adverse events such as flooding and power failures  Making sure the working environment promotes health and well-being

The CCG’s indirect environmental and social impacts through the services we commission are significantly greater than any direct impact we could initiate within our own organisation. For this reason we will also be looking to work closely with key service providers to ensure that:  They have SDMPs and Sustainable Travel Plans are in place  They are completing appropriate self-assessment using the GCC toolkit  There is an integrated approach to health care in West Hertfordshire, that can be provided closer to home where appropriate and that includes an emphasis on prevention and self-management

Subsequently, the CCG has developed a SDAP (see appendix 1) which focuses on the three strategic goals outlined in section 5.1.  A healthier environment  Communities and services are ready and resilient for changing times and climates  Every opportunity contributes to healthy lives, healthy communities and health environments

The SDAP will be subject to review and amendment in response to new issues and challenges.

6. MONITORING COMPLIANCE

Progress against the SDMP will be measured using a variety of methods:

 Via the quarterly environmental dashboard, which measures the organisations’ carbon footprint and includes specific information about energy, water and paper usage.  Annually via staff and visitor questionnaires  Via the annual Core Standards for Emergency Preparedness, Resilience and Response assurance process  Using the number of “completed” actions within the SDAP itself

Sustainable Development Management Plan v.1.0 January 2017 10

 Annually, using the Good Corporate Citizen Toolkit self-assessment results

7. EDUCATION AND TRAINING

Sustainability training has been provided to existing CCG staff and new staff will receive training in relation to sustainability as part of the induction process.

Participation in regular national campaigns (e.g. NHS Sustainability Day, Green Office Week, Climate Change Week and Energy Saving Week) will be used to promote sustainable and low carbon behaviours and give staff a sense of ownership in improving their own work areas.

HVCCG will use its website, staff intranet, newsletter and other means to increase awareness and to advise of new or amended policies, procedures and guidelines relating to sustainability.

9. REFERENCES

 Climate Change Act (2008)  National Adaptation Programme (2013)  Carbon reduction Commitment Energy Efficiency Scheme  The Civil Contingencies Act (2004)  Public Services (Social Value) Act (2012)

10. ASSOCIATED DOCUMENTATION

 NHS Constitution – Principle 6 (2012)  Sustainable Development Strategy for the Health, Public Health and Social Care System (2014 – 2020)  Route Map for Sustainable Health (2013)  NHS Carbon Reduction Strategy for England – Saving Carbon, Improving Health (2009); Update (2010)

Sustainable Development Management Plan v.1.0 January 2017 11

Appendix 1: Sustainable Development Action Plan

Strategic Goal Aim Action Taken Owner Time Frame Status RAG for Action / Rating Progress Report

HVCCG will plan the location and design of our estates, and the design of the services we David Evans / March 2017 OPEN commission to minimise traffic (e.g. supporting Hannah Edwards community / home based services or locating services near people & public transport

HVCCG will make use of new technologies and Currently looking at provision of services innovations to minimise travel in the delivery of via telemedicine James Barber / March 2017 OPEN services (e.g. telemedicine). Hannah Edwards

HVCCG will explore the possibility of Raised with the landlord at Hemel One implementing electric alternative fuel charging who is obtaining quotes to have these Adrian Manning March 2017 OPEN points at our sites installed. HCC have advised currently no A healthier plans to install these at Apsley as it is a environment leased property, although they do have charging points at County Hall.

HVCCG will have a Board approved Health and Wellbeing Strategy (or similar) which addresses Adrian Manning / March 2017 OPEN physical activity and how to influence the wider Miranda Sutters community to make health lifestyle choices

The CCG will provide facilities that offer an Teleconferencing facilities are in place at alternative to business travel (e.g. video Apsley at Hemel One and are widely Trudi Mount March 2017 OPEN conferencing) and encourage their use, including promoted. Videoconferencing will be

that staff are trained on their use and availabilitySustainable introduced Development with Management the roll out Plan of v.1.0 NHS.net2 January 201 7 12

Aim Action Taken Owner Time Frame Status RAG for Action / Rating

Progress Report

The CCG will provide information and have Lift share scheme in place and maps with incentives in place to reduce reliance on cars (e.g. public transport and walking routes.

lift share schemes, bike to work schemes, maps Coordinated approach taken involving all with clear walking routes). All parts of our Directorates. Currently in the process of Adrian Manning March 2017 OPEN organisation will take a coordinated approach to looking at introducing a bike to work traffic management (e.g. HR, facilities scheme. We will promote the Working management, Communications) from Home policy and implement more widely (see below).

The CCG will promote and encourage the implementation of the Working From Home

policy more widely throughout the organisation A healthier Amanda Yeates March 2017 OPEN where appropriate, in order to reduce the overall environment staff commute in line the NHS Carbon Reduction Strategy

All parts of our organisation (e.g. energy and Continue to promote energy and waste waste management) will work together to management. Waste Management policy

encourage a joined up approach to sustainable updated to include “office efficiency” – Amanda Yeates March 2017 OPEN development awaiting ratification.

HVCCG will aim to achieve a continual reduction Electricity usage has reduced. Gas usage in our energy use from the 2013/14 baseline has reduced from 2014/15 but still above Amanda Yeates March 2017 OPEN 2013/14 baseline. Sustainable Development Management Plan v.1.0 January 2017 13

HVCCG will aim to demonstrate a reduction in Paper usage has started to reduce but still paper usage from 2013/14 baseline above 2013/14 baseline. Amanda Yeates March 2017 OPEN

The CCG will aim to demonstrate an on-going

reduction in catering costs from 2013/14 baseline Amanda Yeates March 2017 OPEN

Aim Action Taken Owner Time Frame Status RAG for Action / Rating Progress

Report

HVCCG will aim to achieve a continual reduction Waste Management policy updated to in absolute levels of landfill waste from the include “office efficiency” – awaiting Amanda Yeates March 2017 OPEN 2013/14 baseline and encourage an increase in ratification. Organisational recycling A healthier recycling. challenge to be undertaken. environment The CCG will work closely with our water supply

company and other organisations to find new Amanda Yeates March 2017 OPEN ways to minimise water use

The CCG will have a comprehensive adaptation Adaptation plan included within draft plan that we monitor regularly SDMP – awaiting stakeholder engagement Amanda Yeates March 2017 OPEN and ratification. To be monitored quarterly by SDWG.

HVCCG will communicate adaptation plans and SDMP will be communicated after outline how they tie in to our SDMP as well as ratification, this outlines links with Amanda Yeates March 2017 OPEN Communities EPRR plans adaptation and EPRR plans. SDMP will be and services made available on public website and the are ready and intranet. resilient for changing The CCG will work with the local health and times wellbeing board and other local authority colleagues to ensure that adaptation is a keySustainable part Development Management Plan v.1.0 January 2017 14

(Adaptation of the local planning process Miranda Sutters March 2017 OPEN Plan) HVCCG will regularly review the Community Risk Current risks are adequately reflected on Register in conjunction with other local EPRR risk register and mitigated against. Amanda Yeates March 2017 ONGOING stakeholders and ensure risks are adequately Regular review in line with LHRP subgroup

reflected on the Emergency Planning Risk and LA in place. Register and mitigated against

Aim Action Taken Owner Time Frame Status RAG for Action / Rating Progress

Report

HVCCG will coordinate the local health Weather alerts in place, Extreme Weather community’s response to the impacts of plan in place which is line with National Amanda Yeates March 2017 ONGOING adaptation, as outlined by national and local Plans and contains appropriate health

plans (e.g. cold weather, heat wave, flooding etc). economy contacts. Communities The CCG will assess its vulnerability to climate and services change using the “Climate Ready” tool to provide are ready and Amanda Yeates March 2017 OPEN support in the face of a changing climate now, resilient for and in the future changing times HVCCG will accurately assess the current and (Adaptation future health and care needs of its local

Plan) population (in order to improve physical health

and wellbeing), with the aim of reducing Miranda Sutters March 2017 OPEN inequalities within and between communities. HVCCG recognises the importance of the JSNA, with particular focus on the section relative to climate change and extreme events.

Sustainable Development Management Plan v.1.0 January 2017 15

The CCG will demonstrate that plans are robust and will stand the test of time Amanda Yeates March 2017 OPEN

Every The CCG will work with suppliers to agree opportunity sustainable development targets, increasing contributes to ambition over time by ensuring all have SDMPs in 80% of key providers have these in place. Contracts March 2017 OPEN healthy lives, place and are self-assessing against the GCC health toolkit. communities and healthy environments

Aim Action Taken Owner Time Frame Status RAG for Action / Rating

Progress Report

HVCCG will make sure that sustainability is part of our staff annual appraisals and that these link Wendy Bourne March 2017 OPEN into organisational policy – e.g. Waste Management policy, making it a responsibility of all staff to recycle and switch off their computers

The HVCCG staff survey shows we have Every embedded a culture of valuing staff in our Rose Child March 2017 OPEN opportunity organisations contributes to healthy lives, health The CCG will make sure patients/users/clients are Public facing campaigns such as OneYou communities given information about the sustainability of their and promotion via a range of methods are and healthy choices, for example in making healthy and in place e.g. GP practice reception TV environments sustainable food choices and in self-managementSustainable screens, Development social Management media etc. Plan This v.1.0 will January also be 201 7 16

practices with the support of a professional supported by the plan to develop a self- wherever possible. management information hub for Miranda Sutters March 2017 OPEN Hertfordshire. New BMI and Smoke Free policy for all elective procedures will encourage patients to manage their health better. A county-wide self-management website for people with long-term conditions is being developed. There is both PH/Commissioner representation at the Self-Management Steering Group (County). Change 4 life.

Aim Action Taken Owner Time Frame Status RAG for Action / Rating Progress

Report

HVCCG will educate clinical and care staff about how they can contribute to sustainable health Liz Cox March 2017 OPEN and social care delivery and how they can try to

reduce the carbon impact in some areas of service delivery

Every The HVCCG Board understand the concept of Liaising with SDU to attend an upcoming opportunity sustainable health and social care and has Board Development Day and provide Amanda Yeates / March 2017 OPEN contributes to undertaken Board level training training Rod While healthy lives, health The CCG will ensure that appropriate key communities providers are trained to interact with serviceSustainable Development Management Plan v.1.0 January 2017 17

and healthy users using multiple methods and technologies, James Barber / March 2017 OPEN environments that they are trained in the use of equipment and Hannah Edwards

in the style of communication required for each technology.

HVCCG can demonstrate a significant reduction in Liz Cox / Systems March 2017 OPEN emergency admissions from primary and Resilience residential care settings

The CCG will introduce plans and incentives PMOT March 2017 OPEN which will reduce medicine’s and pharmaceuticals wastage. A process will be in place for monitoring progress on a quarterly basis.

HVCCG will work with the local strategic partnership and other key stakeholders to ensure OPEN David Evans March 2017 an integrated local approach to carbon reduction, through the YCYF programme.

Sustainable Development Management Plan v.1.0 January 2017 18

SPACER PAGE

NHS Herts Valleys Clinical Commissioning Group Board Meeting 12 January 2017

Title Investment Committee Report Agenda Item: 16

Purpose* (tick) Decision ☐ Approval ☐ Discussion ☐ Information ☒

Responsible Director(s) and Paul Smith Job Title Investment Committee Chair Author and Job Title Rod While Head of Corporate Governance Short Summary of Paper The paper summarises outcomes from the first four meetings of the investment committee

Recommendation(s) The Board is being asked to: Note the report

Engagement with Individual reports to the investment committee will have been subject to Stakeholders/Patient/Public engagement but not this report. Links to Strategic Objectives (tick all that apply) Objective 1: Effective Engagement. We will continually improve engagement s with member practices, ☒ patients, the public, carers and our staff to contribute to and influence the work of Herts Valleys CCG. Objective 2: High Quality. We will commission safe, high quality services that meet the needs of the ☒ population, reducing health inequalities and supporting local people to avoid ill health and stay well. Objective 3: Transforming Delivery. We will work with health and social care partners to transform the delivery ☒ of care through the implementation of “Your Care, Your Future”, the Strategic Review in west Hertfordshire. Objective 4: Affordable & Sustainable Care. We will ensure that there is a financially sustainable and ☒ affordable healthcare system in west Hertfordshire. Board Assurance Decisions made by the investment committee potential impact on all risks on the Framework (BAF) and Board Assurance Framework and the Corporate Risk Register. Corporate Risk Register (CRR)

What current risks does this report align to? Risks (e.g. patient safety, Not applicable to this report financial, legal) What risks have been identified as a result of this report? How are they being mitigated? Resource Implications Not applicable to this report

Equality Impact Analysis All decisions made by the investment committee are subject to equality impact (indicate the key points the analyses analysis has identified relevant to decision required) Equality Delivery System Better Health Outcomes ☐ (identify which goal your Improved Patient Access and Experience ☐

1 proposal / paper supports) A Representative and Supported Workforce ☐ Inclusive Leadership ☐ Report History None Which Groups or Committees have seen this report and when? Appendices Appendix 1 Disinvestment / service change / investment flowchart

*Purpose – definitions

1. Background In response to the CCG being formally placed in financial turnaround, the investment committee was approved by the CCG Board, alongside terms of reference and committee criteria on 24 November.

The approved terms of reference state that the committee has the following remit: “To review and assess potential service investments and disinvestments in line with NHS Herts Valleys Clinical Commissioning Group’s strategy. This will include assessing business cases focusing on the return on investment and value for money to improve health and reduce health inequalities”.

Committee membership comprises two lay members, two Board GPs, the Accountable Officer and the Chief Finance Officer.

2. Process A flowchart depicting the overall process from a proposal for an investment or disinvestment is shown in appendix 1.

All proposals are first subject to a first pass review by executive. If executive agree that the proposal is feasible and aligned with the overall CCG strategy, the relevant programme board will be expected to work up a full business case alongside a full programme of stakeholder engagement. Commissioning Executive will then consider the business case from a clinical perspective and all business cases with a value of greater that £50k are then considered by the investment committee. All approved business cases are subject to ongoing performance management by the quality and performance committee.

3. Progress Four meetings of the committee have been held between 1 December and 5 January in order to review planned future investments and progress on recent investments to establish evidence of outcomes.

Decisions on the following services have been made by the committee

Investments Disinvestments / service changes Your Care, Your Future/transformation fund Social care discretionary monies 4th Hospital ambulance liaison officer Stroke Emergency Care Practitioner Demographic and non-demographic contract Care Home Implementation Team growth Perinatal and IAPT early implementer funding GP in emergency department Leg ulcer service Integrated point of access CHC back log - short term staff investment Direct access MRI (contract end) AQP physiotherapy AQP vasectomy AQP Ophthalmology Integrated assessment and discharge team Sports and exercise medical service

Item 16 Idea on potential savings scheme to Ian Armitage. Appendix 1 List as part of QIPP Disinvestment / investment

No further No further action Rejected Executive Potential investment action First pass review Not approved

Recommended for further work

Programme Board

Engagement with stakeholders (patients, localities, MPs, Commissioning Executive HCC, district councils, finance, BI, contracting, medical Business case Review proposal director, nursing and quality) Complete business case ensuring sign off from Medical Recommended & >£50k Director, Director of Nursing and Quality and CFO. Not approved Complete EQIA

Monitor Recommended and <£50k implementation Commissioning lead prepares progress at financial implementation plan with Investment Committee Consideration of business case turnaround contracting, finance and BI Approved meetings

Investment

QIPP headline QIPP Report at Q&P progress reported Q&P report to Process start Review of investment at Executive. Cause Board for any shortfalls scheme established Desk based work

Assurance / monitoring Any shortfall in delivery due to clinical reasons to be review by 4 Commissioning Executive Decision point

SPACER PAGE

NHS Herts Valleys Clinical Commissioning Group Board Meeting 12 January 2017

Title Committee Chairs’ Reports and Committee minutes Agenda Item:16

Purpose (tick one only) Decision or Approval ☐ Discussion ☐ Information ☒

Responsible Director(s) and Cameron Ward Job Title Accountable Officer Author and Job Title Committee Chairs: Alison Gardner, Stuart Bloom Short Summary of Paper The Committee Chairs’ report summarises key discussions, areas of assurance and decisions from the most recent Patient and Public Involvement and Quality & Performance committee meetings.

Also included are ratified minutes from Committee meetings. Recommendation(s) The Board is being asked to: Note this report

Engagement with Not applicable Stakeholders/Patient/Public Links to Strategic Objectives (tick all that apply) Objective 1: Effective Engagement. We will continually improve engagement s with member practices, ☒ patients, the public, carers and our staff to contribute to and influence the work of Herts Valleys CCG. Objective 2: High Quality. We will commission safe, high quality services that meet the needs of the ☒ population, reducing health inequalities and supporting local people to avoid ill health and stay well. Objective 3: Transforming Delivery. We will work with health and social care partners to transform the delivery ☒ of care through the implementation of “Your Care, Your Future”, the Strategic Review in west Hertfordshire. Objective 4: Affordable & Sustainable Care. We will ensure that there is a financially sustainable and ☒ affordable healthcare system in west Hertfordshire. Board Assurance All BAF and CRR risks apply Framework (BAF) and Corporate Risk Register

(CRR)

What current risks does this report align to? Risks (e.g. patient safety, Not applicable financial, legal) What risks have been identified as a result of this report? How are they being mitigated? Resource Implications Not applicable

Equality Impact Analysis Not applicable (indicate the key points the analysis has identified relevant to decision required) Equality Delivery System Better Health Outcomes ☒ (identify which goal your Improved Patient Access and Experience ☒ proposal / paper supports) A Representative and Supported Workforce ☒

Inclusive Leadership ☒ Report History Not applicable Which Groups or Committees have seen this report and when? Appendices Committee minutes 16.1 Patient and Public Involvement Committee - 19 October 2016 16.2 Quality and Peformance Committee – 3 November 16.3 Quality and Peformance Committee - 1 December 2016

Chairs report: January 2017

Quality and Performance Committee Dates of Meetings Chair Executive Lead

5 January 2017 Stuart Bloom Caroline Hall / Charles Allan Month 8 Finance report

Transformation and QIPP report

Integrated quality, performance & finance report 30 November 2016

Safeguarding adults & safeguarding children 6 month reports

 Both staffing and training at HPFT in relation to safeguarding adults need to improve.

 Both Safeguarding Boards are operating effectively and joint working is being developed.

CQUINs 2016/17 Q2

 There will be no local CQUIN schemes next year: all are nationally mandated schemes from 2017/18.

Equality & Diversity Annual Report

 HVCCG is compliant with no big issues to report.  The report will be published before 31 January 2017.

Quality Improvement 6 month report

Patient and Public Involvement Committee Dates of Meeting Chair Executive Lead

14 December 2016 Alison Gardner Juliet Rodgers

The committee was briefed on the financial position of the CCG and advised that it was in financial turnaround and being closely monitored by NHS England. The committee acknowledged the widespread difficulties across the NHS at this time and the need for the CCG to ensure that initiatives delivered value for money. The recent decision not to make an extra discretionary payment to Herts County Council in 2017/18 for social care commissioned services over and above the amount mandated to be paid to the Better Care Fund (a pooled fund to help deliver more joined up health and social care) was discussed and supported.

An update on recent and planned communication and engagement around Your Care, Your Future and the STP was provided and the committee agreed that now that the acute hospital option had been agreed, it was important for everyone to work together to deliver it.

The future of West Herts Medical Centre was discussed and the planned consultation by NHS England and HVCCG was noted. Patient representatives were reassured to learn that now that the acute option had been agreed, we were able to consider other service provision, including the urgent care

4 service, across the patch.

The process for moving to full delegated commissioning of GP practice contracts from April 2017 was discussed and the advantages noted to be more informed decision making, based on local knowledge, and support for the re-design of community services and the delivery of Your Care, Your Future.

Heather Aylward presented a number of initiatives to develop and broaden the range of people who actively engaged with the CCG, particularly hard to reach groups. This in turn will make the PPI committee more representative and not rely on and put unfair demand on a few very active and committed patient representatives. This work continues and the committee were supportive of the approach.

Also discussed was a recent meeting which had taken place with representatives from Herts Valleys CCG and Aylesbury Vale CCG and opened discussions about cross-CCG boundary commissioning.

Finally, John Wigley, Chair of the St Albans and Harpenden Patient Group, was commended on the successful public meeting held in the locality on 30 November 2016.

Item 17.1 Approved 14.12.16

Meeting : NHS Herts Valleys CCG Patient and Public Involvement Committee Meeting

Date : 19 October 2016

Time : 10.02 – 12.41

Venue : Apsley Meeting Room, Hemel One

Present: Alison Gardner (AG) Lay Board Member, Meeting Chair Colin Barry (CB) Patient Representative (Watford and Three Rivers) Helen Clothier (HC) Patient Representative (St Albans and Harpenden) Diane Curbishley (DC) Director of Nursing and Quality (for item PPI/90/16) Robert Hillyard (RH) Patient Representative (Hertsmere) (from item PPI/84/16 to end of item PPI/91/16) Gavin Ross (GR) Patient Representative (St Albans and Harpenden) Caroline Sutherland (CS) Patient Representative (Hertsmere) Mike Walton (MW) GP Board Member (St Albans and Harpenden) In attendance: Laura Abel (LA) Corporate Governance Assistant (Secretary to the Committee) Heather Aylward (HA) Public Engagement Manager Louise Manders (LM) Head of Programme Communication and Engagement Your Care, Your Future Juliet Rodgers (JR) Associate Director, Communications and Engagement Nico Schonken (NS) Head of Business Intelligence and Performance (for item PPI/89/16) Gemma Thomas (GT) Head of Planned and Community Care (for item PPI/88/16) Rod While (RW) Head of Corporate Governance

PPI/84/16 Chairman’s introduction and apologies for absence (Chair) 84.1 AG welcomed everyone to the meeting and introductions were made for the benefit of MW, who had replaced Richard Pile as the Board GP member on the committee and LM, recently appointed Head of Programme Communication and Engagement Your Care, Your Future.

84.2 AG noted the very constructive meeting that had taken place on Tuesday 18 October and had focussed on identifying the most effective use of committee time. She thanked all participants for their input.

84.3 Apologies had been received from Brian Gunson (BG), Kevin Minier (KM), Margaret Morgan (MM), and John Wigley (JW).

PPI/85/16 Declarations of interests (Chair) 85.1 There were no new interests declared.

PPI/86/16 Minutes of previous meeting (Chair) 86.1 The minutes were agreed as an accurate record of the meeting held on 17 August 2016.

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PPI/87/16 Matters arising and action log (Chair) 87.1 It was agreed that completed (green) actions would be closed and open (red/amber) actions were discussed in turn.

87.2 PPI/53.5/16 Gluten free prescribing – variation in the costs of gluten free products available to the NHS and commercially RH expressed his disappointment with the response provided. AG noted that this was a national issue. JR agreed to ask the PMOT for a further update.

PPI/76.3/16 – patient participation update: links with patient engagement groups at HPFT and HCT JR explained that as part of collaborative working with partners in Your Care, Your Future (YCYF) she and LM would discuss this with communication leads in provider organisations. It was agreed to close this action and produce a proposal for discussion at a future meeting.

The impact of Brexit on the NHS and Social Care paper submitted by BG was noted.

87.3 The Committee noted the action updates.

87.4 ACTION: J Rodgers to request a further update from the PMOT in respect of the cost of gluten free products. 87.5 ACTION: J Rodgers and L Manders to produce a proposal for collaborative working with patient engagement groups in provider organisations.

PPI/88/16 Your Care, Your Future new pathways update (Head of Planned and Community Care) 88.1 GT provided an update on the progress of multi-provider pathways and the assurance framework for the multi-provider collaborative that had been approved.

88.2 The following points were discussed:  The implementation of enhanced primary medical services for patients in care homes via GP federations. Post meeting note: it was subsequently clarified outside of the meeting, that although the Joint Primary Medical Services Commissioning Committee had approved the preferred option for the implementation of the PCP enhanced service for care homes via GP federations in principle, this was subject to the financial proposal going to the board on 10 November for final decision in the context of the financial plan and other schemes.  JR and HA confirmed that detailed plans were being developed for patient/carer engagement in respect of projects that were still being developed.  Conversation events would update the public about new models of care and hubs and would be well publicised.

88.3 The Committee noted the Your Care, Your Future new pathways update.

PPI/89/16 Data sharing: long-term benefits to clinical care (Head of Business Intelligence and Performance) 89.1 NS presented an update on how patients could benefit from data sharing between providers and commissioners highlighting that:  HVCCG uses data identifiable at the level of NHS number to provide intelligence to support commissioning of health services.  The NHS number is required to ensure that data from different sources can be accurately linked to support the needs of the health profile of the population within the CCG area based on analysis of patient data across health pathways.  Examples of benefits arising from data sharing were noted.

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 Responses to questions from KM can be found at appendix 1 to these minutes. 89.2 Patient concerns about data security were raised and NS provided the following:  Personal information would only ever be shared in accordance with the Data Protection Act (DPA) 1998, the Common Law duty of confidentiality, the NHS Constitution and professional and NHS Codes of Practice.  New legal frameworks were also being developed to enhance safeguarding at every level which covered: o 24 recommendations to the Secretary of State for Health; o a series of three obligations encompassing ten data security standards; o an eight-point opt-out model. o July 2016 publication from CQC and Dame Fiona Caldicott (national data guardian): https://www.gov.uk/government/publications/review-of-data-security-consent-and- opt-outs  Different organisations held different, organisation specific data so that complete patient records were not held in one place.  The safeguards in place needed to be better communicated to patients to allay concerns and encourage data sharing.  MW and NS highlighted that fines of up to £500,000 were imposed for breaching the DPA.  It was agreed that MW and JR would produce an FAQ to articulate the benefits of data sharing, the process for opting out and addressing concerns.  It was also agreed that in order to raise patient awareness, this topic would be taken to a future patient development session.  In response to a question from HC about inaccuracies in medical records and approaches from private companies, MW agreed to address this outside of the meeting with HC.

89.3 The Committee noted the data sharing update. 89.4 ACTION: J Rodgers and M Walton to produce an FAQ relating to data sharing. 89.5 ACTION: J Rodgers and H Aylward to schedule data sharing as a topic for a future patient development session. 89.6 ACTION: M Walton and H Clothier to address issues around inaccuracies in medical records and possible inappropriate access outside of the meeting.

PPI/90/16 Patient Story Quarterly Report (Director of Nursing and Quality) 90.1  DC presented the first report of actions taken following patient experience stories that had been presented to the public board meetings since April 2015.  Any associated learning would be included in the quarterly report to the Quality and Performance Committee. 90.2  The committee discussed the report and DC agreed to provide an updated paper for circulation to the localities.  In response to a question from CB about common themes such as gaps in health and social care provision, DC explained that multi-provider pathways were the part of the vision of YCYF.  It was noted that this report would also go to the board to ensure that board members were aware of the changes made in response to the patient experience stories.  It was agreed that this would be a quarterly agenda item at the committee.

90.3 The Committee noted the patient story update report. 90.4 ACTION: D Curbishley to provide an updated report for patient representatives to share with their localities.

PPI/91/16 Standards of Business Conduct and statutory guidance on conflicts of interest (Head of Corporate Governance) 91.1 RW provided the rationale for the new HVCCG standards of business conduct policy and

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guidance. He highlighted that:  Strong management of conflicts of interest, whether real or perceived, would become even more important if the CCG moved to full delegated commissioning of primary care services.  Training was being developed and would apply to all CCG staff, including the board, and would be provided for the PPI committee.  To date of the meeting no breaches of the policy had been identified.

91.2  AG and MW provided an example of the policy being implemented at the Joint Primary Medical Services Commissioning Committee meeting held on 13 October 2016. Conflicted GP members had been party to the discussion around enhanced primary medical services for patients in care homes via GP federations in order to provide clinical input, but had been excluded from the meeting for the decision. RW noted that this was included on HVCCG’s website in the decision register (http://hertsvalleysccg.nhs.uk/about-us/managing-conflicts- of-interest).  This robust approach was taken for all decisions made throughout the commissioning cycle in order to ensure that clinical input was provided in strategic discussions as CCGs were afterall clinical commissioning groups, but decisions had to be able to withstand scrutiny and potential challenge. This was a difficult balance to maintain, and was discussed in advance of each decision to ensure appropriateness.  RH raised a concern about hospitality (lunch) provided by pharmaceutical companies at locality meetings. RW confirmed that this had been considered in advance of accepting the hospitality offered and it had been agreed that it was acceptable (and declared), but advised RH to contact the Conflict of Interest Guardian, as highlighted in the policy, if he had further concerns.  The guiding principle was: if in doubt, declare.  In response to a question from MW about spouse/close family member declarations being published on the CCG’s website, RW explained that fair processing notices were sent as appropriate and names were not published, only relationship to the board/staff member. It was agreed that this needed to be communicated within the localities.  Pressure groups were discussed, but this was considered not to be of particular concern unless they had an undue influence on decision making. This was also agreed not to be a conflict of interest issue unless this applied to a board or staff member and processes had not been followed.

91.3 The Committee noted the Standards of Business Conduct Policy. 91.4 ACTION: R While to consider how to communicate level of information publicised about spouse/close family member interests on the CCG’s website in order to address concerns.

R Hillyard left the meeting at this point.

PPI/92/16 Patient participation update (Associate Director Communications and Engagement and Public Engagement Manager) 92.1  JR noted the intense activity around the acute reconfiguration options over the summer months and thanked those members of the public who had been involved. There would be more opportunities for involvement as work progressed around YCYF and the development of new models of care and the hubs.  Patient representatives commended the process and agreed that it was important for the public to support the options agreed in order to ensure that the acute reconfiguration received funding and political support.  HA presented the engagement highlights since the previous meeting which included events to broaden participation.

92.2 The Patient Participation update was noted.

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PPI/57/16 Finance Update – Annual Report and Accounts 2015-16 (Chief Finance Officer) PPI/93/16 Locality reports on patient and public involvement (Patient Representatives) 93.1 The Committee noted the reports from the locality patient groups.

PPI/94/16 Update on patient representative involvement in HVCCG business meetings (Patient Representatives) 94.1 The Committee noted the report from CS.

PPI/95/16 Any Other Business (Chair) 95.1 There was no AOB.

PPI/96/16 Risks identified during the meeting 96.1 There were no new risks identified during the meeting.

PPI/97/16 Items for cascade to the localities 97.1  Patient story report  Data sharing

PPI/98/16 Date and time of next meeting 10.00-13.00, Wednesday 14 December 2016.

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Appendix 1

Data sharing

Will data sharing highlight insufficient and surplus capacity?

Not necessarily. Capacity is related to planning and therefore, comparing plans to actual activity will highlight the above however viewing data from multiple providers will also show where there are potential efficiencies to be made in the wider health system. For example, patients could be seeing a consultant closer to home if that patient was willing for their data to be shared between multiple providers and commissioners. Commissioners will be able to plan for the appropriate level of service to be available in a given geography if they knew what the patient’s needs were.

Will data sharing highlight delayed transfers of care?

Instead of highlighting them, it will help in resolving them. More will be known about a patient in advance of a hospital admission which will mean plans could be made in advance regarding a discharge to an appropriate place of care. In theory, this should help in reducing delays.

Will data sharing highlight compliance and failure to meet standards of care (KPIs)?

Not really, as most KPIs are for a specific organisation. However, data sharing will help providers and commissioning bodies to improve their own performance which in turn will improve compliance and standards of care. For example, if a paramedic on an ambulance knew in advance what medication a patient, they are about to attend to, requires, they could prepare in advance and the hospital would know in advance and the entire treatment process would be quicker for the patient with a better outcome. In addition, if healthcare teams could identify all patients at risk of a specific long term condition they could contact the patient directly and offer advice/support/medication where appropriate. This could prevent unnecessary hospital attendances and could even save the NHS money.

Will data sharing provide accurate information to support comments, complaints and compliments regarding service provision?

The information shared is only as good as its source, but if the data entered at source is correct and accurate then sharing that data more widely within the NHS would certainly help to support the above regarding service provision. For example, if a provider is dealing with a complaint from a patient of theirs then accessing details about other attendances that patient had in the wider health system would enable to provider to build a more accurate picture about the nature of the complaint and potentially improve services across the system for that patient and many more.

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Item 17.2 FINAL APPROVED MINUTES

Meeting : QUALITY AND PERFORMANCE COMMITTEE Date : 03/11/16 Time : 2.30pm Venue : Apsley Meeting Room, Hemel One

Present: Stuart Bloom (SB) Board Lay Member and Meeting Chair Charles Allan (CA) Director of Contracting and Resilience Trevor Fernandes (TF) Board GP Member (Dacorum) Alison Gardner (AG) Board Lay Member (from QP/166.3/16) Caroline Hall (CH) Chief Finance Officer Richard Pile (RP) GP Board Member (St Albans & Harpenden) Clare Saunders (CS) Deputy Director of Nursing & Quality Cameron Ward (CW) Accountable Officer In attendance: Annette Keen (AK) AD Planning & Transformation Saqib Khan (SK) Planning PMO Manager Caroline Sutherland (CS) Patient Representative to the Board Miranda Sutters (MS) Locum Consultant in Public Health Katy Patrick (KP) Risk Manager (Minutes)

QP/158/16 Welcome and apologies for absence (SB) 158.1  The Chair welcomed colleagues to the meeting. 158.2  Apologies for absence were received from Diane Curbishley (Clare Saunders attending) and Clair Moring.

QP/159/16 Declarations of interests (SB) 159.1  The Chair confirmed that no conflicts of interest had been declared to him in advance of the meeting by committee members. No interests were declared by attendees in relation to agenda items.

QP/160/16 Minutes of previous meeting (SB) 160.1 The minutes of the previous meeting were reviewed and agreed. 160.2 The minutes were approved as an accurate record of the meeting of 6 October 2016.

QP/161/16 Matters arising and action log (SB) 161.1 QP/148.4/16 Information on the procurement will be presented to the closed Board meeting on 10 November 2016.

QP/162/16 Finance report 2016/17 – month 6 and current QIPP position (CH) 162.1 A brief update on the financial position was shared with members of the committee who were not at the Financial Effectiveness Group immediately preceding this meeting.  Further deterioration of the financial forecast to a potential £10M unmitigated risk means that HVCCG are now moving from financial recovery to being in financial turnaround. This decision has been taken by NHS England who will meet the cost of the turnaround director, but it is the responsibility of HVCCG to make this

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appointment. The CCG has been trying to avoid this position for a number of months, but now the decision has been made we need a strong focus on reducing costs and reaching a break even position by year end. A strategic approach is necessary to safeguard plans for Your Care, Your Future. It is important to improve delivery against schemes while at the same time continuing work to improve performance. Some unpalatable decisions may need to be taken but the CCG will make a proportionate response that is managed in a way that will sustain relationships within the health and care system. 162.2 The following points were raised in discussion:  There needs to be an urgency in the CCG’s response with a credible plan delivered within the next two weeks that both demonstrates how we will break even in year and puts plans in place to sustain transformation going forward.  Considered communications are very important. CW will contact the Board later today; staff will be informed both on email and at a staff meeting on Monday; early next week communications will be shared with external stakeholders. The news needs to be handled in the right way to work with providers.  The Financial Effectiveness Group has identified four areas of potential savings, being: improved QIPP performance; imposition of contracting penalties; examination of return on investment for the social care contribution; and clinical initiatives. Quick decision will be needed as the whole contracting round needs to be in place by December this year. Examination of opportunities will require as much clinical input as possible to balance savings with clinical risk.  From the patient point of view they will want to offer all the support they can. It will be helpful to explain to all PPI representatives how they can be involved and engage with a greater patient cohort. Once the initial communications have been completed, the CCG will move on to plans to engage on an ongoing basis with a range of people.  It is important to be transparent with both GP members and the public about a range of options for savings and seek their feedback on the choices we should make.  It has become clear that we will have to purchase less as commissioners and work is already underway in partnership with Public Health to consider further efficiencies.  There is evidence of problems within the CCG with converting transformation plans into outcomes and delivery against QIPP. The planning team is happy to support colleagues where they can but they are also heavily committed to delivery of the planning round. 162.3 The Committee noted the M6 financial position including QIPP and the risks associated with delivering the financial recovery plan.

QP/165/16 Integrated quality, performance & finance report - IQPFR (CA/CS/CH) 165.1 CA introduced the IQPFR and noted that he would focus this month on an update about the national A&E plan and local delivery board.  System resilience groups (SRGs) have been replaced by A&E local delivery boards (LDBs).  Five elements are mandated in the national plan for delivery by March 2017: - primary and ambulatory care screening in the Emergency Department; - increase the proportion of NHS 111 calls handled by clinicians; - implement the ambulance response programme; - implement measures to improve in-hospital flow; - implement discharge best practice to reduce delayed transfers of care.  Performance against the plan will be overseen by the regional A&E delivery board.  There will also be a regional urgent and emergency care programme management office (PMO), supporting the local PMO function. The chief executive of South Warwickshire acute trust has been appointed as ‘critical friend’.  A key focus for west Hertfordshire will be reducing the number of ‘red’ days spent in 2 | P a g e

acute trusts with no action taking place. This has been identified as the single biggest internal flow issue. There will also be a focus on delayed transfers of care and discharge to assess (home). A number of joint NHS England, NHS Improvement and Emergency Care Improvement Programme (ECIP) events will be aimed at improving engagement with clinicians and medical directors in recovery plan efforts.  The LDB met today (CA and CW attended) and are picking up on all the actions necessary to ensure that there is an adequately resourced and dedicated team in place to deliver and sustain change. A number of the actions necessary are already in the recovery plan. There is an executive lead responsible for delivery of the improvements within all partner organisations. 165.2 The following points were made in discussion:  Ambulance KPIs are still not delivering but are a particular focus in the national plan for all in the system as well as East of England Ambulance Service Trust (EEAST). There are concerns about the reliance upon recruitment, training and retention of staff for improvement to happen. The Trust are good at attracting students but need to improve ongoing training, support and career progression in order to retain them.  Innovation has been built into the new out-of-hours and 111 contract that will support better management of load and near patient testing. Penalties have not been applied to the Herts Urgent Care (HUC) contract because they were not far from targets. A significant issue has been fluctuation in performance between east and west Hertfordshire. The new contract treats acute in-hours visiting separately which should help with this.  Data breakdown for west Herts has been requested from both EEAST and HUC.  Analysis of performance against the plan in last quarter indicates that HVCCG are the 11th worst region, but 9th most improved. Typically, improvement is seen when initiatives are first introduced but then no further improvement, so implementation needs to be improved. For example, 100 per cent shift fill has now been achieved for the GP at front end of the Emergency Department (ED), but they have not progressed to seeing the numbers of people planned; the safer patient flow bundle works well on one ward. Clinicians are meeting to ensure more rigour and improved outcomes. ECIP Cluster 4 of which we are part is actively engaged.  Discharge to assess (home) remains one of the most challenging elements with some stakeholders still wanting beds to be retained in the system. 165.3 CS introduced some quality highlights from the report.  Performance on Clostridium difficile (C.diff) infections is above trajectory with a lot of work ongoing.  Improvement has also been seen on serious incidents and pressure ulcers.  WHHT is still reporting a good mortality ratio which reflects progress on the quality and safety work. Outcomes are not yet where they need to be, but progress is being made in the right direction. 165.4 The following points were raised in discussion:  No formal feedback on the re-inspection of WHHT by the Care Quality Commission (CQC) will be received before end of December 2016. Whatever, the outcome, it is important to sustain the momentum towards improvement, build on achievements and accelerate progress. Good, steady progress is being reported.  National advertising will be promoting ‘choose wisely’ throughout the winter to raise awareness about right care in the right place. HVCCG will also be actively promoting ‘Right Care’ throughout the winter. 165.5 The Committee noted the Integrated Quality, Performance & Finance report and the update on the national A&E plan and local delivery boards.

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QP/166/16 BAF & CRR (KP) 166.1 KP introduced the Q3 position to end of October.  The chart on page 3 of the report shows the relative sizes of strategic threats to CCG objectives. These have undergone some alteration as a result of recommendations made by the Board in September: - BAF 1.1 (public engagement) current risk score increased to 12 - BAF 1.3 (staff engagement) current risk score reduced to 8 - BAF 2.4 (system IM&T capability) adjusted twice – current risk score reduced to 16 to acknowledge that we are on track with plans for 2016/17. Target risk score of 8 – clarified that will be achieved by Mar 2019 as long-term project. - BAF 3.3 (system workforce) current risk score increased to 16 to reflect significance of challenges.  RSM will be conducting an internal audit of risk management from next Monday, 7 November. The auditors have chosen three of these BAF risks to review in depth (staff engagement; system IM&T capability; workforce) and will be interviewing the risk owners and risk leads in relation to each of these.  The report includes a summary presentation of the Corporate Risk Register which has been substantially updated and developed over the last few months following detailed discussion at the Risk Management Group. Notably, 4 key performance risks have been added to the CRR: A&E 4 hour target at WHHT; delayed transfers of care; 18 weeks RTT at WHHT; ambulance KPIs. 166.2 The following point was raised in discussion:  In addition to the NHS national staff survey, our communications and engagement team plan to run an internal survey in quarter 4. 166.3 The Committee noted the update on risk part way through Q3. AG joined the meeting QP/167/16 Serious Incident Report 2016/17 Q2 (CS) 167.1 CS introduced the quarter 2 report:  There has been an increase in declared serious incidents (SIs), but this is not necessarily a bad thing as reporting is being encouraged.  The increase seen at WHHT has been in pressure ulcers meeting the SI criteria, which is being investigated by way of a detailed thematic review.  There has been a slight improvement in process timings for SIs. 167.2 The following points were raised in discussion:  The Committee would like some feedback on key actions taken and target dates. A meeting next week will agree an action plan. 167.3 The Committee noted the Serious Incident report for Q2.

QP/168/16 Quality alert system (QAS) 2016/17 Q2 (CS) 168.1 CS introduced the quarter 2 report.  Inappropriate actions requested as part of the discharge process are being discussed with the liaison manager.  A meeting next week will agree the action plan. 168.2 The following points were raised in discussion:  There should be GP involvement in this group to agree a way forward that is not only subject to internal discussion at the Trust.  There are also issues with the quality and timeliness of communication coming back to GPs from outpatient clinics: it is not only a problem with discharge processes.  The quality team identify common themes from reports received through QAS and triangulate this information with that gained from other sources.  Some of the referrals back to GP for onward referral are apparently being done in order to comply with the Consultant to Consultant (C2C) referral policy. Where there

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are common requests being made, there may be an opportunity to identify a defined pathway instead. If the investigation is required for the same condition as the original referral it should stay in secondary care. 168.3 The Committee noted the update on the quality alert system.

QP/169/16 Committee work plan (SB) 169.1 SB introduced the work plan for 2016/17.  The 2017/18 plan needs to be drawn up but will follow the same pattern as 2016/17. 169.2 The following points were raised in discussion:  Add a note of which committee meetings will be reviewing the quarterly updates on the Improvement and Assessment Framework and clinical priorities. 169.3 The Committee noted the work plan and proposed updates. 169.4 ACTION: Work plan for 2017/18 to be drawn up (KP) 169.5 ACTION: Consult with Stephanie White and add timing of quarterly updates on the Improvement & Assessment Framework to the plan (KP)

QP/170/16 Risks identified during the meeting (SB) 170.1  Financial risks will be communicated in a co-ordinated way and discussed at the Board meeting in public on 10 November.

QP/171/16 Items for cascade to localities (SB) 171.1  The Chair will identify key points in his report to Board.

QP/172/16 Next meeting (SB) 172.1 1 December 2016, Apsley meeting room, 2nd floor, Hemel One, 10.00am

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Item 17.3 Final Minutes

Meeting : QUALITY AND PERFORMANCE COMMITTEE Date : 01/12/16 Time : 10.00am Venue : Apsley Meeting Room, Hemel One

Present: Stuart Bloom (SB) Board Lay Member and Meeting Chair Charles Allan (CA) Director of Contracting and Resilience Diane Curbishley (DC) Director of Nursing & Quality Trevor Fernandes (TF) Board GP Member (Dacorum) (from QP/177.2/16) Alison Gardner (AG) Board Lay Member Caroline Hall (CH) Chief Finance Officer Clair Moring (CM) GP Board Member (Watford & Three Rivers) Richard Pile (RP) GP Board Member (St Albans & Harpenden) Cameron Ward (CW) Interim Accountable Officer Thida Win (TW) Secondary Care Consultant to the Board In attendance: Lynn Dalton (LD) AD Localities & Primary Care Development (QP/179.9/16 only) Annette Keen (AK) AD Planning & Transformation (from QP/178.1/16) Ed Knowles (EK) AD Healthcare Integration (from QP/179.1/16 to QP/179.10/16) Katy Patrick (KP) Risk Manager (Minutes) Hein Scheffer (HS) Director of Workforce (from QP/178.2/16 to QP/179.10/16) Caroline Sutherland (CS) Patient Representative to the Board Miranda Sutters (MS) Locum Consultant in Public Health Jackie Vincent (JV) Deputy Head of Nursing & Quality, HPFT

QP/173/16 Welcome and apologies for absence (SB) 173.1  The Chair welcomed colleagues to the meeting. 173.2  Apologies for absence were received from David Buckle. Lynn Dalton will attend to present the clinical priorities update.  Jackie Vincent, Deputy Director of Nursing from HPFT, was welcomed as a visitor and colleague. The Chair noted that he had agreed to the Transformation and QIPP report being tabled for this meeting due to pressure of work. However, as no-one will have had an opportunity to read the draft operational plan in detail prior to this meeting, that paper will not be discussed by the Committee. Members should send any comments by email to Annette Keen. The final draft will be discussed and agreed at the Board Development session on 22 December, prior to submission on 23 December 2016. 173.3 ACTION: Send comments on the draft operational plan to AK by email (All)

QP/174/16 Declarations of interests (SB) 174.1  The Chair confirmed that no conflicts of interest had been declared to him in advance of the meeting by committee members. No interests were declared by attendees in relation to agenda items.

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QP/175/16 Minutes of previous meeting (SB) 175.1 The minutes of the previous meeting were reviewed and approved. 175.2 The minutes were approved as an accurate record of the meeting of 3 November 2016.

QP/176/16 Matters arising and action log (SB) 176.1 The action log was reviewed. There were no outstanding matters arising not on the agenda.

QP/177/16 Finance report 2016/17 – month 7 (CH) 177.1 CH introduced the report and referred the Committee to the following key points:  Summary position at Appendix 1 shows a year-to-date variance of £9.6M with the last column showing the forecast unmitigated variance of £18.5M. There are pressures on every line, notably including an acute variance of £20M.  Appendix 2 shows acute expenditure by Trust, with most over-performing against their contracts. The expectation, with QIPP plans in place, was that most contracts would be underperforming. Subsequent discussions with NHS England (NHSE) are not reported in the paper:  NHSE are starting to recognise that HVCCG may not achieve the balanced position declared. We are currently declaring an unmitigated risk of £8M with no mitigations yet in place. The financial recovery plan at Appendix 8 shows the following:  A reported unmitigated forecast variance of £18.5M.  A forecast variance of £10.3M after identified mitigations.  There are still a number of final numbers for risks to be worked up, not least of which is Continuing Healthcare (CHC). The new Investment Committee will be working to solidify the position later today.  The Turnaround Director may identify further things to contribute to recovery. Appendix 4 shows the underlying recurrent surplus/deficit:  At the beginning of the year this was -£6.3M, but it has now deteriorated to -£10.9M. 177.2 The following points were raised in discussion:  Most opportunities relating to the balance sheet or underspends have already been looked at, but there may be budgets that have not been thought about or that could be treated differently.  Previous years have shown a problem of £2-3M each year, but this has not been identified as a cumulative risk soon enough.  There is an opportunity now to realise the extent of the problem as well as the causes and re-examine investments this year and last year, across the system, to assess value-added and affordability. It is common practice in many organisations for business cases to be signed off by the CFO prior to consideration. This has not been the process for HVCCG in the past. It is important that business cases are considered in terms of clinical viability, but the revised process will include more focus on finance. Unless plans are affordable the CCG cannot improve quality. TF joined the meeting 177.3 CH noted that the financial recovery plan (FRP) concerns the CCG’s position this year. Plans are also underway for next year:  The planning round has been brought forward this year. This puts teams under pressure, but also offers an opportunity to be better prepared for 1 April 2017.  We have not yet identified the £45M of QIPP that will be needed. 177.4 The following points were raised in discussion:  A priority is to look at areas that we can influence within contracts. By Monday 5 December the CCG will need to flag whether we plan to go to arbitration. The preference would be to avoid these decisions being made outside of local control, with the associated costs in time and effort, as focus is required elsewhere. 2 | P a g e

 Some elements of the new contracts will be block, particularly non-electives. The CCG is under pressure to provide evidence that QIPP schemes can reduce activity and agree appropriate tariffs. Trusts will be seeking to include the lowest risk possible within block elements.  Changes to the rules for arbitration to a ‘pendulum’ system mean that the financial risks are considerably increased. All providers are therefore motivated to avoid arbitration, but the current contract negotiation gap with West Herts Hospital Trust (WHHT) is £20M. Trusts are under pressure not to agree any contracts that they cannot deliver and WHHT pressures are particularly great, but Chief Executives are trying to agree on a way forward.  Some partners would argue that a reduction in the current (discretionary) social care contribution will increase pressures on the Trust which is already having great difficulty discharging patients. The A&E local delivery board has been looking at causes of discharge delays. It estimates that only 15 per cent is due to delayed transfers of care (DTOCs) and blockages in the social care system, with 85 per cent of the current delays being due to internal processes at WHHT. This suggests that there are further actions that need to be taken by the Trust. The Emergency Care Improvement Programme (ECIP) is working with the Trust on related issues including professional standards. 177.5 The Committee noted financial performance to M7 2016/17. AK joined the meeting QP/178/16 Transformation & QIPP report (AK) 178.1  AK introduced the report and noted that QIPP delivery has not improved since last month.  An additional risk has been identified relating to missing activity in data sets due to ‘Type 2’ objections by patients to the sharing of their details outside of primary care. The number of objections registered represents on average 3.5% of patients. The missing data affects the CCG’s ability to monitor individual activity accurately.  Sally Adams is working with WHHT to get a plan in place for excess bed days and improve patient flow.  There has been no progress on first to follow-ups with ratios deteriorating quite significantly. It is very important that next year’s contract is informed by an absolute definition of ambulatory care. A huge amount of work has already been undertaken by TF and Kevin Barrett, identifying £900K of challenges. The ability to follow individual movement of patients is vital to this process. 178.2 The following points were made in discussion:  Contract negotiations are underway.  At a meeting with NHSE on Monday 5 December the FRP and plans for next year will be discussed. A timescale for completion of all schemes will also be agreed.  The Turnaround Director has asked every delivery lead to produce a month-by-month performance forecast for the rest of the year, together with key actions needed.  We will be able to gain some further advice and guidance from elsewhere to improve planning and delivery.  The report to the January meeting should include more detail as well as a focus on next year. HS joined the meeting 178.2  It is important that plans negotiated for two years include certainty, rigour and contd. process. This will inspire more confidence in them from NHSE.  GPs will need to have confidence that there have been hard negotiations in the contracts.  A cultural change is necessary in order to persuade patients that it is not always necessary for them to return to providers for follow-up appointments. Equally, there needs to be a cultural change within providers which would be supported by block 3 | P a g e

contracts. 178.3 DC noted that the Committee should be aware that there has been deterioration in the negative variance forecast for CHC.  A nationally mandated increase of £1.8M for funded nursing care has meant that the variance has been projected at £2M for most of this year.  An over spend of £6.4M is now being predicted.  An internal investigation has been conducted by Rod While and the report is being finalised.  Actions are being taken in the meantime to gain a greater understanding of the variance. A project manager and some short-term support in the finance team have been engaged.  A number of causes are evident so far: - last year’s over spend had to be taken from this year’s budget (£1M); - failure to realise full savings associated with the £1.7M QIPP; - increased cost of FNC (£1.8M); - invoices not being paid because the system is not clear – this is the main cause of the late identification of the size of the problem although early figures suggest a 10 per cent growth in demand;  Fundamental issues have been identified with the working between CHC and Finance teams. Oversight of improvements required will mainly sit with the Audit Committee but this Committee will also be kept informed of progress. 178.4 The following points were raised in discussion:  Going forward, CHC is ‘business as usual’ with an ageing population and increasing demand.  Commissioning policy has already been tightened for CHC with no package to be over 20 per cent above the indicated cost for a care home bed.  Appointment of a very experienced new AD will also drive improvement.  The QIPP schemes are backward looking, focused on review of Fast Track cases and historic high cost packages. Fast Track is intended for end of life and a maximum of three months’ duration, but some packages have continued for over a year.  Until a robust look back at the ledger has been completed, the suggested figure of £6.4M variance cannot yet be assured.  There will be another QIPP scheme in next year’s plan for CHC because there are still reviews to be completed.  The lower eligibility criteria for Fast Track referrals may encourage consultants to take a pessimistic view of a patient’s prognosis. The CCG may wish to consider including further conditions that would allow for a maximum period. 178.5  AK noted that the plan is intended to affect the bottom line for both 2017/18 and 2018/19 and the Turnaround Director is looking beyond work streams.  It is very important that the same numbers are being communicated to WHHT in contract negotiations.  Savings on first to follow ups are forecast to increase in year 2.  Savings are also being considered in other areas. For example we are examining the evidence for follow ups in community ENT. 178.6 The Committee noted the QIPP update. 178.7 ACTION: QIPP report to the Committee on 5 January to include more detail and a focus on next year’s plans (AK) EK joined the meeting QP/179/16 Integrated Quality, Performance & Finance report (CA/DC/HS/EK/LD) 179.1  CA noted that he would take the paper as read and invited questions. 179.2 The following points was raised in discussion:  Although patients being referred for a two week appointments are informed in three different ways (verbally and handed a leaflet, plus sent a letter), many patients still 4 | P a g e

report that they had not been told that their appointments were urgent.  The report includes a link (on the front sheet) to full dashboards for individual providers that are a source of more detailed information.  Herts Urgent Care (HUC) performance has improved over the last few months.  Issues with Hertfordshire Partnership Foundation Trust (HPFT) performance on 24- hour waits for urgent referrals to community mental health teams (CMHT) to be picked up outside of the meeting.  There is a marked difference in performance between East & North Herts Trust (ENHT) and WHHT on Referral to Treatment (RTT) 18 week targets, with ENHT performance being consistently ‘green’ and WHHT ‘red’ and deteriorating. Trusts may prioritise 18 week or 62 day waits for different reasons, but have only one resource for both. The context for WHHT is that a number of referrals that had not been processed were uncovered.  The comparative figures on page 11 for unplanned hospitalisation for chronic ambulatory care sensitive conditions are relevant to consideration of Rapid Response performance and the need for clearer thresholds about the level of risk they are expected to handle.  Increases in demand for A&E at Royal Free London (RFL) may be related to overnight closures at North Middlesex. Further information has been requested.  Quality Premium is delivered one year in arrears. £724K is expected in respect of 2015/16. No quality premium will be awarded for 2016/17 if HVCCG fails to achieve a break-even financial position. 179.3 HS presented the quarter 2 workforce dashboard:  Staff turnover was 9.18%. The vacancy rate reduced slightly, to 36.  Reasons for staff leaving have been looked at more closely and the category ‘other’ has been removed as an option from the form. Most frequent reasons cited are: - work-life balance; - better remuneration; - lack of promotion opportunities. 179.4 The following points were raised in discussion:  Total agency spend to date is approximately £600K. This is monitored very closely and minimised as much as possible. Discussions with other CCGs about potential for joint working have included consideration of opportunities to share staff resources.  The recently updated authorisation process for appointing to vacancies requires the Executive team to be assured that all options have been considered: this includes the option of apprenticeship for positions at all levels.  The CCG is not currently in a position to support apprenticeships in primary care, but the Deputy Director of Nursing is working with nurses in primary care to develop learning support.  There are opportunities for HVCCG employees to apply for promotion and staff development is encouraged wherever possible. Some may need to broaden their education or opportunities by moving to other NHS organisations where appropriate development is not possible locally. All posts are subject to an open competition process that may deter some applicants.  Less than 10% turnover in an organisation is generally considered to be an acceptable figure. 179.5 EK introduced the Better Care Fund (BCF) Q2 update and further information available since submission of data for this report:  The issue of receiving information from homecare providers has been resolved.  An improvement has been seen in BCF 3 – the proportion of older people maintained in their own home following a hospital admission.  There has also been an improvement in service user experience reported – BCF 5. This is currently at 87% with more improvement needed to meet the 2016/17 target of 5 | P a g e

90%.  Strongest performance has been seen in BCF 2 (long term support for older people), with BCF 1 (non-electives) and BCF 4 (DTOCs) performing worst. Recovery plans are in place to address performance issues identified.  The new BCF framework is expected on 7 December. There has been suggestion that the metrics for measuring improvements in integration need to be reviewed. 179.6 The following points were raised in discussion:  The target rate for DTOCs of 1545 may not be realistic when compared to the figure of 1212 in 2015/16. BCF only contributes to a broader range of schemes designed to reduce DTOCs. What is important is to ensure that we make the best use of current services before considering any new schemes.  There is no feedback expected on the Care Quality Commission (CQC) re-inspection at WHHT until end of December. Need for improvement in the mental health room and senior decision-making noted during the inspection were addressed immediately. There was an acknowledgement of significant improvements in maternity and end of life care. The oversight committee continues to meet monthly. LD joined the meeting 179.7 LD introduced the Q2 update on the six clinical priorities within the new 2016/17 CCG assurance framework.  The data is produced by NHSE and now available for 42 of the 60 assurance categories.  The report includes a summary of the 60 key performance indicators RAG status (where available), including next steps.  Progress is reported to GPs through the clinical leads.  A proposal for services commissioned from GPs in 2017/18 is being prepared for review by the GP clinical chairs.  Feedback on the GP resilience programme is awaited. 179.8 DC noted that key quality updates from this report will be picked up in the Q2 Quality Report. 179.9 The Committee noted the IQPFR at 31 October 2016. 179.10 ACTION: Discuss HPFT 24hr waits for urgent referrals to CMHT with SB (CA) HS, EK and LD left the meeting QP/180/16 Quality Report 2016/17 Q2 (DC) 180.1 DC introduced the quarter 2 report:  Since the report was issued, a never event has been reported by WHHT maternity. This is subject to immediate mitigations and investigation.  A Serious Incident (SI) has also been reported by WHHT. Investigation suggests that this may also be a never event. This matter will be confirmed in the next few days.  Some incidence of the norovirus has emerged, both at Langton Ward in St Albans and in the community. Following deep cleaning, Langton should re-open by 2 December.  Jane Padmore has been appointed as Director of Nursing at HPFT.  We have been successful as a ‘fast follower’ site for Nursing Associate roles with 69 posts being funded across east and west Hertfordshire. Clare Saunders will look at the opportunities that this scheme might offer in primary care settings.  A really positive quality assurance visit has been reported from maternity at WHHT with a return visit planned for the next few months.  A key challenge currently is 62 day waits at RFL.  Going forward it is intended that the patient story summary will be included in quarterly quality reports. 180.2 The following points were raised in discussion:  The initial patient story report was very well received by the Patient and Public Involvement Committee (PPI): it is very good for encouragement of constructive contributions.  Unexpected deaths recorded by HPFT are not necessarily suicides: some may be 6 | P a g e

related to other conditions, or drug/alcohol misuse for example.  The street triage project for mental health has been extended into west Hertfordshire. 180.3 The Committee noted the Quality report for Q2.

QP/181/16 Complaints & Enquiries Report 2016/17 Q2 (DC) 181.1 DC introduced the quarter 2 report.  There was an increase in complaints, compared to Q1, with the main source still being CHC delays and funding decisions..  All learning from complaints and enquiries is built into the CHC action plan. Complaints largely focus on poor communications.  There has been success in recent recruitment rounds for CHC posts. 181.2 The following points were raised in discussion:  Delays in CHC assessments are in some cases linked to delays within the hospital and the work being done on ‘red’ and ‘green’ days in beds.  Systems are in place for CHC assessments but they have not been working well. There is work ongoing to improve this process in collaboration with the Trust. 181.3 The Committee noted the complaints and enquiries report Q2.

QP/182/16 Freedom of Information report 2016/17 Q2 (DC) 182.1 DC introduced the quarter 2 report.  HVCCG continues to achieve compliance with FOI deadlines.  There has been a sustained and steady increase in FOI requests in 2016/17 as against 2015/16.  There has been a significant increase in requests related to CHC this month due to a single enquirer submitting a high number of requests. The individual concerned has been advised to go to the Information Commissioner or PHSO as per FOI guidance and no further formal responses will be sent to them by HVCCG.

QP/183/16 Committee work plan (SB) 183.1 SB introduced the work plan for 2016/17.  The 2017/18 plan needs to be drawn up but will follow the same pattern as 2016/17. 183.2 The Committee noted the work plan and proposed updates. 183.3 ACTION: Work plan for 2017/18 to be presented to January meeting (KP)

QP/184/16 Risks identified during the meeting (SB) 184.1  Financial risks are of concern and will be communicated in a co-ordinated way.

QP/185/16 Items for cascade to localities (SB) 185.1  Contracting round brought forward and underway now.  Extension of the mental health street triage pilot to west Herts is being considered.

QP/186/16 Next meeting (SB) 186.1 5 January 2017, Apsley meeting room, 2nd floor, Hemel One, 10.00am

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