Agenda Nhs Bolton Clinical Commissioning Group Public

AGENDA NHS BOLTON CLINICAL COMMISSIONING GROUP PUBLIC BOARD MEETING Date: 23rd January 2015 Time: 12.30pm – 15.00pm Venue: Main Meeting Room, Friends Meeting House Start Duration Item Subject Paper/ By Whom Time No. Verbal General Business: 12.30pm 1. Apologies for Absence. Verbal Joanne Taylor 12.30pm 5 mins 2. Introductions & Chair’s Update. Verbal Wirin Bhatiani 12.35pm 10 mins 3. Questions/Comments from the Verbal All Public on any item on the agenda. 12.45pm 5 mins 4. Declarations of Interest in Items on Verbal All the Agenda (In addition to those recorded by Members on the Declarations of Interest Register). 12.50pm 5 mins 5. Minutes of the Part 1 & Part 2 Papers Wirin Bhatiani Meetings previously agreed by the Board and Action Log from 28th November 2014 meeting. 12.55pm 10 mins 6. Patient Story. Presentation Colin Mercer Items for Decision: 13.05pm 30 mins 7. Co-Commissioning Joint Paper to follow Stephen Committee Report - Bolton Quality Liversedge Contract. 13.35pm 5 mins 8. Information Governance Paper Mike Robinson Framework. Priority Assurance Items: 13.40pm 10 mins 9. Annual Equality Data Publication. Paper Mike Robinson 13.50pm 20 mins 10. Ambulance Turnaround Update. Paper Jackie Bell 14.10pm 10 mins 11. Corporate Performance Dashboard. Paper Colin Mercer 14.20pm 10 mins 12. Report of the Chief Finance Officer. Paper Annette Walker 14.30pm 10 mins 13. QIPP Programme Update. Paper Fiona Moore Items to Receive: 14.40pm 5 mins 14. (i) Healthier Together Committee Paper For noting in Common Minutes 21/11/14. (ii) GM Association of CCGs Paper For noting Summary 6/1/15. For noting (iii) CCG Executive Update. Minutes from:- (iv) Q&S Committee 12/11/14 and 10/12/14. Available on (v) Audit Committee 5/11/14. the CCG (vi) Governance & Risk Committee website 14/11/14. (vii) Health & Wellbeing Board 10/12/14. (viii)Joint Commissioning Committee 18/12/14 & 22/12/14. 14.45pm 5 mins 15. Annual Review of Gifts & Paper For noting Hospitality and Declarations of Interest Registers. 14.50pm 5 mins 16. Any Other Business. Verbal For noting 14.55pm 17. Date of next meeting:- Verbal For noting Friday 27th February 2015 at 12.30pm in the Main Meeting Room, Friends Meeting House. Part 2 Board Meeting (if required): 14.55pm 18. Exclusion of the Public:- Verbal Chair to “That publicity would be prejudicial to the confirm public interest by reason of the confidential nature of the business to be transacted, and that the public be excluded”.

MINUTES

NHS Bolton Clinical Commissioning Group Board Meeting

Date: 28th November 2014

Time: 12.30pm

Venue: Main Meeting Room, Friends Meeting House

Present: Wirin Bhatiani Chair Joe Leigh Vice Chair & Lay Member, Governance Alan Stephenson Lay Member Colin Mercer Clinical Director, Clinical Governance & Safety Stephen Liversedge Clinical Director, Primary Care & Health Improvement Barry Silvert Clinical Director, Commissioning Charles Hendy GP Board Member Charlotte Mackinnon GP Board Member Tarek Bakht GP Board Member Shri Kant GP Board Member Ann Benn Lay Member, Patient Engagement Su Long Chief Office Annette Walker Chief Finance Officer Mary Moore Chief Nurse

In attendance: Wendy Meredith Director of Public Health, Bolton LA Sarah Fletcher-Hogg Communications Officer Rob Bellingham Director of Commissioning, NHSE Area Team Minutes by: Joanne Taylor Board Secretary

Minute Topic No. 183/14 Apologies for absence Apologies for absence were received from: • Tarek Bakht, GP Board Member.

184/14 Introductions and Chair’s Update Board members introduced themselves. There were 21 members of the public recorded on the attendance sheet.

Karen Reissmann introduced the members that had attended who were representing the Save the Bolton health services campaign. Karen had submitted some follow up questions to the Chair and Chief Officer further to the questions raised at the October board meeting.

Karen also handed the Chair a petition including over 8,000 names of people in support of the campaign.

The Chair also reported that he had received a letter of resignation from Charlotte Mackinnon from her roles as Board member and clinical lead for children and maternity. Charlotte was to continue in her clinical lead role for safeguarding and would be serving a period of notice on her other roles. The CCG would be undertaking an election process in the future to recruit to the vacant board member position.

The Chair also reported that interviews had been undertaken that day for the secondary care specialist board member role. An announcement on the successful candidate would be made once all the recruitment paperwork had been completed.

185/14 Questions/Comments from the Public on any item on the agenda The Chair had discussed with Karen Reissmann prior to the meeting that only questions specific to items on the agenda can be taken and that there were other routes for questions being raised to be answered. However, Karen requested that the Chair allow her to read out her questions at the meeting. The Chair agreed to this and confirmed that answers would not be able to be given at the meeting.

The Chief Officer responded to the questions raised by confirming that a letter had been sent to Karen Reissmann answering the questions raised at the October board meeting and that a copy of the letter would be appended to the minutes from that meeting. In summing up, the Chief Officer reported that the CCG had to follow the rules within the Health Act regarding procurement when implementing service changes. Su Long also confirmed that it was not the CCG’s intention to reduce spend on IAPT services, the intention was to increase spend on mental health services by reducing resources spent on other acute services. Su Long had also made a statement in her response letter that this will not lead to privatisation. The CCG had to ensure that the correct procurement processes were in place and that this was communicated to the relevant organisations, however this could not be shared with individuals. Su confirmed that the Board meeting was not the place for continued questions and answers on this particular area, however she was willing to speak to people outside the Board meeting if this would be helpful.

186/14 Declarations of Interest in Items on the Agenda GP Board Members expressed an interest in the item on the agenda regarding improving primary care in Bolton. There would be no requirement for the GPs to remove themselves from these discussions, as there were no decisions being taken at this meeting on this item.

Barry Silvert expressed a potential conflict of interest in the item on the agenda regarding Bolton FT estates and proposed to leave the meeting at this stage. Charles Hendy, Charlotte Mackinnon and Shri-Kant also confirmed an interest in this item.

Following the comments made by members of the public, Wendy Meredith expressed her ongoing declaration of interest regarding psychological therapy services.

The Board noted that ongoing declarations of interest stood for every Board meeting and were publicised on the CCG’s website.

187/14 Minutes of the Meeting previously agreed by the Board and Action Log from 24th October 2014 meeting The Minutes were agreed as an accurate record and the update on the action log noted.

188/14 Patient Story Colin Mercer presented the patient story for this month. This focused on a complaint from a Bolton patient who unfortunately had a poor experience with Arriva Patient Transport service. The report details how the CCG has addressed this complaint and further action to be taken with Arriva at a future performance meeting being held in December.

Members queried the service being provided by Arriva, given the mode of transport that was used to transport this patient home was by taxi. It was acknowledged that these issues would be discussed with Arriva through the contract monitoring meeting to be held to ensure standards are improved further. Members noted that although standards had improved, 80% meant that 1 in 5 patients were not getting the required standard of pick up within 1 hour.

The Board noted the update. Presenting patient stories in different formats would continue to be developed with the CCG’s Communications and Engagement team.

189/14 Relocation of Children’s Outpatient Department and Minerva Day Centre Dr Barry Silvert left the meeting at this point.

Bolton FT has proposed the relocation of Children’s Outpatient Departments from the Bolton FT site and Hallliwell Health Centre and services from the Minerva Day Centre to Bolton One. These moves would provide improved environments for patients to receive clinical care, whilst addressing the risk of harm to patients and staff in respect of the high and significant backlog maintenance issues identified with the premises that the services are currently delivered from. This proposal is in accordance with Bolton FT’s estates strategy to reduce the hospital footprint and utilise community premises, and aligns with the CCG’s estates strategy relating to transferring services into the community and into higher quality buildings.

It was noted that the Quality Impact Assessments (QIAs) and the Equality Impact Assessments (EIAs) processes were still ongoing. However, it was appropriate to present the proposal at this stage acknowledging that approval would be subject to finalising these processes.

Members discussed the proposal and sought confirmation that services proposed to be moved would be the services that the CCG would want to relocate into the community. It was agreed these are services that have the poorest estate currently and are the right services to move. It was acknowledged that this was an opportunity to look at innovative ways to look after children in the community and would provide a central base for patients. Members discussed the role of the Strategic Estates Group, in particular the process for consultation with the local population and GPs regarding the deployment of community services. It was noted that the group’s main role was to co-ordinate, align and understand the wider estate strategies to develop the best options for the whole health economy.

It was noted that the paper from the Bolton FT board meeting was appended to this report detailing the wider estates proposals in relation to the FT’s estate. This was the only part of these proposals that the CCG had the ability to approve. Members raised the question of whether appropriate public consultation had been carried out and if the estates issues outlined in the FT’s report were included on their risk register.

The Board supported Bolton FT’s proposal to relocate the Children’s Outpatient Departments and services from the Minerva Day Centre to Bolton One. The Board also agreed to delegate responsibility for final sign off of the relocation to the Executive once the EIA and QIA processes have been finalised. Confirmation would also be sought to ensure that risks regarding Bolton FT’s estate plans were included in their risk register.

Dr Silvert rejoined the meeting at this point.

190/14 Improving Primary Care in Bolton The Board was presented with the case for improving general practice in Bolton and the work done to date to develop an innovative approach to this for commissioning in 2015/16. The proposal focused on the CCG’s strategic plan and vision regarding the transfer of services into the community and primary care setting.

The intention is to deliver a contract that supports the required investment in capacity in General Practice through providing a guaranteed income per patient and incentives for delivery of standards. This exciting initiative is being supported by the Greater Manchester Area Team of NHS England, has been shared with all Greater Manchester CCGs as being at the forefront of meeting the needs of the GM Strategy for Primary Care and is receiving positive interest nationally from influential leaders in NHS England and the Department of Health.

The Bolton Quality contract will set a clear set of standards for General Practice in Bolton and will be separate to the core contract already in place. The CCG was seeking agreement to use locally enhanced services (LES) and additional CCG investment to achieve consistent high level standards in general practice, offering higher quality of care and deliver savings at a level to allow the contract to pay for itself. It was noted that the publication in the Bolton News on the national funding available for extended hours was not part of this process. The CCG’s priority is to develop this contract to improve services within core hours before further developments around extended hours are considered.

The risks involved in developing this contract were highlighted to the Board, and acknowledged that these risks need to be mitigated further before the investment can be made. Some risks had been identified by Health Watch regarding asking more from an already overworked service. It was acknowledged that by making this investment, the aim was to increase capacity to help the workforce to become less stretched.

Stephen Liversedge presented some in depth information on the nature and standards to be implemented within this contract and the game changing concept to be achieved. He highlighted the current inequity in funding within practices, growing demand, and the need for primary care to be developed to be fit for purpose in the future. It was noted that primary care is dealing with current demand and having less time to deal with more important issues. Quality and safety in primary care is also in danger if it continues to work in the same way.

It was noted that the KPIs had been designed to realise savings. The CCG had undertaken significant engagement with member practices in designing the standards and KPIs which have been modified throughout the process. It was noted that the majority of practices were in agreement with the development of the contract.

It was also noted that due to CCG conflicts of interest and the joint nature of the commissioning process required for this Bolton Quality contract, there would be a need to delegate to the Primary Care co-commissioning committee the agreement of the standards, measures, contractual terms, and payment arrangements and make a case to the CCG Board to approve the inclusion of the investment needed in the financial plan for 2015/16.

Rob Bellingham, Director of Commissioning from NHS England Area Team, was invited to the discussions. He confirmed NHS England’s support to the development of this contract. He took the Board back to the agreement by all 12 CCGs to the Greater Manchester Primary Care strategy, which was reliant on developments such as the Bolton Contract. He was further assured that the Board had been involved from the commencement of this process

4 and supported this development. He was keen to support the Joint Committee and would be the representative for NHS England. He reiterated the interest this development had generated both regionally and nationally and confirmed that this work had been shared with other organisations.

Members discussed the financial risks and ring fencing of GP budgets. It was reported that further due diligence work on the finances was being undertaken. The key theme is to ensure this is understood and risks identified. Rob Bellingham identified the different types of GP contracts, GMS, PMS and APMS, with the latter two being subject to review. With regard to the PMS review, Rob confirmed that any money released from a contract must be reinvested into general practice and the CCG area from which it came. With regard to APMS contract which were due for review as these were only for an initial term, the area team was clear that the process to review contracts and reprocure will be done in agreement with the relevant CCG. The degree of assurance given is that all reviews will be done in conjunction with the responsible CCG and this was the clear approach across Greater Manchester in moving towards a co-commissioning process.

Members questioned the status of the NHS England representative on the joint committee and the committee’s role. It was confirmed that there would be equal authority across all organisations when running a co-commissioning body. Level B requires a joint committee to be established and model terms of reference had now been published for adoption. Rob Bellingham confirmed that the challenge for NHS England Area Team would be logistically representing a possible eight joint committees across Greater Manchester. However, he gave assurances that representatives of the right seniority with the ability to make appropriate decisions would be put forward.

Wendy Meredith reported on the risks highlighted in the report regarding the public health position. Wendy confirmed that the Local Authority public health broadly supported this approach with regard to the innovative nature and potential outcomes this could bring. Further work would be undertaken with the CCG around the financial mechanisms for paying practices and assurance on access to information, performance issues etc. Subject to these issues. It was noted that discussions with the Council to develop the proposal further were due to take place.

Members sought clarification on whether this was the CCG’s proposal for co-commissioning with NHS England. It was noted that the Joint Committee will be a place where the CCG can have an influence over some of the work undertaken by NHS England, for example on current contract reviews, plus other developments such as the Bolton Quality Contract. It was noted that formalising of the committee arrangements will be from April 2015 and will focus on tasks from NHS England. However, the governance arrangements would be put in place sooner as a shadow co-commissioning arrangement which would be formalised through the CCG’s constitution, which would be shared once developed.

Members noted the support received from the local population on the development of the contract. Annette Walker also commented that part of the solution to the problem regarding limited resources is around ensuring that funds are used in the correct way, acknowledging the risks but ensuring the right decisions are made for Bolton patients. Members acknowledged the initial additional work this will place on GP practices, but agreed this was an opportunity to invest to deliver better services for the future.

The Board agreed the delivery of a Bolton Quality Contract for General Practice to be set as a commissioning intention for 2015/16 by the CCG. The Board noted the risks highlighted in section 8 of the report which need to be mitigated further before the investment can be made.

Due to CCG conflicts of interest and the joint nature of the commissioning process required for this Bolton Quality Contract, delegate to the Primary Care co- commissioning committee the tasks outlined in the report and make a case to the CCG Board to approve the inclusion of the investment needed in the financial plan for 2015/16.

191/14 Risk Management Strategy A Risk Management Strategy was approved by CCG Executive and the Governance and Risk Committee in October 2013. It was submitted to the Board at its meeting on 22nd November 2013 for noting, along with the minutes of the Governance and Risk Committee meeting held 30th October 2013. The CCG Constitution requires that the CCG Board approve the Risk Management Strategy and it is therefore presented to the Board for adoption and to agree a review date of November 2016.

The Board adopted the Risk Management Strategy and agreed a review date of November 2016. 192/14 GM Policies for approval The Board was updated on the policies that have been through the agreed GM EUR Governance arrangements and were approved by the AGG on 4th November, namely: • Common Benign Skin Lesions – not commissioned for aesthetic reasons but may be funded for clinical reasons such as pain or dysfunction. This policy does not apply to primary care which is NHS England funded. • Hyperhidrosis – commissioned according to clinical need and as Bolton do not currently have a specific policy for hyperhidrosis there is no significant impact anticipated. • Persistent Non-specific Low Back Pain – a number of procedures are shown to be of little or no benefit and are therefore not commissioned. Bolton do not currently have a policy and there may therefore be a reduction in activity. • Labiaplasty – only considered for funding if there is objective evidence of significant anatomical distortions as a result of obstetric trauma, other trauma or vulval disease. These numbers are currently small. This is not funded for aesthetic purposes.

The policies approved by the AGG are still required to be ratified by CCG governing bodies as the AGG is not a statutory organisation and therefore cannot decide policy. Once approved by the CCG the implementation process will be followed.

Members discussed the governance of these policies, how they were reviewed and accessed by members of the public. There was a process in place whereby approved policies were uploaded onto the CCG’s website and linked into the work regarding patient pathway development. It was also confirmed that patient engagement processes were included in the development of these policies. Members agreed that wider publication of these policies with the local population was key. It was also important that GPs were aware of the CCG’s support when making decisions for their patients when certain procedures were not available.

The Board approved the policies for implementation.

193/14 Safeguarding Policies for approval Two safeguarding policies were presented to the Board for ratification, namely the policy for Managing Allegations Made Against Staff in Respect of Children and Young People Policy and Safeguarding Children and Vulnerable Adults: A Strategic Framework for Training. These had been discussed by the CCG Executive previously. It was noted that the Safeguarding Team would disseminate these policies as required once approved.

Assurances on the levels of training required were highlighted. This was normally undertaken through the annual appraisal process. However, the LMC had noted in recent minutes that this was not mandatory. Charlotte Mackinnon reported that clarification on this was currently being sought with NHS England. It was also noted that this policy related to staff employed by both commissioners and providers. Responsibility for delivery of the training will also be included in the policy.

The Board ratified the above policies. The Board noted the queries raised regarding clarification on levels of training required to be reviewed through the annual appraisal process and the methodology to be used regarding resourcing of training will be implemented separately to the approval of the policy.

194/14 Integration Update on Milestone Plans The Board was informed on the current status of the Health and Social Care Integration programme. Highlighted was the development of the integrated neighbourhood teams now working in the community. The key risk noted was the lack of development with regard to the intermediate tier work. The delay in progress was due to the planned move of services from Winifred Kettle and the time taken to recruit staff in the home based care services. It had been agreed by the Joint Transformation Board that further testing on holding some of these beds to review pressures in the system prior to finalising the closure of this part of the service. The Board noted the issues regarding IT that need to be developed to ensure integration fully worked.

The Board noted the update.

195/14 Board Assurance Framework The report provides the Board with an update on High level risks included in the Quarter 2 Board Assurance Framework (BAF) that may affect the achievement of the CCG’s strategic and operations objectives. Risks assessed as High (15 or above) are routinely reported to the Board. The attached document provides details of risks assessed 15 or above (High) included in the Board Assurance Framework.

Highlighted to the Board was the risk regarding specialist commissioning and the functions to be devolved back to CCGs. Greater Manchester CFOs were working with NHS England to agree the required management processes which will give more clarity regarding the scale of this risk. The Board noted however that these services were currently carrying an overspend.

The Board accepted the attached extract from the Board Assurance Framework 2014/15 and the assessment of high level risks for Quarter 2 (July to September).

196/14 Corporate Performance Dashboard The report highlights the CCG’s performance against all the key delivery priorities (quality, activity & finance) for the month of September 2014 (Month 6). It was noted that a Community Services Dashboard is in development. Section 2 of this report highlighted exception reports against all indicators where the CCG is not achieving its targets. Section 3 provides an update on achievement of the 2013/14 Quality Premium.

The key points highlighted was the failure of the A&E target for the second month. This was also the case both regionally and nationally and discussions were being held with NHS England which would be reported back to the Board at the next meeting. NWAS ambulance handovers and category A targets had also failed for a further month. A progress report on the remedial action plan would be also be presented to the Board at the next meeting.

It was noted that the CCG has achieved a rate of 17.40% for IAPT Access in September. The target is to achieve a rate of 15% (in Quarter 4). Bolton FT had failed to achieve 2 of the 3 stroke targets in September. 70% of patients were admitted to a designated stroke bed within 4 hours against a target of 80% with 79% of patients spent 90% of the stay in hospital on a stroke unit against a target of 80%. The FT has given assurance that this target will be met from October and the remedial action plan is being closely monitored through the Quality and Performance Group.

The CCG has also received information from the CQC regarding the early analysis undertaken and proposed inspections of GP practices. The CCG has highlighted issues with the data received. The data is not a judgement on quality, more an initial analysis. Further information was expected following the inspections undertaken.

Information on achievement of the Quality Premium for 2013/14 was also noted. The CCG would not achieve the full quality premium as it had not achieved the 62 day cancer wait target and reducing avoidable admissions measure which the CCG was perceived not be be achieving due to admissions to the Bolton Community Unit not previously being counted as hospital admissions but due to the closure of the unit, admissions were now counted as hospital admissions. The CCG has appealed this decision based on the data used by NHS England not containing the Bolton Community Unit activity and are awaiting their decision.

A report was also tabled providing an update on community services, further to the detailed work undertaken on quality concerns previously raised by the CCG. Section 2 of the report details the concerns regarding staffing levels, lack of clear visibility and lack of data quality measures. There was not enough detail received to assure the Board that community services were at the appropriate level regarding quality. A correction was noted in section 2.2. The number of incident reports related to Bolton FT and not just community services.

The report detailed key themes that the CCG now required the FT to provide the required level of assurance and the Board was asked to agree the list. Bolton FT would be invited to present assurances to the Board in mid December. Members discussed the level of sanctions that may be implemented if Bolton FT did not confirm that appropriate actions had been taken.

The Board noted the formal month end position for September 2014/Month 6 in respect of performance against key delivery priority targets and requested a detailed report on the action plan regarding ambulance handovers be provided at the next meeting.

The Board also agreed to the list highlighted in section 4 of the community services review report that was to be sent to the Chief Executive of Bolton FT with the changes highlighted above and agreed to use the Board Development session on 12th December to discuss these issues further with Bolton FT.

197/14 Report of the Chief Finance Officer The Board was updated on the expected financial performance and risks to delivery.

It was reported that the CCG is showing delivery of its key financial duties but with significant risks specifically due to counting and coding and contract challenges with Bolton FT, which have escalated over the last few months. Bolton FT and the CCG are working through a process to resolve the contracting issues. This could result in an additional payment above the planned contract level to Bolton FT which would result in an under delivery against the control total and a breach of statutory duty.

In this scenario, the CCG would have to implement a range of emergency measures to reduce activity and expenditure to deliver in line with its statutory financial duty. These measures are currently under development with the CCG clinical directors to ensure plans are in place, if required.

It was also reported that the financial position to month 7 is a surplus of £2,060k, which is in line with the CCG’s financial plan. There is an increased financial pressure on the continuing healthcare (CHC) budget due to issues around late invoicing from nursing homes and legacy issues regarding CHC restitution cases. The over spend on acute services did not include the full risk regarding the contract challenges with the FT. There were also issues regarding prescribing and the possibility that the CCG may be liable for additional charges regarding FP10 prescribing. This related to invoices now being received from the PPA not previously invoiced for. Work was progressing to understand this in more detail and ensure appropriate protocls were in place to control this expenditure further. Whilst there are some under spend in other areas, reserves are currently being utilised to ensure that the CCG delivers the required surplus.

It was noted that expected performance on the revenue position had moved to amber and delivery of QIPP to red.

The Board’s attention was drawn to the contract issues with Bolton FT, in particular the changes that have occurred following the closure of the BCU and the impact of this on non- elective performance and caused significant change in case mix regarding critical care. A full review of the financial risks had also been undertaken. The contract challenges with Bolton FT had been listed as a separate risk item. It was reported that if any further risks develop, this would have a significant effect on the CCG’s current forecast.

Members discussed the increase in patient flows to the BMI Beaumont and questioned whether this suggests that patients were exercising choice. Also discussed were any possible issues regarding the timing of admissions for elective care. It was reported that the CCG had expected some shift with regard to BMI Beaumont now that the referral management and booking service (RMBS) was provided in house and ensuring that choice is fully available to patients and, due to this, an annual review of the flow of patients would be undertaken. With regard to elective care, the CCG was reviewing referrals and admissions. Given the financial challenges, the CCG needs to look at commissioning plans being implemented at a faster pace based on clinical evidence to avoid the situation elsewhere in the country where services are just stopped for the remainder of the year to try to keep them on track. The CCG has to do the right thing and prioritise services that are important.

The Board noted the update at month 7 and noted the increased level of risk identified and the processes put in place by the Executive. The Board would be kept up to date with regard to the contract challenges with Bolton FT.

198/14 QIPP Programme Update The report provides an overview of the CCG’s QIPP Programme and gives a year to date position on progress. It was noted that the year to date QIPP delivery at month 7 stands at £1,642k against a month 7 plan of £2,184k. This includes additional schemes that were not included in the plan at the beginning of the year.

The forecast outturn for QIPP savings in 2014/15 is £3,551m against a target of £4.7m to deliver our financial requirements. This is based on the current in year delivery and profiled trend to year end. Further schemes for 2014/15 have been identified and anticipated financial savings values have been allocated to some while others are still being profiled. This will only go part way to achieving the £4.7m target.

Also highlighted were the 2015/16 QIPP projections. Members discussed the use of more modest trajectories at the start of the year as implementation takes time. The CCG was assessing trajectories and planning this with managers going forward. It was appropriate to highlight the projections to the Board at this stage showing those schemes that will have an expected impact. The focus would also be on escalation of in year pressures.

The Board noted the report and noted the gap at month 7 in delivery against plan which requires getting schemes back on track and identification of additional new schemes to deliver the required QIPP target of £4.7m.

199/14 Healthier Together Committee in Common Minutes 15/10/14 The minutes were noted.

CCG Executive Update The update was noted.

Minutes from the Quality & Safety Committee 8/10/14 The minutes were noted.

Minutes from the Health & Wellbeing Board 22/10/14 The minutes were noted.

200/14 EPRR Core Standards Assurance The Board noted the assurance with regard to Bolton’s compliance with the core standards regarding emergency preparedness resilience and response which had been signed off by Barry Silvert as the responsible Clinical Director.

201/14 Dates of Board Meetings for 2015 The dates for future Board meetings for 2015 were noted.

202/14 Any Other Business There was no further business discussed.

203/14 Date of Next Meeting Agreed as Friday 25th January 2015 at 12.30pm in the Main Meeting room, Friends Meeting House.

Part 2 Board Meeting (if required): 204/14 Exclusion of the Public The public part of the meeting was closed and the public were requested to withdraw. The Chairman proposed that “members of the public be excluded from the remainder of this meeting under Section 1(2) Public Bodies (Admissions to Meetings) Act 1960”. This being agreed.

PART 2 CONFIDENTIAL MINUTES - SUMMARY

NHS Bolton Clinical Commissioning Group Board Meeting

Date: 28th November 2014

Time: 15.00pm

Venue: Main Meeting Room, Friends Meeting House

In attendance: Wendy Meredith Director of Public Health, Bolton LA Minutes by: Joanne Taylor Board Secretary

Minute Topic No. 17/14 Apologies for absence Apologies were received from: • Tarek Bakht, GP Board Member.

18/14 Contractual Issues with Bolton FT The Board received an update on the current contractual issues with Bolton FT. The Board noted the update and would be kept informed of the outcome of the mediation meeting on 16th December.

KEY ACTION LOG: Updated from 28th November 2014 meeting: This action log aims to cover all matters arising from previous meetings. Members will raise any further queries with the Chair in advance of the next meeting.

OUTSTANDING ACTIONS: Date/No./ Action Details: Current Status: Due date: Comments/Progress/ Initials [SEE NOTE 2] Original AND Explanations: [NOTE 1] any agreed Revisions 22/11/13 Innovation Fund – Process Outcome: To be progressed once the pilots had July 14 Board members have 185/13 The Board agreed to share the process been reviewed. Revised date: received programme for SL undertaken with NHS England Area Team Nov 14 review. and the wider NHS community once the outcomes are known. 13/12/13 Quality Premium: PHE have now issued the long-awaited Feb 14 CCG to receive public 200/13 To share with the Board the public health’s consultation on the Health Premium. WM Revised date: health response. WM measures on their health premium when to start to formulate a draft response June 14 available. which will be discussed with the CCG Revised date: PHE have published an prior to submission. Aug/Sept 14 update on the health Revised date: premium w/c 12/1/15. Public Oct/Nov 14 Health are currently doing Revised date: some work on the Jan/Feb 15 implications which the CCG will be updated on once concluded.

30/5/14 Prevention of Diabetes Project Update: SL fed back to WM. Proposals to be Aug 14 Plan to be made with 78/14 To discuss with Wendy Meredith and considered jointly for H&WB Board. Revised date: Wendy Meredith on SLiv H&WB Board with regard to future Oct 14 timescales. investment in prevention outcomes. Revised date: Nov 14

COMPLETED ACTIONS: 22/8/14 Report of the Chief Finance Officer: 135/14 Discussion to be held on the impact of Progressing. Oct 14 Completed – CCG currently SL private providers linking to the CCG’s Revised date: link with relevant private commissioning intentions at a future Dec 14/Jan 15 provider (Beaumont). meeting.

22/8/14 Healthier Together CiC Briefing Note: 143/14 Clarification to be sought to ensure that the Progressing Oct 14 Completed – early draft SL/WB healthier together consultation report be Revised date: shows consultation broken down into specific Nov/Dec 14 response report is broken responses/themes for each area of Greater down into specific response Manchester in one report rather than a themes. separate report for Bolton.

26/9/14 Corporate Performance Dashboard: 155/14 • Look to provide information on Data has been requested from Bolton FT. Nov/Dec 14 Completed – information to BS/ML community services in future be included at a future date AW reports. once further work progressed with Bolton FT. Discussions being held via the contract performance management route with Bolton FT.

28/11/14 Relocation of Children’s Outpatient 189/14 Department & Minerva Day Centre: Jan/Feb 15 Completed – delegated SL Agreed to delegate responsibility for final authority to the Executive. sign off to the Executive once the EIA and QIA processes have been finalised. Dec 14 Completed – CCG written to Also seek confirmation that risks regarding Bolton FT to seek Bolton FT’s estate plans were included in clarification. Will report their risk register. back to the Board if confirmation not received.

28/11/14 Corporate Performance Dashboard: Jan 15 Completed – presented to 196/14 Detailed report on the action plan regarding the January board meeting. BS/ML ambulance handovers to be provided at the next meeting.

List highlighted in the community services Progressing Dec 14 Completed – discussions review report to be sent to Bolton FT Chief held with Bolton FT at Board Executive with invite to meet on 12th Development session on December to discuss issues further. 12th December.

Actions completed since April 2014 = 84 Number of actions remaining at 23rd January 2015 = 3

NOTE 1: SL Su Long FM Fiona Moore AW Annette Walker NO Nicola Onley CM Colin Mercer BS Barry Silvert ML Melissa Laskey WM Wendy Meredith SLiv Stephen Liversedge JT Joanne Taylor MR Mike Robinson

NOTE 2: Current Status, (incl. relevant dates): Completed, Overdue, On target, Delayed

NHS BOLTON CLINICAL COMMISSIONING GROUP Public Board Meeting

AGENDA ITEM NO: ………7………………

Date of Meeting: ……..23rd January 2015…………..

TITLE OF REPORT: Bolton Quality Contract: Outcomes from Co- Commissioning Committee

AUTHOR: Su Long, Chief Officer

PRESENTED BY: Stephen Liversedge, Clinical Director. Su Long, Chief Officer.

PURPOSE OF PAPER: To discuss the case for improving general (Linking to Strategic Objectives) practice in Bolton and the work done to date to develop an innovative approach to this for commissioning in 2015/16.

RECOMMENDATION TO THE The Board is recommended to: BOARD: • Agree the implementation of the Bolton (Please be clear if decision Quality Contract from 1st April 2015. required, or for noting) • Agree the difference between current core contract and £95 per weighted head of registered population be the contract value to practices (total investment required: £3,403,521.75). • Agree the intention is for this investment to be recurrent, based on the expectation that delivery of the standards and KPIS will deliver a 100% return on investment in year 1. • If the expected benefits are not met in year 1, the Board will agree either exit arrangements or changes to the contract.

COMMITTEES/GROUPS CCG Executive PREVIOUSLY CONSULTED: CCG Practice Leads & Member Practices Health & Wellbeing Board members HealthWatch Bolton CVS Health & Care Forum Joint Commissioning Committee

VIEW OF THE PATIENTS, Public views on General Practice are CARERS OR THE PUBLIC, AND incorporated into the paper and the aim of the THE EXTENT OF THEIR contract will be to improve the quality and INVOLVEMENT: experience of general practice.

EQUALITY IMPACT Detailed in section 7. ASSESSMENT (EIA) COMPLETED & OUTCOME OF ASSESSMENT:

Bolton Quality Contract: Outcomes from Co-commissioning Committee

1. Introduction

The CCG Board received a headline case in November and agreed to the Bolton Quality Contract for General Practice to be set as a commissioning intention for 2015/16 by the CCG.

The NHS Bolton CCG Primary Care Co-Commissioning Committee was established in accordance with NHS Bolton Clinical Commissioning Group’s Constitution, Standing Orders and Scheme of Delegation.

The Co commissioning committee is a sub-committee of the Board of Bolton CCG and was delegated responsibility to:

• Agree the current contracts to be incorporated into the Bolton Quality Contract

• Oversee the agreement of the following: - fair standards and KPIs - the contractual form of the contract - the payment arrangements and mechanisms - the requirements of practices to achieve payment and criteria for payment (as part of this, the practice plan agreement process) - the arrangements for performance management and monitoring

• Produce a case for investment that mitigates the risks to the CCG

This report provides a summary of the decisions made by the co commissioning committee and seeks a decision from Bolton CCG Board on whether they support the prioritisation of the Bolton Quality Contract in the CCG financial plan for 2015/16.

2. The aims and benefits of the proposed Bolton Quality Contract

The Bolton Quality contract will set a clear set of standards for General Practice in Bolton, which have been developed to: - Set a step-change requirement in quality - Increase capacity in General Practice to improve the service offered to Bolton people and set a good baseline for the development of more integrated models of care - Support the delivery of the Greater Manchester Strategy for Primary Care - Reflect the balanced aims of improved population health, better quality and patient experience of care and value for money

Bolton Quality Contract Decision Paper 1

- Incorporate all local contracts with General Practice (except the most specialist) - Provide a consistency of offer to Bolton people, no matter which Practice they are registered with - Meet the commissioning priority of Bolton people for improved access to General Practice

The case for change for the introduction of this new GP contract, in addition to the core contract for General Practices, includes: • reduction in NHS spend on primary care • increasing demand and pressure in GP practices.

The intention is for this Quality Contract to pay for itself, as well as raising quality. This will enable an ongoing recurrent level of funding to General Practice in return for delivery of clear standards.

3. Decisions made on Bolton Quality Contract

NHS Bolton CCG set up its first co-commissioning committee on 18th December 2014 (members as per terms of reference) and has met three times in total in order to discuss the detail of the proposed contract and make decisions.

3.1 Contracting basis • The Bolton Quality Contract will be an independent contract in addition to the core GMS/PMS/APMS contracts. • It will be mutually dependent on the provider having one of these contracts • Direct Enhanced Schemes and QoF (decided nationally) will be separate to and, in addition to, this contract. • The CCG will be the lead commissioner

3.2 Contracting principles – inclusions/ exclusions • It was agreed that Local Enhanced Schemes (LES) that all practices can deliver would be rolled into this single contract. • The contract will therefore include : - Oral glucose tolerance testing - Phlebotomy - Membership engagement activities - Best care for long-term conditions - Shared care monitoring for DMARDS (disease modifying anti- rheumatic drugs) and anti-psychotics - Quality &safety • The specialist LESs which will be excluded from the contract are: - Anti-coag - Asylum seekers - Nursing Homes - Insulin initiation & management - Multiple Sclerosis

Bolton Quality Contract Decision Paper 2

• The Public Health LESs which will be included and rolled into the contract (subject to formal member approval) are: - Health Checks - Alcohol (Audit C) - Sexual Health • The inclusion of services commissioned by NHS England, immunisation/ vaccinations and screening were included based on confirmation by NHS England that the standards would represent a stretch target from core contract.

3.3 Contracting principles – Equity • Due to different contracts in place in General Practice, and changes since contracts were awarded, Practices are not funded equitably. NHS England has written to Practices making clear their intention to review contracts with a future common level set at £78.66 per weighted patient (see graph below)

'core' £ per weighted patient now versus NHS England intention of £78.66 £190.00

£170.00

£150.00

£130.00

£110.00

£90.00

£70.00

£50.00 01 03 05 07 09 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49

Practice Practice Practice Practice Practice Practice Practice Practice Practice Practice Practice Practice Practice Practice Practice Practice Practice Practice Practice Practice Practice Practice Practice Practice Practice

• The investment principle is to level up, setting a £ per weighted patient that practices can expect to achieve for full achievement of this contract to ensure this is equitable. • The contract will pay the difference between the core contract payment and £95 per weighted head of registered population. • No practice would get less from the quality contract than they received in 2014/15 from will have their payments reduced if their current core contract and LES payments total greater than £95 per weighted head. • Practice income above this level is still at risk from contractual changes by NHS England.

Bolton Quality Contract Decision Paper 3

(The graph below indicates how this investment would start the progress towards equity in year 1)

190.00

170.00 Practice income at risk from NHS Bolton Quality England contract changes over the 150.00 Contract £95 per weighted head limit available payment from the Bolton Quality contract available 130.00 { Current payment 110.00 per weighted patient 90.00 (including LES)

70.00

50.00

• This takes into account the age and needs of the practice population (using the national Carr-Hill weighting formula). If this formula is altered nationally in future, the committee will need to decide how to handle this. • Work has commenced by NHSE to ensure alignment between APMS contracts and the Bolton Quality Contract.

3.4 Contracting Principles - Practice sign up • Practices should sign up to whole contract with no separation of elements. • To ensure patients are not disadvantaged if a Practice did not take part in the contract: - a clause be added regarding the ability to sub-contract to another practice, subject to agreement with the commissioner to ensure practices were delivering in accordance with what is outlined - some parts of this contract can stand alone so separate LES to this contract could be offered, but this would have to be done according to the rules governing procurement, using competitive bidding processes open to all Practices and other providers.

3.5 Contract Standards - It was agreed the standards should include - alignment with GM strategy, - a focus on CCG priorities that are informed by Bolton people and - additional to core contract requirements

Bolton Quality Contract Decision Paper 4

- 19 local standards were agreed (ordered alphabetically):

1. Access to General Practice 2. Best Care - Diabetes, Heart Failure, COPD, Asthma, High risk reviews 3. Cancer Referral 4. Carers 5. Emergency Planning 6. End of Life Care 7. Exception Reporting 8. Health Improvement 9. Health Protection 10. Membership Engagement 11. Mental Health 12. Patient Experience 13. Patient Safety 14. Phlebotomy 15. Prescribing 16. Referrals meeting evidence 17. Screening 18. Sexual Health 19. Transfer of Care

Further information on the rationale for choosing each standard is available in the table on pages 9-11.

Members discussed a number of standards in detail specifically:

3.5.1 Access Capacity regarding the access standard was discussed. Within this standard, practices are expected to open 8.00 – 6.30pm Monday to Friday and offer 75 contacts per 1000 patients per week.

An access audit undertaken in May 2014, showed current contacts on average to be 71 contacts per 1000 per week with the access standard being set at 75 contacts in order to represent a stepped increase in capacity for most practices (see chart below)

This was challenged in comparison to a national study recently undertaken by Deloittes that showed consultation rates at 6.3 set to rise to 8 per patient per

Bolton Quality Contract Decision Paper 5

year on average over the next three years. It was recognised that this difference related to the national study including Practice Nurse contacts, whereas the Bolton audit excluded these, concentrating on GP and Nurse Practitioner contacts.

(The graph below shows, by practice, the current baseline of GP/NP contacts, with the target of 75 contacts per patient per week.)

This would provide over 61,000 additional appointments/ contacts per year with GPs or highly trained diagnostic Nurse Practitioners, an increase of 5.5%. Kings Fund research indicates that improved in-hours GP responsiveness should reduce A&E attendances.

It was agreed that it was important to retain different measures in the access standard, including patient views of access.

3.5.2 Health Improvement More detail was given to support the inclusion of ‘at risk of’ Diabetes target that included the local protocol on identification of at risk of diabetes used within GP practices. The high target of 82% was challenged but supported when the current performance of 77.4% was shared.

3.5.3 Cancer Referral The Cancer referral standard was discussed and members informed that the CCG would be monitoring emergency first presentations and DNA rates for 2 week referrals. The standard was based more on the process of stressing referral requirements and communicating the urgency to attend. The

Bolton Quality Contract Decision Paper 6

incentive would be based on Practices undertaking root cause analysis for DNAs and emergency first presentations, not based on numbers.

3.5.4 Mental Health Members were concerned on targets for screening people with learning disabilities, due to concern that setting an incentive for improving screening could raise issues of informed consent. It was agreed incentive would not be linked achieving screening and would be focused on physical health checks due to the importance of gaining parity of esteem.

3.5.5 Other Opportunities The issue regarding the gap in service relating to unplanned admissions and the option of including a standard in the contract was discussed. It was recognised that several quality standards should have a positive benefit to preventing unplanned admissions. The CCG plans for proactive care are included in the Better Care Fund plans but do not specifically align to a contract for each of 50 Practices.

3.6 Key performance indicators

Of the 19 standards, four standards will be mandated. These are: - phlebotomy, - emergency planning, - membership engagement and - acceptance of clinically agreed transfers of care.

These standards are expected to be delivered, with no incentive for performance.

The key performance indicators for the other standards had been developed using the following method: • Where there was no clear difference between peer group clusters’ ability to achieve the target, a target was set for all Practices (generally based on 75th centile) • Where deprivation or ethnicity clearly created a difference in current performance, peer group averages were used • Continuous improvement would be encouraged by expecting improvement from practices already achieving the target • Not all Practices can be expected to deliver the full stretch in year 1, but patients in Bolton will expect the same service wherever they go. All Practices need to be clear that on-going improvement continues after year 1 to achieve a common high standard, with the potential for new targets to be added.

3.7 Principles for payment – risk sharing

• The principles for payment show the commitment to sharing the risk between the commissioner and practices, recognising the need for

Bolton Quality Contract Decision Paper 7

investment in general practice capacity to deliver improvement in access & quality. • In order to provide some certainty to Practices to support the aimed for objective of employing additional staff, 60% of the contract value total for each Practice will be paid on agreement of a plan to deliver the standards and delivery of the 4 mandatory standards in section 3.6, above. • 40% of the total contract value to each Practice can be earned on achievement of KPIs • It was agreed, in future years, this balance of risk share would be likely to be altered according to performance of practices.

3.8 Principles for payment – payment schedule

The payment schedule will be as follows – quarterly, as per weighted list size: Q1. – 20% (April 2015) Q2. – 20% (July 2015) Q3. – 20% (October 2015) Q4. – 20% of your expected KPI (January 2016) May 2016 – the balance will be paid based on actual achievement of KPIs

3.9 Principles for payment – method for incentive payment

Costing of every standard was undertaken to set an appropriate value for each.

Members discussed options for deciding the incentive payments that included: • applying a weighting to the standards, • grouping standards • if no impact shown through monitoring or failing to deliver in one area this could be performance managed as a breach to the whole contract • only pay if practices deliver the target on 80% of the standards • Gold/Silver/Bronze prize for those practices that do the best or most improved practices on all areas was suggested.

Experience from previous improvements in general practice in Bolton based on incentives were used to decide on the visibility of a payment for each target (KPI) and a sliding scale of payment at 25%, 50%, 75% and 100% rather than an all or nothing payment.

The total Bolton value of the Bolton contract across the KPIs is shown in the table, below

Bolton Quality Contract Decision Paper 8

Available Reason chosen Underlying KPI incentive for STANDARD meeting KPI

Mandatory Standards: Phlebotomy convenience for patients, avoiding hospital visits Phlebotomy & shared care monitoring Emergency Planning importance of continuity of service in the case of an emergency Continuity plan Membership engagement to support truly clinical Attendance at clinical leads and CCG events Engagement commissioning Participate in audits Transfer of Care reliable and consistent offer to patients that is clear whether general practice or hospital is right place for care Accept transfer of care Contract payment on approval of Practice Plan and delivery of these mandatory elements £ 2,880,000.00

Standards where incentive available for meeting KPIs Access Bolton people regularly report difficulty Reduce minor A&E £ 48,000.00 with gettting in hours appointments, Reduce OOH £ 48,000.00 research indicates A&E attends should Patient Survey: Making an appointment £ 48,000.00 reduce Patient Survey: Ease of getting through on phone £ 48,000.00

Best Care Provide evidence based best care to Diabetes £ 19,200.00 people with long term conditions, COPD £ 19,200.00 improving ability to live with their Asthma £ 19,200.00 condition and reducing their risk of Heart Failure £ 19,200.00 hospital admission >20% CVD Risk £ 57,600.00

Bolton Quality Contract Decision Paper 9

Available Reason chosen Underlying KPI incentive for STANDARD meeting KPI Cancer ensure people are aware of potential serious diagnosis on referral, review what Process to reduce DNA £ 4,800.00 GP could have done earlier Process to reduce emergency presentation £ 4,800.00

Carers focus on identofying carers and meeting Carers registers £ 19,200.00 their health needs Health checks £ 19,200.00

End of Life improve quality of care & experience DNACPR Training £ 9,600.00

Exception reporting ensure actual improvement in care Practice Policy £ 19,200.00

Health Improvement identify people with risk of developing Reduce CVD NEL serious long term conditions and improve NHS Health Check £ 153,600.00 their care to improve health and reduce Audit C £ 96,000.00 risk of hospital admission Screening for diabetes £ 38,400.00 Pulse Checks £ 76,800.00

Health Protection Improve vaccination rates for better Flu 65 yrs + £ 9,600.00 health, focusing on the elderly. Evidence Flu <65yrs at risk £ 4,800.00 this reduces admissions Pneumococcal £ 4,800.00

Mental Health identify people with dementia and mental Health checks MH/LD £ 19,200.00 health needs, ensuring they get support Dementia prevalence £ 19,200.00 they need and physical health checks for Annual review dementia £ 19,200.00 parity of esteem Depression prevalence £ 19,200.00

Bolton Quality Contract Decision Paper 10

Available Reason chosen Underlying KPI incentive for STANDARD meeting KPI Patient Experience to specifically focus practices on engaging Patient forum £ 19,200.00 with patients on improvement Patient survey £ 19,200.00

Patient Safety encourage learning from incidents and Incident reporting £ 9,600.00 attendance at training to improve qualtiy Attendance at events £ 9,600.00 and safety of General Practice Mandatory training £ 9,600.00

Prescribing Improve safety and reduce waste Prescribing £ 729,600.00

Referrals Ensure evidence based guidelines are followed to refer to right place. Avoid Reduce Procedures of limited clinical value £ 96,000.00 wasted journeys and appointments, Reduce outpatient follow up £ 48,000.00 prioritising resource. Reduce outpatient 1st appt £ 48,000.00

Screening Improve take‐up of screening through GPs Breast £ 19,200.00 encouraging and reminding patients. Bowel £ 19,200.00 Improved chance of best health outcomes Cervical £ 19,200.00 AAA

ensure services available to all Bolton Sexual Health people in convenient setting Chlamydia £ 9,600.00

Total available as incentive for meeting standards £ 1,920,000.00

Bolton Quality Contract Decision Paper 11

3.10 Performance • All Practices will be required to submit a plan to meet the standards in the format agreed by the co-commissioning committee. • This will include current staffing information as a baseline to identify the increase in capacity gained from this contract. • Co-commissioners will review plans outside of the full Committee but the Committee will be provided with sample plans to gain assurance that the correct processes were in place for reviewing the plans. • Proposed criteria to be used would be shared with members prior to the review of Practice plans commencing. • On monitoring, the Committee would receive quarterly data analysis as part of the on-going performance review process. Quarterly reports would be presented to the CCG Board once approved by the Committee. • Practices would continue to be supported by the primary care team and any disputes would be resolved locally or with support from NHS England. • It was also agreed to include in contract that annual results of individual practices will be required to be published on their website

4. Financial case for £95 per weighted patient

The co-commissioning committee recommended that the Bolton Quality Contract should be clearly presented as an investment to save as well as an investment in improved quality and capacity in General Practice.

Additional investment required by CCG (over and above historic LES contracts) to meet £95 per weighted head of registered patients for all Practices and prevent any Practice from reduced income in year 1: £ 3,403,521.75

Savings –year 1 (if contract KPIs achieved) A&E £28,669 OOH £112,345 Prescribing £2,977,207 NEL –BestCare £241,474 Procedures limited clinical value 429,200

Total savings £3,788,895

Members recommend this is a fair value base for year 1, recognising the CCG Board must decide the eventual investment based on risk that all practice targets may not be met.

Bolton Quality Contract Decision Paper 12

5. Summary of outcomes and benefits of Bolton Quality Contract

5.1 The Bolton Quality Contract has been designed to deliver a step-change improvement in standards over the core GMS/PMS contract. The core aims are to give Bolton people access to consistent GP services which are delivered to an agreed level of quality, and ensure that patients are treated outside of hospital whenever appropriate. This will contribute to the CCG Commissioning Plan and Bolton Health & Wellbeing Strategy.

5.2 Expected outcomes will be:

5.2.1 Improved access to General Practice • All Practices open for all core hours Monday to Friday • More responsive access through investment in capacity in General Practice

5.2.2 Improved health outcomes for the population • Early identification through screening, health checks, etc • Provide optimum care for those already living with long term conditions • Referrals made at the right time, using evidence based pathways

5.2.3 Reduced health inequalities • Focus on supporting carers and people with mental health needs • Equitable Practice funding, with performance indicators which reflect population demographics

5.2.4 Consistent High Quality Care • Standards set for all Bolton Practices • By combining all current Local Enhanced Schemes with new standards into one contract, Practices will be expected to take part and deliver on all areas, removing the option of ‘cherry-picking’ which quality standards are met

5.2.5 Support CCG QIPP Challenge • Reduce demand on secondary care services • Reduce waste in prescribing

5.3 Summary of Benefits to Bolton People

• Get to see a GP when they need to (current target for 5.5% increase in appointments/contacts, an increase of over 61,0000 contacts per year) • Better experience when using General Practice • Better health through getting the best care, early • Improved support for healthcare needs, close to home • Reduce wasted journeys from unnecessary hospital appointments

5.4 Summary of Benefits to Practices

• Investment to increase staffing capacity to meet demand and deliver the standards of responsive access and quality expected of the contract • A guarantee of practice income, for the medium term, at a time when this income is under threat from contract negotiations and reviews by NHS England

Bolton Quality Contract Decision Paper 13

6. Risk Mitigation

Original Risks highlighted to CCG Board and the results of mitigation are provided below:

Risk Impact Mitigation & comments Remaining risk NHS England contract HIGH Confirmation received from LOW reviews in future shift NHSE that Bolton General resources out of Bolton Practice budget allocation will be ring-fenced to Bolton and PMS review savings will be retained in Bolton Public Health LESs not MED Bolton Council Officers support LOW included inclusion of Public Health LESs. Awaiting formal Member sign- off. Practices do not sign LOW Regular Practice engagement LOW up to the new contract being maintained. Expressions of interest from Practices sought in December, show very high support for this Contract Practices sign up to MED History in Bolton of practices MED the standards but do meeting standards set for them not deliver Joint process to review plans and monitor The workforce is not HIGH Practices will be asked to work MED/HIGH available to recruit to on innovative ideas for roles deliver the capacity and attracting staff required CCG to take a role influencing the workforce needs of the future through University and Health Education England Rapid decision will enable Bolton to be in the market early The resources do not HIGH Contract arrangements to MED shift from secondary support the CCG Strategy will care as planned in need to be delivered. order to secure the on- Majority of savings in going funding prescribing in year 1 The Carr Hill formula HIGH This would impact the contract Likelihood for calculating practice payment to each practice. = HIGH weighted list size alters It is expected that this would Impact = MED nationally happen with a notice period in order to give practices time to adjust.

Bolton Quality Contract Decision Paper 14

7. Equality Impact Assessment

The equality impact assessment highlights a mostly beneficial impact of the implementation of the planned Bolton Quality Contract. The benefits include: - Specific focus on protected groups, namely people with Learning Disabilities (and to locally identified priority group, namely carers) - Providing more equitable funding to Practices, through using national weighted formula which takes into account age, ethnicity… - Setting targets for Practices based on peer cluster groups which take into account age, deprivation and ethnicity

The potential negative impact is that peer group clustering and setting targets based on peer averages will lead to differential performance and therefore outcomes for people from protected groups (eg bowel screening rates lower in certain ethnic groups). The mitigation is that the eventual aim of the Bolton Quality Contract will be to increase standards overall and the greatest improvement is sought in the Practices furthest from target.

Patients not registered with a GP will not receive the benefits from this contract. Work continues with voluntary sector partners to encourage Bolton people to register with a GP to gain all of the health benefits that this primary intervention can deliver.

8. Recommendations

Bolton CCG Board Members are recommended to:

8.1 Agree the implementation of the Bolton Quality Contract from 1st April 2015. 8.2 Agree the difference between current core contract and £95 per weighted head of registered population be the contract value to Practices. (total investment required: £3,403,521.75 8.3 Agree the intention is for this investment to be recurrent, based on the expectation that delivery of the standards and KPIS will deliver a 100% return on investment in year 1. 8.4 If the expected benefits are not met in year 1, the Board will agree either exit arrangements or changes to the contract.

Bolton Quality Contract Decision Paper 15

Acronyms AAA Abdominal Aortic Aneurysm APMS Alternative Provider Medical Services BQC Bolton Quality Contract CCG Clinical Commissioning Group COPD Chronic Obstructive Pulmonary Disease CVD Cardiovascular Disease DMARDS Disease modifying anti-rheumatic drugs DNA Did not attend DNACPR Do Not Attempt Cardiopulmonary Resuscitation GMC General Medical Council GMS General Medical Services GP General Practioner HbA1c Haemoglobin A1c (glycated haemoglobin) HF Heart Failure KPIs Key Performance Indicators LD Learning Disabilities LES Local Enhanced Service LMC Local Medical Committee MH Mental Health NEL Non elective NHSE NHS England NP Nurse Practioner OOH Out of Hours PHE Public Health England PLCV Procedures of Limited Clinical Value PMS Personal Medical Services QoF Quality Outcomes Framework

NHS BOLTON CLINICAL COMMISSIONING GROUP Public Board Meeting

AGENDA ITEM NO: ………8………………

Date of Meeting: 23rd January 2015

TITLE OF REPORT: Information Governance Framework

AUTHOR: NWCSU IG Team

PRESENTED BY: Michael Robinson

PURPOSE OF PAPER: The Information Governance Framework (Linking to Strategic Objectives) document aims to capture Bolton Clinical Commissioning Group’s approach to Information Governance and completion of the IG Toolkit.

RECOMMENDATION TO THE Approval and acceptance of CCG Board BOARD: (Please be clear if decision required, or for noting)

COMMITTEES/GROUPS IM&T Operations Board where consulted during PREVIOUSLY CONSULTED: the review and the amendment of section 4 Training and Guidance, to ensure it reflects the approved TNA.

CCG Executive.

VIEW OF THE PATIENTS, CARERS N/A OR THE PUBLIC, AND THE EXTENT OF THEIR INVOLVEMENT:

EQUALITY IMPACT ASSESSMENT Analyses of Effect completed September 2013. (EIA) COMPLETED & OUTCOME OF ASSESSMENT:

Information Governance Management Framework

Policy Number IG010 Target Audience CCG Staff Approving Committee CCG Board Date Approved 27th September 2013 Last Review Date September 2014 Next Review Date September 2015 Policy Author Lead IG Officer (CSU) Version Number V1.1

The CCG is committed to an environment that promotes equality, embraces diversity and respects human rights both within our workforce and in service delivery. This document should be implemented with due regard to this commitment.

This document can only be considered valid when viewed via the CCG’s intranet. If this document is printed into hard copy or saved to another location, you must check that the version number on your copy matches that of the one online.

Approved documents are valid for use after their approval date and remain in force beyond any expiry of their review date until a new version is available.

Version Control Sheet

Version Date Reviewed By Comment 0.1 September 2013 Suzanne Bell Document development 0.1 September 2013 Mike Robinson, Document Review Annette Walker, Grace Birch, Dr Mercer, Diane Sankey 1.0 September 2013 CCG Board Approved 1.1 September 2014 NWCSU Section 4, Training and Guidance updated 2.0 November 2014 IM&T Ops Board

Analysis of Effect By: Date: completed Suzanne Bell 19th September 2013

Issue Date: September Page 2 of 10 Information Governance Management Framework Version No: 1.0 2013

Contents

1.0 Introduction 4 2.0 Senior Roles 4 3.0 Governance Framework 7 4.0 Training & Guidance 7 5.0 Information Governance Incident Management 8 6.0 Key Information Governance Documentation 8 7.0 Reporting Structure 9 8.0 Information Governance Organisational Structure 10

1.0 Introduction

The Information Governance Framework document aims to capture Bolton Clinical Commissioning Group’s (CCG) approach to Information Governance.

Robust Information Governance requires clear and effective management and accountability structures, governance processes, documented policies and procedures, trained staff and adequate resources. The way that the CCG will deliver this is documented within this Information Governance Management Framework. This will be reviewed annually by the IM&T Operations Group and presented to the CCG Executive to support in readiness for Board approval.

The Information Governance Framework must be read in conjunction with the CCG’s Information Governance Policy and associated procedures.

The framework provides a summary / overview of how the CCG is addressing the Information Governance agenda and adapted appropriately to the capacity and capability of the organisation.

2.0 Senior Roles

Accountable Officer The Chief Operational Officer (COO) has overall responsibility for Information Governance within Bolton CCG this is Susan Long. As Accountable Officer, Su is responsible for the management of Information Governance and for ensuring appropriate mechanisms are in place to support service delivery and continuity. Information Governance provides a framework to ensure information is used appropriately and is held securely.

Senior Information Risk Owner (SIRO) The Senior Information Risk Owner (SIRO) is held by a member of the CCG Executive Board. They are responsible for identifying and managing the information risks to the CCG. This includes oversight of the organisation’s information security / governance incident reporting and response arrangements and the Registration Authority business process. For Bolton CCG, the SIRO role will be the responsibility of Annette Walker, Chief Financial Officer.

Caldicott Guardian The Caldicott Guardian is a senior person responsible for protecting the confidentiality of the patient and service user information and enabling appropriate information sharing. For Bolton CCG, this will be Dr Colin Mercer, CCG GP Lead.

CCG Information Governance Lead

Issue Date: November Page 4 of 10 Information Governance Management Framework Version No: 2.0 2014

The Associate Director of Integrated Governance & Policy has been appointed to act as the overall CCG Information Governance lead for Bolton CCG. This role is the responsibility of Michael Robinson.

NWCSU Information Governance Team Responsibilities The NWCSU Information Governance Team will act as the delegated Information Governance lead for CCG’s. Support is provided to Bolton CCG by the following:

Lead IG & Audit Officer - Suzanne Bell Senior IG & Audit Officer - Andrea Hughes

The NWCSU IG Team will be responsible for ensuring all tasks delegated to NWCSU meet the required standards in line with any formal undertaking between the parties.

Key tasks are:

• Developing and maintaining the currency of comprehensive and appropriate documentation that demonstrates commitments to and ownership of IG responsibilities, for example, production of IG Framework document supported by relevant policies and procedures • Ensure that there is top level awareness and support for IG resourcing and implementation of improvements with the CCG clinical executive • Establishing working groups, if necessary, to co-ordinate the activities of staff with IG responsibilities • Ensuring annual assessments and audits of IG are implemented and reported • Ensuring that annual assessment and regular improvement plans / progress reports are prepared for approval by the Chief Finance Officer • Ensuring that the approach to information handling is communicated to all staff and made available to the public • Ensuring that appropriate training is made available to staff and completed • Liaising with other committees, working groups and programme boards in order to promote and integrate IG standards • Monitoring information handling activities to ensure compliance with law and guidance • Providing a focal point for the resolution and / or discussion of Information Governance issues

All staff

Issue Date: November Page 5 of 10 Information Governance Management Framework Version No: 2.0 2014

All staff, whether permanent, temporary, contracted or contractors are responsible for ensuring that they are aware of their responsibilities in respect to Information Governance.

Issue Date: November Page 6 of 10 Information Governance Management Framework Version No: 2.0 2014

3.0 Governance Framework

Responsibility and accountability for Information Governance is cascaded through the CCG and is co-ordinated by the CCG IG Lead & NWCSU IG Officers via the following:

• IM&T Operations Group • Staff contracts of employment • Information Sharing Agreement / Data Processor Agreement • IG Questions for tender processes • Privacy Impact Assessment Proforma • Information Asset Ownership – documented within the Information Asset Register • IG Training (via the IG Training Tool) • IG Training Needs Analysis • IG Updates in CCG Staff bulletins • IG Policies and Procedures

4.0 Training & Guidance

Staff receive clear guidelines on expected working practices and the consequences of failing to follow policies and procedures via the methods as outlined above in the Governance Framework section.

Information Governance training is outlined in the Training Needs Analysis.

All staff are mandated to undertake Information Governance Training either Face to Face provided by Dilys Jones Associates or using the IGTT. Information Governance training is required to be undertaken on an annual basis.

Staff will be informed via the Information Governance Training Needs Analysis and Communications as to what training they need to complete.

All agency / temporary staff must have evidence of adequate Information Governance training and / or undertake the mandatory IG training programme via the IG Training Tool. This must be evidenced by managers.

NWCSU Information Governance Staff are officially trained in Data Protection and Freedom of Information (ISEB qualification).

Training and advice is provided to staff on request.

Issue Date: November Page 7 of 10 Information Governance Management Framework Version No: 2.0 2014

5.0 Information Governance Incident Management

All IG incidents are reported via the CCG IG Incident Reporting Procedure (IG007) and escalated via StEIS when required. Staff must report any IG incident to [email protected] or via the CCG’s incident reporting system available on the intranet http://sg01/safeguard/. The IG Incident Reporting Procedure outlines the extra reporting requirements, guidance on the assessment of IG incidents and is available on the CCG Intranet.

NWCSU IG Officers are consulted regarding all IG incidents and score the incident using the guidance stated in the IG Toolkit Incident Reporting Tool.

Any Serious Incident Requiring Investigation (SIRI) scored at a level 2 will be reported on the IG Toolkit Reporting Tool and automatically reported to the HSCIC, DoH and ICO. This will be completed by the NWCSU IG Officer following consultation with the CCG Chief Officer, SIRO and Caldicott Guardian.

The CCG adheres to the Checklist for Reporting, Managing and Investigating Information Governance Serious Untoward Incidents document (DoH, June 2013).

6.0 Key Information Governance Documentation

• IG001 Information Governance Policy • IG002 Confidentiality and Data Protection Policy • IG003 Corporate Information Security Policy • IG004 Acceptable Use Policy (IT, Email and Internet) • IG005 Records Management Policy • IG006 Information Risk Policy • IG007 Information Governance Incident Reporting Procedure • IG008 IG Staff Handbook • IG009 Confidentiality Audit Procedure • IG010 Information Governance Management Framework • IG011 Privacy Impact Assessment Procedure & Template • IG012 Secure Transfer of Information Procedures • IG013 Subject Access Procedures • IG014 Remote Working Procedure • IG Training Needs Analysis

Issue Date: November Page 8 of 10 Information Governance Management Framework Version No: 2.0 2014

7.0 Reporting Structure

The CCG’s IM&T Operational Group which reports to the CCG Executive Team, controls the implementation and compliance of Information Governance principles. The responsibilities of the group include, but are not limited to:

• Recommending for approval and adoption all related polices, protocols, strategies and procedures within the Information Governance arena, having due regard to illegal and NHS requirements. • Recommending for approval the annual submission of compliance with the requirements in the NHS IG Toolkit and related action plans. • To co-ordinate and monitor the Information Governance Policy across the organisation. • Make recommendations on the necessary resourcing to support requirements. • To address all issues surrounding information management and information security issues that may affect the CCG. • To identify and approve all necessary staff information and training as outlined in the NHS IG Toolkit. • Ensure that risks are included on the corporate risk register.

The CCG will monitor and co-ordinate with service suppliers the implementation and on-going management of the Information Governance framework and IG Toolkit requirements via the IM&T Operational Group.

Bolton CCG Board

Bolton CCG Executive Board

IM&T Operations Group

Issue Date: November Page 9 of 10 Information Governance Management Framework Version No: 2.0 2014

8.0 Information Governance Organisational Structure

Chief Operating Officer

SIRO Caldicott Guardian

Associate Director Integrated Governance & Policy

NWCSU Lead IG & Audit Officer

NWCSU Senior IG & Audit Officer

Issue Date: November Page 10 of Information Governance Management Framework Version No: 2.0 2014 10

NHS BOLTON CLINICAL COMMISSIONING GROUP Public Board Meeting

AGENDA ITEM NO: ……9…………………

Date of Meeting: ………23rd January 2015……………………

TITLE OF REPORT: Annual Equality Data Publication

AUTHOR: Rosie Kingham and Michael Robinson

PRESENTED BY: Michael Robinson

PURPOSE OF PAPER: The paper which is required to be published on (Linking to Strategic Objectives) the CCG website, demonstrates the CCG’s commitment to promoting equality and reducing health inequalities in Bolton, and sets out the way the CCG fulfils our responsibilities arising from the Equality Act 2010.

RECOMMENDATION TO THE The CCG Board is asked to note the publication, BOARD: and approve accordingly for publication on the (Please be clear if decision CCG website by the 31st January. required, or for noting)

COMMITTEES/GROUPS CCG Executive PREVIOUSLY CONSULTED: EDHR Steering Group

VIEW OF THE PATIENTS, CARERS N/A OR THE PUBLIC, AND THE EXTENT OF THEIR INVOLVEMENT:

EQUALITY IMPACT ASSESSMENT N/A (EIA) COMPLETED & OUTCOME OF ASSESSMENT:

Annual Equality Data Publication January 2015

Version Date Comments 1 9.12.2014 EDHR Steering Group 2 14.1.2015 Executive Committee 3 23.1.2015 CCG Board

Contents

Item Page 1 Executive Summary 3 2 Background 3 3 Demographics and health Challenges 4 4 Legal Obligations 5 5 Workforce report 6 6 Equality Objectives 6 7 Monitoring Provider Organisations 7 8 Patient Engagement and Experience 8 9 Making Decisions 9 10 Governance Structures 10 11 Main Priorities 10 12 Equality Delivery System 10 13 Joint Commissioning 11 14 Achievements 11 15 Plans 12 16 Recommendations 12

1. Executive Summary

This is Bolton Clinical Commissioning Group’s (CCG) second Annual Equality Data Publication. It shows our commitment to promoting equality and reducing health inequalities, and sets out the way we fulfill our responsibilities arising from the Equality Act 2010. This Act requires public bodies to publish appropriate information showing compliance with the Equality Duty on or before 31st January each year.

This information includes overviews of our role and aims, and of Bolton’s diverse population and health challenges. It sets out our legal responsibilities in demonstrating ‘due regard’ to the Public Sector Equality Duty’s three aims and will provide evidence for meeting the specific equality duty. It will set out the way in which we strive to commission for inclusion. It shows our four Equality Objectives and explains how we monitor the equality performance of our providers.

We need to be assured that the organisations providing the services we commission can effectively collect and analyse data to improve service provision and achieve better health outcomes for vulnerable groups in Bolton. This report is best read in conjunction with the equivalent reports published by our providers, which also must be published by 31st January.

The report gives examples of work we have undertaken to take account of the needs of our vulnerable communities, looks at our plans to improve the way we commission services and identifies future areas for development. It also shows the equality progress we have made since our first Publication in 2014.

The report will also show any significant gaps we have identified. We aim to use our equality data for service improvements, and to deliver the equality objectives set out in our Equality and Diversity Strategy.

This publication reflects our open and transparent approach to inclusion and to local vulnerable protected groups, and will be available in other formats on request.

2. Background

NHS Bolton CCG buys, or commissions, health services on behalf of the Bolton GP registered population. We are responsible for making sure that local people have safe, high quality health services delivered within an allocated budget, that meet the different needs of our diverse communities.

Bolton’s vision and aims: We have four main objectives which underpin all our work: • Improve health outcomes • Shift resources from hospital to community and primary care services • Improve the quality of care and patients' experience of care • Ensure best value of our budget

Each one of the 50 GP practices in Bolton is a CCG member and all work together to meet these aims and represent the needs of our 298,000 registered population.

We commission: • planned hospital care • rehabilitative care • urgent and emergency care (including out-of-hours) • community health services • mental health and learning disability services

We are also responsible for improving the quality of the services offered by our member GP practices.

We do not routinely commission primary care services (for example GPs, dentists, pharmacies) or certain specialist services (for example cancer services from the Christie) as these are commissioned by NHS England. However, we have commissioned a number of primary care initiatives to improve health outcomes for particular communities and there are a number of plans developing that will involve co-commissioning with NHS England from April 2015.

3. Demographics and Health challenges

Commissioning health services presents particular challenges. Bolton is a very diverse borough, with a rich and exciting multicultural heritage. It has areas of high deprivation where health outcomes are relatively poor, and areas of affluence where health outcomes are generally relatively good. Certain vulnerable groups within the borough have poorer health outcomes than the general population, or experience particular barriers to service access.

Life expectancy (from National Bolton Bolton 2012 JSNA) in years Average Bolton average Best Worst Gap Men 78.6 76.5 81.7 69.2 12.5 Women 82.6 80.6 85.2 74.8 10.4 . • From the Census 2011, the percentage of Bolton residents with a long-term health problem or disability was 19.8% (54,913 people); higher than the national average of 17.6% but lower than the North West average of 20.3%. Halliwell ward has 24.8% residents with a limiting long-term health problem or disability compared with Bromley Cross at 15.4%. • Bolton has a higher rate of infant mortality than the regional and national averages, with approximately 22 infant deaths per year in Bolton. This rate is higher in the most deprived fifth of Bolton’s population. • Bolton has a greater proportion of low birth weight births of less than 2,500grammes (around 8.0%) than the average for both England and the North West region. • Bolton’s smoking in pregnancy rate (2011/12) is 18.3% compared to just 13.20% nationally and 17% across the North West.

More information can be found here: Bolton JSNA Bolton Health Profile

4. Legal obligations

We are committed to making sure the services we commission offer fair access for all our registered populations, and that they reduce the barriers, disadvantages and poorer health outcomes experienced by particular vulnerable groups.

Part of this commitment includes meeting the requirements of the Equalities Act (2010), the UK’s discrimination law which replaced previous laws with a single Act. This legally protects people from discrimination and unfair treatment in the workplace, in education, when accessing healthcare services and in wider society. Like a ll public bodies, we must also meet the requirements of the Public Sector Equality Duty (PSED) to: • Eliminate unlawful discrimination, harassment, or victimisation • Advance equality of opportunity between people who share a protected characteristic and people who do not share it • Foster good relations between people who share a protected characteristic and people who do not share it.

Protected characteristics in the context of the Public Sector Equality Duty are defined as: • Age • Religion or Belief • Gender • Sexual Orientation • Disability • Pregnancy, maternity and • Gender Reassignment breastfeeding mothers (Transgender) • Marriage and civil partnership • Race

We also considers ‘carers’ as a protected characteristic when making commissioning decisions.

For more information see the Equality and Diversity page on our website.

4.1 What this means for health care commissioning

We aim to commission services that give all our vulnerable groups the same oppo rtunities to access healthcare and experience the same health outcomes as the general population. We therefore pay due regard to: • Reducing inequalities in health outcomes and experience between patients. • Reducing any barriers or inequalities faced by more vulnerable protected community groups in accessing healthcare • Minimising disadvantages suffered by people due to their protected characteristics. • Raising awareness of our health services and their benefits among communities who are traditionally less likely to use health services. • Engaging and involving patients and their carers in making decisions about how their health care is provided and about different treatments or hospitals.

“Due regard” means that we think about issues of equality and discrimination before making any policy or key decision that may impact on local protected groups. We will 5

find out what the barriers for protected groups might be in advance (as far as possible) and put arrangements in place to reduce them. One way of doing this is by Equality Analysis (see Section 9 below).

4.2 Meeting our statutory Human Rights responsibilities

We will work with members of the public, patients, carers and partner organisations to build a culture in which we treat everyone with fairness, respect, equality and dignity, and respect their autonomy (the FREDA principles).

We will ensure that our HR policies are fair and transparent. We regularly review Complaints/Patient Advice and Liaison Service (PALS) issues, patient stories and clinical incidents to check that no breaches of Human Rights have occurred; we also scrutinise them for discrimination by protected characteristic (including violent discrimination or hate crime). We have procedures in place to record and report discrimination through our quality governance structures. This will help to ensure that we act compatibly with the Human Rights Act (1998) in everything we do.

5. Workforce report

As part of the PSED, public service employers may have to monitor recruitment, promotion, training, pay, grievances and disciplinary action by the protected characteristics of their staff. Some larger organisations use this equality information to check if any equality-related issues are a cause for concern.

We are not required to publish workforce data as we have fewer than 150 staff – however, an annual workforce report is received and reviewed by our Governing Body. We will ensure that our recruitment, selection and training policies and practice are fair and equitable, and that our workforce is protected from any discrimination linked to the protected characteristics.

6. Our Equality Objectives

We are keen to involve local people in the development and monitoring of our Equality Objectives. This transparent approach will help us commission the right health care services, have well trained staff to deliver them, ensure our providers meet their equality requirements and promote patient’s rights.

We developed our equality objectives for 2013-2017 using the views, observations and comments of patients, carers and members of the public via our processes of engagement and outreach.

The objectives link to our strategic aims and key priorities, the Equality Delivery System goals, the JSNA priorities and the NHS Outcomes Framework.

6.1 Bolton CCG’s Equality Objectives for the next 4 years are: • Engage with local vulnerable groups to identify barriers to accessing services and to ensure their voices are heard in commissioning decisions

• Ensure meaningful equality information is collected, collated and analysed • Ensure that the Board understands its EDHR responsibilities and fulfils them • Commission a transformed health service that brings care into community settings and pays due regard to the needs of vulnerable groups as identified via engagement, service access and other data.

For more information follow Equality Objectives.

7. Monitoring Provider Organisations

We commission service providers that meet NHS standards. These can be NHS hospitals, social enterprises, charities, or private sector providers. We must be assured of the quality of services they provide, taking into account National Institute for Health and Care Excellence (NICE) guidelines, the Care Quality Commission's (CQC) data about service providers and their compliance with the Public Sector Equality Duty.

Our largest contracts are with the following provider organisations:- • Bolton Foundation Trust • Greater Manchester West Mental Health Trust • BMI Beaumont We regularly monitor their equality performance, patient experience and service access.

With the support of the North West Commissioning Support Unit’s (NWCSU) Equa lity, Diversity and Human Rights team, we assure the quality of provider services from an Equality, Diversity and Human Rights point of view by: • Ensuring that provider organisations meet the requirements we have specified in their contracts. The NWCSU has developed a revised contract schedule for proposed use across Greater Manchester. This will provide even richer information on which to base decisions, better outcomes for vulnerable groups and a consistent approach to equality monitoring. • Scrutinising the Equality and Diversity information on providers’ websites to ensure they show how they meet their legal Equality obligations. • Working with provider organisations to improve their understanding of Equality, Diversity and Human Rights.

Individual providers will publish Annual Equality Data Publications to show how they are meeting the requirements of the Public Sector Equality Duty. In some cases, the proportion of particular protected characteristic using services can be compared to the proportion of people with a disability in the general Bolton population. We can then identify areas, or communities, where people do not use services or overuse them, and to commission services to respond to this.

Below is a diagram showing provider compliance from our main providers:

NHS or other providers Equality Published Equality Undertaken EDS Objectives information in 2014 grading around agreed and 2013-14 published performance Bolton Foundation Trust Yes Yes External grading planned for 2015 Greater Manchester West Yes Yes External grading Mental Health Trust planned for early 2015 BMI Beaumont No Will have information Planned for 2015 available in 2015

More information about equality, diversity and human rights in these providers, and to view their Annual Equality Data Publications, follow the links below to the Equality and Diversity pages of their websites.

Bolton Foundation Trust Greater Manchester West Mental Health Trust BMI Beaumont

8. Patient Experience and Engagement

8.1 Engagement with local protected characteristic groups

We are accountable to local people for the way we allocate our resources. We engage our stakeholders on how decisions are made, about their choices and about what services might be commissioned.

Bolto n CCG has therefore encouraged staff at all levels to engage with and seek the views of local protected characteristic groups. Examples include: • The Communications and Engagement team sought views from 8 protected characteristics around proposed mental health service changes. • Improving Access to Psychological Therapy (IAPT) focus groups were held with Carers and BME groups. We engaged people via online and paper surveys, community networks and a meeting where people from all 9 protected groups were represented. • Detailed work with members of the deaf community, resulting in GP practice staff being able to correctly access British Sign Language or other support for deaf patients. • We commission Bolton Community and Voluntary Services to run a network for local protected characteristic groups, the Equality Target Action Group (ETAG). Feedback from the ETAG is a standing item on the agenda of the Equality, Diversity and Human Rights (EDHR) steering group, thereby ensuring that issues raised by local protected characteristic groups feed through our governance structures. • Work is continuing with ETAG to increase the range of protected characteristic groups on its circulation and to align ETAG meetings with the timings of CCG key commissioning decisions.

The feedback from this and other engagement with protected characteristic groups will help to inform our commissioning decisions. . For more information contact Bolton CCG’s Engagement Officer, Hannah Carrington, on [email protected]

8.2 P atient Experience All providers are required, via their contracts, to disaggregate their patient experience information, such as surveys and complaints, to establish whether: • Their complaints process is accessible to all sections of the community • One group has a worse experience than another

The information depends on the willingness of patients to disclose protected characteristics. It is expected that the new EDHR contract schedule will enable us and our providers to gather richer patient experience information.

Our complaints process also disaggregates by protected characteristic as detailed in our annual report. Information is monitored quarterly, and governed via the CCGs Quality and Safety Committee.

9. Making decisions

The CCG Chair and Governing Body are committed to embedding Equality, Diversity and Human Rights in all we do, ensuring that the decisions we take make a positive difference to the lives of our patients.

We do not simply assume that our decisions will be equally beneficial for everyone. We test our assumptions before making decisions and assess the effects of a decision on particular populations in order to increase the likelihood that a decision will promote equality of access and equity of outcomes.

We have adopted the Equality Analysis toolkit used by NWCSU to analyse the possible effect of our decisions upon equality, diversity and human rights. We progress the issues raised through governance structures via the EDHR Steering Group and the Quality and Safety Committee. This gives Quality Impact Assessments and Equality Analysis equal prominence and contributes to the evidence on which decisions are based.

Any paper going to the Governing Body for consideration must include an equality analysis and human rights risk assessment. We carry these analyses on new projects to ensure we pay ‘due regard’ to the three aims of the PSED and Human Right s Act.

The following are examples of Equality Analysis undertaken in 2014: • Mental Health IAPT • Sign IAPT • Care home support project • Primary care innovation fund pilot projects including: ¾ 5 Access pilots 9

¾ 4 Redesign pilots ¾ 5 pilots to move services to community settings from secondary care

10. Governance structures

Our Governing Body needs to be assured that the decisions it makes will not imp act adversely on one group more th an another. The processes by which it does this are shown below and for more information see our Equality Strategy:

Governance Outcome CCG process Assurance EDHR Action Plan Shows how we are meeting our Equality Executive Objectives Committee Equality Analysis Service changes, service specifications and EDHR steering scrutiny of key contracts take into account the needs of different group changes groups; decisions are assessed for potential impacts on people from protected groups Equality risk Staff use the corporate risk management Executive management procedure to identify and manage EDHR risks Committee from earliest stages to reach agreed solutions EDS2 See section 12. EDHR steering group Discrimination and CCG and provider partners can recognise and Governing hate c rime reporting report any potential discrimination incidents. Body Bi-mon thly report on Accountable evidence of progress as a “you said, EDHR steering EDHR outcomes we did” approach to inclusion for marginalised or group achieved vulnerable communities

11. Main Priorities

Our main priorities are shown in our 5 Year Strategic Plan 2014 to 2019. It is built on our current and future understanding of local health needs and reflects the partner role NHS Bolton CCG has in the overall health and wellbeing economy within Bolton. It has a focus on whole patient pathways from prevention to end of life care.

Our nine priority areas and the areas of work to support them can be seen here and the 5 Year Strategic Plan 2014 to 2019 can be seen here

12. Equality Delivery System (EDS2)

We adopted EDS2 as a performance framework to help us demonstrate how we are meeting the Equality Duty. EDS2 is intended to drive up equality performance and embed equality into mainstream NHS business.

Our EDHR Steering Group agreed that the 2014 grading would focus on Goal 4 Inclusive Leadership as this is fundamental to inclusive commissioning. In November 2014, we held a public grading highlighting the inclusive leadership gains made in the last 12 months and plans for future improvement. 10

. This EDS2 2014 Dashboard shows the progress NHS Bolton CCG is making:

Goal 4: Inclusive Leadership 2014 Grading Outcome 4.1: Boards and senior leaders routinely demonstrate their commitment to promoting equality within and beyond their Achieving organisations. Outcome 4.2: Papers that come before the Board and other major Committees identify equality-related impacts including Achieving risks, and say how these risks are to be managed. Outcome 4.3: Middle managers and other line managers support their staff to work in culturally competent ways within a work Achieving environment free from discrimination.

13. Joint commissioning

Bolton CCG is an active member of Bolton Health and Wellbeing Board. This forum brings together key leaders from the health and care system to work together to improve the health and wellbeing of Bolton people and to reduce health inequalities.

The Health and Wellbeing Board in Bolton: • Ensures stronger democratic legitimacy and involvement across health systems • Provides leadership across health and social care • Strengthens working relationships between health and social care • Encourages the development of more integrated commissioning of services • Works collaboratively to achieve the aims of its Health and Wellbeing Strategy

Bolton CCG and the other members of the HWBB take a partnership approach to assessing health needs across Bolton and develop joint aims accordingly. The HWBB aims to work together to commission services that improve the health outcomes of all Bolton residents, especially for vulnerable or disadvantaged groups who currently experience poorer health outcomes or experiences of care.

Some of our joint projects include working to integrate services currently provided by a variety of organisations. We want to provide a responsive, coordinated and individual service to improve outcomes for adults who have a combination of issues including mental health and deprivation needs and for those who do not currently or consistently engage with services.

For more information see the Bolton Health and Well-being Strategy 2013-16.

14. Achievements

We have been working throughout the year to increase the inclusivity of the services we commission. Below are some of the actions we have taken:

• This year we sponsored the British Transplant Games to highlight the importance of keeping active and registering as an organ donor. • Undertaken public engagement and voluntary sector engagement work to encourage patients to register with a GP; this addresses inequality in that a greater proportion of people from more disadvantaged groups are not registered with a GP and unregistered patients are disadvantaged because of lack of access to primary care • Developing and extending the “Take Home and Tuck Up” service to facilitate discharge from A&E for elderly patients back to their home or care homes throughout the night. This service was extended to October, pending a final decision by the Board • Investing in a new memory assessment centre for Bolton, in response to engagement with local groups • Working with patients and carers to improve support and information given to cancer patients and carers and help prevent some cancers, in response to engagement with local groups • Linked together our practices into clusters, to enable GP practices to deliver innovative solutions to reduce health inequalities and address specific local health needs (for example a pilot project to increase access to GPs among communities whose English is poor) • Developed a detailed EDHR overarching Action Plan 2014-17 which has a focus on health inequalities for particular protected groups and is linked to commissioning intentions, NHS Outcomes Framework, and the JSNA • Delivered EDHR training to clinical and non-clinical staff in addition to the mandatory training

15. Plans

We intend to take the following actions in 2015/16 to increase the inclusivity of the services we commission. • Work with NWCSU to encourage staff to disclose protected characteristics to give us a better understanding of its staff and their possible needs • Deliver further staff training and awareness-raising briefings to explain and our staff’s job role responsibilities with regards equality and human rights legal compliance. This guidance can then be cascaded as appropriate • The results of a recent staff EDHR survey will inform future work to ensure Bolton CCG is as inclusive an employer as possible. • Deliver a programme of work for senior staff to engage with local protected characteristic groups and individuals to gain greater insight and understanding of their healthcare issues and barriers to access.

16. Recommendations

We need to improve the collection of information on protected characteristics to better understand the views of different groups about the services they receive. The new EDHR contract schedule will help to drive this but to continue improving our EDRH performance, we will: • Ask service providers to show patient experience by protected characteristics to ensure no community group has a worse experience than others 12

• Ensure that Equality Leads hold regular face to face visits with provider Equality Leads to support compliance requirements throughout the year • Ensure that providers develop an EDHR compliance action plan to achieve and maintain full compliance within a reasonable timescale • Raise any variances at the EDHR steering group to resolve any issues and provide assurance of the required progress • Provide evidence of Board Papers routinely discussing protected groups and giving 'due regard' to their needs • Demonstrate that staff (including governing body members) have engaged with local groups to learn more about a particular community and understand their healthcare needs and how best to promote provision of fair access for that community • A dopt the additional actions in the EDS2 as described above • The EDHR team and Engagement team will work together to explore ways of not only providing an ‘accessible to all website’, but also inclusive Board papers and other CCG documents

NHS BOLTON CLINICAL COMMISSIONING GROUP Public Board Meeting

AGENDA ITEM NO: ……..10…………….

Date of Meeting: ………….23rd January 2015……………….

TITLE OF REPORT: Ambulance Turnaround Update

AUTHOR: Jackie Bell, Deputy Head of Commissioning

PRESENTED BY: Jackie Bell, Deputy Head of Commissioning

PURPOSE OF PAPER: To update the Board on progress to improve (Linking to Strategic Objectives) ambulance turnaround times at Bolton FT.

RECOMMENDATION TO THE The Board is asked to note the update. BOARD: (Please be clear if decision required, or for noting)

COMMITTEES/GROUPS Systems Resillience Group PREVIOUSLY CONSULTED:

VIEW OF THE PATIENTS, CARERS N/A OR THE PUBLIC, AND THE EXTENT OF THEIR INVOLVEMENT:

EQUALITY IMPACT ASSESSMENT N/A (EIA) COMPLETED & OUTCOME OF ASSESSMENT:

Ambulance Handover Update

1 Executive Summary

Bolton CCG Board has noted an increasing concern about the ongoing problem of patient handovers from ambulances at Bolton Foundation Trust. The unacceptably long handover times at certain times of the day are sufficient to warrant focused attention. A review of best practice around the UK has been undertaken and a joint Action Plan has been developed.

2 Introduction and Background

2.1 Turnaround is the time from ambulance arrival at hospital to the time the ambulance crew keys in clear; for the next job. It is broken down into two parts; crew arrival at A&E to patient handover to hospital staff, and time from completion of patient handover to ambulance clear. The times are recorded in the NWAS CAD system and are informed in the A&E department through inputs into the HAZ Screens. This involves both the ambulance crews and the A&E staff inputting to confirm handover (dual pin procedure).

2.2 Patient handover delays are not solely the responsibility of ambulance services and emergency departments. Delays are often associated with compromised ‘down- stream’ flow in acute hospitals and whole-system issues in managing demand and expediting discharge. Reducing delays requires whole system working as well as slick processes in emergency departments and ambulance services. Other papers in this series provide guidance on these wider issues, while this paper focuses more narrowly on tactical approaches to avoid delays.

2.3 From the National Best Practice listed in the appendix representatives from the CCG, NWAS and Bolton FT have identified changes to be made at Bolton A&E and in practice with the NWAS crews; these include,

• Development of a falls referral pathway to community providers • Alternative to transport service doing acute home visits on behalf of GPs to avoid admission and admission surge; • High-volume service user planning in conjunction with GPs and acute Trusts • Hospital Ambulance Liaison Officer (HALO) in A&E during surge periods • Review of escalation plans in A&E • Commissioning a Care Home community service to support care planning for residents

All the actions directly being undertaken by A&E and NWAS are in the action plan, however as evidenced from the list above other actions are being taken to support the issue.

3 Local Picture

3.1 There is increasing concern about the ongoing problem of patient handovers from ambulances at Bolton Foundation Trust. The unacceptably long handover times at certain times of the day are sufficient to warrant focused attention. There is no doubt that the delays have an adverse impact on patients’ experience of the service and may increase risk to patient safety. We must therefore take a “zero tolerance” approach to handover delays, and recognise that there is a joint responsibility on ambulance and hospital trusts to ensure such delays are minimised, and a much wider economy responsibility to optimise services to promote patient flow and admission avoidance where appropriate.

Locally in Bolton, commissioners have taken a keen interest in failure to deliver prompt handovers and expect that handovers occur within 15 minutes of ambulances’ arrival at the A&E department. There is a “Duty of Cooperation” to ensure effective working at the interface of health care organisations, which is also reflected in the Terms of Authorisation with which Foundation Trusts and aspirant Foundation Trusts are required to comply. Where local handover delays continue to be problematic, both Monitor and the Care Quality Commission have the responsibility to assure compliance with this duty and they can take appropriate action where organisations fail to do so.

For some time now there has been an increasing problem with ambulance turnaround times at Bolton FT A&E department. The Bolton CCG Board has requested a review of the situation and the development of a detailed action plan. Patient handover delays are not solely the responsibility of ambulance services and emergency departments. Delays are often associated with compromised ‘down- stream’ flow in acute hospitals and whole-system issues in managing demand and expediting discharge. Reducing delays requires whole system working as well as slick processes in emergency departments and ambulance services.

NWAS average overall time to clear time ‐ Bolton NHS FT Turnaround time at Bolton FT Gtr Manchester average

43:12 (mm:SS)

35:31 36:00 34:34 33:02 time

31:43 31:06 30:51 30:30 30:30 30:25 29:59 29:32 28:37 28:48 Average

21:36

14:24

7:12 29:06 29:19 28:22 28:36 28:39 28:38 28:57 28:39 29:10 29:44 30:10 0:00 14 14 14 14 14 14 14 14 14 14 14 14 ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ Jul Jan Jun Oct Apr Feb Sep Dec Aug Nov Mar May Month

Graph 1: Ambulance Turnaround Times by Month 2014

Graph 2: Ambulance Handovers over 30 mins and over 60 mins by Month

4 Action Plan

This action plan concentrates on improvements within the A& E department, ambulance service and support from the CCG; however work needs to be consider across the whole system from Primary Care to Community Services as well as patient flow through the Foundation Trust with focus on discharge procedures and processes. NEAS, BFT and the CCG have jointly developed the plan and are signed up to its delivery.

Action Description Organisation Responsible Timescale Status Lead SHORT TERM Permanent HAS screen BFT Richard By end to be installed near Brownhill January A&E Co-ordinator to 2015 show ambulances enroute to A&E Staff education re: HAS BFT Richard Immediately Completed screens, compliance Brownhill and dual PIN Staff education re: HAS NWAS Stuart Immediately Completed screens, compliance Marshall and dual PIN

Use notice boards in BFT Richard December Completed A&E to promote HAS Brownhill 19th 2014 screen compliance Request regular CCG Jackie Bell 25th compliance reports January from ROCC broken 2015 down into A&E time and NWAS clear time Encourage NWAS staff NWAS Stuart December Completed to place patient in chair Marshall 19th 2014 and take to minors where appropriate – PRF to Triage Nurse (non-rapid handover patients) Request data from GM CCG Jackie Bell By end Completed Utilisation Team of December ambulance arrivals by 2014 DoW and ToD – target HALO support to A&E at most challenging times Review CCG Jackie Bell By end Completed recommendations December made by Peter Bradley 2014 (London Ambulance Service) following Turnaround Review London

MEDIUM TERM Review of GPAU and BFT Richard March 2015 CDU utilisation: Brownhill Ambulatory Care Develop and implement CCG Jackie Bell End March “Frequent Caller” 2015 project with economy stakeholders Drive forward GM CCG Barry Silvert End March agreement on NWAS & Jackie 2015 deflection Bell Emergency BFT/NWAS/CCG Richard End March departments and Brownhill / 15 ambulance services Phil undertake joint Howcroft / observational audit to Jackie Bell look at patient handover processes. Review A&E Escalation BFT Richard End March Policy for effectiveness. Brownhill 15

Escalation policies should include trigger points in advance of 30 minute waits to deal with issues arising in advance of patients waiting.

Executive “Champions” BFT/CCG Richard End March should be identified in Brownhill / 15 BFT and CCG Jackie Bell LONG TERM Create “Observation BFT Richard July 2015 Area” for patients Brownhill confirmed as admissions but no bed identified

5 Conclusion

There is confidence in delivery of the actions outlined above and the move to use nationally recognised best practice by NWAS and the A&E department within BFT, however as outlined previously overcoming this issue is reliant on whole system changes across the health economy from Primary Care to Secondary and Community Care. Underlying the whole problem is the size of the A&E department and this being inadequate for the current demand going through the hospital doors, however cannot be quickly remedied. BFT are considering within their estates strategy the A&E issue.

6 Recommendations

6.1 NHS Bolton Clinical Commissioning Group Governing Body Board is asked to note the contents of the report.

Name of person presenting the paper: Jackie Bell Title: Deputy Head of Commissioning Date: 16/01/15

7 Appendix

National Best Practice for Ambulance Handovers

Ambulance services should aim to reduce conveyance rates to type 1 emergency departments (through ‘hear and treat’, ‘see and treat’ or alternative pathways). Schemes that have been successful in reducing conveyance rates include: • Alternative care pathways to take patients directly to Urgent Care Centre/Walk-in centres; • Falls referral pathway to community providers; • Increasing the scope of paramedic practice to provide treatment without the need for conveyance; • Alternative to transport service doing acute home visits on behalf of GPs to avoid admission and admission surge; • High-volume service user planning in conjunction with GPs and acute Trusts; • Direct referral to intermediate care/community rapid response nursing services and direct conveyance to hospice.

For patients who do need to be conveyed, ambulance services can help minimise handover delays by: • Reviewing patients’ conditions and needs en-route and sending details ahead to the receiving emergency department; • Avoiding the use of ambulance trolleys for patients who are able to walk into the department; • Using alternative vehicles to convey patients to the emergency department; • Implementing electronic patient handovers; • Sharing predicted activity levels with acute Trusts on an hourly and daily basis to trigger effective escalation when demand rises.

Local operations managers should develop good working relationships with senior nurses, clinicians and managers in the emergency department and assessment units. They should meet with them on a regular basis to review waits over 30 minutes (‘wait’ being time from arrival to handover between ambulance crew and ED) and agree shared actions to reduce handover delays.

If waits do occur and ambulances are queuing outside an emergency department, the acute trust and commissioners, working in partnership with the ambulance service, must agree the safest way to release crews back into the field. This should be done within the context of an agreed escalation policy. Some hospitals have an agreed area in which to manage waiting patients and specific processes to support this arrangement. It is critical that such queues are managed safely and with appropriate levels of senior staffing. Ambulance Services should work with partner organisations to agree effective escalation procedures and interventions for periods of high demand.

Ambulance Services should have in place a regional capacity management system and undertake local work to understand patient flow across the whole health economy.

Acute Trusts and ambulance Trusts should appoint a clinical lead to oversee the development and implementation of clinical handover protocols for acute departments. These protocols should have a focus on patient safety and the need to minimise delays to assessment/treatment.

If delays do develop for handover, patients should have access to interventions such as pain relief. This should be part of the acute Trust’s escalation procedures. In some organisations, this may be included within an ED ‘full capacity protocol’. The guidelines should make it clear whose responsibility it is to ensure the patients are assessed and pain relief and other first-line treatment given.

Primary care can smooth demand for ambulance conveyance by responding rapidly to requests for urgent home visits and ensuring they are not “batched” at the end of surgeries. This helps reduce mid-afternoon arrival peaks in ED departments and assessment units that causes crowding and increases admission rates. Practical approaches include a dedicated visiting GP carrying out urgent domiciliary visits across a patch, or staggering clinic start times, so the practice has at least one GP available to do urgent visits.

Practices should review all emergency department frequent attenders, admissions and discharges to identify local alternatives for frequent attenders or gaps in service. This should include partnership working with ambulance services and acute trusts to identify frequent ambulance users.

CCGs should work with area teams to develop local enhanced schemes to take responsibility for care homes to avoid the need for residents to be conveyed to hospital for an urgent review.

Advanced care planning for patients at high risk has been effective in some areas. Patients are now much more likely to die in their place of choice, rather than in Hospital.

Community Services should have rapid response teams to see patients in their own homes. Best practice is for teams to reach patients within 60 minutes of a request, and never longer than two hours. Rapid response teams need a mix of nurses, therapists and care workers to support patients safely at home for a few days until they recover or a more permanent support package is put in place.

Some community services have multi-disciplinary teams supporting care homes by providing a range of treatments that nursing home staff do not feel confident to provide.

In partnership with local practices, many community teams use advance care plans, especially for older people and those in care settings. All GP out of hours services should have special notes for care plans and all GP practices should ensure that the service has up to date information on who is on an end of life register and what their wishes are.

Emergency departments and assessment units should review their handover model to ensure it is not creating a bottleneck.

Emergency departments and assessment units should consider introducing a rapid assessment and treatment model. This will improve patient safety and flow by reducing assessment time, creating more effective streaming and a proactive ‘pull’ approach to the management of new patients.

Hospitals should review the administrative support to the ambulance handover process and consider whether value could be added and delays reduced by introducing clerical support to help complete non-clinical paperwork.

The infrastructure for patient handover should be critically reviewed:

• Are there dedicated terminals to complete electronic handover in a timely manner? • Are terminals available in all areas that receive ambulances? • Is there a protected terminal that shows all crews en-route and the current status of handover times? • Is the ambulance handover desk/station optimally located? If it is difficult to access and creates practical problems in terms of queuing, can any work be done to improve access and experience of patients/crews queuing?

Leads for acute and emergency medicine should work on improving the relationships between their teams and ambulance crews. This can result in less time taken up with managing and supervising crews and the creation of a shared vision for improvement.

Working in partnership, the emergency department and ambulance service should agree joint codes of behaviour that may include: • Ambulance crews to be greeted immediately on arrival and informed of any delays. • The clinical priority of arriving patients to be checked promptly. • Crews to be kept informed of likely waiting time and actions being taken. • Ambulance crews to promptly escalate any clinical concerns to the nurse in charge. • Ambulance crews to communicate with their operations manager to inform them of delays at the emergency department.

Emergency departments and ambulance services should undertake joint observational audits to look at patient handover processes over a number of peak periods and days. A consistent methodology should be agreed for capturing data and observations and a forum set up where these will be fed back and turned into action.

Consider a joint, process-mapping exercise to look at ambulance delays and identify where there are hold-ups in the system that could be removed. Some Trusts are now using experience-based design to ensure that the patient experience is effectively captured and built into any changes to systems.

Emergency department and ambulance leaders should make a commitment to address crew or hospital issues in a timely manner with appropriate feedback to parties concerned and learning fed back into the handover system improvement programme.

Joint stores should be set up at the hospital so that crews can easily re-stock post- handover if required.

Hospitals should provide additional wheelchairs where required to reduce delays.

The hospital should agree the specific actions that will happen if waits exceed local trigger points (e.g. 30 or 45 minutes):- • who does something different; • who needs to know; • and what is expected of them?

These should be formalised in an escalation policy that should be reviewed for effectiveness at least every six months. Escalation policies should include trigger points in advance of 30 minute waits to deal with issues arising in advance of patients waiting (for example, number of ambulances inbound versus capacity in the department).

Hospitals should review the management of ambulance queues. Can resources be moved in the short term to support handover if the constraint is people rather than assessment space?

There should be a daily review of long waits for handover. This could be done at the same time as a four-hour review meeting. The results of this analysis should be fed into departmental and Trust-wide meetings on emergency care flows with agreed actions.

Ambulance delays should be reported at site-wide bed meetings in order to ensure that there is a whole system response to patient handover delays when required. This also helps to maintain a focus on this issue and ensure it is a trust wide priority.

In the event that queues do occur, emergency departments should have a clear policy to manage waiting ambulances safely. This should deliver a safe waiting environment, have a clear process for escalating clinical concerns and ensure that patient privacy and dignity is considered. It should also include a clear section on communication with patients and relatives.

There should be clear, executive level ownership of, and accountability for, the Trust’s strategy to reduce handover delays. A number of trusts who have achieved success in improving ambulance handover times have reported that this is a critical factor in their success.

All acute Trusts, ambulance Trusts and commissioners should identify an executive lead with responsibility for ensuring timely patient handover. There must be a commitment to working with other organisations in the local community to address the issue.

The executive team should ensure that ambulance handover is reviewed at urgent care improvement meetings and has profile at Trust executive meetings and the Trust Board:

• Performance on ambulance handover should be part of the hospital’s emergency care metrics and reviewed on a weekly basis. • Patient experience relating to ambulance handover should also be captured routinely.

There should be a clear improvement plan with ‘SMART’ objectives to address patient handover delays. This should link into the whole system urgent and emergency care improvement programmes.

The executive team should establish ambulance review meetings to create and sign- off turnaround improvement plans between CCG, ambulance services and acute Trusts

Executive involvement in escalation plans when long waits occur

Patient handover delays are usually symptoms of delays and problems along the wider urgent and emergency pathway and may arise from: • Emergency department overcrowding due to ‘access block’ into the main hospital or activity surges; • Ambulance services diverting crews from discharges and transfers to deal with 999 calls, thus contributing to a lack of available hospital beds; GP referred patients arriving in surges, due to all domiciliary visits, and thus conveyance requests taking place after morning clinics.

It is critical that Acute Trusts look at how they can support their emergency departments by reducing overcrowding and this involves looking at the opportunities for improvement across the whole acute urgent and emergency care process:

• Develop escalation plans jointly. These should be linked to patterns of known demand and peak activity. • Consider implementing regional capacity and information systems. These allow hospitals and ambulances services to look at capacity in an agreed area in real time and includes processes for diverting patients at times of significant pressure

This allows clinicians and managers to make better informed decisions about patient care and use of alternative care pathways.

There should be formalised regional plans to deal with delayed patient handovers (and system pressures that contribute to this) including defined levels of involvement by senior managers and directors and processes for escalation to Clinical Commissioning Groups and area teams of NHS England.

NHS BOLTON CLINICAL COMMISSIONING GROUP Public Board Meeting

AGENDA ITEM NO: ………11………………

Date of Meeting: …23rd January 2015…………

TITLE OF REPORT: CCG Corporate Performance Report

AUTHOR: Fiona Moore – Assistant Chief Officer Grace Birch – AD Outcomes Delivery & Business Support Jackie Murray – Deputy Chief Finance Officer Melissa Laskey – AD Commissioning Mike Robinson – AD Integrated Governance PRESENTED BY: Dr Colin Mercer (other board leads available to answer questions) PURPOSE OF PAPER: The purpose of the attached report is to indicate (Linking to Strategic Objectives) performance against all the key delivery priorities (quality, activity & finance) for the CCG in 2014/15 against which NHS Bolton Clinical Commissioning Group is nationally measured RECOMMENDATION TO THE Members are requested to : BOARD: Note the formal month end position for (Please be clear if decision November 2014/Month 8 (unless stated required, or for noting) otherwise) in respect of performance against key delivery priority targets

COMMITTEES/GROUPS Performance is reported to: PREVIOUSLY CONSULTED: CCG Clinical Executive Contract Performance Group Quality and Safety Committee

VIEW OF THE PATIENTS, CARERS Patients’ views are not specifically sought as OR THE PUBLIC, AND THE EXTENT part of this monthly report, but it is recognised OF THEIR INVOLVEMENT: that many of these targets such as waiting times are a priority for patients. The report does include performance against the ‘Friends and Family Test’ at Bolton FT

CCG Corporate Performance Report

1. Executive Summary

1.1. This report highlights NHS Bolton Clinical Commissioning Group’s performance against all the key delivery priorities (quality, activity & finance) for the month of November 2014 (Month 8).

1.2. Appendix 1 contains the detailed reports for each set of performance indicators the CCG is measured against: - Bolton CCG Objectives - NHS Constitution - Outcome & Quality Framework - Finance & Contract Performance - Quality Premium - Quality Indicators - Workforce/HR Performance

1.3. A Community Services Dashboard is in development.

1.4. Section 2 of this report exception reports against all indicators where the CCG is not achieving its targets.

2. Exception Reporting

2.1. Quality & Safety – Board Lead, Dr Colin Mercer

2.1.1. Friends & Family Test – Bolton FT

Although Bolton FT are meeting their targets for A&E response rates for the FFT (20.2%), their performance against the Net Promoter Score (NPS) for A&E remains below target at 51%. Detail was presented regarding this in the November Board report along with the changes to the FFT reporting. The actions are continuing to be implemented and the CCG are becoming an active member of the FT’s Patient Inclusion and Experience Group.

FFT reached another milestone on 1 January, as it was rolled-out to community and mental health services just a month after going live in GP practices. The CCG will look to modify its reporting to account for these additional sectors in 15/16. The FFT will soon reach the milestone of the 5 millionth piece of feedback being submitted. The FFT Guidance is one of many resources that are available on the FFT web page to help Providers implement and manage FFT. See the following link: www.england.nhs.uk/ourwork/pe/fft/

2.1.2. Mixed Sex Accommodation

There were 2 MSA breeches in October and the FT has presented feedback regarding both. The first patient, on High Dependency Unit (HDU), followed escalation processes and the Chief Operating Officer was notified. Unfortunately a lack of appropriate bed availability restricted one of the moves and the patient breeched. The second patient, also on HDU, needed to be specialised due to the procedure they required. Unfortunately the request for a special should have been undertaken earlier to avoid a delay in step down. The learning from both incidents has been shared with the HDU team.

Bolton FT have acknowledged that while it may be clinically acceptable for HDU to be a mixed environment, once the patient is well enough for step down they must be moved to an appropriate single sex area within a specified time or be counted as a breach.

2.1.3. Complaints – Bolton FT

Complaints responded to within timescale failed in month (82.4% against a target of 95%) but are projected to meet the target in December. A recovery plan had been developed by the Head of Governance in order to ensure that there were no outstanding complaint responses by the end of October. The main factor in this dip in performance is due to the FT not allowing extensions to complaint handling and measuring compliance against the initially agreed response timescale with the patient. Looking forward, there are 28 complaints with December deadlines and it is forecast that performance will return to 95% by the end of December.

Reasons for 6 overdue responses (4 related to A&E, 1 to Ward C3 and 1 to Maternity care): • Information provided not in the form of a draft response • Draft response not adequate and therefore is returned for additional information, revised terminology or clarity of information provided • Further changes requested following proof reading at Divisional and Director level

Further actions have been implemented to improve performance: • Daily review of status of responses by Patient Experience Manager • Discussion and support from Divisions to ensure timely quality responses are provided with escalation to relevant others when necessary • Escalation of unavoidable extensions for approval to Director of Nursing only • Roles reviewed across whole Patient Experience team. Vacancy to evolve into an administrative support role designed to help speed up progress with individual complaints • Review and create a better Complaints monitoring Metric for 2015/16

• In November only one complaint was granted an extension –for family/patient reason or request, no extension was granted for organisational reasons • 60 staff members, managers and clinicians have received training on the ‘Management of Complaints’ in Nov and Dec.

The FTs draft complaints policy has been shared with the CCG for comments and includes an Action and Learning Log to facilitate the roll out of lessons learned. This policy will be taken to the FT’s Clinical Governance & Quality Committee in February.

2.1.4. Never Event

Bolton FT reported a Wrong Site Surgery Never Event in October 2014. The final report has just been received and will be assessed by the CCG’s Serious Incident Review Panel. Lessons learned will be shared with the Quality & Safety Committee and further assurances will be gained from the FT as required.

The numbers of Never Events reported on STEIS by across GM by organisation is shown in the table below:

No. of Never No. of Never No. of Never Events Apr14 to Provider Events 12/13 Events 13/14 date CMFT 5 5 1 Salford Royal 2 2 1 Pennine Acute 2 1 0 The Christie 1 0 0 Bolton FT 3 1 3 Independent Contractor* 1 3 0 WWL 2 2 3 UHSM 0 2 2 Stockport FT 0 2 2 Tameside FT 0 1 1 BMI Beaumont Hospital** 0 1 Total 16 19 14 *In 2013/14 HMR CCG reported 3 Never Events on behalf of independent contractors: 2 Care UK and 1 BMI ** Reported by Bolton CCG

The number and type of Never Events reported across GM between 1 Apr and 1 Dec 2014 are detailed in the chart below:

Bolton CCG has requested, via the GM Quality Surveillance Group, that there is provision of feedback from Never Events that occur and are reported across the country, in order that lessons can be learned. This has been added to the GM risk log and escalated regionally.

2.1.5. Serious Incidents

In October Bolton FT reported one new Grade 3 Pressure Ulcer was reported (StEIS 2014/35237). The incident is currently under investigation and the learning from this event will be presented to the Quality and Safety Committee (process followed as above with the Never Event).

2.1.6. Workforce – Bolton FT

Although Sickness absence has fallen and performance has improved compared to 2012/13 it remains above target. The FT will produce a graph to show this long term trend in improvement of sickness absence. There is significant variation between the divisions; the family division are significantly below the target with a rate of 3.38% while the other two divisions are at 5%.

Sickness absence has increased to 5.06% in October. This period usually sees the beginning of the seasonal increase so this slight increase is not unusual. The FTs challenge is to ensure that sickness absence does not increase to the same levels as last year during the winter months and initiatives are in place to support this.

Mandatory training is continuing an upward trend and is at 86.5%. The new e-learning system, Moodle, is now operational and should contribute to a steadily improving position. This target is being monitored closely as it had failed for 6 consecutive months until October. Release for face to face training of front line staff presents an operational challenge to the FT.

Appraisal rates have met the target threshold for only the second time this year. Divisions are challenged on all the workforce metrics during their respective performance management meetings. Divisions are taking the target seriously and are going through lists of staff that have not had an appraisal to ensure this is addressed. This management focus in certain areas is helping to achieve the target of 80%.

2.1.7. Surgical WHO Checklist Compliance (Elective & Emergency)

Elective theatres demonstrated 99% compliance in October consistent with last month. Team managers have been required to develop action plans to ensure all processes are robust. Emergency theatres also only achieved 99% in October but Maternity theatres remained 100% compliant. All areas will continue to be monitored monthly and share best practice.

2.2. Commissioning – Board Lead, Dr Barry Silvert

2.2.1. Reduce Emergency Admissions

The CCG has set a target of reducing emergency admissions by the end of 2014/15. The year to date number of emergency admissions is 22,912. Compared to the recorded 2013/14 outturn, this represents an increase of 7.6% above plan. However, activity which was previously counted under the Bolton Community Unit (BCU) is included in the 2013/14 baseline so analysis is underway to understand and confirm the implications of this.

2.2.2. Reduce Emergency Readmissions

The CCG has set a target of reducing emergency readmissions to 3,634 by the end of 2014/15 (from a baseline of 4,412 2013/14 outturn). The year to date number of emergency readmissions is 4,061. This issue is being picked up through the contracting governance process.

2.2.3. NHS Constitution

Bolton FT failed to achieve the target for patients having their operation cancelled on the day being offered another date within 28 days with 1 breach in November – giving a year to date figure of 6. The November breach was due to the cancellation of elective surgery as a result of the winter pressures across the hospital.

The A&E target was failed in November with performance of 90.3% (against a target of 95%). The significant decrease in performance is due to the sustained emergency pressures across Greater Manchester. Due to the number of breaches of the target so far this year, this performance metric for Bolton cannot now be achieved for the year.

NWAS failed both Category A targets in November with performance of 68.0% for Emergency Response arriving within 8 minutes (Red 1) and 69.6% within 15 minutes (Red 2) - against a target of 75% for both. This is the fifth month in a row in which both targets have failed and is also due to the sustained urgent care pressures across Greater Manchester. November performance for Category A calls resulting in an ambulance arriving at the scene within 19 minutes was 93.1% (against a target of 95%).

2.2.4. Contractual Performance

There were 235 patient handovers (from ambulances to A&E) over 30 minutes and 106 over 60 minutes in November (against a target of 0 for both). This is an ongoing performance concern which is being monitored by a remedial action plan which is being discussed at the January Board meeting under a separate paper.

The CCG did not achieve the 50% target for Improving Access to Psychological Services (IAPT) Recovery Rate with performance of 44.8% in November. Performance against this metric is being discussed with the three service providers.

Bolton FT failed one of the two stroke targets in November. 73.1% of patients were admitted to a designated stroke bed within 4 hours (against a target of 80%). The TIA target was also failed with 50% of cases investigated and treated within 24 hours (against a target of 60%).The Remedial Action Plan is being closely monitored through the Quality and Performance Group and the Contract Review Board.

On a positive note, performance against the cancer standards continues to be strong and the 18 week Referral to Treatment targets are being achieved every month. The redesign of the Child and Adolescent Mental Health service (CAMHs) which was a result if the contract notice served to Bolton FT has been very positive. Access and quality have improved and waiting times are down to the maximum agreed standard of 4 weeks.

2.3. Finance – Board Lead, Annette Walker

2.3.1. Contract Performance (month 9)

The overall position on contract performance at the end of November is £1,433k over plan. All NHS Acute contracts are over performing apart from Central Manchester and WWL. BMI Beaumont is predominantly the main cause of overspend on the Independent Sector contracts.

If the current contract performance continues at the same rate, the forecast outturn position will be a £2.1m overspend for 2014/15.

To mitigate the risk of continued overperformance an urgent review of contract performance has taken place and has resulted in an action plan being implemented to challenge specific areas of performance with providers.

Contract Validation continues on the AQP contracts to ensure pathway payments are adhered to and to provide assurance there is no duplication and more detailed reports have been requested from NW CSU.

2.3.2. Contract Performance in November across all providers was £17k below plan. Cumulative performance as at the end of November 2014 was £1,433k above plan.

Detailed work continues each month across all providers to understand the areas of over performance and to identify where contract challenges can be made.

2.3.3. Full details by provider and point of delivery can be found in the data pack at appendix 1.

2.3.4. QIPP

QIPP is currently behind target with YTD delivery of 66% as at month 9, and as a result reserves are being used to ensure that the required surplus is met. Mitigation plans are in place to ensure that additional schemes are implemented to ensure full delivery of QIPP by the end of the financial year.

2.4. CCG Workforce/HR – Board Lead, Su Long

The sickness absence rate for October for the CCG is now double the HSCIC target. Managers have been made aware and have been asked to ensure reasons for sickness absence are correctly recorded so themes can be identified and to ensure return to work interviews are undertaken to support staff.

3. Recommendations

3.1. The Board is asked to note 3.1.1. the performance in September and the actions being taken 3.1.2. the current position with regard to the quality premium payment against 2013/14 performance

Fiona Moore Assistant Chief Officer 16th January 2015

Index

2 Corporate Objectives 3-4 NHS Constitution Deliverables 5-7 Performance Report 8 CCG Health Outcome Indicators 9-10 Finance Dashboard 11-14 Key Contract Performance All Providers 15 Key Contract Performance Bolton FT 16 Quality Premium 17-18 Quality 19 Workforce/HR BOLTON CCG CORPORATE REPORT

From (2011/12) To 2015 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 YTD 14/15 Forecast Comments Forecast Year End position Objective Key Measures of Success (Goals) 2013/14 for Emergency admissions) Improve Health For 2010-2012 Male 1.8 Female 1.6 Outcomes Reduce the gap in life expectancy 1.85 years 2.05 years (2010) between Bolton and England (2015)

For 2006-2010 Male 13.5 Female 11.3

Reduce the gap in life expectancy m13.5 m13 between the most and least deprived f11.5 f11 areas in Bolton 1

Improve quality of Number of failing targets out of 22 care and patient See NHS Constitution report experience of care Achievement of all key targets / NHS Several failing All achieved 2 7 5 5 5 5 8 5 Running total Constitution

NB Data no longer comparative as measure description has changed; Friends and Family for A&E and Bolton patients and carers would Net agree +41% Net agree 50% 63 69 72 69 77 73 72 65 64 60 65 62 63 66 66 64 59 63 74 Inpatients. Required to show recommend health services improvement from Q1 - score of 74

Best Value: All emergency admissions to all providers.

Reduce emergency admissions 32,763 31,878 2,733 2,501 2,662 2,870 2,753 2,880 2,878 2,633 2,870 2,845 3,021 2,773 2,975 2,537 2,827 3,042 2,892 22,912 34,368 7.60% Data source - MAR

BCU activity has been added into the 13/14 baseline to allow like for like comparison Including BCU data 35,145 33,915 2,952 2,723 2,902 3,067 2,927 3,036 2,955 2,633 2,870 2,845 3,021 2,773 2,975 2,537 2,827 3,042 2,892 22,912 34,368 1.29% Data source - MAR

Shift care closer to Admissions to all providers.14/15 home Forecast of 3.15 (5 year strategic plan El 3.3 (baseline - El 3.15 4.0 4.0 4.5 4.1 4.1 4.5 3.6 3.6 4.3 4.4 4.0 4.3 3.8 4.6 4.6 3.8 3.1 4.1 4.17 EL 4.17 based on NHS Comparators )Revised strategic plan) figure using scale of change 4.17 Reduce elective & non elective length of stay (Ave LOS) LOS over 90 days is trimmed to 90 days. Data source: SUS 14/15 forecast 4.8 (5 NE 4.9 (baseline - NE 4.8 5.5 5.3 5.2 5.3 4.8 4.8 5.3 4.8 4.7 4.7 5.0 4.5 4.9 5.5 5.1 4.9 4.7 4.9 4.80 NE 4.8 year strategic plan) strategic plan)

Emergency readmissions within 30 days of previous discharge, as per the PbR definition. Data source: SUS. Taking in to account the number of discharges, the readmission rate increased from 7.6% in 2 481 449 454 445 470 456 519 458 527 520 552 538 476 449 500 533 493 4,061 6,092 Reduce emergency readmissions 4,412 3,634 2011/12 to 7.8% in 2012/13 the current YTD for 14/15 is 9.5%

Readmissions as % of discharges No Baseline No Target 9.1% 8.9% 8.8% 7.8% 8.7% 9.0% 9.1% 8.8% 9.3% 9.9% 9.9% 10.0% 8.6% 9.4% 9.1% 9.2% 9.5% 9.5% 8.8%

-Excludes spells with a primary diagnosis of cancer - Excludes spells with an obstetrics HRG 2 PbR definition for readmissions:- - Excludes patients aged under 4 - Excludes patients who self discharged from the initial admission - Excludes spells which do not have a NHS Constitution Indicators - November 2014.

Forecast Indicator Target Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 YTD Exceptions Trend (Apr13-Nov14) Achieve/Fail

Referral to Treatment waiting times for non urgent consultant led treatment - All

Aggregated target achieved, specialties failed for all providers are Plastic Surgery (82.4%) and Cardiology (88.9%). Bolton FT failed Plastics (82.5%) and Orthopaedics (84.5%) for Admitted patients to start treatment within a maximum of 18 weeks November 2014. Other breaches for November are Gen Surgery at South Man (66.7%); 90% 94.0% 96.1% 95.6% 94.9% 93.6% 93.7% 94.4% 94.0% 94.6% A Orthopaedics at Central Man (75%), East Lancs (50%),Lancs Teaching (80%) and Pennine from referral (50%); ENT at Central Man (50%); Ophthalmology at Central Man (80%); Plastics at South Man (69%); Cardiology at Central Man (66.7%); Other specs at Central Man (84.6%) and Pennine (66.7%)

Aggregated target achieved, in month specialties failed for all providers are Orthopaedics (91.8%), Gastro (87.5%), Cardiology (93.8%), Dermatology (93.7%) and Neurology (87.5%); Bolton FT failed Orthopaedics (84.5%) and Plastics (94.1%); Other breaches for November are Non-admitted patients to start treatment within a maximum of 18 95% 97.3% 97.7% 97.0% 97.1% 96.1% 96.5% 96.4% 96.0% 96.8% A Urology at Care UK (88.5%) ; Orthopaedics at Pennine (85.7%) and Salford (65.4%); Gastro at weeks from referral Salford (85%); Cardiology at Lancs Teaching (66.7%); Cardiology at Lancs Teaching (66.7%) and South Man (66.7%); Dermatology at Salford (83.3%);Thoracic Medicine at South Man (88.9%); Rheumatology at WWL (66.7%); Gynae at Salford (60%) and Other Specialties at Central Man (80.8%)

Aggregated target achieved, in month specialty failure is Plastics (91.2%). Bolton FT failed Orthopaedics for November (91.4%) . Other breaches are General Surgery at Central Manchester (84%), East lancs (89%), Lancs Teaching (85%), South Man (81.8%) and WWL (85.7%); Urology at Central Man (55.6%), Lancs Teaching (77.8%), Salford (88.9%) and Patients on incomplete non emergency pathways (yet to start 92% 95.9% 96.3% 96.0% 94.8% 95.1% 96.3% 95.6% 95.3% 95.6% A Stockport (50%); Orthopaedics at Lancs Teaching (89%), RN Orthopaedic Hosp (66.7%) and treatment) Salford (86.5%); ENT at Central Man (90%); Ophthalmology at Central Man (90.6%), East Lancs (83%) and LAncs Teaching (90%); Plastics at BMI (84%), Lancs Teaching (66.7%) and South Man (87.5%); Gastro at Pennine (84.6%); Cardiology at Blackpool (50%), Lancs Teaching (66.7%) and South Man (91.1%); Dermatology at Mid Yorkshire (60%) and Salford (90.9%) and Other Specs at Central Man (89%)

Number of patients waiting more than 52 weeks - (Bolton FT only) 0 0 0 0 0 0 0 0 0 0 A

Number of patients who are not offered another binding date within 28 days Number of patients who are not offered another binding date within 0 0 1 0 1 1 1 1 1 6 F 28 days

Diagnostic test waiting times All providers

Patients waiting for a diagnostic test should have been waiting less 1% 0.7% 1.1% 1.1% 0.8% 1.6% 1.01% 1.03% 0.96% 1.03% A than 6 weeks from referral

A & E waits - Bolton FT Failure by 367 patients Patients should be admitted, transferred or discharged within 4 95% 93.6% 97.3% 95.7% 95.4% 96.5% 94.98% 92.60% 90.30% 94.50% A hours of their arrival at an A&E department - Bolton FT

Cancer patients - 2 week wait -All Providers

Maximum two-week wait for first outpatient appointment for 93% 97.4% 97.5% 97.1% 98.0% 95.9% 97.4% 98.2% 97.0% 97.3% A patients referred urgently with suspected cancer by a GP

Maximum two week wait for first out patient appointment for patients referred urgently with breast symptoms (where cancer was 93% 97.8% 94.7% 97.1% 98.4% 95.1% 98.2% 95.0% 98.1% 96.9% A not initially suspected) NHS Constitution Indicators - November 2014.

Forecast Indicator Target Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 YTD Exceptions Trend (Apr13-Nov14) Achieve/Fail

Cancer patients - 31 day wait -All Providers Maximum one month (31 day) wait from diagnosis to first definitive 96% 98.9% 95.7% 99.0% 98.1% 97.8% 96.4% 98.0% 99.1% 97.8% A treatment for all cancers

Maximum 31 day wait for subsequent treatment where that 94% 100.0% 92.9% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 99.2% A treatment is surgery

Maximum 31 day wait for subsequent treatment where the 98% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% A treatment is an anti-cancer drug regimen

Maximum 31 day wait for subsequent treatment where the 94% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% A treatment is a course of radiotherapy

Cancer waits - 62 days - All Providers Maximum two month (62 day) wait from urgent GP referral to first 85% 94.3% 93.1% 82.0% 89.8% 90.6% 85.1% 84.8% 90.9% 88.8% A definitive treatment for cancer

Maximum 62 day wait from referral from an NHS screening service 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 90.0% 87.5% 96.9% A to first definitive treatment for all cancers

Maximum 62 day wait for first definitive treatment following a consultants decision to upgrade the priority of the patients (all 85% 66.7% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 95.8% A cancers) Category A ambulance calls NWAS At the present time, the level of demand is outpacing the resource available to NWAS, Category A calls resulting in an emergency response arriving within 8 75% 75.70% 73.40% 71.50% 68.50% 72.70% 71.50% 71.20% 68.00% 71.60% F despite additional resource having been brought in from the private and voluntary sectors. minutes (Red 1)

Category A calls resulting in an emergency response arriving within 8 75% 75.30% 74.70% 73.20% 69.20% 72.10% 73.30% 73.70% 69.60% 72.70% F minutes (Red 2)

Category A calls resulting in an ambulance arriving at the scene 95% 96.20% 95.60% 95.40% 94.20% 95.30% 95.10% 93.60% 93.10% 94.80% A within 19 minutes Mixed sex accommodation breaches - Bolton FT

Zero tolerance MSA breaches 0 0 1 2 1 0 0 2 0 6 F

Mental Health - GMW

Care Programme Approach (CPA): The proportion of people under 95% 98.40% 96.80% 98.40% 96.90% 96.60% 95.90% 95.70% 96.10% 96.90% A adult mental illness specialties on CPA -Completed

Care Programme Approach (CPA): The proportion of people under 95% 98.80% 98.50% 100.00% 98.70% 94.30% 97.30% 98.10% 97.60% 98.10% A adult mental illness specialties on CPA - 7 day follow up NHS Bolton Key Contract Performance Dashboard - November 2014.

Commissioner Performance Dashboard

Forecast Indicator Target Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 YTD Exceptions Trend (Apr13-Nov14) Achieve/Fail

Referral to Treatment waiting times for non urgent consultant led treatment - All

Aggregated target achieved, specialties failed for all providers are Plastic Surgery (82.4%) and Cardiology (88.9%). Bolton FT failed Plastics (82.5%) and Orthopaedics (84.5%) for Admitted patients to start treatment within a maximum of 18 weeks November 2014. Other breaches for November are Gen Surgery at South Man (66.7%); 90% 93.6% 94.0% 96.1% 95.6% 94.9% 93.6% 93.7% 94.4% 94.0% 94.6% A Orthopaedics at Central Man (75%), East Lancs (50%),Lancs Teaching (80%) and Pennine from referral (50%); ENT at Central Man (50%); Ophthalmology at Central Man (80%); Plastics at South Man (69%); Cardiology at Central Man (66.7%); Other specs at Central Man (84.6%) and Pennine (66.7%)

Aggregated target achieved, in month specialties failed for all providers are Orthopaedics (91.8%), Gastro (87.5%), Cardiology (93.8%), Dermatology (93.7%) and Neurology (87.5%); Bolton FT failed Orthopaedics (84.5%) and Plastics (94.1%); Other breaches for November Non-admitted patients to start treatment within a maximum of 18 95% 97.3% 97.3% 97.7% 97.0% 97.1% 96.1% 96.5% 96.4% 96.0% 96.8% A are Urology at Care UK (88.5%) ; Orthopaedics at Pennine (85.7%) and Salford (65.4%); weeks from referral Gastro at Salford (85%); Cardiology at Lancs Teaching (66.7%); Cardiology at Lancs Teaching (66.7%) and South Man (66.7%); Dermatology at Salford (83.3%);Thoracic Medicine at South Man (88.9%); Rheumatology at WWL (66.7%); Gynae at Salford (60%) and Other Specialties at Central Man (80.8%)

Aggregated target achieved, in month specialty failure is Plastics (91.2%). Bolton FT failed Orthopaedics for November (91.4%) . Other breaches are General Surgery at Central Manchester (84%), East lancs (89%), Lancs Teaching (85%), South Man (81.8%) and WWL (85.7%); Urology at Central Man (55.6%), Lancs Teaching (77.8%), Salford (88.9%) and Patients on incomplete non emergency pathways (yet to start 92% 96.0% 95.9% 96.3% 96.0% 94.8% 95.1% 96.3% 95.6% 95.3% 95.6% A Stockport (50%); Orthopaedics at Lancs Teaching (89%), RN Orthopaedic Hosp (66.7%) and treatment) Salford (86.5%); ENT at Central Man (90%); Ophthalmology at Central Man (90.6%), East Lancs (83%) and LAncs Teaching (90%); Plastics at BMI (84%), Lancs Teaching (66.7%) and South Man (87.5%); Gastro at Pennine (84.6%); Cardiology at Blackpool (50%), Lancs Teaching (66.7%) and South Man (91.1%); Dermatology at Mid Yorkshire (60%) and Salford (90.9%) and Other Specs at Central Man (89%)

Number of patients waiting more than 52 weeks - (Bolton FT only) 0 0 0 0 0 0 0 0 0 0 0 A

Number of patients who are not offered another binding date within 28 days Bolton FT Number of patients who are not offered another binding date within 0 0 0 1 0 1 1 1 1 1 6 F 28 days

Diagnostic test waiting times All providers

Patients waiting for a diagnostic test should have been waiting less 1% 0.4% 0.7% 1.1% 1.1% 0.8% 1.6% 1.01% 1.03% 0.96% 1.03% A than 6 weeks from referral

A & E waits - Bolton FT Failure by 367 patients Patients should be admitted, transferred or discharged within 4 95% 95.3% 93.6% 97.3% 95.7% 95.4% 96.5% 94.98% 92.60% 90.30% 94.5% A hours of their arrival at an A&E department - Bolton FT

Cancer patients - 2 week wait -All Providers

Maximum two-week wait for first outpatient appointment for 93% 97.1% 97.4% 97.5% 97.1% 98.0% 95.9% 97.4% 98.2% 97.0% 97.3% A patients referred urgently with suspected cancer by a GP

Maximum two week wait for first out patient appointment for patients referred urgently with breast symptoms (where cancer was 93% 95.7% 97.8% 94.7% 97.1% 98.4% 95.1% 98.2% 95.0% 98.1% 96.9% A not initially suspected)

Forecast Indicator Target Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 YTD Exceptions Trend (Apr13-Nov14) Achieve/Fail

Cancer patients - 31 day wait -All Providers Maximum one month (31 day) wait from diagnosis to first definitive 96% 98.1% 98.9% 95.7% 99.0% 98.1% 97.8% 96.4% 98.0% 99.1% 97.8% A treatment for all cancers

Maximum 31 day wait for subsequent treatment where that 94% 95.5% 100.0% 92.9% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 99.2% A treatment is surgery

Maximum 31 day wait for subsequent treatment where the 98% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% A treatment is an anti-cancer drug regimen

Maximum 31 day wait for subsequent treatment where the 94% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% A treatment is a course of radiotherapy

Cancer waits - 62 days - All Providers NHS Bolton Key Contract Performance Dashboard - November 2014.

Maximum two month (62 day) wait from urgent GP referral to first 85% 86.7% 94.3% 93.1% 82.0% 89.8% 90.6% 85.1% 84.8% 90.9% 88.8% A definitive treatment for cancer

Maximum 62 day wait from referral from an NHS screening service to 91.7% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 90.0% 87.5% 96.9% A first definitive treatment for all cancers

Maximum 62 day wait for first definitive treatment following a consultants decision to upgrade the priority of the patients (all 85% 100.0% 66.7% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 95.8% A cancers) Category A ambulance calls NWAS Category A calls resulting in an emergency response arriving within 8 75% 75.30% 75.70% 73.40% 71.50% 68.50% 72.70% 71.50% 71.20% 68.00% 71.60% F At the present time, the level of demand is outpacing the resource available to NWAS, minutes (Red 1) despite additional resource having been brought in from the private and voluntary sectors.

Category A calls resulting in an emergency response arriving within 8 75% 75.40% 75.30% 74.70% 73.20% 69.20% 72.10% 73.30% 73.70% 69.60% 72.70% F minutes (Red 2)

Category A calls resulting in an ambulance arriving at the scene 95% 96.30% 96.20% 95.60% 95.40% 94.20% 95.30% 95.10% 93.60% 93.10% 94.80% A within 19 minutes

Report failed for August All handovers between ambulance and A&E must take place within 0 170 175 134 181 191 Not Available 196 219 235 1331 F 15 minutes (no of patients waiting >30 mins<59 mins) Bolton FT

Report failed for August All handovers between ambulance and A&E must take place within 0 58 50 41 42 34 Not Available 36 62 106 371 F 15 minutes (no of patients waiting >60 mins) Bolton FT Mixed sex accommodation breaches - Bolton FT

Zero tolerance MSA breaches 0 1 0 1 2 1 0 0 2 0 6 F

Mental Health - GMW

Care Programme Approach (CPA): The proportion of people under 95% 99.00% 98.40% 96.80% 98.40% 96.90% 96.60% 95.90% 95.70% 96.10% 96.90% A adult mental illness specialties on CPA -Completed

Care Programme Approach (CPA): The proportion of people under 95% 97.60% 98.80% 98.50% 100.00% 98.70% 94.30% 97.30% 98.10% 97.60% 98.10% A adult mental illness specialties on CPA - 7 day follow up

For November GMW at 54%, Think Positive at 58.4% and 1 point at 29.4% IAPT Recovery rate - (GMW, 1 point and Think Positive) 50% 51.00% 45.40% 50.96% 47.35% 46.95% 45.80% 47.08% 45.82% 44.84% 46.76% A

IAPT Access rate - (GMW, 1 point and Think Positive) 15.0% 12.40% 12.70% 12.10% 13.70% 14.40% 13.10% 17.40% 16.10% 16.30% 14.50% A

Number of ongoing waiters >18 weeks 0 0 0 0 0 0 0 0 0 0 0 A

Forecast Indicator Target Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 YTD Exceptions Trend (Apr13-Nov14) Achieve/Fail

HCAI-Healthcare Associated Infections Annual target

MRSA-Post 48 hrs (Hospital) 0 0 0 0 0 0 0 0 0 0 0 A

CDIFF-Post 72 hrs (Hospital) 48 2 3 2 3 1 1 0 0 1 11 A Friends and family

A&E Score 69 44 47 56 50 54 61 57 56 51 54 F

A&E Response Rate 15% 8.2% 16.1% 18.7% 15.5% 19.3% 17.8% 17.9% 14.9% 20.2% 17.5% A

78 79 82 80 79 81 77 77 80 78 79 A Inpatient Score

15% 33.4% 36.8% 41.9% 43.8% 41.3% 37.0% 42.6% 35.2% 39.0% 39.7% A Inpatient Response Rate

73 64 60 65 62 63 66 66 64 59 63 F Combined Score

15% 13.9% 20.3% 23.4% 21.1% 23.8% 21.5% 22.8% 18.8% 24.0% 21.9% A Combined Response Rate Never events Never events 0 0 0 0 2 0 0 0 1 0 3 F Stroke - Bolton FT

% Stroke admissions spending 90% of time on stroke unit 80% 91.4% 86.8% 87.5% 85.7% 64.8% 88.1% 79.2% 83.7% 81.6% 82.20% A NHS Bolton Key Contract Performance Dashboard - November 2014.

Assurances given by Bolton FT that the target will be met from October onwards Stroke patients arriving in a designated stroke bed within 4 hours 80% 83.3% 80.0% 78.9% 75.0% 57.5% 70.4% 70.0% 82.8% 73.1% 73.50% A

2 patients out of 4 Transient Ischaemic Attack (TIA) cases with a higher risk of stroke 60% 75.0% 62.5% 33.0% 57.1% 71.0% 62.5% 61.5% 21.1% 50.0% 52.3% A treated within 24 hours OUTCOME AND QUALITY INDICATORS

Domain 1 - Preventing people from dying prematurely This domain captures how successful the NHS is in reducing the number of avoidable deaths.

2009 2010 2011 2012 2013 14/15 Target Potential years of life lost (PYLL) from causes considered amenable - healthcare CCG (Direct Standard Rate) 2667 2644 2240 2531 2326 2564 GP registered population from NHAIS (Exeter), the Primary Care Mortality Latest data released Sept 14 - next due Sept 15, a revised methodology was introduced in Sept 14 therefore values have been revised Database (PCMD) and ONS mid - year census based England population estimates Domain 2 - Enhancing quality of life for people with long-term conditions This domain captures how successfully the NHS is supporting people with long-term conditions to live as normal a life as possible.

2011/12 2012/13 2013/14 Health related quality of life for people with long term conditions CCG 0.71 0.72 0.72 GP Patient Survey (GPPS) update Sept 14 People feeling supported to manage their condition CCG 67.90 67.20 68.20 GP Patient Survey (GPPS) update Sept 14 Health-related quality of life for carers, aged 18 and above CCG 0.79 0.80 78.20 GP Patient Survey (GPPS) update Sept 14

Domain 3 - Helping people to recover from episodes of ill health or following injury This domain captures how people recover from ill health or injury and wherever possible how it can be prevented.

2010/11 2011/12 2012/13 2013/14 Emergency admissions for acute conditions that should not usually require hospital admission - CCG 1047.8 1080 1291 1385.2 (provisional) HES next version due Dec 14

Domain 4 - Ensuring that people have a positive experience of care This domain looks at the importance of providing a positive experience of care for patients, service users and carers.

2010/11 2011/12 2012/13 2013/14 National Inpatient Patient experience of GP Services (sept 13) Survey Programme 87.3 Patient experience of GP Out of Hours (sept 13) 72.4 Patient experience of hospital care (RBH) 74.7 77.6 77.6 79.5

Responsiveness to inpatients' personal needs (RBH) 66 69.6 68.9 70.9

Domain 5 - Treating and caring for people in a safe environment and protecting them from avoidable harm This domain explores patient safety and its importance in terms of quality of care to deliver better health outcomes. Indicator in development Apr-Sept 13 Patient safety incidents (per 1000 bed days) 24 HES next version due Mar 15 Finance Dashboard - 2014/15 Month 9

Statutory Duties Financial Performance All statutory duties are being achieved. Indicator Summary All of the indicators used to measure financial performance of Indicator Summary the CCG are on track. The CCG is planning to deliver control total of £3.5m but with some risk due to contract dispute issues with Bolton FT. In The CCG has a total allocation of £358.1m, following an addition the CCG has been asked to increase the target surplus increase of £0.5m for Quality Premium awards. to £4.4m to reflect the return of CHC funding for restitution cases required for future years. The underlying recurrent surplus is 2.75% and non recurrent funds are being managed within processes. The CCG is operating within its approved maximum cash draw down (MCD) of £354.4m. The year to date surplus in line with plan, however the FOT surplus has increased to £4.4m to reflect the return of CHC The running costs target is £7.0m and at month 9 the forecast national underspends. outturn shows an underspend of £488k. QIPP is currently behind target with YTD delivery of 66% as at The CCG is achieving the Better Payments Practice Code and at Green Amber Red month 9, and as a result reserves are being used to ensure that Green Amber Red month 9 had paid 95.75% of invoices, by volume, within 30 4 1 0 the required surplus is met. Mitigation plans are in place to 8 0 0 days and 98.88% by value. ensure that additional schemes are implemented to ensure full delivery of QIPP by the end of the financial year. Financial Governance Contract Performance The CCG Finance team had 12 Internal Audit Recommendations Indicator Summary Overall expenditure trends are 1% above plan for NHS Indicator Summary at the start of the year. At month 9, 10 of these have been contracts, however, Independent Sector Contracts are currently completed, revised completion dates have been agreed for 2 14% above plan. remaining low risk recommendations and are on target. The forecast contract with Bolton NHS Foundation Trust is The cash drawn down is 74.0% of the MCD and the bank currently assumed to be in line with plan. balance is within the tolerance limit. Expenditure on non contracted activity is 9% above plan at At month 9 the CCG had mitigations in place for all potential month 9 and it is expected to be 8% above plan by the end of risks, but the forecast position is tight. the year.

AQP expenditure is 17% above plan at month 9.

Green Amber Red Green Amber Red 2 1 0 4 0 6 Finance Dashboard - 2014/15 Month 9

Statutory Duties RAG Rating RAG Rating Threshold Plan/ No Indicator Target Month 1 Month 2 Month 3 Month 4 Month 5 Month 6 Month 7 Month 8 Month 9 Month 10 Month 11 Month 12 Green Amber Red Positive variance to plan or negative variance <= 0.1% > variance <0.5% (negative variance) Negative variance => 0.5% 1 Revenue - delivery of CCG's planned surplus £3.535m £3.535m £3.535m £3.535m £3.535m £3.535m £3.535m £3.535m £3.535m 0.1% Cash - Operate within its approved cash maximum draw- 2 down limit in each and every year. £349.5m £349.5m £349.5m £349.5m £350.9m £350.2m £353.3m £353.3m £353.3m <100% N/A >100% Better Payments Practice Code - to pay 95% of invoices N/A 3 by volume within 30 days >95% 97.70% 96.80% 96.43% 96.70% 96.20% 96.16% 95.98% 95.75% >95% <95% Better Payments Practice Code - to pay 95% of invoices N/A 4 by value within 30 days >95% 99.60% 99.60% 99.41% 99.50% 99.30% 99.33% 98.97% 98.88% >95% <95% Running Costs - Not to exceed the Running Cost <= RCA N/A > RCA 5 Allowance £7.029m £7.029m £6.992m £6.973m £6.673m £6.673m £6.656m £6.568m £6.541m

Financial Performance (including QIPP) RAG Rating RAG Rating Threshold Plan/ No Indicator Target Month 1 Month 2 Month 3 Month 4 Month 5 Month 6 Month 7 Month 8 Month 9 Month 10 Month 11 Month 12 Green Amber Red Underlying recurrent surplus on exit of 2014/15 1 (monitored quarterly) >=2.5% N/A 2.77% N/A N/A 2.75% N/A N/A N/A >=2.5% 0 - 2.49% <0%

2 Management of 2.5% NR Funds within agreed processes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes N/A No >= 95% >= 95% of plan >=75% of plan and < 95% of plan < 75% of plan 3 QIPP - year to date delivery of plan 33% 27% 100% 100% 100% 100% 100% 100% >= 95% of plan >=75% of plan and < 95% of plan < 75% of plan 4 QIPP - full year forecast £4.7m £4.7m £4.7m £4.7m £4.7m £4.7m £4.7m £4.7m £4.7m Positive variance to plan or negative variance <= 1% 0.1% > variance <0.5% (negative variance) Negative variance => 0.5% 5 YTD surplus/(deficit) 1% 1% 1% 1% 1% 1% 1% 1% 0.1% Positive variance to plan or negative variance <= 1% 0.1% > variance <0.5% (negative variance) Negative variance => 0.5% 6 FOT surplus/(deficit) 1% 1% 1% 1% 1% 1% 1% 1% 0.1% +ve / -ve Positive movement from previous month or 0.1% > movement <0.5% (negative movement) Negative movement => 0.5% 7 Movement in FOT surplus/(deficit) <=0.01% 0% 0% 0% 0% 0% 0% 0% 0% negative movement <= 0.1% Difference < 1% (positive or negative) 1% > = difference (positive or negative) < 5% Difference (positive or negative) => 5% 8 Full year run rate difference 1% 3.29% TBC TBC TBC TBC TBC TBC

Financial Governance RAG Rating RAG Rating Threshold Plan/ No Indicator Target Month 1 Month 2 Month 3 Month 4 Month 5 Month 6 Month 7 Month 8 Month 9 Month 10 Month 11 Month 12 Green Amber Red Number of Internal Audit Recommendations that are due 1 - completed 100% 72% 55% 42% 50% 100% 100% 100% 100% 100% 33% - 99% <33%

2 Bank balance within target 9% 0% 0 3.3% 5.7% 2.1% 0% 4.8% <=5% 5.1% - 10% >10% Clear identification of risks against financial delivery and Net risk = Risks not fully mitigated and the CCG would be in 3 mitigations 0 0 0 0 0 0 1 1 1 Mitigations equal to or greater than risks Risks not fully mitigated but no impact on surplus deficit

Contract Performance RAG Rating RAG Rating Threshold

No Indicator Month 1 Month 2 Month 3 Month 4 Month 5 Month 6 Month 7 Month 8 Month 9 Month 10 Month 11 Month 12 Green Amber Red <101% of 1 All NHS Contracts - Expenditure Trends - year to date plan 99% 100% 101% 101% 101% 101% 101% <101% of plan <103% of plan >=103% of plan <101% of 2 All NHS Contracts - Expenditure Trends - full year forecast plan 99% 100% 101% 100% 100% 100% 100% <101% of plan <103% of plan >=103% of plan All Independent Sector Contracts - Expenditure Trends - <101% of 3 year to date plan 98% 106% 109% 107% 112% 114% 114% <101% of plan <103% of plan >=103% of plan All Independent Sector Contracts - Expenditure Trends - <101% of 4 full year forecast plan 98% 106% 109% 107% 112% 114% 114% <101% of plan <103% of plan >=103% of plan <101% of 5 Bolton FT - Expenditure Trends - year to date plan 99% 100% 101% 100% 100% 101% 100% <101% of plan <103% of plan >=103% of plan <101% of 6 Bolton FT - Expenditure Trends - full year forecast plan 99% 100% 101% 100% 100% 100% 100% <101% of plan <103% of plan >=103% of plan <101% of 7 NCA's - Expenditure - year to date plan 106% 102% 102% 98% 98% 100% 109% <101% of plan <103% of plan >=103% of plan <101% of 8 NCA's - Expenditure- full year forecast plan 100% 102% 102% 100% 100% 105% 108% <101% of plan <103% of plan >=103% of plan <101% of 7 AQP - Expenditure - year to date plan 144% 148% 120% 128% 127% 129% 117% <101% of plan <103% of plan >=103% of plan <101% of 8 AQP - Expenditure- full year forecast plan 139% 148% 120% 128% 127% 129% 117% <101% of plan <103% of plan >=103% of plan Bolton CCG - Total Contract Summary Report - November 2014

Headline Summary

The overall position on contract performance at the end of November is £1,433k over plan. All NHS Acute contracts are overperforming apart from Central Manchester and WWL. BMI Beaumont is predominantly the main cause of overspend on the Independent Sector contracts.

Month 8 Position Month 8 Cumulative Position Annual Annual Budget Value Contract Planned Actual Activity Planned Actual Activity HEALTHCARE PROVIDER £ Value £ Activity Activity Variance £ Plan £ Actual £ Variance Activity Activity Variance £ Plan £ Actual £ Variance

NHS Acute £159,744,487 £159,644,487 38,272 46,073 7,801 £13,198,349 £13,226,215 £27,866 310,299 376,689 66,391 £106,118,188 £106,990,156 £871,968

Independent Sector £8,913,212 £8,913,212 1,344 1,791 447 £690,360 £724,168 £33,808 20,334 20,820 486 £5,572,670 £6,024,386 £451,716

AQP £1,180,062 £1,180,062 £98,338 £34,622 £(63,716) £786,708 £923,293 £136,585

Community Services £40,739,126 £39,585,126 £3,394,964 £3,398,085 £3,121 £27,159,711 £27,184,690 £24,979

Mental Health £22,824,565 £22,824,565 £1,902,047 £1,897,549 £(4,498) £15,216,377 £15,211,879 £(4,498)

Ambulance £8,264,543 £8,264,543 £688,712 £678,259 £(10,453) £5,509,695 £5,473,539 £(36,156)

111 £957,110 £957,110 £79,759 £76,714 £(3,045) £638,073 £626,760 £(11,313)

Grand Total £242,623,105 £241,369,105 39,616 47,864 8,248 £20,052,529 £20,035,612 £(16,917) 330,633 397,509 66,877 £161,001,423 £162,434,702 £1,433,280 Risks / Actions

RISKS: If the current contract performance continues at the same rate, the forecast outturn position will be a £2.1m overspend for 2014/15.

ACTIONS: To mitigate the risk of continued overperformance an urgent review of contract performance has taken place and has resulted in an action plan being implemented to challenge specific areas of performance with providers. Contract Validation continues on the AQP contracts to ensure pathway payments are adhered to and to provide assurance there is no duplication and more detailed reports have been requested from NW CSU.

Underperformance - Overperformance - Worse No Underperformance - Overperformance - Better than last KEY Worse than last month than last month Change Better than last month month Positive variance (red font, no brackets) signify an over plan figure, Negative variance (black font, in brackets) signify an under plan figure Bolton CCG - Total Healthcare Provider Report - November 2014

Headline Summary Contract Performance in November across all providers was £17k below plan. Cumulative performance as at the end of November 2014 was £1,433k above plan. Detailed work continues each month across all providers to understand the areas of over performance and to identify where contract challenges can be made.

Month 8 Position Month 8 Cumulative Position Narrative Annual Annual Budget Value Contract Planned Actual Activity Planned Actual Activity NHS PROVIDERS £ Value £ Activity Activity Variance £ Plan £ Actual £ Variance Activity Activity Variance £ Plan £ Actual £ Variance RISKS / ACTIONS BOLTON FT £135,538,566 £135,538,566 32,387 39,549 7,162 11,190,171 11,092,089 £(98,082) 263,817 325,184 61,367 90,213,594 90,651,864 £438,271 Bolton FTs November position was £98k CENTRAL MANCHESTER £5,368,701 £5,329,701 1,116 1,217 101 443,871 520,531 £76,660 8,755 10,101 1,346 3,536,626 3,476,028 £(60,597) below plan, the cumulative reported position EAST LANCASHIRE £557,186 £557,186 258 302 44 46,610 88,827 £42,217 2,062 2,257 195 371,507 447,364 £75,858 was a £438k over performance after an LANCASHIRE TEACHING £1,674,473 £1,674,473 1,110 1,109 (2) 164,674 150,024 £(14,650) 8,078 8,308 231 1,088,026 1,170,536 £82,510 adjustment for Critical Care of £299k based LIVERPOOL & BROADGREEN £117,305 £117,305 24 48 24 9,505 12,166 £2,661 203 275 72 78,328 121,272 £42,944 on challenge raised to the Trust. The Salford PENNINE ACUTE £1,466,935 £1,466,935 378 375 (3) 119,555 111,464 £(8,091) 3,167 3,196 29 987,304 1,033,230 £45,927 positon has deteriorated in October by £86k SALFORD ROYAL £7,506,848 £7,476,848 1,434 1,578 144 614,988 701,718 £86,730 11,558 12,486 928 4,929,195 5,111,503 £182,308 due to an increase in Elective and Daycase STOCKPORT £82,021 £82,021 21 21 0 2,217 6,709 £4,492 173 204 31 21,169 71,954 £50,786 due to RTT waiting list 16 week additional SOUTH MANCHESTER £1,991,857 £1,991,857 385 730 345 167,194 163,250 £(3,944) 3,126 4,879 1,753 1,337,511 1,440,661 £103,149 activity. Funding for RTT has now been WWL £5,440,595 £5,409,595 1,159 1,144 (15) 439,562 379,435 £(60,127) 9,360 9,799 439 3,554,929 3,465,742 £(89,187) incorporated into budgets to reduce this Grand Total £159,744,487 £159,644,487 38,272 46,073 7,801 £13,198,349 £13,226,215 £27,866 310,299 376,689 66,391 £106,118,188 £106,990,156 £871,968 overspend.

Month 8 Position Month 8 Cumulative Position Narrative Annual Annual INDEPENDENT SECTOR Budget Value Contract Planned Actual Activity Planned Actual Activity PROVIDERS £ Value £ Activity Activity Variance £ Plan £ Actual £ Variance Activity Activity Variance £ Plan £ Actual £ Variance RISKS / ACTIONS BMI BEAUMONT £4,833,335 £4,833,335 1,231 1,641 410 £397,018 £459,230 £62,212 9,843 12,716 2,873 £3,176,154 £3,691,631 £515,477 BMI performance has continuted the trend of OAKLANDS £299,225 £299,225 80 114 34 £24,328 £44,141 £19,813 637 823 186 £194,618 £293,076 £98,458 overperformance in month of £62k above EUXTON £140,047 £140,047 33 36 3 £11,409 £7,553 £(3,856) 265 269 4 £91,271 £67,425 £(23,846) plan and cumulatively by £515k. The Care UK CARE UK (85% plan) £2,852,149 £2,852,149 0 £191,900 £153,919 £(37,981) 9,589 7,012 (2,577) £1,584,990 £1,483,165 £(101,825) position has improved in month with a ALLIANCE MEDICAL £634,629 £634,629 £52,886 £45,611 £(7,275) £423,086 £387,311 £(35,775) utilisation adjustment applied to the MARIE STOPES £6,000 £6,000 £500 £500 £0 £4,000 £4,000 £0 contract. FRATERDRIVE £147,827 £147,827 £12,319 £13,214 £895 £98,551 £97,778 £(773) Grand Total £8,913,212 1,344 1,791 447 £690,360 £724,168 £33,808 20,334 20,820 486 £5,572,670 £6,024,386 £451,716

Month 8 Position Month 8 Cumulative Position Narrative Annual Annual Budget Value Contract Planned Actual Activity Planned Actual Activity AQP PROVIDERS £ Value £ Activity Activity Variance £ Plan £ Actual £ Variance Activity Activity Variance £ Plan £ Actual £ Variance RISKS / ACTIONS BOLTON FT £770,000 £770,000 £64,166 -£49,613 £(113,779) £513,333 £419,036 £(94,297) The CCG has continued to see an increase in OTHER PROVIDERS £410,062 £410,062 £34,172 £84,235 £50,063 £273,375 £504,257 £230,882 AQP invoices in November which are being Grand Total £1,180,062 £1,180,062 0 0 0 £98,338 £34,622 £(63,716) 0 0 0 £786,708 £923,293 £136,585 reviewed and validated.

Month 8 Position Month 8 Cumulative Position Narrative Annual Annual Budget Value Contract Planned Actual Activity Planned Actual Activity COMMUNITY £ Value £ Activity Activity Variance £ Plan £ Actual £ Variance Activity Activity Variance £ Plan £ Actual £ Variance RISKS / ACTIONS BOLTON FT £40,577,953 £39,423,953 £3,381,533 £3,381,533 £0 £27,052,262 £27,052,262 £0 The CCG has now recognised the FP10 spend BRIDGEWATER £95,346 £95,346 £7,946 £7,946 £0 £63,564 £63,564 £0 incurred by Bolton FT and this is now SALFORD £65,827 £65,827 £5,486 £8,607 3,121 0 £43,885 £68,864 £24,979 reflected in the position. The overspend on Grand Total £40,739,126 £39,585,126 0 0 0 £3,394,964 £3,398,085 £3,121 0 0 0 £27,159,711 £27,184,690 £24,979 Salford relates to District Nurses. Bolton CCG - Total Healthcare Provider Report - November 2014

Month 8 Position Month 8 Cumulative Position Narrative Annual Contract Planned Actual Activity Planned Actual Activity MENTAL HEALTH Value £ Activity Activity Variance £ Plan £ Actual £ Variance Activity Activity Variance £ Plan £ Actual £ Variance RISKS / ACTIONS GMW £22,069,105 £22,069,105 £1,839,092 £1,839,092 £0 £14,712,737 £14,712,737 £0 Mental Health Block Contracts are in place 5 BOROUGHS £47,615 £47,615 £3,968 £3,968 £0 £31,743 £31,743 £0 with a £250k risk share cap to manage the CALDERSTONES £576,457 £576,457 £48,038 £48,038 £0 £384,305 £384,305 £0 financial impact of MH PbR. Notice had been MANCHESTER MH £4,233 £4,233 £353 £353 £0 £2,822 £2,822 £0 served to GMW to decommission the IAPT PENNINE CARE £71,616 £71,616 £5,968 £5,968 £0 £47,744 £47,744 £0 Service in the final quarter of 2014/15, LANCASHIRE CARE £55,539 55,539 £4,628 £130 £(4,498) £37,026 £32,528 £(4,498) however this has now been formally paused. Grand Total £22,824,565 £22,824,565 0 0 0 £1,902,047 £1,897,549 £(4,498) 0 0 0 £15,216,377 £15,211,879 £(4,498)

Month 8 Position Month 8 Cumulative Position Narrative Annual Annual Contract Contract Planned Actual Activity Planned Actual Activity AMBULANCE Value £ Value £ Activity Activity Variance £ Plan £ Actual £ Variance Activity Activity Variance £ Plan £ Actual £ Variance RISKS / ACTIONS NWAS - PES £7,004,658 £7,004,658 £583,722 £583,633 £(89) £4,669,772 £4,659,723 £(10,049) PES and Arriva contracts continue to ARRIVA - CORE £1,186,175 £1,186,175 £98,848 £88,478 £(10,370) £790,783 £764,505 £(26,278) underperformance in November. However, ARRIVA - OOHs £73,710 £73,710 £6,143 £6,148 £6 £49,140 £49,311 £171 slight over performance is seen on the OOHs Grand Total £8,264,543 £8,264,543 0 0 0 £688,712 £678,259 £(10,453) 0 0 0 £5,509,695 £5,473,539 £(36,156) contract.

Month 8 Position Month 8 Cumulative Position Narrative Annual Annual Contract Contract Planned Actual Activity Planned Actual Activity 111 Value £ Value £ Activity Activity Variance £ Plan £ Actual £ Variance Activity Activity Variance £ Plan £ Actual £ Variance RISKS / ACTIONS BARDOC £517,110 £517,110 £43,093 £43,073 £(20) £344,740 £344,625 £(115) There is slight underperformance on the NHS NWAS £440,000 £440,000 £36,667 £33,641 £(3,026) £293,333 £282,135 £(11,198) 111 contract with NWAS and BARDOC. Grand Total £957,110 £957,110 0 0 0 £79,759 £76,714 £(3,045) 0 0 0 £638,073 £626,760 £(11,313)

Total £233,709,893 £241,369,105 £39,616 £47,864 £8,248 £20,052,529 £20,035,612 £(16,917) £330,633 £397,509 £66,877 £161,001,423 £162,434,702 £1,433,280 Bolton CCG - Total Provider Report by Point of Delivery - November 2014 (NHS Acute & IS Secondary Care Activity & Finance) Month 8 Position Month 8 Cumulative Position Annual Contract Point of Delivery Value £ Planned Activity Actual Activity Activity Variance £ Plan £ Actual £ Variance Planned Activity Actual Activity Activity Variance £ Plan £ Actual £ Variance

Accident and Emergency £9,430,497 7,397 7,608 211 £754,921 £791,153 £36,232 61,970 63,312 1,342 £6,322,416 £6,518,907 £196,491

Non Elective Admissions £55,984,068 2,663 2,678 15 £4,185,249 £4,356,476 £171,227 20,465 21,500 1,035 £32,937,507 £34,948,733 £2,011,226

Maternity £6,452,917 1,321 1,259 (62) £1,054,856 £1,085,704 £30,848 10,929 11,089 160 £8,788,058 £8,926,741 £138,683

Elective & Daycase £35,903,564 2,507 2,588 81 £3,026,091 £2,812,067 £(214,024) 20,189 21,398 1,209 £24,035,169 £23,873,228 £(161,941)

Outpatient First £9,577,347 6,196 6,412 216 £814,711 £844,964 £30,253 50,564 54,442 3,878 £6,686,241 £7,062,171 £375,930

Outpatient Follow Up £11,067,762 12,013 12,207 194 £924,973 £933,286 £8,313 98,114 97,636 (478) £7,523,774 £7,401,037 £(122,737)

Outpatient Procedures £7,003,606 3,735 3,697 (38) £597,992 £567,852 £(30,140) 29,975 29,083 (892) £4,845,296 £4,583,637 £(261,659)

Excess Bed Days £3,136,910 1,136 820 (316) £251,753 £188,471 £(63,282) 9,413 9,447 34 £2,086,759 £2,140,348 £53,589

Unbundled Diagnostics £2,247,057 155 2,492 2,337 £188,667 £194,893 £6,226 1,245 19,274 18,029 £1,509,759 £1,540,472 £30,713

Direct Access - Pathology £2,714,917 0 0 (0) £226,243 £226,242 £(1) 1 0 (1) £1,809,944 £1,809,937 £(7)

Direct Access - Radiology £1,070,534 202 2,156 1,954 £88,644 £90,942 £2,298 1,664 19,072 17,408 £713,402 £762,630 £49,228

ECG £590,380 720 654 (66) £55,456 £50,361 £(5,095) 5,168 5,204 36 £397,970 £400,729 £2,759

OTHER £19,887,479 983 4,659 3,676 £1,781,361 £1,958,545 £177,184 7,694 35,344 27,650 £14,270,460 £13,420,242 £(850,218) Grand Total £165,067,037 39,029 47,230 8,201 £13,950,915 £14,100,956 £150,040 317,392 386,801 69,409 £111,926,755 £113,388,812 £1,462,057

A&E Actual This Year & Last Year v Plan £'000s Emergency Care Actual This Year & Last year v Plan £'000s Planned Care Actual this Year & Last Year v Plan £'000s (excludes outpatient activity) 3500 1000 6000 900 3000 800 5000 2500 700 4000 600 2000 500 3000 1500 400 2000 300 1000 200 1000 100 500 0 0 0

13/14 £000s 14/15 £000s 1415 Plan £000s 13/14 £000s 14/15 £000s 1415 Plan £000s 13/14 £000s 14/15 £000s 1415 Plan £000s

A&E Accident & Emergency activity across all providers in November was above plan by 211 (2.85%) attendances and £196k cumulatively, at the end of November 2014.

Emergency Care Non Elective admissions are above plan by 15 spells in November across all providers and cumulatively above plan by 1,035 spells (5%) and £2,011k at the end of November 2014. This is before the application of the NEL Threshold adjustment of £930k which is shown within the other block element of the contract. The net overperformance on NEL admissions is therefore £1,028k.

Planned Care Daycase and Electives are 81 above plan in terms of activity in November which represents 3% above plan and 1,209 (6%) above cumulatively, however in terms of Finance this area remains below plan by £162k (1%). Outpatients are 371 apointments above plan in terms of activity in November and 2,508 year to date, which is £8k below plan in finance terms. Contract baselines haven't been adjusted for the increase in planned care year to date relating to the 16 & 18 week Waiting List Initiatives.

Maternity Maternity spend is above plan in November by £31k and the year to date figure is also above plan by £139k (2%) indicating an increase in activity in month.

Other Other consists mainly of the block areas of the contracts, but also contains Critical Care, PbR Excluded Drugs & Devices and other cost & volume items that are based on actual performance. The other also includes the contract adjustments for Bolton FT and Salford Royal. Bolton Hospitals Foundation Trust Finance and Activity Performance in 2014/15 Month 8

Contract Performance - November 2014 Headline Narrative

Year to Date Forecast Outturn Risks A&E and Non Elective over performance Contract Value £117,265,856 £175,112,462 Issues Contract baselines have not yet been adjusted for waiting list funding received from NHS England. Actual Cost £118,838,701 £175,112,462 Adjustments RTT and KPI penalties have now been applied to the contract reports received from the Trust. Adjustment Applied for KPI Penalties/RTT Breaches £(539,770) £0 Further adjustment made for the pending CV for RTT activity which will be issued in February. Critical Care has Variance as per Trust SLAM Reports £2,112,616 £0 been adjusted pending the Audit, and FP10 over spends have now been recognised by the CCG and are CCG Adjustments £(1,674,344) £0 reflected in the CCG Community Services budgets. Adjusted Forecast Outturn £438,272 £0 Issued Queries Critical Care overperformance.

Contract Performance - By POD Month 8 Year to Date Annual Contract Point of Delivery Value £ Planned Activity Actual Activity Activity Variance £ Plan £ Actual £ Variance Planned Activity Actual Activity Activity Variance £ Plan £ Actual £ Variance

Accident and Emergency £8,614,057 6,773 6,935 162 £688,646 £717,188 £28,543 56,814 57,901 1,087 £5,777,241 £5,942,975 £165,734

Non Elective Admissions £45,091,493 2,477 2,472 (5) £3,819,680 £3,899,072 £79,392 18,989 19,994 1,005 £30,024,399 £31,805,336 £1,780,937

Maternity £12,733,894 1,285 1,233 (52) £1,031,280 £1,062,462 £31,182 10,636 10,826 190 £8,597,256 £8,702,488 £105,232

Elective & Daycase £24,702,814 1,809 1,862 53 £2,076,977 £1,795,495 £(281,483) 14,604 15,309 705 £16,377,657 £15,721,382 £(656,275)

Outpatient First £8,068,524 5,303 5,425 122 £682,767 £699,302 £16,536 43,309 46,430 3,121 £5,613,346 £5,861,683 £248,336

Outpatient Follow Up £8,477,270 9,699 9,370 (329) £700,743 £673,482 £(27,260) 79,325 75,979 (3,346) £5,697,234 £5,414,415 £(282,819)

Outpatient Procedures £6,071,577 3,253 3,244 (9) £517,983 £493,053 £(24,930) 26,128 24,892 (1,236) £4,205,836 £3,873,116 £(332,720)

Excess Bed Days £2,743,575 1,001 690 (311) £219,052 £155,149 £(63,902) 8,341 8,100 (241) £1,826,036 £1,830,769 £4,733

Unbundled Diagnostics £2,085,064 0 2,290 2,290 £173,755 £173,755 £0 0 17,745 17,745 £1,390,043 £1,390,043 £0

Direct Access - Pathology £2,714,905 0 0 0 £226,242 £226,242 £0 0 0 0 £1,809,937 £1,809,937 £0

Direct Access - Radiology £844,474 0 1,951 1,951 £70,373 £70,373 £0 0 16,906 16,906 £562,983 £562,983 £0

ECG £587,818 717 649 (68) £55,242 £49,973 £(5,269) 5,146 5,170 24 £396,263 £398,090 £1,827

Community £39,274,010 0 0 0 £3,173,780 £3,252,448 £78,668 0 0 0 £25,837,519 £26,607,151 £769,633

Block - Acute £4,408,960 0 47 47 £361,647 £407,084 £45,438 0 204 204 £2,962,373 £3,085,246 £122,873

OTHER £8,694,027 69 3,381 3,312 £773,538 £903,499 £129,961 525 25,728 25,203 £6,187,733 £6,372,857 £185,124 Total 174,962,519 32,387 39,549 7,162 £14,571,704 £14,578,579 £6,875 263,817 325,184 61,367 £117,265,856 £119,378,471 £2,112,616

Urgent Care - Actual v Plan - £'000s Planned Care - Actual v Plan - £'000s RBH - GP Referrals £6,000 £4,500 GP Referrals RBH - (Excludes Dental) £4,000 4500 £5,000 £3,500

£4,000 £3,000 4000

£2,500

£3,000 £000s £000's 2011/12 Plan £2,000 Plan 3500 Actual Actual 2012/13 £2,000 £1,500 2013/14 3000 2014/15 £1,000 £1,000 £500 2500 £0 £0

Actions / Reviews

To understand the increase in Urgent Care the following CCG reviews are ongoing and will be reported at the next F & A Group in February: * A comprehensive review is being undertaken to determine what is driving the increased activity in urgent care which includes the investigations on the impact on NELs following the closure of BCU. * A&E Conversion rates against 2014/15 plan and year on year comparison will be reviewed. * Readmission performance year on year on against the agreed threshold of 18% which was set following the November 2014 joint readmission audit. * Best Practice Tariffs - Audits planned in February to validate that Best Practice Tariffs applied in year meet the BPT criteria. * Critical Care - An audit is planned at the end of January to validate the acuity of patients and to understand if the baseline assumption and plan reflects last years actual. BOLTON CCG QUALITY PREMIUM RESULTS 13/14

£524,811 £874,684 ACHIEVED* MISSED Patient Population: 279,899 * Subject to quality and budget contraints Total Quality Premium Available: £1,399,495

14 15 16 17 18 19 20 21 22 23 24 25 2014 26 27 YTD / Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Target £ Potential £ Achieved* Commentary Forecast

Reducing PYLL through Latest data released Sept 14 2326 2564 £174,937 £174,937 for 01/01/13-31/12/13 (Next Y amenable mortality publication Sept 15)

Reducing avoidable admissions 245 221 202 217 191 199 233 221 253 257 230 247 2716 3767 £349,874 £0 N Friends and Family Test - IP 78 77 78 73 79 78 76 79 79 80 84 79 82 80 79 81 78 (monthly) In order to achieve the quality £174,937 premium RBH has to show £0 an improvement from Q1 N Friends and Family Test - A&E 74 71 63 57 59 67 62 75 61 59 49 44 47 56 50 50 69 13/14 (68) to Q1 14/15 (monthly) 2 1 0 0 0 0 0 1 0 0 0 0 4 0 MRSA Incidence (monthly) £174,937 £0 N C. difficile Incidence (monthly) 7 9 11 10 10 8 6 7 7 10 6 5 96 52

(revis Lastest data released Health-related quality of life for (old ed 72.2% 71.6% 71% £174,937 £174,937 Aug 14 for 2013/14. Next Y people with LTC figure) figure Version due August 15 )

Lastest data released Aug 14 Total health gain assessed by PROMS score comparsion 44% 41% £174,937 £174,937 provisional data for 01/04/12- Y patients-Hip replacement 30/03/13 EQ-5D Index (HSCIC)

National Diabetes Audit- Miquest data gathered patients achieving all 9 care 51.9% 53.3% 56.4% 59% 55% £174,937 £174,937 from each GP practice on Y processes a quarterly basis

Unadjusted Total £699,748 18 week RTT - Incomplete 95.8% 96.1% 95.7% 95.0% 94.5% 94.6% 94.9% 95.4% 94.9% 95.3% 95.8% 96.0% 95.3% 92% -25% £0 Y (monthly)

A&E <4h CCG level (monthly) 94.7% 97.4% 97.3% 97.3% 97.1% 94.4% 96.4% 96.3% 96.9% 96.3% 96.6% 95.3% 96.4% 95% -25% £0 Y Cancer 62 day waits GP 82.9% 84.3% 95.5% 85.7% 92.1% 84.6% 86.7% 80.9% 74.2% 81.3% 83.3% 86.7% 84.4% 85% -25% £174,937 * Note N Referral (monthly)

Amb response <8 min (monthly) 75.6% 77.7% 79.6% 75.5% 78.8% 72.0% 74.2% 73.9% 74.9% 77.1% 75.3% 75.0% 75.8% 75% -25% £0 Y

Adjusted Total £524,811

* Please note that the 'reducing avoidable admissions' metric is currently being challenged due to an inconsistent methd of counting around the Bolton Community Unit * Note: none achievement of the constitution measures result in a penalty QUALITY REPORT

2014/15 Annual Area Performance Indicator Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Cumulative YTD Trend (Apr14-Nov14) Target

REDUCING MORTALITY

Summary Hospital Mortality Indicator (SHMI) (Oct 12-Sept 13) <1.1 1.078 1.078 1.078 1.063 1.063 1.063 1.056 1.056 1.068 Next data due July 14

PATIENT SAFETY

MRSA bacteraemia 0 0 0 0 0 0 0 0 0 0

HCAI - Trust only

Rates of C Difficile maximum 48 for full year 3 2 3 1 1 0 0 1 11

Number of falls 982 82 66 84 77 81 78 72 540

Falls with harm <5% Harm 3 2 na na na na na na 5

Percentage of Harm (Safety thermometer) <5% Harm 3.47% 5.11% 4.05% 4.17% 5.12% 3.69% 3.52% 1.64% 3.84%

Medication Incidents >834 FYE 74 76 78 127 109 121 123 89 797

Total Incidents 690 697 800 1053 841 974 1201 874 7130

(Apr13-Sept13) NPSA % Total incidents with no harm 59.3% 53.5% 54.0% 55.7% 61.1% 65.2% 56.4% 59.7% 58.1% 50%

Avoidable New Pressure Ulcers (Grades 2, 3 & 4) Acute& 105 FYE 5 10 8 7 5 Unavailable Unavailable Unavailable 35 Community

Nursing (nurses/midwifes) shifts (% Actual Vs Planned) Day need to agree tolerance No data available 90.6% 88.8% 86.0% 88.0% 90.1% 98.4% Not Yet Available 88.5%

Nursing shifts (% Actual Vs Planned) Night need to agree tolerance No data available 94.7% 94.8% 93.0% 93.0% 95.7% 92.9% Not Yet Available 94.2%

Care Staff shifts (% Actual Vs Planned) Day need to agree tolerance No data available 99.2% 100.8% 102.0% 104.2% 101.7% 95.9% Not Yet Available 100.7%

Care Staff shifts (% Actual Vs Planned) Night need to agree tolerance No data available 117.1% 113.1% 114.0% 121.7% 114.2% 109.8% Not Yet Available 114.7%

Number of SUIs 0 2 0 0 1 0 1 1 1 4

Number of never events 0 0 2 0 0 0 1 0 3

PATIENT EXPERIENCE (Bolton FT)

Complaints Responded to within time period 95% 97% 97% 94% 94% 78% 75% 91% 82% 89%

A&E Net Promoter Score 69 47 56 50 54 61 57 56 51 54

A&E Response Rate 15% 16.1% 18.7% 15.5% 19.3% 17.8% 17.9% 14.9% 20.2% 17.5%

78 82 80 79 81 77 77 80 78 80 Inpatient Net Promoter Score

15% 36.8% 41.9% 43.8% 41.3% 37.0% 42.6% 35.2% 39.0% 39.7%

Inpatient Response Rate

74 65 73 62 47 69 81 No Responses 67 Maternity Q1 Antenatal Care Net Promoter Score No target set

7.1% 9.4% 2.9% na na na na na 6.4%

Maternity Q1 Antenatal Care Response Rate No target set Response rate no longer being submitted

92 92 88 93 85 70 73 77 85 Maternity Q2 Birth Net Promoter Score No target set

10.8% 23.0% 12.3% 2.8% 6.9% 18.4% 17.9% 18.9% 15.0%

Maternity Q2 Birth Response Rate No target set

100 81 92 86 72 76 68 79 83 Maternity Q3Postnatal Net Promoter Score No target set

0.2% 14.3% 17.1% na na na na na 10.7%

Maternity Q3 Postenatal Response Rate No target set Response rate no longer being submitted

83 92 91 100 100 67 No Responses No Responses 84 Maternity Q4 Postnatal Community Net Promoter Score No target set

4.9% 2.7% 2.6% na na na na na 3.4%

Maternity Q4 Postnatal Community Response Rate No target set Response rate no longer being submitted

56.0% 59.0% 57.5% Friends and family staff (Quarterly)Percentage recommended - work No target set

71.0% 75.0% 73.0% Friends and family staff (Quarterly)Percentage recommended - Care No target set 2014/15 Annual Area Performance Indicator Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Cumulative YTD Trend (Apr14-Nov14) Target

STAFFING

Sickness Absence 3.75% 5.17% 4.81% 4.60% 4.70% 4.76% 4.57% 5.06% 4.78%

Mandatory Training - Compliance 100% 84.80% 85.20% 85.90% 85.60% 85.30% 85.50% 86.50% 85.50%

Quality Impact Indicators Appraisals Completed 80% 81.8% 79.4% 77.9% 78.3% 79.0% 79.0% 80.1% 79.1%

Induction Attendance 100% 81.50% 81.70% 81.30% 77.80% 68.10% 77.00% 82.90% 77.90%

Substantive staff turnover Headcount (rolling average 12 <=10% 9.3% 9.3% 9.3% 9.3% 9.4% 9.1% 9.2% 9.3% months)

CLINICAL EFFICIENCY AND EFFECTIVENESS

100% 97% 96% 98% 99.5% 98.0% 99.0% 99.0% 98%

Better Care, Better Value Surgical WHO Checklist compliance (Elective)

100% 97% 97% 100% 100% 100% 100% 99% 99%

Surgical WHO Checklist compliance (Emergency)

BEAUMONT

Number of SUIs 0 0 0 0 0 0 0 0 0 0

Independent Sector

Number of never events 0 0 0 1 0 0 0 0 0 1

PRIMARY CARE

Number of practices with 5 red indicators on the Primary Care Running Total 5 5 5 5 5 5 5 5 5 Dashboard Primary Care

Please note that due to Bolton FT not having a December Board some data will not be available until the next Board Meeting at the end of January 15. Reporting period: November 14 PERFORMANCE STATUS TREND Budgetted FTE Actual FTE RED Performance is above Target Increase since last month AMBER Performance is slightly above target No Change (may be on target and green) 142.07 94.89 GREEN Performance is on or below Target Decrease since last month

Performance Previous Month Current Month Organisation's Comments Indicator Against Trend Target Hotspots Measure Period Measure Period Target SECTION 1 Organisational Profile Total Headcount 112 Oct-14 112 Nov-14 N/A N/A Includes Non Exec/Lay Members

Total Staff in post (FTE) 94.79 Oct-14 94.89 Nov-14 N/A N/A

Substantive 96 Oct-14 95 Nov-14 N/A N/A

FTC 16 Oct-14 17 Nov-14 N/A N/A Includes 1 "undefined" Employment Employment Composition Bank 0 Oct-14 0 Nov-14 N/A N/A

SECTION 2 Organisational Movement Total No. Leavers 0 Oct-14 2 Nov-14 N/A N/A

Total No. New Starters 0 Oct-14 1 Nov-14 N/A N/A Turnover Rate 13.6% National Av Total FTE of Leavers in year / Average Total FTE of 8.56% Oct-14 10.92% Nov-14 GREEN (Average Calculation) 10.33% GM CCGs Employees in year No. 1 Oct-14 2 Nov-14 N/A N/A Advertised Vacancies FTE 1.00 Oct-14 2.00 Nov-14 N/A N/A

SECTION 3 Organisational Behaviour FTE Days Absent / FTE Days Available Rate 3.71% Sep-14 4.92% Oct-14 2.44% HSCIC * RED Month Sickness Absence NOTE: Sickness Absence information is only Cost £14,386 Sep-14 £21,656 Oct-14 N/A N/A available one month behind the current reporting period due to recording schedules. Rate 3.03% Sep-14 3.25% Oct-14 2.44% HSCIC * RED FTE Days Absent / FTE Days Available Annual Sickness Absence Cost £96,041 Sep-14 £114,526 Oct-14 N/A N/A

Community Services Quality Update to Board

1. Executive Summary

1.1 This is an update to Board on the current position with community services following the last report on the CCG’s ongoing quality concerns and relevant actions to be taken by Bolton FT.

1.2 The specific concerns raised to Bolton FT in relation to community services comprised of: • Several delays in the production of service delivery models for the key community services (in response to commissioner service specifications provided in summer 2014) • Delays in recruitment to new posts and existing vacancies • Concerns about high sickness rates across some services • Clinical incident reporting • Data quality of community services reporting

2. Action to Date

2.1 Bolton FT Executives were invited to present on the above issues to Bolton CCG Board members. This presentation and discussion took place on 12 December 2014.

The outcome of this meeting was outlined in a letter from the CCG Chief Officer to Bolton FT Chief Executive. The CCG Board did not receive the assurance or action plans required and raised specific concerns about the governance of community services quality and the commitment of Bolton FT to admission avoidance.

2.2 In order to provide evidence of delivery in community services, Bolton FT has been tasked with actions to improve performance, quality and data reporting. An action plan is under development (to be submitted by the end of January) and, once approved by the CCG, will form the basis of a monthly update to Board for assurance (from February 2015).

2.3 The concerns of the CCG Board about delivery of community services by Bolton FT have been escalated to Bolton Council as a key partner in Better Care Fund and integrated care commissioning and delivery.

2.4 To date the FT has met the first 2 key actions. Draft service delivery models were received by the CCG on the 9th of January in line with the agreed deadline. The CCG’s comments on these have been fed back to the FT and the Trust is now working on the final service delivery model submission at the end of January.

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The second action has been a meeting held between the CCG and the FT to discuss and agree the changes required to the community services reports to enable improved assurance to CCG Executive and Board. The new reports will include the additional CCG specified metrics of actual staff in post compared to budgeted posts, a breakdown of activity across new and follow up, more detail about harm free care and incidents and exception reporting from each service where the monthly performance means that the indicator is red RAG rated.

2.3 In terms of recruitment, all of the posts in the first phase of the Intermediate Tier expansion have been recruited to and recruitment to the second phase (from April 2015) is underway. There were also key areas with identified vacancies which are all being actively filled.

3. Further Action Required

3.1 Clear action plan with timescales that Bolton CCG can hold Bolton FT to account on for data improvement, service quality improvement and new service development.

3.2 Bolton FT is reviewing the information submitted on current staffing establishment (compared to the transfer under TCS) as the data did not correlate to previous information submitted to the CCG.

3.2 The CCG has not yet received a comprehensive report on the learning and actions from incidents and harm free care panels nor an agreed process for such in the future. This is being discussed with the FT at the February follow up meeting.

4. Summary of all Actions to be included in Plan from Bolton FT

4.1 From actions to date and outstanding actions, below is a high level list of all actions required from Bolton FT:

• Ongoing reporting on progress of recruitment across all community services

• Review of information on staffing levels (where there were differences between data submitted)

• Final submission of service delivery models in response to community service specifications by 31 January 2015

• Development of the revised community services dashboard (to include learning and actions from incidents and harm free care panels) and improvement in quality metrics

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5. Recommendations

This report highlights that, although progress has been made since the Board received the presentation from the FT in December 2014 from which Board concerns were fed back in a letter to Jackie Bene on 19th December, the Board cannot be fully assured of the quality of community services due to gaps in current information.

The Board of Bolton CCG is recommended to

• Request a formal update of progress against the action plan every month from February 2015

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NHS BOLTON CLINICAL COMMISSIONING GROUP Public Board Meeting

AGENDA ITEM NO: ……12…………

Date of Meeting: 23rd January 2015

TITLE OF REPORT: Chief Finance Officer Report for the month ending 31st December 2014. AUTHOR: Annette Walker/Jackie Murray

PRESENTED BY: Annette Walker

PURPOSE OF PAPER: (Linking to Strategic Objectives) To update the Board on the expected financial performance and risks to delivery

RECOMMENDATION TO THE NHS Bolton Clinical Commissioning Group is BOARD: asked to:- (Please be clear if decision 1. To note the contents of the report and the required, or for noting) financial position as at Month 9. 2. Recognise the increased level of risk and the decisions and required corrective actions. COMMITTEES/GROUPS PREVIOUSLY CONSULTED: The CCG executive has discussed and supports the recommendations to the Board.

The Board has been kept up to date on financial plans and the QIPP target required.

VIEW OF THE PATIENTS, CARERS OR THE PUBLIC, AND THE EXTENT Views of stakeholders will be obtained as part of OF THEIR INVOLVEMENT: the CCG commissioning plans.

EQUALITY IMPACT ASSESSMENT (EIA) COMPLETED & OUTCOME OF An EIA assessment is not required necessary ASSESSMENT: for the report.

1 Report of the Chief Finance Officer for December 2014

Financial Overview

Financial Plan Context: The financial plan is based upon notified allocations of £353m for Programme and Running Costs. Previously, allocations have been received relating to the national transitional monies to support Primary Care IT, the funding for Providers to ensure the delivery of Referral to Treat (RTT) targets, and additional RTT and winter resilience funding. This month an expected allocation of £525k has been received for the Quality Premium based upon performance in 2013/14. The current allocation is now £358.1m.

Key Financial Duties: The CCG is showing delivery of its key financial duties but there still remains some risk whilst the contract dispute with Bolton FT is drawing to a conclusion. The CCG is still working on a range of emergency measures to ensure delivery in line with its statutory financial duty. The CCG has been notified this month of a refund of the contribution to the Continuing Health Care risk pool for legacy claims. The funding has been returned on the basis that CCGs are required to show a corresponding increase in their surplus by an amount equivalent to this refund. The forecast surplus has therefore been increased by the CHC refund of £830k to £4,365k.

Year to Date Financial Performance: The financial position to month 9 is a surplus of £2,650k which is in line with the CCG’s financial plan. There is an on-going and increasing financial pressure on the Continuing Healthcare and Prescribing budgets. Whilst there are some underspends in other areas, reserves are currently being utilised to offset these pressures and deliver the year to date required surplus.

QIPP Programme: A separate paper presented to the CCG Board this month shows a significant shortfall against the year to date plan and a forecast shortfall of £1,370k against the full year plan. The impact of this on the CCG’s financial position is being managed through the application of the contingency reserve set aside at the beginning of the year. Detailed QIPP trajectories are presented to the Executive Team and continue to be updated monthly.

1. Summary of Expected Performance against Key Financial Duties

Table 1 below summarises the CCG’s statutory financial duties and performance targets required by NHS England. CCG financial plans have been formulated to ensure that these requirements are met. More detailed updates on these duties are provided from Section 2 onwards.

Table 1: CCG Financial Performance Targets Section Description Financial Performance Targets Expected Performance 2 Revenue Position Operate within approved revenue resource allocation in each and every year. Deliver a cumulative surplus carry forward of 1% minimum. Amber Hold a contingency of at least 0.5%. Spend 2.5% non-recurrently (including 1% for transformation/Call to Action).

3 Capital Work with NHS England to agree strategic estates N/A developments.

2 4 Running Costs Not to exceed the Running Cost Allowance of Green £7,029k.

5 Cash Operate within its approved cash maximum draw- Green down limit in each and every year. 6 Business Conduct Comply with the Better Payments Practices Code. Green

7 Quality, Deliver an efficiency across the CCG’s expenditure Innovation, baseline in order to meet the QIPP challenge. Red Productivity & Prevention (QIPP 8 Financial Risk Financial risks and mitigating actions are identified Amber and reviewed on a monthly basis.

9 Statement of Net Current Assets matches Taxpayers Equity. Green Financial Position

2. Revenue Position

The current revenue position as at month 9 is summarised in Table 2 below. The CCG is reporting a year to date surplus of £2,650k and a forecast year-end surplus of £4,365k which is above the original target due to the return of funding from the CHC risk pool for legacy claims. There continues to be a number of areas causing concern, namely, Acute Services, Prescribing and Continuing Care.

Table 2: Revenue Budget 2014/15 November YTD YTD YTD Annual Forecast Forecast Budget Spend Variance Budget Spend Variance £000’s £000’s £000’s £000’s £000s £000s Acute Services 137,927 139,576 (1,649) 186,172 187,652 (1,480) Mental Health 21,006 20,935 71 27,977 28,005 (29) Learning Disabilities 3,032 2,799 233 4,343 3,877 467 Prescribing 37,895 38,372 (477) 50,604 51,318 (714) Community Services 34,543 34,435 108 46,419 46,319 100 Other Commissioning 5,091 5,038 53 6,191 6,229 (37) Primary Care 2,033 2,001 32 2,711 2,691 20 Continuing Care/Funded Nursing Care 12,466 13,302 (836) 15,373 16,498 (1,125) Corporate – Running Costs 5,107 4,691 416 7,029 6,541 488 Corporate – Non Running Costs 1,022 962 60 1,362 1,295 67 Reserve 0 (1,989) 1,989 6,393 3.319 3,074 Total CCG Expenditure 260,122 260,122 0 354,574 353,744 830

Allocation (262,772) (262,772) 0 (358,109) (358,109) 0

Surplus 2,650 2,650 0 3,535 4,365 830

The financial position of the CCG is driven by the performance of commissioned activity against contracted levels and delivery of QIPP schemes. There are significant concerns regarding the delivery in line with CCG budgets set as part of the financial plan and these have been identified in the Risks section of this report. It should be noted that over spends on some budgets has meant that the CCG has had to release reserves to ensure a balanced position is reported.

3. Budget Movements

There has been an allocation increase this month of £525k for the Quality Premium which has been based upon performance in 2013/14. This is lower than expected by £125k due to the increases seen in non-elective demand.

3 4. Expenditure Variances

Contract Performance Table 3 below is a summary of the year to date performance against contracts in place.

Table 3: Contract Performance 2014/15 Annual YTD YTD YTD Provider Budget Budget Actual Value Variance Value at at Month 9* at Month 9* £000’s Month 9 £000’s £000’s £000’s (Over)/Under Bolton FT (Acute only) 135,838 101,879 102,372 (493) Salford Royal 7,507 5,638 5,843 (205) Central Manchester 5,369 4,036 3,968 68 Wrightington, Wigan & Leigh 5,441 4,088 3,988 100 UH South Manchester 1,992 1,494 1,610 (116) Lancs Teaching Hospital 1,631 1,223 1,316 (93) Pennine Acute 1,467 1,100 1,152 (52) East Lancashire Hospital 557 418 503 (85) Royal Liverpool 117 88 136 (48) Stockport 82 62 119 (57) Total Acute NHS Services 160,001 120,026 121,007 (981) BMI Beaumont 4,883 3,663 4,242 (580) Care UK (85% of contract ) 2,424 1,818 1,704 115 Alliance Medical 635 476 436 40 Oaklands Hospital 299 224 335 (111) Euxton Hall 140 105 78 27 Other 154 115 114 1 Total Independent Sector 8,536 6,402 6,910 (508) Ambulance Services 8,194 6,145 6,104 41 Non Contract Activity 2,450 1,837 1,995 (158) AQP 1,180 883 1,036 (153) Other 5,812 2,634 2,523 111 Total Acute Services 186,172 137,927 139,576 (1,649) * Performance based on month 8 actuals projected to month 9.

The CCG has received month 8 performance data relating to acute contract activity from all providers. The position on acute contracts shows a reduction in over performance from £1,724k in November to £1,649k in December. All providers are above plan apart from Central Manchester FT, Wrightington, Wigan and Leigh FT, Care UK, Alliance Medical and Euxton Hall.

Bolton FT’s contract continues to over perform significantly in the areas of A&E and Emergency Admissions. This trend has continued from the previous year and is considered to be linked to the closure of the Bolton Community Unit (BCU), which the FT is disputing but discussions are taking place to understand this. The FT is reporting an over performance on the acute element of the signed contract of £1,343k, of which the CCG is challenging £299k in relation to critical care. A further sum of £533k relating to additional activity to achieve 18 Week RTT has been adjusted from the position as this will be funded by contract variation from national funding. The contract position is being discussed in detail through the joint Finance & Activity Sub Group of the Contract Review Board which meets monthly.

The performance on Salford Royal relates to critical care, a high number of excess bed days and upper gastrointestinal procedures. The position has deteriorated in month due to an increase in Daycase & Elective activity relating to 18 week waiting list backlog additional activity, however, the CCG has funded this from reserves. Re- allocation of critical care activity following the discharge of the patients to NHS

4 England continues between flex and freeze positions each month therefore the November position has been adjusted for the estimated rebate due.

The BMI Beaumont contract over performance has increased during November to a cumulative variance of £580k above plan. Further analysis of planned care, across all providers, has concluded that overall the CCG is below plan by £693k for Electives, Daycase and Outpatients; therefore it appears that the over spend at BMI Beaumont is due to a shift in year from NHS Trusts to the Independent Sector.

The contract over performance on AQP of £153k includes Bolton FT activity however increased activity with other AQP accredited providers for Diagnostics and Adult Hearing is driving the overspend in 2014/15. Validation processes are being agreed with NW CSU across all areas of activity which will provide assurance to the Board that the CCG is being charged appropriately.

Community Services

The Community Services budget is forecast to underspend by £100k mainly due to slippage in Integration and Intermediate Tier budgets.

The Bolton FT Community Services Contract is predominantly on a block arrangement. However Bolton FT has advised that they are incurring additional estimated charges of £1.2m for non-medical prescribing on FP10s within Community Services. The CCG has worked to verify this information with Bolton FT and has now built this into the forecast outturn position and has funded from reserves.

There is an over performance of £28k on the community contract with Salford Royal FT relating to additional activity on District Nursing. To off-set this, there is a small under performance on the community contract with Lancashire Care.

Prescribing

The Prescribing budgets for 2014/15 are based on 2013/14 outturn. The over spend to date is based on the actual spend for April to October and estimated spend for November and December based on the average monthly spend. There is a forecast overspend on GP prescribing and oxygen, partially offset by an under spend on the central drugs budget which is also included in this expenditure category. The net position is a forecast over spend of £714k which is an increase of £553k from last month’s position. This overspend is after additional funding transferring from CCG reserves for the category M policy change.

The forecast is provided by the NHS Prescription Service and the national position on prescribing is reporting a similar, higher than anticipated, increase in forecast outturn figures. This is the result of both category M price increases and an increase in prescription volumes for October, above that typically expected for the month.

The NHS Prescription Service states that it expects to see this figure decreasing over the next few months once the seasonal increase in volume has passed. However, based on Bolton’s expenditure trends over previous years, there is usually an increase in costs in the last quarter of the year so there is a risk that the final annual cost could be higher and this is identified as a risk in Table 7.

5 Continuing Care

The Continuing Care commissioning budget has been set at 2013/14 outturn. The budget continues to overspend, which is a cause for concern and is recognised as a further area of risk in Table 7. The forecast outturn position has increased from £928k reported last month to £1,125k this month. The increase is mainly due to new CHC packages awarded and late invoices for previous periods of care. A recovery plan and action plan is now in place and this work is being led by the Chief Nurse.

The CCG has contributed £1,333k to a risk pool for the estimated cost of legacy claims to be settled this financial year. There is an underutilisation of this pool and CCGs have been notified this month that they are to be refunded their appropriate share of this. For Bolton CCG the refund is £830k but does not impact on the forecast outturn variance on the Continuing Care budget as the funding has to be shown as an increase to the surplus.

Reserves

The detail of the reserves held by the CCG and the movement from the position in the 2014/15 Financial Plan is reported in Table 4 below:

Table 4: Reserves Movement As Per Movement Movement Current Financial up to this Balance Plan month 9 month £000’s £000’s £000’s £000’s Investments & Pressures 3,577 (735) (979) 1,863 2.5% Non-Recurrent Reserve 8,650 (5,928) 648 3,370 0.5% Contingency 1,767 0 0 1,767 Risk/Contract Reserve 6,348 (2,255) 0 4,093 QIPP (4,700) 0 0 (4,700) Total 15,642 (8,918) (331) 6,393

The main changes this month on reserves relate to an additional allocation for Quality Premium of £525k and a refund from the national risk pool for Continuing Health Care legacy claims £830k. The following non-recurrent funding has transferred into budgets:- - Innovation Schemes £123k - FP10 pressure on Bolton Community contract £1,154k - Cat M drug price increase £350k - GM Risk Share £52k.

5. Capital

The governance and approval process has been established for investment in property, equipment and ICT for CCGs and Primary Care for which capital funds are available in 2014/15. CCG and Primary Care schemes that are eligible for capital funding have been reviewed and prioritised in accordance with the guidance, and submitted to NHS England in for consideration. The CCG is awaiting a response on those bids which have been successful, but early indications are positive.

6 6. Running Costs

The running cost budget is set to match the CCG’s running cost allocation of £7,029k. There is an under spend to date of £416k and a forecast outturn underspend of £488k. This is mainly due to slippage on posts, an under spend on the training budget and a reduction on the GM Commissioning Support Unit SLA relating to Provider Quality Management and IT. CCGs are able to underspend against their running cost allocation in 2014/15 in preparation for the planned reduction of 10% in 2015/16. A review of recurrent running costs has taken place through the Executive Team and further work is on-going to ensure that this reduction will be delivered for next year.

7. Cash

The Maximum Cash Drawdown (MCD) issued by NHS England at month 9 is £354.4m. The MCD is based on the allocation at month 3 with adjustments for the planned surplus, other non-cash items and any subsequent allocation adjustments to date. The MCD will be reviewed periodically throughout 2014/15 to enable the CCG to revise the MCD in year to reflect actual cash requirements, subject to the overall NHS England cash position. The CCG has received £262.2m of the MCD, representing 74.0% to December 2014. There are no concerns regarding the delivery of this target.

8. Business Conduct

The Better Payment Practice Code (BPPC) target for the CCG is to pay 95% of valid invoices by volume and value within 30 days. Table 5 below shows achievement of the target for the financial year by paying 99.0% of invoices (by value) and 96.0% (by volume) within 30 days, after adjustments for local knowledge.

Table 5: Better Payment Practice Code % of Invoices Paid Year To Date Target Status within Payment Terms % % By Value 99.0 95.0

By Volume 96.0 95.0

9. Quality, Innovation, Productivity & Prevention (QIPP)

In order to meet its statutory financial duties, manage financial risk and fund required investments, the CCG plans to deliver QIPP savings of £4.7m in 2014/15. This is planned to be achieved through the delivery of the CCG’s Commissioning Plans, the details of which are being presented in a separate QIPP paper at this CCG Board meeting. A summary of the forecast achievement against the financial plan is shown in Table 6 overleaf:

7 Table 6: Summary of QIPP 2014/15 Plan FOT Variance £000’s £000’s £000’s Commissioning 2,791 2,590 (201) Medicine optimisation 904 738 (166) Other 1,005 2 (1,003) Additional Required 0 1,370 1,370 Total 4,700 4,700 0

There is currently a shortfall against the plan and as a result reserves are being utilised to ensure that the CCG delivers a balanced position. The table above identifies the level of additional schemes required to ensure the delivery of the £4.7m target. This level of achievement is built into the forecast financial position. However, risks to the delivery of QIPP have been included in the next section.

10. Financial Risk

An evaluation of our financial risks has been undertaken. Table 7 below shows the risk areas, probability, value and mitigation in place to manage the risk. The level of risk has reduced from £5.8m last reported in month 7 to £2.8m in month 9. The Board should note this reduced level of risk but that if these risks crystallised then the CCG would under deliver its control total.

Table 7: Evaluation of Financial Risks – not included in the current forecast Risk H/M/L Value Change from Previous / Mitigating Actions £ Failure to control demand M 0.5 Reduced from £1m last month as more certainty on the position as we near year end. Elective and non-elective QIPP programmes established. Risk reserve established. QIPP plans fail to deliver the M 0.5 QIPP processes embedded and regular required level of cost monitoring in place. improvement Health economy governance established and developing, including engagement directly with BFT divisional teams. Detailed updates to Executive and CCG Board. Entered onto risk register. Risks included in the financial position. Failure to control prescribing M 0.5 Category M price increase from 1st October spend and deliver efficiency 2014. Medicines management QIPP programme established. Regular monitoring in place. Bolton FT Community Contract FP10 additional spend. Validation processes and discussions with BFT underway. Failure to control demand and M 0.2 Further risk reduced from £0.3m following spend on Continuing increased costs recognised in forecast Healthcare. outturn. Reported forecast outturn position increased to £0.9m so further risk reduced from £1m to £0.3m. Forecast outturn position on budget has stabilised over last 3 months so risk reduced from £1.5m to £1m. 8 Full review and recovery plan in process. £0.5m of risk included in financial position from mth 3 so reduced from £2m to £1.5m. New database being implemented from May will help streamline processes and improve cost forecasts. Failure to control demand and M 0 Risk removed as any further pressures spend on high cost placements expected to be met from existing budget eg mental health for this year. High cost placements to date funded within existing budgets and risk of further placements reduces as year goes on. Risk reserve established.

Specialist Commissioning – L 0 Risk removed as any further alignment funding risk due to further will not be agreed. alignment of contracts CCG will not agree any further alignment of funding as moved to new allocation formulae. Bolton FT Contract Challenges M 0.8 This risk has been reduced following including Counting and coding further discussions with the FT. The issues process is expected to conclude by the end of January CCG working through a process to resolve the issues. Total 2.5

The executive team will continue to review the level of financial risk every month and review the full range of financial scenarios to ensure mitigations are in place and keep the Board fully apprised of the forecast outturn.

11. Statement of Financial Position

Table 8 below shows the Statement of Financial Position as at 31st December 2014 compared to the position reported in the CCG annual accounts at 31st March 2014.

Table 8: Statement of Financial Position Statement of Financial Position 31‐Dec‐14 31‐Mar‐14 Commentary £'000 £'000 Total Non‐Current assets 0 0 Current assets Trade and Other Receivables Receivables 1,554 1,246 Monies owing to CCG by other organisations Prepayments and accrued income 4,320 236 Expenditure paid in advance /income not yet invoiced Cash & cash equivalents 1,212 1 Cash at bank/in hand Total Assets 7,086 1,483 Total monies owed to CCG plus cash /bank Current Liabilities Trade & Other Payables Payables (7,812) (5,274) Invoices received from providers/suppliers but not yet approved/paid Accruals and deferred income (12,851) (11,814) Expenditure for services received not yet invoiced by provider/supplier Provisions Current (717) (358) CHC Restitutions and EUR cases approved and the Bolton CCG share of CMUHFT reconfiguration costs payable within 1 year Non current 0 (415) Total Liabilities (21,380) (17,861) Total monies owed by CCG Total Assets Employed (14,294) (16,378) Total monies owed by CCG net of total monies owing to the CCG Financed by Taxpayers’ Equity General Fund (14,298) (16,382) Compares the total costs incurred since established, less cash funding Revaluation Reserve 4 4 Revaluation reserve held on nil value Furniture and Fittings transferred from Bolton PCT Total Taxpayers’ Equity (14,294) (16,378) Total Investment by Taxpayers

9 The movement in taxpayer’s equity reflects the timing of cash flows compared to expenditure incurred, however fluctuations are normal as the year progresses. There are no significant issues to report. The movement between current and non-current provisions anticipates the payment of Bolton CCG’s share of Central Manchester University Hospital FT reconfiguration costs within 1 year.

Action Requested

The CCG Board is asked to:

1. Note the financial position at month 9 and the increase in the required control total. 2. Recognise the increased level of risk and the decisions and required corrective.

Annette Walker Chief Finance Officer

NHS BOLTON CLINICAL COMMISSIONING GROUP Public Board Meeting

AGENDA ITEM NO: ………13………………

Date of Meeting: …23rd January 2015………

TITLE OF REPORT: QIPP Programme Update

AUTHOR: Fiona Moore – Assistant Chief Officer

PRESENTED BY: Su Long – Chief Officer

PURPOSE OF PAPER: NHS Bolton CCGs Quality Improvement (Linking to Strategic Objectives) Productivity & Prevention (QIPP) Programme concentrates on improving productivity and eliminating waste while focusing relentlessly on clinical quality to: • Improve health outcomes. • Shift resources from hospital to community and primary care services. Our aim is to have fewer emergency admissions and more people supported in their own homes rather than in hospital.

This supports the CCG Objectives to improve the quality of care and patients' experience of care and to ensure best value of our budget, funded by the taxpayer.

This report: - Provides further detail to Bolton CCG Board on the progress of the QIPP Programme. - Highlights the schemes in development to enable achievement of the QIPP and financial plans.

RECOMMENDATION TO THE NHS Bolton Clinical Commissioning Group BOARD: Governing Body Board is asked to:- (Please be clear if decision • Note the contents of this paper. required, or for noting) • There is a gap at month 9 in delivery against plan which requires getting schemes back on track and identification of additional new schemes to deliver the required QIPP target of £4.7m.

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COMMITTEES/GROUPS CCG Executive PREVIOUSLY CONSULTED:

VIEW OF THE PATIENTS, View of patients, carers and the public will be CARERS OR THE PUBLIC, AND obtained on appropriate QIPP Projects; this is THE EXTENT OF THEIR embedded into each project plan.

INVOLVEMENT: Public views on the commissioning plan are currently being gathered – these include ideas for reducing waste and redesigning services which will be used to influence our QIPP projects.

EQUALITY IMPACT All schemes within the programme are Equality and ASSESSMENT (EIA) Quality Impact Assessed as part of Project initiation. COMPLETED & OUTCOME OF ASSESSMENT:

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QIPP Programme Update

1. Executive Summary

1.1. This paper provides an overview of Bolton Clinical Commissioning Group (CCG) Quality Innovation Productivity & Prevention (QIPP) Programme and gives a year to date position on progress.

1.2. In summary: - Year to date QIPP delivery at month 9 stands at £2,065k against a month 9 plan of £3,264k – this includes additional schemes that were not included in the plan at the beginning of the year. - The forecast outturn for QIPP savings in 2014/15 is £3.33m against a target of £4.7m to deliver our financial requirements. This is based on the current in year delivery and profiled trend to year end. - Further schemes for 2014/15 have been identified and anticipated financial savings values have been allocated to some while others are still being profiled – this will only go part way to achieving the £4.7m target. - Additional schemes to a minimum value of £1,648 and/or over delivery of current schemes are required to achieve the £4.7m target.

2. Introduction and Background

2.1. The purpose of this document is to give an update and provide assurance on the current delivery status of Bolton CCGs 2014/15 QIPP programme for the CCG Board and external scrutiny.

2.2. The purpose of the QIPP programme is to ensure the best use of allocated resources to support the organisations objectives and free up resource to invest in the transformation of services outlined in the commissioning strategy.

2.3. All commissioning schemes have been re-profiled – as a result of later than anticipated scheme start dates and additional information as the schemes have developed. This has resulted in a reduction in the anticipated savings previously reported.

2.4. New schemes have been identified to fill some of this gap.

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3. Finance Update

3.1. The graphic below outlines the 2014/15 Bolton CCG QIPP Programme position at month 9 in a visual format.

- Forecast Outturn – is an estimate of what the activity or position will be as at the end of the Financial Year based on the information at month 9. - Actual - is the actual QIPP savings figure for the period between April 2014 and December 2014 (month 9). The actual year to date QIPP saving being achieved is £2,065k against a month 9 target of £3,264k (£667k original schemes and £1,397k additional schemes) - 2014/15 Plan - is the QIPP savings figure the current in year schemes were planned to deliver. - 2014/15 Target - this is the QIPP savings target set for the current year 2014/15 £4.7m. - Additional Schemes – is the current potential impact of additional schemes in the work up stage of the QIPP process. - Unallocated QIPP – is the gap between the planned schemes, additional schemes and the target set i.e. the number of further additional schemes required for the CCG to be able to achieve its QIPP target. To address this gap currently, £1060k has been transferred from reserves – an improvement on the position last month.

3.2. Appendix 1 provides the above information in more detail, at individual project level and in tabular format.

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3.3. There is a gap at month 9 in delivery against plan which requires getting schemes back on track and identification of additional new schemes to deliver the required QIPP target of £4.7m.

3.4. To enable the planned investments that were to be funded from QIPP achievement a transfer from reserves has taken place – for complete transparency this is also highlighted above and in appendix 1.

3.5. The impact of potential non delivery of QIPP this year results in an increased QIPP target for 2015/16 – this is highlighted in graphical form below

3.6. If we continue with the current level of QIPP delivery for 2014/15 there will be a shortfall which will need to be recovered in 2015/16.

3.7. Schemes to deliver QIPP in 2015/16 are currently in development and have been profiled as indicated in appendix 1.

4. Exception Reporting

4.1. Integration As previously reported it was anticipated that savings from the implementation of Integrated Health and Social Care would be realised from July 2014. Due to the current pace of delivery of this programme of work the anticipated savings are yet to be seen and expectation that these would start to deliver in quarter 3 at the latest have not been realised.

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4.2. Medicines Optimisation – planned schemes As previously reported new schemes, such as the changeover of antipsychotic medication, are dependent on new molecules gaining MHRA approval – likely to be in Q3/Q4 2014/15, but this will generate substantial savings, once approved and licensed. A paper giving an overview and explanation of current prescribing budget streams, the central issues and drivers behind the pressures has been produced for the CCG Clinical Executive and shared with Board members to give a level of assurance when reviewing or assessing performance versus expected milestones. A further more detailed paper has now been requested given further deterioration in this area.

4.3. Continuing Healthcare (CHC) The CHC budget continues to overspend. The Chief Nurse is undertaking a workforce review of the Continuing Healthcare Team to identify new and efficient ways of working and clarity on job and roles.

4.4. Out of Area Placements The development of an Out of Area Framework has now been on hold for 12 months as a result of delays and decision making within the North West Commissioning Support Unit.

4.5. Provider Delays A number of schemes have been taken longer than anticipated due to participation of providers: - Delays in recruitment – Integration, Intermediate Care and Care Homes - Issues with provider engagement – Acute Paediatric Redesign, Gynaecology and A&E Redesign - Provision of information – RAID

4.6. Governance Process A number of schemes have taken longer than anticipated to implement as the governance/decision making/engagement processes had not been included realistically within project plans – MSK & Gastroenterology. All commissioning/project managers now have a meeting plan for the year to ensure they plan governance/decision making/engagement processes.

4.7. Clinical Lead Identification The lack of a Clinical Lead has delayed the progress of the Ambulatory Care Pathways scheme – this post has now been appointed to.

4.8. Commissioning Manager Capacity Within the area of elective care there were a large number of schemes to deliver. Now that those schemes listed in section 5 are in the delivery monitoring phase schemes such as Diagnostics and the Bolton Offer can now be picked up.

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5. Schemes in Delivery

5.1. A number of schemes Gynaecology, ENT and Urology have moved into the delivery monitoring phase. As can be seen from the detail in appendix 1 these schemes are delivering although not all to plan – this has been confirmed through data analysis and tracked through to under spend within the elective care budget.

6. Additional Schemes

6.1. A number of the additional schemes have now been worked up to a level where financial targets have been developed and are being achieved - £1,397k.

6.2. Work has started on profiling the impact of the ‘Bolton Offer’ and these are now highlighted in appendix 1 – although the schemes won’t deliver in year this enables us to forward plan for 2015/16.

7. Recommendations

7.1. NHS Bolton Clinical Commissioning Group Governing Body Board is asked to:- 7.1.1. Note the contents of this paper 7.1.2. There is a gap at month 9 in delivery against plan which requires getting schemes back on track and identification of additional new schemes to deliver the required QIPP target of £4.7m

Fiona Moore Assistant Chief Officer 15th January 2015

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QIPP 2013/14 - January Report Month 10 In Year Performance Full Year Effect Year to Year to Year to Date Date Annual Forecast Forecast Annual Forecast Forecast Start date Date Plan Actual Variance Plan Actual Variance Plan Actual Variance £000's £000's £000's £000's £000's £000's £000's £000's £000's H1 Urgent Care Demand Apr £2,500 £2,094 -£406 £3,000 £2,513 -£487 £3,000 £3,000 £0 H2 Elective Care Apr £2,500 £901 -£1,599 £3,000 £1,081 -£1,919 £3,000 £3,000 £0

Hold H3 Prescribing/Medicines Apr £1,667 £1,667 £0 £2,000 £2,000 £0 £2,000 £2,000 £0 Total 'Hold' Schemes £6,667 £4,662 -£2,005 £8,000 £5,594 -£2,406 £8,000 £8,000 £0 R1 Referrals Management Nov £436 £436 £524 £524 £1,176 £1,176 £0 R2 Reduce Follow-ups Nov £1,123 £1,123 £1,348 £1,348 £1,348 £1,348 £0 R3 Care Homes Jan £0 £0 £0 £0 £139 £139 £0 R4 Continuing Healthcare Oct £0 £0 £0 £0 £2,000 £0 -£2,000 R5 Out of Area Placements Oct £93 £93 £114 £114 £114 £114 £0 R6 SIP Feeds Dec £0 £0 £12 £12 £321 £321 £0 R7 Dressings Oct £7 £7 £13 £13 £23 £23 £0

R8 Generic to Brand Apr £371 £371 £409 £409 £409 £409 £0 Reduce R9 Existing Medicines Management Apr £349 £349 £474 £474 £474 £474 £0 R10 RAID Jan £0 £0 £75 £75 £600 £600 £0 R11 Estates and Infrastructure Apr £44 £44 £50 £50 £50 £50 £0 R12 MSK pathway review* £0 £0 £0 £0 £350 £350 £0 R13 Advancing Quality* £0 £0 £0 £0 £243 £243 £0 Total 'Reduce' Schemes £0 £2,423 £2,423 £0 £3,018 £3,018 £7,248 £5,248 -£2,000 Sub-Total of Identified Schemes £6,667 £7,085 £418 £8,000 £8,612 £612 £15,248 £13,248 -£2,000 Schemes under development/yet to be identified £2,752 R14 Intermediate Tier R15 Integration R16 Acute paediatric pathways R17 Ambulatory Care R18 High cost drugs R19 A&E deflection R20 Community Redesign R21 IAPT review work R22 Gynaecology R23 ENT R24 Upper GI R25 Urology R26 Dermatology R27 Cardiology R28 Respiratory R29 Anticoagulation R30 Diagnostics R31 GM CATs

R32 Looked After Children Additional Schemes R33 Interpretation Services R34 Contracting 1 – C2C R35 Contracting 2 – OPFU R36 Contracting 3 - Readmissions R37 Contracting 4 – Pre Op Assessments R38 Contracting 5 – ECG R39 Corporate 1 - Printers R40 Corporate 2 - Parking R41 Decapeptyl SR Triptorelin SR for Prostate Cancer R42 ONS and Sachet based feeding R43 Antipsychotic treatment – Standard tablets R44 Isosorbide Mononitrate MR R45 Psoriasis treatment

NHS BOLTON CLINICAL COMMISSIONING GROUP Public Board Meeting

AGENDA ITEM NO: ………14(i)………………

Date of Meeting: …28th November 2014………

TITLE OF REPORT: Healthier Together Committee in Common (CiC) Minutes from 21/11/14 meeting.

AUTHOR: Healthier Together Team.

PRESENTED BY: Su Long – Chief Officer

PURPOSE OF PAPER: To provide the Board with an update on the (Linking to Strategic Objectives) discussions at the Healthier Together CiC meeting in November.

RECOMMENDATION TO THE The Board is asked to note the update. BOARD: (Please be clear if decision required, or for noting)

COMMITTEES/GROUPS Healthier Together Committee in Common. PREVIOUSLY CONSULTED:

VIEW OF THE PATIENTS, Patient views are not specifically sought as part of

CARERS OR THE PUBLIC, AND this report. THE EXTENT OF THEIR INVOLVEMENT:

EQUALITY IMPACT EIA and an assessment is not considered ASSESSMENT (EIA) necessary for the report. COMPLETED & OUTCOME OF ASSESSMENT:

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Shared Minutes of the Healthier Together Committees in Common Meeting held in Public

Agenda Item Number A1.4

Date of meeting: 17 December 2014

Date of paper: 21.11.2014 Subject: Healthier Together Committees in Common Decision / Opinion Required: For approval Author of paper and contact Lisa Murch [email protected] details: Purpose of paper:

For record of the Shared Minutes of the Healthier Together Committees in Common meeting held in public on 19 November 2014.

The item has been discussed n/a previously at these meetings:

Title Minutes taken at the meeting of the Greater Manchester CCG Healthier Together Committees in Committee

Author Lisa Murch

Version 0.2 Target Audience Healthier Together Committees in Common

Date Created 21/11/2014

Date of Issue 10/11/2014

To be Agreed 17/12/2014 Document Status Draft (Draft/Final)

Description Greater Manchester CCG Healthier Together Committees in Common minutes of meeting 19/11/2014 Document History:

Date Version Author Notes

21/11/2014 0.1 L Murch Draft minutes created

10/12/2014 0.2 G Batchelor Review of draft minutes

Approved:

Signature:

Phil Watson CBE, Chairman

Greater Manchester CCG Healthier Together Committees in Common (HTCiC)

SHARED MINUTES OF MEETING

Wednesday 19th November 2014 George Hatton Hall, Dukinfield Town Hall, King Street, Dukinfield, SK16 4LA

Chair – Phil Watson CBE

ATTENDANCE

Confirm meeting of the 12 Committees of : Bolton CCG Bury CCG Central Manchester CCG Heywood, Middleton & Rochdale CCG North Manchester CCG Oldham CCG Salford CCG South Manchester CCG Stockport CCG Tameside and Glossop CCG Trafford CCG Wigan Borough CCG Other organisations in Attendance: GM Service Transformation Hempsons Members in Attendance: Phil Watson CBE Independent Chair Dr Wirin Bhatiani Bolton CCG Stuart North Bury CCG -Deputy for Dr Kiran Patel Dr Michael Eeckelaers Central Manchester CCG Simon Wootton North Manchester CCG -Deputy for Dr Martin Whiting Denis Gizzi Oldham CCG -Deputy for Dr Ian Wilkinson Dr Paul Bishop Salford CCG Dr Ranjit Gill Stockport CCG Dr Bill Tamkin South Manchester CCG Steve Allinson Tameside and Glossop CCG -Deputy for Dr Alan Dow Dr Nigel Guest Trafford CCG Frank Costello Wigan Borough CCG -Deputy for Dr Tim Dalton Ken Griffiths Chair of Healthier Together External Reference Group Steven Pleasant Lead Local Authority Chief Executive for Health – AGMA Rep. Hamish Steadman Chair of the AGG Leila Williams Director Service Transformation Alex Heritage Programme Director Healthier Together Ian Williamson HT Lead CCG and SRO

Page 1 Other Attendees: Sophie Hargreaves Associate Director Service Re-Design Christian Dingwall Hempsons Solicitors Gemma Batchelor Assistant Director Programme Management Lisa Murch Portfolio Support Manager Service Transformation Apologies: Dr Kiran Patel Bury CCG Dr Chris Duffy Heywood Middleton & Rochdale CCG Dr Jerry Hawker East Cheshire CCG Dr Alan Dow Tameside & Glossop CCG Dr Thomas MacKenzie East Lancashire CCG Dr Tim Dalton Wigan Borough CCG Dr Jerry Hawker East Cheshire CCG Dr Debbie Austin North Derbyshire CCG Joanne Newton Chair of the HT Finance & Estates Group Quorate Requirements:

Achieved For a meeting at which no Category 1 decisions will be made, as close to 75% (in terms of whole numbers) of the voting members of the HTCiC are required to be in attendance or able to participate virtually by using video or telephone or web link or other live and uninterrupted conferencing facilities (9 out of the 12 voting members).

AGENDA

Item Paper/ Verbal Presenter 1. Welcome and Introductions Verbal Chair

1.1 Apologies for Absence Verbal Chair

1.2 Quorum Confirmation Verbal Chair

Declarations of Interests 1.3 Verbal Chair Confirmation of Part A Minutes 1.4 Paper Chair Decision Making Paper 2. Presentation / Ian Williamson / Paper Alex Heritage Consultation Reach and Engagement Report 3. Paper Ian Williamson Consultation response from the Greater Manchester Joint 4. Paper Scrutiny Committee Ian Williamson

Equalities Report 5. Paper Ian Williamson Briefing on Joint Working Group with Specialised 6. Paper Commissioning Leila Williams

Proposed Agenda for December (17th) 7. Paper Chair Any Other Business 8. Verbal Chair

Page 2 Item Paper/ Verbal Presenter Public Questions 9. Verbal Chair Date, Time & Venue of Next Meeting Wednesday 17th December 2014, Conference Hal, GMCVO, St Thomas Centre, Ardwick Green North, Manchester, M12 6FZ

MEETING NARRATIVE & OUTCOMES

1 Welcome and Introductions

The Chair welcomed everyone to the meeting and introductions were made.

1.1 Apologies for Absence

The Chair advised that apologies had been received from Kiran Patel, Chris Duffy, Jerry Hawker, Alan Dow, Thomas MacKenzie, Tim Dalton, Jerry Hawker, Debbie Austin, and Joanne Newton.

1.2 Quorum Confirmation

It was noted the meeting was quorate.

1.3 Declaration of Interests

It was established there were no declarations of Interest to be recorded for this meeting and members were advised to indicate any interests arising during the course of the meeting immediately.

1.4. Minutes of the previous meeting held on 15th October 2014

The minutes were accepted as a true record.

ID Type Risk/Issue/Action/Decision/Outcome Description Owner Nil

2. Decision Making Paper Ian Williamson introduced the paper which had been updated from the previous meeting in respect of the programme plan and timescales. The new proposal has reduced the timescales by 4 months whilst still maintaining a robust process. The central team has been supported by other programmes and regulators to ensure the process maximises the chances of success.

Alex Heritage delivered the presentation which highlighted all the planning theory and pointed out that an earlier version was sent out to Chief Executive Officers, Chief Officers and Chief Financial Officers. Some activities would run in parallel and the decision making would run to August 2015. The update included greater emphasis placed on leadership required to attain consensus between Commissioners and Providers; and the increased risk due to the timescale changes that the Committees in Common would have reduced time to review and make key decisions.

Page 3 The plan would be to ensure scenario 1 is met by attaining consensus during the timescale proposed with the revised governance arrangements put in place to strengthen locality ownership. It was also highlighted that the only decision makers would be CiC / Joint Committee.

Ian Williamson reminded colleagues that Category 1 decisions would need to be made at each further meeting so attendance at these meetings would be critical.

Ranjit Gill asked if a date had been secured for Dame Barbara Hakin to attend a future meeting and also if anything was forthcoming from NHS England.

Denis Gizzi advised that scenario 1 gives the shortest timeframe but asked what the mechanism was to liaise with Providers.

Stuart North explained that he was fully supportive of scenario 1 but if scenario 2 was to be followed Bury CCG would have to take stock as to an alternative scenario due to the North East Sector being unable to work to the timescales and would need to take legal advice.

Frank Costello asked how would the evaluation for the North West Sector be undertaken and how rigorous would the process be. He was also aware that Healthwatch has produced a detailed and lengthy transport response and asked how that would be picked up.

Ian Williamson thanked colleagues for the questions and comments. In relation to variant options raised, for example from other sectors, it was outlined that the Programme Board would discuss these and determine if they were viable. If a variant option was deemed viable the Programme Board would then recommend to the Joint Committee / CiC to that further analysis is undertaken on these variant options.

Alex Heritage confirmed he would write to NHS England again to gain clarity on the assurance process.

In respect of Dame Barbara Hakin no compatible dates have been found and informal dialogue remains with Paul Baumann.

Leila Williams added that it was important that everyone affected by the process had the opportunity to discuss with the CiC and therefore necessary to keep the Programme Board in an advisory capacity and to also draw out all the issues and influence.

The approach was agreed as a way forward.

ID Type Risk/Issue/Action/Decision/Outcome Description Owner Action Alex Heritage confirmed he would write to NHS England again to gain AH clarity on the assurance process.

3. Consultation Reach and Engagement Report Ian Williamson presented the paper which demonstrated how Healthier Together had complied with legislation in a variety of ways, and had used at times somewhat innovative or new to the NHS, methods to communicate, engage and consult with the public, patients and carers over the proposed changes. The paper also showed the effect that each method had in making Healthier Together visible to the Greater Manchester public and neighboring area and how they had responded, the total number of responses received was 29,347. He also reported that ORS would be invited to present at the December CiC meeting.

Bill Tamkin asked how the response rate compared with the North West London consultation. Ian Williamson advised that consultation received 17,000 responses and the Healthier Together Consultation received the largest number of responses for a consultation of this type.

Leila Williams added that what was most important was what could be independently verified, for

Page 4 example how many people visited the website and what activity they undertook which was all captured on the site.

ID Type Risk/Issue/Action/Decision/Outcome Description Owner Nil

4. Consultation response from the Greater Manchester Joint Health Scrutiny Committee Ian Williamson presented the paper and highlighted that the GM Joint Health Scrutiny Committee agreed that changes to services were needed and recognised the joint principles agreed by AGMA and the CIC during 2013. It also supported the main aims of Healthier Together to provide best care for the Greater Manchester public. It was also broadly supportive of the consultation and recognized the complexities of this type of consultation and also highlighted some risks to the three reform programmes. The final report will make the detailed comments on the consultation process and the report will be produced following the CiC confirmation of the decision making timescales.

Steven Pleasant asked how sighted the Scrutiny Committee were about the two scenarios. Sophie Hargreaves explained that this was raised at their last meeting and were introduced to the concept but further detail would need to be given.

ID Type Risk/Issue/Action/Decision/Outcome Description Owner Nil

5. Equalities Report Ian Williamson presented the paper which had assessed how accessible the consultation was for the identified protected groups and reflected the national requirements about consultation drawing on best practice for engaging those groups. A mid-point review was carried out to assess how accessibility could be improved that led to a number of amendments to the strategy which included targeted communications and engagement activity to ensure that everything possible was carried out to ensure the consultation was accessible to all. The key element was not the final numbers of people who had responses from those groups but that those groups had been afforded sufficient opportunity to respond.

Wirin Bhatiani thought the numbers of responses were low and asked if enough had been done and that CiC needed to be sure.

Sophie Hargreaves explained that analysis and assessment had been carried out and whilst the numbers are not the highest the opportunity was given.

ID Type Risk/Issue/Action/Decision/Outcome Description Owner nil

6. Briefing on Joint Working Group with Specialised Commissioning Leila Williams presented the paper which provided a briefing on a joint forum that was being established between Healthier Together and Specialised Commissioning regarding Adult Major Trauma Services and pointed out the forum was not a decision making group.

Leila Williams explained that a CCG Chair was needed to complete the membership of the joint forum and that she would not be a member of the forum and asked for any volunteers.

Martin Whiting and Ian Wilkinson were suggested but were not present at the CiC.

Page 5

ID Type Risk/Issue/Action/Decision/Outcome Description Owner nil

7. Proposed Agenda for December (17th) The meeting in December would be held fully in public with no private session.

ID Type Risk/Issue/Action/Decision/Outcome Description Owner Nil

8. Any Other Business No further business.

ID Type Risk/Issue/Action/Decision/Outcome Description Owner Nil

9. Public Questions

As no members of the public attended the meeting the Chair thanked all for their attendance and closed the meeting.

ID Type Risk/Issue/Action/Decision/Outcome Description Owner Nil

SUMMARY OF NEW ACTIONS FROM THIS MEETING

ID Risk / Issue/ Action / Decision Description Owner Alex Heritage confirmed he would write to NHS England again to gain clarity on AH the assurance process.

Page 6

NHS BOLTON CLINICAL COMMISSIONING GROUP Public Board Meeting

AGENDA ITEM NO: ………14(ii)………………

Date of Meeting: ……23rd January 2015………………………

TITLE OF REPORT: GM Association of CCGs Summary from January 2015 meeting

AUTHOR: GM Association of CCGs

PRESENTED BY: Su Long, Chief Officer

PURPOSE OF PAPER: To update the Board on the discussions held at (Linking to Strategic Objectives) the meeting on 6th January 2015.

RECOMMENDATION TO THE The Board is asked to note the summary. BOARD: (Please be clear if decision required, or for noting)

COMMITTEES/GROUPS GM Association of CCGs. PREVIOUSLY CONSULTED:

VIEW OF THE PATIENTS, CARERS Patient views are not specifically sought as part OR THE PUBLIC, AND THE EXTENT of this report. OF THEIR INVOLVEMENT:

EQUALITY IMPACT ASSESSMENT EIA and an assessment is not considered (EIA) COMPLETED & OUTCOME OF necessary for the report. ASSESSMENT:

GM ASSOCIATION OF CCGs: Association Governing Group (AGG) Summary Date: 06/01/2015 Time: 08:30 – 12:30 Venue: 5th Floor Townside Primary Care Centre, Knowsley Street Bury

Attendance: Steve Allinson NHS Tameside &Glossop CCG Trish Anderson NHS Wigan Borough CCG Wirin Bhatiani NHS Bolton CCG Alan Campbell NHS Salford CCG Tim Dalton NHS Wigan Borough CCG Andrea Dayson GM Association of CCGs Alan Dow NHS Tameside & Glossop CCG Chris Duffy (Chair) NHS Heywood, Middleton & Rochdale CCG Michael Eeckelaers NHS Central Manchester CCG Ranjit Gill NHS Stockport CCG Denis Gizzi NHS Oldham CCG Nigel Guest NHS Trafford CCG Warren Heppolette Health & Social Care Reform Gina Lawrence NHS Trafford CCG Su Long NHS Bolton CCG Wendy Meredith Bolton Council – Public Health Lesley Mort NHS Heywood, Middleton & Rochdale CCG Gaynor Mullins NHS Stockport CCG Stuart North NHS Bury CCG Kiran Patel NHS Bury CCG Karen Proctor NHS Salford CCG (HOCs Chair) Jenny Scott NHS England – specialized Commissioning Melissa Surgey GM Association of CCGs Bill Tamkin NHS South Manchester CCG Annette Walker NHS Bolton CCG (HOCs Chair) Leila Williams Service Transformation Ian Williamson NHS Central Manchester CCG Simon Wotton NHS North Manchester CCG Apologies: Rob Bellingham Greater Manchester LAT Hamish Stedman (Chair) NHS Salford CCG Martin Whiting NHS North Manchester CCG Ian Wilkinson NHS Oldham CCG Alan Dow NHS Tameside & Glossop CCG

In Attendance: Sandy Bering NHS Trafford Sara Roscoe NHS E Jonathan Berry Primary Care

Page 1 of 9

1.WELCOME & APOLOGIES FOR ABSENCE

Members were welcomed to the meeting and in particular to Karen Proctor (HoC Chair) and Annette Walker (CFO Chair).

2. MINUTES OF THE LAST MEETING (4.11.14)

The minutes of the previous meeting were agreed as an accurate record – the action log was updated.

Matters Arising: GL provided an update on the One to One Midwifery issues; this service is a current AQP contract. Trafford led a review on behalf of GM as there were noted concerns with the service not complying with the GM specification. CQC did a separate report and felt service was adequate, the report for the AGG highlighted significant issues. There is to be a summit which will bring together users across the country that has raised similar concerns. Julie Higgins is leading on behalf of the Area Teams and has sent questionnaires relating to choice to all CCGs. The GM report has been shared with CQC and we are awaiting a response. Following the summit at end of January it is expected that we may have a have a clearer steer

3. SPECIALISED COMMISSIOING

JS provided a verbal update the new arrangements for the North West this includes 2 areas teams instead of 4, Greater Manchester/Lancashire and Cheshire &Mersey. The North of England has 3 bases – North West still based in Stockton Heath. Now have National Director, Richard Jevins and a regional director Alison Tonge and regional Clinical Director Alison Rylands. Director of Nursing is Lesley Patel. Emphasis is on a regional basis rather than local still 10 hubs across the country but with different reporting arrangements. Jenny Scott will be leaving to go to the Christie at the end of February; new Associate Director of specialised commissioning will be Andrew Bibby.

Contracting Single NHS England contract with different schedules but still awaiting contract and CQUIN guidance. Sign off 11th March for all 41 contracts. QIPP will be a 2.4% target and currently have plans for £30m of the £48m and looking at national procurement and other schemes to meet the rest of the 2.4% target. PbR guidance is out for consultation which closed before Christmas with radical proposals – commissioners only pay 50% above baseline activity. Awaiting guidance on contracting and this proposal but have had discussions with providers but need guidance before proceeding.

Collaborative commissioning Is the term now being used as opposed to co‐commissioning. The four services to be transferred – Outpatient GPreferred neurology and specialist wheelchairs confirmed but bariatric surgery and dialysis are still being discussed. So for this year these will be included in the specialist contract and a contract variation in year will be raised if agreed to include these services in year. The CFOs through Steve Dixon have been testing out methodology and preparing finance impact for Specialised commissioning on a CCG basis and discussions around these 4 services but will hold off any implementation until confirmation has been received that they should transfer. The general direction of travel is that a significant proportion will over a number of years be transferred to CCGs. Highly specialised services, devolved back to national rather than local Area Teams. Guidance is expected at the end of January.

Page 2 of 9

JS has started discussions and met with Ivan Benett, GM GP lead, yesterday to progress the development of collaborative commissioning. This needs to be extended to include more clinical leads and managerial input. Need to consider how we progress this work and involve Lancashire with extended footprint. Over next 2‐3 weeks small group needs to start discussions and recommend how we take this forward.

• Vascular services – had hoped on consensus on which of the 3 sites are going to be 2 arterial units this has not been agreed and so now needs to be taken to procurement for GM • Cancer IOGs – gynaecology has been agreed, hepato biliary agreed, neurology will be finalised in February and upper GI will go to procurement.

Thanks extended to Jenny Scott for all of the support given over the years.

4. HEALTHIER TOGETHER DECSION MAKING BUSINESS CASE – FINANCIAL

AW provided an update on the approval of the Decision Making Business Case and reported that this is still work in progress and that a paper will be submitted from Joanne Newton to next week CFOs meeting. Following this AW will report and update position to the AGG. It was confirmed that one CCG was not supportive in its current state but other CCGs also stated that their Governing Bodies had also requested additonal information for assurance purposes.

ACTION: • AW to report back to AGG member prior to the next AGG

5. HEALTHIER TOGETHER UPDATE

Programme update circulated which provided all information needed in terms of the progress. IW confirmed that no decision of hospital sites will be made until after the election

6. GREATER MANCHESTER CCGs MENTAL HEALTH PROGRAMME UPDATE

Sandy Bering presented an update as the GM Mental Health lead for reporting purposes and to ensure due governance.

National Mental Health priorities: • Improved Quality of Life Outcomes for All and Targeted Groups – Military Veterans, LGBT, LT Conditions/MUS, BME, LDD, Autism, Dual Diagnoses, CAMHS and Transitions, Out‐of‐Area Placements, Offenders • Integration of Physical and Mental Health – Reducing Health Inequalities and Better Physical Health (eg smoking, alcohol, exercise, healthy workplaces) – Support for Co‐Morbid Conditions – Good End of Life experiences • Public Sector Reform – Starting Early Upstream ‐ Enhancing mental health well being / prevention with MH Friendly Lifestyles/Communities and normalising distress where appropriate – Reducing Risk (eg Suicide and Self‐Harm) and Learning Lessons – Work and Jobs – Support for Families, Carers and Communities as a whole

Page 3 of 9

A local Transforming Care Concordat Service Offer Declaration and Practical Action Plan • A Targeted Resettlement Programme to Reduce Use of In‐Patient Beds in line with Agreed Best Practice Norms and the National LD Commissioning Framework • Working Arrangements to Make Sure Effective Access to Early Support is Available with Proactive Early Detection and Emergency Response Systems Operating in Each Locality for When a Crisis Does Occur (thereby Reducing Restrictive Out‐of‐Area Placements/Practice and In‐Patient Admissions) • Effective Community LD Teams and Services that Prioritise Staying Well, Recovery and Preventing Future Crises

Mental Health Leadership Priorities Across Greater Manchester AGG (2014/15) • Joint GM MH Service Contract Management/Development /Support (Lead Commissioner Networks, Commissioner‐Provider Forums, MH PbR, Calderstones,Military Veterans IAPT) • Working with GMP – To Deliver the MH Crisis Concordat • GM Alcohol Strategy & RADAR • LD CQUIN for Acute and Community Health Services to Reduce Premature Deaths & Joint LD Health & Social Care Self Assessment Framework

GM Performance & Resilience Issues • Improved Access to Psychological Therapies – Access/Prevalence/Recovery • More Dementia Diagnosis + Post‐Diagnostic Support + Less Meds • RAID and MH/LD Liaison in Place • Working with Police to reduce Demand • Specialist Services Review (egEarly Intervention in Psychosis, Community Eating Disorders) • Fewer Restrictive Secure Hospital Placements more local specialist health and social care • Effective CPA/care management and resource panels/reviews – S117 • More Local Autism / LD Support *** • Public Sector Reforms – Early Intervention and Working Well

Future GM MH Focus Priorities ‘Safe, Sound, Supportive’ • IAPT Access/Recovery (? Atlas website accuracy) • MH Crisis Care Concordat and Reducing Demand for Expensive, Reactive Services • Early Assessment for 1st Episode Psychosis • De‐medicalising Mental Illness / Health issues ‐ especially Dementia support • Co‐production with patient leaders/groups to agree management of demands with reduced core capacity ‘Parity of Esteem’ • Addressing Inequalities in Health – Physical Health of People with Mental Health and Mental Health of People with Physical Health Problems, Patients with LT Conditions ‐ providing IAPT services to In‐pts on Medical Wards, Embedding MH Liaison services when the Patients Access Primary/Acute Care Services • Prevention and Early Intervention – Supporting Early Years and Promoting Mental Well‐ being and Emotional Resilience in Children, Suicide prevention, Work, Liaison and Diversion • Common approaches to standards and measures

THE FORWARDVIEW INTO ACTION: PLANNING FOR 2015/16 • Mandate from the government to the NHS is broadly stable, apart from the introduction of new and important access standards for mental health.

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• These form part of our wider ambition to achieve a genuine parity of esteem between mental and physical health by 2020. • To support that ambition, we expect each CCG’s spending on mental health services in 2015/16 to increase and grow by at least as much as each CCG’s allocation increase. • Major expansion in 2015/16 in the offer and delivery of personal health budgets to people • Mandate to NHS England remains largely unchanged. Commissioners will need to develop revised plans where they are not on track … for example on dementia diagnosis or delivery of improving access to psychological therapies (IAPT) service standards. • 2015/16 … introduction of access and waiting time standards in mental health services for the first time. Part of the 2015/16 contracting round, mental health commissioners will need to develop service development and improvement plans with mental health providers • By April 2016, it is expected that more than 50% of people experiencing a first episode of psychosis will receive treatment within two weeks • The Crisis Care Concordat ‐ includes the provision of mental health support as an integral part of NHS 111 services; 24/7 Crisis Care Home Treatment Teams; and the need to ensure that there is enough capacity to prevent children, young people or vulnerable adults, undergoing mental health assessments in police cells.

In deploying the additional funding NHS England is seeking to: • Ensure that mental health spend will rise in real terms in every CCG and grow at least in line with each CCG’s overall allocation growth

Transforming care for people in the justice system & armed forces • People in the justice system have disproportionately higher health needs, both mental and physical, than the population as a whole. 2015/16 NHS England roll out new models of liaison and diversion services for people in police custody and the courts. • For people in the armed forces, 2015/16 priorities are to improve equitable access, focus on the transition for individuals leaving the armed forces particularly in respect of mental health and musculo‐skeletal services, and work with partners to improve care for veterans

Parity of Esteem • The resources you are allocating to mental health to achieve parity of esteem? • Identification and support for young people with mental health problems? • Plans to reduce the 20 year gap in life expectancy for people with severe mental illness? • The planned level of real terms increase in spending on mental health services?

RADAR – has been reviewed through November CFOs and HOCs outcome of which both approved with the finance processes to be managed through CFOs if ratified by the AGG. The paper provided an update on the extended implementation of the RADAR programme, as one important, innovative and effective way to address the practical significant burden of alcohol complex dependency presentations to acute hospitals in Greater Manchester. Since 2012/13 this programme has enabled a pathway for the rapid transfer of patients from acute hospital beds for inpatient alcohol detoxification. RADAR is a medically‐managed programme operating a multi‐disciplinary team approach to detoxification, with 24‐hour medical and nursing (Hospital at Night) cover provided.

The AGG agreed to this extended funding to support RADAR for a further 12 months to allow for a more detailed review of the evidence and through this time address issues of disparity in access across Greater Manchester in line with the outcomes of the emerging Greater Manchester Alcohol Strategy. The RADAR programme has demonstrated its effectiveness in reducing alcohol‐related acute admissions, reducing lengths of stay and preventing re‐admissions

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AGG was asked to note and confirm continued support for the RADAR programme in the context of the national and local Greater Manchester Alcohol Strategy and wider transformation agendas faced by the health and care systems over the next five to ten years. As such:

1. The Association of Greater Manchester CCG’s supports the continuation of investment in the RADAR programme for a further 2‐year period in line with the confirmed clinical, social and health economic benefits through reduced hospital admissions from the independent economic evaluation. 2. The Association of Greater Manchester CCG’s commit consideration of any other non‐recurrent funds to further develop this service as part of the wider integration of RAID and other Mental Health Complex Dependency A&E diversion programmes. 3. Greater Manchester CCG’s consider financial investments to the RADAR programme in line with option 4 as supported by the GM Heads of Commissioning and Chief Finance Officers Groups, and confirm the agreement through their final Commissioning Intentions and strategic plans.

The AGG: • Noted the update provided as part of Trafford Lead CCG arrangements for Mental Health RADAR • All CCGs agreed to the RADAR proposal in principle but that this needed to be confirmed through CFOs in terms of affordability • Bolton have agreed but would want further collaborative work to progress further evidence • Did not approve recommendation 2 • Approved recommendation 1 for a 1 year period for an update in 9 months • Approved recommendation 3 with finances and payment methodology to be approved through CFOs

7. NORTH WEST OXYGEN SERVICES

GL provided an update for this service commissioned by Trafford through Lead CCG arrangements. There have been concerns about the company in terms of reporting of KPIs to the value of £6m. NHSE have been involved and solicitors have worked through a process to ensure remuneration. The contract will continue as the quality of the service was not in question this is purely accounting around KPIs. A clinical audit is being undertaken which will be reported back and a framework set up to measure any impact on patients. Indications are that there was no impact on patients but issues highlighted on the interpretation of the contact.

Have agreed a collective way forward across North West to try to negotiate further money back without going to court but this will be an individual CCG decision. Question moving forward whether stay with same company or re‐procure the service there are not a huge range of providers. Company have dismissed staff involved and completely changed how company is managed.

ACTION: • Feedback of the clinical audit when completed ‐ GL

8. PMO UPDATE

Melissa Surgey GM ACCGs Progamme Manager presented a paper to update the AGG on progress made in establishing a GM Programme Framework. The AGG are asked to note the work to date and

Page 6 of 9 make suggestions for further development if appropriate. The GM Programme Framework was originally commissioned by Mike Burrows in early 2014 with the framework in its existing form developed by PA Consulting. Responsibility for further development and maintenance of the framework was later transferred to the GM Association of CCGs. The Association appointed a Programme Manager in September 2014 to oversee the framework’s development and act as a liaison between stakeholders across GM.

The GM Programme Framework’s purpose is to provide a detailed and up to date overview of all health and social care programmes across the conurbation.

Upon its completion, the GM Programme Framework will: • Provide a comprehensive and up to date list of all GM health and social care programmes • Outline governance arrangements for each programme with regards to responsible officers, project managers and governance forums • Detail the intent of each programme including aims and objectives, target delivery dates and anticipated benefits • Track the delivery of each programme against core milestones based on the commissioning cycle, possibility of adding further custom milestones depending on a programme’s needs • Track programme reporting and approval through the Association’s governance structure including AGG, COs, HoCs, CFOs and other GM sub‐groups • Feed into a central GM risk register overseen by the Association’s Programme Manager

Prior to the appointment of a Programme Manager within the GM Association of CCGs, the GM Programme Framework had not been updated or reviewed since May 2014. Given the significant developments within the conurbation over the past year, parts of the framework are being completely reworked to ensure it is fit for purpose. Key developments in the past three months: • Working with PA Consulting to refine the framework and hand it over to the Association • Developing a framework user guide to support data collection • Briefing key stakeholders on the framework and seeking feedback and suggestions for further development (ongoing) • Amending the programme list and identifying programmes leads

Once the GM Programme Framework goes live, it will be able to inform regular reports to AGG and other Association groups. The framework will contain large volumes of detailed information and therefore it may not be appropriate or practical to share it in its entirety regularly. The information can be cut in a variety of ways depending on stakeholder need. Potential options include: • RAG rating e.g. summary of RAG ratings of all programmes; summary of all red rated programmes • Ownership e.g. Association‐led programmes; programmes owned by a particular individual • Milestone e.g. all programmes at the contracting stage • Risk e.g. all programmes with a risk rating of [x] or above

The AGG is asked to: • Note the progress to date with regards to the GM Programme Framework • Where AGG members are responsible leads for programmes, they are asked to support the Programme Manager in identifying relevant individuals and acquiring missing information for their programmes (a list of programmes and leads will be circulated in early January) • Consider which reporting methods may be most appropriate and frequency of reports • Review a draft of the GM Programme Framework in February and make recommendations for improvements and further development

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The AGG • Noted the progression of the work and approved next steps • Update required for February

9. PROGRESS ON RESOURCING PROACTIVE PRIMARY CARE (GM TRANSFORMATIONAL STANDARDS FOR GENERAL PRACTICE) Sara Roscoe and Jonathan Berry presented a paper that looks at defining a Greater Manchester approach to improving the quality and performance of General Practice alongside a corresponding increase of resource in Primary Care.

Following the decision by the Association Governing Group in October 2014 to develop a suite of general practice standards, a series of workshops have taken place to develop a set of ‘sentinel’ standards for Greater Manchester. The aim of the standards is to reduce unwarranted variation, drive up the quality of general practice and improve health outcomes. AGG asked the GM Primary Care Transformation Team to facilitate this work but decisions would be made by AGG. Subsequent implementation would be at individual CCG level at a suitable time within 2015/16.

Following 3 workshops, a set of general practice ‘sentinel standards’ have been developed and shared with CCGs for them to engage with their member practices. Early feedback from a number of CCGs has identified that appropriate consultation with their members will take time and there are already differences in opinion as to what should/should not be included in the standards.

These 9 proposed standards have been disseminated to CCGs, LMCs and Public Health England for further review and feedback. Public Health England has responded with proposed metrics for a number of the GM sentinel standards

9 DRAFT STANDARDS: 1. Primary Care Access (extended hours) 2. Equitable access for vulnerable groups 3. Prescribing 4. Health Improvement – early detection 5. Cancer referral 6. Best care / LTCs 7. Mental Health 8. Carers 9. Child Health

It is therefore proposed: • AGG reaffirms the view that determining GM wide general practice standards remains the direction of travel. These, once resourced appropriately and implemented, will enable a clear statement of ambition to improve health outcomes, reduce unwarranted variation and improve the overall scope and quality of general practice.

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• Feedback on the proposed standards continues to be collated by the Primary Care Transformation team, under the direction of Rob Bellingham, Director of Commissioning as mandated by the AGG and on behalf of all CCGs • A general practice Clinical Reference Group (CRG) is established to review evidence for each standardprioritise accordingly. CRG to also be tasked to determine the most effective mechanism for measuring performance and report back to AGG. • In light of the move to co‐commissioning and the importance of this agenda, for the Area Team Primary Care Transformation team to provide progress updates as determined by AGG.

Recommendation: • AGG is requested to reaffirm the need for GM wide general practice standards to drive improvements in the quality of primary care across Greater Manchester • To note the progress in developing the standards as outlined within this paper • AGG to review and determine the next steps for these standards based on the next steps.

The AGG noted: • Reaffirmed the work moving forward; need to ensure feedback • Requested a current baseline for benchmarking purposes – Bolton agreed to share their approach SL to disseminate • Timelines would add influence to the work • Level A decision at present until we have combined agreement through CCG membership • Review/update requested in the spring

10. CHAIRS / VICE CHAIRS

HS has indicated that he is happy to continue in the post of Chair but for members to have the conversation. The AGG may require a different structure moving forward so for the moment to continue as we are. AD argued that the current Job Descriptions does not reflect the time committed so will review the job description of the AGG Chair and Managerial Chair. Need to consider the length of tenure and the possibility of having a rotational chair. However, continuity is crucial as well as considering the funding and structure/job description of the posts. There is a need to understand all CCGs contribution to GM work and also conduct a review of lead CCG commitments with a view to developing criteria and for the CFOs to determine if additonal resource is needed. In addition, as the AGG does make commissioning decisions, the guidance suggests meetings should be held in public and we need to consider how this might be managed. SN stepping down as COOs Chair in April TA will be new Chair and AGG managerial lead/Vice Chair. CD Vice Chair role any expression of interest to be submitted to AD

The AGG • Agreed that the governance discussion be progressed through COOs • To be added to the Friday (9.1.14) away day agenda

Next meeting: ‐ Tuesday 3 February 13.30 – 17.30 Bury CCG 5th Floor, Bury Townside Primary Care Centre , Knowsley Street, Bury

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NHS BOLTON CLINICAL COMMISSIONING GROUP Public Board Meeting

AGENDA ITEM NO: ……14(iii)…………………

Date of Meeting: …23rd January 2015………

TITLE OF REPORT: CCG Executive Update

AUTHOR: Fiona Moore

PRESENTED BY: Fiona Moore

PURPOSE OF PAPER: To update board members decisions taken – (Linking to Strategic Objectives) within the Scheme of Delegation - at the Executive Committee that have a financial, reputational or operational impact.

RECOMMENDATION TO THE The Board are asked to note the contents. BOARD: (Please be clear if decision required, or for noting)

COMMITTEES/GROUPS All items will have been through Executive PREVIOUSLY CONSULTED: Committee.

Most items will have been to other relevant committees/groups dependant on topic.

VIEW OF THE PATIENTS, CARERS Patients, carers or the public will have been OR THE PUBLIC, AND THE EXTENT involved as required for each individual topic OF THEIR INVOLVEMENT: area.

EQUALITY IMPACT ASSESSMENT Each topic will have been individually assessed (EIA) COMPLETED & OUTCOME OF for equality impact as required. ASSESSMENT:

Page 1 of 3

CCG Clinical Executive Update

1. Executive Summary

1.1. Under the Scheme of Reservation and Delegation - appendix D of the NHS Bolton CCG Constitution a number of decisions are delegated to the CCG Clinical Executive Committee.

1.2. Where these decisions are of an operational, financial or reputational matter they will be reported to the board within this CCG Executive Update.

1.3. Decisions between the 19th November 2014 and 16th January 2015 are contained within this report.

2. Estates

2.1. A paper detailing options for the refurbishment and repair of St Peters House and lease review were discussed – there are 4 years to run on the current lease.

Executive agreed not to extend the lease at this stage and consider alternatives for CCG premises in the future.

The required St Peters House repairs and landlord capital work were approved.

3. Non Medical Prescribing

3.1. Non Medical Prescribing sits outside of the provider contract and the current costs to the CCG are £1.2m.

A paper with a set of requirements to be evidenced to enable payment have been developed and have been presented to the CCG Clinical Executive. Invoices in relation to Non Medical Prescribing will be checked against the agreed requirements prior to payment.

4. Pharmacy Ordering Policy

4.1. Options for pharmacy ordering of repeat prescriptions on behalf of patients were discussed.

The CCG Clinical Executive agreed to the development of a Bolton policy to promote a standard, cost effective ordering procedure for community pharmacies and GP surgeries. The policy will ensure greater collaborative working where GP and community pharmacies sign agreement to ensure appropriate ordering.

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5. Dietician Funding

5.1. The CCG Clinical Executive approved the funding for the primary care support dietician to become a substantive as opposed to temporary post. Evidence was provided as to the value and added benefit of the post – including achievement of QIPP savings.

6. Out of Hours GP Provider

6.1. The current Out of Hours GP provider is experiencing demand increases and to ensure both stability of the service and improved efficiency now and in the future additional funding has been requested by the provider.

The CCG Clinical Executive supported a joint risk share approach linked to a Quality Premium to support reduced costs through demand decreases and efficiency through improved patient care.

7. Recommendations

7.1 NHS Bolton Clinical Commissioning Group Governing Body Board is asked to note the content of this paper.

Title: Fiona Moore Date: 16th January 2015

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NHS BOLTON CLINICAL COMMISSIONING GROUP Public Board Meeting

AGENDA ITEM NO: ………14(iv)………………

Date of Meeting: ……23rd January 2015…………

TITLE OF REPORT: Quality & Safety Committee Minutes

AUTHOR: Michael Robinson

PRESENTED BY: Dr Colin Mercer, Clinical Director Clinical Governance and Safety

PURPOSE OF PAPER: For the Board to receive and review the minutes (Linking to Strategic Objectives) of the Quality and Safety Committee meetings held on 12th November and 10th December 2014.

RECOMMENDATION TO THE The Board is asked to note: BOARD: Update from Bolton FTs Head of Governance in (Please be clear if decision November minutes and management of care required, or for noting) home concerns in December minutes.

COMMITTEES/GROUPS Quality & Safety Committee PREVIOUSLY CONSULTED:

VIEW OF THE PATIENTS, CARERS Patient views are not specifically sought as part OR THE PUBLIC, AND THE EXTENT of this report. OF THEIR INVOLVEMENT:

EQUALITY IMPACT ASSESSMENT EIA and an assessment is not considered (EIA) COMPLETED & OUTCOME OF necessary for the report. ASSESSMENT:

QUALITY & SAFETY COMMITTEE

WEDNESDAY 12th NOVEMBER 2014 9.00 am – 11.00 am, BOARDROOM, ST PETER’S HOUSE

Present: Colin Mercer (Chair) (CM) Mike Robinson(MR) Ann Benn (AB) Suzanne Mackie (SM) Nicola Onley (NO) Lynda Helsby (LHe) Grace Birch (GB) Jackie Bell (JB) Mary Moore (MM) Ben Woodhouse (BW)

In attendance: Diane Sankey (DS) Helen Bolton (HB) Richard Sachs (RS), Head of Governance Bolton FT Minutes by: Joanne Meaney (JM)

No. ACTION

1 Apologies for Absence Apologies for absence were received from Pam Jones, John Tabor, Helen Bolton, Nicola Onley

2 Declarations of Interest None declared

3 Minutes of the previous meeting Approved as a correct record

4 Matters Arising /Actions (refer to action sheet) • Safeguarding - MM reported the interim cover for adult safeguarding had been discontinued, at substantive appointment Kaleel Khan is due to commence on1.12.14 • Primary care - NHSE are securing confirmation on safeguarding arrangements. Chief Officers meeting discussed the role of named GP and confirmation is awaited Training is being addressed within the Bolton Quality Contract – HB forward look in respect of assurance and capabilities and serious case review requirements MR – queried with RS whether training is ongoing and if the doctors are trained to Level 3, RS confirmed that a new Head of Safeguarding was due to commence and he would provide this information via the metric RS requested by CCG HB to report back at the next meeting regarding the GP training HB • Board Assurance Framework – deferred to the next meeting DS

5 Minutes of Other Meetings to Note and Associated Actions

CSB – first initial meeting of the bi-monthly formal and operational group – well attended by both primary and secondary. Discussed Terms of Reference. 1

No. ACTION

BY Lengthy discussions regarding NICE guidance actions for both organisations, including CG181 – Bolton Offer 20%,NICE would like 10% Principles to be developed regarding inappropriate referral to primary care – MR/CM CVD – LHe requested that appropriate communication to general practice. LHe LHe looking at implications and providing recommendations to next CSB

MR – CQC validations and CQUIN - Ann Eccles to report to next meeting

MR queried with RS from a governance perspective how this Board fits into the Trust’s structure. RS indicated that the Trust need an appropriate mechanism to feedback into the organisation and that he would raise this internally RS

JB requested clarity on some items in minutes, particularly in relation to risk assessment for staff and would raise this with the Chair JB

6 Governance, Quality & Safety at Bolton Hospital NHS Trust Richard Sachs, Head of Governance gave a presentation highlighting governance, quality and safety [copy of the presentation appended to the minutes for information] Governance - CCG to be invited to attend the Quality Assurance Group. - Huge exercise to review policies - Serious incident training has been undertaken - Looking at a single governance office function. - Conducted internal inspection [similar to CQC inspection] in July and November, similar process to be undertaken for community services in February 15. - There is a healthier appetite to identify risk, incident reporting on a monthly basis and learning. Currently 5 incidents per 100 admissions, Trust working to should show 10 incidents per 100 admission for April to Sept 14 [RS to circulate consultation doc]. Data broadly representative. more work to be done in the community setting, raising awareness through training.

CM highlighted that the CCG have done a considerable amount of work and increased incident reporting, challenge is to ensure that action is taken and learning disseminated. A joined up process across the whole pathway for the patient and shared learning would be the way forward and recognises further work to be done to demonstrate how organisations have learnt

MM asked what framework is to be used for community quality inspection – RS stated similar to the other process - 3 teams visiting a number of areas, using 10 CQC key lines enquiry

Duty of candour – CM queried what are the Trust plans for implementation? RS reported that this would be within incident reporting system, triggering moderate harm, automatically triggers duty of candour. There is still some work to do and what it means for staff by 27.11.14 but the commitment and infrastructure is in place

No. ACTION

7 Looked After Children Report received for information which highlighted a change in language, to ‘Children Looked After [CLA]’. The news article that AB tabled at the meeting reported on a recent Ofsted report. There are some areas for improvement. To gain a richer picture in respect of CLA it was recommended that the designated doctor and designated nurse be invited to a future meeting to give a more detailed update MM AB requested facts relating to health checks and what the numbers are undertaken in order to give assurance that this cohort receive appropriate health care.

Noted the update and supported that the designated doctor and nurse attend a future meeting

8 Safeguarding update CHC full report is to be presented to the Executive on 19.11.14, MM to present MM to the December meeting

SM reported that an audit of nursing homes re safeguarding practice is being undertaken to gain an idea of where nursing homes sit in relation to performance. Deadline of 18.11.14 support has been offered. RS stated that this would be useful to use at Darley Court and requested that audit information be sent. SM to report at future meeting SM

9 Duty of Candour MR reported that this has been included within standard contract and work is being undertaken on mechanisms for commissioner responsibility in relation to providers Noted

10 Serious Incidents and Never Event update Pressure ulcers – outstanding reports being addressed 1 – delayed diagnosis – dressing retained, draft report now available 1 – death of a patient – preliminary report received 1 – never event – nose lesion A number of open cases at GMW – CSU and Salford commissioners lead, SM invited to attend panel when Bolton cases are being discussed – process issues have been highlighted and the CSU are providing a report GM Quality meeting SM is finalising a draft policy for serious incidents to be taken through Executive and Board Noted

11 Q2 Customer Services and Incident Report 100 PALS and complaints, 400 incidents reported Graph detail is broken down by quarter GM Area Team – there are some outstanding issues in respect of the learning points being disseminated Copy of the Learning & Development newsletter has been circulated to members for information. Discussion took place regarding the possibility of a

No. ACTION

BY joint newsletter with the Trust. RS appeared comfortable with this idea and further discussions will take place. Noted

12 Standing Items : Quality Matrix - November Infection control –slight concern regarding pre 72 hour – continued monitoring MRSA- 3 cases not health intervention related BMI – never event closed Quality Assurance Committee – MR has been invited to attend this meeting at the Trust Four seasons – suspended placements – suspension applies to all aspects SM meeting with safeguarding lead at home Mixed sex accommodation – breaches in HDU continues to be an issue in relation to the infrastructure of the bedded units Suspension of GP – GMC placed conditions on registration to restrict from undertaking any private work GMW – serious incidents – as discussed under item 10 Noted

13 Board update – Falls Benchmarking per 1000 bed days – less than 1 fall, Bolton is an outlier with 4-5 per 1000 bed days. Trust requested to confirm if there has been any change in data collection and reporting, categorisation to justify why the numbers have increased and drill down in severity. SM Linking in with GM Noted

14 QIPP – QCIAs Bolton Contract Risk on patient choice, clinical effectiveness and review of policies, link with equality aspect. Policies go through a rigorous analysis before adoption

Action : noted and approved for sign off

15 GM Quality Collaborative Pressure ulcers a priority, reporting consistent Work across GM regarding reporting on STEIS Newly established Patient safety Collaborative, to be chaired by Trish Bennett Noted

16 Any Other Business None

17 Date and Time of Next Meeting Next meeting would take place on 10th December 2014 9-11, Bevan Room

Apologies in advance of the meeting :

QUALITY & SAFETY COMMITTEE

WEDNESDAY 10th DECEMBER 2014 9.00 am – 11.00 am, BOARDROOM, ST PETER’S HOUSE

Present: Colin Mercer (Chair) (CM) Mike Robinson(MR) Suzanne Mackie (SM) Nicola Onley (NO) Lynda Helsby (LHe) Jackie Bell (JB) Mary Moore (MM) Ben Woodhouse (BW) John Tabor (JT) Mary Moore (MM)

In attendance: Diane Sankey (DS) Helen Bolton (HB) Minutes by: Joanne Meaney (JM)

No. ACTION

1 Apologies for Absence Apologies for absence were received from Pam Jones, Ann Benn, Grace Birch

2 Declarations of Interest None declared

3 Minutes of the previous meeting Approved as a correct record

4 Matters Arising /Actions (refer to action sheet)

• Primary care – safeguarding training –remains with NHSE collaborative team being discussed at the GM Quality meeting. Training will be part of the new accountability framework when published. Responsibility is likely to come back to local commissioners. Focusing on GPs, level 3 is required – at the GP learning event held on 5.12.14 requirements and competency were discussed. E learning is not adequate as a stand-alone training package. CCG need assurance that the wider workforce have undertaken level 3 and submit compliance. MR chased Trust compliance Safeguarding team are looking at what practices need, how the training will be provided and how often and repeat the audit MM/HB

• Looked After Children – data on medical checks available if required

• Safeguarding in nursing homes – progressing, SM reviewing the SM evidence - 10 out of the 11 homes have responded

5 Minutes of Other Meetings to Note and Associated Actions Infection Prevention Control Committee – well attended, working well. HCAI - no MRSA, C Diff significantly lower this year, 2 substantive microbiologists in 1

No. ACTION

BY post. Process robust and responsive. Main concern Ebola if and when this may occur Health acquired infection CPE, concern across GM, in situ in two Manchester hospitals – Trust undertaking preparedness MRSA RCA feedback for pre-48hrs. Diagnosis/prevention of UTI – how is this linked into other organisations such as care homes, GP OOHs and NWAS. SM confirmed that this is specific to homes and she will progress.

Antibiotic prescribing for MRSA pre-treatment – Bolton Trust to undertake de- colonisation. Minutes should reflect that this relates to treatment responsibility when seen at Trust outside GM. Raised at GM Collaborative

Audit antibiotic stewardship – results available in Jan.

Patient Safety

6 Safeguarding update Information Sharing (CP-IS) HB tabled an update paper. National system for better information sharing for child protection for health and social care. The NHS number will be key identifier. HB to check children without a number and addressing this at a local level

Chief Coroner for England request that if a person dies subject deprivation of liberty then the coroner should be notified. DS confirmed that John Balcombe, Bolton Council makes contact with practices

New adult safeguarding lead – Kaleel Khan in post

CHC update Refresh monthly to Executive – developing a dashboard, audit of CHC team working and team being reviewed, role definitions, report not yet finalised Restitution cases progressing, timescale March 2015 – nationally 2017

Four seasons – single item QSG, CQC less exercised, deep dive review being undertaking by CCG, more specifically to learn. All patients clinical care have been reviewed. 7 out of 8 standards required improvement. Placements still suspended. QSG attended by MR, but no update on Bolton. Governance management of this home to be discussed further in a formal meeting, LA to be invited to attend. MR Recognition that there may be a shortage of nursing home beds in the system if placements suspended. The home are working to a prescriptive timescale and CQC are to revisit

CDOP annual report recommendations Recommendations 1 and 6 specific to CCG CDOP is a sub group of Bolton Children’s Board, part of the governance structure and the recommendations can be disseminated and monitored through this forum

No. ACTION

BY Late booking discussed at Board level, assurance required from Trust that this is being met Suicide- reassure Board and feedback to GPs Action – regular update/evidence – think about how this is reported across organisations

7 Serious Incidents and Never Event update 4 open – delayed diagnosis, Patient fall – report received and requested coroner’s report Never event overdue [lesion removal] Incident at BMI Beaumont – knee replacement

Serious Incident Policy Expectations of providers, to go into contract, based on national guidance Circulated around commissioning team for comment Executive for discussion on 17.12.14 – approval at Board in January

Serious incident review group established - formal and objective way of monitoring serious incidents [MM, SM, MR,CM] – collate and feedback to Trust and when happy sign off on STEIS. JB to feedback to commissioners from this committee

8 Board updates – Falls No more information, data being updated by Trust Falls performance at Trust risen making them an outlier – counting and reporting issue Action - SM to chase Trust SM

Effectiveness

9 Quality Risks Report indicates specifically the ‘red’ indicators at 15 or higher requesting Q&S satisfaction with the controls and risk rating. To be received by the Governance and Risk committee in January Recognition that there are improved links between Trust and governance A&E – doing a lot of work, levels of activity have increased SOR3 - Poor compliance – Committee requested a further paper for discussion as to why this is such a high risk, recognising that this encompasses a lot of areas Action : Diane and Mike report next time DS/MR

10 Quality Matrix HCAI good performance Four seasons update [see item 6] Mixed sex accommodation – 6 breaches year to date, against GM ‘0’, currently an outlier due to HDU configuration, escalation plans in place, SRG monitoring this GMW Serious incident reporting – lesser number outstanding, but GMW are still asking for extensions to report. Lead commissioner, Salford, seeking assurance of internal processes Noted

No. ACTION

11 Bolton FT Quality Account – mid term review Quality account sets out key priorities. BI requesting data as data not available on a lot of areas Committee to requested that the 14/15 account include a focus on community MR

12 GM Quality Collaborative update Bi-monthly meeting, SM to report in January SM Noted

13 GM AHSN Safety Network Received for information GM AHSN setting up a number of courses – Patient Safety Network and Capability Building’ Action : Committee agreed to promote through next bulletin DS

Personalised Care

14. Patient Experience/Engagement update Friends and family data now available, concern raised that these were not Real time solutions

Now updated on : - the move of children’s outpatients support - Patient story / video – Board in January - Engagement issues – deaf centre – patients accessing care and no access to a signer, a contract exists and informed primary care

Communication campaign ongoing and update to be presented in the New NO Year

Noted 15 Any Other Business

1.51 Meeting dates : future meeting dates scheduled for the second Wednesday in JM the month to be emailed out to members

16 Date and Time of Next Meeting Next meeting would take place on 14th January 2015 9-11, Bevan Room

Apologies in advance of the meeting :

NHS BOLTON CLINICAL COMMISSIONING GROUP Public Board Meeting

AGENDA ITEM NO: ………14(v)………………

Date of Meeting: ……23rd January 2015…………

TITLE OF REPORT: Audit Committee Minutes

AUTHOR: Annette Walker

PRESENTED BY: Joe Leigh, Audit Committee Chair

PURPOSE OF PAPER: For the Board to receive and review the minutes (Linking to Strategic Objectives) of the Audit Committee meeting held on 5th November 2014.

RECOMMENDATION TO THE The Board is asked to note the minutes. BOARD: (Please be clear if decision required, or for noting)

COMMITTEES/GROUPS Audit Committee. PREVIOUSLY CONSULTED:

VIEW OF THE PATIENTS, CARERS Patient views are not specifically sought as part OR THE PUBLIC, AND THE EXTENT of this report. OF THEIR INVOLVEMENT:

EQUALITY IMPACT ASSESSMENT EIA and an assessment is not considered (EIA) COMPLETED & OUTCOME OF necessary for the report. ASSESSMENT:

MINUTES

CCG Audit Committee

Date: 5 November 2014

Time: 11.30am – 12.30pm

Venue: Main Meeting Room, Friends Meeting House

Present: Joe Leigh (JL) Vice Chair & Lay Member Governance (Chair) Alan Stephenson (AS) Lay Member Shri Kant (SK) GP Board Member In attendance: Annette Walker (AW) Chief Finance Officer Amanda Williams (AAW) Head of Financial Accounting & Reporting Jackie Murray (JM) Deputy Chief Finance Officer Su Long (SL) Chief Offier Lisa Warner (LW) Senior Internal Audit Manager, MIAA Karan Wheatcroft Operations Director MIAA Trevor Rees (TR) KPMG Partner Public Sector Audit Kath Robson (KR) Anti-Fraud Specialist MIAA Minutes by: Linda Hughes (LH) Personal Assistant

Item Topic Action By 1 Apologies and Declarations of Interest Apologies for absence were received from: • Tim Crowley, Director, MIAA. • Dr Tarek Bakht GP Board Member. • Debra Chamberlain External Audit Manager, KPMG.

There were no declarations of interest.

2 Minutes of the previous meeting The minutes of the last meeting held on 30 May 2014 were accepted as a true and accurate record.

3 Matters arising from minutes, not otherwise on the agenda and review of action log The action log was noted.

4 MIAA (internal audit) 4.1 Internal Audit Progress Report LW provided an update against the 2014/15 internal audit plan detailing results arising from internal audit work undertaken providing a summary of management’s progress and implementation of previous internal audit recommendations.

The committee discussed the audit regarding the RMBS Business Continuity Plan and it was noted that a further review was to be undertaken.

The findings of the Mobile Computing audit were also discussed. These findings would be escalated to the CSU to seek assurances that issues would be addressed as a matter of urgency. AW informed work had commenced with CSU and a short position statement on progress and any identified gaps would be obtained.

JL requested that key messages in future reports needed to be clearer and standardisation was needed. JL stated a current position statement from management was needed for the audit committee. AW agreed to meet with LW to discuss this process.

The committee noted the report.

AW to obtain position statement on progress of Mobile AW Computing and any identified gaps.

AW to meet LW to discuss position statement for Audit AW Committee.

4.2 Internal Audit Charter Karen Wheatcroft presented the Internal Audit Charter which established the internal audit’s activity position within the CCG. This is a standard document which would need to be reviewed again in 12 months to personalise to Bolton CCG.

AW asked that a sentence be included to reflect the arrangements for interim reporting is via the CFO as delegated KW by the CO, and that it is made clear that work undertaken by internal auditors is within the plan agreed by the audit committee.

The committee approved the report.

4.3 Audit Committee Handbook Briefing Paper LW presented the audit committee briefing paper highlighting the main changes to the NHS Audit Committee Handbook third edition June 2014. KW highlighted a new self-assessment checklist is included in the handbook but recommended using MIAA’s workshop based approach.

The committee noted the report.

4.4 MIAA Briefing Notes: LW briefed the committee on the MIAA briefing notes regarding Sustainability and Human Factors for members to consider further.

The committee noted the reports.

5 External Audit (KPMG) 5.1 Annual Audit Letter TR presented the annual audit letter 2013/14 which summarises the 2013/14 audit Bolton CCG. The document included the fees charged and formally closes the audit.

The committee noted the letter.

6 GMCSU Service Auditor Report AW commented on the paper circulated by the CSU regarding the internal control system for the CSU. It was noted that the risks to the CCG are low due to the range of services purchased. This was due to the gross risk being spread across a significant range of services, which are non-interdependent; therefore, the real risk is lower.

The committee noted the report.

7 External Auditor Appointments AAW reported on the consultation that had taken place earlier in the year regarding appointments of external auditors from 2015/16. It was noted that these results had not yet been shared.

It was reported that external audit contracts are likely to be extended for 2 years. The audit committee will then appoint its own external audit from April 2017.

The Committee noted the letter.

8 Board Assurance Framework and Risk Register AW presented paper. The committee discussed the timing of the paper and agreed that Q1 was out of date and recognised that Q2 had not yet been to the Governance and Risk Committee. AW to feed back to DS.

AW to feed back to DS timing of reports. AW

The Committee noted the report.

9 Corporate Registers The committee reviewed the corporate registers. JL commented on the need for standardisation and consistency of entries in the declarations of interest register from individuals.

JT to review declarations of interest register as per above JT comments.

10 Anti-Fraud Progress Report CR advised the committee on the progress against the agreed anti fraud 2014/15 work plan for the period of April –Sept 2014.

Key points discussed: • National Fraud initiative (NFI), fair processing notice shared on intranet and included in payslips and will be included in the next staff newsletter. Payroll and creditor data has also been

uploaded to the audit commission. Any data matches will be investigated. • Guidance of overpayment of salary and potential of when it should be investigated as a fraud or an error. • On track with plan and no activity.

• Working with CCG with fraud awareness sessions and will present case studies on types of fraud and distribute leaflets and posters.

11 QIPP Lay Member Lead AS asked if consideration should be given to having a lay lead member for QIPP. It was agreed to add QIPP reports as a standing item to the Governance and Risk committee. QIPP project leads would also be invited to attend the Governance and Risk committee to discuss progress on the QIPP schemes.

The above proposals to be added to the Governance and Risk DS Committee forward planner.

12 Minutes of Other Meetings The following minutes were noted:- 12.1 Governance and Risk 11 April 2014. 12.2 Governance and Risk 11 July 2014. 12.3 Governance and Risk 12 September 2014.

13 Chief Officer Feedback The Chief Officer gave an overview of work over the past twelve months.

Members requested a position statement from the Executive SL regarding responses to audit recommendations and delivery of QIPP. 14 Any Other Business AS had attended the financial summit organised by MIAA. Presentation slides would be forwarded to members when AS received.

There was no further business discussed.

15 Date and Time of Next Meeting Agreed as Wednesday 11th February 2015, 2.00pm – 3.30pm in the Bevan Room, St Peters House.

Future meeting dates Venue Board Room St Peters House Wednesday 29th April 2015, 2.00pm-3.30pm.

Potentially 22 May 2015 directly before the Board meeting subject to confirmation on timings on submission of the annual accounts.

Weds 30 Sept 2015, 2.00pm-3.30pm. Weds 27 Jan 2016, 2.00pm-3.30pm.

NHS BOLTON CLINICAL COMMISSIONING GROUP Public Board Meeting

AGENDA ITEM NO: ………14(vi)………………

Date of Meeting: ……23rd January 2015…………

TITLE OF REPORT: Governance and Risk Committee Minutes

AUTHOR: Diane Sankey

PRESENTED BY: Joe Leigh, Lay Member, Governance

PURPOSE OF PAPER: For the Board to receive and review the minutes (Linking to Strategic Objectives) of the Governance and Risk Committee meeting held on 14th November 2014.

RECOMMENDATION TO THE The Board is asked to note the minutes. BOARD: (Please be clear if decision required, or for noting)

COMMITTEES/GROUPS Audit Committee. PREVIOUSLY CONSULTED:

VIEW OF THE PATIENTS, CARERS Patient views are not specifically sought as part OR THE PUBLIC, AND THE EXTENT of this report. OF THEIR INVOLVEMENT:

EQUALITY IMPACT ASSESSMENT EIA and an assessment is not considered (EIA) COMPLETED & OUTCOME OF necessary for the report. ASSESSMENT:

MINUTES GOVERNANCE AND RISK COMMITTEE

Date: 14 November 2014

Venue: Bevan room, SPH

Present: Joe Leigh (Chair) (JL) Alan Stephenson (AL) Dr Shri-Kant, GP Member (SK) Lisa Warner (LW) Annette Walker (AW) Dr Tarek Bakht (TB)

In attendance: Diane Sankey, Risk and Complaints Manager (DS) Fiona Moore, Assistant Chief Officer (FM)

Minutes by: Janet Mitchell, Administrative Assistant

No Topic Action By 111. Apologies for Absence Apologies received from Charlotte Mackinnon (CM), Wirin Bhatiani (WB), Su Long (SL), Mike Robinson (MR)

112. Declarations of Interest Dr Shri-Kant and Dr Bakht declared and interest in Item No 5 which related to co-commissioning of GP services.

113. Notes of the previous meeting Minutes of meeting held 12 September approved as a correct record.

114. Matters Arising & Review of Key Action Log The Committee noted matters arising and actions completed. Item 106 running costs report expected to be completed in 2015 and reviewed by Exec. 115. Co-commissioning Governance Discussion took place about the co-commissioning governance paper presented by FM. NHSE will be issuing a model TOR that has been legally approved and guidance on valid structures for co-commissioning arrangements. These will be too slow for Bolton CCG to progress as required with their own plans and the Committee discussed membership of the Bolton Co-Commissioning Group. Members asked for clarification relating to the senior officer representative from Bolton Council. TB thought it would be beneficial to have someone from public health on the 1

group and members agreed it needed to be someone with senior authority to take decisions on behalf of the local authority. FM agreed to liaise with Bolton Council and further information to Members re Terms of Reference in light of NHSE guidance FM 116 CSU Notice AW informed Members of the CCGs intention to cancel the Total Provider Management and Business Intelligence SLAs from NWCSU. The Committee was asked to note the termination notices served, accept the assurances provided in relation to the decision making process, proposed alternative arrangements, note the benefit and risks identified along with mitigations and note NHS England requirements and intended approach.

It is noted there was a risk on terminating the SLAs but CSU was not delivering what Bolton CCG needed and the current arrangement was no longer sustainable. AW advised there would be a small cost to the CCG in terminating the SLAs but in the long term, it would prove better value for money. The SLAs for TPM was currently £600,000 and BI product £300,000. Members noted the CSU was not set up to help deliver the CCG’s objectives and agreed it needed to bring services in- house.

AW assured the Committee the CCG will give notice and work constructively with CSU bringing services in-house and would update the Committee with any key issues.

117 MIAA CCG Assurance Framework Benchmarking LW discussed her report and confirmed that Bolton CCG data had not been included within the benchmarking exercise. The report had been shared with MR and DS prior to the Governance and Risk Committee. LW and AW to discuss submission of Bolton’s information and who/when MIAA had requested this from.

LW agreed to prepare a paper for the next Governance and Risk Committee that included the Bolton Assurance Framework information so Members could review how it compared to other CCGs.

LW commented that Bolton seemed to have a lot of high risks in its BAF.

FM advised the Committee the CCG was looking into a new system for monitoring objectives/performance/risks/QIPP that managers and senior officers could update electronically on a central database. This would be discussed with the Executive.

Actions: LW to prepare a paper that included Bolton CCG BAF information for review at the next meeting. LW

FM to take proposal for new performance/risk system to future Executive meeting FM

118 Risk Management Report 13/14 The Committee received the Risk Management Report for 2013/14.

Members noted health and safety policies had yet to be updated by the CCG from the former PCT. FM advised most CCGs were in the same position and although enquiries had been made with Propco who own the building and are responsible for NHS estates/facilities, they have declined to assist as they do not feel it is their role.

CSU has a product and could produce standard policies but this is not felt to be legally adequate. One GM CCG had used an external organisation to provide health and safety expertise and to train a number of key staff. It was noted Bolton CCG employs between 90-95 employees.

FM agreed to outline options for Executive Committee to consider at a future meeting. FM

119 Lease Car Scheme Proposal Discussion took place about the proposed lease car scheme which had been reviewed by Executive Committee.

Two lease companies had been seen by the CCG and AW confirmed there was one more to see before a decision was made. The scheme will be available to all staff, it is not contractual but an optional equitable scheme. The Committee asked if the contract will be with CCG or the employee taking the offer of a lease car. AW advised that the contract is between CCG and Lease company then employee and CCG.

Due to potential conflicts of interest, Members agreed this should be considered by the Remuneration Committee. Internal auditors were AW also asked to look at optional schemes and advise the CCG and LW LW agreed to liaise with AW.

120 Risk Management Strategy November 2014 An updated Risk Management Strategy was received. It was noted that the Risk Management Strategy was approved by the Committee in November 2014 and although it had been noted by the Board in 2014 with the minutes of the meeting, it should have been considered and adopted by the Board as per the CCG’s Constitution.

Members agreed the Strategy to be submitted to governing body at its next meeting and that the Board would be asked to confirm a review date of two years. DS

121 Organisational Change Policy The policy had been through Staff Forum and Executive and it had been agreed to change the four years pay protection to two years. The FT have shared their policy and they are looking to change its policy to two years protection. The Committee noted the updated policy. 122 Qtr 2 BAF and Risk Register DS informed the Committee three new risks had been added in Qtr 3, 3

six strategic objective risks were rated at high (15 or above) and ten risks had reduced. Risk had been reviewed by Executive Committee and by Quality & Safety Committee. There was a correction to the risk score for Operational Risk OR15 –Loss of control due to lead arrangements with partner organisations. Risk Score should read 16, not 15.

JL requested Risk SOR3.4 Concerns at staffing levels in FT community nursing services (Risk Score 9 Significant) to be reviewed again by Executive Committee, following the update received by Members at its development session earlier today.

FM queried Operational Risk OR6 Poor performance or failure of CSU to deliver SLAs (Risk Score 12 Significant) was high enough and JL asked if an exception report relating to CSU delivery could be completed

DS to feedback actions at next meeting. BAF/Risk Register accepted – to be submitted to Audit Committee and High risks to DS Board.

123 Any Other Business Dates for 2015 were circulated to Members.

124 Date & time of next meeting Friday 23rd January 2015 Bevan room, SPH 3-4pm (Venue to be confirmed due to estates works at SPH in Jan 2015)

NHS BOLTON CLINICAL COMMISSIONING GROUP Public Board Meeting

AGENDA ITEM NO: ……14(vii)…………………

Date of Meeting: ……23rd January 2015………………………

TITLE OF REPORT: Health and Wellbeing Board Minutes 10th December 2014

AUTHOR: Health and Wellbeing Board

PRESENTED BY: Su Long, Chief Officer

PURPOSE OF PAPER: To update the Board on the discussions held at (Linking to Strategic Objectives) the meeting held on 10th December 2014.

RECOMMENDATION TO THE The Board is asked to note the minutes. BOARD: (Please be clear if decision required, or for noting)

COMMITTEES/GROUPS Health and Wellbeing Board. PREVIOUSLY CONSULTED:

VIEW OF THE PATIENTS, CARERS Patient views are not specifically sought as part OR THE PUBLIC, AND THE EXTENT of this report. OF THEIR INVOLVEMENT:

EQUALITY IMPACT ASSESSMENT EIA and an assessment is not considered (EIA) COMPLETED & OUTCOME OF necessary for the report. ASSESSMENT:

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HEALTH AND WELLBEING BOARD

MEETING, 10 th DECEMBER, 2014

Representing Bolton Council

Councillor Morris (Vice-Chairman) Councillor Bashir-Ismail Councillor Cunliffe Councillor Dean Councillor Peacock Councillor Mrs Fairclough

Representing Bolton Clinical Commissioning Group

Dr W. Bhatiani Dr C. Mercer GP Mr A. Stephenson Ms S. Long – Chief Officer

Representing Royal Bolton Hospital Foundation Trust

Dr J. Bene – Chief Executive

Representing Healthwatch

Mr J. Firth - Chairman

Representing Voluntary Sector

Ms K. Minnitt – Bolton CVS

Also in Attendance

Ms W. Meredith – Director of Public Health, Bolton Council Mr A. Crook – Assistant Director, Children’s and Adult Services Department – Bolton Council Ms J. Hall – Programme Manager for Integration, Bolton CCG Ms J. Robinson – Early Years Strategic Lead – Bolton Council Mrs D. Lythgoe – Policy and Performance, Bolton Council Mrs S. Bailey – Democratic Services, Bolton Council

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Apologies for absence were submitted on behalf of Councillor Mrs Thomas (Chairman), Mr S. Harriss, Ms M. Asquith, Dr C. Mackinnon GP, Mr A. Harrison and Ms B. Humphrey.

Councillor Morris in the Chair.

35. MINUTES OF PREVIOUS MEETING

The minutes of the proceedings of the meeting of the Board held on 22 nd October, 2014 were submitted and signed as a correct record.

Further to Minute 26, Ms Long reported that the findings from the Healthier Together consultation would be reported to the next CCG Board meeting.

Resolved – That the update be noted.

36. HEALTH AND SOCIAL CARE INTEGRATION AND BETTER CARE FUND UPDATE

The Director of Children’s and Adult Services submitted a report which outlined the latest progress on health and social care integration in Bolton and Greater Manchester using the new standard reporting format.

Mr Crook advised that the programme was now starting to deliver changes.

Mr Firth referred to problems currently being experienced in terms of the 111 emergency number. Ms Long advised that this service was currently being redesigned and that she would raise the issues as part of the review.

Resolved – That the report be noted.

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37. IMPROVING GENERAL PRACTICE IN BOLTON – A NEW BOLTON QUALITY CONTRACT

Dr Colin Mercer GP declared an interest in the following item of business in his capacity as a GP.

Ms S. Long submitted a report which outlined proposals to introduce new standards for GPs in the form of a Quality Contract.

The new standards would be part of investment in General Practice required in order to meet the Bolton Health and Wellbeing Strategy, the CCG Commissioning Plan and the Greater Manchester Strategy for Primary Care.

The report outlined the main aims and objectives of the Contract which would set clear standards for General Practice in Bolton which had been developed to:

- set a step-change requirement in quality; - increase capacity in General Practice to improve the service offered to Bolton people and set a good baseline for the development of more integrated models of care; - support the delivery of the Greater Manchester Strategy for Primary Care; - reflect the balances aims of improved population health, better quality and patient experience of care and value for money; - incorporate all local contracts with General Practice (except the most specialist); - provide a consistency of offer to Bolton people, no matter which Practice they were registered with; and - meet the commissioning priority of Bolton people for improved access to General Practice.

The standards had been based on detailed work carried out by the CCG in order to understand some of the key issues relating to General Practice and access. The key findings were summarised in the report, as follows:

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- most people expected to be seen on the same day if they had an urgent issue; - the differences in whether people could book appointments ahead or had to ring on the day for appointments; - continuity of care was strongly supported as important for serious or on-going problems – less so for minor issues; - having the opportunity to request a GP of the same gender was important for certain circumstances; - 55% supported seeing a nurse rather that a GP for less complex urgent needs, 45% said it depended on the situation and only 2% said they always wanted to see their GP; - 86% supported GPs having time for longer appointments for those people with greatest need; and - most felt that all GPs should offer more routine services for example, blood tests

The intention was for the Quality Contract to pay for itself as there was potential to deliver 100% return on investment in year 1, with additional longer term benefits to population health that the focus on prevention and early intervention would bring. It was noted that more detailed plans would come forward on delivery from individual practices at a later stage.

The report advised that the aim was to have the Contract in place for April, 2015.

Resolved – That the report be noted and that an update on progress be submitted to this Board at a future meeting.

38. HEALTH AND WELLBEING STRATEGY – STARTING WELL - PERFORMANCE REPORT – QUARTER 3 2014/15

The Director of Public Health submitted a report which updated the Board on the performance of the Health and Wellbeing Strategy as it related to the Starting Well chapter.

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The report provided details in relation to each priority with some further commentary on the outcomes and an outline of the actions.

Ms Meredith highlighted that there had been a small improvement in children’s oral health. However, performance in neighbouring authorities had also improved and Bolton’s overall position was the third lowest in the North West. Action was being taken to address this.

With regard to breastfeeding, Ms Minnitt reported that performance was good and that much work had been undertaken to promote Bolton as a breastfeeding friendly town with many establishments now fully trained and equipped to deal with mothers who wish to feed their babies.

Resolved – That the report be noted.

39. STARTING TOGETHER, DEVELOPING WELL

A report of the Director of Public Health was submitted which outlined the findings to date in relation to the Early Years new delivery model and the next steps.

Ms J. Robinson gave a presentation to supplement the report which outlined the Early Years overall objectives, namely to increase the number of children who were ready for school age 5 years by making the best use of resources to improve outcomes for all children in their early years and close the gap in performance for the Early Years Foundation Stage Profile between the most disadvantaged children and the rest.

The proposals included the introduction of an integrated 8 stage assessment pathway for all children, core pathways and evidence based interventions.

Bolton was an early adopter of the proposals and was testing out the Model at the Oxford Grove Children’s Centre reach area by engaging with all services working with children and families from pregnancy to 5 years. The findings from the Early

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Adopter were also detailed together with proposed next steps, which included:

- continuation of the early adopter and taking the learning forward to inform the roll-out; - exploring opportunities to align existing multi-agency services and developing co-located early years teams across the Borough; - further development of integrated/shared leadership of early years services; - further review of the investment model and understanding current and to be costs; and - development of a realistic investable proposition across key partners to inform a phased roll-out across the Borough from April, 2015.

Resolved – That the report be noted and that Ms Robinson be thanked for her informative presentation.

40. TRANSFER OF COMMISSIONING OF 0-5 CHILDREN’S PUBLIC HEALTH SERVICES

Councillor Bashir-Ismail declared an interest in the following item of business due to the nature of her employment.

The Director of Public Health submitted a report which updated the Board on the latest position regarding the transition of the Early Years public health commissioning responsibilities

The Board was reminded that Children’s Public Health commissioning responsibilities for 0-5 year olds would transfer from NHS England to local authorities on 1 st October, 2015. The Public Health Commissioning Transfer Programme Board had been established to coordinate and have oversight of the transition.

The report went on to outline the scope of the transfer, the responsibilities involved and current and proposed commissioning arrangements.

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Resolved – That the report be noted.

41. NHS BOLTON CLINICAL COMMISSIONING GROUP BOARD UPDATE – MINUTES OF MEETING

The minutes of the proceedings of the meeting of the Clinical Commissioning Group Board held on 24 th October, 2014 were submitted for information.

Resolved – That the minutes be noted.

42. MONITORING REPORT

The Chief Executive submitted a report which monitored the progress of decisions taken at previous meetings of the Board.

Resolved – That the monitoring report be noted.

43. HEALTH AND WELLBEING BOARD FORWARD PLAN 2014/15

The Chief Executive submitted a draft Forward Plan which had been formulated to guide the work of the Health and Wellbeing Board over the forthcoming year.

Resolved – That the Forward Plan, as now submitted, be approved.

(The meeting started at 12.30pm and finished at 1.30pm)

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N O T E S

NHS BOLTON CLINICAL COMMISSIONING GROUP Public Board Meeting

AGENDA ITEM NO: ……14(viii)…………………

Date of Meeting: ……23rd January 2015………………………

TITLE OF REPORT: Joint Commissioning Committee

AUTHOR: Su Long, Chief Officer

PRESENTED BY: Su Long, Chief Officer

PURPOSE OF PAPER: To update the Board on the discussions held at (Linking to Strategic Objectives) the Joint Commissioning Committee meetings held on 18th and 22nd December 2014.

RECOMMENDATION TO THE The Board is asked to note the minutes. BOARD: (Please be clear if decision required, or for noting)

COMMITTEES/GROUPS Joint Commissioning Committee. PREVIOUSLY CONSULTED:

VIEW OF THE PATIENTS, CARERS Patient views are not specifically sought as part OR THE PUBLIC, AND THE EXTENT of this report. OF THEIR INVOLVEMENT:

EQUALITY IMPACT ASSESSMENT EIA and an assessment is not considered (EIA) COMPLETED & OUTCOME OF necessary for the report. ASSESSMENT:

MINUTES

Joint Commissioning Committee

Date: 18th December 2014

Time: 5.00pm

Venue: Bevan Room, 2nd Floor, St Peters House

Present: Alan Stephenson CCG Lay Member (Chair of Committee) Su Long CCG Chief Officer Annette Walker CCG Chief Finance Officer Lynda Helsby CCG Associate Director Primary Care & Health Improvement Rob Bellingham Director of Commissioning, NHSE (AT) representative Vicki Owen-Smith Public Health England representative Wendy Meredith Local Authority representative In attendance: Jack Firth Health Watch representative Ivan Benett External GP representative Ben Squires Head of Primary Care, NHSE (AT) representative Minutes by: Joanne Taylor Board Secretary

Item Topic 1/14 Apologies for Absence Apologies were received from Debra Malone. Wendy Meredith attended the meeting on Debra’s behalf.

2/14 Introductions Committee members introduced themselves.

3/14 Scene Setting Su Long presented to members the background to the establishment of the Committee. For some time now, Bolton CCG has been engaging with practices regarding the development of a quality contract for Bolton GPs. This was following on from the successes gained by Liverpool PCT further to the investments made and the setting of higher standards in primary care. The offer of co-commissioning from NHSE fits with the ideas being developed locally around general practice and an application was submitted for co-commissioning.

Investment in General Practice is needed to meet the Bolton Health & Wellbeing Strategy, the CCG Commissioning Plan and the Greater Manchester Strategy for Primary Care.

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of the GM Strategy for Primary Care and is receiving positive interest nationally from influential leaders in NHSE and the Department of Health.

The Bolton Quality contract will set a clear set of standards for General Practice in Bolton and will recognise inequalities in Bolton and the different demands Bolton practices are under due to the age and deprivation of their population, provided by the national weighted payment formula and the local setting of performance requirements against each standard based on peer groups with similar populations.

The intention is for this Quality Contract to pay for itself. There is potential to deliver 100% return on investment in year 1, with additional longer term benefits to population health that the focus on prevention and early intervention will bring.

4/14 Declarations of Interest There were no declarations of interest.

5/14 Draft Terms of Reference and Membership of the Committee The Terms of Reference and membership had been drafted from the national model. The membership had adapted to include an external GP representative to ensure robust processes were in place to reduce any conflicts of interest that would arise from representation by a local GP. It was noted this would not preclude the Committee inviting local GPs to give further detail/views at future meetings.

It was noted that a PHE representative had been invited due to the need to develop the standards within the contract to improve health outcomes and reduce health inequalities for the population. Members discussed the requirement of the PHE representative and the possible duplication due to the NHSE representation on the committee. It was agreed this would be reviewed prior to the next meeting on 22nd December.

It was noted that Ben Squires was also in attendance from NHSE Area Team as it had been recognised that as meetings develop across Greater Manchester, it was important that other senior members of the team are involved from the start to enable NHSE to build the required capacity. It was agreed that there should be the ability for additional representatives to sit on the committee as attendees.

Rob Bellingham outlined the governance arrangements and highlighted that the Bolton Quality Contract was a Local Enhanced Scheme that CCG can do under its own authorisation rights to commission. NHSE supported the process the CCG was putting in place around the wider assurances required to develop this. With regard to wider co-commissioning, this does require a change to the CCG’s constitution to give the CCG the ability to influence the core contract as a commissioning partner.

The CCG has formally set up this committee with delegations from the CCG Board to develop this Bolton quality contract without conflicts of interest.

The draft terms of reference and membership of the Committee was approved. It was agreed to review the PHE representation by 22nd December.

6/14 Presentation of Proposal for the Bolton Quality Contract Su Long presented the case for change and highlighted the current issues within general practice which included the proportion of NHS spend on general practice reducing, more demand and pressures in general practice, threats to contract income and the targeting of standard core spend by 2021 to £78.66 which would make 23 Bolton practices lose out if equalised down to this level. Page 2 of 4

It was noted that the Bolton quality contract is in addition to the core contract and mutually reliant and the expectation was that QoF or national enhanced schemes will be excluded from this. Practices must sign up to the whole of the contract and if any did not sign up, they would not be able to earn from these standards separately. Members discussed the possibility of d neighbouring practices or federations carrying out this work on behalf of practices to earn the whole. It was agreed this needed further discussion.

The financial arrangements were presented. Current local enhanced schemes that all practices are capable of delivering will be brought into the new contract, alongside investment from the CCG to level up the total payment to each practice to a minimum of £95 per weighted patient. The investment required by the CCG of over £3 million will be in return for the delivery of a new set of standards for primary care. The effect of the investment and standard payment per head of weighted population (using the national Carr-Hill formula) will be that most practices receive increased funding. Seven practices will receive no increase in funding in year 1.

It was noted that the CCG would not remove any funding from practices above the line. However, it was noted that this may change over time from directives from NHSE. It was also noted that funding would be found from CCG allocation, and the contract would need to pay for itself by the moving of activity from acute and reducing prescribing spend. The plan was to invest up front to save later and set this as a commissioning intention and include in the financial planning for the CCG. The committee’s role was to agree this for submission to the CCG board for final approval. The risks to the contract were acknowledged. The plan is to mitigate these risks to take this forward.

Lynda Helsby presented a summary of the standards. It was noted all standards were aligned with the GM Primary Care Strategy and focussed on CCG priorities and had been informed by Bolton people. These also addressed community based standards and included LES and Public Health schemes.

Members discussed the standards and raised the following points:

• Query raised on capacity within the access standards to meet demand. • Payment mechanisms proposal to be brought to the next meeting. Acknowledged there needed to be some element of risk share between the CCG and GPs. • Query raised on at risk of diabetes targets due to the lack of national guidance. • Query raised on the cancer referral target, in particular emergency 1st presentations. It was noted that Bolton practices had carried out an audit where the main findings were around patients presenting late. As there is no specific KPI on this, further monitoring will be carried out internally. • Whether annual health checks have been reviewed against NICE guidance. It was noted that a further review was being undertaken with the LMC, therefore the percentage could change. PHE support for approach of lifestyle intervention rather than statin. • Ethical issues raised regarding screening people with learning disabilities/cervical screening. Agreed this would be fed back to senior commissioners. • The patient experience standard should be number one. It was noted that the standards should be listed in alphabetical order. • Need to confirm with Bolton Council the sexual health component of the contract further.

It was reported that work had been carried out to check these standards against the core

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contract to ensure no duplication and ensure the CCG was being explicit as to what is being asked of practices. Ben Squires confirmed that what was being asked for is additional to the core contract or helps by firming up requirements not made explicit in the core contract.

It was noted that a full specification on the rationale for each standard, the support to be offered to practices and expectations etc., was being developed. Members expressed how impressed they were with the detailed data and the level of improvement being expected. It was explained that this was due to Bolton’s position of high achievement already in work to improve health checks and health outcomes.

Also presented was the current performance on each measure by practice and peer clustering, and where the CCG would require practices to achieve at the same level or take into account deprivation/ethnicity factors where achievement of the peer cluster average was required.

Members discussed the need to be explicit regarding maintaining performance. The CCG would be looking at improvements from all practices, bearing in mind the level of improvement will depend on where they are starting from.

Members also discussed the savings to be made and whether the £3.5m was achievable. The CCG had undertaken some preparatory work and identified that elimination of waste in prescribing and NEL secondary care will achieve the savings. The methodology applied to identify potential savings was also presented. It was agreed this would support shifting resources to the right place in the system.

Members agreed the proposed contract would raise the bar for quality and improve equity, leading to better outcomes for patients.

The question of development of the 7 day access target was also raised. It was clarified that the CCG priority was to improve the baseline service first. The Prime Ministers Challenge fund bid being submitted by the CCG would go some way to addressing this challenge along with the development of a federation.

The Committee noted the presentation and agreed to discuss the key decisions required (from the report tabled) at the next meeting.

7/14 Any Other Business There was no further business discussed.

8/14 Date of Next Meeting Monday 22nd December 2014 at 3.00pm

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MINUTES

Joint Commissioning Committee

Date: 22nd December 2014

Time: 3.00pm

Venue: Bevan Room, 2nd Floor, St Peters House

Present: Alan Stephenson CCG Lay Member (Chair of Committee) Su Long CCG Chief Officer Lynda Helsby CCG Associate Director Primary Care & Health Improvement Rob Bellingham Director of Commissioning, NHSE (AT) representative Vicki Owen-Smith Public Health England representative Debra Malone Local Authority representative In attendance: Jack Firth Health Watch representative Ivan Benett External GP representative Ben Squires Head of Primary Care Operations, NHSE (AT) representative Minutes by: Joanne Taylor Board Secretary

Item Topic 9/14 Apologies for Absence Apologies were received from Annette Walker.

10/14 Declarations of Interest There were no declarations of interest.

11/14 Minutes of the last meeting held on 18th December The minutes were agreed as an accurate record following clarification of the comments made by Vicky Owen-Smith on NICE guidance on statins and parity of esteem in the ethics of screening and health checks.

Ben Squires confirmed his title should be corrected to head of primary care operations.

Members also discussed whether the committee meetings should be held in public. It was clarified by Rob Bellingham that the national guidance on co-commissioning committees would come into force from April when these are formalised and truly joint committees. It was agreed that as this was a sub-committee of the Bolton CCG Board and the eventual decision to fund and implement the Bolton Quality Contract was within the scope of responsibility of the CCG Board, holding this committee’s meetings in public was not required.

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The committee would provide regular reports to the CCG Board detailing the outcome of these meetings and minutes would be available to the Board. The question of sharing information with other CCGs was also discussed. It was agreed that the Committee was open to sharing the information and minutes if requested by other CCGs.

12/14 Decision-Making Steps Members were taken through the decisions required to be made to design the contract:

1. Proposed contracting basis – this would be an independent contract in addition to the core GMS/PMS/APMS contracts. It would be mutually dependent on the provider having one of these contracts and separate to DES and QoF.

2. Contracting principles – Work had been undertaken in the primary care team to identify LES schemes that all practices can deliver and those that are more specialist. Based on the principle of what all practices should deliver, it was agreed this was an appropriate list to roll into a single contract to be jointly commissioned.

Also included was the Public Health LES commissioned by Bolton Council and the inclusion of services commissioned by NHS England. It was noted that part of the sexual health LES regarding increasing uptake in chlamydia screening was being developed into a Greater Manchester contract. Debra Malone requested that further advice be sought from the Greater Manchester sexual health commissioners on the development of a local standard. It was accepted by NHS England that the standards represented additional requirement over and above the standard GP contracts. It was noted that the standards on immunisation and vaccination and screening commissioned by NHSE was a stretch target compared to what is currently commissioned by NHSE.

The principle of levelling up was discussed. Members discussed the different contracts currently in place and the levelling up that will be implemented in the future by NHS England against the plans in the quality contract. It was also noted that some contracts (APMS) were due for review. Any changes on APMS contracts would be a jointly made decision. It was noted that no practice would get less from the quality contract. The likely impact regarding deprivation was also raised and the need for equity around delivery of the contract was noted.

The CCG has been clear with practices that practices need to sign up to the whole of the contract. Members raised the issue of duty of care to patients if practices do not sign up. Practices have been informed that the CCG assumption is that all practices take part so it could be considered that the contract does not commence without all 50 practices on Board. The option of competitive tendering to ensure all patients can access these standards was discussed. It was noted that some parts of the contract can stand alone as individual elements, but could not be delivered without practices delivering the core contract. The facility to sub-contract may be considered and included in this contract, in particular for small/single-handed GP practices and it may be feasible to enable this within the contracting clauses.

The CCG has discussed practices seeing other practice’s patients with the LMC. The LMC had raised reservations regarding this. However some innovation projects had shown the willingness to inter-refer and do work for each other.

Action: Members agreed with the contracting principles, the LES schemes to be included and agreed that further discussions be held regarding the sexual health contract. The CCG would continue to develop the sexual health

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contract due to the small amount of funding involved.

Members also agreed with principle that practices should sign up to whole contract with no separation of elements. Plans would be put in place to ensure patients are not disadvantaged if a practice did not take part in the contract.

Members also agreed that the investment principle is to level up, setting a £ per weighted patient that practices can expect to achieve for full achievement of this contract to ensure this is equitable. The contract will pay the difference between the core contract payment and £95 per weighted head of registered population. If the Carr-Hill weighting formula is altered nationally in future, the committee will need to decide how to handle this.

Members agreed that a clause be added regarding the ability to sub-contract to another practice, subject to agreement with the commissioner to ensure practices were delivering in accordance with what is outlined.

3. Bolton standards – The principles underpinning the development of the standards were presented.

Capacity regarding the access standard was revisited. The national study recently undertaken by Deloittes was showing consultation rates at 6.3 set to rise to 8 over the next three years. It was noted that whatever was set by Bolton would be the Greater Manchester benchmark and what is happening nationally and the need for future proofing suggests the target should be set to more than 75 contacts. Following discussion, it was recognised that the national study included Practice Nurse contacts in addition to GP and Nurse Practitioner consultations. Bolton’s target of 75 is set for only GP and nurse practitioner contacts.

Action: Members agreed that to assure this committee and the public, the CCG would look at the data collected for nurse contacts and include in its calculations. It was agreed that seeking improvement in year 1 was appropriate. The current practice delivery will be presented against the target to assure the committee of improvement targeted.

Queries previously raised on some of the other standards were discussed:

• Current opening hours – The CCG had reviewed the range of contracts currently in place against the average contacts per cluster to look at what any increase per week per year may mean. Different opening hours were now in operation with some practices operating extended hours. Information on opening hours shared with Jack Firth.

• Risk of Diabetes target - the local protocol on identification and at risk was highlighted. It was noted that the target was 82%, and the CCG was currently at 77.4%. Also highlighted was the national diabetes prevention plan and work developing with NHS England and partners. The local evaluation submitted to the CCG Board would be shared with members.

• Cancer referral target – the CCG would carry on monitoring emergency first presentations. The target was based more on the process of stressing referral requirements and communicating the urgency to attend. There was no incentive

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• Advice on consent issues regarding learning disabilities checks was to be sought.

• The CCG would be re-ordering the standards alphabetically.

The issue regarding the gap in service relating to unplanned admissions and the option of including a standard in the contract was discussed. Plans for practices to increase levels around proactive care was to be included in the Better Care Fund plans. However, members felt there was a need to focus heavily on reducing unplanned admissions and that the CCG needed to be clear that this was covered elsewhere or look to include in the contract.

Action: It was agreed that there was a need to be more explicit on the impact on unplanned care and that this be part of the assessment on quality and payment as one of the measures.

Members also agreed to accept the proposed Bolton standards subject to detailed service specification being circulated to reflect the comments raised. The CCG would also consider any further developments required to underline standards in unplanned admissions to ensure any standards added are flexible and can be stretched.

4. The key performance indicators had been developed using the peer group clustering or setting certain percentages to reach the required target.

Support was required from the committee to confirm that the approach to setting KPIs under each standard was correct and included equity, stretch around general improvement and reflected the difference in peer clusters with differing populations.

Members agreed there was a need to ensure that patients in Bolton will expect the same service wherever they go and therefore all practices need to be clear that ongoing improvement continues after year 1 to achieve a common high standard.

The four standards where no standards were set but practices were required to achieve included phlebotomy, emergency planning, membership engagement and acceptance of clinically agreed transfers of care. The CCG expected delivery on these. Members discussed the need to ensure this is worded correctly confirming there is no incentive for performance and that all four standards are required to be achieved.

Action: Members agreed with the principles set for the KPIs and suggested a longer term plan that all practices need to be at a certain standard.

5. Business case for £95 per weighted patient – The CCG had made a high level business case for the level to be set at £95 per weighted patient. Ultimately this will be a Board decision on the investment to be made. It was noted that if all practices meet the standards, the total savings could be around £3.8m and the investment to make £95 per head of population would be recovered.

The possible implications across Greater Manchester in setting a benchmark and the possible destabilisation for other CCGs was also discussed. It was agreed that individual CCGs would need to develop their own business cases.

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Members discussed the need to present the contract as an investment to save as well as investment in quality to ensure the correct messages were made across the health economy. There was a need to ensure this was seen as investing money in general practice to improve service delivery and money may move around the system but this was not additional monies.

Action: Members agreed this was a fair value base for year 1, recognising the CCG Board will decide the eventual investment based on risk that all practice targets may not be met.

6. The principles for payment show the commitment to sharing the risk between the commissioner and practices, recognising the need for investment in general practice capacity to deliver improvement in access & quality. It was agreed practices need some certainty so they take the expected action of employing additional staff.

The proposal was for 60% of the contract value total to be paid on agreement of a plan to deliver the standards and 40% dependent on achievement of KPIs to ensure appropriate risk sharing. Members discussed delivery in year two and possible changes to the risks going forward. It was agreed this would be included in this principle and the CCG would be likely to alter the balance of risk share at 60% if practices fail.

Costing of every standard had been undertaken and an appropriate value set for each. These include a spread across value for money, quality and health improvement. To earn the total incentive which the 40% represents is dependent on practice delivery.

A list of values showing the appropriate amount of funding against each KPI was tabled, showing a total contract value of £4.8m. Methods previously used to incentivise and to stretch practices had been used. Members discussed the option of applying a weighting to the standards. The challenges around this were acknowledged.

The action planning will show clear plans to deliver against each of the areas and if there is no impact shown through monitoring, failing to deliver in one area could be performance managed as a breach to the whole contract, to ensure there is a balance in order to ensure a level of consistency of delivery across the whole of the contract from individual practices. The option to only pay if practices deliver 80% of the standards was suggested. It was agreed this may encourage practices to achieve the less valuable standards.

The suggestion of a Gold/Silver/Bronze prize for those practices that do the best or most improved practices on all areas was suggested.

The use of a staggered payment mechanism was also discussed.

Action: Members agreed to: - The process followed and - the staggered payments. - The principle around risk sharing of 60% and 40% and - the incentivisation for each standard being based on a sliding scale to push practices to achieve each KPI. - Further work to be done on the technicalities of incentive payments for achievement, based on the suggestions made.

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7. Performance – a draft practice plan was presented. It was agreed that current staffing information should be sought as a baseline. The aim was to have practices produce a plan based on each standard and identify staffing requirements to achieve this. This would give the opportunity to highlight to practices their eventual position and what increases would be expected in a staged process.

The process for reviewing practice plans was discussed. Members also discussed the wording regarding the prescribing spend in the practice baseline information and agreed that wording such as “optimising prescribing performance” be used. It was noted that the CCG has approached the GMC and LMC asking for comments to ensure the wording used is appropriate.

Members suggested publishing information via the CCG website or even on practice websites to provide transparency and public accountability.

Action: Members agreed that co-commissioners would review plans outside this Committee but that the Committee would have sight of sample plans to gain assurance that the correct processes were in place for reviewing the plans. Proposed criteria to be used would be shared with members prior to the review commencing.

On monitoring, the Committee would receive quarterly data analysis as part of the ongoing performance review process. Quarterly reports would be presented to the CCG Board once approved by the Committee.

Practices would continue to be supported by the primary care team and any disputes would be resolved locally or with support from NHS England.

It was also agreed to include in the contract that annual results of individual practices will be required to be published on their website and that sample plans would be shared with members of the public and the CCG Communications team to advise on the language that best describes the aims.

13/14 Any Other Business • Frequency of meetings going forward – Members agreed to exchange any further ideas outside the meeting and that a further meeting to finalise the report to be submitted to the January CCG Board would be arranged in January.

14/14 Date of Next Meeting Agreed as Monday 19th January at 3pm in St Peters House.

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NHS BOLTON CLINICAL COMMISSIONING GROUP Public Board Meeting

AGENDA ITEM NO: ………15………………

Date of Meeting: ……23rd January 2015.…

TITLE OF REPORT: Annual Review of Gifts & Hospitality and Declarations of Interest Registers

AUTHOR: Joanne Taylor, Board Secretary

PRESENTED BY: N/A – Item to note.

PURPOSE OF PAPER: Declarations of Interest: (Linking to Strategic Objectives) In accordance with the CCG’s Conflicts of Interest Policy, the Register of Interest for CCG Board members, the GP membership, employees and interim and sessional employees, including clinical leads, will be submitted annually to the Board for noting. The Register is attached detailing the relevant and material interests declared since the last report received by the Board in January 2014.

Gifts and Hospitality Register: In accordance with the CCG’s corporate governance processes, the Register will be submitted annually to the Board for noting. The Register is attached detailing gifts and hospitality received by Board members, employees and clinical leads from January 2014.

RECOMMENDATION TO THE The Board is asked to note the relevant and BOARD: material interests that have been declared and (Please be clear if decision note the gifts and hospitalities received from required, or for noting) January 2014 to date.

COMMITTEES/GROUPS Board Members. PREVIOUSLY CONSULTED: Clinical Leads. Membership practices. CCG staff.

VIEW OF THE PATIENTS, CARERS This is a statutory requirement of the CCG OR THE PUBLIC, AND THE EXTENT therefore views from members of the public, OF THEIR INVOLVEMENT: patients are not required. EQUALITY IMPACT ASSESSMENT This report has been considered against the (EIA) COMPLETED & OUTCOME OF criteria of EIA and an assessment is not ASSESSMENT: considered necessary for the report.

Declaration of interests form for members/employees

Member / employee/ governing body member / committee or sub-committee member (including committees and sub-committees of the governing body) declaration form: financial and other interests

This form is required to be completed in accordance with the CCG’s Constitution and section 14O of The National Health Service Act 2006.

Notes: • Each CCG must make arrangements to ensure that the persons mentioned above declare any interest which may lead to a conflict with the interests of the CCG and the public for whom they commission services in relation to a decision to be made by the CCG. • A declaration must be made of any interest likely to lead to a conflict or potential conflict as soon as the individual becomes aware of it, and within 28 days. • If any assistance is required in order to complete this form, then the individual should contact the Board Secretary, Joanne Taylor on 462028 or email [email protected] . • The completed form should be sent by both email and signed hard copy to the Board Secretary, details as above. • Any changes to interests declared must also be registered within 28 days by completing and submitting a new declaration form. • The register will be published on the CCG’s website. • Any individual – and in particular members and employees of the CCG - must provide sufficient detail of the interest, and the potential for conflict with the interests of the CCG and the public for whom they commission services, to enable a lay person to understand the implications and why the interest needs to be registered. • If there is any doubt as to whether or not a conflict of interests could arise, a declaration of the interest must be made.

Interests that must be declared (whether such interests are those of the individual themselves or of a family member, close friend or other acquaintance of the individual) include: • roles and responsibilities held within member practices; • directorships, including non-executive directorships, held in private companies or PLCs; • ownership or part-ownership of private companies, businesses or consultancies likely or possibly seeking to do business with the CCG; • shareholdings (more than 5%) of companies in the field of health and social care; • a position of authority in an organisation (e.g. charity or voluntary organisation) in the field of health and social care; • any connection with a voluntary or other organisation contracting for NHS services; • research funding/grants that may be received by the individual or any organisation in which they have an interest or role; • any other role or relationship which the public could perceive would impair or otherwise influence the individual’s judgement or actions in their role within the CCG. If there is any doubt as to whether or not an interest is relevant, a declaration of the interest must be made.

CCG Board - Register of Interests

Name Date Position/ Role Interest declared Potential or actual area Action taken to mitigate where interest could risk occur Alan Stephenson 22/11/13 Lay Member • Governor at Wigan and Leigh Decisions/activities Would not take part in College (personal interest). related to education or decision young people’s services. making/procurement or other activities relating to this interest. • Member of Bolton FT, Central Decisions/activities Manchester FT, Wrightington, related to all services Membership of FTs Wigan and Leigh FT, The provided by these FTs. does not constitute a Walton Centre NHS FT, NWAS, conflict of interest. Bridgewater Community (personal interest). Ann Benn 12/8/14 Lay Member, • Hospital manager for the Decisions/activities Would not take part in Public purposes of the Mental Health related to mental health. decision Engagement Act (1983) at GMW Mental making/procurement or Health Trust – fee received for other activities relating session/reviews. Decisions/activities to this interest. • Member of Bolton FT, GMW, related to all services Membership of FTs Christie, Clatterbridge Centre for provided by these FTs. does not constitute a Oncology (Wirral). Decisions/activities conflict of interest. • Husband, member of Health related to these Would not take part in Watch, BEER Board. organisations. decision • Minute secretary for making/procurement or Westhoughton Community other activities relating Network (introduced senior to this interest. solutions to CCG integrated care team).

Annette Walker 21/1/14 Chief Finance • Public Sector Director, BRAHM No conflict. No pecuniary interest; Officer LIFT Co. role held by virtue of • Bolton School Alumni – invited No conflict. being CFO. Invited to to speak to school on careers in continue by Community the NHS. Health Partnerships, wholly owned by Department of Health. Barry Silvert 9/1/15 Clinical Director, • GP senior partner, Stonehill Decisions or activities Would not take part in Integrated Medical Centre. related to primary care in decision Commissioning • Wife is nurse practitioner particular primary care making/procurement or employed by the practice. estates. other activities relating • 12.5% shareholder in to this interest. Quicksecure Limited (community pharmacy). • Stonehill Medical Centre has been approached by Bardoc who have expressed a interest in using SMC as a satellite centre for out of hours. This would initially encompass only weekends but where Bardoc to be the preferred future provider, this may involve daily usage. There would be financial benefit to SMC if this interest results in a contract. Charles Hendy 13/12/13 GP Board Member • GP partner, Halliwell Surgery Decisions or activities Would not take part in owing 1/3rd of the premises. related to primary care. decision • Wife is a staff nurse on Decisions or activities making/procurement or Endoscopy Unit at Bolton NHS related to endoscopy other activities relating Foundation Trust. services. to this interest.

Charlotte 13/11/13 GP Board Member • Salaried GP, Cornerstone Decisions or activities Would not take part in Mackinnon Surgery. related to primary care. decision • Employee of Bolton NHS FT as Decisions or activities making/procurement or GP with special interest in related to adolescent other activities relating Adolescent Health. health services. to this interest. • Husband is a podiatrist Decisions or activities employed by Bolton NHS related to podiatry Foundation Trust. services. • Occasional lecturer/advisor for Decisions or activities MSD Pharamceutical company related to contraception with regard to contraception, in services. particular Implanon. Colin Mercer 22/11/13 Clinical Director, • Part time GP, Mandalay Medical Decisions or activities Would not take part in Clinical Centre. related to primary care. decision Governance & making/procurement or Safety other activities relating to this interest. Joe Leigh 13/11/13 Lay Member, • Director Wythenshawe Housing Decisions/activities Would not take part in Governance Group. related to Wythenshawe decision • Trustee, Family Fund. Housing Group, Family making/procurement or • Wife is a former Trustee of Fund and Carers Support. other activities relating Bolton Carers Support (to to this interest. November 2013).

Mary Moore 30/7/14 Chief Nurse • Director share Videre Decisions/activities Would not take part in management services ltd. related to providing decision • 50% share Videre management healthcare consultancy on making/procurement or services. inspection reviews and other activities relating service redesign services to these interests. to NHS and private healthcare providers nationally and internationally.

Shri-Kant 16/12/13 GP Board Member • GP partner, Spring View Medical Decisions or activities Would not take part in Centre. related to primary care. decision • Wife is a partner in the practice. making/procurement or • Rented pharmacy in the other activities relating practice premises with no to this interest. influence on its business or decision making or financial interests. Stephen Liversedge 30/7/14 Clinical Director, • GP Principal, Drs Liversedge, Decisions or activities Would not take part in Primary Care & McCurdie and Wong. related to primary care. decision Health • Chair of Independent Decisions or activities making/procurement or Improvement Remuneration Committee for relating to Bolton Council other activities relating Bolton Council. remuneration. to these interests. • Son is a Project Manager for Decisions or activities Division of Medicine, East relating to East Lancashire NHS Hospital Trust. Lancashire NHS Hospital • Close friend works for public Trust. health department Bolton Decisions or activities Council as a public health relating to public health specialist. services. • Expenses paid by Columbian Decisions or activities Government to facilitate health relating to health services improvement initiatives. in Columbia. Susan Long 16/3/13 Chief Officer • Partner is Consultant Decisions or activities Would not take part in Respiratory Physician at Aintree related to thoracic, decision University Hospitals NHS haematology, palliative making/procurement or Foundation Trust, oversees the care, dermatology, cancer other activities relating Thoracic, Haematology and at Aintree University to this interest. Palliative Care Departments and Hospitals NHS FT. is Trust Lead Cancer Clinician. Tarek Bakht 10/1/14 GP Board Member • Locum GP in Bolton. Decisions or activities Would not take part in related to primary care. decision making/procurement or other activities relating to this interest.

Wendy Meredith 8/1/14 Director of Public • Employee of Bolton Council. Decisions or activities Would not take part in Health (non voting related to Bolton Council. decision member) making/procurement or other activities relating to this interest. Wirin Bhatiani 24/1/14 GP Chair • Managing partner, Unsworth Decisions or activities Would not take part in Group practice. related to primary care. decision • Appointed to the Board of Decisions or activities making/procurement or Director (from Jan 14), Bolton related to Bolton Arena. other activities relating Arena. to these interests.

Clinical Lead - Register of Interests Name Date Position/ Role Interest declared Potential or actual area Action taken to mitigate where interest could risk occur Alison Lyon 21/1/14 Clinical Lead – • GP partner, Lever Chambers. Decisions or activities Would not take part in Prescribing • Husband is partner in related to primary care. decision pharmacy at Kildonan House. making/procurement or other activities relating to this interest. Bob Hunt 8/11/13 Clinical Lead – • GP partner, Halliwell surgery. Decisions or activities Would not take part in Demand Management • Appointed Trustee of Bolton related to primary care. decision Hospice. Decisions or activities making/procurement or related to Bolton Hospice. other activities relating to this interest. Jane Bradford 28/1/14 Clinical Lead – • GP partner, Dr Lancashire Decisions or activities Would not take part in Prescribing and Partners. related to primary care. decision • Attendance at 2 advisory making/procurement or boards discussing epilepsy other activities relating and dermatology (June 13). to these interests. John Tabor 24/2/14 Clinical Governance • GP partner, Kildonan House. Decisions or activities Would not take part I Lead (Bolton West • Part time owner of Kildonan related to primary care. decision and South East) Healthcare which runs making/procurement or Kildonan Pharmacy, an NHS other activities relating pharmacy based at the to these interests. practice. • Secretary of Bolton LMC. • Wife is a practice nurse.

Liaqat Natha 18/11/13 Clinical Lead – IM&T. • GP partner, Kearsley Medical Decisions or activities Would not take part in Centre. related to primary care. decision • Member, Bolton Local Decisions or activities making/procurement or Medical Committee. related to Bolton LMC. other activities relating • Volunteer for the Health Decisions or activities to these interests. Forum Bolton Council of related to BCOM. Mosques (BCOM), a 3rd sector voluntary organisation. Martyn Fletcher 15/11/13 Clinical Lead – Mental • GP partner, Mandalay Decisions or activities Would not take part in Health. Medical Centre. related to primary care. decision making/procurement or other activities related to this interest. Paul Nixon 30/4/14 Clinical Lead – • Co-investigator/ Decisions or activities Would not take part in Respiratory Service investigator for clinical related to primary care, in decision Review drug trials. particular respiratory making/procurement or • Pulmonary rehabilitation services and pulmonary other activities related to at practice. rehabilitation services. this interest. • Clinical lead role for respiratory (for period February to October 14). Tara Breslin 21/1/14 Clinical Lead – NIL N/A N/A Pathway Development. CCG Staff - Register of Interests

Name Date Position/ Role Interest declared Potential or actual area Action taken to mitigate where interest could risk occur Ben Woodhouse 8/1/14 Medicines • Private consultancy, advisory Decisions or activities Would not take part in Optimisation & and training work for a variety related to pharmacy decision Prescribing Lead of pharmaceutical companies services and consultancy making/procurement or and consultancy firms. firms. other activities relating Detailed submissions are to this interest. sent to the Board Secretary and Clinical Director, Primary Care & Health Improvement every 2 months. Dimple Thakrar 10/12/14 Prescribing Support • Founder of Fresh Nutrition Decisions or activities Would not take part in Dietician Ltd carrying out 1 to 1 patient related to dietetic services decision consultations in the North and consultancy firms. making/procurement or West and dietetic consultancy other activities relating training in the workplace. to this interest. • Also provide dietetic cover for private/NHS hospitals outside Bolton. • Dietetic support for DMU and Tesco roadshows/shopping tours in Bolton. Jole Hannah 21/1/14 Medicines • Father is GP adviser to the Decisions or activities Would not take part in Optimisation Isle of Man Department of related to the Isle of Man decision Pharmacist Health. Department of Health. making/procurement or • Carried out advisory boards other activities relating for the following companies: to this interest. Thornton and Ross, Viropharma, Blue River Consulting, iRx Solutions. Leanne Fane 20/1/14 Prescribing Support • Bank staff for occasional Decisions or activities Would not take part in Technician work at Bolton NHS related to pharmacy at decision Foundation Trust. Bolton NHS FT. making/procurement or other activities relating to this interest.

Lynda Helsby 11/11/14 Associate Director, • Son works as administrative Decisions or activities Would not take part in Primary Care & assistant at Bolton FT in the related to single point of decision Health Improvement Single Point of Access access service at Bolton making/procurement or service. NHS FT. other activities relating to this interest. Michael Brown 22/12/14 Associate Director, • Wife employed as Manager Decisions or activities Would not take part in Contract Management within Manchester Mental related to Manchester decision Health and Social Care Trust. Mental Health & Social making/procurement or Care Trust. other activities relating to this interest. Michael Robinson 7/1/14 Associate Director, • Wife works as a senior Decisions or activities Would not take part in Integrated cardiac rehabilitation related to physiotherapy decision Governance & Policy physiotherapist for Salford and Cardiac making/procurement or Royal Hospitals NHS Trust. Rehabilitation services at other activities relating Salford Royal Hospitals to this interest. NHS Trust. Natalie Fleming 14/1/14 Prescribing Support • Husband is a Sterile Decisions or activities Would not take part in Technician Production Manager at related to pharmacy at decision Preston Pharmaceuticals. Preston Pharmaceuticals. making/procurement or • One off participation in a other activities relating commissioning & prescribing Decisions or activities to these interests. advisory board in related to dermatology. Dermatology (Emollients) for IRX solutions limited (private work). Sumayya Patel 11/9/14 Project Support • Husband is a senior IT Decisions or activities Would not take part in Officer, engineer, GMW. related to IT services at decision Commissioning GMW. making/procurement or other activities relating to these interests.

CCG Member Practices - Register of Interests (excludes interests already declared by GPs working as GP Board Members/Clinical Leads)

Name Date Position/ Role Interest declared Potential or actual area Action taken to mitigate where interest could risk occur Abdul Atcha 2/6/14 GP NIL N/A N/A Abdul Hafeez 19/5/14 GP Member of Association of Decisions or activities Would not take part in Pakistani Physicians and related to primary care. decision surgeons. making/procurement or other activities related to this interest. Abubaker Zarrouk 23/9/14 GP NIL N/A N/A Adam Bashir 19/5/14 GP NIL N/A N/A Ahmed Ariff 18/9/14 Senior Partner NIL N/A N/A Ali Haroon Khan 19/5/14 GP NIL N/A N/A Amanda Stafford 23/9/14 Salaried GP NIL N/A N/A Anant Prasad 14/5/14 GP NIL N/A N/A Andrew Lloyd 30/4/14 GP Principal NIL N/A N/A Anjana Kumar 25/9/14 GP NIL N/A N/A Anjani Kumar 25/9/14 GP Principal NIL N/A N/A Anne Hawkridge 29/9/14 Salaried GP Member Royal College of GPs. Decisions or activities Would not take part in Education Associate, General related to primary care. decision Medical Council. making/procurement or other activities related to this interest. Antoni Pomian 17/9/14 GP Partner NIL N/A N/A Anu Mehra 19/11/14 GP Lead NIL N/A N/A Aruna Gupta 21/5/14 GP NIL N/A N/A Bernard Newgrosh 7/5/14 GP NIL N/A N/A Bethany Haves 18/9/14 GP NIL N/A N/A Charalambos 16/10/14 GP Partner NIL N/A N/A Charidemou Charlotte Moran 17/10/14 Salaried GP NIL N/A N/A Christopher 17/9/14 GP NIL N/A N/A Earnshaw Chidananda Barua 22/9/14 GP NIL N/A N/A Clare Haslam 18/9/14 GP Partner NIL N/A N/A David McAuley 23/9/14 Salaried GP Appraiser. Decisions or activities Would not take part in relating to primary care, in decision particular appraisal making/procurement or services. other activities related to this interest. David Wall 19/11/14 GP Partner NIL N/A N/A Dharmesh Mistry 30/4/14 Practice Clinical Lead One session per week as GP out Decisions or activities Would not take part in of hours. relating to primary care, in decision particular out of hours making/procurement or services. other activities related to this interest. Donna White 19/8/14 Salaried GP NIL N/A N/A Edward Gillooly 26/8/14 GP NIL N/A N/A Elizabeth Perry 6/5/14 GP NIL N/A N/A Emily Acomb 23/9/14 Salaried GP NIL N/A N/A Eve Haworth 17/9/14 GP Partner NIL N/A N/A Farhan Munawar 9/9/14 GP Partner Director and shareholder of FML Decisions or activities Would not take part in Locum Ltd. relating to primary care, in decision Member and shareholder of particular regarding these making/procurement or Federation “Healthier Bolton companies/organisations. other activities related to Together”. these interests. Ferjana Thagia 17/9/14 GP Partner NIL N/A N/A Gavin Faulkner 30/4/14 GP Partner NIL N/A N/A George Ogden 16/10/14 GP Partner Chair of Bolton LMC. Decisions or activities Would not take part in relating to primary care, in decision Wife Consultant Anaesthetists, particular regarding the making/procurement or Lancashire Teaching Hopsital. LMC, anaesthetic other activities related to services and development these interests. Member of working group of GP federations. looking at setting up GP federation. Gillian Counsell 25/9/14 GP Partner NIL N/A N/A Gillian Rink 30/4/14 GP Partner NIL N/A N/A Golam Chowdhury 19/12/14 Salaried GP NIL N/A N/A

Helen Wall 15/5/14 GP On call work for Bolton Hospice. Decisions or activities Would not take part in Out of hours work. related to primary care, in decision particular in relation to the making/procurement or out of hours service and other activities related to on-call work for Bolton this interest. Hospice. Helen Yoxall 29/4/14 GP NIL N/A N/A Hilary Healey 22/5/14 GP Partner Spouse, children and Dr Healey Decisions or activities Would not take part in are shareholders in Quicksecure related to primary care, in decision Ltd (community pharmacy). particular in relation to the making/procurement or community pharmacy other activities related to services. this interest. Hussain Aboud 21/5/14 Locum/Salaried GP Long term locum at Bolton Decisions or activities Would not take part in General Practice. related to primary care. decision making/procurement or other activities related to this interest. Ian Caldwell 29/4/14 Senior GP Partner Involved in primary care Decisions or activities Would not take part in research trials. related to primary care, in decision particular research trials. making/procurement or other activities related to this interest. Ian Hamer 16/9/14 GP Principal 17.5% share in Kildonan Decisions or activities Would not take part in Healthcare Pharmacy. relating to primary care, in decision Hospital practitioner Diabetic particular regarding making/procurement or Clinic at Chorley Hospital. pharmacy and diabetes other activities related to services. these interests. Imtiaz Sidat 30/4/14 GP NIL N/A N/A

Jack Leach 8/9/14 Salaried GP Director and 50% shareholder in Decision or activities Would not take part in KJ Physiotherapy and Medical relating to primary care, in decision Consultancy Ltd. particular physiotherapy, making/procurement or Medical Advisor to ARCH drug and alcohol and other activities related to Initiatives, 3rd sector drug & substance misuse these interests. alcohol treatment service, services. Merseyside, Lancashire and Greater Manchester. Member of Royal College of General Practitioners, substance misuse and allied health unit involved in development of training in primary care. Jacqueline Thomas 20/9/14 Salaried GP NIL N/A N/A Jane Lowe 30/4/14 GP Partner NIL N/A N/A Janet Symes 19/8/14 GP Principal NIL N/A N/A Jayanthan 23/5/14 Salaried GP NIL N/A N/A Mylvaganam Javed Bax 8/4/14 GP Partner Member of Bolton Council of Decisions or activities Would not take part in Mosques Health Forum. relating to primary care, in decision particular health service making/procurement or decisions made with other activities related to Bolton Council of this interest. Mosques. John Kirby 16/5/14 GP GP with special interest in Decisions or activities Would not take part in dermatology. related to primary care, in decision Some out of hours sessions. particular dermatology making/procurement or and out of hours services. other activities related to these interests. John Scott 30/4/14 GP Partner Bowel cancer screening Decisions or activities Would not take part in research. relating to primary care, in decision particular bowel cancer making/procurement or screening. other activities related to this interest. Jonathan Jones 8/4/14 GP Partner NIL N/A N/A Jonathon Varker 23/4/14 GP NIL N/A N/A Julian Page 25/4/14 GP NIL N/A N/A Julian Tomkinson 20/5/14 GP NIL N/A N/A Julie Hall 30/4/14 GP Principal Vice Chair, Bolton LMC. Decisions or activities Would not take part in GP Appraiser. relating to primary care, in decision particular the GP making/procurement or appraisal process and other activities related to LMC work. this interest. Julie McMillen 1/5/14 GP Public Health Service Decisions or activities Would not take part in Ombudsman Clinical Advisor related to primary care, in decision particular in relation to the making/procurement or public health service other activities related to ombudsman. this interest. Kamran Khan 29/4/14 GP Principal NIL N/A N/A Kate Outterside 17/9/14 Salaried GP NIL N/A N/A Katherine Rothwell 22/9/14 GP NIL N/A N/A Kathryn Birkinshaw 17/9/14 Salaried GP NIL N/A N/A Katie Hilton 18/9/14 Salaried GP NIL N/A N/A Ketankumar Patel 22/9/14 GP NIL N/A N/A Kushal Boodhun 22/9/14 GP NIL N/A N/A Lakshmi Manoharan 21/5/14 GP Occasionally do out of hours GP Decisions or activities Would not take part in work (1 session per month in related to primary care, in decision Wigan). particular out of hours making/procurement or services. other activities related to this interest. Lawrence Wong 1/5/14 GP NIL N/A N/A Leah Robinson 1/5/14 Salaried GP NIL N/A N/A Lisa Collins 17/10/14 GP Partner NIL N/A N/A Lorraine Lowe 19/5/14 Nurse Practitioner NIL N/A N/A Lyn Wardman 29/4/14 GP Partner GP with special interest in Decision or activities Would not take part in dermatology, Bolton NHS FT. relating to primary care, in decision particular dermatology making/procurement or services. other activities related to this interest. Maeve Hague 22/9/14 GP Partner NIL N/A N/A Mahadeva 30/4/14 GP NIL N/A N/A Selvarajan Maitrayee Arya 28/4/14 GP Partner Participation in drug trials. Decisions or activities Would not take part in relating to primary care, in decision particular relating to drug making/procurement or trials. other activities related to this interest. Malcolm Brown 30/4/14 GP Principal Associate Dean HENW. Decisions or activities Would not take part in Employee Health Education relating to primary care, in decision England (HEE). particular deanery work making/procurement or and work with Health other activities related to Education England. this interest. Manohar 16/4/14 GP NIL N/A N/A Dakshina-Murthi Manu Jeyam 15/5/14 GP partner Family member Director and Decision or activities Would not take part in shareholder of Nethra Ltd. related to consulting with decision this firm. making/procurement or other activities related to this interest. Mark Hall 19/8/14 GP Principal Joint Director, Kildonan Decisions or activities Would not take part in Pharmacy. related to primary care, in decision particular relating to making/procurement or pharmacy services. other activities related to this interest. Michael Davies 29/4/14 GP Principal Occasional out of hours sessions Decisions or activities Would not take part in (short term). relating to primary care, in decision particular out of hours making/procurement or services. other activities related to this interest. Michael McCurdie 29/4/14 GP Partner NIL N/A N/A Minto Chowdhury 17/9/14 GP Principal NIL N/A N/A Mohammad Majid 16/4/14 GP NIL N/A N/A Mohamed Mirza 18/9/14 GP Principal NIL N/A N/A Mohomed Choksi 29/4/14 GP Partner Involved in primary care Decisions or activities Would not take part in research trials. related to primary care, in decision particular research trials. making/procurement or other activities related to this interest. Muhammad Akram 28/4/14 GP Principal NIL N/A N/A Muhammad Saleem 21/5/14 GP Director and shareholder in Decisions or activities Would not take part in Peace Health, complementary related to primary care, in decision therapy. particular complementary making/procurement or therapy. other activities related to this interest. Nasima Sidda 28/8/14 GP NIL N/A N/A

Nathan Goldrick 28/8/14 GP GP Appraiser for GMAT. Decisions or activities Would not take part in GP Trainer. related to primary care, in decision particular appraisal and making/procurement or GP training. other activities related to this interest. Nick Pendleton 21/10/14 GP Partner Partner at Heaton Medical Decisions or activities Would not take part in Centre. relating to primary care, in decision Programme Director and GP particular education/ making/procurement or Educator for Bolton GP training appraisal services and other activities related to programme. activities relating to this interest. GP Appraiser. residential homes. Company Director, Mayfield House Residential Block (Didsbury) – not related to medical field of practice.

Nicola Robbie 23/5/14 GP Partner NIL N/A N/A Niruban Ratnarajah 29/4/14 GP Principal Director, Ratnarajah Medical Decisions or activities Would not take part in Services Ltd (locum/out of hours relating to primary care, in decision work). particular locum/out of making/procurement or hours services. other activities related to this interest. Patricia Cross 17/9/14 Salaried GP NIL N/A N/A Penelope Parr 16/9/14 GP Chair of Clinical Advisory Group, Decisions or activities Would not take part in Bolton Community Practice relating to primary care, in decision Board. particular services making/procurement or provided by Bolton other activities related to Community Practice. this interest. Peter Priest 11/6/14 GP NIL N/A N/A Peter Saul 164/14 GP NIL N/A N/A Prabodh Jain 29/4/14 GP NIL N/A N/A Preeti Adma 30/4/14 Salaried GP NIL N/A N/A Rachel Jesudas 22/5/14 GP NIL N/A N/A Rashmnita Malhotra 23/9/14 GP NIL N/A N/A Reshma Jeena 16/9/14 Salaried GP NIL N/A N/A Riad Falouji 30/4/14 GP NIL N/A N/A Richard Simpson 29/4/14 GP Principal NIL N/A N/A Richard Swann 17/9/14 GP NIL N/A N/A Rita Patel 25/9/14 Salaried GP NIL N/A N/A Robert Walker 6/5/14 GP NIL N/A N/A Saeeda Anwar 15/9/14 GP Partner Director and shareholder of Decisions or activities Would not take part in Locum GP 4U Ltd. relating to primary care, in decision Member and shareholder of particular regarding these making/procurement or Federation “Healthier Bolton companies/organisations. other activities related to Together”. this interest. Salaam Muhsin 26/8/14 GP NIL N/A N/A Samir Naseef 29/4/14 GP Director Healthier Bolton Decisions or activities Would not take part in Together Ltd. related to primary care. decision Director – CMEDS. making/procurement or Director – Dr Naseef Ltd. other activities related to these interests. Sanjay Pitalia 14/5/14 GP Director and shareholder SSP Decisions or activities Would not take part in Health Ltd. related to primary care. decision Director and shareholder Pall making/procurement or Mall Medical Holding Ltd and Decisions or activities other activities related to group of companies. related to consulting with these interests. Member JY Kinsha LLP. any of these firms. Member ULC LLP. Member RN Jay LLP. Director and shareholder Planet Construction (UK) Ltd. Director and shareholder Identity Office Ltd. Director and shareholder Oasis Living Ltd. Director and shareholder Identity Life Ltd. Director and shareholder STL Solutions Holding Ltd. OOL Property Ltd. Spa Medica. Sanjay Wahie 18/9/14 GP Shareholder – Cardium. Decisions or activities Would not take part in Wigan CCG governing body related to primary care. decision member. making/procurement or Saturday surgeries in SSP other activities related to surgeries. these interests. Sarah Green 26/8/14 GP NIL N/A N/A Sarah McLoughlin 19/9/14 GP NIL N/A N/A Saveena Ghaie 16/4/14 GP Appraiser and appraisal lead for Decisions or activities Would not take part in NHS England. relating to primary care, in decision Member of Bolton LMC. particular appraisal making/procurement or processes and LMC work. other activities related to these interests. Savita Agarwal 16/10/14 GP Partner NIL N/A N/A Seema Rajpura 15/4/14 GP NIL N/A N/A Shahid Munshi 24/9/14 GP Partner NIL N/A N/A Shaista Hanif 2/5/14 GP NIL N/A N/A Shaneela Ibrar 19/9/14 Salaried GP NIL N/A N/A Sharif Uddin 4/9/14 GP Partner Director of LTD Excel Medical Decisions or activities Would not take part in Solutions and wife is a relating to primary care, in decision shareholder. particular regarding these making/procurement or GP practice is a member of companies/organisations. other activities related to Bolton Federation “Healthier these interests. Together”. Vice Chair of Federation “Healthier Together”. Communications lead for NEW RCGP Faculty. Shawn Sacks 21/5/14 GP NIL N/A N/A Shehriar Hussain 18/9/14 GP Partner Interest in Dermatology. Decisions or activities Would not take part in related to primary care, in decision particular dermatology making/procurement or services. other activities related to these interests.

Shikha Pitalia 14/5/14 GP Director and shareholder SSP Decisions or activities Would not take part in Health Ltd. related to primary care. decision Director and shareholder Pall making/procurement or Mall Medical Holding Ltd and Decisions or activities other activities related to group of companies. related to consulting with these interests. Member JY Kinsha LLP. any of these firms. Member ULC LLP. Member RN Jay LLP. Non-Executive Director, Trustech. Spa Medica. Shital Koshti 30/4/14 Salaried GP Salaried in GP in ABL (Choose Decisions or activities Would not take part in to Loose weight) once a week. related to primary care, in decision particular relating to making/procurement or weight loss services. other activities related to this interest. Shuba Panja 16/9/14 GP NIL N/A N/A Simon Caswell 25/9/14 GP Partner NIL N/A N/A Simon Hall 18/9/14 GP Partner Wife is a member of Bolton LMC. Decisions or activities Would not take part in relating to primary care, in decision particular LMC work. making/procurement or other activities related to this interest. Sophia Ahsan 19/9/14 Salaried GP NIL N/A N/A Stephen 25/9/14 GP Partner NIL N/A N/A Greenhalgh Stephen James- 27/5/14 GP NIL N/A N/A Authe Steven Whittaker 30/4/14 GP Partner NIL N/A N/A Sumit Guhathakurta 16/10/14 GP Pilot Palpitation clinics. Decisions or activities Would not take part in relating to primary care, in decision particular palpitation making/procurement or services. other activities related to this interest. Surinder Malhotra 16/9/14 GP NIL N/A N/A Surinder Singh 27/5/14 GP NIL N/A N/A Talha Patel 18/9/14 Salaried GP Trustee of Well Wishers Trust. Decisions or activities Would not take part in relating to primary care, in decision particular the Well making/procurement or Wishers Trust. other activities related to these interests. Tasneem Irshad 22/9/14 Salaried GP Executive Committee member of Decisions or activities Would not take part in Internal Foundation for Mother & relating to primary care, in decision Child (IFMCH) particular children’s making/procurement or services. other activities related to these interests.

Thiruppathy 17/10/14 GP Shareholder member and GP in Decisions or activities Would not take part in Subramanian Bolton Community Practice CIC relating to primary care, in decision Asocial Enterprise. particular Bolton making/procurement or Community practice, other activities related to Part-time clinical assistant in otolaryngology services these interests. otolaryngology at Bolton NHS and out of hours services. FT.

Non-contractual shift work offering general practice work to BARDOC out of hours service provider in Bolton. Tim Isaac 1/5/14 GP Partner NIL N/A N/A Tom Lynch 13/5/14 GP Partner NIL N/A N/A Varghese George 16/10/14 GP Partner NIL N/A N/A Vineet Kalhan 7/10/14 GP NIL N/A N/A Yogesh Loomba 17/11/14 GP Lead NIL N/A N/A Zafar Chowdhury 14/5/14 GP Partner NIL N/A N/A Zaheda Atcha 16/9/14 GP Joint Director Kildonan Decisions or activities Would not take part in Pharmacy. related to primary care, in decision particular relating to making/procurement or pharmacy services. other activities related to these interests.

NHS BOLTON CCG - DECLARATIONS OF HOSPITALITY AND GIFTS

Name Department Name of Date of offer Offer Description of Actual/ Additional Company or Receipt of Accepted/ Hospitality/Gift Estimated Details offering Hospitality/Gift Not Value Hospitality/Gift accepted Dimple Dietician, Aymes 15/12/14 Accepted Knife set – to support Not known N/A Thakrar Primary Care food preparation for food first training.

Nicola Onley Comms & Comments 19/12/14 Accepted Remote control VW Not known N/A Engagement Campervan campervan.