Enc 00
Cannock Chase Clinical Commissioning Group South East Staffordshire and Seisdon Peninsula Clinical Commissioning Group Stafford and Surrounds Clinical Commissioning Group
Stafford and Surrounds Clinical Commissioning Group Governing Body Meeting in PUBLIC to be held on 28th March 2017 at The Amerton Room, The Hub – VAST, 17 Eastgate Street, Stafford ST16 2LZ
AGENDA 12:30 – 14:00 Confidential Governing Body Meeting 1. Welcome by the Chair 2. Apologies 3. Conflicts of Interests 4. Minutes & Actions of the last Meeting 5. Staffordshire & Stoke on Trent Partnership Trust (SSOTP) Community Review 6. Acute Visiting Service
FOLLOWED BY: 14:00 – 16:30 Governing Body Meeting in Public
A=Approval R=Ratification S=Assurance D=Discussion I=Information Enc Lead A/R/S/D/I 1. Welcome by the Chair Verbal PH I 2. Apologies Verbal PH I 3. Quoracy Verbal PH I 4. Conflicts of Interest Enc. 01 PH I 5. Minutes of the Meeting held on 24/01/2017 Enc. 02 PH A 6. Actions from the Meeting held on 24/01/2017 Enc. 03 PH A
Standing Items 7. Chair’s Report Verbal PH I 8. Chief Officer’s Report Enc. 04 AD I 9. Quality Report Enc. 05 HJ S 10. Board Assurance Framework (BAF) & Risk Register Enc. 06 SY D/I 11. Finance Report Enc. 07 PS D/I 12. Performance Report Enc. 08 CB S
We are honest, accessible Quality is our day job We innovate and deliver Care and respect for all and we listen
Enc 00
Items for Consideration 13. Sustainability and Transformation Plan Enc. 09 AD A 14. Financial/Operational Plans 2017-18 Pres. PS/JB A Prime Financial Policies and Standing Financial 15. Enc. 10 PS A Instructions Anti-Fraud & Bribery Policy Enc. 11-1 Whistle Blowing Policy Enc. 11-2 16. SY A Policy for the Development and Management of Enc. 11-3 CCG Policies and other Documents.
Items for Information 17. Audit Feedback Report Enc. 12 I HR/OD Group Report Enc. 13 I Quality Approved Minutes Enc. 14 I Audit Committee Minutes Enc. 15 I Finance Performance and Contract Committee Enc. 16 I Minutes Joint Comms & Engagement Committee Minutes Enc. 17 I HR/OD Group Minutes Enc. 18 I
Glossary of Terms Enc. 19 I 18. Any Other Business Verbal 19. Questions from members of the public Verbal Date, Time and venue of next meeting in Public:- Date: 23rd May 2017 20. Time: 14:00 – 16:30 Venue: The Amerton Room, The Hub – VAST, 17 Eastgate Street, Stafford ST16 2LZ
We are honest, accessible Quality is our day job We innovate and deliver Care and respect for all and we listen
Item: 04 Enc: 01 CONFLICTS OF INTEREST REGISTER 2016-17 (Quarter 3) GOVERNING BODY AS OF JANUARY 2017
Forename Surname Role in the CCG Directorships held in Ownership of private Shareholdings in Positions of authority Connection Research Any other role or relationship private companies, companies, health & social care in field of health and with voluntary, funding/grants PLCs businesses, social care other consultancies organisation
Manu Agrawal Clinical Lead Director of GPF Rising None Practice is a member None None None Membership Board Member Brook Limited and shareholder in GP First Ltd. (GP Federation)
Ian Baines* Executive Director of None None None None None None None Organisational Development Chris Bird* Executive Director of None None None None None None None Contracting & Performance Jonathan Bletcher* Executive Director of None None None None None None None Planning & Strategy
Andrew Donald* Chief Officer None None None None None None None Janet Eames Clinical Lead None Senior Partner at Practice is a member None None None Member of the LMC Mansion House Surgery and shareholder in GP Practice representative on CCG GB and First Ltd. (GP Membership Board Federation)
Gillian Hackett * Executive Assistant None None None None None None None Paddy Hannigan Chair of Governing None Partner at Holmcroft Practice is a member None None None Spouse is a Consultant Neonatologist at Body Surgery and shareholder in GP Univeristy Hospital North Midlands (UHNM) First Ltd. (GP Federation)
Sue Harper Lay Member - Patient Board Member with None None Secretary at Weeping None None Justice of the Peace, South Staffordshire and Public Interest Professional Mediators Cross Patient Bench Association Participant Group
Marianne Holmes Clinical Lead None Partner of Hazeldene Practice is a member None None None None House Surgery and shareholder in GP Partner of Great First Ltd. (GP Haywood Healthcare Federation) Limited Harry Ireland Lay Member - Non-Executive Director None None None None None Chair of the Police Misconduct Panel, West Governance with the Wreakin Midlands Region Housing Trust, Telford
Heather Johnstone* Executive Director of None None None None None None Family member employed by Midlands and Quality & Safety and Lancashie CSU which delivers services to the Chief Nurse CCG. Family member employed by G4S Healthcare.
Lynn Millar* Executive Director of None None None None None None None Primary Care Item: 04 Enc: 01 Forename Surname Role in the CCG Directorships held in Ownership of private Shareholdings in Positions of authority Connection Research Any other role or relationship private companies, companies, health & social care in field of health and with voluntary, funding/grants PLCs businesses, social care other consultancies organisation
Kate Millward Clinical Lead None Partner at Mansion Practice is a member None None None None House Surgery and shareholder in GP First Ltd. (GP Federation)
Douglas Robertson * Secondary Care Associate Medical Received Role works across North Staffordshire CCG Consultant Director and consultant Educational 'Clinical Lead for Planned Care in physician at Leighton Grants from, Staffordshire Transformation programme Hospital Crewe (Mid taken part in 'Honorary Lecturer in Education at Warwick Cheshire Hospitals FT) clinical research Medical School for, and have consulted for, the pharmaceutical companies Takeda, Sanofi and NovoNordisk
Paul Simpson* Executive Director of None None None None None None None Finance Diana Smith Lay Member (Non- None None None None None None Member of Labour Party Statutory) Member of Weeping Cross PPG
Sally Young * Director of Corporate None None None None None None None Governance, Communications & Engagement
* Individual/role works across Cannock Chase CCG, South East Staffordshire & Seisdon Peninsual CCG, Stafford & Surrounds CCG. Item: 05 Enc: 02
Cannock Chase Clinical Commissioning Group South East Staffordshire and Seisdon Peninsula Clinical Commissioning Group Stafford and Surrounds Clinical Commissioning Group
The healthiest place to live and work, by 2025
Stafford and Surrounds Clinical Commissioning Group Governing Body Meeting in PUBLIC
Tuesday 24th January 2017 2.00 pm – 4.30 pm The Amerton Room, The Hub - VAST, Stafford, ST16 2LZ
Members: 26/04/16 26/04/16 28/06/16 27/09/16 22/11/16 24/01/17 28/03/17 Quoracy Quoracy Paddy Hannigan (PH) Chair Andy Donald (AD) Chief Officer Paul Simpson (PS) Executive Director of Finance Heather Johnstone (HJ) Executive Director of Quality & Safety Dr Doug Robertson (DR) Secondary Care Consultant Dr Marianne Holmes (MH) Clinical Leader Dr Kate Millward (KM) Clinical Leader
Dr Manu Agrawal (MA) Clinical Leader Leaders Clinical 6 Voting Members member and at least 2 2 at least and member Sue Harper (SH) PPI Lay Member / Vice Chair lay one at least Officer, Chief officer/Chief Finance Finance Chief officer/Chief Harry Ireland (HI) Lay Member for Governance Chair, Chair/Vice including Diana Smith (DS) Lay Member Dr Janet Eames (JE) LMC Representative In attendance: Sally Young (SY) Director of Corporate Governance & Communications Chris Bird (CB) Executive Director of Contracting & Performance Gill Hackett – Minutes (GH) Executive Assistant - Minutes Ian Baines (IB) Executive Director of Organisational Development Jonathan Bletcher (JB) Executive Director of Planning & Strategy Lynn Millar (LM) Executive Director of Primary Care Adele Edmondson (AE), Comms & Engagement Allison Heseltine (AH) Deputy Director of Quality & Safety Visitors: Julie Beedon, Tricordant Emma Engstom, Tricordant
Action 1. Welcome by the Chair The Vice Chair welcomed all present to the meeting, and gave the Chairs apologies.
2. Apologies for Absence Paddy Hannigan, Heather Johnstone
3. Quoracy The Chair confirmed that the meeting was quorate.
4. Conflicts of Interest It was noted that any matters relating to GP First were a conflict of interest for the GP Clinical Leads. 5. Minutes of Previous Meeting
Page 1 of 7
Item: 05 Enc: 02
Action It was noted that Members confirmed that the minutes of 22nd November 2016 were a true and accurate record of the meeting.
6. Actions of Previous Meeting Actions were noted on the Action List
7. Chair’s Report SH gave the Chair’s Report on behalf of Dr Paddy Hannigan and stated that it was still work as normal for the CCG in order to get the best possible outcome for patients in the area.
The Governing Body RECEIVED the contents of the Chair’s Report. 8. Chief Officer’s Report AD thanked everyone involved in the successful completion of the contracting round for 2017/18 and 2018/19.
AD advised that Finance would be picked up by PS during his report.
AD announced that the STP was launched on 15th December 2016 in public and was received well. He explained that the document set out a number of changes that would be needed and would come to either the OD session in February or the March public session for formal sign off by the Governing Body.
ACTION: STP to come back to Governing body in February or March for formal sign off.
AD advised that the winter period had been very difficult and announced that during the 1st week of January there were 36 breaches at County. He stated that it was now stable, but numbers had increased in the last couple of days. AD advised that he was involved in telephone calls with NHSE and Trusts every day. It was a challenging period across the whole country.
AD advised that although he was moving into his last 3 months, he had listed nine areas of work which he would be focussing on before he retired.
SH advised that there were two visitors from Tricordant who were observing how we work within the Governing Body. SH added that she was seeing a lot of signs of work based stress amongst staff and we needed to combine the work across the 3 CCGs and reduce duplication. AD agreed that we were committed to another year of continued development and added that we could not sustain another 12 months of 3 individual Governing Bodies every month.
DR added that he had observed the Governing Body in Common between SOT and NS CCGs where duplication was reduced and would recommend it to these CCGs as well. IB also agreed about the duplication across the 3 CCGs, although the workforce was generally content and our turnover was minimal. LM added that the Primary Care away day was held and was well received by all staff.
MA advised that 7 out of 14 practices for secondary care were now offering extra appointments in Stafford.
The Governing Body RECEIVED the contents of the Chief Officer’s report 9. Quality & Safety Report AH took papers as read.
Page 2 of 7
Item: 05 Enc: 02
Action
AH announced that the Quality team had made some changes to the reporting and had now included a broad quality report at the end of the provider report. She also stated that they would be holding the first joint quality meeting across all Staffordshire in February and this would be chaired by Paul Gallagher.
AH brought the Board’s attention to the never events at RWT and had received– assurance from lead commissioner that they were monitoring the situation.
MH referred to SSSFT being rated as green, although there was still concern about their communication with primary care and their behaviour towards primary care. AH advised that this had been raised with the Quality Committee and was being investigated. MH stated that she and Dr Gary Free would be attending a meeting with SSSFT together with CCG Medicines Optimisation and a pharmacist relating to drugs. AH suggested that Katie Montgomery should also attend the meeting as she was the lead for the Trust. AH confirmed that she would follow this up with the Quality team and ensure that Katie Montgomery attended the meeting with SSSFT.
The Governing Body RECEIVED the Report for assurance. 10. Board Assurance Framework (BAF) SY advised that there were 15 BAF risks and these were reviewed monthly at the Risk Group. She advised that the Risk Register had also been included for those risk rates 12 and above. SY stated that of the Risks on the risk Register, 11 related to Cancer and EOL and SY had advised the Programme Manager to consolidate those risks to show where we were now that the pause on the programme had been lifted.
SY reiterated that the Risk Group needed to ensure that they had up to date information from the directorates. She stated that this process would be refined by Risk Group who would give assurance to the Governing Body in future. The Risk Group would invite each Exec Directors to present their risks to the Group for discussion.
The Governing Body RECEIVED the update on of the BAF and risk register across the three CCGs 11. Finance Report PS reported that they had agreed a control total £29m against the original control total of £22m. He stated that it was critical that we delivered this control total with NHSE. PS added that the NHS was under a lot of pressure. We are focusing on delivering the control total for 2016/17.
2017/18 PS referred to the presentation on the collective financial position which was given to the Governing Bodies on 14th December 2016. He announced that the gap was 1% (£6m). Although PS stated that we needed to go further than that in order to find some flexibility and with some headroom. PS reiterated that there could be no excuses next year if we failed to deliver the control total.
HI agreed with the contingency on gaining some headroom, although could we confirm that there would be no unannounced expenditures or surprises from NHSE next year. PS responded that this was a valid point, however, most of the decisions are national decisions and we would be held accountable.
DR asked about 1% kept back by NHSE. PS shared that his view that that he thought that this sum would be used by NHSE against the country deficit.
Page 3 of 7
Item: 05 Enc: 02
Action AD added that the 1% would be used to contribute to balance the books of the NHS.
The Governing Body RECEIVED the Report for information. 12. Performance Report CB reported that the information in the pack focused on the national validated data.
CB advised that for SAS, November was the worst month. He stated that when the reporting data had caught up for January, February and March there would be sustained 12 hours breaches, ambulance delays etc. and an increase in numbers attending A&E. CB announced that the Director of Urgent Care and the urgent care team had been present at County in order to support the hospital during this period.
CB advised that waiting lists and backlogs were beginning to move out for Planned care.
CB advised that with Cancer 2 week waits, UHNM had booked a record number of people and they were struggling with capacity of the demand of those patients. He stated that there had been instances of MSA, as a consequence of flow through the hospital.
AD referred to the quality of care with cancer patients and asked how we would know that no harm had come to those individuals. CB responded that we had information available as to when they were treated and we know that they were not waiting too long although not within the standard wait times. He advised that UHNM had agreed with NHSI on a 62 day wait. CB also stated that anyone waiting more than 104 days would have an RCA with a harm review.
SH mentioned that there was a lot of red compared to other CCGs and asked if there was something that we needed to do. AD said that we were pretty invasive and we would not compromise on performance and quality and confirmed that the quality team would always investigate. AD confirmed that the CCG follow any issues through on real time basis and we needed to make sure the system was working effectively. CB added that patient flow for CC and SES was through RWT, whereas in Stafford the majority of patient flow was through UHNM. AD advised that he had embedded 3 members of staff in County hospital for 3 weeks to resolve the problem.
DR stated that this was a general problem. These problems were well established and Ian Sturgess had mentioned that people were making decisions that were not in the best interest of the patients.
The Governing Body RECEIVED the Report for assurance. 13. Equality & Inclusion Report 2016/17 FF introduced herself to the Board and went through the key points of the report.
She explained that the publication set out what we had achieved over the past year in relation to equality and diversity performance and set out equality data we were aware of in 2016/17 for local protected groups. She explained that it also highlighted any significant gaps or trends with links to our agreed Equality Objectives.
FF advised that we had achieved a lot in respect of Equality and Inclusion and the feedback from the grading events had been fed into the Organisational
Page 4 of 7
Item: 05 Enc: 02
Action Development Plan for the organisations. FF confirmed that all 3 Governing Bodies had been trained in equality and inclusion.
AD stated that we needed to find pockets of where people were not fairing as well in the system. SY responded that we had started this at the grading event with staff and now underpin the Organisational Development through the HR/OD committee. SH added that she was pleased with the HR/OD group as this was an important part of our role within the CCG. AD added that the STP would also lead into this.
CB mentioned the age band within the report. IB agreed that we were an ageing workforce.
The Governing Body APPROVED the Equality & Inclusion Report 2016/17 14. Conflicts of Interest & Commercial Sponsorship Policies SY advised that the Conflicts of Interest and Commercial Sponsorship policies had been to the January Audit Committee, who recommended the policies for approval by the Governing Body. MH suggested that policies should be shared with Governing Body members once approved by the sub-committees, rather than being brought to the meeting. AD agreed and suggested that perhaps just a short paper should be sent to Governing Body members stating that the policy had been ratified. It was noted that there would need to be an audit trail of who had seen the policies.
SY advised that the COI policy now included the Gifts and Hospitality policy and confirmed that it would also be going to the other 5 CCGs for Staffordshire.
KM referred to the Primary Care Commissioning committee and gave her concerns regarding decision making. SY responded that lay members were voting members, but confirmed that the clinical chairs were in attendance at these committee meetings. HI confirmed that any decisions made by the lay members were based on the advice from the clinicians.
LM added that the Primary Care Committee did not overturn any clinical decisions taken by Membership Boards and gave the example with PMS, where a recommendation was made by the Task and Finish Group.
AD added that there were two safeguards, it was delegated commissioning and also that the PCTs in 2000 commissioned primary care and non-executive directors formed the Committee that oversaw this. AD gave assurance that the lay members would not make a decision without the full clinical advice from the clinicians.
The Governing Body RATIFIED the Conflicts of Interest and Commercial Sponsorship policies 15. Risk Strategy SY advised that Risk Strategy set out the way in which we dealt with the Risk Register. She explained that the Strategy had been aligned across the three CCG’s. SY confirmed that a new sharepoint risk drive was now being used which incorporated both the Board Assurance Framework and Risk Register making it simpler to update and monitor risk management within the CCGs.
SY explained that the Risk Group was now established across the three CCGs and was meeting on a monthly basis to monitor and evaluate risk management processes and challenge Executive Directors on the risks within their portfolios.
Page 5 of 7
Item: 05 Enc: 02
Action
SY confirmed that the draft Risk Strategy had been reviewed by the Audit Committee and recommended for approval by the Governing Body. She stated that the Risk Strategy had also been to EMT.
The Governing Body RATIFIED the Risk Strategy 16. Appointment Process for the Accountable Officer SY outlined the process for the Accountable Officer asked the Governing Body to approve to process for the recruitment of the AO.
SY explained that recruitment was being run through Veredus. She advised that the interviews had been set for 23rd February 2017.
SY advised that there would be three stakeholder panels consisting of EMT members, representatives from the staff, Governing Body Members and external stakeholders. SY explained that the three Chairs would be on the interview panel, along with Wendy Saviour and a Lay Member. SY asked all members of the Board if they would be available to join the stakeholder panel on the morning of the 23rd March.
The Governing Body APPROVED the Appointment Process for the Accountable Officer 17. Developing effective Communications and Engagement AE explained that an audit across had taken place on the communications & engagement services provided by the CSU. She advised that they worked with joint C&E Committee and held a stakeholder event which involved patient groups. The feedback received had been put into the model that was presented to the Governing Body. AE advised that a Patient Council would be developed which would lead the new model.
SH stated that she was pleased to see this and confirmed that with this model we could get more patient input.
The Governing Body APPROVED new model Developing effective Communications and Engagement 18. Review of Consultant-led Obstetric Care in Stafford AD presented the paper and explained that the review had published its findings which reported that consultant-led Obstetric Care could not be appropriately or safely brought back to Stafford.
AD confirmed that the review had been done independently by the Secretary of State and the report was clear on what was looked at and why it could not return.
The Governing Body NOTED the content and recommendation of the review. 19. Safeguarding & Looked After Children Policy AH explained that the Safeguarding and Looked after Children Policy had been written by Kristine Brayford-West before her departure. AH advised that the Policy had been approved at both Joint Quality Committees and was being presented at the Governing Body Meeting for ratification.
The Governing Body RATIFIED the Safeguarding & Looked After Children Policy. 20. Items for Information The Governing Body RECEIVED and ACKNOWLEDGED the items for information.
Page 6 of 7
Item: 05 Enc: 02
Action 21. Any Other Business 21.1 SY advised that the new training system for Mandatory Training had been released and explained that there was a framework for the training. It was agreed that not all of the training was relevant to the Lay Members.
ACTION: SY agreed to let members know what training they would be SY required to do.
AD added that all the Mandatory Training was required to be completed by all staff by 31st March 2017.
22. Questions from the Public John Ogden referred to the item on consultant-led obstetrics and stated that everyone knew it was not going to come back to Stafford.
John Ogden asked when consultation on STP would take place. AD responded that it would not happen before June because of the local elections so he anticipated that it would be June/July 2017.
Paul Wilson stated that it was good to see the CCG getting more involved with the patient participation groups across the areas and asked how much interest was there in the public about doing the work with the STP. SH agreed that it was difficult to engage with the public. AE confirmed that there are 57 active ambassadors from the public. AD added when the CCG held events very few members of the public were involved, but confirmed that we needed to get involved with the majority that would not come these events. AE agreed that we needed to go to them, rather than they come to us. Paul Wilson agreed to speak to AE to give details of the patient participation groups.
Anne George stated that a lot of people at some of the participation groups said they did not want to call an ambulance because they didn’t want to go to Stoke. It was noted that It was a perception that if you went to Stafford hospital late, you would end up at Stoke and then be stranded there. It therefore suggested that perhaps the CCG could hold another public meeting to let them know.
23. Next Meeting
Next Governing Body Meeting in Public
Date: Tuesday 28h March 2017 Time: 2.00 pm to 4.30 pm Venue: The Amerton Room, The Hub - VAST, 17 Eastgate Street, Stafford, ST16 2LZ
Page 7 of 7
Item: 06 Enc: 03
Cannock Chase Clinical Commissioning Group South East Staffordshire and Seisdon Peninsula Clinical Commissioning Group Stafford and Surrounds Clinical Commissioning Group
STAFFORD & SURROUNDS CCG GOVERNING BODY MEETING LIVE PUBLIC ACTION LIST
MEETING Responsible Outcome/update AGENDA ITEM REFERENCE Action (Completed Actions remain on the Action List for the following FPC and are DATE Officer then removed to the 'Completed' Worksheet) 24.01.2017 Any Other Business 21 SY agreed to let Lay Members know what Mandatory training they would be required to do SY Completed; Advice shared with Lay Members. AD advised that he would discuss social enterprises with NESTA to see if they could do 22.11.2016 Chief Officer's Report 8 AD AD has called NESTA and waiting for a response. something in Stafford and the local area.
X:\CCG\Cannock Staffs and Surrounds\Corporate\Governance\Mtgs ‐ Leg Require\02 SaS GB\2016‐17\12. 28.03.17 ‐ PUBLIC\Public\Enc 03 DRAFT SAS Public Action 24 01 17 ‐ SY 1 of 1 Item:08 Enc: 04
Cannock Chase Clinical Commissioning Group South East Staffordshire and Seisdon Peninsula Clinical Commissioning Group Stafford and Surrounds Clinical Commissioning Group
The healthiest place to live and work, by 2025
REPORT TO: The Stafford and Surrounds Clinical Commissioning Group Governing Body Meeting in PUBLIC TO BE HELD ON: Tuesday 28th March 2017
Subject: Chief Officer’s Report Board Lead: Andrew Donald Officer Lead: Chief Officer Approval/ Recommendation: Assurance Discussion Information Ratification
PURPOSE OF THE REPORT: To update Governing Body members on the work of the Chief Officer during March 2017 To highlight any matters of interest or risk
KEY POINTS: Introduction This report will be my last report in public to the Stafford and Surrounds Governing Body.
I was appointed as the CCGs Accountable Officer in April 2012 and I am now approaching the end of my fifth year as the Accountable Officer. The last five years have been characterised by significant financial challenges for the CCG and the need to turn round that position. In many respects the turn round hasn’t happened on finance particularly if you look at this years projected financial outturn. The next year and the injection of a resource into the CCG will see financial turn round by the end of 2018/19 financial year.
However to focus on finance would be to do a disservice to the challenges faced through the TSA process and the changes to clinical services that have been achieved over the five years.
There are many aspects of service change that the CCG and its members can be proud.
The organisation as part of the group of CCGs has a high performing integrated management team. An engaged and actively working Membership Board who challenge and support the CCG in equal measure and are now starting to address the challenges facing Primary Care.
The Membership in Stafford and Surrounds has never shied away from a challenge or an issue and I am sure the foundations of the last five years will enable the next stage of development to be successful.
The plans put in place since August 2015 (Stafford and Surrounds and Cannock Chase were joined by South East Staffordshire and Seisdon) to support turn round has been fully implemented and this has resulted in the CCG alongside South East Staffordshire and Seisdon and Cannock Chase
We are honest, accessible Quality is our day job We innovate and deliver Care and respect for all and we listen Page | 1 Item:08 Enc: 04 demonstrating a level of grip and rigour on its business that wasn’t previously in place.
The CCG is on target to achieve its revised control total in 2016/17 (a deficit of -£12.2m) this has increased from the -£7.5m deficit in 2015/16. This is due to the lack of delivery of the level of efficiencies agreed at the start of the financial year.
Performance against constitutional standards is as good as other CCGs in the North Midlands despite the challenges at the CCGs main provider. Progress is being achieved against the Integrated Assessment Framework. The Quarter four meeting with NHS England will take place on the 30th March 2017. Dementia Diagnosis remains a significant challenge.
A single management team works across the three CCGs, joint committees are in place to run the business of the three CCGs and there is now real cohesion about how the CCGs run their business.
Communication and engagement has increased with staff and the HR / OD Committee is an important part of the infrastructure.
The Organisational Development programme continues and the intention is to commission this programme for a further year to ensure the organisations and individuals are been given the support they need for the next part of CCGs development.
The culture that has been developed is critical to the future and it is a priority to further embed our vision and values across all parts of the organisation including our membership.
The CCG has played an active part in the STP which equates to circa £1m in time and senior management resource. This input will need to increase further if we are to deliver the STP aspirations which will ultimately support the completion of the turn round of the CCGs.
From 1st April 2017 all three CCGs will have responsibility delegated to them for Primary Care Commissioning, this is important as it reflects a level of confidence in the CCGs.
Clearly there are still challenges and the CCGs Governing Bodies will need to remain focused and maintain grip and rigour on the key matters particularly engagement with the membership. The three sixty degree survey (although we don’t yet have the results yet), will show a good response rate overall, although a higher response rate has been seen amongst our GP member practices in Stafford and Surrounds (93%).
The staff survey sets the CCG a number of challenges to address. The good response rate of 62% gives the CCGs something to build on. The HR and OD committee will be producing an action plan to ensure we follow through on what the staff were articulating in their response to the survey questions.
The organisation has made good progress over the four years since authorisation and the foundations are in place for the organisation to complete its turn round in the coming years.
The following updates Governing Body members on key matters of interest.
Matters of Interest Control Total The CCG will deliver its agreed control total.
Finance and Operational Plan 17/18 These plans are presented for Governing Body sign-off. There are no outstanding issues.
All the plans have been reviewed by NHS England; this includes meetings with the Regional
We are honest, accessible Quality is our day job We innovate and deliver Care and respect for all and we listen Page | 2 Item:08 Enc: 04
Director. Nationally NHS England has provided support through Deloittes to support execution and delivery of our QIPP plans. This is work undertaken in March 2017 across the three CCGs and will involve support to ensure that all QIPP schemes have the best chance of success.
Executive Directors objectives for 17/18 All Executive Directors have submitted their draft objectives and these will be signed off during March 2017. All Executive Directors will have received an appraisal of their performance during 2016/17 by the end of April 2017.
Performance 2016/17 The CCGs quarter four performance reviews with NHS England takes place on the 30th March 2017, a full review of performance will be presented at a future Governing Body meeting.
Delegated Commissioning This has formally been agreed by all three Governing Bodies and delegated responsibility will commence on the 1st April 2017. All documentation was signed and submitted to NHS England in line with the agreed timescales.
Organisational Development Plan The specification for the Organisational Development work in 2017/18 is in the process of being developed.
Annual Reports for the three CCGs Work continues to complete the three annual reports for the 2016/17 year.
Communications and Engagement across the three CCGs The CCGs will by the end of the month have a significant amount of data to be able to develop further the approach to Communications and Engagement through the staff survey and the three sixty degree survey. This will be supplemented by the information and intelligence gathered through the PPGs and Patient Council.
Sustainability and Transformation Plan The plan was formally launched to the public on the 15th December 2016, since then meetings have taken place with scrutiny committees, local councils and other interested parties to discuss the plans.
The five Senior Responsible Officers for the workstreams have presented the progress on work to date to the Health and Care Transformation Board. This work will lead to the development of business cases and options appraisals which will form part of the public consultation in the summer of 2017.
CCG GOALS: Change the culture: Structures are being developed to ensure that Hospital to home the roles and functions of the management Professional to patient team are focused on these key objectives More focus on prevention As above Involving everyone for improved health and As above care Empower and support patients to take control As above of their own health Services supporting people to make informed As above decisions
We are honest, accessible Quality is our day job We innovate and deliver Care and respect for all and we listen Page | 3 Item:08 Enc: 04
IMPLICATIONS: The CCG needs to ensure it acts within employment legislation and Legal and/or Risk ensures that the changes proposed do not increase the risks of the CCG The Sustainability and Transformation Plan address the need to improve CQC CQC ratings of all Providers Patient Safety All parts of the report are underpinned by Patients remaining safe Patient Engagement This will be a key part of delivering the changes proposed in the STP All costs of the management of change need to be within the running Financial cost envelope of the three CCGs Sustainability The structures need to be continually reviewed for sustainability Further Organisational Development will be part of the Management of Workforce/Training Change process
RECOMMENDATIONS/ACTION REQUIRED: The Governing Body is asked to: That the Governing Body notes the Chief Officer Report.
Not KEY REQUIREMENTS Yes No Applicable Has a quality impact assessment been undertaken? Has an equality impact assessment been undertaken? Has a privacy impact assessment been completed? Has a comms & engagement impact assessment been completed? Have partners/public been involved in design? Are partners/public involved in implementation? Are partners/public involved in evaluation?
CCG VALUES We are honest, accessible and listen
Care and respect for all
Quality is our day job
We innovate and deliver
We are honest, accessible Quality is our day job We innovate and deliver Care and respect for all and we listen Page | 4 Item: 09 Enc: 05
Cannock Chase Clinical Commissioning Group South East Staffordshire and Seisdon Peninsula Clinical Commissioning Group Stafford and Surrounds Clinical Commissioning Group
The healthiest place to live and work, by 2025
REPORT TO: The Stafford and Surrounds Clinical Commissioning Group Governing Body Meeting in PUBLIC TO BE HELD ON: Tuesday 28th March 2017
Subject: Quality Report Board Lead: Heather Johnstone, Chief Nurse and Executive Director of Quality & Safety Officer Lead: Allison Heseltine, Deputy Director of Nursing, Quality & Safety Approval/ Recommendation: Assurance Discussion Information Ratification
PURPOSE OF THE REPORT: This report is intended to provide the Governing Body with assurance in respect of the on-going monitoring of quality and safety with all key providers and work undertaken by the Quality Team. This assurance is obtained as a result of day to day quality and safety monitoring and regular interaction with providers.
KEY POINTS: Key quality information is routinely reported to the Joint Quality Committee which meets on a monthly basis to review in detail all information and data available in respect of commissioned services and quality assurance.
In addition to the provider reports, you will find a Quality Directorate report containing additional information received by and discussed in Joint Quality Committee as well as general information relating to quality, safety and nursing.
The following report is to enable members of the Governing Body to quickly identify the key areas as follows: ‐ Quality KPI (dashboard) breaches. ‐ External opinion obtained via the key regulatory bodies. ‐ Assurance levels for both safety and quality. ‐ The position in respect of local quality requirements grouped under the Darzi quality headings of Safety, Patient Experience and Effectiveness. ‐ Identified emerging themes and trends. ‐ Specifics in relation to local quality trends. ‐ Risks and mitigations.
Governing Body reports are intended to be by exception reports to alert members to areas of concern and to highlight actions being taken by the Quality Team and/or the Joint Quality Committee. Other data and information from providers, where not reported, is within expected ranges and not causing concerns.
We are honest, accessible Quality is our day job We innovate and deliver Care and respect for all and we listen Page | 1 Item: 09 Enc: 05 Key provider highlights.
BHFT Neurology Service - Derby Hospital ceased accepting new referrals from 6th March 2017 and UHNM will cease accepting patients from 1st June 2017. Weekly teleconference calls between ESCCG, BHFT and VCIL to seek resolution. NHSE are aware of the situation and on-going discussions are taking place. SSOTP have been informed that by CQC that they are likely to receive their follow up inspection sometime after April 2017. The CQC has awarded the West Midlands Ambulance Service Outstanding following the publication of their report. This is the first Ambulance Trust to be awarded this rating. BHFT has reported 3 never events relating to Ophthalmology surgery. These are currently being investigated and the Trust has commissioned an external review.
CCG GOALS: The JQC challenge the status quo and put Change the culture: patients and service users at the heart of its Hospital to home values and principles ensuring every Professional to patient discussion that takes place has the quality of care at the centre. Prevention is a fundamental aspect of the More focus on prevention delivery of high quality and safe services. Quality ensures integration of a wide spectrum Involving everyone for improved health and of the CCGs demographic population and care service wide inclusion at the Committee. The CCG patient representatives enable Empower and support patients to take control achievement and committee members strive to of their own health improve patient care but also maintain a focus on personal responsibility for patients The JQC serves to provide assurance to the Governing Body and to members of the public Services supporting people to make informed that the quality and safety of local services has decisions been reviewed thus empowering patients and clinicians to make informed choices.
IMPLICATIONS: Legal and/or Risk Risks identified and managed via the Board Assurance Framework CQC Updates contained within the report Patient Safety Levels of assurance agreed within JQC Patient Engagement Priority agenda item at JQC reflected within the Quality GB report Financial Aligned to CCG financial recovery plan Sustainability of Service Providers is a key part of CQRM which feeds in Sustainability to JQC Workforce/Training Details contained within report relating to Providers by exception
RECOMMENDATIONS/ACTION REQUIRED: The CCG Governing Body is asked to: Members are asked to take assurance that a detailed assessment of quality and safety has been undertaken for each provider at the JQC, and that levels of assurance were agreed as outlined in
We are honest, accessible Quality is our day job We innovate and deliver Care and respect for all and we listen Page | 2 Item: 09 Enc: 05 the report body. In addition and if considered necessary, members of the Governing Body are invited to suggest any further actions they would like to see in respect of any of the issues raised.
Not KEY REQUIREMENTS Yes No Applicable Has a quality impact assessment been undertaken? Has an equality impact assessment been undertaken? Has a privacy impact assessment been completed? Has a comms & engagement impact assessment been completed? Have partners/public been involved in design? Are partners/public involved in implementation? Are partners/public involved in evaluation?
CCG VALUES We are honest, accessible and listen Care and respect for all Quality is our day job We innovate and deliver
We are honest, accessible Quality is our day job We innovate and deliver Care and respect for all and we listen Page | 3 Item: 09 Enc: 05 Explanation of acronyms used in this report: Acronym Explanation 2WW Two Week Wait ACDP Advisory Committee on Dangerous Pathogens BHFT Burton Hospitals Foundation Trust CAMHS Child & Adolescent Mental Health Services CAS Central Alerting System CCG Clinical Commissioning Group CDIFF Clostridium Difficile CHC Continuing Healthcare CNAG Community Nursing Assurance Group CPD Continuing Professional Development CPN Community Psychiatric Nurse CQC Care Quality Commission CQRM Clinical Quality Review Meeting CQUIN Commissioning for Quality and Innovation CSU Commissioning Support Unit CT Computerised tomography (Scan) DGHFT Dudley Group of Hospitals Foundation Trust DN District Nurse DNA Did Not Attend DPS Dynamic Purchasing System DTHFT Derby Teaching Hospitals NHS Foundation Trust ED Emergency Department EHCPs Education, Health & Care Plans EMSA Eliminating Mixed Sex Accommodation FFT Friends and Family Test FTE Full Time Equivalent GP General Practitioner HCAI Healthcare Acquired Infection HED Healthcare Evaluation Data HEFT Heart of England Foundation Trust HSMR Hospital Standardised Mortality Ratios IAPT Improving Access to Psychological Therapies IL Improving Lives IPC Infection Prevention and Control ITU Intensive Therapy Unit JQC Joint Quality Committee LSAB Local Safeguarding Adult Board MDT Multi-disciplinary team MICATS Musculoskeletal Integrated Clinical Assessment and Treatment Service MRI Magnetic resonance imaging (Scan) MRSA Methicillin Resistant Staphylococcus Aureus MRSAb Methicillin Resistant Staphylococcus Aureus Bacteraemia NHS 111 National Out of Hours Telephone Triage Service NHSI National Health Service Improvement NSL Non Urgent Patient transport provider OOH General Practitioners Out of Hours Service PALS Patient Advisory Liaison Service PROMS Patient Reported Outcome Measures PUST Pressure Ulcer Steering Group We are honest, accessible Quality is our day job We innovate and deliver Care and respect for all and we listen Page | 4 Item: 09 Enc: 05 PURG Pressure Ulcer Review Group QIA Quality Impact Assessment RAP Remedial Action Plan RCA Root Cause Analysis RED (WMAS) 8 minutes response to be on scene AMBER (WMAS) Ambulance response not categorised to receive an 8 Minute response. GREEN (WMAS) Ambulance response not categorised as Urgent or Emergency. RTT Referral to Treatment Times RWT Royal Wolverhampton Trust SALT Speech and Language Therapy SDUC Staffordshire Doctor Urgent Care SEND Special Educational Needs & Disabilities SHMI Summary Hospital-level Mortality Indicator SI Serious Incidents SOP Standard operating procedure SPA Single Point of Access SSOTPT Staffordshire and Stoke on Trent Partnership Trust SSSFT South Staffordshire and Shropshire NHS Mental Health Foundation Trust SVA Safeguarding Vulnerable Adults TCP Transforming Care Partnership TDA Trust Development Authority TV Tissue Viability VCIL Virgin Care Improving Lives VTE Venous-thrombus Embolism WHT Walsall Hospitals Trust WMAS West Midlands Ambulance Service YTD Year to Date
We are honest, accessible Quality is our day job We innovate and deliver Care and respect for all and we listen Page | 5 Item: 09 Enc: 05
Stafford and Surrounds Clinical Commissioning Group
Governing Body Quality Report – This report is produced for March 2017 Governing Body for Stafford & Surrounds CCG. The report contains data from January 2017 which was reported to the March 2017 Joint Quality Committee. Please note in some instances the data provided relates to December 2016, also the Governing Body are asked to note not all Providers are reported at JQC on a monthly basis, this is reflected in the report.
CCG Name: Stafford and Surrounds CCG
Date of meeting: 28th March 2017
Authors: Debbie Vucetic, Nigel Williams, Katie Montgomery, Jennifer Napier-Dodd & Kay Roberts. Item: 09 Enc: 05
Quality Report Page
Burton Hospital NHS Foundation Trust ...... 4 Royal Wolverhampton Hospital Trust ...... 8 South Staffordshire and Shropshire Foundation Trust ...... 11 Staffordshire and Stoke on Trent Partnership Trust ...... 16 NHS 111 ...... 21 Quality Directorate Report ...... 26
Item: 09 Enc: 05
At each meeting of the Committee the Core Members and Expert Representatives are asked to consider their assessment of each of the providers’ service provision in terms of quality and safety, compare this to the agreed assurance level descriptions and declare a numerical score for safety and a numerical score for quality (0 - 1 being Not Assured, 2 – 4 being Limited Assurance, 5 – 7 being Partial Assurance and 8 - 10 being Full Assurance), the average of these scores is then taken to provide overall scores for quality and safety for each provider. The recorded overall assurance scores from the Committee meetings held in March 2017 and are shown below.
Stafford & Surrounds Provider organisation Overall assurance - safety Overall assurance - quality Staffordshire & Stoke on Trent Partnership Trust (SSOTPT) 7 - Partial Assurance 6 - Partial Assurance Burton Hospital Foundation Trust (BHFT) 6 - Partial Assurance 7 - Partial Assurance Royal Wolverhampton Trust (RWT) 7 - Partial Assurance 6 - Partial Assurance NHS 111 8 - Full Assurance 8 - Full Assurance South Staffordshire and Shropshire Healthcare NHS Foundation Trust 8 – Full Assurance 8 – Full Assurance (SSSFT) West Midlands Ambulance Service (WMAS) Deferred to April 2017
Item: 09 Enc: 05
Burton Hospital NHS Foundation Trust Cancer Performance Percentage of Service Users waiting no more than two months (62 days) from urgent GP referral to first definitive treatment for cancer (Target 85%): Performance increased to 72.6% in December 2016 from 60.2% in November 2016. This equated to 13 patients whom have breached, which are either still under review at BHFT or treated at a tertiary centre, therefore not known if any harm came to the patients, BHFT are seeking this information. Percentage of Service Users referred urgently with breast symptoms (where cancer was not initially suspected) waiting no more than two weeks for first outpatient appointment (Target 93%): Performance in December 2016 = 91.4% (Overall Q3 performance = 95.3%). This affected 8 patients who all had an earlier appointment within target time but was cancelled by the patient. The Trust reports no harm to any of the women who breached. Percentage of Service Users waiting no more than 62 days for first definitive treatment following a consultant’s decision to upgrade the priority of the Service User (all cancers)(Target 95%): November 2016 performance = 66.7%. This was due to one breach. No harm reported. December 2016 performance = 50% which equated to one patient breaching who had a complex pathway. Safety Dashboard Breaches Stroke Services % of people who spend at least 90% of their time on a stroke unit (Target 80%): Performance in January 2017 = 78%. The Trust report this was attributable to an increasing number of admissions from 30 to 51 causing an increased demand for beds. Never Events: 3 were reported in January 2017 all of which are non SAS CCG patients. These have been reported as Wrong Site Surgery. One occurred in orthopaedics, whereby a patient had a procedure started on the wrong finger; The other 2 occurred in Ophthalmology. Action: As a result of the Ophthalmology Never Events, BHFT have appointed an external Consultant from Moorfields Eye Hospital NHS Foundation Trust is to undertake an independent full review of Ophthalmic services being delivered by the Trust. The review has already commenced. It is anticipated the first draft report will be shared with the Trust in July 2017. Serious incidents: In January 2017, 7 serious incidents reported; 1 x diagnostic Incident; 1 x grade 3 pressure Ulcer; 1 x of a deteriorating patient 1 x Diagnostic Incident (escalation from a Critical Incident); 1 x Suboptimal Care of a deteriorating Patient; 1 x Treatment delay; 1 x Surgical/invasive Procedure. Actions: All Serious incidents are subject to an investigation, and themes and trends monitored at the CCG SI group. Item: 09 Enc: 05
The numbers of serious incidents are reducing, and the quality of the investigations is improving. Actions to improve the SI process are in place at the Trust and are incorporated in to the wider CQC action plan. Internal safety Incidents (formally termed Critical Incidents): In January 2017 11 were reported Slip/trips/falls x 1 Suboptimal Care of a deteriorating patient x 1; Treatment Delay; x 1; Medical equipment/devises x 1; Surgical / invasive Procedure x 1; Pressure Ulcers x 5; Diagnostic Incident x 1. Actions: All Internal Safety Incidents are subject to an internal investigation and if found there were omissions in care they are escalated to a serious Incident. All are discussed at the CQRM. Patient safety incidents: The number of patient safety Incidents reported in 641 reported in January 2017 = 641. The top five themes were Pressure Ulcers (100); fall/accident (79); Diagnostic Procedures (54); Medication/biologics/fluids (50); communication (47). Action: Patient safety incidents are monitored at the CQRM. Mortality data: The latest mortality data shows: A HSMR (HED) Rolling 12 months of December 2015 – November 2016 (latest available) = 109 HSMR November 2016 (latest data available) = 107 The Trust report that since the introduction of the HED system, monitoring of HSMR has become clearer and more accurate. The minutes of the mortality review group were discussed at the CQRM, as weekend mortality according to the minutes identify both SHMI and HSMR to be higher at the weekend. The Trust is putting plans in place to improve the monitoring of this. The timeframe for this work has is not yet know. In respect of the SHMI data which covers July 2015 to June 2016, this shows BHFT is within the expected range and not a cause for concern. Out of the 45 Trusts Burton Hospital NHS Foundation Trust is in 16th place A&E waiting times: Percentage of A & E attendances where the service user was admitted transferred or discharged within 4 hours of their arrival at an A&E department Target 95%. Performance in December 2016 = Effectiveness 87.2%. Performance improved slightly to 87.2% in January 2017. Action: A Remedial Action Plan (RAP) is in place. NHS England have identified Burton Hospitals NHS Foundation Trust as being in the top 25% of Trusts in respect of A&E performance overall, and are encouraged by the data over the recent weeks. Eliminating Mixed Sex Accommodation: 11 reported in in January 2017 in Critical Care when the Trust was at escalation levels of 3 – 4. No patient complaints have been received in respect of these breaches. Patient experience Patient experience: Patient experience score continues to be green with a score of 97% in January 2017. Actions: The Matrons discuss the scores at their ward meetings, and actions are put in place to address area of Item: 09 Enc: 05
concern. Patient experience in relation to Discharge This is no longer a question on the patient experience questionnaire, and the trust reports no plans to reintroduce the question. Actions: Work around discharge initiatives would give the Trust an opportunity to showcase the work around discharge. The Trust is trialling projects around certain wards with pharmacy technicians, which would be presented to the CQRM in a report at a later date. A full staffing review is currently being undertaken in order to address discharge, looking at potential further employment of discharge nurses. The Trust gave full assurance to members that if there were any major concerns or issues associated with discharge this would be escalated via the Trust and to Commissioners. Friends and Family test: Overall Emergency Care scores dipped in December 2016, in particular the A&E FFT score down to 78.1%, but increased in January 2017 to 86.21%. In respect of compliments the emergency department received 7 in December 2016 8 in January 2017. Actions: All Senior Sisters and department managers are able to identify where improvements can be made and share them with staff. Complaints: In January 2017 15 complaints were received. The dominant complaint categories continue to relate to clinical treatment, communication, and patient care issues of which all are reflected across the three clinical divisions. Action: All complaints are investigated and learning from complaints is shared with Staff for learning and improvements to be made. PALs Contacts: The total number of PALs contacts received in January 2017 = 264. The top issues: Informal resolution (94); request for advice/information (81); providing information/feedback (53); Compliments (24); support needed (12). The issue causing the most PALs enquiries are consistently related to car parking. Action: car parking will always be a contentious issue and has been discussed at CQRM, but the Trust has no plans to stop charging for car parking. Regulatory / external NHS Improvement, National Reporting and Learning System (Part of NHS Improvement) & Care Quality bodies Commission (inspectorate): No update from the November 2016 Report. Complaints in respect of services at BHFT have decreased, patient experience remains green, and the Trust is taking Summary of emerging themes actions on issues. The internal management of the serious incident process continues to improve, & the number of and trends serious incidents is reducing. Areas where work is taking place to improve the patient journey: Item: 09 Enc: 05
Cancer Performance 62 day wait: Remedial action Plan in place. The Trust anticipates compliance with this target by March 2017. The Trust report no harm has come to any patient as a result of these breaches. Neurology services: A Contract Performance Notice was issued on 13th October 2016 following notification of the suspension of Neurology service provision from 1st July 2016. Weekly teleconference calls between ESCCG, BHFT and VCIL to seek resolution. NHSE are aware of the situation and on-going discussions are taking place with NHSE. Accident and Emergency 4 hour Performance: The Contract Performance Notice will remain in place until performance has achieved the target for two consecutive months. The Accident and Emergency recovery is supported by the Staffordshire A&E Delivery Board. The Trust report no harm has come to patients as a result of these breaches. Risks and Mitigations Risk Mitigation Historic 52 week breaches in Ophthalmology, and increasing External Consultant from Moorfields Eye hospital has commenced complaints/PALS enquiries regarding appointment issues in an independent full review of Ophthalmic services being delivered by Ophthalmology; One never event in November 2016, two never the Trust. The Trust anticipates the report will be completed by July events in January 2017. 2017. Serious Incident Reporting. Contract performance notice submitted. The Trust has added actions from the external review to their central action plan. Until all actions are complete the Contract performance notice and remedial action plan will remain in place. Percentage of A & E attendances where the service user was The RAP has been signed off by NHSE as being appropriate, and all admitted, transferred or discharged within 4 hours of their arrival actions are on track or being delivered. The Accident and at an A&E department: Target = 95%. Emergency recovery is supported by the Staffordshire A&E Delivery Board. Neurology Services: Current lack of provision for new patients The Trust is seeking to secure additional sessions from Consultant and those Patients awaiting a follow up appointment. Neurologists from across the health economy. Actions are being taken by the Commissioners to assist in getting these patients reviewed. NHSE are involved in seeking a resolution. Item: 09 Enc: 05
Royal Wolverhampton Hospital Trust A&E 4hour Wait & Ambulance Handover Delays: The Trust continues to underperform against the A&E 4 hour standard (86.36%) and the impact of the winter pressures is now becoming more apparent with a significant decline in this standard and a significant increase in the number of ambulance handover delays (increase from 17 to 41 handovers >60minutes). A new trajectory has now been agreed which will see the Trust recover this target (95%) by the end of March 17. Actions: A recovery action plan detailing the actions to be taken is being implemented (updated January 17). This continues to address joint working with Vocare to triage the Urgent care Centre, on-going recruitment, daily information sharing and real time bed management system to enable patient ‘flow’ and ensure availability of beds. 18 week Referral to Treatment/ Zero Tolerance to waits >52 weeks: RTT Incomplete performance improved in January 2017 but still continues to underperform (90.59%) against the national target (92%). The number of patients reported > 52 weeks at the end of January 2017 is 19; however, the Trust remains ahead of the month end trajectory of 35. All 19 patients waiting > 52 weeks are within the orthodontic pathway. This pathway is delivered by one consultant and this person had planned leave in February. As a consequence the Trust has predicted a further increase in breaches in February but is predicting recovery of this target in March 2017. Safety Actions: Continued validation of the waiting list and all patients waiting over 18 weeks, on-going focus on the recruitment of nursing and medical staff and pathway monitoring training. All patients waiting > 52 weeks (as of November 2016) triggered a Multi-disciplinary Review. The Trust reported ‘no-harm’ for all patients as a result of the delay in treatment. Diagnostic 6 week Wait: There was a small improvement during January 2017. The main issue continues to relate to reduced capacity available for MRI and CT sessions. Action: Efforts to identify further capacity are on-going. Cancelled Operations: 33 operations were cancelled in January 2017. A root cause analysis is completed for each cancellation which is caused by a non-medical reason. The reported reasons included: ran out of theatre time, consultant unavailability, no beds and postponement due to more urgent cases. All cancellations were rebooked within the 28 days required and no urgent operations were cancelled for a second time. Actions: Continuing evaluation of theatre time efficiency to ensure capacity is maximised and a continued focus on the reduction of delayed transfer of patients in order to maintain patient ‘flow’. Cancer Standards 31 day Subsequent or Second Treatment (Surgery): There were 10 breaches of this standard in January 2017. Of Item: 09 Enc: 05
these 9 were urology patients and 1 gynaecology/urology combined. Actions: Successful recruitment of another consultant urologist which created increased capacity and the Trust is now planning additional activity to recover this situation. 62 day Standard – Urgent GP Referral to Treatment: There were 26 breaches of this standard in January 2017. The Trust have identified the following reasons for non-compliance with the 62 Day Cancer Standard: Reduced Urology capacity. Late tertiary referrals. Insufficient radiology capacity. Increased demand has put pressure on the service to deliver reports and scans in a timely manner. Actions: The implementation of a 62 day cancer standard improvement plan which has now been formalised into a Remedial Action Plan (agreed 4/1/17) with a trajectory to reach the required target by June 2017. This RAP has now been agreed with the CCG commissioners. The CCG’s have requested monthly updates to be presented at the CRB meetings regarding progress with milestones agreed. The actions detailed previously are on-going and include: improved tracking of patients, weekly escalation meetings, and on-going focus on recruitment. Safety Thermometer: The Trust reported a significant improvement in the completion of the initial VTE risk assessment. December 2016 compliance was reported as 97%. However the completion of the follow up assessment was significantly lower (59%) and the Trust has noted the requirement for an additional focus in this area. Actions: include a focus on junior doctor education. Sickness: The Trust absence rate during January 2017 was 5.31%, which is 2.07% above the Trust's target of 3.24%. Sickness % has been increasing month on month across the Trust since January 2016. For the rolling 12 months period 1st Feb 2016 to 31st Jan 2017, the Trust sickness rate is 5.09%; For the same rolling 12 months period between 1st Feb 2015 and 31st Jan 2016 the sickness absence rate was 4.71%, therefore showing an Effectiveness increase compared to the same time last year. Actions: Continuing implementation of the 16/17 CQUIN pertaining to improving the health and well-being of staff members and the roll out of a new Attendance Policy which has a much greater emphasis on wellness. However, the HR department have reported that it will take up to 12months to see the positive impact of this new approach. No significant concerns pertaining to patient experience indicators i.e. Friends & Family, Complaints, EMSA and Duty Patient Experience of Candour. Regulatory / External No updates to report. CCG quality improvement manager will request information pertaining to progress against the Item: 09 Enc: 05
Bodies action plan to be presented routinely to the CQRM and report any exceptions in subsequent JQC reports. Summary of RWT continue to underperform against many key performance indicators including A&E 4 hour wait, ambulance Emerging Themes handovers, referral to treatment, patients waiting in excess 52 weeks and the 62 day cancer standards. and Trends Risks and Mitigations Risk Mitigation Workforce Staff sickness in continuing to rise an as a Trust is implementing the 16/17 National Staff Health & Well-being consequence use of agency staff may be rising. The use of CQUIN. New Attendance Policy launched which has a much greater locum medical staff is rising. emphasis on staff well-being. Full recruitment process is in progress and many posts are being successfully filled. Cancer Pathways On-going breaches of some cancer standards. Robust 62 day cancer standard Remedial Action Plan in place and being implemented. Monthly updates to be presented at the CRB meetings have now been requested. A&E 4 hour Breach A recovery action plan detailing the actions to be taken is being implemented (updated January 2017). Patients waiting > 52 weeks Currently all patients waiting > 52 weeks trigger an MDT review. On- going assurance of no harm to these patients is required, an SOP has been requested.
Item: 09 Enc: 05
South Staffordshire and Shropshire Foundation Trust There were no reported Never Events, Local Avoidable Events, Pressure Ulcers Grade 3 or 4 and no Eliminating Mixed Sex Breaches, Clostridium Difficile or MRSA cases in December 2016 or January 2017. Serious Incidents: There were 8 reported in December 2016; 1 Under 18 Admissions to Adult Mental Health Facility, 1 Unexpected Death of an Inpatient, 6 Unexpected Deaths – Community Patient. The Unexpected Inpatient Death is currently under investigation. There was 8 serious incidents reported in January 2017; 2 Under 18 Admissions to Adult Mental Health Facility, 4 Unexpected Deaths – Community Patient and 1 Death of Recently Discharged Patient and 1 Self Harm. Investigations are in progress and each incident will be reviewed by the CCG Serious Incident Review Group and any themes, trends and appropriate escalations will be determined. Under 18 Admissions to Adult Mental Health Facility: There was one admission in December 2016 (Non SAS CCG) a 17 year old was admitted to Brocton Ward, St Georges under Section 2 Mental Health Act, 1983. In January 2017 there were a further 2, 17 year olds reported. These have all been transferred to appropriate placements. Serious Incidents >60 Days: 3 were reported in December 2016 and 2 in January 2017. This is monitored and challenged at the Serious Incident Review Group, no concerns. Patient Safety Incidents: The total number of patient safety incidents reported for the month of January 2017 is 167 Safety and 166 in December 2016. The main area of concern in January 2017 was an increase in incident figures for adult mental health inpatient services from 58 to 123 when compared with the previous month. This takes the total above the Trust statistical upper control limit by 14 incidents. This is in part due to an increase in self-harm incidents (53% of the reported incidents) that was as a result of (in the main) 2 patients with repeated occurrence of incidents. In the areas where incidents occurred there are increased levels of sickness, vacancies and turnover rates which must be noted. The Trust provided a detailed narrative around these 2 patients which was further discussed at the Joint Quality Committee. In terms of workforce the Trust have sent in assurance regarding the actions being taken; these will be further explored at CQRM in March 2017 coupled with quality assurance visits to Chebsey and Brocton Wards are to be scheduled as part of 2017/18 visit plans. Coroners Regulation 28 (Avoiding Future Deaths): There was one Coroners Regulation 28 for the month of December 2016 (Mental Health Staffordshire). The matter of concern raised by the Coroner was that there was no specific examination for the risk of venous thromboembolism. Current Trust Prevention of VTE Policy was deemed as more fitting for a physical health setting, and the Coroner suggested that the Trust should adopt a more specific policy. Action: In response, the Trust acknowledged that the current policy was not specific to mental health settings and the Deputy Director of Nursing is now leading some work to bring the VTE assessment into the Trust’s physical health Item: 09 Enc: 05
pathway documentation which will be reported to the CQRM having been through Trust internal governance processes. Mental Health Safety Thermometer (88.19% - National): The latest published result was reported in November at, 82.70% (National 88.19%) due to increases in the proportion of patients that have been ‘victim of violence and aggression’ and have had an ‘omission of medication in the last 24 hours’. The Trust reported that unfortunately the dashboard continues to be un-available nationally as the contract with NHSE to support the Safety Thermometer is in the process of changing over to another company. An email validating the Trusts verbal update was received from NHSE and the website continues to state “work in progress”. Action: The CQRM has a planned themed discussion around Safer Medicines Management and the Trust is presenting their annual thematic review into this in May 2017. The Trusts appraisal, mandatory training and safeguarding mandatory training: Rates for appraisal and mandatory are just below the Trusts internal target of 90% ranging between 84-89% with a small number of Directorates that are low in compliance such as Learning Disabilities, which is being managed at Divisional level. It is anticipated that there will be a small dip in compliance for appraisals over the next 3 months which is reflective of last year’s strategy used by the Trust. Action: To continue to monitor at CQRM and expect rates to fall for the next 3 months whilst appraisals are being completed. Vacancy Rate for Specialist and Family Services Directorate is at 9.65%. Individual teams such as IAPT East, IAPT South East Staffordshire and Brocton Ward have >15% rates this month. The Trust has stated there is a management of change in progress, promotion and retirement and re-modelling have had an effect, a small number of staff has chosen to leave. Positively, both Specialist Learning Disabilities and Mental Health Staffordshire Directorates as a Effectiveness whole are below 8% which is a great improvement. Action: This will continue to be monitored at CQRM coupled with the HR Director for SSSFT attending CQRM in March 2017 where low compliance rates will be further discussed. Turnover Rate (target 10-15%) has declined since the last report to 15.44%, Adult Mental Health Directorate reporting highest at 15.94% followed by Specialist and Family Services Directorate at 11.73%, however pleasingly an area that was once one of the highest reporting rates, Specialist Learning Disabilities is now 8.68%. Action: This will continue to be monitored at CQRM coupled with the HR Director for SSSFT attending CQRM in March 2017 where low compliance rates will be further discussed. Sickness Rate is above the threshold of 4.20% for January at 4.55%. Adult Mental Health is the hot-spot where it is currently sitting at 6.10% with 0.31% of this rate related to staff stress and anxiety. As discussed within the incident section, Adult Mental Health has several workforce indicators that are high with specific areas more concerning than others. Action: There is a planned Quality Assurance Visit to CMHTs across South Staffordshire in March 2017 and Item: 09 Enc: 05
provisional plans to visit Chebsey and Brocton Ward. Further assurance has been requested around what is being done in particular for Adult Mental Health staff ‘stress and anxiety’ which will be presented to the March 2017 CQRM. Psychiatric Liaison Urgent: service users should be seen and assessed within 24 hours (95%): The Trust reported 84% in December 2016 and 87% in January 2017 (Trust wide). In respect of a further breakdown, South East Staffordshire (138%) are the areas where the performance fell below the required threshold, all other areas where 100%. There were no reported impacts caused by the breaches however the performance has been noted at CRB as low for South East Staffordshire. The joint working between the Trust and CCG in relation to the commissioning arrangements of this service is still in progress and therefore there may be areas of low performance due to the potential gap in provision. Action: to continue to closely monitor at CQRM and CRB. Psychiatric Liaison - Urgent: service users should be seen and assessed within 48 hours (95%): Significant deterioration in December 2016 to 25% and reported an improvement to 67% in January 2017. This has been escalated from CQRM to CRB in respect of the significant drop in performance and has since been found to be very likely, small numbers. There has been no reported quality impact such as incidents, complaints, PALS concerns from service users, carers and staff. Action: Commissioning discussions continue in respect of the current specifications across South Staffordshire. To continue to closely monitor at CQRM and CRB. ICPA - All service users to have a care plan or statement of care as appropriate that is reviewed and updated every 12 months – CPA (95%): The Trust are reporting compliance at 96% however, Stafford and Surround and East Staffs are below the required threshold performing at 93%. Assurance has been provided by the Trust, no harm or impact was reported as part of the virtual CQRM process. Action: This will continue to be monitored at CQRM and CRB. Did Not Attend Rates: The performance has seen some improvements in areas such as CAMHS, Learning Disabilities, Paediatric and Dementia where the rates fall below 10% however it is not demonstrating sustainability each month. Mother and Baby are lower than expected in South East Staffordshire and the percentage for this indicator fluctuates across the remaining South Staffordshire CCGs due to small numbers. Adult Mental Health is reduced across all localities ranging between 11-21%. Action: The Trust is undertaking a thematic review which is due to be presented at CQRM in March/April 2017. Friend and Family Staff: Advance notice to the Governing Body members, there will be no reporting nationally for Patient experience Quarter 3 2016/17 due to the NHS Staff Survey results being released and this being the focus for Q3. Friend and Family Test Staff for Work and Care Quarter 2: The Trust reported above the national average for staff recommending care (70%), however the areas the Trust failed was not recommended care (19%), recommended work Item: 09 Enc: 05
(70%) and not recommended work (19%). The Trust informed the response rate was completed by only 27 staff members in total and no trends detailed in the narrative of these responses were identified. Furthermore, the Trust are expecting the NHS Staff Survey results to be released shortly after the 7th March 2017 (currently embargoed as per National requirements) however early verbal indications from the Trust are positive in respect of the staff survey response rate and detailed data which will inform future work needed for the Trust. The CCG is awaiting the NHS Staff Survey results which will be presented to CQRM in May 2017. Friend and Family Test Patient: reporting above the national averages for both recommended care, 91% and 4% not recommended. Continue to be monitored at CQRM. Soft Intelligence: 4 soft intelligence reports were logged in December 2016 and January 2017. 2 related to Access and Waiting (Memory Services and 1 unknown) and 2 discharge summaries not received by the GPs. Of the 4 reported, 1 patient has now been re-referred into the service for follow-up and letters have now been received by the GPs. Issues shared with the Trust with no further action required. CQC Full Inspection Quality Report: – The last published report was on the 12th July 2016 were rated as “Good” for each individual domain and overall. The Action Plan continues to be reported to CQRM on a quarterly basis with no Regulatory / external bodies concerns. In respect of the one area that “required improvement” – estates work has commenced to extend, refurbish and centralise the Section 136 Suites to St Georges Hospital. Action: To continue to monitor the action plan at CQRM until assured all actions have been completed and forward plan to visit the new suites once opened. No other themes or trends other than those identified in the report. Summary of emerging themes and trends
Risks and Mitigations Risk Mitigation Lack of engagement and implementation of Public Health Suicide The County Council will continue to play a role in leading and co- Prevention Strategy for Staffordshire and Stoke on Trent. ordinating implementation of the Strategy.
Meeting held with the County Council in February 2017. The refreshed Suicide Prevention Action Plan is due to be presented in May 2017 to the JQC. Item: 09 Enc: 05
Staffordshire and Stoke on Trent Partnership Trust Item: 09 Enc: 05 Never Events & Clostridium Difficile: Nil reported in January 2017. Serious Incident: There was 1 reported Grade 3 Avoidable/Attributable in January 2017 for South Division. The RCA was reviewed at the Pressure Ulcer Review Group which was attended by the CCG. The root causes identified were; delays in the delivery of preventative equipment; poor risk assessment and care-planning documentation; and failure to raise a clinical incident. Action: An action plan has been developed and implementation of these actions is being monitored by the Trust at a divisional level. Patient Safety Incidents: There were a total of 744 incidents reported across the organisation during January 2017. Of these, 238 (32%) were attributed to the South Division. The highest incident reporting areas continues to be outside SAS CCG areas. The themes identified continue to be Tissue Viability Pressure Ulcer Acquired (increase from last month), Tissue Viability Non Pressure Related (increase from last month) Staffing Levels (marked decrease from last month) in the South Division. Action: The CCG continues to challenge and ensure robust Governance at Pressure Ulcer Review Group (PURG), Community Nursing Assurance Group (CNAG) and CQRM. Staffing Levels: In January 2017 staffing level incidents decreased from 51 to 20 which is the lowest number reported since April 2016. Of the 20 staffing level incidents reported in January for the South Division, 4 (20%) have been Safety identified as triggering the Safer Staffing Escalation Policy and appropriate actions taken to maintain quality and safety. This will continue to be monitored at CQRM and CNAG. Pressure Ulcers: Pressure Ulcer incidents are the highest reported cause group in the South Division, equating to 40% of all incidents reported in January 2017. The number of acquired pressure ulcers reported this data month was the highest in any month of the period reviewed. The themes emerging are delays or failing to document key assessment and planning information and a failure to proactively refer to Specialist Teams. Action: The Trust has reported that there will be a number of campaigns during 2017/18 responding to these trends and themes, i.e. focusing on prevention for certain body areas. This programme of work will address timely reporting, verification, pressure ulcer grading, root cause analysis, duty of candour and the work of the Pressure Ulcer Review Group. In addition to this the Trust is delivering an essential training programme for unregistered staff. The programme promotes early intervention and preventative care where early signs of damage are noted. To date seventy seven staff has attended this training and these sessions will continue into 2017/18. The training plan is monitored by the Trust Training and Development Department and areas of low attendance are monitored at divisional level and focussed attendance is subsequently driven. The Trust will report compliance quarterly to the CQRM.
Item: 09 Enc: 05
Slips/Trips and Falls: It was highlighted in last month’s report that there was possibly a disparity is the reporting of slips/trips and falls, the Trust confirmed this was the case. For clarity, falls incidents throughout the Division are raised by the teams against either residential homes or the patient’s home. These incidents relate to patients falling when the teams are not present. The other incidents are falls that are reported when the teams are present at the time of the fall. Reporting of patient falls has risen from 5 in December 2016 to 22 in January 2017 and, with Stafford reporting 10 of those incidents, (55% not witnessed by teams). These incidents are reported to the Trusts bi-monthly Falls Prevention and Management Group to help identify any potential areas where support from the Group would be beneficial. Action: The Trust has been asked by CQRM to clarify the Falls Policy in respect to the management of repeat fallers in the patient’s home and what the referral criteria is into other specialist teams such as, the Falls Prevention Service. Safety Thermometer - Harm Free Care: results continue to be below the national average and exceeding in new harms, reporting 91%. This is in respect of new pressure ulcers and falls. Whilst this is a point-prevalence audit, it does correlate with other quality data that is received around pressure ulcers and harm. This will continue to be challenged and monitored at CQRM and the Pressure Ulcer Review Group. Face to Face Contacts: Positively the number of contacts delivered by all teams has improved significantly this last month demonstrating that more patients are being seen however the quality of these contacts are not reported. This is an area that will be focussed on during the repeated District Nurse Focus Groups which are planned for the Summer. Appraisal Compliance: The Trust is reporting 93.30% compliance against an internal target of 90% which is an improvement. Action: The Trust Compliance will continue to be monitored at CQRM. Mandatory Training: The Trust compliance is 91.43% which is an increase of 0.71% over last month figures against an internal target of 90% compliance. It shows an improving picture for each team and the trust has focussed efforts on Effectiveness low compliance areas. Action: The Trust compliance will continue to be monitored at CQRM. Sickness Rates: The Trust is reporting non-compliance against their internal Trust wide target of 4.33%. The Trust has reported several initiatives in February and March 2017 which will along with the rates be monitored at CQRM. Actions: Launch of an e-learning package for managers to increase sickness management training, launch of a new Team Prevent Service and the development of a Sickness Accountability Framework has recently commenced. The evaluation of these initiatives in respect of success will be over the coming months. Turnover Rates: Turnover rates have increased this month from 14.29% to 14.89% with South East Staffordshire teams having the highest rates. The CNAG has requested an evaluation since the recruitment of newly qualified and ‘new’ staff appointments to establish if, staff have been retained and if not the reasons behind why they are leaving. Item: 09 Enc: 05
Action: The evaluation is due in May 2017 and the CNAG will continue to monitor rates and escalate to CQRM if concerned. Friends and Family Test: The Trust is reporting very good performance rates for service users, 98% and carers 100%. The CQRM has requested narrative around patient surveys to further understand the themes and trends in relation to patient, staff and carer feedback. Action: this will be reported at CQRM in April 2017. Complaints: Three complaints were received in January 2017 for one South Community District Nursing Team. This is a decrease from the previous month when five complaints were reported. Two of the complaints relate to patients attending clinics rather than receiving home visits and the third complaint relates to staff attitude Action: A Quality Assurance visit and a District Nurse Focus Group to this particular Nursing Team are planned for the Summer 2017. PALS: 22 PALS contacts were received for January 2017 for South Community Teams. This has decreased slightly from last month which was 25. Themes identified were Appointments (4) waiting for; long wait; difficulty in contacting Patient experience the service; OT (4 South East and 1 West) – 3 Communication; 1 Access to Drugs and Treatment and 1 Facilities; Podiatry (2 South East and 1 West) – Appointments delays and South Staffordshire District Nursing Team, 1 Access to Treatment and 1 Values and Behaviours. No trend or theme was identified from the remaining eight contacts as these were for different services. This will continue to be monitored at CQRM. Compliments: there were 466 compliments received for South Staffordshire Community Teams. This will continue to be monitored at CQRM. Soft Intelligence: there are 7 reported soft intelligence cases this month. 3 related to ‘Access and Waiting’, 1 to Cannock Chase Respiratory Services, 1 about MICATS and 2 related to delay in care and treatment (1 referral delayed as form incorrectly triaged and 1 where District Nurse Hub not able to forward call directly to District Nurses who were out on visits). No themes identified in isolation however the intelligence received around the District Nurse Hub has been noted due to previous issues reported. This will continue to be monitored via the CQRM. Item: 09 Enc: 05
CQC Full Quality Inspection: The CQC Action Plan was reported to the February 2017 CQRM, all areas rated as ‘Green’ were agreed as completed and areas flagged as ‘Amber’ discussed. Sexual Health: the Trust declared the timeline for completion was overdue due to there being further work needed to fully complete this action. Re-schedule District Nursing appointments are being monitored by Team Leaders and escalated to the Chief Operating Officers End of Life Care Plan training has achieved 75% at Seisdon and Lichfield however, it is recognised by the Trust that this requires acceleration in order to roll out the plan by the end of March as not all areas are meeting their required Regulatory / external bodies training milestones. Action: The Trust is arranging a workshop in March to meet with Operational Managers to discuss the CQC Action Plan with the aim of producing a’ heat map’ to pick up areas that required improvement against the action plan individual timelines. CQC Follow-Up Inspection: The Trust is expected to receive a follow-up visit from the CQC early April 2017. The visit will focus on the areas which were rated as ‘Requiring Improvement’. To date no information regarding when the visit will be undertaken has been received from the CQC. Action: await confirmation of CQC follow up visit date(s) from the Trust. Administration and Healthcare Support Worker Vacancies: there are a number of vacancies reported by the Trust particularly for administration and Healthcare Support Worker posts that may potentially be having an adverse effect Summary of on the District Nursing workforce, currently the CCG are not aware of where the vacancies are. The Trust has been emerging themes requested by the Lead Commissioner to review and detail the number of vacancies, the impact these maybe having and trends and what actions are being taken to resolve. Action: The Trust is due to feedback to the CQRM in April 2017, however have assured the CCGs in the meantime that there are currently no freezes of Healthcare Support Worker vacancies and therefore active recruitment is in operation for these roles.
Risks and Mitigations Item: 09 Enc: 05 Risk Mitigation Registered Nurse Staffing Workforce (Number and Skill The number of vacancies is improving as the Trust continues to actively recruit. Mix) – Vacancies This is complimented by the Trust working with local Health Education Partners to promote District Nursing as a post qualifying option. A full induction and preceptorship programme is in place and support is being provided by the corporate team to mentors and team leaders. Speech and Language Therapy Provision – Long waits Remedial Action Plan issued and finances withheld until performance is for appointments sustained for more than 3 months. Serious Incidents, Patient Safety Incidents and Patient Feedback monitored in terms of quality impact. This will be reviewed in April 2017.
Item: 09 Enc: 05
NHS 111 Positive NHS 111 indicators: The CQRM noted positive reports and the triangulated information was presented to the March 2017 JQC. Total Ambulance Referral Rate: Action: The provider has presented a tangible action plan in the ED Consultant project. This project will utilise ED Consultants to receive ED and Green Ambulance referrals. Pilot indications from the North East Project have indicated reductions in the overall ED and Green Ambulance referrals and greater emphasis on self-care. This pilot is a positive approach to Emergency outcome management and has been supported at CQRM. Emergency Department Referral Rates: Staffordshire NHS 111 service was below the national average for the first time this year. A positive indication of improvements in the service and impacts on the quality and safety for patients. Position has been reviewed at CQRM and CRB. The South Staffordshire CCG figures are:- SAS CCG – January 2017 – 9.11%. Calls transferred - called back within 60mins: The provider reports that the calls have all been reviewed for clinical safety for these Staffordshire wide calls and a datix completed for any clinical concerns identified 11 calls breached. All reported as receiving safe and appropriate outcomes. All calls have been reviewed at CQRM and a Safety narrative report has been reported to the March 2017 JQC. Incidents: The March 2017 CQRM has reviewed the following incidents for South Staffordshire patients:
Serious Incidents: The provider has 1 reportable serious incident in January 2017: Case concerning an omission re: reporting a possible safeguarding incident. 72 hour report received, RCA in progress. Ambulance Trust and NHS Trust (A&E) had reported the case on the day so patient was safe. The RCA will be reviewed at the CCG Serious Incident (SI) review meeting once completed. Serious Incident reporting meeting: from February 2017. The process now includes representation by the CQIM at the Serious Incident closure meetings. All NHS 111 SIs will be closed and reviewed by this JQC sub-committee. NHS 111 End to End Call Review Summaries: Call review management is one of the key elements of securing clinical quality assurance within the NHS 111 service. The review meeting facilitates evaluation and review of the whole patient pathway. January 2017 Call Review: Emergency Department end outcomes. These were December 2016 calls taken over the Christmas / New Year period. There were 5 calls reviewed with no identified safety issues. All Quality issues have been feedback to the provider and actions have been completed. Review of the call review minutes and actions Item: 09 Enc: 05 has been completed at CQRM. The JQC noted through reporting that the CCG patient representative present at the call review meeting felt that NHS 111 was being accepted by the public and the public were becoming more aware of the value of calling NHS 111 before attending a service. This is very positive as the commissioning aim of NHS 111 is to get the right patient to the right place in the right time frame. Call review December 2016: The theme for the December call review was November 2016 dental calls taken by the Dental advisors. Dental advisors have been introduced to the SDUC NHS 111 within the last two months to ensure a positive experience for the patients calling with dental pain and dental problems. The patients are able to speak to an experienced dental clinician, whom are able to provide comprehensive dental advice. There were 6 calls reviewed with no identified safety issues. All Quality issues have been feedback to the provider and actions have been completed. Review of the call review minutes and actions has been completed at CQRM. The JQC noted through reporting that dental advisors at the call review meeting from North & South Staffordshire Emergency Dental Service commented that they had seen a significant reduction in dental calls over the last few weeks and that the quality of the calls they were receiving were more appropriate. Audit: NHS 111 report that Staffordshire did not achieve 100% audit for December 2016 due to there being limited availability to take auditors off line to review the audits. Therefore, for January 2017 to meet the licencing required standards and to ensure that our mitigating circumstances were achieved there was an increase in the amount of audits completed. January 2017 - The provider reports that there were 3 clinicians who failed calls, but passed the audit overall. Action: NHS 111 will re-audit these clinicians to gain an accurate picture of development and clinicians have formally reflected on their practice. The outcome will be reported into JQC through provider reporting. There were several failed calls from the call advisor’s audits (however, all audits were passed overall), the themes highlighted similar themes to those of previous months, and however these were from different call advisors. Action: NHS 111 report all advisors receive extra one to one coaching and constant support to ensure learning from mistakes. A healthy learning environment is encouraged; although constant audit is challenging, positive feedback is also given. The outcome will be reported into JQC through provider reporting. At the CQRM it has been confirmed that all calls where a theme has been identified have been reflected on by the individual, the provider has added a new dimension to the pathways training and re-training element around injury and illness. The CQRM were assured that appropriate actions have been identified and acted upon by the provider. The audit will remain as part of the CQRM agenda. Safeguarding Referrals: The provider has reported the number of Safeguarding referrals for December 2016 is Adult: 7 Child: 7 & January 2017 is Adult: 7 Child: 9. The provider reports that all safeguarding referrals are verbally Item: 09 Enc: 05
handed over to social services and hard copies of referral form are also sent. All recorded within NHS 111 patient notes. The CQRM will continue to monitor safeguarding referrals. CQRM has noted the issue of follow up. The provider now provides a follow up report to CQRM in the Quality reporting. Action: CQRM action is that the safeguarding report is shared with the South Staffordshire Adult and Children Safeguarding Leads who interrogate with expert analysis for any actions to be taken up at CQRM. Duty of Candour (DOC): The NHS 111 provider has recorded 2 episodes requiring duty of candour in December 2016 & January 2017 these will be reviewed under serious incident reporting. A 3rd Duty of Candour has been agreed to be inappropriate as this was completed through the safeguarding route in the safeguarding SI. Staffing: The Provider was over forecasted staffing levels for January 2017. Staffing Levels: Staffing levels remain on the whole above minimum staffing requirements. This will be continued to be monitored at CQRM for Quality and Safety Impact. Effectiveness Statutory and Mandatory Training: At the January 2017 & February 2017 CQRM the provider reported to CQRM 100% compliance with Mandatory Training (excluding Maternity leave and long term sickness staff). The Provider is looking at their requirements to ensure that the staff are compliant to national standards. This work should be completed by April 2017. This will be presented to the April 2017 CQRM. Complaints: Complaints for the South Staffordshire CCGs are 3 for December 2016. Sufficient challenge has been given at CQRM and JQC has been provided with an analysis. JQC assured that there were no safety issues and quality issues have been identified and actioned. January 2017 - 2 under investigation. 1 has no identified clinical risk and 1 under review to evaluate, if the delay caused any patient harm (patient has now been seen). Both case outcomes will be reported to CQRM when completed. Friends and Family Feedback: The provider records 62 Surveys were completed in January 2017. NHS 111 has provided a sample of positive responses in the caller’s own words which has been reviewed at CQRM and the JQC Patient experience have received and overview for information. The overall analysis from the Clinical Quality Improvement Manager is that NHS 111 is reporting that they are having difficulty in completing surveys due to extreme pressure on the service. The have assured the CQRM that all staff are required on line taking calls to ensure we capture calls coming into the service. Actions: The provider has reported a number of actions to JQC including calendar to allocate FFT calls, improving the collection of survey information & Patient/Public involvement meetings to gain more direct access. It has been agreed at CQRM that an update on this would be given in March’s CQRM. Compliments: For March 2017 CQRM the provider reported 3 compliments received in January 2017. Themes noted remain good communication and listening skills, approachable staff and both clinical and non-clinical staff Item: 09 Enc: 05
acting appropriately. CQC Inspection 16th June 2016 – Published - 16th November 2016: The expected CQC report was published on Regulatory / external in November 2016. Overall services have been rated as good for the Staffordshire NHS 111 provider. The provider bodies has been requested for an action plan for: 2 ‘Should Do’ Actions reported by the CQC, these will be presented to the April 2017 CQRM. Contact Disposition Meeting – February 2016: As directed by the CQRM, the Urgent Care Commissioning Team, CCG Clinical Quality Improvement Manager, NHS 111 & GP OOH met at the end of February to discuss the Patients being booked directly into OOH for Contact Dispositions. This has been supported by the NHS 111/GP OOH Provider Regional Director. The Action plan from this meeting will be monitored at the CQRM and any further meetings will be instigated from the CQRM. Ambulance and ED Pilot: The Provider reports that Vocare Group have been successful in securing funding for a workforce development project which will run until the end of March 2017. As part of this project we want to understand why our referral rates to 999 and ED are above target and develop mechanisms to address this. It is anticipated that this will improve the service overall which will in turn affect the patients journey and have an impact on the wider health economy. The provider will update the CQRM on any Quality and Safety issues during the pilot phase. Summary of emerging themes and EMD Pilot: The provider presented the February 2017 CQRM a project to establish if further clinical validation of ED trends and Green Ambulance Calls by ED Consultants. These changes are anticipated to make changes the outcome of the call; increases the acceptability of the advice offered by 111 and influences patient behaviour following their contact with 111. The Call Advice System will be both physical and virtual with clinicians working from a number of sites including Staffordshire House (Stoke on Trent), Arun House (Stafford) and Vocare House (Newcastle upon Tyne). The pilot is due to run for a 12 week period in the first instance and its quality and safety impact will be reported to the CQRM on a monthly basis. Safeguarding Leads: An out of area CCG raised an issue that the VOCARE safeguarding leads were not appropriately trained. The CCG CQIM raised through contracting an information request on behalf of the CCG for assurances. Assurances have been received and the oversight by the organisation has now been rectified and the JQC was assured by the swift action the provider has taken to rectify this issue and the swift action from the Quality and Safety Team to gain assurance. Risks and Mitigations Item: 09 Enc: 05
Risk Mitigation Key Risks have not been identified.
Item: 09 Enc: 05
Quality Directorate Report March 2017
This section of the report provided by the Chief Nurse/Executive Director of Quality and Safety is to briefly share with the Governing Body the additional work being undertaken by the team locally and as well as informing on any initiatives affecting the CCG locally, regionally and nationally.
The first South Staffordshire Wide Joint Quality Committee took in February 2017 bringing together the current JQCs held between ES CCG and SESP CCG and also CC and SAS CCGs, and was chaired by Paul Gallagher. This was a successful meeting with excellent attendance and it was agreed to hold a second single meeting in March to further trial the process which will now be evaluated.
NHS 2016 Staff Survey has been published in March 2017; this involved 316 NHS organisations in England. Over 982,000 NHS staff were invited to participate using an online or postal self-completion questionnaire. They received responses from over 423,000 NHS staff, a response rate of 44% (41% in 2015). Full-time and part-time staff who were directly employed by an NHS organisation on September 1st 2016 were eligible.
The results are primarily intended for use by NHS organisations to help them review and improve staff experience. The Care Quality Commission will use the results from the survey to monitor ongoing compliance with essential standards of quality and safety. The survey will also support accountability of the Secretary of State for Health to Parliament for delivery of the NHS Constitution.
Joint Quality Committee – 9th March 2017.
Stafford & Surrounds CCG and Cannock Chase CCG; South East Staffs and Seisdon Peninsular with East Staffs.
This section includes other reports received by the JQC not pertaining to the Providers and is intended to provide further assurance (not detail) to members of the respective Governing Bodies in relation to key quality activity.
Primary Care Reports CC SAS, SES & SP CCG The update includes: feedback from primary care quality related meetings, education, practice quality improvement/engagement visits, Pan-Staffordshire primary care quality workshops and workforce updates.
CQC have a few visits left to take place (only in the Cannock Chase area). Those practices with any rating less than good will be re-inspected either via a desktop review, targeted visit or a full re-inspection depending on the outcome of the first inspection.
Quality Impact Assessment
Cannock Chase, Stafford and Surrounds, East Staffordshire, South East Staffordshire and Seisdon Peninsula Clinical Commissioning Groups (CCGs) are committed to ensuring that commissioning decisions, business cases and any other business plans are assessed and Item: 09 Enc: 05 the potential consequences on quality are considered and any necessary mitigating actions are outlined in a uniformed way.
The Quality Impact Assessment (QIA) Group acts as a sub-group of the Joint Quality Committee to ensure robust clinical governance and assurance is provided to the Governing Bodies on the potential and actual quality impact of service change.
Training dates have now been planned; the audience will include staff responsible for service change, transformation and re-design; focusing on the QIA system and processes.
GP 60 Second Reporting
The Reports received from the GP members of the JQC will be raised / discussed with the appropriate Provider or Commissioner by the Quality Improvement Managers and reported back where appropriate in line with the procedure operated in the CCGs; they may be for information only as dealt with by the membership boards. Please see an example of items raised in March 2017 JQC below:
Communication difficulties between GPs and Paediatric Consultants at UHNM, which are being followed up.
NHS England Quality Surveillance Group
The CCG Chief Nurse and Executive Director of Quality and Safety attends the QSG; this meeting receives information in relation to provider performance on quality and safety, highlighting any areas of concern by exception and promotes shared learning across organisations. These meeting are held bi-monthly.
Items discussed at the February 2017 meeting included a presentation from CQC regarding the new inspection regime, Regional work on mixed sex accommodation breaches which the CCG Chief Nurse has been involved in and the shortage of Neurology Consultants.
Safeguarding Reports
Adults Safeguarding Board Funding for 16/17 remains unchanged, from 17/18 it has been determined that the three statutory partners of the board, i.e. the Local Authorities, Police and CCG’s will finance the board which will be seen as a cost saving across all the NHS partners.
Key points discussed in the paper: Updates from Local Safeguarding Adult Board (LSAB) and its’ sub groups Safeguarding Adult Reviews Mental Capacity Act Update Nursing homes Safeguarding concerns including Large Scale Investigations Domestic Homicide Reviews The Q1 Safeguarding Dashboards – Note submissions not received from UHNM PREVENT Counter-terrorism update Training General Update including Service Development
Item: 09 Enc: 05
Nursing Homes The report provides an update to the Joint Quality Committee of the Care Quality Commission ratings and quality issues relating to commissioned nursing homes.
There are 56 CCG Commissioned nursing homes based in the geographical area of CC, SaS and SESP CCGs: • All the homes have now been inspected by the CQC utilising the new methodology introduced in October 2014. • Out of 56 homes, 1 home has been rated inadequate, 29 good and 21 require improvement. • 3 homes are currently in Large Scale Enquiry. • 2 homes have exited the Large Scale Enquiry process. • 1 home has a Large Scale Enquiry planning meeting. 4 homes have placement suspensions in place.
Children The key discussed at Joint Quality Committee are as follows: • In April 2016 the CQC completed a review of health services for Children Looked After and Safeguarding in Staffordshire. This review included CCG’s and Provider services across North & South Staffordshire. The CCG and Provider action plans developed from the recommendations have been overseen by the CCG. Presently the CCG actions are currently being internally audited. The CCG oversight action plan is attached for assurance. • One of the specific actions for the CCGs was to strengthen the Looked after children services. The CCG have already advertised a post for a Designated Nurse for Looked After Children. Short listing has commenced and an interview date has been set. • Safeguarding children’s dashboards continue to be monitored via CQRMs and are over seen by (Clinical) Quality Improvement Managers. • Primary Care children’s safeguarding (level 3) sessions have been booked and are planned to run throughout 2017/18.
Infection Prevention and Control
The key issues discussed at Joint Quality Committee are as follows: • No avoidable MRSAb infections this YTD in the Staffordshire locality. Unfortunately there are 2 avoidable cases in our patients, both occurring at HEFT. • CDI - S&S CCG are 22 cases under the cumulative objective at the end of January 2016/17, correlating with improvements in antimicrobial prescribing. • CDI - CC CCG are 3 cases under the cumulative objective at the end of January 2016/17. • CDI – SES & SP are 1 case over the cumulative objective.
Transforming Care Report
An update was received by the Joint Quality Committee on the work programme and next set of key milestones for Transforming Care (people with learning disabilities, and/or autism who display behaviour that challenges, including those with a mental health condition).
The key points discussed at Joint Quality Committee are as follows: Item: 09 Enc: 05
• Progress towards achieving trajectories. Revised trajectories have been agreed for 2017/18 and 2018/19 with NHSE which are more realistic and achievable for CCG commissioned patients. • Financial Risk Share – negotiation of virtual pool arrangements. The CCG’s and Local Authorities are currently negotiating a virtual pool arrangement to ensure that funding future placements is agreed quickly and does not obstruct the discharge process. Staffordshire County Council have agreed in principle to adopt the Risk Share proposal. • Dynamic Purchasing System (DPS). Commissioners are looking at new ways on how the current local market can be stimulated to attract new skilled providers to offer services in our Transforming Care Partnership (TCP) area. In Staffordshire and Stoke on Trent a Dynamic Purchasing System was formally launched on 23 January 2017. This will be aimed at providers who can work with a range of individuals within the Transforming Care Cohort alongside clients who have complex needs that may not form part of the TCP but require bespoke packages of care to be procured and purchased. • In addition to the overall TCP Risk Register, CCGs have individual Risk Registers which are currently being reported and updated on through governance processes on a monthly basis.
Burton Hospital NHS Foundation Trust Access Policy
This policy was presented to JQC and approved.
The Access Policy informs patients, relatives and staff of their rights and what to expect from a Trust - it is linked to the NHS Constitution and therefore to certain legal rights.
Special Educational Needs and Disabilities Reforms update (SEND)
The key issues discussed at Joint Quality Committee are as follows: • The NHS Mandate contains a specific objective on supporting children and young people with Special Educational Needs and Disabilities (SEND). • Commencing in May 2016, each local area (based on the local authority footprint) will be inspected jointly by Ofsted and the Care Quality Commission (CQC) to test how effectively areas fulfil their responsibilities to children and young people who have SEND. • To date progress has been made in a number of areas, particularly: - Recruitment of a DCO. - Identification of SEND Champions on the Governing Bodies. - Inclusion of a narrative, regarding SEND, in service specifications. - Engagement with key partners/stakeholders and children, young people, parents and carers. - CCG contribution to the SEND Local Offer. - Improving the process for Education, Health and Care Plans (EHCPs). - Identification of gaps in provision and risks associated with these across the system and within our providers.
Patient Engagement Report
The meeting discussed the proposed joint model for face-to-face engagement across the three CCGs which were supported by the membership. The process to develop the model Item: 09 Enc: 05 was praised for the manner in which members of the Patients Council were involved and ‘listened to.’
Allison Heseltine attended the Patient Council meeting to discuss the work of the Quality Directorate. Allison’s presentation and discussion were well received to the extent that a representative of the Quality Directorate was requested to attend regularly.
Health watch provided an update on patient involvement in the STP process, which they will continue to do at each meeting.
Concerns are raised by members of the Patient Experience Group which are then followed up and reported on as appropriate.
Equality Impact Assessments are being looked at by the Joint Communications and Engagement Committee and how they link into Quality Impact Assessments.
Risk Register
The risk register includes quality risks related to Cannock Chase CCG, South East Staffordshire & Seisdon Peninsula CCG and Stafford & Surrounds CCG, associated to the Quality Committee. These risks are regularly reviewed by the Risk Owners. There are a total of 10 quality risks are active on the risk register; two being recommended for closure and two new risks awaiting approval.
Item: 10 Enc: 06
Cannock Chase Clinical Commissioning Group South East Staffordshire and Seisdon Peninsula Clinical Commissioning Group Stafford and Surrounds Clinical Commissioning Group
The healthiest place to live and work, by 2025
REPORT TO: The Stafford and Surrounds Clinical Commissioning Group Governing Body Meeting in PUBLIC TO BE HELD ON: Tuesday 28th March 2017
Subject: Board Assurance Framework and Risk Register Board Lead: Paul Simpson, Director of Finance Officer Lead: Sally Young, Assistant to Chief Officer Approval/ Recommendation: Assurance Discussion Information Ratification
PURPOSE OF THE REPORT: To present to the Governing Body with the Board Assurance Framework (BAF) risks and exceptional and high scoring risks from the risk register that could threaten the delivery of the CCGs strategic aims and objectives that have been identified and to provide assurance that these are being monitored and mitigated to reduce the threat to the CCG.
KEY POINTS: The Board Assurance Framework details the overarching strategic risks and details high scoring risks totalling 12 or more from the risk register. The Board Assurance Framework is updated monthly by the Senior Manager responsible for the risk and to provide the Audit Committee and Governing Body with the assurance that the CCGs are robustly managing risks that could give potentially harm the business of the CCGs.
The Risk Group met on Monday 13 March 2017 to review the BAF and Risk Register, together with proposed new risks and risk for closure.
There were 10 new risks to consider:
New Risks- Risk Register Cancer – there were three risks relating to the Cancer programme: RR 263 – Bidders withdrawing due to delays and uncertainty or approval. RR 264 – NHSE Assurance process delays in awarding/approving contracts. RR 265 – Potential claims for wasted costs
The scoring for the above risks were reviewed and were accepted as scoring 12 as proposed.
RR 266, RR 267 and RR 268 are the same risks as above, but relate to End of Life, these risks were scored as 9 as they were not considered to be as high risk to the CCG as the Cancer programme.
We are honest, accessible Quality is our day job We innovate and deliver Care and respect for all and we listen Page 1 of 4 Item: 10 Enc: 06
The Programme Director and the team have reviewed the risks and following legal procurement advice have produced a risk register for the Cancer and End of Life programme and proposed three risks which could impact the CCG. The three risks are the same but they have been separated out due to the timelines in rolling out the separate programmes.
RR 259 – Children and young people attending the County site A&E staffed by staff who don’t have the correct skills/expertise to treat children with other conditions that may present. This risk is also link to risk RR 242 which has been closed.
RR 260 – The CCG Safeguarding team currently operating under capacity with two roles unoccupied and one staff member currently on long term leave.
RR 261 – CQRM have raised concerns with the mandatory training system for GP OOH not allowing compliance reports to be pulled off electronically.
RR 262 – South East Staffordshire and Seisdon Peninsula CCG’s AVS service is in place but not supported by a contract.
The above risks were accepted onto the risk register by the Risk Group.
There were no new risks to be considered for the BAF.
Closed Risks – Risk Register RR 242 – UHNM have notified the CCG of their decision to temporarily suspend A&E at County hospital for children and people under the age of 18. This risk has been closed as it has been superceeded into risk RR 259, as detailed above.
RR 127 – Patients contracting avoidable MRSA bacteraemia due to lapses in care or systems failure. This risk has been merged into risk RR 126 which includes all health care associated infections.
The Risk Group accepted the closure of the above risks.
Closed Risks – BAF BAF-96 – Capacity of finance team being limited and the need to in-house the CSU team. The group considered the closure of this risk as the CSU team have now been in-housed and vacant posts within the team have been recruited to. The risk group are to enquire with The Executive Director of Finance the status of this risk.
BAF-112 – Failure to progress integrated commissioning in particular children’s mental health. The Executive Director of Strategy and Planning has confirmed that the CCG will commission independently of the local authority but will continue to review the opportunities of integration on a service by service basis. The group agreed the closure of this risk.
BAF-101 and BAF-113 – (BAF-101 Capacity and monetary impact of Co-commissioning impacting on primary care) (BAF-113 potential financial and governance risks for the CCG assuming responsibility for delegated commissioning) – The group considered these risks to be very similar and therefore suggested the two be merged into one overall risk. The Executive Director of Primary Care to consider the merging of these two risks.
The group noted that there were no pending risks awaiting review by the group.
We are honest, accessible Quality is our day job We innovate and deliver Care and respect for all and we listen Page 2 of 4 Item: 10 Enc: 06
CCG GOALS: Change the culture: The Board Assurance Framework and risk register will Hospital to home inform the CCGs of any issues arising in supporting the Professional to patient change in culture. The BAF and risk registers will provide assurance that risks More focus on prevention are being monitored and will highlight any issues around prevention. Involving everyone for improved Assurance that risks are being monitored will enable a more health and care focused approach to improving health and care. Patients will have more confidence to monitor their own Empower and support patients to health needs knowing risks are being monitored and take control of their own health mitigated. Services supporting people to Risk monitoring gives the CCGs assurance that the services make informed decisions they are promoting are safe for patients to make decisions.
IMPLICATIONS: The CCGs have a responsibility to provide services that are safe and low Legal and/or Risk risk. The BAF and risk register continually monitors any potential risks that could harm the business and services of the CCGs. The Quality Committee oversee SRI’s and input into the BAF and risk CQC register to monitor and mitigate risks. The Quality Committee monitors patient safety through their monthly Patient Safety Quality Committee meetings. The BAF is within the Governing Body papers for the public to see from Patient Engagement which they can have assurance that risks are being monitored/mitigated. The CCGs have an obligation to meet their financial budgets and the Financial CCGs monitor finances on a daily basis and are discussed at monthly Finance and Performance meetings and fed back to the Boards. The Governing Bodies can be assured that the CCGs take risk monitoring Sustainability very seriously and this is evidenced by the updates of the BAF and risk register. A workshop will be held for all staff where they will be fully trained on Workforce/Training completion of both the BAF and risk register.
RECOMMENDATIONS/ACTION REQUIRED: The Governing Body is asked to: Receive the update on of the BAF and risk register across the three CCGs.
We are honest, accessible Quality is our day job We innovate and deliver Care and respect for all and we listen Page 3 of 4 Item: 10 Enc: 06
Not KEY REQUIREMENTS Yes No Applicable Has a quality impact assessment been undertaken? Has an equality impact assessment been undertaken? Has a privacy impact assessment been completed? Has a comms & engagement impact assessment been completed? Have partners/public been involved in design? Are partners/public involved in implementation? Are partners/public involved in evaluation?
CCG VALUES We are honest, accessible and listen Care and respect for all Quality is our day job We innovate and deliver
We are honest, accessible Quality is our day job We innovate and deliver Care and respect for all and we listen Page 4 of 4 Cannock Chase CCG, South East Staffordshire Seisdon Peninsula CCG and Stafford Surrounds CCG Board Assurance Framework
BAF ID Description of Risk Objective Mitigating Action (internal) Future Actions (Internal) Assurance (Internal)
CCG
Lead
Date
Score Score
Initial Initial Initial
Review
Current
Current
Created
Exec Risk Exec Risk
Initial Risk Risk Initial
Likelihood Likelihood
Risk Owner Risk
ClinicalRisk
Last Review Review Last
Committees
Current Risk CurrentRisk
Date Next of Date
Consequence Consequence BAF-99 Failure to deliver the control total Be responsive and deliver what we No 4 5 20 NS\simpp2 21/02/2017 11:17:09 - 21/02/17 - The CCGs are planning NS\simpp2 21/02/2017 11:17:09 - 21/02/17 - The financial NS\simpp2 21/02/2017 11:17:09 - 21/02/17 - The 4 5 20 promise to customers and excel in to deliver against a revised deficit Control Total of £29.7m (which is mitigations are discussed at EMT, and lead directors have identified mitigations are released into the CCG's delivery;#Finance £22m higher than the original planned DCT). To this end a series of the responsibility to ensure that the identified mitigations financial position when there is a high degree of financial mitigations have been identified, which are reported are delivered. The Finance team have continued to provide confidence that they have been delivered. Any regularly at both EMT and the FPC Committee. an updated financial position, taking into consideration the mitigations that are still to be delivered are RAG rated identified mitigations, to ensure an accurate financial and discussed at EMT and FPC Committee. The At this point in the FY, there is a reasonably high degree of forecast is maintained.
NS\Tracey.Revill 17/11/2016 financial position of the CCGs is also regularly confidence that this revised CT will be delivered, although there are a 15:44:51 - 16/11/2016 - Unfortunately Cannock Chase CCG discussed with NHSE.
NS\Tracey.Revill
still a number of risks that need to be mitigated in order to ensure and Stafford and Surrounds CCG will not be able to deliver 17/11/2016 15:44:51 - 16/11/2016 - The CCGs have SimpsonPaul (CCG) CCCCG Executive Director of Finance Director Executive
the revised CT is not exceeded.
NS\Tracey.Revill 17/11/2016 the in-year control totals. confirmed with NHSE that it will be unable to meet all 21/02/2017 15:44:51 - 16/11/2016 - Financial Recovery Plan is in the process of three of the 16/17 control totals (it is exepcted that 21/03/2017
13/09/2016 15:41 being developed in light of the financial pressures on the three CCGs. Cannock Chase and Stafford and Surrounds will not be This is being discussed with NHSE on 25 November. delivered but South East Staffordshire will).
eam.
NS\whitfm 01/11/2016 15:17:06 -
Finance Performance and Contracts Committee Contracts and Performance Finance
Cannock Chase CCG;#South East Staffordshire and and Cannock Staffordshire Chase CCG;#South East Seisdon Peninsula CCG;#Stafford and Surrounds CCG Peninsula Surrounds CCG;#Stafford and Seisdon
BAF-98 Failure to deliver QIPP targets and Be responsive and deliver what we No 3 4 12 NS\Tracey.Revill 03/03/2017 09:03:45 - Comply and explain process NS\Tracey.Revill 03/03/2017 09:03:45 - Develop action plan NS\Tracey.Revill 03/03/2017 09:03:45 - FPC monthly 5 4 20 other savings targets promise to customers and excel in run by Head of Performance and Programmes. Monthly report sent in response to QIPP Internal Audit report. basis.
delivery;#Finance;#Constitutional to FPC.
NS\Tracey.Revill 17/11/2016 15:54:31 - 16/11/2016 -
NS\Tracey.Revill 17/11/2016 15:54:31 - 16/11/2016 - PwC IA report.
NS\Tracey.Revill 17/11/2016 SESCCG
Standards;#New Models of Care – Update to be provided and circulated before Governing Body. Update to be provided and circulated before Governing 15:54:31 - 16/11/2016 - Update to be provided and Contracting & Contracting
Delivery Body. circulated before Governing Body. Cannock Chase
Bird Chris (CCG)Bird
CCG;#South East CCG;#South East
03/04/2017 02/03/2017
Staffordshire and and Staffordshire
and Contracts Contracts and Peninsula Seisdon
13/09/2016 15:41
Executive Director of Director Executive Finance Performance Performance Finance BAF-96 Capacity of finance team is limited Be responsive and deliver what we No 3 4 12 NS\simpp2 21/02/2017 11:26:28 - 21/02/17 - All CSU staff have now NS\simpp2 21/02/2017 11:26:28 - 21/02/17 - No further NS\simpp2 21/02/2017 11:26:28 - 21/02/17 - the 2 3 6 and need to in-house CSU team promise to customers and excel in been "in-housed" and the CCGs are currently in the process of actions will be required in terms of capacity, upon the capacity and capability of the Finance team will through LPF delivery;#Constitutional Standards recruiting to the remaining vacant posts. This process should be conclusion of current recruitment process. A team continue to be monitored but it expected that the largely concluded by the end of the FY.
NS\houghr 18/11/2016 development day is beings scheduled for May to allow for changes that have been implemented/are underway, 08:45:15 - 16/11/216 - The Director of Finance has served notice on the year-end process and for new staff to take up their will ensure the team is fit for purpose for the the finance element of the current CSU SLA, given the failures of NHS posts.
NS\houghr 18/11/2016 08:45:15 - 16/11/2016 foreseeable future.
NS\houghr 18/11/2016 England to approve the business case, despite this being sent to - The Business Case has not been approved within a 08:45:15 - 16/11/2016 - A Business Case to in-house them in May 2016 (6months prior). This has caused significant reasonable time scale and as such, action has been served the CCG embedded finance staff was submitted to
operational issues in the finance team as well as anxiety and on the CSU SLA. NHS England in May 2016. Delays in NHS England Executive Director of Finance Director Executive uncertainty for the staff involved. approving the business case have given rise to the Director of Finance now serving notice on this element
of the current CSU SLA. The affected staff will transfer
21/03/2017 21/02/2017
to the CCG in January 2017 and there will then be 13/09/2016 15:41
restructuring exercise within the finance team, that CCG Surrounds Peninsula CCG;#Stafford and will strengthen the capcity and capability of the SimpsonPaul (CCG) CCCCG
finance function.
Cannock Chase CCG;#South East Staffordshire and Seisdon Seisdon and Cannock Staffordshire Chase CCG;#South East Finance Performance and Contracts Committee;#Audit Committee Committee;#Audit Contracts and Performance Finance BAF-48 The CCG in conjunction with the Be responsive and deliver what we No 4 4 16 NS\donaa5 19/01/2017 13:53:59 - 19/01/2017 The STP was formally NS\donaa5 19/01/2017 13:53:59 - 19/01/2017 See NS\donaa5 19/01/2017 13:53:59 - 19/01/2017 STP 4 4 16 PAN Staffordshire programme is promise to customers and excel in launched on the 15th December to the publ;ic. The Executive Forum mitigating actions-Further actions have been developed by Plan launched publicly on the 15th December unable to deliver the pace of change delivery;#New Models of Care – Delivery and the Health and Care Transformation continue to monitor the five the CCG to ensure any shrotfall in initial savings plans are 2016.Regular reports to the three Governing
required due to lack of work areas to ensure progress is being made on putting in the future proofed through further pipeline schemes Bodies.
NS\houghr 18/11/2016 09:02:30 - Chief Officer understanding, capacity and groundwork to execute the plan. The STP and CCG Operational Plans
NS\houghr 18/11/2016 09:02:30 - 07.10.2016 - Gap 07.10.2016 - Further submission of Staffordshire organisational boundaries/conflict. are now aligned and any savings achieved through the CCGs will identified in financial position between STP and CCGs. Transformation Plan (STP) due to on 21 October 2016. contribute to the STP Plan. Officers work programmes are also Finance submission completed by STP on 16 clearly aligned to STP Objectives September 2016.
NS\houghr 18/11/2016 09:02:30 - 07.10.2016 - Work
continues to develop programme and work streams. Executive 07/10/2016
forum (Chief Executives) meet fortnightly. 07/11/2016 13/09/2016 15:41
System architecture work being undertaken (workshop 29
September 2016). (SCLUS)DonaldAndrew Cluster Staffordshire
Cannock Chase CCG;#South East Staffordshire and and Cannock Staffordshire Chase CCG;#South East Seisdon Peninsula CCG;#Stafford and Surrounds CCG Peninsula Surrounds CCG;#Stafford and Seisdon
1 Cannock Chase CCG, South East Staffordshire Seisdon Peninsula CCG and Stafford Surrounds CCG Board Assurance Framework
BAF ID Description of Risk Objective Mitigating Action (internal) Future Actions (Internal) Assurance (Internal)
CCG
Lead
Date
Score Score
Initial Initial Initial
Review
Current
Current
Created
Exec Risk Exec Risk
Initial Risk Risk Initial
Likelihood Likelihood
Risk Owner Risk
ClinicalRisk
Last Review Review Last
Committees
Current Risk CurrentRisk
Date Next of Date
Consequence Consequence BAF-113 There are potential financial and Sustainable Primary Care No 3 4 12 NS\Tracey.Revill 10/03/2017 15:48:54 - Due diligence process has NS\Tracey.Revill 10/03/2017 15:48:54 - Oversight of NS\Tracey.Revill 10/03/2017 15:48:54 - Monitor 3 4 12 governance risks associated for the Service;#Finance been led by finance who have identified a level of manageable risk delegated commissioning through Primary Care Committee through PCC, monthly finance CCGs assuming responsibility for the which has been supported by FPC. Recommendation to move which is a sub committee of the Governing Body and will reports.
NS\Tracey.Revill 23/11/2016 15:31:09 - delegated commissioning of general towards delegated commissioning supported by FPC and Governing include financial governance arrangements. The CCGs have been working to the revised NHS practices if this is approved by NHS Bodies.
NS\Tracey.Revill 23/11/2016 15:31:09 - A shadow
NS\Tracey.Revill 23/11/2016 15:31:09 - Continue with England Conflicts of Interest Guidance. The Shadow England. primary care committee is now in place which is lay member led. due diligence discussions in relation to financial elements. Primary Care Committee is lay member led and will Discussions are underway to ensure due diligence in relation to the The conflict of interest policy is to be approved at the have oversight of the transition towards delegated
financial implications. An agreement is in place that the current NHS December audit committee. commissioning if approved. The primary care Millar Lynn(CCG) Millar SASCCG England team will be retained as a Staffordshire wide hub to work on committee will then be in place to oversee the CCGs in
behalf of the CCGs for delegated commissioning. The CCGs have terms of being delegated commissioners for primary
10/04/2017 10/03/2017
been working to the new conflict of interest guidance released by care. of Primary Care Director Executive
23/11/2016 15:31 NHS England, the policy has been revised across Staffordshire.
Cannock Chase CCG;#South East Staffordshire and and Cannock Staffordshire Chase CCG;#South East Seisdon Peninsula CCG;#Stafford and Surrounds CCG Peninsula Surrounds CCG;#Stafford and Seisdon
BAF-108 Staff morale, capability and capacity New Models of Care – Delivery No 3 4 12 NS\Tracey.Revill 02/03/2017 08:32:47 - The staff survey has been NS\Tracey.Revill 02/03/2017 08:32:47 - An action plan will NS\Tracey.Revill 02/03/2017 08:32:47 - The Director 3 3 9 is insufficient to deliver the scale completed and the results are to be communicated to staff over the be developed following the feedback from the staff survey, of OD also sees the action as a core component of the and pace of change first two weeks of March 2017. The core themes arising from the the plan will be based on the themes arising from the OD programme for 2017/18. The action will be staff survey will form the basis of an action plan to mitigate the risks survey.
NS\youngs 12/12/2016 15:40:43 - 12/12/2016 approved and monitored through the HR/OD
outline in the survey.
NS\youngs 12/12/2016 15:40:43 - - The CCGs will analyse the results of the staff survey and Committee.
NS\youngs 12/12/2016 15:40:43 - Baines Ian (CCG) Ian Baines
HR/OD Committee 12/12/2016 - The CCGs has spent the last 6-months rolling out a develop an action plan for an recommendations. The CCGs 12/12/2016 - The HR/OD Committee oversees this risk Management of Change programme. This coupled wiht the are also ensuring regular communications to all staff via and will report to Governing Bodies in public via a challenges the CCGs are facing has meant the staff morale has Andy Donalds (Chief Officer) Friday Note and the fortnightly highlight report. The Chair of the HR/OD Committee is dipped. The CCGs now have a Human Resources/Organisational Staff Bulletin. The new Executive Directors and the a former HR professional and has a keen interest in Development Committee which is a formal sub committee of each Directors are carrying out regular team meetings, one-to- ensuring the CCGs is a fulfilling place to
Governing Body which is monitoring staff morale through the ones and appraisals. The CCGs are also running a work.
NS\houghr 18/11/2016 09:37:42 - CCGSurrounds CCG;#Stafford and temperature check which is a standing item for all meetings and the Development Programme for bands 6-8 and a newly 16/11/2016 - 14 posts not filled at stage 2 of the MOC roll-out of the first staff survey in January 2017.
NS\houghr designed Development Programme for bands 2-5. process and have been advertised to whole team.
18/11/2016 09:37:42 - 16/11/2016 - Executive Management Team
NS\houghr 18/11/2016 09:37:42 - 16/11/2016 - Some posts will need to go to external recruitment. 02/03/2017 receives update and the Governing Bodies have also received Initiatives to keep morale going and improved are in place 03/04/2017 01/11/2016 14:19 updates as appropriate. Management of Change process is now through HR/OD agenda. In particular these include
drawing to a close and should be finished at the end of November. Management Development Programme for middle Communications & Governance, of Corporate Director managers and new programme for admin staff, achievement of the month, health and well being and tam
building.
Cannock Chase CCG;#South East Staffordshire and Seisdon Peninsula Peninsula Seisdon and Cannock Staffordshire Chase CCG;#South East Engagement Engagement Chief Sally to Young– Officer Assistant
BAF-107 The current systems and processes Quality Outcomes Yes 4 3 12 NS\Tracey.Revill 01/03/2017 12:57:41 - The re-forming of the NS\Tracey.Revill 01/03/2017 12:57:41 - Nursing home NS\Tracey.Revill 01/03/2017 12:57:41 - The lead for 4 3 12 and lack of clarity or ownership by nursing home quality assurance group is going to take place in the quality assurance group is to be re-formed and there will be this area of work has been tasked with re-forming the key parties for Nursing and Care next three months.
NS\houghr 18/11/2016 09:46:43 - an understanding regarding the full remit this group and the group.
NS\houghr 18/11/2016 09:46:43 - homes present a number of quality 16/11/2016 - The Executive Director for Nursing, Quality and Safety expectations of attendees.
NS\houghr 18/11/2016 16/11/2016 - We have a nursing home Quality and safety risks to local patients. is reviewing a way forward to facility stakeholders working together 09:46:43 - 16/11/2016 - Nursing home quality assurance Improvement Manager who is working with
Quality Committee Quality in a more cohesive way to monitor and support Nursing Homes. group has not been re-formed due to an understanding the stakeholders and using information to inform planned and Surrounds CCGSurrounds and full remit this group and the expectations of attendees. and responsive visits. In addition, she works with the 08/2016 - Executive Director of Nursing, Quality and Safety exploring
NS\whitfm 01/11/2016 14:18:26 - safeguarding lead on homes which have been options for review and service improvement plan related to this identified as being of concern.
complex area. Nursing Home quality assurance group established. Strong systems of safeguarding vulnerable adults to highlight any (CCG) Heather SESCCGJohnstone identified issues.
NS\whitfm 01/11/2016 14:18:26 - "Exec Director for Nursing, Quality and Safety exploring options for review
and service improvement plan related to this complex area. 01/03/2017 Nursing Home quality assurance group established. 01/06/2017
01/11/2016 14:18 Strong systems of safeguarding vulnerable adults to highlight any Executive Director of& &Quality Safety Director Chief Nurse Executive identified issues."
NS\whitfm 01/11/2016 14:18:26 - "Exec Director for Nursing, Quality and Safety exploring options for review and service
improvement plan related to this complex area. Cannock Chase CCG;#South East Staffordshire and Seisdon Peninsula Peninsula CCG;#StaffordSeisdon and Cannock Staffordshire Chase CCG;#South East
2 Cannock Chase CCG, South East Staffordshire Seisdon Peninsula CCG and Stafford Surrounds CCG Board Assurance Framework
BAF ID Description of Risk Objective Mitigating Action (internal) Future Actions (Internal) Assurance (Internal)
CCG
Lead
Date
Score Score
Initial Initial Initial
Review
Current
Current
Created
Exec Risk Exec Risk
Initial Risk Risk Initial
Likelihood Likelihood
Risk Owner Risk
ClinicalRisk
Last Review Review Last
Committees
Current Risk CurrentRisk
Date Next of Date
Consequence Consequence BAF-106 Failure to adequately quality impact Quality Outcomes Yes 3 3 9 NS\Tracey.Revill 01/03/2017 12:53:24 - Terms of Reference have NS\Tracey.Revill 01/03/2017 12:53:24 - The electronic tool NS\Tracey.Revill 01/03/2017 12:53:24 - The Quality 3 3 9 assess current change programmes been strengthened to provide further assurance around Governance. which was to be developed is no longer going to be Impact Assessment Group are meeting every month including, but not limited to the STP However, as STP work progresses further work is required on the implemented due to the financial cost. The current and the Terms of Reference have been reviewed to work programes. Staffordshire wide QIA.
NS\houghr 18/11/2016 09:56:47 - management of the QIA and audit trails for meetings and reflect the changes within the CCG. In addition lay 16/11/2016 - The Quality Impact Assessment (QIA) subgroup are outcomes is robust and a decision has been made to membership attendance is to be reviewed.
Quality Committee Quality receiving completed QIAs for services which are being continue with this.
commissioned, de-commissioned and changed. The process appears &Safety Chief Nurse 01/03/2017
to be working well. 03/04/2017
Staffordshire and Seisdon Seisdon and Staffordshire
01/11/2016 14:16
Cannock Chase;#South East East Cannock Chase;#South
Executive Director of& Quality Director Executive
Johnstone Heather (CCG) Heather SESCCGJohnstone Peninsula;#Stafford and Surrounds and Peninsula;#Stafford BAF-105 Failure to identify quality and safety Quality Outcomes Yes 3 4 12 NS\Tracey.Revill 01/03/2017 12:48:24 - The team are now NS\Tracey.Revill 01/03/2017 12:48:24 - An evaluation is NS\Tracey.Revill 01/03/2017 12:48:24 - By joining the 3 4 12 risks impacting upon patient presenting reports to a CCG wide joint quality committee, the first required of the success and the continuation of the CCG two joint quality committees it reduces the risk of outcomes including patient one took place in February 2017 which should provide the wide joint quality committee which will take place over the differing assurance levels and provides a higher degree experience consistency regarding assurance scoring of providers. The CCG wide next few months.
NS\houghr 18/11/2016 10:04:06 - of consistent challenge across the CCG wide joint quality committee should reduce the replication and duplication 16/11/2016 - The two Joint Quality Committee will not be landscape.
NS\houghr 18/11/2016 10:04:06 -
Quality Committee Quality and provide a much more robust challenging process. However, the formally joining until at least March 2017, due to the 16/11/2-16 - Further development of an electronic decision to continue these has not yet been made as there needs to operational management of the meetings. tool to strengthen governance and auditing processes. be an evaluation of their success.
NS\houghr 18/11/2016 10:04:06 - 16/11/2016 - The team continue to work across both
Joint Quality Committees providing assurance. presently there are
30/05/2017 01/03/2017
no indication that Committee outcomes regarding provider (CCG) Heather SESCCGJohnstone 01/11/2016 14:15
assurance is different.
Cannock Chase CCG;#South East Staffordshire and and Cannock Staffordshire Chase CCG;#South East
Executive Director of& &Quality Safety Director Chief Nurse Executive Seisdon Peninsula CCG;#Stafford and Surrounds CCG Peninsula Surrounds CCG;#Stafford and Seisdon BAF-104 The CCGs are unable to hit Constitutional Standards;#Quality Yes 4 4 16 NS\Tracey.Revill 03/03/2017 09:07:37 - Report to FPC. NS\Tracey.Revill 03/03/2017 09:07:37 - Agreed series of NS\Tracey.Revill 03/03/2017 09:07:37 - FPC monthly 5 4 20 constitutional targets Outcomes Deep dives into specific topics i.e. Cancer.
NS\houghr improvements with the Chair of FPC.
NS\houghr meetings. 06/02/2017 14:18:16 - Constitutional targets are split between those 06/02/2017 14:18:16 - Recovery Action plans are agreed Reports to Governing Body.
NS\houghr that are zero tolerance and those which are monitored in aggregate. with host CCGs and the relevant provider which sets out the 06/02/2017 14:18:16 - Monthly reports to Governing The CCG produces a monthly performance report to Governing Body issues impacting on performance, the actions to resolve Body and Finance, Performance and Contracts (GB) and Finance, Performance and Contracts Committee (FPC) them and the trajectory to recover, these are also Committee details the individual CCG position against which sets out the individual CCG position against each summarized in the performance pack.
NS\houghr each constitutional target in two views; year to date
Constitutional target in two years views; year to date and in month. 18/11/2016 10:14:18 - 16/11/2016 - Update to be provided and on month.
NS\houghr 18/11/2016 10:14:18 - Chris (CCG)Bird SESCCG This enables GB and FPC to form views as to the current and and circulated before Governing Body. 16/11/2016 - Update to be provided and circulated historical performance of the CCG against a particular standard. before Governing Body,
Performance against the targets is analysed at individual provider 02/03/2017 level with additional dashboards included in the monthly pack. The 03/04/2017
01/11/2016 14:13 CCGs have failed zero tolerance targets and these are highlighted and
reported in the pack.
NS\houghr 18/11/2016 10:14:18 - CCG Surrounds Peninsula CCG;#Stafford and
Finance Performance and Contracts Committee Contracts and Performance Finance 16/11/2016 - Update to be provided and circulated before Governing Executive Director of Contracting & of Performance Contracting Director Executive
Body. Cannock Chase CCG;#South East Staffordshire and Seisdon Seisdon and Cannock Staffordshire Chase CCG;#South East
BAF-103 Failure to engage the membership Sustainable Primary Care Service;#New Yes 3 3 9 NS\Tracey.Revill 13/03/2017 10:45:06 -
NS\houghr NS\Tracey.Revill 13/03/2017 10:45:06 -
NS\houghr NS\Tracey.Revill 13/03/2017 10:45:06 - 3 3 9 thus disenfranchising Primary Care Models of Care – Delivery 06/02/2017 15:20:43 - Locality and Membership Boards continue to 06/02/2017 15:20:43 - Locality and Membership Boards
NS\houghr 06/02/2017 15:20:43 - Ensure from the objectives and priorities of be held, supported by the Primary Care Team.
NS\houghr continue to be held on a monthly basis.
NS\houghr continuation and engagement with the primary Care the CCG 18/11/2016 10:19:06 - 06/2016 - Effective locality and membership 18/11/2016 10:19:06 - 12/08/2016 - Three engagement Committee
NS\houghr 18/11/2016 10:19:06 - boards in place. Executive Director of primary Care and associated events planned for September 2016. 12/08/2016 - Monitored through monthly team supporting primary care. Primary Care Committee in place. Membership/locality boards.
NS\whitfm
Good engagement by CCG Chairs and Locality Directors. CCG 01/11/2016 14:12:01 - 12.08.16 - Monitored through 06/02/2017
recognises high priority to maintain locality feel.
NS\whitfm monthly Memberships/locality boards. 27/03/2017 Millar Lynn(CCG) Millar SASCCG
01/11/2016 14:11 01/11/2016 14:12:01 -
Cannock Chase CCG;#South East
CCG;#Stafford and Surrounds CCGSurrounds CCG;#Stafford and
Executive Director of Primary Care Director Executive Staffordshire and Seisdon Peninsula Peninsula Seisdon and Staffordshire
3 Cannock Chase CCG, South East Staffordshire Seisdon Peninsula CCG and Stafford Surrounds CCG Board Assurance Framework
BAF ID Description of Risk Objective Mitigating Action (internal) Future Actions (Internal) Assurance (Internal)
CCG
Lead
Date
Score Score
Initial Initial Initial
Review
Current
Current
Created
Exec Risk Exec Risk
Initial Risk Risk Initial
Likelihood Likelihood
Risk Owner Risk
ClinicalRisk
Last Review Review Last
Committees
Current Risk CurrentRisk
Date Next of Date
Consequence Consequence BAF-102 Failure to engage the population in New Models of Care – No 4 4 16 NS\Tracey.Revill 02/03/2017 08:14:45 - New model of face to face NS\Tracey.Revill 02/03/2017 08:14:45 - A further facilitated NS\Tracey.Revill 02/03/2017 08:14:45 - Extensive 4 4 16 potential service change and hence Delivery;#Sustainable Primary Care engagement developed in co-production with representatives from workshop is being developed with the patient council and discussions at Governing Body and comms and wide-spread public and political Service;#Constitutional Standards patient councils, district and local groups and PPGs. Presentation district and local groups to input into how these groups will engagement committee recognise that trying to opposition to any changes. delivered to all three Governing Bodies and approved subject to the work and agree all key principles.
NS\houghr engage with the whole population for the three CCGs detail being developed with Lay Members and the Comms and 18/11/2016 10:29:32 - 16/11/2016 - New model being is a huge task and that the new arrangements in place Engagement Committee. The paper that went to Governing Body developed with feedback from pateitn workshop and paper are only the start of this journey. Closer links with STP also outlined the core business as usual comms and engagement going to Govenring Body and setting out implementation engagement and more joined up working with other
functions and the link we will be making with the STP engagement plan from Communications and Engagement Committee, engagement mechanisms in Staffordshire will help eg Young Sally (CCG) SASCCG activities.
NS\houghr 18/11/2016 10:29:32 - 16/11/2016 - clearly identified core embedded processes and plance dor working with Healthwatch and the patient reference Governing Body members held discussion about development plan increasing engagement. groups being developed for the STP.
NS\houghr
and patient workshop to look at engaging with a wider population. 18/11/2016 10:29:32 - 16/11/2016 - Communications CCGSurrounds CCG;#Stafford and
NS\whitfm 01/11/2016 14:10:36 - "11.08.16 - C&E team Budget for CSU service has now been agreed for 2016/17. and Engagement team will be joining Executive
working across the three CCGs and all bulletins and newsletters are Director team meetings to identify news that is fed
03/04/2017 02/03/2017
co-ordinated centrally. into website, weekly brief and chief Officers team 01/11/2016 13:56 Communications and Engagement Committee Communications Engagement and brief.
NS\whitfm 01/11/2016 14:10:36 - "11.08.2016 - Planned work with new teams by C&E
team to ensure all directorates are updating websites Communications & Governance, of Corporate Director
and feeding in messages to be shared.
Engagement Engagement Chief Sally to – Officer Assistant Cannock Chase CCG;#South East Staffordshire and Seisdon Peninsula Peninsula Seisdon and Cannock Staffordshire Chase CCG;#South East
BAF-101 Capacity and monetary impact of Co- Finance;#Sustainable Primary Care No 4 4 16 NS\Tracey.Revill 10/03/2017 15:51:04 - GP Forward view developed NS\Tracey.Revill 10/03/2017 15:51:04 - Delivery of the GP NS\Tracey.Revill 10/03/2017 15:51:04 - Staffordshire 4 4 16 Commissioning is greater than Service and submitted to NHSE to support sustainability of general practice. Forward view.
NS\houghr 18/11/2016 10:37:23 - wide PMO has been established to ensure delivery envisaged and has a detrimental
NS\houghr 18/11/2016 10:37:23 - 16/11/2016 - Financial due 16/11/2016 - Governing Body approval of application for against the GP Forward view and assurance to impact on Primary Care and the diligence process underway. full delegation.
NS\whitfm 01/11/2016 14:09:47 - NHSE.
NS\houghr 18/11/2016 10:37:23 - CCG. "12.08.16 - Present project plan to Primary Care Committee 16/11/2016 - Finance & Performance Committee to Membership Board support is being developed to manage transition. in September 2016. sign off financial due diligence.
NS\whitfm
NS\whitfm 01/11/2016 14:09:47 - "12.08.16 - Project plan is 01/11/2016 14:09:47 - 12.08.16 - Due diligence 10/03/2017
being developed to manage transition. process will be put in place. 10/04/2017 Millar Lynn(CCG) Millar SASCCG
01/11/2016 13:09
Cannock Chase CCG;#South East
CCG;#Stafford and Surrounds CCGSurrounds CCG;#Stafford and
Executive Director of Primary Care Director Executive Staffordshire and Seisdon Peninsula Peninsula Seisdon and Staffordshire
BAF-100 An ageing and reducing Primary Sustainable Primary Care Service Yes 4 4 16 NS\Tracey.Revill 13/03/2017 10:46:00 -
NS\houghr NS\Tracey.Revill 13/03/2017 10:46:00 -
NS\houghr NS\Tracey.Revill 13/03/2017 10:46:00 - 4 4 16 Care workforce is unable to 06/02/2017 15:18:58 - A workforce strategy has now been set up 06/02/2017 15:18:58 - A number of workforce workshops
NS\houghr 06/02/2017 15:18:58 - A workforce maintain /increase productivity to chaired by NHSE feeding up through the STP workforce workstream have been arranged by NHSE to showcase some of the strategy has now been set up chaired by NHSE feeding meet current demands/challenges and includes reps from the CCGs, LMCs, federations, CEPN, different roles that can be utilised in primary care - the up through the STP workforce workstream and Healthwatch. A strategy is being developed by the group and will South Staffordshire workshop is set to take place on 2nd includes reps from the CCGs, LMCs, federations, CEPN, also be monitored through this group. A survey was undertaken in Feb. A strategy is being developed by the group and will Healthwatch.
NS\houghr 18/11/2016 10:45:16 - October 2016 to ask practices about their current and future also be monitored through this group.
NS\houghr 16/11/2016 - EPCC Programme Board
workforce and this information will be used as part of the overall 18/11/2016 10:45:16 - 16/11/2016 - New model of care established.
NS\whitfm 01/11/2016 14:07:59 - Millar Lynn(CCG) Millar SASCCG strategy. Some initial priorities discussed include retention of GPs, an framework developed - under consultation. Agree 12.08.16 - Workforce programme in place across
ongoing plan for the diversification of the primary care workforce, framework and develop delivery plan.
NS\whitfm Staffordshire. Oversight through Enhanced Primary
06/04/2017 06/03/2017 mentorship for new roles and patient communication around 01/11/2016 14:07:59 - "12.08.16 - Implement receptionist and Community Care Steering Group. of Primary Care Director Executive 01/11/2016 12:57 workforce in general practice.
NS\houghr 18/11/2016 training to support and strenghten practice teams and
NS\whitfm 01/11/2016 13:26:22 - y5454
10:45:16 - 16/11/2016 - EPCC Programme to sustain primary care manage demands.
and develop localities.
Cannock Chase CCG;#South East Staffordshire and and Cannock Staffordshire Chase CCG;#South East Seisdon Peninsula CCG;#Stafford and Surrounds CCG Peninsula Surrounds CCG;#Stafford and Seisdon
4 Cannock Chase CCG, South East Staffordshire Seisdon Peninsula CCG and Stafford Surrounds CCG Risk Register
Risk Description Of Risk Objective Associated BAF Risks Mitigating Action (Internal) Future Actions (Internal) Assurance (Internal) CCG
ID
Lead Date
Score Score
Initial Initial
Review
Current Current
Created
Exec Risk
Likelihood Likelihood
Initial Risk
Risk Owner
Clinical Risk Last Review
Committees
Current Risk
Date of Next
Consequence Consequence 241 BAF - The CCGs fail to deliver Constitutional Standards;#Finance Failure to deliver the control total;#99 No 4 4 16 NS\Tracey.Revill 30/08/2016 15:51:07 - NS\Tracey.Revill 30/08/2016 15:51:07 - NS\whitfm 31/10/2016 13:35:35 - 10.08.16 - Plan 4 4 16 Cannock Chase CCG;#Stafford & 2016/17 Control Total.
totals for the three CCGs. Decisions taken by the Governing the true nature of the financial gap across Staffordshire Bodies will then be incorporated into a financial update to NHSE on we are aiming for in 2016/17. Membership sign-up 12 September 2016.
contract management and capability of team.
30/08/2016 30/09/2016
programme does not deliver fast enough.
Previous history archived.
Simpson Paul (CCG) CCCCG Executive Director of FinanceDirector Executive Previous history archived.
239 Transforming Care Partnership - New Models of Care – Failure to deliver QIPP targets;#98;#Failure Yes 5 4 20 02/02/2017 12:16:08 NS\Laura.McGarvie - TCP Steering Group and NS\Laura.McGarvie 02/02/2017 12:16:08 - TCP Steering NS\Laura.McGarvie 02/02/2017 12:16:08 - TCP 4 4 16 Cannock Chase CCG;#Stafford & INTEGRATION OF Delivery;#Quality to deliver the control total;#99 Partnership Board to review this on an on-going basis along with Group and Partnership Board to review this on an on- Steering Group and Partnership Board to review this Surrounds CCG;#South East Staffordshire SERVICE/PARTNERSHIPS Outcomes;#Finance NHSE to ensure effectiveness governance.
21/11/2016 going basis along with NHSE to ensure effect governance. on an on-going basis along with NHSE to ensure effect and Seisdon Peninsula CCG A number of stakeholders are 16:07:57 NS\adamc4 - TCP Steering Group and Partnership Board to Membership of the Board and workstreams to be governance.
NS\adamc4 21/11/2016 16:07:57 - included within the programme. review this on an on-going basis along with NHSE to ensure effect reviewed regularly
NS\adamc4 21/11/2016 As above. This may mean decision making is governance.
NS\Tracey.Revill 17/08/2016 08:55:26 - 16:07:57 - TCP Steering Group and Partnership Board to Terms of Reference for Board will be reviewed and
slow and not enable the review this on an on-going basis along with NHSE to updated on a regular basis.
NS\whitfm 02/03/2017 programme to move at the ensure effect governance. 02/02/2017
17/08/2016 08:55 required pace, organisations may Previous history archived. Previous history archived. not be willing or able to change Previous history archived. of IntegrationDirector
the integration or culture within Adams Christine (CCG) SASCCG the required timescales. 194 The risk is the continued scrutiny New Models of Care – Failure to deliver QIPP targets;#98;#The CCG No 4 4 16 26/11/2015 16:28:37 NS\Tracey.Revill - NS\Tracey.Revill 26/11/2015 16:28:37 - NS\whitfm 31/10/2016 13:59:56 - Comms and 4 4 16 Cannock Chase CCG;#Stafford & of commissioning plans for all Delivery;#Constitutional Standards in conjunction with the PAN Staffordshire Regular attendance at scrutiny committee to keep members up to Convenors to ensure all commissioning plans identify Engagement plan for consultations required is being Surrounds CCG;#South East Staffordshire three CCGs. In particular the programme is unable to deliver the pace of date with commissioning plans. whether consultation or engagement is required at the developed. CCGs inability to manage consultation and Seisdon Peninsula CCG impact of regional and national change required due to lack of outset of the programme. Engagement Manager from process within timescales. Timescales for service sign-off for consultations for any understanding, capacity and organisational Previous history archived. SES attended QIPP Confirm & Challenge session to ensure changes often do not allow enough time to follow the service changes. boundaries/conflict.;#48;#Failure to all QIPP plans identify engagement required from the consultation through properly and shortage of capacity
adequately quality impact assess current outset and this can be planned into the work streams. within the CCG and the CSU to develop the
12/12/2016 16/01/2017
change programmes including, but not consultation documentation.
Officer Chief
07/08/2015 14:51 limited to the STP work programes. Previous history archived.
;#106;#The CCGs are unable to hit Previous history archived. Young Sally (CCG) SASCCG constitutional targets;#104
234 URGENT CARE SYSTEM CAPACITY: Constitutional Standards;#Quality Failure to identify quality and safety risks No 3 5 15 01/09/2016 11:08:13 NS\Tracey.Revill - NS\Tracey.Revill 01/09/2016 11:08:13 - NS\whitfm 31/10/2016 13:53:55 - Weekly team 3 5 15 Cannock Chase CCG;#Stafford & There are significant pressures on Outcomes impacting upon patient outcomes including
is required to work with local targets;#104;#Failure to deliver QIPP and County Hospitals to facilitate flow and discharge of patients avoidance through AVS and support hospital in prompt providers to address this. Failure targets;#98 working with Social Care.
performance targets (for example
01/09/2016 01/10/2016
A&E 4 hour wait) as well as an
16/08/2016 14:19 Director of IntegrationDirector impacting on the quality of McCandless Kate (CCG) services and the delivery of the CCG's transformation agenda.
265 Cancer risk, Bidders withdraw, Finance No 5 3 15 NS\Sherry.Samaan 13/03/2017 14:05:42 - Continue constructive NS\Sherry.Samaan 13/03/2017 14:05:42 - Developing NS\Sherry.Samaan 13/03/2017 14:05:42 - Risk has 3 4 12 Cannock Chase CCG;#Stafford & procurement ceases, potential engagement and clear lines of engagement with bidders. Develop of Plan B through Westmidlands Cancer Alliance been reveiwed regularly at TCEOLP Programme Board Surrounds CCG claim for wasted costs. Outcomes Plan B. of the programme will be
delivered.
13/03/2017 13/04/2017
13/03/2017 14:05
Samaan (CCG) SESCCG Sherry Executive Director of PlanningDirector Executive & Strategy 264 Cancer risk, stakeholder New Models of Care – Delivery No 5 4 20 14/03/2017 09:23:13 NS\Sherry.Samaan - The pause made this NS\Sherry.Samaan 14/03/2017 09:23:13 - Risk has been NS\Sherry.Samaan 13/03/2017 14:01:17 - Risk has 3 4 12 Cannock Chase CCG;#Stafford & engagement need for continued difficult as the programme was not able to undertake any reveiwed regularly at the TCEOLP Programme Board been regularly reviewed at the TCEOLP Programme Surrounds CCG engagement with public, patients engagement activity. Continue engagement with public and
NS\Sherry.Samaan 13/03/2017 14:01:17 - Board and professionals. professionals. There needs to be a detailed engagement plan Developing Plan B through Westmidlands Cancer Alliance developed with the SIs which includes a schedule of stakeholder engagement through briefings, meetings and events.
NS\Sherry.Samaan 13/03/2017 14:01:17 - Build approval process
into the timelines. Plan B Business Case will demonstrate case for, Strategy
13/03/2017 13/04/2017
and benefits and riks of procurement in context of revised health 13/03/2017 14:01
economy lanscape and learning from Uniting care.
Samaan (CCG) SESCCG Sherry Executive Director of PlanningDirector Executive &
263 Cancer risk, negative perceptionof New Models of Care – Delivery No 5 4 20 14/03/2017 09:49:11 NS\Sherry.Samaan - Negativity publicity has NS\Sherry.Samaan 13/03/2017 13:53:03 - Plan B being NS\Sherry.Samaan 14/03/2017 09:49:11 - Risk has 3 4 12 Cannock Chase CCG;#Stafford & programme. Ongoing risk due to made engagement with some stakeholders challenging but clear developed as part of West Midlands Cancer Alliance been regularly reviewed at the TCEOLP Programme Surrounds CCG private sector involvement in the communication has seen that the media has been more balance and approach Board
NS\Sherry.Samaan 13/03/2017 13:53:03 - bidding process. more stakeholders understand the programme. Need to continue to Risk has been regularly reviewed at the TCEOLP work with all stakeholders and media to make sure that any Programme Board. negativity and inaccuracy about the programme is addressed.
NS\Sherry.Samaan 13/03/2017 13:53:03 - Build approval process
13/03/2017 13/04/2017
into the timelines & Performance
13/03/2017 13:53
Samaan (CCG) SESCCG Sherry Executive Director of ContractingDirector Executive 259 The UHNM Childrens Emergency New Models of Care – Failure to adequately quality impact assess Yes 4 3 12 13/03/2017 15:44:49 NS\houghr - 13/03/2017 - Quality Committee NS\houghr 13/03/2017 15:44:49 - 13/03/2017 - Quality NS\houghr 13/03/2017 15:44:49 - 13/03/2017 - 4 3 12 Cannock Chase;#Stafford & Surrounds centre has been reopened and is Delivery;#Quality Outcomes current change programmes including, but are aware and are monitoring
NS\Lynn.Tolley 25/01/2017 Committee continue to monitor
NS\Lynn.Tolley Continue monitoring through visits and CQRM
now called the Childrens Minor not limited to the STP work programes. 15:39:45 - 25/01/16 - Communications to the public, GPs, WMAS has 25/01/2017 15:39:45 - 25/01/17 - The CCG have carried NS\Lynn.Tolley 25/01/2017 15:39:45 - 25/01/17 - the Injuries Unit. The Minor Injuries ;#106 been a priority to ensure that children and families are aware that if out an unnnounced visit and it appeared that the children unannounced visit indicated that the Provider had Unit is for children under 16 years there child is presenting with any other injuries or illnesses other presenting to the unit are appropriate the majority of the dealt with all children whom attended appropriately.
with head injuries, limb injuries, than the ones which UHNM have identified need to access other NHS time. The Provider and CCG are awaiting the outcome of 10/04/2017
wounds, sprains, bruises, fractures. services the Royal College of paediatrians review. 13/03/2017
25/01/2017 15:39 Quality Committee
The risk relates to children and of Director Executive Quality & Safety & Chief young people attending the Tolley Lynn (CCG) SASCCG
1 Cannock Chase CCG, South East Staffordshire Seisdon Peninsula CCG and Stafford Surrounds CCG Risk Register
Risk Description Of Risk Objective Associated BAF Risks Mitigating Action (Internal) Future Actions (Internal) Assurance (Internal) CCG
ID
Lead Date
Score Score
Initial Initial
Review
Current Current
Created
Exec Risk
Likelihood Likelihood
Initial Risk
Risk Owner
Clinical Risk Last Review
Committees
Current Risk
Date of Next
Consequence Consequence 256 There is a risk that funds relating Sustainable Primary Care Failure to deliver the control No 4 3 12 02/02/2017 09:44:39 NS\Eleanor.Spalding - Due diligence continues NS\Eleanor.Spalding 02/02/2017 09:44:39 - Completion of NS\Eleanor.Spalding 02/02/2017 09:44:39 - Paper to 4 3 12 Cannock Chase CCG;#Stafford & to the commissioning of general Service;#Finance total;#99;#Delegated Commissioning to be undertaken to ensure that appropriate funds are transferred. due diligence
NS\Tracey.Revill 23/11/2016 be submitted to FPC and each CCG GB.
Surrounds CCG;#South East Staffordshire practice will be retained by NHS Potential financial and governance Once complete all papers will be circulated to each CCG GB for sign 15:49:30 - Continue discussions regarding due diligence NS\Tracey.Revill 23/11/2016 15:49:30 - MOU to be in and Seisdon Peninsula CCG England and monies that are risks.;#113 off and assurance
NS\Tracey.Revill 23/11/2016 15:49:30 - Due and ensure a robust MoU is in place with the NHS England place taking into account the transfer of funding currently utilised to ensure that diligence is currently taking place to ensure that appropriate budgets team. including any risks associated with this. services are running effectively will are due to be transferred and no risk is transferred to the CCG in
not be released to the CCG if assuming responsibility. This will also be a key element of the MOU 02/03/2017 taking on delegated with the NHS England team. 02/02/2017
23/11/2016 15:49 commissioning responsibility.
Wood Eleanor (SES & SP CCG) Executive Director of Care Primary Director Executive 255 There is a risk of the CCGs not Sustainable Primary Care Capacity and monetary impact of Co- No 4 3 12 02/02/2017 09:46:47 NS\Eleanor.Spalding - Mitigating action NS\Eleanor.Spalding 02/02/2017 09:46:47 - MOU to be NS\Eleanor.Spalding 02/02/2017 09:46:47 - As per 4 3 12 Cannock Chase CCG;#Stafford & having the resource / capacity and Service;#Constitutional Standards Commissioning is greater than envisaged remains unchanged. Changes to take effect from 1st April if the CCG agreed at JCC and PCC
NS\Tracey.Revill 23/11/2016 previous
NS\Tracey.Revill 23/11/2016 15:39:13 - Surrounds CCG;#South East Staffordshire expertise to assume delegated and has a detrimental impact on Primary assume delegated commissioning. MOU has been drafted and is in 15:39:13 - Shadow Primary Care Committee continues to The local NHS England team remains in place as a hub and Seisdon Peninsula CCG commissioning responsibility of Care and the CCG. ;#101;#The CCGs are the process of being finalised
NS\Tracey.Revill 23/11/2016 meet and to have oversight of the transition towards across the Staffordshire area. general practice. unable to hit constitutional targets;#104 15:39:13 - It is acknowledged via a Staffordshire wide footprint and delegated commissioning. the six Staffordshire CCGs have agreed to retain the current NHS England team. This team will work on behalf of both the CCG and NHS England to deliver primary care services. In doing this the CCG retain the expertise of the current team and ensure that there is adequate capacity. Splitting the team would reduce its effectiveness
and add unnecessary risk to General Practice and the retained 02/03/2017 services. This will also assist in retaining the relationships member 02/02/2017
23/11/2016 15:39 practices have with the CCG and NHS England although it is acknowledged that difficult decisions may have to be made which
may cause strain to relationships. Wood Eleanor (SES & SP CCG) Executive Director of Care Primary Director Executive
240 Transforming Care Partnership - New Models of Care – Failure to deliver QIPP targets;#98;#Failure Yes 4 3 12 03/02/2017 11:22:51 NS\Laura.McGarvie - Market Development NS\Laura.McGarvie 03/02/2017 11:22:51 - Market NS\Laura.McGarvie 03/02/2017 11:22:51 - Market 4 3 12 Cannock Chase CCG;#Stafford & INSUFFICIENT MARKET RESOURCE Delivery;#Quality to deliver the control total;#99 Engagement Workshop took place on 23rd January 2017 and around Development Engagement Workshop took place on 23rd Development Engagement Workshop took place on Surrounds CCG;#South East Staffordshire AND DEVELOPMENT Outcomes;#Finance 75 providers attended. Feedback received was positive and this has January 2017 and around 75 providers attended. 23rd January 2017 and around 75 providers attended. and Seisdon Peninsula CCG There is a risk that the provider started to stimulate local provider market through the establishment Feedback received was positive and this has started to Feedback received was positive and this has started to market does not have the capacity of the Dynamic Procurement System (DPS) for specialist community stimulate local provider market through the stimulate local provider market through the or capabilty to support the new provision. establishment of the Dynamic Procurement System (DPS) establishment of the Dynamic Procurement System service model which focuses upon for specialist community provision. (DPS) for specialist community provision. prevention, early intervention and Previous history archived. A Procurement group meeting has been established and wellbeing to minimise meets fortnightly which is being led by SCC.
Previous history archived.
inappropriate admissions to a NS\adamc4 21/11/2016 15:59:40 - Market development 02/02/2017 range of complex and challenging engagement workshop planned. Commissioning 03/02/2017
17/08/2016 08:58 ptient group. intentions developed and work underway to develop Director of IntegrationDirector
dynamic health and care procurement framework. Adams Christine (CCG) SASCCG
Previous history archived.
237 Transforming Care Programme - New Models of Care – Failure to deliver QIPP targets;#98;#Failure Yes 5 4 20 06/02/2017 10:50:58 NS\Laura.McGarvie - The CCG’s and Local NS\Laura.McGarvie 06/02/2017 10:50:58 - The CCG’s and NS\Laura.McGarvie 06/02/2017 10:50:58 - The CCG’s 4 3 12 Cannock Chase CCG;#Stafford & INSUFFICIENT FINANCIAL Delivery;#Quality to deliver the control total;#99 Authorities are currently negotiating a virtual pool arrangements to Local Authorities are currently negotiating a virtual pool and Local Authorities are currently negotiating a virtual Surrounds CCG;#South East Staffordshire RESOURCE Outcomes;#Finance ensure that funding future placements is agreed quickly and does not arrangements to ensure that funding future placements is pool arrangement to ensure that funding future and Seisdon Peninsula CCG There is a risk the programme obstruct the discharge process. The key challenge relating to CCGs agreed quickly and does not obstruct the discharge placements is agreed quickly and does not obstruct the costs required to deliver the has been that we have had to fund a number of placements at 100% process. The key challenge relating to CCGs has been that discharge process. The key challenge relating to CCGs programme can not be met by cost in the absence of virtual pool arrangements. The Risk Share we have had to fund a number of placements at 100% has been that we have had to fund a number of partner organisations within Proposal has now been shared across the partners and Staffordshire cost in the absence of virtual pool arrangements. The Risk placements at 100% cost in the absence of virtual pool budget constraints with the result County Council have agreed in principle to work with this pending Share Proposal has now been shared across the partners arrangements. The Risk Share Proposal has now been that there is an insufficient budget Cabinet approval. Further discussions are being undertaken within and Staffordshire County Council have agreed in principle shared across the partners and Staffordshire County to fully transform the outcomes Stoke City Council for agreement to be reached. One of the to work with this pending Cabinet approval. Further Council have agreed in principle to work with this for the service users and objectives outstanding issues to resolve was the mechanism for transferring discussions are being undertaken within Stoke City pending Cabinet approval. Further discussions are of the programme are not resources to Local Authorities/Clinical Commissioning Groups (CCGs) Council for agreement to be reached. One of the being undertaken within Stoke City Council for achieved. from NHS England, when NHSE-funded beds are closed, and where a outstanding issues to resolve was the mechanism for agreement to be reached. One of the outstanding pooled budget is not in place. It has now been agreed to transfer transferring resources to Local Authorities/Clinical issues to resolve was the mechanism for transferring
funds by adjusting CCG allocations – to cover community support for Commissioning Groups (CCGs) from NHS England, when resources to Local Authorities/Clinical Commissioning 06/03/2017 both dowry and non-dowry-eligible patients. The Deputy Director of NHSE-funded beds are closed, and where a pooled budget Groups (CCGs) from NHS England, when NHSE-funded 06/02/2017
17/08/2016 08:47 Finance, North Staffordshire and Stoke on Trent CCGs and the is not in place. It has now been agreed to transfer funds beds are closed, and where a pooled budget is not in Director of IntegrationDirector Transforming Care Programme Manager are working with the West by adjusting CCG allocations – to cover community place. It has now been agreed to transfer funds by Midlands Alignment Working Group to establish how funds will flow support for both dowry and non-dowry-eligible patients. adjusting CCG allocations – to cover community Adams Christine (CCG) SASCCG to enable the CCGs to meet costs of step down placements from support for both dowry and non-dowry-eligible secure accommodation. We have now agreed revised trajectories for patients. 2017/18 and 2018/19 with NHSE which are more realistic and achievable for CCG commissioned patients and have been signed-off in agreement by the DCO team for Midlands and East.
235 DEMENTIA PREVALENCE Constitutional Standards;#Quality Failure to deliver QIPP targets;#98;#The Yes 2 4 8 16/11/2016 12:24:34 NS\Tracey.Revill - A Recovery Action plan is NS\Tracey.Revill 16/11/2016 12:24:34 - Training session NS\Tracey.Revill 16/11/2016 12:24:34 - The dementia 3 4 12 Cannock Chase CCG;#Stafford & IDENTIFICATION: The CCG has a Outcomes CCGs are unable to hit constitutional reviewed on a monthly basis in order to ensure that all steps are for practice nurses planned for May 2017 across the three diagnosis rate is continuing to increase slowly, which Surrounds CCG;#South East Staffordshire target to reach diagnosis of 67% of targets;#104 being taken to increase the diagnosis rate for dementia. Work CCGs being delivered by Worcester University which was indicates that all work to increase diagnosis is and Seisdon Peninsula CCG the estimated prevalence for involves supporting GP practices to consider dementia when seeing commissioned through the West Midlands NHS Dementia identifying new patients and this will hopefully patients with dementia. The CCG patients and also working with SSSFT to ensure that the outcomes of Lead.
NS\Tracey.Revill 16/08/2016 14:21:49 - continue over time.
failed to meet this target in all patients referred to them and assessed are reported back to the 2014/15 and changes to the way in referring GP practice. A cross-triangulation of information from GP which this this target is measured practices and SSSFT about people with dementia is being carried out
for 2015/16 have reduced the to identify any unregistered patients with dementia. We are 28/02/2017 CCGs rates by -8.1% (the most reviewing the contractual arrangements with Alzheimer's Society in 16/11/2016
16/08/2016 14:21 significant reduction in the region). order to commission more appropriate and wide-spread support for Lusuardi Rob (CCG)
The change in prevalence increases patients and their carers post diagnosis. of IntegrationDirector the denominator by 300 patients, the impact of this is that the CCG Previous history archived. rate that was 53% in March 2015, dropped immediately to 44% in
2 Cannock Chase CCG, South East Staffordshire Seisdon Peninsula CCG and Stafford Surrounds CCG Risk Register
Risk Description Of Risk Objective Associated BAF Risks Mitigating Action (Internal) Future Actions (Internal) Assurance (Internal) CCG
ID
Lead Date
Score Score
Initial Initial
Review
Current Current
Created
Exec Risk
Likelihood Likelihood
Initial Risk
Risk Owner
Clinical Risk Last Review
Committees
Current Risk
Date of Next
Consequence Consequence 225 QUEENS HOSPITAL (Burton Quality Outcomes The CCGs are unable to hit constitutional Yes 4 4 16 08/02/2017 09:22:52 NS\houghr - The number of serious incidents NS\houghr 08/02/2017 09:22:52 - The action plan NS\houghr 08/02/2017 09:22:52 - The action plan 4 3 12 South East Staffordshire and Seisdon Hospitals NHS Foundation Trust) targets;#104;#Failure to identify quality and has reduced, and the Quality of the Submitted RCas has improved. remains in place and will continue to be monitored. The remains in place and will continue to be monitored. Peninsula CCG SERIOUS INCIDENTS safety risks impacting upon patient The Action plan is monitored and the Trust is monitoring to ensure trust is monitoring to ensure sustained improvements. The trust is monitoring to ensure sustained An increase in the number of outcomes including patient experience;#105 sustained improvements.
30/01/2017 09:37:51 NS\houghr -
NS\houghr 30/01/2017 09:37:51 - 17/01/17 The improvements.
NS\houghr 30/01/2017 09:37:51 - serious and critical incidents has 17/01/17 Following on from the issuing of the Contract Performance External Investigation into the Serious Incidents at the 17/01/17 Monitoring of the actions takes place at the been reported by the Trust. Notice, a meeting took place between the CCG and the Provider, Trust is now complete and has been shared with BHFT. CQRM.
NS\heseal 02/12/2016 13:55:17 - where it was agreed that the CCG will receive a briefing on all The Trust has included the actions which need to be taken 02/12/16 From the recommendations of the potential SIs followed by a conversation to jointly agree following the completion of the review to their central independent review of SIs the trust has developed an classification, if it is not clear whether or not the incident is an SI. action plan linked to others such as the CQC.
action plan which is being monitored by ESCCG quality The discussions between Provider and Commissioner are now NS\heseal 02/12/2016 13:55:17 - 02/12/16 team.
embedded in to the SI process, with positive and open discussions Recommendations from the external review have been 27/03/2017 taking place to decide the pathway for reporting. put into an action plan by the Trust which are being Previous history archived. 08/02/2017 16/08/2016 11:47 monitored by the East Staffordshire CCG Quality Team. Previous history archived. The Chief Nurse now has oversight of all SI’s and the Medical Director involved in investigation as appropriate. Allison (CCG) SESCCGHeseltine
Previous history archived. Executive Director of QualityDirector Executive & Safety & Nurse Chief
221 LIMITED CCG INFLUENCE ON Finance;#Constitutional Failure to deliver the control Yes 4 5 20 06/02/2017 14:04:41 NS\houghr - The Contract Management NS\houghr 06/02/2017 14:04:41 - Specific actions have NS\houghr 06/02/2017 14:04:41 - A monthly Contract 4 3 12 South East Staffordshire and Seisdon CONTRACTS FOR WHICH IT IS NOT Standards;#Quality Outcomes total;#99;#Failure to identify quality and Strategy has been developed in order to manage the risk. The been identified for specific providers and these are Management Executive Team meeting is held which Peninsula CCG THE LEAD COMMISSIONER: The safety risks impacting upon patient reviewed by Executive Management Team on a weekly acts as a stock take of all unknown issues in relation to CCG does not lead on any of the outcomes including patient Previous history has been archived. basis.
NS\Tracey.Revill 16/08/2016 11:03:53 - the contracts and to identify any further actions contracts with the acute providers experience;#105;#The CCGs are unable to CCG engaged in continuing debate with BBCS CCG's and required.
NS\whitfm 31/10/2016 13:45:52 - that its patients attend. This limits hit constitutional targets;#104;#Failure to the BBCS collaborative forum regarding reinvestment of Update 15.07.2016 the ability to influence contractual deliver QIPP targets;#98 fines and penalties. Letter from CFO to BBCS CFO's Recommenced Contract Management Executive Team discussions and thus presents a confirming our CCG default position being zero re- on a monthly basis to act as contracts stocktake and
financial risk to the organisation. invetment without written approval from the CFO. ensure all contract facing colleagues have a shared 01/03/2017 undestanding of the current position. 06/02/2017
16/08/2016 11:03 Previous history has been archived.
Previous history has been archived. Bird (CCG) SESCCGChris
Finance and Performance Contracts Committee Executive Director of ContractingDirector Executive & Performance 219 Overall procurement timeline for Quality Outcomes;#Finance;#New Failure to deliver the control total;#99 No 3 4 12 10/03/2017 12:02:56 NS\kings4 - Cancer - Bidder has confirmed its NS\kings4 10/03/2017 12:02:56 - Continued work through NS\kings4 10/03/2017 12:02:56 - Paper to Programme 3 4 12 Cannock Chase CCG;#Stafford & cancer not achieved. Significant Models of Care – Delivery bid remains valid until 30th September 2017. A list of outstanding outstanding issues to ensure that the final contractual Board detailing how the recommendations from Surrounds CCG;#South East Staffordshire delay is likely to lead to delay in issues with a timescale for resolution has been agreed with the position is clear prior to the financial submission.
reviews into Uniting Care contract and reviews of the and Seisdon Peninsula CCG commencment of phase 1 and bidder to ensure that the final contractual position is clear and NS\kings4 07/12/2016 12:36:42 - Progress procurement in programme have been implemented.
NS\kings4 deliver of key objects re improving unambiguous prior to the financial submission. The timeline has be line with procurement. legal and commercial advice
07/12/2016 12:36:42 - Approval from NHSE and CCGs care. Programme Risk ID 610 agreed to work towards awarding preferred bidder status by April 17 NS\kings4 01/11/2016 14:00:51 - GBs to continue with the procurement process.
Following the Extraordinary Governing Body, based on EOL – has not been progressed as focus on progressing cancer the agreed options for progressing the procurements, procurement. timeline plans will be amended.
23/01/2017 12:00:07 NS\kings4 - Following our discussion the Previous history has been archived.
Cancer bidder 18th January 2017 a timeline up until contract 28/04/2017 signature has been agreed which details milestones, anticipated 23/01/2017
10/08/2016 16:59 completion dates and responsibilities. Joint working groups, comprising CCG, NHS England Specialised Commissioning and the bidder personnel and their advisors, have been established to work
through and reach agreement on the following outstanding items by King Sharon Stoke on(5PJ) Trent PCT 24th February 2017. of PlanningDirector Executive & Strategy
Previous history has been archived.
205 The CCG is responsible for the Finance;#Sustainable Primary Care Failure to deliver the control total;#99 No 4 4 16 05/01/2017 12:09:50 NS\coxtr - A task and finish group has been set NS\coxtr 05/01/2017 12:09:50 - Reinvestment to be NS\coxtr 05/01/2017 12:09:50 - Plan to be in place by 4 3 12 Cannock Chase;#Stafford & reinvestment decision regarding Service up to develop a pragmatic plan for re-investment of the PMS discussed at relevant membership and locality boards and April 2017 for reinvestment.
NS\houghr Surrounds;#South East Staffordshire and the reinvestment of the PMS premium over a 5 year period. Plans will go to the relevant an agreement to be made in association with NHSE and Seisdon Peninsula premium. The financial membership and locality boards in January. Practices (both PMS and LMC.
NS\coxtr 31/08/2016 17:32:05 - Previous history has been archived. consequences of the PMS contract GMS) have agreed to a cost per head payment to ensure that The CCG are currently working with NHSE and LMC to changes may exceed the premium services continue to be delivered in the interim until the plan is in discuss reinvestment of the PMS premium. and cause a financial pressure for place from April 2017.
the CCG. In addition, there may be Previous history has been archived. 28/02/2017
an issue around service continuity Previous history has been archived. 05/01/2017 31/01/2016 17:35
if practices choose to cease Head of Care Primary
services as a result of the review. Millar Lynn (CCG) SASCCG
192 The risk is the introduction of the New Models of Care – Failure to adequately quality impact assess No 4 3 12 27/11/2015 09:53:59 NS\Tracey.Revill - NS\Tracey.Revill 27/11/2015 09:53:59 - NS\whitfm 31/10/2016 14:01:23 - CSU providing a 4 3 12 Cannock Chase CCG;#Stafford & PAN Staffordshire Transformation Delivery;#Constitutional Standards current change programmes including, but This risk also incorporates risk 34 which has been closed on This risk also incorporates risk 34 which has been closed member of staff to lead on comms and engagement Surrounds CCG;#South East Staffordshire programme will dilute the focus of not limited to the STP work programes. 27.11.2015. on 27.11.2015. for the transformation programme. and Seisdon Peninsula CCG Comms and Engagement for local ;#106;#The CCG in conjunction with the PAN 27/11/2015 09:51:31 NS\Tracey.Revill - NS\Tracey.Revill 27/11/2015 09:51:31 - Comms and Engagement Committee. Failure to put CCGs Staffordshire programme is unable to deliver Working with three CCGs to share learning from Comms and Engagement lead from SES attended the QIPP Confirm suitable person in role of comms and engagement the pace of change required due to lack of Engagement. and Challenge event for QIPP schemes across the three lead.
understanding, capacity and organisational CCGs to develop robust engagement plans for each QIPP
12/12/2016 18/01/2017
boundaries/conflict.;#48 Previous history has been archived. scheme. Previous history has been archived. Officer Chief 07/08/2015 14:37
Previous history has been archived. Young Sally (CCG) SASCCG
3 Item: 11 Enc: 07
Cannock Chase Clinical Commissioning Group South East Staffordshire and Seisdon Peninsula Clinical Commissioning Group Stafford and Surrounds Clinical Commissioning Group
The healthiest place to live and work, by 2025
REPORT TO: The Stafford and Surrounds Clinical Commissioning Group Governing Body Meeting in PUBLIC TO BE HELD ON: Tuesday 28th March 2017
Subject: Finance Report Month 11 Board Lead: Paul Simpson – Director of Finance and Deputy Accountable Officer Officer Lead: Vicky Hilpert – Deputy Director of Finance Approval/ Recommendation: Assurance Discussion Information Ratification
PURPOSE OF THE REPORT:
To present to members the financial performance at month 11
KEY POINTS: Following discussions with the Executive Management team, NHS England have advised Stafford and Surrounds CCG to revise the forecast outturn to a deficit of £12.66m.
Financial risks are being managed across the three organisations (Stafford, Cannock and South East Staffs CCG’s). The revised forecast outturn requires the group to deliver additional identified mitigations of £16.6m
The revised forecast assumes that the CCG will fully deliver its proportion of the £16.6m mitigations identified by the Executive Management team.
CCG GOALS: Change the culture: Hospital to home Professional to patient More focus on prevention Involving everyone for improved health and care Empower and support patients to take control of their own health Services supporting people to make informed decisions
Page | 1 Item: 11 Enc: 07
IMPLICATIONS: Legal and/or Risk Failure of the CCG to achieve its financial duty. CQC NA Patient Safety NA Patient Engagement NA Must hit the control total and demonstrate that the CCG is sustainable Financial over the longer term. Sustainability See above Workforce/Training NA
RECOMMENDATIONS/ACTION REQUIRED: The Governing Body is asked to: Note the content of the report and discuss accordingly
Not KEY REQUIREMENTS Yes No Applicable Has a quality impact assessment been undertaken? Has an equality impact assessment been undertaken? Has a privacy impact assessment been completed? Has a comms & engagement impact assessment been completed? Have partners/public been involved in design? Are partners/public involved in implementation? Are partners/public involved in evaluation?
CCG VALUES We are honest, accessible and listen Care and respect for all Quality is our day job We innovate and deliver
Page | 2
Cannock Chase Clinical Commissioning Group South East Staffordshire and Seisdon Peninsula Clinical Commissioning Group Stafford and Surrounds Clinical Commissioning Group
The healthiest place to live and work, by 2025 REPORT TO: The Stafford and Surrounds Clinical Commissioning Group Governing Body Meeting in PUBLIC TO BE HELD ON: Tuesday 28th March 2017
Report To: Governing Body Report From: Paul Simpson, Director of Finance and Deputy Accountable Officer Report Author: Vicky Hilpert, Deputy Director of Finance Title: Finance Report Month 11 (1st February 2017 to 28th February 2017)
1.0 Introduction
1.1 The purpose of this report is to inform Governing Body Members of the CCG’s financial position as at the end of Month 11 (2016/17).
2.0 Financial Position
2.1 As the Governing Body will be aware, the Executive Management Team (EMT) have been in discussions with NHS England regarding the financial position of the CCG. As a result of these discussions, NHS England has advised the CCG to revise the forecast outturn to a deficit of £12.66m against a breakeven control total. The senior management team have had regular escalation meetings with NHSE to discuss the CCG’s in-year position, the plans for 17/18 and the development of a medium term financial recovery plan. 2.2 Governing Body members will also be aware that the financial risks are being managed across the three organisations (Stafford and Surrounds CCG, Cannock Chase CCG and South East Staffordshire and Seisdon Peninsula CCG). The revised forecast outturn requires the CCG group to deliver identified mitigations of £16.6m. 2.3 The revised out turn of £12.66m has been driven by significant in year cost pressures, notably in association with the acute position, continuing healthcare and prescribing).The cost pressures have been mitigated with the use of the CCG’s reserves and a proportion of the £16.6m mitigations identified by EMT.
3.0 Financial position to Month 11
3.1 Income and expenditure by services commissioned is shown in Table 1 with the detailed position provided in the Appendices.
Page | 1 of 8
Table 1 - Income and Expenditure by Service – Year to Date
Year to Date SaS
YTD YTD Budget YTD Variance Month 11 (February 17) Expenditure
£,000 £,000 £,000 Revenue Resource Allocation -155,423 -155,423 0
Expenditure Acute 86,422 89,120 2,698 Mental Health 13,983 14,384 401 Community 16,473 17,364 891 Prescribing 21,685 22,979 1,294 Primary Care Other 2,302 1,636 -666 Cont Care & FNC 15,598 17,795 2,197 Other -4,429 5,433 9,862 Total HCHS 152,035 168,712 16,677
Corporate/Running Costs 3,388 3,113 -275
Total Expenditure 155,423 171,825 16,402
Total In-Year Surplus / Deficit -0 16,402 16,402
3.2 The year to date position is a deficit of £16.4m. The acute overspend relates predominantly an over spend on UHNM (£612k) which is offset by an under spend against RWT of £645k. In addition, underachievement across the portfolio of QIPP savings throughout the year is driving the current contract wide portfolio position (£2.7m). Year end deals have now been agreed with UHNM, Rowley and Burton and have been reflected in the position above. Negotiations with RWT are ongoing. 3.3 The prescribing year to date position is an extrapolation of nine month’s data. This has been validated against the forecast outturn report from the Business Services Authority. 3.4 Continuing healthcare’s year to date position is overspent by £2.2m. This includes the nationally mandated 40% increase in funded nursing care costs, back dated to 1st April and the increase in prices charged by providers, due to the impact of the National Living Wage. A prior year benefit of £779k has been factored into the forecast outturn in month 11, but no adjustment has been made to the year to date position.
Page | 2 of 8
Table 2 - Income and Expenditure by Service – Forecast
Forecast Outturn SaS
Mitigations Variance for Analysis Reporting Budget Forecast Variance Month 11 (February 17) £,000 £,000 £,000 £,000 £,000 Revenue Resource Allocation -173,169 -173,169 00
Expenditure Acute 94,170 97,272 3,102 -173 2,928 Mental Health 15,316 15,747 431 -883 -452 Community 17,953 18,938 985 -75 911 Prescribing 23,656 25,055 1,399 -307 1,092 Primary Care Other 2,535 2,075 -461 -461 Cont Care & FNC 16,011 19,586 3,575 3,575 Other 193 3,824 3,631 1,438 5,069 Total HCHS 169,834 182,497 12,663 0 12,663
Corporate/Running Costs 3,335 3,332 -3 0 -3
Total Expenditure 173,169 185,829 12,660 0 12,660
Total In-Year Surplus / Deficit 0 12,660 12,660 0 12,660
3.5 The CCG is forecasting a deficit outturn of £12.7m. The revised forecast reflects both the under-delivery of the CCGs savings programme and a significant number of additional cost pressures that have materialised since the planning round. The Governing Body should note the majority of these cost pressures relate to nationally mandated requirement such as an increase of 40% to pay for FNC and the removal of contractual penalties. 3.6 The CCG corporate running costs are monitored separately within the Revenue Resource Limit (RRL). The budget shown below is greater than the running cost RRL as it includes the Safeguarding team which are classified as a clinical cost. The forecast position is a £3k underspend.
Table 3 - Running Costs
Forecast out turn SaS Corporate Running Costs Budget Expenditure Variance Acute £,000 £,000 £,000 Pay 1,420 1,400 -21 Non-Pay 630 731 101 CSU 1,236 1,199 -37 Income 0 -42 -42 Safeguarding 48 44 -4 Total Corporate Running Costs 3,335 3,332 -3
4.0 Revenue Resource Limit
Page | 3 of 8
4.1 The Revenue Resource Limit at Month 11 is £147.2m which includes the non recurrent impact of the prior year cumulative deficit of £26.0m.
Table 4 - Revenue Resource Limit
SaS Revenue Resource Limit Non‐ Total Recurrent Recurrent Resource Month Month 11 (February 17) Confirmed £000 £000 £000 Return of Surplus / (Deficit) ‐25,957 ‐25,957 Initial CCG Programme Allocation M02 168,275 168,275 Initial CCG Running Cost Allocation M02 3,188 3,188 Paediatric T&O Activity at UHNM M02 ‐43 ‐43 Eating Disorder Service Q1 M03 73 73 GP Support Team ‐ Pay Budget M03 259 259 GP Support Team ‐ Travel Budget M03 10 10 H&J Secondary Care M04 228 228 Specialised Wheelchairs M04 ‐12 ‐12 Health Visitors M04 ‐288 ‐288 Learning Disability Transformation funding to TCPs M04 139 139 Children Health Information Service Transfer M05 ‐103 ‐103 GP Development Programme ‐ reception and clerical training M05 13 13 Transfer to CCG ‐ GP Support Team Pay Budget ‐ Additional Cost M06 3 3 Transfer to CCG ‐ GP Support Team Pay Budget ‐ Additional Cost M07 20 20 Specialised Wheelchairs M07 86 86 Specialised Wheelchairs M07 5 5 CYP Local Transformation Mental Health M7 ‐ NHS Stafford and Surrounds CCG M07 31 31 NHS111 (IUC) Workforce Programme ‐ Early Adopters Backfill Funding M07 49 49 Mth08 CEOV adjustment M08 ‐215 ‐215 Quality Premium Awards 2015/16 M09 283 283 Winter Resilience Funding M10 385 385 MoD Out of Hours M10 9 9 Primary Care Investment M10 64 64 PC Investment Training in Redirecting Workflow M10 59 59 GP Support Team Expansion M10 270 270 Improving Access to General Practice M10 63 63 CYP WL & WT Reduction: 2nd tranche M10 31 31 Funding Transfer for IUC Evaluation Pilots ‐ Michelle Young M11 289 289 Total Month 11 171,380 ‐24,167 147,213
5.0 Contracting Position at Month 11
5.1 The position is based on contracting information to the end of January (Month 10) for the majority of contracts. 5.2 The Acute portfolio is currently forecast to overspend by £3.1m prior to mitigations of £0.2m. UHNM (£0.7m) and Rowley Hall (£0.1m) are the key drivers of the variance offset slightly by underperformance at Royal Wolverhampton (£0.7m). £2.7m of the remaining forecast overspend relates to underachievement across the portfolio of QIPP savings throughout the year. 5.3 Year end deals have been agreed with UHNM, Rowley Hall and Burton and the impact of these are included in the forecast above. Year end deal discussions are ongoing with RWT and Walsall. 5.4 The mental health contract portfolio has a £431k forecast overspend before mitigations. The majority of this overspend relates to cost and volume case management activity at SSSFT
Page | 4 of 8
(£242k forecast overspend on the contract) and prior year costs associated with Mind Drop-in Centres which the CCG is challenging (£178k). 5.5 The community contract portfolio is currently forecast to overspend by £985k before mitigations. The overspend is driven by cost and volume performance at SSOTP (£110k) and an overspend on the community dermatology and Audiology budget within the ‘Any Qualified Provider’ services.
6.0 Use of Reserves
6.1 The NHS England planning rules require the CCG to include two reserves in their plans.
0.5% Contingency which is available for CCGs to release to support the bottom line 1% headroom which CCGs are unable to commit without approval from NHSE to do so
6.1 To support the M11 forecast position the full 0.5% contingency has been released.
Table 5 - Reserves
SaS Balance Annual Committed Remaining Reserves Budget to forecast Reserves £000's £000's £000's 0.5% Contingency ‐857 857 0 1% Headroom ‐1,683 0 ‐1,683 2,540 857 ‐1,683
7.0 Recommendations
7.1 The Governing Body is asked to note that:
The CCG are forecasting to breach the agreed control total by £12.7m. The decision to move the forecast to a deficit position has been agreed with NHS England. That the senior management team have been having regular escalation meetings with NHSE to discuss the CCG’s in-year positon, plans for 17/18 and the development of a Medium Term FRP. The year to date position has seen a number of cost pressures emerging, notably in prescribing and continuing healthcare, which have been mitigated by the application of the CCG’s reserves and the CCG’s general contingency.
Page | 5 of 8
Appendix 1 – Acute Services
YTD Forecast Forecast Mitigations Variance for Stafford & Surrounds CCG Acute Providers Annual Budget YTD Budget YTD Variance Expenditure Expenditure Variance Analysis Reporting Month 11 (February 17) £,000 £,000 £,000 £,000 HEC £,000 £,000 £,000 £,000 University Hospital North Midlands NHS Trust 61,628 56,492 57,104 612 0 62,298 669 0 669 Royal Wolverhampton Hospitals NHS Trust 18,100 16,592 15,947 -645 0 17,404 -696 -160 -856 Heart of England NHS FT 193 177 121 -56 0 136 -58 -0 -58 Burton Hospitals NHS FT 334 306 301 -5 0 329 -5 0 -5 Walsall Healthcare NHS Trust 184 169 166 -3 0 178 -6 0 -6 Dudley Group of Hospitals NHS FT 161 148 141 -6 0 154 -7 -13 -20 University Hospitals of Birmingham NHS FT 748 685 711 26 0 772 24 24 Derby Teaching Hospitals NHS FT 112 102 146 44 0 159 47 47 Shrewsbury & Telford Hospitals NHS Trust 841 771 675 -96 0 736 -104 -104 Sandwell & West Birmingham NHS Trust 147 135 172 37 0 188 41 41 Royal Orthopaedic Hospital NHS FT 278 255 343 89 0 377 99 99 Birmingham Childrens Hospital NHS FT 253 232 238 6 0 256 3 3 University Hospital Coventry and Warwickshire NHS Trust 0 0 0 0 0 00 0 West Midlands Ambulance Services NHS FT 5,335 4,890 4,882 -8 0 5,362 28 0 28 Total Main Acute Providers 88,313 80,954 80,948 -6 88,349 35 -173 -138
Rowley Hall Hospital 5,231 4,796 4,902 107 0 5,347 116 0 116 Other acute - NHS -1,772 -1,444 836 2,281 0 913 2,685 0 2,685 Other acute - Non-NHS 2,398 2,117 2,433 316 0 2,663 265 265 Other acute 626 673 3,270 2,597 3,576 2,950 0 2,950 Total Acute 94,170 86,422 89,120 2,698 0 97,272 3,102 -173 2,928
Page | 6 of 8
Appendix 2 – Community and Mental Health Services
YTD Forecast Forecast Stafford & Surrounds Mental Health Providers Annual Budget YTD Budget YTD Variance Expenditure Expenditure Variance Month 11 (February 17) £,000 £,000 £,000 £,000 HEC £,000 £,000 South Staffordshire & Shropshire Healthcare NHS FT 13,282 12,175 12,313 138 0 13,434 152 Starfish Mental Health Services 801 735 735 -0 0 801 0 Midlands Psychology 236 216 216 0 0 236 0 North Staffordshire Combined Healthcare NHS Trust 249 241 281 40 0 307 58 Black County Partnership NHS FT 156 143 79 -64 0 84 -72 Birmingham & Solihull NHS FT 26 24 24 0 0 26 0 Dudley & Walsall MH Partnership NHS Trust 82 62 63 0 0 82 0 Derbyshire Healthcare NHS FT 70 64 64 0 0 70 0 Total Main Mental Health Providers 14,902 13,660 13,775 115 0 15,040 138 0 Other MH - NHS 0 0 -6 -6 0 -2 -2 Other MH - Non NHS 413 322 615 292 0 709 296 Total Mental Health - Pre Mitigations 15,316 13,983 14,384 401 0 15,747 431 Mitigations 00-883 -883 Total Mental Health - Post Mitigations 15,316 13,983 14,384 401 0 14,864 -452
Stafford & Surround CCG Group Community YTD Forecast Forecast Annual Budget YTD Budget YTD Variance Providers Expenditure Expenditure Variance Month 11 (February 17) £,000 £,000 £,000 £,000 HEC £,000 £,000 Staffordshire and Stoke on Trent Partnership NHS Trust 11,063 10,141 10,242 101 0 11,173 110 Staffordshire CC 4,341 3,979 4,012 32 0 4,376 35 Royal Wolverhampton Hospitals NHS Trust 162 149 157 9 0 172 9 Shropshire Community NHS Trust 44 40 37 -3 0 41 -3 Walsall Healthcare NHS Trust 684 627 627 0 0 684 0 Total Main Community Providers 16,294 14,936 15,075 139 0 16,445 152 0 Other community 1,659 1,537 2,289 751 2,493 834 Total Community - Pre Mitigations 17,953 16,473 17,364 891 0 18,938 985 Mitigations 00 -75 -75 Total Community - Post Mitigations 17,953 16,473 17,364 891 0 18,864 911
Page | 7 of 8
Appendix 3 – Continuing Healthcare
SaS Annual Budget 16,010,638 Forecast Outturn 19,585,965 YTD Budget 15,598,172 YTD Spend 17,795,476
The CHC budget is forecast to be overspent by £3.6m. This is partially driven by nationally mandated 40% price increases in funded nursing care, applied retrospectively from 1st Appril 2016 and the increase in care home prices driven by the National Living Wage uplift. This includes £0.78m prior year benefit released into the forecast position following a forensic review of prior year accruals by the CHC team. The NHS England plan included £1.9m of growth relating to CHC. This is being held separately in the CCG’s reserves; however, this has been fully released into the position as a mitigation.
Page | 8 of 8
Item: 12 Enc: 08
Cannock Chase Clinical Commissioning Group South East Staffordshire and Seisdon Peninsula Clinical Commissioning Group Stafford and Surrounds Clinical Commissioning Group
The healthiest place to live and work, by 2025
REPORT TO: The Stafford and Surrounds Clinical Commissioning Group Governing Body Meeting in PUBLIC TO BE HELD ON: Tuesday 28th March 2017
Subject: Performance Report Board Lead: Chris Bird, Director of Performance & Assurance Officer Lead: Ruth Yates, Head of Performance and Programmes Approval/ Recommendation: Assurance Discussion Information Ratification
PURPOSE OF THE REPORT: To share the key points of CCG delivery in respect of performance
KEY POINTS: There were 80 12 hour trolley breaches at UHNM. This is a signification reduction on previous months. The Urgent Care Workstream as part of STP is working with the provider to address. All 3 CCGs failed the 92% RTT Incomplete target achieving 90.08% (SaS), 90.68% (Cannock) and 91.91% (SES&SP). SaS have only achieved this target once in the last 6 months. This failure relates almost completely to breaches at UHNM; Mitigating actions to recover RTT and a recovery trajectory are included in a draft Remedial Action Plan. SES&SP failed after a period of achievement. Both Cannock and SES&SP had one MRSA case; at UHNM and HEFT respectively. HEFT: There is an MRSA RAP in place, with a weekly and monthly review of MRSA screening by IPCT are in place, in addition to this, one of the senior infection prevention and control nurses has re- launched the MRSA training package which will be compulsory for nursing staff during February and March 2017. SaS and SES&SP incurred 52 week+ waiters. SES&SP CCG, of which 2 x RoH & 1 x UHNM in General Surgery. SaS incurred 4 breaches apportioned to 1 x RoH & 3 x UHNM (2 x Gen Surgery; 1 x Urology) Diagnostics – All 3 CCGs failed the diagnostic target, with disparate providers attributing to each of the individual CCGs under performance. Over 50% of the breaches for SES&SP were MRI scanning at Dudley. The data is being reviewed. Driven by the high volumes witnessed across A&E, there were 10 Mixed Sex Accommodation Breaches for SES&SP. 3 x BHT, 3 x HEFT and 4 x Dudley. There were also 2 breaches for Cannock patients at Walsall. This relates to an ongoing step-down issue from critical care units Cancer performance overall remains a challenge, with poor performance witnessed. In particular there is a sustained non delivery of the 62 day standard None of the providers achieved the A&E target whereby patients should be admitted, transferred or discharged within 4 hours of their arrival at an A&E department, attributing to the CCGs overall performance. There are RAPs in place across all core providers to the CCGs SaS continues to witness WMAS over performance both in month and YTD; however, SES&SP witnessed a significant variance in January, over performing by 14.6%. This will be monitored.
Page | 1 Item: 12 Enc: 08
CCG GOALS: Change the culture: Hospital to home N/A Professional to patient More focus on prevention N/A Involving everyone for improved health and N/A care Empower and support patients to take control N/A of their own health Services supporting people to make informed N/A decisions
IMPLICATIONS: Risk of services not being delivered as per contracted levels of quality or Legal and/or Risk performance CQC None arising directly from this report Patient Safety None arising directly from this report Patient Engagement None arising directly from this report Financial Risks to delivery of CCG control total are being adequately mitigated Sustainability None arising directly from this report Workforce/Training None arising directly from this report
RECOMMENDATIONS/ACTION REQUIRED: The Governing Body is asked to: Note the contents of this report
Not KEY REQUIREMENTS Yes No Applicable Has a quality impact assessment been undertaken? Has an equality impact assessment been undertaken? Has a privacy impact assessment been completed? Has a comms & engagement impact assessment been completed? Have partners/public been involved in design? Are partners/public involved in implementation? Are partners/public involved in evaluation?
CCG VALUES We are honest, accessible and listen Care and respect for all Quality is our day job We innovate and deliver
Page | 2 Performance Report
January 2017
The healthiest place to live and work by 2025 Performance Overview
Current Financial Year 2016-17 There were 4 instances at Cdiff for Cannock Chase, of which 2 were apportioned to both UNHM and RWT. All 3 instances at SES&SP were incurred at HEFT. The futher Latest Data Month 10 instance for SaS was at UHNM. Both Cannock and SES&SP increased 1 x MRSA occurrence at UHNM and HEFT respectively. Report Month Mar 17
Stafford & Surrounds Rolling 12 Cannock Chase Rolling 12 South East Staffs & Seisdon Peninsula Rolling 12 Indicators Target 16/17 Months Trend / 16/17 Months Trend / 16/17 Months Trend / YTD Nov 16 Dec 16 Jan 17 Performance YTD Nov 16 Dec 16 Jan 17 Performance YTD Nov 16 Dec 16 Jan 17 Performance Healthcare Acquired Infections MRSA 0 0 0 0 0 3 1 0 1 6 1 1 1 C.difficile 59/48/47 27 5 3 1 36 2 1 4 40 2 6 3 Referral to Treatment Times RTT Admitted n/a 77.97% 79.73% 78.01% 79.89% n/a 80.24% 77.96% 80.55% 78.14% n/a 79.94% 75.96% 79.01% 80.59% n/a RTT Non-Admitted n/a 95.14% 94.93% 95.50% 94.88% n/a 94.71% 93.22% 95.41% 94.25% n/a 93.34% 93.55% 93.95% 94.57% n/a RTT incompletes 92% 91.74% 91.10% 90.35% 90.08% 92.19% 92.15% 90.76% 90.68% 92.38% 92.48% 92.01% 91.99% RTT 52 week + waiters 0 46 6 3 4 13 3 0 0 6 0 2 3 Diagnostic test waiting times Diagnostics 6 weeks + 99% 99.40% 99.32% 98.87% 98.94% 98.99% 98.64% 98.85% 98.89% 98.99% 99.38% 99.04% 98.78% Cancer waits Cancer 2 week wait 93% 92.48% 92.64% 92.53% 88.98% 94.23% 93.04% 94.37% 96.90% 94.84% 96.50% 95.99% 91.45% Cancer Breast Symptoms 2 week wait 93% 92.42% 86.67% 96.15% 90.00% 93.14% 95.83% 95.00% 92.31% 94.33% 93.42% 96.25% 96.70% Cancer 31 day first definitive treatment 96% 96.05% 93.94% 98.25% 92.19% 96.49% 96.23% 95.74% 95.00% 96.88% 92.98% 100.00% 95.31% Cancer 31 day subsequent treatment - surgery 94% 95.71% 90.48% 100.00% 100.00% 97.14% 100.00% 90.91% 90.00% 92.75% 90.48% 91.67% 91.30% Cancer 31 day subsequent treatment - drug 98% 100.00% 100.00% 100.00% 100.00% 98.84% 100.00% 100.00% 95.00% 98.80% 97.14% 90.91% 100.00% Cancer 31 day subsequent treatment - radiotherapy 94% 96.41% 100.00% 94.12% 96.43% 97.80% 100.00% 91.67% 100.00% 95.29% 97.06% 95.45% 100.00% Cancer 62 day standard 85% 78.19% 72.92% 72.22% 78.26% 71.80% 69.44% 70.00% 53.57% 82.05% 60.53% 80.95% 80.85% Cancer 62 day screening 90% 78.38% 100.00% 77.78% 75.00% 77.27% 50.00% 83.33% 83.33% 91.40% 100.00% 100.00% 100.00% Cancer 62 day upgrade 0% 96.48% 95.24% 100.00% 85.71% 88.46% 86.96% 95.24% 94.12% 91.95% 86.67% 100.00% 94.12% Ambulance Red 75% 64.13% 66.09% 60.16% 69.84% 64.46% 71.54% 57.05% 58.41% 57.75% 57.46% 52.06% 62.90% Mixed Sex Accommodation Breaches Mixed Sex Accommodation Breaches 0 1 0 0 0 7 1 1 2 26 2 8 10
16/17 16/17 16/17 YTD Nov 16 Dec 16 Jan 17 Rolling 12 YTD Nov 16 Dec 16 Jan 17 Rolling 12 YTD Nov 16 Dec 16 Jan 17 Rolling 12 Accident & Emergency - Provider Target Months Trend / Months Trend / Months Trend / UNIVERSITY HOSPITALS OF NORTH Performance THE ROYAL WOLVERHAMPTON NHS Performance THE DUDLEY GROUP NHS FOUNDATION Performance MIDLANDS NHS TRUST TRUST TRUST
A&E 4 Hour Target 95% 78.20% 75.97% 73.37% 75.31% 90.36% 92.24% 91.47% 86.48% 94.19% 91.97% 90.78% 87.70% 12 hour trolley breaches 0 590 233 178 80 0 0 0 0 4 0 0 4 HEART OF ENGLAND NHS FOUNDATION BURTON HOSPITALS NHS FOUNDATION WALSALL HEALTHCARE NHS TRUST TRUST TRUST A&E 4 Hour Target 95% 86.16% 85.45% 81.54% 77.14% 89.69% 91.48% 87.17% 87.35% 84.73% 81.17% 78.97% 75.65% 12 hour trolley breaches 0 3 0 0 0 3 2 0 0 2 0 0 2 Additional commentary
Current Financial Year 2016-17 Latest Data Month 10 Report Month Mar 17
Infection Control
There were 4 instances at Cdiff for Cannock Chase; 2 at UNHM and 2 at RWT. All 3 cases for SES&SP were at HEFT and the case for SaS was at UHNM. Both Cannock and SES&SP had one MRSA case; at UHNM and HEFT respectively. HEFT: There is an MRSA RAP in place, with a weekly and monthly review of MRSA screening by IPCT are in place, in addition to this, one of the senior infection prevention and control nurses has re-launched the MRSA training package which will be compulsory for nursing staff during February and March 2017.
Mixed Sex Accommodation Breaches
For the second consecutive month SES&SP had a high number of breaches. In January SES&SP has 10 breaches, of which 3 x BHT, 3 x HEFT and 4 x Dudley. HEFT at provider level incurred 5 EMSA's, of which 4 occurred whilst HEFT Good Hope site experience high volumes of patients through Emergency and AMU departments. Patients bedded down in triage as no available beds in hospital. Patients mixed in Day Surgery (flex area). Patient safety was not compromised. Patients were being nursed in a higher level of care than they required.
In January, Dudley had 26 EMSA at Trust level. All of these breaches have occurred due to the specific standard that patients who have spent a necessary period in high dependency areas who are then deemed ‘wardable’ i.e. are well enough to be transferred to a general ward are counted as a breach if they stay in the high dependency area more than four hours before transfer (e.g. in January: 11 MHDU, 4 ITU and 11 SHDU). It has to be stressed that none of these breaches are mixing patients of the opposite sex in general wards. It is clear therefore that these patients have not been exposed to any safety concerns. The breaches have all been due to capacity issues with the general wards being full and priority on safety grounds being given to incoming patients in the emergency department. All breaches at BHT were due to a lack of beds, which resulted in patients being retained in critical care. The issues of bed capacity are being addressed through the A&E RAP and the DTOC RAP.
Cannock Chase also had 2 EMSAs; both at Walsall. Bed capacity pressures continue to impact on the timely step down of patients from the critical care unit. The Lead CCG has now received a revised action plan and details of Q3 breaches following the meeting with the Trust on 2 February. A further meeting has been planned to jointly review the RCAs for these breaches to consider any further recommendations. The committee should be aware that until the new Intensive Critical Care Unit build is completed there remains the likelihood of further breaches albeit at levels lower than previously reported.
Trolley Breaches
UHNM have persistently high numbers of breaches. Whilst this information is not available at CCG level, it would be logical to assume, given the apportionment of activity that SaS, and other CCG cohorts will impacted on these breaches. A RAP was agreed on 13.01.17. STF applies, meaning that funds cannot be withheld. All milestones up to date, recurring issues have been identified and actions are in place. The actions are to be completed by the end of March 17. A&E Performance
BHFT HEFT WHCT Performance Trajectory Performance Trajectory Performance 95% 95% 95%
60% 60% 60% Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan 16 16 16 16 16 16 16 16 16 16 16 16 17 16 16 16 16 16 16 16 16 16 16 16 16 17 16 16 16 16 16 16 16 16 16 16 16 16 17
DGHFT RWT UHNM Performance Trajectory 95% 95% 95%
60% 60% 60% Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan 16 16 16 16 16 16 16 16 16 16 16 16 17 16 16 16 16 16 16 16 16 16 16 16 16 17 16 16 16 16 16 16 16 16 16 16 16 16 17
Comments:
None of our core providers achieved the 4 hour A&E target of 95%. A&E remains an ongoing pressure. Ongoing monitoring of performance across all providers is being undertaken from contract mechanisms, primarily Remedial Action Plans (RAPs). A&E RAPs are as follows:-
Burton – Revised RAP to be submitted to host commissioners and was agreed on 28th February 2017.
RWT – A RAP is currently in place. Commissioners are currently reviewing the RAP with a view to requesting further actions and assurance. The root cause of underperformance against the A&E 95% standard have been considered and discussed by the operational and clinical leads. Findings identified within the Emergency Care Intensive Support Team report have been re-visited to ensure implementation has been effective. In September 2016, RWT introduced joint triage between RWT and Vocare to the Urgent Care centre. It has been acknowledged that further improvements to signposting/triaging to Vocare is required. In addition to this, performance has been impacted by staffing shortages/recruitment issues. Daily information is shared with key managers across the Trust to advise on position.
UHNM – The RAP has been agreed following amendments being made at the request of commissioners for further assurances. Demand management strategies have been implemented over Q3, and continue to be implemented over Q4. Although not exhaustive, these include; ensuring that patients arriving with GP letter use the correct e ntry portals, ensuring the appropriateness of GP referrals, reviewing senior decision makers at the front door and increasing discharges completed earlier in the day. The RAPs continue to be monitored via CRB.
Dudley – Following a sustained period of achievement, this is the third consecutive time Dudley have failed the A&E target. In light o f this, a Contract Performance Notice has been issued by the host commissioner.
HEFT continues to fail the 4 hour target but the performance for M1-5 was greater than the RAP trajectory which is in line with the STF trajectory. Months 6, 7, 8 and 9 performance is below the RAP/STF trajectory. Therefore the RAP remains open. Attendances Trust-wide are running at 7.3% above the commissioned levels during January. The number of ambulance attendances to ED was 6039 during January 2017, compared to 5897 in December. Internally to cope with demand a number of processes have been put in place including red to green project. Also electives had been cancelled to cope with emergency demand. Two wards were also closed due to flu and c.diff which affected capacity An overnight resilience plan to be worked up for BHH and GHH.
Walsall – January’s performance declined to 75.65% from 78.97% in December resulting in a 17.35% gap from the monthly trajectory of 93. 0%. The A&E Delivery Board continues to monitor the delivery of the local improvement plan. This is consistent with the 5 national directives but has a more detailed set of actions specific to the Walsall system. Improvement plan is in place. RTT Performance
Latest Month : Jan 17 Year to Date
90.08% 90.68% 91.99% 91.74% 92.19% 92.38% 92% 92%
0% 0% SAS CC SESSP SAS CC SESSP
Notes on Charts below: % of Backlog - If this shows Red it means a fail for the month. Green triangle - better than previous month
% of % of % of Waiting List 18 Week Backlog Backlog Waiting List 18 Week Backlog Backlog Waiting List 18 Week Backlog Backlog Jan 16 8515 516 6.06% Jan 16 7201 411 5.71% Jan 16 12673 766 6.04% Feb 16 8683 563 6.48% Feb 16 7430 432 5.81% Feb 16 13122 788 6.01% Mar 16 9150 605 6.61% Mar 16 7920 470 5.93% Mar 16 13908 920 6.61% Apr 16 9062 622 6.86% Apr 16 7739 471 6.09% Apr 16 9262 641 6.92% May 16 8913 576 6.46% May 16 7534 475 6.30% May 16 9282 607 6.54% Jun 16 9385 692 7.37% Jun 16 7725 520 6.73% Jun 16 8085 609 7.53% Jul 16 9729 812 8.35% Jul 16 7975 585 7.34% Jul 16 8443 645 7.64% Aug 16 9927 860 8.66% Aug 16 8184 694 8.48% Aug 16 8571 645 7.53%
Sep 16 9395 741 7.89% Cannock Chase Sep 16 7698 602 7.82% Sep 16 8335 666 7.99%
Stafford & Surrounds Stafford Oct 16 9388 791 8.43% Oct 16 8301 715 8.61% Oct 16 8652 724 8.37%
Nov 16 9395 839 8.93% Nov 16 8534 671 7.86% East Staffs & South Seisdon Nov 16 13392 1007 7.52% Dec 16 9461 914 9.66% Dec 16 8407 777 9.24% Dec 16 13205 1057 8.00% Jan 17 9559 948 9.92% Jan 17 8297 773 9.32% Jan 17 12991 1041 8.01%
Comments:
All 3 CCGs failed the 92% target. SES&SP failed by 0.01%. All providers failed for CC cohort patients. This included; RWT (91.8%), UHNM (85.1%) and WHT (87.5%). Specialities of failure include General Surgery, Urology, T&O, Ophthalmology and ENT. At overall Trust level, none of these providers achieved the target, with all falling significantly below the threshold (RWT – 91%, UHNM – 86%) attributing to the under performance.
UHNM failed for the SaS cohort patients performing at 87.5%. Despite failing at overall Trust level, RWT achieved the target for SaS patients performing at 92.8%. Only Gynae, Dermatology, neurology, cardiology and geriatric medicine met the threshold for SaS patients. UHNM performed at 80% for both T&0 and Gen Surgery.
There were 3 instances of 52 week breahces SES&SP CCG, of which 2 x RoH & 1 x UHNM in General Surgery. SaS incurred 4 breaches apportioned to 1 x RoH & 3 x UHNM (2 x Gen Surg; 1 x Urology) The CCG doesn’t get the PTL for UHNM, due to PAS replacement. There is a CPN in place with UHNM, RAPs not agreed by commissioners; notification sent to governing body on 30.09.16. STF applies so funds cannot be withheld for failure to agree the RAP. CCGs did not want to go to dispute for this matter. Commissioners agreed to postpone further discussion until the implementation of Medway; however, a meeting is planned to discuss RTT and 52 weeks w/c 13.03.17 Diagnostic Performance
Number of 6 week diagnostic breaches by type and provider
UHNM BHFT RWT HEFT DGHFT WHCT OTHER TOTAL SAS CC SES&SP SAS CC SES&SP SAS CC SES&SP SAS CC SES&SP SAS CC SES&SP SAS CC SES&SP SAS CC SES&SP SAS CC SES&SP Total Colonoscopy 4 1 0 0 0 0 0 0 0 0 0 2 0 0 0 0 0 0 0 0 0 4 1 2 7 Cystoscopy 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Endoscopy Flexi sigmoidoscopy 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 1 Gastroscopy 3 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 3 1 2 6 Endoscopy Total 7 2 1 0 0 0 0 0 0 0 0 2 0 0 0 0 1 1 0 0 0 7 3 4 14 Barium Enema 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Computed Tomography 0 0 0 0 0 0 6 0 2 0 0 0 0 0 0 0 0 0 1 1 0 7 1 2 10 Imaging DEXA Scan 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 1 1 Magnetic Resonance Imaging 0 0 0 0 0 0 1 5 4 0 0 0 0 0 1 0 0 0 0 0 4 1 5 9 15 Non-obstetric ultrasound 0 0 0 0 0 0 0 0 0 0 0 0 0 0 16 0 0 0 2 0 0 2 0 16 18 Imaging Total 0 0 0 0 0 0 7 5 6 0 0 0 0 0 18 0 0 0 3 1 4 10 6 28 44 Audiology - Audiology Assessments 1 4 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 4 0 5 Cardiology - echocardiography 0 0 0 0 0 1 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 2 2 Physiological Cardiology - electrophysiology 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Measurements Neurophysiology - peripheral neurophysiology 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Respiratory physiology - sleep studies 3 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 3 1 0 4 Urodynamics - pressures & flows 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 2 1 0 2 3 Physiological Measurements Total 4 5 0 0 0 1 0 0 0 0 0 0 0 0 1 0 0 0 1 0 2 5 5 4 14 Grand Total 11 7 1 0 0 1 7 5 6 0 0 2 0 0 19 0 1 1 4 1 6 22 14 36 72
Comments: SaS 99%
Overall: 22 breaches out of 2,079 = 98.94%. RWT's is the only core provider to fail the threshold.
UHNM met the target for SaS cohort – 99.35% (11 breaches out of 1,703). A CPN was initally issued in June 2016, but was subsequently withdrawn. There is no CPN in place at
UHNM. SAS
99.92%
99.76%
99.68% 99.66%
99.57% 99.52% 99.50%
99.32%
99.26%
98.87% 98.94% 98.61% RWT – Failed for SaS cohort of patients, incurring 7 breaches out of a total of 224 activity - 96.88%, of which 6 breaches related to CT Scans. Diagnostics at RWT provider level 98.49% saw a slight improvement during January, however, the main issue relates to cancelled and reduced capacity available for MRI and CT sessions. Work is on-going throughout February to ensure additional capacity is provided. RWT have failed this target for the previous 3 months. 0% Jan 16 Feb 16 Mar 16 Apr 16 May 16 Jun 16 Jul 16 Aug 16 Sep 16 Oct 16 Nov 16 Dec 16 Jan 17 The further 4 breaches in the 6 week target were at:- Global Diagnostics (Norwich) x 2 Ramsey Healthcare x 1 99%
University Hospital Birmingham x 1
Cannock
CC
99.65%
99.53%
99.36%
99.27%
99.22% 99.16%
99.11%
98.90% 98.85% 98.89%
98.81% 98.76% Cannock failed the target for the fourth consecutive month. 98.64% Overall: 14 breaches out of 1249 = 98.9%. UHNM for CC cohort - 97.91%% (7 breaches out of 335), of which 4 were in audiology 0% RWT (5 breaches out of 735) - 99.32%%, of which 5 were in MRI Jan 16 Feb 16 Mar 16 Apr 16 May 16 Jun 16 Jul 16 Aug 16 Sep 16 Oct 16 Nov 16 Dec 16 Jan 17 Walsall (1 breach out of 34) –97.06% (This breach was solely in Gastrology)
50% (7 out of 14) of the total number of breaches were witnessed at UHNM, with all core providers failing the target for the CC cohort of patients. Audiology encountered 4 99%
breaches.
SES&SP
SESSP
99.48%
99.41% 99.38%
99.18%
99.04% 99.05%
98.93%
98.91% 98.90%
98.78%
98.67% 98.68% SES&SP CCG failed the target after 2 months of consecutive achievement. Of the 36 breaches, over 50% 19 breaches were attributed to Dudley, of which 16 were apportioned to 97.88% MRI scanning. A CPN is place for Diagnostics at Dudley. The Lead Commissioner is already in discussion with DGFT and are aware of a view that they are unlikely to reach recovery until April 2017. Noteworthy, this quality requirement is subject to the sanction suspension by NHSI and NHSE. Further information from the host commissioner has 0% been sought on the root cause of breaches in January. Jan 16 Feb 16 Mar 16 Apr 16 May 16 Jun 16 Jul 16 Aug 16 Sep 16 Oct 16 Nov 16 Dec 16 Jan 17 Cancer Performance Performance Trend (rolling 13 months) and Current Breaches Note: Breaches for only the main providers for each CCG are shown, therefore Total may be higher than the sum of these YTD Current Pass Current Fail Target 100% 05V00 05V00 05V00 Trend Breaches (Jan 17) RJE RL4 Total 75% Cancer 2 week wait 50 6 56 Cancer Breast Symptoms 2 week wait 3 3 50% Cancer 31 day first definitive treatment 5 5 Cancer 31 day subsequent treatment - surgery 25% Cancer 31 day subsequent treatment - drug
Stafford & Surrounds Stafford 0% Cancer 31 day subsequent treatment - radiotherapy 1 1 Cancer 2 week Cancer Breast Cancer 31 day Cancer 31 day Cancer 31 day Cancer 31 day Cancer 62 day Cancer 62 day Cancer 62 day Cancer 62 day standard 8 2 10 wait Symptoms 2 week first definitive subsequent subsequent subsequent standard screening upgrade wait treatment treatment - treatment - drug treatment - Cancer 62 day screening 1 1 surgery radiotherapy Cancer 62 day upgrade 2 2
YTD Current Pass Current Fail Target 100% 04Y00 04Y00 04Y00 04Y00 Trend Breaches (Jan 17) RJE RL4 RBK Total 75% Cancer 2 week wait 4 5 2 11 Cancer Breast Symptoms 2 week wait 1 1 3 50% Cancer 31 day first definitive treatment 2 2 Cancer 31 day subsequent treatment - surgery 1 1 25%
Cannock Cannock Chase Cancer 31 day subsequent treatment - drug 0% Cancer 31 day subsequent treatment - radiotherapy Cancer 2 week Cancer Breast Cancer 31 day Cancer 31 day Cancer 31 day Cancer 31 day Cancer 62 day Cancer 62 day Cancer 62 day Cancer 62 day standard 6 6 1 13 wait Symptoms 2 first definitive subsequent subsequent subsequent standard screening upgrade week wait treatment treatment - treatment - treatment - Cancer 62 day screening 1 1 surgery drug radiotherapy Cancer 62 day upgrade 1 1
YTD Current Pass Current Fail Target 100% 05Q00 05Q00 05Q00 05Q00 05Q00 Trend Breaches (Jan 17) RL4 RJF RNA RR1 Total 75% Cancer 2 week wait 2 27 6 12 47 Cancer Breast Symptoms 2 week wait 2 1 3 50% Cancer 31 day first definitive treatment 1 1 2 Cancer 31 day subsequent treatment - surgery 1 1 2 25% Cancer 31 day subsequent treatment - drug
0% Cancer 31 day subsequent treatment - radiotherapy Cancer 2 week Cancer Breast Cancer 31 day Cancer 31 day Cancer 31 day Cancer 31 day Cancer 62 day Cancer 62 day Cancer 62 day South East Staffs & South Seisdon Cancer 62 day standard 2 1 1 1 5 wait Symptoms 2 week first definitive subsequent subsequent subsequent standard screening upgrade wait treatment treatment - treatment - drug treatment - Cancer 62 day screening surgery radiotherapy Cancer 62 day upgrade 1 1 Comment: Cannock Chase CCG 2ww (Breast) – 3 breaches out of 39 = 92.31%. In total there were 3 breaches, which occurred at: 1 x RWT, 1 x HEFT, 1 x UHNM. 62 Day – 53.57% - The maximum number of breaches to achieve target:4. Actually incurred: 13, thus failing by 9 patients. This was predominantly c aused by an under performance at RWT and UHNM. With a further under performance at WHT. RWT - for the levels of activity meant that the threshold would have allowed CC to have 3 patients breach; however 6 patients breac hed, meaning this was 3 more than the limit. Applying this logic to UHNM, UHNM activity allowed for 1 breach, but incurred 6 for CC patients. UHNM only achieved 14.39% (6 breaches out of 7) for CC patients. RWT 68.42% (6 breaches out of 19). The further breach was at Wal sall. No provider achieved the 62 day target for CC patients. SES&SP 2ww - 47 breaches out of 550 activity – 91.45% against 93% target. 7 specialities fell below the 96% target. Including: Lower GI, urological, Gynae, Lung, Upper GI, Head and Neck and Urological. HEFT and Burton failed for SES&SP cohort of patients achieving 93.33% and 86.43% respectively. Contextualised, of the 47 breaches, 27 occurred at BHT and 12 at HEFT attributing to the underperformance at SES&SP. 31 day subsequent Surgery – there we 2 breaches out of 23. There was 1 breach each at BHT (80%) and RWT (80%). Due to the small activity levels in order to meet this target, only 1 breach was permitted to achieve the threshold. 62 Day – 80.09% (9 breaches out of 47) Despite a CPN being in place at BHT, with the exception of BHT, all core providers failed the requirement for SES&SP cohorts of patients. RWT (81.82%), HEFT (57.50), Derby (50.00%), Dudley (66.67%). Based on the activity, the threshold allowed for 7 breaches, but overall incurred 9. This meant SES&SP had 2 more breaches than the activity would have permitted. There is a C PN in place at RWT, with a known issue with receiving late tertiary referrals from Dudley. There is also a RAP in place at HEFT and Burton. Stafford & Surrrounds 2ww – 56 breaches out of 508, equating to 88.98%. Contextualised 50 breaches incurred at UHNM (88.37% for SaS patients). RWT achieved 92.21%, and incurred 6 breaches out of 77. SaS incurred 26 more breaches than the activity permitted, of which, when apportioned to provider, this equates to 25 at UHNM, meaning the root of the underperformance at SaS predominantly resid ed at UHNM. 2ww Breast – the only breaches incurred resided at UHNM (3 breaches). UHNM performed at 86.96% for SaS patients. RWT achieved 100%. The activity volumes meant in order to achieve the target only 1 breach was permitted. Therefore there were 2 more breaches than the activity allowed. BHT Update: - Breast Surgery – concerns over possible gap in service provision with symptomatic service to transfer from UNHM to Royal Derby. Immediate problems appear to have been addressed. RAP to be submitted 17/03. 31 day First Definitive - 2 breaches out of 64 activity – 92.19% against 93%. RWT achieved for SaS patients (100%). The only provider to fail for SaS was UHNM, achieving 90.20% (5 breaches out of 51) For UHNM 31 day. JI ToR meeting scheduled for 16.02.17 but UHNM did not attend. Commissioners agreed to allow until 06.03.17 to agree JI TOR but UHNM still not agreed. Options to be given at UHNM Pre-CRB on withholding funds for failure to agree RAP. STF does not apply funds can be withheld. 62 day – overall SaS incurred 10 breaches out of 46 activity. Both RWT and UHNM failed for SaS patients, achieving 81.82% and 77.14% respectively. UHNM 62 day - UHNM has accepted STF and thus fines and penalties that are now applicable to this contract are yet to be finalised. For 62 days a CPN was issued and a remedial action plan has been implemented and agreed by ommissioners in October 2016. However, UHNM are not achieving the trajectory. Discussions taking place re. next steps for this performance notice at Pre-CRB 09.03.17. UHNM: Clinical/directorate management teams are continuing to carve out additional surgical capacity for cancer to ensure further improvement in performance. Additional capacity is being sourced at the County site. Daily cancer PTL meetings are taking place; in attendance are the DADs, members of the cancer services team and directorate management teams. Each individual patient’s pathway is discussed; updates and actions to mitigate delays are agreed. WMAS Performance
Latest Month Latest Month SAS CC SESSP 05V00 04Y00 05Q00 Other Latest Month YTD Latest Month YTD Latest Month YTD 75% 75% Activity 2,232 22,438 2,155 20,532 3,563 31,664 Plan 2,096 20,237 2,039 19,685 3,109 30,011 Variance 136 2,201 116 847 454 1,653 Var % 6.49% 10.88% 5.69% 4.30% 14.60% 5.51%
69.8% Latest month: Actual vs Planned Activity % 58.4% 62.9% 75%
0%
50%
05J00
05L00
05F00
05Y00 05T00 04Y00
13P00 05P00
04X00 05X00
05C00
05R00
05V00
05A00 06A00
05D00 06D00
05H00
05G00 05N00
0% 05Q00 05W00 05V00 04Y00 05Q00 25% 14.60% 6.49% 5.69% Year to Date Year to Date 0% SAS CC SESSP 05V00 04Y00 05Q00 Other
75% 75% YTD: Actual vs Planned Activity %
45% 35% 25% 10.88% 64.1% 64.5% 15% 57.8% 4.30% 5.51% 5% -5% 0% -15%
SAS CC SESSP
05J00 05L00
0% 05F00
05Y00 05T00 04Y00
13P00 05X00 04X00 05P00
05C00
05R00
05V00
06A00 05A00
05D00 06D00
05H00
05G00
05N00 05Q00 05V00 04Y00 05Q00 05W00
Comments:
All of the 3 CCGs activity was over plan incurring the following over . In previous months, SaS has been the outlier of commissioenrs; however, in January SES&SP over performed by 14.60%. YTD SaS is still performing significantly above plan. The WMAS KPIs have been subjected to a national pilot. Version 2.2 went live 12/10/2016; following the identification of the initial pilot that further refining to the nature of call and required disposition was required to ensure the target is challenging to the provider, yet achievable. This amended the classification of incidents from Red, Amber and Green to Categories 1 to 4:
Category 1 = Red (8 minute response) Category 2 = Amber (indicative 19 minute response) Category 3 = Amber (indicative 40 minute response) Category 4 = Greens (indicative 90 minute response) The outcome of ARP Version 2.2 is being presented at WMAS CQRM 1st March 2017
N.B. ‘YTD actual’ includes assigned incidents (Out of Area and/or recorded without CCG code cases) that have retrospectively been identified against a CCG and/or have been proportionally distributed against/across all CCGs The Dudley Group of Hospitals NHS Foundation Trust DGHFT RNA Current Financial Year 2016-17 Benchmarking Charts Key: Latest Data Month 10 5th and 95th Percentile Ranges Latest Quarter Data Q4 16-17 Upper Quartile Range Report Month Mar 17 Lower Quartile Range
Cancer Waits (Quarterly) Referral To Treatment (Incompletes) HCAI Breaches
Provider Benchmarking - latest quarter position Provider Benchmarking - latest month position C.Difficile MRSA [Source: NHSE Quarterly Cancer Published Data] [Source: NHSE RTT Published Data] Total YTD Total YTD Cancer Indicators RTT Incompletes 30 0
100% 100% Latest Month Latest Month 98% 99% 96% 2 0
95% 90% 94% 86% Mixed Sex Accommodation Breaches 90% 80% Total YTD Latest Month
85% 54 26 70%
Provider Performance Diagnostics 60%
Latest Month Overall 50% Cancer Two Week Wait Cancer Breast Symptoms Two Week Cancer 31 Day First Definitive Cancer 62 Day First Definitive Overall 100% Wait Treatment Treatment 99% 92.24% 98% 97% Actual Values Latest Period (green indicator shows performance improvement on previous period) Endoscopy 96% 95% 99.5% 99.5% 99.4% Cancer 31 Day Cancer 31 Day Cancer 31 Day Cancer 62 Day Cancer 62 Day 99.0% 99.2% 99.0% 98.6% Cancer Breast Cancer 31 Day Cancer 62 Day 99.49% 94% 98.0% 97.7% 98.1% Cancer Two Subsequent Subsequent Subsequent First Definitive First Definitive 97.4% Symptoms Two First Definitive First Definitive 93% Week Wait Treatment - Treatment - Treatment - Treatment - Treatment - Week Wait Treatment Treatment Imaging Drugs Radiotherapy Surgery NHS Screening Upgrade 92% 93.5% 91% 92.2%
Provider Target 93% 93% 96% 98% 94% 94% 85% 90% 0% 91.12% 90%
Jul 16 Jul Jan 16 Jan
Total Physiological 17 Jan Jun 16 Jun
DGHFT 3,289 393 460 58 1 73 227 36 160 16 Oct
Apr16
Sep 16 Sep Feb 16 Feb
Dec 16 Dec
Aug 16 Aug
Nov 16 Nov
Mar 16 Mar May 16 May DGHFTDGHFT Breaches 137 9 6 0 0 1 33 0 5 94.42% DGHFT Target England DGHFT Performance 96% 98% 99% 100% 100% 99% 86% 100% 97%
Accident & Emergency DTOC (Delayed Days) Latest Month YTD Year to Date A&E Performance (Types 1-3) Attends DGHFT % 4 Hours Target Average Monthly Days Delayed (NHS Responsible) Days delayed divided by days in month 4 Hour 100% 18,000 Total 14,090 Responsible % 95% 16,000 87.70% 94.19% 96.3% 96.8% 95.8% 95.4% 95.6% 96.1% 96.2% 95.8% 95.3% 95.5% NHS 43% 90% 14,000 32.07
92.0%
Trolley Breaches Social Care 51% 90.8% 12,000 85% 87.7% Both 6% 4 4 10,000 23.35 22.77 80% 22.16 8,000 18.58 Latest Month 17.84 17.40
75% 16.06 16.16 Attendances Performance 6,000 14.87 14.55 70% 12.62 Trust Performance vs. England (13 Months) 4,000 Total 1,350 10.58 65% 2,000 Responsible % 60% 0 NHS 43%
Social Care 50%
Jul 16 Jul 16 Jul
Jan 16 Jan 17 Jan 16 Jan Jan 17 Jan
Jun 16 Jun Jun 16 Jun
Oct 16 Oct 16 Oct
Apr 16 Apr Apr16
Sep 16 Sep 16 Sep Feb 16 Feb 16 Feb
Dec 16 Dec 16 Dec
Aug 16 Aug 16 Aug
Nov 16 Nov 16 Nov
Mar 16 Mar 16 Mar May 16 May Both 7% 16 May Heart of England NHS Foundation Trust HEFT RR1 Current Financial Year 2016-17 Benchmarking Charts Key: Latest Data Month 10 5th and 95th Percentile Ranges Latest Quarter Data Q4 16-17 Upper Quartile Range Report Month Mar 17 Lower Quartile Range
Cancer Waits (Quarterly) Referral To Treatment (Incompletes) HCAI Breaches
Provider Benchmarking - latest quarter position Provider Benchmarking - latest month position C.Difficile MRSA [Source: NHSE Quarterly Cancer Published Data] [Source: NHSE RTT Published Data] Total YTD Total YTD Cancer Indicators RTT Incompletes 67 7
100% Latest Month Latest Month 100% 99% 97% 96% 10 2
90% 91% 95% 92% Mixed Sex Accommodation Breaches 90% 80% Total YTD Latest Month
85% 40 20 70%
Provider Performance Diagnostics 60%
Latest Month Overall 50% Cancer Two Week Wait Cancer Breast Symptoms Two Week Cancer 31 Day First Definitive Cancer 62 Day First Definitive Overall 100% Wait Treatment Treatment 99% 99.72% 98% 97% Actual Values Latest Period (green indicator shows performance improvement on previous period) Endoscopy 96%
95% 99.4% 99.7% 99.8% 99.8% 99.8% 99.9% 99.7% 99.7% 99.7% Cancer 31 Day Cancer 31 Day Cancer 31 Day Cancer 62 Day Cancer 62 Day 99.2% 99.3% 99.2% Cancer Breast Cancer 31 Day Cancer 62 Day 98.98% 94% Cancer Two Subsequent Subsequent Subsequent First Definitive First Definitive 96.9% Symptoms Two First Definitive First Definitive 93% Week Wait Treatment - Treatment - Treatment - Treatment - Treatment - Week Wait Treatment Treatment Imaging Drugs Radiotherapy Surgery NHS Screening Upgrade 92% 91%
Provider Target 93% 93% 96% 98% 94% 94% 85% 90% 0% 99.95% 90%
Jul 16 Jul Jan 16 Jan
Total Physiological 17 Jan Jun 16 Jun
HEFT 6,549 834 884 223 2 206 433 14 110 16 Oct
Apr16
Sep 16 Sep Feb16
Dec 16 Dec
Aug 16 Aug
Nov 16 Nov
Mar 16 Mar May 16 May HEFTHEFT Breaches 221 30 5 0 0 2 37 1 14 98.71% HEFT Target England HEFT Performance 97% 96% 99% 100% 100% 99% 91% 96% 87%
Latest Month YTD Year to Date A&E Performance (Types 1-3) Attends HEFT % 4 Hours Target Average Monthly Days Delayed (NHS Responsible) Days delayed divided by days in month 4 Hour 100% 30,000 Total 15,169 Responsible % 95% 77.14% 86.16% 25,000 NHS 42% 27.61 90%
92.1% 25.74
Trolley Breaches Social Care 54% 24.33 89.4% 20,000 23.14 85% 87.9% 88.4% 22.23 86.8% 86.8% Both 5% 21.52 21.35 86.1% 85.4% 20.30 20.71 0 3 84.4% 85.1% 85.1% 19.55 80% 15,000 18.03 81.5% 16.50 Latest Month 15.19
75% 77.1% Attendances Performance 10,000 70% Trust Performance vs. England (13 Months) Total 1,573 5,000 65% Responsible % 60% 0 NHS 39%
Social Care 58%
Jul 16 Jul 16 Jul
Jan 16 Jan 17 Jan 16 Jan Jan 17 Jan
Jun 16 Jun Jun 16 Jun
Oct 16 Oct 16 Oct
Apr 16 Apr Apr 16 Apr
Sep 16 Sep 16 Sep Feb 16 Feb 16 Feb
Dec 16 Dec 16 Dec
Aug 16 Aug 16 Aug
Nov 16 Nov 16 Nov
Mar 16 Mar 16 Mar May 16 May Both 4% 16 May The Royal Wolverhampton NHS Trust RWHT RL4 Current Financial Year 2016-17 Benchmarking Charts Key: Latest Data Month 10 5th and 95th Percentile Ranges Latest Quarter Data Q4 16-17 Upper Quartile Range Report Month Mar 17 Lower Quartile Range
Cancer Waits (Quarterly) Referral To Treatment (Incompletes) HCAI Breaches
Provider Benchmarking - latest quarter position Provider Benchmarking - latest month position C.Difficile MRSA [Source: NHSE Quarterly Cancer Published Data] [Source: NHSE RTT Published Data] Total YTD Total YTD Cancer Indicators RTT Incompletes 41 0
100% 100% Latest Month Latest Month 96% 96% 94% 1 0
90% 95%
Mixed Sex Accommodation Breaches 90% 91% 80% Total YTD Latest Month
73% 85% 4 0 70%
Provider Performance Diagnostics 60%
Latest Month Overall 50% Cancer Two Week Wait Cancer Breast Symptoms Two Week Cancer 31 Day First Definitive Cancer 62 Day First Definitive Overall 100% Wait Treatment Treatment 99% 98.75% 98% 97% Actual Values Latest Period (green indicator shows performance improvement on previous period) Endoscopy 96%
95% 100.0% 100.0% 100.0% 99.4% Cancer 31 Day Cancer 31 Day Cancer 31 Day Cancer 62 Day Cancer 62 Day 99.2% 99.2% 99.0% 99.2% 99.0% 99.1% 98.7% 98.8% Cancer Breast Cancer 31 Day Cancer 62 Day 100.00% 94% Cancer Two Subsequent Subsequent Subsequent First Definitive First Definitive 97.6% Symptoms Two First Definitive First Definitive 93% Week Wait Treatment - Treatment - Treatment - Treatment - Treatment - Week Wait Treatment Treatment Imaging Drugs Radiotherapy Surgery NHS Screening Upgrade 92% 91%
Provider Target 93% 93% 96% 98% 94% 94% 85% 90% 0% 98.01% 90%
Jul 16 Jul Jan 16 Jan
Total Physiological 17 Jan Jun 16 Jun
RWT 3,494 589 622 168 350 135 258 35 214 16 Oct
Apr16
Sep 16 Sep Feb 16 Feb
Dec 16 Dec
Aug 16 Aug
Nov 16 Nov
Mar 16 Mar May 16 May RWTRWHT Breaches 223 21 22 1 7 20 69 4 21 100.00% RWHT Target England RWT Performance 94% 96% 96% 99% 98% 85% 73% 88% 90%
Accident & Emergency DTOC (Delayed Days) Latest Month YTD Year to Date A&E Performance (Types 1-3) Attends RWHT % 4 Hours Target Average Monthly Days Delayed (NHS Responsible) Days delayed divided by days in month 4 Hour 100% 25,000 Total 13,436 Responsible % 86.48% 90.36% 95% 20,000 NHS 28% 16.84 90% 93.9% 91.6% 92.3% 92.2%
91.5% Trolley Breaches 90.3% Social Care 66% 14.80 89.3% 89.4% 14.17 85% 88.3% 88.6% 88.2% 13.87 15,000 Both 6% 12.97 13.13 86.5% 12.26 12.23 0 0 85.4% 11.71 80% 10.39 10,000 Latest Month 9.59 9.29
75% 8.06
Attendances Performance 70% Trust Performance vs. England (13 Months) 5,000 Total 1,264 65% Responsible % 60% 0 NHS 29%
Social Care 66%
Jul 16 Jul 16 Jul
Jan 16 Jan 17 Jan 16 Jan Jan 17 Jan
Jun 16 Jun Jun 16 Jun
Oct 16 Oct 16 Oct
Apr 16 Apr Apr16
Sep 16 Sep 16 Sep Feb 16 Feb 16 Feb
Dec 16 Dec 16 Dec
Aug 16 Aug 16 Aug
Nov 16 Nov 16 Nov
Mar 16 Mar 16 Mar May 16 May Both 5% 16 May University Hospitals of North Midlands NHS Trust UHNM RJE Current Financial Year 2016-17 Benchmarking Charts Key: Latest Data Month 10 5th and 95th Percentile Ranges Latest Quarter Data Q4 16-17 Upper Quartile Range Report Month Mar 17 Lower Quartile Range
Cancer Waits (Quarterly) Referral To Treatment (Incompletes) HCAI Breaches
Provider Benchmarking - latest quarter position Provider Benchmarking - latest month position C.Difficile MRSA [Source: NHSE Quarterly Cancer Published Data] [Source: NHSE RTT Published Data] Total YTD Total YTD Cancer Indicators RTT Incompletes 80 2
100% 100% Latest Month Latest Month 95% 94% 94% 5 1
90% 95%
Mixed Sex Accommodation Breaches 90% 80% Total YTD Latest Month 86% 85% 0 0 70% 68%
Provider Performance Diagnostics 60%
Latest Month Overall 50% Cancer Two Week Wait Cancer Breast Symptoms Two Week Cancer 31 Day First Definitive Cancer 62 Day First Definitive Overall 100% Wait Treatment Treatment 99% 99.61% 98% 97% Actual Values Latest Period (green indicator shows performance improvement on previous period) Endoscopy 96%
95% 99.6% 99.5% 99.7% 99.8% 99.9% 99.9% 99.5% 99.6% 99.5% 99.6% 99.6% Cancer 31 Day Cancer 31 Day Cancer 31 Day Cancer 62 Day Cancer 62 Day Cancer Breast Cancer 31 Day Cancer 62 Day 98.28% 94% 98.3% Cancer Two Subsequent Subsequent Subsequent First Definitive First Definitive 96.8% Symptoms Two First Definitive First Definitive 93% Week Wait Treatment - Treatment - Treatment - Treatment - Treatment - Week Wait Treatment Treatment Imaging Drugs Radiotherapy Surgery NHS Screening Upgrade 92% 91%
Provider Target 93% 93% 96% 98% 94% 94% 85% 90% 0% 99.96% 90%
Jul 16 Jul Jan 16 Jan
Total Physiological 17 Jan Jun 16 Jun
UHNM 6,385 269 950 223 346 161 499 112 240 16 Oct
Apr16
Sep 16 Sep Feb 16 Feb
Dec 16 Dec
Aug 16 Aug
Nov 16 Nov
Mar 16 Mar May 16 May UHNMUHNM Breaches 414 17 47 6 14 11 161 22 13 99.15% UHNM Target England UHNM Performance 94% 94% 95% 97% 96% 93% 68% 80% 95%
Accident & Emergency DTOC (Delayed Days) Latest Month YTD Year to Date A&E Performance (Types 1-3) Attends UHNM % 4 Hours Target Average Monthly Days Delayed (NHS Responsible) Days delayed divided by days in month 4 Hour 100% 25,000 Total 26,125 Responsible % 75.31% 78.20% 95% 20,000 NHS 58%
90% 71.00
Trolley Breaches Social Care 27% 66.73 85% 15,000 Both 15% 80 590 53.29 52.35 80% 83.6% 46.65 46.58 79.9% 79.5% 79.4% 41.93 75% 78.8% 79.3% 10,000 Latest Month 39.31 39.07 39.39
77.7% 37.03 35.77 Attendances Performance 76.7% 76.5% 75.6% 76.0% 75.3% 70% 73.4% Trust Performance vs. England (13 Months) 5,000 Total 2,225 24.13 65% Responsible % 60% 0 NHS 73%
Social Care 25%
Jul 16 Jul 16 Jul
Jan 16 Jan 17 Jan 16 Jan Jan 17 Jan
Jun 16 Jun Jun 16 Jun
Oct 16 Oct 16 Oct
Apr 16 Apr Apr16
Sep 16 Sep 16 Sep Feb 16 Feb 16 Feb
Dec 16 Dec 16 Dec
Aug 16 Aug 16 Aug
Nov 16 Nov 16 Nov
Mar 16 Mar 16 Mar May 16 May Both 2% 16 May Burton Hospitals NHS Trust BHFT RJF Current Financial Year 2016-17 Benchmarking Charts Key: Latest Data Month 10 5th and 95th Percentile Ranges Latest Quarter Data Q4 16-17 Upper Quartile Range Report Month Mar 17 Lower Quartile Range
Cancer Waits (Quarterly) Referral To Treatment (Incompletes) HCAI Breaches
Provider Benchmarking - latest quarter position Provider Benchmarking - latest month position C.Difficile MRSA [Source: NHSE Quarterly Cancer Published Data] [Source: NHSE RTT Published Data] Total YTD Total YTD Cancer Indicators 11 2
100% Latest Month Latest Month 100% 100% 97% 95% 1 0
90% 95% 92% Mixed Sex Accommodation Breaches 90% 80% Total YTD Latest Month
85% 47 8 70% 71%
Provider Performance Diagnostics 60%
Latest Month Overall 50% Cancer Two Week Wait Cancer Breast Symptoms Two Week Cancer 31 Day First Definitive Cancer 62 Day First Definitive Overall 100% Wait Treatment Treatment 99% 99.90% 98% 97% Actual Values Latest Period (green indicator shows performance improvement on previous period) Endoscopy 96% 95% 99.6% 99.9% 100.0% 99.9% Cancer 31 Day Cancer 31 Day Cancer 31 Day Cancer 62 Day Cancer 62 Day 99.3% 98.8% 98.0% Cancer Breast Cancer 31 Day Cancer 62 Day 99.80% 94% 97.4% 98.0% Cancer Two Subsequent Subsequent Subsequent First Definitive First Definitive 96.6% Symptoms Two First Definitive First Definitive 93% 95.9% Week Wait Treatment - Treatment - Treatment - Treatment - Treatment - Week Wait Treatment Treatment Imaging Drugs Radiotherapy Surgery NHS Screening Upgrade 92% 91%
Provider Target 93% 93% 96% 98% 94% 94% 85% 90% 0% 99.95% 90%
Jul 16 Jul Jan 16 Jan
Total Physiological 17 Jan Jun 16 Jun
BHFT 2,039 277 202 20 0 36 118 18 9 16 Oct
Apr16
Sep 16 Sep Feb 16 Feb
Dec 16 Dec
Aug 16 Aug
Nov 16 Nov
Mar 16 Mar May 16 May BHFTBHFT Breaches 62 13 1 0 0 2 35 0 3 99.84% BHFT Target England BHFT Performance 97% 95% 100% 100% no data 94% 71% 100% 65%
Accident & Emergency DTOC (Delayed Days) Latest Month YTD Year to Date A&E Performance (Types 1-3) Attends BHFT % 4 Hours Target Average Monthly Days Delayed (NHS Responsible) Days delayed divided by days in month 4 Hour 100% 12,000 Total 6,572 Responsible % 87.35% 89.69% 95% 10,000 NHS 24% 90% 91.9% 91.9% 7.71
91.5%
91.3% 7.52 Trolley Breaches 90.3% Social Care 64% 89.9% 89.3% 89.1% 8,000 7.19 85% 88.3% 87.6% 6.77 0 3 87.2% 87.3% Both 12% 80% 6,000 5.60 5.68 5.52 Latest Month 4.68 4.53
75% 78.9% 4.29 Attendances Performance 4,000 3.90 70% 3.03 3.20 Trust Performance vs. England (13 Months) Total 655 2,000 65% Responsible % 60% 0 NHS 20%
Social Care 71%
Jul 16 Jul 16 Jul
Jan 16 Jan 17 Jan 16 Jan Jan 17 Jan
Jun 16 Jun Jun 16 Jun
Oct 16 Oct 16 Oct
Apr 16 Apr Apr16
Sep 16 Sep 16 Sep Feb 16 Feb 16 Feb
Dec 16 Dec 16 Dec
Aug 16 Aug 16 Aug
Nov 16 Nov 16 Nov
Mar 16 Mar 16 Mar May 16 May Both 8% 16 May Item: 13 Enc: 09
Cannock Chase Clinical Commissioning Group South East Staffordshire and Seisdon Peninsula Clinical Commissioning Group Stafford and Surrounds Clinical Commissioning Group
The healthiest place to live and work, by 2025
REPORT TO: The Stafford and Surrounds Clinical Commissioning Group Governing Body Meeting in PUBLIC TO BE HELD ON: Tuesday 28th March 2017
Subject: Staffordshire and Stoke-on-Trent Sustainability and Transformation Plan Board Lead: Andrew Donald, Chief Officer Officer Lead: Andrew Donald, Chief Officer Approval/ Recommendation: Assurance Discussion Information Ratification
PURPOSE OF THE REPORT:
The Sustainable and Transformation Plan is about local leaders working together and with local people to join up and improve health and care within the budgets available.
KEY POINTS: There are 44 STPs and each has a ‘footprint’ — the area that it covers. Our footprint is Staffordshire and Stoke-on-Trent and we have named our plan ‘Together we’re Better’.
We have two local authorities, six Clinical Commissioning Groups, who are responsible for buying healthcare for the area, and five NHS trusts providing services to 1.1 million people. In addition, Royal Wolverhampton Trust runs Cannock Hospital.
Our population needs are changing as people live longer, often with more complex conditions. There is a life expectancy gap in some of our communities.
Our financial position is challenging — in four years’ time all organisations across Staffordshire and Stoke-on-Trent will be in deficit, and we will have a funding gap of £542m if we don’t change things.
CCG GOALS: Change the culture: Hospital to home Professional to patient More focus on prevention Involving everyone for improved health and All the CCG Goals are supported by the STP care Empower and support patients to take control of their own health Services supporting people to make informed decisions
We are honest, accessible Quality is our day job We innovate and deliver Care and respect for all and we listen Page | 1 Item: 13 Enc: 09
IMPLICATIONS: Legal and/or Risk CQC Patient Safety Patient Engagement To be considered as we move to implementation Financial Sustainability Workforce/Training
RECOMMENDATIONS/ACTION REQUIRED: The Governing Body is asked to:
Formally sign of the Staffordshire and Stoke-on-Trent Sustainability and Transformation Plan.
Not KEY REQUIREMENTS Yes No Applicable Has a quality impact assessment been undertaken? Has an equality impact assessment been undertaken? Has a privacy impact assessment been completed? Has a comms & engagement impact assessment been completed? Have partners/public been involved in design? Are partners/public involved in implementation? Are partners/public involved in evaluation?
CCG VALUES We are honest, accessible and listen Care and respect for all Quality is our day job We innovate and deliver
We are honest, accessible Quality is our day job We innovate and deliver Care and respect for all and we listen Page | 2 An Introduction to the Staffordshire and Stoke-on-Trent Sustainability and Transformation Plan Contents
1 Introduction 3
2 STP area map 4
3 How things should be… 5
4 How things really are… 6
5 The challenges facing our health and care system health and wellbeing 7
6 The challenges facing our health and care system quality of care 8
7 The challenges facing our health and care system finance and efficiency 9
8 How will we solve this? 10
9 Why hospital care isn’t always the best place for you when you’re ill 12
10 We all need to take more responsibility for our own health, where appropriate 13
11 What does the future look like? 15
12 Public engagement 16
13 We need to make these big decisions together 18
14 Where can I find out more? 20
2 Together We’re Better Staffordshire and Stoke-on-Trent Sustainability and Transformation Plan 3 1 Introduction
STPs are about local leaders working together and with local people to join up and improve health and care within the budgets available to us.
There are 44 STPs and each has a ‘footprint’ — the area that it covers. Our footprint is Staffordshire and Stoke-on- Trent and we have named our Clinical plan ‘Together we’re Better’. Commissioning Groups We have two local authorities, six Clinical Commissioning 44STPs nationally 6across Staffordshire Groups, who are responsible and Stoke-on-Trent area for buying healthcare for the area, and five NHS trusts providing services to 1.1 million people. In addition, Royal
Wolverhampton Trust runs Cannock Hospital.
Our population needs are changing as people live longer, often with more complex conditions. There is a life expectancy gap in some of our communities.
Our financial position is Providing services to In four years’ time we challenging — in four years’ time all organisations across estimate a funding gap of Staffordshire and Stoke-on- Trent will be in deficit, and we will have a funding gap of £542m if we don’t 542m change things. 1.1mpeople in Staffordshire for all organisations and Stoke-on-Trent across Staffordshire and Stoke-on-Trent, if we don’t change things
2 Together We’re Better Staffordshire and Stoke-on-Trent Sustainability and Transformation Plan 3 2 STP area map
Stoke-on-Trent CCG
North Staffordshire Stoke-on-Trent CCG City Council
Royal Stoke Leek University Moorlands Hospital Hospital Leek Haywood Bradwell Hospital Hospital
Cheadle Newcastle-under-Lyme Hospital North Stoke-on-Trent Staffordshire Cheadle Combined East Healthcare NHS Trust Staffordshire CCG University Stone Uttoxeter Hospitals of North Midlands Queen’s NHS Trust Stafford & Hospital Surrounds Samuel CCG Johnson Burton upon Trent Staffordshire and Stafford Hospital Stoke-on-Trent County Partnership NHS Hospital Trust Rugeley
Cannock Burton Hospitals Chase CCG NHS Foundation Cannock Trust Lichfield
South Tamworth Staffordshire Staffordshire and Shropshire County Healthcare NHS Foundation Council Trust South East Cannock Sir Robert Staffordshire Chase Peel and Seisdon Hospital Hospital Peninsula CCG
Not a geographical representation
4 Together We’re Better Staffordshire and Stoke-on-Trent Sustainability and Transformation Plan 5 3 How things should be…
Everyone deserves difficulties, or a combination Health and care should be an of all of these. equal partnership between good quality, safe, you and the professionals health and social care The services you use most of who support you. We believe services that make the time should be as close that prevention is always to where you live as possible, better than cure and that the best possible use as long as this is safe and we all have a role to play in of taxpayers’ money. the local health and care managing our own health and system can afford this. For care — including planning and These should be readily the vast majority of the time budgeting for our needs as available to you regardless you should go home as soon we get older. of your age, ethnicity, social as treatment is completed. and employment status, More specialist care will sexuality or where you live. be delivered in a centre of excellence, so you may need The standard of care should to travel a little further for be the same whether you this — but rehabilitation need physical, mental health and follow-up treatment/ or social care services, appointments will happen support with conditions close to home. associated with learning
4 Together We’re Better Staffordshire and Stoke-on-Trent Sustainability and Transformation Plan 5 4 How things really are…
There are many we often live longer with ill [[ A quarter of all patients health. Currently we treat admitted to hospital with reasons why we disease and conditions to a physical illness also have are not providing prolong life, but not always a mental health condition the standard of with people’s dignity that in most cases is not and quality of life as our treated whilst in hospital. care we have just priority. described. Our We are a growing, biggest challenges patients are ageing population… can be summarised 800 admitted to our local hospitals as follows: [[ By 2021 the number of people aged 65+ will rise every day by 16% 1. We’re spending far too of these 330 admissions much money and are [[ 30% of health and care are unplanned building up a very big costs for those aged over debt — £542million in five 65 years are spent on patients are years if we don’t act now hospital care 60 readmitted — but we’re not seeing within 30 days enough improvements in [[ Half the local Clinical of discharge health and care as a result. Commissioning This matters because we Groups (CCGs), who of people in a won’t be able to make are responsible for buying 33% hospital bed at investments in improving local healthcare services, any at any one care, the latest technology exceed the average time could be and equipment such as for injuries due to falls treated better scanners, and training. in people aged 65+, elsewhere It will also make it even Stoke-on-Trent was 30% more difficult to attract above the national average. of acute bed GPs, nurses and surgeons 30% occupancy is to work here …with more complex by those with health needs mental health 2. Our major hospitals are needs struggling to meet quality [[ People are living longer standards and demand — — this is good you’ve all heard the stories of long queues in A&E and [[ Many are living with cancelled operations complex long term conditions 3. We’re not always providing the right care at [[ Too many people end up the right time in the right in hospital, particularly way — and sometimes this A&E, when there are other, means we actually cause more appropriate and far you harm. The fact we are less expensive alternatives living longer means that
6 Together We’re Better Staffordshire and Stoke-on-Trent Sustainability and Transformation Plan 7 5 The challenges facing our health and care system health and wellbeing
Cancer Mental health Frail and elderly [[ Main cause of premature [[ 1 in 4 adults have [[ Injuries from falls death a mental health issue 30% higher than at any one time national average [[ Only 75% of patients seen within 62 days [[ Many cases of stress, [[ Reablement spend is anxiety and depression can 59% lower than national [[ Local CCGs have poor be treated at home with average. cancer detection rates. the right support.
Smoking Obesity [[ Higher rate of death [[ One in ten children aged due to smoking related four to five is obese illnesses [[ This rises to one in five [[ Need improved by age 11 education about health risks. [[ Two out of three adults have excess weight problems.
6 Together We’re Better Staffordshire and Stoke-on-Trent Sustainability and Transformation Plan 7 6 The challenges facing our health and care system quality of care
Readmissions A & E Access and [[ Hip fracture readmissions [[ Poor performance locally wait times are up to 35% more likely against 4 hour wait targets [[ Large variation in the number of GPs per head [ [ [ Mental health unplanned [ 30% more attendances at of population readmissions worse than A&E than other areas national average. [[ Non — elective admissions, [ [ More education needed 62 week wait, all higher around alternatives. than national average
[[ Improvements here would make a real difference.
8 Together We’re Better Staffordshire and Stoke-on-Trent Sustainability and Transformation Plan 9 7 The challenges facing our health and care system finance and efficiency
We face a significant financial challenge – £129million gap for 2015/16
This equates to:
[[ 8% of the total health spend
[[ 500 beds in acute hospitals
High levels of hospital Estates — buildings [[ Over 3,000 NHS staff, admissions and land including doctors and nurses
[[ The six Staffordshire and = Stoke-on-Trent CCGs are currently forecast to end the year with a debt of £135million
[[ By 2020/21 the CCGs will receive 14.8% more money per year, but health costs will rise 20% in the same High costs of Duplication and period emergency care planned care [[ If we do nothing, the recurring deficit in 2020/21 is currently forecast to be £286 million
[[ Add in the cost pressures in social care, this forecast increases to £542 million by 2020/21.
8 Together We’re Better Staffordshire and Stoke-on-Trent Sustainability and Transformation Plan 9 8 How will we solve this?
Our draft plan puts together some ideas about how we can solve these problems based around five key areas:
We think there are two steps to achieving the care you deserve:
1. Affordable care (The next 1-5 years) We need to have honest and possibly difficult conversations about what Focused prevention Enhanced primary (i.e. GP) we can do without, do less and community care of, or do in a more effective way; but this may involve making some difficult decisions. For example: should we move from three A&E sites to two and turn the third into an urgent care centre? How would this work? How could we ensure the quality of care improved as a result? Would this adequately serve the needs of the local population? Effective and efficient Simplified urgent and planned care emergency care system 2. Transforming care (the next 3-10 years) This is the exciting bit. We want to work with you to plan the steps needed to transform the way that we will provide health and care services in the future £ so that these fit in with Mental health services the way that we live and (including learning work today. We need to disabilities) are a part of make sure that everyone is all of these areas treated fairly and gets the Reduced costs of services right support.
10 Together We’re Better Staffordshire and Stoke-on-Trent Sustainability and Transformation Plan 11
Affordable care Transforming care
Focused Reduce the number of people Work in new ways together to make prevention with problems caused by prevention and wellbeing everyone’s alcohol, obesity and smoking. business. Tackle health inequalities by This will reduce expensive dealing with the social, economic and hospital admissions by twice environmental causes of ill health in as much as trying to prevent your community. Share with you the their admission once the responsibility for staying well. Develop problem is there. holistic approaches to support people with both mental and physical health needs.
Enhanced Increase the proportion of Improve access to care when you need primary care in the community rather it. Take your mental health as seriously as and than hospitals. Reduce the your physical health, and provide access community number and severity of to mental health professionals /support care complications from long within these teams so you receive care term conditions. Develop a earlier, reducing barriers and stigma. Plan workforce plan to cope with your care with you if you have a long term the changes in training, roles condition. Share with you the responsibility and demand for different for managing your condition. Join up care kinds of professionals. and allow your medical records to travel with you.
Effective Reduce ineffective treatment, Perform more diagnostic tests and and reduce duplication of tests follow up in the community so you only efficient and concentrate experts and go to hospital once. Develop a dual care planned specialised diagnostics in a approach addressing both physical and care few centres of excellence. mental health needs. Provide quicker and less invasive treatments such as more physiotherapy and less surgery, more talking therapy and less drugs.
Simplified Increase community based Provide better access to more urgent care urgent and urgent care and reduce nearer to your home. Make it easier for emergency A&E attendances. Reduce you to know where to go for urgent advice care emergency hospital and treatment. Provide safe alternatives to system admissions and readmissions. admission to hospital. Rapid 24/7 access to mental health care for those in A&E who need it; 24/7 home treatment for those in a mental crisis.
Reduced Review buildings, grounds and Involve you in all difficult decisions about cost of bed capacity to ensure we what we can afford. Provide safe and services are providing the right care in efficient environments for care, which are the right place. Increase the designed for 21st Century requirements. amount organisations work Maximise the use of technology to improve together to reduce excess communication, information, monitoring management costs. and problem solving.
10 Together We’re Better Staffordshire and Stoke-on-Trent Sustainability and Transformation Plan 11 9 Why hospital care isn’t always the best place for you when you’re ill
If not hospital, then that treating people closer to When you need where? home through more localised hospital care, it will be services leads to them there People currently view hospital getting better quicker and as the best — or only — place having a better quality of life, It is important to know that for them when they’re ill but extra support is needed if hospitals will always be there because they either don’t we are to achieve this. when you need them, but by know about the alternatives, giving you better options for or those alternatives don’t Alternatives may include your health needs, it will help exist. If we are to encourage improved access to GPs with relieve some of the pressure people to go to hospital only a wider range of services the hospitals currently face, when it’s really necessary, we available; access to walk-in allowing them to focus on the need to ensure there are high centres and specially trained people that really need their quality alternatives available pharmacists or developing specialist care, improving elsewhere and that people centres of excellence that quality as a result as well as know they exist and know focus on specific health being able to better manage how and when to access needs, such as cancer or demand and wait times. them. Evidence suggests diabetes.
12 Together We’re Better Staffordshire and Stoke-on-Trent Sustainability and Transformation Plan 13 10 We all need to take more responsibility for our own health, where appropriate
NHS and social care services It’s not all about health should continue to be there We recognise that to truly tackle some of when we really need them, but to the health issues we face in our area, we ensure this happens in the future, need to look not just at the symptoms but at the root cause — and these aren’t always many of us could take on more health related. Poor housing, social isolation personal responsibility for our and a missing sense of community all contribute to poor health, particularly mental own health. This could be through health. We recognise that we need to treat making better lifestyle choices to your mental health as equally as your physical help us stay well, or by managing health. It makes absolute sense to engage with the voluntary and third sectors. It is clear that our own health better when we all need to work together to help improve we are ill. It could even involve health and social care across Staffordshire making use of new technology to and Stoke-on-Trent. monitor and maintain long term conditions in the home.
12 Together We’re Better Staffordshire and Stoke-on-Trent Sustainability and Transformation Plan 13 14 Together We’re Better Staffordshire and Stoke-on-Trent Sustainability and Transformation Plan 15 11 What does the future look like?
We certainly don’t These teams will work We believe that it will also be have all the answers closely together with patients less expensive as long as we as equal partners in the are all prepared to accept that yet but local clinical management of their physical if we get this right the roles of leaders have been and mental health, and people hospitals will change. working on a new will be given the necessary advice, support and resource This is likely to mean fewer community ‘model to help them stay well for as hospital beds, less staff of care’ in which a long as possible. working in a hospital setting number of health and and more specialist services When they are ill, they will in fewer hospitals. As part care professionals be given the necessary of this we will look to move with different skills knowledge and help to from three to two A&Es and will work in small manage their own conditions one Urgent Care Centre and wherever appropriate and an exploration of potential teams (we call these possible, giving them more options, though no decisions ‘multi-disciplinary’), control over their lives. on the locations of these which will both services has been made. This kind of proactive support and learn approach to care will Doing this well would mean from one another. help us all work together our financial position would to reduce the number of begin to improve in the We think we would need times people need to be longer term and we would around 23 teams based admitted to hospitals for both be able to meet the national around local populations pre-planned and emergency standards for care within our in Staffordshire and care, allowing people to major hospitals — something Stoke-on-Trent of between remain independent, in control we have all struggled with in 30,000 — 70,000, many of and sleep in their recent years. This will mean whom will need relatively own beds rather than on less queues in A&E, reduced little support from the hospital wards. waits for operations, better system most of the time. care and better patient This will help to reduce a lot experience. These teams will need to of the stress associated with have the right information illness for patients and their We will have to make some about their patients at their families, as well as being a investment in the short term fingertips in order to help much more convenient, cost to make sure this works, and identify those who may effective way of providing we have factored this into need additional support, services. our plans as we know this help and advice. will lead to savings in the longer term. They will focus on the overall needs of the person rather than dealing with a series of individual symptoms, putting the “jigsaw” together when it comes to looking after people.
14 Together We’re Better Staffordshire and Stoke-on-Trent Sustainability and Transformation Plan 15 12 Public engagement
In partnership with [[How can we make Healthwatch Staffordshire the best use of public and Healthwatch Stoke- money? on-Trent, throughout November and December The events were held at: 2016 we held a number [[ Staffordshire Moorlands of patient and public (Biddulph) engagement events, [[ South Staffordshire known as Conversation (Codsall) Staffordshire and [[ Stoke-on-Trent Stoke-on-Trent. These (two events) events were about local people talking about [[ Stafford the very real, very [[ Newcastle-under-Lyme serious issues outlined [ in a Conversation [ Lichfield Staffordshire and [[ Tamworth Stoke-on-Trent [[ Cannock document through an open, two-way [[ East Staffordshire (Burton) discussion. These events offered the opportunity to have frank and We asked: open discussions with leaders from [[Which services are the STP about the work we have done so far, and difficult decisions valued most? that may need to be made going [[How can they be forward, as well as some of the opportunities this will create. shaped and improved? These were not full consultation [ events, but the discussions may in [Where do patients the future inform the content of need to access those any future consultations about any services? major changes to health and care services.
16 Together We’re Better Staffordshire and Stoke-on-Trent Sustainability and Transformation Plan 17 During the events we Many clinicians and health No decisions can or will received feedback professionals have been be made until we have and ideas on: involved in the work we have thoroughly engaged with done so far, but we now need you, our staff, politicians [[ What you have seen that to get everybody involved. and voluntary sector could be done better We need people who care organisations, and any about their local services and major changes to service [[ Where money could be who are interested in seeing have to go through a formal better spent their local NHS not only consultation process. survive the coming months [[ What services mean the and years, but also begin to We are lucky to have a most to you and how we thrive and improve as we National Health Service as can improve them move towards 2020. well as the social care that wraps around it. By getting [[ If more of the care you We must also be realistic involved now, you can help need were available close — with a population of well to make sure your local NHS to where you live, how over one million people continues to provide high far would be acceptable it’s unlikely we can please quality, easily accessible to travel to receive everyone, and not all ideas healthcare to you, your specialist care and proposals will be friends and your family achievable. However, we for years to come. [[ What we can do without will do our best to ensure decisions made are in [[ Whether it is right to collaboration with the public. expect people to budget for their care needs as Local Scrutiny Committees, well as their overall living your local MPs, councillors, expenses in old age. the voluntary sector and patient representatives Healthwatch Staffordshire will all have an important and Healthwatch Stoke-on- role to play in commenting Trent will be providing a more upon and challenging our detailed report which will plans. We have also set up be used to inform ongoing an Ambassador Training engagement. Programme for patients, staff No decisions about major and local people who want changes to local services will to learn more so they can be made without extensive share information with their public consultation and communities. feedback.
16 Together We’re Better Staffordshire and Stoke-on-Trent Sustainability and Transformation Plan 17 13 We need to make these big decisions together
During our engagement You said: events to date we have set There are lots about our current services out a “direction of travel”, that you value highly, but you also gave us examples of poor experiences, and but there are a number of overall concerns that the current way we big decisions that we need deliver care is not working as it should. to make with you in 2017 We did: and beyond: The plan is based on a new model of care [[ How quickly, and in which locations, which will be more joined up, and bring care as close to home as possible, but also should we deliver the new joined up help people take more control of their own way of providing primary, community, health and care. mental health and end of life care services?
[[ How can we best use community You said: hospitals and other estate (buildings You are worried about the pressures on and land) to complement this? our A&E services, and there is confusion about what services to use when. [[ What is the most sensible and cost effective way of providing elective We did: (planned) care? Should we centralise We recognise the need to simplify the University Hospitals of North Midlands current system, and our proposals about NHS Trust care services onto one site, redesign of urgent care are based on and should we have fewer, high quality improving the service offered at local level. centres of excellence? Where should These will be subject to consultation in the summer. these be? [[ Improving urgent care in line with national recommendations may You said: reduce the need for A&E services. You understand and agree with our Do we need the same number of A&Es ambition to provide care closer to and if so where should they be? Our home, but you have real concerns that current thinking is that we could move community services do not exist at from three to two A&E sites and one present to make this happen. Urgent Care Centre. This is something we will hold a consultation about in We did: summer 2017. We recognise that the development of these locality teams will require investment [[ Can we make further cost savings and transition funding. This is built into the by sharing services or organising STP plan. ourselves differently?
18 Together We’re Better Staffordshire and Stoke-on-Trent Sustainability and Transformation Plan 19 You said: You said: We need to recognise the differences The current system is fragmented, there are between local areas, and the and care is often affected by lack of different needs of local populations. communication between professionals.
We did: We did: We agree and can reassure you that the The fundamental basis for the plan is development of these new models will the development of integrated teams be bottom up — driven locally. The most at locality levels who will deliver a more likely form will either be multispecialty consistent service offer. These locality community provider (MCP) or Primary teams will over time develop into new and Acute Care System (PACS). A MCP models of care in line with the five moves specialist care out of hospitals year vision for the NHS. This will mean into the community, whilst a PACS joins professionals working together in teams up GP, hospital, community and mental to give you a joined up service. These are health services. The STP has not made any the cornerstone of the STP. statement about the format or geography of these developments.
You said: Are there any ways of slimming down You said: your management costs or sharing You are really concerned about the facilities? future of the community hospitals in Staffordshire and Stoke-on-Trent, and feel in many places these are under-utillised; We listened: you gave us lots of ideas about how we We recognise that reduction of cost is could use these facilities better. important and we will look closely at the way we work to see if there are any sensible ways of joining up our services. We did: The STP is very clear that reduction in beds will be supported by additional investment in ‘out of hospital’ services You said: including community, mental health, We have dedicated and committed staff primary and social care. The CCGs will in our NHS and care services, and you be consulting formally in the new year value highly their work. about their plans for the future use of community hospitals and we welcome suggestions from local people. We listened: We agree that our staff are fundamental to delivering the plan and every organisation is committed to supporting their staff through the delivery of the plan.
18 Together We’re Better Staffordshire and Stoke-on-Trent Sustainability and Transformation Plan 19 14 Where can I find out more?
You can read the full STP submission here.
This will give you more detailed information about the work that is underway. It sets out our direction of travel but no decisions have been made yet — so there is plenty of time to have your say.
We want to know what you think, so if you have any comments on the draft plan or would like to get more involved please call the Communications and Engagement Team at Midlands and Lancashire Commissioning Support Unit on 0333 150 1602.
ABHC_5393_Staffordshire and Stoke-on-Trent STP Public Facing Document Item: 14 Enc: 10
Cannock Chase Clinical Commissioning Group South East Staffordshire and Seisdon Peninsula Clinical Commissioning Group Stafford and Surrounds Clinical Commissioning Group
The healthiest place to live and work, by 2025
REPORT TO: The Stafford and Surrounds Clinical Commissioning Group Governing Body Meeting in PUBLIC TO BE HELD ON: Tuesday 28th March 2017
Scheme of Delegation – Schedule of Matters Delegated to Officers and Subject: Prime Financial Policies Board Lead: Paul Simpson, Executive Director of Finance Officer Lead: Dave Skelton, Financial Controller Approval/ Recommendation: Assurance Discussion Information Ratification
PURPOSE OF THE REPORT: In accordance with the Constitution, the Executive Director of Finance is required to review the Scheme of Delegation – Schedule of Matters Delegated to Officers and the Prime Financial Policies of each CCG on an annual basis.
The purpose of this report is to summarise the review carried out between December 2016 and February 2017, with particular regard to the implementation of the Management of Change process that took place during the current financial year, and also in recognition of Primary Care Co-Commissioning being implemented from 1st April 2017.
Changes have been recommended to the Scheme of Delegation in respect of the CSU staff responsibilities, to reflect the transfer of the embedded finance team into the CCG and also to increase the authorisation limits of the FPC Committee up to £249,999. No changes are recommended to the Prime Financial Policies.
The Scheme of Delegation covers only matters delegated by the Governing Body to the Chief Accountable Officer and Directors and certain other specific matters referred to in Prime Financial policies. The Prime Financial Policies are included within the Constitution of each CCG.
KEY POINTS:
1. The schedule of matters delegated to officers was reviewed and amended in May 2014, presented to the Audit Committee and was subsequently approved. 2. Governing Bodies are due to be presented with budgets for 2017/18 later this month. Once the approved budgets are in place, expenditure will be committed in line with the approved Scheme of Delegation. 3. The Scheme of Delegation applies to CCG staff and any staff to which further delegation applies, for example to CSU staff or NHS England staff in respect of Primary Care
Enclosure 04 Page 1 of 3 Audit Committee – March 2017
Item: 14 Enc: 10
Delegated Commissioning. 4. Some changes to the Scheme of Delegation are proposed in respect of CSU staff responsibilities particularly in relation to matters 1b,1e and 5 and the revised version is attached at Appendix A for scrutiny 5. The Authorisation limit of the FPC Committee in respect of the approval of Business Cases is proposed to be increased to £249,999. This amendment is set out in Appendix A. 6. A further change has been made in recognition of Primary Care Delegated Commissioning. 7. The Prime Financial Policies are contained within the Constitution documents. No changes are proposed following the review by the Executive Director of Finance. These are attached at Appendix B for completeness and the Audit Committee confirms that no changes are required.
CCG GOALS: Change the culture: Hospital to home n/a Professional to patient More focus on prevention n/a Involving everyone for improved health and n/a care Empower and support patients to take control n/a of their own health Services supporting people to make informed n/a decisions
IMPLICATIONS: The changes set out in this report will form part of the individual CCG Legal and/or Risk Constitutions CQC None Patient Safety None Patient Engagement None Financial Changes to delegated limits are set out in this report Sustainability None Workforce/Training None
RECOMMENDATIONS/ACTION REQUIRED:
The Governing Body is asked to approve the changes proposed to the Scheme of Delegation (Schedule of Matters Delegated to CCG Officers), attached at Appendix A and to note that there have been no changes to the Prime Financial Policies attached at Appendix B.
Enclosure 04 Page 2 of 3 Audit Committee – March 2017
Item: 14 Enc: 10
Not KEY REQUIREMENTS Yes No Applicable Has a quality impact assessment been undertaken? Has an equality impact assessment been undertaken? Has a privacy impact assessment been completed? Has a comms & engagement impact assessment been completed? Have partners/public been involved in design? Are partners/public involved in implementation? Are partners/public involved in evaluation?
CCG VALUES We are honest, accessible and listen Care and respect for all Quality is our day job We innovate and deliver
Enclosure 04 Page 3 of 3 Audit Committee – March 2017
Item: 14 Enc: 10
Cannock Chase Clinical Commissioning Group South East Staffordshire and Seisdon Peninsula Clinical Commissioning Group Stafford and Surrounds Clinical Commissioning Group
The healthiest place to live and work, by 2025
REPORT TO: The Stafford and Surrounds Clinical Commissioning Group Governing Body Meeting in PUBLIC TO BE HELD ON: Tuesday 28th March 2017
1. Introduction
1.1 The initial Schedule of Matters Delegated to Officers was developed in conjunction with the organisation’s Prime Financial Policies and Standing Orders. These documents provide guidance for both CCG and the Commissioning Support Unit staff as to the framework within which budgets and financial expenditure is managed, where authority has been delegated. Delegated matters in respect of decisions which may have a far reaching effect must be reported to the Chief Accountable Officer. The full scheme of delegation is attached at Appendix A and Prime Financial Policies are shown at Appendix B.
2. Governing Body Responsibilities
2.1 In accordance with Prime Financial Policies, the Governing Body exercises financial supervision and control by:
(a) Authorising the operational plan: (b) Requiring the submission and approval of budgets within approved allocations/overall income: (c) Defining and approving essential features in respect of important procedures and financial systems (including the need to obtain value for money): and (d) Defining specific responsibilities placed on members of the Governing Body, Committees, Members and Employees as indicated in the Scheme of Delegation. (e) Approving provision of shared services through the Commissioning Support Unit (CSU).
2.2 Once the Governing Body has reviewed and approved the Operational Plan and any supporting financial plan/budget, the Governing Body will delegate approval to the Chief Accountable Officer, the Executive Director of Finance and other Directors and Employees to commit these resources for the purpose set out in the plan subject to the financial thresholds set out in the Scheme of Delegation. Note that 2017/18 budgets are due to be approved later this month.
3. Scheme of Delegation
3.1 Revisions to the Scheme of Delegation have been proposed, and are attached within Appendix A.
3.2 Revisions pertain to Matters 1b/1e where “CSU” has been replaced by “Financial Controller/Financial Accountant” and Matters 5 where “including CSU” has been removed
Page | 1 Item: 14 Enc: 10
3.3 The driver for these amendments is the TUPE transfer of the CSU embedded finance team into the CCG thus negating the need for the matters to be delegated to a third party.
3.4 For the avoidance of doubt, delegation (subject to the limits approved by the Governing Body in the Scheme of Delegation) includes:
• Awarding of Contracts including the signing of appropriate contract documentation • Payment of sums due against approved contracts • Agreement of contract variations and subsequent amendments to contract payments • Organisation of appropriate procurement processes within agreed financial thresholds • Budgetary delegation including approval of non-pay single orders, payroll expenditure and authorisation for the raising of invoices to debtors • Approval to vire (transfer) budgets within overall available financial resources and in line with the Operating Plan • Approval of disposals, condemnations, losses and special payments
3.5 Other points to note are as follows:
• Authority can be delegated upwards with no further action required by the Accountable Officer • All financial limits in the Schedule of Matters delegated to officers are subject to sufficient budget being available. • Standing Orders (SOs) and the Prime Financial Policies set out in some detail the financial responsibilities of the Accountable Officer, the Executive Director of Finance and other Executive Directors of the CCG. • The Scheme of Delegation covers only matters delegated by the Governing Body to the Accountable Officer and Directors and certain other specific matters referred to in Prime Financial Policies. • Further delegation may be approved.by the Governing Body in approving specific management policies
i. by the CCG Chief Accountable Officer ii. as part of the Financial Procedures approved by the Executive Director of Finance
• Each CCG Director may consider the arrangements for authorisation of expenditure against delegated budgets and further delegation of management/professional responsibilities where the Scheme of Delegation allows this.
4. Prime Financial Policies
4.1 The Prime Financial Policies of the CCGs should be reviewed annually. No changes are recommended at this time.
5. Scrutiny required.
Page | 2 Item: 14 Enc: 10
5.1 The Audit Committee is asked to scrutinise and confirm to the Governing Body that no changes are presently required to the Scheme of Delegation, attached at Appendix A, (Schedule of Matters Delegated to CCG Officers) and the Prime Financial Policies attached at Appendix B.
Page | 3 Appendix
Scheme of Delegation Ref Matter delegated Delegate to 1 Bank accounts a) Executive Director of Finance a) Maintenance and operation in accordance with mandate b) Financial Controller/Financial Accountant in approved by Governing Board accordance with the CCG Cash Limit Resource and b) Cash Requisitions / Draw Down provision of cash flow reports c) Payment Requests – outside of normal c) Management Accountant – within available cash process/routines d) Urgent – CHAPS d) Only Payroll – agreed via SCSU e) RFT/BACS e) Financial Controller/Financial f) Cash Advances to Commissioning Providers Accountant within available cash/payment code f) Executive Director of Finance 2 Budget management
Responsibility for maintaining expenditure within approved budgets a) Designated budget holder a) At individual budget level (pay and non-pay) b) CCG Director b) For the totality of services covered by the directorate
3 Business Cases
a) Business cases cost neutral or a non-recurrent cost not a) Accountable Officer and the Executive Director of exceeding £25,000 Finance b) Business cases with a cost (recurrent or non-recurrent) b) Executive Committee exceeding £25,000 but not exceeding £249,999 c) Business cases exceeding £250,000 c) Governing Body approval.
4 Commissioning contracts including with Foundation Trusts, the private or voluntary sector, Service Level Agreements including with CSU or NHS Trusts, Primary Care partnership agreements with Local Authorities, grants a) CCG Director a) Up to 250,000 b) Accountable Officer or Executive Director of Finance b) £250,000 to £1,000,000 c) Accountable Officer c) Over £1,000,000
Appendix 5 Monthly Orders and Invoices for healthcareservices with signed contracts under section 4 above, in line with agreed payments profiles as specified in the contract: a) Up to £250,000 a) Budget Holder or nominated representative b) Over £250,000 b) CCG Director or nominated representative 6 Commissioning and other healthcareorders and invoices for non-
contracted activity including over performance above signed contracted sums: a) Up to £25,000 a) Budget holder b) £25,000 to£250,000 b) CCG Director c) £250,000 to £1,000,000 c) Executive Director of Finance d) Over £1,000,000 d) Accountable Officer
7 Orders and requisitions for admin and corporate costs a) Up to £1,000 a) Budget holder b) £1,000 to £25,000 b) CCG Director c) Over £25,000 c) Executive Director of Finance
8 Fees and charges
a) Overseas visitors, income generation and other patient a) Executive Director of Finance related services b) All other income sources b) Executive Director of Finance 9 Hospitality
Declaration in Hospitality Register where value for any All Staff hospitality received exceeds £25 per individual per instance 10 Invoice certification; excluding commissioning expenditure covered by section 5
a) Up to £24,999 a) Designated Budget Holder b) £25,000 to £74,999 b) Executive Director of Finance c) £75,000 to £249,999 c) Accountable Officer d) Over £250,000 d) Accountable Officer & Executive Director of Finance
Appendix 11 Losses, write-offs and compensation: Executive Director of Finance & Accountable Officer Any write offs of any value
12 Management Consultancy
a) Where aggregate commitment in any one year or a) Executive Director of Finance total commitment is £24,999 or less b) Where aggregate commitment in any one year is b) Accountable Officer £25,000 or above
13 Primary Care Delegated Commissioning Schedule of GP Payments
a) Primary Care Accountant – NHS England a) Up to £29,999 b) Assistant Head of Finance – NHS England b) £30,000 to £89,999 c) Primary Care Finance Manager – CCG c) £90,000 to £149,999 d) Head of Commissioning Finance – CCG d) £150,000 to £249,999 e) Executive Director of Finance
e) £250,000 to £1,000,000
Appendix A 14 Personal & Pay
a) Authority to fill funded posts on the establishment with a) Designated Budget permanent staff Holder b) Accountable b) Authority to appoint staff to post not on the formal Officer establishment c) The granting of additional increment to staff c) Executive Director within budget of Finance d) Staff upgrades d) Accountable Officer e) Additional staff to the agreed establishment within e) Executive Director of specifically allocated finance Finance f) Additional staff to the agreed establishment without specifically f) Accountable Officer allocated g) Pay finance g) Pay i. Executive Director of Finance i. Authority to complete standing date forms ii. Designated Budget Holder affecting pay, new starters, variations and iii. Executive Director of Finance leavers iv. Designated Budget ii. Authority to complete and authorise positive Holder reporting forms h) Leave iii. Authority to authorise overtime i. Immediate line manager iv. Authority to authorise travel and ii. Immediate line manager subsistence expenses iii. Executive Director of Finance h) Leave iv. Immediate line manager i. Approval annual leave and study leave v. Executive Director of Finance vi. Immediate line ii. Compassionate leave up to 3 days manager iii. Compassionate leave up to 6 days vii. Immediate line iv. Special leave arrangements up to 3 manager days v. Special leave arrangements up viii. Automatic approval with to 6 days guidance i) Sick leave vi. Leave without i. Executive Director of Finance pay vii. Time off in ii. Remuneration lieu committee iii. Remuneration viii. Maternity leave – paid and committee unpaid i) Sick leave i. Extension of sick leave on half pay up to 3 months ii. Return to work part-time on full pay to assist recovery iii. Extension of sick leave on full pay
15 (a) Petty Cash disbursements up to £50 per item a) Designated budget holder (b) Petty cash float replenishment up to £500 per week b) Executive Director of Finance
APPENDIX B PRIME FINANCIAL POLICIES
1. INTRODUCTION
1.1. General
1.1.1. These prime financial policies and supporting detailed financial policies shall have effect as if incorporated into the CCG’s constitution.
1.1.2. The prime financial policies are part of the CCG’s control environment for managing the organisation’s financial affairs. They contribute to good corporate governance, internal control and managing risks. They enable sound administration; lessen the risk of irregularities and support commissioning and delivery of effective, efficient and economical services. They also help the Chief Accountable Officer and Executive Director of Finance to effectively perform their responsibilities. They should be used in conjunction with the scheme of reservation and delegation.
1.1.3. In support of these prime financial policies, the CCG has prepared more detailed policies, approved by the Chief Accountable Officer and Executive Director of Finance, known as detailed financial policies. The CCG refers to these prime and detailed financial policies together as the CCG’s financial policies.
1.1.4. These prime financial policies identify the financial responsibilities which apply to everyone working for the CCG and its constituent organisations. They do not provide detailed procedural advice and should be read in conjunction with the detailed financial policies. The Chief Accountable Officer and Executive Director of Finance are responsible for approving all detailed financial policies.
1.1.5. A list of the CCG’s detailed financial policies will be available to patients and the public via the CCG’s Website.
1.1.6. Should any difficulties arise regarding the interpretation or application of any of the prime financial policies then the advice of the Chief Accountable Officer or Executive Director of Finance must be sought before acting. The user of these prime financial policies should also be familiar with and comply with the provisions of the CCG’s constitution, standing orders and scheme of reservation and delegation.
1.1.7. Failure to comply with prime financial policies and standing orders can in certain circumstances be regarded as a disciplinary matter that could result in dismissal.
1.2. Overriding Prime Financial Policies
1.2.1. If for any reason these prime financial policies are not complied with, full details of the non-compliance and any justification for non-compliance and the circumstances around the non-compliance shall be reported to the next formal meeting of the Governing Body’s Audit Committee for referring action or
ratification. All of the CCG’s members and employees have a duty to disclose any non-compliance with these prime financial policies to the Executive Director of Finance as soon as possible.
1.3. Responsibilities and delegation
1.3.1. The roles and responsibilities of CCG’s members, employees, members of the Governing Body, members of the governing body’s committees and sub- committees, members of the CCG’s committee and sub-committee (if any) and persons working on behalf of the CCG are set out in chapters 6 and 7 of this constitution.
1.3.2. The financial decisions delegated by members of the CCG are set out in the CCG’s scheme of reservation and delegation (see Appendix D).
1.4. Contractors and their employees
1.4.1. Any contractor or employee of a contractor who is empowered by the CCG to commit the CCG to expenditure or who is authorised to obtain income shall be covered by these instructions. It is the responsibility of the Chief Accountable Officer to ensure that such persons are made aware of this.
1.5. Amendment of Prime Financial Policies
1.5.1. To ensure that these prime financial policies remain up-to-date and relevant, the Executive Director of Finance will review them at least annually. Following consultation with the Chief Accountable Officer and scrutiny by the Governing Body’s audit committee, the Executive Director of Finance will recommend amendments, as fitting, to the Governing Body for approval. As these prime financial policies are an integral part of the CCG’s constitution, any amendment will not come into force until the CCG applies to the NHS England and that application is granted.
2. INTERNAL CONTROL
POLICY – the CCG will put in place a suitable control environment and effective internal controls that provide reasonable assurance of effective and efficient operations, financial stewardship, probity and compliance with laws and policies
2.1. The Governing Body is required to establish an Audit Committee with terms of reference agreed by the Governing Body (see clause 6.4 of the CCG’s constitution for further information).
2.2. The Chief Accountable Officer has overall responsibility for the CCG’s systems of internal control.
2.3. The Executive Director of Finance will ensure that:
a) financial policies are considered for review and update annually;
b) a system is in place for proper checking and reporting of all breaches of financial policies; and
c) a proper procedure is in place for regular checking of the adequacy and effectiveness of the control environment.
3. AUDIT
POLICY – the CCG will keep an effective and independent internal audit function and fully comply with the requirements of external audit and other statutory reviews
3.1. In line with the terms of reference for the Governing Body’s Audit Committee, the person appointed by the CCG to be responsible for internal audit and the Audit Commission appointed external auditor will have direct and unrestricted access to audit committee members and the Chair of the Governing Body, Chief Accountable Officer and Executive Director of Finance for any significant issues arising from audit work that management cannot resolve, and for all cases of fraud or serious irregularity.
3.2. The person appointed by the CCG to be responsible for internal audit and the external auditor will have access to the Audit Committee and the Chief Accountable Officer to review audit issues as appropriate. All Audit Committee members, the Chair of the Governing Body and the Audit Committee will have direct and unrestricted access to the head of internal audit and external auditors.
3.3. The Executive Director of Finance will ensure that:
a) the CCG has a professional and technically competent internal audit function; and
b) the Audit Committee approves any changes to the provision or delivery of assurance services to the CCG.
4. FRAUD AND CORRUPTION
POLICY – the CCG requires all staff to always act honestly and with integrity to safeguard the public resources they are responsible for. The CCG will not tolerate any fraud perpetrated against it and will actively chase any loss suffered
4.1. The Audit Committee will satisfy itself that the CCG has adequate arrangements in place for countering fraud and shall review the outcomes of counter fraud work. It shall also approve the counter fraud work programme.
4.2. The Audit Committee will ensure that the CCG has arrangements in place to work effectively with NHS Protect.
5. EXPENDITURE CONTROL
5.1. The CCG is required by statutory provisions to ensure that its expenditure does not exceed the aggregate of allotments from the NHS England and any other sums it has received and is legally allowed to spend.
5.2. The Chief Accountable Officer has overall executive responsibility for ensuring that the CCG complies with certain of its statutory obligations, including its financial and accounting obligations, and that it exercises its functions effectively, efficiently and economically and in a way which provides good value for money.
5.3. The Executive Director of Finance will:
a) provide reports in the form required by the NHS England;
b) ensure money drawn from the NHS England is required for approved expenditure only is drawn down only at the time of need and follows best practice;
c) be responsible for ensuring that an adequate system of monitoring financial performance is in place to enable the CCG to fulfil its statutory responsibility not to exceed its expenditure limits, as set by direction of the NHS England.
6. ALLOTMENTS
6.1. The CCG’s Executive Director of Finance will:
a) periodically review the basis and assumptions used by the NHS England for distributing allotments and ensure that these are reasonable and realistic and secure the CCG’s entitlement to funds;
b) prior to the start of each financial year submit to the Governing Body for approval a report showing the total allocations received and their proposed distribution including any sums to be held in reserve; and
c) regularly update the Governing Body on significant changes to the initial allocation and the uses of such funds.
7. COMMISSIONING STRATEGY, BUDGETS, BUDGETARY CONTROL AND MONITORING
POLICY – the CCG will produce and publish an annual Commissioning Plan that explains how it proposes to discharge its financial duties. The CCG will support this with comprehensive medium term financial plans and annual budgets
7.1. The Chief Accountable Officer will compile and submit to the Governing Body a commissioning strategy which takes into account financial targets and forecast limits of available resources.
7.2. Prior to the start of the financial year the Executive Director of Finance will, on behalf of the Chief Accountable Officer, prepare and submit budgets for approval by the Governing Body.
7.3. The Executive Director of Finance shall monitor financial performance against budget and plan, periodically review them, and report to the Governing Body. This report should include explanations for variances. These variances must be based on any significant departures from agreed financial plans or budgets.
7.4. The Chief Accountable Officer is responsible for ensuring that information relating to the CCG’s accounts or to its income or expenditure, or its use of resources is provided to the NHS England as requested.
7.5. The Governing Body will approve consultation arrangements for the CCG’s Commissioning Plan.
8. ANNUAL ACCOUNTS AND REPORTS
POLICY – the CCG will produce and submit to the NHS England accounts and reports in accordance with all statutory obligations, relevant accounting standards and accounting best practice in the form and content and at the time required by the NHS England
8.1. The Executive Director of Finance will ensure the CCG:
a) prepares a timetable for producing the annual report and accounts and agrees it with external auditors and the Governing Body;
b) prepares the accounts according to the timetable approved by the Governing Body;
c) complies with statutory requirements and relevant directions for the publication of Annual Report;
d) considers the external auditor’s management letter and fully address all issues within agreed timescales; and
8.1.2. the external auditor’s management letter will be available to patients and the public via the CCG’s Website
9. INFORMATION TECHNOLOGY
POLICY – the CCG will ensure the accuracy and security of the CCG’s computerised financial data
9.1. The Executive Director of Finance is responsible for the accuracy and security of the CCG’s computerised financial data and shall
a) devise and implement any necessary procedures to ensure adequate (reasonable) protection of the CCG's data, programs and computer hardware from accidental or intentional disclosure to unauthorised persons, deletion or modification, theft or damage, having due regard for the Data Protection Act 1998;
b) ensure that adequate (reasonable) controls exist over data entry, processing, storage, transmission and output to ensure security, privacy, accuracy, completeness, and timeliness of the data, as well as the efficient and effective operation of the system;
c) ensure that adequate controls exist such that the computer operation is separated from development, maintenance and amendment;
d) ensure that an adequate management (audit) trail exists through the computerised system and that such computer audit reviews as the Executive Director of Finance may consider necessary are being carried out.
9.2. In addition the Executive Director of Finance shall ensure that new financial systems and amendments to current financial systems are developed in a controlled manner and thoroughly tested prior to implementation. Where this is undertaken by another organisation, assurances of adequacy must be obtained from them prior to implementation.
10. ACCOUNTING SYSTEMS
POLICY – the CCG will run an accounting system that creates management and financial accounts
10.1. The Executive Director of Finance will ensure:
a) the CCG has suitable financial and other software to enable it to comply with these policies and any consolidation requirements of the NHS England;
b) that contracts for computer services for financial applications with another health organisation or any other agency shall clearly define the responsibility of all parties for the security, privacy, accuracy, completeness, and timeliness of data during processing, transmission and storage. The contract should also ensure rights of access for audit purposes.
10.2. Where another health organisation or any other agency provides a computer service for financial applications, the Executive Director of Finance shall periodically seek assurances that adequate controls are in operation.
11. BANK ACCOUNTS
POLICY – the CCG will keep enough liquidity to meet its current commitments
11.1. The Executive Director of Finance will:
a) review the banking arrangements of the CCG at regular intervals to ensure they are in accordance with Secretary of State directions, best practice and represent best value for money;
b) manage the CCG's banking arrangements and advise the CCG on the provision of banking services and operation of accounts;
c) prepare detailed instructions on the operation of bank accounts.
11.2. The Audit Committee shall approve the banking arrangements.
12. INCOME, FEES AND CHARGES AND SECURITY OF CASH, CHEQUES AND OTHER NEGOTIABLE INSTRUMENTS.
POLICY – the CCG will • operate a sound system for prompt recording, invoicing and collection of all monies due • seek to maximise its potential to raise additional income only to the extent that it does not interfere with the performance of the CCG or its functions • ensure its power to make grants and loans is used to discharge its functions effectively
12.1. The Executive Director of Finance is responsible for:
a) designing, maintaining and ensuring compliance with systems for the proper recording, invoicing, and collection and coding of all monies due;
b) establishing and maintaining systems and procedures for the secure handling of cash and other negotiable instruments;
c) approving and regularly reviewing the level of all fees and charges other than those determined by the NHS England or by statute. Independent professional advice on matters of valuation shall be taken as necessary;
d) for developing effective arrangements for making grants or loans.
3. TENDERING AND CONTRACTING PROCEDURE
POLICY – the CCG: • will ensure proper competition that is legally compliant within all purchasing to ensure we incur only budgeted, approved and necessary spending • will seek value for money for all goods and services • shall ensure that competitive tenders are invited for o the supply of goods, materials and manufactured articles; o the rendering of services including all forms of management consultancy services (other than specialised services sought from or provided by the Department of Health); and o for the design, construction and maintenance of building and engineering works (including construction and maintenance of grounds and gardens) for disposals
13.1. The CCG shall ensure that the firms / individuals invited to tender (and where appropriate, quote) are among those on approved lists or where necessary a framework agreement. W here in the opinion of the Executive Director of Finance it is desirable to seek tenders from firms not on the approved lists, the reason shall be recorded in writing to the Chief Accountable Officer, the CCG Governing Body and the CCG’s Finance, Performance & QIPP Committee.
13.2. The Governing Body may only negotiate contracts on behalf of the CCG, and the CCG may only enter into contracts, within the statutory framework set up by the 2006 Act, as amended by the 2012 Act. Such contracts shall comply with:
a) the CCG’s standing orders;
b) the Public Contracts Regulation 2006, any successor legislation and any other applicable law; and
c) take into account as appropriate any applicable NHS England or the Independent Regulator of NHS Foundation Trusts (Monitor) guidance that does not conflict with (b) above.
13.3. In all contracts entered into, the CCG shall endeavour to obtain best value for money. The Chief Accountable Officer shall nominate an individual who shall oversee and manage each contract on behalf of the CCG.
14. COMMISSIONING
POLICY – working in partnership with relevant national and local stakeholders, the CCG will commission certain health services to meet the reasonable requirements of the persons for whom it has responsibility
14.1. The CCG will coordinate its work with the NHS England, other clinical commissioning CCGs, local providers of services, local authority(ies), including through Health & W ellbeing Boards, patients and their carers and the voluntary sector and others as appropriate to develop robust Commissioning Plans.
14.2. The Chief Accountable Officer will establish arrangements to ensure that regular reports are provided to the Governing Body and Finance, Performance & QIPP Committee detailing actual and forecast expenditure and activity for each contract.
14.3. Where the CCG makes arrangements for the provision of services by non-NHS providers it is the Chief Accountable Officer who is responsible for ensuring that the agreements put in place have due regard to the quality and cost-effectiveness of services provided. Before making any agreement with non-NHS providers, the CCG should explore fully the scope to make maximum cost-effective use of NHS facilities.
14.4. The Executive Director of Finance will maintain a system of financial monitoring to ensure the effective accounting of expenditure under contracts. This should provide a suitable audit trail for all payments made under the contracts whilst maintaining patient confidentiality.
15. RISK MANAGEMENT AND INSURANCE
POLICY – the CCG will put arrangements in place for evaluation and management of its risks
15.1. The Executive Director of Finance will prepare the Board Assurance Framework, which will be a standing agenda item at meetings of the CCG. This document will reviewed at each meeting of the Governing Body.
16. PAYROLL
POLICY – the CCG will put arrangements in place for an effective payroll service
16.1. The Executive Director of Finance will ensure that the payroll service
selected: a) is supported by appropriate (i.e. contracted) terms and
conditions; b) has adequate internal controls and audit review
processes;
c) has suitable arrangements for the collection of payroll deductions and payment of these to appropriate bodies.
16.2. In addition the Executive Director of Finance shall set out comprehensive procedures for the effective processing of payroll.
17. NON-PAY EXPENDITURE
POLICY – the CCG will seek to obtain the best value for money goods and services received
17.1. The Chief Accountable Officer will approve the level of non-pay expenditure on an annual basis and the Chief Accountable Officer will determine the level of delegation to budget managers 17.2. The Chief Accountable Officer shall set out procedures on the seeking of professional advice regarding the supply of goods and services.
17.3. The Executive Director of Finance will:
a) advise the Governing Body on the setting of thresholds above which quotations (competitive or otherwise) or formal tenders must be obtained; and, once approved, the thresholds should be incorporated in the scheme of reservation and delegation;
b) be responsible for the prompt payment of all properly authorised accounts and claims;
c) be responsible for designing and maintaining a system of verification, recording and payment of all amounts payable.
18. CAPITAL INVESTMENT, FIXED ASSET REGISTERS AND SECURITY OF ASSETS
POLICY – the CCG will put arrangements in place to manage capital investment, maintain an asset register recording fixed assets and put in place polices to secure the safe storage of the CCG’s fixed assets
18.1. The Chief Accountable Officer will
a) ensure that there is an adequate appraisal and approval process in place for determining capital expenditure priorities and the effect of each proposal upon plans;
b) be responsible for the management of all stages of capital schemes and for ensuring that schemes are delivered on time and to cost;
c) shall ensure that the capital investment is not undertaken without confirmation of purchaser(s) support and the availability of resources to finance all revenue consequences, including capital charges;
d) be responsible for the maintenance of registers of assets, taking account of the advice of the Executive Director of Finance concerning the form of any register and the method of updating, and arranging for a physical check of assets against the asset register to be conducted once a year.
18.2. The Executive Director of Finance will prepare detailed procedures for the disposals of assets.
19. RETENTION OF RECORDS
POLICY – the CCG will put arrangements in place to retain all records in accordance with NHS Code of Practice Records Management 2006 and other relevant notified guidance
19.1. The Chief Accountable Officer shall:
a) be responsible for maintaining all records required to be retained in accordance with NHS Code of Practice Records Management 2006 and other relevant notified guidance;
b) ensure that arrangements are in place for effective responses to Freedom of Information requests;
c) publish and maintain a Freedom of Information Publication Scheme.
20. TRUST FUNDS AND TRUSTEES
POLICY – the CCG will put arrangements in place to provide for the appointment of trustees if the CCG holds property on trust
20.1. The Executive Director of Finance shall ensure that each trust fund which the CCG is responsible for managing is managed appropriately with regard to its purpose and to its requirements.
Page 19 of 19 Audit Committee Item: 15 Enc: 11
Cannock Chase Clinical Commissioning Group South East Staffordshire and Seisdon Peninsula Clinical Commissioning Group Stafford and Surrounds Clinical Commissioning Group
The healthiest place to live and work, by 2025
REPORT TO: The Stafford and Surrounds Clinical Commissioning Group Governing Body Meeting in PUBLIC TO BE HELD ON: Tuesday 28th March 2017
Policies: Conflicts of Interest Policy, Anti Fraud, Bribery Policy, Subject: Whistleblowing Policy and Policy for the Development and Management of Policies and other documents Board Lead: Paul Simpson, Executive Director of Finance Officer Lead: Sally Young, Director of Corporate Governance Author: Rebecca Hough, Governance Manager Approval/ Recommendation: Assurance Discussion Information Ratification
PURPOSE OF THE REPORT:
The Governance Team have reviewed the Anti-Fraud and Anti-Bribery Policy, Whistleblowing policy and have presented these to the Audit Committee on 09 March 2017 which recommends approval by the Governing Body.
The Policy for the Development of Polices and Other Documents has been reviewed ahead of all CCG policies being revised and updated following some suggestions from the Internal Audit PwC.
The Governing Body is asked to approve and ratify the policies.
KEY POINTS:
The CCGs’ Anti-Fraud specialists PwC have drafted the Anti-Fraud and Anti-Bribery policy as a combined document policy and also the Whistleblowing policy in line with NHS Improvement and NHS England, it is recommended that the CCGs adopt the policies. These were presented to the Audit Committee on 09 March 2017 which recommended approval.
Anti-Fraud/Anti-Bribery Policy significant changes: The policy has been reviewed against the changes to NHS Protect Services and responsibility. The policy has been combined as one document as opposed to two separate documents.
Whistleblowing Policy: This policy has been developed in line with the standard by NHS England and NHS Improvement. The policy sets out the criteria for raising any concerns within the CCGs; there is now a requirement for the CCGs to have a Freedom to Speak up Guardian (FTSUG) who would be appointed by the Chief Officer. The role is to act as an independent and impartial Page 1 of 3
Item: 15 Enc: 11
source of advice to staff at any stage of raising a concern with access to anyone in the organisation, including the Chief Officer, or if necessary, outside of the organisation.
Policy for the Development and Management of Policies and Other Documents This has been reviewed and suggestions from Internal Audit, PwC have been included in the policy.
The Governing Body is asked to approve and ratify the policies.
CCG GOALS: Change the culture: Hospital to home Not applicable Professional to patient More focus on prevention Not applicable Involving everyone for improved health and Not applicable care Empower and support patients to take control Not applicable of their own health Services supporting people to make informed Not applicable decisions
IMPLICATIONS: To ensure the correct process is undertaken by staff to ensure decision Legal and/or Risk making of the CCG is not compromised CQC Not applicable Patient Safety Not applicable Patient Engagement Not applicable To ensure the decision making within the CCG is not compromised which Financial could lead to financial implication e.g. litigation and re-procurements Sustainability Not applicable Workforce/Training Not applicable
RECOMMENDATIONS/ACTION REQUIRED: The Governing Body is asked to: Approve the policies
Page 2 of 3
Item: 15 Enc: 11
Not KEY REQUIREMENTS Yes No Applicable Has a quality impact assessment been undertaken? Has an equality impact assessment been undertaken? Has a privacy impact assessment been completed? Has a comms & engagement impact assessment been completed? Have partners/public been involved in design? Are partners/public involved in implementation? Are partners/public involved in evaluation?
CCG VALUES We are honest, accessible and listen Care and respect for all Quality is our day job We innovate and deliver
Page 3 of 3
Item:15 Enc:11-1
Anti-Fraud, Bribery and Corruption Policy and Response Plan
February 2017
Agreed at Cannock Chase CCG
Signature: Designation: Chair of Cannock Chase CCG Date:
Agreed at South East Staffordshire & Seisdon Peninsula CCG
Signature: Designation: Chair of South East Staffordshire & Seisdon Peninsula CCG Date:
Agreed at Stafford and Surrounds CCG
Signature: Designation: Chair of Stafford & Surrounds CCG Date:
Anti-Fraud, Bribery and Corruption Policy Item:15 Enc:11-1
The Anti-Fraud, Bribery and Corruption Policy for Stafford & Surrounds Clinical Commissioning Group, Cannock Chase Clinical Commissioning Group and South East Staffordshire & Seisdon Peninsular Clinical Commissioning Group
Policy number Version number 2.0 Responsible Executive Lead Sally Young, Director of Corporate Governance Author(s) Neil Mohan, Local Counter Fraud Manager PwC Date approved by Audit Committee 09 March 2017 Date ratified by Governing Body See cover page Date issued Review date Date approved by Equality Impact Assessment Target audience All CCG staff including Governing Body Members and Clinical Leaders
HISTORY OF CHANGES Old version number Significant changes New version number 1.0 Review of the three CCG policies and refreshed in 2.0 accordance to guidance by the LCFMS
SUMMARY All suspicions of fraud committed against the CCGs will be investigated Fraud can be defined as “wrongful or criminal deception intended to result in financial or personal gain, or to cause the loss or risk of loss to another. Bribery can be defined as “The offering, giving, receiving, or soliciting of something of value for the purpose of influencing the action of an official in the discharge of his or her public or legal duties” Corruption can be defined as being “where someone is influenced by bribery, payment or benefit in kind to unreasonably use their position to give some advantage to themselves or to another.” Offences under the Fraud Act carry prison sentences of up to 10 years in addition to heavy fines. When an employee suspects that there has been an incident of fraud, bribery or corruption, they must report the matter to the nominated Local Counter Fraud Specialist, or the Chief Finance Officer. Under no circumstances should staff attempt to investigate any instance of actual or suspected fraud, bribery or corruption nor subject any individual(s) to surveillance of any kind. Failure to gather evidence in an appropriate legal manner may undermine any potential criminal investigation and subsequent prosecution.
Anti-Fraud, Bribery and Corruption Policy Item:15 Enc:11-1
CONTENTS PAGE 1. Introduction 4
2. Scope 4
3. Policy Statement 5
4. NHS Protect 5
5. Local Counter Fraud Specialist 7
6. Definitions 8 6.1 Fraud 8 6.2 Bribery 9 6.3 Corruption 9
7. Anti-Bribery Procedure 10
8. Roles and responsibilities 12 8.1 All employees 12 8.2 Managers 13 8.3 Chief Finance Officer 13 8.4 Local Counter Fraud Specialist 14 8.5 Internal and external audit 14 8.6 Human Resources 14
9. Prevention Arrangements 15
10. Investigating Fraud, Bribery and Corruption 15 10.1 Reporting Fraud, Bribery or Corruption 15 10.2 The Process 17 10.3 Investigating Procedures and Methods 17
11. Disciplinary Sanctions 18
12. Recovery 18
13. Conclusion 19
Anti-Fraud, Bribery and Corruption Policy Item:15 Enc:11-1
1.0 INTRODUCTION 1.1 Cannock Chase Clinical Commissioning Group, South East Staffordshire & Seisdon Peninsular Clinical Commissioning Group and Stafford & Surrounds Clinical Commissioning Group, (“the CCGs”) are committed to the anti-fraud, bribery and corruption procedures as laid down in this policy.
1.2 This document sets out the CCGs’ policy for dealing with detected or suspected fraud, bribery or corruption, and the avoidance of such activity as directed by NHS Protect.
1.3 The policy also includes a response plan, setting out the procedure to be followed when employees or members of the public wish to raise concerns in connection with suspected fraud, bribery or corruption.
1.4 The Governing Bodies of the CCGs wishes to encourage anyone having reasonable suspicions of fraud, bribery or corruption to report those suspicions.
1.5 The CCGs will ensure that no employee will suffer in any way as a result of reporting reasonably held suspicions of fraud, bribery or corruption. For these purposes “a reasonably held suspicion” shall mean any suspicion other than those which are raised maliciously.
1.6 All suspicions of fraud committed against the CCGs will be investigated.
1.7 The ultimate aim of the policy is to protect the patients, staff, property, finances and reputation of the CCGs and wider NHS.
2.0 SCOPE 2.1 This policy applies to all employees and members of the CCGs and should also be used by interim staff, agency workers, contractors or suppliers, to report any concerns they may have.
2.2 The CCGs will adhere to the NHS Protect anti-fraud Standards and the NHS Anti-Fraud Manual when investigating cases and seeking to impose sanctions.
2.3 The CCGs will make every effort to investigate fully any suspicion of fraud. It is the policy of the CCGs to seek to recover all losses arising from any identified fraud-related activities, and to take such sanctions as are appropriate.
2.4 All investigations into fraud, bribery or corruption against the CCGs will be reported to the Chief Finance Officer and NHS Protect.
3.0 POLICY STATEMENT 3.1 All employees have a personal responsibility to protect the assets of the CCGs, including buildings, equipment and monies, against the loss from theft, fraud, corruption or any other irregularity.
3.2 The CCGs are committed to maintaining an honest, open culture, so as to best fulfil the objectives of the CCGs and of the NHS.
3.3 The CCGs are also committed to the elimination of any form of fraud, bribery or corruption, to the rigorous investigation of any related allegations and to taking appropriate sanctions when fraud, bribery or corruption is identified. This may include any appropriate combination of criminal prosecution, disciplinary action and undertaking steps to recover any assets lost as a result fraud, bribery or corruption.
Anti-Fraud, Bribery and Corruption PolicyV2 Page | 1
Item:15 Enc:11-1
3.4 It is the responsibility of each member of staff to report any reasonable suspicions to the nominated LCFS. No individual will suffer any detrimental treatment as a result of reporting reasonably held suspicions.
4.0 NHS PROTECT 4.1 NHS Protect is responsible for the prevention of crime within the NHS, and sets the standards that NHS organisations have to follow when tackling crime across NHS funded services.
4.2 As well as setting organisational standards, NHS Protect also sets the standards by which investigators must operate when combating crime within the NHS.
4.3 Only accredited NHS Protect Local Counter Fraud Specialists can be nominated by an NHS organisation to undertake their anti-fraud, bribery and corruption activities.
5.0 LOCAL COUNTER FRAUD SPECIALIST 5.1 The CCGs will nominate an appropriate and accredited person to act as its Local Counter Fraud Specialist (“LCFS”). The roles and responsibilities of an LCFS are determined by NHS Protect and set out within the Anti-Fraud Standards and the NHS Anti-Fraud Manual.
5.2 The LCFS will actively promote an anti-fraud, bribery and corruption culture throughout the CCGs.
5.3 The LCFS will investigate all cases of fraud, bribery and corruption committed against the CCGs, in line with the NHS Anti-Fraud Manual, NHS Anti-Fraud Standards and mindful of the Data Protection Act 1998 and relevant criminal legislation.
5.4 The LCFS will report to CCGs’ Chief Finance Officer, Audit Committee and NHS Protect.
5.5 The LCFS will produce an anti-fraud, bribery and corruption work plan with the CCGs’ Chief Finance Officer, which will be ratified by the Audit Committee.
5.6 The LCFS will attend Audit Committee meetings of the CCGs, to report progress on the annual work plan and raise matters of concern.
The LCFS will regularly liaise with the Chief Finance officer of the CCGs, to discuss matters including any investigations. The LCFS has direct access to the Audit Committee Chair.
6.0 DEFINITIONS 6.1 Fraud can be defined as “wrongful or criminal deception intended to result in financial or personal gain, or to cause the loss or risk of loss to another.”
The Fraud Act 2006 includes a number of offences relating to fraudulent and dishonest actions, the main ones being:-
- Fraud by false representation - Fraud by failing to disclose information - Fraud by abuse of position
Offences under the Fraud Act carry prison sentences of up to 10 years in addition to heavy fines.
6.2 Bribery can be defined as “The offering, giving, receiving, or soliciting of something of value for the purpose of influencing the action of an official in the discharge of his or her public or legal duties”
Anti-Fraud, Bribery and Corruption PolicyV2 Page | 2
Item:15 Enc:11-1
6.3 Corruption can be defined as being “where someone is influenced by bribery, payment or benefit in kind to unreasonably use their position to give some advantage to themselves or to another.”
The Bribery Act 2010, includes a number of offences in relation to bribery and corruption. The generic term “corruption” is accommodated into this act. The main offences listed in the Bribery Act 2010 involve:-
- Offering or paying a bribe - Asking for or receiving a bribe - Bribing a foreign public official - Failing to prevent bribes being paid on behalf of an organisation.
The offences apply to all UK ‘bodies corporate’, which includes all NHS organisations.
The fourth offence is a corporate offence applicable where bribes are paid on behalf of an organisation that has not taken appropriate measures to prevent bribery from occurring. While there are few scenarios within the NHS where this might prove likely, the CCGs and other NHS organisations are nevertheless required to be mindful of the risks that this offence poses.
7.0 ANTI-BRIBERY PROCEDURES 7.1 The guidance accompanying the Bribery Act features a number of principles that apply when considering the risk of bribery and corruption. Being able to demonstrate that these principles have been properly addressed provides some legal defence, should it be proven that bribery has taken place on behalf of the organisation. Although the risk of this occurring in an NHS context is generally considered to be low, the principles form a useful framework for any organisation to demonstrate that it is has adequate procedures in place to prevent bribery.
7.2 The six principles are:
Proportionality The CCGs must have procedures in place to prevent bribery by persons associated with it. These are proportionate to the bribery risks faced by the organisation and to the nature, scale and complexity of the organisation’s activities. They are also clear, practical, accessible, effectively implemented and enforced.
Top Level Commitment The CCGs’ Accountable Officer and Directors should demonstrate that they are committed to preventing bribery by persons associated with the CCGs. They will foster a culture within the organisation in which bribery is never acceptable.
Risk Assessment There are periodic and documented assessments undertaken on the nature and extent of the CCGs’ exposure to potential external and internal risk of bribery. This will include the risk that bribery is carried out on behalf of the CCGs, by persons associated with the CCGs. This includes financial risks but also other risks such as reputational damage.
Due Diligence The CCGs take a proportionate and risk based approach, in respect of persons who perform or will perform services for or on their behalf, in order to mitigate identified bribery risks.
Communication (including training) The CCGs seek to ensure that its bribery prevention policies and procedures are embedded and understood throughout the organisation, through internal and external communication, including training that is proportionate to the risks it faces.
Anti-Fraud, Bribery and Corruption PolicyV2 Page | 3
Item:15 Enc:11-1
Monitoring and Review The CCG will monitor and review that its procedures designed to prevent bribery by persons associated with the CCGs and make improvements to minimise the risk where necessary.
8.0 ROLES AND RESPONSIBILITIES 8.1 All Employees Employees of the CCGs are expected to adhere to the policies and procedures of the Clinical Commissioning Groups and to the Public Service Values (“the Nolan Principles”). All employees also have a duty to protect the assets of the CCGs, including information and goodwill, in addition to property.
Employees are expected to act in accordance with the standards laid down by their Professional Institutes, where applicable.
The CCGs’ Standing Orders and Standing Financial Instructions place an obligation on all staff, to act in accordance with best practice. In addition, all senior staff, and Governing Body Members must declare and register any interests that might potentially conflict with those of the CCGs or the wider NHS.
When an employee suspects that there has been an incident of fraud, bribery or corruption, they must report the matter to the nominated Local Counter Fraud Specialist, or the Chief Finance Officer. (See Section 10 below)
Under no circumstances should staff attempt to investigate any instance of actual or suspected fraud, bribery or corruption nor subject any individual(s) to surveillance of any kind.
All employees should be aware that failure to gather evidence in an appropriate legal manner may undermine any potential criminal investigation and subsequent prosecution.
8.2 Managers Managers must be vigilant and ensure that procedures to guard against fraud, bribery and corruption are followed. They should be alert to the possibility that unusual events or transactions could be symptoms of fraud. Where they have any doubt they must seek advice from their nominated Local Counter Fraud Specialist.
They must establish an anti-fraud and corruption culture within their team and ensure that information on procedures is made available to all staff
Managers should make all members of staff aware of this policy and its contents.
8.3 Chief Finance Officer The Chief Finance Officer is responsible for the funds of the CCGs.
The Chief Finance Officer will oversee the work of the nominated Local Counter Fraud Specialist for the CCGs, and will liaise and discuss with the nominated Local Counter Fraud Specialist the anti-fraud, bribery and corruption arrangements and any investigations undertaken.
The Chief Finance Officer will liaise with NHS Protect with regard to anti-fraud, bribery and corruption arrangements and investigations relating to the CCGs.
The Chief Finance Officer will authorise any prosecution, following discussion with the nominated Local Counter Fraud Specialist and NHS Protect. When investigations have been referred to the Police or the investigation is in conjunction with the Police, the Crown Prosecution Service will make the decision concerning any prosecution.
Anti-Fraud, Bribery and Corruption PolicyV2 Page | 4
Item:15 Enc:11-1
The Chief Finance Officer will, depending on the outcome of investigations (whether on an interim/on-going or a concluding basis) and/or the potential significance of suspicions that have been raised, inform the Chair of the CCGs and the Chair of the Audit Committee of cases, when deemed appropriate or necessary.
8.4 Local Counter Fraud Specialist The nominated Local Counter Fraud Specialist is responsible for delivering all anti-fraud, bribery and corruption arrangements at the CCGs, in accordance with national standards as set by NHS Protect and the NHS Anti-Fraud Manual. The LCFS reports directly to the Chief Finance Officer.
The nominated Local Counter Fraud Specialist will work with key colleagues and stakeholders to promote anti-fraud work and effectively respond to system weaknesses.
The LCFS will investigate allegations of fraud, bribery and corruption.
8.5 Internal and External Audit Internal and external auditors appointed by the CCGs have a duty to pass on any incident or suspicion of fraud, bribery or corruption that they identify as part of an audit, to the nominated Local Counter Fraud Specialist for the CCGs.
8.6 Human Resources (HR) Human Resources will liaise closely with the nominated Local Counter Fraud Specialist, from the outset where an employee is suspected of being involved in fraud, bribery or corruption. Close liaison between the nominated Local Counter Fraud Specialist and HR is essential to ensure that any parallel sanctions (i.e. criminal and disciplinary) are applied effectively and in a coordinated manner.
9.0 PREVENTION ARRANGEMENTS 9.1 Prevention arrangements are a key part of an organisation’s defence against fraud, bribery or corruption. Therefore deterring and preventing dishonesty is a key component in combating internal or external fraud, bribery and corruption.
9.2 Prevention arrangements include revising and strengthening procedures, administrative processes and providing input for review of policies.
9.3 The CCGs need to be aware of system weaknesses that are identified during an investigation. The nominated Local Counter Fraud Specialist and Internal Auditors will advise on the development of procedures to prevent fraud, bribery and corruption when organisational weaknesses have been identified.
10.0 INVESTIGATING FRAUD, BRIBERY AND CORRUPTION 10.1 A key aspect of an effective anti-fraud, bribery and corruption strategy is the ability to undertake a professional and objective investigation into allegations of fraud, bribery or corruption. Early detection both helps an investigation and will minimise the potential for further loss to the organisation.
10.2 Anyone who encounters behaviour, or finds documents that they suspect may constitute fraud, bribery or corruption, should take the following action:-
You should report your suspicions to the nominated Local Counter Fraud Specialist for Cannock Chase Clinical Commissioning Group, South East Staffordshire and Seisdon Peninsula Clinical Commissioning Group and Stafford & Surrounds Clinical Commissioning Group:-
Anti-Fraud, Bribery and Corruption PolicyV2 Page | 5
Item:15 Enc:11-1
Neil Mohan Lead Counter Fraud Specialist Telephone 01509 604029 Email [email protected]
Alternatively, complete the online referral form which is located on the CCGs’ website under the Anti-Fraud Section.
You can also report your concerns to the CCGs’ Chief Finance Officer:-
Paul Simpson Chief Finance Officer Telephone 01785 355784 Email [email protected]
You can also report your suspicions directly to NHS Protect via the Fraud and Corruption Reporting Line on 0800 028 4060,
Alternatively, you can report your suspicions directly to NHS Protect on-line via www.reportnhsfraud.nhs.uk.
10.3 All referrals received will be treated in confidence. The Public Interest Disclosure Act 1998 came into force in July 1999 and provides statutory protection, within defined parameters, to staff that make disclosures about a range of concerns, including fraud, bribery or corruption, which they believe to be happening within the organisation employing them.
While there will be an expectation that referrals will be made having considered any information you may already know. You should retain any potential evidence and make notes of any issues and concerns immediately. You should take no further action once suspicions have been raised in accordance with the policy.
On no account should anyone seek to investigate suspicions of fraud, bribery or corruption themselves, as this may cause difficulties later.
As an example, before making a referral a line manager may want to check records such as an employee’s diary, to ascertain where they should have been on a specific day. Nobody should ever attempt to follow or undertake any type of surveillance on anybody.
Not only might an investigation be jeopardised, but this may entail breaking the law in itself.
10.4 Investigating Procedures and Methods All investigations will be undertaken in a professional and objective manner in accordance with the criminal legislation and procedure, NHS Protect policy and the NHS Fraud and Corruption Manual.
The nominated Local Counter Fraud Specialist for the CCGs will be allowed access to all CCGs employees, directors, contractors, and providers, as well as to systems, processes, records, data and information, as is necessary, in order to progress any investigation. All information requests will be made in accordance with the relevant sections of the Data Protection Act 1998.
During the course of an investigation all relevant legislation will be taken into account.
11.0 Disciplinary Sanctions 11.1 The CCGs will decide on appropriate disciplinary action, in accordance with applicable legislation, in instances when fraud, bribery or corruption has taken place involving an employee.
Anti-Fraud, Bribery and Corruption PolicyV2 Page | 6
Item:15 Enc:11-1
11.2 There will be instances when it is appropriate to pursue more than one course of action at the same time e.g. a criminal investigation and a disciplinary investigation. In such instances close liaison must exist between those investigating criminal and disciplinary matters.
Anti-Fraud, Bribery and Corruption PolicyV2 Page | 7
Item:15 Enc:11-1
11.3 Criminal action should take precedence over disciplinary action. However, care must be exercised as criminal investigations and prosecutions can take much longer to complete and the CCGs should avoid being in a position where they are paying for a member of staff to be suspended whilst awaiting a criminal trial.
11.4 Close liaison must exist between those investigating criminal and disciplinary matters. In situations where an investigation impacts on another, the matter will be referred to the CCGs’ Chief Finance Officer to consider the advice from each investigator and to agree which investigation takes priority.
12.0 RECOVERY 12.1 The CCGs will consider all forms of recovery available under both criminal and civil law, when seeking to obtain recovery. This could include the Proceeds of Crime Act 2002 or the use of debt collection agencies.
12.2 The Chief Finance Officer will consider the recovery options available and authorise the appropriate recovery action, dependent on the circumstances.
13.0 CONCLUSION 13.1 All employees of the CCGs have a duty to protect the assets of the NHS.
13.2 All employees should at all times comply with the CCGs’ internal control systems and procedures, and report any reasonable suspicions of fraud, bribery, corruption or serious criminal misconduct.
Anti-Fraud, Bribery and Corruption PolicyV2 Page | 8
Item: 15 Enc: 11-2
Cannock Chase Clinical Commissioning Group South East Staffordshire and Seisdon Peninsula Clinical Commissioning Group Stafford and Surrounds Clinical Commissioning Group
Cannock Chase Clinical Commissioning Group and Stafford & Surrounds Clinical Commissioning Group
Freedom to speak up: raising concerns (whistleblowing) policy for the NHS February 2017
Item: 15 Enc: 11-2
Contents
Speak up – we will listen ...... 3 This policy ...... 3 What concerns can I raise? ...... 3 Feel safe to raise your concern ...... 3 Confidentiality ...... 4 Who can raise concerns? ...... 4 Who should I raise my concern with? ...... 4 Advice and support ...... 4 How should I raise my concern? ...... 5 What will we do? ...... 5 Raising your concern with an outside body ...... 6 Annex A: Example process for raising and escalating a concern ...... 7 Annex B: A vision for raising concerns in the NHS ...... 8
2
Item: 15 Enc: 11-2
Speak up – we will listen Speaking up about any concern you have at work is really important. In fact, it’s vital because it will help us to keep improving our services for all patients and the working environment for our staff.
You may feel worried about raising a concern, and we understand this, but please don’t be put off. In accordance with our duty of candour, our senior leaders and entire board are committed to an open and honest culture. We will look into what you say and you will always have access to the support you need.
This policy This ‘standard integrated policy’ was one of a number of recommendations of the review by Sir Robert Francis into whistleblowing in the NHS, aimed at improving the experience of whistleblowing in the NHS. It is expected that this policy (produced by NHS Improvement and NHS England) will be adopted by all NHS organisations in England as a minimum standard to help to normalise the raising of concerns for the benefit of all patients.
Our local process has been integrated into the policy/adheres to the principles of this policy and provides more detail about how we will look into a concern [insert link].
What concerns can I raise? You can raise a concern about risk, malpractice or wrongdoing you think is harming the service we Commission. Just a few examples of this might include (but are by no means restricted to):
unsafe patient care unsafe working conditions inadequate induction or training for staff lack of, or poor, response to a reported patient safety incident suspicions of fraud, which can also be reported to our local counter-fraud specialist - Neil Mohan, 01509 604029, [email protected] a bullying culture (across a team or organisation rather than individual instances of bullying).
For further examples, please see the Health Education England video.
Remember that if you are a healthcare professional you may have a professional duty to report a concern. If in doubt, please raise it.
Don’t wait for proof. We would like you to raise the matter while it is still a concern. It doesn’t matter if you turn out to be mistaken as long as you are genuinely troubled.
This policy is not for people with concerns about their employment that affect only them – that type of concern is better suited to our grievance policy [insert link]. http://www.cannockchaseccg.nhs.uk/about-us/our-services/policies/human-resources/171-ccg- grievance-policy
http://www.staffordsurroundsccg.nhs.uk/about-us/our-services2/policies/human-resources/240- ccg-grievance-policy
Feel safe to raise your concern If you raise a genuine concern under this policy, you will not be at risk of losing your job or suffering any form of reprisal as a result. We will not tolerate the harassment or victimisation of anyone raising a concern. Nor will we tolerate any attempt to bully you into not raising any such concern. Any such behaviour is a breach of our values as an organisation and, if upheld 3
Item: 15 Enc: 11-2
following investigation, could result in disciplinary action.
4
Item: 15 Enc: 11-2
Provided you are acting honestly, it does not matter if you are mistaken or if there is an innocent explanation for your concerns.
Confidentiality We hope you will feel comfortable raising your concern openly, but we also appreciate that you may want to raise it confidentially. This means that while you are willing for your identity to be known to the person you report your concern to, you do not want anyone else to know your identity. Therefore, we will keep your identity confidential, if that is what you want, unless required to disclose it by law (for example, by the police). You can choose to raise your concern anonymously, without giving anyone your name, but that may make it more difficult for us to investigate thoroughly and give you feedback on the outcome.
Who can raise concerns? Anyone who works (or has worked) in the NHS, or for an independent organisation that provides NHS services can raise concerns. This includes agency workers, temporary workers, students, volunteers and governors.
Who should I raise my concern with? In many circumstances the easiest way to get your concern resolved will be to raise it formally or informally with your line manager (or lead clinician or tutor).1 But where you don’t think it is appropriate to do this, you can use any of the options set out below in the first instance.
If raising it with your line manager (or lead clinician or tutor) does not resolve matters, or you do 2 not feel able to raise it with them, you can contact one of the following people:
our Freedom to Speak Up Guardian (or equivalent designated person) [insert name(s) and contacts details] – this is an important role identified in the Freedom to Speak Up review to act as an independent and impartial source of advice to staff at any stage of raising a concern, with access to anyone in the organisation, including the chief executive, or if necessary, outside the organisation
our risk management team [insert contact details].
If you still remain concerned after this, you can contact:
our executive director with responsibility for whistleblowing [insert name and contact details]
our non-executive directorLay Member with responsibility for whistleblowing [insert name and contact details].
All these people have been trained in receiving concerns and will give you information about where you can go for more support.
If for any reason you do not feel comfortable raising your concern internally, you can raise concerns with external bodies, listed on page 8.
1 The difference between raising your concern formally and informally is explained in our local process. In due course NHS England and NHS Improvement will consider how recording could be consistent nationally, with a view to a national reporting system. 2 Annex A sets out an example of how a local process might demonstrate how a concern might be escalated.
5
Item: 15 Enc: 11-2
How should I raise my concern? You can raise your concerns with any of the people listed above in person, by phone or in writing (including email).
Whichever route you choose, please be ready to explain as fully as you can the information and circumstances that gave rise to your concern.
What will we do? We are committed to the principles of the Freedom to Speak Up review and its vision for raising concerns, and will respond in line with them (see Annex B).
We are committed to listening to our staff, learning lessons and improving patient care. On receipt the concern will be recorded and you will receive an acknowledgement within two working days. The central record will record the date the concern was received, whether you have requested confidentiality, a summary of the concerns and dates when we have given you updates or feedback.
Investigation Where you have been unable to resolve the matter quickly (usually within a few days) with your line manager, we will carry out a proportionate investigation – using someone suitably independent (usually from a different part of the organisation) and properly trained – and we will reach a conclusion within a reasonable timescale (which we will notify you of). Wherever possible we will carry out a single investigation (so, for example, where a concern is raised about a patient safety incident, we will usually undertake a single investigation that looks at your concern and the wider circumstances of the incident3). The investigation will be objective and evidence-based, and will produce a report that focuses on identifying and rectifying any issues, and learning lessons to prevent problems recurring.
We may decide that your concern would be better looked at under another process; for example, our process for dealing with bullying and harassment. If so, we will discuss that with you.
Any employment issues (that affect only you and not others) identified during the investigation will be considered separately.
Communicating with you We will treat you with respect at all times and will thank you for raising your concerns. We will discuss your concerns with you to ensure we understand exactly what you are worried about. We will tell you how long we expect the investigation to take and keep you up to date with its progress. Wherever possible, we will share the full investigation report with you (while respecting the confidentiality of others).
How will we learn from your concern? The focus of the investigation will be on improving the service we provide for patients. Where it identifies improvements that can be made, we will track them to ensure necessary changes are made, and are working effectively. Lessons will be shared with teams across the organisation, or more widely, as appropriate.
3 If your concern suggests a Serious Incident has occurred, an investigation will be carried out in accordance with the Serious Incident Framework.
6
Item: 15 Enc: 11-2
Governing Body Board oversight The Governing Body board will be given high level information about all concerns raised by our staff through this policy and what we are doing to address any problems. We will include similar high level information in our annual report. The Governing Body board supports staff raising concerns and wants you to feel free to speak up.
Review We will review the effectiveness of this policy and local process at least annually, with the outcome published and changes made as appropriate.
Raising your concern with an outside body Alternatively, you can raise your concern outside the organisation with:
NHS Improvement for concerns about: . how NHS trusts and foundation trusts are being run . other providers with an NHS provider licence . NHS procurement, choice and competition . the national tariff Care Quality Commission for quality and safety concerns NHS England for concerns about: . primary medical services (general practice) (until 31st March 2017 and this will be the CCGs) . primary dental services . primary ophthalmic services . local pharmaceutical services Health Education England for education and training in the NHS NHS Protect for concerns about fraud and corruption.
Making a ‘protected disclosure’ There are very specific criteria that need to be met for an individual to be covered by whistleblowing law when they raise a concern (to be able to claim the protection that accompanies it). There is also a defined list of ‘prescribed persons’, similar to the list of outside bodies on page 8, who you can make a protected disclosure to. To help you consider whether you might meet these criteria, please seek independent advice from the Whistleblowing Helpline for the NHS and social care, Public Concern at Work or a legal representative.
National Guardian Freedom to Speak Up The new National Guardian (once fully operational) can independently review how staff have been treated having raised concerns where CCGs, NHS trusts and foundation trusts may have failed to follow good practice, working with some of the bodies listed above to take action where needed.
7
Item: 15 Enc: 11-2
Annex A: Example process for raising and escalating a concern
Step one If you have a concern about a risk, malpractice or wrongdoing at work, we hope you will feel able to raise it first with your line manager, lead clinician or tutor (for students). This may be done orally or in writing.
Step two If you feel unable to raise the matter with your line manager, lead clinician or tutor, for whatever reason, please raise the matter with our local Freedom to Speak up Guardian:
[Name] [Contact details] This person has been given special responsibility and training in dealing with whistleblowing concerns. They will:
treat your concern confidentially unless otherwise agreed
ensure you receive timely support to progress your concern
escalate to the board any indications that you are being subjected to detriment for raising your concern
remind the organisation of the need to give you timely feedback on how your concern is being dealt with
ensure you have access to personal support since raising your concern may be stressful.
If you want to raise the matter in confidence, please say so at the outset so that appropriate arrangements can be made.
Step three If these channels have been followed and you still have concerns, or if you feel that the matter is so serious that you cannot discuss it with any of the above, please contact [chief executive, medical director, responsible officer, nursing director, nominated Lay Member].
Step four You can raise concerns formally with external bodies [relevant list of prescribed bodies to be provided, similar to that on page 8].
8
Item: 15 Enc: 11-2
Annex B: A vision for raising concerns in the NHS
Source: Sir Robert Francis QC (2015) Freedom to Speak Up: an independent report into creating an open and honest reporting culture in the NHS.
9
Item: 15 Enc: 11- 2
Cannock Chase Clinical Commissioning Group South East Staffordshire and Seisdon Peninsula Clinical Commissioning Group Stafford and Surrounds Clinical Commissioning Group
Contact us
NHS Cannock Chase Clinical Commissioning Group NHS South East Staffordshire and Seisdon Peninsula Clinical Commissioning Group NHS Stafford and Surrounds Clinical Commissioning Group Staffordshire Place 2 Stafford ST16 2LP
T: Staffordshire Place: 07185 356790, 01785 356944
NHS Improvement is the operational name for the organisation that brings together Monitor, NHS Trust Development Authority, Patient Safety, the National Reporting and Learning System, the Advancing Change Team and the Intensive Support Teams.
This publication can be made available in a number of other formats on request.
© NHS Improvement (April 2016) Publication code: Policy 01/16 Publications Gateway Reference: 04877
15 Enc: 11-3
Policy for the Development and Management of CCG Policies and Other Documents
Agreed at Governing Body
Date: ………………………………………………………………………...
Signature: …………………………………………………………......
Chair, Cannock Chase CCG Designation: ………………………………………………………………..
Review Date: ……………………………………………………………….
Agreed at Governing Body
Date: ………………………………………………………………………...
Signature: …………………………………………………………......
Chair, South East Staffs & Seisdon Peninsula CCG Designation: ………………………………………………………………..
Review Date: ……………………………………………………………….
Agreed at Governing Body
Date: ………………………………………………………………………...
Signature: …………………………………………………………......
Chair, Stafford & Surrounds CCG Designation: ………………………………………………………………..
Review Date: ……………………………………………………………….
Policy for the Development and Management of CCG Policies / Version 4.1 Page 1 of 14
15 Enc: 11-3
Policy for the Development and Management of CCG Policies and Other Documents
Policy number Version number 4.1 Responsible Executive Lead Sally Young, Assistant to Chief Officer Author(s) Rebecca Hough, Governance Manager Date approved by XXX Committee Date ratified by Governing Body Date issued Review date Target audience All CCG staff including Governing Body Members and Clinical Leaders
HISTORY OF CHANGES Old version number Significant changes New version number 4.0 Agreed at Governing Body page added Title Page including policy details, history changes and summary Previous review changes not known
SUMMARY To assist with the development of policies by describing and demonstrating the format to be used All policies should be reviewed on a 3-yearly basis. If there is known constant updates this should be set at a shorter date i.e. 12months All policies shall be reviewed by the appropriate Committee prior to ratification of the Governing Body Policies are to be aligned across the three CCG’s unless this is inappropriate All policies should clearly state which CCG they apply to
Policy for the Development and Management of CCG Policies / Version 4.1 Page 2 of 14
15 Enc: 11-3
Contents
Section Section title Page number 1.0 Purpose of Policy 4 2.0 Scope 4 3.0 Definitions 4 4.0 Roles and Responsibilities 5 5.0 The Process for Consultation, Approval and Ratification 6 6.0 Approval Process 7 7.0 Ratification Process 7 8.0 Format, Version Control and storage of Policies, 7 Procedures, Guidelines & Standards
9.0 Equality Impact Assessment 7
10.0 Training 7 11.0 References 8 12.0 Monitoring and Evaluation 8 13.0 Review 8 14.0 References 8 Appendix 1: Format for CCG Policies and Procedures Appendix 2: Route for Policy Ratification Appendix 3: Checklist for Processing and Ratifying CCG Policies, Standards, Procurement and Clinical Guidelines
This policy applies to Cannock Chase CCG, South East Staffs & Seisdon Peninsula CCG and Stafford and Surrounds CCG. Where the term CCG is used, this applies to all three CCGs listed above.
Policy for the Development and Management of CCG Policies / Version 4.1 Page 3 of 14
15 Enc: 11-3
1.0 Purpose The purpose of this document is to provide a CCG wide recognised process for agreeing, producing and monitoring Policies and Procedures.
1.1 The reasons for this are: To enable the CCG’s to meet legal and other compliance standards To provide a clear process for approving and ratifying Policies and Procedures Provides a robust policy management and approval system To ensure a process for the review and updating of policies and procedures To ensure a robust system of risk management and compliance with Governance Standards To ensure consistency in the delivery of practices and procedures within the organisation. To ensure policies and procedures are available for all staff within a recognised format
1.2 All policies are to align process across the three CCG’s, Cannock Chase CCG, South East Stafford and Seisdon Peninsula CCG and Stafford and Surrounds CCG where appropriate to do so.
2.0 Scope This policy describes the process for the development, ratification and review of CCG policies, procedures, guidelines and standards, as defined in section 5 of this policy.
3.0. Definitions 3.1 Policy A policy is a way of ensuring that the philosophy and goals of the service are applied uniformly throughout the organisation, forming a framework within which everyone works. Essentially it provides the organisation with rules.
3.2 Strategy A strategy is a document which describes the organisation’s long term or overall aim on a specific subject
3.3 Procedure/Protocol The term procedure implies that it is an established local sequence and uniform method for performing activity; it gives specific information for those performing the activity.
3.4 Guidelines Often confused with procedure, guidelines are a suggested course of action that provides advice as to when and how an activity should be performed.
3.5 Standards A standard is a required level of quality or competence for a specific practice.
3.8 Consultation The requirement to seek view and opinions of stakeholders within a defined period of time.
3.6 Stakeholders Those with an interest in the matter i.e. patients and service users, staff representatives, finance, human resources, healthcare providers
3.7 Approval The acceptance to put in practice a policy, procedure or any other document by the appropriate Committee.
Policy for the Development and Management of CCG Policies / Version 4.1 Page 4 of 14
15 Enc: 11-3
3.9 Ratification The process that is undertaken to validate a decision made.
4.0 Roles & Responsibilities 4.1 The CCG Governing Body The CCGs’ Governing Bodies have overall responsibility for the policy making process. Delegated authority will be given to the formal sub Committees of the Governing Bodies to approve polices, as described in paragraph 4. HR Policies will need to be signed off by the Staffside Partnership Forum which meets quarterly across Staffordshire and Shropshire CCGs.
4.2 The CCG Committees The CCG Committees have delegated responsibility from the Governing Body to review and approve policies as defined in section 6. The approving Committee should scrutinise the stakeholders that have been involved ensuring sufficient time has been provided, seek assurance that the policy meets statutory duty groups of patients, staff or any others are not excluded.
The Chair of the Committee should ensure that the minutes record the scrutiny and assurance made for the decision of approving or refusing any policy.
4.3 Governance Lead: The Governance Lead has responsibility for: The governance arrangements for CCG policies and procedures Providing the consistency check for all policies and procedures to avoid duplicate and contradictory processes across policies To provide assurance to the Audit Committee meeting held in common that the process for the development and management is robust Liaison between CCGs to provide consistency and in order to avoid duplication Ensure the policies and procedures are provided in key areas of practice, working with colleagues as appropriate Ensuring robust management of policies and procedures Co-ordinating the process of ratification via the CCGs’ committee structure and reporting to the Governing Body Maintaining a database of policies and procedures and production of associated reports on progress Notifying identified individuals of any policies and procedures that require review and/or have not been reviewed/ratified Co-ordinating the process of approval via the formal sub committees of the Governing Bodies and ratification by the Governing Body Ensuring that audit is carried out as part of the monitoring and review process The transfer of ratified signed policies to the CCG websites
4.3 The Executive Management Team are responsible for: The co-ordination of service specific policies, and procedures such as finance & HR across all three CCGs Co-ordinating the review of policies and procedures for all CCGs with an agreed timescale in line with this policy and that the necessary Impact Assessment recording sheet and summary sheet have been completed Ensuring the CCG policies and procedures are accessible to staff at all times and that staff are familiar with them, and ensuring that these are included in the departmental induction process Ensuring out of date policies and procedures are replaced with new policies and procedures when reviewed and re-issued
Policy for the Development and Management of CCG Policies / Version 4.1 Page 5 of 14
15 Enc: 11-3
Maintain a record of signatures by staff members having read and understood certain policies
4.4 All individual employees of the CCG are responsible for: Reading CCG policies and procedures Adhering to CCG policies and procedures Reporting any concerns with implementation to their line manager Participating in appropriate audit relating to individual policies and procedures
4.5 Policy Control The designated officer will be the Governance Lead and responsibilities will be to: i) Ensure ratified policies and procedures will be stored electronically on the CCG X: Drive and be available on the intranet ii) To maintain a copy of previous existing policies for any potential litigation purposes iii) Maintain an electronic database of policies and procedures to inform policy reviews iv) Ensure regular updates to staff about policies and any change to policies v) Co-ordinate the review of policies and procedures within the CCGs within the allotted timescale vi) Maintain the database on the CCG website in line with the CCG Freedom of Information publication scheme
5.0 The Process for Consultation, Approval and Ratification
5.1 Consultation Process It is recognised that it is best practice to consult staff, stakeholders on policy development, bearing in mind that the contents of some policies are a statutory requirement. Stakeholders should be given ample time to review and submit any comments.
If there is an element within any policy being developed that may require staff consultation, then the policy should be considered by the Staffside Partnership Forum for Staffordshire and Shropshire for Consultation.
Any policy / procedure developed must: Contain the watermark ‘Draft’ to be clearly marked on each page until it has been ratified by the CCG processes described in section 4 Adhere to and follow specific ratification process (see below) Demonstrate an evidence based approach with reference clearly identified Be made available, for consultation and comment, in draft format, as widely as possible to groups across the CCGs, prior to ratification Be submitted to the Governance Lead for the consistency check before submission for ratification with the necessary Impact Assessment forms Process as illustrated in flow chart in Appendix 2
5.2 Review Process Minor changes do not require the ratification of Governing Body but may still need to be approved by the relevant Committee. Where the content or process of the policy has changed this will require ratification by the Governing Body. It may also require consultation of appropriate stakeholders.
Substantial changes to a policy or procedure will need to be approved by the formal sub committees of the Governing Bodies (as defined in section 4 and appendix 2) whereby the content of the policy has dramatically changed.
Policy for the Development and Management of CCG Policies / Version 4.1 Page 6 of 14
15 Enc: 11-3
Any change made to the layout or format of a policy does not require approval or where content has not made a substantial change to process. The Governance Team can advise if the approval process is required to be undertaken.
6.0 Approval Process The policy definitions and ratification process is defined below. All approved policies will be signed by the Chair of the three Governing Bodies following ratification.
6.1 Audit Committee Very few, role to monitor application and management of policies
6.2 Finance and Performance Committee Finance and Performance Committee has delegated responsibility to review and approve all corporate policies and procedures that relate to corporate wide issues.
6.3 Quality Committee The Quality Committee has delegated responsibility to review and approve all clinical policies and procedures.
The policies will be shared prior to this with the Chief Nurse to decide whether it will go to the Membership Board and/or Quality Committee and will consult with appropriate specialists including the Head of Infection Prevention and control.
*Infection Prevention & Control Policies are available through Staffordshire & Stoke on Trent Partnership Trust web-site (through their Infection Prevention & Control Team) for all commissioned services under the Service Level Agreement
5.2 6uman Resources / Organisational Development Committee The HR/OD Committee has delegated responsibility to review and approve all policies and procedures relating to human resources, health and safety and organisational development. HR and Health and Safety policies and procedures will be formally reviewed at the Staffside Partnership Forum for Staffordshire and Shropshire or Consultation and approved at the HR OD Group and the Governing Body for ratification before distribution.
7.0 Ratification Process All policies approved will be notified to the Governing Body on approval.
8.0 Format, Version Control and storage of Policies, Procedures, Guidelines & Standards All CCG policies and procedures will be centrally recorded and monitored as well as being stored on the CCG Shared Drive, Intranet site and the CCGs’ websites.
Each policy, procedure, guideline or standard will be assigned a reference number and will adhere to version control. Version numbers will be decimal, substantial changes will require a change of the integer number; minor changes will only require a change to the decimal number. Version numbers will take format ‘0.x’ until they have been ratified, upon ratification the version number will be ‘1.0’.
9.0 Equality Impact Assessment An Equality Impact Assessment must be undertaken to ensure that the policies remain fair and equal.
10.0 Training The implementation of this policy will not require staff to undergo any specific training. The CCG Governance Team will provide assistance on an individual basis, when required.
Policy for the Development and Management of CCG Policies / Version 4.1 Page 7 of 14
15 Enc: 11-3
11.0 References The template for CCG policies and the template for CCG procedures, can be found in appendix 1
12.0 Monitoring and Evaluation The CCG Governance Team will monitor the effectiveness of the policy.
13.0 Review The policy will be reviewed every three years.
14.0 Appendices Appendix 1 – Format for CCG Policies and procedures Appendix 2 – Equality Impact Initial Assessment Appendix 3 – Route for Policy Ratification Appendix 4 – Checklist for Governance Manager
Policy for the Development and Management of CCG Policies / Version 4.1 Page 8 of 14
15 Enc: 11-3
APPENDIX 1 FORMAT FOR CCG POLICIES AND PROCEDURES
Are you writing a policy, procedure, protocols or guidelines – see definitions in the Policy Making Process document.
The document needs to be accessible to those who need to use it so use short, headed paragraphs. It is very daunting to be faced with large tracts of text, which are unlikely to be read. The layout of this policy should be in Font Arial 11 single line spaced, main headings font arial 11 uppercase, subheadings arial 11 lowercase and footers in font arial 9. Each page should contain a footer, with the exception of the cover page and title page, to show policy title, version number and page number. There must be no embedded documents or links to other documents. All policies should be signed by the Governing Body Chairs.
Front Cover - The title of the policy will be selected to ensure that it is memorable and refers to the contents of the policy.
Title Page – For ease of reference it is required to submit a few bullet points to describe the main points of the policy. All field must be completed upon this including details of the changes made to versions.
Contents page – For easy reference to the provisions – the document needs to be user friendly, the whole purpose is that it is used as a reference and should be accessible to those who need it.
Title – this should include the word policy or procedure.
Introduction - A purpose for the policy should be clearly stated along with the need for policy and why there is a requirement (reflects the values of the organisation or policy change from the Government). Any research based evidence and national / professional policy used in formulating the policy should be properly referenced to avoid plagiarism.
Scope – of the policy should also be stated, that is, what are the boundaries of the policy, who does it apply to, who will be carrying it out?
Definitions – it might be necessary to include definitions to ensure clarity. In some cases it might be useful to include a glossary. Abbreviations should be avoided as much as possible. If it is necessary to use abbreviations then a clear indication of their meaning must be included.
Roles and Responsibilities – who is responsible for aspects of the policy, if relevant.
Main body of the policy itself – insert the policy statement text.
Reference to other documents/policies/legislation/guidance – details of procedures might be included in the policy as an appendix. Alternatively the policy might refer to other documents such as strategies, policies, protocols, and procedures – references should be clear so that people can easily find these documents. Particular attention should be paid to the requirements of the Mental Capacity Act, which affects decisions about people aged 16 or over who lack capacity to make decisions for themselves.
Training – any specific training required.
Policy Review - policies need to be reviewed regularly – how often will depend on the subject matter. In the main this should be three years. It if deals with an area that is constantly updating, where more legislation is planned etc then the review period will need to be shorter for example 12 months.
Policy for the Development and Management of CCG Policies / Version 4.1 Page 9 of 14
15 Enc: 11-3
Monitoring and Evaluation – It is good practice to include this information. It should say who will monitor the effectiveness of the policy and how it will be evaluated. This might include reporting requirements. It might refer to internal or external audit. It might include information about Key Indicators to be used or how we benchmark our effectiveness.
References - for any studies/national guidance/articles/legislation etc.
Appendices - these might include:
procedures needed to give effect to the policy forms / documents to be used extracts from national legislative guidance etc. flow charts – for example, showing a process or accountability flow through the organisation any other documents/tools, which help an individual, put the policy in practice
Policy for the Development and Management of CCG Policies / Version 4.1 Page 10 of 14
Appendix 2 - Equality Analysis Initial Assessment
Title of the change proposal or policy:
Brief description of the proposal:
.
Name(s) and role(s) of staff completing this assessment:
Date of assessment:
Please answer the following questions in relation to the proposed change:
Will it affect employees, customers, and/or the public? Please state which.
Is it a major change affecting how a service or policy is delivered or accessed?
Will it have an effect on how other organisations operate in terms of equality?
If you conclude that there will not be a detrimental impact on any equality group, caused by the proposed change, please state how you have reached that conclusion:
APPENDIX 3 - ROUTE FOR POLICY RATIFICATION
Corporate and Clinical Health and HR Policies Commissionin Policies * Safety g Policies
Chief Nurse, who will consult with appropriate specialist e.g. Head of Consultation Infection through formal Prevention & HR/OD subcommittee Control, and Committee and other other formal sub appropriate committees or meetings if membership/loc appropriate ality boards e.g. IG Group, Risk Group etc
Consistency Consistency Consistency Check – Check– Check – Governance Lead Governance Governance and EMT Lead and EMT Lead and
Staffside Partnership Finance and Forum for Performance Consultation Committee Joint Quality Committee
CCG Governing Bodies for ratification
*Infection Prevention & Control Policies are available through Staffordshire & Stoke on Trent Partnership Trust web-site (through their Infection Prevention & Control Team) for all commissioned services under the Service Level Agreement
APPENDIX 4 Checklist for Processing and Ratifying CCG Policies, Standards, Procedures & Clinical Guidelines
TO BE COMPLETED BY THE GOVERNANCE MANAGERS ON REVIEW OF DOCUMENTS
Yes/No/ Title of document being reviewed: Comments Unsure 1. Title Is the title clear and unambiguous? Is it clear whether the document is a guideline, policy, protocol or standard? Is it clear in the introduction whether this document replaces or supersedes a previous document? 2. Introduction Are reasons for development of the document stated?
Are the summary bullets clear and define what the policy is about?
Does the history summarise the changes reflected between the previous version? 3. Consultation Is the method described in brief?
Are people involved in the development identified? Do you feel a reasonable attempt has been made to ensure relevant expertise has been used? Is there evidence of consultation with stakeholders and users? Has the EIA been completed and approved? 4. Content Is the objective of the document clear? Is the target population clear and unambiguous? Are the intended outcomes described? Are the statements clear and unambiguous? Are acronyms referenced in full?
Have links to other document or embedded documents been removed? 5. Evidence Base
Is the type of evidence to support the document identified explicitly?
Yes/No/ Title of document being reviewed: Comments Unsure Are key references cited? Are the references cited in full? Are supporting documents referenced? Has the Mental Capacity Act requirement been included? What evidence has been obtained and is this referenced? 6. Approval
Does the document identify which committee/group will approve it? Has the Staffside Partnership Forum for Staffordshire and Shropshire been consulted? 7. Dissemination and Implementation
Is there an outline/plan to identify how this will be done? Does the plan include the necessary training/support to ensure compliance? 8. Document and Version Control Does the document identify where it will be held? Have archiving arrangements for superseded documents been addressed? Has the version number been updated?
Is there a clear footer which included policy name and page number? Has the Governance Policy Tracker been updated? 9. Compliance and Effectiveness
Are there measurable standards or KPIs to support the monitoring of compliance with and effectiveness of the document? Is there a plan to review or audit compliance with the document? 10. Review Date Is the review date identified?
Is the frequency of review identified? If so is it acceptable? 11. Overall Responsibility for the Document Is it clear who will be responsible for implementation and review of the document?
Item: 16 Enc: 12
Cannock Chase Clinical Commissioning Group South East Staffordshire and Seisdon Peninsula Clinical Commissioning Group Stafford and Surrounds Clinical Commissioning Group
The healthiest place to live and work, by 2025
Audit Committee Meeting in Common 9th March 2017 Feedback Sheet to: The Stafford and Surrounds Clinical Commissioning Group Governing Body Meeting in PUBLIC TO BE HELD ON: Tuesday 28th March 2017
1 Members present: Chair J. Jobson; N. Chambers; H. Ireland; In attendance: S. Young; P. Simpson; Tracey Revill; Rebecca Hough; Internal Auditors – PWC; Anti-fraud – PWC; External Auditors – Grant Thornton. Quorate for SESSP: yes 2 Declarations of Interest: None Declared. 3 Key Points discussed: ‐ Private discussion with Auditors prior to the full meeting. ‐ Financial Instructions recommended changes to include £250k limit for FPC meeting sign off and added delegated limits for Primary care sub-committee. ‐ Reviewed action plan and timetables for year end for annual accounts, report and governance statement. – on target. ‐ Assurance on the CSU and future account management discussed including information governance. ‐ Internal Audit progress – audit completions late in the final quarter. Qipp audit report reviewed. ‐ Anti-fraud progress – on plan including fraud risk workshop completed. ‐ External Audit progress – on plan. ‐ Joint governance implementation plan – good progress with a number of areas now completed including joint BAF/ risk register process/ freedom of information requests/training plans/constitution amendments/ revised policies on conflicts of interest, commercial sponsorship etc. ‐ BAF reviewed. ‐ Internal Audit actions tracker – old actions completed, new on track. ‐ Policies for Anti-fraud and bribery & Whistleblowing. ‐ Hospitality registers/conflicts of interest register/Single Tender Transactions/Losses and special payments reviewed. ‐ Risk register additions – no new risks highlighted. ‐ Note the virtual approval by the IG Group of the IG Handbook and the Subject Access Review Standing operating procedure.
Item: 16 Enc: 12
4 Next steps: ‐ Ensure the year end is completed to plan including the Audit committees input in April and May. ‐ Ensure actions from Internal Audit of QIPP are implemented. ‐ Ensure the hand over plan between newly appointed and existing External Auditors is completed. ‐ Review of the CSU contract management with a new service level agreement to improve performance particularly in regard to information governance. ‐ Embed the principles and actions from the conflicts of interest guidance, particularly in regard to the formation of the new Primary care committee. Review of register to be completed in detail by Governance Lay members before the year end. ‐ Ensure Audit time is allocated to review LES/PMS governance in 17/18. ‐ Ensure Audit time is allocated to delegated commissioning governance in 17/18. ‐ Encourage sub-committee Chairs to proactively use the BAF to guide the discussions and actions needed in their areas to reduce CCGs risks
5 Issues for escalation/ items to Note:
‐ Good progress has been made in combining many aspects of the 3 CCG s governance processes. ‐ Still require improvements in the process of QIPP and need to improve the assurance /service levels from the CSU particularly in the area of information governance. ‐ Complexity and workload in the area of Primary care will increase and therefore propose we focus more audit time to review these areas in 17/18. ‐ Recommend the governing body approves changes on the scheme of delegation to raise approval limits for FPC (£250k) and to propose limits for Primary care. ‐ Audit committee recommends approval of the Anti-fraud and Bribery, and Whistle blowing policies to the governing bodies.
Item: 16 Enc: 13
Cannock Chase Clinical Commissioning Group South East Staffordshire and Seisdon Peninsula Clinical Commissioning Group Stafford and Surrounds Clinical Commissioning Group
The healthiest place to live and work, by 2025
REPORT TO: The Stafford & Surrounds Clinical Commissioning Group Governing Body Meeting in PUBLIC TO BE HELD ON: Tuesday 28th March 2017
Human Resources and Organisational Development (HROD) Committee – Subject: Update Report Board Lead: Sue Harper (Lay Member – Stafford & Surrounds CCG) Officer Lead: Ian Baines/Sally Young Approval/ Recommendation: Assurance Discussion Information Ratification
PURPOSE OF THE REPORT:
This report provides an update on the key points/issues discussed at the HROD sub committee of the Board.
KEY POINTS:
The main points from the January and March Committees are:
Achievement of the Month is going well and has been adopted by the organisations. The nominations received promote the good work of individuals and teams against the CCGs four values. In December we saw a high of 17 nominations over the month that encompassed 22 people. The nominations February were discussed by the March Committee and noted that 10 nominations had been received that valued the work of 17 members of staff. Given the number of nominations a Winner and a Highly Commended were selected for March and subsequently announced in the Accountable Officers weekly message. The HROD performance report was received by the March Committee. It was noted that the rolling 12 month average of sickness had fallen to 2.96%. This is slightly above our own internal target (2.5%) but is encouraging in relation to the Management of Change impact, Winter and the challenging circumstances the CCGs have found themselves in. Encouragingly the in month sickness for January was just 2.48% (target 2.5%). Turnover also remains low at just 0.9% (target 1%) and again is commendable given present circumstances of the CCG. Turnover has remained consistently low over the last quarter. The Committees in January and March heard and discussed feedback from three facets of the Organisational Development Programme:
Page | 1
We are honest, accessible Quality is our day job We innovate and deliver Care and respect for all and we listen
Item: 16 Enc: 13
Cannock Chase Clinical Commissioning Group South East Staffordshire and Seisdon Peninsula Clinical Commissioning Group Stafford and Surrounds Clinical Commissioning Group
Management Development Programme – An internal management development programme has been developed in partnership with the CSU. The programme is aimed at giving people some basic grounding in good management practices (manageing absence, developing teams, undertaking 1:1s) whilst also giving some space for reflection and self awareness. The course is run over three days and to date we have run two co-horts and had 22 CCG managers either completed or actively on the course presently. Feedback has been extremely positive and where improvements could be made we have actively taken on board and altered proceedings. A third cohort is planned for May and June and this may be offered out to other organisations in conjunction with the CSU.
Health & Well Being – the March Committee noted that many of the findings from the recent survey and staff groups aligned to the core themes within the Staff Survey. In particular staff are supportive of formal approaches to weight management, healthy eating and internal mental health initiatives (including apps, guest speakers running relaxation and meditation classes). Support was also given to the ‘Social’ group that has started within the CCGs.
Staff Survey Results – A detailed a lengthy discussion was had in relation to the Staff Survey results and the key themes of strategic vision, consistency of behaviours, learning and development, motivation, environmental factors and teamwork/well being. It was noted that an Action Plan will be developed and be brought back to the Committee for review and assurance. The need to review the appraisal system was seen as an important part of addressing the issues raised and a short life task group is being set up accordingly. It will provide a vehicle for managers to align our goals and values to work of the individual and should also address training and development needs to do their job.
The March Committee noted the progress against the Equality and inclusion goals. In particular the Committee noted the point raised in the staff survey results in regard to equality in the recruitment process. Consideration may be needed to changing the goals of the strategy to ensure that this concern is addressed. The January Committee resolved that statutory and mandatory training needed to be a priority for the Committee and the organisations. The discussion at the March Committee noted that presently mandatory training compliance/recording of compliance is at 48% which whilst improving is still low. At the time of writing this report this had increased slightly to 56%. A communication thanking those that have completed their training is to be sent out and encouraging others to complete by 31st March. The Committee received and approved updates to three HR policies that form the basis of good management practice – Disciplinary, Absence Management and Performance Management. As part of the process for redrafting and agreeing these policies it was necessary to clarify arrangements for sign off by Staff Side for HR policies. These policies will be presented to the Governing Bodies for ratification and adoption.
Page | 2
We are honest, accessible Quality is our day job We innovate and deliver Care and respect for all and we listen
Item: 16 Enc: 13
Cannock Chase Clinical Commissioning Group South East Staffordshire and Seisdon Peninsula Clinical Commissioning Group Stafford and Surrounds Clinical Commissioning Group
CCG GOALS: Change the culture: Culture change at an organisational and Hospital to home personal level is particularly relevant to the Professional to patient agenda of the HROD committee. More focus on prevention Not applicable Yes – the HROD agenda empowers the staff Involving everyone for improved health and and wider to take control of the agenda and care take it forward. Empower and support patients to take control Not directly applicable of their own health Services supporting people to make informed Not directly applicable decisions
IMPLICATIONS: Business Cycle now in place. Committee wants to focus on key areas of Legal and/or Risk legal risk to ensure that individuals/organisation gains benefit whilst protecting legal status – HR Policies and Mandatory Training. Need to have robust HR Governance in place and demonstrate our CQC commitment to staff issues and organisational health. Patient Safety N/A Patient Engagement Recognising that there are links into Comms re the engagement of staff. Implications of sickness and moral can often have a large impact on the Financial financial position of an organisation. See above – recognise that organisational health is equally important in Sustainability delivering and ensuring stability. Training in particular needs to be addressed as there could be both Workforce/Training operational and legal problems should staff not be suitably trained, this is particularly apparent with regard to mandatory training compliance.
RECOMMENDATIONS/ACTION REQUIRED: Governing Body is asked to:
Receive the report from the HROD Committee.
Page | 3
We are honest, accessible Quality is our day job We innovate and deliver Care and respect for all and we listen
Item: 16 Enc: 13
Cannock Chase Clinical Commissioning Group South East Staffordshire and Seisdon Peninsula Clinical Commissioning Group Stafford and Surrounds Clinical Commissioning Group
Not KEY REQUIREMENTS Yes No Applicable Has a quality impact assessment been undertaken? Has an equality impact assessment been undertaken? Has a privacy impact assessment been completed? Has a comms & engagement impact assessment been completed? Have partners/public been involved in design? Are partners/public involved in implementation? Are partners/public involved in evaluation?
CCG VALUES We are honest, accessible and listen Care and respect for all Quality is our day job We innovate and deliver
Page | 4
We are honest, accessible Quality is our day job We innovate and deliver Care and respect for all and we listen
Item: 16 Enc: 14
Cannock Chase Clinical Commissioning Group East Staffordshire Clinical Commissioning Group South East Staffordshire and Seisdon Peninsula Clinical Commissioning Group Stafford & Surrounds Clinical Commissioning Group
The healthiest place to live and work, by 2025
JOINT QUALITY COMMITTEE
Thursday 9 February 2017, 1.00 pm Cedar Tree Hotel, Rugeley, WS15 1DY
Quoracy
09.02.17 09.03.17 Paul Gallagher (PG) Interim Chair Lay Member for PPI (CC CCG) Lay Member for Quality (SES&SP CCG) Lynne Smith (LS) Lay Member for Quality (ES CCG) Anne Heckels (AH) Lay Member Patient & Public Involvement /Finance & Performance (SES&SP CCG) Jan Toplis (JT) Lay Member (CC CCG) Diane Smith (DS) Lay Member (SAS CCG) Raj Saha (RS) X Secondary Care Consultant (ES CCG) Doug Robertson (DR) X Secondary Care Consultant (SES&SP CCG) Dr Adrian Parkes (AP) Clinical Director Quality (SES&SP CCG) Dr Pat Staite (PS) GP (CC CCG) Dr Miriam Masaud (MMa) Clinical Lead (ES CCG) Dr Kate Millward (KM) Clinical Leader – GP (SaS CCG) Heather Johnstone (HJ) Chief Nurse/Director of Quality & Safety Allison Heseltine (AHe)
Deputy Director of Nursing, Quality & Safety (CC, SAS, CCG each from representative CCGplus one SES&SP CCG) Lynn Tolley (LT) Head of Quality & Safety (CC, SAS, SES&SP CCG) Quorum shall be no less than five core members, to include: to include: members, core five than less no be shall Quorum Paul Winter (PW) (Head of Performance & Governance (ES CCG)
Jan Sensier (JS) one Lay Member, one Clinical Quality Lead or Secondary Care Consultant Chief Executive (Healthwatch Staffordshire) Katie Montgomery (KLM) Clinical Quality Improvement Manager X (CC, SAS, SES&SP CCG) Letitia Murray (LM)
X Clinical Quality Improvement Manager (ES CCG)
Page 1 of 17
Item: 16 Enc: 14
Quoracy
09.02.17 09.02.17 09.03.17 Jenny Napier-Dodd (JN-D) Clinical Quality Improvement Manager (CC, SAS, SES&SP CCG) Kay Roberts (KR) Quality Improvement Manager X (CC, SAS, SES&SP CCG) Nigel Williams (NW) Clinical Quality Improvement Manager X (CC, SAS, SES&SP CCG) Debbie Vucetic (DV)
Clinical Quality Improvement Manager (ES CCG) Sue Wilson (SW)
Clinical Quality Improvement Manager (ES CCG) Rob Boland (RB) Quality Improvement Support Manager (CC, SAS, SES&SP CCG) William Hill (WH) Quality Support Facilitator (CC, SAS, SES&SP CCG) Lesley Arnold (LA) Quality Improvement Support Officer (CC, SAS, SES&SP CCG) Mary Johnson (MJ) Senior Medicines Optimisation Pharmacist (SES&SP CCG) Sue Bamford (SB)
Head of Medicines Optimisation (ES CCG) Sharuna Reddy (SR)
SN Pharmaceutical Advisor (CC/SAS CCG) Rebecca Hough (RH)
Governance Manager (CC, SAS, SES&SP CCG) Lisa Bates (LB)
Lead Nurse Adult Safeguarding Jackie Derby (JD)
Head of Infection Prevention & Control Eleanor Wood (EW) Senior Primary Care Development Manager (SES&SP CCG) Tracey Cox (TC) Senior Primary Care Development Manager (CC/SAS CCG) Julie Hughes (JH)
Primary Care Manager (ES CCG) Tracey Finney (TF)
Executive Assistant (Minutes)
AGENDA MINUTES ACTION ITEM NO 1. Welcome and Apologies
Apologies received from: Raj Saha (RS), Doug Robertson (DR), Nigel Williams (NW), Letitia Murray (LM), Kay Roberts (KR), Katie Montgomery (KLM)
2. Declaration of Conflicts of Interest MMa works in A&E at BHFT
Page 2 of 17
Item: 16 Enc: 14
KM and PS are members of GP First Federation
Quoracy The meeting was declared as quorate.
3. Minutes of the Previous Meeting
ES CCG/SES&SP CCG 11 January 2017 The Minutes of the meeting held on the11 January 2017 were agreed as a true and accurate record.
CC/SAS CCG 12 January 2017 The Minutes of the meeting held on the 12 January 2017 were agreed as a true and accurate record.
4. Actions from the Previous Meeting
ES CCG/SES&SP CCG 11 January 2017 Action sheet updated as attached
CC/SAS CCG 12 January 2017 Action sheet updated as attached.
5. Patient Engagement
SES&SP CCG Verbal report given by AH.
The Patient Council held on the 1 February 2017 discussed the new proposals for a joint patient engagement model across CC, SAS and SES&SP CCGs. A presentation from AHe was also given on the work of the quality team, which is valued by the members of the Patient Council. A copy of the new Quality report to the Governing Bodies was also shared with members.
The three PPI Lay Members for CC, SAS and SES&SP have been working towards sharing learning across the three CCGs in terms of face to face management with the public. At the workshop held on the 10 January 2017 it was proposed to move to one Patient Council meeting linking with the Governing Bodies and Comms & Engagement Committee. The membership will be widened to include more representatives from the Voluntary Sector as well as Healthwatch. Sitting below that group will be four district patient groups with representatives from all the key areas the CCGs serve. It is
recognised that there is work to be done to ensure engagement from those hard to reach groups. KM suggested contacting local secondary schools to link in with pupils who have an interest in working within health services. JS also suggested linking in with Young Healthwatch. AH agreed to forward these suggestions to Adele Edmondson, Comms and Engagement Manager.
Two patient stories were reported:
SSOTP Diabetes Service. Patients are being sent letters stating they will be discharged if they do not notify the service if they cannot attend appointments. However when patients contact the service they reach
Page 3 of 17
Item: 16 Enc: 14
an answerphone and are not receiving call backs. KLM to raise this with the Trust. KLM
SDUC 111. A patient was telephoned at 1.30 am asking them to contact their GP as soon as possible in relation to blood tests.
ES CCG LS informed the committee that Ron Dougan (RD), PPI Lay Member for ES CCG had had to stand down from his role. The committee recorded their thanks to RD for his contribution and the value he brought to the committee.
6. Complaints, PALS and Soft Intelligence
Members received the report.
HJ agreed to take any queries back to the CSU team who produce the report. Feedback will also be given to David Brewin (DB), Head of Complaints and PALS.
No themes or trends related to SSOTP.
PG identified that the report for each CCG appears to be in different formats.
LS asked if more qualitative data could be included to provide more assurance.
DS asked whether there was a mechanism to include suggestions as well as complaints and compliments.
JS reported that Healthwatch are currently undertaking a project on access to community services and agree to bring a report back to the April 2017 JS meeting.
JS stated that triangulation of data from different sources had been looked at previously; however this had proved not to be possible. She agreed to bring a prototype report to the committee on the feedback received from JS Healthwatch on different services. JS also reported that UHNM have asked Healthwatch to work with them on their complaints procedure, and are looking at a peer review approach across the county. CCG support and involvement would be welcomed.
7. Risk Register
ES CCG Members received the report produced by PW.
Two new risks have been added to the register. A54 Neurology service provision – BHFT and A55 Neurology service provision – BHFT & VCIL Risk A52 HCAIs (C-Diff Trajectory) has been re-scored higher. Risk A50 Tier 3 Waistlines is proposed for closure by the risk owner.
Page 4 of 17
Item: 16 Enc: 14
No risks have been rescored lower.
The committee agreed to the closure of Risk A50. LS queried whether Risk A48 Non-emergency patient transport should be closed as the service has now been re-procured. PW stated that the risk has been changed from procurement based risk to high dependency transfer and commissioning. The risk is likely to be closed and a new risk opened.
JT queried Risk A39 Safeguarding – MCA/DoLS and asked whether any
additional staff had been recruited to assist with the backlog of DoLS applications. PW agreed to take this back to the risk owner. PW PW clarified that the report was for the committees’ approval. Report Approved.
CC, SAS and SES&SP CCG Members received the report produced by RH.
Two proposed new risks are awaiting approval from the Risk Group. Risk 259 relating to the reopening of UHNM Children’s Emergency Centre and Risk 260 relating to safeguarding capacity.
Two recommendations for closure will be discussed at the Risk Group on the 14 February 2017. Risk 127 avoidable MRSA and Risk 242 relating to the lack of experienced workforce for children and young people at A&E County Hospital.
LS requested Risk 236 be amended to reflect that the lack of a Suicide Action Plan is currently the issue with managing suicide risk. RH agreed to update the register with the risk owner.
8. Quality Impact Assessment
Members received the report produced by KLM and presented by LT.
Governance processes have now been strengthened and a robust audit process is in place.
The plans to procure a new QIA tool have now been placed on hold.
HJ raised the following queries: Use of acronyms within the report. Retrospective £5 per head QIA – needs to be clearer why this review is retrospective. Clarity on the differences between Stage 1 and Stage 2 QIAs. How is the outcome from each QIA reported to other CCGs.
Members agreed to discuss Agenda Item 12 QIA Terms of Reference at this point in the meeting.
9. GP 60 Second Reporting
CC CCG Verbal report given by PS.
Page 5 of 17
Item: 16 Enc: 14
Smoking cessation services across Staffordshire have been decommissioned by Staffordshire County Council (SCC). KM confirmed that practices had been informed that referrals for smoking cessation could no longer be made.
JS highlighted that the issue of public health cuts had been discussed at previous committees and she had raised this with SCC. Healthwatch are currently carrying out a survey on the impact of public health cuts called Funding for the Future, JS agreed to share the link to the survey with the committee and asked if this could be shared as appropriate. A specific survey has also been carried out on drug and alcohol services. JS raised her concerns that although individual Community Impact Assessments (CIA) have been carried out, no cumulative assessment has been undertaken for
those people effected by some or all of the cuts. AH asked whether the CIA for smoking cessation services could be requested and LT agreed to ask for a copy of this.
ES CCG LT No items for discussion reported.
SES&SP CCG Members received the report from AP.
Referrals to Good Hope Hospital being turned down due to lack of capacity.
Issue with no discharge summary issued for a patient which meant the GP was not aware patient had been discharged. KR to raise with
Trust.
Unsafe discharges from BHFT related to bed capacity. Patients being readmitted shortly after discharge. KR
LS raised general concerns regarding unsafe admissions and queried whether readmissions after 30 days were monitored. PW stated that a request for data would need to be made to the contract team. HJ proposed a
focussed piece of work be carried out on discharges and readmissions by a clinical quality improvement manager and WH, working with the contract team to produce a report for the committee.
SAS CCG Members received the report from KM. NW/WH
Outpatient backlog at UHNM creating workload issues for GPs and
practice staff. JN-D stated that a report was due to the UHNM CQRM on the outpatient backlog, however this was not received and only a verbal update given. This has now been raised at the Contract Review Board pre-meet and the lead commissioner is meeting shortly with the Trust. A second request for a report is being submitted, if not received will be raised via contractual levers.
Concerns over the length of time needed to refer patients for
emergency assessments, particularly at UHNM. Issues with trying to get through to switchboard and the Emergency Department, Senior Clinicians then have to be consulted by department staff before referrals are accepted. Anecdotal reports that the Trust will also not
Page 6 of 17
Item: 16 Enc: 14
speak to practice pharmacists or advanced nurse practitioners. PS suggested that a single access point model, such as the one used in Shropshire, would ease some of these problems. JS suggested taking concerns to the A&E Delivery Board which she attends with
Andy Donald (AD), Chief Officer. HJ agreed to raise these issues with AD with a view to discussion at the A&E Delivery Board.
HJ/JS 10. Quality Reports all key providers
Assurance The committee are asked to consider separate assurance levels for Safety
and Quality for each provider. Members are asked to note that any agreement of any level less than assured in relation to safety would require immediate escalation to the relevant Governing Body with a recommendation of any action to be taken.
HJ reminded the committee that the information contained in the provider reports is current up to the point when papers are submitted with a general agreement that any subsequent identified concerns be reported by exception
only. Recently however there have been a number of issues, eg never events, which would impact on the agreed assurance level. It is therefore proposed that any significant new or emerging issues which would impact on assurance levels, and where there is supporting evidence, be raised by quality leads in the committee and taken into account by committee members when scoring that provider.
AHe asked members to note the assurance level reported for BHFT on the
front cover sheet was inaccurate. This should read full assurance for both safety and quality.
Staffordshire & Stoke on Trent Partnership Trust (SSOTP) Members received the report produced by KLM and presented by JN-D.
HJ raised the following queries:
The report front cover sheet states that the Trust will receive a follow up inspection visit from CQC to focus on areas rated as ‘requiring improvement’ and ‘outstanding’. Queried as there were no areas rated as ‘outstanding’ by CQC. JN-D explained this was the description used by the Trust’s Director of Nursing for areas of significant concern or check maintenance of areas that were
performing well. AHe stated she felt thought this was the worded used by CQC. HJ asked that unless formally rated by CQC as having areas outstanding, these words should either be clarified or omitted.
CQC recommendations on page 3 of the report. Clarity needed on whether the Trust is making any progress against the CQC recommendations. JN-D reported this has been raised with the Trust on several occasions which has resulted in the deep dives to CQRM,
Page 7 of 17
Item: 16 Enc: 14
however not completely assured by these. AHe/LT to discuss this with KLM.
Three clinical care incidents reported relating to three separate patients with dysphagia. Further information required on what the
issue was and action put in place by the Trust.
Assurance required on harm free care as reporting is poor with new harm consistently exceeding national levels. KLM The following other queries were raised:
Graph 4 on page 13 of the report re pressure ulcer documentation issues. MMA queried whether there were any pressure ulcers not KLM being documented. JN-D replied that she did not believe so; however documentation was an issue that had been raised at the pressure ulcer review group. Chronology and level of information contained in patient notes was not sufficient to evidence whether pressure ulcers were unavoidable. These then have to be reported as an SI.
SW highlighted that the low number of incidents reported for East Staffs on page 6 of the report would be expected as the Trust do not provide services in East Staffs.
LS highlighted that the staffing data on page 19 of the report includes social care and asked if this could be split out between social care and health. JN-D agreed to take this back to KLM for the March 2017 report.
Trends and themes from learning actions. LS asked for assurance that actions are being progressed and report on numbers closed and outstanding.
JT asked who was referred to in the CQC rating – are services well- led – rated as inadequate. HJ replied this is the Trust’s leadership team who are held to account by their Executive Team. An external KLM review of governance has been undertaken by the Trust with a number of actions identified. JT stated that she felt the Trust did not appear to be leading or promoting any improvements. AP stated that the quality report correlated with what is being seen on the ground in terms of workforce data. JN-D advised caution when looking at the report as the workforce figures contain social care data. Community teams in Tamworth and Lichfield are fully recruited to with sickness rates falling.
Members agreed the following assurance levels for SSOTP: SAFETY: Partial Assurance QUALITY: Partial Assurance
Burton Hospital NHS Foundation Trust (BHFT) Members received the report produced by DV.
The following verbal updates were given:
Page 8 of 17
Item: 16 Enc: 14
Three never events have been reported in January 2017, two of which were in ophthalmology. The Consultant Ophthalmologist has been suspended and an external review commissioned from Moorfields Eye Hospital. A
communication is to be sent to GP practices. LS highlighted that the Trust’s Medical Director, Magnus Harrison, had attended the Joint Quality Committee in January 2016 with a re-visit planned for September 2016. The Trust at that time agreed to commission an external review which did not take place. There have since been a number of patient stories and issues identified with the department. LS asked if the Trust could provide a date by which the review from Moorfields Eye Hospital is to be concluded. HJ stated that this was discussed at the February 2017 CQRM and the Trust had offered to
share the Terms of Reference for the review. Significant assurance had been provided by the Medical Director between January and September 2016. It was agreed that DV would ask the Trust for a date when the review would be concluded at the next CQRM.
The Trust is looking to source additional help with the neurology waiting list
backlog. Discussions have taken place at the ES CCG Governing Body in respect of GPs reviewing the waiting list to confirm which patients may be removed or need to take priority. The data needs to be validated prior to sharing with practices. Once agreed a communication will be sent out to practices. DV KM queried the drop off in cancer 62 days for first treatment numbers. DV replied that a remedial action plan is in place and the CCG is working closely with the Trust to improve these numbers.
LS highlighted the two breaches for cancer 31 day for subsequent treatment where that treatment is surgery and asked how soon patients had been seen. DV reported that both patients had been offered appointments within the
target time however had chosen to reschedule.
HJ highlighted that the dashboard showed HSMR mortality data but further on in the report went on to discuss SHMI and advised that reports needed to be consistent. Members agreed the following assurance levels for BHFT: SAFETY: Partial Assurance QUALITY: Partial Assurance
Virgin Care Improving Lives (VCIL)
Members received the report produced by LM and presented by DV.
Members were reminded that scoring for VCIL is in respect of community services, with a score for the prime contractor role being determined outside of the meeting.
The following queries were raised:
PG highlighted that 2 complaints were reported for December 2016 in the dashboard, but the narrative on page 3 of the report stated 12. DV replied that the number reported was 2.
Vacancy rate on the dashboard is given in numbers for some months
Page 9 of 17
Item: 16 Enc: 14
and percentages for other. LS requested that these are reported in one format only in future. HJ also highlighted that the dashboard is reporting 11 vacancies in December 2016 with the narrative stating 25. DV replied that this is a cumulative figure for November (14) and
December (11).
LS asked whether, given the issues that SSOTP have experienced in recruiting nursing staff, VCIL were more successful. DV replied that VCIL have been able to recruit staff and assured the committee that any vacancies were due to increasing establishments and not an inability to recruit.
LS highlighted that the newly appointed pulmonary rehabilitation
physiotherapist has resigned. DV assured the committee that VCIL have secured 3 slots a week from BOC healthcare and are looking to recruit a replacement member of staff.
JN-D highlighted the 6.5 District Nursing vacancies and whether this would have an impact on SSOTP with staff possibly leaving the Trust to join VCIL.
Members agreed the following assurance levels for VCIL Community Services: SAFETY: Assured QUALITY: Assured
West Midlands Ambulance Service (WMAS) Members received the report produced by NW and presented by RB.
HJ highlighted WMAS receiving an Outstanding rating following their CQC inspection.
The following queries were raised for NW:
Sheffield University were clinically evaluating all red cases as part of the national ARP pilot. LS asked for the outcome of this.
There has been no CQRM since November 2016; LS asked whether a meeting had been held in January 2017. AHe reported that WMAS have proposed moving to a quarterly CQRM via the Contract Review Board. This is currently being considered. AHe also stated that NW has been asked to review governance between the locality group and regional group.
SAS CCG is an outlier for red responses and JT asked if there was a reason for this. JS asked if there was a trajectory for performance to improve.
SW highlighted that the scoring matrix does not allow for organisations where CQRM’s are continually cancelled. To be considered as part of the review of the scoring matrix. Members agreed the following assurance levels for WMAS:
Page 10 of 17
Item: 16 Enc: 14
SAFETY: Assured QUALITY: Partial Assurance
The committee asked that WMAS be informed that assurance levels would be
impacted if CQRM meetings continued to be cancelled.
University Hospital North Midlands Members received the report produced by JN-D.
The following points were raised:
KM highlighted the continued issues with A&E performance. JS stated that some of the issues are related to systems. Patients are not reporting any adverse experiences.
AP asked how assured the committee could be assured on never events and the Trust’s response. JN-D replied that three never events have been reported in the last three months. The Trust is following correct procedures for reporting and has a robust evaluation process in place.
DS stated that it would be useful to have more information on how the Trust are working with WMAS to reduce ambulance demand, but also how they are working with other agencies.
DS asked for assurance on the deep dives carried out by the Trust given lack of assurance into the deep dives carried out by SSOTP.
JN-D replied that a high level of assurance is being provided by the Director of Nursing and the Human Resources team. JN-D is carrying out a deep dive into falls, evaluating RCA’s and the action plans from those. The Trust has a clinical excellence framework and work with each ward area to evaluate the domains within this framework.
LS asked that despite a number of actions reported, there are no reasons given for the Trust’s failure to meet their cancer targets and
asked if this could be included in future reports.
LS asked for HSMR or SHMI mortality date to be included on the dashboard in future reports as this has not been reported since July 2016.
MMA asked whether the ambulance handover >60 minutes was a cumulative figure including the >30 minutes data. JN-D replied that
yes this was a cumulative figure.
Members agreed the following assurance levels for UHNM: SAFETY: Partial Assurance QUALITY: Partial Assurance
Royal Wolverhampton Hospital NHS Trust (RWT)
Members received the report produced by JN-D.
Page 11 of 17
Item: 16 Enc: 14
The following queries were raised:
PG asked whether two never events had been reported by the Trust. JN-D replied this was correct, with one in September 2016 and one in
October 2016.
LS queried whether the friends and family figures for the number of staff who would recommend were correct as these seemed to be low. JN-D agreed to check whether this was recommend or not recommend.
Appraisal rate target on the dashboard is 80%. JN-D to raise at the
CQRM that the committee is not happy with this target.
DS highlighted the development of the frequent attenders project and asked JN-D if she could provide her with more information on the project.
AP asked for more assurance that the Trust are learning from never events as there appears to be no evidence of this. AHe reported that a conversation had been held with the Chief Nurse at Wolverhampton
CCG. The CCG have carried out a visit to the Trust and are supporting an external review. The mitigations recommended have been taken forward by the Trust.
JN-D asked about the no harm proforma for >52 week breaches. JN- D reported this is an initiative put in place by KLM with the Trust. This was due to be presented at the last CQRM. JN-D will chase the Trust for a copy.
Members agreed the following assurance levels for RWT: SAFETY: Partial Assurance QUALITY: Partial Assurance
JN-D Heart of England Foundation Trust (HEFT)
Members received the report produced by KR and presented by AHe
No additional information was reported and no questions raised.
Members agreed the following assurance levels for HEFT: SAFETY: Assured QUALITY: Partial Assurance
Dudley Group NHS Foundation Trust (DGHFT) Members received the report produced by KR and presented by AHe.
Apologies were given for the issues with the data content within the report circulated with the meeting papers. An updated report is available on JN-D request.
The following queries were raised:
Page 12 of 17
Item: 16 Enc: 14
PG highlighted the increase in the number of SIs reported. KR to raise this with the Trust.
Cancer reporting on the dashboard states available quarterly, DV
stated this is monthly data. AHe to feed this back to KR.
LS highlighted missing data from the dashboard which is received from other providers and asked if this could be included in future reports.
LS reminded the committee that there had previously been an issue with a delay in issuing clinical letters, with a KPI being issued by the lead commissioner. She asked if this was still a concern or had been resolved by the introduction of the KPI. KR to raise this with the Trust.
Following discussion, the committee agreed that given the lack of data within the report an assurance level could not be concluded this month. A more comprehensive report to be submitted to the March 2017 meeting.
SDUC OOH Members received the report produced by NW and presented by LT.
LT informed the committee that the provider had failed to submit a quality report on time for the November 2016 period. The report was received on the 30 January 2017. This was challenged at the January 2017 CQRM and escalated to the Contract Review Board for action and will be discussed at the February 2017 CQRM. KR
The following points were raised:
The provider are still manually counting appraisals and mandatory training and do not have an electronic system in place. An action plan and trajectory for receipt of data has been requested.
LS highlighted the difference in the information in the VCIL report and
this report and asked if VCIL were receiving more information. LT stated that NW is aware of this and will speak to DV regarding this outside of the meeting.
JT asked if there was any impact on patients due to the reported KR staffing shortages, particularly in Cannock and Stafford. LT replied that there is no evidence of any patients coming to harm, with cover always being obtained. The provider has ceased its policy of
enhanced payments for short notice booking of shifts. Whilst difficulties were encountered during the transition period, this has overall been a successful process leading to more stability within the GP rota. MMA asked if anything was known about the issues with the indemnity package Vocare were providing for GPs and this could possibly be linked to staffing shortages.
LS highlighted the patient feedback comments, with many saying no further action could be taken due to lack of detail. She felt this was an
Page 13 of 17
Item: 16 Enc: 14
opportunity lost by the provider to investigate the themes behind the feedback. NW to feed this back to SDUC OOH.
Members agreed the following assurance levels for SDUC OOH:
SAFETY: Partial Assurance QUALITY: Partial Assurance
Walsall Healthcare NHS Trust Members received the report produced by NW and presented by RB.
The following queries were raised:
SW asked if there was any reason the Trust did not know they if they were compliant with duty of candour as no data had been reported between September and December 2016. LT reported that the Trust are undertaking an audit and cleansing process of all incidents etc and updates should be provided in future quality reports.
LS asked whether the Trust had an action plan in place for the follow up appointment backlogs and if there was a date by when these would be reduced. RB replied that the issue had been discussed at CQRM and an action plan is in place, but he was not aware of a date. LS asked if the next quality report could include details of how the Trust is performing against the plan.
JS asked whether the committee should be concerned about mortality rates at the Trust as the report states that hospital deaths are continuing to rise and it is unclear whether this is a system issue. RB replied that the Trust are looking into their mortality reporting and are carrying out an 18 point review of care. Mortality reporting will be monitored by the CQRM.
Members agreed the following assurance levels for Walsall: SAFETY: Partial Assurance QUALITY: Partial Assurance
Page 14 of 17
Item: 16 Enc: 14
11. Medicines Optimisation
CC/SAS.SES&SP Members received the report produced by SR.
The report includes information on the three CCGs performance on antibiotic prescribing targets and also incidences of C-Diff. The report also discusses Use of Point of Care C-Reactive Protein (CRP) tests in primary care.
Members agreed to discuss Agenda Item 13 Strategic Medicines Management at this point in the meeting.
ES CCG Members received the report produced by SB.
SB informed the committee that changes had been made to the report to include a rag rating for the CCGs position against both the national baseline and a local rating. The committee approved these changes to the report.
No questions were raised.
12. QIA Terms of Reference (TOR)
Discussed after Agenda item 8.
The QIA Terms of Reference were presented to the committee for approval.
Changes have been made to the membership and quoracy sections of the TOR to ensure lay member representation from all four CCGs. If a QIA specifically affects one CCG and that lay member is not able to attend, an opportunity must be given for that lay member to be able to provide feedback on the QIA. JT asked whether all lay members were able to join the group as she has not been invited to attend. PG advised that Sally Young, Director of Governance, is reviewing lay member roles and would be able to advise which lay members should attend.
Page 15 of 17
Item: 16 Enc: 14
The TOR were Approved subject to the following amendments:
Core membership should read Deputy Director of Nursing, Quality and Safety or Head of Nursing, Quality & Safety or Assistant Head of Nursing, Quality & Safety. Lay member representation: To be changed to indicate the number of lay members who are core members of the group.
13. Strategic Medicines Management
Discussed after Agenda item 11.
Controlled Drug Local Intelligence Network (LIN) Members received the report produced by SR.
Area Prescribing Group (APG) Members received the report produced by SR.
SR brought to the committee’s attention guidelines for gluten-free prescribing which were approved by the APG and Diabetes Guidelines which will be presented to the CCG Membership Boards for review.
A number of issues have been identified in relation to shared care agreements and a mapping exercise of what shared care agreements are currently in use and any gaps is to be undertaken. This report will be brought to a future meeting.
14. Serious Incident Report
Members received the reports for both ESCCG/SES&SP CCG and CC/SAS CCGs produced by the Risk Team.
No questions were raised.
15. Items to Report to Governing Body
Decommissioning of Smoking Cessation Services
Items to Report to Other CCG Committees
None
Items for Escalation to the Area Team
None
20. Items for the Risk Register and leads identified
None
21. Any Other Business
Page 16 of 17
Item: 16 Enc: 14
PG proposed holding a second joint committee in March 2017, after which an evaluation will take place on taking this forward. The committee agreed to this proposal.
HJ reported that she has been nominated for the West Midlands Leadership Academy Recognition Awards – Inspirational Leader Award. She is one of three finalists and will attend the award ceremony on the 28 February 2017.
LT asked the committee for their feedback on the changes to the provider quality reports. PG asked if reports could be more consistent in reporting in future.
Date and time of next meeting
Thursday 9 March 2017, 1.00 pm, Rugeley Community Centre, Burnthill Lane, Rugeley, Staffs, WS15 2HX.
Page 17 of 17
Item: 16 Enc: 15
The healthiest place to live and work, by 2025
REPORT TO: The Stafford and Surrounds Clinical Commissioning Group Governing Body Meeting in PUBLIC TO BE HELD ON: Tuesday 28th March 2017
AUDIT COMMITTEE (Meeting held in common)
Thursday 5 January 2017, 2.00 pm Dining Room, County Buildings, Stafford
Members
Quoracy
18.04.16 23.05.16 25.07.16 08.09.16 05.01/17 Present
Jeni Jobson (Chair) (JJB) Lay Member Governance X SES&SP CCG Neil Chambers (NC) Lay Member Governance CC CCG Paul Gallagher (PG) Lay Member PPI CC CCG X
Lay Member Quality SES&SP CCG
Anne Heckels (AH) Lay Member PPI & Finance X SES&SP CCG Harry Ireland (HI) Lay Member Governance X X X X SAS CCG Diana Smith (DS) Non-statutory Lay Member X X SAS CCG
each CCG from One Lay Member Quoracy: In Attendance
Paul Simpson (PS)
X Director of Finance Sally Young (SY)
Assistant to Chief Executive Rebecca Hough (RH) Governance Manager SES&SP CCG Tracey Revill (TR) Governance Manager SAS/CC X CCGs
Minutes Approved ‐ Audit Committee held 09.03.17 Page 1 of 10
Item: 16 Enc: 15
Members Quoracy 18.04.16 18.04.16 23.05.16 25.07.16 08.09.16 05.01.17 In Attendance
Alison Breadon (AB) Head of Internal Audit X X X PricewaterhouseCoopers Joanna Watson (JW) Internal Audit Senior Manager X PricewaterhouseCoopers Neil Mohan (NM) Counter Fraud Senior Manager X X X PricewaterhouseCoopers Dominika Kortus (DK) Internal Audit Senior Manager X X X PricewaterhouseCoopers Grant Patterson (GP)
X X X Grant Thornton Simon Turner (ST)
X X Grant Thornton James Mclarnon (JM)
X X Grant Thornton
Andrew Donald (AD)
X X X Chief Officer Vicky Hilpert (VH)
X X Deputy Director of Finance Tom Theron (TT)
X Interim Financial Controller David Skelton (DS)
Financial Controller
The minutes are produced in order of the agenda.
AGENDA MINUTES ACTION ITEM NO 1. Welcome and Apologies
Apologies were received from: Harry Ireland (HI), Anne Heckels (AH), Alison Breadon (AB), Neil Mohan (NM), Grant Patterson (GP)
Declaration of Conflicts of Interest None were declared.
Quoracy The meeting was quorate for Cannock Chase (CC) and South East Staffs & Seisdon Peninsula (SES&SP) CCGs, but not quorate for Stafford & Surrounds (SAS) CCG. HI and DS would be asked to approve items for approval on behalf of Stafford and Surrounds CCG.
2. Minutes from the meeting held on the 8 September 2016
The Minutes of the meeting held on 8 September 2016 were agreed as a true Minutes Approved ‐ Audit Committee held 09.03.17 Page 2 of 10
Item: 16 Enc: 15
and accurate record with the following amendment:
Page 5 Review External Audit Progress Reports: Final bullet point to be changed from NC made to highlighted the statement to NC highlighted the statement.
It was agreed that Price Waterhouse Coopers would be referred to as PwC. 3. Actions from the meeting held on the 8 September 2016
Action sheet updated as attached.
4. Review of internal audit progress reports
The Committee received the report produced by PwC and presented by JW.
Progress made against the 2016/17 internal audit plan:
Corporate governance: regular meetings continue to be held with the CCGs. A number of documents including the Risk Management Strategy have been critically evaluated. A survey will be performed to assess whether CCG employees feel the new shared management team is operating effectively.
Risk management: terms of reference have been agreed and observations at two Governing Body meetings have been carried out so far with the third booked for the end of January. Observations have also taken place at EMT and Risk Group has taken place. There will be a focussed review of risk management in quarter 4.
Finance: work commenced in December 2016 focussing on financial reporting processes within the CCGs.
IT risk diagnostic: a workshop was held on the 12 December 2016 with representatives from all the Staffordshire CCGs and CSU. A sample of controls is being validated and a draft report is anticipated at the end of January 2017.
Audit follow up: waiting on supporting evidence requested from the CCGs.
QIPP: the final report has been agreed with Chris Bird (CB) Director of Contracts, Performance & Information. The report has been classified as high risk; The review looked at month 5 data. The findings were reported as: High Risk Governing Body reporting: delays found in reporting from the Finance & Performance (F&P) Committee. SY reported she had had a discussion with CB about the possibility of a highlight report to Governing Body. JJB advised that the SES&SP Governing Body receives a report from the Chair of each committee on key issues. PS stated he was assured the Governing Bodies were fully apprised of both the individual and collective financial position for the three CCGs, of which QIPP equates to a low contribution of the overall finances. GP engagement: insufficient engagement was found from clinicians. This has been discussed with CB and each QIPP scheme will be
Minutes Approved ‐ Audit Committee held 09.03.17 Page 3 of 10
Item: 16 Enc: 15
assigned a GP as clinical champion. Medium Risk PMO reporting – medium risk: this includes the financial recovery plan and contract challenges as well as QIPP. Soft intelligence reporting: action include soft intelligence to be adequately captured and reported to the FPC committee, increased use of action logs in comply and explain sessions. Clarity of financial reporting Formalised process
Report on actions to be brought to the March 2017 Audit Committee.
Medicines management: agreed with the Director of Primary Care this was to be conducted with pharmacies contracted by NHS England rather than the CCGs and therefore out of the scope of PwC’s work.
Contract arrangements with CSU: work has been paused whilst the CSU contract is out to tender.
Partnership engagement: draft terms of reference have been agreed.
Primary care co-commissioning: draft terms of reference have been agreed.
Conflicts of interest: draft scope document has been issued to the CCGs for discussion and agreement.
Information governance (IG): internal audit of the IG toolkit will be carried out as required by HSCIC, across all Staffordshire CCGs. SY stated she felt there was now a consistent approach to information governance across the three CCGs. IG officers employed by the CSU offer advice on individual areas of expertise. PG stated his concerns with IG with regard to efficiency and timeliness of dealing with issues. SY asked RH/TR to look at PG’s concerns. RH/TR to raise with IG Team RH/TR
PS reported to the committee that he would be meeting with AB shortly in order to look at the plan for 2017/18.
5. Review and approve counter fraud progress reports
The Committee received the report produced by PwC and presented by RB which detailed progress made against the plan.
The main areas of work outstanding are those under prevent and deter including holding a fraud risk group and review of CCG policies. The fraud risk group needs to be completed by February 2017, if not this may affect the Self Review Tool (SRT) due to be submitted in March 2017. An alternative proposed is for PwC to provide the CCG with a general fraud risk assessment based on knowledge of work with other CCGs for PS and SY to review. SY reported difficulties had been encountered in gaining representatives from directorates to hold a fraud risk meeting. The following actions were agreed:
RB to send PS/SY fraud risk assessment for review. PS/SY
Minutes Approved ‐ Audit Committee held 09.03.17 Page 4 of 10
Item: 16 Enc: 15
SY to convene a fraud risk group to discuss the fraud risk assessment SY with NM.
Three referrals were received in 2016/17, with two now closed and one ongoing. A further referral has been received and an update will be provided to a future committee.
The Committee accepted the report.
6. Investigation Report
Item discussed in confidential session. 7. Review external audit progress reports
The Committee received the report produced by Grant Thornton and presented by ST. Highlights from the report included:
Interim accounts audit: visits have been agreed with the CCGs’ finance teams for January and February 2017. Visits will include a review of the CCG control environment, updated understanding of financial systems, review of internal audit report on core financial systems, early work on emerging accounting issues and early substantive testing. The Audit Plan will be brought to the March 2017 committee.
Statutory powers: consideration will be given to a referral to the Secretary of State due to a breach in revenue resource limits.
Final accounts and value for money audit: will take place in between late April and late May 2017. The audit findings report will be presented to the May 2017 committee.
Value for money conclusion: an initial risk assessment will be carried out and reported in the Audit Plan.
NC asked PS/DS for assurance that the finance team would have sufficient time available to work with external audit and ensure that deadlines are not missed. PS and DS both gave assurance this would be the case.
The Audit Committee accepted the report.
8. Appointment of External Audit
The committee was asked to approve the terms of reference for the Audit Panel. They were advised that an Audit Panel meeting had been held prior to the meeting.
Audit Panel Terms of Reference APPROVED, subject to confirmation of approval by HI & DS.
9. Prime Financial Policies and Scheme of Delegation
DS presented the report on the Prime Financial Policies and Scheme of
Minutes Approved ‐ Audit Committee held 09.03.17 Page 5 of 10
Item: 16 Enc: 15
Delegation.
He advised that there are no changes recommended to the Prime Financial Policies.
The proposed changes to the Scheme of Delegation are in respect of CSU staff responsibilities reflecting the transfer of the embedded finance team into the CSU.
JJB queried whether the authorisation by Remuneration Committee of any changes to salaries and payments for the Accountable Officer and Executive Directors should be included in the Scheme of Delegation to ensure it is clear where this responsibility lies. PS and SY both stated they felt the CCGs’ constitution clearly set out the Remuneration Committee’s responsibilities. SY/DS Discussion took place on whether this should be included and SY/DS agreed to review this.
NC asked what the approval process was for contracts with either the voluntary or private sector. PS replied that any such contracts would be reviewed by the F&P Committee prior to submission to the Governing Body.
10. Review of the LPF and CSU Assurance
PS gave a verbal update to the committee.
Discussions have been held with Derek Kitchen (DK), Managing Director of Midlands and Lancashire CSU, with regard to moving away from the Lead Provider Framework (LPF) with the re-provision of services to be based on specifications developed for the LPF process. DK is seeking clarity on this from NHS England. A report will be presented to the three Governing Bodies.
The Committee received the verbal update.
11. Presentation of the Board Assurance Framework (BAF) and Risk Register Process
SY reported that considerable work has been carried out on the BAF and Risk Register.
She provided assurance that the risks are being more effectively managed with the Risk Group now holding Executive Directors to account, but there is still work to be done. NC stated he expected to Executive Directors to consider risk management a key role with their new portfolios.
The Committee received the reports.
12. Draft Risk Strategy
The Risk Strategy has been under review and re-drafted in line with the new BAF and Risk Register. This has also been reviewed by internal audit.
SY asked Governing Body members to review the strategy and submit
Minutes Approved ‐ Audit Committee held 09.03.17 Page 6 of 10
Item: 16 Enc: 15
comments by the 11 January 2017. The strategy will then be sent to the three Governing Bodies for approval.
It was recommended by the committee that Governing Body APPROVE this policy following any additional comments made.
13. Annual Report and Account 2015/16 Submission
SY presented the report to the committee, which includes prominent dates for submission of the Annual Report and Accounts.
14. Dynamic Procurement Tool (Continuing Healthcare)
The committee welcomed Trish O’Donnell (TD), CHC Business Lead for MLCSU, Rebecca Crawford (BC), CHC Finance Manager and Karen Farrell (KF), Interim QIPP Development Manager, to the meeting.
An overview and progress towards the objectives set as part of the implementation of the ‘adam’ dynamic procurement tool were given to the committee which included:
Improving the measurement of quality: this concerns being clearer on which homes are meeting CQC requirements. A wider range of checks are now carried out before an organisation can enrol on to the system as a provider. The main one of these is that each one must achieve an 84% quality measure. There are also local KPIs in place. Each provider has to sign up to the particular categories of care they wish to provide, which ensures that patients are placed appropriately. This can be evidenced from an audit point of view. The patient’s requirements are automatically sent out by the system to an average of 20 -25 providers with offers coming back within 24 hours.
Reducing cost: an average of 67 referrals are received per month with a 2 to 3 days reduction in discharge time being achieved. One of the savings from this can be seen in hospital bed days. There has also been a change to payment processes, which means finance teams now have more time to carry out data validation and audit checks. There are now 56 providers enrolled on ‘adam’ which were not being used prior to implementation. There have unfortunately been a number of home closures which has seen the closure of approximately 245 beds, mainly in South Staffordshire. This has impacted on capacity and competition savings.
Contract management: each provider is now required to have an NHS contract which is managed by the CSU business management team.
Sustainability and further value: placements are now based on a geographical catchment area which families can specify. More intelligent decisions can be made on where to place patients, which can lead for example to fewer complaints. The tool provides data on where capacity is, which providers can using if they are looking to invest in additional beds. There is a public access website which shows activity including the number of cases, category and the value attached to each case.
Minutes Approved ‐ Audit Committee held 09.03.17 Page 7 of 10
Item: 16 Enc: 15
The discussion was then held open to questions from the committee:
JJB asked whether people could still be placed manually. TD advised that this does happen on occasion. However the ‘adam’ system provides a clear audit trail on the decision process.
PG asked whether recent home closures had had an impact and if this was likely to recur in the future. TD replied that there is a significant risk of home closures occurring again and the team are working with the Care Quality Commission (CQC). The CHC team have been looking to introduce some local quality measures. A return is completed by the team each time a visit is undertaken and this acts as an early warning system.
NC thanked the team for the work they have carried out since the counter fraud investigation. He went on to ask how the system managed step up or step down of a patients needs and any associated increase or decrease in payment. TD replied that a service receipt is required weekly from each home, which includes confirming that the patient is still in the home and any changes to the level of care, before any payment is made. . Homes can request an increase in fees, however this is not agreed or paid until an assessment by the CHC team has been carried out. A review process is in place where each patient is reviewed as a minimum every 12 months, with some patients reviewed every 3 months.
NC further queried whether all outstanding overpayments had been paid back. TD confirmed they have, however stated that overpayments could still occur.
PG enquired about double payments, where both the NHS and Local Authority pay for a patient’s care. TD stated there is a risk of this happening with two different financial systems, with CHC not sited on the local authority system. There is a line in the contract stating that the provider must declare any double payments.
PS asked whether the lack of placements available for patients exerted any pressure on cost. TD replied that there is a direct correlation between lack of placements and an increase in fees. Recent home closures has led to a lack of capacity and a drop in the number of offers received, with available placements being taken up by displaced patients. The team do have a cost containment plan in place and as part of this do try to re-engage with any homes that no longer make offers.
JJB thanked TD, BC and KF for attending the committee.
The Committee received the report.
15. Conflicts of Interest including Gifts and Hospitality Policy Commercial Sponsorship Policy
The committee were asked to approve the above policies.
PS reminded the committee that the role of the Audit Committee was to
Minutes Approved ‐ Audit Committee held 09.03.17 Page 8 of 10
Item: 16 Enc: 15
scrutinise policies and ensure they were fit for purpose before recommending approval by the Governing Bodies.
Conflicts of Interest including Gifts and Hospitality Policy. It was recommended by the committee that Governing Body APPROVE this policy
Commercial Sponsorship Policy. It was recommended by the committee that Governing Body APPROVE this policy
16. Conflicts of Interest
SY presented the Conflicts of Interest register for governing body members. The register for GP practice staff is currently being updated with data still being collected from practices.
NC asked if any GP practice staff fail to declare a conflict of interest and a conflict subsequently came to light, where would responsibility for any actions lie. SY reported that all practice staff including GPs, practice managers and practice nurses (who are involved in any CCG commissioning work) are now required to declare any conflicts. She suggested that the governance lay members could review the register with RH/TR.
The Committee received the register
17. Internal Audit Recommendations Tracker
RH presented the internal audit recommendation tracker. One recommendation remains open for the three CCGs from 2015/16 which relates to the Quality Strategy. It is anticipated this will be complete by the end of January 2017. JW confirmed there would be no implications for the CCGs if this action remained incomplete at the end of the financial year.
The Committee noted the outstanding recommendation and the update provided.
18. Update from the Information Governance (IG) Group
RH gave a verbal update from the Information Governance Group. The last meeting was held in November 2016.
With regard to IG training, Cannock Chase and Stafford & Surrounds CCGs are at 61% and South East Staffs & Seisdon Peninsula at 77%. Training sessions are still available for staff to attend. The overall toolkit score is at 27%. This should increase over the next few weeks.
The IG handbook is due for renewal, however the CSU IG team have advised that there are no changes required and have issued this to the CCGs for signing off.
The Committee received the verbal update.
Minutes Approved ‐ Audit Committee held 09.03.17 Page 9 of 10
Item: 16 Enc: 15
19. Review of the Hospitality Register
For information only. No questions were raised.
20. Review of the Losses and Special Payments
For information only.
PS reported that there has been one voluntary redundancy approved as part of the recent Management of Change.
21. Review of waivers for Single Tender Contracts
For information only.
JJB queried the payment made to KPMG on the 5 May 2016. PS informed the committee this payment was for pre-work carried out by KPMG prior to them winning the competitive tender process for the STP work.
22. Counter Fraud Circular: Quality Assurance Process (C/G/06/2016-17)
For information only. No questions were raised.
23. Crimestoppers, tackling NHS Fraud: 24 hour line reporting
For information only. No questions were raised.
24. Cycle of Business
No questions were raised.
25. Any Other Business
None.
26. Items to be reported to the Governing Body
To recommend approval of the following documents: Conflicts of Interests Policy Commercial Sponsorship Policy Risk Strategy .
27. Date and time of next meeting
Thursday 9 March 2017,1.30 pm, Drawing Room, County Buildings, Stafford
Minutes Approved ‐ Audit Committee held 09.03.17 Page 10 of 10
Item: 16 Enc: 16
Cannock Chase Clinical Commissioning Group South East Staffordshire and Seisdon Peninsula Clinical Commissioning Group Stafford and Surrounds Clinical Commissioning Group
The healthiest place to live and work, by 2025
Joint Finance, Performance and Contracts Committee Monday 23rd January 2017 2.30 pm – 17.00 pm Western Springs Room, Cannock Chase District Council Offices, Cannock, WS11 1BG
Members: 20/04/16 19/05/16 22/09/16 20/10/16 23/01/17 Quoracy 21/07/16 17/08/16 Anne Heckels (AH) – Chair - Lay Member PPI and Finance (SESSP) Jeni Jobson (JJB) – Lay Member for Governance (SES&SP) Dr Tim Dukes (TD) – Locality Director, Seisdon (SESSP) Dr Sekhar Singu (SS) – Locality Director, Tamworth (SESSP) Dr John James (JJ) – Chair of SES (SESSP)
Dr Gary Free (GF) – Clinical Lead (CC) Dr Mohammed Huda (MH) - GP Chair/Clinical Lead (CC) Dr Shammy Noor (SN) Locality Director, Lichfield and Burntwood (SESSP) Rob Lusuardi (RL) - Director of Operations Lynn Millar (LM) - Director of Primary Care Diana Smith (DS) - Non-statutory Lay Member (SAS) Dr Marianne Holmes (MaH) - Clinical Lead (SAS) Harry Ireland (HI) - Lay Member Governance (SAS) Chris Bird (CB) - Director of Performance, South East Staffordshire and Seisdon Peninsular Paul Simpson (PS) - Director of Finance Allison Heseltine (AHe) - Deputy Director of Nursing Quality and n/a n/a Safety.(Joined the organisation in May 2016)
Elizabeth King (EK) Executive Assistant (minute taker) Barry Weaver (BW) – Senior Improvement IFR Manager n/a n/a n/a n/a Sarah Carter (SC) – Interim Consultant QIPP n/a n/a n/a n/a Michael Brookes (MB) - Head of Contracts, CSU n/a Samantha Buckingham (SB) - Medicines Management n/a n/a n/a n/a Mahesh Mistry (MM) - Head of Medicines Optimisation n/a n/a n/a n/a Steve Forsyth (SF) - Head of Quality and Nursing n/a n/a n/a n/a Victoria Hilpert (VH) - Deputy Director of Finance n/a n/a n/a Ruth Yates (RY) - Head of Performance and Programme n/a n/a n/a n/a Jane Chapman (JC) – Priorities Commissioner n/a n/a n/a Bethany Ballinger (BB) - Administrator n/a n/a n/a n/a Alex Bennett (AB) - n/a n/a n/a n/a n/a n/a Action Welcome by the Chair 1.
The Chair welcomed all present to the meeting. Apologies for Absence 2.
Dr Mo Huda, Dr John James, Lynn Millar, Dr Paddy Hannigan, Alison Heseltine
Page 1 of 7
We are honest, accessible Quality is our day job We innovate and deliver Care and respect for all and we listen
Item: 16 Enc: 16
Action
Quoracy 3. It was noted that the meeting was quorate.
Conflicts of Interest 4.
It was noted that any matters relating to GP First were a conflict of interest for the GPs present.
5. Minutes of Previous Meeting
Members confirmed that the minutes of the 21st December 2016 are a true and accurate record of the meeting subject to the following amendments:
Page 3, paragraph 5 PS confirmed he is unaware of what will happen nationally although it was confirmed the position which Staffordshire is currently in will be replicated throughout the country. It is believed £8million which is being held back will be distributed to break even.
PS requested that the paragraph is amended to state that “it is likely to be replicated throughout the country”. He also asked that the number in the next sentence be amended to £800,000.
Page 4, paragraph 5 JJb queried the Community Hospitals Review and the £50,000 which was allocated originally, and presumed this does not relate to the change in the opening hours, it was confirmed this was accounted for in the QIPP.
The other £50,000 was over and above, originally there was £1million against Community Hospitals and it has a transactional QIPP element and the quadrant plan.
The Committee highlighted a typo within the above paragraph, advising that the Community Hospital Review were original allocated £500,000 not £50,000.
Page 9, Finance Recovery Plan, paragraph 5 It was important to note, that during EMT earlier in the morning, AD and PS received an email from Rachel Hardy, Regional Finance Director at NHS England, which stated she had been informed by the National Team that it is likely that there will be funds of £314.9 million received for the Trust Special Administrator (TSA), it must be confirmed however this should factor this into the plans for the 23rd December. AH queried whether this was included in the plan and PS confirmed it is classed as Legacy Funding.
The Committed confirmed that Rachel Hardy had advised that the total amount promised for the TSA totalled £14.9 million.
Minutes to be amended.
Actions of Previous Meeting 6.
Page 2 of 7
We are honest, accessible Quality is our day job We innovate and deliver Care and respect for all and we listen
Item: 16 Enc: 16
Action Actions were noted on attached document – Enclosure 02. 7. Finance
The CCG remain committed to achieving the control total of £22m as agreed by NHS England. Regular meetings with NHS England remain on-going to provide assurance. PS reiterated the importance of meeting the control total. There have been a number of benefits, additional funds for SES for property services following an increase in market rents. At the beginning of the financial year each of the CCGs allocated £500k to support the STP. PS informed the Committee that following the initial assessment, it was identified that around £150k for Stafford and Surrounds CCG (SaS) and Cannock Chase CCG (CC) and £220k for South East Staffordshire and Seisdon (SES). Risk remains high, PS stated that both SaS and CC CCG will not meet the year end control total, therefore focus remains on SES to ensure delivery. A revised plan submitted to NHS England on Friday, there are a number of factors outside the control of the CCG which has seen cost implications, an example of which was the non-contracted QIPP. The revised plan included a shortfall of £6m, the CCG now have a few weeks to identify a plan to
PS informed the Committee that the CCG have made no formal offers in relation to acute contracts, with the exception of Walsall Healthcare Trust. Formal correspondence has been sent to Walsall in relation providing a formal offer to the Trust. PS advise that the CCG have also attempted dialogue on a number of occasions to commence discussions around the 2017/18 contract which currently remains unsigned. Committee Members were advised that schedules will be created for each of the acute provider contracts, which will then form the basis of identifying contract offers. The CCG successful met the deadline of the 23rd December 2016 for agreeing all 2017/18 contracts, with the exception of Walsall Healthcare Trust. A formal offer was made to Walsall on the 9th January 2017, which as of yet has not been acknowledged by the Trust.
CB stated that the value of contracts signed for 2017/18 is more than the provision within the financial plan. The next stage is to produce a contract summary sign off sheet which details the contract affordability gap, the risks and issues and how these will be addressed.
Discussions have commenced with SSSFT in relation to the Mental Health Trust taking on the role as lead providers for Continuing Healthcare from the CSU. Michael Brookes left the meeting, declaring a conflict of interest.
Michael Brookes re-joined the meeting. Performance 8.
The Committee noted the information contained within the performance report in relation to Month 8, November 2016.
CB provided an overview of the month 8 position. Extensive pressure within Urgent Care Services, in particular A&E, which resulted in the suspension of planned elective care. There is sustained failure of the 4 hour wait target across all providers and multiple 12 hour trolley breaches. Ambulance turn over days in excess of 1 hour increases, instances of more than 2 hours. The Urgent Care team and Rob Lusuardi have been working with County Hospital and Burton to support a return to business.
Page 3 of 7
We are honest, accessible Quality is our day job We innovate and deliver Care and respect for all and we listen
Item: 16 Enc: 16
Action
In terms of urgent care, all providers have experienced a difficult few weeks. Nationally UHNM, including Royal Stoke and County Hospital are the poorest performers 12 hour trolley breaches.
The committee queried whether data had changed, during the last meeting discussions around 12-hour breeches at UHNM as it was reported no trolley breeches, and in the report today it states 56 breeches. Action: CB to clarify CB data specific to the three CCGs and feedback to the Committee the number of 12-hour breeches.
The Royal Stoke, pressures, discussions around whether the A&E can support capacity, as a result of space, workforce, infrastructure.
The number of attendees and admissions at the County Hospital has reduced within the last few weeks. MH queried whether the admissions are self-referral into A&E or are they referrals from medics. Action: CB to provide the CB Committee with a breakdown of admission attendance
As a consequence planned care is struggling. Each of the 3 CCGs remains above the 92% target, however as a result of performance during the last few months each CCG is currently just above the 92%. CB felt that each of the CCGs do not have the necessary head room required to remain above target through to the end of March.
Burton has started to report again and is compliant, as are HEFT. Dudley. Wolves, UHNM continue to struggle.
There are some examples of appointments being cancelled for cancer treatments and this will continue to be monitored. AH queried whether Quality Committee is ensuring there is no harm to patients. Unannounced visits were completed at County Hospital to ensure the service provision remained clinically safe. MH queried staffing levels of Oncology Consultants and whether impact of locum staff.
AH queried whether CB is confident with the data now being submitted by Burton Hospital in respect of the SES & SP waiting list.
CB reported that there are regular reports being received into the Burton contract management group. Confidence level is increasing but is not where it should be at this moment. Discussions have been held at Quality Committee, the Quality Team have provided assurance that there is improvement. CB will continue to monitor and feedback into Committee.
9. 2017 – 18 QIPP Report / Internal Audit QIPP Report
RY reported that the CCG QIPP target for 2017/18 is £16.78m; the forecast for the year is £12.75m, with a variance of just under £4m.
The reasons have not changed since last month, largely resulting in urgent care schemes under delivering. A number of QIPP schemes are back ended, therefore throughout the year savings have been reported as planned, however if there is a failure to deliver at Q3 and Q4, the position deteriorates and there is
Page 4 of 7
We are honest, accessible Quality is our day job We innovate and deliver Care and respect for all and we listen
Item: 16 Enc: 16
Action insufficient time to take necessary action.
PS advised that QIPP taken into overall financial position, specific contract performance is taken into account. Finance Team work closes with Ruth around the financial position of QIPP.
Remedial action – urgent care programme team bringing forward work to cover shortfall of losses against their schemes.
In terms of 17/18 there are around 10 projects at the moment in various states of work up which will go through a Star Chamber process on the 15th February 2017. By the next meeting there will be a clearer idea of the Star Chamber process. Timeframe given to leads to address any concerns raised during the Star Chamber process will be short. Exogen
Exogen is an ultrasonic non-invasive device used to assist with the healing of fractures. AB advised that 21.4% of fractures do not heal after a period of 9 months following the date of injury. Of this number around 50% of patients are eligible for Exogen therapy. 86% of patients undergoing treatment will make a full recovery and 14% will require surgical intervention.
AB was asked to review the policy following the review of NICE guidance identifying a CPAG score above the threshold for funding of long-bone fracture with non-union.
AB stated that the implementation of the policy will have no direct cost to the CCG as if treatment is unsuccessful, the Trust can claim funds, which in turn are credited back to the CCG.
Activity levels for each of the CCGs are small. Data collated from the CSU and provided to the Committee details that the number of patients eligible for Exogen therapy will be in single figures per Trust. 10. AB highlighted the clinical pathway to determine eligibility for Exogen therapy. The cost of each device is £2562.50, which is delivered to the provider. AB advised that eligible patients will receive 6 months of Exogen therapy, following which the patient will attend two follow up appointments.
There is no inequity to the service as patients are required to meet the criteria to access treatment. Committee Members were asked to approve the implantation of the policy with CCG providers. AB advised that regular audits will be completed to collate data, either on a monthly or quarterly basis dependent on the numbers moving through the service.
A representative from Bioventus and the patient’s consultant meet with the patient to provide the education, placing and management of therapy. This also provides an opportunity to determine whether the patient is a suitable candidate for the therapy.
AH queried the recommendation to the Committee as details within the paper were unclear. AB advised that the Committee are asked to approve and support the business case, following which the paper will be taken to each of the
Page 5 of 7
We are honest, accessible Quality is our day job We innovate and deliver Care and respect for all and we listen
Item: 16 Enc: 16
Action Membership Board Meetings for clinical approval.
GF clarified that as this the implementation of the policy will result in a change of clinical commissioning, a clinical discussion at the Membership Board Meetings is required.
MH queried the number of treatments each device is programmed to deliver, highlighting a discrepancy between the number detailed within the business case and the number detailed within the CCG Commissioning Policy.
MH also queried the three month time frame for patients between the 6 months of Exogen treatment until the pathway supports surgery at 9 months. MH raised queried whether the provider would perform surgery at 6 months should it identified as appropriate. AB advised that following the pathway, Trusts should not be offering surgery at 6 months.
MH raised concern in relation to the definition of failure within the policy. MH queried callus formation, specifically where formation appears minimal however the patient’s mobility impaired and limb function restricted. Action: AB to query AB will raise with surgeons to identify whether limb function is also included within the evaluation process.
PS requested clarification in relation to the figures provided within the report front cover. The Committee are advised that 82% of patients do not heal after either 6 months following surgery or 6 months following Exogen®, thus resulting in the same failure rate of 18%. PS highlighted that the report also details that 86% of patients undergoing the treatment make a full recovery (healing of non-union) and 14% will need to go on and have surgical intervention. AB clarified that that of the number of patients eligible for therapy, 86% of patients will make a full recovery.
Queries were raised around the direct benefits to patients and whether releasing capacity would be replaced with additional volume. AB stated that the impact on RTT performance is likely to be small. The implantation of the service would have a positive impact on the quality of care to patients.
CB highlighted the importance of confirming the evaluation criteria prior to implementation. CB acknowledged that historically, non-invasive therapy has been unavailable to patients and also acknowledged the financial risk to the CCG as minimal. CB queried the process which resulted in moving from an excluded service to restricted. AB explained that a change to NICE guidelines had resulted in a review of the policy. MH recommended including the CPAG score within papers.
GF reported that POLCVs are discussed at the planned care group, CPAG, following which clinical papers are taken to Membership Board for approval. Funding is a decision for the Governing Body.
AB reiterated the need for a 12 month review. PH commented that he did not feel a requirement for this to go to membership boards. However GF requested that a clinical discussion is requested
The Committee approved subject to discussions and approval from the
Page 6 of 7
We are honest, accessible Quality is our day job We innovate and deliver Care and respect for all and we listen
Item: 16 Enc: 16
Action Membership Board and Clinical Directors.
The Committee also requested clarification around governance processes and the consistency.
AB left the meeting.
It was noted that MB wished his standing declaration of interest to be noted as it had not been recorded earlier in the meeting.
Finance Performance Contracts Committee Terms of Reference
The terms of reference were presented for review. They were agreed, for approval at the March Governing Body meetings with the following amendments:
PS to discuss with Lynn Millar her attendance. Members felt that this would be a high priority after 1st April 2017 should the CCGs take on responsibility for 11. delegated commissioning of GP primary care.
It was recommended that delegated approval be increased to £250,000. PS to action.
There were a number of areas of repetition and inaccuracies in membership numbers. PS to edit.
12. Audiology AQP Contracts
GF queried the contract values, not included within the report.
13. Any Other Business
There was no further business.
14. Next Meeting
Thursday 16th February 2017 14:30 – 16:30 Venue: Marmion House, Tamworth
Page 7 of 7
We are honest, accessible Quality is our day job We innovate and deliver Care and respect for all and we listen
Item: 16 Enc: 17
Cannock Chase Clinical Commissioning Group South East Staffordshire and Seisdon Peninsula Clinical Commissioning Group Stafford and Surrounds Clinical Commissioning Group
The healthiest place to live and work, by 2025
Joint Communications and Engagement Committee Tuesday 13th December 2016 13:00-15:00 Boardroom, Staffordshire Place Two, Stafford, ST16 2LP
Members: [Date] [Date] 16.08.16 16.08.16 15.09.16 25.10.16 13.12.16 Quoracy Quoracy Sue Harper (SH) Chair – Lay Member for Patient & Public Involvement (SAS CCG) Diana Smith (DS) – Non-statutory Lay Member (SAS CCG) Sally Young (SY) – Director of Corporate Governance, Communications & Engagement (CC, SAS & SESSP CCGs) Adele Edmondson (AE) – Senior Communications & Engagement Manager (CSU) Amy Egan (AEg) – Communications & Engagement Specialist (CSU) Anne Heckels (AH) – Lay Member for Patient & Public Involvement and Lay Member for Finance (SESSP CCG)
Fleur Fernando (FF) – Partnership and Engagement Manager representation. (CC, SAS & SESSP CCGs) Ruth Boyd (RB) – Communications & Engagement Senior Partner (CSU) Jeni Jobson (JJb) – Lay Member for Governance (SESSP CCG) representation and Lay Member and Lay Member representation
Paul Gallagher (PG) – Lay Member for Patient & Public Involvement including officers, five of minimum A Community. CCG representation, CSU representation, CCG Community. representation from each CCG and the and the CCG each from representation (CC CCG) Harry Ireland (HI) – Lay Member for Governance (SAS CCG) Jan Toplis (JT) – Non-statutory Lay Member (CC CCG) Neil Chambers (NC) – Lay Member for Governance (CC CCG) In attendance: Elizabeth King (EK) – Executive Administrator (CCG) Sian Calderwood (SC) – Commissioning Manager for Children’s and Maternity services (CCG)
Action 1. Welcome by the Chair The Chair welcomed all present to the meeting.
2. Apologies for Absence Apologies received from Jeni Jobson and Jan Toplis.
3. Quoracy It was noted that the meeting was quorate.
4. Conflicts of Interest None
Page 1 of 4
We are honest, accessible Quality is our day job We innovate and deliver Care and respect for all and we listen
Item: 16 Enc: 17
Action 5. Minutes of Previous Meeting Members confirmed that the minutes from the Joint Communications and Engagement committee meeting on 25th October 2016 were a true and accurate record subject to the following amendments: Page 2: Anne Heckels should be abbreviated to ‘AH’ not ‘Ahe’ Page 3: Action amended to: AEg to investigate whether a hard copy of the bi-monthly ‘In Touch with your NHS’ newsletter is still sent out to those members on the database who are not on email. Page 3: Spelling error – ‘behaviour’ not ‘behavior’
Action – minutes to be amended AEg
6. Actions of Previous Meeting Actions were noted on the Action List and amendments made where necessary.
7. Face to face engagement model Enc 03 provided a summary of the committee’s discussions to date, along with strengths and weaknesses of each of the current engagement models, and an overview of feedback from the patient workshop on 2nd November 2016. AE stressed that the model is only one part of the CCGs’ plans moving forwards.
Following input from the committee, the ideas will be expanded further at the focus group (10th January 2017) before a paper is presented to the governing bodies.
PG stressed that the new model must be effectively led, properly supported and easily accessible considering the larger geographical area. AH added that the model needs to be recognised and owned by all involved.
SY acknowledged that the detail of the proposed model is still to be confirmed but that the CCGs are currently recruiting to fill gaps in the admin team and are looking at a new model for the communications and engagement team to ensure we have the resource in place. It was agreed that the primary care team also needs to provide support, and that GP representation at meetings is valued highly by the patients.
Action: AE to update the document with all suggestions made by the AE committee at this meeting ready for the focus group meeting.
Action: AE to update the document with all suggestions made by the AE focus group and then share with the committee via email as must be resolved before the next committee meeting.
Action: AE & SY to finalise the document to be presented to the AE & governing bodies at the end of January 2017. SY
Page 2 of 4
We are honest, accessible Quality is our day job We innovate and deliver Care and respect for all and we listen
Item: 16 Enc: 17
Action
Action: AE to share the volunteers’ policy that dates from the PCT as AE an example of how the CCGs may decide to offer payment or expenses for those attending patient meetings.
8. Progress against work plan Enc 04 provided detail of the progress made against the Communications and Engagement workplan. AE clarified that this only covered the additional activities, not the ‘core’, everyday activities listed in a separate document shared by AE at the last meeting. This replaces the previous ‘look back/look forward’ activity report – AE asked the committee if the new format provided the right level of detail for members.
PG asked that every cell in the current quarter’s column should be populated and that this should be viewed alongside the core report to understand the Communications and Engagement team’s workload. He added that the CSU’s daily ‘Media digest’ email often includes news from North Staffordshire and Stoke-on-Trent but lacked proactive news from South Staffordshire.
Action: The committee agreed that the social media strategy needed AE to be renewed for a more targeted approach.
9. Together We’re Better (Sustainability Transformation Plan) update The public version of the STP will be published on 15th December with a press conference to be held at 1pm. All organisations will post announcements about the launch at the same time, and all will link to the Together We’re Better website where the document will be hosted.
The Ambassador Training continues, with more dates announced for the New Year.
Action: AE to share the forthcoming Ambassador Training dates with AE the committee.
Action: AE to provide training for committee members at the next AE Communications and Engagement committee meeting, and share the relevant resources.
10. Any Other Business AE reported that the contact lists for the three CCGs were submitted to Ipsos Mori on 12th December in order for them to conduct the 360° stakeholder survey. Following feedback from members who had not responded to previous surveys, it has been agreed that we will sit with the Cannock membership board for them to go through the survey together. This approach could also be offered to Stafford and SESSP CCGs.
Action: AE to look at when the next ‘Feeling the difference’ survey is
Page 3 of 4
We are honest, accessible Quality is our day job We innovate and deliver Care and respect for all and we listen
Item: 16 Enc: 17
Action due as this can provide useful insight into peoples’ confidence in their practices.
Next meeting
Date: Wednesday 21st February 2017 Time: 13:00-15:00 Venue: Boardroom, 1st Floor, Staffordshire Place Two, Stafford, ST16 2LP
Page 4 of 4
We are honest, accessible Quality is our day job We innovate and deliver Care and respect for all and we listen
Item: 16 Enc: 18
Cannock Chase Clinical Commissioning Group South East Staffordshire and Seisdon Peninsula Clinical Commissioning Group Stafford and Surrounds Clinical Commissioning Group
The healthiest place to live and work, by 2025
HUMAN RESOURCES & ORGANISATIONAL DEVELOPMENT MEETING Minutes of meeting held on: Tuesday 20 December 2016 Ivanovo Room, County Buildings, Stafford
Members Quoracy 19.04.16 17.05.16 21.06.16 19.07.16 16.08.16 20.09.16 18.10.16 21.11.16 20.12.16 17.01.17 21.02.17 21.03.17 Core members Sue Harper (SH) X X n/a CHAIR - Lay Member SAS CCG Sally Young (SY) n/a X Assistant to Chief Executive
Ian Baines (IB) QUORACY n/a x Director of Transformation James Breakwell (JB)
X n/a Administrator Adele Edmondson (AE)
X X X X n/a X X Comms & Engagement Manager CSU Fleur Fernando (FF)
X n/a x x Engagement and Partnership Manager Alison Gooding (AG)
x Assistant HR Business Partner - CSU Rebecca Hough (RH)
X X n/a x Governance Manager Sarah Hunter (SHu)
X X X n/a X X Health & Safety Advisor – CSU Lisa Kelly (LK)
Senior HR Business Partner – CSU Tracey Revill (TR)
n/a X X Governance Manager Sara Rogers (SR)
n/a Corporate Services Manager Staff Representation Julie Beedon (JuB)
x x x x x x x X x Tricordant Tracey Finney (TF)
X X n/a X Executive Assistant Andy Hadley (AH) Senior Primary Care Development X X X n/a X X Manager Katie Montgomery (KLM)
X n/a X x x x Clinical Quality Improvement Manager Jennifer Napier-Dodd (JND)
Quality Improvement Manager Anne Perry (AP)
X X n/a X Finance Manager Sabrina Richards (SRi) Equality and Inclusion Business Partner CSU Eleanor Wood (EW) Senior Primary Care Development X X n/a X x X x Manager
We are honest, accessible Quality is our day job We innovate and deliver Care and respect for all and we listen 1
Item: 16 Enc: 18
Cannock Chase Clinical Commissioning Group South East Staffordshire and Seisdon Peninsula Clinical Commissioning Group Stafford and Surrounds Clinical Commissioning Group
Members Quoracy 19.04.16 17.05.16 21.06.16 19.07.16 16.08.16 20.09.16 18.10.16 21.11.16 20.12.16 17.01.17 21.02.17 21.03.17 Ruth Yates (RY)
X x Commissioning and Contracting In Attendance Leanne Russell (LR)
Quality Administrator Lesley Arnold (LA)
x x x Unison Representative Caroline Lawrence (CL)
X n/a X x X Senior HR Business Partner - CSU Sian Calderwood (SC) Commissioning Manager – Graduate Management Trainee
AGENDA MINUTES ACTION ITEM NO. 1 Welcome and Apologies
Apologies were received from: Lesley Arnold, Fleur Fernando and Ruth Yates.
2 Conflicts of Interest and Quoracy Check
The group was confirmed as quorate. There were no Conflicts of Interests identified.
3 Minutes from meeting held on 21st November 2016
The Minutes of the meeting held on the 21st November 2016 were agreed as a true and accurate record.
4 Actions from the meeting held on 21st November 2016
The actions from the meeting held on 21st November 2016 were agreed as a true and accurate record and updated as per Enclosure 02.
Ian Baines left the meeting at 9.41and returned at 9:45.
5 CCG Temperature Check
Administration There are currently six vacant positions in the administration team. This is due to staff members progressing to new posts following the Management of Change process, maternity leave and long term sickness. SR reported that the existing team, (8 members of staff), are under increased pressure and has asked that all staff are mindful of this. Administration, Communications and Engagement, Governance and HR teams attended the Team Development Day at the end of November 2016 which received positive feedback.
Equality & Inclusion SRi reported that Equality and Inclusion training sessions are currently in progress. Equality Impact Assessment training for Commissioning and Contracting teams is also underway. There are currently plans to hold an Equality and Inclusion Masterclass in the new year.
Assistant to Chief Executive Recruitment is now in progress to appoint the STP Chair and Accountable Officer. Vacancies are due to be advertised as soon as possible. The recruitment process will include
We are honest, accessible Quality is our day job We innovate and deliver Care and respect for all and we listen 2
Item: 16 Enc: 18
Cannock Chase Clinical Commissioning Group South East Staffordshire and Seisdon Peninsula Clinical Commissioning Group Stafford and Surrounds Clinical Commissioning Group
shortlisting, stakeholder panels, psychometric tests (identifying strengths using Strengthfinders) and a final interview.
Commissioning The Commissioning team are currently focusing on contracting deadlines which are due on 23rd December 2016. This busy time for the team has prevented discussions regarding the Health and Wellbeing Programme and being able to provide feedback from the teams. A team meeting is due to be held in early January 2017 to discuss this.
Finance AP reported that the finance team are more positive now the Management of Change is underway. SY noted the Finance Management of Change process will mirror that which was previously used. Victoria Hilpert and SR are currently working together with this.
Andy Hadley arrived at the meeting at 09:57
Quality The Quality team requested information on the remit of the Vacancy Control Panel and progress on the Staff Survey. They also expressed their disappointment on finding out about the STP through the Health Service Journal rather than it being discussed with staff in the first instance. AE confirmed there had been a communications leakage late on the 14th December 2016 and that the information was circulated to all staff on the morning of 15th December 2016. Unfortuantely these were circumstances out of the control of the CCGs and appropriate action was taken as soon as possible.
Primary Care AH reorted that it has been a busy time for the Primary Care team. There is currently work on-going regarding PMF reallocation, digital roadmap etc. Interviews for a Deputy Director for Primary Care have been undertaken.
CSU – HR Senior Business Partner Day two of the Management Development Programme took place on 19th December 2016. Upon review of day two, amendments will be made to develop the programme going forward. This will include splitting sections of the programme and delivering them on different days. Nine people have been signed up for the second cohort.
Communications and Engagement AE reported it has been a busy period for the team which included work undertaken regarding Major Incidents and the STP launch. AE expressed the need for the organisation to understand there is a lot of work that goes on behind the scenes in Communications and Engagement that is sometimes overlooked.
Director of Transformation There has been a positive response to the initiative for Achievement of the Month. Nineteen nominations have been received in four weeks. IB reflected the organisation has worked hard over the last few weeks and was aware that teams are tired and under continued pressure particularly Finance and Commissioning.
Health & Safety During November the CSU Health and Safety Team were mainly focusing on security work. The self-review tools for each CCG had to be submitted to NHS Protect by the end of November. SHu reported that she is due to go on maternity leave in April 2017 and, at this point in time, is unaware of what plans are in place to cover her leave. SY will liaise with SY CSU to confirm arrangements.
Chair – Lay Member SH thanked members for the updates and commented that all staff should be proud of themselves for all of their hard work. We are honest, accessible Quality is our day job We innovate and deliver Care and respect for all and we listen 3
Item: 16 Enc: 18
Cannock Chase Clinical Commissioning Group South East Staffordshire and Seisdon Peninsula Clinical Commissioning Group Stafford and Surrounds Clinical Commissioning Group
6 HR/OD Flash Report
This month there has been an increased sickness rate. LK and AG are currently reviewing this. Sickness absence through stress and anxiety has also increased across the organisation; 64 days were lost in the last month compared to an average of 24 days. IB noted that Jason Howle from CSU can provide further data regarding this. SH suggested this increase is reinforcing evidence to push the Health and Wellbeing strategy.
There has been a spike in turnover rate, rising from 1.07% to 2.74%.
SY noted that despite the whole-time equivalent being 108.52 there are actually up to 150 staff which includes Clinical directors and Governing Body members.
The OD Plan now moves into quarter 3. Masterclasses were reported as underperforming in previous reports but are now in the early stages of development. There have been two team building days and three more are expected to take place in January. The finance team’s development day will take place once the Management of Change process is complete.
Day 3 of the Management Development Programme is currently in development. IB has been working with the CSU to develop the programme further. Julie Beedon, Tricordant, has also offered to spend time with this cohort regarding Strengthfinders. Day 3 is due to take place in mid-January 2017.
The Staff Survey is due to be released in January 2017.
A Mentoring Development Programme is currently by reviewed by t Health Education England (HEE). IB will review the programme to see if it can be rolled out within the CCGs.
A Joint Governing Body OD session was held on 25 November 2016. IB reflected that there was a noticeable change in the integration of the Governing Bodies. SY noted the three separate Governing Bodies are the only remaining separate Board meeting which a high volume of duplication is incurred. SH noted this duplication as a concern and promised to take this issue forward to move towards having one Governing Body.
7 Terms of Reference
The Terms of Reference were reviewed by the Committee members and the following changes were suggested:
SH commented that the section on Equalities in section 9. SY to amend. SY
8 Network Update
IB reported that he recently attended an event called the “Health Education England, The power of conversation training day for OD and coaching practitioners”. At this event, IB was advised by Cherry Dale, Operating Officer at South Central CCGs that they had utilised Health Education England to enable effective HR/OD agendas in their CCG. IB intends to develop links with HEE going forward.
IB has also been accepted onto the board for the National Framework for Improvement and Leadership which will enable CCGs to develop a talent network.
Through the STP there is a focus on ensuring that the cultural and behaviours are correct across the organisation; bringing senior leaders together to review behaviours. There is also support regarding improvement methodologies offered to the individual programme leads.
We are honest, accessible Quality is our day job We innovate and deliver Care and respect for all and we listen 4
Item: 16 Enc: 18
Cannock Chase Clinical Commissioning Group South East Staffordshire and Seisdon Peninsula Clinical Commissioning Group Stafford and Surrounds Clinical Commissioning Group
9 National Framework for Improvement & Leadership
The National Framework for Improvement Leadership is a re-commitment to leadership and values within the NHS recognising that people need leadership development support due to a noticeable struggle to appoint to senior positions within the NHS. IB explained this is a national document but there is also a requirement for it to be undertaken locally. IB requested assistance from volunteers to review the action plan within the document and assit JND/AH with developing a strategy. JND, AH, SH and SR volunteered to assist with this and a /SH/SR meeting will be set up to consider drafting responses to the document . SH impressed the need to include a strong equalities aspect within the strategy.
10 Update on Work Completed Discussed and updated as part of agenda item 6.
11 Staff Survey (Planning)
IB and Ash Carvelli from the CSU have worked together to implement the Staff Survey. The planned launch for the release of the survey will be week commencing 9th January 2017. Final processes are being reviewed by Ash Carvelli prior to circulation. The staff survey will be sent to CCG staff only and will be live for approximately one month. Once the survey closes it will take approximately two weeks for the data to be released. AE queried if CSU staff are included. IB will review this.
AH queried how will issues such as bullying will be picked up in an anonymised survey. IB stated there will be a detailed analysis of the outcomes of the survey and an action plan on will be created.
12 Establishment Control Processes and Budget Management
Discussed in agenda item 5, CCG Temperature Check, Assistant to the Chief Executive.
13 Vacancy Control Panel
SY informed the group a new terms of reference need drawing up and conversations with Executive Directors about what their responsibilities are to avoid local decisions being made in teams which do not fit into the wider HR system across the organisation.
14 Management of Change
The recruitment for administration posts is currently in progress. There are eight further vacant posts. There is currently a pause on a vacancy in the Quality team. There is now a vacancy in Primary Care for a band 8A as the current 8A has been promoted into a a band 8B role. There are vacancies for specialist roles which will be advertised such as a Band 8C Mental Health Commissioner.
All of the vacancies will be advertised once all appropriate information is sent to SR. Staff are advised to be conscious of time with recruitment processes and action appropriately.
15 HR Policy Refresh
The HR Policy Review highlights the level of risk for policies which require periodic review. LK explained that some policies are similar across the three CCGs with exceptions such as Probationary Period Review policy and Retirement policy. SH noted there is an absence of an Equalities policy on the HR Policy refresh table. Members agreed the Dignity and Respect Policy will be replaced by two policies; Bullying and Harassment Policy and Equal
We are honest, accessible Quality is our day job We innovate and deliver Care and respect for all and we listen 5
Item: 16 Enc: 18
Cannock Chase Clinical Commissioning Group South East Staffordshire and Seisdon Peninsula Clinical Commissioning Group Stafford and Surrounds Clinical Commissioning Group
Opportunities Policy. LK to amend. LK
The HR Policy Review table will be updated once policies have been reviewed at the Staffside Partnership Forum.
AE noted that HR Policies on the CCG website need to be reviewed and in the interim a note would be added to the website to the effect that they were under review and in the interim the policies as stated still applied. The owner of each policy should be attached and mapping of the policies needs to be undertaken. SH stressed the need to ensure that an early meeting was arranged with staff side reps to agree the changes to revised policies.
Sara Rogers left the meeting at 11:10
16 Mandatory Training This was discussed The new Mandatory training system, Learning Pool is currently set to go live on 5th January between 2017. SR reported that there is a need to ensure that job roles, titles and staff bands are agenda correct on the system prior to going live. The Learning Pool contains 8 mandatory units and items 10 & can be completed at work or at home. There will be 3 Web-Ex’s to explain how to use the 11 system on the 4th, 5th and 11th January 2017. Prior to Christmas, SR will liaise with the SR Communications team to ensure that CCG staff are kept informed on the forthcoming training. Welcome emails will be circulated to all staff on the 3rd January 2017.
SR has been working with James Bell from CSU to review who has been completed mandatory training within the past 12 months as this will be counted towards certification.
Members agreed that there is an appetite from staff to complete mandatory training and agreed that the step up target should be set to 90% by end of March 2017. SY explained this will be discussed at EMT on 21st December 2016 and a paper will also go to Governing Body for a decision on what the expected target should be. Members also agreed there should be protected learning time for CCG staff to complete all mandatory training modules. JND queried how long it would take to complete all eight modules in one go. SR will liaise with SR James Bell to find out this information and report back.
TR reported that noted that Conflicts of Interest training is due for completion by the end of January 2017. However NHS England have not yet released the training module and it would be unreasonable to expect 100% compliance by CCG staff by this time.
17 EDS/WRES/Equality etc.
There were no updates from FF.
18 Demonstration of new Equality Impact and Risk assessment process
SRi provided members with a presentation that explained the process for undertaking an Equality Impact and Risk Assessment using the UAssure website. SRi explained that Equality Impact and Risk Assessments must be completed at the start of any new project. IB queried what support can be given to staff members who are undertaking new projects; SRi has offered to support all staff. SRi explained that Equality Impact and Risk Assessments are saved on the same system which enables the CCG to maintain an accurate record of these assessments.
SRi explained there is a link on UAssure to differentiate Quality Impact Assessments from Equality Impact Risk Assessments.
SC reported that she had attended the Equality Impact Risk Assessment training and had provided feedback which was intended to be reported back to the developers to improve the We are honest, accessible Quality is our day job We innovate and deliver Care and respect for all and we listen 6
Item: 16 Enc: 18
Cannock Chase Clinical Commissioning Group South East Staffordshire and Seisdon Peninsula Clinical Commissioning Group Stafford and Surrounds Clinical Commissioning Group
training. SRi confirmed the version released is the original version without the feedback updates and any updates will occur during phase two of the training.
SY suggested all completed Equality Impact Risk Assessment’s are presented to the HR/OD Committee. Another training session is planned on 23 January 2017.
SRi confirmed Equality Impact Risk Assessments should be expected to be completed by providers. AE noted as part of EDS2 it is a providers contractual obligation to complete Equality Impact Risk Assessments.
19 Draft Equality Inclusion Annual Report
The Equality Inclusion Annual report was circulated to the group. Any comments on the report should be submitted to SRi by the second week of January 2017.
SY provided feedback which included such as: There is no reference to HR/OD committees and how they have an overall influence of Equality and Inclusion. Link to STP to pull value from what they achieve. The CCG now has an Equalities lead and an embedded CSU role. The Staff grading event outcomes helped to develop OD plan.
20 Achievement of the Month – Award
IB reported there have been 19 nominations in a 4 week period. Due to the number of nominations there will be one winner and three highly commended. The results will be announced in Andrew Donalds message on 2st1 December 2016. A letter will also be sent out to the winner.
21 Items to be Reported to Team Meetings
More feedback is needed from the teams regarding Health and wellbeing. To feedback how busy the CCG is. Andrew Donald’s message will also convey this . Inform the teams of the forthcoming Mandatory Training. Explain theimportance of Equality Impact Assessments. Inform teams of the Leadership Academy Awards. Staff opening times for 23th December 2016 and 30th December 2016.
22 Update for Governing Body
Training
23 Any Other Business
SY informed the group that all staff can leave from all bases at 2pm on 23rd December 2016 and at 4pm on 30th December 2016. If the building closes before any of these times staff are reminded to either work from another location or work from home.
Prior to his retirement SY has requested Andrew Donald attend a HR/OD Committee to see how the Committee has evolved.
IB has asked for staff to review the information of the West Midlands Leadership Academy ALL Awards around leadership and nominate. AE will circulate this information to staff.
DATE AND TIME OF NEXT MEETING 24 Tuesday 24th January 2016 09:30 – 11:30 White Room, County Buildings, Stafford We are honest, accessible Quality is our day job We innovate and deliver Care and respect for all and we listen 7
Item: 16 Enc: 18
Cannock Chase Clinical Commissioning Group South East Staffordshire and Seisdon Peninsula Clinical Commissioning Group Stafford and Surrounds Clinical Commissioning Group
Approved: 24 January 2017
SIGNED: ...... DATE: ...... (Chairman)
We are honest, accessible Quality is our day job We innovate and deliver Care and respect for all and we listen 8 Item: 16 Enc: 19 Acronyms
1. A&E Accident & Emergency 2. ADNS Advanced Diploma in Nursing Studies (UK) 3. ADP Accelerated Development Programme 4. AED Automated External Defibrillator 5. AHP Allied Health Professional 6. ALAN Adult Literacy and Numeracy 7. ALE Auditors Local Evaluation 8. ALOS Average Length of Stay 9. ANNP Advanced Neonatal Nurse Practitioner 10. AO Accountable Officer 11. APMS Alternative Provider Medical Services 12. AQP Any Qualified Provider 13. ASD Autism Spectrum Disorder 14. AVS Acute Visiting Service 15. BADGER Birmingham and District General Emergency Rooms 16. BAF Board Assurance Framework 17. BCF Better Care Fund 18. BCHFT Birmingham Children’s Hospital NHS Foundation Trust 19. BEN Birmingham East and North PCT 20. BHFT Burton Hospital NHS Foundation Trust 21. BNP Brain Natriuretic Peptide 22. BOTOX Botulinum Toxin Type A 23. BPAS British Pregnancy Advisory Service 24. C&E Communications & Engagement 25. CAG Commissioning Advisory Group 26. CAMHS Children and Adolescent Mental Health Service 27. CAS Clinical Assessment Service 28. CB Commissioning Board 29. CBSA Commissioning Business Support Agency 30. CC Cannock Chase 31. CCG Clinical Commissioning Group 32. Cdiff Clostridium Difficile Infection 33. CEO Chief Executive Officer 34. CGA Comprehensive Geriatric Assessment 35. CHAI No longer in existence 36. CHC Continuing Health Care 37. CHI No longer in existence 38. CHKS Leading provider of healthcare intelligence and quality improvement services 39. CHPP Children’s Health Promotion Programme 40. CHRT Crisis Home Resolution Team 41. CIAMs Commissioning Investment Asset Management Strategy 42. CIG Clinical Informatics Group 43. CIP Cost Improvement Programme 44. CMT Contract Management Team 45. CNST Clinical Negligence Scheme for Trusts 46. CoE Care of the Elderly 47. COG Clinical Oversight Group 48. COPD Chronic Obstructive Pulmonary Disease 49. CPAG Clinical Policies Advisory Group 50. CPN Community Psychiatrist Nurse 51. CQC Care Quality Commission 52. CQINS Cancer Quality Improvement Network System 53. CQRM Clinical Quality Review Meetings 54. CQUIN Commissioning for Quality and Innovation 55. CRL Capital Resource Limit 56. CRT Crisis Response Team 57. CSIP Clinical Services Improvement Programme 58. CSU Commissioning Support Unit
Item: 16 Enc: 19 59. CSW Clinical Support Worker 60. CWG Clinical Working Group 61. D&V Diarrhoea & Vomiting 62. DC Day Care 63. DCC Direct Clinical Care 64. DES Direct Enhanced Service 65. DIPC Director of Infection Prevention & Control 66. DN District Nurse 67. DoH Department of Health 68. DOLS Deprivation of Liberty Standards 69. DPA Data Protection Act 70. DPD Dental Practice Division 71. DPP Developing Patient Partnerships 72. DQF Data Quality Facilitator 73. DRS Dental Reference Service 74. DTC Delayed Transfer of Care 75. EAU Emergency Admissions Unit 76. ECDL European Computer Driving Licence 77. ECIST Emergency Care Intensive Support Team 78. ED Emergency Department 79. EDD Expected Discharge Date 80. EDS Equality Delivery System 81. EL Elective 82. EMS Escalation Management System 83. EMSA Eliminating Mixed Single Sex Accommodation 84. EMT Executive Management Team 85. ENT Ear Nose Throat 86. EOL End of Life 87. EPO Emergency Planning Officers 88. EPR Electronic Patient Record 89. ESR Electronic Staff Record 90. EWISS Emotional Well Being in Stafford & Surrounds 91. EWTD European Working Time Directive 92. F&P Finance and Performance 93. FE Frail Elderly 94. FET Funding Exceptional Treatment 95. FFT Friends and Family Test 96. FIG Financial Improvement Group 97. FIMS Financial Information Management System 98. FIT Funding Individual Treatment – now FET 99. FNOF Fractured Neck of Femur 100. FOI Freedom of Information 101. FPC Finance Performance & Contract Committee 102. FRP Financial Recovery Plan 103. GAAP Generally Accepted Accounting Principles 104. GB Governing Body 105. GDC General Dental Council 106. GDS General Dental Services 107. GMS General Medical Services (Practice) 108. GP General Practitioner 109. GPWSI GP with special interest 110. GSF Gold Standard Framework 111. HALO Hospital Ambulance Liaison Officer 112. HCAI Healthcare Associated Infections 113. HCC No longer in existence 114. HEFCE Higher Education Funding Council for England 115. HEFT Heart of England Foundation NHS Trust 116. HFMA Healthcare Financial Management Association 117. HIS Health Informatics Service 118. HOT Heads of Terms
Item: 16 Enc: 19 119. HPS Health promoting Schools 120. HPSS Health promoting Schools Scheme 121. HR Human Resources 122. HRG4 Healthcare Resource Group 4 123. HROD Human Resources Organisational Development 124. HSJ Health Service Journal 125. IAPT Improving Access to Psychological Therapies 126. ICG Infection Control Group 127. ICSI Intracytoplasmic Sperm Injection 128. IFR Independent Funding Request 129. IFRS International Financial Reporting Systems 130. IG Information Governance 131. IM&T Information Management and Technology 132. IP Inpatients 133. IPC Infection Prevention & Control 134. IPR Individual Performance Review 135. IQT Improving Quality Team 136. ISA Intermediate Support Assistant 137. ISFE Integrated Single Financial Environment 138. ITT Invite to Tender 139. IV Intravenous Therapy 140. IVF Intravenous Fertilisation 141. IWL Improving Working Lives 142. JCI Joint Clinical Investigation 143. JCU Joint Commissioning Unit (SCC) 144. JSNA Joint Strategic Needs Assessment 145. JSP Joint Staff Partnership 146. KPI(s) Key Performance Indicator(s) 147. KPMG Global Network of Profession Firms providing audit, tax and advisory services 148. LAA Local Area Agreement 149. LCCB Local Collaborative Commissioning Boards 150. LCP Liverpool Care Pathway 151. LDD Learning Disability and/or Difficulty 152. LDP Local Delivery Plan 153. LES Local Enhanced Service 154. LETB Local Education and Training Board 155. LH Local Hospital 156. LHE Local Health Economy 157. LIN Local Intelligence Network 158. LMC Local Medical Council 159. LMS Local Medical Services 160. LOC Local ophthalmic Committee 161. LQR Local Quality Indicator 162. LSP Local Strategic Partnership 163. LTB Local Transition Board 164. LTC Long Term Conditions 165. LTFM Long Term Financial Model 166. M&L CSU Midlands & Lancashire Commissioning Support Unit 167. MAT Maternity 168. MAU Medical Assessment Unit 169. MB Membership Board 170. MCA Mental Capacity Act 171. MCD Maximum Cash Drawdown 172. MDT Multidisciplinary Team 173. MFCA Multi Factorial Comprehensive Assessment 174. MHRA Medicines & Healthcare products Regulatory Agency 175. MICATS Musculoskeletal Integrated Clinical Assessment & Treatment Service 176. MICOT Minor Injuries Community Outreach Team 177. MIU Minor Injuries Unit 178. MLU Midwife-led Unit
Item: 16 Enc: 19 179. MOI Memorandum of Information 180. MORI (Market & Opinion Research International) 181. MOU Memorandum of Understanding 182. MPIG Medical Practice Income Guarantee 183. MRSA Meticillin-Resistant Staphylococcus Aureusis Infection 184. MSFT Mid Staffordshire NHS Foundation Trust (now part of UHNM as County Hospital) 185. MSK Musculoskeletal 186. MUR Medicine Use Review 187. NCAS National Clinical Assessment Service 188. NCB National Commissioning Board (now known as NHS England) 189. NCT National Childbirth Trust 190. NEDs None Executive Directors 191. NEL Non-Elective 192. NES National Enhanced Service 193. NHQAC Nursing Home Quality Assurance Group 194. NHS National Health Service 195. NHSE NHS England 196. NHSU NHS University 197. NICE National Institute for Clinical Excellence 198. NICU Neonatal Intensive Care Unit 199. NMC Nursing and Midwifery Council 200. NRPSI National Register of Public Service Interpreters 201. NSL Non Urgent Patient Transport Provider 202. NTDA NHS Trust Development Authority 203. OBD Occupied Bed Days 204. OD Organisational Development 205. OFSTED Officer for Standards in Education, Children’s Services & Skills 206. OOH Out of Hours, also Out of Hospital 207. OP (D) Outpatients (Department) 208. OT Occupational Therapist 209. PA Programmed Activities 210. PAED Paediatrics 211. PALS Patient Advice and Liaison Service 212. PASS Professional Advice and Support Service 213. PAU Paediatric Assessment Unit 214. PBC Practice Based Commissioning 215. PBR Payment By Results 216. PC Planned Care 217. PCR Patient Charge Revenue 218. PCT Primary Care Trust 219. PCTDS PCT Dental Service 220. PEAT Patient Environment Action Team (now known as Place) 221. PEC Professional Executive Committee 222. PHSO Public Health Service Ombudsman 223. PID Project Initiation Document 224. PII Period of Increased Incidence 225. PiP Partners in Paediatrics 226. PIS Prescribing Incentive Scheme 227. PLCV Procedures of Limited Clinical Value 228. PLT Protected Learning Time 229. PM Practice Manager 230. PMO Programme Management Office 231. PMS Personal Medical Services 232. POPP Partnerships for Older People Projects 233. PPG Patient Participation Group 234. PPI Patient and Public Involvement 235. PPI (prescribing) Proton Pump Inhibitors 236. PPV Post Payment Verification 237. PQQ Pre Qualifying Questionnaire 238. PRF Patient Report Form
Item: 16 Enc: 19 239. PRISM Personnel Resource Information System for Management 240. PROMs Patient Related Outcome Measures 241. PT Physical Therapist 242. PTL Patient Target List 243. PU Pressure Ulcer 244. PWSI Pharmacist with Special Interest 245. QIA Quality Impact Assessment 246. QIF Quality Improvement Framework 247. QIL Quality Improvement Lead 248. QIP Quality Improvement Programme 249. QIPP Quality, innovation, productivity and prevention. 250. QOF Quality and Outcomes Framework 251. QSG Quality Surveillance Group 252. QSISM Quality and Safeguarding Information Sharing Group 253. RAG Red Amber Green 254. RAP Remedial Action Plan 255. RCA Root Cause Analysis 256. RIA Risk Impact Assessment 257. RIO Electronic Care System 258. RRL Revenue Resource Limit 259. RSUH Royal Stoke University Hospital 260. RTT Referral to Treatment 261. RWT Royal Wolverhampton Hospital Trust 262. SALT Speech & Language Therapist 263. SARC Sexual Assaults Referrals Centre 264. SAS Stafford and Surrounds 265. SCBU Special Care Baby Unit 266. SCC Staffordshire County Council 267. SCIO Staffordshire Consortium of Infrastructure Organisations 268. SCR Strategic Change Reserve 269. SCWP Social Care Workforce Planning 270. SDB Service Delivery Board 271. SDIP Service Delivery Improvement Plan 272. SI Serious Incident 273. SIB Service Improvement Board 274. SIC Statement of Internal Control 275. SIRO Senior Information Risk Officer 276. SLAM Service Level Agreement Model 277. SPA Supporting Programmed Activities 278. SPEC Strategic Public Engagement Committee 279. SSHLF South Staffordshire Health Libraries Federation 280. SSOTP Staffordshire & Stoke on Trent Partnership Trust 281. SSPAU Short Stay Paediatric Assessment Unit 282. SSSFT South Staffordshire & Shropshire Foundation Trust 283. SSSHFT South Staffs & Shropshire Healthcare Foundation Trust 284. SUI Serious Untoward Incident(now known as SI’s) 285. SUS Secondary User Services 286. TDA Trust Development Authority 287. TOR Terms of Reference 288. TSA Trust Special Administrator 289. TV Team Tissue Viability Team 290. UCC Urgent Care Centre 291. UDA Units of Dental Activity 292. UHB University Hospital Birmingham 293. UHNM University Hospitals of North Midlands NHS Trust 294. UHNS University Hospital North Staffordshire 295. UOA Units of Orthodontic Activity 296. VAT Value Added Tax 297. VFM Value for Money 298. VO Variation Order
Item: 16 Enc: 19 299. VT Vocational Trainee 300. WCC World Class Commissioning 301. WHT Walsall Hospitals Trust 302. WIC Walk in Centre 303. WMAS West Midlands Ambulance Service 304. WMQRS West Midlands Quality Review Service 305. WMSCG West Midlands Strategic Commissioning Group 306. WRES Workforce Race Equality Standard 307. WTE Whole Time Equivalent 308. WUCTAS Wolverhampton Urgent Care Triage Access Service 309. YTD Year to Date